Risk-Adjusted Mortality Rates as a Quality Proxy Outperform Volume in Surgical Oncology—A New Perspective on Hospital Centralization Using National Population-Based Data

PURPOSE Despite a long-known association between annual hospital volume and outcome, little progress has been made in shifting high-risk surgery to safer hospitals. This study investigates whether the risk-standardized mortality rate (RSMR) could serve as a stronger proxy for surgical quality than volume. METHODS We included all patients who underwent complex oncologic surgeries in Germany between 2010 and 2018 for any of five major cancer types, splitting the data into training (2010-2015) and validation sets (2016-2018). For each surgical group, we calculated annual volume and RSMR quintiles in the training set and applied these thresholds to the validation set. We studied the overlap between the two systems, modeled a market exit of low-performing hospitals, and compared effectiveness and efficiency of volume- and RSMR-based rankings. We compared travel distance or time that would be required to reallocate patients to the nearest hospital with low-mortality ranking for the specific procedure. RESULTS Between 2016 and 2018, 158,079 patients were treated in 974 hospitals. At least 50% of high-volume hospitals were not ranked in the low-mortality group according to RSMR grouping. In an RSMR centralization model, an average of 32 patients undergoing complex oncologic surgery would need to relocate to a low-mortality hospital to save one life, whereas 47 would need to relocate to a high-volume hospital. Mean difference in travel times between the nearest hospital to the hospital that performed surgery ranged from 10 minutes for colorectal cancer to 24 minutes for pancreatic cancer. Centralization on the basis of RSMR compared with volume would ensure lower median travel times for all cancer types, and these times would be lower than those observed. CONCLUSION RSMR is a promising proxy for measuring surgical quality. It outperforms volume in effectiveness, efficiency, and hospital availability for patients.

Impact of the Surgical Environment on the Incidence, Timing, and Severity of Complications Associated With Oromaxillofacial Oncologic Surgery in Dogs

Numerous reports describe complication rates associated with oromaxillofacial oncologic surgery in dogs, however, investigation regarding the impact of the surgical environment on the incidence of complications is under reported. The objective of this retrospective cohort study, including 226 dogs surgically treated for oromaxillofacial tumors between January 1, 1997 and December 31, 2018, is to evaluate the impact of the surgical environment on the incidence of complications in oromaxillofacial oncologic surgery in dogs. A secondary objective is to report the incidence of local complications in oromaxillofacial oncologic surgery and characterize the type, timing, and severity of complications encountered. Incidence of complications was identified to be 69.9%. No significant association was identified between the incidence, timing, or severity of complications and the training background of the clinician, physical location of the procedure, or the ostectomy instrument used. These results suggest that the surgical environment has little impact on the incidence, timing, and severity of complications in dogs undergoing oromaxillofacial oncologic surgery. The results also emphasize the importance of preparing the surgical team and the client for a high incidence of complications associated with oromaxillofacial oncologic surgery in dogs and indicate that both short-term and long-term follow up is important in these cases. Oromaxillofacial surgery performed by residents-in-training within a veterinary teaching environment with adequate supervision appears to be safe.

Development of an Enhanced Recovery Program in Pediatric, Adolescent, and Young Adult Surgical Oncology Patients

Enhanced recovery after surgery (ERAS) protocols are standardized perioperative treatment plans aimed at improving recovery time in patients following surgery using a multidisciplinary team approach. These protocols have been shown to optimize pain control, improve mobility, and decrease postoperative ileus and other surgical complications, thereby leading to a reduction in length of stay and readmission rates. To date, no ERAS-based protocols have been developed specifically for pediatric patients undergoing oncologic surgery. Our objective is to describe the development of a novel protocol for pediatric, adolescent, and young adult surgical oncology patients. Our protocol includes the following components: preoperative counseling, optimization of nutrition status, minimization of opioids, meticulous titration of fluids, and early mobilization. We describe the planning and implementation challenges and the successes of our protocol. The effectiveness of our program in improving perioperative outcomes in this surgical population could lead to the adaptation of such protocols for similar populations at other centers and would lend support to the use of ERAS in the pediatric population overall.

A Network-Based Approach to Glioma Surgery: Insights from Functional Neurosurgery

The evaluation and manipulation of structural and functional networks, which has been integral to advancing functional neurosurgery, is beginning to transcend classical subspecialty boundaries. Notably, its application in neuro-oncologic surgery has stimulated an exciting paradigm shift from the traditional localizationist approach, which is lacking in nuance and optimization. This manuscript reviews the existing literature and explores how structural and functional connectivity analyses have been leveraged to revolutionize and individualize pre-operative tumor evaluation and surgical planning. We describe how this novel approach may improve cognitive and neurologic preservation after surgery and attenuate tumor spread. Furthermore, we demonstrate how connectivity analysis combined with neuromodulation techniques can be employed to induce post-operative neuroplasticity and personalize neurorehabilitation. While the landscape of functional neuro-oncology is still evolving and requires further study to encourage more widespread adoption, this functional approach can transform the practice of neuro-oncologic surgery and improve the care and outcomes of patients with intra-axial tumors.

Collateral effects of the SARS-CoV-2 pandemic on oncologic surgery in Bavaria

Background The ongoing SARS-COV-2 pandemic has severe implications for people and healthcare systems everywhere. In Germany, worry about the consequences of the pandemic led to the deferral of non-emergency surgeries. Tumor surgery accounts for a large volume in the field of visceral surgery and cannot be considered purely elective. It is not known how the SARS-COV-2 pandemic has changed the surgical volume in tumor patients. Methods Retrospective analysis of the amount of oncological surgeries in three academic visceral surgery departments in Bavaria, Germany, in 2020. Procedures were split into subgroups: Upper Gastrointestinal (Upper GI), Colorectal, Hepato-Pancreato-Biliary (HPB), Peritoneal and Endocrine. Procedures in 2020 were compared to a reference period from January 1st, 2017 to December 31st 2019. Surgical volume was graphically merged with SARS-COV-2 incidence and the number of occupied ICU beds. Results Surgical volume decreased by 7.6% from an average of 924 oncologic surgeries from 2017 to 2019 to 854 in 2020. The decline was temporally associated with the incidence of infections and ICU capacity. Surgical volume did not uniformly increase to pre-pandemic levels in the months following the first pandemic wave with lower SARS-COV-2 incidence and varied according to local incidence levels. The decline was most pronounced in colorectal surgery where procedures declined on average by 26% following the beginning of the pandemic situation. Conclusion The comparison with pre-pandemic years showed a decline in oncologic surgeries in 2020, which could have an impact on lost life years in non-COVID-19 patients. This decline was very different in subgroups which could not be solely explained by the pandemic.

Preparation of Tubular Biocellulose Implants and Its Use in Surgery—A Review

This review highlights the current state regarding the preparation and characterization of tubular biocellulose materials as well as their application and application potential with a special focus on abdominal oncologic surgery. Biocellulose is a natural polymer synthesized by acetic acid bacteria from low molecular sugars and alcohols as a mechanically stable nanofiber network at the interface between the aqueous culture medium and air. This hydrogel is characterized by very high purity and biocompatibility, dimensional stability, and good surgical handling. With this property profile, biocellulose proves to be a promising candidate for the development of novel medical soft tissue implants. This requires close R&D cooperation between chemists, material scientists, biotechnologists, and surgeons. In this sense, this review spans from the natural polymer to the design of biocellulose implants and surgical suitability. It is also a concern of this article to show concretely the great need for such implants and the fields of application in oncological abdominal surgery where tubular biocellulose is or could be the focus of research. Furthermore, a critical assessment for the use of biocellulose materials concerning incidence malignancy and surgical interventions, complication rates, and current studies is emphasized. The regeneration of damaged bile ducts by the use of biocellulose implants is a first example.

Evaluation and Comparison of Functional and Aesthetic Outcomes of McGregor and Stepped Lower Lip-Split Incisions for Extirpation of Primary Tumor in Cases of Squamous Cell Carcinoma of Oral Cavity (SCCOC)

Background: Clear surgical margins are of utmost importance in surgical oncological procedures. Secondary consideration includes the functional and aesthetic outcomes of the patients after the procedure. The recognised surgical approach to the posteriorly located oral cavity and oropharyngeal tumors involves the splitting of the lower lip with or without mandibulectomy. In order to perk up postoperative function and aesthetics, quite a lot of modifications of the unique midline lower lip-splitting incision have been projected by various authors till date. A stepped ladder lower lip split incision (LLSI) helps in improved functional and aesthetic outcomes. Objectives: The prime accent of the study is to compare the McGregor LLSI and the stepped LLSI with respect to functional and aesthetic outcomes in tumors ablation for SCCOC. Methodology: The study population (n=22) is assigned randomly in two equal groups as a subject in the ratio of 1:1. Systemically healthy histologically diagnosed patients of SCCOC requiring LLSI for the tumours ablation will be included. In Group A- McGregor LLSI will be performed and in Group B- a Stepped LLSI would performed. Post-operative assessment of functional and aesthetic outcomes will be done. Expected Results: A stepped ladder LLSI used for tumours ablation will be effective in preserving post-operative lip movement, lip competency and cosmesis. Conclusion: Utility of a Stepped ladder LLSI for accessibility and ablation of posterior oral and oropharyngealtumors would be undoubtfully beneficial for improving post-operative functional and aesthetic outcomes and could be executed in routine oncologic surgery.