Low Surgical Volume Research Articles

IGFL2 expression and surgical volume: Independent predictors of survival in gastric cancer.

This study aimed to assess the impact of surgeons' annual volume and insulin-like growth factor-like family member 2 (IGFL2) expression on gastric cancer prognosis. Clinicopathological data from 475 patients who underwent D2 lymph node dissection were analyzed. IGFL2 expression was evaluated using immunohistochemistry. Patients were divided into training (70%) and validation (30%) groups. Univariate and multivariate Cox regression identified risk factors for overall survival (OS) and disease-free survival (DFS), leading to a clinical prediction model. Model performance was evaluated using C-index. High IGFL2 expression and low surgical volume independently predicted poorer OS and DFS (hazard ratio = 2.13, 2.17, all P < .01). Surgeons performing >26 cases annually had higher OS and DFS (hazard ratio = 1.65, 1.58, all P < .01). Nomograms integrating surgical volume, IGFL2 expression, grade, TNM staging, and carcinoembryonic antigen showed superior predictive accuracy for OS and DFS compared to TNM alone, with robust C-indices and area under the curve values. Surgeons' annual volume and IGFL2 expression independently predict gastric cancer prognosis, emphasizing the need for specialized training and further research on IGFL2's molecular mechanisms to enhance patient outcomes.

Exploring barriers and enabling factors for surgical task sharing with physician assistants in Liberia: a qualitative pre-implementation study

ObjectivesThis study explores potential barriers and enabling factors that may influence the acceptance of implementation of a surgical task-sharing initiative targeting physician assistants (PAs) in Liberia.DesignA qualitative, pre-implementation study using...

Differential impacts of clinical, anatomical, and procedural factors on early and late mortality following open thoracoabdominal aortic repair: a retrospective observational study

BackgroundThe operative outcomes of thoracoabdominal aortic aneurysms (TAAAs) are challenged by high operative mortality and disabling complications. This study aimed to explore the baseline clinical, anatomical, and procedural risk factors that impact early and late outcomes following open repair of TAAAs.MethodsWe reviewed the medical records of 290 patients who underwent open repair of TAAAs between 1992 and 2020 at a tertiary referral center. Determinants of early mortality (within 30 days or in hospital) were analyzed using multivariable logistic regression models, while those of overall follow-up mortality were explored using multivariable Cox proportional hazards models and landmark analyses.ResultsThe rates of early mortality and spinal cord deficits were 13.1% and 11.0%, respectively, with Crawford extent II showing the highest rates. In the logistic regression models, older age (P < 0.001), high cardiopulmonary bypass (CPB) time (P < 0.001), and low surgical volume of the surgeon (P < 0.001) emerged as independent factors significantly associated with early mortality. During follow-up (median, 5.0 years; interquartile range, 1.1–7.6 years), 82 late deaths occurred (5.7%/patient-year). Cox proportional hazards models demonstrated that older age (P < 0.001) and low hemoglobin level (P = 0.032) were significant risk factors of overall mortality, while the landmark analyses revealed that the significant impacts of low surgical volume (P = 0.017), high CPB time (P = 0.002), and Crawford extent II (P = 0.017) on mortality only remained in the early postoperative period, without significant late impacts (all P > 0.05).ConclusionThere were differential temporal impacts of perioperative risk variables on mortality in open repair of TAAAs, with older age and low hemoglobin level having significant impacts throughout the postoperative period, and low surgical volume, high CPB time, and Crawford extent II having impacts in the early postoperative phase.

Surgeon Factors and Trends Associated With the Use of Subacromial Decompression at the Time of Rotator Cuff Repair

Subacromial decompression (SAD) has historically been described as an essential part of the surgical treatment of rotator cuff disorders. However, investigations throughout the 21st century have increasingly questioned the need for routine SAD during rotator cuff repair (RCR). Our purpose was to assess for changes in the incidence of SAD performed during RCR over a 12-year period. In addition, we aimed to characterize surgeon and practice factors associated with SAD use. Records from two large tertiary referral systems in the United States from 2010 to 2021 were reviewed. All cases of RCR with and without SAD were identified. The outcome of interest was the proportion of SAD performed during RCR across years and by surgeon. Surgeon-specific characteristics included institution, fellowship training, surgical volume, academic practice, and years in practice. Yearly trends were assessed using binomial logistic regression modeling, with a random effect accounting for surgeon-specific variability. During the study period, 37,165 RCR surgeries were performed by 104 surgeons. Of these cases, 71% underwent SAD during RCR. SAD use decreased by 11%. The multivariable model found that surgeons in academic practice, those with lower surgical volume, and those with increasing years in practice were significantly associated with increased odds of performing SAD. Surgeons with fellowship training were significantly more likely to use SAD over time, with the greatest odds of SAD noted for sports medicine surgeons (odds ratio= 3.04). Although SAD use during RCR appears to be decreasing, multiple surgeon and practice factors (years in practice, fellowship training, volume, and academic practice) are associated with a change in SAD use. These data suggest that early-career surgeons entering practice are likely driving the trend of declining SAD. Despite evidence suggesting limited clinical benefits, SAD remains commonly performed; future studies should endeavor to determine factors associated with practice changes among surgeons.

Relationship between patient safety indicator events and hospital location for inpatient hysterectomy.

Previous studies suggest surgical quality outcomes are similar between rural and urban hospitals, but data about gynecology in rural hospitals is sparse. This was a retrospective cohort study utilizing the National Inpatient Sample database from the Agency of Healthcare Research and Quality. Patients who underwent benign hysterectomy for non-prolapse indications between 2012-2016 were identified using ICD-9 and 10 codes. Patients were stratified into rural or urban non-teaching groups; urban teaching hospitals were the referent group. The primary outcome was the rate of patient safety indicator (PSI) events. PSI events were identified using ICD-9 and 10 codes. Statistical analysis was performed using analysis of variance and uni- and multivariate Poisson regressions. 154,810 patients met all inclusion criteria. The cumulative rate of PSI events was 11.9% at rural hospitals, 13.9% at urban non-teaching hospitals and 16.9% at urban teaching hospitals, P<0.001. The most common PSI events were postoperative metabolic derangement, hemorrhage, and accidental puncture. The rate of transfusion was highest in urban teaching hospitals (6.7%) and similar for rural (5.1%) and urban non-teaching hospitals (5.5%), P<0.001. The rate of genitourinary tract injury was between 1.4-1.6%, and similar across sites, P=0.89. After adjusting for confounders, the risk of PSI events was similar across locations. The risk of transfusion was lower at rural hospitals (aRR=0.84, 95% CI: 0.74-0.94). Hysterectomy performed at rural hospitals, typically thought of as having low surgical volume compared to urban hospitals, is associated with similar risk of PSI events and lower risk of transfusion.

Wound complication risk factors following open reduction and internal fixation of ankle fractures.

This study was designed to identify risk factors for wound complications including surgical site infection (SSI) and wound healing issues following open reduction and internal fixation (ORIF) of ankle fractures. A retrospective analysis of individuals with ankle fractures treated with ORIF was undertaken. Study subjects were divided into a wound complications (WC) group and a no wound complication (NWC) group. The WC group was further divided into an SSI group and wound healing issues group. Twenty-one potential risk factors associated with wound complications after ORIF were tracked. Uni- and multivariate binary logistical regression analyses were used to identify risk factors associated with wound complications, ISS and wound healing issues. In total, 613 individuals, who had undergone surgery for ankle fractures formed the study cohort. The incidence of postoperative wound complications was 10.3% (63 cases), including 5.2% of SSI (32 cases) and 5.1% of wound healing issues (31 cases). The independent risk factors for wound complications were age 65 years or older, preoperative serum albumin level below 35 g/L, peripheral neuropathy, open fracture, fewer than seven cases per year in surgical volume, and attending surgeon level. The independent risk factors for SSI were age 65 years or older, preoperative serum albumin level below 35 g/L, open fracture and fewer than seven cases per year in surgical volume. The independent risk factors for wound healing issues were preoperative serum albumin level below 35 g/L, peripheral neuropathy, open fracture and attending surgeon level. Herein we found both factors inherent to the injury and individual and those pertaining to the surgical team affected the frequency of wound complications after ORIF of ankle fractures. Specifically, advanced age and low surgical volume were associated with a greater risk of SSI. Peripheral neuropathy and the low expertise level on the part of the surgeon were associated with a greater risk of wound healing issues. Hypoproteinaemia and open fracture were both associated with a greater risk of both SSI and wound healing issues.

Increased 90-Day Readmissions and Complications Following Hip Arthroscopy in Centers With Low Surgical Volume in New York State

The aims of the study were to (1) classify surgical centers in New York State by volume of hip arthroscopies performed, (2) calculate rates of readmissions and complications by center volume, and (3) identify socioeconomic predictive factors for readmissions and complications following hip arthroscopy. Patients who underwent hip arthroscopy at New York State health care facilities from 2010 to 2020 were retrospectively identified using the New York Statewide Planning and Research Cooperative System (SPARCS) database. Hip arthroscopic procedures were identified using the following Current Procedural Terminology codes. Surgical center volumes were classified into 3 categories: low (<85th percentile), medium (85th-95th percentile), and high (>95th percentile). Incidence of readmissions and complications within 90 days was abstracted from SPARCS. Neighborhood socioeconomic status was quantified using the U.S. Area Deprivation Index. Multivariable logistic regression was used to determine whether center volume and other socioeconomic variables were independent predictors of outcomes. In total, 50,252 patients who underwent hip arthroscopy were identified in SPARCS from 2010 to 2020. Of these patients, 13,861 (27.6%) underwent surgery at low-volume centers, 11,757 (23.4%) at medium-volume centers, and 24,634 (49.0%) at high-volume centers. Minorities, publicly insured patients, and patients from lower socioeconomic status neighborhoods made up a larger proportion of cases seen by low-volume centers versus high-volume centers (P < .001). Patients in the low-volume group experienced significantly greater 90-day rates of readmissions (P < .001) and all-cause complications (P < .001) than the other groups. Furthermore, high-volume centers were independently associated with lower odds of readmission (odds ratio 0.57, P < .001) and all-cause complications (odds ratio 0.73, P < .001) versus low-volume centers. Low-volume surgical centers are associated with increased readmission and complication rates following hip arthroscopy, independent of other socioeconomic factors such as age, sex, race, insurance status, and neighborhood socioeconomic status. III, retrospective comparative prognostic trial.

Femur-First Technique for Mobile Bearing Unicompartmental Knee Arthroplasty Results in Decreased Implant Variability and Early Improvements in Function and Survivorship

BackgroundHigher failure rates of unicompartmental knee arthroplasty (UKA) are seen with lower surgical volume. Surgical techniques that introduce less variability improving implant positioning may lead to improved survivorship. A femur-first (FF) technique has been described, but survivorship data compared to traditional tibia-first (TF) technique are under-reported. We report the results of mobile-bearing UKA using the FF technique compared to the TF technique with emphasis on implant position and survivorship. MethodsA total of 430 UKAs were performed by a single surgeon between 2007 and 2020. After 2012, there were 141 consecutive UKAs performed with the FF technique which were compared with 147 consecutive UKAs prior. Mean follow-up was 6 years (range, 2 to 13 years), average age was 63 years (range, 23 to 92 years), and there were 132 women. Postoperative radiographs were reviewed to determine implant positioning. Survivorship analyses were performed using Kaplan-Meier curves. ResultsThe FF resulted in significantly thinner polyethylene (3.4 ± 0.7 mm versus 3.7 ± 0.9 mm) (P = .002) and 4 mm or less bearing thickness in 94% of cases. At 5 years, there was an early trend toward improved survivorship free from component revision (98% for the FF group and 94% for the TF [P = .35]). The FF cohort had higher Knee Society Functional scores at final follow-up (P < .001). ConclusionCompared to traditional TF technique, the FF was more bone-preserving and improved radiographic positioning. The FF technique is an alternative method for mobile-bearing UKA and was associated with an improvement in implant survivorship and function.

Impact of COVID on surgical case volume at military treatment facilities with surgical residencies

IntroductionThe Military Health System (MHS) is tasked with the dual mission of providing medical care to beneficiaries while ensuring medical readiness. MHS provides care through a combination of military treatment facilities (MTF) (“direct care”; DC) & off-base civilian facilities (“purchased care”; PC). Given recent concerns regarding low surgical volume at MTFs, we sought to evaluate COVID's impact on elective and non-elective case volume at MTFs with surgical residencies. MethodsRetrospective review of 2017–2021 M2 database was performed on Tricare beneficiaries who underwent bariatric surgery or major colorectal surgery in the DC or PC market at, or, surrounding MTFs with surgical residencies. Procedures were identified using ICD-10 procedure codes and Medicare severity-diagnosis related groups. A detailed analysis was then performed on changes in case volume in the DC and PC markets. Results5,698 bariatric and 5,517 major colorectal procedures were performed during the study period. There was an 84% vs 20% quarterly decrease in elective bariatric surgeries completed in the DC and PC markets from Q1 to Q2 2020. Pre to post-COVID (Q1 2017 – Q1 2020 vs Q3 2020 – Q4 2021) there was a decrease in the percentage of bariatric surgeries completed in the DC market (74.1% vs 55.0%, p = 0.001). Meanwhile, major colorectal surgery quarterly case volume remained unchanged in the DC (137 vs 125, p = 0.18) and PC (146 v 137, p = 0.13) markets, pre- and post-COVID. DiscussionBariatric surgical case volume at MTFs disproportionately decreased during COVID when compared to the PC market and major colorectal cases. Bariatric case volume has rebounded in PC markets surpassing pre-COVID levels while DC case volume remains depressed. Further attention is warranted regarding decreased elective surgical case volume at MTFs.

High-Volume Hospitals Have Lower Open Reduction Rates and Lower Cost of Care for Pediatric Supracondylar Humerus Fractures

Background: Open reduction and percutaneous pinning (ORPP) of pediatric supracondylar humerus (SCH) fractures is associated with increased morbidity compared to closed reduction. This investigation sought to assess variation in ORPP rates among U.S. children's hospitals by hospital treatment volume and ranking. Secondarily, we investigated costs associated with ORPP and closed reduction and percutaneous pinning (CRPP).Methods: The Pediatric Health Information System (PHIS), a database of U.S. children's hospitals, was queried for patients 3-10 years treated with ORPP or CRPP for closed SCH fractures from 2010-2014. Pediatric orthopaedic hospital rankings were collected from U.S. News and World Report. To account for differences in patient population, hospital ORPP rates were adjusted for patient characteristics. Analysis then assayed the effect of hospital treatment and ranking on cost of care and likelihood to treat with ORPP.Results: 28,100 patients were treated at 42 pediatric hospitals. 26,465 (94.2%) SCH fractures underwent CRPP and 1,635 (5.8%) underwent ORPP. Unadjusted ORPP rates varied from 1.9%-12.8%. Adjusted for patient characteristics, ORPP rates ranged from 4.2%–15.0%. Analysis demonstrated significant variation in cost and ORPP rates between hospitals (p<0.001). Patients treated at high-volume centers were less likely to undergo ORPP than patients at lower-volume centers (5.1% vs. 6.7%; Odds Ratio 0.70, 95% CI: 0.54-0.90). There was no difference in ORPP rates based on the USNWR ranking. Cost of care was also significantly lower at high-volume centers (p<0.001).Conclusions: At hospitals with low surgical volumes, children with SCH fractures are more likely to undergo ORPP and have a significantly higher cost of care.Level of Evidence: Therapeutic Level IIIKey Concepts•There is variability in operative pediatric supracondylar humerus (SCH) fracture care with some patients receiving less invasive closed reduction and percutaneous pinning (CRPP) and some receiving more morbid open reduction and percutaneous pinning (ORPP).•Patients treated at high-volume hospitals are 30% less likely to receive ORPP compared to patients treated at low-volume centers.•Cost of care was significantly less expensive at high-volume hospitals.

Discrepancies in survival after conversion to open in minimally invasive pancreatoduodenectomy

BackgroundThe extent by which conversion to open (CTO) during minimally invasive procedures for pancreatic cancer impact survival outcomes is not fully understood. MethodsThe 2010–2017 National Cancer Database identified 12,424 non-metastatic patients who underwent pancreatoduodenectomy for ductal adenocarcinoma. Patients were stratified into three cohorts: open (OPD), completed MIPD (cMIPD), and CTO. Subgroups were dichotomized by hospital MIPD volume. ResultsAcross the study period, 80.6% of patients underwent OPD, 19.4% MIPD, and 24% were CTO. Median overall survival was worse after CTO (21.8 months) than for OPD (23.6 months) or cMIPD (25.2 months) (p < 0.001). Although this effect persisted for <10 MIPD/year, CTO did comparably to OPD at hospitals performing ≥10MIPD/year (CTO = 26.8 months, OPD = 27.9 months; p = 0.128). Ninety-day mortality after CTO was worse at ≤ 10 MIPD/year hospitals (9.3% vs. 2.6%). ConclusionsShort and long-term survival is impacted by CTO after MIPD, especially at lower surgical volumes, stressing careful adoption while ascending the learning curve.

National Trends in Utilization of Neoadjuvant Radiation for Pancreatic Adenocarcinoma

<h3>Purpose/Objective(s)</h3> Neoadjuvant therapy (NAT) has been shown to improve clinical outcomes for patients (pts) with operable pancreatic adenocarcinoma (PDAC). The precise type of NAT used in the United States (US), such as chemotherapy alone or in sequence with external beam radiation therapy (RT), remains controversial. Our aim was to examine the use of neoadjuvant RT for pts who underwent pancreatectomy for PDAC in the US. <h3>Materials/Methods</h3> The National Cancer Database (NCDB) was queried for patients with localized PDAC who underwent pancreatectomy between 2009-2018. NAT was defined as receipt of chemotherapy and/or external beam RT prior to surgery at a dose 30-70 Gy, excluding palliative regimens. Center volumes were examined by surgical and RT cases/year. Comparisons and trends were made using the χ2 and Mann-Kendall tests. Logistic regression (LR) models were used to identify patient and institutional factors associated with receipt of neoadjuvant RT. <h3>Results</h3> A total 58,653 pts underwent pancreatectomy for PDAC and 13,223 (22.5%) received any NAT prior to surgery. Of these, 4,568 (7.8%) received RT; 4,453 (97.5%) of 4,568 received RT in combination with neoadjuvant chemotherapy and 115 (2.5%) of 4,568 received RT as the sole NAT. While the proportion of pts who received any NAT rose significantly from 13.5% in 2009-12 to 32.3% in 2016-18, the proportion of pts who received RT as a component of NAT rose only modestly from 6.8% in 2009-12 to 8.8% in 2016-18 (<i>p</i><0.001). Among the 4,568 pts who received neoadjuvant RT, administration of conventionally fractionated chemo-RT (25-28 fractions) declined from 62.4% in 2009-12 to 49.9% in 2016-18. Stereotactic body radiation therapy (SBRT) increased from 5.0% in 2009-12 to 25.9% in 2016-18 (<i>p</i><0.001). A total 598 unique centers treated the 4,568 pts who received neoadjuvant RT. The median pts treated annually per center was 3.2/year (IQR 6.9). Treating ≥7 pts/year qualified a center as being in the top tertile (67-100th percentile) for the use of neoadjuvant RT. In a multivariable LR model, pts with advanced age (OR 0.98, 95% CI 0.97-0.98), uninsured (0.64, 0.49-0.84), on Medicaid (0.74, 0.64-0.87), and treated at low surgical volume centers (0.80, 0.72-0.90) had decreased odds of receiving neoadjuvant RT. Pts treated in later years (2016-18: 1.57, 1.45-1.70) and with larger (cT3 or cT4) tumors (2.66, 2.49-2.84) had increased odds of receiving neoadjuvant RT. <h3>Conclusion</h3> Less than 10% of pts with operable PDAC received neoadjuvant RT over the last decade. The slight increase in the use of RT may have been due to the expanding role for surgery in patients with borderline and locally advanced PDAC. SBRT is gaining in popularity despite the absence of phase II/III trials confirming its safety/efficacy in the neoadjuvant setting. The routine use of neoadjuvant RT appears localized to a small number of high-volume academic centers, a finding that may change with the recent publication of the PREOPANC trial.

Impact of stereotactic body radiation therapy volume on surgical patient selection, short-term survival, and long-term survival in early-stage non–small cell lung cancer

ObjectivesStereotactic body radiation therapy (SBRT) is increasingly used to treat non–small cell lung cancer. The purpose of this study is to analyze relationships between facility SBRT utilization and surgical patient selection and survival after surgery. MethodsData on patients with TI/T2N0M0 lesions and treatment facility characteristics were abstracted from the National Cancer Database, 2008 to 2017. Facilities were stratified using an SBRT/surgery ratio previously associated with short-term survival benefit for patients treated surgically, and by a previously identified surgical volume threshold. Multiple regression analyses, Cox proportional-hazard regressions, and Kaplan–Meier log rank test were employed. ResultsIn total, 182,610 patients were included. Proportion of high SBRT:surgery ratio (≥17%) facilities increased from 118 (11.5%) to 558 (48.4%) over the study period. Patients undergoing surgery at high-SBRT facilities had comparable comorbidity scores and tumor sizes to those at low-SBRT facilities, and nonclinically significant differences in age, race, and insurance status. Among low-volume surgical facilities, treatment at a high SBRT-using facility was associated with decreased 30-day mortality (1.8% vs 1.4%, P < .001) and 90-day mortality (3.3% vs 2.6%, P < .001). At high-volume surgical facilities, no difference was observed. At 5 years, a survival advantage was identified for patients undergoing resection at facilities with high surgical volumes (hazard ratio, 0.91; confidence interval, 0.90-0.93 P < .001) but not at high SBRT-utilizing facilities. ConclusionsDifferences in short-term survival following resection at facilities with high-SBRT utilization may be attributable to low surgical volume facilities. Patients treated at high volume surgical facilities do not demonstrate differences in short-term or long-term survival based on facility SBRT utilization.

Posterior-Stabilized Antibiotic Cement Articulating Spacer With Endoskeleton-Reinforced Cam Reduces Rate of Post-Cam Mechanical Complications in Prosthetic Knee Infection: A Preliminary Study.

Posterior-stabilized antibiotic cement articulating spacers (PS spacers) reduce spacer mechanical complications in prosthetic knee infections (PKIs); however, joint dislocation after femoral cam fracture has been reported. We hypothesized that the rate of post-cam mechanical complications is lower in PS spacers with an endoskeleton-reinforced cam. A retrospective study of PKIs using PS spacers with or without a Kirschner wire-reinforced cam (K-PS or nK-PS spacers, respectively) was conducted between 2015 and 2019. The rates of post-cam mechanical complications and reoperation, as well as risk factors for post or cam failure, were analyzed. The cohort included 118 nK-PS and 49 K-PS spacers. All patients were followed up for 2 years. The rate of joint subluxation/dislocation after femoral cam fracture was lower in K-PS (0%) than in nK-PS spacers (17.8%; P= .002). The reoperation rate for spacer mechanical complications was lower in K-PS (0%) than in nK-PS spacers (11.9%; P= .008). The identified risk factors for femoral cam fractures were body mass index ≥25 kg/m2, femoral spacer size ≤2, and surgical volume ≤12 resection arthroplasties per year. This preliminary study highlights that K-PS spacers have a lower rate of post-cam mechanical complications than nK-PS spacers. We recommend the use of PS spacers with endoskeleton-reinforced cam when treating PKIs performed by surgeons with lower surgical volumes, especially in patients with higher body mass index and smaller femoral spacer sizes.

Risk Factors for Femoral Cortical Button Malposition in Posterior Cruciate Ligament Reconstruction.

Background:Femoral cortical button suspension fixation is a popular and reliable technique for posterior cruciate ligament reconstruction (PCLR). Button malposition during graft fixation can lead to postoperative graft loosening.Purpose:To determine the risk factors of femoral cortical button malposition in PCLR when neither direct visualization nor intraoperative fluoroscopy is used.Study Design:Case-control study; Level of evidence, 3.Methods:Of the 206 consecutive patients who underwent PCLR without direct visualization or intraoperative radiographs in 2019 at a single institution, 182 met the selection criteria and were included in the study. The distance from the suspension button to the femoral cortex was measured on postoperative computed tomography scans. The button was considered malpositioned if its distance to the femoral cortex was ≥2 mm. We evaluated patient-related and surgery-related variables, including age, sex, concomitant ligament reconstruction, button type, and surgeon experience. Multivariate logistic regression was conducted to evaluate the risk factors for button malposition.Results:The overall prevalence of button malposition was approximately 17.0% (31/182), and the mean distance from the button to the femoral cortex was 6.11 ± 5.82 mm in the malposition group. Male sex was the most significant risk factor for button malposition (odds ratio [OR], 13.86; 95% confidence interval [CI], 1.73-111.17; P = .013). Other independent risk factors were low surgical volume (completing ≤3 procedures; OR, 6.41; 95% CI, 1.89-21.72; P = .003), concomitant ligament reconstruction (OR, 5.56; 95% CI, 2.12-14.58; P < .001), and fixed-loop button (OR, 3.96; 95% CI, 1.11-14.18; P = .034).Conclusion:Male sex, low surgical volume, concomitant ligament reconstruction, and fixed-loop button were independent risk factors for femoral cortical button malposition during PCLR.

Cholecystectomy for people aged 50 years or more with mild gallstone pancreatitis: predictors and outcomes of index and interval procedures.

ObjectivesTo estimate the proportions of people aged 50 years or more with mild gallstone pancreatitis who undergo index cholecystectomy (during their initial hospital admission) or interval cholecystectomy (during a subsequent admission); to compare outcomes following index and interval cholecystectomy; and to identify factors associated with undergoing interval cholecystectomy.Design, setting, participantsAnalysis of linked hospitalisation and deaths data for all people aged 50 years or more with mild gallstone pancreatitis who underwent cholecystectomy in New South Wales within twelve months of their index admission, 1 July 2008 ‒ 30 June 2018.Main outcome measuresCholecystectomy classification (index or interval). Secondary outcomes: all‐cause mortality (30‒365 days), emergency re‐admissions with gallstone‐related disease (within 28 or 180 days of discharge); hospital lengths of stay (index admission, and all admissions with gallstone‐related disease over six months).ResultsA total of 1836 patients underwent index cholecystectomy (37.9%) and 3003 interval cholecystectomy (62.1%). Mortality to twelve months was similar in the two groups. Larger proportions of people who underwent interval cholecystectomy were re‐admitted within 28 days (246, 8.2% v 23, 1.3%) or 180 days (527, 17.6% v 59, 3.2%), or required open cholecystectomy (238, 7.9% v 69, 3.8%). Mean index admission length of stay was longer for index than interval cholecystectomy (7.7 [SD, 4.7] days v 5.3 [SD, 3.9] days), but six‐month total length of stay was similar (8.2 [SD, 5.6] days v 7.9 [SD, 5.8] days). Interval cholecystectomy was more likely for patients with three or more comorbid conditions (adjusted odds ratio [aOR], 1.29; 95% CI, 1.08‒1.55) or private health insurance (aOR, 1.31; 95% CI, 1.13‒1.51), and for those admitted to low surgical volume hospitals (aOR, 1.84; 95% CI, 1.03‒3.31).ConclusionsMost NSW people over 50 with mild gallstone pancreatitis did not undergo index cholecystectomy, despite recommendations in international guidelines. Delayed cholecystectomy was associated with more frequent open cholecystectomy procedures and gallstone disease‐related emergency re‐admissions, as well as with low or medium hospital surgical volume, comorbidity, and having private insurance.

Variation in Hospital Cost and 1-Year Episodes of Care after Diaphragmatic Hernia Repair.

Diaphragmatic hernia repair is a common operation performed at all types of hospitals. The variation in costs and repeat episodes of care after this operation is not known. The Healthcare Cost and Utilization Project State Inpatient and State Ambulatory Surgery and Services Databases for Florida were queried to identify patients undergoing diaphragmatic hernia repair between 2011 and 2018 and the associated inpatient and outpatient encounters within 12 months postoperatively. Hospitals were ranked by cost and grouped into quintiles. All costs and charges were reliability and case-mix adjusted with the use of hierarchical multivariable regression. In total, 8,848 patients underwent diaphragmatic hernia operations at 158 hospitals. The most expensive hospital quintile had lower surgical volume, location in rural settings, and fewer than 100 beds. There was a wide variation in costs after diaphragmatic hernia repair. On unadjusted comparison, index costs were $23,041 more expensive in hospitals in the highest quintile than in the lowest quintile. Cost differences were persistent even after case-mix and reliability adjustment. The variation in adjusted aggregate charges for associated outpatient and inpatient encounters in the first year after the index operation was considerably lower than that of the index hospitalization. There is nearly a 2-fold variation in the cost of a diaphragmatic hernia repair across hospitals. Most of the variation occurs during the index surgical encounter and not for repeat encounters during the first postoperative year. As bundled payment models mature, hospitals and payers will need to target this variation to ensure cost-efficiency.

Emotional status and fear in patients scheduled for elective surgery during COVID-19 pandemic: a nationwide cross-sectional survey (COVID-SURGERY)

BackgroundFragmented data exist on the emotional and psychological distress generated by hospital admission during the pandemic in specific populations of patients, and no data exists on patients scheduled for surgery. The aim of this multicentre nationwide prospective cross-sectional survey was to evaluate the impact of pandemic on emotional status and fear of SARS-CoV-2 contagion in a cohort of elective surgical patients in Italy, scheduled for surgery during the COVID-19 pandemic.ResultsTwenty-nine Italian centres were involved in the study, for a total of 2376 patients surveyed (mean age of 58 years ± 16.61; 49.6% males). The survey consisted of 28 total closed questions, including four study outcome questions. More than half of patients had at least one chronic disease (54%), among which cardiovascular diseases were the commonest (58%). The most frequent type of surgery was abdominal (20%), under general anaesthesia (64%). Almost half of the patients (46%) declared to be frightened of going to the hospital for routine checkups; 55% to be afraid of getting SARS-CoV-2 infection during hospitalization and 62% were feared of being hospitalised without seeing family members. Having an oncological disease and other patient-related, centre-related or perioperative factors were independently associated with an increased risk of fear of SARS-CoV-2 infection during hospitalization and of being hospitalised without seeing family members. A previous infection due to SARS-COV-2 was associated with a reduced risk of worse emotional outcomes and fear of SARS-CoV-2 infection during hospitalization. Patients who showed the most emotionally vulnerable profile (e.g. use of sleep-inducing drugs, higher fear of surgery or anaesthesia) were at higher risk of worse emotional status towards the hospitalization during COVID-19 pandemic. Being operated in hospitals with lower surgical volume and with COVID-19 wards was associated with worse emotional status and fear of contagion.ConclusionsAdditional fear and worse emotional status may be frequent in patients scheduled for elective surgery during COVID-19 pandemic. More than half of the participants to the survey were worried about not being able to receive family visits. Psychological support may be considered for patients at higher risk of psychological distress to improve perioperative wellbeing during the pandemic.

Variation in Vaginal Hysterectomy Rates in an Integrated Healthcare System

To describe trends in minimally invasive hysterectomy (MIH) and assess patient, surgical, and provider characteristics associated with differences in vaginal versus laparoscopic rates within an integrated healthcare system. A retrospective cohort study. Kaiser Permanente Northern California from 2008 to 2018. Patients who underwent MIH for benign conditions excluding uterine prolapse and incontinence surgeries. Hysterectomies. A total of 27518 hysterectomies were performed for benign indications. Of these, the proportion of MIH increased from 29.1% (2008) to 96.7% (2018) (p <.001). The proportion of vaginal hysterectomies (VHs) of all hysterectomies did not change significantly over the study period (p=.07); however, the proportion of VH among MIH cases decreased from a high of 50.6% in 2008 to 13.2% in 2018 (p <.001). VH rates were lower in obese and morbidly obese patients (p <.001 and p=.02, respectively) and in women with uterine weights >250 g (p <.001). The differences persisted after controlling for patient demographic, clinical, and surgery characteristics. Low surgical volume was inversely associated with VH (adjusted relative risk, 7.19; 95% confidence interval, 6.62-7.81; p <.001). VH rates ranged from 11.5% to 27.8% across service areas (hospitals). Service area remained a significant predictor of VH after controlling for patient (including body mass index and uterine weight) and surgery-related characteristics. Postoperative hospital stay decreased from 33.8 ± 16.4 hours (2008) to 6.1 ± 12.2 (2018) for VH. Operative time was shorter for VH than laparoscopic hysterectomies (LHs) (1.7 vs 2.5 hours; p <.001). Overall operative/perioperative complications were low and not significantly different (VH vs LH). As the proportion of MIH increased, LH became the preferred route despite similar rates of postoperative stay and intraoperative complications and shorter operative time for VH compared with LH. Service area and provider volume were independent predictors of MIH route, suggesting that training and evidence-based guidelines for route selection may help preserve VH rates.

Abstract 12850: The Effect of Regionalization on End-of-Life Hospitalizations for Adult Congenital Cardiology Patients

Introduction: Adult congenital heart disease (ACHD) patients may have shortened life expectancy due to complications of interventions and accrued comorbidities. Specialized ACHD care has become standard of care. The effect of regionalization on ACHD patient death is not known. Methods: The Office of Statewide Health Planning and Development database identified ACHD patients ≥ 18 years who died in California hospitals from 1995 - 2018. Specialized ACHD centers were self-designated, so high and low ACHD surgical volume centers were also compared. Results: Of 3,724 patients, when comparing by volume, more deaths occurred at low (85.2%) than high volume centers (14.8%); when comparing by specialization, more deaths occurred at non-ACHD (78.8%) than ACHD centers (21.2%). Moderate (9.4%) and high complexity (4.4%) lesions were rare. Common causes of death were sepsis (14.6%), myocardial infarction (9.3%), stroke (7.5%), and heart failure (7.1%). High volume centers were more likely the location of death than low volume centers for patients aged 18-64, with private insurance, and who lived &gt;20 miles away (p &lt;0.0001 for all). These held true for ACHD vs non-ACHD centers (p &lt;0.0001 for all). Low volume centers were more likely the location of death than high volume centers for patients from zip codes with relative poverty (p 0.0243). This held true for non-ACHD vs ACHD centers (p 0.0182). Over 24 years, the proportion of patients dying at ACHD centers increased (Figure 1), while the proportion of patients dying at high volume centers decreased. Conclusion: ACHD patients who die at high surgical volume and ACHD self-designated centers are more likely to be young, have private insurance, be referred to centers far from home, and have higher socioeconomic status. These likely reflect disparities in access to specialized ACHD care. Despite regionalization with an increase in specialized ACHD centers over time, the majority of ACHD patients continue to die at non-specialized centers.