Contemporary Assessment of Adhesiolysis and Resection for Adhesive Small Bowel Obstruction in the State of New York.

BACKGROUND: Adhesive small bowel obstruction (aSBO) is a common surgical problem, with some advocating for a more aggressive operative approach to avoid recurrence. Contemporary outcomes in a real-world setting were examined. STUDY DESIGN: A retrospective cohort study was performed using the New York Statewide Planning and Research Cooperative database to identify adults admitted with aSBO, 2016-2020. Patients were stratified by the presence of inflammatory bowel disease (IBD) and cancer history. Diagnoses usually requiring resection were excluded. Patients were categorized into four groups: non-operative, adhesiolysis, resection, and 'other' procedures. In-hospital mortality, major complications, and odds of undergoing resection were compared. RESULTS: 58,976 patients were included. 50,000 (84.8%) underwent non-operative management. Adhesiolysis was the most common procedure performed (n = 4,990, 8.46%), followed by resection (n = 3,078, 5.22%). In-hospital mortality in the lysis and resection groups was 2.2% and 5.9% respectively. Non-IBD patients undergoing operation on the day of admission required intestinal resection 29.9% of the time. Adjusted odds of resection were highest for those with a prior aSBO episode (OR 1.29 95%CI 1.11-1.49), delay to operation ≥3 days (OR1.78 95%CI 1.58-1.99), and non-New York City (NYC) residents being treated at NYC hospitals (OR1.57 95%CI 1.19-2.07). CONCLUSION: Adhesiolysis is currently the most common surgery for aSBO, however nearly one-third of patients will undergo a more extensive procedure, with an increased risk of mortality. Innovative therapies are needed to reduce the risk of resection.

Financial and Inpatient Burden of Adhesion-Related Small Bowel Obstruction: A Systematic Review of the Literature.

BACKGROUND: Postoperative adhesions may occur after >90% of laparotomies and is the most common cause of small bowel obstruction (SBO). Despite the high incidence, there is a lack of data related to financial implications of adhesion-related SBO (ASBO). This systematic literature review of in-hospital costs for treatment of ASBO searched PubMed, Scopus and Google Scholar databases according to PRISMA guidelines. Exclusion criteria were reviews, editorials, clinical vignettes, studies of patients <18 years of age, studies with no English full text and studies assessing adhesiolysis for causes other than SBO or that used extrapolations with economic models. Main outcome measures were financial costs per patient and national costs. RESULTS: Seven studies, published between 1999 and 2016, incorporating a total of 39 573 patients, were identified. Four were undertaken in European countries, one in the USA, 1 in New Zealand and 1 in Nigeria. Overall national costs regarding treatment of patients with ASBO ranged between $3.468 million and $1.77 billion. Median overall cost in the medical management group was $2371.5 ($1814-$2568) vs $12370 ($4914-$25321) in the surgical group. Median length of stay was 4 (3-7) days for patients conservatively treated and 11.5 (8-16.3) days for patients who underwent surgery. Median length of stay of operated patients on was almost triple that of patients conservatively managed. CONCLUSIONS: Given the major financial implications of ASBO, further initiatives are needed to avoid operations for SBO when clinically appropriate and minimize delays taking patients with high suspicion of complete SBO to the operating room.

Decision tree model predicts live birth after surgery for moderate-to-severe intrauterine adhesions.

BACKGROUND: After treatment of intrauterine adhesions, the rate of re-adhesion is high and the pregnancy outcome unpredictable and unsatisfactory. This study established and verified a decision tree predictive model of live birth in patients after surgery for moderate-to-severe intrauterine adhesions (IUAs). METHODS: A retrospective observational study initially comprised 394 patients with moderate-to-severe IUAs diagnosed via hysteroscopy. The patients underwent hysteroscopic adhesiolysis from January 2013 to January 2017, in a university-affiliated hospital. Follow-ups to determine the rate of live birth were conducted by telephone for at least the first postoperative year. A classification and regression tree algorithm was applied to establish a decision tree model of live birth after surgery. RESULTS: Within the final population of 374 patients, the total live birth rate after treatment was 29.7%. The accuracy of the model was 83.8%, and the area under the receiver operating characteristic curve (AUC) was 0.870 (95% CI 7.699-0.989). The root node variable was postoperative menstrual pattern. The predictive accuracy of the multivariate logistic regression model was 70.3%, and the AUC was 0.835 (95% CI 0.667-0.962). CONCLUSIONS: The decision tree predictive model is useful for predicting live birth after surgery for IUAs; postoperative menstrual pattern is a key factor in the model. This model will help clinicians make appropriate clinical decisions during patient consultations.

Emergency General Surgery Procedures and Cost of Care for Older Adults in the State of Maryland.

BACKGROUND: Older adults (OAs) ≥ 65 years of age, representing the fastest growing segment in the United States, are anticipated to require a greater percentage of emergency general surgery procedures (EGSPs) with an associated increase in health care costs. The aims of this study were to identify the frequency of EGSP and charges incurred by OA compared to their younger counterparts in the state of Maryland. METHODS: A retrospective review of the Maryland Health Services Cost Review Commission from 2009 to 2018 was undertaken. Patients undergoing urgent or emergent ESGP were divided into 2 groups (18-64 years and ≥65 years). Data collected included demographics, APR-severity of illness (SOI), APR-risk of mortality (ROM), the EGSP (partial colectomy [PC], small bowel resection [SBR], cholecystectomy, operative management of peptic ulcer disease, lysis of adhesions, appendectomy, and laparotomy), length of stay (LOS), and hospital charges. P-values (P < .05) were significant. RESULTS: Of the 181,283 patients included in the study, 55,401 (38.1%) were ≥65 years of age. Older adults presented with greater APR-SOI (major 37.7% vs 21.3%, extreme 5.2% vs 9.3%), greater APR-ROM (major 25.3% vs 8.7%, extreme 22.3% vs 5.3%), underwent PC (24.5% vs 10.9%) and SBR (12.8% vs 7.0%) more frequently, and incurred significantly higher median hospital charges for every EGSP, consistently between 2009 and 2018 due to increased LOS and complications when compared to those ≤65 years of age. CONCLUSION: These findings stress the need for validated frailty indices and quality improvement initiatives focused on the care of OAs in emergency general surgery to maximize outcomes and optimize cost.

Early operative management in patients with adhesive small bowel obstruction: population-based cost analysis.

BACKGROUND: Adhesive small bowel obstruction (aSBO) is a potentially recurrent disease. Although non-operative management is often successful, it is associated with greater risk of recurrence than operative intervention, and may have greater downstream morbidity and costs. This study aimed to compare the current standard of care, trial of non-operative management (TNOM), and early operative management (EOM) for aSBO. METHODS: Patients admitted to hospital between 2005 and 2014 in Ontario, Canada, with their first episode of aSBO were identified and propensity-matched on their likelihood to receive EOM for a cost-utility analysis using population-based administrative data. Patients were followed for 5 years to determine survival, recurrences, adverse events and inpatient costs to the healthcare system. Utility scores were attributed to aSBO-related events. Cost-utility was presented as the incremental cost-effectiveness ratio (ICER), expressed as Canadian dollars per quality-adjusted life-year (QALY). RESULTS: Some 25 150 patients were admitted for aSBO and 3174 (12·6 per cent) were managed by EOM. Patients managed by TNOM were more likely to experience recurrence of aSBO (20·9 per cent versus 13·2 per cent for EOM; P < 0·001). The lower recurrence rate associated with EOM contributed to an overall net effectiveness in terms of QALYs. The mean accumulated costs for patients managed with EOM exceeded those of TNOM ($17 951 versus $11 594 (€12 288 versus €7936) respectively; P < 0·001), but the ICER for EOM versus TNOM was $29 881 (€20 454) per QALY, suggesting cost-effectiveness. CONCLUSION: This retrospective study, based on administrative data, documented that EOM may be a cost-effective approach for patients with aSBO in terms of QALYs. Future guidelines on the management of aSBO may also consider the long-term outcomes and costs.

ANTECEDENTES: La oclusión de intestino delgado por adherencias (adhesive small bowel obstruction, aSBO) es una enfermedad potencialmente recidivante. Aunque el tratamiento no quirúrgico es a menudo eficaz, se asocia con un mayor riesgo de recidiva que la intervención quirúrgica, y puede provocar más adelante morbilidad y costes. El objetivo de este estudio fue comparar un Ensayo de Tratamiento No Quirúrgico (Trial of Non-operative Management, TNOM, el estándar actual de tratamiento) con Tratamiento Operatorio Precoz (Early Operative Management, EOM) para el tratamiento de aSBO. MÉTODOS: Pacientes ingresados en el hospital entre 2005-2014 en Ontario, Canadá con un primer episodio de aSBO fueron identificados y emparejados por puntaje de propensión respecto a la probabilidad de recibir EOM para un análisis de coste-utilidad utilizando datos administrativos de base poblacional. Los pacientes fueron seguidos durante 5 años para determinar la supervivencia, recidivas, eventos adversos, y costes de la hospitalización para el sistema de salud. Las puntuaciones de utilidad se atribuyeron a los eventos relacionados con la aSBO. El coste-utilidad se presentó como la razón costo efectividad incremental (incremental cost-effectiveness ratio, ICER) expresada como dólares por año de vida ajustado por calidad (quality-adjusted life-year, QALY). RESULTADOS: Un total de 25.150 pacientes fueron ingresados por aSBO y 3.174 (12,6%) fueron tratados con EOM. Los pacientes tratados mediante TNOM tenían más probabilidades de presentar una recidiva de la aSBO (20,9% versus 13,2%, P < 0,0001). La menor incidencia de recidivas asociada con EOM contribuyó a una eficacia neta global en términos de QALYs. Mientras que los costes medios acumulados para los pacientes tratados con EOM superaron a los de TNOM ($17,951 versus $11,594, P < 0,0001), el ICER de EOM versus TNOM fue $29,881/QALY, lo que sugiere un coste-eficacia de esta estrategia. CONCLUSIÓN: Este estudio retrospectivo basado en datos administrativos evidenció que EOM puede representar un abordaje coste-efectivo para pacientes con aSBO en términos de QALYs. Las futuras guías clínicas para el tratamiento de la aSBO pueden también considerar los resultados a largo plazo y los costes.

Decision Tree Analysis: A Retrospective Analysis of Postoperative Recurrence of Adhesions in Patients with Moderate-to-Severe Intrauterine.

OBJECTIVE: To establish and validate a decision tree model to predict the recurrence of intrauterine adhesions (IUAs) in patients after separation of moderate-to-severe IUAs. DESIGN: A retrospective study. SETTING: A tertiary hysteroscopic center at a teaching hospital. POPULATION: Patients were retrospectively selected who had undergone hysteroscopic adhesion separation surgery for treatment of moderate-to-severe IUAs. INTERVENTIONS: Hysteroscopic adhesion separation surgery and second-look hysteroscopy 3 months later. MEASUREMENTS AND MAIN RESULTS: Patients' demographics, clinical indicators, and hysteroscopy data were collected from the electronic database of the hospital. The patients were randomly apportioned to either a training or testing set (332 and 142 patients, respectively). A decision tree model of adhesion recurrence was established with a classification and regression tree algorithm and validated with reference to a multivariate logistic regression model. The decision tree model was constructed based on the training set. The classification node variables were the risk factors for recurrence of IUAs: American Fertility Society score (root node variable), isolation barrier, endometrial thickness, tubal opening, uterine volume, and menstrual volume. The accuracies of the decision tree model and multivariate logistic regression analysis model were 75.35% and 76.06%, respectively, and areas under the receiver operating characteristic curve were 0.763 (95% CI 0.681-0.846) and 0.785 (95% CI 0.702-0.868). CONCLUSIONS: The decision tree model can readily predict the recurrence of IUAs and provides a new theoretical basis upon which clinicians can make appropriate clinical decisions.

New insertion method of transnasal ileus tube for small bowel obstruction: Anterior balloon method.

BACKGROUND: Small bowel obstruction (SBO) is usually caused by postoperative adhesions and malignant disease, and decompression is effective for SBO. Our previous case report suggested that a new transnasal ileus tube insertion method, the anterior balloon method (ABM), could achieve decompression for adhesive SBO. AIMS: The study aimed to investigate the effectiveness of a new method for inserting transnasal ileus tubes in patients with SBO. METHODS: Altogether, 134 patients with small bowel obstruction treated from January 2011 to December 2017 were reviewed. The patients were categorized into two groups: those with the new method that inserts an anterior balloon (ABM group: 52 patients, 2014-2017) versus those with the ordinary insertion method (OIM group: 82 patients, 2011-2014). RESULTS: The patients' characteristics and symptoms on admission were similar in the ABM and OIM groups. Adhesions were the main cause of ileus in the two groups. The insertion time duration was significantly shorter in the ABM group than in OIM group (28.4 ± 9.1 vs. 33.5 ± 13.0 min; p = 0.01). The ABM group also had significantly longer tubes than OIM group (222.4 ± 32.2 vs. 157.4 ± 31.7 cm; p < 0.001), which resulted in a significantly shorter time until clinical symptoms were relieved in ABM group. There were no significant differences in adverse events between the two groups. CONCLUSIONS: The ABM group had shorter insertion duration and longer tubes than those of OIM group. The ABM might become a preferred therapeutic choice to achieve decompression in patients with SBO.

Quality of life, functional status and adhesiolysis during elective abdominal surgery.

BACKGROUND: Adhesiolysis during abdominal surgery can cause iatrogenic organ injury, increased operative time and a more complicated convalescence. We assessed the impact of adhesiolysis and adhesiolysis-related complications on quality of life and functional status following elective abdominal surgery. METHODS: Prospective cohort study, comparing patients requiring and not requiring adhesiolysis during an elective laparotomy or laparoscopy using the SF-36 and DASI questionnaire scores. RESULTS: 518 patients were included. Pre- and postoperative quality of life did not significantly differ between both groups. Patients with adhesiolysis had a significantly lower pre- and postoperative functional status (p < 0.01). Higher age, concomitant pulmonary disease, postoperative complications, readmissions and chronic abdominal pain 6 months after surgery were all associated with a significant and independent decline in quality of life and functional status six months after surgery. CONCLUSION: Adhesiolysis in itself does not affect functional status and quality of life six months after surgery. Postoperative complications, readmissions and chronic abdominal pain are associated with a lower health status.

Impact of hospital volume on outcomes for laparoscopic adhesiolysis for small bowel obstruction.

BACKGROUND: Volume-to-outcome data have been studied in several complex surgical procedures, demonstrating improved outcomes at higher volume centers. Laparoscopic lysis of adhesions (LLOA) for small bowel obstruction (SBO) may result in better outcomes, but there is no information on the learning curve for this potentially complex case. This study evaluates the effect of institutional procedural volume on length of stay (LOS), outcomes, and costs in LLOA for SBOs. MATERIALS AND METHODS: The Nationwide Inpatient Sample data set between 2000 and 2013 was queried for discharges for a diagnosis of SBO involving LLOA in adult patients. Patients with intra-abdominal malignancy and evidence of any other major surgical procedure during hospitalization were excluded. The procedural volume per hospital was calculated over the period, and high-volume hospitals were designated as those performing greater than five LLOA per year. Patient characteristics were described by hospital volume status using stratified cluster sampling tabulation and linear regression methods. LOS, total charges, and costs were reported as means with standard deviation and median values. P < 0.05 was considered significant. RESULTS: A total of 9111 discharges were selected, which was representative of 43,567 weighted discharges nationally between 2000 and 2013. Over the study period, there has been a 450% increase in the number of LLOA performed. High-volume hospitals had significantly shorter LOS (mean: 4.92 ± standard error (SE) 0.13 d; median: 3.6) compared to low-volume hospitals (mean: 5.68 ± 0.06 d; median: 4.5). In multivariate analysis, high-volume status was associated with a decreased LOS of 0.72 d (P < 0.0001) as compared to low-volume status. Other significant predictors for decreased LOS included decreased age, decreased comorbidity, and the absence of small bowel resection. There was no significant association between volume status and total charges in multivariate or univariate models, but high-volume hospitals were associated with lower costs in multivariate models by approximately $984 (P = 0.017). CONCLUSIONS: This study demonstrates that high hospital volume was associated with decreased LOS for LLOA in SBO. Although volume was not associated with differences in total charges, there was a small decrease in hospital costs.

In-hospital costs of an admission for adhesive small bowel obstruction.

BACKGROUND: Previous research on the costs of treatment for ASBO is outdated and often based on reimbursements, rather than true healthcare provider costs of the admission and related interventions. An accurate estimate of the true costs of treatment is necessary to understand the healthcare burden and to model cost-efficacy of adhesion strategies. The aim of this study was to provide an accurate cost estimate of the in-hospital costs for treatment of adhesive small bowel obstruction (ASBO) using micro-costing methods. METHODS: Consecutive patients admitted for ASBO to the Radboud University Medical Center from November 2013 to November 2015 were included. An episode of ASBO was defined as an admission for SBO with operative confirmation of adhesions or after radiological exclusion of other causes for SBO. For the purpose of generalization we used the costs of medication and interventions as provided by the Dutch Healthcare Authority and only if these were not available local hospital costs. We evaluated costs separately for operative and non-operative treatment for ASBO. RESULTS: During the study period 39 admissions for ASBO were eligible for analysis. An operative treatment was required in 19 patients (48.7 %). Mean hospital stay for ASBO with operative treatment was 16.0 ± 11 days versus 4.0 ± 2.0 days for non-operative treatment (P = 0.003). A total of 12 patients developed complications, 2 in the non-operative group (10 %) and 10 in the operative group (52.6 %; P = 0.004). Overall costs for an admission for ASBO with operative treatment were €16 305 (SD €2 513), and for non-operative treatment € 2 277 (SD € 265) (p = <0.001). The highest expenditure with operative treatment for ASBO was made for ward stay (mean €7 856, SD €6 882), OR time (mean €2 6845, SD €1 434), ICU stay (mean €2 183, SD €4 305) and (parenteral) feeding costs (mean €1797, SD €2070). A table with correction coefficient to correct for differences in price levels for goods and services between different countries has been added. CONCLUSION: The in-hospital costs of an admission for ASBO are higher than previously thought. These costs can be used to guide hospital reimbursement policy and for the development of a cost-effective model for the use of adhesion barriers.

Use of National Burden to Define Operative Emergency General Surgery.

IMPORTANCE: Emergency general surgery (EGS) represents 11% of surgical admissions and 50% of surgical mortality in the United States. However, there is currently no established definition of the EGS procedures. OBJECTIVE: To define a set of procedures accounting for at least 80% of the national burden of operative EGS. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review was conducted using data from the 2008-2011 National Inpatient Sample. Adults (age, ≥18 years) with primary EGS diagnoses consistent with the American Association for the Surgery of Trauma definition, admitted urgently or emergently, who underwent an operative procedure within 2 days of admission were included in the analyses. Procedures were ranked to account for national mortality and complication burden. Among ranked procedures, contributions to total EGS frequency, mortality, and hospital costs were assessed. The data query and analysis were performed between November 15, 2015, and February 16, 2016. MAIN OUTCOMES AND MEASURES: Overall procedure frequency, in-hospital mortality, major complications, and inpatient costs calculated per 3-digit International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes. RESULTS: The study identified 421 476 patient encounters associated with operative EGS, weighted to represent 2.1 million nationally over the 4-year study period. The overall mortality rate was 1.23% (95% CI, 1.18%-1.28%), the complication rate was 15.0% (95% CI, 14.6%-15.3%), and mean cost per admission was $13 241 (95% CI, $12 957-$13 525). After ranking the 35 procedure groups by contribution to EGS mortality and morbidity burden, a final set of 7 operative EGS procedures were identified, which collectively accounted for 80.0% of procedures, 80.3% of deaths, 78.9% of complications, and 80.2% of inpatient costs nationwide. These 7 procedures included partial colectomy, small-bowel resection, cholecystectomy, operative management of peptic ulcer disease, lysis of peritoneal adhesions, appendectomy, and laparotomy. CONCLUSIONS AND RELEVANCE: Only 7 procedures account for most admissions, deaths, complications, and inpatient costs attributable to the 512 079 EGS procedures performed in the United States each year. National quality benchmarks and cost reduction efforts should focus on these common, complicated, and costly EGS procedures.

Impact of Adhesiolysis on Outcome of Colorectal Surgery.

BACKGROUND/AIMS: Adhesiolysis is a frequent part of colorectal surgery, potentially impeding the operation and causing inadvertent bowel injury. Such difficulties might compromise convalescence and oncological quality of resection. The aim of this prospective cohort study was to assess the impact of adhesiolysis on clinical outcomes and histopathological results in colorectal surgery. METHODS: Colorectal procedures were selected from a prospective cohort study of adhesiolysis-related problems. We compared the incidence of bowel injury, morbidity, costs, and the histopathology between patients undergoing elective colorectal surgery with or without adhesiolysis. RESULTS: Two hundred and forty nine colorectal surgeries were analysed. Adhesiolysis was required in 59.0%. The mean adhesiolysis time was 28 min. In the adhesiolysis group, enterotomies occurred in 6.1% and seromuscular injuries in 27.2% compared to 0 and 6.9% respectively in the non-adhesiolysis group (p = 0.012 and p < 0.001). In patients requiring adhesiolysis, 29.9% had major surgery-related complications (MSRC) compared to 15.7% without adhesiolysis (p = 0.007). There were no statistically significant differences regarding inpatient costs and resection margin or number of harvested lymph nodes. CONCLUSIONS: Adhesiolysis during colorectal surgery is related to an increased incidence of iatrogenic bowel injuries and MSRC. Despite the technical challenges associated with adhesiolysis, good histopathological results were obtained in oncological resections.

Assessing the Cost of Prophylactic Antibiotic Use After Cleft Lip and Lip Adhesion Procedures.

EXECUTIVE SUMMARY: The purpose of this study was to understand the true cost of administering prophylactic antibiotics postoperatively to patients undergoing cleft lip and lip adhesion procedures for which the rate of infection is historically low. Using time-driven activity-based costing (TDABC) methodologies, the plastic surgery department of one hospital created a process map with related time intervals and personnel cost rates for administering the antibiotic. The cost for each provider, based on standard salary information, was multiplied by the time required to complete his or her stage of the process, and this outcome was added to the supply costs. Overall cost was determined by summing the cost of all the steps. The cost of administering four doses of ampicillin/sulbactam to a patient during an inpatient stay ranged from $61.91 to $81.83. The total cost included all steps, from the initial antibiotic prescription through the final administration by a nurse. We attributed variations in cost to the staff member's level of familiarity with the antibiotic and dosing protocols for that patient. Over the course of a year, the cost of administering prophylactic antibiotics for this patient population was between $3,281.23 and $4,336.99. The results of this study effectively demonstrate the use of TDABC to determine the cost of administering prophylactic postoperative antibiotics. If we assume that antibiotics are of limited value for all clean-contaminated plastic surgery procedures, the plastic surgery department can expect to save $18,000 to $22,000 each year by forgoing their use. Furthermore, when clinically supported, reducing the use of prophylactic antibiotics not only diminishes the cost of care but also reduces the complexity of postoperative care.

Systematic assessment of surgical complications in laparoscopically assisted vaginal hysterectomy for pelvic organ prolapse.

OBJECTIVE: To assess patient safety and complication rates in native tissue vaginal prolapse repair combined with laparoscopically assisted vaginal hysterectomy and prophylactic salpingectomy/salpingoophorectomy. STUDY DESIGN: This was a single-centre retrospective study conducted at the University Hospital, Urogynaecological Unit, with a certified urogynaecological surgeon. A cohort of 321 consecutive patients received laparoscopically assisted vaginal hysterectomy for pelvic organ prolapse grade II-IV combined with defect-specific vaginal native tissue repair. Analysis of the total cohort and subgroups according to prolapse grade and concomitant laparoscopic procedures was performed. Student's t-tests and chi-squared tests were used for descriptive statistical analysis. Surgical complications were classified using the Clavien-Dindo (CD) classification system of surgical complications. RESULTS: Complications were classified as CD I (1.87%), CD II (13.39%), CD IIIa (0.62%), and CD IIIb (1.87%); no CD IV or CD V complication occurred. One (0.31%) intraoperative bladder lesion, but no rectal lesion, ureter lesion, or intraoperative haemorrhage requiring blood transfusion, was noted. The overall morbidity rate, including the intraoperative bladder lesion and the CD I complication, was 18.06%. All (n=321) patients underwent prophylactic salpingectomy. Additional oophorectomy was performed in 222 post-menopausal patients. Pelvic adhesions were found in 123 (38.31%) patients and 148 (46%) patients presented grade IV prolapse. Operating time was longer for grade IV than for grade II/III prolapse (p<0.01), but CD III complication rates did not differ between these groups. Operating time was longer when laparoscopic adhesiolysis was performed (p=0.025), but this factor did not affect CD III complication rates. CONCLUSIONS: The combination of vaginal site-specific prolapse repair with laparoscopically assisted hysterectomy leads to low complication rates. Prophylactic salpingectomy or salpingoophorectomy can be performed safely in combination with hysterectomy for pelvic organ prolapse. In terms of surgical safety laparoscopy seems to be a meaningful addition to vaginal native tissue prolapse surgery.

The Risk Factors of Readmission in Postoperative Gynecologic Oncology Patients at a Single Institution.

INTRODUCTION: Hospital readmission rates are an important measure of quality care and have recently been tied to reimbursement. This study seeks to identify the risk factors for postoperative readmission in patients treated by a gynecologic oncology service. METHODS: A 7-year retrospective review (2007-2013) of all patients operated on by the University of Virginia gynecologic oncology service who were readmitted within 30 days of discharge was performed. Abstracted data included demographics, dates of surgery, operative details, cancer history, and relevant medical history. The readmitted patients (n = 166) were compared with randomly selected controls (n = 168) from the same service in a matching time frame and analyzed using univariate and multivariate models. RESULTS: In the study period, 2993 operations were performed. One hundred sixty-six unique patients (5.5%) were readmitted within 30 days of discharge from their operative procedure. On multivariate analysis, the factors that were associated with a higher risk of readmission were a history of psychiatric disease, postoperative complication, type of insurance, surgical modality, and lysis of adhesions at the time of surgery. The most common readmission diagnoses were infection (44%), nausea/vomiting (28%), thrombosis (6%), bowel leak (4%), and bleeding (4%). CONCLUSIONS: Postoperative readmissions are a common problem and are increasingly important as a measure of quality. Although patients were generally admitted for infections or gastrointestinal complaints, we also found that individual factors such as mental health and socioeconomic status also contributed. Our data suggest that we can preoperatively identify high-risk individuals for whom extra resources can be directed postoperatively to avoid unnecessary readmissions.

Small Bowel Obstruction Is a Surgical Disease: Patients with Adhesive Small Bowel Obstruction Requiring Operation Have More Cost-Effective Care When Admitted to a Surgical Service.

BACKGROUND: Adhesive small bowel obstruction (ASBO), although a potential surgical emergency, is increasingly being managed by medical hospitalists due to the likelihood these patients will not require operation. However, the value of care delivered by medical hospitalists to patients with ASBO has not been reported. STUDY DESIGN: We hypothesized that patients admitted to the medical hospitalist service (MHS) for presumed ASBO have increased length of stay (LOS) and charges compared with patients admitted to the surgical service (SS). There were 555 consecutive admissions with presumed ASBO from 2008 to 2012; these were reviewed and grouped according to admitting service and whether an operation was performed. Group medians were compared and multivariate analysis was performed to identify variables independently associated with increased LOS, time to operation (TTO), and charges. RESULTS: Median LOS among patients whose ASBO resolved nonoperatively was similar for those on SS and MHS (2.85 days vs 2.98 days; p = 0.49). In patients without nonoperative resolution of ASBO, those admitted to MHS had longer median LOS when compared with those admitted to SS (9.57 days vs 6.99 days; p = 0.002) and higher median charges ($38,800 vs $30,100; p = 0.025). Patients admitted to MHS who had an operation, had a greater median TTO than operative patients on SS (51.72 hours vs 8.4 hours; p < 0.001). Multivariate analysis did not identify factors independently predictive of increased LOS, TTO, or charges. CONCLUSIONS: Adhesive small bowel obstruction patients are treated in a heterogeneous fashion in our hospital, causing disparate outcomes depending on admitting service when patients undergo operation. Admitting all suspected ASBO patients to SS has the potential to dramatically decrease LOS and reduce waste in those requiring operation, thereby reducing health care expenditures.

Anterior Chamber Angle Assessment by Anterior-segment Optical Coherence Tomography After Phacoemulsification With or Without Goniosynechialysis in Patients With Primary Angle Closure Glaucoma.

PURPOSE: To evaluate changes of anterior chamber angle (ACA) by anterior-segment optical coherence tomography (AS-OCT) in patients with primary angle closure glaucoma (PACG) following phacoemulsification (phaco) with or without goniosynechialysis (GSL). METHODS: Patients with PACG recruited into 2 randomized controlled trials comparing phaco-GSL versus phaco were pooled for analysis. Images of ACA were obtained by AS-OCT before surgery, and at 1 and 2 weeks, and 1, 3, and 6 months after surgery. The following parameters were analyzed: angle opening distance (AOD) at 500 and 750 µm from the scleral spur, trabecular-iris space area (TISA) at 500 and 750 µm, angle recess area (ARA) at 500 and 750 µm, and scleral spur angle (SSA). RESULTS: All parameters of ACA increased significantly after phaco-GSL (P<0.001), whereas no increase occurred in the phaco group. Negatively significant correlations were found in ΔAOD500 (P<0.05), ΔARA750 (P<0.05), ΔTISA500 (P<0.05), and ΔTISA750 (P<0.05) at 1, 3, and 6 months, and ΔSSA (P<0.05) at 3 and 6 months after phaco-GSL against Δ intraocular pressure (IOP). In the phaco-GSL group, 23 of 23 eyes had IOP<21 mm Hg without any antiglaucoma medication postoperatively. In the phaco group, 12 of 20 eyes (60%) had IOP<21 mm Hg without medication, 8 of 20 eyes required medication with IOP<21 mm Hg (15%) and uncontrollable IOP (25%) after surgery. CONCLUSIONS: On AS-OCT evaluation, ACA in eyes with PACG opened and widened significantly after phaco-GSL in our study. It is suggested that ΔAOD500, ΔARA750, ΔTISA500, ΔTISA750, and ΔSSA would provide valuable information to estimate the effectiveness of phaco-GSL.

Early versus late adhesiolysis for adhesive-related intestinal obstruction: a nationwide analysis of inpatient outcomes.

BACKGROUND: Classical teaching advocates watchful waiting for 2 days before operating on adhesive-related intestinal obstructions (AIOs). Our aim was to compare the clinical and cost outcomes of early versus late adhesiolysis for AIOs. DESIGN: Patients undergoing adhesiolysis for AIOs from the 2007 Nationwide Inpatient Sample were stratified to early (≤2 days from admission) vs. late (>2 days) adhesiolysis. The primary outcome was in-hospital mortality and secondary outcomes were post-operative complications (POCs), post-operative length of stay (PLOS), and in-hospital cost. RESULTS: From 5,443 patients who underwent adhesiolysis for AIOs, 53 and 47 % underwent early and late adhesiolysis, respectively. Late adhesiolysis patients were older (65.0 vs. 60.1 years) and more co-morbid compared to the early group (p < 0.05). After adjustment with propensity score methods, late adhesiolysis patients had no difference in mortality (odds ratio [OR] 0.95, 95%-confidence intervals [CI] 0.67-1.36, p = 0.79) or POCs (OR 1.01, 95%CI 0.89-1.14, p = 0.91) compared to the early group, but had 9.8 % increased PLOS and 41.9 % increased in-hospital cost (p < 0.001). CONCLUSIONS: The 2-day limit of watchful waiting is not associated with increased mortality or POCs for those patients undergoing adhesiolysis for an AIO. Late adhesiolysis, however, was associated with significantly increased PLOS and in-hospital cost compared to early adhesiolysis.

Surgical management of pediatric adhesive bowel obstruction.

INTRODUCTION: The objective of this study was to analyze a population-based database for recent trends in surgical management of pediatric adhesive bowel obstruction and compare open versus laparoscopic lysis of adhesions (LOA). SUBJECTS AND METHODS: Pediatric adhesive bowel obstruction cases were identified in the Kids' Inpatients Database from 1997, 2000, 2003, 2006, and 2009. Data analysis included patients' demographics, hospital variables, length of stay (LOS), and total hospital charges (THC). Complications analysis included postoperative shock, hemorrhage, hematoma, seroma, wound complications, infection, fistula, and pulmonary complications. RESULTS: In total, 20,679 pediatric adhesive bowel obstruction cases were identified during the study period. These were characterized by a median age of 11 years old, with 59.0% of the population female. Overall treatment included 88.6% open and 11.4% laparoscopic LOA. A more than twofold increase in utilization of laparoscopy was observed from 7.2% in 1997 to 17.2% in 2009 (P<.001). Complication rates were lower for laparoscopic LOA versus open (5.6% versus 10.4%; odds ratio 0.512; 95% confidence interval 0.394-0.667; P<.001), especially accidental puncture or laceration rate (2.2% versus 3.9%; odds ratio 0.566; 95% confidence interval 0.375-0.854; P=.006). Conversion to open LOA occurred in 1.9%. Laparoscopy was associated with a shorter median LOS (6 versus 8 days; P<.001) and a lower mean THC ($38,241.11 versus $48,552.51; P<.001) compared with open LOA. Multivariate regression analysis did not find hospital bed size, location, teaching status, and regions to be statistically significant predictors for utilization of laparoscopy. CONCLUSIONS: Laparoscopic LOA is a safe option for pediatric adhesive bowel obstruction with lower complication rates and a reduced economic burden. Despite the increase in utilization of laparoscopy in recent years, only a minority of patients underwent laparoscopic LOA. Further studies are needed to identify and characterize the subgroup of patients who benefit from laparoscopic LOA.