Ashar Ata

Postoperative hyperglycemia and surgical site infection in general surgery patients.

HYPOTHESIS Postoperative hyperglycemia is an independent risk factor for postoperative surgical site infection (SSI). DESIGN Retrospective medical record review. SETTING Academic tertiary referral center. PATIENTS A total of 2090 general and vascular surgery patients in an institutional quality improvement database between November 1, 2006, and April 30, 2009. MAIN OUTCOME MEASURE Postoperative SSI. RESULTS Postoperative glucose levels were available for 1561 patients (74.7.0%), of which 803 (51.4%) were obtained within 12 hours of surgery. The significant univariate predictors of SSI in general surgery patients were increasing age, emergency status, American Society of Anesthesiologists physical status classes P3 to P5, operative time, more than 2 U of red blood cells transfused, preoperative glucose level higher than 180 mg/dL (to convert to millimoles per liter, multiply by 0.0555), diabetes mellitus, and postoperative hyperglycemia. On multivariate adjustment, increasing age, emergency status, American Society of Anesthesiologists classes P3 to P5, operative time, and diabetes remained significant predictors of SSI for general surgery patients. After adjustment for postoperative glucose level, all these variables ceased to be significant predictors of SSI; only incremental postoperative glucose level remained significant. Subanalysis revealed that a serum glucose level higher than 140 mg/dL was the only significant predictor of SSI (odds ratio, 3.2; 95% confidence interval [CI], 1.4-7.2) for colorectal surgery patients. Vascular surgery patients were 1.8 times (95% CI, 1.3-2.5 times) more likely to develop SSI than were general surgery patients. Operative time and diabetes mellitus were the only significant univariate predictors of SSI among vascular surgery patients, and postoperative hyperglycemia was not associated with SSI. CONCLUSIONS Postoperative hyperglycemia may be the most important risk factor for SSI. Aggressive early postoperative glycemic control should reduce the incidence of SSI.

Increased Glycemic Variability Is Independently Associated With Length of Stay and Mortality in Noncritically Ill Hospitalized Patients

OBJECTIVE To investigate the association between glycemic variability (GV) and both length of stay (LOS) and 90-day mortality in noncritically ill hospitalized patients. RESEARCH DESIGN AND METHODS This study retrospectively analyzed 4,262 admissions to the general medicine or surgery services during a 2 year period. Patients with point-of-care glucose monitoring and a minimum of two glucose values per day on average were selected. GV was assessed by SD and coefficient of variation (CV). Data were analyzed with linear and logistic multivariate regression analysis in separate models for SD and CV. Analysis was performed with generalized estimating equations to adjust for correlation between multiple admissions in some individual cases. RESULTS After exclusions, 935 admissions comprised the sample. Results of adjusted analysis indicate that for every 10 mg/dL increase in SD and 10–percentage point increase in CV, LOS increased by 4.4 and 9.7%, respectively. Relative risk of death in 90 days also increased by 8% for every 10-mg/dL increase in SD. These associations were independent of age, race, service of care (medicine or surgery), previous diagnosis of diabetes, HbA1c, BMI, the use of regular insulin as a sole regimen, mean glucose, and hypoglycemia occurrence during the hospitalization. CONCLUSIONS Our results indicate that increased GV during hospitalization is independently associated with longer LOS and increased mortality in noncritically ill patients. Prospective studies with continuous glucose monitoring are necessary to investigate this association thoroughly and to generate therapeutic strategies targeted at decreasing GV.

Impact of preinjury warfarin and antiplatelet agents on outcomes of trauma patients

BACKGROUND Warfarin and antiplatelet agents (WAA) are prevalent among trauma patients, but the impact of these agents on patient outcomes has not been clearly defined. In this study, we examined the impact of preinjury WAA on outcomes in trauma patients. METHODS A 40-month (September 2004 to December 2007) retrospective review of data in the trauma registry at a New York State level 1 trauma center was performed. Patients on WAA were compared to those not on these medications. The primary outcome of interest was mortality, and the secondary outcomes of interest were as length of stay (LOS) and disposition on discharge. A separate analysis was done for patients with intracranial hemorrhage (ICH). The chi-square test, the Student t test, and the modified Poisson regression analysis were used to estimate the incident risk ratios for the outcomes. RESULTS A total of 3,436 trauma patients were identified, of whom 456 were taking anticoagulants (warfarin, n = 91 patients; aspirin, n = 228; clopidogrel, n = 43; and various combinations, n = 94). Patients on warfarin were 3.1 times more likely to die (relative risk [RR], 3.2; 95% confidence interval [CI], 1.6-6.6), after adjusting for potential confounders. Aspirin and clopidogrel were not associated with increased mortality, but WAA were associated with increased risk of ICH (49.8% vs 30.5%; RR, -1.6; 95% CI, 1.4-1.9). WAA did not affect LOS or disposition. Among patients with ICH, only warfarin increased mortality (28.9% vs 5.8%; RR, -3.1; 95% CI, 1.3-7.2). CONCLUSION Preinjury warfarin treatment was found to be an independent risk factor for mortality. WAA agents increased risk of ICH. Among those patients with ICH, only warfarin was associated with increased mortality. Antiplatelet agents did not affect mortality or LOS.

Characteristics of Highly Ranked Applicants to General Surgery Residency Programs

IMPORTANCE With duty hour debates, specialization, and sex distribution changes in the applicant pool, the relative competitiveness for general surgery residency (GSR) is undefined. OBJECTIVE To determine the modern attributes of top-ranked applicants to GSR. DESIGN Validation cohort, survey. SETTING National sample of university and community-based GSR programs. PARTICIPANTS Data were abstracted from Electronic Residency Application Service files of the top 20-ranked applicants to 22 GSR programs. We ranked program competitiveness and blinded review of personal statements. MAIN OUTCOMES AND MEASURES Characteristics associated with applicant ranking by the GSR program (top 5 vs 6-20) and ranking by highly competitive programs were identified using t and χ2 tests and modified Poisson regression. RESULTS There were 333 unique applicants among the 440 Electronic Residency Application Service files. Most applicants had research experience (93.0%) and publications (76.8%), and 28.4% had Alpha Omega Alpha membership. Nearly half were women (45.2%), with wide variation by program (20.0%-75.0%) and a trend toward fewer women at programs in the South and West (38.0% and 37.5%, respectively). Men had higher United States Medical Licensing Examination Step 1 scores (238.0 vs 230.1; P < .001) but similar Step 2 scores (245.3 vs 244.5; P = .54). Using bivariate analysis, highly competitive programs were more likely to rank applicants with publications, research experience, Alpha Omega Alpha membership, higher Step 1 scores, and excellent personal statements and those who were male or Asian. However, the only significant predictors were Step 1 scores (relative risk [RR], 1.36 for every 10-U increase), publications (RR, 2.20), personal statements (RR, 1.62), and Asian race (RR, 1.70 vs white). Alpha Omega Alpha membership (RR, 1.62) and Step 1 scores (RR, 1.01) were the only variables predictive of ranking in the top 5. CONCLUSIONS AND RELEVANCE This national sample shows GSR is a highly competitive, sex-neutral discipline in which academic performance is the most important factor for ranking, especially in the most competitive programs. This study will inform applicants and program directors about applicants to the GSR program.

Management of splenic trauma: a single institution’s 8-year experience

BACKGROUND Management of splenic trauma has evolved, with current practice favoring selective angiographic embolization and non-operative treatment over immediate splenectomy. Defining the optimal selection criteria for the appropriate management strategy remains an important question. METHODS This retrospective registry review was conducted at a Level I trauma center. The patient population consisted of 20,561 patients in the State Trauma Registry from April 2004 to May 2012. Splenectomy, angiography, splenic embolization, nonoperative, and noninterventional (NI) observation were the management strategies under study. Morbidity and mortality were the outcome measures. Morbidity and mortality by management strategy. RESULTS During the 8-year study period, 926 (4.5%) patients sustained splenic injury. Observational management increased over time despite the similar distribution of splenic injury grade over the study period: grade I/II (50%), grade III (24.2%), and grade IV/V (25.8%). Mortality rates associated with each management strategy were the following: immediate splenectomy (IS; 25%), splenic embolization (SE; 3.9%), and angiography only or observation, that is, NI (6.5%) management. Injury severity score (ISS) was highest in IS (36.1 ± 1.3) compared with SE (29.1 ± 1.0, P = .001) and NI (21.6, P < .001). Splenectomy was required in 5 of the 129 (3.9%) patients managed with SE and 9 of the 677 (1.3%) patients managed by NI. Mortality was significantly lower among those managed by SE (odds ratio .12, 95% confidence interval: .05 to .32) or NI (odds ratio .21, 95% confidence interval: .12 to .35). This survival benefit was explained by the association of IS with systolic blood pressure <90, high ISS, low GCS at presentation, ISS, development of shock, need for transfusion, and multiorgan failure. CONCLUSIONS In this large 8-year single institution study, we observed an increase in nonoperative management by an increased application of angiography and embolization. An aggressive utilization of SE in patients with appropriate indications will result in low failure rates and improved mortality.

Predictors of Hospital Readmission after Bariatric Surgery

BACKGROUND Identification of factors that might predict readmission after bariatric surgery could help surgeons target high-risk patients. The purpose of this study was to identify comorbidities, surgical variables, and postoperative complications associated with readmission. STUDY DESIGN Patients with bariatric surgery as their primary procedure were identified from the 2012 American College of Surgeons (ACS) NSQIP database. Patient variables, operative times, and major postoperative complications were analyzed for predictors of readmission. The ACS NSQIP estimated probability of morbidity (MORBPROB) was also considered. Chi-square tests and Poisson regression were used for statistical analysis to identify significant predictors. RESULTS There were 18,186 patients who met inclusion criteria. There were 1,819 who had a laparoscopic gastric band, 9,613 who had laparoscopic Roux-en-Y gastric bypass (RYGB), 6,439 who had gastroplasties (vertical banded gastroplasty and sleeve), and 315 who had open RYGB. Age, sex, BMI, American Society of Anesthesiologists (ASA) class, diabetes, hypertension, steroid use, type of procedure, and operative time all were significantly associated with readmission within 30 days of operation. All major postoperative complications were significant predictors of readmission. Patients expected to be at high risk based on the ACS NSQIP MORBPROB had a significantly higher rate of readmissions. The overall readmission rate for patients undergoing bariatric surgery was 5%. The readmission rate among patients with any major complication was 31%. CONCLUSIONS Bariatric surgery is a low-risk procedure. Complexity of operation, ASA class, prolonged operative time, and major postoperative complications are important determinants of high risk for readmission. The ACS NSQIP MORBPROB may be a useful tool to identify and target patients at risk for readmission.

Spontaneous Pneumomediastinum: An Extensive Workup Is Not Required

BACKGROUND Spontaneous pneumomediastinum is a rare entity usually caused by alveolar rupture and air tracking along the tracheobronchial tree. Despite its benign nature, an extensive workup is often undertaken to exclude hollow viscus perforation. We sought to review our experience with this condition and examine the optimal management strategy. STUDY DESIGN We conducted a retrospective review of all radiographic pneumomediastinum cases at a tertiary hospital between 2006 and 2011. The main outcomes measures included length of hospital stay, mortality, and need for investigative procedures. RESULTS Forty-nine patients with spontaneous pneumomediastinum were identified, including 26 male patients (53%). Mean age was 19 ± 9 years. Chest pain was the most common presenting symptom (65%), followed by dyspnea (51%). Forceful coughing (29%) or vomiting (16%) were the most common eliciting factors, and no precipitating event was identified in 41% of patients. Computed tomography was performed in 38 patients (78%) and showed a pneumomediastinum that was not seen on chest x-ray in 9 patients. Esophagography was performed in 17 patients (35%) and was invariably negative for a leak. Thirty-eight patients (78%) were hospitalized for a mean of 1.8 ± 2.6 days. No mortality was recorded. Compared with patients who presented with pneumomediastinum secondary to esophageal perforation, spontaneous pneumomediastinum patients were younger, had a lower white cell count, and were less likely to have a pleural effusion. CONCLUSIONS Spontaneous pneumomediastinum is a benign entity and rarely correlates with true esophageal perforation. Additional investigation with esophagography or other invasive procedures should be performed selectively with the aim of expediting the patients care. The prognosis is excellent with conservative management and the risk for recurrence is low.

Reverse Alignment “Mirror Image” Visualization as a Laparoscopic Training Tool Improves Task Performance

Reverse alignment (mirror image) visualization is a disconcerting situation occasionally faced during laparoscopic operations. This occurs when the camera faces back at the surgeon in the opposite direction from which the surgeon’s body and instruments are facing. Most surgeons will attempt to optimize trocar and camera placement to avoid this situation. The authors’ objective was to determine whether the intentional use of reverse alignment visualization during laparoscopic training would improve performance. A standard box trainer was configured for reverse alignment, and 34 medical students and junior surgical residents were randomized to train with either forward alignment (DIRECT) or reverse alignment (MIRROR) visualization. Enrollees were tested on both modalities before and after a 4-week structured training program specific to their modality. Student’s t test was used to determine differences in task performance between the 2 groups. Twenty-one participants completed the study (10 DIRECT, 11 MIRROR). There were no significant differences in performance time between DIRECT or MIRROR participants during forward or reverse alignment initial testing. At final testing, DIRECT participants had improved times only in forward alignment performance; they demonstrated no significant improvement in reverse alignment performance. MIRROR participants had significant time improvement in both forward and reverse alignment performance at final testing. Reverse alignment imaging for laparoscopic training improves task performance for both reverse alignment and forward alignment tasks. This may be translated into improved performance in the operating room when faced with reverse alignment situations. Minimal lab training can account for drastic adaptation to this environment.

Increased Incidence of Surgical Site Infection in IBD Patients.

BACKGROUND: Surgical site infection is a key hospital-level patient safety indicator. All risk factors for surgical site infection are not always taken into account and adjusted for. OBJECTIVE: This study aimed to measure the impact of IBD in comparison with diverticulitis and colorectal cancer on the national rates of surgical site infection. DESIGN: The American College of Surgeons National Surgical Quality Improvement Project database was queried for all patients undergoing elective colectomy for colon cancer, diverticulitis, and IBD from 2008 through 2012. OUTCOME MEASURES: The association between surgical site infection and IBD patients was assessed. Patient demographics, rates of surgical site infection, wound class, return to operating room, and various patient characteristics were analyzed. Logistic regression was performed to determine the association with surgical site infection. RESULTS: The query yielded 71,845 patients undergoing elective colectomy. Of these patients, 42,132 had colon cancer, 22,143 had diverticulitis, and 7570 had IBD. The rate of surgical site infection was 12.0% for colon cancer, 12.8% for diverticulitis, and 18.0% for IBD. Return to operating room within 30 days was 7.3% for IBD patients, 4.4% for patients with diverticulitis, and 4.9% for patients with colorectal cancer. Return to operating room within 30 days had the highest correlation to surgical site infection in both univariate and multivariable analysis. Other associative factors for surgical site infection common to both analyses included diabetes mellitus, smoking, open procedures, and obesity. LIMITATIONS: This study was limited by the data collection errors inherent to large databases, exclusion of emergent operations, and the inability to identify patients taking immunosuppressive agents. CONCLUSIONS: Patients with IBD undergoing elective colectomy have significantly increased rates of surgical site infection, specifically deep and organ/space infections. Given this information, risk adjustment models for surgical site infection may need to include IBD in their calculation.

A prospective evaluation of the effect of sample collection site on intraoperative parathormone monitoring during parathyroidectomy.

BACKGROUND Sample collection site may affect the dynamics of intraoperative parathyroid hormone monitoring (IPM) and influence surgical decisions. METHODS We prospectively studied 45 patients undergoing parathyroidectomy for primary hyperparathyroidism. The IPM cure criterion was a decrease in peripheral vein (PV) parathyroid hormone (PTH) of >50% at 10 minutes after gland excision. PTH samples were collected simultaneously from PV and central vein (CV) and compared for PTH decay, the incidence of >50% PTH decay, and the incidence of normal PTH values after gland excision. RESULTS Mean PTH levels were significantly higher from the CV before and after gland excision. Mean PTH decay 10 minutes after gland excision was 89% PV versus 88% CV, resulting in mean PTH levels of 27 +/- 23 and 39 +/- 35 pg/mL, respectively (P < .0001). At 5 minutes, >50% decay in PTH was present in 98% PV versus 88% CV samples. By 10 minutes, the incidence of >50% PTH decay was equivalent (98%). This yielded normal range PTH levels from the PV versus CV in 90% versus 76% of patients at 5 minutes, 96% versus 89% at 10 minutes, and 95% versus 81% at 20 minutes. Of 45 patients, 44 (98%) are normocalcemic at a mean follow-up of 6.3 months. IPM predicted the single operative failure. CONCLUSIONS CV sampling produces significantly higher PTH levels. Surgeons sampling from a PV may observe a >50% decrease in PTH and normal range PTH values starting 5 minutes after gland excision. Surgeons who sample from the CV and require normalization of PTH levels may have to wait longer and/or continue potentially unnecessary neck exploration.