Severe Increase in Nursing Labor Cost and Effect on Surgical Department Financial Margins at an Academic, Tertiary Medical Center.

BACKGROUND: A pre-existing nationwide nursing shortage drastically worsened during the pandemic, causing a significant increase in nursing labor costs. We examined the financial impact of these changes on department of surgery financial margins. STUDY DESIGN: Operating room, inpatient, and outpatient financial metrics were analyzed. Monthly averages from a 14-month control cohort, January 2019 to February 2020 (pre-COVID-19), were compared with a 21-month cohort, March 2020 to November 2021 (COVID-19). True revenue and cost data from hospital accounting records, not estimates or administrative projections, were analyzed. Statistics were performed with standard Student's t -test and the Anderson-Darling normality test. RESULTS: Monthly surgical nursing costs increased significantly, with concomitant significant decreases in departmental contribution to margin. No significant change was observed in case volume per month, length of stay per case, or surgical acuity, as standardized by the US Centers for Medicare & Medicaid Services Case Mix Index. To obviate insurance payor mix as a variable and standardize cost data, surgical nursing expense per relative value unit was analyzed, demonstrating a significant increase. Hospital-wide agency nursing costs increased from $5.1 to $13.5 million per month (+165%) in 2021. CONCLUSIONS: Our results demonstrate a significant increase in surgical nursing labor costs with a resultant erosion of department of surgery financial margins. Use of real-time accounting data instead of commonly touted administrative approximations or Medicare projections increases both the accuracy and generalizability of the data. The long-term impact of both direct costs from supply chain interruption and indirect costs, such as limited operating room and ICU access, will require further study. Clearly this ominous trend is not viable, and fiscal recovery will require sustained, strategic workforce allocation.

Ultrasound findings after endovascular stent deployment in transplant liver hepatic artery stenosis.

OBJECTIVE: Endovascular stenting is a safe, effective treatment of hepatic artery stenosis after liver transplant, but no detailed evaluation has been completed of changes in ultrasound monitoring parameters after stenting. This study aims to improve poststenting surveillance by delineating the expected postoperative findings. MATERIALS AND METHODS: Thirty-one stent procedures were performed at our institution for hepatic artery stenosis after liver transplant between October 2010 and October 2012. Of these, 28 (90%) were technically successful, of which 23 met the minimum follow-up time (76 days, defined by the earliest diagnosed restenosis). These patients were followed with serial ultrasound, per the following schedule: within 1 week of stenting, 3 months after stenting, 6 months after stenting, and every 6 months thereafter; additional, unscheduled examinations were frequently performed when indicated on the basis of deterioration of clinical and laboratory status. Follow-up examinations (mean, 268 days total follow-up) were compared with prestenting examinations to evaluate changes in peak systolic velocity (PSV), resistive index (RI), and tardus-parvus waveforms. Data were analyzed to determine a normal range for postprocedure values and time course of change in values. RESULTS: Of the 23 patients, six experienced restenosis. In all patients, mean PSV decreased by 124 cm/s, and mean RI increased by 0.13 within 48 hours after stenting. PSV differed between patency and restenosis groups only at more than 90 days after stenting (mean PSV, 234 and 400 cm/s, respectively), with PSV above 300 cm/s serving as a high-sensitivity threshold for the determination of restenosis. Prestenting RI of below 0.40 had a strong correlation with restenosis. Poststenting RI differed between patency and restenosis groups only at more than 48 hours after stenting, with RI of below 0.55 having a strong correlation with restenosis. Tardus-parvus waveform resolution was often delayed well beyond 48 hours after stenting, and time to tardus-parvus waveform resolution had no correlation with patency or restenosis. CONCLUSION: Ultrasound is convenient and useful to follow stents in hepatic artery stenosis after liver transplant. Prestenting hemodynamics can have value in predicting restenosis. Diagnosis of restenosis can be made with RI and PSV, whereas resolution time of tardus-parvus waveform is of less concern. These parameters can guide which patients require closer monitoring and aggressive treatment.

Laparoscopic versus robot-assisted surgery for median arcuate ligament syndrome.

BACKGROUND: Median arcuate ligament syndrome (MALS) is an uncommon disorder characterized by postprandial abdominal pain, weight loss, and vomiting related to the compression of the celiac artery by the median arcuate ligament. This syndrome has been classically treated with an open surgical approach. More recently, laparoscopic and robotic approaches have been used. We present our outcomes with laparoscopic and robot-assisted treatment of MALS. METHODS: We performed a retrospective review of all patients treated for MALS from March 2006 to August 2012 at a single institution. RESULTS: A total of 16 patients with MALS were treated: 12 patients via a laparoscopic approach and 4 patients via a robot-assisted approach. Patient characteristics and comorbidities were similar between groups. We experienced no intraoperative or perioperative conversions, complications, or deaths. The mean operative time for the laparoscopic approach was significantly shorter than for the robotic approach (101.7 vs. 145.8 min; P = 0.02). However, we found no significant difference in length of hospital stay (1.7 vs. 1.3 days, P = 0.23). The mean length of follow-up for laparoscopically treated patients was 22.2 months and for robotically treated patients it was 20 months. Eight patients (67 %) in the laparoscopic group and two patients (50 %) in the robotic group had full resolution of their abdominal pain. Three patients in the laparoscopic group and two patients in the robotic group ceased chronic narcotic use after surgery. CONCLUSIONS: Both laparoscopic and robotic approaches to MALS treatment can be performed with minimal morbidity and mortality. The laparoscopic approach was associated with a significantly shorter operative time. While innovative, the true advantages to robot-assisted MALS surgery are yet to be seen.

Brave new world: the role for endovascular aneurysm repair in contemporary vascular surgery.

Endovascular abdominal aortic aneurysm repair (EVAR) poses certain challenges to the vascular surgeon. Based upon our 6-year experience, we have highlighted important aspects of patient selection. EVAR can be performed in patients with significant co-morbidities, but technical success may be limited by anatomic criteria. Short to mid-term outcomes report low mortality and morbidity from EVAR. Acute and delayed conversion, rupture, endoleak, limb occlusion, and migration are complications occurring in EVAR; their frequency, presentation and management are described. EVAR has up to 90% success rate at several years follow-up including the use of secondary procedures. Secondary procedures are not infrequent after EVAR; thus close follow-up is of the utmost importance. We predict that EVAR will continue to be a valuable tool in the future.

Influence of NASCET/ACAS trial eligibility on outcome after carotid endarterectomy.

PURPOSE: Proponents of carotid angioplasty and stenting suggest that "high risk" patients, defined as patients excluded from the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and Asymptomatic Carotid Atherosclerosis Study (ACAS), may have a significantly higher risk of stroke with carotid endarterectomy (CEA). However, this selected patient cohort has been poorly studied. METHODS: A retrospective review of patients who underwent CEA during a 2-year period at a tertiary referral institution was performed. Each patient was evaluated and categorized, according to the exclusion criteria, by NASCET and ACAS standards. Statistical analysis using chi(2) and Fisher exact tests was performed. RESULTS: There were 366 CEAs performed on 348 patients, including 32 (8.7%) for recurrent stenosis. A subgroup of 169 (46.2%) patients were trial ineligible. Focal ipsilateral symptoms were present in 148 (40.4%) of the patients. There were 9 (2.5%) strokes and 1 (0.3%) death, secondary to a major stroke, for an overall stroke and death rate of 2.5%. Trial-eligible patients had a stroke/death rate of 1.5% (3/197) while trial-ineligible patients had a 3.6% (6/169) stroke/death rate (P = .17). CONCLUSION: Patients who were considered high risk for CEA as defined by trial ineligibility were common, comprising approximately half of our patients. Although trial-ineligible patients had a nonsignificant trend toward higher neurologic morbidity when compared with the eligible group, the risks were still comparable with NASCET/ACAS results. CEA was a safe procedure even in this "high risk" group. As such, ineligibility for a randomized carotid intervention trial should not be employed as a "de novo" indication for carotid stenting.

Multicenter evaluation of a polyurethaneurea vascular access graft as compared with the expanded polytetrafluoroethylene vascular access graft in hemodialysis applications.

OBJECTIVES: The purpose of this study was to compare in a randomized, prospective, and controlled study, the performance of a multilayered, self-sealing polyurethane vascular access graft (PVAG) and expanded polytetrafluoroethylene (ePTFE) vascular access grafts in hemodialysis applications. Performance measures included graft survival, complications, time to early cannulation, and hemostasis times after cannulation. STUDY DESIGN: A total of 142 patients were randomized equally to receive one of the two grafts after meeting all eligibility requirements. All patients were followed up prospectively to 12 months or to the end of secondary patency. Specifically, this study documented the performance of the PVAG and ePTFE grafts by determining the patencies and complications for both grafts. RESULTS: Patient characteristics between the two groups were similar with respect to risk factors and demographic characteristics (P >.05). Life-table patencies from the date of first dialysis were primary patency: PVAG 55% versus ePTFE 47% (6 months) and PVAG 44% versus ePTFE 36% (12 months) and secondary patency: PVAG 87% versus ePTFE 90% (6 months) and PVAG 78% versus ePTFE 80% (12 months). None of these differences were significant (P >.05). Both primary and secondary patencies were also not significantly different when the date of implantation was the starting point. Adverse events and complications were similar for the two groups, except the PVAG group had a higher incidence of technical complications manifested by graft kinking when compared with the control cohort (P <.05). Additionally, there was no significant difference in complication rates between these two groups with regard to infection and bleeding. When the time to hemostasis after cannulation was compared at 5minutes or less, there were more PVAG cannulation sites that achieved hemostasis compared with ePTFE sites, and this difference was significant (P <.0001). When time to first dialysis access was compared between the two grafts, 53.9% of all PVAG grafts were cannulated before 9 days versus none with the ePTFE grafts (P <.001). However, long-term graft survival was not significantly different when PVAG patients were stratified into early (< 9 days) and the late access (9 >/= days) groups (P =.29). CONCLUSIONS: The PVAG graft allows for early access without compromising long-term performance. Both PVAG and standard ePTFE grafts have similar long-term outcomes, despite early access with the PVAG vascular access grafts.

External transabdominal manipulation of vessels: a useful adjunct with endovascular abdominal aortic aneurysm repair.

During endovascular abdominal aortic aneurysm repair, a severely angulated aortic neck or tortuous iliac arteries can make delivery of endografts difficult. We describe a simple adjunct in which transabdominal manipulation of vessels is used, which can greatly facilitate delivery of these devices in patients with challenging anatomy.

Comparison of open transabdominal AAA repair with endovascular AAA repair in reduction of postoperative stress response.

Operative intervention causes a necessary biologic response known as the hypermetabolic stress response. Less invasive operative procedures may cause fewer metabolic and endocrine derangements. To evaluate the metabolic and endocrine differences between endovascular and transperitoneal abdominal aortic aneurysm (AAA) repair, 10 patients underwent standard open repair (open group) and 10 patients underwent endovascular repair of AAA (endovascular group) with a modular bifurcated endograft. Blood samples were obtained prior to general anesthesia (baseline) and every 6 hr for a 24-hr period. Assays for hormones related to the postoperative stress response as well as retinol-binding protein were performed. Peak hormonal values are presented in relation to the baseline. Demographic analysis of the two groups showed that there were no significant differences in age or ASA classification. The open group had a 9.6-fold increase in epinephrine release, which was significantly higher than the 1.6-fold increase in the endovascular group (p < 0.05). Elevations in cortisol were also significantly higher in the open group. Early postoperative nutritional derangements, as reflected by the levels of retinol-binding protein, were far less in the endovascular group than in the open group. Endovascular AAA repair appears to be associated with a marked reduction in the hypermetabolic stress response and nutritional deterioration, compared to traditional open repair. This reduction in physiologic stress may have salutary effects on the incidence of postoperative medical morbidity.

Acute renal failure after redo thoracoabdominal aortic aneurysm repair in a patient with a solitary kidney: successful percutaneous treatment.

PURPOSE: To report the successful percutaneous treatment of renal artery stenosis that precipitated renal failure following surgical repair of a thoracoabdominal aortic aneurysm (TAAA). METHODS AND RESULTS: A 70-year-old woman with a solitary kidney became anuric 2 hours after urgent repair of a symptomatic true aneurysm of the Carrel patch from an 8-year-old TAAA repair. After medical treatment failed, aortography was performed, identifying complete occlusion of the solitary renal artery. Balloon dilation and implantation of a Palmaz stent restored renal perfusion and improved function. At 6-month follow-up, she was normotensive and her creatinine within normal limits. CONCLUSIONS: Renal artery stenosis or occlusion is a treatable cause of acute renal failure after TAAA repair. Percutaneous treatment options are likely to be better tolerated than surgical revascularization in this patient population.

Orally administered unfractionated heparin with carrier agent is therapeutic for deep venous thrombosis.

BACKGROUND: Orally administered heparin (OHEP) is unreliable because of poor absorption. Sodium N-(8[2-hydroxybenzoyl]amino) caprylate (SNAC) is an amido acid that facilitates the gastrointestinal absorption of heparin. We evaluated the effectiveness of OHEP combined with SNAC (OHEP/SNAC) in the treatment of deep-vein thrombosis (DVT). METHODS AND RESULTS: An internal jugular DVT was produced in 54 male Sprague-Dawley rats. Animals were assigned to 6 different groups for 7 days of treatment: untreated control, subcutaneous heparin (SC HEP) (300 U/kg SC TID), SNAC only (300 mg/kg PO TID), OHEP only (30 mg/kg PO TID), low-molecular-weight heparin (LMWH) (enoxaparin 5 mg/kg SC QD), and OHEP/SNAC (30 mg/kg:300 mg/kg PO TID). The activated partial thromboplastin time (aPTT) and anti-factor X (anti-Xa) levels were measured. The incidence of residual DVT after 1 week of treatment was 100% (9 of 9) in the control group versus 10% (1 of 10) in the OHEP/SNAC and 10% (1 of 10) in the LMWH groups (P<0.001). There was also a significant reduction in clot weights between these groups. Compared with controls, there were no significant differences in the residual DVT in the SNAC-only (6 of 6), OHEP-only (9 of 9), or SC HEP (8 of 10) groups. Combination OHEP/SNAC was as effective in the resolution of the clot and reducing clot weight as LMWH. The aPTT levels in the OHEP/SNAC group peaked at 30 minutes and were significantly higher than in all other groups (P<0.01). Anti-Xa levels were elevated at 15 minutes after dosing in the OHEP/SNAC group and remained significantly elevated at 4 hours (P<0.001). CONCLUSIONS: OHEP combined with a novel carrier agent (SNAC) successfully treated DVT in this rat model.

Endovascular treatment of multiple visceral artery paradoxical emboli with mechanical and pharmacological thrombolysis.

PURPOSE: To report a case of paradoxical emboli to multiple visceral vessels treated with both mechanical (AngioJet device) and pharmacological (urokinase) thrombolysis. METHODS AND RESULTS: A 72-year-old man presented with a 48-hour history of symptomatic right renal ischemia, which was treated with heparinization. Five days later, an abrupt creatinine elevation prompted arteriography, which demonstrated thromboembolism of the superior mesenteric artery (SMA) and both renal arteries. The AngioJet aspiration device was employed to successfully remove the clot from the SMA; urokinase infusion restored flow to the left kidney. At the 16-month follow-up evaluation, the patient was normotensive without medication and had a stable creatinine (1.4 mg/dL). CONCLUSIONS: Because of its speed and minimal morbidity, the AngioJet device may be an attractive alternative to surgical embolectomy or pharmacological thrombolysis in highly selected cases of acute visceral artery thromboembolism.

Treatment of experimentally induced caval thrombosis with oral low molecular weight heparin and delivery agent in a porcine model of deep venous thrombosis.

OBJECTIVE: This experiment evaluated enterally administered low molecular weight heparin (LMWH) combined with sodium N-[10-(2-hydroxybenzoyl)amino] decanoate (SNAD) for the treatment of induced venous thrombosis. SUMMARY BACKGROUND DATA: SNAD is a delivery agent that potentiates the gastrointestinal absorption of LMWH. METHODS: Forty female pigs were equally assigned to four groups: control (saline); enteral LMWH, 2,000 IU/kg; enteral SNAD, 50 mg/kg; and enteral LMWH, 2,000 IU/kg and SNAD, 50 mg/kg. Under fluoroscopic guidance, the infrarenal vena cava was occluded with a balloon catheter. Two milliliters of ethanol was injected into the distal vena cava. The inflated balloon catheter remained in situ for 5 days, at which time animals angiographically exhibiting thrombus were randomly assigned to the four groups. Study medications were dosed at 12-hour intervals by means of a gastrostomy tube placed previously. After 7 days of treatment, thrombus was extracted. A separate group of 10 animals was used to measure plasma antifactor Xa levels for 6 hours after enteral dosing of LMWH/SNAD. RESULTS: The amount of residual thrombus after treatment with enteral LMWH/SNAD was significantly decreased. Antifactor Xa levels were significantly elevated in the LMWH/SNAD group versus baseline. CONCLUSION: The combination of enterally administered LMWH and SNAD given for 7 days appeared to decrease caval thrombosis in this model of deep vein thrombosis. Enteral LMWH/SNAD effected an increase in plasma levels of antifactor Xa.

Hospital cost of endovascular versus open repair of abdominal aortic aneurysms: a multicenter study.

BACKGROUND: Technology-driven innovation in medicine is frequently associated with higher costs than conventional therapy. A significantly higher cost for endovascular ($21,250, n = 190) versus open abdominal aortic aneurysm (AAA) repair ($12,342, n = 60) was suggested by a direct cost analysis of patients in a multicenter trial. Estimated inpatient costs (not charges) incurred nationwide by hospitals for endovascular and open repair of AAA were studied to validate these observed trends. METHODS: A retrospective analysis of 131 patients undergoing endovascular AAA repair was compared with 49 patients undergoing open repair as part of a Food and Drug Administration phase II prospective multicenter clinical investigation (AneuRx-Medtronic). A model to estimate costs was constructed using important clinical descriptors of these patients. These clinical characteristics where then matched with those from 22, 460 patients undergoing AAA repair obtained from a large national database (Medicare Provider Analysis and Review). Estimated hospital cost was then assigned to each study patient according to the national average of the total hospital costs for the respective matched patients in Medicare Provider Analysis and Review. RESULTS: Total inpatient hospital costs of endovascular repair were significantly higher than that of open repair ($19,985 +/- 7396 versus $12,546 +/- 5944, respectively, P =.0001). Endograft device cost ($10,400) accounted for 52% of the total cost of endovascular repair. The 1999 mean blended Medicare reimbursement for AAA repair was $18,989. CONCLUSION: In this early development stage, hospital cost for endovascular AAA repair is significantly greater than open repair when device cost greatly exceeds $5000. Although incremental reductions in cost of endovascular repair may be anticipated if use of diagnostic studies, operating time, and length of stay decrease, device cost has the single greatest impact on the expense of endovascular AAA repair. At current device pricing, mean blended Medicare reimbursement does not cover the cost of endovascular AAA repair.

Minimally invasive vascular techniques.

The recent and continuing developments in radiotherapy, gene therapy, and the technologies of imaging, materials, and devices, as well as the techniques for their implementation, have expanded the options available for the treatment of peripheral vascular disease. Though long-term data are still lacking, percutaneous transluminal angioplasty (PTA) has developed into a treatment modality in its own right and continues to be an adjuvant treatment to traditional surgical revascularization. Numerous stents and grafts are currently available for the treatment of arterial lesions and aneurysms, while the testing of many more continues. In addition to these new devices, developments in gene therapy and brachytherapy have brought several new minimally invasive options to the treatment of peripheral vascular disease.

Complications associated with percutaneous closure devices.

BACKGROUND: In an effort to reduce time to hemostasis after angiography, several closure devices have been marketed. We report some of their complications. METHODS: A retrospective review was conducted. RESULTS: Over an 8-month study period, 2,181 diagnostic and interventional procedures were performed. Closure devices were used in 408 (19%) of these patients. The Angio-Seal closure device is composed of a collagen sponge and an absorbable polymer anchor that compresses the hole in the arteriotomy. The ProstarXL sealing device consists of a rotating barrel that deploys 4 needles through the arteriotomy, and then individual knots are extracorporeally tied. The Duett device consists of a balloon occluding catheter and injectable collagen and thrombin. Ten of the patients developed a complication from the closure device (2.5%). Four of these were subcutaneous abscesses. Two of these patients had expanding pseudaneurysms, 2 had lower extremity ischemia, and 1 patient had an acute bleed. These complications were all managed surgically. Another patient developed a retroperitoneal bleed that was managed nonoperatively. CONCLUSIONS: As the use of these devices increase, these complications will become more common.

Oral low-molecular weight heparin and delivery agent prevents jugular venous thrombosis in the rat.

PURPOSE: Sodium N-[10-(2-hydroxybenzoyl)amino]decanoate (SNAD) is a novel carrier that allows the gastrointestinal absorption of low-molecular weight heparin (LMWH). The purpose of this experiment was to evaluate oral LMWH with SNAD for the prevention of deep venous thrombosis. METHODS: Sixty Sprague-Dawley rats were equally assigned to five experimental groups: group 1 (control), oral saline solution; group 2, oral LMWH (15 mg/kg); group 3, oral SNAD (300 mg/kg); group 4, subcutaneous LMWH (5 mg/kg); and group 5, oral LMWH (15 mg/kg) and SNAD (300 mg/kg). After treatment, the jugular vein was isolated, occluded, and bathed in an ethanol and formalin solution for 2 minutes. Two hours later, the vessel was examined for patency, presence of thrombus, and thrombus weight. Serum measurement of anti-factor Xa activity was performed in a separate set of 30 rats, which were placed into the following four groups: group A, LMWH (5 mg/kg); group B, oral LMWH (15 mg/kg) and SNAD (300 mg/kg); group C, oral LMWH (15 mg/kg); and group D, SNAD (300 mg/kg). RESULTS: The animals that underwent oral LMWH/SNAD therapy had a statistically significant decrease in visible thrombi. The thrombus weight of the oral LMWH/SNAD group was significantly less than the weights of all other groups, except the subcutaneous LMWH group. Anti-factor Xa levels were significantly elevated in the LMWH/SNAD group. There was no statistically significant difference between the data for the oral LMWH/SNAD group and the subcutaneous LMWH group. CONCLUSION: The combination of oral LMWH and SNAD prevented deep venous thrombosis. The oral LMWH and SNAD therapy effected an increase in levels of anti-factor Xa.

Carotid endarterectomy in patients with significant renal dysfunction.

PURPOSE: Recent reports suggest that carotid endarterectomy (CEA) should not be performed in patients with end-stage renal disease (ESRD) because of an unacceptable rate of perioperative stroke and other morbidity. Because these conclusions were based on a small number of patients, we reviewed the perioperative and long-term outcome of patients with ESRD and chronic renal insufficiency (CRI) who underwent CEA at our institution. METHODS: The 1081 patients who had a CEA between 1990 and 1997 were cross-referenced with those patients in whom renal insufficiency had been diagnosed. These charts were reviewed for patient demographics and perioperative and long-term outcome. Patients undergoing CEA during a 1-year period (1993) served as controls. RESULTS: Fifty-one CEAs were performed in 44 patients with CRI (32 in 27 patients) and ESRD (19 in 17 patients). In the CRI+ESRD group, 66.7% were symptomatic, and 70.7% of the control group were symptomatic. Six operations (11.8%) in the CRI+ESRD group were redo endarterectomies. There were no perioperative strokes in the CRI+ESRD group, but one patient died 29 days postoperatively because of a myocardial infarction, for a combined stroke-mortality rate of 2.0%. The control group had a 2.6% combined stroke-mortality rate. Long-term survival analysis revealed a 4-year survival rate of 12% for patients with ESRD and 54% for patients with CRI, compared with 72% for controls (P <.05). CONCLUSION: CEA can be performed safely in patients with ESRD or CRI, with perioperative stroke and death rates equivalent to that of patients without renal dysfunction. However, the benefit of long-term stroke prevention in the asymptomatic patient with ESRD is in question because of the high 4-year mortality rate of this patient population.

Endovascular repair of abdominal aortic aneurysms.

Endovascular treatment of abdominal aortic aneurysms (AAAs) is an exciting new minimally invasive treatment option for patients with this disease. Ochsner Clinic has been the only institution in the Gulf South participating in FDA clinical trials of these investigational devices. Early results with endovascular AAA repair demonstrate a trend towards lower mortality and morbidity when compared with traditional open surgery. Length of stay has been reduced by two-thirds with a marked reduction in postoperative pain and at-home convalescence. If the long-term data on efficacy and durability of these devices are good, most AAAs in the future will be treated with this minimally invasive technique.