Factors Associated With Major Lower Extremity Amputations in Diabetic Foot Infections at a County Hospital in Guatemala.

INTRODUCTION: Outcomes from diabetic foot infections (DFIs) at the major referral hospital (Hospital Nacional de San Benito) in El Petén, Guatemala have not been analyzed. We hypothesized that poor diabetic control might be associated with a high rate of major lower extremity amputations (mLEAs; above the ankle). METHODS: We performed a retrospective analysis at Hospital Nacional de San Benito between (8/14 and 6/23) in patients presenting with DFIs. Patients receiving mLEAs were compared with all others (AO = [trans-metatarsal amputations, toe amputations, incision and drainage, and antibiotic treatment]). Interviews surgeons were undertaken to ascertain reasons for index operation choice. Univariable and multivariable analyses were undertaken to determine factors associated with mLEAs. RESULTS: Of 110 patients with DFIs, there were 23 mLEAs (above the knee = 21, below the knee = 2). Age, duration with diabetes, and a prior ipsilateral minor amputation were associated with mLEAs. Multivariable analysis identified white blood cell count as significant for mLEA (odds ratio = 1.5 95% confidence interval [1.0 to 2.5]). Cited reasons for a high rate of above the knee amputation (AKAs) versus below the knee amputation were patient related (advanced disease, patient frailty, and poor compliance), systemic (lack of vascular equipment and knee immobilizer), and surgeon related. CONCLUSIONS: This cohort of patients presented with an average of 15 years with diabetes mellitus and poor adherence to diabetic treatment (40%). Many of these diabetic patients developed a DFI requiring mLEAs (21%), most of which were AKAs (91%). Efforts to minimize the number of AKA versus below the knee amputation require immediate attention. Programs to adhere to DM control and foot care in patients with DM are urgently needed.

Unsafe Practices of Motorcycle Riders in El Petén, Guatemala: A Community Observational Study and a Retrospective Institutional Review.

INTRODUCTION: Outcomes from trauma at the major referral hospital [Hospital Nacional de San Benito (HNSB)] in El Petén, Guatemala, have not been analyzed. Empirical evidence demonstrated a high number of motorcycle accidents (MAs). We hypothesized a large incidence of head trauma with poor outcomes in MAs compared to all other forms of blunt trauma. METHODS: Our hypothesis was tested by performing a community observational study and a retrospective chart review in El Petén, Guatemala. An independent observer catalogued 100 motorcycle riders on the streets of El Petén for riding practices as well as helmet utilization. HNSB does not have electronic medical records. For this study, we performed a retrospective chart review of randomly selected nonconsecutive trauma admission at HNSB between March 2018 and June 2023. Blunt trauma was compared between MAs versus all others. Variables were examined by parametric and nonparametric tests as well as contingency table analyses. RESULTS: Most motorcycles riders involved multiple individuals (2.61 ± 0.79/motorcycle). Seventy riders included children (median = 1.0 [Q1-Q3 range = 1.0-3.0]/motorcycle). Overall, only three riders were wearing helmets. Forty-one were women. Of patients presenting to HNSB with trauma, 91 charts were reviewed (33.0 [20.0-37.0] y old; male 89%), 76.7% were blunt, and 23.3% were penetrating trauma. Within blunt trauma, 57.1% were MAs versus 42.9% all others; P = 0.13. MAs were younger (29.5 [20.0-37.0] versus 34.0 [21.8-45.8] y old; P < 0.05) and of similar gender (male 82.5% versus 96.6%; P = 0.1). More MAs had a computed tomography (70.0% versus 30.0%; P < 0.01) and they were more likely to present with head trauma (72.5% versus 46.7%; P = 0.04) but similar Glasgow Coma Scale (15.0 [13.5-15.0] versus 15.0 [12.5-15.0]; P = 0.7). MAs were less likely to require surgical intervention (37.5% versus 56.7%; P = 0.05) but had similar hospital length of stay (4.0 [2-6] versus 4.0 [2-10.5] d; P = 0.5). CONCLUSIONS: Unsafe motorcycle practices in El Petén are staggering. Most trauma at HNSB is blunt, and likely from MAs. More patients with MAs presented with head trauma. However, severe trauma might be transferred to higher level hospitals or mortality might occur on scene, which will need further investigations. Assessment of mortality from trauma admissions is ongoing. These findings should lead to enforcement of safe motorcycle practices in El Petén, Guatemala.

The impact of crohn's disease on patients undergoing total knee arthroplasty.

BACKGROUND: The knee joint remains the most affected joint in extra-intestinal manifestations of Crohn's disease (CD). Given the increasing prevalence of CD and overall demand for total knee arthroplasty (TKA), it is likely that an increasing number of patients with CD will require TKA. The purpose of this study was to assess the inpatient postoperative complication in patients with CD undergoing TKA. MATERIALS AND METHODS: We queried the Nationwide Inpatient Sample (NIS) database between the years of 2016 to 2019, including a total of 558,371 patients who underwent primary TKA. Among these, 1461 were in the CD group and 556,910 were in the non-CD group (controls). Data pertaining to demographics, length of stay (LOS), total healthcare cost, mortality, and in-hospital complications (blood loss anemia, blood transfusion, periprosthetic infection, periprosthetic dislocation, periprosthetic mechanical complication, acute renal failure, myocardial infarction, pneumonia, pulmonary embolism, deep vein thrombosis, superficial/deep surgical site infection, and wound dehiscence) were compared between the two groups. RESULTS: Patients diagnosed with CD had higher postoperative complications such as blood loss anemia (OR: 1.22, 95% CI: 1.07-1.39, p = 0.004), periprosthetic infection (OR: 1.80, 95% CI: 1.23-2.63, p = 0.006), and the need for blood transfusion (OR: 1.447, 95% CI: 1.01-2.06, p = 0.044) in comparison to the control group. In-hospital mortality and acute renal failure were similar in both groups. The CD group had a significantly prolonged LOS (2.54 vs. 2.35 days, p < 0.001). No statistically significant difference was noted concerning in-hospital charges between the two groups. CONCLUSIONS: CD patients undergoing TKA experienced increased LOS and postoperative complications. However, these complications were minor and did not affect total hospital cost. Further prospective cohort studies could build upon the findings described to continue to maximize outcomes in CD patients undergoing TKA, which might extend to other cohorts.

Does obesity predict morbidity and mortality amongst patients undergoing transfemoral amputations?

BACKGROUND: We investigated the role of obesity on morbidity and mortality in patients undergoing above knee amputation. METHODS: Data of 4225 patients undergoing AKAs was extracted from NIS Database (2016-2019) for a retrospectively matched case-control study and were grouped into; Non-obese (N-Ob-BMI <29.9 kg/m2; n = 1413), class I/II obese (Ob-I/II-BMI: 30-39.9 kg/m2; n = 1413), and class III obese groups (Ob-IIIBMI > 40; n = 1399). Morbidity, mortality, length of stay, and hospital charges were analyzed. RESULTS: Blood loss anemia (OR = 1.42; 95% CI = 1.19-1.64), superficial SSI (OR = 5.10; 95% CI = 1.4717.63) and acute kidney injury (AKI- OR = 1.42; 95% CI = 1.21-1.67) were higher in Ob-III patients. Mortality was 5.8%, 4.5%, and 6.4% in N-Ob, Ob-I/II and Ob-III patients (p < 0.001; Ob-I/II vs. Ob-III), respectively. Hospital LOS was 3 days higher in Ob-III (16.1 ± 18.0), comparatively resulting in $25,481 higher inpatient-hospital charge. CONCLUSION: Patients in Ob-III group were noted to have increased morbidity, higher LOS, and inpatient-hospital cost.

The Veteran Affair Surgical Quality Improvement Program Calculator is a Poor Predictor of Morbidity and Mortality in Octogenarian and Nonagenarian Veterans Undergoing Major Lower Extremity Amputations.

BACKGROUND: Morbidity and mortality for major (above the ankle) lower extremity amputation (LEA) is high in veteran patients and age is a predictor of mortality. The Veteran Affair Surgical Quality Improvement Program (VASQIP) risk assessment tool has been validated for several operations but not for elderly patients undergoing LEA. The present study interrogated the accuracy for the VASQIP calculator for a medium/high-risk operation in a high-risk veteran population (octogenarians and nonagenarians). METHODS: Variables required from input for the VASQIP calculator were retrospectively obtained for 57 octogenarians and 11 nonagenarians submitting to LEA at our institution from 2009 to 2021. The six-outcome variables provided by the VASQIP calculator (30-day mortality, 180-day mortality, 30-day morbidity, 30-day surgical site infection risk, probability of intensive care unit stay, and probability of hospital stay) were compared to observed morbidity and mortality. The accuracy of the calculator was assessed by area under the receiver operating characteristic curve and reported by the area under the curve (AUC) as previously described. RESULTS: In the 68 patients included in this analysis, the time to death from the last index operation was 422.0 ± 604.9 days for octogenarians and 65.6 ± 89.3 days for nonagenarians. Predicted versus observed 30-day mortality for octogenarians and nonagenarians was 8.46 vs. 24.56 [AUC = 0.739; 95% confidence interval (0.581 to 0.898)] and 24.46 vs. 45.45 [AUC = 0.600 (0.171 to 1.000)], respectively. Predicted versus observed 180-day mortality for the same cohorts was 25.22 vs. 47.37 [AUC = 0.578 (0.427 to 0.728)] and 45.34 vs. 90.91 [AUC = 0.100 (0.000 to 0.286)], respectively. Thirty-day morbidity, 30-day surgical site infection, probability of intensive care unit, and probability of in-hospital stay produced an AUC less than 0.600 for all these outcomes. CONCLUSIONS: The VASQIP risk calculator is a poor predictor of short-term outcomes in octogenarians and nonagenarians undergoing major LEA. Most octogenarian and nonagenarian veterans died within 1 year, and the mean survival for nonagenarians was less than 3 months after LEA. The decision for major LEA in octogenarian and nonagenarian veterans warrants an informed discussion with the patient and family.

Feasibility of a Local Anesthesia Program for Inguinal Hernia Repair at a Veteran Affairs Hospital.

BACKGROUND: Local anesthesia (LA) for open inguinal hernia repair (OIHR) is not widely used in the United States. An LA program for OIHR was initiated at the Dallas Veteran Affairs Medical Center in 2015. We hypothesize that outcomes under LA for OIHR are similar to general anesthesia with adequate patient satisfaction. METHODS: A total of 1422 groin hernias were performed by a single surgeon using a standardized technique at the Dallas Veteran Affairs Medical Center (2015-2019). Only unilateral, primary, elective, OIHRs were included (n = 1092). LA was used in 26.0% (n = 285) and compared with patients undergoing general anesthesia. Univariate analysis was performed by the Student t-test for continuous variables and χ2 test (or the Fisher exact test) for categorical variables. RESULTS: OIHR performed with LA increased from 15.5% in 2015 to 76.6% in 2019. Patients undergoing LA were older and had significantly more comorbidities. Holding time to operating room (OR), OR to start of the operation, skin-to-skin time, and end of the operation to out of the OR were all reduced with LA (all P values <0.05). Inguinodynia, recurrence, and overall complications were similar. Patients undergoing LA indicated that they were comfortable (93.0%), rated their worst pain as 2.03 ± 2.2 (of 10), and would undergo LA if they had to do it again (94.0%). CONCLUSIONS: LA was associated with decreased OR times and had good patient satisfaction. Overall complication rates were similar despite a higher burden of comorbid conditions in patients undergoing LA.

Open, Laparoscopic, and Robotic Inguinal Hernia Repair: Outcomes and Predictors of Complications.

BACKGROUND: The robotic approach to an inguinal hernia has not been compared head to head with the open and laparoscopic techniques in randomized controlled trials. Furthermore, long-term outcomes for robotic inguinal hernia repair (RHR) are lacking. In this study, we compared laparoscopic inguinal hernia repair (LHR) and RHR with open inguinal hernia repair (OHR) in veteran patients performed by surgeons most familiar with each approach. METHODS: A retrospective single-institution analysis of 1299 inguinal hernia repairs performed at the VA North Texas Health Care System between 2005 and 2017 was undertaken. Three surgeons performed the operations, each an expert in one approach, and there was no crossover in techniques. A total of 1100 OHRs, 128 LHRs, and 71 RHRs were performed. Univariable analysis was undertaken to determine associations between techniques and outcomes (OHR versus LHR; OHR versus RHR; LHR versus RHR). Setting complications as a dependent variable, multivariable analyses were undertaken to determine an association with complications as well as independent predictors of complications. RESULTS: Patient demographics were similar among groups except for age that was higher in the OHR cohort. The average follow-up was 5.2 ± 3.4 y. In the present report, recurrence was associated with a higher rate in the RHR versus OHR (5.6% versus 1.7%; P < 0.02), but not in the LHR versus OHR (3.9% versus 1.9%; P = 0.09). Inguinodynia was more likely to occur in both the LHR and RHR compared with the OHR (9.4% and 14.1 versus 1.5%; both P's < 0.001). Urinary retention was also more common in the LHR and RHR than in the OHR (5.5% and 5.6% versus 1.8%, both P's < 0.05) as was the rate of overall complications (34.4% and 38.0% versus 11.2%, both P's < 0.001). Multivariable regression analysis showed femoral hernias, ASA, serum albumin, operative room time, a recurrent hernia, and the minimally invasive approaches were independent predictors of overall complications. CONCLUSIONS: Outcomes in the OHR cohort were, in general, superior compared with both the LHR and RHR. However, these strategies should be viewed as complementary. The best approach to an inguinal hernia repair rests on the specific expertise of the surgeon.

Barriers to adoption of laparoscopic cholecystectomy in a county hospital in Guatemala.

BACKGROUND: Despite international efforts to increase performance of laparoscopic cholecystectomy (LC) in rural Guatemala, the vast majority of cholecystectomies are still performed via the open cholecystectomy (OC) approach. Our goal was to explore barriers to the adoption of LC in Guatemala as well as possible mechanisms to overcome them. METHODS: We reviewed 9402 cholecystectomies performed over 14 years by surgeons at the Hospital Nacional de San Benito (HNSB) in El Peten, Guatemala, with either an open or a laparoscopic approach. We conducted personal interviews with all the surgeons who perform cholecystectomies at HNSB to determine current practice and barriers to adopting LC. RESULTS: Overall, seven general surgeons were interviewed who regularly perform cholecystectomy. Of the total number of cholecystectomies reviewed, 8440 (90%) were open and 962 (10%) were laparoscopic. The mean number of cholecystectomies performed per surgeon was 1341.1 ± 1244.9, with OC at 1205.7 ± 1194.9, and LC at 137.4 ± 188.0. Lack of formal training in laparoscopy was identified in 57% of surgeons. Lack of government funds to implement a laparoscopic program was noted by 71% of surgeons (29% felt there was insufficient ancillary staff, 29% poor allocation of hospital funding to purchase laparoscopic equipment/training). Lack of sufficient laparoscopic equipment was identified by 71% of surgeons. CONCLUSIONS: Ninety percent of cholecystectomies performed by surgeons at HNSB continue to be OC. The major limitation is the lack of funding to provide sufficient equipment or ancillary staff. The majority of surgeons preferred to perform LC if these problems could be addressed.

Resident postgraduate year does not influence rate of complications following inguinal herniorrhaphy.

BACKGROUND: Previous data indicate that patients who undergo surgery with a postgraduate year 3 (PGY-3) resident as the junior surgeon have a lower rate of recurrence compared with PGY-1 and PGY-2 after an open inguinal herniorrhaphy. Lower PGY level was also associated with increased operative time. We hypothesize that when controlling for surgeon, technique, and hernia type, the outcomes for inguinal herniorrhaphy are the same independent of PGY level. MATERIALS AND METHODS: A retrospective review of all open unilateral inguinal hernia repairs done by residents who assisted the same senior surgeon at the Veterans Affairs North Texas Health Care System was performed. RESULTS: Seven hundred fifty-two open unilateral inguinal hernia were identified: mean patient age = 60.6 ± 12.7 y; mean body mass index = 27.0 ± 10.8 kg/m2; American Society of Anesthesia III-IV = 51%; and Nyhus type 2 = 44.7%, 3a = 41.6%, and 3b = 13.7%. Residents involved were PGY-1 (17.2%), PGY-2/3 (71.1%), and PGY-4/5 (11.7%). Postoperative complications for intern, junior (PGY-2 and PGY-3), and senior residents (PGY-4 and PGY-5) were 4%, 9%, and 6%, respectively (P = 0.14). Compared to interns, junior residents finished the operation 3.9 min faster (95% confidence interval = -7.5, -0.3). There was no time difference between interns and senior residents completing the operations after controlling for hernia type. Logistic regression did not identify PGY level as an independent predictor of complications or recurrence. CONCLUSIONS: There was a slight decrease in operative time when the repair was done with junior-level residents. PGY level did not influence outcomes for open, unilateral inguinal herniorrhaphy when controlled for hernia type and technique.

Surgical approach to gallbladder disease in rural Guatemala.

BACKGROUND: In this article, we report the current surgical approach to gallbladder disease at a major referral hospital in rural Guatemala. Complications in a cohort of patients undergoing open versus laparoscopic cholecystectomy were catalogued. METHODS: We reviewed cholecystectomies performed by surgeons at the Hospital Nacional de San Benito in El Peten, Guatemala, after the adoption of the laparoscopic approach. Laparoscopic cholecystectomies (LCs) between 2014 and 2015 (n = 42) were reviewed and matched by 58 randomly selected open cholecystectomies (OCs) during the same period. RESULTS: Patient demographics were similar in the LC and OC groups. Of the 63 patients who had elective surgery, 43 (68%) underwent OC. Conversion rate, hospital length of stay, and readmission rate were 4%, 4.8 days, and 5%, respectively. Complications were similar between groups. CONCLUSIONS: Despite the low number of LCs, their complications were not different from that of OCs. During the study period, a large number of cholecystectomies continued to be open, even in the elective setting.