The cost of obesity for nonbariatric inpatient operative procedures in the United States: national cost estimates obese versus nonobese patients.

OBJECTIVE: To evaluate the economic impact of obesity on hospital costs associated with the commonest nonbariatric, nonobstetrical surgical procedures. BACKGROUND: Health care costs and obesity are both rising. Nonsurgical costs associated with obesity are well documented but surgical costs are not. METHODS: National cost estimates were calculated from the Healthcare Cost and Utilization Project (HCUP) Nationwide Inpatient Sample (NIS) database, 2005-2009, for the highest volume nonbariatric nonobstetric procedures. Obesity was identified from the HCUP-NIS severity data file comorbidity index. Costs for obese patients were compared with those for nonobese patients. To control for medical complexity, each obese patient was matched one-to-one with a nonobese patient using age, sex, race, and 28 comorbid defined elements. RESULTS: Of 2,309,699 procedures, 439,8129 (19%) were successfully matched into 2 medically equal groups (obese vs nonobese). Adjusted total hospital costs incurred by obese patients were 3.7% higher with a significantly (P < 0.0001) higher per capita cost of $648 (95% confidence interval [CI]: $556-$736) compared with nonobese patients. Of the 2 major components of hospital costs, length of stay was significantly increased in obese patients (mean difference = 0.0253 days, 95% CI: 0.0225-0.0282) and resource utilization determined by costs per day were greater in obese patients due to an increased number of diagnostic and therapeutic procedures needed postoperatively (odds ratio [OR] = 0.94, 95% CI: 0.93-0.96). Postoperative complications were equivalent in both groups (OR = 0.97, 95% CI: 0.93-1.02). CONCLUSIONS: Annual national hospital expenditures for the largest volume surgical procedures is an estimated $160 million higher in obese than in a comparative group of nonobese patients.

Laparoscopic versus open anterior abdominal wall hernia repair: 30-day morbidity and mortality using the ACS-NSQIP database.

OBJECTIVE: To compare short-term outcomes after laparoscopic and open abdominal wall hernia repair. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2009), 71,054 patients who underwent an abdominal wall hernia repair were identified (17% laparoscopic, 83% open). Laparoscopic and open techniques were compared. Regression models and nonparametric 1:1 matching algorithms were used to minimize the influence of treatment selection bias. The association between surgical approach and risk-adjusted adverse event rates after abdominal wall hernia repair was determined. Subgroup analysis was performed between inpatient/outpatient surgery, strangulated/reducible, and initial/recurrent hernias as well as between umbilical, incisional and other ventral hernias. RESULTS: Patients undergoing laparoscopic repair were less likely to experience an overall morbidity (6.0% vs. 3.8%; odds ratio [OR], 0.62; 95% confidence interval [CI], 0.56-0.68) or a serious morbidity (2.5% vs. 1.6%; OR, 0.61; 95% CI, 0.52-0.71) compared to open repair. Analysis using multivariate adjustment and patient matching showed similar findings. Mortality rates were the same. Laparoscopically repaired strangulated and recurrent hernias, had a significantly lower overall morbidity (4.7% vs. 8.1%, P < 0.0001 and 4.1% vs. 12.2%, P < 0.0001, respectively). Significantly lower overall morbidity was also noted for the laparoscopic approach when the hernias were categorized into umbilical (1.9% vs. 3.0%, P = 0.009), ventral (3.9% vs. 6.3%, P < 0.0001), and incisional (4.3% vs. 9.1%, P < 0.0001). No differences were noted between laparoscopic and open repairs in patients undergoing outpatient surgery, when the hernias were reducible. CONCLUSION: Laparoscopic hernia repair is infrequently used and associated with lower 30-day morbidity, particularly when hernias are complicated.

Significant reduction of wound infections with daily probing of contaminated wounds: a prospective randomized clinical trial.

HYPOTHESIS: Local wound management using a simple wound-probing protocol (WPP) reduces surgical site infection (SSI) in contaminated wounds, with less postoperative pain, shorter hospital stay, and improved patient satisfaction. DESIGN: Prospective randomized clinical trial. SETTING: Academic medical center. PATIENTS: Adult patients undergoing open appendectomy for perforated appendicitis were enrolled from January 1, 2007, through December 31, 2009. INTERVENTIONS: Study patients were randomized to the control arm (loose wound closure with staples every 2 cm) or the WPP arm (loosely stapled closure with daily probing between staples with a cotton-tipped applicator until the wound is impenetrable). Intravenous antibiotic therapy was initiated preoperatively and continued until resolution of fever and normalization of the white blood cell count. Follow-up was at 2 weeks and at 3 months. OUTCOME MEASURES: Wound pain, SSI, length of hospital stay, other complications, and patient satisfaction. RESULTS: Seventy-six patients were enrolled (38 in the WPP arm and 38 in the control arm), and 49 (64%) completed the 3-month follow-up. The patients in the WPP arm had a significantly lower SSI rate (3% vs 19%; P = .03) and shorter hospital stays (5 vs 7 days; P = .049) with no increase in pain (P = .63). Other complications were similar (P = .63). On regression analysis, only WPP significantly affected SSI rates (P = .02). Age, wound length, body mass index, abdominal circumference, and diabetes mellitus had no effect on SSI. Patient satisfaction at 3 months was similar (P = .69). CONCLUSIONS: Surgical site infection in contaminated wounds can be dramatically reduced by a simple daily WPP. This technique is not painful and can shorten the hospital stay. Its positive effect is independent of age, diabetes, body mass index, abdominal girth, and wound length. We recommend wound probing for management of contaminated abdominal wounds.

Laparoscopic versus open appendectomy for the obese patient: a subset analysis from a prospective, randomized, double-blind study.

BACKGROUND: The clinical outcomes for patients randomized to either open or laparoscopic appendectomy are comparable. However, it is not known whether this is true in the subset of the adult population with higher body mass indexes (BMIs). This study aimed to compare the outcomes of open versus laparoscopic appendectomy in the obese population. METHODS: A subgroup analysis of a randomized, prospective, double-blind study was conducted at a county academic medical center. Of the 217 randomized patients, 37 had a BMI of 30 kg/m(2) or higher. Open surgery was performed for 14 and laparoscopic surgery for 23 of these patients. The primary outcome measures were the postoperative complication rates. The secondary outcomes were operative time, length of hospital stay, time to resumption of diet, narcotic requirements, and Medical Outcomes Survey Short Form 36 (SF-36) quality-of-life data. RESULTS: No differences in complications between the open and laparoscopic groups were found. Also, no significant differences were seen in any of the secondary outcomes except for a longer operative time among the obese patients. CONCLUSIONS: In this study, laparoscopic appendectomy did not show a benefit over the open approach for obese patients with appendicitis.

Acute respiratory distress syndrome in nontrauma surgical patients: a 6-year study.

BACKGROUND: Acute respiratory distress syndrome (ARDS) has been shown to increase morbidity but not mortality in trauma patients; however, little is known about the effects of ARDS in nontrauma surgical patients. The purpose of this study is to evaluate the risk factors for and outcomes of ARDS in nontrauma surgical patients. STUDY: A prospective observational study was performed in the surgical intensive care unit (ICU) of an academic tertiary care center. From 2000 to 2005, all nontrauma surgical admissions to the surgical ICU were evaluated daily for ARDS based on predefined diagnostic criteria. Logistic regression analysis identified independent predictors for ARDS and ICU mortality. RESULTS: Of 2,046 patient identified, 125 (6.1%) met criteria for ARDS. The incidence of ARDS declined annually from 12.2% to 2.1% during the study period (p < 0.001). ARDS patients were significantly older (55.4 years vs. 51.8 years, p = 0.014) and more likely to be obese (32% vs. 22%, p = 0.007) than the non-ARDS population. Independent predictors of ARDS included use of pressors (relative risk, RR = 3.30), sepsis (RR = 1.72), and body mass index >or=30 kg/m (RR = 1.57). Independent predictors of ICU mortality included ARDS (RR = 6.88), pressors (RR = 2.85), positive fluid balance (RR = 2.27), Acute Physiology and Chronic Health Evaluation II (RR = 1.04), and age (RR = 1.02). CONCLUSIONS: Unlike trauma patients, ARDS was an independent predictor of ICU mortality in nontrauma surgical patients, independent of age and disease severity. Nontrauma surgical patients who developed ARDS were older, sicker, and had a longer ICU stay. Independent predictors of ARDS included use of pressors, sepsis, and obesity.

Breast abscess bacteriologic features in the era of community-acquired methicillin-resistant Staphylococcus aureus epidemics.

HYPOTHESIS: Increasing rates of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infections have also affected the microbial profile of breast abscesses. OBJECTIVE: To update the decade-old bacteriologic description of breast abscesses to improve the choice of initial antibacterial drug therapy. DESIGN: Retrospective case series. SETTING: County hospital emergency department. PATIENTS: Forty-four women (mean age, 41 years; age range, 20-63 years) with breast abscesses. METHODS: All cultures from the breast abscesses of patients were reviewed. MAIN OUTCOME MEASURES: The microbiologic features and sensitivities of breast abscesses. RESULTS: Of 46 specimens only 28 showed bacterial yield (61%). Of these, 11 (39%) were polymicrobial, for an average of 1.4 isolates per specimen. The most common organism was S aureus, present in 12 of 37 aerobic cultures (32%), with MRSA in 7 (58%). The remaining organisms included coagulase-negative Staphylococcus (16%), diphtheroids (16%), Pseudomonas aeruginosa (8%), Proteus mirabilis (5%), and other isolates (22%). All MRSA was sensitive to clindamycin, trimethoprim-sulfamethoxazole, and linezolid. Only 2 patients (29%) were sensitive to levofloxacin. Two anaerobic cultures were positive for Propionibacterium acnes and Peptostreptococcus anaerobius. CONCLUSIONS: Staphylococcus aureus is the most common pathogenic organism in modern breast abscesses. Many breast abscesses have community-acquired MRSA, with more than 50% of all S aureus and 19% of all cultures being MRSA. This finding parallels the local and national increases in MRSA reported in other soft-tissue infections. With increasing bacterial resistance and more minimally invasive management of breast abscesses, understanding the current bacteriologic profile of these abscesses is essential to determining the correct empirical antibiotic drug therapy.

Impact of the 80-hour workweek on patient care at a level I trauma center.

HYPOTHESIS: The 80-hour workweek limitation for surgical residents is associated with an increase in mortality and complication rates among adult trauma surgical patients. DESIGN: Retrospective cohort study. SETTING: Academic level I trauma center. PATIENTS: Trauma patients admitted before and after the 80-hour workweek limitation. METHODS: We compared death and complication rates for adult trauma patients admitted during a 24-month period before (2001-2003) and a 24-month period after (2004-2006) implementation of the 80-hour workweek at our institution. Relative risk and its 95% confidence intervals were examined. MAIN OUTCOME MEASURES: Patient care outcomes included preventable and nonpreventable complications and deaths. RESULTS: The patient populations from the 2 time periods were clinically similar. No significant differences were found in the total and the preventable death rates. The time period after the 80-hour workweek mandate had a significantly higher total complication rate (5.64% vs 7.28%; relative risk, 1.29; 95% confidence interval, 1.15-1.45; P < .001), preventable complication rate (0.89% vs 1.28%; relative risk, 1.43; 95% confidence interval, 1.06-1.91; P = .02), and nonpreventable complication rate (4.75% vs 5.81%; relative risk, 1.22; 95% confidence interval, 1.08-1.39; P = .002). CONCLUSION: Although there was no difference in deaths between the 2 time periods, there was a significant increase in total, preventable, and nonpreventable complications. This increase in complication rate may be due, in part, to the new 80-hour workweek policy.

Early ductal decompression versus conservative management for gallstone pancreatitis with ampullary obstruction: a prospective randomized clinical trial.

OBJECTIVE: To compare the efficacy of endoscopic retrograde cholangiopancreatography +/- endoscopic sphincterotomy (ERCP +/- ES) versus traditional conservative management in early gallstone pancreatitis with persistent ampullary obstruction (GSP + AO). SUMMARY BACKGROUND DATA: The effectiveness of early ERCP +/- ES in this setting is controversial. METHODS: Sixty-one consecutive patients with GSP + AO within 48 hours from the onset of symptoms were randomized to receive either conservative treatment and selective ERCP +/- ES after 48 hours (control group, 31 patients) or initial conservative treatment and systematic ERCP +/- ES within 48 hours if obstruction persisted 24 hours or longer (study group, 30 patients). Patient outcome was compared in relation to treatment groups and to duration of obstruction. RESULTS: In the control group, 22 patients disobstructed spontaneously within 48 hours; 3 of the remaining 9 patients underwent ERCP +/- ES and none had impacted stones. In the study group, 16 patients disobstructed spontaneously and 14 underwent ERCP within 48 hours from the onset of symptoms; impacted stones were found and extracted by ES in 79% (11 of 14) of these. PATIENTS: There were no deaths in either group. Patients in the study group showed a shorter period of obstruction (P = 0.016) and a lower rate of immediate complications (P = 0.026) than controls. Patients with obstruction lasting < or =48 hours regardless of the treatment group had fewer immediate complications than those whose obstruction persisted longer (P < 0.001). CONCLUSIONS: This study shows that in patients with GSP + AO limiting the duration of obstruction to not longer than 48 hours by ERCP + ES decreased morbidity.

Use of serum bicarbonate measurement in place of arterial base deficit in the surgical intensive care unit.

HYPOTHESIS: Serum bicarbonate (HCO(3)) measurement may accurately and reliably be substituted for the arterial base deficit (BD) assay in the surgical intensive care unit (ICU). DESIGN: Retrospective criterion standard analysis. SETTING: Surgical ICU in a tertiary care facility. PATIENTS: Consecutive sample of non-trauma-related surgical ICU admissions from January 1996 to January 2004 with simultaneously obtained serum HCO(3) and arterial BD levels. MAIN OUTCOME MEASURES: Correlation between HCO(3) and BD at admission and during the ICU stay; predictive value of serum HCO(3) for significant metabolic acidosis and ICU mortality. RESULTS: The study included 2291 patients with 26 063 sets of paired laboratory data. The mean +/- SD age was 52 +/- 16 years and mean ICU stay was 5.8 +/- 9.8 days. There were 174 ICU deaths (8%). Serum HCO(3) levels showed significant correlation with arterial BD levels both at admission (r = 0.85, R(2) = 0.72, P<.001) and throughout the ICU stay (r = 0.88, R(2) = 0.77, P<.001). Serum HCO(3) reliably predicted the presence of significant metabolic acidosis (BD > 5) with an area under the receiver operating characteristic curve (AUC) of 0.93 at admission and 0.95 overall (both P<.001), outperforming pH (AUC, 0.80), anion gap (AUC, 0.70), and lactate (AUC, 0.70). The admission serum HCO(3) level predicted ICU mortality as accurately as the admission arterial BD (AUCs of 0.68 and 0.70, respectively) and more accurately than either admission pH or anion gap. CONCLUSIONS: Serum HCO(3) provides equivalent information to the arterial BD and may be used as an alternative predictive marker or guide to resuscitation. Low HCO(3) levels should prompt immediate metabolic acidosis evaluation and management.

Analysis of 185 iliac vessel injuries: risk factors and predictors of outcome.

HYPOTHESIS: Iliac vascular injuries incur high mortality. DESIGN: Retrospective 100-month study (January 1, 1992, through April 30, 2000). PATIENTS: One hundred forty-eight patients with 185 iliac vessel injuries. OUTCOME MEASURES: Survival and mortality, analyzed by univariate and logistic regression. RESULTS: Admission mean +/- SD systolic blood pressure was 81 +/- 42 mm Hg, mean Revised Trauma Score was 6.0 +/- 2.8, and mean Injury Severity Score was 20.0 +/- 9.5. The mechanism of injury was penetrating in 140 patients (95%) and blunt in 8 (5%). The mean estimated blood loss was 6246 +/- 6174 mL. Of the 185 injured vessels, 71 (99%) of 72 iliac arteries were repaired, 101 (89%) of 113 iliac veins were ligated, and 12 (11%) of 113 iliac veins were repaired. Overall survival was 51% (76/148). Mortality was 82% (49/72) in patients with exsanguination. Survival by vessel: iliac artery, 57% (20/35); iliac vein, 55% (42/76); and iliac artery and vein, 38% (14/37). Significant predictors of outcome were thoracotomy in the emergency department, associated aortic injury, inferior vena cava injuries, iliac artery and vein injury, intraoperative arrhythmia, and intraoperative coagulopathy. On logistic regression, independent risk factors for survival were absence of thoracotomy in the emergency department, surgical management, and arrhythmia. Mortality by grade on the Organ Injury Scale of the American Association for the Surgery of Trauma (AAST-OIS) was as follows: grade III, 35% (33/95); grade IV, 71% (24/34); and grade V, 79% (15/19). CONCLUSIONS: Mortality remains high. Associated vessel injuries and intraoperative complications predict mortality. AAST-OIS grade for abdominal vascular injuries correlates well with mortality.

Operative management and outcomes in 103 AAST-OIS grades IV and V complex hepatic injuries: trauma surgeons still need to operate, but angioembolization helps.

BACKGROUND: American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) grades IV and V complex hepatic injuries are highly lethal. Our objectives were to review experience and identify predictors of outcome and to evaluate the role of angioembolization in decreasing mortality. METHODS: This was a retrospective 8-year study of all patients sustaining AAST-OIS grades IV and V hepatic injuries managed operatively. Statistical analysis was performed using univariate and multivariate logistic regression. The main outcome measure was survival. RESULTS: The study included 103 patients, with a mean Revised Trauma Score of 5.61 +/- 2.55 and a mean Injury Severity Score of 33 +/- 9.5. Mechanism of injury was penetrating in 80 (79%) and blunt in 23 (21%). Emergency department thoracotomy was performed in 21 (25%). AAST grade IV injuries occurred in 51 (47%) and grade V injuries occurred in 52 (53%). Mean estimated blood loss was 9,414 mL. Overall survival was 43%. Adjusted overall survival rate after emergency department thoracotomy patients were excluded was 58%. Results stratified to AAST-OIS injury grade were as follows: grade IV, 32 of 51 (63%); grade V, 12 of 52 (23%); grade IV versus grade V (p < 0.001) odds ratio, 2.06; 95% confidence interval, 2.72 (1.40-3.04). Logistic regression analysis identified as independent predictors of outcome Revised Trauma Score (adjusted p < 0.0002), angioembolization (adjusted p < 0.0177), direct approach to hepatic veins (adjusted p < 0.0096), and packing (adjusted p < 0.0013). CONCLUSION: Improvements in mortality can be achieved with an appropriate operative approach. Angioembolization as an adjunct procedure decreases mortality in AAST-OIS grades IV and V hepatic injuries.

A prospective study on the safety and efficacy of angiographic embolization for pelvic and visceral injuries.

BACKGROUND: Angiographic embolization (AE) is used with increasing frequency as an alternative to surgery for control of intraperitoneal and retroperitoneal bleeding. There are no prospective studies on its efficacy, safety, and indications. PATIENTS: From April 1999 to June 2001, patients with abdominal visceral organ injuries or major pelvic fractures sent for AE were prospectively studied. Patients were transported to the angiography suite either because they were hemodynamically unstable ("emergent" angiography) or hemodynamically stable but had injuries likely to bleed ("preemptive" angiography). The efficacy of AE was derived from its ability to control bleeding radiographically and clinically; the safety of AE was determined by the complications related to transport, vascular access, catheter insertion, contrast administration, and tissue necrosis after interruption of blood supply to organs. Predictors of bleeding were identified by comparing patients who showed contrast extravasation on angiography with those who did not by univariate and multivariate analysis. RESULTS: Of 100 consecutive patients evaluated by angiography for bleeding from major pelvic fractures (n = 65) or solid visceral organ injuries (n = 35), 57 were found to have active contrast extravasation and were embolized, 23 were found to have indirect signs of vascular injury or ongoing hemodynamic instability and were embolized, and 20 had no signs of bleeding and were not embolized. AE was effective and safe in 95% and 94%, respectively, of 80 patients who were embolized. Four patients had recurrent bleeding after AE and five developed AE-related complications. In three of the four patients, bleeding was controlled by repeat AE. In all five patients, the complications were managed with no further sequelae. Three independent factors were predictive of bleeding identified on angiography: age older than 55 years, absence of long-bone fractures, and emergent angiography. The presence of all three independent predictors was associated with a 95% probability of bleeding; however, the probability of bleeding was still 18% when all three independent predictors were absent. CONCLUSION: AE is highly effective in controlling bleeding caused by abdominal and pelvic injuries and difficult to manage by surgery. Older age, the absence of long-bone fractures, and emergent angiography increase the likelihood of finding active bleeding angiographically. However, there are no clinical characteristics to exclude reliably all patients who are not actively bleeding internally. Because of this and its reasonable safety profile, AE should be offered liberally in patients with selected injuries of the pelvis and abdominal visceral organs.

Severe trauma is not an excuse for prolonged antibiotic prophylaxis.

HYPOTHESIS: For critically injured patients, a limited course of antibiotics is as effective as a prolonged course in preventing sepsis and organ failures. DESIGN: Prospective nonrandomized study. SETTING: Surgical intensive care unit (SICU) of an academic hospital with a level I trauma center. PATIENTS: A population of 250 trauma patients who required an operation and SICU stay of 3 days or more received antibiotic prophylaxis by 1 antibiotic for 24 hours (SHORT group, n = 133) or 1 or more antibiotics for more than 24 hours (LONG group, n = 117). MAIN OUTCOME MEASURES: Twenty-two outcome variables, including 9 conventional outcomes (eg, sepsis, septic shock, and organ failure) and 13 objective outcomes (days with temperature >38.5 degrees C, days with white blood cell count >14.0 x10(3)/microL, positive cultures, cultures with antibiotic-resistant bacteria, SICU and hospital stay, and death). RESULTS: The LONG group included more patients with orthopedic injuries (60 patients [51%] vs 52 [39%], P =.05) and orthopedic operations (47 patients [40%] vs 30 [23%], P =.003) than did the SHORT group. No other difference was identified in compared characteristics between the 2 groups. There was no difference in any of the examined outcomes except for a higher incidence of resistant infections in the LONG group compared with the SHORT group (59 patients [50%] vs 47 [35%], P =.02). Patients with resistant infections stayed in the hospital longer (mean +/- SD, 33 +/- 18 vs 15 +/- 11 days, P<.001) and had a higher mortality rate (13% vs 1%, P<.001) compared with patients without resistant infections. Prolonged prophylaxis by multiple antibiotics was an independent risk factor of resistant infection (odds ratio, 2.13, 95% confidence interval, 1.22-3.74; P =.008). CONCLUSIONS: The prophylactic administration of more than 1 antibiotic for more than 24 hours following severe trauma does not offer additional protection against sepsis, organ failure, and death, but increases the probability of antibiotic-resistant infections.

Visceral vascular injuries.

This article deals with injuries to the celiac trunk, superior and inferior mesenteric arterial injuires. Surgical approaches and physiological implications of interruption of the mesenteric arterial circulation are addressed in detail. Surgical techniques for the management of these injuries and the need for second look operations are also examined.

Influence of flail chest on outcome among patients with severe thoracic cage trauma.

Flail chest is associated with a higher morbidity compared with multiple rib fractures, and it requires early intubation. This was a prospective comparative uncontrolled study at an academic level 1 trauma center. Twenty-two patients with flail chest (FLAIL) were compared with 90 patients with more than two rib fractures but no flail chest (RIBS) to determine differences in outcomes such as mortality, significant respiratory complications (pneumonia and adult respiratory distress syndrome), need for mechanical ventilation, and length of hospital stay. Stepwise logistic regression identified independent risk factors of poor outcome. Despite similar age and rates of lung contusion and extrathoracic injury, FLAIL patients had a higher need for mechanical ventilation (86% versus 42%, P < 0.01), higher incidence of significant respiratory complications (64% versus 26%, P < 0.01), and longer hospital stay (28 +/- 21 versus 17 +/- 19 days, P = 0.04) compared with RIBS patients. Flail chest and extrathoracic injuries were independent risk factors of significant respiratory complications. Of 11 FLAIL patients who were not intubated on arrival, eight required intubation within the next 24 hours, often while receiving diagnostic studies in poorly monitored hospital areas; two of these patients suffered morbidity directly related to the delay in intubation. Three patients without associated injuries were managed successfully without intubation. Flail chest is an independent marker of poor outcome among patients with thoracic cage trauma. The majority of patients with flail chest need mechanical ventilatory support and develop significant respiratory complications. In the presence of associated injuries, intubation is unavoidable and should be done under controlled conditions early after arrival to avoid morbidity related to sudden respiratory decompensation.