Utility of computed tomography reconstructed thoracolumbar spinal imaging in blunt trauma.

OBJECTIVES: Fractures of the thoracolumbar (TL) spine are common and may cause neurologic damage, pain, and reduced quality of life. Computed tomography (CT) TL reconstructions from CT chest, abdomen, and pelvis (CAP) are used to identify TL fractures; however, their benefit over CAP imaging is unclear. We hypothesized that reformatted TL images do not identify additional clinically significant injuries or change outcomes. METHODS: Retrospective data were collected 2016 to 2021 from trauma patients at a level 1 trauma center. All patients 18 years or older with TL fractures on CT CAP with/without CT TL reformats were included. Clinically significant TL fractures were defined as requiring operative fixation, brace, or spinal rehabilitation. A binary classification model was created to assess the diagnostic utility of CTCAP compared with CTTL in predicting clinically significant fractures in patients who underwent CT CAP/TL. RESULTS: There were 828 patients with TL fractures, 634 had both CT CAP/CT TL (CAPTL) and 194 CTCAP only (CAP). There were 134 clinically significant TL fractures (16%) (14 [7.2%] CT CAP vs. 120 [18.9%] CT CAPTL, p < 0.001). There were no differences among unstable fractures, fractures on magnetic resonance imaging (MRI) only, mortality, or neurologic deficits on discharge between CAPTL and CAP ( p > 0.05). Among clinically significant fractures, CAPTL was not associated with increased MRI utilization, surgery, spinal brace, or spinal cord rehabilitation ( p > 0.05). Among clinically insignificant fractures, CAPTL was associated with increased MRIs, length of stay (LOS), and intensive care unit LOS ( p < 0.05). CAPTL was also an independent predictor of increased MRIs (odds ratio, 5.79; 95% confidence interval, 2.29-14.65; p < 0.01) and spine consultation (odds ratio, 2.39; 95% confidence interval, 1.64-3.67; p < 0.01). More CT CAP/TL were performed in those with clinically significant fractures; however, CTCAP was equivalent to CTTL for detection of fractures ( p > 0.05). CONCLUSION: CTCAP alone is sufficient to identify clinically significant TL fractures. While the addition of TL reformatted imaging minimizes missed injuries, it is associated with increased hospital LOS and MRI resource utilization. Therefore, careful consideration is needed for appropriate CT TL patient selection. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Prospective Evaluation of a Standardized Opioid Reduction Protocol after Anorectal Surgery.

BACKGROUND: Surgery for anorectal disease is thought to cause significant postoperative pain. Our previous work demonstrated that most opioids prescribed after anorectal surgery are not used. We aimed to evaluate a standardized protocol for pain control after anorectal surgery. METHODS: We prospectively evaluated a standardized opioid reduction protocol over a 13-mo period for all patients undergoing elective anorectal surgery at our institution. Protocol components include preoperative query, procedural local-anesthetic blocks, first-line nonopioid analgesic use ± opioid prescription of five pills, and standardized postoperative instructions. Patients completed questionnaires at postoperative follow-up. Patients with history of opioid abuse or use within 30 d of operation, loss to follow-up, or surgical complications were excluded. Primary outcome was quality of pain control on a five-point scale. Secondary outcomes included use of nonopioid analgesics, opioids used, and need for refill. RESULTS: A total of 55 patients were included. Mean age was 47 ± 17 y with 23 women (42%). Anorectal abscess/fistula procedures were the most common (69%) followed by pilonidal procedures (11%) and hemorrhoidectomy (7%). Most had general anesthesia (60%) with the remainder local anesthesia ± sedation. Fifty-four (98%) had procedural local-anesthetic blocks. Twenty-six patients (47%) were prescribed opioids with a median of five pills. Forty-seven patients (85%) reported the use of nonopioid analgesics. Forty-six patients (84%) reported excellent to very good pain control. About 220 opioid pills were prescribed, and 122 were reported to be used. One patient (2%) received an opioid refill. CONCLUSIONS: Satisfactory pain control after anorectal surgery can be achieved with multimodality therapy with little to no opioid use for most patients.

Transfusions in Children's Surgery: Characterization and Development of a Model for Benchmarking.

BACKGROUND: Perioperative blood transfusions in children are associated with patient morbidity and are often overutilized. In this study, we identify procedures most commonly associated with the use of red blood cells (RBC) in childrens surgery and develop risk-adjusted models for benchmarking. METHODS: Data from the 2012-2015 National Surgical Quality Improvement Program-Pediatric participant use data files were used. CPT (Current Procedural Terminology) codes were grouped to identify the procedures where transfusions were allocated and associated patient demographics and comorbidities. Patients were stratified in two age groups (0-3 mo and 3 mo to 18 y), and a logistic regression model was developed for each age group. RESULTS: Of 369,176 total cases, 21,410 (5.8%) were associated with a perioperative transfusion. 659 CPT codes were grouped in 207 clusters according to their similarities. The most common procedures associated with transfusion were arthrodesis for spinal deformity (n = 9533, 44.5%), followed by craniectomy for craniosynostosis (n = 1853, 8.7%). The logistic regression model for patients <3 mo included 18 variables and had excellent discriminatory performance (area under the curve 0.866). The model for patients ≥3 mo to 18 y had 21 variables and an area under the curve of 0.911. CONCLUSIONS: The majority of transfusions used in children's surgery are concentrated within a relatively few procedural groups. These findings can help centers in focusing blood optimization efforts on common surgeries with high transfusion rates. In addition, multiple preoperative factors have been built into a risk-adjusted model that can be used for benchmarking blood transfusions among hospitals.

The Effect of Nonoperative Management of Chronic Anal Fissure and Hemorrhoid Disease on Bowel Function Patient-Reported Outcomes.

BACKGROUND: Nonoperative management has been reported to decrease symptoms from common anorectal conditions such as chronic anal fissures and hemorrhoids. The effects of these interventions on bowel function are unknown. OBJECTIVE: This study aims to perform a prospective evaluation of patient-reported outcomes of bowel function on nonoperative management for chronic anal fissures and hemorrhoid disease. DESIGN: This is a prospective, observational study. SETTINGS: Patient-reported outcome measures were collected from the clinical practice of the division of colon and rectal surgery at a tertiary colon and rectal surgery referral center. INTERVENTION: All patients received standardized dietary counseling including fiber supplementation as well as toileting strategies. Those with chronic anal fissures were also prescribed topical calcium channel blockers. The Colorectal Functional Outcome questionnaire was administered at baseline and at first follow-up visit. MAIN OUTCOME MEASURES: The primary outcomes measured were the mean change in patient-reported bowel function scores after nonoperative management for each disease and in aggregate. RESULTS: A cohort of 64 patients was included, 37 patients (58%) with chronic anal fissure and 27 patients with hemorrhoid disease. Incontinence, social impact, stool-related aspects, and the global score were observed to have statistically significant improvement in the aggregate group. When analyzed by diagnosis, hemorrhoid disease demonstrated a statistically significant improvement in incontinence and stool-related aspects, whereas chronic anal fissure was associated with a statistically significant change in social impact, stool-related aspects, and the global score. LIMITATIONS: This study was limited by the small cohort size and unclear patient adherence to medical management. CONCLUSIONS: Nonoperative management of chronic anal fissures and hemorrhoid disease is associated with significant improvement in patient-reported outcome scores in several domains, suggesting that dietary counseling and medical therapy should be the first-line outpatient therapy for these diseases. See Video Abstract at http://links.lww.com/DCR/A726.

Patterns of opioid use and prescribing for outpatient anorectal operations.

BACKGROUND: Surgery for anorectal diseases is thought to cause significant pain postoperatively. There is little known regarding standardized opioid-prescribing trends and patient use following surgery for anorectal diseases. We aimed to evaluate and analyze opioid-prescribing trends and patient use for outpatient anorectal operations. MATERIALS AND METHODS: All patients who underwent outpatient anorectal surgery performed over a 1-y period at a single institution were eligible. Procedures included hemorrhoidectomy, anal fistula repair/seton, anal fissure treatment with sphincterotomy, and transanal excision of rectal tumors. Demographic, operative, and postoperative data were obtained. Patients were given a survey to determine postoperative pain control with opioid and non-narcotic analgesia use; respondents were included in analysis. RESULTS: Forty-two outpatient anorectal surgery patients were included: 13 had hemorrhoidectomy, 22 had anal fistula repair/seton, one had sphincterotomy, and six had transanal excisions. All patients had multimodality treatment with either an anal block and/or postoperative nonopioid analgesics. Ninety percent were prescribed opioids postoperatively with a median of 20 pills (range: 0-120 pills). Forty-three percent (18/42) did not fill their prescription. For those who used opioids, the median number of pills taken was four. Eighty percent of pills prescribed were not used. One patient required a refill. Greater than 60% of respondents reported good to excellent pain control on a five-point scale. CONCLUSIONS: Most patients had adequate pain control after anorectal surgery with little to no use of opioids and that more than 80% of opioid pills prescribed were not consumed. We intend to standardize our prescribing opioid quantities for outpatient anorectal operations to reflect this reduced use.

Safety of outpatient laparoscopic cholecystectomy in children: analysis of 2050 elective ACS NSQIP-pediatric cases.

PURPOSE: Limited data exists evaluating the extent of utilization and safety of outpatient laparoscopic cholecystectomy (LC) in children. The aim of this study was to investigate the safety of outpatient LC in the pediatric population utilizing a national surgical quality improvement database. METHODS: The National Surgical Quality Improvement Program-Pediatric (NSQIP-P) databases from 2012 and 2013 were queried to identify pediatric patients who underwent elective LC. Patients who underwent outpatient LC were compared with those who underwent inpatient LC. Outcomes of interest included 30-day overall morbidity, readmission, and reoperation. RESULTS: A total of 2,050 LC were identified, 995 (48.5 %) were performed as an outpatient procedure and 1055 (51.5 %) as inpatient. Patients who underwent outpatient LC were more often white (79.6 vs. 69.2 %; p = <0.0001). Choledocholithiasis was more often treated in inpatient setting (12.5 vs. 1.7 %; p < 0.0001), while biliary dyskinesia was performed in outpatient setting (26.1 v. 12.6 %; p = 0.0001). Overall 30-day morbidity was greater in the inpatient group (2.5 vs. 0.8 %; p = 0.03). There were no differences in term of 30-day readmission rate and related reoperations (0.9 vs 0.3 % respectively; p = 0.09). CONCLUSION: This analysis of a large multicenter dataset demonstrates that pediatric patients without significant associated comorbidities can safely undergo laparoscopic cholecystectomy as an outpatient procedure.

Regionalization of Pediatric Surgery: Trends Already Underway.

INTRODUCTION: This study aims to characterize the delivery of pediatric surgical care based on hospital volume stratified by disease severity, geography, and specialty. Longitudinal regionalization over the 10-year study period is noted and further explored. METHODS: The Kids' Inpatient Database (KID) was queried from 2000 to 2009 for patients <18 years undergoing noncardiac surgery. Hospitals nationwide were grouped into commutable regions and identified as high-volume centers (HVCs) if they had more than 1000 weighted procedures per year. Regions that had at least one HVC and one or more additional lower volume center were included for analysis. Low-risk, high-risk neonatal, and surgical subspecialties were analyzed separately. RESULTS: A total of 385,242 weighted pediatric surgical admissions in 33 geographical regions and 224 hospitals were analyzed. Overall, HVCs comprised 33 (14.7%) hospitals, medium-volume center (MVC) 33 (14.7%), and low-volume center (LVC) 158 (70.5%). The four low-risk procedures analyzed were increasingly regionalized: appendectomy (52% in HVCs in 2000 to 60% in 2009, P < 0.001), fracture reduction (63% to 68%, P < 0.001), cholecystectomy (54% to 63%, P < 0.001), and pyloromyotomy (65% to 85%, P < 0.001). Neonatal surgery showed significant regionalization trends for tracheoesophageal fistula (66% to 87%, P < 0.001) and gastroschisis (76% to 89%, P < 0.001). CONCLUSIONS: This is the first large-scale, multi-region analysis to demonstrate that pediatric surgical care has transitioned to HVCs over a recent decade, particularly for low-risk patients. It is important for practitioners and policymakers alike to understand such volume trends in order to ensure hospital capacity while maintaining an optimal quality of care.

Patient Satisfaction After Minimally Invasive Repair of Pectus Excavatum in Adults: Long-Term Results of Nuss Procedure in Adults.

BACKGROUND: Extensive literature has proved that the Nuss procedure leads to permanent remodeling of the chest wall in pediatric patients with pectus excavatum (PE). However, limited long-term follow-up data are available for adults. Herein, we report a single-institution experience in the management of adult PE with the Nuss procedure, evaluating long-term outcomes and overall patient satisfaction after bar removal. METHODS: Adult patients who underwent PE repair with a modified Nuss procedure between January 1998 and June 2011 were retrospectively identified. Outcomes of interest were postoperative pain, recurrence, and patient satisfaction. A modified single-step Nuss questionnaire was administered to evaluate patient satisfaction and quality-of-life improvement after PE repair. RESULTS: Ninety-eight patients with a median age of 30.9 years (range, 21.8 to 55.1 years) at the time of repair were identified. One bar was placed in most patients (89.7%). Four patients (4.1%) required reoperation for bar displacement. Results after bar removal were overall satisfactory in 94.4% of patients; 2 patients required reoperation for recurrence. Thirty-nine patients participated in the survey. Satisfaction with chest appearance was reported by 89.7% of responders. Seven patients reported dissatisfaction with the overall results; the most common complaints were severe postoperative chest pain and dissatisfaction with surgical scars. CONCLUSIONS: Favorable long-term results can be achieved with the Nuss procedure in adults. However, postoperative pain may require a more aggressive analgesic regimen, and it may be the overriding factor in the patient's perception of the quality of the postoperative course.