Risk-adjusted cumulative sum (RA-CUSUM) method for real time monitoring of surgical units performance.

BackgroundHepatectomy is the only potentially curable treatment for intrahepatic cholangiocarcinoma (IHCC) and colorectal liver metastasis (CRLM). This study aimed to explore the difference in intraoperative outcomes and postoperative complications between IHCC and CRLM in different surgical methods including major hepatectomy and minor hepatectomy.MethodsWe included 319 patients with IHCC or CRLM who underwent hepatectomy at our hospital. According to major hepatectomy and minor hepatectomy, eligible patients were divided into two groups. In each group, the clinicopathological characteristics of IHCC and CRLM patients were compared, then propensity score matching (PSM) was performed based on the results. Intraoperative outcomes and postoperative complications were compared between IHCC and CRLM before and after PSM. Intraoperative variables, including intraoperative blood transfusion, duration of operation, and intraoperative blood loss, were used to evaluate the intraoperative conditions of patients. The postoperative complications were measured according to the Clavien-Dindo classification. Grade III to V complications were defined as major complications.ResultsThe major hepatectomy group included 118 patients with IHCC and 93 patients with CRLM. IHCC patients presented a longer operation time and a higher postoperative complication rate than CRLM patients. The infection-related complication rate of the CRLM patients was significantly higher than the IHCC patients. In multivariate analysis, major hepatectomy for IHCC was independently associated with the presence of postoperative complications. The minor hepatectomy group included 146 IHCC patients and 62 CRLM patients. Compared with CRLM patients, IHCC patients presented a longer operation time. There was no significant difference in the intra-operative blood loss, postoperative complication rate, the major complications rate, and the minor complications rate between the IHCC patients and CRLM patients.ConclusionsThis study revealed major hepatectomy for IHCC led to significantly higher morbidity of postoperative complications than CRLM patients. For minor hepatectomy, there was no difference in postoperative complications between IHCC and CRLM. More attention should be paid to improving the preoperative planning and surgical management of hepatic malignancies especially in the setting of IHCC.

Cumulative Sum Curves and Their Prediction Limits

Objective To study the learning curve of laparoscopic pacreaticoduodenectomy (LPD) with a view to find an appropriate way to develop LPD step by step. Methods 112 consecutive patients who completely underwent LPD in a single surgery center at the First People’s Hospital of Changzhou from December 2015 to February 2018 were retrospectively reviewed. By using both the cumulative sum (CUSUM) and the risk-adjusted CUSUM (RA-CUSUM) methods to analyze the perioperative data of these patients, the learning curve of LPD was studied in a more scientific way. Results The learning curve could be divided into three phases: Phase 1, the initial period (the initial 45 patients); Phase 2, the enhancement period (the subsequent 31 patients); Phase 3, the maturation period (the remaining patients). For these 3 phases, the corresponding operative times were (448.4±75.0), (381.3±74.3), and (336.2±52.1) min, respectively (P<0.05). The intraoperative blood losses were (373.3±250.1), (332.3±211.6), and (265.3±253.2) ml, respectively (P<0.05). The times to oral intake were 6.0(5.0, 8.0), 5.0(3.0, 6.0), and 3.0(3.0, 5.0) days, respectively (P<0.05). The number of lymph nodes harvested were (10.0±7.0), (8.8±4.3), and (13.3±6.2), respectively (P<0.05). All these showed significant improvement through the 3 phases. On the other hand, the postoperative stays, the postoperative pancreatic fistula rates were also decreased. But these failed to reach statistical significance. Vascular reconstruction was carried out in the 48th patient in phase 2 of the study. Conclusions The initial phase of LPD passed after LPD for 46 patients, but the maturation phase occurred after LPD on 76 patients. Vascular reconstruction should be considered as passing through the learning phase rather than reaching the maturity phase. Adjustments made in the enhancement phase helped to get through the maturation phase earlier. Key words: Laparoscopy; Pancreaticoduodenectomy; Pancreatic neoplasms; Bile duct neoplasms; Learning curve; Treatment outcome

Outcome data on robotic major hepatectomy are lacking. This study was undertaken to compare robotic vs. 'open' major hepatectomy utilizing patient propensity score matching (PSM). With institutional review board approval, we prospectively followed 183 consecutive patients who underwent robotic or 'open' major hepatectomy, defined as removal of three or more Couinaud segments. 42 patients who underwent 'open' approach were matched with 42 patients who underwent robotic approach. The criteria for PSM were age, resection type, tumor size, tumor type, and BMI. Survival was individually stratified for hepatocellular carcinoma (HCC), intrahepatic cholangiocarcinoma (IHCC), and colorectal liver metastases (CLM). The data are presented as: median (mean ± SD). Operative duration for the robotic approach was 293 (302 ± 131.5) vs. 280 (300 ± 115.6) minutes for the 'open' approach (p = NS). Estimated Blood Loss (EBL) was 200 (239 ± 183.6) vs. 300 (491 ± 577.1) ml (p = 0.01). There were zero postoperative complications with a Clavien-Dindo classification ≥ III for the robotic approach and three for the 'open' approach (p = NS). ICU length of stay (LOS) was 1 (1 ± 0) vs. 2 (3 ± 2.0) days (p = 0.0001) and overall LOS was 4 (4 ± 3.3) vs. 6 (6 ± 2.7) days (p = 0.003). In terms of long-term oncological outcomes, overall survival was similar for patients with IHCC and CLM regardless of the approach. However, patients with HCC who underwent robotic resection lived significantly longer (p = 0.05). Utilizing propensity score matched analysis, the robotic approach was associated with a lower EBL, shorter ICU LOS, and shorter overall LOS while maintaining similar operative duration and promoting survival in patients with HCC. We believe that the robotic approach is safe and efficacious and should be considered a preferred alternative approach for major hepatectomy.

ObjectivesWe have previously shown a learning phase of 61 procedures when starting with robot-assisted surgery for early-stage cervical cancer. We evaluated the learning phase with a novice robotic surgeon who...

ObjectivesLiterature suggests that with increasing experience the sentinel lymph node (SLN) detection rate improves. We evaluated if a learning curve affects the SLN detection rate in early-stage cervical cancer.MethodsAll patients...

Major hepatectomy for intrahepatic cholangiocarcinoma or colorectal liver metastases. Are we talking about the same story?

Background: Heart failure (HF) is among the most common reasons for hospitalization in the United States. Hospital length of stay (LOS) is a driver of cost and disease burden. Objectives: To examine factors associated with LOS of HF hospitalizations. Methods: Medicare beneficiaries with fee-for-service and pharmacy coverage who had HF hospitalizations (inpatient claims with ≥1 overnight stay/2 hospital days with HF as the primary discharge diagnosis, discharged alive) between 2007 and 2011 were identified in the Medicare national 5% sample. The median and interquartile range (IQR) LOS was calculated by demographic characteristics, comorbidities, and discharge status based on Medicare claims data with the Kruskal-Wallis test to compare distributions in the overall population with HF (n = 45,584) and in the subpopulation with documented systolic dysfunction (n = 10,256). Results: The median LOS was 5 days (range 2-255, IQR 4-8 days) in the overall HF population and 5 days (range 2-204, IQR 4-8 days) in those with systolic dysfunction. Across most demographic characteristics and comorbidities, the median LOS was 5 days but was higher among nursing home residents and individuals with malnutrition in both groups and with chronic kidney disease in those with systolic dysfunction ( Figure ). All comorbidities were associated with a shift in the distribution toward longer LOS in the population with systolic dysfunction and all but coronary heart disease in the overall population (p &lt; 0.001). HF patients discharged to a skilled nursing facility had longer LOS (median 7 days, IQR 5-10 days) versus other discharge statuses (median 5 days, IQR 3-7 days, p &lt; 0.001) in both populations. Conclusions: In patients hospitalized for HF, the median LOS was 5 days across most comorbidities and other characteristics, but comorbidities were associated with a shift in the upper tail of the distribution toward longer LOS. Worse functional status (nursing residence or discharge to a skilled nursing facility) was associated with a higher median LOS.

hepatectomy and beyond -again, to 'resect the unresectable' but this time based on reintroduction of a new surgical paradigm. Only the future will tell if vessel-guided hepatectomy conveying the paradox combination of parenchyma-sparing and major hepatectomy is a step forward or not.

SummaryThe standard cumulative sum (CUSUM), risk-adjusted CUSUM and Shiryayev–Roberts schemes for monitoring surgical performance are compared. We find that both CUSUM schemes are comparable in run length performance except when there is a high heterogeneity of surgical risks, in which case the risk-adjusted CUSUM scheme is more sensitive in detecting a shift in surgical performance. The Shiryayev–Roberts scheme is found to be less sensitive compared with the CUSUM schemes in detecting a deterioration in surgical performance. Using the Markov chain method, the exact average run length of a standard CUSUM scheme can be computed whereas the average run length of a risk-adjusted CUSUM scheme is approximated. For a risk-adjusted CUSUM scheme, the accuracy of the average run length depends on the fineness of the discretization of CUSUM values, which relies on the chart limit, shift to be detected optimally and in-control surgical risk distribution. A sensitivity analysis shows that the risk-adjusted CUSUM and Shiryayev–Roberts schemes still perform moderately well in detecting a deterioration and an improvement in surgical performances respectively even though there is a misspecification of the in-control surgical risk distribution. In general, the run length performance of the Shiryayev–Roberts scheme is comparatively less sensitive to a misspecification of the in-control surgical risk distribution.

To assess the oncological efficiency of laparoscopic minor and major hepatectomy for primary and metastatic liver malignant neoplasms. Retrospective single-center study. Tertiary university hospital. One hundred twenty-eight patients undergoing 133 laparoscopic liver resections for malignant diseases. Perioperative results and midterm overall and disease-free survival. Surgical indications were colorectal carcinoma liver metastasis (n=83), hepatocellular carcinoma (n=18), neuroendocrine tumor metastasis (n=17), non-colorectal carcinoma liver metastasis (n=11), lymphoma (n=2), and intrahepatic cholangiocarcinoma (n=2). Two patients had 2-stage laparoscopic resections for bilobar colorectal carcinoma liver metastasis. Three patients had repeated liver resection for recurrent colorectal carcinoma liver metastasis. Forty-two major hepatectomies (32%) were performed. The median operative time was 210 minutes (range, 30-480 minutes). The median postoperative length of stay was 4 days (range, 1-15 days). Seven patients required conversion to formal open surgery and 4 patients required conversion to a laparoscopic-assisted procedure. Sixteen patients (13%) developed significant postoperative complications. One patient (0.8%) died in the hospital. In the 17 patients with neuroendocrine tumor metastasis, 6 (35%) had microscopic positive resection margins. Most of these patients underwent debulking and cytoreductive surgery. A microscopic negative resection margin was obtained in the remaining 112 of 116 resections (97%). We recorded 2-year overall survivals of 80%, 77%, and 91% in the groups with colorectal carcinoma liver metastasis, hepatocellular carcinoma, and neuroendocrine tumor metastasis, respectively. Our data support the safety and oncological efficiency of laparoscopic resection for liver malignant neoplasms. Adequate patient selection and extensive experience in hepatic and laparoscopic surgery are essential prerequisites to optimize outcomes.

Risk Factors For Early Recurrence After Liver Resection For Colorectal Liver Metastases (CRLM): A Single Centre Study

The risk-adjusted Bernoulli cumulative sum (CUSUM) chart developed by Steiner et al. (2000) is an increasingly popular tool for monitoring clinical and surgical performance. In practice, however, the use of a fixed control limit for the chart leads to a quite variable in-control average run length performance for patient populations with different risk score distributions. To overcome this problem, we determine simulation-based dynamic probability control limits (DPCLs) patient-by-patient for the risk-adjusted Bernoulli CUSUM charts. By maintaining the probability of a false alarm at a constant level conditional on no false alarm for previous observations, our risk-adjusted CUSUM charts with DPCLs have consistent in-control performance at the desired level with approximately geometrically distributed run lengths. Our simulation results demonstrate that our method does not rely on any information or assumptions about the patients' risk distributions. The use of DPCLs for risk-adjusted Bernoulli CUSUM charts allows each chart to be designed for the corresponding particular sequence of patients for a surgeon or hospital.

Quality of Pancreatic Transplant Program Assessment Using a Risk-adjusted Cumulative Sum Chart: Experience From a Single, Small Center

Learning Curve for Laparoscopic Pancreaticoduodenectomy: a CUSUM Analysis