Patient and operative factors influence delayed discharge following bariatric surgery in an enhanced recovery setting.

BACKGROUND: Enhanced Recovery After Surgery (ERAS) programs have been widely adopted in bariatric surgery. However, not all patients are successfully managed in the ERAS setting and there is currently little way of predicting the patients who will deviate from the program. Early identification of these patients could allow for more tailored protocols to be implemented preoperatively to address the issues, thereby improving patient outcomes. OBJECTIVES: The aim of this study was to elucidate the factors which preclude discharge by comparing patients who were successfully discharged by the end of the first postoperative day (POD 0/1) to those who stayed longer, including revisional surgery in this analysis. SETTING: A tertiary, high-volume Bariatric Centre, United Kingdom. METHODS: A retrospective analysis was performed of all patients undergoing bariatric surgery in a single centre in 1 year. Multivariate analyses compared patient and operative variables between patients who were discharged on POD 0/1 and those who stayed longer. RESULTS: A total of 288 bariatric operations were performed: 78% of operations performed were laparoscopic Roux-en-Y gastric bypass; 22% laparoscopic sleeve gastrectomy. Of these cases, 13% were revisional operations. Four patients returned to theatre on the index admission. 81% of patients were discharged by POD 0/1. A re-presentation within 30 days was seen in 6% of patients. There was no significant difference in length of stay for the type of operation performed (P = .86). Patients who had a revisional procedure were not more likely to stay longer. Length of stay was also independent of age, BMI, and comorbidities. Caucasian patients were more likely to be discharged on POD 0/1 than those of other ethnicities (90% versus 78%; P = .02). Operations performed by trainee surgeons, under consultant supervision, were significantly more likely to be discharged on POD 0/1 (P = .03). However, a logistic regression analysis was unable to predict patients who had a prolonged stay. CONCLUSIONS: Patient length of stay is independent of BMI, operation, and comorbidities and these factors do not need special consideration in ERAS pathways. Patients undergoing revisional procedures can be managed in the same way as those having primary procedures, with a routine POD 0/1 discharge. However, the impact of individual patient factors, and their interaction, is complex and cannot predict overstay.

Long-term BAROS scores and independent obesity-related co-morbidity predictors of failure after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Long-term (>5 yr) studies assessing outcomes after laparoscopic Roux-en-Y gastric bypass (LRYGB) using the Bariatric Analysis and Reporting Outcome System (BAROS) are limited. Evidence of predictors of failure long-term after LRYGB is also lacking. OBJECTIVES: To compare BAROS scores at 5 and 10 years post LRYGB and to establish whether individual obesity-related co-morbidities are associated with suboptimal outcomes at these time points. SETTING: Single bariatric unit. METHODS: BAROS scores were analyzed in patients who were 5 years (group A) and 10 years (group B) post LRYGB. Obesity-related co-morbidities as predictors of failure of surgery (defined by % excess weight loss [%EWL] <50% or BAROS total score ≤1) were examined. Intergroup comparative analysis of outcomes and logistic regression modeling to determine predictors of weight loss failure were conducted. RESULTS: A total of 88 patients were 5 years post LRYGB (group A), and 91 patients were 10 years post LRYGB (group B). A total of 52.3% (46/88) in group A and 54.9% (50/91) in group B had failure of weight loss defined by %EWL <50%. There were no significant differences in percentage of total weight loss, %EWL, or BAROS scores between the 2 groups (21.8% versus 22.0%, P = .897; 48.5% versus 47.1%, P = .993; and 3.7 versus 3.3, P = .332, respectively). No individual obesity-related co-morbidity at time of surgery was associated with suboptimal outcomes (%EWL <50% or BAROS total score ≤1) at 5 years or 10 years after LRYGB. CONCLUSIONS: Long-term outcomes assessed by the BAROS score appear sustainable between 5 and 10 years after LRYGB surgery, and weight loss achieved at 5 years is maintained at 10 years. Preoperative presence of specific obesity-related co-morbidities was not associated with failure of surgery long-term.

Long-Term Outcomes and Quality of Life at More than 10 Years After Laparoscopic Roux-en-Y Gastric Bypass Using Bariatric Analysis and Reporting Outcome System (BAROS).

INTRODUCTION: Literature on long-term (> 10 years) outcomes in terms of weight loss, resolution of co-morbidities, and quality of life (QoL) after bariatric surgery is limited. The aim of this study was to investigate the excess weight loss (EWL), resolution of comorbidities, and QoL more than 10 years after laparoscopic Roux-en-Y gastric bypass (LRYGB) using the Bariatric Analysis and Reporting Outcome System (BAROS). METHODS: Data on patient demographics, weight, body mass index (BMI), comorbidities, type of surgery, complications, and QoL were collected from a prospectively maintained database. RESULTS: A total of 92 patients out of 104 who underwent LRYGB during the study period and completed a median follow-up of 130 months were successfully contacted. The median age was 48 years (IQR 42-54 years) and 85.9% had a BMI of more than 40. The median excess weight loss (EWL) was 46.5% (IQR 27.9-64.3%). Type 2 diabetes mellitus reduced from 56.5 to 23.9% (p < 0.001), hypertension from 51.1 to 39.1% (p = 0.016), and obstructive sleep apnoea from 33.7 to 12.0% (p < 0.001). Participants reported feeling better (median 0.2, IQR 0.2-0.4), engaging in more physical activity (0.1, IQR 0.1-0.3), having more satisfactory social contacts (0.4, IQR 0.2-0.5), a better ability to work (0.3, IQR - 0.1-0.5), and a healthier approach to food (0.2, IQR - 0.3-0.3) at the end of follow-up. CONCLUSION: LRYGB leads to positive outcomes in terms of weight loss, reduction in comorbidities, and improvement in QoL at a follow-up of more than 10 years.

Surgeon Volume and Cancer Esophagectomy, Gastrectomy, and Pancreatectomy: A Population-based Study in England.

OBJECTIVE: The aim of the study was to assess whether there is a proficiency curve-like relationship between surgeon volume and operative mortality and determine the minimum surgeon volume for optimum operative mortality. BACKGROUND: The inverse relationship between hospital volume and operative mortality is well-established for esophageal, gastric, and pancreatic cancer. The recommended minimum surgeon volumes are however uncertain. METHODS: We retrieved data on esophagectomies, gastrectomies, and pancreatectomies for cancer from the NHS Hospital Episodes Statistics database from April 2000 to March 2010. We defined mortality as in-hospital death within 30 days of surgery. We determined whether there was a proficiency curve relationship by inspecting surgeon volume-mortality graphs after adjusting for patient age, sex, socioeconomic, and comorbidity indices. We then statistically determined the minimum surgeon volume that produced a mortality rate insignificantly different from the optimum of the curve. RESULTS: Sixteen thousand five hundred seventy-two esophagectomies, 12,622 gastrectomies, and 9116 pancreatectomies were examined. Surgeon volume ranged from 2 to 29 esophagectomies, from 1 to 14 gastrectomies, and from 2 to 31 pancreatectomies per surgeon per year. We demonstrated a proficiency relationship between surgeon volume and mortality in esophageal, gastric, and pancreatic cancer surgery. Each additional case of esophagectomy, gastrectomy, and pancreatectomy would reduce 30-day mortality odds by 3.4%, 7.2%, and 4.1%, respectively. However, as surgeon volume increased, mortality rate continued to improve. Therefore, we were unable to recommend minimum surgeon volume. CONCLUSIONS: Mortality after resections for esophageal, gastric, and pancreatic cancer falls as surgeon volume rises up to 30 cases. Within this range, we did not demonstrate any statistical threshold that could be recommended as a minimum volume target.

Is It Time to Centralize High-risk Cancer Care in the United States? Comparison of Outcomes of Esophagectomy Between England and the United States.

OBJECTIVE: To determine the difference in in-hospital mortality and length of hospital stay (LOS) after esophagectomy between the United States and England. BACKGROUND: Since 2001, complex procedures such as esophagectomy have been centralized in England, but in the United States no formal plan for centralization exists. METHODS: Patients who underwent esophagectomy for cancer between 2005 and 2010 were identified from the Nationwide Inpatient Sample (United States) and the Hospital Episodes Statistics (England). In-hospital mortality and LOS were compared. RESULTS: There were 7433 esophagectomies performed in 66 English hospitals and 5858 resections in 775 US hospitals; median number of resections per center per year was 17.5 in England and 2 in the United States. In-hospital mortality was greater in US hospitals (5.50% vs 4.20%, P = 0.001). In multiple regression analysis, predictors of mortality included patient age, comorbidities, hospital volume, and surgery performed in the United States [odds ratio (OR) = 1.20 (1.02-1.41), P = 0.03]. Median LOS was greater in the English hospitals (15 vs 12 days, P < 0.001). However, when subset analysis was done on high-volume centers in both health systems, mortality was significantly better in US hospitals (2.10% vs 3.50%, P = 0.02). LOS was also seen to decrease in the US high-volume centers but not in England. CONCLUSIONS: The findings from this international comparison suggest that centralization of high-risk cancer surgery to centers of excellence with a high procedural volume translates into an improved clinical outcome. These findings should be factored into discussions regarding future service configuration of major cancer surgery in the United States.

Outlier identification in colorectal surgery should separate elective and nonelective service components.

BACKGROUND: The identification of health care institutions with outlying outcomes is of great importance for reporting health care results and for quality improvement. Historically, elective surgical outcomes have received greater attention than nonelective results, although some studies have examined both. Differences in outlier identification between these patient groups have not been adequately explored. OBJECTIVE: The aim of this study was to compare the identification of institutional outliers for mortality after elective and nonelective colorectal resection in England. DESIGN: This was a cohort study using routine administrative data. Ninety-day mortality was determined by using statutory records of death. Adjusted Trust-level mortality rates were calculated by using multiple logistic regression. High and low mortality outliers were identified and compared across funnel plots for elective and nonelective surgery. SETTINGS: All English National Health Service Trusts providing colorectal surgery to an unrestricted patient population were studied. PATIENTS: Adults admitted for colorectal surgery between April 2006 and March 2012 were included. INTERVENTION(S): Segmental colonic or rectal resection was performed. MAIN OUTCOME MEASURES: The primary outcome measured was 90-day mortality. RESULTS: Included were 195,118 patients, treated at 147 Trusts. Ninety-day mortality rates after elective and nonelective surgery were 4% and 18%. No unit with high outlying mortality for elective surgery was a high outlier for nonelective mortality and vice versa. Trust level, observed-to-expected mortality for elective and nonelective surgery, was moderately correlated (Spearman ρ = 0.50, p< 0.001). LIMITATIONS: This study relied on administrative data and may be limited by potential flaws in the quality of coding of clinical information. CONCLUSIONS: Status as an institutional mortality outlier after elective and nonelective colorectal surgery was not closely related. Therefore, mortality rates should be reported for both patient cohorts separately. This would provide a broad picture of the state of colorectal services and help direct research and quality improvement activities.

The role of caseload in determining outcome following laparoscopic colorectal cancer resection: an observational study.

BACKGROUND: This study aimed to evaluate using national data the role of surgeon laparoscopic caseload in determining outcome following elective laparoscopic colorectal cancer resection. METHODS: All patients who underwent an elective laparoscopic primary colorectal cancer resection between 2002 and 2008 were included from the Hospital Episode Statistics database. Surgeon teams were divided into tertiles according to the mean laparoscopic caseload per year. High volume corresponded to more than 12 laparoscopic procedures per year and low volume corresponded to seven or fewer procedures per year. Outcome measures were 30-day in-hospital mortality, return to theatre (RTT), 30-day medical morbidity, 365-day medical morbidity, length of stay (LOS), and unplanned 28-day readmission. RESULTS: There was a significant increase in the number of surgeons selecting patients for the laparoscopic approach between 2002-2003 and 2007-2008. In 2002-2003, a total of 41 surgeon teams performed laparoscopic resections whereas in 2007-2008 there were 398 surgeon teams. The patients of high-volume surgeon teams had a shorter LOS [OR 0.88 (0.85-0.91), p < 0.0001]. Patients of medium-volume surgeon teams had the highest medical morbidity rates [30-day medical morbidity: OR 1.24 (1.04-1.48), p = 0.015; 365-day medical morbidity: OR 1.22 (1.04-1.45), p = 0.018]. There were no differences between the high- and low-volume groups in terms of mortality, morbidity, RTT, or readmission. CONCLUSION: Although there has been a significant increase in the number of surgeon teams offering the minimal access approach, this study has not found a consistent relationship between surgeon laparoscopic cancer surgery caseload and outcome. WHAT'S NEW IN THIS MANUSCRIPT: This is the first national study to explore the role of surgical volume in determining outcome following laparoscopic surgery. This study questions the impact of surgeon caseload on laparoscopic surgical outcome.

National outcomes and uptake of laparoscopic gastrectomy for cancer in England.

BACKGROUND: Gastrectomy remains the mainstay of curative treatment for gastric cancer, yet it is associated with significant postoperative mortality. The laparoscopic approach has been introduced in an attempt to improve surgical outcomes. This study examines the uptake of laparoscopic gastrectomy in England and quantifies postoperative mortality and morbidity following gastrectomy for cancer. METHODS: A population-based study of a national administrative database was undertaken. Patients undergoing gastrectomy for cancer in any National Health Services hospital in England between April 2000 and March 2010 were included. The main outcome measures were mortality, morbidity and length of stay. RESULTS: A total of 10,713 patients underwent gastrectomy, of which 10,233 (95.5%) underwent open gastrectomy (OG), and 480 (4.5%) underwent laparoscopic gastrectomy (LG). There was no significant difference in 30-day in-hospital mortality between OG and LG (5.6% vs. 4.8%; p = 0.461). Medical complications occurred in 2,311 (22.6%) and 120 (25%) patients from OG and LG groups respectively (p = 0.217). Patients in the LG groups had a shorter hospital stay than OG with median (interquartile range) of 11 (8-17) versus 14 (11-19) days respectively (p < 0.001). Readmission and reoperation rates were 10.2 versus 12.1% (p = 0.175) and 4 versus 4.6% (p = 0.523) for OG and LG respectively. CONCLUSIONS: LG is increasingly being performed in England. Postoperative morbidity and mortality of LG is similar to that of OG, but it is associated with a shorter hospital stay. Data from randomised controlled trials evaluating long term survival and patients' reported outcomes are essential before the final judgement on the value of LG in the management of gastric cancer.

Failure to rescue patients after reintervention in gastroesophageal cancer surgery in England.

IMPORTANCE: Gastroesophageal cancer resections are associated with significant reintervention and perioperative mortality rates. OBJECTIVE: To compare outcomes following operative and nonoperative reinterventions between high- and low-mortality gastroesophageal cancer surgical units in England. DESIGN: All elective esophageal and gastric resections for cancer between 2000 and 2010 in English public hospitals were identified from a national administrative database. Units were divided into low- and high-mortality units (LMUs and HMUs, respectively) using a threshold of 5% or less for 30-day adjusted mortality. The groups were compared for reoperations and nonoperative reinterventions following complications. SETTING: Both LMUs and HMUs. PARTICIPANTS: Patients who underwent esophageal and gastric resections for cancer. EXPOSURE: Elective esophageal and gastric resections for cancer, with reoperations and nonoperative reinterventions following complications. MAIN OUTCOMES AND MEASURES: Failure to rescue is defined as the death of a patient following a complication; failure to rescue-surgical is defined as the death of a patient following reoperation for a surgical complication. RESULTS: There were 14 955 esophagectomies and 10 671 gastrectomies performed in 141 units. For gastroesophageal resections combined, adjusted mortality rates were 3.0% and 8.3% (P < .001) for LMUs and HMUs, respectively. Complications rates preceding reoperation were similar (5.4% for LMUs vs. 4.9% for HMUs; P = .11). The failure to rescue-surgical rates were lower in LMUs than in HMUs (15.3% vs. 24.1%; P < .001). The LMUs performed more nonoperative reinterventions than the HMUs did (6.7% vs. 4.7%; P < .001), with more patients surviving in LMUs than in HMUs (failure to rescue rate, 7.0% vs. 12.5%; P < .001). Overall, LMUs reintervened more than HMUs did (12.2% vs 9.6%; P < .001), and LMUs had lower failure to rescue rates following reintervention than HMUs did (9.0% vs. 18.3%; P = .001). All P values stated refer to 2-sided values. CONCLUSIONS AND RELEVANCE: Overall, LMUs were more likely to reintervene and rescue patients following gastroesophageal cancer resections in England. Patients were more likely to survive following both reoperations and nonsurgical interventions in LMUs.

Poor 1-year survival in elderly patients undergoing nonelective colorectal resection.

BACKGROUND: Colorectal resection in elderly patients is associated with significant morbidity and mortality, especially in an emergency setting. OBJECTIVES: This study aims to quantify the risks associated with nonelective colorectal resection up to 1 year after surgery in elderly patients. DESIGN: This is a population-based observational study. SETTING: Data were obtained from the Hospital Episode Statistics database. POPULATION: All patients aged 70 years and older who underwent a nonelective colorectal resection in an English National Health Service Trust hospital between April 2001 and March 2008 were included. MAIN OUTCOME MEASURES: : The primary outcomes measured were 30-day in hospital mortality, 365-day mortality, unplanned readmission within 28 days of discharge, and duration of hospital stay. RESULTS: During the study period, 36,767 nonelective colorectal resections were performed in patients aged ≥ 70 years in England. Patients were classified into 3 age groups: A (70-75 years), B (76-80 years), and C (>80 years). Thirty-day mortality was 17.0%, 23.3%, and 31.0% in groups A, B, and C (p < 0.001). The overall 30-day medical complication rate was 33.7%, and the reoperation rate was 6.3%. Cardiac and respiratory complications were significantly higher in group C (22.2% and 18.2%, p < 0.001). Mortality in Group C was 51.2% at 1-year postsurgery. Advanced age was an independent determinant of mortality in risk-adjusted regression analyses. LIMITATIONS: This is a retrospective analysis of a prospective database. Stage of disease at presentation, severity of complications, and cause of death cannot be ascertained from this database. CONCLUSIONS: In this population-based study, half of all English patients aged over 80 years undergoing nonelective colorectal resection died within 1 year of surgery. Further research is required to identify perioperative and postdischarge strategies that may improve survival in this vulnerable cohort.

Short-term outcomes following open versus minimally invasive esophagectomy for cancer in England: a population-based national study.

OBJECTIVE: To compare short-term outcomes of open and minimally invasive esophagectomy (MIE) for cancer. BACKGROUND DATA: Numerous studies have demonstrated the safety and possible advantages of MIE in selected cohorts of patients. The increasing use of MIE is not coupled with conclusive evidence of its benefits over "open" esophagectomy, especially in the absence of randomized trials. METHODS: Hospital Episode Statistics data were analyzed from April 2005 to March 2010. This is a routinely collected database of all English National Health Service Trusts. Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures, 4th revision (OPCS-4), procedure codes were used to identify index resections and International Statistical Classification of Diseases, 10th Revision (ICD-10), diagnostic codes were used to ascertain comorbidity status and complications. Thirty-day in-hospital mortality, medical complications, and surgical reinterventions were analyzed. Unadjusted and risk-adjusted regression analyses were undertaken. RESULTS: Seven thousand five hundred and two esophagectomies were undertaken; of these, 1155 (15.4%) were MIE. In 2009-2010, 24.7% of resections were MIE. There was no difference in 30-day mortality (4.3% vs 4.0%; P = 0.605) and overall medical morbidity (38.0% vs 39.2%; P = 0.457) rates between open and MIE groups, respectively. A higher reintervention rate was associated with the MIE group than with the open group (21% vs 17.6%, P = 0.006; odds ratio, 1.17; 95% confidence interval, 1.00-1.38; P = 0.040). CONCLUSIONS: Minimally invasive esophagectomy is increasingly performed in the United Kingdom. Although the study confirmed the safety of MIE in a population-based national data, there are no significant benefits demonstrated in mortality and overall morbidity. Minimally invasive esophagectomy is associated with higher reintervention rate. Further evidence is needed to establish the long-term survival of MIE.

Reduced risk of medical morbidity and mortality in patients selected for laparoscopic colorectal resection in England: a population-based study.

OBJECTIVES: To quantify the occurrence of significant medical complications following elective colorectal resection and investigate potential differences in medical morbidity following open and minimal access colorectal surgery. DESIGN: Retrospective analysis of Hospital Episode Statistics, which is a prospectively maintained national database. SETTING: All patients undergoing colorectal resection in National Health Service trusts in England. PATIENTS: Adult patients undergoing elective or planned surgery between April 2001 and March 2008. INTERVENTION: Colorectal resection for benign and malignant diagnoses. MAIN OUTCOME MEASURES: Mortality and morbidity at 30 days and 1 year following elective colorectal resection. RESULTS: One hundred thirty-eight thousand seven hundred thirty-five elective colorectal resections were identified between the study dates. Thirty-day in-hospital mortality was 3.4% and 1.7% following conventional and laparoscopic surgery, respectively (P < .001). Overall, the 30-day postoperative medical morbidity rate was 14.6%. Use of the minimal access approach demonstrated a significant reduction in total morbidity risk at 30 days (odds ratio, 0.79; P < .001) and 365 days (odds ratio, 0.81; P < .001) following case-mix adjustment. Multiple regression analyses demonstrated that cardiorespiratory complications and venous thromboembolism occurred less frequently during the index admission and up to 1 year following minimal access surgery when compared with the conventional approach (P < .049). CONCLUSIONS: In this population-based study, patients selected for laparoscopic colorectal resection were associated with lower risk of mortality as well as reduced cardiorespiratory and venous thromboembolic risk than those undergoing open surgery.

Chronic cervicothoracic spinal subdural hematoma.

A 33-year-old female presented with an extremely rare case of chronic spinal subdural hematoma in the cervicothoracic region manifesting as sudden onset of flaccid paraplegia and urinary retention. She was receiving warfarin medication for an episode of superior sagittal sinus thrombosis 2 years earlier. Two months previously, she had undergone a minilaparotomy under general anesthesia following unsuccessful spinal anesthesia. Magnetic resonance imaging showed a large cervicothoracic extramedullary mass causing cord compression. However, laminectomy for excision of mass revealed a purely subdural hematoma. Her neurological deficits were partially resolved after removal of subdural hematoma.

Neuroprotective effects of vitamin E in cold induced cerebral injury in guinea pigs.

Significant reduction in hemorrhage (10 v/s 13), necrosis (2 v/s 4), cavitations (7 v/s 13), neuronal degeneration, perivascular and parenchymal inflammatory infiltrate (7 v/s 11) were observed in Vitamin E treated cold induced head injury in guinea pigs, evaluated post injury using the modified Benderson's scale. The results suggest that Vitamin E is highly effective in promoting clinical and histopathological recovery in cold induced head injury in guinea pigs.