Extracorporeal membrane oxygenation in severe traumatic brain injury: Is it safe?

BACKGROUND: Patients with severe traumatic brain injury (TBI) are at an increased risk of respiratory failure refractory to traditional therapies. The safety of extracorporeal membrane oxygenation (ECMO) in this population remains unclear. We aimed to examine outcomes following ECMO compared with traditional management in severe TBI patients. METHODS: We performed a retrospective cohort study using the Trauma Quality Improvement Program (2017-2020). We identified patients 18 years or older with severe TBI (Abbreviated Injury Score head, ≥3) who underwent ECMO or had either in-hospital cardiac or acute respiratory distress syndrome during their hospitalization. The study excluded pPatients who arrived without signs of life, had a prehospital cardiac arrest, had an unsurvivable injury, were transferred out within 48 hours of arrival, or were received as a transfer and died within 12 hours of arrival Patients with missing information regarding in-hospital mortality were also excluded. Outcomes included mortality, in-hospital complications, and intensive care unit length of stay. To account for patient and injury characteristics, we used 1:1 propensity matching. We performed a subgroup analysis among ECMO patients, comparing patients who received anticoagulants with those who did not. RESULTS: We identified 10,065 patients, of whom 221 (2.2%) underwent ECMO. In the propensity-matched sample of 134 pairs, there was no difference in mortality. Extracorporeal membrane oxygenation was associated with a higher incidence of cerebrovascular accidents (9% vs. 1%, p = 0.006) and a lower incidence of ventilator-associated pneumonia. In the subgroup analysis of 64 matched pairs, patients receiving anticoagulation had lower mortality, higher unplanned return to the operating room, and longer duration of ventilation and intensive care unit length of stay. CONCLUSION: Extracorporeal membrane oxygenation use in severe TBI patients was not associated with higher mortality and should be considered a potential intervention in this patient population. Systemic anticoagulation showed mortality benefit, but further work is required to elucidate the impact on neurological outcomes, and the appropriate dosing and timing of anticoagulation. LEVEL OF EVIDENCE: Therapeutic; Level IV.

Limb Hemorrhage Control Failure with Counterfeit Tourniquet: A Ukrainian War MEDEVAC Case Report.

Rapid and effective tourniquet application is crucial in life-threatening limb hemorrhage to minimize mortality. However, the widespread availability of counterfeit tourniquets is a growing concern, as these devices may lack essential quality control measures, potentially compromising patient care. We describe one case where the delayed mechanical failure of a Combat Application Tourniquet (CAT)-like tourniquet caused the death of a Ukrainian soldier during evacuation to an urban trauma center. In April 2022, a 19-year-old male underwent a bilateral below-the-knee amputation from an antipersonnel landmine. Massive hemorrhage prompted the use of bilateral CAT-like tourniquets. During transportation, the right tourniquet's windlass broke, resulting in a brisk hemorrhage. Due to the high patient-to-healthcare-personnel ratio, the bleeding remained unaddressed for an unknown amount of time, resulting in death from hemorrhagic shock. This study underscores the need for robust quality control measures and the establishment of strict regulations against deploying counterfeit tourniquets to avoid preventable deaths.

Renal angioembolization vs. surgery for high-grade renal trauma: a nationwide comparative analysis.

PURPOSE: Renal angioembolization (RAE) is widely employed in low-grade renal injuries and associated with improved patient outcomes, while surgery remains the mainstay for managing high-grade injuries. We compared the outcomes following surgery and RAE in high-grade renal trauma (HGRT). METHODS: We used the ACS TQIP 2016-2020 to identify patients ≥ 16 years with HGRT who underwent RAE or surgery. Morbidity was the primary outcome, while mortality and lengths of stay were secondary outcomes. We accounted for clinically relevant characteristics using multilevel logistic regression analyses. RESULTS: We included 591 patients, of whom 279 (47.2%) underwent RAE. After adjusting, there was no difference in morbidity, hospital LOS, or ICU LOS. The surgery cohort had increased odds of mortality (aOR 4.93; [95% CI] 1.53-15.82; p = 0.007) compared to RAE. In the penetrating injury subgroup, no associations between management and outcomes were observed. In the grade V injury subgroup, morbidity was significantly higher after surgery (aOR 4.64; [95% CI] 1.49-14.47; p = 0.008). CONCLUSION: Overall, RAE did not significantly impact morbidity but was associated with improved mortality. RAE could safeguard renal function by augmenting the efficacy of concurrent non-operative interventions. Randomized studies are needed to further validate the utility of RAE in HGRT.

Outcomes of severe isolated blunt chest trauma in young and geriatric patients.

PURPOSE: Our understanding of the growing geriatric population's risk factors for outcomes after traumatic injury remains incomplete. This study aims to compare outcomes of severe isolated blunt chest trauma between young and geriatric patients and assess predictors of mortality. METHODS: The ACS-TQIP 2017-2020 database was used to identify patients with severe isolated blunt chest trauma. Patients having extra-thoracic injuries, no signs of life upon presentation to the emergency department (ED), prehospital cardiac arrest, or who were transferred to or from other hospitals were excluded. The primary outcome was in-hospital mortality. Univariate and multivariable regression analyses were performed to assess independent predictors of mortality. RESULTS: A total of 189,660 patients were included in the study, with a median age of 58 years; 37.5% were aged 65 or older, and 1.9% died by discharge. Patients aged 65 and older had significantly higher mortality (3.4% vs. 1.0%, p < 0.001) and overall complications (7.0% vs. 4.7%, p < 0.001) compared to younger patients. Age ≥ 65 was independently associated with mortality (OR: 5.45, 95%CI: 4.96-5.98, p < 0.001), prolonged hospitalization, and complications. In the geriatric group, age > 75 was an independent predictor of mortality compared to ages 65-75 (OR: 2.62, 95%CI: 2.37-2.89, p < 0.001). Geriatric patients with an MVC, presenting with a GCS ≤ 8, and having an SBP < 90 had the highest mortality of 56.9%. CONCLUSION: The geriatric trauma patient with isolated severe blunt chest injury has significantly higher mortality and morbidity compared to younger patients and warrants special consideration of multiple factors that affect outcomes. Individual predictors of mortality carry a greater impact on mortality in geriatric patients.

Racial and Ethnic Disparities in Emergency General Surgery Outcomes Among Older Adult Patients.

INTRODUCTION: Racial and ethnic disparities in emergency general surgery (EGS) patients have been well described in the literature. Nonetheless, the burden of these disparities, specifically within the more vulnerable older adult population, is relatively unknown. This study aims to investigate racial and ethnic disparities in clinical outcomes among older adult patients undergoing EGS. METHODS: This retrospective analysis used data from 2013 to 2019 American College of Surgeons National Surgery Quality Improvement Program database. EGS patients aged 65 y or older were included. Patients were categorized based on their self-reported race and ethnicity. The primary outcomes evaluated were in-hospital mortality, 30-d mortality, and overall morbidity. Multivariable logistic regression was performed to examine the relationship between race/ethnicity and postoperative outcomes while adjusting for relevant factors including age, comorbidities, functional status, preoperative conditions, and surgical procedure. RESULTS: A total of 54,132 patients were included, of whom 79.8% identified as non-Hispanic White, 9.5% as non-Hispanic Black (NHB), 5.8% as Hispanic, and 4.2% as non-Hispanic Asian. After risk adjustment, compared to non-Hispanic White patients, NHB, non-Hispanic Asian, and Hispanic patients had decreased odds of 30-d mortality. For 30-d readmission and reoperation, differences among groups were comparable. However, NHB patients had significantly increased odds of overall morbidity (adjusted odds ratio, 1.18; 95% confidence interval: 1.10-1.26; P < 0.001) and postoperative complications including sepsis, venous thromboembolism, and unplanned intubation. Hispanic ethnicity was associated with lower odds of postoperative myocardial infarction and stroke. CONCLUSIONS: Among older adult patients undergoing emergency general surgery, minority patients experienced higher morbidity rates, but paradoxical disparities in mortality were detected. Further research is necessary to identify the cause of these disparities and develop targeted interventions to eliminate them.

The impact of comorbidities and functional status on outcomes in the older adult emergency general surgery patient.

BACKGROUND: The aim of this study is to quantify the relative contribution of comorbidities and pre-operative functional status on outcomes in geriatric emergency general surgery (EGS) patients. METHODS: This is a retrospective study of older-adult EGS patients at an academic medical center between 2017 and 2018. Patients ≥65 years were included. The primary outcomes examined were 30-day mortality, 30-day morbidity, and length of stay (LOS). RESULTS: 734 patients were included. The mean age was 76, and 48.9 â€‹% received non-operative management. The median LOS was 6.8 days; 11.8 â€‹% of patients died within 30 days, and 40.6 â€‹% developed morbidities. Lacking capacity to consent on admission was independently associated with 30-day mortality (OR: 2.63, [1.32-5.25], p â€‹= â€‹0.006). Comorbidities associated with developing morbidity were CVA with neurologic deficit (OR: 2.29, [1.20-4.36], p â€‹= â€‹0.012), CHF (OR: 2.60, [1.64-4.11], p â€‹< â€‹0.001), in addition to pre-operative delirium (OR: 3.42, [1.43-8.14], p â€‹= â€‹0.006). CONCLUSIONS: A significant contribution to outcomes is determined by pre-admission comorbidities and cognitive and functional status. Opportunities exist for collaboration between Acute Care Surgery and geriatric medicine teams for the optimization of comorbidities.

First do no harm: Predicting futility of intervention in geriatric emergency general surgery.

BACKGROUND: Emergent surgical conditions are common in geriatric patients, often necessitating major operative procedures on frail patients. Understanding risk profiles is crucial for decision-making and establishing goals of care. METHODS: We queried NSQIP 2015-2019 for patients ≥65 years undergoing open abdominal surgery for emergency general surgery conditions. Logistic regression was used to identify 30-day mortality predictors. RESULTS: Of 41,029 patients, 5589 (13.6 â€‹%) died within 30 days of admission. The highest predictors of mortality were ASA status 5 (aOR 9.7, 95 â€‹% CI,3.5-26.8, p â€‹< â€‹0.001), septic shock (aOR 4.9, 95 â€‹% CI,4.5-5.4, p â€‹< â€‹0.001), and dialysis (aOR 2.1, 95 â€‹% CI,1.8-2.4, p â€‹< â€‹0.001). Without risk factors, mortality rates were 11.9 â€‹% after colectomy and 10.2 â€‹% after small bowel resection. Patients with all three risk factors had a mortality rate of 79.4 â€‹% and 100 â€‹% following colectomy and small bowel resection, respectively. CONCLUSIONS: In older adults undergoing emergent open abdominal surgery, septic shock, ASA status, and dialysis were strongly associated with futility of surgical intervention. These findings can inform goals of care and informed decision-making.

Lost in transition: Impact of interhospital transfer on outcomes after emergency general surgery in the older adult population.

BACKGROUND: Emergency general surgery performed among patients over 65 years of age represents a particularly high-risk population. Although interhospital transfer has been linked to higher mortality in emergency general surgery patients, its impact on outcomes in the geriatric population remains uncertain. We aimed to establish the effect of interhospital transfer on postoperative outcomes in geriatric emergency general surgery patients. METHODS: Emergency general surgery patients 65 years and older were identified with American College of Surgeons National Surgical Quality Improvement Program 2013 to 2019. Patients were categorized based on admission source as either directly admitted or transferred from an outside hospital inpatient unit or emergency department. The primary outcomes evaluated were in-hospital mortality, 30-day mortality, and overall morbidity. Propensity score matching was used to control for confounders, including age, race, comorbidities, and preoperative conditions. Kaplan-Meier survival analysis and the log-rank test were used to compare 30-day survival in the matched cohort. RESULTS: Among the 88,424 patients identified, 13,872 (15.7%) were transfer patients. The median age was 74, and 53% were of female sex. Transfer patients had higher rates of comorbidities and preoperative conditions, including a higher prevalence of preoperative sepsis (21.8% vs 19.3%, P < .001) and ventilator dependence (6.4% vs 2.6%, P < .001). After propensity score-matched analysis, transferred patients exhibited higher rates of in-hospital mortality, 30-day mortality, and overall morbidity. Transfer patients were also less likely to be discharged home and more likely to be discharged to an acute care facility. Kaplan-Meier survival analysis confirmed a poorer 30-day survival in transferred patients. CONCLUSION: Interhospital transfer independently contributed to overall mortality and morbidity amongst geriatric emergency general surgery patients. Further investigation into improved coordination between hospitals, tailored care plans, and comprehensive risk assessments are needed to help mitigate the observed differences in outcomes.

Discharge to Skilled Nursing Facility Is a Risk Factor for Readmission: A Nationwide Propensity-Matched Study.

INTRODUCTION: General surgery procedures place stress on geriatric patients, and postdischarge care options should be evaluated. We compared the association of discharge to a skilled nursing facility (SNF) versus home on patient readmission. METHODS: We retrospectively reviewed the Nationwide Readmission Database (2016-2019) and included patients ≥65 y who underwent a general surgery procedure between January and September. Our primary outcome was 30-d readmissions. Our secondary outcome was predictors of readmission after discharge to an SNF. We performed a 1:1 propensity-matched analysis adjusting for patient demographics and hospital course to compare patients discharged to an SNF with patients discharged home. We performed a sensitivity analysis on patients undergoing emergency procedures and a stepwise regression to identify predictors of readmission. RESULTS: Among 140,056 included patients, 33,916 (24.2%) were discharged to an SNF. In the matched population of 19,763 pairs, 30-d readmission was higher in patients discharged to an SNF. The most common diagnosis at readmission was sepsis, and a greater proportion of patients discharged to an SNF were readmitted for sepsis. In the sensitivity analysis, emergency surgery patients discharged to an SNF had higher 30-d readmission. Higher illness severity during the index admission and living in a small or fringe county of a large metropolitan area were among the predictors of readmission in patients discharged to an SNF, while high household income was protective. CONCLUSIONS: Discharge to an SNF compared to patients discharged home was associated with a higher readmission. Future studies need to identify the patient and facility factors responsible for this disparity.

The Open Abdomen After Intra-Abdominal Contamination in Emergency General Surgery.

INTRODUCTION: Delayed fascial closure (DFC) is an increasingly utilized technique in emergency general surgery (EGS), despite a lack of data regarding its benefits. We aimed to compare the clinical outcomes of DFC versus immediate fascial closure (IFC) in EGS patients with intra-abdominal contamination. METHODS: This retrospective study was conducted using the 2013-2020 American College of Surgeons National Surgical Quality Improvement Program database. Adult EGS patients who underwent an exploratory laparotomy with intra-abdominal contamination [wound classification III (contaminated) or IV (dirty)] were included. Patients with agreed upon indications for DFC were excluded. A propensity-matched analysis was performed. The primary outcome was 30-d mortality. RESULTS: We identified 36,974 eligible patients. 16.8% underwent DFC, of which 51.7% were female, and the median age was 64 y. After matching, there were 6213 pairs. DFC was associated with a higher risk of mortality (15.8% versus 14.2%, P = 0.016), pneumonia (11.7% versus 10.1%, P = 0.007), pulmonary embolism (1.9% versus 1.6%, P = 0.03), and longer hospital stay (11 versus 10 d, P < 0.001). No significant differences in postoperative sepsis and deep surgical site infection rates between the two groups were observed. Subgroup analyses by preoperative diagnosis (diverticulitis, perforation, and undifferentiated sepsis) showed that DFC was associated with longer hospital stay in all subgroups, with a higher mortality rate in patients with diverticulitis (8.1% versus 6.1%, P = 0.027). CONCLUSIONS: In the presence of intra-abdominal contamination, DFC is associated with longer hospital stay and higher rates of mortality and morbidity. DFC was not associated with decreased risk of infectious complications. Further studies are needed to clearly define the indications of DFC.

Debunking the "Obesity Paradox": Obesity Is Associated With Adverse Outcomes in Emergency General Surgery.

INTRODUCTION: Obesity is increasingly prevalent both nationwide and in the emergency general surgery (EGS) population. While previous studies have shown that obesity may be protective against mortality following EGS procedures, the association between body mass index (BMI) and postoperative outcomes, as well as intraoperative decision-making, remains understudied. METHODS: The National Surgical Quality Improvement Program 2015-2019 database was used to identify all adult patients undergoing an open abdominal or abdominal wall procedure for EGS conditions. Our outcomes included 30-d postoperative mortality, composite 30-d morbidity, delayed fascial closure, reoperation, operative time, and hospital length of stay (LOS). Multivariable logistic regression models were used to explore the association between BMI and each outcome of interest while adjusting for patient demographics, comorbidities, laboratory tests, preoperative and intraoperative variables. RESULTS: We identified 78,578 patients, of which 3121 (4%) were categorized as underweight, 23,661 (30.1%) as normal weight, 22,072 (28.1%) as overweight, 14,287 (18.2%) with class I obesity, 7370 (9.4%) with class II obesity, and 8067 (10.3%) with class III obesity. Class III obesity was identified as a risk factor for 30-d postoperative morbidity (adjusted odds ratio 1.14, 95% CI, 1.03-1.26, P < 0.01). An increase in obesity class was also associated with a stepwise increase in the risk of undergoing delayed fascial closure, experiencing a prolonged operative time, and having an extended LOS. CONCLUSIONS: Obesity class was associated with an increase in delayed fascial closure, longer operative time, higher reoperation rates, and extended hospital LOS. Further studies are needed to explore how a patient's BMI impacts intraoperative factors, influences surgical decision-making, and contributes to hospital costs.

Emergency general surgery in older adult patients: Factors associated with fragmented care.

BACKGROUND: Care fragmentation has been shown to lead to increased morbidity and mortality. We aimed to explore the factors related to care fragmentation after hospital discharge in geriatric emergency general surgery patients, as well as examine the association between care fragmentation and mortality. METHODS: We designed a retrospective study of the Nationwide Readmissions Database 2019. We included patients ≥65 years old admitted with an emergency general surgery diagnosis who were discharged alive from the index admission. The primary outcome was 90-day care fragmentation, defined as an unplanned readmission to a non-index hospital. Multivariable logistic regression was performed, adjusting for patient and hospital characteristics. RESULTS: A total of 447,027 older adult emergency general surgery patients were included; the main diagnostic category was colorectal (22.6%), and 78.2% of patients underwent non-operative management during the index hospitalization. By 90 days post-discharge, 189,622 (24.3%) patients had an unplanned readmission. Of those readmitted, 20.8% had care fragmentation. The median age of patients with care fragmentation was 76 years, and 53.2% were of female sex. Predictors of care fragmentation were living in rural counties (odds ratio 1.76, 95% confidence interval: 1.57-1.97), living in a low-income ZIP Code, discharge to intermediate care facility (odds ratio 1.28, 95% confidence interval: 1.22-1.33), initial non-operative management (odds ratio 1.17, 95% confidence interval: 1.12-1.23), leaving against medical advice (odds ratio 2.60, 95% confidence interval: 2.29-2.96), and discharge from private investor-owned hospitals (odds ratio 1.18, 95% confidence interval: 1.10-1.27). Care fragmentation was significantly associated with higher mortality. CONCLUSION: The burden of unplanned readmissions in older adult patients who survive an emergency general surgery admission is underestimated, and these patients frequently experience care fragmentation. Future directions should prioritize evaluating the impact of initiatives aimed at alleviating the incidence and complications of care fragmentation in geriatric emergency general surgery patients.

Two big bones, one big decision: When to fix bilateral femur fractures.

PURPOSE: For polytrauma patients with bilateral femoral shaft fractures (BFSF), there is currently no consensus on the optimal timing of surgery. This study assesses the impact of early (≤ 24 h) versus delayed (>24 h) definitive fixation on clinical outcomes, especially focusing on concomitant versus staged repair. We hypothesized that early definitive fixation leads to lower mortality and morbidity rates. METHODS: The 2017-2020 Trauma Quality Improvement Program was used to identify patients aged ≥16 years with BFSF who underwent definitive fixation. Early definitive fixation (EDF) was defined as fixation of both femoral shaft fractures within 24 h, delayed definitive fixation (DDF) as fixation of both fractures after 24 h, and early staged fixation (ESF) as fixation of one femur within 24 h and the other femur after 24 h. Propensity score matching and multilevel mixed effects regression models were used to compare groups. RESULTS: 1,118 patients were included, of which 62.8% underwent EDF. Following propensity score matching, 279 balanced pairs were formed. EDF was associated with decreased overall morbidity (12.9% vs 22.6%, p = 0.003), lower rate of deep venous thrombosis (2.2% vs 6.5%, p = 0.012), a shorter ICU LOS (5 vs 7 days, p < 0.001) and a shorter hospital LOS (10 vs 15 days, p < 0.001). When compared to DDF, early staged fixation (ESF) was associated with lower rates of ventilator acquired pneumonia (0.0% vs 4.9%, p = 0.007), but a longer ICU LOS (8 vs 6 days, p = 0.004). Using regression analysis, every 24-hour delay to definitive fixation increased the odds of developing complications by 1.05, postoperative LOS by 10 h and total hospital LOS by 27 h. CONCLUSION: Early definitive fixation (≤ 24 h) is preferred over delayed definitive fixation (>24 h) for patients with bilateral femur shaft fractures when accounting for age, sex, injury characteristics, additional fractures and interventions, and hospital level. Although mortality does not differ, overall morbidity and deep venous thrombosis rates, and length of hospital and intensive care unit stay are significantly lower. When early definitive fixation is not possible, early staged repair seems preferable over delayed definitive fixation.

Development of a two-hit lethal liver injury model in swine.

PURPOSE: Noncompressible truncal hemorrhage remains a leading cause of preventable death in the prehospital setting. Standardized and reproducible large animal models are essential to test new therapeutic strategies. However, existing injury models vary significantly in consistency and clinical accuracy. This study aims to develop a lethal porcine model to test hemostatic agents targeting noncompressible abdominal hemorrhages. METHODS: We developed a two-hit injury model in Yorkshire swine, consisting of a grade IV liver injury combined with hemodilution. The hemodilution was induced by controlled exsanguination of 30% of the total blood volume and a 3:1 resuscitation with crystalloids. Subsequently, a grade IV liver injury was performed by sharp transection of both median lobes of the liver, resulting in major bleeding and severe hypotension. The abdominal incision was closed within 60 s from the injury. The endpoints included mortality, survival time, serum lab values, and blood loss within the abdomen. RESULTS: This model was lethal in all animals (5/5), with a mean survival time of 24.4 ± 3.8 min. The standardized liver resection was uniform at 14.4 ± 2.1% of the total liver weight. Following the injury, the MAP dropped by 27 ± 8mmHg within the first 10 min. The use of a mixed injury model (i.e., open injury, closed hemorrhage) was instrumental in creating a standardized injury while allowing for a clinically significant hemorrhage. CONCLUSION: This novel highly lethal, consistent, and clinically relevant translational model can be used to test and develop life-saving interventions for massive noncompressible abdominal hemorrhage.

Analyzing the Impact of Concomitant COVID-19 Infection on Outcomes in Trauma Patients.

BACKGROUND: The impact of COVID-19 infection at the time of traumatic injury remains understudied. Previous studies demonstrate that the rate of COVID-19 vaccination among trauma patients remains lower than in the general population. This study aims to understand the impact of concomitant COVID-19 infection on outcomes in trauma patients. METHODS: We conducted a retrospective cohort study of patients ≥18 years old admitted to a level I trauma center from March 2020 to December 2022. Patients tested for COVID-19 infection using a rapid antigen/PCR test were included. We matched patients using 2:1 propensity accounting for age, gender, race, comorbidities, vaccination status, injury severity score (ISS), type and mechanism of injury, and GCS at arrival. The primary outcome was inpatient mortality. Secondary outcomes included hospital length of stay (LOS), Intensive Care Unit (ICU) LOS, 30-day readmission, and major complications. RESULTS: Of the 4448 patients included, 168 (3.8%) were positive (COV+). Compared with COVID-19-negative (COV-) patients, COV+ patients were similar in age, sex, BMI, ISS, type of injury, and regional AIS. The proportion of White and non-Hispanic patients was higher in COV- patients. Following matching, 154 COV+ and 308 COV- patients were identified. COVID-19-positive patients had a higher rate of mortality (7.8% vs 2.6%; P = .010), major complications (15.6% vs 8.4%; P = .020), and thrombotic complications (3.9% vs .6%; P = .012). Patients also had a longer hospital LOS (median, 9 vs 5 days; P < .001) and ICU LOS (median, 5 vs 3 days; P = .025). CONCLUSIONS: Trauma patients with concomitant COVID-19 infection have higher mortality and morbidity in the matched population. Focused interventions aimed at recognizing this high-risk group and preventing COVID-19 infection within it should be undertaken.

The overlooked factor: The impact of disability on postoperative complications after emergency general surgery procedures.

BACKGROUND: Despite more than 61 million people in the United States living with a disability, studies on the impact of disability on health care disparities in surgical patients remain limited. Therefore, we aimed to understand the impact of disability on postoperative outcomes. METHODS: We performed a retrospective cohort study using the Nationwide Readmission Database (2019). We compared patients ≥18 years undergoing emergency general surgery procedures with a disability condition with those without a disability. In accordance with the Centers for Disease Control and Prevention, disability was defined as severe hearing, visual, intellectual, or motor impairment/caregiver dependency. The primary outcome was 30-day readmission rates. Secondary outcomes included hospital length of stay and 30-day complications and mortality. Patients were 1:1 propensity-matched using patient, procedure, and hospital characteristics. RESULTS: Among our population of 378,733 patients, 5,877 (1.6%) patients had at least 1 disability condition. A higher proportion of patients with a disability had low household income, $1 to $45,999, and an Elixhauser Comorbidity score ≥3. Among 5,768 matched pairs, patients with a disability had a significantly higher incidence of 30-day readmission (17.2% vs 12.7%; P < .001), infectious complications (29.8% vs 19.5%; P < .001), and a longer length of stay (8 vs 6 days; P < .001). Motor impairment, the most common disability, was associated with the greatest increase in patient readmission, morbidity, and length of stay. CONCLUSION: Severe intellectual, hearing, visual, or motor impairments were associated with higher readmission, morbidity, and longer length of stay. Further research is needed to understand the mechanisms responsible for these disparities and to develop interventions to ameliorate them.

To Resect or Not to Resect: A Nationwide Comparison of Management of Sigmoid Volvulus.

INTRODUCTION: Despite the high recurrence rate of sigmoid volvulus, there is reluctance to perform a prophylactic colectomy in frail patients due to the operation's perceived risks. We used a nationally representative database to compare risk of recurrence in patients undergoing a prophylactic colectomy versus endoscopic detorsion alone. METHODS: We performed a retrospective cohort study using the National Readmission Database (2016-2019) including patients aged ≥18 y who had an emergent admission for sigmoid volvulus and underwent endoscopic detorsion on the day of admission. We performed a 1:1 propensity matching adjusting for patient demographics, frailty score comprising of 109 components, and hospital characteristics. Our primary outcome was readmission due to colonic volvulus and secondary outcomes included mortality, complications, length of stay (LOS), and costs during index admission and readmission. We performed a subgroup analysis in patients with Hospital Frailty Score >5. RESULTS: We included 2113 patients of which 1046 patients (49.5%) underwent a colectomy during the initial admission. In the matched population of 830 pairs, readmission due to colonic volvulus was significantly lower in patients undergoing endoscopy followed by colectomy than endoscopy alone. Patients undergoing a colectomy had higher gastric and renal complications, longer LOS, and higher costs but no difference in mortality. In the subgroup analysis of frail patients, readmission was significantly lower in patients with prophylactic colectomy with no significant difference in mortality in 439 matched patients. CONCLUSIONS: Prophylactic colectomy was associated with lower readmission, a higher rate of complications, increased LOS, and higher costs compared to sigmoid decompression alone.

Does practice make perfect? The impact of hospital and surgeon volume on complications after intra-abdominal procedures.

BACKGROUND: There is increasing interest in the regionalization of surgical procedures. However, evidence on the volume-outcome relationship for emergency intra-abdominal surgery is not well-synthesized. This systematic review and meta-analysis summarize evidence regarding the impact of hospital and surgeon volume on complications. METHODS: We identified cohort studies assessing the impact of hospital/surgeon volume on postoperative complications after emergency intra-abdominal procedures, with data collected after the year 2000 through a literature search without language restriction in the PubMed, Web of Science, and Cochrane databases. A weighted overall complication rate was calculated, and a random effect regression model was used for a summary odds ratio. A sensitivity analysis with the removal of studies contributing to heterogeneity was performed (PROSPERO: CRD42022358879). RESULTS: The search yielded 2,153 articles, of which 9 cohort studies were included and determined to be good quality according to the Newcastle Ottawa Scale. These studies reported outcomes for the following procedures: cholecystectomy, colectomy, appendectomy, small bowel resection, peptic ulcer repair, adhesiolysis, laparotomy, and hernia repair. Eight studies (2,358,093 patients) with available data were included in the meta-analysis. Low hospital volume was not significantly associated with higher complications. In the sensitivity analysis, low hospital volume was significantly associated with higher complications when appropriate heterogeneity was achieved. Low surgeon volume was associated with higher complications, and these findings remained consistent in the sensitivity analysis. CONCLUSION: We found that hospital and surgeon volume was significantly associated with higher complications in patients undergoing emergency intra-abdominal surgery when appropriate heterogeneity was achieved.

The association of disability conditions with access to minimally invasive general surgery.

BACKGROUND: Despite the high prevalence of disability conditions in the US, their association with access to minimally invasive surgery (MIS) remains under-characterized. OBJECTIVE: To understand the association of disability conditions with rates of MIS and describe nationwide temporal trends in MIS in patients with disability conditions. METHODS: We conducted a retrospective cohort study using the Nationwide Readmission Database (2016-2019). We included patients ≥18 years undergoing general surgery procedures. Our primary outcome was the impact of disability conditions on the rate of MIS. We performed 1:1 propensity matching, comparing patients with disability conditions with those without and adjusting for patient, procedure, and hospital characteristics. We performed a subgroup analysis among patients<65 years and with patients with each type of disability. We evaluated temporal trends of MIS in patients with disabilities. We identified predictors of undergoing MIS using mixed effects regression analysis. RESULTS: In the propensity-matched comparison, a lower proportion of patients with disabilities had MIS. In the sub-group analyses, the rate of MIS was significantly lower in patients below 65 years with disabilities and among patients with motor and intellectual impairments. There was an increasing trend in the proportion of patients with disabilities undergoing MIS (p < 0.005). The regression analysis confirmed that the presence of a disability was associated with decreased odds of undergoing MIS. CONCLUSIONS: This study characterizes the negative association of disability conditions with access to MIS. As the healthcare landscape evolves, considerations on how to equitably share new treatment modalities with a wide range of patient populations are necessary.