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1.
Medicine (Baltimore) ; 100(5): e24409, 2021 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-33592888

RESUMO

ABSTRACT: Infection with the SARS-CoV-2 virus seems to contribute significantly to increased postoperative complications and mortality after emergency surgical procedures. Additionally, the fear of COVID-19 contagion delays the consultation of patients, resulting in the deterioration of their acute diseases by the time of consultation. In the specific case of urgent digestive surgery patients, both factors significantly worsen the postoperative course and prognosis. Main working hypothesis: infection by COVID-19 increases postoperative 30-day-mortality for any cause in patients submitted to emergency/urgent general or gastrointestinal surgery. Likewise, hospital collapse during the first wave of the COVID-19 pandemic increased 30-day-mortality for any cause. Hence, the main objective of this study is to estimate the cumulative incidence of mortality at 30-days-after-surgery. Secondary objectives are: to estimate the cumulative incidence of postoperative complications and to develop a specific postoperative risk propensity model for COVID-19-infected patients.A multicenter, observational retrospective cohort study (COVID-CIR-study) will be carried out in consecutive patients operated on for urgent digestive pathology. Two cohorts will be defined: the "pandemic" cohort, which will include all patients (classified as COVID-19-positive or -negative) operated on for emergency digestive pathology during the months of March to June 2020; and the "control" cohort, which will include all patients operated on for emergency digestive pathology during the months of March to June 2019. Information will be gathered on demographic characteristics, clinical and analytical parameters, scores on the usual prognostic scales for quality management in a General Surgery service (POSSUM, P-POSSUM and LUCENTUM scores), prognostic factors applicable to all patients, specific prognostic factors for patients infected with SARS-CoV-2, postoperative morbidity and mortality (at 30 and 90 postoperative days). The main objective is to estimate the cumulative incidence of mortality at 30 days after surgery. As secondary objectives, to estimate the cumulative incidence of postoperative complications and to develop a specific postoperative risk propensity model for SARS-CoV-2 infected patients.The protocol (version1.0, April 20th 2020) was approved by the local Institutional Review Board (Ethic-and-Clinical-Investigation-Committee, code PR169/20, date 05/05/20). The study findings will be submitted to peer-reviewed journals and presented at relevant national and international scientific meetings.ClinicalTrials.gov Identifier: NCT04479150 (July 21, 2020).


Assuntos
Doenças do Sistema Digestório , Procedimentos Cirúrgicos do Sistema Digestório , Tratamento de Emergência , Controle de Infecções , Complicações Pós-Operatórias , Tempo para o Tratamento , Adulto , /prevenção & controle , Doenças do Sistema Digestório/diagnóstico , Doenças do Sistema Digestório/epidemiologia , Doenças do Sistema Digestório/mortalidade , Doenças do Sistema Digestório/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Procedimentos Cirúrgicos do Sistema Digestório/mortalidade , Emergências/epidemiologia , Tratamento de Emergência/efeitos adversos , Tratamento de Emergência/métodos , Tratamento de Emergência/mortalidade , Feminino , Humanos , Incidência , Controle de Infecções/métodos , Controle de Infecções/estatística & dados numéricos , Masculino , Mortalidade , Estudos Multicêntricos como Assunto , Estudos Observacionais como Assunto , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Projetos de Pesquisa , Medição de Risco/métodos
2.
Anticancer Res ; 41(2): 1069-1076, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33517317

RESUMO

BACKGROUND/AIM: Emergency surgery for colorectal cancer (CRC) is a high-risk procedure with high morbidity and mortality rates, especially for older patients. The relationship between patient age status and long-term outcomes is unclear. We hypothesize that patient age might be associated with long-term outcomes in patients with CRC who undergo emergency surgery. PATIENTS AND METHODS: Utilizing a database of CRC patients who received emergency surgery, we examined the prognostic association of patient age. RESULTS: The ≥80-years group was significantly associated with American Society of Anesthesiologists (ASA) physical status, bowel obstruction, N stage, shorter operating time, and less adjuvant chemotherapy (all p<0.03); and also, with shorter recurrence-free survival [multivariable hazard ratio, 2.79; 95% confidence interval, 1.13-7.21; p=0.026]. ASA status and adjuvant chemotherapy were significantly associated with recurrence-free survival (all p<0.03). CONCLUSION: Advanced age is associated with shorter recurrence-free survival in CRC patients who undergo emergency surgery.


Assuntos
Neoplasias Colorretais/mortalidade , Neoplasias Colorretais/cirurgia , Tratamento de Emergência/métodos , Obstrução Intestinal/etiologia , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Quimioterapia Adjuvante , Neoplasias Colorretais/tratamento farmacológico , Bases de Dados Factuais , Tratamento de Emergência/efeitos adversos , Feminino , Humanos , Obstrução Intestinal/epidemiologia , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Prognóstico , Estudos Retrospectivos , Análise de Sobrevida
3.
Cochrane Database Syst Rev ; 1: CD012899, 2021 01 27.
Artigo em Inglês | MEDLINE | ID: mdl-33501650

RESUMO

BACKGROUND: Patients with chronic kidney disease (CKD) who require urgent initiation of dialysis but without having a permanent dialysis access have traditionally commenced haemodialysis (HD) using a central venous catheter (CVC). However, several studies have reported that urgent initiation of peritoneal dialysis (PD) is a viable alternative option for such patients. OBJECTIVES: This review aimed to examine the benefits and harms of urgent-start PD compared to HD initiated using a CVC in adults and children with CKD requiring long-term kidney replacement therapy. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 25 May 2020 for randomised controlled trials through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. For non-randomised controlled trials, MEDLINE (OVID) (1946 to 11 February 2020) and EMBASE (OVID) (1980 to 11 February 2020) were searched. SELECTION CRITERIA: All randomised controlled trials (RCTs), quasi-RCTs and non-RCTs comparing urgent-start PD to HD initiated using a CVC. DATA COLLECTION AND ANALYSIS: Two authors extracted data and assessed the quality of studies independently. Additional information was obtained from the primary investigators. The estimates of effect were analysed using random-effects model and results were presented as risk ratios (RR) with 95% confidence intervals (CI). The GRADE framework was used to make judgments regarding certainty of the evidence for each outcome. MAIN RESULTS: Overall, seven observational studies (991 participants) were included: three prospective cohort studies and four retrospective cohort studies. All the outcomes except one (bacteraemia) were graded as very low certainty of evidence given that all included studies were observational studies and few events resulting in imprecision, and inconsistent findings. Urgent-start PD may reduce the incidence of catheter-related bacteraemia compared with HD initiated with a CVC (2 studies, 301 participants: RR 0.13, 95% CI 0.04 to 0.41; I2 = 0%; low certainty evidence), which translated into 131 fewer bacteraemia episodes per 1000 (95% CI 89 to 145 fewer). Urgent-start PD has uncertain effects on peritonitis risk (2 studies, 301 participants: RR 1.78, 95% CI 0.23 to 13.62; I2 = 0%; very low certainty evidence), exit-site/tunnel infection (1 study, 419 participants: RR 3.99, 95% CI 1.2 to 12.05; very low certainty evidence), exit-site bleeding (1 study, 178 participants: RR 0.12, 95% CI 0.01 to 2.33; very low certainty evidence), catheter malfunction (2 studies; 597 participants: RR 0.26, 95% CI: 0.07 to 0.91; I2 = 66%; very low certainty evidence), catheter re-adjustment (2 studies, 225 participants: RR: 0.13; 95% CI 0.00 to 18.61; I2 = 92%; very low certainty evidence), technique survival (1 study, 123 participants: RR: 1.18, 95% CI 0.87 to 1.61; very low certainty evidence), or patient survival (5 studies, 820 participants; RR 0.68, 95% CI 0.44 to 1.07; I2 = 0%; very low certainty evidence) compared with HD initiated using a CVC. Two studies using different methods of measurements for hospitalisation reported that hospitalisation was similar although one study reported higher hospitalisation rates in HD initiated using a catheter compared with urgent-start PD. AUTHORS' CONCLUSIONS: Compared with HD initiated using a CVC, urgent-start PD may reduce the risk of bacteraemia and had uncertain effects on other complications of dialysis and technique and patient survival. In summary, there are very few studies directly comparing the outcomes of urgent-start PD and HD initiated using a CVC for patients with CKD who need to commence dialysis urgently. This evidence gap needs to be addressed in future studies.


Assuntos
Cateteres Venosos Centrais , Tratamento de Emergência/métodos , Diálise Renal/métodos , Insuficiência Renal Crônica/terapia , Tempo para o Tratamento , Bacteriemia/epidemiologia , Bacteriemia/prevenção & controle , Viés , Infecções Relacionadas a Cateter/epidemiologia , Infecções Relacionadas a Cateter/prevenção & controle , Tratamento de Emergência/efeitos adversos , Tratamento de Emergência/instrumentação , Tratamento de Emergência/mortalidade , Hospitalização/estatística & dados numéricos , Humanos , Estudos Observacionais como Assunto/estatística & dados numéricos , Diálise Peritoneal/efeitos adversos , Diálise Peritoneal/instrumentação , Diálise Peritoneal/métodos , Diálise Peritoneal/mortalidade , Peritonite/epidemiologia , Diálise Renal/efeitos adversos , Diálise Renal/instrumentação , Diálise Renal/mortalidade , Insuficiência Renal Crônica/mortalidade
4.
J Surg Res ; 257: 252-259, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32862053

RESUMO

BACKGROUND: Emergency laparotomy (EL) is an increasingly common procedure in the elderly. Factors associated with mortality in the subpopulation of frail patients have not been thoroughly investigated. Sarcopenia has been investigated as a surrogate for frailty and poor prognosis. Our primary aim was to evaluate the association between easily measured sarcopenia parameters and 30-day postoperative mortality in elderly patients undergoing EL. Length of stay (LOS) and admission to an intensive care unit were secondary end points. METHODS: We conducted a retrospective cohort study, over a 5-year period, of patients aged 65 y and older who underwent EL at a tertiary university hospital. Sarcopenia was evaluated on admission computed tomography scan by two methods, first by psoas muscle attenuation and second by the product of perpendicular cross-sectional diameters (PCSDs). The lowest quartile of PCSDs and attenuation were defined as sarcopenic and compared with the rest of the cohort. Attenuation was stratified for the use of contrast enhancement. Multivariant logistic regression was performed to determine independent risk factors. RESULTS: During the study period, 403 patients, older than 65 y, underwent EL. Of these, 283 fit the inclusion criteria and 65 (23%) patients died within 30 d of surgery. On bivariate analysis, psoas muscle attenuation, but not PCSDs, was found to be associated with 30-day mortality (OR = 2.43, 95% CI = 1.34-4.38, P = 0.003) and longer LOS (35.7 d versus 22.2 d, Δd 13.5, 95% CI = 6.4-20.7, P < 0.001). In a multivariate analysis, psoas muscle attenuation, but not PCSDs, was an independent risk factor for 30-day postoperative mortality (OR = 2.35, 95% CI = 1.16-4.76, P = 0.017) and longer LOS (Δd = 14.4, 95% CI = 7.7-21.0, P < 0.001). Neither of the sarcopenia parameters was associated with increased admission to an intensive care unit. DISCUSSION: Psoas muscle attenuation is an independent risk factor for 30-day postoperative mortality and LOS after EL in the elderly population. This measurement can inform clinicians about the operative risk and hospital resource utilization.


Assuntos
Tratamento de Emergência/efeitos adversos , Fragilidade/diagnóstico , Laparotomia/efeitos adversos , Complicações Pós-Operatórias/mortalidade , Músculos Psoas/diagnóstico por imagem , Sarcopenia/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Estudos de Viabilidade , Feminino , Fragilidade/complicações , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Sarcopenia/complicações , Tomografia Computadorizada por Raios X
5.
J Surg Res ; 257: 278-284, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32866668

RESUMO

BACKGROUND: Emergency general surgery has higher adverse outcomes than elective surgery. Patients leaving the hospital against medical advice (AMA) have a greater risk for readmission and complications. We sought to identify clinical and demographic characteristics along with hospital factors associated with leaving AMA after EGS operations. METHODS: A retrospective review of the Nationwide Inpatient Sample was performed. All patients who underwent an EGS procedure accounting for >80% of the burden of EGS-related inpatient resources were identified. 4:1 propensity score analysis was conducted. Regression analyses determined predictive factors for leaving AMA. RESULTS: 546,856 patients were identified. 1085 (0.2%) patients who underwent EGS left AMA. They were more likely to be men (59% versus 42%), younger (median age 51 y, IQR [37.61] versus 54, IQR [38.69]), qualify for Medicaid (26% versus 13%) or be self-pay (17% versus 9%), and be within the lowest quartile median household income (40% versus 28%) (all P < 0.05). After applying 4:1 propensity score matching, individuals who were self-pay (OR 3.15, 95% CI 2.44-4.06) or insured through Medicare (OR 2.75, 95% CI 2.11-3.57) and Medicaid (OR 3.58, 95% CI 2.83-4.52) had increased odds of leaving AMA compared with privately insured patients. In addition, history of alcohol (OR 2.21, 95% CI 1.65-2.98), drug abuse (OR 4.54, 95% CI 3.23-6.38), and psychosis (OR 2.31, 95% CI 1.65-3.23) were associated with higher likelihood for leaving AMA. CONCLUSIONS: Patients undergoing EGS have a high risk of complications, and leaving AMA further increases this risk. Interventions to encourage safe discharge encompassing surgical, psychiatric, and socioeconomic factors are warranted to prevent a two-hit effect and compound postoperative risk.


Assuntos
Tratamento de Emergência/efeitos adversos , Cooperação do Paciente/estatística & dados numéricos , Alta do Paciente/normas , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adulto , Fatores Etários , Idoso , Feminino , Humanos , Renda/estatística & dados numéricos , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Cooperação do Paciente/psicologia , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos , Fatores de Risco , Fatores Sexuais , Estados Unidos/epidemiologia
6.
J Urol ; 205(1): 264-270, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-32749908

RESUMO

PURPOSE: Postoperative opioids are overprescribed in the United States. In November 2016 the State of Pennsylvania required an opioid consent for minors. Our hypothesis is that this mandate decreased postoperative opioid prescriptions in our division. MATERIALS AND METHODS: All patients who received a urological outpatient or minor emergency procedure from August 2015 to August 2019 were identified. Surgeries performed within 6 months after mandate implementation were excluded to account for the transition period. Perioperative data including case type were extracted by a clinical data warehouse from preexisting fields within the health record. The frequencies of postoperative prescriptions, delayed prescriptions and emergency department encounters were assessed. A multivariable logistic regression to identify predictors of opioid prescription at discharge was performed. RESULTS: A total of 4,349 patients were analyzed. The frequency of postsurgical opioid prescriptions decreased from 45.3% to 2.6% (p <0.001). The median morphine milligram equivalent decreased by 22.5 among children prescribed an opioid (p <0.001). Rates of an emergency department visits (3% vs 2.7%) or delayed nonopioid prescriptions (0.8% vs 1.2%) within 30 days of discharge were unchanged (p >0.05). Fewer patients received a delayed opioid prescription after mandate implementation (0.03% vs 0.5%, p <0.001). Female patients were less likely (OR 0.309, 95% CI 0.195-0.491; p <0.001) to receive opioids prior to but not after the mandate (OR 0.309, 95% CI 0.544-2.035; p=0.122). Increasing age was predictive of receiving an opioid before (OR 1.187, 95% CI 1.157-1.218; p <0.001) and after (OR 1.241, 95% CI 1.186-1.299; p <0.001) the mandate. CONCLUSIONS: A state mandated opioid consent for minors greatly reduced post-urological surgery opioid prescription rates without increasing rates of readmission or delayed prescriptions.


Assuntos
Analgésicos Opioides/efeitos adversos , Consentimento Livre e Esclarecido/legislação & jurisprudência , Manejo da Dor/normas , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica/estatística & dados numéricos , Procedimentos Cirúrgicos Urológicos/efeitos adversos , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Analgésicos Opioides/normas , Criança , Pré-Escolar , Uso de Medicamentos/legislação & jurisprudência , Uso de Medicamentos/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Tratamento de Emergência/métodos , Feminino , Humanos , Lactente , Consentimento Livre e Esclarecido/normas , Masculino , Epidemia de Opioides/prevenção & controle , Manejo da Dor/métodos , Dor Pós-Operatória/etiologia , Readmissão do Paciente/estatística & dados numéricos , Pennsylvania , Padrões de Prática Médica/legislação & jurisprudência , Padrões de Prática Médica/normas , Estudos Retrospectivos , Governo Estadual , Procedimentos Cirúrgicos Urológicos/métodos , Urologistas/legislação & jurisprudência , Urologistas/normas , Urologistas/estatística & dados numéricos
7.
Cochrane Database Syst Rev ; 12: CD012913, 2020 12 15.
Artigo em Inglês | MEDLINE | ID: mdl-33320346

RESUMO

BACKGROUND: Urgent-start peritoneal dialysis (PD), defined as initiation of PD within two weeks of catheter insertion, has been emerging as an alternative mode of dialysis initiation for patients with chronic kidney disease (CKD) requiring urgent dialysis without established permanent dialysis access. Recently, several small studies have reported comparable patient outcomes between urgent-start and conventional-start PD. OBJECTIVES: To examine the benefits and harms of urgent-start PD compared with conventional-start PD in adults and children with CKD requiring long-term kidney replacement therapy. SEARCH METHODS: We searched the Cochrane Kidney and Transplant Register of Studies up to 25 May 2020 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. For non-randomised controlled trials, MEDLINE (OVID) (1946 to 27 June 2019), EMBASE (OVID) (1980 to 27 June 2019), Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov (up to 27 June 2019) were searched. SELECTION CRITERIA: All randomised controlled trials (RCTs) and non-RCTs comparing the outcomes of urgent-start PD (within 2 weeks of catheter insertion) and conventional-start PD ( ≥ 2 weeks of catheter insertion) treatment in children and adults CKD patients requiring long-term dialysis were included. Studies without a control group were excluded. DATA COLLECTION AND ANALYSIS: Data were extracted and quality of studies were examined by two independent authors. The authors contacted investigators for additional information. Summary estimates of effect were examined using random-effects model and results were presented as risk ratios (RR) with 95% confidence intervals (CI) as appropriate for the data. The certainty of evidence for individual outcome was assessed using the GRADE approach. MAIN RESULTS: A total of 16 studies (2953 participants) were included in this review, which included one multicentre RCT (122 participants) and 15 non-RCTs (2831 participants): 13 cohort studies (2671 participants) and 2 case-control studies (160 participants). The review included unadjusted data for analyses due to paucity of studies reporting adjusted data. In low certainty evidence, urgent-start PD may increase dialysate leak (1 RCT, 122 participants: RR 3.90, 95% CI 1.56 to 9.78) compared with conventional-start PD which translated into an absolute number of 210 more leaks per 1000 (95% CI 40 to 635). In very low certainty evidence, it is uncertain whether urgent-start PD increases catheter blockage (4 cohort studies, 1214 participants: RR 1.33, 95% CI 0.40 to 4.43; 2 case-control studies, 160 participants: RR 1.89, 95% CI 0.58 to 6.13), catheter malposition (6 cohort studies, 1353 participants: RR 1.63, 95% CI 0.80 to 3.32; 1 case-control study, 104 participants: RR 3.00, 95% CI 0.64 to 13.96), and PD dialysate flow problems (3 cohort studies, 937 participants: RR 1.44, 95% CI 0.34 to 6.14) compared to conventional-start PD. In very low certainty evidence, it is uncertain whether urgent-start PD increases exit-site infection (2 cohort studies, 337 participants: RR 1.43, 95% CI 0.24 to 8.61; 1 case-control study, 104 participants RR 1.20, 95% CI 0.41 to 3.50), exit-site bleeding (1 RCT, 122 participants: RR 0.70, 95% CI 0.03 to 16.81; 1 cohort study, 27 participants: RR 1.58, 95% CI 0.07 to 35.32), peritonitis (7 cohort studies, 1497 participants: RR 1.00, 95% CI 0.68 to 1.46; 2 case-control studies, participants: RR 1.09, 95% CI 0.12 to 9.51), catheter readjustment (2 cohort studies, 739 participants: RR 1.27, 95% CI 0.40 to 4.02), or reduces technique survival (1 RCT, 122 participants: RR 1.09, 95% CI 1.00 to 1.20; 8 cohort studies, 1668 participants: RR 0.90, 95% CI 0.76 to 1.07; 2 case-control studies, 160 participants: RR 0.92, 95% CI 0.79 to 1.06). In very low certainty evidence, it is uncertain whether urgent-start PD compared with conventional-start PD increased death (any cause) (1 RCT, 122 participants: RR 1.49, 95% CI 0.87 to 2.53; 7 cohort studies, 1509 participants: RR 1.89, 95% CI 1.07 to 3.3; 1 case-control study, 104 participants: RR 0.90, 95% CI 0.27 to 3.02; very low certainty evidence). None of the included studies reported on tunnel tract infection. AUTHORS' CONCLUSIONS: In patients with CKD who require dialysis urgently without ready-to-use dialysis access in place, urgent-start PD may increase the risk of dialysate leak and has uncertain effects on catheter blockage, malposition or readjustment, PD dialysate flow problems, infectious complications, exit-site bleeding, technique survival, and patient survival compared with conventional-start PD.


Assuntos
Obstrução do Cateter/etiologia , Infecções Relacionadas a Cateter/etiologia , Tratamento de Emergência/efeitos adversos , Diálise Peritoneal/efeitos adversos , Insuficiência Renal Crônica/terapia , Estudos de Casos e Controles , Estudos de Coortes , Soluções para Diálise , Tratamento de Emergência/métodos , Hemorragia/etiologia , Humanos , Diálise Peritoneal/métodos , Diálise Peritoneal/mortalidade , Peritonite/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo , Cicatrização
8.
Can J Surg ; 63(5): E435-E441, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33009902

RESUMO

BACKGROUND: Most of the literature on emergency general surgery (EGS) has investigated appendiceal and biliary disease; however, EGS surgeons manage many other complex conditions. This study aimed to describe the operative burden of these conditions throughout Canada. METHODS: This multicentre retrospective cohort study evaluated EGS patients at 7 centres across Canada in 2014. Adult patients (aged ≥ 18 yr) undergoing nonelective operative interventions for nonbiliary, nonappendiceal diseases were included. Data collected included information on patients' demographic characteristics, diagnosis, procedure details, complications and hospital length of stay. Logistic regression was used to identify predictors of morbidity and mortality. RESULTS: A total of 2595 patients were included, with a median age of 60 years (interquartile range 46-73 yr). The most common principal diagnoses were small bowel obstruction (16%), hernia (15%), malignancy (11%) and perianal disease (9%). The most commonly performed procedures were bowel resection (30%), hernia repair (15%), adhesiolysis (11%) and débridement of skin and soft tissue infections (10%). A total of 47% of cases were completed overnight (between 5 pm and 8 am). The overall inhospital mortality rate was 8%. Thirty-three percent of patients had a complication, with independent predictors including increasing age (p = 0.001), increasing American Society of Anesthesiologists score (p = 0.02) and transfer from another centre (p = 0.001). CONCLUSION: This study characterizes the epidemiology of nonbiliary, nonappendiceal EGS operative interventions across Canada. Canadian surgeons are performing a large volume of EGS, and conditions treated by EGS services are associated with a substantial risk of morbidity and mortality. Results of this study will be used to guide future research efforts and set benchmarks for quality improvement.


Assuntos
Tratamento de Emergência/estatística & dados numéricos , Cirurgia Geral/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Padrões de Prática Médica/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Idoso , Benchmarking , Canadá , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Feminino , Cirurgia Geral/organização & administração , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Padrões de Prática Médica/organização & administração , Melhoria de Qualidade , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Resultado do Tratamento
9.
Surgery ; 168(3): 509-517, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32439207

RESUMO

BACKGROUND: Ventral hernias in patients with intra-abdominal metastases may not be addressed owing to other oncologic priorities, but they can affect quality of life and lead to sequelae necessitating an emergency operation. We compared the national trends and perioperative outcomes for elective and nonelective ventral hernia repairs for patients with intra-abdominal metastases. METHODS: Patients were identified from the National Inpatient Sample (2003-2015). Temporal trends were described using average annual percent change. Perioperative outcomes between elective and nonelective ventral hernia repairs were compared using multivariable regressions. RESULTS: An estimated 947,112 ventral hernia repairs were performed nationally, including 5,602 (0.6%) in patients with intra-abdominal metastases. Among patients with intra-abdominal metastases, 40.1% had a nonelective ventral hernia repair, mean (standard deviation) age was 64 (12) years, and 65.1% were women. Between 2003 and 2015, the total number of ventral hernia repairs performed nationally did not change (average annual percent change 0.062, P = .84). For patients with intra-abdominal metastases, although there was no change in the number of elective ventral hernia repairs (average annual percent change 0.65, P = .59), the number of nonelective ventral hernia repairs increased significantly (average annual percent change 2.7, P = .025). By multivariable analyses, patients with intra-abdominal metastases who underwent a nonelective repair were more likely to experience complications (odds ratio 1.76, P = .001), nonroutine discharge (odds ratio 1.93, P < .001), and mortality (odds ratio 2.27, P = .035). Nonelective ventral hernia repairs was also associated with a 38.5% (P < .001) longer hospital stay and 24.4% (P < .001) higher charges. CONCLUSION: The number of nonelective ventral hernia repairs, which is associated with substantial perioperative morbidity, has increased significantly among patients with intra-abdominal metastases. Surgeons should consider a nonemergency operation for select patients to mitigate the burden of nonelective ventral hernia repairs.


Assuntos
Neoplasias Abdominais/complicações , Procedimentos Cirúrgicos Eletivos/tendências , Tratamento de Emergência/tendências , Hérnia Ventral/cirurgia , Herniorrafia/tendências , Complicações Pós-Operatórias/epidemiologia , Neoplasias Abdominais/secundário , Idoso , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Tratamento de Emergência/estatística & dados numéricos , Feminino , Hérnia Ventral/etiologia , Herniorrafia/efeitos adversos , Herniorrafia/métodos , Herniorrafia/estatística & dados numéricos , Mortalidade Hospitalar/tendências , Humanos , Tempo de Internação/estatística & dados numéricos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Período Perioperatório/estatística & dados numéricos , Período Perioperatório/tendências , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Qualidade de Vida , Estudos Retrospectivos , Estados Unidos/epidemiologia
10.
Ann R Coll Surg Engl ; 102(6): 437-441, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32374217

RESUMO

INTRODUCTION: In the UK, general surgeons must demonstrate competency in emergency general surgery before obtaining a certificate of completion of training. Subsequently, many consultants develop focused elective specialist interests which may not mirror the breadth of procedures encountered during emergency practice. Recent National Emergency Laparotomy Audit analysis found that declared surgeon special interest impacted emergency laparotomy outcomes, which has implications for emergency general surgery service configuration. We sought to establish whether local declared surgeon special interest impacts emergency laparotomy outcomes. METHODS: Adult patients having emergency laparotomy were identified from our prospective National Emergency Laparotomy Audit database from May 2016 to May 2019 and categorised as colorectal or oesophagogastric according to operative procedure. Outcomes included 30-day mortality, return to theatre and length of stay. Binomial logistic regression was used to identify any association between declared consultant specialist interest and outcomes. RESULTS: Of 600 laparotomies, 358 (58.6%) were classifiable as specialist procedures: 287 (80%) colorectal and 71 (20%) oesophagogastric. Discordance between declared specialty and operation undertaken occurred in 25% of procedures. For colorectal emergency laparotomy, there was an increased risk of 30-day mortality when performed by a non-colorectal consultant (unadjusted odds ratio 2.34; 95% confidence interval 1.10-5.00; p = 0.003); however, when adjusted for confounders within multivariate analysis declared surgeon specialty had no impact on mortality, return to theatre or length of stay. CONCLUSION: Surgeon-declared specialty does not impact emergency laparotomy outcomes in this cohort of undifferentiated emergency laparotomies. This may reflect the on-call structure at Birmingham Heartlands Hospital, where a colorectal and oesophagogastric consultant are paired on call and provide cross-cover when needed.


Assuntos
Competência Clínica/normas , Tratamento de Emergência/estatística & dados numéricos , Gastroenteropatias/cirurgia , Laparotomia/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Idoso , Certificação/normas , Competência Clínica/estatística & dados numéricos , Colo/cirurgia , Consultores/estatística & dados numéricos , Estado Terminal/mortalidade , Estado Terminal/terapia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Esôfago/cirurgia , Feminino , Gastroenteropatias/mortalidade , Cirurgia Geral/organização & administração , Cirurgia Geral/normas , Mortalidade Hospitalar , Humanos , Laparotomia/efeitos adversos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Estudos Prospectivos , Reto/cirurgia , Reoperação/estatística & dados numéricos , Estômago/cirurgia , Cirurgiões/organização & administração , Cirurgiões/normas , Resultado do Tratamento
11.
Med. oral patol. oral cir. bucal (Internet) ; 25(3): e353-e358, mayo 2020. tab
Artigo em Inglês | IBECS | ID: ibc-196321

RESUMO

BACKGROUND: Intubation is necessary during critical situations to reduce the risk of death. In Brazil, a need exists to determine the prevalence of tooth avulsions in emergency and urgent care. The objective of this study was to identify the causes of orotracheal intubation (OTI), the number of tooth avulsions, and the avulsed teeth that result from urgent and emergency intubation. MATERIAL AND METHODS: The sample consisted of 116 patients (total group) in intensive care units (ICUs) distributed across Group 1 (G1), which was composed of 71 patients from an urgent-care hospital, and Group 2 (G2), which was composed of 45 patients from an emergency hospital. Clinical examinations showed dental alveolus with signs of recent exodontia in the upper and lower anterior regions. Sociodemographic data and the reason for intubation were evaluated. The Shapiro-Wilk normality test, chi-square test, Fisher's exact test, Mann-Whitney U test, and univariate logistic regression were performed with a significance level of 5%. RESULTS: The avulsion prevalence was 4.3%, with more cases receiving emergency intubation (n = 4). All avulsions occurred in adults, and a significant difference (p = 0.011) was observed with regard to the elderly. A 1-year reduction in age increased the chance of tooth avulsion during intubation by 1.09 times; being female increased the chance by 2.88 times. CONCLUSION: Pulmonary problems were the major causes of intubation, with the highest tooth avulsion prevalence observed during emergency intubation. The avulsed teeth were 11, 12, 13, 22, 32, and 33 across all cases


No disponible


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Avulsão Dentária/etiologia , Avulsão Dentária/epidemiologia , Intubação Intratraqueal/efeitos adversos , Tratamento de Emergência/efeitos adversos , Estatísticas não Paramétricas , Modelos Logísticos , Prevalência , Distribuição por Idade e Sexo , Fatores de Risco , Brasil/epidemiologia , Estudos Transversais , Serviço Hospitalar de Emergência
12.
Ann R Coll Surg Engl ; 102(6): 412-417, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32306742

RESUMO

INTRODUCTION: The national reconfiguration of vascular surgery means that arterial centres serve larger populations with increased demand on resources. Emergency general surgery ambulatory clinics facilitate timely review and intervention, avoiding admission; a critical limb ischaemia (CLI) 'hot clinic' (HC) was implemented to achieve similar for vascular patients. The aim of the study was to determine HC efficacy. METHODS: This was a prospective cohort study comparing HC patients with emergency admission (EA) patients between 1 May and 1 December 2017. Age, sex, comorbidities, CLI severity and smoking status were noted. HC patients were provided with satisfaction surveys. Primary outcome measures were freedom from reintervention and major amputation. Secondary outcome measures included time to procedure, length of stay, returns to theatre and 30-day readmission. RESULTS: A total of 147 patients (72 HC, 75 EA) were enrolled in the study. No statistical difference was found in age, sex, smoking status, severity of CLI or prevalence of comorbidities between the groups except that diabetes was more prevalent in EA patients (p=0.028). The median length of stay for the HC cohort was shorter (3 days vs 17 days, p<0.001), with no difference between time to procedure, return to theatre or 30-day readmission. HC patients were nearly 6 times more likely to experience freedom from reintervention (odds ratio: 5.824, p<0.001) and 2.5 times less likely to undergo amputation (odds ratio: 2.616, p=0.043). HC utilisation saved a total of 441 bed days. Over 90% of attendees responded with 100% positive feedback. CONCLUSIONS: A vascular HC facilitates urgent review and revascularisation. It provides comparable in-hospital outcomes and better long-term outcomes, with greater efficiency than hospital admission, demonstrating its value in treating CLI.


Assuntos
Tratamento de Emergência/estatística & dados numéricos , Isquemia/cirurgia , Salvamento de Membro/estatística & dados numéricos , Ambulatório Hospitalar/organização & administração , Doença Arterial Periférica/cirurgia , Procedimentos Cirúrgicos Vasculares/estatística & dados numéricos , Idoso , Amputação/estatística & dados numéricos , Estado Terminal/terapia , Eficiência Organizacional , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Feminino , Humanos , Isquemia/diagnóstico , Perna (Membro)/irrigação sanguínea , Tempo de Internação/estatística & dados numéricos , Salvamento de Membro/efeitos adversos , Masculino , Ambulatório Hospitalar/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Doença Arterial Periférica/diagnóstico , Estudos Prospectivos , Fatores de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Tempo para o Tratamento , Resultado do Tratamento , Reino Unido , Procedimentos Cirúrgicos Vasculares/efeitos adversos
13.
J Surg Res ; 252: 125-132, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32278966

RESUMO

BACKGROUND: Deep vein thromboses (DVTs) are a significant sequela of surgery and are associated with significant of morbidity and mortality in the United States. Operative emergency general surgery (EGS) cases have been demonstrated to have a greater burden of DVT than other types of surgery. MATERIALS AND METHODS: DVT in EGS cases were identified from the National Inpatient Sample-Healthcare Cost and Utilization Project database from 2001 to 2015 Q3 based on ICD-9 code specification. National incidence of DVT in EGS was calculated using the National Inpatient Sample-Healthcare Cost and Utilization Project sampling methodology, and propensity score matching was used to assess costs associated with DVT. RESULTS: Among 15,148,352 sample-weighted hospitalizations, 0.623% (94,392) experienced DVT. Incidence of DVT was greatest in GI ulcer surgery (1.705%) and lowest in appendectomy (0.095%). Patients with a perioperative DVT incurred $22,301 more in hospital-related costs than their counterparts who did not have a DVT. Although rates of DVT remained stable over the period analyzed, DVT-associated costs increased at a 2.09% annual rate in excess of inflation during the period analyzed. This increase in costs was most significant for laparotomy, which increased at a rate of 8.09% annually. CONCLUSIONS: DVT continues to be a significant burden on resources in EGS in spite of efforts with DVT prophylaxis. Considering the increase in costs and little change in incidence, further research on cost-effective management of DVT in EGS is warranted.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Custos de Cuidados de Saúde/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Trombose Venosa/epidemiologia , Idoso , Efeitos Psicossociais da Doença , Serviço Hospitalar de Emergência/economia , Serviço Hospitalar de Emergência/tendências , Tratamento de Emergência/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde/tendências , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/terapia , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Estados Unidos/epidemiologia , Trombose Venosa/economia , Trombose Venosa/terapia
14.
J Surg Res ; 247: 115-120, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31812338

RESUMO

Trainee research collaborative networks have revolutionized how trainees participate in clinical research. Three North East of England trainee-led research groups, the Intensive Care and Anesthesia Research Network of North East Trainees (INCARNNET), the Northern Surgical Trainees Research Association (NOSTRA) in General Surgery and the Collaborative Orthopedic Research Network (CORNET) in Trauma and Orthopedics have joined, creating a multispecialty collaborative. This multispecialty collaborative undertook a two-phase research Delphi, between November 2017 and June 2018, to identify key research questions. This Delphi identified three high priority research questions common to the three specialties: what is the impact of diabetes control on perioperative outcomes, what factors affect theater efficiency, and how to prevent postoperative chest infection following emergency surgery? These research questions will be developed into collaborative projects. The Delphi also identified specialty-specific questions to be taken forward as research projects by each network.


Assuntos
Pesquisa Biomédica/organização & administração , Técnica Delfos , Colaboração Intersetorial , Anestesiologia/educação , Anestesiologia/organização & administração , Complicações do Diabetes/prevenção & controle , Diabetes Mellitus/terapia , Eficiência , Tratamento de Emergência/efeitos adversos , Inglaterra , Cirurgia Geral/educação , Cirurgia Geral/organização & administração , Humanos , Salas Cirúrgicas/organização & administração , Ortopedia/educação , Ortopedia/organização & administração , Assistência Perioperatória , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Procedimentos Cirúrgicos Operatórios/efeitos adversos
15.
J Surg Res ; 246: 300-304, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31648068

RESUMO

BACKGROUND: The National Emergency Laparotomy Audit (NELA) highlights the importance of identifying high-risk patients due to the potential for significant morbidity and mortality. The NELA risk prediction calculator (NRPC) was developed from data in England and Wales and is one of several calculators available. We seek to determine the utility of NRPC in the Australian population and compare it with Portsmouth Physiological and Operative Severity Score for the enumeration of mortality and Morbidity (P-POSSUM) and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) calculators. METHODS: A retrospective review of all emergency laparotomies undertaken at four Australian centers was performed between January 2016 and December 2017. Data extracted from patient records were used to calculate NRPC, ACS-NSQIP, and P-POSSUM scores for 30-day mortality risk. The sensitivity of NRPC was assessed using the NELA high-risk cohort score of ≥10% and this was compared with the other two calculators. RESULTS: There were 562 (M = 261, mean age = 66 [±17] y) patient charts reviewed in the study period. 59 patients died within 30 d (10.5%). NRPC was able to identify 52 (sensitivity = 88.1%) of these as being within the high-risk group. Using the NELA high-risk cutoff, NRPC identified 52 deaths of 205 (25.4%) high-risk patients, P-POSSUM identified 46 of 245 (18.8%), and ACS-NSQIP identified 46 of 201 (22.9%). Using the McNemar test, no significant difference was noted between NRPC and P-POSSUM (P = 0.07) or NRPC and ACS-NSQIP (P = 0.18). CONCLUSIONS: In the Australian context, the NRPC is a highly sensitive and useful tool for predicting 30-day mortality in high-risk emergency laparotomy patients and is comparable with P-POSSUM and ACS-NSQIP calculators.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Laparotomia/efeitos adversos , Auditoria Médica/normas , Complicações Pós-Operatórias/mortalidade , Idoso , Idoso de 80 Anos ou mais , Austrália/epidemiologia , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/normas , Tratamento de Emergência/estatística & dados numéricos , Feminino , Humanos , Laparotomia/estatística & dados numéricos , Masculino , Auditoria Médica/estatística & dados numéricos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Melhoria de Qualidade , Estudos Retrospectivos , Medição de Risco/métodos , Medição de Risco/normas
16.
J Surg Res ; 247: 287-293, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31699538

RESUMO

BACKGROUND: Low hospital volume for emergency general surgery (EGS) procedures is associated with worse patient outcomes within the civilian health care system. The military maintains treatment facilities (MTFs) in remote locations to provide access to service members and their families. We sought to determine if patients treated at low-volume MTFs for EGS conditions experience worse outcomes compared with high-volume centers. MATERIALS AND METHODS: We analyzed TRICARE data from 2006 to 2014. Patients were identified using an established coding algorithm for EGS admission. MTFs were divided into quartiles based on annual EGS volume. Outcomes included 30-d mortality, complications, and readmissions. Logistic regression models adjusting for clinical and sociodemographic differences in case-mix including EGS condition, surgical intervention, and comorbidities were used to determine the influence of hospital volume on outcomes. RESULTS: We identified 106,915 patients treated for an EGS condition at 79 MTFs. The overall mortality rate was 0.21%, with complications occurring in 8.55% and readmissions in 4.45%. After risk adjustment, lowest-volume MTFs did not demonstrate significantly higher odds of mortality (OR: 2.02, CI: 0.45-9.06) or readmissions (OR: 0.77, CI: 0.54-1.11) compared with the highest-volume centers. Lowest-volume facilities exhibited a lower likelihood of complications (OR: 0.76, CI: 0.59-0.98). CONCLUSIONS: EGS patients treated at low-volume MTFs did not experience worse clinical outcomes when compared with high-volume centers. Remote MTFs appear to provide care for EGS conditions comparable with that of high-volume facilities. Our findings speak against the need to reduce services at small, critical access facilities within the military health care system.


Assuntos
Tratamento de Emergência/estatística & dados numéricos , Hospitais Militares/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Carga de Trabalho/estatística & dados numéricos , Demandas Administrativas em Assistência à Saúde/estatística & dados numéricos , Adulto , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Feminino , Mortalidade Hospitalar , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Hospitais com Baixo Volume de Atendimentos/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Militares/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Resultado do Tratamento , Adulto Jovem
17.
J Surg Res ; 245: 629-635, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31522036

RESUMO

BACKGROUND: Emergency general surgery (EGS) accounts for more than 2 million U.S. hospital admissions annually. Low-income EGS patients have higher rates of postoperative adverse events (AEs) than high-income patients. This may be related to health care segregation (a disparity in access to high-quality centers). The emergent nature of EGS conditions and the limited number of EGS providers in rural areas may result in less health care segregation and thereby less variability in EGS outcomes in rural areas. The objective of this study was to assess the impact of income on AEs for both rural and urban EGS patients. MATERIALS AND METHODS: The National Inpatient Sample (2007-2014) was queried for patients receiving one of 10 common EGS procedures. Multivariate regression models stratified by income quartiles in urban and rural cohorts adjusting for sociodemographic, clinical, and other hospital-based factors were used to determine the rates of surgical AEs (mortality, complications, and failure to rescue [FTR]). RESULTS: 1,687,088 EGS patients were identified; 16.60% (n = 280,034) of them were rural. In the urban cohort, lower income quartiles were associated with higher odds of AEs (mortality OR, 1.21 [95% CI, 1.15-1.27], complications, 1.07 [1.06-1.09]; FTR, 1.17 [1.10-1.24] P < 0.001). In the rural context, income quartiles were not associated with the higher odds of AE (mortality OR, 1.14 [0.83-1.55], P = 0.42; complications, 1.06 [0.97-1,16], P = 1.17; FTR, 1.12 [0.79-1.59], P = 0.52). CONCLUSIONS: Lower income is associated with higher postoperative AEs in the urban setting but not in a rural environment. This socioeconomic disparity in EGS outcomes in urban settings may reflect health care segregation, a differential access to high-quality health care for low-income patients.


Assuntos
Tratamento de Emergência/efeitos adversos , Disparidades em Assistência à Saúde/economia , Renda/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Adolescente , Adulto , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/estatística & dados numéricos , Falha da Terapia de Resgate/estatística & dados numéricos , Feminino , Acesso aos Serviços de Saúde/economia , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Mortalidade Hospitalar , Hospitais Rurais/estatística & dados numéricos , Hospitais Urbanos/estatística & dados numéricos , Humanos , Pacientes Internados/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , População Rural/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Estados Unidos/epidemiologia , População Urbana/estatística & dados numéricos , Adulto Jovem
18.
J Surg Res ; 245: 119-126, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31415933

RESUMO

BACKGROUND: Data on outcomes after surgery for sigmoid volvulus is limited. The aim of this study was to develop a model to predict need for emergent surgery and mortality after resection for sigmoid volvulus. METHODS: The NSQIP database was queried from 2012 to 2016 to identify patients undergoing segmental resection for sigmoid volvulus. Pre-, intra-, and post-operative variables were compared. Primary and secondary outcomes were emergent surgery and risk of mortality, respectively. Chi-square and Fischer's test for categorical variables and the Mann-Whitney test for continuous variables were used. Significant variables for each outcome were entered into a logistic regression model to predict the outcomes. RESULTS: 2086 patients met inclusion criteria. Factors associated with emergency surgery included female gender, relative hematocrit elevation, relative leukocytosis, acute kidney injury, preoperative sepsis, prior functional independence, and bleeding disorders. Laparoscopic resection and mechanical bowel preparation were more commonly used in the nonemergent setting. Patients having emergent resection were more likely to suffer from postoperative superficial surgical site infection, pneumonia, cardiac arrest, septic shock, myocardial infarction, and receive perioperative transfusion. No difference was seen in ileus, readmission or reoperation rates in the emergent and nonemergent groups. Factors predictive of postoperative mortality included increased age, systemic sepsis, and emergent surgery. Independence before illness, higher albumin levels, and lower BMI were shown to be protective. CONCLUSIONS: Emergent resection is independently associated with poor postoperative outcomes and mortality. Predictors of need for emergent resection and mortality identified in this study can be used to aid in shared decision-making for patients with sigmoid volvulus.


Assuntos
Tratamento de Emergência/efeitos adversos , Volvo Intestinal/cirurgia , Complicações Pós-Operatórias/mortalidade , Doenças do Colo Sigmoide/cirurgia , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais/estatística & dados numéricos , Tomada de Decisão Compartilhada , Tratamento de Emergência/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Volvo Intestinal/mortalidade , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Período Perioperatório , Complicações Pós-Operatórias/etiologia , Medição de Risco/métodos , Fatores Sexuais , Doenças do Colo Sigmoide/mortalidade
19.
J Surg Res ; 245: 315-320, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31421379

RESUMO

BACKGROUND: Transplant patients are at the risk of serious sequelae from medical and surgical intervention. The incidence and burden of emergency general surgery (EGS) in transplant patients are scarcely known. This study aims to identify predictors of outcomes in transplant patients with EGS needs. METHODS: The Nationwide Inpatient Sample (2007-2011) was queried for adult patients (aged ≥16 y) who underwent abdominal visceral transplantation. These were further queried for a secondary diagnosis of an American Association for the Surgery of Trauma-defined EGS condition. Outcome measures included mortality, complications, length of stay, and cost of care. Propensity scores were used to match patients across baseline characteristics. Multivariate analysis was used to further adjust propensity score quintiles and hospital-level characteristics. RESULTS: A total of 35,573 transplant patients were identified. Of these, 30% (n = 10,676) developed an EGS condition. Most common EGS conditions were resuscitation (7.7%), intestinal obstruction (7.3%), biliary conditions (3.9%), and hernias (3.2%). Patients with public insurance, those in the highest income quartile, and those treated at larger hospitals had a lower likelihood of developing an EGS condition (P < 0.05). Patients with an EGS condition had a ninefold higher likelihood of mortality and a threefold higher likelihood of developing complications (odds ratio [95% confidence interval (CI)]: 9.21 [1.80-10.89] and 3.17 [3.02-3.34], respectively). Transplant patients after EGS had a longer risk-adjusted length of stay and cost of index hospitalization (Absolute difference [95% CI]: 12.70 [12.14-13.26] and $57,797 [55,415-60,179], respectively]). CONCLUSIONS: Transplant patients fare poorly after developing an EGS condition. The results of this study will help in identifying at-risk patients and determining outcomes.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Tratamento de Emergência/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Transplantados/estatística & dados numéricos , Adulto , Idoso , Bases de Dados Factuais/estatística & dados numéricos , Tratamento de Emergência/efeitos adversos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Pontuação de Propensão , Estudos Retrospectivos , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Estados Unidos
20.
J Surg Res ; 247: 95-102, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31787316

RESUMO

BACKGROUND: Frailty has been increasingly recognized as a modifiable risk factor prior to elective general surgery. There is limited evidence regarding the association of frailty with perioperative outcomes after specific emergency general surgery procedures. MATERIAL AND METHODS: A retrospective cohort study of 57,173 patients older than 40 y of age from 2010 to 2014 American College of Surgeons National Surgical Quality Improvement Program underwent appendectomy, cholecystectomy, large bowel resection, small bowel resection, or nonbowel resection (lysis of adhesion, ileostomy creation) on an emergent basis. Preoperative modified frailty index (mFI) was determined for each patient and was used in a multivariable logistic regression to determine the association with perioperative morbidity, mortality, and discharge destination. RESULTS: A total of 57,173 patients (46% men, mean [SD] age 60 [13] y) underwent an emergency appendectomy (n = 26,067), cholecystectomy (n = 8138), large bowel resection (n = 12,107), small bowel resection (n = 6503), or nonbowel resection (n = 4358). Among them, 14,300 (25.0%) experienced any perioperative complication, and 12,668 (22.2%) experienced a serious complication with an overall 30-d mortality of 5.1%. Highly frail patients had a 30-d mortality of 19.0% across all five operations. In multivariable analysis, mFI was associated with any complication and 30-d mortality in a step-wise fashion for each emergency operation. Intermediate and high mFI were also inversely associated with discharge home for each operation. CONCLUSIONS: Frailty is associated with increased perioperative morbidity and mortality in common emergency general surgery operations. Frailty should be assessed by surgeons to inform decisions on operative intervention and to inform patients/families on expected outcomes.


Assuntos
Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Tratamento de Emergência/efeitos adversos , Idoso Fragilizado/estatística & dados numéricos , Fragilidade/epidemiologia , Complicações Pós-Operatórias/mortalidade , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Comorbidade , Conjuntos de Dados como Assunto , Procedimentos Cirúrgicos do Sistema Digestório/métodos , Tratamento de Emergência/métodos , Feminino , Fragilidade/diagnóstico , Avaliação Geriátrica/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
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