When Is Intensive Care Unit Admission Needed After an Esophagectomy?

INTRODUCTION: Due to the high morbidity associated with esophagectomies, patients are often directly admitted to intensive care units (ICUs) for postoperative monitoring. However, critical complications can arise after this initial ICU stay. We hypothesized that the timing of ICU stay was not optimal for the care of patients after esophagectomy and aimed to determine when patients are at risk for developing critical complications. METHODS: We searched the National Safety and Quality Improvement Program for patients who underwent an esophagectomy between 2016 and 2021. The outcome of interest was the interval between surgery and first critical complication. A critical complication was defined as one likely to require intensive care, including respiratory failure, septic shock, etc. Multivariate regression was performed to identify the risks of complications. RESULTS: This study included 6813 patients from more than 70 institutions. Within the first 30 d postesophagectomy, 21.59% of patients experienced at least one critical complication. Half of first critical complications occurred after postoperative day 5, and 85.05% of them occurred after postoperative day 2. Risk factors for critical complications included age greater than 60 y, preoperative comorbidities, and open surgical approach. Malignancies were associated with a significantly lower incidence of critical complications. CONCLUSIONS: Critical complications occurred beyond the immediate postesophagectomy period. Therefore, low-risk patients undergoing minimally invasive esophagectomies can be safely monitored outside the ICU, allowing for better patient care and resource utilization.

Hospital readmission after blunt traumatic rib fractures.

BACKGROUND: Hospital readmissions are resource intensive, associated with increased morbidity, and often used as hospital-level quality indicators. The factors that determine hospital readmission after blunt thoracic trauma have not been sufficiently defined. We sought to identify predictors of hospital readmission in patients with traumatic rib fractures. METHODS: We performed an 8-year (2011-2019) retrospective chart review of patients with traumatic rib fractures who required unplanned readmission within 30 days of discharge at a Level 1 trauma center. Patient characteristics, injury severity, and hospital complications were examined using quantitative analysis to identify readmission risk factors. RESULTS: There were 13,046 trauma admissions during the study period. The traumatic rib fracture cohort consisted of 3,720 patients. The cohort included 206 patients who were readmitted within 30 days of discharge. The mean age of the traumatic rib fracture cohort was 57 years, with a 6-day median length of stay. The 30-day mortality rate was 5%. Use of anticoagulation (11.0 vs. 5.4; p = 0.029), diagnosis of a psychiatric disorder (10.2 vs. 5.3; p = 0.01), active smoking (7.3 vs. 5.0; p = 0.008), associated hemothorax (8.3 vs. 5.2; p = 0.010), higher abdominal Abbreviated Injury Scale (33.3 vs. 8.4 vs. 6.5; p = 0.002), rapid response activation (8.9 vs. 5.2; p = 0.005), admission to intensive care unit (7.7 vs. 4.5; p = 0.001), and diagnosis of in-hospital pneumonia (10.1 vs. 5.4; p = 0.022) were predictors of hospital readmission. On multivariate analysis, prescribed anticoagulation (odds ratio [OR], 2.22; p = 0.033), active smoking (OR, 1.58; p = 0.004), higher abdominal Abbreviated Injury Scale (OR, 1.50; p = 0.054), and diagnosis of a psychiatric disorder (OR, 2.00; p = 0.016) predicted hospital readmission. CONCLUSION: In patients with traumatic rib fractures, those with anticoagulant use, those who actively smoke, those with a psychiatric diagnosis, or those with associated abdominal injuries are at the highest risk of rehospitalization following discharge. Quality improvement should focus on strategies and protocols directed toward these groups to reduce nonelective readmissions. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Dependent functional status is a risk factor for complications after surgery for diverticulitis coli.

BACKGROUND: Functional dependence (FD) is associated with poor postoperative outcomes. We investigated the influence of FD on the postoperative outcomes of colectomy. METHODS: The 2012-2020 National Surgical Quality Improvement Program was queried for patients who had undergone colectomy for diverticulitis. The patients were analyzed based on FD or functionally independent (FI) status. RESULTS: Of the 62,409 patients 991 (1.6%) were FD. Compared to FI patients, those with FD were older (mean age, 72.7 vs. 59.1 years, p < 0.001), with higher comorbidities and more unplanned open procedures (79.7% vs. 38.0%, p < 0.001). After adjusting for American Society of Anesthesia status, age, and comorbidities, the FD patients were 1.12 times (95% CI:1.07-1.17) more likely to have postoperative morbidity and 1.53 times (95% CI: 1.2-1.82) more likely to have 30-day mortality. CONCLUSIONS: Dependent functional status is an independent risk factor for complications after surgery for diverticulitis.

Dependent status is a risk factor for complications after thyroidectomy.

BACKGROUND: Functional dependency has been associated with increased risk of adverse events following many surgical procedures. We hypothesized that dependent patients would have an increased risk of complications following thyroidectomy. METHODS: We performed a retrospective review of total thyroidectomies performed from 1/2012-12/2019 as identified by CPT codes using the National Surgical Quality Improvement Project (NSQIP) database. Functional dependent status was identified from within the NSQIP database with partially or totally dependent combined into the dependent group. RESULTS: A total of 64,978 patients were included, with 0.53% identified as functionally dependent (FD). Functional dependency was associated with an increased risk of wound disruption, pneumonia, UTI, stroke, cardiac arrest, PE/DVT, and sepsis/septic shock. Dependent patients had higher rates of unplanned intubation, ventilator use, and significant bleeding. On multivariate analysis, FD patients were more likely to suffer from major complications and have an increased length of stay. CONCLUSIONS: Dependent status was associated with an increased risk of complications following thyroidectomy. Focused preoperative and disposition planning for these patients can help to minimize adverse outcomes and optimize resource utilization.

Minimally invasive management of traumatic biliary fistula in the setting of gastric bypass.

The current management of persistent biliary fistula includes biliary stenting and peritoneal drainage. Endoscopic retrograde cholangiopancreatography (ERCP) is preferred over percutaneous techniques and surgery. However, in patients with modified gastric anatomy, ERCP may not be feasible without added morbidity. We describe a 37-year-old woman with traumatic biliary fistula, large volume choleperitonitis and abdominal compartment syndrome following a motor vehicle collision who was treated with laparoscopic drainage, lavage and biliary drain placement via percutaneous transhepatic cholangiography.

Do Lidocaine Patches Reduce Opioid Use in Acute Rib Fractures?

BACKGROUND: Pain control is an important aspect of rib fracture management. With a rise in multimodal care approaches, we hypothesized that transdermal lidocaine patches reduce opioid utilization in hospitalized patients with acute rib fractures not requiring continuous opioid infusion. METHODS: We performed a retrospective analysis of adult trauma patients with acute rib fractures admitted to the Trauma Service from January 2011 to October 2018. We compared patients who received transdermal lidocaine patches to those who did not and evaluated cumulative opioid consumption, expressed in morphine milligram equivalents (MMEs). Secondary outcomes included the rate of pulmonary complications and length of hospital stay. RESULTS: Of the 21 190 trauma admissions, 3927 (18.5%) had rib fractures. Overall, 1555 patients who received continuous opioid infusion were excluded. Of the remaining 2372 patients, 725 (30.6%) patients received lidocaine patches. The mean total MME of patients who received lidocaine patches was 55.7 MME (30.7 MME on multivariate analysis) and was lower than that of patients who did not receive lidocaine patches (P ≤ .01). There was no difference in hospital length of stay (no lidocaine patches vs received lidocaine patches: 6.2 days vs 6.5 days, P = .34) or pulmonary complications (1.7% vs 2.8%, P = .08). DISCUSSION: In admitted trauma patients with acute rib fractures not requiring continuous intravenous opiates, lidocaine patch use was associated with a significant decrease in opiate utilization during the patients' hospital course.

Are there variations in timing to tracheostomy in a tertiary academic medical center?

BACKGROUND: It is unclear what drives variation in timing to tracheostomy among different patients. METHODS: Age, ethnicity, admission service, and income were retrospectively collected for patients undergoing tracheostomy in a Level 1 trauma center from 2007 to 2017. The primary outcome was time to tracheostomy with early tracheostomy (ET) or late tracheotomy (LT) defined as 3-7 or ≥ 10 days post-intubation, respectively. Secondary outcomes included length of stay (LOS), ventilator associated pneumonia, and mortality. RESULTS: Among 1,640 patients, more men had ET compared to women (30% vs 28%; p = 0.05). The mean time to tracheostomy was 11.2 ± 7.7 days. Neurology and trauma patients had significantly shorter time to tracheostomy compared to other services. Age, ethnicity, and income showed no differences in timing to tracheostomy. Patients who underwent LT had a longer LOS (46 vs 32 days, p < 0.01) and higher mortality (19% vs 13% p < 0.01). CONCLUSIONS: There were no disparities in timing to tracheostomy based on age, ethnicity, or income. We detected a hesitation in performing tracheostomies by certain providers with shorter LOS and improved mortality in ET.

Streptococcus pyogenes peritonitis: a rare, lethal imitator of appendicitis.

Streptococcus pyogenes is a common cause of infection. Since 2010, the Centers for Disease Control has noted a 24% rise in invasive S. pyogenes infections with a mortality rate of 10%. We present a case series and review of the English literature. Two patients presented with findings concerning for appendicitis, each underwent laparoscopic appendectomies. Both had diffuse peritoneal inflammation without appendicitis, cultures grew S. pyogenes and both recovered with appropriate antibiotics. Thirty cases were identified in a review of the English literature. The average age was 27 years, 75% were in women, 9% were immunocompromised, 15% had rashes and 88% underwent surgical intervention. Previous work identified female gender, immunosuppression and preceding varicella infection as risk factors for invasive S. pyogenes. Given the similarities to appendicitis, early suspicion can influence antibiotic therapy and possibly improve outcomes.

Perceptions in rib injuries: A multidisciplinary single center survey of clinician differences in risk stratification and management of patients with rib fractures.

BACKGROUND: Although associated with significant morbidity, there is no universally accepted management of rib fractures. We hypothesized that variations in risk stratification may influence this. METHODS: A questionnaire was developed to assess providers' perceived risk factors and injury stratification of rib fracture patients at a Level 1 trauma center. RESULTS: There were 143 responses (36% physician response rate). Hypoxia, age, number of ribs fractured, pre-existing pulmonary disease, and flail chest were identified as the most important risk factors determining morbidity and mortality in blunt chest trauma. While clinicians agreed on predicted mortality for <2 fractured ribs, significant variation for 5-6 and >8 rib fractures was seen. EM and surgery providers significantly differed in assessment of injury severity. CONCLUSION: Providers identified common risk factors for increased morbidity and mortality. However, the difference in perceived severity between providers indicates a need for clinical tools to assist in better standardizing rib fracture management.

Impact of blunt pulmonary contusion in polytrauma patients with rib fractures.

BACKGROUND: We investigated the impact of blunt pulmonary contusion (BPC) in patients with rib fractures. METHODS: Adult patients with rib fractures caused by blunt mechanisms were enrolled over 3 years at a Level 1 trauma center. BPC was defined according to percentage of lung affected as: moderate (1-19% contusion) or severe (≥20% contusion). RESULTS: In total, 1448 of the 7238 admitted patients had rib fractures. Of these, 321 (22.2%) had BPC: 236 moderate and 85 severe. Patients with BPC were more likely to be admitted to the ICU (moderate: OR 1.55, 95% CI 1.10-2.19; severe: OR 2.74, 95% CI 1.41-5.32). Significantly increased rates of pneumonia (OR 2.52, 95% CI 1.43-4.90) and empyema (OR 4.80, 95% CI 1.07-21.54) were found for moderate and severe BPC, respectively. CONCLUSIONS: ICU admission and infectious pulmonary complications were more likely with BPC. The presence of BPC on admission CT is also prognostic of increased resource utilization.

Outcomes of preinjury anticoagulation in patients with traumatic rib fractures.

BACKGROUND: Anticoagulant and antiplatelet agents (ACAP) have been shown to negatively affect trauma patients. METHODS: Outcomes in adults with rib fractures were reviewed. Pearson chi-square test was used for analysis. Multivariate logistic regression was used to adjust for potential confounders. RESULTS: Of the 1448 included patients, 149 (10.3%) took preinjury ACAP; these patients were significantly older than non-anticoagulated patients (72 vs. 54 years, P ≤ 0.05). There was no difference in pulmonary complications, ICU admissions or ICU LOS. The preinjury ACAP group had a significantly longer LOS (12.03 vs. 9.33 days, P = 0.004), fewer pulmonary contusions (15.43% vs. 22.94%, P = 0.037), and fewer thoracic drainage procedures (10.74% vs. 18.17%, P = 0.023). Multivariate adjustment for possible confounders revealed that patients taking warfarin had a significantly longer LOS (+7.38 days). After adjustment there was no difference in mortality. CONCLUSION: Preinjury ACAP use does not increase mortality or morbidity in patients with rib fractures. SUMMARY: We demonstrated that preinjury anticoagulation and antiplatelet agents do not increase mortality or morbidity in patients with rib fractures. However, they lead to a longer hospital length of stay, particularly in patients on warfarin.

Vertical Plate for Flail Chest Repair.

Operative treatment of rib fractures in the context of flail chest and respiratory failure is a well-established approach. In-line rib osteosynthesis with plates is the standard treatment sufficient to eliminate flail, achieve sufficient stability, and create chest rigidity to improve the respiratory cycle and maintain reduction. However, bridging large skeletal defects with missing portion of ribs is very challenging, particularly in the absence of suitable anchoring rib fragments. We describe an unusual use of vertical plate rib osteosynthesis in a patient with traumatic flail chest, exacerbated by a prior thoracoplasty and severe osteoporosis.

Rescue Re-Do Inline Osteosynthesis with Wire Cerclage for Failed Rib Plating of Multilevel Rib Nonunion.

Rib nonunion is a rare occurrence that requires surgical management and has a high rate of failure that may necessitate repeated intervention. We present the case of successful rescue redo repair of previously failed plating of chronic nonunion for multilevel posterior rib fractures, reinforced by wire cerclage of the osteosynthesis plate. Our objective is to illustrate the feasibility of repeated interventions, and the technique to resolve this challenging problem.

New Protocol Avoiding Tube Feed Interruptions in Critically Ill Patients Requiring Tracheostomy.

Current anesthesia guidelines require tube feed (TF) interruption for at least four hours before tracheostomy. We hypothesized that preprocedural TF interruption is not required before tracheostomy. We developed a protocol allowing continued feeding. Fifty-six patients undergoing tracheostomy with or without percutaneous endoscopic gastrostomy placement were included. Eleven patients underwent tracheostomy without TF interruption (TF group); the remaining 45 patients had TFs held per the existing anesthesia protocol (nil per os group). Data were collected by retrospective chart review. The groups were similar with regard to age, sex, race, risk of mortality, and preoperative albumin levels (3.2 vs 2.9 g/dL). There was no difference in pulmonary complications. No intraoperative aspiration occurred in either group, and there was no increase in mortality in the TF group (9.1 vs 22.2%, P = 0.43). The TF group had feeds held for 9.5 ± 6.3 vs 25.4 ± 19.0 hours (P = 0.0018). The TF group had a decreased missed caloric intake [761.5 ± 566.6 vs 1983.5 ± 1590.8 kcal (P = 0.0039)]. The TF group had a shorter time from consultation [40.4 vs 50.6 hours (P = 0.54)] and case booking [7.9 vs 12.8 hours (P = 0.40)] to the OR. The average length of stay for the TF group was 26.3 versus 31.1 days (P = 0.45). There was no increase in pulmonary complications or mortality in the fed patients, who experienced less procedural delays. Meanwhile, patients kept nil per os sustained a substantial caloric deficit. Tracheostomy without TF interruption is feasible and reduces malnutrition.

Analgesic efficacy of laparoscopic-guided transverse abdominis plane block using liposomal bupivacaine in bariatric surgery.

BACKGROUND: Postoperative pain management is a major contributor to recovery and discharge in bariatric surgery. Local anesthetic agents are of particular interest: they're non-sedating and may reduce postoperative pain and hospital length of stay (LOS). DESIGN: Researchers queried the Bariatric Surgery Service Database for patients undergoing laparoscopic weight loss surgery from January 2012-December 2014. Patients were divided between those who did and did not receive liposomal bupivacaine intra-operatively. Measures included demographics, narcotic use, LOS, antiemetic use, and pain scales. RESULTS: The liposomal group consisted of 233 patients and the PCA group consisted of 243 patients. The liposomal group had significantly less narcotic use than the PCA group in terms of IV morphine equivalents. This did not translate into a reduction in LOS in the liposomal group. CONCLUSIONS: TAP block using liposomal bupivacaine provides effective analgesia comparable to PCA.

Increased Incidence of Surgical Site Infection in IBD Patients.

BACKGROUND: Surgical site infection is a key hospital-level patient safety indicator. All risk factors for surgical site infection are not always taken into account and adjusted for. OBJECTIVE: This study aimed to measure the impact of IBD in comparison with diverticulitis and colorectal cancer on the national rates of surgical site infection. DESIGN: The American College of Surgeons National Surgical Quality Improvement Project database was queried for all patients undergoing elective colectomy for colon cancer, diverticulitis, and IBD from 2008 through 2012. OUTCOME MEASURES: The association between surgical site infection and IBD patients was assessed. Patient demographics, rates of surgical site infection, wound class, return to operating room, and various patient characteristics were analyzed. Logistic regression was performed to determine the association with surgical site infection. RESULTS: The query yielded 71,845 patients undergoing elective colectomy. Of these patients, 42,132 had colon cancer, 22,143 had diverticulitis, and 7570 had IBD. The rate of surgical site infection was 12.0% for colon cancer, 12.8% for diverticulitis, and 18.0% for IBD. Return to operating room within 30 days was 7.3% for IBD patients, 4.4% for patients with diverticulitis, and 4.9% for patients with colorectal cancer. Return to operating room within 30 days had the highest correlation to surgical site infection in both univariate and multivariable analysis. Other associative factors for surgical site infection common to both analyses included diabetes mellitus, smoking, open procedures, and obesity. LIMITATIONS: This study was limited by the data collection errors inherent to large databases, exclusion of emergent operations, and the inability to identify patients taking immunosuppressive agents. CONCLUSIONS: Patients with IBD undergoing elective colectomy have significantly increased rates of surgical site infection, specifically deep and organ/space infections. Given this information, risk adjustment models for surgical site infection may need to include IBD in their calculation.

Open reduction and internal fixation of rib fractures in polytrauma patients with flail chest.

BACKGROUND: Open reduction and internal fixation (ORIF) of fractured ribs for flail chest is safe and effective but who is most likely to benefit is unknown. Our purpose is to compare ORIF with nonoperative management (NOM) in polytrauma patients. METHODS: Albany Medical Center Hospital Trauma Registry was queried for adult patients with flail chest admitted over 7 years. RESULTS: Eighty-six patients with radiographic flail chest were identified who met inclusion criteria. The 41 ORIF and 45 NOM patients had similar demographics and injury severity. Hospital length of stay and intensive care unit length of stay were significantly longer in the ORIF group than that of the NOM group. There was a trend toward longer time on the ventilator in the ORIF group. CONCLUSIONS: In this retrospective study, patients treated by ORIF had longer hospitalization and ventilator duration. Future studies should be designed to optimally identify patients who are most likely to benefit from ORIF.

Laparoscopic sigmoid colectomy for complicated diverticulitis is safe: review of 576 consecutive colectomies.

INTRODUCTION: Laparoscopic resection of diverticular disease is typically offered to selected patients. We present the outcomes of laparoscopic colectomy in consecutive patients suffering from either simple diverticulitis (SD) or complicated diverticulitis (CD). PURPOSE: To examine the outcomes of laparoscopic sigmoid colectomy for complicated diverticulitis. METHODS: Between December 2001 and May 2013, all patients with diverticulitis requiring elective operation were offered laparoscopic sigmoid colectomy as the initial approach. All cases were managed at a large tertiary care center on the colorectal surgery service. Preoperative, intraoperative, and postoperative variables were prospectively entered into the colorectal surgery service database (CRSD) and analyzed retrospectively. RESULTS: Of the 576 patients in the CRSD, 139 (24.1%) had CD. The overall conversion rate was 12.8% (n = 74). The average BMI was 29.8 kg/m(2). The conversion rate for CD was 12.2%. The return of bowel function time was delayed in the CD group when compared to the SD group (3.1 vs 3.8 days, p = 0.04). The hospital length of stay (HLOS) was similar between the groups (5.1 vs 5.8 days, p = 0.08). The overall anastomotic leak rate was 2.1% (n = 12). Patients undergoing laparoscopic resection for SD had a postoperative complication rate of 10.0% (n = 38), whereas those with CD had a postoperative morbidity rate of 19.6% (n = 24). CD patients who had conversion to an open procedure had an even higher rate of postoperative complications (29.4%, n = 5, p = 0.35). On non-parsimonious multivariate adjustment, only CD (RR 1.96, 95% CI 1.11-3.46, p = 0.02) was found to be an independent risk factor for the development of postoperative complications. CONCLUSIONS: Complicated diverticulitis did not affect the conversion rate to an open procedure. However, patients with CD are prone to postoperative complications. The laparoscopic approach to sigmoid colectomy is safe and preferable in experienced hands.