Impact of hospital volume on quality indicators for rectal cancer surgery in British Columbia, Canada.

BACKGROUND: The relationship between hospital volume and patient outcomes remains controversial for rectal cancer. METHODS: This is a population-based database study. Patients treated with surgery for a stage I to III rectal adenocarcinoma from 2003 to 2009 were identified. High-volume hospitals (HVH) were those centers performing 20 surgeries or more per year. Primary outcomes were operative and perioperative factors that have proven influence on patient outcomes. RESULTS: In all, 2,081 patients had surgery for rectal cancer. Of these, 1,690 patients had surgery in an HVH and 391 had surgery in a low-volume hospital. On multivariate analysis, patients who had surgery in an HVH were more likely to have sphincter-preserving surgery, 12 or more lymph nodes removed with the tumor, neoadjuvant radiation therapy, and receive pre-operative or postoperative chemotherapy. CONCLUSIONS: For rectal cancer patients in British Columbia, Canada, being treated at an HVH is associated with several quality indicators linked to better patient outcomes.

Survival after hepatic resection: impact of surgeon training on long-term outcome.

BACKGROUND: Mortality for liver resection has remarkably improved owing to multiple factors. We sought to determine the impact of the various types of fellowship training on patient survival after liver resection. METHODS: Patients who underwent hepatic resection between 1995 and 2004 in either the Calgary or Capital health regions (Edmonton) of Alberta, Canada, were identified using ICD-9 and -10 codes. Primary outcomes included in-hospital mortality and patient survival according to surgeon volume and training type (surgical oncology v. hepatobiliary v. others). RESULTS: A total of 1033 patients underwent hepatic resection. Surgeon volume was not predictive of either in-hospital mortality (adjusted odds ratio 0.63, 95% confidence interval [CI] 0.32-1.20) or patient survival (unadjusted hazard ratio 1.11, 95% CI 0.82-1.51). Nonsignificance was also demonstrated for a surgeon's type of fellowship training. CONCLUSION: The various modes of fellowship training do not appear to influence inhospital mortality or patient survival after hepatic resection.

CONTEXTE: Le taux de mortalité dans les cas de résection du foie a diminué considérablement à cause de multiples facteurs. Nous avons cherché à déterminer l'effet des divers types de formation au niveau du fellowship sur la survie des patients après une résection du foie. MÉTHODES: Les patients qui ont subi une résection hépatique entre 1995 et 2004 dans les régions sanitaires de Calgary ou de la Capitale (Edmonton) de l'Alberta, au Canada, ont été identifiés au moyen des codes CIM-9 et 10. La mortalité à l'hôpital et la survie des patients selon le volume de patients traités par le chirurgien et le type de la formation (oncologie chirurgicale c. hépatobiliaire c. autres) ont constitué les principales mesures de résultats. RÉSULTANTS: Au total, 1033 patients ont subi une résection hépatique. Le volume de patients traités par le chirurgien n'était pas un prédicteur de mortalité à l'hôpital (rapport de cotes rajusté, 0,63, intervalle de confiance [IC] à 95 % 0,32­1,20) ni de survie du patient (rapport de risque non rajusté, 1,11, IC à 95 % 0,82­1,51). On a aussi démontré la non importance de la formation au niveau du fellowship selon le type de chirurgien. CONCLUSIONS: Les divers modes de formation au niveau du fellowship ne semblent pas avoir d'effet sur la mortalité à l'hôpital ou la survie des patients après une résection hépatique.

The effect of a focused instructional session on knowledge of surgical staplers in general surgery residents.

INTRODUCTION: Surgical stapling devices have been used for a variety of purposes in both laparoscopic and open surgery. Nevertheless, trainees rarely receive any focused instruction on their application and use. This study attempts to determine the baseline knowledge of surgical stapling devices possessed by surgical residents. Furthermore, we attempt to evaluate the effectiveness of a short didactic session in improving the trainee's knowledge of the use and function of surgical staplers. METHODS: A 20-question multiple-choice test was created to evaluate a general surgery resident's knowledge on the design and use of circular, linear, and laparoscopic surgical staplers. The test was administered before and after attending a 40-minute instructional session on surgical stapling devices. The tests were then scored by a data analyst. RESULTS: A total of 26 residents of 39 in the residency program (26/39, 67%) participated. The pretest mean was 10.62/20 (53%), whereas the posttest mean was 15.38/20 (77%). These results were significantly different on paired samples t-test analysis (t((25)) = -10.3; p < 0.05). The mean pretest scores were also significantly different between resident levels (R1-R2, 9.50; R3-R5, 11.31; t((24)) = -2.10; p < 0.05). Senior-level residents scored higher on posttest analysis, but this result was not significant (R1-R2, 14.70; R3-R5, 15.81; t((24)) = -1.63; p > 0.05). DISCUSSION: There is a deficiency of knowledge of surgical staplers in general surgery residents, more so in junior residents. Didactic instruction is effective in raising the level of knowledge of surgical staplers in all residents, up to a similar level. Surgical educators should consider implementing programs like these for staplers and other types of surgical equipment.

Hepatic resection in Canada: rates and geographic variation.

BACKGROUND: Liver resection (LR) is the only curative therapy for hepatic malignancy. Despite this, the rates of LR across Canada are unknown. We sought to determine the rate and regional variation of LR in Canada, its provinces and census divisions for the period 1995-2004. METHODS: We obtained discharge data for 1995-2004 from all provinces but Quebec from the Canadian Institute for Health Information, and we searched for LR by residential site. Then we calculated rates and variations in rates. RESULTS: The national age- and sex-adjusted rate of LR per 100,000 people aged 18 years and older increased from 3.22 in 1995 to 5.86 in 2004. There was a high degree of variation across provinces and census divisions. CONCLUSION: Liver resection volumes are increasing in Canada. Significant regional variation exists for LR in Canada, likely reflecting a variety of important supply-demand issues.

Recent trends of hepatic resection in Canada: 1995-2004.

INTRODUCTION: Recently, many surgical procedures have become regionalized in the United States, likely owing to research demonstrating a relationship between volume and outcome. We sought to describe patient characteristics and outcomes according to hospital volume along with patterns of regionalization for hepatic resection in Canada from 1995 to 2004. METHODS: Discharge data from all hospitals across Canada except Quebec were obtained from the Canadian Institute for Health Information for 1995-2004. All patients undergoing a hepatic resection were identified using ICD-9 and ICD-10 codes. High-volume hospitals were defined as those performing ten or more procedures per year. RESULTS: A total of 9,912 patients (mean age 59 years) underwent hepatic resection. The proportion of procedures performed at high-volume hospitals increased from 42% in 1995 to 84% in 2004. Overall mortality rate for the study period was 5.0% which decreased over time. Mortality rates were higher at low-volume (6.1%) compared to high-volume centers (4.6%), but this finding was not statistically significant (p = 0.7451). Those factors predictive of mortality in a multivariate analysis included age, gender, year of operation, operative indication, comorbidity score, and admission status. DISCUSSION: Mortality rates have significantly improved. Hospital volume is not a significant predictor of mortality following liver resection in Canada.

Laparoscopic management of splenic cysts: marsupialization, cavity lining with surgicel and omentopexy to prevent recurrence.

INTRODUCTION: Open total splenectomy, once the treatment of choice for splenic cysts, has largely been replaced by laparoscopic, splenic preserving procedures. These techniques have resulted in reduced hospitalization times and rates of overwhelming postsplenectomy infection. We report 2 cases of laparoscopic management of large, symptomatic splenic cysts. METHODS: Two patients presented with symptomatic splenic cysts. The first was a simple cyst by history, the second a posttraumatic cyst. Both patients were treated by laparoscopic cyst marsupialization followed by lining the cavity with Surgicel (Ethicon, Somerville, NJ) and performance of an omentopexy. RESULTS: Both procedures were performed without complication. At 25 months, neither patient showed any evidence of symptomatic or radiologic recurrence. Pathology confirmed the preoperative diagnoses. CONCLUSIONS: Laparoscopic marsupialization of splenic cysts in combination with lining the cyst cavity with Surgicel and omentopexy is a safe, feasible, and efficacious method of management with excellent results at 25-month follow-up.