Efficient evaluation of center-level emergency surgery performance using a high-yield procedure set: A step towards an EGS registry.

BACKGROUND: Emergency general surgery (EGS) lacks mechanisms to compare performance between institutions. Focusing on higher-risk procedures may efficiently identify outliers. METHODS: EGS patients were identified from the 2016 State Inpatient Databases of Florida, New York, and Kentucky. Risk-adjusted mortality was calculated as an O:E ratio, generating expected mortality from a model including demographic and procedural factors. Outliers were centers whose 90% confidence intervals excluded 1. This was repeated in several subsets, to determine if these yielded outliers similar to the overall dataset. RESULTS: We identified 45,430 EGS patients. Overall, 3 high performing centers and 5 low performing centers were identified. Exclusion of appendectomies and cholecystectomies resulted in a remaining data set of 13,569 patients (29.9% of the overall data set), with 2 high performers and 5 low performers. One low performer in the limited data set was not identified in the overall set. CONCLUSION: Evaluation of 5 procedures, making up less than a third of EGS, identifies most outliers. A streamlined monitoring procedure may facilitate maintenance of an EGS registry.

Socio-economic disparity in risk of undergoing emergency laparotomy and postoperative mortality.

Aims: Socio-economic disparities in health and access to care are well documented, but socio-economic disparities in surgical care and outcomes have received less attention. The aim of the study was to determine if there are socio-economic disparities in the risk of undergoing emergency laparotomy and postoperative mortality in a universal health-care system with free and equal access to care. Methods: This was a nationwide case-control study including patients undergoing non-malignant emergency laparotomy involving resection, ostomy or open drainage between 2003 and 2014 and population references matched 1:1 on age and sex. Socio-economic disparities in one-year postoperative mortality were explored through a cohort study including all patients. Exposure measures were register-based household disposable income, educational level and employment status. Analyses were adjusted by age, sex, country of origin, marital status and co-morbidity. Results: A total of 11,962 cases and 11,962 population references were included. The highest odds ratios (OR) for undergoing surgery were found among those with the lowest income (OR=1.51; 95% confidence interval (CI) 1.39-1.63), those with elementary school education (OR=1.33; 95% CI 1.22-1.46) and those on early-retirement pension (OR=3.49; 95% CI 3.07-3.98). One-year postoperative mortality was highest among those with lowest income (hazard ratio (HR)=1.51; 95% CI 1.35-1.69), those with elementary school education (HR=1.39; 95% CI 1.22-1.59) and those on early-retirement pension (HR=2.12; 95% CI 1.73-2.61). Conclusions: Socio-economic disparities in health exist in relation to non-malignant emergency laparotomies and still exist after adjustment for confounders, including co-morbidity, indicating that mechanisms other than differences in disease burden are involved. There is a substantial need for exploration of mechanisms and preventive measures.

Socioeconomic deprivation and mortality after emergency laparotomy: an observational epidemiological study.

BACKGROUND: Socioeconomic circumstances can influence access to healthcare, the standard of care provided, and a variety of outcomes. This study aimed to determine the association between crude and risk-adjusted 30-day mortality and socioeconomic group after emergency laparotomy, measure differences in meeting relevant perioperative standards of care, and investigate whether variation in hospital structure or process could explain any difference in mortality between socioeconomic groups. METHODS: This was an observational study of 58 790 patients, with data prospectively collected for the National Emergency Laparotomy Audit in 178 National Health Service hospitals in England between December 1, 2013 and November 31, 2016, linked with national administrative databases. The socioeconomic group was determined according to the Index of Multiple Deprivation quintile of each patient's usual place of residence. RESULTS: Overall, the crude 30-day mortality was 10.3%, with differences between the most-deprived (11.2%) and least-deprived (9.8%) quintiles (P<0.001). The more-deprived patients were more likely to have multiple comorbidities, were more acutely unwell at the time of surgery, and required a more-urgent surgery. After risk adjustment, the patients in the most-deprived quintile were at significantly higher risk of death compared with all other quintiles (adjusted odds ratio [95% confidence interval]: Q1 [most deprived]: reference; Q2: 0.83 [0.76-0.92]; Q3: 0.84 [0.76-0.92]; Q4: 0.87 [0.79-0.96]; Q5 [least deprived]: 0.77 [0.70-0.86]). We found no evidence that differences in hospital-level structure or patient-level performance in standards of care explained this association. CONCLUSIONS: More-deprived patients have higher crude and risk-adjusted 30-day mortality after emergency laparotomy, but this is not explained by differences in the standards of care recorded within the National Emergency Laparotomy Audit.

Outcomes following emergency laparotomy in Australian public hospitals.

BACKGROUND: International studies reporting outcomes following emergency laparotomies have consistently demonstrated wide inter-hospital variation and a 30-day mortality in excess of 10%. The UK then prioritized the funding of the National Emergency Laparotomy Audit. In a prospective Western Australian audit there was minimal inter-hospital variation and a 6.6% 30-day mortality. In the absence of any multi-hospital Australian data the aim of the present study was to compare national administrative data with that previously reported. METHODS: Data on emergency laparotomies performed in Australian public hospitals during 2013/2014 and 2014/2015 were extracted from admitted patient activity and costing data sets collated by the Independent Hospital Pricing Authority. The data sets, containing episode-level data relating to admitted acute and sub-acute care patients, included administrative, demographic and clinical information such as patient age, cost, length of stay, in-hospital mortality, diagnosis and surgical procedure details. RESULTS: Ninety-nine public hospitals undertaking at least 50 emergency laparotomies performed 20 388 procedures over the 2 years. The overall in-hospital mortality was 5.2%. There was a wide interstate and inter-hospital variation in risk-adjusted in-hospital mortality (4.8-6.6% and 0-9.3%, respectively), length of stay (12.5-16.8 days and 5.8-18.9 days, respectively) and intensive care unit admissions (24.5-40.2% and 0-75.7%, respectively). CONCLUSION: This data suggest the wide variation in outcomes and care process observed overseas exist in Australia. However, administrative data has considerable limitations and is not a substitute for high quality prospective data. Minimizing variations through prospective quality improvement processes will improve patient outcomes.

Risk assessment tools validated for patients undergoing emergency laparotomy: a systematic review.

Emergency laparotomies are performed commonly throughout the world, but one in six patients die within a month of surgery. Current international initiatives to reduce the considerable associated morbidity and mortality are founded upon delivering individualised perioperative care. However, while the identification of high-risk patients requires the routine assessment of individual risk, no method of doing so has been demonstrated to be practical and reliable across the commonly encountered spectrum of presentations, co-morbidities and operative procedures. A systematic review of Embase and Medline identified 20 validation studies assessing 25 risk assessment tools in patients undergoing emergency laparotomy. The most frequently studied general tools were APACHE II, ASA-PS and P-POSSUM. Comparative, quantitative analysis of tool performance was not feasible due to the heterogeneity of study design, poor reporting and infrequent within-study statistical comparison of tool performance. Reporting of calibration was notably absent in many prognostic tool validation studies. APACHE II demonstrated the most consistent discrimination of individual outcome across a variety of patient groups undergoing emergency laparotomy when used either preoperatively or postoperatively (area under the curve 0.76-0.98). While APACHE systems were designed for use in critical care, the ability of APACHE II to generate individual risk estimates from objective, exclusively preoperative data items may lead to better-informed shared decisions, triage and perioperative management of patients undergoing emergency laparotomy. Future endeavours should include the recalibration of APACHE II and P-POSSUM in contemporary cohorts, modifications to enable prediction of morbidity and assessment of the impact of adoption of these tools on clinical practice and patient outcomes.

Influence of early goal-directed therapy using arterial waveform analysis on major complications after high-risk abdominal surgery: study protocol for a multicenter randomized controlled superiority trial.

BACKGROUND: Early goal-directed therapy refers to the use of predefined hemodynamic goals to optimize tissue oxygen delivery in critically ill patients. Its application in high-risk abdominal surgery is, however, hindered by safety concerns and practical limitations of perioperative hemodynamic monitoring. Arterial waveform analysis provides an easy, minimally invasive alternative to conventional monitoring techniques, and could be valuable in early goal-directed strategies. We therefore investigate the effects of early goal-directed therapy using arterial waveform analysis on complications, quality of life and healthcare costs after high-risk abdominal surgery. METHODS/DESIGN: In this multicenter, randomized, controlled superiority trial, 542 patients scheduled for elective, high-risk abdominal surgery will be included. Patients are allocated to standard care (control group) or early goal-directed therapy (intervention group) using a randomization procedure stratified by center and type of surgery. In the control group, standard perioperative hemodynamic monitoring is applied. In the intervention group, early goal-directed therapy is added to standard care, based on continuous monitoring of cardiac output with arterial waveform analysis. A treatment algorithm is used as guidance for fluid and inotropic therapy to maintain cardiac output above a preset, age-dependent target value. The primary outcome measure is a combined endpoint of major complications in the first 30 days after the operation, including mortality. Secondary endpoints are length of stay in the hospital, length of stay in the intensive care or post-anesthesia care unit, the number of minor complications, quality of life, cost-effectiveness and one-year mortality and morbidity. DISCUSSION: Before the start of the study, hemodynamic optimization by early goal-directed therapy with arterial waveform analysis had only been investigated in small, single-center studies, including minor complications as primary endpoint. Moreover, these studies did not include quality of life, healthcare costs, and long-term outcome in their analysis. As a result, the definitive role of arterial waveform analysis in the perioperative hemodynamic assessment and care for high-risk surgical patients is unknown, which gave rise to the present trial. Patient inclusion started in May 2012 and is expected to end in 2016. TRIAL REGISTRATION: This trial was registered in the Dutch Trial Register (registration number NTR3380) on 3 April 2012.

Insurance status predicts survival for trauma patients undergoing urgent intervention.

BACKGROUND: The purpose of this study was to investigate the relationship between insurance status and outcomes for trauma patients presenting without vital signs undergoing urgent intervention. MATERIALS AND METHODS: The National Trauma Data Bank was queried for patients presenting with a systolic blood pressure equal to zero and a Glasgow Coma Scale score of three ("clinically dead"), who underwent urgent thoracotomy and-or laparotomy (UTL). Insured patients were compared with uninsured (INS [-]) patients. RESULTS: There were 18,171 patients presenting clinically dead having a payment source documented. INS (-) patients were more likely to undergo UTL (5.4% [416-7704] versus 2.7% [285-10,467], 1.481 [1.390-1.577], <0.001). Out of 689 patients who underwent UTL and meeting inclusion criteria, 416 (60.4%) were INS (-). Patients with insurance demonstrated a significantly greater survival (9.9% [27-273] versus 1.7% [7-416], 5.878 [2.596-13.307] P < 0.001). Adjusting for mechanism, race, age, injury severity, and comorbidities, insured status was independently associated with survival. CONCLUSIONS: The presence of health insurance is independently associated with survival in trauma patients presenting with cardiovascular collapse who undergo urgent surgical intervention.

Emergency laparotomy in high risk general surgical patients: a review of perioperative care.

High risk general surgical patients account for the largest proportion of surgical deaths. There is concern from the Royal College of Surgeons of England (RCSEng) and National Confidential Enquiry into Patient Outcome and Death (NCEPOD) that these patients may receive suboptimal care. Patients undergoing an emergency laparotomy were identified and the notes reviewed; patients had high observed and predicted mortalities. Consultant involvement, patient consent and nutritional planning were all assessed. An agreed method of patient identification and quantification of risk was recommended. The use of an emergency laparotomy proforma was suggested.

Roux en Y gastric bypass by single-incision mini-laparotomy: outcomes in 3,300 consecutive patients.

BACKGROUND: Although the laparoscopic technique of Roux en Y gastric bypass (LRYGB) has popularized this weight loss procedure, the costs are justifiable if outcomes are superior to the open technique. We report our results with single-incision mini-laparotomy. METHODS: From June 2000 through November 2009, RYGB was performed in 3,300 consecutive patients using a 10-15-cm single-abdominal incision. Established guidelines for patient selection were followed and protocols were developed for patient education and for the prevention of perioperative complications. Weight loss (WL) over time and complications were recorded prospectively. Actual 90-day mortality was compared to that predicted by the Obesity Surgery Mortality Risk Score (OS-MRS). RESULTS: Eighty-four percent of patients were females with a mean body mass index (BMI) of 50 ± 13. BMI of males was 54 ± 9. There was a normal distribution of the WL response over 2,000 days. Complications included bleeding (1.4%), leak (1%), pulmonary embolism (0.7%), internal hernia (2.5%), and incisional hernia (5.6%). There were 1,793 Class A, 1,288 Class B, and 219 Class C patients. Eleven patients (0.3%) died within 90 days (one Class A, seven Class B, and three Class C), with mortality rates in all classes less than expected by the OS-MRS. Average hospital charges were $13,000. CONCLUSIONS: Our protocols and operative technique should be reproducible in other centers and may have a special appeal, if the costs of LRYGB limit access to bariatric surgery in qualified patients.

Preoperative risk stratification for mortality and major morbidity in major colorectal surgery.

INTRODUCTION: Risk stratification in major colorectal surgery, in general, has used preoperative, intraoperative, and postoperative variables, and has been used for purposes of comparative audit. To enable preoperative clinical use, this study aimed to stratify risk by use of preoperative risk factors only. METHODS: This is a single-institutional prospective observational study. RESULTS: There were 887 major colorectal procedures assessed. Independent risk factors for mortality were American Society of Anesthesiologists' physical status Grades III to V, age, high comorbidity count, and low surgeon case volume. For major morbidity, risk factors were American Society of Anesthesiologists' Grades III to V, urgent operation, and operation to excise the rectum. Overall, mortality was 4.51%, and major morbidity was 19.6%. The estimated risk of mortality was stratified by risk factor profile from 0.12% (95% CI, 0.02-0.93) to 42.4% (95% CI, 23.5-63.9). The risk of major morbidity was stratified from 7.22% (95% CI, 4.82-10.7) to 49.2% (95% CI, 34.2-64.4). Model discrimination was favorable to the existing risk adjustment models applied to our cohort. The Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (including Portsmouth and ColoRectal modifications), and Association of ColoProctology of Great Britain and Ireland Colorectal Cancer models (mortality: area under receiver operating characteristic (AU ROC) curves 0.87 compare 0.70-0.81, major morbidity: 0.69 compare 0.66)). CONCLUSIONS: Simple and readily available preoperative risk factors can achieve risk stratification. Risk stratification based on preoperative risk factors only possibly has comparable efficacy with those models that use preoperative, intraoperative, and postoperative risk factors.

Usefulness of multidetector computed tomography for the initial assessment of blunt abdominal trauma patients.

BACKGROUND: The prompt detection and accurate localization of abdominal injuries are difficult. Some diagnostic modalities, including laboratory tests, ultrasound, and diagnostic peritoneal lavage (DPL) were used to evaluate patients with blunt abdominal trauma, with various advantages and pitfalls. We aimed to evaluate the risk and benefit of using multidetector computed tomography (MDCT) as an initial assessment tool for proper diagnosis and treatment planning of patients with blunt abdominal trauma. METHODS: Two hundred fifty-two patients with blunt abdominal trauma were prospectively enrolled. Multidetector computed tomography was performed during resuscitation. The risk and benefit of using MDCT in the diagnosis and planning of treatment were analyzed. RESULTS: The time required for a MDCT examination averaged 10.2 minutes. Of the studies done, 224 revealed abdominal injuries. Of those, 34 were performed in patients with unstable hemodynamic status without adverse effect. Prompt diagnosis and proper treatment were given according to the MDCT findings. A total of 43 (17.1%) MDCTs showed contrast extravasation. Active bleeding was confirmed in all and treated with transarterial embolization (30) or surgery (13). Another 58 patients sustained bowel, mesenteric, or pancreatic injuries (BMPI) necessitating laparotomy. The sensitivity, specificity, and accuracy of MDCT in identifying patients with active bleeding or BMPI were all 100%. CONCLUSIONS: Multidetector computed tomography was useful as a second line initial assessment tool to identify injuries and determine treatment planning in blunt abdominal trauma patients. No increased risk was found if the facility is readily available, the protocol is well designed, and the patient is well prepared.

Outcomes in heart failure patients after major noncardiac surgery.

OBJECTIVES: The purpose of this study was to evaluate mortality and readmission rates of heart failure (HF) patients after major noncardiac surgery. BACKGROUND: There is a lack of generalizable outcome data on HF patients undergoing major noncardiac surgery because previous studies have been limited to a few academic centers or have not focused on this group of patients. METHODS: Using the 1997 to 1998 Standard Analytic File 5% Sample of Medicare beneficiaries, we identified patients with HF who underwent major noncardiac surgery. A multivariable logistic regression model was used to provide adjusted mortality and readmission rates in patients after noncardiac surgery. Patients with coronary artery disease (CAD) and all other remaining patients (Control) who had similar surgery served as reference groups. RESULTS: Of 23,340 HF patients and 28,710 CAD patients, 1,532 (6.56%) HF patients and 1,757 (6.12%) CAD patients underwent major noncardiac surgery. There were 44,512 patients in the Control group with major noncardiac surgery. After accounting for demographic characteristics, type of surgery, and comorbid conditions, the risk-adjusted operative mortality (death before discharge or within 30 days of surgery) was HF 11.7%, CAD 6.6%, and Control 6.2% (HF vs. CAD, p < 0.001; CAD vs. Control, p = 0.518). The risk-adjusted 30-day readmission rate was HF 20.0%, CAD 14.2%, and Control 11.0% (p < 0.001). CONCLUSIONS: In patients 65 years of age and older, HF patients undergoing major noncardiac surgery suffer substantial morbidity and mortality despite advances in perioperative care, whereas patients with CAD without HF have similar mortality compared with a more general population.

A population-based cohort study comparing laparoscopic cholecystectomy and open cholecystectomy.

OBJECTIVES: Laparoscopic cholecystectomy (LC) has become a popular alternative to open cholecystectomy (OC). Previous studies comparing outcomes in LC and OC used small selected cohorts of patients and did not control for comorbid conditions that might affect outcome. The aims of this study were to characterize the morbidity, mortality, and costs of LC and OC in a large unselected cohort of patients. METHODS: We used the population-based North Carolina Discharge Abstract Database (NCHDAD) for January 1, 1991, to September 30, 1994 (n = 850,000) to identify patients undergoing OC and LC. We identified the indications for surgery, complications, and type of perioperative biliary imaging used. We compared length of stay, hospital charges, complications, morbidity, and mortality between OC and LC patients. To account for variations in outcomes from differences in age and comorbidity between the OC and LC groups, we used the age-adjusted Charlson Comorbidity Index in regression analyses quantifying the association between type of surgery and outcome. RESULTS: Our cohort consisted of 43,433 patients (19,662 LC and 23,771 OC). The mean age-adjusted Charlson Comorbidity Index score was slightly higher for the OC compared to the LC group (4.3 vs 4.1, p < 0.05). The OC patients had longer hospitalizations, generated more charges ($12,125 vs $9,139, p < 0.05), and required home care more often. The crude risk ratio comparing risk of death in OC to LC was 5.0 (95% CI = 3.9-6.5). After controlling for age, comorbidity, and sex, the odds of dying in the OC group was still 3.3 times (95% CI = 1.4-7.3) greater than in the LC group. In the LC group, the number of patients with acute cholecystitis rose over the study period, whereas the number of patients with chronic cholecystitis declined. In the OC group, the number of patients with acute and chronic cholecystitis declined. The use of intraoperative cholangiography was greater in the OC group but declined in both groups over the study period. The use of ERCP was greater in the LC group and increased in both groups over time. CONCLUSIONS: The introduction of LC has resulted in a change in the management of cholecystitis. Despite a higher proportion of patients with acute cholecystitis, the risk of dying was significantly less in LC than in OC patients, even after controlling for age and comorbidity. Based on lower costs and better outcomes, LC seems to be the treatment of choice for acute and chronic cholecystitis.

[Symptomatic common bile duct lithiasis: endoscopic treatment or surgical treatment?]. / Lithiase de la voie biliaire principale symptomatique: traitement endoscopique ou traitement chirurgical?

Since 1974, endoscopic sphincterotomy (ES) has been considered by most practitioners as the gold standard for the treatment of symptomatic common bile duct lithiasis (CBDL). Results of the seven prospectives randomized controlled trials comparing ES to surgery in the treatment of CBDL, acute pancreatitis and angiocholitis excluded, demonstrated that: 1) the rate of feasibility of ES ranged from 90 to 100%; 2) the rate of residual stones after first extraction attempt ranged from 4 to 23% and after second extraction attempt from 6 to 25%. After surgery, rate of residual stone ranged from 2 to 14%; 3) major complications were more frequent after ES than after surgery; on the opposite, minor complications were more frequent after surgery than after ES; 4) immediate mortality was higher after ES than after surgery; 5) cost of ES with or without de principle cholecystectomy was higher than surgery. In conclusion ES should not be the first treatment of symptomatic CBDL.

[Mortality in emergency abdominal surgery. 304 cases. A plea for better clinical practice]. / Mortalité en chirurgie abdominale d'urgence. A propos de 304 observations. Plaidoyer pour la clinique.

Survey of 304 cases of surgical, abdominal emergencies (peritonitis and bowel occlusions). We deplored 42 post-operative deaths (14%). When patients are operated within 12 hours after the beginning of the pain, out of a group of 56 patients, two died (4%). After the 48th hour, of 114 patients operated, 26 died (23%) despite a stay in an intensive care unit. 174 patients, under 60 years old, we operated; 4 died (2.3%). This is mainly due to a stay in an intensive care unit (50 were operated after the 48th hour). Out of a group of 60 eighty years old patients, 18 were operated before the 24th hour; one death, that of a 94 years old patient, was deplored. Out of the 42 patients operated after the 24th hour, 19 died (45%). On the 304 patients, 56 (18%) were operated before the 12th hour, and 18 only, before the 6th hour (6%). the delay in operating, does not increases mortality only, but increase the duration of hospitalisation; this in itself increase expenses and sufferings. The causes of these delays are analyzed. A wiser use of clinical examination would decrease them.

Decision analysis to evaluate lymphangiography in the management of patients with Hodgkin's disease.

We used decision analysis to explore the role of lymphangiography for staging Hodgkin's disease. Factors included were status of the patient before the test, accuracy and mortality of lymphangiography, mortality of laparotomy and effectiveness of selected treatment. We analyzed hypothetical cases with varying probabilities being in Stages I+II, III and IV to determine the population in which indication for laparotomy would depend upon results of lymphangiography. Calculations made for asymptomatic patients revealed that the diagnostic usefulness of lymphangiography is restricted to patients either with a relatively low probability of Stage IV or with a very high probability of Stage IV disease. This population is further restricted as false-positive and false-negative results of lymphangiography increase.