Augustine Obirieze

Optimal Time for Early Laparoscopic Cholecystectomy for Acute Cholecystitis

IMPORTANCE There is growing evidence in support of performing early laparoscopic cholecystectomy (LC) for acute cholecystitis. However, the definition of early LC varies from 0 through 10 days depending on the research protocol. The optimum time to perform early LC is still unclear. OBJECTIVES To determine whether outcomes after early LC for acute cholecystitis vary depending on time from presentation to surgery and to determine the optimum time to perform LC for acute cholecystitis. DESIGN, SETTING, AND PARTICIPANTS We performed a retrospective review of prospectively collected data from the Nationwide Inpatient Sample (NIS) for 2005 through 2009. The population-based sample included 95,523 adults (18 years and older) who underwent LC within 10 days of presentation for acute cholecystitis. INTERVENTIONS Patients were categorized and analyzed in 2 ways based on length of time from presentation to surgery. First, patients were categorized into 3 groups: 0 through 1 day, 2 through 5 days, and 6 through 10 days. Second, we compared outcomes for each incremental preoperative day (days 0-5). MAIN OUTCOMES AND MEASURES Outcomes of interest were mortality, length of stay, complications, and cost. Propensity score matching and generalized linear modeling were used. The hypothesis being tested was formulated after data collection was complete. RESULTS A total of 95,523 patients were selected. After matching the 3 groups based on propensity scores, patients who underwent surgery during days 2 through 5 and days 6 through 10 had increasingly worse outcomes when compared with those undergoing surgery on days 0 through 1. The odds of mortality were 1.26 (95% CI, 1.00-1.58) and 1.93 (95% CI, 1.38-2.68), and the odds of postoperative infections were 0.88 (95% CI, 0.69-1.12) and 1.53 (95% CI, 1.05-2.23) for days 2 through 5 and days 6 through 10, respectively. Adjusted mean hospital cost increased from

Surgical Management of Complicated Diverticulitis: A Comparison of the Laparoscopic and Open Approaches

8974 (days 0-1) to

Outcomes of trauma care at centers treating a higher proportion of older patients: The case for geriatric trauma centers

17,745 (days 6-10). Analysis by each incremental day revealed the optimal time of surgery to be within the first 48 hours of presentation. CONCLUSIONS AND RELEVANCE Laparoscopic cholecystectomy performed within 2 days of presentation of acute cholecystitis yielded the best outcomes and lowest costs. Although causality could not be established, delaying LC was associated with more complications, higher mortality, and higher costs.

Incremental Cost of Emergency Versus Elective Surgery.

BACKGROUND Laparoscopy has become a commonly used method of performing colectomies, but the outcomes associated with laparoscopy in the emergency setting have not been well studied. STUDY DESIGN The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients with diverticulitis without hemorrhage who underwent a colectomy. Patient data retrieved included demographics and preoperative comorbidities. Each member of the cohort received either a primary anastomosis (PA) or a colostomy. Open and laparoscopic procedures were compared within these subgroups. Multivariate logistic regression analyses were performed to compare the risk-adjusted odds of postoperative morbidity and mortality for laparoscopic and open procedures. The risk-adjusted impact of preoperative comorbidities was also assessed. RESULTS A total of 11,981 patients in the database met the study criteria. The majority were female (53%) and Caucasian (82%), and the mean age was 58 (±13) years. Comorbidities of the cardiovascular, pulmonary, or renal systems were present in 47%, 5%, and 1% of the cohort, respectively. On bivariate analysis, patients undergoing laparoscopy experienced lower rates of complications with both PA (14% vs 26%, p < 0.001) and colostomy (30% vs 37%, p = 0.02). The laparoscopic approach was associated with decreased mortality rates for patients undergoing PA (0.24% vs 0.79%, p < 0.001). Multivariate analysis revealed that preoperative cardiovascular and pulmonary comorbidities were each associated with increased postoperative morbidity, and that the laparoscopic approach was associated with lower postoperative morbidity for patients undergoing PA. The reduced risk of death for patients undergoing laparoscopic PA (vs open approach) did not achieve statistical significance (odds ratio 0.68, p = 0.3). A small number of patients underwent laparoscopic colostomy (n = 237, 2.4%), and they did not have a significantly different risk of death. CONCLUSIONS The laparoscopic approach is associated with lower complication rates compared with the open approach for the surgical treatment of diverticulitis with a primary anastomosis.

Open versus endovascular repair of thoracic aortic aneurysms: a Nationwide Inpatient Sample study.

BACKGROUND The burden of injury among older patients continues to grow and accounts for a disproportionate number of trauma deaths. We wished to determine if older trauma patients have better outcomes at centers that manage a higher proportion of older trauma patients. METHODS The National Trauma Data Bank years 2007 to 2011 was used. All high-volume Level 1 and Level 2 trauma centers were included. Trauma centers were categorized by the proportion of older patients seen. Adult trauma patients were categorized as older (≥65 years) and younger adults (16–64 years). Coarsened exact matching was used to determine differences in mortality and length of stay between older and younger adults. Risk-adjusted mortality ratios by proportion of older trauma patients seen were analyzed using multivariate logistic regression models and observed-expected ratios. RESULTS A total of 1.9 million patients from 295 centers were included. Older patients accounted for one fourth of trauma visits. Matched analysis revealed that older trauma patients were 4.2 times (95% confidence interval, 3.99–4.50) more likely to die than younger patients. Older patients were 34% less likely to die if they presented at centers treating a high versus low proportion of older trauma (odds ratio, 0.66; 95% confidence interval, 0.54–0.81). These differences were independent of trauma center performance. CONCLUSION Geriatric trauma patients treated at centers that manage a higher proportion of older patients have improved outcomes. This evidence supports the potential advantage of treating older trauma patients at centers specializing in geriatric trauma. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

Surgical management of esophageal diverticulum: a review of the Nationwide Inpatient Sample database.

OBJECTIVE To determine hospital costs and the adjusted risk of death associated with emergent versus elective surgery. BACKGROUND Emergency surgery has a higher cost and worse outcomes compared with elective surgery. However, no national estimates of the excess burden of emergency surgery exist. METHODS Nationwide Inpatient Sample (NIS) data from 2001 to 2010 were analyzed. Patients aged 18 years or older who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, or colon resection for neoplasm were included. Using generalized linear models with propensity scores, cost differences for emergent versus elective admission were calculated for each procedure. Multivariable logistic regression was performed to investigate the adjusted odds of mortality comparing elective and emergent cases. Discharge-level weights were applied to analyses. RESULTS A total of 621,925 patients, representing a weighted population of 3,057,443, were included. The adjusted mean cost difference for emergent versus elective care was

Open abdominal surgery: a risk factor for future laparoscopic surgery?

8741.22 (30% increase) for abdominal aortic aneurysm repair,

Regional variations in cost of trauma care in the United States: who is paying more?

5309.78 (17% increase) for coronary artery bypass graft, and

Beyond incidence: Costs of complications in trauma and what it means for those who pay

7813.53 (53% increase) for colon resection. If 10% of the weighted estimates of emergency procedures had been performed electively, the cost benefit would have been nearly

State-by-state variation in emergency versus elective colon resections: room for improvement.

1 billion, at