Dr. Mary T. Hawn is the Stanford Medicine Professor of Surgery and Chair of the Department of Surgery at Stanford University. Dr. Hawn, a native of Michigan, received her education and surgical training at the University of Michigan. Her clinical area of specialty is minimally invasive foregut surgery. Dr. Hawn is a funded health services researcher and her projects focus on quality measurement and policy in surgical populations. She is a Director for the American Board of Surgery and serves on the editorial board of Annals of Surgery, Journal of the American College of Surgeons, Journal of Gastrointestinal Surgery and the American Journal of Surgery. Dr. Hawn has several additional leadership roles in American Surgery including Chair of the American College of Surgeons Scientific Forum Committee and as a Trustee and Treasurer for the Surgical Society of the Alimentary Tract. She is the co-Editor of a new surgical textbook Operative Techniques in Surgery.
- General Surgery
- Gastroesophageal Reflux Disease
- Hiatal Hernias
- Gallbladder Disease
Professor and Chair, Department of Surgery (2015 - Present)
Honors & Awards
Distinguished Alumni of the Year, Department of Surgery, Oregon Health Sciences University (2016)
Honor Society, Alpha Omega Alpha
Boards, Advisory Committees, Professional Organizations
Director, American Board of Surgery (2015 - Present)
Treasurer, Surgical Society of the Alimentary Tract (2016 - Present)
Chair, Scientific Forum Committee, American College of Surgeons (2014 - Present)
Member, American Surgical Association
Member, Society of Clinical Chairs
Board Certification: General Surgery, American Board of Surgery (1999)
Residency:University of MichiganMI
Internship:University of MichiganMI
Fellowship:Oregon Health and Science University (2001) ORUnited States of America
Medical Education:University Of Michigan (1991) MI
M.P.H., University of Michigan School of Public Health, MPH Epidemiology (1996)
M.D., University of Michigan Medical School (1991)
B.S., University of Michigan, Biomedical Sciences (1987)
Current Research and Scholarly Interests
My area of research is health services researcher focusing on surgical quality measurement and policy. I have a background and training in epidemiology coupled with my leadership roles in surgical quality measurement. My expertise and extensive experience in evaluation of surgical quality process and outcome linkage has impacted national policy and changed guidelines. We performed a comprehensive evaluation of the Surgical Care Improvement Project (SCIP) implementation using national VA data. Defining robust metrics of surgical quality that are actionable and can lead to sustained improvement in our field are of utmost importance. I also have experience with risk prediction modeling for surgical patients. Our Decision Support for Safer Surgery study developed models of real-time risk prediction for major complications and prospectively validated our models in patients and with expert surgeons. We were able to discern where computational risk prediction has added value and where it falls short. We currently have a national study investigating readmissions following major surgical procedures to identify opportunities for improving care and reducing costs.
Understanding the Value of Both Laparoscopic and Robotic Approaches Compared to the Open Approach in Colorectal Surgery.
Journal of laparoendoscopic & advanced surgical techniques. Part A
2016; 26 (11): 850-856
Although the use of laparoscopy has significantly increased in colorectal procedures, robotic surgery may enable additional cases to be performed using a minimally invasive approach. We separately evaluated the value of laparoscopic and robotic colorectal procedures compared to the open approach.Patients undergoing nonemergent colorectal operations from 2010 to 2013 with National Surgical Quality Improvement Project data were identified. Robotic and laparoscopic procedures were separately matched (1:1) to open cases. Outcomes included 30-day composite morbidity, length of stay, operative time, and inpatient costs. Frequently used intraoperative disposable items were categorized, and significant cost contributors were identified by surgical approach. Statistical differences were determined with Chi-square and Wilcoxon signed-rank tests.Both laparoscopic (n = 67) and robotic (n = 45) approaches were associated with decreased composite morbidity compared to matched open cases (lap vs. open: 22.4% vs. 49.2%, P < .01; robotic vs. open: 6.7% vs. 33.3%, P < .01). Median length of stay was significantly shorter for both laparoscopic and robotic compared to open surgery (lap vs. open: 5 vs. 7 days, P < .01; robotic vs. open: 5 vs. 7 days, P < .01). Median hospital costs were similar between laparoscopic and open surgery ($13,319 vs. $14,039; P = .80) and robotic and open surgery ($13,778 vs. $13,629; P = .48).These findings illustrate the value for both laparoscopic and robotic approaches to colorectal surgery compared to the open approach in terms of short-term outcomes and inpatient costs. Advanced intraoperative disposable items such as cutting staplers and energy devices are important targets for additional cost containment.
View details for PubMedID 27398733
Consensus Statement of Society of Abdominal Radiology Disease-Focused Panel on Barium Esophagography in Gastroesophageal Reflux Disease.
AJR. American journal of roentgenology
2016; 207 (5): 1009-1015
The Society of Abdominal Radiology established a panel to prepare a consensus statement on the role of barium esophagography in gastroesophageal reflux disease (GERD), as well as recommended techniques for performing the fluoroscopic examination and the gamut of findings associated with this condition.Because it is an inexpensive, noninvasive, and widely available study that requires no sedation, barium esophagography may be performed as the initial test for GERD or in conjunction with other tests such as endoscopy.
View details for PubMedID 27490234
Postoperative 30-day Readmission: Time to Focus on What Happens Outside the Hospital.
Annals of surgery
2016; 264 (4): 621-631
The aim of this study is to understand the relative contribution of preoperative patient factors, operative characteristics, and postoperative hospital course on 30-day postoperative readmissions.Determining the risk of readmission after surgery is difficult. Understanding the most important contributing factors is important to improving prediction of and reducing postoperative readmission risk.National Veterans Affairs Surgical Quality Improvement Program data on inpatient general, vascular, and orthopedic surgery from 2008 to 2014 were merged with laboratory, vital signs, prior healthcare utilization, and postoperative complications data. Variables were categorized as preoperative, operative, postoperative/predischarge, and postdischarge. Logistic models predicting 30-day readmission were compared using adjusted R and c-statistics with cross-validation to estimate predictive discrimination.Our study sample included 237,441 surgeries: 43% orthopedic, 39% general, and 18% vascular. Overall 30-day unplanned readmission rate was 11.1%, differing by surgical specialty (vascular 15.4%, general 12.9%, and orthopedic 7.6%, P < 0.001). Most common readmission reasons were wound complications (30.7%), gastrointestinal (16.1%), bleeding (4.9%), and fluid/electrolyte (7.5%) complications. Models using information available at the time of discharge explained 10.4% of the variability in readmissions. Of these, preoperative patient-level factors contributed the most to predictive models (R 7.0% [c-statistic 0.67]); prediction was improved by inclusion of intraoperative (R 9.0%, c-statistic 0.69) and postoperative variables (R 10.4%, c-statistic 0.71). Including postdischarge complications improved predictive ability, explaining 19.6% of the variation (R 19.6%, c-statistic 0.76).Postoperative readmissions are difficult to predict at the time of discharge, and of information available at that time, preoperative factors are the most important.
View details for DOI 10.1097/SLA.0000000000001855
View details for PubMedID 27355263
Transitional care interventions and hospital readmissions in surgical populations: a systematic review.
American journal of surgery
2016; 212 (2): 327-335
Despite hospital readmission being a targeted quality metric, few studies have focused on the surgical patient population. We performed a systematic review of transitional care interventions and their effect on hospital readmissions after surgery.PubMed was searched for studies evaluating transitional care interventions in surgical populations within the years 1995 to 2015. Of 3,527 abstracts identified, 3 randomized controlled trials and 7 observational cohort studies met inclusion criteria.Discharge planning programs reduced readmissions by 11.5% (P = .001), 12.5% (P = .04), and 23% (P = .26). Patient education interventions reduced readmissions by 14% (P = .28) and 23.5% (P < .05). Primary care follow-up reduced readmissions by 8.3% for patients after high-risk surgeries (P < .001). Home visits reduced readmissions by 7.69% (P = .023) and 4% (P = .161), respectively. Therefore, improving discharge planning, patient education, and follow-up communication may reduce readmissions.
View details for DOI 10.1016/j.amjsurg.2016.04.004
View details for PubMedID 27353404
A Role for the Early Warning Score in Early Identification of Critical Postoperative Complications.
Annals of surgery
2016; 263 (5): 918-923
We examined whether an early warning score (EWS) could predict inpatient complications in surgical patients.Abnormal vitals often precede in-hospital mortality. The EWS calculated using vital signs has been developed to identify patients at risk for mortality.Inpatient general surgery procedures with National Surgical Quality Improvement Project data from 2013 to 2014 were matched with enterprise data on vital signs and neurologic status to calculate the EWS for each postoperative vital set measured on the ward. Outcomes of major complications, unplanned intensive care unit transfer, and medical emergency team activation were classified using the Clavien-Dindo system as grade I to V. Relationship with EWS and timing of complication was assessed using Kruskal-Wallis test and linear regression accounting for clustering with generalized estimating equation.Among 552 patients admitted to the ward postsurgery, 68 (12.3%) developed at least one grade I to III complication and 37 (6.7%) developed a grade IV/V complication. The mean maximum EWS was significantly higher preceding grade IV/V complications (10.1) compared with grade I to III complications (6.4) or across the hospital stay in patients without complications (5.4; P < 0.01). EWS significantly increased in the 3 days preceding grade IV/V complications (P < 0.001) and declined in patients without complications in the 3 days before discharge (P < 0.001). A threshold EWS of 8 predicted occurrence of grade IV/V complications with 81% sensitivity and 84% specificity.Critical postoperative complications can be preceded by rising EWS. Interventional studies are needed to evaluate whether EWS can reduce the severity of postoperative complications and mortality for surgical patients through early identification and intervention.
View details for DOI 10.1097/SLA.0000000000001514
View details for PubMedID 26692076
Racial Disparities in Readmissions for Patients with Inflammatory Bowel Disease (IBD) After Colorectal Surgery
JOURNAL OF GASTROINTESTINAL SURGERY
2016; 20 (5): 985-993
The incidence of inflammatory bowel disease (IBD) in minorities is increasing, and health outcome disparities are becoming more apparent. Our aim was to investigate the contribution of race to readmissions in IBD patients undergoing colorectal surgery.The National Surgical Quality Improvement Program database from 2012 to 2013 was queried for all patients with IBD undergoing elective colorectal surgery. After stratifying by race, unadjusted univariate and bivariate comparisons were made. Primary outcome was all-cause 30-day readmission. Predictors of readmission were identified using multivariable logistic regression.Of the 2523 patients with IBD who underwent elective colon surgery, 15.0 % were readmitted within 30 days of index operation. Black patients constituted 7.7 % of the entire cohort. Black patients were significantly different in smoking status (27 vs. 22 %) and Crohn's diagnosis (84 vs. 73 %) (p < 0.05). Black patients had significantly higher readmission rates (20 vs. 15 %) and longer length-of-stays (8 vs. 6 days) after surgery (p < 0.05). On multivariable analysis, black race remained a significant predictor for 30-day readmissions in patients with IBD (odds ratio 1.6, 95 % confidence interval 1.1-2.5).Black patients with IBD have an increased risk for readmission after colorectal surgery. Efforts to reduce readmissions need to target not only well-studied risk factors such as postoperative complications, but also investigate non-NSQIP-measured elements such as social and behavioral determinants of health.
View details for DOI 10.1007/s11605-015-3068-9
View details for Web of Science ID 000375462500016
View details for PubMedID 26743885
White Paper: SSAT Commitment to Workforce Diversity and Healthcare Disparities
JOURNAL OF GASTROINTESTINAL SURGERY
2016; 20 (5): 879-884
The Society for Surgery of the Alimentary Track (SSAT) is committed to diversity and inclusiveness of its membership, promotion of research related to healthcare disparities, cultural competency of practicing gastrointestinal surgeons, and cultivation of leaders with unique perspectives. The SSAT convened a task force to assess the current state of diversity and inclusion and recommend sustainable initiatives to promote these goals. Working through the current committee structure of the Society, and by establishing a permanent Diversity and Inclusion liaison committee, the SSAT will maintain its commitment and strive towards diversity of thought and inclusiveness on every level to improve the well-being and betterment of its membership and the patients they serve.
View details for DOI 10.1007/s11605-016-3107-1
View details for Web of Science ID 000375462500001
View details for PubMedID 26940942
The Incremental Risk of Coronary Stents on Postoperative Adverse Events: A Matched Cohort Study.
Annals of surgery
2016; 263 (5): 924-930
To determine the incremental risk of coronary stents on adverse events in surgical patients and whether it varies over time from stent placement.Postoperative adverse cardiac events decrease as the time from stent placement increases, but the risk attributable to the stent versus the underlying cardiac disease is uncertain, as prior studies lack a control surgical population.Data for patients with coronary stents implanted in a VA hospital from 2000 to 2010 were matched with VA Surgical Quality Improvement Program data to identify noncardiac surgery within 24 months of stent placement. Each patient with stent was matched with 2 surgical patients without stent on surgical characteristics and cardiac risk factors. Outcomes of myocardial infarction (MI), revascularization, and death within 30 days after surgery were modeled using logistic regression. Adjusted risk differences between stented and nonstented populations were compared across time after stent placement.Adverse cardiac events followed surgery in 531 (5.7%) of the 9391 patients with stent and 680 (3.6%) of the 18,782 patients without stent (P < 0.001). In adjusted models, 30-day postoperative MI (odds ratio = 1.90; 95% confidence interval, 1.57-2.30) and revascularization (odds ratio = 2.03; 95% confidence interval, 1.65-2.50) but not mortality (odds ratio = 0.84; 95% confidence interval, 0.69-1.02) were higher in the stented cohort. Assessing trends over the 2 years after stent placement, the incremental risk for MI decreased from 5% immediately after stent placement to 2% at 1 year and then was no longer significantly elevated. The incremental risk did not vary by stent type.Surgery after coronary stent placement is associated with an approximate 2% absolute risk for postoperative MI but no difference in mortality compared with nonstented matched controls.
View details for DOI 10.1097/SLA.0000000000001246
View details for PubMedID 25894416
Association of Coronary Stent Indication With Postoperative Outcomes Following Noncardiac Surgery
2016; 151 (5): 462-469
Current guidelines for delaying surgery after coronary stent placement are based on stent type. However, the indication for the stent may be an important risk factor for postoperative major adverse cardiac events (MACE).To determine whether the clinical indication for a coronary stent is associated with postoperative MACE.Retrospective cohort study in patients at US Veterans Affairs hospitals who had a coronary stent placed between January 1, 2000, and December 31, 2010, and underwent noncardiac surgery within the following 24 months. The association between the indication for stent and postoperative MACE rates was examined using logistic regression to control for patient and procedure factors.Three subgroups of stent indication were examined: (1) myocardial infarction (MI); (2) unstable angina; and (3) revascularization not associated with acute coronary syndrome (non-ACS).Composite 30-day postoperative MACE rates including all-cause mortality, MI, or revascularization.Among 26 661 patients (median [IQR] age, 68 [61.0-76.0] years; 98.4% male; 88.1% white) who underwent 41 815 surgical procedures within 24 months following coronary stent placement, the stent indication was MI in 32.8% of the procedures, unstable angina in 33.8%, and non-ACS in 33.4%. Postoperative MACE rates were significantly higher in the MI group (7.5%) compared with the unstable angina (2.7%) and non-ACS (2.6%) groups (P < .001). When surgery was performed within 3 months of percutaneous coronary intervention, adjusted odds of MACE were significantly higher in the MI group compared with the non-ACS group (odds ratio [OR] = 5.25; 95% CI, 4.08-6.75). This risk decreased over time, although it remained significantly higher at 12 to 24 months from percutaneous coronary intervention (OR = 1.95; 95% CI, 1.58-2.40). The adjusted odds of MACE for the unstable angina group were similar to those for the non-ACS group when surgery was performed within 3 months (OR = 1.11; 95% CI, 0.80-1.53) or between 12 and 24 months (OR = 1.08; 95% CI, 0.86-1.37) from stent placement. Stent type was not significantly associated with MACE regardless of indication.Surgery in patients with a coronary stent placed for MI was associated with increased postoperative MACE rates compared with other stent indications. The risk declined over time from PCI, and delaying surgery up to 6 months in this cohort of patients with stents may be important regardless of stent type.
View details for DOI 10.1001/jamasurg.2015.4545
View details for Web of Science ID 000376011600018
View details for PubMedID 26720292
Robotic Esophagectomy for Cancer: Early Results and Lessons Learned.
Seminars in thoracic and cardiovascular surgery
2016; 28 (1): 160-169
Minimally invasive esophagectomy with intrathoracic dissection and anastomosis is increasingly performed. Our objectives are to report our operative technique, early results and lessons learned. This is a retrospective review of 85 consecutive patients who were scheduled for minimally invasive Ivor Lewis esophagectomy (laparoscopic or robotic abdominal and robotic chest) for esophageal cancer. Between 4/2011 and 3/2015, 85 (74 men, median age: 63) patients underwent robotic Ivor Lewis esophageal resection. In all, 64 patients (75%) had preoperative chemoradiotherapy, 99% had esophageal cancer, and 99% had an R0 resection. There were no abdominal or thoracic conversions for bleeding. There was 1 abdominal conversion for the inability to completely staple the gastric conduit. The mean operative time was 6 hours, median blood loss was 35ml (no intraoperative transfusions), median number of resected lymph nodes was 22, and median length of stay was 8 days. Conduit complications (anastomotic leak or conduit ischemia) occurred in 6 patients. The 30 and 90-day mortality were 3/85 (3.5%) and 9/85 (10.6%), respectively. Initial poor results led to protocol changes via root cause analysis: longer rehabilitation before surgery, liver biopsy in patients with history of suspected cirrhosis, and refinements to conduit preparation and anastomotic technique. Robotic Ivor Lewis esophagectomy for cancer provides an R0 resection with excellent lymph node resection. Our preferred port placement and operative techniques are described. Disappointingly high thoracic conduit problems and 30 and 90-day mortality led to lessons learned and implementation of change which are shared.
View details for DOI 10.1053/j.semtcvs.2015.10.006
View details for PubMedID 27568155
Blood Transfusion and 30-Day Mortality in Patients With Coronary Artery Disease and Anemia Following Noncardiac Surgery
2016; 151 (2): 139-145
Although liberal blood transfusion thresholds have not been beneficial following noncardiac surgery, it is unclear whether higher thresholds are appropriate for patients who develop postoperative myocardial infarction (MI).To evaluate the association between postoperative blood transfusion and mortality in patients with coronary artery disease and postoperative MI following noncardiac surgery.Retrospective cohort study involving Veterans Affairs facilities from January 1, 2000, to December 31, 2012. A total of 7361 patients with coronary artery disease who underwent inpatient noncardiac surgery and had a nadir postoperative hematocrit between 20% and 30%. Patients with significant bleeding, including any preoperative blood transfusion or transfusion of greater than 4 units during the intraoperative or postoperative setting, were excluded. Mortality rates were compared using both logistic regression and propensity score matching. Patients were stratified by postoperative nadir hematocrit and the presence of postoperative MI.Initial postoperative blood transfusion.The 30-day postoperative mortality rate.Of the 7361 patients, 2027 patients (27.5%) received at least 1 postoperative blood transfusion. Postoperative mortality occurred in 267 (3.6%), and MI occurred in 271 (3.7%). Among the 5334 patients without postoperative blood transfusion, lower nadir hematocrit was associated with an increased risk for mortality (hematocrit of 20% to <24%: 7.3%; 24% to <27%: 3.7%; and 27% to 30%: 1.6%; P < .01). In patients with postoperative MI, blood transfusion was associated with lower mortality, for those with hematocrit of 20% to 24% (odds ratio, 0.28; 95% CI, 0.13-0.64). In patients without postoperative MI, transfusion was associated with significantly higher mortality for those with hematocrit of 27% to 30% (odds ratio, 3.21; 95% CI, 1.85-5.60).These findings support a restrictive postoperative transfusion strategy in patients with stable coronary artery disease following noncardiac surgery. However, interventional studies are needed to evaluate the use of a more liberal transfusion strategy in patients who develop postoperative MI.
View details for DOI 10.1001/jamasurg.2015.3420
View details for Web of Science ID 000371319200009
View details for PubMedID 26444569
Patient and lesion-specific characteristics predict risk of major adverse cardiovascular events among patients with previous percutaneous coronary intervention undergoing noncardiac surgery.
Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions
To identify predictors of major adverse cardiovascular outcomes (MACE) among patients with prior percutaneous coronary intervention (PCI) who require noncardiac surgery.Patients with prior PCI who undergo noncardiac surgery have an increased risk of postoperative MACE, but few studies have examined the association of PCI lesion characteristics with subsequent operative risk.Patients were identified using the VA Clinical Assessment, Reporting, and Tracking (CART) program. Patients who underwent noncardiac surgery within 2 years after stent placement were linked to VA and non-VA surgical records. A multivariable logistic regression model was developed to identify predictors of postoperative MACE.Among 12,621 patients with a history of prior PCI who underwent subsequent noncardiac surgery, 570 (4.5%) developed postoperative MACE. The median time from stent placement to surgery was 368 days (IQR 181-528). The strongest predictors of postoperative MACE were urgency of the operation, revised cardiac risk index, the indication for the prior PCI, and timing of the surgery after the PCI. Lesion characteristics independently associated with postoperative MACE included PCI to a distal (AOR 1.43, 95% CI 1.11-1.83) or ostial lesion (AOR 1.52, 95% CI 1.11-2.08), and lesion calcification (AOR 1.29, 95% CI 1.03-1.61), but stent length and target vessel were not independently associated with outcomes. Placement of a bare metal stent was also an independent predictor of MACE after noncardiac surgery (AOR 1.29, 95% CI 1.06-1.57).While patient and operative characteristics are the strongest predictors of MACE after noncardiac surgery, specific lesion characteristics including ostial or distal lesion location and calcification are novel risk factors for postoperative MACE. © 2016 Wiley Periodicals, Inc.
View details for DOI 10.1002/ccd.26624
View details for PubMedID 27315550
Pre-operative echocardiography among patients with coronary artery disease in the United States Veterans Affairs healthcare system: A retrospective cohort study.
BMC cardiovascular disorders
2016; 16 (1): 173-?
Echocardiography is not recommended for routine pre-surgical evaluation but may have value for patients at high risk of major adverse cardiovascular events (MACE). The objective of this study was to evaluate whether pre-operative echocardiography is associated with lower risk of post-operative MACE among patients with coronary artery disease.Using administrative and registry data, we examined associations of echocardiography within 3 months prior to surgery with postoperative MACE (myocardial infarction, revascularization, or death within 30 days) among patients with coronary artery disease undergoing elective, non-cardiac surgeries in the United States Veterans Affairs healthcare system in 2000-2012.Echocardiography preceded 4,378 (16.4 %) of 26,641 surgeries. MACE occurred within 30 days following 944 (3.5 %) surgeries. A 10 % higher case-mix adjusted rate of pre-operative echocardiography assessed at the hospital level was associated with a hospital-level risk of MACE that was 1.0 % (95 % confidence interval [CI] 0.1 %, 2.0 %) higher overall and 1.7 % (95 % CI 0.2 %, 3.2 %) higher among patients with recent myocardial infarction, valvular heart disease, or heart failure. At the patient level, pre-operative echocardiography was associated with an odds ratio for MACE of 1.9 (95 % CI 1.7, 2.2) overall and 1.8 (95 % CI 1.5, 2.2) among patients with recent myocardial infarction, valvular heart disease, or heart failure adjusting for MACE risk factors.Pre-operative echocardiography was not associated with lower risk of post-operative MACE, even in a high risk population. Future guidelines should encourage pre-operative echocardiography only in specific patients with cardiovascular disease among whom findings can be translated into effective changes in care.
View details for DOI 10.1186/s12872-016-0357-5
View details for PubMedID 27596717
- Delays in Surgery for Patients With Coronary Stents Placed After Diagnosis of Colorectal Cancer. JAMA surgery 2016; 151 (1): 86-88
- Frequency of Surgery Cancellations Associated With Myocardial Infarction or Death 6 Months After Coronary Stent Placement JAMA SURGERY 2015; 150 (12): 1199-1201
Hospital Acquired Conditions Are the Strongest Predictor for Early Readmission: An Analysis of 26,710 Arthroplasties
JOURNAL OF ARTHROPLASTY
2015; 30 (8): 1299-1307
Hospital readmission is a metric of hospital quality of care, yet little is known what factors predict hospital readmission following arthroplasty. Our aim was to identify variables associated with early readmission following knee and hip arthroplasty, with focus upon hospital acquired conditions (HACs). Retrospective cohort analysis using Surgical Care Improvement Project (SCIP) and Veteran's Affairs Surgical Quality Improvement Program (VASQIP) data was performed over a five-year period. Following 26,710 total and partial primary arthroplasties (16,808 knees and 9902 hips), the overall 30-day readmission was 7.3% (1940) with readmission rates of 6.6% for knee arthroplasty and 8.4% for hip arthroplasty. HACs accounted for 42% of all complications and were the strongest predictor of readmission. Efforts to reduce these events may improve cost and safety of arthroplasty.
View details for DOI 10.1016/j.arth.2015.02.024
View details for Web of Science ID 000358083400002
View details for PubMedID 25770864
Acceptability of the decision support for safer surgery tool
AMERICAN JOURNAL OF SURGERY
2015; 209 (6): 977-984
We examined providers' perceptions of the Decision Support for Safer Surgery (DS3) tool, which provided preoperative patient-level risk estimates of postoperative adverse events.The DS3 tool was evaluated at 2 academic medical centers. During the validation study, surgeons provided usefulness ratings of the DS3 tool for each patient before surgery. At the end of the study, providers' perceptions of the DS3 tool were assessed via questionnaire. Data were analyzed using descriptive statistics and independent samples t tests.During the trial, 23 surgeons completed usefulness ratings of the DS3 tool for 1,006 patients. Surgeons rated the tool as "very useful" or "moderately useful" in 251 (25%) of the cases, "neutral" in 469 (46.6%) of the cases, and "moderately unuseful" or "not useful" in 286 (28.4%) cases. At the end of the trial, 32 providers completed the questionnaire; perceptions were relatively neutral, although several aspects were rated quite favorably.The DS3 tool may be most useful for achieving particular tasks (eg, training novice surgeons, increasing patient engagement) or encouraging specific processes (eg, team-based care) in surgical care settings.
View details for DOI 10.1016/j.amjsurg.2014.06.037
View details for Web of Science ID 000355120700009
View details for PubMedID 25457241
Oral Antibiotic Bowel Preparation Significantly Reduces Surgical Site Infection Rates and Readmission Rates in Elective Colorectal Surgery
ANNALS OF SURGERY
2015; 261 (6): 1034-1040
To determine the relationship between oral antibiotic bowel preparation (OABP) and surgical site infection (SSI) rates in a national colectomy cohort.OABP for elective colorectal surgery has fallen out of favor. Large cohort studies show that OABP is associated with a 50% reduction in SSI after colectomy.A retrospective analysis of the National Surgical Quality Improvement Program colectomy cohort from 2011 to 2012 was performed to examine the association between use of OABP and outcomes of SSI, length of stay (LOS), and readmission after elective colectomy. Univariate and multivariable analyses for SSI were performed.The cohort included 8415 colorectal operations of which 5291 (62.9%) had a minimally invasive surgical (MIS) approach. Overall, 25.6% had no bowel preparation, 44.9% had mechanical bowel preparation (MBP) only, and 29.5% received OABP. The SSI rate was 11.1%, and it varied by preparation type: 14.9% no preparation, 12.0% MBP, and 6.5% OABP (P < 0.001). OABP group had significantly shorter hospital LOS: (median = 4, interquartile range: 3-6) versus other preparations (median LOS = 5) (P < 0.001). Readmission rates were lowest in OABP (8.1%) and highest in the no preparation group (11.8%). Multivariable logistic regressions found OABP associated with lower SSI [adjusted odds ratio (ORadj) = 0.46, 95% confidence interval (CI): 0.36-0.59]. Stratified models found OABP protective for SSI for both open procedures (ORadj = 0.40, 95% CI: 0.30-0.53) and MIS procedures (ORadj = 0.48, 95% CI: 0.36-0.65).OABP is associated with reduced SSI rates, shorter LOS, and fewer readmissions. Adoption of OABP before elective colectomy would reduce SSI without effecting LOS. The practice of MBP alone should be abandoned.
View details for DOI 10.1097/SLA.0000000000001125
View details for Web of Science ID 000369611600029
View details for PubMedID 25607761
Association Between Inpatient Surveillance and Venous Thromboembolism Rates After Hospital Discharge
2015; 150 (6): 520-527
Venous thromboembolism (VTE) surveillance practices in hospitals, but not adherence to Surgical Care Improvement Program VTE prophylaxis measures, have been reported to explain the variation in VTE rates in hospitals.To examine the relationship between inpatient surveillance testing for VTE and postdischarge VTE rates at the hospital level to determine whether more frequent inpatient surveillance is associated with reduced occurrence of postdischarge VTEs.Retrospective study of a US national cohort of Veterans Affairs (VA) patients. National VA Surgical Quality Improvement Program outcome data were linked to VA administrative data on patients undergoing inpatient surgery from 2005 to 2009 and were included in the Surgical Care Improvement Program VTE measurement population.Surveillance was identified using Current Procedural Terminology codes for diagnostic VTE imaging. Relationships between hospital-level surveillance and VTE rates were assessed with Pearson correlation coefficients, and the postdischarge VTE rate was modeled using linear regression, adjusting for hospital volume, inpatient VTE rate, inpatient surveillance rate, and case mix.Of 25 975 patients at 79 VA facilities, 296 (1.4%) experienced a VTE during the index hospitalization, and 114 (0.4%) experienced a postdischarge VTE within 30 days after surgery. The median length of stay was 11 days for those with a positive surveillance test result and 9 days for those with a negative test result. There was a positive correlation between inpatient surveillance and inpatient VTE rates (R = 0.33, P = .003) but no significant correlation of inpatient surveillance with either postdischarge surveillance (R = 0.11, P = .29) or postdischarge VTE rates (R = 0.03, P = .76). In an adjusted regression model of the postdischarge VTE rate, only the inpatient VTE rate was significant (β = 0.13, P = .05).Hospitals with higher VTE surveillance rates have higher inpatient VTE rates but not decreased postdischarge VTE rates. However, hospitals with higher inpatient VTE rates have higher postdischarge VTE rates, which suggests that surveillance may be influenced by higher observed rates and not surveillance practices alone.
View details for DOI 10.1001/jamasurg.2015.35
View details for Web of Science ID 000356615400007
View details for PubMedID 25831412
- Unintended Consequences of the Hospital Readmission Reduction Program ANNALS OF SURGERY 2015; 261 (6): 1032-1033
- Intraoperative Nerve Monitoring and Vocal Cord Paralysis: Controlling Bias In reply to Nguyen and Wang JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS 2015; 220 (5): 973-974
The Significance of Preoperative Impaired Sensorium on Surgical Outcomes in Nonemergent General Surgical Operations
2015; 150 (1): 30-36
With an aging population, preoperative assessment of the frail older adult requires evaluation beyond simply accounting for chronic diseases. Impaired cognition is a recognized characteristic of the frail older adult.To examine the effect of preoperative impaired sensorium (IS) on general surgical outcomes.Retrospective cohort study using data between January 2005 and December 2010 at academic and community hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. Patients undergoing nonemergent general surgical operations were studied. Multivariable logistic regression involving 45 preoperative patient-level risk factors and comorbidities was used to calculate the conditional probability of having IS. Patients having and not having preoperative IS were matched on their propensity scores using a 1:1 greedy matching technique. Propensity score matching resulted in almost all (n = 1765) patients with IS uniquely matching to a patient without IS, resulting in a cohort size of 3530. Complication rates between patients with and without IS were compared.Rates of postoperative complications and death following nonemergent general surgical operations.In total, 294 037 patients were studied, of whom 1771 (0.6%) had preoperative IS. Patients with IS were older and had more significant preoperative risk factors and comorbidities. As a result, unadjusted analysis found that 22 of 23 postoperative complications were significantly more likely to occur in patients with IS. Within the matched cohort, rates of postoperative pneumonia, ventilator dependence, progressive renal insufficiency, urinary tract infection, stroke, venous thromboembolism, and postoperative death continued to be significantly (P < .05) elevated in patients with IS.Impaired sensorium significantly increases postoperative morbidity and mortality independent of other preoperative risk factors and comorbidities following nonemergent general surgical operations. Incorporation of impaired cognitive function into routine preoperative risk assessment and decision making could be an important addition to traditional risk assessment strategies.
View details for DOI 10.1001/jamasurg.2014.863
View details for Web of Science ID 000348232900008
View details for PubMedID 25409305
- Surgical quality measurement: the good, the bad, and the ugly. JAMA surgery 2015; 150 (1): 58-?
The Incremental Risk of Noncardiac Surgery on Adverse Cardiac Events Following Coronary Stenting
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
2014; 64 (25): 2730-2739
Recent coronary stent placement and noncardiac surgery contribute to the risk of adverse cardiac events, but the relative contributions of these two factors have not been quantified.This research was designed to determine the incremental risk of noncardiac surgery on myocardial infarction (MI) and coronary revascularization following coronary stenting.A U.S. retrospective cohort study of patients receiving coronary stents at Veterans Affairs medical centers between 2000 and 2010 was used to match patients undergoing noncardiac surgery within 24 months of stent placement to two patients with stents not undergoing surgery. Patients were matched on stent type and cardiac risk factors present at the time of stent placement. A composite endpoint of MI and/or cardiac revascularization for the 30-day interval post-surgery was calculated. Adjusted risk differences (RD) were compared across time periods following stent implantation, using generalized estimating equations.We matched 20,590 surgical patients to 41,180 nonsurgical patients. During the 30-day interval following noncardiac surgery, the surgical cohort had higher rates of the composite cardiac endpoint (3.1% vs. 1.9%; RD: 1.3%; 95% confidence interval: 1.0% to 1.5%). The incremental risk of noncardiac surgery adjusted for surgical characteristics ranged from 3.5% immediately following stent implantation to 1% at 6 months, after which it remained stable out to 24 months. Factors associated with a significant reduction in risk following surgery more than 6 months post-stent included elective inpatient procedures (ΔRD: 1.8%; p = 0.01), high-risk surgery (ΔRD: 3.7%; p = 0.01), and drug-eluting stent (DES) (ΔRD: 1.3%; p = 0.01).The incremental risk of noncardiac surgery on adverse cardiac events among post-stent patients is highest in the initial 6 months following stent implantation and stabilizes at 1.0% after 6 months. Elective, high-risk, inpatient surgery, and patients with DES may benefit most from delay from a 6-month delay after stent placement.
View details for DOI 10.1016/j.jacc.2014.09.07
View details for Web of Science ID 000346734900003
View details for PubMedID 25541124
- Occult Gastrointestinal Bleeding JAMA SURGERY 2014; 149 (12): 1335-1336
Improved Adverse Postoperative Outcomes With Revised American College of Cardiology/American Heart Association Guidelines for Patients With Cardiac Stents
2014; 149 (11): 1113-1120
In 2007, the American College of Cardiology/American Heart Association guidelines were revised for patients with cardiac stents in need of subsequent surgery to recommend delaying elective noncardiac surgery by 365 days in patients with drug-eluting stents (DESs).To examine the effect of the guidelines on postoperative major adverse cardiac events (MACEs) in subsequent noncardiac surgery.Patients receiving a cardiac stent between fiscal years 2005 and 2010 were identified by International Classification of Diseases, Ninth Revision diagnosis codes in the Veterans Affairs Medical SAS data sets. The Veterans Affairs Surgical Quality Improvement Program data were used to identify subsequent operations in the 2 years following stenting. The preguideline period was defined as fiscal years 2005 through 2007 and the postguideline period was defined as fiscal years 2008 through 2010. Surgery patients admitted through the emergency department or transferred from another hospital were excluded from analyses. Overall, 16,634 elective noncardiac operations were identified (8034 [48.3%] in the preguideline period; 8600 [51.7%] in the postguideline period).Composite 30-day postoperative MACEs. We used χ² tests to examine differences in bivariate frequencies and used logistic models to examine adjusted associations with 2-year postoperative MACEs.The median time to surgery was 364 days (interquartile range, 184-528 days). A total of 11,026 operations (66.3%) followed DES placement, and 5608 (33.7%) followed bare metal stent placement. After the guidelines' publication, surgery timing increased following DES placement from 323 to 404 days (P < .001) and decreased following bare metal stent placement from 402 to 309 days (P < .001). In addition, postoperative MACE rates decreased from 4.2% to 3.3% (P = .002). After adjusting for cardiac risk factors and procedure characteristics, there was an overall absolute risk reduction of 0.9% for MACEs (odds ratio = 0.74; 95% CI, 0.62-0.89). On further examination of trends across time, MACE rates with DES placement began to decrease prior to the guidelines' publication from 5.5% in 2005 to 4.3% in 2006 and remained stable through 2010. In contrast, MACE rates with bare metal stent placement increased from 4.3% in 2005 to 8.0% in 2007 but decreased to 4.8% following the guidelines' publication.After the guidelines' publication, noncardiac surgery was delayed in patients with DESs but not bare metal stents. With a 26% reduction in MACEs following the guidelines, it would appear that the guidelines did improve postoperative outcomes; however, when examined over time, it becomes evident that there are many more factors influencing management of patients with cardiac stents in need of subsequent surgery.
View details for DOI 10.1001/jamasurg.2014.2044
View details for Web of Science ID 000345443800005
View details for PubMedID 25188466
- Perioperative Management of the Patient with a Coronary Artery Stent ANESTHESIOLOGY 2014; 121 (5): 1093-1098
Examining National Outcomes after Thyroidectomy with Nerve Monitoring
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2014; 219 (4): 765-770
Previous intraoperative nerve monitoring (IONM) studies have demonstrated modest-to-no benefit and did not include a nationwide sample of hospitals representative of broad thyroidectomy practices. This national study was designed to compare vocal cord paralysis (VCP) rates between thyroidectomy with IONM and without monitoring (conventional).We performed a retrospective analysis of 243,527 thyroidectomies during 2008 to 2011 using the Nationwide Inpatient Sample.Use of IONM increased yearly throughout the study period (2.6% , 5.6% , 6.1% , 6.9% ) and during this time, VCP rates in the IONM group initially increased year-over-year (0.9% , 2.4% , 2.5% , 1.4% ). In unadjusted analyses, IONM was associated with significantly higher VCP rates (conventional 1.4% vs IONM 1.9%, p < 0.001). After propensity score matching, IONM remained associated with higher VCP rates in partial thyroidectomy and lower VCP rates for total thyroidectomy with neck dissection. Hospital-level analysis revealed that VCP rates were not explained by differential laryngoscopy rates, decreasing the likelihood of ascertainment bias. Additionally, for hospitals in which IONM was applied to more than 50% of thyroidectomies, lower VCP rates were observed (1.1%) compared with hospitals that applied IONM to less than 50% (1.6%, p = 0.016). Higher hospital volume correlated with lower VCP rates in both groups (<75, 75 to 299, >300 thyroidectomies/year: IONM, 2.1%, 1.7%, 1.7%; conventional, 1.5%, 1.3%, 1.0%, respectively).According to this study, IONM has not been broadly adopted into practice. Overall, IONM was associated with a higher rate of VCP even after correction for numerous confounders. In particular, low institutional use of IONM and use in partial thyroidectomies are associated with higher rates of VCP. Further studies are warranted to support the broader application of IONM in patients where benefit can be reliably achieved.
View details for DOI 10.1016/j.jamcollsurg.2014.04.013
View details for Web of Science ID 000342422500022
View details for PubMedID 25158909
Improved Outcomes Associated With a Revised Quality Measure for Continuing Perioperative beta-Blockade
2014; 149 (10): 1031-1037
The Surgical Care Improvement Project perioperative β-blocker (BB) (SCIP-BB) continuation measure was revised in 2012 to incorporate inpatient BB continuation after discharge from the postanesthesia care unit.To determine whether adherence to the original or revised SCIP-BB measure is associated with decreased adverse events.Retrospective cohort study using national Veterans Affairs patient-level data on adherence to the original SCIP-BB measure and inpatient BB continuation for operations between July 2006 and August 2009.Data for SCIP-BB measure adherence, inpatient BB continuation, and patient and procedure risk variables were used to estimate the associations between adherence to the original and revised SCIP-BB measures and outcomes of major adverse cardiovascular or cerebrovascular events (MACCEs) and their components of cardiovascular events, cerebrovascular events, and 30-day mortality. In addition to unadjusted estimates, propensity score matching and bootstrapping were used to estimate the associations and generate 95% CIs.Major adverse cardiovascular or cerebrovascular events.Of 14,420 nonemergent operations with at least 2 postoperative inpatient days, 13,170 (91.3%) adhered to the original SCIP-BB measure, and 480 (3.3%) experienced a MACCE. Propensity score-matched analyses showed that adherence to the original SCIP-BB measure was not associated with MACCEs (odds ratio [OR], 1.00; 95% CI, 0.66-1.54) but was associated with increased cerebrovascular events (OR, 3.01; 95% CI, 1.00-10.07). Adherence to the revised SCIP-BB measure occurred in 11,597 (80.4%), and in matched analysis adherence was associated with decreased MACCEs (OR, 0.75; 95% CI, 0.57-0.95), cardiovascular events (OR, 0.66; 95% CI, 0.46-0.93), and 30-day mortality (OR, 0.74; 95% CI, 0.53-0.98). Adherence to the revised SCIP-BB measure was not associated with increased cerebrovascular events (OR, 1.22; 95% CI, 0.62-2.38).Adherence to the original SCIP-BB measure was associated with increased cerebrovascular events but not improved cardiovascular event outcomes. β-Blocker continuation consistent with the revised SCIP-BB measure is associated with reduced MACCEs, cardiovascular events, and 30-day mortality. These data provide a cautionary tale of implementing performance measures before they have been rigorously tested. Although the observed associations between adherence to the revised SCIP-BB measure and outcomes are promising, they should be evaluated in the postimplementation period.
View details for DOI 10.1001/jamasurg.2014.351
View details for Web of Science ID 000343987300009
View details for PubMedID 25141795
- Adoption of Preoperative Oral Antibiotics Decreases Surgical Site Infection for Elective Colorectal Surgery AMERICAN SURGEON 2014; 80 (9): E270-E273
Effect of elective inguinal hernia repair on urinary symptom burden in men
AMERICAN JOURNAL OF SURGERY
2014; 208 (2): 180-186
Our study sought to examine the prevalence of urinary symptoms in men undergoing hernia repair and whether there is an association between symptoms and short-term outcomes.This is a prospective cohort study of male veterans consenting to inguinal hernia repair. The American Urological Association Symptom Score (AUASS) was administered preoperatively at 48 hours and again at 30 days after surgery.Median preoperative AUASS was 6 (interquartile range [IQR]: 3 to 12); at 48 hours, the median score increased significantly to 10 (IQR: 4 to 16, P < .01) and at 30 days, the median score dropped below baseline to 3 (IQR: 1 to 8, P < .0001). Multivariable linear regression modeling revealed that the use of an intraoperative urinary catheter was significantly associated with an increase in AUASS from preop to both 48 hours and 30 days.Elective repair of an inguinal hernia is associated with reduction in urinary symptom burden at 30 days, whereas the use of an intraoperative foley catheter is associated with no improvement at 30 days.
View details for DOI 10.1016/j.amjsurg.2014.02.004
View details for Web of Science ID 000341149400005
View details for PubMedID 24815528
Identification of Process Measures to Reduce Postoperative Readmission
JOURNAL OF GASTROINTESTINAL SURGERY
2014; 18 (8): 1407-1415
Readmission rates after intestinal surgery have been notably high, ranging from 10 % for elective surgery to 21 % for urgent/emergent surgery. Other than adherence to established strategies for decreasing individual postoperative complications, there is little guidance available for providers to work toward reducing their postoperative readmission rates.Processes of care that may affect postoperative readmissions were identified through a systematic literature review, assessment of existing guidelines, and semi-structured interviews with individuals who have expertise in hospital readmissions and surgical quality improvement. Eleven experts ranked potential process measures for validity on the basis of the RAND/University of California, Los Angeles Appropriateness Methodology.Of 49 proposed process measures, 34 (69 %) were rated as valid. Of the 34 valid measures, two measures addressed care in the preoperative period. These included evaluation of patient's comorbidities, providing written instruction detailing the anticipated perioperative course, and communication with the patient's referring or primary care doctor. A measure addressing perioperative care stated that institutions should have a standardized perioperative care protocol. Additional measures focused on discharge instructions and communication.An expert panel identified several aspects of care that are considered essential to quality patient care and important to reducing postoperative readmissions.
View details for DOI 10.1007/s11605-013-2429-5
View details for Web of Science ID 000339420600005
View details for PubMedID 24912913
- Surgical Site Infection After Arthroplasty: Comparative Effectiveness of Prophylactic Antibiotics Do Surgical Care Improvement Project Guidelines Need to Be Updated? JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME 2014; 96A (12): 970-977
The Relationship Between Timing of Surgical Complications and Hospital Readmission
2014; 149 (4): 348-354
Readmissions after surgery are costly and may reflect quality of care in the index hospitalization.To determine the timing of postoperative complications with respect to hospital discharge and the frequency of readmission stratified by predischarge and postdischarge occurrence of complications.This is a retrospective cohort study of national Veterans Affairs Surgical Quality Improvement Program preoperative risk and outcome data on the Surgical Care Improvement Project cohort for operations performed from January 2005 to August 2009, including colorectal, arthroplasty, vascular, and gynecologic procedures. The association between timing of complication with respect to index hospitalization and 30-day readmission was modeled using generalized estimating equations.All-cause readmission within 30 days of the index surgical hospitalization discharge. RESULTS Our study of 59 273 surgical procedures performed at 112 Department of Veterans Affairs (VA) hospitals found an overall complication rate of 22.6% (predischarge complications, 71.9%; postdischarge complications, 28.1%). The proportion of postdischarge complications varied significantly, from 8.7% for respiratory complications to 55.7% for surgical site infection (P < .001). The overall 30-day readmission rate was 11.9%, of which only 56.0% of readmissions were associated with a currently assessed complication. Readmission was predicted by patient comorbid conditions, procedure factors, and the occurrence of postoperative complications. Multivariable generalized estimating equation models of readmission adjusting for patient and procedure characteristics, hospital, and index length of stay found that the occurrence of postdischarge complications had the highest odds of readmission (odds ratio, 7.4-20.8) compared with predischarge complications (odds ratio, 0.9-1.48).More than one-quarter of assessed complications are diagnosed after hospital discharge and strongly predict readmission. Hospital discharge is an insufficient end point for quality assessment. Although readmission is associated with complications, almost half of readmissions are not associated with a complication currently assessed by the Veterans Affairs Surgical Quality Improvement Program.
View details for DOI 10.1001/jamasurg.2013.4064
View details for Web of Science ID 000334609900008
View details for PubMedID 24522747
A 100% Departmental Mortality Review Improves Observed-to-Expected Mortality Ratios and University HealthSystem Consortium Rankings
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2014; 218 (4): 554-562
Public reporting of mortality, Patient Safety Indicators (PSI) and hospital-acquired conditions (HACs) is the reality of quality measurement. A review of our department's data identified opportunities for improvement. We began a surgeon-led 100% review of mortality, PSIs, and HACs to improve patient care and surgeon awareness of these metrics.From December 2012 through August 2013, there were 11,899 patients cared for on 12 surgical services. A surgeon from each service led monthly reviews of all mortality, PSIs, or HACs with central reporting of preventability and coding accuracy. We compared the University HealthSystem Consortium observed-to-expected (OE) mortality ratios (mean <1 fewer observed than expected deaths) and University HealthSystem Consortium relative rankings (lower number is better) before and after implementation. Statistical significance was p < 0.05 by Poisson regression.Of the 11,899 patients in the study period, there were 235 deaths, 290 PSIs, and 26 HACs identified and reviewed. The most common PSIs were postoperative deep vein thrombosis/pulmonary thromboembolism (n = 75), respiratory failure (n = 61), hemorrhage/hematoma (n = 33), and accidental puncture/laceration (n = 33). Before December 20, 2012, the OE ratio for mortality was consistently >1, then fell and remained <1 during the study period (p < 0.05). The OE mortality ratio in the fourth quarter of 2012 was 1.14 and fell to 0.88, 0.91, and 0.75 in the first, second, and third quarters of calendar year 2013 (p < 0.05). The overall Inpatient Quality Indicators #90 (composite postoperative mortality rank) rankings increased from 109 of 118 in the third quarter of 2012 to 47 of 119 in the third quarter of 2013.A surgeon-led systematic review of mortality, PSIs, and HACs improved our OE ratio and University HealthSystem Consortium postsurgical relative rankings. Surgeon engagement and ownership is critical for success.
View details for DOI 10.1016/j.jamcollsurg.2013.12.023
View details for Web of Science ID 000333250300008
View details for PubMedID 24529804
Alabama Veterans Rural Health Initiative: A Pilot Study of Enhanced Community Outreach in Rural Areas
JOURNAL OF RURAL HEALTH
2014; 30 (2): 153-163
Access, enrollment, and engagement with primary and specialty health care services present significant challenges for rural populations worldwide. The Alabama Veterans Rural Health Initiative evaluated an innovative outreach intervention combining motivational interviewing, patient navigation, and health services education to promote utilization of the United States Veterans Administration Healthcare System (VA) by veterans who live in rural locations.Community outreach workers completed the intervention and assessment, enrolling veterans from 31 counties in a southern state. A total 203 participants were randomized to either an enhanced enrollment and engagement outreach condition (EEE, n = 101) or an administrative outreach (AO, n = 102) condition.EEE participants enrolled and attended VA appointments at higher rates and within fewer days than those who received AO. Eighty-seven percent of EEE veterans attended an appointment within 6 months, compared to 58% of AO veterans (P < .0001). The median time to first appointment was 12 days for the EEE group and 98 days for the AO group (P < .0001). Additionally, a race by outreach group interaction emerged: black and white individuals benefited equally from the EEE intervention; however, black individuals who received AO took significantly longer to attend appointments than their white counterparts.Results provide needed empirical support for a specific outreach intervention that speeds enrollment and engagement for rural individuals in VA services. Planned interventions to improve service utilization should ameliorate ambivalence about accessing health care in addition to addressing traditional systems or environmental-level barriers.
View details for DOI 10.1111/jrh.12054
View details for Web of Science ID 000333691800005
View details for PubMedID 24330220
- Cardiovascular Event Risk After Noncardiac Surgery Reply JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 2014; 311 (5): 525-526
Comparison of Prospective Risk Estimates for Postoperative Complications: Human vs Computer Model
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2014; 218 (2): 237-?
Surgical quality improvement tools such as NSQIP are limited in their ability to prospectively affect individual patient care by the retrospective audit and feedback nature of their design. We hypothesized that statistical models using patient preoperative characteristics could prospectively provide risk estimates of postoperative adverse events comparable to risk estimates provided by experienced surgeons, and could be useful for stratifying preoperative assessment of patient risk.This was a prospective observational cohort. Using previously developed models for 30-day postoperative mortality, overall morbidity, cardiac, thromboembolic, pulmonary, renal, and surgical site infection (SSI) complications, model and surgeon estimates of risk were compared with each other and with actual 30-day outcomes.The study cohort included 1,791 general surgery patients operated on between June 2010 and January 2012. Observed outcomes were mortality (0.2%), overall morbidity (8.2%), and pulmonary (1.3%), cardiac (0.3%), thromboembolism (0.2%), renal (0.4%), and SSI (3.8%) complications. Model and surgeon risk estimates showed significant correlation (p < 0.0001) for each outcome category. When surgeons perceived patient risk for overall morbidity to be low, the model-predicted risk and observed morbidity rates were 2.8% and 4.1%, respectively, compared with 10% and 18% in perceived high risk patients. Patients in the highest quartile of model-predicted risk accounted for 75% of observed mortality and 52% of morbidity.Across a broad range of general surgical operations, we confirmed that the model risk estimates are in fairly good agreement with risk estimates of experienced surgeons. Using these models prospectively can identify patients at high risk for morbidity and mortality, who could then be targeted for intervention to reduce postoperative complications.
View details for DOI 10.1016/j.jamcollsurg.2013.10.027
View details for Web of Science ID 000329763900013
View details for PubMedID 24440066
Surgical Site Infection After Arthroplasty: Comparative Effectiveness of Prophylactic Antibiotics: Do Surgical Care Improvement Project Guidelines Need to Be Updated?
The Journal of bone and joint surgery. American volume
2014; 96 (12): 970-977
Prophylactic antibiotics decrease surgical site infection (SSI) rates, and their timing, choice, and discontinuation are measured and reported as part of the Surgical Care Improvement Project (SCIP). The aim of this study was to assess the comparative effectiveness of the SCIP-approved antibiotics for SSI prevention.METHODS: This retrospective cohort study utilized national Veterans Affairs (VA) data on patients undergoing elective hip or knee arthroplasty from 2005 to 2009. Data on prophylactic antibiotics were merged with VA Surgical Quality Improvement Program data to identify patient and procedure-related risk factors for SSI. Patients were stratified by documented penicillin allergy. Chi-square and Wilcoxon rank-sum tests were used to compare SSI rates among patients receiving SCIP-approved prophylactic antibiotics.RESULTS: A total of 18,830 elective primary arthroplasties (12,823 knee and 6007 hip) were included. Most patients received prophylactic cefazolin as the sole agent (81.9%), followed by vancomycin as the sole agent (8.0%), vancomycin plus cefazolin (5.6%), and clindamycin (4.5%). Documented penicillin allergy accounted for 54.1% of cases involving vancomycin administration compared with 94.6% of cases involving clindamycin. The overall thirty-day SSI rate was 1.4%, and the unadjusted rate was 2.3% with vancomycin only, 1.5% with vancomycin plus cefazolin, 1.3% with cefazolin only, and 1.1% with clindamycin. Unadjusted analysis of penicillin-allergic patients revealed an SSI rate of 2.0% with vancomycin only compared with 1.0% with clindamycin (p = 0.18). For patients without penicillin allergy, the SSI rate was 2.6% with vancomycin only compared with 1.6% with vancomycin plus cefazolin (p = 0.17) and 1.3% with cefazolin only (p < 0.01).CONCLUSIONS: Current SCIP guidelines address antibiotic timing but not antibiotic dosage. (The generally accepted recommendation for vancomycin is 15 mg/kg.) Although vancomycin is a narrower-spectrum antibiotic than either cefazolin or clindamycin, our finding of higher SSI rates following prophylaxis with vancomycin only may suggest a failure to use an appropriate dosage rather than an inequality of antibiotic effectiveness.LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
View details for DOI 10.2106/JBJS.M.00663
View details for PubMedID 24951731
Choice of Intravenous Antibiotic Prophylaxis for Colorectal Surgery Does Matter
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2013; 217 (5): 763-769
The Surgical Care Improvement Program endorses mandatory compliance with approved intravenous prophylactic antibiotics; however, oral antibiotics are optional. We hypothesized that surgical site infection (SSI) rates may vary depending on the choice of antibiotic prophylaxis.A retrospective cohort study of elective colorectal procedures using Veterans Affairs Surgical Quality Improvement Program (VASQIP) and SSI outcomes data was linked to the Office of Informatics and Analytics (OIA) and Pharmacy Benefits Management (PBM) antibiotic data from 2005 to 2009. Surgical site infection rates by type of IV antibiotic agent alone (IV) or in combination with oral antibiotic (IV + OA) were determined. Generalized estimating equations were used to examine the association between type of antibiotic prophylaxis and SSI for the entire cohort and stratified by use of oral antibiotics.After 5,750 elective colorectal procedures, 709 SSIs (12.3%) developed within 30 days. Oral antibiotic + IV (n = 2,426) had a lower SSI rate than IV alone (n = 3,324) (6.3% vs 16.7%, p < 0.0001). There was a significant difference in the SSI rate based on type of preoperative IV antibiotic given (p ≤ 0.0001). Generalized estimating equations adjusting for significant covariates of age, body mass index, procedure work relative value units, and operation duration demonstrated an independent protective effect of oral antibiotics (odds ratio [OR] 0.37, 95% CI 0.29 to 0.46), as well as increased rates of SSI associated with ampicillin/sulbactam (OR 2.21, 95% CI 1.37 to 3.56) and second generation cephalosporins (cefoxitin, OR 2.50, 95% CI 1.83 to 3.42; cefotetan, OR 2.70, 95% CI 1.72 to 4.22) when compared with first generation cephalosporin/metronidazole.The choice of IV antibiotic was related to the SSI rate; however, oral antibiotics were associated with reduced SSI rate for every antibiotic class.
View details for DOI 10.1016/j.jamcollsurg.2013.07.003
View details for Web of Science ID 000325759500003
View details for PubMedID 24045142
Risk of Major Adverse Cardiac Events Following Noncardiac Surgery in Patients With Coronary Stents
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION
2013; 310 (14): 1462-1472
Guidelines recommend delaying noncardiac surgery in patients after coronary stent procedures for 1 year after drug-eluting stents (DES) and for 6 weeks after bare metal stents (BMS). The evidence underlying these recommendations is limited and conflicting.To determine risk factors for adverse cardiac events in patients undergoing noncardiac surgery following coronary stent implantation.A national, retrospective cohort study of 41,989 Veterans Affairs (VA) and non-VA operations occurring in the 24 months after a coronary stent implantation between 2000 and 2010. Nonlinear generalized additive models examined the association between timing of surgery and stent type with major adverse cardiac events (MACE) adjusting for patient, surgery, and cardiac risk factors. A nested case-control study assessed the association between perioperative antiplatelet cessation and MACE.A composite 30-day MACE rate of all-cause mortality, myocardial infarction, and cardiac revascularization.Within 24 months of 124,844 coronary stent implantations (47.6% DES, 52.4% BMS), 28,029 patients (22.5%; 95% CI, 22.2%-22.7%) underwent noncardiac operations resulting in 1980 MACE (4.7%; 95% CI, 4.5%-4.9%). Time between stent and surgery was associated with MACE (<6 weeks, 11.6%; 6 weeks to <6 months, 6.4%; 6-12 months, 4.2%; >12-24 months, 3.5%; P < .001). MACE rate by stent type was 5.1% for BMS and 4.3% for DES (P < .001). After adjustment, the 3 factors most strongly associated with MACE were nonelective surgical admission (adjusted odds ratio [AOR], 4.77; 95% CI, 4.07-5.59), history of myocardial infarction in the 6 months preceding surgery (AOR, 2.63; 95% CI, 2.32-2.98), and revised cardiac risk index greater than 2 (AOR, 2.13; 95% CI, 1.85-2.44). Of the 12 variables in the model, timing of surgery ranked fifth in explanatory importance measured by partial effects analysis. Stent type ranked last, and DES was not significantly associated with MACE (AOR, 0.91; 95% CI, 0.83-1.01). After both BMS and DES placement, the risk of MACE was stable at 6 months. A case-control analysis of 284 matched pairs found no association between antiplatelet cessation and MACE (OR, 0.86; 95% CI, 0.57-1.29).Among patients undergoing noncardiac surgery within 2 years of coronary stent placement, MACE were associated with emergency surgery and advanced cardiac disease but not stent type or timing of surgery beyond 6 months after stent implantation. Guideline emphasis on stent type and surgical timing for both DES and BMS should be reevaluated.
View details for DOI 10.1001/jama.2013.278787
View details for Web of Science ID 000325354100022
View details for PubMedID 24101118
Postoperative risks associated with alcohol screening depend on documented drinking at the time of surgery
DRUG AND ALCOHOL DEPENDENCE
2013; 132 (3): 521-527
Both AUDIT-C alcohol screening scores up to a year before surgery and clinical documentation of drinking over 2 drinks per day immediately prior to surgery ("documented drinking >2d/d") are associated with increased postoperative complications and health care utilization. The purpose of this study was to evaluate whether documented drinking >2d/d contributed additional information about postoperative risk beyond past-year AUDIT-C screening results.Male Veterans Affairs (VA) patients who had a non-emergent, non-cardiac, major surgery assessed by the VA's Surgical Quality Improvement Program 10/2003-9/2006 and completed the AUDIT-C by mailed survey in the prior year were eligible for this study. Linear or logistic regression models compared 30-day postoperative complication(s), return to operating room (OR), hospital length of stay (LOS), and intensive care unit (ICU) days across eight groups defined by past-year AUDIT-C score and clinically documented drinking >2d/d, with AUDIT-C scores 1-4 and no documented drinking >2d/d as the referent, after adjusting for important covariates.Overall 8811 patients met inclusion criteria. Among patients with documented drinking >2d/d immediately prior to surgery, postoperative risk varied widely depending on past-year AUDIT-C score; scores ≥5 were associated with increased risk of complication(s), and scores ≥9 with increased hospital LOS and ICU days. Among patients without documentation of drinking >2d/d, increasing AUDIT-C scores were not associated with these outcomes.Clinical documentation of drinking >2d/d immediately prior to surgery contributed additional information about postoperative risk beyond past-year AUDIT-C score. However, among patients with documented drinking >2d/d, postoperative risk varied widely depending on the AUDIT-C score.
View details for DOI 10.1016/j.drugalcdep.2013.03.022
View details for Web of Science ID 000325510700018
View details for PubMedID 23683792
Advancing age and 30-day adverse outcomes after nonemergent general surgeries.
Journal of the American Geriatrics Society
2013; 61 (9): 1608-1614
To determine whether 30-day postoperative mortality, complications, failure-to-rescue (FTR) rates, and postoperative length of stay increase with advancing age.Retrospective cohort study.Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program.Individuals undergoing nonemergent major general surgeries between 2005 and 2008 were studied (N = 165,600).Postoperative outcomes of interest were complications occurring within 30 days of the index operation, return to the operating room within 30 days, FTR after a postoperative complication, postsurgical length of stay, and 30-day mortality.Postoperative mortality, overall morbidity, and each type of postoperative complication increased with increasing age. Rates of FTR after each type of postoperative complication also increased with age. Mortality in individuals aged 80 and older after renal insufficiency (43.3%), stroke (36.5%), myocardial infarction (MI) (35.6%), and pulmonary complications (25-39%) were particularly high. Median postoperative length of stay increased with age after surgical site infection, urinary tract infection, pneumonia, return to the operating room, and overall morbidity but not after venous thromboembolism, stroke, MI, renal insufficiency, failure to wean from the ventilator, or reintubation.Thirty-day mortality and complication and FTR rates increase with age after nonemergent general surgeries. Individuals aged 80 and older have especially high mortality after renal, cardiovascular, and pulmonary complications. Surgeons need to be more selective with advancing age regarding who will benefit from the surgical intervention.
View details for DOI 10.1111/jgs.12401
View details for PubMedID 23927841
Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection
2013; 148 (7): 649-657
Timing of prophylactic antibiotic administration for surgical procedures is a nationally mandated and publicly reported quality metric sponsored by the Centers for Medicare and Medicaid Services Surgical Care Improvement Project. Numerous studies have failed to demonstrate that adherence to the Surgical Care Improvement Project prophylactic antibiotic timely administration measure is associated with decreased surgical site infection (SSI). OBJECTIVE; To determine whether prophylactic antibiotic timing is associated with SSI occurrence.Retrospective cohort study using national Veterans Affairs patient-level data on prophylactic antibiotic timing for orthopedic, colorectal, vascular, and gynecologic procedures from 2005 through 2009.National Veterans Affairs Surgical Care Improvement Project data from 112 Veterans Affairs hospitals and matched Veterans Affairs Surgical Quality Improvement Program data.Patients undergoing hip or knee arthroplasty, colorectal surgical procedures, arterial vascular surgical procedures, and hysterectomy.Timing of prophylactic antibiotic administration with respect to surgical incision time.Data for prophylactic antibiotic agent, prophylactic antibiotic timing with respect to surgical incision, and patient and procedure risk variables were assessed for their relationship with the occurrence of a composite superficial or deep incisional SSI within 30 days after the procedure. Nonlinear generalized additive models were used to examine the association between antibiotic timing and SSI.Of the 32,459 operations, prophylactic antibiotics were administered at a median of 28 minutes (interquartile range, 17-39 minutes) prior to surgical incision, and 1497 cases (4.6%) developed an SSI. Compared with procedures with antibiotic administration within 60 minutes prior to incision, higher SSI rates were observed for timing more than 60 minutes prior to incision (unadjusted odds ratio [OR] = 1.34; 95% CI, 1.08-1.66) but not after incision (unadjusted OR = 1.26; 95% CI, 0.92-1.72). In unadjusted generalized additive models, we observed a significant nonlinear relationship between prophylactic antibiotic timing and SSI when considering timing as a continuous variable (P = .01). In generalized additive models adjusted for patient, procedure, and antibiotic variables, no significant association between prophylactic antibiotic timing and SSI was observed. Vancomycin hydrochloride was associated with higher SSI occurrence for orthopedic procedures (adjusted OR = 1.75; 95% CI, 1.16-2.65). Cefazolin sodium and quinolone in combination with an anaerobic agent were associated with fewer SSI events (cefazolin: adjusted OR = 0.49; 95% CI, 0.34-0.71; quinolone: adjusted OR = 0.55; 95% CI, 0.35-0.87) for colorectal procedures.The SSI risk varies by patient and procedure factors as well as antibiotic properties but is not significantly associated with prophylactic antibiotic timing. While adherence to the timely prophylactic antibiotic measure is not bad care, there is little evidence to suggest that it is better care.
View details for DOI 10.1001/jamasurg.2013.134
View details for Web of Science ID 000323556600018
View details for PubMedID 23552769
Coronary Stents and Subsequent Surgery: Reported Provider Attitudes and Practice Patterns
2013; 79 (5): 514-523
Management of antiplatelet therapy in patients with cardiac stents who need subsequent surgery is complex. Current guidelines recommend delaying elective surgery or, if surgery is emergent, proceeding without aspirin cessation. This study assessed provider knowledge, attitudes, and practices for patients with cardiac stents needing subsequent surgery. A national survey was administered to Veterans Administration surgeons, anesthesiologists, and cardiologists. Questions examined guideline awareness and agreement, perceptions of bleeding risk and stent thrombosis, practice patterns for antiplatelet therapy management, and experience with perioperative stent thrombosis. Chi-square tests and generalized estimating equations were used to examine differences in reported practices. Among 295 respondents, guideline awareness (92%) and agreement (93%) were high but higher among cardiologists and anesthesiologists than surgeons. Guideline agreement and personal experience with stent thrombosis were also associated with reported practice patterns. In adjusted models for early surgeries, cardiologists and anesthesiologists were more likely to report continuation of dual therapy as compared with surgeons regardless of stent type (drug-eluting P = 0.03; bare metal P < 0.01). Despite successful guideline adoption, significant variations in practice patterns by provider type were found. Understanding reasons behind the variation and outcomes of various antiplatelet management strategies are important steps in optimizing care of patients with coronary stents undergoing noncardiac surgery.
View details for Web of Science ID 000317947000013
View details for PubMedID 23635588
The Risk of Major Elective Vascular Surgical Procedures in Patients With End-Stage Renal Disease
ANNALS OF SURGERY
2013; 257 (4): 766-773
To examine the postoperative complications and death rate of major elective vascular surgery procedures in patients with end-stage renal disease (ESRD).Patients with ESRD undergoing elective major vascular surgical procedures are thought to have a high rate of postoperative complications and death.The American College of Surgeons-National Surgical Quality Improvement Program database was used to select ESRD and non-ESRD patients who had elective major vascular surgical procedures between 2004 and 2008. Multivariable logistic regression analysis was used to examine the impact of ESRD on 30-day surgical outcomes adjusted for age, race, sex, work relative value units, American Society of Anesthesiology class, and recent operations (within the past 30 days).ESRD patients undergoing elective major vascular surgery were significantly more likely than non-ESRD patients to develop surgical site infection, unplanned intubation, ventilator dependence, combined pulmonary outcome, and a need for reoperation within 30 days of surgery. Importantly, ESRD patients undergoing elective major vascular surgery were also at higher risk for composite outcome and death within 30 days from surgery. ESRD patients above age 65 years undergoing elective major vascular surgery had far worse 30-day outcomes when compared with the younger ESRD cohort. Examining these data by their anatomic site (carotid, aortic, and peripheral) demonstrated elevated rates of postoperative complications and death in patients with ESRD undergoing open abdominal aortic aneurysm repair, carotid endarterectomies, and peripheral vascular operations compared with the non-ESRD cohort. Endovascular abdominal aortic aneurysm repair in ESRD patients had complications and death rates comparable with non-ESRD patients.Patients with ESRD undergoing elective vascular surgery have a significantly elevated risk of postoperative complications and death after major vascular surgical operations--particularly in patients over age 65. These data, in combination with well-established reduced survival for the older ESRD population, call into question the utility of most carotid and aortic operations in these patients in the absence of symptoms or a rapidly enlarging aneurysm.
View details for DOI 10.1097/SLA.0b013e3182686b87
View details for Web of Science ID 000315990100034
View details for PubMedID 22982978
Oral Antibiotic Bowel Preparation Reduces Length of Stay and Readmissions after Colorectal Surgery
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2013; 216 (4): 756-762
Oral antibiotic bowel preparation (OABP) before colorectal resection has been shown to reduce surgical site infections. We examined whether OABP decreases length of stay (LOS) and readmissions for colorectal surgery.This retrospective study used national Veterans Affairs Surgical Quality Improvement Program preoperative risk and outcomes data linked to Veterans Affairs Administrative and Pharmacy Benefits Management data on patients undergoing elective colorectal resections from 2005 to 2009. Exclusion criteria were preoperative LOS >2 days, American Society of Anesthesiologists class 5, or death before discharge. Patient and surgery characteristics, bowel preparation use, presence of an ostomy, indication for surgery, and indication for readmission using ICD-9 codes were determined. Negative binomial regression was used to model LOS. Logistic regression analyses modeled 30-day readmission.Of the 8,180 patients, 1,161 (14.2%) were readmitted within 30 days. Length of stay and readmissions varied significantly by bowel preparation, procedure, presence of an ostomy, and American Society of Anesthesiologists class. Oral antibiotic bowel preparation was associated with a below-median postoperative LOS (negative binomial regression estimate = -0.1159; p < 0.0001) and fewer 30-day readmissions (adjusted odds ratio = 0.81; 95% CI, 0.68-0.97). Overall, 4.9% were readmitted for infections (ICD-9 codes) and this varied by bowel preparation (no preparation 6.1%, mechanical 5.4%, OABP 3.9%; p = 0.001). The readmission rate for noninfectious reasons was 9.3% and did not differ significantly by bowel preparation (no preparation 9.9%, mechanical 9.6%, OABP 8.8%; p = 0.38).Oral antibiotic bowel preparation before elective colorectal surgery is associated with shorter postoperative LOS and lower 30-day readmission rates, primarily due to fewer readmissions for infections. Prospective studies are needed to verify these results.
View details for DOI 10.1016/j.jamcollsurg.2012.12.039
View details for Web of Science ID 000316727400049
View details for PubMedID 23521958
Risk of Major Nonemergent Inpatient General Surgical Procedures in Patients on Long-term Dialysis
2013; 148 (2): 137-143
Patients on long-term dialysis undergoing major nonemergent general surgical procedures are thought to have high rates of postoperative complications and death.Retrospective cohort study.Academic and private hospitals.The American College of Surgeons National Surgical Quality Improvement Program database was used to select dialysis and nondialysis patients who had undergone nonemergent major general surgical procedures between 2005 and 2008. Multivariable logistic regression analysis was used to examine the effect of dialysis on 30-day surgical outcomes adjusted for age, race, sex, work relative value units, American Society of Anesthesiologists class, and recent operations (within the past 30 days).Patient morbidity, mortality, and failure-to-rescue rates.Dialysis patients undergoing major nonemergent general surgical procedures were significantly more likely to develop pneumonia, unplanned intubation, ventilator dependence, and need for a reoperation within 30 days from the index procedure. Dialysis patients also had a higher risk of vascular complications and postoperative death. Older dialysis patients (aged ≥ 65 years) had a significantly higher postoperative mortality rate compared with their younger counterparts. Dialysis patients were significantly more likely to die after any complication occurred, and mortality rates were especially high following stroke, myocardial infarction, and reintubation. Abnormalities in potentially modifiable preoperative variables (blood urea nitrogen level, albumin level, and hematocrit) did not increase the risk of postoperative complications or death in dialysis patients compared with nondialysis patients.Dialysis patients undergoing nonemergent general surgery have significantly elevated risks of postoperative complications and death, particularly if they are aged 65 years or older.
View details for DOI 10.1001/2013.jamasurg.347
View details for Web of Science ID 000316681300005
View details for PubMedID 23560284
Technical aspects and early results of robotic esophagectomy with chest anastomosis
JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY
2013; 145 (1): 90-96
Minimally invasive esophagectomy with a chest anastomosis has advantages. We present technical lessons learned and early results.A retrospective review was conducted of minimally invasive laparoscopic and robotic Ivor Lewis esophagectomy.Over 10 months, 22 patients (19 men) underwent laparoscopic gastric mobilization, with robotic esophagectomy. All had the thoracic portion completed robotically and 21 had the stomach mobilized laproscopically. All had esophageal cancer and 20 received neoadjuvant chemoradiotherapy. All had R0 resection with a median of 18 lymph nodes removed and a blood loss of 40 mL. The first 6 patients underwent a stapled posterior and hand-sewn anterior anastomosis; five of these patients experienced a major morbidity, including 1 anastomotic leak and 1 leak from the gastric staple line. The last 16 patients had a 2-layered completely hand-sewn anastomosis, and there were no anastomotic leaks or major morbidities. There were no 30- or 90-day mortalities. Technical improvements included placing a loop around the esophagus in the abdomen for third arm retraction, advancing the gastric conduit into the chest using nonrobotic instruments, using 10-cm nonabsorbable interrupted sutures for the outer layer, and a running 22-cm long absorbable suture for the inner layer.Robotic thoracic esophagectomy using ports only is feasible, safe, and affords R0 resection with thorough thoracic lymph node dissection. It also allows the sewing of a 2-layered chest anastomosis with good early results.
View details for DOI 10.1016/j.jtcvs.2012.04.022
View details for Web of Science ID 000312386300023
View details for PubMedID 22910197
Mediation of smoking-associated postoperative mortality by perioperative complications in veterans undergoing elective surgery: data from Veterans Affairs Surgical Quality Improvement Program (VASQIP)-a cohort study
2013; 3 (4)
To assess the mediation of smoking-associated postoperative mortality by postoperative complications.Observational cohort study.Using data from the Veterans Affairs (VA) Surgical Quality Improvement Programme, a quality assurance programme for major surgical procedures in the VA healthcare system, we assessed the association of current smoking at the time of the surgery with 6-month and 1-year mortality.Using mediation analyses, we calculated the relative contribution of each smoking-associated complication to smoking-associated postoperative mortality, both unadjusted and adjusted for age, race/ethnicity, work relative value unit of the operation, surgeon specialty, American Society of Anesthesiologists class and year of surgery. Smoking-associated complications included surgical site infection (SSI), cardiovascular complications (myocardial infarction, cardiac arrest and/or stroke) and pulmonary complications (pneumonia, failure to wean and/or reintubation).There were 186 632 never smokers and 135 741 current smokers. The association of smoking and mortality was mediated by smoking-related complications with varying effects. In unadjusted analyses, the proportions of mediation of smoking to 6-month mortality explained by the complications were as follows: SSIs 22%, cardiovascular complications 12% and pulmonary complications 89%. In adjusted analyses, the per cents mediated by each complication were as follows: SSIs 2%, cardiovascular complications 4% and pulmonary complications 22%. In adjusted analyses for 1-year mortality, respective per cents mediated were 2%, 3% and 16%.Pulmonary complications, followed by cardiovascular complications and SSIs were mediators of smoking-associated 6-month and 1-year mortality. Interventions targeting smoking cessation and prevention and early treatment of pulmonary complications has the likelihood of reducing postoperative mortality after elective surgery.
View details for DOI 10.1136/bmjopen-2012-002157
View details for Web of Science ID 000329809200016
View details for PubMedID 23604347
Preoperative screening and case cancellation in cocaine-abusing veterans scheduled for elective surgery.
Anesthesiology research and practice
2013; 2013: 149892-?
Background. Perioperative management of cocaine-abusing patients scheduled for elective surgery varies widely based on individual anecdotes and personal experience. Methods. Chiefs of the anesthesia departments in the Veterans Affairs (VA) health system were surveyed to estimate how often they encounter surgical patients with cocaine use. Respondents were asked about their screening criteria, timing of screening, action resulting from positive screening, and if they have a formal policy for management of these patients. Interest in the development of VA guidelines for the perioperative management of patients with a history of cocaine use was also queried. Results. 172 VA anesthesia departments' chiefs were surveyed. Response rate was 62%. Over half of the facilities see cocaine-abusing patients at least once a week (52%). Two thirds of respondents canceled or delayed patients with a positive screen regardless of clinical symptoms. Only eleven facilities (10.6%) have a formal policy. The majority of facilities (80%) thought that having formal guidelines for perioperative management of cocaine-abusing patients would be helpful to some extent. Results. 172 VA anesthesia departments' chiefs were surveyed. Response rate was 62%. Over half of the facilities see cocaine-abusing patients at least once a week (52%). Two thirds of respondents canceled or delayed patients with a positive screen regardless of clinical symptoms. Only eleven facilities (10.6%) have a formal policy. The majority of facilities (80%) thought that having formal guidelines for perioperative management of cocaine-abusing patients would be helpful to some extent. Conclusions. There is a general consensus that formal guidelines would be helpful. Further studies are needed to help formulate evidence-based guidelines for managing patients screening positive for cocaine prior to elective surgery.
View details for DOI 10.1155/2013/149892
View details for PubMedID 24069030
Preoperative Oral Antibiotics Reduce Surgical Site Infection Following Elective Colorectal Resections
DISEASES OF THE COLON & RECTUM
2012; 55 (11): 1160-1166
Surgical site infection is a major cause of morbidity after colorectal resections. Despite evidence that preoperative oral antibiotics with mechanical bowel preparation reduce surgical site infection rates, the use of oral antibiotics is decreasing. Currently, the administration of oral antibiotics is controversial and considered ineffective without mechanical bowel preparation.The aim of this study is to examine the use of mechanical bowel preparation and oral antibiotics and their relationship to surgical site infection rates in a colorectal Surgical Care Improvement Project cohort.This retrospective study used Veterans Affairs Surgical Quality Improvement Program preoperative risk and surgical site infection outcome data linked to Veterans Affairs Surgical Care Improvement Project and Pharmacy Benefits Management data. Univariate and multivariable models were performed to identify factors associated with surgical site infection within 30 days of surgery.This study was conducted in 112 Veterans Affairs hospitals.Included were 9940 patients who underwent elective colorectal resections from 2005 to 2009.The primary outcome measured was the incidence of surgical site infection.Patients receiving oral antibiotics had significantly lower surgical site infection rates. Those receiving no bowel preparation had similar surgical site infection rates to those who had mechanical bowel preparation only (18.1% vs 20%). Those receiving oral antibiotics alone had an surgical site infection rate of 8.3%, and those receiving oral antibiotics plus mechanical bowel preparation had a rate of 9.2%. In adjusted analysis, the use of oral antibiotics alone was associated with a 67% decrease in surgical site infection occurrence (OR=0.33, 95% CI 0.21-0.50). Oral antibiotics plus mechanical bowel preparation was associated with a 57% decrease in surgical site infection occurrence (OR=0.43, 95% CI 0.34-0.55). Timely administration of parenteral antibiotics (Surgical Care Improvement Project-1) had a modest protective effect, with no effect observed for other Surgical Care Improvement Project measures. Hospitals with higher rates of oral antibiotics use had lower surgical site infection rates (R = 0.274, p < 0.0001).Determination of the use of oral antibiotics and mechanical bowel preparation is based on retrospective prescription data, and timing of actual administration cannot be determined.Use and type of preoperative bowel preparation varied widely. These results strongly suggest that preoperative oral antibiotics should be administered for elective colorectal resections. The role of oral antibiotics independent of mechanical bowel preparation should be examined in a prospective randomized trial.
View details for DOI 10.1097/DCR.0b013e3182684fac
View details for Web of Science ID 000309818400015
View details for PubMedID 23044677
Factors influencing emergency department preference for access to healthcare.
The western journal of emergency medicine
2012; 13 (5): 410-415
African-Americans are more likely than Caucasians to access healthcare through the emergency department (ED); however, the reasons behind this pattern are unclear. The objective is to investigate the effect of race, insurance, socioeconomic status, and perceived health on the preference for ED use.This is a prospective study at a tertiary care ED from June to July 2009. Patients were surveyed to capture demographics, healthcare utilization, and baseline health status. The primary outcome of interest was patient-reported routine place of healthcare. Other outcomes included frequency of ED visits in the previous 6 months, barriers to primary care and patient perception of health using select questions from the Medical Outcomes Study Short Form 36 (SF-36).Two hundred and ninety-two patients completed the survey of whom 58% were African-American and 44% were uninsured. African-Americans were equally likely to report 3 or more visits to the ED, but more likely to state a preference for the ED for their usual place of care (24% vs. 13%, p < 0.01). No significant differences between groups were found for barriers to primary care, including insurance. African-Americans less often reported comorbidities or hospitalization within the previous 6 months (23% vs. 34%, p = 0.04). On logistic regression modeling, African-Americans were more than 2 times as likely to select the ED as their usual place of healthcare (OR 2.24, 95% CI 1.22 - 4.08).African-Americans, independent of health insurance, are more likely than Caucasians to designate the ED as their routine place of healthcare.
View details for DOI 10.5811/westjem.2011.11.6820
View details for PubMedID 23359637
- Individual surgical decision-making and comparative effectiveness research SURGERY 2012; 152 (5): 787-789
Association between Surgical Care Improvement Program venous thromboembolism measures and postoperative events
AMERICAN JOURNAL OF SURGERY
2012; 204 (5): 591-597
In 2006, the Surgical Care Improvement Program (SCIP) implemented measures to reduce venous thromboembolism (VTE). There are little data on whether these measures reduce VTE rates. This study proposed to examine associations between SCIP-VTE adherence and VTE rates.SCIP-VTE adherence for 30,531 surgeries from 2006 to 2009 was linked with VA Surgical Quality Improvement Program data. Patient demographics, comorbidities, and surgical characteristics associated with VTE were summarized. VTE rates were compared by SCIP-VTE adherence. Multivariable logistic regression was used to model VTE by adherence, adjusting for multiple associated factors.Of 30,531 surgeries, 89.9% adhered to SCIP-VTE; 1.4% experienced VTE. Logistic regression identified obesity, smoking, functional status, weight loss, emergent status, age older than 64 years, and surgical time as associated with VTE. SCIP-VTE was not associated with VTE (1.4% vs 1.33%; P = .3), even after adjustment.This study identified several important risk factors for VTE but found no association with SCIP-VTE adherence.
View details for DOI 10.1016/j.amjsurg.2012.07.006
View details for Web of Science ID 000311734000013
View details for PubMedID 22906249
Adverse cardiac events in patients with coronary stents undergoing noncardiac surgery: a systematic review
AMERICAN JOURNAL OF SURGERY
2012; 204 (4): 494-501
When patients with drug-eluting stents (DES) present for surgery, current guidelines recommend delaying elective surgeries until 1 year of dual antiplatelet therapy has been completed.We performed a systematic literature review of the major adverse cardiac events (MACE) associated with noncardiac surgery in patients with DES.Twenty-eight of 358 studies met inclusion criteria. Overall, MACE rates decreased as time to surgery increased and varied from 0% to 18% for surgeries within 1 year as compared with 0% to 12% for surgery more than 1 year after a stent. In addition, the current literature showed limited evidence for a protective effect of continuing perioperative dual antiplatelet therapy on MACE rates.The current literature supports a significant decrease in MACE when surgery is performed 1 year after DES placement; however, the level of evidence is weak. Larger studies are needed to determine the safe interval for surgery after stent placement.
View details for DOI 10.1016/j.amjsurg.2012.04.008
View details for Web of Science ID 000309805500014
View details for PubMedID 22867724
Toward prospective identification of high-risk surgical patients.
2012; 78 (7): 755-760
The purpose of this study was to explore the feasibility of prospectively identifying patients at high risk for surgical complications using automatable methods focused on patient characteristics. We used data from the Michigan Surgical Quality Collaborative (60,411 elective surgeries) performed between 2003 and 2008. Regression models for postoperative mortality, overall morbidity, cardiac, thromboembolic, pulmonary, renal, and surgical site infection complications were developed using preoperative patient and planned procedure data. Risk was categorized by quartiles of predicted probability: "low" risk corresponding to the bottom quartile, "average" to the middle two quartiles, and "high" to the top quartile. C-indices were calculated to measure discrimination; model validity was assessed by cross-validation. Models were repeated using only patient characteristics. Risk category was closely related to event rates; 80 to 90 per cent of mortality and cardiac, renal, and pulmonary complications occurred among the 25 per cent of "high-risk" patients. Although thromboembolisms and surgical site infections were less predictable, 60 to 70 per cent of events occurred among high-risk patients. Cross-validation results were consistent and only slightly attenuated when predictors were restricted to patient characteristics alone. Adverse postoperative events are concentrated among patients identifiable preoperatively as high risk. Preoperative risk assessment could allow for efficient interventions targeted to high-risk patients.
View details for PubMedID 22748533
Prevalence of alcohol misuse among men and women undergoing major noncardiac surgery in the Veterans Affairs health care system
2012; 152 (1): 69-81
Patients who screen positive for alcohol misuse on the Alcohol Use Disorder Identification Test Consumption Questionnaire (AUDIT-C ≥5 points) have significantly increased postoperative complications. Severe alcohol misuse (AUDIT-C ≥9 points) is associated with increased postoperative health care use; however, little is known about the prevalence of alcohol misuse in demographic and clinical subgroups of surgical patients.The prevalence of alcohol misuse was evaluated among 10,284 patients (9,771 men and 513 women) who underwent major noncardiac surgery in Veterans Affairs (VA) hospitals during the fiscal years 2004 to 2006 and completed the AUDIT-C. Sex-stratified analyses evaluated prevalence rates of alcohol misuse (AUDIT-C ≥5) and severe misuse (AUDIT-C ≥9) across demographic and clinical subgroups.Overall, 1,607 (16%) men and 24 (5%) women screened positive for alcohol misuse (AUDIT-C ≥5) in the year before operation, with 4% and 2% screening positive for severe misuse (AUDIT-C ≥9), respectively. Alcohol misuse was more common among men who were <60 years of age, divorced or separated, current smokers, or American Stoke Association class 1 or 2, and those with cirrhosis/hepatitis or substance use disorders. Among patients with alcohol misuse, 36% of men and 58% of women were American Society of Anesthesiologists class 1 or 2, and most did not have diagnoses that were commonly associated with alcohol misuse.Alcohol misuse is relatively common in male surgical patients. Moreover, surgical patients undergoing operation who screen positive for alcohol misuse are often relatively healthy, without health problems that might alert providers to their alcohol misuse in the absence of screening.
View details for DOI 10.1016/j.surg.2012.02.007
View details for Web of Science ID 000305853800011
View details for PubMedID 22503319
All-Cause Mortality after Tracheostomy at a Tertiary Care Hospital over a 10-Month Period
OTOLARYNGOLOGY-HEAD AND NECK SURGERY
2012; 146 (6): 918-922
To evaluate perioperative mortality after tracheostomy in intensive care unit (ICU) patients undergoing routine tracheostomy over a 10-month period.Case series with planned data collection.Tertiary care hospital.Mechanically ventilated patients.Prospective analysis of ICU patients undergoing tracheostomy placement over 10 months was performed. Variables evaluated were demographics, pretracheostomy length of stay, time on ventilator, time to death, preoperative comorbidities, and cause of death.There were 129 consultations resulting in 115 tracheostomies, of which 100 were included for study. The overall 30-day postoperative mortality rate was 25%, including palliative care deaths. Cause of death in all cases was due to a preexisting condition and not from tracheostomy. Patients who died within the 30-day postoperative period were found to have significant differences in age, pretracheostomy length of stay, location of tracheostomy, and preoperative comorbidity scores. No significant difference was found in time on ventilator, sex, or race/ethnicity. Mean time from consultation to tracheostomy was 2.5 days (range, 0-12 days).High rates of mortality after tracheostomy can possibly affect hospital quality ratings for surgical services. There were no deaths directly related to surgery. Despite this, the mortality rate in this population was quite high. This illustrates the significant disease burden in these patients and the need to stratify postoperative mortality as well as to consider comorbidity and age when evaluating patients for tracheostomy.
View details for DOI 10.1177/0194599812437316
View details for Web of Science ID 000305522400008
View details for PubMedID 22344290
Adverse Effects of Smoking on Postoperative Outcomes in Cancer Patients
ANNALS OF SURGICAL ONCOLOGY
2012; 19 (5): 1430-1438
The possible negative effects of smoking on postoperative outcomes have not been well studied in cancer patients.We used the VA Surgical Quality Improvement Program (VASQIP) database for the years 2002-2008, which assesses preoperative risk factors and postoperative outcomes for patients undergoing major surgery within the VA healthcare system.Compared with never smokers, prior smokers and current smokers with GI malignancies were significantly more likely to have surgical site infection (SSI) (odds ratio [OR], 1.25; 95% confidence interval [95% CI], 1.09-1.44) (OR, 1.20; 95% CI, 1.05-1.38), combined pulmonary complications (combined pulmonary outcome [CPO]: pneumonia, failure to wean from ventilator, reintubation) (OR, 1.60; 95% CI, 1.38-1.87) (OR, 1.96; 95% CI, 1.68-2.29), and return to the operating room (OR, 1.20; 95% CI, 1.03-1.39) (OR, 1.31; 95% CI, 1.13-1.53), respectively. Both prior and current smokers had a significantly higher mortality at 30 days (OR, 1.50; 95% CI, 1.19-1.89) (OR, 1.41; 95% CI, 1.08-1.82) and 1 year (OR, 1.22; 95% CI, 1.08-1.38) (OR, 1.62; 95% CI, 1.43-1.85). Thoracic surgery patients who were current smokers were more likely to develop CPO (OR, 1.62; 95% CI, 1.25-2.11) and mortality within 1 year (OR, 1.50; 95% CI, 1.17-1.92) compared with nonsmokers, but SSI rates were not affected by smoking status. Current smokers had a significant increase in postsurgical length of stay (overall 4.3% [P < .001], GI 4.7% [P = .003], thoracic 9.0% [P < .001]) compared with prior smokers.Prior and current smoking status is a significant risk factor for major postoperative complications and mortality following GI cancer and thoracic operations in veterans. Smoking cessation should be encouraged prior to all major cancer surgery in the VA population to decrease postoperative complications and length of stay.
View details for DOI 10.1245/s10434-011-2128-y
View details for Web of Science ID 000303375400011
View details for PubMedID 22065194
The Incidence and Timing of Noncardiac Surgery after Cardiac Stent Implantation
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2012; 214 (4): 658-666
In November 2007, national guidelines were released recommending delay of elective noncardiac surgery after cardiac revascularization with drug eluting stents (DES) for 12 months compared with 6 weeks after implantation of bare metal stents (BMS).To determine the incidence of noncardiac surgery within 24 months after stent placement, national VA data on cardiac stent implantation were merged with data from the VA National Surgery Office and Medicare. Using chi-square tests and log-rank analyses, we measured the incidence of noncardiac surgery after BMS and DES in relation to guideline release and surgical characteristics.From 2000 to 2010, 126,773 stent procedures were followed by 25,977 (20.5%) noncardiac operations within 24 months. Overall, 11.8% of the BMS surgery cohort had early surgery (less than 6 weeks) compared with 46.7% of the DES surgery cohort, which had early surgery (less than 12 months). The incidence of surgery differed significantly by stent type (BMS 24.1% vs DES 17.5%, p < 0.001) and in relation to guideline release (pre- 24.6% vs postguideline 13.1%, p < 0.001). Higher complexity operations (work relative value units) were more likely to occur in the early period for both BMS (p < 0.0001) and DES (p < 0.003). After guideline release, the incidence of surgery within 12 months decreased from 16.7% to 10.0% (p < 0.0001).We found evidence that guidelines recommending delaying surgery appear to be effective in decreasing the incidence of early surgery; however, early surgery is still a frequent occurrence. Additional research is needed to better define the risk of cardiac and bleeding complications in patients undergoing subsequent noncardiac surgery, as well as the optimal time for surgery and method of antiplatelet management.
View details for DOI 10.1016/j.jamcollsurg.2011.12.011
View details for Web of Science ID 000302485300055
View details for PubMedID 22341201
AUDIT-C Alcohol Screening Results and Postoperative Inpatient Health Care Use
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2012; 214 (3): 296-U69
Alcohol screening scores ≥5 on the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) up to a year before surgery have been associated with postoperative complications, but the association with postoperative health care use is unknown. This study evaluated whether AUDIT-C scores in the year before surgery were associated with postoperative hospital length of stay, total ICU days, return to the operating room, and hospital readmission.This cohort study included male Veterans Affairs patients who completed the AUDIT-C on mailed surveys (October 2003 through September 2006) and were hospitalized for nonemergent noncardiac major operations in the following year. Postoperative health care use was evaluated across 4 AUDIT-C risk groups (scores 0, 1 to 4, 5 to 8, and 9 to 12) using linear or logistic regression models adjusted for sociodemographics, smoking status, surgical category, relative value unit, and time from AUDIT-C to surgery. Patients with AUDIT-C scores indicating low-risk drinking (scores 1 to 4) were the referent group.Adjusted analyses revealed that among eligible surgical patients (n = 5,171), those with the highest AUDIT-C scores (ie, 9 to 12) had longer postoperative hospital length of stay (5.8 [95% CI, 5.0-6.7] vs 5.0 [95% CI, 4.7-5.3] days), more ICU days (4.5 [95% CI, 3.2-5.8] vs 2.8 [95% CI, 2.6-3.1] days), and increased probability of return to the operating room (10% [95% CI, 6-13%] vs 5% [95% CI, 4-6%]) in the 30 days after surgery, but not increased hospital readmission within 30 days postdischarge, relative to the low-risk group.AUDIT-C screening results could be used to identify patients at risk for increased postoperative health care use who might benefit from preoperative alcohol interventions.
View details for DOI 10.1016/j.jamcollsurg.2011.11.007
View details for Web of Science ID 000301770100008
View details for PubMedID 22244208
Outcomes for incisional hernia repair in patients undergoing concomitant surgical procedures.
2012; 78 (2): 243-249
The safety and efficacy of performing concomitant surgical procedures with an incisional hernia repair (IHR) is not well understood. There are conflicting reports on the outcomes for permanent mesh implantation in the setting of clean-contaminated procedures. The purpose of this study was to review the effect of concomitant surgical procedures on IHR outcomes. This is a retrospective multisite cohort of patients undergoing elective IHR at 16 Veterans Affairs hospitals from 1998 to 2002. Concomitant procedure status, hernia characteristics, and operative details were determined using physician-abstracted operative notes. Hernia outcomes of recurrence and mesh explantation were determined from the medical chart. χ(2) tests, Kaplan-Meier curves, and Cox regression were used to evaluate the effects of concomitant status on hernia outcomes. Of the 1495 elective IHRs, 75 (4.8%) were same site and 56 (3.8%) different site concomitant procedures. At median follow-up of 69.3 months (range 19.1-98.3), 33.6 per cent of patients had a recurrence, mesh explantation, or both. Permanent mesh placement was less likely among concomitant procedures as compared with nonconcomitant procedures (P < 0.0001). Adjusted Cox proportional hazards models of hernia outcomes resulted in an increased hazard for recurrence among same site clean procedures (Hazard Ratio (HR) = 1.8, P = 0.03) and an increased hazard for mesh explantation among same site clean-contaminated procedures (HR = 8.4, P = 0.002). Concomitant same site procedures are significantly associated with adverse hernia outcomes as compared with isolated IHR or IHR with other site concomitant procedures. The high failure rate of hernia repairs among same site concomitant procedures should be taken into account during the surgical decision-making process.
View details for PubMedID 22369837
Translating preoperative smoking cessation interventions into routine clinical care of veterans: provider beliefs.
Translational behavioral medicine
2011; 1 (4): 604-608
Smoking among veterans undergoing surgery is estimated to be 36%. Smoking has been linked to postoperative surgical complications including ischemia and cardiac arrhythmias, pneumonia, deep venous thrombosis, pulmonary embolism, and surgical site infection. Preoperative smoking cessation interventions, in which smokers quit at least 6 weeks prior to surgery, have been shown to be effective both in smoking cessation and reduction of postoperative complications; however, little is known about physician beliefs regarding the optimal location and the responsible provider for intervention, or whether surgery should be postponed or delayed based on smoking status. Within the routine coordination from medical to surgical care, how should cessation interventions best be implemented? To better inform the translation of preoperative best practices for smoking cessation into clinical care in VA, a survey regarding preoperative smoking cessation beliefs and practices was administered to primary care physicians, surgeons, and anesthesia providers. Chi-square tests were used to examine differences in proportions by provider type. Most providers agreed that the primary care clinic is the best location for intervention, with preoperative and surgical clinics ranked by few as the optimal location (13% and 11%, respectively); most respondents (82%) reported that they would refuse or delay surgery in some cases based on smoking status. There were no differences in either beliefs on location or delay based on provider type. Primary care providers were most likely to advise (86.7%) and assess (80.0%) while anesthesia providers were least likely (59.1% and 22.7%, respectively). Taking time to counsel and the belief that dedicated resources would improve quit rates were associated with advising patients to quit smoking, while being uncomfortable with counseling, the belief that acute health takes precedence and the belief that there is not always time to counsel were identified as barriers to assessing patients for smoking cessation intervention. Primary care providers were more optimistic (100%) that patients would quit if counseled, more often (73.3%) reported having time to counsel, and were less likely to report that acute health takes precedence. Most providers believe that smoking cessation would reduce postoperative complications, with the ideal location for the intervention being the primary care clinic, and that some surgical cases should be delayed for this intervention.
View details for DOI 10.1007/s13142-011-0096-1
View details for PubMedID 24073083
The Attributable Risk of Smoking on Surgical Complications
ANNALS OF SURGERY
2011; 254 (6): 914-920
This study aimed to assess the attributable risk and potential benefit of smoking cessation on surgical outcomes.Risk reduction with the implementation of surgical care improvement project process measures has been the primary focus for improving surgical outcomes. Little emphasis has been placed on preoperative risk factor recognition and intervention.A retrospective cohort analysis of elective operations from 2002 to 2008 in the Veterans Affairs Surgical Quality Improvement Program for all surgical specialties was performed. Patients were stratified by current, prior, and never smokers. Adjusted risk of complication and death was calculated using multilevel, multivariable logistic regression.Of 393,794 patients, 135,741 (34.5%) were current, 71,421 (18.1%) prior, and 186,632 (47.4%) never smokers. A total of 6225 pneumonias, 11,431 deep and superficial surgical-site infections, 2040 thromboembolic events, 1338 myocardial infarctions, and 4792 deaths occurred within 30 days of surgery. Compared with both never and prior smokers individually and controlled for patient and procedure risk factors, current smokers had significantly more postoperative pneumonia, surgical-site infection, and deaths (P < 0.001 for all). There was a dose-dependent increase in pulmonary complications based on pack-year exposure with greater than 20 pack years leading to a significant increase in smoking-related surgical complications.This is the first study to assess the risk of current versus prior smoking on surgical outcomes. Despite being younger and healthier, current smokers had more adverse perioperative events, particularly respiratory complications. Smoking cessation interventions could potentially reduce the occurrence and costs of adverse perioperative events.
View details for DOI 10.1097/SLA.0b013e31822d7f81
View details for Web of Science ID 000297375200012
View details for PubMedID 21869677
- Translating preoperative smoking cessation interventions into routine clinical care of veterans: provider beliefs TRANSLATIONAL BEHAVIORAL MEDICINE 2011; 1 (4): 604-608
Descriptive Operative Reports: Teaching, Learning, and Milestones to Safe Surgery
JOURNAL OF SURGICAL EDUCATION
2011; 68 (6): 452-458
Few tasks are more ingrained within the minds of practicing surgeons than the dictation of the narrative report of an operation. However, the construct of these reports varies widely among surgeons and is rarely formally taught and not tested formally during surgical training or board certification.A cohort of patients undergoing incisional hernia repair (IHR) over a 5-year period from 16 academically affiliated Veterans' Administration (VA) hospitals was identified. Technical details of the operative approach were obtained only from operative notes. Frequency of missing elements was analyzed by postgraduate year of the resident.Overall, 1367 IHR operative reports were analyzed, comprising 456 (33%) suture repairs, 802 (59%) open mesh repairs, 97 (7%) laparoscopic repairs, and 12 (1%) where repair type could not be determined. Hernia size in any dimension was absent in 63.5% of dictations and was similar regardless of PGY, (54%, 56%, 71%, 67%, and 66% for PGY 1-5, respectively). Among the 906 mesh repairs, 65% failed to mention the mesh size. This absence was similar across PGY (64%, 69%, 65%, 66%, and 68% for PGY 1-5, respectively), and attending reports were only marginally better, with mesh size absent in 57% of reports. In the 456 cases repaired by suture alone, 76% did not record the type of suture used with significant variation by PGY (78%, 59%, 87%, 89%, and 69% for PGY 1-5, attending - 86%).Resident dictation of the operative report represents an opportunity to understand current cognitive deficits regarding the procedure and to allow for intervention. Future studies to validate that internalization of the cognitive aspects of operations can be measured by audit of operative notes are needed. These endeavors will ensure that not only the technical but also the mental guides to safe surgery are acquired.
View details for DOI 10.1016/j.jsurg.2011.06.015
View details for Web of Science ID 000296268600002
View details for PubMedID 22000530
Smoking As a Risk Factor for Short-Term Outcomes Following Primary Total Hip and Total Knee Replacement in Veterans
ARTHRITIS CARE & RESEARCH
2011; 63 (10): 1365-1374
To assess the effect of smoking on postoperative complications following elective primary total hip replacement (THR) or primary total knee replacement (TKR).We used data from the national Veterans Affairs Surgical Quality Improvement Program to examine the association of smoking status at surgery with 30-day postoperative complication rates (including surgical site and other infections, pneumonia, stroke, myocardial infarction, mortality, and other complications) in veterans undergoing primary elective THR or TKR. Multilevel multivariable-adjusted logistic regression models, adjusted for age, race/ethnicity, work relative value units, American Society of Anesthesiology classification, and year of surgery, with additional adjustment for wound classification for surgical site infections, were used.A total of 33,336 patients, 95% men and 80% white with a mean age of 64 years, underwent elective primary THR/TKR between October 2001 and September 2008. Fifty-seven percent never smoked, 19% were prior smokers, and 24% were current smokers. Current smokers undergoing THR/TKR were significantly more likely than never smokers to have surgical site infections (odds ratio [OR] 1.41, 95% CI 1.16-1.72), pneumonia (OR 1.53, 95% CI 1.10-2.14), stroke (OR 2.61, 95% CI 1.26-5.41), and 1-year mortality (OR 1.63, 95% CI 1.31-2.02). Prior smokers were significantly more likely than nonsmokers to have pneumonia, (OR 1.34, 95% CI 1.00-1.80), stroke (OR 2.14, 95% CI 1.12-4.10), and urinary tract infection (OR 1.26, 95% CI 1.02-1.55).Current smoking at the time of elective THR or TKR is associated with increased postarthroplasty complications, especially surgical site infections and pneumonia. Preoperative smoking cessation programs should be considered in patients undergoing elective THR or TKR.
View details for DOI 10.1002/acr.20555
View details for Web of Science ID 000295255200002
View details for PubMedID 21770042
Surgical Site Infection Prevention Time to Move Beyond the Surgical Care Improvement Program
ANNALS OF SURGERY
2011; 254 (3): 494-501
The objective of this study was to evaluate whether the Surgical Care Improvement Project (SCIP) improved surgical site infection (SSI) rates using national data at the patient level for both SCIP adherence and SSI occurrence.The SCIP was established in 2006 with the goal of reducing surgical complications by 25% in 2010.National Veterans' Affairs (VA) data from 2005 to 2009 on adherence to 5 SCIP SSI prevention measures were linked to Veterans' Affairs Surgical Quality Improvement Program SSI outcome data. Effect of SCIP adherence and year of surgery on SSI outcome were assessed with logistic regression using generalized estimating equations, adjusting for procedure type and variables known to predict SSI. Correlation between hospital SCIP adherence and SSI rate was assessed using linear regression.There were 60,853 surgeries at 112 VA hospitals analyzed. SCIP adherence ranged from 75% for normothermia to 99% for hair removal and all significantly improved over the study period (P < 0.001). Surgical site infection occurred after 6.2% of surgeries (1.6% for orthopedic surgeries to 11.3% for colorectal surgeries). None of the 5 SCIP measures were significantly associated with lower odds of SSI after adjusting for variables known to predict SSI and procedure type. Year was not associated with SSI (P = 0.71). Hospital SCIP performance was not correlated with hospital SSI rates (r = -0.06, P = 0.54).Adherence to SCIP measures improved whereas risk-adjusted SSI rates remained stable. SCIP adherence was neither associated with a lower SSI rate at the patient level, nor associated with hospital SSI rates. Policies regarding continued SCIP measurement and reporting should be reassessed.
View details for DOI 10.1097/SLA.0b013e31822c6929
View details for Web of Science ID 000294252500012
View details for PubMedID 21817889
Agreement between patient survey and medical chart: Pitfalls in measurement strategies for hernia recurrence
2011; 150 (3): 371-378
Little information is available on agreement between patient-reported outcomes and data collected from medical chart abstraction (MCA) for recurring events. Recurring conditions pose a risk of misclassification, especially when events occur relatively close together in time. We examined agreement, predictors of agreement, and relative accuracy of patient survey and MCA for assessment of outcomes of incisional hernia repair (IHR).Surveys to assess hernia outcomes were mailed to 1,124 living patients who underwent ≥ 1 IHR during 1998-2002 at 16 Veteran's Affairs Medical Center study sites. Patients were asked if they developed a recurrence or an infection at their hernia site. Physician-abstracted data from the medical chart were compared with patient response. Chi-square tests were used to assess significance.Of 487 (43.3%) individuals responding to the survey, 33 (6.8%) with >1 re-repair during 1998-2002 and 98 (20.5%) with a repair before the 1998-2002 period were excluded from the analysis. Although recurrence rates derived from self-reported data and data abstracted from the medical chart were similar (29.3% and 26.1%, respectively), overall concordance was low. Only 49% (n = 54) of self-reported recurrences were confirmed by data abstracted from the medical chart. In addition, 16 (8.3%) recurrences abstracted from the medical chart were not reported by the patient. Factors associated with discordance were high reported pain intensity (P = .02), poorer general health (P = .03), and poorer perceived repair results (P < .0001).Multiple recurrences and subsequent operations across the study period complicate the interpretation of both patient response and data abstracted from the medical chart when referring to a hernia repair. Further study on how best to assess treatment outcomes for recurring conditions is warranted.
View details for DOI 10.1016/j.surg.2011.06.007
View details for Web of Science ID 000295108300002
View details for PubMedID 21783217
Outcomes of Emergent Incisional Hernia Repair
2011; 77 (8): 971-976
This study examines the effect of emergent repair on incisional hernia repair outcomes at 16 Veteran's Affairs Medical Centers between 1998 and 2002. Of the 1452 cases reviewed, 63 (4.3%) were repaired emergently. Patients undergoing emergent repair were older (P = 0.02), more likely to be black (P = 0.02), and have congestive heart failure (P = 0.001) or chronic obstructive pulmonary disease (P = 0.001). Of emergent repairs, 76.2 per cent involved intestinal incarceration versus 7.2 per cent of elective repairs (P < 0.0001), and 17.5 per cent had concomitant bowel resection compared with 3.9 per cent of elective cases (P < 0.0001). Patients undergoing emergent repair were also more likely to receive primary suture repair (49.2 vs 31.1%, P = 0.003), develop a postoperative complication (26.0 vs 11.3%, P = 0.002), and have increased postoperative length of stay (7 vs 4 days, P < 0.0001). There were nine (14.3%) deaths at 30 days for the emergent group compared with 10 (0.7%) in the elective group (P < 0.001). However, there was no significant difference between emergent and elective repairs in long-term complications. Emergent hernia repair is associated with increased mortality rates, early complications, and longer length of stay; however, long-term outcomes are equivalent to elective cases. These data suggest that technical outcomes for emergent repairs approach those of elective operations.
View details for Web of Science ID 000293927200002
View details for PubMedID 21944508
Predictors of mesh explantation after incisional hernia repair
AMERICAN JOURNAL OF SURGERY
2011; 202 (1): 28-33
Prosthetic mesh used for incisional hernia repair (IHR) reduces hernia recurrence. Mesh infection results in significant morbidity and challenges for subsequent abdominal wall reconstruction. The risk factors that lead to mesh explantation are not well known.This is a multisite cohort study of patients undergoing IHR at 16 Veterans Affairs hospitals from 1998 to 2002.Of the 1,071 mesh repairs, 55 (5.1%) had subsequent mesh explantation at a median of 7.3 months (interquartile range 1.4-22.2) after IHR with permanent mesh prosthesis. Infection was the most common reason for explantation (69%). No differences were observed by the type of repair. Adjusting for covariates, same-site concomitant surgery (hazard ratio [HR] = 6.3) and postoperative surgical site infection (HR = 6.5) were associated with mesh explantation.Patients undergoing IHR with concomitant intra-abdominal procedures have a greater than 6-fold increased hazard of subsequent mesh explantation. Permanent prosthetic mesh should be used with caution in this setting.
View details for DOI 10.1016/j.amjsurg.2010.10.011
View details for Web of Science ID 000293593700009
View details for PubMedID 21741517
Effect of Mesh Type and Position on Subsequent Abdominal Operations after Incisional Hernia Repair
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2011; 212 (4): 496-502
The frequency of subsequent abdominal operations (SAO) and complications attributable to earlier ventral incisional hernia repair (VIHR) are unknown. We examined the effect of repair type and technique on the difficulty and complications of subsequent surgery.A cohort of VIHRs at 16 Veterans Affairs hospitals between 1998 and 2002 was examined for postrepair abdominal operation by chart review. The primary independent variable was type and technique of the index VIHR: suture or mesh repair stratified by mesh type and position in relation to abdominal wall musculature. Subsequent surgery characteristics including operative time, inadvertent enterotomy, mesh removal, and length of postoperative stay were determined by chart review. Regression modeling was used to adjust for potential confounding variables.At a median of 80 months after VIHR in 1,444 patients, 366 (25.3%) experienced SAO. Nearly two-thirds of these involved rerepair of the VIHR with or without a concomitant procedure. Mesh removal was significantly more likely in expanded polytetrafluoroethylene repairs as compared with polypropylene repairs, regardless of technique (odds ratio = 3.6; p = 0.01). On multivariable regression modeling, polypropylene underlay (p = 0.03) and inlay (p = 0.001) and absorbable/biologic mesh (p = 0.05) significantly increased operative time for SAO. Repair type, mesh type, or position had no significant effect on risk of inadvertent enterotomy during the SAO (p≥0.27).Subsequent abdominal operations after VIHR are common. Underlay or inlay polypropylene mesh increases SAO operative time, but there was no increased risk of intestinal injury. Earlier repair with expanded polytetrafluoroethylene did not increase operative time, but there was equivalent risk for intestinal injury and increased risk for mesh removal.
View details for DOI 10.1016/j.jamcollsurg.2010.12.004
View details for Web of Science ID 000289430000015
View details for PubMedID 21463777
Patient satisfaction, chronic pain, and quality of life after elective incisional hernia repair: effects of recurrence and repair technique
2011; 15 (2): 123-129
To determine the effects of repair technique and hernia recurrence on patient-reported outcomes after incisional hernia repair.This cohort study included patients from sixteen Veteran's Affairs Medical Centers across the United States who underwent elective incisional hernia repair between 1997 and 2002. Technical details and outcomes (repair type and recurrence status) were determined by physician chart review. Patient satisfaction, chronic pain (McGill pain scale and visual analogue scale), and health-related quality of life (Short Form 36) were evaluated with a mailed survey at a median of five years after repair. Multivariable regression modeling was performed to evaluate the effect of repair type and recurrence status on patient-reported outcomes.Of 854 patients alive at the time of survey mailing, 371 responded (43.4%). Patients with active recurrence were more likely to be dissatisfied with their results (odds ratio (OR) 6.2, P < 0.0001), to have chronic sensory hernia site pain (OR 3.2, P = 0.01), to report disturbance from pain (OR 2.1, P = 0.04), and to have significantly worse quality of life on the Physical Function, General Health, and Physical Component Score domains. Repair technique with permanent mesh versus suture had no independent effect on patient satisfaction, chronic pain, or QOL.Recurrence has a substantial negative effect on patient-reported outcomes after incisional hernia repair, whereas the repair technique has no independent effect.
View details for DOI 10.1007/s10029-010-0750-4
View details for Web of Science ID 000288803700002
View details for PubMedID 21072550
Alcohol Screening and Risk of Postoperative Complications in Male VA Patients Undergoing Major Non-cardiac Surgery
JOURNAL OF GENERAL INTERNAL MEDICINE
2011; 26 (2): 162-169
Patients who misuse alcohol are at increased risk for surgical complications. Four weeks of preoperative abstinence decreases the risk of complications, but practical approaches for early preoperative identification of alcohol misuse are needed.To evaluate whether results of alcohol screening with the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) questionnaire-up to a year before surgery-were associated with the risk of postoperative complications.This is a cohort study.Male Veterans Affairs (VA) patients were eligible if they had major noncardiac surgery assessed by the VA's Surgical Quality Improvement Program (VASQIP) in fiscal years 2004-2006, and completed the AUDIT-C alcohol screening questionnaire (0-12 points) on a mailed survey within 1 year before surgery.One or more postoperative complication(s) within 30 days of surgery based on VASQIP nurse medical record reviews.Among 9,176 eligible men, 16.3% screened positive for alcohol misuse with AUDIT-C scores ≥ 5, and 7.8% had postoperative complications. Patients with AUDIT-C scores ≥ 5 were at significantly increased risk for postoperative complications, compared to patients who drank less. In analyses adjusted for age, smoking, and days from screening to surgery, the estimated prevalence of postoperative complications increased from 5.6% (95% CI 4.8-6.6%) in patients with AUDIT-C scores 1-4, to 7.9% (6.3-9.7%) in patients with AUDIT-Cs 5-8, 9.7% (6.6-14.1%) in patients with AUDIT-Cs 9-10 and 14.0% (8.9-21.3%) in patients with AUDIT-Cs 11-12. In fully-adjusted analyses that included preoperative covariates potentially in the causal pathway between alcohol misuse and complications, the estimated prevalence of postoperative complications increased significantly from 4.8% (4.1-5.7%) in patients with AUDIT-C scores 1-4, to 6.9% (5.5-8.7%) in patients with AUDIT-Cs 5-8 and 7.5% (5.0-11.3%) among those with AUDIT-Cs 9-10.AUDIT-C scores of 5 or more up to a year before surgery were associated with increased postoperative complications.
View details for DOI 10.1007/s11606-010-1475-x
View details for Web of Science ID 000287668800015
View details for PubMedID 20878363
Effects of Virtual Reality Simulator Training Method and Observational Learning on Surgical Performance
WORLD JOURNAL OF SURGERY
2011; 35 (2): 245-252
Virtual reality (VR) simulators and Web-based instructional videos are valuable supplemental training resources in surgical programs, but it is unclear how to optimally integrate them into minimally invasive surgical training.Medical students were randomized to proficiency-based training on VR laparoscopy and endoscopy simulators by two different methods: proctored training (automated simulator feedback plus human expert feedback) or independent training (simulator feedback alone). After achieving simulator proficiency, trainees performed a series of laparoscopic and endoscopic tasks in a live porcine model. Prior to their entry into the animal lab, all trainees watched an instructional video of the procedure and were randomly assigned to either observe or not observe the actual procedure before performing it themselves. The joint effects of VR training method and procedure observation on time to successful task completion were evaluated with Cox regression models.Thirty-two students (16 proctored, 16 independent) completed VR training. Cox regression modeling with adjustment for relevant covariates demonstrated no significant difference in the likelihood of successful task completion for independent versus proctored training [Hazard Ratio (HR) 1.28; 95% Confidence Interval (CI) 0.96-1.72; p=0.09]. Trainees who observed the actual procedure were more likely to be successful than those who watched the instructional video alone (HR 1.47; 95% CI 1.09-1.98; p=0.01).Proctored VR training is no more effective than independent training with respect to surgical performance. Therefore, time-consuming human expert feedback during VR training may be unnecessary. Instructional videos, while useful, may not be adequate substitutes for actual observation when trainees are learning minimally invasive surgical procedures.
View details for DOI 10.1007/s00268-010-0861-1
View details for Web of Science ID 000285998400001
View details for PubMedID 21086125
Hospital-level variability in incisional hernia repair technique affects patient outcomes
2011; 149 (2): 185-191
Mesh placement during ventral incisional hernia repair has been shown to result in superior outcomes; however, significant variation persists in the adoption of this technique. We performed a multi-institutional study to understand how variation in surgical technique influences outcomes.This study is a retrospective, facility-level analysis of incisional hernia repairs performed at 16 veteran's administration medical centers between 1997 and 2002. Operative notes and a postoperative course were physician-abstracted from the medical record. Hospital rates for the type of hernia repair, mesh placement, and recurrence were calculated. Spearman's correlation and generalized linear models were performed.A total of 1,612 incisional hernia repairs with a median follow-up of 66.2 months were included in the study. The mean rate of mesh implantation was 63.7% but ranged from 37.5% to 90%. The 5-year recurrence rate was 25.6% and ranged from 16.0% to 38.4%. The rate of mesh use for the incisional hernia repair at the hospital level was associated significantly with the hospital recurrence rate for all cases (R(2) = .27; P = .04) and elective cases (R(2) = .31; P = .02). For every 10% increase in the rate of mesh placement, a corresponding 3.1% decrease was noted in the recurrence rates (P = .001). The hospital rate of mesh use was not associated significantly with rates of complications or patient satisfaction.Hospitals that adopted a higher rate of mesh repair for incisional hernia repairs had lower recurrence rates. These data support that the efficacy of mesh repair previously proven in clinical trials is highly translatable to effective practice in the field. Continued studies on the attributable risk of complications to mesh placement are ongoing.
View details for DOI 10.1016/j.surg.2010.07.001
View details for Web of Science ID 000286713200006
View details for PubMedID 21238712
- Surgical Registries Effective, but How to Pay for Them? ARCHIVES OF SURGERY 2011; 146 (1): 17-17
A functional colonic obstruction: Cannon's point.
Radiology case reports
2011; 6 (4): 557
A patient presented with a large bowel obstruction after laparoscopic hernia repair converted to open inguinal hernia repair. A contrast enema examination revealed an area of narrowing in the midtransverse colon, consistent with Cannon's point. This represents a physiologic sphincter with focal narrowing of the colon lumen.
View details for DOI 10.2484/rcr.v6i4.557
View details for PubMedID 27307934
Retention of Colonoscopy Skills after Virtual Reality Simulator Training by Independent and Proctored Methods
2010; 76 (7): 743-746
Virtual reality (VR) simulators may enhance surgical resident colonoscopy skills, but the duration of skill retention and the effects of different simulator training methods are unknown. Medical students participating in a randomized trial of independent (automated simulator feedback only) versus proctored (human expert feedback plus simulator feedback) simulator training performed a standardized VR colonoscopy scenario at baseline, at the end of training (posttraining), and after a median 4.5 months without practice (retention). Performances were scored on a 10-point scale based on expert proficiency criteria and compared for the independent and proctored groups. Thirteen trainees (8 proctored, 5 independent) were included. Performance at retention testing was significantly better than baseline (median score 10 vs. 5, P < 0.0001), and no different from posttraining (median score 10 vs. 10, P = 0.19). Score changes from baseline to retention and from posttraining to retention were no different for the proctored and independent groups. Overinsufflation and excessive force were the most common reasons for nonproficiency at retention. After proficiency-based VR simulator training, colonoscopy skills are retained for several months, regardless of whether an independent or proctored approach is used. Error avoidance skills may not be retained as well as speed and efficiency skills.
View details for Web of Science ID 000279416500017
View details for PubMedID 20698383
- Surgical Care Improvement Should Performance Measures Have Performance Measures JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION 2010; 303 (24): 2527-2528
Long-Term Follow-Up of Technical Outcomes for Incisional Hernia Repair
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2010; 210 (5): 648-655
Incisional hernia repair (IHR) is plagued by high recurrence rates and lack of long-term outcomes data to guide repair technique. Mesh repair reduces recurrence rates but lacks standardization of technique. We investigated long-term outcomes of elective IHR, focusing on technical predictors of recurrence.This retrospective multicenter cohort study included elective IHR performed at 16 Veterans Affairs hospitals between 1997 and 2002. Hernia characteristics and operative details were abstracted from operative notes, and chart review was performed to identify recurrence and complications. Kaplan-Meier curves and Cox regression models were used to evaluate the effects of hernia characteristics and operative technique on recurrence.There were 1,346 elective IHRs, of which 22% were recurrent hernias. Repair technique was primary suture in 31%, open inlay or onlay mesh in 30%, open underlay in 30%, and laparoscopic in 9%. At median follow-up of 73.4 months, there were 383 recurrences (28.5%), 23 mesh removals (1.7%), and 7 enterocutaneous fistulas (ECF) (0.5%). On Cox regression modeling with adjustment for hernia and Veterans Affairs site characteristics, the effectiveness of mesh varied by position. Compared with suture repair, laparoscopic (hazard ratio = 0.49; 95% CI, 0.28-0.84) and open underlay mesh repair (hazard ratio = 0.72; 95% CI, 0.53-0.98) substantially reduced the recurrence risk, but onlay or inlay mesh repair did not. Mesh position did not affect mesh removal or ECF rates.Underlay technique, either laparoscopic or open, for mesh implantation during elective IHR substantially reduces the risk of recurrence, without increasing the risk of serious mesh infection or ECF.
View details for DOI 10.1016/j.jamcollsurg.2009.12.038
View details for Web of Science ID 000277528700022
View details for PubMedID 20421023
Multiple Preoperative Endoscopic Interventions Are Associated with Worse Outcomes After Laparoscopic Heller Myotomy for Achalasia
JOURNAL OF GASTROINTESTINAL SURGERY
2009; 13 (12): 2095-2102
The effect of preoperative pneumatic dilation or botulinum toxin injection on outcomes after laparoscopic Heller myotomy (LHM) for achalasia is unclear. We compared outcomes in patients with and without multiple preoperative endoscopic interventions.This cohort study categorized achalasia patients undergoing first-time LHM by the number of preoperative endoscopic interventions: zero or one intervention vs. two or more interventions. Outcomes of interest included surgical failure (defined as the need for re-intervention), gastrointestinal symptoms, and health-related quality of life. Logistic regression modeling was performed to determine the independent effect of multiple preoperative endoscopic interventions on the likelihood of surgical failure.One hundred thirty-four patients were included; 88 (66%) had zero to one preoperative intervention, and 46 (34%) had multiple (more than one) interventions. The incidence of surgical failure was 7% in the zero to one intervention group and 28% in the more than one intervention group (p < 0.01). Greater improvements in gastrointestinal symptoms and health-related quality of life were seen in the zero to one intervention group. On logistic regression modeling, the likelihood of surgical failure was significantly higher in the more than one intervention group (odds ratio = 5.1, 95% confidence interval 1.6-15.8, p = 0.005).Multiple endoscopic treatments are associated with poorer outcomes and should be limited to achalasia patients who fail surgical therapy.
View details for DOI 10.1007/s11605-009-1049-6
View details for Web of Science ID 000272303000001
View details for PubMedID 19789928
Elective surgical case cancellation in the Veterans Health Administration system: identifying areas for improvement
AMERICAN JOURNAL OF SURGERY
2009; 198 (5): 600-606
This study evaluated elective surgical case cancellation (CC) rates, reasons for these cancellations, and identified areas for improvement within the Veterans Health Administration (VA) system.CC data for 2006 were collected from the scheduling software for 123 VA facilities. Surveys were distributed to 40 facilities (10 highest and 10 lowest CC rates for high- and low-volume facilities). CC reasons were standardized and piloted at 5 facilities.Of 329,784 cases scheduled by 9 surgical specialties, 40,988 (12.4%) were cancelled. CC reasons (9,528) were placed into 6 broad categories: patient (35%), work-up/medical condition change (28%), facility (20%), surgeon (8%), anesthesia (1%), and miscellaneous (8%). Survey results show areas for improvement at the facility level and a standardized list of 28 CC reasons was comprehensive.Interventions that decrease cancellations caused by patient factors, inadequate work-up, and facility factors are needed to reduce overall elective surgical case cancellations.
View details for DOI 10.1016/j.amjsurg.2009.07.005
View details for Web of Science ID 000271997900005
View details for PubMedID 19887185
Unplanned Intubation after Surgery: Risk Factors, Prognosis, and Medical Emergency Team Effects
2009; 75 (9): 834-838
Unplanned intubation after surgery is a marker for severe adverse events. We investigated the incidence, risk factors, and prognosis of unplanned intubation after general and vascular surgery and sought to determine whether the deployment of a hospital-wide medical emergency team (MET) had a preventive effect. We included all patients undergoing general and vascular surgical procedures between April 1, 2006, and June 30, 2008, from our American College of Surgeons National Surgical Quality Improvement Program data. Risk factors and incidence rates of unplanned intubation were compared before (preMET) and after (postMET) June 7, 2007. Chart review identified case details and fatality rates. There were 2426 patients included (1815 preMET, 611 postMET). The overall incidence of unplanned intubation was 2.6 per cent; significant risk factors included chronic obstructive pulmonary disease, dependent functional status, and emergent operation. Most (84%) unplanned intubations occurred in a critical care setting and the most common underlying reason was sepsis (40%). The overall case fatality rate was 43 per cent but varied significantly depending on the underlying reason for unplanned intubation. Incidence rates of unplanned intubation did not change significantly after MET deployment, suggesting that other strategies are needed to prevent this rare but highly morbid and mortal event.
View details for Web of Science ID 000269346700026
View details for PubMedID 19774957
Proficiency-Based Laparoscopic and Endoscopic Training With Virtual Reality, Simulators: A Comparison of Proctored and Independent Approaches
JOURNAL OF SURGICAL EDUCATION
2009; 66 (4): 201-207
Virtual reality (VR) simulators for laparoscopy and endoscopy may be valuable tools for resident education. However, the cost of such training in terms of trainee and instructor time may vary depending upon whether an independent or proctored approach is employed.We performed a randomized controlled trial to compare independent and proctored methods of proficiency-based VR simulator training. Medical students were randomized to independent or proctored training groups. Groups were compared with respect to the number of training hours and task repetitions required to achieve expert level proficiency on laparoscopic and endoscopic simulators. Cox regression modeling was used to compare time to proficiency between groups, with adjustment for appropriate covariates.Thirty-six medical students (18 independent, 18 proctored) were enrolled. Achievement of overall simulator proficiency required a median of 11 hours of training (range, 6-21 hours). Laparoscopic and endoscopic proficiency were achieved after a median of 11 (range, 6-32) and 10 (range, 5-27) task repetitions, respectively. The number of repetitions required to achieve proficiency was similar between groups. After adjustment for covariates, trainees in the independent group achieved simulator proficiency with significantly fewer hours of training (hazard ratio, 2.62; 95% confidence interval, 1.01-6.85; p = 0.048).Our study quantifies the cost, in instructor and trainee hours, of proficiency-based laparoscopic and endoscopic VR simulator training, and suggests that proctored instruction does not offer any advantages to trainees. The independent approach may be preferable for surgical residency programs desiring to implement VR simulator training.
View details for DOI 10.1016/j.jsurg.2009.07.007
View details for Web of Science ID 000271984600006
View details for PubMedID 19896624
Open suture versus mesh repair of primary incisional hernias: a cost-utility analysis
2009; 13 (2): 173-182
Despite 100,000 ventral hernia repairs (VHR) being performed annually, no gold standard for the technique exists. Mesh has been shown to decrease recurrence rates, yet, concerns of increased complications and costs prevent its systematic use. We examined the cost-effectiveness of open suture (OS) versus open mesh (OM) in primary VHR.A decision analysis model from the payer's perspective comparing OS to OM was constructed for calculating the total costs and cost-effectiveness. Probabilities for complications and outcomes were derived from the literature. The costs represented institutional fixed costs. The outcome measure of effectiveness was recurrence. One-way sensitivity analysis and a probabilistic analysis using Monte Carlo simulation were performed.OS was associated with a total cost of $16,355 (+/-6,041) per repair, while OM was $16,947 (+/-7,252). At 3-year follow-up, OM was the more effective treatment with 73.8% being recurrence-free, compared with 56.3% in the OS group. The incremental cost to prevent one recurrence by the placement of mesh was $1,878. OM became the less effective treatment strategy when the infection rate exceeded 35%. At a willingness to pay level of $5,500, OM was the more cost-effective treatment strategy.In subjects without contraindication to mesh placement, OM repair is the more effective surgical treatment for VHR, with a lower risk of recurrence at a small cost to the payer.
View details for DOI 10.1007/s10029-008-0462-1
View details for Web of Science ID 000264810800010
View details for PubMedID 19142563
Prevention of Post-operative Leak Following Laparoscopic Heller Myotomy
JOURNAL OF GASTROINTESTINAL SURGERY
2009; 13 (2): 200-205
Laparoscopic Heller myotomy is the preferred treatment for achalasia. Post-operative leaks cause significant morbidity and impair functional outcome. This study assesses the efficacy of intra-operative leak testing on post-operative leak rate.A retrospective analysis of 106 consecutive patients undergoing laparoscopic Heller myotomy by a single surgeon between November 2001 and August 2006 was undertaken. Intra-operative leak testing was performed in all patients. Variables associated with intra-operative mucosotomy were assessed by univariate analysis and logistic regression modeling.Intra-operative mucosotomy occurred in 25% of patients. All mucosotomies were repaired primarily and tested with methylene-blue-stained saline. Dor fundoplication was performed in 74% of the patients. There were no post-operative leaks and patients were started on diet day of surgery. Mean LOS was 1.4(+/-0.7) days. Logistic regression modeling demonstrated that prior myotomy was associated with a statistically significant increase in the rate of mucosotomy (p = 0.033), while previous botox injection (p = 0.193), pneumatic dilation (p = 0.599) or concomitant hiatal hernia (p = 0.874) were not significantly associated with mucosotomy.Laparoscopic Heller myotomy for the treatment of achalasia is a safe procedure. Intra-operative leak testing minimizes the risk of post-operative leaks and expedites post-operative management. Prior endoscopic treatment does not impair operative results.
View details for DOI 10.1007/s11605-008-0687-4
View details for Web of Science ID 000262987400004
View details for PubMedID 18781365
Variation in mesh placement for ventral hernia repair: an opportunity for process improvement?
AMERICAN JOURNAL OF SURGERY
2008; 196 (2): 201-206
Incisional hernia repair (IHR) with mesh has been associated with decreased hernia recurrence. We analyzed variation in mesh use for IHR.A cohort undergoing IHR from 16 Veterans' Administration (VA) Hospitals was identified. Patient-specific variables were obtained from National Surgical Quality Improvement Program (NSQIP) data. Operative variables were obtained from physician-abstracted operative notes. Univariate and multivariable logistic regression analyses were used to model mesh implantation predictors.A total of 1,123 IHR cases were analyzed; Mesh was implanted in 69.6% (n = 781). Regression models demonstrated repair at a high performing facility was associated with a nearly 4-fold increase in mesh utilization. Other significant predictors include repair of recurrent hernia, chronic steroid use, and multiple fascial defects.There is variation in the rate of mesh placement for IHR by VA facility, even after accounting for key explanatory variables. Patterns of mesh placement in IHR appear to be based on practice style.
View details for DOI 10.1016/j.amjsurg.2007.09.041
View details for Web of Science ID 000258248200010
View details for PubMedID 18513688
Does cholecystectomy prior to the diagnosis of pancreatic cancer affect outcome?
2008; 74 (7): 602-605
Early diagnosis and curative resection are significant predictors of survival in patients with pancreatic cancer. We hypothesize that cholecystectomy within 12 months of pancreatic cancer affects 1-year survival. The Surveillance Epidemiology and End Result (SEER) database linked to Medicare data was used to identify patients diagnosed with pancreatic cancer who underwent cholecystectomy 1 to 12 months prior to cancer diagnosis. The SEER database identified 32,569 patients from 1995 to 2002; 415 (1.3%) underwent cholecystectomy prior to cancer diagnosis. Patients who underwent cholecystectomy had a higher proportion of diabetes (40.2% vs 20.5%; P < 0.01), obesity (8.9% vs 3.1%; P < 0.01), jaundice (17.3% vs 0.7%; P < 0.01), cholelithiasis (70.4% vs 4.2%; P < 0.01), choledocholithiasis (0.7% vs 0.0%; P < 0.01), weight loss (17.3% vs 4.7%; P < 0.01), abdominal pain (79.5% vs 22.5%), steatorrhea (0.7% vs 0.0%; P < 0.01), and cholecystitis (32.3% vs 1.7% ; P < 0.0001). After controlling for tumor stage, patient demographics, and symptoms, survival at 1 year was significantly lower in patients undergoing cholecystectomy (OR, 0.75; 95% CI, 0.58-0.97). Recent cholecystectomy is associated with decreased 1-year survival among patients with pancreatic cancer. For patients older than 65 years of age, further evaluation prior to cholecystectomy may be necessary to exclude pancreatic cancer, especially patients with jaundice, weight loss, and steatorrhea.
View details for Web of Science ID 000256967700010
View details for PubMedID 18646477
Percutaneous transhepatic duodenal diversion for the management of duodenal fistulae
JOURNAL OF GASTROINTESTINAL SURGERY
2008; 12 (6): 1103-1109
The aim of this study was to determine the success of the nonoperative management of persistent duodenal fistulae (DF) with percutaneous transhepatic duodenal diversion (PTDD).Retrospective chart review identified six patients with DF managed by PTDD from 2006 to 2007. Patient outcomes and complications were assessed.The etiology of DF included pancreatic surgery (three patients), gastrectomy (two patients), and Crohn's disease (one patient). PTDD was performed by interventional radiology at a median time of 37 days after fistula recognition. After PTDD, fistula drainage decreased from 775 cc/day (range 200 to 2,525 cc/day) to <50 cc/day at a median of 8 days. Patients were discharged 32 days (median) after PTDD. One patient with Crohn's disease required definitive surgical treatment. Of the remaining five patients, the PTDD tube was capped at 27 days (median) after placement and was removed on an outpatient basis at 79 days (median) after placement. There was no mortality, no fistula recurrence, or complications associated with PTDD placement.We present an algorithm for the nonoperative management of persistent postoperative DF. In this limited series, PTDD was highly effective at definitively treating DF, especially in the acute setting. PTDD should be considered by surgeons facing the management of postoperative DF.
View details for DOI 10.1007/s11605-007-0456-9
View details for Web of Science ID 000255629100017
View details for PubMedID 18172607
Risk of complications from enterotomy or unplanned bowel resection during elective hernia repair
ARCHIVES OF SURGERY
2008; 143 (6): 582-586
Enterotomy or unplanned bowel resection (EBR) may occur during elective incisional hernia repair (IHR) and significantly affects surgical outcomes and hospital resource use.Retrospective review of patients undergoing IHR between January 1998 and December 2002.Sixteen tertiary care Veterans Affairs medical centers.A total of 1124 elective incisional hernia repairs identified in the National Surgical Quality Improvement Program data set.Elective IHR.Thirty-day postoperative complication rate, return to operating room, length of stay, and operative time.Of the 1124 elective procedures, 74.1% were primary IHR, 13.3% were recurrent prior mesh IHR, and 12.6% were recurrent prior suture. Overall, 7.3% had an EBR. The incidence of EBR was increased in patients with prior repair: 5.3% for primary repair, 5.7% for recurrent prior suture, and 20.3% for prior mesh repair (P < .001). The occurrence of EBR was associated with increased postoperative complications (31.7% vs 9.5%; P < .001), rate of reoperation within 30 days (14.6% vs 3.6%; P < .001), and development of enterocutaneous fistula (7.3% vs 0.7%; P < .001). After adjusting for procedure type, age, and American Society of Anesthesiologists class, EBR was associated with an increase in median operative time (1.7 to 3.5 hours; P < .001) and mean length of stay (4.0 to 6.0 days; P < .001).Enterotomy or unplanned bowel resection is more likely to complicate recurrent IHR with prior mesh. The occurrence of EBR is associated with increased postoperative complications, return to the operating room, risk of enterocutaneous fistula, length of hospitalization, and operative time.
View details for Web of Science ID 000256795200015
View details for PubMedID 18559752
Association of timely administration of prophylactic antibiotics for major surgical procedures and surgical site infection
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2008; 206 (5): 814-821
Prophylactic antibiotic (PA) administration 1 to 2 hours before surgical incision (SIP-1) is a publicly reported process measure proposed for performance pay. We performed an analysis of patients undergoing major surgical operations to determine if SIP-1 was associated with surgical site infection (SSI) rates in Department of Veterans Affairs (VA) hospitals.Patients with External Peer Review Program Surgical Care Improvement Project (SCIP)-1 data with matched National Surgical Quality Improvement Program data were included in the study. Patient and facility level analyses comparing SCIP-1 and SSI were performed. We adjusted for clustering effects within hospitals, validated SSI risk score, and procedure type (percentage of colon, vascular, orthopaedic) using generalized estimating equations and linear modeling.The study population included 9,195 elective procedures (5,981 orthopaedic, 1,966 colon, and 1,248 vascular) performed in 95 VA hospitals. Timely PA occurred in 86.4% of patients. Untimely PA was associated with a rate of SSI of 5.8%, compared with 4.6% in the timely group (odds ratio = 1.29, 95% CI 0.99, 1.67) in bivariable unadjusted analysis. Patient level risk-adjusted multivariable generalized estimating equation modeling found the SSI risk score was predictive of SSI (p < 0.001); SIP-1 was not associated with SSI. Hospital level multivariable generalized linear modeling found procedure mix (p < 0.0001), but not SIP-1 rate or facility volume, to be associated with facility SSI rate. The study had 80% power to detect a 1.75% difference for patient level SSI rates.Timely PA did not markedly contribute to overall patient or facility SSI rates. These data are important for the ongoing discourse on how to measure and pay for quality of surgical care.
View details for DOI 10.1016/j.jamcollsurg.2007.12.013
View details for Web of Science ID 000255624400006
View details for PubMedID 18471703
Umbilical herniorrhapy in cirrhosis: Improved outcomes with elective repair
JOURNAL OF GASTROINTESTINAL SURGERY
2008; 12 (4): 675-681
This study was undertaken to examine the effect of cirrhosis on elective and emergent umbilical herniorrhapy outcomes.Procedures were identified from the Veterans' Affairs National Surgical Quality Improvement Program at 16 hospitals. Medical records and operative reports were physician abstracted to obtain preoperative and intraoperative variables.Of the 1,421 cases reviewed, 127 (8.9%) had cirrhosis. Cirrhotics were more likely to undergo emergent repair (26.0% vs. 4.8%, p < 0.0001), concomitant bowel resection (8.7% vs. 0.8%, p < 0.0001), return to operating room (7.9% vs. 2.5%, p = 0.0006), and increased postoperative length of stay (4.0 vs. 2.0 days, p = 0.01). Best-fit regression models found cirrhosis was not a significant predictor of postoperative complications. Significant predictors of complications were emergent case (OR 5.4; 95% CI 3.1-9.4), diabetes (OR 2.1; 95% CI 1.2-3.8), congestive heart failure (OR 4.0; 95% CI 1.4-11.4), and chronic obstructive pulmonary disease (OR 2.0; 95% CI 1.1-3.6). Among emergent repairs, cirrhosis (OR 4.4; 95% CI 1.3-14.3) was strongly associated with postoperative complications.Elective repair in cirrhotics is associated with similar outcomes as in patients without cirrhosis. Emergent repair in cirrhotics is associated with worse outcomes. Early elective repair may improve the overall outcomes for patients with cirrhosis.
View details for DOI 10.1007/s11605-008-0496-9
View details for Web of Science ID 000253994400012
View details for PubMedID 18270782
- Advances in abdominal wall hernia repair - Preface SURGICAL CLINICS OF NORTH AMERICA 2008; 88 (1): XVII-XIX
Surgical progress in inguinal and ventral incisional hernia repair
SURGICAL CLINICS OF NORTH AMERICA
2008; 88 (1): 17-?
The goals of this article are to describe the history of hernia repair and how innovations in surgical technique, prosthetics, and technology have shaped current practice.
View details for DOI 10.1016/j.suc.2007.11.007
View details for Web of Science ID 000254084400004
View details for PubMedID 18267159
Timely administration of prophylactic antibiotics for major surgical procedures
JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS
2006; 203 (6): 803-811
Prophylactic antibiotics (PA) given within 60 minutes before surgical incision decrease risk of subsequent surgical site infection. Nationwide quality improvement initiatives have focused on improving the proportion of patients who receive timely prophylactic antibiotics.This is a cohort study of major surgical procedures performed in 108 Veterans Affairs hospitals between January and December 2005. Using data from the External Peer Review Program and the National Surgical Quality Improvement Program, we examined factors associated with timely PA administration. Univariate and multivariable analyses were performed.There were 8,137 major surgical procedures: cardiac (2,664), hip and knee arthroplasty (3,603), colon (1,142), arterial vascular (606), and hysterectomy (122). Timely PA occurred in 76.2% of patients, 18.2% received them too early, and 5.4% received them too late. Early administration accounted for 79% of untimely PA. Differences in timeliness were seen by procedure type (68% to 87%; p < 0.0001), admission status (67% to 80%; p < 0.0001), and antibiotic class (65% to 89%; p < 0.0001). PA administration occurred in the operating room for 63.5% of patients. When PA administration occurred in the operating room, they were timely in 89% of patients, compared with 54% of patients where administration was outside the operating room (odds ratio, 7.74; 95% CI = 6.49 to 9.22).Early PA administration accounted for the majority of inappropriately timed PA. Efforts to improve performance on this measure should focus on administering antibiotics in the operating room.
View details for DOI 10.1016/j.jamcollsurg.2006.08.010
View details for Web of Science ID 000242567300003
View details for PubMedID 17116547
- Treating obesity - There is no free lunch MEDICAL CARE 2006; 44 (8): 703-705
Improvement in gastrointestinal symptoms and quality of life after cholecystectomy
AMERICAN JOURNAL OF SURGERY
2006; 192 (2): 196-202
Laparoscopic cholecystectomy (LC) is the accepted treatment for symptomatic cholelithiasis but has been criticized as an overused procedure. This study assesses the effectiveness of LC on reduction in gastrointestinal (GI) symptoms and the impact on quality of life (QOL).A prospective cohort of subjects evaluated for gallstone disease between August 2001 and July 2004 completed preoperative and postoperative GI gallbladder symptom surveys (GISS) and SF36 QOL surveys. The GISS was developed to quantify the magnitude, severity, and distressfulness of 16 GI symptoms. Surveys were scored and evaluated using paired t tests.Fifty-five subjects were included in the final analysis. The GISS revealed significant improvement in biliary type symptoms but not reflux or irritable bowel symptoms after LC (P > .05). Significant improvement was seen in QOL (P < .01).This study supports the utility of LC by showing not only a significant reduction of GI symptoms but also marked improvement in patients' general QOL.
View details for DOI 10.1016/j.amjsurg.2006.01.020
View details for Web of Science ID 000239580900010
View details for PubMedID 16860629
Patient-reported outcomes after inguinal herniorrhaphy
2006; 140 (2): 198-205
Patient-reported outcomes (PRO) reflect the functional outcomes of inguinal herniorrhaphy. We studied the effect of hernia recurrence and complications on PRO for participants in the Veterans Affairs trial of Open or Laparoscopic Repair of Inguinal Hernia.Analyzed PRO included (1) the Medical Outcomes Study Short Form 36, version 2, (2) the Surgical Pain Scale, (3) the Activities Assessment Scale, and (4) patient satisfaction. Recurrences and complications were recorded at follow-up visits. Complications were categorized by (1) hematoma/seroma, (2) orchitis, (3) neuralgia, and (4) other. Univariate and multivariable regression analyses identified variables significantly associated with postoperative PRO.Of the 1603 patients with PRO data, 105 had a recurrence and 342 had a complication at 2 years. Multivariable analyses showed neuralgia (P < .0005) adversely affected all PRO, and recurrence (P < .05) affected patient-reported pain, activity, and satisfaction, but not the score for the Medical Outcomes Study Short Form 3. Patients with a recurrence after open repair had more pain than those with a recurrence after laparoscopic repair (P = .0001). Patients with other complications after laparoscopic repair reported more pain and less activity than those with other complications after open repair (P = .003 and P = .009, respectively).The effectiveness of inguinal herniorrhaphy should be measured by the rate of recurrence and neuralgia. Postoperative neuralgias have a deleterious effect on all patient-reported outcomes.
View details for DOI 10.1016/j.surg.2006.02.003
View details for Web of Science ID 000240043200010
View details for PubMedID 16904970
Economical and clinical outcomes of alternative treatment strategies in the management of common bile duct stones in the elderly: Wait and see or surgery?
AMERICAN JOURNAL OF GASTROENTEROLOGY
2006; 101 (4): 746-752
Common bile duct stones (CBDS) are especially prevalent in the elderly population. Although the standard of care for stone removal is endoscopic retrograde cholangiography with sphincterotomy (ERC-S), the clinician's decision to refer a patient for cholecystectomy after ERC-S depends on several factors including potential for future biliary symptoms and complications, morbidity and mortality related to cholecystectomy, and costs associated with referral for cholecystectomy versus conservative approach. Using decision analysis, we explored the economic implications of cholecystectomy versus expectant management following ERC-S in elderly patients with CBDS.A decision tree was constructed with DATA 3.5 (Williamstown, MA) to estimate the costs and outcomes associated with two treatment strategies following ERC-S for CBDS in patients age 60 yr and older: (1) elective cholecystectomy, and (2) expectant management. Probabilities for potential complications and outcomes were derived from the medical literature and cost reflected Medicare reimbursement rates at our institution. The time horizon of the analysis was 2 yr.Elective cholecystectomy was associated with total costs of 5,259 dollars with 94.3% of the cohort alive (1.886 life-years) at 2 yr, whereas expectant management was associated with total costs of 1,173 dollars with 94.7% of the cohort alive (1.894 life-years). The results were sensitive to the probability of recurrent biliary symptoms in patients treated conservatively. Compared to elective cholecystectomy, expectant management became less effective and more expensive at a yearly probability of recurrent symptoms greater than 40% and 90%, respectively.In patients aged 60 and older, expectant management after ERC-S for CBDS is a reasonable approach, but the economic attractiveness of this strategy is highly dependent on the probability of recurrent symptoms.
View details for DOI 10.1111/j.1572-0241.2006.00491.x
View details for Web of Science ID 000236666800013
View details for PubMedID 16494588
Outcomes of cholecystectomy after endoscopic sphincterotomy for choledocholithiasis
JOURNAL OF GASTROINTESTINAL SURGERY
2006; 10 (2): 292-296
Laparoscopic cholecystectomy (LC) for treatment of symptomatic common bile duct stones (CBDS) after endoscopic sphincterotomy (ES) is associated with increased conversion and complications compared with other indications. We examined factors associated with conversion and complications of LC after ES. A retrospective study of 32 patients undergoing ES for CBDS followed by cholecystectomy was undertaken. Surgical outcomes for this group were compared with a control population of 499 LCs for all other indications. Factors associated with open cholecystectomy and complications in the ES group were analyzed. Patients undergoing LC preceded by ES had a significantly higher complication (odds ratio [OR] = 7.97; 95% CI, 2.84-22.5) and conversion rate (OR = 3.45; 95% CI, 1.56-7.66) compared with LC for all other indications. Pre-ES serum bilirubin greater than 5 mg/dL was predictive of conversion (positive predictive value = 63%, P < 0.005). Patients with symptomatic CBDS that undergo LC after ES have higher complication and conversion rates than patients undergoing LC without ES. Pre-ES serum bilirubin is useful in identifying patients who may not have a successful laparoscopic approach at cholecystectomy.
View details for DOI 10.1016/j.gassur.2005.05.013
View details for Web of Science ID 000235388700025
View details for PubMedID 16455464
Variation in Institutional Review processes for a multisite observational study
AMERICAN JOURNAL OF SURGERY
2005; 190 (5): 805-809
The Veterans Administration is an ideal setting for multisite studies; however, individual VA Institutional Review Board (IRB) approval is necessary. This study examines the burden of multisite IRB approval on a Health Services Research and Development (HSRD) ventral hernia outcomes observational study.Data gathered on the IRB process per site included time required for application completion, staff training and compliance, IRB affiliation (VA or university), approval status, and time to IRB approval. Wilcoxon rank sum tests were used to determine differences in median times for application completion and approval. Financial and temporal expenses were calculated.Significant differences were found in median time to complete applications by IRB affiliation (P < .01) and median time to approval by changes required to the consent letter (P < .05).The IRB process for a multisite observational study is expensive in both time and money. A VA national IRB for multisite studies would significantly decrease the financial and temporal burden for observational studies.
View details for DOI 10.1016/j.amjsurg.2005.07.024
View details for Web of Science ID 000232935200027
View details for PubMedID 16226962
Predictors of wound infection in ventral hernia repair
AMERICAN JOURNAL OF SURGERY
2005; 190 (5): 676-681
Postoperative wound infection is a significant risk factor for recurrence after ventral hernia repair (VHR). The current study examines patient- and procedure-specific variables associated with wound infection.A cohort of subjects undergoing VHR from 13 regional Veterans Health Administration (VHA) sites was identified. Patient-specific risk variables were obtained from National Surgical Quality Improvement Program (NSQIP) data. Operative variables were obtained from physician-abstracted operative notes. Univariate and multivariable logistic regression analysis was used to model predictors of postoperative wound infection.A total of 1505 VHR cases were used for analysis; wound infection occurred in 5% (n = 74). Best-fit logistic regression models demonstrated that steroid use, smoking, prolonged operative time, and use of absorbable mesh, acting as a surrogate marker for a more complex procedure, were significant independent predictors of wound infection.Permanent mesh placement was not associated with postoperative wound infection. Smoking was the only modifiable risk factor and preoperative smoking cessation may improve surgical outcomes in VHR.
View details for DOI 10.1016/j.amjsurg.2005.06.041
View details for Web of Science ID 000232935200003
View details for PubMedID 16226938
Surgical approach to gastroesophageal reflux disease: What the radiologist needs to know
2005; 25 (6): 1485-1499
Gastroesophageal reflux disease (GERD) is defined as gastroesophageal reflux resulting in symptoms or in injury to the esophageal epithelium. Although the medical management of GERD has improved, an increasing number of laparoscopic antireflux surgical procedures are being performed. Barium studies, endoscopy, manometry, and pH monitoring are all integral components of preoperative evaluation. Barium swallow examination must allow critical evaluation of esophageal peristalsis, the presence and extent of gastroesophageal reflux, and complications including esophagitis, stricture, and Barrett esophagus. It is crucial to identify and characterize hiatal hernia and longitudinal stricture, which can result in a shortened esophagus. In such cases, it becomes necessary for the surgeon to incorporate an esophageal lengthening procedure prior to fundoplication; otherwise, poor surgical outcome is likely. Normal postfundoplication radiographic findings as well as postoperative complications (eg, tight wrap, perforation, abscess, complete or partial dehiscence, recurrent stricture, recurrent hernia, intrathoracic migration of the wrap) must also be recognized and clearly understood by the radiologist. Given the chronic nature and prevalence of symptomatic GERD and the increasing number of patients undergoing surgical intervention, it is imperative that the radiologist understand the pre- and postsurgical evaluation of affected patients.
View details for DOI 10.1148/rg.256055016
View details for Web of Science ID 000236951800005
View details for PubMedID 16284130
Obesity status and use of general surgery resources
2005; 71 (11): 963-969
Obesity is a rapidly growing epidemic. This study assesses the impact of obesity on surgeon workload for general surgical services. A retrospective study of patients undergoing cholecystectomy, unilateral mastectomy, and colectomy between January 2000 and December 2003 was undertaken. Obesity was defined as body mass index > or = 30. The proportion of obese patients was compared to the 2002 BRFSS obesity prevalence data for Alabama. Data were adjusted to control for potential confounders. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. A total of 1,385 patients were included in analysis. The prevalence of obesity in the study population was 35.5 per cent compared to the statewide prevalence of 25.2 per cent (OR = 1.73, 95% CI = 1.51, 1.98). These data were stratified by procedure, age, and gender. The cholecystectomy group had a significantly higher proportion of obese for all age groups and female gender. The mastectomy group had a higher proportion of obese in the 45-64 age group. The stratified colectomy group did not reach statistical significance. There was no evidence of referral bias to explain these findings. This study demonstrates there is a greater use of general surgery services, particularly cholecystectomy and mastectomy, in obese patients than predicted by the prevalence of obesity in the population.
View details for Web of Science ID 000233398200021
View details for PubMedID 16372616
Colon cancer in pregnancy.
2005; 12 (3): 196-202
View details for PubMedID 16062167
Impact of obesity on resource utilization for general surgical procedures
ANNALS OF SURGERY
2005; 241 (5): 821-828
To determine the impact of the obesity epidemic on workload for general surgeons.In 2001, the prevalence of obesity in the United States reached 26%, more than double the rate in 1990. This study focuses on the impact of obesity on surgical practice and resource utilization.A retrospective analysis was done on patients undergoing cholecystectomy, unilateral mastectomy, and colectomy from January 2000 to December 2003 at a tertiary care center. The main outcome variables were operative time (OT), length of stay (LOS), and complications. The key independent variable was body mass index. We analyzed the association of obesity status with OT, LOS, and complications for each surgery, using multivariate regression models controlling for surgeon time-invariant characteristics.There were 623 cholecystectomies, 322 unilateral mastectomies, and 430 colectomies suitable for analysis from 2000 to 2003. Multivariable regression analyses indicated that obese patients had statistically significantly longer OT (P < 0.01) but not longer LOS (P > 0.05) or more complications (P > 0.05). Compared with a normal-weight patient, an obese patient had an additional 5.19 (95% confidence interval [CI], 0.15-10.24), 23.67 (95% CI, 14.38-32.96), and 21.42 (95% CI, 9.54-33.30) minutes of OT with respect to cholecystectomy, unilateral mastectomy, and colectomy. These estimates were robust in sensitivity analyses.Obesity significantly increased OT for each procedure studied. These data have implications for health policy and surgical resource utilization. We suggest that a CPT modifier to appropriately reimburse surgeons caring for obese patients be considered.
View details for DOI 10.1097/01.sla.0000161044.20857.24
View details for Web of Science ID 000228681700016
View details for PubMedID 15849518
Serum lactic acid determines the outcomes of CT diagnosis of pneumatosis of the gastrointestinal tract
2004; 70 (1): 19-23
Computed tomography (CT) diagnosis of pneumatosis involving the gastrointestinal tract can represent a broad range of clinical entities from a benign process to ischemic bowel. The purpose of this study is to define the significance and outcome of pneumatosis intestinalis (PI). All CT scans from 5/93 to 12/01 with the finding of PI were reviewed. Eighty-six CT scans had the finding of PI, with the colon being the most frequent location (51%), followed by small bowel (36%) and gastric (9%). Forty per cent of patients underwent surgery, with an overall mortality rate of 42 per cent and a surgical mortality rate of 47 per cent. Univariate analysis demonstrated significant correlation between serum lactic acid (LA) > 2.0 mmol/L [odds ratio (OR) = 23.4; 95% confidence interval (C.I.), 7.21-75.92] and serum creatinine > 1.5 mg/dL (OR = 3.05; 95% C.I., 1.25-7.42) with mortality. Age was suggestive but not a significant risk factor for mortality (P = 0.09). Multivariate analysis found serum LA > 2.0 (OR = 30.37; 95% C.I., 7.31-126.2) to be the only significant predictor of mortality. CT diagnosis of PI is associated with significant in-hospital mortality, especially in the elderly. Serum LA level > 2.0 mmol/L at time of diagnosis is associated with a greater than 80 per cent mortality. Surgical consultation is necessary to determine which patients need urgent surgical intervention.
View details for Web of Science ID 000188597200007
View details for PubMedID 14964540
Duplicate publications in the otolaryngology literature
2003; 113 (5): 772-774
A duplicate publication duplicates other published work by the same author(s). The purpose of the study was to define the extent of this problem within the otolaryngology literature.Retrospective review of the literature.Original articles published in Archives of Otolaryngology-Head and Neck Surgery and Laryngoscope in 1999 were reviewed using the OVID search engine. Titles and abstracts from English articles written by the same first, second, or last author were analyzed, and suspected publications were evaluated. Duplicate publications were classified as dual (identical data set and conclusions) or suspected dual (nearly identical data set and conclusions) publications.Of the 492 articles evaluated, 40 index articles were identified. These led to a total of 42 (8.5%) duplicate articles of which 27 were classified as dual and 15 as suspected dual publications. Approximately half of the duplicate publications were published by authors in the United States (55%). Duplicate articles usually appeared within 12 months of the each other (74%) and failed to cross-reference the earlier publication (83%).Journal editors have become aware of an increase in the number of duplicate publications in the medical literature. The incidence of duplicate publications in the otolaryngology literature appears to be similar to that in other specialties.
View details for Web of Science ID 000182729200002
View details for PubMedID 12792309
Gallbladder and biliary tract disease in the intensive care unit.
Seminars in gastrointestinal disease
2003; 14 (1): 28-33
Intensive care unit patients present a difficult challenge in the diagnosis and treatment of complications related to the biliary tract. Altered mental status interferes with the patient's ability to communicate symptoms and give a reliable physical examination. Laboratory data are often nonspecific in diagnosing complications of biliary tract disease because of the high incidence of cholestasis in intensive care unit patients. Likewise, routine radiographic evaluation has a marked decreased sensitivity and specificity in evaluating biliary tract disorders. Taken together, these factors often lead to a delay in diagnosis of biliary tract problems in the intensive care unit patient. Intervention in these patients is associated with high morbidity and mortality when compared to the ambulatory setting. This article reviews the clinical presentation, differential diagnosis, and management options of biliary tract complications in this complex patient population.
View details for PubMedID 12610852
Quality of life after laparoscopic bilateral adrenalectomy for Cushing's disease
2002; 132 (6): 1064-1068
Bilateral adrenalectomy to control symptoms of Cushing's disease after failed transsphenoidal operation is effective. We examined surgical outcomes and quality of life after laparoscopic bilateral adrenalectomy for the treatment of Cushing's disease.Eighteen patients underwent laparoscopic bilateral adrenalectomy from November 1994 through December 2000. Patient data were obtained from chart reviews. Patients completed a follow-up survey including the SF-36 health survey (QualityMetric Inc, Lincoln, Neb).Laparoscopic bilateral adrenalectomy was accomplished in all 18 patients. There was 1 intraoperative complication of a colotomy, and 2 postoperative complications including 1 pancreatic pseudocyst and 1 hemorrhage. Three patients died at 12, 19, and 50 months after operation. At a median follow-up of 29 months, patients reported improvement in all Cushing's-related symptoms. Nine of 11 patients who responded to the survey stated their heath was improved after adrenalectomy. Results of the SF-36 health survey showed significantly lower scores in all 8 measured parameters when compared with the general population.Results of laparoscopic bilateral adrenalectomy show this procedure is comparable with open adrenalectomy in controlling symptoms of Cushing's disease. Despite patient reported improvement in health after adrenalectomy, this patient population continues to experience poor health as measured by the SF-36 when compared with the general population.
View details for DOI 10.1067/msy.2002.128482
View details for Web of Science ID 000180123000042
View details for PubMedID 12490856