Textbook Outcome as a measure of surgical quality assessment and prognosis in gastric neuroendocrine carcinoma:A large multicenter sample analysis

Objective:Quality assurance is crucial for oncological surgical treatment assessment.For rare diseases,singlequality indicators are not enough.We aim to develop a comprehensive and reproducible measurement,called the"Textbook Outcome"(TO),to assess the quality of surgical treatment and prognosis of gastric neuroendocrine carcinoma(G-NEC)patients.Methods:Data from patients with primary diagnosed G-NEC included in 24 high-volume Chinese hospitals from October 2005 to September 2018 were analyzed.TO included receiving a curative resection,≥15 lymph nodes examined,no severe postoperative complications,hospital stay≤21 d,and no hospital readmission≤30 d after discharge.Hospital variation in TO was analyzed using a case mix-adjusted funnel plot.Prognostic factors of survival and risk factors for non-Textbook Outcome(non-TO)were analyzed using Cox and logistic models,respectively.Results:TO was achieved in 56.6%of 860 G-NEC patients.TO patients had better overall survival(OS),disease-free survival(DFS),and recurrence-free survival(RFS)than non-TO patients(P<0.05).Moreover,TO patients accounted for 60.3%of patients without recurrence.Multivariate Cox analysis revealed non-TO as an independent risk factor for OS,DFS,and RFS of G-NEC patients(P<0.05).Increasing TO rates were associated with improved OS for G-NEC patients,but not hospital volume.Multivariate logistic regression revealed that nonlower tumors,open surgery,and>200 mL blood loss were independent risk factors for non-TO patients(P<0.05).Conclusions:TO is strongly associated with multicenter surgical quality and prognosis for G-NEC patients.Factors predicting non-TO are identified,which may help guide strategies to optimize G-NEC outcomes.

Variability in Surgical Quality among Surgeons in Breast Cancer Surgery

Introduction: Quality assurance is an essential aspect of cancer care. Assessment of surgical quality in breast cancer is still evolving. Variability in surgical care among surgeons has been well documented in literature and we sought to investigate such variation between two groups of surgeons referring patients to our oncology center. Methods: A prospective review of patient records of all breast cancer referrals to our department was made. Two groups were identified and segregated based on the performance of mastectomy by a general surgeon (GS) or by a surgical oncologist (SO). Patients treated with modified radical mastectomy for clinical stages 1 - 3 were included for the study. Patient demographic data and disease related information were collected in addition to thorough evaluation of the surgical pathology report. Margin positivity, mean nodal harvest, nodal ratio, inadequate axillary clearance, revision surgery and the use of radiotherapy for inadequate nodal dissection were the parameters evaluated in the study. Results: A total of 142 patient records were evaluated 72 designated as group 1 (general surgeons) and 70 as group 2 (surgical oncologist). The median age was 52 years and both groups were evenly balanced for age, laterality of breast lesion, histological type and grade. The mean nodal harvest was 8 vs. 14 nodes, and significant differences were observed in favor of surgical oncology group in margin positivity (P = 0.01), inadequate axillary clearance (P = 0.0001), and requirement of radiotherapy for inadequate axillary clearance (P = 0.0001) but not for revision surgery (P = 0.134). An assessment of prognostic factors revealed both groups to be well balanced for confounding factors. Conclusion: Breast cancer surgical care is amenable to quality assessment. Variation in oncological clearance exists between surgical oncologist and non-oncology trained surgeons involved in mastectomy for breast cancer. An assessment of factors leading to the observed quality differences may be addressed in future trials to ensure optimal breast cancer care.

Quality assessment of surgery for colorectal cancer:Where do we stand?

Quality assurance in surgery has been one of the most important topics of debate among colorectal surgeons in the past decade.It has produced new surgical standards that led in part to the impressive oncological outcomes we see in many units today.Total mesorectal excision,complete mesocolic excision(CME),and the Japanese D3 lymphadenectomy are now benchmark techniques embraced by many surgeons and widely recommended by surgical societies.However,there are still ongoing discrepancies in outcomes largely based on surgeon performance.This is one of the main reasons why many countries have shifted colorectal cancer surgery only to high volume centers.Defining markers of surgical quality is thus a perquisite to ensure that standards and oncological outcomes are met at an institutional level.With the evolution of CME surgery,various quality markers have been described,mostly based on measurements on the surgical specimen and lymph node yield,while others have proposed radiological markers(i.e.arterial stumps)measured on postoperative scans as part of the routine cancer follow-up.There is no ideal marker;however,taken together and assembled into a new score or set of criteria may become a future point of reference for reporting outcomes of colorectal cancer surgery in research studies and defining subspecialization requirements both at an individual and hospital level.

Impact of pre- and peri-operative risk factors on length of stay and hospital readmission following minimally-invasive partial nephrectomy

Objective:We conducted an analysis of the American College of Surgeons National Surgical Quality Improvement Program database for minimally-invasive partial nephrectomy cases reported with the goal to identify pre-and peri-operative variables associated with length of stay(LOS)greater than 3 days and readmission within 30 days.Methods:Records from 2008 to 2018 for“laparoscopy,surgical;partial nephrectomy”for prolonged LOS and readmission cohorts were compiled.Univariate analysis with Chi-square,t-tests,and multivariable logistic regression analysis with odds ratios(ORs),p-values,and 95%confidence intervals assessed statistical associations.Results:Totally,20306 records for LOS greater than 3 days and 15854 for readmission within 30 days were available.Univariate and multivariable analysis exhibited similar results.For LOS greater than 3 days,undergoing non-elective surgery(OR=5.247),transfusion of greater than four units within 72 h prior to surgery(OR=5.072),pre-operative renal failure or dialysis(OR=2.941),and poor pre-operative functional status(OR=2.540)exhibited the strongest statistically significant associations.For hospital readmission within 30 days,loss in body weight greater than 10%in 6 months prior to surgery(OR=2.227)and bleeding disorders(OR=2.081)exhibited strongest statistically significant associations.Conclusion:Multiple pre-and peri-operative risk factors are independently associated with prolonged LOS and hospital readmission within 30 days of surgery using the American College of Surgeons National Surgical Quality Improvement Program data.Recognizing the risks factors that can potentially be improved prior to minimally-invasive partial nephrectomy is crucial to informing patient selection,optimization strategies,and patient education.

Patient safety and quality improvements in parotid surgery

Parotidectomy is the mainstay treatment for tumors of the parotid gland.In an effort to improve clinical outcomes,several modern surgical techniques and perioperative interventions have been evaluated and refined.This review discusses current and actively debated perioperative interventions aimed at improving patient safety and the quality of parotidectomy.Relevant high-impact literature pertaining to preoperative diagnostic modalities,intraoperative surgical techniques,and postoperative care will be described.

Influence of staff number and internal constellation on surgical site infection in an operating room

Prediction of bacteria-carrying particle （BCP） dispersion and particle distribution released from staffmem- bers in an operating room （OR） is very important for creating and sustaining a safe indoor environment. Postoperative wound infections cause significant morbidity and mortality, and contribute to increased hospitalization time. Increasing the number of personnel within the OR disrupts the ventilation airflow pattern and causes enhanced contamination risk in the area of an open wound. Whether the amount of staffwithin the OR influences the BCP distribution in the surgical zone has rarely been investigated. This study was conducted to explore the influence of the number of personnel in the OR on the airflow field and the BCP distribution. This was performed by applying a numerical calculation to map the airflow field and Lagrangian particle tracking （LPT） for the BCP phase. The results are reported both for active sampling and passive monitoring approaches. Not surprisingly, a growing trend in the BCP concentration （cfu/ms） was observed as the amount of staff in the OR increased. Passive sampling shows unpredictable results due to the sedimentation rate, especially for small particles （5-10 i^m）. Risk factors for surgical site infections （SSls） must be well understood to develop more effective prevention programs.

Machine learning predicts unpredicted deaths with high accuracy following hepatopancreatic surgery

Background:Machine learning to predict morbidity and mortality-especially in a population traditionally considered low risk-has not been previously examined.We sought to characterize the incidence of death among patients with a low estimated morbidity and mortality risk based on the National Surgical Quality Improvement Program(NSQIP)estimated probability(EP),as well as develop a machine learning model to identify individuals at risk for“unpredicted death”(UD)among patients undergoing hepatopancreatic(HP)procedures.Methods:The NSQIP database was used to identify patients who underwent elective HP surgery between 2012-2017.The risk of morbidity and mortality was stratified into three tiers(low,intermediate,or high estimated)using a k-means clustering method with bin sorting.A machine learning classification tree and multivariable regression analyses were used to predict 30-day mortality with a 10-fold cross validation.C statistics were used to compare model performance.Results:Among 63,507 patients who underwent an HP procedure,median patient age was 63(IQR:54-71)years.Patients underwent either pancreatectomy(n=38,209,60.2%)or hepatic resection(n=25,298,39.8%).Patients were stratified into three tiers of predicted morbidity and mortality risk based on the NSQIP EP:low(n=36,923,58.1%),intermediate(n=23,609,37.2%)and high risk(n=2,975,4.7%).Among 36,923 patients with low estimated risk of morbidity and mortality,237 patients(0.6%)experienced a UD.According to the classification tree analysis,age was the most important factor to predict UD(importance 16.9)followed by preoperative albumin level(importance:10.8),disseminated cancer(importance:6.5),preoperative platelet count(importance:6.5),and sex(importance 5.9).Among patients deemed to be low risk,the c-statistic for the machine learning derived prediction model was 0.807 compared with an AUC of only 0.662 for the NSQIP EP.Conclusions:A prognostic model derived using machine learning methodology performed better than the NSQIP EP in predicting 30-day UD among low risk patients undergoing HP surgery.

An NSQIP evaluation of practice patterns and outcomes following surgery for anorectal abscess and fistula in patients with and without Crohn’s disease

Background:Patients with Crohn’s disease(CD)are believed to have more aggressive anorectal abscess and fistula disease.We assessed the types of procedures performed and perioperative complications associated with the surgical management of anorectal abscess and fistula disease in patients with and without CD.Methods:The American College of Surgeons National Surgical Quality Improvement Program database(ACS-NSQIP,2005-2010)was used to calculate 30-day outcomes using regression modeling,accounting for demographics,comorbidities and surgical procedures.ICD-9 codes for anorectal abscess or fistula were used for initial selection.Patients were then stratified,based on the presence or absence of underlying CD.Local procedures included incision and drainage of abscesses,fistulotomy and seton placement.Cutaneous fistulas were considered simple,while all others were classified as complex(-vaginal,-urethral and-vesical).Results:A total of 7,218 patients(mean age 45 years;64%male)met inclusion criteria,with underlying CD in 345(4.8%).CD patients were more likely to have a seton placed(9.9 vs 8.2%,P<0.001)and be on steroids(15.4 vs 4.3%,P<0.001).Thirty-seven percent of CD patients underwent local procedures,while 46%had a proctectomy and8%underwent diversion.Fistulotomy was more common in those without underlying CD(16 vs 11%,P<0.001).The overall complication rate after local treatment was 4.9%,with no difference between patients with and without CD(7.7 vs 4.9%,P=0.144).This was not affected by fistula type-simple(7.9 vs 3.9%,P=0.194)vs complex(33 vs 7.1%,P=0.21)—or when stratified by wound(3.8 vs 2.4%;P=0.26)or systemic complications(3.8 vs 2.5%;P=0.53).Yet,complications following emergency procedures were higher in patients with CD(21.4 vs 5.9%,P=0.047).Factors significantly associated with increased complications were Crohn’s disease(OR=8.2),lack of functional independence(OR=2.0),pre-operative weight loss(OR=2.6)and pre-operative acute renal failure(OR=5.6).Steroids were also associated with a 1.7-fold increase in complications,independent from CD.Conclusions:While most patients with anorectal abscess/fistula are treated with local procedures,proctectomy and diversion use is fairly common in those with underlying CD.Although complication rates following elective local procedures for anorectal abscess/fistula are similar in patients with and without CD,they are higher in patients on steroids and in CD patients undergoing emergent procedures.

A propensity score matched analysis of obesity as an independent risk factor for postoperative complications in reduction mammaplasty

Aim:Reduction mammaplasty is a commonly performed procedure for the treatment of symptomatic macromastia and is increasingly desired by the obese population.With the increasing prevalence obesity in the population,it is imperative to understand its effect on postoperative outcomes.The purpose of this study is to evaluate obesity as an independent risk factor for postoperative complications in breast reduction surgery using 1:1 patient matching through propensity scores between obese patients and non-obese controls.Methods:Between 2005 and 2013,the National Surgical Quality Improvement Program dataset identified a total of 6,016 patients as having undergone primary reduction mammaplasty with 30-day postoperative follow-up.Patients were divided into obese[body mass index(BMI)of 30 or more]vs.not obese(BMI below 30).Patients were initially analyzed using standard multivariable analysis.Using propensity scores obtained from a logistic regression model,patients were subsequently matched 1:1 according to preoperative and operative variables to truly isolate the effect of obesity on surgical outcomes.Outcomes were compared between the matched cohorts using McNemar’s test and the Wilcoxon signed rank test.Results:In unmatched multivariable analysis,rates of overall complications(7.2%vs.5.3%,P=0.0024),wound complications(5.5%vs.3.6%,P=0.0004),superficial surgical site infection(4.1%vs.2.8%,P=0.0050),and wound dehiscence(0.3%vs.1.1%,P=0.0005)were found to be statistically different between obese vs.non-obese,respectively.However,when comparing 1:1 matched obese and non-obese patients,only wound complications(4.6%vs.3.1%,P=0.0334)were significantly increased in the obese cohort.Conclusion:Using the most robust statistical tools available,obesity was determined to affect wound complications after breast reduction without increased detriment on other major complications when compared to the non-obese.Obesity should be a considered with other preoperative comorbidities,rather than an independent contraindication to surgery.Breast reduction appears to be safe in the obese patient who is otherwise healthy.