Surgeon education through a surgical cost feedback system reduces supply cost in endoscopic skull base surgery.

OBJECTIVE: A large proportion of healthcare expense is operating room (OR) costs. As a means of cost mitigation, several institutions have implemented surgeon education programs to bring awareness about supply costs. This study evaluates the impact of a surgical cost feedback system (surgical receipt) on the supply costs of endoscopic skull base surgery (ESBS) procedures. METHODS: The supply costs of each ESBS surgical case were prospectively collected and analyzed before and after the implementation of a nonincentivized, automated, and itemized weekly surgical receipt system between January 2017 and December 2019. Supply cost data collected 15 months prior to intervention were compared with cost data 21 months after implementation of the surgical receipt system. Demographics, surgical details, and OR time were collected retrospectively. RESULTS: Of 105 ESBS procedures analyzed, 36 preceded and 69 followed implementation of cost feedback. There were no significant differences in patient age (p = 0.064), sex (p = 0.489), surgical indication (p = 0.389), or OR anesthesia time (p = 0.51) for patients treated before and after implementation. The mean surgical supply cost decreased from $3824.41 to $3010.35 (p = 0.002) after implementation of receipt feedback. Usage of dural sealants (p = 0.043), microfibrillar collagen hemostat (p = 0.007), and oxidized regenerated cellulose hemostat (p < 0.0001) and reconstructive technique (p = 0.031) significantly affected cost. Mediation analysis confirmed that the overall cost reduction was predominantly driven by reduced use of dural sealant; this cost saving exceeded the incremental cost of greater use of packing materials such as microfibrillar collagen hemostat. CONCLUSIONS: Education of surgeons regarding surgical supply costs by a surgical receipt feedback system can reduce the supply cost per case of ESBS operations.

Surgeon cost feedback through a surgical receipt program reduces cost in sinonasal surgery.

BACKGROUND: Operating room (OR) costs are a large portion of healthcare expenses. This study evaluates the impact of a surgeon-targeted surgical receipt cost feedback system on OR supply costs in sinonasal surgery and individual components contributing to procedural cost. METHODS: Itemized weekly surgical receipts detailing individual case supply costs were analyzed before and after the implementation of a non-incentivized surgeon cost feedback system between January 2017 and June 2019. Supply cost data collected 15 months prior to intervention was compared to cost data 15 months after implementation of the weekly automated receipt dissemination to surgeons. Chi square test was used for categorical data and the Wilcoxon test was used to compare change in cost. Univariate and mediation analyses were performed to assess variables impacting cost. RESULTS: Of 502 sinonasal procedures analyzed, 239 were before and 264 after cost feedback implementation. There were no significant differences in age/gender, or indication for surgery. The median OR supply cost decreased from $1229.64 to $1097.22 (p = 0.02) after receipt implementation. There were effects of procedure type (p = 0.02), circulating nurse specialization (p < 0.001), steroid eluting stent (p = 0.002), and sinus drill (p < 0.001) on cost. Mediation analysis confirmed full mediation by decreasing use of steroid-eluting stents. CONCLUSION: Surgeon cost feedback in the form of individualized OR surgical receipts is an effective model to reduce supply cost per case in sinonasal surgery.

The Impact of Duty-Hour Restrictions on Complication Rates Following Major Head and Neck Procedures.

OBJECTIVES/HYPOTHESIS: To assess the impact of resident duty-hour restrictions (DHR) in otolaryngology via comparison of postoperative outcomes between otolaryngology teaching hospitals (Oto-TH) and nonteaching hospitals (NTH) before and after complete implementation. STUDY DESIGN: Retrospective database review. METHODS: The Nationwide Inpatient Sample was queried for all major head and neck cases between 2000 and 2002 (n = 34,064) and 2008 and 2010 (n = 33,094). Cases were stratified into Oto-TH (n = 28,771) and NTH (n = 38,387) and assessed for procedure type, patient comorbidities, and complications. A subpopulation matched by procedure type was generated for direct comparison of complication rates using χ2 and binary logistic regression analyses. RESULTS: In the years following DHR, total case volume and average case complexity increased at Oto-TH only. Using a case-matched subpopulation, regression analysis found Oto-TH status to be protective for medical complications both before (odds ratio [OR]: 0.60, P < .001) and after (OR: 0.76, P = .001) DHR. In contrast, Oto-TH cases had lower risk for surgical complications in 2000 to 2002 (OR: 0.77, P < .001) but not 2008 to 2010 (OR: 1.07, P = .275). When comparing time periods, the years following DHR were associated with a significant decrease in medical complications and mortality across hospital cohorts. For surgical complications, rates significantly improved at NTH only (OR: 0.82, P = .002), with no difference at Oto-TH (OR: 0.95, P = .450). CONCLUSIONS: In the years following DHR, rates of medical complications, surgical complications, and mortality have significantly improved at NTH. At Oto-TH, there has been a lack of similar improvement in surgical complications, even after accounting for increasing case volume and complexity in more recent years. While the cause is likely multifactorial, DHR in otolaryngology residency may play a role. LEVEL OF EVIDENCE: 4 Laryngoscope, 128:2804-2810, 2018.

The Role of Fast Imaging Employing Steady-State Acquisition (FIESTA) Magnetic Resonance Imaging for Assessment of Delayed Enhancement of Fat Graft Packing on Postoperative Imaging After Vestibular Schwannoma Surgery.

OBJECTIVE: To investigate the role and efficacy of fast imaging employing steady-state acquisition (FIESTA) imaging in distinguishing fat graft enhancement from residual or recurrent tumor after vestibular schwannoma (VS) surgery. METHODS: A retrospective study of 33 patients who underwent VS resection via the retrosigmoid or translabyrinthine approach with fat graft reconstruction was performed. Magnetic resonance imaging (MRI) was collected at different time points: preoperative, immediate postoperative (24-48 hours), delayed postoperative (3-6 months after surgery), and yearly postoperative. The image sets contained T1, T2, fat-suppressed T1-weighted with gadolinium, and FIESTA. The radiographs were analyzed for tumor recurrence by the primary neurosurgeon and an independent blinded neuroradiologist. If fat-suppressed T1-weighted images demonstrated postoperative enhancement in the resection bed, a comparison was made with FIESTA imaging. RESULTS: At 3-6 months postoperatively and at 1 year and beyond, 28 (84.8%) and 33 (100%) of patients, respectively, displayed delayed enhancement of the fat graft on postgadolinium fat-suppressed T1-weighted MRI. The enhancement seen on postgadolinium, fat-suppressed, T1-weighted MRI consistently correlated with the characteristic fat graft signal on FIESTA imaging and not tumor recurrence. FIESTA imaging was able to distinguish residual tumor from enhancing fat graft compared with postgadolinium, fat-suppressed, T1-weighted MRI (P < 0.0001) due to distinctive signaling patterns. CONCLUSIONS: FIESTA is an effective tool in discerning fat graft enhancement from residual or recurrent tumor on delayed postoperative imaging after VS resection. Fat graft used in reconstruction consistently enhances on delayed postoperative postgadolinium, fat-suppressed, T1-weighted imaging, which correlates with the fat graft signal seen on FIESTA images.

Limitations of the endoscopic endonasal transcribriform approach.

The endoscopic endonasal transcribriform approach (EETA) has become a useful strategy in the treatment of various anterior skull base pathologies, including meningoencephaloceles, olfactory groove meningiomas, schwannomas, esthesioneuroblastomas, and other sinonasal malignancies. However, not all pathologies are optimally treated through this approach due to tumor size, extent of the lesion, vascular involvement, and the presence of intact olfaction. One must be prepared to use a transcranial approach if the EETA is not favorable. In some patients, a combined approach (transcranial-EETA) may be needed in appropriate cases. Therefore, patient selection is paramount for achieving a successful result with avoidance of complications. For certain tumors, the limitations of the EETA may result in lower rates of gross-total resection, higher rates of cerebrospinal fluid leakage, postoperative impairment of olfaction, and higher complication rates. In this paper, we discuss the limitations of the EETA when considering approach selection to treat anterior skull base lesions.

Gruber, Gradenigo, Dorello, and Vail: key personalities in the historical evolution and modern-day understanding of Dorello's canal.

A century ago an ambitious young anatomist in Rome, Primo Dorello, who sought to understand the cause of abducent nerve palsy that often occurred in patients with severe middle ear infections, conducted intricate studies on the intracranial course of the nerve. In his findings, he identified that the abducent nerve passes through a narrow sinus near the apex of the petrous bone, which formed an osteofibrous canal. Dorello suggested that in this enclosed region the abducent nerve may be particularly vulnerable to compression due to the vascular edema accompanying the infection. Although his work was widely appreciated, it was not well received by all. Interestingly, Giuseppe Gradenigo, one of the most prominent Italian otologists of the early 20th century, who was known for his work on a triad of symptoms (Gradenigo's syndrome) that accompanies petrous apicitis, a result of severe middle ear infections, was obstinate in his criticism of Dorello's findings. Thus a scientific duel began, with a series of correspondence between these two academics-one who was relatively new to the otological community (Dorello) and one who was well reputed in that community (Gradenigo). The disagreement ultimately ebbed in 1909, when Dorello published a report in response to Gradenigo's criticisms and convinced Gradenigo to change his views. Today Dorello's canal is widely recognized as a key landmark in skull base surgery of the petroclival region and holds clinical significance due to its relation to the abducent nerve and surrounding vascular structures. Yet, although academics such as Dorello and Gradenigo are recognized for their work on the canal, it is important not to forget the others throughout history who have contributed to the modern-day understanding of this anatomical structure. In fact, although the level of anatomical detail found in Dorello's work was previously unmatched, the first description of the canal was made by the experienced Austrian anatomist Wenzel Leopold Gruber in 1859, almost 50 years prior to Dorello's landmark publication. Another critical figure in building the understanding of Dorello's canal was Harris Holmes Vail, a young otolaryngologist from Harvard Medical School, who in 1922 became the first person to describe Dorello's canal in the English language. Vail conducted his own detailed anatomical studies on cadavers, and his publication not only reaffirmed Dorello's findings but also immortalized the eponym used today-"Dorello's canal." In this article the authors review the life and contributions of Gruber, Dorello, Gradenigo, and Vail, four men who played a critical role in the discovery of Dorello's canal and paved the way toward the current understanding of the canal as a key clinical and surgical entity.