Bruce L. Hall

Validity and Feasibility of the American College of Surgeons Colectomy Composite Outcome Quality Measure.

Objective: To develop a reliable, robust, parsimonious, risk-adjusted 30-day composite colectomy outcome measure. Background: A fundamental aspect in the pursuit of high-quality care is the development of valid and reliable performance measures in surgery. Colon resection is associated with appreciable morbidity and mortality and therefore is an ideal quality improvement target. Methods: From 2010 American College of Surgeons National Surgical Quality Improvement Program data, patients were identified who underwent colon resection for any indication. A composite outcome of death or any serious morbidity within 30 days of the index operation was established. A 6-predictor, parsimonious model was developed and compared with a more complex model with more variables. National caseload requirements were calculated on the basis of increasing reliability thresholds. Results: From 255 hospitals, 22,346 patients were accrued who underwent a colon resection in 2010, most commonly for neoplasm (46.7%). A mortality or serious morbidity event occurred in 4461 patients (20.0%). At the hospital level, the median composite event rate was 20.7% (interquartile range: 15.8%–26.3%). The parsimonious model performed similarly to the full model (Akaike information criterion: 19,411 vs 18,988), and hospital-level performance comparisons were highly correlated (R = 0.97). At a reliability threshold of 0.4, 56 annual colon resections would be required and achievable at an estimated 42% of US and 69% of American College of Surgeons National Surgical Quality Improvement Program hospitals. This 42% of US hospitals performed approximately 84% of all colon resections in the country in 2008. Conclusions: It is feasible to design a measure with a composite outcome of death or serious morbidity after colon surgery that has a low burden for data collection, has substantial clinical importance, and has acceptable reliability.

Routine drainage of the operative bed following elective distal pancreatectomy does not reduce the occurrence of complications.

Background: Routine drainage of the operative bed following elective pancreatectomy remains controversial. Data specific to distal pancreatectomy (DP) have not been examined in a multi-institutional collaborative.Methods: Data from the American College of Surgeons-National Surgical Quality Improvement Program Pancreatectomy Demonstration Project were utilized. The impact of drain placement on development of pancreatectomy-related and overall morbidity were analyzed. Propensity scores for drain placement were calculated, and nearest neighbor matching was used to create a matched cohort. Groups were compared using bivariate and logistic regression analyses.Results: Over 14xa0months, 761 patients undergoing DP were accrued; 606 were drained. Propensity score matching was possible in 116 patients. Drain and no drain groups were not different with respect to multiple preoperative and operative variables. All pancreatic fistulas (pu2009<u20090.01) and overall morbidity (pu2009<u20090.05) were more common in patients who received a drain. The placement of a drain did not reduce the incidence of clinically relevant pancreatic fistula nor the need for postoperative procedures.Conclusions: Placement of drains following elective distal pancreatectomy was associated with a higher overall morbidity and pancreatic fistulas. Drains did not reduce intra-abdominal septic morbidity, clinically relevant pancreatic fistulas, nor the need for postoperative therapeutic intervention.

Minimally invasive hepatopancreatobiliary surgery in North America: an ACS-NSQIP analysis of predictors of conversion for laparoscopic and robotic pancreatectomy and hepatectomy

BACKGROUNDnProcedural conversion rates represent an important aspect of the feasibility of minimally invasive surgical (MIS) approaches. This study aimed to outline the rates and predictors of procedural completion/conversion for MIS hepatectomy and pancreatectomy.nnnMETHODSnAll 2014 ACS-NSQIP laparoscopic and robotic hepatectomy and pancreatectomy procedures were identified and grouped into pure, open assist, or unplanned conversion to open. Risk adjusted multinomial logistic regression models were generated with completion (Pure) set as the primary outcome.nnnRESULTSn1667 (laparoscopicxa0=xa01360, roboticxa0=xa0307) resections were captured. After risk adjustment, robotic DP was associated with similar open assist (relative risk ratioxa0-1.9%, Pxa0=xa00.602), but lower unplanned conversion (-8.2%, Pxa0=xa00.004) and open assistxa0+xa0unplanned conversion (-10.1%, Pxa0=xa00.015) compared to laparoscopic DP; while robotic PD was associated with lower open assist (-22.2%, Pxa0<xa00.001), unplanned conversions (-15%, Pxa0=xa00.006) and open assistxa0+xa0unplanned conversions (-37.2, Pxa0<xa00.001) compared to laparoscopic PD. The robotic and laparoscopic approaches to hepatectomy were not associated with differences in pure MIS completion rates (Pxa0=xa0NS) after risk adjustment.nnnCONCLUSIONSnThe robotic approach to pancreatectomy was associated with higher rates of pure MIS completion compared to laparoscopy, whereas no difference in MIS completion rates was noted for robotic versus laparoscopic hepatectomy.

New anthropometric classification scheme of preoperative nutritional status in children: a retrospective observational cohort study

Objective WHO uses anthropometric classification scheme of childhood acute and chronic malnutrition based on low body mass index (BMI) (‘wasting’) and height for age (‘stunting’), respectively. The goal of this study was to describe a novel two-axis nutritional classification scheme to (1) characterise nutritional profiles in children undergoing abdominal surgery and (2) characterise relationships between preoperative nutritional status and postoperative morbidity. Design This was a retrospective observational cohort study. Setting The setting was 50 hospitals caring for children in North America that participated in the American College of Surgeons National Surgical Quality Improvement Program Paediatric from 2011 to 2013. Participants Children >28 days who underwent major abdominal operations were identified. Interventions/main predictor The cohort of children was divided into five nutritional profile groups based on both BMI and height for age Z-scores: (1) underweight/short, (2) underweight/tall, (3) overweight/short, (4) overweight/tall and (5) non-outliers (controls). Main outcome measures Multiple variable logistic regressions were used to quantify the association between 30-day morbidity and nutritional profile groups while adjusting for procedure case mix, age and American Society of Anaesthesiologists class. Results A total of 39u2009520 cases distributed as follows: underweight/short (656, 2.2%); underweight/tall (252, 0.8%); overweight/short (733, 2.4%) and overweight/tall (1534, 5.1%). Regression analyses revealed increased adjusted odds of composite morbidity (35%) and reintervention events (75%) in the underweight/short group, while overweight/short patients had increased adjusted odds of composite morbidity and healthcare-associated infections (43%), and reintervention events (79%) compared with controls. Conclusion Stratification of preoperative nutritional status using a scheme incorporating both BMI and height for age is feasible. Further research is needed to validate this nutritional risk classification scheme for other surgical procedures in children.