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Purpose: Emerging evidence supporting the use of laparoscopic colectomy in patients with cancer has led to dramatic increases in utilization. Though certain patient and hospital characteristics may be associated with the use of laparoscopy, the influence of geography is poorly understood., Methods: We used national Medicare claims data from 2009 and 2010 to examine geographic variation in utilization of laparoscopic colectomy for patients with colon cancer. Patients were assigned to hospital referral regions (HRRs) where they were treated. Multivariable logistic regression was used to generate age, sex, and race-adjusted rates of laparoscopic colectomy for each HRR. Patient quintiles of adjusted HRR utilization were used to evaluate differences in patient and hospital characteristics across low and high-utilizing HRRs., Results: A total of 93,786 patients underwent colon resections at 3,476 hospitals during the study period, of which 30,502 (32.5%) were performed laparoscopically. Differences in patient characteristics between the lowest and highest quintiles of HRR utilization were negligible, and there was no difference in the availability of laparoscopic technology. Yet adjusted rates of laparoscopic colectomy utilization varied from 0% to 66.8% across 306 HRRs in the United States., Conclusion: There is wide geographic variation in the utilization of laparoscopic colectomy for Medicare patients with colon cancer, suggesting treatment location may substantially influence a patient's options for surgical approach. Future efforts to reduce variation will require increased dissemination of training techniques, novel opportunities for learning among surgeons, and enhanced educational resources for patients., (© 2014 by American Society of Clinical Oncology.)

Objective: To determine whether the relationship between hospital volume and mortality has changed over time., Background: It is generally accepted that hospital volume is associated with mortality in high-risk procedures. However, as surgical safety has improved over the last decade, recent evidence has suggested that the inverse relationship has diminished or been eliminated., Methods: Using national Medicare claims data from 2000 through 2009, we examined mortality among 3,282,127 patients who underwent 1 of 8 gastrointestinal, cardiac, or vascular procedures. Hospitals were stratified into quintiles of operative volume. Using multivariable logistic regression models to adjust for patient characteristics, we examined the relationship between hospital volume and mortality, and assessed for changes over time. We performed sensitivity analyses using hierarchical logistic regression modeling with hospital-level random effects to confirm our results., Results: Throughout the 10-year period, a significant inverse relationship was observed in all procedures. In 5 of the 8 procedures studied, the strength of the volume-outcome relationship increased over time. In esophagectomy, for example, the adjusted odds ratio of mortality in very low volume hospitals compared to very high volume hospitals increased from 2.25 [95% confidence interval (CI): 1.57-3.23] in 2000-2001 to 3.68 (95% CI: 2.66-5.11) in 2008-2009. Only pancreatectomy showed a notable decrease in strength of the relationship over time, from 5.83 (95% CI: 3.64-9.36) in 2000-2001, to 3.08 (95% CI: 2.07-4.57) in 2008-2009., Conclusions: For all procedures examined, higher volume hospitals had significantly lower mortality rates than lower volume hospitals. Despite recent improvements in surgical safety, the strong inverse relationship between hospital volume and mortality persists in the modern era.

Background: Postcardiotomy shock affects 0.5% to 6% of cardiac operations and is associated with a high mortality. Many of these patients had their procedures performed at lower-volume cardiac surgery centers with limited resources. The objective of this study was to determine the outcomes in patients in postcardiotomy shock who were transferred to a tertiary care center for escalated care., Methods: We performed a retrospective review of 104 postcardiotomy shock patients transferred to our institution between 2004 and 2012. Univariable and multivariable analyses were performed to determine predictors of in-hospital and overall survival., Results: Seventy-eight percent of patients were receiving temporary mechanical support. The in-hospital mortality in our series was 46%. Multivariable predictors of in-hospital mortality included higher initial creatinine level on arrival and a history of known heart failure. Multivariable predictors of overall mortality included higher initial creatinine and lactate levels, lower initial ejection fraction, and a history of heart failure and hypertension. The Kaplan-Meier estimation of 5-year survival was 39% in all patients and 72% in patients who survived to hospital discharge., Conclusions: Patients with postcardiotomy cardiac failure transported to a tertiary care center for advanced cardiac support had a nearly 50% survival, with excellent long-term survival of those discharged alive. Preservation of end-organ function, often with mechanical support, can improve survival., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: The reported influence of Accreditation Council for Graduate Medical Education resident duty hour limitations on operative case volume has been mixed. Additional restrictions instituted in July 2011 further limited the work hours of postgraduate year 1 (PGY-1) residents, threatening to reduce availability for educational and operative activities. In this study, we evaluate our novel intern call schedule, which we hypothesized would preserve operative experience despite these increased restrictions., Design: A retrospective analysis of PGY-1 operative reports was conducted. Operations outside of major case categories were excluded. Operative case volumes in the Section of General Surgery for the same period were analyzed, as were average duty hours for each resident. Comparative statistics were generated using Wilcoxon rank sum tests., Setting: Single-institution study conducted at the University of Michigan, a tertiary-care academic hospital., Participants: Overall, 50 categorical general surgery residents from 2005 to present were included. Three residents were subsequently excluded as they were preliminary interns rather than categorical; 2 residents were excluded having completed their intern years at other institutions., Results: The median number of major cases done during the PGY-1 for all evaluated residents was 89 (interquartile range [IQR]: 72-101). For interns between the years 2005 and 2011, the median number of major cases was 87 (IQR: 73-101), whereas interns in the 2011 to 2013 academic years performed 91.5 (IQR: 69.5-101.5, p = 0.91). Although case volume varied between intern classes, no significant differences were observed between any 2 individual classes in the study. Analysis of annual case volumes among each PGY revealed a relative increase of 29% (p < 0.001) among PGY-2 residents, and 20% (p = 0.02) by PGY-3 residents. Relative increases among senior residents (8% for both PGY-4 and PGY-5) did not reach statistical significance., Conclusions: Our novel call schedule attempts to minimize prolonged night-float coverage responsibilities for interns in hopes of preserving their operative experience. In spite of increased duty hour restrictions, PGY-1 operative volume has not decreased significantly at our institution. However, in the same time period, PGY-2 and PGY-3 case volume has increased. Our findings highlight the challenges faced by surgical residencies in light of these new restrictions, particularly the 16-hour limit. Additional rigorously designed prospective studies should be conducted to better understand the influence of the most recent Accreditation Council for Graduate Medical Education work hour limitations on the subjective and objective experiences of surgical residents., (Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Importance: Disparities in operative mortality due to socioeconomic status (SES) have been consistently demonstrated, but the mechanisms underlying this disparity are not well understood., Objective: To determine whether variations in failure to rescue (FTR) contribute to socioeconomic disparities in mortality after major cancer surgery., Design, Setting, and Participants: We performed a retrospective cohort study using the Medicare Provider Analysis and Review File and the Medicare Denominator File. A summary measure of SES was created for each zip code using 2000 US Census data linked to residence. Multivariable logistic regression was used to examine the influence of SES on rates of FTR, and fixed-effects hierarchical regression was used to evaluate the extent to which disparities could be attributed to differences among hospitals. A total of 596,222 patients undergoing esophagectomy, pancreatectomy, partial or total gastrectomy, colectomy, lung resection, and cystectomy for cancer from 2003 through 2007 were studied., Main Outcomes and Measures: Operative mortality, postoperative complications, and FTR (case fatality after ≥1 major complication)., Results: Patients in the lowest quintile of SES had mildly increased rates of complications (25.6% in the lowest quintile vs 23.8% in the highest quintile, P = .003), a larger increase in mortality (10.2% vs 7.7%, P = .0009), and the greatest increase in rates of FTR (26.7% vs 23.2%, P = .007). Analysis of hospitals revealed a higher FTR rate for all patients (regardless of SES) at centers treating the largest proportion of patients with low SES. The adjusted odds ratios (95% CIs) of FTR according to SES ranged from 1.04 (0.95-1.14) for gastrectomy to 1.45 (1.21-1.73) for pancreatectomy. Additional adjustment for hospital effect nearly eliminated the disparity observed in FTR across levels of SES., Conclusions and Relevance: Patients in the lowest quintile of SES have significantly increased rates of FTR. This finding appears to be in part a function of the hospital where patients with low SES are treated. Future efforts to improve socioeconomic disparities should concentrate on hospital processes and characteristics that contribute to successful rescue.

Objective: To review the literature evaluating the effect of practice guidelines and decision aids on use of surgery and regional variation., Background: The use of surgical procedures varies widely across geographic regions. Although practice guidelines and decision aids have been promoted for reducing variation, their true effectiveness is uncertain., Methods: Studies evaluating the influence of clinical practice guidelines or consensus statements, shared decision making and decision aids, or provider feedback of comparative utilization, on rates of surgical procedures were identified through literature searches of Ovid MEDLINE, EMBASE, and Web of Science., Results: A total of 1946 studies were identified and 27 were included in the final review. Of the 12 studies evaluating implementation of guidelines, 6 reported a significant effect. Those examining overall population-based rates had mixed effects, but all studies evaluating procedure choice described at least a small increase in use of recommended therapy. Three of 5 studies examining the effect of guidelines on regional variation reported a significant reduction after dissemination. Of the 15 studies examining decision aids, 5 revealed significant effects. Many studies of decision aids reported decreases in population-based procedure rates. Nearly all studies evaluating the impact of decision aids on procedure choice reported increases in rates of less invasive procedures. Only one study of decision aids assessed changes in regional variation and found mixed results., Conclusions: Both practice guidelines and decision aids have been proven effective in many clinical contexts. Expanding the clinical scope of these tools and eliminating barriers to implementation will be essential to further efforts directed toward reducing regional variation in the use of surgery.

Background: The current economic environment necessitates efforts to prevent avoidable losses in clinical revenue in academic cardiothoracic surgery programs. Inadequate documentation frequently results in delayed, denied, or reduced reimbursement. With the recent increase in integrated residency programs, documentation and compliance are becoming increasingly dependent on junior residents; however, their understanding of reimbursement and documentation guidelines is currently unknown., Methods: An electronically distributed, multi-institutional survey of 6 general and subspecialty surgery programs was conducted consisting of open-ended numeric estimation of Medicare reimbursement for various levels of patient encounters. Closed-ended questions were used to assess resident knowledge of documentation requirements, accompanied by self-estimated compliance with those requirements., Results: Thirty-seven percent (n = 106) of residents completed the survey. Most residents (77%) believe they play the primary role in documentation; however, knowledge of and compliance with higher level documentation practices range from 19% to 78% and 41% to 76%, respectively. On average, residents overestimate Medicare reimbursement of lower level encounters by as much as 77% and underestimate higher level encounters by as much as 38%. In many cases, the standard deviation of residents' estimates approaches the actual reimbursement value., Conclusions: Residents have a limited knowledge of documentation requirements. Self-reported compliance, even when guidelines are known, is low. Estimation of financial reimbursement is extremely variable. Residents overestimate reimbursement of lower level encounters and underappreciate reimbursement at higher levels. Ensuring appropriate reimbursement for services rendered will require formal cardiothoracic resident education and ongoing quality control., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: To meet the Accreditation Council for Graduate Medical Education core competency in Practice-Based Learning and Improvement, educational curricula need to address training in quality improvement (QI). We sought to establish a program to train residents in the principles of QI and to provide practical experiences in developing and implementing improvement projects., Design: We present a novel approach for engaging students, residents, and faculty in QI efforts-Team Action Projects in Surgery (TAPS)., Setting: Large academic medical center and health system., Participants: Multiple teams consisting of undergraduate students, medical students, surgery residents, and surgery faculty were assembled and QI projects developed. Using "managing to learn" Lean principles, these multilevel groups approached each project with robust data collection, development of an A3, and implementation of QI activities., Results: A total of 5 resident led QI projects were developed during the TAPS pilot phase. These included a living kidney donor enhanced recovery protocol, consult improvement process, venous thromboembolism prophylaxis optimization, Clostridium difficile treatment standardization, and understanding variation in operative duration of laparoscopic cholecystectomy. Qualitative and quantitative assessment showed significant value for both the learner and stakeholders of QI related projects., Conclusion: Through the development of TAPS, we demonstrate a novel approach to addressing the increasing focus on QI within graduate medical education. Efforts to expand this multilevel team based approach would have value for teachers and learners alike., (Copyright © 2014. Published by Elsevier Inc.)

Background: Although resident involvement has been shown to be safe for most procedures, the impact of residents on outcomes after complex laparoscopic procedures is not well understood. We sought to examine the impact of resident involvement on outcomes after bariatric surgery using a population-based clinical registry., Study Design: We analyzed 17,057 patients who underwent a primary laparoscopic gastric bypass in the 35-hospital Michigan Bariatric Surgery Collaborative from July 2006 to August 2012. Resident involvement was characterized at the surgeon level. Using hierarchical logistic regression, we examined the influence of resident involvement on 30-day complications, accounting for patient characteristics as well as hospital and surgeon case volume. To evaluate potential mediating factors for specific complications, we also adjusted for operative duration., Results: Risk-adjusted 30-day complication rates with and without residents were 13.0% and 8.5%, respectively (p < 0.01). Resident involvement was independently associated with wound infection (odds ratio [OR] = 2.06; 95% CI, 1.24-3.43) and venous thromboembolism (OR = 2.01; 95% CI, 1.19-3.40), but not with any other medical or surgical complications. Operative duration was longer with resident involvement (median duration with residents 129 minutes vs 88 minutes without; p < 0.01). After adjusting for operative duration, resident involvement was still independently associated with wound infection (OR = 1.67; 95% CI, 1.01-2.76), but not venous thromboembolism (OR = 1.73; 95% CI, 0.99-3.04)., Conclusions: Resident involvement in laparoscopic gastric bypass is independently associated with wound infections and venous thromboembolism. The effect appears to be mediated in part by longer operative times. These findings highlight the importance of strategies to assess and improve resident technical proficiency outside the operating room., (Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The reasons why some patients with benign esophageal diseases require esophagectomy remain poorly understood. In this study we sought to define the rate of progression to esophagectomy and the postesophagectomy outcomes of patients with benign esophageal conditions in whom 1 or more previous interventions failed., Study Design: Using a prospective database, we retrospectively identified patients who had esophagectomies for benign disease between 1978 and 2010. Patients who underwent 1 or more esophageal interventions before resection met inclusion criteria. We examined factors associated with progression to esophagectomy and with postesophagectomy complications., Results: One hundred eleven patients underwent 1 or more esophageal interventions before esophagectomy. The most common indications for initial intervention were achalasia (37%, n = 41) and gastroesophageal reflux (33%, n = 37). More rapid progression to esophagectomy was associated with acquired esophageal disease (p < 0.01), initial esophageal intervention at age ≥ 18 (p < 0.01), and previous fundoplication (p = 0.03). Complications of esophagectomy included 30-day mortality (n = 2, 1%), chylothorax (n = 4, 3%), anastomotic leak (n = 17, 11%), and reoperation (n = 17, 11%)., Conclusions: These findings highlight the importance of increased awareness of the potential progression to esophagectomy during repeated procedural interventions for benign esophageal disease. A subset of the patients who progress more rapidly, including adult patients and those with acquired disease and/or previous fundoplication, may benefit from counseling about potential esophagectomy., (Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

The use of common surgical procedures varies widely across regions. Differences in illness burden, diagnostic practices, and patient attitudes about medical intervention explain only a small degree of regional variation in surgery rates. Evidence suggests that surgical variation results mainly from differences in physician beliefs about the indications for surgery, and the extent to which patient preferences are incorporated into treatment decisions. These two components of clinical decision making help to explain the so-called surgical signatures of specific procedures, and why some consistently vary more than others. Variation in clinical decision making is, in turn, affected by broad environmental factors, including technology diffusion, supply of specialists, local training frameworks, financial incentives, and regulatory factors, which vary across countries. Better scientific evidence about the comparative effectiveness of surgical and non-surgical interventions could help to mitigate regional variation, but broader dissemination of shared decision aids will be essential to reduce variation in preference-sensitive disorders., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Purpose: Significant concerns exist regarding the content and reliability of oncology clinical practice guidelines (CPGs). The Institute of Medicine (IOM) report "Clinical Practice Guidelines We Can Trust" established standards for developing trustworthy CPGs. By using these standards as a benchmark, we sought to evaluate recent oncology guidelines., Methods: CPGs and consensus statements addressing the screening, evaluation, or management of the four leading causes of cancer-related mortality in the United States (lung, breast, prostate, and colorectal cancers) published between January 2005 and December 2010 were identified. A standardized scoring system based on the eight IOM standards was used to critically evaluate the methodology, content, and disclosure policies of CPGs. All CPGs were given two scores; points were awarded for eight standards and 20 subcriteria., Results: No CPG fully met all the IOM standards. The average overall scores were 2.75 of 8 possible standards and 8.24 of 20 possible subcriteria. Less than half the CPGs were based on a systematic review. Only half the CPG panels addressed conflicts of interest. Most did not comply with standards for inclusion of patient and public involvement in the development or review process, nor did they specify their process for updating. CPGs were most consistent with IOM standards for transparency, articulation of recommendations, and use of external review., Conclusion: The vast majority of oncology CPGs fail to meet the IOM standards for trustworthy guidelines. On the basis of these results, there is still much to be done to make guidelines as methodologically sound and evidence-based as possible., Competing Interests: Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.

Bronchogastric conduit fistula is a rare and potentially fatal complication after esophagectomy for esophageal cancer. We report a case of a patient transferred to our institution with a complex bronchogastric conduit fistula after a thoracoscopic three-hole esophagectomy for midesophageal squamous cell carcinoma. The defect involved the entire membranous airway of the bronchus intermedius, with a 15-cm dehiscence of the gastric conduit staple line. This was successfully reconstructed with a single-stage repair by use of an Alloderm patch reinforced with an intercostal muscle flap. At postoperative follow-up the patient is doing well and tolerating a regular diet without dysphagia., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Open primary transthoracic repair is a well established treatment for large paraesophageal hernias. The rate of major post-operative complications has been reported to be low, and no cases of acute diaphragmatic injury have previously been reported. Here we present a case of open primary transthoracic repair of a type IV paraesophageal hernia that was complicated by rupture of the left diaphragm in the immediate post-operative period, and was successfully repaired with Gore DualMesh® (W.L Gore and Assoc. Flagstaff, AZ)., (© JSCR.)