Reduction In Reoperation Research Articles

Comparative Effectiveness and Complications of Surgical and Conservative Management in Breast Abscess Patients: A Prospective Analytical Study

Background: Mammary abscesses are infections that are enclosed without involving the surrounding tissues they are common with breast cancer patients through uncontrolled or poorly controlled mastitis. Hence, this work seeks to assess the management of surgical and conservative approaches for treating breast abscesses. Objective: The objective of the study was to ascertain the treatment methods used in management of breast abscesses and to determine the results and adverse outcomes of those that are applied. Methodology: A prospective analytical study was conducted in the Department of Surgery at Ghurki Trust & Teaching Hospital, Lahore, Pakistan, from February 2023 to March 2024. A total of 270 patients were initially enrolled, with 200 completing the 3-month follow-up. Patients were divided into two groups based on the treatment modality. Group I (Surgical Treatment) and Group II (Conservative/Minimally Invasive Treatment). SPSS version-20 was used to analyse results Patient groups were compared using the chi-squared test for categorical variables, for continuous variables, such as age, an independent samples t-test was utilized to compare the means between the two groups (p≤0.05) was considered. Results: Surgical treatment (Group I) demonstrated a significant reduction in reoperations and respiration compared to conservative treatments (Group II), where a notable percentage of patients (41.7%) needed further intervention. Notably, the rate of deformity due to scarring and contracture was higher in the conservative/minimally invasive group, affecting 30% of these patients, compared to 14.3% in the surgical group. Moreover, there was no carcinoma reported in group II in contrast with group I of the surgically operated patients 5% of them were found to have carcinoma. Conclusion: Surgical treatment for breast abscesses, particularly larger ones, offers more definitive resolution with fewer long-term complications compared to conservative management. Personalized treatment planning is essential to optimize patient outcomes and reduce morbidity.

Does Bone Morphogenetic Protein Use Reduce Pseudarthrosis Rates in Single-Level Transforaminal Lumbar Interbody Fusion Surgeries?

Recombinant human bone morphogenetic protein 2 (rhBMP-2, or BMP for short) is a popular biological product used in spine surgeries to promote fusion and avoid the morbidity associated with iliac crest autograft. BMP's effect on pseudarthrosis in transforaminal lumbar interbody fusion (TLIF) remains unknown. To assess the rates of pseudarthrosis in single-level TLIF with and without concurrent use of BMP. This was a retrospective cohort study conducted at a single academic institution. Adults undergoing primary single-level TLIF with a minimum of 1 year of clinical and radiographic follow-up were included. BMP use was determined by operative notes at index surgery. Non-BMP cases with iliac crest bone graft were excluded. Pseudarthrosis was determined using radiographic and clinical evaluation. Bivariate differences between groups were assessed by independent t test and χ 2 analyses, and perioperative characteristics were analyzed by multiple logistic regression. One hundred forty-eight single-level TLIF patients were included. The mean age was 59.3 years, and 52.0% were women. There were no demographic differences between patients who received BMP and those who did not. Pseudarthrosis rates in patients treated with BMP were 6.2% vs 7.5% in the no BMP group (P = 0.756). There was no difference in reoperation for pseudarthrosis between patients who received BMP (3.7%) vs those who did not receive BMP (7.5%, P = 0.314). Patients who underwent revision surgery for pseudarthrosis more commonly had diabetes with end-organ damage (revised 37.5% vs not revised 1.4%, P < 0.001). Multiple logistic regression analysis demonstrated no reduction in reoperation for pseudarthrosis related to BMP use (OR 0.2, 95% CI 0.1-3.7, P = 0.269). Diabetes with end-organ damage (OR 112.6,95% CI 5.7-2225.8, P = 0.002) increased the risk of reoperation for pseudarthrosis. BMP use did not reduce the rate of pseudarthrosis or the number of reoperations for pseudarthrosis in single-level TLIFs. Diabetes with end-organ damage was a significant risk factor for pseudarthrosis. BMP is frequently used "off-label" in transforaminal lumbar interbody fusion; however, little data exists to demonstrate its safety and efficacy in this procedure.

The use of a total bowel length measurement protocol may reduce reoperations and complications after single-anastomosis duodenal switch.

Most surgeons who perform single-anastomosis duodeno-ileal switches (SADI-S) use a pre-determined common channel length without measuring total bowel length (TBL). However, TBL varies between patients, and a standardized common channel length could contribute to malabsorptive complications and reoperations following SADI-S. The purpose of this study was to determine whether using a TBL measurement protocol to individualize common channel length would be associated with reduced reoperations and complications. A prospectively maintained data registry was retrospectively reviewed to identify all patients who underwent SADI-S between September 2017 and February 2022. In April 2021, we began using TBL measurements during SADI-S with 40% of the TBL used as the length for the common channel. Outcomes pre-TBL and post-TBL measurement protocol were compared. A total of 119 SADI-S recipients (59 pre-TBL; 60 post-TBL) were included. The pre-TBL group had a higher frequency of reoperations (23.7% vs 1.7%, p < 0.001) and late complications (29.3% vs 3.3%, p < 0.001). The mean time to reoperation was 13.7months in the pre-TBL group and 6.7months in the post-TBL group (p = 0.347). Patients in the post-TBL group had significantly higher serum albumin levels at 3months (4.2g/dL vs 3.5g/dL, p < 0.001), 6months (4.1g/dL vs 3.6g/dL, p < 0.001), and 12months (4.2g/dL vs 3.8g/dL, p = 0.023) postoperatively when compared to the pre-TBL group. Using TBL measurements to individualize common channel length was associated with a significant reduction in reoperations and late complications following SADI-S.

Low-Cost Wound Healing Protocol Reduces Infection and Reoperation Rates After Cranioplasty: A Retrospective Cohort Study.

Cranioplasty infections are a common and expensive problem associated with significant morbidity. Our objective was to determine whether a wound healing protocol after cranioplasty reduced the rate of infections and to determine the value of this intervention. This is a single-institution retrospective chart review of 2 cohorts of cranioplasty patients over 12 years. The wound healing protocol, consisting of vitamin and mineral supplementation, fluid supplementation, and oxygen support, was instituted for all patients aged older than 15 years undergoing cranioplasty. We retrospectively reviewed the charts of all patients over the study period and compared outcomes before and after protocol institution. Outcomes included surgical site infection, return to operating room within 30 days, and cranioplasty explant. Cost data were collected from the electronic medical record. We included 291 cranioplasties performed before the wound healing protocol and 68 postprotocol. Baseline demographics and comorbidities were comparable between preprotocol and postprotocol groups. Odds of takeback to operating room within 30 days were the same before and after the wound healing protocol (odds ratio [OR] 2.21 [95% CI 0.76-6.47], P = .145). Odds of clinical concern for surgical site infection were significantly higher in the preprotocol group (OR 5.21 [95% CI 1.22-22.17], P = .025). Risk of washout was higher in the preprotocol group (HR 2.86 [95% CI 1.08-7.58], P = .035). Probability of cranioplasty flap explant was also significantly higher in the preprotocol group (OR 4.70 [95% CI 1.10-20.05], P = .036). The number needed to treat to prevent 1 cranioplasty infection was 24. A low-cost wound healing protocol was associated with reduced rate of infections after cranioplasty with concomitant reduction in reoperations for washout, saving the health care system more than $50,000 per 24 patients. Prospective study is warranted.

Rates of reoperation after breast conserving cancer surgery in Western Australia before and after publication of the SSO-ASTRO margins guideline.

A 2014 SSO-ASTRO guideline on surgical margins aimed to reduce unnecessary reoperation after breast conserving surgery (BCS). We investigate whether publication of the guideline was associated with a reduction in reoperation in Western Australia (WA). In this retrospective, population-based cohort study, cases of newly-diagnosed breast cancer were identified from the WA Cancer Registry. Linkage to the Hospital Morbidity Data Collection identified index BCS for invasive cancer between January 2009 and June 2018 (N=8059) and reoperation within 90 days. Pre-guideline (2009-2013) and post-guideline (2014-2018) reoperation proportions were compared, and temporal trends were estimated with generalised linear regression. The pre-guideline reoperation proportion was 25.8% compared with 21.7% post-guideline (difference -4.0% [95% CI -5.9, -2.2, p<0.001], odds ratio [OR] 0.80 [95% CI 0.72, 0.89, p<0.001]). Absolute reductions were similar for repeat BCS (16.3% versus 14.6%; difference -1.8% [95% CI -3.4, -0.2, p=0.03]) and conversion to mastectomy (9.4% versus 7.2%; difference -2.2% [95% CI -3.4, -1.0, p<0.001]). Over the study period, there was an annual absolute change in reoperation of -0.8% (95% CI -1.2, -0.5, p<0.001). Accounting for this linear trend, the difference in reoperation between time periods was -0.5% (95% CI -4.3, 3.3; p=0.81), reflecting a non-significant reduction in conversion to mastectomy. Comparisons of pre- versus post-guideline time periods in WA showed reductions in reoperation that were similar to international estimates; however, an annual decline in reoperation predated the guideline. Analyses that do not account for temporal trends are likely to overestimate changes in reoperation associated with the guideline.

The Ross Procedure in Children: Defining the Optimal Age.

It has been proposed that delaying the Ross procedure to later in childhood, allowing autograft stabilisation and placement of a larger pulmonary conduit, may improve outcomes. However, the effect of age at the time of Ross procedure on outcomes remains unclear. All patients who underwent the Ross procedure between 1995 and 2018 were included in the study. Patients were divided into four groups: infants, age 1 to 5 years, age 5 to 10 years and age 10 to 18 years. A total of 140 patients underwent the Ross procedure in the study period. Early mortality was 23.3% (7/30) for infants compared to 0% for older children (p<0.001). Survival at 15 years was significantly lower in infants (76.3%±9.9%), compared to children aged 1 to 5 years (90.9%±20.1%), 5 to 10 years (94%±13.3%), and 10 to 18 years (86.7%±10.0%), p=0.01. Freedom from autograft reoperation at 15 years was significantly lower in infants (58.4%±16.2%), compared to children aged 1 to 5 years (77.1%±14.9%), 5 to 10 years (84.2%±6.0%) and 10 to 18 years (87.8%±9.0%), p=0.01. Overall freedom from reoperation at 15 years was13.0%±6.0% for infants, 24.2%±9.0% for children aged 1 to 5 years, 46.7%±15.8% for children aged 5to 10 years, and 78.4%±10.4%, p<0.001. The Ross procedure performed after 10 years of age appears to be associated with improved freedom from reoperation, primarily due to a reduction in reoperation on the pulmonary conduit.

Prophylactic transanal drainage tube placement for preventing anastomotic leakage after anterior resection for rectal cancer: A meta-analysis.

The aim was to evaluate the efficacy of transanal drainage tube (TDT) placement for preventing anastomotic leakage after low anterior resection for rectal cancer. PubMed, the Cochrane Central Register of Controlled Trials, Embase and ClinicalTrials.gov databases were searched up to October 2021. Studies comparing outcomes following low anterior resection with or without TDT were included. The primary outcomes measured were anastomotic leakage rate, reoperation rate and anastomotic bleed rate. Three randomized controlled trials (RCTs) and 16 observational studies (prospective or retrospective) involving 4560 patients satisfied the basic inclusion criteria. In RCTs, a TDT was associated with no statistically significant differences in anastomotic leakage (OR=0.67, 95% CI 0.42-1.05, P=0.08), reduction in reoperation (OR=0.11, 95% CI 0.03-0.51, P=0.004) and increased anastomotic bleeding rate (OR=2.36, 95% CI 1.11-5.01, P=0.03). In observational studies, a TDT was associated with significant reduction in anastomotic leak (OR=0.44, 95% CI 0.30-0.64, P < 0.0001) and reoperation (OR=0.47, 95% CI 0.33-0.69, P < 0.0001), with no statistically significant differences in anastomotic bleeding (OR=1.30, 95% CI 0.20-8.30, P=0.78). In RCTs, a TDT for rectal cancer was correlated with no detectable differences in anastomotic leakage and with an increased risk of anastomotic bleeding. In observational studies, a TDT was correlated with reduction in anastomotic leakage and no detectable differences in anastomotic bleeding. Both RCTs and observational studies demonstrated a comparable reduction in reoperation rate with TDT. These data in aggregate indicated that TDTs may not show superiority but emphasized differences between RCT and observational data.

60% Reduction of reoperations and complications for elderly patients with hip fracture through the implementation of a six-item improvement programme

IntroductionHip fractures are common, serious and costly fractures in the elderly population. Several guidelines seeking to ensure best practice have been introduced. Although our institution complied with national guidelines for...

Cost-Effectiveness of perioperative Vaginally Administered estrogen in postmenopausal women undergoing prolapse surgery (EVA trial): study protocol for a multicenter double-blind randomized placebo-controlled trial

BackgroundSurgery for pelvic organ prolapse (POP) is associated with high recurrence rates. The costs associated with the treatment of recurrent POP are huge, and the burden from women who encounter recurrent POP, negatively impacts their quality of life. Estrogen therapy might improve surgical outcome for POP due to its potential beneficial effects. It is thought that vaginal estrogen therapy improves healing and long-term maintenance of connective tissue integrity. Hence, this study aims to evaluate the cost-effectiveness of perioperative vaginal estrogen therapy in postmenopausal women undergoing POP surgery.MethodsThe EVA trial is a multi-center double-blind randomized placebo-controlled trial conducted in the Netherlands comparing the effectiveness and costs-effectiveness of vaginal estrogen therapy. This will be studied in 300 postmenopausal women undergoing primary POP surgery, with a POP-Q stage of ≥ 2. After randomization, participants administer vaginal estrogen cream or placebo cream from 4 to 6 weeks preoperative until 12 months postoperative. The primary outcome is subjective improvement of POP symptoms at 1 year follow-up, measured with the Patient Global Impression of Improvement (PGI-I) scale. Secondary outcomes are POP-Q anatomy in all compartments, re-interventions, surgery related complications, general and disease specific quality of life, sexual function, signs and complaints of vaginal atrophy, vaginal pH, adverse events, costs, and adherence to treatment. Follow up is scheduled at 6 weeks, 6 months and 12 months postoperative. Data will be collected using validated questionnaires and out-patient visits including gynecological examination performed by an independent gynecologist.DiscussionThis study investigates whether perioperative vaginal estrogen will be cost-effective in the surgical treatment of POP in postmenopausal women. It is hypothesized that estrogen therapy will show a reduction in recurrent POP symptoms and a reduction in reoperations for POP, with subsequent improved quality of life among women and cost savings.Trial registrationNetherlands Trial Registry: NL6853; registered 19-02-2018, https://www.trialregister.nl/trial/6853. EudraCT: 2017-003144-21; registered: 24-07-2017.

Changes in Reoperation After Publication of Consensus Guidelines on Margins for Breast-Conserving Surgery

The 2014 publication of the Society of Surgical Oncology-American Society for Radiation Oncology (SSO-ASTRO) Consensus Guideline on Margins for Breast-Conserving Surgery recommended a negative margin definition of no ink on tumor. Adoption of this guideline would represent a major change in surgical practice that could lower the rates of reoperation. To assess changes in reoperation rates after publication of the SSO-ASTRO guideline. A systematic search of Embase, PREMEDLINE, Evidence-Based Medicine Reviews, Scopus, and Web of Science for biomedical literature published from January 2014 to July 2019 was performed. This search was supplemented by web searches and manual searching of conference abstracts. Included studies compared the reoperation rates in preguideline vs postguideline cohorts (actual change), retrospectively applied the SSO-ASTRO guideline to a preguideline cohort (projected change), or described the economic outcomes of the guideline. Study characteristics and reoperation rates were extracted independently by 2 reviewers. Odds ratios (ORs) were pooled by random effects meta-analysis. Analyses were stratified by study setting (institutional or population) and preguideline accepted margins. The economic outcomes of the guideline were summarized narratively. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was followed. Odds ratios for postguideline vs preguideline reoperation rates. From 1114 citations, 30 studies (with 599 016 participants) reported changes in reoperation rates. Studies included a median (range) of 487 (100-521 578) participants, and 20 studies were undertaken in the US, 6 in the UK, 3 in Canada, and 1 in Australia. Among 21 studies of actual changes, pooled ORs showed a statistically significant reduction in reoperation, with an OR lower in institution-based studies than in population-based studies (OR, 0.62 [95% CI, 0.52-0.74] vs 0.76 [95% CI, 0.72-0.80]; P = .04 for subgroup differences). Among 9 studies of projected changes, the pooled OR was lower for preguideline margin thresholds of 2 mm or more compared with 1 mm (OR, 0.47 [95% CI, 0.40-0.56] vs 0.85 [95% CI, 0.79-0.91; P < .001 for subgroup differences). Projected changes were likely to overestimate actual changes. Six studies that estimated the postguideline economic outcome found the guideline to be potentially cost saving, with a median (range) saving of US $3540 ($1800-$25 650) per woman avoiding reoperation. This study found a decrease in reoperation rates after the publication of the SSO-ASTRO guideline; this reduction was greater at an institutional level than a population level, the latter reflecting the differences in guideline adoption between centers. These early outcomes may be conservative estimates of longer-term implications.

Implementation of Minimally Invasive Esophagectomy From a Randomized Controlled Trial Setting to National Practice.

The aim of this study was to examine the external validity of the randomized TIME trial, when minimally invasive esophagectomy (MIE) was implemented nationally in the Netherlands, using data from the Dutch Upper GI Cancer Audit (DUCA) for transthoracic esophagectomy. Original patient data from the TIME trial were extracted along with data from the DUCA dataset (2011-2017). Multivariate analysis, with adjustment for patient factors, tumor factors, and year of surgery, was performed for the effect of MIE versus open esophagectomy on clinical outcomes. One hundred fifteen patients from the TIME trial (59 MIE v 56 open) and 4,605 patients from the DUCA dataset (2,652 MIE v 1,953 open) were included. In the TIME trial, univariate analysis showed that MIE reduced pulmonary complications and length of hospital stay. On the contrary, in the DUCA dataset, MIE was associated with increased total and pulmonary complications and reoperations; however, benefits included increased proportion of R0 margin and lymph nodes harvested, and reduced 30-day mortality. Multivariate analysis from the TIME trial showed that MIE reduced pulmonary complications (odds ratio [OR], 0.19; 95% CI, 0.06 to 0.61). In the DUCA dataset, MIE was associated with increased total complications (OR, 1.36; 95% CI, 1.19 to 1.57), pulmonary complications (OR, 1.50; 95% CI, 1.29 to 1.74), reoperations (OR, 1.74; 95% CI, 1.42 to 2.14), and length of hospital stay. Multivariate analysis of the combined and MIE datasets showed that inclusion in the TIME trial was associated with a reduction in reoperations, Clavien-Dindo grade > 1 complications, and length of hospital stay. When adopted nationally outside the TIME trial, MIE was associated with an increase in total and pulmonary complications and reoperation rate. This may reflect nonexpert surgeons outside of high-volume centers performing this minimally invasive technique in a nonstandardized fashion outside of a controlled environment.

Posttransplant Complications: Biliary and Vascular

Since it was first described, the overall patient and graft survival after liver transplant have improved with advances in immunosuppression and surgical and anesthetic techniques. Despite this improvement, there continues to be both biliary and vascular complications associated with this life-saving operation, which can lead to further procedures, reoperation, and retransplant. Advances in endoscopic and percutaneous techniques have had a significant impact on the perioperative management of posttransplant complications, resulting in a reduction in reoperations and retransplants. Changes in intraoperative management with the use of thrombolytic therapy have allowed for the expansion of the donor pool, allowing the use of donation after cardiac death with increased safety and decreased risk of ischemic biliary tract injury. This article serves to highlight the vascular and biliary complications following transplant, their etiology, diagnosis, and management. This review contains 9 figures, 1 table, and 33 references. Key Words: bile leak, biliary stricture, deceased donor liver transplant, donation after brain death (DBD), donation after cardiac death, hepatic artery thrombosis, ischemic cholangiopathy, living donor liver transplant, portal vein thrombosis, thrombolytic therapy, venous outflow obstruction.

Posttransplant Complications: Biliary and Vascular

Since it was first described, the overall patient and graft survival after liver transplant have improved with advances in immunosuppression and surgical and anesthetic techniques. Despite this improvement, there continues to be both biliary and vascular complications associated with this life-saving operation, which can lead to further procedures, reoperation, and retransplant. Advances in endoscopic and percutaneous techniques have had a significant impact on the perioperative management of posttransplant complications, resulting in a reduction in reoperations and retransplants. Changes in intraoperative management with the use of thrombolytic therapy have allowed for the expansion of the donor pool, allowing the use of donation after cardiac death with increased safety and decreased risk of ischemic biliary tract injury. This article serves to highlight the vascular and biliary complications following transplant, their etiology, diagnosis, and management. This review contains 9 figures, 1 table, and 33 references. Key Words: bile leak, biliary stricture, deceased donor liver transplant, donation after brain death (DBD), donation after cardiac death, hepatic artery thrombosis, ischemic cholangiopathy, living donor liver transplant, portal vein thrombosis, thrombolytic therapy, venous outflow obstruction.

Tranexamic acid and post-tonsillectomy hemorrhage: propensity score and instrumental variable analyses.

Although post-tonsillectomy hemorrhage occurs rarely, it can be life-threatening. Previous studies showed that tranexamic acid (TXA) had insignificant association with the rate of post-tonsillectomy hemorrhage, but those findings were limited by small sample sizes. The purpose of this study was to examine the effectiveness of TXA in preventing post-tonsillectomy hemorrhage using nationwide database. Data of a retrospective cohort of 117,598 patients from 750 hospitals, who had undergone tonsillectomy between 2010 and 2016, were drawn from the Diagnosis Procedure Combination database in Japan and studied. Propensity score-matched analysis showed no significant differences in proportions of reoperation or blood transfusion after tonsillectomy between the treatment (TXA from the day of tonsillectomy) and control groups (1.50% vs. 1.47%, p = 0.64). Instrumental variable analysis also showed no significant differences (odds ratio, 0.98; 95% confidence interval, 0.86-1.13; p = 0.82). Higher proportions of reoperation or blood transfusion were significantly associated with male sex, older age, emergency hospitalization, prolonged anesthesia, and medium hospital volume (annual number of tonsillectomies). Administration of TXA from the day of tonsillectomy is not associated with reduction in reoperation or blood transfusion rates.

Dual-chamber pacemakers for treating symptomatic bradycardia due to sick sinus syndrome without atrioventricular block: a systematic review and economic evaluation.

Bradycardia [resting heart rate below 60 beats per minute (b.p.m.)] can be caused by conditions affecting the natural pacemakers of the heart, such as sick sinus syndrome (SSS) and atrioventricular (AV) blocks. People suffering from bradycardia may present with palpitations, exercise intolerance and fainting. The only effective treatment for patients suffering from symptomatic bradycardia is implantation of a permanent pacemaker. To appraise the clinical effectiveness and cost-effectiveness of dual-chamber pacemakers compared with single-chamber atrial pacemakers for treating symptomatic bradycardia in people with SSS and no evidence of AV block. All databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Health Technology Assessment database, NHS Economic Evaluations Database) were searched from inception to June 2014. A systematic review of the clinical and economic literature was carried out in accordance with the general principles published by the Centre for Reviews and Dissemination. Randomised controlled trials (RCTs) evaluating dual-chamber and single-chamber atrial pacemakers and economic evaluations were included. Pairwise meta-analysis was carried out. A de novo economic model was developed. Of 493 references, six RCTs were included in the review. The results were predominantly influenced by the largest trial DANPACE. Dual-chamber pacing was associated with a statistically significant reduction in reoperation [odds ratio (OR) 0.48, 95% confidence interval (CI) 0.36 to 0.63] compared with single-chamber atrial pacing. The difference is primarily because of the development of AV block requiring upgrade to a dual-chamber device. The risk of paroxysmal atrial fibrillation was also reduced with dual-chamber pacing compared with single-chamber atrial pacing (OR 0.75, 95% CI 0.59 to 0.96). No statistically significant difference was found between the pacing modes for mortality, heart failure, stroke, chronic atrial fibrillation or quality of life. However, the risk of developing heart failure may vary with age and device. The de novo economic model shows that dual-chamber pacemakers are more expensive and more effective than single-chamber atrial devices, resulting in a base-case incremental cost-effectiveness ratio (ICER) of £6506. The ICER remains below £20,000 in probabilistic sensitivity analysis, structural sensitivity analysis and most scenario analyses and one-way sensitivity analyses. The risk of heart failure may have an impact on the decision to use dual-chamber or single-chamber atrial pacemakers. Results from an analysis based on age (> 75 years or ≤ 75 years) and risk of heart failure indicate that dual-chamber pacemakers dominate single-chamber atrial pacemakers (i.e. are less expensive and more effective) in older patients, whereas dual-chamber pacemakers are dominated by (i.e. more expensive and less effective) single-chamber atrial pacemakers in younger patients. However, these results are based on a subgroup analysis and should be treated with caution. In patients with SSS without evidence of impaired AV conduction, dual-chamber pacemakers appear to be cost-effective compared with single-chamber atrial pacemakers. The risk of developing a complete AV block and the lack of tools to identify patients at high risk of developing the condition argue for the implantation of a dual-chamber pacemaker programmed to minimise unnecessary ventricular pacing. However, considerations have to be made around the risk of developing heart failure, which may depend on age and device. This study is registered as PROSPERO CRD42013006708. The National Institute for Health Research Health Technology Assessment programme.

Cost-Effectiveness of Referring Patients to Centers of Excellence for Mitral Valve Surgery

BACKGROUNDThe 2014 American Heart Association/American College of Cardiology Valvular Heart Disease Guidelines state that mitral valve diseases should be repaired at a Center of Excellence (CoE). We evaluate the cost-effectiveness of such referrals. METHODSWe estimate patients’ life expectancy based on projected survival of patients after mitral valve surgery and develop a cost model to calculate short- and long-term benefits and costs to both patients and payers. Benefits include increased life expectancy and avoidance of medical complications for patients. Short-term costs include all upfront payments by patients and payers at the time of discharge. Long-term costs include all payments associated with the condition that prompted the surgical procedure incurred during the remainder of a patient’s life. We assess cost-effectiveness of treating patients with various ages and major comorbidities at CoEs vs non-CoEs. RESULTSFull implementation of the guidelines would result in an increase in the percentage of patients obtaining mitral valve repair instead of valve replacement from 58% to 72%. Depending on the patient’s age and comorbidities, it would also result in a 6.64% to 12.47% reduction in mortality, 7.85% to 9.97% reduction in reoperation, 9.97% to 17.16% reduction in stroke, and an average gain of 3.77 to 9.88 months of life expectancy. Finally, greater reliance on CoEs results in financial savings to payers, due to avoidance of the costs of future complications.CONCLUSIONPatients benefit from mitral valve surgery at a CoE regardless of their age or comorbidities. Payers may incur additional short-term costs when patients are referred to a CoE, but these are fully offset by long-term savings at the current repair rate gap of 24% between CoEs and non-CoEs in New York State. Redesigning co-pay structures and/or refining the set of patients who are referred to CoEs could further align the incentives of patients and payers on a case-by-case basis and achieve an even more desirable social outcome.

Pedicle Screw Malposition in Revision Spinal Surgery: Efficacy of Intraoperative CT-Based Navigation

Introduction The improved screw accuracy of intraoperative 3D imaging with navigation has been primarily reported in cadaveric studies and spinal deformity surgeries. Revision surgery poses unique technical challenges for pedicle screw instrumentation because of an established fusion mass, lack of reliable anatomical landmarks, and limited fixation options. The aim of this study was to examine our early experience of pedicle screw malposition rates in revision surgeries comparing O-arm and StealthStation navigated cases to the traditional freehand technique and evaluate the impact on patient outcome. Materials and Methods This ambispective study compared two matched cohorts of patients undergoing revision thoracolumbar surgery. The study group comprised 56 consecutive patients who underwent O-arm and StealthStation navigation-assisted pedicle screw instrumentation (NAV) between January 1, 2008 and December 31, 2012. The control group comprised 34 historical matched cases with surgery between January 1, 2006 and December 31, 2008, using traditional (freehand or with fluoroscopy), nonnavigated techniques (non-NAV). Cases were matched on age, gender, surgical location, number of surgical levels, and primary diagnosis. We examined the differences in screw placement and accuracy, patient outcomes, and surgery-related adverse events. Results There was a significant difference in the number of misplaced screws between the NAV and non-NAV groups (31 vs. 54, p &lt; 0.001). The average number of misplaced screws per case was 0.57 (SD = 0.92) with navigation and 1.86 (SD = 2.49) without ( p = 0.01). No difference existed in the number of screws revised intraoperatively (10 vs. 7, p = 0.54). One patient in the NAV group and two patients in the non-NAV group required early postoperative screw revision during the same admission ( p = 0.33). No screws in the NAV group required revision during subsequent admissions. No difference was observed in grade of screw malposition ( p = 0.11) or anatomical location of malposition ( p = 0.26). Anatomically, a majority of misplaced screws were located below T6 in both groups. The use of navigation resulted in a significant difference in intraoperative massive blood loss (&gt; 2L in 3 hours), 3.3% of the NAV cases compared with 7.8% of the non-NAV cases. There was no significant difference in the duration of surgery ( p = 0.11), incidence of intraoperative dural tear ( p = 1.00), wound infection ( p = 1.00), or length of stay ( p = 0.78). Conclusion This early analysis of our experience in revision surgery demonstrates an increased accuracy of pedicle screw placement utilizing O-arm imaging and StealthStation navigation systems, without an increase in OR time. Small case numbers likely explain the comparable early screw revision rates, as our experience with a larger number of degenerative cases demonstrates a statistically significant reduction in reoperation for symptomatic screw misplacement. The use of intraoperative 3D imaging and navigation in revision spine surgeries results in lower mean blood loss, and fewer cases of massive intraoperative blood loss may occur because navigation avoids the extent of dissection normally required and facilitates safe pedicle screw instrumentation while minimizing surgical exposure. Data collection and analysis is ongoing to examine diagnosis-specific incidence of screw malposition and patient outcome.

Is intraoperative frozen section analysis of reexcision specimens of value in preventing reoperation in breast-conserving therapy?

A prior study at our institution showed a marked reduction in reoperation for margin reexcision following the development of an intraoperative frozen section evaluation of margins (FSM) practice on lumpectomy specimens from patients undergoing breast-conserving therapy (BCT). This study aimed to examine the frequency of FSM utilization, FSM pathology performance, and outcomes for BCT patients undergoing margin reexcision only. Consecutive reexcision-only specimens were reviewed from a 40-month period following the development of the FSM practice. Clinicopathologic features and patient outcomes were assessed. FSM was performed in 46 (30.7%) of 150 reexcision-only operations. Of the 46 operations with FSM, there were 28 (60.9%) true-negative, 12 (26.1%) true-positive, six (13.0%) false-negative, and no false-positive cases. There was no difference in further reexcision, total operations, or conversion to mastectomy among patients with and without FSM. Need for further reexcision was significantly associated with tumor multifocality (P = .008). Despite overall good pathology performance for FSM in reexcision-only specimens, use of FSM did not affect patient outcome. Rather, underlying disease biology appeared most significant in predicting whether adequate surgical margins could be attained.

Perioperative goal-directed hemodynamic optimization using noninvasive cardiac output monitoring in major abdominal surgery: a prospective, randomized, multicenter, pragmatic trial: POEMAS Study (PeriOperative goal-directed thErapy in Major Abdominal Surgery).

In this study, our objective was to determine whether a perioperative hemodynamic protocol based on noninvasive cardiac output monitoring decreases the incidence of postoperative complications and hospital length of stay in major abdominal surgery patients requiring intensive care unit admission. Secondary objectives were the time to peristalsis recovery and the incidence of wound infection, anastomotic leaks, and mortality. A randomized clinical trial was conducted in 6 tertiary hospitals. One hundred forty-two adult patients scheduled for open colorectal surgery, gastrectomy, or small bowel resection were enrolled. A hemodynamic protocol including fluid administration and vasoactive drugs based on arterial blood pressure, cardiac index, and stroke volume response was compared with standard practice. Patients were followed until hospital discharge (determined by a surgeon blinded to the study) or death. In contrast to previous studies, we designed a pragmatic trial (as opposed to explanatory trials) to mimic real practice and obtain maximal external validity for the study. Fluid administration was similar except for the number of colloid boluses (2.4 ± 1.8 [treated] vs 1.3 ± 1.4 [control]; P < 0.001) and packed red blood cell units (0.6 ± 1.3 [treated] vs 0.2 ± 0.6 [control]; P = 0.019). Dobutamine was used in 25% (intraoperatively) and 19.4% (postoperatively) of the treated patients versus 1.4% and 0% in the control group (P < 0.001). We have observed a reduction in reoperations in the treated group (5.6% vs 15.7%; P = 0.049). However, no significant differences were observed in overall complications (40% vs 41%; relative risk 0.99 [0.67-1.44]; P = 0.397), length of stay (11.5 [8-15] vs 10.5 [8-16]; P = 0.874), time to first flatus (62 hours [40-76] vs 72 hours [48-96]; P = 0.180), wound infection (7 vs 14; P = 0.085), anastomotic leaks (2 vs 5; P = 0.23), or mortality (4.2% vs 5.7%; P = 0.67). The results of our pragmatic study indicate that a perioperative hemodynamic protocol guided by a noninvasive cardiac output monitor was not associated with a decrease in the incidence of overall complications or length of stay in major abdominal surgery.

Process improvement in cardiac surgery: Development and implementation of a reoperation for bleeding checklist

High-performing health care organizations differentiate themselves by focusing on continuous process improvement initiatives aimed at enhancing patient outcomes. Reoperation for bleeding is an event associated with considerable morbidity risk. Hence, our primary objective was to develop and implement a formal operative checklist to reduce technical reasons for postoperative bleeding. From January 1, 2011, through June 30, 2012, 5812 cardiac surgical procedures were performed at Cleveland Clinic (Cleveland, OH). A multidisciplinary team developed a simple, easy-to-perform hemostasis checklist based on the most common sites of bleeding. An extensive educational in-service was performed before limited, then universal, checklist implementation. Geometric charts were used to track the number of cases between consecutive reoperations for bleeding. We compared these before (phase 0) and after the first limited implementation phase (phase 1) and the universal implementation phase (phase 2) of the checklist. The average number of cases between consecutive reoperations for bleeding increased from 32 in phase 0 to 53 in both phase 1 (P=.002) and phase 2 (P=.01). A substantial reduction in reoperation for bleeding cases followed implementation of a formalized hemostasis checklist. Our findings underscore the important influence of memory aids that focus attention on surgical techniques to improve patient outcomes in a complex, operative work environment.