Effects of additional laparoscopic cholecystectomy on outcomes of laparoscopic gastrectomy in patients with gastric cancer based on a national administrative database

Background

Little information is available on the effects of adding laparoscopic cholecystectomy to laparoscopic gastrectomy on outcomes of patients with gastric cancer. The aim of this study is to investigate the effects of adding laparoscopic cholecystectomy to laparoscopic gastrectomy on outcomes in patients with gastric cancer using a national administrative database.

Methods

A total of 14,006 patients treated with laparoscopic gastrectomy for gastric cancer were referred to 744 hospitals in Japan between 2009 and 2011. Patients were divided into two groups, those who also underwent simultaneous laparoscopic cholecystectomy for gallbladder stones (n = 1484) and those who underwent laparoscopic gastrectomy alone (n = 12,522). Laparoscopy-related complications, in-hospital mortality, length of stay, and medical costs during hospitalization were compared in the patient groups.

Results

Multiple logistic regression analysis revealed that adding laparoscopic cholecystectomy did not affect laparoscopy-related complications (odds ratio, 1.02; 95% confidence interval [CI], 0.84–1.24; P = 0.788) or in-hospital mortality (odds ratio, 1.16; 95% CI, 0.49–2.76; P = 0.727). Multiple linear regression analysis also showed that adding laparoscopic cholecystectomy did not affect the length of stay (unstandardized coefficient, 0.37 d; 95% CI, −0.47 to 1.22 d; P = 0.389). However, adding laparoscopic cholecystectomy was associated with significantly increased medical costs during hospitalization (unstandardized coefficient, $1256.0 (95% CI, $806.2–$1705.9; P < 0.001).

Conclusions

This study demonstrated that adding laparoscopic cholecystectomy did not affect outcomes of patients undergoing laparoscopic gastrectomy for gastric cancer, although medical costs during hospitalization were significantly increased.     

Can it wait until morning? A comparison of nighttime versus daytime cholecystectomy for acute cholecystitis

Background

The urgency of laparoscopic cholecystectomy for acute cholecystitis is under debate. We hypothesized that nighttime cholecystectomy is associated with decreased length of stay.

Methods

Retrospective review of 1,140 patients at 2 large urban referral centers with acute cholecystitis who underwent daytime (7 am to 7 pm) versus nighttime (7 pm to 7 am) cholecystectomy was conducted.

Results

Nighttime cholecystectomy did not affect the overall length of stay (3.7 vs 3.8 days, P = .08) or complication rate (5% vs 7%, P = .5) versus daytime cholecystectomy. Nighttime cholecystectomy was associated with a higher conversion rate to open cholecystectomy (11% vs 6%, P = .008). On multivariable analysis, independent predictors of conversion to open surgery were nighttime cholecystectomy, age, and gangrenous cholecystitis (P = .01). The only predictor of complications was gangrenous cholecystitis (P = .02).

Conclusions

Nighttime cholecystectomy is associated with an increased conversion to open surgery without decrease in length of stay or complications. These findings suggest that laparoscopic cholecystectomy for acute cholecystitis should be delayed until normal working hours.     

Gender based differences in management and outcomes of cholecystitis

Background

During the reproductive years, women have a 4-fold higher prevalence of gallstones than men, making gallbladder disease a critically important topic in women's health. Among age-matched women and men hospitalized for cholecystitis, gender based differences in demographics, management, and economic and clinical outcomes were identified.

Methods

A cross-sectional study was conducted using the Nationwide Inpatient Sample. Outcomes were mortality, complications, length of stay, and cost.

Results

Women accounted for 65% of admissions for cholecystitis, with women more likely to have shorter time to surgery (1.6 vs 1.9 days) and laparoscopy (86 vs 76%) (P < .05). After cholecystectomy, women had lower mortality (.6% vs 1.1%), fewer complications (16.9 vs 24.1), shorter lengths of stay (4.2 vs 5.4 days), and lower costs ($10,556 vs $13,201) (P < .05). On multivariate analysis of age-matched patients, women had lower odds of mortality (odds ratio [OR], .75), complications (OR, .86), length of stay (OR, .95), and cost (OR, .93). Longer time to surgery and open cholecystectomy were independent predictors of worse outcomes.

Conclusions

In cholecystitis and cholecystectomy, women have better clinical and economic outcomes then age-matched men.     

Abdominal wall reconstruction in the obese: an assessment of complications from the National Surgical Quality Improvement Program datasets

Background

This study utilizes the American College of Surgeons National Surgical Quality Improvement Program database to better understand the impact of obesity on perioperative surgical morbidity in abdominal wall reconstruction (AWR).

Methods

We reviewed the 2005 to 2010 American College of Surgeons National Surgical Quality Improvement Program databases, identifying cases of AWR and examining early complications in the context of obesity (body mass index > 30, World Health Organization classes 1 to 3).

Results

Of 1,695 patients undergoing AWR, 1,078 (63.2%) patients were obese (mean body mass index = 37.6 kg/m²). Major surgical complications (15.3% vs 10.1%, P = .003), wound complications (12.5% vs 8.1%, P = .006), medical complications (16.2% vs 11.2%, P = .005) and return to the operating room (9.1% vs 5.4%, P = .006) were significantly increased, while renal complications (1.9% vs .8%, P = .09) neared significance. On logistic regression, obesity only directly led to a significantly increased odds of having a renal complication (odds ratio = 4.4, P = .04). Complications were still noted to increase with World Health Organization classification, including a concerning incidence of venous thromboembolism.

Conclusions

Although the incidence of complications increased with obesity, obesity itself does not appear to increase the odds of perioperative morbidity. Specific care should be given to VTE prophylaxis and to preventing renal complications.     

Effects of weight reduction surgery on the abdominal wall fascial wound healing process

Background

Bariatric surgery patients enter into a catabolic state postoperatively, which can lead to an aberrant wound healing process. To improve the future treatment of morbidly obese patients, the aim of our study was to understand the link between bariatric surgery and alterations in the wound healing processes.

Methods

A total of 18 morbidly obese Zucker rats were separated into three groups and underwent one of three surgical procedures: Roux-en-Y gastric bypass (RYGB; n = 6); sleeve gastrectomy (GS; n = 6); or midline laparotomy only (n = 6). The rats were weighed on postoperative day 0, 3, 7, and 14. On day 14, the abdominal wall was harvested and underwent histologic and biomechanical evaluation.

Results

A significant difference was found in the weight gain between the laparotomy control group (LC) and bariatric surgical groups at 7 and 14 d. By postoperative day 7, the GS and RYGB rats weighed significantly less than the LC group, losing, on average, 7% and 6% of their initial body weight, respectively, and the LC gained 4% of their weight (P < 0.05). By postoperative day 14, the LC had gained 20% of their original weight, and the two bariatric groups both weighed significantly less (P < 0.05). The breaking strength in the RYGB group (0.42 ± 0.18 N/mm) was significantly lower statistically than LC (0.69 ± 0/19 N/mm). The LC and GS groups (0.62 ± 0.27 N/mm) did not show a significant difference. The results of the histologic analysis showed that the collagen deposition in the wound was significantly lower statistically in the RYGB group compared with the LC group. No histologic difference was noted between the RYGB and GS groups.

Conclusions

Malabsorptive bariatric surgery negatively affects wound healing both histologically and biomechanically compared with nonbariatric models. Although obesity remains a significant factor in the wound healing process, understanding the link between bariatric surgery and alterations in wound healing is imperative before advocating simultaneous repair of ventral hernias during concomitant bariatric surgery.     

Preoperative cholangitis during biliary drainage increases the incidence of postoperative severe complications after pancreaticoduodenectomy

Background

It remains controversial how preoperative biliary drainage affects occurrence of severe complications after pancreaticoduodenectomy (PD).

Methods

One hundred twenty-seven patients (60 external drainage and 67 internal drainage) required biliary drainage before PD were retrospectively reviewed.

Results

Preoperative cholangitis in internal drainage group (22.4%) occurred significantly more often than in external drainage group (1.7%; P < .001). The incidence of severe complications (grade III or more) was significantly higher in patients with cholangitis (62.5%) than in those without it (25.2%; P = .002). The incidence of delayed gastric emptying was significantly higher in patients with cholangitis (31.2%) than in those without it (5.4%; P = .001). A multivariate logistic regression analysis revealed that preoperative cholangitis (odds ratio 4.61, 95% confidence interval 1.3 to 16.5; P = .019) was the independent risk factor for severe complications after PD.

Conclusions

Preoperative cholangitis during biliary drainage significantly increases incidence of severe complications after PD.     

Effect of alcohol in traumatic brain injury: is it really protective?

Background

Studies have proposed a neuroprotective role for alcohol (ETOH) in traumatic brain injury (TBI). We hypothesized that ETOH intoxication is associated with mortality in patients with severe TBI.

Methods

Version 7.2 of the National Trauma Data Bank (2007–2010) was queried for all patients with isolated blunt severe TBI (Head Abbreviated Injury Score ≥4) and blood ETOH levels recorded on admission. Primary outcome measure was mortality. Multivariate logistic regression analysis was performed to assess factors predicting mortality and in-hospital complications.

Results

A total of 23,983 patients with severe TBI were evaluated of which 22.8% (n = 5461) patients tested positive for ETOH intoxication. ETOH-positive patients were more likely to have in-hospital complications (P = 0.001) and have a higher mortality rate (P = 0.01). ETOH intoxication was an independent predictor for mortality (odds ratio: 1.2, 95% confidence interval: 1.1–2.1, P = 0.01) and development of in-hospital complications (odds ratio: 1.3, 95% confidence interval: 1.1–2.8, P = 0.009) in patients with isolated severe TBI.

Conclusions

ETOH intoxication is an independent predictor for mortality in patients with severe TBI patients and is associated with higher complication rates. Our results from the National Trauma Data Standards differ from those previously reported. The proposed neuroprotective role of ETOH needs further clarification.     

The incidence and risk factors of gastrointestinal complications after hepatectomy: a retrospective observational study of 1329 consecutive patients in a single center

Background

Despite of the importance of gastrointestinal (GI) complications in morbidity and mortality after major and moderate surgeries, it is not yet specifically studied in patients undergoing hepatectomy. This study was aimed to investigate the in-hospital incidence and potential risk factors of GI complications after open hepatectomy in our hospital.

Subjects and methods

Prospectively recorded perioperative data from 1329 patients undergoing elective hepatectomy were retrospectively reviewed. The in-hospital incidence of GI complications was investigated, and independent risk factors were analyzed by multiple logistic regression.

Results

GI complications occurrence was 46.4%. Univariate analysis showed that preoperative Child-Pugh score, total bilirubin, aspartate transaminase, anesthesia duration, operation duration, intraoperative blood loss, crystalloid and colloid infusion, blood transfusion, urine output, use of Pringle maneuver were statistically different between patients with and without GI complications (P < 0.05). Moreover, patients with GI complications had a more prolonged postoperative parenteral nutrient supporting time, hospital stay and ICU stay, and higher incidence of other complications than those without GI complications (P < 0.05). Multivariate regression indicated that long duration of anesthesia (odds ratio 2.51, P < 0.001) and use of Pringle maneuver (odds ratio 1.37, P = 0.007) were independent risk factors of GI complications after hepatectomy.

Conclusions

The incidence of GI complications after hepatectomy is high, which is related to an increase of other complications and a prolonged hospital stay. Avoidance of routinely use of Pringle maneuver and shortening the duration of anesthesia are important measures to reduce the postoperative GI complications.     

Infection Complications and Pattern of Bacterial Resistance in Living-Donor Liver Transplantation: A Multicenter Epidemiologic Study in Egypt

Introduction

Data on the prevalence and pattern of infection after living-donor liver transplantation (LDLT) are scarce in Egypt. We therefore conducted this study to quantify the incidence, risk factors, and pattern of bacterial resistance post-LDLT in 3 hospitals in Egypt.

Patients and Methods

We conducted a retrospective, multicenter study of the medical records of 246 patients who underwent LDLT between January 2006 and April 2011 at 3 transplant centers in Egypt.

Results

Of 246 patients enrolled in this study, 127 (52%) developed infectious complications after LDLT, with 416 episodes of infection occurring within 3 months of transplantation. Biliary tract infection was the most common, occurring in 169 (40.6%) patients. The rate of infection with Gram-negative bacteria was higher than that of infection with Gram-positive bacteria (310 [74%] vs 87 [21%]; P < .001). Overall, 75% of Gram-negative isolates were multidrug resistant. Significant independent risk factors for infection were portal vein thrombosis (odds ratio, 2.4; P = .037) and biliary complications (odds ratio, 5.4; P < .001).

Conclusions

Our data showed a high-resistance pattern of bacterial infection after LDLT in Egypt. Early biliary complications were an independent risk factor for bacterial infection.     

Do gallstones found before sleeve gastrectomy behave the same as those formed after surgery due to weight loss?

Background

Gallstone formation is prevalent in the bariatric population and after weight loss. We believe that gallstones found preoperatively behave differently and may not cause significant complications as those developing after weight loss. Thus, prophylactic cholecystectomy before or during sleeve gastrectomy (SG) may not be necessary.

Methods

Patients undergoing SG from January 2011 to May 2012 were evaluated for the presence of gallstones and development of symptoms or need for cholecystectomy postoperatively.

Results

Group 1 (n = 18) had gallstones preoperatively. Group 2 (n = 29) developed gallstones after weight loss. Both groups' demographics were similar. Symptomatic gallstones occurred in 1 patient (5.6%) in group 1 and in 9 patients (31.0%) in group 2 (P = .19). Percent excess body mass index loss (%EBL) was 58 ± 24% vs 70 ± 22% (P = .11) with a mean follow-up of 8.9 ± 6.2 and 14.7 ± 3.9 months for group 1 and group 2, respectively (P = .005).

Conclusions

Asymptomatic gallstones found before SG tend to have less risk of becoming symptomatic than those formed after weight loss. There was no statistical significant difference because of small sample. Prophylactic cholecystectomy, however, may not be warranted in these patients.     

Surgical site infection after thyroidectomy: a rare but significant complication

Background

Surgical site infections (SSIs) after thyroidectomy are rare but can have significant consequences. Thyroidectomy is a clean case, and the patterns for use of prophylactic antibiotics vary. We hypothesized that patient and operative characteristics may predict a higher risk of SSI, and that SSI are associated with other complications leading to increased resource utilization.

Methods

Data from the American College of Surgeons National Surgical Quality Improvement Program dataset for patients who underwent thyroidectomy through cervical incisions from 2005–2011 were included. Bivariate analysis using t-tests and chi-square tests were performed, and variables with P < 0.2 were considered for inclusion in a multivariate logistic regression model.

Results

A total of 49,326 patients underwent thyroidectomy from 2005–2011 and 179 (0.36%) had an SSI. On multivariate analysis, the strongest predictors of SSI were operative time (P < 0.001) and wound classification clean-contaminated (odds ratio 6.1; 95% confidence interval, 3.6, 10.3). Preoperative factors associated with SSI on multivariate analysis had lower magnitudes of influence on SSI risk but included obesity, alcohol use, and nonindependent functional status. Patients with SSI were more likely to have a wound dehiscence, renal insufficiency, bleeding requiring transfusion, and return to the operating room on a multivariate model of outcomes.

Conclusions

Although rare, SSI after thyroidectomy are associated with other postoperative complications. We have identified preoperative and intraoperative factors that are associated with SSI, and this may help identify high-risk patients who may benefit from selective use of antibiotics.     

Comparative analysis of the incidence of surgical site infections in patients with liver resection for colorectal hepatic metastases after neoadjuvant chemotherapy

Background

The aim of this study was to identify the incidence of surgical site infections (SSIs) and postoperative complications, as defined by the Clavien–Dindo classification, after hepatic resection for metastatic colorectal cancer in patients with and without associated neoadjuvant chemotherapy.

Methods

A total of 181 patients were studied retrospectively. Patients were divided into two groups: the first group comprised patients with associated neoadjuvant chemotherapeutic treatment for liver metastases with a latency time <8 wk and the second group comprised patients without associated neoadjuvant chemotherapy.

Results

Variables of duration of liver surgery, length of total hospital stay, and length of postoperative hospital stay seem to be correlated with SSIs and postoperative complications, P < 0.005 and P < 0.0001, respectively. Duration of surgery is a risk factor for SSIs, with an odds ratio of 1.15, and for complications according to the Clavien–Dindo classification, with an odds ratio of 1.35.

Conclusions

Neoadjuvant chemotherapy was not a significant risk factor for SSIs, whereas the total length of hospital stay, length of postoperative hospital stay, and duration of surgery were independent predictors of SSIs and complications according to the Clavien–Dindo classification.     

Cholecystostomy offers no survival benefit in patients with acute acalculous cholecystitis and severe sepsis and shock

Background

Acute acalculous cholecystitis is often managed with cholecystectomy or cholecystostomy, but data guiding surgical practice are lacking.

Materials and methods

Longitudinal analysis of the California Office of Statewide Health Planning and Development Patient Discharge Data was performed from 1995–2009. Patients with acute acalculous cholecystitis were identified by International Classification of Diseases 9 code. Cox proportional hazard analysis found predictors of time to death, adjusting for patient demographics, sepsis, shock, frailty, Charlson comorbidity index, length of stay, insurance status, teaching hospital status, and year.

Results

Of 43,341 patients, 63.5% received a cholecystectomy, 2.8% received a cholecystostomy, and 1.2% received both. Overall, 30.4% of patients died, with higher mortality among patients with cholecystostomy (61.7%) or no procedure (42.0%) than cholecystectomy (23.0%). In patients with severe sepsis and shock, there was no difference in survival of patients with cholecystostomy versus no intervention (hazard ratio [HR] 1.13, P = 0.256), although patients with cholecystectomy (with or without prior cholecystostomy) had improved survival (HR 0.29, P < 0.001; HR 0.56, P < 0.001). Results were similar among patients on the ventilator >96 h.

Conclusions

Although cholecystostomy offered no survival benefit for patients with severe sepsis and shock, cholecystectomy offered improved survival compared with patients without surgical management. Cholecystostomy may not benefit the sickest patients in whom cholecystectomy may never be considered.     

Obesity does not increase morbidity of laparoscopic cholecystectomy

Background

Obesity has historically been a positive predictor of surgical morbidity, especially in the morbidly obese. The purpose of our study was to compare outcomes of obese patients undergoing laparoscopic cholecystectomy (LC).

Methods

We reviewed 1382 consecutive patients retrospectively who underwent LC for various pathologies from January 2008 to August 2011. Patients were stratified based on the World Health Organization definitions of obesity: nonobese (body mass index [BMI] < 30 kg/m²), obesity class I (BMI 30–34.9 kg/m²), obesity class II (BMI 35–39.9 kg/m²), and obesity class III (BMI ≥ 40 kg/m²). The primary end points were conversion rates and surgical morbidity. The secondary end point was length of stay.

Results

There were significantly more females in the obesity II and III groups (P = 0.0002). American Society of Anesthesiologists scores were significantly higher in the obesity I, II, and III groups compared with the nonobese (P < 0.05; P < 0.01; and P < 0.0001, respectively). Independent predictors of conversion on multivariate analysis (MVA) included age (P = 0.01), acute cholecystitis (P = 0.03), operative time (P < 0.0001), blood loss (P < 0.0001), and fellowship-trained surgeons (P < 0.0001). Independent predictors of intraoperative complications on MVA included age (P = 0.009), white patients (P = 0.009), previous surgery (P = 0.001), operative time (P < 0.0001), and blood loss (P = 0.01). Independent predictors of postoperative complications on MVA included American Society of Anesthesiologists score (P < 0.0001), acute cholecystitis (P < 0.0001), and a postoperative complication (P < 0.0001). BMI was not a predictor of conversions or surgical morbidity. Length of stay was not significantly different between the four groups.

Conclusions

This study demonstrates that overall conversion rates and surgical morbidity are relatively low following LC, even in obese and morbidly obese patients.     

Predictive factors for incidental gallbladder dysplasia and carcinoma

Background

This study aims to analyze clinical characteristics and demographics of all patients admitted for cholecystectomy in a tertiary referral center to determine predictors of incidental gallbladder dysplasia (IGBD) and incidental gallbladder carcinoma (IGBC).

Methods

A retrospective analyses of clinical, demographic, and histologic features of patients undergoing cholecystectomy in a single tertiary institution from 2005–2012 were performed using a logistic regression model to determine the predictors of IGBD and IGBC.

Results

Some 771 (28 conversions to open surgery [3.6%]) and 93 patients (10.7%) underwent laparoscopic and open cholecystectomies for gallstone disease, respectively. At final pathology, IGBD (low-grade [n = 10], high-grade [n = 2], mixed-grade [n = 1], and adenoma-associated [n = 5] dysplasia) was found in 18 patients (2%; median age, 45 y; interquartile range, 42.5–63.5; male-to-female ratio, 1:2; six Caucasian; and 12 Asian). IGBC was found in seven patients (0.8%; median age, 69 y; interquartile range, 69–72; one Afro-Caribbean; four Caucasian; and two Asian). Logistic regression analysis revealed Asian patients to be at a higher risk of IGBD (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.1–8.0; P = 0.02). Only age (OR, 1.12; 95% CI, 1.04–1.2; P < 0.01) and polypoid lesions (OR, 37.4; 95% CI, 2.97–470.6; P = 0.01) were significantly associated with IGBC. Receiver operating characteristic curve analysis demonstrated that age >68 y correlated positively to IGBC.

Conclusions

IGBD and IGBC are fairly common incidental histologic finding after cholecystectomy for gallstone disease. When considering cholecystectomy, patients' demographics, in particular age and race, should always be considered as this might help the surgeon and the pathologist to institute the appropriate treatment.     

Semi-urgent surgery in hospitalized patients with severe ulcerative colitis does not increase overall J-pouch complications

Background

Surgeons frequently discourage patients with ulcerative colitis from having surgery in the midst of an acute flare for fear of complications and poor long-term outcomes.

Methods

Outcomes of patients undergoing urgent versus elective surgery for ulcerative colitis were compared via retrospective review.

Results

Patients undergoing urgent (n = 80) versus elective (n = 99) surgery were younger, were more malnourished, had more severe active disease, and had higher steroid use (P ≤ .05). During surgery, hemodynamic stability was similar, but urgent patients underwent more subtotal colectomies (5.1% vs 29%, P < .0001) and fewer laparoscopic procedures (8.8% vs 18%, P = .07). Multivariate regression suggested that short-term complications were increased with higher body mass index and urgency status (P ≤ .05). Anastomotic leaks and long-term complications were similar between groups. Surgeon inexperience and use of immunomodulators other than infliximab were associated with increased odds of long-term fistula/abscess (odds ratio, 5.56; P = .05] and pouch failure (odds ratio, 13.3; P = .01).

Conclusions

Surgery in patients with acute ulcerative colitis flares is associated with more short-term complications than elective procedures but does not appear to affect risk for anastomotic leak or long-term complications when performed by an expert.     

Strategies to Reduce Infectious Complication Using Epidemiologic Data Analysis in Liver Transplant Recipients

Background

Infectious complications are major factors for morbidity and mortality in liver transplant recipients. To establish a proper strategy to reduce infectious complications, we analyzed epidemiologic and risk factors for post-transplant infections.

Methods

We analyzed the medical records of 231 consecutive liver transplant recipients from December 2007 to November 2011, including at least 1-year follow up, for comparison with those from 1996 to 2005.

Results

Among 231 patients, 126 (54.5%) experienced 244 infectious episodes, a rate of 1.05 per patient. Among overall mortality of 9.9% (23/231), infections were more prevalent (P = .04). Predominant infections were postoperative intra-abdominal problems (36.1%), peritonitis (15.2%), pneumonia (13.5%), bacteremia (4.1%), wound complications (1.6%), viral etiologies (18.0%), and other causes (11.5%). Causative organisms were bacterial (68.9%), viral (14.7%), fungal (7.0%), and unproven ones (9.4%). Multivariate analysis of risks for infection showed significant impacts of Model for End-stage Liver Disease score [P = .027; odds ratio (OR), 1.04], post-transplant biliary complications (P < .001; OR, 3.50), and rejection episodes (P = .023; OR, 3.39). Mortality was related to retransplantation (P = .003), post-transplant dialysis (P = .006), and infection (P = .056) upon univariate analysis, none of which were significant in multivariate analysis. Compared with data from the previous period, overall and infection-related mortality decreased from 24.5% to 9.9% and 52.9% to 26.1%, respectively. There were no significant changes in the types of infection or rate of drug-resistant bacteria, but candidal infections and cytomegalovirus reactivations were more prevalent.

Conclusion

Our data showed current perioperative antimicrobial regimens need not be changed: however, new strategies are needed to reduce infectious complications after liver transplantation, to reduce biliary complications and to properly manage rejection episodes.     

Procalcitonin in the recognition of complications in critically ill surgical patients

Background

Procalcitonin (PCT) is a relatively new, promising indirect parameter for infection. In the intensive care unit (ICU) it can be used as a marker for sepsis. However, in the ICU there is a need for reliable markers for clinical deterioration in the critically ill patients. This study determines the clinical value of PCT concentrations in recognizing surgical complications in a heterogeneous group of general surgical patients in the ICU.

Material and methods

We prospectively collected PCT concentration data from April 2010 to June 2012 for all general surgical patients admitted to the ICU. Both the relationships between PCT levels and events (diagnostic and therapeutic interventions) as well as between PCT levels and surgical complications (abscesses, bleeding, perforation, ischemia, and ileus) were studied.

Results

PCT concentrations were lower in patients who developed complications than those who did not develop complications on the same day, although not significant (P = 0.27). A 10% increase in PCT levels resulted in a 2% higher complication odds, but again this was not significant (odds ratio [OR], 1.020; 95% confidence interval [CI], 0.961–1.083; P = 0.51). Even a 20% or 30% increase in PCT concentrations did not result in higher complication probability (OR, 1.039; 95% CI, 0.927–1.165 and OR, 1.057; 95% CI, 0.897–1.246). Furthermore, an increase in PCT levels did not show an increase or a reduction in the number of diagnostic and therapeutic interventions.

Conclusions

An increase in PCT levels does not help to predict surgical complications in critically ill surgical patients.     

Emergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study

Background

Morbidity and mortality are very high for critically ill patients who develop acute acalculous cholecystitis (AAC). The aim of this study was to compare outcomes in extremely ill patients with AAC treated with percutaneous cholecystostomy (PC), laparoscopic cholecystectomy (LC), or open cholecystectomy (OC), which were also analyzed together in the LC-plus-OC (LO) group.

Methods

Discharge data from the University HealthSystem Consortium database were accessed using International Classification of Diseases codes. The University HealthSystem Consortium's Clinical Data Base/Resource Manager allows member hospitals to compare patient-level, risk-adjusted outcomes. Multivariate regression models for extremely ill patients undergoing PC or LO for the diagnosis of AAC were created and analyzed.

Results

A total of 1,725 extremely ill patients were diagnosed with AAC between October 2007 and June 2011. Patients undergoing PC (n = 704) compared with the LO group (n = 1,021) showed decreased morbidity (5.0% with PC vs 8.0% with LO, P < .05), fewer intensive care unit admissions (28.1% with PC vs 34.6% with LO, P < .05), decreased length of stay (7 days with PC vs 8 days with LO, P < .05), and lower costs ($40,516 with PC vs $53,011 with LO, P < .05). Although perioperative outcomes of PC compared with LC were statistically similar, PC had lower costs compared with LC ($40,516 vs 51,596, P < .005). Multivariate regression analysis showed that LC (n = 822), compared with OC (n = 199), had lower mortality (odds ratio [OR], .3; 95% confidence interval [CI], .1 to .6), lower morbidity (OR, .4; 95% CI, .2 to .7), reduced intensive care unit admission (OR, .3; 95% CI, .2 to .5), and similar 30-day readmission rates (OR, 1.0; 95% CI, .6 to 1.5). Also, decreased length of stay (7 days with LC vs 8 days with OC) and costs ($51,596 with LC vs $61,407 with OC) were observed, with a 26% conversion rate to an open procedure.

Conclusions

On the basis of this experience, extremely ill patients with AAC have superior outcomes with PC. LC should be performed in patients in whom the risk for conversion is low and in whom medical conditions allow. These results show PC to be a safe and cost-effective bridge treatment strategy with perioperative outcomes superior to those of OC.     

Gallstone ileus: revisiting surgical outcomes using National Surgical Quality Improvement Program data

Background

Although surgical management remains the mainstay of therapy for gallstone ileus, the optimal approach—enterolithotomy alone or combined with biliary-enteric fistula disruption—is controversial because of the reliance on small single-center series to describe outcomes. Using the American College of Surgeons' National Surgical Quality Improvement Program database, we sought to (1) review the outcomes of patients undergoing surgical management of gallstone ileus and (2) determine if cholecystectomy in addition to enterolithotomy increased morbidity or mortality rate.

Methods

We analyzed the demographics, comorbidities, acuity, operative time, postoperative hospitalization length, and 30-d morbidity and mortality rates of 127 patients from 2005 to 2010 who underwent a procedure for the relief of gallstone ileus. We identified a subset of 14 patients who underwent simultaneous cholecystectomy. We compared the “no cholecystectomy” and “cholecystectomy” groups using standard statistical methods.

Results

The overall 30-d postoperative morbidity and mortality rate was 35.4% and 5.5%, respectively. Superficial surgical site infection and urinary tract infection were the most common complications. There was no significant difference in mortality rate between the no cholecystectomy and the cholecystectomy groups (5.3% versus 7.1%, respectively; P = 0.78), but the latter group did experience more minor complications, longer operations, and longer postoperative hospitalization.

Conclusions

Other recent studies on this topic have collected data or reviewed literature across several decades, making this study in particular one of the largest truly modern series. Perhaps reflecting changes in perioperative management, surgical treatment of gallstone ileus is less morbid than previously described, but there is still insufficient evidence to favor concurrent cholecystectomy.