Emergent Open Repair Research Articles

Prehospital Needle Decompression of Suspected Tension Pneumothorax: Outcomes and Consequences.

Tension pneumothorax (TPT) identified in the prehospital setting requires prehospital needle decompression (PHND). This study aimed to evaluate complications from PHND when it was performed without meeting clinical criteria. A retrospective review was performed of patients undergoing (PHND) from 2016 through 2022 at a level 1 trauma center. Patient data who received PHND were reviewed. Of 115 patients, 85 did not meet at least one clinical criterion for PHND. The majority of patients in this cohort 76 (89%) required a chest tube and 22 (25%) had an iatrogenic pneumothorax from PHND. 5 patients (6%) were admitted due to iatrogenic PHND. Two vascular injuries in this population were directly due to PHND and required emergency operative repair. This study shows the negative consequences of PHND when performed without clear indications. Several patients underwent unnecessary procedures with significant clinical consequences.

Current management of acute Stanford type A aortic dissection complicated with mesenteric malperfusion

The management of acute type A aortic dissection (aTAAD) with mesenteric malperfusion (MMP) is quite challenging as it is often associated with high mortality and poor outcomes, and an optimal treatment strategy is lack of consensus for this critically ill condition. Emergent open surgical repair of the ascending aorta is a life-saving operation and remains the standard of care for aTAAD with MMP, but is associated with a high rate of mortality. In recent years, reperfusion of superior mesenteric artery (SMA) by endovascular repair as the first treatment strategy in the treatment of aTAAD with MMP has been concerned and reported. Only endovascular repair and conservative medical treatment are also introduced in few cases with poor outcomes. There are many urgent issues that need to be addressed in current strategies. The optimal management strategies remain controversial, and further investigation and research are needed. These issues were addressed in this article.

The management of patients with popliteal artery aneurysms presenting with acute limb ischemia

ObjectiveEndovascular popliteal artery aneurysm (PAA) repair has acceptable outcomes compared with open repair for elective therapy. Endovascular repair for urgent PAA causing acute limb ischemia (ALI) has not been well-studied. This project compares outcomes of urgent endovascular and open repair of PAA with ALI. MethodsThe Vascular Quality Initiative database for peripheral vascular interventions (PVIs) and infrainguinal bypass were reviewed for PAAs with ALI from 2010 to 2021. Only patients entered as having symptoms of ALI in the PVI module and ALI as indication in the infrainguinal bypass module were included. In addition, patients undergoing elective treatment were excluded and the sample analyzed was restricted to patients undergoing urgent and emergent open and endovascular repair. Patient demographics and comorbidities as well as procedural details were compared between the two groups. Perioperative complications up to 30 days were compared as well as long-term outcomes including major amputation and mortality at 1 year. ResultsUrgent PAA repair for ALI constituted 10.5% (n = 571) of all PAAs. Most urgent repairs were open (80.6%; n = 460) with 19.4% (n = 111) endovascular. The proportion of endovascular repair significantly increased from 16.7% in 2010 to 85.7% in 2021. Patients undergoing endovascular repair were older (71.2 ± 12.5 vs 68.0 ± 11.8; P = .011) than patients undergoing open repair. They were also more likely to have coronary artery disease (32.4% vs 21.7%; P = .006). Open PAA repair was associated with more bleeding complications (20.8% vs 2.7%; P < .001), longer postoperative length of stay (8.1 ± 9.3 days vs 4.9 ± 5.6 days; P < .001), and less likelihood of discharge to home (64.9% vs 70.3%; P = .051). Perioperative major amputation rate was 7.5% with no difference between the two treatment strategies up to 1 year. However, patients receiving endovascular repair had higher inpatient (1.1% vs 0%; P < .001), 30-day (6.3% vs 0.4%; P < .001), and 1-year (16.5% vs 8.4%; P = .02) mortality. Multivariable regression analysis suggested that endovascular repair was possibly associated with increased 30-day mortality, but not 1-year mortality. ConclusionsEndovascular PAA has exponentially increased from 2010 to 2021. Endovascular repair is associated with decreased complications and hospital length of stay. The increased perioperative mortality seen in this group is likely due to selection bias.

Emergent open repair of a symptomatic type III thoracoabdominal aneurysm.

Emergent open repair of a symptomatic type III thoracoabdominal aneurysm.

The impact of prior cardiac surgery on patients undergoing surgical repair for acute type A aortic dissection.

To determine the impact of reoperative versus first-time sternotomy for emergent open repair of acute Type A aortic dissection (ATAAD). This was an observational study of consecutive aortic surgeries from 2007 to 2021. Kaplan-Meier survival estimation and multivariable Cox regression analysis were performed to assess the impact of reoperative versus first-time sternotomy upon survival after ATAAD repair. A total of 601 patients with ATAAD were identified, of which 72 (12%) underwent reoperative sternotomy. The reoperative group had a higher prevalence of baseline comorbidities, including hypertension, diabetes, peripheral vascular disease, atrial fibrillation, and coronary artery disease. Central cannulation of the aorta was achieved at a similar rate across each group (81.9% vs. 81.5%, p = .923), and cardiopulmonary bypass (CPB) time was similar across each group (204 ± 84.8 vs. 203 ± 72.4 min, p = .923). Postoperative outcomes were similar across both groups, including in-hospital mortality, stroke, pulmonary complications, renal failure, and reexploration for excessive bleeding. Five-year survival was 74.5% (70.5, 78.3) for the first-time group and was 71.6% (60.0, 81.9) for the reoperative group. After multivariable Cox regression, reoperative sternotomy was not significantly associated with an increased hazard of death compared to first-time sternotomy (hazards ratio: 0.90, 95% confidence interval: 0.56, 1.43, p = .642). These findings suggest that re-sternotomy can be safely performed with similar outcomes as first-time sternotomy. Central initiation of CPB after sternal reentry limits CPB time and may therefore represent a protective strategy that enhances outcomes for patients presenting with ATAAD and prior cardiac surgery.

Comparison of emergent laparoscopic and open repair of acutely incarcerated and strangulated hernias-short- and long-term results.

Incarcerated and strangulated hernias are a common clinical presentation encompassing several challenges in acute care surgery. The role of laparoscopy is still controversial and the data is scarce. Laparoscopy enables better evaluation of the incarcerated organ and its viability. The use of mesh repair in these emergent operations is also a major concern. In this series we aimed to evaluate the safety and efficacy of laparoscopic emergent repairs of acutely incarcerated and strangulated hernias, and their long-term results, in comparison to the conventional open repairs. Retrospective review of prospectively collected data of all adult patients, between the ages of 18 and 89, who underwent emergent operation due to an incarcerated and strangulated hernia between November 2017 and December 2020. During the study period, 89 patients underwent emergent operation due to incarcerated hernias-63 laparoscopic repair and 26 underwent an open repair. In the laparoscopic group (LG) 38 patients had a groin hernia and 25 had a ventral hernia, while in the open group (OG) the distribution was 12 and 14, respectively. When operated laparoscopically, all groin hernias but one were repaired in the TAPP approach and most ventral hernias were repaired using the IPOM + approach. During the peri-operative period there were 3 mortalities (1 in the LG). There were no significant differences between the groups in minor or major complications. Mean follow-up time in the LG was 27.9months and 29.4months in the OG. There was no significant difference in recurrence rates. Long-term results showed better outcome in the LG regarding pain at rest, difficulty doing exercise and local discomfort. Laparoscopic emergent repair of incarcerated hernias is a safe and feasible approach, with better short and long-term results compared to the open approach.

Emergent Open Repair of a Symptomatic Type III Thoracoabdominal Aneurysm

This is a case of an emergent open repair of a type III thoracoabdominal aortic aneurysm performed for a symptomatic inflammatory aneurysm with impending rupture. Four-vessel visceral reconstruction, bilateral iliac bypasses, and intercostal reimplantation were performed. The patient did well and was discharged home on postoperative day 22.

S1961 Mediastinal Tuberculosis: A Rare Cause of Spontaneous Esophageal Perforation

INTRODUCTION: Esophageal perforation secondary to mediastinal tuberculosis is a rarely documented medical occurrence. We describe a patient admitted with sudden onset chest pain, followed by hematemesis, who was found to have a spontaneous esophageal perforation with mediastinal aspirates growing Mycobacterium tuberculosis (TB). CASE DESCRIPTION/METHODS: A 53 year old male with past medical history of atrial fibrillation on long term anticoagulation presented to the emergency department with sudden onset chest pain. His chest pain was followed by sudden hematemesis. Chest computed tomography (CT) revealed extensive pneumomediastinum consistent with esophageal perforation with mediastinal lymphadenopathy (Figure 1). Barium esophagram confirmed evidence of a large distal esophageal perforation (Figure 2). The patient underwent emergent esophageal stent placement and open repair of perforation. There was no reported evidence of mediastinal granuloma or fistula leading to the esophagus at the level of perforation. Mediastinal fluid cultures later returned positive for Mycobacterium tuberculosis. DISCUSSION: Esophageal perforation confers a high mortality risk to affected patients. Therefore, swift diagnosis and identification of underlying cause is important. We present a case of esophageal perforation thought to be secondary to tuberculosis induced mediastinal lymphadenopathy (1,2). It is believed that over time, persistent lymphadenopathy erodes though the esophageal wall leading to perforation. Though esophageal complications are only present in 0.15% of patient with active tuberculosis, it is important to identify tuberculosis as a potential cause of spontaneous perforation in at risk populations (3). Failure to confirm this diagnosis may lead to inadequate treatment and exposure to staff and community.Figure 1.: CT revealing mediastinal perforation with free air surrounding esophagus (arrow).Figure 2.: Esophagram revealing contrast (arrow) leaking into mediastinal cavity confirming esophageal perforation.

Managing Malperfusion Syndrome in Acute Type A Aortic Dissection With Previous Cardiac Surgery

Patients with acute type A aortic dissection with a previous cardiac surgery (PCS) and malperfusion syndrome (MPS) are extremely difficult to manage and have poor outcomes. From 1996 to 2018, 668 patients underwent emergent open aortic repair or endovascular fenestration/stenting for MPS for an acute type A aortic dissection, including those with PCS (PCS, n= 64) and those without PCS (No-PCS, n= 604). The groups were further divided into PCS+MPS, PCS+No-MPS, No-PCS+MPS, and No-PCS+No-MPS. Compared with the No-PCS group, the PCS group had significantly more coronary artery disease, acute renal failure, and mesenteric and renal MPS. Forty-two percent of patients with PCS underwent upfront endovascular fenestration/stenting for endovascular-amendable MPS. The in-hospital mortality was significantly higher in patients with PCS+MPS (40%) compared with PCS+No-MPS (5.9%), No-PCS+MPS (30%), and No-PCS+No-MPS (6.7%). Multivariable logistic regression showed cardiogenic shock (odds ratio, 7.3) and MPS (odds ratio, 6.6) were risk factors for in-hospital mortality (P < .001). After recovering from MPS the PCS group (n= 54) had similar rates of postoperative complications, including 30-day mortality (7.4% vs 6.3%, P= .77), compared with the No-PCS group (n= 557). The 5-year survival was significantly lower in the PCS group compared with the No-PCS group (60% vs 72%, P= .004) and was lowest in those with PCS+MPS (46%). PCS was not a significant risk factor for in-hospital (odds ratio, 1.2; P= .63) or late (hazard ratio, 1.3; P= .27) mortality. Because of severe preoperative comorbidities and the complexity of open aortic repair, in acute type A aortic dissection patients with PCS and MPS, endovascular fenestration and stenting first with delayed redo sternotomy and central aortic repair was a valid approach.

Transverse colon perforation in the mediastinum after esophagectomy: a case report

BackgroundWhile anastomotic leakage, recurrent laryngeal nerve paralysis, and pneumonia are well-known complications of esophagectomy, the incidence of hiatal hernia after esophagectomy for carcinoma has been reported to only be between 0.6 and 10%. We report a very rare case of hiatal hernia with transverse colon rupture in the mediastinum after esophagectomy in a 65-year-old woman.Case presentationThe patient underwent definitive chemoradiotherapy for clinical stage IIA esophageal squamous cell carcinoma and salvage esophagectomy with gastric tube reconstruction through a posterior mediastinum route for residual carcinoma. Three years after the initial surgery, two metastatic nodules in the lateral and posterior segments of the liver were detected on follow-up CT and were treated with oral anticancer drugs. After 6 months, the patient was readmitted for anorexia. Upon admission, computed tomography revealed an ileus caused by a hiatal hernia. Emergent operative repair was performed; an incarcerated herniation of the transverse colon was perforated in the mediastinum, and partial transverse colon resection and colostomy were performed. Intensive care was required to control septic shock after surgery, and the patient was discharged on the 53rd postoperative day.ConclusionsCases of hiatal hernia with digestive tract prolapsing into the mediastinum after esophagectomy with reconstruction through posterior mediastinum are rare but potentially life-threatening complications.

Ruptured abdominal aortic aneurysm identified on point-of-care ultrasound in the emergency department

BackgroundRuptured abdominal aortic aneurysm (AAA) is a highly lethal condition which requires rapid identification and treatment to improve the chance of survival. Computed tomography is the diagnostic modality of choice for ruptured AAA though it is time-consuming and often requires movement of the patient out of the emergency department (ED). Point-of-care ultrasound in the ED has excellent sensitivity and specificity for the detection of AAA, though less is known about its use to diagnose AAA rupture. We report a case of ruptured AAA identified on ultrasound performed at the bedside in the ED.Case presentationA 77-year-old woman on warfarin with a known AAA presented to our ED with 2 days of epigastric abdominal pain. Point-of-care ultrasound revealed several findings suggestive of rupture of the AAA, which was confirmed on computed tomography. The patient was subsequently taken for emergent operative repair of the AAA and was later discharged from the hospital.ConclusionsCharacteristics suggestive of AAA rupture may be seen on ultrasound. As ED physicians become more familiar with the use of point-of-care ultrasound in the evaluation of abdominal pain, identification of these characteristics may aid in the rapid diagnosis of AAA rupture.

Contemporary mortality after emergent open repair of complex abdominal aortic aneurysms

ObjectiveMortality after open repair for emergent complex abdominal aortic aneurysm (AAA) is poorly defined. This study evaluated the 30-day mortality of open complex AAA repair performed for rupture or other emergent indication using a national surgical registry. We subsequently identified factors associated with mortality. MethodsThe targeted vascular module from the American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing open repair for juxtarenal and suprarenal AAAs or type IV thoracoabdominal aneurysms (TAAAs) for rupture or other emergent indication from 2011 to 2017. Univariate analyses were performed using the Fisher's exact test for categorical variables and the Wilcoxon rank sum test for continuous variables. Multivariable logistic regression was performed to identify factors independently associated with mortality. ResultsWe included 374 patients who underwent an emergent complex open AAA repair during the study period. There were 142 (38%) cases performed for rupture with hypotension, 141 (38%) for rupture without hypotension, 40 (11%) for symptomatic AAA, and 51 (14%) for another indication. The distribution by aneurysm type was 224 juxtarenal AAAs, 122 suprarenal AAAs, and 28 type IV TAAAs. Overall, there was a 30-day mortality of 32% (118 deaths). For those with juxtarenal AAA repair, 67 (30%) patients died within 30 days; there were 38 (31%) deaths within 30 days in those with suprarenal AAA, and 13 (46%) deaths within 30 days in those with type IV TAAA. On univariate analysis, preoperative variables associated with death were increasing age, use of a transperitoneal surgical approach, lower preoperative estimated glomerular filtration rate, low baseline albumin concentration (<3.5 g/dL), need for preoperative transfusion, low body mass index (<18.5 kg/m2), and hypotension at presentation. Intraoperative variables associated with mortality were supraceliac clamp location and concurrent renal revascularization. On multivariable analysis, factors independently associated with death included rupture with associated hypotension (reference: other emergent indication; adjusted odds ratio [AOR], 3.28; confidence interval [CI], 1.75-5.41; P < .001), age >60 years (reference: <60 years; AOR, 1.59; CI, 1.18-2.13; P = .002), longitudinal laparotomy incision (reference: retroperitoneal; AOR, 3.28; CI, 1.75-6.16; P < .001), and supraceliac cross-clamp (reference: clamp above one renal artery; AOR, 2.14; CI, 1.31-3.50; P = .003). ConclusionsNearly one-third of patients die within 30 days of emergent open complex AAA repair. Mortality is particularly high for patients with type IV TAAAs, approaching 50%. Predictors of 30-day mortality include rupture with associated hypotension, increasing age, supraceliac clamp location, and longitudinal transperitoneal repair approach. These results will help inform surgical decisions preoperatively and intraoperatively.

Expectant Management of Patients with Ventral Hernias: 3 Years of Follow-up.

The safety and effectiveness of expectant management (e.g., watchful waiting or initially managing non-operatively) for patients with a ventral hernia is unknown. We report our 3-year results of a prospective cohort of patients with ventral hernias who underwent expectant management. A hernia clinic at an academic safety-net hospital was used to recruit patients. Any patient undergoing expectant management with symptoms and high-risk comorbidities, as determined by a surgeon based on institutional criteria, would be included in the study. Patients unlikely to complete follow-up assessments were excluded from the study. Patient-reported outcomes were collected by phone and mailed surveys. A modified activities assessment scale normalized to a 1-100 scale was used to measure results. The rate of operative repair was the primary outcome, while secondary outcomes include rate of emergency room (ER) visits and both emergent and elective hernia repairs. Among 128 patients initially enrolled, 84 (65.6%) completed the follow-up at a median (interquartile range) of 34.1 (31, 36.2) months. Overall, 28 (33.3%) patients visited the ER at least once because of their hernia and 31 (36.9%) patients underwent operative management. Seven patients (8.3%) required emergent operative repair. There was no significant change in quality of life for those managed non-operatively; however, substantial improvements in quality of life were observed for patients who underwent operative management. Expectant management is an effective strategy for patients with ventral hernias and significant comorbid medical conditions. Since the short-term risk of needing emergency hernia repair is moderate, there could be a safe period of time for preoperative optimization and risk-reduction for patients deemed high risk.

Discharge to a Post-Acute Care Facility after Emergent Femoral Artery Repair is Not Protective Against Wound Complications

Access site complication is the most common adverse event after endovascular intervention, and when emergent operative repair of the common femoral artery (CFA) is needed, patient morbidity can be significantly increased. The intent of this project was to identify predictors of wound events after emergent operative repair of the CFA due to an access site complication. It was hypothesized that patients discharged to a facility would benefit from an ongoing relationship with healthcare professionals as evidenced by more consistent follow-up and lower wound complication rates. Patients who had a percutaneous CFA access complication and required emergent open CFA repair at an academic medical institution between 2015 and 2018 were included, and the charts were reviewed retrospectively. Primary outcomes included wound complication and outpatient compliance with vascular surgery clinic visit. Dichotomous groups were evaluated by the chi-squared test, and continuous variables were evaluated by Student's t-test. Univariate and multivariate regression analyses were completed to assess risk factors contributing to wound event or failure of clinic follow-up. Forty-four patients were identified with emergent CFA repair due to an access complication between July 2015 and June 2018. Among this population, 33% of patients had wound complications and 27% were discharged to a facility. Among those discharged to a facility, the rate of follow-up to the vascular surgeon's clinic was significantly lower than those discharged to home (40% vs. 85%, P<0.05), and the incidence of wound complications appeared greater but did not reach statistical significance (50% vs. 27%, P=0.11). Univariate analysis indicated that kidney disease, albumin <3g/dL, and current smoking were predictive of wound complication, whereas on multivariate analysis, only kidney disease remained predictive (P<0.05, odds ratio=22). The modified frailty index (mFI) was not predictive of wound complications or compliance with follow-up. However, mFI did approach statistical significance when predicting discharge to a facility. Despite the availability of medical personnel to arrange transportation and provide wound care in post-acute care facilities, patients who were discharged to a facility after CFA injury requiring emergent repair experienced lower compliance with clinic follow-up and may have suffered more wound complications. Strategies to improve compliance with patient follow-up and wound healing in patients sent to post-acute care facilities are warranted.

Management of malperfusion syndrome in acute type A aortic intramural hematoma.

We report the outcomes of acute type A aortic intramural hematoma (ATAAIMH) with malperfusion treated with endovascular intervention and delayed open aortic repair. Between April 1998 and April 2018, 644 patients were treated at our institution with an acute type A aortic dissection (ATAAD) or ATAAIMH, 82 (13%) had intramural hematomas (IMHs) including 12 (15%) with malperfusion syndrome (MPS) and 70 (85%) without MPS (no MPS). Data was obtained through medical record review, the Society of Thoracic Surgeons data elements, and the National Death Index database. Both MPS and No MPS groups had similar comorbidities including coronary artery disease, hypertension, diabetes, and peripheral vascular disease; however, those with MPS were sicker on admission with higher rates of acute renal failure (50% vs. 1%, P<0.0001) and acute paralysis (17% vs. 0%, P=0.02). Patients with MPS amenable to endovascular reperfusion (n=10) underwent endovascular fenestration/stenting and delayed aortic repair. Those with cerebral or coronary MPS (n=2) and those without MPS (n=70) underwent emergent open aortic repair. Of the ten patients undergoing fenestration/stenting, seven went on to aortic repair, one survived to discharge without aortic repair, one died from aortic rupture on hospital day 34, and one died from organ failure prior to aortic repair. Following endovascular fenestration/stenting or aortic repair, all patients with MPS had higher in-hospital mortality (17% vs. 0%), P=0.02. Following aortic repair, patients with MPS had more postoperative sepsis and longer postoperative length of stay (all P<0.05). However, both groups had a 0% operative mortality (including in-hospital and 30-day mortality following aortic repair). The 5-year survival of all ATAAIMH patients was 79%. The 2-year survival was significantly better in the No MPS group (94% vs. 62%, P=0.006). ATAAIMH with MPS can be effectively managed with upfront endovascular fenestration/stenting followed by delayed aortic repair.

IPC06. Predictors of Mortality Following Emergent Open Repair of Complex Abdominal Aortic Aneurysms

IPC06. Predictors of Mortality Following Emergent Open Repair of Complex Abdominal Aortic Aneurysms

Brucella-Induced Ruptured Infrarenal Dissecting Abdominal Aortic Aneurysm.

Mycotic aneurysms, often saccular, accounting for approximately 2.5% of all abdominal aortic aneurysms, possess increased risk of rupture, uncontrolled sepsis, and protracted hospital stay and are associated with high morbidity and mortality. The authors report the case of a 49-year-old female with no known comorbidities who presented with free rupture of an infrarenal dissecting mycotic aneurysm and underwent emergent open repair successfully. The etiological agent, Brucella melitensis , a Gram-negative zoonotic coccobacillus, is rarely reported to cause mycotic aneurysm.

Endovascular Aortic Repair Is a Viable Strategy for Treatment of Primary Infected Abdominal Aortic Aneurysm

Infected abdominal aortic aneurysm (IAAA) is rare, and information is limited whether endovascular aortic repair (EVAR) can be considered a permanent treatment or is a temporary fix preceding open surgery. This retrospective study reviewed the short- and long-term outcomes of open surgery, emergent EVAR, and elective EVAR in the treatment of primary IAAA. Between January 2008 and January 2017, 16 men and 3 women (aged 60.7y; range 30-76y) with IAAA were treated with emergent open repair, emergent EVAR, or elective EVAR, after adjunctive antibiotic therapy. Demographics, aneurysm anatomy, clinical presentations, laboratory tests, details of aneurysm repair, morbidity, mortality, and postoperative outcomes of these patients were reviewed. Positive microbial cultures were obtained in 12 patients. Six and 3 patients underwent emergent EVAR and open repair, respectively. Ten patients who completed the full antibiotic regimen received elective EVAR. The mean follow-up duration was 28.8mo (range, 1.5-96mo). The 30-day mortality rates of the emergent EVAR, open repair, and elective EVAR groups were 16.7% (1/6), 0%, and 0%, respectively; the 1-year survival rates were 16.7% (1/6), 100% (1/1), and 88.9% (8/9). Reduction in the blood erythrocyte sedimentation rate (ESR) during the first week of antibiotic treatment was inversely related to aneurysm rupture and correlated with patients' post-EVAR survival time. Elective EVAR for IAAA had acceptable short- and long-term outcomes. Patients' response to initial antibiotic treatment may help facilitate management. Less than 0.130 reduction in ESR during the first week of antibiotic treatment may indicate risk of aneurysm rupture.

Discharge to a Facility Is not Protective Against Wound Events Following Emergent Femoral Artery Repair

Access site complication is the most common adverse event following endovascular intervention and may significantly increase morbidity. The intent of this project was to identify risk factors for wound events after emergent operative repair of the femoral artery. It was hypothesized that patients discharged to a facility would benefit from ongoing care of medical professionals, with more consistent follow-up and lower wound complication rates.

The influence of payor status on outcomes associated with surgical repair of upper gastrointestinal perforations due to peptic ulcer disease in the United States

BackgroundAn association between lack of insurance and inferior outcomes has been well described for a number of surgical emergencies, yet little is known about the relationship of payor status and outcomes of patients undergoing emergent surgical repair for upper gastrointestinal (UGI) perforations. We evaluated the association of payor status and in-hospital mortality for patients undergoing emergency surgery for UGI perforations in the United States. MethodsNationwide Inpatient Sample (NIS) was queried to identify patients between 18 and 64 years of age who underwent emergent (open or laparoscopic) repair for UGI perforations secondary to peptic ulcer disease (2010–2014). Primary outcome was in-hospital mortality. Secondary outcomes were major and minor postoperative complications. The main predictor outcome was insurance status (Private, Medicaid, Uninsured). Univariate and multivariable regression analyses were performed. Data were weighted to provide national estimates. Results21,005 patients underwent surgical repair for UGI perforations. Patients with private insurance represented the largest payor group (47%). After adjustment of other factors, payor status was not a statistically significant predictor of in-hospital mortality (Medicaid vs. Private: [OR] 1.1; 95% [CI] 0.67–1.81; Uninsured vs. Private: OR 0.9, 95% CI 0.52–1.61). However, payor status remained a statistically significant predictor of major postoperative complications (Medicaid vs. Private [OR] 1.4; 95% CI 1.1, 1.8; Uninsured vs. Private [OR]1.2, 95% CI 0.9, 1.5) and minor postoperative complications (Medicaid vs. Private [OR] 1.4; 95% CI 1.1, 1.9; Uninsured vs. Private [OR]1.2, 95% CI 0.9, 1.6). ConclusionsEmergency surgery for UGI perforations is associated with high mortality and morbidity across all payor classes; however, Medicaid is a predictor for both major and minor postoperative complications. Preventing perforation through preventative measures will be key to reducing the burden of peptic ulcer disease across all populations.