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Branche C, Chervu N, Porter G, Vadlakonda A, Sakowitz S, Ali K, Mallick S, Benharash P. The impact of rurality on racial disparities in costs of bowel obstruction treatment. Surg Open Sci 2024; 20:27-31. [PMID: 38873333 PMCID: PMC11170271 DOI: 10.1016/j.sopen.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 05/24/2024] [Indexed: 06/15/2024] Open
Abstract
Background Black race has been associated with increased resource utilization after operation for small bowel obstruction (SBO). While prior literature has similarly demonstrated differences between urban and rural institutions, limited work has defined the impact of rurality on resource utilization by race. Methods The 2016-2020 National Inpatient Sample was used to identify adults undergoing adhesiolysis after non-elective admission for SBO. The primary endpoint was hospitalization costs. Additional outcomes included surgical delay (≥ hospital day 3), length of stay (LOS), and nonhome discharge. Regression models were developed to identify the impact of Black race and rurality on the outcomes of interest with an interaction term to examine the incremental association of Black race on rurality. Results Of an estimated 132,390 patients, 11.4 % were treated at an annual average of 377 rural hospitals (18.5 % of institutions). After adjustment, rural hospitals had higher costs (β + $4900, 95 % Confidence Interval [CI] [4200, 5700]), compared to others. However, rurality was associated with reduced odds of surgical delay (Adjusted Odds Ratio [AOR] 0. 76, CI[0.69, 0.85]), decreased LOS (β -1.66 days, CI[-1.99, -1.36]), and nonhome discharge (AOR 0.78, CI[0.70, 0.87]). While White patients experienced significant cost reductions at urban centers ($26,100 [25,800-26,300] vs $31,000 [30,300-31,700]), this was not noted for Black patients ($30,100 [29,400-30,700] vs $30,800 [29,300-32,400]). Conclusions We found that Black patients do not benefit from the same cost protection afforded by urban settings as White patients after operative SBO admission. Future work should focus on setting-specific interventions to address drivers of disparities within each community.
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Affiliation(s)
- Corynn Branche
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Nikhil Chervu
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, UCLA, Los Angeles, CA, USA
| | - Giselle Porter
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Amulya Vadlakonda
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Sara Sakowitz
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Konmal Ali
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Saad Mallick
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Peyman Benharash
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, UCLA, Los Angeles, CA, USA
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Thacker C, Lauer C, Nealon K, Wang S, Factor M. Should Surgical Services Admit Small Bowel Obstructions Managed Non-operatively? Am Surg 2022; 88:1845-1848. [PMID: 35395913 DOI: 10.1177/00031348221085669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Over the past decade, small bowel obstructions (SBO) have been increasingly managed non-operatively. Prior studies have looked at outcomes based on admission to surgical services (SS) or medicine services (MS), but most are restricted to operative patients. This study evaluates the outcomes of non-operative patients specifically. METHODS A 12-year retrospective cohort study of patients ≥18-years-old admitted with SBO within one healthcare system was performed. Only non-operative patients were included. Clinicodemographic characteristics and admission details were extracted from the electronic medical record. Statistical analysis was performed using the student's t-test, chi-square, and multivariable regression. RESULTS A total of 3278 patients were included, of which 933(28.4%) patients were admitted to a SS. MS patients were older (57.7 vs 54.7 years, P < .001) and more likely to have diabetes (24.1 vs 20.2%, P = .015), CHF (5.7 vs 3.1%, P = .002), and AKI (29.8 vs 16.7%, P < .001). SS patients were more likely to have cancer (19.3 vs 13.7%, P < .001). Univariate analysis showed admission to SS decreased length of stay (3.4 vs 4.1 days, P < .001) and index admission mortality (0.1 vs 2.2%, P < .001). On multivariable analysis, admission to a SS decreased admission mortality (OR 0.056), 30-day mortality (OR 0.15), and 180-day mortality (OR 0.307). Similarly, 30-day readmissions (OR 0.683) and 180-day readmission (OR 0.54) were also significantly decreased. Length of stay was decreased by .6 days (P < .001). DISCUSSION In patients with non-operative SBO, admission to a surgical service decreased length of stay, mortality, and readmission. Further work should be completed evaluating how increased comorbidities affect long term outcomes. However, significantly decreased length of stay and mortality continue to support surgical services admitting SBO patients.
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Affiliation(s)
| | - Claire Lauer
- 21599Geisinger Medical Center, Danville, PA, USA
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Thacker C, Lauer C, Nealon K, Walker C, Factor M. Admitting Service and Outcome for Small Bowel Obstruction. Am Surg 2021; 88:643-647. [PMID: 34791886 DOI: 10.1177/00031348211054065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Small bowel obstruction (SBO) is a common admission diagnosis. Prior research has shown improved length of stay and time to operation for SBO patients on surgical services (SS) compared to medical services (MS). This study evaluates the impact of admitting service on readmission and mortality. METHODS A 12-year retrospective cohort study of patients ≥18 years old, admitted with SBO to either a MS or SS within one health care system was performed. Clinicodemographic characteristics and admission details were extracted and reviewed. Statistical analyses performed included the Student's t-test, chi-square, and multivariable regression. RESULTS The study included 7921 patients, of which 3862 (48.8%) were admitted to a SS. No significant clinicodemographic differences existed between the groups except SS patients were more likely to have cancer (23.3% vs 15.2%, P < .0001) and to be within a 30-day post-operative period (9.4% vs 1.8%, P < .0001). On multivariable analysis, admission to a SS was associated with a decreased admission mortality (OR .70), 30-day mortality (OR .42), and 180-day mortality (OR .42). 30-day readmissions (OR .54) and 180-day readmission (OR .43) were also significantly decreased for SS patients. In patients requiring a procedure during admission, there was significantly decreased admission mortality (OR .684), 30-day mortality (OR .470), 180-day mortality (OR .431), 30-day readmission (OR .63), and 180-day readmission (OR .50). CONCLUSION In patients with SBO, admission to a SS confers decreased odds of readmission and mortality compared to MS. Future studies are needed to understand the management decisions potentially underlying these differences. These findings may help better define admission pathways and improve outcomes.
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Affiliation(s)
| | - Claire Lauer
- 21599Geisinger Medical Center, Danville, PA, USA
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Malizia RA, Martinolich JL, Ata A, Fitz NG, Williams KK, Valerian BT, Stain SC, Lee EC. Management of Nonoperative Diverticulitis : Is Surgical Admission Always Best? Am Surg 2020; 87:321-327. [PMID: 32967441 DOI: 10.1177/0003134820950292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Institutional pathways (IPs) allow efficient utilization of health care resources. Recent literature reports decreased hospital length of stay (LOS), complications, and costs with the admittance of surgical disease to surgical services. Our study aimed to demonstrate that admission to surgery for nonoperative, acute diverticulitis reduces hospital LOS, and cost, with comparable complication rates. METHODS In January 2017, we defined IPs for diverticulitis, mandating emergency department admission to a surgical service. Patients admitted from October 2015 to June 2016 (pre-protocol, control cohort) were compared with those admitted January 2017-September 2018 (post-protocol, IP cohort). Primary outcomes included hospital LOS, direct cost, indirect cost, total cost, and 30-day readmission. Student's 2-tailed t-test and chi-square analysis were utilized, with statistical significance P < .05. RESULTS Nonoperative management of acute diverticulitis occurred in 62 (74%) patients in the control cohort. One hundred and eleven patients (85%) were admitted to the IP cohort. Patient characteristics were similar, except for a higher percentage of surgical patients utilizing private insurance and younger in age. Interestingly, no difference in hospital LOS (3.8 vs 4.7 days; P = 0.07), direct cost ($2639.44 vs $3251.52; P = .19), or overall cost ($5968.67 vs $6404.08, P = .61) was found between cohorts. Thirty-day readmission rates were comparable at 8% and 11% (P = .59). CONCLUSION Institutional policy mandating admissions for patients receiving nonoperative management of diverticulitis to surgical services does not reduce hospital LOS or cost. This argues that admission to medical services may be an acceptable practice. This raises the question, is acute diverticulitis always a surgical issue?
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Affiliation(s)
| | | | - Ashar Ata
- Department of Surgery, Albany Medical College, Albany, NY, USA
| | - Nicholas G Fitz
- Department of Surgery, Albany Medical College, Albany, NY, USA
| | | | | | - Steven C Stain
- Department of Surgery, Albany Medical College, Albany, NY, USA
| | - Edward C Lee
- Department of Surgery, Albany Medical College, Albany, NY, USA
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Kassam AF, Kim Y, Cortez AR, Dhar VK, Wima K, Shah SA. The impact of opioid use on human and health care costs in surgical patients. Surg Open Sci 2020; 2:92-95. [PMID: 32754712 PMCID: PMC7391897 DOI: 10.1016/j.sopen.2019.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 10/07/2019] [Accepted: 10/09/2019] [Indexed: 12/02/2022] Open
Abstract
Background Preoperative narcotic use impacts hospital cost and outcomes in surgical patients, but the underlying reasons are unclear. Methods A single-center retrospective analysis was performed on surgical patients admitted with intestinal obstruction (2010–2014). Patients were grouped into active opioid and nonopioid user cohorts. Active opioid use was defined as having an opioid prescription overlapping the date of admission. Chronic opioid use was defined by duration of use ≥ 90 days. Admission or intervention due to opioid-related illness was determined through consensus decision of 2 independent, blinded clinicians. Primary end point was the effect of active opioid use on hospital resource utilization. Results During the study period, 296 patients were admitted with a primary diagnosis of intestinal obstruction. Active opioid users accounted for 55 (18.6%) of these patients, with a median length of opioid use of 164 days (interquartile range 54–344 days). Average length of use was 164 days, with the majority of active users (n = 42, 76.4%) meeting criteria for chronic use. A subgroup analysis of active users demonstrated that opioid-related conditions were responsible for 10 admissions (18.2%) and 2 readmissions (3.6%). Among active users requiring surgical intervention, 3 procedures (21.4%) were due to opioid-related illnesses. Median hospital length of stay was 2 days longer (8 vs 6 days) and hospital costs were greater ($12,241 vs $8489) among active users (P < .05 each). Conclusion Active opioid users are predisposed to avoidable admissions and interventions for opioid-related illnesses. Efforts to address opioid use in the surgical population may improve patient outcomes and health care spending.
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Affiliation(s)
- Al-Faraaz Kassam
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Young Kim
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alexander R Cortez
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Vikrom K Dhar
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Koffi Wima
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Shimul A Shah
- Cincinnati Research in Outcomes and Safety in Surgery (CROSS), Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
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Hernandez MC, Finnesgard EJ, Shariq OA, Knight A, Stephens D, Aho JM, Kim BD, Schiller HJ, Zielinski MD. Disease Severity and Cost in Adhesive Small Bowel Obstruction. World J Surg 2020; 43:3027-3034. [PMID: 31555867 DOI: 10.1007/s00268-019-05148-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Adhesive small bowel obstruction (ASBO) severity has been associated with important clinical outcomes. However, the impact of ASBO severity on hospitalization cost is unknown. The American Association for the Surgery of Trauma (AAST) developed an Emergency General Surgery (EGS) disease severity grading system for ASBO. We stratified patients' ASBO severity and captured hospitalization costs hypothesizing that increased disease severity would correlate with greater costs. METHODS This was a single-center study of hospitalized adult patients with SBO during 2015-2017. Clinical data and estimated total cost (direct + indirect) were abstracted. AAST EGS grades (I-IV) stratified disease severity. Costs were normalized to the median grade I cost. Univariate and multivariate analyses evaluated the relationship between normalized cost and AAST EGS grade, length of hospital and ICU stay, operative time, and Charlson comorbidity index. RESULTS There were 214 patients; 119 (56%) were female. AAST EGS grades included: I (62%, n = 132), II (23%, n = 49), III (7%, n = 16), and IV (8%, n = 17). Relative to grade I, median normalized cost increased by 1.4-fold for grade II, 1.6-fold for grade III, and 4.3-fold for grade IV disease. No considerable differences in patient comorbidity between grades were observed. Pair-wise comparisons demonstrated that grade I disease cost less than higher grades (corrected p < 0.001). Non-operative management was associated with lower normalized cost compared to operative management (1.1 vs. 4.5, p < 0.0001). In patients who failed non-operative management, normalized cost was increased 7.2-fold. Collectively, the AAST EGS grade correlated well with cost (Spearman's p = 0.7, p < 0.0001). After adjustment for covariates, AAST EGS grade maintained a persistent relationship with cost. CONCLUSION Increasing ASBO severity is independently associated with greater costs. Efforts to identify and mitigate costs associated with this burdensome disease are warranted. LEVEL OF EVIDENCE III, economic/decision.
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Affiliation(s)
- Matthew C Hernandez
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, Mary Brigh 2-810, 1216 Second Street SW, Rochester, MN, 55902, USA
| | | | - Omair A Shariq
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, Mary Brigh 2-810, 1216 Second Street SW, Rochester, MN, 55902, USA
| | - Ariel Knight
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, Mary Brigh 2-810, 1216 Second Street SW, Rochester, MN, 55902, USA
| | - Daniel Stephens
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, Mary Brigh 2-810, 1216 Second Street SW, Rochester, MN, 55902, USA
| | - Johnathon M Aho
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, Mary Brigh 2-810, 1216 Second Street SW, Rochester, MN, 55902, USA
| | - Brian D Kim
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, Mary Brigh 2-810, 1216 Second Street SW, Rochester, MN, 55902, USA
| | - Henry J Schiller
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, Mary Brigh 2-810, 1216 Second Street SW, Rochester, MN, 55902, USA
| | - Martin D Zielinski
- Division of Trauma, Critical Care and General Surgery, St. Mary's Hospital, Mayo Clinic, Mary Brigh 2-810, 1216 Second Street SW, Rochester, MN, 55902, USA.
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Clinical course of patients presenting to the emergency department with small bowel obstruction in New York State. Surg Endosc 2020; 35:3040-3046. [PMID: 32632484 DOI: 10.1007/s00464-020-07754-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 06/22/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Small Bowel Obstruction (SBO) is a common reason for emergency department (ED) visits in the United States. However, little is known regarding the clinical course of these patients. This study aims to identify all patients presenting to the ED in New York State with SBO and follow their clinical course. METHODS The New York SPARCS administrative database was used to identify all patients who presented to an ED with the diagnosis of SBO from 2012 to 2014. Patients were followed to identify discharges from the ED, admissions, operations, 30-day readmissions, transfers, and in-hospital death. RESULTS Between 2012 and 2014, 43,567 ED visits (events) from 35,646 patients were identified, with 2824 (6.5%) resulting in direct discharge from the ED. A majority (n = 31,193; 71.6%) of ED visits were admitted to the presenting institution without surgery, while 7673 (17.6%) were admitted and underwent surgery. A minority (n = 1947; 4.5%) were transferred to a tertiary center. The overall 30-day readmission rate was 17.9%. Those who underwent surgery were more likely to experience in-hospital death but less likely to have 30-day readmission. CONCLUSION To our knowledge, this is the first study that examines the disposition of all patients presenting to the ED with SBO in a large statewide cohort. The majority of admitted patients underwent non-operative management, with overall low rates of readmission, transfer, and in-hospital death.
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Short-Term Clinical Outcomes after Using Novel Deeper Intubation Technique (DIT) of Ileus Tube for Acute Bowel Obstruction Patients. Gastroenterol Res Pract 2020; 2020:1625154. [PMID: 32508909 PMCID: PMC7245673 DOI: 10.1155/2020/1625154] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 04/13/2020] [Accepted: 04/21/2020] [Indexed: 11/18/2022] Open
Abstract
Background The ileus tube has been widely used for the treatment of acute small bowel obstruction. However, it is difficult to get the tube sufficiently adjacent to the obstruction site due to various reasons. Methods We developed a novel intubation technique, named Deeper Intubation Technique (DIT), by using the Zebra Urological Guidewire and digital gastrointestinal fluoroscopy, where we deepened the catheter intubation, and further compared the effects of DIT with the Traditional Intubation Technique (TIT) on the short-term clinical outcomes of 183 patients. Results The average intubation depth of DIT apparently exceeds that of TIT (213.89 ± 31.11 vs. 134.67 ± 18.22 cm, P < 0.001). Compared with patients in the TIT group, patients in the DIT group got a lower pain score (P < 0.001), shorter recovery time for anal exhaust defecation (2.87 ± 1.50 vs. 3.37 ± 1.52 d, P = 0.040), higher recovery rate in anal exhaust defecation (24 h, 16.8% vs. 5.7%, P = 0.021; 48 h, 46.3% vs. 27.3%, P = 0.009), better symptomatic remission rate and imaging relief rate (P < 0.05), and increased drainage volume (1006.88 ± 583.45 vs. 821.02 ± 358.73 ml, P = 0.009). Importantly, the emergency surgery rate in the DIT group was lower than that in the TIT group (3.2% vs. 13.6%, P = 0.014). In addition, the DIT procedure was effective for patients with adhesive obstruction but not for cancerous and stercoral bowel obstruction. Conclusion Compared to TIT, DIT produced better short-term clinical outcomes, indicating that DIT is a safe and feasible technique for the treatment of adhesive intestinal obstruction.
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Evolving Management Strategies in Patients with Adhesive Small Bowel Obstruction: a Population-Based Analysis. J Gastrointest Surg 2018; 22:2133-2141. [PMID: 30051307 DOI: 10.1007/s11605-018-3881-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/10/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND In patients with adhesive small bowel obstruction (aSBO), the decision to operate as well as the timing and technique of surgery have significant impacts on clinical outcomes. Trends in the management of aSBO have not been described at the population level and guideline adherence is unknown. We sought to evaluate the secular trends in the management of aSBO in a large North American population. METHODS We used administrative data to identify patients admitted to hospital for their first episode of aSBO over 2005-2014. We evaluated temporal trends in admission for aSBO and in management practices using Cochran-Armitage tests. Multivariable logistic regressions were used to assess trends when controlling for potential confounders. RESULTS Patients (40,800) were admitted with their first episode of aSBO. The mean age was 68.5 years and 55% of patients were female. The population-based rate of admission for aSBO decreased over the study period, from 39.1 to 38.1 per 100,000 persons per year. There was a significant increase in the proportion of patients who underwent surgery for aSBO (19 to 23%, p < 0.0001). Among those who underwent surgery, there were significant increases in the proportions of patients who underwent laparoscopic procedures (4 to 14%, p < 0.0001) and who underwent surgery within 1 day of admission (51 to 60%, p < 0.0001). CONCLUSION Between 2005 and 2014, there was a decrease in the population-based rate of aSBO, which may reflect increased utilization of minimally invasive techniques. There were significant trends towards increased operative intervention, with surgery occurring earlier and increasingly using laparoscopic approach.
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Comparisons of the surgical outcomes and medical costs between transferred and directly admitted patients diagnosed with intestinal obstruction in an American tertiary referral center. Int J Colorectal Dis 2018; 33:1617-1625. [PMID: 29679151 DOI: 10.1007/s00384-018-3052-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE Intestinal obstruction is a leading cause of patient mortality and the most common reason for emergent operation in colorectal surgery. The influence of inter-hospital transfer on patients' outcomes varies greatly in different diseases. We aimed to compare the surgical outcomes and medical costs between transferred and directly admitted patients diagnosed with intestinal obstruction in an American tertiary referral center. METHODS All intestinal obstruction patients operated in Cleveland Clinic from Jan 2012 to Dec 2016 were collected from a prospectively maintained database. Preoperative characteristics; surgical outcomes, including intraoperative complication, postoperative complication, readmission, reoperation, and postoperative 30-day mortality; and medical cost were collected. All parameters were compared between two groups before and after propensity score match. Multivariate logistic analysis was used to explore risk factors of surgical outcomes. RESULTS A total of 576 patients were included, with 75 in the transferred group and 501 in the directly admitted group. Before match, the transferred patients had longer waiting interval from admission to surgery (p < 0.001), more contaminated or infected wounds (p = 0.02), different surgical procedures (p = 0.02), and similar surgical outcomes and total medical cost (all p > 0.05), compared with the directly admitted group. Multivariate analysis showed that inter-hospital transfer was not an independent predictor of any surgical outcome. After matching to balance the preoperative characteristics between two groups, no significant differences were identified in all surgical outcomes and total medical cost between two groups (all p > 0.05). CONCLUSIONS Compared with directly admitted patients, transferred intestinal obstruction patients are associated with similar surgical outcomes and similar medical costs.
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Tang L, Zhao P, Kong D. The risk factors for benign small bowel obstruction following curative resection in patients with rectal cancer. World J Surg Oncol 2018; 16:212. [PMID: 30348158 PMCID: PMC6198517 DOI: 10.1186/s12957-018-1510-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 10/09/2018] [Indexed: 11/13/2022] Open
Abstract
Background So far there have been limited studies about the risk factors for benign small bowel obstruction (SBO) after colorectal cancer surgery. This study aimed to determine the factors affecting the development of benign SBO following curative resection in patients with rectal cancer. Methods Patients (3472) receiving curative resection of rectal cancer at the Department of Colorectal Cancer, Tianjin Medical University Cancer Institute and Hospital, between January 2003 and December 2012 were retrospectively studied. The incidence of benign SBO and its risk factors were then determined. Results The incidence of benign SBO was 7.3% (253/3472) in follow-up studies with an average time of 68 months. Further, 27% (68/253) of the patients received operative treatment because of the signs of strangulation or the lack of clinical improvement with conservative management. Open surgery and radiotherapy were defined as the risk factors for benign SBO after curative resection in patients with rectal cancer (P < 0.001). Conclusion Open surgery plus radiotherapy led to an increased risk of benign SBO in rectal cancer patients receiving curative resection.
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Affiliation(s)
- Liang Tang
- Department of Colorectal Cancer, Tianjin Medical University Cancer Institute and Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center of Cancer, Huanhuxi Road, Hexi District, Tianjin, People's Republic of China
| | - Peng Zhao
- Department of Colorectal Cancer, Tianjin Medical University Cancer Institute and Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center of Cancer, Huanhuxi Road, Hexi District, Tianjin, People's Republic of China
| | - Dalu Kong
- Department of Colorectal Cancer, Tianjin Medical University Cancer Institute and Hospital, Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center of Cancer, Huanhuxi Road, Hexi District, Tianjin, People's Republic of China.
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Bower KL, Lollar DI, Williams SL, Adkins FC, Luyimbazi DT, Bower CE. Small Bowel Obstruction. Surg Clin North Am 2018; 98:945-971. [PMID: 30243455 DOI: 10.1016/j.suc.2018.05.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Identifying patients with small bowel obstruction who need operative intervention and those who will fail nonoperative management is a challenge. Without indications for urgent intervention, a computed tomography scan with/without intravenous contrast should be obtained to identify location, grade, and etiology of the obstruction. Most small bowel obstructions resolve with nonoperative management. Open and laparoscopic operative management are acceptable approaches. Malnutrition needs to be identified early and managed, especially if the patient is to undergo operative management. Confounding conditions include age greater than 65, post Roux-en-Y gastric bypass, inflammatory bowel disease, malignancy, virgin abdomen, pregnancy, hernia, and early postoperative state.
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Affiliation(s)
- Katie Love Bower
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA.
| | - Daniel I Lollar
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - Sharon L Williams
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - Farrell C Adkins
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - David T Luyimbazi
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
| | - Curtis E Bower
- Carilion Clinic and Virginia Tech Carilion School of Medicine, Carilion Clinic Department of Surgery, 1906 Belleview Avenue, Med. Ed., 3rd Floor, Suite 332, Roanoke, VA 24014, USA
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Blackwell RH, Kothari AN, Shah A, Gange W, Quek ML, Luchette FA, Flanigan RC, Kuo PC, Gupta GN. Adhesive Bowel Obstruction Following Urologic Surgery: Improved Outcomes with Early Intervention. Curr Urol 2018; 11:175-181. [PMID: 29997459 DOI: 10.1159/000447215] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 08/25/2017] [Indexed: 11/19/2022] Open
Abstract
Objective To describe the long-term incidence of adhesive bowel obstruction following major urologic surgery, and the effect of early surgery on perioperative outcomes. Methods The Healthcare Cost and Utilization Project State Inpatient Databases for California and Florida (2006-2011) were used to identify major urologic oncologic surgery patients. Subsequent adhesive bowel obstruction admissions were identified and Kaplan-Meier time-to-event analysis was performed. Early surgery for bowel obstruction was defined as occurring on-or-before hospital-day four. The effects of early surgery on postoperative minor/moderate complications (wound infection, urinary tract infection, deep vein thrombosis, and pneumonia), major complications (myocardial infarction, pulmonary embolism, and sepsis), death, and postoperative length-of-stay were assessed. Results Major urologic surgery was performed on 104,400 patients, with subsequent 5-year cumulative incidence of adhesive bowel obstruction admission of 12.4% following radical cystectomy, 3.3% following kidney surgery, and 0.9% following prostatectomy. During adhesive bowel obstruction admission, 71.6% of patients were managed conservatively and 28.4% surgically. Early surgery was performed in 65.4%, with decreased rates of minor/moderate complications (18 vs. 30%, p = 0.001), major complications (10 vs. 19%, p = 0.002), and median postoperative length of stay (8 vs. 11 days, p < 0.001) compared with delayed surgery. On multivariate analysis early surgery decreased the odds of minor/ moderate complications by 43% (p = 0.01), major complications by 45% (p = 0.03), and postoperative length of stay by 3.1 days (p = 0.01). Conclusion Adhesive bowel obstruction is a significant long-term sequela of urologic surgery, for which early surgical management may be associated with improved perioperative outcomes.
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Affiliation(s)
- Robert H Blackwell
- Department of Urology, Loyola University Medical Center, Maywood, IL.,the One: MAP Division of Clinical Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - Anai N Kothari
- Department of Surgery, Loyola University Medical Center, Maywood, IL.,the One: MAP Division of Clinical Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - Arpeet Shah
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - William Gange
- the One: MAP Division of Clinical Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - Marcus L Quek
- Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Fred A Luchette
- Department of Surgery, Loyola University Medical Center, Maywood, IL.,Department of Surgical Services, Edward Hines Jr Veterans Administration Medical Center, Hines
| | - Robert C Flanigan
- Department of Urology, Loyola University Medical Center, Maywood, IL.,the One: MAP Division of Clinical Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - Paul C Kuo
- Department of Surgery, Loyola University Medical Center, Maywood, IL.,the One: MAP Division of Clinical Analytics, Loyola University Medical Center, Maywood, IL, USA
| | - Gopal N Gupta
- Department of Urology, Loyola University Medical Center, Maywood, IL.,Department of Surgery, Loyola University Medical Center, Maywood, IL.,the One: MAP Division of Clinical Analytics, Loyola University Medical Center, Maywood, IL, USA
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Affiliation(s)
- Christopher T Aquina
- Department of Surgery, University of Rochester Medical Center, Box SURG, 601 Elmwood Avenue, Rochester, NY 14642, USA
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY 14642, USA.
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Aquina CT, Becerra AZ, Probst CP, Xu Z, Hensley BJ, Iannuzzi JC, Noyes K, Monson JRT, Fleming FJ. Patients With Adhesive Small Bowel Obstruction Should Be Primarily Managed by a Surgical Team. Ann Surg 2017; 264:437-47. [PMID: 27433901 DOI: 10.1097/sla.0000000000001861] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To evaluate the impact of a primary medical versus surgical service on healthcare utilization and outcomes for adhesive small bowel obstruction (SBO) admissions. SUMMARY BACKGROUND DATA Adhesive-SBO typically requires hospital admission and is associated with high healthcare utilization and costs. Given that most patients are managed nonoperatively, many patients are admitted to medical hospitalists. However, comparisons of outcomes between primary medical and surgical services have been limited to small single-institution studies. METHODS Unscheduled adhesive-SBO admissions in NY State from 2002 to 2013 were identified using the Statewide Planning and Research Cooperative System. Bivariate and mixed-effects regression analyses were performed assessing factors associated with healthcare utilization and outcomes for SBO admissions. RESULTS Among 107,603 admissions for adhesive-SBO (78% nonoperative, 22% operative), 43% were primarily managed by a medical attending and 57% were managed by a surgical attending. After controlling for patient, physician, and hospital-level factors, management by a medical service was independently associated with longer length of stay [IRR = 1.39, 95% confidence interval (CI) = 1.24, 1.56], greater inpatient costs (IRR = 1.38, 95% = 1.21, 1.57), and a higher rate of 30-day readmission (OR = 1.32, 95% CI = 1.22, 1.42) following nonoperative management. Similarly, of those managed operatively, management by a medicine service was associated with a delay in time to surgical intervention (IRR = 1.84, 95% CI = 1.69, 2.01), extended length of stay (IRR=1.36, 95% CI = 1.25, 1.49), greater inpatient costs (IRR = 1.38, 95% CI = 1.11, 1.71), and higher rates of 30-day mortality (OR = 1.92, 95% CI = 1.50, 2.47) and 30-day readmission (OR = 1.13, 95% CI = 0.97, 1.32). CONCLUSIONS This study suggests that management of patients presenting with adhesive-SBO by a primary medical team is associated with higher healthcare utilization and worse perioperative outcomes. Policies favoring primary management by a surgical service may improve outcomes and reduce costs for patients admitted with adhesive-SBO.
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Affiliation(s)
- Christopher T Aquina
- *Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY †Center for Colon and Rectal Surgery, Florida Hospital Group, University of Central Florida College of Medicine, Orlando, FL
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Kothari AN, Liles JL, Holmes CJ, Zapf MAC, Blackwell RH, Kliethermes S, Kuo PC, Luchette FA. "Right place at the right time" impacts outcomes for acute intestinal obstruction. Surgery 2015; 158:1116-25; discussion 1125-7. [PMID: 26243347 DOI: 10.1016/j.surg.2015.06.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 06/07/2015] [Accepted: 06/24/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND The purpose of this study was to measure how the duration of nonoperative intervention for intestinal obstruction impacted patient outcomes and whether hospital characteristics influenced the timing of operative intervention. METHODS The State Inpatient Database (Florida) of the Health Care Utilization Project and the Annual Survey database of the American Hospital Association were linked from 2006 to 2011. Included were patients ≥18 years of age with a primary diagnosis of intestinal obstruction. Patient factors included age, sex, socioeconomic factors, and comorbid conditions. RESULTS A total of 116,195 patients met our inclusion criteria, and 43,079 underwent operative intervention (37.1%). Patients who required operative correction of the intestinal obstruction after the fifth day of hospitalization, compared with patients who underwent an operation on the day of admission, had increases in mortality (6.1% vs 1.8%, P < .001), complication rates (15.4% vs 4.0%, P < .001), and postoperative hospital stay (9 vs 5 days, P < .001). Patients cared for at a large teaching facility (with surgery residents) had increased odds of early operative intervention by 23% (odds ratio 1.23, [1.20-1.28]), whereas patients at low-volume hospitals had decreased odds of early intervention (odds ratio 0.88, [0.73-0.91]). CONCLUSION Initial nonoperative treatment in patients with uncomplicated intestinal obstruction is an important strategy, but the odds of having an adverse event increase as intestinal obstruction is delayed. Importantly, the presence of surgery residents and increasing bed size are hospital characteristics associated with earlier operative intervention, suggesting a quality benefit for care at large teaching hospitals.
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Affiliation(s)
- Anai N Kothari
- Department of Surgery, Loyola University Medical Center, Maywood, IL; One:MAP Surgical Analytics Group at LUMC Surgery, Loyola University Medical Center, Maywood, IL
| | - Jordan L Liles
- Loyola Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Casey J Holmes
- Department of Surgery, Loyola University Medical Center, Maywood, IL
| | - Matthew A C Zapf
- One:MAP Surgical Analytics Group at LUMC Surgery, Loyola University Medical Center, Maywood, IL; Loyola Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Robert H Blackwell
- One:MAP Surgical Analytics Group at LUMC Surgery, Loyola University Medical Center, Maywood, IL; Department of Urology, Loyola University Medical Center, Maywood, IL
| | - Stephanie Kliethermes
- One:MAP Surgical Analytics Group at LUMC Surgery, Loyola University Medical Center, Maywood, IL; Department of Public Health Sciences, Loyola University Chicago, Maywood, IL
| | - Paul C Kuo
- Department of Surgery, Loyola University Medical Center, Maywood, IL; One:MAP Surgical Analytics Group at LUMC Surgery, Loyola University Medical Center, Maywood, IL
| | - Fred A Luchette
- Department of Surgery, Loyola University Medical Center, Maywood, IL; One:MAP Surgical Analytics Group at LUMC Surgery, Loyola University Medical Center, Maywood, IL; Edward Hines Jr. Veterans Administration Medical Center, Hines, IL.
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Bilderback PA, Massman JD, Smith RK, La Selva D, Helton WS. Small Bowel Obstruction Is a Surgical Disease: Patients with Adhesive Small Bowel Obstruction Requiring Operation Have More Cost-Effective Care When Admitted to a Surgical Service. J Am Coll Surg 2015; 221:7-13. [DOI: 10.1016/j.jamcollsurg.2015.03.054] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 02/23/2015] [Accepted: 03/25/2015] [Indexed: 10/23/2022]
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Schmocker RK, Vang X, Cherney Stafford LM, Leverson GE, Winslow ER. Involvement of a surgical service improves patient satisfaction in patients admitted with small bowel obstruction. Am J Surg 2015; 210:252-7. [PMID: 25886702 DOI: 10.1016/j.amjsurg.2014.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 10/16/2014] [Accepted: 11/02/2014] [Indexed: 02/01/2023]
Abstract
BACKGROUND For patients with small bowel obstruction (SBO), surgical care has been associated with improved outcomes; however, it remains unknown how it impacts satisfaction. METHODS Patients admitted for SBO who completed the hospital satisfaction survey were eligible. Only those with adhesions or hernias were included. Chart review extracted structural characteristics and outcomes. RESULTS Forty-seven patients were included; 74% (n = 35) were admitted to a surgical service. Twenty-six percent of the patients (n = 12) were admitted to medicine, and 50% of those (n = 6) had surgical consultation. Patients with surgical involvement as the consulting or primary service (SURG) had higher satisfaction with the hospital than those cared for by the medical service (MED) (80% SURG, 33% MED, P = .015). SURG patients also had higher satisfaction with physicians (74% SURG, 44% MED, P = .015). CONCLUSION Surgical involvement during SBO admissions is associated with increased patient satisfaction, and adds further weight to the recommendation that these patients be cared for by surgeons.
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Affiliation(s)
- Ryan K Schmocker
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA
| | - Xia Vang
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA
| | - Linda M Cherney Stafford
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA
| | - Glen E Leverson
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA
| | - Emily R Winslow
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA.
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Wahl WL, Wong SL, Sonnenday CJ, Hemmila MR, Dimick JB, Flanders SA, Desmond JS, Bahl V, Henke PK. Implementation of a small bowel obstruction guideline improves hospital efficiency. Surgery 2012; 152:626-32; discussion 632-4. [PMID: 22939746 DOI: 10.1016/j.surg.2012.07.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 07/13/2012] [Indexed: 01/27/2023]
Abstract
BACKGROUND We performed an internal review of triage decisions and outcomes for all patients admitted for small bowel obstruction (SBO). Concern for potential delays in operation led to formalization of an institution-wide SBO management guideline. We hypothesized that use of the guideline would improve initial triage and patient outcomes. METHODS Members of the departments of surgery, medicine, and emergency medicine created a SBO service triage and initial management guideline that was instituted in 2011 after education and a multidisciplinary Grand Rounds on the subject. Administrative data from fiscal year 2010 (FY2010) was compared with the first 6 months of 2011. Time to computed tomography scan, the OR, general surgery (GS) consultation, and hospital duration of stay were collected and compared for those admitted to a medicine service before (Med2010) and after (Med2011) the guideline and those admitted to a general surgery service before (GS2010) and after (GS2011) the guideline. Groups were compared with Student t test and χ2 analysis. RESULTS There were 490 SBO admissions in FY2010 and 240 in the first 6 months of 2011. After implementation of the guidelines, the percent of SBO patients admitted to GS2011 increased from 55 to 66% (P < .01). The percent of patients admitted to a medicine service requiring operation for SBO did not change from 14 to 7% for Med2011, but there was a shorter time to GS consultation (P < .001). Time from admission to operation decreased from 0.9 to 0.4 days (P < .05) with a mean decrease in hospital duration of stay of 2 days (8 ± 6 compared with 6 ± 4 days, P < .001) for those admitted during GS2011. CONCLUSION Implementation of a hospital-wide SBO guideline that addressed initial management and triage shortened time to operative intervention and hospital duration of stay for patients requiring operative therapy for SBO.
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Affiliation(s)
- Wendy L Wahl
- Trauma and Surgical Critical Care, Saint Joseph Mercy Ann Arbor, Ann Arbor, MI 48106-0995, USA.
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Dorsey ST, Harrington ET, Iv WFP, Emerman CL. Ileus and small bowel obstruction in an emergency department observation unit: are there outcome predictors? West J Emerg Med 2012; 12:404-7. [PMID: 22224128 PMCID: PMC3236160 DOI: 10.5811/westjem.2011.3.2175] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Revised: 02/21/2011] [Accepted: 03/23/2011] [Indexed: 11/11/2022] Open
Abstract
Introduction The purpose of our study was to describe the evaluation and outcome of patients with ileus and bowel obstruction admitted to an emergency department (ED) observation unit (OU) and to identify predictors of successful management for such patients. Methods We performed a retrospective chart review of 129 patients admitted to a university-affiliated, urban, tertiary hospital ED OU from January 1999 through November 2004. Inclusion criteria were all adult patients admitted to the OU with an ED diagnosis of ileus, partial small bowel obstruction, or small bowel obstruction, and electronic medical records available for review. The following variables were examined: ED diagnosis, history of similar admission, number of prior abdominal surgeries, surgery in the month before, administration of opioid analgesia at any time after presentation, radiographs demonstrating air–fluid levels or dilated loops of small bowel, hypokalemia, use of nasogastric decompression, and surgical consultation. Results Treatment failure, defined as hospital admission from the OU, occurred in 65 (50.4%) of 129 patients. Only the use of a nasogastric tube was associated with OU failure (21% discharged versus 79% requiring admission, P = 0.0004; odds ratio, 5.294; confidence interval, 1.982–14.14). Conclusion Half of the patients admitted to our ED OU with ileus or varying degrees of small bowel obstruction required hospital admission. The requirement of a nasogastric tube in such patients was associated with a greater rate of observation unit failure.
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Affiliation(s)
- Steven T Dorsey
- Emergency Services Institute, Cleveland Clinic, Cleveland, Ohio
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Malangoni MA. Invited commentary on Hwang U et al: factors associated with delays to emergency care for bowel obstruction-we have issues. Am J Surg 2011; 202:8-9. [PMID: 21741516 DOI: 10.1016/j.amjsurg.2010.08.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 08/08/2010] [Indexed: 11/15/2022]
Affiliation(s)
- Mark A Malangoni
- Department of Surgery, Case Western Reserve University, MetroHealth Medical Center, Cleveland, OH 44109-1998, USA.
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Abstract
Abdominal pain in older adults is a concerning symptom common to a variety of diagnoses with high morbidity and mortality. Organizing the differential into categories based on pathology (inflammatory, obstructive, vascular, or other causes) provides a framework for the history, physical, and diagnostic studies. An organized approach and treatment and considerations specific to the geriatric population are discussed.
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Affiliation(s)
- Luna Ragsdale
- Division of Emergency Medicine, Duke University Medical Center, Durham, NC 27710, USA.
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Schwenter F, Poletti PA, Platon A, Perneger T, Morel P, Gervaz P. Clinicoradiological score for predicting the risk of strangulated small bowel obstruction. Br J Surg 2010; 97:1119-25. [PMID: 20632281 DOI: 10.1002/bjs.7037] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Intestinal ischaemia as a result of small bowel obstruction (SBO) requires prompt recognition and early intervention. A clinicoradiological score was sought to predict the risk of ischaemia in patients with SBO. METHODS A clinico-radiological protocol for the assessment of patients presenting with SBO was used. A logistic regression model was applied to identify determinant variables and construct a clinical score that would predict ischaemia requiring resection. RESULTS Of 233 consecutive patients with SBO, 138 required laparotomy of whom 45 underwent intestinal resection. In multivariable analysis, six variables correlated with small bowel resection and were given one point each towards the clinical score: history of pain lasting 4 days or more, guarding, C-reactive protein level at least 75 mg/l, leucocyte count 10 x 10(9)/l or greater, free intraperitoneal fluid volume at least 500 ml on computed tomography (CT) and reduction of CT small bowel wall contrast enhancement. The risk of intestinal ischaemia was 6 per cent in patients with a score of 1 or less, whereas 21 of 29 patients with a score of 3 or more underwent small bowel resection. A positive score of 3 or more had a sensitivity of 67.7 per cent and specificity 90.8 per cent; the area under the receiver operating characteristic curve was 0.87 (95 per cent confidence interval 0.79 to 0.95). CONCLUSION By combining clinical, laboratory and radiological parameters, the clinical score allowed early identification of strangulated SBO.
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Affiliation(s)
- F Schwenter
- Department of Surgery, Geneva University Hospital and Medical School, Geneva, Switzerland
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Oyasiji T, Angelo S, Kyriakides TC, Helton SW. Small Bowel Obstruction: Outcome and Cost Implications of Admitting Service. Am Surg 2010. [DOI: 10.1177/000313481007600720] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We compared patients with small bowel obstruction (SBO) admitted through the emergency department to the surgical service (SS) with those admitted to the medical service (MS) with respect to outcomes and healthcare cost. We conducted a retrospective analysis of our SBO database comparing 482 patients admitted to SS and 153 patients admitted to MS at a single institution over a 5-year period (January 2003 to December 2007). Study outcomes included length of hospital stay (LOS), time to surgery (TTS), hospital charges, incidence of bowel resection, and mortality. Both groups were comparable for age, gender, and race. The SS group had a shorter LOS (6.1 vs 7.5 days; P = 0.01), less hospital charges ($29,549 vs $35,789; P = 0.06), shorter TTS (log rank comparison; P = 0.006), and less mortality (eight [1.66%] vs six [3.92]; P = 0.11). The SS group had more bowel resections (13.1 vs 5.2%; P = 0.007). Coronary artery disease (CAD), acute renal failure (ARF), admission to SS, and female gender were significant predictors of bowel resection. CAD and ARF were significant predictors of mortality. Two hundred forty-four patients required operative intervention (surgery operative subgroup [SOS] 210 [43.6%], medicine operative subgroup [MOS] 34 [22.2%]). SOS and MOS were comparable for gender and race. SOS had shorter LOS (9.1 vs 12.3 days; P = 0.02), less hospital charges ($46,258 vs $62,778, P = 0.05), and less mortality (eight [3.81%] vs four [11.76%]; P = 0.07). Bowel resection was comparable (SOS 30% vs MOS 23%; P = 0.44). CAD and congestive heart failure (CHF) were significant predictors of bowel resection, whereas CAD was the only significant predictor of mortality in this subgroup. We recommend that patients with SBO be admitted to SS because this might translate to shorter LOS, earlier operative intervention, and reduced healthcare use direct cost. Bowel resection and death are more likely to occur in patients with comorbidities like CHF, CAD, diabetes mellitus, and ARF.
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Affiliation(s)
| | - Steve Angelo
- Medicine, Hospital of Saint Raphael, New Haven, Connecticut
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Conservative management of adhesive small bowel obstructions in patients previously operated on for primary colorectal cancer. J Gastrointest Surg 2008; 12:926-32. [PMID: 18060466 DOI: 10.1007/s11605-007-0423-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2007] [Accepted: 11/07/2007] [Indexed: 01/31/2023]
Abstract
This study aimed to determine the incidence of adhesive small bowel obstruction (SBO) after primary colorectal cancer surgery and the outcomes of conservative management using gastrointestinal tubes in such cases. Between October 2000 and December 2005, 2,586 primary colorectal cancer patients underwent consecutive operations and were followed up completely for a median of 38 months. During the follow-up periods, 119 patients with 130 consecutive cases of adhesive SBO underwent conservative management using nasogastric tubes and long intestinal tubes. The overall adhesive SBO rate was 5.0% in 38 months of follow-up, and the observed incidence rate was 0.0013 per patient-month. Of the 130 cases, 104 cases (80%) were successfully treated by conservative management, and the symptoms of SBO were resolved by the sixth day (range 1 to 22). Twenty-six cases (20%) underwent surgery because of lack of clinical improvement (17) or signs of strangulation (9). The high success rate indicates that initial conservative management with intestinal decompression using gastrointestinal tubes is recommended for patients with adhesive SBO after primary colorectal cancer surgery.
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Frankel H, Sperry J, Kaplan L, Foley A, Rabinovici R. Classification of adverse events occurring in a surgical intensive care unit. Am J Surg 2007; 194:328-32. [PMID: 17693277 DOI: 10.1016/j.amjsurg.2007.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Revised: 01/31/2007] [Accepted: 02/01/2007] [Indexed: 11/23/2022]
Abstract
INTRODUCTION We aimed to describe the preventability and provider specificity of surgical intensive care unit (SICU) deaths and complications compared with those in a cohort of trauma patients. METHODS Data were collected on all trauma and SICU admissions from July 1, 2001, to June 30, 2004, from administrative (Trauma Base and Project Impact) and morbidity databases. Services were protocol driven and staffed by in-house attendings. Performance improvement assessments were made by consensus. Deaths and complications were classified as preventable, potentially preventable, or nonpreventable, and provider-specific or not. Statistical significance was established at the P < .05 level. RESULTS One hundred sixty-eight deaths (5.6% rate), 464 procedure-related, and 694 non-procedure-related complications were noted in 2969 SICU patients compared with 166 deaths (3.6% rate), 178 procedure-related, and 261 non-procedure-related complications in 4,655 trauma patients. Thirty-one percent of SICU deaths were preventable/potentially preventable compared with 14% of trauma deaths, but only 1.9% was attributable to the SICU provider. SICU complications were less frequently preventable/potentially preventable than in trauma patients (52% versus 61%) and less often provider-specific (5% versus 19%). CONCLUSIONS SICU complications are deemed preventable less often than in trauma patients and, if so, infrequently incriminate the SICU provider. Preventable and potentially preventable SICU deaths are rarely attributed to SICU care. These data suggest that SICU performance improvement should focus on systems solutions and pre-SICU care.
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Affiliation(s)
- Heidi Frankel
- UT Southwestern Medical Center, Burn/Trauma/Critical Care Surgery, 5323 Harry Hines Blvd, E5.514, Dallas, TX 75390-9158, USA.
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Gowen GF. Rapid resolution of small-bowel obstruction with the long tube, endoscopically advanced into the jejunum. Am J Surg 2007; 193:184-9. [PMID: 17236844 DOI: 10.1016/j.amjsurg.2006.11.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Long-tube decompression has achieved a 75% to 80% success rate in 5 studies, and the short tube had a 40% success rate in 3 studies. METHODS From 1984 to 1991, an endoscope-advanced long intestinal tube was placed into the jejunum in 17 patients, and from 1992 to 2004 an improved long tube was used in 23 patients. Costs were calculated for each type of procedure. RESULTS In the first group, decompression was successful in 12 of 17 patients (70%). In the second group, decompression was successful in 21 of 23 patients (90%). The average charges were as follows: for the short tube the average charge was 21,687 dollars, and for the long tube the average charge was 11,316 dollars. CONCLUSIONS First, by using the improved long tube, which was advanced endoscopically into the jejunum, the success rate was 90% with procedures that are standard in every hospital. Second, most patients who fail the short-tube procedure are candidates for the long tube. Third, the improved long tube, endoscopically advanced into the jejunum, is recommended strongly because it provides significant advantages, both clinically and economically, over the short-tube approach. A prospective randomized study comparing the short tube for 3 days versus the long tube for 3 days is recommended to prove the superiority of the long tube in patients with small-bowel obstruction.
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Bristow RE, Santillan A, Diaz-Montes TP, Gardner GJ, Giuntoli RL, Peeler ST. Prevention of adhesion formation after radical hysterectomy using a sodium hyaluronate-carboxymethylcellulose (HA-CMC) barrier: a cost-effectiveness analysis. Gynecol Oncol 2006; 104:739-46. [PMID: 17097723 DOI: 10.1016/j.ygyno.2006.09.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2006] [Revised: 09/09/2006] [Accepted: 09/28/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of an adhesion prevention strategy compared to routine care, in which no adhesion prevention measures are taken, through a decision analysis model in the clinical setting of patients undergoing radical hysterectomy and pelvic lymphadenectomy for Stage IB cervical cancer. METHODS A decision analysis model compared two strategies to manage the risk of adhesion-related morbidity following radical hysterectomy for Stage IB cervical cancer: (1) routine care with no adhesion prevention measures, and (2) the intervention strategy with a HA-CMC anti-adhesion barrier. The cost-effectiveness of each strategy was evaluated from the perspective of society and that of a third party payer. RESULTS From the perspective of society, the HA-CMC strategy had an overall cost per patient of $1932 and effectiveness of 7.901 QALYs and dominated the routine care strategy, which had a cost per patient of $3043 and effectiveness of 7.805 QALYs. From the perspective of a third party payer, the HA-CMC strategy had an overall cost per patient of $1247 and effectiveness of 7.987 QALYs and dominated the routine care strategy, which had a cost per patient of $1629 and effectiveness of 7.970 QALYs. A series of one-way sensitivity analyses confirmed the robustness of the model. CONCLUSIONS Under a conservative set of clinical and economic assumptions, an adhesion prevention strategy utilizing a HA-CMC barrier in patients undergoing radical hysterectomy for Stage IB cervical cancer is cost-effective from both the perspective of society as a whole and that of a third party payer.
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Affiliation(s)
- Robert E Bristow
- The Kelly Gynecologic Oncology Service, Department of Obstetrics and Gynecology, The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21287, USA.
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Foster NM, McGory ML, Zingmond DS, Ko CY. Small bowel obstruction: a population-based appraisal. J Am Coll Surg 2006; 203:170-6. [PMID: 16864029 DOI: 10.1016/j.jamcollsurg.2006.04.020] [Citation(s) in RCA: 158] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2006] [Revised: 04/19/2006] [Accepted: 04/20/2006] [Indexed: 02/07/2023]
Abstract
BACKGROUND Small bowel obstruction (SBO) is a common reason for surgical consultation, but little is known about the natural history of SBO. We performed a population-based analysis to evaluate SBO frequency, type of operation, and longterm outcomes. STUDY DESIGN Using the California Inpatient File, we identified all patients admitted in 1997 with a diagnosis of SBO. Patients were excluded if they had a diagnosis of bowel obstruction in the previous 6 years (1991 to 1996). Of the remaining cohort, the natural history of SBO over the subsequent 5 years (1998 to 2002) was analyzed. Index hospitalization outcomes (eg, surgical versus nonsurgical management, length of stay, in-hospital mortality), and longterm outcomes, including SBO readmissions and 1-year mortality, were evaluated. RESULTS We identified 32,583 patients with an index admission for SBO in 1997; 24% had surgery during the index admission. The distribution of surgical procedures was: 38% lysis of adhesions, 38% hernia repair, 18% small bowel resection with lysis of adhesions, and 6% small bowel resection with hernia repair. Patients who underwent operations during index admission had longer lengths of stay, lower mortality, fewer SBO readmissions, and longer time to readmission than patients treated nonsurgically. Regardless of treatment during the index admission, 81% of surviving patients had no additional SBO readmissions over the subsequent 5 years. CONCLUSIONS Most of the 32,583 patients requiring admission for index SBO in 1997 were treated nonsurgically, and few of these patients were readmitted. This is the first longitudinal population-based analysis of SBO evaluating surgical versus nonsurgical management and outcomes, including mortality and readmissions.
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Affiliation(s)
- Nova M Foster
- Center for Surgical Outcomes and Quality, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, CA 90095, USA
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Merlino JI, Delaney CP, Senagore AJ. Physiological Impact, Clinical Manifestations, and Complications of Postoperative Ileus, and Early Postoperative Small Bowel Obstruction. SEMINARS IN COLON AND RECTAL SURGERY 2005. [DOI: 10.1053/j.scrs.2006.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Abstract
Gastrointestinal disorders during pregnancy that require surgery often mimic the symptoms and signs of conditions that do not require surgery. Anatomic and physiologic changes of pregnancy can alter the usual clinical presentation of gastrointestinal disorders that require surgery. These alterations can be a challenge to diagnosis. Prompt treatment is critical to successful management. Most elective and urgent operations can be performed during pregnancy with minimal maternal and fetal risk. The condition of the mother should always take priority because proper treatment of the mother usually benefits the fetus as well.
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Affiliation(s)
- Mark A Malangoni
- Department of Surgery, Case Western Reserve University, MetroHealth Medical Center Campus, 2500 MetroHealth Drive, H-914, Cleveland, OH 44109, USA.
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Affiliation(s)
- Barbara L Bass
- Surgical Care Center, Baltimore VA Medical Center, and Department of Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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Vibert E, Regimbeau JM, Panis Y, Lê P, Soyer P, Boudiaf M, Rymer R, Valleur P. [Post-operative small bowel obstruction: spiral computed tomography]. ANNALES DE CHIRURGIE 2002; 127:765-70. [PMID: 12538097 DOI: 10.1016/s0003-3944(02)00880-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The aim of this study was to evaluate prospectively the impact of the routine use of abdominal spiral computed tomography (SCT) in patients with postoperative small bowel obstruction (SBO) for whom initial conservative treatment was proposed. PATIENTS AND METHODS We have compared the management of SBO in patients with clinical stable condition in two successive periods : from 1989 to 1998, 127 patients (preSCT group) for whom management was based on standard clinical-biological-radiological assessment (CBRA) et from 1999 to 2000, 30 patients (SCT group) for whom management included SCT. The decision of surgical team was correlated with the type of small bowel obstruction at laparotomy : closed-loop obstruction without intestinal necrosis (true-positive), intestinal necrosis as a consequence of delayed diagnosis defined as false-negative, diffuse adhesion defined as false-positive et patient non operated defined as true-negative. RESULTS Among the 127 patients from the preSCT group, 87 were treated conservatively and 40 were operated : SBO with closed-loop obstruction without intestinal necrosis (n = 29,72%), SBO with diffuse adhesion (n = 4, 10%) and SBO with intestinal necrosis (n = 7, 17%). Among the 30 patients from the SCT group, 16 were treated conservatively and 14 were operated: SBO with closed-loop obstruction without intestinal necrosis (n = 8, 57%), SBO with diffuse adhesion (n = 6,43%) and SBO with intestinal necrosis (n = 0,0%; NS). Both groups were similar for rates of patients with SBO with or without necrosis and rate of patients treated conservatively (NS). In SCT group, there was significantly more patients operated for diffuse adhesions (p < 0,01). Negative predictive value of CBRA + TDM was significantly higher than those of CBRA alone (p = 0,041). CONCLUSION Due to a very high sensibility, TDM increase probably the rate of early laparotomies, maybe unnecessary, in patients without any sign of SBO due to closed-loop obstruction. Thus, systematic use of TDM in patients with clinical suspicion of SBO remains to be evaluated.
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Affiliation(s)
- E Vibert
- Service de chirurgie hôpital Lariboisière, 2, rue Ambroise-Paré, 75475 Paris cedex 10, France
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