A Population-Based Cohort Study of Emergency Appendectomy Performed in England and New York State

Background

To compare selected outcomes (30-day reoperation and total length of hospital stay) following emergency appendectomy between populations from New York State and England.

Methods

This retrospective cohort study used demographic and in-hospital outcome data from Hospital Episode Statistics (HES) and the New York Statewide Planning and Research Cooperative System (SPARCS) administrative databases for all patients aged 18+ years undergoing appendectomy between April 2009 and March 2014. Univariate and adjusted multivariable logistic regression were used to test significant factors. A one-to-one propensity score matched dataset was created to compare odd ratios (OR) of reoperations between the two populations.

Results

A total of 188,418 patient records, 121,428 (64.4%) from England and 66,990 (35.6%) from NYS, were extracted. Appendectomy was completed laparoscopically in 77.7% of patients in New York State compared to 53.6% in England (P < 0.001). The median lengths of hospital stay for patients undergoing appendectomy were 3 (interquartile range, IQR 2–4) days versus 2 (IQR 1–3) days (P < 0.001) in England and New York State, respectively. All 30-day reoperation rates were higher in England compared to New York State (1.2 vs. 0.6%, P < 0.001), representing nearly a twofold higher risk of 30-day reoperation (OR 1.88, 95% CI 1.64–2.14, P < 0.001). As the proportion of appendectomy completed laparoscopically increased, there was a reduction in the reoperation rate in England (correlation coefficient ?0.170, P = 0.036).

Conclusions

Reoperations and total length of hospital stay is significantly higher following appendectomy in England compared to New York State. Increasing the numbers of appendectomy completed laparoscopically may decrease length of stay and reoperations.

     

Abdominal Drainage Following Appendectomy and Cholecystectomy

Consecutive patients undergoing emergency appendectomy (283) or urgent cholecystectomy (51) were prospectively studied for the development of post-operative incisional or peritoneal sepsis. Severity of the original peritoneal infection was carefully recorded, while use of a Penrose dam to drain the peritoneum was randomized according to pre-assigned hospital number. Both aerobic and anaerobic cultures were taken from the abdomen at the time of operation as well as from all postoperative infectious foci. Results demonstrated no essential differences in incidence of wound and peritoneal infection following appendectomy for simple or suppurative appendicitis (187) or following cholecystectomy for acute cholecystitis (51). However, with gangrenous or perforative appendicitis (94), incisional and intra-abdominal infection rates were 43% and 45%, respectively, when a drain was used; yet only 29 and 13%, respectively, without a drain. These latter differences were significant (p < 0.001). In addition, intra-abdominal abscesses were three times as likely to drain through the incision than along any tract provided by the rubber conduit. Cultures revealed that hospital pathogens accounted for a greater proportion of wound and peritoneal sepsis after cholecystectomy and appendectomy for simple or suppurative appendicitis if a drain had been inserted than if managed otherwise. By contrast, a mixed bacterial flora was responsible for most infections following appendectomy for gangrenous or perforated appendicitis, irrespective as to use of a drain.     

Litigation following groin hernia repair in England

Purpose

Since 1995, litigation following surgical procedures has cost the National Health Service (NHS) over 1.3 billion GBP (Great British Pounds)/2.1 billion USD (United States Dollars)/1.4 billion Euros. Despite it being the most commonly undertaken general surgical operation, no study has examined clinical negligence claims in England following groin hernia repairs.

Methods

Data from the NHS Litigation Authority of all claims made from 1995 to 2009 was obtained and interrogated.

Results

In total, 398 claims were made. Of these, 209 cases had been settled, of which 144 (46.6%) were in favour of the claimant to a cost of 7.35 million GBP/12 million USD/7.93 million Euros. Testicular injury and chronic pain featured in 40% of all claims. Visceral injuries and injuries requiring corrective procedures were the only predictors of a successful claim (P = 0.015 and P = 0.002, respectively). Claims associated with visceral and vascular injuries were more likely to occur in laparoscopic than in open repairs. Sexual dysfunction and chronic pain resulted in the highest average payouts of 85,467 GBP/140,565 USD/92,177 Euros and 81,288 GBP/133,693 USD/87,674 Euros, respectively.

Conclusion

Patients should be fully informed of the incidence of testicular injury and chronic pain during the consent process. Approaches minimising visceral and vascular injury particularly in laparoscopic repair should be adopted to reduce litigation and improve patient care.     

腹腔镜阑尾切除术后再手术原因分析

目的 分析腹腔镜阑尾炎手术后再手术的原因,探讨腹腔镜阑尾炎手术中应注意的事项.方法 2003年5月~2013年3月,发生11例腹腔镜阑尾切除术后再手术.急性阑尾炎10例,慢性阑尾炎1例.再手术原因：腹腔脓肿4例,回盲部肿瘤1例,腹腔大出血并休克1例,腹膜后血肿1例,小肠漏1例,肠粘连1例,盆腔炎1例,胰腺炎1例.经保守治疗无效,8例行腹腔镜探查,3例开腹探查.结果 二次手术均成功.腹腔脓肿4例行腹腔镜脓肿清洗引流,腹腔大出血并休克1例行腹腔镜探查腹壁下动脉结扎,肠粘连1例行腹腔镜探查粘连带松解,盆腔炎1例行腹腔镜盆腔冲洗引流＋抗感染治疗,胰腺炎1例行腹腔镜胰腺被膜打开胰腺周围置管引流;小肠漏1例行腹腔镜探查＋开腹小肠肠管部分切除吻合术,腹膜后血肿1例行开腹探查阑尾动脉结扎,回盲部肿瘤1例行开腹右半结肠切除术（病理高分化腺癌）.术后7~21天痊愈出院.结论 腹腔镜下阑尾切除术后再手术的原因为：术前术中漏诊、误诊;术中脓液清洗不彻底,术后引流不通畅致腹腔脓肿形成;术中操作不规范,致腹壁下血管、阑尾动脉出血.腹腔镜阑尾切除术应注意规范操作,术中应探查仔细,防止漏诊、误诊.     

IV Acetaminophen Results in Lower Hospital Costs and Emergency Room Visits Following Bariatric Surgery: a Double-Blind,Prospective, Randomized Trial in a Single Accredited Bariatric Center

Background

Postoperative pain control in bariatric surgery is challenging, despite use of intravenous (IV) narcotics. IV acetaminophen is one pain control alternative.

Objective

The aim of this study was to investigate the economic impact of IV acetaminophen in bariatric surgery and its effect on patients’ pain, satisfaction, and hospital length of stay.

Methods

In a randomized controlled trial, Group 1 (treatment) received IV acetaminophen plus IV narcotics 30 min before surgery, then medication plus IV narcotics/PO narcotics for the remaining 18 h. Group 2 (control) received IV normal saline plus IV/PO narcotics. Patients underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (SG). Primary outcomes included direct hospital costs, length of stay, postoperative pain, and patient satisfaction. Secondary outcomes included indirect costs, rescue narcotics dosage, and 30-day outcomes.

Results

Mean direct hospital cost in the treatment group (n?=?50) was $3089.18 versus $2991.62 for the control group (n?=?50) (p?>?0.05). Pain scores did not differ significantly (p?=?0.61). After adjusting for surgery type, there was no significant difference in length of stay (p?=?0.95). Significantly more control group patients incurred surgery-related indirect costs (10 versus 2 %, p?<?0.05), with greater presentation to the emergency department (ED) for abdominal pain (5/50 versus 1/50), yielding higher total indirect costs ($39,293 versus $13,185).

Conclusions

Using IV acetaminophen for postoperative pain management produced notable indirect cost savings and reduced ED visits in the first 30 days postoperatively, with good safety and tolerance. Decreased statistical power may have accounted for certain non-significant findings.

     

Feasibility,Effectiveness and Costs Associated with a Web-Based Follow-Up Assessment Following Total Joint Arthroplasty

The purpose of this study was to assess the feasibility, effectiveness and costs of a web-based follow-up compared to in-person assessment following primary total hip or total knee arthroplasty. Patients who were at least 12 months postoperative were randomized to follow-up method. We excluded patients who had revision surgery, osteolysis, complications or identified radiographic issues. 229 patients (118 Web, 111 in-person) completed the study. There were no patients who had an issue missed by the web-based follow-up. Patients in the web-based group travelled less (28.2 km vs 103.7 km, (P < 0.01)), had lower associated costs ($10.45 vs $21.36, (P < 0.01)) and took less time to complete (121.7 min web vs 228.7 min usual). Web-based follow-up is a feasible, clinically effective alternative with lower associated costs than in-person clinic assessment.     

Implications of Hospital Volume on Costs Following Esophagectomy in the United States

Background

With increasing focus on health care quality and cost containment, volume-based referral strategies have been proposed to improve value in high-cost procedures, such as esophagectomy. While the effect of hospital volume on outcomes has been demonstrated, our goal was to evaluate the economic consequences of volume-based referral practices for esophagectomy.

Methods

The nationwide inpatient sample (NIS) was queried for the years 2004–2013 for all patients undergoing esophagectomy. Patients were stratified by hospital volume quartile and substratified by preoperative risk and age. Clustered multivariable hierarchical logistic regression analysis was used to assess adjusted costs and mortality.

Results

In total, 9270 patients were clustered based on annual hospital volume quartiles of <?7, 7 to 22, 23 to 87, and >?87 esophagectomies. After stratification by patient variables, high-volume centers performed esophagectomies in high-risk patients at the same cost as low-volume centers without significant difference in resource utilization. Overall, mortality decreased across volume quartiles (lowest 8.9 versus highest 3.6%, p?<?0.0001). The greatest volume-mortality differences were observed among patients aged between 70 and 80 years (lowest 12.2 versus highest 6.2%, p?=?0.009). Patients with high preoperative risk also derived mortality benefits with increasing hospital volume (lowest 17.5 versus highest 11.8%, p?<?0.0001).

Conclusions

This study demonstrates that the mortality improvements for high-risk patients undergoing esophagectomy at high-volume centers do not come at increased costs. These results suggest that health systems should consider selectively referring high-risk patients to high-volume centers within their region.

     

High Bundled Payment Costs Following Total Hip and Knee Arthroplasty in African Americans

BackgroundConcerns exist that minorities who utilize more resources in an episode-of-care following total hip (THA) and knee arthroplasty (TKA) may face difficulties with access to quality arthroplasty care in bundled payment programs. The purpose of this study is to determine if African American patients undergoing TKA or THA have higher episode-of-care costs compared to Caucasian patients.MethodsWe queried Medicare claims data for a consecutive series of 7310 primary TKA and THA patients at our institution from 2015 to 2018. We compared patient demographics, comorbidities, readmissions, and 90-day episode-of-care costs between African American and Caucasian patients. A multivariate regression analysis was performed to identify the independent effect of race on episode-of-care costs.ResultsCompared to Caucasians, African Americans were younger, but had higher rates of pulmonary disease and diabetes. African American patients had increased rates of discharge to a rehabilitation facility (20% vs 13%, P < .001), with higher subacute rehabilitation ($1909 vs $1284, P < .001), home health ($819 vs $698, P = .022), post-acute care ($5656 vs $4961, P = .008), and overall 90-day episode-of-care costs ($19,457 vs $18,694, P = .001). When controlling for confounding comorbidities, African American race was associated with higher episode-of-care costs of $440 (P < .001).ConclusionAfrican American patients have increased episode-of-care costs following THA and TKA when compared to Caucasian patients, mainly due to increased rates of home health and rehabilitation utilization. Further study is needed to identify social variables that can help reduce post-acute care resources and prevent reduction in access to arthroplasty care in bundled payment models.     

A Description of Deaths Following Emergency Abdominal Surgery

Objective

Emergency major abdominal surgery carries a high mortality rate. The aim of this present study was to characterize a population of deceased abdominal surgical patients, to examine how many died unexpectedly and how many were subject to treatment limitations.

Materials and methods

We included adult emergency abdominal surgical patients who died within 30 days postoperatively. We collected data from January 1, 2013, to December 31, 2014, in a Danish tertiary care hospital (Herlev).

Results

A total of 138 patients were included which corresponded to a crude mortality rate of 16.5% in the population. Four percent (5 of 138) of the patients died unexpectedly without any prior signs of deterioration and 46% (65 of 138) experienced a complicated treatment course, 67% of which was treated in the intensive care unit (ICU). The remaining 50% (68 of 138) had treatment limitations, applied pre- or postoperatively, of which 4% were treated in the ICU ward.

Conclusions

In the present study, we found a high number of patients with treatment limitations, offering one explanation to why so relatively few high-risk surgical patients are admitted to the ICU ward. Whether intermediary wards could serve as a viable alternative for these patients, securing a sufficient level of treatment without taking up scarce beds in the intensive care unit, remains an important question for future studies. Furthermore, five patients died unexpectedly, without any clear cause of death, proving that continual strides toward improving the overall process of postoperative care are still demanded.

     

Diabetes Outcomes More than a Decade Following Sustained Weight Loss After Laparoscopic Adjustable Gastric Band Surgery

Background

Long-term outcome data are needed to define the role of bariatric surgery in type 2 diabetes (T2D). To address this, we collated diabetes outcomes more than a decade after laparoscopic adjustable gastric band (LAGB) surgery.

Method

Clinical and biochemical measures from 113 obese T2D patients who underwent LAGB surgery in 2003 and 2004 were analyzed. Diabetes remission was defined as HbA1c < 6.2% (44 mmol/mol) and fasting glucose < 7.0 mmol/L.

Results

Seventy-nine patients had weight data at 10 years and attained a median [Q1, Q3] weight loss of 16 [10, 21] percent. Sixty patients attended a follow-up assessment. Their baseline HbA1c of 7.8 [7.1, 9.3] percentage units (62 [54, 78] mmol/mol) had decreased to 6.6 [6.1, 8.4] (49 [43, 68] mmol/mol) despite no significant change in glucose-lowering therapy. Eleven patients (18%) were in diabetes remission and another 18 had HbA1c ≤ 6.5%. Significant improvements in physical measures of quality of life, blood pressure, and lipid profile were also observed but there was no change in the proportion of patients with albuminuria and a significant decline in estimated glomerular filtration rate. Twelve patients in the follow-up cohort (20%) required anti-reflux medication after surgery and 26 (43%) underwent gastric band revision surgery.

Conclusion

Weight loss for over 10 years after LAGB surgery delivers clinically meaningful improvements in HbA1c, blood pressure, lipids, and quality of life at the cost of a high rate of revision surgery and increased use of anti-reflux medication. These findings support the use of bariatric surgery as a long-term treatment for weight loss and wellbeing in patients with T2D.

Study Registration

Registered with the Australian Clinical trials registry as ACTRN12615000089538.

     

Bundled Payments Are Effective in Reducing Costs Following Bilateral Total Joint Arthroplasty

BackgroundAlternative payment models such the Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement (BPCI) initiative have been effective in reducing costs following unilateral total hip (THA) and knee arthroplasty (TKA), but few studies exist on bilateral arthroplasty. This study aimed to determine whether the BPCI program for bilateral THA and TKA reduced episode-of-care costs.MethodsWe retrospectively reviewed a consecutive series of patients who underwent simultaneous bilateral primary THA and TKA between 2015 and 2016. We recorded demographic variables, comorbidities, readmissions, and calculated 90-day episode-of-care costs based on Centers for Medicare and Medicaid Services claims data. We compared data from patients before and after the start of our BPCI program, and performed a multivariate analysis to identify independent risk factors for increased costs.ResultsOf 319 patients, 38 underwent bilateral THA (12%) while 287 underwent bilateral TKA (88%). There were 239 patients (74%) in the bundled payment group. Although there was no change in readmission rate (9% vs 8%), the post-BPCI group demonstrated reduced hospital costs ($21,251 vs $18,783), post–acute care costs ($15,488 vs $12,439), and overall 90-day episode-of-care costs ($39,733 vs $34,305). When controlling for demographics, procedure, and comorbidities, our BPCI model demonstrated a per-patient reduction of $5811 in overall claims costs. Additional risk factors for increased episode-of-care costs included age ($516/y increase) and cardiac disease ($5916).ConclusionOur bundled payment program for bilateral THA and TKA was successful with reduction in 90-day episode-of-care costs without placing the patient at higher risk of readmission. Older Medicare beneficiaries and those with cardiac disease should likely not undergo a simultaneous bilateral procedure due to concerns about increased costs.     

Hypothyroidism Increases 90-Day Complications and Costs Following Primary Total Knee Arthroplasty

Background

Thyroid disease is common and often remains undetected in the US population. Thyroid hormone has an array of metabolic, immunologic, and musculoskeletal functions crucial to well-being. The influence of thyroid disease on perioperative outcomes following primary total knee arthroplasty (TKA) is poorly understood. We hypothesized that hypothyroidism was associated with a higher risk of postoperative complications and 90-day costs following primary TKA.

腹腔镜与开腹手术治疗急性阑尾炎穿孔的比较

目的：探讨腹腔镜治疗急性阑尾炎穿孔的效果和价值。方法回顾性分析2010年1月～2011年2月我院由同一组高年资医师完成的77例穿孔性阑尾炎手术的临床资料,其中腹腔镜阑尾切除术（laparoscopic appendectomy, LA）35例（LA组）,开腹阑尾切除术（open appendectomy, OA）42例（OA组）,比较2组手术时间、肠道功能恢复时间、切口感染率、腹腔脓肿发生率、住院时间、住院费用。结果2组手术时间无显著性差异[（64．1±18．1） min vs．（65．1±13．8） min,t＝0.275,P＝0．784];腹腔脓肿发生率无显著差异[2．9％（1/35） vs．4．8％（2/42）,χ2＝0．000,P＝1．000]。与OA组相比,LA组切口感染率显著降低[5．7％（2/35） vs．26．2％（11/42）,χ2＝5．704,P＝0．017];肠功能恢复时间明显缩短[（26．1±4．6）h vs．（36．1±11．9）h, t＝-4．684,P＝0．000）;住院时间明显缩短[（7．1±2．8）d vs．（9．2±4．8）d, t＝-2．283,P＝0．025];住院费用显著升高[（12．6±2．2）千元vs．（8．1±2．9）千元,t＝7．545,P＝0．000]。结论腹腔镜经验丰富的外科医生应用腹腔镜治疗穿孔性阑尾炎有显著优势,手术费用的增加是唯一缺点。     

Incidence of Venous Thromboembolism Following Major Emergency Abdominal Surgery

Background

In a retrospective cohort study, we looked at the incidence and risk factors of developing in-hospital venous thromboembolism (VTE) after major emergency abdominal surgery and the risk factors for developing a venous thrombosis.

Methods

Data were extracted through medical records from all patients undergoing major emergency abdominal surgery at a Danish University Hospital from 2010 until 2016. The primary outcome was the incidence of venous thrombosis developed in the time from surgery until discharge from hospital. The secondary outcomes were 30-day mortality and postoperative complications. Multivariate logistic analyses were used for confounder control.

Results

In total, 1179 patients who underwent major emergency abdominal surgery during 2010–2016 were included. Thirteen patients developed a postoperative venous thromboembolism (1.1%) while hospitalized. Eight patients developed a pulmonary embolism all verified by CT scan and five patients developed a deep venous thrombosis verified by ultrasound scan. Patients diagnosed with a VTE were significantly longer in hospital with a length of stay of 34 versus 14 days, P < 0.001, and they suffered significantly more surgical complications (69.2% vs. 30.4%, P = 0.007). Thirty-day mortality was equal in patients with and without a venous thrombosis. In a multivariate analysis adjusting for gender, ASA group, BMI, type of surgery, dalteparin dose and treatment with anticoagulants, we found that a dalteparin dose ≥5000 IU was associated with the risk of postoperative surgical complications (odds ratio 1.55, 95% CI 1.11–2.16, P = 0.009).

Conclusion

In this study, we found a low incidence of venous thrombosis among patients undergoing major emergency abdominal surgery, comparable to the incidence after elective surgery.

     

Early Emergency Department Visits Following Primary Hip and Knee Arthroplasty

BackgroundPostoperative emergency department (ED) utilization remains an understudied aspect of total joint arthroplasty (TJA). The purpose of this study is to characterize 30-day ED visits following TJA.MethodsWe reviewed 4061 primary unilateral total hip and knee arthroplasty cases performed at our hospital from 2013 to 2017. The primary outcome was presentation to our institution’s ED within 30 days of surgery. Chief complaints and their association to the TJA encounter, as well as readmissions and reoperations, were recorded. One-to-three propensity score matched analysis was used to identify index admission variables associated with early ED visits.ResultsThere were 253 recorded ED visits within 30 days of TJA (218 cases, 5.4%). Nearly 60% of ED visits were directly related to the TJA encounter. The remainder were medically related, most commonly for gastrointestinal complaints. The most common TJA-related complaints were surgical limb pain (28%), wound concerns (20%), and swelling (20%). These complaints comprised two-thirds of TJA-related ED visits, though accounted for only 19.4% and 9.5% of readmissions and reoperations observed in this cohort, respectively. Perioperative transfusion, length of stay, primary insurer, and discharge disposition were not associated with an ED visit.ConclusionED visits within 30 days of TJA were common (5.4%). Most visits related to the index procedure were due to surgical limb pain, wound concerns, and swelling. These complaints accounted for a minority of readmissions and reoperations. This study suggests that perioperative strategies addressing common postoperative concerns are warranted to mitigate acute care use after TJA.     

The Use of Autologous Fibrin Glue for the Treatment of Postoperative Fecal Fistula Following an Appendectomy: Report of a Case

We herein report a case of postoperative fecal fistula following an appendectomy which was successfully treated by the use of autologous fibrin glue. An 82-year-old man had acute appendicitis and underwent an appendectomy. Later, a fecal fistula developed and he underwent drainage treatment twice. After 4 weeks of drainage and during the third recurrence, the remaining fistula was successfully treated using autologous fibrin glue, instead of surgery, due to potential complications and the risks of associated with advanced age. No recurrence has been observed for 5 months. In conclusion, autologous fibrin gluing for fecal fistula was found to be a safe, economical, and effective treatment. A search of Medline from 1980 until 2002 revealed no other report of this treatment for postoperative fecal fistula following an appendectomy.