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1.
Dis Colon Rectum ; 2022 May 09.
Artigo em Inglês | MEDLINE | ID: mdl-35533321

RESUMO

BACKGROUND: Racial and ethnic disparities in receipt of recommended colorectal cancer screening exist, however the impact of social determinants of health on such disparities has not been recently studied in a national cohort. OBJECTIVE: The objective of this study was to determine whether social determinants of health attenuate racial disparities in receipt of colorectal cancer screening. DESIGN: Cross-sectional telephone survey of self-reported race and ethnicity and up-to-date colorectal cancer screening. Associations between race/ethnicity and colorectal cancer screening were tested before and after adjustment for demographics, behavioral factors, and social determinants of health. SETTING: This was a nationally representative telephone survey of USA residents in 2018. PATIENTS: The patients were USA residents aged 50-75 years. MAIN OUTCOME MEASURES: Up-to-date colorectal cancer screening status, according to 2008 U.S. Preventative Services Task Force recommendations. RESULTS: This study included 226,106 respondents aged 50 to 75 years. Prior to adjustment, all minority racial and ethnic groups demonstrated a significantly lower odds of screening compared to non-Hispanic White respondents. After adjustment for demographics, behavioral factors, and social determinants of health, compared to non-Hispanic White respondents, odds of screening was increased among non-Hispanic Black respondents (OR 1.10, p = 0.02); lower but attenuated among Hispanic respondents (OR 0.73, p < 0.001), non-Hispanic American Indian/Alaskan Native respondents (OR 0.85, p = 0.048), and non-Hispanic respondents of other races (OR 0.82, p = 0.01); and lower but not attenuated among non-Hispanic Asian (OR 0.68, p < 0.001) respondents. LIMITATIONS: Recall bias and participant bias, as well as residual confounding. CONCLUSIONS: Adjustment for social determinants of health reduced racial and ethnic disparities in colorectal cancer screening among all minority racial and ethnic groups except non-Hispanic Asian individuals; however, other unmeasured confounders likely exist. See Video Abstract at http://links.lww.com/DCR/B977.

2.
Surg Oncol Clin N Am ; 31(2): xv-xvi, 2022 04.
Artigo em Inglês | MEDLINE | ID: mdl-35351282
3.
Surg Oncol Clin N Am ; 31(2): 265-278, 2022 04.
Artigo em Inglês | MEDLINE | ID: mdl-35351277

RESUMO

The management of patients with metastatic colorectal cancer (CRC) has evolved significantly over the last decade owing to advances in aggressive multimodality chemotherapy options, targeted therapy, development of sophisticated operative techniques, and adjunct radiotherapy options. Patients with synchronous CRC require complex decision-making with multidisciplinary collaboration to develop individualized treatment strategies taking into account tumor biology and patients' individual goals and objectives. We will outline important considerations with regard to treatment options for patients with synchronous metastatic CRC to facilitate contemporary evidence-based management decisions and optimize oncologic outcomes.


Assuntos
Neoplasias Colorretais , Neoplasias Hepáticas , Neoplasias Retais , Neoplasias Colorretais/patologia , Humanos , Neoplasias Hepáticas/cirurgia , Oncologia
4.
J Am Coll Surg ; 234(4): 624-631, 2022 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-35290282

RESUMO

BACKGROUND: Women surgeons face numerous barriers to career advancement. Inequitable citation of surgical literature may represent a contributing factor to gender disparities in academic surgery. STUDY DESIGN: This was a cross-sectional analysis of publications from 50 top-ranking surgery journals in 2017 and 2018, as defined by the 2019 InCites Journal Citation Reports. The citation rate of publications by women vs men first authors was compared. Similarly, the citation rate of publications by men vs women last authors was also compared. Adjusted regression analyses of citation rates accounted for the time interval since publication as well as the journal within which the article was published, among other potential confounding factors. RESULTS: A total of 19,084 publications from 48 surgery journals with a median (interquartile range) of 8 (4 to 15) citations contributing to a median (interquartile range) Journal Impact Factor of 4.0 (3.4 to 4.6) were analyzed. Compared with man-first author publications, woman-first author publications demonstrated a 9% lower citation rate (incidence rate ratio 0.91, p < 0.001). Similarly, compared with publications by man-last authors, woman-last author publications demonstrated a 4% lower citation rate (incidence rate ratio 0.96, p = 0.03). These associations persisted after multivariable adjustment for additional confounding factors, however, not on sensitivity analysis of 24 of the highest-ranking journals. CONCLUSIONS: Among top-tier surgical journals, publications by women-first and -last authors were less cited compared with publications by men-first and -last authors, but not among the highest-tier surgical journals. Gender bias may exist in the citation of surgical research, contributing to gender disparities in academic surgery.


Assuntos
Bibliometria , Cirurgiões , Estudos Transversais , Feminino , Humanos , Fator de Impacto de Revistas , Masculino , Sexismo
5.
J Am Coll Surg ; 234(1): 1-11, 2022 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-35213454

RESUMO

BACKGROUND: Previous studies have focused on the development and evaluation of care bundles to reduce the risk of surgical site infection (SSI) throughout the perioperative period. A focused examination of the technical/surgical aspects of SSI reduction during CRS has not been conducted. This study aimed to develop an expert consensus on intraoperative technical/surgical aspects of SSI prevention by the surgical team during colorectal surgery (CRS). STUDY DESIGN: In a modified Delphi process, a panel of 15 colorectal surgeons developed a consensus on intraoperative technical/surgical aspects of SSI prevention undertaken by surgical personnel during CRS using information from a targeted literature review and expert opinion. Consensus was developed with up to three rounds per topic, with a prespecified threshold of ≥70% agreement. RESULTS: In 3 Delphi rounds, the 15 panelists achieved consensus on 16 evidence-based statements. The consensus panel supported the use of wound protectors/retractors, sterile incision closure tray, preclosure glove change, and antimicrobial sutures in reducing SSI along with wound irrigation with aqueous iodine and closed-incision negative pressure wound therapy in high-risk, contaminated wounds. CONCLUSIONS: Using a modified Delphi method, consensus has been achieved on a tailored set of recommendations on technical/surgical aspects that should be considered by surgical personnel during CRS to reduce the risk of SSI, particularly in areas where the evidence base is controversial or lacking. This document forms the basis for ongoing evidence for the topics discussed in this article or new topics based on newly emerging technologies in CRS.


Assuntos
Cirurgia Colorretal , Procedimentos Cirúrgicos do Sistema Digestório , Cirurgia Colorretal/efeitos adversos , Consenso , Técnica Delfos , Humanos , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle
6.
J Am Coll Surg ; 234(2): 176-181, 2022 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-35213438

RESUMO

BACKGROUND: Many residency programs struggle to meet the ACGME requirement for resident participation in quality improvement initiatives. STUDY DESIGN: As part of an institutional quality improvement effort, trainees from the Departments of Surgery and Anesthesiology at a single academic medical center were teamed with institutional content experts in 7 key risk factor areas within preoperative patient optimization. A systematic review of each subject matter area was performed using the MEDLINE database. Institutional recommendations for the screening and management of each risk factor were developed and approved using modified Delphi consensus methodology. Upon project completion, an electronic survey was administered to all individuals who participated in the process to assess the perceived value of participation. RESULTS: Fifty-one perioperative stakeholders participated in recommendation development: 26 trainees and 25 content experts. Residents led 6 out of 7 groups specific to a subject area within preoperative optimization. A total of 4,649 abstracts were identified, of which 456 full-text articles were selected for inclusion in recommendation development. Seventeen out of 26 (65.4%) trainees completed the survey. The vast majority of trainees reported increased understanding of their preoperative optimization subject area (15/17 [88.2%]) as well as the Delphi consensus method (14/17 [82.4%]) after participation in the project. Fourteen out of 17 (82.4%) trainees stated that they would participate in a similar quality improvement initiative again. CONCLUSIONS: We demonstrate a novel way to involve trainees in an institutional quality initiative that served to educate trainees in quality improvement, the systematic review process, Delphi methodology, and preoperative optimization. This study provides a framework that other residency programs can use to engage residents in institutional quality improvement efforts.


Assuntos
Anestesiologia , Internato e Residência , Centros Médicos Acadêmicos , Educação de Pós-Graduação em Medicina , Humanos , Melhoria de Qualidade , Inquéritos e Questionários
7.
Surg Infect (Larchmt) ; 23(1): 66-72, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-34652237

RESUMO

Background: Pre-operative administration of combined oral antibiotic agents and mechanical bowel preparation has been demonstrated to improve post-operative outcomes after elective colectomy, however, many patients do not receive combined preparation. Patient and procedural determinants of combined preparation receipt remain understudied. Patients and Methods: All patients undergoing elective colectomy within the 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use File and Targeted Colectomy datasets were included. Univariable and multivariable logistic regression analyses were performed to identify factors associated with receipt of combined preparation. Results: A total of 21,889 patients were included, of whom 13,848 (63.2%) received combined preparation pre-operatively. Patients who received combined preparation tended to be younger, male, of white race, and of non-Hispanic ethnicity (all p < 0.05). After multivariable adjustment, male gender, body mass index (BMI) 30-39 kg/m2, independent functional status, and laparoscopic and robotic surgical approaches were associated with receipt of combined preparation (all p < 0.05), whereas Asian race, hypertension, disseminated cancer, and inflammatory bowel disease were associated with omission of combined preparation (all p < 0.05). Conclusions: Patients with risk factors for infectious complications-including a poor functional status, comorbid conditions, and undergoing an open procedure-are less likely to receive combined preparation before elective colectomy. Similarly, female and Asian patients are less likely to receive combined preparation, emphasizing the need for equitable administration of combined preparation.


Assuntos
Fístula Anastomótica , Antibioticoprofilaxia , Administração Oral , Antibacterianos/uso terapêutico , Colectomia , Procedimentos Cirúrgicos Eletivos , Feminino , Humanos , Masculino , Cuidados Pré-Operatórios , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/tratamento farmacológico , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/prevenção & controle
8.
Surg Endosc ; 36(4): 2532-2540, 2022 04.
Artigo em Inglês | MEDLINE | ID: mdl-33978851

RESUMO

BACKGROUND: While total sleep duration and rapid eye movement (REM) sleep duration have been associated with long-term mortality in non-surgical cohorts, the impact of preoperative sleep on postoperative outcomes has not been well studied. METHODS: In this secondary analysis of a prospective observational cohort study, patients who recorded at least 1 sleep episode using a consumer wearable device in the 7 days before elective colorectal surgery were included. 30-day postoperative outcomes among those who did and did not receive at least 6 h of total sleep, as well as those who did and did not receive at least 1 h of rapid eye movement (REM) sleep, were compared. RESULTS: 34 out of 95 (35.8%) patients averaged at least 6 h of sleep per night, while 44 out of 82 (53.7%) averaged 1 h or more of REM sleep. Patients who slept less than 6 h had similar postoperative outcomes compared to those who slept 6 h or more. Patients who averaged less than 1 h of REM sleep, compared to those who achieved 1 h or more of REM sleep, had significantly higher rates of complication development (29.0% vs. 9.1%, P = 0.02), and return to the OR (10.5% vs. 0%, P = 0.04). After adjustment for confounding factors, increased REM sleep duration remained significantly associated with decreased complication development (increase in REM sleep from 50 to 60 min: OR 0.72, P = 0.009; REM sleep ≥ 1 h: OR 0.22, P = 0.03). CONCLUSION: In this cohort of patients undergoing elective colorectal surgery, those who developed a complication within 30 days were less likely to average at least 1 h of REM sleep in the week before surgery than those who did not develop a complication. Preoperative REM sleep duration may represent a risk factor for surgical complications; however additional research is necessary to confirm this relationship.


Assuntos
Cirurgia Colorretal , Procedimentos Cirúrgicos do Sistema Digestório , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Humanos , Estudos Prospectivos , Sono REM
9.
Surg Endosc ; 36(2): 1584-1592, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-33782756

RESUMO

BACKGROUND: The proliferation of wearable technology presents a novel opportunity for perioperative activity monitoring; however, the association between perioperative activity level and readmission remains underexplored. This study sought to determine whether physical activity data captured by wearable technology before and after colorectal surgery can be used to predict 30-day readmission. METHODS: In this prospective observational cohort study of adults undergoing elective major colorectal surgery (January 2018 to February 2019) at a single institution, participants wore an activity monitor 30 days before and after surgery. The primary outcome was return to baseline percentage, defined as step count on the day before discharge as a percentage of mean preoperative daily step count, among readmitted and non-readmitted patients. RESULTS: 94 patients had sufficient data available for analysis, of which 16 patients (17.0%) were readmitted within 30 days following discharge. Readmitted patients achieved a lower return to baseline percentage compared to patients who were not readmitted (median 15.1% vs. 31.8%; P = 0.004). On multivariable analysis adjusting for readmission risk and hospital length of stay, an absolute increase of 10% in return to baseline percentage was associated with a 40% decreased risk of 30-day readmission (odds ratio 0.60; P = 0.02). Analysis of the receiver operating characteristic curve identified 28.9% as an optimal return to baseline percent threshold for predicting readmission. CONCLUSIONS: Achieving a higher percentage of an individual's preoperative baseline activity level on the day prior to discharge after major colorectal surgery is associated with decreased risk of 30-day hospital readmission.


Assuntos
Cirurgia Colorretal , Dispositivos Eletrônicos Vestíveis , Adulto , Humanos , Tempo de Internação , Readmissão do Paciente , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco
10.
Dis Colon Rectum ; 65(1): 108-116, 2022 01 01.
Artigo em Inglês | MEDLINE | ID: mdl-34538832

RESUMO

BACKGROUND: Fecal management systems have become ubiquitous in hospitalized patients with fecal incontinence or severe diarrhea, especially in the setting of perianal wounds. Although fecal management system use has been shown to be safe and effective in initial series, case reports of rectal ulceration and severe bleeding have been reported, with a relative paucity of clinical safety data in the literature. OBJECTIVE: The purpose of this study was to determine the rate of rectal complications attributable to fecal management systems, as well as to characterize possible risk factors and appropriate management strategies for such complications. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at a large academic medical center. PATIENTS: All medical and surgical patients who underwent fecal management system placement from December 2014 to March 2017 were included. MAIN OUTCOME MEASURES: We measured any rectal complication associated with fecal management system use, defined as any rectal injury identified after fecal management system use confirmed by lower endoscopy. RESULTS: A total of 629 patients were captured, with a median duration of fecal management system use of 4 days. Overall, 8 patients (1.3%) experienced a rectal injury associated with fecal management system use. All of the patients who experienced a rectal complication had severe underlying comorbidities, including 2 patients on dialysis, 1 patient with cirrhosis, and 3 patients with a recent history of emergent cardiac surgery. In 3 patients the bleeding resolved spontaneously, whereas the remaining 5 patients required intervention: transanal suture ligation (n = 2), endoscopic clip placement (n = 1), rectal packing (n = 1), and proctectomy in 1 patient with a history of pelvic radiotherapy. LIMITATIONS: The study was limited by its retrospective design and single institution. CONCLUSIONS: This is the largest study to date evaluating rectal complications from fecal management system use. Although rectal injury rates are low, they can lead to serious morbidity. Advanced age, severe comorbidities, pelvic radiotherapy, and anticoagulation status or coagulopathy are important factors to consider before fecal management system placement. See Video Abstract at http://links.lww.com/DCR/B698. INCIDENCIA Y CARACTERIZACIN DE LAS COMPLICACIONES RECTALES DE LOS SISTEMAS DE MANEJO FECAL: ANTECEDENTES:Los sistemas de manejo fecal se han vuelto omnipresentes en pacientes hospitalizados con incontinencia fecal o diarrea severa, especialmente en el contexto de heridas perianales. Aunque se ha demostrado que el uso del sistema de tratamiento fecal es seguro y eficaz en la serie inicial, se han notificado casos de ulceración rectal y hemorragia grave, con una relativa escasez de datos de seguridad clínica en la literatura.OBJETIVO:Determinar la tasa de complicaciones rectales atribuibles a los sistemas de manejo fecal. Caracterizar los posibles factores de riesgo y las estrategias de manejo adecuadas para tales complicaciones.DISEÑO:Estudio de cohorte retrospectivo.ENTORNO CLINICO:Centro médico académico de mayor volumen.PACIENTES:Todos los pacientes médicos y quirúrgicos que se sometieron a la colocación del sistema de manejo fecal desde diciembre de 2014 hasta marzo de 2017.PRINCIPALES MEDIDAS DE VALORACION:Cualquier complicación rectal asociada con el uso del sistema de manejo fecal, definida como cualquier lesión rectal identificada después del uso del sistema de manejo fecal confirmada por endoscopia baja.RESULTADOS:Se identificaron un total de 629 pacientes, con una duración media del uso del sistema de manejo fecal de 4,0 días. En general, 8 (1,3%) pacientes desarrollaron una lesión rectal asociada con el uso del sistema de manejo fecal. Todos los pacientes que mostraron una complicación rectal tenían comorbilidades subyacentes graves, incluidos dos pacientes en diálisis, un paciente con cirrosis y tres pacientes con antecedentes recientes de cirugía cardíaca emergente. En tres pacientes el sangrado se resolvió espontáneamente, mientras que los cinco pacientes restantes requirieron intervención: ligadura de sutura transanal (2), colocación de clip endoscópico (1), taponamiento rectal (1) y proctectomía en un paciente con antecedentes de radioterapia pélvica.LIMITACIONES:Diseño retrospectivo, institución única.CONCLUSIONES:Este es el estudio más grande hasta la fecha que evalúa las complicaciones rectales del uso del sistema de manejo fecal. Si bien las tasas de lesión rectal son bajas, pueden provocar una morbilidad grave. La edad avanzada, las comorbilidades graves, la radioterapia pélvica y el estado de anticoagulación o coagulopatía son factores importantes a considerar antes de la colocación del sistema de manejo fecal. Consulte Video Resumen en http://links.lww.com/DCR/B698.


Assuntos
Incontinência Fecal/terapia , Fissura Anal/diagnóstico , Hemorragia/diagnóstico , Doenças Retais/patologia , Reto/lesões , Idoso , Comorbidade/tendências , Gerenciamento Clínico , Endoscopia do Sistema Digestório/métodos , Incontinência Fecal/epidemiologia , Feminino , Fissura Anal/epidemiologia , Fissura Anal/cirurgia , Hemorragia/epidemiologia , Hemorragia/cirurgia , Humanos , Incidência , Ligadura/métodos , Masculino , Pessoa de Meia-Idade , Pelve/patologia , Pelve/efeitos da radiação , Protectomia/métodos , Doenças Retais/cirurgia , Reto/diagnóstico por imagem , Reto/patologia , Estudos Retrospectivos , Fatores de Risco , Segurança , Suturas , Cirurgia Endoscópica Transanal/métodos
11.
Clin Colon Rectal Surg ; 34(6): 400-405, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34853561

RESUMO

Management of the acute anastomotic leak is complex and patient-specific. Clinically stable patients often benefit from a nonoperative approach utilizing antibiotics with or without percutaneous drainage. Clinically unstable patients or nonresponders to conservative management require operative intervention. Surgical management is dictated by the degree of contamination and inflammation but includes drainage with proximal diversion, anastomotic resection with end-stoma creation, or reanastomosis with proximal diversion. Newer therapies, including colorectal stenting, vacuum-assisted rectal drainage, and endoscopic clipping, have also been described.

12.
PLoS One ; 16(10): e0258452, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34624059

RESUMO

BACKGROUND: Telemedicine has been rapidly adopted in the wake of the COVID-19 pandemic. There is limited work surrounding demographic and socioeconomic disparities that may exist in telemedicine utilization. This study aimed to examine demographic and socioeconomic differences in surgical patient telemedicine usage during the COVID-19 pandemic. METHODS: Department of Surgery outpatients seen from July 1, 2019 to May 31, 2020 were stratified into three visit groups: pre-COVID-19 in-person, COVID-19 in-person, or COVID-19 telemedicine. Generalized linear models were used to examine associations of sex, race/ethnicity, Distressed Communities Index (DCI) scores, MyChart activation, and insurance status with telemedicine usage during the COVID-19 pandemic. RESULTS: 14,792 patients (median age 60, female [57.0%], non-Hispanic White [76.4%]) contributed to 21,980 visits. Compared to visits before the pandemic, telemedicine visits during COVID-19 were more likely to be with patients from the least socioeconomically distressed communities (OR, 1.31; 95% CI, 1.08,1.58; P = 0.005), with an activated MyChart (OR, 1.38; 95% CI, 1.17-1.64; P < .001), and with non-government or commercial insurance (OR, 2.33; 95% CI, 1.84-2.94; P < .001). Adjusted comparison of telemedicine visits to in person visits during COVID-19 revealed telemedicine users were more likely to be female (OR, 1.38, 95% CI, 1.10-1.73; P = 0.005) and pay with non-government or commercial insurance (OR, 2.77; 95% CI, 1.85-4.16; P < .001). CONCLUSIONS: During the first three months of the COVID-19 pandemic, telemedicine was more likely utilized by female patients and those without government or commercial insurance compared to patients who used in-person visits. Interventions using telemedicine to improve health care access might consider such differences in utilization.


Assuntos
COVID-19/epidemiologia , Acesso aos Serviços de Saúde , Disparidades em Assistência à Saúde , Pandemias , SARS-CoV-2 , Telemedicina , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores Sexuais , Procedimentos Cirúrgicos Operatórios
13.
J Surg Oncol ; 124(1): 16-24, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-33788957

RESUMO

BACKGROUND: Childhood cancer survivors (CCS) are at elevated risk of secondary malignancies (SM). Enhanced screening for SM is recommended, but compliance is poor. We hypothesized that CCS with adult-onset SM (colorectal cancer [CRC], melanoma, or breast cancer [BC]) would present with more advanced disease and have decreased overall survival (OS). METHODS: The Surveillance, Epidemiology, and End Results Program was queried for patients diagnosed with cancer at age less than or equal to 18 also diagnosed with adult-onset CRC, melanoma, or BC. A cohort without a history of prior malignancy was likewise identified. Tumor features and clinical outcomes were compared. RESULTS: CCS with a SM (n = 224) were compared with patients without a childhood cancer history (n = 1,392,670). CCS were diagnosed younger (BC = 37.6 vs. 61.3, p < 0.01, CRC = 35.0 vs. 67.1, p < 0.01, melanoma = 29.6 vs. 61.3 years old, p < 0.01). CCS with BC were more likely to have Stage III or IV disease (25.2% vs. 16.5%, p = 0.01). Hormone-receptor expression also differed; CCS were less likely to develop Luminal A-type tumors (48.6% vs. 66.9%, p = 0.01). After age-adjustment, CCS had worse OS (Hazard ratio: CRC = 2.449, p < 0.01, melanoma = 6.503, p < 0.01, BC = 3.383, p < 0.01). CONCLUSION: CCS were younger when diagnosed with a SM. After age-adjustment, OS was diminished. Heightened surveillance may be necessary for CCS diagnosed with SM.


Assuntos
Neoplasias da Mama/mortalidade , Sobreviventes de Câncer/estatística & dados numéricos , Neoplasias Colorretais/mortalidade , Melanoma/mortalidade , Programa de SEER/estatística & dados numéricos , Adolescente , Adulto , Idoso , Neoplasias da Mama/patologia , Estudos de Casos e Controles , Criança , Neoplasias Colorretais/patologia , Feminino , Seguimentos , Humanos , Masculino , Melanoma/patologia , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida
16.
Surg Endosc ; 35(5): 2067-2074, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-32394171

RESUMO

BACKGROUND: As the opioid epidemic escalates, preoperative opioid use has become increasingly common. Recent studies associated preoperative opioid use with postoperative morbidity. However, limited study of its impact on patients within enhanced recovery protocols (ERP) exists. We assessed the impact of preoperative opioid use on postoperative complications among colorectal surgery patients within an ERP, hypothesizing that opioid-exposed patients would be at increased risk of complications. METHODS: Elective colorectal cases from August 2013 to June 2017 were reviewed in a retrospective cohort study comparing preoperative opioid-exposed patients to opioid-naïve patients. Postoperative complications were defined as a composite of complications captured by the American College of Surgeons National Surgical Quality Improvement Program. Logistic regression identified risk factors for postoperative complications. RESULTS: 707 patients were identified, including 232 (32.8%) opioid-exposed patients. Opioid-exposed patients were younger (57.9 vs 61.9 years; p < 0.01) and more likely to smoke (27.6 vs 17.1%; p < 0.01). Laparoscopic procedures were less common among opioid-exposed patients (44.8 vs 58.1%; p < 0.01). Median morphine equivalents received were higher in opioid-exposed patients (65.0 vs 20.1 mg; p < 0.01), but compliance to ERP elements was otherwise equivalent. Postoperative complications were higher among opioid-exposed patients (28.5 vs 15.0%; p < 0.01), as was median length of stay (4.0 vs 3.0 days; p < 0.01). Logistic regression identified multiple patient- and procedure-related factors independently associated with postoperative complications, including preoperative opioid use (p = 0.001). CONCLUSION: Preoperative opioid use is associated with increased risk of postoperative complications in elective colorectal surgery patients within an ERP. These results highlight the negative impact of opioid use, suggesting an opportunity to further reduce the risk of surgical complications through ERP expansion to include preoperative mitigation strategies for opioid-exposed patients.


Assuntos
Analgésicos Opioides , Cirurgia Colorretal/métodos , Complicações Pós-Operatórias/etiologia , Idoso , Analgésicos Opioides/toxicidade , Neoplasias Colorretais/cirurgia , Cirurgia Colorretal/efeitos adversos , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/métodos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Transtornos Relacionados ao Uso de Opioides/complicações , Período Pré-Operatório , Estudos Retrospectivos , Resultado do Tratamento
18.
Surg Infect (Larchmt) ; 22(2): 174-181, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32379549

RESUMO

Background: Fever is a common response to both infectious and non-infectious physiologic insults in the critically ill, and in certain populations it appears to be protective. Fever is particularly common in trauma patients, and even more so in those with infections. The relationship between fever, trauma status, and mortality in patients with an infection is unclear. Patients and Methods: A review of a prospectively maintained institutional database over a 17-year period was performed. Surgical and trauma intensive care unit (ICU) patients with a nosocomial infection were extracted to compare in-hospital mortality among trauma and non-trauma patients with and without fever. Univariable analyses compared patient and infection characteristics between trauma and non-trauma patients. A multivariable logistic regression model was created to identify predictors of in-hospital mortality, with a focus on fever and trauma status. Results: Nine hundred forty-one trauma patients and 1,449 non-trauma patients with ICU-acquired infections were identified. Trauma patients were younger (48 vs. 59, p < 0.001), more likely to be male (73% vs. 56%, p < 0.001), more likely to require blood transfusion (74% vs. 47%, p < 0.001), had lower Acute Physiology and Chronic Health Evaluation (APACHE) II scores (18 vs. 19, p = 0.02), and had lower rates of comorbidities. Trauma patients were more likely to develop a fever (72% vs. 43%, p < 0.001) and had lower in-hospital mortality (9.6% vs. 22.6%, p < 0.001). In multivariable analysis, non-trauma patients with fever had a lower odds of mortality compared with non-trauma patients without fever (odds ratio [OR] 0.63, p = 0.004). Trauma patients with fever had the lowest odds ratio for mortality when compared to non-trauma patients without fever (OR 0.25, p < 0.001). Conclusions: In this large cohort of trauma and surgical ICU patients with ICU-acquired infections, fever was associated with a lower odds of mortality in both trauma and non-trauma patients. Further investigation is needed to determine the mechanisms behind the interplay between trauma status, fever, and mortality.


Assuntos
Estado Terminal , Unidades de Terapia Intensiva , APACHE , Cuidados Críticos , Feminino , Mortalidade Hospitalar , Humanos , Masculino
19.
Anesth Analg ; 132(2): 442-455, 2021 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-33105279

RESUMO

BACKGROUND: Enhanced Recovery (ER) is a change management framework in which a multidisciplinary team of stakeholders utilizes evidence-based medicine to protocolize all aspects of a surgical care to allow more rapid return of function. While service-specific reports of ER adoption are common, institutional-wide adoption is complex, and reports of institution-wide ER adoption are lacking in the United States. We hypothesized that ER principles were generalizable across an institution and could be implemented across a multitude of surgical disciplines with improvements in length of stay, opioid consumption, and cost of care. METHODS: Following the establishment of a formal institutional ER program, ER was adopted in 9 distinct surgical subspecialties over 5 years at an academic medical center. We compared length of stay, opioid consumption, and total cost of care in all surgical subspecialties as a function of time using a segmented regression/interrupted time series statistical model. RESULTS: There were 7774 patients among 9 distinct surgical populations including 2155 patients in the pre-ER cohort and 5619 patients in the post-ER cohort. The introduction of an ER protocol was associated with several significant changes: a reduction in length of stay in 5 of 9 specialties; reduction in opioid consumption in 8 specialties; no change or reduction in maximum patient-reported pain scores; and reduction or no change in hospital costs in all specialties. The ER program was associated with an aggregate increase in profit over the study period. CONCLUSIONS: Institution-wide efforts to adopt ER can generate significant improvements in patient care, opioid consumption, hospital capacity, and profitability within a large academic medical center.


Assuntos
Centros Médicos Acadêmicos/economia , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/economia , Recuperação Pós-Cirúrgica Melhorada , Custos Hospitalares , Tempo de Internação/economia , Manejo da Dor/economia , Redução de Custos , Análise Custo-Benefício , Humanos , Análise de Séries Temporais Interrompida , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde , Melhoria de Qualidade/economia , Indicadores de Qualidade em Assistência à Saúde/economia , Fatores de Tempo
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