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ABSTRACT: Right lobe donor hepatectomy (RLDH) is a potential source of liver allografts given the ongoing shortage of deceased donor organs available. Since there is no live donor registry in the United States, a population-based, unsolicited state-wide analysis has yet to be reported.
The New York (NY) State Inpatient Database was used to query 1,524 elective liver lobectomies performed from 2001 to 2006. RLDH were identified in this cohort (n = 195; 13%). Most common indications for elective right lobe hepatectomy (ERH) were metastatic colon cancer (50%) and hepatocellular carcinoma (HCC) (34%). Primary outcomes were mortality, perioperative resources and major postoperative complications.
After a dramatic drop in 2002, there was a slow increase in RLDH from 2003 to 2006 in New York. Donors were younger (median age 36 vs. 60 years, P < 0.0001) and healthier (75% with no comorbidities vs. 18%, P < 0.0001) than patients undergoing ERH for other causes. Median length of hospital stay was 7 days in both groups. Donors were less likely to require blood transfusion (22.6 vs. 62.8%, P < 0.0001) and received less blood (mean 0.10 units vs. 2.4 units). Major post-operative complications based on the Clavien classification occurred in only 2.6% of donor cases compared to 13.8% in non-donors (P < 0.0001). There was one RLDH in-hospital mortality (0.5%) in New York compared to 4.3% after ERH (P = 0.003).
This study represents one of the first unsolicited regional analyses of donor morbidity and resource utilization for RLDH and further emphasizes the need and utility of a live donor registry.
Digestive Diseases and Sciences 11/2010; 56(6):1869-75. · 2.12 Impact Factor
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ABSTRACT: Regionalization of care has been proposed for complex operations based on hospital/surgeon volume-mortality relationships. Controversy exists about whether more common procedures should be performed at high-volume centers. Using mortality alone to assess routine operations is hampered by relatively low perioperative mortality. We used a large national database to analyze the risk of major in-hospital complications after laparoscopic cholecystectomy (LC).
Patients undergoing LC were identified in the Nationwide Inpatient Sample 1998-2006 from states with surgeon/hospital identifiers. Previously validated major complications including acute myocardial infarction, pulmonary compromise, postoperative infection, deep vein thrombosis, pulmonary embolism, hemorrhage, and reoperation were assessed. Univariate and multivariable analyses were performed and independent risk factors of complications were identified.
A total of 1,102,071 weighted patient discharges were identified, with a complication rate of 6.8%. Univariate analyses showed that advanced age, male gender, and higher Charlson Comorbidity Score were associated with higher complication rates (p < 0.0001). Higher surgeon volume (>or=36/year versus <12/year) and higher hospital volume (>or=225/year versus <or=120/year) were associated with fewer complications (6.7% versus 7.0%, 6.4% versus 7.0%, respectively; p < 0.0001). Multivariable analysis showed that advanced age (65 years or older versus younger than 65 years; adjusted odds ratio [AOR] = 2.16; 95% CI, 2.01-2.32), male gender (AOR = 1.14; 95% CI, 1.10-1.19), and comorbidities (Charlson Comorbidity Score 2 versus 0; AOR = 2.49; 95% CI, 2.34-2.65) were associated with complications. Neither surgeon nor hospital volume was independently associated with increased risk of complications.
Major in-hospital complications after LC are associated with individual patient characteristics rather than surgeon or hospital operative volumes. These results suggest regionalization of general surgical procedures might be unnecessary. Rather, careful patient selection and preoperative preparation can diminish overall complication rates.
Journal of the American College of Surgeons 07/2010; 211(1):73-80. · 4.55 Impact Factor
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ABSTRACT: There is controversy over the optimal management strategy for patients with acute pancreatitis (AP). Studies have shown a hospital volume benefit for in-hospital mortality after surgery, and we examined whether a similar mortality benefit exists for patients admitted with AP.
Using the Nationwide Inpatient Sample, discharge records for all adult admissions with a primary diagnosis of AP (n = 416,489) from 1998 to 2006 were examined. Hospitals were categorized based on number of patients with AP; the highest third were defined as high volume (HV, >or=118 cases/year) and the lower two thirds as low volume (LV, <118 cases/year). A matched cohort based on propensity scores (n = 43,108 in each group) eliminated all demographic differences to create a case-controlled analysis. Adjusted mortality was the primary outcome measure.
In-hospital mortality for patients with AP was 1.6%. Hospital admissions for AP increased over the study period (P < .0001). HV hospitals tended to be large (82%), urban (99%), academic centers (59%) that cared for patients with greater comorbidities (P < .001). Adjusted length of stay was lower at HV compared with LV hospitals (odds ratio, 0.86; 95% confidence interval, 0.82-0.90). After adjusting for patient and hospital factors, the mortality rate was significantly lower for patients treated at HV hospitals (hazard ratio, 0.74; 95% confidence interval, 0.67-0.83).
The rates of admissions for AP in the United States are increasing. At hospitals that admit the most patients with AP, patients had a shorter length of stay, lower hospital charges, and lower mortality rates than controls in this matched analysis.
Gastroenterology 10/2009; 137(6):1995-2001. · 11.68 Impact Factor
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ABSTRACT: Laparoscopic (LAP) surgery has experienced significant growth since the early 1990s and is now considered the standard of care for many procedures like cholecystectomy. Increased expertise, training, and technological advancements have allowed the development of more complex LAP procedures including the removal of solid organs. Unlike LAP cholecystectomy, it is unclear whether complex LAP procedures are being performed with the same growth today.
Using the Nationwide Inpatient Sample (NIS) from 1998 to 2006, patients who underwent elective LAP or open colectomy (n = 220,839), gastrectomy (n = 17,289), splenectomy (n = 9,174), nephrectomy (n = 64,171), or adrenalectomy (n = 5,556) were identified. The Elixhauser index was used to adjust for patient comorbidities. To account for patient selection and referral bias, a matched analysis was performed using propensity scores. The main endpoints were adjusted for in-hospital mortality and prolonged length of stay (LOS).
Complex LAP procedures account for a small percentage of total elective procedures (colectomy, 3.8%; splenectomy, 8.8%; gastrectomy, 2.4%; nephrectomy, 7.0%; and adrenalectomy, 14.2%). These procedures have been performed primarily at urban (94%) and teaching (64%) centers. Although all LAP procedures trended up, the growth was greatest in LAP colectomy and nephrectomy (P < .001). In a case-controlled analysis, there was a mortality benefit only for LAP colectomy (hazard ratio [HR] = 0.53; 95% confidence interval [CI] = 0.34-0.82) when compared with their respective open procedures. All LAP procedures except gastrectomy had a lower prolonged LOS compared with their open counterparts.
Despite the significant benefits of complex LAP procedures as measured by LOS and in-hospital mortality, the growth of these operations has been slow unlike the rapid acceptance of LAP cholecystectomy. Future studies to identify the possible causes of this slow growth should consider current training paradigms, technical capabilities, economic disincentive, and surgical specialization.
Surgery 09/2009; 146(2):367-74. · 3.10 Impact Factor
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ABSTRACT: Improved outcomes after pancreatic resection (PR) by high volume (HV) surgeons have been reported in single center studies, which may be confounded with potential selection and referral bias. We attempted to determine if improved outcomes by HV surgeons are reproducible when patient demographic factors are controlled at the population level.
Using the Nationwide Inpatient Sample, discharge records with surgeon identifiers for all nontrauma PR (n = 3581) were examined from 1998 to 2005. Surgeons were divided into 2 groups: (HV; > or = 5 operations/year) or low volume (LV; <5 operations/year). We created a logistic regression model to examine the relationship between surgeon type and operative mortality while accounting for patient and hospital factors. To further eliminate differences in cohorts and determine the true effect of surgeon volume on mortality, case-control groups based on patient demographics were created using propensity scores.
One hundred thirty-four HV and 1450 LV surgeons performed 3581 PR in 742 hospitals across 12 states that reported surgeon identifier information over the 8-year period. Patients who underwent PR by HV surgeons were more likely to be male, white raced, and a resident of a high-income zip code (P < 0.05). Significant independent factors for in-hospital mortality after PR included increasing age, male gender, Medicaid insurance, and surgery by HV surgeon. HV surgeons had a lower adjusted mortality compared with LV surgeons (2.4% vs. 6.4%; P < 0.0001).
After controlling for patient demographics and factors, pancreatic resection by a HV surgeon in this case-controlled cohort was independently associated with a 51% reduction in in-hospital mortality.
Annals of surgery 04/2009; 249(4):635-40. · 7.90 Impact Factor
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ABSTRACT: The outcomes after elective surgery in patients with cirrhosis have not been well studied.
We used the Nationwide Inpatient Sample (NIS) to identify all patients undergoing elective surgery for four index operations (cholecystectomy, colectomy, abdominal aortic aneurysm repair, and coronary artery bypass grafting) from 1998 to 2005. Elixhauser comorbidity measures were used to characterize patients' disease burden. Three distinct groups were created based on severity of liver disease: patients without cirrhosis (NON-CIRR), those with cirrhosis (CIRR), and patients with cirrhosis complicated by portal hypertension (PHTN). In-hospital mortality was the primary endpoint.
There were 22,569 patients with cirrhosis (of whom 4,214 had PHTN) who underwent 1 of the 4 index operations compared with approximately 2.8 million patients without cirrhosis having these operations. Patients with CIRR or PHTN were more likely to be women (49.5% versus 44.0%, p < 0.0001) and were less likely to be treated in a large hospital (62.8% versus 67.6%, p < 0.0001) than NON-CIRR patients. Length of hospital stay and total charges per hospitalization increased with severity of liver disease for all operations (p < 0.001, respectively). Adjusted mortality rates increased with increasing liver disease for each operation (cholecystectomy: CIRR hazard ratio [HR] 3.4, 95% CI 2.3 to 5.0; PHTN HR 12.3, 95% CI 7.6 to 19.9; colectomy: CIRR HR 3.7, 95% CI 2.6 to 5.2; PHTN HR 14.3, 95% CI 9.7 to 21.0; coronary artery bypass grafting: CIRR HR 8.0, 95% CI 5.0 to 13.0, PHTN HR 22.7, 95% CI 10.0 to 53.8; abdominal aortic aneurysm: CIRR HR 5.0, 95% CI 2.6 to 9.8, PHTN HR 7.8, 95% CI 2.3 to 26.5).
In-hospital mortality, length of stay, and total hospital charges are significantly higher after elective surgery in cirrhotic patients, even in the absence of portal hypertension. Careful decision-making about surgery in these patients is critical as the nationwide increase in hepatitis C and cirrhosis continues.
Journal of the American College of Surgeons 02/2009; 208(1):96-103. · 4.55 Impact Factor
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ABSTRACT: The optimal management of acute pancreatitis remains controversial and current treatment protocols vary in degrees of medical and surgical management. Our group has previously shown in population-based studies that high-volume (HV) hospitals have lower rates of in-hospital mortality after pancreatectomy. We sought to examine if a similar mortality benefit exists for patients admitted with acute pancreatitis.
Using the Nationwide Inpatient Sample (NIS), we examined discharge records for all adult admissions during 1998-2006 with a primary diagnosis of acute pancreatitis of any aetiology. Unique hospital identifiers were used to divide hospital volumes into equal thirds based on the number of admissions for acute pancreatitis per year (lowest tertile [low volume, LV] < or = 64 admissions/year; medium tertile [medium volume, MV] 65-117 admissions/year; highest tertile [high volume, HV] > or = 118 admissions/year). Covariates included patient demographics, hospital characteristics and patient co-morbidities using the Elixhauser index. Adjusted mortality represented the primary outcome measure and adjusted length of stay (LOS) and total charges were considered secondary measures.
There were 416,489 primary admissions for acute pancreatitis during the study period. In-hospital mortality for the cohort amounted to 1.6% (n = 6446). Hospital admissions for acute pancreatitis increased over the study period (P < 0.0001). High-volume hospitals tended to be large (82%), urban (99%) teaching (59%) centres (P < 0.0001), which cared for patients with more co-morbidities (35.9% of patients at HV hospitals vs. 29.1% at LV hospitals had at least three co-morbidities; P < 0.0001). Low-volume centres appeared more likely to perform pancreatic procedures than HV hospitals (odds ratio [OR] 1.50, 95% confidence interval [CI] 1.32-1.70). Patients at HV hospitals had a lower likelihood of a prolonged adjusted LOS compared with those at LV (OR 0.75, 95% CI 0.71-0.79) or MV (OR 0.82, 95% CI 0.79-0.85) hospitals. After adjusting for patient and hospital factors, there was an in-hospital mortality benefit associated with being treated at an HV centre (OR 0.70, 95% CI 0.63-0.77). The decision to operate on a given patient did not alter the mortality benefit of the HV hospital.
Rates of admissions for acute pancreatitis in the USA are increasing. High annual hospital volume of acute pancreatitis cases confers a shorter LOS, lower adjusted mortality and a lower likelihood of pancreatic procedure for patients admitted with acute pancreatitis. Although HV hospitals were less likely than MV or LV centres to perform pancreatic procedures, the role of surgery remains unclear. Further studies should examine other possible reasons for this mortality benefit, such as the availability of specialists, the quality of critical care facilities and the timing of operative intervention.
HPB 01/2009; 11(5):391-7. · 1.60 Impact Factor
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ABSTRACT: Cholecystectomy, which can be performed with either a laparoscopic (LC) or open (OC) approach, remains the definitive treatment for acute cholecystitis (AC) in the United States. There has not been an overall evaluation of the safety and efficacy of LC vs. OC as treatment for AC.
We used the Nationwide Inpatient Sample to identify all patients with AC from 1998-2005. Rates of LC or OC, patient and hospital characteristics, hospital cost, and mortality were analyzed. In order to assess if differences in outcomes exist, propensity scores were created to eliminate differences in cohorts. A case-controlled analysis was then performed, comparing in-hospital mortality and likelihood of conversion to OC.
From approximately 1.8 million admissions for AC, 1.4 million patients underwent cholecystectomy (1,240,212 LC; 147,190 OC) for AC from 1998 to 2005. The number of cholecystectomies increased over time. The ratio of LC performed increased from 83% in 1998 to 93% in 2005; 12% of cases were attempted laparoscopically but converted to OC. When compared with OC, patients who underwent LC were more likely to be female, carry private insurance, be discharged to home, have lesser hospital cost per patient, have no comorbid conditions, and have a lesser unadjusted mortality. After adjusting for age, comorbidity and sex, the adjusted odds ratio for death was 4.6-fold greater (95% CI 4.1-5.1) with OC compared with LC as the treatment for AC.
LC is performed with increasing frequency as the treatment for AC with lesser mortality, hospital stay, and cost compared with OC. Despite differences in cohorts, these results support a continued aggressive approach with laparoscopy as the treatment of choice for AC.
Surgery 08/2008; 144(2):283-9. · 3.10 Impact Factor
