RESUMO
BACKGROUND: Variations in care have been demonstrated both within and among institutions in many clinical settings. By standardizing perioperative practices, Enhanced Recovery After Surgery (ERAS) pathways reduce variation in perioperative care. We sought to characterize the variation in cytoreductive surgery (CRS)/heated intraperitoneal chemotherapy (HIPEC) perioperative practices among experienced US medical centers. METHODS: Data from the US HIPEC Collaborative represents a retrospective multi-institutional cohort study of CRS and CRS/HIPEC procedures performed from 12 major academic institutions. Patient characteristics and perioperative practices were reported and compared. Institutional variation was analyzed using hierarchical mixed-effects linear (continuous outcomes) or logistic (binary outcomes) regression models. RESULTS: A total of 2372 operations were included. CRS/HIPEC was performed most commonly for appendiceal histologies (64.2%). The rate of complications (overall 56.3%, range: 31.8-70.9) and readmissions (overall 20.6%, range: 8.9-33.3) varied by institution (P < .001). Institution-level variation in perioperative practice patterns existed among measured ERAS pathway process/outcomes (P < .001). The percentages of variation with each process/outcome measure attributable solely to institutional practices ranged from 0.6% to 66.6%. CONCLUSIONS: Significant variation exists in the perioperative care of patients undergoing CRS/HIPEC at major US academic institutions. These findings provide a strong rationale for the investigation of best practices in CRS/HIPEC patients.
Assuntos
Procedimentos Cirúrgicos de Citorredução/métodos , Quimioterapia Intraperitoneal Hipertérmica/métodos , Neoplasias/terapia , Estudos de Coortes , Procedimentos Cirúrgicos de Citorredução/normas , Procedimentos Cirúrgicos de Citorredução/estatística & dados numéricos , Recuperação Pós-Cirúrgica Melhorada , Feminino , Humanos , Quimioterapia Intraperitoneal Hipertérmica/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Neoplasias/tratamento farmacológico , Neoplasias/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: Differences in clinical staging and survival among pancreatic head, body, and tail cancers are not well defined. We aim to identify the prognostic relevance of primary tumor location in patients undergoing treatment for pancreatic ductal adenocarcinoma (PDAC). MATERIALS AND METHODS: The National Cancer Database was used to identify patients with PDAC from 1998 to 2011 (n = 175,556). Patients were categorized by primary tumor site into head (67.5%, n = 118,343), body (15.5%, n = 27,218), and tail (17.0%, n = 29,885) groups. Univariate and Cox regression analyses were used to determine covariates associated with overall survival (OS). RESULTS: Patients with head PDAC presented with earlier stage disease (39.2% Stage I/II versus 19.7% versus 16.0%, P < 0.001) and underwent resection more often (27.9% versus 10.7% versus 17.0%, P < 0.001) than those with body or tail tumors. Of surgically resected PDAC, those localized to the head had advanced pathologic stage (84.8% stage II/III versus 66.6% versus 65.6%, P < 0.001), higher nodal positivity (64.9% versus 45.8% versus 45%, P < 0.001), and worse tumor grade (35.9% poorly differentiated versus 29.5% versus 27.8%, P < 0.001). Despite increased utilization of adjuvant therapies (54.4% versus 45.6% versus 42.0%, P < 0.001), patients with head PDAC had inferior OS compared with those with body and tail tumors (P < 0.001). CONCLUSIONS: When examining patients with PDAC undergoing resection, tumor localization to the head is associated with improved resectability because they present earlier. Of resected PDACs, however, those localized to the head have worse OS compared with body and tail tumors. This discrepancy may represent a combination of lead time and selection biases and biologic differences between tumor sites.
Assuntos
Carcinoma Ductal Pancreático/cirurgia , Pâncreas/patologia , Pancreatectomia , Neoplasias Pancreáticas/cirurgia , Idoso , Carcinoma Ductal Pancreático/mortalidade , Carcinoma Ductal Pancreático/patologia , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias , Pâncreas/cirurgia , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: The purpose of the study was to characterize the prevalence and impact of perioperative blood use for patients undergoing hepatic lobectomy at academic medical centers. METHODS: The University HealthSystem Consortium (UHC) database was queried for hepatic lobectomies performed between 2011 and 2014 (n = 6476). Patients were grouped according to transfusion requirements into high (>5 units, 7%), medium (2-5 units, 6%), low (1 unit, 8%), and none (0 units, 79%) during hospital stay for comparison of outcomes. RESULTS: Over 20% of patients undergoing hepatic lobectomy received blood perioperatively, of which 35% required more than 5 units. Patients with high transfusion requirements had increased severity of illness (p < 0.01). High transfusion requirements correlated with increased readmission rates (23.4% vs. 19.2% vs. 16.6% vs. 13.5%), total direct costs ($31,982 vs. $20,859 vs. $19,457 vs. $16,934), length of stay (9 days vs. 8 vs. 7 vs. 6), and in-hospital mortality (10.8% vs. 2.0% vs. 0.9% vs. 2.0%) compared to medium, low, and no transfusion amounts (all p < 0.01). Neither center nor surgeon volume were associated with transfusion use. CONCLUSION: High transfusion requirements after hepatic lobectomy in the United States are associated with worse perioperative quality measures, but may not be influenced by center or surgeon volume.
Assuntos
Centros Médicos Acadêmicos/estatística & dados numéricos , Transfusão de Sangue/estatística & dados numéricos , Hepatectomia/métodos , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/prevenção & controle , Sistema de Registros , Idoso , Bases de Dados Factuais , Feminino , Seguimentos , Mortalidade Hospitalar/tendências , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Medição de Risco , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Traditionally, intraductal papillary mucinous neoplasms (IPMNs) of the pancreas with "high risk stigmata" (HRS) or "worrisome features" (WF) are referred for resection. We aim to assess if IPMN location is predictive of harboring either high grade dysplasia (HGD) or invasive cancer (IC). METHODS: Patients undergoing resection for IPMN from seven institutions between 2000 and 2015 (n = 275) were analyzed. HRS and WF were defined by the 2012 Fukuoka international consensus guidelines. RESULTS: 168 (61%) patients had head/uncinate cysts, while 107 (39%) had neck/body/tail cysts. No differences were noted between groups with regard to age, duct type, cyst size, or presence of at least one WF. Patients with cysts in the head/uncinate were more often male (55% vs. 40%), had at least one HRS (24% vs. 11%), and more often harbored HGD or IC(49% vs. 27%)[all p < 0.05]. On multivariate analysis, only cyst location in the head/uncinate remained associated with presence of HGD or IC(odds ratio 4.76, p = 0.02). DISCUSSION: Cyst location is predictive of HGD or IC in patients with IPMNs. Head/uncinated cysts are more likely to harbor malignancy compared to those of the neck/body/tail. Additional studies are needed to confirm these findings, however, cyst location should be considered part of the decision making process for surveillance vs. resection for IPMNs.
Assuntos
Cistadenocarcinoma Mucinoso/patologia , Neoplasias Intraductais Pancreáticas/patologia , Neoplasias Pancreáticas/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Cistadenocarcinoma Mucinoso/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Invasividade Neoplásica , Neoplasias Intraductais Pancreáticas/cirurgia , Neoplasias Pancreáticas/cirurgia , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND: Single institution reports demonstrate variable safety profiles when liver-directed therapy with Yttrium-90 (Y-90) is followed by hepatectomy. We hypothesized that in well-selected patients, hepatectomy after Y90 is feasible and safe. METHODS: Nine institutions contributed data for patients undergoing Y90 followed by hepatectomy (2008-2017). Clinicopathologic and perioperative data were analyzed, with 90-day morbidity and mortality as primary endpoints. RESULTS: Forty-seven patients were included. Median age was 59 (20-75) and 62% were male. Malignancies treated included hepatocellular cancer (n = 14; 30%), colorectal cancer (n = 11; 23%), cholangiocarcinoma (n = 8; 17%), neuroendocrine (n = 8; 17%) and other tumors (n = 6). The distribution of Y-90 treatment was: right (n = 30; 64%), bilobar (n = 14; 30%), and left (n = 3; 6%). Median future liver remnant (FLR) following Y90 was 44% (30-78). Resections were primarily right (n = 16; 34%) and extended right (n = 14; 30%) hepatectomies. The median time to resection from Y90 was 196 days (13-947). The 90-day complication rate was 43% and mortality was 2%. Risk factors for Clavien-Dindo Grade>3 complications included: number of Y-90-treated lobes (OR 4.5; 95% CI1.14-17.7; p = 0.03), extent of surgery (p = 0.04) and operative time (p = 0.009). CONCLUSIONS: These data demonstrate that hepatectomy following Y-90 is safe in well-selected populations. This multi-disciplinary treatment paradigm should be more widely studied, and potentially adopted, for patients with inadequate FLR.
Assuntos
Hepatectomia , Neoplasias Hepáticas/radioterapia , Neoplasias Hepáticas/cirurgia , Radioisótopos de Ítrio/uso terapêutico , Adulto , Idoso , Terapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
OBJECTIVE: The relevance of margin positivity on recurrence after resection of intraductal papillary mucinous neoplasms (IPMNs) is poorly defined and represents one reason controversy remains regarding optimal surveillance recommendations. METHODS: Patients undergoing surgery for noninvasive IPMN at 8 academic medical centers from the Central Pancreas Consortium were analyzed. A positive margin was defined as presence of IPMN or pancreatic intraepithelial neoplasia. RESULTS: Five hundred two patients underwent surgery for IPMN; 330 (66%) did not have invasive cancer on final pathology and form the study cohort. Of these, 20% harbored high grade dysplasia. A positive margin was found in 20% of cases and was associated with multifocal disease (P = 0.02). The majority of positive margins were associated with low grade dysplasia. At a median follow-up of 36 months, 34 (10.3%) patients recurred, with 6.7% developing recurrent cystic disease and 3.6% developing invasive cancer. On multivariate analysis, margin positivity was not associated with recurrence of either IPMN or invasive cancer (P > 0.05). No association between margin status and development of recurrence at the margin was found. Only 6% of recurrences developed at the resection margin and median time to recurrence was 22 months. Of note, 18% of recurrences occurred > 5 years following surgery. CONCLUSION: Margin positivity after resection for noninvasive IPMNs is primarily due to low grade dysplasia and is not associated with developing recurrence in the remnant pancreas or at the resection margin. Long-term surveillance is required for all patients, as a significant number of recurrences developed over 5 years after the index operation.
Assuntos
Adenocarcinoma Mucinoso/patologia , Adenocarcinoma Mucinoso/cirurgia , Carcinoma Ductal Pancreático/patologia , Carcinoma Ductal Pancreático/cirurgia , Margens de Excisão , Recidiva Local de Neoplasia/patologia , Neoplasias Pancreáticas/patologia , Neoplasias Pancreáticas/cirurgia , Centros Médicos Acadêmicos , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Estudos Retrospectivos , Resultado do Tratamento , Estados UnidosRESUMO
BACKGROUND: Although national operative volumes have remained stable, surgical educators should appreciate the changing experience of today's surgical residents. We set out to evaluate operative volume trends at our institution and study the impact of resident learning styles on operative experience. MATERIALS AND METHODS: The Accreditation Council for Graduate Medical Education operative log data from 1999 to 2017 for a single general surgery residency program were examined. All residents completed the Kolb Learning Style Inventory. Statistical analyses were performed using linear regression analysis, Student's t-test, and Fischer's exact test. RESULTS: Over the study period, 106 general surgery residents graduated from our program. There were 87% action learners and 13% observation learners. Although there was no change in total major, total chief, or total non-chief cases, a decrease in teaching assistant cases was observed. Subcategory analysis revealed that there was an increase in operative volume on graduation in the following categories: skin, soft tissue, and breast; alimentary tract; abdomen; pancreas; operative trauma; pediatric; basic laparoscopy; complex laparoscopy; and endoscopy with a concurrent decrease in liver, vascular, and endocrine. Learning style analysis found that action learners completed significantly more cases than observation learners in most domains in which operative volume increased. CONCLUSIONS: While the operative volume at our center remained stable over the study period, the experience of general surgery residents has become narrowed toward a less subspecialized, general surgery experience. These shifts may disproportionally impact trainees as observation learners operate less than action learners. Residency programs should therefore incorporate methods such as learning style assessment to identify residents at risk of a suboptimal experience.
Assuntos
Educação de Pós-Graduação em Medicina/tendências , Cirurgia Geral/educação , Internato e Residência/tendências , Especialização/tendências , Carga de Trabalho/estatística & dados numéricos , Competência Clínica , Educação de Pós-Graduação em Medicina/estatística & dados numéricos , Feminino , Cirurgia Geral/estatística & dados numéricos , Cirurgia Geral/tendências , Humanos , Internato e Residência/estatística & dados numéricos , Masculino , Aprendizagem Baseada em Problemas/estatística & dados numéricos , Aprendizagem Baseada em Problemas/tendências , Especialização/estatística & dados numéricosRESUMO
BACKGROUND: We aimed to characterize variability in cost after straightforward orthotopic liver transplant (OLT). METHODS: Using the University HealthSystem Consortium and Scientific Registry of Transplant Recipients databases, we identified patients who underwent OLT between 2011 and 2014. Patients meeting criteria for straightforward OLT, defined as length of stay < 14 days with discharge to home, were selected (n = 5763) and grouped into tertiles (low, medium, high) according to cost of perioperative stay. RESULTS: Patients undergoing straightforward OLT were of similar demographics regardless of cost. High cost patients were more likely to require preoperative hemodialysis, had higher severity of illness, and higher model for end-stage liver disease (MELD) (p < 0.01). High cost patients required greater utilization of resources including lab tests, blood transfusions, and opioids (p < 0.01). Despite having higher burden of disease and requiring increased resource utilization, high cost OLT patients with a straightforward perioperative course were shown to have identical 2-year graft and overall survival compared to lower cost patients (p = 0.82 and p = 0.63), respectively. CONCLUSION: Providing adequate perioperative care for OLT patients with higher severity of illness and disease burden requires increased cost and resource utilization; however, doing so provides these patients with long term survival equivalent to more routine patients.
Assuntos
Doença Hepática Terminal/economia , Doença Hepática Terminal/cirurgia , Custos Hospitalares , Transplante de Fígado/economia , Avaliação de Processos e Resultados em Cuidados de Saúde/economia , Adolescente , Adulto , Idoso , Doença Hepática Terminal/diagnóstico , Feminino , Sobrevivência de Enxerto , Nível de Saúde , Humanos , Tempo de Internação/economia , Transplante de Fígado/efeitos adversos , Masculino , Pessoa de Meia-Idade , Alta do Paciente/economia , Cuidados Pós-Operatórios/economia , Diálise Renal/economia , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: Laparoscopic subtotal cholecystectomy (LSC) is considered a safe alternative to laparoscopic cholecystectomy (LC) if biliary anatomy is obscured by inflammation. While case series studies have observed low morbidity rates with LSC, the impact of operative conversion on patient outcomes is poorly understood. METHODS: A national analysis of all patients who underwent LC or LSC from 2009 to 2013 was performed using the University HealthSystem Consortium database. A 1:1 propensity score match was used to compare procedural outcomes accounting for clinical and demographic factors. Matched samples had <10% standardized differences of each baseline covariate. RESULTS: A total of 131,082 LC and 487 LSC were performed during the study period. Compared with LC, patients undergoing LSC were more likely to be older (56 versus 48 years), male (54.2% versus 32.3%), and have higher severity of illness scores on admission (9.2% versus 3.5% extreme severity of illness; P < 0.001 each). LSC patients had a prolonged hospital length of stay (LOS, 4 versus 3 days), greater total direct cost ($9053 versus $6398), higher readmission rates (11.9% versus 7.0%), and higher mortality rates (0.82% versus 0.28%, P < 0.05 each). After matching, the difference in total direct cost persisted ($9053 versus $7,581, P < 0.001), but there were no differences in hospital LOS, readmission rates, or overall mortality. CONCLUSIONS: LSC is an important alternative to LC for the difficult gallbladder. Conversion to LSC is associated with increased patient morbidity and resource utilization leading to perceived poor outcomes, but this is due to patient factors at initial presentation. Health care providers should consider LSC if the patient may be at risk for iatrogenic injury to the biliary tract.
Assuntos
Colecistectomia Laparoscópica/mortalidade , Adulto , Idoso , Colecistectomia Laparoscópica/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND: Although increased hospital volume has been correlated with improved outcomes in certain surgical procedures, the effect of center volume on pancreas transplantation (PT) is less understood. Our study aims to establish whether a volume-outcome effect exists for PT. METHODS: Through an established linkage between the University HealthSystem Consortium and the Scientific Registry of Transplant Recipients (SRTR) databases, we performed a retrospective cohort analysis of adult PT recipients between 2009 and 2012. Surgical volume was divided equally into low volume (LV), middle volume (MV), and high volume (HV) tertiles for each year that was studied. Hospital outcomes were measured through University HealthSystem Consortium, and long-term outcomes were measured through Scientific Registry of Transplant Recipients. Statistical analysis was performed using regression analyses and the Kaplan-Meier method. Median follow-up period was 2 y. RESULTS: Among the 2309 PT recipients included, 815 (35.3%) were performed at LV centers, 755 (32.7%) at MV centers, and 739 (32.0%) at HV centers. Compared with MV and LV centers, organs transplanted at HV centers were more frequently donation after cardiac death (5.1% versus 2.4% versus 3.3%, P = 0.01) and from older donors (2.8% [>50 y] versus 0.8% versus 0.1%, P < 0.001). In addition, HV recipients were older (31.5% [>50 y] versus 20.9% versus 19.7%, P < 0.001) and had worse functional status (39.5% dependent versus 9.7% versus 9.9%, P < 0.001). Patient and graft survival were similar across hospital volume tertiles. Center volume was not predictive of readmission rates, total length of stay, intensive care unit length of stay, or total direct cost on multivariate analysis (all P > 0.05). CONCLUSIONS: Short- and long-term outcomes after PT are not affected by hospital volume. Although LV centers confine their cases to low-risk patients, HV centers transplant a higher percentage of high-risk donor and recipient combinations with equivalent outcomes.
Assuntos
Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Transplante de Pâncreas , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Seguimentos , Sobrevivência de Enxerto , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Transplante de Pâncreas/mortalidade , Transplante de Pâncreas/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos , Adulto JovemRESUMO
BACKGROUND AND OBJECTIVES: In patients with borderline resectable pancreas cancers, clinicians frequently consider radiographic response as the primary driver of whether patients should be offered surgical intervention following neoadjuvant therapy (NT). We sought to determine any correlation between radiographic and pathologic response rates following NT. METHODS: Between 2005 and 2015, 38 patients at a tertiary care referral center underwent NT followed by pancreaticoduodenectomy for borderline resectable pancreas cancer. Radiographic response after the completion of NT and pathologic response after surgery were graded according to RECIST and Evans' criteria, respectively. RESULTS: Preoperatively, 50% of patients underwent chemotherapy alone and 50% underwent chemotherapy and chemoradiation. Radiographically, one patient demonstrated a complete radiologic response, 68.4% (n = 26) of patients had stable disease (SD), 26.3% (n = 10) demonstrated a partial response, and one patient had progressive. Among patients without radiographic response, 77.7% (n = 21) achieved a R0 resection. Of patients with SD on imaging, 26.9% (n = 7) had Evans grade IIB or greater pathologic response. CONCLUSIONS: Our data indicate that approximately one-fourth of patients who did not have a radiologic response had a grade IIB or greater pathologic response. In the absence of metastatic progression, lack of radiographic down-staging following NT should not preclude surgery.
Assuntos
Terapia Neoadjuvante , Neoplasias Pancreáticas/diagnóstico por imagem , Neoplasias Pancreáticas/patologia , Idoso , Albuminas/administração & dosagem , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Antígeno CA-19-9/sangue , Quimiorradioterapia Adjuvante , Quimioterapia Adjuvante , Desoxicitidina/administração & dosagem , Desoxicitidina/análogos & derivados , Cloridrato de Erlotinib/administração & dosagem , Feminino , Fluoruracila/uso terapêutico , Humanos , Leucovorina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Compostos Organoplatínicos/uso terapêutico , Paclitaxel/administração & dosagem , Neoplasias Pancreáticas/terapia , Pancreaticoduodenectomia , Estudos Retrospectivos , Centros de Atenção Terciária , GencitabinaRESUMO
BACKGROUND: Sequencing therapy for patients with periampullary malignancy is controversial. Clinical trial data report high rates of adjuvant therapy completion, though contemporary, real-world rates remain incomplete. We sought to identify patients who failed to receive adjuvant therapy and those at risk for early recurrence (ER) who might benefit most from neoadjuvant therapy (NT). METHODS: We retrospectively reviewed medical records of 201 patients who underwent pancreaticoduodenectomy for periampullary malignancies between 1999 and 2015; patients receiving NT were excluded. Univariate and multivariate analyses were performed to identify predictors of failure to receive adjuvant therapy and ER (within 6 months) as the primary end points. RESULTS: The median age at the time of surgery was 65.5 years (interquartile range 57-74 years). The majority of tumors were pancreatic ductal adenocarcinoma (76.6 %), and 71.6 % of patients received adjuvant therapy after resection. Univariate predictors of failure to undergo adjuvant therapy were advanced age, age-adjusted Charlson comorbidity index, operative transfusion, reoperation, length of stay, and 30- to 90-day readmissions (all p < 0.05). Advanced age, specifically among patients >70 years, persisted as a significant preoperative predictor on multivariate analysis (p < 0.01). Patients who failed to receive adjuvant therapy and/or developed ER had significantly worse overall survival rates compared to all other patients (27.8 vs. 9.7 months; p < 0.01). CONCLUSIONS: Approximately one-third of surgery-first patients undergoing pancreaticoduodenectomy at our institution did not receive adjuvant therapy and/or demonstrated ER. This substantial subset of patients may particularly benefit from NT, ensuring completion of multimodal therapy and/or avoiding futile surgical intervention.
Assuntos
Ampola Hepatopancreática , Carcinoma Ductal Pancreático/terapia , Terapia Combinada/estatística & dados numéricos , Neoplasias do Ducto Colédoco/terapia , Neoplasias Duodenais/terapia , Recidiva Local de Neoplasia/diagnóstico por imagem , Neoplasias Pancreáticas/terapia , Fatores Etários , Idoso , Carcinoma Ductal Pancreático/secundário , Neoplasias do Ducto Colédoco/patologia , Neoplasias Duodenais/patologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias Pancreáticas/patologia , Pancreaticoduodenectomia , Estudos Retrospectivos , Taxa de Sobrevida , Fatores de TempoRESUMO
OBJECTIVE: As the competitiveness of applicants for general surgery residency grows, it is becoming challenging for programs to differentiate qualified candidates with a genuine interest in matching at their institution. The purpose of this study was to examine geographic trends in the general surgery match in order to elicit regional biases and optimize applicant interview selection strategies. DESIGN: In this single-center retrospective study, geographical information regarding birth place, college, medical school, and final match institution for general surgery residency applicants was examined. SETTING: This study was set at the University of Cincinnati College of Medicine. PARTICIPANTS: All general surgery residency applicants interviewing at our institution between 2015-2017 were included. METHODS: Academic variables and geographical information were collected for all applicants in the cohort. Statistical analyses were performed using chi-square and logistic regression techniques to determine any association between geography and match outcomes. RESULTS: Of 198 applicants included in the analysis, approximately 25% matched at an institution located in the same state as their medical school. Total 75% of applicants matched at a residency program located less than 640 miles away from either their birth place, college, or medical school, while only 15% matched at an institution located over 1000 miles away and 4% matched over 2000 miles away. When examining applicant characteristics, there were no significant differences in gender, clerkship grade, United States Medical Licensing Exam scores, Alpha Omega Alpha Honor Society membership, or quality of recommendation letters between applicants who matched in the lowest and highest quartiles of distance to final residency program location. CONCLUSIONS: A significant proportion of general surgery applicants matched at institutions located in a region near either their birth place, college, or medical school. Given the limited number of interviews able to be offered by institutions and the associated opportunity costs, general surgery programs should consider regional biases when evaluating residency applicants.
Assuntos
Cirurgia Geral , Internato e Residência , Viés , Escolaridade , Cirurgia Geral/educação , Geografia , Humanos , Estudos Retrospectivos , Estados UnidosRESUMO
BACKGROUND: Thrombelastography has become increasingly used in liver transplantation. The implications of thrombelastography at various stages of liver transplantation, however, remain poorly understood. Our goal was to examine thrombelastography-based coagulopathy profiles in liver transplantation and determine whether preoperative thrombelastography is predictive of transfusion requirements perioperatively. METHODS: A retrospective review of 364 liver transplantations from January 2013 to May 2017 at a single institution was performed. Patients were categorized as hypocoagulable or nonhypocoagulable based on their preoperative thrombelastography profile. The primary outcome was intraoperative transfusion requirements. RESULTS: Of patients undergoing liver transplantation, 47% (nâ¯=â¯170) were hypocoagulable and 53% (nâ¯=â¯194) were nonhypocoagulable preoperatively. Hypocoagulable patients had higher transfusion requirements compared to nonhypocoagulable patients, requiring more units of packed red blood cells (7 vs 4, Pâ¯<â¯.01), fresh frozen plasma (14 vs 8, Pâ¯<â¯.01), cryoprecipitate (2 vs 1, Pâ¯<â¯.01), platelets (3 vs 2, Pâ¯<â¯.01), and cell saver (3 vs 2 L, Pâ¯<â¯.01). Additionally, these patients were more likely to receive platelets and cryoprecipitate in the first 24â¯hours following liver transplantation (both Pâ¯<â¯.05). No differences were found between rates of intensive care unit length of stay, 30-day readmission, or mortality. CONCLUSION: Coagulation abnormalities are common among liver transplantation patients and can be identified using thrombelastography. Identification of a patient's coagulation state preoperatively aids in guiding transfusion during liver transplantation. This work serves to better direct clinicians during major surgery to improve perioperative resource utilization. Future prospective work should aim to identify specific thrombelastography values that may predict transfusion requirements.
RESUMO
BACKGROUND: Preoperative narcotic use impacts hospital cost and outcomes in surgical patients, but the underlying reasons are unclear. METHODS: A single-center retrospective analysis was performed on surgical patients admitted with intestinal obstruction (2010-2014). Patients were grouped into active opioid and nonopioid user cohorts. Active opioid use was defined as having an opioid prescription overlapping the date of admission. Chronic opioid use was defined by duration of use ≥ 90â¯days. Admission or intervention due to opioid-related illness was determined through consensus decision of 2 independent, blinded clinicians. Primary end point was the effect of active opioid use on hospital resource utilization. RESULTS: During the study period, 296 patients were admitted with a primary diagnosis of intestinal obstruction. Active opioid users accounted for 55 (18.6%) of these patients, with a median length of opioid use of 164â¯days (interquartile range 54-344â¯days). Average length of use was 164â¯days, with the majority of active users (nâ¯=â¯42, 76.4%) meeting criteria for chronic use. A subgroup analysis of active users demonstrated that opioid-related conditions were responsible for 10 admissions (18.2%) and 2 readmissions (3.6%). Among active users requiring surgical intervention, 3 procedures (21.4%) were due to opioid-related illnesses. Median hospital length of stay was 2 days longer (8 vs 6â¯days) and hospital costs were greater ($12,241 vs $8489) among active users (Pâ¯<â¯.05 each). CONCLUSION: Active opioid users are predisposed to avoidable admissions and interventions for opioid-related illnesses. Efforts to address opioid use in the surgical population may improve patient outcomes and health care spending.
RESUMO
BACKGROUND: Traditional piggyback implantation has often been used in liver transplant; however, this technique may be hindered by difficult visualization and postoperative incidences of outflow obstruction. Side-to-side cavocavostomy is an alternative approach, but perioperative outcomes associated with this technique remain largely unknown. METHODS: In July 2017, side-to-side cavocavostomy was adopted as the standard implantation technique at our institution by all surgeons (n = 4). A prospective cohort of patients undergoing liver transplant with side-to-side cavocavostomy after July 2017 until October 2018 was compared with a historical cohort of patients who underwent liver transplant with traditional piggyback previously from January 2016 to October 2018. RESULTS: Of 290 liver transplant patients, 50% (n = 145) underwent side-to-side cavocavostomy, while the remainder underwent traditional piggyback. There were no differences in recipient age, sex, race, Model for End-Stage Liver Disease score, or donor characteristics between groups. Side-to-side cavocavostomy was associated with decreased mean number intraoperative, red blood cell transfusions (2 vs 5 units), fresh frozen plasma (5 vs 10 units), cell saver (1.0 vs 2.0 L), and rates of temporary abdominal closure (8.3% vs 24.1%) compared with traditional piggyback (all P < .05). The side-to-side cavocavostomy group had lesser Rt3s of postoperative transfusion rates of red blood cells (21.4% vs 35.9%; P = .01). CONCLUSION: Side-to-side cavocavostomy may be superior to traditional piggyback implantation with regard to technical ease and perioperative transfusion requirements. To determine the optimal implantation technique, futures studies should evaluate side-to-side cavocavostomy versus traditional piggyback in a prospective, multicenter, randomized approach.
Assuntos
Transfusão de Sangue/estatística & dados numéricos , Doença Hepática Terminal/cirurgia , Transplante de Fígado/métodos , Fígado/cirurgia , Veia Cava Inferior/cirurgia , Idoso , Anastomose Cirúrgica/efeitos adversos , Anastomose Cirúrgica/métodos , Perda Sanguínea Cirúrgica/prevenção & controle , Feminino , Humanos , Fígado/irrigação sanguínea , Transplante de Fígado/efeitos adversos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estudos Retrospectivos , Índice de Gravidade de Doença , Resultado do TratamentoRESUMO
BACKGROUND: Selection of patients for hyperthermic intraperitoneal chemotherapy (HIPEC) continues to evolve. We hypothesized that adjuvant HIPEC for patients at high-risk of peritoneal progression is safe and associated with favorable outcomes. METHODS: The institutional database of a high-volume center was queried for patients with high-risk disease undergoing HIPEC with a peritoneal carcinomatosis index (PCI) of 0. High-risk patients were defined as those with ruptured primary tumors or locally advanced (T4) disease. RESULTS: 37 patients underwent adjuvant HIPEC, with a median follow-up of 5.2 years. 54% had low-grade (LG) tumors while 46% had high-grade (HG) tumors. No patients underwent neoadjuvant chemotherapy, while eleven patients (32.4%) received adjuvant chemotherapy. There were no perioperative mortalities, and the overall complication rate was 43%. For the entire cohort, five year recurrence-free survival (RFS) and overall survival (OS) were 77% and 100%, respectively. Five year RFS and OS were 75% and 100% for LG patients and 81% and 100% for HG patients, respectively. CONCLUSIONS: Adjuvant HIPEC for patients at high-risk of peritoneal progression, with PCI 0, is safe and associated with favorable long-term survival. Additional prospective investigation is needed to identify patient populations who may benefit most from HIPEC.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Quimioterapia do Câncer por Perfusão Regional/mortalidade , Procedimentos Cirúrgicos de Citorredução/mortalidade , Hipertermia Induzida/mortalidade , Recidiva Local de Neoplasia/terapia , Neoplasias/terapia , Neoplasias Peritoneais/terapia , Adulto , Idoso , Quimioterapia Adjuvante , Terapia Combinada , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/patologia , Neoplasias/patologia , Neoplasias Peritoneais/secundário , Prognóstico , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
BACKGROUND: Patients undergoing complex surgery at safety net hospitals have been shown to suffer inferior short-term outcomes. Liver transplantation, one of the most complex surgical interventions, is offered at certain safety net hospitals. We sought to identify whether patients undergoing liver transplantation at safety net hospitals have inferior outcomes compared with lower burden centers. METHODS: Using a link between the University HealthSystem Consortium and Scientific Registry of Transplant Recipient databases, we identified 11,047 patients undergoing liver transplantation at 63 centers between 2009 and 2012. Hospitals were grouped by safety net burden, defined as the proportion of Medicaid or uninsured patient encounters during that time. The highest quartile (safety net hospitals) was compared to medium- and low-burden hospitals regarding recipient and donor characteristics, perioperative outcomes, and long-term survival. RESULTS: Liver transplantation recipients at safety net hospitals were more often black and of lower socioeconomic status (P < .01), but had similar model for end-stage liver disease scores (20 vs 20 vs 18) compared with median-burden hospitals and low burden hospitals. Length of stay and readmission rates were similar; however, safety net hospitals demonstrated higher in-hospital mortality (5.2% vs 4.5% vs 2.9%, P < .01). Despite this, there was no significant difference in overall patient or graft survivals in patients who underwent liver transplantation at safety net hospitals and survived the perioperative setting at a median follow-up of 2 years (P > .05). CONCLUSION: Despite differences in perioperative outcomes at safety net hospitals, these centers achieve noninferior long-term patient and graft survival for potentially vulnerable patients requiring liver transplantation. Strict care standardization, as achieved in liver transplantation, may be a mechanism by which outcomes can be improved at safety net hospitals after other complex surgical procedures.
Assuntos
Doença Hepática Terminal/cirurgia , Sobrevivência de Enxerto , Hospitais/estatística & dados numéricos , Transplante de Fígado/efeitos adversos , Provedores de Redes de Segurança/estatística & dados numéricos , Adolescente , Adulto , Negro ou Afro-Americano/estatística & dados numéricos , Idoso , Doença Hepática Terminal/diagnóstico , Doença Hepática Terminal/mortalidade , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Transplante de Fígado/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Estudos Retrospectivos , Índice de Gravidade de Doença , Classe Social , Resultado do Tratamento , Estados Unidos/epidemiologia , Populações Vulneráveis/estatística & dados numéricos , Adulto JovemRESUMO
INTRODUCTION: Safety-net hospitals provide care to an inherently underprivileged patient population. These hospitals have previously been shown to have inferior surgical outcomes after complex, elective procedures, but little is known about how hospital payer-mix correlates with outcomes after more common, emergent operations. METHODS: The University HealthSystem Consortium database was queried for all emergency general surgery procedures performed from 2009 to 2015. Emergency general surgery was defined as the seven operative procedures recently identified as contributing most to the national burden. Only urgent and emergent admissions were included (n = 653,305). Procedure-specific cohorts were created and hospitals were grouped according to safety-net burden. Multivariate analyses were done to study the effect of safety-net burden on hospital outcomes. RESULTS: For all seven emergency procedures, patients at hospitals with a high safety-net burden were more likely to be young and black (p < 0.01 each). Patients at high-burden hospitals had similar severity of illness scores to those at other hospitals. Compared with lower burden hospitals, in-hospital mortality rates at high-burden hospitals were similar or lower in five of seven procedures (p = NS or < 0.01, respectively). After adjusting for patient factors, high-burden hospitals had similar or lower odds of readmission in six of seven procedures, hospital length of stay in four of seven procedures, and cost of care in three of seven procedures (p = NS or < 0.01, respectively). CONCLUSION: Safety-net hospitals provide emergency general surgery services without compromising patient outcomes or incurring greater healthcare resources. These data may help inform the vital role these institutions play in the healthcare of vulnerable patients in the USA.
Assuntos
Hospitais/estatística & dados numéricos , Provedores de Redes de Segurança/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Adulto , Custos e Análise de Custo/estatística & dados numéricos , Bases de Dados Factuais/estatística & dados numéricos , Emergências/economia , Emergências/epidemiologia , Feminino , Cirurgia Geral/economia , Cirurgia Geral/estatística & dados numéricos , Mortalidade Hospitalar , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Seguro Saúde/economia , Seguro Saúde/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Ohio/epidemiologia , Provedores de Redes de Segurança/economia , Procedimentos Cirúrgicos Operatórios/economiaRESUMO
BACKGROUND: Variability in blood use after pancreaticoduodenectomy and the associated impact on readmission, mortality, and cost is not well understood at the national level. METHODS: The University HealthSystem Consortium database was queried for all pancreaticoduodenectomies performed between the years 2011-2013 (nâ¯=â¯9,582). Patients were grouped according to transfusion requirements into none (0 units, 64%), low (1-2 units, 15%), medium (3-5 units, 13%), and high (>5 units, 8%). Multivariable analyses were used to determine predictors of increased transfusions, readmission, in-hospital mortality, and cost. RESULTS: Of the patients undergoing pancreaticoduodenectomy, 36% received blood perioperatively. Patients with high transfusion requirements were less often white, more often male, and had a higher severity of illness (all P < .01). High transfusion requirements correlated with higher readmission rates (OR 1.23, Pâ¯=â¯.03), cost (RR 1.84, P < .01), length of stay (18 vs. 13 vs. 10 vs. 8 days, P < .01), and in-hospital mortality (12.5% vs. 3.1% vs. 0.5% vs. 0.4%, P < .01). Higher-volume surgeons demonstrated lower transfusion requirements (OR 0.61, P < .01). CONCLUSION: Significant variability exists nationally in transfusion practices for patients undergoing pancreaticoduodenectomy, which may be driven most by severity of illness and surgeon volume. Efforts to reduce such variability could lead to improved outcomes and healthcare cost savings.