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What If We Do Not Operate? Outcomes of Nonoperatively Managed Emergency General Surgery Patients.

ABSTRACT:

Introduction

Although two-thirds of patients with emergency general surgery (EGS) conditions are managed nonoperatively, their long-term outcomes are not well described. We describe outcomes of nonoperative management in a cohort of older EGS patients and estimate the projected risk of operative management using the NSQIP Surgical Risk Calculator (SRC).

Materials and methods

We studied single-center inpatients aged 65 y and more with an EGS consult who did not undergo an operation (January 2019-December 2020). For each patient, we recorded the surgeon's recommendation as either an operation was "Not Needed" (medical management preferred) or "Not Recommended" (risk outweighed benefits). Our main outcome of interest was mortality at 30 d and 1 y. Our secondary outcome of interest was SRC-projected 30-day postoperative mortality risk (median % [interquartile range]), calculated using hypothetical low-risk and high-risk operations.

Results

We included 204 patients (60% female, median age 75 y), for whom an operation was "Not Needed" in 81% and "Not Recommended" in 19%. In this cohort, 11% died at 30 d and 23% died at 1 y. Mortality was higher for the "Not Recommended" cohort (37% versus 5% at 30 d and 53% versus 16% at 1 y, P < 0.05). The SRC-projected 30-day postoperative mortality risk was 3.7% (1.3-8.7) for low-risk and 5.8% (2-11.8) for high-risk operations.

Conclusions

Nonoperative management in older EGS patients is associated with very high risk of short-term and long-term mortality, particularly if a surgeon advised that risks of surgery outweighed benefits. The SRC may underestimate risk in the highest-risk patients.

SUBMITTER: Deverakonda DL

PROVIDER: S-EPMC9911375 | biostudies-literature | 2023 Apr

REPOSITORIES: biostudies-literature

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What If We Do Not Operate? Outcomes of Nonoperatively Managed Emergency General Surgery Patients.

Deverakonda Divya L DL Kishawi Sami K SK Lapinski Mariah F MF Adomshick Victoria J VJ Siff Jonathan E JE Brown Laura R LR Ho Vanessa P VP

The Journal of surgical research 20221216

<h4>Introduction</h4>Although two-thirds of patients with emergency general surgery (EGS) conditions are managed nonoperatively, their long-term outcomes are not well described. We describe outcomes of nonoperative management in a cohort of older EGS patients and estimate the projected risk of operative management using the NSQIP Surgical Risk Calculator (SRC).<h4>Materials and methods</h4>We studied single-center inpatients aged 65 y and more with an EGS consult who did not undergo an operation ...[more]

PMID: 36529078

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Project description:IntroductionTransferred emergency general surgery (EGS) patients are a vulnerable, high acuity population. The outcomes of and health care utilization among transferred (TRAN) as compared to directly admitted (DA) patients have been studied primarily using single institution or hospital system data which limits generalizability. We evaluated these outcomes among EGS patients using a national database.MethodsWe identified encounters of patients aged ≥18 years with a diagnosis of EGS as defined by the American Association for the Surgery of Trauma in the 2008-2011 Nationwide Inpatient Sample (NIS). Multivariable regression analyses determined if transfer status independently predicted in-hospital mortality (logistic regression) and morbidity (presence of any complication among those who survived to discharge; logistic regression), cost (log-linear regression), and duration of stay (among those who survived to discharge; log-linear regression) accounting for the NIS sampling design.ResultsWe identified 274,145 TRAN (57,885 unweighted) and 10,456,100 DA (2,187,132 unweighted) encounters. On univariate analysis, TRAN patients were more likely to have greater comorbidity scores, have Medicare insurance, and reside in an area with a lesser median household income compared to DA patients (p<0.0001). Mortality was greater in the TRAN vs DA groups (4.4% vs 1.6%; p<0.0001). Morbidity (presence of any complication) was also greater among TRAN patients (38.8% vs 26.1%; p<0.0001). Morbidity among TRAN patients was primarily due to urinary- (13.7%), gastrointestinal- (12.9%), and pulmonary-related (13.3%) complications. Median duration of hospital stay was 4.3 days for TRAN vs 3.0 days for DA (p<0.0001) patients. Median cost was greater for TRAN patients ($8,935 vs $7,167; p<0.0001). Regression analyses determined that after adjustment, TRAN patients had statistically significantly greater mortality, morbidity, and cost as well as longer durations of stay.ConclusionsEGS patients who are transferred experience increased in-hospital morbidity and mortality as well as increased durations of stay and cost. As the population and age of patients diagnosed with EGS conditions increase while the EGS workforce decreases, the need for inter-hospital transfers will increase. Identifying risk factors associated with worse outcomes among transferred patients can inform the design of initiatives in performance improvement and direct the finite resources available to this vulnerable patient population.

Project description:BackgroundThere continues to be controversy regarding treatment options for Achilles tendon ruptures (ATR). The aim of our study is to compare outcomes between operatively and nonoperatively managed Achilles ruptures in young adults (age 18-30 years), which has not been previously evaluated.MethodsAt a single institution, all patients aged 18-30 years at time of injury who underwent treatment for an acute ATR from 2014 to 2021 were evaluated. Medical records were reviewed to collect demographics, dates of injury and treatment, smoking status, body mass index (BMI), Charlson Comorbidity Index (CCI), rate of deep venous thrombosis (DVT) after treatment, and rate of rerupture. Patients then completed Patient-Reported Outcomes Measurement Information System (PROMIS) physical function (PF) and pain interference (PI) questionnaires. Mann-Whitney nonparametric testing was used to evaluate for any statistical differences in PROMIS scores.ResultsSixty-six operative patients qualified and 28 (42%) participated. Thirty-seven nonoperative patients qualified and 14 (38%) participated. All patients had a CCI of 0. One patient in the operative cohort and 2 in the nonoperative reported active smoking. In the operative and nonoperative cohorts, respectively, the average age was 24.4 and 27.8 years; average BMI 26.5 (SD = 4.8) and 27.3 (SD = 4.3, P = .52); DVT rates 4 (6.1%) and 2 (5.4%); and rerupture rates 2 (3.0%) and 1 (2.7%), respectively. PROMIS scores did not differ in the operative and nonoperative groups: PROMIS PF mean of 60.4 (SD = 9.8) and 62.9 (SD = 9.1), respectively (P = .33); as well as PROMIS PI mean of 44.6 (SD = 5.9) and 43.9 (SD = 6.5), respectively (P = .59).ConclusionThis study should be interpreted with the understanding that we had a considerable loss to follow-up rate. In the study cohort, we found that young adults with ATR may be considered for either operative or nonoperative management. Rates of DVT, rates of rerupture, and PROMIS scores were not dissimilar between the 2 cohorts.Level of evidenceLevel III, retrospective cohort study.

Project description:PurposeThe purposes of this study were to determine whether patients with mild biceps tendonitis required revision surgery after the biceps tendon was not surgically treated, while addressing concomitant pathology, and to evaluate whether preoperative groove pain affected patient-reported outcomes.MethodsPatients who underwent shoulder arthroscopy between 2015 and 2018 by a single surgeon for rotator cuff pathology, debridement, and distal clavicular excision (DCE), with or without subacromial decompression (SAD), and where the biceps tendon was not surgically addressed were retrospectively identified. Inclusion criteria were mild LS (<50% hyperemic appearing biceps tendon arthroscopically), and a minimum 2-year follow-up. The primary outcome measure was the incidence of revision surgery. Secondary outcomes included American Shoulder and Elbow Surgeons (ASES) score, simple shoulder test (SST), pain level, and satisfaction scores. Two sample t-tests compared postoperative patient-reported outcomes based on the presence or absence of preoperative bicipital groove tenderness.ResultsSixty-four of 69 eligible subjects (93%) were evaluated at a minimum of 2 years postoperatively. One out of 64 subjects underwent revision to perform a biceps tenodesis. Overall, patients had high patient-reported outcome measures (PROMs) postoperatively. Ninety-seven percent of patients reported they would have the surgery again. The presence of preoperative bicipital groove tenderness had no effect on ASES (P = .62), SST (P = .83) scores, and postoperative pain (P = .65). Patients without bicipital groove pain had average respective ASES and SST scores of 93.70 ± 11.84 and 10.66 ± 2.47; those with bicipital groove pain averaged 92.00 ± 15.31 and 10.78 ± 1.87. There was no significant difference in overall satisfaction scores between patients with groove pain (9.42 ± 1.40) and those without (9.46 ± 1.38; P = .92).ConclusionsPatients with mild biceps tendonitis showed favorable outcomes with low revision rates and high patient satisfaction when the biceps tendon was not surgically addressed when the primary shoulder pathology was treated during arthroscopy, independent of preoperative groove pain.Level of evidenceLevel III, retrospective cohort study.

Project description:BackgroundLateral talar subluxation (LTS) was introduced as a measurement tool for evaluating isolated Weber B ankle fractures, with LTS >4 mm on gravity stress (GS) radiographs possibly indicating need for surgery. This study reviews LTS measurements in nonoperatively managed isolated Weber B fibula fractures to further investigate the validity of this previously stated cutoff.MethodsThe senior authors previously reported outcomes of a novel algorithm for nonoperative management of isolated Weber B ankle fractures. Outcome scores reported include American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot, Olerud-Molander (OMA), Foot and Ankle Ability Measure for activities of daily living (FAAM/ADL), and visual analog scale (VAS) scores. All patients achieved union of their fracture. LTS was measured on GS radiographs of both injured and contralateral uninjured extremities.ResultsForty-two patients were included with minimum 1-year follow-up. Average age was 49 years (range 19-72). Mean measurements on injury GS radiographs were as follows: medial clear space (MCS) 4.45 mm (SD = 0.93), superior clear space (SCS) 3.46 mm (SD = 0.70), and LTS 2.33 mm (SD = 1.57, range 0-4.7 mm), with 35 (83.3%) patients having injury LTS ≤4 mm. Mean measurements on contralateral (uninjured) GS radiographs were as follows: MCS 3.39 mm (SD = 0.63), SCS 3.15 mm (SD = 0.50), and LTS 1.30 mm (SD = 1.28, range 0-4.8 mm). There was no statistically significant difference in all outcome measures based on amount of LTS (<2 mm, 2-4 mm, >4 mm).ConclusionMost patients had injury LTS ≤4 mm, although those with LTS >4 mm had excellent outcome scores. LTS measurements on normal ankles reveal a large range. LTS may be a useful adjunct in evaluating isolated Weber B ankle fractures but the 4-mm cutoff may not be entirely reliable. Further studies are required to validate LTS as a decision-making tool.Level of evidenceLevel IV, case series.

Project description:IntroductionDue to immunosuppression and underlying comorbidities, transplant recipients represent a vulnerable population following emergency general surgery (EGS) operations. The present study sought to evaluate clinical and financial outcomes of transplant patients undergoing EGS.MethodsThe 2010-2020 Nationwide Readmissions Database was queried for adults (≥18 years) with non-elective EGS. Operations included bowel resection, perforated ulcer repair, cholecystectomy, appendectomy and lysis of adhesions. Patients were classified by transplant history (Non-transplant, Kidney/Pancreas, Liver, Heart/Lung). The primary outcome was in-hospital mortality while perioperative complications, resource utilization and readmissions were secondarily considered. Multivariable regression models evaluated the association of transplant status on outcomes. Entropy balancing was employed to obtain a weighted comparison to adjust for intergroup differences.ResultsOf 7,914,815 patients undergoing EGS, 25,278 (0.32 %) had prior transplantation. The incidence of transplant patients increased temporally (2010: 0.23 %, 2020: 0.36 %, p < 0.001) with Kidney/Pancreas comprising the largest proportion (63.5 %). Non-transplant more frequently underwent appendectomy and cholecystectomy while transplant patients more commonly received bowel resections. Following entropy balancing, Liver was associated with decreased odds of mortality (AOR: 0.67, 95 % CI: 0.54-0.83, Reference: Non-transplant). Incremental hospitalization duration was longer in Liver and Heart/Lung compared to Non-transplant. Odds of acute kidney injury, readmissions and costs were higher in all transplant types.ConclusionThe incidence of transplant recipients undergoing EGS operations has increased. Liver was observed to have lower mortality compared to Non-transplant. Transplant recipient status, regardless of organ, was associated with greater resource utilization and non-elective readmissions. Multidisciplinary care coordination is warranted to mitigate outcomes in this high-risk population.

Project description:BackgroundOutcomes for patients undergoing emergency thoracic operations have not been well described. This study was designed to compare postoperative outcomes among patients undergoing emergency versus nonemergency thoracic operations.MethodsWe retrospectively analyzed the American College of Surgeons National Surgical Quality Improvement Program database (2005-2018). We identified patients who underwent emergency thoracic operations using current procedural technology codes. Patients were then sorted into 1 of 4 cohorts: lung and chest wall, hiatal hernia, esophagus, and pericardium. Emergency versus nonemergency outcomes were compared. Univariate logistic regression was performed with "emergency status" as the independent variable and 30-day postoperative outcomes as the dependent variables. Multiple logistic regression models were performed to control for preoperative factors.ResultsOf 90,398 thoracic operations analyzed, 4,044 (4.5%) were emergency. Common emergency operations were pericardial window (n = 580, 10.2%), laparoscopic hiatal hernia repair (n = 366, 8.9%), thoracoscopic partial lung decortication (n = 334, 8.1%), thoracoscopic wedge resection (n = 301, 7.3%), thoracoscopic total lung decortication (n = 256, 6.2%), and open repair of hiatal hernia without mesh (n = 254, 6.2%). In all 4 cohorts, 30-day postoperative complications occurred more frequently after emergency surgery. After controlling for patient characteristics, 8 complications were more frequent after emergency lung and chest wall surgery, 5 complications were more frequent after emergency hiatal hernia surgery, and 3 complications were more frequent after emergency pericardium surgery. Risk-adjusted complications were not different after emergency esophageal surgery.ConclusionPatients undergoing emergency thoracic operations have worse risk-adjusted outcomes than those undergoing nonemergency thoracic operations. Subset analysis is needed to determine what factors contribute to increased adverse outcomes in specific patient populations.

Project description:BackgroundAlthough nearly 1 million older adults are admitted for emergency general surgery conditions yearly, the extent to which baseline health influences the development and treatment of emergency general surgery conditions is unknown. We evaluated baseline health and older patients with and without emergency general surgery conditions.MethodsWe used the prospectively collected Medicare Current Beneficiary Survey with Medicare claims and 2 validated health frameworks: (1) Deficit Accumulation Frailty Score and (2) Complex Multimorbidity. Self-reported health and function items were used to derive pre-emergency general surgery conditions Deficit Accumulation Frailty Score and Complex Multimorbidity scores. Deficit Accumulation Frailty Score ranges from 0 (no frailty deficits) to 100 (all possible deficits present). Complex Multimorbidity is a 3-point categorical rank based on the presence of chronic conditions, functional limitations, and geriatric syndromes. Specific survey factors were also examined to determine association with development of emergency general surgery conditions or use of operative management.ResultsOf 54,417 individuals, 1,960 had emergency general surgery conditions (median age 79 [interquartile range 73-84]). Patients with emergency general surgery conditions had significantly higher Deficit Accumulation Frailty Score (19 [interquartile range 11-31] vs 14 [8-24]) and were more likely to be in the most severe Complex Multimorbidity category (38% vs 29%). Emergency general surgery conditions patients had higher proportions of nearly every health category, with the most striking differences in functional limitations. Patients who were treated nonoperatively had the poorest overall baseline health.ConclusionPatients who developed emergency general surgery conditions had more severe health burden than patients who did not, particularly in functional status. Clinicians must better understand the interaction between baseline health vulnerability and emergency surgical disease to improve prognostication and ensure alignment of patient goals and treatment strategies.

Dataset Information

What If We Do Not Operate? Outcomes of Nonoperatively Managed Emergency General Surgery Patients.

Introduction

Materials and methods

Results

Conclusions

Publications

What If We Do Not Operate? Outcomes of Nonoperatively Managed Emergency General Surgery Patients.

Similar Datasets

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