Mesh infection in ventral incisional hernia repair: incidence, contributing factors, and treatment

BACKGROUND

Prosthetic mesh infection is a catastrophic complication of ventral incisional hernia (VIH) repair.

METHODS

The current surgical literature was reviewed to determine the incidence, microbiology, risk factors, and treatment of mesh infections.

RESULTS

Mesh infections tend to present late. Diagnosis depends on high clinical suspicion and relies on culture of the fluid surrounding the mesh or of the mesh itself. Risk factors may include a high body mass index (obesity); chronic obstructive pulmonary disease; abdominal aortic aneurysm repair; prior surgical site infection; use of larger, microporous, or expanded polytetrafluoroethylene mesh; performance of other procedures via the same incision at the time of repair; longer operative time; lack of tissue coverage of the mesh; enterotomy; and enterocutaneous fistula. The best treatment is prevention. Treatment of mesh infection is evolving on a case-by-case basis from explantation toward mesh salvage, to prevent complications such as hernia recurrence.

CONCLUSION

Higher-quality reporting on mesh infection in VIH repair must be achieved through better classification and quantification of these infections. Tactics to avoid mesh infection should be based on best evidence and high-quality prospective trials and observational studies.

Risk factors and outcomes of acute versus elective groin hernia surgery

BACKGROUND

Hernia characteristics and patient factors associated with acute compared with elective groin hernia surgery are unknown.

STUDY DESIGN

A retrospective study of 1,034 consecutive groin hernia repair cases performed between 2001 and 2009 at a single Veterans Affairs Hospital was conducted. Patient variables, hernia characteristics, time to surgery, and morbidity and mortality outcomes were abstracted and compared between acute and elective hernia repairs. A Kaplan-Meier survival analysis for the two groups was also performed. Logistic regression analysis was conducted to identify associations between type of surgery, patient demographics, and hernia characteristics.

RESULTS

Compared with 971 elective repair patients, the 63 acute repair patients had a higher rate of femoral hernias (2.5% vs 7.4%, p = 0.03), a higher rate of scrotal hernias (16.2% vs 32.4%, p = 0.0006), and a higher rate of recurrent hernias (16.7% vs 30.9%, p = 0.0026). Patient age, femoral, scrotal, and recurrent hernias were significantly associated with acute hernia presentation on univariate and multivariable analyses. Complications occurred in 27% and 15.1% of acute and elective repair patients, respectively (p = 0.01). Intraoperative organ resection was required in 7 (11.1%) acute hernia repairs, and in 2 (0.2%) elective repairs (p < 0.0001). Three acute repair patients (4.8%) underwent reoperation within 30 days after surgery, compared with 15 elective repair patients (1.5%), p = 0.05. Age-adjusted Kaplan-Meier survival analysis revealed a shorter time to death among acute repair patients compared with elective repair patients (p < 0.0001).

CONCLUSIONS

Age, femoral, scrotal, and recurrent groin hernias are associated with increased risk for acute hernia surgery. Acute hernia repair carries a higher morbidity and lower survival.

How valid is the AHRQ Patient Safety Indicator "postoperative physiologic and metabolic derangement"?

BACKGROUND

The Agency for Healthcare Research and Quality Patient Safety Indicator postoperative physiologic and metabolic derangement (PMD) uses ICD-9-CM codes to screen for potentially preventable acute kidney injury (AKI) requiring dialysis plus diabetes-related complications after elective surgery. Data on PMD's accuracy in identifying true events are limited. We examined the indicator's positive predictive value (PPV) in the Veterans Health Administration (VA).

STUDY DESIGN

Trained abstractors reviewed medical records of 119 PSI software-flagged PMD cases. We calculated PPVs overall and separately for renal- and diabetes-related complications. We also examined false positives to determine reasons for incorrect identification, and true positives to determine PMD-related outcomes and risk factors.

RESULTS

Overall 75 cases were true positives (PPV 63%, 95% CI 54% to 72%); 73 of 104 AKI cases were true positives (PPV 70%, 60% to 79%); only 2 of 15 diabetes cases were true positives (PPV 13%, 2% to 40%). Of all false positives, 70% represented nonelective admissions and 23% had the complication present on admission. Of AKI true positives, 37% died and 26% were discharged on dialysis; 55% had chronic kidney disease (≥ stage 3) present on admission. Cardiac surgery represented the largest category of AKI-associated index procedures (30%). AKI was most commonly attributed to perioperative renal hypoperfusion (84% of true positives), followed by nephrotoxins (33%) including contrast (11%).

CONCLUSIONS

Due to its low PPV, we recommend removing diabetes complications from the indicator and focusing on AKI. PMD's PPV could be significantly improved by using present-on-admission codes, and specific to the VA, by introduction of admission status codes. Many PMD-identified cases appeared to be at high risk based on patient- and procedure-related factors. The degree to which such cases are truly preventable events requires further assessment.

How valid is the AHRQ Patient Safety Indicator "postoperative respiratory failure"?

BACKGROUND

The Agency for Healthcare Research and Quality Patient Safety Indicator postoperative respiratory failure (PRF) uses administrative data to screen for potentially preventable respiratory failure after elective surgery based on a respiratory failure diagnosis or an intubation or ventilation procedure code. Data on PRF accuracy in identifying true events is scant; a recent study using University HealthSystem Consortium data found a positive predictive value (PPV) of 83%. We examined the indicator's PPV in the Veterans Health Administration.

STUDY DESIGN

We applied the Patient Safety Indicator software (v.3.1a) to fiscal year 2003-2007 VA discharge data. Trained abstractors reviewed medical records of 112 software-flagged PRF cases. We calculated the PPV and examined false positives to determine reasons for incorrect identification and true positives to determine clinical consequences and potential risk factors of PRF.

RESULTS

Seventy-five cases were true positive (PPV 67%; 95% CI, 57-76%); 13% were identified by a diagnosis code, 53% by a procedure code, 33% by both. Of false positives, 19% represented coding errors, 76% represented nonelective admissions. Of true positives, 28% of patients died, 56% had an American Society of Anesthesiologists level higher than II. Of associated index procedures, 53% were abdominal/pelvic, and 56% lasted >3 hours.

CONCLUSIONS

Based on our and University HealthSystem Consortium's findings, PRF should continue to be used as a screen for potential patient-safety events. Its PPV could be substantially improved in the Veterans Health Administration through introduction of an admission status code. Many PRF-identified cases appeared to be at high risk, based on patient and procedure-related factors. The degree to which such cases are truly preventable events requires additional assessment.

Positive predictive value of the AHRQ Patient Safety Indicator "Postoperative Sepsis": implications for practice and policy

BACKGROUND

Patient Safety Indicator (PSI) 13, or "Postoperative Sepsis," of the Agency for Healthcare Quality and Research (AHRQ), was recently adopted as part of a composite measure of patient safety by the Centers for Medicare and Medicaid Services (CMS). We sought to examine its positive predictive value (PPV) by determining how well it identifies true cases of postoperative sepsis.

STUDY DESIGN

Two retrospective cross-sectional studies of hospitalization records that met PSI 13 criteria were conducted, one within the Veterans Administration (VA) Hospitals from fiscal years (FY) 2003 to 2007, and one within community hospitals between October 1, 2005 and March 31, 2007. Trained abstractors reviewed medical records from each database using standardized abstraction instruments. We determined the PPV of the indicator and performed descriptive analyses of cases.

RESULTS

Of 112 cases flagged and reviewed within the VA system, 59 were true events of postoperative sepsis, yielding a PPV of 53% (95% CI 42% to 64%). Within the community hospital sector, of 164 flagged and reviewed cases, 67 were true cases of postoperative sepsis, yielding a PPV of 41% (95% CI 28% to 54%). False positives were due to infections that were present on admission, urgent or emergent cases, no clinical diagnosis of sepsis, or other coding limitations such as nonspecific shock in postoperative patients.

CONCLUSIONS

PSI 13 has relatively poor predictive ability to identify true cases of postoperative sepsis in both the VA and nonfederal sectors. The lack of information on diagnosis timing, confusion about the definition of elective admission, and coding limitations were the major reasons for false positives. As it currently stands, the use of PSI 13 as a stand-alone measure for hospital reporting appears premature.

The impact of resident duty hour reform on hospital readmission rates among Medicare beneficiaries

BACKGROUND

A key goal of resident duty hour reform by the Accreditation Council for Graduate Medical Education (ACGME) in 2003 was to improve patient outcomes.

OBJECTIVE

To assess whether the reform led to a change in readmission rates.

DESIGN

Observational study using multiple time series analysis with hospital discharge data from July 1, 2000 to June 30, 2005. Fixed effects logistic regression was used to examine the change in the odds of readmission in more versus less teaching-intensive hospitals before and after duty hour reform.

PARTICIPANTS

All unique Medicare patients (n = 8,282,802) admitted to acute-care nonfederal hospitals with principal diagnoses of acute myocardial infarction, congestive heart failure, gastrointestinal bleeding, or stroke (combined medical group), or a DRG classification of general, orthopedic, or vascular surgery (combined surgical group).

MAIN MEASURES

Primary outcome was 30-day all-cause readmission. Secondary outcomes were (1) readmission or death within 30 days of discharge, and (2) readmission, death during the index admission, or death within 30 days of discharge.

KEY RESULTS

For the combined medical group, there was no evidence of a change in readmission rates in more versus less teaching-intensive hospitals [OR = 0.99 (95% CI 0.94, 1.03) in post-reform year 1 and OR = 0.99 (95% CI 0.95, 1.04) in post-reform year 2]. There was also no evidence of relative changes in readmission rates for the combined surgical group: OR = 1.03 (95% CI 0.98, 1.08) for post-reform year 1 and OR = 1.02 (95% CI 0.98, 1.07) for post-reform year 2. Findings for the secondary outcomes combining readmission and death were similar.

CONCLUSIONS

Among Medicare beneficiaries, there were no changes in hospital readmission rates associated with resident duty hour reform.

Validity of selected Patient Safety Indicators: opportunities and concerns

BACKGROUND

The Agency for Healthcare Research and Quality (AHRQ) recently designed the Patient Safety Indicators (PSIs) to detect potential safety-related adverse events. The National Quality Forum has endorsed several of these ICD-9-CM-based indicators as quality-of-care measures. We examined the positive predictive value (PPV) of 3 surgical PSIs: postoperative pulmonary embolus and deep vein thrombosis (pPE/DVT), iatrogenic pneumothorax (iPTX), and accidental puncture and laceration (APL).

STUDY DESIGN

We applied the AHRQ PSI software (v.3.1a) to fiscal year 2003 to 2007 Veterans Health Administration (VA) administrative data to identify (flag) patients suspected of having a pPE/DVT, iPTX, or APL. Two trained nurse abstractors reviewed a sample of 336 flagged medical records (112 records per PSI) using a standardized instrument. Inter-rater reliability was assessed.

RESULTS

Of 2,343,088 admissions, 6,080 were flagged for pPE/DVT (0.26%), 1,402 for iPTX (0.06%), and 7,203 for APL (0.31%). For pPE/DVT, the PPV was 43% (95% CI, 34% to 53%); 21% of cases had inaccurate coding (eg, arterial not venous thrombosis); and 36% featured thromboembolism present on admission or preoperatively. For iPTX, the PPV was 73% (95% CI, 64% to 81%); 18% had inaccurate coding (eg, spontaneous pneumothorax), and 9% were pneumothoraces present on admission. For APL, the PPV was 85% (95% CI, 77% to 91%); 10% of cases had coding inaccuracies and 5% indicated injuries present on admission. However, 27% of true APLs were minor injuries requiring no surgical repair (eg, small serosal bowel tear). Inter-rater reliability was >90% for all 3 PSIs.

CONCLUSIONS

Until coding revisions are implemented, these PSIs, especially pPE/DVT, should be used primarily for screening and case-finding. Their utility for public reporting and pay-for-performance needs to be reassessed.

Malignant eccrine spiradenoma: a meta-analysis of reported cases

BACKGROUND

Malignant eccrine spiradenoma is an aggressive sweat gland tumor with poorly understood behavior and no currently accepted therapeutic regimen.

METHODS

An individual patient data meta-analysis with Kaplan–Meier survival curves was performed on 72 reported cases of malignant eccrine spiradenoma.

RESULTS

In 35 patients with no distant metastasis, local resection resulted in 100% disease-free survival. Of 7 patients with lymph node but no distant metastasis treated with surgical resection and lymph node dissection, 6 patients remained disease-free at final follow-up evaluation. For the 24 cases with confirmed distant metastatic disease, patient survival did not significantly differ between local resection and surgery with adjuvant chemoradiotherapy (P = .8763).

CONCLUSIONS

Heightened awareness is recommended among surgeons likely to treat this entity. An aggressive surgical approach is supported in the absence of metastasis. When lymph nodes are not clinically involved, sentinel node may have a role followed by lymph node dissection in patients with a positive node.

Development of trigger tools for surveillance of adverse events in ambulatory surgery

BACKGROUND

The trigger tool methodology uses clinical algorithms applied electronically to 'flag' medical records where adverse events (AEs) have most likely occurred. The authors sought to create surgical triggers to detect AEs in the ambulatory care setting.

METHODS

Four consecutive steps were used to develop ambulatory surgery triggers. First, the authors conducted a comprehensive literature review for surgical triggers. Second, a series of multidisciplinary focus groups (physicians, nurses, pharmacists and information technology specialists) provided user input on trigger selection. Third, a clinical advisory panel designed an initial set of 10 triggers. Finally, a three-phase Delphi process (surgical and trigger tool experts) evaluated and rated the suggested triggers.

RESULTS

The authors designed an initial set of 10 surgical triggers including five global triggers (flagging medical records for the suspicion of any AE) and five AE-specific triggers (flagging medical records for the suspicion of specific AEs). Based on the Delphi rating of the trigger's utility for system-level interventions, the final triggers were: (1) emergency room visit(s) within 21 days from surgery; (2) unscheduled readmission within 30 days from surgery; (3) unscheduled procedure (interventional radiological, urological, dental, cardiac or gastroenterological) or reoperation within 30 days from surgery; (4) unplanned initial hospital length of stay more than 24 h; and (5) lower-extremity Doppler ultrasound order entry and ICD code for deep vein thrombosis or pulmonary embolus within 30 days from surgery.

CONCLUSION

The authors therefore propose a systematic methodology to develop trigger tools that takes into consideration previously published work, end-user preferences and expert opinion.

Comparison of laparoscopic and open repair with mesh for the treatment of ventral incisional hernia: a randomized trial

BACKGROUND

Laparoscopic repair of ventral incisional hernias has not been proved to be safer than open mesh repair.

DESIGN

Prospective randomized trial conducted between February 1, 2004, to January 31, 2007.

SETTING

Four Veterans Affairs medical centers.

PARTICIPANTS

One hundred sixty-two patients with ventral incisional hernias.

INTERVENTIONS

Standardized laparoscopic or open repair.

MAIN OUTCOME MEASURES

Overall complication rates at 8 weeks and the odds of complications, adjusted for study site, body mass index, and hernia type.

RESULTS

Of the 162 randomized patients, 146 underwent surgery (73 open and 73 laparoscopic repairs). Complications were less common in the laparoscopic group (23 patients [31.5%]) compared with the open repair group (35 patients [47.9%]; adjusted odds ratio [AOR], 0.45; 95% confidence interval [CI], 0.22-0.91; P = .03). Surgical site infection through 8 weeks was less common in the laparoscopic group (5.6% vs 23.3%; AOR, 0.2; 95% CI, 0.1-0.6). The mean worst pain score in the laparoscopic group was 15.2 mm lower on a visual analog scale at 52 weeks (95% CI, 1.0-29.3; P = .04). Time to resume work activities was shorter for the laparoscopic group than for the open repair group (median, 23.0 days vs 28.5 days), with an adjusted hazard ratio of 0.54 (95% CI, 0.28-1.04; P = .06). Overall recurrence at 2 years was 12.5% in the laparoscopic group and 8.2% in the open repair group (AOR, 1.6; 95% CI, 0.5-4.7; adjusted P = .44).

CONCLUSIONS

Laparoscopic repair was associated with fewer, albeit more severe, complications and improved some patient-centered outcomes. Trial Registration clinicaltrials.gov Identifier: NCT00240188.

Classification and valuation of postoperative complications in a randomized trial of open versus laparoscopic ventral herniorrhaphy

PURPOSE

Generic instruments used for the valuation of health states (e.g., EuroQol) often lack sensitivity to notable differences that are relevant to particular diseases or interventions. We developed a valuation methodology specifically for complications following ventral incisional herniorrhaphy (VIH).

METHODS

Between 2004 and 2006, 146 patients were prospectively randomized to undergo laparoscopic (n = 73) or open (n = 73) VIH. The primary outcome of the trial was complications at 8 weeks. A three-step methodology was used to assign severity weights to complications. First, each complication was graded using the Clavien classification. Second, five reviewers were asked to independently and directly rate their perception of the severity of each class using a non-categorized visual analog scale. Zero represented an uncomplicated postoperative course, while 100 represented postoperative death. Third, the median, lowest, and highest values assigned to each class of complications were used to derive weighted complication scores for open and laparoscopic VIH.

RESULTS

Open VIH had more complications than laparoscopic VIH (47.9 vs. 31.5%, respectively; P = 0.026). However, complications of laparoscopic VIH were more severe than those of open VIH. Non-parametric analysis revealed a statistically higher weighted complication score for open VIH (interquartile range: 0-20 for open vs. 0-10 for laparoscopic; P = 0.049). In the sensitivity analysis, similar results were obtained using the median, highest, and lowest weights.

CONCLUSION

We describe a new methodology for the valuation of complications following VIH that allows a direct outcome comparison of procedures with different complication profiles. Further testing of the validity, reliability, and generalizability of this method is warranted.

Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis

BACKGROUND

Since the patient's skin is a major source of pathogens that cause surgical-site infection, optimization of preoperative skin antisepsis may decrease postoperative infections. We hypothesized that preoperative skin cleansing with chlorhexidine-alcohol is more protective against infection than is povidone-iodine.

METHODS

We randomly assigned adults undergoing clean-contaminated surgery in six hospitals to preoperative skin preparation with either chlorhexidine-alcohol scrub or povidone-iodine scrub and paint. The primary outcome was any surgical-site infection within 30 days after surgery. Secondary outcomes included individual types of surgical-site infections.

RESULTS

A total of 849 subjects (409 in the chlorhexidine-alcohol group and 440 in the povidone-iodine group) qualified for the intention-to-treat analysis. The overall rate of surgical-site infection was significantly lower in the chlorhexidine-alcohol group than in the povidone-iodine group (9.5% vs. 16.1%; P=0.004; relative risk, 0.59; 95% confidence interval, 0.41 to 0.85). Chlorhexidine-alcohol was significantly more protective than povidone-iodine against both superficial incisional infections (4.2% vs. 8.6%, P=0.008) and deep incisional infections (1% vs. 3%, P=0.05) but not against organ-space infections (4.4% vs. 4.5%). Similar results were observed in the per-protocol analysis of the 813 patients who remained in the study during the 30-day follow-up period. Adverse events were similar in the two study groups.

CONCLUSIONS

Preoperative cleansing of the patient's skin with chlorhexidine-alcohol is superior to cleansing with povidone-iodine for preventing surgical-site infection after clean-contaminated surgery. (ClinicalTrials.gov number, NCT00290290.)

Elective surgical case cancellation in the Veterans Health Administration system: identifying areas for improvement

BACKGROUND

This study evaluated elective surgical case cancellation (CC) rates, reasons for these cancellations, and identified areas for improvement within the Veterans Health Administration (VA) system.

METHODS

CC data for 2006 were collected from the scheduling software for 123 VA facilities. Surveys were distributed to 40 facilities (10 highest and 10 lowest CC rates for high- and low-volume facilities). CC reasons were standardized and piloted at 5 facilities.

RESULTS

Of 329,784 cases scheduled by 9 surgical specialties, 40,988 (12.4%) were cancelled. CC reasons (9,528) were placed into 6 broad categories: patient (35%), work-up/medical condition change (28%), facility (20%), surgeon (8%), anesthesia (1%), and miscellaneous (8%). Survey results show areas for improvement at the facility level and a standardized list of 28 CC reasons was comprehensive.

CONCLUSIONS

Interventions that decrease cancellations caused by patient factors, inadequate work-up, and facility factors are needed to reduce overall elective surgical case cancellations.

Outcomes of care of abdominal aortic aneurysm in Veterans Health Administration facilities: results from the National Surgical Quality Improvement Program

This report describes outcomes of care for abdominal aortic aneurysms (AAAs), along with methods used by the Veterans Affairs (VA) National Surgical Quality Improvement Program (NSQIP) in tracking, monitoring, and improving surgical results in VA facilities. Since the inception of NSQIP in 1994, a continual drop in overall surgical mortality, along with decreased morbidity, has occurred. A parallel improvement in results of vascular surgery and AAA repair was also observed. Soon after introduction of endovascular aneurysm repair (EVAR), with Food and Drug Administration device approval in 1999, robust electronic NSQIP records immediately began to capture individual facility performances and outcomes for both types of AAA repair. The NSQIP data center provided actual and risk-adjusted analyses for both procedures semiannually. These analyses have been used by its executive board to provide recommendations, often based on site visits, to improve outcomes. Requirements for reporting of facility-specific data and feedback, paper audits, and site visits appear to relate directly to improved AAA care. Veterans Health Administration (VHA) outcomes of AAA repair are comparable to those reported nationally and internationally and have continued to improve in recent years. National VHA initiatives, based on data feedback and active oversight, relate to some of the lowest AAA mortality rates available. This review describes past, present, and possible future NSQIP strategies to improve outcomes for AAA repair with general comments about recent alternative proposals.

How does patient safety culture in the operating room and post-anesthesia care unit compare to the rest of the hospital?

BACKGROUND

A strong patient safety culture in the operating room (OR) and post-anesthesia care unit (PACU) is essential to promote safe care.

METHODS

The Patient Safety Climate in Healthcare Organizations (PSCHO) survey was administered to employees at 30 Veterans Affairs (VA) hospitals. The survey consisted of 42 close-ended items representing 12 different dimensions of safety. We measured percent problematic response (PPR); higher PPR values reflect weaker safety culture. The "OR/PACU" and the "Other Work Areas" groups' item-specific, dimension-specific, and overall problematic responses were compared.

RESULTS

The overall and dimension-specific PPRs were similar between the OR/PACU and the Other Work Areas group (overall: 20.2% and 18.1%, respectively; P = .41). When the 2 groups were compared on an item-by-item level, the OR/PACU staff reported more frequent witnessing of unsafe patient care (PPR 55.1% vs 43.2%; P = .01), and perceived less understanding by senior leadership of clinical care (PPR 28.3% vs 17.1%; P = .01) and less hospital interest in quality of care (PPR 20.4% vs 12.5%; P = .03).

CONCLUSIONS

Specific areas of safety culture in the OR/PACU were found that should be targeted for improvement.

Outcomes associated with initial versus later vancomycin use in patients with complicated skin and skin-structure infections

BACKGROUND

Delayed coverage of pathogens including meticillin-resistant Staphylococcus aureus (MRSA) in pneumonia and bacteraemia has been associated with increased mortality and length of hospital stay (LOS). However, less is known about the impact of delayed appropriate coverage in complicated skin and skin-structure infections (cSSSIs).

OBJECTIVE

To evaluate the clinical and economic outcomes associated with early versus late use of vancomycin in the management of patients hospitalized for cSSSIs.

METHODS

Retrospective analysis was performed using an inpatient claims database of >500 US hospitals in 2005. Using prescription claims, patients with primary or secondary cSSSI admissions were classified into three groups: 1 = early vancomycin monotherapy; 2 = early vancomycin combination therapy; 3 = late vancomycin therapy. Outcomes studied included LOS and inpatient hospital costs. One-way analysis of variance was used for unadjusted analysis and multivariate regression methods were used to control for co-variates.

RESULTS

A total of 34,942 patients (27.78% of all patients with cSSSIs) were treated with vancomycin. Mean age was 54.7 years and 54.3% of the patients were males. Mean unadjusted total LOS was 8.46, 9.44 and 13.2 days, and hospital costs in 2005 values were USD10 211.94, USD12 361.94 and USD18 344.00 for groups 1, 2 and 3, respectively. In-hospital mortality rate was highest in group 3 (4.18%) and lowest in group 1 (1.75%). Generalized linear models used to control for potential confounding variables between early versus late vancomycin use suggest that among cSSSI patients late vancomycin use is an independent predictor of higher LOS and costs.

CONCLUSION

In this large inpatient database, later vancomycin use in patients with cSSSIs appears to be significantly associated with higher LOS and total costs.

Comparative costs of ertapenem and cefotetan as prophylaxis for elective colorectal surgery

BACKGROUND AND PURPOSE

The costs of treating surgical site infections can be considerable. There is a cost associated with the prophylactic use of antibiotics; however, the use of prophylactic agents may reduce infection rates and lengths of stay, thus offsetting the overall treatment cost and potentially generating cost savings to hospitals. This project was intended to determine the potential cost impact of using ertapenem 1 g vs. cefotetan 2 g as prophylaxis for elective colorectal surgery.

METHODS

Cost analysis using efficacy data from the PREVENT clinical trial and drug acquisition and total hospital costs in 2005 dollars from Premier's Perspective Comparative Database in patients > or = 18 year of age, evaluable at four weeks after elective surgery of the colon or rectum and prophylactic treatment with ertapenem (n = 338) or cefotetan (n = 334). The primary outcome measures were the rate of prophylactic drug failure and the difference between the ertapenem and cefotetan groups in costs related to and total hospital stay. Prophylactic failure was defined as a surgical site infection, unexplained antibiotic use, or anastomotic leak.

RESULTS

Prophylactic failure occurred in 28.1% of the patients receiving ertapenem and 42.8% of those receiving cefotetan (p < 0.05). The most common prophylactic failure was surgical site infection: 18.3% for ertapenem, 31.1% for cefotetan, difference (95% confidence interval) -13.0% (-19.5, -6.5%) (p < 0.05). The mean +/- standard deviation length of stay for all patients, including prophylactic successes and failures, was 7.6 +/- 6.6 days for ertapenem and 8.7 +/- 9.5 days for cefotetan. The mean per-patient cost of prophylactic drugs and hospital room and board was $15,245 with ertapenem and $17,428 cefotetan, a net difference of -$2,181.

CONCLUSIONS

Ertapenem used in prophylaxis for elective colorectal operations results in a lower rate of surgical site infection and a shorter average length of stay than cefotetan. The calculated net difference in prophylactic antibiotic drug and hospital costs represents a saving of $2,181 per patient with ertapenem relative to cefotetan.

Time of day is associated with postoperative morbidity: an analysis of the national surgical quality improvement program data

OBJECTIVE

To examine the association between surgical start time and morbidity and mortality for nonemergent procedures.

SUMMARY BACKGROUND DATA

Patients require medical services 24 hours a day. Several studies have demonstrated a difference in outcomes over the course of the day for anesthetic adverse events, death in the ICU, and dialysis care. The relationship between operation start time and patient outcomes is yet undefined.

METHODS

We performed a retrospective cohort study of 144,740 nonemergent general and vascular surgical procedures performed within the VA Medical System 2000-2004 and entered into the National Surgical Quality Improvement Program Database. Operation start time was the independent variable of interest. Logistic regression was used to adjust for patient and procedural characteristics and to determine the association between start time and, in 2 independent models, mortality and morbidity.

RESULTS

Unadjusted later start time was significantly associated with higher surgical morbidity and mortality. After adjustment for patient and procedure characteristics, mortality was not significantly associated with start time. However, after appropriate adjustment, operations starting between 4 pm and 6 pm were associated with an elevated risk of morbidity (OR = 1.25, P < or = 0.005) over those starting between 7 am and 4 pm as were operations starting between 6 pm and 11 pm (OR = 1.60, P < or = 0.005).

CONCLUSIONS

When considering a nonemergent procedure, surgeons must bear in mind that cases that start after routine "business" hours within the VA System may face an elevated risk of complications that warrants further evaluation.

Surgical progress in inguinal and ventral incisional hernia repair

The goals of this article are to describe the history of hernia repair and how innovations in surgical technique, prosthetics, and technology have shaped current practice.

Factors associated with postoperative complications and hernia recurrence for patients undergoing inguinal hernia repair: a report from the VA Cooperative Hernia Study Group

BACKGROUND

We sought to determine perioperative variables predictive of complications or recurrence for patients undergoing surgical repair of inguinal hernias.

PATIENTS AND METHODS

Using data from the Veterans Affairs trial, regression analyses were utilized to identify perioperative factors significantly associated with complications (overall, short-term and long-term), long-term pain, and to develop a risk model for recurrence.

RESULTS

Recurrent and scrotal hernias were predictors for short term and overall complications, regardless of technique. Older age and higher Mental Component Score of the SF-36 were associated with higher risk of long term complications in the open group while prostatism and increased body mass index were the significant predictors in the laparoscopic group. Long-term pain complaints decreased as patient age increased in both groups. Patient and surgeon factors were predictive of recurrence but varied greatly depending on surgical technique.

CONCLUSIONS

Regardless of technique, scrotal and recurrent hernias were associated with a greater risk of complications and younger patients had more long-term pain. Predictors of recurrence vary based on surgical technique.

Telerehabilitation for veterans with a lower-limb amputation or ulcer: Technical acceptability of data

A study was undertaken to determine the technical acceptability of information available via a customized telerehabilitation system regarding patients with lower-limb ulcers or recent lower-limb amputations receiving care at a Veterans Affairs Medical Center. Among the 54 participants, 57 wounds (39 ulcers, 19 amputation incisions) were evaluated by means of still photographs and skin temperature data sent via ordinary telephone lines. Three experienced clinicians served as raters. Intrarater agreements and McNemar chi(2) tests were assessed between decisions made after telerehabilitation sessions and decisions made by the same rater after in-person sessions. Interrater agreements and kappa coefficients were assessed between two raters for both telerehabilitation and in-person sessions. The intrarater agreement on 57 wounds for the primary rater was 93%, and the McNemar test indicated no significant difference in the ratings (p < 0.63). Interrater agreement on 18 wounds was 78% (kappa = 0.55, p < 0.02) for the telerehabilitation sessions and 89% (kappa = 0.77, p < 0.001) for the in-person sessions. Most qualitative comments by three clinicians on picture quality (54/63 = 86%) and temperature data (39/44 = 88%) were favorable (good to excellent). The information yielded from this study provides evidence that the telerehabilitation system has the potential to present sufficient information to experienced clinicians so they can make informed decisions regarding wound management. The next phase of the study will include in-home trials and improvements in the technology.

Polyethylene glycol versus sodium phosphate mechanical bowel preparation in elective colorectal surgery

BACKGROUND

The type of mechanical bowel preparation (MBP) used before elective colorectal surgery remains controversial.

METHODS

This post hoc analysis of a prospective randomized controlled antibiotic prophylaxis trial (ertapenem vs. cefotetan) evaluated the effect of polyethylene glycol (PEG) and sodium phosphate (SP) MBPs on the rates of postoperative surgical site infections (SSI).

RESULTS

Good to excellent MBPs were observed in 281 of 303 (93%) evaluable patients for the PEG and 336 of 367 (92%) for the SP types. A higher rate of SSI was observed in the PEG (34%) than SP (24%) group (difference, 10%; 95% confidence interval, 3.4-17.2). The MBP type was a significant risk factor for SSI, with SP favored over PEG (odds ratio, .6; 95% confidence interval, .43-.85) in univariate analysis; multivariate analysis favored SP, but was not significant (odds ratio, .69; 95% confidence interval, .46-1.02). SSI was lowest with SP and ertapenem (19%) and highest with PEG and cefotetan (44%).

CONCLUSIONS

SP, coupled with ertapenem antibiotic prophylaxis, may improve outcomes and reduce SSIs in patients undergoing elective colorectal surgery when compared with PEG coupled with cefotetan antibiotic prophylaxis.

Ertapenem versus cefotetan prophylaxis in elective colorectal surgery

BACKGROUND

Ertapenem, a long-acting carbapenem, may be an alternative to the recommended prophylactic antibiotic cefotetan.

METHODS

In this randomized, double-blind trial, we assessed the efficacy and safety of antibiotic prophylaxis with ertapenem, as compared with cefotetan, in patients undergoing elective colorectal surgery. A successful outcome was defined as the absence of surgical-site infection, anastomotic leakage, or antibiotic use 4 weeks postoperatively. All adverse events were collected until 14 days after the administration of antibiotic prophylaxis.

RESULTS

Of the 1002 patients randomly assigned to study groups, 901 (451 in the ertapenem group and 450 in the cefotetan group) qualified for the modified intention-to-treat analysis, and 672 (338 in the ertapenem group and 334 in the cefotetan group) were included in the per-protocol analysis. After adjustment for strata, in the modified intention-to-treat analysis, the rate of overall prophylactic failure was 40.2% in the ertapenem group and 50.9% in the cefotetan group (absolute difference, -10.7%; 95% confidence interval [CI], -17.1 to -4.2); in the per-protocol analysis, the failure rate was 28.0% in the ertapenem group and 42.8% in the cefotetan group (absolute difference, -14.8%; 95% CI, -21.9 to -7.5). Both analyses fulfilled statistical criteria for the superiority of ertapenem. In the modified intention-to-treat analysis, the most common reason for failure of prophylaxis in both groups was surgical-site infection: 17.1% in the ertapenem group and 26.2% in the cefotetan group (absolute difference, -9.1; 95% CI, -14.4 to -3.7). In the treated population, the overall incidence of Clostridium difficile infection was 1.7% in the ertapenem group and 0.6% in the cefotetan group (P=0.22).

CONCLUSIONS

Ertapenem is more effective than cefotetan in the prevention of surgical-site infection in patients undergoing elective colorectal surgery but may be associated with an increase in C. difficile infection. (ClinicalTrials.gov number, NCT00090272 [ClinicalTrials.gov].).

Linezolid reduces length of stay and duration of intravenous treatment compared with vancomycin for complicated skin and soft tissue infections due to suspected or proven methicillin-resistant Staphylococcus aureus (MRSA)

We compared the health outcomes in patients treated with linezolid or vancomycin for complicated skin and soft tissue infections (cSSTIs). This analysis is part of a randomised, open-label, multinational trial involving 1200 adult patients hospitalised with cSSTIs due to suspected or proven methicillin-resistant Staphylococcus aureus (MRSA). Subjects received linezolid 600 mg intravenous (i.v.) or oral, or vancomycin 1g i.v. every 12 h. A test-of-cure was assessed at 7 days post therapy. Compared with vancomycin, linezolid treatment was associated with significantly shorter length of stay (all P < 0.01), decreased i.v. antibiotic treatment duration (all P < 0.0001) and higher discharge rates (all P < 0.05). Thus, linezolid has the potential to reduce medical resource use for the treatment of cSSTIs.

Surgical resident supervision in the operating room and outcomes of care in Veterans Affairs hospitals

BACKGROUND

There has been concern that a reduced level of surgical resident supervision in the operating room (OR) is correlated with worse patient outcomes. Until September 2004, Veterans' Affairs (VA) hospitals entered in the surgical record level 3 supervision on every surgical case when the attending physician was available but not physically present in the OR or the OR suite. In this study, we assessed the impact of level 3 on risk-adjusted morbidity and mortality in the VA system.

METHODS

Surgical cases entered into the National Surgical Quality Improvement Program database between 1998 and 2004, from 99 VA teaching facilities, were included in a logistic regression analysis for each year. Level 3 versus all other levels of supervision were forced into the model, and patient characteristics then were selected stepwise to arrive at a final model. Confidence limits for the odds ratios were calculated by profile likelihood.

RESULTS

A total of 610,660 cases were available for analysis. Thirty-day mortality and morbidity rates were reported in 14,441 (2.36%) and 63,079 (10.33%) cases, respectively. Level 3 supervision decreased from 8.72% in 1998 to 2.69% in 2004. In the logistic regression analysis, the odds ratios for mortality for level 3 ranged from .72 to 1.03. Only in the year 2000 were the odds ratio for mortality statistically significant at the .05 level (odds ratio, .72; 95% confidence interval, .594-.858). For morbidity, the odds ratios for level 3 supervision ranged from .66 to 1.01, and all odds ratios except for the year 2004 were statistically significant.

CONCLUSIONS

Between 1998 and 2004, the level of resident supervision in the OR did not affect clinical outcomes adversely for surgical patients in the VA teaching hospitals.

Proficiency of surgeons in inguinal hernia repair: effect of experience and age

OBJECTIVES

We examined the influence of surgeon age and other factors on proficiency in laparoscopic or open hernia repair.

SUMMARY BACKGROUND DATA

In a multicenter, randomized trial comparing open and laparoscopic herniorrhaphies, conducted in Veterans Administration hospitals (CSP 456), we reported significant differences in recurrence rates (RR) for the laparoscopic procedure as a result of surgeons' experience. We have also reported significant differences in RR for the open procedure related to resident postgraduate year (PGY) level.

METHODS

We analyzed data from unilateral laparoscopic and open herniorrhaphies from CSP 456 (n = 1629). Surgeon's experience (experienced > or =250 procedures; inexperienced <250), surgeon's age, median PGY level of the participating resident, operation time, and hospital observed-to-expected (O/E) ratios for mortality were potential independent predictors of RR.

RESULTS

Age was dichotomized into older (> or =45 years) and younger (<45 years). Surgeon's inexperience and older age were significant predictors of recurrence in laparoscopic herniorrhaphy. The odds of recurrence for an inexperienced surgeon aged 45 years or older was 1.72 times that of a younger inexperienced surgeon. For open repairs, although surgeon's age and operation time appeared to be related to recurrence, only median PGY level of <3 was a significant independent predictor.

CONCLUSION

This analysis demonstrates that surgeon's age of 45 years and older, when combined with inexperience in laparoscopic inguinal herniorrhaphies, increases risk of recurrence. For open repairs, only a median PGY level of <3 was a significant risk factor.

Does resident hours reduction have an impact on surgical outcomes?

BACKGROUND

We assessed the impact of restricting surgical resident work hours as required by the Accreditation Council for Graduate Medical Education (ACGME), on postoperative outcomes.

MATERIALS AND METHODS

The divisions of General and Vascular Surgery at the Michael E. DeBakey Houston Veteran Affairs Medical Center implemented a limited work hours schedule effective October 1, 2002. We compared the rate of postoperative morbidity and mortality before and after the new schedule. Clinical data were collected by the VA National Surgical Quality Improvement Program (NSQIP) for the periods of October 1, 2001 to September 30, 2002 (preintervention), and October 1, 2002 to September 30, 2003 (postintervention). We assessed risk-adjusted observed to expected (O/E) ratios of mortality and prespecified postoperative morbidity for each study period.

RESULTS

In the preintervention period, there were 405 general surgery and 202 vascular surgery cases as compared to 382 and 208 cases, respectively in the postintervention period. There were no significant differences in mortality O/E ratios between the pre- and postintervention periods (0.63 versus 0.60 in general surgery; 0.78 versus 0.81 in vascular surgery; P = 0.90 and 0.94, respectively) or in morbidity O/E ratios (1.06 versus 1.27 in general surgery; 1.47 versus 1.50 in vascular surgery; P = 0.20 and 0.90, respectively).

CONCLUSION

The restricted resident work hour schedule in general and vascular surgery in our facility did not significantly affect postoperative outcomes.

Does resident post graduate year influence the outcomes of inguinal hernia repair?

INTRODUCTION

We evaluated the effect of the postgraduate medical education level (PGY) of surgery residents on recurrence of inguinal hernia, complications, and operative time.

METHODS

Post hoc analysis was performed on prospectively collected data from a multicenter Veterans Affairs (VA) cooperative study. Men were randomly assigned to open or laparoscopic inguinal hernia repairs with mesh. Surgery residents performed repairs with designated attending surgeons present throughout all procedures. PGY level of the resident was recorded for each procedure. All patients were followed for 2 years for hernia recurrence and complications. PGY levels were grouped as follows: group I = PGY 1 and 2; group II = PGY 3; group III = PGY >/= 4; rates of recurrence, complications and mean operative time were compared.

RESULTS

A total of 1983 patients underwent hernia repair. group III residents had significantly lower recurrence rates for open repairs when compared with group I (adjusted odds ratio = 0.24, 95% confidence interval [CI], 0.06, 0.997). The recurrence rate was similar among the groups for laparoscopic repair (P > 0.05) Complication rates were not different for either repair (P > 0.05). Mean operative time was significantly shorter for group III compared with group I for both open (-6.6 minutes; 95% CI, -11.7, -1.5) and laparoscopic repairs (-12.9 minutes; 95% CI, -19.8, -6.0) and between group II and group I for laparoscopic repair (-15.0; 95% CI, -24.3, -5.7).

CONCLUSIONS

Despite the presence of an attending surgeon, open hernia repairs performed by junior residents were associated with higher recurrence rates than those repaired by senior residents. Lower resident level was associated with increased operative time for both open and laparoscopic repair.

Does Surgeon Frustration and Satisfaction with the Operation Predict Outcomes of Open or Laparoscopic Inguinal Hernia Repair?

BACKGROUND

A surgeon's level of frustration when performing an operation and level of satisfaction at completion may be correlated with patients' outcomes. We evaluated the relationship between the attending surgeons' frustration and satisfaction and recurrence and complications of open and laparoscopic inguinal hernia repair.

STUDY DESIGN

Men with detectable inguinal hernias were randomized to undergo open or laparoscopic herniorrhaphy at 14 Veterans Affairs hospitals. After completion of the procedure, surgeons were asked to assess their level of frustration during the operation and their overall satisfaction with the operative result. Two subjective scales ranging from 1 (not frustrated/not satisfied) to 5 (very frustrated/very satisfied) were used to independently assess both parameters. Reasons for surgeon frustration were evaluated. Patients were followed for 2 years for recurrence and complications.

RESULTS

Of 1,983 patients who underwent hernia repair, 1,622 were available for analysis; 808 had open repair and 813 had laparoscopic repair. Surgeons reported less frustration and more satisfaction with open than with laparoscopic repair (p = 0.0001 and 0.0001, respectively). Frustration was associated with a higher rate of hernia recurrence at 2 years (adjusted odds ratio, 2.01, 95% CI, 1.15-3.51) in open repair, and a higher overall rate of postoperative complications (adjusted odds ratio, 1.27, 95% CI, 1.03-1.56) in both open and laparoscopic hernia repair. Satisfaction was not correlated with recurrence or complications.

CONCLUSIONS

The level of a surgeon's frustration during performance of an inguinal herniorrhaphy was a better predictor of outcomes of the operation than was satisfaction with the procedure. Sources of intraoperative frustration should be controlled to improve outcomes.

Repair of ventral incisional hernia: the design of a randomized trial to compare open and laparoscopic surgical techniques

The appearance of incisional hernia after laparotomy closure continues to be an important postoperative complication. Advances in anesthesia techniques, adequate prevention and treatment of infection during surgery, and the use of new suture materials have reduced the incidence of incisional hernia. Nevertheless, incisional hernia still occurs in 0.5% to 11% of all laparotomies performed. There are many different techniques currently in use for ventral incisional hernia (VIH) repair. Among these techniques, laparoscopic repair has been reported to be superior to open repair because of less pain, a lower recurrence rate, fewer complications, and earlier return to work. The lower rate of complications may be a major contributing factor to a reduced incidence of recurrence. However, laparoscopic repair requires expensive equipment and supplies, and it is not yet generally accepted. No conclusive randomized trial of sufficient size and power has been done to establish the "gold standard" for VIH repair, and surgeons are calling for proper evaluation. This randomized clinical trial conducted at 3 Veterans Affairs medical centers was designed to compare open VIH repair with the laparoscopic technique with respect to postoperative complications at 8 weeks, health-related quality of life, postoperative pain, time to return to normal activities, patient satisfaction, and recurrence rate of the hernia at 1 and 2 years. The study design calls for randomization of 314 men over a period of 32 months. This will allow > or =80% power to detect a 15% difference in complication rates between the 2 surgical procedures at 8 weeks. Randomization is stratified by hospital, whether the hernia is recurrent and whether the patient's body mass index is > or =35 or <35. We report the design and beginning of a multicenter trial comparing open and laparoscopic VIH repair. When completed, this study will provide surgeons and their patients with information that will help guide their choice of surgical technique.

Linezolid eradicates MRSA better than vancomycin from surgical-site infections

BACKGROUND

The purpose of this analysis was to compare the efficacy of linezolid versus vancomycin in patients with suspected or proven gram-positive methicillin-resistant Staphylococcus aureus (MRSA) surgical-site infections.

METHODS

An open-label, randomized, comparator-controlled, multicenter, multinational study was conducted in hospitalized patients. Patients were randomized 1:1 to receive linezolid 600 mg (intravenous [IV] or oral) every 12 hours (n = 66) or vancomycin 1 g every 12 hours IV (n = 69) for 7 to 21 days. Patients were assessed at the test-of-cure (TOC) visit, 7 days after completing therapy.

RESULTS

Clinical success at TOC was documented in similar proportions of patients treated with linezolid or vancomycin. Of those with MRSA isolated, significantly more patients who received linezolid compared with those who received vancomycin were microbiologically cured (87% vs 48%, respectively; 95% confidence interval 16.51 to 60.27; P = 0.0022).

CONCLUSION

Intravenous or oral linezolid was well tolerated and superior to vancomycin in treating patients with MRSA-infected surgical-site infections.

Thirty-day and one-year predictors of death in noncardiac major surgical procedures

BACKGROUND

We evaluated the predictive value of the American College of Cardiology/American Heart Association (ACC/AHA) cardiac risk classification, as well as other potential risk factors (procedure risk, smoking, obesity, hyperlipidemia, and renal insufficiency), on all-cause mortality at 30 days and at 1 year postoperatively.

METHODS

In the year 2000, 1238 consecutive patients undergoing general anesthesia for various noncardiac surgical procedures at the Houston Veterans Affairs Medical Center were screened preoperatively and classified according to the ACC/AHA guidelines. Patients' charts were reviewed for the above-mentioned risk factors.

RESULTS

A logistic regression analysis demonstrated that older age and higher procedure risk were associated with higher 30-day mortalities (P = 0.0012 and 0.0441, respectively). The ACC/AHA classification was positively correlated with mortality at 1 year (P = 0.0071).

CONCLUSIONS

The ACC/AHA classification predicts mortality at 1 year but not at 30 days for major noncardiac surgeries; procedure-related risk is a better predictor of 30-day postoperative mortality in our patient population.

Use of a predictive equation for diagnosis of acute gangrenous cholecystitis

BACKGROUND

Factors previously identified by multivariate logistic regression that were predictive for gangrenous cholecystitis (GC) were used to develop a predictive equation. Our objective was to evaluate the sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values of this equation for detecting GC in patients with acute cholecystitis (AC).

METHODS

Medical records of patients who presented to a tertiary care hospital with AC were reviewed. Twenty-one patient and clinical variables were recorded. We prospectively tested the results of the following equation against pathologic diagnosis: P=e((0.7116+0.9944.DM+1.7157.WBC-1.0319.ALT.2.0518.ALP+2.7078.PCF))/(1+e([-0.7116+0.9944.DM+1.7157.WBC-1.0319.ALT-2.0518.ALP+2.7078.PCF])), where P = predicted value; DM = diabetes mellitus; WBC = white blood cell count; ALT = alanine aminotransferase; AST = aspartate aminotransferase; and PCF = pericholecystic fluid.

RESULTS

Ninety-eight patients presented with AC and 18% had GC (18 of 98). Using a cutoff of P = 0.724, our equation had a specificity of 93%, sensitivity of 83%, PPV of 71%, and NPV of 96%, P <0.001 for the detection of GC.

CONCLUSIONS

Our study demonstrates the equation may be useful in detecting the subset of AC patients who have GC.

Physician leadership is a new mandate in surgical training

BACKGROUND

Traditionally, development of physician leadership has occurred at random in surgical training. One possible reason is that surgical educators have focused on detailed instruction on critical patient situations, resuscitation, and technical skills, but they have provided little formal training in the essential leadership skills.

METHODS

To determine resident perceptions about the importance of these skills and individual strengths and weaknesses in these areas, a questionnaire was administered to 43 residents in our general surgery program. In part one of the questionnaire, the residents ranked 18 leadership skills on a scale of 1 to 4 in importance ("not important," "minimally important," "somewhat important," and "very important") for career development. The second portion of the questionnaire asked the residents to rate themselves on a similar scale with regard to their personal confidence and competence in these same areas.

RESULTS

Twenty-three residents (53%) completed the entire questionnaire. The majority of the residents (92%) rated all 18 leadership skills "somewhat" or "very important" for career development. More than 50% of the residents rated themselves as not competent or minimally competent in 10 of the 18 areas. Ethics was the only area in which >75% of the residents believed themselves to be more than minimally competent. There were no significant differences between postgraduate training levels in any of the parameters calculated.

CONCLUSIONS

We conclude that although residents see these nontraditional topics as an important part of their professional education, they do not necessarily feel confident or competent in these areas. Establishing a conscious effort to teach these topics and to emphasize their importance during training will enhance residents' self-image, performance, and potential as future leaders.

Perioperative beta-blockade: a survey of physician attitudes in the department of veterans Affairs

OBJECTIVE

To delineate clinician opinion on the efficacy, safety, and logistics of perioperative beta-adrenergic blockade for patients undergoing noncardiac surgery.

DESIGN

Survey of opinions and clinical practices.

SETTING

Internet-based survey form.

PARTICIPANTS

Members of the Associations of Veterans Affairs Anesthesiologists and Surgeons and chiefs of cardiology in centers with surgical programs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One hundred twenty-seven responses from 62 Veterans Affairs Medical Centers in 35 states (57 anesthesiologists, 45 surgeons, 25 cardiologists) were analyzed. Ninety-two percent agreed that it is effective in reducing short-term adverse outcomes, declining to 60% for long-term outcome. There was greater enthusiasm for its use in patients with known coronary artery disease (87%) than in patients with risk factors only (72%). Although 66% considered it efficacious in vascular surgery, only 30% were convinced it was for nonvascular surgery (with a similar distribution for safety in these settings). Preoperative use was favored (94%), with most physicians favoring use within 1 week of surgery (52%). Most favored 1 to 2 weeks of postoperative therapy (43%), with the remainder favoring shorter (19%) or longer (35%) durations. Although 71% of clinicians reported frequent use in their practice, most believed its use was largely informal by their colleagues (83%) and rarely based on a formal clinical pathway (13%).

CONCLUSION

A wide range of opinions by clinicians regarding the efficacy, safety, and logistics of perioperative beta-adrenergic blockade was encountered, suggesting need for additional clinical research and centralized efforts at increasing compliance with existing guidelines.

Prognostic factors for the development of gangrenous cholecystitis

BACKGROUND

The operative morbidity and mortality for patients with gangrenous cholecystitis (GC) remains high. Our objective was to identify preoperative prognostic factors for GC in order to distinguish this subset of patients with acute cholecystitis (AC).

METHODS

From 1/98 to 11/01 the medical records of patients who presented with the diagnosis of AC were reviewed. Univariate and multivariate analysis were performed on this retrospective data.

RESULTS

Of 113 patients with acute cholecystitis, 45 (39.8%) had histologically confirmed gangrenous cholecystitis. Nine variables were identified that were associated with GC by univariate analysis: age > or =51 years, African-American race, white blood cell count > or =15,000, diabetes, pericholecystic fluid, asparate aminotransferase, alanine aminotransferase, alkaline phosphatase, and lipase. Two variables were identified by multivariate analysis: diabetes, and white blood cell count.

CONCLUSIONS

Our data suggest that patients with a history of diabetes and white blood cell count >15,000 to be at an increased risk for having GC upon presentation and they should have urgent surgical intervention.