Renal insufficiency predicts mortality in geriatric patients undergoing emergent general surgery.

Clinical predictors of perioperative mortality in geriatric patients undergoing emergent general surgery have not been well described. The purpose of this study was to determine the incidence of postoperative morbidity and mortality in geriatric patients and factors associated with mortality. A retrospective review of patients 65 years of age or older undergoing emergent general surgery at a public teaching hospital was performed over a 7-year period. Data collected included demographics, comorbidities, laboratory studies, perioperative morbidities, and mortality. Descriptive statistics and predictors of morbidity and mortality are described. The mean age was 74 years. Indications for surgery included small bowel obstruction (24%), diverticulitis (20%), perforated viscous (16%), and large bowel obstruction (9%). The overall complication rate was 41 per cent with six cardiac complications (14%) and seven perioperative (16%) deaths. Mean admission serum creatinine was significantly higher in patients who died (3.6 vs 1.5 mg/dL, P = 0.004). Mortality for patients with an admission serum creatinine greater than 2.0 mg/dL was 42 per cent (5 of 12) compared with 3 per cent (2 of 32) for those 2.0 mg/dL or less (OR, 10.7; CI, 1.7 to 67; P = 0.01). Morbidity and mortality in geriatric patients undergoing emergency surgery remains high with the most significant predictor of mortality being the presence of renal insufficiency on admission.

Decreased bile duct injury rate during laparoscopic cholecystectomy in the era of the 80-hour resident workweek.

BACKGROUND: Considerable concern has been raised about the effects of restricted duty hours on surgical training. However, to our knowledge, the effect of the 80-hour resident workweek on operative outcomes after laparoscopic cholecystectomy has not been well studied. OBJECTIVE: To compare the rates of bile duct injury and overall complications after laparoscopic cholecystectomy before and after the institution of the duty-hour restriction. DESIGN: Retrospective review of patient medical records to determine morbidity and mortality before (January 1, 2000, to June 30, 2003; period 1) and after (July 1, 2003, to June 30, 2006; period 2) implementation of duty hour limitations. SETTING: Major public teaching hospital. PATIENTS: A total of 2470 patients who had undergone laparoscopic cholecystectomy. MAIN OUTCOME MEASURES: Bile duct injury and overall complication rates as determined using multivariate analysis. RESULTS: Overall, 2470 laparoscopic cholecystectomy procedures were performed, including 1353 in period 1 and 1117 in period 2. In period 2, more patients had acute cholecystitis as the indication for surgery (49% vs 35% in period 1, P < .001), and a higher percentage of patients were male (22% vs 18%, P = .01). The incidence of bile duct injury and total complications decreased in period 2 from 1% to 0.4%(P = .04) and from 5% to 2% (P < .001), respectively. Mortality was unchanged. Multivariate analysis revealed that period 2 was protective for bile duct injury (odds ratio, 0.31; 95% confidence interval, 0.1-0.96; P = .04). For complications, both female sex (odds ratio, 0.62; 95% confidence interval, 0.38-0.9) and surgery during period 2 (odds ratio, 0.46; 95% confidence interval, 0.28-0.75) were protective, whereas older age (odds ratio, 1.03; 95% confidence interval, 1.02-1.05) was associated with complications. CONCLUSION: At a major public teaching hospital, the bile duct injury rate and the overall complication rate decreased after implementation of the 80-hour workweek.