Hospital Operative Volume and Esophagectomy Outcomes in the Veterans Affairs System

INTRODUCTION: Previous studies reported that increased hospital case volume improves outcomes after esophagectomy. Yet, the standard for high and low-volume hospitals varies in the literature. This study attempts to define the relationship between hospital operative volume and 30-day post-operative outcomes of esophagectomy in the Veterans Affairs (VA) system. METHODS: This is a retrospective review of patients that underwent esophagectomy from 2008 to 2019 utilizing the Veterans Affairs Surgical Quality Improvement Program Database. Receiver operating characteristic (ROC) analysis quantified an inflection point of optimal association between 30-day morbidity and mortality by facility volume. This point was used to separate cohorts for comparison of outcomes using 1:1 propensity score matching (PSM) to account for confounding covariates. RESULTS: Two thousand two hundred and twelve esophagectomies were performed from 2008 to 2019 and ROC analysis identified an inflection point at 43 cases (4 cases/y) where bidirectional operative volume significantly affected outcomes. Subsequent PSM resulted in 1718 cases utilized for analysis (n = 859 per cohort). Facility volume ≥4 cases/y was significantly associated with decreased odds of 30-day mortality (odds ratio(OR) = 0.57; P = 0.03), shorter length of stay (median 13 versus 14 d; P = 0.04) and longer operative times (6.5 versus 6.0 h; P \u3c 0.001). CONCLUSIONS: VA hospitals that averaged ≥4 esophagectomies/y had significantly lower rates of mortality and length of stay. This volume threshold may serve as a benchmark to determine the optimal setting for esophageal resection. However, our findings also may reflect the benefits of cumulative operating room and multidisciplinary team experience at VA centers in conjunction with dedicated surgeons. Future studies should focus on long-term outcomes after esophagectomy in relation to hospital operative volume

Uniportal Video-Assisted Thoracoscopic Lung Resection: A Single-Surgeon Experience and Comparison with Multiportal Technique in the Veteran Population

Uniportal video-assisted thoracoscopic surgery (VATS) has been shown to offer improved postoperative outcomes compared with multiportal technique. Shorter operative time has rarely been described. Our objective was to compare operative time and clinical outcomes between uniportal and multiportal VATS approaches for lung resection. This is a retrospective review of patients that underwent video-assisted thoracoscopic lung resection at United States Veterans Affairs centers between 2008 and 2018 using the Veteran Affairs Surgical Quality Improvement Program. Cases were assigned to uniportal (single surgeon) or multiportal cohorts. Multivariable analysis of clinical outcomes was performed, adjusting for preoperative confounding covariates. Temporal trend in operative time in uniportal cohort was analyzed in the context of cumulative operative volume using Spearman\u27s rank correlation coefficient, rho (). In total, 8,212 cases were selected from 2008 to 2018 at Veterans Affairs centers: 176 (2.1%) uniportal and 8036 (97.9%) multiportal cases. Uniportal cohort was significantly associated with shorter operative time (1.7 hours versus 3.1 hours,  \u3c .001), higher adjusted odds of surgical site infection (adjusted odds ratio = 2.76;  = .005), and longer length of stay (6 days versus 5 days;  = .04). Uniportal cohort operative time decreased over time ( = -0.474), with most significant change corresponding with increased cumulative operative volume from 25 to 44 cases. Uniportal technique offered shorter operative duration in veterans compared with multiportal approach, validating its technical advantages. Operative time decreased as cumulative operative volume increased, demonstrating a learning curve. Future studies should prospectively investigate any association between operative time and clinical outcomes after thoracoscopic lung resection

Clinical Outcomes and Technical Approach of Thymectomy in the Veterans Health Administration

BACKGROUND: Thymectomy is traditionally performed through a transsternal incision, but less invasive modalities have emerged, including transcervical, thoracoscopic, and robotic approaches. Despite the advantages of video-assisted thoracoscopic surgery (VATS) over thoracotomy, most thymectomies are performed through sternotomy. This study compared the use and 30-day postoperative outcomes of transsternal, transcervical, and VATS thymectomy in the Veterans Health Administration. METHODS: This was a retrospective review of veterans who underwent thymectomy through the Veterans Affairs Surgical Quality Improvement Program. Their 30-day outcomes were compared among techniques, by adjusting for confounding covariates. Temporal trends were analyzed using the Spearman\u27 rank correlation coefficient, rho(ρ). RESULTS: From 2008 to 2019, 594 thymectomies were performed: 376 (63.3%) transsternal, 113 (19.0%) VATS (including robotic approaches), and 105 (17.7%) transcervical cases. VATS use increased from 0% in 2008 to 61% of case volume in 2019. Relative to the transsternal technique, VATS thymectomy was associated with decreased odds of pulmonary complications (adjusted odds ratio, 0.06; P = .028) and shorter hospital stay (2.9 ± 0.4 days shorter; P \u3c .001). No difference in outcomes was detected between VATS and transcervical thymectomy. The postoperative complication rate decreased from 17.7% in 2008 to 5.6% in 2019 (ρ = -0.101; P = .014). Length of stay decreased from median 4 days in 2008 to 3 days in 2019 (ρ = -0.093; P = .026). In thymic cancer, VATS 5-year overall survival was noninferior to the transsternal approach (71.3% vs 74.6%; P = .54). CONCLUSIONS: The transsternal approach comprised most thymectomy cases in veterans, whereas VATS thymectomy use increased over time and was associated with favorable outcomes. The 30-day outcomes after thymectomy improved over time, which may reflect a trend toward wider use of less invasive approaches. Future studies should examine long-term outcomes

Predictors of 30-Day Pulmonary Complications after Video-Assisted Thoracoscopic Surgery Lobectomy

BACKGROUND: Pulmonary complications are the most common adverse event after lung resection, yet few large-scale studies have examined pertinent risk factors after video-assisted thoracoscopic surgery (VATS) lobectomy. Veterans, older and less healthy compared with nonveterans, represent a cohort that requires further investigation. Our objective is to determine predictors of pulmonary complications after VATS lobectomy in veterans. METHODS: A retrospective review was conducted on patients who underwent VATS lobectomy from 2008 to 2018 using the Veterans Affairs Surgical Quality Improvement Program database. Patients were divided into two cohorts based on development of a pulmonary complication within 30 days. Patient characteristics were compared via multivariable analysis to determine clinical predictors associated with pulmonary complication and reported as adjusted odds ratios (aORs) with 95% confidence intervals. Patients with preoperative pneumonia, ventilator dependence, and emergent cases were excluded. RESULTS: In 4,216 VATS lobectomy cases, 480 (11.3%) cases had ≥1 pulmonary complication. Preoperative factors independently associated with pulmonary complication included chronic obstructive pulmonary disease (COPD) (aOR = 1.37 [1.12-1.69];  = 0.003), hyponatremia (aOR = 1.50 [1.06-2.11];  = 0.021), and dyspnea (aOR = 1.33 [1.06-1.66];  = 0.013). Unhealthy alcohol consumption was associated with pulmonary complication via univariable analysis (17.1 vs. 13.0%;  = 0.016). Cases with pulmonary complication were associated with increased mortality (12.1 vs. 0.8%;  \u3c 0.001) and longer length of stay (12.0 vs. 6.8 days;  \u3c 0.001). CONCLUSION: This analysis revealed several preoperative factors associated with development of pulmonary complications. It is imperative to optimize pulmonary-specific comorbidities such as COPD or dyspnea prior to VATS lobectomy. However, unhealthy alcohol consumption and hyponatremia were linked with development of pulmonary complication in our analysis and should be addressed prior to VATS lobectomy. Future studies should explore long-term consequences of pulmonary complications

Risk factors for cerebrovascular accident after isolated coronary artery bypass grafting in Veterans

BACKGROUND: Cerebrovascular accident (CVA) after coronary artery bypass grafting (CABG) is a devastating complication. Patient comorbidities and intraoperative elements contribute to the risk of CVA. The aim of this study is to identify risk factors for CVA in Veterans undergoing CABG. METHODS: Veterans undergoing isolated CABG from 2008 to 2019 were retrospectively identified using the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database. Thirty-day postoperative outcomes were observed. Univariate analysis followed by multivariable logistic regression identified independent risk factors for postoperative CVA. Receiver operating characteristic diagnostics identified optimal inflection points between continuous risk factors and odds of CVA. RESULTS: Twenty-eight thousand seven hundred fifty-seven patients met inclusion criteria. Incidence of CVA was 1.1% (310 cases). In multivariate analysis, preoperative cerebrovascular disease had the strongest association with postoperative CVA (adjusted odds ratio = 2.29; p \u3c .001). There was an inverse relationship between CVA incidence and ejection fraction (EF), with EF of 35%-39% conferring a 2.11 times higher risk compared to EF \u3e55% (p \u3c .001). CVA incidence was not different in on-pump versus off-pump cases; however, after 104 min or more on bypass patients had a 55% greater adjusted odds of CVA (p \u3c .001). Other risk factors included poor kidney function, prior myocardial infarction, and intra-aortic balloon pump use. CONCLUSION: The risk of CVA after CABG is multifactorial and involves multiple organ systems, including cardiac disease, poor renal function, and cerebrovascular disease, which was the strongest contributing risk factor. Optimization of these comorbidities and time on bypass may help improve clinical outcomes and lower the risk of this devastating complication