Surgical Practice Patterns Research Articles

Penile cancer: Welcome changes in disease management and remaining challenges.

Achieving the best possible practice in the management of patients with penile cancer is hampered by a lack of evidence owing to the rare occurrence of this disease. New population-based data from the USA show improved surgical and medical practice patterns but also highlight challenges in providing optimum care to all patients.

Trends in Inpatient Urological Surgery Practice Patterns

IntroductionAs the nation’s population ages and the number of practicing urologists per capita decreases, characterization of practice patterns is essential to understand the current state of the urological workforce and anticipate future needs. Accordingly, we examined trends in adult inpatient urological surgery practice patterns during a 5-year period. MethodsWe used the Nationwide Inpatient Sample data from 2005 through 2009 to identify surgeons and urological surgeries. We classified the urological surgeries into 1 of 7 clinical domains (endourology and stone disease, incontinence, urogenital reconstruction, urologic oncology, benign prostate, renal transplant, and other urological procedures). For each urological surgeon 3 parameters were determined for each year, including 1) case diversity (the number of distinct urological clinical domains in which he/she performed 2 or more procedures per year), 2) subspecialty (the predominant clinical domain of cases that each surgeon performed) and 3) subspecialty focus (the proportion of a surgeon’s total urological cases per year that belonged to his/her assigned clinical domain). We examined trends in these metrics during a 5-year period and compared results between urban and rural practice settings. ResultsWe analyzed data for 2,237 individual surgeons performing 144,138 inpatient surgeries. Urologists’ practice patterns evolved with time toward less case diversity (p <0.001) and greater subspecialty focus (p <0.001). These trends were more pronounced for surgeons practicing in urban vs rural settings (p <0.05). ConclusionsAt a national level urologists’ inpatient surgical practice patterns are narrowing, with less case diversity and greater subspecialty focus. These trends are even more prominent among urologists in urban compared with rural practice settings.

Internal mammary sentinel lymph node biopsy: abandon or persist?

Although the 2009 American Joint Committee on Cancer incorporated the internal mammary sentinel lymph node biopsy (IM-SLNB) concept, there has been little change in surgical practice patterns due to the low visualization rate of internal mammary sentinel lymph nodes with the traditional injection technique. Meanwhile, as internal mammary lymph nodes (IMLN) metastases are mostly found concomitantly with axillary lymph nodes (ALN) metastases, previous IM-SLNB clinical trials fail to evaluate the status of IMLN in patients who are really in need (only in clinically ALN negative patients). Our modified injection technique (periareolar intraparenchymal, high volume, and ultrasonographic guidance) significantly improved the visualization rate of internal mammary sentinel lymph nodes, making the routine IM-SLNB possible in daily practice. IM-SLNB could provide individual minimally invasive staging, prognosis, and decision-making for breast cancer patients, especially for patients with clinically positive ALN. Moreover, IMLN radiotherapy should be tailored and balanced between the potential benefit and toxicity, and IM-SLNB-guided IMLN radiotherapy could achieve this goal. In the era of effective adjuvant therapy, within the changing treatment approach – more systemic therapy, less loco-regional therapy – clinicians should deliberate the application of regional IMLN therapy.

Gender gap and declining surgical activity among new graduates: cataract surgery in Ontario

ObjectiveTo investigate the proportion of ophthalmologists performing cataract surgery; the volume performed; and the influence of career stage, sex, and trends over time. DesignPopulation-based study of cataract surgical practice patterns among all ophthalmologists in Ontario, Canada, from April 1999 to March 2013. ParticipantsAll active ophthalmologists in Ontario, Canada, providing government health care for the provincial population of approximately 13 million. MethodsThe IntelliHealth database operated by the Ministry of Health and Long Term Care, which has excellent accuracy for procedure performance, was used to obtain anonymized physician services. ResultsThe percentage of ophthalmologists performing cataract surgery decreased (68% to 64%), but the yearly mean number of cataract surgeries performed per person increased 1.5 times (307.7 to 470.2). The percentage of early-career ophthalmologists performing cataract surgery declined from 85% to 62%, and this was accompanied by a decline in the median number of cases performed per early-career surgeon (from 243.0 to 169.5). This decline in surgical activity among new graduates was accompanied by growth in the percentage of high-volume and late-career surgeons. In each of the years studied, males performed more surgeries per person than their female counterparts, and this gap grew from 1.4 times to 1.7 times more cataract surgery from 2000 to 2013. ConclusionsEarly-career ophthalmologists are becoming less active with cataract surgery, which may be explained by the increasing surgical activity among late-career and high-volume ophthalmologists. A large sex and volume gap exists among cataract surgeons, which continues to increase.

Proportion of medical-only versus surgical ophthalmology practices: associations and trends

ObjectiveTo investigate what proportion of ophthalmologists have medical-only practices and the influence of career stage, sex, and time. DesignPopulation-based study of medical and surgical practice patterns among all ophthalmologists in Ontario, Canada, from April 1999 to March 2013. ParticipantsAll active ophthalmologists in Ontario, Canada, providing universal health care for the provincial population of approximately 13 million. MethodsThe IntelliHealth database operated by the Ministry of Health and Long Term Care, which has excellent accuracy for procedure performance, was used to obtain anonymized physician services. Ophthalmologists were categorized as surgical or medical-only based on billing claims data. ResultsThe proportion of medical-only versus surgical ophthalmologists changed little over the 14-year period, averaging 30.5% medical-only and 69.5% surgical. Recent graduates showed a decreasing trend toward performing surgery of 1.6% per year, whereas late-career ophthalmologists demonstrated an increasing trend of 1.5% per year. Female ophthalmologists were less likely to perform surgery than male ophthalmologists but showed an increasing surgical trend. Ophthalmologists performing surgery saw on average 1.6 times the number of yearly consultations and assessments than their medical peers. Late-career ophthalmologists saw significantly fewer patients than their younger counterparts in each year studied. ConclusionsA significant number of ophthalmologists have medical-only practices. The large majority of late-career ophthalmologists have transitioned to a medical-only practice. A decreasing trend in the proportion of young ophthalmologists performing surgery coincides with a growth of late-career surgical ophthalmologists, which may be limiting surgical opportunities for new graduates.

The Gender Divide: The Impact of Surgeon Gender on Surgical Practice Patterns in Urology

There is a perception in urology that female urologists encounter gender based role assignments and are often pigeonholed into caring for more female patients and female specific urological issues than their male colleagues. We assessed the influence of surgeon gender on patient gender demographics by exploring the surgical case logs of American urologists. Six-month case logs of certifying urologists from 2003 to 2012 were obtained from the ABU (American Board of Urology). We reviewed case logs based on CPT codes of common urological procedures, focusing on 6 index gender neutral and gender specific procedure groups, including treatment of nephrolithiasis, nephrectomy, resection of bladder tumors, treatment of stress urinary incontinence, elective sterilization and treatment of prostate cancer. Among a cohort of 6,166 urologists 1,011,800 cases were logged. Female surgeons operated on a significantly higher percent of female patients than their male peers (54.4% vs 32.5%, p <0.01). Female surgeons performed significantly more female specific procedures, such as slings, than their male counterparts (18vs 10 per year, p <0.001). Male urologists performed significantly more male specific procedures than their female colleagues, including 3 times as many vasectomies (32 vs 12 per year, p <0.001) and more than twice as many prostatectomies (15 vs 6 per year, p <0.001). These trends were consistent across all subspecialties and geographic regions (p <0.01). Female surgeon gender has a significant influence on patient gender demographics among index urological procedures. As the number of women in urology grows, increasing attention to gender biases is necessary to understand how these disparities will shape the clinical landscape.

An Analysis of Case Logs From American Urologists in the Treatment of Peyronie's Disease

To review recent trends in the treatment of Peyronie's disease (PD), we assess surgical practice patterns of urologists in the United States with emphasis on specialty training, demographics, and temporal changes. Six-month case log data of American urologists between 2004 and 2013 were obtained from the American Board of Urology. Current Procedural Terminology (CPT) codes were used to identify surgical procedures, including plaque injection. A total of 6564 urologists were included in the surgical cohort, logging 8195 surgical procedures for PD. Only 15.4% of urologists (1012/6564) reported a surgical case for PD. Andrologists (urologist subspecialty designation) accounted for 5.3% of these urologists (54/1012) and performed 18.5% of PD procedures (P = .0001). The frequency of plaque injections increased from 499 in 2004 to 797 in 2013, a 59% increase, whereas surgical correction remained stable. Urologists performed four times as many injections as surgical procedures for PD (P = .001) with andrologists more likely to attempt injection than surgical correction (P = .045). Among surgeries performed, 73.2% were corrections of angulation without plaque excision, 20.5% were excisions of plaque (with possible grafting) up to 5 cm, and 6.2% were excisions of plaque (with possible grafting) >5 cm. There was a 313% increase in the ratio of plication to plaque manipulation (0.92 in 2004 to 2.91 in 2013). PD is treated by a minority of urologists and disproportionately by subspecialist in andrology. When compared with surgical interventions, excluding prosthesis implantation, most surgeons favor conservative treatment. The majority of surgical corrections were corrections of angulation without plaque manipulation.

Internal Mammary Sentinel Lymph Node Biopsy With Modified Injection Technique: High Visualization Rate and Accurate Staging.

Although the 2009 American Joint Committee on Cancer incorporated the internal mammary sentinel lymph node biopsy (IM-SLNB) concept, there has been little change in surgical practice patterns because of the low visualization rate of internal mammary sentinel lymph nodes (IMSLN) with the traditional radiotracer injection technique. In this study, various injection techniques were evaluated in term of the IMSLN visualization rate, and the impact of IM-SLNB on the diagnostic and prognostic value were analyzed.Clinically, axillary lymph nodes (ALN) negative patients (n = 407) were divided into group A (traditional peritumoral intraparenchymal injection) and group B (modified periareolar intraparenchymal injection). Group B was then separated into group B1 (low volume) and group B2 (high volume) according to the injection volume. Clinically, ALN-positive patients (n = 63) were managed as group B2. Internal mammary sentinel lymph node biopsy was performed for patients with IMSLN visualized.The IMSLN visualization rate was significantly higher in group B than that in group A (71.1% versus 15.5%, P < 0.001), whereas the axillary sentinel lymph nodes were reliably identified in both groups (98.9% versus 98.3%, P = 0.712). With high injection volume, group B2 was found to have higher IMSLN visualization rate than group B1 (75.1% versus 45.8%, P < 0.001). The IMSLN metastasis rate was only 8.1% (12/149) in clinically ALN-negative patients with successful IM-SLNB, and adjuvant treatment was altered in a small proportion. The IMSLN visualization rate was 69.8% (44/63) in clinically ALN-positive patients with the IMSLN metastasis rate up to 20.5% (9/44), and individual radiotherapy strategy could be guided with the IM-SLNB results.The modified injection technique (periareolar intraparenchymal, high volume, and ultrasound guidance) significantly improved the IMSLN visualization rate, making the routine IM-SLNB possible in daily practice. Internal mammary sentinel lymph node biopsy could provide individual minimally invasive staging, prognosis, and decision making of the internal mammary radiotherapy, especially for clinically ALN-positive patients.

Which Fixation Device is Preferred for Surgical Treatment of Intertrochanteric Hip Fractures in the United States? A Survey of Orthopaedic Surgeons.

The best treatment for intertrochanteric hip fractures is controversial. The use of cephalomedullary nails has increased, whereas use of sliding hip screws has decreased despite the lack of evidence that cephalomedullary nails are more effective. As current orthopaedic trainees receive less exposure to sliding hip screws, this may continue to perpetuate the preferential use of cephalomedullary nails, with important implications for resident education, evidence-based best practices, and healthcare cost. We asked: (1) What are the current practice patterns in surgical treatment of intertrochanteric fractures among orthopaedic surgeons? (2) Do surgical practice patterns differ based on surgeon characteristics, practice setting, and other factors? (3) What is the rationale behind these surgical practice patterns? (4) What postoperative approaches do surgeons use for intertrochanteric fractures? A web-based survey containing 20 questions was distributed to active members of the American Academy of Orthopaedic Surgeons. Three thousand seven-hundred eighty-six of 10,321 invited surgeons participated in the survey (37%), with a 97% completion rate (3687 of 3784 responded to all questions in the survey). The survey elicited information regarding surgeon demographics, preferred management strategies, and decision-making rationale for intertrochanteric fractures. Surgeons use cephalomedullary nails most frequently for treatment of intertrochanteric hip fractures. Sixty-eight percent primarily use cephalomedullary nails, whereas only 19% primarily use sliding hip screws, and the remaining 13% use cephalomedullary nails and sliding hip screws with equal frequency. The cephalomedullary nail was the dominant approach regardless of experience level or practice setting. Surgeons who practiced in a nonacademic setting (71% versus 58%; p < 0.001), did not supervise residents (71% versus 61%; p < 0.001), or treated more than five intertrochanteric fractures a month (78% versus 67%; p < 0.001) were more likely to use primarily cephalomedullary nails. Of the surgeons who used only cephalomedullary nails, ease of surgical technique (58%) was cited as the primary reason, whereas surgeons who used only sliding hip screws cite familiarity (44%) and improved outcomes (37%) as their primary reasons. Of those who use only short cephalomedullary nails, ease of technique (59%) was most frequently cited. Postoperatively, 67% allow the patient to bear weight as tolerated. Nearly all respondents (99.5%) use postoperative chemical thromboprophylaxis. Despite that either sliding hip screw or cephalomedullary nail fixation are associated with equivalent outcomes for most intertrochanteric femur fractures, the cephalomedullary nail has emerged as the preferred construct, with the majority of surgeons believing that a cephalomedullary nail is easier to use, associated with improved outcomes, or is biomechanically superior to a sliding hip screw. The difference between what is evidence-based and what is done in clinical practice may be attributed to several factors, including financial considerations, educational experience, or inability of our current outcomes measures to reflect the experiences of surgeons. The educators, researchers, and policymakers among us must work harder to better define the roles of sliding hip screws and cephalomedullary nails and ensure that the increasing population with hip fractures receives high-quality and economically responsible care. Level V, therapeutic study.

Abstract P2-01-22: Internal mammary sentinel lymph node biopsy with modified injection technique: High visualization rate and accurate staging

Abstract Background: Although the 2009 AJCC incorporated the internal mammary sentinel lymph node biopsy (IM-SLNB) concept, there has been little change in surgical practice patterns due to the low internal mammary sentinel lymph nodes (IM-SLNs) visualization rate (VR) with the traditional radiotracer injection technique (average 13%, 0-37%). In this study, various injection techniques were evaluated in term of the IM-SLNs VR in clinically axilla lymph nodes (ALNs) negative patients, and the impact of IM-SLNB on the diagnostic and prognostic value were analyzed both in clinically ALNs negative (NCT01642511) and positive patients (NCT01668914). Methods: 340 patients with T1-2 invasive breast cancer were enrolled. Clinically ALNs negative patients (n=293) were divided into 3 groups according to the study period and radiotracer injection technique. Group A: traditional technique (peritumoral intraparenchymal injection) for the initial 58 cases; Group B: periareolar intraparenchymal injection under the ultrasonography guidance in the latter 235 cases, the injection sites were chosen at the 6 and 12 o’clock positions 0.5-1.0 cm from areola (about 2.0-4.0 cm from the nipple). Group B was then separated into 2 groups according to the radiotracer injection volume: Group B1, low volume (&amp;lt;0.5ml/point, n=41); Group B2, high volume (≥0.5ml/point, n=194). Clinically ALNs positive patients (n=47) were managed as group B2. IM-SLNB was performed for patients with IM-SLNs visualized on preoperative lymphoscintigraphy and/or detected by intraoperative gamma probe. Results: Clinically ALNs-negative: The IM-SLNs VR was significantly higher by lymphoscintigraphy in Group B than that in Group A (63.0% vs. 13.8%, P&amp;lt;0.001), while the axillary VR was similar in these two groups (84.3% vs. 77.6%, P=0.227). The VR of sentinel lymph nodes was improved by the intraoperative gamma probe compared to lymphoscintigraphy: Group A (axilla: 77.6%→98.3%, P=0.001; internal mammary: 13.8%→15.5%, P=0.794) and Group B (axilla: 84.3%→98.7%, P&amp;lt;0.001; internal mammary: 63.0%→70.6%, P=0.078). Group B2 was found to have the highest IM-SLNs VR (74.2% vs. 53.7% Group B1, P=0.009). The successful rate of IM-SLNB was 95.8%, and arrived 100% after 20 cases learning curve. In the patients who underwent IM-SLNB, the IM-SLNs metastases rate was 8.7%, systemic treatment was changed only in 4.3%; however, radiotherapy treatment was changed in 8.7%. For the patients with upper inner quadrant tumor, systemic and radiotherapy treatment was changed in 8.8% and 20.6%. Clinically ALNs-positive: IM-SLNB was performed in all patients with drainage to IM-SLNs (VR: 70.2%, 33/47); the successful rate was 100 % (33/33). The IM-SLNs was positive in 21.2% patients, and the internal mammary radiotherapy could be guided with this IM-SLNB results. Conclusions: The modified injection technique (periareolar intraparenchymal, high volume and ultrasonography guidance) significantly improved the IM-SLNs VR, making the routine IM-SLNB possible in daily practice. IM-SLNB could provide individual staging, prognosis, and decision-making of the internal mammary radiotherapy for breast cancer patients, especially in positive ALNs and high-risk negative ALNs patients. Citation Format: Peng-Fei Qiu, Bin-bin Cong, Rong-Rong Zhao, Yan-Bing Liu, Guo-Ren Yang, Peng Chen, Yong-Sheng Wang. Internal mammary sentinel lymph node biopsy with modified injection technique: High visualization rate and accurate staging [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-01-22.

Surgical Management of Stage T1 Renal Tumors in Canadian Academic Centers

The proportion of patients with stage 1 renal tumours receiving partial nephrectomy is considered a quality of care indicator. The objective of this study was to characterize surgical practice patterns at Canadian academic institutions for the treatment of these tumours. The Canadian Kidney Cancer Information System (CKCis) is a multicentre collaboration of 13 academic institutions in Canada. All patients with pathologic stage T1 renal tumours in CKCis were identified. Descriptive statistics were performed to characterize practice patterns over time. Associations between patient, tumour, and treatment factors with the use of partial nephrectomy were determined. From 1988 to April 2014, 1453 patients with pathologic stage 1 renal tumours were entered in the CKCis database. Of these, 977 (67%) patients had pT1a tumours; of these, 765 (78%) received partial nephrectomy. Of the total number of patients (1453), 476 (33%) had pT1b tumours; of these, 204 (43%) received partial nephrectomy. The use of partial nephrectomy increased over time from 60% to 90% for pT1a tumours and 20% to 60% for pT1b tumours. Stage pT1b (relative risk [RR] 0.56, 95% confidence interval [CI] 0.50-0.63) and minimally invasive surgical approach (RR 0.78, 95% CI 0.73-0.84 for pT1a and RR 0.23, 95% CI 0.17-0.30 for pT1b) were associated with decreased use of partial nephrectomy. Most patient factors including age, gender, body mass index, hypertension, and renal function were not significantly associated with use of partial nephrectomy (p > 0.05). Almost all pT1a and most pT1b renal tumours managed surgically at academic centres in Canada receive partial nephrectomy. The use of partial versus radical nephrectomy appears to occur independently of patient age and comorbid status, which may indicate that urologists are performing partial nephrectomy whenever technically feasible based on tumour factors. Although the ideal proportion patients receiving partial nephrectomy cannot be determined, treatment distribution observed in this cohort may indicate an achievable case distribution among experienced surgeons.

The role of laparoscopy in the management of pediatric appendicitis: a survey of Polish pediatric surgeons.

IntroductionDespite the increase in use of laparoscopic appendectomy (LA) in recent years, until now no nationwide survey on this issue has been performed in Poland.AimTo determine current surgical practice patterns among Polish pediatric surgeons in the treatment of appendicitis in children.Material and methodsThe nationwide survey was conducted in the form of an internet questionnaire asking for information concerning treatment of children suspected of having acute appendicitis in the years 2007–2011. Twenty-seven major pediatric surgical departments in Poland were invited to participate in the study.ResultsThe overall survey response rate was 70.37%. Laparoscopic appendectomy was offered in all departments except one. Laparoscopy was used in 33% of cases and was the standard procedure in 4 departments. In 1 center 100% of appendectomies were performed laparoscopically. The 3-port technique was used in all departments. Five centers offered transumbilical laparoscopic extracorporeal appendectomy and 2 centers single-port appendectomy. In LA the mesoappendix was mostly divided using bipolar or monopolar coagulation and the appendix was ligated using endoloops or was clipped. The mean hospitalization time was 3.31 days after laparoscopy and 5.47 days after open appendectomy.ConclusionsDespite an apparent consensus on some aspects of pediatric appendicitis among Polish pediatric surgeons, significant inconsistency exists in the operative approach. The low rate of LA suggests that LA still remains far from being a standard. Personal experience and preference have a major influence on the choice of operative approach. It is recommended that national guidelines be set up, which could standardize the care for children and training of pediatric surgery residents.

Surgical Care in Liberia and Implications for Capacity Building.

Situational needs of health care facilities inform the optimal allocation of resources and quality improvement efforts. This study examines surgical care delivery metrics at a tertiary care institution in Liberia. We retrospectively reviewed operative and ward logbooks from January 1 to December 31, 2012. Data parameters included patients' age, diagnosis, procedure, mortality, and perioperative provider information. In 2012, 1,036 operations were performed. The breakdown of adult surgical cases reveals 452 (45.1%) general surgery operations, 192 (18.5%) orthopedic operations, and 180 (17.4%) ophthalmic operations. Other significant case volume included urologic 53 (5.1%), ENT 36 (3.5%), neurosurgical 31 (3.0%), vascular 24 (2.3%), and plastic 14 (1.4%) operations. Pediatric patients accounted for 24.5% (243) of surgical cases, and 9% of pediatric surgical cases were for hydrocephalus. General, spinal, and total intravenous anesthesia was provided by non-physician personnel, except when surgeons provided their own anesthesia. Ward logs documented 7.4% mortality among all patients admitted to the surgical ward, most of which occurred after exploratory laparotomy (44%), in burn (14%) patients, and in patients with head/neck emergencies (12%). This operative log review can be used to identify surgical practice patterns, needs, and deficits in order to inform the growth of surgical capacity at Liberia's only tertiary medical institution. Using this data to identify critical areas of high-yield operations (e.g., for pediatric hydrocephalus), or excessively high mortality rates (e.g., in burn care), can focus the direction of limited resources toward areas of need. While the heavy reliance on non-consultant surgeons reflects human capacity shortages and a pressing need for postgraduate training programs, identifying the breadth of surgical expertise demonstrated in these operative logs reveals the proficiencies required of surgeons to provide comprehensive surgical care in this setting.

Patterns of surgical practice in very low birth weight neonates born in the United States: a Vermont Oxford Network analysis

Background/PurposeThe distribution of surgical care of very low birth weight (VLBW) neonates among centers with varying specialized care remains unknown. This study quantifies operations performed on VLBW neonates nationally with respect to center type. MethodsVLBW neonates born 2009–2012 were assessed using a prospectively collected multi-center database encompassing 80% of all VLBW neonates in the United States. Surgical centers were categorized based on availability of pediatric surgery (PS) and anesthesia (PA). Results48,711 major procedures (29,512 abdominal operations) were performed on 24,318 neonates. Of all patients, 20,892 (85.9%) underwent surgery at centers with PS and PA available on site. 1663 (6.8%) patients were treated at centers with neither specialty on site. Neonates requiring complex operations were more likely to receive surgery at centers with both PS and PA on staff than those requiring non-complex operations (95.6% vs 93.6%). ConclusionThis study confirms that most operations on VLBW neonates in the U.S. are performed at centers with pediatric surgeons and anesthesiologists on staff. Further research is necessary, however, to elucidate why a significant minority of this challenging population continues to be managed at centers without pediatric specialists.

Practice patterns of carotid endarterectomy as performed by different surgical specialties at a single institution and the effect on perioperative stroke and cost of preoperative imaging

Carotid endarterectomy (CEA) is currently performed by various surgical specialties with varying outcomes. This study analyzes different surgical practice patterns and their effect on perioperative stroke and cost. This is a retrospective analysis of prospectively collected data of 1000 consecutive CEAs performed at ourinstitution by three different specialties: general surgeons (GS), cardiothoracic surgeons (CTS), and vascular surgeons (VS). VS did 474 CEAs, CTS did 404, and GS did 122. VS tended to operate more often on symptomatic patients than CTS and GS: 40% vs 23% and 31%, respectively (P< .0001). Preoperative workups were significantly different between specialties: duplex ultrasound (DUS) only in 66%, 30%, and 18%; DUS and computed tomography angiography in 27%, 35%, and 29%; and DUS and magnetic resonance angiography in 6%, 35%, and 52% for VS, CTS, and GS, respectively (P< .001). The mean preoperative carotid stenosis was not significantly different between the specialties. The mean heparin dosage was 5168, 7522, and 5331 units (P= .0001) and protamine was used in 0.2%, 19%, and 8% (P< .0001) for VS, CTS, and GS, respectively. VS more often used postoperative drains; however, no association was found between heparin dosage, protamine, and drain use and postoperative bleeding. Patching was used in 99%, 93%, and 76% (P< .0001) for VS, CTS, and GS, respectively. Bovine pericardial patches were used more often by CTS and ACUSEAL (Gore-Tex; W. L. Gore and Associates, Flagstaff, Ariz) patches were used more often by GS (P< .0001). The perioperative stroke/death rates were 1.3% for VS and 3.1% for CTS and GS combined (P= .055); and were 0.7% for VS and 3% for CTS and GS combined for asymptomatic patients (P< .034). Perioperative stroke rates for patients who had preoperative DUS only were 0.9% vs 3.3% for patients who had extra imaging (computed tomography angiography/magnetic resonance angiography; P= .009); and were 0.9% vs 3% for asymptomatic patients (P= .05). When applying hospital billing charges for preoperative imaging workups (cost of DUS only vs DUS and other imaging), the VSpractice pattern would have saved $1180 per CEA over CTS and GS practice patterns; a total savings of $1,180,000 in this series. CEA practice patterns differ between specialties. Although the cost was higher for non-VS practices, the perioperative stroke/death rate was somewhat higher. Therefore, educating physicians who perform CEAs on cost-saving measures may be appropriate.

Attention To Surgeons And Surgical Care Is Largely Missing From Early Medicare Accountable Care Organizations

The Affordable Care Act supports the growth of accountable care organizations (ACOs) as a potentially powerful model for health care delivery and payment. The model focuses on primary care. However, surgeons and other specialists have a large role to play in caring for ACOs' patients. No studies have yet investigated the role of surgical care in the ACO model. Using case studies and a survey, we examined the early experience of fifty-nine Medicare-approved ACOs in providing surgical care. We found that ACOs have so far devoted little attention to surgical care. Instead, they have emphasized coordinating care for patients with chronic conditions and reducing unnecessary hospital readmissions and ED visits. In the years to come, ACOs will likely focus more on surgical care. Some ACOs have the ability to affect surgical practice patterns through referral pressures, but local market conditions may limit ACOs' abilities to alter surgeons' behavior. Policy makers, ACO administrators, and surgeons need to be aware of these trends because they have the potential to affect the surgical care provided to ACO patients as well as the success of ACOs themselves.

Practice patterns in complex ventral hernia repair and place of biological grafts: A national survey among French digestive academic surgeons

Despite the prevalence of complex ventral hernias, there is little agreement on the most appropriate technique or prosthetic to repair these defects, especially in contaminated fields. Our objective was to determine French surgical practice patterns among academic surgeons in complex ventral hernia repair (CVHR) with regard to indications, most appropriate techniques, choice of prosthesis, and experience with complications. A survey consisting of 21 questions and 6 case-scenarios was e-mailed to French practicing academic surgeons performing CVHR, representing all French University Hospitals. Forty over 54 surgeons (74%) responded to the survey, representing 29 French University Hospitals. Regarding the techniques used for CVHR, primary closure without reinforcement was provided in 31.6% of cases, primary closure using the component separation technique without mesh use in 43.7% of cases, mesh positioned as a bridge in 16.5% of cases, size reduction of the defect by using aponeurotomy incisions without mesh use in 8.2% of cases. Among the 40 respondents, 36 had experience with biologic mesh. There was a strong consensus among surveyed surgeons for not using synthetic mesh in contaminated or dirty fields (100%), but for using it in clean settings (100%). There was also a strong consensus between respondents for using biologic mesh in contaminated (82.5%) or infected (77.5%) fields and for not using it in clean setting (95%). In clean-contaminated surgery, there was no consensus for defining the optimal therapeutic strategy in CVHR. Infection was the most common complication reported after biologic mesh used (58%). The most commonly reported influences for the use of biologic grafts included literature, conferences and discussion with colleagues (85.0%), personal experience (45.0%) and cost (40.0%). Despite a lack of level I evidence, biologic meshes are being used by 90% of surveyed surgeons for CVHR. Importantly, there was a strong consensus for using them in contaminated or infected fields and for not using them in clean setting. To better guide surgeons, prospective, randomized trials should be undertaken to evaluate the short- and long-term outcomes associated with these materials in various surgical wound classifications.

Gross-total resection outcomes in an elderly population with glioblastoma: a SEER-based analysis

There is limited information on the relationship between patient age and the clinical benefit of resection in patients with glioblastoma. The purpose of this study was to use a population-based database to determine whether patient age influences the frequency that gross-total resection (GTR) is performed, and also whether GTR is associated with survival difference in different age groups. The authors identified 20,705 adult patients with glioblastoma in the Surveillance, Epidemiology, and End Results (SEER) registry (1998-2009). Surgical practice patterns were defined by the categories of no surgery, subtotal resection (STR), and GTR. Kaplan-Meier and multivariate Cox regression analyses were used to assess the pattern of surgical practice and overall survival. The frequency that GTR was achieved in patients with glioblastoma decreased in a stepwise manner as a function of patient age (from 36% [age 18-44 years] to 24% [age ≥ 75]; p < 0.001). For all age groups, glioblastoma patients who were selected for and underwent GTR showed a 2- to 3-month improvement in overall survival (p < 0.001) relative to those who underwent STR. These trends remained true after a multivariate analysis that incorporated variables including ethnicity, sex, year of diagnosis, tumor size, tumor location, and radiotherapy status. Gross-total resection is associated with improved overall survival, even in elderly patients with glioblastoma. As such, surgical decisions should be individually tailored to the patient rather than an adherence to age as the sole clinical determinant.

Trends in otolaryngology residency training in the surgical treatment of obstructive sleep apnea

Most patients with obstructive sleep apnea (OSA) have multilevel obstruction. Improved outcomes with multilevel surgery compared to isolated palatal surgery have been well documented. Despite this, surgical practice patterns in the United States have been slow to change. The purpose of this study was to evaluate whether current practice patterns are a reflection of limited surgical residency training in hypopharyngeal procedures. Cross-sectional Internet survey. Program directors from 103 accredited U.S. otolaryngology residency programs were surveyed regarding past (2000, 2005) and more recent (2010) resident surgical competency in operative techniques for treatment of OSA. Of the 48 survey respondents, 85%, 90%, and 100% reported resident surgical competency for oropharyngeal procedures in 2000, 2005, and 2010, respectively. Uvulopalatopharyngoplasty and tonsillectomy were the most common procedures reported in all 3 years. In contrast, 63%, 71%, and 83% reported resident surgical competency for hypopharyngeal procedures in 2000, 2005, and 2010. Lingual tonsillectomy was the most common procedure in all 3 years. Surgical practice patterns in the United States do not reflect current practice recommendations for treatment of OSA, which emphasize multilevel surgery. Limited surgical residency training in hypopharyngeal procedures may be a contributing factor, although there appears to be an increasing trend in resident competency. Improvement in the scope of resident surgical training for treatment of OSA may lead to improved surgical outcomes. 3b.

Changing trends in pelvic lymphadenectomy in radical prostatectomy with the advent of robotic surgery.

39 Background: It is important to determine whether changes in technology have impacted surgical practice. With the adoption of robotic surgery, it is our hypothesis that rates of pelvic lymphadenectomy (LND) have decreased, even when controlling for cancer risk and comorbidities. To assess whether adoption of surgical technology versus practice patterns in the extent of surgery over time changed, we propose to compare the rates of pelvic LND at the time of radical prostatectomy during the time period when robotic surgery was adopted. Methods: Data was extracted from CaPSURE, a multi-institutional, longitudinal observational database of men with prostate cancer. A total of 3,938 men diagnosed with localized prostate cancer between 2000 and 2011 were included in the analysis if they underwent surgical extirpation. The inclusion of LND was calculated for both groups. Other information included site type, age at diagnosis, comorbidities, and CAPRA risk assessment score. Results: A total of 3,616 open retropubic prostatectomies and 322 robotic prostatectomies were included for analysis. Among the open prostatectomies, 78.9% underwent pelvic LND. During the same time period, among robotic prostatectomies, 45.3% underwent pelvic LND. There was a statistically significant correlation between method of radical prostatectomy and the performance of LND (p &lt; 0.001). There were no statistically significant differences between the two groups in CAPRA score, age, or comorbidities (p= 0.06, 0.29, and 0.60; respectively). The adjusted odds ratio of LND for the open group compared to the robotic group is 5.90 (95% CI [4.48,7.78]) while adjusting for clinical stage, grade, and PSA. Conclusions: Controlling for other factors, the difference in rates of LND between the open and robotic groups were statistically significant. These data suggest changes in surgical practice may have been altered by the adoption of a new technique to perform surgery (rather than new scientific data supporting omission of LND).