Unseen Burden of Injury: Post-Hospitalization Mortality in Geriatric Trauma Patients.

BACKGROUND/OBJECTIVES: Older adults are at risk for adverse outcomes after trauma, but little is known about post-acute survival as state and national trauma registries collect only inpatient or 30-day outcomes. This study investigates long-term, out-of-hospital mortality in geriatric trauma patients. METHODS: Level I Trauma Center registry data were matched to the US Social Security Death Index (SSDI) to determine long-term and out-of-hospital outcomes of older patients. Blunt trauma patients aged ≥65 were identified from 2009 to 2015 in an American College of Surgeons Level 1 Trauma Center registry, n = 6289 patients with an age range 65-105 years, mean age 78.5 ± 8.4 years. Dates of death were queried using social security numbers and unique patient identifiers. Demographics, injury, treatments, and outcomes were compared using descriptive and univariate statistics. RESULTS: Of 6289 geriatric trauma patients, 505 (8.0%) died as an inpatient following trauma. Fall was the most common mechanism of injury (n = 4757, 76%) with mortality rate of 46.5% at long-term follow-up; motor vehicle crash (MVC) (n = 1212, 19%) had long-term mortality of 27.6%. Overall, 24.1% of patients died within 1 year of trauma. Only 8 of 488 patients who died between 1 and 6 months post-trauma were inpatient. Mortality rate varied by discharge location: 25.1% home, 36.4% acute rehabilitation, and 51.5% skilled nursing facility, P < .0001. CONCLUSION: Inpatient and 30-day mortality rates in national outcome registries fail to fully capture the burden of trauma on older patients. Though 92% of geriatric trauma patients survived to discharge, almost one-quarter had died by 1 year following their injuries.

Technique and Outcomes in Laparoscopic Repair of Morgagni Hernia in Adults.

Background: Morgagni hernias (MHs) are rare anteromedial congenital diaphragmatic hernias. This study describes the effectiveness of a laparoscopic approach for these defects. Methods: A prospectively collected institutional database at a tertiary referral center was queried for patients (≥18 years) with MHs. Results: Fifteen adults underwent laparoscopic MH repair. Abdominal pain was the most common presentation (71.5%), and 2 patients (13.3%) presented with acute obstruction. Laparoscopic bridged mesh repair was the most common approach (66.7%) and was achieved by suturing a bridged synthetic mesh to the diaphragmatic portion of the defect and fixing it with transfascial sutures and/or tacks to the anterior abdominal wall. Primary suture repair was utilized for smaller defects. No mortalities or recurrences occurred after 20.2 months median follow-up. Conclusions: Laparoscopic synthetic mesh repair of adult MHs offers an effective hernia repair with minimal complications and no detected recurrences in long-term follow-up of this patient sample.

Safety first: significant risk of air embolism in laparoscopic gasketless insufflation systems.

BACKGROUND: Gasketless laparoscopic insufflator systems are marketed for the ability to prevent desufflation of pneumoperitoneum during laparoscopy. However, surgeons raised concern for possible introduction of non-absorbable room air, including oxygen (O2), with these systems. A community-university collaborative was created to test this hypothesis. METHODS: An artificial abdomen, calibrated to equivalent compliance and volume of an average abdomen, was connected to a flow meter, oxygen concentration sensor, and commercially available laparoscopic gasketless cannula system. A commercially available gasketed cannula system was utilized as a control. Intra-abdominal concentration of oxygen was measured at 0-60 L per minute (L/min) of insufflated carbon dioxide (CO2) aspiration, as would occur during laparoscopic suctioning. For reference, a 5-mm laparoscopic suction device has an aspiration rate of approx. 42 L per minute. At the test facility, room air was 20.5% O2 at 50% humidity. Descriptive and univariate statistics were calculated with p < 0.05 considered significant. RESULTS: At 0 L/min CO2 aspiration, there was minimal (< 0.5%) oxygen detected intra-abdominally. However, with increasing rates of aspiration of pneumoperitoneum, increasing amounts of room air were detected intraabdominally in the gasketless versus gasketed cannula systems (mean ± standard deviation): 14.7 ± 1.2% versus 1.2 ± 0.5%, p < 0.0001 at 5 L/min aspiration, 18.1 ± 0.69% versus 1.1 ± 0.02%, p < 0.0001 at 10 L/min, 50.4 ± 2.19% vs 1.01 ± 0.003%, p < 0.0001 at 20 L/min. Above 25 L/min aspiration, the standard gasketed cannula systems experienced desufflation, but the gasketless system continued to entrain air to maintain insufflation: 64% room air at 30 L/min aspiration, 71% at 40 L/min aspiration, 77% at 50 L/min aspiration, and 84% at 60 L/min aspiration. CONCLUSIONS: Gasketless cannula insufflation systems maintain abdominal insufflation by entraining non-medical room air. Especially at high aspiration rates, the majority of absorbable CO2 was replaced by non-medical room air, increasing potential for gas embolism with poorly absorbed oxygen and nitrogen. Authors have reported these experimental findings to the FDA and companies marketing these devices.

Emergent Laparoscopic Ventral Hernia Repairs.

BACKGROUND: Emergent repairs of incarcerated and strangulated ventral hernia repairs (VHR) are associated with higher perioperative morbidity and mortality than those repaired electively. Despite increasing utilization of minimally invasive techniques in elective repairs, the role for laparoscopy in emergent VHR is not well defined, and its feasibility has been demonstrated only in single center studies. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database (2009-2016) was queried for emergent VHR. Laparoscopic and open techniques were compared using univariate and multivariate analyses. RESULTS: A total of 11,075 patients who underwent emergent ventral and incisional hernia repairs were identified: 85.5% open ventral hernia repair (OVHR), 14.5% laparoscopic ventral hernia repair (LVHR). Patients who underwent emergent OVHRs were older, more comorbid, and more likely to be septic at the time of surgery than those undergoing emergent LVHRs. Emergent OVHR patients were more likely to have minor complications (22.1% versus 11.0%; OR 1.7; 95% CI 1.069-2.834). After controlling for confounding variables, LVHR and OVHR had similar outcomes, with the exception of higher rates of superficial surgical site infection in OVHR (5.0% versus 1.8%; odd's ratio (OR) 2.7; 95% confidence interval (CI) 1.176-6.138). Following multivariate analysis, laparoscopic approach demonstrated similar outcomes in major complications, reoperation, and 30-d mortality compared to open repairs. However, when controlling for other confounding factors, LVHR had reduced length of stay compared to OVHR (6.7 versus 4.0 d; 1.6 d longer, standard error 0.77, P < 0.03). CONCLUSIONS: Emergent LVHR is associated with fewer superficial surgical site infection and shorter length of stay than OVHR but no difference in major complications, reoperation or 30-d mortality is associated with LVHR in the emergency setting.

Defining Dogma: Quantifying Crystalloid Hemodilution in a Prospective Randomized Control Trial with Blood Donation as a Model for Hemorrhage.

BACKGROUND: The concept of hemodilution after blood loss and crystalloid infusion is a surgical maxim that remains unproven in humans. We sought to quantify the effect of hemodilution after crystalloid administration in voluntary blood donors as a model for acute hemorrhage. STUDY DESIGN: A prospective, randomized control trial was conducted in conjunction with community blood drives. Donors were randomized to receive no IV fluid (noIVF), 2 liters of normal saline (NS), or 2 liters lactated Ringer's (LR) after blood donation. Blood samples were taken before donation of 500 mL of blood, immediately after donation, and after IV fluid administration. Hemoglobin (Hgb) was measured at each time point. Hemoglobin measurements between time points were compared between groups using standard statistical tests and the Bonferroni correction for multiple comparisons. Statistical significance was set at p ≤ 0.0167. RESULTS: Of 165 patients consented, 157 patients completed the study. Average pre-donation Hgb was 14.3 g/dL. There was no difference in the mean Hgb levels after blood donation between the 3 groups (p > 0.05). Compared with the control group, there was a significant drop in Hgb in the crystalloid infused groups from the post-donation level to post-resuscitation (13.2 vs 12.1 vs 12.2 g/dL, p < 0.0001). A formula was created to predict hemoglobin levels from a given estimated blood loss (EBL) and volume replacement (VR): Hemodilution Hgb = (mean pre-donation Hgb - hemorrhage Hgb drop - equilibration hemoglobin drop - resuscitation Hgb drop) = Mean pre-donation Hgb - [(EBL/TBV)*l] - [(EBL/TBV)*h] - [(VR/TBV)*r], l = 5.111g/dL = blood loss coefficient, h = 6.722 g/dL = equilibration coefficient, r = 2.617g/dL = resuscitation coefficient. CONCLUSIONS: This study proves the concept of hemodilution and derived a mathematical relationship between blood loss and resuscitation. These data may help to estimate response of hemoglobin levels to blood loss and fluid resuscitation in clinical practice.

Accreditation Council for Graduate Medical Education (ACGME) Surgery Resident Operative Logs: The Last Quarter Century.

STUDY OBJECTIVE: To describe secular trends in operative experience for surgical trainees across an extended period using the most comprehensive data available, the Accreditation Council for Graduate Medical Education (ACGME) case logs. BACKGROUND: Some experts have expressed concern that current trainees are inadequately prepared for independent practice. One frequently mentioned factor is whether duty hours' restrictions (DHR) implemented in 2003 and 2004 contributed by reducing time spent in the operating room. METHODS: A dataset was generated from annual ACGME reports. Operative volume for total major cases (TMC), defined categories, and four index laparoscopic procedures was evaluated. RESULTS: TMC dropped after implementation of DHR but rebounded after a transition period (949 vs 946 cases, P = nonsignificance). Abdominal cases increased from 22% of overall cases to 31%. Alimentary cases increased from 21% to 26%. Trauma and vascular surgery substantially decreased. For trauma, this drop took place well before DHR. The decrease in vascular surgery also began before DHR but continued afterward as well: 148 cases/resident in the late 1990s to 107 currently. CONCLUSIONS: Although total operative volume rebounded after implementation of DHR, diversity of operative experienced narrowed. The combined increase in alimentary and abdominal cases is nearly 13%, over a half-year's worth of operating in 5-year training programs. Bedrock general surgery cases-trauma, vascular, pediatrics, and breast-decreased. Laparoscopic operations have steadily increased. If the competence of current graduates has, in fact, diminished. Our analysis suggests that operative volume is not the problem. Rather, changing disease processes, subspecialization, reductions in resident autonomy, and technical innovation challenge how today's general surgeons are trained.

The effect of component separation technique on quality of life (QOL) and surgical outcomes in complex open ventral hernia repair (OVHR).

INTRODUCTION: Outcomes following OVHR may be affected by type of component separation. In this study, outcomes including QOL of patients undergoing OVHR were evaluated based on the utilization of transversus abdominis release (TAR), posterior rectus sheath release (PRSR) alone or in combination with external oblique release (EOR + PRSR). METHODS: A prospective, single-institution study following open ventral hernia repair involving component separation was performed from May 2005 to April 2015. Self-reported QOL outcomes were obtained preoperatively and at 1, 6 and 12 months postoperatively using the Carolinas Comfort Scale (CCS). A CCS of 2 (mild but bothersome discomfort) or greater was considered symptomatic. Comorbidities, complications, outcomes and CCS scores were reviewed. Univariate group comparisons were performed using Chi-square and Wilcoxon two-sample tests with statistical significance set at p < 0.05. RESULTS: During the study period, 292 OVHRs with CST met inclusion criteria. Single-sided, different releases on opposite sides, etc., were eliminated. Demographics included: average age-57.9 ± 11.9 years, BMI-34.0 ± 7.9 kgm2, 53.2% female, 69% at least one prior hernia repair and average defect size-291.2 ± 236.2 cm2. Preoperative discomfort (82 vs. 75 vs. 79%, p = 0.77) and movement limitation (94 vs. 70 vs. 78%, p = 0.1) in TAR, PRSR and EOR + PRSR were similar. Average follow-up was 16.4 months. At 1, 6 and 12 months postoperatively, there was no difference in reported CCS pain scores, movement limitation or mesh sensation among the groups (p > 0.05). Comparing OVHR patients outcomes by CST type, TAR was associated with decreased wound infections compared to others (3.2 vs. 16.1 vs. 20%, p = 0.07) while recurrence rates were increased in EOR + PRSR compared to TAR and PRSR alone(8.4 vs. 3 vs. 1.8%, p = 0.03). Eighty percent of recurrences had a biologic mesh secondary to contaminated field during hernia repair. The other two recurrences were one which occurred superior to the mesh at a suture site and one who developed a wound infection postoperatively. Mesh infection rates were low (0 vs. 1.5 vs. 2.6%, p > 0.05) even including contaminated cases (0 vs. 2 vs. 3.6%, p > 0.05) and were statistically equivalent among all three techniques. CONCLUSION: While QOL is not impacted by type of component separation on short- or long-term follow-up, the TAR may provide benefits such as decreased wound infection rates. Overall QOL had a significant improvement from preoperative regardless of type of component separation. When controlling for field contamination, there were no differences in recurrence or infection.

The cost of preventable comorbidities on wound complications in open ventral hernia repair.

BACKGROUND: Patients with complex ventral hernias may benefit from preoperative optimization. This study evaluates the financial impact of preventable comorbidities (PCM) in elective open ventral hernia repair. METHODS: In this single institution prospectively collected data from 2007-2011, hospital charges (included all hernia-related visits, interventions, or readmissions) and wound-related complications in patients with PCM-diabetes, tobacco use, and obesity-were compared to patients without such risks using standard statistical methods. RESULTS: Within the study period, there were 118 patients with no PCM; of those, 33 had complications, and 85 did not. In the 131 patients with two or more PCM, 81 had complications; 89 of 251 patients had complications in the group with only 1 PCM; groups with PCM were significantly more likely to have complications compared to the no PCM group (62% versus 35.4% versus 28%, P < 0.05). The majority of the patient population was female (57.2%) with a mean age of 57.8 y (range, 22-84 ys), and median defect size was 150 cm2 (interquartile range, 50-283 cm2). Body mass index was higher in PCM group with complications than in PCM without complications (40 versus 36 kg/m2, P < 0.05). For patients with complications, the average hospital charges were $80,660 in the PCM group compared to $55,444 in the no PCM group (P = 0.038). Hospital charges in those with PCM without complications compared to no PCM with complications were equivalent ($65,453 versus $55,444, P = 0.55). Even when no complications occurred, patients with PCM incurred higher charges than No PCM for inpatient ($61,269 versus $31,236, P < 0.02), outpatient ($4,185 versus $552, P < 0.04), and total hospital charges ($65,453 versus $31,788, P ≤ 0.001). Those patients without complications but with a single PCM incurred larger charges than those with no PCM during follow-up ($3578 versus $552, P = 0.04), but there was no difference in hospital or overall total charges (P > 0.05). Interestingly, patients without complications, both hospital ($38,333 versus $61,269, P = 0.02) and total charges ($41,911 versus $65,453, P = 0.01) were increased for patients with 2+ PCM compared to those with only a single PCM. If complications occurred, no difference between the single PCM group compared to the two or more PCM groups existed for hospital, follow-up, or overall charges (P > 0.05). CONCLUSIONS: Patients with PCM undergoing open ventral hernia repair are more likely to have complications than patients without comorbidities. Patients with PCM generate higher hospital charges than those without PCM even when no complications occur; furthermore, the more PCM, the patient has the more significant the impact. Interestingly, patients with multiple PCM and no complications had equivalent hospital costs compared to patients with no PCM and with complications. Aggressive risk reduction may translate into significant savings. Preoperative preparation of patients before elective surgery is indicated.

Quantification of the Effect of Diabetes Mellitus on Ventral Hernia Repair: Results from Two National Registries.

Two national databases were analyzed to determine the effect of varying severity of diabetes mellitus (DM) on ventral hernia repair (VHR) outcomes. The National Surgical Quality Improvement Program (NSQIP) and the National Inpatient Sample (NIS) were queried for patients with and without DM who underwent elective VHR between 2005 to 2012 and 1998 to 2011, respectively. In addition, patients with insulin dependent versus noninsulin-dependent DM were compared in NSQIP; complicated and uncomplicated diabetics were compared in NIS. Univariate and multivariate analyses were used. In NSQIP, 25,819 of 219,625 patients undergoing VHR were diabetic. In open VHR (OVHR), DM patients had an increased complication rate (P < 0.0001); DM patients requiring insulin had increased odds of wound, minor, and major complications (P < 0.0001). For laparoscopic VHR (LVHR), insulin dependence did not affect complication rates (P > 0.05). In NIS, 45,248 of 238,627 patients undergoing VHR were diabetic. In OVHR, patients with complicated diabetes had higher rates of minor complications (17.3% vs 12.7%, P < 0.0001) and had 58 per cent greater odds of major complications than patients with uncomplicated diabetes. LVHR had no difference in complications for complicated versus uncomplicated DM (P > 0.05). After multivariate analysis, insulin-dependent or complicated DM undergoing OVHR had significantly worse outcomes compared with noninsulin-dependent and uncomplicated diabetics. Preoperative optimization and LVHR should be considered in diabetic patients.

Biologic mesh in ventral hernia repair: Outcomes, recurrence, and charge analysis.

BACKGROUND: Biologic mesh choice in ventral hernia repair is challenging due to lack of prospective data. This study examines long-term, single-center biologic mesh outcomes. METHODS: Prospective operative outcomes data was queried for open ventral hernia repair with biologic mesh. Univariate and multivariate analysis were used to compare mesh outcomes. RESULTS: In the study, 223 patients underwent open ventral hernia repair with biologic mesh, including 40 with Alloderm, 23 AlloMax, 70 FlexHD, 68 Strattice, and 22 Xenmatrix. Overall, 9.8% had an American Society of Anesthesiology classification of 4, 54.6% with a classification of 3, and 35.6% with a classification of 1 or 2. Operative time averaged 241 minutes with estimated blood loss of 202 mL. Hernia defects averaged 257 ± 245 cm2 with mesh size 384 cm2. Biologic mesh was used as a fascial bridge in 19.6%, component separation was performed in 47.5%, and 82% had concomitant procedure. Inpatient mortality was 1.4%. Hernia recurrence varied significantly by mesh type: 35% Alloderm, 34.5% AlloMax, 37.1% FlexHD, 14.7% Strattice, and 59.1% Xenmatrix (P = .001). The mean follow-up was 18.2 months. After multivariate analysis comparing to Strattice, AlloMax had a 3.4 higher odds ratio for recurrence, FlexHD a 2.9 odds ratio, and Xenmatrix a 7.8 odds ratio. The rate of mesh infections requiring explantation was <1%. Total hospital charges averaged $131,004 ± $143,320. Mean charges varied significantly between meshes; Xenmatrix was the most expensive and AlloMax was the least expensive (P < .05). CONCLUSION: In 223 ventral hernia repair performed with biologic mesh at a tertiary care institution, Strattice, a porcine acellular dermal mesh, had significantly lower odds of hernia recurrence compared with AlloMax, FlexHD, and Xenmatrix. Choice of biologic mesh affects long-term postoperative outcomes in ventral hernia repair.

Predictive modeling for chronic pain after ventral hernia repair.

BACKGROUND: Few studies predict which patients have dissolution of their postoperative discomfort or develop chronic pain after ventral hernia repair (VHR). This study develops a predictive model to determine which patients are at the greatest risk of chronic pain after VHR. METHODS: A prospective study of VHR patients was performed via the International Hernia Mesh Registry. Anonymous, self-reported, quality of life data using the Carolinas Comfort Scale (CCS) was recorded preoperatively, and 1,6, and 12 months postoperatively. Pain was identified as a score of 2 or more (mild but bothersome to severe) for any Carolinas Comfort Scale pain-specific questions. Logistic regression analyses were performed to determine statistically significant predictors of chronic pain. Univariate analysis selected potential predictors with a P value less than .15, and a subsequent multivariable model was built using backward elimination setting retention criterion at P < .15. Goodness-of-fit of the model was tested using Hosmer-Lemeshow test. A value of greater than 70% for the area under the curve (AUC) was considered most accurate diagnostically. The final model was then internally validated with bootstrap analysis. RESULTS: A total of 887 patients underwent VHR between 2007 and 2014. The patients had an average age of 57.2 ± 12.8 years, 52.4% were female, 17.0% were active smokers, and 13.2% used narcotics preoperatively. With 74% follow-up at 1 year, 26.0% of the patients reported chronic discomfort. After logistic regression model, independent predictors of pain at 6 months were preoperative pain score 2 or more (P < .0001), preoperative narcotic use (P = .06), and 1-month postoperative pain score 2 or more (P < .0001), AUC = .74. Baseline, 1-month, and 6-month predictors determined the final multivariate regression model for prediction of chronic pain at 1 year, AUC = .73. Older age was protective against chronic pain (odds ratio [OR] .98, 95%confidence interval [CI] = .96 to .998, P = .03), female sex increased risk with an OR of 1.7(CI = 1.1 to 2.7, P = .02); preoperative pain, and recurrent hernia repair nearly doubled the risk of developing chronic pain postoperatively (OR = 3.0, CI = 1.8 to 4.8, P < .0001 and 1.6, CI = .98 to 2.6, P = .06, respectively). Importantly, presence of pain at 1 month was a strong predictor of chronic pain at 1-year follow-up (OR = 2.6, CI = 1.7 to 4.2, P < .0001). CONCLUSIONS: Patients who have preoperative pain and at 1 month postoperatively are significantly more likely to have chronic pain. Both short- and long-term pain can be predicted from female sex, younger age, and repair of recurrent hernias. This predictive model may aid in preoperative counseling and when considering postoperative intervention for pain management in VHR patients.

A prospective randomized double-blinded controlled trial evaluating indocyanine green fluorescence angiography on reducing wound complications in complex abdominal wall reconstruction.

BACKGROUND: The purpose of this prospective, randomized, double-blinded controlled trial was to investigate the utility of indocyanine green fluorescence angiography (ICG-FA) in reducing wound complications in complex abdominal wall reconstruction. MATERIALS AND METHODS: All consented patients underwent ICG-FA with SPY Elite after hernia repair and before flap closure. They were randomized into the control group, in which the surgical team was blinded to ICG-FA images and performed surgery as they normally would, or the experimental group, in which the surgery team viewed the images and could modify tissue flaps according to their findings. Patient variables and wound complications were compared with standard statistical methods. RESULTS: Among 95 patients, n = 49 control versus n = 46 experimental, preoperative characteristics were similar including age (58.3 versus 56.7 y; P = 0.4), body mass index (34.9 versus 33.6 kg/m(2); P = 0.8), tobacco use (8.2% versus 8.7%; P = 0.9), diabetes (30.6% versus 37.0%; P = 0.5), and previous hernia repair (71.4% versus 60.9%; P = 0.3). Operative characteristics were also similar, including rate of panniculectomy (69.4% versus 58.7%; P = 0.3) and component separation (73.5% versus 69.6%; P = 0.6). The experimental group more often had advancement flaps modified (37% versus 4.1%, P < 0.0001). There was no difference between groups in rates of skin necrosis (6.1% versus 2.2%; P = 0.3), fat necrosis (10.2% versus 13.0%, P = 0.7), reoperation (14.3% versus 26.1%, P = 0.7), wound infection (10.2% versus 21.7%; P = 0.12), or overall wound-related complications (32.7% versus 37.0%, P = 0.7). Skin/subcutaneous hypoperfusion on ICG-FA was associated with higher rates of wound infection (28% versus 9.4%, P < 0.02), but flap modification after viewing images did not prevent wound-related complications (15.6% versus 12.5%, P = 0.99). CONCLUSIONS: This is the first randomized, double-blinded, controlled trial to evaluate ICG-FA in abdominal wall reconstruction. Although ICG-FA guidance and intraoperative modification of flaps did not prevent wound-related complications or reoperation, it did identify at risk patients.

National Trends in Utilization of Endoscopic Ultrasound for Gastric Cancer: a SEER-Medicare Study.

INTRODUCTION: Accurate preoperative staging is important for patients with gastric cancer. This study identifies the rate of utilization of endoscopic ultrasound (EUS) and its associated factors in Medicare patients with gastric adenocarcinoma. METHODS: The linked Surveillance, Epidemiology, and End Results (SEER)-Medicare claims database was queried from 1996 to 2009 for patients with gastric cancer who underwent gastric resection. Analysis with univariate, multivariate, and Cochran-Armitage trend tests were performed. RESULTS: In 5826 patients with gastric cancer with an average age of 76.9 ± 6.62 years, 59.1% had regionalized spread of cancer. EUS utilization increased significantly during the study period from 2.6% to 22% (p < 0.0001). EUS patients were more likely to be male, white, married, have higher education and income quartiles, and live in large metropolitan areas compared to non-EUS patients (p < 0.0001). Even after controlling for confounding factors, patients who underwent EUS were more likely to have >15 lymph nodes examined (odds ratio (OR) 1.26, 95% confidence interval (CI) 1.04-1.53) and have the administration of both pre- and postoperative chemotherapy (OR 1.27, 95% CI 1.03-1.57). CONCLUSION: EUS is currently under-utilized but increasing. Patients who underwent EUS (12.9%) were more likely to receive other NCCN-recommended care, including perioperative chemotherapy and adequate nodal retrieval.

Nationwide variation in outcomes and cost of laparoscopic procedures.

INTRODUCTION: Healthcare systems and surgeons are under increasing pressure to provide high-quality care for the lowest possible cost . This study utilizes national data to examine the outcomes and costs of common laparoscopic procedures based on hospital type and location. METHODS: The National Inpatient Sample was queried from 2008 to 2011 for five laparoscopic procedures: colectomy (LC), inguinal hernia repair, ventral hernia repair (LVHR), Nissen fundoplication (NF), and cholecystectomy (LCh). Outcomes, including complication rate and inpatient mortality, were stratified by region and hospital type. Both univariate and multivariate regression analyses were performed using regression-based survey methods; risk-adjusted mean costs for hospital were calculated after adjusting for patient characteristics. RESULTS: In univariate analysis, the rates of minor complications varied significantly between geographic regions for LCh, LC, NF, and LVHR (p < 0.05). Though LCh and LVHR had statistical variation between regions for rates of major complications (p < 0.05), all regions were equivalent in rates of inpatient mortality for the procedures (p > 0.05). Rural and urban centers had similar rates of complications (p > 0.05), except for higher rates of major complications following IHR and LC in rural centers (p < 0.02) and following Nissen fundoplication in urban facilities(p < 0.0003). Though urban centers were more expensive for all procedures (p < 0.0001), mortality was similar between groups (p > 0.05). For hospital ownership, private investor-owned facilities were substantially more expensive (p < 0.0001), but had no significant differences in complications compared to other hospital types (p > 0.05). In multivariate analysis, while patient factors helped explain differences between outcome differences in different hospital types and locations, in general, the difference in cost remained statistically significant between hospitals. CONCLUSION: Though patient demographics and characteristics accounted for some differences in postoperative outcomes after common laparoscopic procedures, higher cost of care was not associated with better outcomes or more complex patients.

Acuity, outcomes, and trends in the transfer of surgical patients: a national study.

INTRODUCTION: With the regionalization of surgical care, reduction in the rural workforce, rising healthcare costs, and increasing focus on surgical outcomes, appropriate transfer of surgical patients is an increasingly important aspect of health care. This study examines patients transferred for surgical intervention through a national sample. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2005 to 2012 for surgery patients who were transferred from an outside hospital or emergency department (ED) and compared patients undergoing surgery without transfer. Patients were divided into two time periods (TP): 2005-2008 (TP1) and 2008-2012 (TP2) for analysis; patient characteristics and top CPT codes for each TP were collected. Univariate analysis and matched cohorts were used to compare the groups. RESULTS: Overall, 61,204 patients were transferred and underwent surgery. The rate of transferred surgery patients increased from 3.2% in TP1 to 4.5% in TP2 (p < 0.0001). Compared to non-transferred patients, transferred patients had higher rates of diabetes (23.4 vs. 17.6%, p < 0.0001), tobacco use (27.9 vs. 20.3%, p < 0.0001), Charlson comorbidity index (mean score 1.5 vs. 0.8, p < 0.0001), preoperative sepsis (32.0 vs. 9.4%, p < 0.0001), and need for emergent surgery (41.3 vs. 14.4%, p < 0.0001). From TP1 to TP2, there was an increase in transferred patients who were obese (33.9-36.4%, p < 0.0001) and had emergent transfers (39.6-41.8%, p < 0.0001), with a decrease in diabetic patients (24.7-23.1%, p < 0.0001). From TP1 to TP2, transferred patients had more minor complications (17.7-31.0%, p < 0.0001), but fewer major complications (32.1-23.9%, p < 0.0001) and lower 30-day mortality (11.8-8.1%, p < 0.0001). CONCLUSIONS: Patients transferred for surgery represent a higher acuity population than non-transferred patients, and the number of transfers continues to rise. Even when matched by comorbidities, transferred patients have worse outcomes. Surgical sub-specialization and physician tiering may complicate future transfer practices. Efficient transfers, effective physician communication, and ready availability of medical records are critical in improving patient transfers.

The Centers for Medicare and Medicaid Services (CMS) two midnight rule: policy at odds with reality.

INTRODUCTION: To reduce costs, the Centers for Medicare and Medicaid Services (CMS) implemented new policies governing which patients are automatically admitted as inpatients (staying greater than "two midnights") and which require additional justification with physician documentation to be admitted. This study examines procedures missing from the Medicare Inpatient Only (MIO) list and uses national data to evaluate its appropriateness. METHODS: Non-MIO procedures were identified from the current MIO list. Utilizing relevant billing codes, procedures were queried in the National Surgery Quality Improvement Program database for length of stay (LOS), percentage requiring >2 day stay, and inpatient status from 2005 to 2012. In addition, a separate analysis was performed for patients 65 years old or older who would qualify for Medicare. RESULTS: A majority of patients stayed more than 2 days for several procedures not included on the MIO list (% staying >2 days, mean LOS), including component separation (79.1%, 5.9 ± 12.3 days), diagnostic laparoscopy (64.2%, 5.5 ± 11.9 days), laparoscopic splenectomy (60.0%, 9.0 ± 13.6 days), open recurrent ventral hernia repair (58.2%, 6.3 ± 9.0 days), laparoscopic esophageal surgery (46.4%, 5.3 ± 13.3 days), and laparoscopic ventral hernia repair (24.7%, 2.5 ± 8.8 days). In patients ≥65 years, the average LOS was longer than the general population; for example, 40.2% of laparoscopic appendectomies and 38.7% of laparoscopic cholecystectomies in this older group required more than two nights in the hospital. In 92.3% of procedures examined, patients ≥65 years required greater than two nights in the hospital with an average LOS of 2.5-10.7 days. CONCLUSION: Commonly encountered non-MIO surgical procedures have national precedents for inpatient status. Before enacting policy, CMS and other regulatory bodies should consider current data to ensure rules are evidence-based and applicable.

Laparoscopic versus open peritoneal dialysis catheter placement.

BACKGROUND: Laparoscopy revolutionized many General Surgery procedures by decreasing hospital stay, minimizing recovery time, and reducing wound infection rates. This study evaluates the potential benefits of laparoscopic approach to peritoneal dialysis catheter (PDC) placement. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for laparoscopic and open PDC placement. We evaluated patient demographics, comorbidities, operative time, length of stay (LOS), and postoperative outcomes. Univariate comparison and multivariate logistic regression analysis (MVA) adjusting for confounding factors including age, body mass index (BMI), comorbidities, and preoperative conditions were performed. RESULTS: A total of 3134 patients undergoing PDC placement were recorded in the NSQIP database between 2005 and 2012, including 2412 laparoscopic cases (LPDC) (77%) and 722 open (OPDC). Overall, the majority of cases were performed by General Surgeons (81%) with most of the remainder completed by Vascular Surgeons (16.8%). Patients undergoing LPDC versus OPDC demonstrated no significant difference in gender (54 vs. 56% males, p = 0.4), smoking history (8.5 ± 18.3 vs. 7.2 ± 16.9 pack years, p = 0.06), diabetes (42 vs. 40%, p = 0.4), COPD (4.6 vs. 5%, p = 0.63), or preoperative dialysis requirement (72 vs. 73 %, p = 0.6), but they were younger (57.2 ± 14.8 vs. 60.5 ± 15.9 years, p = 0.05) and had a higher BMI (29.3 vs. 29 kg/m(2), p = 0.04). In univariate analysis of LPDC versus OPDC, overall wound complications (1.6 vs. 2.9 %, p = 0.02), deep surgical site infections (0.12 vs. 0.83%, p < 0.006), minor complications (3.8 vs. 6.5 %, p < 0.05), major complications (4.3 vs. 6.9%, p < 0.05), and LOS (1.8 ± 11.9 vs. 4.4 ± 10 days, p < 0.0001) favored the LPDC approach, but only operative time (57.6 ± 4.6 vs. 71.8 ± 5.3, p < 0.001) remained significant in MVA after controlling for confounding factors. Both LPDC and OPDC had equivalently low rates of catheter failure (0.21 vs. 0.14%, p = 0.7). CONCLUSION: Using univariate analysis, there appears to be a benefit from LPDC placement. However, after controlling for confounding variables, the techniques appear to have equal outcomes. Surgeons should perform a LPDC or OPDC according to the approach with which they are most familiar. However, continued adoption, dispersal, and refinement of the laparoscopic approach may further optimize patient outcomes.

Optimal Timing of Surgical Resection After Radiation in Locally Advanced Rectal Adenocarcinoma: An Analysis of the National Cancer Database.

BACKGROUND: In the treatment of rectal cancer, a longer radiation-surgery interval from the end of neoadjuvant radiation therapy to surgery has been associated with higher rates of complete pathologic response (pCR), but the optimal interval with respect to survival has not been established. Data from the National Cancer Database (NCDB) was used to evaluate the impact of radiation-surgery interval on oncologic outcomes. METHODS: The NCDB was searched for patients diagnosed with nonmetastatic rectal cancer who underwent preoperative radiation followed by radical surgical resection. A Cox proportional hazards model was constructed to examine the influence of radiation-surgery interval while controlling for potential confounding factors. Sensitivity analysis was used to confirm the results of the model. RESULTS: A cohort of 6397 patients meeting all inclusion and exclusion criteria from 2004-2006 was identified, and the pCR rate for this cohort was 6.9%. Of those who experienced a pCR, 76.2% had done so by 60 days. Intervals greater than 60 days were associated with higher rates of positive surgical margins (6.7 vs. 4.8%, p = 0.009) and lower rates of sphincter-preserving surgery (64.9 vs. 68.9%, p = 0.007). An interval greater than 60 days was associated with significantly shorter survival (hazard ratio (HR), 1.314; 95% CI 1.191-1.449; p < 0.001). CONCLUSIONS: Radiation-surgery interval beyond 60 days is associated with increased rate of positive surgical margins, decreased rate of sphincter-preserving surgery, and decreased survival. Delay of surgery for rectal cancer beyond 60 days after the completion of neoadjuvant therapy should be done with caution.

Indocyanine Green: Historical Context, Current Applications, and Future Considerations.

BACKGROUND: Indocyanine green (ICG) is a dye used in medicine since the mid-1950s for a variety of applications in in cardiology, ophthalmology, and neurosurgery; however, its fluorescent properties have only recently been used in the intraoperative evaluation of tissue perfusion. METHOD: A literature review was conducted on the characterization and employment of ICG within the medical field. Historical and current context of ICG was examined while also considering implications for its future use. RESULTS: ICG is a relatively nontoxic, unstable compound bound by albumin in the intravascular space until rapid clearance by the liver. It has widespread uses in hepatic, cardiac, and ophthalmologic studies, and its use in analyzing tissue perfusion and identifying sentinel lymph nodes in cancer staging is gaining popularity. CONCLUSIONS: ICG has myriad applications and poses low risk to the patient. Its historical uses have contributed to medical knowledge, and it is now undergoing investigation for quantifying tissue perfusion, providing targeted therapies, and intraoperative identification of neurovascular anatomy, ophthalmic structures, and sentinel lymph nodes. New applications of ICG may lead to reduction in postoperative wound-related complications, more effective ophthalmologic procedures, and better detection and treatment of cancer cells.

Systematic Review of Randomized Controlled Trials Comparing Manual Compression to Vascular Closure Devices for Diagnostic and Therapeutic Arterial Procedures.

PURPOSE: A multitude of vascular closure devices (VCDs) are currently on the market for femoral arteriotomy closure after diagnostic and interventional angiography. Randomized, controlled trials (RCTs) comparing these devices to manual compression (MC) and their effect on time to hemostasis, time to ambulation, time to discharge, and immediate as well as long term complications have been studied. A systematic and through review of these evaluations and outcomes has not previously been performed. MATERIALS AND METHODS: A systematic review was completed to include all available RCTs comparing vascular closure device use to manual compression. Devices meeting inclusion criteria were as follows: VasoSeal® (Datascope Corporation, Montvale, NJ), AngioSeal™ (Sherwood-Davis & Geck, St Louis, MO/St Jude Medical, St Paul, MN), ProGlide® (Abbott Vascular, Abbott Park, IL), ProStar® (Abbot Vascular, Menlo Park, CA), StarClose SE® (Abbott Vascular, Redwood City, CA), ExoSeal™ (Cordis, Warren, NJ), Boomerang™ Wire (Cardiva Medical, Mountainview, CA), FemoSeal™ (St Jude Medical Systems, Uppsala, Sweden), EVS™ (expanded vascular stapling, Angiolink Co, Taunton, MA), X-PRESS™ (X-Site Medical, Blue Bell, PA), Duett™ (Vascular Solutions, Minneapolis, MN), EpiClose-T® (CardioDex Ltd., Tirat Ha Carmel, Israel), and FISH™ (femoral introducer sheath and hemostasis, FISH Device, Bloomington, IN). Vascular closure devices were compared both to manual compression and across all devices used for the following outcomes: time to hemostasis, time to ambulation, time to discharge, and outcomes such as bleeding, hematoma, pseudoaneurysm, limb ischemia, and overall major and minor complications, as well as impact on quality of life, cost analysis, and trends over time. Both diagnostic and interventional procedures were included. RESULTS: PUBMED and MEDLINE searches were carried out for VCDs identifying 1,363 articles. Manuscripts that included manual compression in the study numbered 176. Of these, 34 randomized controlled trials were included. Studies that met inclusion criteria were published from 1992-2015 and described a total of 14,401 patients, 5,659 patients undergoing MC, and 8,742 patients undergoing VCD placement. Overall, the rate of procedural success for VCD patients was 95.7%. The highest rate of unsuccessful device deployment was seen in the ExoSeal™ subset, which averaged 37.9% failure. The overall median time to hemostasis for manual compression was 22.9 minutes compared to VCDs at 5.95 minutes; FemoSeal™ had the shortest median time to hemostasis of 0.75 minutes. When comparing the type of procedure and its median time to hemostasis, MC versus VCD was 17 minutes versus 3.7 minutes for diagnostic procedures and 29.1 minutes versus 7.6 minutes for interventional procedures with similar sheath sizes at 6 and 7 French, respectively. Similarly, median time to ambulation for MC was eight hours compared to 3.5 hours for patients who received a VCD. Median time to discharge was similar at 1.6 days. However, time to discharge has diminished over the last decade comparing MC to VCD, with a median time to discharge of 3.1 versus 2.2 days compared to current trends at 0.8 versus 0.5 days, respectively. The overall rates of complications were similar between MC at 13.1% versus VCDs at 12.2% but varied significantly according to the VCD that was selected. For patients randomized to the vascular closure device who had undergone prior angioplasty, 94.4% of these patients preferred the use of VCD if a further angioplasty were to be performed in the future. A 13% reduction in overall costs with VCD was demonstrated due to earlier discharge and less required time with physician and nursing staff. CONCLUSION: Overall, the review of 34 RCTs demonstrates the utility of VCDs has shortened time to hemostasis, ambulation, and discharge compared to patients receiving MC. Over the last decade, with emphasis on and implementation of same-day procedures, use of VCDs has resulted in a reduction in time to discharge to half a day and a significant decrease in cost. Overall complication rates are similar, but vary between different devices on the market. Better short-term quality of life has also been described with the use of VCDs compared to MC. Further clinical and financial improvements may be found as newer technological advances of VCDs become available.