Anand Singla

Admission volume determines outcome for patients with acute pancreatitis

BACKGROUND & AIMS There is controversy over the optimal management strategy for patients with acute pancreatitis (AP). Studies have shown a hospital volume benefit for in-hospital mortality after surgery, and we examined whether a similar mortality benefit exists for patients admitted with AP. METHODS Using the Nationwide Inpatient Sample, discharge records for all adult admissions with a primary diagnosis of AP (n = 416,489) from 1998 to 2006 were examined. Hospitals were categorized based on number of patients with AP; the highest third were defined as high volume (HV, >or=118 cases/year) and the lower two thirds as low volume (LV, <118 cases/year). A matched cohort based on propensity scores (n = 43,108 in each group) eliminated all demographic differences to create a case-controlled analysis. Adjusted mortality was the primary outcome measure. RESULTS In-hospital mortality for patients with AP was 1.6%. Hospital admissions for AP increased over the study period (P < .0001). HV hospitals tended to be large (82%), urban (99%), academic centers (59%) that cared for patients with greater comorbidities (P < .001). Adjusted length of stay was lower at HV compared with LV hospitals (odds ratio, 0.86; 95% confidence interval, 0.82-0.90). After adjusting for patient and hospital factors, the mortality rate was significantly lower for patients treated at HV hospitals (hazard ratio, 0.74; 95% confidence interval, 0.67-0.83). CONCLUSIONS The rates of admissions for AP in the United States are increasing. At hospitals that admit the most patients with AP, patients had a shorter length of stay, lower hospital charges, and lower mortality rates than controls in this matched analysis.

Surgeon Volume Metrics in Laparoscopic Cholecystectomy

AimNumerous reports in the 1990s pointed to a learning curve for laparoscopic cholecystectomy (LC), critical in achieving excellent outcomes. As LC is now standard therapy for acute cholecystitis (AC), we aimed to determine if surgeon volume is still vital to patient outcomes.MethodsThe Nationwide Inpatient Sample was used to query 80,149 emergent/urgent cholecystectomies performed for AC from 1999 to 2005 in 12 states with available surgeon/hospital identifiers. Volume groups were determined based on thirds of number of cholecystectomies performed per year for AC; two groups were created [low volume (LV): ≤15/year; high volume (HV): >15/year]. Primary endpoints were the rate of open conversion, bile duct injury (BDI), in-hospital mortality, and prolonged length of stay (LOS). Propensity scores were used to create a matched cohort analysis. Logistic regression models were created to further assess the effect of surgeon volume on primary endpoints.ResultsThe number of cases performed by HV surgeons increased from 24% to 44% from 1999 to 2005. HV surgeons were more likely to perform LC, had fewer conversions, lower incidence of prolonged LOS, lower BDI, and lower in-hospital mortality. After matching the volume cohorts to create a case-controlled analysis, multivariate analysis confirmed that surgeon volume was an independent predictor of open conversion and prolonged LOS but not BDI and in-hospital mortality.ConclusionsIncreasing surgical volume remains associated with improved outcomes after surgery during emergent/urgent admission for AC with fewer open conversions and prolonged LOS. Our results suggest that referral to HV surgeons has improved outcomes after LC for AC.

Surgical management of acute cholecystitis at a tertiary care center in the modern era.

HYPOTHESIS The advent of laparoscopy has changed the paradigm of surgical training and care delivery for the treatment of patients with acute cholecystitis (AC). DESIGN Retrospective data collection and analysis. SETTING Hospital admissions with a primary diagnosis of AC at a tertiary care center from January 1, 2002, to January 1, 2007. PATIENTS During the study period, 923 patients were admitted with a primary diagnosis of AC. One hundred fourteen patients were excluded from the study because of missing data, medical management, incomplete operative notes or documents, or metastatic gastrointestinal cancer. MAIN OUTCOME MEASURES Patient demographics, preoperative morbidity, procedures (medical and surgical), and postoperative outcomes were statistically analyzed using chi(2) test, t test, and analysis of variance. RESULTS Eight hundred nine patients (87.6%) with a primary diagnosis of AC underwent surgery by 44 surgeons. Procedures included 663 laparoscopic cholecystectomies (LCs) (82.0%), 9 open cholecystectomies (1.1%), 51 conversions from LC to open cholecystectomy (6.3%), and 86 cholecystostomy tube placements (10.6%). During the study period, cholecystostomy tube placements increased, while open cholecystectomies and conversions from LC to open cholecystectomy decreased (P < .05). Laparoscopic cholecystectomy was associated with significantly better outcomes, including shorter postsurgical stay (2.2 vs 6.3 days for other modalities) and fewer complications (8.5% vs 17.0%). CONCLUSIONS Based on 5-year results from a tertiary care center, LC was performed with a low conversion rate to open surgery and was associated with decreased morbidity and mortality compared with other surgical modalities to treat AC. Our data confirm the benefits and widespread use of LC in the modern era, reflecting changes in the training paradigm and learning curve for laparoscopy.

Is the growth in laparoscopic surgery reproducible with more complex procedures

BACKGROUND Laparoscopic (LAP) surgery has experienced significant growth since the early 1990s and is now considered the standard of care for many procedures like cholecystectomy. Increased expertise, training, and technological advancements have allowed the development of more complex LAP procedures including the removal of solid organs. Unlike LAP cholecystectomy, it is unclear whether complex LAP procedures are being performed with the same growth today. METHODS Using the Nationwide Inpatient Sample (NIS) from 1998 to 2006, patients who underwent elective LAP or open colectomy (n = 220,839), gastrectomy (n = 17,289), splenectomy (n = 9,174), nephrectomy (n = 64,171), or adrenalectomy (n = 5,556) were identified. The Elixhauser index was used to adjust for patient comorbidities. To account for patient selection and referral bias, a matched analysis was performed using propensity scores. The main endpoints were adjusted for in-hospital mortality and prolonged length of stay (LOS). RESULTS Complex LAP procedures account for a small percentage of total elective procedures (colectomy, 3.8%; splenectomy, 8.8%; gastrectomy, 2.4%; nephrectomy, 7.0%; and adrenalectomy, 14.2%). These procedures have been performed primarily at urban (94%) and teaching (64%) centers. Although all LAP procedures trended up, the growth was greatest in LAP colectomy and nephrectomy (P < .001). In a case-controlled analysis, there was a mortality benefit only for LAP colectomy (hazard ratio [HR] = 0.53; 95% confidence interval [CI] = 0.34-0.82) when compared with their respective open procedures. All LAP procedures except gastrectomy had a lower prolonged LOS compared with their open counterparts. CONCLUSION Despite the significant benefits of complex LAP procedures as measured by LOS and in-hospital mortality, the growth of these operations has been slow unlike the rapid acceptance of LAP cholecystectomy. Future studies to identify the possible causes of this slow growth should consider current training paradigms, technical capabilities, economic disincentive, and surgical specialization.

National hospital volume in acute pancreatitis: analysis of the Nationwide Inpatient Sample 1998–2006

BACKGROUND The optimal management of acute pancreatitis remains controversial and current treatment protocols vary in degrees of medical and surgical management. Our group has previously shown in population-based studies that high-volume (HV) hospitals have lower rates of in-hospital mortality after pancreatectomy. We sought to examine if a similar mortality benefit exists for patients admitted with acute pancreatitis. METHODS Using the Nationwide Inpatient Sample (NIS), we examined discharge records for all adult admissions during 1998-2006 with a primary diagnosis of acute pancreatitis of any aetiology. Unique hospital identifiers were used to divide hospital volumes into equal thirds based on the number of admissions for acute pancreatitis per year (lowest tertile [low volume, LV] < or = 64 admissions/year; medium tertile [medium volume, MV] 65-117 admissions/year; highest tertile [high volume, HV] > or = 118 admissions/year). Covariates included patient demographics, hospital characteristics and patient co-morbidities using the Elixhauser index. Adjusted mortality represented the primary outcome measure and adjusted length of stay (LOS) and total charges were considered secondary measures. RESULTS There were 416,489 primary admissions for acute pancreatitis during the study period. In-hospital mortality for the cohort amounted to 1.6% (n = 6446). Hospital admissions for acute pancreatitis increased over the study period (P < 0.0001). High-volume hospitals tended to be large (82%), urban (99%) teaching (59%) centres (P < 0.0001), which cared for patients with more co-morbidities (35.9% of patients at HV hospitals vs. 29.1% at LV hospitals had at least three co-morbidities; P < 0.0001). Low-volume centres appeared more likely to perform pancreatic procedures than HV hospitals (odds ratio [OR] 1.50, 95% confidence interval [CI] 1.32-1.70). Patients at HV hospitals had a lower likelihood of a prolonged adjusted LOS compared with those at LV (OR 0.75, 95% CI 0.71-0.79) or MV (OR 0.82, 95% CI 0.79-0.85) hospitals. After adjusting for patient and hospital factors, there was an in-hospital mortality benefit associated with being treated at an HV centre (OR 0.70, 95% CI 0.63-0.77). The decision to operate on a given patient did not alter the mortality benefit of the HV hospital. CONCLUSIONS Rates of admissions for acute pancreatitis in the USA are increasing. High annual hospital volume of acute pancreatitis cases confers a shorter LOS, lower adjusted mortality and a lower likelihood of pancreatic procedure for patients admitted with acute pancreatitis. Although HV hospitals were less likely than MV or LV centres to perform pancreatic procedures, the role of surgery remains unclear. Further studies should examine other possible reasons for this mortality benefit, such as the availability of specialists, the quality of critical care facilities and the timing of operative intervention.

The Impact of Socioeconomic Status on Presentation and Treatment of Diverticular Disease

IntroductionDiverticular disease is a common medical problem, but it is unknown if lower socioeconomic status (SES) affects patient outcomes in diverticular disease.Material and methodsThe New York (NY) State Inpatient Database was used to query 8,117 cases of diverticular disease occurring in patients aged 65–85 in 2006. Race and SES were assessed by creating a composite score based on race, primary insurance payer, and median income bracket.ResultsPrimary outcomes were differences in disease presentation, use of elective surgery, complication rates when surgery was performed, and overall mortality and length of stay. Patients of lower SES were younger, more likely to be female, to have multiple co-morbid conditions, to present as emergent/urgent admissions, and to present with diverticulitis complicated by hemorrhage (p < 0.0001).DiscussionOverall, patients of low SES were less likely to receive surgical intervention, while rates of surgery were similar in elective cases. When surgery was performed, patients of lower SES had similar complication rates (25.4% vs. 20.2%, p = 0.06) and higher overall mortality (9.0% vs. 4.4%, p = 0.003).ConclusionPatients of low SES who are admitted with diverticular disease have an increased likelihood to present emergently, have worse disease on admission, and are less likely to receive surgery.

Surgery for Ulcerative Colitis Is Associated with a High Rate of Readmissions at 30 Days

Background:Currently, the predictors of readmission after colectomy specifically for ulcerative colitis (UC) are poorly investigated. We sought to determine the rates and predictors of 30-day readmissions after colectomy for UC. Methods:Patients undergoing total proctocolectomy and end ileostomy, abdominal colectomy with end ileostomy, proctocolectomy with ileoanal pouch anastomosis (IPAA) formation and diverting ileostomy, one stage IPAA, or abdominal colectomy with ileorectal anastomosis at a tertiary care center between January 2002 and January 2012 for UC were included. Patients were identified using ICD-9 code 556.x. Each record was manually reviewed. The electronic record system was reviewed for demographic information, medical histories, UC history, medications, and data regarding the admission and discharge. Charts were reviewed for readmissions within 30 days of surgery. Univariate and multivariate analyses were performed using Stata v.13. Results:Two hundred nine patients with UC underwent a colectomy. Forty-three percent had a proctocolectomy with IPAA and diverting ileostomy and 32% had abdominal colectomy with end ileostomy. Seventy-six percent of surgeries were due to failure of medical therapy and 68% of patients were electively admitted for surgery. Thirty-two percent (n = 67/209) of the cohort was unexpectedly readmitted within 30 days. In multivariate model, proctocolectomy with IPAA and diverting ileostomy (odds ratio [OR] = 2.11; 95% CI, 1.06–4.19; P = 0.033) was the only significant predictor of readmission. Hospital length of stay >7 days (OR = 1.82; 95% CI, 0.98–3.41; P = 0.060), presence of limited UC (OR = 2.10; 95% CI, 0.93–4.74; P = 0.074), and steroid before admission (OR = 1.69; 95% CI, 0.90–3.2; P = 0.100) trended toward significance. Conclusions:Surgery for UC is associated with a high rate of readmission. Further prospective studies are necessary to determine the means to reduce these readmissions.

Hospitalization for Complications of Cirrhosis: Does Volume Matter

IntroductionClose to 30,000 people die of cirrhosis in the USA each year. Previous studies have shown a survival advantage with high-volume (HV) hospitals for complex surgical procedures. We examined whether a volume benefit exists for hospitals dealing with specialized disorders like complications of cirrhosis.MethodsUsing the Nationwide Inpatient Sample, we identified all cases of cirrhosis-related complications (n = 217,948) from 1998 to 2006. Hospital volume was divided into tertile-based admissions for cirrhosis per year.ResultsThe primary outcome was in-hospital mortality, and secondary endpoints included length of stay (LOS) and hospital charges. The number of admissions for cirrhosis increased over time (p < 0.0001). HV centers were more likely to be large (86.8%) and teaching (81.5%) hospitals compared to lower volume centers. The average LOS and hospital charges were greater at the HV centers, but hospitalization at a HV center resulted in an adjusted mortality benefit (HR 0.88; 95% CI 0.83–0.92) compared to care at lower volume hospitals.ConclusionDespite increased LOS and hospital cost, a mortality benefit exists at HV centers. Future studies are necessary to determine other processes of care that may exist at HV centers that may account for this survival benefit.

Su1103 30 Day Readmissions Rate and Predictors of Readmission in Hospitalized Patients With Ulcerative Colitis

Background: 30 day readmission rates have been evaluated in many diseases and are a measure of quality of care. Currently the Affordable Care Act mandates the Centers for Medicare and Medicaid Services to penalize hospitals with high 30 day readmissions. To date, no study has systematically examined the rates or predictors of readmission in ulcerative colitis (UC). Our goal was to evaluate the overall 30 day rate of readmission and predictors of readmission in patients hospitalized with severe UC. Methods: A total of 720 admissions for severe UC were reviewed from January 2002 to January 2012 at a tertiary care medical center. Charts were reviewed to confirm the diagnosis of UC. Demographic information, admission and discharge date, past medical history, UC related history, medication history prior to admission, during admission, and on discharge, laboratory testing on admission, procedures and surgeries during admission were all assessed. All records were evaluated for readmission within 30 days of the initial hospitalization and the reason for readmission. Readmissions were further evaluated as to whether they were related to UC and if they were pre-planned. Univariate and multivariate analysis was performed using SAS v9.3. Variables with p value <0.1 were included inmultivariate analysis Results: See table 1 for demographics. 15% (109/720) of patients were readmitted within 30 days of their initial admission for a UC. Median length of stay (LOS) of this admit was 4 days. 38% (41/109) were readmitted for a recurrent UC flare or related symptoms, 45% (49/109) were related to UC surgery on the initial admission, 3% (3/109) were planned readmissions. 2% (2/109) of the readmitted patients died. An additional 26% (28/109) were readmitted a second time. The median LOS for this admission was 4 days. Surgery related issues accounted for 54% (15/28) of these readmissions; 18% (5/28) were planned readmissions. On univariate analysis extent of disease involving proctosigmoiditis, or left sided colitis, or extensive colitis, weekend discharge, abdominal x-ray during admission, CT abdomen/pelvis during admission, higher creatinine level on day of admission, use of systemic steroids prior to admission, and surgery during admission all had p values < 0.1. On multivariate analysis, systemic steroids prior to admission (P 0.049), surgery during hospitalization (P <0.005), CT abdomen/pelvis during hospitalization (P 0.012), and higher levels of creatinine on day of admission (P 0.0086) were all significant predictors of readmission (Table 2). Conclusion: UC has a high 30 day rate of readmission. Patients admitted on systemic steroids, have elevated creatinine on admission or undergo surgery during admission should be closely monitored to minimize readmissions. Future studies are necessary to validate predictors of readmission and ways to reduce readmission.

Hilar Malignant Strictures

When it comes to endoscopic management, a malignant stricture at the biliary confluence poses a significant challenge to the therapeutic endoscopist both diagnostically and therapeutically. The diagnostic goal is to determine malignant or benign etiology of a biliary stricture and to determine resectability. In addition to proper imaging of the biliary hilum with computed tomography (CT) and magnetic resonance (MR), endoscopic tissue acquisition is an extremely important component to determining the etiology of a biliary stricture, specifically to differentiate between malignant and benign process. Brushings for cytology, intraductal biopsies, and even endoluminal fine-needle aspiration can all be performed at the time of endoscopic retrograde cholangiography (ERC), while endoscopic ultrasound (EUS) offers additional opportunity for fine-needle aspiration. Peroral cholangioscopy is an emerging technique that can directly visualize a malignant hilar stricture and allow for directed biopsies. Therapeutically, the ultimate goal is palliative biliary drainage to relieve biliary obstruction. This can be accomplished endoscopically with the placement of plastic or metal biliary stents to drain the most obstructed lobe of the liver, with uncovered self-expanding metal stents (SEMS) being preferred. Photodynamic therapy and radiofrequency ablation are emerging endoscopic techniques that allow for localized destruction of tumor cells, potentially improving biliary drainage, quality of life, and survival in most patients, but require further randomized, controlled studies.