Rapid advances in auto-segmentation of organs at risk and target volumes in head and neck cancer.

Advances in technical radiotherapy have resulted in significant sparing of organs at risk (OARs), reducing radiation-related toxicities for patients with cancer of the head and neck (HNC). Accurate delineation of target volumes (TVs) and OARs is critical for maximising tumour control and minimising radiation toxicities. When performed manually, variability in TV and OAR delineation has been shown to have significant dosimetric impacts for patients on treatment. Auto-segmentation (AS) techniques have shown promise in reducing both inter-practitioner variability and the time taken in TV and OAR delineation in HNC. Ultimately, this may reduce treatment planning and clinical waiting times for patients. Adaptation of radiation treatment for biological or anatomical changes during therapy will also require rapid re-planning; indeed, the time taken for manual delineation currently prevents adaptive radiotherapy from being implemented optimally. We are therefore standing on the threshold of a transformation of routine radiotherapy planning via the use of artificial intelligence. In this article, we outline the current state-of-the-art for AS for HNC radiotherapy in order to predict how this will rapidly change with the introduction of artificial intelligence. We specifically focus on delineation accuracy and time saving. We argue that, if such technologies are implemented correctly, AS should result in better standardisation of treatment for patients and significantly reduce the time taken to plan radiotherapy.

Comparative analysis of the outcomes of elective abdominal aortic aneurysm repair in England and Sweden.

BACKGROUND: There is substantial international variation in mortality after abdominal aortic aneurysm (AAA) repair; many non-operative factors influence risk-adjusted outcomes. This study compared 90-day and 5-year mortality for patients undergoing elective AAA repair in England and Sweden. METHODS: Patients were identified from English Hospital Episode Statistics and the Swedish Vascular Registry between 2003 and 2012. Ninety-day mortality and 5-year survival were compared after adjustment for age and sex. Separate within-country analyses were performed to examine the impact of co-morbidity, hospital teaching status and hospital annual caseload. RESULTS: The study included 36 249 patients who had AAA treatment in England, with a median age of 74 (i.q.r. 69-79) years, of whom 87·2 per cent were men. There were 7806 patients treated for AAA in Sweden, with a median of age 73 (68-78) years, of whom 82·9 per cent were men. Ninety-day mortality rates were poorer in England than in Sweden (5·0 versus 3·9 per cent respectively; P < 0·001), but were not significantly different after 2007. Five-year survival was poorer in England (70·5 versus 72·8 per cent; P < 0·001). Use of EVAR was initially lower in England, but surpassed that in Sweden after 2010. In both countries, poor outcome was associated with increased age. In England, institutions with higher operative annual volume had lower mortality rates. CONCLUSION: Mortality for elective AAA repair was initially poorer in England than Sweden, but improved over time alongside greater uptake of EVAR, and now there is no difference. Centres performing a greater proportion of EVAR procedures achieved better results in England.

Influence of national centralization of oesophagogastric cancer on management and clinical outcome from emergency upper gastrointestinal conditions.

BACKGROUND: In England in 2001 oesophagogastric cancer surgery was centralized. The aim of this study was to evaluate whether centralization of oesophagogastric cancer to high-volume centres has had an effect on mortality from different emergency upper gastrointestinal conditions. METHODS: The Hospital Episode Statistics database was used to identify patients admitted to hospitals in England (1997-2012). The influence of oesophagogastric high-volume cancer centre status (20 or more resections per year) on 30- and 90-day mortality from oesophageal perforation, paraoesophageal hernia and perforated peptic ulcer was analysed. RESULTS: Over the study interval, 3707, 12 441 and 56 822 patients with oesophageal perforation, paraoesophageal hernia and perforated peptic ulcer respectively were included. There was a passive centralization to high-volume cancer centres for oesophageal perforation (26·9 per cent increase), paraoesophageal hernia (19·5 per cent increase) and perforated peptic ulcer (23·0 per cent increase). Management of oesophageal perforation in high-volume centres was associated with a reduction in 30-day (HR 0·58, 95 per cent c.i. 0·45 to 0·74) and 90-day (HR 0·62, 0·49 to 0·77) mortality. High-volume cancer centre status did not affect mortality from paraoesophageal hernia or perforated peptic ulcer. Annual emergency admission volume thresholds at which mortality improved were observed for oesophageal perforation (5 patients) and paraoesophageal hernia (11). Following centralization, the proportion of patients managed in high-volume cancer centres that reached this volume threshold was 88·0 per cent for oesophageal perforation, but only 30·3 per cent for paraoesophageal hernia. CONCLUSION: Centralization of low incidence conditions such as oesophageal perforation to high-volume cancer centres provides a greater level of expertise and ultimately reduces mortality.

Expansion rate of descending thoracic aortic aneurysms.

BACKGROUND: Surveillance is mandatory for all patients with a thoracic aortic aneurysm (TAA). The frequency of surveillance imaging, however, is not evidence-based, as few data exist regarding TAA growth rates. This study aimed to determine the rate of TAA expansion and to inform surveillance intervals based on TAA diameter. METHODS: Patients with a TAA for whom morphological data were available from serial CT scans were studied. Annualized growth rates based on diameter at presentation and time taken to reach a theoretical intervention threshold of 55 mm were calculated. The number of patients who would have achieved the threshold undetected was determined based on simulated imaging intervals of 6 months, 1, 2 and 3 years. RESULTS: A total of 2916 scans from 995 patients were analysed. The mean aortic expansion rate was 2·76 mm per year for all patients, with an exponential increase observed at sizes above 45 mm. Only 3·9 per cent of patients with a starting diameter of 30-39 mm and 5·3 per cent of those with a diameter of 40-44 mm achieved threshold size within 2 years. Conversely, the probability of expansion to more than 55 mm was 74·5 per cent in 2 years for patients with a starting diameter of 50-54 mm, rising to 85·7 per cent at 3 years. CONCLUSION: Based on a threshold of 55 mm for intervention, most patients with a maximum aortic diameter below 40 mm could safely undergo surveillance at 2-yearly intervals. Above 45 mm, annual surveillance is recommended. Patients with a diameter greater than 50 mm could be optimized for possible repair, if this is clinically appropriate.

Cardiovascular risk prevention and all-cause mortality in primary care patients with an abdominal aortic aneurysm.

BACKGROUND: Perioperative mortality is low for patients undergoing abdominal aortic aneurysm (AAA) repair, but long-term survival remains poor. Although patients diagnosed with AAA have a significant burden of cardiovascular disease and associated risk factors, there is limited understanding of the contribution of cardiovascular risk management to long-term survival. METHODS: General practice records within The Health Improvement Network (THIN) were examined. Patients with a diagnosis of AAA and at least 1 year of registered medical history were identified from 2000 to 2012. Medical therapies for cardiovascular risk were classified as antiplatelet, statin or antihypertensive agents. Progression to death was investigated using the G-computation formula with time-dependent co-variables to account for differences in exposure to cardiovascular risk-modifying treatments and the confounding between exposure, co-morbidities and death. RESULTS: Some 12 485 patients had a recorded diagnosis of AAA. From 2000 to 2012, prescription of medications that modify cardiovascular risk increased: from 26·6 to 76·7 per cent for statins, from 56·5 to 73·9 per cent for antiplatelet agents and from 75·3 to 84·0 per cent for antihypertensive drugs. Adjusted Kaplan-Meier curves demonstrated a better 5-year survival rate in patients receiving statins (68·4 versus 42·2 per cent), antiplatelet agents (63·6 versus 39·7 per cent) or antihypertensive agents (61·5 versus 39·1 per cent), compared with rates in patients not receiving each therapy. CONCLUSION: Appropriate risk factor modification could significantly reduce long-term mortality in patients with AAA. In the UK, up to 30 per cent of patients are not currently receiving these medications.

The Endovascular Sealing Device in Combination with Parallel Grafts for Treatment of Juxta/Suprarenal Abdominal Aortic Aneurysms: Short-term Results of a Novel Alternative.

BACKGROUND: The chimney technique using parallel grafts offers an alternative to fenestrated or branched endovascular solutions for juxtarenal and suprarenal aneurysms. Endograft deployment proximal to the renal or visceral ostia is combined with parallel stents to the aortic side branches. Application of the chimney technique using the Nellix device (Ch-EVAS) may offer some potential advantages with respect to the seal between the endograft and the parallel grafts. This study aimed to investigate the feasibility and efficacy of the Nellix endovascular aneurysm sealing (EVAS) system in conjunction with parallel grafts for the treatment of juxtarenal and suprarenal aneurysms. METHODS: A prospective evaluation of patients treated for juxtarenal and suprarenal non-ruptured aortic aneurysms using Ch-EVAS was undertaken in a single vascular unit. Patients were treated with this technique if they were unsuitable for either open repair or a custom-made complex branched/fenestrated endograft. Procedural, postoperative morbidity, and mortality data were recorded. RESULTS: Between March 2013 and April 2015, 28 patients were treated with Ch-EVAS. The median age was 75 years (range 60-87 years) and the median aneurysm diameter 66 mm (IQR 60-73 mm). Eight patients underwent suprarenal aneurysm repair including parallel grafts in the superior mesenteric artery and renal arteries. Five patients had a double chimney configuration; all the other patients were treated with a single chimney configuration. There was one 30-day or in-hospital mortality in a patient with a symptomatic aneurysm (4%) and three further deaths within 1 year of follow-up. One proximal type I endoleak and one type II endoleak occurred. Four patients underwent a reintervention. One patient experienced a transient ischemic attack and two patients suffered from a minor stroke (7%), therefore the total number of cerebrovascular complications was 11%. No patient required postoperative renal replacement therapy. CONCLUSIONS: Ch-EVAS appears to offer a feasible solution for juxtarenal and suprarenal aneurysms with adverse morphology. In this short-term follow-up endoleak rates were low and re-intervention rates were acceptable. Outcomes over extended follow-up will determine the application of this novel technique and better define which patients and aneurysm morphology can be treated effectively.

Systematic Review of the Growth Rates and Influencing Factors in Thoracic Aortic Aneurysms.

OBJECTIVE/BACKGROUND: The growth rates of thoracic aortic aneurysms (TAAs) and factors influencing their expansion are poorly understood. This study aimed to review systematically published literature describing TAA expansion and examine factors that may be associated with this. METHODS: A comprehensive search of MEDLINE and Embase databases was performed until 30 April 2015. Studies describing rates of TAA growth were identified and systematically reviewed. Outcomes of interest were TAA growth rates and associated factors. Study quality was assessed using Scottish Intercollegiate Guidelines Network quality checklists for cohort studies. RESULTS: Eleven publications, involving 1383 patients, met the eligibility criteria and were included in the review. Included studies were generally low in quality. Aneurysm measurement and growth-rate estimation techniques were inconsistently reported. Mean growth rates for all TAAs ranged from 0.2 to 4.2 mm/year. Mean growth rates for ascending and aortic arch aneurysms ranged from 0.2 to 2.8 mm/year, while those for descending and thoracoabdominal aneurysms ranged from 1.9 to 3.4 mm/year in studies reporting according to anatomical location. Large aneurysm size, distal aneurysm locations, presence of Marfan's syndrome, and bicuspid aortic valve were consistently associated with accelerated TAA growth. Presence of chronic dissection and chronic obstructive pulmonary disorder were also implicated as risk factors for faster TAA growth. Associations between medical comorbidity and aneurysm expansion were conflicting. Previous aortic surgery and anticoagulants were reported to have a protective effect on aneurysm growth in two studies. CONCLUSION: There is a shortfall in the understanding of TAA expansion rates. Existing studies are heterogeneous in methodology and reported outcomes. Identified unifying themes suggest that TAAs grow at a slow rate with large presenting diameter, distal aneurysm, and history of bicuspid aortic valve or Marfan's syndrome serving as main risk factors for accelerated aneurysm growth. High-quality studies with a standardised approach to TAA growth assessment are required.

Mortality of emergency general surgical patients and associations with hospital structures and processes.

BACKGROUND: Variations in patient outcomes between providers have been described for emergency admissions, including general surgery. The aim of this study was to investigate whether differences in modifiable hospital structures and processes were associated with variance in mortality, amongst patients admitted for emergency colorectal laparotomy, peptic ulcer surgery, appendicectomy, hernia repair and pancreatitis. METHODS: Adult emergency admissions in the English NHS were extracted from the Hospital Episode Statistics between April 2005 and March 2010. The association between mortality and structure and process measures including medical and nursing staffing levels, critical care and operating theatre availability, radiology utilization, teaching hospital status and weekend admissions were investigated. RESULTS: There were 294 602 emergency admissions to 156 NHS Trusts (hospital systems) with a 30-day mortality of 4.2%. Trust-level mortality rates for this cohort ranged from 1.6 to 8.0%. The lowest mortality rates were observed in Trusts with higher levels of medical and nursing staffing, and a greater number of operating theatres and critical care beds relative to provider size. Higher mortality rates were seen in patients admitted to hospital at weekends [OR 1.11 (95% CI 1.06-1.17) P<0.0001], in Trusts with fewer general surgical doctors [1.07 (1.01-1.13) P=0.019] and with lower nursing staff ratios [1.07 (1.01-1.13) P=0.024]. CONCLUSIONS: Significant differences between Trusts were identified in staffing and other infrastructure resources for patients admitted with an emergency general surgical diagnosis. Associations between these factors and mortality rates suggest that potentially modifiable factors exist that relate to patient outcomes, and warrant further investigation.

Comparison of long-term mortality after ruptured abdominal aortic aneurysm in England and Sweden.

BACKGROUND: Concern has been raised regarding international discrepancies in perioperative mortality after repair of ruptured abdominal aortic aneurysm (rAAA). The variation in in-hospital mortality is difficult to interpret, owing to international differences in discharge strategies. This study compared 90-day and 5-year mortality in patients who had a rAAA in England and Sweden. METHODS: Patients undergoing rAAA repair were identified from English Hospital Episode Statistics and the Swedish Vascular Registry (Swedvasc) between 2003 and 2012. Ninety-day and 5-year mortality were compared after matching for age and sex. Within-country analyses examined the impact of co-morbidity, teaching hospital status or hospital annual caseload, adjusted with causal inference techniques. RESULTS: Some 12 467 patients underwent rAAA repair in England, of whom 83.2 per cent were men; the median (i.q.r.) age was 75 (70-80) years. A total of 2829 Swedish patients underwent rAAA repair, of whom 81.3 per cent were men; their median (i.q.r.) age was 75 (69-80) years. The 90-day mortality rate was worse in England (44.0 per cent versus 33.4 per cent in Sweden; P < 0.001), as was 5-year mortality (freedom from mortality 38.6 versus 46.3 per cent respectively; P < 0.001). In England, lower mortality was seen in teaching hospitals with larger bed capacity, higher annual caseloads and greater use of endovascular aneurysm repair (EVAR). In Sweden, lower mortality was associated with EVAR, high annual caseload, or surgery on weekdays compared with weekends. CONCLUSION: Short- and long-term mortality after rAAA repair was higher in England. In both countries, mortality was lowest in centres performing greater numbers of AAA repairs per annum, and more EVAR procedures.

Systematic Review and Meta-analysis of Long-term survival After Elective Infrarenal Abdominal Aortic Aneurysm Repair 1969-2011: 5 Year Survival Remains Poor Despite Advances in Medical Care and Treatment Strategies.

BACKGROUND: Improved critical care, pre-operative optimization, and the advent of endovascular surgery (EVAR) have improved 30 day mortality for elective abdominal aortic aneurysm (AAA) repair. It remains unknown whether this has translated into improvements in long-term survival, particularly because these factors have also encouraged the treatment of older patients with greater comorbidity. The aim of this study was to quantify how 5 year survival after elective AAA repair has changed over time. METHODS: A systematic review was performed identifying studies reporting 5 year survival after elective infrarenal AAA repair. An electronic search of the Embase and Medline databases was conducted to January 2014. Thirty-six studies, 60 study arms, and 107,814 patients were identified. Meta-analyses were conducted to determine 5 year survival and to report whether 5 year survival changed over time. RESULTS: Five-year survival was 69% (95% CI 67 to 71%, I(2) = 87%). Meta-regression on study midpoint showed no improvement in 5 year survival over the period 1969-2011 (log OR -0.001, 95% CI -0.014-0.012). Larger average aneurysm diameter was associated with poorer 5 year survival (adjusted log OR -0.058, 95% CI -0.095 to -0.021, I(2) = 85%). Older average patient age at surgery was associated with poorer 5 year survival (adjusted log OR -0.118, 95% CI -0.142 to -0.094, I(2) = 70%). After adjusting for average patient age, an improvement in 5 year survival over the period that these data spanned was obtained (adjusted log OR 0.027, 95% CI 0.012 to 0.042). CONCLUSION: Five-year survival remains poor after elective AAA repair despite advances in short-term outcomes and is associated with AAA diameter and patient age at the time of surgery. Age-adjusted survival appears to have improved; however, this cohort as a whole continues to have poor long-term survival. Research in this field should attempt to improve the life expectancy of patients with repaired AAA and to optimise patient selection.

Endovascular aneurysm sealing for infrarenal abdominal aortic aneurysms: 30-day outcomes of 105 patients in a single centre.

OBJECTIVE: Endovascular aneurysm sealing (EVAS) has been proposed as a novel alternative to endovascular aneurysm repair (EVAR) in patients with infrarenal abdominal aortic aneurysms (AAA). The early clinical experience, technical refinements, and learning curve of EVAS in the treatment of AAA at a single institution are presented. METHODS: One-hundred and five patients were treated with EVAS between March 2013 and November 2014. Prospective data were recorded on consecutive patients receiving EVAS. Data included demographics, preoperative aneurysm morphology, and 30-day outcomes, including rates of endoleak, limb occlusion, reintervention, and death. Postoperative imaging consisted of duplex ultrasound and computed tomographic angiography. RESULTS: The mean age of the cohort was 76 ± 8 years and 12% were female. Adverse neck morphology was present in 72 (69%) patients, including aneurysm neck length <10 mm (20%), neck diameter >32 mm (18%), ß-angulation >60° (21%), and conical aneurysm neck (51%). There was one death within 30 days. The incidence of Type 1 endoleak within 30 days was 4% (n = 4); all were treated successfully with transcatheter embolisation. All four proximal endoleaks were associated with technical issues that resulted in procedure refinement, and all were in patients with adverse proximal aortic necks. The persistent Type 1 endoleak rate at 30 days was 0% and there were no Type 2 or Type 3 endoleaks. Angioplasty and adjunctive stenting were performed for postoperative limb stenosis in three patients (3%). CONCLUSIONS: EVAS appears to be associated with reasonable 30-day outcomes despite the necessity of procedural evolution in the early adoption of this technique. EVAS appears to be applicable to patients with challenging aortic morphology and endoleak rates should reduce with procedural experience. The utility of EVAS will be defined by the durability of the device in long-term follow-up, although the absence of Type 2 endoleaks is encouraging.

Association of hospital structures with mortality from ruptured abdominal aortic aneurysm.

BACKGROUND: There is significant variation in the mortality rates of patients with a ruptured abdominal aortic aneurysm (rAAA) admitted to hospital in England. This study sought to investigate whether modifiable differences in hospital structures and processes were associated with differences in patient outcome. METHODS: Patients diagnosed with rAAA between 2005 and 2010 were extracted from the Hospital Episode Statistics database. After risk adjustment, hospitals were grouped into low-mortality outlier, expected mortality and high-mortality outlier categories. Hospital Trust-level structure and process variables were compared between categories, and tested for an association with risk-adjusted 90-day mortality and non-corrective treatment (palliation) rate using binary logistic regression models. RESULTS: There were 9877 patients admitted to 153 English NHS Trusts with an rAAA during the study. The overall combined (operative and non-operative) mortality rate was 67·5 per cent (palliation rate 41·6 per cent). Seven hospital Trusts (4·6 per cent) were high-mortality and 15 (9·8 per cent) were low-mortality outliers. Low-mortality outliers used significantly greater mean resources per bed (doctors: 0·922 versus 0·513, P < 0·001; consultant doctors: 0·316 versus 0·168, P < 0·001; nurses: 2·341 versus 1·770, P < 0·001; critical care beds: 0·045 versus 0·019, P < 0·001; operating theatres: 0·027 versus 0·019, P = 0·002) and performed more fluoroscopies (mean 12·6 versus 9·2 per bed; P = 0·046) than high-mortality outlier hospital Trusts. On multivariable analysis, greater numbers of consultants, nurses and fluoroscopies, teaching status, weekday admission and rAAA volume were independent predictors of lower mortality and, excluding rAAA volume, a lower rate of palliation. CONCLUSION: The variability in rAAA outcome in English National Health Service hospital Trusts is associated with modifiable hospital resources. Such information should be used to inform any proposed quality improvement programme surrounding rAAA.

International validation of a risk score for complications and reinterventions after endovascular aneurysm repair.

BACKGROUND: Lifelong surveillance is considered mandatory after endovascular repair (EVAR) of abdominal aortic aneurysms to detect endograft complications and prevent aneurysm rupture. Current protocols are not cost-effective or clinically effective. The international validity of the St George's Vascular Institute (SGVI) score for EVAR complications was examined. METHODS: The ENGAGE registry recruited patients undergoing EVAR at 79 centres in 30 countries. Reinterventions and endograft complications were recorded for up to 3 years after surgery. Preoperative aneurysm morphology was extracted from the registry database, and used to predict whether patients would be at low or high risk of complications after EVAR based on the SGVI score. Kaplan-Meier analysis was used to compare the incidence of endograft complications and reinterventions in patients predicted to be at low risk compared with those predicted to be at high risk. RESULTS: Some 1207 patients underwent EVAR, with follow-up of up to 3 years. The SGVI score accurately discriminated freedom from reinterventions (90·5 versus 79·3 per cent in low- versus high-risk patients; P < 0·001), freedom from endograft complications (77·9 versus 69·6 per cent in low- versus high-risk patients; P = 0·012), and freedom from a composite outcome measure of reinterventions or endograft complications (75·0 versus 66·1 per cent in low- versus high-risk patients; P = 0·006) during mid-term follow-up. CONCLUSION: This study has provided international validation of a morphological risk score that predicts mid-term reinterventions and endograft complications. The results may enable risk-stratified surveillance after EVAR.

Enhanced recovery pathways lead to an improvement in postoperative outcomes following esophagectomy: systematic review and pooled analysis.

The aim of this systematic review and pooled analysis is to determine the effect of enhanced recovery programs (ERP) on clinical outcome measures following esophagectomy. Medline, Embase, trial registries, conference proceedings, and reference lists were searched for trials comparing clinical outcome from esophagectomy followed by a conventional pathway with esophagectomy followed by an ERP. Primary outcomes were the incidence of postoperative mortality, anastomotic leak and pulmonary complications, and secondary outcomes were length of hospital stay and the incidence of 30-day readmission. Nine studies were included comprising 1240 patients, 661 patients underwent esophagectomy followed conventional pathway, and 579 patients underwent ERP. Utilization of ERP was associated with a reduction in the incidence of anastomotic leak (12.2-8.3%; pooled odds ratios = 0.61; 95% confidence interval = 0.39 to 0.96; P = 0.03) and pulmonary complications (29.1-19.6%; pooled odds ratios = 0.52; 95% confidence interval = 0.36 to 0.77; P = 0.001) and length of hospital stay, and no significant change in postoperative mortality or readmission rate. There was significant variation in the design of enhanced recovery protocols, surgical approach, and utilization of neoadjuvant therapies between the studies that are important confounding variables to be considered. This study suggests a benefit to the utilization of ERP following esophagectomy. The pathways provide a template for all medical personnel interacting with these patients in order to provide incremental changes in all aspects of clinical care that translates into global improvements seen in postoperative outcomes.

The impact of pyloric drainage on clinical outcome following esophagectomy: a systematic review.

Delayed emptying of the gastric conduit following esophagectomy can be associated with an increased incidence of complications including aspiration pneumonia and anastomotic leak. The aim of this systematic review is to evaluate the current modalities of pyloric drainage following esophagectomy and their impact on anastomotic integrity and postoperative morbidity. Medline, Web of Science, Cochrane library, trial registries, and conference proceedings were searched. Five pyloric management strategies following esophagectomy were evaluated: no intervention, botulinum toxin (botox) injection, finger fracture, pyloroplasty, and pyloromyotomy. Outcomes evaluated were hospital mortality, anastomotic leak, pulmonary complications, delayed gastric emptying, and the late complication of bile reflux. Twenty-five publications comprising 3172 patients were analyzed. Pooled analysis of six comparative studies published after 2000 revealed pyloric drainage to be associated with a nonsignificant trend toward a reduced incidence of anastomotic leak, pulmonary complications, and delayed gastric emptying. Overall, the current level of evidence regarding the merits of individual pyloric drainage strategies remains very poor. There is significant heterogeneity in the definitions of clinical outcomes, in particular delayed gastric emptying, which has prevented meaningful assessment and formulation of consensus regarding the management of the pylorus during esophagectomy. Pyloric drainage procedures showed a non-significant trend toward fewer anastomotic leaks, pulmonary complications, and reduced gastric stasis when employed following esophagectomy. However, the ideal technique remains unproven suggesting that further collaborative investigations are needed to determine the intervention that will maximize the potential benefits, if any, of pyloric intervention.

Failure-to-rescue and interprovider comparisons after elective abdominal aortic aneurysm repair.

BACKGROUND: The use of postoperative complication rates to derive metrics such as failure-to-rescue (FTR) is of increasing interest in assessing the quality of care. The aim of this study was to quantify FTR rates for elective abdominal aortic aneurysm (AAA) repair in England using administrative data, and to examine its validity against case-note review. METHODS: A retrospective observational study using Hospital Episode Statistics (HES) data was combined with a multicentre audit of data quality. All elective AAA repairs done in England between 2005 and 2010 were identified. Postoperative complications were extracted, FTR rates quantified, and differences in FTR and in-hospital death rates established. A multicentre case-note review was performed to establish the accuracy of coding of complications, and the impact of inaccuracies on FTR rates derived from HES data. RESULTS: A total of 19 638 elective AAA repairs were identified from HES; the overall mortality rate was 4·6 per cent. Patients with complications (19·2 per cent) were more likely to die than those without complications (odds ratio 12·22, 95 per cent c.i. 10·51 to 14·21; P < 0·001) and had longer hospital stays (P < 0·001). FTR rates correlated strongly with death rates, whereas complication rates did not. On case-note review (661 procedures), 41·5 per cent of patients had a complication recorded in the case notes. There was evidence of systematic under-reporting of complications in HES, leading to an overall misclassification rate of 36·3 (95 per cent c.i. 33·7 to 39·2) per cent (P < 0·001), which was less pronounced for surgical complications (12·6 (11·1 to 13·9) per cent; P <0·001). Despite this, the majority of FTR rates derived from HES were not significantly different from those derived from case-note data. CONCLUSION: Postoperative complication and FTR rates after elective AAA repair can be derived from HES data. However, use of the metric for interprovider comparisons should be done cautiously, and only with concurrent case-note validation given the degree of miscoding identified.

Endoscopic vein harvesting in lower extremity arterial bypass: a systematic review.

OBJECTIVE: Endoscopic vein harvesting (EVH) for arterial bypass surgery may be associated with lower wound complication rates than open vein harvesting (OVH), but other long-term outcomes remain controversial, and there are concerns that graft patency may be poorer after EVH compared with OVH. We conducted a systematic review of all available evidence for EVH in lower extremity arterial bypass (LEAB). METHODS: A literature search of Medline, Embase, Ovid and Cochrane databases between 1996 and 2013 was performed using the terms "endoscopic vein harvesting", "minimally invasive vein harvest", "peripheral bypass surgery", and "lower extremity bypass surgery", and detailed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Primary outcomes were graft patency and overall wound complication rates. Secondary outcomes were wound infection, length of hospital stay, and cost-effectiveness. Summary estimates were calculated by random effects meta-analysis if sufficient data were available. RESULTS: We identified 18 cohort studies and case series, with considerable clinical heterogeneity, including 2,343 patients. Meta-analysis of six studies revealed a significantly reduced rate of primary patency after EVH (hazard ratio 1.29, 95% confidence interval [CI] 1.03-1.63), with no significant difference between EVH and OVH with respect to wound infection in 12 studies (odds ratio 0.81, 95% CI 0.61-1.08). There was a lack of strong evidence to support the secondary outcomes of EVH. CONCLUSION: EVH reduces primary patency rates after LEAB, but does not demonstrate an advantage with respect to postoperative wound complications. However, the available data are heterogeneous, and uncertainty is introduced by both evolution in technology and increasing technical experience. EVH should be used with caution and in the context of formal research.

Inter-relationship of procedural mortality rates in vascular surgery in England: retrospective analysis of hospital episode statistics from 2005 to 2010.

BACKGROUND: Wide variations in vascular surgical outcomes have been demonstrated in England. The objective of this study was to determine whether risk-adjusted postoperative mortality rates for elective and emergency vascular surgical procedures were inter-related. METHODS AND RESULTS: A retrospective observational study using National Health Service administrative data on adult patients undergoing elective or emergency vascular surgery from 2005 to 2010. The 10 procedures covered the broad spectrum of workload for a vascular surgical service. The primary outcome measure was in-hospital mortality, and secondary outcomes were 30-day and 1-year mortality. Data were risk-adjusted using multilevel modeling. Analyses comprised a 2-level basket designed to evaluate variations in outcome and whether the outcome of each procedure could be predicted by the composite outcome of all other procedures. A total of 116,596 vascular surgical procedures were performed across 166 providers. For 9 of 10 procedures, there were hospitals lying outside 95% control limits for ≥1 mortality outcome. The key finding was that ≥1 risk-adjusted mortality outcome for any 1 of the 9 vascular surgical procedures could be predicted by the aggregated within provider performance of the other vascular surgical procedures combined. CONCLUSIONS: Hospital-level risk-adjusted mortality for both elective and emergency vascular procedures in England varies considerably, and providers were globally high or low performers. The data should be made available to patients, relatives, and the purchasers of services to drive improvements in the provision of vascular surgical services.