Journal of the American College of Surgeons
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Inadequate access has contributed to widespread racial disparities in cancer care in the United States. However, the outcomes for racial minorities at quality-seeking hospitals, such as those participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), remain unknown. We hypothesized that operative outcomes for racial and ethnic minority patients after cancer surgery at ACS NSQIP hospitals are comparable with those for white patients. ⋯ Racial and ethnic minority patients who undergo their cancer surgery at ACS NSQIP hospitals have short-term operative outcomes similar to white patients, but they remain hospitalized longer. These findings suggest that access to quality-driven hospitals might ameliorate racial disparities in cancer care and outcomes. Future policies should focus on expanding access to quality-driven surgical facilities as a step toward timely and optimal cancer care.
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Ischemia-reperfusion injury (IRI) can occur during hepatic surgery and transplantation. IRI causes hepatic mitochondrial and microcirculatory impairment, resulting in acute liver dysfunction and failure. We proposed a novel strategy of regulated hepatic reperfusion (RHR) to reverse the cellular metabolic deficit that incurred during organ ischemia by using a substrate-enriched, oxygen-saturated, and leukocyte-depleted perfusate delivered under regulated reperfusion pressure, temperature, and pH. We investigate the use of RHR in mitigating IRI after a prolonged period of warm ischemia. ⋯ Regulated hepatic reperfusion mitigates IRI, facilitates liver function recovery, and improves survival after a prolonged period of hepatic warm ischemia. This novel strategy has potential applicability to clinical hepatic surgery and liver transplantation when marginal grafts are used.
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Comparative Study
Mortality after elective colon resection: the search for outcomes that define quality in surgical practice.
Process measures constitute the focal point of surgical quality studies. High levels of compliance with such processes have not correlated with improved outcomes. Wide ranges of reported hospital death rates led us to hypothesize that survival after elective colon resection would be a legitimate outcomes measure for quality of surgical practice. ⋯ Elective colon resection is a safe procedure in both teaching hospitals and nonteaching hospitals, with an impressively homogenous mean mortality rate of 1.56% in teaching hospitals, and 1.38% in nonteaching hospitals. We reject our original hypothesis because the data do not sufficiently discriminate to permit the use of death after elective colon resection as a differentiating quality measure; however, the data do identify individual poor performers. Poor performing institutions/surgeons should seek extramural guidance to improve their outcomes or discontinue performing such operations.
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Comparative Study
Adherence to a simplified management algorithm reduces morbidity and mortality after penetrating colon injuries: a 15-year experience.
Our previous experience with colon injuries suggested that operative decisions based on a defined algorithm improve outcomes. The purpose of this study was to evaluate the validity of this algorithm in the face of an increased incidence of destructive injuries observed in recent years. ⋯ Despite an increase in the incidence of destructive colon injuries, our management algorithm remains valid. Destructive injuries associated with pre- or intraoperative transfusion requirements of more than 6 units packed RBCs and/or significant comorbidities are best managed with diversion. By managing the majority of other destructive injuries with resection plus anastomosis, acceptably low morbidity and mortality can be achieved.
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Led by the Tennessee Chapter of the American College of Surgeons, in May 2008 a 10-hospital collaborative was formed between the Tennessee Chapter of ACS, the Tennessee Hospital Association, and the BlueCross BlueShield of Tennessee Health Foundation. We hypothesized that by forming the Tennessee Surgical Quality Collaborative using the National Surgical Quality Improvement Program (NSQIP) system to share surgical process and outcomes data, overall patient surgical outcomes would improve. ⋯ Data organization and scrutiny are the initial steps of process improvement. Participation in our regional surgical quality collaborative resulted in improved outcomes and reduced costs. Although the mechanisms for these changes are likely multifactorial, the collaborative establishes communication, process improvement, and frank discussion among the members as best practices are identified and shared and standardized processes are adopted.