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Tran Z, Lee J, Richardson S, Bakhtiyar SS, Shields L, Benharash P. Clinical and financial outcomes of transplant recipients following emergency general surgery operations. Surg Open Sci 2023; 13:41-47. [PMID: 37131533 PMCID: PMC10149279 DOI: 10.1016/j.sopen.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 04/08/2023] [Indexed: 05/04/2023] Open
Abstract
Introduction Due to immunosuppression and underlying comorbidities, transplant recipients represent a vulnerable population following emergency general surgery (EGS) operations. The present study sought to evaluate clinical and financial outcomes of transplant patients undergoing EGS. Methods The 2010-2020 Nationwide Readmissions Database was queried for adults (≥18 years) with non-elective EGS. Operations included bowel resection, perforated ulcer repair, cholecystectomy, appendectomy and lysis of adhesions. Patients were classified by transplant history (Non-transplant, Kidney/Pancreas, Liver, Heart/Lung). The primary outcome was in-hospital mortality while perioperative complications, resource utilization and readmissions were secondarily considered. Multivariable regression models evaluated the association of transplant status on outcomes. Entropy balancing was employed to obtain a weighted comparison to adjust for intergroup differences. Results Of 7,914,815 patients undergoing EGS, 25,278 (0.32 %) had prior transplantation. The incidence of transplant patients increased temporally (2010: 0.23 %, 2020: 0.36 %, p < 0.001) with Kidney/Pancreas comprising the largest proportion (63.5 %). Non-transplant more frequently underwent appendectomy and cholecystectomy while transplant patients more commonly received bowel resections. Following entropy balancing, Liver was associated with decreased odds of mortality (AOR: 0.67, 95 % CI: 0.54-0.83, Reference: Non-transplant). Incremental hospitalization duration was longer in Liver and Heart/Lung compared to Non-transplant. Odds of acute kidney injury, readmissions and costs were higher in all transplant types. Conclusion The incidence of transplant recipients undergoing EGS operations has increased. Liver was observed to have lower mortality compared to Non-transplant. Transplant recipient status, regardless of organ, was associated with greater resource utilization and non-elective readmissions. Multidisciplinary care coordination is warranted to mitigate outcomes in this high-risk population.
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Affiliation(s)
- Zachary Tran
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, CA, United States of America
- Department of Surgery, Loma Linda University Health, Loma Linda, CA, United States of America
| | - Jonathan Lee
- Department of Surgery, Loma Linda University Health, Loma Linda, CA, United States of America
| | - Shannon Richardson
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, CA, United States of America
| | - Syed Shahyan Bakhtiyar
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, CA, United States of America
| | - Lauren Shields
- Department of Surgery, Loma Linda University Health, Loma Linda, CA, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, CA, United States of America
- Corresponding author at: UCLA David Geffen School of Medicine, CHS 62-249, 10833 Le Conte Ave, Los Angeles, CA 90095, United States of America.
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Gomez D, Acuna SA, Joseph Kim S, Nantais J, Santiago R, Calzavara A, Saskin R, Baxter NN. Incidence and Mortality of Emergency General Surgery Conditions Among Solid Organ Transplant Recipients in Ontario, Canada: A Population-based Analysis. Transplantation 2023; 107:753-761. [PMID: 36117253 DOI: 10.1097/tp.0000000000004299] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Emergency general surgery (EGS) conditions and their outcomes are perceived to be disproportionately high among solid organ transplant recipients (SOTRs). However, this has not been adequately investigated at a population level. We characterized the incidence and mortality of EGS conditions among SOTRs compared with nontransplant patients. METHODS Data were collected through linked administrative population-based databases in Ontario, Canada. We included all adult SOTRs (kidney, liver, heart, and lung) who underwent transplantation between 2002 and 2017. We then identified posttransplantation emergency department visits for EGS conditions (appendicitis, cholecystitis, choledocolithiasis, perforated diverticulitis, incarcerated/strangulated hernias, small bowel obstruction, and perforated peptic ulcer). Age-, sex-, and year-standardized incidence rate ratios (SIRRs) were generated. Logistic regression models were used to evaluate association between transplantation status and 30 d mortality after adjusting for demographics, year, and comorbidities. RESULTS Ten thousand seventy-three SOTRs and 12 608 135 persons were analyzed. SOTRs developed 881 EGS conditions (non-SOTRs: 552 194 events). The incidence of all EGS conditions among SOTR was significantly higher compared with the nontransplant patients [SIRR 3.56 (95% confidence interval [CI] 3.32-3.82)], even among those with high Aggregated Diagnosis Groups scores ( > 10) [SIRR 2.76 (95% CI 2.53-3.00)]. SOTRs were 1.4 times more likely to die at 30 d [adjusted odds ratio 1.44 (95% CI 1.08-1.91)] after an EGS event compared with nontransplant patients, predominantly amongst lung transplant recipients [adjusted odds ratio 3.28 (95% CI 1.72-6.24)]. CONCLUSIONS The incidence of EGS conditions is significantly higher in SOTRs even after stratifying by comorbidity burden. This is of particular importance as SOTRs also have a higher likelihood of death after an EGS condition, especially lung transplant recipients.
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Affiliation(s)
- David Gomez
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Division of General Surgery, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, ON, Canada
| | - Sergio A Acuna
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - S Joseph Kim
- ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, ON, Canada
- Department of Medicine, University of Toronto and Kidney Transplant Program, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Jordan Nantais
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Robin Santiago
- Canadian Institute of Health Information, Ottawa, ON, Canada
| | | | | | - Nancy N Baxter
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- ICES, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, ON, Canada
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
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Huckaby LV, Dadashzadeh ER, Li S, Campwala I, Gabriel L, Sperry J, Handzel RM, Forsythe R, Brown J. Accuracy of Risk Estimation for Surgeons Versus Risk Calculators in Emergency General Surgery. J Surg Res 2022; 278:57-63. [PMID: 35594615 PMCID: PMC10024255 DOI: 10.1016/j.jss.2022.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 03/21/2022] [Accepted: 04/08/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Surgical risk calculators have expanded in both number and sophistication of their predictive approach. These calculators are gaining popularity as validated tools to help surgeons estimate mortality and complications following emergency general surgery (EGS). However, the accuracy of risk estimates generated by these calculators compared to risk estimation by practicing surgeons has not been explored. METHODS Acute care surgeons at a quaternary care center prospectively estimated 30-d mortality and complications for adult EGS patients (2019-2021). Surgeon predictions were compared to Predictive OpTimal Trees in Emergency Surgery Risk (POTTER) and NSQIP estimates. Observed-to-expected (O:E) ratios of median aggregate estimates were calculated. C-statistics for surgeon and calculator estimations were utilized to quantify predictive accuracy. RESULTS Among 150 patients (median 61 y, 45% male), 30-d mortality was 15% (n = 23). Observed rates of prolonged mechanical ventilation and acute renal failures were 30% and 10%, respectively. Overall, surgeon predictions were similar to risk calculator estimates for mortality (c-statistics 0.843 [surgeon] versus 0.848 [POTTER] and 0.815 [NSQIP]) and need for prolonged ventilation (c-statistics 0.801 versus 0.722 and 0.689, respectively). Surgeons tended to overestimate complication risks. Surgeon experience was not significantly associated with mortality prediction in an adjusted model. CONCLUSIONS Acute care surgeons at a quaternary care center predicted postoperative mortality and complications with similar discrimination when compared to surgical risk calculators. Surgeon expertise should be utilized in conjunction with risk calculators when counseling EGS patients regarding anticipated postoperative outcomes. Surgeons should be cognizant of patterns in overestimation or underestimation of complications.
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Affiliation(s)
- Lauren V Huckaby
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Shimena Li
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Insiyah Campwala
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Lucine Gabriel
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jason Sperry
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert M Handzel
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Raquel Forsythe
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Joshua Brown
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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