Surgeon Burnout: A Systematic Review Dimou, Francesca M., MD; Eckelbarger, David, BS; Riall, Taylor S., MD, FACS, PhD
Journal of the American College of Surgeons,
06/2016, Letnik:
222, Številka:
6
Journal Article
Background The Fistula Risk Score (FRS) is a clinical tool developed from single-institutional data using primarily intraoperative factors to characterize the risk of clinically relevant pancreatic ...fistula (CR-POPF) after pancreaticoduodenectomy. We developed a modified FRS based on objective, nationally accrued data that is more readily determined before resection. Study Design The 2012 NSQIP Pancreatic Demonstration Project (PDP) was used to identify 1,731 pancreaticoduodenectomy resections over 14 months (2011 to 2012). A randomly generated 70% cohort was used for model development, and the remaining 30% for internal validation. Univariate analysis was used to identify predictors of CR-POPF. Variables with a value of p < 0.1 were included in multivariable modeling. Results Five significant predictors of CR-POPF were identified and assigned points based on odds ratios: sex, BMI, preoperative total bilirubin, pancreatic ductal diameter, and gland texture. The 10-point model was further applied to the 2014 PDP for external validation. In the testing group, risk scores of 0 to 2 (negligible risk), 3 to 6 (low risk), 7 to 8 (intermediate risk), and 9 to 10 (high risk) were associated with CR-POPF rates of 0%, 6.7%, 16.4%, and 33.7%, respectively. Similar values were seen using the internal validation cohort: 0%, 6.3%, 13.5%, and 31.0%, respectively. The external validation values were 2.9%, 10.2%, 16.4%, and 25.8%, respectively. Conclusions This modified FRS allows for estimation of CR-POPF risk using preoperative and easily determined intraoperative factors, and will allow comparison of performance data for individual surgeons to national norms, improved perioperative counseling, and potential for scrutinizing and/or implementing interventions designed to decrease CR-POPF rates.
BACKGROUND:BDI is the most common serious complication of laparoscopic cholecystectomy. To address this problem, a multi-society consensus conference was held to develop evidenced-based ...recommendations for safe cholecystectomy and prevention of BDI.
METHODS:Literature reviews were conducted for 18 key questions across 6 broad topics around cholecystectomy directed by a steering group and subject experts from 5 surgical societies (Society of Gastrointestinal and Endoscopic Surgeons, Americas Hepato-Pancreato-Biliary Association, International Hepato-Pancreato-Biliary Association, Society for Surgery of the Alimentary Tract, and European Association for Endoscopic Surgery). Evidence-based recommendations were formulated using the grading of recommendations assessment, development, and evaluation methodology. When evidence-based recommendations could not be made, expert opinion was documented. A number of recommendations for future research were also documented. Recommendations were presented at a consensus meeting in October 2018 and were voted on by an international panel of 25 experts with greater than 80% agreement considered consensus.
RESULTS:Consensus was reached on 17 of 18 questions by the guideline development group and expert panel with high concordance from audience participation. Most recommendations were conditional due to low certainty of evidence. Strong recommendations were made for (1) use of intraoperative biliary imaging for uncertainty of anatomy or suspicion of biliary injury; and (2) referral of patients with confirmed or suspected BDI to an experienced surgeon/multispecialty hepatobiliary team.
CONCLUSIONS:These consensus recommendations should provide guidance to surgeons, training programs, hospitals, and professional societies for strategies that have the potential to reduce BDIs and positively impact patient outcomes. Development of clinical and educational research initiatives based on these recommendations may drive further improvement in the quality of surgical care for patients undergoing cholecystectomy.
Most patients with pancreatic cancer will present with metastatic or locally advanced disease. Unfortunately, most patients with localized disease will experience recurrence even after multimodality ...therapy. As such, pancreatic cancer patients arrive at a common endpoint where decisions pertaining to palliative care come to the forefront. This article summarizes surgical, endoscopic, and other palliative techniques for relief of obstructive jaundice, relief of duodenal or gastric outlet obstruction, and relief of pain due to invasion of the celiac plexus. It also introduces the utility of the palliative care triangle in clarifying a patient's and family's goals to guide decision making.
OBJECTIVE:Gastrointestinal cancers are increasingly being treated with NAT before surgical resection. Currently, quality metrics are linked to the number of LNs resected to determine subsequent ...treatment and prognosis. We hypothesize that NAT decreases LN metastasis, downstages patients, and decreases overall lymph node yields (LNY) compared to initial surgical resection. With increasing use of NAT, this brings into question the validity of quality metrics.
METHODS:Gastric (stage II/III), pancreatic (stage I/II/III), and rectal cancers (stage II/III) (2010–2015) treated with surgery with/without NAT were identified in National Cancer Database. We evaluated total LNY and LN metastasis with/without NAT and clinical and pathological stage to evaluate rates of downstaging.
RESULTS:A total of 7934 gastric, 15,908 pancreatic, and 21,354 rectal cancer patients were included of which 61.1%, 21.2%, and 85.7% received NAT, respectively. NAT patients were more likely to be downstaged (39.9% vs 11.1% gastric P< 0.001, 30.6% vs 3.2% pancreatic P< 0.001, 52.0% vs 16.3% rectal P< 0.001), have lower LNYs (18.8 vs 19.1 gastric P = 0.239, 18.4 vs 17.5 pancreatic P< 0.001, 15.7 vs 20.0 rectal P< 0.001) and have N0 pathologic disease (43.6% vs 26.7% gastric P< 0.001, 51.1% vs 30.9% pancreatic P< 0.001, 65.9% vs 49.4% rectal P< 0.001) when compared to initial surgical resection.
CONCLUSION:NAT for gastrointestinal cancers results in overall lower LN yields, lower LN metastases, and significant downstaging of tumors. As all patients undergoing NAT receive multimodality therapy, LN yield recommendations may not be true quality metric changing.
Routine preoperative laboratory testing for ambulatory surgery is not recommended.
Patients who underwent elective hernia repair (N = 73,596) were identified from the National Surgical Quality ...Improvement Program (NSQIP) database (2005-2010). Patterns of preoperative testing were examined. Multivariate analyses were used to identify factors associated with testing and postoperative complications.
A total of 46,977 (63.8%) patients underwent testing, with at least one abnormal test recorded in 61.6% of patients. In patients with no NSQIP comorbidities (N = 25,149) and no clear indication for testing, 54% received at least one test. In addition, 15.3% of tested patients underwent laboratory testing the day of the operation. In this group, surgery was done despite abnormal results in 61.6% of same day tests. In multivariate analyses, testing was associated with older age, ASA (American Society of Anesthesiologists) class >1, hypertension, ascites, bleeding disorders, systemic steroids, and laparoscopic procedures. Major complications (reintubation, pulmonary embolus, stroke, renal failure, coma, cardiac arrest, myocardial infarction, septic shock, bleeding, or death) occurred in 0.3% of patients. After adjusting for patient and procedure characteristics, neither testing nor abnormal results were associated with postoperative complications.
Preoperative testing is overused in patients undergoing low-risk, ambulatory surgery. Neither testing nor abnormal results were associated with postoperative outcomes. On the basis of high rates of testing in healthy patients, physician and/or facility preference and not only patient condition currently dictate use. Involvement from surgical societies is necessary to establish guidelines for preoperative testing.
To trace the evolution of pancreaticoduodenectomy from the decade of the 1960s through the first decade of the new Millenium, through the experience of one surgeon doing 1000 consecutive operations.
...A regional resection of the head of the pancreas was first performed successfully by Kausch in 1909. The operation was popularized by Whipple in 1935, who reported 3 pancreaticoduodenectomies. Because of a hospital mortality of approximately 25%, the operation was performed infrequently until the 1980s. From the 1980s on, experience with this complex alimentary tract operation increased, and high-volume centers developed. This resulted in a significant drop in hospital mortality and allowed institutions and individuals to gain large experiences.
Between March 1969 and May 2003, 1000 consecutive pancreaticoduodenectomies were performed by a single surgeon. A retrospective review of a prospectively maintained database was performed to determine the management and outcome of these patients, as well as to document the evolution of this operative procedure over 5 decades.
The median operative time decreased significantly over the decades, being 8.8 hours in the 1970s and 5.5 hours during the 2000s. Postoperative length of stay dropped from a median of 17 days in the 1980s to 9 days in the 2000s. There were only 10 postoperative/hospital deaths, for a mortality of 1%. A total of 405 patients underwent pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas. Overall 5-year survival was 18%; for the lymph node-negative patients, it was 32%; and for node-negative, margin-negative patients, it was 41%.
Pancreaticoduodenectomy has become a commonly performed operation in many tertiary care centers. Operative time, blood loss, and length of stay have dropped substantially. The operation has become safe, with a low hospital mortality. It has become an effective operation for pancreatic cancer in those patients in whom their tumor is margin negative and node negative.
Background Operations requiring biliary-enteric anastomosis are uncommon, and the true incidence of postoperative stricture is unknown. Our goal was to determine the timing, incidence, and management ...of stricture after biliary-enteric anastomosis. Methods We used 5% Medicare claims data (1996–2011) to identify patients ≥66 years who underwent an operation requiring a biliary-enteric anastomosis. A cumulative incidence curve was used to describe timing of stricture diagnosis. The use of imaging and intervention was evaluated. A Cox proportional hazards model was constructed to identify factors associated with stricture. Results A total of 3,374 patients underwent an operation requiring either a hepaticojejunostomy (54.33%; N = 1,833) or choledochojejunostomy (45.67%; N = 1,541); 2-year survival was 57.0%. Overall, 403 (11.9%) patients developed a stricture. The cumulative incidence of stricture was 12.5% at 2 years. Mean time to stricture diagnosis was 16.8 ± 21.6 months (median = 8.5 months); 23% of patients with a stricture required hospitalization for cholangitis ( N = 94). Only 18 (4.5%) patients with a stricture required reoperation. Younger age (hazard ratio 0.98; 95% confidence interval 0.98–0.99) was associated with a decreased likelihood of stricture formation; presence of an endostent (hazard ratio 1.66; 95% confidence interval 1.35–2.04) predicted stricture formation. Conclusion Biliary-enteric anastomotic strictures occur with significant frequency after a biliary-enteric anastomosis. Although many patients are managed nonoperatively, stricture diagnosis remains burdensome.
Background The Tokyo Guidelines recommend initial cholecystostomy tube drainage, antibiotics, and delayed cholecystectomy in patients with grade III cholecystitis. Study Design We used Medicare data ...(1996 to 2010) to identify patients 66 years and older who were admitted with grade III acute cholecystitis. We evaluated adherence to the Tokyo Guidelines and compared mortality, readmission, and complication rates with and without cholecystostomy tube placement in a propensity-matched (1:3) cohort of patients with grade III cholecystitis. Results There were 8,818 patients admitted with grade III cholecystitis; 565 patients (6.4%) had a cholecystostomy tube placed. Cholecystostomy tube placement increased from 3.9% to 9.7% during the study period. Compared with 1,689 propensity-matched controls, patients with cholecystostomy tube placement had higher 30-day (hazard ratio HR = 1.26; 95% CI 1.05 to 1.50), 90-day (HR = 1.26; 95% CI 1.08 to 1.46), and 2-year mortality (HR = 1.19; 95% CI 1.04 to 1.36) and were less likely to undergo cholecystectomy in the 2 years after initial hospitalization (33.4% vs 64.4%; HR = 0.26; 95% CI 0.21 to 0.31). Readmissions were also higher at 30 days (HR = 2.93; 95% CI 2.12 to 4.05), 90 days (HR = 3.48; 95% CI 2.60 to 4.64), and 2 years (HR = 3.08; 95% CI 2.87 to 4.90). Conclusions Since the introduction of the Tokyo Guidelines (2007), use of cholecystostomy tubes in patients with grade III cholecystitis has increased, but the majority of patients do not get cholecystostomy tube drainage as first-line therapy. Cholecystostomy tube placement was associated with lower rates of definitive treatment with cholecystectomy, higher mortality, and higher readmission rates. These data suggest a need for additional evaluation and refinement of the Tokyo Guidelines.
Introduction
The impact of neoadjuvant therapy on postpancreatectomy complications is inadequately described.
Methods
Data from the NSQIP Pancreatectomy Demonstration Project (11/2011 to 12/2012) was ...used to identify patients with pancreatic adenocarcinoma who did and did not receive neoadjuvant therapy. Neoadjuvant therapy was classified as chemotherapy alone or radiation ± chemotherapy. Outcomes in the neoadjuvant vs. surgery first groups were compared.
Results
Of 1,562 patients identified at 43 hospitals, 199 (12.7 %) received neoadjuvant therapy (99 chemotherapy alone and 100 radiation ± chemotherapy). Preoperative biliary stenting (57.9 vs. 44.7 %,
p
= 0.0005), vascular resection (41.5 vs. 17.3 %,
p
< 0.0001), and open resections (94.0 vs. 91.4 %,
p
= 0.008) were more common in the neoadjuvant group. Thirty-day mortality (2.0 vs. 1.5 %,
p
= 0.56) and postoperative morbidity rates (56.3 vs. 52.8 %,
p
= 0.35) were similar between groups. Neoadjuvant therapy patients had fewer organ space infections (3.0 vs. 10.3 %,
p
= 0.001), and neoadjuvant radiation patients had fewer pancreatic fistulas (7.3 vs. 15.4 %,
p
= 0.03).
Conclusions
Despite evidence for more extensive disease, patients receiving neoadjuvant therapy did not experience more complications. Neoadjuvant radiation was associated with lower pancreatic fistula rates. These data provide evidence against higher postoperative complication rates in patients with pancreatic cancer who are treated with neoadjuvant therapy.
PDF
