Audit of a surgical firm by microcomputer: five years' experience

From 1982 to 1986 inclusive work of one surgical firm was audited with a microcomputer. Data were recorded on 4336 patients having 3355 operations, who were under the care of one consultant in a general surgical unit; fifty items of information were recorded on each patient, allowing a wide range of analyses to be performed—for example, the number of admissions and operations, grades of operation, diagnostic grouping, complications, and complication rates associated with individual surgeons. Data collected for the audit provided a valuable baseline for the unit, defining aspects of practice that could be reviewed and improved. During the audit the overall rate of complications as a percentage of admissions fell significantly from 13% to 9% and the rate of postoperative complications decreased significantly from 16% in 1982 to 11% in 1986. The incidence of chest and wound infections also decreased significantly. The system was improved by using the data to produce discharge summaries as well as audit; the microcomputer thus became an integral part of the office work of the unit.     

Gastric cancer: a curable disease in Britain.

OBJECTIVE--To determine whether more vigorous efforts aimed at earlier diagnosis allied to radical surgical resection lead to improved survival of patients with gastric cancer. DESIGN--Prospective audit of all cases of gastric cancer treated during 1970-89. SETTING--Department of surgery, general hospital. SUBJECTS--493 consecutive patients with gastric adenocarcinoma. MAIN OUTCOME MEASURES--Operative mortality, postoperative morbidity, and five year survival after radical potentially curative resection. RESULTS--207 (42%) patients underwent potentially curative resection. The proportion of all patients in whom this was possible increased significantly (p < 0.01) from 31% in the first five year period to 53% in the last five year period. The proportion of patients who had early gastric cancer rose from 1% to 15% (p < 0.01) and stage I disease rose from 4% to 26% (p < 0.001). After potentially curative resection, mortality 30 days after operation was 6%. Operative mortality decreased from 9% in the 1970s to 5% in the 1980s. Likewise, the incidence of serious postoperative complications decreased from 33% in the 1970s to 17% in the 1980s (p < 0.01). Five year survival was 60% in patients who underwent curative resection, 98% in patients with early gastric cancer, and 93%, 69%, and 28% in stage I, II, and III disease respectively. By the late 1980s five year survival after operation was about 70%. CONCLUSIONS--These findings suggest that an increasing proportion of patients with gastric cancer could be diagnosed at a relatively early pathological stage when about two thirds are curable by means of radical surgery.     

Local treatment in unresectable hepatic metastases of carcinoid tumors: Experiences with hepatic artery embolization and radiofrequency ablation

Background

The study was aimed to identify pre- and intraoperative risk factors that potentially influence morbidity and mortality after esophagectomy for esophageal carcinoma with particular emphasis on the predominant tumor types.

Patients and methods

Between September 1985 and March 2004, 424 patients underwent esophagectomy for esophageal carcinoma. Of these, 186 (43.9%) patients had a transhiatal, and 231 (54.5%) patients underwent a transthoracic procedure with two-field lymphadenectomy. Pre-, intraoperative risk factors and tumor characteristics were included in the risk analysis to assess their influence on postoperative morbidity and mortality.

Results

Multivariate analysis (logistic regression model) identified the surgical procedure as the most important risk factor for postoperative morbidity and mortality with the transthoracic technique associated with a significant higher risk. The comparison of the risk profile between the different histological tumor types, a significantly higher nutritional risk, poorer preoperative lung function and a higher prevalence of hepatopathy was observed in patients with squamous cell carcinoma (n = 229) compared to adenocarcinoma (n = 150) (p < 0.05). Although there was no significant difference in surgical complications between the two groups, the rate of general complications, length of postoperative intensive care unit-stay and mortality rate was significantly higher in patients with squamous cell carcinoma (p < 0.05).

Conclusion

The present risk analysis shows that the selection and the type of the surgical procedure are crucial factors for both the incidence of postoperative complications and the mortality rate. The higher risk of the transthoracic procedure is justified with a view to a better long term prognosis.     

Modified frailty index and hypoalbuminemia as predictors of adverse outcomes in older adults presenting to acute general surgical unit

IntroductionHealth professionals are progressively drawing on the concept of frailty as a determinant of adverse surgical outcomes in of older adults. We aimed to determine the prevalence of frailty and the correlation between frailty and mortality among older adults admitted to the acute surgical unit.Materials and methodsThis prospective cohort study was conducted in the acute general surgical unit over a two month period. We recruited 150 consecutive patients aged 65yrs and above. The modified frailty index was employed to measure frailty and the albumin levels on admission were obtained from electronic medical records. The patients were followed up for a period of thirty days.ResultsWe found that more than 40% of the older adults admitted to the acute general surgical unit were frail and frailty was associated with higher rate of mortality at 30 days. Hypoalbuminemia was associated with a longer length of stay, higher rate of complications, and an increased likelihood of discharge to a rehabilitation facility. There was also a significant univariate correlation between frailty and the presence of hypoalbuminemia on admission.ConclusionFrailty and hypoalbuminemia are common in older general surgical patients and predict the likelihood of some of the adverse outcomes relevant to older adults and health economy such as mortality, increased length of stay, rate of complications, and likelihood of discharge to a rehabilitation facility. Further studies should investigate a possible causal association between frailty and low albumin levels in an acute surgical setting.     

Impact of variability among surgeons on postoperative morbidity and mortality and ultimate survival.

OBJECTIVE--To assess the differences among surgeons in postoperative complications, postoperative mortality, and survival in patients undergoing surgery for colorectal cancer. DESIGN--Prospective study of patients with colorectal cancer managed by one of 13 consultant surgeons, none of whom had a special interest in colorectal surgery. SETTING--Royal Infirmary, Glasgow. PATIENTS--645 sequential patients with colorectal cancer presenting over the six years from 1974 to 1979. MAIN OUTCOME MEASURES--Postoperative complications, postoperative mortality (within 30 days), and survival (up to 10 years); predictive factors for postoperative mortality and survival; and relative hazard rate ratios for individual surgeons. RESULTS--The proportion of patients undergoing apparently curative resection varied among surgeons from 40% to 76%; overall postoperative mortality varied from 8% to 30%. After curative resection postoperative mortality varied from 0% to 20%, local recurrence from 0% to 21%, and the rate of anastomotic leak from 0% to 25%. Survival at 10 years in patients who underwent curative resection varied from 20% to 63%, two year survival in those who underwent palliative resection varied from 7% to 32%, and median survival in those who underwent palliative diversion varied from one to eight months. The hazard rate ratios among individual surgeons, taking into account the identified risk factors, varied from 0.56 to 2.03, from 0.17 to 1.92, and from 0.57 to 1.50 for curative resection, palliative resection, and palliative diversion, respectively. CONCLUSION--There were significant variations in patient outcome among surgeons after surgery for colorectal cancer; such differences compromise survival. A considerable improvement in overall survival might be achieved if such surgery were undertaken by surgeons with a special interest in colorectal surgery or surgical oncology.     

Postoperative adverse outcomes in intellectually disabled surgical patients: a nationwide population-based study

Background

Intellectually disabled patients have various comorbidities, but their risks of adverse surgical outcomes have not been examined. This study assesses pre-existing comorbidities, adjusted risks of postoperative major morbidities and mortality in intellectually disabled surgical patients.

Methods

A nationwide population-based study was conducted in patients who underwent inpatient major surgery in Taiwan between 2004 and 2007. Four controls for each patient were randomly selected from the National Health Insurance Research Database. Preoperative major comorbidities, postoperative major complications and 30-day in-hospital mortality were compared between patients with and without intellectual disability. Use of medical services also was analyzed. Adjusted odds ratios using multivariate logistic regression analyses with 95% confidence intervals were applied to verify intellectual disability''s impact.

Results

Controls were compared with 3983 surgical patients with intellectual disability. Risks for postoperative major complications were increased in patients with intellectual disability, including acute renal failure (odds ratio 3.81, 95% confidence interval 2.28 to 6.37), pneumonia (odds ratio 2.01, 1.61 to 2.49), postoperative bleeding (odds ratio 1.35, 1.09 to 1.68) and septicemia (odds ratio 2.43, 1.85 to 3.21) without significant differences in overall mortality. Disability severity was positively correlated with postoperative septicemia risk. Medical service use was also significantly higher in surgical patients with intellectual disability.

Conclusion

Intellectual disability significantly increases the risk of overall major complications after major surgery. Our findings show a need for integrated and revised protocols for postoperative management to improve care for intellectually disabled surgical patients.     

Improving surgical outcome following the Norwood procedure

Background

The Norwood procedure consists of three palliative operations, performed in neonates with hypoplastic left heart syndrome. Especially the first stage (Norwood I) is associated with the highest mortality rates in paediatric cardiac surgery (up to 25%). During surgery, the aorta is reconstructed and a systemic-to-pulmonary shunt is applied. Originally the modified Blalock-Taussig shunt was used, but recently the right-ventricle-to-pulmonary-artery shunt is increasingly being employed. We reviewed the results of our operative strategy, where an individualised choice of shunt is made. Furthermore, attempts to reduce interstage mortality (between Norwood I and II) were assessed.

Methods

All neonates who underwent Norwood stage I palliation from August 2004 until November 2010 were included in this retrospective analysis. Mortality rates and management strategies were compared.

Results

Thirty-six patients were available for analysis. Overall 30-day mortality was 5.6% (2 patients) and interstage mortality after discharge was 14% (5 patients). In 2006, a novel clinical protocol was introduced, aimed at reduction of mortality during the interstage period. This resulted in reduction of interstage mortality from 23% to 9% (3 of 13 infants, versus 2 of 23), with a cumulative survival of 82% (maximum follow-up 4 years).

Conclusion

Early surgical results following the Norwood procedure using an individualised shunt choice are favourable.     

Emergency geriatric surgical admissions

The emergency surgical work load created by patients aged 80 and over in a district hospital was assessed and the results of treatment examined. Over one year 248 patients aged 80 or over were admitted as emergencies, and the overall mortality rate was 21·8%. When terminal disease was excluded mortality rate was 12·5%. These elderly patients had an average length of stay in the acute surgical ward of 14·7 days compared with a mean of 8·4 days for all patients, and all but seven patients were discharged to their original place of referral.Elderly patients do exacerbate the bed shortage in acute surgical wards because they tend to stay longer than younger patients, but these elderly surgical patients imposed only a small load on the inpatient geriatric services, as 78% were discharged straight to their own homes and a further 17% went home after a period on the surgical convalescent wards.     

Standard abdominal wound edge protection with surgical dressings vs coverage with a sterile circular polyethylene drape for prevention of surgical site infections (BaFO): study protocol for a randomized controlled trial

ABSTRACT: BACKGROUND: Postoperative surgical site infections cause substantial morbidity, prolonged hospitalization, costs and even mortality and remain one of the most frequent surgical complications. Approximately 14% to 30% of all patients undergoing elective open abdominal surgery are affected and methods to reduce surgical site infection rates warrant further investigation and evaluation in randomized controlled trials. METHODS: To investigate whether the application of a circular plastic wound protector reduces the rate of surgical site infections in general and visceral surgical patients that undergo midline or transverse laparotomy by 50%. BaFO is a randomized, controlled, patient-blinded and observer-blinded multicenter clinical trial with two parallel surgical groups. The primary outcome measure will be the rate of surgical site infections within 45 days postoperative assessed according to the definition of the Center for Disease Control. Statistical analysis of the primary endpoint will be based on the intention-to-treat population. The global level of significance is set at 5% (2 sided) and sample size (n = 258 per group) is determined to assure a power of 80% with a planned interim analysis for the primary endpoint after the inclusion of 340 patients. DISCUSSION: The BaFO trial will explore if the rate of surgical site infections can be reduced by a single, simple, inexpensive intervention in patients undergoing open elective abdominal surgery. Its pragmatic design guarantees high external validity and clinical relevance. Trial registration http://www.clinicaltrials.gov NCT01181206. Date of registration: 11 August 2010; date of first patient randomized: 8 September 2010.     

Indications for surgical treatment of abdominal aortic aneurysms]

The results of the surgical treatment of 115 patients with the abdominal aortal aneurysms are presented. Indications to surgery depending on the stage of aneurysm, way of classification, and coexisting cardiological disorders have been discussed. Excellent and favorable results of surgery have been achieved in 70 patients (60.9%). Overall hospital mortality rate was 39.1%. Out of patients who underwent elective surgery 11.6% died, in the group operated urgently--43.3%, and in emergency situation 89.4% of the operated patients died. Percentage of patients with coexisting cardiological disorders amounted to 54%, 62%, and 80% respectively. A strict correlation of the results of surgery and duration of the disease, and consequently classification to the treatment, has been noted. Indications to the elective surgery are related to the size of aneurysm, rate of its enlargement, patient's age, and general health.     

Pulmonary embolism in surgical patients: 1959-79.

The Edinburgh surgical statistics (audit) have been analysed for the years 1959, 1964, 1969, 1974, and 1979 to determine the trends in pulmonary embolism in surgical patients who died. There was a total of 61,038 operations, 1528 postoperative deaths, 804 necropsies, and 158 reported pulmonary emboli. The incidence of embolism diagnosed clinically and at necropsy fell throughout the period. This fall held good after corrections for necropsy rates, prognosis, and proportions of major operations. Although the overall necropsy rate fell from 58% to 40%, in patients expected to have a good prognosis the rate rose from 68% to 75%. Necropsy-proved embolism in "good prognosis" patients fell from 0.5% to 0.15% per 100 major operations. The main reduction has taken place since most surgeons in the area adopted methods of prophylaxis against venous thrombosis, but a direct relationship is not proved by this study.     

E-PASS评分系统用于评估老龄患者消化道手术后并发症和转归的临床价值研究

目的:评价日常活动和手术应激评估(Estimation of physiologic ability and surgical stress,E-PASS)系统用于评估老龄患者消化道手术后并发症和转归的临床价值。方法:回顾性分析2011年7月至2013年7月西京医院消化外科所有65岁以上的患者的临床资料,计算其中行消化道手术者的E-PASS评分,并记录这些患者术后并发症的发生情况和患者术后的住院时间。分析E-PASS评分和几项该评分未涉及的因素与老龄患者消化道手术后并发症的发病率、死亡率、住院时间的相关性。结果:研究共纳入1236例老龄行消化道手术的患者,其中521例发生术后并发症(42.15%),8例死亡(0.65%)。患者术前E-PASS评分系统中,三项评分均与术后住院时间相关,术前风险评分(Preoperative risk score,PRS)和综合风险评分(Comprehensive risk score,CRS)与术后并发症的发病率和死亡率显著相关(P均0.05)。E-PASS评分系统未包含的指标中,麻醉方法与术后并发症发生和住院时间无关,术后入ICU、术中使用血管活性药物和急诊手术与术后发病率、死亡率和住院时间相关(P均0.05)。结论:E-PASS评分系统可用于预测老龄患者行消化道手术后并发症的发生情况和转归,纳入术后入ICU、术中使用血管活性药物和急诊手术三项指标可能进一步提高E-PASS评分系统的预测准确性。     

Selection of operation in patients with bleeding esophageal varices.

The results of surgical treatment of bleeding esophageal varices over an 8-year period in 155 patients are reviewed. Primary treatment of bleeding was conservative, with intravenous administration of vasopressin and balloon tamponade. Emergency operations were carried out after 48 hours in persons with persistent bleeding who were surgical candidates. Operative mortality was higher in this group (40%) than in those undergoing elective or urgent operations (each 10%). Postoperative encephalopathy occurred in 35% of patients and was correlated closely to late death after establishment of a shunt. The mesocaval shunt is no better than the portacaval but appears to be a good alternative in an emergency. In a controlled trial the distal splenorenal shunt was found to be associated with a lower rate of postoperative encephalopathy than the portacaval shunt, but thus far the long-term survival rates have not differed.     

Adverse Outcomes after Major Surgery in Patients with Pressure Ulcer: A Nationwide Population-Based Retrospective Cohort Study

BackgroundPostoperative adverse outcomes in patients with pressure ulcer are not completely understood. This study evaluated the association between preoperative pressure ulcer and adverse events after major surgeries.MethodsUsing reimbursement claims from Taiwan’s National Health Insurance Research Database, we conducted a nationwide retrospective cohort study of 17391 patients with preoperative pressure ulcer receiving major surgery in 2008-2010. With a propensity score matching procedure, 17391 surgical patients without pressure ulcer were selected for comparison. Eight major surgical postoperative complications and 30-day postoperative mortality were evaluated among patients with pressure ulcer of varying severity.ResultsPatients with preoperative pressure ulcer had significantly higher risk than controls for postoperative adverse outcomes, including septicemia, pneumonia, stroke, urinary tract infection, and acute renal failure. Surgical patients with pressure ulcer had approximately 1.83-fold risk (95% confidence interval 1.54-2.18) of 30-day postoperative mortality compared with control group. The most significant postoperative mortality was found in those with serious pressure ulcer, such as pressure ulcer with local infection, cellulitis, wound or treatment by change dressing, hospitalized care, debridement or antibiotics. Prolonged hospital or intensive care unit stay and increased medical expenditures were also associated with preoperative pressure ulcer.ConclusionThis nationwide propensity score-matched retrospective cohort study showed increased postoperative complications and mortality in patients with preoperative pressure ulcer. Our findings suggest the urgency of preventing and managing preoperative pressure ulcer by a multidisciplinary medical team for this specific population.     

The Roles of Albumin Levels in Head and Neck Cancer Patients with Liver Cirrhosis Undergoing Tumor Ablation and Microsurgical Free Tissue Transfer

Objective

To evaluate the changes of serum albumin levels during the peri-operative period, and correlate these changes to surgical outcomes, postoperative morbidity and mortality in head and neck cancer patients with cirrhosis.

Methods

57 patients with liver cirrhosis out of 3,022 patients who underwent immediate free flap reconstruction after surgical ablation of head and neck cancer performed over a 9-year period were included in the study. Two sets of groups were arranged based on the preoperative albumin (>3.5 g/dL vs. ≤ 3.5 g/dL) and POD1 albumin (>2.7 g/dL vs. ≤ 2.7 g/dL) levels and were compared with respect to patient-related variables, surgical outcomes, medical and surgical complications, and mortalities.

Results

All patients had significant decreases in albumin levels postoperatively. Hypoalbuminemia, both preoperative and postoperative, was associated with the model for end-stage liver disease (MELD) score, the amount of blood loss, the duration of ICU stay and hospital stay, and postoperative medical and surgical complications. In particular, preoperative hypoalbuminemia (serum albumin ≤ 3.5 g/dL) was associated strongly with medical complications and mortality, while postoperative hypoalbuminemia (serum albumin ≤ 2.7 g/dL) with surgical complications.

Conclusion

Our study demonstrated the prognostic values of albumin levels in head and neck cancer patient with liver cirrhosis. The perioperative albumin levels can be utilized for risk stratification to potentially improve surgical and postoperative management of these challenging patients.     

Comparison of the results of surgical and non-surgical treatment of combat urogenital injuries in Bosnia war 1992-1995

Goal was to compare the results of surgical and non-surgical treatments of combat injuries of genitourinary system and to compare our data with data collected in the recent studies. The study was designed as a retrospective review of data collected in prospective databases. The data extracted from inpatients' medical records included demographics, mechanisms and type of injury, distribution of the lesions, clinical presentation features, applied diagnostic studies, treatment modalities, types of complication and results of treatment. Among 4.125 patients treated in the Mostar War Hospital, 111 had injury of genitourinary tract: 62 underwent a surgical and 49 non-surgical treatment. Mortality among operated patients was 16 (26%). Complications were noted in 47 patients (42%); in 33 (70%) were manifested as early complications, and 14 (30) as delayed ones (p = 0.006). Among the surgically treated patients, 40 (36%) had some complication, in comparison to 8 (7.2%) patients with complications among non-surgically treated patients; which represent a statistically significant difference (p < 0.05). In this study, there was a surprisingly high number of non-surgically treated patients, and this sub-group of UGT trauma patients had in some ways the superior treatment results in comparison with surgically treated patients. Conservatively treated patients had lower rate of complications, no mortality, and no patients with permanent disability.     

Endocystectomy as a conservative surgical treatment for hepatic cystic echinococcosis: A systematic review with single-arm meta-analysis

BackgroundIn patients with hepatic cystic echinococcosis (CE), treatment effectiveness, outcomes, complications, and recurrence rate are controversial. Endocystectomy is a conservative surgical approach that adequately removes cyst contents without loss of parenchyma. This conservative procedure has been modified in several ways to prevent complications and to improve surgical outcomes. This systematic review aimed to evaluate the intraoperative and postoperative complications of endocysectomy for hepatic CE as well as the hepatic CE recurrence rate following endocystectomy.MethodsA systematic search was made for all studies reporting endocystectomy to manage hepatic CE in PubMed, Web of Science, and Cochrane CENTRAL databases. Study quality was assessed using the methodological index for non-randomized studies (MINORS) criteria and the Cochrane revised tool to assess risk of bias in randomized trials (RoB2). The random-effects model was used for meta-analysis and the arscine-transformed proportions were used to determine complication-, mortality-, and recurrence rates. This study is registered with PROSPERO (number CRD42020181732).ResultsOf 3,930 retrieved articles, 54 studies reporting on 4,058 patients were included. Among studies reporting preoperative anthelmintic treatment (31 studies), albendazole was administered in all of them. Complications were reported in 19.4% (95% CI: 15.9–23.2; I² = 84%; p-value <0.001) of the patients; biliary leakage (10.1%; 95% CI: 7.5–13.1; I² = 81%; p-value <0.001) and wound infection (6.6%; 95% CI: 4.6–9; I² = 27%; p-value = 0.17) were the most common complications. The post-endocystectomy mortality rate was 1.2% (95% CI: 0.8–1.8; I² = 21%; p-value = 0.15) and the recurrence rate was 4.8% (95% CI: 3.1–6.8; I² = 87%; p-value <0.001). Thirty-nine studies (88.7%) had a mean follow-up of more than one year after endocystectomy, and only 14 studies (31.8%) had a follow-up of more than five years.ConclusionEndocystectomy is a conservative and feasible surgical approach. Despite previous disencouraging experiences, our results suggest that endocystectomy is associated with low mortality and recurrence.     

Management of Patients With Low-Risk Papillary Thyroid Carcinoma

ObjectiveTo define a rational, cost-effective, simple approach to managing most patients with papillary thyroid cancer (PTC) who are at low-risk of either cause-specific mortality or tumor recurrence.MethodsTaking advantage of the collective experience of a cohort of 2512 patients with PTC who had initial definitive treatment at the Mayo Clinic in Rochester, Minnesota, between 1940 and 2000, a 5-step approach to the management of low-risk PTC has been devised. This program is based on appropriate preoperative ultrasound localization of neck disease and potentially curative surgery consisting of near-total or total thyroidectomy, with appropriate neck nodal exploration and resection.ResultsThe emphasis of the present program is on the extent of initial surgery, where optimal care is ascribed to a near-total thyroidectomy with curative intent and appropriate neck nodal resection as predicated by appropriate preoperative ultrasonography evaluation of regional lymph nodes. Radioiodine remnant ablation (RRA) is not applicable to patients with PTC who are defined on the day of definitive initial surgery to be at low risk as defined by a metastasis, age, completeness of resection, invasion, and size (MACIS) score of less than 6.ConclusionThe outlook for patients with low-risk PTC is very optimistic, with rates at 30 postoperative years of only 1% for cause-specific mortality and less than 15% for tumor recurrence at any site. The long-term results obtained by potentially curative bilateral resection, appropriate regional lymph nodal excision, and selective use of RRA are excellent. Realistically improving these acceptably low rates for cause-specific mortality and tumor recurrence may be difficult. (Endocr Pract. 2007;13:521-533)     

Incidence,Predictive Factors,and Clinical Outcomes of Acute Kidney Injury after Gastric Surgery for Gastric Cancer

Background

Postoperative acute kidney injury (AKI), a serious surgical complication, is common after cardiac surgery; however, reports on AKI after noncardiac surgery are limited. We sought to determine the incidence and predictive factors of AKI after gastric surgery for gastric cancer and its effects on the clinical outcomes.

Methods

We conducted a retrospective study of 4718 patients with normal renal function who underwent partial or total gastrectomy for gastric cancer between June 2002 and December 2011. Postoperative AKI was defined by serum creatinine change, as per the Kidney Disease Improving Global Outcomes guideline.

Results

Of the 4718 patients, 679 (14.4%) developed AKI. Length of hospital stay, intensive care unit admission rates, and in-hospital mortality rate (3.5% versus 0.2%) were significantly higher in patients with AKI than in those without. AKI was also associated with requirement of renal replacement therapy. Multivariate analysis revealed that male gender; hypertension; chronic obstructive pulmonary disease; hypoalbuminemia (<4 g/dl); use of diuretics, vasopressors, and contrast agents; and packed red blood cell transfusion were independent predictors for AKI after gastric surgery. Postoperative AKI and vasopressor use entailed a high risk of 3-month mortality after multiple adjustments.

Conclusions

AKI was common after gastric surgery for gastric cancer and associated with adverse outcomes. We identified several factors associated with postoperative AKI; recognition of these predictive factors may help reduce the incidence of AKI after gastric surgery. Furthermore, postoperative AKI in patients with gastric cancer is an important risk factor for short-term mortality.     

Prospective pricing and DRGs.

In the Congenital Heart Program at San Diego Children''s Hospital, alterations in medical practice have reduced costs without impairing quality or access. Pediatric cardiac catheterization was done in 483 consecutive elective patients without overnight hospital stay. Hospital readmission was required in one patient for psoas tendinitis. Avoiding overnight hospital stay minimized attendant risks of hospital care, lessened psychosocial trauma and reduced the average hospital bill by $493 (29%). Hospital stay was also reduced for elective surgical correction of congenital heart disease on a case-by-case basis. Review of 151 consecutive cases (1978 through 1982) showed a decrease in both preoperative days in hospital and postoperative days in an intensive care unit. The duration of the postoperative stay was shortened from 6.8 days in 1978-1979 to 4.4 days in 1982 (P <.05). No increase in morbidity and no mortality resulted from the shortened perioperative hospital stay. Financial savings from this process averaged $991 per procedure.Diagnostic tests were reassessed and many precatheterization laboratory tests were eliminated. Without change in new patients seen or surgical volume, the use of cardiac catheterization decreased from 241 procedures in 1981 to 161 in 1982 and the number of operations without catheterization increased (11 to 22, 1981 to 1982). No increase in surgical morbidity or mortality was found comparing those diagnosed only by echocardiography with those who had preoperative cardiac catheterization. The decrease of 80 catheterizations in one year resulted in a savings of $188,800.True cost containment (reducing cost without reducing quality) can be accomplished in congenital heart programs. Similar cost containments in other disciplines may also be achieved.