JAMA Surgery: Patient Safety/Medical Error Topic Collection

Outcomes and Costs of Elective Surgery for Diverticular Disease A Comparison With Other Diseases Requiring Colectomy Elective Surgery for Diverticular Disease

Van Arendonk KJ, Tymitz KM, Gearhart SL, et al. — Mon, 01 Apr 2013 00:00:00 GMT

Objective

To compare outcomes and costs of elective surgery for diverticular disease (DD) with those of other diseases commonly requiring colectomy.

Design

Multivariable analyses using the Nationwide Inpatient Sample to compare outcomes across primary diagnosis while adjusting for age, sex, race, year of admission, and comorbid disease.

Setting

A sample of US hospital admissions from 2003-2009.

Patients

All adult patients (≥18 years) undergoing elective resection of the descending colon or subtotal colectomy who had a primary diagnosis of DD, colon cancer (CC), or inflammatory bowel disease (IBD).

Main Outcome Measures

In-hospital mortality, postoperative complications, ostomy placement, length of stay, and hospital charges.

Results

Of the 74 879 patients, 50.52% had DD, 43.48% had CC, and 6.00% had IBD. After adjusting for other variables, patients with DD were significantly more likely than patients with CC to experience in-hospital mortality (adjusted odds ratio, 1.90; 95% CI, 1.37-2.63; P < .001), develop a postoperative infection (1.67; 1.48-1.89; P < .001), and have an ostomy placed (1.87; 1.65-2.11; P < .001). The adjusted total hospital charges for patients with DD were $6678.78 higher (95% CI, $5722.12-$7635.43; P < .001) and length of stay was 1 day longer (95% CI, 0.86-1.14; P < .001) compared with patients with CC. Patients with IBD had the highest in-hospital mortality, highest rates of complications and ostomy placement, longest length of stay, and highest hospital charges.

Conclusions

Despite undergoing the same procedure, patients with DD have significantly worse and more costly outcomes after elective colectomy compared with patients with CC but better than patients with IBD. These relatively poor outcomes should be recognized when considering routine elective colectomy after successful nonoperative management of acute diverticulitis.

Portomesenteric Thrombosis Following Laparoscopic Bariatric Surgery Incidence, Patterns of Clinical Presentation, and Etiology in a Bariatric Patient Population Portomesenteric Thrombosis Following LBS

Goitein D, Matter I, Raziel A, et al. — Mon, 01 Apr 2013 00:00:00 GMT

Objective

To describe the incidence of, the patterns of clinical presentation of, and the reasons for portomesenteric vein thrombosis among patients who underwent laparoscopic bariatric surgery.

Design

Retrospective, multicenter study.

Setting

Six academic bariatric centers.

Patients

Morbidly obese patients diagnosed with portomesenteric vein thrombosis following laparoscopic bariatric surgery between January 2007 and June 2012.

Main Outcome Measures

Clinical presentation, diagnostic measures used, treatments employed, outcome, and hematologic workup of patients.

Results

Of 5706 patients who underwent laparoscopic bariatric surgery, 17 (0.3%) had portomesenteric vein thrombosis, 16 after sleeve gastrectomy and 1 following adjustable gastric banding. Seven patients were women, the mean age was 38 years, and the mean body mass index was 44.3. The median time to presentation was 10.1 days, and the median time to diagnosis was 11.7 days. New-onset epigastric pain was present in all patients, whereas other signs and symptoms were sporadically found. Computed tomography was performed and was diagnostic in 16 cases. Ultrasonography was used for 9 patients, and positive results were found for 8 of these patients. Patients were treated by anticoagulation with subcutaneous low-molecular-weight heparin (n = 15) or intravenous heparin (n = 2), followed by warfarin sodium. One patient underwent transhepatic portal infusion of streptokinase. Three patients required surgery: laparoscopic splenectomy due to infarct and abscess for 1 patient and laparotomy for 2 patients (with necrotic small-bowl resection for 1 of these patients). There were no deaths.

Conclusions

Portomesenteric vein thrombosis is rare after laparoscopic bariatric surgery. Familiarity with this dangerous entity is important. Prompt diagnosis and care, initiated by a high index of suspicion, is crucial.

Concomitant Vascular Reconstruction During Pancreatectomy for Malignant Disease A Propensity Score–Adjusted, Population-Based Trend Analysis Involving 10 206 Patients Vascular Reconstruction and Pancreatic Surgery

Worni M, Castleberry AW, Clary BM, et al. — Mon, 01 Apr 2013 00:00:00 GMT

Objective

To assess trends in the frequency of concomitant vascular reconstructions (VRs) from 2000 through 2009 among patients who underwent pancreatectomy, as well as to compare the short-term outcomes between patients who underwent pancreatic resection with and without VR.

Design

Single-center series have been conducted to evaluate the short-term and long-term outcomes of VR during pancreatic resection. However, its effectiveness from a population-based perspective is still unknown. Unadjusted, multivariable, and propensity score–adjusted generalized linear models were performed.

Setting

Nationwide Inpatient Sample from 2000 through 2009.

Patients

A total of 10 206 patients were involved.

Main Outcome Measures

Incidence of VR during pancreatic resection, perioperative in-hospital complications, and length of hospital stay.

Results

Overall, 10 206 patients were included in this analysis. Of these, 412 patients (4.0%) underwent VR, with the rate increasing from 0.7% in 2000 to 6.0% in 2009 (P < .001). Patients who underwent pancreatic resection with VR were at a higher risk for intraoperative (propensity score–adjusted odds ratio, 1.94; P = .001) and postoperative (propensity score–adjusted odds ratio, 1.36; P = .008) complications, while the mortality and median length of hospital stay were similar to those of patients without VR. Among the 25% of hospitals with the highest surgical volume, patients who underwent pancreatic surgery with VR had significantly higher rates of postoperative complications and mortality than patients without VR.

Conclusions

The frequency of VR during pancreatic surgery is increasing in the United States. In contrast with most single-center analyses, this population-based study demonstrated that patients who underwent VR during pancreatic surgery had higher rates of adverse postoperative outcomes than their counterparts who underwent pancreatic resection only. Prospective studies incorporating long-term outcomes are warranted to further define which patients benefit from VR.

The Influence of Intern Home Call on Objectively Measured Perioperative Outcomes

Kastenberg ZJ, Rhoads KF, Melcher ML, et al. — Mon, 01 Apr 2013 00:00:00 GMT

Hypothesis

In July 2011, surgical interns were prohibited from being on call from home by the new residency review committee guidelines on work hours. In support of the new Accreditation Council for Graduate Medical Education work-hour restrictions, we expected that a period of intern home call would correlate with increased rates of postoperative morbidity and mortality.

Design

Prospective cohort.

Setting

University-affiliated tertiary Veterans Affairs Medical Center.

Patients

All patients identified in the Veterans Affairs National Surgical Quality Improvement Program database who underwent an operation performed by general, vascular, urologic, or cardiac surgery services between fiscal years (FYs) 1999 and 2010 were included.

Main Outcome Measures

During FYs 1999-2003, the first call for all patients went to an in-hospital intern. In the subsequent period (FYs 2004-2010), the first call went to an intern on home call. Thirty-day unadjusted morbidity and mortality rates and risk-adjusted observed to expected ratios were analyzed by univariate analysis and joinpoint regression, respectively.

Results

Unadjusted overall morbidity rates decreased between 1999-2003 and 2004-2010 (12.14% to 10.19%, P = .003). The risk-adjusted morbidity observed to expected ratios decreased at a uniform annual percentage change of −6.03% (P < .001). Unadjusted overall mortality rates also decreased between the 2 periods (1.76% to 1.26%; P = .05). There was no significant change in the risk-adjusted mortality observed to expected ratios during the study.

Conclusions

The institution of an intern home call schedule was not associated with increased rates of postoperative morbidity or mortality.

The Risk-Benefit Ratio Comment on “Outcomes and Costs of Elective Surgery for Diverticular Disease” The Risk-Benefit Ratio

Ludwig KA, Kosinski LA. — Mon, 01 Apr 2013 00:00:00 GMT

Van Arendonk et al used the Nationwide Inpatient Sample database to evaluate outcomes for colon surgery based on the disease being treated: colon cancer (CC), diverticular disease (DD), or inflammatory bowel disease (IBD). They conclude that elective resection for DD, when the analysis is adjusted for demographic and clinical characteristics, is associated with a higher morbidity and mortality rate than that seen when operating because of CC and that these data should then be used to question the advisability of offering routine elective colectomy after successful nonoperative management of acute diverticulitis. The underlying concept or assumption seems to be that many patients being offered elective resection for DD do not really need the operation, since recent data and guidelines would suggest that the course of their disease may not ultimately take them to a middle-of-the-night emergency operation for perforation that routinely involves a stoma and the subsequent operation to reestablish gastrointestinal tract continuity. The implication is that, before we offer an elective resection for DD, we should be aware that the risk of such an undertaking may be greater than we appreciate, suggesting that perhaps we should stand down, observe, treat expectantly, and not operate so frequently. I assume we are to suppose that the sequelae of DD—inflammation, distortion of tissue planes, thick mesentery, etc—make surgery riskier and that, since the natural course of the disease is such that complications may not arise after an episode or two, why operate?

Variations on a Theme Comment on “Variant Adrenal Venous Anatomy in 546 Laparoscopic Adrenalectomies” Variant Venous Adrenal Anatomy at Work

Sadowski SM, Kebebew E. — Mon, 01 Apr 2013 00:00:00 GMT

The number of adrenalectomies performed in the last 2 decades has almost doubled, and many of these procedures are being performed laparoscopically because of the improved patient outcomes associated with this surgical technique. Thus, knowledge of adrenal venous anatomy and its variations is important to avoid one of the common complications of an adrenalectomy, bleeding. Furthermore, in patients with pheochromocytoma, early identification and division of the adrenal vein(s) are often emphasized to minimize intraoperative hemodynamic instability.

Variant Adrenal Venous Anatomy in 546 Laparoscopic Adrenalectomies Variant Adrenal Venous Anatomy in Adrenalectomy

Scholten A, Cisco RM, Vriens MR, et al. — Mon, 01 Apr 2013 00:00:00 GMT

Importance

Knowing the types and frequency of adrenal vein variants would help surgeons identify and control the adrenal vein during laparoscopic adrenalectomy.

Objectives

To establish the surgical anatomy of the main vein and its variants for laparoscopic adrenalectomy and to analyze the relationship between variant adrenal venous anatomy and tumor size, pathologic diagnosis, and operative outcomes.

Design, Setting, and Patients

In a retrospective review of patients at a tertiary referral hospital, 506 patients underwent 546 consecutive laparoscopic adrenalectomies between April 22, 1993, and October 21, 2011. Patients with variant adrenal venous anatomy were compared with patients with normal adrenal venous anatomy regarding preoperative variables (patient and tumor characteristics [size and location] and clinical diagnosis), intraoperative variables (details on the main adrenal venous drainage, any variant venous anatomy, duration of operation, rate of conversion to hand-assisted or open procedure, and estimated blood loss), and postoperative variables (transfusion requirement, reoperation for bleeding, duration of hospital stay, and histologic diagnosis).

Intervention

Laparoscopic adrenalectomy.

Main Outcomes and Measures

Prevalence of variant adrenal venous anatomy and its relationship to tumor characteristics, pathologic diagnosis, and operative outcomes.

Results

Variant venous anatomy was encountered in 70 of 546 adrenalectomies (13%). Variants included no main adrenal vein identifiable (n = 18), 1 main adrenal vein with additional small veins (n = 11), 2 adrenal veins (n = 20), more than 2 adrenal veins (n = 14), and variants of the adrenal vein drainage to the inferior vena cava and hepatic vein or of the inferior phrenic vein (n = 7). Variants occurred more often on the right side than on the left side (42 of 250 glands [17%] vs 28 of 296 glands [9%], respectively; P = .02). Patients with variant anatomy compared with those with normal anatomy had larger tumors (mean, 5.1 vs 3.3 cm, respectively; P < .001), more pheochromocytomas (24 of 70 [35%] vs 100 of 476 [21%], respectively; P = .02), and more estimated blood loss (mean, 134 vs 67 mL, respectively; P = .01). For patients with variant anatomy vs those with normal anatomy, the rates of transfusion requirement (2 of 70 [3%] vs 10 of 476 [2%], respectively; P = .69) and reoperation for bleeding (1 of 70 [1%] vs 3 of 476 [1%]; P = .46) were similar between groups.

Conclusions and Relevance

Understanding variant adrenal venous anatomy is important to avoid bleeding during laparoscopic adrenalectomy, particularly in patients with large tumors or pheochromocytomas. Surgeons should anticipate a higher probability of adrenal vein variants when operating on pheochromocytomas and larger adrenal tumors.

Low Rates of Short- and Long-term Graft Loss After Kidney-Pancreas Transplant From a Single Center Low Graft Loss Rates in Kidney-Pancreas Transplant

Tai DS, Hong J, Busuttil RW, et al. — Mon, 01 Apr 2013 00:00:00 GMT

Importance

Since the 1980s, pancreas transplant has become the most effective treatment strategy to restore euglycemia in patients with type 1 diabetes mellitus. However, technical complications and BK virus nephropathy continue to be important causes of early and late graft loss. These and other complications lead to cited 1- and 3-year graft survival rates of 74% and 67% (pancreas) and 81% and 73% (kidney).

Objective

To examine our center's outcomes with pancreas-kidney transplant and early BK virus screening and treatment.

Design

Prospective study from August 2004 to January 2012.

Setting

University medical center.

Participants

Sixty-five patients with type 1 diabetes who underwent simultaneous kidney and pancreas, pancreas after kidney, or pancreas transplant alone at a single center.

Intervention

Pancreas transplant.

Main Outcome Measures

Pancreas and kidney survival; patient survival; and kidney loss due to BK virus nephropathy.

Results

Patient survival at 1, 3, and 5 years was 100%, 98.4%, and 98.4%, respectively. Of 2 early pancreatic allograft losses, 1 was due to thrombosis (1.6%). One- and 5-year pancreas graft survival rates were 95.4% and 92.3%; losses after more than 1 year were due to rejection. Kidney survival rates were 100% and 95.2% at 1 and 5 years; losses were due to nephropathy and noncompliance, with 1 death with function. BK virus incidence was 29.2%, with no graft losses due to BK infection.

Conclusions and Relevance

While pancreas transplant can be complicated by early graft loss, our results suggest that excellent outcomes at 5 years can be achieved. Posttransplant BK virus screening and treatment are essential tools to long-term success.

Patient Satisfaction as a Possible Indicator of Quality Surgical Care Patient Satisfaction and Quality of Surgical Care

Lyu H, Wick EC, Housman M, et al. — Mon, 01 Apr 2013 00:00:00 GMT

Importance

In 2010, national payers announced they would begin using patient satisfaction scores to adjust reimbursements for surgical care.

Objective

To determine whether patient satisfaction is independent from surgical process measures and hospital safety.

Design

We compared the performance of hospitals that participated in the Patient Satisfaction Survey, the Centers for Medicare & Medicaid Services Surgical Care Improvement Program, and the employee Safety Attitudes Questionnaire.

Setting

Thirty-one US hospitals.

Participants

Patients and hospital employees.

Interventions

There were no interventions for this study.

Main Outcomes and Measures

Hospital patient satisfaction scores were compared with hospital Surgical Care Improvement Program compliance and hospital employee safety attitudes (safety culture) scores during a 2-year period (2009-2010). Secondary outcomes were individual domains of the safety culture survey.

Results

Patient satisfaction was not associated with performance on process measures (antibiotic prophylaxis, R = −0.216 [P = .24]; appropriate hair removal, R = −0.012 [P = .95]; Foley catheter removal, R = −0.089 [P = .63]; deep vein thrombosis prophylaxis, R = 0.101 [P = .59]). In addition, patient satisfaction was not associated with a hospital's overall safety culture score (R = 0.295 [P = .11]). We found no association between patient satisfaction and the individual culture domains of job satisfaction (R = 0.327 [P = .07]), working conditions (R = 0.191 [P = .30]), or perceptions of management (R = 0.223 [P = .23]); however, patient satisfaction was associated with the individual culture domains of employee teamwork climate (R = 0.439 [P = .01]), safety climate (R = 0.395 [P = .03]), and stress recognition (R = −0.462 [P = .008]).

Conclusions and Relevance

Patient satisfaction was independent of hospital compliance with surgical processes of quality care and with overall hospital employee safety culture, although a few individual domains of culture were associated. Patient satisfaction may provide information about a hospital's ability to provide good service as a part of the patient experience; however, further study is needed before it is applied widely to surgeons as a quality indicator.