Preoperative intraaortic balloon pumps in high-risk patients undergoing open heart surgery

BACKGROUND: The use of the preoperative intraaortic balloon pump (IABP) in patients with severe left ventricular dysfunction or unstable angina with critical coronary anatomy is becoming more frequent as surgical casemix changes. The aim of this study was to determine the impact of preoperative IABP use on survival in high-risk patients having open heart surgery. METHODS: Prospectively collected data for 645 consecutive patients were reviewed. Patients receiving an IABP were identified and grouped as follows: group A (preoperative IABP for high-risk nonemergent cases), group B (preoperative IABP for emergent cases), and group C (intra/postoperative IABP). Risk-adjusted hospital mortality rates in these three groups was compared using the modified Parsonnet score for preoperative risk stratification. RESULTS: IABPs were used in 101 cases (16%). The predicted versus actual hospital mortality rate was 20% versus 5.7% in group A, 32.1% versus 47.6% in group B, and 12.6% versus 22.2% in group C (group A vs group B, p = 0.0014; group A vs group C, p = 0.012). IABP-related morbidity occurred in 3% of cases (all in group C). CONCLUSIONS: Risk-adjusted mortality was significantly lower in high-risk cases with preoperative IABPs compared with emergent cases and intraoperative/postoperative IABPs. We encourage the use of preoperative IABPs in selected high-risk patients.     

Emergent and elective colon surgery in the extreme elderly: do the results warrant the operation?

With the elderly population rising continuously, surgeons are increasingly confronted by the dilemma of operative management in these patients, which frequently encompasses end-of-life issues. Increasing age and emergent surgery are known risk factors for poor outcomes in colon surgery. The purpose of this study is to delineate differences in outcomes between emergent and elective colon surgery and identify risk factors that can guide the surgeon in caring for the extreme elderly (age 80 years or older). From 2001 to 2006, a retrospective review of the resident database at Greenville Hospital System identified 104 extreme elderly patients who underwent colon surgery (65 elective, 39 emergent). Comparing elective and emergent operations, results showed substantial differences in morbidity (20% vs 51.2%, P < 0.001), 30-day mortality rate (7.7% vs 30.7%, P < 0.005), and length of stay (13.6 days vs 21.6 days, P < 0.004). Percentage of patients discharged to home was significantly less in the emergent group (13% vs 59%, P < 0.001). Evaluation of the emergent surgery group revealed male gender, history of smoking, and ischemic changes on pathologic examination were statistically significant risk factors for failure of surgery. As a result of the high-risk nature of emergent colon operations in the extreme elderly, it is important that surgeons carefully assess the benefits in relation to the risks and functional outcomes of surgery when planning patient care and providing informed consent.     

Outcomes of emergent incisional hernia repair

This study examines the effect of emergent repair on incisional hernia repair outcomes at 16 Veteran's Affairs Medical Centers between 1998 and 2002. Of the 1452 cases reviewed, 63 (4.3%) were repaired emergently. Patients undergoing emergent repair were older (P = 0.02), more likely to be black (P = 0.02), and have congestive heart failure (P = 0.001) or chronic obstructive pulmonary disease (P = 0.001). Of emergent repairs, 76.2 per cent involved intestinal incarceration versus 7.2 per cent of elective repairs (P < 0.0001), and 17.5 per cent had concomitant bowel resection compared with 3.9 per cent of elective cases (P < 0.0001). Patients undergoing emergent repair were also more likely to receive primary suture repair (49.2 vs 31.1%, P = 0.003), develop a postoperative complication (26.0 vs 11.3%, P = 0.002), and have increased postoperative length of stay (7 vs 4 days, P < 0.0001). There were nine (14.3%) deaths at 30 days for the emergent group compared with 10 (0.7%) in the elective group (P < 0.001). However, there was no significant difference between emergent and elective repairs in long-term complications. Emergent hernia repair is associated with increased mortality rates, early complications, and longer length of stay; however, long-term outcomes are equivalent to elective cases. These data suggest that technical outcomes for emergent repairs approach those of elective operations.     

Effect of emergent presentation on outcome from rectal cancer management

BACKGROUND: We have previously reported outcomes for all rectal cancers in BC in 1996. We found that our local recurrence rates and survival were suboptimal relative to current standards in recent literature. METHODS: In this retrospective, population-based study, we report the influence of emergent presentation (obstruction, perforation, massive hemorrhage) on outcomes, types of surgical procedures and use of staging investigations, and use of adjuvant radiation and chemotherapy. RESULTS: There were 452 invasive adenocarcinomas of the rectum of which 45 were emergent and 407 nonemergent. Disease-specific survival at 4 years for emergent and nonemergent stage II cancers were 66% versus 80%, respectively, and for stage III cancers, 60% versus 73%, respectively (P <0.04). Local recurrence rates at 4 years for emergent and nonemergent stage II cancers were 20% versus 15%, respectively, and for stage III cancers, 70% and 20%, respectively (P <0.05). Surgical resection more frequently involved a stoma for emergent (60%) than for nonemergent (35%) cases (P <0.01). Percent of patients having complete staging investigations were similar between emergent (42%) and nonemergent patients (39%). Adjuvant radiation was given in similar proportion to emergent (61%) and nonemergent (55%) patients. Adjuvant chemotherapy was given to a slightly higher proportion of emergent patients (63%) than nonemergent patients (43%). CONCLUSIONS: We conclude that outcome from rectal cancer management is worse for emergent than nonemergent presentation. Since there is no difference in use of staging investigations or adjuvant therapy, the difference in outcome is likely due to difference in surgical technique between emergent and nonemergent cases.     

Laparoscopic versus open colonic resection for complicated diverticular disease in the emergency setting: a safe choice? A retrospective comparative cohort study

Background

We conducted a retrospective cohort study to compare the outcomes of laparoscopic colon resection (LCR) with open colon resection (OCR) for complicated diverticular disease (CDD) during emergent hospital admission.

Methods

Charts from all patients undergoing colon resection for CDD during emergent hospital admission at a single academic institution were reviewed. The primary outcomes were overall 30-day postoperative morbidity and mortality.

Results

From 2000 to 2010, 125 cases were retrieved (49 LCR and 86 OCR). Conversion rate was 5.1%. Overall morbidity significantly decreased with laparoscopic surgery compared with OCR. No mortality occurred with LCR. Prolonged ileus was less frequent (12.8% vs 32.6%; P = .02), time to oral intake shorter (3 vs 6 days; P < .01), and LOS shorter (5 vs 8 days; P = .05) for LCR.

Conclusions

In our series, in the patients selected, LCR for CDD during emergent hospital admission appears to be a safe procedure associated with decreased morbidity, time to oral intake, and LOS compared with OCR.     

Emergent right hemicolectomies

Emergent right hemicolectomies have historically been associated with surprisingly high morbidity and mortality rates. A retrospective review of emergent right hemicolectomies over a 7-year period was performed to assess current morbidity and mortality. Emergent right hemicolectomy was defined as a procedure performed for an acute abdomen with no formal preoperative cleansing of the colon. Demographic data, diagnostic evaluation, length of stay and outcomes were evaluated. Over the study period, 122 emergent right hemicolectomies were performed on both general surgery and trauma patients. The average patient was 52.9 +/- 18.5 years old, and the majority of patients (66.4%) were male. The indications for the procedures performed were bowel perforation (51), hemorrhage (25), cancer (16), benign obstruction (14), phlegmon (8), ischemia (6), or other (2). Resection with primary anastomosis was performed in 98 patients, 16 had an end ileostomy, and 8 underwent damage control procedures in which gastrointestinal continuity was not reestablished at the time of the original operation. Postoperative complications developed in 48 patients (39.3%). The majority of the complications (83.3%) were related to infection including intra-abdominal abscess (21 patients), sepsis (16), and wound infection (5). Other complications included anastomotic leak (5), wound dehiscence (3), stoma-related (3) and postoperative bowel obstruction (2). The patients who developed complications did not differ from those who had an uneventful postoperative course in terms of age, indication for procedure, or presence of intraabdominal abscess or gross contamination at the time of the original procedure. The overall mortality rate was 13 per cent. Patients who died were older than those who lived (63 +/- 19 vs 52 +/- 18; P = 0.03) and were significantly more likely to have evidence of shock on presentation (P = 0.0013). Emergent right hemicolectomies continue to be associated with high morbidity and mortality rates. The most common complications are related to infection. Age and manifestations of shock at the time of admission are strong predictors of mortality.     

Comparison of risk-adjusted 30-day postoperative mortality and morbidity in Department of Veterans Affairs hospitals and selected university medical centers: general surgical operations in men

BACKGROUND: We used data from the Patient Safety in Surgery Study to compare patient populations, operative characteristics, and unadjusted and risk-adjusted 30-day postoperative mortality and morbidity between the Veterans Affairs (VA) (n = 94,098) and private (n = 18,399) sectors for general surgery operations in men. STUDY DESIGN: This is a prospective cohort study. Trained nurses collected preoperative risk factors, operative variables, and 30-day postoperative mortality and morbidity outcomes in male patients undergoing major general surgery operations at 128 VA medical centers and 14 university medical centers from October 1, 2001, to September 30, 2004. Multiple logistic regression analysis was used to identify preoperative predictors of postoperative mortality and morbidity. An indicator variable for VA versus private-sector medical center was added to the model to determine if risk-adjusted outcomes were significantly different in the two systems. RESULTS: The unadjusted 30-day mortality rate was higher in the VA compared with the private sector (2.62% versus 2.03%, p = 0.0002); unadjusted morbidity rate was lower in the VA compared with the private sector (12.24% versus 13.99%, p < 0.0001). After risk adjustment, odds ratio for mortality for the VA versus private sector was 1.23 (95% CI, 1.08-1.41). For morbidity after risk adjustment, the indicator variable for health-care system just missed statistical significance (p = 0.0585). Thirty-day postoperative mortality was comparable in the VA and private sector for very common operations but was higher in the VA for less common, more complex operations. CONCLUSIONS: In general surgery operations in men, the VA appeared to have a higher risk-adjusted mortality rate compared with the private sector, but differences in mortality ascertainment in the two sectors might account for some of this effect. The higher mortality in the VA could be the result of higher mortality in the less common, more complex operations. There is a trend toward lower risk-adjusted morbidity in the VA compared with the private sector.     

An assessment of different scoring systems in cirrhotic patients undergoing nontransplant surgery

BackgroundDetermining surgical risk in cirrhotic patients is difficult and multiple scoring systems have sought to quantify this risk. The purpose of our study was to assess the impact of Childs-Turcotte-Pugh (CTP), Model of End-Stage Liver Disease (MELD), and MELD-Sodium (MELD-Na) scores on postoperative morbidity and mortality for cirrhotic patients undergoing nontransplant surgery.MethodsWe performed a single-center retrospective review of all cirrhotic patients who underwent nontransplant surgery under general anesthesia over a 6-year period of time to analyze outcomes using the 3 scoring systems.ResultsSixty-four cirrhotic patients (mean age, 57 y; 62 men) underwent nontransplant surgery under general anesthesia. A CTP score of ≥7.5 was associated with an 8.3-fold increased risk of 30-day morbidity, a MELD score of ≥14.5 was associated with a 5.4-fold increased risk of 3-month mortality, and a MELD-Na score ≥14.5 was associated with a 4.5-fold increased risk of 1-year mortality. Emergent surgery, the presence of ascites, and low serum sodium level were associated significantly with morbidity and 1-year mortality.ConclusionsThe major strengths of the 3 scoring systems are for CTP in estimating 30-day morbidity, MELD for estimating 3-month mortality, and MELD-Na for estimating 1-year mortality.     

Synergistic effect of age and body mass index on mortality and morbidity in general surgery

Background

The elderly population (aged 65 y and older) is expected to be the dominant age group in the United States by 2030. In addition, the prevalence of obesity in the United States is growing exponentially. Obese elderly patients are increasingly undergoing elective or emergent general surgery. There are few, if any, studies highlighting the combined effect of age and body mass index (BMI) on surgical outcomes. We hypothesize that increasing age and BMI synergistically impact morbidity and mortality in general surgery.

Materials and methods

We collected individual-level, de-identified patient data from the Michigan Surgical Quality Collaborative. Subjects underwent general surgery with general anesthetic, were >18 y, and had a BMI between 19 and 60. Primary and secondary outcomes were 30-d “Any morbidity” and mortality (from wound, respiratory, genitourinary, central nervous system, and cardiac systems), respectively. Preoperative risk variables included diabetes, dialysis, steroid use, cardiac risk, wound classification, American Society of Anesthesiology class, emergent cases, and 13 other variables. We conducted binary logistic regression models for 30-d morbidity and mortality to determine independent effects of age, BMI, interaction between both age and BMI, and a saturated model for all independent variables.

Results

We identified 149,853 patients. The average age was 54.6 y, and the average BMI was 30.9. Overall 30-d mortality was 2%, and morbidity was 6.7%. Age was a positive predictor for mortality and morbidity, and BMI was negatively associated with mortality and not significantly associated with morbidity. Age combined with higher BMI was positively associated with morbidity and mortality when the higher age groups were analyzed. Saturated models revealed age and American Society of Anesthesiology class as highest predictors of poor outcomes.

Conclusions

Although BMI itself was not a major independent factor predicting 30-d major morbidity or mortality, the morbidly obese, elderly (>50 and 70 y, respectively) subgroup may have an increased morbidity and mortality after general surgery. This information, along with patient-specific factors and their comorbidities, may allow us to better take care of our patients perioperatively and better inform our patients about their risk of surgical procedures.     

Comparable Postoperative Morbidity and Mortality After Laparoscopic and Open Emergent Restorative Colectomy: Outcomes From the ACS NSQIP

Background

Laparoscopic surgery is safe and effective in the management of common abdominal emergencies. However, there is currently a lack of data about its use for emergency colorectal surgery. We hypothesized that laparoscopy can improve the postoperative outcomes of emergency restorative colon resection.

Methods

Adult patients undergoing emergent open and laparoscopic colon resection with primary anastomosis were retrieved from the American College of Surgeons National Surgical Quality Improvement Program database for the years 2005 to 2008 inclusive. Demographic and operative characteristics, laboratory values, and postoperative outcomes were compared between patients undergoing laparoscopic and open colon resection using univariate analyses, multivariate logistic regression, and propensity score analyses.

Results

A total of 341 laparoscopic (9.6?%) and 3211 (90.4?%) open colon resections were included. Patients undergoing laparoscopic surgery had a significantly lower prevalence of co-morbidities and better postoperative outcomes. On multivariate analysis, laparoscopic surgery was an independent predictor of a longer operating time (p?<?0.001) and shorter total (p?=?0.013) and postoperative (p?=?0.004) hospital stays, but it did not affect the need for intraoperative blood transfusion (p?=?0.488), the 30-day reoperation rates (p?=?0.969), or mortality (p?=?0.417). After adjusted propensity score analysis, postoperative morbidity (p?=?0.833) and mortality (p?=?0.568) were comparable in patients undergoing laparoscopic and open surgery.

Conclusions

On a national scale, laparoscopic emergent colon resections are being performed in a small number of patients, who have favorable co-morbidity characteristics and improved postoperative outcomes. Laparoscopic emergent colon resection with primary anastomosis has postoperative morbidity and mortality rates comparable to those seen with the open approach, and it reduces the total and postoperative length of hospital stay.     

Risk factors of abdominal surgery in patients with collagen diseases

Patients with collagen diseases have been reported to demonstrate a greater risk when undergoing surgical operations. To determine the risk factors in abdominal surgery for patients with collagen diseases, 32 patients with collagen diseases who underwent abdominal surgery were analyzed for their clinical features and surgical results by comparing 26 cases from the favorable prognosis group (Group A) and 6 cases resulting in hospital death (Group B). The analysis revealed that emergent operations tended to result in worse outcomes (P = 0.011) than elective operations and that cases undergoing operations for collagen disease-related problems, including intestinal perforation and acute pancreatitis, also showed a worse postoperative course than those who underwent operations for problems unrelated to collagen diseases, such as carcinomas and cholelithiasis (P = 0.0006). The dose of steroids administered at the time of operation was also significantly higher in Group B than in Group A (P = 0.03). These results suggested that the patients with collagen diseases should be followed periodically not only for the primary disease but also for any potential surgical diseases to identify such diseases at an early stage and to avoid an emergent operation, and that patients treated with high doses of steroids also need intensive care after abdominal surgery.     

Multidisciplinary day surgery unit: seven years' experience

The autonomous multidisciplinary day surgery unit is the gold standard for day surgery procedures. The Authors report their experience with the Pescina Hospital autonomous multidisciplinary day surgery unit (Avezzano Heath Authority, University of L'Aquila). In total, 4140 patients were enrolled to the day surgery setting from 2001 to 2007. Age, gender and ASA of patients, type of disease, surgery, anaesthesia and the usual day surgery activity quality indices (cancellation and delays of operations, postoperative pain and nausea or vomiting, postoperative morbidity, discharge and early readmission) were evaluated. 4046 patients underwent day surgery (orthopaedic 29.8%, general surgery 26.2%, ophthalmology 21.6%, vascular surgery 19.8%, miscellaneous 2.6%). Rates of cancelled and delayed operations were 2.3% and 2.4%, respectively. Local anaesthesia was performed in 54.3% of operations. None of the patients reported postoperative nausea and vomiting. Severe postoperative pain was present in 10% of cases. 77% of patients was discharged within four hours of surgery, and the others within six hours. Four patients (0.11%) were readmitted early. The postoperative morbidity and mortality rates were 0.49% and 0%, respectively. None of the postoperative events correlated with gender, age, ASA, or type of surgery and anaesthesia. The multidisciplinary day surgery unit, with dedicated medical and nursing staff and suitable organisation such as ours is characterised by favourable surgery activity quality indices and good patient outcomes.     

Do the risks of emergent colectomy justify nonoperative management strategies for recurrent diverticulitis?

Background

The nonoperative approach to recurrent and even multiple recurrent diverticulitis has recently been advocated. This approach, however, may result in more frequent acute attacks requiring emergent colectomy. Our aim was to compare the colectomy outcomes for diverticulitis in the elective and acute settings.

Methods

All patients with diverticulitis undergoing elective (EL) and emergent (EM) colectomy selected from the 2001 to 2002 Nationwide Inpatient Sample Database were analyzed and compared.

Results

Five thousand ninety-seven (27.1% emergent) colectomy cases were analyzed. EL patients had a significantly reduced length of stay (7.5 vs 13.3 days) and total hospital charges ($25,420 vs $51,170). Postsurgical morbidity and mortality were significantly higher in the EM group (29.0% vs 14.9% and 7.4% vs .8%, respectively). Colostomy was needed in 5.7% of EL and in 48.9% of EM patients (P = .001).

Conclusions

Emergent colectomy in the setting of diverticulitis is associated with significantly higher morbidity, longer hospitalization, greater hospital charges, and a 9-fold increase in mortality. Prophylactic resection in the setting of recurrent diverticulitis should continue to be an acceptable and possibly more “conservative” approach.     

Child-Turcotte-Pugh versus MELD score as a predictor of outcome after elective and emergent surgery in cirrhotic patients

BACKGROUND: Cirrhotic patients who present for elective and emergent surgery pose a formidable challenge for the surgeon because of the high reported morbidity and mortality. The Child-Turcotte-Pugh (CTP) score previously has been used to evaluate preoperative severity of liver dysfunction and to predict postoperative outcome. Recently, a more objective scoring classification, the model for end-stage liver disease (MELD), has been shown to predict accurately the 3-month mortality for cirrhotic patients awaiting transplantation. We sought to compare the CTP and MELD scores in predicting outcomes in cirrhotic patients undergoing surgical procedures requiring general anesthesia. METHODS: During the study period, 40 patients with a history of cirrhosis who required elective (E) or emergent (EM) surgical procedures under general anesthesia were reviewed (E = 24, EM = 16). The preoperative CTP and MELD scores were calculated and patient short- (30-day) and long-term (3-month) outcomes were recorded. RESULTS: There was a significant difference in the 1-month and 3-month mortality rates between the emergent and elective groups (EM group: 1 mo = 19%, 3 mo = 44%; E group: 1 mo = 17%, 3 mo = 21%, P <0.05). There was good correlation between the CP and MELD scores, which was greater in the emergent groups as compared with the elective group (EM: r = 0.81; E: r = 0.65). CONCLUSIONS: Our study shows that cirrhotic patients who undergo surgery under general anesthesia have an extremely high 1- and 3-month mortality rate that progressively increases with severity of preoperative liver dysfunction. Additionally, the MELD score correlates well with the CTP score, providing a more objective predictor of postoperative mortality in cirrhotic patients undergoing surgery.     

Does resident hours reduction have an impact on surgical outcomes?

BACKGROUND: We assessed the impact of restricting surgical resident work hours as required by the Accreditation Council for Graduate Medical Education (ACGME), on postoperative outcomes. MATERIALS AND METHODS: The divisions of General and Vascular Surgery at the Michael E. DeBakey Houston Veteran Affairs Medical Center implemented a limited work hours schedule effective October 1, 2002. We compared the rate of postoperative morbidity and mortality before and after the new schedule. Clinical data were collected by the VA National Surgical Quality Improvement Program (NSQIP) for the periods of October 1, 2001 to September 30, 2002 (preintervention), and October 1, 2002 to September 30, 2003 (postintervention). We assessed risk-adjusted observed to expected (O/E) ratios of mortality and prespecified postoperative morbidity for each study period. RESULTS: In the preintervention period, there were 405 general surgery and 202 vascular surgery cases as compared to 382 and 208 cases, respectively in the postintervention period. There were no significant differences in mortality O/E ratios between the pre- and postintervention periods (0.63 versus 0.60 in general surgery; 0.78 versus 0.81 in vascular surgery; P = 0.90 and 0.94, respectively) or in morbidity O/E ratios (1.06 versus 1.27 in general surgery; 1.47 versus 1.50 in vascular surgery; P = 0.20 and 0.90, respectively). CONCLUSION: The restricted resident work hour schedule in general and vascular surgery in our facility did not significantly affect postoperative outcomes.     

The effect of left internal mammary artery utilization on short-term outcomes after coronary revascularization

BACKGROUND: The purpose of this study was to determine whether use of the left internal mammary artery (LIMA) during coronary revascularization influences short-term morbidity in all patients undergoing revascularization, as well as in patients over the age of 75 years, female patients, and patients with diabetes. The study also explored variability in the utilization of LIMA grafts across an entire state. METHODS: Using the Clinical Outcomes Assessment Program (COAP) of the state of Washington, procedural outcomes were compared for patients receiving and patients not receiving LIMA grafts as part of revascularization procedures from January 1, 1999 to December 31, 2000. Mortality and major complications were examined, both as unadjusted rates and after adjusting for baseline patient risk factors. RESULTS: A total of 16 centers performed 8,797 nonemergent coronary artery revascularizations, including 81.7% with LIMA grafts. The use of a LIMA graft was associated with a significantly lower mortality (3.7% No LIMA vs 1.6% LIMA), as well as decreases in ventricular arrhythmias, need for postoperative dialysis, need for transfusions, ventilator dependence, and length of hospital stay. These trends were true for the population as a whole as well as for all subgroups analyzed, and they persisted after correcting for differences in comorbid conditions. In addition, there was wide variability in the use of LIMA grafts from center to center in the state. CONCLUSIONS: The use of LIMA grafts for coronary revascularization is associated with decreased mortality and morbidity. Despite these advantages, there is great variability in its application across the state of Washington.     

Cardiac surgery in octogenarians

BACKGROUND: Early and late results were studied in order to improve the indications for surgery in the elderly. METHODS: Two hundred and thirty-seven patients aged 80 years or older underwent cardiac surgery between 1987 and 2001. The mean age of patients, which included 148 men and 89 women, was 82 years. Elective operations were performed in 194 patients and urgent or emergency operations in 43. Coronary artery bypass grafting (CABG) was performed in 104 patients, valve surgery in 60, CABG plus valve in 58, and other surgery in 15. Late results were obtained in 91% of patients, and the mean follow-up period was 54 months. RESULTS: Operative mortality was 9% in total; 7% in CABG, 5% in valve, 10% in CABG plus valve. Operative mortality was significantly higher in the urgent/emergency group than in the elective group (25% vs 6%). The actuarial survival rate for hospital survivors at 60 months after surgery was 75% and the mean survival period 76 months. There were no significant differences among operations. Preoperatively 81% of the patients had been in New York Heart Association class III or IV, and 88% of survivors were in class I or II in the late period. CONCLUSIONS: Early and late results for elective surgery in octogenarians are satisfactory. However, for urgent or emergent cases, there is a marked increase in morbidity and mortality.     

After-hours urgent and emergent surgery in the elderly: outcomes and prognostic factors

Surgeons are becoming increasingly involved in the care of elderly patients. The purpose of this project was to evaluate contemporary outcomes of emergent surgeries performed after hours in elderly patients and to determine any risk factors for poor outcome. We retrospectively reviewed patients 80 years or older undergoing an urgent or emergent surgery at our medical center from 6 pm to 6 am from October 2006 through July 2009. Comparisons were made between survivors and nonsurvivors using Wilcoxon rank sum and Fisher exact test when indicated. P < 0.05 was considered significant. During the study period, 59 patients met inclusion criteria; the average age was 84 years (range, 80 to 102 years). A total of 70 procedures were performed; the most common were colectomy (18), small bowel resection (13), lysis of adhesions (9), and gastric surgery (8). The majority of patients were female (68%) with 47 per cent and 53 per cent of patients undergoing emergent and urgent surgery, respectively. Sixty-seven complications occurred in 38 patients; the morbidity rate was 64 per cent, and the mortality rate was 25 per cent. The only studied factors significantly associated with mortality were higher American Society of Anesthesiologists score (P = 0.004), increased intravenous fluids (P = 0.03), decreased intraoperative urine output (P = 0.03), and the need for intraoperative blood (P = 0.003). After-hours urgent and emergent surgery in the elderly has a high morbidity and mortality rate. We identified several risk factors for a poor prognosis that may be useful to the surgeon when discussing the patient's prognosis with the family.     

A population-based analysis of emergent versus elective paraesophageal hernia repair using the Nationwide Inpatient Sample

Background

As the life expectancy in the United States continues to increase, more elderly, sometimes frail patients present with sub-acute surgical conditions such as a symptomatic paraesophageal hernia (PEH). While the outcomes of PEH repair have improved largely due to the proliferation of laparoscopic surgery, there is still a defined rate of morbidity and mortality. We sought to characterize the outcomes of both elective and emergent PEH repair using a large population-based data set.

Methods

The Nationwide Inpatient Sample was queried for primary ICD-9 codes associated with PEH repair (years 2006–2008). Outcomes were in-hospital mortality and the occurrence of a pre-identified complication. Multivariate analysis was performed to determine the risk factors for complications and mortality following both elective and emergent PEH repair.

Results

A total of 8,462 records in the data, representing 41,723 patients in the US undergoing PEH repair in the study interval, were identified. Of these procedures, 74.2 % was elective and 42.4 % was laparoscopic. The overall complication and mortality rates were 20.8 and 1.1 %, respectively. Emergent repair was associated with a higher rate of morbidity (33.4 vs. 16.5 %, p < 0.001) and mortality (3.2 vs. 0.37 %, p < 0.001) than elective repair. Emergent repair patients were more likely to be male, were older, and more likely to be minority. Logistic modeling revealed that younger age, elective case status, and a laparoscopic approach were independently associated with a lower probability of complications and mortality.

Conclusions

Patients undergoing emergent PEH repair in the United States tend to be older, more likely a racial minority, and less likely to undergo laparoscopic repair. Elective repair, younger age, and a laparoscopic approach are associated with improved outcomes. Considering all of the above, we recommend that patients consider elective repair with a surgeon experienced in the laparoscopic approach, especially when symptoms related to the hernia are present.