Pediatric and adult trauma centers differ in evaluation, treatment, and outcomes for severely injured adolescents

BACKGROUND/PURPOSE

This study aims to investigate differences in imaging, procedure utilization, and clinical outcomes of severely injured adolescents treated at adult versus pediatric trauma centers.

METHODS

The National Trauma Data Bank was queried retrospectively for adolescents, 15-19years old, with a length of stay (LOS) >1day and Injury Severity Score (ISS) >25 treated at adult (ATC) or pediatric (PTC) Level 1 trauma centers from 2007 to 2011. Patient demographics and utilization of imaging and procedures were analyzed. Univariate and multivariate regression analysis was used to compare outcomes.

RESULTS

Of 12,861 adolescents, 51% were treated at ATC. Older age and more nonwhites were seen at ATC (p<0.01). Imaging and invasive procedures were more common at ATC (p<0.01). Shorter LOS (p=0.03) and higher home discharge rates (p<0.01) were seen at PTC. ISS and mortality did not differ. Age, race, ATC care (all p<0.01), and admission systolic blood pressure (SBP) (p=0.03) were predictors of CT utilization. ISS, SBP, and race (p<0.01) were risk factors for overall mortality; SBP (p=0.03) and ISS (p<0.01) predicted death from penetrating injury.

CONCLUSIONS

Severely injured adolescents experience improved outcomes and decreased imaging and invasive procedures without additional mortality risk when treated at PTC. PTC is an appropriate destination for severely injured adolescents.

Early Recurrence and Omission of Adjuvant Therapy after Pancreaticoduodenectomy Argue against a Surgery-First Approach

BACKGROUND

Sequencing therapy for patients with periampullary malignancy is controversial. Clinical trial data report high rates of adjuvant therapy completion, though contemporary, real-world rates remain incomplete. We sought to identify patients who failed to receive adjuvant therapy and those at risk for early recurrence (ER) who might benefit most from neoadjuvant therapy (NT).

METHODS

We retrospectively reviewed medical records of 201 patients who underwent pancreaticoduodenectomy for periampullary malignancies between 1999 and 2015; patients receiving NT were excluded. Univariate and multivariate analyses were performed to identify predictors of failure to receive adjuvant therapy and ER (within 6 months) as the primary end points.

RESULTS

The median age at the time of surgery was 65.5 years (interquartile range 57-74 years). The majority of tumors were pancreatic ductal adenocarcinoma (76.6 %), and 71.6 % of patients received adjuvant therapy after resection. Univariate predictors of failure to undergo adjuvant therapy were advanced age, age-adjusted Charlson comorbidity index, operative transfusion, reoperation, length of stay, and 30- to 90-day readmissions (all p < 0.05). Advanced age, specifically among patients >70 years, persisted as a significant preoperative predictor on multivariate analysis (p < 0.01). Patients who failed to receive adjuvant therapy and/or developed ER had significantly worse overall survival rates compared to all other patients (27.8 vs. 9.7 months; p < 0.01).

CONCLUSIONS

Approximately one-third of surgery-first patients undergoing pancreaticoduodenectomy at our institution did not receive adjuvant therapy and/or demonstrated ER. This substantial subset of patients may particularly benefit from NT, ensuring completion of multimodal therapy and/or avoiding futile surgical intervention.

The natural history of chronic pancreatitis after operative intervention: The need for revisional operation

BACKGROUND

For patients with chronic pancreatitis, duodenum-sparing head resections and pancreaticoduodenectomy are effective operations to relieve abdominal pain. For patients who develop recurrent symptoms after their index operation, the long-term management remains controversial.

METHODS

Between 2002 and 2014, patients undergoing operative intervention for chronic pancreatitis were identified retrospectively. Patients requiring reoperation after their index operation were reviewed.

RESULTS

A total of 121 patients with chronic pancreatitis underwent an index operation. At a median time of 33 months, 85 patients underwent no further operative intervention, while 36 patients underwent reoperation. A reoperative procedure was completed with acceptable perioperative morbidity and blood loss. After a revision operation, 25% of patients became narcotic independent. Narcotic requirements decreased from 143 morphine equivalent milligrams per day (MEQ/d) to 80 MEQ/d, and 58% of patients required less than 50 MEQ/d. Insulin requirements were not increased from preoperative levels. Multivariate analysis demonstrated only narcotic requirement and exocrine insufficiency after the index operation to be predictive for the need for a revision operation.

CONCLUSION

Our data demonstrate the following: (1) A significant number of patients undergoing duodenum-sparing head resections (26%) or pancreaticoduodenectomy (29%) required reoperation for recurrent abdominal pain; and (2) a revisional operation can be effective in relieving recurrent abdominal symptoms. Patients with recurrent symptoms should be considered for additional operative intervention.

Operative Variability Among Residents Has Increased Since Implementation of the 80-Hour Workweek

BACKGROUND

The ACGME instituted duty hour restrictions in 2003. This presents a challenge for surgical residents who must acquire a medical and technical knowledge base during their training. Although the effect of work hour limitations on operative volume has been examined, no study has examined whether duty hour reform has had an effect on operative volume variability.

STUDY DESIGN

The ACGME operative log data of graduating general surgery residents from 1992 to 2015 were examined. Residents with the most and fewest total major cases were identified and case logs, learning styles, and evaluations were analyzed. Statistical analysis was performed using linear regression analysis, chi-square test, Student's t-test, and Wilcoxon rank sum test. Significance was defined as p < 0.05.

RESULTS

One hundred and thirty-five residents graduated from 1992 to 2015. No change in overall operative volume was seen after the 2003 duty hour reform, however, there was an increase in operative variability. In addition, there was an increase in the variability of total major cases between the resident completing the most and fewest cases per class (183.3; p = 0.02) after the start of work hour restrictions. The residents who graduated with the highest operative volume were more likely to be action-based learners (odds ratio = 6.81; 95% CI, 2.84-16.34; p < 0.001) and received superior evaluation scores.

CONCLUSIONS

After the implementation of the 80-hour workweek, we found a significant increase in operative variability. This might suggest a growing disparity in the operative experience among surgical residents and, consequently, a varying quality of graduating residents. Programs should therefore consider using learning styles and developing competency-based training curricula to ensure equitable training among all trainees.

Aneurysm growth and de novo aneurysms during aneurysm surveillance

OBJECTIVE Many low-risk unruptured intracranial aneurysms (UIAs) are followed for growth with surveillance imaging. Growth of UIAs likely increases the risk of rupture. The incidence and risk factors of UIA growth or de novo aneurysm formation require further research. The authors retrospectively identify risk factors and annual risk for UIA growth or de novo aneurysm formation in an aneurysm surveillance protocol. METHODS Over an 11.5-year period, the authors recommended surveillance imaging to 192 patients with 234 UIAs. The incidence of UIA growth and de novo aneurysm formation was assessed. With logistic regression, risk factors for UIA growth or de novo aneurysm formation and patient compliance with the surveillance protocol was assessed. RESULTS During 621 patient-years of follow-up, the incidence of aneurysm growth or de novo aneurysm formation was 5.0%/patient-year. At the 6-month examination, 5.2% of patients had aneurysm growth and 4.3% of aneurysms had grown. Four de novo aneurysms formed (0.64%/patient-year). Over 793 aneurysm-years of follow-up, the annual risk of aneurysm growth was 3.7%. Only initial aneurysm size predicted aneurysm growth (UIA < 5 mm = 1.6% vs UIA ≥ 5 mm = 8.7%, p = 0.002). Patients with growing UIAs were more likely to also have de novo aneurysms (p = 0.01). Patient compliance with this protocol was 65%, with younger age predictive of better compliance (p = 0.01). CONCLUSIONS Observation of low-risk UIAs with surveillance imaging can be implemented safely with good adherence. Aneurysm size is the only predictor of future growth. More frequent (semiannual) surveillance imaging for newly diagnosed UIAs and UIAs ≥ 5 mm is warranted.

Cost-Effectiveness in Hepatic Lobectomy: the Effect of Case Volume on Mortality, Readmission, and Cost of Care

OBJECTIVE(S)

Higher-volume centers demonstrate better perioperative outcomes for complex surgical interventions, though resource utilization implications of this hospital-level variation are unclear. We hypothesized that for hepatic lobectomy, higher operative volume correlates with better outcomes and lower costs.

METHODS

From 2009 to 2011, 4163 patients undergoing hepatic lobectomy were identified from the University HealthSystems Consortium database. Univariate, multivariate logistic regression, and decision analytic models were constructed to identify differences in hospital utilization and cost. Cost included both index and readmission hospitalizations, when applicable.

RESULTS

The annual number of hepatic lobectomies performed by the institutions within the study ranged from 1 to 86. The median age of the 4163 patients was 58 years with a roughly equal gender split (M/F 49 %:51 %) and a racial breakdown which reflected that of the general US population. For all patients, the overall perioperative mortality rate was 2.3 % and the 30-day readmission rate was 13.4 %. Hospitals performing >30 hepatic lobectomies per year had significantly lower mortality and readmission rates than those hospitals performing ≤15 lobectomies annually (both p < 0.05). On multivariate analysis, higher severity of illness (odd ratio (OR) 2.13, 95 % confidence interval (CI) [1.48-3.07], p < 0.001), discharge to rehab (OR 1.84, [1.28-2.64], p < 0.001), home with home health care (OR 1.38, [1.08-1.76], p = 0.01), and surgery at a low-volume hospital (OR 1.49, [1.18-1.88], p < 0.001) were significant predictors of readmission. Conversely, surgical intervention at high-volume centers was associated with decreased risk of readmission (OR 0.67, [0.53-0.85], p < 0.001). When both index and readmission costs were considered, per-patient cost at low-volume centers was 21.9 % higher than at high-volume centers ($19,669 vs. $16,137). Sensitivity analyses adjusting for perioperative mortality and readmission at all centers did not significantly change the analysis.

CONCLUSIONS

These data, for the first time, demonstrate that hospital volume in hepatic lobectomy is an important, modifiable risk factor for readmission and cost. To optimize resource utilization, patients undergoing complex hepatic surgery should be directed to higher-volume surgical institutions.

Disparities in care for patients with curable hepatocellular carcinoma

BACKGROUND

The incidence of hepatocellular carcinoma (HCC) is increasing, but surgical management continues to be underutilized. This retrospective review investigates treatment decisions and survival for early stage HCC.

METHODS

The National Cancer Database (NCDB) was queried for all patients with curable HCC (Stage I/II) from 1998 to 2011 (n = 43 859). Patient and tumour characteristics were analysed to determine predictors of having surgery and of long-term survival.

RESULTS

Only 39.7% of patients received surgery for early stage HCC. Surgical therapies included resection (34.6%), transplant (28.7%), radiofrequency ablation (27.1%) and other therapies. Surgery correlated with improved median survival (48.3 versus 8.4 months), but was only performed on 42% of stage I patients and 50% of tumours smaller than 2 cm. Patients were more likely to receive surgery if they were Asian or white race, had private insurance, higher income, better education, or treatment at an academic centre (P < 0.05). However, private insurance and treatment at an academic centre were the only variables associated with improved survival (P < 0.05).

CONCLUSION

Fewer than half of patients with curable HCC receive surgery, possibly as a result of multiple socioeconomic variables. Past these barriers to care, survival is related to adequate and reliable treatment. Further efforts should address these disparities in treatment decisions.

In the Absence of a Mechanical Bowel Prep, Does the Addition of Pre-Operative Oral Antibiotics to Parental Antibiotics Decrease the Incidence of Surgical Site Infection after Elective Segmental Colectomy?

BACKGROUND

Pre-operative oral antibiotics administered the day prior to elective colectomy have been shown to decrease the incidence of surgical site infections (SSI) if a mechanical bowel prep (MBP) is used. Recently, the role for mechanical bowel prep has been challenged as being unnecessary and potentially harmful. We hypothesize that if MBP is omitted, oral antibiotics do not alter the incidence of SSI following colectomy.

METHODS

We selected patients who underwent an elective segmental colectomy from the 2012 and 2013 National Surgical Quality Improvement Program colectomy procedure targeted database. Indications for surgery included colon cancer, diverticulitis, inflammatory bowel disease, or benign polyp. Patients who received mechanical bowel prep were excluded. The primary outcome measured was surgical site infection, defined as the presence of superficial, deep or, organ space infection within 30 d from surgery.

RESULTS

A total of 6,399 patients underwent elective segmental colectomy without MBP. The incidence of SSI differed substantially between patients who received oral antibiotics, versus those who did not (9.7% vs. 13.7%, p=0.01). Multivariate analysis indicated that age, smoking status, operative time, perioperative transfusions, oral antibiotics, and surgical approach were associated with post-operative SSI. When controlling for confounding factors, the use of pre-operative oral antibiotics decreased the incidence of surgical site infection (odds ratio=0.66, 95% confidence interval=0.48-0.90, p=0.01).

CONCLUSION

Even in the absence of mechanical bowel prep, pre-operative oral antibiotics appear to reduce the incidence of surgical site infection following elective colectomy.

Organ quality metrics are a poor predictor of costs and resource utilization in deceased donor kidney transplantation

BACKGROUND

The desire to provide cost-effective care has lead to an investigation of the costs of therapy for end-stage renal disease. Organ quality metrics are one way to attempt to stratify kidney transplants, although the ability of these metrics to predict costs and resource use is undetermined.

METHODS

The Scientific Registry of Transplant Recipients database was linked to the University HealthSystem Consortium Database to identify adult deceased donor kidney transplant recipients from 2009 to 2012. Patients were divided into cohorts by kidney criteria (standard vs expanded) or kidney donor profile index (KDPI) score (<85 vs 85+). Length of stay, 30-day readmission, discharge disposition, and delayed graft function were used as indicators of resource use. Cost was defined as reimbursement based on Medicare cost/charge ratios and included the costs of readmission when applicable.

RESULTS

More than 19,500 patients populated the final dataset. Lower-quality kidneys (expanded criteria donor or KDPI 85+) were more likely to be transplanted in older (both P < .001) and diabetic recipients (both P < .001). After multivariable analysis controlling for recipient characteristics, we found that expanded criteria donor transplants were not associated with increased costs compared with standard criteria donor transplants (risk ratio [RR] 0.97, 95% confidence interval [CI] 0.93-1.00, P = .07). KDPI 85+ was associated with slightly lower costs than KDPI <85 transplants (RR 0.95, 95% CI 0.91-0.99, P = .02). When KDPI was considered as a continuous variable, the association was maintained (RR 0.9993, 95% CI 0.999-0.9998, P = .01).

CONCLUSION

Organ quality metrics are less influential predictors of short-term costs than recipient factors. Future studies should focus on recipient characteristics as a way to discern high versus low cost transplantation procedures.

The effect of surgical approach on short-term oncologic outcomes in rectal cancer surgery

BACKGROUND

Although evidence to support the use of laparoscopic and robotic approaches for the treatment of rectal cancer is limited, these approaches are being adopted broadly. We sought to investigate national practice patterns and compare short-term oncologic outcomes of different approaches for rectal cancer resections.

METHODS

The 2010 National Cancer Database was queried for operative cases of rectal cancer. Approach was classified as open, laparoscopic, or robotic. Patient, tumor, and hospital characteristics and surgical margin status were evaluated. Propensity score matching was used to compare outcomes across approaches.

RESULTS

We identified 8,712 patients. Laparoscopic and robotic approaches were more common in privately insured and wealthier patients at high-volume centers (P < .001). Open approaches were used for tumors with higher histologic grade and pathologic stage (P < .001). A minimally invasive approach was associated with fewer positive margins and shorter hospital stays. After propensity score matching, the laparoscopic approach was associated with a 2.0% lesser (P = .01) and robotic surgery with a 3.8% lesser (P = .004) incidence of positive margins compared with open surgery.

CONCLUSION

An open approach is often used in rectal cancers with higher pathologic stages. Matched patient analysis suggests minimally invasive approaches are associated with improved R0 resections.

Does race affect management and survival in hepatocellular carcinoma in the United States?

BACKGROUND

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death, and its incidence is increasing in the United States. This analysis describes the association between race, treatment decisions, operative outcomes, and survival for patients with HCC.

METHODS

The National Cancer Database was queried for all patients diagnosed with HCC from 1998 to 2011 (n = 143,692) who were white (76.9%), black (14.7%), or Asian (8.4%). Multivariate logistic regression was performed to determine factors that affected the likelihood of having surgery and postoperative mortality, and a Cox regression was performed to evaluate the effect of these factors on survival.

RESULTS

The proportion of black patients with HCC increased in the United States during the 13-year period. There were no substantial differences among races in tumor size, grade, or overall clinical stage at the time of presentation; however, black patients were less likely to have surgery (odds ratio 0.69, 95% confidence interval 0.67-0.72). Of patients who had surgery, there were no significant differences in pathologic stage, margin negative resection rate, or 30-day mortality; however, black patients had the longest interval between diagnosis and surgery, as well as the worst overall adjusted survival (hazard ratio 1.14, 95% confidence interval 1.05-1.25). These findings were independent of HCC stage, insurance provider, and socioeconomic status.

CONCLUSION

Despite similar clinical presentation of HCC, substantial racial differences exist with regard to management and outcomes. Black patients are less likely to receive surgery for HCC and have worse long-term survival, despite similar perioperative quality metrics. This difference in long-term survival may highlight neighborhood, cultural, or biological differences between races.

Ventriculostomy-associated infection: a new, standardized reporting definition and institutional experience

OBJECTIVE

Shortcomings created by the lack of both a uniform definition of ventriculostomy-associated infection (VAI) and reporting standards have led to widely ranging infections rates (2-24%) whose significance is uncertain. We propose a standardized definition of VAI and a consistent reporting format compliant with Centers for Disease Control and Prevention (CDC) for device-related infections. Using those parameters to establish an infection-control surveillance program, we report our 4-year institutional VAI rates.

METHODS

In this prospective study covering ventriculostomy utilization (October 2006-December 2010), 498 patients had a total of 4,673 ventriculostomy days. By review of the literature and our institutional analysis, we defined VAI as a positive CSF culture in a patient with ventriculostomy catheter, plus one or more of the following (1) fever recorded >101.5 °F or (2) cerebrospinal fluid (CSF) glucose level, either <50 mg/dL or <50% of a serum glucose level drawn within 24 h of the CSF glucose. In a report format that is CDC compliant, rates of VAI are reported.

RESULTS

Among our patients, the CDC-compliant infection rate was 2.14 per 1,000 ventriculostomy days. Of the 10 VAIs occurring in 498 patients during 4,673 ventriculostomy days, this 2.0% infection rate was lower than the previously reported 8.8% composite rates of VAI. Average duration of ventriculostomy was 9.4 days. Neither antibiotic-impregnated catheters nor periprocedural or prophylactic antibiotics were used.

CONCLUSIONS

Our standardized VAI definition and CDC format seems promising toward facilitating future study and guideline development. Given our strict protocol of sterile catheter placement and care, and our institution's low 2.0% infection rates, we propose an infection-rate target of ≤5 per 1,000 device days. Our results suggest that the use of antibiotics or antibiotic-impregnated catheters is unwarranted--a positive given concerns of evolving anti-microbial resistance.

Is liver transplantation safe and effective in elderly (≥70 years) recipients? A case-controlled analysis

BACKGROUND

Elderly patients are evaluated for liver transplantation (LT) with increasing frequency, but outcomes in this group have not been well defined.

METHODS

A linkage of the Scientific Registry of Transplant Recipients (SRTR) and the University HealthSystem Consortium (UHC) databases identified 12,445 patients who underwent LT during 2007-2011. Two cohorts were created consisting of, respectively, elderly recipients aged ≥70 years (n = 323) and recipients aged 18-69 years (n = 12,122). A 1:1 case-matched analysis was performed based on propensity scores.

RESULTS

Elderly recipients had lower Model for End-stage Liver Disease (MELD) scores at LT (median 15 versus 19; P < 0.0001), more often underwent transplantation at high-volume centres (46% versus 33%; P < 0.0001) and more often received grafts from donors aged >60 years (24% versus 15%; P < 0.0001). The two cohorts had similar hospital lengths of stay, in-hospital mortality, hospital costs and 30-day readmission rates. There were no differences in graft survival between the two cohorts (P = 0.10), but elderly recipients had worse longterm overall survival (P = 0.009). However, a case-controlled analysis confirmed similar perioperative hospital outcomes, graft survival and longterm patient survival in the two matched cohorts.

CONCLUSIONS

Elderly LT recipients accounted for <3% of all LTs performed during 2007-2011. Selected elderly recipients have perioperative outcomes and survival similar to those in younger adults.

Cost effectiveness after a pancreaticoduodenectomy: bolstering the volume argument

BACKGROUND

The cost implication of variability in pancreatic surgery is not well described. It was hypothesized that for a pancreaticoduodenectomy (PD), lower volume centres demonstrate worse peri-operative outcomes at higher costs.

METHODS

From 2009-2011, 9883 patients undergoing a PD were identified from the University HealthSystems Consortium (UHC) database and stratified into quintiles by annual hospital case volume. A decision analytic model was constructed to assess cost effectiveness. Total direct cost data were based on Medicare cost/charge ratios and included readmission costs when applicable.

RESULTS

The lowest volume centres demonstrated a higher peri-operative mortality rate (3.5% versus 1.3%, P < 0.001) compared with the highest volume centres. When both index and readmission costs were considered, the per-patient total direct cost at the lowest volume centres was $23,005, or 10.9% (i.e. $2263 per case) more than at the highest volume centres. One-way sensitivity analyses adjusting for peri-operative mortality (1.3% at all centres) did not materially change the cost effectiveness analysis. Differences in cost were largely recognized in the index admission; readmission costs were similar across quintiles.

CONCLUSIONS

For PD, low volume centres have higher peri-operative mortality rates and 10.9% higher cost per patient. Performance of PD at higher volume centres can lead to both better outcomes and substantial cost savings.

High readmission rates after surgery for chronic pancreatitis

BACKGROUND

Readmission after complex gastrointestinal surgery is a frequent occurrence that burdens the health care system and leads to increased cost. Recent studies have demonstrated 30- and 90-day readmission rates of 15% and 19%, respectively, following pancreaticoduodenectomy. Given the psychosocial issues often associated with chronic pancreatitis, we hypothesized that readmission rates following surgery for chronic pancreatitis would be higher than previously reported for pancreaticoduodenectomy.

METHODS

We retrospectively reviewed patients undergoing surgery for chronic pancreatitis at a single institution between 2001 and 2013. Patients in this cohort underwent pancreaticoduodenectomy, Berne, Beger, or Frey procedures. Readmission to a primary or secondary hospital was evaluated at both 30 and 90 days after discharge. Multivariate logistic regression analysis was performed to identify factors associated with readmission.

RESULTS

The records of 111 patients were evaluated, of which 69 (62%) underwent duodenal-preserving pancreatic head resection (Berne, Beger, or Frey), while the remaining 42 (38%) underwent pancreaticoduodenectomy. Within the duodenal-preserving pancreatic head resection arm, readmission rates at 30 and 90 days were 30.4% and 43.5%, respectively. Readmission rates following pancreaticoduodenectomy were similar with 33.3% at 30 days and 40.5% at 90 days. The most common reasons for readmission were pain control, infectious complications, and recurrent pancreatitis. On multivariate analysis, wound infection during the initial hospital stay was a predictor of readmission at both 30 and 90 days (P = .02).

CONCLUSION

To our knowledge, our data represent the first report demonstrating very high readmission rates after surgery for chronic pancreatitis, more than double the previous rates reported for pancreaticoduodenectomy. This cohort of patients requires extensive discharge planning focused on pain control, nutritional optimization, and close postoperative monitoring.

Cost discrepancies for common acute care surgery diagnoses in Ohio: influences of hospital characteristics on charge and payment differences

BACKGROUND

Charge and payment discrepancies exist between hospitals, although such variation is understood incompletely. We hypothesized that hospital characteristics may account for such differences.

METHODS

The 2011 Medicare Inpatient Prospective Payment System for Ohio hospitals was queried for discharge diagnoses of gastrointestinal bleed (GIB), GI obstruction (GIO), and laparoscopic cholecystectomy (LC). Analyses were performed to assess the association of hospital variables with charges and payments.

RESULTS

For all three diagnoses, urban hospitals had greater median charges than rural hospitals; payments were not significantly different. Consequently, urban centers had lesser cost to charge ratios than rural centers for GIB, GIO, and LC: 0.29 versus 0.32 (P = .004), 0.27 versus 0.47 (P = .0007), and 0.26 versus 0.40 (P = .04), respectively. Centers with the greatest bed size had higher median charges and payments. Other discrepancies for all three diagnoses were greater payments at verified Level 1 centers and major teaching institutions (P value range <.0001 to .03). On multivariate analysis, excess charges were greater at urban centers for both GIB ($4,482, P = .02) and GIO ($5,700, P < .01).

CONCLUSION

Hospital characteristics are associated with differences in charges and payments for acute care surgery diagnoses. Further study should investigate whether these cost discrepancies are associated with outcomes.

Increasing prevalence of nonalcoholic steatohepatitis as an indication for liver transplantation

BACKGROUND

In Ohio, the obesity rate has increased from 21.5% in 2000 to 30.1% in 2012. Nonalcoholic steatohepatitis is believed to be increasing as an indication for orthotopic liver transplantation.

METHODS

We evaluated the diagnosis of nonalcoholic steatohepatitis as an indication for orthotopic liver transplantation and ensuing outcomes relative to other common hepatic diseases requiring orthotopic liver transplantation in Ohio. We queried 2,356 patients with nonalcoholic steatohepatitis, alcoholic cirrhosis (ETOH), and hepatitis C cirrhosis from the Ohio Solid Organ Transplantation Consortium who were listed for and/or received an orthotopic liver transplant from 2000 to 2012.

RESULTS

The proportion of listed patients with nonalcoholic steatohepatitis increased from 0% to 26% and the proportion of transplanted patients increased from 0% to 23.4%. Compared with patients with hepatitis C and ETOH, patients with nonalcoholic steatohepatitis were older, and more likely to be white, and have private insurance (P < .05 for each). There was no difference in median waiting time among patients with nonalcoholic steatohepatitis, hepatitis C, and ETOH (P = .18) and Model for End-Stage Liver Disease scores at orthotopic liver transplantation among patients with nonalcoholic steatohepatitis, hepatitis C (P = .48), and ETOH (P = .27). Patient and graft survival after orthotopic liver transplantation was comparable between patients with nonalcoholic steatohepatitis and ETOH (P = .79 and P = .86, respectively); however, patients with nonalcoholic steatohepatitis had better patient and graft survival compared with patients with hepatitis C after orthotopic liver transplantation (P < .01 and P = .02, respectively). Additionally, body mass index had no influence on overall or graft survival for patients with nonalcoholic steatohepatitis undergoing orthotopic liver transplantation.

CONCLUSION

This study reflects the growing potential for transplantation in patients with fatty liver disease and suggests the outcomes are equivalent or superior to other common indications for orthotopic liver transplantation.

Increasing age is a predictor of short-term outcomes in esophagectomy: a propensity score adjusted analysis

BACKGROUND

Esophagectomy is a high-risk surgical procedure. As the population ages, more elderly candidates are being evaluated for esophagectomy. The effects of patient age on outcomes after esophagectomy need to be evaluated.

STUDY DESIGN

We identified all nonemergent esophagectomies in patients at least 18 years of age within the University HealthSystems Consortium Clinical Database/Resource Manager from 2009 to 2012. Using univariate and multivariate methods, the impact of increasing age on outcomes was analyzed. Additionally, propensity scoring was used to match patients to further investigate the effect of age on the stated outcomes.

RESULTS

Increasing age is associated with increased mortality (p < 0.001), length of stay (p < 0.001), discharge to rehabilitative care (p < 0.001), and cost (p < 0.001). The effects of age on mortality (8.0 vs 4.2 %, p = 0.03) and discharge to rehabilitative care (44.1 vs 23.4 %, p < 0.01) were confirmed using propensity scoring, comparing patients above 80 with those age 70-79.

CONCLUSIONS

Increasing age has a significant impact on outcomes following esophagectomy, particularly mortality and discharge disposition. Compared to patients under age 80, patients at least 80 years of age considering esophagectomy should be recognized as a high-risk cohort, and these patients must be carefully risk-stratified, counseled, and selected for surgical intervention to prevent unnecessary hospitalization and mortality.

Changes in computed tomography perfusion parameters after superficial temporal artery to middle cerebral artery bypass: an analysis of 29 cases

Introduction Analysis of computed tomography perfusion (CTP) studies before and after superficial temporal artery to middle cerebral artery (STA-MCA) bypass is warranted to better understand cerebral steno-occlusive pathology. Methods Retrospective review was performed of STA-MCA bypass patients with steno-occlusive disease with CTP before and after surgery. CTP parameters were evaluated for change after STA-MCA bypass. Results A total of 29 hemispheres were bypassed in 23 patients. After STA-MCA bypass, mean transit time (MTT) and time to peak (TTP) improved. When analyzed as a ratio to the contralateral hemisphere, MTT, TTP, and cerebral blood flow (CBF) improved. There was no effect of gender, double vessel versus single vessel bypass, or time until postoperative CTP study to changes in CTP parameters after bypass. Conclusions Blood flow augmentation after STA-MCA bypass may best be assessed by CTP using baseline MTT or TTP and ratios of MTT, TTP, or CBF to the contralateral hemisphere. The failure of cerebrovascular reserve to improve after cerebral bypass may indicate irreversible loss of autoregulation with chronic cerebral vasodilation or the inability of CTP to detect these improvements.