Variation In Surgical Management Research Articles

Epidemiology and Regional Variation in Additional Surgical Interventions for Children with Congenital Diaphragmatic Hernia: A Multi-institutional Analysis.

To determine practice variation in surgical management of co-morbidities in pediatric patients with Congenital Diaphragmatic Hernia (CDH). A higher percentage of CDH patients are surviving to discharge, accompanied by an increase in morbidity requiring surgical interventions such as tracheostomy and gastrostomy tube insertion. The frequency, trends, and regional variations in operative management of these co-morbidities in this population are unclear. Neonates who underwent CDH repair between 2012-2022 in the United States Pediatric Health Information System database were identified. Multivariable regression identified predictive factors for additional surgical morbidity after CDH repair, defined by an additional surgical intervention during index hospitalization or within one year after discharge. To narrow the spectrum of severity of disease, only patients with an intensive care unit admission on index hospitalization were included. Secondary analysis compared frequency of operations and hospital resource utilization by region. 4003 patients underwent CDH repair and were discharged from their index hospitalization. 1939 (48%) underwent at least one additional surgical procedure after the index CDH repair. Most performed surgeries were gastrostomy tube (28%), fundoplication (13%), and tracheostomy (5%). Covariates associated with additional surgical morbidity included: prematurity (OR 1.38; 95% CI: 1.20-1.59), cardiac co-morbidity (OR 1.31; 95% CI: 1.14-1.49), and chromosomal anomalies (OR 1.76, 95% CI: 1.30-2.40). Northeast (OR: 2.43; CI 1.42-3.52), Midwest (OR 2.11; 95% CI: 1.45-3.07), and South (OR 1.45, 95% CI 1.02-2.12) regions were associated with additional surgical morbidity. Patients who required additional surgical procedures had longer initial inpatient length of stays (71 versus 31d) and higher associated costs ($357,000 versus $161,000). Surgical morbidity exists in CDH patients after initial CDH repair. Counseling families on these outcomes is important in establishing expectations for management. Establishing guidelines for optimal surgical management will require continued reporting from multi-institutional studies.

Concomitant Surgical Ablation in Paroxysmal vs Persistent Atrial Fibrillation During Mitral Surgery

BackgroundDespite prospective randomized evidence supporting concomitant treatment of atrial fibrillation (AF) during mitral valve (MV) surgery, variation in surgical management of AF remains. We assessed longitudinal outcomes after surgical treatment of persistent or paroxysmal AF during MV surgery in Medicare beneficiaries. MethodsAll Medicare beneficiaries with a diagnosis of AF undergoing MV surgery (2018-2020) were evaluated. Patients were stratified by no AF treatment, left atrial appendage obliteration (LAAO) alone, or surgical ablation and LAAO (SA+LAAO). Doubly robust risk adjustment and subgroup analysis by persistent or paroxysmal AF were performed. ResultsA total of 7517 patients with preoperative AF underwent MV surgery (32.1% no AF treatment, 23.1% LAAO alone, 44.7% SA+LAAO). After doubly robust risk adjustment, AF treatment with SA+LAAO or LAAO alone were associated with lower 3-year readmission for stroke or bleeding. However, SA+LAAO was associated with reduced 3-year mortality and readmission for AF or heart failure compared with no AF treatment or LAAO alone. Compared with no AF treatment or LAAO alone, SA+LAAO was associated with lower composite end point of stroke (hazard ratio, 0.75) or death (hazard ratio, 0.83) at 3 years. Subgroup analysis identified similar longitudinal benefits of SA+LAAO in patients with persistent or paroxysmal AF. ConclusionsIn Medicare beneficiaries with AF undergoing MV surgery, SA+LAAO was associated with improved longitudinal outcomes compared with LAAO alone or no AF treatment in patients with paroxysmal or persistent AF. These contemporary real-world data further clarify the benefit of SA+LAAO during MV surgery across all types of AF.

Textbook outcome in the surgical treatment of liver hydatid cyst

BackgroundTextbook outcome is a composite measure used in surgery to define the ideal postoperative period and to assess the quality of care. The aim of this study was to analyze the incidence of textbook outcome and the factors independently associated with its achievement following surgical treatment of liver hydatid cysts. MethodsRetrospective cohort study of patients operated on for liver hydatid cysts between January 2006 and December 2021. Textbook outcome was achieved when all the following criteria were fulfilled: no mortality within 90 days, no major complications within 90 days, no hospital readmission within 90 days, and no prolonged hospital stay. Univariable and multivariable analyses were performed to identify factors associated with textbook outcome. ResultsDuring the study period, 296 patients underwent surgery. Textbook outcome was recorded in 65.9% (195/296). Female gender (odds ratio 2.02; P = .010), noncomplicated cyst (odds ratio 3.97, P < .001), and radical surgery (odds ratio 2.26, P = .003) were the variables associated with a higher probability of achieving textbook outcome. ConclusionTextbook outcome may be a useful measure to assess the variations in surgical management between different centers, and to improve quality of care after liver hydatid cysts resection.

Decompression alone or decompression and fusion in degenerative lumbar spondylolisthesis.

SummaryBackgroundClinically, there are substantive practice variations in surgical management of degenerative lumbar spondylolisthesis. We aimed at evaluating whether decompression alone outcomes for patients with degenerative lumbar spondylolisthesis are comparable to those of decompression with fusion.MethodsIn this meta-analysis, the Embase, PubMed, and Cochrane Library databases were searched from inception to February 16th, 2022. Randomised controlled trials (RCTs) and cohort studies comparing decompression alone with decompression and fusion for patients with degenerative lumbar spondylolisthesis were included in this study. There were no language limitations. Odds ratio (OR), mean difference (MD) and 95% confidence interval (CI) were used to report results in the random-effects model. Main outcomes included Oswestry disability index (ODI), pain, clinical satisfaction, complication and reoperation rates. The study protocol was published in PROSPERO (CRD42022310645).FindingsThirty-three studies (6 RCTs and 27 cohort studies) involving 94 953 participants were included. Differences in post-operative ODI between decompression alone and decompression with fusion were not significant. A small difference for back (MD, 0.13; [95% CI, 0.08 to 0.18]; I2:0.00%) and leg pain (MD, 0.30; [95% CI, 0.09 to 0.51]; I2:48.35%) was observed on the 3rd post-operative month. The results did not reveal significant differences in leg pain and back pain between decompression alone and fusion groups on the 6th, 12th, and 24th post-operative months. Difference in clinical satisfaction between decompression alone and decompression with fusion were not significant from RCTs (OR, 0.26; [95% CI, 0.03 to 1.92]; I2:83.27%). Complications (OR, 1.54; [95% CI, 1.16 to 2.05]; I2:48.88%), operation time (MD, 83.39; [95% CI, 55.93 to 110.85]; I2:98.75%), intra-operative blood loss (MD, 264.58; [95% CI, 174.99 to 354.16]; I2:95.61%) and length of hospital stay (MD, 2.85; [95% CI, 1.60 to 4.10]; I2:99.49%) were higher with fusion.InterpretationClinical effectiveness of decompression alone was comparable to that of decompression with fusion for degenerative lumbar spondylolisthesis. Decompression alone is recommended for patients with degenerative lumbar spondylolisthesis.FundingThis work was supported by grants from the National Natural Science Foundation of China (No. 81871818), Tangdu Hospital Seed Talent Program (Fei-Long Wei), Natural Science Basic Research Plan in Shaanxi Province of China (No.2019JM-265) and Social Talent Fund of Tangdu Hospital (No.2021SHRC034).

Epidemiology and management of abdominal injuries in children

Although more guideline-adherent care has been described in pediatric compared to adult trauma centers, we aimed to provide a more detailed characterization of management and resource utilization of children with intra-abdominal injury (IAI) within pediatric centers. Our primary objective was to describe the epidemiology, diagnostic evaluation, and management of children with IAI across U.S. children's hospitals. Our secondary objective was to describe the interhospital variation in surgical management of children with IAI. We conducted a cross-sectional study of 33 hospitals in the Pediatric Health Information System. We included children aged <18 years evaluated in the emergency department from 2010 to 2019 with IAI, as defined by ICD coding, and who underwent an abdominal computed tomography (CT). Our primary outcome was abdominal surgery. We categorized IAI by organ system and described resource utilization data. We used generalized linear regression to calculate adjusted hospital-level proportions of abdominal surgery, with a random effect for hospital. We studied 9265 children with IAI. Median (IQR) age was 9.0 (6.0-13.0)years. Abdominal surgery was performed in 16% (n= 1479) of children, with the lowest proportion of abdominal surgery observed in children aged <5 years. Liver (38.6%) and spleen (32.1%) were the most common organs injured. A total of 3.1% of children with liver injuries and 2.8% with splenic injuries underwent abdominal surgery. Although there was variation in rates of surgery across hospitals (p< 0.001), only three of 33 hospitals had rates that were statistically different from the aggregate mean of 16%. Most children with IAI are managed nonoperatively, and most children's hospitals manage children with IAI similarly. These data can be used to inform future benchmarking efforts across hospitals to assess concordance with guidelines for the management of children with IAI.

Variation in surgical treatment of degenerative spondylolisthesis in Canada: surgeon assessment of stability and impact on treatment.

Controversy exists regarding the optimal surgical treatment of degenerative lumbar spondylolisthesis (DS). Not all DS patients are the same, and the degree to which inherent stability may dictate treatment is unknown. The purpose of this study was to determine the variability in surgical approach relative to surgeon classified stability. The secondary objective was to compare patient-reported outcomes (PROs) across different surgical techniques and grades of stability. Patients prospectively enrolled from eleven tertiary care institutions and followed from 2015 to 2019. The surgical technique was at the surgeon's discretion. Surgeons were asked to grade the degree of instability based on the degenerative spondylolisthesis instability classification system (DSIC). DSIC categorizes three different types (I-stable, II-potentially unstable, and III-unstable). One-year changes in PROs were compared between each group. Multivariable regression was used to identify any characteristics that explained variability in treatment. There were 323 patients enrolled in this study. Surgeons' stability classification versus procedure [decompression alone (D)/decompression and posterolateral fusion (D-PL)/and decompression with posterior/transforaminal lumbar interbody fusion (D-PLIF/TLIF)] were as follows: type I (n = 91): D-41%/D-PL-13%/D-PLIF/TLIF-46%; type II (n = 175): D-23%/D-PL-17%/D-PLIF/TLIF-60%; and type III (n = 57):(D-0%/D-PL-14%/D-PLIF/TLIF-86%). Type I patients undergoing D-PL had some improvements in EQ-5D and NRS versus those undergoing D-PLIF/TLIF but otherwise there were no other significant differences between groups. Regression analysis demonstrated advanced age (OR = 1.06, CI 1.02-10.12) andtype I (OR = 2.61, CI 1.17-5.81) were associated with receiving decompression surgery alone. There exists considerable variation in surgical management of DS in Canada. Given similar PROs in two of the three groups, there is potential to tailor surgical intervention and improve resource utilization.

Second surgery for progressive glioblastoma: a multi\u2010centre questionnaire and cohort\u2010based review of clinical decision\u2010making and patient outcomes in current practice

PurposeGlioblastoma prognosis is poor. Treatment options are limited at progression. Surgery may benefit, but no quality guidelines exist to inform patient selection. We sought to describe variations in surgical management at progression, highlight where further evidence is needed, and build towards a consensus strategy.MethodsCurrent practice in selection of patients with progressive GBM for second surgery was surveyed online amongst specialists in the UK and Europe. We complemented this with an assessment of practice in a retrospective cohort study from six United Kingdom neurosurgical units. We used descriptive statistics to analyse the data.Results234 questionnaire responses were received. Maintaining or improving patient quality of life was key to decision making, with variation as to whether patient age, performance status or intended extent of resection was relevant. MGMT methylation status was not important. Half considered no minimum time after first surgery. 288 patients were reported in the cohort analysis. Median time to second surgery from first surgery 390 days. Median overall survival 815 days, with no association between time to second surgery and time to death (p = 0.874).ConclusionsThis is the most wide-ranging examination of contemporaneous practice in management of GBM progression. Without evidence-based guidelines, the variation is unsurprising. We propose consensus guidelines for consideration, to reduce heterogeneity in decision making, support data collection and analysis of factors influencing outcomes, and to inform clinical trials to establish whether second surgery improves patient outcomes, or simply selects to patients already performing well.

Variation in surgical management of primary hyperparathyroidism in the US Department of Veterans Affairs healthcare system: A 15-year observational study

BackgroundPrimary hyperparathyroidism is underdiagnosed and undertreated nationally despite the benefits of parathyroidectomy. However, the degree of hospital-level variation in the management of primary hyperparathyroidism is unknown. MethodsWe performed a national, retrospective study of Veterans with primary hyperparathyroidism using the Veterans Affairs Corporate Data Warehouse from January 2000 to September 2015. The objective was to characterize the extent of hospital-level variation in the use of parathyroidectomy for the management of primary hyperparathyroidism within a national, integrated healthcare system. Rate of parathyroidectomy in patients with primary hyperparathyroidism was stratified by (1) geographic region, (2) facility complexity level, (3) volume of parathyroidectomies per facility, and (4) frequency of parathyroid hormone testing in hypercalcemic patients. ResultsAmong 47,158 Veterans with primary hyperparathyroidism, 6,048 (12.8%) underwent parathyroidectomy. Rates of parathyroidectomy were significantly higher in the Continental (17.0%) and Pacific (16.0%) regions than in other areas (11.4%, P < .01). The highest complexity referral centers had the highest rate of parathyroidectomy (13.6%) compared with all other facilities (12.1%, P < .01). Centers that performed the highest volume of parathyroidectomies were more likely to offer surgery (13.3%) than low volume centers (8.9%, P < .01). Facilities with higher frequency of parathyroid hormone testing among hypercalcemic patients were more likely to offer parathyroidectomy (15.2%) than those with the lowest parathyroid hormone testing frequency (12.6%, P < .01). ConclusionAlthough there is notable variation in parathyroidectomy use for definitive treatment of primary hyperparathyroidism between Veterans Affairs facilities, parathyroidectomy rates are low across the entire system. Further research is needed to understand additional local contextual and other patient and clinician-level factors for the undertreatment of primary hyperparathyroidism to subsequently guide corrective interventions.

Variability in surgical management of kidney cancer between urban and rural hospitals in Queensland, Australia: a population-based analysis.

BackgroundInternational guidelines recommend partial over radical nephrectomy for management of kidney tumours, due to perceived advantages of kidney function preservation. In Queensland, oncological nephrectomy is performed in both metropolitan and rural hospitals. Previous studies have shown that patients from rural areas with kidney tumours are less likely to undergo partial nephrectomy compared with those in major cities. The aim of this study was to investigate patterns of partial nephrectomy according to geographical area, and to identify patient- and health-service-level characteristics associated with partial nephrectomy.MethodsAll 3,799 incident kidney cancer cases in Queensland (Jan 2009 to Dec 2014) were ascertained. Patients aged <18 yrs (n=47), who did not receive surgery (n=988), or had end-stage kidney disease (ESKD) before surgery (n=17) were excluded. The final sample included 2,747 patients. Data were analysed using multivariable logistic regression in order to identify associations with partial nephrectomy.ResultsOf 2,747 patients, 637 (25%) underwent partial nephrectomy. The likelihood of undergoing partial nephrectomy increased with more recent year of surgery (P<0.001) and higher socioeconomic status (P<0.001). The likelihood of undergoing partial nephrectomy decreased for patients managed in lower-volume centres (P=0.004), with increasing age (P<0.001), and hospital location outside of a major city (P<0.001). Overall, the number of nephrectomies, and proportion/number of partial nephrectomies, performed in rural hospitals has increased over the study period.ConclusionsOur results suggest that, although patients who are managed in major cities are more likely to undergo partial nephrectomy, likelihood of undergoing partial nephrectomy in rural centres is increasing, consistent with international best practice.

Understanding surgical decision-making in older adults with differentiated thyroid cancer: A discrete choice experiment

BackgroundPrior studies demonstrated that older adults tend to undergo less surgery for thyroid cancer. Our objective was to use a discrete choice experiment to identify factors influencing surgical decision-making for older adults with thyroid cancer. MethodsActive and candidate members of the American Association of Endocrine Surgeons were invited to participate in a web-based survey. Multinomial logistic regression was utilized to assess patient and surgeon factors associated with treatment choices. ResultsComplete survey response rate was 25.7%. Most respondents were high-volume surgeons (88.5%) at academic centers (76.9%). Multinomial logistic regression demonstrated that patient age was the strongest predictor of management. Increasing age and comorbidities were associated with the choice for active surveillance (P = .000), not performing a lymphadenectomy in patients with nodal metastases (relative-risk ratio: 2.5, 95% CI: 1.4–4.2, P = .002 and relative-risk ratio: 1.6, 95% CI: 1.2–2.1, P = .004, respectively), and recommending hemithyroidectomy versus total thyroidectomy for a cancer >4 cm (relative-risk ratio: 4.4, 95% CI: 2.5–7.9, P = .000 and relative-risk ratio: 3.4, 95% CI: 2.3–5.1, P = .000, respectively). Surgeons with ≥10 years of experience (relative-risk ratio: 3.3, 95% CI: 1.1–10.3, P = .039) favored total thyroidectomy for a cancer <4 cm, and nonfellowship trained surgeons (relative-risk ratio: 7.3, 95% CI: 1.3–42.2, P = .027) opted for thyroidectomy without lymphadenectomy for lateral neck nodal metastases. ConclusionThis study highlights the variation in surgical management of older adults with thyroid cancer and demonstrates the influence of patient age, comorbidities, surgeon experience, and fellowship training on management of this population.

Regional Variation in the Management of Nontraumatic Subdural Hematomas Across the United States

Nontraumatic subdural hematomas are a common indication for inpatient hospitalization in the United States, yet there is little high-quality evidence regarding which patients should receive surgical or medical treatment. We sought to assess variation in surgical management and medical treatment with steroids for nontraumatic subdural hematomas across the United States. Using the Premier database, we analyzed patients with a primary discharge diagnosis of nontraumatic subdural hematoma in 2014. International Classification of Diseases, Ninth Revision, procedure codes were used to identify patients who underwent surgical management, and pharmacy data were used to identify patients treated with dexamethasone. Univariable and multivariable analyses were used to examine the association of age, race, sex, academic versus nonacademic center, and regions of the United States with conservative or surgical management. There were 3915 inpatient hospitalizations for nontraumatic subdural hematomas in 2014 in the Premier database, of whom 1860 (47.5%) underwent surgery, and 360 (9.2%) underwent treatment with dexamethasone, either as a primary treatment or as an adjuvant to surgery. Older age, female sex, and being managed outside of the Western U.S. region were associated with a lower likelihood of undergoing surgical management on multivariable analysis; only younger age was associated with a greater likelihood of being treated with dexamethasone. There is considerable variability in surgical management of nontraumatic subdural hematomas across the United States based on age, sex, and region. Future studies should explore the reasons for the variability and attempt to better clarify indications for surgical management of subdural hematomas.

Variation in surgical management of asymptomatic umbilical hernia at freestanding children's hospitals

PurposeTo examine hospital-level variation in the timing of asymptomatic umbilical hernia repair in children. MethodsRetrospective analysis of children undergoing umbilical hernia repair at 38 children's hospitals using the Pediatric Health Information System database (01/2013–12/2017). Early repair was defined as surgery performed at 3 years of age or younger. Repairs were categorized as emergent/urgent if associated with diagnostic or procedural codes indicating obstruction or strangulation, or if they occurred within 2 weeks of an emergency department encounter. Multivariable regression was used to calculate hospital-level observed-to-expected (O/E) ratios for early repair adjusting for emergent/urgent repair and patient characteristics. Results23,144 children were included, of which 30% underwent early repair (hospital range: 6.9%–54.3%, p ≪ 0.001). Overall, 3.8% of all repairs were emergent/urgent, and higher rates of early repair did not correlate with higher rates of emergent/urgent repair across hospitals (r = −0.10). Following adjustment, hospital-level O/E ratios for early repair varied 8.9-fold (0.19–1.70, p ≪ 0.001). ConclusionTiming of asymptomatic umbilical hernia repair varies widely across children's hospitals, and the magnitude of this variation cannot be explained by differences in patient characteristics or the acuity of repair. Many children may be undergoing repair of hernias that may spontaneously close with further observation. Level of Evidence.Level III (retrospective comparative study).

Cerebellar mutism after posterior fossa tumor resection in children: a multicenter international retrospective study to determine possible modifiable factors.

A preliminary survey of pediatric neurosurgeons working at different centers around the world suggested differences in clinical practice resulting in variation in the risk of pediatric cerebellar mutism (CM) and cerebellar mutism syndrome (CMS) after posterior fossa (PF) tumor resection. The purposes of this study were (1) to determine the incidence and severity of CM and CMS after midline PF tumor resection in children treated at these centers and (2) to identify potentially modifiable factors related to surgical management (rather than tumor biology) that correlate with the incidence of CM/CMS. Attending pediatric neurosurgeons at British Columbia's Children's Hospital (BCCH) and neurosurgeons who completed a pediatric neurosurgery fellowship at BCCH were invited to provide data from the center where they currently practiced. Children aged from birth to less than 18years who underwent initial midline PF tumor resection within a contemporary, center-selected 2-year period were included. Data was obtained by retrospective chart and imaging review. Modifiable surgical factors that were assessed included pre-resection surgical hydrocephalus treatment, surgical positioning, ultrasonic aspirator use, intraoperative external ventricular drain (EVD) use, surgical access route to the tumor, and extent of resection. CM was defined as decreased or absent speech output postoperatively and CMS as CM plus new or worsened irritability. There were 263 patients from 11 centers in 6 countries (Canada, Germany, the Netherlands, India, Indonesia, and the USA). Median age at surgery was 6years (range < 1 to 17years). The overall incidence of postoperative CM was 23.5% (range 14.7-47.6% for centers with data on ≥ 20 patients). The overall incidence of CMS was 6.5% (range 0-10.3% for centers contributing data on ≥ 20 patients). A multivariate logistic regression on the full data set showed no significant association between pre-resection surgical hydrocephalus treatment, prone position, ultrasonic aspirator use, EVD use, telovelar approach, complete or near total resection, or treating center and either postoperative CM or CMS. While there was variation in surgical management of midline PF tumors among centers participating in this study, the factors in management that were examined did not predict postoperative CM or CMS.

Suture fistula revisited for long gap esophageal atresia

BackgroundLong gap esophageal atresia presents a challenge to pediatric surgeons due to the variability in surgical management when primary anastomosis is not feasible. Mechanical traction procedures enhance tissue growth that allows early anastomosis, before delayed primary closure (DPC) would be attempted to allow for rapid oral feeding, or when operative discoveries require flexibility of the surgical plan. The Suture Fistula procedure, first published by Alan Shafer and Tirone David in 1974, is a simple, effective, but underutilized single-stage procedure which results in spontaneous fistulization of approximated, non-anastomosed esophageal segments using tension sutures. MethodsA retrospective chart review was performed of patients who underwent the Suture Fistula procedure at a single institution since 1992. A literature review of all published case series of patients who underwent this procedure was also performed. ResultsThere were 5 case series found with a total of 24 patients, and three new cases presented. Patients were noted to have spontaneous fistulization with gastrostomy tube feed reflux noted in the upper esophagus or mouth on average of post-operative day 14, which occurred in over 85% of patients. While nearly all patients required esophageal dilation and anti-reflux procedures, the morbidity of the procedure, including esophageal leak, is very low, and similar to the Foker or Kimura procedures, which have been more popular despite their surgical complexity. ConclusionWe propose the Suture Fistula technique to be a simpler, more effective, and safe alternative to other mechanical traction suture procedures in cases where primary anastomosis is not feasible. Level of evidenceLevel IV.

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study

BackgroundAppendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide.MethodsThis is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days.Results4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33–4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76–2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42–0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14–0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11–0.44) and SSI (OR 0.21 95% CI 0.09–0.45).ConclusionA laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments.Trial registration: NCT02179112.

Variation in surgical management of neurogenic bowel among centers participating in National Spina Bifida Patient Registry.

Optimal management of neurogenic bowel in patients with spina bifida (SB) remains controversial. Surgical interventions may be utilized to treat constipation and provide fecal continence, but their use may vary among SB treatment centers. We queried the National Spina Bifida Patient Registry (NSBPR) to identify patients who underwent surgical interventions for neurogenic bowel. We abstracted demographic characteristics, SB type, functional level, concurrent bladder surgery, mobility, and NSBPR clinics to determine whether any of these factors were associated with interventions for management of neurogenic bowel. Multivariable logistic regression with adjustment for selection bias was performed. We identified 5,528 patients with SB enrolled in the 2009-14 NSBPR. Of these, 1,088 (19.7%) underwent procedures for neurogenic bowel, including 957 (17.3%) ACE/cecostomy tube and 155 (2.8%) ileostomy/colostomy patients. Procedures were more likely in patients who were older, white, non-ambulatory, with higher-level lesion, with myelomeningocele lesion, with private health insurance (all p< 0.001), and female (p= 0.006). On multivariable analysis, NSBPR clinic, older age (both p< 0.001), race (p= 0.002), mobility status (p= 0.011), higher lesion level (p< 0.001), private insurance (p= 0.002) and female sex (p= 0.015) were associated with increased odds of surgery. There is significant variation in rates of procedures to manage neurogenic bowel among NSBPR clinics. In addition to SB-related factors such as mobility status and lesion type/level, non-SB-related factors such as patient age, sex, race and treating center are also associated with the likelihood of undergoing neurogenic bowel intervention.

Prevalence and orthopedic management of foot and ankle deformities in Charcot-Marie-Tooth disease.

ABSTRACT Introduction: Foot deformities are frequent complications in Charcot–Marie–Tooth disease (CMT) patients, often requiring orthopedic surgery. However, there are no prospective, randomized studies on surgical management, and there is variation in the approaches among centers both within and between countries. Methods: In this study we assessed the frequency of foot deformities and surgery among patients recruited into the Inherited Neuropathies Consortium (INC). We also designed a survey addressed to orthopedic surgeons at INC centers to determine whether surgical approaches to orthopedic complications in CMT are variable. Results: Foot deformities were reported in 71% of CMT patients; 30% of the patients had surgery. Survey questions were answered by 16 surgeons working in different specialized centers. Most of the respondents were foot and ankle surgeons. There was marked variation in surgical management. Discussion: Our findings confirm that the approaches to orthopedic management of CMT are varied. We identify areas that require further research. Muscle Nerve 57: 255–259, 2018

Variability in surgical management of benign ovarian neoplasms in children

Background/purposeAlthough most pediatric ovarian neoplasms are benign and may be treated with ovary-sparing surgery (OSS), consensus is lacking on the optimal surgical approach. We aimed to determine the proportion of pediatric benign ovarian neoplasms managed with OSS and to assess variability in management across hospitals and specialties. MethodsUsing the Pediatric Health Information System, we studied patients aged 6–21 years treated in 2006–2014 for a benign ovarian neoplasm with oophorectomy or OSS. Inter-hospital variability and predictors of the type of surgery were determined using logistic mixed effects models with random hospital effects. ResultsOf 1164 patients with benign ovarian neoplasms, 646 underwent oophorectomy, and 518 underwent OSS. Across hospitals, there was significant variability in the proportion of OSS (range: 21.7–76.6%). In multivariable analysis, patients managed by pediatric surgeons (vs. pediatric and adolescent gynecologists) (OR: 0.27, 95%CI: 0.17–0.43, p<0.001), younger patients (OR: 0.94 per year, 95%CI: 0.90–0.98, p=0.007), and those admitted through the emergency department (OR: 0.76, 95%CI: 0.58–0.99, p=0.04) were less likely to undergo OSS. Inter-hospital variability remained significant after adjusting for relevant patient and hospital characteristics (p<0.001). ConclusionsSignificant variability exists in management of benign ovarian neoplasms across hospitals and specialties. Collaborative efforts between treating specialists may improve implementation of evidence-based guidelines for OSS. Type of studyretrospective study Level of evidenceIII.

Disease homogeneity and treatment heterogeneity in idiopathic subglottic stenosis.

Idiopathic subglottic stenosis (iSGS) is a rare and potentially life-threatening disease marked by recurrent and progressive airway obstruction frequently requiring repeated surgery to stabilize the airway. Unknown etiology and low disease prevalence have limited the ability to characterize the natural history of iSGS and resulted in variability in surgical management. It is uncertain how this variation relates to clinical outcomes. Medical record abstraction. Utilizing an international, multi-institutional collaborative, we collected retrospective data on patient characteristics, treatment, and clinical outcomes. We investigated variation between and within open and endoscopic treatment approaches and assessed therapeutic outcomes; specifically, disease recurrence and need for tracheostomy at last follow-up. Strikingly, 479 iSGS patients across 10 participating centers were nearly exclusively female (98%, 95% confidence interval [CI], 96.1-99.6), Caucasian (95%, 95% CI, 92.2-98.8), and otherwise healthy (mean age-adjusted Charlson Comorbidity Index 1.5; 95% CI, 1.44-1.69). The patients presented at a mean age of 50 years (95% CI, 48.8-51.1). A total of 80.2% were managed endoscopically, whereas 19.8% underwent open reconstruction. Endoscopic surgery had a significantly higher rate of disease recurrence than the open approach (chi(2) = 4.09, P = 0.043). Tracheostomy was avoided in 97% of patients irrespective of surgical approach (95% CI, 94.5-99.8). Interestingly, there were outliers in rates of disease recurrence between centers using similar treatment approaches. Idiopathic subglottic stenosis patients are surprisingly homogeneous. The heterogeneity of treatment approaches and the observed outliers in disease recurrence rates between centers raises the potential for improved clinical outcomes through a detailed understanding of the processes of care. 4. Laryngoscope, 126:1390-1396, 2016.

Practice pattern variation in surgical management of pelvic organ prolapse and urinary incontinence in The Netherlands.

Practice pattern variation (PPV) is the difference in care that cannot be explained by the underlying medical condition. The aim of this study was to describe PPV among Dutch gynecologists regarding treatment of pelvic organ prolapse (POP) and urinary incontinence (UI). PPV was calculated from data of healthcare declaration codes of 2010. Data were provided by Vektis and Kiwa Carity. PPV for POP and UI in general was calculated per hospital and per region. Furthermore, PPV for transvaginal mesh and surgical treatment of uterine descent was assessed. PPV of surgical treatment for POP and UI in general was assessed for 91 hospitals. PPV for surgical treatment of uterine descent and transvaginal mesh placement was calculated for 88 hospitals. A high PPV per hospital and per region was found. In some hospitals, a hysterectomy was performed in all cases of uterovaginal prolapse, while in other hospitals, uterus-preserving techniques were mostly performed. A high PPV of transvaginal mesh placement was observed. In the small country of The Netherlands, we found a high PPV in surgical management of POP and UI with respect to the choice for surgical treatment and the type of surgery. This finding might be due to the absence of clearly defined guidelines. Studies with respect to conservative versus surgical treatment and the type of surgery are of need to establish evidence-based guidelines.