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BACKGROUND: Given the risks associated with urgent colectomy for large bowel obstruction, preoperative colonic stenting has been utilized for decompression and optimization prior to surgery. This study examined national trends in the use of colonic stenting as a bridge to resection for malignant large bowel obstruction and evaluated outcomes relative to immediate colectomy. METHODS: Adults undergoing colonic stenting or colectomy for malignant, left/sigmoid large bowel obstruction were identified in the 2010-2016 Nationwide Readmissions Database. Patients were classified as immediate resection (IR) or delayed resection (DR) if undergoing colonic stenting prior to colectomy. Generalized linear models were used to evaluate the impact of resection strategy on ostomy creation, in-hospital mortality, and complications. RESULTS: Among 9,706 patients, 9.7% underwent colonic stenting, which increased from 7.7 to 16.4% from 2010 to 2016 (p < 0.001). Compared to IR, the DR group was younger (63.9 vs 65.9 years, p = 0.04), had fewer comorbidities (Elixhauser Index 3.5 vs 3.9, p = 0.001), and was more commonly managed at high-volume centers (89.4% vs 68.1%, p < 0.001). Laparoscopic resections were more frequent among the DR group (33.1% vs 13.0%, p < 0.001), while ostomy rates were significantly lower (21.5% vs 53.0%, p < 0.001). After risk adjustment, colonic stenting was associated with reduced odds of ostomy creation (0.34, 95% confidence interval 0.24-0.46), but similar odds of mortality and complications. CONCLUSION: Colonic stenting is increasingly utilized for malignant, left-sided bowel obstructions, and associated with lower ostomy rates but comparable clinical outcomes. These findings suggest the relative safety of colonic stenting for malignant large bowel obstruction when clinically appropriate.
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Neoplasias del Colon , Neoplasias Colorrectales , Obstrucción Intestinal , Adulto , Humanos , Neoplasias del Colon/complicaciones , Neoplasias del Colon/cirugía , Obstrucción Intestinal/etiología , Obstrucción Intestinal/cirugía , Stents/efectos adversos , Colectomía/efectos adversos , Resultado del Tratamiento , Neoplasias Colorrectales/cirugíaRESUMEN
BACKGROUND: Perirectal abscess is a common problem. Despite a seemingly simple disease to manage, clinical outcomes of perirectal abscesses can vary significantly given the wide array of patients who are susceptible to this disease. OBJECTIVE: Our aims were to evaluate the outcomes after operative incision and drainage for perirectal abscess and to examine factors associated with length of stay, reoperations, and readmissions. DESIGN: This was a retrospective analysis of the National Surgical Quality Improvement Program database. SETTINGS: The study was conducted with hospitals participating in the surgical database. PATIENTS: Adult patients undergoing outpatient perirectal abscess procedures from 2011 through 2016 were included. MAIN OUTCOME MEASURES: Study outcomes were length of stay, reoperation, and readmission. RESULTS: We identified 2358 patients undergoing incision and drainage for perirectal abscesses. Approximately 35% of patients required hospital stay. Reoperations occurred in 3.4%, with median time to reoperation of 15.5 days. The majority of reoperations (79.7%) were performed for additional incision and drainage. Readmissions rate was 3.0%, with median time to readmission of 10.5 days. Common indications for readmissions included recurrent/persistent abscess (41.4%) and fever/sepsis (8.6%). Risk factors for hospitalization in multivariable analysis were preoperative sepsis, bleeding disorder, and non-Hispanic black and Hispanic races. For reoperations, risk factors included morbid obesity, preoperative sepsis, and dependent functional status. Lastly, for readmissions, female sex, steroid/immunosuppression, and dependent functional status were significant risk factors. LIMITATIONS: The study was limited by its retrospective analysis and potential selection bias in decisions on hospital stay, reoperation, and readmission. CONCLUSIONS: Suboptimal outcomes after outpatient operative incision and drainage for perirectal abscesses are not uncommon in the United States. In the era of value-based care, additional work is needed to optimize use outcomes for high-risk patients undergoing perirectal incision and drainage. Strategies to prevent inadequate drainage at the time of the initial operative incision and drainage (ie, use of imaging modalities and thorough examination under anesthesia) are warranted to improve patient outcomes. See Video Abstract at http://links.lww.com/DCR/B229. INCISIÓN Y DRENAJE QUIRÚRGICOS DE ABSCESOS PERIRRECTALES: CUALES SON LOS FACTORES DE RIESGO PARA UNA ESTADÍA PROLONGADA, REINTERVENCIÓN Y READMISION?: Los abscesos perirrectales son un problema frecuente. A pesar que parecen ser una afección aparentemente simple de manejar, los resultados clínicos de la incisión y drenaje quirúrgicos pueden variar significativamente dada la amplia variedad de pacientes susceptibles de sufrir esta afección.Evaluar los resultados después de la incisión y el drenaje quirúrgicos de un absceso perirrectal y analizar los factores asociados con la duración de la hospitalización, la reoperación y la readmisión.Análisis retrospectivo de la base de datos del Programa Americano de Mejora de la Calidad Quirúrgica.Hospitales que participan en la base de datos quirúrgica.Pacientes adultos sometidos a incisión y drenaje quirúrgico ambulatorio de un absceso perirrectal desde 2011 hasta 2016.Los resultados del estudio fueron la duración de la hospitalización, la reoperación y el reingreso.Fueron estudiados 2,358 pacientes sometidos a incisión y drenaje por abscesos perirrectales. Aproximadamente el 35% de los pacientes requirieron hospitalización. Las reoperaciones ocurrieron en 3.4% con una mediana de tiempo de reoperación de 15.5 días. La mayoría de las reoperaciones (79.7%) se realizaron para una incisión y drenaje adicionales. La tasa de reingreso fue del 3.0% con una mediana de tiempo de reingreso de 10.5 días. Las indicaciones comunes para los reingresos incluyeron abscesos recurrentes / persistentes (41.4%) y fiebre / sepsis (8.6%). Los factores de riesgo para la hospitalización en el análisis multivariable fueron sepsis preoperatoria, trastorno hemorrágico, raza negra no hispánica y raza hispana. Para las reoperaciones, los factores de riesgo incluyeron obesidad mórbida, sepsis preoperatoria y estado funcional dependiente. Por último, para los reingresos, el sexo femenino, uso de corticoides / inmunosupresores y un estadío funcional dependiente fueron factores de riesgo significativos.Análisis retrospectivo y posible sesgo de selección en las decisiones sobre hospitalización, reoperación y reingreso.Un resultado poco satisfactorio después de la incisión quirúrgica el drenaje de abscesos perirrectales ambulatoriamente no son infrecuentes en los Estados Unidos. En la era de la atención basada en los resultados, se necesita mucho más trabajo para optimizar los mismos en pacientes de alto riesgo sometidos a incisión y drenaje perirrectales. Las estrategias para prevenir el drenaje inadecuado en el momento de la incisión quirúrgica inicial y el drenaje (es decir, el uso de modalidades de imágenes, un examen completo bajo anestesia) son una garantía para mejorar los resultados en estos pacientes. Consulte Video Resumen en http://links.lww.com/DCR/B229.
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Absceso/cirugía , Readmisión del Paciente/estadística & datos numéricos , Recto/patología , Reoperación/estadística & datos numéricos , Adulto , Drenaje/métodos , Femenino , Fiebre/epidemiología , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Mejoramiento de la Calidad , Recto/cirugía , Estudios Retrospectivos , Factores de Riesgo , Sepsis/epidemiología , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Accurate and comprehensive surgical pathology reports are integral to the quality of cancer care. Despite guidelines from the College of American Pathologists, variations in reporting quality continue to exist. OBJECTIVE: The aim of this study was to evaluate the quality of rectal cancer pathology reports and to identify areas of deficiency and potential sources of reporting variations. DESIGN: This is a retrospective analysis of prospectively obtained pathology reports. SETTING: This study is based at the hospitals participating in the National Surgical Adjuvant Breast and Bowel Project Protocol R-04 study. PATIENTS: Patients with rectal cancer undergoing surgical resection between July 2004 and August 2010 were included. MAIN OUTCOME MEASURES: The primary outcomes measured were the adherence to the College of American Pathologists guidelines and the impact of synoptic reporting, academic status, rural/urban setting, and hospital bed size on reporting quality. RESULTS: We identified 1004 surgical pathology reports for rectal cancer surgery from 383 hospitals and 755 pathologists. The overall adherence rate to the College of American Pathologists guidelines was 73.3%. Notable reporting deficiencies were found in several key pathology characteristics, including tumor histologic grade (reporting rate 77.8%), radial margin (84.6%), distance from the closest margin (47.9%), treatment effect (47.1%), and lymphovascular (73.1%)/perineural invasions (35.4%). Synoptic reporting use and urban hospital settings were associated with better adherence rates, whereas academic status and hospital bed size had no impact. Reporting variations existed not only between institutions, but also within individual hospitals and pathologists. There was a trend for improved adherence over time (2005 = 65.7% vs 2010 = 82.3%, p < 0.001), which coincided with the increased adoption of synoptic reporting by pathologists (2005 vs 2010, 9.4% vs 25.3%, p < 0.001). LIMITATIONS: Data were obtained from a restricted setting (ie, hospitals participating in a randomized clinical trial). CONCLUSIONS: Wide variations in the quality of pathology reporting are observed for rectal cancer. The National Accreditation Program for Rectal Cancer mandates that programs meet strict quality standards for surgical pathology reporting. Further improvement is needed in this key aspect of oncology care for patients with rectal cancer. See Video Abstract at http://links.lww.com/DCR/B238.ClinicalTrials.gov registration: NCT00058 EVALUACIÓN DE LA CALIDAD DE LOS INFORMES DE PATOLOGÍA QUIRÚRGICA EN CASOS DE CÁNCER DE RECTO DEL NSABP R-04/ ONCOLOGÍA DEL NRG: Un informe de patología quirúrgica preciso y completo es fundamental en la calidad de atención de pacientes con cáncer. A pesar de las normas establecidas por el Colegio Americano de Patología, la variabilidad en la calidad de los informes es evidente.Evaluar la calidad de los informes de patología en casos de cáncer de recto para así identificar las áreas con deficiencias y las posibles fuentes variables en los mencionados informes.Análisis retrospectivo de informes de patología quirúrgica obtenidos prospectivamente.Hospitales que participan del Protocolo del Estudio Nacional R-04 como Adyuvantes Quirúrgicos de Mama e Intestino.Todos aquellos pacientes con cáncer de recto sometidos a resección quirúrgica entre Julio 2004 y Agosto 2010.Cumplimiento de las normas del Colegio Americano de Patología, del impacto de los informes sinópticos, del estado académico, del entorno rural / urbano y el número de camas hospitalarias en en la calidad de los informes.Identificamos 1,004 informes de patología quirúrgica en casos de cirugía en cáncer de recto en 383 hospitales y 755 patólogos. La tasa general de adherencia a las directivas del Colegio Americano de Patología fue del 73.3%. Se encontraron deficiencias notables en los informes en varias características patológicas clave incluidos, el grado histológico del tumor (tasa de informe 77.8%), margenes radiales (84.6%), distancia del margen más cercano (47.9%), efecto del tratamiento (47.1%) invasión linfovascular (73.1 %) / invasion perineural (35.4%). El uso de informes sinópticos y los entornos hospitalarios urbanos se asociaron con mejores tasas de adherencia, mientras que el estado académico y el número de camas hospitalarias no tuvieron ningún impacto. Hubo variaciones en los informes no solo entre instituciones, sino también dentro de hospitales y patólogos individuales. Hubo una tendencia a una mejor adherencia a lo largo del tiempo (2005 = 65.7% v 2010 = 82.3%, p < 0.001), que coincidió con la mayor adopción de informes sinópticos por parte de los patólogos (2005 v 2010, 9.4% v 25.3%, p < 0.001)Datos obtenidos de un entorno restringido (es decir, hospitales que participan en un ensayo clínico aleatorizado).Se observaron grandes variaciones en la calidad de los informes de patología quirúrgica en casos de cáncer de recto. El Programa Nacional de Acreditación para Cáncer de Recto exige que los programas cumplan con estrictos estándares de calidad para los informes de patología quirúrgica. Se necesita una mejoría adicional en este aspecto clave de la atención oncológica para pacientes con cáncer de recto. Video Resumen en http://links.lww.com/DCR/B238.Registro de Clinical Trials.gov: NCT00058.
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Adhesión a Directriz/estadística & datos numéricos , Patología Clínica/estadística & datos numéricos , Neoplasias del Recto/patología , Neoplasias del Recto/cirugía , Humanos , Márgenes de Escisión , Clasificación del Tumor , Evaluación de Resultado en la Atención de Salud , Patólogos/organización & administración , Mejoramiento de la Calidad , Calidad de la Atención de Salud , Informe de Investigación/tendencias , Estudios Retrospectivos , Estados Unidos/epidemiologíaRESUMEN
There is increasing pressure from the public and insurance payors for transparency and accountability in ensuring the quality of health care. In response to this, hospitals are now mandated to participate in quality improvement initiatives, and to report on their performance. This article describes three programs related to the measurement of quality that impact colon and rectal surgery: the Surgical Care Improvement Project, the National Surgical Quality Improvement Program, and the Surgical Care and Outcomes Assessment Program.
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BACKGROUND: Benign colon polyps may require bowel resection if endoscopic polypectomy cannot be performed to assess adequately for cancer. However, endoscopic removal still may be possible using combined endoscopic and laparoscopic surgery (CELS). The CELS procedure allows for intra- and extraluminal manipulation of the bowel wall to facilitate polyp removal, thereby avoiding bowel resection. This study evaluated the authors' institutional experience with CELS in this patient population. METHODS: Between August 2008 and October 2012, all patients referred to undergo surgery for a benign colon polyp were retrospectively reviewed for operative characteristics, pathology, and postoperative outcomes. Of 14 patients, five were considered candidates for CELS and were compared with nine patients who underwent resection. RESULTS: The average patient age was similar between the two groups (CELS, 64.9 years vs. resection, 68.3 years). The mean polyp size was 2.3 cm in the CELS group and 2.9 cm in the resection group. In the CELS group, polyps were successfully removed in all cases. The mean operating room time was 159 min in the CELS group and 205 min in the resection group. The median hospital stay was 1 day in the CELS group and 5 days in the resection group. No complications occurred in the CELS group. Two patients in the resection group (22 %) experienced a wound infection. One patient had a postoperative ileus (11 %). Four patients in the CELS group had a benign adenoma. One patient had a benign frozen section evaluation, but the final pathology showed adenocarcinoma requiring a subsequent colectomy. In the resection group, six patients had a benign adenoma, and three patients had a T1N0 cancer. In the CELS group, repeat endoscopy was performed an average of 9.9 months after CELS. Two patients had a residual polyp, and two patients had new polyps in a different location. All were successfully removed. CONCLUSION: For benign-appearing polyps not amenable to endoscopic techniques alone, CELS may be an alternative to formal bowel resection for carefully selected patients. The CELS procedure can be performed safely with minimal morbidity and with outcomes that compare favorably with those of formal colectomy.
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Pólipos del Colon/cirugía , Colonoscopía/métodos , Laparoscopía/métodos , Adulto , Anciano , Anciano de 80 o más Años , Terapia Combinada , Humanos , Tiempo de Internación , Persona de Mediana Edad , Tempo Operativo , Estudios RetrospectivosRESUMEN
Purpose: The objective of this study was to assess how teleconferencing variables influence faculty impressions of mock residency applicants. Methods: In October 2020, we conducted an online experiment studying five teleconferencing variables: background, lighting, eye contact, internet connectivity, and audio quality. We created interview videos of three mock residency applicants and systematically modified variables in control and intervention conditions. Faculty viewed the videos and rated their immediate impression on a 1-10 scale. The effect of each variable was measured as the mean difference between the intervention and control impression ratings. One-way analysis of variance (ANOVA) was performed to assess whether ratings varied across applicants. Paired-samples Wilcoxon signed-rank tests were conducted to assess the significance of the effect of each variable. Results: Of 711 faculty members who were emailed a link to the experiment, 97 participated (13.6%). The mean ratings for control videos were 8.1, 7.2, and 7.6 (P < .01). Videos with backlighting, off-center eye contact, choppy internet connectivity, or muffled audio quality had lower ratings when compared with control videos (P < .01). There was no rating difference between home and conference room backgrounds (P = .77). Many faculty participants reported that their immediate impressions were very much or extremely influenced by audio quality (60%), eye contact (57%), and internet connectivity (49%). Conclusions: Teleconferencing variables may serve as a source of assessment bias during residency interviews. Mock residency applicants received significantly lower ratings when they had off-center eye contact, muffled audio, or choppy internet connectivity, compared to optimal teleconferencing conditions. Supplementary Information: The online version contains supplementary material available at 10.1007/s44186-022-00053-w.
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In 2019, the American Society for Gastrointestinal Endoscopy (ASGE) guideline on the endoscopic management of choledocholithiasis modified the individual predictors of choledocholithiasis proposed in the widely referenced 2010 guideline to improve predictive performance. Nevertheless, the primary literature, especially for the 2019 iteration, is limited. We performed a systematic review with meta-analysis to examine the diagnostic performance of the 2010, and where possible the 2019, predictors. PROSPERO protocol CRD42020194226. A comprehensive literature search from 2001 to 2020 was performed to identify studies on the diagnostic performance of any of the 2010 and 2019 ASGE choledocholithiasis predictors. Identified studies underwent keyword screening, abstract review, and full-text review. The primary outcomes included multivariate odds ratios (ORs) and 95% confidence intervals for each criterion. Secondary outcomes were reported sensitivities, specificities, and positive and negative predictive value. A total of 20 studies met inclusion criteria. Based on reported ORs, of the 2010 guideline "very strong" predictors, ultrasound with stone had the strongest performance. Of the "strong" predictors, CBD > 6 mm demonstrated the strongest performance. "Moderate" predictors had inconsistent and/or weak performance; moreover, all studies reported gallstone pancreatitis as non-predictive of choledocholithiasis. Only one study examined the new predictor (bilirubin > 4 mg/dL and CBD > 6 mm) proposed in the 2019 guideline. Based on this review, aside from CBD stone on ultrasound, there is discordance between the proposed strength of 2010 choledocholithiasis predictors and their published diagnostic performance. The 2019 guideline appears to do away with the weakest 2010 predictors.
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Coledocolitiasis , Colangiopancreatografia Retrógrada Endoscópica , Coledocolitiasis/diagnóstico por imagen , Endoscopía Gastrointestinal , Humanos , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Ultrasonografía , Estados UnidosRESUMEN
Importance: Characteristics of outstanding graduating surgical residents are currently undefined. Identifying these qualities may be important in guiding resident selection and resident education. Objective: To determine characteristics that are most strongly associated with being rated as an outstanding graduating surgical resident. Design, Setting, and Participants: The multi-institutional study had 3 phases. First, an expert panel developed a list of characteristics embodied by top graduating surgical residents. Second, groups of faculty from 14 US general-surgery residency programs ranked 2017 through 2020 graduates into quartiles of overall performance. Third, faculty evaluated their graduates on each characteristic using a 5-point Likert scale. Data were analyzed using Spearman rank-order correlation to identify which individual characteristics were associated with overall graduate performance. A least absolute shrinkage and selection operator (LASSO) ordinal regression was performed to select a parsimonious model to predict the outcome of overall performance rating from individual characteristic scores. Main Outcome and Measures: Surgical educators' rankings of general surgery residency graduates' overall performance. Results: Fifty faculty from 14 US residency programs with a median of 13 (range, 5-30) years of surgical education experience evaluated 297 general surgery residency graduates. Surgical educators identified 21 characteristics that they believed outstanding graduating surgical residents possessed. Two hundred ninety-seven surgical residency graduates were evaluated. Higher scores in every characteristic correlated with better overall performance. Characteristics most strongly associated with higher overall performance scores were surgical judgment (r = 0.728; P < .001), leadership (r = 0.726; P < .001), postoperative clinical skills (r = 0.715; P < .001), and preoperative clinical skills (r = 0.707; P < .001). The remainder of the characteristics were moderately associated with overall performance. The LASSO regression model identified 3 characteristics from which overall resident performance could be accurately predicted without measuring other qualities: surgical judgment (odds ratio [OR] per 1 level of 5-level Likert scale OR, 1.27; 95% CI, 1.03-1.51), leadership (OR, 1.27; 95% CI, 1.06-1.48), and medical knowledge (OR, 1.16; 95% CI, 1.01-1.33). Conclusions and Relevance: All individual characteristics identified by surgical educators as being qualities of outstanding graduating surgical residents were positively associated with overall graduate performance. Surgical judgment and leadership skills had the strongest individual associations. Assessment of only 3 qualities (surgical judgment, leadership, and medical knowledge) were required to predict overall resident performance ratings. These findings highlight the importance of developing specific surgical judgment and leadership skills curricula and assessments during surgical residency.
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Internado y Residencia , Competencia Clínica , Curriculum , Educación de Postgrado en Medicina , HumanosRESUMEN
BACKGROUND: Adherence to quality indicators may be especially important to disease-specific outcomes for uninsured, vulnerable patients. The objective of this study was to measure adherence to National Initiative for Cancer Care Quality (NICCQ) breast cancer quality indicators in a public hospital and compare performance to published rates in a previously collected 5-city cohort. METHODS: One hundred five consecutive, newly diagnosed, stage I-III, breast cancer patients at a public hospital (from 2005 to 2007) were identified. Adherence rates to 31 quality indicators were measured by using medical record abstraction. Rates were calculated for individual indicators, aggregated domains, and components of care and were compared with the 5-city cohort results by using a 2-sided test of proportions. RESULTS: Overall adherence to the NICCQ indicators at the public hospital was 82%, versus 86% in the 5-city cohort. Public hospital adherence was better in 3 domains and components (Management of Treatment Toxicity 95% vs 73%, Referrals 76% vs 15%, and Documentation of Key Clinical Factors 72% vs 64%, P < .05 for all), but it was lower in others (Testing 82% vs 96%, Adjuvant Therapy 76% vs 83%, Surgery 72% vs 86%, Surveillance 63% vs 94%, and Respect for Patient Preferences 52% vs 72%, P < .001 for all). CONCLUSIONS: The results showed that it is possible to deliver breast cancer care to vulnerable patients comparable in quality to the care received by the broader population. Further study should identify the factors that lead to variation in adherence across domains of quality.
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Neoplasias de la Mama/terapia , Indicadores de Calidad de la Atención de Salud , Poblaciones Vulnerables , Anciano , Femenino , Adhesión a Directriz , Hospitales Públicos , Humanos , Los Angeles , Persona de Mediana Edad , Indicadores de Calidad de la Atención de Salud/normasRESUMEN
Importance: Diverticulitis of the colon is an increasingly prevalent disease with significant implications for patient quality of life and health system resource expenditure. Although several randomized clinical trials and meta-analyses of Hartman procedure (HP) and primary anastomosis and proximal diversion (PAPD) have found surgical equipoise, questions regarding the relative performance of these treatments when applied broadly remain. Objective: To examine use of and outcomes after urgent sigmoid colectomy with end colostomy (ie, HP) vs PAPD in management of complicated diverticulitis. Design, Setting, and Participants: This retrospective cross-sectional study was a multicenter, population-based examination of inpatient hospitalizations, not including long-term rehabilitation facilities, using data from the 2014 to 2017 Nationwide Readmissions Database. It was performed from November 2020 to January 2021. Included patients were adults admitted with acute diverticulitis requiring HP or PAPD within 48 hours of admission. Exposures: Undergoing HP vs PAPD. Main Outcomes and Measures: Inverse probability treatment analysis was used to compare outcomes, including index mortality, composite complications (ie, neurologic, infectious, and cardiovascular complications), length of stay, and readmissions within 90 days. Results: During the study period, an estimated 1â¯072â¯395 adults (615â¯954 [57.4%] women; median [IQR] age, 64 [52-76] years) required nonelective hospitalization for acute colonic diverticulutus. A total of 34â¯126 patients required diversion, with 32â¯326 patients (94.7%) undergoing HP and 1800 patients (5.3%) undergoing PAPD within 48 hours of admission. Patients undergoing PAPD had a decreased median (IQR) age (60 [51-70] years vs 65 [54-74] years; P < .001) and decreased rates of end organ dysfunction (520 patients [28.9%] vs 11â¯514 patients [35.6%]; P < .001). In inverse probability treatment weight analysis, the odds of mortality (adjusted odds ratio [aOR], 0.63; 95% CI, 0.32-1.40), complications (aOR, 0.86; 95% CI, 0.66-1.13), and nonhome discharge (aOR 1.15; 95% CI, 0.83-1.60) were similar for PAPD compared with HP. Among 1772 patients who underwent PAPD and survived index hospitalization, there was an increased incidence of 90-day readmission compared with 30â¯851 patients who underwent HP and survived index hospitalization (393 patients [22.2%] vs 4384 patients [14.2%]; P < .001) with increased hazard of ostomy reversal (hazard ratio, 1.46; 95% CI, 1.08-1.99). Conclusions and Relevance: This study found that the use of PAPD was associated with comparable index hospitalization outcomes vs use of HP, while readmission rate and ostomy risk were statistically significantly increased among patients who underwent PAPD compared with patients who underwent HP. These findings suggest that further delineation of criteria for appropriate application of PAPD in the urgent setting are warranted.
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Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/estadística & datos numéricos , Diverticulitis del Colon/cirugía , Complicaciones Posoperatorias/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Anastomosis Quirúrgica/métodos , Estudios de Cohortes , Bases de Datos Factuales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Readmisión del Paciente/estadística & datos numéricos , Estudios Retrospectivos , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
Self-expanding metallic stents (SEMSs) are frequently used to decompress malignant large bowel obstruction (LBO) and avoid emergent surgery with often permanent colostomy creation. However, limited data are available on the use and outcomes of SEMS in patients with nonmalignant LBO. We present a case series of 4 patients who were found to have nonmalignant LBO for which they underwent emergent colonic stenting as a bridge to elective surgery following interdisciplinary discussion between gastroenterology, colorectal surgery, and radiology. Through each patient vignette, we illustrate the use of SEMSs as a potential alternative to emergent surgery. 2 of 4 patients avoided stoma creation at the time of surgery, and 1 patient avoided surgery altogether; overall, however, the outcomes of this approach were mixed in this series, indicating a need for further investigation to better identify the patient population that would benefit most from initial SEMS placement for decompression of nonmalignant LBO.
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BACKGROUND AND AIMS: Noninvasive predictors of choledocholithiasis have generally exhibited marginal performance characteristics. We aimed to identify noninvasive independent predictors of endoscopic retrograde cholangiopancreatography (ERCP)-confirmed choledocholithiasis and accordingly developed predictive machine learning models (MLMs). METHODS: Clinical data of consecutive patients undergoing first-ever ERCP for suspected choledocholithiasis from 2015-2019 were abstracted from a prospectively-maintained database. Multiple logistic regression was used to identify predictors of ERCP-confirmed choledocholithiasis. MLMs were then trained to predict ERCP-confirmed choledocholithiasis using pre-ERCP ultrasound (US) imaging only and separately using all available noninvasive imaging (US/CT/magnetic resonance cholangiopancreatography). The diagnostic performance of American Society for Gastrointestinal Endoscopy (ASGE) "high-likelihood" criteria was compared to MLMs. RESULTS: We identified 270 patients (mean age 46 years, 62.2% female, 73.7% Hispanic/Latino, 59% with noninvasive imaging positive for choledocholithiasis) with native papilla who underwent ERCP for suspected choledocholithiasis, of whom 230 (85.2%) were found to have ERCP-confirmed choledocholithiasis. Logistic regression identified choledocholithiasis on noninvasive imaging (odds ratio (OR) = 3.045, P = 0.004) and common bile duct (CBD) diameter on noninvasive imaging (OR=1.157, P = 0.011) as predictors of ERCP-confirmed choledocholithiasis. Among the various MLMs trained, the random forest-based MLM performed best; sensitivity was 61.4% and 77.3% and specificity was 100% and 75.0%, using US-only and using all available imaging, respectively. ASGE high-likelihood criteria demonstrated sensitivity of 90.9% and specificity of 25.0%; using cut-points achieving this specificity, MLMs achieved sensitivity up to 97.7%. CONCLUSIONS: MLMs using age, sex, race, presence of diabetes, fever, body mass index (BMI), total bilirubin, maximum CBD diameter, and choledocholithiasis on pre-ERCP noninvasive imaging predict ERCP-confirmed choledocholithiasis with good sensitivity and specificity and outperform the ASGE criteria for patients with suspected choledocholithiasis.
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OBJECTIVE: Female surgeons face gender-specific obstacles during residency training, yet longitudinal data on gender bias experienced by female surgery residents are lacking. We aimed to investigate the evolution of gender bias, identify obstacles experienced by female general surgery residents, and discuss approaches to supporting female surgeons during residency training. METHODS: Between August 2019 and January 2021, we conducted a retrospective cohort study using structured telephone interviews of female graduates of the UCLA General Surgery Residency training program. Responses of early graduates (1981-2009) were compared with those of recent graduates (2010-2020). Quantitative data were compared with Fisher's exact tests and Chi-squared tests. Interview responses were reviewed to catalog gender bias, obstacles experienced by female surgeons, and advice offered to training programs to address women's concerns. RESULTS: Of 61 female surgery residency graduates, 37 (61%) participated. Compared to early graduates (Nâ¯=â¯20), recent graduates (Nâ¯=â¯17) were significantly more likely to pursue fellowship training (100% vs. 65%, p < 0.01) and have children before or during residency (65% vs. 25%, pâ¯=â¯0.02). A substantial proportion in each cohort experienced some form of gender bias (71% vs. 85%, pâ¯=â¯0.43). Compared to early graduates, recent graduates were significantly less likely to report experiencing explicit gender bias (12% vs. 50%, pâ¯=â¯0.02) but equally likely to report implicit gender bias (71% vs. 55%, pâ¯=â¯0.50). Female graduates across the decades advocated for specific measures to champion work-life balance in residency (51%), strengthen female mentorship (49%), increase childcare support (41%), and promote women into leadership positions (32%). CONCLUSIONS: While having children during residency has become more common and accepted over the decades, female surgery residents continue to experience implicit gender bias in the workplace. Female surgeons advocate for targeted interventions to establish systems for parental leave, address gender bias, and strengthen female mentorship.
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Internado y Residencia , Sexismo , Niño , Becas , Femenino , Humanos , Masculino , Estudios Retrospectivos , Encuestas y CuestionariosRESUMEN
The continuum of breast cancer care requires multidisciplinary efforts. Patient navigators, who perform outreach, coordination, and education, have been shown to improve some areas of care. However, little research has assessed the impact of navigators on breast cancer treatment in uninsured populations. Our objective is to report on the impact of a patient navigator program on breast cancer quality of care at a public hospital. One hundred consecutive newly diagnosed patients with breast cancer (Stages I to III) were identified (2005 to 2007). Forty-nine patients were treated before the use of navigators and 51 after program implementation. Nine breast cancer quality indicators were used to evaluate quality of care. Overall adherence to the quality indicators improved from 69 to 86 per cent with the use of patient navigators (P < 0.01). Only one individual indicator, use of surveillance mammography, improved significantly (52 to 76%, P < 0.05). All nine indicators reached 75 per cent or greater adherence rates after implementation of the navigator program compared with only four before implementation. Patient navigators appear to improve breast cancer quality of care in a public hospital. In populations in which cultural, linguistic, and financial barriers are prevalent, navigator programs can be effective in narrowing the observed gaps in the quality of cancer care.
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Neoplasias de la Mama/cirugía , Defensa del Paciente , Indicadores de Calidad de la Atención de Salud , Adulto , Anciano , Anciano de 80 o más Años , Relaciones Comunidad-Institución , Femenino , Adhesión a Directriz/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/tendencias , Hospitales Públicos , Humanos , Los Angeles , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Indicadores de Calidad de la Atención de Salud/normas , Indicadores de Calidad de la Atención de Salud/tendenciasRESUMEN
Background Luminal stenting is safe, effective, and at times the preferred method for relieving gastrointestinal obstruction. However, stent placement is not technically feasible when lesions cannot be traversed with a guidewire, resulting in the need for more invasive methods of palliation and urgent/emergent surgical intervention. In this series, we report our experience with cap-assisted stenting to improve lumen visualization in obstructed segments of the gastrointestinal tract and salvage cases that may have otherwise resulted in technical failure. Methods A clear cap (i.âe. distal attachment) was affixed to the scope tip to facilitate visualization and stenting in two cases of gastroduodenal obstruction and three cases of colonic obstruction. Indications for stent placement included malignant obstruction, diverticulitis-associated obstruction, and Crohn's disease-associated stricture. Results In this report, we demonstrate that use of a clear cap facilitated endoscopic stenting in challenging cases of malignant and benign gastroduodenal and colonic obstruction. Conclusions A clear cap for endoscopic stenting can be used in cases in which standard techniques are unsuccessful or those anticipated to be technically difficult at the outset. Cases with tortuous anatomy or particularly tight, friable, or exophytic obstructive lesions may benefit most from this novel technical modification.
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INTRODUCTION: Mock oral examinations (MOE) are used to prepare residents and assess their readiness for the American Board of Surgery Certifying Exam (ABSCE). Delivery of MOEs varies by institution and previous studies have demonstrated significant implementation barriers such as availability of faculty examiners and exam scenarios. OBJECTIVE: To assess the value and participant satisfaction of a standardized multi-institutional MOE for general surgery residents. PARTICIPANTS: Thirty-three general surgery residents and 37 faculty members from 3 institutions participated in a regional MOE. Residents were examined in three 20-minute sessions. Faculty examiners were given a wide selection of prescripted exam scenarios and instructed to use standardized grading rubrics during a brief orientation on the day of the exam. All participants were surveyed on their overall experience. RESULTS: Of 33 participating residents, 26 (79%) passed the MOE (92% of R5, 91% R4, and 50% of R3). Response rates were 91% for residents, and 57% for faculty members respectively. Most respondents were satisfied with the overall exam experience (88%), standardized question quality (86%) and question variety (82%). A total of 92% of respondents agreed that the time, effort, and cost of the MOE was justified by its educational value to residents. Higher medical knowledge ratings assigned by faculty examiners correlated with stronger trainee performance (ßâ¯=â¯0.48; 95% confidence interval [CI] 0.29-0.66), while patient care and interpersonal communication skill ratings were not associated with trainee performance. The standardized grading rubric achieved moderate inter-rater reliability among examiner pairs with 70.6% agreement (Kappa 0.47). CONCLUSIONS: General Surgery residents and faculty perceived the standardized multi-institutional MOE to be a highly satisfactory educational experience and valuable assessment tool. Developing a repertoire of scripted exam scenarios made it feasible to recruit sufficient faculty participants, and standardizing grading rubrics allowed for a consistent exam experience with moderate inter-rater reliability.
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Cirugía General , Internado y Residencia , Competencia Clínica , Evaluación Educacional , Cirugía General/educación , Humanos , Reproducibilidad de los Resultados , Encuestas y CuestionariosRESUMEN
The American Society of Colon and Rectal Surgeons rectal cancer checklist describes a set of best practices for rectal cancer surgery. The objective of this study was to assess the quality of operative reports for rectal cancer surgery based on the intraoperative American Society of Colon and Rectal Surgeons checklist items. Patients undergoing rectal cancer surgery at two public teaching hospitals from 2009 to 2015 were included. A total of 12 intraoperative checklist items were assessed. One hundred and fifty-eight operative reports were reviewed. Overall adherence to checklist items was 55 per cent, and was significantly higher in attending versus resident dictated reports (67% vs 51%, P < 0.01). Senior residents had significantly higher adherence to checklist items than junior residents (55% vs 44%, P < 0.01). However, overall adherence to rectal cancer checklist items was low. This represents an opportunity to improve the quality of operative documentation in rectal cancer surgery, which could also impact the technical quality of the operation itself.