Early surgery for perforated appendicitis: Are we moving the needle on postoperative abscess?

BACKGROUND: Perforated appendicitis is often managed nonoperatively though upfront surgery is becoming more common. We describe postoperative outcomes for patients undergoing surgery at their index hospitalization for perforated appendicitis. METHODS: We used the 2016-2020 National Surgical Quality Improvement Program database to identify patients with appendicitis who underwent appendectomy or partial colectomy. The primary outcome was surgical site infection (SSI). RESULTS: 132,443 patients with appendicitis underwent immediate surgery. Of 14.1% patients with perforated appendicitis, 84.3% underwent laparoscopic appendectomy. Intra-abdominal abscess rates were lowest after laparoscopic appendectomy (9.4%). Open appendectomy (OR 5.14, 95% CI 4.06-6.51) and laparoscopic partial colectomy (OR 4.60, 95% CI 2.38-8.89) were associated with higher likelihoods of SSIs. CONCLUSIONS: Upfront surgical management of perforated appendicitis is now predominantly approached by laparoscopy, often without bowel resection. Postoperative complications occurred less frequently with laparoscopic appendectomy compared to other approaches. Laparoscopic appendectomy during the index hospitalization is an effective approach to perforated appendicitis.

Predictors of care discontinuity in geriatric trauma patients.

BACKGROUND: Readmission to a non-index hospital, or care discontinuity, has been shown to have worse outcomes among surgical patients. Little is known about its effect on geriatric trauma patients. Our goal was to determine predictors of care discontinuity and to evaluate its effect on mortality in this geriatric population. METHODS: This was a retrospective analysis of Medicare inpatient claims (2014-2015) of geriatric trauma patients. Care discontinuity was defined as readmission within 30 days to a non-index hospital. Demographic and clinical characteristics (including readmission diagnosis category) were collected. Multivariate logistic regression analysis was performed to identify predictors of care discontinuity and to assess its association with mortality. RESULTS: We included 754,313 geriatric trauma patients. Mean age was 82.13 years (SD, 0.50 years), 68% were male and 91% were White. There were 21,615 (2.87%) readmitted within 30 days of discharge. Of these, 34% were readmitted to a non-index hospital. Overall 30-day mortality after readmission was 25%. In unadjusted analysis, readmission to index hospitals was more likely to be due to surgical infection, GI complaints, or cardiac/vascular complaints. After adjusted analysis, predictors of care discontinuity included readmission diagnoses, patient- and hospital-level factors. Care discontinuity was not associated with mortality (OR, 0.93; 95% confidence interval, 0.86-1.01). CONCLUSION: More than a third of geriatric trauma patients are readmitted to a non-index hospital, which is driven by readmission diagnosis, travel time and hospital characteristics. However, unlike other surgical settings, this care discontinuity is not associated with increased mortality. Further work is needed to understand the reasons for this and to determine which standardized processes of care can benefit this population. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Gender and Racial/Ethnic Disparities in Operative Volumes of Graduating General Surgery Residents.

INTRODUCTION: Gender disparities in resident operative experience have been described; however, their etiology is poorly understood, and racial/ethnic disparities have not been explored. This study investigated the relationship between gender, race/ethnicity, and surgery resident case volumes. MATERIALS AND METHODS: A retrospective analysis of graduating general surgery resident case logs (2010-2020) at an academic medical center was performed. Self-reported gender and race/ethnicity data were collected from program records. Residents were categorized as underrepresented in medicine (URM) (Black, Hispanic, Native American) or non-URM (White, Asian). Associations between gender and URM status and major, chief, and teaching assistant (TA) mean case volumes were analyzed using t-tests. RESULTS: The cohort included 80 residents: 39 female (48.8%) and 17 URM (21.3%). Compared to male residents, female residents performed fewer TA cases (33 versus 47, P < 0.001). Compared to non-URM residents, URM residents graduated with fewer major (948 versus 1043, P = 0.008) and TA cases (32 versus 42, P = 0.038). Male URM residents performed fewer TA cases than male non-URM residents (32 versus 50, P = 0.031). Subanalysis stratified by graduation year demonstrated that from 2010 to 2015, female residents performed fewer chief (218 versus 248, P = 0.039) and TA cases (29 versus 50, P = 0.001) than male residents. However, from 2016 to 2020, when gender parity was achieved, no significant associations were observed between gender and case volumes. CONCLUSIONS: Female and URM residents perform fewer TA and major cases than male non-URM residents, which may contribute to reduced operative autonomy, confidence, and entrustment. Prioritizing gender and URM parity may help decrease case volume gaps among underrepresented residents.

The impact of the Affordable Care Act's medicaid expansion on patients admitted for burns: An analysis of national data.

INTRODUCTION: The first states began implementing the Medicaid expansion provisions of the Patient Protection and Affordable Care Act (ACA) in 2014. Studies have yet to address its impact on burn patients. METHODS: Burn patients in geographic regions that expanded Medicaid coverage were compared to patients in regions that did not expand Medicaid before and after implementation of the ACA using bivariate statistics and a difference-in-differences model. A multivariable logistic regression was used to identify factors associated with having Medicaid insurance. The primary outcome of this study was the rate of Medicaid insurance. RESULTS: Of 25,331 discharges, we found greater increases in Medicaid coverage after the ACA in the Medicaid expander regions (23.4-40.2%) compared to the non-expander regions (18.5-20.1%). The difference-in-differences estimate between the expander and non-expander regions was 0.15 (95% CI: 0.11-0.18, p < 0.001). Patients admitted in expander regions were more likely to be insured by Medicaid (OR 1.57 [95%CI 1.21-2.05]), as were patients of Black race (OR 1.25 [95%CI 1.19-1.32), Hispanic ethnicity (OR 1.29 [95%CI 1.14-1.46]), and female sex (OR 1.59 [95%CI 1.11-2.27]). We also found a significant interaction between time period (pre-ACA/post-ACA) and expander region location (OR 2.10 [95%CI 1.67-2.62]). CONCLUSIONS: The Medicaid expansion provision of the ACA led to increased Medicaid coverage among burn patients which was significantly higher in areas with widespread implementation of the expansion.

Outcomes of a low-osmolar water-soluble contrast pathway in small bowel obstruction.

BACKGROUND: Adhesive small-bowel obstruction (SBO) is a common surgical condition accounting for a significant proportion of acute surgical admissions and surgeries. The implementation of a high-osmolar water-soluble contrast challenge has repeatedly been shown to reduce hospital length of stay and possibly the need for surgery in SBO patients. The effect of low-osmolar water-soluble contrast challenge however, is unclear. The aim of this study is to evaluate the outcomes of an SBO pathway including a low-osmolar water-soluble contrast challenge. METHODS: A prospective cohort of patients admitted for SBO were placed on an evidence-based SBO pathway including low-osmolar water-soluble contrast between January 2017 and October 2018 and were compared with a historical cohort of patients prior to the implementation of the pathway from September 2013 through December 2014. The primary outcome was length of stay less than 4 days with a secondary outcome of failure of nonoperative management. RESULTS: There were 140 patients enrolled in the SBO pathway during the study period and 101 historic controls. The SBO pathway was independently associated with a length of stay less than 4 days (odds ratio, 1.76; 95% confidence interval, 1.03-3.00). Median length of stay for patients that were successfully managed nonoperatively was lower in the SBO pathway cohort compared with controls (3 days vs. 4 days, p = 0.04). Rates of readmission, surgery, and bowel resection were not significantly different between the two cohorts. CONCLUSION: Implementation of an SBO pathway using a low-osmolarity contrast is associated with decreased hospital length of stay. Rates of readmission, surgery, and need for bowel resection for those undergoing surgery were unchanged. An SBO pathway utilizing low-osmolarity water-soluble contrast is safe and effective in reducing length of stay in the nonoperative management of adhesive small-bowel obstructions. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Disparities in peptic ulcer disease: A nationwide study.

BACKGROUND: While advances in diagnosis and treatment of peptic ulcer disease have led to a decrease in hospital admissions the socioeconomic distribution of these benefits is unknown. METHODS: We designed a retrospective cohort study using the National Inpatient Sample from 2012 to 2013 including all patients that were admitted for peptic ulcer disease. We compared the types of ulcer related complications, the rates of intervention and the outcomes based on race and insurance status. RESULTS: Of 42,046 patients admitted for peptic ulcer disease 80.25% had an ulcer related complication. Black patients had the lowest rates of bleeding and highest rates of perforation and were less likely to undergo surgery for their complication but mortality was not different from white patients. Uninsured patients also had lower rates of bleeding and higher rates of perforation and they were at increased risk for death. CONCLUSIONS: Unlike other surgical conditions insurance status, not race, predicts mortality in peptic ulcer disease.

The independent effect of emergency general surgery on outcomes varies depending on case type: A NSQIP outcomes study.

BACKGROUND: Emergency general surgery (EGS) is an independent risk factor for morbidity and mortality, and seven procedures account for 80% of the National burden of operative EGS. We aimed to characterize the excess morbidity and mortality attributable to these procedures based on the level of procedural risk. METHODS: Retrospective analysis of the ACS National Surgical Quality Improvement Project (ACS-NSQIP) database. (2005-2014). Seven EGS procedures were stratified as high risk and low risk. Primary outcomes were overall mortality, overall morbidity, major morbidity. Multivariable logistic regression was performed. RESULTS: There were 619,174 patients identified. Comparing EGS to non-EGS in high-risk cases the OR for overall mortality was 1.39(1.33,1.45), overall morbidity 1.07 (0.98, 1.16), and major morbidity 1.15(1.03,1,27). In low-risk cases the OR for overall mortality was 1.03 (0.89, 1.19) overall morbidity 1.35 (1.23, 1.48), and major morbidity 2.18(1.90, 2.50). CONCLUSIONS: Using a Nationally representative clinical database we identified significant heterogeneity in the outcomes of EGS depending on procedural risk. Risk stratification and benchmarking strategies need to account for the inherent heterogeneity of EGS.

Hospital Factors Associated With Care Discontinuity Following Emergency General Surgery.

Importance: Although there is evidence that changes in clinicians during the continuum of care (care discontinuity) are associated with higher mortality and complications among surgical patients, little is known regarding the drivers of care discontinuity among emergency general surgery (EGS) patients. Objective: To identify hospital factors associated with care discontinuity among EGS patients. Design, Setting, and Participants: We performed a retrospective analysis of the 100% Medicare inpatient claims file, from January 1, 2008, to November 30, 2011, and matched patient details to hospital information in the 2011 American Hospital Association Annual Survey database. We selected patients aged 65 years and older who had the most common procedures associated with the previously defined American Association for the Surgery of Trauma EGS diagnosis categories and survived to hospital discharge across the United States. The current analysis was conducted from February 1, 2016, to March 24, 2016. Main Outcomes and Measures: Care discontinuity defined as readmission within 30 days to nonindex hospitals. Results: There were 109 443 EGS patients readmitted within 30 days of discharge and 20 396 (18.6%) were readmitted to nonindex hospitals. Of the readmitted patients, 61 340 (56%) were female. Care discontinuity was higher among patients who were male (19.5% vs 18.0%), those younger than 85 years old (19.0% vs 16.6%), and those who lived 12.8 km (8 miles) or more away from the index hospitals (23.7% vs 14.8%) (all P < .001). Care discontinuity was independently associated with mortality (adjusted odds ratio [aOR], 1.16; 95% CI, 1.08-1.25). Hospital factors associated with care discontinuity included bed size of 200 or more (aOR, 1.45; 95% CI, 1.36-1.54), safety-net status (aOR, 1.35; 95% CI, 1.27-1.43), and teaching status (aOR, 1.18; 95% CI, 1.09-1.28). Care discontinuity was significantly lower among designated trauma centers (aOR, 0.89; 95% CI, 0.83-0.94) and highest among hospitals in the Midwest (aOR, 1.15; 95% CI, 1.05-1.26). Conclusions and Relevance: Nearly 1 in 5 older EGS patients is readmitted to a hospital other than where their original procedure was performed. This care discontinuity is independently associated with mortality and is highest among EGS patients who are treated at large, teaching, safety-net hospitals. These data underscore the need for sustained efforts in increasing continuity of care among these hospitals and highlight the importance of accounting for these factors in risk-adjusted hospital comparisons.

Racial disparities in emergency general surgery: Do differences in outcomes persist among universally insured military patients?

BACKGROUND: Racial disparities in surgical care are well described. As many minority patients are also uninsured, increasing access to care is thought to be a viable solution to mitigate inequities. The objectives of this study were to determine whether racial disparities in 30-/90-/180- day outcomes exist within a universally insured population of military-/civilian-dependent emergency general surgery (EGS) patients and ascertain whether differences in outcomes differentially persist in care received at military versus civilian hospitals and among sponsors who are enlisted service members versus officers. It also considered longer-term outcomes of EGS care. METHODS: Five years (2006-2010) of TRICARE data, which provides insurance to active/reserve/retired members of the US Armed Services and dependents, were queried for adults (≥18 years) with primary EGS conditions, defined by the AAST. Risk-adjusted survival analyses assessed race-associated differences in mortality, major acute care surgery-related morbidity, and readmission at 30/90/180 days. Models accounted for clustering within hospitals and possible biases associated with missing race using reweighted estimating equations. Subanalyses considered restricted effects among operative interventions, EGS diagnostic categories, and effect modification related to rank and military- versus civilian-hospital care. RESULTS: A total of 101,011 patients were included: 73.5% white, 14.5% black, 4.4% Asian, and 7.7% other. Risk-adjusted survival analyses reported a lack of worse mortality and readmission outcomes among minority patients at 30, 90, and 180 days. Major morbidity was higher among black versus white patients (hazard ratio [95% confidence interval): 30 days, 1.23 [1.13-1.35]; 90 days, 1.18 [1.09-1.28]; and 180 days, 1.15 [1.07-1.24], a finding seemingly driven by appendiceal disorders (hazard ratio, 1.69-1.70). No other diagnostic categories were significant. Variations in military- versus civilian-managed care and in outcomes for families of enlisted service members versus officers altered associations, to some extent, between outcomes and race. CONCLUSIONS: While an imperfect proxy of interventions is directly applicable to the broader United States, the contrast between military observations and reported racial disparities among civilian EGS patients merits consideration. Apparent mitigation of disparities among military-/civilian-dependent patients provides an example for which we as a nation and collective of providers all need to strive. The data will help to inform policy within the Department of Defense and development of disparities interventions nationwide, attesting to important differences potentially related to insurance, access to care, and military culture and values. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

Evaluation of the Perceived Association Between Resident Turnover and the Outcomes of Patients Who Undergo Emergency General Surgery: Questioning the July Phenomenon.

IMPORTANCE: The influx of new surgical residents and interns at the beginning of the academic year is assumed to be associated with poor outcomes. Referred to as the July phenomenon, this occurrence has been anecdotally associated with increases in the frequency of medical errors due to intern inexperience. Studies in various surgical specialties provide conflicting results. OBJECTIVE: To determine whether an association between the July phenomenon and outcomes exists among a nationally representative sample of patients who underwent emergency general surgery (EGS). DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of data from the 2007-2011 Nationwide Inpatient Sample. Data on adult patients (≥16 years of age) presenting to teaching hospitals with a principal diagnosis of an EGS condition, as defined by the American Association for the Surgery of Trauma, were retrospectively analyzed. The patients who were included in our study were dichotomized into early (July-August) vs late (September-June) management. The original analyses were conducted in March 2015. MAIN OUTCOMES AND MEASURES: Risk-adjusted multivariable regression based on calculated propensity scores was assessed for associations with differences in in-hospital mortality, complications, length of stay, and total hospital cost. RESULTS: A total of 1,433,528 patients who underwent EGS were included, weighted to represent 7,095,045 patients from 581 teaching hospitals nationwide; 17.6% were managed early. Relative to patients managed later, early patients had marginally lower risk-adjusted odds of mortality (odds ratio [OR], 0.96 [95% CI, 0.92-0.99]), complications (OR, 0.98 [95% CI, 0.96-0.99]), and developing a secondary EGS condition (OR, 0.97 [95% CI, 0.97-0.98]). Length of stay and total hospital cost were comparable between the 2 groups (P > .05). CONCLUSIONS AND RELEVANCE: Contrary to expectations, the EGS patients who were managed early fared equally well, if not better, than the EGS patients who were managed later. Potentially attributable to increased manpower and/or hypervigilance on the part of supervising senior residents or attending physicians, the results suggest that concerns among EGS patients related to the July phenomenon are unfounded.

Wound healing trajectories in burn patients and their impact on mortality.

The rate of wound healing and its effect on mortality has not been well described. The objective of this article is to report wound healing trajectories in burn patients and analyze their effects on in-hospital mortality. The authors used software (WoundFlow) to depict burn wounds, surgical results, and healing progression at multiple time points throughout admission. Data for all patients admitted to the intensive care unit with ≥ 20% TBSA burned were collected retrospectively. The open wound size (OWS), which includes both unhealed burns and unhealed donor sites, was measured. We calculated the rate of wound closure (healing rate), which we defined as the change in OWS/time. We also determined the time delay (DAYS) from day of burn until day on which there was a reduction in OWS < 10%. Data are medians [interquartile range]. There were 38 patients with complete data; 25 had documentation of successful healing (H), and 13 did not (NH). H differed from NH on age (38 years [32-57] vs 63 [51-74]), body mass index (27 [21-28] vs 32 [19-52]), 24-hour fluid resuscitation (12 L [10-16] vs 18 [15-20]), pressors during first 48 hours (72% vs 100%), use of renal replacement therapy (32% vs 92%), and mortality (4% vs 100%). Repeated measures analysis of covariance showed a significant difference between survivors and nonsurvivors on OWS as a function of time (P<.001). Patients with a positive healing rate (+2%/day) after postburn day 20 had 100% survival whereas those with a negative healing rate (-2%/day) had 100% mortality. For H patients, median DAYS was 41 (28-54); median DAYS/TBSA was 1.3 (1.0-1.9). Survivors had a 0.62% drop in OWS/day, or 4.3%/week. In this cohort of patients with ≥ 20% TBSA, there was a difference in mortality after postburn day 20, between patients with a positive healing rate (+2%/day, 100% survival) and those with a negative healing rate (-2%/day, 100% mortality, P < .05).

Prevalence and impact of late defecation in the critically ill, thermally injured adult patient.

The aim of this study was to determine the prevalence of late defecation (absence of laxation for more than 6 days after admission) as an indicator of lower-gastrointestinal (GI) tract dysfunction in burn patients. In addition, the authors wanted to determine whether the addition of polyethylene glycol 3350 to the standard bowel regimen led to improvement in markers of lower-GI function and outcomes. The authors conducted a retrospective chart review of patients admitted to the burn intensive care unit during a 26-month period. Inclusion criteria were 20% or more TBSA burn, requirement for mechanical ventilation, and age over 18 years. Of 83 patients included, the prevalence of late defecation was 36.1% (n = 30). There was no association between late defecation and mortality. Patients with late defecation had more frequent episodes of constipation after first defecation (P =.03), of feeding intolerance (P =.007), and received total parenteral nutrition more frequently (P =.005). The addition of polyethylene glycol to the standard bowel regimen did not affect markers of lower-GI function. Late defecation occurs in more than one third of critically ill burn patients. Late defecation was associated with ongoing lower-GI dysfunction, feeding intolerance, and the use of total parenteral nutrition. The causal relationship between these problems has not been determined. A prospective study at the authors' institution is currently planned to attempt to validate late defecation as a marker of lower-GI tract dysfunction, determine its relationship to various outcomes, and determine risk factors for its development.

High risk but not always lethal: the effect of cirrhosis on thermally injured adults.

The aim of this article was to determine the effect of cirrhosis on mortality in thermally injured adult patients. We conducted a retrospective review of patients admitted to our burn center during 2003 to 2010. Eight hundred eight patients were included in this study, of whom 24 had the diagnosis of cirrhosis established from electronic medical records and/or autopsy reports. The mortality rate for the cirrhotic patients was 50%, and for the noncirrhotic patients it was 14.8%. On logistic regression, age (odds ratio [OR], 1.08; confidence interval [CI], 1.06-1.10), TBSA (OR, 1.08; CI, 1.06-1.10), inhalation injury (OR, 3.17, CI, 1.61-6.25), and cirrhosis (OR, 8.78; CI, 2.97-25.98) had independent effects on mortality. Of the 24 cirrhotic patients in this study, the admission Model for End-Stage Liver Disease score for the patients who survived hospitalization was 12.1 ± 4.0, and for the patients who died it was 13.8 ± 6.0 (P = .4). When comparing patients with 10 to 50% TBSA burn, the mortality rate for cirrhotic patients was 83.3% (10/12), and for the noncirrhotic patients it was only 12.7% (50/394), P < .0001. Adults with cirrhosis are rarely able to survive burn injuries > 10% TBSA. Although we did not detect a significant association between admission Model for End-Stage Liver Disease score and death, the presence of cirrhosis is a high premorbid contributor and, therefore, new strategies are needed to improve outcomes.

Risk factors for hypotension in urgently intubated burn patients.

BACKGROUND: When urgently intubating patient in the burn intensive care unit (BICU), various induction agents, including propofol, are utilized that may induce hemodynamic instability. METHODS: A retrospective review was performed of consecutive critically ill burn patients who underwent urgent endotracheal intubation in BICU. Basic burn-related demographic data, indication for intubation, and induction agents utilized were recorded. The primary outcomes of interest were clinically significant hypotension requiring immediate fluid resuscitation, initiation or escalation of vasopressors immediately after intubation. Secondary outcomes included ventilator days, stay length, and in-hospital mortality. RESULTS: Between January 2003 and August 2010, we identified 279 urgent intubations in 204 patients. Of these, the criteria for presumed sepsis were met in 60% (n=168) of the intubations. After intubation, 117 patients (42%) experienced clinically significant hypotension. Propofol (51%) was the most commonly utilized induction agent followed by etomidate (23%), ketamine (15%), and midazolam (11%). On multiple logistic regression, %TBSA (OR 1.016, 95% CI 1.004-1.027, p<0.001) and presumed sepsis (OR 1.852, 95% CI 1.100-3.117, p=0.02) were the only significant predictors of hypotension. None of the induction agents, including propofol, were significantly associated with hypotension in patients with or without presumed sepsis. CONCLUSIONS: In critically ill burn patients undergoing urgent endotracheal intubation, specific induction agents, including propofol, were not associated with clinically significant hypotension. Presumed sepsis and %TBSA were the most important risk factors.