Objectives/Hypothesis
To characterize contemporary patterns of thyroid surgical care and the effect of volume status on surgical care and short‐term outcomes.
Study Design
Retrospective ...cross‐sectional study.
Methods
Discharge data from the Nationwide Inpatient Sample for 871,644 patients who underwent surgery for thyroid disease in 1993 through 2008 were analyzed using cross‐tabulations and multivariate regression modeling.
Results
Surgical cases increased from 364,288 in 1993 through 2000 to 507,356 in 2001 through 2008, with an increase in thyroid cancer surgical cases from 28% to 34%. Cases performed by high‐volume surgeons increased from 12% in 1993 through 2000 to 25% in 2001 through 2008, whereas cases performed by very‐low volume surgeons decreased from 51% to 34% (P < .001). Cases performed at high‐volume hospitals increased from 14% in 1993 through 2000 to 29% in 2001 through 2008, whereas cases performed at very‐low volume hospitals decreased from 46% to 33% (P < .001). High‐volume surgeons were significantly more likely to perform total thyroidectomy (odds ratio OR = 1.4, P < .001) and had a lower incidence of recurrent laryngeal nerve injury (OR = 0.7, P = .024), hypocalcemia (OR = 0.7, P = .002), and in‐hospital death (OR = 0.3, P = .004). High‐volume hospital care was not associated with extent of surgery, postoperative morbidity, or mortality after adjusting for surgeon volume. After controlling for other variables, thyroid surgery in 2001 through 2008 was associated with an increase in cases performed by low‐volume (relative risk ratio RRR = 1.5, P < .001), intermediate‐volume (RRR = 1.7, P < .001), and high‐volume surgeons (RRR = 2.1, P < .001), high‐volume hospitals (RRR = 2.0, P = .008), total thyroidectomy (RRR = 2.1, P < .001), and neck dissection (RRR = 1.3, P = .016).
Conclusions
These data reflect changing trends in the surgical management of thyroid disease, with meaningful differences in the type of surgical care provided by high‐volume surgeons.
Level of Evidence
2c. Laryngoscope, 123:2056–2063, 2013
Objectives/Hypothesis
A variety of techniques have been proposed for reconstruction of the parotidectomy defect. We reviewed our experience with free abdominal fat transfer (FAT) graft reconstruction ...of parotidectomy defects for benign and malignant disease.
Methods
The medical records of patients who underwent parotidectomy for benign or malignant disease from 2007 to 2015 were retrospectively reviewed.
Results
One hundred and five patients underwent 108 parotidectomies with FAT reconstruction, with bilateral parotidectomy performed in three patients. The majority of patients had benign pathology (71%) and tumors < 3 cm (57%). Prior surgery had been performed in 13 cases (12%) and prior radiation had been performed in three (3%). Superficial parotidectomy was performed in 62 patients (57%) and concurrent elective neck dissection was performed in eight (7%). A facelift incision was utilized in 59 patients (55%). Postoperative radiation was used in 21 patients (19%). Abdominal donor site complications occurred in 11 patients (10%), consisting of hematoma in eight patients (7%) and seroma in three (3%). Parotidectomy wound dehiscence occurred in six cases (6%); all responded to conservative management. There was no association between age, tumor size, comorbidity, smoking status, extent of surgery, incision, or prior radiation on the development of wound complications. Fat transfer graft debulking was required in three patients with persistent overcorrection beyond 6 months postoperatively. No patient demonstrated undercorrection or further FAT resorption beyond 6 months.
Conclusion
Fat transfer reconstruction of the parotidectomy defect is safe and achieves a consistent and predictable long‐term cosmetic result.
Level of Evidence
4. Laryngoscope, 126:2694–2698, 2016
Objectives/Hypothesis
Transoral surgery is an increasingly frequent treatment modality for tumors of the upper aerodigestive tract. This is in large part related to the introduction of transoral ...robotic surgery (TORS) for oropharyngeal cancer resection, which has demonstrated excellent oncologic and functional outcomes. There is limited data, however, on how TORS compares to traditional open surgery in overall costs and length of hospitalization. With increasing pressure to contain and reduce the costs of medical care, we sought to evaluate the impact of TORS on a national sample of patients undergoing surgery for oropharyngeal cancer.
Study Design
Retrospective cross‐sectional study.
Methods
A cross‐sectional analysis of 9,601 patients who underwent an extirpative procedure for a malignant oropharyngeal neoplasm in 2008 to 2009 was performed using discharge data from the Nationwide Inpatient Sample.
Results
TORS was performed in 116 (1.2%) of cases. TORS patients had a lower rate of gastrostomy tube placement (0% vs. 19%), tracheotomy tube placement (0% vs. 36%), and nonroutine discharge (0% vs. 44%) compared to patients undergoing non‐TORS procedures. After controlling for all other variables, including comorbidity, extent of surgery, and teaching hospital status, TORS was associated with significantly decreased length of hospitalization (mean, −1.5 days) and hospital‐related costs (mean, −$4,285).
Conclusions
TORS is becoming an increasingly frequent technique to treat tumors of the upper aerodigestive tract. These data demonstrate that TORS is associated with a decreased length of hospitalization and hospital‐related costs compared to other surgical techniques.
Level of Evidence
2c. Laryngoscope, 124:165–171, 2014
Objective
To determine the relationship between frailty and comorbidity, in‐hospital mortality, postoperative complications, length of hospital stay (LOS), and costs in head and neck cancer (HNCA) ...surgery.
Study Design
Cross‐sectional analysis.
Methods
Discharge data from the Nationwide Inpatient Sample for 159,301 patients who underwent ablative surgery for a malignant oral cavity, laryngeal, hypopharyngeal, or oropharyngeal neoplasm in 2001 to 2010 was analyzed using cross‐tabulations and multivariate regression modeling. Frailty was defined based on frailty‐defining diagnosis clusters from the Johns Hopkins Adjusted Clinical Groups frailty‐defining diagnosis indicator.
Results
Frailty was identified in 7.4% of patients and was significantly associated with advanced comorbidity (odds ratio OR = 1.51.3–1.8), Medicaid (OR = 1.51.3–1.8), major procedures (OR = 1.61.4–1.8), flap reconstruction (OR = 1.71.3–2.1), high‐volume hospitals (OR = 0.70.5–1.0), discharge to a short‐term facility (OR = 4.42.9–6.7), or other facility (OR = 5.44.5–6.6). Frailty was a significant predictor of in‐hospital death (OR = 1.61.1–2.4), postoperative surgical complications (OR = 2.01.7–2.3), acute medical complications (OR = 3.93.2–4.9), increased LOS (mean, 4.9 days), and increased mean incremental costs ($11,839), and was associated with higher odds of surgical complications and increased costs than advanced comorbidity. There was a significant interaction between frailty and comorbidity for acute medical complications and length of hospitalization, with a synergistic effect on the odds of medical complications and LOS in patients with comorbidity who were also frail.
Conclusion
Frailty is an independent predictor of postoperative morbidity, mortality, LOS, and costs in HNCA surgery patients, and has a synergistic interaction with comorbidity that is associated with an increased likelihood of medical complications and greater LOS in patients with comorbidity who are also frail.
Level of Evidence
2c. Laryngoscope, 128:102–110, 2018
Objectives/Hypothesis:
The past 2 decades have witnessed an increase in the use of chemoradiation in the treatment of laryngeal cancer. We sought to characterize contemporary patterns of laryngeal ...cancer surgical care and the effect of volume status on surgical care and short‐term outcomes.
Study Design:
Retrospective cross‐sectional study.
Methods:
Using the Nationwide Inpatient Sample database, temporal trends in laryngeal cancer surgical care were evaluated in 78,478 cases performed in 1993 to 2008. Relationships between volume and mortality, complications, length of stay, and costs were evaluated in 24,856 cases performed in 2003 to 2008 using regression analysis, with adjustment for patient and provider characteristics.
Results:
Laryngeal cancer surgery in 2001 to 2008 was associated with increased utilization of high‐volume hospitals (odds ratio OR = 2.0, P = .039), a decrease in partial and total laryngectomy procedures (OR = 0.7, P < .001), an increase in flap reconstruction (OR = 1.6, P < .001), prior radiation (OR = 2.2, P < .001), comorbidity (OR = 1.6, P < .001), and wound complications (OR = 4.0, P < .001), compared to 1993 to 2000. High‐volume hospitals were significantly associated with partial laryngectomy (OR = 1.8, P = .026) and flap reconstruction (OR = 1.8, P = .027). High‐volume surgeons were associated with partial laryngectomy (OR = 1.7, P = .048), flap reconstruction (OR = 1.6, P = .029), prior radiation (OR = 2.2, P = .013), and comorbidity (OR = 0.4, P = .008). After controlling for all other variables, a statistically significant negative correlation was observed between surgery at a high‐volume hospital and length of hospitalization, and surgery by a high‐volume surgeon was associated with even greater reductions in length of hospitalization as well as lower hospital‐related costs.
Conclusions:
These data reflect changing trends in the primary management of laryngeal cancer, with meaningful differences in the type of surgical care provided by high‐volume providers.
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