Predicting Postoperative Complications after Acute Care Surgery: How Accurate Is the ACS NSQIP Surgical Risk Calculator?

The ACS NSQIP Surgical Risk Calculator (SRC) is an evidence-based clinical tool commonly used for evaluating postoperative risk. The goal of this study was to validate SRC-predicted complications by comparing them with observed outcomes in the acute care surgical setting. In this study, pre- and postoperative data from 1693 acute care surgeries (hernia repair, enterolysis, intestinal incision/excision and enterectomy, gastrectomy, debridement, colectomy, appendectomy, cholecystectomy, gastrorrhaphy, and incision and drainage of soft tissue, breast abscesses, and removal of foreign bodies) performed at a Level I trauma center over a five-year time period were abstracted. Predictions for any and serious complications were based on SRC were compared with observed outcomes using various measures of diagnostic. When evaluated as one group, the SRC had good discriminative power for predicting any and serious complications after acute care surgeries (Area Under the Curve (AUC) 0.79, 0.81). In addition, the SRC met Brier score requirements for an informative model overall. However, the predictive accuracy of the SRC varied for various procedures within the acute care patient population. For serious complications, the diagnostic measures ranged from an AUC of 0.61 and negative likelihood ratio of 0.716 for incision & drainage soft tissue to AUC of 0.91 and negative likelihood ratio of 0.064 for gastrorrhaphy. Length of stay was significantly underestimated by the SRC overall (8.56 days, P < 0.01) and for individual procedures. The SRC performs well at predicting complications after acute care surgeries overall; however, there is great variability in performance between procedure types. Further refinements in risk stratification may improve SRC predictions.

Perceptions in rib injuries: A multidisciplinary single center survey of clinician differences in risk stratification and management of patients with rib fractures.

BACKGROUND: Although associated with significant morbidity, there is no universally accepted management of rib fractures. We hypothesized that variations in risk stratification may influence this. METHODS: A questionnaire was developed to assess providers' perceived risk factors and injury stratification of rib fracture patients at a Level 1 trauma center. RESULTS: There were 143 responses (36% physician response rate). Hypoxia, age, number of ribs fractured, pre-existing pulmonary disease, and flail chest were identified as the most important risk factors determining morbidity and mortality in blunt chest trauma. While clinicians agreed on predicted mortality for <2 fractured ribs, significant variation for 5-6 and >8 rib fractures was seen. EM and surgery providers significantly differed in assessment of injury severity. CONCLUSION: Providers identified common risk factors for increased morbidity and mortality. However, the difference in perceived severity between providers indicates a need for clinical tools to assist in better standardizing rib fracture management.

Impact of blunt pulmonary contusion in polytrauma patients with rib fractures.

BACKGROUND: We investigated the impact of blunt pulmonary contusion (BPC) in patients with rib fractures. METHODS: Adult patients with rib fractures caused by blunt mechanisms were enrolled over 3 years at a Level 1 trauma center. BPC was defined according to percentage of lung affected as: moderate (1-19% contusion) or severe (≥20% contusion). RESULTS: In total, 1448 of the 7238 admitted patients had rib fractures. Of these, 321 (22.2%) had BPC: 236 moderate and 85 severe. Patients with BPC were more likely to be admitted to the ICU (moderate: OR 1.55, 95% CI 1.10-2.19; severe: OR 2.74, 95% CI 1.41-5.32). Significantly increased rates of pneumonia (OR 2.52, 95% CI 1.43-4.90) and empyema (OR 4.80, 95% CI 1.07-21.54) were found for moderate and severe BPC, respectively. CONCLUSIONS: ICU admission and infectious pulmonary complications were more likely with BPC. The presence of BPC on admission CT is also prognostic of increased resource utilization.

Outcomes of preinjury anticoagulation in patients with traumatic rib fractures.

BACKGROUND: Anticoagulant and antiplatelet agents (ACAP) have been shown to negatively affect trauma patients. METHODS: Outcomes in adults with rib fractures were reviewed. Pearson chi-square test was used for analysis. Multivariate logistic regression was used to adjust for potential confounders. RESULTS: Of the 1448 included patients, 149 (10.3%) took preinjury ACAP; these patients were significantly older than non-anticoagulated patients (72 vs. 54 years, P ≤ 0.05). There was no difference in pulmonary complications, ICU admissions or ICU LOS. The preinjury ACAP group had a significantly longer LOS (12.03 vs. 9.33 days, P = 0.004), fewer pulmonary contusions (15.43% vs. 22.94%, P = 0.037), and fewer thoracic drainage procedures (10.74% vs. 18.17%, P = 0.023). Multivariate adjustment for possible confounders revealed that patients taking warfarin had a significantly longer LOS (+7.38 days). After adjustment there was no difference in mortality. CONCLUSION: Preinjury ACAP use does not increase mortality or morbidity in patients with rib fractures. SUMMARY: We demonstrated that preinjury anticoagulation and antiplatelet agents do not increase mortality or morbidity in patients with rib fractures. However, they lead to a longer hospital length of stay, particularly in patients on warfarin.

Patient Characteristics Associated with Comfort Care among Trauma Patients at a Level I Trauma Center.

Trauma patients admitted to the intensive care unit are a unique population with high mortality. This study aims to identify characteristics predicting the likelihood of progressing to palliative management often referred to as comfort care measures, thus enabling the trauma team to broach end-of-life decisions earlier in these patients' care. This is a retrospective analysis of the prospectively collected New York State Trauma Registry database for a single Level I trauma center for patients admitted from 2008 to 2015. During this time, a total of 13,662 patients were admitted to the trauma service and there were 827 deaths, resulting in a crude annual mortality rate of approximately 6 per cent. Approximately one-half of the total mortalities, 404 of 827 (48.9%), were ultimately designated as comfort care. Univariate analysis identified the following risk factors for comfort care designation: advanced age, multiple comorbidities, blunt trauma mechanism, traumatic brain injury, and admission location. Multivariate analysis confirmed advanced age and traumatic brain injury. Subgroup analysis also identified advanced directives, pre-existing dementia, and bleeding disorders as significant associations with comfort care designation. The identification of factors predicting comfort care will result in improved care planning and resource utilization.

Sharps and Needlestick Injuries Among Medical Students, Surgical Residents, Faculty, and Operating Room Staff at a Single Academic Institution.

BACKGROUND: The hospital is a place of high risk for sharps and needlestick injuries (SNI) and such injuries are historically underreported. METHODS: This institutional review board approved study compares the incidence of SNI among all surgical personnel at a single academic institution via an anonymous electronic survey distributed to medical students, surgical residents, general surgery attendings, surgical technicians, and operating room nurses. RESULTS: The overall survey response rate was 37% (195/528). Among all respondents, 55% (107/195) had a history of a SNI in the workplace. The overall report rate following an initial SNI was 64%. Surgical staff reported SNIs more frequently, with an incidence rate ratio (IRR) of 1.33 (p = 0.085) when compared with attendings. When compared with surgical attendings, medical students (IRR of 2.86, p = 0.008) and residents (IRR of 2.21, p = 0.04) were more likely to cite fear as a reason for not reporting SNIs. Approximately 65% of respondents did not report their exposure either because of the time consuming process or the patient involved was perceived to be low-risk or both. CONCLUSIONS: The 2 most common reasons for not reporting SNIs at our institution are because of the inability to complete the time consuming reporting process and fear of embarrassment or punitive response because of admitting an injury. Further research is necessary to mitigate these factors.

Open reduction and internal fixation of rib fractures in polytrauma patients with flail chest.

BACKGROUND: Open reduction and internal fixation (ORIF) of fractured ribs for flail chest is safe and effective but who is most likely to benefit is unknown. Our purpose is to compare ORIF with nonoperative management (NOM) in polytrauma patients. METHODS: Albany Medical Center Hospital Trauma Registry was queried for adult patients with flail chest admitted over 7 years. RESULTS: Eighty-six patients with radiographic flail chest were identified who met inclusion criteria. The 41 ORIF and 45 NOM patients had similar demographics and injury severity. Hospital length of stay and intensive care unit length of stay were significantly longer in the ORIF group than that of the NOM group. There was a trend toward longer time on the ventilator in the ORIF group. CONCLUSIONS: In this retrospective study, patients treated by ORIF had longer hospitalization and ventilator duration. Future studies should be designed to optimally identify patients who are most likely to benefit from ORIF.

Management of splenic trauma: a single institution's 8-year experience.

BACKGROUND: Management of splenic trauma has evolved, with current practice favoring selective angiographic embolization and non-operative treatment over immediate splenectomy. Defining the optimal selection criteria for the appropriate management strategy remains an important question. METHODS: This retrospective registry review was conducted at a Level I trauma center. The patient population consisted of 20,561 patients in the State Trauma Registry from April 2004 to May 2012. Splenectomy, angiography, splenic embolization, nonoperative, and noninterventional (NI) observation were the management strategies under study. Morbidity and mortality were the outcome measures. Morbidity and mortality by management strategy. RESULTS: During the 8-year study period, 926 (4.5%) patients sustained splenic injury. Observational management increased over time despite the similar distribution of splenic injury grade over the study period: grade I/II (50%), grade III (24.2%), and grade IV/V (25.8%). Mortality rates associated with each management strategy were the following: immediate splenectomy (IS; 25%), splenic embolization (SE; 3.9%), and angiography only or observation, that is, NI (6.5%) management. Injury severity score (ISS) was highest in IS (36.1 ± 1.3) compared with SE (29.1 ± 1.0, P = .001) and NI (21.6, P < .001). Splenectomy was required in 5 of the 129 (3.9%) patients managed with SE and 9 of the 677 (1.3%) patients managed by NI. Mortality was significantly lower among those managed by SE (odds ratio .12, 95% confidence interval: .05 to .32) or NI (odds ratio .21, 95% confidence interval: .12 to .35). This survival benefit was explained by the association of IS with systolic blood pressure <90, high ISS, low GCS at presentation, ISS, development of shock, need for transfusion, and multiorgan failure. CONCLUSIONS: In this large 8-year single institution study, we observed an increase in nonoperative management by an increased application of angiography and embolization. An aggressive utilization of SE in patients with appropriate indications will result in low failure rates and improved mortality.

Impact of preinjury warfarin and antiplatelet agents on outcomes of trauma patients.

BACKGROUND: Warfarin and antiplatelet agents (WAA) are prevalent among trauma patients, but the impact of these agents on patient outcomes has not been clearly defined. In this study, we examined the impact of preinjury WAA on outcomes in trauma patients. METHODS: A 40-month (September 2004 to December 2007) retrospective review of data in the trauma registry at a New York State level 1 trauma center was performed. Patients on WAA were compared to those not on these medications. The primary outcome of interest was mortality, and the secondary outcomes of interest were as length of stay (LOS) and disposition on discharge. A separate analysis was done for patients with intracranial hemorrhage (ICH). The chi-square test, the Student t test, and the modified Poisson regression analysis were used to estimate the incident risk ratios for the outcomes. RESULTS: A total of 3,436 trauma patients were identified, of whom 456 were taking anticoagulants (warfarin, n = 91 patients; aspirin, n = 228; clopidogrel, n = 43; and various combinations, n = 94). Patients on warfarin were 3.1 times more likely to die (relative risk [RR], 3.2; 95% confidence interval [CI], 1.6-6.6), after adjusting for potential confounders. Aspirin and clopidogrel were not associated with increased mortality, but WAA were associated with increased risk of ICH (49.8% vs 30.5%; RR, -1.6; 95% CI, 1.4-1.9). WAA did not affect LOS or disposition. Among patients with ICH, only warfarin increased mortality (28.9% vs 5.8%; RR, -3.1; 95% CI, 1.3-7.2). CONCLUSION: Preinjury warfarin treatment was found to be an independent risk factor for mortality. WAA agents increased risk of ICH. Among those patients with ICH, only warfarin was associated with increased mortality. Antiplatelet agents did not affect mortality or LOS.

Effect of comorbidities and medications on left ventricular mass regression after bariatric surgery.

Hypertension, diabetes, and obesity frequently coexist and significantly contribute to cardiovascular morbidity and mortality. Weight loss in obese individuals has been associated with improved blood pressure control and regression in left ventricular (LV) hypertrophy. The authors investigated the impact of comorbidity and medication on clinical and echocardiographic parameters after weight loss in obese patients. Serial echocardiography and clinical data were collected in 62 patients before bariatric surgery and after 6 months or 10% weight loss. Obese patients with diabetes or hypertension had higher baseline LV mass (LVM) (334 + or - 73 g in hypertension and diabetes vs 252 + or - 97 g in hypertension and 219 + or - 75 g in disease-free patients, P = .003; P = .089 for differences in LVM indexed by height), despite the lack of significant differences in body mass index or systolic blood pressure. There were no significant differences in baseline LVM or LVM index related to the medication used to treat hypertension. After weight loss, patients on beta-blocker therapy experienced the most significant LV hypertrophy regression (-76.5 + or - 79.1 g with beta-blockers, -17.8 + or - 43.7 g with diuretics, -4.5 + or - 46.6 g with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and -23.1 + or - 50.9 g in not treated patients, overall P = .538; beta-blockers vs no therapy P < .005; P = .145 for differences in LVM index). Bariatric surgery, combined with a weight loss program, provide substantial weight and LVM reduction regardless of comorbidities or blood pressure changes. beta-Blocker therapy appears to be associated with the greatest LVM regression after weight loss.

Gastro-broncho-pleural fistula after laparoscopic gastric band placement.

Laparoscopic gastric band placement is a common procedure for morbid obesity. Common complications include gastric perforation, band erosion, and band slippage. We present the first report in the literature of gastro-bronchial-pleural fistula after laparoscopic gastric band placement.

The impact of weight loss on cardiac structure and function in obese patients.

BACKGROUND: Obesity frequently results in structural and physiologic changes in the cardiovascular system. Whether weight reduction leads to reversal of these changes is not well-established. This investigation sought to identify the effect of a weight reduction program on right and left ventricular structure and function. METHODS: Sixty-two patients presenting to the eating disorders clinic at a single academic institution for weight loss programs were prospectively enrolled. Baseline and follow-up transthoracic echocardiograms were obtained after at least 10% weight reduction or 6 months after baseline echocardiogram. Complete 2-dimensional echocardiograms were performed with M-mode, flow Doppler, and tissue Doppler evaluation. RESULTS: Patients lost an average of 28.2 +/- 3 kg over a period of 266 +/- 36 days. Left ventricular mass decreased significantly from 255.87 +/- 12 to 228 +/- 11 gm. There were no statistically significant changes in contractility or diastolic indices. The ratios of early-to-late diastolic mitral inflow velocities (E/A) increased from 1.30 +/- 0.05 to 1.32 +/- 0.06. The ratio of early mitral flow to early annular velocity (E/Em) also increased from 5.57 +/- 0.22 cm to 5.82 +/- 0.23 cm. Deceleration time increased from 213.26 +/- 5.3 s to 228.47 +/- 5.7 s. CONCLUSIONS: Weight reduction is associated with decrease in left ventricular diastolic size and left ventricular mass. This weight reduction is not associated with statistically significant improvement in systolic or diastolic function.

Comparing outcomes of laparoscopic versus open bariatric surgery.

OBJECTIVE: The objective of this study was to use nationally representative data to compare outcomes of open gastric bypass (OGB) versus laparoscopic gastric bypass (LGB) surgery. BACKGROUND: The number of bariatric procedures continues to grow. Increasingly, these surgeries are being performed laparoscopically. However, few population-based studies have examined differences in outcomes between LGB and OGB surgeries. Population-based studies can provide further insight into differences in outcomes between open and laparoscopic bariatric procedures. METHODS: Using the Nationwide Inpatient Sample, we identified adults undergoing LGB or OGB surgery during 2005 (n = 19,156). Following preliminary descriptive statistics, multiple logistic and linear regressions were used to obtain risk-adjusted outcomes, including postoperative in-hospital complications, reoperation, length of stay, and total charges. RESULTS: The majority of patients in the study sample (74.5%) underwent laparoscopic bypass surgery in 2005. After adjusting for patient and hospital level factors, patients undergoing OGB surgery were more likely to experience reoperation as well as the following complications: pulmonary (odds ratio [OR] = 1.92 (1.54-2.38), P < 0.001); cardiovascular (OR = 1.54 [1.07-2.23], P = 0.02); procedural (OR = 1.29 [1.06-1.57], P < 0.01); sepsis (OR = 2.18 [1.50-3.16], P < 0.001); and anastomotic leak (OR = 1.32 [1.02-1.71], P = 0.03). After risk adjustment, LGB was associated with a shorter length of stay but higher total charges. CONCLUSION: Overall, LGB patients are less likely to experience reoperation and postoperative complications in the hospital and have a shorter length of stay but incur higher total charges than OGB patients.

Regional variations in gastric bypass surgery: results from the 2005 nationwide inpatient sample.

BACKGROUND: The purpose of this study is to use nationally representative data to examine regional variations in the use and outcomes of gastric bypass surgery. METHODS: Using data from the Nationwide Inpatient Sample (NIS), we identified adults undergoing gastric bypass surgery (n = 92,910) in 2005. Following descriptive analyses, multiple logistic regression models were constructed to examine regional variations in the likelihood of laparoscopic vs. open approaches and in the likelihood of complications while controlling for patient and hospital characteristics. RESULTS: After indirectly adjusting for age and sex, the gastric bypass rates per 100,000 were as follows: Northeast, 70; Midwest, 39; South, 37; and West, 61. After adjusting for both patient and hospital characteristics, the odds of receiving laparoscopic surgery for patients living in the West were 1.79 times the mean [95% confidence interval (CI): 1.67-1.92], while the odds of receiving laparoscopic surgery for patients in the Midwest were 0.66 of the mean (95% CI: 0.62-0.70) and those of the Northeast were 0.88 of the mean (95% CI: 0.83-0.94). When adjusting for both patient and hospital characteristics, the odds of one or more postoperative complications among patients living in the South were greater than the mean (OR: 1.14, 95% CI: 1.02-1.26). CONCLUSIONS: Findings from this study suggest that gastric bypass surgery is more common in the Northeast and West. There is a greater likelihood of gastric bypass being performed laparoscopically in the West; it is less likely to be performed in the Northeast and Midwest. Postoperative complications are more likely to occur in the South.

Cystogram may be unreliable in cases of gunshot wounds to the bladder: a case report.

INTRODUCTION: Gunshot wounds to the bladder are not uncommon; however it is unusual that a bullet come to rest within the urinary bladder. Properly performed plain film cystography is trusted as a highly sensitive tool for identifying significant bladder injuries due to both blunt and penetrating trauma. Several reports suggest that cystography may be less sensitive in cases of gunshot wounds to the bladder. METHODS: We report our recent experience with a gunshot wound to the bladder and review the use of cystography in the diagnosis of bladder injury in this setting. RESULTS: Anecdotal case reports suggest that cystography may fail to identify gunshot injuries to the bladder. No large studies have been performed to evaluate its utility in this unique trauma circumstance. CONCLUSIONS: Although reliable for the diagnosis of bladder perforation in most trauma settings, cystography may fail to diagnose a penetrating bladder injury due to a gunshot wound. High clinical suspicion based on bullet trajectory, history, and physical exam should guide the workup and treatment of such patients.

Relationship between surgeon and hospital volume and readmission after bariatric operation.

BACKGROUND: Few studies have focused on the relationship between provider volume and short-term readmissions among bariatric operation patients. STUDY DESIGN: Using New York State's inpatient discharge database, we identified adults undergoing a bariatric procedure between January 1, 2003, and November 30, 2003 (n = 7,868). After preliminary descriptive analyses, a multiple logistic regression model was constructed to examine the relationship between surgeon and hospital volume and readmission after 30 days of discharge for bariatric operation, while controlling for demographics, comorbidity, and length of index hospitalization. RESULTS: Among patients undergoing bariatric operation in New York in 2003, 7.6% were readmitted within 30 days of discharge after their operation. The most common readmission diagnosis was "digestive system complications of surgical care." Multiple logistic regression showed that both surgeon and hospital volume were significantly associated with short-term readmissions. Patients operated on by a low-volume surgeon ( 150 procedures per year) were also significantly (p < 0.001) more likely to be readmitted compared with those operated on by medium-volume surgeons. Patients in each of the lower hospital volume categories were more likely to be readmitted compared with the highest volume category (> 300 procedures per year) (

Predictors of in-hospital postoperative complications among adults undergoing bariatric procedures in New York state, 2003.

BACKGROUND: Our aim was to determine the relationship between patient level characteristics and in-hospital postoperative complications among obese adults who underwent a bariatric procedure in New York state in 2003. Understanding patient level factors that predict or are associated with adverse outcomes among bariatric surgery patients can help to identify patients who need to be monitored particularly carefully. METHODS: Using New York's inpatient discharge database, we identified adults who underwent a bariatric operation between January 1, 2003 and December 31, 2003 (n=7,868). Following preliminary descriptive analyses, a stepwise logistic regression model was constructed to identify significant patient level predictors of postoperative complications. Patient level risk factors included age, gender, race/ethnicity, and 24 co-morbid conditions. RESULTS: 6.8% of adults undergoing a bariatric procedure in New York in 2003 experienced one or more of the postoperative complications included in the study. Respiratory complications were the most common type of complication, with >2% of patients experiencing pneumonia, collapsed lung, and/or respiratory complications secondary to the operation. Multivariate analyses by stepwise logistic regression identified age > or =50 years, male gender, Hispanic ethnicity, congestive heart failure, cardiac arrhythmia, other neurological disorders, and peptic ulcer as predictors of complications. CONCLUSIONS: Certain subpopulations of persons undergoing bariatric procedures may be at increased risk for adverse events and will need to be monitored carefully.