Background
While the negative impact of postoperative complications on hospital costs, survival, and cancer recurrence is well known, few studies have quantified the impact of postoperative ...complications on patient-centered outcomes such as functional status. The objective of this study was to estimate the impact of postoperative complications on recovery of functional status after elective abdominal surgery in elderly patients.
Methods
Elderly patients (70 years and older) undergoing elective abdominal surgery, with a planned length of stay >1 day, were prospectively enrolled between July 2012 and December 2014. The primary outcome was time to recovery to the preoperative functional status measured by the short physical performance battery (SPPB) preoperatively and at 1 week, 1, 3, and 6 months after surgery. The comprehensive complication index was calculated to grade the severity and number of postoperative complications. A Weibull survival model with interval censoring was performed, controlling for age, sex, body mass index (BMI), comorbidities (Charlson comorbidity index−CCI), frailty, presence of cancer, nutritional status, wound class, preoperative functional status, and surgical approach.
Results
Hundred and forty-nine patients (79 men and 70 women) were included in the analysis. Mean age was 77.7 ± 4.9 years, mean BMI was 27.2 ± 5.5 kg/m
2
, and the median CCI was 3 (IQR 2–6). The mean preoperative SPPB score was 9.62 ± 2.33. A total of 52 patients (34.9 %) experienced one or more postoperative complications, including four mortalities, and a total of 72 complications. The mean comprehensive complication index score for these patients was 25.7 ± 23.8. In the presence of all other variables included in the model, a higher comprehensive complication index score was found to significantly decrease the hazard of recovery (HR 0.96, CI 0.94–0.98,
p
value = 0.0004) and hence increase the time to recovery.
Conclusion
Following elective abdominal surgery, elderly patients who experience a greater number and more severe postoperative complications take longer to return to their preoperative functional status.
Background
Laparoscopic surgery has an important role to play in the care of patients with inguinal hernias, but the procedure is difficult to learn. This study aimed to assess whether training to ...proficiency using a novel laparoscopic inguinal hernia repair (LIHR) simulation curriculum improved operating room (OR) performance.
Methods
For this study, 17 surgical residents postgraduate years (PGYs) 2–5 participated in a didactic LIHR course and then were randomized to a training (T) or a control (C, standard residency) group. Performance of totally extraperitoneal (TEP) LIHR in the OR at baseline and after the study was measured using the Global Operative Assessment of Laparoscopic Skills–Groin Hernia (GOALS-GH).
Results
Of the 17 residents, 14 (5 T and 9 C) completed their final evaluations. The two groups showed no differences in terms of LIHR experience. The baseline GOALS-GH scores in the OR were similar (T 14.8; range 12.8–16.8 vs. C 13.6; range 12.3–14.8;
P
= 0.20). The mean number of training sessions needed to achieve proficiency was 4.8 (range 4.4–5.2), and the mean total training time was 109 min (range 61.9–149.1 min). After training, OR performance improved in the T group by 3.4 points (range 2.0–4.8 points;
P
= 0.002), whereas no significant change was seen in the C group 1.2; (range −1.1 to 3.6;
P
= 0.27). The final total GOALS-GH scores showed a trend toward better performance in the T group than in the C group 18.2; (range 14.9–21.5) vs. 14.8; (range 12.4–17.1);
P
= 0.06).
Conclusions
This study demonstrated the skills required for transfer of LIHR to the OR using a low-cost procedure-specific simulator. Residents who trained to proficiency on the McGill Laparoscopic Inguinal Hernia Simulator (MLIHS) showed greater skill improvement than their colleagues who did not. These results provide evidence supporting the use of simulation to teach and assess LIHR.
Background Minimally invasive pancreatic surgery has evolved rapidly, but total laparoscopic pancreaticoduodenectomy has not been widely adopted owing to its technical complexity. Hybrid ...laparoscopy-assisted pancreaticoduodenectomy (HLAPD) combines the relative ease of open surgery with the benefits of a minimally invasive approach. This study evaluates the safety and effectiveness of the hybrid approach compared with open surgery. Methods We retrospectively analyzed data of consecutive patients undergoing either hybrid or open pancreaticoduodenectomy (OPD) at our institution between September 2009 and December 2013. Demographic, operative and oncologic data were collected to compare outcomes between HLAPD and OPD. Results Our analysis included 33 patients (HLAPD: n = 13; OPD: n = 20). There were no differences in patient demographics, comorbidities or surgical indications. The HLAPD group had significantly lower intraoperative blood loss (450 mL v. 1000 mL, p = 0.023) and shorter length of hospital stay (8 v. 12 d, p = 0.025) than the OPD group. Duration of surgery did not differ significantly between the groups. There were no differences in postoperative analgesic requirements, Clavien grade I/II or grade III/IV complications or 90-day mortality. Oncologic outcomes showed no significant differences in tumour size, R1 resection rate or number of lymph nodes harvested. Conclusion In select patients, HLAPD is a safe and effective procedure with comparable outcomes to conventional open surgery. Wider adoption of the hybrid approach will allow a greater number of patients to benefit from a less invasive procedure while facilitating the transition toward purely minimally invasive pancreaticoduodenectomy.
The management of pancreatic pseudocysts has changed greatly over the last decade. As laparoscopic and endoscopic techniques continue to evolve, their use in the treatment of pseudocysts has gained ...acceptance, whereas the role of percutaneous drainage has become more limited. The literature on laparoscopic, endoscopic, and percutaneous management of pancreatic pseudocyst is reviewed here and, based on these data, a treatment algorithm is suggested.
Summary Significance of signet ring cells in mucinous adenocarcinoma of the peritoneum from appendiceal origin has never been specifically studied. We retrospectively reviewed cases of mucinous ...adenocarcinoma of the peritoneum from appendiceal origin (n = 55) and collected clinical follow-up data. Signet ring cells were identified in 29 of 55 cases. No low-grade mucinous adenocarcinoma case (n = 11) had signet ring cells, whereas 29 of 44 high-grade mucinous adenocarcinoma cases did. Cases of high-grade mucinous adenocarcinoma were subdivided into 3 groups: (1) high-grade mucinous adenocarcinoma without signet ring cells (n = 15), (2) high-grade mucinous adenocarcinoma with signet ring cells only within mucin pools (n = 20), and (3) high-grade mucinous adenocarcinoma with signet ring cells invading tissue (n = 9). Overall survival (OS) and progression-free survival were subsequently evaluated. Five-year OS for cases of high-grade mucinous adenocarcinoma without signet ring cells and high-grade mucinous adenocarcinoma with signet ring cells within mucin pools were similar at 31.8% (SE, 14.4%) and 35.8% (SE, 13.9%), respectively. A significant survival difference was seen for cases of high-grade mucinous adenocarcinoma with signet ring cells invading tissue with a median OS of 0.5 years versus 2.9 and 2.4 years ( P = .04 and P = .03), respectively, for cases of high-grade mucinous adenocarcinoma without signet ring cells and high-grade mucinous adenocarcinoma with signet ring cells within mucin pools. Finding signet ring cells floating in extracellular mucin pools made no prognostic difference when compared with cases of high-grade mucinous adenocarcinoma without signet ring cells. In contrast, high-grade mucinous adenocarcinoma with signet ring cells invading tissue was significant for worse survival, and thus, we propose reporting signet ring cell tissue invasion particularly when extensive.
Abstract Background The purpose of this study was to determine the impact of a formal surgical research program (leading to a postgraduate degree) during residency, on future research productivity. ...Methods We surveyed all North American graduates of the McGill University general surgery residency program between 1987 and 2005. The survey included questions on research involvement before, during, and after general surgery residency. This was combined with a literature search revealing all research publications of the participants. Outcomes were the yearly average of publications and awarded funding as faculty members. Results Seventy-five of 119 graduates (63%) responded. Staff physicians who had participated in formal research programs during residency (n = 35), compared with those who had not (n = 40), produced more publications per year (2.8 ± 2.3 vs 1.1 ± 1.2, P < .01) and had greater funding success (81% vs 55%, P = .03). Conclusions Residents who had participated in formal research programs during residency were more likely to have greater academic success.
Background Pancreatic resections have traditionally been associated with substantial morbidity and mortality. The robotic platform is believed to improve technical aspects of the procedure while ...offering minimally invasive benefits. We sought to determine the safety and feasibility of the first robotic pancreaticoduodenectomies performed at our institution. Methods We retrospectively reviewed data on all patients who underwent robotic-assisted pancreaticoduodenectomy (RAPD) between July 2010 and June 2014 and compared them to outcomes of patients undergoing hybrid laparoscopic pancreaticoduodenectomies (HLAPD) during the same time period. Results Fifteen patients were scheduled for RAPD; 2 were converted to an open approach and 1 to a mini-laparotomy during the laparoscopic portion of the procedure. Patients who had RAPD ( n = 12) had a median duration of surgery of 596.6 (range 509–799) minutes, estimated blood loss of 275 (range 50–1000) mL and median length of stay of 7.5 (range 5–57) days. Mean total opioid use up to postoperative day 7 was 142.599 ± versus 176.9 ± mg equivalents of intravenous morphine for RAPD and HLAPD, respectively. There was no significant difference between RAPD and HLAPD in any parameters, highlighting the safety and feasibility of a step-wise minimally invasive learning platform. Most patients in the RAPD group had malignant pathology (88.2%). Oncologic outcomes were maintained with no significant difference in ability to resect lymph nodes or achieve negative margins. There were 4 (28.5%) Clavien I–II complications and 3 (29.4%) Clavien III–IV complications, 2 of which required readmission. There were no reported deaths at 90 days. Complication, pancreatic leak and mortality rates did not differ significantly from our laparoscopic experience. Conclusion Outcomes of RAPD and HLAPD were comparable at our centre, even during the early stages of our learning curve. These results also highlight the safety, feasibility and patient benefits of a step-wise transition from open to hybrid to fully robotic pancreaticoduodenectomies in a high-volume academic centre.
Background Measuring the quality of surgical care is essential to identifying areas of weakness in the delivery of effective surgical care and to improving patient outcomes. Our objectives were to ...(1) assess the quality of surgical care delivered to adult patients; and (2) determine the association between quality of surgical care and postoperative complications. Methods This retrospective, pilot, cohort study was conducted at a single university-affiliated institution. Using the institution's National Surgical Quality Improvement Program database (2009–2010), 273 consecutive patients ≥18 years of age who underwent elective major abdominal operations were selected. Adherence to 10 process-based quality indicators (QIs) was measured and quantified by calculating a patient quality score (no. of QIs passed/no. of QIs eligible). A pass rate for each individual QI was also calculated. The association between quality of surgical care and postoperative complications was assessed using an incidence rate ratio, which was estimated from a Poisson regression. Results The mean overall patient quality score was 67.2 ± 14.4% (range, 25–100%). The mean QI pass rate was 65.9 ± 26.1%, which varied widely from 9.6% (oral intake documentation) to 95.6% (prophylactic antibiotics). Poisson regression revealed that as the quality score increased, the incidence of postoperative complications decreased (incidence rate ratio, 0.19; P = .011). A sensitivity analysis revealed that this association was likely driven by the postoperative ambulation QI. Conclusion Higher quality scores, mainly driven by early ambulation, were associated with fewer postoperative complications. QIs with unacceptably low adherence were identified as targets for future quality improvement initiatives.
Background The ability to measure surgical quality of care is important and can lead to improvements in patient safety. As such, processes should be carried out in an identical fashion for all ...patients, regardless of how vulnerable or complex they are. Our objectives were to assess quality of surgical care delivered to elderly patients and to determine the association between patient characteristics and quality of care. Study Design This is a retrospective pilot cohort study, conducted in a single university-affiliated hospital. Using the institution's National Surgical Quality Improvement Program (NSQIP) database (2009 to 2010), 143 consecutive patients 65 years or older, undergoing elective major abdominal surgery, were selected. Adherence to 15 process-based quality indicators (QIs) was measured, and a pass rate was calculated for each individual QI. The association between patient characteristics (age, sex, Charlson Comorbidity Index, functional status, wound class) and patient quality score was assessed using multiple linear regression. Results Quality indicators with the lowest pass rates included postoperative delirium screening (0%), level of care documentation (0.7%), cognition and functional assessment at discharge (4.9%), oral intake documentation (12.6%), and pressure ulcer risk assessment (35.0%). The mean patient quality score was 46.8% ± 10.7% (range 16.7% to 75.0%). No association was found between patient characteristics and patient quality score. Conclusions Quality of care delivered to elderly patients undergoing major surgery at our institution was generally poor and independent of patient characteristics. Although quality appears to be uniform across different patients, these results provide targets for quality improvement initiatives.
Background. The reported incidence of noncurative laparotomies for pancreatic cancer using standard imaging (SI) techniques for staging remains high. The objectives of this study are to determine the ...diagnostic accuracy of diagnostic laparoscopy with ultrasound (DLUS) in assessing resectability of pancreatic tumors. Study Design. We systematically searched the literature for prospective studies investigating the accuracy of DLUS in determining resectability of pancreatic tumors. Results. 104 studies were initially identified and 19 prospective studies (1,573 patients) were included. DLUS correctly predicted resectability in 79% compared to 55% for SI. DLUS prevented noncurative laparotomies in 33%. Of those, the most frequent DLUS findings precluding resection were liver metastases, vascular involvement, and peritoneal metastases. DLUS had a morbidity rate of 0.8% with no mortalities. DLUS remained superior to SI when analyzing studies published only in the last five years (100% versus 81%), enrolling patients after the year 2000 (74% versus 58%), or comparing DLUS to modern multidimensional CT (100% versus 78%). Conclusion. DLUS seems to still have a role in the preoperative staging of pancreatic cancer. With its ability to detect liver metastases, vascular involvement, and peritoneal metastases, the use of DLUS leads to less noncurative laparotomies.
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