Simplified risk-prediction for benchmarking and quality improvement in emergency general surgery. Prospective, multicenter, observational cohort study.

BACKGROUND AND AIMS: Emergency General Surgery (EGS) conditions account for millions of deaths worldwide, yet it is practiced without benchmarking-based quality improvement programs. The aim of this observational, prospective, multicenter, nationwide study was to determine the best benchmark cutoff points in EGS, as a reference to guide improvement measures. METHODS: Over a 6-month period, 38 centers (5% of all public hospitals) attending EGS patients on a 24-h, 7-days a week basis, enrolled consecutive patients requiring an emergent/urgent surgical procedure. Patients were stratified into cohorts of low (i.e., expected morbidity risk <33%), middle and high risk using the novel m-LUCENTUM calculator. RESULTS: A total of 7258 patients were included; age (mean ± SD) was 51.1 ± 21.5 years, 43.2% were female. Benchmark cutoffs in the low-risk cohort (5639 patients, 77.7% of total) were: use of laparoscopy ≥40.9%, length of hospital stays ≤3 days, any complication within 30 days ≤ 17.7%, and 30-day mortality ≤1.1%. The variables with the greatest impact were septicemia on length of hospital stay (21 days; adjusted beta coefficient 16.8; 95% CI: 15.3 to 18.3; P < .001), and respiratory failure on mortality (risk-adjusted population attributable fraction 44.6%, 95% CI 29.6 to 59.6, P < .001). Use of laparoscopy (odds ratio 0.764, 95% CI 0.678 to 0.861; P < .001), and intraoperative blood loss (101-500 mL: odds ratio 2.699, 95% CI 2.152 to 3.380; P < .001; and 500-1000 mL: odds ratio 2.875, 95% CI 1.403 to 5.858; P = .013) were associated with increased morbidity. CONCLUSIONS: This study offers, for the first time, clinically-based benchmark values in EGS and identifies measures for improvement.

Use of the preoperative levels of CEA in patients with colorectal cancer.

BACKGROUND/AIMS: Preoperative carcinoembryonic antigen has been considered useful as a prognostic factor and recurrence indicator of colorectal neoplasms. However, its diagnostic ability related to some parameters such as resectability or tumor staging has been less studied. The aim of this study was to evaluate the use of this marker as a diagnostic test for these parameters of colorectal cancer. METHODOLOGY: In a sample of 283 patients operated on for colorectal carcinoma data were retrospectively recorded corresponding to preoperative carcinoembryonic antigen, type of surgery performed (curative vs. non-curative), tumor intramural spread, lymph node involvement, distant metastasis, TNM stage, tumoral differentiation, survival time and survival time free of disease. Bivariate analysis between carcinoembryonic antigen and the rest of the parameters was performed. Also, the sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy (efficiency) of the marker considered as a diagnostic test, were analyzed in relation to the tumoral resectability and tumoral spread. RESULTS: Preoperative level of serum carcinoembryonic antigen was statistically significantly associated with type of surgery performed (p < 0.001); tumoral intramural spread (p = 0.001); lymph node involvement (p < 0.001); presence of distant metastasis (p < 0.001); TNM staging (p < 0.001); overall survival period (p < 0.001) and disease-free survival time (p = 0.04). There was no relation between carcinoembryonic antigen and the degree of tumoral differentiation. The carcinoembryonic antigen's greatest sensitivity corresponded with the prediction for the type of the surgery performed and with the existence of distant metastasis, 80% and 70.9%, respectively. The negative predictive value was also high (> 90% in both cases). When considering the intramural spread, the specificity was 82% and its positive predictive value 93.1%. CONCLUSIONS: Preoperative levels of serum carcinoembryonic antigen, considered as a diagnostic test, are useful as predictors of resectability and tumor spread in colorectal carcinoma.

Anatomic characteristics of the infraorbital foramen: a cadaver study.

PURPOSE: The aim of this study was to document the variability in the position of the infraorbital foramen with relation to the facial midline, infraorbital rim, supraorbital notch, and maxillary teeth. MATERIALS AND METHODS: Forty-seven cadavers (94 sides) were dissected, exposing the infraorbital foramen, supraorbital foramen, and orbital floor bilaterally. Measurements made included (A) distance between the infraorbital foramen and inferior orbital rim; (B) distance of the infraorbital foramen from the facial midline; (C) distance of the supraorbital foramen from the facial midline; (D) distance between the infraorbital foramen and supraorbital foramen. Means, standard deviations, and ranges were determined, and statistical differences were calculated between the left and right orbits and sexes by use of an unpaired sample t-test (P < .05). RESULTS: In men, the mean distance between the infraorbital foramen and the inferior orbital rim was 8.5 +/- 2.2 mm. In women, this was 7.8 +/- 1.6 mm. The distance between the infraorbital foramen from the facial midline was 27.7 +/- 4.3 mm in males and 26.2 +/- 3.2 mm in females. The mean distance between the infraorbital foramen and supraorbital notch in males was 43.3 +/- 3.1 mm and in females was 42.2 +/- 2.4 mm. The average distance of the supraorbital notch from the midline was 26.5 +/- 3.5 mm in males and 26.3 +/- 3.3 mm in females. There were no statistically significant differences between the left and right sides or between sexes. The maxillary tooth most commonly found in the same vertical plane as the infraorbital foramen was the first premolar. Multiple ipsilateral foramina were found in 15% of cadavers. CONCLUSION: These anatomic characteristics may have important implications for surgical and local anesthetic planning.

Neurosensory deficit and functional impairment after sagittal ramus osteotomy: a long-term follow-up study.

PURPOSE: This study evaluated persistent neurosensory deficit (NSD) and functional sensory deficit (FSD) after mandibular bilateral sagittal split osteotomies (BSSO) and their association with patient age at time of operation and eight additional variables. PATIENTS AND METHODS: Eighty-five patients more than 2 years post-BSSO were identified and stratified by age: group 1, 10 to 19 years (n=16); group 2, 20 to 29 years (n=24); group 3, 30 to 39 years (n=30); group 4, older than 40 years (n=15). Mean mandibular advancement, incidence of "bad split," excessive intraoperative bleeding, nerve manipulation, removal of third molars, use of rigid fixation, simultaneous mandibular procedures, and associated systemic disease were documented for each group. A questionnaire modified from Zuniga was used to document the presence of persistent (2 years or longer) NSD and FSD. Statistical analysis was performed to determine differences between groups. Logistic regression was used to evaluate each variable and determine its association with persistent NSD and FSD. RESULTS: Persistent NSD by age was: group 1, 81%; group 2, 46%; group 3, 73%; group 4, 87%. The trend of increasing persistence with increasing age was not significant (P=.248). However, persistent FSD with increasing age was highly significant (P=.003). The incidence of FSD in group 4 was statistically greater than in the other groups (P < .001; P < .001; P=.004, respectively). Logistic regression identified patient age and "bad splits" as associated with FSD (P=.003; P=.015, respectively). CONCLUSIONS: The incidence of persistent FSD more than 2 years post-BSSO increases with increasing age in a predictable and highly significant manner. Presurgical counseling should address this issue. FSD is also significantly associated with "bad splits." No other variables were found to be significant.

Sensory abnormalities associated with mandibular fractures: incidence and natural history.

PURPOSE: The aims of this study were to determine the incidence of inferior alveolar nerve (IAN) abnormalities in patients with mandibular fractures and to document the natural history and spontaneous recovery rate in patients with a sensory disturbance. PATIENTS AND METHODS: This was a retrospective evaluation of patients (n = 150) with mandibular fractures at risk for IAN injury admitted to the Oral and Maxillofacial Surgery Service between 1985 and 1995. The inclusion criteria were: 1) fractures between the mandibular and mental foramina, 2) availability of the results of a post-injury, preoperative sensory examination, and 3) at least 1 year follow-up. Fracture characteristics, physical examination findings, hospital course, operative treatment, and follow-up were documented. Patient interviews were conducted to determine the incidence of long-term sensory disturbance and associated morbidity. The results were evaluated with chi-square analysis. RESULTS: Fifty-six percent of patients (84 of 150) had a post-injury/pretreatment IAN abnormality. Patients with sensory disturbance had a significantly higher frequency of displaced fractures than those without sensory disturbance (P < .001). Sixteen of 24 patients (66.7%) with an abnormal post-injury/ pretreatment sensory examination reported a permanent sensory deficit (mean follow-up, 74.3 months); 55% of these patients complained of impairment. CONCLUSIONS: The incidence of postinjury IAN deficits in patients with mandibular fractures was greater than 50% and was related to fracture displacement. One third of these patients regained normal sensation; the remaining two thirds reported a persistent sensory deficit. A significant number of these patients complained of discomfort and impairment after a mean follow-up of greater than 6 years.