Are Kids More Than Just Little Adults? A Comparison of Surgical Outcomes.

INTRODUCTION: While complication rates have been well described using the National Surgical Quality Improvement Program (NSQIP) and National Surgical Quality Improvement Program-Pediatric registries, there have been no direct comparisons of outcomes between adults and children. Our objective was to describe differences in postoperative outcomes between children and adults undergoing common surgical procedures. METHODS: Using data from 2013 to 2017, we identified patients undergoing laparoscopic appendectomy, laparoscopic cholecystectomy, thyroidectomy, and colectomy. Propensity score matching on gender, race, American Society of Anesthesiologists class, surgical indication, and procedure type was performed. Outcomes included surgical site infection (SSI), readmission rates, mortality/serious morbidity, and hospital length of stay and were analyzed using χ2 and student's t-test with statistical significance defined as P < 0.05. RESULTS: We matched 79,866 patients from 812 hospitals. Compared to adults, children had higher rates of SSI following appendectomy (4.12% versus 1.40%, P < 0.01) and cholecystectomy (0.96% versus 0.66%, P = 0.04), readmission following appendectomy (4.26% versus 2.47%, P < 0.01), and longer length of stay in all procedures. In adults, 30-day mortality/serious morbidity was higher for all procedures. CONCLUSIONS: Compared to adults, children demonstrate unique surgical complication and outcome profiles. Quality improvement efforts such as SSI prevention bundles and enhanced recovery protocols used in adults should be expanded to children.

Post Hepatectomy Liver Failure Risk Calculator for Preoperative and Early Postoperative Period Following Major Hepatectomy.

BACKGROUND: Post hepatectomy liver failure (PHLF) is associated with significant perioperative morbidity and mortality. A tool to identify patients at risk for PHLF may allow for earlier intervention to mitigate its severity and help clinicians when counseling patients. Our objective was to develop a PHLF risk calculator. STUDY DESIGN: Patients who underwent hepatectomy for any indication from 2014 to 2017 were identified from ACS NSQIP. A multivariable logistic regression model was developed that included preoperative and intraoperative variables. Model fit was assessed for discrimination using the C-statistic, and calibration using Hosmer and Lemeshow (HL) Chi square. Validation of the calculator was performed utilizing tenfold cross validation. RESULTS: Among 15,636 hepatectomy patients analyzed, the overall incidence of clinically significant PHLF was 2.8%. Preoperative patient factors associated with increased PHLF were male gender, preoperative ascites within 30 days of surgery, higher ASA class, preoperative total bilirubin greater than 1.2 mg/dl, and AST greater than 40 units/l. Disease related factors associated with PHLF included histology, and use of neoadjuvant therapy. Intraoperative factors associated with PHLF were extent of resection, open surgical approach, abnormal liver texture, and biliary reconstruction. The calculator's C-statistic was 0.83 and the HL Chi square was 10.9 (p = 0.21) demonstrating excellent discrimination and calibration. On tenfold cross validation, the mean test group C-statistic was 0.82 and the HL p value was 0.26. CONCLUSION: We present a multi-institutional preoperative and early postoperative PHLF risk calculator, which demonstrated excellent discrimination and calibration. This tool can be used to help identify high-risk patients to facilitate earlier interventions.

Association of preoperative biliary drainage technique with postoperative outcomes among patients with resectable hepatobiliary malignancy.

BACKGROUND: Endoscopic biliary stenting (EBS) and percutaneous transhepatic biliary drainage (PTBD) are two techniques used for preoperative biliary drainage prior to hepatobiliary resection. The objectives of this study were to determine predictors of the drainage technique selection and to evaluate the association between drainage technique and postoperative outcomes. METHODS: Using ACS NSQIP data (2014-2017), patients who underwent preoperative biliary drainage prior to hepatobiliary resection for malignancy were identified. Separate multivariable-adjusted, propensity score (PS) adjusted, and PS matched logistic regression models were constructed to evaluate the association between drainage technique and postoperative outcomes. RESULTS: Of 527 patients identified, 431 (81.8%) received EBS and 96 (18.2%) received PTBD. Patients who underwent PTBD had more preoperative co-morbidities, including higher ASA class, recent weight loss, and hypoalbuminemia (all p < 0.05). After multivariable adjustment, PTBD was significantly associated with 30-day DSM (OR 1.92, 95% CI 1.24-2.97, p = 0.004), overall SSI (OR 1.74, 95% CI 1.10-2.76, p = 0.019), and superficial SSI (OR 2.08, 95% CI 1.20-3.60, p = 0.010). These findings remained significant for both PS-adjusted and PS-matched models. CONCLUSION: Patients undergoing hepatobiliary resection selected for PTBD had significantly more preoperative co-morbidities and nutritional deficits. Compared to EBS, PTBD was associated with significantly higher odds of postoperative morbidity and mortality.

Surgical technical evidence review for gynecologic surgery conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery.

BACKGROUND: The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Armstrong Institute at Johns Hopkins, developed the Safety Program for Improving Surgical Care and Recovery, which integrates principles of implementation science into adoption of enhanced recovery pathways and promotes evidence-based perioperative care. OBJECTIVE: The objective of this study is to review the enhanced recovery pathways literature in gynecologic surgery and provide the framework for an Improving Surgical Care and Recovery pathway for gynecologic surgery. STUDY DESIGN: We searched PubMed and Cochrane Central Register of Controlled Trials databases from 1990 through October 2017. Studies were included in hierarchical and chronological order: meta-analyses, systematic reviews, randomized controlled trials, and interventional and observational studies. Enhanced recovery pathways components relevant to gynecologic surgery were identified through review of existing pathways. A PubMed search for each component was performed in gynecologic surgery and expanded to include colorectal surgery as needed to have sufficient evidence to support or deter a process. This review focuses on surgical components; anesthesiology components are reported separately in a companion article in the anesthesiology literature. RESULTS: Fifteen surgical components were identified: patient education, bowel preparation, elimination of nasogastric tubes, minimization of surgical drains, early postoperative mobilization, early postoperative feeding, early intravenous fluid discontinuation, early removal of urinary catheters, use of laxatives, chewing gum, peripheral mu antagonists, surgical site infection reduction bundle, glucose management, and preoperative and postoperative venous thromboembolism prophylaxis. In addition, 14 components previously identified in the colorectal Improving Surgical Care and Recovery pathway review were included in the final pathway. CONCLUSION: Evidence and existing guidelines support 29 protocol elements for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery in gynecologic surgery.

A national study of postoperative thyroid hormone supplementation rates after thyroid lobectomy.

BACKGROUND: The American Thyroid Association updated guidelines in 2015 to allow lobectomy for low-risk thyroid cancers. The objectives of this study were (1) to determine thyroid hormone supplementation rates after lobectomy and (2) to evaluate the effect of the American Thyroid Association guideline change on lobectomy and hormone supplementation rates among thyroid cancer patients. METHODS: The Merative MarketScan Databases was used to identify adult (≥age 18) patients who underwent thyroidectomy for benign nodules or thyroid cancer. The association between indication for surgery and postoperative thyroid hormone supplementation was examined using χ2 analyses and multivariable logistic regression models. Among patients with thyroid cancer, lobectomy and hormone supplementation rates were compared in the periods before (2008-2015) and after the guideline change (2016-2019). RESULTS: Of the 81,926 patients identified, 33,756 (41.2%) underwent thyroid lobectomy, 45,104 (55.1%) underwent total thyroidectomy, and 3,066 (3.7%) underwent completion thyroidectomy. Patients who underwent lobectomy for malignancy were significantly more likely to require hormone supplementation (59.3% vs 39.4% [P < .001], adjusted odds ratio 2.34 [95% confidence interval 2.20-2.48]) compared to those with benign disease. Compared to the 2008 to 2015 period, the proportion of patients who underwent lobectomy for thyroid cancer was higher in the 2016 to 2019 period (34.3% vs 30.3%, P < .001), with fewer patients requiring completion thyroidectomy (25.6% vs 29.8%, P < .001) and thyroid hormone supplementation (56.9% vs 60.1%, P = .04). CONCLUSION: The postoperative thyroid hormone supplementation rate was significantly higher in patients who had thyroid cancers compared to benign diseases. After the American Thyroid Association guidelines changed, lobectomy rates increased significantly without a concomitant increase in the completion of thyroidectomy.

Evidence Review for the American College of Surgeons Quality Verification Part III: Standardization, Protocols, and Achieving Better Outcomes for Patient Care.

BACKGROUND: After decades of experience supporting surgical quality and safety by the American College of Surgeons, the ACS Quality Verification Program (ACS QVP) was developed to help hospitals improve surgical quality and safety. This review is the final installment of a three-part review aimed to synthesize evidence supporting the main principles of the ACS QVP. STUDY DESIGN: Evidence was systematically reviewed for three principles: standardized team-based care across five phases of surgical care, disease-based management, and external regulatory review. MEDLINE was searched for articles published from inception to January 2019 and two reviewers independently screened studies for inclusion in a hierarchical fashion, extracted data, and summarized results in a narrative fashion. A total of 5,237 studies across these three topics were identified. Studies were included if they evaluated the relationship between the standard of interest and patient-level or organization measures within the last twenty years. RESULTS: After applying inclusion criteria, a total of 150 studies in systematic reviews and primary studies were included for assessment. Despite institutional variation in standardized clinical pathways, evidence demonstrated improved outcomes such as reduced length of stay (LOS), costs, and complications. Evidence for multidisciplinary disease-based care protocols was mixed, though trended towards improving patient outcomes such as reduced LOS and readmissions. Similarly, the evidence for accreditation and adherence to external process measures was also mixed, though several studies demonstrated the benefit of accreditation programs on patient outcomes. CONCLUSIONS: The identified literature supports the importance of standardized multidisciplinary and disease-based processes and external regulatory systems to improve quality of care.

Choice in Ablative Therapies for Thyroid Nodules.

Ultrasound-guided ablation procedures have been growing in popularity and offer many advantages compared with traditional surgery for thyroid nodules. Many technologies are available, with thermal ablative techniques being the most popular currently though other nonthermal techniques, such as cryoablation and electroporation, are gaining interest. The objective of the present review is to provide an overview of each of the currently available ablative therapies and their applications in various clinical indications.

Cost analysis of reflexive versus selective molecular testing for indeterminate thyroid nodules.

BACKGROUND: Molecular testing is now commonly used to refine the diagnosis of indeterminate thyroid nodules. The purpose of this study is to compare the costs of a reflexive molecular testing strategy to a selective testing strategy for indeterminate thyroid nodules. METHODS: A Markov model was constructed to estimate the annual cost of diagnosis and treatment of a real-world cohort of patients with cytologically indeterminate thyroid nodules, comparing a reflexive testing strategy to a selective testing strategy. Model variables were abstracted from institutional clinical trial data, literature review, and the Medicare physician fee schedule. RESULTS: The average cost per patient in the reflexive testing strategy was $8,045, compared with $6,090 in the selective testing strategy. In 10,000 Monte Carlo simulations, diagnostic thyroid lobectomy for benign nodules was performed in 2,440 patients in the reflexive testing arm, compared with 3,389 patients in the selective testing arm, and unintentional observation for malignant nodules occurred in 479 patients in the reflexive testing arm, compared with 772 patients in the selective testing arm. The cost of molecular testing had the greatest impact on overall costs, with $1,050 representing the cost below which the reflexive testing strategy was cost saving compared with the selective testing strategy. CONCLUSION: In this cost-modeling study, reflexive molecular testing for indeterminate thyroid nodules enabled patients to avoid unnecessary thyroid lobectomy at an estimated cost of $20,600 per surgery avoided.

Evidence Review for the American College of Surgeons Quality Verification Part II: Processes for Reliable Quality Improvement.

After decades of experience supporting surgical quality and safety by the American College of Surgeons, the American College of Surgeons Quality Verification Program was developed to help hospitals improve surgical quality, safety, and reliability. This review is the second of a 3-part review aiming to synthesize the evidence supporting the main principles of the American College of Surgeons Quality Verification Program. Evidence was systematically reviewed for 5 principles: case review, peer review, credentialing and privileging, data for surveillance, and continuous quality improvement using data. MEDLINE was searched for articles published from inception to January 2019 and 2 reviewers independently screened studies for inclusion in a hierarchical fashion, extracted data, and summarized results in a narrative fashion. A total of 9,098 studies across the 5 principles were identified. After exclusion criteria, a total of 184 studies in systematic reviews and primary studies were included for assessment. The identified literature supports the importance of standardized processes and systems to identify problems and improve quality of care.

Same-day discharge is not associated with increased readmissions or complications after thyroid operations.

BACKGROUND: Overnight hospitalization after thyroid surgery has been a widely adopted practice because of the concern for complications such as hypocalcemia and hematoma. Same-day discharge, however, has become popular in recent years. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Targeted Thyroidectomy database (2016-2017) was used to identify patients who underwent thyroid resections. A 1:1 propensity score matching was used to match patients who were discharged on postoperative day 0 and those discharged on postoperative days 1 or 2. Multivariable logistic regression models were constructed to assess the association between discharge timing and postoperative outcomes. RESULTS: Of the 10,502 patients, 2,776 (26.4%) were discharged on postoperative day 0, and 7,726 (73.6%) were discharged on postoperative days 1 or 2. After propensity score matching, 1,977 matched pairs were created. In this matched cohort, the rates of readmission were similar when comparing patients discharged on postoperative day 0 with those discharged on postoperative days 1 or 2 (odds ratio 1.26, 95% confidence interval 0.78-2.05). Likewise, no differences were observed in the rates of surgical site infection, clinically severe hypocalcemia, neck hematoma, or recurrent laryngeal nerve injury. CONCLUSION: In a national cohort of patients undergoing thyroid surgery, same-day discharge was not associated with greater rates of readmission or complications when compared with discharge 1 or 2 days after thyroid surgery.

Evidence Review for the American College of Surgeons Quality Verification Part I: Building Quality and Safety Resources and Infrastructure.

Decades of quality program development by the American College of Surgeons (ACS) have identified the key components of a successful program for optimal surgical care and quality improvement. These key principles have been developed into a verification program-the ACS Quality Verification Program-to guide hospitals to improve surgical quality, safety, and reliability across all surgical specialties. The aim of this review was to synthesize the evidence supporting the first 4 of 12 ACS Quality Verification Program core principles of building quality and safety resources and infrastructure. MEDLINE was searched for articles published from inception to January 2019 for studies describing principles of leadership commitment to surgical quality and safety, a surgical quality officer, a surgical quality committee, and a culture of safety and high reliability. Two reviewers independently screened studies for inclusion in a hierarchical fashion, extracted data, and summarized results in a narrative fashion. A total of 5,332 studies across the 4 principles were identified. After exclusion criteria, a total of 477 studies in systematic reviews and primary studies were included for assessment. Despite heterogeneous study design and lack of randomized controlled trials, the available literature supports the importance of committed top-level hospital leadership, mid-level leadership, and committee dedicated to surgical quality and culture of safety and high reliability. In conclusion, adequate resources and infrastructure integral to the ACS Quality Verification Program are critical to achieving safe and high-quality surgical outcomes.

Best Practices in Data Use for Achieving Successful Implementation of Enhanced Recovery Pathway.

BACKGROUND: Although enhanced recovery pathways (ERPs) have demonstrated promising results in published literature, their effectiveness has been inconsistent. The objective of this study was to identify the most important data use practices associated with successful implementation of ERPs. STUDY DESIGN: As part of a national ERP implementation initiative, data regarding hospitals' previous ERP implementation experience were collected. Specifically, 4 data use practices (data collection, report generation, feedback to leadership, and feedback to frontline providers) and 2 data types (process measures and outcome measures) were correlated with ERP implementation outcomes (hospital-reported success and patient outcomes from the American College of Surgeons [ACS] NSQIP data). RESULTS: Of 140 hospitals evaluated, 73 (52.1%) reported previous ERP implementation, with wide variations in data use practices. Of these, 33 (45.2%) reported successful implementation. Feedback of both process and outcome measure data was performed by only 15.1% of hospitals, but was associated with significantly higher likelihood of successful implementation when compared with no feedback (relative risk [RR] 2.45, 95% CI 1.69 to 3.56; p < 0.001) and feedback of only outcome measure data (RR 2.73, 95% CI 1.06 to 7.00; p = 0.037). Using ACS NSQIP data from 6,888 colorectal surgery patients from 52 hospitals with colorectal ERPs, hospital-reported success was associated with significantly lower surgical site infection rates (6.6% vs 8.1%; p = 0.011) and shorter length of stay (6.2 vs 7.0 days; p < 0.001). CONCLUSIONS: The most important data use practice associated with successful ERP implementation was data feedback to frontline providers of both process and outcome measures. However, this was rarely performed in a national cohort of hospitals and represents a substantial but straightforward opportunity for improvement.

Approach to the Patient with Chronic Groin Pain.

Chronic postoperative inguinal pain has become a primary outcome parameter after elective inguinal hernia repair with significant consequences affecting patient productivity, employment, and quality of life. A systematic and thorough preoperative evaluation is important to identify the etiologies and types of pain. Owing to the complex nature of chronic pain, a multimodal and multidisciplinary treatment approach is recommended. Patients with chronic pain refractory to conservative measures may be considered for surgical intervention. Triple neurectomy remains the most definitive and accepted remedial operation performed and provides effective relief in the majority of patients.

Surgical Technical Evidence Review of Hip Fracture Surgery Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery.

BACKGROUND: Enhanced recovery pathways (ERPs) have been shown to improve patient outcomes in a variety of contexts. This review summarizes the evidence and defines a protocol for perioperative care of patients with hip fracture and was conducted for the Agency for Healthcare Research and Quality safety program for improving surgical care and recovery. STUDY DESIGN: Perioperative care was divided into components or "bins." For each bin, a semisystematic review of the literature was conducted using MEDLINE with priority given to systematic reviews, meta-analyses, and randomized controlled trials. Observational studies were included when higher levels of evidence were not available. Existing guidelines for perioperative care were also incorporated. For convenience, the components of care that are under the auspices of anesthesia providers will be reported separately. Recommendations for an evidence-based protocol were synthesized based on review of this evidence. RESULTS: Eleven bins were identified. Preoperative risk factor bins included nutrition, diabetes mellitus, tobacco use, and anemia. Perioperative management bins included thromboprophylaxis, timing of surgery, fluid management, drain placement, early mobilization, early alimentation, and discharge criteria/planning. CONCLUSIONS: This review provides the evidence basis for an ERP for perioperative care of patients with hip fracture.

Surgical Technical Evidence Review for Elective Total Joint Replacement Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery.

BACKGROUND: Use of enhanced recovery pathways (ERPs) can improve patient outcomes, yet national implementation of these pathways remains low. The Agency for Healthcare Research and Quality (AHRQ; funder), the American College of Surgeons, and the Johns Hopkins Medicine Armstrong Institute for Patent Safety and Quality have developed the Safety Program for Improving Surgical Care and Recovery-a national effort to catalyze implementation of practices to improve perioperative care and enhance recovery of surgical patients. This review synthesizes evidence that can be used to develop a protocol for elective total knee arthroplasty (TKA) and total hip arthroplasty (THA). STUDY DESIGN: This review focuses on potential components of the protocol relevant to surgeons; anesthesia components are reported separately. Components were identified through review of existing pathways and from consultation with technical experts. For each, a structured review of MEDLINE identified systematic reviews, randomized trials, and observational studies that reported on these components in patients undergoing elective TKA/THA. This primary evidence review was combined with existing clinical guidelines in a narrative format. RESULTS: Sixteen components were reviewed. Of the 10 preoperative components, most were focused on risk factor assessment including anemia, diabetes mellitus, tobacco use, obesity, nutrition, immune-modulating therapy, and opiates. Preoperative education, venous thromboembolism (VTE) prophylaxis, and bathing/Staphylococcus aureus decolonization were also included. The routine use of drains was the only intraoperative component evaluated. The 5 postoperative components included early mobilization, continuous passive motion, extended duration VTE prophylaxis, early oral alimentation, and discharge planning. CONCLUSION: This review synthesizes the evidence supporting potential surgical components of an ERP for elective TKA/THA. The AHRQ Safety Program for Improving Surgical Care and Recovery aims to guide hospitals and surgeons in identifying the best practices to implement in the surgical care of TKA and THA patients.