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PURPOSE - Standardized care via a unified surgeon preference card for pediatric appendectomy can result in significant cost reduction. The purpose of this study was to evaluate the impact of cost and outcome feedback to surgeons on value of care in an environment reluctant to adopt a standardized surgeon preference card.
METHODS - Prospective observational study comparing operating room (OR) supply costs and patient outcomes for appendectomy in children with 6-month observation periods both before and after intervention. The intervention was real-time feedback of OR supply cost data to individual surgeons via automated dashboards and monthly reports.
RESULTS - Two hundred sixteen children underwent laparoscopic appendectomy for non-perforated appendicitis (110 pre-intervention and 106 post-intervention). Median supply cost significantly decreased after intervention: $884 (IQR $705-$1025) to $388 (IQR $182-$776), p<0.001. No significant change was detected in median OR duration (47min [IQR 36-63] to 50min [IQR 38-64], p=0.520) or adverse events (1 [0.9%] to 6 [4.7%], p=0.062). OR supply costs for individual surgeons significantly decreased during the intervention period for 6 of 8 surgeons (87.5%).
CONCLUSION - Approaching value measurement with a surgeon-specific (rather than group-wide) approach can reduce OR supply costs while maintaining excellent clinical outcomes.
LEVEL OF EVIDENCE - Level II.
Copyright © 2018 Elsevier Inc. All rights reserved.
Pancreatic mucinous cystic neoplasms (MCNs) are rare tumors typically of the distal pancreas that harbor malignant potential. Although resection is recommended, data are limited on optimal operative approaches to distal pancreatectomy for MCN. MCN resections (2000-2014; eight institutions) were included. Outcomes of minimally invasive and open MCN resections were compared. A total of 289 patients underwent distal pancreatectomy for MCN: 136(47%) minimally invasive and 153(53%) open. Minimally invasive procedures were associated with smaller MCN size (3.9 vs 6.8 cm; P = 0.001), lower operative blood loss (192 vs 392 mL; P = 0.001), and shorter hospital stay(5 vs 7 days; P = 0.001) compared with open. Despite higher American Society of Anesthesiologists class, hand-assisted (n = 46) had similar advantages as laparoscopic/robotic (n = 76). When comparing hand-assisted to open, although MCN size was slightly smaller (4.1 vs 6.8 cm; P = 0.001), specimen length, operative time, and nodal yield were identical. Similar to laparoscopic/robotic, hand-assisted had lower operative blood loss (161 vs 392 mL; P = 0.001) and shorter hospital stay (5 vs 7 days; P = 0.03) compared with open, without increased complications. Hand-assisted laparoscopic technique is a useful approach for MCN resection because specimen length, lymph node yield, operative time, and complication profiles are similar to open procedures, but it still offers the advantages of a minimally invasive approach. Hand-assisted laparoscopy should be considered as an alternative to open technique or as a successive step before converting from total laparoscopic to open distal pancreatectomy for MCN.
BACKGROUND - Level one evidence has shown that minimally invasive surgery (MIS) for colon cancer improves short-term outcomes with equivalent long-term oncologic results when compared to open surgery. However, the adoption of MIS for patients with colon cancer has not been universal. The goal of this study is to identify barriers to the use of MIS surgery in colon cancer resection across the United States.
METHODS - The National Cancer Database was queried for all cases of colonic adenocarcinoma resection from 2010 to 2012. Patients undergoing an MIS approach were compared with those undergoing open surgery (OS). MIS was defined as either robotic or laparoscopic surgery. Patients with metastatic disease, surgery for palliation, or tumors >8 cm were excluded. Multivariable modeling was used to identify variables associated with the use of open surgery.
RESULTS - After applying exclusion criteria, 124,205 cases were identified. An MIS approach was used in only 54,621 (44%) patients. In a multivariable model adjusting for stage and tumor size, a number of important factors were associated with decreased odds of a MIS approach including black race (OR .91; p < .0001), lack of insurance (OR .51; p < .0001), lower education (OR .88; p < .0001), lower income (OR .83; p < .0001), treatment at a community program (OR .86; p < .0001), and treatment at a low-volume center (OR .79; p < .0001). Utilization of MIS increased over the study period (2010: 38.7%, 2011: 44.0%, 2012: 49.1%; p < .0001).
CONCLUSIONS - MIS approach is utilized in less than half of all colon resections in this national database, which accounts for over 70% of all diagnosed cancers in the US. Significant variability exists among age, race, insurance status, socioeconomic status, region, and facility type. In light of the recognized benefits of the MIS approach, local and national policy should focus on narrowing these disparities and continuing the upward trend of MIS utilization.
UNLABELLED - ♦
BACKGROUND - In general, efforts to standardize care based on group consensus practice guidelines have resulted in lower morbidity and mortality. Although there are published guidelines regarding insertion and perioperative management of peritoneal dialysis (PD) catheters, variation in practice patterns between centers may exist. The objective of this study is to understand variation in PD catheter insertion practices in preparation for conducting future studies. ♦
METHODS - An electronic survey was developed by the research committee of the International Society for Peritoneal Dialysis - North American Research Consortium (ISPD-NARC) to be completed by physicians and nurses involved in PD programs across North America. It consisted of 45 questions related to 1) organizational characteristics; 2) PD catheter insertion practices; 3) current quality-improvement initiatives; and 4) interest in participation in PD studies. Invitation to participate in the survey was given to nephrologists and nurses in centers across Canada and the United States (US) identified by participation in the inaugural meeting of the ISPD-NARC. Descriptive statistics were applied to analyze the data. ♦
RESULTS - Fifty-one ISPD-NARC sites were identified (45% in Canada and 55% in the US) of which 42 responded (82%). Center size varied significantly, with prevalent PD population ranging from 6 - 300 (median: 60) and incident PD patients in the year prior to survey administration ranging from 3 - 180 (median: 20). The majority of centers placed fewer than 19 PD catheters/year, with a range of 0 - 50. Availability of insertion techniques varied significantly, with 83% of centers employing more than 1 insertion technique. Seventy-one percent performed laparoscopic insertion with advanced techniques (omentectomy, omentopexy, and lysis of adhesions), 62% of sites performed open surgical dissection, 10% performed blind insertion via trocar, and 29% performed blind placement with the Seldinger technique. Use of double-cuff catheters was nearly universal, with a near even distribution of catheters with pre-formed bend versus straight inter-cuff segments. There was also variation in the choice of perioperative antibiotics and perioperative flushing practices. Although 86% of centers had quality-improvement initiatives, there was little consensus as to appropriate targets. ♦
CONCLUSIONS - There is marked variability in PD catheter insertion techniques and perioperative management. Large multicenter studies are needed to determine associations between these practices and catheter and patient outcomes. This research could inform future trials and guidelines and improve practice. The ISPD-NARC is a network of PD units that has been formed to conduct multicenter studies in PD.
Copyright © 2016 International Society for Peritoneal Dialysis.
OBJECTIVE - To compare biochemical recurrence (BCR)-free survival and predictors of BCR in intermediate-risk (IR) and high-risk (HR) patients undergoing robotic-assisted laparoscopic prostatectomy (RALP) vs open radical prostatectomy (ORP).
MATERIALS AND METHODS - We conducted a retrospective study on 1336 men with D'Amico IR or HR prostate cancer who underwent RALP or ORP between 2003 and 2009. Exclusion criteria were use of neoadjuvant therapy, <6 months of follow-up, and insufficient clinicopathologic data. We compared demographic, clinical, and pathologic variables between groups. Kaplan-Meier analysis was performed to compare the 5-year BCR-free survival between groups. Multivariate models were developed to determine whether surgical approach influences BCR.
RESULTS - A total of 979 IR and HR patients (237 ORP and 742 RALP patients) met inclusion criteria. Median follow-up was shorter for RALP (43 vs 63 months; P<.001). ORP patients had a higher median prostate-specific antigen level (7.9 vs 6.7 ng/mL; P<.002), significantly more Gleason sum 8-10 tumors, and more adverse pathologic features overall. There was no difference in positive surgical margins between groups. Pathologic features including extraprostatic extension, seminal vesicle involvement, lymph node involvement, pathologic Gleason sum, and positive surgical margin were significant independent predictors of BCR in multivariate analysis. Surgical approach (RALP vs ORP) did not predict BCR when controlling for other known predictors of BCR.
CONCLUSION - Among IR and HR prostate cancer patients, the oncologic outcomes are similar between RALP and ORP. Not surprisingly, adverse pathologic features are harbingers of BCR.
Copyright © 2014 Elsevier Inc. All rights reserved.
OBJECTIVE - To compare perioperative outcomes after robotic-assisted laparoscopic partial nephrectomy (RALPN) with hilar clamping vs parenchymal clamping.
METHODS - A retrospective, single-institution review of the patients undergoing RALPN with hilar or parenchymal clamping was performed. Associations between perioperative factors and clinicopathologic outcomes were determined using the t test, Fisher's exact test, and multivariate linear regression.
RESULTS - In 51 patients undergoing RALPN, 36 (71%) and 15 (29%) were performed with hilar and parenchymal clamping, respectively. Median tumor diameter was 2.8 cm for both groups (range, 1.1-6.1; P = .93). Tumor complexity by nephrometry score was mild (69% vs 80%), moderate (29% vs 20%), and high (2% vs 0%) in the respective groups (P = .65). Operative time was significantly shorter in the parenchymal clamp group (median 245 vs 320 minutes; P <.0001). There was no difference in blood loss and need for transfusion. On multivariate analysis, hilar clamping (P <.01), higher body mass index (P = .01), and higher complexity tumors (P = .02) were significantly associated with longer operative times. The parenchymal clamp group had better preservation of immediate postoperative glomerular filtration rate (GFR) from baseline to postoperative day 2 (median ΔGFR 0 vs -18 mL/min/1.73 m(2), P = .02). These differences from baseline did not persist (median ΔGFR -6 vs -7 mL/min/1.73 m(2), P = .35) at a median follow-up of 6.6 months. Final pathology determination of malignancy (P = .51) and positive margin rates (P = .26) were similar in both groups.
CONCLUSION - Compared with hilar clamping, selective regional ischemia with the parenchymal clamp for mild-moderately complex tumors is feasible and safe during RALPN. Parenchymal clamping is associated with enhanced immediate preservation of GFR and shorter operative times.
Copyright © 2014 Elsevier Inc. All rights reserved.
Retroperitoneoscopic adrenalectomy (RA) provides a direct approach to the adrenal gland. RA represents a complex approach with unique orientation that is less intuitive. The authors objectively evaluated the impact of mentorship on the performance of RA and also compared it with laparoscopic adrenalectomy (LA). After implementing the use of RA, a retrospective review of the operative experience of two high-volume endocrine surgeons was performed. Both surgeons participated in a hands-on RA mentorship. Clinical presentation and perioperative outcomes were compared. Subgroup analysis was used to compare RA pre- and postmentorship and with LA. Sixty-one LAs and 31 RAs were included in the analysis. The mean operative time was 115 for LA versus 90 minutes for RA (P = 0.002). Blood loss was greater for LA versus RA (56 vs 22 mL; P = 0.001). Length of stay (LOS) for LA was 2.2 versus 1.5 days for RA (P = 0.029). Ten patients were treated by RA in the prementorship era versus 21 in the postmentorship era. The mean operative time for the prementorship group was 118 minutes, which decreased to 77 minutes postmentorship (P < 0.0001). LOS also decreased from 2.0 to 1.2 days (P = 0.04) in the postmentorship era. RA demonstrates a shorter operative time, less blood loss, and decrease length of hospital stay as compared with standard LA. After proper mentorship and patient selection, RA may represent a superior option for removal of small, benign adrenal tumors.
Malignant mesothelioma (MM) is an uncommon neoplasm with a poor prognosis usually associated with asbestos exposure. 18F-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET)/computed tomography (CT) has become an invaluable tool for the diagnosis, staging, and prognosis of this severe disease as it combines both anatomic and functional information in a single imaging procedure, allowing for improved management of this disease. For many authors, 18F-FDG-PET/CT is the cornerstone of the pre-therapeutic evaluation of mesothelioma patients, particularly when multimodal therapy (including extra-pleural pneumonectomy or omentectomy) is considered. However, while characteristic patterns have been reported as predictive of macroscopic pleural or peritoneal involvement, false negative findings are possible, both for pleural and peritoneal mesothelioma, during the initial diagnosis or during the patient's surveillance as illustrated by this report of three cases of suspected MM with negative PET/CT. This report highlights the limitations of PET/CT in the diagnostic evaluation of MM and the importance of histopathological confirmation by thoracoscopy and/or laparoscopy, which remain the most important diagnostic procedures in MM.
Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.
BACKGROUND - Complete surgical removal of the prostate, radical prostatectomy, is the most frequently used treatment option for men with localised prostate cancer. The use of laparoscopic (keyhole) and robot-assisted surgery has improved operative safety but the comparative effectiveness and cost-effectiveness of these options remains uncertain.
OBJECTIVE - This study aimed to determine the relative clinical effectiveness and cost-effectiveness of robotic radical prostatectomy compared with laparoscopic radical prostatectomy in the treatment of localised prostate cancer within the UK NHS.
DATA SOURCES - MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, BIOSIS, Science Citation Index and Cochrane Central Register of Controlled Trials were searched from January 1995 until October 2010 for primary studies. Conference abstracts from meetings of the European, American and British Urological Associations were also searched. Costs were obtained from NHS sources and the manufacturer of the robotic system. Economic model parameters and distributions not obtained in the systematic review were derived from other literature sources and an advisory expert panel.
REVIEW METHODS - Evidence was considered from randomised controlled trials (RCTs) and non-randomised comparative studies of men with clinically localised prostate cancer (cT1 or cT2); outcome measures included adverse events, cancer related, functional, patient driven and descriptors of care. Two reviewers abstracted data and assessed the risk of bias of the included studies. For meta-analyses, a Bayesian indirect mixed-treatment comparison was used. Cost-effectiveness was assessed using a discrete-event simulation model.
RESULTS - The searches identified 2722 potentially relevant titles and abstracts, from which 914 reports were selected for full-text eligibility screening. Of these, data were included from 19,064 patients across one RCT and 57 non-randomised comparative studies, with very few studies considered at low risk of bias. The results of this study, although associated with some uncertainty, demonstrated that the outcomes were generally better for robotic than for laparoscopic surgery for major adverse events such as blood transfusion and organ injury rates and for rate of failure to remove the cancer (positive margin) (odds ratio 0.69; 95% credible interval 0.51 to 0.96; probability outcome favours robotic prostatectomy = 0.987). The predicted probability of a positive margin was 17.6% following robotic prostatectomy compared with 23.6% for laparoscopic prostatectomy. Restriction of the meta-analysis to studies at low risk of bias did not change the direction of effect but did decrease the precision of the effect size. There was no evidence of differences in cancer-related, patient-driven or dysfunction outcomes. The results of the economic evaluation suggested that when the difference in positive margins is equivalent to the estimates in the meta-analysis of all included studies, robotic radical prostatectomy was on average associated with an incremental cost per quality-adjusted life-year that is less than threshold values typically adopted by the NHS (£30,000) and becomes further reduced when the surgical capacity is high.
LIMITATIONS - The main limitations were the quantity and quality of the data available on cancer-related outcomes and dysfunction.
CONCLUSIONS - This study demonstrated that robotic prostatectomy had lower perioperative morbidity and a reduced risk of a positive surgical margin compared with laparoscopic prostatectomy although there was considerable uncertainty. Robotic prostatectomy will always be more costly to the NHS because of the fixed capital and maintenance charges for the robotic system. Our modelling showed that this excess cost can be reduced if capital costs of equipment are minimised and by maintaining a high case volume for each robotic system of at least 100-150 procedures per year. This finding was primarily driven by a difference in positive margin rate. There is a need for further research to establish how positive margin rates impact on long-term outcomes.
FUNDING - The National Institute for Health Research Health Technology Assessment programme.