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Rafaqat W, Lagazzi E, McChesney S, Smith MC, UrRahman M, Lee H, DeWane MP, Khan A. To Resect or Not to Resect: A Nationwide Comparison of Management of Sigmoid Volvulus. J Surg Res 2024; 297:101-108. [PMID: 38484451 DOI: 10.1016/j.jss.2023.12.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 10/29/2023] [Accepted: 12/24/2023] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Despite the high recurrence rate of sigmoid volvulus, there is reluctance to perform a prophylactic colectomy in frail patients due to the operation's perceived risks. We used a nationally representative database to compare risk of recurrence in patients undergoing a prophylactic colectomy versus endoscopic detorsion alone. METHODS We performed a retrospective cohort study using the National Readmission Database (2016-2019) including patients aged ≥18 y who had an emergent admission for sigmoid volvulus and underwent endoscopic detorsion on the day of admission. We performed a 1:1 propensity matching adjusting for patient demographics, frailty score comprising of 109 components, and hospital characteristics. Our primary outcome was readmission due to colonic volvulus and secondary outcomes included mortality, complications, length of stay (LOS), and costs during index admission and readmission. We performed a subgroup analysis in patients with Hospital Frailty Score >5. RESULTS We included 2113 patients of which 1046 patients (49.5%) underwent a colectomy during the initial admission. In the matched population of 830 pairs, readmission due to colonic volvulus was significantly lower in patients undergoing endoscopy followed by colectomy than endoscopy alone. Patients undergoing a colectomy had higher gastric and renal complications, longer LOS, and higher costs but no difference in mortality. In the subgroup analysis of frail patients, readmission was significantly lower in patients with prophylactic colectomy with no significant difference in mortality in 439 matched patients. CONCLUSIONS Prophylactic colectomy was associated with lower readmission, a higher rate of complications, increased LOS, and higher costs compared to sigmoid decompression alone.
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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
| | - Shannon McChesney
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael C Smith
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mujeeb UrRahman
- Department of Surgery, District Headquarters Hospital, Buner, Pakistan
| | - Hanjoo Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, California
| | - Michael P DeWane
- Division of Trauma, Emergency General Surgery, and Surgical Critical care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aimal Khan
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.
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Loria A, Cai X, Gao S, Zhao T, Juviler P, Li Y, Cupertino P, Fleming FJ. Development and validation of multivariable predictive models for recurrence and mortality following nonoperative management of sigmoid volvulus. Colorectal Dis 2024; 26:356-363. [PMID: 38151763 DOI: 10.1111/codi.16849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/10/2023] [Accepted: 11/13/2023] [Indexed: 12/29/2023]
Abstract
AIM Sigmoid volvulus is a challenging condition, and deciding between elective surgery or expectant management can be complex. The aim of this study was to develop a tool for predicting the risk of recurrent sigmoid volvulus and all-cause mortality within 1 year following initial nonoperative management. METHOD This is a retrospective cohort study using Medicare claims data from 2016 to 2018 of beneficiaries admitted urgently/emergently for volvulus, undergoing colonic decompression and discharged alive without surgery (excluding those discharged to hospice). The primary outcomes were recurrent sigmoid volvulus and all-cause mortality within 1 year. Proportional hazards models and logistic regression were employed to identify risk factors and develop prediction equations, which were subsequently validated. RESULTS Among the 2078 patients managed nonoperatively, 36.1% experienced recurrent sigmoid volvulus and 28.6% died within 1 year. The prediction model for recurrence integrated age, sex, race, palliative care consultations and four comorbidities, achieving area under the curve values of 0.63 in both the training and testing samples. The model for mortality incorporated age, palliative care consultations and nine comorbidities, with area under the curve values of 0.76 in the training and 0.70 in the testing sample. CONCLUSION This study provides a straightforward predictive tool that utilizes easily accessible data to estimate individualized risks of recurrent sigmoid volvulus and all-cause mortality for older adults initially managed nonoperatively. The tool can assist clinicians and patients in making informed decisions about such risks. While the accuracy of the calculator was validated, further confirmation through external validation and prospective studies would enhance its clinical utility.
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Affiliation(s)
- Anthony Loria
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York, USA
| | - Shan Gao
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York, USA
| | - Tony Zhao
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Peter Juviler
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Yue Li
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Paula Cupertino
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Fergal J Fleming
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
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Mallick S, Sakowitz S, Bakhtiyar SS, Chervu N, Valenzuela A, Kim S, Benharash P. Administrative coding of frailty: Its association with clinical outcomes and resource use in kidney transplantation. Clin Transplant 2024; 38:e15200. [PMID: 38041448 DOI: 10.1111/ctr.15200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 11/07/2023] [Accepted: 11/14/2023] [Indexed: 12/03/2023]
Abstract
INTRODUCTION Although not formalized into current risk assessment models, frailty has been associated with negative postoperative outcomes in many specialties. However, national analyses of the association between frailty and post-transplant outcomes following kidney transplantation (KT) are lacking. METHODS This was a retrospective cohort study of adults undergoing KT from 2016 to 2020 in the Nationwide Readmissions Databases. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty indicator. RESULTS Of an estimated 95 765 patients undergoing KT during the study period, 4918 (5.1%) were frail. After risk adjustment, frail patients were associated with significantly higher odds of in-hospital mortality (AOR 2.17, 95% CI: 1.33-3.57) compared to their non-frail counterparts. Our findings indicate that frail patients had an average increase in postoperative hospital stay of 1.44 days, a $2300 increase in hospitalization costs, as well as higher odds of developing a major perioperative complication as compared to their non-frail counterparts. Frailty was also associated with greater adjusted risk of non-home discharge. CONCLUSIONS Frailty, as identified by administrative coding, is independently associated with worse surgical outcomes, including increased mortality and resource use, in adults undergoing KT. Given the already limited donor organ pool, novel efforts are needed to ensure adequate optimization and timely post-transplantation care of the growing frail cohort undergoing KT.
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Affiliation(s)
- Saad Mallick
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Sara Sakowitz
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | | | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Alberto Valenzuela
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Shineui Kim
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine, University of California, Los Angeles, California, USA
- Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
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Schaefer G, Regier D, Stout C. Palliative Emergency General Surgery. Surg Clin North Am 2023; 103:1283-1296. [PMID: 37838468 DOI: 10.1016/j.suc.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Acute care surgeons encounter patients experiencing surgical emergencies related to advanced malignancy, catastrophic vascular events, or associated with multisystem organ failure. The acute nature is a factor in establishing a relationship between surgeon, patient, and family. Surgeons must use effective communication skills, empathy, and a knowledge of legal and ethical foundations. Training in palliative care principles is limited in many medical school and residency curricula. We offer examples of clinical situations facing acute care surgeons and discuss evidence-based recommendations to facilitate successful treatment and outcomes.
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Affiliation(s)
- Gregory Schaefer
- Division of Trauma, Surgical Critical Care, and Acute Care Surgery, Surgical Critical Care, J.W. Ruby Memorial Hospital, West Virginia University Medicine, West Virginia University, Morgantown, WV, USA; Division of Military Medicine, J.W. Ruby Memorial Hospital, West Virginia University Medicine, West Virginia University, Morgantown, WV, USA; Department of Surgery, West Virginia University, Morgantown, WV, USA.
| | - Daniel Regier
- Department of Surgery, West Virginia University, Morgantown, WV, USA
| | - Conley Stout
- Department of Surgery, West Virginia University, Morgantown, WV, USA
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Zhang H, Wu F, Sun J, Liu Y, Zhou Z, Wu X, Liang B. The impact of frailty evaluation on the risk of venous thromboembolism in patients with hip fracture following surgery: a meta-analysis. Aging Clin Exp Res 2023; 35:2413-2423. [PMID: 37707745 DOI: 10.1007/s40520-023-02529-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/03/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Frailty has been associated with a higher incidence of overall postoperative complications and mortality. However, the influence of frailty on the risk of venous thromboembolism (VTE) in patients with hip fracture following surgery remains unclear. We performed a meta-analysis to systematically evaluate the above association. METHODS PubMed, Embase, Cochrane Library, Wanfang and CNKI were searched for relevant observational studies comparing the incidence of postoperative VTE in patients of hip fracture with and without frailty. Data collection, literature searching, and statistical analysis were conducted independently by two authors. Using a heterogeneity-incorporating random-effects model, the results were pooled. RESULTS In this meta-analysis, 9509 patients from nine cohort studies were included. Pooled results showed that compared to those without frailty, patients with frailty at admission had a higher incidence of postoperative VTE (odds ratio [OR]: 2.59, 95% confidence interval [CI]: 1.25-5.39, p = 0.01; I2 = 66%). Subgroup analysis suggested the association between frailty and postoperative VTE was more remarkable in studies of patients with frailty prevalence < 50% (OR 6.28, 95% CI 3.31-11.90, p < 0.001; I2 = 8%) as compared to those ≥ 50% (OR 1.30, 95% CI 0.80-2.11, p = 0.28; I2 = 0%; p for subgroup difference < 0.001). Further meta-analyses showed that frailty at baseline was associated with a higher incidence of deep venous thrombosis (OR 3.15, 95% CI 1.33-7.47, p = 0.009; I2 = 59%), but not pulmonary embolism (OR 1.13, 95% CI 0.59-2.16, p = 0.72; I2 = 0%). CONCLUSION Frailty is associated with a higher incidence of postoperative VTE in patients with hip fracture.
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Affiliation(s)
- Haixia Zhang
- Department of Anesthesia and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Fang Wu
- Department of Anesthesia and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Jianbin Sun
- Department of Hand, Foot and Ankle Surgery, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Yongchao Liu
- Department of Anesthesia and Perioperative Medicine, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Zifu Zhou
- Burn and Plastic Surgery Department, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Xuejun Wu
- Burn and Plastic Surgery Department, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Bin Liang
- Department of Anesthesiology, People's Hospital of Ningxia Hui Autonomous Region, No. 301, Zhengyuan Beijie, Jinfeng District, Yinchuan, 750004, China.
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Ebrahimian S, Verma A, Sakowitz S, Olmedo MO, Chervu N, Khan A, Hawkins A, Benharash P, Lee H. Association of hospital volume with conversion to open from minimally invasive colectomy in patients with diverticulitis: A national analysis. PLoS One 2023; 18:e0284729. [PMID: 37115767 PMCID: PMC10146460 DOI: 10.1371/journal.pone.0284729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 04/05/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND Despite the known advantages of minimally invasive surgery (MIS) for diverticular disease, the impact of conversions to open (CtO) colectomy remains understudied. The present study used a nationally representative database to characterize risk factors and outcomes associated with CtO in patients with diverticular disease. METHODS All elective adult hospitalizations entailing colectomy for diverticulitis were identified in the 2017-2019 Nationwide Readmissions Database. Annual institutional caseloads of MIS and open colectomy were independently tabulated. Restricted cubic splines were utilized to non-linearly estimate the risk-adjusted association between hospital volumes and CtO. Additional regression models were developed to evaluate the association of CtO with outcomes of interest. RESULTS Of an estimated 110,281 patients with diverticulitis who met study criteria, 39.3% underwent planned open colectomy, 53.3% completed MIS, and 7.4% had a CtO. Following adjustment, an inverse relationship between hospital MIS volume and risk of CtO was observed. In contrast, increasing hospital open volume was positively associated with greater risk of CtO. On multivariable analysis, CtO was associated with lower odds of mortality (AOR 0.3, p = 0.001) when compared to open approach, and similar risk of mortality when compared to completed MIS (AOR 0.7, p = 0.436). CONCLUSION In the present study, institutional MIS volume exhibited inverse correlation with adjusted rates of CtO, independent of open colectomy volume. CtO was associated with decreased rates of mortality compared to planned open approach but equivalence risk relative to completed MIS. Our findings highlight the importance of MIS experience and suggest that MIS may be safely pursued as the initial surgical approach among diverticulitis patients.
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Affiliation(s)
- Shayan Ebrahimian
- Division of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Arjun Verma
- Division of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Sara Sakowitz
- Division of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Manuel Orellana Olmedo
- Division of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, United States of America
| | - Nikhil Chervu
- Division of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Aimal Khan
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Alexander Hawkins
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Peyman Benharash
- Division of Cardiac Surgery, Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Hanjoo Lee
- Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA, United States of America
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