首页期刊导航|The Journal of surgical research.
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The Journal of surgical research.
Academic Press
The Journal of surgical research.

Academic Press

0022-4804

The Journal of surgical research./Journal The Journal of surgical research.
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    Major Surgery and Long Term Cognitive Outcomes: The Effect of Postoperative Delirium on Dementia in the Year Following Discharge

    Mohanty S.Gillio A.Lindroth H.Ortiz D....
    8页
    查看更多>>摘要：? 2021 Elsevier Inc.Background: Delirium is among the most common complications following major surgery. Delirium following medical illness is associated with the development of chronic cognitive decline. The objective of this study was to determine the association of postoperative delirium with dementia in the year following surgery. Materials and methods: This was a retrospective cohort study in a large health network (January 2013 to December 2019). All patients over age 50 undergoing surgery requiring an inpatient stay were included. Our main exposure was an episode of delirium. The primary outcome was a new dementia diagnosis in the 1 y following discharge. Secondary outcomes included hospital length of stay, non-home discharge destination, mortality and rehospitalizations in 1 y. Results: There were 39,665 patients included, with a median age of 66. There were 4156 of 39,665 emergencies (10.5%). Specialties were general surgery (12,285/39,665, 31%) and orthopedics (11,503/39,665, 29%). There were 3327 (8.4%) patients with delirium. Delirious patients were older and were more likely to have comorbid conditions and undergone complex procedures. There were 1353 of 39,665 (3.5%) patients who developed dementia in the year following their surgery; 4930 of 39,665 (12.4%) who died; and 8200 of 39,665 (20.7%) who were readmitted. Delirium was associated with a new dementia diagnosis after adjusting for baseline characteristics (Odds ratio [OR] 13.9; 95% CI, 12.2-15.7). Similarly, delirium was also associated with 1 y mortality (OR 3.1; 95% CI 2.9-3.4) and readmission (OR 1.9, 95% CI 1.7-2.0). Conclusions: Postoperative delirium is the strongest factor associated with development of dementia in the year following a major operation. Strategies to prevent, identify, and treat delirium in the postoperative setting may improve long-term cognitive recovery.
      原文链接:
    • NSTL
    • Elsevier

    Comparative Analysis of Rural-Urban Definitions in Predicting Surgeon Workforce Supply

    Herb J.Stitzenberg K.Holmes M.
    7页
    查看更多>>摘要：? 2021Background: There are multiple different systems that define a rural area in health services research, but few studies compare their ability to measure access to health resources. Our objective was to compare various definitions of rurality to determine which system best measures local surgeon supply. Materials and methods: In this retrospective observational study, we used the 2019 Area Health Resource File to obtain the 2017 county-level supply of general surgeons, surgical subspecialists, and total physicians for all counties in the United States. Physicians per 100,000 population were calculated for each physician measure and were the primary outcomes. The rural-urban measurements included were the Office of Management and Budget 2017 definition, Urban Influence Codes (UIC), Rural-Urban Commuting Codes (RUCCs), and Census urban population within the county. We also developed and tested a measure combining the RUCCs and Census urban population. Linear regression was used to compare performance of these definitions for each outcome using adjusted R2 values. Results: In 3138 counties included in the study, dichotomous measures of rural-urban using the UIC/RUCC had the lowest adjusted R2 values across all outcomes. Quartiles using the Census urban population and the RUCC/Census urban population combined measure had the highest adjusted R2 values for all outcomes. Conclusions: The Census urban population had the best performance in measuring geographic access to surgical care. This study can inform surgical health services researchers who want to include measures of rurality in their analysis.
      原文链接:
    • NSTL
    • Elsevier

    Abdominal Body Contouring: Does Body Mass Index Affect Clinical and Patient Reported Outcomes?

    Christopher A.N.Morris M.P.Patel V.Broach R.B....
    11页
    查看更多>>摘要：? 2021 Elsevier Inc.Background: Obese individuals are thought to be higher risk for complications after excisional abdominal body contouring (EAC) due to co-morbidities and significant tissue resection. Objectives: We comparatively analyzed EAC patients with Body Mass Index (BMI) ≥35 kg/m2 and BMI <35 kg/m2 to highlight key differences in clinical and patient-reported-outcomes (PROs). Methods: Patients ≥18 years-old undergoing EAC by a single surgeon from 01/2018–01/2020 were identified and separated into cohorts based on BMI (<35 and ≥35 kg/m2). Patients were excluded if they had a cosmetic abdominoplasty without history of bariatric surgery or massive weight loss, or if they had <1000 gs of tissue resected. Clinical outcomes and PROs using the BODY-Q were comparatively analyzed. Results: 70 total patients with median BMIs of 30[26–32] and 41[37–45] kg/m2 in each cohort, were identified. Patients with BMI ≥35 kg/m2 were more likely to have higher ASA (P<0.01) and use of incisional negative pressure wound devices (P = 0.042). Alternatively, they were less likely to have had concurrent liposuction (P = 0.05). There were no differences in development of an SSO, SSI or SSOpi (P>0.05) between cohorts. Multivariate logistic regression showed that BMI ≥35 kg/m2, iNPWD and liposuction were not associated with the development of complications. PROs demonstrated improvement in multiple domains despite BMI. Conclusion: There was no association with BMI ≥35 kg/m2 and the development of complications within our cohort. We encourage preoperative weight loss when possible, however these procedures can be performed safely with acceptable outcomes even in individuals who are obese and/or require extensive tissue removal.
      原文链接:
    • NSTL
    • Elsevier

    Perceived Barriers to the De-implementation of Routine Preoperative History & Physicals Preceding Low-risk Ambulatory Procedures: A Qualitative Study of Surgeon Perspectives

    Baskin A.S.Mansour A.I.Kawakibi A.R.Das P.J....
    10页
    查看更多>>摘要：? 2021Background: For patients undergoing surgery at an Ambulatory Surgical Center, recent changes to Centers for Medicare and Medicaid Services policy allow for the omission of a 30-day preoperative History and Physical (H&P). Preoperative H&Ps for low-risk surgery may contribute to health care waste and lead to unnecessary preoperative testing and treatment cascades. Methods: In this qualitative study, we conducted 30 semi-structured interviews with surgeons who frequently perform low-risk surgeries. We aimed to evaluate surgeon perspectives on the continued use of the 30-day preoperative H&P and specifically the potential risks and benefits associated with the elimination of a preoperative H&P requirement from institutional practice. We used an interpretive description approach to generate a thematic description. Results: Most participants felt that the 30-day preoperative H&P was low value and frequently described it as “unnecessary,” “redundant,” or “just checking a box.” Many viewed the 30-day requirement as arbitrary and felt that new H&P findings were rare and unlikely to influence surgical care. The participants who favored the preoperative H&P felt it was a safeguard to ensure “nothing was missed” and were less likely to be burdened by the requirement than participants who felt it was low value. Conclusions: Surgeons performing low-risk procedures question the utility and value of conducting a preoperative H&P within 30 days of surgery. De-implementation of the 30-day preoperative H&P for low-risk patients may increase convenience for patients and providers. Furthermore, it may improve value in surgery by increasing access to services for patients with greater need for preoperative assessment.
      原文链接:
    • NSTL
    • Elsevier

    Machine Learning for Military Trauma: Novel Massive Transfusion Predictive Models in Combat Zones

    Lammers D.Marenco C.Morte K.Conner J....
    7页
    查看更多>>摘要：? 2021Background: Damage control resuscitation has become the standard of care in military and civilian trauma. Early identification of blood product requirements may aid in optimizing the clinical decision-making process while improving trauma related outcomes. This study aimed to assess and compare multiple machine learning models for predicting patients at highest risk for massive transfusion on the battlefield. Methods: Supervised machine learning approaches using logistic regression, support vector machine, neural network, and random forest techniques were used to create predictive models for massive transfusion using standard prehospital and arrival data points from the Department of Defense Trauma Registry, 2008-2016. Seventy percent of the population was used for model development and performance was validated using the remaining 30%. Models were tested for accuracy and compared by standard performance statistics. Results: A total of 22,158 patients (97% male, 58% penetrating injury, median age 25-29 y/o, average Injury Severity Score 9, with an overall mortality of 3%) were included in the analysis. Massive transfusion was required by 7.4% of patients. Overall accuracy was found to be above 90% in all models tested. Following cross validation and model training, the random forest model outperformed the alternatively tested models for precision, recall, and area under the curve. Conclusion: Machine learning techniques may allow for more optimal and rapid identification of combat trauma patients at highest risk for massive transfusion. These powerful approaches may uncover novel correlations and help improve triage, activation of massive transfusion resources, and trauma-related outcomes. Further research seeking to optimize and apply these algorithms to trauma-centered research should be pursued.
      原文链接:
    • NSTL
    • Elsevier

    The Impact of Seatbelt Use on Trauma Outcomes in Adult Motor Vehicle Collision Patients With Rib Fractures: A National ACS-TQP-PUF Database Analysis

    Boserup B.Sutherland M.Paloka R.McKenney M....
    10页
    查看更多>>摘要：? 2021 Elsevier Inc.Background: Motor vehicle collisions (MVCs) are a leading cause of morbidity and mortality. However, there is limited evidence examining the effects seatbelt use has on MVC-related injuries and outcomes in patients with rib fractures. We aim to assess how seatbelt use affects associated injuries and outcomes in adult MVC patients with ≥2 rib fractures. Methods: This retrospective study utilized the American College of Surgeons (ACS) Trauma Quality Programs (TQP) Participant Use File (PUF) Database. Drivers/passengers who sustained ≥2 rib fractures following an MVC and had an AIS ≤2 for extra-thoracic body regions were analyzed. Patients were then subdivided by presence of flail chest into two cohorts, which were subdivided according to injury severity score (ISS) and seatbelt use. Logistic and linear regression was used to assess the impact of seatbelt use on outcomes. Results: Among both low and intermediate ISS classifications, restrained patients in the non-flail chest cohort had decreased incidence of pneumothorax, pulmonary contusion, and liver injury (P < 0.001). After adjusting for confounders, restrained patients (versus unrestrained) had decreased odds of pneumothorax (aOR = 0.91, P = <0.001) and acute respiratory distress syndrome (aOR=0.65, P = 0.02), while having increased odds of splenic laceration (aOR = 1.18, P = 0.003) (intermediate ISS group). Compared to unrestrained patients, restrained non-flail chest patients had a significantly decreased hospital length of stay (LOS) and intensive care unit LOS (P < 0.05). Conclusions: Seatbelt use may be protective against serious injuries in patients with ≥2 rib fractures, resulting in improved outcomes. Education programs should be developed to bolster seatbelt compliance.
      原文链接:
    • NSTL
    • Elsevier

    Perioperative Skeletal Muscle Fluctuations in High-Acuity Liver Transplantation

    Chong J.Guorgui J.Coy H.Ito T....
    8页
    查看更多>>摘要：? 2021 Elsevier Inc.Background: Frailty has been implicated as a negative predictor of Liver Transplant (LT) outcomes. However, an understanding of changes in patient muscle mass peri-LT, and their effect in high-acuity patients remains lacking. We examined the impact of perioperative muscle mass changes (ΔSMI) on high-acuity (MELD ≥35) LT recipients. Materials and Methods: Skeletal muscle index (SMI) was calculated using CT imaging. Patients were divided into two groups, based on severity of peri-operative SMI decrease. LT recipients with chronic end-stage liver disease, MELD ≥35, and abdominal CT ≤30 days prior, and 30-90 days post LT were included. [1011 adult LT recipients reviewed, 2012–2018]. Results: Of 1011 patients reviewed, 88 met inclusion criteria (median MELD 41.1). The median ΔSMI was -5.0 (-29.4 - +21.1 cm2/m2) (fig A). Patients were classified into two groups: ΔSMI<-5.0 (median ΔSMI: -0.4, n = 44) and ΔSMI>-5.0 (median ΔSMI: -9.2, n = 44). Recipients with ΔSMI<-5.0 had higher pre-LT SMI (35.4 versus 31.2 cm2/m2, P <0.001) and lower post-LT SMI (26.0 versus 30.8 cm2/m2, P <0.001). The ΔSMI<-5.0 group had higher early allograft dysfunction (40.9 versus 20.5%, P = 0.037), and inferior patient and graft survival (P = 0.015, 0.017, respectively). Multivariate analysis identified ΔSMI<-5.0 (HR: 2.938, P = 0.048), long cold-ischemia time (≥9h, HR: 7.332, P = 0.008), HCV (HR: 5.614, p = 0.001), and tracheostomy after LT (HR:9.218, P <0.001) as negative prognostic factors for patient survival. Conclusions: Progressive perioperative sarcopenic deterioration was associated with inferior patient and graft survival in high acuity LT. These findings may guide pre and post-operative patient care and rehabilitation efforts in this challenging patient population.
      原文链接:
    • NSTL
    • Elsevier

    Using the Surgical Risk Preoperative Assessment System to Define the “High Risk” Surgical Patient

    Dyas A.R.Bronsert M.R.Meguid R.A.Colborn K.L....
    11页
    查看更多>>摘要：? 2021 Elsevier Inc.Background: Defining a “high risk” surgical population remains challenging. Using the Surgical Risk Preoperative Assessment System (SURPAS), we sought to define “high risk” groups for adverse postoperative outcomes. Materials and Methods: We retrospectively analyzed the 2009-2018 American College of Surgeons National Surgical Quality Improvement Program database. SURPAS calculated probabilities of 12 postoperative adverse events. The Hosmer Lemeshow graphs of deciles of risk and maximum Youden index were compared to define “high risk.” Results: Hosmer-Lemeshow plots suggested the “high risk” patient could be defined by the 10th decile of risk. Maximum Youden index found lower cutoff points for defining “high risk” patients and included more patients with events. This resulted in more patients classified as “high risk” and higher number needed to treat to prevent one complication. Some specialties (thoracic, vascular, general) had more “high risk” patients, while others (otolaryngology, plastic) had lower proportions. Conclusions: SURPAS can define the “high risk” surgical population that may benefit from risk-mitigating interventions.
      原文链接:
    • NSTL
    • Elsevier

    Percutaneous Cholecystostomy Tube for Acute Cholecystitis: Quantifying Outcomes and Prognosis

    Huang R.Patel D.C.Kallini J.R.Wachsman A.M....
    8页
    查看更多>>摘要：? 2021Background: Percutaneous cholecystostomy tubes (PCT) are utilized in the management of acute cholecystitis in patients deemed unsuitable for surgery. However, the drive for these decisions and the outcomes remain understudied. We sought to characterize the practices and utilization of PCT and evaluate associated outcomes at an urban medical center. Methods: Patients undergoing PCT placement over a 12-y study period ending May 2019 were reviewed. Demographics, clinical presentation, labs, imaging studies, and outcomes were abstracted. The primary and secondary outcomes were 30-d mortality and interval cholecystectomy, respectively. Results: Two hundred and four patients met inclusion criteria: 59.3% were male with a median age of 67.5 y and a National Surgical Quality Improvement Program (NSQIP) risk of serious complication of 8.0%. Overall, 57.8% of patients were located in an intensive care unit setting. The majority (80.9%) had an ultrasound and 48.5% had a hepatobiliary iminodiacetic acid scan. The overall 30-d mortality was 31.9%: 41.5% for intensive care unit and 18.6% for ward patients (P < 0.01). Of patients surviving beyond 30 d (n = 139), the PCT was removed from 106 (76.3%), and a cholecystectomy was performed in 55 (39.6%) at a median interval of 58.0 d. A forward logistic regression identified total bilirubin (Adjusted Odds Ratio: 1.12, adjusted P < 0.01) and NSQIP risk of serious complication (Adjusted Odds Ratio: 1.16, adjusted P < 0.01) as the only predictors for 30-d mortality. Conclusions: Patients selected for PCT placement have a high mortality risk. Despite subsequent removal of the PCT, the majority of surviving patients did not undergo an interval cholecystectomy. Total bilirubin and NSQIP risk of serious complication are useful adjuncts in predicting 30-d mortality in these patients.
      原文链接:
    • NSTL
    • Elsevier

    Perioperative Outcomes After Combined Esophagectomy and Lung Resection

    Patel D.C.Bhandari P.Shrager J.B.Berry M.F....
    8页
    查看更多>>摘要：? 2021 Elsevier Inc.Introduction: The impact of concomitant lung resection during esophagectomy on short-term outcomes is not well characterized. This study tests the hypothesis that lung resection at the time of esophagectomy is not associated with increased perioperative morbidity or mortality. Methods: Perioperative outcomes for esophageal cancer patients who underwent esophagectomy alone (EA) were compared to patients who had concurrent esophagectomy and lung resection (EL) using the NSQIP database between 2006-2017. Predictors of morbidity and mortality, including combined surgery, were evaluated using multivariable logistic regression. Results: Among the 6,225 study patients, 6,068 (97.5%) underwent EA and 157 (2.5%) underwent EL. There were no differences in baseline characteristics between the two groups. Operating time for EL was longer than EA (median 416 versus 371 minutes, P < 0.01). Median length of stay was 10 d for both groups. Perioperative mortality was not significantly different between EL and EA patients (5.1% versus 2.8%, P = 0.08). EL patients had higher rates of postoperative pneumonia (22.3% versus 16.2%, P = 0.04) and sepsis (11.5% versus 7.1%, P = 0.03), however major complication rates overall were similar (40.8% versus 35.3%, P = 0.16). Combining lung resection with esophagectomy was not independently associated with increased postoperative morbidity (AOR 1.21 [95% CI 0.87-1.69]) or mortality (AOR 1.63 [95% CI 0.74-3.58]). Conclusions: Concurrent lung resection during esophagectomy is not associated with increased mortality or overall morbidity, but is associated with higher rates of pneumonia beyond esophagectomy alone. Surgeons considering combined lung resection with esophagectomy should carefully evaluate the patient's risk for pulmonary complications and pursue interventions preoperatively to optimize respiratory function.
      原文链接:
    • NSTL
    • Elsevier