Search

Background: Frailty is a state of decreased physiologic reserve contributing to functional decline and is associated with adverse surgical outcomes, particularly in the elderly. Racial disparities have been reported previously both in frail individuals and in limb-salvage patients. Our goal was to assess whether race and ethnicity are disproportionately linked to frailty status in geriatric patients undergoing lower-limb amputation, leading to an increased risk of complications., Methods: A 3-year analysis was conducted of the National Surgical Quality Improvement Program database and included all geriatric (age ≥65 years) patients who underwent amputation of the lower limb. The frailty index was calculated using the 11-factor modified frailty index with a cutoff limit of 0.27 defined for frail status. Outcomes were 30-day complications, mortality, and readmissions. Multivariate regression analysis was performed., Results: A total of 4,218 geriatric patients underwent surgical amputation of a lower extremity (above knee: 41%; below knee: 59%). Of these patients, 29% were frail, 26% were African American, and 9% were Hispanic. Being African American (odds ratio: 1.6 [1.3-1.9]) and Hispanic (odds ratio: 1.1 [1.05-2.5]) was independently associated with frail status. Frail African Americans had a higher likelihood of 30-day complications (odds ratio: 3.2 [1.9-4.4]) and 30-day readmissions (odds ratio: 2.9 [1.8-3.6]) when compared with nonfrail individuals. Similarly, frail Hispanics had higher 30-day complications (odds ratio: 2.6 [1.9-3.1]) and 30-day readmissions (odds ratio: 1.4 [1.1-2.7]) compared with nonfrail Hispanics/Latinos., Conclusion: African American and Hispanic geriatric patients undergoing lower-limb amputation are at increased risk for frailty status and, as a result, increased associated operative complications. These disparities exist regardless of age, sex, comorbid conditions, and location of amputation. Further studies are needed to highlight disparities by race and ethnicity to identify potentially modifiable risk factors, decrease frailty, and improve outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Failure to rescue (FTR) is becoming a ubiquitous metric of quality care. The aim of our study is to determine the type and number of complications associated with FTR after trauma., Methods: We reviewed the Trauma Quality Improvement Program including patients who developed complications after admission. Patients were divided as the following: "FTR" if the patient died or "rescued" if the patient did not die. Logistic regression was used to ascertain the effect of the type and number of complications on FTR., Results: A total of 25,754 patients were included with 972 identified as FTR. Logistic regression identified sepsis (odds ratio [OR] = 6.61 [4.72-9.27]), pneumonia (OR = 2.79 [2.15-3.64]), acute respiratory distress syndrome (OR = 4.6 [3.17-6.69]), and cardiovascular complications (OR = 24.22 [19.39-30.26]) as predictors of FTR. The odds ratio of FTR increased by 8.8 for every single increase in the number of complications., Conclusions: Specific types of complications increase the odds of FTR. The overall complication burden will also increase the odds of FTR linearly., Level of Evidence: Level III Prognostic., (Copyright © 2020. Published by Elsevier Inc.)

Background: Cognitive impairment (CI) is common in geriatric patients. We aimed to evaluate the prevalence and impact of CI on outcomes in geriatric patients undergoing emergency general surgery (EGS)., Methods: We performed a (2017-2018) prospective analysis of patients (age ≥65y) who underwent EGS. Cognition was assessed using the Montreal Cognitive Assessment (MoCA). Patients were stratified into: CI (MoCA score<26) and no-CI (MoCA≥26). Outcomes were the prevalence of CI, in-hospital complications, discharged to rehab/skilled nursing facility (SNF), and mortality., Results: A total of 142 patients were enrolled. Overall prevalence of CI was 20%. Patients with CI had higher rates of complications (OR 1.6 [1.4-1.9]; p = 0.01), and discharge to rehab/SNF (OR 2.2 [2.0-2.5]; p = 0.03). There was no difference in mortality (OR 1.1 [0.6-1.8]; p = 0.24) between the 2 groups., Conclusion: One in five geriatric EGS patients has CI. It is associated with higher complications and adverse discharge. Cognitive assessment should be included in preoperative risk stratification., Competing Interests: Declaration of competing interest There are no identifiable conflicts of interest to report., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The prevalence of delirium and its impact on outcomes after emergency general surgery (EGS) remain unexplored. The aims of our study were to assess the impact of frailty on delirium and the impact of delirium on outcomes in geriatric EGS patients., Study Design: We performed a 1-year (2017) prospective cohort analysis of all geriatric (age ≥ 65 years) patients who underwent EGS. Frailty was calculated using the Emergency General Surgery-Specific Frailty Index (ESFI). Delirium was assessed using the Confusion Assessment Method (CAM). Patients were dichotomized as delirious or non-delirious. We performed regression analysis controlling for demographics, admission vitals, American Society of Anesthesiologists (ASA) score, comorbidity, and the diagnosis and type of surgery., Results: A total of 163 patients underwent emergency general surgery and were included. Mean age was 71 ± 7 years, and 59% were male. Overall, the incidence of postoperative delirium was 26%. Patients who developed postoperative delirium were more likely to be frail (40% vs 14%, p < 0.01), on more than 3 medications (29% vs 18%, p < 0.01), and were more likely to have 3 or more comorbidities (32% vs 21%, p < 0.01). On regression analysis, frail status (odds ratio [OR] 3.7 [2.4-4.2], p < 0.01) and receiving more than 3 medications (OR 1.3 [range 1.1-1.4], p < 0.01) were independent predictors of developing postoperative delirium. An episode of delirium was associated with longer hospital length of stay (LOS) (6 days vs 3 days, p < 0.01), higher odds of ICU admission (OR 2 [1.3-4.5], p < 0.01), longer ICU LOS (2 days vs 1 day, p < 0.01), and higher odds of unplanned intubation (OR 1.8 [1.2-3.4], p < 0.01)., Conclusions: The incidence of delirium after EGS was 26%. Frailty and polypharmacy were associated with increased risk of delirium. Delirium appears to be associated with higher rates of in-hospital adverse events., (Copyright © 2020 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Metabolic syndrome (MS) is defined as the cluster: hypertension, obesity, and diabetes. Operative diverticulitis in the setting of MS can be challenging to manage. The aim of our study was to evaluate the impact of MS on outcomes in operative acute diverticulitis patients., Methods: We analyzed the (2012-2015) NSQIP database. We identified acute diverticulitis patients who underwent surgery. MS was defined as follows: body mass index (BMI) >30 kg/m 2 , hypertension, and diabetes. Our primary outcome measure was the occurrence of any adverse events (complications, 30-d readmission, and mortality). Secondary outcome measures were complications, hospital length of stay, 30-d readmission, and mortality. Regression and receiver operating characteristic curve analysis was performed., Results: A total of 4572 patients were identified. Mean BMI was 29 ± 10 kg/m 2 . 14.6% (275) of obese patients had metabolic syndrome. Adverse events were higher in patients with MS (odds ratio [OR], 8.1; P < 0.001) versus the obese group and the obese and hypertensive group. Patients with MS had higher odds of reintubation (OR 1.9; P = 0.03), >48 h ventilator dependence (OR 3.5; P = 0.01), myocardial infarction (OR 2.3; P = 0.03), and superficial or deep surgical-site infections (OR 2.1; P = 0.01) compared with patients with no MS. MS patients had a longer length of stay (β = 1.23; P = 0.02), higher 30-d readmissions (OR 1.7; P < 0.01), and mortality (OR 2.1; P < 0.01). The area under the receiver operating characteristic curve of metabolic syndrome for predicting adverse outcomes was 0.797, which was higher than the area under the receiver operating characteristic curve for BMI (0.58), hypertension (0.51), or diabetes (0.64) alone., Conclusions: Adverse events in patients with MS after surgery for diverticulitis are higher than obesity, hypertension, or diabetes alone. Patients with MS have longer recovery, and higher rates of complications, readmissions, and mortality., Level of Evidence: Level III Prognostic., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: We evaluated the association between operating room time and developing a deep vein thrombosis (DVT) or pulmonary embolus (PE) after emergency general surgery (EGS)., Methods: We reviewed six common EGS procedures in the 2013-2015 NSQIP dataset. After tabulating their incidence of postoperative VTE events, we calculated predictors of developing a VTE using adjusted multivariate logistic regressions., Results: Of 108,954 EGS patients, 1,366 patients (1.3%) developed a VTE postoperatively. The median time to diagnosis was 9 days [5-16] for DVTs and 8 days [5-16] for PEs. Operating room time of 100 min or more was associated with increased risk of developing a DVT (OR 1.30 [1.12-2.21]) and PE (OR:1.25 [1.11-2.43]) with a 7% and 5% respective increase for every 10 min increase after the 100 min. Other independent predictors of VTE complications were older age, and history of cancer, and emergent colectomies on procedure-level analysis., Conclusion: Prolonged operating room time is independently associated with increased risk of developing VTE complications after an EGS procedure. Most of the VTE complications were delayed in presentation., (Copyright © 2019. Published by Elsevier Inc.)

Essentials Operative spine trauma patients are at increased risk of venous thromboembolism (VTE). Direct oral anticoagulants (DOACs) may have a favorable efficacy and safety in spine trauma. Patients on DOACs had lower rates of VTE in comparison to low molecular weight heparin. DOACs did not augment the risk of surgical bleeding (transfusion, decompressive procedures)., Background: Spinal trauma patients are at high risk for venous thromboembolism (VTE)., Objective: To compare the impacts of direct oral anticoagulants (DOACs) and low molecular weight heparin (LMWH) as thromboprophylactic agents on outcomes in operative spinal trauma patients., Methods: A 2-year (2015-2016) retrospective cohort analysis of such patients (spine Abbreviated Injury Scale [AIS] ≥ 3 and other AIS < 3) who received LMWH or DOACs was performed. Propensity score matching (1:2 ratio) followed stratification into two groups. Outcomes included rates of deep vein thrombosis (DVT) and/or pulmonary embolism (PE), packed red blood cell (pRBC) transfusion, operative interventions for spinal cord decompression, and mortality., Results: Of 6036 patients, 810 (270 receiving DOACs; 540 receiving LMWH) were matched. The mean age was 62 ± 15 years, 58% were male, and the median Injury Severity Score was 12 (10-18). Matched groups were similar in demographics, injury parameters, emergency department vital signs, hospital stay, rates of inferior vena cava filter placement, and timing of initiation of thromboprophylaxis. The overall rate of in-hospital DVT was 5.6%, the overall rate of in-hospital PE was 1.6%, and the mortality rate was 2.5%. DOAC patients were less likely to develop DVT (1.8% vs 7.4%) and PE (0.3% vs 2.1%). There were no differences in postprophylaxis pRBC transfusion requirements, postprophylaxis decompressive procedures on the spinal cord, or mortality., Conclusion: In operative spinal trauma patients, thromboprophylaxis with DOACs appears to be associated with lower rates of DVT and PE. Further prospective clinical trials should evaluate the role of DOACs in preventing VTE events in spinal trauma patients., (© 2019 International Society on Thrombosis and Haemostasis.)

Background: Failure to rescue (FTR) is an important measure of quality of care. The aim of this study was to assess FTR in patients with colon cancer (CC) who underwent surgical resection. We hypothesized that patient managed in urban centers had lower FTR., Methods: We performed a 1-y (2011) retrospective analysis of the National Inpatient Sample database and identified all patients with CC who underwent surgical management. Patients were stratified based on the location of treatment: urban versus rural. Outcome measure was FTR, which was defined as death after major complications. Regression analysis was performed to evaluate the independent predictors of FTR., Results: A total of 49,789 patients with CC who underwent surgery were analyzed. The mean age was 71 ± 20.2 y and 59% were males. About 21.5% patients developed in-hospital complications. The overall rates of complications, mortality, and FTR were 21.5%, 3.0%, and 33.8% respectively. Patient managed in rural centers had higher FTR compared with urban centers (39.5% versus 30.1%, P = 0.01). On regression analysis after controlling for age, gender, type of procedure, Charlson Comorbidity Index, and insurance status, management in rural center was independently associated with FTR (odds ratio: 1.9 [1.4-3.7]). On subanalysis of urban centers, management in teaching urban hospital was independently associated with higher FTR (odds ratio: 1.4 [1.2-3.8])., Conclusions: Disparities exist among centers managing patients with CC undergoing surgical intervention. Rural centers have higher FTR compared with similar cohort of patients managed in urban centers. Teaching urban hospital performed worse than nonteaching urban centers. Understanding the reason for these differences may help standardize care across centers and help improve patient outcomes., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The aim of our study was to evaluate outcomes in patients who are admitted on weekend compared with those admitted on a weekday for acute gallstone pancreatitis., Methods: We performed a 3-y (2010-2012) analysis of the Nationwide Inpatient Sample database. Patients with acute gallstone pancreatitis who underwent endoscopic retrograde cholangiopancreatography (ERCP) were included and were divided into two groups: admission on the weekend versus the weekday. Primary outcome measures were time to ERCP, adverse events, and mortality. Secondary outcome measures were hospital length of stay and total cost., Results: A total of 5803 patients with acute gallstone pancreatitis who underwent ERCP were included in our study; of which 22.6% were admitted on the weekend, whereas 77.4% were admitted on a weekday. Mean age was 57 ± 18 y and 57.1% were female. Within 24 h, the rate of ERCP was higher in patients admitted on the weekday compared with those admitted on the weekend (40% versus 24%; P < 0.001). Similarly, by 48 h, the rate of ERCP was higher in the weekday group (69% versus 49%, P < 0.001). Patients admitted over the weekends had higher complications rate (P = 0.03), hospital length of stay (P < 0.001), and the total cost of hospitalization (P < 0.001) compared with the weekday group with no difference in in-hospital mortality., Conclusions: Patients admitted on weekends for acute gallstone pancreatitis experience a delay in getting ERCP and have higher complications, prolonged hospital stay, and increased hospital costs compared with those admitted on weekdays., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: Assessing outcomes in patients with colon cancer (CC) undergoing surgical intervention is challenging. Frailty has been as established tool for assessing patient outcomes. The aim was of this study was to assess role of frailty in patients with CC., Methods: National estimates for patients with CC were abstracted from the National Inpatient Sample (NIS) database (2011). Frailty was calculated using a 11 variable CCFI. Patient was stratified as frail (FL) (mFI≥0.25) and non-frail (Non-FL). Outcome measures were: in-hospital complications, hospital and intensive care unit (ICU) length of stay (LOS), discharge disposition, and mortality. Regression analysis was performed., Results: A total of 53,652 patients with CC who underwent surgery were analyzed. The mean age was 69 ± 19 years with 62% males and mean CCFI being 0.13. 34% of patients were frail. 22.3% patients had in-hospital complications and mortality rate was 3.2%. Frail patients were more likely to have in-hospital complications (p = 0.001), longer hospital LOS (p = 0.001), more likely to be discharged to a facility (p = 0.001). On regression analysis after controlling for age, gender, type of procedure, hospital status, insurance status, frail status was independently associated with in-hospital complications (OR[95% CI]: 1.8[1.1-2.9], p = 0.035) and adverse discharge disposition (OR[95% CI]: 1.3[1.08-3.5], p = 0.043)., Conclusion: Frailty status is an independent predictor of adverse outcomes (complications, discharge disposition, and LOS) in CC patient undergoing surgical intervention. Age was not independently associated with outcome and had poor correlation with frailty status. Pre-operative assessment of frailty in CC patient may help early identifications and risk stratification to help improve outcomes and discharge planning., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Patients with spinal trauma are at high risk for venous thromboembolic events (VTE). Guidelines recommend prophylactic anticoagulation but they are unclear on timing of initiation of thromboprophylaxis. The aim of our study was to assess the impact of early versus late initiation of venous thromboprophylaxis in patients with spinal trauma who underwent operative intervention., Methods: We performed a 2-year (2013-2014) review of patients with isolated spine trauma (spine-Abbreviated Injury Scale score, ≥ 3 and no other injury in another body region with Abbreviated Injury Scale score, > 2) who underwent operative intervention and received thromboprophylaxis postoperatively. Patients were divided into two groups based on the timing of initiation of thromboprophylaxis: early(<48 hours) and late(≥48 hours), and were matched in a 1:1 ratio using propensity score matching for demographics, admission vitals, injury parameters, type of operative intervention, hospital course, and type of prophylaxis(low molecular weight heparin vs. unfractionated heparin). Outcomes were rates of deep vein thrombosis (DVT) and/or pulmonary embolism, red-cell transfusions, the rate of operative interventions for spinal cord decompression and mortality after initiation of thromboprophylaxis., Results: Nine thousand five hundred eighty-five patients underwent operative intervention and received anticoagulants, of which 3554 patients (early, 1,772; late, 1,772) were matched. Matched groups were similar in demographics, injury parameters, emergency department vitals, hospital length of stay, rates of inferior vena cava (IVC) filter placement and time to operative procedure. Patients who received thromboprophylaxis within 48 hours of operative intervention, unlike those who did not, were less likely to develop DVT (2.1% vs. 10.8%, p < 0. 01). However, the rate of pulmonary embolism was similar in both groups (p = 0.75). Additionally, there was no difference in postprophylaxis red cell transfusion requirements (p = 0.61), rate of postprophylaxis decompressive procedure on the spinal cord (p = 0.27), and mortality (p = 0.53)., Conclusion: Early VTE prophylaxis is associated with decreased rates of DVT in patients with operative spinal trauma without increasing the risk of bleeding and mortality. The VTE prophylaxis should be initiated within 48 hours of surgery to reduce the risk of DVT in this high-risk patient population., Level of Evidence: Therapeutic studies, level IV.