Acute Kidney Injury After Large Ventral Hernia Repair Requiring Transversus Abdominis Release.

BACKGROUND: Acute kidney injury (AKI) is a known postoperative complication of open ventral hernia repair contributing to increased costs, hospital length of stay, and mortality. The aim of this study was to identify whether the muscle injury that occurs in a posterior separation of components via transversus abdominis release (TAR) contributes to a higher incidence of postoperative AKI. METHODS: A retrospective cohort study of patients who underwent open retrorectus ventral hernia repair with and without TAR at a single institution between 2012 and 2019 was performed. Patients who underwent a separation of components via either unilateral or bilateral transversus abdominis release were compared to those who did not undergo TAR as part of their hernia repair (non-TAR). The outcome of interest was the development of postoperative AKI. Acute kidney injury was defined as an increase in creatinine of greater than 50% of the preoperative baseline. Univariate and multivariate analyses were performed to determine the influence of TAR on the development of AKI. RESULTS: There were 523 patients who met inclusion criteria, of which 159 (30.4%) had a TAR as part of their retrorectus hernia repair. No differences were found in preoperative characteristics between the TAR and non-TAR group including age, gender, history of kidney disease, or history of diabetes. By contrast, the TAR group had significantly greater median estimated blood loss (100 mL vs 75 mL, P < .01), mean positive intraoperative fluid balance (2255 mL vs 1887 mL, P < .01), and operative duration (321 min vs 269 min, P < .001). The rate of AKI in the TAR group was 11% (n = 18) vs 6% (n = 23, P = .0503) in the non-TAR group. On multivariate analysis controlling for patient characteristics and intraoperative factors, TAR was the only factor with a significantly increased odds of AKI (OR 1.97, 95% CI 0.994-3.905, P = .0521). CONCLUSIONS: In patients with large ventral hernias requiring retrorectus repair, performing a TAR is associated with a nearly 2-fold increase in the development of postoperative AKI. These findings suggest that these patients should be optimized perioperatively with emphasis on fluid resuscitation, limiting nephrotoxic medications and monitoring urine output.

Sarcopenia predicts poor outcomes in urgent exploratory laparotomy.

BACKGROUND: Emergent laparotomies are associated with higher rates of morbidity and mortality. Recent studies suggest sarcopenia predicts worse outcomes in elective operations. The purpose of this study is to examine outcomes following urgent exploratory laparotomy in sarcopenic patients. METHODS: This was a retrospective review of patients in a rural tertiary care facility between 2010 and 2014. Patients underwent a laparotomy within 72 h of admission and had an abdomen/pelvis CT scan were included. Primary outcomes were predictors of morbidity and mortality. Sarcopenia is the lowest quartile cross sectional area of the psoas muscles. RESULTS: Multivariate analysis of 967 patients found that sarcopenic patients had higher mortality, complication rate, were less likely to be discharged home, were more likely to undergo unplanned re-operation, and had a longer length of stay. Increasing abdominal wall fat has favorable outcomes in mortality, discharge destination, and complications. CONCLUSIONS: Sarcopenia is measured from CT scans, making it an accessible outcome predictor. In urgent laparotomies, sarcopenia was associated with higher morbidity, mortality, length of stay, and worse discharge destination.

Analyzing the Impact of Compliance with National Guidelines for Pancreatic Cancer Care Using the National Cancer Database.

IMPORTANCE: Management of pancreatic cancer is complex, requiring coordination of multiple providers. National Comprehensive Cancer Network guidelines, developed for standardization and quality improvement, recommend a multimodal approach. OBJECTIVE: This study analyzed national rates of compliance with National Comprehensive Cancer Network recommendations, assessed factors affecting compliance, and evaluated whether compliance with evidence-based guidelines improved overall survival. DESIGN: This is a retrospective review of adults diagnosed with pancreatic cancer entered into the National Cancer Database. Patients included had stage I and II pancreatic cancer, and complete data in the database. Patients were classified as compliant if they underwent both surgery and a second treatment modality (chemotherapy, radiation, or chemoradiation). Clinico-pathologic variables were analyzed using univariate and multivariate models to predict overall survival. SETTING: Hospital-based national study population. PARTICIPANTS: Patients with stage I or II pancreatic cancer. MAIN OUTCOMES AND MEASURES: Compliance with National Comprehensive Cancer Network recommendations, factors affecting compliance, and overall survival based on compliance. RESULTS: A total of 52,450 patients were included; 19,272 patients (37%) were compliant. Patients were found to be most compliant in the 50-59-year-old range (49% complaint), with decreased compliance at the extremes of age. Male patients were more compliant than female patients (39 vs 34%, p < 0.0001). Caucasians were more compliant (39%) than African Americans (32%) or other races (32%, p < 0.0001). Patients treated at academic/research centers were more compliant than patients treated at other facilities (39% compliant, p < 0.0001). Patients with stage II disease were more compliant compared with stage I disease (43 vs 18%, p < 0.0001). Compliance was shown to improve overall survival (p < 0.0001). CONCLUSION: Adherence to National Comprehensive Cancer Network guidelines for pancreatic cancer patients improves survival. Compliance nationwide is low, especially for older patients and minorities and those treated outside academic centers. More studies will need to be performed to identify factors that hinder compliance.

The Effect of Sarcopenia on Outcomes in Geriatric Blunt Trauma.

Elderly patients are at a higher risk of morbidity and mortality after trauma, which is reflected through higher frailty indices. Data collection using existing frailty indices is often not possible because of brain injury, dementia, or inability to communicate with the patient. Sarcopenia is a reliable objective measure for frailty that can be readily assessed in CT imaging. In this study, we aimed to evaluate the effect of sarcopenia on the outcomes of geriatric blunt trauma patients. Left psoas area (LPA) was measured at the level of the third lumbar vertebra on the axial CT images. LPA was normalized for height (LPA mm2/m2) and after stratification by gender, sarcopenia was defined as LPA measurements in the lowest quartile. A total of 1175 patients consisting of 597 males and 578 females were studied. LPAs below 242.6 mm2/m2 in males and below 187.8 mm2/m2 in females were considered to be sarcopenic. We found sarcopenia in 149 males and 145 females. In multivariate analysis, sarcopenia was associated with a higher risk of in-hospital mortality (odds ratio [OR]: 1.61, 95% confidence interval [CI]: 1.01-2.56) and a higher risk of discharge to less favorable destinations (OR: 1.42, 95% CI: 1.05-1.97). Lastly, sarcopenic patients had an increased risk of prolonged hospitalization (hazard ratio: 1.21, 95% CI: 1.04-1.40).

Disparities in the Care of Differentiated Thyroid Cancer in the United States: Exploring the National Cancer Database.

Differentiated thyroid cancer (DTC) treatment is multifaceted, and may be influenced by socioeconomic factors. The goal of this study is to examine disparities in DTC treatment. DTC patients from 1998 to 2012 were identified using the National Cancer Database. DTC was identified in 262,041 patients. The mean age was 48.2. The majority of patients (52%) received care at Comprehensive Community Cancer Programs (CCCPs). Total thyroidectomy was less common at Community Cancer Programs (CCPs) [odds ratio (OR): 0.735; 95% confidence interval (CI): 0.707-0.764), and more common at academic centers (OR: 1.129; 95% CI: 1.102-1.157) compared with CCCP. A central neck dissection was performed most often at academic center (20.6%) versus CCP (10.0%). Black patients were less likely to undergo central neck dissection compared with white patients (OR: 0.468; 95% CI: 0.452-0.484). Patients more likely to receive radioactive iodine were white compared with black patients (hazard ratio: 0.833; 95% CI: 0.806-0.861), privately insured compared with uninsured patients (hazard ratio: 1.272; 95% CI: 1.210-1.341), and patients treated at CCCP. Disparities exist in DTC treatment. Individuals at risk for under-treatment are black patients, uninsured patients, and those treated at CCP. As the Affordable Care Act changes access to health care, future studies will be needed to readdress disparities.

Mode of Transport and Clinical Outcome in Rural Trauma: A Helicopter versus Ambulance Comparison.

Helicopter Emergency Medical Services (HEMS) is presumably an effective way of patient transport in rural trauma, yet the literature addressing its effectiveness is scarce. In this study, we compared the clinical outcome of rural trauma patients between Ground Emergency Medical Services (GEMS) and HEMS transportation from the beginning of 2006 to the end of 2012. Focus was placed on identifying factors associated with survival to discharge in these patients. Over the seven-year study period, 4492 patients met the inclusion criteria with 2414 patients (54%) being transferred by GEMS and 2078 patients (46%) being transferred by HEMS. In comparison with GEMS, patients transferred by HEMS were younger men who were admitted with a higher mean Injury Severity Score and a lower mean Glasgow Coma Score (all Ps < 0.0001). HEMS patients were more frequently intubated before arrival at the trauma center (32% vs 9%, P < 0.0001) and were more frequently transferred to the operating room from the emergency department (11% vs 5%, P < 0.0001). In multivariate analysis, transfer by HEMS was associated with a significant increase in survival to discharge (odds ratio: 1.57, 95% confidence interval: 1.03-2.40, P = 0.036). Blunt injury, no intubation, and Glasgow Coma Score >8 were also associated with significantly improved odds of survival to discharge (all P < 0.0001). These findings show that although patients transferred by HEMS arrived in less favorable clinical conditions, HEMS transfer was associated with significantly higher odds of survival in rural trauma.

Morphometric Predictors of Morbidity after Pancreatectomy.

Pancreatic surgery has historically been associated with high morbidity and mortality. One model that could predict outcomes is the assessment of preoperative morphometrics. The objective of this study was to compare different clinical and morphometric features of patients undergoing pancreatectomy to predict morbidity. This is a retrospective chart review of patients undergoing pancreatectomy from December 2004 to October 2013. Morphometric parameters on preoperative CT scans were measured and patients were grouped to examine their association with postoperative morbidity. A total of 180 patients were included in this study (90 males and 90 females). At the time of diagnosis, patients had an average age of 66.7 years (range = 24-90), and median body mass index of 27.4 kg/m2 (range = 16-58 kg/m2). Sixty-one patients (33.9%) experienced surgical complications. Of the individual morphometric variables examined, sarcopenia was the best predictor of length of stay and surgical complications. On multivariate analysis, there was a strong statistically significant correlation of sarcopenia with surgical complications (odds ratio = 3.524, P = 0.0049). No other morphometric variables predicted morbidity. Sarcopenia is a useful predictor for postoperative morbidity after pancreatectomy. The results of this study suggest that noninvasive preoperative testing can be used to quantify postoperative complications after pancreatic surgery.