The association of pre-operative anaemia with morbidity and mortality after emergency laparotomy

Pre-operative anaemia is associated with poor outcomes after elective surgery but its relationship with outcomes after emergency surgery is unclear. We analysed National Emergency Laparotomy Audit data from 1 December 2013 to 30 November 2017, excluding laparotomy for haemorrhage. Anaemia was classified as ‘mild’ 129–110 g.l−1; ‘moderate’ 109–80 g.l−1; or ‘severe’ ≤ 79 g.l−1. The primary outcome was 90-day mortality. Secondary outcomes were 30-day mortality, return to theatre and postoperative hospital stay. The primary outcome was available for 86,763 patients, of whom 45,306 (52%) were anaemic. There were 12,667 (15%) deaths at 90 postoperative days and 9246 (11%) deaths at 30 postoperative days. Anaemia was associated with increased 90-day and 30-day mortality, odds ratio (95%CI): mild, 1.15 (1.09–1.21); moderate, 1.44 (1.36–1.52); and severe, 1.42 (1.24–1.63), p < 0.001 for all; mild, 1.07 (1.00–1.12), p = 0.030; moderate, 1.30 (1.21–1.38), p < 0.001; and severe, 1.22 (1.05–1.43), p = 0.010, respectively. All categories of anaemia were associated with prolonged hospital stay, adjusted coefficient (95%CI): mild, 1.31 (1.01–1.62); moderate, 3.41 (3.04–3.77); severe, 2.80 (1.83–3.77), p < 0.001 for all. Moderate and severe anaemia were associated with increased risk of return to the operating theatre, odds ratio (95%CI): moderate 1.13 (1.06–1.21), p < 0.001; and severe 1.23 (1.06–1.43), p = 0.006. Pre-operative anaemia is common in patients undergoing emergency laparotomy and is associated with increased postoperative mortality and morbidity.     

IMPACT-Global Hip Fracture Audit: Nosocomial infection,risk prediction and prognostication,minimum reporting standards and global collaborative audit: Lessons from an international multicentre study of 7,090 patients conducted in 14 nations during the COVID-19 pandemic

AimsThis international study aimed to assess: 1) the prevalence of preoperative and postoperative COVID-19 among patients with hip fracture, 2) the effect on 30-day mortality, and 3) clinical factors associated with the infection and with mortality in COVID-19-positive patients.MethodsA multicentre collaboration among 112 centres in 14 countries collected data on all patients presenting with a hip fracture between 1st March-31st May 2020. Demographics, residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, management, ASA grade, length of stay, COVID-19 and 30-day mortality status were recorded.ResultsA total of 7090 patients were included, with a mean age of 82.2 (range 50–104) years and 4959 (69.9%) being female. Of 651 (9.2%) patients diagnosed with COVID-19, 225 (34.6%) were positive at presentation and 426 (65.4%) were positive postoperatively. Positive COVID-19 status was independently associated with male sex (odds ratio (OR) 1.38, p = 0.001), residential care (OR 2.15, p < 0.001), inpatient fall (OR 2.23, p = 0.003), cancer (OR 0.63, p = 0.009), ASA grades 4 (OR 1.59, p = 0.008) or 5 (OR 8.28, p < 0.001), and longer admission (OR 1.06 for each increasing day, p < 0.001). Patients with COVID-19 at any time had a significantly lower chance of 30-day survival versus those without COVID-19 (72.7% versus 92.6%, p < 0.001). COVID-19 was independently associated with an increased 30-day mortality risk (hazard ratio (HR) 2.83, p < 0.001). Increasing age (HR 1.03, p = 0.028), male sex (HR 2.35, p < 0.001), renal disease (HR 1.53, p = 0.017), and pulmonary disease (HR 1.45, p = 0.039) were independently associated with a higher 30-day mortality risk in patients with COVID-19 when adjusting for confounders.ConclusionThe prevalence of COVID-19 in hip fracture patients during the first wave of the pandemic was 9%, and was independently associated with a three-fold increased 30-day mortality risk. Among COVID-19-positive patients, those who were older, male, with renal or pulmonary disease had a significantly higher 30-day mortality risk.     

Emergency surgery comparison of right versus left acute colonic diverticulitis: A 10-year outcome analysis

IntroductionThe difference in outcome between right (RCD) and left colonic diverticulitis (LCD) is not well established. The aim of this study was to analyse the presentation and surgical outcome of RCD versus left-sided disease following emergency surgery.MethodWe conducted a retrospective review of patients presenting with acute diverticulitis over a 10-year period from 2004 to 2014 to a tertiary unit. Patient demographics, Hinchey classification, need for emergency surgery, perioperative outcome and recurrence were evaluated.ResultsIn total 360 patients presented with acute diverticulitis, 218 (61%) were right-sided and 142 (39%) were left-sided. The mean age (57 yrs vs 68 yrs) and median length of stay (4 days vs 5 days) were significantly less in RCD (p < 0.001). The need for emergency surgery was similar between RCD and LCD (30.7% vs 23.2%, p = 0.12). Sixty-seven (31%) patients with RCD required emergency surgery, 42 (62.7%) of these were based on a presumptive diagnosis of appendicitis and underwent laparoscopic appendicectomy only. Operative morbidity (10.4% vs 51.5%, p < 0.001) and mortality were significantly higher in LCD (1.5% v 15.2%, p = 0.007). Subgroup analysis of non-appendicectomy, RCD patients, showed LCD were more likely to require surgery (11.5% vs 23.2%, p = 0.003). There was no difference in recurrence (p = 0.6).ConclusionRight colonic diverticulitis patients are younger and disease course is more benign compared to LCD. Presentation can be confused with appendicitis without proper imaging. In the rare cases where emergency surgery is required, RCD is associated with a lower operative morbidity and mortality compared to left-sided disease.     

Complex surgery and optimal consent: A variety of opinions exist among healthcare professionals

BackgroundEstablishing healthcare professional's views on optimal consent in complex surgery could guide tailored consent policy, improving the process in challenging scenarios. To date, no studies have established if professionals of differing specialities agree on major aspects of consent in areas such as emergency surgery and cancer surgery.MethodsAn anonymous web based survey was distributed to a variety of disciplines in a tertiary referral centre. Questions regarding optimal methods and timing of consent in emergency and cancer surgery were posed. Comparative analyses of quantitative data were performed using chi-squared test.Results57 responses were received from doctors and nurses of varying disciplines. Differences were found between doctors of separate specialities and nurses in opinion of optimal timing of consent (p = 0.02), consent validity over time (p < 0.001) and the utility of introducing more specific consent policy (p = 0.01). Almost all respondents agreed that healthcare professionals have differing ideas of what consent is.ConclusionsThis study demonstrates differences in opinion regarding optimal consent for cancer and emergency surgery. Consideration should be given to developing consensus among healthcare professionals regarding what consent for complex surgery constitutes.     

Preliminary results of laparoscopic versus open pancreaticoduodenectomy in Vietnam: A retrospective analysis from a multi-center research

IntroductionThe goal of this study was to compare the results of LPD with those of open pancreaticoduodenectomy (OPD).MethodData were retrospectively collected from a database of patients who underwent PD from January 2010 to May 2020. Intraoperative, postoperative, and follow-up assessment studies were conducted.ResultsA total of 149 patients were selected. Compared with OPD, LPD was fewer intraoperative blood transfusions (p = 0.015), a longer median operative time (p < 0.001), hospital stay (p = 0.034), a higher rate of bile leakage (p = 0.02), overall morbidity (p = 0.045), and re-operation (p = 0.044). There was no difference between the two groups in severe pancreatic fistula, postoperative bleeding, delayed gastric emptying, Clavien-Dindo classification ≥ III, or 30-day mortality. LPD had a similar number of excised lymph nodes, R0 resection rate, and long-term survival cases involving malignant tumors, ampulla of Vater cancer, and pancreatic ductal adenocarcinoma.ConclusionIn the early period, the benefit of LPD has not been found as there was a high rate of conversion to laparotomy, morbidity, and re-operation. Despite that, LPD is a feasible oncological approach with long-term survival comparable to OPD.     

Does mortality after trauma team activation peak at shift change?

BackgroundPrior institutional data have demonstrated trauma mortality to be highest between 06:00–07:59 at our center, which is also when providers change shifts (07:00–07:30). The objective was definition of patient, provider, and systems variables associated with trauma mortality at shift change among patients arriving as trauma team activations (TTA).MethodsAll TTA patients at our ACS-verified Level I trauma center were included (01/2008–07/2019), excluding those with undocumented arrival time. Study groups were defined by arrival time: shift change (SC) (06:00–07:59) vs. non-shift change (NSC) (all other times). Univariable/multivariable analyses compared key variables. Propensity score analysis compared outcomes after matching.ResultsAfter exclusions, 6020 patients remained: 229 (4%) SC and 5791 (96%) NSC. SC mortality was 25% vs. 16% during NSC (p < 0.001). More SC patients arrived with SBP <90 (19% vs. 11%, p < 0.001) or GCS <9 (35% vs. 24%, p < 0.001). ISS was higher during SC (43[32–50] vs. 34[27–50], p < 0.001). Time to CT scan (36[23–66] vs. 38[23–61] minutes, p = 0.638) and emergent surgery (94[35–141] vs. 63[34–107] minutes, p = 0.071) were comparable. Older age (p < 0.001), SBP <90 (p < 0.001), GCS <9 (p < 0.001), need for emergent operative intervention (p = 0.044), and higher ISS (p < 0.001) were independently associated with mortality. After propensity score matching, mortality was no different between SC and NSC (p = 0.764).ConclusionsEarly morning is a low-volume, high-mortality time for TTAs. Increased mortality at shift change was independently associated with patient/injury factors but not provider/systems factors. Ensuring ample clinical resource allocation during this high acuity time may be prudent to streamline patient care at shift change.     

A prospective cohort study of the safety of breast cancer surgery during COVID-19 pandemic in the West of Scotland

IntroductionIn order to minimise the risk of breast cancer patients for COVID-19 infection related morbidity and mortality prioritisation of care has utmost importance since the onset of the pandemic. However, COVID-19 related risk in patients undergoing breast cancer surgery has not been studied yet. We evaluated the safety of breast cancer surgery during COVID-19 pandemic in the West of Scotland region.MethodsA prospective cohort study of patients having breast cancer surgery was carried out in a geographical region during the first eight weeks of the hospital lockdown and outcomes were compared to the regional cancer registry data of pre-COVID-19 patients of the same units (n = 1415).Results188 operations were carried out in 179 patients. Tumour size was significantly larger in patients undergoing surgery during hospital lockdown than before (cT3-4: 16.8% vs. 7.4%; p < 0.001; pT2 – pT4: 45.5% vs. 35.6%; p = 0.002). ER negative and HER-2 positive rate was significantly higher during lockdown (ER negative: 41.3% vs. 17%, p < 0.001; HER-2 positive: 23.4% vs. 14.8%; p = 0.004). While breast conservation rate was lower during lockdown (58.6% vs. 65%; p < 0.001), level II oncoplastic conservation was significantly higher in order to reduce mastectomy rate (22.8% vs. 5.6%; p < 0.001). No immediate reconstruction was offered during lockdown. 51.2% had co-morbidity, and 7.8% developed postoperative complications in lockdown. There was no peri-operative COVID-19 infection related morbidity or mortality.Conclusionbreast cancer can be safely provided during COVID-19 pandemic in selected patients.     

Impact of interhospital transfer on patient outcomes in emergency general surgery

BackgroundEmergency general surgery patients are at an increased risk for morbidity and mortality compared to their elective surgery counterparts. The complex nature of emergency general surgery conditions can challenge community hospitals, which may lack appropriate systems and personnel. Outcomes related to transfer have not been well-established. We aimed to compare postoperative outcomes of patients who were transferred from another hospital to a center with dedicated acute care surgery services with patients admitted directly to the acute care surgery centers.MethodsWe performed a secondary analysis of a national, multicenter review of emergency general surgery patients undergoing complex emergency general surgery at 5 centers across Canada. The primary outcome was the development of any complication. The adjusted odds of postoperative complication was assessed using logistic regression, controlling for age, comorbidities, duration of stay before transfer, American Society of Anesthesiologists classification, and booking priority.ResultsA total of 1,846 patients were included in the study, and 176 (9.5%) were transferred. Of these 21% (n = 37) underwent an operative procedure, and 15% (n = 27) underwent an operation at the transferring center. Transferred patients were more likely to have at least 1 comorbidity (68% vs 57%; P = .004), were classified as greater urgency on arrival (<2 hours booking priority, 43% vs 17%; P < .001), had a greater American Society of Anesthesiologists classification (American Society of Anesthesiologists ≥3 = 81% vs 65%; P < .001), a greater duration of operation (119 vs 110 minutes; P = .004), and were more likely to undergo a second operation (28% vs 14%; P < .001) compared to patients directly admitted to an acute care surgery center. On univariate analysis, transferred patients had greater rates of complications (48% vs 31%; P < .001), mortality (14% vs 7%; P = .005), and admission to the intensive care unit (22% vs 12%; P < .001). Transfer status remained an independent predictor of complication (odds ratio 1.9 [95% confidence interval 1.3–2.7]; P < .001) and intensive care unit admission (odds ratio 1.9 [95% confidence interval 1.2–3.0]; P = .007), but not mortality (odds ratio 1.1 [95% confidence interval 0.6–1.9]; P = .79) on regression analysis.ConclusionComplex emergency general surgery patients transferred to acute care surgery centers may have worse outcomes and greater use of resources compared to those admitted directly. This finding has clinically and financially important implications for the design and regionalization of acute care surgery services as well as resource allocation at acute care surgery centers.     

Outcomes following outpatient anterior cervical discectomy and fusion for the treatment of myelopathy

IntroductionAnterior cervical discectomy and fusion (ACDF) is a commonly performed procedure for the treatment of degenerative cervical disease. With continued increase in U.S. healthcare expenditure, surgeons have begun to more closely examine the benefits of performing ACDF in an outpatient setting to increase efficiency, reduce the overall financial burden on patients/providers, and provide streamlined care for these patients. The purpose of this study was to analyze outcomes following outpatient ACDF for the treatment of myelopathy.Methods14,490 patients who had undergone ACDF for myelopathy from 2010 to 2018 were included in this retrospective study, of which 2956 (20.40%) patients were considered to have undergone outpatient surgery. Pearson chi-squared tests and Fischer’s Exact Tests were used to analyze differences in categorical variables of demographics, preoperative comorbidities, and postoperative complications, while Mann-Whitney-U-Tests were used to compare mean values of continuous variables. Coarsened-exact-matching (CEM) was implemented to control for baseline differences in demographics and comorbidities, and post-matching diagnostics included multivariate and univariate imbalance measure assessment. Outcomes were compared between the CEM-matched inpatient and outpatients ACDF cohorts.ResultsUpon CEM-matching (L1-statistic <0.001), the outpatient cohort (n = 2610, 25.13%) demonstrated significantly lower rates of any complication (p < 0.001), minor complications (p = 0.001), urinary tract infections (p = 0.029), blood transfusions (p < 0.001), major complications (p < 0.001), deep incisional surgical site infections (p = 0.017), ventilator dependence (p = 0.027), cardiac arrest (p = 0.028), unplanned reoperations (p = 0.001), and mortality (p = 0.006) in the 30-day postoperative period when compared to inpatient controls (n = 7774, 74.87%).ConclusionACDF has been a target amongst spinal procedures as a prime candidate for outpatient surgery. However, no previous reports have described complication rates and perioperative parameters in the sub-population of outpatient ACDF patients with myelopathy. In addition to shorter times from admission to operating room, operative time, and LOS, our study also demonstrated lower rates of major and overall complications in outpatient ACDF’s for myelopathy in comparison to their inpatient counterparts. Performing ACDF’s for myelopathy in an outpatient setting may help to curb costs, improve outcomes, and serve as a valuable learning resource for graduate medical education with rapid turnovers and shorter operative times.     

Factors influencing short‐ and long‐term mortality after lower limb amputation

Mortality after lower limb amputation is high, with UK 30‐day mortality rates of 9–17%. We performed a retrospective analysis of factors affecting early and late outcome after lower limb amputation for peripheral vascular disease or diabetic complications at a UK tertiary referral vascular centre between 2003 and 2010. Three hundred and thirty‐nine patients (233 male), of median (IQR [range]) age 73 (62–79 [26–92]) years underwent amputation. Thirty‐day mortality was 12.4%. On regression modelling, the risk of 30‐day mortality was increased in patients of ASA grade ≥ 4 (OR 4.23, 95% CI 2.07–8.63), p < 0.001 and age between 74 and 79 years (OR 3.8, 95% CI 1.10–13.13), p = 0.04 and older than 79 years (OR 4.08, 95% CI 1.25–13.25), p = 0.02. Peri‐operative (30‐day) mortality for these groups was 23.2%, 13.7% and 18.8%, respectively. Survival and Cox regression analysis demonstrated that long‐term mortality was associated with: age 74–79 years (HR 2.15, 95% CI 1.38–3.35), p = 0.001; age > 79 years (HR 2.78, 95% CI 1.82–4.25), p < 0.001; ASA grade ≥ 4 (HR 2.04, 95% CI 1.51–2.75), p < 0.001; out‐of‐hours operating (HR 1.51, 95% CI 1.08–2.10), p = 0.02; and chronic kidney disease stage 4–5 (1.57, 95% CI 1.07–2.30), p = 0.02. Anaesthetic technique was associated with long‐term mortality on survival analysis (p = 0.04), but not when analysed using regression modelling. Mortality after lower limb amputation relates to patient age, ASA, out‐of‐hours surgery and renal dysfunction. These data support lower limb amputations’ being performed during daytime hours and after modification of correctable risk factors.     

Association between preoperative administration of gabapentinoids and 30-day hospital readmission: A retrospective hospital registry study.

Study objectiveTo evaluate the effectiveness of preoperative gabapentinoid administration.DesignRetrospective hospital registry study.SettingTertiary referral center (Boston, MA).Patients111,008 adult non-emergency, non-cardiac surgical patients between 2014 and 2018.InterventionsPreoperative administration of gabapentinoids (gabapentin or pregabalin).MeasurementsWe tested the primary hypothesis that preoperative gabapentinoid use was associated with lower odds of hospital readmission within 30 days. Contingent on this hypothesis, we examined whether lower intraoperative opioid utilization mediated this effect. Secondary outcome was postoperative respiratory complications.Main resultsGabapentinoid administration was associated with lower odds of readmission (adjusted odds ratio [OR_adj] 0.80 [95% CI, 0.75–0.85]; p < 0.001). This effect was in part mediated by lower intraoperative opioid utilization in patients receiving gabapentinoids (8.2% [2.4–11.5%]; p = 0.012). Readmissions for gastrointestinal disorders (OR_adj 0.74 [0.60–0.90]; p = 0.003), neuro-psychiatric complications (OR_adj 0.66 [0.49–0.87]; p = 0.004), non-surgical site infections (OR_adj 0.68 [0.52–0.88; p = 0.004) and trauma or poisoning (OR_adj 0.25 [0.16–0.41]; p < 0.001) occurred less frequently in patients receiving gabapentinoids. The risk of postoperative respiratory complications was lower in patients receiving gabapentinoids (OR_adj 0.77 [0.70–0.85]; p < 0.001). Lower doses of pregabalin (< 75 mg) and gabapentin (< 300 mg) compared to both, no and high-dose administration of gabapentinoids, were associated with a lower risk of postoperative respiratory complications (OR_adj 0.61 [0.50–0.75]; p < 0.001 and OR_adj 0.70 [0.53–0.92]; p = 0.012, respectively). These lower gabapentinoid doses prevented 30-day readmission (OR_adj 0.74 [0.65–0.85]; p < 0.001). The results were robust in several sensitivity analyses including surgical procedure defined subgroups and patients undergoing ambulatory surgery.ConclusionsThe preoperative use of pregabalin and gabapentin, up to doses of 75 and 300 mg respectively, mitigates the risks of hospital readmission and postoperative respiratory complications which can in part be explained by lower intraoperative opioid use. Further research is warranted to elucidate mechanisms of the preventive action.     

Postoperative morbidity survey,mortality and length of stay following emergency laparotomy

Thirty‐day mortality following emergency laparotomy is high, and greater amongst elderly patients. Studies systematically describing peri‐operative complications are sparse, and heterogeneous. We used the postoperative morbidity survey to describe the type and frequency of complications, and their relationship with outcomes for 144 patients: 114 < 80 years old, and 30 ≥ 80 years old. Cumulative postoperative morbidity survey scores and patterns of morbidity were similar (p = 0.454); however, 28‐day mortality was higher in the elderly (10/30 (33.3%) vs 11/114 (9.6%), p = 0.008), and hospital stay was longer (median (IQR [range]) 17 (13–35 [6–62]) days vs 11 (7–21 [2–159]) days, p = 0.006). Regression analysis indicated that cardiovascular, haematological, renal and wound complications were associated with longer hospital stay, and that cardiovascular complications predicted mortality. The postoperative morbidity survey system enabled structured mapping of the number and type of complications, and their relationship with outcome, following emergency laparotomy. These results indicate that rather than a greater propensity to complications following surgery, it was the failure to tolerate these that increased mortality in the elderly.     

The impact of long-term corticosteroid use on acute postoperative complications following lumbar decompression surgery

BackgroundCorticosteroids have a negative impact on the human immune system’s ability to function at an optimal level. Studies have shown that patients on long-term corticosteroids have higher infection rates. However, the rates of infection and other complications following lumbar decompression surgery remains under-investigated. The aim of our study was to determine the impact of preoperative long-term corticosteroid usage on acute, 30-day postoperative complications in a subset of patients undergoing lumbar spine decompression surgery, without fusion or instrumentation. We hypothesize that patients on long-term corticosteroids will have higher rates of infection and other postoperative complications after undergoing lumbar decompression surgery of the spine.MethodsA retrospective cohort study was conducted using data collected from the National Surgical Quality Improvement Program database data from 2005 to 2016. Lumbar decompression surgeries, including discectomies, laminectomies, and others were identified using CPT codes. Chi-square analysis was used to evaluate differences among the corticosteroid and non-corticosteroid groups for demographics, preoperative comorbidities, and postoperative complications. Logistic regression analysis was done to determine if long-term corticosteroid use predicts incidence of postoperative infections following adjustment.Results26,734 subjects met inclusion criteria. A total of 1044 patients (3.9%) were on long-term corticosteroids prior to surgical intervention, and 25,690 patients (96.1%) were not on long-term corticosteroids. Patients on long-term corticosteroids were more likely to be older (p < 0.001), female (p < 0.001), nonsmokers (p < 0.001), and have a higher American Society of Anesthesiologist class (p < 0.001). Multivariate analysis demonstrated that long-term corticosteroid usage was associated with increased overall complications (odds ratio [OR]: 1.543; p < 0.001), and an independent risk factor for the development of minor complications (OR: 1.808; p < 0.001), urinary tract infection (OR: 2.033; p = 0.002), extended length of stay (OR: 1.244; p = 0.039), thromboembolic complications (OR: 1.919; p = 0.023), and sepsis complications (OR: 2.032; p = 0.024).ConclusionLong-term corticosteroid usage is associated with a significant increased risk of acute postoperative complication development, including urinary tract infection, sepsis and septic shock, thromboembolic complications, and extended length of hospital stay, but not with superficial or deep infection in patients undergoing lumbar decompression procedures. Spine surgeons should remain vigilant regarding postoperative complications in patients on long-term corticosteroids, especially as it relates to UTI and propensity to decompensate into sepsis or septic shock. Thromboembolic risk attenuation is also imperative in this patient group during the postoperative period and the surgeon should weigh the risks and benefits of more intensive anticoagulation measures.     

Spinal or general anaesthesia for surgical repair of hip fracture and subsequent risk of mortality and morbidity: a database analysis using propensity score-matching

Around 76,000 people fracture their hip annually in the UK at a considerable personal, social and financial cost. Despite longstanding debate, the optimal mode of anaesthesia (general or spinal) remains unclear. Our aim was to assess whether there is a significant difference in mortality and morbidity between patients undergoing spinal anaesthesia compared with general anaesthesia during hip fracture surgery. A secondary analysis examined whether a difference exists in mortality for patients with pre-existing cardiovascular disease or chronic obstructive pulmonary disease. This was a clinical database analysis of patients treated for hip fracture in Nottingham, UK between 2004 and 2015. Propensity score-matching was used to generate matched pairs of patients, one of whom underwent each mode of anaesthesia. Data were analysed using conditional logistic regression, with 7164 patients successfully matched. There was no difference in 30- or 90-day mortality in patients who had spinal rather than general anaesthesia (OR [95%CI] 0.97 [0.8–1.15]; p = 0.764 and 0.93 [0.82–1.05]; p = 0.247 respectively). Patients who had a spinal anaesthetic had a lower-risk of blood transfusion (OR [95%CI] 0.84 [0.75–0.94]; p = 0.003) and urinary tract infection (OR [95%CI] 0.72 [0.61–0.84]; p < 0.001), but were more likely to develop a chest infection (OR [95%CI] 1.23 [1.07–1.42]; p = 0.004), deep vein thrombosis (OR [95%CI] 2.18 [1.07–4.45]; p = 0.032) or pulmonary embolism (OR [95%CI] 2.23 [1.16–4.29]; p = 0.016). The mode of anaesthesia for hip fracture surgery resulted in no significant difference in mortality, but there was a significant difference in several measures of postoperative morbidity.     

What are the results of laparoscopic re-operative rectal surgery?

IntroductionReoperative rectal surgery is challenging, performed selectively by experienced colorectal surgeons. The minimally invasive approach has not been well defined. This study reviewed the results of laparoscopy in this challenging setting.MethodsRetrospective analysis of patients who underwent trans-abdominal re-operative rectal surgery from 2010 to 2019 was performed.ResultsSeventy-eight patients [35 females (45%); BMI 25kg/m2) were included. Reasons for reoperation were recurrent cancer in 18 (43%) patients and anastomotic failure in 57 (73%). Twenty-two (28%) had laparoscopic surgery and 4 had attempted laparoscopy converted to laparotomy. A higher success rate was noted for laparoscopy with prior laparoscopic surgery. Benefits of laparoscopy included significant reduction in length of stay (6.7 vs 9.7 days, p = 0.012) and abdominal superficial surgical site infection (0% vs 25%, p < 0.001) and higher rate of achieving bowel continuity compared to laparotomy (77% vs 50%, p = 0.021)ConclusionsReoperative laparoscopic rectal surgery is safe and feasible in the context of a high-volume laparoscopic surgeon with substantial experience in redo proctectomies. It offers clear benefits including decreased surgical site infection rates and length of stay.     

Influence of race and sociodemographic factors on declining resection for gastric cancer: A national study

BackgroundThe purpose of this study was to determine whether racial or other demographic characteristics were associated with declining surgery for early stage gastric cancer.MethodsPatients with clinical stage I-II gastric adenocarcinoma were identified from the NCDB. Multivariable logistic models identified predictors for declining resection. Patients were stratified based on propensity scores, which were modeled on the probability of declining. Overall survival was evaluated using the Kaplan-Meier method.ResultsOf 11,326 patients, 3.68% (n = 417) declined resection. Patients were more likely to refuse if they were black (p < 0.001), had Medicaid or no insurance (p < 0.001), had shorter travel distance to the hospital (p < 0.001) or were treated at a non-academic center (p = 0.001). After stratification, patients who declined surgery had worse overall survival (all strata, p < 0.001).ConclusionsRacial and sociodemographic disparities exist in the treatment of potentially curable gastric cancer, with patients who decline recommended surgery suffering worse overall survival.     

Impact of inhalation injury on outcomes in critically ill burns patients: 12-year experience at a regional burns centre

IntroductionBurns inhalation injury increases the attributable mortality of burns related trauma. However, diagnostic uncertainties around bronchoscopically graded severity, and its effect on outcomes, remain. This study evaluated the impact of different bronchoscopic burns inhalation injury grades on outcomes.MethodsA single-centre cohort study of all patients admitted to the London Burns centre intensive care unit (BICU) over 12 years. Demographic data, burn and burns inhalation injury characteristics, and ICU-related parameters were collected retrospectively. The primary outcome was mortality. Secondary outcomes were hospital and ICU lengths of stay. The impact of pneumonia was determined. Univariate and multivariable Cox’s proportional hazards regression analyses informed factors predicting mortality.ResultsBurns inhalation injury was diagnosed in 84 of 231 (36%) critically ill burns patients; 20 mild (grade 1), 41 severe (grades 2/3) and 23 unclassified bronchoscopically. Median (IQR) total body surface area burned (TBSA) was 20% (10?40). Mortality was significantly higher in patients with burns inhalation injury vs those without burns inhalation injury (38/84 [45%] vs 35/147 [24%], p < 0.001). Patients with pneumonia had a higher mortality than those without (34/125 [27%] vs 8/71 [11%], p = 0.009). In multivariable analysis, severe burns inhalation injury significantly increased mortality (adjusted HR=2.14, 95%CI: 1.12–4.09, p = 0.022), compared with mild injury (adjusted HR=0.58, 95% CI: 0.18–1.86, p = 0.363). Facial burns (adjusted HR=3.13, 95%CI: 1.69–5.79, p < 0.001), higher TBSA (adjusted HR=1.05, 95%CI: 1.04–1.06, p < 0.001) and older age (adjusted HR=1.04, 95%CI: 1.02–1.07, p < 0.001) also independently predicted mortality, though pneumonia did not.ConclusionsSevere burns inhalation injury is a significant risk factor for mortality in critically ill burns patients. However, pneumonia did not increase mortality from burns inhalation injury. This work confirms prior implications of bronchoscopically graded burns inhalation injury. Further study is suggested, through registries, into the diagnostic accuracy and reliability of bronchoscopy in burns related lung injury.     

The impact of hospital grade,hospital-volume,and surgeon-volume on outcomes for adults undergoing appendicectomy

IntroductionAcute Appendicitis and appendicectomy are common surgical emergencies worldwide. However, there is a lack of published data on the impact of hospital grade, surgeon- and hospital-volumes on patient outcomes following appendicectomy.AimTo establish if hospital grade, hospital-volume, or surgeon-volume impacted patient outcomes following appendicectomy.MethodsUsing the National Quality Assurance and Improvement System (NQAIS) data for all appendicectomies performed in Ireland between January 2014 and November 2017 were examined. Data relating to patient demographics, type of surgery (open/laparoscopic/laparoscopic converted to open), length of stay (LOS), mortality, admission to critical care and re-admission rates were collected and analysed.ResultsDuring the study period, 15,896 adult appendicectomies were performed, 14,521 were laparoscopic procedures. Patients treated in district general hospitals (DGHs) had lower LOS (2.96 v 3.37 days, p < 0.0001) than patients treated in tertiary referral hospitals (TRHs), had lower rates of laparoscopic procedures (87.38% v 95.56% p < 0.0001) and higher admission rates to critical care (1.91% v 0.75% p < 0.0001). No significant outcome difference was seen between those treated by high-volume (>62 cases/year) or low volume surgeons (<20 cases/year). Patients treated in high-volume hospitals (>260 cases/year) had higher rates of laparoscopic procedures (94.9% v 83.5%, p < 0.0001), lower rates of admission to critical care (0.85% v 2.25%, p < 0.0001) and lower 7-day re-admission rates (2.54% v 3.55%, p = 0.02) than those operated in low-volume hospitals (<161 cases/year).ConclusionPatients operated on in high-volume hospitals benefit from higher rates of laparoscopic surgery and fewer critical care admissions. No significant difference in outcome was noted in those patients operated upon by high- or low-volume surgeons or based on hospital grade.     

Do-Not-Resuscitate status is an independent risk factor for medical complications and mortality among geriatric patients sustaining hip fractures

BackgroundThe purpose of this study was to compare outcomes after hip fracture surgery between DNR/DNI and full code cohorts to determine whether DNR/DNI status is an independent predictor of complications and mortality within one year. A significant number of geriatric hip fracture patients carry a code status designation of DNR/DNI (Do-Not-Resuscitate/Do-Not-Intubate). There is limited data addressing how this designation may influence prognosis.MethodsA retrospective chart review of all geriatric hip fractures treated between 2002 and 2017 at a single level-I academic trauma center was performed. 434 patients were eligible for this study with 209 in the DNR/DNI cohort and 225 in the full code cohort. The independent variable was code-status and dependent variables included patient demographics, surgery performed, American Society of Anesthesiologists, score, Charlson Comorbidity Index, significant medical and surgical complications within one year of surgery, duration of follow-up by an orthopaedic surgeon, duration of follow-up by any physician, and mortality within 1 year of surgery. One-year complication rates were compared, and multiple logistic regression analyses were performed to analyze the relationship between independent and dependent variables.ResultsThe DNR/DNI cohort experienced significantly more surgical complications compared to the full code cohort (14.8% vs 7.6%, p = 0.024). There was a significantly higher rate of medical complications and mortality in the DNR/DNI cohort (57.9% vs 36%, p < 0.001 and 19.1% vs 3.1%, p = 0.037, respectively). In the regression analysis, DNR/DNI status was an independent predictor of a medical complication (odds ratio 2.33, p = 0.004) and one-year mortality (odds ratio 9.69, p < 0.001), but was not for a surgical complication (OR 1.95, p = 0.892).ConclusionsIn our analysis, DNR/DNI code status was an independent risk factor for postoperative medical complications and mortality within one year following hip fracture surgery. The results of our study highlight the need to recognize the relationship between DNR/DNI designation and medical frailty when treating hip fractures in the elderly population.