Surgical management of primary colonic lymphoma: Big data for a rare problem

Background and ObjectivesPrimary colonic lymphoma (PCL) is rare, heterogeneous, and presents a therapeutic challenge for surgeons. Optimal treatment strategies are difficult to standardize, leading to variation in therapy. Our objective was to describe the patient characteristics, short‐term outcomes, and five‐year survival of patients undergoing nonpalliative surgery for PCL.MethodsWe performed a retrospective cohort analysis in the National Cancer Database. Included patients underwent surgery for PCL between 2004 to 2014. Patients with metastases and palliative operations were excluded. Univariate predictors of overall survival were analyzed using multivariable Cox proportional hazard analysis.ResultsWe identified 2153 patients. Median patient age was 68. Diffuse large B‐cell lymphoma accounted for 57% of tumors. 30‐ and 90‐Day mortality were high (5.6% and 11.1%, respectively). Thirty‐nine percent of patients received adjuvant chemotherapy. For patients surviving 90 days, 5‐year survival was 71.8%. Chemotherapy improved survival (surgery+chemo, 75.4% vs surgery, 68.6%; P = .01). Adjuvant chemotherapy was associated with overall survival after controlling for age, comorbidity, and lymphoma subtype (HR 1.27; 95% CI, 1.07‐1.51; P = .01).ConclusionsPatients undergoing surgery for PCL have high rates of margin positivity and high short‐term mortality. Chemotherapy improves survival, but <50% receive it. These data suggest the opportunity for improvement of care in patients with PCL.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/150597/1/jso25582_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/150597/2/jso25582.pd

WSES Guidelines for the management of acute left sided colonic diverticulitis in the emergency setting

Acute left sided colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in acute setting. A World Society of Emergency Surgery (WSES) Consensus Conference on acute diverticulitis was held during the 3rd World Congress of the WSES in Jerusalem, Israel, on July 7th, 2015. During this consensus conference the guidelines for the management of acute left sided colonic diverticulitis in the emergency setting were presented and discussed. This document represents the executive summary of the final guidelines approved by the consensus conference.Peer reviewe

No association between Helicobacter pylori infection or CagA-bearing strains and glaucoma

Background and Purpose: Accumulating evidence indicates that a variety of infections contribute to the pathogenesis of glaucoma. The role of Helicobacter pylori infection in glaucoma is controversial

Determinants of Value in Coronary Artery Bypass Grafting

Background Over 180 000 coronary artery bypass grafting (CABG) procedures are performed annually, accounting for $7 to$10 billion in episode expenditures. Assessing tradeoffs between spending and quality contributing to value during 90-day episodes has not been conducted but is essential for success in bundled reimbursement models. We, therefore, identified determinants of variability in hospital 90-day episode value for CABG. Methods Medicare and private payor admissions for isolated CABG from 2014 to 2016 were retrospectively linked to clinical registry data for 33 nonfederal hospitals in Michigan. Hospital composite risk-adjusted complication rates (≥1 National Quality Forum-endorsed, Society of Thoracic Surgeons measure: deep sternal wound infection, renal failure, prolonged ventilation \u3e24 hours, stroke, re-exploration, and operative mortality) and 90-day risk-adjusted, price-standardized episode payments were used to categorize hospitals by value by defining the intersection between complications and spending. Results Among 2573 total patients, those at low- versus high-value hospitals had a higher percentage of prolonged length of stay \u3e14 days (9.3% versus 2.4%, P=0.006), prolonged ventilation (17.6% versus 4.8%, P\u3c0.001), and operative mortality (4.8% versus 0.6%, P=0.001). Mean total episode payments were $51 509 at low-compared with$45 526 at high-value hospitals (P\u3c0.001), driven by higher readmission ($3675 versus$2177, P=0.005), professional ($7462 versus$6090, P\u3c0.001), postacute care ($7315 versus$5947, P=0.031), and index hospitalization payments ($33 474 versus$30 800, P\u3c0.001). Among patients not experiencing a complication or 30-day readmission (1923/2573, 74.7%), low-value hospitals had higher inpatient evaluation and management payments ($1405 versus$752, P\u3c0.001) and higher utilization of inpatient rehabilitation (7% versus 2%, P\u3c0.001), but lower utilization of home health (66% versus 73%, P=0.016) and emergency department services (13% versus 17%, P=0.034). Conclusions To succeed in emerging bundled reimbursement programs for CABG, hospitals and physicians should identify strategies to minimize complications while optimizing inpatient evaluation and management spending and use of inpatient rehabilitation, home health, and emergency department services

Transcatheter versus surgical aortic valve replacement episode payments and relationship to case volume

BACKGROUND: Transcatheter aortic valve replacement (TAVR) has increased in volume as an alternative to surgical aortic valve replacement (SAVR). Comparisons of total episode expenditures, although largely ignored thus far, will be key to the value proposition for payers. METHODS: We evaluated 6,359 Blue Cross Blue Shield of Michigan and Medicare fee-for-service beneficiaries undergoing TAVR (17 hospitals, n = 1,655) or SAVR (33 hospitals, n = 4,704) in Michigan between 2012 and 2016. Payments through 90 post-discharge days between TAVR and SAVR were price-standardized and risk-adjusted. Centers were divided into terciles of procedural volume separately for TAVR and SAVR, and payments were compared between lowest and highest terciles. RESULTS: Payments (± SD) were higher for TAVR than SAVR ($69,388 ±$22,259 versus $66,683 ±$27,377, p \u3c 0.001), while mean hospital length of stay was shorter for TAVR (6.2 ± 5.6 versus 10.2 + 7.5 days, p \u3c 0.001). Index hospitalization payments were $4,374 higher for TAVR (p \u3c 0.001), whereas readmission and post-acute care payments were$1,150 (p = 0.001) and $739 (p = 0.004) lower, respectively, and professional payments were similar. For SAVR, high-volume centers had lower episode payments (difference: 5.0$3,255; p = 0.01) and shorter length of stay (10.0 ± 7.5 versus 11.1 ± 7.9 days, p = 0.002) than low volume centers. In contrast, we found no volume-payment relationship among TAVR centers. CONCLUSIONS: Episode payments were higher for TAVR, despite shorter length of stay. Although not a driver for TAVR, center SAVR volume was inversely associated with payments. These data will be increasingly important to address value-based reimbursement in valve replacement surgery