Elderly patients in surgical workloads: a population-based analysis

Elderly (80+ year old) individuals are the fastest-growing segment of the U.S. population. The objective of this study was to use population-based data to examine trends in the number of elderly undergoing major general, vascular, and cardiothoracic surgical procedures. California inpatient data from 1990-2000 was used to identify patients undergoing six procedures: abdominal aortic aneurysm repair (AAA), coronary artery bypass graft (CABG), carotid endarterectomy (CEA), colon resections, lung resections, and pancreatic resections. Despite comprising only 2.7 per cent of the California population, elderly patients were a significant percentage (6-22%) of the caseloads for the six procedures examined. For all six procedures, the percentage of patients that were elderly increased during the study period. The age-specific incidence rates for elderly individuals increased significantly for three of these procedures (CABG, CEA, lung resection), remained unchanged for two (AAA, pancreas resection), and decreased for one (colon resection). Elderly patients are a large and growing part of surgical caseloads. In the near future, the number of elderly individuals in the California state and the U.S. populations will increase dramatically (41% and 35% between 2000 and 2020). To provide the best quality of care, surgeons should embrace research, training, and educational opportunities regarding the treatment of elderly patients.     

Factors associated with anaesthesia-related maternal mortality in a tertiary hospital in Nigeria

BACKGROUND: Maternal mortality related to anaesthesia is low compared with that resulting from obstetric factors in developed countries. The role of anaesthesia in maternal mortality in developing countries is obscure. The purposes of this study were to determine the incidence of maternal mortality related to anaesthesia, to analyse the causes and to suggest measures to improve anaesthetic safety for parturients. METHODS: The hospital surgical registry was reviewed from 1 January 1991 to 31 December 2000 to identify patients who had undergone surgical procedures in pregnancy or puerperium. Data were obtained from the surgical registry in the Labour and Delivery Suite, Intensive Care Unit records and maternal mortality database to determine the demographic characteristics and anaesthetic technique. Maternal mortality after surgical procedures was further scrutinized to evaluate the anaesthetic care and the contribution of anaesthesia to mortality. RESULTS: A total of 12,394 deliveries occurred in the hospital during the period under review. Caesarean section accounted for 2323 deliveries (18.7%). Eighty-four maternal mortalities were recorded, with a maternal mortality rate of 678 per 100,000 deliveries. Infection, haemorrhage, pre-eclampsia/eclampsia and anaesthesia were the leading causes of maternal mortality. Anaesthesia was the sole cause of six maternal deaths. The patients received general anaesthesia for the surgical procedure. CONCLUSION: Difficult airway management during general anaesthesia, inadequate supervision of trainee anaesthetists and a lack of appropriate monitors were the major anaesthetic reasons for maternal mortality. Recommendations have been made to ensure that parturients and the unborn child receive the best anaesthetic care attainable in the hospital.     

National trends in utilization and outcomes of antireflux surgery

BACKGROUND: Studies examining the outcomes of surgery for gastroesophageal reflux disease (GERD) have consisted primarily of case series. We sought to assess trends in both utilization and outcomes of antireflux surgery from a national perspective. METHODS: Using ICD-9 codes, we identified all antireflux procedures (N = 24,208) performed on adults from 1990 to 1997 in hospitals participating in the Nationwide Inpatient Sample, the largest all-payer inpatient care database in the United States. Using sampling weights and U.S. Census data, we then calculated the national population-based rate of antireflux surgery for each year and examined secular trends in utilization, in-hospital mortality, splenectomy (a technical complication), and length of hospital stay. Using a coding algorithm, we also assessed trends in the proportion of procedures performed via the laparoscopic, open abdominal, and thoracic approaches. RESULTS: From 1990 to 1997, the population-based annual rate of antireflux surgery increased from 4.4 to 12.0 per 100,000 adults. A substantial increase in utilization was observed from 1993 to 1995, but annual rates before and after this period were relatively stable. Between 1990 and 1997, in-hospital surgical mortality decreased from 1.2% to 0.5% (p = 0.002), splenectomy rates decreased from 3.9% to 1.5% (p <0.001), and median length of stay decreased from 7 to 2 days (p <0.01). The proportion of antireflux procedures performed laparoscopically increased from 0.5% to 64% (p <0.001), and the proportion of procedures performed using a thoracic approach decreased from 12% to 1% (p <0.001). CONCLUSIONS: With the dissemination of the laparoscopic approach, the population-based rate of antireflux surgery has more than doubled. At the same time, operative mortality and splenectomy risks have diminished.     

Changing surgical management for acute aortic dissections type a improves immediate outcomes

BACKGROUND: Surgical treatment of acute aortic dissection type A is well established. This study analyzes the impact of changing surgical management of Type A dissections on hospital mortality and postoperative complications. METHOD: Between January 1980 and December 2002, 141 consecutive patients were operated for acute Type A aortic dissection. Patients were analyzed in 3 time periods; 1980-1989, n = 26, 1990-1999, n = 71 and 2000-2002, n = 44). Antegrade cerebral perfusion via subclavian cannulation, a more extensive resection as well as valvar repair was introduced as routine procedures from January 2000. RESULTS: Mortality and neurological complications decreased over time; from 31% to 9.1% and from 27% to 2.5%, respectively. During follow-up, 14 patients (12%) required surgical re-intervention for aneurysms (1 to 17 years later) with associated hospital mortality of 21%. CONCLUSIONS: Antegrade cerebral perfusion reduces neurological complications and more extensive surgical approach did not increase mortality and morbidity.     

The Effect of Surgical Subspecialization on Outcomes in Peptic Ulcer Disease Complicated by Perforation and Bleeding

BACKGROUND: Emergency surgical services in Edinburgh were restructured in July 2002 to deliver subspecialist management of colorectal and upper-gastrointestinal emergencies on separate sites. The effect of emergency subspecialization on outcome from perforated and bleeding peptic ulceration was assessed. METHODS: All patients admitted with complicated peptic ulceration (January 2000-February 2005) were identified from a prospectively compiled database. RESULTS: Perforation: 148 patients were admitted with perforation before the service reorganization (period A - 31 months) of whom 126 (85.1%) underwent surgery; 135 patients were admitted in period B (31 months) of whom 114 (84.4%) were managed operatively. The in-hospital mortality was lower in period B (14/135, 10.4%) than period A (30/148, 20.3%; P = 0.023; relative risk (RR), 0.51; 95% confidence interval (CI), 0.28-0.91). There was a significantly higher rate of gastric resection in the second half of the study (period A 1/126 vs. period B 8/114; P = 0.015; RR, 8.84; 95% CI, 1.48-54.34). Length of hospital stay was similar for both groups. Bleeding: 51 patients underwent operative management of bleeding peptic ulceration in period A and 51 in period B. There were no differences in length of stay or mortality between these two groups. CONCLUSION: Restructuring of surgical services with emergency subspecialization was associated with lower mortality for perforated peptic ulceration. Subspecialist experience, intraoperative decision-making, and improved postoperative care have all contributed to this improvement.     

Importance of hospital volume in the overall management of pancreatic cancer.

OBJECTIVE: To determine whether hospital volume is associated with clinical and economic outcomes for patients with pancreatic cancer who underwent pancreatic resection, palliative bypass, or endoscopic or percutaneous stent procedures in Maryland between 1990 and 1995. SUMMARY BACKGROUND DATA: Previous studies have demonstrated that outcomes for patients undergoing a Whipple procedure improve with higher surgical volume, but only 20% to 35% of patients with pancreatic cancer qualify for curative resection. Most patients undergo palliative procedures instead with a surgical bypass or biliary stent. METHODS: Analysis of hospital discharge data from all nonfederal acute care hospitals in Maryland identified all patients with pancreatic cancer who underwent a pancreatic resection, palliative bypass, or stent procedure between 1990 and 1995. Hospitals (n = 48) were categorized as high-, medium-, and low-volume providers according to their average annual volume of these procedures. Multivariate regression was used to examine the association between hospital volume and in-hospital mortality rate, length of stay, and hospital charges, after adjusting for differences in case mix and surgeon volume. RESULTS: Increased hospital volume is associated with markedly decreased in-hospital mortality rates and a decreased or similar length of stay for all three types of procedures and with decreased or similar hospital charges for resections and stents. After adjustment for case mix differences, the relative risk (RR) of in-hospital death after pancreatic resection was 19.3 and 8 at the low- and medium-volume hospitals, respectively, versus the high-volume hospital; after bypasses, the RR of death was 2.7 and 1.9, respectively; and after stents, the RR was 4.3 and 4.8, respectively. CONCLUSIONS: Patients with pancreatic cancer who are to be treated with curative or palliative procedures appear to benefit from referral to a high-volume provider.     

Influence of surgical subspecialty training on in-hospital mortality for gastrectomy and colectomy patients

OBJECTIVE: This study examined the relationship of surgeon subspecialty training and interests to in-hospital mortality while controlling for both hospital and surgeon volume. SUMMARY BACKGROUND DATA: The relationship between volume of surgical procedures and in-hospital mortality has been studied and shows an inverse relationship. METHODS: A large Statewide Planning and Research Cooperative System was used to identify all 55,016 inpatients who underwent gastrectomy (n = 6434) or colectomy (n = 48,582) between January 1, 1998 and December 31, 2001. Surgical subspecialty training and interest was defined as surgeons who were members of the Society of Surgical Oncology (training/interest; n = 68) or the Society of Colorectal Surgery (training; n = 61) during the study period. The association of in-hospital mortality and subspecialty training/interest was examined using a logistic regression model, adjusting for demographics, comorbidities, insurance status, and hospital and surgeon volume. RESULTS: Overall mortality for colectomy patients was 4.6%; the adjusted mortality rate for subspecialty versus nonsubspecialty-trained surgeons was 2.4% versus 4.8%, respectively (adjusted odds ratio [OR] = 0.45; 95% confidence interval [CI] = 0.34, 0.60; P < 0.0001). Gastrectomy patients experienced an overall mortality rate of 8.4%; the adjusted mortality rate for patients treated by subspecialty trained surgeons was 6.5%, while the adjusted mortality rate for nonsubspecialty trained surgeons was 8.7% (adjusted OR = 0.70; 95% CI = 0.46, 1.08; P = 0.10). CONCLUSIONS: For gastrectomies and colectomies, risk-adjusted mortality is substantially lower when performed by subspecialty interested and trained surgeons, even after accounting for hospital and surgeon volume and patient characteristics. These findings may have implications for surgical training programs and for regionalization of complex surgical procedures.     

Clinical and economic effects of pulmonary artery catheterization in nonemergent coronary artery bypass graft surgery

OBJECTIVE: To examine the association between use of pulmonary artery catheterization with hospital outcomes and costs in nonemergent coronary artery bypass graft (CABG) surgery. DESIGN: Retrospective cohort study. SETTING: Fifty-six community-based hospitals in 26 states. PARTICIPANTS: A total of 13,907 patients undergoing nonemergent CABG surgery between January 1, 1997, and December 31, 1997. MEASUREMENTS AND MAIN RESULTS: Discharge abstracts for each patient were examined. Stratified and multivariate analyses were used to assess the impact of pulmonary artery catheters (PACs) on in-hospital mortality, length of stay in the intensive care unit, total length of stay, and hospital costs. Outcomes were adjusted for patient demographic factors, hospital characteristics, and hospital volume of PAC use in the year of analysis. Fifty-eight percent of the patients received a PAC. After adjustment, the relative risk of in-hospital mortality was 2.10 for the PAC group compared with the patients who did not receive a PAC (95% confidence interval [CI], 1.40 to 3.14; p < 0.001). The mortality risk was significantly higher in hospitals with the lowest third of PAC use (odds ratio, 3.35; 95% CI, 1.74 to 6.47; p < 0.001) and not significantly increased in the highest two thirds of users (odds ratio, 1.62; 95% CI, 0.99 to 2.66; p = 0.09). Days spent in critical care were similar; however, total length of hospital stay was 0.26 days longer in the PAC group (p < 0.001). Hospital costs were $1,402 higher in the PAC group. CONCLUSION: In the setting of nonemergent CABG surgery, pulmonary artery catheterization was associated with an increased risk of in-hospital mortality, greater length of stay, and higher total costs, particularly in hospitals with low volume of PAC use.     

Impact of race on the outcome of carotid endarterectomy: a population-based analysis of 9,842 recent elective procedures

OBJECTIVE: To examine the influence of race and other potentially confounding variables on the outcome of carotid endarterectomy (CEA). SUMMARY: Previous studies have demonstrated that CEA is performed less frequently in black patients, although little attention has been focused on the influence of race on the outcome of surgery. METHODS: The Maryland Health Services Cost Review Commission database was reviewed to identify all elective CEA procedures performed in all nonfederal acute care hospitals in the state from 1990 through 1995 to examine the influence of race and other factors on the rates of in-hospital complications, in-hospital stroke, length of stay, and total hospital charges. RESULTS: Carotid endarterectomy was performed in 9,219 (94%) white and 623 (6%) black patients during this period. The in-hospital stroke rate was 1.7%-3. 1% among black patients and 1.6% among white patients. Black patients had a longer length of stay and higher mean hospital charges than white patients. Multivariate logistic regression analysis identified black race as an independent risk factor for in-hospital stroke. Performance of CEA by a high-volume surgeon was protective for the combined occurrence of in-hospital stroke or death, and whites were more than twice as likely to undergo surgery performed by high-volume surgeons. Conversely, undergoing surgery in a low-volume hospital was associated with in-hospital stroke, and blacks were four times as likely to use low-volume hospitals. CONCLUSIONS: Black patients who underwent elective CEA in Maryland from 1990 to 1995 had an increased incidence of in-hospital stroke, a longer hospital stay, and higher hospital charges than whites. Black race was identified as an independent risk factor for in-hospital stroke, although the reasons for this influence of race on outcome are undefined. The authors' observations also suggest the possibility of limited access to optimal surgical care among blacks, and this issue warrants further study.     

Percutaneous transluminal angioplasty for critical limb ischaemia in octogenarians and nonagenarians.

OBJECTIVE: To determine the early and late outcome of percutaneous transluminal angioplasty (PTA) for critical limb ischaemia (CLI) in patients aged 80 years and over. METHODS: Retrospective case note review of all patients aged 80 years and over who underwent attempted PTA for CLI between 1st January 1999 and 31st December 2000. Minimum follow-up was 12 months with a maximum of 42 months. RESULTS: One hundred and twenty-eight PTAs were attempted in 113 severely ischaemic limbs of 98 patients (36 men and 62 women of median age 84, range 80-97, years). Seventy patients had significant co-morbidity. The indication for revascularisation was rest pain in 47 procedures, ulceration in 66 and digital gangrene in 15. The anatomical segments involved were iliac (n=19), superficial femoral (n=92), popliteal (n=91) and infrapopliteal (n=72). The technical success rate was 108 of 128 (84%) procedures. Early technical complications occurred in 24 (19%) procedures: four major, 20 minor. The 30-day operative mortality rate was six of 128 (5%). The median (range) in-hospital stay was two (1-72) days. Early or delayed surgical revascularisation was required in 11 limbs and there were six major limb amputations during the study period. The 24-month patient survival rate was 59%. The 24-month primary and secondary symptomatic patency and secondary limb salvage rates were 52, 69 and 95%, respectively. DISCUSSION: PTA is safe, requires a short hospital stay, and is clinically effective in the majority of very elderly patients with CLI. Although minimally invasive, the relatively high peri-procedural mortality rate and low 24-month survival rate reflect the high co-morbidity of this group of patients.     

Ten-year surgical experience with nontraumatic pericardial effusions: a comparison between the subxyphoid and transthoracic approaches to pericardial window

HYPOTHESIS: The approach to pericardial window in patients with nontraumatic pericardial effusion impacts outcome. DESIGN: Retrospective review and comparison of all cases of pericardial window performed over 10 years. Follow-up was to patient death. SETTING: Three hospitals performing cardiothoracic surgery at a single university. PATIENTS: All patients in whom pericardial window was performed for nontraumatic pericardial effusion. MAIN OUTCOME MEASURES: Outcomes associated with the subxyphoid approach to pericardial window were compared with those associated with the transthoracic approach. The primary outcome was postsurgical recurrence of pericardial effusion. Secondary outcomes included operative time, intraoperative and postoperative complications, in-hospital mortality, hospital and intensive care unit lengths of stay, and days between surgery and death. RESULTS: Over 10 years, there were 342 patients with procedural codes for pericardial window in the medical record databases of 3 hospitals performing cardiothoracic surgery at 1 university center. One hundred fifty-one patients were excluded because the operation was performed for trauma, postoperative tamponade, or pericardial biopsy without effusion. The results are, therefore, based on the remaining 191 procedures. The subxyphoid approach was used in 78 patients, and the transthoracic approach in 113 patients. Patients were well matched for age (P = .31), sex (P = .05), preoperative tamponade (P = .08), and comorbidities (P > .05). No differences were observed between the 2 approaches in terms of recurrence of effusion, operative time, overall intraoperative or postoperative complications, and hospital or intensive care unit lengths of stay. In-hospital mortality was significantly greater in the subxyphoid group (27 of 78 vs 18 of 113 patients; P = .003). CONCLUSIONS: Over 10 years, there were 191 pericardial windows performed for nontraumatic pericardial effusions. The subxyphoid and transthoracic approaches were well tolerated by patients, required short operative times, and resulted in similar rates of overall postoperative complications and intensive care unit and hospital lengths of stay. Recurrence rates were low with both procedures.     

Colorectal Surgery Fellowship Improves In-hospital Mortality After Colectomy and Proctectomy Irrespective of Hospital and Surgeon Volume

Background

General surgery residents are increasingly pursuing sub-specialty training in colorectal (CR) surgery. However, the majority of operations performed by CR surgeons are also performed by general surgeons. This study aimed to assess in-hospital mortality stratified by CR training status after adjusting for surgeon and hospital volume.

Methods

The Statewide Planning and Research Cooperative system database was used to identify all patients who underwent colectomy/proctectomy from January 1, 2000, to December 31, 2014, in the state of New York. Operations performed by board-certified CR surgeons were identified. The relationships between CR board certification and in-hospital mortality, in-hospital complications, length of stay, and ostomy were assessed using multivariate regression models.

Results

Two hundred seventy thousand six hundred eighty-four patients underwent colectomy/proctectomy over the study period. Seventy-two thousand two hundred seventy-nine (26.7%) of operations were performed by CR surgeons. Without adjusting for hospital and surgeon volume, in-hospital mortality was lower for those undergoing colectomy/proctectomy by a CR surgeon (OR 0.49, CI 0.44–0.54, p = 0.001). After controlling for hospital and surgeon volume, the odds of inpatient mortality after colectomy/proctectomy for those operated on by CR surgeons weakened to 0.76 (CI 0.68–0.86, p = 0.001). Hospital and surgeon volume accounted for 53% of the reduction in in-hospital mortality when CR surgeons performed colectomy/proctectomy. Patients who underwent surgery by a CR surgeon had a shorter inpatient stay (0.8 days, p = 0.001) and a decreased chance of colostomy (OR 0.86, CI 0.78–0.95, p < 0.001).

Conclusions

For patients undergoing colectomy/proctectomy, in-hospital mortality decreased when the operation was performed by a CR surgeon even after accounting for hospital and surgeon volume.

     

The hospital volume-outcome relationship in general thoracic surgery. Is the surgeon the critical determinant?

BACKGROUND: Complex operations, such as those performed in thoracic surgery, have a hospital volume-outcome relationship. It is difficult to isolate the effect of the surgeon in this relationship since experienced thoracic surgeons tend to practice in high-volume tertiary care hospitals. An American comprehensive cancer hospital created a community outreach satellite program in thoracic surgery, and this provided a unique opportunity to study the hospital volume-outcome relationship without the confounding variable of surgeon experience. METHODS: A retrospective review of thoracic surgical operations done over a 4-year period at a small community hospital, by a tertiary care hospital surgeon, was conducted. Operative mortality was the major outcome measure. Two high complexity operations (pneumonectomy and esophagectomy) were specifically scrutinized. RESULTS: 486 thoracic surgical procedures (317 minor and 169 major cases) were done. There was one in-hospital death (aspiration pneumonia after esophageal stenting) and one 30-day mortality (readmission for cerebral vascular accident after lobectomy). Data,for the 10 esophagectomy patients is as follows: age - 66+/-13 years; length of stay - 12.8+/-3.4 days; anastomotic leaks - 0; operative mortality - 0. Data for the 6 pneumonectomy patients is as follows: age - 69+/-8 years; length of stay - 8.5+/-5.2 days; preoperative FEV1 - 1.6+/-0.3 litres; fistulas or empyema - 0; operative mortality - 0. CONCLUSIONS: Despite having a very low volume of thoracic surgical cases the community hospital had crude outcomes comparable to those reported from high volume tertiary hospitals. This suggests that the surgeon may be a more important factor in the hospital volume-outcome relationship than previously thought. Nevertheless, complex thoracic surgical operations are ideally performed by an experienced surgeon, and in a high volume hospital     

Outcomes after open versus laparoscopic gastric bypass

In expert hands, laparoscopic gastric bypass (LGB) is associated with reduced morbidity and mortality compared with open bariatric surgery. The purpose of our study was to determine whether or not the results of LGB have been realized in the general US population. We used data from the nationwide inpatient sample to define differences in outcomes after LGB versus open techniques (OGB). We calculated hospital stay, in-hospital mortality, and major complications for both OGB and LGB. We noted a total of 26,940 gastric bypass procedures: LGB was coded in 16.3% and OGB in 83.7%. The mean hospital stay, mortality, wound, gastrointestinal, pulmonary, and cardiovascular complications were significantly lower after LGB (P<0.001). After we adjusted for covariates, hospital stay, pulmonary morbidity, and mortality remained significantly lower after LGB (P<0.001). In conclusion, LGB is associated with significantly lower mean hospital stay and with reduced morbidity and mortality as compared with OGB.     

National trends in utilization and outcomes of bariatric surgery

Background Because of the growing interest in surgery to treat morbid obesity, this study examined changes in the utilization and in-hospital outcomes of bariatric surgery in the United States over a 10-year period.Methods Data were obtained from the Nationwide Inpatient Sample, the largest all-payer discharge database in the United States. International Classification of Disease (ICD-9) codes were used to identify all bariatric procedures performed for adults from 1990 to 2000. Population-based rates of surgery for each year were calculated by applying sampling weights and U.S. Census data. Secular trends in annual rates of surgery, changes in patient characteristics, and in-hospital mortality and complications were analyzed.Results From 1990 to 2000, the national annual rate of bariatric surgery increased nearly six fold, from 2.4 to 14.1 per 100,000 adults (p = 0.001). There has been more than a ninefold increase in the use of gastric bypass procedures (1.4 to 13.1 per 100,000; p < 0.001). This represents an increase from 55% of all bariatric procedures in 1990 to 93% of such procedures in 2000 (p < 0.001). The rates of in-hospital mortality were low (0.4% overall), but increased slightly over time (0.2% in 1990 to 0.5% in 2000; p = 0.009). There is no significant difference in adjusted mortality for the past 8 years, but a slight rise did occur over the full 10-year period. The rates for reoperation (1.3%) and pulmonary emboli (0.3%) remained stable. The rates for respiratory failure associated with bariatric surgery declined from 7.7% in 1990 to 4.5% in 2000 (p < 0.001). Over this time, the mean length of hospital stay declined from 6.0 to 4.1 days (p < 0.001).Conclusions The annual rate of bariatric surgery in the United States increased nearly six fold between 1990 and 2000, with_little change in in-hospital morbidity and mortality. This appears to be driven largely by the increasing popularity of gastric bypass procedures.Presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) 2004     

Outcome of elderly patients with appendicitis: effect of computed tomography and laparoscopy

HYPOTHESIS: Elderly patients who have appendicitis have a greater morbidity and mortality rate when compared with younger patients. We hypothesized that recent changes in the diagnosis and management of appendicitis in elderly patients might affect the outcome. DESIGN: Retrospective review. SETTING: Large metropolitan teaching hospital. PATIENTS: All patients aged 70 years and older who underwent appendectomy for appendicitis between January 1, 1991, and December 31, 2000, were divided into groups 1 (those treated from January 1, 1991, through December 31, 1995) and 2 (those treated from January 1, 1996, through December 31, 2000). MAIN OUTCOME MEASURES: Age, sex, preoperative evaluation, operative duration and findings, postoperative course, duration of hospital stay, and mortality rate. Continuous and categorical variables were analyzed using t and chi(2) tests, respectively. RESULTS: Ninety-five patients met inclusionary criteria. The mean age (78 years), sex, preoperative suggestion of appendicitis (group 1, 39 [83%] of 47 patients; group 2, 45 [94%] of 48 patients), and duration of the preoperative hospitalization over 24 hours (group 1, 11 patients [23%]; group 2, 9 patients [19%]) were similar in both groups. There was an increasing use of diagnostic computed tomography (group 1, 13 patients [28%]; group 2, 32 patients [67%]; P<.001) and laparoscopy (group 1, 14 patients [30%]; group 2, 23 patients [48%]; P =.02) between the 2 study periods associated with no significant difference in the duration of hospitalization, frequency of appendiceal perforation or abscess, occurrence of complications, or mortality. The length of operating time increased in the second period (ie, January 1, 1996, through December 31, 2000). CONCLUSIONS: Appendicitis in elderly patients continues to be a challenging surgical problem. While computed tomography may represent a useful diagnostic tool and laparoscopic appendectomy may be appropriate therapy for selected patients, neither has affected outcome when measured for morbidity and mortality rates. Overall results might improve with earlier consideration of the diagnosis in elderly patients with abdominal pain, followed by prompt surgical consultation and operation.     

Clinical pathway for hip fractures in the elderly: the Hospital for Joint Diseases experience

Hip fractures are common injuries in the elderly and are associated with considerable morbidity and mortality. Although technical advances in the treatment of the elderly have resulted in improved fracture fixation and surgical outcomes, clinical pathways have been developed to further improve patient outcome while shortening hospital length of stay after hip fracture. We describe the clinical pathway used since 1990 at the Hospital for Joint Diseases. The outcomes of 747 patients treated before 1990 were compared with outcomes of 318 patients treated at our hospital after initiation of the clinical pathway. Use of the clinical pathway was associated with significant decreases in the acute care hospital length of stay, in-hospital mortality, and 1-year mortality.     

Trends in demographics, comorbidity profiles, in-hospital complications and mortality associated with primary knee arthroplasty

We analyzed the National Hospital Discharge Survey to elucidate temporal changes in the demographics, comorbidities, hospital stay, in-hospital complications, and mortality of patients undergoing primary total knee arthroplasties (TKAs) in the United States. Three 5-year periods were created (1990-1994, 1995-1999, and 2000-2004), and temporal changes were analyzed. The number of TKAs performed increased by 125% for the 3 periods. The increasing proportion of younger patients was accompanied by a concomitant decrease of Medicare-insured patients. Length of stay decreased from 8.44 to 4.18 days. An increase in the proportion of discharges to long-term and short-term care facilities and in procedures performed in small hospitals was noted. Although the prevalence of procedure-related complications decreased over time, comorbidities increased. Despite a decrease in mortality from the first to the second study period (0.50% vs 0.21%), a slight increase was noticed more recently (0.28%). We identified significant changes in most variables studied.     

Surgery for Parkinson disease in the United States, 1996 to 2000: practice patterns, short-term outcomes, and hospital charges in a nationwide sample

OBJECT: The surgical treatment of Parkinson disease (PD) has undergone a dramatic shift, from stereotactic ablative procedures toward deep brain stimulaion (DBS). The authors studied this process by investigating practice patterns, mortality and morbidity rates, and hospital charges as reflected in the records of a representative sample of US hospitals between 1996 and 2000. METHODS: The authors conducted a retrospective cohort study by using the Nationwide Inpatient Sample database; 1761 operations at 71 hospitals were studied. Projected to the US population, there were 1650 inpatient procedures performed for PD per year (pallidotomies, thalamotomies, and DBS), with no significant change in the annual number of procedures during the study period. The in-hospital mortality rate was 0.2%, discharge other than to home was 8.1%, and the rate of neurological complications was 1.8%, with no significant differences between procedures. In multivariate analyses, hospitals with larger annual caseloads had lower mortality rates (p = 0.002) and better outcomes at hospital discharge (p = 0.007). Placement of deep brain stimulators comprised 0% of operations in 1996 and 88% in 2000. Factors predicting placement of these devices in analyses adjusted for year of surgery included younger age, Caucasian race, private insurance, residence in higher-income areas, hospital teaching status, and smaller annual hospital caseload. In multivariate analysis, total hospital charges were 2.2 times higher for DBS (median dollar 36,000 compared with dollar 12,000, p < 0.001), whereas charges were lower at higher-volume hospitals (p < 0.001). CONCLUSIONS: Surgical treatment of PD in the US changed significantly between 1996 and 2000. Larger-volume hospitals had superior short-term outcomes and lower charges. Future studies should address long-term functional end points, cost/benefit comparisons, and inequities in access to care.     

Intensive care unit hospitalization after colorectal surgery

OBJECTIVE: Intensive care units (ICU) support critically ill patients during the perioperative period. Few studies exist focusing on ICU hospitalisation after colorectal surgery. The objective of the study was to 1) detect predictive factors of mortality and length of stay in ICU after colorectal procedures, and 2) compare the autonomy status of the patients before and 30 days after their ICU stay. PATIENTS AND METHODS: This study followed a prospective non randomized cohort in our colorectal surgery unit. During a period of one year (January 1st to December 31th, 2000) 351 colorectal procedures were performed and 54 patients were admitted to ICU after surgery. For each patient, 37 parameters were collected on a standardized register. Predictive factors of mortality (30 days after the procedure) and ICU stay (up to 3 days) were studied by univariate and multivariate statistical analysis. Self autonomy before surgery and 30 days after was also investigated. RESULTS: "Multiple-intervention" was the only independent factor influencing mortality. Both "low autonomy status before surgery" and "pulmonary comorbidity" increased the length of stay. Regarding the 48 survivors, 45 (94%) recovered the same autonomy index as in the preoperative period 30 days after the procedure. CONCLUSION: This study highlights the poor predictive factors influencing mortality during or after ICU stay following colorectal surgery, and emphasizes two preoperative parameters increasing the length of stay up to 3 days. This should guide the informations given to the patients families. Finally, this study confirms the good quality of self-sufficiency after ICU stay even for a long time (over 3 days).