Inpatient Surgery Research Articles

Temporal Trends and Outcomes of Gender-Affirming Gynecologic Surgery

We performed a population-based analysis to examine the trends in utilization and outcomes of gynecologic surgical procedures performed for gender-affirming care using the National Inpatient and Ambulatory Surgery Samples. Overall, 3,344,186 (95% CI, 3,281,163–3,407,209) unique individuals who underwent gynecologic surgery were identified. Transgender and gender-diverse (TGD) individuals accounted for 19.7% (345/1,748) of the labiaplasty–clitoroplasty procedures, 15.0% (3,355/22,433) of vaginoplasties, 2.0% (212/10,679) of vaginectomies, 0.2% (5,369/2,346,748) of hysterectomies, and 0.1% (515/962,578) of oophorectomies. The percentage of cases performed in TGD individuals increased substantially from 2016 to 2020 for vaginoplasty (6.2–24.1%) and clitoroplasty–labiaplasty (8.0–35.1%). Among patients who underwent vaginoplasty, the complication rate was significantly higher among TGD individuals (16.5% vs 11.1%) (adjusted odds ratio 1.85, 95% CI, 1.22–2.81). For the other procedures, the complication rate was not higher.

Association of non-English language preference with postoperative hospital visits among California Medicaid enrollees

BackgroundPatients with non-English language preference encounter language barriers across phases of surgical care. Patients with a non-English language preference represent 35% of California households and are disproportionately insured by Medicaid. To determine whether language predicts surgical outcomes, we investigated the association of patient non-English language preference with postoperative emergency department visits and readmissions among California Medicaid enrollees. MethodsOur retrospective analysis of adult Medicaid enrollees undergoing 1 of 10 common inpatient operations using California hospital administrative data (2016–2019) modeled the association between non-English language preference and 30-day postoperative emergency department visits and readmissions using mixed effects logistic regression with hospital random intercept, adjusting for patient, operation, hospital, and community characteristics. Secondary analyses stratified by operation urgency and by insurance type in an all-payor cohort. ResultsOf 115,527 Medicaid enrollees, 17.2% had non-English language preference (n = 19,881), 66% were female (n = 73,653), and 40% were Hispanic/Latino (n = 45,541). Patients with non-English language preference experienced fewer postoperative emergency department visits (non-English language preference: 13.5%, English preference: 17.9%, P < .001) and readmissions (non-English language preference: 7.5%, English preference: 8.5%, P < .001), which persisted in adjusted models (adjusted odds ratio emergency department, 0.80, 95% confidence interval, 0.77–0.85; readmissions: adjusted odds ratio, 0.86, 95% confidence interval, 0.80–0.92). Non-English language preference was associated with fewer emergency department visits after elective (adjusted odds ratio, 0.80; 95% confidence interval, 0.73–0.88) and urgent/emergent surgery (adjusted odds ratio, 0.80; 95% confidence interval, 0.75–0.85) but not readmissions after elective surgery (adjusted odds ratio, 0.89; 95% confidence interval, 0.78–1.01). This pattern was only observed for Medicaid and not other insurance types. ConclusionPatients with non-English language preference who receive Medicaid have fewer postoperative emergency department visits and readmissions, even after urgent surgery. Our findings suggest that patterns of health care seeking after surgery vary by patient language, and investigating explanatory mechanisms is needed.

The impact of transanal drainage tube on the incidence of anastomotic leakage and small bowel obstruction in radical surgery (Dixon) for rectal cancer: a retrospective cohort study.

Anastomotic leakage (AL) and small bowel obstruction (SBO) are common complications after rectal cancer radical surgery (Dixon). Although the commonly used defunctioning stoma (DS) can reduce the incidence and harm of AL, it increases the probability of other adverse consequences, including SBO. Therefore, a safe and effective method for preventing the complications related to the radical surgery of rectal cancer is urgently needed. Previous studies have found that transanal drainage tube (TDT) can have a positive impact on the incidence of these two complications by draining gas and feces from the intestinal lumen, without causing other serious consequences. Therefore, this article further explores the clinical benefits that TDT can bring by analyzing the clinical data of postoperative patients with rectal cancer. This study included 221 patients who underwent radical surgery (Dixon) for rectal cancer in Hubei Cancer Hospital from September 2020 to February 2023, determine whether it meets the inclusion criteria of this study based on preoperative examination, intraoperative exploration results, and treatment methods. DS was used in 70 patients and TDT in 88 patients during the surgery; meanwhile, no protective anastomotic measures were applied in 63 patients. Seventy patients subjected to DS were categorized as group 1, 88 patients subjected to TDT as group 2, and 63 patients with no protective measures for anastomosis as group 3. Through postoperative clinical manifestations, imaging examinations, and laboratory tests, a total of 18 cases of AL and 30 cases of SBO were identified in the three groups. The effectiveness of TDT and that of other surgical procedures in preventing complications, accelerating postoperative recovery, and reducing surgical costs were compared through univariate and multivariate analyses. The clinical features of the three groups have baseline comparability. No statistically difference was noted in baseline characteristics between three groups (all P>0.05). The incidence of AL and SBO in group 1 are 7.1% and 27.1%, in group 2 are 3.4% and 4.5%, and in group 3 are 15.9% and 11.1%. Compared to patients in no protective anastomotic measures with TDT and DS, TDT has a lower incidence of postoperative AL (P<0.05) and SBO (P>0.05), and faster postoperative recovery (P<0.05). The cost of inpatient surgery is not significantly different (P>0.05). Although DS can reduce the incidence of AL to a certain extent (P>0.05), it significantly increased the incidence of SBO (P<0.05), delayed postoperative defecation time (P<0.05) and caused higher cost (P<0.001). Compared to DS, the incidence of AL in TDT is not significantly different (P>0.05), but the incidence of SBO is noticeably lower (P<0.001), with faster postoperative recovery and less cost (P<0.05). TDT is a safer, more effective, and more economical surgery for preventing postoperative complications.

Clinical implications and costs of in-hospital versus outpatient orthopedic surgeries

Objective: This article reviews clinical implications and costs associated with orthopedic surgeries performed in inpatient versusoutpatient settings. Methods: Studies spanning the publication period between 2000 and 2023 were included, exploring a variety of study designs. Results: Results indicate that outpatient surgeries are associated with lower rates of postoperative complications, shorter recovery times, and greater patient satisfaction, as well as with significantly lower direct and indirect costs. Analysis of postoperative complications suggests that factors such as the home recovery environment and early mobilization may contribute to improved clinical outcomes, corroborating existing literature on the safety and efficacy of outpatient surgeries. Faster recovery after outpatient surgeries was consistently observed, with patients returning to normal activities an average of two weeks earlier compared with those undergoing inpatient surgeries. The greater patient satisfaction with outpatient surgeries reflects the convenience of avoiding hospitalization, with less disruption to daily life and reduced anxiety associated with the hospital environment. In economic terms, outpatient surgeries have been shown to be a financially advantageous alternative, with reduced direct costs due to the lower hospital fees and nursing services required, as well as lower indirect costs due to reduced productivity loss and transportation expenses. Conclusion: Findings are particularly relevant in a context of increasing pressure to contain spending in the health system. Level of Evidence I; Systematic review of level I studies.

Cleft Lip Repair Comparison Between Inpatient and Outpatient Surgeries: A Multi-Surgeon Experience.

Great variability exists as to whether cleft lip (CL) repair is performed as an inpatient or outpatient surgery. This study's aim is to investigate the authors' institutional experience to see if there is an increase in complications, emergency department (ED) visits, or readmissions to the hospital when performed as outpatient. This study reviewed patients who underwent CL repair between 2012 and 2023 at the authors' institution. Data collected included patient demographics, perioperative details, ED visits and readmissions within thirty days of surgery, and complications. One hundred forty-five patients met inclusion measures. When the surgery was performed as outpatient, there was no significant difference in returning to the ED (p = 0.767) or readmission to the hospital (p = 0.447) within thirty days as compared to inpatient surgeries. Outpatients did not have more postoperative complications (p = 0.698). Bilateral cleft lips were more likely to be performed as inpatient (p = 0.001). Inpatients had a lower weight at time of repair (p = 0.033). Patients with a respiratory (p = .006), gastrointestinal (p = 0.003), or hematologic (p = 0.013) comorbidity had a higher readmission rate. Patients were more likely to be readmitted if they had a younger gestational age (p = 0.005). There was no increased return to the ED or readmission for patients undergoing inpatient versus outpatient CL repair. CL repair can be performed safely in an outpatient setting with careful patient selection.

Complication rates are not higher after outpatient compared to inpatient fast-track total hip arthroplasty: a propensity-matched prospective comparative study.

Concerns remain with regards to safety of fast-track (FT) and especially outpatient procedures. The purpose of this study was to compare complication rates and clinical outcomes of propensity-matched patients who received FT total hip arthroplasty (THA) in outpatient versus inpatient settings. The hypothesis was that 90-day postoperative complication rates of outpatient FT THA would not be higher than after inpatient FT THA. This is a prospective study of consecutive patients who received FT THA at various rates of outpatient and inpatient surgery by 10 senior surgeons (10 centres). The decision between outpatient and inpatient surgery was made on a case-by-case basis depending on the surgeon and patient. All patients were followed until 90 days after surgery. Complications, readmissions and reoperations were collected, and their severity was assessed according to Clavien-Dindo. Patients completed Oxford Hip Score (OHS) at the latest follow-up. Compared to inpatient FT THA, patients scheduled for outpatient FT THA had no significant differences in 90-day postoperative complication rates (10.7% vs. 12.9%, p = 0.129). There were no significant differences between the 2 groups in 90-day readmission rates and reoperation rates, in severity of postoperative complications, and in time of occurrence of postoperative complications. There were no differences in rates of intraoperative complications, 90-day postoperative complications, readmissions, or reoperations between outpatient and inpatient FT THA. These findings may help hesitant surgeons to move towards outpatient THA pathways as there is no greater risk of early postoperative complications that could be more difficult to manage after discharge.

Same-day parathyroidectomy for primary hyperparathyroidism -an over 20-year practice.

There has been a shift in recent years toward same-day parathyroidectomies due to the decrease in mutual costs with few significant differences in postoperative morbidity or mortality. We sought to determine if demographics, preoperative patient risk factors, or comorbidities were associated with a patient's likelihood of having same-day or inpatient surgery. A prospective database of parathyroid operations from 2001 to 2022 (n=2948 patients) was reviewed for surgeries completed for primary hyperparathyroidism. Patients were categorized as same-day or inpatient surgery; demographics, risk factors, and co-morbidities were examined and differences across practice patterns during the 21-year period were studied and also analyzed in a subset of patients from 2013 to 2022. In a recent subset of patients from 2013 to 2022, patients having inpatient surgery were more likely to be Black and use anticoagulation or antiplatelet therapy. Multivariable regression confirmed increased odds of aging and black patients requiring inpatient parathyroidectomy. Compared to 2001-2003, there was a significantly increased proportion of patients undergoing same-day surgery; compared to 2010-2012, there was a similar proportion of patients undergoing outpatient surgery between 2013 and 2018, and there was an increased proportion from 2019 through 2022. Same-day parathyroidectomies have been shown to be safe and has become the typical practice for high-volume parathyroid surgeons over the last decade. Complications such as postoperative hematoma or hypocalcemia were previously shown to be incompletely mitigated by increased LOS or inpatient surgery, although demographics are considered to increase the odds of inpatient parathyroidectomy.

RETROSPECTIVE ANALYSIS OF PATIENT-REPORTED OUTCOME MEASURES IN A MATCHED COHORT OF INPATIENT AND DAY-SURGERY HIP ARTHROPLASTY PATIENTS

Most hip replacements are performed in an in-patient setting; however, there has been a shift in recent years in Canada towards doing more on an outpatient basis. In 2021–2022, 15.6% of hip replacements were performed as day surgeries compared to 0.7% in 2018–2019. This analysis will assess patient reported outcome measures of patients who had inpatient versus outpatient hip replacement surgery between 2018 and 2021.We analysed a retrospective sample of 4917 adult patients who had an elective primary unilateral hip replacement. Preoperative and three-month postoperative PROMs were completed - the Oxford Hip Score, EQD5L and patient satisfaction with the outcome were recorded. Patients who had an outpatient procedure were matched 1:1 with patients who are admitted to hospital for surgery based on age, sex and pre-COVID versus the COVID (March 15, 2020 as the start). Preoperative PROMs and Charlson Comorbidity Index were collected. T-tests and chi-square tests were used to assess the differences.The inpatient group on average was older, female and had a lower preoperative PROMs score and more comorbidities than the outpatient group. With cohort matching the sample consisted of 1244 patients. The inpatient and outpatient groups have similar Oxford scores, postoperative EQ-5D-5L scores and the proportion satisfied with their surgical results. The Oxford postoperative score was slightly higher in the outpatient group compared to the inpatient group; however, this is not clinically significant.We observed that outpatient protocols have no difference in patient satisfaction, self-reported functional outcomes and self-reported health-related quality of life three months after a hip replacement. Day surgery protocols represented potential solution to the challenges caused by the expected increase in demand for hip replacements. Our results demonstrated that patients do well clinically with day surgery procedures and there does not appear to be any detrimental effect on PROMs.

Shifting paradigms in endoscopic sinus surgery: a comprehensive analysis from Japan’s national database

Background In 2013, Japan established a standardized classification system for categorizing endoscopic sinus surgery (ESS) into types I–V, yet no evaluation has been conducted thereof. Objective We assessed the ESS trends and status in Japan, focusing on outpatient and inpatient surgeries. Material and Methods This descriptive retrospective cohort study used Japan’s National Database of Health Insurance Claims and Specific Health Checkups between 2014 and 2021. The distribution of ESS types I–V and outpatient and inpatient surgeries was analysed, along with age groups and regional differences, focusing on ESS type III. Results Overall, 427,813 ESS procedures were performed, with types III and IV being most common. Outpatient ESS type III increased substantially compared to inpatient surgeries. Younger individuals favoured outpatient ESS type III over inpatient surgeries, with substantial regional variations across prefectures. Conclusions and Significance The adoption of a standardized ESS classification in Japan has facilitated a detailed understanding of surgical trends. The shift toward outpatient surgeries, especially for type III ESS, aligns with global trends toward minimally invasive procedures and reflects changing patient preferences and healthcare delivery practices. Consequently, continuous monitoring and research are crucial for adapting surgical practices to the evolving healthcare needs and patient expectations.

Effects of rural hospital closures on nurse staffing levels and health care utilization at nearby hospitals.

Our study examines the causal effect of rural hospital closures on nearby hospitals' nurse staffing levels and health care utilization. We use data from the 2014-2019 American Hospital AssociationSurvey on nurse staffing level outcomes including licensed practical or vocational nurses (LPNs), registered nurses (RNs), and advanced practice nurses (APNs); and health care utilization outcomes, including inpatient and outpatient surgical operations and emergency department (ED) visits. Using propensity score matchingand difference-in-differences (DID) methods, we find that rural hospital closures lead to an average increase of 37.3% in the number of nurses in nearby rural hospitals during the 4years following the closure. This increase is found across all categories of nurses, including LPNs, RNs, and APNs. We also find a substantial increase in the provision of inpatient and outpatient surgical operations but there is no change in ED visits. We do not find any effects for nearby urban hospitals. Our study suggests that a large proportion of the nursing workforce relocates to nearby hospitals after a rural hospital closure, which mitigates the negative consequences of such closures and allows these nearby hospitals to provide a larger volume of highly profitable services.

Incidence of post-operative delirium increases as severity of frailty increases.

The surgical population is ageing and often frail. Frailty increases the risk for poor post-operative outcomes such as delirium, which carries significant morbidity, mortality and cost. Frailty is often measured in a binary manner, limiting pre-operative counselling. The goal of this study was to determine the relationship between categorical frailty severity level and post-operative delirium. We performed an analysis of a retrospective cohort of older adults from 12 January 2018 to 3 January 2020 admitted to a tertiary medical center for elective surgery. All participants underwent frailty screening prior to inpatient elective surgery with at least two post-operative delirium assessments. Planned ICU admissions were excluded. Procedures were risk-stratified by the Operative Stress Score (OSS). Categorical frailty severity level (Not Frail, Mild, Moderate, and Severe Frailty) was measured using the Edmonton Frail Scale. Delirium was determined using the 4 A's Test and Confusion Assessment Method-Intensive Care Unit. In sum, 324 patients were included. The overall post-operative delirium incidence was 4.6% (15 individuals), which increased significantly as the categorical frailty severity level increased (2% not frail, 6% mild frailty, 23% moderate frailty; P < 0.001) corresponding to increasing odds of delirium (OR 2.57 [0.62, 10.66] mild vs. not frail; OR 12.10 [3.57, 40.99] moderate vs. not frail). Incidence of post-operative delirium increases as categorical frailty severity level increases. This suggests that frailty severity should be considered when counselling older adults about their risk for post-operative delirium prior to surgery.

European Society of Clinical Microbiology and Infectious Diseases/European Committee on infection control clinical guidelines on pre-operative decolonization and targeted prophylaxis in patients colonized by multidrug-resistant Gram-positive bacteria before surgery

ScopeThe aim of these guidelines is to provide recommendations for decolonization and perioperative antibiotic prophylaxis (PAP) in multidrug-resistant Gram-positive bacteria (MDR-GPB) adult carriers before inpatient surgery. MethodsThese European Society of Clinical Microbiology and Infectious Diseases/European Committee on Infection Control guidelines were developed following a systematic review of published studies targeting methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci, methicillin-resistant coagulase-negative Staphylococci, and pan-drug-resistant-GPB. Critical outcomes were the occurrence of surgical site infections (SSIs) caused by the colonizing MDR-GPB and SSIs-attributable mortality. Important outcomes included the occurrence of SSIs caused by any pathogen, hospital-acquired infections, all-cause mortality, and adverse events associated with the interventions, including resistance development to the agents used and the incidence of Clostridioides difficile infections. The last search of all databases was performed on 1 November 2023. The level of evidence and the strength of each recommendation were defined according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Consensus of a multidisciplinary expert panel was reached for the final list of recommendations. Antimicrobial stewardship considerations were included. RecommendationsThe guideline panel reviewed the impact of decolonization, targeted PAP, and combined interventions (e.g. decolonization and targeted PAP) on the risk of SSIs and other outcomes in MDR-GPB carriers, according to the type of bacteria and type of surgery.We recommend screening for S. aureus before high-risk operations, such as cardiothoracic and orthopaedic surgery. Decolonization with intranasal mupirocin with or without a chlorhexidine bath is recommended in patients colonized with S. aureus before cardiothoracic and orthopaedic surgery and suggested in other surgeries. The addition of vancomycin to standard prophylaxis is suggested for MRSA carriers in cardiothoracic surgery, orthopaedic surgery, and neurosurgery. Combined interventions (e.g. decolonization and targeted prophylaxis) are suggested for MRSA carriers undergoing cardiothoracic and orthopaedic surgery. No recommendation could be made regarding screening, decolonization and targeted prophylaxis for vancomycin-resistant enterococci because of the lack of data. No evidence was retrieved for methicillin-resistant coagulase-negative Staphylococci and pan-drug-resistant-GPB. Careful consideration of the laboratory workload and involvement of antimicrobial stewardship and infection control teams are warranted before implementing screening procedures or performing changes in PAP policy. Future research should focus on novel decolonizing techniques, on the monitoring of resistance to decolonizing agents and PAP regimens, and on standardized combined interventions in high-quality studies.

Patients With a History of Lumbar Fusion Have a Greater Risk of Revision Arthroscopy and Conversion to Total Hip Arthroplasty After Primary Hip Arthroscopy

PurposeTo characterize the risk of revision hip arthroscopy or conversion to total hip arthroplasty (THA) among patients with a history of lumbar fusion undergoing primary hip arthroscopy. MethodsWe used the Statewide Planning and Research Cooperative System, an administrative database including all ambulatory and inpatient surgery encounters in New York (NY), to identify all patients who underwent hip arthroscopy for FAI between 2010–2020. Patients with prior lumbar fusion were identified using CPT and ICD 9th/10th Revision coding definitions. Patients with and without prior fusion were matched in a 1:5 ratio according to age and comorbidity burden. The number of levels fused was defined in the following fashion: i) no fusion, ii) 1-2 levels, or iii) ≥3 levels. Patients were followed for two years to evaluate the rate of revision hip arthroscopy or conversion to THA. Multivariable logistic regression models were used to measure the association between number of levels fused and revision hip arthroscopy or conversion to THA. ResultsBetween 2010–2020, there were 23,277 patients that underwent primary hip arthroscopy in NY state. Of these, 348 (1.4%) had a prior lumbar fusion. After matching for age and comorbidities, the composite rate of revision hip arthroscopy or conversion to THA was higher in patients with prior lumbar fusion compared to patients without (16.5% vs. 8.5%; P < 0.001). This risk increased with the number of levels fused (1-2 levels: 15.1%; aOR, 1.8; 95% CI, 1.3–2.6; vs. ≥3 levels: 26.3%; aOR, 3.4; 95% CI, 1.7–7.0). ConclusionPatients with a history of lumbar fusion had significantly higher rates of revision hip arthroscopy and conversion to THA compared to patients without prior fusion. The risk of revision hip arthroscopy or conversion to THA was increased approximately 2-fold in patients with 1-2 levels fused and 3-fold in patients with 3 or more levels fused. Level of EvidenceLevel III, prognostic retrospective matched comparative case series.

Factors Influencing Neuromuscular Blockade Reversal Choice in the United States Before and During the COVID-19 Pandemic: Retrospective Longitudinal Analysis.

Neuromuscular blockade (NMB) agents are a critical component of balanced anesthesia. NMB reversal methods can include spontaneous reversal, sugammadex, or neostigmine and the choice of reversal strategy can depend on various factors. Unanticipated changes to clinical practice emerged due to the COVID-19 pandemic, and a better understanding of how NMB reversal trends were affected by the pandemic may help provide insight into how providers view the tradeoffs in the choice of NMB reversal agents. We aim to analyze NMB reversal agent use patterns for US adult inpatient surgeries before and after the COVID-19 outbreak to determine whether pandemic-related practice changes affected use trends. A retrospective longitudinal analysis of a large all-payer national electronic US health care database (PINC AI Healthcare Database) was conducted to identify the use patterns of NMB reversal during early, middle, and late COVID-19 (EC, MC, and LC, respectively) time periods. Factors associated with NMB reversal choices in inpatient surgeries were assessed before and after the COVID-19 pandemic reached the United States. Multivariate logistic regression assessed the impact of the pandemic on NMB reversal, accounting for patient, clinical, procedural, and site characteristics. A counterfactual framework was used to understand if patient characteristics affected how COVID-19-era patients would have been treated before the pandemic. More than 3.2 million inpatients experiencing over 3.6 million surgical procedures across 931 sites that met all inclusion criteria were identified between March 1, 2017, and December 31, 2021. NMB reversal trends showed a steady increase in reversal with sugammadex over time, with the trend from January 2018 onwards being linear with time (R2>0.99). Multivariate analysis showed that the post-COVID-19 time periods had a small but statistically significant effect on the trend, as measured by the interaction terms of the COVID-19 time periods and the time trend in NMB reversal. A slight increase in the likelihood of sugammadex reversal was observed during EC relative to the pre-COVID-19 trend (odds ratio [OR] 1.008, 95% CI 1.003-1.014; P=.003), followed by negation of that increase during MC (OR 0.992, 95% CI 0.987-0.997; P<.001), and no significant interaction identified during LC (OR 1.001, 95% CI 0.996-1.005; P=.81). Conversely, active reversal (using either sugammadex or neostigmine) did not show a significant association relative to spontaneous reversal, or a change in trend, during EC or MC (P>.05), though a slight decrease in the active reversal trend was observed during LC (OR 0.987, 95% CI 0.983-0.992; P<.001). We observed a steady increase in NMB active reversal overall, and specifically with sugammadex compared to neostigmine, during periods before and after the COVID-19 outbreak. Small, transitory alterations in the NMB reversal trends were observed during the height of the COVID-19 pandemic, though these alterations were independent of the underlying NMB reversal time trends.

Disparities in outpatient rural cholecystectomy outcomes

BackgroundPrevious studies showed comparable outcomes for common in-patient general surgery operations, but it is unknown if this extends to outpatient operations. Our aim was to compare outpatient cholecystectomy outcomes between rural and urban hospitals. MethodsA retrospective cohort analysis was done using the Nationwide Ambulatory Surgery Sample for patients 20-years-and-older undergoing cholecystectomy between 2016 and 2018 ​at rural and urban hospitals. Survey-weighted multivariable regression analysis was performed with primary outcomes including use-of-laparoscopy, complications, and patient discharge disposition. ResultsThe most common indication for operation was cholecystitis in both hospital settings. On multivariable analysis, rural hospitals were associated with higher transfers to short-term hospitals (adjusted odds ratio [aOR] 2.40, 95%CI 1.61-3.58, p ​< ​0.01) and complications (aOR 1.39, 95%CI 1.11-1.75, p ​< ​0.01). No difference was detected with laparoscopy (aOR 1.93, 95%CI 0.73-5.13, p ​= ​0.19), routine discharge (aOR 1.50, 95%C I0.91-2.45, p ​= ​0.11), or mortality (aOR 3.23, 95%CI 0.10–100.0, p ​= ​0.51). ConclusionsPatients cared for at rural hospitals were more likely to be transferred to short-term hospitals and have higher complications. No differences were detected in laparoscopy, routine discharge or mortality.

A Nationwide Analysis of Complications, Reoperations and Cost of Wide-Awake Flexor Tendon Repairs.

Some papers suggest that wide-awake flexor tendon repair (FTR) may reduce rates of postoperative tendon gapping and rupture due to improved intraoperative testing of the repair. The current study is a nationwide cohort study comparing FTRs performed wide-awake and with traditional anesthesia. Patients undergoing zone II FTR between 2010-2022 were identified in PearlDiver. Exclusion criteria were other tendon repairs, concomitant treatment for vascular injury, fracture, dislocation or amputation, inpatient or office surgery, age <18 years and <1 year of follow-up. Patients were stratified by anesthesia technique: traditional anesthesia (general anesthesia, monitored anesthesia care, regional blocks) or wide-awake. Patients were matched based on age, sex, Elixhauser Comorbidity Index (ECI) score, geographical region, insurance coverage, number of tendon repairs and presence of concomitant nerve repair. 30-day wound complications, emergency department visits and readmissions and 1-year reoperations were identified. Total reimbursement for surgery was determined. Each matched cohort included 2,563 patients. Wide-awake patients had fewer 30-day emergency department visits (2.7% vs 4.8%). There were no differences in 30-day wound complications or readmissions. There was no difference in 1-year reoperations for rupture or for stiffness. Multivariable linear regression identified wide-awake surgery to be a significantly associated with lower total reimbursement. Performing digital FTR using wide-awake techniques can reduce costs, but the hypothesis that wide-awake repairs may reduce rates of tendon rupture was not supported by the current study.

The evaluation of feasibility of ambulatory laparoscopic cholecystectomy using intraoperative instillation of bupivacaine: a retrospective observational study.

This study aimed to compare outcomes of opioid patients-controlled anesthesia (PCA) and intraoperative local anesthesia in terms of postoperative pain, lab results, patient surveys, and discharge scores to evaluate the feasibility of ambulatory laparoscopic cholecystectomy (LC). Patients who underwent LC for acute cholecystitis were assigned to the outpatient surgery (OPS) group or inpatient surgery (IPS) group according to the surgeon. In the OPS group, a mixture of bupivacaine and epinephrine was injected into trocar sites and sprayed on the surgical dissection field. Oral opioid and analgesics were given twice a day. In the IPS group, patients received opioid PCA. Numeric rating scale (NRS) for walking, erythrocyte sedimentation rate (ESR), CRP, self-assessed survey on general physical condition and discharge, and discharge score of ambulatory surgery were assessed postoperatively. NRS was significantly lower in the OPS group. There were no significant differences in ESR and CRP between the groups. Self-assessed survey on general conditions and the possibility of discharge were significantly better in the OPS group. The discharge scores at 3, 6, and 9 hours were significantly higher in the OPS group. Intraoperative instillation of bupivacaine at port sites and dissection fields had a better effect on short-term postoperative pain, patient surveys, and discharge criteria of ambulatory surgery than opioid PCA.

Preoperative vs Postoperative Opioid Prescriptions and Prolonged Opioid Refills Among US Youths

High-risk practices, including dispensing an opioid prescription before surgery when not recommended, remain poorly characterized among US youths and may contribute to new persistent opioid use. To characterize changes in preoperative, postoperative, and refill opioid prescriptions up to 180 days after surgery. This retrospective cohort study was performed using national claims data to determine opioid prescribing practices among a cohort of opioid-naive youths aged 11 to 20 years undergoing 22 inpatient and outpatient surgical procedures between 2015 and 2020. Statistical analysis was performed from June 2023 to April 2024. The primary outcome was the percentage of initial opioid prescriptions filled up to 14 days prior to vs 7 days after a procedure. Secondary outcomes included the likelihood of a refill up to 180 days after surgery, including refills at 91 to 180 days, as a proxy for new persistent opioid use, and the opioid quantity dispensed in the initial and refill prescriptions in morphine milligram equivalents (MME). Exposures included patient and prescriber characteristics. Multivariable logistic regression models were used to estimate the association between prescription timing and prolonged refills. Among 100 026 opioid-naive youths (median [IQR] age, 16.0 [14.0-18.0] years) undergoing a surgical procedure, 46 951 (46.9%) filled an initial prescription, of which 7587 (16.2%) were dispensed 1 to 14 days before surgery. The mean quantity dispensed was 227 (95% CI, 225-229) MME; 6467 youths (13.8%) filled a second prescription (mean MME, 239 [95% CI, 231-246]) up to 30 days after surgery, and 1216 (3.0%) refilled a prescription 91 to 180 days after surgery. Preoperative prescriptions, increasing age, and procedures not typically associated with severe pain were most strongly associated with new persistent opioid use. In this retrospective study of youths undergoing surgical procedures, of which, many are typically not painful enough to require opioid use, opioid dispensing declined, but approximately 1 in 6 prescriptions were filled before surgery, and 1 in 33 adolescents filled prescriptions 91 to 180 days after surgery, consistent with new persistent opioid use. These findings should be addressed by policymakers and communicated by professional societies to clinicians who prescribe opioids.

Is Preoperative Chemoprophylaxis Safe for Venous Thromboembolism Prevention in Patients With Head and Neck Cancer?

To assess the safety of preoperative chemoprophylaxis (PEC) in head and neck cancer (HNC) patients undergoing oncologic procedures. Retrospective cohort study. Tertiary academic center. HNC patients with Caprini risk score (CRS) ≥5 who underwent inpatient surgery ≥3 hours between 2015 and 2020 were included. Patients were divided into 2 cohorts, PEC and control, based on whether or not they received a single dose of low molecular weight heparin or unfractionated heparin prior to surgery. The primary endpoint was the 30-day rate of major bleeding events. A total of 539 patients were included; 427 patients received PEC prior to surgery. The rate of major bleeding was 6.7%. The PEC cohort was more likely to have received concurrent aspirin or ketorolac (225 of 427 patients vs 36 of 112 patients; P = .0002), greater duration of chemoprophylaxis (7.8vs 5.0 days; P < .0001), have higher CRS (7.2 vs 6.6; P < .0001), longer operative times (596vs 512 minutes; P < .0001), higher blood loss (265vs 214 ml; P = .02), and higher bleeding rates when compared to the control (34 of 427 patients; P = .03). On multivariate analysis, only PEC was associated with bleeding (odds ratio, 8.74; 95% confidence interval, 1.15-66.5). The rate of VTE was 1.3% and was not significantly different between cohorts. PEC was associated with an increase in bleeding and did not result in lower rates of VTE in patients with HNC. This study highlights the need to determine the optimal regimen of chemoprophylaxis in this patient cohort.

Aiming for Zero: Success of the Hysterectomy Surgical Site Infection Prevention Bundle

Background: The Center for Disease Control’s National Healthcare Safety Network (NHSN) reported an increased Standardized Infection Ratio (SIR) at a large community hospital, calculated by the number of observed infections over the number of predicted infections. In response to the increased SIR, a multidisciplinary Hysterectomy Surgical Site Infection (SSI) Prevention Workgroup was formed in 2019. Objective: To promote a surgical site infection prevention bundle that was implemented at a large community hospital to reduce hysterectomy associated surgical site infections. Study Design: The Workgroup implemented an evidence-based Hysterectomy SSI Prevention Bundle which enforced standardization of measures and techniques at: The pre-operative clinic appointment, the day of surgery, the intra-operative time prior to incision, the intra-operative time from incision to closure, and in the immediate post-operative recovery. The Hysterectomy SSI Prevention Bundle was implemented November 2, 2020. This study included all hysterectomies for benign pathologies from 10/1/2018 to 9/30/2020 [pre-implementation (n=811)] and 1/1/2021 to 9/30/2022 [post-implementation (n=772)]. Per NHSN data categorization guidelines, a designation of abdominal hysterectomy includes both open and laparoscopic routes. Inpatient surgery was defined as that with a date of discharge different from date of operation; outpatient surgery was defined as the one with the same date of discharge. SSIs included superficial, deep and organ/space, while complex SSIs included deep and organ/space. Patient demographics were categorized and evaluated for statistical significance. Results: After implementation of the SSI bundle, SIR for hysterectomies was reduced to &lt; 1.0, indicating infection prevention. Outpatient abdominal hysterectomy SIR pre-implementation was 2.551 and post-implementation was 0.868 (p=0.007). The outpatient vaginal hysterectomy SIR pre-implementation was 0, and post-implementation remained 0 (p=0.364). Inpatient abdominal hysterectomy SIR pre-implementation was 1.554 and post-implementation was 0.443 (p=0.072). The inpatient vaginal hysterectomy SIR preimple-mentation was 1.064, and post-implementation was 0 (p &lt;0.001). The inpatient complex abdominal hysterectomy SIR pre-implementation was 1.757 and post-implementation was 0 (p=0.040). The inpatient complex vaginal hysterectomy SIR pre-implementation was 1.001, and post-implementation was 0 (p &lt;0.001). Differences between the pre- and post-implementation groups were significant for increased laparoscopic hysterectomies (p&lt;0.001), decreased vaginal hysterectomies (p&lt;0.001), increased number of same day discharges (p&lt;0.001), longer procedure duration (p&lt;0.001), and younger age (p=0.039). Conclusion: Implementation of an evidence-based surgical site infection prevention bundle at a large community hospital has significantly reduced SIR for inpatient vaginal hysterectomies, outpatient abdominal hysterectomies, and all inpatient complex hysterectomies.