Low Case Volume Research Articles

Predictors of pouch failure and quality of life following ileal pouch-anal anastomosis for ulcerative colitis: a retrospective multicenter study.

This study aimed to investigate the causes of failure after the ileal pouch-anal anastomosis (IPAA) procedure for ulcerative colitis (UC) and to determine the independent risk factors affecting their quality of life. This multi-center cohort study included all UC patients who underwent IPAA at nine referral centers in Türkiye from 2010 to 2018. Centers were categorized as high-volume (≥10 cases/year) or low-volume (<10 cases/year). Outcomes assessed included postoperative complications, pouch failure, and QoL using the Cleveland Global Quality of Life (CGQL) and modified Oresland Score. Logistic and linear regression analyses were used to identify risk factors for pouch failure and QoL determinants, respectively. Of 296 patients included, pouches were constructed in 172 (58.1%) as a two-staged and in the remaining patients as a three-staged procedure. The high-volume center had higher rates of biologic (45.1% versus 16%) and steroid use (63.9% versus 22.1%). The overall pouch failure rate was 4.7% at the end of follow-up of 66.1 months. Independent risk factors for pouch failure included pelvic sepsis (OR = 47.47, P = 0.002), biologic use (OR = 13.45, P = 0.033), chronic pouchitis (OR = 14.31, P = 0.013), postoperative blood transfusion (OR = 7.04, P = 0.048), and low annual case volume (OR = 30.86, P = 0.047). CGQL and Oresland scores averaged 0.77 ± 0.1 and 6.3 ± 1.1, respectively. Factors negatively impacting QoL included two-staged procedures, small bowel obstruction, venous thromboembolism, chronic pouchitis, increased frequency of bowel movements, and low annual case volume. IPAA surgery in UC patients in Türkiye demonstrates acceptable rates of complications and pouch failure, with high patient satisfaction in terms of QoL and functional outcomes. Optimizing long-term results requires enhanced surgical expertise and coordinated multidisciplinary management strategies.

EGS SO12 - A District General Hospital experience for setting up a "Hot Gallbladder" pathwayBackground

Abstract Background This project details a quality improvement initiative at Chesterfield Royal Hospital (CRH) to establish a “Hot Gallbladder” pathway (HGP) amidst immense NHS pressures. Before this service, CRH performed emergency cholecystectomies solely in an NCEPOD emergency theatre shared with other specialities, resulting in low case volumes, unpredictability, long patient waiting times with extended inpatient stays. The new service now dedicates two half-day lists per week to suitable patients admitted acutely and managed by five dedicated surgeons. Method This quality improvement project involves two separate yearly retrospective audits analysing patients who underwent gallbladder removal through the HGP in 2022 and 2023 at CRH. The primary objective was to assess the HGP's efficacy in terms of the number of cases performed and list completion (2 cases per half-day list). The secondary objective evaluatedadherence to the HGP protocol, appropriate patient selection, indications, and completion of adequate pre-operative investigations. The final objective assessed the HGP's safety by comparing incidence of complications and length of stay with patients undergoing cholecystectomy on the emergency NCEPOD list. Results 268 patients had gallbladder removal through the HGP and 84 cases in the emergencyNCEPOD theatre. The median age was 51, with a 3:1 female-to-male ratio. 75% of patients were managed through surgical ambulatory care. The HGP saw a 30% increase in cases and list completion rates rose from 41% to 61% in one year. NCEPOD emergency theatre usage reduced to 37%. All patients had appropriate indications and pre-operative investigations. 70% of cholecystitis patients were operated within 7 days. The HGP had a lower complication rate (6.2%) compared to emergencies (8%) and shorter post-operative stays (2 days vs 2.5 days). Conclusion This project demonstrates the benefits of establishing a HGP in a DGH. Inpatient stays were significantly reduced as 75% of patients were managed through the ambulatory carepathway. This led to financial benefits and greater patient satisfaction. Timely operations by dedicated surgeons resulted in a lower complication rate and shorter length of stay. The pathway increased the number of cases performed. The reduction in emergency theatre cases allowed better care for patients requiring emergency theatre access.

The Barriers to Cardiothoracic Surgery Training in Nigeria: Key Insights From Trainees.

Aim Cardiothoracic surgery has the potential to improve care in resource-deprived countries like Nigeria. This study analyzes the barriers to training in cardiothoracic surgery and gaps in the existing curriculum from a cardiothoracic surgery trainee perspective. Methods An online nationwide mixed-method cross-sectional survey was conducted. The participants were from a pool of senior residents in cardiothoracic surgery. A five-point Likert scale was utilized to rate and evaluate their training experiences. The motivations for choosing cardiothoracic surgery, gaps in the training curriculum, perceived barriers, and facilitators in their training programs were also assessed. The survey included closed and open-ended questions to capture quantitative data and qualitative insights. Thequantitative data were analyzed using SPSS21 (Armonk, NY: IBM Corp), while the qualitative data were analyzed using MAXQDA 24 (Berlin, Germany: VERBI Software). Results Sixteen senior cardiothoracic surgery residents completed the survey. Thematic grouping identified several key barriers, such as low case volume, lack of infrastructure and equipment, and reduced trainee autonomy during cases. The significant deficiencies in the existing curriculum are the absence of clear minimum competencies, lack of local and international collaboration, and robust cardiac training. In low-resource settings like Nigeria, government participation and improved funding, increased collaboration between local and international programs, and establishment of regional centers may offer solutions and successful implementation of cardiothoracic surgery training and improve access to surgical care. Conclusion Cardiothoracic trainees are highly interested in their training despite several barriers. Increased funding, collaboration, and infrastructure development will help improve the training experience.

Predictors of prolonged length of stay after elective carotid revascularization

ObjectivePostoperative day-one discharge is used as a quality-of-care indicator after carotid revascularization. This study identifies predictors of prolonged length of stay (pLOS), defined as a postprocedural LOS of >1 day, after elective carotid revascularization. MethodsPatients undergoing carotid endarterectomy (CEA), transcarotid artery revascularization (TCAR), and transfemoral carotid artery stenting (TFCAS) in the Vascular Quality Initiative between 2016 and 2022 were included in this analysis. Multivariable logistic regression analysis was used to identify predictors of pLOS, defined as a postprocedural LOS of >1 day, after each procedure. ResultsA total of 118,625 elective cases were included. pLOS was observed in nearly 23.2% of patients undergoing carotid revascularization. Major adverse events, including neurological, cardiac, infectious, and bleeding complications, occurred in 5.2% of patients and were the most significant contributor to pLOS after the three procedures. Age, female sex, non-White race, insurance status, high comorbidity index, prior ipsilateral CEA, non-ambulatory status, symptomatic presentation, surgeries occurring on Friday, and postoperative hypo- or hypertension were significantly associated with pLOS across all three procedures. For CEA, additional predictors included contralateral carotid artery occlusion, preoperative use of dual antiplatelets and anticoagulation, low physician volume (<11 cases/year), and drain use. For TCAR, preoperative anticoagulation use, low physician case volume (<6 cases/year), no protamine use, and post-stent dilatation intraoperatively were associated with pLOS. One-year analysis showed a significant association between pLOS and increased mortality for all three procedures; CEA (hazard ratio [HR],1.64; 95% confidence interval [CI], 1.49-1.82), TCAR (HR,1.56; 95% CI, 1.35-1.80), and TFCAS (HR, 1.33; 95%CI, 1.08-1.64) (all P < .05). ConclusionsA postoperative LOS of more than 1 day is not uncommon after carotid revascularization. Procedure-related complications are the most common drivers of pLOS. Identifying patients who are risk for pLOS highlights quality improvement strategies that can optimize short and 1-year outcomes of patients undergoing carotid revascularization.

Survey-based Study to Assess the Self-perceived Competency in and Knowledge about Reconstructive Microsurgery among Young Plastic Surgeons

Objective: Microvascular free tissue transfer has become a preferred reconstructive technique for managing complex wounds and defects. The aim of this questionnaire-based study was to assess self-perceived competency in and knowledge about reconstructive microsurgery among plastic surgeons who graduated from the Faculty of Medicine Siriraj Hospital, Mahidol University during 2015-2019. Materials and Methods: Questionnaire was sent by email elicited information about the amount of microsurgery performed in practice, types of microsurgeries performed, reconstructive methods, types of flaps used, and respondent’s opinion about the microsurgery course attended during residency/fellowship training. Results: The total response rate was 87.5%. Almost all respondents work in a government hospital (90.4%), and responses came from all regions of Thailand. Thirty-eight percent of respondents reported no microsurgery cases, and the majority of those who did perform microsurgery did so less than 20 times/year. Hand reconstruction was the most common type of microsurgical procedure. The factors that negatively influence microsurgery in clinical practice include insufficiency of resources and personnel (29.1%), excessive workload (27.3%), and long operative time (23.6%). Suggestions for improvement of the microsurgical training course include having a good objective method for assessing microsurgical practices (27.7%), increasing the volume of practice on animal model (25.5%), and an appropriate number of microsurgery cases to gain necessary experience (25.5%). Conclusion: Reconstructive microsurgery was found to be a challenging procedure for many junior-level plastic surgeons. A low volume of cases limits a surgeon’s ability to develop needed skills. Important improvements in the microsurgery training course were also recommended.

113 The Effect of Civilian Purchased Care on Military Neurosurgery Wartime Readiness

INTRODUCTION: The current landscape of military neurosurgery reflects the relative peacetime for the US-World relationship - a problem of intrinsically low case volume compounded by patients being deferred away from Military Treatment Facilities (MTFs). TRICARE is the healthcare program of the US Department of Defense Military Health Care System, in which ‘Purchased Care’ or civilian based health care, is used to supplement healthcare needs when services are not readily available to TRICARE beneficiaries. Within military neurosurgery, case volume and complexity continue to be diverted via purchased case pathways, greatly affecting wartime readiness. Neurosurgery wartime readiness can be measured through the Knowledge, Skills and Abilities (KSA) metric based on case complexity and volume. METHODS: We analyzed case counts and KSA values of active-duty military neurosurgery capable MTFs and purchased care counterparts using the CarePoint Access portal. Residents, civilian contractors, and retirees were excluded. RESULTS: In 2022, the KSA total for 16 MTFs was 139005, a result of 2286 cases and 47 surgeons. The average KSA/surgeon/month was 393.8, extrapolating to 4725.5/surgeon/year - 59% of the KSA goal of 8000/surgeon/year. The purchased care KSA of 10 MTFs totaled 301535 in 2022 from 7324 cases. Purchased care out-performed MTF case volume by over 300%. Recovering full purchased care volume would increase the individual MTF neurosurgeon KSA by 135%. CONCLUSIONS: The military neurosurgical community cannot maintain wartime readiness as defined by the KSA metric with current trends in military neurosurgery case volume and high incidence of purchased care. The solution lies in either recovering purchased care patients or expanding military-civilian partnerships to base military neurosurgeons at local academic hospitals and trauma centers.

Procedure-specific simulation for vaginal surgery training: Arandomized controlled trial.

Vaginal surgery has a superior outcome profile compared with other surgical routes, yet skills are declining because of low case volumes. Graduating residents' confidence and preparedness for vaginal surgery has plummeted in the past decade. The objective of the present study was to investigate whether procedure-specific simulation skills, vs usual training, result in improved operative competence. We completed a randomized controlled trial of didactic and procedural training via low fidelity vaginal surgery models for anterior repair, posterior repair (PR), vaginal hysterectomy (VH), recruiting novice gynecology residents at three academic centers. We evaluated performance via global rating scale (GRS) in the real operating room and for corresponding procedures by attending surgeon blinded to group. Prespecified secondary outcomes included procedural steps knowledge, overall performance, satisfaction, self-confidence and intraoperative parameters. A priori sample size estimated 50 residents (20% absolute difference in GRS score, 25% SD, 80% power, alpha 0.05). gov: Registration no. NCT05887570. We randomized 83 residents to intervention or control and 55 completed the trial (2011-23). Baseline characteristics were similar, except for more fourth-year control residents. After adjustment of confounders (age, level, baseline knowledge), GRS scores showed significant differences overall (mean difference 8.2; 95% confidence interval [CI]: 0.2-16.1; p = 0.044) and for VH (mean difference 12.0; 95% CI: 1.8-22.3; p = 0.02). The intervention group had significantly higher procedural steps knowledge and self-confidence for VH and/or PR (p < 0.05, adjusted analysis). Estimated blood loss, operative time and complications were similar between groups. Compared to usual training, procedure-specific didactic and low fidelity simulation modules for vaginal surgery resulted in significant improvements in operative performance and several other skill parameters.

Hemifacial spasm: a neurosurgical perspective.

Hemifacial spasm (HFS) causes both physical and psychological disabilities that significantly impact quality of life. Medical management with serial botulinum toxin injections provides transient spasm relief and is widely reported as highly effective, as compared to no treatment. While there is an excellent potential for disease cure with microvascular decompression (MVD) surgery, utilization rates remain very low in North America (approximately 10%) and many patients are not adequately informed of this surgical option. Although the majority of MVD neurosurgeons maintain a low annual case volume, excellent safety and success rates can be achieved with attention to technical nuances and anatomical appreciation of the target facial root exit zone. Attention to better informing patients and optimizing surgical outcomes should lead to a greater role for neurosurgery in the treatment and cure of HFS.

Variation in hospital performances after colorectal cancer surgery: A case-mix adjusted Dutch population based study

BackgroundThis study aimed to investigate hospital variability in postoperative mortality and anastomotic leakage (AL) after colorectal cancer surgery, as well as the association with hospital volume and teaching status. Materials and methodsThis nationwide population based study derived data from CRC patients who underwent a surgical resection with primary anastomosis from the Netherlands Cancer Registry between 2015 and 2020. Primary outcomes were 90-day mortality and AL for colon cancer (CC) patients, and AL for rectal cancer (RC) patients. Logistic regression modelling was used to evaluate the association between case-mix factors and hospital volume. Variability in outcomes between hospitals was analysed with Poisson regression. ResultsThis study included 44,101 CRC patients, comprising 35,164 CC patients, and 8937 RC patients. In the CC cohort, the unadjusted rates of AL ranged from 2.6 % to 14.4 %, and the unadjusted 90-day mortality rates ranged from 0.0 % to 6.7 %. In the RC cohort, the unadjusted rates of AL ranged from 0.0 % to 28.6 %. After case-mix adjustment, two hospitals performed significantly worse than expected regarding 90-day mortality in the CC cohort, and in both CC and RC cohorts, significant outliers were observed concerning AL. Amongst CC patients, low case volume (OR 1.26 95%CI 1.08–1.46) was significantly associated with AL. ConclusionStatistically significant variations in hospital performance were observed among Dutch hospitals after CRC surgery, but this effect could not be entirely attributed to hospitals’ teaching status. Nevertheless, concentrating care has the potential to improve outcomes by enhancing individual surgical performance and optimizing care pathways.

Factors Associated with Stereotactic Radiation Plan Revision in Prospective Peer Review.

Stereotactic radiotherapy (SR) is highly effective but has risks for serious toxicity. We sought to identify risk factors for SR plans requiring revision in a comprehensive, prospective peer review program conducted across a network of affiliated radiation centers. We hypothesized that increased physician experience and SR case volume would be associated with lower rates of SR plan revision. Weekly peer review rounds were conducted to review SR cases for image fusion, contours, plan, and dose constraints, all prior to start of radiation. Cases recommended for revision were recorded and tracked prospectively. Factors potentially associated with case revision including body site, SR type, physician experience, and physician case load were assessed for significance using univariate and multivariable logistic regression. From March 2019 to January 2023, 1,015 SR cases were prospectively reviewed, including 312 brain stereotactic radiosurgery (SRS), 190 multi-fraction brain SRS (fSRS), and 513 stereotactic body radiotherapy (SBRT). Revision was recommended in 177 cases (17%). The yearly revision rate was 21% in 2019, 16% in 2020, 17% in 2021, and 18% in 2022. There were 13 individual treating physicians with a median of 5 years' experience (range: 2-18 years), measured at the time of each SR case review. Physicians were categorized as junior (< = 2 years of experience), mid-career (3-9 years), or senior (> = 10 years). The physician's SR case volume in the preceding 3 months (median 25 cases) was dichotomized as low volume (< = 25) or high volume (>25). Logistic regression results are shown in Table 1. Statistical significance was determined by p <0.05. SR plans utilizing SRS (as opposed to SBRT) and treated by physicians with high case volume had lower revision rates. Junior attendings had higher revision rates. These data imply a high value to peer review for junior attendings and for those with low SR case volume. Adequate case volume may be a critical factor for safe delivery of SR, analogous to surgical literature. Annual revision rates in the program remained stable over time, demonstrating the ongoing importance of an effective peer review program for SR.

Impact of Hospital Case Volume on Uterine Sarcoma Prognosis: SARCUT Study Subanalysis.

High-complexity and low-prevalence procedures benefit from treatment by referral centers. The volume of cases necessary to maintain high training in the treatment of gynecologic sarcoma is currently unknown. This study aimed to determine differences in survival and recurrence as a function of the volume of patients treated per center. The multicentric cross-sectional SARComa of the Uterus (SARCUT) study retrospectively collected cases of uterine sarcomas from 44 centers in Europe from January 2001 to December 2007. The survival of patients treated in high case-volume (HighCV) centers was compared with the survival of patients treated in low case-volume (LowCV) centers. The study enrolled 966 patients: 753 in the LowCV group and 213 in the HighCV. Overall survival (OS) was 117 months, and cancer-specific survival (CSS) was 126 months. The difference was significant (respectively p = 0.0003 and 0.0004, log rank). After adjustment for other confounding factors, the remaining significant factors were age (hazard ratio [HR], 1.04; 95% confidence interval [CI], 1.03-1.05), histology (HR, 1.19; 95% CI, 1.06-1.34), extrauterine involvement (HR, 1.61; 95% CI, 1.24-2.10) and persistent disease after treatment (HR, 3.22; 95% CI, 2.49-4.18). The cytoreduction performed was significantly associated with the CSS and OS in both groups. The log rank for surgical cytoreduction was a p value lower than 0.0001 for OS, lower than 0.0001 for the LowCV centers, and 0.0032 for the HighCV centers. The prognosis for patients with uterine sarcoma is directly related to complete tumor cytoreduction, histologic type, and FIGO stage, with significant differences between low and high case-volume centers. Patients with uterine sarcomas should be centralized in HighCV centers to improve their oncologic outcomes.

A Multi-Hospital Survey of Current Practices for Supporting Recovery From Sepsis.

Electronic survey assessing the use of best practices for recovery from COVID-related and non-COVID-related sepsis. Questions included four-point Likert responses of "never" to "always/nearly always." Twenty-six veterans affairs hospitals with the highest (n = 13) and lowest (n = 13) risk-adjusted 90-day sepsis survival. Inpatient and outpatient clinician leaders. None. For each domain, we calculated the proportion of "always/nearly always" responses and mean Likert scores. We assessed for differences by hospital survival, COVID versus non-COVID sepsis, and sepsis case volume. Across eight domains of care, the proportion "always/nearly always" responses ranged from: 80.7% (social support) and 69.8% (medication management) to 22.5% (physical recovery and adaptation) and 0.0% (emotional support). Higher-survival hospitals more often performed screening for new symptoms/limitations (49.2% vs 35.1% "always/nearly always," p = 0.02) compared with lower-survival hospitals. There was no difference in "always/nearly always" responses for COVID-related versus non-COVID-related sepsis, but small differences in mean Likert score in four domains: care coordination (3.34 vs 3.48, p = 0.01), medication management (3.59 vs 3.65, p = 0.04), screening for new symptoms/limitations (3.13 vs 3.20, p = 0.02), and anticipatory guidance and education (2.97 vs 2.84, p < 0.001). Lower case volume hospitals more often performed care coordination (72.7% vs 43.8% "always/nearly always," p = 0.02), screening for new symptoms/limitations (60.6% vs 35.8%, p < 0.001), and social support (100% vs 74.2%, p = 0.01). Our findings show variable adoption of practices for sepsis recovery. Future work is needed to understand why some practice domains are employed more frequently than others, and how to facilitate practice implementation, particularly within rarely adopted domains such as emotional support.

Consensus and Equipose in the Management of Military Trainee Femoral Neck Stress Fractures: A Survey of Military Surgeons.

Femoral neck stress fractures (FNSFs) are a unique injury pattern not commonly treated in the civilian trauma population; however, it is particularly high with military trainees engaged in basic combat training. To date, no study has surveyed a population of military orthopedic surgeons on treatment preferences for military service members (SMs) with FNSF. We aim to evaluate the extent of clinical equipoise that exists in the management of these injuries, hypothesizing that there would be consensus in the factors dictating surgical and non-surgical intervention for FNSF. A 27-question survey was created and sent to U.S. military orthopedic surgeon members of the Society of Military Orthopaedic Surgeons. The survey was designed in order to gather the experience among surgeons in treating FNSF and identifying variables that play a role in the treatment algorithm for these patients. In addition, seven detailed, clinical vignettes were presented to further inquire on surgeon treatment preferences. Binomial distribution analysis was used to evaluate for common trends within the surgeon's treatment preferences. Seventy orthopedic surgeons completed the survey, the majority of whom were on active duty status in the U.S. Military (82.86%) and having under 5 years of experience (61.43%). Majority of surgeons elected for a multiple screw construct (92.86%), however the orientation of the multiple screws was dependent on whether the fracture was open or closed. Management for compression-sided FNSF involving ≥50% of the femoral neck width, tension-sided FNSF, and stress fractures demonstrating fracture line progression had consensus for operative management. Respondents agreed upon prophylactic fixation of the contralateral hip if the following factors were involved: Complete fracture (98.57%), compression-sided fracture line >75% (88.57%), compression-sided fracture line >50-75% with hip effusion (88.57%), contralateral tension-sided fracture (87.14%), and compression-sided fracture line >50-75% (84.29%). An FNSF < 50% on the contralateral femoral neck or a hip effusion was indeterminate in surgeons indicating need for prophylactic fixation. Majority of surgeons (77.1%) utilized restricted toe-touch weight-bearing for postoperative mobility restrictions. Consensus exists for surgical and non-surgical management of FNSF by U.S. military orthopedic surgeons, despite the preponderance of surgeons reporting a low annual volume of FNSF cases treated. However, there are certain aspects in the operative and non-operative management of FNSF that are unanimously adhered to. Specifically, our results demonstrate that there is no clear indication on the management of FNSF when an associated hip effusion is involved. Additionally, the indications for surgically treating contralateral FNSF are unclear. IV.

Meniscal repair failure following concurrent primary anterior cruciate ligament reconstruction: results from the New Zealand ACL Registry

PurposeThis study aimed to identify the risk factors for meniscal repair failure following concurrent primary anterior cruciate ligament (ACL) reconstruction.MethodsProspective data recorded by the New Zealand ACL Registry and the Accident Compensation Corporation were reviewed. Meniscal repairs performed during concurrent primary ACL reconstruction were included. Repair failure was defined as a subsequent reoperation involving meniscectomy of the repaired meniscus. Multivariate survival analysis was performed to identify the risk factors for failure.ResultsA total of 3,024 meniscal repairs were analysed with an overall failure rate of 6.6% (n = 201) at a mean follow-up of 2.9 years (SD 1.5). The risk of medial meniscal repair failure was higher with hamstring tendon autografts (adjusted HR [aHR] = 2.20, 95% CI 1.36–3.56, p = 0.001), patients aged 21–30 years (aHR = 1.60, 95% CI 1.30–2.48, p = 0.037) and in patients with cartilage injury in the medial compartment (aHR = 1.75, 95% CI 1.23–2.48, p = 0.002). The risk of lateral meniscal repair failure was higher in patients aged ≤ 20 years (aHR = 2.79, 95% CI 1.17–6.67, p = 0.021), when the procedure was performed by a low case volume surgeon (aHR = 1.84, 95% CI 1.08–3.13, p = 0.026) and when a transtibial technique was used to drill the femoral graft tunnel (aHR = 2.30, 95% CI 1.03–5.15, p = 0.042).ConclusionThe use of a hamstring tendon autograft, younger age and the presence of medial compartment cartilage injury are risk factors for medial meniscal repair failure, whereas younger age, low surgeon volume and a transtibial drilling technique are risk factors for lateral meniscal repair failure.Level of evidenceLevel II.

Provision of revision knee arthroplasty services across Scotland: A national audit

BackgroundThere is increasing evidence that both low surgeon and centre case volumes are associated with poorer outcomes following Revision Knee Arthroplasty (rTKA). Given the unique challenges faced in Scotland relating to funding and geography, understanding details on the complexity of cases is required to guide development of future rTKA services. MethodsUtilising the Scottish Collaborative Orthopaedic Trainee Research Network (SCOTnet) a retrospective review of all Scottish 2019 rTKA cases was undertaken. Regional leads co-ordinated local data collection using individual case note review. The number of cases performed by regions, hospitals and individual surgeons were identified. Patient demographics and case complexity (Revision Knee Complexity Classification [RKCC]) were also collected. Results were compared against current standards. Results17 units performed rTKA, delivered by 77 surgeons. A total of 506 cases were included. The mean age was 69 years (46% male). Revision for infection accounted for 147/506 (29%) cases. Extensor compromise was present in 35/506 (7%) and 11/506 (2%) required soft tissue reconstruction. According to the RKCC − 214/503 (43%) were classified as R1 (Less complex cases), 228/503 (45%) R2 (complex cases), and 61/503 (12%) R3 (most complex / salvage cases).5/17 (29%) units met current national guidelines for case volume/year, with only 11/77 (14%) surgeons meeting recommended individual case volumes. 37/77 (48%) surgeons performed ≤ 2 cases per year. ConclusionsMost individual centre volumes could be increased by re-organising services or locations providing rTKA within a region. This should provide better access to Multidisciplinary Team (MDT) involvement. We recorded a significant number of very low volume surgeons (≤2 year) that is contradictory to current evidence-based practice.

Thoracoscopic Resection of Pulmonary Lesions in Israel: The Mentorship Approach.

Most congenital pulmonary airway malformations (CPAMs) are detected antenatally. The majority of newborns are asymptomatic. Patients are prone to subsequent respiratory complications and to a lesser extent malignant transformation remains concerning. In Israel, until 2013, pediatric surgeries were performed by thoracotomy. To minimize its morbidity, we introduced thoracoscopy using a mentorship approach. We present our experience with thoracoscopic resections coordinated by the mentorship of a pediatric worldwide leader in his field and compare our results with resections performed by thoracotomy. A retrospective review of records of children operated between 2013 and 2020 was conducted. Data were compared using t-test for quantitative variables. Fifty patients were operated by thoracoscopy with a median age of 4 years, a thoracoscopic lobectomy performed in 68%. There was no conversion with a median length of stay (LOS) of 3½ days. Thirty patients were operated by thoracotomy by a thoracic surgeon with a median age of 3.5 years. A lobectomy was performed in 87% with a median LOS of 7 days. Thoracoscopic lobectomy is a technically demanding procedure with a long learning curve, strongly related to the low volume of cases. The role of a mentorship program in acquiring those surgical skills is crucial through standardization of the technique applied and supervised by the mentor. Early thoracoscopy for congenital pulmonary lesions at an early age can be achieved with a low conversion rate and minimal complications creating a change in the paradigm of practice when considering surgery for CPAM in Israel.

Outcomes in pediatric total thyroidectomy following implementation of a two-surgeon operative approach.

Pediatric total thyroidectomy is an uncommon procedure. Higher rates of complication are reported for pediatric patients compared to adults which may be secondary to lower case volume. In this study, we examine the effect of a two-surgeon operative approach on outcomes in pediatric total thyroidectomy. A retrospective review of 152 pediatric patients undergoing total thyroidectomy at a single institution was performed. A control group of 89 patients, with one attending surgeon present, was compared to a cohort of 63 pediatric patients who underwent total thyroidectomy with two attendings present. Primary outcomes included rates of permanent hypoparathyroidism and recurrent laryngeal nerve (RLN) injury. The secondary outcomes included postoperative hematoma, length of stay (LOS), LOS greater than 1 day (>1d) secondary to hypocalcemia, and readmissions secondary to hypocalcemia. One RLN injury was documented in each cohort and no postoperative hematomas were documented. Rates of permanent hypoparathyroidism decreased in the two-surgeon cohort (11.48%) when compared to the control group (15.73%) but was not significant. There was a statistically significant decrease in LOS >1d secondary to hypocalcemia in the two-surgeon cohort. LOS >1d attributable to hypocalcemia was seen in 38.2% in the control group versus 15.87% in the 2-surgeon cohort (p=0.003). Implementation of a two-surgeon operative approach was shown to lead to a significant decrease in length of stay >1d attributable to hypocalcemia. However, this change was in the setting of multidisciplinary thyroid team and postoperative protocol implementation, and concentration of surgeons performing the operation. Further studies are needed to investigate the effects of the two-surgeon operative approach further.

Association of Pulmonary Artery Pressure Change With Post-Lung Transplantation Survival: Retrospective Analysis of China Registry.

Extracorporeal membrane oxygenation (ECMO) has been used as intraoperative hemodynamic support in patients with end-stage lung diseases and pulmonary hypertension undergoing lung transplantation (LT). The aim of this study was to identify the association of pulmonary artery pressure change during ECMO and post-LT survival. The study investigators collected and analyzed the data from Chinese Lung Transplantation Registry. Patients who have severe pulmonary hypertension with intraoperative ECMO support were enrolled. Post-LT mortality and morbidity were further collected and compared. A total of 208 recipients were included in the study, during which 53 deaths occurred post-LT. All the patients had severe pulmonary hypertension and were supported by intraoperative ECMO. Using eXtreme Gradient Boosting, or XGboost, model method, 20 variables were selected and ranked. Changes of mean pulmonary artery pressure at the time of ECMO support and ECMO wean-off (ΔmPAP) were related to post-LT survival, after adjusting for potential confounders (recipient age, New York Heart Association functional class status before LT, body mass index, pre-LT hypertension, pre-LT steroids, and pre-LT ECMO bridging). A nonlinear relationship was detected between ΔmPAP and post-LT survival, which had an inflection point of 35mmHg. Recipients with ΔmPAP ≦35 mmHg had higher mortality rate calculated through the Kaplan-Meier estimator (P = 0.041). Interaction analysis showed that recipients admitted in LT center with high case volume (≥50 cases/year) and ΔmPAP >35mmHg had better long-term survival. The trend was reversed in recipients who were admitted in LT center with low case volume (<50 cases/year). The relationship between ΔmPAP and post-LT survival was nonlinear. Optimal perioperative ECMO management strategy with experienced team is further warranted.

Robotic vs Open Lateral Hernia Repair: A Multicenter Propensity Score–Matched Analysis of 30-day Outcomes

INTRODUCTION: Lateral ventral hernia repair (LVHR) is a challenging surgical dilemma due to location, different anatomical considerations, and low volume of cases. Our study aims to compare and assess early 30-day outcomes between open LVHR (oLVHR) and robotic-assisted LVHR (rLVHR) approach. METHODS: A retrospective review of prospectively collected data from the Abdominal Core Health Quality Collaborative (ACHQC) was performed to include all adult patients who underwent elective LVHR based on European Hernia Society classification. A 1:1 propensity score match (PSM) analysis was conducted for balanced groups. Univariate analysis was performed to compare the 2 groups (oLVHR and rLVHR) across preoperative, intraoperative, and postoperative timeframes. RESULTS: ACHQC database identified 2,569 LVHR patients. A PSM analysis stratified 665 patients to each oLVHR and rLVHR group. Median length of stay is higher in the oLVHR 3 days (interquartile range [IQR] 1 to 5) vs rLVHR 1 day (IQR 0 to 2; p < 0.001). The surgical site infection rate was higher in the oLVHR 3% vs 1% (p = 0.006). Surgical site occurrence (SSO) such as wound cellulitis was also found at a higher rate in the oLVHR 21% vs the rLVHR 0% (p < 0.001). Seroma rate was higher in the rLVHR (6.5% vs 5.6%, p < 0.001). oLVHR had 18% postoperative complication compared with rLVHR 12% (p < 0.001). There was no difference in quality-of-life measures (HerQLes and PROMIS pain 3a surveys) between groups at 30 days and 1 year. CONCLUSION: Robotic-assisted LVHR is safe with decreased length of stay and SSO compared with the conventional open approach. However, it does carry a higher seroma rate with no clinical significance.

Which surgeon demographic factors influence postoperative complication rates after total knee arthroplasty at U.S. News and World Report top-ranked orthopedic hospitals?

IntroductionComplication rates are used to evaluate surgical quality-of-care and determine health care reimbursements. The U.S. News & World Report (USNWR) hospital rankings are a highly-referenced source for top hospitals. The objective of this study was to determine the surgeon demographics of those practicing at USNWR Top Ranked Orthopedic Hospitals and if any influence complication rates after total knee arthroplasty (TKA).MethodsThe 2009–2013 USNWR ‘Orthopedic’ hospital rankings were identified. A database of TKA surgeons with postoperative complication rates was compiled utilizing publicly available data from the Centers for Medicare and Medicaid Services (2009–2013). Using an internet search algorithm, demographic data were collected for each surgeon and consisted of: fellowship training, years in practice, age, gender, practice setting, medical degree type, residency reputation, case volume, and geographic region of hospital. Logistic regression was used to assess the relationship between surgeon demographics and postoperative complication rates. A P value of < 0.008 was considered significant.ResultsFrom 2009 to 2013, 660 orthopedic surgeons performed TKA at 80 different USNWR Top-Ranked Hospitals. Mean TKA case volume was 172 (Range, 20–1323) and age of surgeon was 50.8 (Range, 32–77). A total of 372 (56.8%) completed an orthopedic surgery fellowship. Mean adjusted 30-day complication rate was 2.24% (Range, 1.2–4.5%). After adjustment, factors associated with increased complication rates were surgeon age ≤ 42 (OR 3.15; P = 0.007) and lower case volume (≤ 100 cases) (OR 2.52; P < 0.0001). Gender, hospital geographic region, completion of a fellowship, medical degree type, and residency reputation were not significant factors.DiscussionComplication rates of total knee arthroplasty surgeons may be utilized by patients and hospitals to gauge quality of care. Certain surgeon factors may influence complication rates of surgeons performing TKA at USNWR Top Ranked Orthopedic Hospitals.Study TypeLevel III, retrospective observational study.