Background
Surgical advancements have improved outcomes for cholangiocarcinoma (CCA) patients, but this expertise is not uniformly available. This research examines CCA surgical treatment patterns.Methods
A retrospective analysis of the U.S. Nationwide Inpatient Sample from 1998?C2009 identified CCA patients at high-volume (HV) versus low-volume (LV) hospitals, and teaching versus nonteaching hospitals. We performed multinomial and multivariate logistic regressions to compare differences of surgical treatment between HV vs. LV hospitals, and teaching vs. nonteaching hospitals. Liver resection (LR), pancreaticoduodenectomy, bile duct (BD) resection, and combined liver/BD resection were considered more aggressive therapy than BD stent or bypass.Results
A total of 32,561 patients with CCA were identified. The proportion receiving surgery declined from 36 to 30?%. There was no increase in the proportion of LRs or combined liver/BD resection. Patients at HV or teaching hospitals were more likely to receive surgical treatment [odds ratio (OR), 1.3, p?<?0.001; OR, 1.4, p?<?0.001].Discussion
Despite increasing evidence that surgical resection increases survival, the number of patients receiving surgery has decreased. Although combined liver/BD resection has been advocated as standard management for proximal CCA, the practice has not increased. All patients with CCA should be considered for assessment at a HV teaching hospital. 相似文献Objective
The aim of the present study was to compare the outcomes of conservative versus surgical treatment for acute appendicitis.Background
Although acute appendicitis is a common disease, great debate exists regarding the appropriate management of patients. Conservative treatment has shown positive results in several RCTs, eliciting questions about indications to surgery, therapeutic appropriateness and ethical conduct.Methods
Data were prospectively collected; a Propensity Score-based matching method was implemented in order to reduce bias arising from characteristics of the patients; a proportion of patients (69 in total) were excluded to obtain two comparable groups of study (1a). Main outcomes of the study were: failure rate, in-hospital length of stay (at first admission and cumulative), post-discharge absence from work. Within the medical group, failure was defined as the necessity for appendectomy after conservative treatment, while it was identified with complications and negative appendectomy within the surgical group (Failure 1). In parallel, an additional definition of failure was proposed (Failure 2) and excluded negative appendectomy from the reasons for failure within the surgical group (5b).Results
The failure rate for the conservative treatment resulted to be inferior, as compared to the surgical treatment (16.5 vs. 28.4%, OR 0.523 p = 0.019), considering negative appendectomy as a reason for failure. When excluding negative appendectomy from the definition of failure, medical and surgical treatment appeared to perform equally (failure rate: 16.5 vs. 18.3%, OR 1.014 p = 0.965). Patients managed conservatively showed to have a shorter length of stay at first admission than the patients who underwent appendectomy (3.11 vs. 4.11 days, β = ?0.628 days, p < 0.0001). A lower number of lost work days after discharge resulted from a conservative approach (6 vs. 14.64 days, β = ?8.7 days, p < 0.0001).Conclusions
Considering each outcome as part of a wide-angle analysis, the conservative management of acute appendicitis resulted to be safe and effective in the selected group of patients. In terms of failure rate, the medical treatment resulted to perform as effectively as surgical treatment, if negative appendectomy was excluded from failure, or better, when negative appendectomy was included in the definition of failure. A diminished length of stay during the first admission and a reduced number of lost work days were evident with a conservative approach. The comparison between medical and surgical treatment for acute appendicitis requires a change in perspective, from a spare ‘effectiveness analysis’ to a more thorough ‘appropriateness analysis’: in the present study, the conservative treatment showed to address the clinical requirements in terms of therapeutic appropriateness. Although acute appendicitis is considered a ‘surgical disease’, increasing evidence supports the effectiveness and safety of a conservative approach for selected groups of patients.Background
Utilization of bariatric surgery has changed dramatically over the past two decades. The aim of this study was to update the trends in volume and procedural type of bariatric surgery in the USA. Data were derived from the National Inpatient Sample from 2009 through 2012.Methods
We used ICD-9 diagnosis and procedural codes to identify all hospitalizations during which a bariatric procedure was performed for the treatment of severe obesity. The data were reviewed for patient demographics and characteristics, annual number of bariatric operations, and specific procedural types and proportion of laparoscopic cases. The US Census data were used to calculate the population-based annual rate of bariatric surgery per 100,000 adults.Results
Between 2009 and 2012, the number of inpatient bariatric operations ranged between 81,005 and 114,780 cases annually. During this time period, the annual rate of bariatric procedures was highest for 2012 at 47.3 procedures per 100,000 adults. The bariatric surgery approach most commonly performed continues to be laparoscopic, ranging between 93.1 and 97.1 %. In 2012, there was a precipitous reduction in the number of gastric bypass and gastric banding operations and replaced by an increase in the number of sleeve gastrectomy operation. The in-hospital mortality rate remains low, ranging from 0.07 to 0.10 %.Conclusions
In the USA, the annual volume of inpatient bariatric surgery continues to be stable. Utilization of the laparoscopic approach to bariatric surgery remains high, while the in-hospital mortality continues to be low at ≤0.10 % throughout the 4-year period.Background
Gastrointestinal (GI) tract perforation during endoscopy is a rare but severe complication. The aim of this study was to determine predictors of morbidity and mortality after iatrogenic endoscopic perforation.Materials and methods
All cases with iatrogenic endoscopic perforation receiving surgery at a tertiary referral center in a 15-year period (2000–2015) were retrospectively analyzed. Demographics, type of endoscopy, site of perforation, operative procedure, morbidity and mortality were analyzed. Multiple logistic regression was used to identify parameters predicting survival.Results
A total of 106.492 endoscopies were performed, and 82 (0.08%) patients were diagnosed with GI perforation. Most perforations (63.4%) occurred in the lower GI tract, compared to 36.6% in the upper GI tract. In 21 cases (25%), perforation was noticed during endoscopy, whereas 61 perforations (75%) were diagnosed during the further clinical course. Operative care was applied within 24 h in 61%. Surgery of perforations was almost completely performed maintaining the intestinal continuity (68%), whereas diversion was performed in 32%. Mortality was associated with age above 70 (OR 4.89, p = 0.027), ASA class > 3 (OR 4.08, p = 0.018), delayed surgery later than 24 h after perforation (OR 5.9, p = 0.015), peritonitis/mediastinitis intraoperatively (OR 4.68, p = 0.031) and severe postoperative complications with a Clavien–Dindo grade ≥III (OR 5.12, p = 0.023).Conclusion
The prevalence of iatrogenic endoscopic perforation is low, although it is associated with a serious impact on morbidity and mortality. Delayed management worsens prognosis. To achieve successful management of endoscopic perforations, early diagnosis is essential in cases of deviation from the normal post-interventional course, especially in elderly.Background:
Traumatic spinal cord injury (SCI) that occurs in children and adolescents who are still developing represents a different challenge than SCI in adults. However, information on the epidemiology and incidence of SCI in a population-based cohort is lacking.Objective:
To describe the epidemiology of pediatric SCI in a population-based cohort in the United States and to assess trend in incidence over a 15-year period (1998–2012).Methods:
Children and adolescents (0–21 years) with SCI were identified through the South Carolina SCI Surveillance Registry using hospital discharge records from 1998 to 2012. Overall age-adjusted incidence rates were calculated for each year, and incidence rates were stratified by age, gender, and race.Results:
The overall age-adjusted incidence rate was 26.9 per million population, and there was a trend (P = .0583) toward decreasing incidence of pediatric SCI. When stratified by race, there was a significant decrease in incidence among Whites (P = .0052) but not among non-Whites. Younger participants were more likely to be female, to be injured through sports, and to be more likely to have concomitant traumatic brain injury. Since 1998, the proportion of older pediatric patients (16–22 years) with SCI has increased, as has the proportion of non-White patients.Conclusions:
Although there was an overall trend toward decreasing incidence in this population-based cohort, when stratified by race, this trend only occurred in the White population.Key words: epidemiology, incidence, pediatric, spinal cord injuriesBecause children and adolescents are still developing, traumatic spinal cord injury (SCI) that occurs in the pediatric population represents different challenges than SCI in the adult population.1–3 Although etiology of injury has been shown to differ between pediatric and adult populations,4 information on the incidence and trend of pediatric SCI in the United States is lacking, as most studies focus solely on adult patients or combine children and adolescents with adults. Understanding the incidence, trend, and epidemiology of pediatric SCI is crucial to planning the allocation of resources and development of prevention programs.Internationally, incidence rates of pediatric SCI have been reported as between 2.4 and 4.6 per million population, depending on inclusion criteria. Pickett et al5 found an overall incidence of 3.37 per million population; however, they included all ages, with the youngest being only 9 years old. Their findings were based on fewer than 5 cases. A Swedish study, defining children as 0 to 15 years, found an annual rate of 4.6 per million population including prehospital deaths and 2.4 per million excluding prehospital deaths.6In the United States, few studies have focused on the incidence of pediatric SCI, with rates ranging from 6 to 116.7 per million population, depending on the cohort and the ages included. Vitale et al7 reported an annual incidence rate of 19.9 per million children (ages 0 to 18 years), with an estimated 1,455 admitted to the hospital each year. They did not use the standard Centers for Disease Control and Prevention (CDC) definition of SCI, as they included cases presenting as late effects of SCI (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] code = 907.2).8 Two analyses have been published from population-based, state surveillance system registries. A study in Mississippi revealed annual rates of 11.3 and 116.7 per million population among ages 0 to 15 years and 15 to 19 years, respectively.9 In Oklahoma, Price et al10 found an annual incidence rate of 6 per million in those 0 to 14 years and 94 per million in those 15 to 19 years. While providing valuable information, these population-based studies only included data through 1994 and did not assess trend. Thus, updated information on the incidence of pediatric SCI is needed.Because population-based information on the epidemiology of pediatric SCI in the United States is lacking and outdated, the purpose of this study is to describe the epidemiology of pediatric SCI in a population-based cohort in the United States and to assess trend in incidence over a 15-year period (1998–2012). 相似文献Introduction
Pancreatoduodenal (PD) injury is an uncommon but serious complication of blunt and penetrating trauma, associated with high mortality. The aim of this study was to assess the incidence, mechanisms of injury, initial operation rates and outcome of patients who sustained PD trauma in the UK from a large trauma registry, over the period 1989–2013.Methods
The Trauma Audit and Research Network database was searched for details of any patient with blunt or penetrating trauma to the pancreas, duodenum or both.Results
Of 356,534 trauma cases, 1,155 (0.32%) sustained PD trauma. The median patient age was 27 years for blunt trauma and 27.5 years for penetrating trauma. The male-to-female ratio was 2.5:1. Blunt trauma was the most common type of injury seen, with a ratio of blunt-to-penetrating PD injury ratio of 3.6:1. Road traffic collision was the most common mechanism of injury, accounting for 673 cases (58.3%). The median injury severity score (ISS) was 25 (IQR: 14–35) for blunt trauma and 14 (IQR: 9–18) for penetrating trauma. The mortality rate for blunt PD trauma was 17.6%; it was 12.2% for penetrating PD trauma. Variables predicting mortality after pancreatic trauma were increasing age, ISS, haemodynamic compromise and not having undergone an operation.Conclusions
Isolated pancreatic injuries are uncommon; most coexist with other injuries. In the UK, a high proportion of cases are due to blunt trauma, which differs from US and South African series. Mortality is high in the UK but comparison with other surgical series is difficult because of selection bias in their datasets. 相似文献We sought to characterize trends in demographics, comorbidities, and postoperative complications among patients undergoing primary and revision cervical disc replacement (pCDR/rCDR) procedures.
MethodsIn this retrospective database study, the Premier Healthcare database was queried from 2006 to 2019. Annual proportions or medians were calculated for patient and hospital characteristics, comorbidities, and postoperative complications associated with CDR surgery. Trends were assessed using linear regression analyses with year of service as the sole predictor.
ResultsA total of 16,178 pCDR and 758 rCDR cases were identified, with a median (IQR) age of 46 (39; 53) and 51 (43; 60) years among patients, respectively. The annual number of both procedures increased between 2006 and 2019, from 135 to 2220 for pCDR (p < 0.001), and from 17 to 49 for rCDR procedures (p < 0.001), with radiculopathy being the main indication for surgery in both groups. Mechanical failure was identified as a major indication for rCDR procedures with an increase over time (p = 0.002). Baseline patient comorbidity burden (p = 0.045) and complication rates (p < 0.001) showed an increase. For both procedures, an increase in outpatient surgeries and procedures performed in rural hospitals was seen (pCDR: p = 0.045; p = 0.006; rCDR: p = 0.028; p = 0.034).
ConclusionPCDR and rCDR procedures significantly increased from 2006 to 2019. At the same time, comorbidity burden and complication rates increased, while procedures were more often performed in an outpatient and rural setting. The identification of these trends can help guide future practice and lead to further areas of research.
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