Christine Hwang

Resident versus no resident: a single institutional study on operative complications, mortality, and cost.

BACKGROUND Previous studies have demonstrated an increase in surgical morbidity, mortality, duration of stay, and costs in teaching hospitals. These studies are confounded by many variables. Controlling for these variables, we studied the effect of surgical residents on these outcomes during rotations with non-academic-based teaching faculty at a teaching hospital. METHODS Patients received care at a single teaching hospital from a group of 8 surgeons. Four surgeons did not have resident coverage (group 1) and the other 4 had coverage (group 2). Continuous severity adjusted complications, mortality, length of stay, cost, and hospital margin data were collected and compared. RESULTS Five common procedures were examined: bowel resection, laparoscopic cholecystectomy, hernia, mastectomy, and appendectomy. Comparing all procedures together, there were no differences in complications between the groups, although there was greater mortality, a greater duration of stay, and higher costs in group 2. When comparing the 5 most common procedures individually, there was no difference in complications or mortality, although a greater length of stay and higher costs in group 2. CONCLUSIONS Comparing the most common procedures performed individually, patients cared for by surgeons with surgical residents at a teaching hospital have an increase in duration of stay and cost, although no difference in complications or mortality compared to surgeons without residents.

The cost of resident education

BACKGROUND Patients cared for by surgeons with resident coverage have an increase in cost versus those patients cared for by surgeons without resident coverage, despite no significant difference in complications. We evaluated the reasons for the disparate cost. METHODS In a single institutional analysis, patients received their care from a group of eight surgeons, four with and four without resident coverage. We analyzed ancillary costs, including pharmacy, radiology, laboratory, and central supply costs, and length of stay, total cost, and hospital margin for these patients. In a separate analysis, we compared data that contributes to cost from the National Surgical Quality Improvement Program (NSQIP) database, including age in years, ASA class I-IV, total operating room time in minutes (min), length of hospital stay in days (d), number of patients with a return to OR in 30 d, and complications. RESULTS There were no significant differences in ancillary costs in patients cared for by residents. The length of stay was longer in patients cared for by residents (3.3 versus 4.6 d, no resident versus resident, respectively, P = 0.0001). When adjusted for the length of stay, the difference between total costs was

Laparoscopic ventral hernia repair is safer than open repair: analysis of the NSQIP data.

1949/d versus

Peritoneal dialysis access: open versus laparoscopic surgical techniques

2103/d (P = NS) for the no resident versus resident groups, respectively. There were 32,685 patients evaluated in the NSQIP database. In all comparisons, operating room time was significantly longer in patients with procedures involving residents. CONCLUSION The increase in cost in patients cared for by surgeons with residents is not from significant differences in ancillary costs, and may be from length of stay. Surgical procedures are significantly longer with resident involvement.

Transplantation: pediatric en bloc kidneys are suitable for adult recipients.

INTRODUCTION Previous single institutional studies have demonstrated fewer complications in laparoscopic ventral hernia repair (LVHR) compared to open ventral hernia repair (OVHR). We questioned whether or not these data were supported in large cross-sectional studies. MATERIALS AND METHODS We evaluated the National Surgical Quality Improvement Program (NSQIP) database comparing all LVHR versus primary OVHR for patients from 2005 to 2006. We compared demographic data, ASA class, wound classification, and outcome data. We also evaluated recurrent open repair (R-OVHR) data. Differences were considered significant for P < or = 0.05. No statistical comparisons were made with the R-OVHR group. RESULTS There were no differences in demographic data, except older age, between the LVHR and OVHR groups. Wound and ASA classifications were not different. There were fewer total complications (5.7% versus 9.8%, P<0.001), and fewer superficial (1.5% versus 4.1%, P<0.001) and deep (0.5% versus 1.6%, P=0.001) infections in the laparoscopic group. There were more total and infectious complications in the R-OVHR group. CONCLUSION Despite no differences in ASA class or wound classification, there were more total and infectious complications in the OVHR group. This large cross-sectional study supports single institutional studies that demonstrate fewer complications and infections in patients with laparoscopic versus open ventral hernia repair.

High Risk Donor Kidneys should be Used in Pediatric Kidney Transplant Recipients

Aim To outline pros and cons with the open and laparoscopic techniques when placing peritoneal dialysis (PD) catheters. Background Controversy exists regarding which technique, the open and laparoscopic, if any, is superior to the other. In addition, there is the question of which approach is best in rescuing malfunctioning PD catheters. Results Rather than promoting one doctrine fits all, philosophically, doing the right thing for the patient by specific criteria is ethically the better model. These specific selection criteria include patient characteristics, the teams skills and knowledge and institutional resources and commitment. Also, the sophistication of a PD unit for training and monitoring of patients is crucial for successful outcomes. Open paramedian and two laparoscopic approaches are described in detail, outlining advantages and disadvantages of each, with suggestions when one method is preferred. Conclusions In general, the laparoscopic technique is associated with longer operative times, higher costs and the need to utilize general anesthesia. It is, however, the preferred method when rescuing malfunctioning catheters and may increase the PD patient population in patients with previous abdominal surgeries. The dialysis access surgeon should be familiar with both open and laparoscopic techniques and appropriately choose the ideal method based upon the individual patient and institutional resources.

Peritoneal dialysis is feasible as a bridge to combined liver-kidney transplant

A number of concerns have prevented the widespread use of pediatric en bloc kidneys for transplantation in adults. New evidence suggests that some of these concerns could be unfounded and that en bloc pediatric kidneys might perform as well, or even better, than grafts from traditional donors.

Novel Application of Extracorporeal Photopheresis as Treatment of Graft-versus-Host Disease Following Liver Transplantation

Introduction There continues to be a shortage of kidneys for pediatric patients listed for transplantation. A strategy to increase the donor pool would be to utilize kidneys from donors who are considered to be Centers for Disease Control and Prevention (CDC) high risk for transmission of certain types of infections. We questioned if use of CDC high risk kidneys in the pediatric patient population was warrented by examining outcomes in this patient population. Materials and Methods The United Network for Organ Sharing database was examined to investigate outcomes in all kidney transplant recipients from 1996 to 2017. The patients were then divided upon adult and pediatric (under age 18 years) status and presence or absence of CDC high risk status. Donor and recipient demographic data were examined, and Kaplan Meier survival curves were generated. Categorical differences were compared using the unpaired Students t-test and nominal variables using either the Chi Square or Fischers exact test. A p-value of <0.05 was considered to be significant. Results and Discussion A total of 357 pediatric kidney transplant recipients received a kidney from a CDC high risk donor. The average donor age in the pediatric CDC high risk recipient group was 22.0 vs. 28.6 years (p<0.05) in the non CDC high risk recipients, and the average KDPI in the CDC high risk group was 18% vs. 24% (p<0.05). The average cold storage time in the CDC high risk group was 14.3 vs. 10.3 hours (p<0.05). The average age in the CDC high risk recipients was 11.3 vs. 10.7 years (p<0.05), and the length of stay was 13.0 vs. 13.2 days (p=NS) in the high risk vs. non high risk groups. The rate of rejection in the first year post transplant was significantly higher in the non CDC high risk group, 27.0% vs. 16.8% (p<0.05). When examining patient and allograft survival in all pediatric recipients who received a CDC high risk allograft, survival was not significantly different between the two groups. The donors in the CDC high risk group were significantly younger, had a lower KDPI, and had a longer cold storage time. The recipients in the CDC high risk were older, had fewer rejections, and had no significant difference in length of stay. Patient and allograft survival were similar when compared to those recipients who did not receive a CDC allograft, indicating that the CDC high risk kidney is a viable option to increase the donor pool for kidneys in pediatric recipients. Conclusion Patient and allograft survival in CDC high risk donor kidneys is similar to those allografts that are not considered to be CDC high risk. Use of CDC high risk kidney allografts should be strongly considered to increase the organ pool for pediatric patients. Figure. No caption available.

Increased risk of vascular thrombosis in pediatric liver transplant recipients with thrombophilia.

Patients with combined liver and kidney failure may remain on dialysis for years while awaiting simultaneous liver-kidney transplantation (SLKT). The role of peritoneal dialysis (PD) in patients with advanced liver and kidney failure awaiting SLKT remains to be defined. We present our single-institution experience with PD in cirrhotics, 3 of whom went on to receive successful SLKT. Patients initiated in our PD program between 2006 and 2016 who had both liver and kidney failure were identified. Medical and dialysis records were reviewed retrospectively. Outcomes included mortality, transplantation status, hospitalizations, need for large-volume paracentesis (LVP), peritonitis rates, PD treatment longevity, and albumin level. Twelve patients with combined liver and kidney failure were treated in our PD program. No patients died and 3 patients received SLKT. Four patients remain listed for transplantation. There was no need for LVP after initiating dialysis. The rate of peritonitis was 0.2 events per patient per year, most commonly due to coagulase-negative Staphylococcus. Our data illustrate that PD is a viable bridging therapy for patients with liver and kidney failure who await SLKT.

Acute Liver Failure in a Pediatric Patient with Disseminated Tuberculosis

A 48-year-old man with hepatitis C virus (HCV) cirrhosis complicated by hepatocellular carcinoma underwent liver transplantation. His course was complicated by fever, diarrhea, abdominal pain, and pancytopenia. He developed a diffuse erythematous rash, which progressed to erythroderma. Biopsies of the colon and skin were consistent with acute graft-versus-host disease. Donor-derived lymphocytes were present in the peripheral blood. The patient was treated with corticosteroids and cyclosporine; however, he had minimal response to intensive immunosuppressive therapy. Extracorporeal photopheresis was initiated as a salvage therapy. He had a dramatic response, and his rash, diarrhea, and pancytopenia resolved. He is maintained on minimal immunosuppression 24 months later.