摘要:

ObjectiveAimed at reducing surgical deaths, several recent initiatives have attempted to establish volume-based referral strategies in high-risk surgery. Although payers are leading the most visible of these efforts, it is unknown whether volume standards will also reduce resource use.MethodsWe studied postoperative length of stay and 30-day readmission rate after 14 cardiovascular and cancer procedures using the 1994-1999 national Medicare database (total n = 2.5 million). We used regression techniques to examine the relationship between length of stay, 30-day readmission, and hospital volume, adjusting for age, gender, race, comorbidity score, admission acuity, and mean social security income.ResultsMean postoperative length of stay ranged from 3.4 days (carotid endarterectomy) to 19.6 days (esophagectomy). There was no consistent relationship between volume and mean length of stay; it significantly increased across volume strata for 7 of the 14 procedures and significantly decreased across volume strata for the other 7. Mean length of stay at very-low-volume and very-high-volume hospitals differed by more than 1 day for 6 procedures. Of these, the mean length of stay was shorter in high-volume hospitals for 3 procedures (pancreatic resection, esophagectomy, cystectomy), but longer for other procedures (aortic and mitral valve replacement, gastrectomy). The 30-day readmission rate also varied widely by procedure, ranging from 9.9% (nephrectomy) to 22.2% (mitral valve replacement). However, volume was not related to 30-day readmission rate with any procedure.ConclusionAlthough hospital volume may be an important predictor of operative mortality, it is not associated with resource use as reflected by length of stay or readmission rates.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo predict the impact of the aging population on the demand for surgical procedures.Summary Background DataThe population is expanding and aging. According to the US Census Bureau, the domestic population will increase 7.9% by 2010, and 17.0% by 2020. The fastest growing segment of this population consists of individuals over the age of 65; their numbers are expected to increase 13.3% by 2010 and 53.2% by 2020.MethodsData on the age-specific rates of surgical procedures were obtained from the 1996 National Hospital Discharge Survey and the National Survey of Ambulatory Surgery. These procedure rates were combined with corresponding relative value units from the Centers for Medicare and Medicaid Services. The result quantifies the amount of surgical work used by an average individual within specific age groups (<15 years old, 15–44 years old, 45–64 years old, 65+ years old). This estimate of work per capita was combined with population forecasts to predict future use of surgical services.ResultsBased on the assumption that age-specific per capita use of surgical services will remain constant, we predict significant increases (14–47%) in the amount of work in all surgical fields. These increases vary widely by specialty.ConclusionsThe aging of the US population will result in significant growth in the demand for surgical services. Surgeons need to develop strategies to manage an increased workload without sacrificing quality of care.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo review the current concepts in the mediastinal staging of nonsmall cell lung cancer (NSCLC), evaluating traditional and modern staging modalities.Summary Background DataStaging of NSCLC includes the assessment of mediastinal lymph nodes. Traditionally, computed tomography (CT) and mediastinoscopy are used. Modern staging modalities include magnetic resonance imaging (MRI), positron emission tomography (PET), and endoscopic ultrasound with fine-needle aspiration (EUS-FNA)MethodsLiterature was searched with PubMed and SUMSearch for original, peer-reviewed, full-length articles. Studies were evaluated on inclusion criteria, sample size, and operating characteristics. Endpoints were accuracy, safety, and applicability of the staging methods.ResultsCT had moderate sensitivities and specificities. With few exceptions magnetic resonance imaging (MRI) offered no advantages when compared with CT, against higher costs. PET was significantly more accurate than CT. Mediastinoscopy and its variants were widely used as gold standard, although meta-analyses were absent. Percutaneous transthoracic needle biopsy (PTNB) and transbronchial needle biopsy (TBNA) were moderately sensitive and specific. EUS-FNA had high sensitivity and specificity, is a safe and fast procedure, and is cost-effective. EUS-FNA evaluates largely a nonoverlapping mediastinal area compared with mediastinoscopy.ConclusionsPET has the highest accuracy in the mediastinal staging of NSCLC, but is not generally used yet. EUS-FNA has the potential to perform mediastinal tissue sampling more accurate than TBNA, PTNB, and mediastinoscopy, with fewer complications and costs. Although promising, EUS-FNA is still experimental. Mediastinoscopy is still considered as gold standard for mediastinal staging of NSCLC.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveThe aim of the study was to compare the efficacy and mechanical consequences of 2 partial fundoplications performed laparoscopically under the framework of a randomized, controlled clinical trial.Summary Background DataAlthough laparoscopic total fundoplication procedures have proven their effectiveness in the control of gastroesophageal reflux, problems remain with the functional consequences after a supra-competent gastric cardia high-pressure zone. Partial fundoplications have been found to be associated with fewer mechanical side effects.Patients and MethodsDuring a 2-year period, 95 patients with gastroesophageal reflux disease were enrolled into a randomized, controlled single-institution clinical trial comparing a partial posterior (Toupét, n = 48) fundoplication and an anterior partial wrap (Watson, n = 47). All patients were assessed postoperatively at predefined time points, and the 12-month follow-up data are presented in terms of clinical results and 24-hour pH monitoring variables.ResultsBoth patient groups were strictly comparable at the time of randomization. All operations were completed laparoscopically, and no serious complications were encountered. During the first postoperative year, a difference regarding the control of reflux symptoms was observed in favor of the posterior fundoplication. Esophageal acid exposure (% time pH <4) was substantially reduced by both operations but to a significantly lower level after a Toupét compared with the Watson partial fundoplication (1.0 ± 0.3 vs. 5.6 ± 1.1 mean ± SEM;p< 0.001). Postfundoplication symptoms were infrequently recorded with no difference between the groups.ConclusionsWhen performing a laparoscopic partial fundoplication, the posterior modification (Toupét) offers advantages in terms of better reflux control compared with an anterior type (Watson).

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo identify clinically useful parameters obtainable before treatment of predicting clinical outcomes in patients with esophageal carcinoma.Summary Background DataVarious factors regarding the biologic state of tumors or the nutritional state of patients have been individually reported to correlate with prognosis. Reliable estimates of life expectancy before treatment are important, and consideration needs to be given not only to tumor-related but also to host-related factors in patients with esophageal carcinoma.MethodsThe following clinicopathological factors were retrospectively analyzed in 356 consecutive patients with surgical treatment: sex; age; serum C-reactive protein (CRP); proportion of lymphocytes; body weight changes; serum albumin; clinical TNM staging; tumor location; serum squamous cell-related antigen; serum carcinoembryonic antigen; and histology. Factors related to prognosis were evaluated by using univariate and multivariate analyses.ResultsAccording to univariate analysis, significant differences in survival were found for sex, serum CRP, proportion of lymphocytes, body weight change, serum albumin, serum squamous cell-related antigen, and clinical TNM staging. Multivariate analysis demonstrated that CRP levels (P= 0.0285), body weight change (P= 0.0165), and clinical TNM staging (P= 0.0008) displayed independent correlations to prognosis. When serum CRP elevation, body weight loss, and clinical TNM staging III and IV were scored as a combined index, the total score (prognostic index for esophageal cancer, PIEC) demonstrated a good stratification value for prognosis. Moreover, PIEC was superior to the conventional clinical TNM staging by the likelihood ratio test.ConclusionsPIEC based on serum CRP, body weight change, and clinical TNM staging before treatment offers a very simple and informative method for predicting the prognosis of patients with esophageal carcinoma.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo assess long-term quality of life in a population-based sample of rectal cancer patients.Summary Background DataQuality of life in rectal cancer patients who suffer reduced bowel and sexual function is very important. Few studies, however, have long term follow-up data or sufficient sample sizes for reliable comparisons between operation groups.Patients and MethodsA 4-year prospective study of rectal cancer patients’ quality of life was assessed by using the European Organization for Research and Treatment of Cancer QLQ-30 and CR38 questionnaires.ResultsA total of 329 patients returned questionnaires. Overall, anterior resection patients had better quality of life scores than abdominoperineal extirpation patients. High-anterior resection patients had significantly better scores than both low-anterior resection and abdominoperineal extirpation patients. Low-anterior resection patients, however, overall had a better quality of life than abdominoperineal extirpation patients, especially after 4 years. Abdominoperineal extirpation patients’ quality of life scores did not improve over time. Stoma patients had significantly worse quality of life scores than nonstoma patients. Quality of life improved greatly for patients whose stoma was reversed.ConclusionsAnterior resection and nonstoma patients, despite suffering micturition and defecation problems, had better quality of life scores than abdominoperineal extirpation and stoma patients. Comparisons between abdominoperineal extirpation and anterior resection patients should consider the effect of temporary stomas. Improvements in quality of life scores over time may be explained by reversal of temporary stomas or physiologic adaptation.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectivesTo compare a colonic J-pouch or a side-to-end anastomosis after low-anterior resection for rectal cancer with regard to functional and surgical outcome.Summary Background DataA complication after restorative rectal surgery with a straight anastomosis is low-anterior resection syndrome with a postoperatively deteriorated anorectal function. The colonic J-reservoir is sometimes used with the purpose of reducing these symptoms. An alternative method is to use a simple side-to-end anastomosis.MethodsOne-hundred patients with rectal cancer undergoing total mesorectal excision and colo-anal anastomosis were randomized to receive either a colonic pouch or a side-to-end anastomosis using the descending colon. Surgical results and complications were recorded. Patients were followed with a functional evaluation at 6 and 12 months postoperatively.ResultsFifty patients were randomized to each group. Patient characteristics in both groups were very similar regarding age, gender, tumor level, and Dukes’ stages. A large proportion of the patients received short-term preoperative radiotherapy (78%). There was no significant difference in surgical outcome between the 2 techniques with respect to anastomotic height (4 cm), perioperative blood loss (500 ml), hospital stay (11 days), postoperative complications, reoperations or pelvic sepsis rates. Comparing functional results in the 2 study groups, only the ability to evacuate the bowel in <15 minutes at 6 months reached a significant difference in favor of the pouch procedure.ConclusionsThe data from this study show that either a colonic J-pouch or a side-to-end anastomosis performed on the descending colon in low-anterior resection with total mesorectal excision are methods that can be used with similar expected functional and surgical results.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

ObjectiveTo evaluate how age affects functional outcome and quality of life after ileal pouch anal anastomosis (IPAA).Summary Background DataBecause of the limited number of older patients undergoing IPAA, it has been difficult to assess functional outcome and quality of life stratified by age.MethodsIPAA was performed in 1895 patients. Patients were stratified by age into <45 (n = 1410), 46–55 (n = 289), 56–65 (n = 154), and more than 65 years (n = 42). Outcome was assessed prospectively. Results are presented at 1, 3, 5, and 10 years after surgery.ResultsPatients were followed for 4.6 ± 3.7 years (maximum, 17 years). Pouch failure occurred in 4.1% (pouch excision or permanent diversion). Incontinence and night time seepage were more common in older patients. There were minor differences in the quality of life, health, energy and happiness between age groups, with a slight benefit for those under 45 years. Fourteen percent or fewer patients experienced social, sexual or work restrictions. Overall, 96% of patients were happy to have undergone their surgery, and 98% recommended it to others. Although the respective figures were 89% and 96% in the over-65 age group, the difference was not significant.ConclusionsThese data provide a unique assessment of outcome after IPAA at multiple time points. Although functional outcome after IPAA is not as good in older patients, appropriate case selection confers acceptable function and quality of life to patients of all ages.

ISSN:0003-4932    

出版商:OVID    

年代:2003

数据来源: OVID