Hospital costs of complications after a pancreatoduodenectomy.

BACKGROUND: A pancreatoduodenectomy (PD) is a highly advanced procedure associated with considerable post-operative complications and substantial costs. In this study the hospital costs associated with complications after PD were assessed. METHODS: A retrospective cohort study was conducted on 100 consecutive patients who underwent a pylorus-preserving (PP)PD between January 2012 and July 2013. Per patient, all complications occurring during admission or in the 30-day period after discharge were documented. All hospital costs related to the (PP)PD were defined as the costs of all medical interventions and resources during the hospitalisation period as recorded by the electronic supply tracking system. RESULTS: The median hospital costs ranged from €17 482 for a patient without complications to €55 623 for a patient with a post-operative haemorrhage. A post-operative haemorrhage was associated with a 39.6% increase in total hospital costs after adjusting for patient characteristics. Other factors significantly associated with an increase in total hospital costs were: the presence of a malignancy other than a pancreatic adenocarcinoma (29.4% cost increase), the severity grade of a complication (34.3-70.6% increase) and the presence of a post-operative infection (32.4% increase). CONCLUSIONS: This study provides an in-depth analysis of hospital costs and identifies factors that are associated with substantial cost consequences of specific complications occurring after a PD.

Morbidity related to defunctioning ileostomy closure after ileal pouch-anal anastomosis and low colonic anastomosis.

PURPOSE: Defunctioning ileostomies are widely performed in order to prevent or treat anastomotic leakage after colorectal surgery. The aim of the present study was to determine morbidity related to stoma closure and to identify predictive factors of a complicated postoperative course. METHODS: A consecutive series of 138 patients were retrospectively analyzed after stoma reversal. Data collection included general demographics and surgery-related aspects. Morbidity related to stoma closure was retrieved from our prospectively collected registry of complications. RESULTS: In 74 of 138 patients, defunctioning ileostomy was performed after restorative proctocolectomy and ileal pouch-anal anastomosis (IPAA). The remaining ileostomies (n = 64) were constructed after a low colorectal or coloanal anastomosis. A total of 46 complications were recorded in 28 patients resulting in an overall complication rate of 20.3%. Anastomotic leakage rate was 4.3%, and reoperation rate was 8.0%. The number of complications according to the Clavien-Dindo classification was 5 for grade I (10.9%), 26 for grade II (56.5%), 13 for grade III (28.3%), 1 for grade IV (2.2%), and 1 for grade V (2.2%). Multivariate analysis revealed a significantly higher ASA score in the complicated group (P = 0.015, odds ratio 2.6, 95% confidence interval 1.2-5.6). CONCLUSIONS: Closure of a defunctioning ileostomy is associated with 20% morbidity and a reoperation rate of 8%. There is an urgent need for criteria on which a more selective use of a defunctioning ileostomy after low colonic anastomosis or IPAA can be based given its associated morbidity.

Questionnaire versus telephone follow-up to detect postdischarge complications in surgical patients: randomized clinical trial.

BACKGROUND: Postdischarge complications in surgical patients are usually recorded only when readmission is required, a method that likely underestimates the overall complication rate. Our aim was to determine which method-telephone interview or questionnaire by mail-collects the most postdischarge complications. METHODS: We performed a randomized clinical equivalence trial. From December 2008 until August 2009, all adult surgical patients admitted to a university hospital were randomized to be approached by mail or by phone 30 days after discharge to collect information about postdischarge complications. Primary outcome was the total number of reported complications after discharge. Secondary outcome was the severity of the complications. RESULTS: In all, 1595 patients were reached: 890 by means of a telephone interview and 705 through a questionnaire. Response rate was higher in the telephone group than in the questionnaire group (63.8 % vs. 51.3 %). The percentage of patients reporting one or more complications did not differ significantly between the groups: 43.3 % in the telephone group versus 39.6 % in the questionnaire group. Length of stay, American Society of Anesthesiologist class, and type of surgery-but not the survey techniques compared here-significantly influenced the number of complications reported. The percentage of patient-reported complications requiring treatment did not differ significantly between the groups. CONCLUSIONS: The two survey methods did not differ in their ability to appreciate postdischarge complications as reported by the patients. The decision to use either method may be determined by the institution, costs involved, and labor requirement.

The Evaluation of an Interprofessional QI Program: A Qualitative Study.

Background: Quality Improvement (QI) is the key for every healthcare organization. QI programs may help healthcare professionals to develop the needed skills for interprofessional collaboration through interprofessional education. Furthermore, the role of diversity in QI teams is not yet fully understood. This evaluation study aimed to obtain in-depth insights into the expectations and experiences of different stakeholders of a hospital-wide interprofessional QI program. Methods: This qualitative study builds upon 20 semi-structured interviews with participants and two focus groups with the coaches and program advisory board members of this QI program. Data were coded and analyzed using thematic analysis. Results: Three themes emerged from the analysis: "interprofessional education", "networking" and "motivation: presence with pitfalls". Working within interprofessional project groups was valuable, because participants with different experiences and skills helped to move the QI project forward. It was simultaneously challenging because IPE was new and revealed problems with hierarchy, communication and planning. Networking was also deemed valuable, but a shared space to keep in contact after finalizing the program was missing. The participants were highly motivated to finish their QI project, but they underestimated the challenges. Conclusions: A hospital-wide QI program must explicitly pay attention to interprofessional collaboration and networking. Leaders of the QI program must cherish the motivation of the participants and make sure that the QI projects are realistic.

Complications in multitrauma patients in a Dutch level 1 trauma center.

BACKGROUND: Complication registration is an important part of monitoring the quality of health care. The aim of this article was to describe the incidence, type, and impact of complications occurring within 6 months after the initial trauma in multitrauma patients. METHODS: During a 2-year period, all trauma patients with an Injury Severity Score (ISS) ≥ 16 who were not directly transferred to other hospitals were included. We used the Dutch National Surgical Complication Registry of the Academic Medical Center, a level 1 trauma center, to assess complications within 6 months after the initial trauma. For verification, we additionally performed a chart review. Complications were graded 0 (no real health loss) to 4 (lethal). RESULTS: Three hundred three multitrauma patients were included with a median ISS of 22 (interquartile range, 17-29). Within 181 patients, 358 complications occurred (60%). The most frequently occurring complications were respiratory and urinary tract infections. Most complications (73%) were grade 1 and resolved completely without operative (re-)intervention There were 27 patients (8%) with a grade 2 complication, which required operative (re-)interventions. All eight (2%) grade 3 complications which caused (potential) permanent damage or disability, were of neurologic origin. Overall mortality was 18.8% and complication associated readmission rate was 4%. Emergency interventions and high ISS tended to be associated with the occurrence of complications. In patients with complications, hospital stay was doubled from 9 to 18 days. CONCLUSIONS: Multitrauma patients are at high risk for developing complications. Most frequently encountered complications were infections. The majority of complications resolved completely without a surgical intervention.

Recruitment of Rab27a to phagosomes controls microbial antigen cross-presentation by dendritic cells.

Polyreactive immunoglobulins (Ig) and complement components are present in tissues and blood of healthy individuals. They facilitate pathogen uptake and inactivation in lysosomes of phagocytes and thereby provide rapid protection against infection. Dendritic cells (DCs) are phagocytes that can acquire peptides from phagocytosed antigen to elicit cytotoxic immune responses by CD8(+) T lymphocytes. The mechanisms that select peptides for cross-presentation are not fully resolved. Here we investigated the role of polyreactive Ig and complement in directing phagosomal antigen processing for cross-presentation. Phagocytosis facilitated by serum opsonization required the presence of Ig for effective antigen cross-presentation of microbe-derived antigen. The presence of complement C3 in serum promoted phagocytosis, yet phagosomes were defective in antigen degradation. The small GTPase Rab27a was recently implicated in antigen cross-presentation and was rapidly recruited to phagosomes only when Ig was present. Our data suggest that prebinding of antigen by polyreactive Ig potentiates the efficiency of antigen cross-presentation to CD8(+) T cells through recruitment of Rab27a.

Which clinical scenarios do surgeons record as complications? A benchmarking study of seven hospitals.

OBJECTIVES: To investigate agreement and potential differences in the application and interpretation of the definition among surgical departments of various hospitals. DESIGN: 24 cases were formulated including general, trauma, gastrointestinal and vascular surgery, and based on points of discussion about the definition and ambiguities regarding complication registration as encountered in daily practice. The cases were presented to the surgical staff and residents in seven Dutch hospitals, using the national registration system of complications and an electronic response system. RESULTS: In total, 134 participants responded. Interpretation differences were particularly found regarding: (1) complications considered as logical consequences of a surgical procedure; (2) complications occurring after radiological interventions; (3) severity criteria such as when to consider a complication as a '(probably) permanent damage or function loss'; (4) registering a cancelled operation as a complication and (5) patients with serial complications during hospital stay. CONCLUSIONS: The definition of surgical complications as currently applied in the Netherlands does not ensure a uniform complication registration. Improvement of this registration system is mandatory before benchmarking of these findings in the public domain is appropriate. Modifications of the current definition of a surgical complication, and improved consensus about specific clinical situations and training of surgeons might improve the quality of benchmarking.

Predictors of surgical complications: A systematic review.

BACKGROUND: Operative complications occur more frequently, often are more preventable, and their consequences can be more severe than other types of complications. Controversy exists regarding how best to identify and predict operative complications. Several studies on predictive factors for operative complications focused on a specific predictor for a specific outcome. To develop a reliable tool to identify patients with operative complications, insight in predictive factors for operative complications is required. PATIENTS AND METHODS: We searched all publications addressing predictive factors for the development of operative complications in adult patients admitted to the gastrointestinal, vascular, or general surgery departments. Data were extracted regarding study design, patient characteristics, operative specialty, types of operative procedures, types of complications, possible predictors, and associated complication risk increase (expressed as an odds ratio; OR). RESULTS: The final set of 30 articles yielded a total of 53 predictive factors studied in various settings, operative specialties, and disorders. To focus our analysis we selected the 25 most robust and clinically applicable factors (ie, appearing in 3 or more studies). These factors were then categorized into 4 different groups: Patient-related factors, Co-morbidities, Laboratory values, and Surgery-related factors. The most predictive factors for morbidity in these groups were body mass index (ORs from 1.80 to 6.30), age (1.02-4.62 years), American Society of Anesthesiologists classification (1.77-7.10), dyspnea (1.23-1.30), serum creatinine (1.39-2.14), emergency surgery (1.50-2.54), and functional status (1.36-4.07). CONCLUSION: This review presents a set of factors predictive of operative complications for general surgery departments. These easily retrievable factors can and should be validated in the specific patient populations of each hospital.

Registration of surgical adverse outcomes: a reliability study in a university hospital.

OBJECTIVE: Accurate registration of adverse surgical outcomes is essential to detect areas for improvement of surgical care quality. One reason for inaccurate adverse outcome registration may be the method to collect these outcomes. The authors compared the completeness of the national complication registry database (LHCR) as used in our hospital with relevant information from other available resources. DESIGN: Retrospective reliability analysis. SETTING: University hospital. PARTICIPANTS: From the 3252 patients admitted to the surgical wards in 2010, the authors randomly selected a cohort of 180 cases, oversampling those with adverse outcomes. The LHCR contains adverse outcomes as reported during morning hand-offs or in discharge letters. The authors checked if the number and severity of adverse outcomes recorded in the LHCR agreed with those reported in morning hand-offs, discharge letters and medical and nursing files. RESULTS: In 135 of 180 patients, all resources could be retrieved completely. Fourteen per cent of the patients with adverse outcomes were not recorded in the LHCR. Missing adverse outcomes were all reversible without the need for (re)operation, for example, postoperative pain, delirium or urinary tract complications. Only 38% of these adverse outcomes were reported in the morning hand-offs and discharge letters but were best reported in the medical and nursing files. CONCLUSIONS: Registration of surgical adverse outcomes appears largely depending on the reliability of the underlying sources. For a more complete adverse outcome registration, the authors advocate a better hand-off and additional consultation of the patient's dossier. This extra effort allows for improvement actions to eventually avoid 'mild' adverse outcomes patients perceive as important and undesirable.

T cell priming by tissue-derived dendritic cells: new insights from recent murine studies.

Dendritic cells (DCs) act as sentinels in peripheral tissues, continuously scavenging for antigens in their immediate surroundings. Their involvement in T cell responses is generally thought to consist of a linear progression of events, starting with capture of antigen in peripheral tissues such as the skin followed by migration to draining lymphoid organs and MHC-restricted presentation of antigen-derived peptide to induce T cell priming. The role of tissue-derived DCs in the direct priming of immune responses has lately been challenged. It now appears that, at least in some instances, a non-migratory subtype of DCs in the secondary lymphoid tissue presents tissue-derived antigen to T cells. Here, we review recent developments in research on DC function in the priming of immune responses.