Brian R. Englum

Racial, Ethnic, and Insurance Status Disparities in Use of Posthospitalization Care after Trauma

BACKGROUND Posthospitalization care is important for recovery after trauma. Disadvantaged populations, like racial or ethnic minorities and the uninsured, make up substantial percentages of trauma patients, but their use of posthospitalization facilities is unknown. STUDY DESIGN This study analyzed National Trauma Data Bank admissions from 2007 for 18- to 64-year-olds and estimated relative risk ratios (RRR) of discharge to posthospitalization facilities--home, home health, rehabilitation, or nursing facility--by race, ethnicity, and insurance. Multinomial logistic regression adjusted for patient characteristics including age, sex, Injury Severity Score, mechanism of injury, and length of stay, among others. RESULTS There were 136,239 patients who met inclusion criteria with data for analysis. Most patients were discharged home (78.9%); fewer went to home health (3.3%), rehabilitation (5.0%), and nursing facilities (5.4%). When compared with white patients in adjusted analysis, relative risk ratios of discharge to rehabilitation were 0.61 (95% CI 0.56, 0.66) and 0.44 (95% CI 0.40, 0.49) for blacks and Hispanics, respectively. Compared with privately insured white patients, Hispanics had lower rates of discharge to rehabilitation whether privately insured (RRR 0.45, 95% CI 0.40, 0.52), publicly insured (RRR 0.51, 95% CI 0.42, 0.61), or uninsured (RRR 0.20, 95% CI 0.17, 0.24). Black patients had similarly low rates: private (RRR 0.63, 95% CI 0.56, 0.71), public (RRR 0.72, 95% CI 0.63, 0.82), or uninsured (RRR 0.27, 95% CI 0.23, 0.32). Relative risk ratios of discharge to home health or nursing facilities showed similar trends among blacks and Hispanics regardless of insurance, except for black patients with insurance whose discharge to nursing facilities was similar to their white counterparts. CONCLUSIONS Disadvantaged populations have more limited use of posthospitalization care such as rehabilitation after trauma, suggesting a potential improvement in trauma care for the underprivileged.

Saphenous Vein Graft Failure After Coronary Artery Bypass Surgery Insights From PREVENT IV

Background— Coronary artery bypass grafting success is limited by vein graft failure (VGF). Understanding the factors associated with VGF may improve patient outcomes. Methods and Results— We examined 1828 participants in the Project of Ex Vivo Vein Graft Engineering via Transfection IV (PREVENT IV) trial undergoing protocol-mandated follow-up angiography 12 to 18 months post–coronary artery bypass grafting or earlier clinically driven angiography. Outcomes included patient- and graft-level angiographic VGF (≥75% stenosis or occlusion). Variables were selected by using Fast False Selection Rate methodology. We examined relationships between variables and VGF in patient- and graft-level models by using logistic regression without and with generalized estimating equations. At 12 to 18 months post–coronary artery bypass grafting, 782 of 1828 (42.8%) patients had VGF, and 1096 of 4343 (25.2%) vein grafts had failed. Demographic and clinical characteristics were similar between patients with and without VGF, although VGF patients had longer surgical times, worse target artery quality, longer graft length, and they more frequently underwent endoscopic vein harvesting. After multivariable adjustment, longer surgical duration (odds ratio per 10-minute increase, 1.05; 95% confidence interval, 1.03–1.07), endoscopic vein harvesting (odds ratio, 1.41; 95% confidence interval, 1.16–1.71), poor target artery quality (odds ratio, 1.43; 95% confidence interval, 1.11–1.84), and postoperative use of clopidogrel or ticlopidine (odds ratio, 1.35; 95% confidence interval, 1.07–1.69) were associated with patient-level VGF. The predicted likelihood of VGF in the graft-level model ranged from 12.1% to 63.6%. Conclusions— VGF is common and associated with patient and surgical factors. These findings may help identify patients with risk factors for VGF and inform the development of interventions to reduce VGF. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00042081.

Robotic Low Anterior Resection for Rectal Cancer: A National Perspective on Short-term Oncologic Outcomes.

Objective: This study examines short-term outcomes and pathologic surrogates of oncologic results among patients undergoing robotic versus laparoscopic low anterior resection for rectal cancer. A total of 6403 patients met inclusion criteria. Although the robotic approach required significantly fewer conversions to open, surrogates for proper oncologic surgery were nearly identical between the 2 approaches. Background: Although laparoscopic low anterior resection (LLAR) has gained popularity as an acceptable approach, the robotic low anterior resection (RLAR) remains largely unproven. We compared short-term oncologic outcomes between rectal cancer patients undergoing either RLAR or LLAR. Study Design: All patients with rectal cancer in the National Cancer Data Base undergoing RLAR or LLAR from 2010 to 2011 were included. Predictors of RLAR were modeled with multivariable logistic regression. Groups were matched on propensity to undergo RLAR. Primary endpoints included lymph node retrieval and margin status, whereas secondary 30-day outcomes were mortality, hospital length of stay (LOS), and unplanned readmission rates. Results: A total of 6403 patients met inclusion criteria, of which 956 (14.9%) underwent RLAR. RLAR patients were more likely to be treated at academic centers, receive neoadjuvant therapy, and have higher T-stage and longer time to surgery (all P < 0.001). Neoadjuvant therapy and treatment at an academic/research center remained the only significant predictors of robotic use after multivariable adjustment. After propensity matching, RLAR was associated with lower conversion (9.5 vs 16.4%, P < 0.001). There were no significant differences in lymph node retrieval, margin status, 30-day mortality, readmission, or hospital LOS. Conclusions: In this largest series to date, we demonstrated equivalent perioperative safety and patient outcomes for robotic compared to LLAR in the setting of rectal cancer. Although the robotic approach required significantly fewer conversions to open, surrogates for proper oncologic surgery were nearly identical between the 2 approaches, suggesting that a robotic approach may be a suitable alternative. Further studies comparing long-term cancer recurrence and survival should be performed.

Antegrade versus retrograde cerebral perfusion for hemiarch replacement with deep hypothermic circulatory arrest: Does it matter? A propensity-matched analysis

OBJECTIVE The choice of cerebral perfusion strategy for aortic arch surgery has been debated, and the superiority of antegrade (ACP) or retrograde (RCP) cerebral perfusion has not been shown. We examined the early and late outcomes for ACP versus RCP in proximal (hemi-) arch replacement using deep hypothermic circulatory arrest (DHCA). METHODS A retrospective analysis of a prospectively maintained database was performed for all patients undergoing elective and nonelective hemiarch replacement at a single referral institution from June 2005 to February 2013. Total arch cases were excluded to limit the analysis to shorter DHCA times and a more uniform patient population for whom clinical equipoise regarding ACP versus RCP exists. A total of 440 procedures were identified, with 360 (82%) using ACP and 80 (18%) using RCP. The endpoints included 30-day/in-hospital and late outcomes. A propensity score with 1:1 matching of 40 pre- and intraoperative variables was used to adjust for differences between the 2 groups. RESULTS All 80 RCP patients were propensity matched to a cohort of 80 similar ACP patients. The pre- and intraoperative characteristics were not significantly different between the 2 groups after matching. No differences were found in 30-day/in-hospital mortality or morbidity outcomes. The only significant difference between the 2 groups was a shorter mean operative time in the RCP cohort (P = .01). No significant differences were noted in late survival (P = .90). CONCLUSIONS In proximal arch operations using DHCA, equivalent early and late outcomes can be achieved with RCP and ACP, although the mean operative time is significantly less with RCP, likely owing to avoidance of axillary cannulation. Questions remain regarding comparative outcomes with straight DHCA and lesser degrees of hypothermia.

Induction Therapy Does Not Improve Survival for Clinical Stage T2N0 Esophageal Cancer

Introduction: This study compared survival after initial treatment with esophagectomy as primary therapy to induction therapy followed by esophagectomy for patients with clinical T2N0 (cT2N0) esophageal cancer in the National Cancer Database (NCDB). Methods: Predictors of therapy selection for patients with cT2N0 esophageal cancer in the NCDB from 1998 to 2011 were identified with multivariable logistic regression. Survival was evaluated using Kaplan-Meier and Cox proportional hazards methods. Results: Surgery was used in 42.9% (2057 of 4799) of cT2N0 patients. Of 1599 esophagectomy patients for whom treatment timing was recorded, induction therapy was used in 44.1% (688). Pretreatment staging was proven accurate in only 26.7% of patients (210 of 786) who underwent initial surgery without induction treatment and had complete pathologic data available: 41.6% (n = 327) were upstaged and 31.7% (n = 249) were downstaged. Adjuvant therapy (chemotherapy or radiation therapy) was given to 50.2% of patients treated initially with surgery who were found after resection to have nodal disease. There was no significant difference in long-term survival between strategies of primary surgery and induction therapy followed by surgery (median 41.1 versus 41.9 months, p = 0.51). In multivariable analysis, induction therapy was not independently associated with risk of death (hazard ratio [HR], 1.16, p = 0.32). Conclusions: Current clinical staging for early-stage esophageal cancer is highly inaccurate, with only a quarter of surgically resected cT2N0 patients found to have had accurate pretreatment staging. Induction therapy for patients with cT2N0 esophageal cancer in the NCDB is not associated with improved survival.

Degree of hypothermia in aortic arch surgery – optimal temperature for cerebral and spinal protection: deep hypothermia remains the gold standard in the absence of randomized data

Since the pioneering report by Griepp in 1975, the use of deep hypothermia for cerebral and visceral organ protection has ushered in the modern era of safe and effective operation on the aortic arch during circulatory arrest (1). In large part due to advanced circulatory management strategies, the number of proximal aorta and arch replacements have increased each year since 2005, with over 10,000 operations reported to the Society of Thoracic Surgeons National Database in 2009 alone (2). However, despite these advances, neurologic complications remain a sobering limitation of arch repair, with national rates of major neurologic morbidity ranging between 3-5% for elective arch repairs and 9-13% for non-elective repairs (2). In addition, visceral organ injury such as renal failure requiring dialysis occurs in 3-6% of patients (2), highlighting the need for additional investigation into methods for ischemic end-organ protection during circulatory arrest. The concept of using hypothermia to temporarily reduce the oxygen and metabolic requirements of hypoxic tissues is intuitive and supported by decades of laboratory, translational, and clinical science. Nonetheless, the optimal temperature for hypothermic circulatory arrest (HCA) during arch surgery remains unclear and is confounded by a myriad of other clinical variables that are also without consensus, such as location of temperature measurement, cannulation site, perfusion rates, rapidity of cooling and rewarming, anesthetic and pharmacologic adjuncts, selective cerebral perfusion technique, and use of intraoperative electroencephalographic (EEG) neuromonitoring to guide cooling. As a result, HCA strategies vary considerably, even between respected high-volume centers, and are often dictated as much by dogma and tradition as by evidence. Maximal suppression of the cerebral metabolic rate of oxygen consumption occurs at EEG isoelectricity, or electrocerebral inactivity (ECI) (3,4), with modern aortic surgeons traditionally aiming to achieve this level of metabolic suppression through the use of ‘profound’ or ‘deep’ hypothermia. Although cooling below 18 °C was initially thought necessary to achieve ECI (3,4), more recent studies have shown that ECI can occur anywhere between 10 and 27 °C in human subjects (Figure 1) (5-7). As a result, many experienced centers, including our own, employ neurophysiologic intraoperative monitoring with EEG to precisely detect ECI prior to the initiation of circulatory arrest (6,8-10). Cooling to ECI by EEG ensures maximal suppression of cerebral metabolic activity prior to circulatory arrest, while minimizing perfusion time and hypothermic injury by avoiding excessive cooling (5). Figure 1 Cumulative (A) nasopharyngeal temperature and (B) cooling time required to achieve electrocerebral inactivity (ECI) in a series of 325 adult patients who underwent thoracic aortic surgery at Duke University Medical Center with deep hypothermic circulatory ... However, as early as 1983, concerns over the physiologic consequences of profound temperature reductions led some to advocate lesser degrees of hypothermia with circulatory arrest (11). Initial concerns focused primarily on bleeding complications thought to result from hypothermia-induced coagulopathy, as well as increased systemic inflammatory response from the prolonged perfusion times required for cooling and rewarming (11,12). More recently, concerns over subtle neurocognitive deficits caused by hypothermic neuronal injury have been raised (13-15), despite reports documenting complete neurocognitive preservation following deep HCA (16). In light of these theoretic concerns along with the advent of cerebral protection strategies, an increasing number of centers now employ ‘moderate’ or even ‘mild’ degrees of systemic hypothermia coupled with selective antegrade cerebral perfusion (SACP) (12,17-21). Although the benefits of SACP with HCA appear well established (10), there remains a lack of objective data demonstrating the superiority, or even non-inferiority, of moderate hypothermia with SACP in comparison to deep hypothermia with SACP, particularly pertaining to visceral organ and spinal cord protection (9). In the present article, we provide a brief overview of the history and evidence that shapes the current controversy regarding the optimal temperature for central nervous system and visceral organ protection with HCA employed during aortic arch repair. We conclude that, given the limitations of existing retrospective observational data, a multi-center randomized trial is needed to directly compare deep and moderate HCA and provide high-quality evidence-based guidelines for this critically important component of aortic arch repair.

The Impact of Functional Dependency on Outcomes After Complex General and Vascular Surgery

OBJECTIVE To describe the outcomes of functionally dependent patients who undergo major general or vascular surgery and to determine the relationship between functional health status and early postoperative outcomes. BACKGROUND In contrast to frailty, functional health status is a relatively easy entity to define and to measure and therefore may be a more practical variable to assess in patients who are being considered for major surgery. To date, few studies have assessed the impact of functional health status on surgical outcomes. METHODS Patients undergoing 1 of 10 complex general or vascular operations were extracted from the 2005 to 2010 America College of Surgeons National Surgical Quality Improvement Program database. Propensity score techniques were used to match patients with and without preoperative functional dependency on known patient- and procedure-related factors. The postoperative outcomes of this matched cohort were then compared. RESULTS A total of 10,246 functionally dependent surgical patients were included for analysis. These patients were more acutely and chronically ill than functionally independent patients, and they had higher rates of mortality and morbidity for each of the 10 procedures analyzed. Propensity-matching techniques resulted in the creation of a cohort of functionally independent and dependent patients who were well matched for known patient- and procedure-related variables. Dependent patients from the matched cohort had a 1.75-fold greater odds of postoperative death (95% confidence interval: 1.54-1.98, P < 0.0001) than functionally independent patients. CONCLUSIONS Preoperative functional dependency is an independent risk factor for mortality after major operation. Functional health status should be routinely assessed in patients who are being considered for complex surgery.

Impact of specific postoperative complications on the outcomes of emergency general surgery patients.

BACKGROUND The relative contribution of specific postoperative complications on mortality after emergency operations has not been previously described. Identifying specific contributors to postoperative mortality following acute care surgery will allow for significant improvement in the care of these patients. METHODS Patients from the 2005 to 2011 American College of Surgeons’ National Surgical Quality Improvement Program database who underwent emergency operation by a general surgeon for one of seven diagnoses (gallbladder disease, gastroduodenal ulcer disease, intestinal ischemia, intestinal obstruction, intestinal perforation, diverticulitis, and abdominal wall hernia) were analyzed. Postoperative complications (pneumonia, myocardial infarction, incisional surgical site infection, organ/space surgical site infection, thromboembolic process, urinary tract infection, stroke, or major bleeding) were chosen based on surgical outcome measures monitored by national quality improvement initiatives and regulatory bodies. Regression techniques were used to determine the independent association between these complications and 30-day mortality, after adjustment for an array of patient- and procedure-related variables. RESULTS Emergency operations accounted for 14.6% of the approximately 1.2 million general surgery procedures that are included in American College of Surgeons’ National Surgical Quality Improvement Program but for 53.5% of the 19,094 postoperative deaths. A total of 43,429 emergency general surgery patients were analyzed. Incisional surgical site infection had the highest incidence (6.7%). The second most common complication was pneumonia (5.7%). Stroke, major bleeding, myocardial infarction, and pneumonia exhibited the strongest associations with postoperative death. CONCLUSION Given its disproportionate contribution to surgical mortality, emergency surgery represents an ideal focus for quality improvement. Of the potential postoperative targets for quality improvement, pneumonia, myocardial infarction, stroke, and major bleeding have the strongest associations with subsequent mortality. Since pneumonia is both relatively common after emergency surgery and strongly associated with postoperative death, it should receive priority as a target for surgical quality improvement initiatives. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.

Traveling to a High-volume Center is Associated With Improved Survival for Patients With Esophageal Cancer

BACKGROUND An association between volume and outcomes has been observed for esophagectomy, though little is known about why or how patients choose low- or high-volume centers. The purpose of this study was to evaluate how travel burden and hospital volume influence treatment and outcomes of patients with locally advanced esophageal cancer. METHODS Predictors of receiving esophagectomy for patients with T1-3N1M0 mid or distal esophageal cancer in the National Cancer Data Base from 2006 to 2011 were identified using multivariable logistic regression. Survival was compared using propensity score-matched groups: patients in the bottom quartile of travel distance who underwent treatment at low-volume facilities (Local) and patients in the top quartile of travel distance who underwent treatment at high-volume facilities (Travel). RESULTS Of 4979 patients who met inclusion criteria, we identified 867 Local patients who traveled 2.7 [interquartile range (IQR): 1.6-4 miles] miles to centers that treated 2.6 (IQR: 1.9-3.3) esophageal cancers per year, and 317 Travel patients who traveled 107.1 (IQR: 65-247) miles to centers treating 31.9 (IQR: 30.9-38.5) cases. Travel patients were more likely to undergo esophagectomy (67.8% vs 42.9%, P < 0.001) and had significantly better 5-year survival (39.8% vs 20.6%, P < 0.001) than Local patients. CONCLUSIONS Patients who travel longer distances to high-volume centers have significantly different treatment and better outcomes than patients who stay close to home at low-volume centers. Strategies that support patient travel for treatment at high-volume centers may improve esophageal cancer outcomes.Background: An association between volume and outcomes has been observed for esophagectomy, though little is known about why or how patients choose low- or high-volume centers. The purpose of this study was to evaluate how travel burden and hospital volume influence treatment and outcomes of patients with locally advanced esophageal cancer. Methods: Predictors of receiving esophagectomy for patients with T1-3N1M0 mid or distal esophageal cancer in the National Cancer Data Base from 2006 to 2011 were identified using multivariable logistic regression. Survival was compared using propensity score-matched groups: patients in the bottom quartile of travel distance who underwent treatment at low-volume facilities (Local) and patients in the top quartile of travel distance who underwent treatment at high-volume facilities (Travel). Results: Of 4979 patients who met inclusion criteria, we identified 867 Local patients who traveled 2.7 [interquartile range (IQR): 1.6–4 miles] miles to centers that treated 2.6 (IQR: 1.9–3.3) esophageal cancers per year, and 317 Travel patients who traveled 107.1 (IQR: 65–247) miles to centers treating 31.9 (IQR: 30.9–38.5) cases. Travel patients were more likely to undergo esophagectomy (67.8% vs 42.9%, P < 0.001) and had significantly better 5-year survival (39.8% vs 20.6%, P < 0.001) than Local patients. Conclusions: Patients who travel longer distances to high-volume centers have significantly different treatment and better outcomes than patients who stay close to home at low-volume centers. Strategies that support patient travel for treatment at high-volume centers may improve esophageal cancer outcomes.

Laparoscopic versus open low anterior resection for rectal cancer: results from the national cancer data base.

BackgroundWhile the use of laparoscopy has increased among patients undergoing colorectal surgery, there is ongoing debate regarding the oncologic equivalence of laparoscopy compared to open low anterior resection (LAR) for rectal cancer.MethodsThe 2010–2011 NCDB was queried for patients undergoing LAR for rectal cancer. Subjects were grouped by laparoscopic (LLAR) versus open (OLAR) technique. Baseline characteristics were compared. Subjects were propensity matched, and outcomes were compared between groups.ResultsA total of 18,765 patients were identified (34.3 % LLAR, 65.7 % OLAR). After propensity matching, all baseline variables were highly similar except for carcinoembryonic antigen (CEA) level. Complete resection was more common in patients undergoing LLAR (91.6 vs. 88.9 %, p < 0.001), and statistically significant benefits were observed for gross, microscopic, and circumferential (>1 mm) margins (all p < 0.001). There was no difference in median number of lymph nodes obtained (15 vs. 15). Patients undergoing LLAR had shorter lengths of stay (5 vs. 6 days, p < 0.001) without a corresponding increase in 30-day readmission rates (6 vs. 7 %, p = 0.02).ConclusionsLaparoscopic LAR appears to result in equivalent short-term oncologic outcomes compared to the traditional open approach as measured via surrogate endpoints in the NCDB. While these results support the increasing use of laparoscopy in rectal surgery, further data are necessary to assess long-term outcomes.