James I. Merlino

Predictors and Outcome of Readmission after Laparoscopic Intestinal Surgery

BackgroundPrevious studies have failed to identify predictors of early readmission after major intestinal operations. The objectives of this study were to determine readmission rates, outcomes, and predictors of readmission for patients undergoing laparoscopic colon and rectal operations.MethodsPatients readmitted (PR) to the hospital within 30 days of discharge after laparoscopic colon and rectal operations were identified from a prospectively maintained database. The PR group was compared with patients that were not readmitted (NR). Outcomes and variables related to readmission were evaluated.ResultsThere were 820 consecutive elective laparoscopic colon and rectal operations performed over a 5-year period, with adequate follow-up data for 787 cases. Seventy-nine (10%) patients were readmitted. There was no difference in the age, sex, surgeon, or type of operation between the PR and NR groups. The most common causes for readmission were bowel obstruction (19%), ileus (18%), intra-abdominal abscess (14%), and anastomotic leak (9%). Overall mean (median) length of stay (LOS) for the index admission was 3.7 ± 4.3 (3.0) days. Patients in the PR group had a trend toward a longer index admission LOS than the NR group (5.4 ± 8.8 [3.0] versus 3.5 ± 3.3 [3.0], p = 0.068). Univariate analysis demonstrated that patients with inflammatory bowel disease, pulmonary comorbidities, and steroid use were more likely to be readmitted. Multivariate analysis confirmed that inflammatory bowel disease and pulmonary comorbidity are independent risk factors for readmission.ConclusionsEarly readmission after laparoscopic colon and rectal operations is not associated with early discharge. Identification of specific patient characteristics indicating risk for early readmission may allow for selective changes in perioperative care or discharge criteria to avoid unexpected readmission.

Erratum: Predictors and outcome of readmission after laparoscopic intestinal surgery (World Journal of Surgery (2007) 31, 11 (2138-2143) DOI: 10.1007/s00268-007-9236-7)

Erratum to: World J Surg DOI 10.1007/s00268-007-9236-7The original version of this article, published online on September 25, 2007 and in print in the November 2007 issue (vol 31/no 11, pp 2138–2143), did not include the full list of authors’ names. The correct list of authors and their affiliations are shown below.The article is reprinted in its entirety.AbstractBackground Previous studies have failed to identify predictors of early readmission after major intestinal operations. The objectives of this study were to determine readmission rates, outcomes, and predictors of readmission for patients undergoing laparoscopic colon and rectal operations.MethodsPatients readmitted (PR) to the hospital within 30 days of discharge after laparoscopic colon and rectal operations were identified from a prospectively maintained database. The PR group was compared with patients that were not readmitted (NR). Outcomes and variables related to readmission were evaluated.ResultsThere were 820 consecutive elective laparoscopic colon and rectal operations performed over a 5-year period, with adequate follow-up data for 787 cases. Seventy-nine (10%) patients were readmitted. There was no difference in the age, sex, surgeon, or type of operation between the PR and NR groups. The most common causes for readmission were bowel obstruction (19%), ileus (18%), intra-abdominal abscess (14%), and anastomotic leak (9%). Overall mean (median) length of stay (LOS) for the index admission was 3.7 ± 4.3 (3.0) days. Patients in the PR group had a trend toward a longer index admission LOS than the NR group (5.4 ± 8.8 [3.0] versus 3.5 ± 3.3 [3.0], p = 0.068). Univariate analysis demonstrated that patients with inflammatory bowel disease, pulmonary comorbidities, and steroid use were more likely to be readmitted. Multivariate analysis confirmed that inflammatory bowel disease and pulmonary comorbidity are independent risk factors for readmission.ConclusionsEarly readmission after laparoscopic colon and rectal operations is not associated with early discharge. Identification of specific patient characteristics indicating risk for early readmission may allow for selective changes in perioperative care or discharge criteria to avoid unexpected readmission.

Prospective Randomized Trials Affect the Outcomes of Intraabdominal Infection

ObjectiveTo compare the characteristics and outcomes of patients with intraabdominal infections enrolled in prospective randomized trials (PRTs) with those of a cohort of patients not enrolled in a trial. Summary Background DataProspective randomized trials are the gold standard for the evaluation of new treatments. Patients are screened using rigorous eligibility criteria and sometimes are excluded from PRTs because of associated medical conditions or more severe illness. However, the effect that the exclusion of these patients has on the applicability of clinical trial outcomes has not been defined. MethodsOne hundred sixty-eight adults with intraabdominal infection were treated at a single institution during 7 years. Fifty-three patients were enrolled in four PRTs comparing various antibiotic regimens for treatment; 115 were not enrolled. Patient characteristics and outcomes of these two groups were compared. ResultsPatients with infections from appendicitis (n = 68) had a low severity of illness and similar outcomes in both groups. These patients and those for whom a concurrent PRT was unavailable were excluded from subsequent analysis. Eighty-eight patients (42 PRT, 46 not enrolled) with serious infection remained for analysis. Patients enrolled in PRTs were younger, had less severe illness, had a decreased length of stay, a lower incidence of antibiotic resistance, and less frequent extraabdominal infections than those not enrolled in a trial. Patients enrolled in PRTs were more likely to be cured and were less likely to die. Logistic regression analysis demonstrated that cure was associated with a lower initial severity of illness, absence of antibiotic resistance, and participation in a PRT. ConclusionsPatients with intraabdominal infection enrolled in PRTs have an increased likelihood of cure and survival. This is due in part to a lower incidence of antibiotic resistance, which may reflect improved drug selection. Patients not enrolled in PRTs are at greater risk for treatment failure and death because of concomitant illness. Outcomes from PRTs may not be applicable to all patients with intraabdominal infections.

Nosocomial infections adversely affect the outcomes of patients with serious intraabdominal infections.

BACKGROUND Patients with serious intraabdominal infections (IAI) who subsequently acquire nosocomial infections (NI) have been shown to have adverse outcomes. We evaluated factors that put patients at risk for developing NI and examined the effect of the NI on outcomes. METHODS This study was a retrospective review of NI among 168 patients diagnosed with IAI over a seven-year period. RESULTS Sixty-six patients (39.3%) developed 98 NI (23 urinary tract, 20 surgical site, 19 pneumonia, 14 bloodstream, 12 recurrent peritonitis, seven intravascular catheter-related, and three enteric). There were 35 males and 31 females. Patients with NI were older (56.0 +/- 18.3 vs. 47.0 +/- 15.6 years, p = 0.001), had a higher admission APACHE II score (10.7 +/- 6.1 vs. 7.5 +/- 5.1 points, p = 0.001), and more often had concomitant medical diagnoses (27.3% vs. 12.7%, OR = 2.57, 95% CI: 1.159-5.69, p = 0.018) than those who did not develop infection. Antimicrobial resistance among the IAI was higher in the NI group (19.7 vs. 5.9%, OR = 3.93, 95% CI: 1.41-10.93, p = 0.006). Patients who developed NI had an increased mortality rate (27.0% vs. 4.0%, OR = 8.87, 95% CI: 2.82-27.86, p < or = 0.0001), longer hospital stay (24.7 +/- 19.5 vs. 11.7 +/- 8.1 days, p < or = 0.0001), required more days of intravenous antibiotics (11.5 +/- 8.0 vs. 7.6 +/- 4.4 days, p < or = 0.0001), and were more likely to be admitted to an intensive care unit (54.5% vs. 25.5%, OR = 3.51, 95% CI: 1.82-6.77, p < or = 0.0001). Multivariate analysis demonstrated that antimicrobial resistance and an APACHE II score of > or = 10 independently predicted the development of a nosocomial infection. Age >/= 50 years, APACHE II score > or = 10, or the presence of a NI independently predicted death. CONCLUSIONS The development of NI following treatment of an IAI significantly affects mortality, hospital length of stay, and treatment. Early recognition and treatment of these infections, combined with strategies to prevent NI, may be important to improve outcomes in this patient population.

Invasive pulmonary mucormycosis with ruptured pseudoaneurysm

A 67-year-old man presented with a dry cough. His medical history was notable for diabetes, prior cadaveric kidney transplantation, and immunologic suppression with daily prednisone and FK-506. Admission chest radiography demonstrated a pulmonary infiltrate. Subsequent bronchoalveolar lavage cultures were positive for methicillin-resistant Staphylococcus aureus. Despite antibiotics he developed hemoptysis, increasing infiltrates, and an enlarging left-sided pleural effusion. Chest computed tomographic scan demonstrated a large, heterogeneous intraparenchymal pulmonary mass consistent with a hematoma and free intrapleural fluid (Fig 1). Pulmonary arteriography confirmed the diagnosis of pseudoaneurysm of the pulmonary artery (Fig 2). During the operation, the pleural space was filled with fresh clot. Proximal control of the pulmonary artery, followed by evacuation of hematoma and left lower lobectomy with lingulectomy were performed. The large defect in the pulmonary artery was excised with the specimen, and the vessel was transected through grossly normal tissue. An intercostal muscle flap was used to separate the arterial and vascular closures. Intraoperative cultures were positive for methicillin-resistant Staphylococcus aureus, Enterococcus faecalis, and zygomyces. Pathologic work-up demonstrated invasive mucormycosis within the arterial walls. Figure 3 shows a cross-section of pulmonary artery with fungal hyphae invading wall (Gomori 61 second methemamine silver stain, original magnification 500). He was treated with antibiotics, amphotericin B, discontinuation of immunologic suppression, and hemodialysis. He was discharged from the hospital on postoperative day 26. Mucormycosis is an opportunistic invasive fungal infection generally affecting immunocompromised patients [1–3]. Classic presentation is a cavitary pulmonary lesion on chest radiograph [2]. Invasion into surrounding structures including vessels and bronchi is common. Pseudoaneurysm develops after invasion and contained rupture of a pulmonary vessel. Diagnosis is usually delayed and frequently is established postmortem [1, 2]. Upon diagnosis amphotericin B should be started immediately [3]. Resection of localized disease improves survival, but despite aggressive treatment the mortality rate still approaches 80% [4].