Perioperative blood transfusion is associated with an increased risk for post-surgical infection following pancreaticoduodenectomy.

BACKGROUND/PURPOSE: Perioperative blood transfusion is common after pancreaticoduodenectomy (PD) and may predispose patients to infectious complications. The purpose of this study is to examine the association between perioperative blood transfusion and the development of post-surgical infection after PD. METHODS: Patients who underwent PD from 2014 to 2015 were identified in the NSQIP pancreas-specific database. Logistic regression analysis was used to compute adjusted odds ratios (aOR) to identify an independent association between perioperative red blood cell transfusion (within 72 h of surgery) and the development of post-operative infection after 72 h. RESULTS: A total of 6869 patients underwent PD during this time period. Of these, 1372 (20.0%) patients received a perioperative blood transfusion. Patients receiving transfusion had a higher rate of post-operative infection (34.7% vs 26.5%, p < 0.001). After adjusting for significant covariates, perioperative transfusion was independently associated the subsequent development of any post-operative infection (aOR 1.41 [1.23-1.62], p < 0.001), including pneumonia (aOR 2.01 [1.48-2.74], p < 0.001), sepsis (aOR 1.62 [1.29-2.04], p < 0.001), and septic shock (aOR 1.92 [1.38-2.68], p < 0.001). CONCLUSION: There is a strong independent association between perioperative blood transfusion and the development of subsequent post-operative infection following PD.

The outcome of trauma patients with do-not-resuscitate orders.

BACKGROUND: Institutional variation in outcome of patients with do-not-resuscitate (DNR) orders has not been well described in the setting of trauma. The purpose of this study was to assess the impact of trauma center designation on outcome of patients with DNR orders. MATERIALS AND METHODS: A statewide trauma database (Pennsylvania Trauma Outcome Study) was used for the analysis. Characteristics of patients with DNR orders were compared between state-designated level 1 and 2 trauma centers. Inhospital mortality and major complication rates were compared using hierarchical logistic regression models that included a random effect for trauma centers. We adjusted for a number of potential confounders and allowed for nonlinearity in injury severity score and age in these models. RESULTS: A total of 106,291 patients (14 level 1 and 11 level 2 trauma centers) were identified in the Pennsylvania Trauma Outcome Study database between 2007 and 2011. We included 5953 patients with DNR orders (5.6%). Although more severely injured patients with comorbid disease were made DNR in level 1 trauma centers, trauma center designation level was not a significant factor for inhospital mortality of patients with DNR orders (odds ratio, 1.33; 95% confidence interval, 0.81-2.18; P = 0.26). Level 1 trauma centers were significantly associated with a higher rate of major complications (odds ratio, 1.75; 95% confidence interval, 1.11-2.75; P = 0.016). CONCLUSIONS: Inhospital mortality of patients with DNR orders was not significantly associated with trauma designation level after adjusting for case mix. More aggressive treatment or other unknown factors may have resulted in a significantly higher complication rate at level 1 trauma centers.

Association of postoperative hyperglycemia with outcomes among patients with complex ventral hernia repair.

IMPORTANCE: Patients with medically complex conditions undergoing repair of large or recurrent hernia of the abdominal wall are at risk for early postoperative hyperglycemia, which may serve as an early warning for delays in recovery and for adverse outcomes. OBJECTIVE: To evaluate postoperative serum glucose level as a predictor of outcome after open ventral hernia repair in patients with major medical comorbidities. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective medical record review of 172 consecutive patients who underwent open ventral hernia repair at Penn State Milton S. Hershey Medical Center, an academic tertiary referral center, from May 1, 2011, through November 30, 2013. We initially identified patients by medical complexity and repair requiring a length of stay of longer than 1 day. MAIN OUTCOMES AND MEASURES: Postoperative recovery variables, including time to the first solid meal, length of stay, total costs of hospitalization, and surgical site occurrence. RESULTS: Postoperative serum glucose values were available for 136 patients (79.1%), with 130 (95.6%) obtained within 48 hours of surgery. Among these patients, Ventral Hernia Working Group grade distributions included 8 patients with grade 1, 79 with grade 2, 41 with grade 3, and 8 with grade 4. Fifty-four patients (39.7%) had a postoperative glucose level of at least 140 mg/dL, and 69 patients (50.7%) required insulin administration. Both outcomes were associated with delays in the interval to the first solid meal (glucose level, ≥140 vs <140 mg/dL: mean [SD] delay, 6.4 [5.3] vs 5.6 [8.2] days; P = .01; ≥2 insulin events vs <2: 6.5 [5.5] vs 5.4 [8.4] days; P = .02); increased length of stay (glucose level, ≥140 vs <140 mg/dL: mean [SD], 8.0 [6.0] vs 6.9 [8.2] days; P = .008; ≥2 insulin events vs <2: 8.3 [6.1] vs 6.5 [8.4] days; P < .001); increased costs of hospitalization (glucose level, ≥140 vs <140 mg/dL: mean [SD], $31 307 [$20 875] vs $22 508 [$22 531]; P < .001; ≥2 insulin events vs <2: $31 943 [$22 224] vs $20 651 [$20 917]; P < .001); and possibly increased likelihood of surgical site occurrence (glucose level, ≥140 vs <140 mg/dL: 37.5% [21 of 56 patients] vs 22.5% [18 of 80 patients]; P = .06; ≥2 insulin events vs <2: 36.4% [24 of 66 patients] vs 21.4% [15 of 70 patients]; P = .06). Not all patients with diabetes mellitus developed postoperative hyperglycemia or needed more intense insulin therapy; however, 46.4% of the patients who developed postoperative hyperglycemia were not previously known to have diabetes mellitus, although most had at least 1 clinical risk factor for a prediabetic condition. CONCLUSIONS AND RELEVANCE: Postoperative hyperglycemia was associated with outcomes in patients in this study who underwent complex ventral hernia repair and may serve as a suitable target for screening, benchmarking, and intervention in patient groups with major comorbidities.

Emphysematous gastritis and gastric emphysema: similar radiographic findings, distinct clinical entities.

INTRODUCTION: Despite similar appearances on imaging studies, emphysematous gastritis (EG) and gastric emphysema (GE) are rare clinical entities encountered in surgical practices. The purpose of this review is to clarify the presentation, natural history, and optimal treatment strategies for these two disorders. METHODS: We conducted a comprehensive literature review for reported adult cases of EG and GE in MEDLINE. Two cases from our institution were also included. Patient with demographics, diagnostic and therapeutic data, and outcomes were compared between patients with EG and GE. RESULTS: A total of 75 cases were included for our review. The finding of intramural air in the stomach was often associated with portal vein gas, pneumatosis intestinalis, or pneumoperitoneum in both groups. Surgical removal of the stomach was performed in 23.1% of EG patients, but only one patient in the GE group. In the EG group, overall mortality (55%) appeared to be driven by sepsis and its complications, whereas in the GE group, mortality (29%) was attributable to comorbid conditions and the underlying illness. CONCLUSIONS: Prompt surgical intervention is more commonly indicated for severe EG and is directed at removal of the septic organ, while the primary indication for surgical intervention in GE is the uncertainty of the diagnosis.

Gastric sleeve leak: a single institution's experience with early combined laparoendoscopic management.

BACKGROUND: Sleeve gastrectomy is an effective weight loss procedure that is technically less complex than Roux-en-Y gastric bypass. However, staple line leak (SLL) remains a significant complication of this procedure with reported incidence ranging from 1%-7%. Multiple treatment strategies for SLL are reported including surgical re-exploration, percutaneous drainage, and endoscopic stenting. Our objective was to review the results of our experience with combined laparoendoscopic procedures in managing SLL. METHODS: A retrospective review of patients with SLL after laparoscopic sleeve gastrectomy (LSG) between June 2008 and October 2013 was performed. Patient characteristics, operative details, and postoperative management strategies were reviewed. All patients were managed with a combination of early laparoscopic washout and endoscopic stenting. RESULTS: One hundred sixty-five patients underwent LSG with SLL identified in 4 patients (2.4%). One patient was transferred from an outside institution for SLL. Average time to SLL diagnosis was postoperative day 3 (range 1-7). After diagnosis patients underwent laparoscopic washout and initial endoscopic stenting. Three patients required additional endoscopic procedures to manage stent migration, and 2 required additional procedures for peri-stent leak. Complications were managed endoscopically with stent adjustment or replacement. Patients had indwelling stents for an average of 29 days (range 15-56). Mean hospital length of stay was 30 days (range 20-42). CONCLUSION: SLL after LSG can confer a high morbidity and mortality. Endoscopic management of SLL with stenting has been advocated because it successfully manages the leaks and avoids additional invasive procedures. Based on our experience, successful management of SLL can be achieved with an early combined laparoendoscopic approach.

A comparative study of three-year weight loss and outcomes after laparoscopic gastric bypass in patients with "yellow light" psychological clearance.

The relationship between psychological factors and bariatric surgical outcomes is unclear. While some psychological contraindications to bariatric surgery are described, there is no consensus on preoperative psychological evaluation or on factors that can predict bariatric outcomes. Our aim was to determine whether full or reserved psychological clearance predicts early weight loss or compliance with follow-up. We found no clinically significant differences in short-term weight loss outcomes or in attendance at scheduled follow-up visits between patients receiving full or "green light" clearance versus "yellow light" clearance, meaning clearance with recommendations for ongoing therapy. Further research may identify psychological predictors of success following bariatric surgery and help optimize preoperative evaluation practices.

Positive and negative volume-outcome relationships in the geriatric trauma population.

IMPORTANCE: In trauma populations, improvements in outcome are documented in institutions with higher case volumes. However, it is not known whether improved outcomes are attributable to the case volume within specific higher-risk groups, such as the elderly, or to the case volume among all trauma patients treated by an institution. OBJECTIVE: To test the hypothesis that outcomes of trauma care for geriatric patients are affected differently by the volume of geriatric cases and nongeriatric cases of an institution. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study using a statewide trauma registry was set in state-designated levels 1 and 2 trauma centers in Pennsylvania. It included 39 431 eligible geriatric trauma patients (aged >65 years) in the Pennsylvania Trauma Outcomes Study. MAIN OUTCOMES AND MEASURES: In-hospital mortality, major complications, and mortality after major complications (failure to rescue). RESULTS: Between 2001 and 2010, 39 431 geriatric trauma patients and 105 046 nongeriatric patients were captured in a review of outcomes in 20 state-designated levels 1 and 2 trauma centers. Larger volumes of geriatric trauma patients were significantly associated with lower odds of in-hospital mortality, major complications, and failure to rescue. In contrast, larger nongeriatric trauma volumes were significantly associated with higher odds of major complications in geriatric patients. CONCLUSIONS AND RELEVANCE: Higher rates of in-hospital mortality, major complications, and failure to rescue were associated with lower volumes of geriatric trauma care and paradoxically with higher volumes of trauma care for younger patients. These findings offer the possibility that outcomes might be improved with differentiated pathways of care for geriatric trauma patients.

Training current and future robotic surgeons simultaneously: initial experiences with safety and efficiency.

Robotic surgery is experiencing a rapidly-increasing presence in the field of general surgery. The adoption of any new technology carries the challenge of training current and future surgeons in a safe and effective manner. We report our experience with the initiation of a robotic general surgery program at an academic institution while simultaneously incorporating surgical trainees. The initial procedure performed was robotic-assisted cholecystectomy (RAC). Concurrent with the introduction of a robotic general surgical program, our institution implemented a progressive surgical trainee curriculum for all active residents and fellows. Immediately after being credentialed to perform RAC, attending surgeons began incorporating surgical trainees into robotic procedures. We retrospectively reviewed our first 50 RACs and compared them with our previous 50 standard laparoscopic cholecystectomies (SLC) to determine the impact of rapid integration of surgical trainees on developing technologies. Despite new technology and novice surgeons, there was no difference in mean operative time between the SLC and RAC groups (75.3 vs. 84.1 min, p = 0.077). Two patients in the robotic-assisted group required intraoperative conversion. Hospital length of stay was similar between groups, with the majority of patients leaving the same day. There were no postoperative complications in either group. A robotic general surgery program can be initiated while concurrently instructing surgical trainees on robotic surgery in a safe and efficient manner. We report our initial experience with the adoption of this rapidly advancing technology and describe our training model.

Variation in the management of adolescent patients with blunt abdominal solid organ injury between adult versus pediatric trauma centers: an analysis of a statewide trauma database.

BACKGROUND: Optimal management of adolescent trauma patients with blunt abdominal solid organ injury (SOI) remains controversial. The purpose of this study was to identify management differences in adolescents with SOI treated at adult trauma centers (ATC) versus pediatric trauma centers (PTC). We hypothesized that adolescents with SOI would undergo different treatment at ATC and PTC. MATERIALS AND METHODS: Retrospective review of the Pennsylvania Trauma Systems Foundation database from 2005-2010 was performed. Adolescent patients (13-18 y old) with SOI (spleen, liver, and kidney injury) were included. Patient baseline characteristics and care processes for each injury were compared between ATC and PTC. RESULTS: A total of 1532 patients with at least one SOI were identified: 946 patients had a splenic injury, 505 had a liver injury, and 424 had a kidney injury. Spleen and liver procedures were performed more often at ATC than at PTC irrespective of injury grade (respectively, 16.1% versus 3.2%, 5.9% versus 0%; P < 0.01). Transarterial embolization for splenic injury was more frequently performed at ATC (2.8% versus 0.6%; P = 0.02). After adjusting for potential confounding factors, care at PTC was significantly associated with lower odds of splenic procedure for patients with splenic injury (OR: 0.16, 95% CI: 0.08-0.36, P < 0.001). In a subgroup analysis of nontransfer patients, care at PTC remained significantly associated with lower odds of splenic procedure (OR: 0.24, 95% CI: 0.10-0.59, P = 0.002) despite higher median injury severity score than ATC. CONCLUSIONS: Significant differences in the management of adolescents with SOI were identified in Pennsylvania. Operative intervention for SOI was more often performed at ATC than at PTC. Further study will be needed to address the impact of these disparities on patient outcomes.

Injured adolescents, not just large children: difference in care and outcome between adult and pediatric trauma centers.

Adolescent injury victims receive care at adult trauma centers (ATCs) and pediatric trauma centers (PTCs). The purpose of this study was to identify care variations and their impact on the outcome of adolescent trauma patients treated at PTC versus ATC. We queried the Pennsylvania Trauma Systems Foundation database for trauma patients between 13 and 18 years of age from 2005 to 2010. Mortality and hospital complication rates between ATC and PTC were compared in univariable and multivariable analysis. In addition, the differences in the delivery of care were also compared. Of 9033 total patients, 6027 (67%) received care at an ATC. Patients in the ATC group were older (16.7 vs. 14.9 years, P < 0.001) and more severely injured (Injury Severity Score: 14.5 vs. 12.2, P < 0.001). Admission diagnostic computed tomography (CT), emergent laparotomy and craniotomy, blood transfusion, and drug screening were more frequently performed at an ATC. After adjustment for potential confounders in multivariable regression models, treatment at a PTC was significantly associated with fewer CTs for transferred patients (odds ratio [OR], 0.28; P < 0.001) and with less frequent emergent laparotomy for all patients (OR, 0.65; P = 0.007). The ATC group had a significantly higher hospital mortality rate (2.9 vs. 0.9%, P < 0.001) and complication rate (9.7 vs. 4.8%, P < 0.001). However, these outcomes were not significantly different between PTC and ATC in multivariable regression models. In the state of Pennsylvania, there were no significant differences in risk-adjusted outcomes between PTC and ATC despite significant difference in use of CT scanning and emergent laparotomy.