The Association Between Low Preoperative Phosphate Levels and Postliver Surgery Outcomes-A Single Center Experience.

INTRODUCTION: Previous research has demonstrated the impact of postoperative phosphate levels on liver regeneration and outcomes after liver resection surgeries, a potential predictor for regenerative success and liver failure. However, little is known about the association between low preoperative serum phosphate levels and outcomes in liver resections. METHODS: We performed a retrospective analysis of liver resections performed at our institution. Patients were categorized based on preoperative phosphate levels (low versus normal). Our primary outcome measure was posthepatectomy liver failure. RESULTS: A total of 265 cases met the study criteria. 71 patients (26.7%) had low preoperative phosphate levels. The incidence of posthepatectomy liver failure was higher in the low preoperative phosphate group (19.2% versus 12.4%). However, after propensity score matching, rates of posthepatectomy liver failure were similar between low and normal preoperative phosphate cohorts (13% versus 14%, P = 0.83). CONCLUSIONS: Low preoperative phosphate levels were not associated with worse postoperative outcomes in this study. Further studies are warranted to investigate this association and its relevance as a clinical prognostic factor for postoperative liver failure.

Outcomes in elderly patients undergoing hepatic resection compared to ablative therapy for hepatocellular carcinoma.

BACKGROUND AND OBJECTIVES: Hepatic resection is an excellent option in the care of patients with hepatocellular carcinoma (HCC). Elderly patients often forego hepatic resection in favor of liver-directed ablative therapies due to the increased likelihood of adverse postoperative outcomes due to age. We sought to determine long-term outcomes in patients who underwent hepatic resection compared to liver-directed ablative therapy in this patient population. METHODS: We queried the National Cancer Database for elderly patients (≥70 years) diagnosed with HCC between 2004 and 2018. The primary outcome was overall survival (OS) computed using the Kaplan-Meier method and Cox proportional hazard regression. RESULTS: A total of 10 032 patients were included in this analysis. On unadjusted analysis (p < 0.001) as well as multivariable analysis (hazard ratio: 0.65, 95% confidence interval: 0.57-0.73), hepatic resection was associated with improved OS. The protective association between hepatic resection and OS persisted after 1:1 propensity score matching. CONCLUSIONS: Hepatic resection is associated with improved survival for well-selected elderly patients with HCC. While age is often thought of as influencing the decision to offer surgery, our study, in combination with others, demonstrates that it should not. Instead, other objective indicators of performance and functional status may be considered.

Metabolic Syndrome Exponentially Increases the Risk of Adverse Outcomes in Operative Diverticulitis.

BACKGROUND: Metabolic syndrome (MS) is defined as the cluster: hypertension, obesity, and diabetes. Operative diverticulitis in the setting of MS can be challenging to manage. The aim of our study was to evaluate the impact of MS on outcomes in operative acute diverticulitis patients. METHODS: We analyzed the (2012-2015) NSQIP database. We identified acute diverticulitis patients who underwent surgery. MS was defined as follows: body mass index (BMI) >30 kg/m2, hypertension, and diabetes. Our primary outcome measure was the occurrence of any adverse events (complications, 30-d readmission, and mortality). Secondary outcome measures were complications, hospital length of stay, 30-d readmission, and mortality. Regression and receiver operating characteristic curve analysis was performed. RESULTS: A total of 4572 patients were identified. Mean BMI was 29 ± 10 kg/m2. 14.6% (275) of obese patients had metabolic syndrome. Adverse events were higher in patients with MS (odds ratio [OR], 8.1; P < 0.001) versus the obese group and the obese and hypertensive group. Patients with MS had higher odds of reintubation (OR 1.9; P = 0.03), >48 h ventilator dependence (OR 3.5; P = 0.01), myocardial infarction (OR 2.3; P = 0.03), and superficial or deep surgical-site infections (OR 2.1; P = 0.01) compared with patients with no MS. MS patients had a longer length of stay (ß = 1.23; P = 0.02), higher 30-d readmissions (OR 1.7; P < 0.01), and mortality (OR 2.1; P < 0.01). The area under the receiver operating characteristic curve of metabolic syndrome for predicting adverse outcomes was 0.797, which was higher than the area under the receiver operating characteristic curve for BMI (0.58), hypertension (0.51), or diabetes (0.64) alone. CONCLUSIONS: Adverse events in patients with MS after surgery for diverticulitis are higher than obesity, hypertension, or diabetes alone. Patients with MS have longer recovery, and higher rates of complications, readmissions, and mortality. LEVEL OF EVIDENCE: Level III Prognostic.

Failure to Rescue in Postoperative Patients With Colon Cancer: Time to Rethink Where You Get Surgery.

BACKGROUND: Failure to rescue (FTR) is an important measure of quality of care. The aim of this study was to assess FTR in patients with colon cancer (CC) who underwent surgical resection. We hypothesized that patient managed in urban centers had lower FTR. METHODS: We performed a 1-y (2011) retrospective analysis of the National Inpatient Sample database and identified all patients with CC who underwent surgical management. Patients were stratified based on the location of treatment: urban versus rural. Outcome measure was FTR, which was defined as death after major complications. Regression analysis was performed to evaluate the independent predictors of FTR. RESULTS: A total of 49,789 patients with CC who underwent surgery were analyzed. The mean age was 71 ± 20.2 y and 59% were males. About 21.5% patients developed in-hospital complications. The overall rates of complications, mortality, and FTR were 21.5%, 3.0%, and 33.8% respectively. Patient managed in rural centers had higher FTR compared with urban centers (39.5% versus 30.1%, P = 0.01). On regression analysis after controlling for age, gender, type of procedure, Charlson Comorbidity Index, and insurance status, management in rural center was independently associated with FTR (odds ratio: 1.9 [1.4-3.7]). On subanalysis of urban centers, management in teaching urban hospital was independently associated with higher FTR (odds ratio: 1.4 [1.2-3.8]). CONCLUSIONS: Disparities exist among centers managing patients with CC undergoing surgical intervention. Rural centers have higher FTR compared with similar cohort of patients managed in urban centers. Teaching urban hospital performed worse than nonteaching urban centers. Understanding the reason for these differences may help standardize care across centers and help improve patient outcomes.

Day of Hospital Admission and Effect on Outcomes: The Weekend Effect in Acute Gallstone Pancreatitis.

BACKGROUND: The aim of our study was to evaluate outcomes in patients who are admitted on weekend compared with those admitted on a weekday for acute gallstone pancreatitis. METHODS: We performed a 3-y (2010-2012) analysis of the Nationwide Inpatient Sample database. Patients with acute gallstone pancreatitis who underwent endoscopic retrograde cholangiopancreatography (ERCP) were included and were divided into two groups: admission on the weekend versus the weekday. Primary outcome measures were time to ERCP, adverse events, and mortality. Secondary outcome measures were hospital length of stay and total cost. RESULTS: A total of 5803 patients with acute gallstone pancreatitis who underwent ERCP were included in our study; of which 22.6% were admitted on the weekend, whereas 77.4% were admitted on a weekday. Mean age was 57 ± 18 y and 57.1% were female. Within 24 h, the rate of ERCP was higher in patients admitted on the weekday compared with those admitted on the weekend (40% versus 24%; P < 0.001). Similarly, by 48 h, the rate of ERCP was higher in the weekday group (69% versus 49%, P < 0.001). Patients admitted over the weekends had higher complications rate (P = 0.03), hospital length of stay (P < 0.001), and the total cost of hospitalization (P < 0.001) compared with the weekday group with no difference in in-hospital mortality. CONCLUSIONS: Patients admitted on weekends for acute gallstone pancreatitis experience a delay in getting ERCP and have higher complications, prolonged hospital stay, and increased hospital costs compared with those admitted on weekdays.

Failure to Rescue After Emergency General Surgery in Geriatric Patients: Does Frailty Matter?

BACKGROUND: Failure to rescue (FTR) is considered as an index of quality of care provided by a hospital. However, the role of frailty in FTR remains unclear. We hypothesized that the FTR rate is higher for frail geriatric emergency general surgery (EGS) patients than nonfrail geriatric EGS patients. METHODS: We performed a 3-y (2015-2017) prospective cohort study of all geriatric patients (age ≥ 65 y) requiring EGS. Frailty was calculated by using the EGS-specific Frailty Index (EGSFI) within 24 h of admission. Patients were divided into two groups: frail (FI ≥ 0.325) and nonfrail (FI < 0.325). We defined FTR as death from a major complication. Regression analysis was performed to control for demographics, type of operative intervention, admission vitals, and admission laboratory values. RESULTS: Three hundred twenty-six geriatric EGS patients were included, of which 38.9% were frail. Frail patients were more likely to be white (P < 0.01) and, on admission, had a higher American Association of Anesthesiologist class (P = 0.03) and lower serum albumin (P < 0.01). However, there was no difference between the groups regarding age (P = 0.54), gender (P = 0.56), admission vitals, and WBC count (P = 0.35). Overall, 26.7% (n = 85) of patients developed in-hospital complications; and mortality occurred in 30% (n = 26) of those patients (i.e., the FTR group). Frail patients had higher rates of FTR (14% vs. 4%, P < 0.001) than nonfrail patients. On regression analysis, after controlling for confounders, frail status was an independent predictor of FTR (OR: 3.4 [2.3-4.6]) in geriatric EGS patients. CONCLUSIONS: Our study demonstrates that in geriatric EGS patients, a frail status independently contributes to FTR and increases the odds of FTR threefold compared with nonfrail status. Thus, it should be included in quality metrics for geriatric EGS patients.

Can Sarcopenia Quantified by Computed Tomography Scan Predict Adverse Outcomes in Emergency General Surgery?

BACKGROUND: Sarcopenia (a decline of skeletal muscle mass) has been identified as a predictor of poor postoperative outcomes. The impact of sarcopenia in emergency general surgery (EGS) remains undetermined. The aim of this study was to evaluate the association between sarcopenia and outcomes after EGS. METHODS: A 3-y (2012-15) review of all EGS patients aged ≥45 y was presented to our institution. Patients who underwent computer tomography-abdomen were included. Sarcopenia was defined as the lowest sex-specific quartile of total psoas index (computer tomography-measured psoas area normalized for body surface area). Patients were divided into sarcopenic (SA) and nonsarcopenic. Primary outcome measures were in-hospital complications, hospital-length of stay [h-LOS], intensive care unit-length of stay, adverse discharge disposition, and in-hospital mortality. Our secondary outcome measures were 30-d complications, readmissions, and mortality. RESULTS: Four hundred fifty-two patients undergoing EGS were included. Mean age was 58 ± 8.7 y, and 60% were males. Hundred thirteen patients were categorized as SA. Compared to nonsarcopenic, SA patients had higher rates of minor complications (28% versus 17%, P = 0.01), longer hospital-length of stay (7d versus 5d, P = 0.02), and were more likely to be discharged to skilled nursing facility/Rehab (35% versus 17%, P = 0.01). There was no difference between the two groups regarding major complications, intensive care unit-length of stay, mortality, and 30-d outcomes. On regression analysis, sarcopenia was an independent predictor of minor complications (OR 1.8 [1.6-3.7]) and discharge to rehab/SNIF (OR: 1.9 [1.5-3.2]). However, there was no association with major complications, mortality, 30-d complications, readmissions, and mortality. CONCLUSIONS: Sarcopenia is an independent predictor of minor postoperative complications, prolonged hospital-length of stay, and an adverse discharge disposition in patients undergoing EGS. Identifying SA EGS patients will improve both resource allocation and discussion about the patient's prognosis between physicians, patients, and their families.

Is There a Need for Platelet Transfusion After Traumatic Brain Injury in Patients on P2Y12 Inhibitors?

BACKGROUND: A significant portion of patients sustaining traumatic brain injury (TBI) are on antiplatelet medications. The reversal of P2Y12 agents after intracranial hemorrhage (ICH) remains unclear. The aim of our study is to evaluate outcomes after TBI in patients who are on preinjury P2Y12 inhibitors and received a platelet transfusion. METHODS: We analyzed our prospectively maintained TBI database from 2013 to 2016 and included all patients with isolated ICH who were on P2Y12 inhibitors (Clopidogrel, Prasugrel, Ticagrelor). Regression analysis was performed adjusting for demographics and injury parameters. Outcome measures included progression of ICH, adverse discharge disposition (skilled nursing facility), and mortality. RESULTS: A total 243 patients with ICH on preinjury P2Y12 inhibitor met our inclusion criteria and were analyzed. Mean age was 55 ± 18 y, 58% were males and 60% were white and median injury severity score was 13 [9-18]. 73.6% received platelet transfusion after admission. The median packs of platelet transfusion were 1 [1-2] units. After controlling for confounders, patients who received platelet transfusion had a lower rate of progression (OR: 0.68, P = 0.01) and decreased rate of neurosurgical intervention (OR: 0.80, P = 0.03). Overall mortality was 12.3%. Patients on P2Y12 inhibitors who received platelet transfusion had lower odds of discharge to a skilled nursing facility (OR: 0.75, P = 0.02) and mortality (OR: 0.85, P = 0.04). CONCLUSIONS: Platelet transfusion after isolated traumatic ICH in patients on P2Y12 inhibitors is associated with improved outcomes. Platelet transfusion was associated with decreased risk of progression of ICH, neurosurgical intervention, and mortality. Further randomized studies to validate the use of platelet transfusion and define the optimal dose in patients on P2Y12 inhibitors are warranted.

Oral Xa Inhibitors Versus Low Molecular Weight Heparin for Thromboprophylaxis After Nonoperative Spine Trauma.

BACKGROUND: Thromboprophylaxis with oral Xa inhibitors (Xa-Inh) are recommended after major orthopedic operation; however, its role in spine trauma is not well-defined. The aim of our study was to assess the impact of Xa-Inh in spinal trauma patients managed nonoperatively. METHODS: A 4-y (2013-2016) review of the Trauma Quality Improvement Program database. We included all patients with an isolated spine trauma (Spine-abbreviated injury scale ≥3 and other-abbreviated injury scale <3) who were managed nonoperatively and received thromboprophylaxis with either low molecular weight heparin (LMWH) or Xa-Inh. Patients were divided into two groups based on the thromboprophylactic agent received: Xa-Inh and LMWH and were matched in a 1:2 ratio using propensity score matching for demographics, vitals and injury parameters, and level of spine injury. Outcomes were rates of deep venous thrombosis, pulmonary embolism, and mortality. RESULTS: We analyzed a total of 58,936 patients, of which 1056 patients (LMWH: 704, Xa-Inh: 352) were matched. Matched groups were similar in demographics, vital and injury parameters, length of hospital stay (P = 0.31), or time to thromboprophylaxis (P = 0.79). Patients who received Xa-Inh were less likely to develop a deep venous thrombosis (2.3% versus 5.7%, P < 0.01). There were no differences in the rate of pulmonary embolism (P = 0.73), postprophylaxis packed red blood cells transfusions (P = 0.79), postprophylaxis surgical decompression of spinal column (P = 0.75), and mortality rate (P = 0.77). CONCLUSIONS: Oral Xa-Inh seems to be more effective as prophylactic pharmacologic agent for the prevention of deep venous thrombosis in patients with nonoperative spinal trauma compared to LMWH. The two drugs had similar safety profile. Further prospective trials should be performed to change current guidelines.

Massive Transfusion: The Revised Assessment of Bleeding and Transfusion (RABT) Score.

BACKGROUND: Massive transfusion (MT) is a lifesaving treatment for trauma patients with hemorrhagic shock, assessed by Assessment of Blood Consumption (ABC) Score based on mechanism of injury, systolic blood pressure (SBP), tachycardia, and FAST exam. The aim of this study was to assess the performance of ABC score by replacing hypotension and tachycardia; with Shock Index (SI) > 1.0 and including pelvic fractures. METHODS: We performed a 2-year (2014-2015) analysis of all high-level trauma activations and excluded patients dead on arrival. The ABC score was calculated using the 4-point score [blunt (0)/penetrating trauma (1), HR ≥ 120 (1), SBP ≤ 90 mmHg (1), and FAST positive (1)]. The Revised Assessment of Bleeding and Transfusion (RABT) score also included 4 points, calculated by replacing HR and SBP with SI > 1.0 and including pelvic fracture. AUROC compared performances of the two scores. RESULTS: A total of 380 patients were included. The overall MT was 27%. Patients receiving MT had higher median ABC scores [1.1 (0-2) vs. 1 (0-2), p = 0.15] and RABT scores [2 (1-3) vs. 1 (0-2), p < 0.001]. The RABT score had better discriminative power (AUROC = 0.828) compared to ABC score (AUROC = 0.617) for predicting the need for MT. Cutoff of RABT score ≥ 2 had a sensitivity of 84% and specificity of 77% for predicting need for MT compared to ABC score with 39% sensitivity and 72% specificity. CONCLUSION: Replacement of hypotension and tachycardia with a SI > 1.0 and inclusion of pelvic fracture enhanced discrimination of ABC score for predicting the need for MT. The current ABC score would benefit from revision to more appropriately identify patients requiring MT.

Primary repair for pediatric colonic injury: Are there differences among adult and pediatric trauma centers?

BACKGROUND: Management of colonic injuries (colostomy [CO] versus primary anastomosis [PA]) among pediatric patients remains controversial. The aim of this study was to assess outcomes in pediatric trauma patient with colonic injury undergoing operative intervention. METHODS: The National Trauma Data Bank (2011-2012) was queried including patients with isolated colonic injury undergoing exploratory laparotomy with PA or CO with age ≤18 y. Missing value analysis was performed. Patients were stratified into two groups: PA and CO. Outcome measures were mortality, in-hospital complications, and hospital length of stay. Multivariate regression analysis was performed. RESULTS: A total of 1151 patients included. Mean ± standard deviation age was 11.61 ± 2.8 y, and median [IQR] Injury Severity Score was 12 [8-16]; 39% (n = 449) of the patients had CO, and 35.6% (n = 410) were managed in pediatric trauma centers (PC). Patients with CO had a higher Injury Severity Score (P < 0.001), a trend toward lower blood pressure (P = 0.40), and an older age (P < 0.001). There was no difference in mortality between the PA and CO groups. However, patients who underwent PA had a shorter length of stay (P < 0.001) and lower in-hospital complications (P < 0.001). A subanalysis shows that, after controlling for all confounding factors, patients managed in PC were 1.2 times (1.2 [1.1-2.1], P = 0.04) more likely to receive a CO than those patients managed in adult trauma centers (AC). Moreover, there was no difference in mortality between the AC and the PC (P = 0.79). CONCLUSIONS: Our data demonstrate no difference in mortality in pediatric trauma patients with colonic injury who undergo primary repair or CO. However, adult trauma centers had lower rates of CO performed as compared to a similar cohort of patients managed in pediatric trauma centers. Further assessment of the reasons underlying such differences will help improve patient outcomes.

The impact of Glasgow Coma Scale-age prognosis score on geriatric traumatic brain injury outcomes.

BACKGROUND: As the population ages, increasing number of geriatric patients sustain traumatic brain injury (TBI). Communication of accurate prognostic information is crucial for making informed decisions on behalf of such patients. Therefore, the aim of our study was to develop a simple and clinically applicable tool that accurately predicts the prognosis in geriatric TBI patients. METHODS: We performed a 1-y (2011) retrospective analysis of isolated geriatric TBI patients (age ≥65 y, head abbreviated injury score [AIS] ≥ 3, and other body AIS < 3) in the National Trauma Data Bank. We calculated a Glasgow Coma Scale (GCS)-age prognosis (GAP) score (age/GCS score) for all patients. Outcome measures were in-hospital adverse outcomes (mortality and Rehab/skilled nursing facility discharge disposition). Regression analysis and receiver operator characteristic curve analysis were performed to determine the discriminatory power of GAP score. RESULTS: A total of 8750 geriatric patients with TBI were included. Mean age was 77.8 ± 7.1 y, the median (interquartile range) GCS was 15 (13-15), and the median (interquartile range) head AIS was 4 (3-4). The overall in-hospital mortality rate was 12.7%, and 34.2% of the patients were discharged home. As the GAP score increased, the mortality rate increased and discharge to-home decreased. Receiver operator characteristic curve analysis revealed excellent discriminatory power for mortality (area under the curve: 0.826). Above a GAP score of 12, the mortality rate was >50% and more than 45% of the patients were discharged to Rehab/skilled nursing facility. CONCLUSIONS: For geriatric patients with TBI, a simple GAP score reliably predicts outcomes. A score above 12 results in a drastic increase in mortality and an adverse discharge disposition. This simple tool may help clinicians provide accurate prognostic information to patients' families.

Early thromboprophylaxis with low-molecular-weight heparin is safe in patients with pelvic fracture managed nonoperatively.

INTRODUCTION: Early initiation of thromboprophylaxis is highly desired in pelvic fracture patients, but it is often delayed due to the fear of hemorrhage. Aim of our study was to assess the safety of early initiation of venous thromboprophylaxis in patients with pelvic trauma managed nonoperatively. METHODS: Three-year (2010-2012) retrospective study of trauma patients with pelvic fractures who were managed nonoperatively and received thromboprophylaxis with low-molecular-weight heparin (LMWH). Patients were stratified in two groups based on the timing of initiation of prophylaxis; early (initiation within first 24 h) and late (after 24 h). Primary outcome measures included decrease in hemoglobin (Hb) levels, number of packed red blood cell (pRBC) units transfused, and the need for hemorrhage control (operative or angioembolization) after initiation of prophylaxis. Regression analysis was performed. RESULTS: 255 patients were included (158 in early and 97 in late group). Mean ± standard deviation age was 48.2 ± 23.3 y, and 50.6% were male. After adjusting for confounders, there was no difference between the two groups in the decrease in Hb levels (b = 0.087, 95% confidence interval [CI] = -0.253 to 1.025; P = 0.23) or pRBC units transfused (b = -0.005, 95% CI = -0.366 to 0.364; P = 0.75).One patient required hemorrhage control postprophylaxis and belonged to the late group. Subanalysis of patients with signs of bleeding (n = 52) showed no difference between the two groups in the decrease in Hb levels or pRBC units transfused. Patients who received LMWH after 24 h had a higher incidence of symptomatic deep venous thrombosis and a longer hospital length of stay. CONCLUSIONS: Early initiation of thromboprophylaxis with LMWH in patients with pelvic fractures managed nonoperatively is safe and decreases the risk of symptomatic deep venous thrombosis.

Antimicrobial susceptibility of organisms isolated from sputum culture of Karachi, Pakistan.

Our study aims to contribute to developing antibiotics prescription guidelines at a national and a regional level directed by the antibiotics susceptibility patterns and rapidly emerging resistant organisms. This study is designed to observe the antimicrobial susceptibility in sputum culture isolates and drug resistance patterns against various antimicrobials. This was a retrospective cohort study; data was collected from two laboratories from 1st Jan to 15 July 2007. All laboratory reports were analyzed using SPSS version 19.0.The sputum culture was found positive for microbial growth in 217 reports out of 864 total (25.11%). The leading organisms were 25.8% Klebsiella pneumoniae, 23.5% Streptococcus pneumoniae, 18% Pseudomonas aeruginosa and 12.9% Staphylococcus aureus. S.pneumoniae and S.aureus were sensitive to the combination of beta lactam antibiotics and anti-beta lactamase while K.pneumoniae and P. aureginosa were susceptible to fluoroquinolones, macrolides and aminoglycosides. The total yield of sputum culture was 25.11%. The gram positive cocci which were isolated were mostly resistant to beta lactam antibiotics alone i.e. only 45% of S. pneumoniae and 33% of S. aureus were sensitive to Amoxicillin alone. Sensitivity to Co-amoxiclav was still high. 90% and 85% of S. pneumonia and S. aureus respectively were sensitive to Co-amoxiclav. The P. aeruginosa resistance to Amikacin in our study is 10%.

Trends and disparities in access to minimally invasive distal pancreatectomy (midp): an eight-year analysis from the national cancer database.

Laparoscopic and robotic approaches to distal pancreatectomy are becoming the standard of care. The aim of our study was to evaluate the trends of utilization and disparities in access to minimally invasive approaches in distal pancreatectomy. We queried the National Cancer Database (NCDB) and analyzed all the patients who underwent distal pancreatectomy from 2010 to 2017. Patients were divided into groups of those with open distal pancreatectomy (ODP) and those with laparoscopic or robotic distal pancreatectomy (MIDP = minimally invasive distal pancreatectomy). Our outcome measures were trends of MIDP and disparities in access to MIDP. Cochran Armitage trend analysis and multivariate regression analysis were used to evaluate outcomes. A total of 13,537 patients with distal pancreatectomy were identified in the NCDB from 2010 to 2017. 7548 (55.8%) underwent ODP, while 5989 (44.2%) underwent MIDP. The MIDP rates increased from 25% in 2010 to 52% in 2017 (p < 0.01). On regression analysis, when controlled for age, gender, diagnosis, tumor size, grade, staging, and chemoradiotherapy, African American patients were 30% less likely to undergo MIDP than White (OR 0.7, 95% CI [0.5-0.8], p < 0.01). Similarly, Hispanic patients were 25% less likely to undergo MIDP than non-Hispanic patients OR 0.75, 95% CI [0.6-0.9], p = 0.02). Compared to Medicare/private insured patients, uninsured patients were 50% less likely to undergo MIDP (OR 0.5, 95% CI [0.4-0.7], p < 0.01). Based on the medium household income, compared to patients in the fourth quartile, patients in the third quartile OR 0.9, 95% CI [0.3-0.9], p = 0.03). Second OR 0.8, 95%CI [0.5-0.9], p < 0.01), first quartile OR 0.7, 95% CI [0.5-0.8], p < 0.01) were less likely to undergo MIPD as well. Utilization of MIDP has increased from one in every four patients in 2010 to every other patient in 2017. However, African Americans, Hispanics, the uninsured, and those from low-income quartiles are less likely to undergo MIDP. Efforts should be made to ensure access to minimally invasive approches are available to minorities.

Effect of conditions being present at time of surgery (PATOS) on outcomes in liver surgery.

INTRODUCTION: Information about condition(s) being present at time of surgery (PATOS) in the American College of Surgeons (ASC) National Surgical Quality Improvement Program (NSQIP) database can influence the postoperative complication rates after liver surgeries. Here, we compare the postoperative complication rates with and without taking condition(s) being PATOS into account. METHODS: We retrospectively reviewed the ACS NSQIP Participant User Files (PUFs) from 2015 through 2019. We analyzed rates of eight different postoperative complications: superficial surgical site infection (SSI), deep SSI, organ space SSI, pneumonia, urinary tract infection, ventilator, sepsis, and septic shock. In addition, we calculated the percent change in event rates after taking into account whether a condition is PATOS. RESULTS: Of the 22,463 patients in the ACS NSQIP PUFs for liver surgery, 334 (1.49%) had one or more conditions PATOS. The percentages of patients with PATOS events ranged from 2.03% for superficial SSI to 14.74% for sepsis. For all complications, event rates declined when taking condition(s) PATOS into account. From 2015 through 2019, the observed-to-expected ratios for most complications remained unchanged. CONCLUSION: Whether a condition is PATOS is important in reporting postoperative complication rates for patients undergoing liver surgery. When taking whether a condition is PATOS into account, we demonstrated an overall decrease in event rates across all eight postoperative complications.

Comparative outcomes of treatment modalities in nonagenarians with nonmetastatic pancreatic adenocarcinoma.

BACKGROUND: There has been an increase in the elderly patient population seeking care for pancreatic ductal adenocarcinoma (PDAC). This study aimed to delineate the effectiveness of therapeutic options in nonagenarians (aged 90-99 years) diagnosed with resectable PDAC. METHODS: This study used the National Cancer Database to identify patients with nonmetastatic PDAC (stage I-III) from 2004 to 2021. The study compared median overall survival (mOS) using Kaplan-Meier curves among 5 treatment categories: surgery, surgery along with chemoradiation, chemotherapy alone, radiotherapy alone, and chemoradiation alone. Cox proportional hazards regression was used in multivariate analyses. RESULTS: Of 459,174 patients, 793 aged ≥ 90 years had nonmetastatic PDAC. Of 793 patients, 245 (30.9 %) underwent chemotherapy alone, 296 (37.3 %) underwent radiotherapy alone, 162 (20.4 %) underwent chemoradiation alone, 58 (7.3 %) underwent curative-intent resection, and 32 (4.0 %) underwent surgery combined with chemoradiation. The mOS estimates in different treatment modalities were 9.5 months (95 % CI, 6.7-14.5) for surgery alone, 19.1 months (95 % CI, 2.4-64.3) for surgery combined with chemoradiation, 8.2 months (95 % CI, 7.2-9.2) for chemotherapy alone, 8.4 months (95 % CI, 7.6-9.6) for radiotherapy alone, and 11.2 months (95 % CI, 8.7-12.9) for chemoradiation alone (P < .001). In multivariate analysis, the odds of survival were better for patients who underwent surgery alone than for those who underwent chemotherapy alone, although the odds of survival did not significantly differ between patients who underwent radiotherapy alone and those who underwent chemoradiation alone. Nonetheless, surgery combined with chemoradiation was associated with decreased mortality risk compared with surgery alone (hazard ratio, 0.46; 95 % CI, 0.25-0.87; P = .02). Operative 30-day mortality rate was 8.8 %, and 90-day mortality rate was 17.8 %. CONCLUSION: Surgery combined with chemoradiation improved the survival of nonagenarians with PDAC compared with other therapies. However, only 1 in 25 patients received all 3 treatment components. Moreover, our study highlights a very high operative mortality rate in nonagenarians.

Is there a need for fresh frozen plasma and platelet transfusion in trauma patients receiving submassive transfusion?

Background: Blood transfusions have become a vital intervention in trauma care. There are limited data on the safety and effectiveness of submassive transfusion (SMT), that is defined as receiving less than 10 units packed red blood cells (PRBCs) in the first 24 hours. This study aimed to evaluate the efficacy and safety of fresh frozen plasma (FFP) and platelet transfusions in patients undergoing SMT. Methods: This is a retrospective cohort, reviewing the Trauma Quality Improvement Program database spanning 3 years (2016 to 2018). Adult patients aged 18 years and older who had received at least 1 unit of PRBC within 24 hours were included in the study. We used a multivariate regression model to analyze the cut-off units of combined resuscitation (CR) (which included PRBCs along with at least one unit of FFP and/or platelets) that leads to survival improvement. Patients were then stratified into two groups: those who received PRBC alone and those who received CR. Propensity score matching was performed in a 1:1 ratio. Results: The study included 85 234 patients. Based on the multivariate regression model, transfusion of more than 3 units of PRBC with at least 1 unit of FFP and/or platelets demonstrated improved mortality compared with PRBC alone. Among 66 319 patients requiring SMT and >3 units of PRBCs, 25 978 received PRBC alone, and 40 341 received CR. After propensity matching, 4215 patients were included in each group. Patients administered CR had a lower rate of complications (15% vs 26%), acute respiratory distress syndrome (3% vs 5%) and acute kidney injury (8% vs 11%). Rates of sepsis and venous thromboembolism were similar between the two groups. Multivariate regression analysis indicated that patients receiving 4 to 7 units of PRBC alone had significantly higher ORs for mortality than those receiving CR. Conclusion: Trauma patients requiring more than 3 units of PRBCs who received CR with FFP and platelets experienced improved survival and reduced complications. Level of evidence: Level III retrospective study.

Does the Surgical Approach Affect the Incidence of Post-Hepatectomy Liver Failure in Cirrhotic Patients? An Analysis of the NSQIP Database.

Background: The association between surgical approach and post-hepatectomy liver failure (PHLF) in cirrhotic patients is poorly understood. We hypothesize that patients will have similar rates of liver failure regardless of whether they undergo minimally invasive liver resection (MILR) or open liver resection (OLR) in major liver resections. In contrast, there will be lower rates of PHLF in patients undergoing minor hepatectomy via the MILR approach.Methods: Propensity score matching was used to analyze regression by matching the MILR to the OLR cohort. Patient demographics from the American College of Surgeons National Surgical Quality Improvement Program, including race, age, gender, and ethnicity, were matched. Chronic obstructive pulmonary disease, congestive heart failure, smoking, hypertension, diabetes, renal failure, dyspnea, dialysis dependence, body mass index, and American Society of Anesthesiologists (ASA) classification (>ASA III) were among the preoperative patient characteristics subject to matching. PHLF (Grade A vs B. vs C) was our primary outcome measure.Results: A total of 2129 cirrhotic patients were included in the study. In the minor hepatectomy group, patients undergoing an OLR were more likely to get discharged to a facility (7.0% vs 4.4%; P = .03), had greater hospital length of stay (5 vs 3 days; P = .02), and had a greater need for invasive postoperative interventions (10.7% vs 4.6%; P < .01). They were also noted to have higher rates of organ space superficial surgical infections (SSIs) (7.3% vs 3.7%; P = .003), Clostridium difficile infection (.9% vs .1%; P = .05), renal insufficiency (2.1% vs .1%; P < .01), unplanned intubations (3.1% vs 1.4%; P = .03), and Grade C liver failure (2.3% vs .9%; P = .03).Conclusion: A higher incidence of PHLF grade C was found in patients undergoing OLR in the minor hepatectomy group. Therefore, in cirrhotic patients who can tolerate minimally invasive approaches, MILR should be offered to prevent postoperative complications as part of their optimization plan.

Feeble, fallen, and forgetting: association of cognitive impairment and falls on outcomes of major intra-abdominal surgeries in older adults.

BACKGROUND: Both cognitive impairment/dementia (CID) and falls occur more commonly in older adults than in younger patients. This study aimed to analyze the association of a history of CID or falls with the postoperative outcomes of older adults undergoing major intra-abdominal surgeries on a national level. METHODS: We retrospectively analyzed the American College of Surgeons-National Surgical Quality Improvement Program 2022 Participant Use Data File. Our primary outcome was postoperative mortality. Statistical analysis was performed using the Chi-square test and multivariate regression analysis. RESULTS: On multivariable regression analyses, a history of both CID (odds ratio [OR] = 1.9; CI: 1.5-2.5; P < .01) and a fall (OR = 1.8; CI: 1.4-2.3; P < .01) were independently associated with higher adjusted odds of mortality. History of CID or falls was also a predictor of overall complications, major complications, and discharge to a care facility. CONCLUSION: A history of CID or falls in older adults before major intra-abdominal surgeries was associated with a high risk of postoperative mortality and morbidity. Further studies are required to establish the causal relation of these factors and the steps to mitigate the risk of associated adverse outcomes.