The open abdomen in mesenteric ischemia: A tool for patients undergoing revascularization.

BACKGROUND: We examined outcomes in Acute Mesenteric Ischemia (AMI) with the hypothesis that Open Abdomen (OA) is associated with decreased mortality. METHODS: We performed a cohort study reviewing NSQIP emergency laparotomy patients, 2016-2020, with a postoperative diagnosis of mesenteric ischemia. OA was defined using flags for patients without fascial closure. Logistic regression was used with outcomes of 30-day mortality and several secondary outcomes. RESULTS: Out of 5514 cases, 4624 (83.9%) underwent resection and 387 (7.0%) underwent revascularization. The OA rate was 32.6%. 10.8% of patients who were closed required reoperation. After adjustment for demographics, transfer status, comorbidities, preoperative variables including creatinine, white blood cell count, and anemia, as well as operative time, OA was associated with OR 1.58 for mortality (95% CI [1.38, 1.81], p < 0.001). Among revascularizations, there was no such association (p = 0.528). OA was associated with ventilator support >48 h (OR 4.04, 95% CI [3.55, 4.62], and p < 0.001). CONCLUSION: OA in AMI was associated with increased mortality and prolonged ventilation. This is not so in revascularization patients, and 1 in 10 patients who underwent primary closure required reoperation. OA should be considered in specific cases of AMI. LEVEL OF EVIDENCE: Retrospective cohort, Level III.

The variable role of damage control laparotomy over 19 years of trauma care in Pennsylvania.

BACKGROUND: Damage control laparotomy emphasizes physiologic stabilization of critically injured patients and allows staged surgical management. However, there is little consensus on the optimal criteria for damage control laparotomy. We examined variability between centers and over time in Pennsylvania. METHODS: We analyzed the Pennsylvania Trauma Outcomes Study data between 2000 and 2018, excluding centers performing <10 laparotomies/year. Laparotomy was defined using International Classification of Diseases codes, and damage control laparotomy was defined by a code for "reopening of recent laparotomy" or a return to the operating room >4 hours from index laparotomy that was not unplanned. We examined trends over time and by center. Multivariable logistic regression models were developed to predict both damage control laparotomy and mortality, generate observed:expected ratios, and identify outliers for each. We compared risk-adjusted mortality rates to center-level damage control laparotomy rates. RESULTS: In total, 18,896 laparotomies from 22 centers were analyzed; 3,549 damage control laparotomies were performed (18.8% of all laparotomies). The use of damage control laparotomy in Pennsylvania varied from 13.9% to 22.8% over time. There was wide variation in center-level use of damage control laparotomy, from 11.1% to 29.4%, despite adjustment. Factors associated with damage control laparotomy included injury severity and admission vital signs. Center identity improved the model as demonstrated by likelihood ratio test (P < .001), suggesting differences in center-level practices. There was minimal correlation between center-level damage control laparotomy use and mortality. CONCLUSION: There is wide center-level variation in the use of damage control laparotomy among centers, despite adjustment for patient factors. Damage control laparotomy is both resource intensive and highly morbid; regional resources should be allocated to address this substantial practice variation to optimize damage control laparotomy use.

Efficient evaluation of center-level emergency surgery performance using a high-yield procedure set: A step towards an EGS registry.

BACKGROUND: Emergency general surgery (EGS) lacks mechanisms to compare performance between institutions. Focusing on higher-risk procedures may efficiently identify outliers. METHODS: EGS patients were identified from the 2016 State Inpatient Databases of Florida, New York, and Kentucky. Risk-adjusted mortality was calculated as an O:E ratio, generating expected mortality from a model including demographic and procedural factors. Outliers were centers whose 90% confidence intervals excluded 1. This was repeated in several subsets, to determine if these yielded outliers similar to the overall dataset. RESULTS: We identified 45,430 EGS patients. Overall, 3 high performing centers and 5 low performing centers were identified. Exclusion of appendectomies and cholecystectomies resulted in a remaining data set of 13,569 patients (29.9% of the overall data set), with 2 high performers and 5 low performers. One low performer in the limited data set was not identified in the overall set. CONCLUSION: Evaluation of 5 procedures, making up less than a third of EGS, identifies most outliers. A streamlined monitoring procedure may facilitate maintenance of an EGS registry.

Differences Between Center-level Outcomes in Emergency and Elective General Surgery.

BACKGROUND: Center-level outcome metrics have long been tracked in elective surgery (ELS). Despite recent interest in measuring emergency general surgery (EGS) quality, centers are often compared based on elective or combined outcomes. Therefore, quality of care for emergency surgery specifically is unknown. METHODS: We extracted data on EGS and ELS patients from the 2016 State Inpatient Databases of Florida, New York, and Kentucky. Centers that performed >100 ELS and EGS operations were included. Risk-adjusted mortality, complication, and failure to rescue (FTR, death after complication) rates were calculated and observed-to-expected ratios were calculated by center for ELS and EGS patients. Centers were determined to be high or low outliers if the 90% CI for the observed: expected ratio excluded 1. We calculated the frequency with which centers demonstrated a different performance status between EGS and ELS. Kendall's tau values were calculated to assess for correlation between EGS and ELS status. RESULTS: A total of 204 centers with 45,500 EGS cases and 49,380 ELS cases met inclusion criteria. Overall mortality, complication, and FTR rates were 1.7%, 8.0%, and 14.5% respectively. There was no significant correlation between mortality performance in EGS and ELS, with 36 centers in a different performance category (high outlier, low outlier, as expected) in EGS than in ELS. The correlation for complication rates was 0.20, with 60 centers in different categories for EGS and ELS. For FTR rates, there was no correlation, with 16 centers changing category. CONCLUSIONS: There was minimal correlation between outcomes for ELS and EGS. High performers in one category were rarely high performers in the other. There may be important differences between the processes of care that are important for EGS and ELS outcomes that may yield meaningful opportunities for quality improvement.

An Assessment of Patient, Caregiver, and Clinician Perspectives on the Post-discharge Phase of Care.

OBJECTIVE: We sought to elicit patients', caregivers', and health care providers' perceptions of home recovery to inform care personalization in the learning health system. SUMMARY BACKGROUND DATA: Postsurgical care has shifted from the hospital into the home. Daily care responsibilities fall to patients and their caregivers, yet stakeholder concerns in these heterogeneous environments, especially as they relate to racial inequities, are poorly understood. METHODS: Surgical oncology patients, caregivers, and clinicians participated in freelisting; an open-ended interviewing technique used to identify essential elements of a domain. Within 2 weeks after discharge, participants were queried on 5 domains: home independence, social support, pain control, immediate, and overall surgical impact. Salience indices, measures of the most important words of interest, were calculated using Anthropac by domain and group. RESULTS: Forty patients [20 whites and 20 African-Americans (AAs)], 30 caregivers (17 whites and 13 AAs), and 20 providers (8 residents, 4 nurses, 4 nurse practitioners, and 4 attending surgeons) were interviewed. Patients and caregivers attended to the personal recovery experience, whereas providers described activities and individuals associated with recovery. All groups defined surgery as life-changing, with providers and caregivers discussing financial and mortality concerns. Patients shared similar thoughts about social support and self-care ability by race, whereas AA patients described heterogeneous pain management and more hopeful recovery perceptions. AA caregivers expressed more positive responses than white caregivers. CONCLUSIONS: Patients live the day-to-day of recovery, whereas caregivers and clinicians also contemplate more expansive concerns. Incorporating relevant perceptions into traditional clinical outcomes and concepts could enhance the surgical experience for all stakeholders.