Psychiatric Diagnoses Are Associated With Postoperative Disparities in Patients Undergoing Major Colorectal Operations.

BACKGROUND: Over 50% of hospitalized patients have comorbid psychiatric diagnoses, resulting in increased risk of morbidity such as longer lengths of stay, worse health-related quality of life, and increased mortality. However, data regarding colorectal surgery postoperative outcomes in patients with psychiatric diagnoses (PD) are limited. METHODS: We queried a single institution's National Surgical Quality Improvement Program from 2013-2019 for major colorectal procedures. Postsurgical outcomes for patients with and without PD were compared. Primary outcomes were prolonged length of stay (pLOS) and 30-day readmission. RESULTS: From a total of 1447 patients, 402 (27.8%) had PD. PD had more smokers (20.9% vs 15%) and higher mean body mass index (29.1 kg/m2 vs 28.2 kg/m2). Bivariate outcomes showed more surgical site infections (SSI) (10.2% vs 6.12%), reoperation (9.45% vs 6.35%), and pLOS (34.8% vs 29.0%) (all P values <.05) in the PD group. On multivariate analysis, PD had higher likelihood of reoperation (OR 1.53, 95% CI: [1.02-2.80]) and SSI (OR 1.82, 95% CI: [1.25-2.66]). DISCUSSION: Psychiatric diagnoses are a risk factor for adverse outcomes after colorectal procedures. Further studies are needed to evaluate the benefit of perioperative mental health support services for these patients.

Oral vitamin D supplementation reduces the incidence of eucalcemic PTH elevation after surgery for primary hyperparathyroidism.

BACKGROUND: As many as 43% of patients will have normocalcemic intact parathyroid hormone (PTH) elevation after undergoing curative parathyroidectomy for primary hyperparathyroidism. This phenomenon may be due in part to an absolute or relative deficiency of vitamin D, which is under-recognized in patients with primary hyperparathyroidism. METHODS: From September 1, 2004, to September 30, 2005, 86 consecutive patients underwent parathyroidectomy for primary sporadic hyperparathyroidism (psHPT). The patients were segregated into 2 groups based on postoperative management. Group 1 was composed of 26 patients who received routine oral calcitriol and calcium carbonate postoperatively. The 60 patients in the second group (group 2) received calcium carbonate postoperatively at the discretion of the primary surgeon. RESULTS: A total of 85 patients (99%) achieved postoperative cure with sustained reduction in serum calcium. Within 30 days postoperatively, mean serum PTH levels normalized in both groups (41 +/- 31 vs 39 +/- 31 pg/ml; P = .91). However, at 1 to 3 months postoperatively, mean serum calcium levels remained similar (9.5 +/- 0.7 vs 9.3 +/- 0.5 mg/dl; P = .39) whereas mean serum PTH levels in groups 1 and 2 were 43 +/- 25 pg/ml and 67 +/- 45 pg/ml (P = .02), respectively. At 4 to 6 months postoperatively, mean PTH was again higher in group 2 (36 +/- 22 vs 67 +/- 35; P = .03), whereas mean serum calcium levels were normal (9.2 +/- 0.8 vs 9.6 +/- 0.4 mg/dl; P = .18). The incidence of postoperative normocalcemic PTH elevation was significantly higher in group 2 at 1 to 3 months (14% vs 39%; P = .04) and at 7 to 12 months (22% vs 83%; P = .04). CONCLUSIONS: Vitamin D supplementation following parathyroidectomy for primary hyperparathyroidism reduces the incidence of postoperative eucalcemic PTH elevation.

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

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

Predictors of Hospital Readmission after Bariatric Surgery.

BACKGROUND: Identification of factors that might predict readmission after bariatric surgery could help surgeons target high-risk patients. The purpose of this study was to identify comorbidities, surgical variables, and postoperative complications associated with readmission. STUDY DESIGN: Patients with bariatric surgery as their primary procedure were identified from the 2012 American College of Surgeons (ACS) NSQIP database. Patient variables, operative times, and major postoperative complications were analyzed for predictors of readmission. The ACS NSQIP estimated probability of morbidity (MORBPROB) was also considered. Chi-square tests and Poisson regression were used for statistical analysis to identify significant predictors. RESULTS: There were 18,186 patients who met inclusion criteria. There were 1,819 who had a laparoscopic gastric band, 9,613 who had laparoscopic Roux-en-Y gastric bypass (RYGB), 6,439 who had gastroplasties (vertical banded gastroplasty and sleeve), and 315 who had open RYGB. Age, sex, BMI, American Society of Anesthesiologists (ASA) class, diabetes, hypertension, steroid use, type of procedure, and operative time all were significantly associated with readmission within 30 days of operation. All major postoperative complications were significant predictors of readmission. Patients expected to be at high risk based on the ACS NSQIP MORBPROB had a significantly higher rate of readmissions. The overall readmission rate for patients undergoing bariatric surgery was 5%. The readmission rate among patients with any major complication was 31%. CONCLUSIONS: Bariatric surgery is a low-risk procedure. Complexity of operation, ASA class, prolonged operative time, and major postoperative complications are important determinants of high risk for readmission. The ACS NSQIP MORBPROB may be a useful tool to identify and target patients at risk for readmission.

A NSQIP risk assessment for thyroid surgery based on comorbidities.

BACKGROUND: Thyroid surgery is associated with low mortality and morbidity and often is performed in an ambulatory setting. The majority of patients undergoing thyroidectomy have an uncomplicated outcome, but common comorbidities may increase mortality and morbidity. Due to low complication rates, studies using single surgeon or single institutional data to identify risk factors for adverse outcomes may be limited by inadequate patient volume. STUDY DESIGN: This retrospective cohort study used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). The study group included all thyroidectomy patients over a 6-year period (2005 to 2010). Common patient comorbidities were identified and analyzed using logistic regression. Risk of adverse outcomes was calculated for single and multiple comorbidities. Statistical significance was set at p < 0.05. RESULTS: The study group included 38,577 consecutive patients. Thirty-day mortality and postoperative morbidity were 0.06% and 1.49%, respectively. The risk factors independently associated with morbidity included hypertension, diabetes, advanced age greater than 70 years, COPD, dialysis, malignant thyroid disease, and surgical approach (total thyroidectomy). Substernal thyroidectomy, hypertension, diabetes, age greater than 70 years, COPD, and dialysis were significant predictors (unadjusted) of mortality. Multiple comorbidities resulted in significant cumulative risk. The presence of 3 or more comorbidities was associated with a postoperative morbidity of 5.1% (p < 0.001) and mortality as high as 12.5%. CONCLUSIONS: Thyroid surgery is generally safe. Common comorbidities significantly increase the risk of adverse outcomes and death. Clinically applicable risk calculation based on overall health may improve patient selection, surgical management, and informed consent.

Does homocysteine contribute to bone disease in hyperparathyroidism?

BACKGROUND: Osteoporosis is a complication of hyperparathyroidism (HPT). Hyperhomocysteinemia (HHCy) is an independent risk factor for osteoporotic fractures. We hypothesize that HHCy correlates with bone disease in HPT. METHODS: A prospectively collected database of 250 patients treated for HPT was reviewed. Patients were categorized into 3 groups: group I, normal renal function; group 2, mild renal insufficiency; and group 3, secondary HPT with end-stage renal disease on dialysis. Serum homocysteine levels, markers of bone metabolism, and bone density studies were examined. RESULTS: The prevalence of HHCy in group 1 (208 patients) was 5%, in group 2 (23 patients), 82%, and in group 3 (19 patients), 78%. Mean (+/-SD) preoperative homocysteinemia (HCy) levels in groups 1, 2, and 3 were 9.3 +/- 4.0, 20 +/- 10.2, and 20.6 +/- 12.3 micromol/L, respectively. Elevated serum markers of bone metabolism increased significantly with decreasing renal function. CONCLUSIONS: Prevalence of HHCy is low in HPT patients with normal renal function. It is significantly greater in those with dialysis-independent and -dependent renal insufficiency. HHCy correlates with other serum markers of bone metabolism in HPT and may be useful for monitoring progression or improvement.

A prospective evaluation of the effect of sample collection site on intraoperative parathormone monitoring during parathyroidectomy.

BACKGROUND: Sample collection site may affect the dynamics of intraoperative parathyroid hormone monitoring (IPM) and influence surgical decisions. METHODS: We prospectively studied 45 patients undergoing parathyroidectomy for primary hyperparathyroidism. The IPM cure criterion was a decrease in peripheral vein (PV) parathyroid hormone (PTH) of >50% at 10 minutes after gland excision. PTH samples were collected simultaneously from PV and central vein (CV) and compared for PTH decay, the incidence of >50% PTH decay, and the incidence of normal PTH values after gland excision. RESULTS: Mean PTH levels were significantly higher from the CV before and after gland excision. Mean PTH decay 10 minutes after gland excision was 89% PV versus 88% CV, resulting in mean PTH levels of 27 +/- 23 and 39 +/- 35 pg/mL, respectively (P < .0001). At 5 minutes, >50% decay in PTH was present in 98% PV versus 88% CV samples. By 10 minutes, the incidence of >50% PTH decay was equivalent (98%). This yielded normal range PTH levels from the PV versus CV in 90% versus 76% of patients at 5 minutes, 96% versus 89% at 10 minutes, and 95% versus 81% at 20 minutes. Of 45 patients, 44 (98%) are normocalcemic at a mean follow-up of 6.3 months. IPM predicted the single operative failure. CONCLUSIONS: CV sampling produces significantly higher PTH levels. Surgeons sampling from a PV may observe a >50% decrease in PTH and normal range PTH values starting 5 minutes after gland excision. Surgeons who sample from the CV and require normalization of PTH levels may have to wait longer and/or continue potentially unnecessary neck exploration.

Parathyroidectomy outcomes according to operative approach.

BACKGROUND: Parathyroidectomy for primary sporadic hyperparathyroidism (psHPT) has evolved with advances in preoperative gland localization and intraoperative parathyroid hormone (ioPTH) monitoring to minimally invasive approaches (MIPS). METHODS: Two hundred twenty patients underwent parathyroidectomy for psHPT. Forty-nine patients underwent bilateral neck exploration (BNE) (group 1), 60 patients underwent BNE with ioPTH monitoring (group 2), and 111 patients underwent MIPS with ioPTH monitoring (group 3). RESULTS: At 3 months postoperatively, mean serum calcium and intact parathyroid hormone (PTH) levels were similar between groups, and eucalcemia rates were 100%, 100%, and 99%. The ultimate rates of persistent disease and recurrence were also similar. Operative time was shorter in group 3 compared to group 2 (P < .001) but not group 1. Frozen sections and patient charges were significantly lower in group 3 compared to groups 1 and 2 (P < .005). CONCLUSION: Parathyroidectomy for psHPT is highly successful with these techniques. When a MIPS approach can be done, it is potentially quicker and associated with lower patient charges.

Short-term outcomes of parathyroidectomy in patients with or without 25-hydroxy vitamin D insufficiency.

BACKGROUND: 25-OH Vitamin D (VitD) plays a role in serum calcium (Ca) and parathyroid hormone (PTH) homeostasis. VitD insufficiency in patients with primary hyperparathyroidism (HPT) may be associated with greater disease severity and a higher incidence of multi-gland disease and postoperative normocalcemic PTH elevation. MATERIALS AND METHODS: One hundred ten patients with HPT undergoing parathyroidectomy had preoperative VitD levels as follows: levels were insufficient (< or =20 ng/mL) in 55 patients (group 1) and sufficient (>20 ng/mL) in 55 patients (group 2). All patients had preoperative localizing sestamibi scans and/or ultrasounds and postoperative serum Ca and PTH levels. A focused approach was performed when possible, and intraoperative PTH monitoring (IPM) was used in all patients. RESULTS: Patients with VitD insufficiency had significantly higher preoperative Ca (11.3 +/- 1.2 versus 10.8 +/- 0.9 mg/dL, P = 0.012) and PTH levels (204 +/- 138 versus 156 +/- 179 pg/mL; P = 0.006) as well as higher bone specific alkaline phosphatase (P = 0.006). Localization studies were similar. IPM levels were significantly higher in group 1 at all time intervals. Both groups were similar in operative time, conversions to bilateral explorations, number of glands removed, and number of frozen sections. The glands in group 1 were larger (1757 versus 524 g; P = 0.005). Postoperative Ca levels, PTH levels, rates of eucalcemia, and rates of eucalcemic PTH elevation were all similar. CONCLUSION: Patients with HPT and VitD insufficiency may have significantly more severe disease based on preoperative serum Ca and PTH levels, bone markers, and gland size. IPM levels in these patients are higher but can be used to predict postoperative eucalcemia, an outcome which appears be independent of VitD status.

Initial nonoperative management and delayed closure for treatment of giant omphaloceles.

PURPOSE: Traditional treatment of giant omphaloceles with silo closure has been associated with respiratory insufficiency, hemodynamic compromise, dehiscence, and inability to close the abdomen with subsequent death. To minimize such complications, initial nonoperative management with delayed closure of the defect has been used. METHODS: Between January 1981 and December 2002, 111 patients with omphaloceles were treated. Twenty-two patients with giant omphaloceles (19 containing liver) underwent initial nonoperative management consisting of silver sulfadiazine dressing changes. After pulmonary and other comorbidities stabilized, the contents were gradually reduced with a loose elastic bandage, and delayed closure was planned at 6 to 12 months. The medical records of these 22 patients were retrospectively reviewed to determine the efficacy and safety of this technique in the setting of severe associated anomalies. Those 15 patients (n = 15) from the latter 10 years were further reviewed to determine additional end points (length of hospital stay, length of intensive care unit stay, duration of mechanical ventilation, time to feed, time to closure, and type of closure). RESULTS: Of the 15 patients treated during the latter 10 years, mean gestational age and birth weight were 38 +/- 1.4 weeks and 3.1 +/- 0.57 kg, respectively. Median length of stay after birth was 20 days (range, 5-239 days). Median time to full diet was 8 days (range, 4-80 days). Four patients were discharged on oral feedings only, 7 with combination oral/gavage, and 4 with tube feedings. Pulmonary hypoplasia or pulmonary hypertension was present in 11 (50%) of 22 patients. There were 11 patients with major cardiac anomalies, 14 with a patent ductus arteriosus, and 8 with a patent foramen ovale. Three early complications (2 ruptured sacs and 1 bleeding sac) and 1 late complication (gastric necrosis) occurred in the initial nonoperative period. In addition, 4 patients were treated for line sepsis, 1 patient for acute renal insufficiency, and 1 for aspiration pneumonia. Three patients required tracheostomy and were discharged with home ventilators. There were no complications associated with the use of silver sulfadiazine. Of the 22 patients, 16 have undergone delayed repair, 2 did not require repair, 1 is awaiting repair, 2 died before closure, and 1 was lost to follow-up. Delayed closure was achieved at a median age of 14 months (range, 2-28 months) and mean weight of 8.8 +/- 3.3 kg. Four patients required implantation of mesh for definitive closure. Median postoperative length of stay was 4 days (range, 2-21 days). Postoperative complications included prolonged ileus, recurrent ventral hernia, and prolonged intubation. Overall mortality rate was 9.1%. One death occurred after diaphragmatic hernia repair, and 1 death was from overwhelming sepsis in the patient with a late gastric perforation. CONCLUSION: The use of silver sulfadiazine dressing changes for initial nonoperative management of giant omphaloceles is a safe and effective bridge to delayed closure. We recommend this method as initial nonoperative management given the high incidence of associated cardiopulmonary malformations because it may facilitate enteral feeding, minimize respiratory compromise, and reduce morbidity and mortality.