Iatrogenic rib fractures and the associated risks of mortality

PURPOSE

Rib fractures, though typically associated with blunt trauma, can also result from complications of medical or surgical care, including cardiopulmonary resuscitation. The purpose of this study is to describe the demographics and outcomes of iatrogenic rib fractures.

METHODS

Patients with rib fractures were identified in the 2016 National Inpatient Sample. Mechanism of injury was defined as blunt traumatic rib fracture (BTRF) or iatrogenic rib fracture (IRF). IRF was identified as fractures from the following mechanisms: complications of care, drowning, suffocation, and poisoning. Differences between BTRF and IRF were compared using rank-sum test, Chi-square test, and multivariable regression.

RESULTS

34,644 patients were identified: 33,464 BTRF and 1180 IRF. IRF patients were older and had higher rates of many comorbid medical disorders. IRF patients were more likely to have flail chest (6.1% versus 3.1%, p < 0.001). IRF patients were more likely to have in-hospital death (20.7% versus 4.2%, p < 0.001) and longer length of hospitalization (11.8 versus 6.9 days, p < 0.001). IRF patients had higher rates of tracheostomy (30.2% versus 9.1%, p < 0.001). In a multivariable logistic regression of all rib fractures, IRF was independently associated with death (OR 3.13, p < 0.001). A propensity matched analysis of IRF and BTRF groups corroborated these findings.

CONCLUSION

IRF injuries are sustained in a subset of extremely ill patients. Relative to BTRF, IRF is associated with greater mortality and other adverse outcomes. This population is understudied. The etiology of worse outcomes in IRF compared to BTRF is unclear. Further study of this population could address this disparity.

Palliative Surgery Outcomes for Patients with Esophageal Cancer: An NCDB Analysis

INTRODUCTION

Many patients with esophageal cancer are not candidates for surgical resection with curative intent, given the advanced stage of disease at presentation. Palliative surgery is one treatment option, but relative survival of palliative surgery has not been described. This study aims to describe the outcomes of palliative surgery in patients with esophageal cancer.

METHODS

We used the National Cancer Database to identify patients with esophageal cancer who received palliative surgery or non-surgical palliation-which consisted of palliative radiation and palliative chemotherapy without any surgery. The outcome of interest was overall survival. Characteristics of patients were compared between the palliative surgery group and the non-surgical group using rank sum test or chi square test. Survival differences between groups were compared using Kaplan Meier estimate and log rank test, and Cox proportional hazards model.

RESULTS

A total of 14,589 patients were included in the analysis, including 2,812 (19.2%) receiving palliative surgery and 11,777 (80.7%) receiving non-surgical palliation (6,512 palliative radiation and 5,265 palliative chemotherapy). Median overall survival in palliative surgery patients was 5.5 mo, shorter than non-surgical palliation (6.4 mo, P = 0.004). However, when correcting for age, sex, nodal status, metastases, Charlson score, histology, academic center, and private insurance, there was no difference in survival between palliative surgery and non-surgical palliation in Cox proportional hazard modeling (HR 1.03 (0.975-1.090), P = 0.281).

CONCLUSIONS

Palliative surgery in advanced esophageal cancer is associated with poor overall survival but is similar to other palliative modalities. Palliative Surgery for esophageal cancer patients should be used sparingly given these poor outcomes.

Concurrent diagnosis of anxiety increases postoperative length of stay among patients receiving esophagectomy for esophageal cancer

OBJECTIVE

Psychiatric comorbidities disproportionately affect patients with cancer. While identified risk factors for prolonged length of stay (LOS) after esophagectomy are primarily medical comorbidities, the impact of psychiatric comorbidities on perioperative outcomes is unclear. We hypothesized that psychiatric comorbidities would prolong LOS in patients with esophageal cancer.

METHODS

The 2016 National Inpatient Sample (NIS) was used to identify patients with esophageal cancer receiving esophagectomy. Concurrent psychiatric illness was categorized using Clinical Classifications Software Refined for ICD-10, creating 34 psychiatric diagnosis groups (PDGs). Only PDGs with >1% prevalence in the cohort were included in the analysis. The outcome of interest was hospital LOS. Bivariable testing was performed to determine the association of PDGs and demographic factors on LOS using rank sum test. Multivariable regression analysis was performed using backward selection from bivariable testing (α ≤ 0.05).

RESULTS

We identified 1,730 patients who underwent esophagectomy for esophageal cancer in the 2016 NIS. The median LOS was 8 days (IQR 5-12). In bivariable testing, a concurrent diagnosis of anxiety was the only PDG associated with LOS (9 days (IQR 6-14) with anxiety diagnosis versus 8 days (IQR 5-12) with no anxiety diagnosis, p = 0.022). Multivariable modeling showed an independent association between anxiety diagnosis and increased LOS (OR 4.82 (1.25-25.23), p = 0.022). Anxiety was not associated with increased hospital cost or in-hospital mortality.

CONCLUSIONS

This analysis demonstrates an independent effect of anxiety prolonging postoperative LOS after esophagectomy in the United States. These findings may influence perioperative care, patient expectations, and resource allocation.