Low Surgical Volume Research Articles

Trends in Total Laryngectomy in the Era of Organ Preservation

To describe time trends in total laryngectomy health services utilization across the United States, such as rates of surgery, cost, length of stay, and insurance payer, and to compare this to important milestones in recommendations for laryngeal cancer treatment. Population-based cohort study. Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-NIS) 1997-2008: stratified sample of all US hospital discharges. All patients with the principal procedure of complete laryngectomy. The unit of analysis was the discharge. Between 1997 and 2008, the number of laryngectomies done in the United States decreased by 48%. New cases of laryngeal cancer decreased 33% during the same time. The proportion of patients older than 65 years decreased from 48% to 43%. Mortality for the procedure was 1.4% in 1997 and 1.1% in 2008. Mean length of stay over the study period increased from 13 days to 14 days. Mean hospital charges rose from $58,000 in 1997 to $109,000 in 2008, consistent with the overall rise in US health care costs. Medicare was the dominant insurer throughout. Home health was ordered in 50% of 2008 discharges but only 32% in 1997. The rate of total laryngectomy has dropped more than the incidence of laryngeal cancer has dropped, consistent with the trend toward nonsurgical treatment. Lower surgical volumes and/or salvage laryngectomy surgeries are hypothesized to play a role in longer length of stay, stable mortality rates despite younger patient age, and increased need for home services after discharge.

Evaluation of 2,590 urological laparoscopic surgeries undertaken by urological surgeons accredited by an endoscopic surgical skill qualification system in urological laparoscopy in Japan

In 2003, the Japanese Urological Association (JUA) and Japanese Society of Endourology (JSE) established a urological laparoscopic skill qualification system, called the Endoscopic Surgical Skill Qualification System in Urological Laparoscopy of JUA and JSE (ESSQSJJ). The main goal of the system is to decrease the prevalence of complications associated with laparoscopic surgery. To validate the qualification system, perioperative outcome and the prevalence of complications in different types of urological laparoscopic surgery performed by accredited surgeons were evaluated. One hundred thirty-six surgeons who obtained the qualification in 2004 were prospectively asked to submit intraoperative and postoperative data of their latest 20 cases at the end of 2009, along with the number of laparoscopic urological surgeries performed in each year for a 5-year period (2004-2009). Intraoperative and postoperative complications were graded according to the Satava classification and modified Clavien classification, respectively. Data of 2,590 urological laparoscopic surgeries of 130 surgeons, including 904 laparoscopic radical nephrectomies, 430 laparoscopic nephroureterectomies, 390 laparoscopic adrenalectomies, 320 laparoscopic radical prostatectomies, and 170 laparoscopic partial nephrectomies, were analyzed. Complications were noted in 97 (3.7%) patients. Major intraoperative complications (grade II or III) occurred in 32 (1.2%) patients, and major postoperative complications (grade III or higher) occurred in 24 (0.9%) patients. The prevalence of conversion to open surgery, allogeneic transfusion, and perioperative mortality was 2.5%, 1.6%, and 0%, respectively. The number of surgeries performed by each qualified surgeon or the role of the surgeon (main operator vs. mentor/instructor) in the surgery did not affect the prevalence of intraoperative complications or postoperative complications. The open conversion rate was significantly higher in surgeons with a low surgical volume. ESSQSJJ can ensure urological laparoscopic surgeons who can perform various types of urological laparoscopic surgeries with a low prevalence of perioperative complications and reasonable outcomes.

Room for improvement? The adoption of multimodal esophageal cancer care in the United States.

78 Background: Consensus guidelines recommend neoadjuvant chemo- or chemoradiation therapy as the preferred treatment for locally advanced esophageal adenocarcinoma; however, it is unknown if this recommendation has been widely adopted in the U.S. Our objective was to examine esophageal cancer multimodal therapy and identify factors associated with the use of neoadjuvant therapy. Methods: From the National Cancer Data Base, patients with middle third, lower third and GE junction (GEJ) adenocarcinomas were identified. Patients who were clinical stage I-III and underwent surgical resection were included. Separate logistic regression models were developed to identify predictors of neoadjuvant therapy utilization and outcomes. Results: From 1998 to 2007, 8,051 patients underwent surgical resection for esophageal cancer: 16.3% stage I, 45.0% stage II and 38.7% stage III. For stage II/III tumors, neoadjuvant use increased (49.0% to 77.8%, p<0.001). After adjustment, factors associated with underuse of neoadjuvant therapy in stage II/III patients were older age, Black or Hispanic ethnicity, more severe comorbidities, tumor location (GEJ and middle vs. lower third), tumor size ≥ 2cm, stage II (vs. III) and geographic region. Stage II/III patients not receiving neoadjuvant had an over two fold increased risk of positive lymph nodes (OR 2.14. 95% CI 1.79 – 2.55, p<0.001). In addition, the positive surgical margin rate increased almost three fold (OR 2.80 95% CI 2.17-3.62, p<0.001) but 30-day postoperative mortality risk was not significantly affected (OR 1.50 95% CI 0.94-2.39; p=0.090). For stage I patients, neoadjuvant therapy decreased over time (38.0% to 11.4%, p<0.001). The overuse of neoadjuvant therapy was associated with higher tumor grade, larger tumor size, and low surgical case volume (all p<0.05). Conclusions: The adoption of neoadjuvant therapy has increased in the past decade; however, opportunity exists to improve guideline treatment for locally advanced esophageal cancer. Registry-based feedback to individual hospitals, such as benchmark comparison tools, could help institutions provide care in concordance with national guidelines. No significant financial relationships to disclose.

Disparities in the Utilization of High-Volume Hospitals for Total Hip Replacement

ObjectiveHigher hospital surgical volumes have been associated with lower complication rates following total-hip replacement. The objective of this study was to identify the characteristics of patients who undergo total-hip replacement at high-volume hospitals and their differences from those who receive care at low-volume hospitals. MethodsDischarge data from patients undergoing total hip replacement in California from 1995 to 2005 were analyzed. Hospitals were classified into 3 tiers of low, intermediate, or high surgical volume. The relationships between race/ethnicity and income to utilization of low-volume and high-volume hospitals were examined by creating logistic regression models that include patient covariates such as age, gender, and comorbidity. ResultsThis study analyzed 138399 cases of primary total-hip replacements during the study period. Patients of Hispanic ethnicity, or black or Asian race had higher relative risk ratios for being treated at a low-volume center compared to white patients. ConclusionsThere are disparities in the characteristics of patients receiving care at hospitals performing a high volume or low volume of total-hip replacements. Hispanic ethnicity, and black and Asian race were statistically significant predictors of utilization of a low-volume hospital.

112 HOSPITAL-LEVEL VARIATION IN DISPOSITION AND READMISSION AFTER SURGERY FOR UROLOGIC CANCERS

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes III1 Apr 2010112 HOSPITAL-LEVEL VARIATION IN DISPOSITION AND READMISSION AFTER SURGERY FOR UROLOGIC CANCERS John L. Gore, Jonathan L. Wright, Hunter Wessells, and Michael P. Porter John L. GoreJohn L. Gore More articles by this author , Jonathan L. WrightJonathan L. Wright More articles by this author , Hunter WessellsHunter Wessells More articles by this author , and Michael P. PorterMichael P. Porter More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.162AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Unexplained variation in outcomes after common surgeries may subtend a quality of care concern. Evaluating and understanding variation in surgical outcomes may identify processes and policy measures that effect surgical quality improvement. We sought to examine hospital-level variation in outcomes after inpatient urologic oncology procedures in the state of Washington. METHODS We accessed Washington state hospital claims (Comprehensive Hospital Abstract Reporting System [CHARS] data) for the years 2003-2007. The CHARS database includes inpatient claims linked at the patient level such that all readmissions and subsequent inpatient procedures are captured. Using International Classification of Diseases, 9th Edition procedure codes, we identified subjects undergoing radical prostatectomy, radical nephrectomy, and radical cystectomy. We measured postoperative length of stay (LOS), death, readmissions, and Agency for Healthcare Quality Patient Safety Indicators (PSIs). We adjusted hospital-level outcomes by patient age and comorbidity. RESULTS We identified 8,228 men who underwent prostatectomy from 51 hospitals, 3,018 nephrectomy patients from 51 hospitals, and 853 cystectomy patients from 37 hospitals. The Table lists age- and comorbidity-adjusted length of stay, 30-day death rates and 1-year readmission rates by hospital volume quartile for each procedure (* indicates p<0.05 compared with volume quartile 4). Complications captured by PSIs were rare. Higher volume hospitals trended toward lower LOS and readmission rates compared with lower volume hospitals. Postoperative death was uncommon after prostatectomy and nephrectomy. Higher volume hospitals had lower 30-day death rates after radical cystectomy than lower volume hospitals, but this difference was not statistically significant. Table 1. Adjusted rates of readmission, alternate disposition, an d death after inpatient urologic oncology surgeries Procedure volume quartile 1 – lowest 2 3 4 - highest Radical prostatectomy LOS (days) 3.0⁎ 2.8⁎ 2.8⁎ 0.6 30-day death (%) 0.00 0.09 0.11 0.11 1-year readmission (no.) 0.17 0.18⁎ 0.14 0.00 Radical nephrectomy LOS (days) 5.0 4.5 4.7 4.5 30-day death (%) 1.8 1.2 1.1 1.1 1-year readmission (no.) 0.56 0.38 0.42 0.34 Radical cystectomy LOS (days) 9.6 10.6 9.9 9.8 30-day death (%) 4.5 4.2 3.4 0.48 1-year readmission (no.) 0.91 1.1 1.4 0.72 ⁎ p<0.05 for comparison with procedure volume quartile 4. CONCLUSIONS Hospital-level variation may confound the care of urologic cancer patients in the state of Washington. Hospitals with lower surgical volume had higher death and readmission rates than higher volume hospitals for radical prostatectomy, radical nephrectomy, and radical cystectomy. Transparent reporting of surgical outcomes and local quality improvement initiatives may ameliorate the variation documented. Seattle, WA© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e46 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information John L. Gore More articles by this author Jonathan L. Wright More articles by this author Hunter Wessells More articles by this author Michael P. Porter More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Extended pelvic lymphadenectomy for prostate cancer: Will the previously reported benefits be reproduced in hospitals with lower surgical volumes?

In the European Association of Urology guidelines on prostate cancer an extended pelvic lymphadenectomy (ePLND) is now recommended, instead of a dissection limited to the obturator fossae (lPLND). This recommendation relies on studies reporting that metastatic disease is identified twice as often with ePLND as with lPLND, with only moderately increased complications. However, these studies were from high-volume centres. This study investigated whether these results could be repeated in a hospital with lower surgical volume, more typical for the Nordic countries. From January 2002 to September 2007 172 patients underwent radical prostatectomy and PLND at the University Hospital of Lund, 108 with ePLND and 64 with lPLND. Perioperative complications and the number of lymph-node metastases found were registered. A median of 17 lymph nodes was identified with ePLND compared with seven with lPLND. Metastases were identified in four out of 64 patients in the lPLND group (6%), versus 22 out of 108 in the ePLND group (20%). In the ePLND group 10 of the patients with metastases had such exclusively outside the obturator fossae. Complications were significantly more common after ePLND (p=0.007): lymphoceles (18 vs 9%), pulmonary embolism (4.6 vs 1.6%), deep venous thrombosis (1 vs 1.5%) and other (haematomas and infectious including sepsis (8 vs 0%). Almost half of the patients with metastases are misclassified by lPLND. Complications are significantly more common after ePLND. This implies that ePLND should be performed, but in selected patients and by high-volume surgeons only.

The identification and treatment of isolated tumor cells reflect disparities in the delivery of breast cancer care

Background Disparities in the quality of health care delivered among different socioeconomic strata (SES), race/ethnic groups, and health care systems are well documented; however, relevant quality measures in breast cancer have been debated. The identification of isolated tumor cells (ITCs) in axillary lymph nodes of patients with breast cancer requires diagnosis of early stage disease, appropriate implementation of sentinel lymph node (SLN) dissection, and pathologic analysis of the SLN with serial sectioning and immunohistochemical staining. We hypothesized that ITCs could be interpreted as a quality indicator and sought to determine factors that are associated with the identification and treatment of ITCs. Methods We performed a retrospective cohort review of women with N0(i+) breast cancer diagnosed between 2004 and 2006 in the California Cancer Registry. The proportions of patients in SES quintiles (1 = lowest, 5 = highest), race/ethnicity groups, and hospital surgical volume tertiles (low, 1–241 cases/y; medium, 242–491 cases/y; high, ≥492 cases/y) were compared for use of SLN dissection, identification of ITCs, and treatment of ITCs with additional axillary surgery or chemotherapy. Results SLN dissections were performed less frequently in women of lower SES, of nonwhite race/ethnicity, and in hospitals with lower surgical volumes ( P <.0001). A total of 369 patients had ITCs (.6%). With increasing SES, the proportion of patients with ITCs increased: 7.1% of patients with ITCs were from SES 1; 15.7% were from SES 2; 20.3% were from SES 3; 23.9% were from SES 4; and 33.1% were from SES 5. A total of 69.4% of patients with ITCs were non-Hispanic white, 12.8% were Asian, 11.9% were Hispanic, and 5.2% were non-Hispanic black. A total of 46.9% of ITCs were identified in high-volume hospitals, although high-volume hospitals represented only one third of all surgical cases. There were no differences in the use of additional axillary surgery among different groups with ITCs, but chemotherapy was given more frequently to Hispanic women ( P = .002) and those in higher-volume hospitals ( P = .01). Conclusions Although the identification and chemotherapy treatment of ITCs vary among SES categories, race/ethnic groups, and hospitals, the infrequent occurrence of ITCs precludes its use as a valid quality indicator. Because significant disparities exist in the use of SLN dissection, further research will be required to validate the use of SLN dissection as a quality measure.

Extended pelvic lymphadenectomy for prostate cancer: Will the previously reported benefits be reproduced in hospitals with lower surgical volumes?

Extended pelvic lymphadenectomy for prostate cancer: Will the previously reported benefits be reproduced in hospitals with lower surgical volumes?

Appropriateness of early breast cancer management in relation to patient and hospital characteristics: a population based study in Northern Italy

Administrative data may provide valuable information for monitoring the quality of care at population level and offer an efficient way of gathering data on individual patterns of care, and also to shed light on inequalities in access to appropriate medical care. The aim of the study was to investigate the role of patient and hospital characteristics in the initial treatment of early breast cancer using administrative data. Incident breast cancer patients were identified from hospital discharge records and linked to the radiotherapy outpatient database during 2000-2004 in the Piedmont region of Northwestern Italy. Women treated with breast-conserving surgery followed by radiotherapy (BCS + RT) were compared to those treated with BCS without radiotherapy (BCS w/o RT) or mastectomy using multinomial logistic regression models. Out of 16,022 incident cases, 46.2% received BCS + RT, 20.3% received BCS w/o RT, and 33.5% received a mastectomy. Compared to BCS + RT, the factors associated with BCS w/o RT were: increased age (OR = 1.54; 95% CI = 1.29-1.85, for ages 70-79 vs. <50), being unmarried (1.24; 1.13-1.36), presence of co-morbidities (1.32; 1.10-1.58), being treated at hospitals with low surgical volume (1.31; 1.07-1.60 for hospitals with less than 50 vs. > or =150 interventions/year), and living far from radiotherapy facilities (1.75; 1.39-2.20 for those at a distance of >45 min). These same factors were also associated with mastectomy. During the 5-year period observed, there was a trend of reduced probability of receiving a mastectomy (0.70; 0.56-0.88 for 2004 vs. 2000). The presence or absence of nodal involvement was positively associated with mastectomy (2.28; 1.83-2.85) and negatively associated with BCS w/o RT (0.65; 0.56-0.76). After adjustment for potential confounders, education level did not show any association with the type of treatment. Social and geographical factors, in addition to hospital specialization, should be considered to reduce inappropriateness of care for breast cancer.

Effect of surgical work volume on postoperative complication: superiority of specialized center in gastric cancer treatment

We investigated the risk factors for early postoperative complications after gastric cancer surgery. The data from a total of 273 patients with gastric cancer were analyzed by univariate and multivariate analysis. We applied physiological and operative severity score for the enumeration of morbidity and mortality (POSSUM) to compare risk-adjusted surgical outcomes among different surgical units. Among the preoperative variables, patient gender, chronic obstructive pulmonary disease, surgical unit, and intraoperative blood loss were independent risk factors for a higher rate of postoperative complications. There were significant differences in complication rates among different surgical units (P = 0.001). The observed-to-expected morbidity ratio (O-to-E ratio) ranged from 0.81 to 1.63. Units with low surgical work volume had higher complication rates. Postoperative length of stay was significantly shorter (P = 0.000) and the rate of moderate and severe complications was significantly lower (P = 0.001) in specialized unit. POSSUM is a valid system for risk-adjusted evaluation of surgical outcomes. We conclude that surgical experience and work volume greatly influence the outcome, with overall surgical outcome in specialized centers superior to that in other units. Hence, gastric cancer surgery should be performed in specialized centers. Risk factors identified in this study need further confirmation by a prospective study involving a larger cohort.

PL-38: Low surgical volumes in hospitals that meet surgical review corporation (SRC) bariatric surgery center of excellence (BSCOE) minimum standards do not demonstrate an adverse impact on surgical outcomes

extremities perioperatively and early ambulation reduce venous thromboembolism (VTE) postoperatively. Anti-coagulation medication is recommended by ASMBS to reduce VTE risk. This study examines 30 day post-op VTE or death among bariatric surgery patients who had sequential compression alone (SEQUEN) or with anticoagulation (ANTICOAG). Methods: LABS participants from 10 centers in the US who underwent their first bariatric surgery between 3/2005 and 10/2007 comprise the study group. We examined 30-day incidence of VTE, defined as DVT or PE, and mortality. Results: Of 3,539 patients, 370 (10%) received sequential compression alone, while the others also received anticoagulation therapy. The two groups were similar in age, race, ethnicity, and BMI. There was a significantly higher percentage of males (30% vs. 20%, p 0.0001) and smokers (7% vs. 3%, p 0.003) in the SEQUEN group. The prevalence of hypertension, diabetes, congestive heart failure, history of VTE , vena cava filter, ischemic heart disease, and pulmonary hypertension at baseline, were not significantly different. The SEQUEN group had longer operative times (207 vs. 169 min, p .0001). The two groups were similar in % of re-hospitalization and re-operation. Open surgery was associated with 1.8% of VTE, and laparoscopic surgery with 0.4%. After adjusting for sex, current smoking, length of operation, and history of VTE, there was not a significant difference between groups in the combined incidence of DVT/PE/mortality (1.0% in ANTICOAG versus 0.4% in SEQUEN, p 0.25). Conclusion: The overall incidence of VTE or death was small (1%). The addition of anticoagulation to the use of sequential compression devices may not lower the rate of VTE following bariatric surgery. Further study of this topic is warranted (sample size). PII: S1550-7289(08)00406-1

Disparities in the Utilization of High-Volume Hospitals for Total Knee Replacement

Higher hospital surgical volumes have been associated with lower complication rates following total knee replacement. The objective of this study is to identify the characteristics of patients who undergo total knee replacement at high-volume hospitals and their differences from those who receive care at low-volume hospitals. Discharge data from patients undergoing total knee replacement in California from 1991-2001 were analyzed. Hospitals were classified into three tiers of low, intermediate or high surgical volume. The relationship between race/ethnicity and insurance status and the utilization of low-volume and high-volume hospitals were examined by creating separate logistic regression models that corrected for covariates, including age, gender and comorbidity. This study analyzed 222,684 primary total knee replacements during the study period. Patients of non-Caucasian race/ethnicity had higher relative risk ratios for being treated at a low-volume center, including black patients [relative risk ratio (RRR) = 1.73, 95% confidence Interval (CI): 1.09-2.76, p = 0.02]; Hispanic patients (RRR = 3.13, 95% CI: 2.31-4.23, p < 0.001) and Asian/Pacific Islanders (RRR = 2.95, 95% CI: 1.89-4.62, p < 0.001). Medicaid insurance was also an independent predictor of treatment at low-volume hospitals. Age and comorbidity were not statistically significant predictors for receiving care at low-volume centers. There are substantial disparities in the characteristics of patients receiving care at hospitals performing a high volume of total knee replacements. Black, Hispanic and Asian race/ethnicity as well as Medicaid insurance were predictors of utilization of a low-volume hospital. This study supports the need to consider racial and socioeconomic disparities in efforts to improve the quality of care of patients undergoing total knee replacement at lower-volume hospitals.

Comparison Between Pancreaticojejunostomy and Pancreaticogastrostomy After Pancreaticoduodenectomy

Pancreatic leakage is a leading cause of morbidity and mortality after pancreaticoduodenectomy (PD). Pancreaticogastrostomy (PG) has been reported to be associated with a lower pancreatic leakage rate and morbidity rate than pancreaticojejunostomy (PJ). This study compared the preoperative characteristics, surgical risk factors, intraoperative parameters, and postoperative outcome between PJ and PG. From March 1992 to March 2005, a comparative study between PJ and PG for patients with periampullary lesions undergoing PD was conducted. A total of 377 consecutive patients underwent PD. Among them, 188 patients underwent PJ and 189 underwent PG. The overall mortality, morbidity and pancreatic leakage following PD were 5%, 45.1% and 10.6%, respectively. The mortality, morbidity and pancreatic leakage were 8.9%, 56.4% and 17.6% in the PJ group, and 2.1%, 33.9% and 3.7% in the PG group (p < 0.001). Mean operative time was 9.3 hours versus 6.7 hours (p < 0.001), mean blood loss was 1032 mL versus 891 mL (p = 0.064) and mean hospital stay was 34.8 days versus 26.1 days (p < 0.001) in the PJ and PG groups, respectively. PJ, soft pancreas, pancreatic duct stenting, low surgical volume (< 20) and age (> 65 years) were identified as risk factors for pancreatic leakage, while PJ, soft pancreas, pancreatic duct stenting and low surgical volume (< 20) were four significant risk factors for surgical morbidity. Further, PJ, pancreatic leakage, low surgical volume (< 20) and age (> 65 years) were identified to be surgical risk factors for mortality. PG is a safer method than PJ following PD as a significantly lower rate of pancreatic leakage, surgical morbidity and mortality, shorter operation time, and shorter postoperative hospital stay are reported.

Aspirin

Dependence on an expanded polytetrafluoroethylene graft for provision of pulmonary blood flow is a common yet precarious interval through which a population of patients with congenital heart disease must pass. The goals of the systemic-to–pulmonary artery shunt are to relieve cyanosis and to provide time before establishing in-series circulation by either complete repair of 2-ventricle lesions or, in the case of the single-ventricle patient, a bidirectional Glenn shunt. In the case of patients with single-ventricle anatomy, this period of parallel circulation is necessary to permit the lung maturation and the reduction in pulmonary vascular resistance that are necessary for subsequent palliation. For patients who will ultimately achieve a 2-ventricle repair, the goals of a preliminary shunt may include increasing the size of the pulmonary artery size or having a larger, older patient at the time of repair. This period of parallel circulation is tenuous, and the patient remains at increased risk during this period of altered circulation. Article p 293

Association between unplanned readmission rate and volume of breast cancer operation cases

This study was conducted to investigate the relationship between unplanned readmission and breast cancer operation cases, with the assumption that the rate of unplanned readmission within 30 days of surgery was solely due to postsurgical complications. We divided hospitals into three categories based on breast cancer operation cases: low-volume hospitals (< or =50 annual procedures), medium-volume hospitals (51-99 annual procedures) and high-volume hospitals (> or =100 annual procedures). The medical records of 1351 subjects in 24 hospitals were investigated. We found unplanned readmission rates were significantly higher in hospitals with a lower surgical volume. From these three groups, a sample consisting of 1351 patients was created and 17 unplanned readmission cases (1.2%) were reported. Of these 17 cases, 12 (70.59%) cases were from low-volume hospitals. The present results indicate that unplanned readmission within 30 days following discharge is an important adverse outcome in breast cancer surgery.

Pancreatogastrostomy after Pancreatoduodenectomy: A Safe, Feasible Reconstruction Method?

Pancreatogastrostomy is a safe reconstructive technique after pancreatoduodenectomy, even when performed as an educational operation in the hands of relatively inexperienced surgeons in a high-volume hospital. Sixteen surgeons with various case volumes operated on 190 consecutive patients and performed pancreatogastrostomy after pancreatoduodenectomy within the last 15 years in a university teaching hospital. Resections were performed for tumors localized in the head of the pancreas, the ampulla of Vater, or the distal common bile duct or duodenum (n = 169); for chronic pancreatitis (n = 16); and for miscellaneous reasons in five cases. The main outcome measures were postoperative mortality and morbidity, particularly the pancreatic leakage rate with special regard to the case volume of the performing surgeon. The overall mortality rate was 4.2% (n = 8), the 30-day mortality rate was 3.2% (n = 6), and mortality directly related to surgery was 2.6% (n = 5). Morbidity occurred in 45%, including severe surgical complications, which required reoperation (9%), and minor surgical complications that could be managed conservatively (30%). There were no significant differences in overall surgical morbidity rates when the groups with varying patient volume per surgeon were compared. The incidence of pancreatic leakage was 7.4%, which did not contribute to mortality in any case and showed no statistical differences between the surgical volume groups. We concluded that pancreatogastrostomy is safe and feasible even in the hands of inexperienced but supervised surgeons. The leakage rate is similar to the data from other high-volume centers. Once a leak is established, it can easily be managed conservatively, so it rarely contributes to severe complications or causes subsequent mortality. We recommend pancreatogastrostomy as a beneficial alternative to pancreatojejunostomy, even in the case of low surgical volume.

Infecciones en cirugía de artroplastía de cadera: Resultados del sistema de vigilancias epidemiológica de las infecciones intrahospitalarias. 1996-1999

109INFECTIONS IN HIP ARTHROPLASTY: RESULTS OF THENOSOCOMIAL INFECTIONS SURVEILLANCE SYSTEM OF CHILE.1996-1999Epidemiological surveillance of nosocomial infections in hip arthroplastywas established in chilean hospitals in 1996. Between 1996 and 1999 the surveillancesystem reported, in 28 hospitals, 134 infections in 3.889 operations, with acummulative rate of 3.5%. Epidemiological surveillance in Chile does notdifferentiate infections of the surgical wound from infections of the hip replacementitself, and the period of follow up is during hospital stay after surgery. The mostfrequent etiological agents were non fermentative Gram negative bacilli (33.3%),mainly Acinetobacter baumannii. Gram positive cocci represented 23.8% of theetiologies. Hospitals with higher mean number of operations had lower rates(5.0% in hospitals with low surgical volume and 2.9% in hospitals with highervolume). The findings of the surveillance system suggest some risk factors thatrequire further research, such as the duration of preoperative hospital stay andexperience of the surgical center.Key words: Nosocomial infection, Arthroplasty, Epidemiological surveillance.EPIDEMIOLOGIA

Jejunum or stomach for the pancreatic anastomosis after pancreaticoduodenectomy.

Objective: The authors hypothesized that pancreaticogastrostomy is safer than pancreaticojejunostomy after pancreaticoduodenectomy and less likely to be associated with a postoperative pancreatic fistula. Summary Background Data: Pancreatic fistula is a leading cause of morbidity and mortality after pancreaticoduodenectomy, occurring in 10% to 20% of patients. Nonrandomized reports have suggested that pancreaticogastrostomy is less likely than pancreaticojejunostomy to be associated with postoperative complications. Methods: Between May 1993 and January 1995, the findings for 145 patients were analyzed in this prospective trial at The Johns Hopkins Hospital. After giving their appropriate preoperative informed consent, patients were randomly assigned to pancreaticogastrostomy or pancreaticojejunostomy after completion of the pancreaticoduodenal resection. All pancreatic anastomoses were performed in two layers without pancreatic duct stents and with closed suction drainage. Pancreatic fistula was defined as drainage of greater than 50 mL of amylase-rich fluid on or after postoperative day 10. Results: The pancreaticogastrostomy (n=73) and pancreaticojejunostomy (n=72) groups were comparable with regard to multiple parameters, including demographics, medical history, preoperative laboratory values, and intraoperative factors, such as operative time, blood transfusions, pancreatic texture, length of pancreatic remnant mobilized, and pancreatic duct diameter. The overall incidence of pancreatic fistula after pancreaticoduodenectomy was 11.7% (171145). The incidence of pancreatic fistula was similar for the pancreaticogastrostomy (12.3%) and pancreaticojejunostomy (11.1%) groups. Pancreatisc fistula was associated with a significant prolongation of postoperative hospital stay (36±5 vs. 15±1 days) (p<0.001). Factors significantly increasing the risk of pancreatic fistula by univariate logistic regression analysis included ampullary or duodenal disease, soft pancreatic texture, longer operative time, greater intraoperative red blood cell transfusions, and lower surgical volume (p<0.05). A multivariate logistic regression analysis revealed the factors most highly associated with pancreatic fistula to be lower surgical volume and ampullary or duodenal disease in the resected specimen. Conclusions: Pancreatic fistula is a common complication after pancreaticoduodenectomy, with an incidence most strongly associated with surgical volume and underlying disease. These data do not support the hypothesis that pancreaticogastrostomy is safer than pancreaticojejunostomy or is associated with a lower incidence of pancreatic fistula.

Operative mortality rates for intact and ruptured abdominal aortic aneurysms in Michigan: An eleven-year statewide experience

The purposes of this study were (1) to determine the current population-based mortality rate for the surgical treatment of abdominal aortic aneurysms (AAA) in Michigan, (2) to document changes in mortality rates over 11 years, and (3) to identify risk factors for operative mortality. A statewide database provided clinical information on all Michigan hospital admissions with a diagnosis of AAA from 1980 to 1990. The mortality rate analysis included all admissions with a primary diagnosis of AAA that underwent repair. Determination of diagnoses and comorbidities were based on International Classification of Diseases-ninth revision-Clinical Modification codes. Conventional surgical repairs were performed on 8185 intact and 1829 ruptured AAA. Hospital mortality rates accompanying operation for intact AAA decreased from 13.6% in 1980 to 5.6% in 1990 (p < 0.001). Mortality rates over the 11 years averaged 10.7% in women and 6.8% in men (p < 0.001). Mortality rates averaged 10.7% in 4170 admissions of patients 70 years old or older and 4.2% in 4015 admissions of patients 69 years old or younger. Preexistent kidney failure was associated with an average mortality rate of 41.2% compared with 6.2% without this comorbidity. Preexistent dysrhythmia increased mortality rates from 6.6% to 13.6%. Uncomplicated hypertension, cerebrovascular disease, chronic obstructive pulmonary disease, diabetes, arterial occlusive disease, and ischemic heart disease in recent years were not associated with increased mortality rates. Hospitals with an annual volume of 21 or more intact AAA repairs had a surgical mortality rate of 6.2%, compared with 8.9% in hospitals with lower surgical volume (p < 0.001). Mortality rates for surgical repair of ruptured AAA averaged 49.8% and did not improve significantly over the 11 years studied. Despite a dramatic drop in surgical mortality rates, repair of intact AAA remains a formidable undertaking. This population-based series documents a substantially higher mortality rate than most selected series. The unchanged mortality rate for ruptured AAA suggests that development of better algorithms to identify those AAA most apt to rupture and earlier intervention in those instances is likely to improve patient survival rates.

Rural hospital inpatient surgical volume: cutting-edge service or operating on the margin?

Surgical services are an important part of modern health care, but providing them to isolated rural citizens is especially difficult. Public policy initiatives could influence the supply, training, and distribution of surgeons, much as they have for rural primary care providers. However, so little is known about the proper distribution of surgeons, their contribution to rural health care, and the safety of rural surgery that policy cannot be shaped with confidence. This study examined the volume and complexity of inpatient surgery in rural Washington state as a first step toward a better understanding of the current status of rural surgical services. Information about rural surgical providers was obtained through telephone interviews with administrators at Washington's 42 rural hospitals. The Washington State Department of Health's Commission Hospital Abstract Recording System (CHARS) data provided a count of the annual surgical admissions at rural hospitals. Diagnosis-related group (DRG) weights were used to measure complexity of rural surgical cases. Surgical volume varied greatly among hospitals, even among those with a similar mix of surgical providers. Many hospitals provided a limited set of basic surgical services, while some performed more complex procedures. None of these rural hospitals could be considered high volume when compared to volumes at Seattle hospitals or to research reference criteria that have assessed volume-outcome relationships for surgical procedures. Several hospitals had very low volumes for some complex procedures, raising a question about the safety of performing them. The leaders of small rural hospitals must recognize not only the fiscal and service benefits of surgical services--and these are considerable--but also the potentially adverse effect of low surgical volume on patient outcomes. Policies that encourage the proper training and distribution of surgeons, the retention of basic rural surgical services, and the rational regionalization of complex surgery are likely to enhance the convenience and safety of surgery for rural citizens.