Evaluation of Medicare Reimbursement and Surgical Patterns for Male and Female Colorectal Surgeons.

INTRODUCTION: There are documented differences in salary for male and female surgeons. Understanding the differences in the clinical practice, composition of male and female surgeons may provide a better understanding of reimbursement differences. We aim to evaluate the differences of Medicare reimbursement for different categories of clinical practice for male and female colorectal surgeons. METHODS: This retrospective cohort study compared Medicare claims made by male and female board-certified colorectal surgeons from the Medicare Provider Utilization and Payment Data between 2013 and 2017. Medicare claims were categorized by surgeon gender. Submitted claims were evaluated based on the following seven procedure categories: open abdominal surgery, laparoscopic abdominal surgery, anorectal surgery, diagnostic endoscopy, therapeutic endoscopy, and inpatient/outpatient services. The main outcomes were number of charges submitted by clinical activity category and procedural code variation billed through Medicare. Secondary outcome was category of procedure activity that each surgeon cohort had participated in. RESULTS: A total of 62,866 claims were reviewed, of which 10,058 (16.0%) were made by female surgeons and 52,808 (84.0%) were made by male surgeons. On average, male surgeons submitted more claims per year, a greater variety of claims per year, and higher revenue generating claims than female surgeons (P < 0.001). CONCLUSIONS: Male and female colorectal surgeons may participate in different categories of clinical activities that result in male surgeons performing more and higher relative value units-generating activity than female surgeons.

Gender Differences in Authorship Among Transplant Physicians: Are We Bridging the Gap?

BACKGROUND: Despite an increase in the number of practicing female physicians, gender disparities in academic medicine persist. For investigating gender gap in the transplantation field, this study examined the relationship between gender and authorship among medical and surgical transplant physicians. MATERIALS AND METHODS: In this observational study, all original clinical science articles published in the journals of Transplantation, American Journal of Transplantation, and Clinical Transplantation were reviewed from January 2008 to December 2017. Chi-square analysis was used to compare the proportions of female and male authors, and the Cochrane-Armitage test was used for comparisons over time. RESULTS: A total of 2530 publications and 2988 individual authors met the inclusion criteria for the study. Male physicians published significantly more articles compared to female physicians as first (67.4% versus 30.4%) and senior authors (82.9% versus 16.2%), respectively. There were increases in the proportion of female first and senior authors between 2008 and 2017. The majority of authors with multiple publications were male (73.6%), specifically male medical physicians (44.3%). Male medical physicians were the most productive in publication amount and authorship positions. CONCLUSIONS: While research activity among female physicians increased over time, gender disparity continues to exist among female and male physicians in the transplantation field. Academic activity is lower among females in publication amount and authorship positions. These trends emphasize the need to identify barriers to female physician academic productivity within the transplantation field.

Public health service increased risk donor kidney grafts for transplant into children, a survey of pediatric nephrologists.

BACKGROUND: Kidney transplant is the best treatment for end-stage renal disease (ESRD); however, access is limited by severe organ shortage. Public Health Service increased risk donors (PHS-IRD) represent a significant portion of available organs which are discarded at disproportional rates. METHODS: Pediatric nephrologists were surveyed regarding PHS-IRD kidneys to understand attitudes and perceived barriers to the use of these grafts in children. We sought to elucidate what methods may help increase the likelihood of PHS-IRD acceptance. RESULTS: Twenty-two responses were received from United States pediatric nephrologists representing 11 UNOS regions (response rate 5.9%). Of respondents, 50% had been practicing for 20+ years, 77% in academic hospitals, and 63% in cities with over 1 000 000 people. All respondents worked in an institution with a kidney transplant program. 41% reported that they would not accept PHS-IRD kidneys under any circumstance, 45% would accept depending on the candidate's medical status, and 14% routinely accepted PHS-IRD kidneys. Infectious transmission was the biggest disincentive reported (59%), with only 55% of respondents feeling comfortable counseling families on the associated risks. 82% of respondents did not perceive all PHS-IRD as the same, and 90% supported stratifying PHS-IRD into tiers based on risk, which would increase the likelihood of organ acceptance (82%) and assist in counseling families (91%). CONCLUSIONS: With improved utilization, PHS-IRD kidneys offer a step toward decreasing the organ shortage. These findings suggest hesitance in use of PHS-IRD kidneys for pediatric recipients. Further stratification of risk could aid in provider organ acceptance and counseling patients.

Incidence of Intra-Abdominal Hypertension and Abdominal Compartment Syndrome: A Systematic Review.

OBJECTIVE: To determine the contemporary prevalence of intra-abdominal hypertension (IAH) and abdominal compartment syndrome in critically ill patients. DATA SOURCES: Medline, Embase, and Central databases. STUDY SELECTION: Studies reporting on the prevalence of IAH in consecutively admitted critically ill patients using the World Society of Abdominal Compartment Syndrome (WSACS) consensus guidelines for intra-abdominal pressure (IAP) measurement. DATA EXTRACTION: Duplicate independent review and data abstraction. DATA SYNTHESIS: The search identified 2428 titles with 6 eligible studies (n = 1965). Reported prevalence ranged from 30% to 49%. Despite abiding by the WSACS guidelines for IAP measurement, studies varied in their definition of IAH, frequency and duration of IAP measurement, and reporting of outcomes. Three of 6 studies reported that IAH, especially at higher grades, was an independent predictor of mortality. CONCLUSIONS: Intra-abdominal hypertension is a common finding in critically ill patients and may be associated with increased mortality, especially at higher grades. Further prospective research is required to examine the effect of screening and treatment of IAH on patient outcomes.

Gender differences in authorship among Hepato-pancreatico-biliary surgeons.

BACKGROUND: While studies have explored the gender gap in scientific publications, no study has investigated surgical literature in much detail. We examined the gender gap in Hepato-pancreato-biliary publications over the last decade. METHODS: All physician authored original clinical science articles published in HPB, Annals of Surgery, Surgery, Annals of Surgical Oncology, and JAMA Surgery were reviewed from 2008 to 2017. Chi square analysis was used to compare the proportions of female and male authors and Cochrane-Armitage test was used for comparisons over time. RESULTS: Of the 1067 publications, 84.0% of all authorships were held by men. Women physicians made up 10.3% of senior and 21.4% of first authorships with increased representation from 2.13% in 2007 to 14.8% in 2017 (p = 0.001). Women physicians comprised 14.1% of senior authors in JAMA Surgery, but only 2.46% in Annals of Surgical Oncology. Male authors were five times more likely to publish multiple articles compared to their female counterparts. Female first authors progressed to senior authors at a rate of 1.13% versus 5.73% for male authors (p = 0.89). CONCLUSION: These findings elucidate the continued underrepresentation of women in senior research roles and the need to recruit and mentor women in all stages of their academic careers.

Venous thromboembolism in emergency general surgery patients: a single-centre retrospective cohort study

Background: There is limited literature on the risk of venous thromboembolism (VTE) in emergency general surgery (EGS) patients. We undertook this study to identify the rate of symptomatic VTE for patients undergoing EGS operations. Methods: We conducted a retrospective cohort study evaluating EGS patients who underwent operative intervention between March and December 2014. Data collected included patient demographics, type of procedure, risk of VTE, VTE prophylaxis, development of symptomatic VTE, and mortality. Results: We included 767 patients in our analysis. The mean age was 53 ± 19.7 years, and 52.2% of patients were female. Eighteen patients (2.3%) experienced VTE in hospital and 12 (1.6%) experienced VTE after discharge. Only 66% of patients received appropriate VTE prophylaxis. High-risk patients had a higher VTE rate (7.4% v. 2.3%, p < 0.001) and higher mortality (17.6% v. 4.0%, p < 0.001) than lowto moderate-risk patients. Conclusion: The risk of VTE in patients requiring EGS is significant and persists after hospital discharge. Further studies on quality improvement with VTE prophylaxis are warranted.

Contexte: La littérature sur le risque de thromboembolie veineuse (TEV) chez les patients soumis à une chirurgie générale urgente est limitée. Nous avons entrepris cette étude afin de mesurer le taux de TEV symptomatique chez les patients ayant subi une intervention urgente en chirurgie générale. Méthodes: Nous avons procédé à une étude de cohorte rétrospective sur les patients qui ont subi une chirurgie générale urgente entre mars et décembre 2014. Parmi les données recueillies, mentionnons données démographiques, type d'intervention, risque de TEV, thromboprophylaxie, apparition d'une TEV symptomatique et mortalité. Résultats: Nous avons inclus 767 patients dans notre analyse. L'âge moyen était de 53 ± 19,7 ans et 52,2 % des patients étaient de sexe féminin. Dix-huit patients (2,3 %) ont présenté une TEV en cours d'hospitalisation et 12 (1,6 %) après leur congé. Seulement 66 % des patients ont reçu une thromboprophylaxie adéquate. Les patients à haut risque ont présenté des taux de TEV (7,4 % c. 2,3 %, p < 0,001) et de mortalité (17,6 % c. 4,0 %, p < 0,001) plus élevés que les patients présentant un risque faible à modéré. Conclusion: Le risque de TEV chez les patients soumis à une chirurgie générale urgente est significatif et persiste après le congé hospitalier. Il faudra mener des études plus approfondies sur l'amélioration de la qualité de la thromboprophylaxie.

Risk factors for survival following recurrence after first liver resection for colorectal cancer liver metastases.

BACKGROUND: Management of recurrence following liver resection for colorectal cancer metastases is a topic of debate. We determined risk factors for survival following recurrence after liver resection. METHODS: Long-term follow-up of patients in the PETCAM trial who had recurrence following liver resection. Risk groups were created according to their survival risk. Differences in overall survival (OS) between groups were estimated. Disease-free survival (DFS), patterns of disease recurrence and management were determined. Cox proportional hazard models, Kaplan-Meier method, and the log-rank test were used. RESULTS: Among 368 patients who underwent liver resection, 264 (72%) experienced disease recurrence (51% lung and 41% liver). Following liver resection, DFS: 17 months (95% CI, 14-19); OS: 57 months (95% CI, 46-70). In those who recurred, 120 (45%) received chemotherapy only, and 112 (42%) underwent second surgical resection. Among patients who experienced recurrence (n = 264), the high-risk group (more than one site of recurrence or disease-free duration < 5 months and node-positive disease) had median OS: 19 months (95% CI, 15-23) vs 36 months (95% CI, 30-48) for patients in the low-risk group (HR = 2.9, 95% CI, 2.2-3.9). CONCLUSION: Recurrence following liver resection is common. Following recurrence after liver resection, patients should be carefully selected for surgical re-resection based on risk factors.

Can we reduce ischemic cholangiopathy rates in donation after cardiac death liver transplantation after 10 years of practice? Canadian single-centre experience

Background: Outcomes in liver transplantation with organs obtained via donation after cardiocirculatory death (DCD) have been suboptimal compared to donation after brain death, attributed mainly to the high incidence of ischemic cholangiopathy (IC). We evaluated the effect of a 10-year learning curve on IC rates among DCD liver graft recipients at a single centre. Methods: We analyzed all DCD liver transplantation procedures from July 2006 to July 2016. Patients were grouped into early (July 2006 to June 2011) and late (July 2011 to July 2016) eras. Those with less than 6 months of follow-up were excluded. Primary outcomes were IC incidence and IC-free survival rate. Results: Among the 73 DCD liver transplantation procedures performed, 70 recipients fulfilled the selection criteria, 32 in the early era and 38 in the late era. Biliary complications were diagnosed in 19 recipients (27%). Ischemic cholangiopathy was observed in 8 patients (25%) in the early era and 1 patient (3%) in the late era (p = 0.005). The IC-free survival rate was higher in the late era than the early era (98% v. 79%, p = 0.01). The warm ischemia time (27 v. 24 min, p = 0.049) and functional warm ischemia time (21 v. 17 min, p = 0.002) were significantly lower in the late era than the early era. Conclusion: We found a significant reduction in IC rates and improvement in ICfree survival among DCD liver transplantation recipients after a learning curve period that was marked by more judicious donor selection with shorter procurement times.

Contexte: L'issue des greffes de foie suite à un don d'organe après décès cardiocirculatoire (DDC) a été sous-optimale comparativement aux dons suivant la mort cérébrale. Cela serait surtout attribuable à une forte incidence de cholangiopathie ischémique (CI). Nous avons évalué l'effet d'une courbe d'apprentissage échelonnée sur 10 ans sur les taux de CI chez des receveurs de greffe de foie après DDC dans un seul centre. Méthodes: Nous avons analysé toutes les greffes de foie consécutives à des DDC entre juillet 2006 et juillet 2016. Les patients ont été regroupés en 2 époques, la première, de juillet 2006 à juin 2011, et la seconde, de juillet 2011 à juillet 2016. Ceux pour lesquels on disposait de moins de 6 mois de suivi ont été exclus. Les paramètres principaux étaient l'incidence de CI et le taux de survie sans CI. Résultats: Parmi les 73 greffes de foie par suite de DDC, 70 receveurs répondaient aux critères de sélection, 32 pour la première époque et 38 pour la seconde époque. Des complications biliaires ont été diagnostiquées chez 19 receveurs (27 %). La cholangiopathie ischémique a été observée chez 8 patients (25 %) de la première époque et 1 patient (3 %) de la seconde (p = 0,005). Le taux de survie sans CI a été plus élevé pendant la seconde époque que pendant la première (98 % c. 79 %, p = 0,01). Le temps d'ischémie chaude (27 minutes c. 24, p = 0,049) et le temps d'ischémie chaude fonctionnelle (21 minutes c. 17, p = 0,002) ont été significativement plus courts durant la seconde époque que durant la première. Conclusion: Nous avons observé une réduction significative des taux de CI et une amélioration de la survie sans CI chez les receveurs de greffes de foie par DDC après une courbe d'apprentissage qui a été marquée par une sélection plus judicieuse des donneurs et des délais d'obtention plus courts.

Intra-Abdominal Hypertension Is More Common Than Previously Thought: A Prospective Study in a Mixed Medical-Surgical ICU.

OBJECTIVES: To determine the prevalence of intra-abdominal hypertension in mixed medical-surgical critically ill patients using modern definitions and measurement techniques. Secondarily to determine variables associated with intra-abdominal hypertension and ICU mortality. DESIGN: A prospective observational study. SETTING: Single institution trauma, medical and surgical ICU in Canada. PATIENTS: Consecutive adult patients admitted to the ICU (n = 285). INTERVENTION: Intra-abdominal pressure measurements twice a day during admission to the ICU. MEASUREMENTS AND MAIN RESULTS: In 285 patients who met inclusion criteria, 30% were diagnosed with intra-abdominal hypertension at admission and a further 15% developed intra-abdominal hypertension during admission. The prevalence of abdominal compartment syndrome was 3%. Obesity, sepsis, mechanical ventilation, and 24-hour fluid balance (> 3 L) were all independent predictors for intra-abdominal hypertension. Intra-abdominal hypertension occurred in 28% of nonventilated patients. Admission type (medical vs surgical vs trauma) was not a significant predictor of intra-abdominal hypertension. Overall ICU mortality was 20% and was significantly higher for patients with intra-abdominal hypertension (30%) compared with patients without intra-abdominal hypertension (11%). Intra-abdominal hypertension of any grade was an independent predictor of mortality (odds ratio, 3.33; 95% CI, 1.46-7.57). CONCLUSIONS: Intra-abdominal hypertension is common in both surgical and nonsurgical patients in the intensive care setting and was found to be independently associated with mortality. Despite prior reports to the contrary, intra-abdominal hypertension develops in nonventilated patients and in patients who do not have intra-abdominal hypertension at admission. Intra-abdominal pressure monitoring is inexpensive, provides valuable clinical information, and there may be a role for its routine measurement in the ICU. Future work should evaluate the impact of early interventions for patients with intra-abdominal hypertension.

Changing donor characteristics in liver transplantation over the last 10 years in Canada.

Liver donor characteristics have a significant impact on graft quality and, in turn, recipient outcomes. In this study, we examined deceased liver donor characteristics and donor risk index (DRI) trends in Canada over the past decade. Data were extracted from the Canadian Organ Replacement Register and Transplant Québec for the decade (2000-2010). Trends in the DRI and donor characteristics, including age, race, height, cause of death (COD), location, cold ischemia time (CIT), and type of donation, were examined. In all, 3746 transplants using deceased liver donors were analyzed. The age of donors, the proportion of black donors, the proportion of cerebrovascular accidents as the COD, and the proportion of donation after cardiac death (DCD) donors all increased over the aforementioned time period. The proportion of transplants classified geographically as local increased, and the CIT for donor livers decreased. Although many of the parameters adversely affecting the DRI increased over the study period, the DRI showed only a slightly significant trend of increasing. The increase in these parameters was counteracted by a decrease in modifiable risk factors such as the CIT and distance traveled. The 5-year recipient survival rate increased from 71.43% (1999-2001) to 75.50% (2005-2007); however, this trend was not significant. Although there was an increase in the use of older and DCD organs, recipient survival was not compromised. In conclusion, demographic trends for liver donors in Canada suggest an increase in the use of higher risk donors. However, the overall graft quality has been not compromised because of a decreasing trend for the CIT and an increase in local transplants. Better coordination and allocation practices in liver transplantation across Canada have minimized the risk of graft failure and resulted in good recipient outcomes.

Transverse Colonic Perforation in Renal Transplant Recipients During the Early Postoperative Period: A Case Series.

There are very few cases of nondiverticulitis episodes of colonic perforation in the acute postoperative period following kidney transplantation described in the literature. Various nondiverticular causes of colonic perforations include ischemia, malignancy, cytomegalovirus (CMV) enterocolitis, and nonobstructive colonic dilatation. Immunosuppressive medication can contribute to colonic perforation, placing kidney recipients at risk for these complications. Since 2011, there have been 2 cases of transverse colonic perforation in the early postoperative period following renal transplantation at our institution. Both patients underwent urgent exploratory laparotomy with resection of perforated transverse colon and creation of a proximal colostomy. The aim of this study is to review the cases of colonic perforation following renal transplantation to gain a greater understanding of this rare occurrence. Despite the lack of a clear cause of perforation, it is imperative to have a high index of suspicion for colonic perforations in these immunocompromised patients to provide prompt surgical management and improved outcomes.

A comparison of survival and pathologic features of non-alcoholic steatohepatitis and hepatitis C virus patients with hepatocellular carcinoma.

AIM: To compare the clinical outcome and pathologic features of non-alcoholic steatohepatitis (NASH) patients with hepatocellular carcinoma (HCC) and hepatitic C virus (HCV) patients with HCC (another group in which HCC is commonly seen) undergoing liver transplantation. METHODS: Patients transplanted for HCV and NASH at our institution from January 2000 to April 2011 were analyzed. All explanted liver histology and pre-transplant liver biopsies were examined by two specialist liver histopathologists. Patient demographics, disease free survival, explant liver characteristics and HCC features (tumour number, cumulative tumour size, vascular invasion and differentiation) were compared between HCV and NASH liver transplant recipients. RESULTS: A total of 102 patients with NASH and 283 patients with HCV were transplanted. The incidence of HCC in NASH transplant recipients was 16.7% (17/102). The incidence of HCC in HCV transplant recipients was 22.6% (64/283). Patients with NASH-HCC were statistically older than HCV-HCC patients (P < 0.001). A significantly higher proportion of HCV-HCC patients had vascular invasion (23.4% vs 6.4%, P = 0.002) and poorly differentiated HCC (4.7% vs 0%, P < 0.001) compared to the NASH-HCC group. A trend of poorer recurrence free survival at 5 years was seen in HCV-HCC patients compared to NASH-HCC who underwent a Liver transplantation (P = 0.11). CONCLUSION: Patients transplanted for NASH-HCC appear to have less aggressive tumour features compared to those with HCV-HCC, which likely in part accounts for their improved recurrence free survival.