Joseph P. Castlen

The Changing Health Care Landscape and Implications of Organizational Ethics on Modern Medical Practice

INTRODUCTION Medicine is rapidly changing, both in the level of collective medical knowledge and in how it is being delivered. The increased presence of administrators in hospitals helps to facilitate these changes and ease administrative workloads on physicians; however, tensions sometimes form between physicians and administrators. ANALYSIS This situation is based on perceptions from both sides that physicians obstruct cost-saving measures and administrators put profits before patients. In reality, increasing patient populations and changes in health care are necessitating action by hospitals to prevent excessive spending as health care systems become larger and more difficult to manage. Recognizing the cause of changes in health care, which do not always originate with physicians and administrators, along with implementing changes in hospitals such as increased physician leadership, could help to ease tensions and promote a more collaborative atmosphere. Ethically, there is a need to preserve physician autonomy, which is a tenet of medical professionalism, and a need to rein in spending costs and ensure that patients receive the best possible care. CONCLUSION Physicians and administrators both need to have a well-developed personal ethic to achieve these goals. Physicians need be allowed to retain relative autonomy over their practices as they support and participate in administrator-led efforts toward distributive justice.

United States neurosurgery annual case type and complication trends between 2006 and 2013: An American College of Surgeons National Surgical Quality Improvement Program analysis

We aimed to identify trends in the neurosurgical practice environment in the United States from 2006 to 2013 using the American College of Surgeons-National Surgical Quality Improvement Program (NSQIP) database, and to determine the complication rate for spinal and cranial procedures and identify risk factors for post-operative complications across this time period. We performed a search of the American College of Surgeons-NSQIP database for all patients undergoing an operation with a surgeon whose primary specialty was neurological surgery from 2006 to 2013. Analysis of patient demographics and pre-operative co-morbidities was performed, and multivariate analysis was used to determine predictors of surgical complications. From 2006 to 2013, the percentage of spinal operations performed by neurosurgeons relative to cranial and peripheral nerve cases increased from 68.0% to 76.8% (p<0.001) according to the NSQIP database. The proportion of cranial cases during the same time period decreased from 29.7% to 21.6% (p<0.001). The overall 30-day complication rate among all 94,621 NSQIP reported patients undergoing operations with a neurosurgeon over this time period was 8.2% (5.6% for spinal operations, 16.1% for cranial operations). The overall rate decreased from 11.0% in 2006 to 7.5% in 2013 (p<0.001). Several predictors of post-operative complication were identified on multivariate analysis.

Safety of remifentanil in transsphenoidal surgery: A single-center analysis of 540 patients

Although some studies have examined the efficacy and safety of remifentanil in patients undergoing neurosurgical procedures, none has examined its safety in transsphenoidal operations specifically. In this study, all transsphenoidal operations performed by a single author from 2008 to 2015 were retrospectively reviewed to evaluate the safety of remifentanil in a consecutive series of patients. During the study period, 540 transsphenoidal operations were identified. Of these, 443 (82.0%) patients received remifentanil intra-operatively; 97 (18.0%) did not. The two groups were well-matched with regard to demographic categories, comorbidities, and pre-operative medications (p>0.05), except pre-operative tobacco use (p=0.021). Patients were also well-matched with regard to radiographic features and surgical techniques. Patients who received remifentanil were more likely to harbor a macroadenoma (78.1% vs. 67.0%, p=0.025), and had slightly longer anesthesia time on average (269.2minvs. 239.4min, p=0.024). All pathologic diagnoses were well-matched between the two groups, except that patients receiving remifentanil were more likely to harbor a non-functioning adenoma (46.5% vs. 26.8%, p<0.001). Analysis of post-operative complications showed no significant difference between patients who received remifentanil and those who did not, and length of stay and prevalence of ICU stay did not differ between the two groups. In a well-matched series of 540 patients undergoing transsphenoidal surgery, remifentanil was found to be a safe anesthetic adjunct. There were no significant differences in post-operative hospital course or complications in patients who did and did not receive intra-operative remifentanil.

Abdominal Fat Graft for Sellar Reconstruction: Retrospective Outcomes Review and Technical Note

BACKGROUND The transsphenoidal approach is the standard of care for the treatment of pituitary adenomas and is increasingly employed for many anterior skull base tumors. Persistent postoperative cerebrospinal fluid (CSF) leaks can result in significant complications. OBJECTIVE To analyze our series of patients undergoing abdominal fat graft repair of the sellar floor defect following transsphenoidal surgery, describe and investigate our current, routine technique, and review contemporary and past methods of skull base repair. METHODS A recent consecutive series (2008-2017) of 865 patients who underwent 948 endonasal procedures for lesions of the sella and anterior skull base was retrospectively reviewed. Three hundred eighty patients underwent reconstruction of the sellar defect with an abdominal fat graft. RESULTS The diagnoses of the 380 patients receiving fat grafts were the following: 275 pituitary adenomas (72.4%), 50 Rathke cleft cysts (13.2%), 12 craniopharyngiomas (3.2%), and a variety of other sellar lesions. Fourteen patients had persistent postoperative CSF leak requiring reoperation and included: 5 pituitary adenomas (1.3%), 4 craniopharyngiomas (1.1%), 2 arachnoid cysts (0.53%), 2 prior CSF leaks (0.53%), and 1 Rathke cleft cyst (0.26%). Four patients (1.1%) developed minor abdominal donor site complications requiring reoperation: 1 hematoma, 2 wound complications, and 1 keloid formation resulting in secondary periumbilical infection. CONCLUSION Minimizing postoperative CSF leaks following endonasal anterior skull base surgery is important to decrease morbidity and to avoid a prolonged hospital stay. We present an evolved technique of abdominal fat grafting that is effective and safe and includes minimal morbidity and expense.