Outcome-volume relationships and transhiatal esophagectomy: minimizing failure to rescue

Abstract

BackgroundThe objective of this study is to describe the system and technical factors that enabled our moderate size transhiatal esophagectomy program to achieve low mortality rates.MethodsA retrospective chart review was conducted on 200 consecutive patients who underwent transhiatal esophagectomy at Robert Wood Johnson University Hospital. Primary outcomes included operative times, estimated blood loss, frequency and nature of complications, and lengths of stay in the hospital and the intensive care unit.ResultsIn general, surgical outcomes tended to improve over the course of this study. We identified decreased operative time, intra-operative blood loss, frequency of complications, and lengths of intensive care unit and hospital stay as the program matured. Through coordinated actions of the surgical and anesthesia teams, all intraoperative injuries were responded to in an effective, emergent fashion and all but one patient was saved. This resulted in an inhospital and 30-day mortality rate of only 0.5%.ConclusionsOur study suggests that a dual attending approach, focus on avoiding “failure to rescue”, increased volume, and a surgeon driven commitment to quality improvement may lead to low mortality rates after transhiatal esophagectomy.

Benchmarking Complications Associated with Esophagectomy

“…In some instances, the incidence of individual complications was lower than that seen in previous reports, such as pneumonia with an overall incidence of 14.6%. This may be due to the fact that this report is based on very recent data and modern practice, potentially reflecting the use of standardized clinical pathways, ERAS protocols and a decreased likelihood of failure to rescue 29,30 in high volume esophagectomy centers. The quality of the contributing centers is Page 13 of 29 reflected in a 30-day mortality rate of 2.4%, 90-day mortality of 4.5% an R0 resection rate of 93.4% and a readmission rate of 11.2%.…”

Age and preexisting conditions as risk factors for severe adverse events and failure to rescue after injury

“…Although initially described nearly 25 years ago, FTR analyses have enjoyed a recent resurgence in interest by surgical outcomes researchers (29–31). The attractive properties of the FTR metric can be summarized as follows: first, while rates of SAE have repeatedly been shown to correlate poorly with mortality rates at the center level (4, 5), FTR rates are clearly associated with mortality rates in a multiple elective surgical cohorts (31–33).…”

“…The attractive properties of the FTR metric can be summarized as follows: first, while rates of SAE have repeatedly been shown to correlate poorly with mortality rates at the center level (4, 5), FTR rates are clearly associated with mortality rates in a multiple elective surgical cohorts (31–33). Second, while rates of SAE and FTR are strongly associated with patient factors such as pre-existing conditions and age (9), FTR rates are relatively more strongly associated with center level variables such as nurse to bed ratios, nursing education levels (34), and board certification status of physicians (35).…”

Does “Two is Better Than One” Apply to Surgeons? Comparing Single-Surgeon Versus Co-surgeon Bilateral Mastectomies

“…In the early 2000s, members of our breast surgical staff proposed and implemented an alternative BM-technique involving two attending surgeons. Although a two-surgeon model has been advocated in other surgical subspecialties for a small subset of cases including orthopedics [13, 14], urology [15–17], thoracics [12] and hepatobiliary surgery [11], to the best of our knowledge it has not been integrated or evaluated in a breast surgical context.…”

“…Research within other surgical subspecialties suggests that a two or ‘co-surgeon’ technique may effectively reduce operative times and complications associated with complex bilateral procedures, possibly leading to improved surgical outcomes [10–12]. The co-surgeon technique has yet to be described or evaluated in breast surgery and currently there are no direct comparisons between co-surgeon and single-surgeon outcomes.…”