Richard F. Heitmiller

Intensive care unit physician staffing is associated with decreased length of stay, hospital cost, and complications after esophageal resection.

ObjectiveTo determine whether having daily rounds by an intensive care unit (ICU) physician is associated with clinical and economic outcomes after esophageal resection. DesignICU information was obtained from a prospective survey and linked to retrospective patient data from the Maryland Health Services Cost Review Commission. The main outcome variables were in-hospital mortality rate, length of stay, hospital cost, and complications after esophageal resection. SettingNonfederal acute care hospitals in Maryland that performed esophageal resection (n = 35 hospitals) during the study period, 1994–1998. PatientsAdult patients who underwent esophageal resection in Maryland (n = 366 patients) from 1994 to 1998. InterventionsPresence vs. absence of daily rounds by an ICU physician. Measurements and Main Results After adjusting for patient case-mix and other hospital characteristics, lack of daily rounds by an ICU physician was independently associated with a 73% increase in hospital length of stay (7 days; 95% confidence interval [CI], 1–15;p = .012) and a 61% increase in total hospital cost (

Hospital volume is related to clinical and economic outcomes of esophageal resection in Maryland

8,839; 95% CI,

Trial of a novel synthetic sealant in preventing air leaks after lung resection

1,674–

Mucoepidermoid lung tumors.

19,192;p = .013), but there was no association with in-hospital mortality rate. In addition, the following postoperative complications were independently associated with lack of daily rounds by an ICU physician: pulmonary insufficiency (odds ratio [OR], 4.0; CI, 1.4–11.0), renal failure (OR, 6.3; CI, 1.4–28.7), aspiration (OR, 1.7; CI, 1.0–2.8), and reintubation (OR, 2.8; CI, 1.5–5.2). ConclusionsHaving daily rounds by an ICU physician is associated with shorter lengths of stay, lower hospital cost, and decreased frequency of postoperative complications after esophageal resection. Healthcare providers and policymakers should use this information to help improve quality of care and reduce costs for patients undergoing high-risk surgical procedures.

Surgical management of postinfarction ventricular septal rupture.

BACKGROUNDnPrevious studies have documented a relationship between hospital volume and perioperative and economic outcomes. Our objective was to determine the effect of hospital volume on outcomes of esophageal resection.nnnMETHODSnStatewide database was analyzed for patients who underwent esophageal resection in Maryland (n = 1,136 patients) from 1984 to 1999. Multivariate regression was used to determine the association of hospital volume with in-hospital mortality, length of stay, and charges after adjusting for case mix and time period.nnnRESULTSnUnadjusted in-hospital mortality rates were lower in high volume hospitals (2.7%) than medium (12.7%) and low (16%) volume hospitals (p < 0.001). High hospital volume was associated with (1) fivefold reduction in the risk of death (odds ratio, 0.21; 95% confidence interval, 0.10 to 0.42; p < 0.001); (2) a 6-day (95% confidence interval, 5 to 7 days; p < 0.001) reduction in length of stay; and (3)

Atypical extralobar sequestration:CT-Pathological correlation

11,673 (95% confidence interval,

Multimodality therapy for esophageal cancer

9,504 to

Course guidelines for minimally invasive cardiac surgery

12,841; p < 0.001) decrease in hospital charges. Conclusions. Hospitals that perform high volumes of esophageal resection have superior clinical and economic outcomes. By referring these patients to high volume centers, we may improve quality and reduce costs.

Policy Statement: Minimally Invasive Coronary Artery Bypass Surgery

BACKGROUNDnPostoperative air leaks are a major cause of morbidity after lung resections. This study was designed to evaluate the efficacy and safety of a new synthetic, bioresorbable surgical sealant in preventing air leaks after pulmonary resection.nnnMETHODSnIn a multicenter trial, 172 patients undergoing thoracotomy were randomized intraoperatively in a 2:1 ratio to receive surgical sealant applied to sites at risk for air leak after standard methods of lung closure (treatment group) or to have standard lung closure only (control group). The primary outcome variable was the percentage of patients free of air leakage throughout hospitalization. Secondary outcome variables were the control of air leaks intraoperatively and the time to postoperative air leak cessation. Time to chest tube removal, time to hospital discharge, and safety outcomes were also evaluated.nnnRESULTSnAir leaks were identified before randomization in 89 of 117 patients in the treatment group and in 39 of 55 patients in the control group. Application of the sealant resulted in control of air leaks in 92% of treated patients (p < or = 0.001). A significantly higher percentage of treated patients than control patients remained free of air leaks during hospitalization (39% versus 11%, p < or =0.001). The mean times to last observable air leak were 30.9 hours in the treatment group and 52.3 hours in the control group (p = 0.006). In the treatment group, trends were observed for reduced time to chest tube removal and earlier discharge. No significant difference was identified in postoperative morbidity and mortality between the two groups.nnnCONCLUSIONSnAir leaks after lung resection occur in most patients. The application of this novel surgical sealant appears to be effective and safe in preventing postoperative air leaks.

Original articleGeneral thoracicInvited Commentary

Mucoepidermoid lung tumors are uncommon, representing 0.2% of all lung tumors and 1% to 5% of bronchial adenomas. Eighteen patients with mucoepidermoid tumors are reported. There were 10 male and 8 female patients with a mean age of 36.8 years (range, 9 to 62 years). On the basis of mitotic activity, cellular necrosis, and nuclear pleomorphism, we subclassified these tumors as low grade (15 patients) or high grade (3 patients). The achievement of complete resection and low-grade versus high-grade staging correlated with prognosis. All 12 patients who had a low-grade tumor that was completely excised are alive with no evidence of disease at a mean follow-up of 4.7 years (range, 1 to 27 years). All high-grade tumors proved fatal within 16 months. Two of the 3 high-grade tumors were unresectable because of extensive local disease. Patients with low-grade tumors and microscopically positive margins require close follow-up and can undergo a successful repeat resection. Nine of the 16 resections were sleeve resections, high-lighting the importance of conservative lung-sparing procedures in these central airway tumors. Both patients with an unresectable high-grade tumor had radiation therapy postoperatively and died 11 months later. The role of radiation therapy with high-grade tumors or incomplete resection has yet to be determined.