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Annals of Surgery Journal Club
Interactive resource for surgery residents and surgeons to discuss and critically evaluate articles published in Annals of Surgery selected by a monthly guest expert who will review an article each month, offer questions and respond to reader's comments.
Saturday, September 06, 2014
Moderator: Gregory D. Kennedy, MD, PhD
Featured Article: Patients’ Perspectives of Care and Surgical Outcomes in Michigan: An analysis using the CAHPS hospital survey. Sheetz, Kyle H.; Waits Seth A.; Girotti, Micah E.; Campbell, Darrell A.; Englesbe, Michael J.  Ann Surg. 2014; 260 (1): 5-9.

In 2001 the Institute of Medicine published their seminal work entitled, “Crossing the quality chasm: a new health system for the 21st century.”(1)  In this report, the authors called for a new agenda that if followed would improve the quality of health care in the United States.  Specifically, they argued that health care should be safe, effective, efficient, timely, equitable and patient centered. 

            The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey was developed by the Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ).  The HCAHPS survey is the first standardized survey of patient satisfaction that allows for comparisons of hospitals across the nation.  The goals for the development of the HCAHPS survey were to motivate hospitals to improve the quality of patient centered care provided and to publicly provide hospital scores.  Publicly reported HCAHPS scores are easily accessible for consumers and are easy to interpret.  While patients are somewhat limited in where they can receive care due to insurance providers and costs, when able patients tend to choose providers and hospitals with higher ratings including satisfaction scores on the HCAHPS survey.(2, 3) 

In addition to patient choice driving improvement on surveys, legislation is increasingly linking reimbursement to performance on the HCAHPS survey.  In 2005, the enactment of the Deficit Reduction Act motivated hospitals to publicly report HCAHPS results by requiring hospitals participating in the Inpatient Prospective Payment System (IPPS) to collect and submit HCAHPS data in order to receive full payment. The recent enactment of the Patient Protection and Affordable Care Act in 2010 includes HCAHPS measures in the Value Based Purchasing (VBP) program.  This VBP program ties the payment of IPPS hospitals to clinical processes of care and patient experience.  Performance on HCAHPS surveys are used to determine the patient experience domain of VBP.  HCAHPS scores encompass 30% of VBP performance, which will account for 2% of Medicare reimbursement by 2017.(4)  With these monetary motivations, most health care systems have put emphasis on patient satisfaction surveys.  While delivery of patient centered care is an important part of the goals of improving health care delivery, health care systems cannot lose sight of delivering safe and effective care.  Much work is now focused on determining if performance on these satisfaction surveys correlates with the delivery of safe and effective care.

The article by Sheetz and others utilized the Michigan Surgical Quality Collaborative (MSQC) data to characterize the relationship between HCAHPS performance and risk-adjusted outcomes after surgery.(5)  The MSQC is an association of hospitals in the state of Michigan which has a long history of improving the quality of general and vascular surgical care delivered.  This program is supported by the American College of Surgeons Nation Surgical Quality Improvement Project.  In this study, they used risk-adjusted postoperative outcomes data from the MSQC database combined with HCAHPS data obtained from the Centers for Medicare and Medicaid Services (CMS) that can be downloaded from the Hospital Compare website.(6)

In this study, the authors analyzed data from 32 hospitals including outcomes for over 41,000 patients.  The hospitals were stratified into quintiles of HCAHPS total performance score and outcomes were compared between quintiles.  The authors found a difference in demographics in hospitals with the lowest HCAHPS total performance score (TPS) compared to those with the highest TPS.  For example, patients treated at the hospitals with the highest HCAHPS TPS tended to be older (median age of 75 v 71) and to be listed as part of the white race (15% v 31% nonwhite race) when compared to the hospitals of the lowest quintile.  Interestingly, while the authors found differences between the quintiles in patient comorbidities, the differences appear to be more random and there does not appear to be a difference between the hospitals in the lowest and highest quintiles.

The authors also found a random association between high performance on the HCAHPS survey and measures of patient safety.  They found no significant differences between rates of mortality between low and high HCAHPS performers.  Furthermore, they found no difference in improvement of safety measures over time when stratified by HCAHPS performance.  In other words, hospitals in the lower quintiles of HCAHPS TPS were as likely to improve their surgical outcomes as those hospitals with high performance on the HCAHPS TPS.

The authors conclude that patients’ perspectives of care do not correlate with the incidence of morbidity and mortality after major inpatient surgery.  Because of this lack of correlation, the authors question the use of HCAHPS scores to inform patient decision making and incentivize quality improvement.


1.            Institute of Medicine (U.S.). Committee on Quality of Health Care in America. Crossing the quality chasm : a new health system for the 21st century. Washington, D.C.: National Academy Press; 2001.

2.            Faber M, Bosch M, Wollersheim H, Leatherman S, Grol R. Public reporting in health care: how do consumers use quality-of-care information? A systematic review. Med Care. 2009;47(1):1-8.

3.            Kolstad JT, Chernew ME. Quality and consumer decision making in the market for health insurance and health care services. Med Care Res Rev. 2009;66(1 Suppl):28S-52S.

4.            HCAHPS Fact Sheet.

5.            Sheetz KH, Waits SA, Girotti ME, Campbell DA, Jr., Englesbe MJ. Patients' Perspectives of Care and Surgical Outcomes in Michigan: An Analysis Using the CAHPS Hospital Survey. Ann Surg. 2014;260(1):5-9.

6.            Hospital Compare.


1.       Given the lack of association between patient satisfaction and complications, why should patient satisfaction surveys be used as a measure of quality?

2.       Others have found associations between hospital volume and patient satisfaction.  Why might these associations exist and what is one potential explanation for why Sheetz did not find this association?

3.       What is the demographic variable that is most frequently associated with high patient satisfaction scores, which was also confirmed by Sheetz?  Why might this variable be associated with giving high satisfaction scores?

Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.

Wednesday, August 06, 2014
Moderator: Grant V. Bochicchio, MD

This study was a retrospective database review of  2447 non-diabetic postoperative colorectal surgical patients in which 16,407 glucose measurements were obtained over a 2 year period.  Nondiabetic patients were identified as those without a preoperative diagnosis of diabetes and/or based on HbA1C levels. The association between any elevated postoperative random glucose value (hyperglycemia: >125 mg/dL) and level of elevation (>125 mg/dL or >200 mg/dL) within 72 hours of surgery and 30-day mortality and infectious and noninfectious complications was assessed.   Significant associations were found between postoperative hyperglycemia

and the length of operation, extent of blood loss, and transfusion requirements. Hyperglycemia (mild or severe) was associated with increased rates of infectious complications (superficial

and deep SSI, urinary tract infections), sepsis, acute renal failure, reintubation and a greater LOS. The risk for complications increased with an increasing level of postoperative glycemia. Reoperations were twice as frequent for patients with severe hyperglycemia

when compared with those with normoglycemia (7.3% vs 3.1%, P = 0.006). Although rare, postoperative mortality was significantly associated with postoperative glycemia, with only 1 (0.12%) patient with normoglycemia having died during the first 30 postoperative days as

compared with 4 (1.2%) of the patients who had 1 or more values of severe postoperative hyperglycemia.



1.       Hyperglycemia in this article was defined as a glucose level greater than 125 mg/dl

a.   During the entire postoperative stay

b.   Within 24 hours of surgery

c.   Within the first 48 hours post surgery

d.   Level obtained prior to infection.


2.      True OR False


Steroid use was associated with a greater risk of reoperation and length of stay in these non-diabetic colorectal surgical patients.


3.      True or False


A single postoperative episode of elevated glucose in this study was associated with a greater risk of morbidity and mortality.


4.       Tight glycemic control

a.   Was associated with a decrease in surgical site infections

b.   Decreased mortality

c.    a & b

d.    None of the above


Answers to these questions can be found in "From the Editorial Office".


Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.







Wednesday, July 02, 2014
Moderator: Jean-Nicolas Vauthey, MD

Featured Article: Phase II Trial of Hepatic Artery Infusional and Systemic Chemotherapy for Patients With Unresectable Hepatic Metastases From Colorectal Cancer: Conversion to Resection and Long-term Outcomes. D’angelica MI, Correa-Gallego C, Paty PB, et al. Ann Surg. 2014 Mar 21. [Epub ahead of print]



The rate of conversion of unresectable colorectal liver metastases (CRLM) to resectable CRLM has improved with modern systemic chemotherapy and biologic therapy. Results of recent studies, including randomized trials, report conversion rates of 20-38%. The combination of hepatic artery infusional (HAI) chemotherapy with systemic chemotherapy has become an attractive option for the treatment of unresectable CRLM owing to the high response rates observed in previous published studies.

This prospective phase II trial aimed to evaluate, as a primary endpoint, the conversion rate to complete resection (resectability rate) in patients with unresectable CRLM treated with HAI fluorodeoxyuridine (FUDR) in combination with systemic chemotherapy including bevacizumab.

Technical and biological criteria were used to define unresectability. Technically unresectable CRLM were those that required resection of 3 hepatic veins, both portal veins, or the retrohepatic vena cava to achieve a negative margin, or those requiring a resection that would leave fewer than 2 adequately perfused and drained segments. Biologically unresectable CRLM were those that included >6 metastases in one lobe, including 1 metastasis ≥5 cm, or those with ≥6 bilobar metastases.

Forty-nine patients with liver-only disease were treated with HAI FUDR in combination with irinotecan and fluorouracil or irinotecan and oxaliplatin with bevacizumab. Sixty-five percent had previously received systemic therapy. The rate of overall grade 3 or 4 toxicity was 41%. After the first 24 patients were enrolled, bevacizumab was removed from the treatment owing to high biliary toxicity (13%; 3 patients required biliary stent placement), and the authors do not recommend the use of the combination of HAI FUDR and bevacizumab. The overall response rate, according to World Health Organization criteria, was 76%; the response rate was 82% in chemotherapy-naïve patients and 72% in previously treated patients. Such response rates led to a resectability rate of 47% (23 patients) at a median period of 6 months from treatment initiation. Resections included a combination of anatomic (17 patients) and non-anatomic multiple resections (6 patients). Radiofrequency ablation was used in 16 patients, and 5 of the 23 patients (22%) had positive margins. Fifteen of the 23 specimens showed a significant pathologic response to chemotherapy (more than 75%), including 3 complete pathologic responses. The median overall survival duration for all patients was 38 months and the median progression-free survival duration was 13 months. As expected, resectability rate was the only factor associated with prolonged overall survival in a multivariate analysis. The 3-year overall survival rate in patients undergoing resection was 80% (compared with 26% in patients who did not undergo resection). After a median follow-up period of 38 months, 20% of patients were disease-free.

The authors conclude that HAI chemotherapy has a potential role in the treatment of unresectable CRLM. How this approach compares with aggressive combination chemotherapy and biologic therapy remains to be studied.



Ychou M, Rivoire M, Thezenas S, Quenet F, Delpero JR, Rebischung C, Letoublon C, Guimbaud R, Francois E, Ducreux M, Desseigne F, Fabre JM, Assenat E. A randomized phase II trial of three intensified chemotherapy regimens in first-line treatment of colorectal cancer patients with initially unresectable or not optimally resectable liver metastases: the METHEP trial. Ann Surg Oncol. 2013;20(13):4289-97.


Goéré D, Deshaies I, de Baere T, Boige V, Malka D, Dumont F, Dromain C, Ducreux M, Elias D.

Prolonged survival of initially unresectable hepatic colorectal cancer patients treated with hepatic arterial infusion of oxaliplatin followed by radical surgery of metastases. Ann Surg. 2010;251(4):686-91.


Hemming AW, Mekeel KL, Zendejas I, Kim RD, Sicklick JK, Reed AI. Resection of the liver and inferior vena cava for hepatic malignancy. J Am Coll Surg. 2013;217(1):115-24.


Brouquet A, Abdalla EK, Kopetz S, Garrett CR, Overman MJ, Eng C, Andreou A, Loyer EM, Madoff DC, Curley SA, Vauthey JN. High survival rate after two-stage resection of advanced colorectal liver metastases: response-based selection and complete resection define outcome. J Clin Oncol. 2011;29(8):1083-90.



1) Usually the future liver remnant is the main factor considered in the definition of unresectability, but in this study, the authors define unresectability as involvement of all 3 hepatic veins or the inferior vena cava. This definition is different from the definition of unresectability used by the Americas Hepato-Pancreato-Biliary Association. That definition specifies complete R0 resection of intrahepatic and extrahepatic disease with preservation of at least 2 adjacent liver segments with adequate vascular inflow and outflow, as well as biliary drainage and an adequate volume of liver (i.e., the future liver remnant) after resection (which usually means at least 20% of the total estimated volume of the liver for normal parenchyma, or 30-60% if the liver is injured by chemotherapy, steatosis, or hepatitis). Should the definition of resectability be limited to anatomical considerations such as those including vascular involvement, as reported by the authors, or should it include functional considerations?


2) The inferior vena cava is rarely invaded in colorectal liver metastases and usually is not a site of local recurrence. Moreover, definite vascular involvement or attachment of the hepatic veins is rarely reversed by conversion therapy. What is your opinion about alternative technical approaches for unresectable disease (e.g., 2-stage resection with portal vein embolization, vascular reconstruction of the inferior vena cava or hepatic veins, radiofrequency ablation)? The authors also define biological unresectability as >6 metastases in a single lobe with 1 metastasis ≥5 cm or ≥6 bilobar metastases. Do you use number, size, or bilobar versus unilobar as appropriate criteria to define biological unresectability? Should response to therapy be used as a biological criterion for resectability? Should mutational status of the tumor (RAS) be considered?


3) Sixty-five percent of patients received the treatment as second-line therapy after first-line therapy failed. Recent studies indicate adequate safety ratings and a resectability rate of up to 67% with aggressive combined systemic chemotherapy (METHEP trial) in well-defined unresectable CRLM. With the data from recent trials, would you consider more aggressive systemic chemotherapy with the combination of oxaliplatin and irinotecan with or without biologic therapy as an initial approach for all patient s rather than the implantation of a pump?


4) HAI chemotherapy with a pump requires a surgical procedure associated with technical complications (a 14% complication rate was reported in the current study), FUDR is not widely available as a pharmacologic agent, and refill and maintenance of the pump requires special expertise. Other centers have reported success with arterial infusion therapy with oxaliplatin, including high resectability rates. Should arterial infusion therapy with oxaliplatin be preferred to HAI FUDR with a pump?



Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.

Monday, June 16, 2014
Moderator: Carlos Fernández-del Castillo, MD
Featured Article: A Randomized Prospective Multicenter Trial of Pancreaticoduodenectomy With and Without Routine Intraperitoneal Drainage"

 Annals of Surgery volume 259, pages 605-612 , April 2014.


This is a randomized trial comparing outcomes of patients undergoing pancreatoduodenectomy(PD) with and without intraperitoneal drain placement. Surgeons from 9 academic hospitals (all considered “high-volume pancreatic centers” because they perform around 50 PD/year) agreed to offer participation into the trial to all their patients undergoing PD or distal pancreatectomy. 282 patients were randomized over a 15-month period, of which 226 were resected. 137 of these underwent PD and are the cohort described in the study.  68 patients were randomized to the “drain arm”, and had one or two closed-suction drains left intraperitoneally at the conclusion of surgery (the number, size and brand were at the discretion of the surgeon), and 69 patients had no drains left. In the group with drains, they were removed once the output was 20 ml/day for 2 consecutive days and/or the amylase concentration was < 3 x the upper limit of normal serum amylase, which turned out to be sometime between postop day 5 and 13 (median of 7). All complications within 60 days were recorded, and patients were followed up to postop day 90 to assess mortality. The study originally intended to enroll 752 patients in order to detect a 10% difference  (that would be statistically significant) in the rate of grade II or more complications between groups.  However, the study was stopped early by the Data Safety Monitoring Board because of excess mortality in the patients undergoing PD without drains.

As expected in a study with good randomization, the two groups were comparable regarding gender, age (mean 63 y), comorbidities, BMI, pathology  (50% had ductal adenocarcinoma), laparoscopic approach (8%), need for vascular resection (18%), and type of pancreatic anastomosis (the most frequent was an end-to-side, duct-to-mucosa).  Operative time (416 min) and need for blood transfusion (7%) were also similar in both groups. 

 The overall number of complications and the complication severity were significantly higher in patients undergoing PD without drainage. Specifically, delayed gastric emptying  (42% vs 24%), intra-abdominal abscess (25% vs 12%), other intra-abdominal fluid collections (12% vs 2%) and severe diarrhea (17% vs 2%) were significantly higher in the no drain group. 

Although the 90-day mortality was 4 times higher in the no-drain group (12% vs 3%), this was not statistically significant (P = 0.097).  The lack of significance was also true with the reoperation rate, which was 9% in the no-drain group and 3% in the drain arm (P = 0.274).

 The authors concluded that elimination of intraperitoneal drains  after PD increases severity and frequency of complications, and may directly increase mortality, and therefore cautioned against their abandonment.


1)    The “magical” P number for statistical significance is <0.05, yet, the Data Safety Monitoring Board made the decision to stop the trial even though the difference in mortality had a P value of only 0.097.  Why do you think they did do?  It is a lot of work to organize a multi-institutional surgical trial, and one could argue it would have been better to continue the trial until a significant difference in mortality and/or reoperation were found.  Can you define what a P value of <0.05 means?  Are all statistically significant differences “clinically” significant and vice versa?  What is a Data Safety Monitoring Board?  Do all clinical trials have to have one?  The mortality in the drain-group was 3%, and in the no-drain 12%. Assume that the mortality in the no-drain group (which is an acceptable mortality for PD) remained the same, how many consecutive patients without mortality would have to be enrolled in the no-drain arm to level off the mortality?

2)   Discuss what is unique in pancreatic surgery, and in particular after PD, that most surgeons around the world continue to leave intraperitoneal drains, whereas routine drainage has been abandoned in practically all other intra-abdominal operations.  To what were the majority of deaths attributed?  One patient in the no-drain group had a laparoscopic PD, was discharged on POD 10, and returned on POD 24 in shock.  He was found to have hemorrhage from the hepatic artery and died.  Can you give potential explanations for this event?

3)   A previous single-institution randomized trial comparing drains vs no drains in PD had in fact shown worse outcomes when drains were used.  Some surgeons in that institution (about half, according to a recent paper published by them)  and others in different parts of the world don’t use drains after a PD.  Do you think it is likely they will change their practice? Those surgeons seem to have good outcomes without using drains; can you come up with potential reasons to explain why the no-drain group in the current study did not do as well?  Is there anything you would have done differently if you were designing this trial?  Name strengths and pitfalls of a multi-institutional vs a single institution trial.

Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.



Wednesday, May 14, 2014
Moderator: Dr. Henry Pitt
Featured Articles:

1. Gutt CN, Encke J, Koninger J, et al. Acute cholecystitis: early versus delayed  cholecystectomy:  a multicenter randomized trial.  Ann Surg 2013; 258: 385-393.

2. DeMestral C, Rotstein OD, Laupacis A, et al. Comparative operative outcomes of early and delayed cholecystectomy for acute cholecytitis: a population-based propensity score analysis.  Ann Surg 2014; 259; 1-x.


Debate regarding the pros and cons of early versus late cholecystectomy in patients with acute cholecystitis has raged for decades. In the open cholecystectomy era prospective randomized controlled trials (RCT’s) favored early surgery, primarily due to shorter overall length of stay and reduced likelihood of ongoing biliary disease.  Over the past 25 years following the introduction of laparoscopic cholecystectomy, RCT’s again have confirmed essentially the same conclusions.  In the 21st century meta-analyses, population studies, and cost-utility analyses also have favored early surgery.  However, despite the significant weight of these data, considerable variation in practice patterns exist within most countries as well as around the world.                                                                                                                                                                   In the September, 2013 issue of Annals of Surgery Gutt et al1 reported the largest RCT of early versus delayed cholecystectomy for acute cholecystitis.  This multicenter trial from Germany, which was presented at the American Surgical Association, documented that the 75-day morbidity was reduced by three-fold with early surgery (p<0.001). In addition, overall length of stay (LOS) was shortened by 4.6 days (p<0.001) and cost was diminished by one-third.  In the January 2014 issue of Annals of Surgery de Mestra et al2  have added  substantially to the literature by reporting a population-based propensity score analysis of more than 22,000 patients undergoing cholecystectomy for acute cholecystitis in Ontario, Canada from 2004-11.  This report is unique because the authors demonstrated, for the first time, that the risk of major bile duct injury (BDI) and early death are substantially reduced with early surgery.  They also confirmed earlier studies documenting reduced LOS with surgery performed early after presentation.  Taken together these two seminal reports document that patient value (quality/cost) is clearly superior with early surgery for acute cholecystitis.


1. Do these seminal papers apply to patients with severe cholecystitis who present with septic shock and/or organ failure?

2. Should frail, very elderly patients with acute cholecystitis undergo early surgery?

3. Despite overwhelming evidence in the literature, why are many patients with acute cholecystitis not managed with early surgery?

Please feel free to comment on any or all of the questions above. We look forward to hearing from you, the Annals readers. This article can be accessed for free.


About the Author

Gregory D. Kennedy, MD, PhD
Gregory D. Kennedy, MD, PhD is an Associate Professor of Surgery and Vice Chair of Quality in the Department of Surgery at the University of Wisconsin School of Medicine and Public Health in Madison, WI. As a busy colon and rectal surgeon he is passionate about quality improvement and tirelessly works to ensure care of the highest quality is delivered to the patients served by the UW. He serves on many committees charged with reducing health care associated infections and is the surgeon champion of the American College of Surgeons National Surgical Quality Improvement Project for UW Health.

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