Aurelie Mailhac

Concomitant hiatal hernia repair with laparoscopic sleeve gastrectomy is safe: analysis of the ACS-NSQIP database☆

BACKGROUND Gastroesophageal acid reflux disease (GERD) is prevalent after laparoscopic sleeve gastrectomy (LSG), a common bariatric surgical procedure worldwide. Some studies have suggested that concomitant hiatal hernia repair (HHR) during LSG reduces the risk of GERD, but this has not been substantiated. Little is known about the safety of adding an HHR in this setting. The present study aims to compare 30-day morbidity and mortality and length of hospital stay between patients undergoing LSG alone and those undergoing LSG with HHR. METHODS A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program database was performed to identify patients who underwent LSG procedures alone or with concomitant HHR between 2010 and 2014. Univariate and multivariate analyses of 30-day morbidity and mortality and length of hospital stay were performed. RESULTS Between 2010 and 2014, 32,581 patients underwent LSG. Of those, 4687 (14.4%) underwent concomitant HHR. No significant differences in 30-day mortality; overall morbidity; reoperation; sepsis; and wound, cardiac, respiratory, and renal complications were found between the 2 study groups on univariate and multivariate analyses. Length of hospital stay, risk of thromboembolic events, and blood transfusions were lower in the LSG+HHR group, even on multivariate analysis. CONCLUSIONS Concomitant HHR at the time of LSG is not associated with increased risk of 30-day mortality or major morbidity. However, the effectiveness of this additional procedure should be assessed using long-term data on the resolution of GERD symptoms after LSG.

Trends and Predictors of Limb Tourniquet Use by Civilian Emergency Medical Services in the United States

Abstract Background: Tourniquet use by Emergency Medical Services (EMS) can be life saving for severely injured patients. The adoption of this intervention is not well described in civilian settings. This study describes patterns and trends of tourniquet use by civilian EMS and identifies predictors of such use. Methods: A retrospective study of four consecutive releases of the U.S. National Emergency Medical Services Information System (NEMSIS) public research dataset (2011–14) was conducted. Descriptive analysis was performed to compare two groups of EMS activations for injuries with or without tourniquet application. This was followed by multivariate logistic regression to identify predictors of tourniquet use. Results: A total of 2,048 tourniquet applications were documented among all EMS activations for injured patients (N = 10,366,537) yielding a prevalence of 0.2 per 1,000 EMS activations. Tourniquets were mainly applied in young (mean age 44.0 ± 21.1 years) male patients (76.5%) in urban and suburban EMS activations (86.4%) and by advanced life support (ALS) EMS services (81.6%). Most common complaints reported by dispatch for EMS activations with tourniquet use were Traumatic injury (25.3%), Hemorrhage/laceration (23.5%), and Traffic accident (16.8%) with injuries mainly related to Stabbing/Accidental cutting (20.3%), Falls (17.1%), and Motor vehicle traffic accident (11.5%). Upper extremity injuries (39.6%) were more common than Lower extremity injuries (27.3%). The providers’ primary impression was predominantly Traumatic injury (92.8%), and patients’ primary symptoms were mainly Bleeding (50.4%) and Wound (28.7%). All prehospital time intervals except on-scene time interval were significantly shorter in the group with tourniquets compared to the group without tourniquets (p < 0.05). Reported prevalence of tourniquet use by EMS (per 1,000 EMS injury activations) increased from 2011 to 2012 then stabilized over the following years (2012–14). Significant predictors of tourniquet use reported by the provider were identified and included demographic characteristics, EMS agency type, specific complaints, injury cause, injury anatomic location, chief complaint organ system, and primary symptom. Conclusion: Reported tourniquet use by EMS for injured patients in the U.S. is low. Increasing adoption mainly by urban services was noted. Predictors for tourniquet use in civilian trauma were identified. Establishing the effectiveness of this intervention by comparing patient outcomes is needed. Key words: emergency medical services; prehospital; tourniquet; injury; NEMSIS; hemorrhage

The Effect of Preoperative Pneumonia on Postsurgical Mortality and Morbidity: A NSQIP Analysis

BackgroundCurrently, only indirect evidence suggests that preoperative pneumonia is a significant risk factor for poor postsurgical outcomes. Although this relationship is clinically intuitive, this is the first study that aims to quantify the extent to which pneumonia impacts morbidity and mortality. The objective of this study was to determine the impact of preoperative pneumonia on 30-day mortality and morbidity among both elective and emergency surgical patients.MethodsWe conducted a retrospective cohort study using 2008–2012 data from the American College of Surgeons National Surgical Quality Improvement Program database. Patients with preoperative pneumonia were matched to controls without preoperative pneumonia. Patient demographics and postoperative outcomes were extracted from the database, including 30-day mortality, specific morbidities (wound, cardiac, respiratory, urinary, central nervous system, thromboembolism and sepsis), composite morbidity, number of blood transfusions and number of patients that returned to the OR. Mortality and composite morbidity were further stratified.ResultsWe obtained data for 137,174 patients, of whom 6933 (0.50%) had preoperative pneumonia. Overall, 6111 were successfully matched to 24,444 patients with no pneumonia. Postoperative mortality and composite morbidity were both higher in patients with pneumonia than in those without pneumonia, with an odds ratio of 1.37 (95% CI 1.26–1.48) and 1.68 (95% CI 1.58–1.79), respectively.ConclusionPreoperative pneumonia significantly increased the rate of postoperative morbidity and mortality across several surgical settings and patient groups. It is our recommendation that elective surgery be delayed until after the pneumonia resolves.

Could sodium imbalances predispose to postoperative venous thromboembolism? An analysis of the NSQIP database

BackgroundHyponatremia is common among patients with pulmonary embolism, while hypernatremia increases the risk of venous thromboembolism (VTE). Our objective was to evaluate the association between sodium imbalances and the incidence of VTE and other selected perioperative outcomes.MethodsWe conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and identified 1,108,704 patients undergoing major surgery from 2008 to 2012. We evaluated 30-day perioperative outcomes, including mortality and cardiac, respiratory, neurological, urinary, wound, and VTE outcomes. Multivariate logistic regressions were used to estimate the odds of 30-day perioperative outcomes.ResultsCompared with the normal sodium group, in which VTE occurred in 1.0% of patients, 1.8% of patients in the hyponatremia group (unadjusted odds ratio (OR) 1.84) and 2.4% of patients in the hypernatremia group (unadjusted OR 2.49) experienced VTE. Crude mortality was 1.3% in the normal sodium group, 4.9% in the hyponatremia group (unadjusted OR 3.93) and 8.4% in the hypernatremia group (unadjusted OR 7.01). Crude composite morbidity was 7.1% for the normal sodium group, 16.7% for the hyponatremia group (unadjusted OR 2.63) and 20.6% for the hypernatremia group (unadjusted OR 3.43). After adjusting for potential confounders, hyponatremia and hypernatremia remained significantly and independently associated with an increased risk of VTE (adjusted OR 1.43 and 1.56, respectively), mortality (adjusted OR 1.39 and 1.39, respectively) and composite morbidity (adjusted OR 2.15 and 3.34, respectively).ConclusionsPre-operative hyponatremia and hypernatremia are potential prognostic markers for perioperative 30-day morbidity, mortality and VTE.

Outcomes of patients with systolic heart failure presenting with sepsis to the emergency department of a tertiary hospital: a retrospective chart review study from Lebanon

Objectives Patients with congestive heart failure (CHF) may be at a higher risk of mortality from sepsis than patients without CHF due to insufficient cardiovascular reserves during systemic infections. The aim of this study is to compare sepsis-related mortality between CHF and no CHF in patients presenting to a tertiary medical centre. Design A single-centre, retrospective, cohort study. Setting Conducted in an academic emergency department (ED) between January 2010 and January 2015. Patients’ charts were queried via the hospital’s electronic system. Patients with a diagnosis of sepsis were included. Descriptive analysis was performed on the demographics, characteristics and outcomes of patients with sepsis of the study population. Participants A total of 174 patients, of which 87 (50%) were patients with CHF. Primary and secondary outcomes The primary outcome of the study was in-hospital mortality. Secondary outcomes included intensive care unit (ICU) and hospital lengths of stay, and differences in interventions between the two groups. Results Patients with CHF had a higher in-hospital mortality (57.5% vs 34.5%). Patients with sepsis and CHF had higher odds of death compared with the control population (OR 2.45; 95% CI 1.22 to 4.88). Secondary analyses showed that patients with CHF had lower instances of bacteraemia on presentation to the ED (31.8% vs 46.4%). They had less intravenous fluid requirements in first 24 hours (2.75±2.28 L vs 3.67±2.82 L, p =0.038), had a higher rate of intubation in the ED (24.2% vs 10.6%, p=0.025) and required more dobutamine in the first 24 hours (16.1% vs 1.1%, p<0.001). ED length of stay was found to be lower in patients with CHF (15.12±24.45 hours vs 18.17±26.13 hours, p=0.418) and they were more likely to be admitted to the ICU (59.8% vs 48.8%, p=0.149). Conclusion Patients with sepsis and CHF experienced an increased hospital mortality compared with patients without CHF.

Preoperative biliary drainage for malignant biliary obstruction: results from a national database

The impact of preoperative biliary drainage (PBD) on postoperative morbidity and mortality in patients with malignant biliary obstruction is still unclear. We examined short‐term surgical outcomes among drained and non‐drained patients.

Surgical Outcomes among Inflammatory Bowel Disease Patients Undergoing Colectomy: Results from a National Database

INTRODUCTION Colectomy is relatively common in inflammatory bowel diseases (IBD), occurring more in Ulcerative Colitis (UC) as compared to Crohns disease (CD). The surgical outcomes among this mixed population of patients are not well understood. This study aims to determine the predictors of post colectomy surgical outcomes in this patient population. METHODS Using the National Surgical Quality Improvement Project (NSQIP) demographics, preoperative and post-operative data were analyzed for all patients undergoing colectomy for either CD or UC. Multiple variables were linked to several outcomes including mortality, anastomotic leak, and reoperation post colectomy. RESULTS A total of 5049 IBD patients that underwent colectomy were identified. Rate of reoperation and anastomotic leak were significantly increased with steroid intake with an Odds Ratio (OR) of 1.66 (95% Confidence Interval (CI) (1.26-2.19)) and 1.81 (95%CI (1.34-2.45)) respectively. As for 30-day mortality, it was significantly lower among patients on steroid (OR=0.41; 95%CI (0.19-0.86)). Comparing UC to CD, anastomotic leaks were less common among UC patients (OR=0.53; 95%CI (0.37-0.76)), but 30-day mortality was significantly more prevalent among UC patients (OR=8.11; 95%CI (4.22-15.6)). CONCLUSION Among IBD patients undergoing colectomy, major surgical complications except 30-day mortality appear to increase with the use of preoperative steroids.

Ventilator use by emergency medical services during 911 calls in the United States

Background: Emergency and transport ventilators use in the prehospital field is not well described. This study examines trends of ventilator use by EMS agencies during 911 calls in the United States and identifies factors associated with this use. Methods: This retrospective study used four consecutive releases of the US National Emergency Medical Services Information System (NEMSIS) public research dataset (2011–2014) to describe scene EMS activations (911 calls) with and without reported ventilator use. Results: Ventilator use was reported in 260,663 out of 28,221,321 EMS 911 scene activations (0.9%). Patients with ventilator use were older (mean age 67 ± 18 years), nearly half were males (49.2%), mostly in urban areas (80.2%) and cared for by advanced life support (ALS) EMS services (89.5%). CPAP mode of ventilation was most common (71.6%). “Breathing problem” was the most common dispatch complaint for EMS activations with ventilator use (63.9%). Common provider impression categories included “respiratory distress” (72.5%), “cardiac rhythm disturbance” (4.6%), “altered level of consciousness” (4.3%) and “cardiac arrest”(4.0%). Ventilator use was consistently higher at the Specialty Care Transport (SCT) and Air Medical Transport (AMT) service levels and increased over the study period for both suburban and rural EMS activations. Significant factors for ventilator use included demographic characteristics, EMS agency type, specific complaints, providers primary impressions and condition codes. Conclusions: Providers at different EMS levels use ventilators during 911 scene calls in the US. Training of prehospital providers on ventilation technology is needed. The benefit and effectiveness of this intervention remain to be assessed.

Safety of Resident Involvement in Surgery: A Starting Point for Improvement of Surgical Residency Training: In Reply to D'Souza and Aggarwal

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