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Rafaqat W, Lagazzi E, Jehanzeb H, Abiad M, Luckhurst CM, Parks JJ, Albutt KH, Hwabejire JO, DeWane MP. Does practice make perfect? The impact of hospital and surgeon volume on complications after intra-abdominal procedures. Surgery 2024; 175:1312-1320. [PMID: 38418297 DOI: 10.1016/j.surg.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 11/26/2023] [Accepted: 01/12/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND There is increasing interest in the regionalization of surgical procedures. However, evidence on the volume-outcome relationship for emergency intra-abdominal surgery is not well-synthesized. This systematic review and meta-analysis summarize evidence regarding the impact of hospital and surgeon volume on complications. METHODS We identified cohort studies assessing the impact of hospital/surgeon volume on postoperative complications after emergency intra-abdominal procedures, with data collected after the year 2000 through a literature search without language restriction in the PubMed, Web of Science, and Cochrane databases. A weighted overall complication rate was calculated, and a random effect regression model was used for a summary odds ratio. A sensitivity analysis with the removal of studies contributing to heterogeneity was performed (PROSPERO: CRD42022358879). RESULTS The search yielded 2,153 articles, of which 9 cohort studies were included and determined to be good quality according to the Newcastle Ottawa Scale. These studies reported outcomes for the following procedures: cholecystectomy, colectomy, appendectomy, small bowel resection, peptic ulcer repair, adhesiolysis, laparotomy, and hernia repair. Eight studies (2,358,093 patients) with available data were included in the meta-analysis. Low hospital volume was not significantly associated with higher complications. In the sensitivity analysis, low hospital volume was significantly associated with higher complications when appropriate heterogeneity was achieved. Low surgeon volume was associated with higher complications, and these findings remained consistent in the sensitivity analysis. CONCLUSION We found that hospital and surgeon volume was significantly associated with higher complications in patients undergoing emergency intra-abdominal surgery when appropriate heterogeneity was achieved.
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Affiliation(s)
- Wardah Rafaqat
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Emanuele Lagazzi
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hamzah Jehanzeb
- Department of Surgery, Medical College, Aga Khan University, Karachi, Pakistan
| | - May Abiad
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Casey M Luckhurst
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jonathan J Parks
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Katherine H Albutt
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - John O Hwabejire
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Michael P DeWane
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
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Rafaqat W, Lagazzi E, Jehanzeb H, Abiad M, Hwabejire JO, Parks JJ, Kaafarani HM, DeWane MP. Which Volume Matters More? Systematic Review and Meta-Analysis of Hospital vs Surgeon Volume in Intra-Abdominal Emergency Surgery. J Am Coll Surg 2024; 238:332-346. [PMID: 37991251 DOI: 10.1097/xcs.0000000000000913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Affiliation(s)
- Wardah Rafaqat
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Emanuele Lagazzi
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Hamzah Jehanzeb
- Medical College, Aga Khan University, Karachi, Pakistan (Jehanzeb)
| | - May Abiad
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - John O Hwabejire
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Jonathan J Parks
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Haytham M Kaafarani
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
| | - Michael P DeWane
- From the Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA (Rafaqat, Lagazzi, Abiad, Hwabejire, Parks, Kaafarani, DeWane)
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Hatchimonji JS, Mavroudis CL, Friedman A, Kaufman EJ, Syvyk S, Wirtalla CJ, Keele L, Reilly PM, Kelz RR. National Cohort Study of Resource Utilization in Older Adults With Emergency General Surgery Conditions. J Surg Res 2023; 290:310-318. [PMID: 37329626 PMCID: PMC10330654 DOI: 10.1016/j.jss.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/22/2023] [Accepted: 05/13/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION Prior studies have sought to describe Emergency General Surgery (EGS) burden, but a detailed description of resource utilization for both operative and nonoperative management of EGS conditions has not been undertaken. METHODS Patient and hospital characteristics were extracted from Medicare data, 2015-2018. Operations, nonsurgical procedures, and other resources (i.e., radiology) were defined using Current Procedural Terminology codes. RESULTS One million eight hundred two thousand five hundred forty-five patients were included in the cohort. The mean age was 74.7 y and the most common diagnoses were upper gastrointestinal. The majority of hospitals were metropolitan (75.1%). Therapeutic radiology services were available in 78.4% of hospitals and operating rooms or endoscopy suites were available in 92.5% of hospitals. There was variability in resource utilization across EGS subconditions, with hepatobiliary (26.4%) and obstruction (23.9%) patients most frequently undergoing operation. CONCLUSIONS Treatment of EGS diseases in older adults involves several interventional resources. Changes in EGS models, acute care surgery training, and interhospital care coordination may be beneficial to the treatment of EGS patients.
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Affiliation(s)
- Justin S Hatchimonji
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Catherine L Mavroudis
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ari Friedman
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elinore J Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Solomiya Syvyk
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christopher J Wirtalla
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Luke Keele
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Patrick M Reilly
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel R Kelz
- Division of Endocrine and Oncologic Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Peden CJ, Aggarwal G, Aitken RJ, Anderson ID, Balfour A, Foss NB, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Johnston C, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Sharoky C, Urman RD, Wick E, Wu CL, Young-Fadok T, Scott MJ. Enhanced Recovery After Surgery (ERAS®) Society Consensus Guidelines for Emergency Laparotomy Part 3: Organizational Aspects and General Considerations for Management of the Emergency Laparotomy Patient. World J Surg 2023; 47:1881-1898. [PMID: 37277506 PMCID: PMC10241556 DOI: 10.1007/s00268-023-07039-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND This is Part 3 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy using an enhanced recovery after surgery (ERAS) approach. This paper addresses organizational aspects of care. METHODS Experts in management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and MEDLINE database searches were performed for ERAS elements and relevant specific topics. Studies were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. RESULTS Components of organizational aspects of care were considered. Consensus was reached after three rounds of a modified Delphi process. CONCLUSIONS These guidelines are based on best current available evidence for organizational aspects of an ERAS® approach to patients undergoing emergency laparotomy and include discussion of less common aspects of care for the surgical patient, including end-of-life issues. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
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Affiliation(s)
- Carol J. Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | - Angie Balfour
- Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU Scotland
| | | | - Zara Cooper
- Center for Surgery and Public Health, Harvard Medical School, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120 USA
- Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- Perioperative Medicine for Older People Undergoing Surgery (POPS), Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Faculty of Life Sciences and Medicine, King’s College London, London, UK
- Research Department of Targeted Intervention, Division of Surgery & Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Hälsovägen 3. B85, S 141 86 Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Carolyn Johnston
- Department of Anaesthesia, St George’s Hospital, Tooting, London, UK
| | - Jeniffer S. Kim
- Kaiser Permanente Research, Department of Research & Evaluation, 100 South Los Robles Ave, 2nd Floor, Pasadena, CA 91101 USA
| | - Nicholas P. Lees
- Department of General & Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Queen’s Medical Centre, Nottingham University Hospitals and University of Nottingham, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, Queen’s Medical Centre, School of Life Sciences, University of Nottingham, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, School of Medical Sciences, Orebro University Hospital, Orebro University, 701 85 Orebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Catherine Sharoky
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Richard D. Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10th Ave, Columbus, OH 43210 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine, and Department of Anesthesiology, Weill-Cornell Medicine, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ 85054 USA
| | - Michael J. Scott
- Department of Anesthesiology and Critical Care Medicine, and Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
- University College London, London, UK
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Barthold LK, Burney CP, Baumann LE, Briggs A. Complexity of Transferred Geriatric Adults Requiring Emergency General Surgery: A Rural Tertiary Center Experience. J Surg Res 2023; 283:640-647. [PMID: 36455417 DOI: 10.1016/j.jss.2022.10.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 08/22/2022] [Accepted: 10/16/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION As the American population ages, the number of geriatric adults requiring emergency general surgery (EGS) care is increasing. EGS regionalization could significantly affect the pattern of care for rural older adults. The aim of this study was to determine the current pattern of care for geriatric EGS patients at our rural academic center, with a focus on transfer status. MATERIALS AND METHODS We performed a retrospective chart review of patients aged ≥65 undergoing EGS procedures within 48 h of admission from 2014 to 2019 at our rural academic medical center. We collected demographic, admission, operative, and outcomes data. The primary outcomes of interest were mortality and nonhome discharge. Univariate and multivariate analyses were performed. RESULTS Over the 5-y study period, 674 patients underwent EGS procedures, with 407 (60%) transferred to our facility. Transfer patients (TPs) had higher American Society of Anesthesiology (ASA) scores (P < 0.001), higher rates of open abdomen (13% versus 5.6%, P = 0.001), and multiple operations (24 versus 11%, P < 0.001) than direct admit patients. However, after adjustment there was no difference in mortality (OR 1.64; 95% CI, 0.82-3.38) or nonhome discharge (OR 1.49; 95% CI, 0.95-2.36). CONCLUSIONS At our institution, the majority of rural geriatric EGS patients were transferred from another hospital for care. These patients had higher medical and operative complexity than patients presenting directly to our facility for care. After adjustment, transfer status was not independently associated with in-hospital mortality or nonhome discharge. These patients were appropriately transferred given their level of complexity.
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Affiliation(s)
- Laura K Barthold
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Charles P Burney
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Laura E Baumann
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Alexandra Briggs
- Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
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de'Angelis N, Marchegiani F, Schena CA, Khan J, Agnoletti V, Ansaloni L, Barría Rodríguez AG, Bianchi PP, Biffl W, Bravi F, Ceccarelli G, Ceresoli M, Chiara O, Chirica M, Cobianchi L, Coccolini F, Coimbra R, Cotsoglou C, D'Hondt M, Damaskos D, De Simone B, Di Saverio S, Diana M, Espin-Basany E, Fichtner-Feigl S, Fugazzola P, Gavriilidis P, Gronnier C, Kashuk J, Kirkpatrick AW, Ammendola M, Kouwenhoven EA, Laurent A, Leppaniemi A, Lesurtel M, Memeo R, Milone M, Moore E, Pararas N, Peitzmann A, Pessaux P, Picetti E, Pikoulis M, Pisano M, Ris F, Robison T, Sartelli M, Shelat VG, Spinoglio G, Sugrue M, Tan E, Van Eetvelde E, Kluger Y, Weber D, Catena F. Training curriculum in minimally invasive emergency digestive surgery: 2022 WSES position paper. World J Emerg Surg 2023; 18:11. [PMID: 36707879 PMCID: PMC9883976 DOI: 10.1186/s13017-023-00476-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 01/09/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Minimally invasive surgery (MIS), including laparoscopic and robotic approaches, is widely adopted in elective digestive surgery, but selectively used for surgical emergencies. The present position paper summarizes the available evidence concerning the learning curve to achieve proficiency in emergency MIS and provides five expert opinion statements, which may form the basis for developing standardized curricula and training programs in emergency MIS. METHODS This position paper was conducted according to the World Society of Emergency Surgery methodology. A steering committee and an international expert panel were involved in the critical appraisal of the literature and the development of the consensus statements. RESULTS Thirteen studies regarding the learning curve in emergency MIS were selected. All but one study considered laparoscopic appendectomy. Only one study reported on emergency robotic surgery. In most of the studies, proficiency was achieved after an average of 30 procedures (range: 20-107) depending on the initial surgeon's experience. High heterogeneity was noted in the way the learning curve was assessed. The experts claim that further studies investigating learning curve processes in emergency MIS are needed. The emergency surgeon curriculum should include a progressive and adequate training based on simulation, supervised clinical practice (proctoring), and surgical fellowships. The results should be evaluated by adopting a credentialing system to ensure quality standards. Surgical proficiency should be maintained with a minimum caseload and constantly evaluated. Moreover, the training process should involve the entire surgical team to facilitate the surgeon's proficiency. CONCLUSIONS Limited evidence exists concerning the learning process in laparoscopic and robotic emergency surgery. The proposed statements should be seen as a preliminary guide for the surgical community while stressing the need for further research.
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Affiliation(s)
- Nicola de'Angelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, Paris, France.
- Faculty of Medicine, University of Paris Est, UPEC, Créteil, France.
| | - Francesco Marchegiani
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, Paris, France
| | - Carlo Alberto Schena
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, Paris, France
| | - Jim Khan
- Department of Colorectal Surgery, Queen Alexandra Hospital, University of Portsmouth, Southwick Hill Road, Cosham, Portsmouth, UK
| | | | - Luca Ansaloni
- Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | | | - Paolo Pietro Bianchi
- Division of General and Robotic Surgery, Department of Health Sciences, San Paolo Hospital, University of Milan, Milan, Italy
| | - Walter Biffl
- Division of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, CA, USA
| | - Francesca Bravi
- Healthcare Administration, Santa Maria Delle Croci Hospital, Ravenna, Italy
| | - Graziano Ceccarelli
- General Surgery, San Giovanni Battista Hospital, USL Umbria 2, Foligno, Italy
| | - Marco Ceresoli
- General and Emergency Surgery, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Osvaldo Chiara
- General Surgery and Trauma Team, ASST Niguarda Milano, University of Milano, Milan, Italy
| | - Mircea Chirica
- Department of Digestive Surgery and Liver Transplantation, Michallon Hospital, Grenoble University, Grenoble, France
| | - Lorenzo Cobianchi
- Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
- Department of Clinical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Department, Pisa University Hospital, Pisa, Italy
| | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | | | - Mathieu D'Hondt
- Department of Digestive and Hepatobiliary/Pancreatic Surgery, Groeninge Hospital, Kortrijk, Belgium
| | | | - Belinda De Simone
- Department of General and Metabolic Surgery, Poissy and Saint-Germain-en-Laye Hospitals, Poissy, France
| | - Salomone Di Saverio
- Unit of General Surgery, San Benedetto del Tronto Hospital, av5 Asur Marche, San Benedetto del Tronto, Italy
| | - Michele Diana
- Digestive and Endocrine Surgery, Nouvel Hôpital Civil, University of Strasbourg, Strasbourg, France
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
| | - Eloy Espin-Basany
- Department of General Surgery, Hospital Valle de Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Stefan Fichtner-Feigl
- Department of General and Visceral Surgery, Medical Center University of Freiburg, Freiburg, Germany
| | - Paola Fugazzola
- Department of General Surgery, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Paschalis Gavriilidis
- Department of HBP Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Caroline Gronnier
- Eso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, Pessac, France
| | - Jeffry Kashuk
- Department of Surgery, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Andrew W Kirkpatrick
- Department of General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, AB, Canada
| | - Michele Ammendola
- Digestive Surgery Unit, Health of Science Department, "Magna Graecia" University Medical School, "Mater Domini" Hospital, Catanzaro, Italy
| | | | - Alexis Laurent
- Faculty of Medicine, University of Paris Est, UPEC, Créteil, France
- Unit of HPB and Service of General Surgery, Henri Mondor University Hospital, Creteil, France
| | - Ari Leppaniemi
- Department of Gastrointestinal Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mickaël Lesurtel
- Department of HPB Surgery and Liver Transplantation, AP-HP Beaujon Hospital, University of Paris Cité, Clichy, France
| | - Riccardo Memeo
- Unit of Hepato-Pancreato-Biliary Surgery, General Regional Hospital "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Marco Milone
- Department of Clinical Medicine and Surgery, Federico II" University of Naples, Naples, Italy
| | - Ernest Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Nikolaos Pararas
- 3Rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Andrew Peitzmann
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick Pessaux
- Visceral and Digestive Surgery, Nouvel Hôpital Civil, University of Strasbourg, Strasbourg, France
- Institute for Image-Guided Surgery, IHU Strasbourg, Strasbourg, France
- Institute of Viral and Liver Disease, INSERM U1110, Strasbourg, France
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Manos Pikoulis
- 3Rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | - Michele Pisano
- 1St General Surgery Unit, Department of Emergency, ASST Papa Giovanni Hospital Bergamo, Bergamo, Italy
| | - Frederic Ris
- Division of Digestive Surgery, University Hospitals of Geneva and Medical School, Geneva, Switzerland
| | - Tyler Robison
- Minimally Invasive Surgery Fellow, Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | | | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Giuseppe Spinoglio
- IRCAD Faculty Member Robotic and Colorectal Surgery- IRCAD, Strasbourg, France
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, Donegal, Ireland
| | - Edward Tan
- Department of Surgery, Trauma Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Yoram Kluger
- Department of General Surgery, Rambam Healthcare Campus, Haifa, Israel
| | - Dieter Weber
- Department of Trauma Surgery, Royal Perth Hospital, Perth, Australia
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, Cesena, Italy
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Costa G, Fransvea P, Puccioni C, Giovinazzo F, Carannante F, Bianco G, Catamero A, Masciana G, Miacci V, Caricato M, Capolupo GT, Sganga G. Gastro-intestinal emergency surgery: Evaluation of morbidity and mortality. Protocol of a prospective, multicenter study in Italy for evaluating the burden of abdominal emergency surgery in different age groups. (The GESEMM study). Front Surg 2022; 9:927044. [PMID: 36189400 PMCID: PMC9524583 DOI: 10.3389/fsurg.2022.927044] [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: 04/23/2022] [Accepted: 09/01/2022] [Indexed: 11/15/2022] Open
Abstract
Gastrointestinal emergencies (GE) are frequently encountered in emergency department (ED), and patients can present with wide-ranging symptoms. more than 3 million patients admitted to US hospitals each year for EGS diagnoses, more than the sum of all new cancer diagnoses. In addition to the complexity of the urgent surgical patient (often suffering from multiple co-morbidities), there is the unpredictability and the severity of the event. In the light of this, these patients need a rapid decision-making process that allows a correct diagnosis and an adequate and timely treatment. The primary endpoint of this Italian nationwide study is to analyze the clinicopathological findings, management strategies and short-term outcomes of gastrointestinal emergency procedures performed in patients over 18. Secondary endpoints will be to evaluate to analyze the prognostic role of existing risk-scores to define the most suitable scoring system for gastro-intestinal surgical emergency. The primary outcomes are 30-day overall postoperative morbidity and mortality rates. Secondary outcomes are 30-day postoperative morbidity and mortality rates, stratified for each procedure or cause of intervention, length of hospital stay, admission and length of stay in ICU, and place of discharge (home or rehabilitation or care facility). In conclusion, to improve the level of care that should be reserved for these patients, we aim to analyze the clinicopathological findings, management strategies and short-term outcomes of gastrointestinal emergency procedures performed in patients over 18, to analyze the prognostic role of existing risk-scores and to define new tools suitable for EGS. This process could ameliorate outcomes and avoid futile treatments. These results may potentially influence the survival of many high-risk EGS procedure.
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Affiliation(s)
- Gianluca Costa
- Surgery Centre, Colorectal Surgery Unit, Fondazione Policlinico Universitariio Campus Bio-Medico, Università Campus Bio-Medico, Rome, Italy
| | - Pietro Fransvea
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Caterina Puccioni
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Catholic University of Sacred Heart, Rome, Italy
| | - Francesco Giovinazzo
- General Surgery and Liver Transplantation, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Filippo Carannante
- Surgery Centre, Colorectal Surgery Unit, Fondazione Policlinico Universitariio Campus Bio-Medico, Università Campus Bio-Medico, Rome, Italy
| | - Gianfranco Bianco
- Surgery Centre, Colorectal Surgery Unit, Fondazione Policlinico Universitariio Campus Bio-Medico, Università Campus Bio-Medico, Rome, Italy
| | - Alberto Catamero
- Surgery Centre, Colorectal Surgery Unit, Fondazione Policlinico Universitariio Campus Bio-Medico, Università Campus Bio-Medico, Rome, Italy
| | - Gianluca Masciana
- Surgery Centre, Colorectal Surgery Unit, Fondazione Policlinico Universitariio Campus Bio-Medico, Università Campus Bio-Medico, Rome, Italy
| | - Valentina Miacci
- Surgery Centre, Colorectal Surgery Unit, Fondazione Policlinico Universitariio Campus Bio-Medico, Università Campus Bio-Medico, Rome, Italy
| | - Marco Caricato
- Surgery Centre, Colorectal Surgery Unit, Fondazione Policlinico Universitariio Campus Bio-Medico, Università Campus Bio-Medico, Rome, Italy
| | - Gabriella Teresa Capolupo
- Surgery Centre, Colorectal Surgery Unit, Fondazione Policlinico Universitariio Campus Bio-Medico, Università Campus Bio-Medico, Rome, Italy
| | - Gabriele Sganga
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Catholic University of Sacred Heart, Rome, Italy
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8
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Osterman E, Helenius L, Larsson C, Jakobsson S, Majumder T, Blomberg A, Wickenberg J, Linder F. Surgery for acute cholecystitis in severely comorbid patients: a population-based study on acute cholecystitis. BMC Gastroenterol 2022; 22:371. [PMID: 35927715 PMCID: PMC9354429 DOI: 10.1186/s12876-022-02453-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/28/2022] [Indexed: 12/07/2022] Open
Abstract
Background International guidelines recommend emergency cholecystectomy for acute cholecystitis in patients who are healthy or have mild systemic disease (ASA1-2). Surgery is also an option for patients with severe systemic disease (ASA3) in clinical practice. The study aimed to investigate the risk of complications in ASA3 patients after surgery for acute cholecystitis.
Method 1 634 patients treated for acute cholecystitis at three Swedish centres between 2017 and 2020 were included in the study. Data was gathered from electronic patient records and the Swedish registry for gallstone surgery, Gallriks. Logistic regression was used to assess the risk of complications adjusted for confounding factors: sex, age, BMI, Charlson comorbidity index, cholecystitis grade, smoking and time to surgery. Results 725 patients had emergency surgery for acute cholecystitis, 195 were ASA1, 375 ASA2, and 152 ASA3. Complications occurred in 9% of ASA1, 13% of ASA2, and 24% of ASA3 patients. There was no difference in 30-day mortality. ASA3 patients stayed on average 2 days longer after surgery. After adjusting for other factors, the risk of complications was 2.5 times higher in ASA3 patients than in ASA1 patients. The risk of complications after elective surgery was 5% for ASA1, 13% for ASA2 and 14% for ASA3 patients. Regardless of ASA 18% of patients treated non-operatively had a second gallstone complication within 3 months. Conclusion Patients with severe systemic disease have an increased risk of complications but not death after emergency surgery. The risk is lower for elective procedures, but a substantial proportion will have new gallstone complications before elective surgery. Trial registration: Not applicable. Supplementary Information The online version contains supplementary material available at 10.1186/s12876-022-02453-0.
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Affiliation(s)
- Erik Osterman
- Department of Surgery, Gävle Hospital, 80187, Gävle, Gävleborg Region, Sweden. .,Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden. .,Centre for Research and Development, Gävle, Gävleborg Region, Sweden.
| | - Louise Helenius
- Department of Surgery, Gävle Hospital, 80187, Gävle, Gävleborg Region, Sweden
| | - Christina Larsson
- Department of Surgery, Gävle Hospital, 80187, Gävle, Gävleborg Region, Sweden
| | - Sofia Jakobsson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Tamali Majumder
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Blomberg
- Department of Surgery, Gävle Hospital, 80187, Gävle, Gävleborg Region, Sweden
| | - Jennie Wickenberg
- Department of Surgery, Gävle Hospital, 80187, Gävle, Gävleborg Region, Sweden
| | - Fredrik Linder
- Department of Surgery, Uppsala University Hospital, Uppsala, Uppsala Region, Sweden.,Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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9
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Cioffi SPB, Chiara O, Del Prete L, Bonomi A, Altomare M, Spota A, Bini R, Cimbanassi S. Failure to Rescue (FTR) and Pitfalls in the Management of Complex Enteric Fistulas (CEF): From Rescue Surgery to Rescue Strategy. J Pers Med 2022; 12:jpm12020292. [PMID: 35207780 PMCID: PMC8875978 DOI: 10.3390/jpm12020292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose: Complex enteric fistulas (CEF) represent general surgeons’ nightmare. This paper aims to explore the impact on failure-to-rescue (FTR) rate of a standardised and integrated surgical and critical care step-up approach. Methods: This was a retrospective observational cohort study. Patients treated for CEF from 2009 to 2019 at Niguarda Hospital were included. Each patient was approached following a three-step approach: study phase, sepsis control and strategy definition phase, and surgical rescue phase. Results: Sixteen patients were treated for CEF. Seven fistulas were classified as complex entero-cutaneous (ECF) and nine as entero-atmospheric fistula (EAF). Median number of surgical procedures for fistula control before definitive surgical attempt was 11 (IQR 2–33.5). The median time from culprit surgery and the first access at Niguarda Hospital to definitive surgical attempt were 279 days (IQR 231–409) and 120 days (IQR 34–231), respectively. Median ICU LOS was 71 days (IQR 28–101), and effective hospital LOS was 117 days, (IQR 69.5–188.8). Three patients (18.75%) experienced spontaneous fistula closure after conversion to simple ECF, whereas 13 (81.25%) underwent definitive surgery for fistula takedown. Surgical rescue was possible in nine patients. Nine patients underwent multiple postoperative revision for surgical complications. Four patients failed to be rescued. Conclusion: An integrated step-up rescue strategy is crucial to standardise the approach to CEF and go beyond the basic surgical rescue procedure. The definition of FTR is dependent from the examined population. CEF patients are a unique cluster of emergency general surgery patients who may need a tailored definition of FTR considering the burden of postoperative events influencing their outcome.
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Affiliation(s)
- Stefano Piero Bernardo Cioffi
- General Surgery and Trauma Team, ASST GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy; (S.P.B.C.); (O.C.); (M.A.); (A.S.); (R.B.)
| | - Osvaldo Chiara
- General Surgery and Trauma Team, ASST GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy; (S.P.B.C.); (O.C.); (M.A.); (A.S.); (R.B.)
- Department of Pathophysiology and Transplants, State University of Milan, Via Festa del Perdono 7, 20122 Milan, Italy
| | - Luca Del Prete
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Alessandro Bonomi
- General Surgery Residency Program, State University of Milan, Via Festa del Perdono 7, 20122 Milan, Italy;
| | - Michele Altomare
- General Surgery and Trauma Team, ASST GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy; (S.P.B.C.); (O.C.); (M.A.); (A.S.); (R.B.)
- Department of Surgical Sciences, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Andrea Spota
- General Surgery and Trauma Team, ASST GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy; (S.P.B.C.); (O.C.); (M.A.); (A.S.); (R.B.)
| | - Roberto Bini
- General Surgery and Trauma Team, ASST GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy; (S.P.B.C.); (O.C.); (M.A.); (A.S.); (R.B.)
| | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy; (S.P.B.C.); (O.C.); (M.A.); (A.S.); (R.B.)
- Department of Pathophysiology and Transplants, State University of Milan, Via Festa del Perdono 7, 20122 Milan, Italy
- Correspondence:
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10
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Nunes AA, Pinheiro RP, Costa HRT, Defino HLA. Predictors of hospital readmission within 30 days after surgery for thoracolumbar fractures: A mixed approach. Int J Health Plann Manage 2022; 37:1708-1721. [PMID: 35170106 DOI: 10.1002/hpm.3437] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 11/10/2021] [Accepted: 01/28/2022] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Readmission followed by surgery to treat spinal fractures has a substantial impact on patient care costs and reflects a hospital's quality standards. This article analyzes the factors associated with hospital readmission followed by surgery to treat spinal fractures. METHODS This was a cross-sectional study with time-series analysis. For prediction analysis, we used Cox proportional hazards and machine-learning models, using data from the Healthcare Cost and Utilization Project, Inpatient Database from Florida (USA). RESULTS The sample comprised 215,999 patients, 8.8% of whom were readmitted within 30 days. The factors associated with a risk of readmission were male sex (1.1 [95% confidence interval 1.06-1.13]) and >60 years of age (1.74 [95% CI: 1.69-1.8]). Surgeons with a higher annual patient volume presented a lower risk of readmission (0.61 [95% CI: 0.59-0.63]) and hospitals with an annual volume >393 presented a lower risk (0.92 [95% CI: 0.89-0.95]). CONCLUSION Surgical procedures and other selected predictors and machine-learning models can be used to reduce 30-day readmissions after spinal surgery. Identification of patients at higher risk for readmission and complications is the first step to reducing unplanned readmissions.
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Affiliation(s)
- Altacílio Aparecido Nunes
- Department of Social Medicine, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Rômulo Pedroza Pinheiro
- Department of Orthopedics and Anesthesiology, Hospital das Clínicas at Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Herton Rodrigo Tavares Costa
- Department of Orthopedics and Anesthesiology, Hospital das Clínicas at Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Helton Luiz Aparecido Defino
- Department of Orthopedics and Anesthesiology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
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11
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Ghneim MH, Kufera JA, Clark J, Harfouche MN, Hendrix CJ, Diaz JJ. Emergency General Surgery Procedures and Cost of Care for Older Adults in the State of Maryland. Am Surg 2021; 88:439-446. [PMID: 34732080 DOI: 10.1177/00031348211048838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Older adults (OAs) ≥ 65 years of age, representing the fastest growing segment in the United States, are anticipated to require a greater percentage of emergency general surgery procedures (EGSPs) with an associated increase in health care costs. The aims of this study were to identify the frequency of EGSP and charges incurred by OA compared to their younger counterparts in the state of Maryland. METHODS A retrospective review of the Maryland Health Services Cost Review Commission from 2009 to 2018 was undertaken. Patients undergoing urgent or emergent ESGP were divided into 2 groups (18-64 years and ≥65 years). Data collected included demographics, APR-severity of illness (SOI), APR-risk of mortality (ROM), the EGSP (partial colectomy [PC], small bowel resection [SBR], cholecystectomy, operative management of peptic ulcer disease, lysis of adhesions, appendectomy, and laparotomy), length of stay (LOS), and hospital charges. P-values (P < .05) were significant. RESULTS Of the 181,283 patients included in the study, 55,401 (38.1%) were ≥65 years of age. Older adults presented with greater APR-SOI (major 37.7% vs 21.3%, extreme 5.2% vs 9.3%), greater APR-ROM (major 25.3% vs 8.7%, extreme 22.3% vs 5.3%), underwent PC (24.5% vs 10.9%) and SBR (12.8% vs 7.0%) more frequently, and incurred significantly higher median hospital charges for every EGSP, consistently between 2009 and 2018 due to increased LOS and complications when compared to those ≤65 years of age. CONCLUSION These findings stress the need for validated frailty indices and quality improvement initiatives focused on the care of OAs in emergency general surgery to maximize outcomes and optimize cost.
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Affiliation(s)
- Mira H Ghneim
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, 137889University of Maryland Medical Center, Baltimore, MD, USA
| | - Joseph A Kufera
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, 137889University of Maryland Medical Center, Baltimore, MD, USA
| | - Jaclyn Clark
- National Study Center for Trauma and Emergency Medical Systems, Center for Shock, Trauma and Anesthesiology Research, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Melike N Harfouche
- National Study Center for Trauma and Emergency Medical Systems, Center for Shock, Trauma and Anesthesiology Research, 12264University of Maryland School of Medicine, Baltimore, MD, USA
| | - Cheralyn J Hendrix
- Department of Surgery, Program in Trauma, R Adams Cowley Shock Trauma Center, 137889University of Maryland Medical Center, Baltimore, MD, USA
| | - Jose J Diaz
- National Study Center for Trauma and Emergency Medical Systems, Center for Shock, Trauma and Anesthesiology Research, 12264University of Maryland School of Medicine, Baltimore, MD, USA
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12
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Skelhorne-Gross G, Nenshi R, Jerath A, Gomez D. Structures, processes and models of care for emergency general surgery in Ontario: a cross-sectional survey. CMAJ Open 2021; 9:E1026-E1033. [PMID: 34815257 PMCID: PMC8612654 DOI: 10.9778/cmajo.20200306] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Emergency general surgery (EGS) patients require urgent surgical evaluation and intervention for various conditions, such as infectious or obstructive diseases of the gastrointestinal tract. We aimed to characterize the structures and processes that are relevant to the delivery of EGS care across Ontario hospitals and to evaluate the availability of critical resources at hospitals with formal EGS models. METHODS Between August 2019 and July 2020, we conducted a cross-sectional survey of Ontario hospitals that offered urgent general surgery (defined as the ability to provide nonelective surgical intervention within 24 to 48 hours of presentation) to adults. People with intimate knowledge of their hospital's EGS program completed a Web-based or telephone survey characterizing the program's organizational structure and staffing, operating room availability, interventional radiology and interventional endoscopy availability, intensive care unit availability and staffing, and regional participation. Their responses were compiled and comparisons were made between hospitals with and without formal EGS models of care, as well as between hospitals based on size and academic status. RESULTS Of the 114 Ontario hospitals identified, 109 responded (95.6% response rate). A third (34.6%; n = 37/107) of hospitals had EGS models of care. Thirty-four of these (91.9%) were large (> 100-bed) institutions that would be likely to have increased resources. However, even for hospitals of similar size, those with EGS models had increased staffing levels compared to those without (clinical associates 17.6% [n = 3/17] v. 10.0% [n = 2/20]; nurse practitioners or physician assistants 27.8% [n = 5/18] v. 14.3% [n = 3/21]). They also had better access to diagnostic and interventional equipment (24/7 access to computed tomography 94.1% [n = 16/17] v. 69.2% [n = 18/26]), interventional radiology (88.9% [n = 16/18] v. 42.3% [n = 11/26]), endoscopy (100% [n = 18/18] v. 69.2% [n = 18/26]) and endoscopic retrograde cholangiopancreatography (77.8% [n = 14/18] v. 42.3% [n = 11/26]), as well as dedicated operating room time (72.2% [n = 13/18] v. 0% [n = 0/25]). INTERPRETATION The structures and processes available to care for patients requiring EGS in Ontario were highly variable between hospitals. Hospitals with formal EGS models were more likely to have access to key resources.
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Affiliation(s)
- Graham Skelhorne-Gross
- Division of General Surgery (Skelhorne-Gross, Gomez), Department of Surgery, University of Toronto, Toronto, Ont.; Division of General Surgery (Nenshi), Department of Surgery, McMaster University, Hamilton, Ont.; Department of Anesthesia and Pain Medicine (Jerath), University of Toronto; Li Ka Shing Knowledge Institute (Gomez), St. Michael's Hospital; ICES Central (Jerath), Toronto, Ont
| | - Rahima Nenshi
- Division of General Surgery (Skelhorne-Gross, Gomez), Department of Surgery, University of Toronto, Toronto, Ont.; Division of General Surgery (Nenshi), Department of Surgery, McMaster University, Hamilton, Ont.; Department of Anesthesia and Pain Medicine (Jerath), University of Toronto; Li Ka Shing Knowledge Institute (Gomez), St. Michael's Hospital; ICES Central (Jerath), Toronto, Ont
| | - Angela Jerath
- Division of General Surgery (Skelhorne-Gross, Gomez), Department of Surgery, University of Toronto, Toronto, Ont.; Division of General Surgery (Nenshi), Department of Surgery, McMaster University, Hamilton, Ont.; Department of Anesthesia and Pain Medicine (Jerath), University of Toronto; Li Ka Shing Knowledge Institute (Gomez), St. Michael's Hospital; ICES Central (Jerath), Toronto, Ont
| | - David Gomez
- Division of General Surgery (Skelhorne-Gross, Gomez), Department of Surgery, University of Toronto, Toronto, Ont.; Division of General Surgery (Nenshi), Department of Surgery, McMaster University, Hamilton, Ont.; Department of Anesthesia and Pain Medicine (Jerath), University of Toronto; Li Ka Shing Knowledge Institute (Gomez), St. Michael's Hospital; ICES Central (Jerath), Toronto, Ont.
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13
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Wohlgemut JM, Ramsay G, Bekheit M, Scott NW, Watson AJM, Jansen JO. Emergency general surgery: Impact of hospital and surgeon admission case volume on mortality. J Trauma Acute Care Surg 2021; 90:996-1002. [PMID: 34016923 DOI: 10.1097/ta.0000000000003128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Emergency general surgery (EGS) is a high-volume and high-risk surgical service. Interhospital variation in EGS outcomes exists, but there is disagreement in the literature as to whether hospital admission volume affects in-hospital mortality. Scotland collects high-quality data on all admitted patients, whether managed operatively or nonoperatively. Our aim was to determine the relationship between hospital admission volume and in-hospital mortality of EGS patients in Scotland. Second, to investigate whether surgeon admission volume affects mortality. METHODS This national population-level cohort study included EGS patients aged 16 years and older, who were admitted to a Scottish hospital between 2014 and 2018 (inclusive). A logistic regression model was created, with in-hospital mortality as the dependent variable, and admission volume of hospital per year as a continuous covariate of interest, adjusted for age, sex, comorbidity, deprivation, surgeon admission volume, surgeon operative rate, transfer status, diagnosis, and operation category. RESULTS There were 376,076 admissions to 25 hospitals, which met our inclusion criteria. The EGS hospital admission rate per year had no effect on in-hospital mortality (odds ratio [OR], 1.000; 95% confidence interval [CI], 1.000-1.000). Higher average surgeon monthly admission volume increased the odds of in-hospital mortality (>35 admissions: OR, 1.139; 95% CI, 1.038-1.250; 25-35 admissions: OR, 1.091; 95% CI, 1.004-1.185; <25 admissions was the referent). CONCLUSION In Scotland, in contrast to other settings, EGS hospital admission volume did not influence in-hospital mortality. The finding of an association between individual surgeons' case volume and in-hospital mortality warrants further investigation. LEVEL OF EVIDENCE Care management, Level IV.
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Affiliation(s)
- Jared M Wohlgemut
- From the Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition (J.M.W.), University of Aberdeen, Aberdeen; Department of General Surgery (J.M.W.), Queen Elizabeth University Hospital, Glasgow; Centre for Trauma Sciences, Blizard Institute (J.M.W.), Queen Mary University of London, Whitechapel, London; General Surgical Department (G.R., M.B.), Aberdeen Royal Infirmary; Rowett Institute for Health (G.R.), University of Aberdeen, Aberdeen, United Kingdom; Department of Surgery (M.B.), Elkabbary Hospital, Alexandria, Egypt; Medical Statistics Team (N.W.S.), University of Aberdeen, Aberdeen; Raigmore Hospital (A.J.M.W.), Inverness, United Kingdom; and Division of Acute Care Surgery (J.O.J.), Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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14
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Kenawy DM, Renshaw SM, George E, Malik AT, Collins CE. Increasing Frailty in Geriatric Emergency General Surgery: A Cause for Concern. J Surg Res 2021; 266:320-327. [PMID: 34052600 DOI: 10.1016/j.jss.2021.04.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 03/05/2021] [Accepted: 04/10/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) presents a challenge for frail, geriatric individuals who often have extensive comorbidities affecting postoperative recovery. Previous studies have shown an association between increasing frailty and adverse outcomes following elective and EGS; no study has explored the same for the geriatric patient population using the modified 5-item frailty index (mFI-5) score. MATERIALS AND METHODS A retrospective cohort study was performed using the 2012-2017 American College of Surgeons - National Surgical Quality Improvement Program database to identify geriatric patients (≥65 years) undergoing EGS procedures within 48 h of admission. The previously validated mFI-5 score was used to assess preoperative frailty. The study cohort was divided into four groups: mFI-5 = 0, mFI-5 = 1, mFI-5 = 2, and mFI-5 ≥ 3; the impact of increasing mFI-5 score on failure-to-rescue (FTR), 30-day complications, readmissions, reoperations, and mortality was assessed. RESULTS A total of 47,216 patients were included: 27.4% with mFI-5 = 0, 45% with mFI-5 = 1, 22.1% with mFI-5 = 2, and 5.5% with mFI-5 ≥ 3. Following multivariate analyses, increasing mFI-5 score was associated with higher odds of FTR (mFI-5 = 1: odds ratio (OR) 1.48, p=0.003; mFI-5 = 2: OR 2.66, p <0.001; mFI-5 ≥ 3: OR 3.97, p <0.001), 30-day complications (mFI-5 = 1: OR 1.46, p <0.001; mFI-5 = 2: OR 2.48, p <0.001; mFI-5≥3: OR 5.01, p <0.001), reoperation (mFI-5 = 1: OR 1.42, p = 0.020; mFI-5 = 2: OR 1.70, p = 0.021; mFI-5 ≥ 3: OR 2.18, p = 0.009) and all-cause mortality (mFI-5 = 1: OR 1.49, p=0.001; mFI-5 = 2: OR 2.67, p <0.001; mFI-5 ≥ 3: 3.96, p <0.001). CONCLUSIONS Increasing frailty in geriatric EGS patients is associated with significantly higher rates of FTR, 30-day complications, reoperations, and all-cause mortality. The mFI-5 score can be used to assess frailty and better anticipate the postoperative course of vulnerable geriatric patients.
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Affiliation(s)
- Dahlia M Kenawy
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Savannah M Renshaw
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Emily George
- College of Medicine, The Ohio State University, Columbus, OH
| | - Azeem Tariq Malik
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Courtney E Collins
- Division of General and Gastrointestinal Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
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15
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Rodionova K, Hindermann M, Hilgers K, Ott C, Schmieder RE, Schiffer M, Amann K, Veelken R, Ditting T. AT II Receptor Blockade and Renal Denervation: Different Interventions with Comparable Renal Effects? Kidney Blood Press Res 2021; 46:331-341. [PMID: 34034251 DOI: 10.1159/000515616] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/02/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Angiotensin II (Ang II) and the renal sympathetic nervous system exert a strong influence on renal sodium and water excretion. We tested the hypothesis that already low doses of an Ang II inhibitor (candesartan) will result in similar effects on tubular sodium and water reabsorption in congestive heart failure (CHF) as seen after renal denervation (DNX). METHODS Measurement of arterial blood pressure, heart rate (HR), renal sympathetic nerve activity (RSNA), glomerular filtration rate (GFR), renal plasma flow (RPF), urine volume, and urinary sodium. To assess neural control of volume homeostasis, 21 days after the induction of CHF via myocardial infarction rats underwent volume expansion (0.9% NaCL; 10% body weight) to decrease RSNA. CHF rat and controls with or without DNX or pretreated with the Ang II type-1 receptor antagonist candesartan (0.5 ug i.v.) were studied. RESULTS CHF rats excreted only 68 + 10.2% of the volume load (10% body weight) in 90 min. CHF rats pretreated with candesartan or after DNX excreted from 92 to 103% like controls. Decreases of RSNA induced by volume expansion were impaired in CHF rats but unaffected by candesartan pointing to an intrarenal drug effect. GFR and RPF were not significantly different in controls or CHF. CONCLUSION The prominent function of increased RSNA - retaining salt and water - could no longer be observed after renal Ang II receptor blockade in CHF rats.
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Affiliation(s)
- Kristina Rodionova
- Department of Department of Internal Medicine 4 (Nephrology und Hypertension), University of Erlangen, Erlangen, Germany
- Department of Department of Internal Medicine 4 (Nephrology und Hypertension), Paracelsus Private Medical School, Klinikum Nuremberg, Nuremberg, Germany
| | - Martin Hindermann
- Department of Department of Internal Medicine 4 (Nephrology und Hypertension), University of Erlangen, Erlangen, Germany
| | - Karl Hilgers
- Department of Department of Internal Medicine 4 (Nephrology und Hypertension), University of Erlangen, Erlangen, Germany
| | - Christian Ott
- Department of Department of Internal Medicine 4 (Nephrology und Hypertension), University of Erlangen, Erlangen, Germany
- Department of Department of Internal Medicine 4 (Nephrology und Hypertension), Paracelsus Private Medical School, Klinikum Nuremberg, Nuremberg, Germany
| | - Roland E Schmieder
- Department of Department of Internal Medicine 4 (Nephrology und Hypertension), University of Erlangen, Erlangen, Germany
| | - Mario Schiffer
- Department of Department of Internal Medicine 4 (Nephrology und Hypertension), University of Erlangen, Erlangen, Germany
| | - Kerstin Amann
- Department of Nephropathology, University of Erlangen, Erlangen, Germany
| | - Roland Veelken
- Department of Department of Internal Medicine 4 (Nephrology und Hypertension), University of Erlangen, Erlangen, Germany
- Department of Department of Internal Medicine 4 (Nephrology und Hypertension), Paracelsus Private Medical School, Klinikum Nuremberg, Nuremberg, Germany
| | - Tilmann Ditting
- Department of Department of Internal Medicine 4 (Nephrology und Hypertension), University of Erlangen, Erlangen, Germany
- Department of Department of Internal Medicine 4 (Nephrology und Hypertension), Paracelsus Private Medical School, Klinikum Nuremberg, Nuremberg, Germany
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16
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Antoniou SA, Mavridis D, Kontouli KM, Drakopoulos V, Gorter-Stam M, Eriksson S, Leone M, Pérez-Bocanegra MC, Smart NJ, Milone M, Carrano FM, Antoniou GA, Vandvik PO. EAES rapid guideline: appendicitis in the elderly. Surg Endosc 2021; 35:3233-3243. [PMID: 33999255 DOI: 10.1007/s00464-021-08524-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is a lack of trustworthy evidence-informed guidelines on the diagnosis and management of acute appendicitis in elderly patients. METHODS We developed a rapid guideline in accordance with GRADE and AGREE II standards. The steering group consisted of general surgeons, members of the EAES Research Committee/Guidelines Subcommittee with expertise and experience in guideline development, advanced medical statistics and evidence synthesis, biostatisticians, and a guideline methodologist. The guideline panel consisted of three general surgeons, an intensive care physician, a geriatrician and a patient advocate. We conducted systematic reviews and the results of evidence synthesis were summarized in evidence tables. Recommendations were authored and published through an online authoring and publication platform (MAGICapp), with the guideline panel making use of an evidence-to-decision framework and a Delphi process to arrive at consensus. RESULTS This rapid guideline provides a weak recommendation against the use of clinical scoring systems to replace cross-sectional imaging in the diagnostic approach of suspected appendicitis in elderly patients. It provides a weak recommendation against the use of antibiotics alone over surgical treatment in patients who are deemed fit for surgery, and a weak recommendation for laparoscopic over open surgery. Furthermore, it provides a summary of surgery-associated risks in elderly patients. The guidelines, with recommendations, evidence summaries and decision aids in user-friendly formats can also be accessed in MAGICapp: https://app.magicapp.org/#/guideline/4494 . CONCLUSIONS This rapid guideline provides evidence-informed trustworthy recommendations on the diagnosis and management of acute appendicitis in elderly patients.
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Affiliation(s)
- Stavros A Antoniou
- Surgical Department, Mediterranean Hospital of Cyprus, Limassol, Cyprus. .,Medical School, European University Cyprus, Nicosia, Cyprus.
| | - Dimitris Mavridis
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece.,Faculté de Médecine, Université Paris Descartes, Paris, France
| | - Katerina Maria Kontouli
- Department of Primary Education, School of Education, University of Ioannina, Ioannina, Greece
| | - Vasileios Drakopoulos
- 1st Department of Surgery & Organ Transplant Unit, Evangelismos General Hospital of Athens, Athens, Greece
| | | | - Sture Eriksson
- Department of Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden
| | - Marc Leone
- Department of Anesthesiology and Critical Care Medicine, Nord Hospital, Marseille, France
| | | | - Neil J Smart
- Department of Surgery, Department of Surgery, Royal Devon & Exeter Hospital, Exeter, UK
| | - Marco Milone
- Department of Clinical Medicine and Surgery, University "Federico II" of Naples, Naples, Italy
| | - Francesco Maria Carrano
- PhD Program in Applied Medical-Surgical Sciences, University of Rome "Tor Vergata", 00133, Rome, Italy.,Department of Surgical Sciences, University of Rome "Tor Vergata", Viale Oxford, 81, 00133, Rome, Italy
| | - George A Antoniou
- Department of Vascular and Endovascular Surgery, The Royal Oldham Hospital, Pennine Acute Hospitals NHS Trust, Northern Care Alliance NHS Group, Manchester, UK.,Division of Cardiovascular Sciences, School of Medical Sciences, The University of Manchester, Manchester, UK
| | - Per Olav Vandvik
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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17
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Mitigating the stress response to improve outcomes for older patients undergoing emergency surgery with the addition of beta-adrenergic blockade. Eur J Trauma Emerg Surg 2021; 48:799-810. [PMID: 33847766 PMCID: PMC9001541 DOI: 10.1007/s00068-021-01647-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/11/2021] [Indexed: 12/14/2022]
Abstract
As population age, healthcare systems and providers are likely to experience a substantial increase in the proportion of elderly patients requiring emergency surgery. Emergency surgery, compared with planned surgery, is strongly associated with increased risks of adverse postoperative outcomes due to the short time available for diagnosis, optimization, and intervention in patients presenting with physiological derangement. These patient populations, who are often frail and burdened with a variety of co-morbidities, have lower reserves to deal with the stress of the acute condition and the required emergency surgical intervention. In this review article, we discuss topical areas where mitigation of the physiological stress posed by the acute condition and asociated surgical intervention may be feasible. We consider the impact of the adrenergic response and use of beta blockers for these high-risk patients and discuss common risk factors such as frailty and delirium. A proactive multidisciplinary approach to peri-operative care aimed at mitigation of the stress response and proactive management of common conditions in the older emergency surgical patient could yield more favorable outcomes.
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18
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Maurer LR, Sakran JV, Kaafarani HM. Predicting and Communicating Geriatric Trauma Outcomes. CURRENT TRAUMA REPORTS 2021. [DOI: 10.1007/s40719-020-00209-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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19
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Current opinion on emergency general surgery transfer and triage criteria. J Trauma Acute Care Surg 2021; 89:e71-e77. [PMID: 32467469 DOI: 10.1097/ta.0000000000002806] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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20
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Paredes AZ, Hyer JM, Tsilimigras DI, Dillhoff M, Cloyd JM, Ejaz A, Tsung A, Collins C, Pawlik TM. The association of Hospital Medicare beneficiary payer-mix, national quality rankings and outcomes following hepatopancreatic surgery. Am J Surg 2020; 221:492-496. [PMID: 33198957 DOI: 10.1016/j.amjsurg.2020.11.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/19/2020] [Accepted: 11/05/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION We sought to determine the impact of payer-mix on post-operative outcomes among Medicare beneficiaries following hepatopancreatic surgery. METHODS Medicare beneficiaries who underwent hepatopancreatic surgery were identified. Hospital quality markers were obtained from the Hospital General Information dataset. Hospitals were dichotomized (low/average vs. high) based on Medicare patient days versus all patient days irrespective of payer type. RESULTS High Medicare patient-mix hospitals were more likely to be ranked higher than the national average relative to safety of care (29.4% vs. 38.1%) and timeliness of care (15.4% vs. 26.3%) versus low burden Medicare hospitals (both p < 0.001). However, Medicare beneficiaries who had hepatopancreatic surgery at a high Medicare patient-mix hospital were at higher risk of a complication (OR = 1.13, 95%CI 1.04-1.22), and death within 30-days (OR = 1.37, 95%CI 1.23-1.53) following surgery. CONCLUSION While hospitals caring for higher numbers of Medicare beneficiaries generally performed better on CMS quality indicators, these rankings did not equate to improved post-operative outcomes.
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Affiliation(s)
- Anghela Z Paredes
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - J Madison Hyer
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Diamantis I Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Mary Dillhoff
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Jordan M Cloyd
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Allan Tsung
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA
| | - Courtney Collins
- Department of Surgery, Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH, USA.
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21
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Mazzeffi M, Ghoreishi M, Alejo D, Fonner CE, Tanaka K, Abernathy JH, Whitman G, Salenger R, Lawton J, Ad N, Brown J, Gammie J, Taylor B. Clinical Practice Variation and Outcomes for Stanford Type A Aortic Dissection Repair Surgery in Maryland: Report from a Statewide Quality Initiative. AORTA : OFFICIAL JOURNAL OF THE AORTIC INSTITUTE AT YALE-NEW HAVEN HOSPITAL 2020; 8:66-73. [PMID: 33152787 PMCID: PMC7644293 DOI: 10.1055/s-0040-1714121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background
Stanford Type A aortic dissection repair surgery is associated with high mortality and clinical practice remains variable among hospitals. Few studies have examined statewide practice variation.
Methods
Patients who had Stanford Type A aortic dissection repair surgery in Maryland between July 1, 2014 and June 30, 2018 were identified using the Maryland Cardiac Surgery Quality Initiative (MCSQI) database. Patient demographics, comorbidities, surgery details, and outcomes were compared between hospitals. We also explored the impact of arterial cannulation site and brain protection technique on outcome.
Results
A total of 233 patients were included from eight hospitals during the study period. Seventy-six percent of surgeries were done in two high-volume hospitals (≥10 cases per year), while the remaining 24% were done in low-volume hospitals. Operative mortality was 12.0% and varied between 0 and 25.0% depending on the hospital. Variables that differed significantly between hospitals included patient age, the percentage of patients in shock, left ventricular ejection fraction, creatinine level, arterial cannulation site, brain protection technique, tobacco use, and intraoperative blood transfusion. The percentage of patients who underwent aortic valve repair or replacement procedures differed significantly between hospitals (
p
< 0.001), although the prevalence of moderate-to-severe aortic insufficiency was not significantly different (
p
= 0.14). There were no significant differences in clinical outcomes including mortality, renal failure, stroke, or gastrointestinal complications between hospitals or based on arterial cannulation site (all
p
> 0.05). Patients who had aortic cross-clamping or endovascualr repair had more embolic strokes when compared with patients who had hypothermic circulatory arrest (
p
= 0.03).
Conclusion
There remains considerable practice variation in Stanford Type A aortic dissection repair surgery within Maryland including some modifiable factors such as intraoperative blood transfusion, arterial cannulation site, and brain protection technique. Continued efforts are needed within MCSQI and nationally to evaluate and employ the best practices for patients having acute aortic dissection repair surgery.
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Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Maryland, Baltimore, Maryland
| | - Mehrdad Ghoreishi
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland, Baltimore, Maryland
| | - Diane Alejo
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Clifford E Fonner
- Division of Cardiothoracic Surgery, Maryland Cardiac Surgery Quality Initiative Inc., Baltimore, Maryland
| | - Kenichi Tanaka
- Department of Anesthesiology, University of Maryland, Baltimore, Maryland
| | - James H Abernathy
- Department of Anesthesiology, Johns Hopkins University, Baltimore, Maryland
| | - Glenn Whitman
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rawn Salenger
- Department of Cardiothoracic surgery, St. Joseph Medical Center, Towson, Maryland
| | - Jennifer Lawton
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Niv Ad
- Department of Cardiothoracic Surgery, Washington Adventist Hospital, Takoma Park, Maryland
| | - James Brown
- Department of Surgery, University of Maryland, Capital Region Health, Cheverly, Maryland
| | - James Gammie
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland, Baltimore, Maryland
| | - Bradley Taylor
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland, Baltimore, Maryland
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22
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Does Emergency General Surgery (EGS) Hospital Volume Contribute to Improved Outcomes? CURRENT SURGERY REPORTS 2020. [DOI: 10.1007/s40137-020-00262-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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23
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Emergency general surgery in geriatric patients: How should we evaluate hospital experience? J Trauma Acute Care Surg 2020; 86:189-195. [PMID: 30444855 DOI: 10.1097/ta.0000000000002142] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION As the aging American population poses unique challenges to acute care services, we determined if either hospital proportion or annual volume of geriatric patients undergoing emergency general surgery (EGS) procedures is associated with outcomes. METHODS Using criteria from the American Association of the Surgery of Trauma, we identified five EGS procedures in the 2012-2015 Nationwide Inpatient Sample common in geriatric patients (65+ years). We defined hospital proportion as the fraction of geriatric EGS patients divided by all EGS patients, where volume was the raw number of geriatric EGS patients. We then divided hospitals into quartiles both by proportion and then by volume of geriatric patients. Multivariable logistic regressions compared four outcomes between these quartiles: mortality, complications, failure to rescue (FTR; death after a complication), and extended length of stay (LOS; procedure-specific top decile of patients). RESULTS We identified 25,084 complex EGS procedures in geriatric patients at 3,528 hospitals (mortality, 10.6%; complications, 30.5%; FTR, 27.7%; extended LOS, 9.1%). The median hospital proportion of geriatric patients among EGS procedures was 42.8% (interquartile range, 33.3-52.2%), whereas the median hospital geriatric EGS volume after nationwide weighting was 40 per year (interquartile range, 20-70/year). After adjustment, the lowest hospital proportion quartile relative to the highest was associated with adverse outcomes: mortality (odds ratio, 1.21 [95% confidence interval, 1.03-1.44]), complications (1.16 [1.05-1.29]), FTR (1.32 [1.08-1.63]), and extended LOS (1.30 [1.12-1.50]). The lowest volume quartile relative to the highest was not associated with adverse outcomes. As the hospital proportion of geriatric patients increased by 10%, the odds of all adverse outcomes decreased: mortality by 7%, complications by 4%, FTR by 9%, and extended LOS by 8%. CONCLUSION When accounting for both, hospital proportion of geriatric EGS patients but not hospital volume is associated with postoperative outcomes, having important implications for quality improvement initiatives, benchmarking endeavors, and health services research. LEVEL OF EVIDENCE Care management, level IV; prognostic, level III.
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24
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Benchmarking the value of care: Variability in hospital costs for common operations and its association with procedure volume. J Trauma Acute Care Surg 2020; 88:619-628. [PMID: 32039972 DOI: 10.1097/ta.0000000000002611] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Efforts to improve health care value (quality/cost) have become a priority in the United States. Although many seek to increase quality by reducing variability in adverse outcomes, less is known about variability in costs. In conjunction with the American Association for the Surgery of Trauma Healthcare Economics Committee, the objective of this study was to examine the extent of variability in total hospital costs for two common procedures: laparoscopic appendectomy (LA) and laparoscopic cholecystectomy (LC). METHODS Nationally weighted data for adults 18 years and older was obtained for patients undergoing each operation in the 2014 and 2016 National Inpatient Sample. Data were aggregated at the hospital-level to attain hospital-specific median index hospital costs in 2019 US dollars and corresponding annual procedure volumes. Cost variation was assessed using caterpillar plots and risk-standardized observed/expected cost ratios. Correlation analysis, variance decomposition, and regression analysis explored costs' association with volume. RESULTS In 2016, 1,563 hospitals representing 86,170 LA and 2,276 hospitals representing 230,120 LC met the inclusion criteria. In 2014, the numbers were similar (1,602 and 2,259 hospitals). Compared with a mean of US $10,202, LA median costs ranged from US $2,850 to US $33,381. Laparoscopic cholecystectomy median costs ranged from US $4,406 to US $40,585 with a mean of US $12,567. Differences in cost strongly associated with procedure volume. Volume accounted for 9.9% (LA) and 12.4% (LC) of variation between hospitals, after controlling for the influence of other hospital (8.2% and 5.0%) and patient (6.3% and 3.7%) characteristics and in-hospital complications (0.8% and 0.4%). Counterfactual modeling suggests that were all hospitals to have performed at or below their expected median cost, one would see a national cost savings of greater than US $301.9 million per year (95% confidence interval, US $280.6-325.5 million). CONCLUSION Marked variability of median hospital costs for common operations exists. Differences remained consistent across changing coding structures and database years and were strongly associated with volume. Taken together, the findings suggest room for improvement in emergency general surgery and a need to address large discrepancies in an often-overlooked aspect of value. LEVEL OF EVIDENCE Epidemiological, level III.
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25
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Failure to rescue in surgical patients: A review for acute care surgeons. J Trauma Acute Care Surg 2020; 87:699-706. [PMID: 31090684 DOI: 10.1097/ta.0000000000002365] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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26
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Unplanned readmission after traumatic injury: A long-term nationwide analysis. J Trauma Acute Care Surg 2020; 87:188-194. [PMID: 31045723 DOI: 10.1097/ta.0000000000002339] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Long-term outcomes after trauma admissions remain understudied. We analyzed the characteristics of inpatient readmissions within 6 months of an index hospitalization for traumatic injury. METHODS Using the 2010 to 2015 Nationwide Readmissions Database, which captures data from up to 27 US states, we identified patients at least 15 years old admitted to a hospital through an emergency department for blunt trauma, penetrating trauma, or burns. Exclusion criteria included hospital transfers, patients who died during their index hospitalizations, and hospitals with fewer than 100 trauma patients annually. After calculating the incidences of all-cause, unplanned inpatient readmissions within 1 month, 3 months, and 6 months, we used multivariable logistic regression models to identify predictors of readmissions. Analyses adjusted for patient, clinical, and hospital factors. RESULTS Among 2,763,890 trauma patients, the majority had blunt injuries (92.5%), followed by penetrating injuries (6.2%) and burns (1.5%). Overall, rates of inpatient readmissions were 11.1% within 1 month, 21.6% within 6 months, and 29.8% within 6 months, with limited variability by year. After adjustment, the following were associated with all-cause 6 months inpatient readmissions: male sex (adjusted odds ratio [aOR], 1.10; 95% confidence interval [95% CI], 1.09-1.10), comorbidities (aOR, 1.21; 95% CI, 1.21-1.22), low-income quartiles (first and second) (aOR, 1.08; 95% CI, 1.07-1.10 and aOR, 1.04; 95% CI, 1.03-1.06, respectively), Medicare (aOR, 1.65; 95% CI, 1.62-1.69), Medicaid (aOR, 1.51; 95% CI, 1.48-1.53), being treated at private, investor-owned hospitals (aOR, 1.15; 95% CI, 1.12-1.18), longer hospital length of stay (aOR, 1.01; 95% CI, 1.01-1.01) and patient disposition to short-term hospital (aOR, 1.55; 95% CI, 1.49-1.62), skilled nursing facility (aOR, 1.43; 95% CI, 1.42-1.45), home health care (aOR, 1.27; 95% CI, 1.25-1.28), or leaving against medical advice (aOR, 1.85; 95% CI, 1.78-1.92). CONCLUSION Unplanned readmission after trauma is high and remains this way 6 months after discharge. Understanding the factors that increase the odds of readmissions within 1 month, 3 months, and 6 months offer a focus for quality improvement and have important implications for hospital benchmarking. LEVEL OF EVIDENCE Epidemiological study, level III.
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27
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Chaudhary MA, Learn PA, Sturgeon DJ, Havens JM, Goralnick E, Koehlmoos T, Haider AH, Schoenfeld AJ. Emergency General Surgery Volume and Its Impact on Outcomes in Military Treatment Facilities. J Surg Res 2019; 247:287-293. [PMID: 31699538 DOI: 10.1016/j.jss.2019.08.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 07/26/2019] [Accepted: 08/14/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Low hospital volume for emergency general surgery (EGS) procedures is associated with worse patient outcomes within the civilian health care system. The military maintains treatment facilities (MTFs) in remote locations to provide access to service members and their families. We sought to determine if patients treated at low-volume MTFs for EGS conditions experience worse outcomes compared with high-volume centers. MATERIALS AND METHODS We analyzed TRICARE data from 2006 to 2014. Patients were identified using an established coding algorithm for EGS admission. MTFs were divided into quartiles based on annual EGS volume. Outcomes included 30-d mortality, complications, and readmissions. Logistic regression models adjusting for clinical and sociodemographic differences in case-mix including EGS condition, surgical intervention, and comorbidities were used to determine the influence of hospital volume on outcomes. RESULTS We identified 106,915 patients treated for an EGS condition at 79 MTFs. The overall mortality rate was 0.21%, with complications occurring in 8.55% and readmissions in 4.45%. After risk adjustment, lowest-volume MTFs did not demonstrate significantly higher odds of mortality (OR: 2.02, CI: 0.45-9.06) or readmissions (OR: 0.77, CI: 0.54-1.11) compared with the highest-volume centers. Lowest-volume facilities exhibited a lower likelihood of complications (OR: 0.76, CI: 0.59-0.98). CONCLUSIONS EGS patients treated at low-volume MTFs did not experience worse clinical outcomes when compared with high-volume centers. Remote MTFs appear to provide care for EGS conditions comparable with that of high-volume facilities. Our findings speak against the need to reduce services at small, critical access facilities within the military health care system.
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Affiliation(s)
- Muhammad Ali Chaudhary
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Peter A Learn
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Daniel J Sturgeon
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joaquim M Havens
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eric Goralnick
- Department of Emergency Medicine, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tracey Koehlmoos
- Department of Preventive Medicine and Biostatistics, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Adil H Haider
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew J Schoenfeld
- Department of Orthopaedic Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Dworsky JQ, Childers CP, Gornbein J, Maggard-Gibbons M, Russell MM. Hospital experience predicts outcomes after high-risk geriatric surgery. Surgery 2019; 167:468-474. [PMID: 31515123 DOI: 10.1016/j.surg.2019.07.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/20/2019] [Accepted: 07/27/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Geriatric patients require specialized perioperative care, yet the impact of geriatric surgery proportion (a measure of experience) and geriatric surgery volume, on clinical outcomes is unknown. This study analyzes the association between proportion and volume and clinical outcomes after high-risk geriatric surgery. METHODS Using the 2014 National Inpatient Sample, hospital encounters for older adults (≥65 years) undergoing high-risk geriatric surgery were identified. Geriatric surgery volume was defined as a hospital's annual volume of geriatric patients undergoing high-risk geriatric surgery. Geriatric surgery proportion was calculated as volume divided by the sum of high-risk surgeries in all ages. Hierarchical multivariable regression models identified predictors of inpatient mortality, postoperative length of stay, and discharge to nursing facility. RESULTS There were an estimated 514,950 hospital encounters for older adults undergoing high-risk geriatric surgery from 3,115 hospitals. Mean proportion was 0.53 ± 0.19; median volume was 60 cases per year, ranging from 5 to 3,235. After adjustment, comparing the 90th to 10th percentiles, higher proportion was associated with decreased mortality (odds ratio [95% confidence interval] 0.81 [0.73-0.88]; P < .001) and shorter postoperative length of stay (-4.44% (-5.49 to -3.39%); P < .0001). Higher volume was not associated with mortality but was associated with longer length of stay (7.76% [6.75-8.77%]; P < .0001) and decreased discharge to nursing facility (0.87 [0.79-0.95]; P= .003). CONCLUSION Treatment of geriatric patients at hospitals with the highest proportion of high-risk geriatric surgery, or the most experience, is associated with improved outcomes. High-proportion hospitals should be examined to understand the mechanisms by which better quality geriatric surgical care is achieved, while lower-proportion hospitals may be targets for quality improvement efforts.
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Affiliation(s)
- Jill Q Dworsky
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Health Policy and Management, Fielding School of Public Health, UCLA, Los Angeles, CA.
| | - Christopher P Childers
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Health Policy and Management, Fielding School of Public Health, UCLA, Los Angeles, CA
| | - Jeffrey Gornbein
- Department of Biomathematics, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | | | - Marcia M Russell
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA
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DeWane MP, Sukumar N, Stolar MJ, Gill TM, Maung AA, Schuster KM, Davis KA, Becher RD. High-performance acute care hospitals: Excelling across multiple emergency general surgery operations in the geriatric patient. J Trauma Acute Care Surg 2019; 87:140-146. [PMID: 31259872 PMCID: PMC7656193 DOI: 10.1097/ta.0000000000002273] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND As the geriatric population grows, the need for hospitals performing high quality emergency general surgery (EGS) on older patients will increase. Identifying clusters of high-performing geriatric emergency general surgery hospitals would substantiate the need for in-depth analyses of hospital-specific structures and practices that benefit older EGS patients. The objectives of this study were therefore to identify clusters of hospitals based on mortality performance for geriatric patients undergoing common EGS operations and to determine if hospital performance was similar for all operation types. METHODS Hospitals in the California State Inpatient Database were included if they performed a range of eight common EGS operations in patients 65 years or older, with a minimum requirement of three of each operation performed over 2 years. Multivariable beta regression models were created to define hospital-level risk-adjusted mortality. Centroid cluster analysis was used to identify groups of hospitals based on mortality and to determine if mortality-performance differed by operation. RESULTS One hundred seven hospitals were included, performing a total of 24,279 operations in older patients. Hospitals separated into three distinct clusters: high, average, and low performers. The high-performing hospitals had survival rates 1 to 2 standard deviations better than the low-performers (p < 0.001). For each cluster, high performance in any one EGS operation consistently translated into high performance across all EGS operations. CONCLUSION Hospitals conducting EGS operations in the geriatric patient population cluster into three distinct groups based on their survival performance. High-performing hospitals significantly outperform the average and low performers across every operation. The high-performers achieve reliable, high-quality results regardless of operation type. Further qualitative research is needed to investigate the perioperative drivers of hospital performance in the geriatric EGS population. LEVEL OF EVIDENCE Study Type Prognostic, level III.
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Affiliation(s)
- Michael P DeWane
- From the Section of General Surgery, Trauma, and Surgical Critical Care, Department of Surgery (M.P.D., A.A.M., K.M.S., K.A.D., R.D.B.), Yale School of Medicine; Yale Center for Analytical Sciences (N.S., M.J.S.), Yale School of Public Health; and Section of Geriatrics, Department of Internal Medicine (T.M.G.), Yale School of Medicine, New Haven, Connecticut
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Schuster K, Davis K, Hernandez M, Holena D, Salim A, Crandall M. American Association for the Surgery of Trauma emergency general surgery guidelines gap analysis. J Trauma Acute Care Surg 2019; 86:909-915. [PMID: 30768554 DOI: 10.1097/ta.0000000000002226] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) has been rapidly adopted as one of the major components of acute care surgery. Although heterogenous, the most common disease states that comprise EGS often have published guidelines containing recommendations for their diagnosis and management. Not all diseases included within EGS however have published guidelines and existing guidelines may have important gaps in their recommendations. We present a thorough assessment of the existing guidelines for the most common EGS diseases and highlight gaps that will require additional literature review or new research to fill. METHODS Literature searches for existing comprehensive guidelines were performed. These guidelines were summarized based on level of supporting evidence and further subcategorized based on American Association for the Surgery of Trauma (AAST) grade of disease. Using these summaries, gaps in the exiting recommendations were then generated and refined through review by at least two authors. RESULTS The initial gap analysis focused on diverticulitis, acute pancreatitis, small bowel obstruction and acute cholecystitis. Despite extensive research into each of these disease processes, critical questions regarding diagnosis and management remain to be answered. Gaps were the result of either low quality research or a complete lack of research. The use of the AAST grade of disease established a framework for evaluating these guidelines and grouping the recommendations. CONCLUSIONS Despite extensive prior research, EGS diseases have multiple areas where additional research would likely result in improved patient care. Consensus on the most important areas for additional research can be obtained through analysis of gaps in existing guidelines. This gap analysis has the potential to inform efforts around developing a research agenda for EGS.
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Affiliation(s)
- Kevin Schuster
- From the Department of Surgery (K.S.), Department of Surgery (K.D.), Yale School of Medicine, New Haven, Connecticut; Department of Surgery (M.H.), Mayo Medical Center, Rochester, Minnesota; Department of Surgery (D.H.), University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery (M.C.), Brigham and Women's Hospital, Boston, Massachusetts
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Recurring emergency general surgery: Characterizing a vulnerable population. J Trauma Acute Care Surg 2019; 86:464-470. [DOI: 10.1097/ta.0000000000002151] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Characterizing the underlying diagnoses for exploratory laparotomies to improve risk-adjustment models of postoperative mortality. J Trauma Acute Care Surg 2019; 86:664-669. [PMID: 30605142 DOI: 10.1097/ta.0000000000002090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgeons perform emergent exploratory laparotomies (ex-laps) for a myriad of surgical diagnoses. We characterized common diagnoses for which emergent ex-laps were performed and leveraged these groups to improve risk-adjustment models for postoperative mortality. METHODS Using American Association for the Surgery of Trauma criteria, we identified hospitalizations where the primary procedure was an emergent ex-lap in the 2012 to 2014 (derivation cohort) and 2015 (validation cohort) Nationwide Inpatient Sample. After tabulating all International Classification of Diseases-9th Rev.-Clinical Modification diagnosis codes within these hospitalizations, we divided them into clinically relevant groups. Using two stepwise regression paradigms-forward selection and backward elimination-we identified diagnostic groups significantly associated with postoperative mortality in multivariable logistic regressions. We evaluated the addition of these groups as individual covariates in risk-adjustment models for postoperative mortality using the area under the receiver operator characteristic curve. All regressions additionally adjusted for clinical factors and hospital clustering. RESULTS We identified 4127 patients in the derivation cohort (median age, 50 years; 46.0% female; 62.1% white), with an overall mortality rate of 13.4%. Among all patients, we tabulated a total of 164 diagnosis codes, of which 27 (16.5%) may have led to an emergent ex-lap. These 27 codes clinically represented seven diagnostic categories, which captured a majority of the patients (70.4%). Backward elimination and forward selection led to four common diagnosis categories associated with mortality: bleeding, obstruction, shock, and ischemia. Adjusting for these four diagnostic groups in a multivariable logistic regression assessing postoperative mortality increased the area under the receiver operator characteristic curve from 74.5% to 88.2% in the derivation cohort and from 73.8% to 88.2% in the validation cohort. CONCLUSION Seven diagnostic groups account for the majority of the emergent ex-laps. Adjusting for four groups may improve the accuracy of risk-adjustment models for mortality and validating such analytic standardization may optimize best research practices for EGS procedures. LEVEL OF EVIDENCE Prognostic and epidemiologic, Level III.
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Varma S, Mehta A, Canner JK, Azar F, Efron DT, Efron J, Safar B, Sakran JV. Surgery After an Initial Episode of Uncomplicated Diverticulitis: Does Time to Resection Matter? J Surg Res 2018; 234:224-230. [PMID: 30527478 DOI: 10.1016/j.jss.2018.09.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/21/2018] [Accepted: 09/12/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND The aim of this study was to determine whether time to surgery after an initial episode of uncomplicated diverticulitis is associated with undergoing an emergent versus an elective resection. METHODS In this retrospective, administrative claims database study, we identified patients at least 18 y old in the 2005-2011 California State Inpatient Database who had an initial episode of uncomplicated diverticulitis and then underwent a bowel resection within 2 y. After characterizing the distribution in time to surgery among all patients, we used a multivariable logistic regression to determine whether time to surgery was associated with undergoing an emergent resection. Next, we assessed differences in three outcomes between elective and emergent resections: at least one of eight postoperative complications, extended length of stay (defined as the top decile of hospitalizations), and 30-d inpatient readmissions. Analyses adjusted for time between initial hospitalization and resection, number of inpatient hospitalizations for diverticulitis before the resection, clinical factors, and hospital clustering. RESULTS We identified 4478 patients with an initial episode of uncomplicated diverticulitis followed by a bowel resection within the subsequent 2 y. One-fifth (21.1%) underwent an emergent resection. The median time from the initial episode to resection was 3.8 mo (IQR: 2.3-8.1 mo) for elective resections and 5.1 mo (IQR: 2.3-12.4 mo) for emergent resections. The adjusted odds of undergoing an emergent relative to an elective resection increased by 7% (aOR 1.07 [1.02-1.11]) for every 3 passing mo. Emergent resections were associated with greater adjusted odds of complications (adjusted odds ratio [aOR] 1.75 [95%-CI 1.43-2.15]), extended LOS (aOR 4.52 [3.31-6.17]), and 30-d readmissions (aOR 1.49 [1.09-2.04]). CONCLUSIONS Among patients who experienced an initial episode of uncomplicated diverticulitis and eventually underwent a resection, the odds of having an emergent relative to elective surgery increased with every 3 passing mo. These findings may inform the management of uncomplicated diverticulitis for high-risk patients eventually needing surgery.
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Affiliation(s)
- Sanskriti Varma
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ambar Mehta
- Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Surgery, NewYork-Presbyterian, Columbia University Medical Center, New York, New York
| | | | - Faris Azar
- Department of Surgery, Johns Hopkins, Baltimore, Maryland
| | - David T Efron
- Department of Surgery, Johns Hopkins, Baltimore, Maryland
| | - Jonathan Efron
- Department of Surgery, Johns Hopkins, Baltimore, Maryland
| | - Bashar Safar
- Department of Surgery, Johns Hopkins, Baltimore, Maryland
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