Association between Endometriosis and Surgical Complications among Benign Hysterectomies.

STUDY OBJECTIVE: To investigate the effect of endometriosis on perioperative outcomes in patients undergoing hysterectomy for benign disease. DESIGN: A retrospective cohort study. SETTING: The American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS: A total of 127 556 hysterectomies performed for benign gynecologic indications INTERVENTIONS: Differences in the primary outcomes were compared between patients with and without endometriosis after adjustment for group differences in covariates using inverse probability of treatment weighting approach. MEASURES AND MAIN RESULTS: Of the 127 556 hysterectomies identified, 19 618 (15.4%) had a diagnosis of endometriosis. Patients with endometriosis were younger with a lower prevalence of chronic comorbidities but had higher rates of concurrent pelvic inflammatory disease and previous abdominal operations. The incidence of postoperative complications was higher in patients with endometriosis (9.9% vs 8.1%; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.17-1.34). The incidence of 30-day mortality (0.1% vs 0.03%; OR, 1.98; 95% CI, 0.69-5.65) and reoperations (1.50% vs 1.36%; OR, 1.18; 95% CI, 0.98-1.42) were not different in patients with and without endometriosis. CONCLUSION: Postoperative complications are more likely in hysterectomies involving endometriosis than those without endometriosis, likely owing to anatomic distortion incurring increased surgical complexity. Patients and surgeons should be aware of the increased risk of complications and plan for mitigating these increased risks before and during surgery for suspected endometriosis.

Failure to Rescue and Mortality Differences After Appendectomy in a Low-Middle-Income Country and the United States.

BACKGROUND: Major disparities in complications and mortality after appendectomy between countries with different income levels have not been well characterized, as comparative studies at patient level between countries are scant. This study aimed to investigate variations in postoperative complications, mortality, and failure to rescue after appendectomy between a high-income country and a low-to-middle-income country. METHODS: Hospital discharges on adult patients who underwent appendectomy were extracted from administrative databases from Colombia and 2 states of the United States (Florida and New York). Outcomes included major postoperative complications, in-hospital mortality, and failure to rescue. Univariate analyses were conducted to compare outcomes between the 2 countries. Multivariable logistic regression analyses were conducted to examine the independent effect of country on outcomes after adjustment for patient age, sex, comorbidity index, severity of appendicitis, and appendectomy route (laparoscopic/open). RESULTS: A total of 62,338 cases from Colombia and 57,987 from the United States were included in the analysis. Patients in Colombia were significantly younger and healthier but had a higher incidence of peritonitis. Use of laparoscopy was significantly lower in Colombia (5.9% vs 89.4%; P < .0001). After adjustment for covariates, multivariable logistic regression analyses revealed that compared to the United States, Colombia had lower complication rates (2.8% vs 6.6%; odds ratio [OR], 0.41; 95% confidence interval [CI], 0.39-0.44; P < .0001) but higher mortality (0.44% vs 0.08%; OR, 8.92; 95% CI, 5.69-13.98; P < .0001) and failure to rescue (13.6% vs 1.0%; OR, 17.01; 95% CI, 10.66-27.16; P < .0001). CONCLUSIONS: Despite lower rates of postoperative complications, in-hospital mortality after appendectomy was higher in Colombia than in the United States. This difference may be explained by higher rates of failure to rescue in the low-to-middle-income country (ie, decreased ability of Colombian hospitals to rescue patients from complications).

Pro-Con Debate: Are Patients With Coronary Stents Suitable for Free-Standing Ambulatory Surgery Centers?

With increasing implantation of coronary artery stents over the past 2 decades, it is inevitable that anesthesiologists practicing in the outpatient setting will need to determine whether these patients are suitable for procedures at a free-standing ambulatory surgery center (ASC). Appropriate selection of patients with coronary artery stents for a procedure in an ASC requires consideration of factors that affect the balance between the risk of stent thrombosis due to interruption of antiplatelet therapy and the thrombogenic effects of surgery, and the risk of perioperative bleeding complications that may occur if antiplatelet therapy is continued. Thus, periprocedure care of these patients presents unique challenges, particularly for extensive surgical procedures that are increasingly scheduled for free-standing ASCs, where consultation and ancillary services, as well as access to percutaneous cardiac interventions, may not be readily available. Therefore, the suitability of the ambulatory setting for this patient population remains highly controversial. In this Pro-Con commentary, we discuss the arguments for and against scheduling patients with coronary artery stents in free-standing ASCs.

Pro-Con Debate: Are Patients With a Cardiovascular Implantable Electronic Device Suitable to Receive Care in a Free-Standing Ambulatory Surgery Center?

Migration of surgical and other procedures that require anesthesia care from a hospital to a free-standing ambulatory surgery center (ASC) continues to grow. Patients with cardiac implantable electronic devices (CIED) might benefit from receiving their care in a free-standing ASC setting. However, these patients have cardiovascular comorbidities that can elevate the risk of major adverse cardiovascular events. CIEDs are also complex devices and perioperative management varies between devices marketed by various manufacturers and require consultation and ancillary services, which may not be available in a free-standing ASC. Thus, perioperative care of these patients can be challenging. Therefore, the suitability of this patient population in a free-standing ASC remains highly controversial. Although applicable advisories exist, considerable discussion continues with surgeons and other proceduralists about the concerns of anesthesiologists. In this Pro-Con commentary article, we discuss the arguments for and against scheduling a patient with a CIED in a free-standing ASC.

Frailty as a Predictor of Mortality for Fenestrated EVAR and Open Surgical Repair of Aortic Aneurysms Involving Visceral Vessels.

OBJECTIVES: Frailty has been correlated with poor outcomes after major surgery across multiple specialties, but has not been studied in patients undergoing open or endovascular repair of suprarenal and thoracoabdominal aortic aneurysms. Fenestrated endovascular aneurysm repair (FEVAR) has emerged as a lower risk alternative to open surgical repair (OSR) for patients with complex aortic aneurysms involving the visceral artery branches. The objective of the current study was to examine the relationship between frailty and peri-operative outcomes for FEVAR and OSR in patients with suprarenal and thoracoabdominal aortic aneurysms. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent FEVAR or OSR for the years 2011 through 2017. Frailty was quantified using a modified 5-factor frailty index (mFI-5) that was previously validated for surgical patients. Frailty was correlated with the primary endpoint of 30-day mortality. Logistic regression was used to identify predictors of 30-day mortality. RESULTS: A total of 675 FEVAR and 1,779 OSR operations were included in the analysis. The 30-day mortality rate was 3.0% for FEVAR and 7.1% for OSR (P = 0.002). Increasing frailty was significantly associated with higher 30-day mortality for both FEVAR (P = 0.018) and OSR (P = 0.0003). Independent predictors of 30-day mortality were frailty score (Odds Ratio [OR] 1.22 [per 0.1-unit increase]; P = 0.0005), type of repair (OSR versus FEVAR, OR 2.46; P = 0.0001), age (OR 1.03; P = 0.0025), female sex (OR 1.61; P = 0.007), Hispanic ethnicity (OR 2.68; P = 0.021), American Society of Anesthesiology [ASA] class (OR 1.57; P = 0.035), preoperative dialysis (OR 3.45; P = 0.032), and history of bleeding disorder (OR 2.60; P < 0.0001). CONCLUSIONS: Frailty, as measured using a mFI-5 score, is an independent predictor of 30-day mortality, overall complications, and length of stay after FEVAR or OSR. Frailty should be used to identify patients at high risk of adverse postoperative outcomes to determine if this risk is modifiable or whether nonoperative is the most appropriate option. FEVAR may offer improved 30-day outcomes, compared to OSR, for the frailest patients.

Global control of COVID-19: good vaccines may not suffice.

The COVID-19 pandemic has unveiled health and socioeconomic inequities around the globe. Effective epidemic control requires the achievement of herd immunity, where susceptible individuals are conferred indirect protection by being surrounded by immunized individuals. The proportion of people that need to be vaccinated to obtain herd immunity is determined through the herd immunity threshold. However, the number of susceptible individuals and the opportunities for contact between infectious and susceptible individuals influence the progress of an epidemic. Thus, in addition to vaccination, control of a pandemic may be difficult or impossible to achieve without other public health measures, including wearing face masks and social distancing. This article discusses the factors that may contribute to herd immunity and control of COVID-19 through the availability of effective vaccines and describes how vaccine effectiveness in the community may be lower than that expected. It also discusses how pandemic control in some countries and populations may face vaccine accessibility barriers if market forces strongly regulate the new technologies available, according to the inverse care law.

La pandemia de COVID-19 ha puesto al descubierto inequidades socioeconómicas y de salud en todo el mundo. Un control epidémico eficaz requiere el logro de la inmunidad colectiva, mediante la cual se confiere a las personas vulnerables una protección indirecta al estar rodeadas de personas inmunizadas. El umbral de inmunidad colectiva determina la proporción de personas que deben vacunarse para llegar a la inmunidad colectiva. Sin embargo, el número de personas vulnerables y las oportunidades de contacto entre las personas infecciosas y las personas vulnerables influyen en el progreso de una epidemia. Por lo tanto, además de la vacunación, el control de una pandemia puede ser difícil o imposible de lograr sin otras medidas de salud pública, como las mascarillas y el distanciamiento social. Este artículo trata sobre los factores que pueden contribuir al logro de la inmunidad colectiva y el control de la COVID-19 mediante la disponibilidad de vacunas efectivas y describe cómo la efectividad de las vacunas en la comunidad puede ser inferior a la prevista. También aborda cómo el control pandémico en algunos países y grupos poblacionales puede enfrentarse a obstáculos que dificultan la accesibilidad de las vacunas si las fuerzas del mercado son el principal factor que regula las nuevas tecnologías disponibles, como se indica en la ley de atención inversa.

A pandemia de COVID-19 revelou iniquidades socioeconômicas e de saúde no mundo todo. Um controle epidêmico eficaz requer a obtenção da imunidade coletiva, em que indivíduos suscetíveis recebem proteção indireta por estarem rodeados de indivíduos imunizados. A proporção de pessoas que precisam ser vacinadas para se alcançar a imunidade coletiva é definida pelo limiar da imunidade coletiva. Porém, o número de indivíduos suscetíveis e as oportunidades de contato entre indivíduos infecciosos e suscetíveis influenciam o progresso de uma epidemia. Portanto, além da vacinação, o controle de uma pandemia pode ser difícil ou impossível de ser alcançado sem outras medidas de saúde pública, incluindo o uso de máscaras e o distanciamento social. Este artigo discute os fatores que podem contribuir para a imunidade coletiva e para o controle da COVID-19 por meio da disponibilidade de vacinas eficazes, e descreve como a eficácia das vacinas na comunidade pode ser menor do que o esperado. Também discute como o controle da pandemia em alguns países e populações pode enfrentar barreiras de acessibilidade às vacinas se as forças de mercado regularem fortemente as novas tecnologias disponíveis, conforme a lei dos cuidados inversos.

Global control of COVID-19: good vaccines may not suffice

[ABSTRACT]. The COVID-19 pandemic has unveiled health and socioeconomic inequities around the globe. Effective epidemic control requires the achievement of herd immunity, where susceptible individuals are conferred indirect protection by being surrounded by immunized individuals. The proportion of people that need to be vaccinated to obtain herd immunity is determined through the herd immunity threshold. However, the number of susceptible individuals and the opportunities for contact between infectious and susceptible individuals influence the progress of an epidemic. Thus, in addition to vaccination, control of a pandemic may be difficult or impossible to achieve without other public health measures, including wearing face masks and social distancing. This article discusses the factors that may contribute to herd immunity and control of COVID-19 through the availability of effective vaccines and describes how vaccine effectiveness in the community may be lower than that expected. It also discusses how pandemic control in some countries and populations may face vaccine accessibility barriers if market forces strongly regulate the new technologies available, according to the inverse care law.

[RESUMEN]. La pandemia de COVID-19 ha puesto al descubierto inequidades socioeconómicas y de salud en todo el mundo. Un control epidémico eficaz requiere el logro de la inmunidad colectiva, mediante la cual se confiere a las personas vulnerables una protección indirecta al estar rodeadas de personas inmunizadas. El umbral de inmunidad colectiva determina la proporción de personas que deben vacunarse para llegar a la inmunidad colectiva. Sin embargo, el número de personas vulnerables y las oportunidades de contacto entre las personas infecciosas y las personas vulnerables influyen en el progreso de una epidemia. Por lo tanto, además de la vacunación, el control de una pandemia puede ser difícil o imposible de lograr sin otras medidas de salud pública, como las mascarillas y el distanciamiento social. Este artículo trata sobre los factores que pueden contribuir al logro de la inmunidad colectiva y el control de la COVID-19 mediante la disponibilidad de vacunas efectivas y describe cómo la efectividad de las vacunas en la comunidad puede ser inferior a la prevista. También aborda cómo el control pandémico en algunos países y grupos poblacionales puede enfrentarse a obstáculos que dificultan la accesibilidad de las vacunas si las fuerzas del mercado son el principal factor que regula las nuevas tecnologías disponibles, como se indica en la ley de atención inversa.

[RESUMO]. A pandemia de COVID-19 revelou iniquidades socioeconômicas e de saúde no mundo todo. Um controle epidêmico eficaz requer a obtenção da imunidade coletiva, em que indivíduos suscetíveis recebem proteção indireta por estarem rodeados de indivíduos imunizados. A proporção de pessoas que precisam ser vacinadas para se alcançar a imunidade coletiva é definida pelo limiar da imunidade coletiva. Porém, o número de indivíduos suscetíveis e as oportunidades de contato entre indivíduos infecciosos e suscetíveis influenciam o progresso de uma epidemia. Portanto, além da vacinação, o controle de uma pandemia pode ser difícil ou impossível de ser alcançado sem outras medidas de saúde pública, incluindo o uso de máscaras e o distanciamento social. Este artigo discute os fatores que podem contribuir para a imunidade coletiva e para o controle da COVID-19 por meio da disponibilidade de vacinas eficazes, e descreve como a eficácia das vacinas na comunidade pode ser menor do que o esperado. Também discute como o controle da pandemia em alguns países e populações pode enfrentar barreiras de acessibilidade às vacinas se as forças de mercado regularem fortemente as novas tecnologias disponíveis, conforme a lei dos cuidados inversos.

Failure to rescue: A quality indicator for postoperative care.

Postoperative complications occur despite optimal perioperative care and are an important driver of mortality after surgery. Failure to rescue, defined as death in a patient who has experienced serious complications, has emerged as a quality metric that provides a mechanistic pathway to explain disparities in mortality rates among hospitals that have similar perioperative complication rates. The risk of failure to rescue is higher after invasive surgical procedures and varies according to the type of postoperative complication. Multiple patient factors have been associated with failure to rescue. However, failure to rescue is more strongly correlated with hospital factors. In addition, microsystem factors, such as institutional safety culture, teamwork, and other attitudes and behaviors may interact with the hospital resources to effectively prevent patient deterioration. Early recognition through bedside and remote monitoring is the first step toward prevention of failure to rescue followed by rapid response initiatives and timely escalation of care.

Patient Selection for Adult Ambulatory Surgery: A Narrative Review.

With migration of medically complex patients undergoing more extensive surgical procedures to the ambulatory setting, selecting the appropriate patient is vital. Patient selection can impact patient safety, efficiency, and reportable outcomes at ambulatory surgery centers (ASCs). Identifying suitability for ambulatory surgery is a dynamic process that depends on a complex interplay between the surgical procedure, patient characteristics, and the expected anesthetic technique (eg, sedation/analgesia, local/regional anesthesia, or general anesthesia). In addition, the type of ambulatory setting (ie, short-stay facilities, hospital-based ambulatory center, freestanding ambulatory center, and office-based surgery) and social factors, such as availability of a responsible individual to take care of the patient at home, can also influence patient selection. The purpose of this review is to present current best evidence that would provide guidance to the ambulatory anesthesiologist in making an informed decision regarding patient selection for surgical procedures in freestanding ambulatory facilities.

Outcomes of Sleep Apnea Surgery in Outpatient and Inpatient Settings.

BACKGROUND: Upper airway surgery is an alternative treatment for patients with severe obstructive sleep apnea (OSA). However, there is controversy regarding selection criteria for outpatient versus inpatient settings for these surgical procedures. The aim of this retrospective study was to compare postoperative outcomes of patients undergoing airway surgery in outpatient and inpatient settings based on length of stay at the facility. METHODS: The 2011-2017 American College of Surgeons National Surgical Quality Improvement databases were used to select adult patients with a diagnosis of OSA undergoing elective airway surgery procedures. Single-level (eg, uvulopalatopharyngoplasty [UPPP]) or multilevel surgery (eg, concomitant procedures on base of tongue, maxilla, palate, nose/turbinate, or tracheotomy) was identified using appropriate current procedural terminology (CPT) codes. Surgery setting was classified as outpatient (length of hospital stay = 0 days) or inpatient (length of stay ≥1 day). Propensity scores derived from logistic regression models were used to match inpatient to outpatient cases at a ratio of 1:1. Primary outcome was a composite of 30-day readmissions, reoperations, and/or postoperative complications. Outcomes between the matched groups were compared with McNemar's tests and generalized mixed linear regression analyses. RESULTS: A total of 3208 cases were identified (1049 [32.7%] outpatient and 2159 [67.3%] inpatient). Inpatients were older, had more comorbidities, larger body mass index, and more multilevel procedures. UPPP was performed in about 96% of both inpatients and outpatients. The overall rate of composite of readmission, reoperations, and/or complications in the whole unmatched sample was 6.4% (6.8% and 5.5% in inpatients and outpatients, respectively). The propensity-matching algorithm produced a sample of 987 patients per surgical setting well balanced on available baseline characteristics. The incidence of the composite primary outcome was not significantly different between the groups (6.2% and 5.9% in inpatients and outpatients, respectively; odds ratio [OR] [95% confidence interval {CI}], 1.06 [0.73-1.53]; P = .77). CONCLUSIONS: This retrospective study found that the complications and 30-day readmission rates after airway surgery for OSA are low. There were no significant differences in the composite outcome of 30-day readmissions, reoperations, or complications between inpatient and outpatient settings. Adequately designed prospective studies are necessary to confirm the retrospective observations of this study.

Readmission Rate After 2-level Lumbar Decompression: A Propensity-matched Cohort Study Comparing Inpatient and Outpatient Settings.

STUDY DESIGN: Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database years 2012-2015. OBJECTIVE: Compare the 30-day readmission and postoperative major complications rates of 2-level lumbar decompression performed in the ambulatory and the inpatient settings. SUMMARY OF BACKGROUND DATA: In recent years, there is an increasing trend toward ambulatory spine surgery. However, there remains a concern regarding risks of readmission and postoperative morbidity after discharge. METHODS: The ACS-NSQIP database from 2012 to 2015 was queried for adult patients who underwent elective 2-level lumbar decompression (CPT code 63047 accompanied with code 63048). A cohort of ambulatory lumbar decompression cases was matched 1:1 with an inpatient cohort after controlling for patient demographics, comorbidities, and complexity of the procedure. The primary outcome was the 30-day readmission rate. Secondary outcomes included a composite of 30-day postoperative major complications and hospital length of stay for hospitalized patients. RESULTS: A total of 7505 patients met our study criteria. The ambulatory 2-level lumbar decompression surgery rate increased significantly over the study period from 28% in 2012 to 49% in 2015 (P<0.001). In the matched sample, there was no statistically significant difference in the 30-day readmission rate (odds ratio, 0.82; 95% confidence interval, 0.64-1.04; P=0.097) between the two cohorts; however, the ambulatory cohort had a lower 30-day postoperative major complication rate (odds ratio, 0.55; 95% confidence interval, 0.38-0.79; P=0.002). CONCLUSIONS: After 2-level lumbar decompression performed on inpatient versus outpatient basis, the 30-day readmission rate is similar. However, the 30-day postoperative complication rate is significantly lower in the ambulatory setting. The reasons for these differences need further exploration. LEVEL OF EVIDENCE: Level III.

Intraoperative Airway Management Considerations for Adult Patients Presenting With Tracheostomy: A Narrative Review.

Tracheotomy is a surgical procedure through which a tracheostomy, an opening into the trachea, is created. Indications for tracheostomy include facilitation of airway management during prolonged mechanical ventilation, treatment of acute upper airway obstruction when tracheal intubation is unfeasible, management of chronic upper airway obstructive conditions, and planned airway management for major head and neck surgery. Patients who have a recent or long-term tracheostomy may present for a variety of surgical or diagnostic procedures performed under general anesthesia or sedation/analgesia. Airway management of these patients can be challenging and should be planned ahead of time. Anesthesia personnel should be familiar with the different components of cuffed and uncuffed tracheostomy devices and their connectivity to the anesthesia circuits. An appropriate airway management plan should take into account the indication of the tracheostomy, the maturity status of the stoma, the type and size of tracheostomy tube, the expected patient positioning, and presence of patient's concurrent health conditions. Management of the patient with a T-tube is highlighted. Importantly, there is a need for multidisciplinary care involving anesthesiologists, surgical specialists, and perioperative nurses. The aim of this narrative review is to discuss the anesthesia care of patients with a tracheostomy. Key aspects on relevant tracheal anatomy, tracheostomy tubes/devices, alternatives of airway management, and possible complications related to tracheostomy are summarized with a recommendation for an algorithm to manage intraoperative tracheostomy tube dislodgement.

Finding the body mass index cutoff for hospital readmission after ambulatory hernia surgery.

BACKGROUND: The suitability of ambulatory surgery in obese patients remains controversial. This study aimed to investigate the "cutoff" value of body mass index (BMI) associated with increased likelihood of hospital readmissions within the first 24 hours of surgery in patients undergoing ambulatory hernia repair. MATERIALS AND METHODS: The study used data from the 2012-2016 American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP). Cochran Armitage trend tests were conducted to assess progression in rates hospital readmissions across categories of patient BMI. The minimum p-value method, Kolmogorov-Smirnov goodness of fit tests, logistic regression, and receiver-operating characteristic (ROC) curve analyses were used to investigate the cutoff of patient BMI indicative of increased likelihood of readmissions. RESULTS: A total of 214,125 ambulatory hernia repair cases were identified. Of those, 908 patients (0.42%) had an unexpected hospital admission within the first 24 hours after surgery. The readmission rates did not significantly increase across the categories of BMI. However, some of the reasons for readmission significantly differed by BMI category. Logistic regression analysis revealed no statistically significant association between BMI and hospital readmissions (odds ratio [95% Cl], 0.96 [0.91-1.02] P = .179). An optimal BMI threshold predictive of an increased likelihood of hospital readmissions was not identifiable by any of the statistical methods used. CONCLUSIONS: Although reasons for readmission differed by BMI category, there is no clear cutoff value of BMI associated with increased hospital readmission within the first 24 hours after surgery.

Failure to rescue after major abdominal surgery: The role of hospital safety net burden.

BACKGROUND: We aimed to examine whether safety-net burden is a significant predictor of failure-to-rescue (FTR) after major abdominal surgery controlling for patient and hospital characteristics, including surgical volume. METHODS: Data were extracted from the 2007-2011 Nationwide Inpatient Sample. FTR was defined as mortality among patients experiencing major postoperative complications. Differences in rates of complications, mortality, and FTR across quartiles of safety-net burden were assessed with univariate analyses. Multilevel regression models were constructed to estimate the association between FTR and safety-net burden. RESULTS: Among 238,645 patients, the incidence of perioperative complications, in-hospital mortality, and FTR were 33.7%, 4.4%, and 11.8%, respectively. All the outcomes significantly increased across the quartiles of safety-net burden. In the multilevel regression analyses, safety-net burden was a significant predictor of FTR after adjustment for patient and hospital characteristics, including hospital volume. CONCLUSION: Increasing hospital safety-net burden is associated with higher odds of FTR for major abdominal surgery.

Defining the threshold surgeon volume associated with improved patient outcomes for carotid endarterectomy.

OBJECTIVE: The outcomes for common vascular operations, such as carotid endarterectomy (CEA), are associated with surgeon volume. However, the number of operations associated with an improved stroke or death rate for CEA is not known. The objective of the current study was to define the annual surgeon volume of CEAs that is associated with a lower risk of stroke or death rate. METHODS: The Nationwide Inpatient Sample was analyzed to identify patients undergoing CEA between 2003 and 2009. Annual surgeon volume was correlated with a composite end point of in-hospital stroke or death. Mixed linear regression analyses were conducted to determine if annual surgeon volume of CEAs is independent predictor of the composite outcome. Receiver operating characteristic curves were constructed from the regression models and used to calculate the Youden Index, which defined the optimal cutoff point of annual surgeon volume of CEAs in predicting in-hospital stroke and death. This cutoff point was further assessed using Chi square analyses to determine whether incremental increases in the annual volume of CEAs were associated with a lower in-hospital stroke or death rate. RESULTS: A total of 104,918 CEA cases with surgeon identifiers were included in the analysis. The crude in-hospital stroke or death rate for CEA was 1.26 %. As expected, the stroke or death rate after CEA was higher for symptomatic patients, compared to asymptomatic patients (6.46 % vs 0.72%; P < .0001). For symptomatic patients, the relationship between surgeon volume and the composite end point was not significant (P = .435). In contrast, there was a strong relationship between surgeon volume and outcomes for asymptomatic patients undergoing CEA with a stroke/death rate of 1.66%, 0.91%, and 0.65% for low-, moderate-, and high-volume surgeons (P < .0001). Multivariate analysis identified age, African-American race, Charlson Comorbidity Index, and surgeon volume as independent predictors of stroke/death after CEA for asymptomatic carotid stenosis. For asymptomatic patients, the optimal cutoff number of CEAs to predict stroke/death rate was 19.4 CEAs per year (sensitivity = 74.9%, specificity = 72.6%, Youden index = 0.475). Analyses of outcomes at different cutoff points of surgeon volume revealed that the rate of crude complications and the adjusted probability of stroke or death was higher with case numbers less than 20 CEAs per year and lower with case numbers of 20 CEA or higher per year. Cutoff points above 20 cases were year did not yield a stroke/death rate that was significantly lower than the stroke/death rate at 20 CEAs per year, which confirmed the cutoff point of 20 CEAs per year. Only 16% of surgeons in the database achieved the threshold of 20 CEAs per year. CONCLUSIONS: Higher surgeon volume is associated with improved outcomes for CEAs performed in patients with asymptomatic carotid disease, but not for symptomatic carotid disease. For asymptomatic carotid disease, the probability of stroke or death was no longer reduced significantly at cutoff points of 20 or more CEAs per year. There are a number of other variables that may impact the clinical outcomes for CEA, so it is premature at this time to restrict privileges based on surgeon volume criteria.

A Randomized Controlled Trial Comparing Learners' Decision-making, Anxiety, and Task Load During a Simulated Airway Crisis Using Two Difficult Airway Aids.

INTRODUCTION: The American Society of Anesthesiologists (ASA) difficult airway algorithm and the Vortex approach are difficult airway aids. Our objective was to demonstrate that a simpler cognitive model would facilitate improved decision-making during a process such as difficult airway management. We hypothesized the simpler Vortex approach would be associated with less anxiety and task load. METHODS: Medical students were randomized to the ASA algorithm (n = 33) or Vortex approach (n = 34). All learned basic airway techniques on day 1 of their rotation. Next, they watched a video of their respective aid then managed a simulated airway crisis. We assessed decision-making using a seven-point airway management score and a completeness score. Completeness was at least one attempt at each of four techniques (mask ventilation, supraglottic airway, intubation, and cricothyrotomy). Two validated tools, the State-Trait Anxiety Inventory Form Y and the National Aeronautics and Space Administration Task Load Index, were used to assess anxiety and task load. RESULTS: Students in the Vortex group had higher airway management scores [4.0 (interquartile range = 4.0 to 5.0) vs. 4.0 (3.0 to 4.0), P = 0.0003] and completeness (94.1% vs. 63.6%, P = 0.003). In the ASA group, the means (SD) of National Aeronautics and Space Administration Task Load Index scores of 55 or higher were observed in mental [61.4 (14.4)], temporal [62.3 (22.9)], and effort [57.1 (15.6)] domains. In the Vortex group, only the temporal load domain was 55 or higher [mean (SD) = 57.8 (25.4)]. There was no difference in anxiety. CONCLUSIONS: Medical students perform better in a simulated airway crisis after training in the simpler Vortex approach to guide decision-making. Students in the ASA group had task load scores indicative of high cognitive load.

The Surgeon Volume-outcome Relationship: Not Yet Ready for Policy.

OBJECTIVE: Increasing surgeon volume may improve outcomes for index operations. We hypothesized that there may be surrogate operative experiences that yield similar outcomes for surgeons with a low-volume experience with a specific index operation, such as esophagectomy. BACKGROUND: The relationship between surgeon volume and outcomes has potential implications for credentialing of surgeons. Restrictions of privileges based on surgeon volume are only reasonable if there is no substitute for direct experience with the index operation. This study was aimed at determining whether there are valid surrogates for direct experience with a sample index operation-open esophagectomy. METHODS: The Nationwide Inpatient Sample (2003-2009) was utilized. Surgeons were stratified into low and high-volume groups based on annual volume of esophagectomy. Surrogate volume was defined as the aggregate annual volume per surgeon of upper gastrointestinal operations including excision of esophageal diverticulum, gastrectomy, gastroduodenectomy, and repair of diaphragmatic hernia. RESULTS: In all, 26,795 esophagectomies were performed nationwide (2003-2009), with a crude inhospital mortality rate of 5.2%. Inhospital mortality decreased with increasing volume of esophagectomies performed annually: 7.7% and 3.8% for low and high-volume surgeons, respectively (P < 0.0001). Among surgeons with a low-volume esophagectomy experience, increasing volume of surrogate operations improved the outcomes observed for esophagectomy: 9.7%, 7.1%, and 4.3% for low, medium, and high-surrogate-volume surgeons, respectively (P = 0.016). CONCLUSIONS: Both operation-specific volume and surrogate volume are significant predictors of inhospital mortality for esophagectomy. Based on these observations, it would be premature to limit hospital privileges based solely on operation-specific surgeon volume criteria.