Trends and disparities in access to minimally invasive distal pancreatectomy (midp): an eight-year analysis from the national cancer database.

Laparoscopic and robotic approaches to distal pancreatectomy are becoming the standard of care. The aim of our study was to evaluate the trends of utilization and disparities in access to minimally invasive approaches in distal pancreatectomy. We queried the National Cancer Database (NCDB) and analyzed all the patients who underwent distal pancreatectomy from 2010 to 2017. Patients were divided into groups of those with open distal pancreatectomy (ODP) and those with laparoscopic or robotic distal pancreatectomy (MIDP = minimally invasive distal pancreatectomy). Our outcome measures were trends of MIDP and disparities in access to MIDP. Cochran Armitage trend analysis and multivariate regression analysis were used to evaluate outcomes. A total of 13,537 patients with distal pancreatectomy were identified in the NCDB from 2010 to 2017. 7548 (55.8%) underwent ODP, while 5989 (44.2%) underwent MIDP. The MIDP rates increased from 25% in 2010 to 52% in 2017 (p < 0.01). On regression analysis, when controlled for age, gender, diagnosis, tumor size, grade, staging, and chemoradiotherapy, African American patients were 30% less likely to undergo MIDP than White (OR 0.7, 95% CI [0.5-0.8], p < 0.01). Similarly, Hispanic patients were 25% less likely to undergo MIDP than non-Hispanic patients OR 0.75, 95% CI [0.6-0.9], p = 0.02). Compared to Medicare/private insured patients, uninsured patients were 50% less likely to undergo MIDP (OR 0.5, 95% CI [0.4-0.7], p < 0.01). Based on the medium household income, compared to patients in the fourth quartile, patients in the third quartile OR 0.9, 95% CI [0.3-0.9], p = 0.03). Second OR 0.8, 95%CI [0.5-0.9], p < 0.01), first quartile OR 0.7, 95% CI [0.5-0.8], p < 0.01) were less likely to undergo MIPD as well. Utilization of MIDP has increased from one in every four patients in 2010 to every other patient in 2017. However, African Americans, Hispanics, the uninsured, and those from low-income quartiles are less likely to undergo MIDP. Efforts should be made to ensure access to minimally invasive approches are available to minorities.

Predicting the need for tracheostomy in trauma patients without severe head injury.

BACKGROUND: Early tracheostomy is recommended in patients with severe traumatic brain injury (TBI); however, predicting the timing of tracheostomy in trauma patients without severe TBI can be challenging. METHODS: A one year retrospective analysis of all trauma patients who were admitted to intensive Care Unit for > 7 days was performed, using the ACS-TQIP database. Univariate and Multivariate regression analyses were performed to assess the appropriate weight of each factor in determining the eventual need for early tracheostomy. RESULTS: A total of 21,663 trauma patients who met inclusion and exclusion criteria were identified. Overall, tracheostomy was performed in 18.3% of patients. On multivariate regression analysis age >70, flail chest, major operative intervention, ventilator days >5 days and underlying COPD were independently associated with need of tracheostomy. Based on these data, we developed a scoring system to predict risk for requiring tracheostomy. CONCLUSION: Age >70, presence of flail chest, need for major operative intervention, ventilator days >5 and underlying COPD are independent predictors of need for tracheostomy in trauma patients without severe TBI.

Day of Hospital Admission and Effect on Outcomes: The Weekend Effect in Acute Gallstone Pancreatitis.

BACKGROUND: The aim of our study was to evaluate outcomes in patients who are admitted on weekend compared with those admitted on a weekday for acute gallstone pancreatitis. METHODS: We performed a 3-y (2010-2012) analysis of the Nationwide Inpatient Sample database. Patients with acute gallstone pancreatitis who underwent endoscopic retrograde cholangiopancreatography (ERCP) were included and were divided into two groups: admission on the weekend versus the weekday. Primary outcome measures were time to ERCP, adverse events, and mortality. Secondary outcome measures were hospital length of stay and total cost. RESULTS: A total of 5803 patients with acute gallstone pancreatitis who underwent ERCP were included in our study; of which 22.6% were admitted on the weekend, whereas 77.4% were admitted on a weekday. Mean age was 57 ± 18 y and 57.1% were female. Within 24 h, the rate of ERCP was higher in patients admitted on the weekday compared with those admitted on the weekend (40% versus 24%; P < 0.001). Similarly, by 48 h, the rate of ERCP was higher in the weekday group (69% versus 49%, P < 0.001). Patients admitted over the weekends had higher complications rate (P = 0.03), hospital length of stay (P < 0.001), and the total cost of hospitalization (P < 0.001) compared with the weekday group with no difference in in-hospital mortality. CONCLUSIONS: Patients admitted on weekends for acute gallstone pancreatitis experience a delay in getting ERCP and have higher complications, prolonged hospital stay, and increased hospital costs compared with those admitted on weekdays.

3-Factor Versus 4-Factor PCC in Coagulopathy of Trauma: Four is Better Than Three.

INTRODUCTION: Coagulopathy of trauma (COT) is common and highly lethal. Prothrombin complex concentrate (PCC) has been advocated for correction of COT. However, the difference in efficacy between three-factor PCC (3-PCC) versus four-factor PCC (4-PCC) remains unclear. The aim of our study was to compare efficacy of 3-PCC versus 4-PCC in COT. METHODS: Five-year (2013-2017) review of coagulopathic trauma patients at our Level-I trauma center who received 3- or 4-PCC. Patients were divided into two groups (4-PCC and 3-PCC) and matched in 1:1 ratio using propensity-score-matching for demographics, injury parameters, admission vitals, and hematological parameters. Primary outcomes were time to correction of international normalized ratio (INR), blood products transfusion, thromboembolic complications, and mortality. Secondary outcomes were hospital-length of stay (LOS), intensive care unit (ICU)-LOS, cost of therapy, and total hospital cost. RESULTS: Six hundred fifty-seven patients met inclusion criteria of whom 250 patients (4-PCC:125; 3-PCC:125) were matched. The mean age was 50 ±â€Š19.4 y, 64% were male, and median-injury severity score was 24[15-33]. 4-PCC was associated with accelerated correction of INR (365 vs. 428 min, P = 0.01), decrease in red blood cells (7 units vs. 10 units, P = 0.04) and FFP (6 units vs. 8 units, P = 0.03) transfused. There was no difference in platelet transfusion, thromboembolic complications, mortality, hospital, and ICU-LOS. 4-PCC was associated with higher cost of PCC therapy, and lower cost of transfusion. There was no difference regarding the total hospital cost between the two groups. CONCLUSION: Compared with 3-factor PCC, the use of 4-factor PCC is associated with a rapid reversal of INR and reduction in transfusion requirement without increasing the overall hospital cost or the risk of thromboembolic events. 4-PCC may be preferred as an adjunct for the resuscitation of coagulopathic trauma patients.

The burden of excess length of stay in trauma patients.

BACKGROUND: Disposition of trauma patients frequently results in excessive hospital-stay. The aim of this study was to assess the risk of developing complications due to excessive stay in the hospital. METHODS: Over a period of 4 years (2012-2015) we analyzed all trauma patients with hospital length-of-stay (h-LOS) >30 days. Outcome measures were complications after termination of medical care. RESULTS: 416 patients were identified having h-LOS>30 days of which 61.0% (254) had an excess hospital stay and were included. The most common causes of excess hospital stay were placement in SNiF followed by placement in Inpatient-Rehabilitation. Excessive hospital-stay was independently associated with the development of complications (p = 0.004). Each excess day in the hospital after completion of medical care was associated with 5% higher odds of complications (OR [95%CI]: 1.05[1.02-1.09]) independent of presenting condition of the patient. CONCLUSION: Each extra day spent in the hospital after completion of medical care was associated with higher odds of developing complications.

Massive Transfusion: The Revised Assessment of Bleeding and Transfusion (RABT) Score.

BACKGROUND: Massive transfusion (MT) is a lifesaving treatment for trauma patients with hemorrhagic shock, assessed by Assessment of Blood Consumption (ABC) Score based on mechanism of injury, systolic blood pressure (SBP), tachycardia, and FAST exam. The aim of this study was to assess the performance of ABC score by replacing hypotension and tachycardia; with Shock Index (SI) > 1.0 and including pelvic fractures. METHODS: We performed a 2-year (2014-2015) analysis of all high-level trauma activations and excluded patients dead on arrival. The ABC score was calculated using the 4-point score [blunt (0)/penetrating trauma (1), HR ≥ 120 (1), SBP ≤ 90 mmHg (1), and FAST positive (1)]. The Revised Assessment of Bleeding and Transfusion (RABT) score also included 4 points, calculated by replacing HR and SBP with SI > 1.0 and including pelvic fracture. AUROC compared performances of the two scores. RESULTS: A total of 380 patients were included. The overall MT was 27%. Patients receiving MT had higher median ABC scores [1.1 (0-2) vs. 1 (0-2), p = 0.15] and RABT scores [2 (1-3) vs. 1 (0-2), p < 0.001]. The RABT score had better discriminative power (AUROC = 0.828) compared to ABC score (AUROC = 0.617) for predicting the need for MT. Cutoff of RABT score ≥ 2 had a sensitivity of 84% and specificity of 77% for predicting need for MT compared to ABC score with 39% sensitivity and 72% specificity. CONCLUSION: Replacement of hypotension and tachycardia with a SI > 1.0 and inclusion of pelvic fracture enhanced discrimination of ABC score for predicting the need for MT. The current ABC score would benefit from revision to more appropriately identify patients requiring MT.

Geriatric rescue after surgery (GRAS) score to predict failure-to-rescue in geriatric emergency general surgery patients.

BACKGROUND: Geriatric-patients(GP) undergoing emergency-general-surgery(EGS) are vulnerable to develop adverse-outcomes. Impact of patient-level-factors on Failure-to-Rescue(FTR) in EGS-GP remains unclear. Aim of our study was to determine factors associated with FTR(death from major-complication) and devise simple-bedside-score that predicts FTR in EGS-GP. METHODS: 3-year(2013-15) analysis of patients, age≥65y on acute-care-surgery-service and underwent EGS. Regression analysis used to analyze factors associated with FTR and natural-logarithm of significant odds-ratio used to calculate estimated-weights for each factor. Geriatric-Rescue-After-Surgery(GRAS)-score calculated for each-patient. AUROC used to assess model discrimination. RESULTS: 725 EGS-patients analyzed. 44.6%(n = 324) had major-complications. The FTR-rate was 11.5%. Overall-mortality rate was 15.3%. On regression, significant-factors with their estimated-weights were:Age≥80y(2), Chronic-Obstructive-Pulmonary-Disease(COPD)(1), Chronic-renal-failure(CRF)(2), Congestive-heart-failure(CHF)(1), Albumin<3.5(1) and ASA score>3(2). AUROC of score was 0.787. CONCLUSION: GRAS-score is first score based on preoperative assessment that can reliably predict FTR in EGS-GP. Preoperative identification of patients at increased-risk of FTR can help in risk-stratification and timely-mobilization of resources for successful rescue of these patients.