Effects of malnutrition on complication rates, length of hospital stay, and revenue in elective surgical patients in the G-DRG-system.

OBJECTIVE: Malnutrition is known to independently affect patient outcomes. The aim of this study was to investigate the prevalence of patients at risk for malnutrition in an elective surgery patient cohort and to analyze the effects of malnutrition on morbidity, mortality, and hospital length of hospital (LOS). Furthermore, we aimed to evaluate the economic effect of a diligent coding of malnutrition, as a side diagnosis, in a simulation of the German Diagnosis-Related Group system. METHODS: The nutritional status of 1244 patients undergoing elective surgery was standardized on the day of admission by the Nutritional Risk Screening (NRS) 2002. To quantify the influence of malnutrition on revenue, the real DRGs of all patients were grouped. In simulation, an appropriate International Classification of Diseases code was used as a secondary diagnosis for all malnourished patients based on the NRS rating. A multivariate logistic regression analysis and a Cox regression were performed to identify potential confounders and to determine the adjusted effect of nutritional status on the occurrence of complications and hospital LOS. RESULTS: The prevalence of patients at risk for malnutrition (NRS ≥3) was 24.1% (300 of 1244). These patients showed a significant increase in hospital LOS (13 versus 7 d). Additionally, postoperative complications were significantly higher in this group (7.23% versus 6.91%). Including malnutrition in the Diagnosis-Related Group coding system resulted in a reimbursement of €1979.67 per patient at risk for malnutrition and a total reimbursement of €79,186.73 for all patients at risk for malnutrition in the present study. CONCLUSION: Establishment of a structured, comprehensive assessment of the nutritional status of hospitalized patients can repetitiously identify patients at risk for malnutrition. Additionally, the diligent codification of malnutrition can lead to cost compensation in the German Diagnosis-Related Group system.

Atrial resection for lung cancer: morbidity, mortality, and long-term follow-up.

BACKGROUND: The purpose of this study was to examine our results of combined resection of the atrium and non-small-cell lung cancer using a concurrent and continuously updated database. METHODS: A total of 35 patients underwent extended pulmonary resection with partial resection of the atrium. The main focus of the study was to define subgroups of patients who can potentially benefit from surgery. RESULTS: Pneumonectomy was performed in 31 cases, and the other 4 patients underwent a lesser resection. Postoperative morbidity was 20%, and the mortality rate was 9%. The median intensive care unit stay was 2 days and the hospital stay 13 days. The survival rates were 80% at 1 year, 21% at 3 years, and 16% at 5 years. The median survival of patients with low-grade tumors (G1/2) was 27 months, contrasted by only 15 months' survival for patients with high-grade tumors (P = 0.026). Multivariate analysis indicated that completeness of resection had a significant impact on survival (P = 0.042). CONCLUSIONS: Combined resection of lung and atrium is a complex surgical procedure, but it can be performed with fair morbidity and mortality rates, even in patients with an increased number of preoperative risk factors. Patients suffering from low-grade tumors benefit significantly from radical surgery. Future studies must define whether a multimodal therapeutic approach that includes induction therapy can prolong patient survival.

A critical analysis of laparoscopic appendectomy: how experience with 1,400 appendectomies allowed innovative treatment to become standard in a university hospital.

BACKGROUND: Although advantages of laparoscopic appendectomy (LA) have not yet been proved, there is increasing evidence that LA provides diagnostic and therapeutic advantages as compared to conventional surgery. This article reports the introduction of LA in a university hospital where LA now represents the standard operative procedure in patients with suspected appendicitis. METHODS: Consecutive patients with appendectomy were prospectively included in the surgical database from 5/1991 to 10/2005. Operating time skin-to-skin in minutes, conversion from laparoscopy to open appendectomy, and complications requiring reoperation as well as surgical expertise were recorded. RESULTS: After initial performance of LA by four experienced specialists in laparoscopic surgery between 1991 and 1994, LA was routinely implemented from 1995 to 2005. Laparoscopic appendectomy was performed in 1,012 patients, and conventional appendectomy in 449 patients, with a LA rate of about 90% in recent years. Intraoperative conversion was deemed necessary in 62 patients (6.2 %) by 40 surgeons among the 103 surgeons who performed LA over 14 years with a mean operative time of 57 +/- 2 min. Between 1995 and 2005 about 25%-30% of LAs were performed as the first LA for the respective surgeon. Laparoscopic appendectomy was associated overall with a reduced length of stay in the hospital compared to open appendectomy (LA: 4.4 +/- 0.1 days versus 6.6 +/- 0.2 in open appendectomy; p < 0.001). CONCLUSIONS: This analysis provides evidence that LA can be introduced in an university hospital with acceptable results despite low operation numbers per surgeon and a liberal teaching policy. The LA procedure, which is associated with a 2%-4% rate of reoperation, may serve as laparoscopy training for young surgeons.

Resection of malignant tumors invading the vena cava: perioperative complications and long-term follow-up.

OBJECTIVE: Invasion of the vena cava by malignant tumors is generally considered an absolute contraindication for surgery as a result of high surgical risk. Surgical treatment with resection of the vena cava may be beneficial for selected patients. This study was performed to evaluate our experiences with resection of the vena cava for malignant tumors, with a special focus on secondary tumors involving the inferior caval vein. METHODS: A total of 35 patients underwent extended resection of malignant tumors invading the vena cava. Prosthetic repair was performed in 13 patients by using a ringed polytetrafluoroethylene graft. Preoperative risk factors, mortality and morbidity, and long-term follow-up and graft patency rates were examined. RESULTS: The operative mortality rate was 6%. Minor complications occurred in 12 patients (34%). The graft patency rate was 85%, and there was no graft-related perioperative morbidity. The 1-, 3-, and 5-year survival rates were 76%, 32%, and 21%, respectively, with a median survival of 29 months. Incomplete resection and cardiopulmonary risk have a significant negative effect on survival. CONCLUSIONS: Radical resection of the vena cava is a feasible procedure in highly selected patients, with low morbidity and mortality and acceptable survival rates, especially in patients with complete resection of the tumor.

Analysis of specific transcriptional regulators as early predictors of independent prognostic relevance in resected colorectal cancer.

PURPOSE: Prognostic studies on transcription factors acting at specific promoter elements have never been done so far. However, in tumors with long necessary follow-up, such as colorectal cancer, early-risk predictors would be needed. The invasion-related gene u-PAR is regulated via an activator protein 2 (AP-2)/Sp1 (-152/-135) and an AP-1 binding promoter motif (-190/-171), mediating u-PAR induction by K-Ras and Src. The present study was done to give first evidence for early prognostic relevance of transcription factors differentially bound to the u-PAR promoter, and their molecular inducers, in colorectal cancer. EXPERIMENTAL DESIGN: Tumor/normal tissues of 92 prospectively followed (median = 26.3 months) patients were analyzed for Src activity/protein, K-ras mutations, and transcription factor binding to both u-PAR promoter motifs (in vivo gel shift, kinase assay, and PCR). RESULTS: Kaplan-Meier/Mantel-Cox analysis showed a significant correlation among elevated Sp1/Sp3 binding to region -152/-135 (P = 0.002 and P = 0.006), the combinations of Sp1/AP-2 and Sp1/AP-1 binding to both motifs (P = 0.010 and P = 0.005), and Sp1 binding/high Src protein in tumors (P < 0.001), with poor survival. Survival decreased with the number of bound transcription factors to both motifs, with binding of three factors defining a high-risk group (P = 0.021). In multivariate analysis, elevated Sp1 binding, combinations of Sp1/AP-2 binding and Sp1/AP-1 binding, or Sp1 binding/high Src were independent prognostic variables; u-PAR expression itself being not yet prognostic. A first molecular staging model (CART) was defined, providing novel early high-risk groups (mean survival time as low as for non-curatively resected patients) from these variables. CONCLUSIONS: This study defines transcription factors acting at specific promoter elements of an invasion-related gene, mediating specific signaling, as novel, independent, early predictors of prognosis in colorectal cancer.