Low incisional hernia incidence using a large-bite, low-tension technique for celiotomy closure.

Background: Incisional herniae (IH) are reported in 5->20 % of patients undergoing open celiotomy, and can be linked to closure technique. The STITCH randomized trial favors a small bite technique for midline celiotomy closure with a 1-year IH rate of 13 % over larger bites (23 %). Methods: A continuous musculofascial mass closure with absorbable looped #1 PDS suture with 2-cm bite size was used for all open celiotomies. IH frequency and associated clinicopathologic factors were retrospectively analyzed from prospective data in 336 consecutive patients undergoing visceral resections by a single surgeon. Results: The study population included 192 men and 144 women, 81 % of whom had a cancer diagnosis, who underwent hepatobiliary, pancreatic, gastroesophageal, and colorectal resections, or a combination. The majority of patients (84 %) had subcostal incisions, and 10 % received a midline incision. At a median follow-up of 19.5 months, the overall IH rate was 3.3 %. Hernia rates were 2.5 % for subcostal margin, 2.9 % for midline, and 5.5 % for other incisions (p = 0.006). Median time to hernia detection was 492 days. Factors associated with IH were increased weight, abdominal depth/girth, male sex, spleen size, visceral fat, and body height (p ≤ 0.04 for all), but not type of resection, prior operations, underlying diagnosis, weight loss, adjuvant chemotherapy or radiation, incision length or suture to incision ratio. Conclusions: The described technique leads to a low IH rate of <3 % in subcostal or midline incisions, and can be recommended for routine use. The observed results appear superior to those of the STITCH trial, even for the smaller midline incision cohort.

Management of post-operative subcutaneous emphysema with the application of wound VAC therapy.

Extensive subcutaneous emphysema (SE) complicates between 1 and 6% of elective thoracic procedures. The management of SE is varied, and may include increasing the suction of chest tubes, placement of additional chest tubes, placement of subcutaneous drains and creation of releasing incisions. We present five patients with post-operative SE treated successfully with a subcutaneous infraclavicular incision and wound VAC therapy. A 5-cm incision was made 2 cm below the clavicle down and through the pectoralis major fascia. A VAC dressing was fitted to the wound and suction was applied to -125 mm Hg. Data were retrospectively collected and analyzed. VAC dressing was placed a median of 6 days after initial operation. All patients had improvement in symptoms and resolution of SE by VAC dressing therapy. Subcutaneous infraclavicular incision and VAC dressing placement is a viable treatment for patients with post-operative SE who fail conservative therapy.

Treatment at an Academic Cancer Center Confers Better Survival by Stage for Signet-Ring Cell and Non-signet-Ring Cell Gastric Cancer.

BACKGROUND: The literature lacks large-scale population studies comparing survival outcomes between signet-ring cell gastric carcinoma (SRGC) and non-SRGC (NSRGC) when treatment is delivered at academic versus community cancer centers. METHODS: The National Cancer Database (NCDB) from 2004 to 2016 was queried to examine the association between treatment facility category and overall survival of patients who underwent gastrectomy for resectable gastric adenocarcinoma (GAC). RESULTS: The study investigated 22,871 patients. Upstaging of resectable GAC to pathologic stage 4 was more evident at community centers (3.5%) than at academic centers (2.8%) for the NSRGC variant (p = 0.211), whereas it was comparable between the two facility categories for the SRGC variant (5.9% vs 6%, respectively). Patients with pathologic stage 1 or 3 NSRGC who underwent gastrectomy at academic programs had better overall survival (OS) (hazard ratio [HR], 0.68; p < 0.0001) than those who underwent gastrectomy at community centers (HR, 0.79; p < 0.0065). Similarly, patients with stage 2 SRGC had better OS when treated at academic versus community centers (HR, 0.54; p = 0.0019). No statistically significant improvement in OS was observed between patients with stage 2 NSRGC (HR, 0.84; p = 0.083) and those with stage 3 SRGC (HR, 0.78; p = 0.054) who were treated at academic centers. No survival benefit was demonstrated for stage 1 SRGC when academic and community centers were compared (p = 0.56). CONCLUSIONS: This is the first study based on a large-scale database in the Western population that addressed the overall survival-by-stage of two distinct GAC histologic variants. Treatment at academic centers was associated with significant improvements in OS.

A Simplified Two-Step Technique for Extended Lymphadenectomy During Resection of Gastroesophageal Malignancy: Early Results Compared to En Bloc Dissection.

BACKGROUND: Extended lymph node dissection (ELND) remains an important component of curative intent resection of mid-stage gastric cancer (GC). Benefits include enhanced staging accuracy, extending regional disease control, and optimizing potential curability. ELND during gastrectomy remains underutilized in US centers due to a low prevalence of GC operations. METHODS: The traditional en bloc ELND was modified into a two-step technique to facilitate greater ease of dissection with better exposure. After completion of the gastrectomy component, retrogastric nodes are dissected in a separate, contiguous specimen. Resulting data were compared to outcomes after en bloc resection. RESULTS: Of 179 consecutive patients undergoing gastrectomy, 129 underwent an ELND (73%). There were 97 men and 32 women, with a median age of 64 years (range 24-98). The median total LN count was 25 (3-86). The two-step dissection yielded an average of 18.3 (± 8.5 S.D.) perigastric and 12.1 (± 5.8) retrogastric nodes. Two-step LND was associated with lower estimated blood loss (265 vs. 448 ml, p = 0.0005), lower transfusion requirements (6 vs. 28%, p = 0.007), greater mean total LN counts (30 vs. 26, p = 0.03), and a greater rate of obtaining at least 15 or 20 LNs (91 vs. 77% and 83 vs. 65%, p = 0.05). Major morbidity (overall 16%), length of stay, and survival outcomes were not different. CONCLUSIONS: The two-step LND technique as described was found to be associated with favorable operative and postoperative outcome parameters and an excellent LN yield. It can be recommended for standard ELND indications in the absence of macroscopically abnormal LNs.

The expedited discharge of patients with multiple traumatic rib fractures is cost-effective.

INTRODUCTION: Rib fractures are a cause of significant morbidity and mortality in trauma patients. It is well documented that optimizing pain control, mobilization, and respiratory care decreases complications. However, the impact of these interventions on hospital costs and length of stay is not well defined. We hypothesized patients with multiple rib fractures can be discharged within three hospital days resulting in decreased hospital costs. METHODS: A retrospective review of adult patients (≥18yrs) admitted to our Level 1 trauma center (2011-2013) with ≥2 rib fractures was performed. Patients were excluded if they were intubated, admitted to the ICU, required chest tube placement, or sustained significant multi-system trauma. (n = 202) Demographics, clinical characteristics, hospital costs, and outcome data were analyzed. Patients discharged within three hospital days of admission were considered to have achieved expedited discharge (ED). Univariate and multivariate analyses determined predictors of failure to achieve ED. A p value of <0.05 was considered significant. RESULTS: Study patients (n = 202) were 60 (SD = 19) years of age with an injury severity score (ISS) of 10 (SD = 5), and 4 (SD = 2) rib fractures. Of 202 patients, 127 (63%) achieved ED while 75 (37%) did not. No differences in chest AIS, ISS, smoking status or history of pulmonary disease were identified between the two groups (all p > 0.05). Average LOS (2 (SD = 1) vs. 7 (SD = 4) days; p < 0.001) and hospital costs ($2865 (SD = 1200) vs. $6085 (SD = 3033)); p < 0.001). were lower in the ED group A lower percentage of ED patients required placement in rehabilitation facilities (6% vs. 48%; p < 0.001). There were no readmissions within 30 days in either group. After controlling for potential confounding variables, multiple variable logistic regression analysis revealed that advancing age (OR 1.05 per year, 1.02-1.07) independently predicted failure to achieve ED. CONCLUSION: The majority of patients admitted to the hospital with multiple rib fractures can be discharged within three days. This expedited discharge results in significant cost savings to the hospital. Early identification of patients who cannot meet the goal of expedited discharge can facilitate improvement in management strategies.

Physician derived versus administrative data in identifying surgical complications. Fact versus Fiction.

BACKGROUND: Administrative data are widely used as determinants of surgical quality. We compared surgical complications identified in a structured surgical review to coding and billing data of over a 19-month period. METHODS: A retrospective review of monthly morbidity and mortality conference reports was compared to a report over the same time period generated from hospital coding and billing data. RESULTS: 807 sequential operative procedures were included. Physician derived data compared to administrative data identified a complication of any severity in 205 (25.4%) versus 111 (13.8%) cases (r = 0.39), and major complications in 68 (8.4%) versus 46 (5.7%) cases (r = 0.36). Review of the administrative data regarding major complications identified 80 false negatives, 52 false positives, and 38 true positive designations. Overall sensitivity, specificity, positive and negative predictive values, and accuracy for administrative data in identifying major complications was 0.32, 0.99, 0.42, 0.99, and 0.99. CONCLUSIONS: The correlation between physician determined and administrative data with regard to identifying surgical complications is poor. Administrative data are insensitive and lack positive predictive value.

Experience with a simplified feeding jejunostomy technique for enteral nutrition following major visceral operations.

BACKGROUND: Background: Perioperative nutrition support has been shown to impact on outcomes for patients with gastrointestinal cancer. Postoperative benefits of feeding tubes must be weighed against morbidity related to placement and use. A simplified jejunostomy tube technique was evaluated for outcomes. METHODS: A 16-Fr rubber tube is secured at the jejunal entry site without Witzel tunnel, followed by a continuous, circumferential and alternating suture between jejunal wall and parietal peritoneum. Prospectively collected data were analyzed. RESULTS: The technique was performed in 343 of 803 major hepatopancreatobiliary and upper gastrointestinal (GI) resections (43%). Of these patients (male =57%, median age: 65.8 years, range, 24.0-98.0 years), 89% had a cancer diagnosis. The procedures included pancreatectomy (n=189, 55%), gastrectomy (n=109, 32%), esophagectomy (n=19, 6%) and others (n=26, 7%). The operative intent was curative in 78%, palliative in 10%, or combined in 12% of patients. Postoperative morbidity rate was 40%, with 19 lethal events (5.5%), and a median length of stay of 10 days (range, 4-111 days). Tube feeds were administered in 139 patients (41%), and in 17% continued beyond discharge. Use of the feeding tube was linked to treatment interval, length of stay, major complication grade (all at P<0.0001), metastatic stage (P=0.0007) and noncurative intent (P=0.001). Tube feeds beyond discharge were associated with time interval (P<0.0001), length of stay (P=0.0006) and noncurative intent (P=0.014). Tube-specific events in 38 patients (11%) were all minor, without any intraabdominal leak, infection or obstruction. CONCLUSIONS: The technique described is safe and expedient, and the overall tube-related morbidity is low. This procedure can be recommended in cases at risk for major morbidity and nutrition support needs.

Simplicity and Safety: Minimized Pancreatic Fistula Rate after Distal Pancreatectomy through Pancreas Stump Sutured Fish-Mouth Closure.

Pancreatic stump leak after distal pancreatectomy (DP) is a major determinant for impaired postoperative recovery. Factors influencing pancreatic fistula (PF) occurrence remain of interest. Prospectively collected data from an academic surgical oncology practice were examined for predictors of PF. Seventy-five of 294 pancreatectomy patients underwent DP (26%). There were 33 men and 42 women, with a median age of 61 years (range: 18-85 years). Underlying conditions included cancer (60%) and benign processes (40%). Resections were comprising open DP (64%), laparoscopic DP (21%), and open multivisceral resections (15%). Of 21 cases with postoperative complications (28%, no death), six were PFs (8%, 2 grade A and 4 grade B). The median length of stay was six days (4-24). The PF rate was 2.0 per cent in 50 patients after sutured fish-mouth closures, but 20 per cent in cases using other techniques including stapling (P = 0.007); no other variable was linked to PF occurrence. Length of stay was linked to complications, resection extent, malignancy, and transfusions (all at P < 0.02), but not to PF. PF rate after DP in this experience is unaffected by splenic vessel resection but seems to be minimized through a sutured fish-mouth closure technique.

Quality measurement affecting surgical practice: Utility versus utopia.

The Triple Aim: improving healthcare quality, cost and patient experience has resulted in massive healthcare "quality" measurement. For many surgeons the origins, intent and strengths of this measurement barrage seems nebulous-though their shortcomings are noticeable. This article reviews the major organizations and programs (namely the Centers for Medicare and Medicaid Services) driving the somewhat burdensome healthcare quality climate. The success of this top-down approach is mixed, and far from convincing. We contend that the current programs disproportionately reflect the definitions of quality from (and the interests of) the national payer perspective; rather than a more balanced representation of all stakeholders interests-most importantly, patients' beneficence. The result is an environment more like performance management than one of valid quality assessment. Suggestions for a more meaningful construction of surgical quality measurement are offered, as well as a strategy to describe surgical quality from all of the stakeholders' perspectives. Our hope is to entice surgeons to engage in institution level quality improvement initiatives that promise utility and are less utopian than what is currently present.