A Review of Factors that Affect Mortality Following Colectomy

Surgical resection for second primary colorectal cancer: a population-based study

Background

Second primary colorectal cancer (CRC) is attributed to a crucial component of the CRC population. Still, its treatments remain unclear due to the troublesome conditions originating from multiple primary cancers and the lack of quality evidence. This study aimed to determine that which type of surgical resection is the eligible treatment for second primary CRC among patients with a prior cancer history.

Methods

This cohort study retrospectively collected patients with second primary stage 0-III CRC in the Surveillance, Epidemiology, and End Results database from 2000 to 2017. Prevalence of surgical resection in second primary CRC, overall survival (OS) and disease-specific survival (DSS) of patients who received different surgical interventions were estimated.

Results

A total of 38,669 patients with second primary CRC were identified. Most of the patients (93.2%) underwent surgical resection as initial treatment. Approximately 39.2% of the second primary CRCs (N = 15,139) were removed with segmental resection, while 54.0% (N = 20,884) were removed through radical colectomy/proctectomy. Surgical resection was associated with a significantly favorable OS and DSS compared to those not receiving any surgical operations for second primary CRC [OS: adjusted Hazard ratios (adjusted HR): 0.35; 95% CI: 0.34-0.37, p < 0.001; DSS: adjusted HR: 0.27; 95% CI: 0.25-0.29, p < 0.001]. Segmental resection considerably outperformed radical resection in terms of OS and DSS (OS: adjusted HR: 0.97; 95% CI: 0.91-1.00, p = 0.07; DSS: adjusted HR: 0.92; 95% CI: 0.87-0.97, p = 0.002). Segmental resection was also associated with a significantly reduced cumulative mortality of postoperative non-cancer comorbidities.

Conclusion

Surgical resection demonstrated excellent oncological superiority for second primary CRC and was used to remove the vast majority of second primary CRCs. In comparison to radical resection, segmental resection offered a better prognosis and reduced postoperative non-cancer complications. The second primary colorectal cancers should be resected if the patients can afford surgical operations.

Emergency Colectomies in the Elderly Population—Perioperative Mortality Risk-Factors and Long-Term Outcomes

Background: As the population ages emergency surgeries among the elderly population, including colonic resections, is also increasing. Data regarding the short- and long-term outcomes in this population is scarce. Methods: A retrospective study was performed to investigate mortality and mortality risk factors associated with emergent colectomies in older compared to younger patients in a single university affiliated tertiary hospital. Patients with metastatic disease, colectomy due to trauma or index colectomy within 30 days prior to emergent surgery were excluded. Results: Operative outcomes compared among age groups, included 30-day mortality, mortality risk-factors and long-term survival. 613 eligible patients were included in the cohort. Mean age was 69.4 years, 45.1% were female. Patients were divided into four age groups: 18–59, 60–69, 70–79 and ≥80-years. Thirty-day mortality rates were 3.2%, 11%, 29.3% and 37.8%, respectively and 22% for the entire cohort. Risk-factors for perioperative death in the younger group were related to severity of ASA score and WBC count. In groups 60–69, 70–79, main risk-factors were ADL dependency and ASA score. In the ≥80 group, risk-factors affecting perioperative mortality, included ASA score, pre-operative albumin, creatinine, WBC levels, cancer etiology, ADL dependency, and dementia. Long-term survival differed significantly between age groups. Conclusion: Perioperative mortality with emergency colectomy increases with patients’ age. Patients older than eighty-years undergoing urgent colectomies have extremely high mortality rates, leading to a huge burden on medical services. Evaluating risk-factors for mortality and pre-operative discussion with patients and families is important. Screening the elderly population for colonic pathologies can result in early diagnosis potentially leading to elective surgeries with decreased mortality.

Surgical outcomes and prognostic factors associated with emergency left colonic surgery

BACKGROUND

Mortality from emergency left-sided colorectal surgery can be substantial due to acuteness of the presentation and the urgent need to operate in the setting of a limited preparation in a morbid patient.

OBJECTIVES

Determine the 30-day postoperative outcomes and identify risk factors for complications and mortality following emergency colorectal operations.

DESIGN

Retrospective SETTINGS: Three tertiary hospitals in three countries.

PATIENTS AND METHODS

Factors that were studied included age, sex, ASA score, type and extent of the operation, and presence/absence of malignancy. Unadjusted 30-day patient outcomes examined were complications and mortality. Differences in proportions were assessed using the Pearson chi-square test while logistic regression analyses were carried out to evaluate the correlation between risk factors and outcomes.

MAIN OUTCOME MEASURES

30-day postoperative morbidity and mortality SAMPLE SIZE: 104 patients.

RESULTS

Among 104 patients, 70 (67.3%) were men, and 34 (32.7%) were women. The mean (SD) age was 57.2 (17.1) years. The most common indication for emergency colonic surgery was malignant obstruction in 33 (31.7%) patients. The postoperative complication rate was 24% (25/104), and the mortality rate was 12.5% (13/104) within 30 days of the operation. The ASA status (P=.02), presence of malignancy (P=.02), and the presence of complications (P=.004) were significantly related to mortality in the multivariable logistic regression analysis.

CONCLUSIONS

The 30-day mortality of emergency colorectal operations is greatly influenced by the presence of malignancy in the colon and physiological status at the time of the procedure.

LIMITATIONS

The retrospective design and small sample size.

CONFLICT OF INTEREST

None.

The factors that affect the mortality of emergency operated ASA 3 colon cancer patients

Introduction

colorectal cancers take third place among cancer-related deaths and 10-28% of these patients are admitted with the necessity of emergency surgical intervention. The main propose of this study was to investigate the factors affecting mortality in ASA 3 colorectal cancer patients who undergo emergency surgery.

Methods

between 2010 and 2017 ASA 3 patients who underwent emergency colon cancer surgery were included in the study. All of the study group was evaluated within the first 30-day time-frame. The results were obtained by a statistical comparison of the data of patients with and without mortality.

Results

one hundred and twenty eight patients included in the study. There was no statistical difference in the demographic data of the groups and the indications of the operation. The differences and durations of surgery also did not make any statistical difference. The complication rate was the same according to the Clavien-Dindo classification.

Conclusion

despite the screening programs applied in colorectal cancers, applications to emergency services and procedures performed under emergency conditions are still at high levels. Surgical operations, which have to be performed in patients with impaired metabolic status, carry major risks for patients, but their outcomes are also satisfactory for them.

Health care disparity exists among those undergoing emergent hernia repairs in New York State

INTRODUCTION

Socioeconomic factors predispose certain populations to an increased exposure to emergent operative procedures. The aim of this study is to evaluate the role socioeconomic factors play in emergent repairs of inguinal, ventral and umbilical hernias.

METHODS

The SPARCS database was used to identify all patients undergoing emergent ventral hernia repair (EVR), emergent inguinal hernia repair (EIR), and emergent umbilical hernia repair (EUR) between 2008 and 2015. Chi-square test with exact p values from Monte Carlo simulation determined marginal associations between repairs (elective vs. emergent), and patient characteristics and comorbidities. Multivariable logistic regression models were further utilized to examine socioeconomic disparity.

RESULTS

107,887 ventral hernias, 66,947 inguinal hernias, and 63,515 umbilical hernias (total 238,349) were noted. African Americans were most likely to undergo an EVR compared to Caucasians (OR 1.55, 95% CI: 1.48-1.61), Asians (OR 1.31, 95% CI: 1.15-1.5), and Hispanics (OR 1.3, 95% CI: 1.23-1.37). African Americans were most likely to undergo EIR compared to Caucasians (OR 2.2, 95% CI: 2.06-2.36), Asians (OR 1.74, 95% CI: 1.49-2.02), and Hispanics (OR 1.22, 95% CI: 1.12-1.34). African Americans were most likely to undergo EUR compared to whites (OR 1.29, 95% CI: 1.22-1.36), Asians (26.62%, OR 1.21, 95% CI: 1.01-1.46) and Hispanic (28.03%, OR 1.08, 95% CI: 1.01-1.16). Medicaid patients were also more likely to undergo EVR (OR 1.31, OR 1.73), EIR (OR 2.92, OR 4.55) and EUR (OR 1.63, OR 2.31) compared to Medicare and commercial insurance.

CONCLUSION

Race is a contributing factor in who undergoes an emergent hernia repair in New York State. A significantly larger proportion of the African American population is undergoing hernia repair in the emergent setting. Socioeconomic status, as indicated by the significant number of Medicaid patients undergoing emergent hernia repairs, also plays a role.

Reduction in Cardiac Arrhythmias Within an Enhanced Recovery After Surgery Program in Colorectal Surgery

BACKGROUND

Enhanced recovery after surgery (ERAS) is a multimodal perioperative care pathway designed to achieve early recovery by preserving preoperative organ function and minimizing the stress response following surgery. Few studies have assessed the association between ERAS and postoperative cardiac complications. The goal of this study is to evaluate the impact of ERAS on postoperative cardiac complications.

MATERIALS AND METHODS

A retrospective review of a prospectively maintained database of colorectal patients who underwent surgery at a tertiary colorectal cancer referral center was carried out. Preoperative, intraoperative, and postoperative factors including demographics, comorbidities, medications, and fluid administration were recorded. The primary outcome was postoperative cardiac arrhythmia, and secondary outcomes included other postoperative complications.

RESULTS

A total of 800 patients who underwent elective colorectal surgery were identified. Four hundred seventeen patients (52%) were in the control group and 383 patients (48%) were in the ERAS group. Patients in both groups were similar with regard to demographics and clinical characteristics. There were significantly higher rates of cardiac arrhythmia in the control group (5.3%) compared with the ERAS group (1.8%), p = 0.009. Multivariable analysis revealed that ERAS was an independent predictor of decreased postoperative cardiac arrhythmia (OR 0.30, 95%CI 0.17-0.55, p < 0.001) while older age was an independent predictor of increased postoperative cardiac arrhythmia (OR 1.08, 95%CI 1.02-1.13, p = 0.008). Patients receiving lower amounts of intravenous fluids had significantly decreased postoperative cardiac arrhythmia (OR = 0.25, 95%CI 0.09-0.67, p = 0.006).

CONCLUSIONS

ERAS and goal-directed fluid therapy are associated with significant reductions in postoperative cardiac arrhythmias.

Achieving the High-Value Colectomy: Preventing Complications or Improving Efficiency

BACKGROUND

There is increased focus on the value of surgical care. Postoperative complications decrease value, but it is unknown whether high-value hospitals spend less than low-value hospitals in cases without complications. Previous studies have not evaluated both expenditures and validated outcomes in the same patients, limiting the understanding of interactions between clinical performance, efficient utilization of services, and costliness of surgical episodes.

OBJECTIVE

This study aimed to identify payment differences between low- and high-value hospitals in colectomy cases without adverse outcomes using a linked data set of multipayer claims and validated clinical outcomes.

DESIGN

This is a retrospective observational cohort study. We assigned each hospital a value score (ratio of cases without adverse outcome to mean episode payment). We stratified hospitals into tertiles by value and used analysis of variance tests to compare payments between low- and high-value hospitals, first for all cases, and then cases without adverse outcome.

SETTING

January 2012 to December 2016, this investigation used clinical registry data from 56 hospitals participating in the Michigan Surgical Quality Collaborative, linked with 30-day episode payments from the Michigan Value Collaborative.

PATIENTS

A total of 2947 patients undergoing elective colectomy were selected.

MAIN OUTCOME MEASURES

The primary outcome measured was risk-adjusted, price-standardized 30-day episode payments.

RESULTS

The mean adjusted complication rate was 31% (±10.7%) at low-value hospitals and 14% (±4.6%) at high-value hospitals (p < 0.001). Low-value hospitals were paid $3807 (17%) more than high-value hospitals ($22,271 vs $18,464, p < 0.001). Among cases without adverse outcome, payments were still $2257 (11%) higher in low-value hospitals ($19,424 vs $17,167, p = 0.04).

LIMITATIONS

This study focused on outcomes and did not consider processes of care as drivers of value.

CONCLUSIONS

In elective colectomy, high-value hospitals achieve lower episode payments than low-value hospitals for cases without adverse outcome, indicating mechanisms for increasing value beyond reducing complications. Worthwhile targets to optimize value in elective colectomy may include enhanced recovery protocols or other interventions that increase efficiency in all phases of care. See Video Abstract at http://links.lww.com/DCR/B56. LOGRANDO LA COLECTOMÍA DE ALTO VALOR: PREVINIENDO COMPLICACIONES O MEJORANDO LA EFICIENCIA: Hay un mayor enfoque en el valor de la atención quirúrgica. Las complicaciones postoperatorias disminuyen el valor, pero se desconoce si en los casos sin complicaciones, los hospitales de alto valor gastan menos que los hospitales de bajo valor. Estudios anteriores no han evaluado ambos gastos y validado resultados en los mismos pacientes, limitando la comprensión de las interacciones entre el rendimiento clínico, utilización eficiente de los servicios y costos de los episodios quirúrgicos.Identificar las diferencias de pago entre los hospitales de alto y bajo valor, en casos de colectomía sin resultados adversos, utilizando un conjunto de datos vinculados de reclamos de pago múltiple y resultados clínicos validados.Estudio de cohorte observacional retrospectivo. Asignamos a cada hospital una puntuación de valor (proporción de casos sin resultado adverso al pago medio del episodio). Estratificamos los hospitales por valor en terciles y utilizamos el análisis de pruebas de varianza para comparar los pagos entre hospitales de bajo y alto valor, primero para todos los casos y luego casos sin resultados adversos.De enero del 2012 a diciembre del 2016, utilizando datos de registro clínico de 56 hospitales que participan en el Michigan Surgical Quality Collaborative, vinculado con pagos de episodios de 30 días, del Michigan Value Collaborative.Un total de 2947 pacientes con colectomía electiva.Pagos por episodio de 30 días, ajustados al riesgo y estandarizados por precio.La tasa media de complicación ajustada fue de 31% (±10.7%) en hospitales de bajo valor y 14% (±4.6%) en hospitales de alto valor (p < 0.001). A los hospitales de bajo valor se les pagó $3807 (17%) más que a los hospitales de alto valor ($22,271 frente a $18,464, p < 0.001). Entre los casos sin resultados adversos, los pagos fueron de $2257 (11%) más altos en hospitales de bajo valor ($19,424 vs $17,167, p = 0.04).Este estudio se centró en los resultados y no se consideraron a los procesos de atención, como impulsores de valor.En la colectomía electiva, los hospitales de alto valor logran pagos de episodios más bajos, que en los hospitales de bajo valor con casos sin resultados adversos, indicando mecanismos para aumentar el valor, más allá que la reducción de complicaciones. Objetivos valiosos para optimizar el valor de la colectomía electiva, pueden incluir mejoras en los protocolos de recuperación, así como otras intervenciones que aumenten la eficiencia en todas las fases de la atención. Vea el resumen del video en http://links.lww.com/DCR/B56.

Disparities in Emergent Colectomy for Colorectal Cancer Contribute to Inequalities in Postoperative Morbidity and Mortality in The US Health Care System

BACKGROUND AND AIMS

Colorectal cancer is the third most common cancer among both men and women in the United States. We aimed to determine racial and socioeconomic disparities in emergent colectomy rates for colorectal cancer in the US Health Care system.

MATERIAL AND METHODS

We performed a retrospective analysis of the National Inpatient Sample including adult patients (⩾18 years) diagnosed with colorectal cancer, and who underwent colorectal resection while admitted between 2008 and 2015. Multivariable logistic and linear regression were used to assess the association between emergent admissions, compared to elective admissions, and postoperative outcomes.

RESULTS

A total of 141,641 hospitalizations were included: 93,775 (66%) were elective admissions and 47,866 (34%) were emergent admissions. Black patients were more likely to undergo emergent colectomy, compared to white patients (42% vs 32%, p < 0.0001). Medicaid and Medicare patients were also more likely to have an emergent colectomy, compared to private insurance (47% and 36% vs 25%, respectively, p < 0.0001), as were patients with low household income, compared to highest (38% vs 31%, p < 0.0001). Emergent procedures were less likely to be laparoscopic (19% vs 38%, p < 0.0001). Patients undergoing emergent colectomy were significantly more likely to have postoperative venous thromboembolism, wound complications, infection, bleeding, cardiac failure, renal failure, respiratory failure, shock, and inpatient mortality.

CONCLUSION

There are significant racial and socioeconomic disparities in emergent colectomy rates for colorectal cancer. Efforts to reduce this disparity in colorectal cancer surgery patients should be prioritized to improve outcomes.

Efficacy of proximal colectomy for surgical management of right-sided first colorectal cancer in Lynch Syndrome mutation carriers

BACKGROUND

This study analyzes the occurrence of colorectal cancer (CRC) in Lynch syndrome (LS) mutation carriers, interval until diagnosis of metachronous CRC, and survival after proximal colectomy (PC) compared with total (TC) and subtotal colectomy (STC) for right-sided first CRC in LS mutation carriers.

METHODS

Sixty-four LS mutation carriers with right-sided first CRC treated with PC or TC + STC were confirmed by clinical records. Bivariate analyses were examined for significance and life tables were generated for risk of metachronous CRC and survival estimates following surgery.

RESULTS

One of 16 (6.3%) mutation carriers treated with TC + STC developed subsequent CRC compared with 13/48 (27%) treated by PC. There was no significant difference in survival estimates between PC compared with TC + STC through 25 years after surgery.

CONCLUSION

Risk of subsequent CRC and survival estimates following PC and TC + STC should be considered in surgical management of right-sided first CRC in LS mutation carriers.

Emergent Colectomy Is Independently Associated with Decreased Long-Term Overall Survival in Colon Cancer Patients

BACKGROUND

The purpose of this study was to examine the long-term overall survival (OS) of colon cancer patients who underwent emergent resection versus patients who were resected electively.

METHODS

The 2006-2012 National Cancer Data Base was queried for colon cancer patients who underwent surgical resection. Emergent resection was defined as resection within 24 h of diagnosis. A mixed-effects logistic regression was used to estimate the effect of emergent resection on 30- and 90-day mortality. A propensity score-matched mixed-effects Cox proportional-hazards model was used to estimate the effect of emergent resection on 5-year OS.

RESULTS

Two hundred fourteen thousand one hundred seventy-four patients met inclusion criteria, 30% of the cohort had an emergent resection. After controlling for patient and hospital factors, pathological stage, lymph node yield, margin status, and adjuvant chemotherapy, emergent resection was associated with increased odds of 30-day mortality (OR = 1.69, 95% CI = 1.60, 1.78) and hazard of death at 5 years (HR = 1.13, 95% CI = 1.09, 1.15) compared to elective resections.

CONCLUSION

Emergent resection for colon cancer is independently associated with poor short-term outcomes and decreased 5-year OS compared to elective resection. With 30% of cases in this study emergent, these findings underlie the importance of adherence to colon cancer screening guidelines to limit the need for emergent resections.

Reviewing the Management of Obstructive Left Colon Cancer: Assessing the Feasibility of the One-stage Resection and Anastomosis After Intraoperative Colonic Irrigation

BACKGROUND

The management of obstructive left colon cancer (OLCC) remains debatable with the single-stage procedure of primary colonic anastomosis after cancer resection and on-table intracolonic lavage now being supported.

PATIENTS AND METHODS

Patients with acute OLCC who were admitted between January 2008 and January 2015 were distributed into 5 different groups. Group ICI underwent emergency laparotomy for primary anastomosis following colonic resection and intraoperative colonic lavage; Group HP underwent emergency Hartmann's Procedure; Group CON consisted of patients treated by conservative management with subsequent elective open cancer resection; Group COL were colostomy patients; and Group INT consisted of patients who had interventional radiology followed by open elective colon cancer resection. The demographics of the patients and comorbidity, intraoperative data, and postoperative data were collected, with P < .05 as significant.

RESULTS

There were 4 deaths in 138 cases (2.90%). There was only 1 patient who had anastomotic leakage (5.56%) in Group ICI, compared with none in Group HP and Group COL, 1 case in Group INT (7.69%), and 2 cases in Group CON (6.06%) (P > .05). Group INT and Group CON, when compared to the three surgical groups, Groups ICI, Group COL, and Group HP, individually, were statistically significant for the duration of surgery (P < .05).

CONCLUSIONS

Primary anastomosis following colonic resection after irrigation can be safely performed in selected patients, with the necessary surgical expertise, with no increased risk in mortality, anastomotic leakage, and other postoperative complications.

Emergency right colectomy: which strategy when primary anastomosis is not feasible?

Background

Primary anastomosis is considered the standard strategy after right emergency colectomy. The present study aimed to evaluate alternative treatment strategies when primary anastomosis is not possible to prevent definitive ostomy.

Methods

This retrospective study included all consecutive patients who underwent right emergency colectomy between July 2006 and June 2013. Demographics, surgical data, and postoperative outcomes were entered in an anonymized database. Comparative analysis was performed between patients with primary anastomosis (PA group) and those where alternative strategies were employed (no-PA group). Outcomes were 30 days complications rate and rate of bowel continuity restoration.

Results

One hundred forty-eight patients (57 % male) with a median age of 65 years (15–96) were included. One hundred and sixteen patients underwent PA (78 %) and 32 were in the no-PA group (22 %). No-PA group patients had more comorbidities (Carlson comorbidity index >3: 98 % vs. 54, p < 0.001). Major complications rate (Dindo-Clavien III to IV) was 24 % in PA group, 88 % in no-PA group (p < 0.001). The 30-day mortality rate was 6 % (n = 7) in PA group versus 25 % (n = 8) in no-PA group (p = 0.004). Fourteen patients in the no-PA group had a split stoma and 18 had a two-staged procedure. Five patients had continuity restoration after initial split stoma (36 %) compared to 10 after a two-staged procedure (55 %; p = 0.265). Anastomotic leak occurred in 10 patients of the PA group (9 %) versus 0 in the no-PA group, where 15 out of 32 patients (47 %) had continuity restoration.

Conclusion

Eighty percent of patients requiring emergency right colectomy were anastomosed primarily. For the remaining a two-staged procedure might facilitate bowel continuity restoration in the long-term.

An evaluation of treatment results of emergency versus elective surgery in colorectal cancer patients

OBJECTIVE

Colorectal cancer is still one of the most common causes of cancer related deaths in the world despite improvements in diagnosis and treatment modalities, and application of community-based screening methods. Symptoms of colorectal cancer are non-specific and usually manifest following local progression. A number of patients with advanced stage colorectal cancer present to emergency departments with obstruction as the first sign of disease without any previous symptoms. This presentation is an indication for emergency surgery that has a high rate of morbidity and mortality. In this study, we aimed to determine the factors associated with early diagnosis and survival by comparing postoperative results of colorectal cancer patients who underwent surgery under emergency or elective situation.

MATERIAL AND METHODS

Files of colorectal patients treated between 2009-2013 were retrospectively analyzed. Data on patient age, gender, operation type, intraoperative results, length of hospital stay, co-morbidities, postoperative complications and pathological results were evaluated and compared.

RESULTS

There was no statistical difference between groups in terms of age, gender, and pathology results (p>0.05). The difference between groups in terms of postoperative length of hospital stay, presence of co-morbid diseases, pathological stage, and postoperative complications was statistically significant (p<0.05). Length of hospital stay, advanced stage on admission, complications such as surgical site infection, evisceration, and anastomosis leakage rates were higher in patients in the emergency surgery group.

CONCLUSION

Risk groups should be determined in order to diagnose colorectal cancer patients at an early stage while they are still asymptomatic, and this information should be incorporated into effective screening programs. This approach will be beneficial to treatment outcomes, complication rates, length of hospital stay, and survival and treatment results.

A meta-analysis of the predictive accuracy of postoperative mortality using the American Society of Anesthesiologists' physical status classification system

BACKGROUND

The American Society of Anesthesiologists' physical status (ASA) tool has been applied to determine compensation, risk adjustment and risk prediction, but little is known about the accuracy and generalizability of this tool for prediction of postoperative mortality.

METHODS

We systematically investigated prior published reports of associations between ASA physical status and mortality to test the hypothesis that ASA physical status will have varying accuracy in prediction of postoperative mortality across surgical populations with varying surgical risk of mortality. We used random effects models and metaregression to account for heterogeneity.

RESULTS

Combining 77 studies with 165,705 patients, the ASA physical status tool demonstrated the following pooled performance (95 % confidence intervals)--sensitivity 0.74 (0.73, 0.74), specificity 0.67 (0.67, 0.67), and area under summary receiver operating curve 0.736 (0.725, 0.747). Metaregression revealed that study death rates and surgical specialty were significant factors.

CONCLUSION

ASA physical status is a better predictor of postoperative mortality in settings with lower rather than higher death rates.

Worse outcomes among uninsured general surgery patients: does the need for an emergency operation explain these disparities?

BACKGROUND

We hypothesize that lack of access to care results in propensity toward emergent operative management and may be an important factor in worse outcomes for the uninsured population. The objective of this study is to investigate a possible link to worse outcomes in patients without insurance who undergo an emergent operation.

METHODS

A retrospective cross-sectional analysis was performed using the Nationwide Inpatient Sample (NIS) 2005-2011 dataset. Patients who underwent biliary, hernia, and colorectal operations were evaluated. Multivariate analyses were performed to assess the associations between insurance status, urgency of operation, and outcome. Covariates of age, sex, race, and comorbidities were controlled.

RESULTS

The uninsured group had greatest odds ratios of undergoing emergent operative management in biliary (OR 2.43), colorectal (3.54), and hernia (3.95) operations, P < .001. Emergent operation was most likely in the 25- to 34-year age bracket, black and Hispanic patients, men, and patients with at least one comorbidity. Postoperative complications in emergencies, however, were appreciated most frequently in the populations with government coverage.

CONCLUSION

Although the uninsured more frequently underwent emergent operations, patients with coverage through the government had more complications in most categories investigated. Young patients also carried significant risk of emergent operations with increased complication rates. Patients with government insurance tended toward worse outcomes, suggesting disparity for programs such as Medicaid. Disparity related to payor status implies need for policy revisions for equivalent health care access.

Does relative value unit-based compensation shortchange the acute care surgeon?

BACKGROUND

Studies have demonstrated that relative value units (RVUs) do not appropriately reflect cognitive effort or time spent in patient care, but RVU continues to be used as a standardized system to track productivity. It is unknown how well RVU reflects the effort of acute care surgeons. Our objective was to determine if RVUs adequately reflect increased surgeon effort required to treat emergent versus elective patients receiving similar procedures.

METHODS

A retrospective analysis using The American College of Surgeons' National Surgical Quality Improvement Program 2011 data set was conducted. The control group consisted of patients undergoing elective colectomy, hernia repair, or biliary procedures as identified by Current Procedural Terminology. Comparison was made to emergent cases after being stratified to laparoscopic or open technique. Generalized linear models and logistic regression were used to assess specific outcomes, controlling for demographics and comorbidities of interest. The RVUs, operative time, and length of stay (LOS) were primary variables, with major/minor complications, mortality, and readmissions being evaluated as the relevant outcomes.

RESULTS

A total of 442,149 patients in the National Surgical Quality Improvement Program underwent one of the operative procedures of interest; 27,636 biliary (91% laparoscopic; 8.5% open), 28,722 colorectal (40.3% laparoscopic, 59.7% open), and 31,090 hernia (26.6% laparoscopic, 73.4% open) operations. Emergent procedures were found to have average RVU values that were identical to their elective case counterparts. Complication rates were higher and LOS were increased in emergent cases. Odds ratios for complications and readmissions in emergent cases were twice those of elective procedures. Mortality was skewed toward emergent cases.

CONCLUSION

Our data indicate that the emergent operative management for various procedures is similarly valued despite increased LOS, more complications, higher mortality risk, and subsequently increased physician attention. Our findings suggest that the RVU system for acute care surgeons may need to be reevaluated to better capture the additional work involved in emergent patient care.

Uncontrolled confounding in studies of screening effectiveness: an example of colonoscopy

OBJECTIVE

To estimate the expected magnitude of error produced by uncontrolled confounding from health behaviours in observational medical record-based studies evaluating effectiveness of screening colonoscopy.

METHODS

We used data from the prospective National Institutes of Health American Association of Retired Persons (NIH-AARP) Diet and Health Study to assess the impact of health behaviour related factors (lifestyle, education, and use of non-steroidal anti-inflammatory drugs [NSAID]) on the association between colonoscopy and colorectal cancer (CRC) mortality. We first examined the difference between adjusted and unadjusted results within the cohort data, and then estimated a broader range of likely confounding errors based on the Breslow-Day approach that uses prevalence of confounders among persons with and without exposure, and the rate ratio reflecting the association between these confounders and the outcome of interest. As dietary factors and habits are often inter-correlated, we combined these variables (physical activity, body mass index, waist-to-hip ratio, alcohol consumption, and intakes of red meat, processed meat, fibre, milk, and calcium) into a "healthy lifestyle score" (HLS).

RESULTS

The estimated error (a ratio of biased-to-true result) attributable to confounding by HLS was 0.959-0.997, indicating less than 5% departure from the true effect of colonoscopy on CRC mortality. The corresponding errors ranged from 0.970 to 0.996 for NSAID, and from 0.974 to 1.006 for education (all ≤3% difference). The results for other CRC screening tests were similar.

CONCLUSION

Health behaviour-related confounders, either alone or in combination, seem unlikely to strongly affect the association between colonoscopy and CRC mortality in observational studies of CRC screening.

Laparoscopic and open subtotal colectomies have similar short-term results

BACKGROUND

Laparoscopic subtotal colectomy (STC) is a complex procedure. It is possible that short-term benefits for segmental resections cannot be attributed to this complex procedure. This study aims to assess differences in short-term results for laparoscopic versus open STC during a 15-year single-institute experience.

METHODS

We reviewed consecutive patients undergoing laparoscopic or open elective or subacute STC from January 1997 to December 2012.

RESULTS

Fifty-six laparoscopic and 50 open STCs were performed. The operation time was significantly longer in the laparoscopic group, median 266 min (range 121-420 min), compared to 153 min (range 90-408 min) in the open group (p < 0.001). Median hospital stay showed no statistical difference, 14 days (range 1-129 days) in the laparoscopic and 13 days (range 1-85 days) in the open group. Between-group postoperative complications were not statistically different.

CONCLUSIONS

Laparoscopic STC has short-term results similar to the open procedure, except for a longer operation time. The laparoscopic approach for STC is therefore only advisable in selected patients combined with extensive preoperative counseling.

A practical mortality risk score for emergent colectomy

BACKGROUND

Critically ill patients requiring emergent colectomy have significant mortality risk.

OBJECTIVE

A national administrative database was used to compose a simple scoring scheme for predicting in-hospital mortality risk.

DESIGN

The 2007 to 2009 Nationwide Inpatient Sample was queried to identify patients requiring nonelective colectomy. Multivariable binary logistic regression analysis was used to identify predictors that increased mortality. Each predictor was given a point value, based on the corresponding logit, the sum of which constituted a risk score. The scoring system was tested by using k-partitions cross-validation.

SETTINGS

This study is based on database analysis.

PATIENTS

A total of 338,348 cases were identified. Mean age was 64, and 53% of the patients were women.

MAIN OUTCOME MEASURES

The primary outcomes measured were mortality and risk score development.

RESULTS

The overall mortality risk was 9%. Regression analysis identified the following risk factors and assigned points: acute renal failure (6), hemodialysis (6), age >65 (4), peripheral vascular disease (4), myocardial infarction (4), chronic obstructive pulmonary disease (2), cardiac arrhythmia (1), and congestive heart failure (1). The maximum score observed was 26 (of a possible 28), which corresponded to 100% mortality. Receiver operator characteristic analysis showed an area under the curve of 0.81.

LIMITATIONS

This study was limited because of its retrospective nature, and because it used database data with variability in coding among participating institutions.

CONCLUSIONS

With the use of a simple 8-variable scoring system, inpatient mortality estimates can be made for patients requiring emergent colectomy. When used judiciously, it can be used as a tool when counseling patients and family both before and after surgery.

Advanced age is an independent predictor for increased morbidity and mortality after emergent surgery for diverticulitis

BACKGROUND

The objectives of our study were to determine the association between age and postoperative outcomes after emergency surgery for diverticulitis and to identify risk factors for postoperative mortality among elderly patients.

METHODS

All patients from the American College of Surgeons National Surgical Quality Improvement Program 2005-2009 Participant User Files undergoing emergent surgery for diverticulitis were included. Multivariate logistic regression was used to determine the association between age and postoperative morbidity and mortality after adjustment for perioperative variables. A separate regression model was used to determine risk factors for postoperative mortality among elderly patients, with specific postoperative complications being included as potential predictors.

RESULTS

We included 2,264 patients for analysis, of whom 1,267 (56%) were <65 years old (nonelderly), 648 (28.6%) were 65-79 years old (elderly), and 349 (15.4%) were ≥80 years old (super-elderly). Advanced age was a significant predictor of 30-day postoperative mortality, and to a lesser extent postoperative morbidity. Among those patients ≥65 years old, super-elderly age classification remained a significant predictor of mortality after adjustment for the presence or absence of postoperative complications. Mortality among elderly and super-elderly patients was greatest in the setting of specific complications, such as septic shock, prolonged postoperative mechanical ventilation, and acute renal failure.

CONCLUSION

Advanced age is an independent risk factor for death after emergency surgery for diverticulitis, with mortality being greatest among elderly patients who experience certain postoperative complications. Prevention of these complications should form the cornerstone of initiatives designed to lower the mortality associated with emergency surgery in elderly patients.

Unplanned reoperations: is emergency surgery a risk factor? A cohort study

BACKGROUND

Unplanned reoperations have been proposed as a quality indicator in surgery but have not been studied extensively, especially concerning risk factors.

METHODS

This was a prospective cohort study in a third-level general surgery service. Data regarding patients operated on between July 2007 and February 2008 and followed up for 30 postoperative days were collected. Unplanned reoperations were the primary end point. The secondary end points were 30-d mortality and length of stay. A multivariate logistic regression analysis evaluated the hypothesis that patients operated on in emergency conditions had a greater chance of being reoperated on, after adjusting for relevant covariates.

RESULTS

There was a 5.9% cumulative incidence of unplanned reoperations. Patients operated on in emergency conditions had a 1.79 crude relative risk (RR) (95% confidence interval [CI], 1.15-2.78) of reoperation. Reoperated patients' RR of mortality was 8.94 (95% CI, 6.11-13.07). The mean postoperative hospital stay was 3d for patients who were not reoperated on and 19d for those who were reoperated on (P=0.00001). The logistic regression model gave a 2.83 odds ratio (95% CI, 1.65-4.87) for reoperation on emergency patients when adjusted for age, gender, body mass index, American Society of Anesthesiology classification, intraoperative inotropic use, and operation complexity.

CONCLUSIONS

Tertiary general surgery service patients had a significantly increased risk of being reoperated on if the initial surgery was an emergency surgery compared with elective surgery. Unplanned reoperations led to a significantly increased mortality risk and a longer postoperative hospital stay, which could be regarded as warning signs in the care of surgical patients.