CONTEXT Misdiagnosis of presumed appendicitis is an adverse outcome that leads
to unnecessary surgery. Computed tomography, ultrasonography, and laparoscopy
have been suggested for use in patients ...with equivocal signs of appendicitis
to decrease unnecessary surgery. OBJECTIVE To determine if frequency of misdiagnosis preceding appendectomy has
decreased with increased availability of computed tomography, ultrasonography,
and laparoscopy. DESIGN, SETTING, AND PATIENTS Retrospective, population-based cohort study of data from a Washington
State hospital discharge database for 85 790 residents assigned International Classification of Diseases, Ninth Revision
procedure codes for appendectomy, and United States Census Bureau data for
1987-1998. MAIN OUTCOME MEASURE Population-based age- and sex-standardized incidence of appendectomy
with acute appendicitis (perforated or not) or with a normal appendix. RESULTS Among 63 707 nonincidental appendectomy patients, 84.5% had appendicitis
(25.8% with perforation) and 15.5% had no associated diagnosis of appendicitis.
After adjusting for age and sex, the population-based incidence of unnecessary
appendectomy and of appendicitis with perforation did not change significantly
over time. Among women of reproductive age, the population-based incidence
of misdiagnosis increased 1% per year (P = .005).
The incidence of misdiagnosis increased 8% yearly in patients older than 65
years (P<.001) but did not change significantly
in children younger than 5 years (P = .17). The proportion
of patients undergoing laparoscopic appendectomy who were misdiagnosed was
significantly higher than that of open appendectomy patients (19.6% vs 15.5%; P<.001). CONCLUSION Contrary to expectation, the frequency of misdiagnosis leading to unnecessary
appendectomy has not changed with the introduction of computed tomography,
ultrasonography, and laparoscopy, nor has the frequency of perforation decreased.
These data suggest that on a population level, diagnosis of appendicitis has
not improved with the availability of advanced diagnostic testing.
This systematic literature review was designed to summarize and compare the reported outcomes of one-stage and two-stage operations for the treatment of perforated diverticulitis with peritonitis.
...This review identified 98 published studies (1957-2003) dealing with the surgical management of perforated diverticulitis with peritonitis, either with primary resection and anastomosis or with the Hartmann's procedure. Aggregated results of adverse outcomes were calculated but statistical comparisons were not appropriate because of data and design heterogeneity.
Operative mortality data from patients with diverticular peritonitis undergoing Hartmann's procedure (n = 1,051) were derived from 54 studies. Considering the Hartmann's procedure and its reversal procedures together, the mortality rate was 19.6 percent (18.8 percent for the Hartmann's procedure and 0.8 percent for its reversal), the wound infection rate was 29.1 percent (24.2 percent for the Hartmann's procedure and 4.9 percent for its reversal), and stoma complications and anastomotic leaks (in the reversal operation) occurred in 10.3 and 4.3 percent, respectively. Of 569 reported cases of primary anastomosis from 50 studies, the aggregated mortality rate was 9.9 (range, 0-75) percent with an anastomotic leak rate of 13.9 (range, 0-60) percent and a wound infection rate of 9.6 (range, 0-26) percent.
Reported mortality and morbidity in patients with diverticular peritonitis who underwent primary anastomosis were not higher than those in patients undergoing Hartmann's procedure were. This suggests that primary anastomosis is a safe operative alternative in certain patients with peritonitis. Despite inclusion of only patients with peritonitis in this analysis, selection bias may have been a limitation and a prospective, randomized trial is recommended.
Bariatric procedures are increasingly performed but their impact on survival is unknown.
We evaluated short- and longterm mortality rates of patients undergoing gastric bypass on a population level ...compared with a nonoperated cohort of patients with morbid obesity in a retrospective study, using the Washington State Comprehensive Hospital Abstract Reporting System database and the Vital Statistics database. The study included all patients (age 18 to 65 years) from 1987 to 2001 who underwent gastric bypass with ICD-9 diagnostic codes for obesity. The comparator group included patients of similar age with a diagnosis of obesity or morbid obesity who did not have a bariatric procedure. Survival analysis was used to determine the association of surgeon experience on 30-day mortality and of the procedure on survival while controlling for age, gender, and comorbidity index.
Of the 66,109 obese patients we evaluated, 3,328 had a bariatric procedure. Incidence of the procedure increased from 0.7 to 10.6 per 100,000 from 1987 to 2001, with a 2.5-fold increase in incidence rate of the procedure in the years after 1996 (incidence rate ratio, 2.5; 95% CI, 2.4 to 2.7). Thirty-day mortality was 1.9% and was associated with surgical inexperience. Within the surgeon’s first 19 procedures the odds of death within 30 days were 4.7 times higher (95% CI, 1.2 to 18.2) than at later points in a surgeon’s case order. At 15 years followup, 16.3% of nonoperated patients had died as compared with 11.8% of patients who had the bariatric procedure. When survival was compared beginning 1 year after the procedure, the adjusted hazard for death was 33% lower than that of nonoperated patients (hazard ratio 0.67; 95% CI, 0.54 to 0.85).
Thirty-day mortality after gastric bypass is higher than previously reported and closely linked to surgeon inexperience. A modest overall survival benefit was associated with the procedure but a marked survival advantage was noted for patients who survive to the first postoperative year.
IMPORTANCE: Nonsteroidal anti-inflammatory drugs (NSAIDs) have many physiologic effects and are being used more commonly to treat postoperative pain, but recent small studies have suggested that ...NSAIDs may impair anastomotic healing in the gastrointestinal tract. OBJECTIVE: To evaluate the relationship between postoperative NSAID administration and anastomotic complications. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 13 082 patients undergoing bariatric or colorectal surgery at 47 hospitals in Washington State from January 1, 2006, through December 31, 2010, using data from the Surgical Care and Outcomes Assessment Program linked to the Washington State Comprehensive Abstract Reporting System. EXPOSURE: NSAID administration beginning within 24 hours after surgery. MAIN OUTCOMES AND MEASURES: We used multivariate logistic regression modeling to assess the risk for anastomotic complications (reoperation, rescue stoma, revision of an anastomosis, and percutaneous drainage of an abscess) through 90 days after bariatric and colorectal surgery involving anastomoses. RESULTS: Of the 13 082 patients (mean SD age, 58.1 15.8 years; 60.7% women), 3158 (24.1%) received NSAIDs. The overall 90-day rate of anastomotic leaks was 4.3% for all patients (151 patients 4.8% in the NSAID group and 417 patients 4.2% in the non-NSAID group; P = .16). After risk adjustment, NSAIDs were associated with a 24% increased risk for anastomotic leak (odds ratio, 1.24 95% CI, 1.01-1.56; P = .04). This association was isolated to nonelective colorectal surgery, for which the leak rate was 12.3% in the NSAID group and 8.3% in the non-NSAID group (odds ratio, 1.70 95% CI, 1.11-2.68; P = .01). CONCLUSIONS AND RELEVANCE: Postoperative NSAIDs were associated with a significantly increased risk for anastomotic complications among patients undergoing nonelective colorectal resection. To determine the role of NSAIDs in colorectal surgery, future evaluations should consider specific formulations, the dose effect, mechanism, and other relevant outcome domains, including pain control, cardiac complications, and overall recovery.
CONTEXT Common bile duct (CBD) injury during cholecystectomy is a significant
source of patient morbidity, but its impact on survival is unclear. OBJECTIVE To demonstrate the relation between CBD ...injury and survival and to identify
the factors associated with improved survival among Medicare beneficiaries. DESIGN, SETTING, AND PATIENTS Retrospective study using Medicare National Claims History Part B data
(January 1, 1992, through December 31, 1999) linked to death records and to
the American Medical Association's (AMA's) Physician Masterfile. Records with
a procedure code for cholecystectomy were reviewed and those with an additional
procedure code for repair of the CBD within 365 days were defined as having
a CBD injury. MAIN OUTCOME MEASURE Survival after cholecystectomy, controlling for patient (sex, age, comorbidity
index, disease severity) and surgeon (procedure year, case order, surgeon
specialty) characteristics. RESULTS Of the 1 570 361 patients identified as having had a cholecystectomy
(62.9% women), 7911 patients (0.5%) had CBD injuries. The entire population
had a mean (SD) age of 71.4 (10.2) years. Thirty-three percent of all patients
died within the 9.2-year follow-up period (median survival, 5.6 years; interquartile
range, 3.2-7.4 years), with 55.2% of patients without and 19.5% with a CBD
injury remained alive. The adjusted hazard ratio (HR) for death during the
follow-up period was significantly higher (2.79; 95% confidence interval CI;
2.71-2.88) for patients with a CBD injury than those without CBD injury. The
hazard significantly increased with advancing age and comorbidities and decreased
with the experience of the repairing surgeon. The adjusted hazard of death
during the follow-up period was 11% greater (HR, 1.11; 95% CI, 1.02-1.20)
if the repairing surgeon was the same as the injuring surgeon. CONCLUSIONS The association between CBD injury during cholecystectomy and survival
among Medicare beneficiaries is stronger than suggested by previous reports.
Referring patients with CBD injuries to surgeons or institutions with greater
experience in CBD repair may represent a system-level opportunity to improve
outcome.
To determine if certain outcomes of incisional hernia repair have improved in recent eras.
Technological developments have been reported to improve outcomes in the repair of abdominal wall incisional ...hernias.
This retrospective, population-based cohort study was conducted using a 1987 to 1999 Washington hospital discharge database. Subjects were all Washington state residents assigned ICD9 procedure codes for incisional hernia repair with or without synthetic material (mesh). Main outcome measure was the rate of reoperative incisional hernia repair, length of hospitalization, and hospital charges based on the use of synthetic material and the era of operative repair (before and after 1995).
A total of 10,822 Washington state patients underwent incisional hernia repair (mean age 58.7 +/- 15.6, 64% female). Of patients undergoing incisional hernia repair, 12.3% underwent at least one subsequent reoperative incisional hernia repair within the first 5 years after initial repair (23.1% at 13 years follow-up). The 5-year reoperative rate was 23.8% after the first reoperation, 35.3% after the second, and 38.7% after the third. The use of synthetic mesh in incisional hernia repairs increased from 34.2% in 1987 to 65.5% in 1999. When controlling for age, sex, comorbidity index of the patient, year of the initial procedure, and hospital descriptors (rural location, nonprofit and teaching status), the hazard for recurrence was 24.1% higher if no mesh was used compared to the hazard if mesh was used. After similar adjustment, no differences were found in the hazard of reoperation based on the era of the operative repair. Mean length of stay for procedures performed after 1995 was 4.9 days compared to 4.8 days in preceding eras.
Incisional hernia repair is associated with high cumulative rates of reoperative repairs. The expectation that important measures of adverse outcome have improved in recent eras is not supported by the results of this large population-based study.
This review was designed to describe the diagnostic performance of computed tomography (CT) in assessing bowel ischemia and complete obstruction in small bowel obstruction (SBO). A MEDLINE search ...(1966–2004) identified 15 studies dealing with the CT diagnosis of ischemia and complete obstruction in SBO. Ischemia was defined by operative findings, and complete obstruction was defined by enteroclysis or operative findings. Aggregated sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated. Eleven of 15 studies reported on the CT diagnosis of ischemia in SBO based on 743 patients. The aggregated performance characteristics of CT for ischemia in SBO were sensitivity of 83% (range, 63–100%), specificity of 92% (range, 61–100%), PPV of 79% (range, 69–100%), and NPV of 93% (range, 33.3–100%). Seven of 15 studies evaluated the CT classification of complete obstruction based on 408 patients. The aggregated performance characteristics of CT for complete obstruction were sensitivity of 92% (range, 81–100%), specificity of 93% (range, 68–100%), PPV of 91% (range, 84–100%), and NPV of 93% (range, 76–100%). This review demonstrates the high sensitivity of CT for ischemia in the setting of SBO and suggests that a CT scan finding of partial SBO is likely to reflect a clinical condition that will resolve without surgical intervention.
Objectives The reported rate of abdominal aortic graft infections (AGIs) is low, but its incidence and associated factors have not been evaluated on a population level. We hypothesized that AGI ...occurs more often in patients with periprocedural nosocomial infections and less often after endovascular aneurysm repair (EVAR). Methods A retrospective cohort study was done of all patients undergoing abdominal aortic aneurysm (AAA) repair (1987-2005) in Washington State by using the Comprehensive Hospital Abstract Reporting System (CHARS) data. Nosocomial infection was defined as one or more of pneumonia, urinary tract infections, blood stream septicemia, or surgical site infection at the index admission. Readmissions and reintervention for graft infections defined AGIs excluding the diagnostic code of renal failure or those who appeared to have dialysis grafts. Results Between 1987 and 2005, 13,902 patients (mean age, 71.3 ± 8.8 years; 90.8% men) underwent AAA repair (12,626 open, 1276 EVAR). The cumulative rate of AGIs in the cohort was 0.44%. The 2-year rate of AGI was 0.19% among open vs 0.16% in EVAR ( P = .75) and 0.2% in both elective and nonelective patients. Open procedures had greater rates of perioperative pneumonia (11.1% vs 2.4%, P < .001), blood stream septicemia (1.6% vs 0.7%, P < .01), and surgical site infection (.5% vs 0%, P < .012) compared with EVAR. When individually analyzed, blood stream septicemia (.93% vs 18%, P = .014) and surgical site infection (1.61% vs 0.19%, P = .01) were significantly associated with AGIs. The median time to AGI was 3.0 years, and AGI presented sooner (≤1.4 years) if nosocomial infection occurred at the index admission. This risk of developing AGI after open repair was highest in the first postoperative year (32% of all AGI occurred in year 1). In an adjusted model, blood stream septicemia was significantly associated with AGI (odds ratio, 4.2; 95% confidence interval, 1.5-11.8) Conclusions The incidence of AGI was low, presented most commonly in the first postoperative year, and was similar among patients undergoing open AAA repair and EAVR. Patients with nosocomial infection had an earlier onset of AGI. The 2-year rate of AGI was significantly higher in patients who had blood stream septicemia and surgical site infection in the periprocedural hospitalization. These data may be helpful in directing surveillance programs for AIG.
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