Volume Matters: Longitudinal Retrospective Cohort Study of Outcomes Following Consultation and Standardization of Adrenal Surgery.

PURPOSE: Subspecialization of adrenal surgery through regionalization has not been adequately evaluated. We assessed implementation of subspecialization and the association of regionalization with adrenalectomy outcomes in a community-based setting. METHODS: In this longitudinal retrospective cohort study, we used an interrupted time series analysis on consecutive adrenal surgeries at Kaiser Permanente Northern California, 2010-2019. The intervention was regionalization of surgery in 2016. Main outcomes include surgical volumes, operative time, length of stay, 30-day return-to-care, and 30-day complications obtained from the electronic medical record. t-Tests and multivariable models were used to analyze time trends in outcomes after accounting for changes in patient and disease characteristics. RESULTS: In total, 850 adrenal surgery cases were eligible. Between 2010 and 2019, the annual incidence of surgery (per 100,000 persons) increased from 2.4 (95% CI 1.9-3.1) to 4.1 (95% CI 3.5-4.8). Average annual surgeon volume increased from 2.4 (95% CI 1.6-3.1) to 9.9 (95% CI 4.9-14.9), while hospital volume increased from 3.5 (95% CI 2.3-4.6) to 15.4 (95% CI 6.9-24.0). Operative time was 34 (23-45) min faster in 2018-2019 compared with 2010-2011. After regionalization, same-day discharges increased to 64% in 2019 (p < 0.0001). The frequency of return-to-care (p = 0.69) and the overall complication rate (p = 0.31) did not change. CONCLUSIONS: Regionalizing adrenal surgery through surgical subspecialization and standardized care pathways was feasible and decreased operative time, and hospital stay, while increasing the frequency of same-day discharges without increasing return-to-care or complications.

Single-incision laparoscopic cholecystectomy using conventional instruments: early experience in comparison with the gold standard.

BACKGROUND: The aim of this pilot study was to describe our initial experience with single-incision laparoscopic cholecystectomy (SILC) using conventional laparoscopic equipment in comparison with concurrent patients undergoing conventional multiincision laparoscopic cholecystectomy. STUDY DESIGN: During the 7-month study period, data from all consecutive patients undergoing SILC by two surgeons were retrospectively analyzed and compared with data from patients undergoing conventional laparoscopic cholecystectomy by the same surgeons during the same time period. Outcomes measures included completion rate of attempted SILC, operative time, length of hospital stay, postoperative pain, and assessment of complications. RESULTS: From 51 laparoscopic cholecystectomies performed during the study period, 29 were attempted using single-incision technique and 22 were performed using the conventional four incisions. Of the attempted SILC cases, 14 (48%) were successfully completed, with the remainder requiring one to three additional skin incisions. There were no conversions to open in either group. Operative time was significantly longer in SILC cases compared with conventional laparoscopic cholecystectomy (85 versus 67 minutes; p = 0.01). There was a tendency toward greater postoperative pain in the SILC group. No substantial difference in complications was identified. CONCLUSIONS: SILC using conventional laparoscopic instrumentation is an effective alternative to standard four-incision laparoscopic cholecystectomy in selected patients. Development of a standardized technique and additional experience is needed for more consistent success. Additional studies of SILC are needed to demonstrate safety, define selection criteria, and determine any benefits over conventional laparoscopic cholecystectomy.