Is laparoscopic repair of incarcerated abdominal hernias safe? Analysis of short-term outcomes

Background

There is a paucity of literature surrounding the safety and feasibility of laparoscopic repair for acutely incarcerated abdominal hernias. The objective of this study was to compare the 30-day morbidity and mortality between laparoscopic and open repairs of incarcerated abdominal hernias.

Methods

A retrospective cohort study was conducted using data from the National Surgery Quality Improvement Program from 2005 to 2012. The study population was selected using ICD-9 diagnostic codes describing abdominal hernias with obstruction, but without gangrene. Cases with documented bowel resection were excluded. Group classification was based on CPT coding. Study outcomes included the 30-day major complication, reoperation and mortality rates. Multivariable logistic regression models were used to adjust for confounding for all study outcomes.

Results

A total of 2688 and 15,562 patients were in the laparoscopic and open group, respectively. After adjustment for clinically relevant confounders, laparoscopic surgery was associated with a significantly lower 30-day infectious (OR 0.36, p < 0.001, 95 % CI 0.23–0.56) and serious complication rates (OR 0.66, p < 0.001, 95 % CI 0.55–0.80). However, there was no statistical difference with respect to the 30-day reoperation (OR 0.81, p = 0.28, 95 % CI 0.56–1.18) or mortality rates (OR 0.94, p = 0.80, 95 % CI 0.58–1.53).

Conclusions

Patients with incarcerated abdominal hernias who underwent laparoscopic repair had a significantly lower 30-day morbidity compared to patients with open repair. Although the 30-day reoperation and mortality rates were also lower, there was no statistically significant difference. Laparoscopic surgery appears to be safe in the management of select incarcerated abdominal hernias.

     

Does Diverting Loop Ileostomy Improve Outcomes Following Open Ileo-Colic Anastomoses? A Nationwide Analysis

Background

Anastomotic leak is one of the most feared complications of gastrointestinal surgery. Surgeons routinely perform a diverting loop ileostomy (DLI) to protect high-risk colo-rectal anastomoses.

Study Design

The NSQIP database was queried from 2012 to 2013 for patients undergoing open ileo-colic resection with and without a DLI. The primary outcome was the development of any anastomotic leak—including those managed operatively and non-operatively. Secondary outcomes included overall complication rate, return to the OR, readmission, and 30-day mortality.

Results

Four thousand one hundred fifty-nine patients underwent open ileo-colic resection during the study period. One hundred eighty-six (4.5 %) underwent a DLI. Factors associated with the addition of a DLI included emergency surgery, pre-operative sepsis, and IBD. There were 197 anastomotic leaks (4.7 %) with 100 patients requiring reoperation (2.4 %). DLI was associated with a decrease in anastomotic leaks requiring reoperation (DLI vs no DLI: 0 (0 %) vs 100 (2.5 %); p?=?0.02) and with increased readmission (OR 1.93; 95 % CI 1.30–2.85; p?=?0.001).

Conclusion

DLI is rarely used for open ileo-colic resection. There were no serious leaks requiring reoperation in the DLI group. A DLI was associated with an almost two-fold increase in the odds of readmission. Surgeons must weigh the reduction in serious leak rate with postoperative morbidity when considering a DLI for open ileo-colic resection.

     

Morbidity and Mortality After Gastrectomy: Identification of Modifiable Risk Factors

Background

Morbidity after gastrectomy remains high. The potentially modifiable risk factors have not been well described. This study considers a series of potentially modifiable patient-specific and perioperative characteristics that could be considered to reduce morbidity and mortality after gastrectomy.

Methods

This retrospective cohort study includes adults in the ACS NSQIP PUF dataset who underwent gastrectomy between 2011 and 2013. Sequential multivariable models were used to estimate effects of clinical covariates on study outcomes including morbidity, mortality, readmission, and reoperation.

Results

Three thousand six hundred and seventy-eight patients underwent gastrectomy. A majority of patients had distal gastrectomy (N?=?2,799, 76.1 %) and had resection for malignancy (N?=?2,316, 63.0 %). Seven hundred and ninety-eight patients (21.7 %) experienced a major complication. Reoperation was required in 290 patients (7.9 %). Thirty-day mortality was 5.2 %. Age (OR?=?1.01, 95 % CI?=?1.01–1.02, p?=?0.001), preoperative malnutrition (OR?=?1.65, 95 % CI?=?1.35–2.02, p?<?0.001), total gastrectomy (OR?=?1.63, 95 % CI?=?1.31–2.03, p?<?0.001), benign indication for resection (OR?=?1.60, 95 % CI?=?1.29–1.97, p?<?0.001), blood transfusion (OR?=?2.57, 95 % CI?=?2.10–3.13, p?<?0.001), and intraoperative placement of a feeding tubes (OR?=?1.28, 95 % CI?=?1.00–1.62, p?=?0.047) were independently associated with increased risk of morbidity. Association between tobacco use and morbidity was statistically marginal (OR?=?1.23, 95 % CI?=?0.99–1.53, p?=?0.064). All-cause postoperative morbidity had significant associations with reoperation, readmission, and mortality (all p?<?0.001).

Conclusions

Mitigation of perioperative risk factors including smoking and malnutrition as well as identified operative considerations may improve outcomes after gastrectomy. Postoperative morbidity has the strongest association with other measures of poor outcome: reoperation, readmission, and mortality.

     

The Impact of Discharge Timing on Readmission Following Hepatopancreatobiliary Surgery: a Nationwide Readmission Database Analysis

Objective

Decreasing hospital length-of-stay (LOS) may be an effective strategy to reduce costs while also improving outcomes through earlier discharge to the non-hospital setting. The objective of the current study was to define the impact of discharge timing on readmission, mortality, and charges following hepatopancreatobiliary (HPB) surgery.

Methods

The Nationwide Readmissions Database (NRD) was used to identify patients undergoing HPB procedures between 2010 and 2014. Length of stay (LOS) was categorized as early discharge (4–5 days), routine discharge (6–9 days), and late discharge (10–14 days). Univariable and multivariable analyses were utilized to identify factors associated with 90-day readmission.

Results

A total of 28,114 patients underwent HPB procedures. Overall median LOS was 7 days (IQR 5–11); 10,438 (37.1%) patients had an early discharge, while 13,665 (48.6%) and 4011 (14.3%) patients had a routine or late discharge. The probability of early discharge increased over time (referent 2010: 2011–4% (OR 1.04, 95% CI 0.96–1.15) vs. 2012–10% (OR 1.10, 95% CI 1.01–1.20) vs. 2013–21% (OR 1.21, 95% CI 1.11–1.32) vs. 2014–32% (OR 1.32, 95% CI 1.21–1.44)) (p?<?0.001). Early discharge was associated with insurance status, diagnosis (benign vs. malignant disease), general health, and overall hospital volume (all p?<?0.05). Among patients who had an early discharge, 30- and 90-day readmission was 11.5 and 17.4%, respectively. In contrast, 30- and 90-day readmission was 16.9 and 24.7%, respectively, among patients who had a routine discharge group (p?<?0.001). Among patients readmitted within 90 days, in-hospital mortality was similar among patients who had early (n?=?43, 2.4%) versus routine discharge (n?=?65, 1.9%). Median charges were lower among patients who had an early versus routine versus late discharge ($54,476 [IQR 40,053–79,100] vs. $75,192 [IQR 53,296–113,123] vs. $115,061 [IQR 79,162–171,077], respectively) (p?<?0.001).

Conclusions

Early discharge after HPB surgery was not associated with increased 30- or 90-day readmission. Overall 90-day in-hospital mortality following a readmission was comparable among patients with an early, routine, and late discharge, while median charges were lower in the early discharge group.

     

Thirty-Day Readmission After Laparoscopic Sleeve Gastrectomy—a Predictable Event?

Background

Thirty-day readmission post-bariatric surgery is used as a metric for surgical quality and patient care. We sought to examine factors driving 30-day readmissions after laparoscopic sleeve gastrectomy (LSG).

Methods

We reviewed 1257 LSG performed between March 2012 and June 2014. Readmitted and nonreadmitted patients were compared in their demographics, medical histories, and index hospitalizations. Multivariable regression was used to identify risk factors for readmission.

Results

Forty-five (3.6 %) patients required 30-day readmissions. Forty-seven percent were readmitted with malaise (emesis, dehydration, abdominal pain) and 42 % with technical complications (leak, bleed, mesenteric vein thrombosis). Factors independently associated with 30-day readmission include index admission length of stay (LOS) ≥3 days (OR 2.54, CI?=?[1.19, 5.40]), intraoperative drain placement (OR 3.11, CI?=?[1.58, 6.13]), postoperative complications (OR 8.21, CI?=?[2.33, 28.97]), and pain at discharge (OR?8.49, CI?=?[2.37, 30.44]). Patients requiring 30-day readmissions were 72 times more likely to have additional readmissions by 6 months (OR?72.4, CI?=?[15.8, 330.5]).

Conclusions

The 30-day readmission rate after LSG is 3.6 %, with near equal contributions from malaise and technical complications. LOS, postoperative complications, drain placement, and pain score can aid in identifying patients at increased risk for 30-day readmissions. Patients should be educated on postoperative hydration and pain management, so readmissions can be limited to technical complications requiring acute inpatient management.

     

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for the Elderly: Is It Reasonable? A Meta-Analysis

Background

Whether cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) is safe and worthwhile for elderly patients remains unclear. This meta-analysis of outcomes after CRS plus HIPEC for the elderly aimed to generate a higher level of evidence and precise indications for these patients.

Methods

A systematic literature search for studies reporting postoperative outcomes after CRS plus HIPEC for elderly patients was performed in the MEDLINE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, Web of Knowledge Conference Proceedings Citation Index-Science, and Google Scholar databases. The included studies evaluated the overall 30-day postoperative morbidity, 90-day postoperative mortality, grade 3 or higher postoperative morbidity, rates of anastomotic leaks, reoperation and readmission, and length of hospital stay.

Results

The inclusion criteria were met by 13 retrospective studies involving 2544 patients. Considering only comparative studies, the 90-day postoperative mortality was significantly increased for elderly patients [odds ratio (OR), 0.49; 95% confidence interval (CI), 0.27–0.88; I ² = 79%]. The 30-day grade 3 or higher postoperative morbidity was increased in the patients 70 years of age or older (14.5%; 95% CI 8.1–24.4 vs. 32.3%; 95% CI 22.4–44.0%; p = 0.004; I ² = 85%). The overall 30-day postoperative morbidity, rates of anastomotic leaks, reoperation and readmission, and length of hospital stay were not affected by age.

Conclusions

Treatment of the elderly with CRS plus HIPEC was associated with increased severe postoperative morbidity and mortality. However, these conclusions should be weighted given the existence of major biases in the included studies. Age alone probably would not be a formal contraindication, but frailty should be taken into account. Further prospective studies are needed.

     

Prediction of Diabetes Remission in Morbidly Obese Patients After Roux-en-Y Gastric Bypass

Background

Morbidly obese patients with type 2 diabetes have shown significant improvement in glycemic control after Roux-en-Y gastric bypass (RYGB). This study aimed to elucidate the predictors of diabetes remission.

Methods

A retrospective review of a prospectively established database identified 134 type 2 diabetes patients who underwent laparoscopic RYGB between January 2011 and February 2014. Partial and complete remission of diabetes was defined as glycated hemoglobin (HbA1c) level <6.5 and <6.0 %, respectively, without the use of antidiabetic medication. Pre- and postoperative clinical outcomes were compared between the remission and non-remission groups to identify the predictors of partial or complete remission of diabetes.

Results

The mean duration of diabetes and preoperative HbA1c level were 4.6 years and 8.0 %, respectively. The body mass index (BMI) of the enrolled patients decreased from 37.9 to 28.8 kg/m² during the mean follow-up of 12.3 months; 61.8 % of the patients achieved partial or complete remission of diabetes. Multivariate analysis revealed that age at operation (odds ratio [OR]?=?0.880; 95 % confidence interval [CI] 0.807–0.960), HbA1c level (OR?=?0.527; 95 % CI 0.325–0.854), and C-peptide level (OR?=?1.463; 95 % CI 1.054–2.029) in the preoperative laboratory study, and the percentage of total weight loss (%TWL) (OR?=?1.186; 95 % CI 1.072–1.313) after RYGB were the independent predictors of partial or complete diabetes remission.

Conclusion

The predictive factors for diabetes remission after RYGB include age at operation, HbA1c and C-peptide levels, and the %TWL after surgery.

     

Selection of Bypass vs Sleeve for the Management of Type-2 Diabetes in Severely Obese: Could Ethnicity Play a Role?

Purpose

Prospective data was evaluated to see whether bariatric procedure type made any difference to diabetes remission.

Methods

One hundred eighty-six consecutive patients of Indian ethnicity (M:F 89:97) with type 2 diabetes mellitus (T2DM) and HbA1c >?6.5 were assessed before and at 1 year following surgery. Age, BMI, C-peptide and duration of diabetes (ABCD - described by WJ Lee), insulin use, baseline HbA1c, and % weight loss were tested as modifiers. We present remission rates (HbA1c ≤?6.0%) and between group remission odds ratio (OR) and adjusted OR after controlling for key modifiers.

Results

Patients selecting RYGB (n?=?113) vs SG (n?=?73) were older (50.7 vs 44.2 years), had a lower BMI (44.1 vs 46.7), lower C-peptide (3.5 vs 4.7 ng/ml), greater duration of diabetes (8 vs 3 years), and higher HbA1c (8.90 and 7.9%) respectively p?<?0.05 for all (combined R²?=?0.38). Weight loss at 1 year was 27 and 30% for RYGB and SG respectively (p?=?0.01). Remission at 1 year was achieved by 37% of patient selecting RYGB and 74% for the SG (OR?=?0.21, 95% CI 0.11–0.41, p?<?0.001). After adjusting for ABCD, the adjusted OR (AOR) still favored the SG (AOR?=?0.32, 0.14–0.74, p?=?0.01), and adjustment for HbA1c and weight loss (AOR 0.4, 0.17–0.95, p?=?0.038) attenuated the effect.

Conclusion

The analysis suggests SG may be superior to RYGB in this Indian population. Ethnicity may play a role in predicting the response to bariatric surgery and hence the choice of procedure. A randomized controlled trial is needed to clarify the relative benefit.

     

Surgeon Volume Correlates with Reduced Mortality and Improved Quality in the Surgical Management of Diverticulitis

Background

Volume has been shown to be an important determinant of quality and cost outcomes.

Methods

We performed a retrospective study of patients who underwent surgery for diverticulitis using the University HealthSystem Consortium database from 2008–2012. Outcomes evaluated included minimally invasive approach, stoma creation, intensive-care admission, post-operative complications, length of stay, and total direct hospital costs by surgeon volume. Surgeon volume was categorized into four categories by mean annual volumes: very-high (VHVS) (>31), high (HVS) (13–31), medium (MVS) (6–12), and low (LVS) (≤5).

Results

A total of 19,212 patients with a mean age of 59 years, 54 % female makeup, and 55 % rate of private insurance were included. Similar to the unadjusted analysis, multivariable analysis revealed decreasing odds of stoma creation, complications, ICU admission, reoperation, readmission, and inpatient mortality with increasing surgeon volume. Additionally, compared with LVS, a higher surgeon volume was associated with higher rates of the minimally invasive approach. Median length of stay and costs were also notably lower with increasing surgeon volume.

Conclusion

Quality and the use of minimally invasive technique are tightly associated with surgeon volume. Further studies are necessary to validate the direct association of volume with outcomes in surgery for diverticulitis.

     

Factors Predicting Length of Stay Following Bariatric Surgery: Retrospective Review of a Single UK Tertiary Centre Experience

Background

Laparoscopic Roux Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) are the most commonly performed bariatric procedures. Improvement in techniques and perioperative management of patients have resulted in shorter hospital stay and reduced overall costs. Many post-operative protocols aspire to post-operative day 1 discharge with studies showing reduction in length of stay without increasing complications. In this study, we investigate the factors predictive of early discharge at our high-volume bariatric centre.

Methods

A retrospective review of all patients who underwent bariatric surgery (RYGB or SG) at a single centre between January 2013 and December 2014 was undertaken. Routine preoperative investigations were performed and patient discussed at bariatric MDT. Post-operative management was as per standard protocols. Demographic data, type of surgery and post-operative data (length of stay, complications, readmission, reoperations) were analysed. Statistical analysis was performed using SPSS.

Results

Five hundred six patients underwent RYGB (407 (80.4%)) or SG (99 (19.6%)). The mean preoperative BMI was 45.9 (range 33.3–80.6). The median length of stay was 1 day (range 1–214 days; interquartile range 1–2 days) for RYGB and 2 days (range 1–8 days; interquartile range 1–3 days) for SG. Two hundred sixty-eight (52.9%) patients were discharged on post-operative day 1. The type of surgery and preoperative BMI were the only significant factors predicative of day 1 discharge after surgery. Patients undergoing SG were 3.3 times more likely to stay longer than 1 day after surgery (p?<?0.001). BMI <?50 is associated with day 1 discharge (p?=?0.030).

Conclusion

Early discharge, on post-operative day 1 appears to be safe and is not associated with a greater risk of readmission. Sleeve gastrectomy and a BMI >?50 are associated with an increased risk of failure to achieve day 1 discharge.

     

Characterizing Short-Term Outcomes Following Surgery for Rectal Cancer: the Role of Race and Insurance Status

Background

There is a paucity of data demonstrating the effect race and insurance status have on postoperative outcomes for patients with rectal cancer. We evaluated factors impacting short-term outcomes following rectal cancer surgery.

Design

Patients who underwent surgery for rectal cancer using the University Health System Consortium database from 2011 to 2012 were studied. Univariate and multivariable analyses were used to identify patient related risk factors for 30-day outcomes after proctectomy: complication rate, 30-day readmission, ICU stay, and length of hospital stay (LOS).

Results

A total of 9272 proctectomies were identified in this cohort. After adjustment for potential confounders, black patients were more likely to have 30-day readmissions (OR 1.51, 95 % CI 1.26–1.81), ICU stays (OR 1.25, 95 % CI 1.03–1.51), and longer LOS (+1.67 days, 95 % CI 1.21–2.13) when compared to whites. Compared to those with private insurance, patients with public or military insurance or who were self-pay had a higher likelihood of having postoperative complications.

Conclusions

In patients who undergo elective proctectomy for rectal cancer, non-white and non-privately insured status are associated with significantly worse short-term outcomes. Further studies are needed to determine the implications with respect to receipt of adjuvant therapy and survival.

     

Cost-Effectiveness in Hepatic Lobectomy: the Effect of Case Volume on Mortality,Readmission, and Cost of Care

Objective(s)

Higher-volume centers demonstrate better perioperative outcomes for complex surgical interventions, though resource utilization implications of this hospital-level variation are unclear. We hypothesized that for hepatic lobectomy, higher operative volume correlates with better outcomes and lower costs.

Methods

From 2009 to 2011, 4163 patients undergoing hepatic lobectomy were identified from the University HealthSystems Consortium database. Univariate, multivariate logistic regression, and decision analytic models were constructed to identify differences in hospital utilization and cost. Cost included both index and readmission hospitalizations, when applicable.

Results

The annual number of hepatic lobectomies performed by the institutions within the study ranged from 1 to 86. The median age of the 4163 patients was 58 years with a roughly equal gender split (M/F 49 %:51 %) and a racial breakdown which reflected that of the general US population. For all patients, the overall perioperative mortality rate was 2.3 % and the 30-day readmission rate was 13.4 %. Hospitals performing >30 hepatic lobectomies per year had significantly lower mortality and readmission rates than those hospitals performing ≤15 lobectomies annually (both p?<?0.05). On multivariate analysis, higher severity of illness (odd ratio (OR) 2.13, 95 % confidence interval (CI) [1.48–3.07], p?<?0.001), discharge to rehab (OR 1.84, [1.28–2.64], p?<?0.001), home with home health care (OR 1.38, [1.08–1.76], p?=?0.01), and surgery at a low-volume hospital (OR 1.49, [1.18–1.88], p?<?0.001) were significant predictors of readmission. Conversely, surgical intervention at high-volume centers was associated with decreased risk of readmission (OR 0.67, [0.53–0.85], p?<?0.001). When both index and readmission costs were considered, per-patient cost at low-volume centers was 21.9 % higher than at high-volume centers ($19,669 vs. $16,137). Sensitivity analyses adjusting for perioperative mortality and readmission at all centers did not significantly change the analysis.

Conclusions

These data, for the first time, demonstrate that hospital volume in hepatic lobectomy is an important, modifiable risk factor for readmission and cost. To optimize resource utilization, patients undergoing complex hepatic surgery should be directed to higher-volume surgical institutions.

     

Impact of Sarcopenia on Unplanned Readmission and Survival After Esophagectomy in Patients with Esophageal Cancer

Background

Although sarcopenia increases postoperative complications following esophagectomy, its effects on prognosis remain unclear. This study was performed to identify the effect of sarcopenia on 90-day unplanned readmission and overall survival (OS) after esophagectomy.

Methods

Ninety-eight patients with esophageal cancer who underwent esophagectomy were enrolled in this study. Unplanned readmission was defined as any emergent hospitalization within 90 days after discharge. Sarcopenia, defined as low muscle mass plus low muscle strength and/or low physical performance according to the Asian consensus definition, was assessed prior to esophagectomy. Multivariate logistic regression analysis was performed to identify factors that contributed to 90-day unplanned readmission. OS was estimated using the Kaplan–Meier method, and a Cox proportional hazards model was used to assess the relationship between sarcopenia and OS.

Results

Thirty-one patients (31.6%) were diagnosed with sarcopenia. The 90-day unplanned readmission rate was significantly higher in patients with sarcopenia than those without (42.9% vs. 16.4%, respectively; p = 0.01). Multivariable logistic regression analysis showed that sarcopenia was an independent predictor of 90-day unplanned readmission [odds ratio 3.71, 95% confidence interval (CI) 1.29–11.05; p = 0.02], and the log-rank test showed that sarcopenia was associated with OS (p = 0.01). Moreover, sarcopenia was a significant predictor of OS after adjustment for age, sex, and pathological stage (hazard ratio 2.35, 95% CI 1.21–4.54; p = 0.01).

Conclusions

Sarcopenia is a risk factor for 90-day unplanned readmission and OS following esophagectomy. Assessment of sarcopenia could help to identify patients at higher risk of a poor prognosis after esophagectomy.

     

The impact of osteoporotic fractures compared with other health conditions in older adults living in Virginia,United States

Summary

This study compared length of stay, hospital costs, 30-day readmission, and mortality for patients admitted primarily for osteoporotic fractures to those admitted for five other common health conditions. The results indicated that osteoporotic fractures were associated with highest hospital charges and the second highest hospital stay after adjusting for confounders.

Introduction

This study aimed to compare the effect of osteoporotic fractures and other common hospitalized conditions in both men and women age 55 years and older on a large in-patient sample.

Methods

De-identified patient level and readmission and transfer data from the Virginia Health Information (VHI) system for 2008 through 2014 were merged. Logistic regression models were used to assess mortality and 30-day readmission, while generalized linear models were fitted to assess LOS and hospital charges.

Results

After adjustment for confounders, osteoporotic fractures had the second longest LOS (6.0 days, 95 % CI?=?5.9–6.0) and the highest average total hospital charges ($47,386.0, 95 % CI?=?$46,707.0–$48,074.0) compared to the other five common health problems.

Conclusion

Recognizing risk and susceptibility to osteoporotic fractures is an important motivator for individual behaviors that mitigate this disease. Furthermore, acknowledging the economic impact and disabling burden of osteoporotic fractures on society are compelling reasons to promote bone health as well as to prevent, diagnose, and manage osteoporosis.

     

Readmission After Abdominal Surgery for Crohn’s Disease: Identification of High-Risk Patients

Background

Although many predictive factors for postoperative morbidity are known, few data are available about readmission after abdominal surgery for Crohn’s disease (CD). The objective of this study is to identify predictive factors and high-risk patients for readmission after abdominal CD surgery.

Methods

All patients who underwent abdominal surgery for CD in one tertiary referral center between January 2004 and December 2016 were included. Patients who required readmission and those without were compared. Perineal procedures, elective readmissions, and abdominal procedures for non-Crohn’s indications were not included.

Results

Nine hundred eight abdominal procedures were performed in 712 patients. Readmission rates were 8, 8.5, 8.6, 8.8, and 8.9% at 30, 60, and 90 days and 12 and 60 months, respectively. The main reasons were wound infection (14%), deep abscess (13%), small-bowel obstruction (13%), and dehydration (11%). Eight (11%) patients required percutaneous drainage and 19 (27%) underwent an unplanned surgery. After multivariate analysis, three independent predictive factors for readmission were identified: older age (OR 1.02, 95%CI 1.005–1.04; p?<?0.006), a history of previous proctectomy (OR 3, 95%CI 1.2–9, p?<?0.02), and higher blood loss volume during surgery (OR 1.0001, 95%CI 1–1.002, p?<?0.05).

Conclusion

Readmission occurred in 8–9% of abdominal procedures for CD within 1–3 months after surgery and it required unplanned reoperation in a quarter of them. Identification of high-risk groups and knowledge of the more common postoperative complications requiring readmission help in increasing postoperative vigilance to select patients who may benefit from early interventions.

     

Laparoscopic Sleeve Gastrectomy and Gastric Bypass for The Aging Population

Background

Laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are the two most common bariatric surgeries for treating morbid obesity. The purpose of this study is to determine differences in outcomes from RYGB or SG between patients ages?≥?60 years and?<?60 years.

Methods

A retrospective review of patients who underwent RYGB and SG at our institution from 01/2008 to 05/2012 was conducted. Forty patients from each group (≥60 years and?<?60 years) were matched based on gender, body mass index (BMI), co-morbidities, and type of bariatric surgery performed, and their charts were reviewed up to 1 year post-operatively. Primary end points measured were mean length of stay, operative time, incidence of complications, and readmissions in the first post-operative year. A secondary end point measured was percent total weight loss (%TWL) and excess weight loss (%EWL).

Results

There were no significant differences between group?<?60 and group?≥?60 in operative time (210 vs. 229 min; p?=?0.177), in-hospital post-operative complication rates (2.5 vs. 5 %; p?=?1.0), long-term complication rates (2.5 vs. 10 %; p?=?0.359), and 30-day readmission rates (2.5 vs. 12.5 %; p?=?0.2). Patients in group?<?60 had shorter lengths of stay (2.2 vs. 2.7 days; p?=?0.031), but this difference is not clinically significant. Both groups achieved similar %TWL (21.4 vs. 20.5 %; p?=?0.711) and %EWL (50.6 vs. 50.7 %; p?=?0.986).

Conclusions

Advanced age (≥60 years) is not a significant predictor of a worse outcome for SG and RYGB.

     

Perioperative Risk Adjustment for Total Shoulder Arthroplasty: Are Simple Clinically Driven Models Sufficient?

Background

There is growing interest in value-based health care in the United States. Statistical analysis of large databases can inform us of the factors associated with and the probability of adverse events and unplanned readmissions that diminish quality and add expense. For example, increased operating time and high blood urea nitrogen (BUN) are associated with adverse events, whereas patients on antihypertensive medications were more likely to have an unplanned readmission. Many surgeons rely on their knowledge and intuition when assessing the risk of a procedure. Comparing clinically driven with statistically derived risk models of total shoulder arthroplasty (TSA) offers insight into potential gaps between common practice and evidence-based medicine.

Questions/Purposes

(1) Does a statistically driven model better explain the variation in unplanned readmission within 30 days of discharge when compared with an a priori five-variable model selected based on expert orthopaedic surgeon opinion? (2) Does a statistically driven model better explain the variation in adverse events within 30 days of discharge when compared with an a priori five-variable model selected based on expert orthopaedic surgeon opinion?

Methods

Current Procedural Terminology codes were used to identify 4030 individuals older than 17 years of age who had TSA in which osteoarthritis was the primary etiology. A logistic regression model for adverse event and unplanned readmission within 30 days was constructed using (1) five variables chosen a priori based on clinic expertise (age, American Society of Anesthesiologists classification ≥ 3, body mass index, smoking status, and diabetes mellitus); and (2) by entering all variables with p < 0.10 in bivariate analysis. We then excluded 870 patients (22%) based on preoperative factors felt to make large discretionary surgery unwise to focus our research on appropriate procedures. Infirm patients have more pressing needs than alleviation of shoulder pain and stiffness. Among the remaining 3160 patients, logistic regression models for adverse event and unplanned readmission within 30 days were constructed in a similar manner to the complete models. The five a priori risk factors used in each model based on clinical expertise were selected by consensus of an expert orthopaedic surgeon panel.

Results

When patients unfit for discretionary surgery were excluded, the clinically driven model found no risk factors and accounted for 1.4% of the variation in unplanned readmission. In contrast, the statistically driven model explained 4.6% of the variation and found operating time (hours) (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.04–1.53) and hypertension requiring medications (OR, 1.95; 95% CI, 1.01–3.76) were associated with unplanned readmission accounting for all other factors. However, neither the clinically driven model (pseudo R², 1.4%) nor statistically driven model (pseudo R², 4.6%) provided much explanatory power. When patients unfit for discretionary surgery were excluded, no factors in the clinically driven model were significant and the model accounted for 0.95% of the variation in adverse events. In the statistically driven model, age (OR, 1.03; 95% CI, 1.01–1.06), men (OR, 1.64; 95% CI, 1.05–2.57), operating time (hours) (OR, 1.27; 95% CI, 1.07–1.52), and high BUN (OR, 3.12; 95% CI, 1.35–7.21) were associated with adverse events when accounting for all other factors, explaining 3.3% of the variation. However, neither the clinically driven model (pseudo R², 0.95%) nor the statistically driven model (pseudo R², 3.3%) provided much explanatory power.

Conclusions

The observation that a statistically derived risk model performs better than a clinically driven model affirms the value of research based on large databases, although the models derived need to be tested prospectively.

Clinical Relevance

Clinicians can utilize our results to understand that clinician intuition may not always offer the best risk adjustment and that factors impacting TSA unplanned readmission and adverse events may be best derived from large data sets. However, because current analyses explain limited variation in outcomes, future studies might look to better define what factors drive the variation in unplanned readmission and adverse events.

     

A national population-based cohort study of urethral injection therapy for female stress and mixed urinary incontinence: the Danish Urogynaecological Database, 2007–2011

Introduction and hypothesis

Urethral injection therapy (UIT) has been performed since the early 20th century and a variety of agents have been launched. In 2006, polyacrylamide hydrogel (PAGH) was introduced and is now widely used as an agent. The objective was to evaluate the efficacy of PAGH based on a national population over a 5-year period (2007–2011) and the influence of patient-related factors, surgeon experience, and department volume.

Methods

A retrospective cohort study was carried out based on data from the Danish Urogynaecological Database (DugaBase).

Results

A total of 731 women were registered in the DugaBase. Cure was achieved in 75 out of 252 women (29.8%) and no leakage at all in 23 out of 252 (9.1%) at the 3-month follow-up. The mean total International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score decreased from 16 (SD 3.8) to 10.6 (SD 6.2; p?<?0.001). UIT was performed at 16 departments, of which four high-volume departments performed 547 out of 814 UITs (67.2%). Women with severe UI had a decreased chance of cure (all ICIQ-SF scores), as did women on antimuscarinic drugs (adjusted OR 0.14; 95%, CI 0.04–0.41 “frequency”) and (adjusted OR 0.33; 95%, CI 0.13–0.82, “amount”). Women treated by a high-volume surgeon had a higher chance of cure (OR 4.51; 95% CI, 1.21–16.82, “frequency”) and a lower risk of 30-day hospital contacts (OR 0.27; 95% CI 0.09–0.76).

Conclusion

The study represented a cure for UIT among women in an everyday life setting. A surgeon learning curve for UIT was indicated, as was assigning interventions to fewer hands to improve the surgical training value and consequently the cure rate for women with UIT.

     

Surgeon-Level Variation in Postoperative Complications

Background

Variation in surgical outcomes is often attributed to patient comorbidities and the severity of underlying disease, but little is known about the extent of variation in outcomes by surgeon and the surgeon factors that are associated with quality.

Methods

Using the Maryland Health Services Cost Review Commission database, we evaluated risk-adjusted postoperative events by surgeon. Operations studied were elective laparoscopic and open colectomy procedures for colon cancer performed over a 2-year period (July 2012–September 2014). Postoperative events were defined using the Agency for Healthcare Research and Quality Patient Safety Indicators. Surgeons performing fewer than ten procedures during the study period were excluded. Logistic regression and post-estimation were used to calculate an observed-to-expected (O/E) ratio of postoperative complications for each surgeon, adjusting for patient and surgeon characteristics.

Results

A total of 2525 patients underwent an elective colectomy during the study period by 276 surgeons at 44 hospitals. Postoperative complications varied more by surgeon (range 0 to 30.0 %) than by hospital (range 0 to 18.2 %). Surgeon-level use of laparoscopic surgery to perform colectomy ranged from 0 to 100 %. After risk adjustment with patient factors, surgeon experience, surgeon medical school, surgeon gender, and annual surgeon colectomy volume were not associated with postoperative complications. Surgeon use of laparoscopy was the strongest predictor of lower complications (vs fourth quartile of surgeons, first quartile OR?=?0.47 (0.26–0.85); second quartile OR?=?0.41 (0.22–0.73); and third quartile OR?=?0.84 (0.52–1.36).

Conclusions

Quality metrics in health care have been measured at the hospital level, but a greater quality improvement potential exists at the surgeon level. Awareness of this variation could better inform patients undergoing elective surgery and their referring physicians.

     

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.