Charles J. Shanley

Accelerating the Pace of Surgical Quality Improvement: The Power of Hospital Collaboration

HYPOTHESISnA regional collaborative approach is an efficient platform for surgical quality improvement.nnnDESIGNnRetrospective cohort study.nnnSETTINGnAcademic research.nnnPATIENTSnPatients undergoing general and vascular surgical procedures in 16 hospitals of the Michigan Surgical Quality Collaborative (MSQC) were evaluated quarterly to discuss surgical quality, to identify best practices, and to assess problems with process implementation.nnnMAIN OUTCOME MEASURESnResults among MSQC patients were compared with those among 126 non-Michigan hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) over the same interval.nnnRESULTSnA total of 315 699 patients were included in the analysis. To assess improvement, patients were stratified into 2 periods (T1 and T2). The 35 422 MSQC patients (10.7% morbidity in T1 vs 9.7% in T2 [9.0% reduction], P = .002) showed improvement, while 280 277 non-Michigan ACS NSQIP patients did not (12.4% morbidity in T1 and T2, P = .49). No improvements in mortality rates were noted in either group. Overall, the odds of experiencing a complication in T2 compared with T1 were significantly less in the MSQC group (odds ratio, 0.898) than in the non-Michigan ACS NSQIP group (odds ratio, 1.000) (P=.004).nnnCONCLUSIONnA statewide surgical quality improvement collaborative supported by a third-party payer showed significant improvement in quality and high levels of participant satisfaction.

Open vs. endovascular repair of isolated iliac artery aneurysms: A 12-year experience

OBJECTIVEnTo examine contemporary operative techniques and outcomes for repair of isolated iliac artery aneurysms.nnnMETHODSnWe retrospectively reviewed the charts of all patients who underwent repair of an isolated iliac artery aneurysm from February 1995 to June 2007. Mycotic aneurysms and patients with concurrent infrarenal abdominal aortic aneurysms greater than 3.5 cm in diameter were excluded from analysis. Patients with prior abdominal aortic aneurysm repair were not excluded.nnnRESULTSnFifty-six patients (96% male; mean age, 72 +/- 10 years) had either open (n = 24) or endovascular (n = 32) repair with median follow-up of 36 months. Seven patients were treated for rupture, six with open repair, and one with an endograft. Average aneurysm size for patients in the open and endovascular repair cohorts was 4.5 +/- 2.4 cm and 4.0 +/- 1.1 cm, respectively (P = .35). One episode of endograft limb thrombosis at five months was treated with catheter-directed thrombolytic therapy and stent placement. Thirty-day mortality for patients undergoing elective and emergent open repair was 1/18 (6%) and 1/6 (17%), respectively. There was no 30-day mortality for the endovascular group. Median length of stay was 10.5 days in the open group and one day in the endovascular elective group (P < .01). There was no mid-term aneurysm-related mortality in either group. Primary patency rates were similar between the open and endovascular groups at five years (100% vs. 96%, P = .07). Aneurysm sac diameter decreased in 67% (21/28) of patients that underwent endovascular repair. One patient with a Type III endoleak required relining of the endograft with a second endograft at 72 months.nnnCONCLUSIONnThese data demonstrate that in appropriately selected patients, endovascular repair of isolated iliac artery aneurysms is a safe, effective alternative to open repair with mid-term follow-up. Endovascular repair is associated with a significantly reduced hospital length of stay and may be associated with decreased need for transfusion and mortality when compared with open repair.

Implementing Standardized Operating Room Briefings and Debriefings at a Large Regional Medical Center

BACKGROUNDnEffective communication and teamwork are critical in many health care settings, particularly the operating room (OR). Several studies have implicated failures of communication and teamwork as the root cause in a high proportion of sentinel events in the OR.nnnMETHODSnIn a prospective cohort study at a high-volume teaching, research, and tertiary care referral hospital, a standardized one-page briefing and debriefing tool was developed and implemented in October 2006 to improve interdisciplinary communication and teamwork in the OR. The briefing portion of the tool was completed by the surgical team after the patients final positioning and before incision; the debriefing portion was initiated and completed by the circulating nurse after the first counts were conducted. Compliance was calculated as the number of cases where the briefing and debriefing tool was completed divided by the total number of eligible cases. Surveys (n=40) were conducted to elicit caregiver perceptions of interdisciplinary communication and teamwork in the OR and the burden and average time taken to complete the briefing and debriefing tool.nnnRESULTSnBetween October 2006 and March 2008, 37,133 briefings and debriefings were conducted. Average compliance varied over time since implementation, with overall compliance ranging from 76% to 95%. The majority of caregivers perceived that the briefing and debriefing tool improved interdisciplinary communication and teamwork. On average, it took 2.9 minutes (range, 1-5 minutes) to complete the briefing portion of the tool and 2.5 minutes (range, 1-5 minutes) to complete the debriefing portion.nnnDISCUSSIONnImplementation of a standardized briefing and debriefing tool in a large regional medical center was a, practical and feasible strategy to improve perceptions of interdisciplinary communication and teamwork in the OR.

Diagnosis of total internal carotid occlusions with duplex ultrasound and ultrasound contrast

It remains a significant technical challenge for duplex ultrasound to accurately differentiate between total and near total internal carotid artery (ICA) occlusions. We have evaluated the efficacy of an ultrasound contrast agent combined with improved imaging techniques in patients with suspected carotid artery occlusions. Patients identified by conventional duplex ultrasound between January and August 2003 as having a possible ICA occlusion were eligible for study. A 1 mL bolus of ultrasound contrast agent was injected into a 50 mL bag of normal saline and given intravenously at a rate of approximately 4–5 mL/minute. Ultrasound imaging and spectral Doppler analysis were done using tissue harmonic imaging for optimum contrast agent to soft tissue discrimination, or with the direct B-mode imaging of blood flow to maximize the brightness of the circulating contrast agent. Ten patients were identified, 6 men and four women with a mean age of 68.3 years. Nine suspected total ICA occlusions were unilateral and 1 was bilateral. Imaging with contrast agent confirmed occlusion of the ICA in 7 of 10 patients; 3 patients had near-total occlusion with flow detected in the distal ICA by spectral and color Doppler. All 3 of these near-total occlusions were ultimately confirmed by either conventional or magnetic resonance carotid angiography. The contrast agent was most beneficial in improving the detection of minimal flow beyond a severe stenosis and in evaluating flow dynamics in the presence of severely calcified plaque. We conclude that the use of an ultrasound contrast agent with newer duplex ultrasound imaging techniques can reliably distinguish total from near-total internal carotid artery occlusions. Future prospective studies should be able to define the efficacy of ultrasound contrast agents in improving the overall diagnostic accuracy of duplex ultrasound in technically difficult cases and in patients with complex peripheral vascular disease.

Outcomes analysis of intraoperative adjuncts during minimally invasive parathyroidectomy for primary hyperparathyroidism

BACKGROUNDnThe aim of this study was to determine whether minimally invasive radioguided parathyroidectomy (MIRP) and intraoperative parathyroid hormone-guided parathyroidectomy (ioPTH) have equivalent intermediate-term outcomes in primary hyperparathyroidism (PHPT).nnnMETHODSnA retrospective study of 244 patients who underwent parathyroidectomy for PHPT in a 25-month time period was conducted. Patients who either underwent MIRP- or ioPTH-guided parathyroidectomies were included. The primary outcome was persistent disease. Conversion to bilateral exploration, complications, and multigland disease (MGD) were secondary outcomes.nnnRESULTSnThere was 1 MIRP patient and no ioPTH patients who had persistent disease. The ioPTH group had more conversions to a bilateral exploration (bilateral neck exploration [BNE]) (3.7% vs 13%, P = .024). In the MIRP group, no patients were found to have MGD. In the ioPTH group, 7 patients with double adenomas and 6 patients with MGD were found (0 vs 13, P = .0028).nnnCONCLUSIONSnioPTH facilitates successful minimally invasive parathyroidectomy (MIP) when compared with MIRP and provides cure rates similar to BNE.

Factors affecting the severity of spontaneous retroperitoneal hemorrhage in anticoagulated patients

BACKGROUNDnClinical manifestations of spontaneous retroperitoneal hemorrhage (SRH) range from a small decrease in hemoglobin to hypotension requiring transfer to the intensive care unit (ICU). Our goal was to identify which anticoagulated patients are at increased risk for SRH and its complications.nnnMETHODSnWe conducted a retrospective review of 180 patients with SRH. Age, sex, presence of comorbidities, hemoglobin decrease, transfusion requirement, ICU stay, and length of ICU stay were recorded. Patients were divided into 5 groups based on their anticoagulants: (1) heparin and Coumadin, (2) heparin only, (3) Coumadin only, (4) heparin +/- Coumadin and aspirin (ASA) +/- Plavix, and (5) other anticoagulants.nnnRESULTSnGroup 4 patients were more likely to require ICU admission and have longer ICU stay compared to others (P = .021 & P < or = 0.0001, respectively, by Kruskall-Wallis test). Patients with coronary artery disease were more likely to require ICU admission (P = .01 by chi-square test).nnnCONCLUSIONSnPatients on combined anticoagulant-antiplatelet therapy are more likely to require ICU admission and longer ICU stay. Close observation is warranted in these patients for early detection of SRH.

Gastrointestinal Complications Following Infrarenal Endovascular Aneurysm Repair

Gastrointestinal complications are known to occur after open elective aortic aneurysm repair. This leads to increased morbidity, mortality, length of stay, and hospital costs. The authors hypothesize a change in the character and/or frequency of early postoperative gastrointestinal complications after endovascular aneurysm repair as compared to open abdominal aortic repair. This is a retrospective cohort study in which the medical records of 153 consecutive patients who underwent endovascular infrarenal aneurysm repair from November 1998 to August 2001 were reviewed for gastrointestinal complications. Of these 153 patients, 9 (5.9%) had postoperative gastrointestinal complications. Three patients (1.9%) underwent exploratory laparotomy for small bowel obstruction. One patient had had a right hemicolectomy for cancer 2 years before stent graft placement. This patient needed a partial small bowel resection. One patient had had a right hemicolectomy 4 months before stent graft placement; he had lysis of adhesions with no bowel resection. A third patient underwent operative repair of an incarcerated inguinal hernia. Six patients (3.9%) had paralytic ileus that was treated by nasogastric tube or observation resulting in an extended hospital length of stay. All cases of ileus resolved without any operative intervention. No patients in this series developed any intestinal ischemia, pancreatitis, cholecystitis, or gastrointestinal bleeding. After endovascular aneurysm repair, gastrointestinal complications such as ileus and postoperative small bowel obstruction are seen with a similar frequency as after open aortic repair. This occurs despite the absence of a laparotomy with mesenteric dissection and evisceration. In this series, these complications are associated with longer hospital length of stay but no increased mortality rate. No instances of colonic ischemia, pancreatitis, cholecystitis, or gastrointestinal bleeding were seen in this series.

Acute Abdominal Vascular Emergencies

Abdominal vascular emergencies are relatively uncommon, frequently catastrophic, and highly lethal. Despite improved understanding of the pathophysiology and natural history of these disorders, delays in diagnosis and treatment remain the most important factors contributing to the observed high mortality. A high index of clinical suspicion together with a sound understanding of the clinical presentation, natural history, and management of these disorders are critical to improving outcomes. This article focuses on abdominal vascular emergencies presenting with acute visceral ischemia or catastrophic intra-abdominal hemorrhage.

Peritonitis from peg tube insertion in surgical intensive care unit patients: identification of risk factors and clinical outcomes

BackgroundPercutaneous endoscopic gastrostomy (PEG) tubes are routinely inserted in the surgical intensive care unit (SICU). Poor tissue healing or technical issues after tube insertion can lead to peritonitis requiring a laparotomy. This study aimed to identify risk factors leading to peritonitis.MethodsA retrospective study reviewed of PEG tubes inserted in SICU patients from 2003 to 2006. Age, sex, body mass index (BMI), organ dysfunction, vasopressor use, fluid balance, steroid use for medical reasons, and nutritional status of the patients were noted. The patients with acute spinal cord injury who received high-dose steroids were excluded from the study. Mortality and peritonitis requiring laparotomy were the outcomes. Logistic regression performed with SAS version 9.1 (Cary, NC) was used for analysis.ResultsOf 322 patients, 16 (5%) required a laparotomy for peritonitis, and 74 (23%) died during the hospital stay. The major predictors of the need for a laparotomy were higher BMI (pxa0=xa00.0005) and a serum albumin level lower than 2.5 gm/dL (pxa0=xa00.0008). Patients with both a BMI exceeding 30xa0kg/m2 and an albumin level lower than 2.5 gm/dL were 25 times more likely to need a laparotomy (95% confidence interval [CI], 7.74–83.3). The mean time from tube placement to laparotomy was 11xa0days. Of the 16 patients who required laparotomy, 9 died during the hospitalization. Patients requiring a laparotomy were five times more likely to die during the hospitalization than patients not requiring a laparotomy (pxa0=xa00.004; 95% CI, 1.68–13.07). The mean time from laparotomy to death was 23xa0days. Signs of sepsis and worsening abdominal examination developed in all 16 laparotomy patients. Dislodged tube with gastric wall not opposed to the abdominal wall was the most common finding at laparotomy.ConclusionApproximately 5% of patients undergoing PEG insertion in the SICU require laparotomy for peritonitis and are more likely to die during the hospitalization. Higher BMI and a lower serum albumin level, by contributing to poor healing, increase the risk of peritonitis.

Duplex ultrasound recognition of spontaneous carotid dissection--a case report and review of the literature.

Spontaneous dissection of the internal carotid artery is an uncommon entity with a variable clinical presentation. A high index of suspicion is required to make the diagnosis, and prompt diagnosis and treatment with anticoagulation are essential for improved patient outcomes. Duplex ultrasound provides a safe and reliable imaging modality for early diagnosis and followup. The authors present a case of spontaneous internal carotid artery dissection with duplex ultrasound findings and a review of the literature.