Use and Outcomes of Epidural Analgesia in Upper Gastrointestinal Tract Cancer Resections.

BACKGROUND: Epidural analgesia (EA) is an appealing adjunct for esophageal and gastric cancer patients. It remains unclear whether EA usage affects postoperative outcomes. There are no national data on the trends of EA utilization for these procedures. This study aims to use the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) to study the utilization and outcomes of EA in open upper GI tract cancer resections. MATERIALS AND METHODS: A retrospective review of NSQIP was performed for patients undergoing open elective esophagectomies and gastrectomies for nonmetastatic cancer between 2014 and 2017. An Armitage trend test was performed. The population was propensity matched and assessed. RESULTS: There were 4802 esophagectomies performed. Twenty-nine percent of patients received EA. Of 2599 gastrectomies, 18% of patients received EA. The recent trends of EA use for esophagectomies (EA range [26.9%, 30.3%] P = 0.6535) and gastrectomies (EA [16.9%, 18.4%], P = 0.7797) remain stable. Propensity matching was performed, and the groups with and without EA were compared. For esophagectomies, EA was associated with blood transfusions (EA 14% versus No EA 10.8%, P = 0.0156). For gastrectomies, EA was associated with longer length of stay (LOS) (EA median [IQR] 8 [7,11] versus No EA 7 [6,11], P = 0.0002). CONCLUSIONS: Despite the current opioid epidemic, the recent trends of EA for esophageal and gastric cancer patients remain stable. EA was associated with blood transfusions for esophagectomies and with a longer LOS for gastrectomies. Therefore, EA should be carefully considered, and its analgesic efficacy in this population should be investigated closely in future studies.

Fewer Levels of Dedicated Trauma Care Leads to Better Outcomes.

BACKGROUND: Dedicated trauma intensive care units (ICUs) staffed by surgical intensivists lead to better patient outcomes. Increased length of stay (LOS) leads to worse outcomes. Little research has focused on the effect of dedicated trauma medical-surgical units or ICU/medicalsurgical systems. In 2018, our Level 1 trauma center transitioned from 3 non-dedicated levels of care (ICU/stepdown unit/medical-surgical) to 2 dedicated levels of care (ICU/medical-surgical). Our objective was to look at patient outcomes pre- and post-intervention. METHODS: Retrospective analysis of trauma registry data was performed on patients (age ≥18) admitted to the trauma service at a Level 1 rural trauma center over 46-months. In the pre-intervention group, step down and medical-surgical patients were combined as "Non-ICU" for analysis. Standard statistical analysis was performed. RESULTS: Analysis included 6103 patients. The group demographics were similar, except pre-intervention patients had higher ISS and fewer comorbidities. Emergency department LOS decreased from 30 versus 13.9% (P < .0001) and 15.9 versus 5.8% (P < .0001) for greater than 3 and 6 hours, respectively. Median LOS decreased for all patients (P < .0001). Mortality dropped from 9.0 versus 5.5% (P = .0009) for ICU and 1.7 versus 0.26% (P = .0013) for non-ICU patients. Overall patient mortality was level at 3.7%. Inpatient complications dropped from 9.9 versus 8.5% (P = .07). Unplanned ICU readmissions were unchanged (P = .4169). For patients with 3+ comorbidities, overall LOS dropped by 2 days (P < .0001) and home discharge increased from 42.8 versus 51% (P < .0001). CONCLUSION: Implementation of 2 levels of dedicated care has decreased ED and hospital LOS for all trauma patients without increasing mortality or complications. Patients with extensive comorbidities saw the most improvements.

Should Surgical Services Admit Small Bowel Obstructions Managed Non-operatively?

INTRODUCTION: Over the past decade, small bowel obstructions (SBO) have been increasingly managed non-operatively. Prior studies have looked at outcomes based on admission to surgical services (SS) or medicine services (MS), but most are restricted to operative patients. This study evaluates the outcomes of non-operative patients specifically. METHODS: A 12-year retrospective cohort study of patients ≥18-years-old admitted with SBO within one healthcare system was performed. Only non-operative patients were included. Clinicodemographic characteristics and admission details were extracted from the electronic medical record. Statistical analysis was performed using the student's t-test, chi-square, and multivariable regression. RESULTS: A total of 3278 patients were included, of which 933(28.4%) patients were admitted to a SS. MS patients were older (57.7 vs 54.7 years, P < .001) and more likely to have diabetes (24.1 vs 20.2%, P = .015), CHF (5.7 vs 3.1%, P = .002), and AKI (29.8 vs 16.7%, P < .001). SS patients were more likely to have cancer (19.3 vs 13.7%, P < .001). Univariate analysis showed admission to SS decreased length of stay (3.4 vs 4.1 days, P < .001) and index admission mortality (0.1 vs 2.2%, P < .001). On multivariable analysis, admission to a SS decreased admission mortality (OR 0.056), 30-day mortality (OR 0.15), and 180-day mortality (OR 0.307). Similarly, 30-day readmissions (OR 0.683) and 180-day readmission (OR 0.54) were also significantly decreased. Length of stay was decreased by .6 days (P < .001). DISCUSSION: In patients with non-operative SBO, admission to a surgical service decreased length of stay, mortality, and readmission. Further work should be completed evaluating how increased comorbidities affect long term outcomes. However, significantly decreased length of stay and mortality continue to support surgical services admitting SBO patients.

Admitting Service and Outcome for Small Bowel Obstruction.

INTRODUCTION: Small bowel obstruction (SBO) is a common admission diagnosis. Prior research has shown improved length of stay and time to operation for SBO patients on surgical services (SS) compared to medical services (MS). This study evaluates the impact of admitting service on readmission and mortality. METHODS: A 12-year retrospective cohort study of patients ≥18 years old, admitted with SBO to either a MS or SS within one health care system was performed. Clinicodemographic characteristics and admission details were extracted and reviewed. Statistical analyses performed included the Student's t-test, chi-square, and multivariable regression. RESULTS: The study included 7921 patients, of which 3862 (48.8%) were admitted to a SS. No significant clinicodemographic differences existed between the groups except SS patients were more likely to have cancer (23.3% vs 15.2%, P < .0001) and to be within a 30-day post-operative period (9.4% vs 1.8%, P < .0001). On multivariable analysis, admission to a SS was associated with a decreased admission mortality (OR .70), 30-day mortality (OR .42), and 180-day mortality (OR .42). 30-day readmissions (OR .54) and 180-day readmission (OR .43) were also significantly decreased for SS patients. In patients requiring a procedure during admission, there was significantly decreased admission mortality (OR .684), 30-day mortality (OR .470), 180-day mortality (OR .431), 30-day readmission (OR .63), and 180-day readmission (OR .50). CONCLUSION: In patients with SBO, admission to a SS confers decreased odds of readmission and mortality compared to MS. Future studies are needed to understand the management decisions potentially underlying these differences. These findings may help better define admission pathways and improve outcomes.