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1.
Am Surg ; 88(5): 953-958, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35275764

RESUMO

BACKGROUND: The American Association for the Surgery of Trauma (AAST) has developed a grading system for emergency general surgery (EGS) conditions. We sought to validate the AAST EGS grades for patients undergoing urgent/emergent colorectal resection. METHODS: Patients enrolled in the "Eastern Association for the Surgery of Trauma Multicenter Colorectal Resection in EGS-to anastomose or not to anastomose" study undergoing urgent/emergent surgery for obstruction, ischemia, or diverticulitis were included. Baseline demographics, comorbidity severity as defined by Charlson comorbidity index (CCI), procedure type, and AAST grade were prospectively collected. Outcomes included length of stay (LOS) in-hospital mortality, and surgical complications (superficial/deep/organ-space surgical site infection, anastomotic leak, stoma complication, fascial dehiscence, and need for further intervention). Multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication or mortality. RESULTS: There were 367 patients, with a mean (± SD) age of 62 ± 15 years. 39% were women. The median interquartile range (IQR) CCI was 4 (2-6). Overall, the pathologies encompassed the following AAST EGS grades: I (17, 5%), II (54, 15%), III (115, 31%), IV (95, 26%), and V (86, 23%). Management included laparoscopic (24, 7%), open (319, 87%), and laparoscopy converted to laparotomy (24, 6%). Higher AAST grade was associated with laparotomy (P = .01). The median LOS was 13 days (8-22). At least 1 surgical complication occurred in 33% of patients and the mortality rate was 14%. Development of at least 1 surgical complication, need for unplanned intervention, mortality, and increased LOS were associated with increasing AAST severity grade. On multivariable analysis, factors predictive of in-hospital mortality included AAST organ grade, CCI, and preoperative vasopressor use (odds ratio (OR) 1.9, 1.6, 3.1, respectively). The American Association for the Surgery of Trauma emergency general surgery grade was also associated with the development of at least 1 surgical complication (OR 2.5), while CCI, preoperative vasopressor use, respiratory failure, and pneumoperitoneum were not. CONCLUSION: The American Association for the Surgery of Trauma emergency general surgery grading systems display construct validity for mortality and surgical complications after urgent/emergent colorectal resection. These results support incorporation of AAST EGS grades for quality benchmarking and surgical outcomes research.


Assuntos
Neoplasias Colorretais , Cirurgia Geral , Laparoscopia , Idoso , Feminino , Humanos , Tempo de Internação , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de Doença , Resultado do Tratamento , Estados Unidos
2.
J Card Surg ; 37(4): 808-817, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-35137981

RESUMO

BACKGROUND: Ischemic gastrointestinal complications (IGIC) following cardiac surgery are associated with high morbidity and mortality and remain difficult to predict. We evaluated perioperative risk factors for IGIC in patients undergoing open cardiac surgery. METHODS: All patients that underwent an open cardiac surgical procedure at a tertiary academic center between 2011 and 2017 were included. The primary outcome was IGIC, defined as acute mesenteric ischemia necessitating a surgical intervention or postoperative gastrointestinal bleeding that was proven to be of ischemic etiology and necessitated blood product transfusion. A backward stepwise regression model was constructed to identify perioperative predictors of IGIC. RESULTS: Of 6862 patients who underwent cardiac surgery during the study period, 52(0.8%) developed IGIC. The highest incidence of IGIC (1.9%) was noted in patients undergoing concomitant coronary artery, valvular, and aortic procedures. The multivariable regression identified hypertension (odds ratio [OR] = 5.74), preoperative renal failure requiring dialysis (OR = 3.62), immunocompromised status (OR = 2.64), chronic lung disease (OR = 2.61), and history of heart failure (OR = 2.03) as independent predictors for postoperative IGIC. Pre- or intraoperative utilization of intra-aortic balloon pump or catheter-based assist devices (OR = 4.54), intraoperative transfusion requirement of >4 RBC units(OR = 2.47), and cardiopulmonary bypass > 180 min (OR = 2.28) were also identified as independent predictors for the development of IGIC. CONCLUSIONS: We identified preoperative and intraoperative risk factors that independently increase the risk of developing postoperative IGIC after cardiac surgery. A high index of suspicion must be maintained and any deviation from the expected recovery course in patients with the above-identified risk factors should trigger an immediate evaluation with the involvement of the acute care surgical team.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Gastroenteropatias , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Gastroenteropatias/etiologia , Humanos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco
3.
Eur J Trauma Emerg Surg ; 48(2): 1197-1204, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-34296323

RESUMO

PURPOSE: The Emergency Surgery Score (ESS) is a reliable point-based score that predicts mortality and morbidity in emergency surgery patients. However, it has been validated only in the U.S. PATIENTS: We aimed to prospectively validate ESS in a Greek patient population. METHODS: All patients who underwent an emergent laparotomy were prospectively included over a 15-month period. A systematic chart review was performed to collect relevant preoperative, intraoperative, and postoperative variables based on which the ESS was calculated for each patient. The relationship between ESS and 30-day mortality, morbidity (i.e., the occurrence of at least one complication), and the need for intensive care unit (ICU) admission was evaluated and compared between the Greek and U.S. patients using the c-statistics methodology. The study was registered on "Research Registry" with the unique identifying number 5901. RESULTS: A total of 214 patients (102 Greek) were included. The mean age was 64 years, 44% were female, and the median ESS was 7. The most common indication for surgery was hollow viscus perforation (25%). The ESS reliably and incrementally predicted mortality (c-statistics = 0.79 [95% CI 0.67-0.90] and 0.83 [95% CI 0.74-0.92]), morbidity (c-statistics = 0.83 [95% CI 0.76-0.91] and 0.79 [95% CI 0.69-0.88]), and ICU admission (c-statistics = 0.88 [95% CI 0.81-0.96] and 0.84 [95% CI 0.77-0.91]) in both Greek and U.S. CONCLUSION: The correlation between the ESS and the surgical outcomes was statistically significant in both Greek and U.S. patients undergoing emergency laparotomy. ESS could prove globally useful for preoperative patient counseling and quality-of-care benchmarking.


Assuntos
Complicações Pós-Operatórias , Estudos de Coortes , Feminino , Grécia/epidemiologia , Humanos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Medição de Risco/métodos
4.
J Surg Res ; 267: 37-47, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34130237

RESUMO

BACKGROUND: Body mass index (BMI) does not reliably predict Surgical site infections (SSI). We hypothesize that abdominal wall thickness (AWT) would serve as a better predictor of SSI for patients undergoing emergency colon operations. METHODS: We retrospectively evaluated our Emergency Surgery Database (2007-2018). Emergency colon operations for any indication were included. AWT was measured by pre-operative CT scans at 5 locations. Only superficial and deep SSIs were considered as SSI in the analysis. Univariate then multivariable analyses were used to determine predictors of SSI. RESULTS: 236 patients met inclusion criteria. The incidence of post-operative SSI was 25.8% and the median BMI was 25.8kg/m2 [22.5-30.1]. The median AWT between patients with and without SSI was significantly different (2.1cm [1.4, 2.8] and 1.8cm [1.2, 2.5], respectively). A higher BMI trended toward increased rates of SSI, but this was not statistically significant. In overweight (BMI 25-29.9kg/m2) and obese (BMI ≥30kg/m2) patients, SSI versus no SSI rates were (50.0% versus 41.9% and 47.4% versus 36.4%, P = 0.365 and 0.230) respectively. The incidence of SSI in patients with an average AWT < 1.8cm was 20% and 30% for patients with average AWT ≥1.8cm. On multivariable analysis, AWT ≥1.8cm at 2cm inferior to umbilicus was an independent predictor of SSI (OR 2.98, 95%CI 1.34-6.63, P = 0.007). CONCLUSIONS: AWT is a better predictor of SSI than BMI. Preoperative imaging of AWT may direct intraoperative decisions regarding wound management. Future clinical outcomes research in emergency surgery should include abdominal wall thickness as an important patient variable.


Assuntos
Parede Abdominal , Colo , Procedimentos Cirúrgicos do Sistema Digestório , Infecção da Ferida Cirúrgica , Parede Abdominal/anatomia & histologia , Parede Abdominal/diagnóstico por imagem , Parede Abdominal/cirurgia , Colo/cirurgia , Humanos , Estudos Retrospectivos , Fatores de Risco , Infecção da Ferida Cirúrgica/diagnóstico por imagem , Infecção da Ferida Cirúrgica/epidemiologia , Infecção da Ferida Cirúrgica/etiologia
5.
World J Surg ; 45(11): 3295-3301, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-33554296

RESUMO

BACKGROUND: In resource-limited countries, open appendectomy is still performed under general anesthesia (GA) or neuraxial anesthesia (NA). We sought to compare the postoperative outcomes of appendectomy under NA versus GA. METHODS: We conducted a post hoc analysis of the International Patterns of Opioid Prescribing (iPOP) multicenter study. All patients ≥ 16 years-old who underwent an open appendectomy between October 2016 and March 2017 in one of the 14 participating hospitals were included. Patients were stratified into two groups: NA-defined as spinal or epidural-and GA. All-cause morbidity, hospital length of stay (LOS), and pain severity were assessed using univariate analysis followed by multivariable logistic regression adjusting for the following preoperative characteristics: age, gender, body mass index (BMI), smoking, history of opioid use, emergency status, and country. RESULTS: A total of 655 patients were included, 353 of which were in the NA group and 302 in the GA group. The countries operating under NA were Colombia (39%), Thailand (31%), China (23%), and Brazil (7%). Overall, NA patients were younger (mean age (SD): 34.5 (14.4) vs. 40.7 (17.9), p-value < 0.001) and had a lower BMI (mean (SD): 23.5 (3.8) vs. 24.3 (5.2), p-value = 0.040) than GA patients. On multivariable analysis, NA was independently associated with less postoperative complications (OR, 95% CI: 0.30 [0.10-0.94]) and shorter hospital LOS (LOS > 3 days, OR, 95% CI: 0.47 [0.32-0.68]) compared to GA. There was no difference in postoperative pain severity between the two techniques. CONCLUSIONS: Open appendectomy performed under NA is associated with improved outcomes compared to that performed under GA. Further randomized controlled studies should examine the safety and value of NA in lower abdominal surgery.


Assuntos
Analgésicos Opioides , Apendicectomia , Adolescente , Anestesia Geral , Apendicectomia/efeitos adversos , Humanos , Tempo de Internação , Complicações Pós-Operatórias/epidemiologia , Padrões de Prática Médica , Estudos Retrospectivos
6.
Surgery ; 169(6): 1434-1440, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-33431187

RESUMO

BACKGROUND: Hospital readmission is an important quality-of-care indicator. We sought to examine the rates and predictors of unplanned readmission for the high-risk non-trauma emergency laparotomy patient. METHODS: This is a post hoc analysis of a multicenter prospective observational study. Between April 2018 and June 2019, a total of 19 centers enrolled all adult patients undergoing emergency laparotomies and systematically collected preoperative, operative, and 30-day postoperative variables. For the purpose of this study, we defined unplanned readmission as a readmission occurring within 30 days from discharge and one that was immediately preceded by an emergency department visit. Patients were excluded if they died during the index admission, were discharged to hospice, or were transferred to other hospitals. Predictors of unplanned readmission were evaluated using a multivariable logistic regression model, adjusting for patient demographics, comorbidities, laboratory variables, and preoperative acuity of disease variables. RESULTS: A total of 1,347 patients were included, of which 234 (17.4%) had an unplanned readmission. The median patient age was 60 y, 49.4% were male, and 71.4% were white. The most common diagnoses were hollow viscus perforation (28.1%) and small bowel obstruction (24.5%). Predictors of unplanned readmission included patient factors (eg, disseminated cancer [odds ratio: 2.22, confidence interval: 1.35-3.64, P = .002], weight loss >10% in the past 6 months [odds ratio: 1.65, confidence interval: 1.07-2.54, P = .023], dyspnea at baseline [odds ratio: 1.62, confidence interval: 1.06-2.48, P = .026], wound complications [odds ratio: 2.23, confidence interval: 1.55-3.19, P < .001], and discharge to nursing homes [odds ratio: 1.68, confidence interval: 1.02-2.80, P = .044]). CONCLUSION: Unplanned readmission after emergency laparotomies are common, especially for patients with wound complications or requiring nursing homes. These system factors are potential quality improvement targets to reduce readmissions.


Assuntos
Tratamento de Emergência/efeitos adversos , Laparotomia/efeitos adversos , Readmissão do Paciente/estatística & dados numéricos , Idoso , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco
7.
J Surg Res ; 261: 152-158, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33429224

RESUMO

BACKGROUND: The Emergency Surgery Score (ESS) has been previously validated as a reliable tool to predict postoperative outcomes in emergency general surgery (EGS). The purpose of this study is to assess the differential performance of the ESS in specific EGS procedures. METHODS: The American College of Surgeons' National Surgical Quality Improvement Program database was retrospectively analyzed for patients undergoing EGS between 2007 and 2017. Patients who underwent the following EGS procedures were identified: laparoscopic appendectomy, laparoscopic cholecystectomy, surgery for small bowel obstruction (SBO), colectomy, and incarcerated ventral or inguinal hernia repair. The performance of the ESS in predicting mortality in each procedure was assessed using receiver operating characteristic analyses. RESULTS: A total of 467,803 patients underwent EGS (mean age 50 ± 19.9 y, females 241,330 [51.6%]), of which 191,930 (41%) underwent laparoscopic appendectomy, 40,353 (8.6%) underwent laparoscopic cholecystectomy, and 35,152 (7.5%) patients underwent surgery for SBO. The ESS correlated extremely well with mortality for patients who underwent laparoscopic appendectomy (area under the curve (AUC) 0.91), laparoscopic cholecystectomy (AUC 0.91), lysis of adhesions for SBO (AUC 0.83), colectomy (AUC 0.83), and incarcerated hernia repair (AUC 0.85). CONCLUSIONS: ESS performance accurately predicts mortality across a wide range of EGS procedures, and its use should be encouraged for preoperative patient counseling and for nationally benchmarking the quality of care of EGS.


Assuntos
Tratamento de Emergência/mortalidade , Cirurgia Geral/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/mortalidade , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco
8.
J Trauma Acute Care Surg ; 90(3): 557-564, 2021 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-33507026

RESUMO

BACKGROUND: The Emergency Surgery Score (ESS) was recently validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively evaluate whether ESS can predict the need for respiratory and/or renal support (RRS) at discharge after emergent laparotomies (EL). METHODS: This is a post hoc analysis of a 19-center prospective observational study. Between April 2018 and June 2019, all adult patients undergoing EL were enrolled. Preoperative, intraoperative, and postoperative variables were systematically collected. In this analysis, patients were excluded if they died during the index hospitalization, were discharged to hospice, or transferred to other hospitals. A composite variable, the need for RRS, was defined as the need for one or more of the following at hospital discharge: tracheostomy, ventilator dependence, or dialysis. Emergency Surgery Score was calculated for all patients, and the correlation between ESS and RRS was examined using the c-statistics method. RESULTS: From a total of 1,649 patients, 1,347 were included. Median age was 60 years, 49.4% were men, and 70.9% were White. The most common diagnoses were hollow viscus organ perforation (28.1%) and small bowel obstruction (24.5%); 87 patients (6.5%) had a need for RRS (4.7% tracheostomy, 2.7% dialysis, and 1.3% ventilator dependence). Emergency Surgery Score predicted the need for RRS in a stepwise fashion; for example, 0.7%, 26.2%, and 85.7% of patients required RRS at an ESS of 2, 12, and 16, respectively. The c-statistics for the need for RRS, the need for tracheostomy, ventilator dependence, or dialysis at discharge were 0.84, 0.82, 0.79, and 0.88, respectively. CONCLUSION: Emergency Surgery Score accurately predicts the need for RRS at discharge in EL patients and could be used for preoperative patient counseling and for quality of care benchmarking. LEVEL OF EVIDENCE: Prognostic and epidemiological, level III.


Assuntos
Serviço Hospitalar de Emergência , Hospitalização , Laparotomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Diálise Renal , Respiração Artificial , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Determinação de Necessidades de Cuidados de Saúde , Complicações Pós-Operatórias/terapia , Valor Preditivo dos Testes , Medição de Risco
9.
Am J Surg ; 221(5): 1069-1075, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-32917366

RESUMO

INTRODUCTION: We sought to evaluate whether the Emergency Surgery Score (ESS) can accurately predict outcomes in elderly patients undergoing emergent laparotomy (EL). METHODS: This is a post-hoc analysis of an EAST multicenter study. Between April 2018 and June 2019, all adult patients undergoing EL in 19 participating hospitals were prospectively enrolled, and ESS was calculated for each patient. Using the c-statistic, the correlation between ESS and mortality, morbidity, and need for ICU admission was assessed in three patient age cohorts (65-74, 75-84, ≥85 years old). RESULTS: 715 patients were included, of which 52% were 65-74, 34% were 75-84, and 14% were ≥85 years old; 51% were female, and 77% were white. ESS strongly correlated with postoperative mortality (c-statistic:0.81). Mortality gradually increased from 0% to 20%-60% at ESS of 2, 10 and 16 points, respectively. ESS predicted mortality, morbidity, and need for ICU best in patients 65-74 years old (c-statistic:0.81, 0.75, 0.83 respectively), but its performance significantly decreased in patients ≥85 years (c-statistic:0.72, 0.64, 0.67 respectively). CONCLUSION: ESS is an accurate predictor of outcome in the elderly EL patient 65-85 years old, but its performance decreases for patients ≥85. Consideration should be given to modify ESS to better predict outcomes in the very elderly patient population.


Assuntos
Tratamento de Emergência/estatística & dados numéricos , Laparotomia/estatística & dados numéricos , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Tratamento de Emergência/efeitos adversos , Tratamento de Emergência/mortalidade , Feminino , Humanos , Laparotomia/efeitos adversos , Laparotomia/mortalidade , Masculino , Medição de Risco , Índice de Gravidade de Doença , Resultado do Tratamento , Estados Unidos
10.
Eur J Emerg Med ; 28(2): 97-103, 2021 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-32941201

RESUMO

BACKGROUND: Acute alcohol intoxication is very common in patients with severe traumatic brain injury (TBI). Whether there is an independent association between alcohol intoxication and mortality is debated. This study hypothesized that alcohol intoxication is independently associated with less mortality after severe TBI (sTBI). METHODS: This retrospective observational cohort study included all patients with sTBI [head-Abbreviated Injury Score (AIS) ≥3, corresponding to serious head injury or worse] admitted from 1 January 2011 to 31 December 2016 in an academic level I trauma center. Patients were classified as with alcohol intoxication or without intoxication based on blood alcohol concentration or description of alcohol intoxication on admission. The primary endpoint was in-hospital mortality. Multivariable logistic regression analysis, including patient and injury characteristics, was used to assess independent association with alcohol intoxication. RESULTS: Of the 2865 TBI patients, 715 (25%) suffered from alcohol intoxication. They were younger (mean age 46 vs. 68 years), more often male (80 vs. 57%) and had a lower median Glasgow Coma Scale upon arrival (14 vs. 15) compared to the no-intoxication group. There was no difference in injury severity by head AIS or Rotterdam CT. Alcohol intoxication had an unadjusted association with in-hospital mortality [unadjusted odds ratio (OR) 0.51; 95% confidence interval (CI), 0.38-0.68]; however, there was no independent association after adjusting for potentially confounding patient and injury characteristics (adjusted OR 0.72; 95% CI, 0.48-1.09). CONCLUSION: In this retrospective study, there was no independent association between alcohol intoxication and higher in-hospital mortality in emergency patients with sTBI.


Assuntos
Intoxicação Alcoólica , Lesões Encefálicas Traumáticas , Lesões Encefálicas , Intoxicação Alcoólica/complicações , Intoxicação Alcoólica/epidemiologia , Concentração Alcoólica no Sangue , Lesões Encefálicas Traumáticas/epidemiologia , Estudos de Coortes , Serviço Hospitalar de Emergência , Escala de Coma de Glasgow , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
11.
J Am Coll Surg ; 231(6): 639-648, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32977034

RESUMO

BACKGROUND: Patients in the US receive disproportionally higher amounts of opioids after operations compared with their non-US counterparts. We aimed to assess the relationship between perceived pain severity after operation and the amount of opioid medications prescribed at discharge in US vs non-US patients. METHODS: We conducted a post-hoc analysis of the International Patterns of Opioid Prescribing multicenter study. Patients 16 years and older who underwent appendectomy, cholecystectomy, or inguinal herniorrhaphy in 1 of 14 participating hospitals across 8 countries between October 2016 and March 2017 were included. In hospitals where pain severity was assessed using a 0 to 10 visual analog scale before hospital discharge, patients were stratified into the following groups, depending on the pain severity: none, mild (1 to 3), moderate (4 to 6), and severe (7 to 10). The number of opioid prescriptions, total number of pills, and oral morphine equivalents prescribed were calculated for each group and US and non-US patients were compared. RESULTS: A total of 2,024 patients were included. Eighty-three percent of US patients without pain were prescribed opioids compared with 8.7% of non-US patients without pain (p < 0.001). The number of opioid prescriptions, number of pills, and oral morphine equivalents prescribed were similar across the 4 pain severity groups in US patients (p > 0.05). In contrast, the number of opioid prescriptions, number of opioid pills, and oral morphine equivalents prescribed among non-US patients were incrementally higher as the pain severity progressed from no pain to severe pain (all, p < 0.05). CONCLUSIONS: US patients are prescribed opioids at high rates and doses regardless of pain severity. Additional efforts should be directed toward tailoring opioid prescriptions to patients' needs.


Assuntos
Analgésicos Opioides/uso terapêutico , Dor Pós-Operatória/tratamento farmacológico , Adulto , Analgésicos Opioides/administração & dosagem , Apendicectomia/efeitos adversos , Colecistectomia/efeitos adversos , Feminino , Herniorrafia/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor , Dor Pós-Operatória/diagnóstico , Estados Unidos/epidemiologia
12.
J Trauma Acute Care Surg ; 89(6): 1023-1031, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32890337

RESUMO

OBJECTIVE: Evidence comparing stoma creation (STM) versus anastomosis after urgent or emergent colorectal resection is limited. This study examined outcomes after colorectal resection in emergency general surgery patients. METHODS: This was an Eastern Association for the Surgery of Trauma-sponsored prospective observational multicenter study of patients undergoing urgent/emergent colorectal resection. Twenty-one centers enrolled patients for 11 months. Preoperative, intraoperative, and postoperative variables were recorded. χ, Mann-Whitney U test, and multivariable logistic regression models were used to describe outcomes and risk factors for surgical complication/mortality. RESULTS: A total of 439 patients were enrolled (ANST, 184; STM, 255). The median (interquartile range) age was 62 (53-71) years, and the median Charlson Comorbidity Index (CCI) was 4 (1-6). The most common indication for surgery was diverticulitis (28%). Stoma group was older (64 vs. 58 years, p < 0.001), had a higher CCI, and were more likely to be immunosuppressed. Preoperatively, STM patients were more likely to be intubated (57 vs. 15, p < 0.001), on vasopressors (61 vs. 13, p < 0.001), have pneumoperitoneum (131 vs. 41, p < 0.001) or fecal contamination (114 vs. 33, p < 0.001), and had a higher incidence of elevated lactate (149 vs. 67, p < 0.001). Overall mortality was 13%, which was higher in STM patients (18% vs. 8%, p = 0.02). Surgical complications were more common in STM patients (35% vs. 25%, p = 0.02). On multivariable analysis, management with an open abdomen, intraoperative blood transfusion, and larger hospital size were associated with development of a surgical complication, while CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion were independently associated with mortality. CONCLUSION: This study highlights a tendency to perform fecal diversion in patients who are acutely ill at presentation. There is a higher morbidity and mortality rate in STM patients. Independent predictors of mortality include CCI, preoperative vasopressor use, steroid use, open abdomen, and intraoperative blood transfusion. Following adjustment by clinical factors, method of colon management was not associated with surgical complications or mortality. LEVEL OF EVIDENCE: Therapeutic study, level IV.


Assuntos
Colectomia/métodos , Cirurgia Colorretal/educação , Doença Diverticular do Colo/cirurgia , Cirurgia Geral/educação , Idoso , Anastomose Cirúrgica , Colectomia/educação , Colectomia/estatística & dados numéricos , Emergências , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Padrões de Prática Médica/estatística & dados numéricos , Estudos Prospectivos , Resultado do Tratamento , Estados Unidos
13.
J Trauma Acute Care Surg ; 89(2): 397-404, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32744834

RESUMO

BACKGROUND: The degree to which malnutrition impacts perioperative outcomes in the elderly emergency surgery (ES) patient remains unknown. We aimed to study the relationship between malnutrition, as measured by the Geriatric Nutritional Risk Index (GNRI), and postoperative outcomes in elderly patients undergoing ES. METHODS: Using the 2007 to 2016 American College of Surgeons National Surgical Quality Improvement Program database, all patients 65 years or older undergoing ES were included in our study. The GNRI, defined as (1.489 × albumin [g/L]) + (41.7 × [weight/ideal weight]) was calculated for each patient in the database. Patients with missing height, weight, or preoperative albumin data were excluded. Patients were divided into four malnutrition groups: very severe (GNRI < 73), severe (GNRI, 73-82), moderate (GNRI, 82-92), and mild (GNRI, 92-98). Geriatric Nutritional Risk Index greater than 98 constituted the normal nutrition group. Risk-adjusted multivariable logistic regressions were performed to study the relationship between malnutrition-measured using either GNRI, albumin level, or body mass index less than 18.5 kg/m-and the following postoperative outcomes: 30-day mortality, 30-day morbidity (including infectious and noninfectious complications), and hospital length of stay. The relationship between GNRI score and 30-day mortality for six common ES procedures was then assessed. RESULTS: A total of 82,725 patients were included in the final analyses. Of these, 55,214 were malnourished with GNRI less than 98 (66.74%). Risk-adjusted multivariable analyses showed that, as malnutrition worsened from mild to very severe, the risk of mortality, morbidity, and the hospital length of stay progressively increased (all p < 0.05). Patients with very severe malnutrition had at least a twofold increased likelihood of mortality (odds ratio [OR], 2.79; 95% confidence interval [CI], 2.57-3.03), deep vein thrombosis (OR, 2.07; 95% CI, 1.77-2.42), and respiratory failure (OR, 1.95; 95% CI, 1.81-2.11). Geriatric Nutritional Risk Index predicted mortality better than albumin or body mass index alone for ES. CONCLUSION: Malnutrition, measured using GNRI, is a strong independent predictor of adverse outcomes in the elderly ES patient and could be used to assess the nutrition status and counsel patients (and families) preoperatively. LEVEL OF EVIDENCE: Prognostic study, Level IV.


Assuntos
Serviço Hospitalar de Emergência , Avaliação Geriátrica/métodos , Desnutrição/complicações , Estado Nutricional , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Complicações Pós-Operatórias , Medição de Risco , Resultado do Tratamento , Estados Unidos
14.
Ann Surg ; 272(6): 879-886, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32657939

RESUMO

OBJECTIVE: The International Patterns of Opioid Prescribing study compares postoperative opioid prescribing patterns in the United States (US) versus the rest of the world. SUMMARY OF BACKGROUND DATA: The US is in the middle of an unprecedented opioid epidemic. Diversion of unused opioids contributes to the opioid epidemic. METHODS: Patients ≥16 years old undergoing appendectomy, cholecystectomy, or inguinal hernia repair in 14 hospitals from 8 countries during a 6-month period were included. Medical records were systematically reviewed to identify: (1) preoperative, intraoperative, and postoperative characteristics, (2) opioid intake within 3 months preoperatively, (3) opioid prescription upon discharge, and (4) opioid refills within 3 months postoperatively. The median/range and mean/standard deviation of number of pills and OME were compared between the US and non-US patients. RESULTS: A total of 4690 patients were included. The mean age was 49 years, 47% were female, and 4% had opioid use history. Ninety-one percent of US patients were prescribed opioids, compared to 5% of non-US patients (P < 0.001). The median number of opioid pills and OME prescribed were 20 (0-135) and 150 (0-1680) mg for US versus 0 (0-50) and 0 (0-600) mg for non-US patients, respectively (both P < 0.001). The mean number of opioid pills and OME prescribed were 23.1 ±â€Š13.9 in US and 183.5 ±â€Š133.7 mg versus 0.8 ±â€Š3.9 and 4.6 ±â€Š27.7 mg in non-US patients, respectively (both P < 0.001). Opioid refill rates were 4.7% for US and 1.0% non-US patients (P < 0.001). CONCLUSIONS: US physicians prescribe alarmingly high amounts of opioid medications postoperatively. Further efforts should focus on limiting opioid prescribing and emphasize non-opioid alternatives in the US.


Assuntos
Analgésicos Opioides/uso terapêutico , Prescrições de Medicamentos/estatística & dados numéricos , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica , Adulto , Idoso , Feminino , Saúde Global , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Estados Unidos
15.
J Trauma Acute Care Surg ; 89(1): 230-237, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32569106

RESUMO

BACKGROUND: Outcome data on the very elderly patients undergoing emergency general surgery (EGS) are sparse. We sought to examine short- and long-term mortality in the 80 plus years population following EGS. METHODS: Using our institutional 2008-2018 EGS Database, all the 80 plus years patients undergoing EGS were identified. The data were linked to the Social Security Death Index to determine cumulative mortality rates up to 3 years after discharge. Univariate and multivariable logistic regression analyses were used to determine predictors of in-hospital and 1-year cumulative mortality. RESULTS: A total of 385 patients were included with a mean age of 84 years; 54% were female. The two most common comorbidities were hypertension (76.1%) and cardiovascular disease (40.5%). The most common procedures performed were colectomy (20.0%), small bowel resection (18.2%), and exploratory laparotomy for other procedures (15.3%; e.g., internal hernia, perforated peptic ulcer). The overall in-hospital mortality was 18.7%. Cumulative mortality rates at 1, 2, and 3 years after discharge were 34.3%, 40.5%, and 43.4%, respectively. The EGS procedure associated with the highest 1-year mortality was colectomy (49.4%). Although hypertension, renal failure, hypoalbuminemia, hyperbilirubinemia, and elevated liver enzymes predicted in-hospital mortality, the only independent predictors of cumulative 1-year mortality were hypoalbuminemia (odds ratio, 2.17; 95% confidence interval, 1.10-4.27; p = 0.025) and elevated serum glutamic pyruvic transaminase (SGOT) level (odds ratio, 2.56; 95% confidence interval, 1.09-4.70; p = 0.029) at initial presentation. Patients with both factors had a cumulative 1-year mortality rate of 75.0%. CONCLUSION: More than half of the very elderly patients undergoing major EGS were still alive at 3 years postdischarge. The combination of hypoalbuminemia and elevated liver enzymes predicted the highest 1-year mortality. Such information can prove useful for patient and family counseling preoperatively. LEVEL OF EVIDENCE: Prognostic, Level III.


Assuntos
Mortalidade/tendências , Procedimentos Cirúrgicos Operatórios , Fatores Etários , Idoso de 80 Anos ou mais , Comorbidade , Emergências , Feminino , Humanos , Hipoalbuminemia/complicações , Fígado/enzimologia , Masculino , Alta do Paciente , Complicações Pós-Operatórias/mortalidade , Fatores de Risco
16.
Am J Surg ; 220(6): 1599-1604, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32409008

RESUMO

BACKGROUND: We aimed to examine the prevalence of, and describe factors associated with, firearm-related injuries in American households. METHODS: Using the 2010-2016 ACS-TQIP database, all ICD-9/10 external causes of injury for firearm-related injuries were queried with the place of occurrence designated as "home". Causes of injury were identified as assault, intentional self-injury, and unintentional injury. Univariate then multivariable regression analyses were performed to identify factors associated with each injury type. RESULTS: 12,657 firearm-related injuries in households were identified. Of those, 49.9% were victims of assault, 35.7% were intentional self-injury, and 14.4% were unintentional. Mortality was highest among self-inflicted injuries (52.4%), followed by assault (12.9%), and unintentional injuries (5.9%). On multivariable analysis, age <45 years, African-American race, and drug use were independently associated with an injury secondary to assault. Age >65 years, White race, psychiatric illness, and alcohol use disorder were independently associated with intentional self-injury. White and American-Indian race were independently associated with unintentional injuries. CONCLUSIONS: Assault is the most common cause of home-related firearm injury requiring hospitalization, while intentional self-injury is the most lethal.


Assuntos
Ferimentos por Arma de Fogo/epidemiologia , Adulto , Características da Família , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Estudos Retrospectivos , Estados Unidos/epidemiologia , Adulto Jovem
17.
Surg Infect (Larchmt) ; 21(10): 828-833, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-32240059

RESUMO

Background: Early diagnosis and prompt debridement of necrotizing soft tissue infection (NSTI) improves the outcome. We sought to determine whether failure to admit NSTI patients to acute care surgery (ACS) departments delays treatment and increases the mortality rate. Methods: Patients with NSTI were identified using the 2007-2018 institutional emergency surgery database at a tertiary care hospital. The diagnosis was confirmed by the operative/pathology reports. Patients who developed NSTI during hospitalization or underwent initial debridement at an outside hospital were excluded. Patients admitted to a non-ACS service (e.g., medicine, gynecology) were compared with those admitted to the ACS service with respect to co-morbidities, clinical presentation, time to surgery, and mortality rate. Multi-variable linear and logistic analyses were performed to determine whether admission to a non-ACS service predicts a delay in surgery or an increase in the mortality rate. Results: Of 132 patients, 91 met the inclusion criteria. The mean age was 53 years; 56% were male. Twenty patients (22%) were admitted to a non-ACS service, two thirds of them with an initial misdiagnosis (e.g., cellulitis). The demographics, co-morbidities, and clinical presentation were similar in the two groups except that the non-ACS group more often had human immunodeficiency virus infection (15.0% versus 2.8%; p = 0.04) and less often presented with erythema (70% versus 94.4%; p = 0.01). The median time to incision in non-ACS patients was significantly longer (24.8 versus 3.9 hours; p < 0.001). The mortality rates were 20.0% for the non-ACS group and 7.0% for the ACS group (p = 0.086). Multi-variable analyses revealed that absence of erythema is independently associated with a non-ACS admission (odds ratio [OR] 5.9; 95% confidence interval [CI] 1.3-25.6; p = 0.02), and non-ACS admissions correlated independently with delayed surgery (OR 35.20; 95% CI 3.86-321.20; p = 0.002). Conclusions: Admission of patients with NSTI to a non-ACS service often occurs because of initial misdiagnosis, especially in the absence of skin erythema; correlates with significantly delayed surgery; and might lead to more deaths.


Assuntos
Fasciite Necrosante , Infecções dos Tecidos Moles , Comorbidade , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Infecções dos Tecidos Moles/diagnóstico , Infecções dos Tecidos Moles/epidemiologia
18.
J Trauma Acute Care Surg ; 89(1): 118-124, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32176177

RESUMO

BACKGROUND: The Emergency Surgery Score (ESS) was recently developed and retrospectively validated as an accurate mortality risk calculator for emergency general surgery. We sought to prospectively validate ESS, specifically in the high-risk nontrauma emergency laparotomy (EL) patient. METHODS: This is an Eastern Association for the Surgery of Trauma multicenter prospective observational study. Between April 2018 and June 2019, 19 centers enrolled all adults (aged >18 years) undergoing EL. Preoperative, intraoperative, and postoperative variables were prospectively and systematically collected. Emergency Surgery Score was calculated for each patient and validated using c-statistic methodology by correlating it with three postoperative outcomes: (1) 30-day mortality, (2) 30-day complications (e.g., respiratory/renal failure, infection), and (3) postoperative intensive care unit (ICU) admission. RESULTS: A total of 1,649 patients were included. The mean age was 60.5 years, 50.3% were female, and 71.4% were white. The mean ESS was 6, and the most common indication for EL was hollow viscus perforation. The 30-day mortality and complication rates were 14.8% and 53.3%; 57.0% of patients required ICU admission. Emergency Surgery Score gradually and accurately predicted 30-day mortality; 3.5%, 50.0%, and 85.7% of patients with ESS of 3, 12, and 17 died after surgery, respectively, with a c-statistic of 0.84. Similarly, ESS gradually and accurately predicted complications; 21.0%, 57.1%, and 88.9% of patients with ESS of 1, 6, and 13 developed postoperative complications, with a c-statistic of 0.74. Emergency Surgery Score also accurately predicted which patients required intensive care unit admission (c-statistic, 0.80). CONCLUSION: This is the first prospective multicenter study to validate ESS as an accurate predictor of outcome in the EL patient. Emergency Surgery Score can prove useful for (1) perioperative patient and family counseling, (2) triaging patients to the intensive care unit, and (3) benchmarking the quality of emergency general surgery care. LEVEL OF EVIDENCE: Prognostic study, level III.


Assuntos
Emergências , Cirurgia Geral , Medição de Risco/métodos , Ferimentos e Lesões/cirurgia , Adulto , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Pontuação de Propensão , Estudos Prospectivos , Ferimentos e Lesões/mortalidade
19.
Am J Surg ; 220(4): 1052-1057, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32089243

RESUMO

BACKGROUND: The performance of the Emergency Surgery Score (ESS), a validated risk calculator, in the elderly emergency general surgery (EGS) patient remains unclear. We hypothesized that ESS accurately predicts outcomes in elderly EGS patients, including octogenarians and nonagenarians. METHODS: Using the 2007-2017 National Surgical Quality Improvement Program (NSQIP) database, we included all EGS patients ≥65 years old. The correlation between ESS, mortality and morbidity was assessed in the 3 patient cohorts (>65, octogenarians and nonagenarians), using the area under the curve (AUC). RESULTS: A total of 124,335 patients were included, of which 34,215 (28%) were octogenarians and 7239 (6%) were nonagenarians. In patients ≥65 years, ESS accurately predicted mortality (AUC 0.81). For octogenarians and nonagenarians, ESS predicted mortality moderately well (AUC 0.77 and 0.69, respectively. CONCLUSION: ESS accurately predicts mortality and morbidity in the elderly EGS patient, but its accuracy in predicting morbidity decreases for nonagenarians.


Assuntos
Emergências/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Medição de Risco/métodos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Gerenciamento de Dados , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Morbidade/tendências , Prognóstico , Reprodutibilidade dos Testes , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
20.
Injury ; 51(1): 32-38, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31540800

RESUMO

INTRODUCTION: Indications for nonoperative management (NOM) after penetrating renal injury remain ill-defined. Using a national database, we sought to describe the experience of operative and nonoperative management in the United States and retrospectively examine risk factors for failure of NOM. MATERIALS AND METHODS: The TQIP database 2010-2016 was used to identify patients with penetrating renal trauma. Outcomes of patients treated with an immediate operation (IO) and NOM are described. Failure of NOM was defined as the need for a renal operation after 4 h from arrival. Univariate then multivariable regression analyses were performed to identify predictors of NOM failure. RESULTS: Out of 8139 patients with kidney trauma, 1,842 had a penetrating mechanism of injury and were included. Of those, 89% were male, median age was 28 years, and 330 (18%) were offered NOM. Compared to IO, NOM patients were less likely to have gunshot wound (59% vs 89% p < 0.001) or high-grade renal injuries [AAST 4-5] (48% vs 76%, p < 0.001). Lower rates of in-hospital complications and shorter ICU and hospital stays were observed in the NOM group. NOM failed in 26 patients (8%). Independent predictors of NOM failure included a concomitant abdominal injury (OR = 3.99, 95% CI 1.03-23.23, p = 0.044), and every point increase in AAST grade (OR = 2.43, 95% CI 1.27-5.21, p = 0.005). CONCLUSIONS: NOM is highly successful in selected patients. Concomitant abdominal injuries and higher grade AAST injuries predict NOM failure and should be considered when selecting patients for IO or NOM.


Assuntos
Traumatismos Abdominais/terapia , Tratamento Conservador/métodos , Gerenciamento Clínico , Rim/lesões , Ferimentos Penetrantes/terapia , Traumatismos Abdominais/diagnóstico , Adulto , Feminino , Seguimentos , Humanos , Escala de Gravidade do Ferimento , Rim/diagnóstico por imagem , Masculino , Seleção de Pacientes , Estudos Retrospectivos , Centros de Traumatologia , Ferimentos Penetrantes/diagnóstico , Adulto Jovem
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