Rebecca L. Hoffman

Analysis of Cyst Size and Tumor Markers in the Management of Pancreatic Cysts: Support for the Original Sendai Criteria

BACKGROUND In 2006, the Sendai Consensus Guidelines identified size >3.0 cm as the only independent predictor of malignancy in incidentally discovered pancreatic cysts. The 2012 updated guidelines increased emphasis on radiographic features over size. Earlier studies included patients with preoperatively diagnosed carcinoma or with a corresponding mass. In this report, we characterize the use of size and serum tumor markers in the initial evaluation of pancreatic cystic neoplasms without preoperatively diagnosed adenocarcinoma and correlate them with clinical and pathologic outcomes. STUDY DESIGN A retrospective cohort study was undertaken of 112 patients with a resected pancreatic cystic neoplasm. Patient demographics, cyst characteristics, preoperative serum tumor markers, morbidity, and mortality were captured. Statistical analysis included nonparametric tests of comparison, multivariate logistic regression, and receiver operating characteristic curve analyses. RESULTS One hundred and twelve pancreatic cystic neoplasms were resected; there was one perioperative death. Mucinous cysts were common (78%), followed by serous cysts (13%). In total, 17% of cysts harbored malignancy. On multivariate analysis, the risk of malignancy in cysts≥3 cm was more than 4 times that of smaller cysts (relative risk (RR)=4.32; 95% CI, 1.55-12.07). There was no significant difference in serum CEA, cancer antigen 19-9, or cyst-fluid CEA levels between the benign and malignant groups. At a median follow-up of 30 months, the incidence of diabetes was 15%. CONCLUSIONS Surgical resection of pancreatic cysts can be performed with low perioperative mortality and acceptable long-term morbidity. Use of cyst size as a rationale for resection of cystic lesion, as per the Sendai criteria, is justified.

Postdischarge occurrences after colorectal surgery happen early and are associated with dramatically increased rates of readmission.

BACKGROUND:Postoperative occurrences have been associated with an increased risk of readmission, yet these occurrences and their timing have not been well characterized. OBJECTIVE:We sought to analyze patients undergoing colorectal surgery as a model for general surgical readmissions. DESIGN:In a retrospective analysis, the impact of a postoperative occurrence on readmission was examined in a multivariable model with adjustment for potential confounders. The timing and type of postoperative occurrence were further characterized. SETTINGS:This study was conducted at a tertiary care hospital. PATIENTS:Patients undergoing colorectal surgery in the American College of Surgeons National Surgical Quality Improvement Program database (fiscal year 2011–2012) were analyzed. MAIN OUTCOME MEASURES:The main outcome measure was admission within 30 days of operation. RESULTS:A total of 54,823 patients undergoing colorectal surgery were identified, with 24% of patients experiencing a postoperative occurrence, and 12% of patients readmitted. The readmission rate in those who experienced an occurrence was 30% compared with 6% in those without an occurrence (p < 0.0001). After an occurrence during the index admission, the readmission rate was 18% compared with 57% if the occurrence happened postdischarge (p < 0.0001). In a multivariable analysis, postdischarge occurrence (risk ratio, 7.5 [95% CI, 7.3–7.8]) was associated with the largest risk of readmission. The median time to postdischarge occurrence was 8 days for organ space infection and wound complication and 7 days for sepsis. By day 14 postdischarge, 74% of organ space infections, 79% of wound complications, and 81% of sepsis had already occurred. LIMITATIONS:This analysis was limited to the variables available in the American College of Surgeons National Surgical Quality Improvement Program. Most significantly, readmission is captured for 30 days postoperatively rather than for 30 days postdischarge. CONCLUSIONS:Readmission occurs frequently (12%) after colorectal surgery and is strongly associated with a postdischarge occurrence. The most frequent postdischarge occurrences are infectious in nature and happen early postdischarge. The majority of postdischarge occurrences have already occurred by day 14, a standard time for the postoperative appointment.

A Milestone-Based Evaluation System—The Cure for Grade Inflation?

PURPOSE Controversy exists over the optimal use of the Milestones in the process of resident evaluation and feedback. We sought to evaluate the performance of a Milestones-based feedback system in comparison to a traditional model. METHODS The traditional evaluation system (TES) consisted of a generic 16-item survey using a 5-point Likert scale ranging from 1 to 5, and a free-text comments section. The Milestones-based evaluation system (MBES) was launched in July 2014, ranging from 0 to 4. Individual milestones were mapped to rotations based on resident educational goals by postgraduate year (PGY). The MBES consisted of a survey with a maximum of 7 items, followed by a free-text comment section. Within each evaluation system, an overall composite score was calculated for each categorical general surgical resident. To scale the 2 systems for comparison, TES scores were adjusted downward by 1 point. Descriptive statistics were performed. Univariate analysis was performed with the Wilcoxon signed-rank test. A test for trend across PGY was used for the MBES only. RESULTS In the traditional system, the median score was 3.66 (range: 3.2-4.0). There was no meaningful difference in the median score by PGY. In the new system, the median score was 2.69 (range: 1.5-3.7, p < 0.01). The median score differed across PGY and increased by PGY of training (p < 0.01). There was an increase in differences between median scores by PGY. CONCLUSIONS On using the milestones to facilitate faculty evaluation of resident knowledge and skill, there was a trend in increasing score by PGY of training. In the MBES, scores could be used to better discriminate resident skill and knowledge levels and resulted in improved differentiation in scoring by PGY. The use of the milestones as a basis for evaluation enabled the program to provide more meaningful feedback to residents and represents an improvement in surgical education.

Failure-to-rescue after injury is associated with preventability: The results of mortality panel review of failure-to-rescue cases in trauma

Background. Failure‐to‐rescue is defined as the conditional probability of death after a complication, and the failure‐to‐rescue rate reflects a centers ability to successfully “rescue” patients after complications. The validity of the failure‐to‐rescue rate as a quality measure is dependent on the preventability of death and the appropriateness of this measure for use in the trauma population is untested. We sought to evaluate the relationship between preventability and failure‐to‐rescue in trauma. Methods. All adjudications from a mortality review panel at an academic level I trauma center from 2005–2015 were merged with registry data for the same time period. The preventability of each death was determined by panel consensus as part of peer review. Failure‐to‐rescue deaths were defined as those occurring after any registry‐defined complication. Univariate and multivariate logistic regression models between failure‐to‐rescue status and preventability were constructed and time to death was examined using survival time analyses. Results. Of 26,557 patients, 2,735 (10.5%) had a complication, of whom 359 died for a failure‐to‐rescue rate of 13.2%. Of failure‐to‐rescue deaths, 272 (75.6%) were judged to be non‐preventable, 65 (18.1%) were judged potentially preventable, and 22 (6.1%) were judged to be preventable by peer review. After adjusting for other patient factors, there remained a strong association between failure‐to‐rescue status and potentially preventable (odds ratio 2.32, 95% confidence interval, 1.47–3.66) and preventable (odds ratio 14.84, 95% confidence interval, 3.30–66.71) judgment. Conclusion. Despite a strong association between failure‐to‐rescue status and preventability adjudication, only a minority of deaths meeting the definition of failure to rescue were judged to be preventable or potentially preventable. Revision of the failure‐to‐rescue metric before use in trauma care benchmarking is warranted.

Development and implementation of a risk identification tool to facilitate critical care transitions for high-risk surgical patients

Quality problem Patients recently discharged from the intensive care unit (ICU) are at high risk for clinical deterioration. Initial assessment Unreliable and incomplete handoffs of complex patients contributed to preventable ICU readmissions. Respiratory decompensation was responsible for four times as many readmissions as other causes. Choice of solution Form a multidisciplinary team to address care coordination surrounding the transfer of patients from the ICU to the surgical ward. Implementation A quality improvement intervention incorporating verbal handoffs, time-sensitive patient evaluations and visual cues was piloted over a 1-year period in consecutive high-risk surgical patients discharged from the ICU. Process metrics and clinical outcomes were compared to historical controls. Evaluation The intervention brought the primary team and respiratory therapists to the bedside for a baseline examination within 60 min of ward arrival. Stakeholders viewed the intervention as such a valuable adjunct to patient care that the intervention has become a standard of care. While not significant, in a comparatively older and sicker intervention population, the rate of readmissions due to respiratory decompensation was 12.5%, while 35.0% in the control group (P = 0.28). Lessons learned The implementation of this ICU transition protocol is feasible and internationally applicable, and results in improved care coordination and communication for a high-risk group of patients.

Development and validation of a prediction model for patients discharged to post–acute care after colorectal cancer surgery

Background. As payment shifts toward bundled reimbursement, decreasing unnecessary inpatient care may provide cost savings. This study examines the association between discharge status, hospital duration of stay, and cost for colorectal operation patients without complications and uses risk factors to predict the need for post–acute care. Methods. We used the New York Statewide Planning and Research Cooperative System and the California Healthcare Cost and Utilization Project State Inpatient Databases to identify all patients who underwent operative resection for colorectal cancer in 2009–2010 and were discharged to home or post–acute care. Patients with complications were excluded. Duration of stay and inpatient costs were calculated. Risk factors associated with discharge to post–acute care were identified using multivariable logistic regression and were incorporated into a model to predict discharge status. Results. A total of 5.4% of 23,942 patients were discharged to a post–acute care facility. Duration of sty was 2 days greater and

Outcomes Registries: An Untapped Resource for Use in Surgical Education

3,823 more costly for patients discharged to post–acute care. Significant risk factors included age, number of comorbidities, emergency admission, open operation, admission in the previous year, and a new ostomy. A scoring system using these factors accurately predicted discharge to post–acute care. Conclusion. Admissions after colorectal operations were greater and more costly for patients discharged to post–acute care even without operative complications. Risk factors can predict the need for post–acute care early in the postoperative course, thereby potentially facilitating early discharge planning.

Overcoming adversity—a critical step toward career satisfaction and leadership in academic surgery

OBJECTIVE To examine the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) for use in profiling the aggregated resident operative experience by postgraduate training year and to demonstrate the extent to which a surgical registry could be used to examine resident exposure to adverse events. BACKGROUND Independent data regarding the operative experience and clinical effectiveness across residency programs remain elusive. In the absence of reliable data, the ability to standardize surgical education and reduce variation in practice remains an unachievable goal. METHODS We identified general surgery cases using the ACS NSQIP Participant Use File 2011. Resident participation was defined according to postgraduate year (PGY). Descriptive statistical analyses were performed regarding procedure type and clinical outcomes. RESULTS Of the total general surgery cases, a PGY 1 to 5 resident participated in 87% (45,423), and 28% (n = 14,559) were performed with PGY 5 residents. Interns were involved with 10% (n = 5448) of the cases. The type of procedures performed varied by PGY, but cholecystectomy was the most common. Overall, 11% (4773) of cases were associated with an adverse event or mortality or both, with a mortality rate of 0.8% (374). The most common adverse event was bleeding (5%). CONCLUSIONS The ACS NSQIP captures the breadth of the resident experience in operative case mix and exposure to adverse events. Although the program was originally designed to uncover areas for quality improvement, the findings of our study demonstrate the utility of an outcomes registry as a guide for the development of future educational content in the resident curriculum.

Racial disparities in surgical outcomes of patients with Inflammatory Bowel Disease

The experiences of life are what shape us. This article relays stories of adversity and resiliency as experienced and told by members of our own surgical community at the Academic Surgical Congress in Las Vegas, NV in February 2017. We aim to express in words the lessons of each experience so that others can learn about life and leadership.

Surgical Residency Training at a University-Based Academic Medical Center

BACKGROUND Inflammatory Bowel Disease (IBD) has not historically been a focus of racial health disparities research. IBD has been increasing in the black community. We hypothesized that outcomes following surgery would be worse for black patients. METHODS A retrospective cohort study of death and serious morbidity (DSM) of patients undergoing surgery for IBD was performed using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP 2011-2014). Multivariable logistic regression modeling was performed to evaluate associations between race and outcomes. RESULTS Among 14,679 IBD patients, the overall rate of DSM was 20.3% (white: 19.3%, black 27.0%, other 23.8%, p < 0.001). After adjustment, black patients remained at increased risk of DSM compared white patients (OR: 1.37; 95% CI 1.14-1.64). CONCLUSIONS Black patients are at increased risk of post-operative DSM following surgery for IBD. The elevated rates of DSM are not explained by traditional risk factors like obesity, ASA class, emergent surgery, or stoma creation.