[Show abstract][Hide abstract]ABSTRACT: Laparoscopic colorectal resection (LC) is associated with known recovery benefits and earlier discharge when compared to open colorectal resection (OC). Whether earlier discharge leads to a paradoxical increase in readmission has not been well characterized. The aim of this study is to compare the risk of readmission after the two procedures in a large, nationally representative sample.
Patients who underwent colorectal resection in 2011 were identified from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. LC and OC patients were compared for patient factors, complications, and readmission rates. A multivariable analysis controlling for significant factors was performed to evaluate factors associated with readmission.
Of 30,428 patients who underwent colorectal resection, 40.2% underwent LC. Length of stay (LOS) after LC was shorter than after OC (5.7 vs. 9.7 days, p < 0.001). LC was associated with a significantly lower rate of surgical site infections (SSI), bleeding, reoperation, 30-day mortality, and complications. Risk of readmission was greater for patients undergoing proctectomy than colectomy (12.7 vs. 10.6 %, p < 0.001), but was lower after laparoscopic than open for both procedures after controlling for confounding factors. Obesity, DM, operating time ≥180 min, steroid use, and ASA class 3-5 were found to be associated with readmission.
Despite its technical complexity, LC can be performed without concerns for increased complications or readmission. The shorter length of stay and the lower risk of readmissions underline the true benefits of the laparoscopic approach for colorectal resection.
Article · Aug 2015 · International Journal of Colorectal Disease
[Show abstract][Hide abstract]ABSTRACT: Background
Previous models of support for premature sheep fetuses have consisted of cesarean delivery followed by catheterization of umbilical or central vessels and support with extracorporeal membrane oxygenation (ECMO). The limitations of these models have been insufficient blood flow, significant fetal edema, and hemorrhage related to anticoagulation.
We performed a gravid hysterectomy on 13 ewes between 135 and 145 days gestational age. The uterine vessels were cannulated bilaterally and circulatory support was provided via ECMO. Successful transition was defined as maintenance of fetal heart rate for 30 minutes after establishing full extracorporeal support. Circuit flow was titrated to maintain mixed venous oxygen saturation (SvO2) of 70–75%.
Seven experiments were successfully transitioned to ECMO, with an average survival time of 2 hours 9 minutes. The longest recorded time from cannulation to death was 6 hours 14 minutes. By delivering a circuit flow of up to 2120 ml/min, all but one of the transitioned uteri were maintained within the desired SvO2 range.
We report a novel animal model of fetal ECMO support that preserves the placenta, mitigates the effects of heparin, and allows for increased circuit flow compared to prior techniques. This approach may provide insight into a technique for future studies of fetal physiology.
[Show abstract][Hide abstract]ABSTRACT: To examine whether density of providers or health care facility factors have a significant effect on the rates of perforated appendicitis in the pediatric population.
A retrospective database analysis. Data were linked to the Area Resource File to determine if there was an association between perforated appendicitis and density of provider and facility factors.
The National Inpatient Sample database and the Kids' Inpatient Database from 1988 to 2005.
All patients included had an age at admission of younger than 18 years and were selected by International Classification of Diseases, Ninth Revision code as having perforated appendicitis (540.0 or 540.1) or acute appendicitis (540.9). Main Outcome Measure Odds ratio of perforated appendicitis to acute appendicitis by county-level density of provider and health care facility factors.
The odds ratio of perforated appendicitis to acute appendicitis when stratified by quartiles of increasing density of providers and facility-level factors was statistically significant only for the highest-density quartile of pediatricians (odds ratio = 0.88; 95% confidence interval = 0.78-0.99).
Increasing geographic density of pediatricians was associated with a decreasing trend in the odds ratio of perforated appendicitis, with a statistically significant protective effect observed in the highest-density quartile of pediatricians. The density of all other provider and health care facility factors analyzed did not demonstrate a significant association with the rates of perforated appendicitis.
Article · Dec 2010 · Archives of surgery (Chicago, Ill.: 1960)
[Show abstract][Hide abstract]ABSTRACT: The present study aimed to determine whether children with perforated appendicitis were more likely to present during specific days of the week or seasons of the year.
After obtaining IRB exemption, a retrospective, population-based study of patients <18 with ICD9 codes of acute (540.9) or perforated (540.0, 540.1) appendicitis in the Kids' Inpatient Database (KID) was performed. Univariate and multivariate analyses were performed analyzing patient and hospital factors.
A total of 31,457 children were identified with acute appendicitis, of whom 10,524 (33.5%) were perforated. Mondays [odds ratio (OR): 1.16; 95% Confidence Interval (CI): 1.05-1.28] were significant for increased likelihood as day of presentation with perforation in US children more than any other day of the week. In seasonal analysis, fall (OR: 1.12; 95% CI: 1.04-1.21) and winter (OR: 1.11; 95% CI: 1.03-1.20) were at higher odds for perforation at presentation. Patients with Medicaid (OR: 1.22; 95% CI: 1.03-1.43) and those uninsured (OR: 1.50; 95% CI: 1.16-1.93) were more likely to present with perforation.
Perforated appendicitis was more likely to present on Mondays in US children. Although appendicitis is most common in summer months, rates of perforated appendicitis were highest in fall and winter.
Article · Jul 2010 · Pediatric Surgery International
[Show abstract][Hide abstract]ABSTRACT: Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency of the neonate. Previous information about this disease has largely been gathered from limited series. We analyzed 13 years of the National Inpatient Sample (NIS) and 3 years of the Kids' Inpatient Database (KID; 1997, 2000, 2003) to generate the most comprehensive profile of outcomes to date of medically versus surgically treated NEC. We identified 20 822 infants with NEC, of whom 15,419 (74.1%) and 5403 (25.9%) were undergoing medical and surgical management, respectively. Overall, surgical patients had greater length of stay, total hospital charges, and mortality. Among infants dying during admission, there was no significant difference in length of stay or charges between the medical and surgical groups. These findings highlight the need for developing a clinically relevant risk stratification tool to identify NEC patients at high risk for death.
[Show abstract][Hide abstract]ABSTRACT: Mortality rates for eight surgical procedures have been endorsed by the Agency for Healthcare Research and Quality as part of the Inpatient Quality Indicators developed to assist hospitals in identifying potential problem areas and as an indirect measure of quality for inpatient adult surgical care. Little to no broad information relating to the overall mortality relating to the surgical care of children is available. An analysis providing national data on the most common procedures performed in children and their associated mortality would be useful in beginning to create benchmarks for standards of surgical care in the pediatric patient.
A total of 93 million admissions from the National Inpatient Sample (NIS) file from the years 1988-1996, 1998, 1999, 2001, 2002, 2004-2005 and the Kids Inpatient Database (KID) from 1997, 2000, 2003 were screened to identify surgical admissions in children under the age of 18 years. Variables such as gender, race, age at admission, length of hospital stay, total hospital charges, insurance status, and inpatient mortality were analyzed. Diagnosis related group (DRG) codes were used to provide inpatient mortality rates for 147 different procedures and 15 surgical subspecialties.
Over the 18-year period considered, a total of 2,087,915 surgical admissions in U.S. children were identified. Most of the patients were white (60.92%), male (54.64%), and were treated in urban, teaching hospitals (60.36%). Overall inpatient mortality was 0.85%, with a median hospital stay of 3 days. Procedures with the highest mortality were craniotomies for trauma (26.27%), liver and/or intestinal transplants (11.12%), heart transplants (10.94%), and other procedures for multiple significant trauma (10.69%). When analyzed by surgical subspecialty, gastrointestinal or general pediatric surgery saw the highest volume of patients, followed by orthopedic and ear, nose, and throat surgery (534,053 vs. 352,228 vs. 257,118 total procedures, respectively).
Pediatric surgical literature has classically focused on disease-based outcomes. However, such data do not provide a comprehensive profile of pediatric surgical outcomes by procedure or subspecialty. The present study provides nationwide data relating to inpatient pediatric surgical outcomes in U.S. hospitals by procedure and pediatric subspecialty.
[Show abstract][Hide abstract]ABSTRACT: Congenital diaphragmatic hernia (CDH) remains one of the most challenging conditions to treat within the pediatric surgical and medical communities. In spite of modern treatment modalities, including extracorporeal membrane oxygenation (ECMO) and improved ventilatory support, mortality remains high. The present study analyzes a US database containing information from nearly 93 million discharges in the US. Infants with congenital diaphragmatic hernia who underwent surgical repair were identified by ICD-9 procedure code and inclusion criteria including an age at admission of less than 1 year. Variables of gender, race, age, geographic region, co-existing diagnoses and procedures, hospital type, hospital charges adjusted to 2006 dollars, length of stay, and inpatient mortality were collected. A total of 89% of patients were either treated initially or rapidly transferred to urban teaching hospitals for definitive treatment of CDH. The inpatient mortality rate was 10.4% with a median length of stay of 20 days (interquartile range of 9-40 days). The median inflation-adjusted total hospital charge was $116,210. Respiratory distress was the most common co-existing condition (68.8%) followed by esophageal reflux (27.8%). The most common concomitant procedures performed were ECMO (17.8%) and fundoplication (17.6%). This study, which represents the largest characterization of US infants who have undergone CDH repair using data from a nationally representative non-voluntary database, demonstrates that surgical repair is associated with significant mortality and morbidity.
Article · Sep 2009 · Pediatric Surgery International