The asymptomatic hernia: "if it's not broken, don't fix it".
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Hernia, Inguinal↗
Biomedical subjects
David R Flum
Publications and source records attributed to David R Flum.
Early mortality among Medicare beneficiaries undergoing bariatric surgical procedures.
CONTEXT: Case series demonstrate that bariatric surgery can be performed with a low rate of perioperative mortality (0.5%), but the rate among high-risk patients and the community at large is unknown. OBJECTIVES: To evaluate the risk of early mortality among Medicare beneficiaries and to determine the relative risk of death among older patients. DESIGN: Retrospective cohort study. SETTING AND PATIENTS: All fee-for-service Medicare beneficiaries, 1997-2002. MAIN OUTCOME MEASURES: Thirty-day, 90-day, and 1-year postsurgical all-cause mortality among patients undergoing bariatric procedures. RESULTS: A total of 16 155 patients underwent bariatric procedures (mean age, 47.7 years [SD, 11.3 years]; 75.8% women). The rates of 30-day, 90-day, and 1-year mortality were 2.0%, 2.8%, and 4.6%, respectively. Men had higher rates of early death than women (3.7% vs 1.5%, 4.8% vs 2.1%, and 7.5% vs 3.7% at 30 days, 90 days, and 1 year, respectively; P<.001). Mortality rates were greater for those aged 65 years or older compared with younger patients (4.8% vs 1.7% at 30 days, 6.9% vs 2.3% at 90 days, and 11.1% vs 3.9% at 1 year; P<.001). After adjustment for sex and comorbidity index, the odds of death within 90 days were 5-fold greater for older Medicare beneficiaries (aged > or =75 years; n = 136) than for those aged 65 to 74 years (n = 1381; odds ratio, 5.0; 95% confidence interval, 3.1-8.0). The odds of death at 90 days were 1.6 times higher (95% confidence interval, 1.3-2.0) for patients of surgeons with less than the median surgical volume of bariatric procedures (among Medicare beneficiaries during the study period) after adjusting for age, sex, and comorbidity index. CONCLUSIONS: Among Medicare beneficiaries, the risk of early death after bariatric surgery is considerably higher than previously suggested and associated with advancing age, male sex, and lower surgeon volume of bariatric procedures. Patients aged 65 years or older had a substantially higher risk of death within the early postoperative period than younger patients.
Adult↗
Filling the gaps in bariatric surgical research.
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Bariatrics↗
Misdiagnosis of appendicitis and the use of diagnostic imaging.
BACKGROUND: CT and ultrasound (US) are increasingly recommended to establish the diagnosis of appendicitis, but population-based rates of misdiagnosis (negative appendectomy [NA]) have not improved over time. The objective of this study was to determine the relationship between CT/US and NA in common practice. STUDY DESIGN: Using data from the Group Health Cooperative on all patients undergoing appendectomy between 1980 and 1999, a longitudinal study was conducted to determine the frequency of NA over time and a case-control, medical record-based study of a subset of patients from the 1990s was conducted to determine the accuracy of CT/US. RESULTS: Of 4,058 patients undergoing appendectomy (mean age 31 +/- 18.6 [SD] years, 49.6% women), 631 (15.5%) had an NA. The overall incidence of NA remained stable over time at 1.5/10,000 patient-years, as did the age and gender adjusted rate (incident rate ratio 0.95, 95% CI 0.97, 1.01). In 1999, nearly 40% of patients had either CT or US. The aggregate sensitivity of these tests was only 74.2% (95% CI 65.7, 83.7), with a positive predictive value of 95.1% (95% CI 91.5, 96.8). CT scans were 88.3% sensitive, with 97.2% positive predictive value (95% CI 92.9, 100). Ultrasounds were 69.5% sensitive, with a positive predictive value of 94.1% (95% CI 89.6, 96.4). More than one in five tests obtained in patients with NA were positive for appendicitis (21.7% for CT and 20.8% for US). CONCLUSIONS: The rate of NA was unchanged over time despite the introduction and use of CT/US, and this appeared to be related to the inconsistent performance characteristics of the tests. This study cautions against overreliance on CT/US in diagnosing appendicitis and emphasizes the need for test benchmarking in routine practice before establishing protocols for presumed appendicitis.
Appendectomy↗
Risk taking and tolerance of uncertainty: implications for surgeons.
BACKGROUND: Adherence to evidence-based adverse outcome prevention techniques is a critical factor in providing high-quality patient care, but many of these interventions are not used by physicians. It is unclear if surgeons' risk attitudes and reactions to uncertainty influence their use of these or other interventions. MATERIALS AND METHODS: A systematic review of the literature was conducted to identify studies evaluating the effects of physicians' risk attitudes, reactions to uncertainty or ambiguity, and personality traits on clinical decision making. RESULTS: A variety of instruments to assess risk attitude and reactions to uncertainty have been developed and tested among physicians involved in critical care and emergency medicine. Scoring systems distinguish risk averse and risk seeking practitioners. In many studies, these characteristics were related to clinical decision making in situations of uncertainty. For example, among patients evaluated in the emergency room for chest pain, "risk-seeking" physicians admitted significantly fewer patients who did not have acute myocardial infarction than risk-avoiding physicians (29% and 47% of patients admitted, respectively). In contrast, risk-seeking physicians were no more likely to discharge a patient who eventually was found to have an acute myocardial infarction. CONCLUSIONS: There are very limited data on the extent to which surgical decision making is linked to risk taking behavior and "comfort with uncertainty". Understanding the behaviors, attitudes and beliefs that make up surgical "judgment" remains a challenge for those interested in influencing behavior.
Attitude of Health Personnel↗
Risk of emergency colectomy and colostomy in patients with diverticular disease.
HYPOTHESIS: Patients with diverticulitis are at a lifetime risk for emergency colectomy and colostomy. Age and recurrence characteristics can serve to predict the risk for these adverse outcomes. DESIGN: Time-to-event analysis and logistic regression were used to determine the risk of emergency colectomy/colostomy. SETTING AND PATIENTS: A retrospective cohort study using a statewide administrative database and identifying all patients hospitalized nonelectively for diverticulitis (1987-2001). MAIN OUTCOME MEASURE: Emergency colectomy and/or colostomy in patients treated nonsurgically after a first episode of acute diverticulitis. RESULTS: A total of 25 058 patients (mean age [ +/- SD], 69 [16] years, 60% female) were hospitalized for an initial episode of diverticulitis. Of the 20 136 patients treated without initial operation, 19% had recurrences, with younger patients (<50 years) more likely to have a recurrence than older patients (27% vs 17%, P<.001). While only 5.5% of patients had recurrent hospitalizations during which an emergency colectomy/colostomy was performed, it occurred more commonly in younger patients (7.5% vs 5%, P<.001). The adjusted hazard ratio for emergency colectomy/colostomy in younger patients was 39% higher than in older patients (hazard ratio, 1.39; 95% confidence interval, 1.21-1.62). Among all patients, the adjusted hazard ratio for emergency colectomy/colostomy was 2.2 times higher with each subsequent admission (hazard ratio, 2.2; 95% confidence interval, 2.1-2.2). The predicted probability of emergency colectomy/colostomy was highest in younger patients with multiple rehospitalizations. CONCLUSIONS: Age and number of recurrent events were associated with the risk of emergency colectomy/colostomy after successful nonoperative management in patients with diverticulitis. Individualization of recommendations regarding elective colectomy based on these factors may be more appropriate than the application of previously published strategies.
Adult↗
Hartmann's colectomy and reversal in diverticulitis: a population-level assessment.
PURPOSE: This study was designed to assess the costs and outcomes of colostomy and colostomy reversal in patients with diverticulitis and examine the impact of such procedures on the health care system. METHODS: We employed a retrospective design and used a Washington State administrative database to identify patients undergoing operations with colostomy (1987-2002) who were followed over time. Descriptive and comparative analysis was performed, focusing on patients with diverticulitis. RESULTS: There were 16,556 patients who underwent colostomy and 5,420 (32.7 percent) were for diverticulitis and its related complications (mean age, 64.8 +/- 15.1 years; 53.2 percent female). In patients with diverticulitis, the rate of colostomy reversal was 56.3 percent (80 percent in patients less than 50 years, and 30 percent in patients over 77 years). The in-hospital mortality rate after colostomy reversal was 0.36 percent, and was 2.6 percent in those over 77 years of age. After colostomy reversal a second stoma was used in 3.4 percent, reoperation was required for bleeding complications in 0.6 percent, and infectious complications were noted in 2 percent. The length of time from colostomy to its reversal was approximately five months (138.1 +/- 164 days; interquartile range, 72-156). The relationship between the length of time from colostomy to reversal was evaluated and the adjusted odds of a second stoma being used at the time of colostomy reversal were 45 percent higher (odds ratio, 1.45; 95 percent confidence interval, 1.22, 1.73) for each increase in time interval (<3, 6-9, 9-12, >12 months). CONCLUSIONS: One-third of all colostomies were related to diverticulitis and only 56 percent were reversed. We identified a higher than expected mortality rate among older patients undergoing colostomy reversal. The impact of colostomy and reversal operations on both patients and the health care system is significant.
Adolescent↗
Wide local excision or abdominoperineal resection as the initial treatment for anorectal melanoma?
BACKGROUND: Anorectal melanoma (AM) is a rare tumor with a poor prognosis. Treatment with abdominoperineal resection (APR) over wide local excision (WLE) is still debated. This study aimed to compare median survival of WLE and APR in patients with AM. METHODS: A systematic review of the literature was performed. Only series that allowed calculation of median survival were included. RESULTS: Fourteen studies met inclusion criteria. Average median survival of stage I WLE patients (N=34) and stage I APR patients (N=31) was 44 and 22 months, respectively (P=.001). For stage II patients, 7 underwent WLE, and 10 underwent APR with an average median survival of 36 and 14 months, respectively (P=.19). CONCLUSIONS: This study identified no stage-specific survival advantage to APR in favor of AM. Given that WLE is a more limited intervention associated with at least comparable survival, we propose that it be considered the initial treatment of choice for AM.
Aged↗
A systematic review of whether oral contrast is necessary for the computed tomography diagnosis of appendicitis in adults.
BACKGROUND: There are several methods of contrast administration when performing computed tomography (CT) scanning for suspected appendicitis. In this systematic review we evaluated the diagnostic performance of CT with and without contrast material. METHODS: Twenty-three reports were identified using a Medline search. RESULTS: The aggregated diagnostic performance characteristics of all modes of CT scanning were excellent with a range of sensitivity (83--97%), specificity (93--98%), positive predictive value (86--98%), negative predictive value (94--99%), and accuracy (92--97%). The diagnostic performance of CT without oral contrast was similar (sensitivity, 95% vs. 92% [not statistically significant]; negative predictive value, 96% for both protocols) or surprisingly better (specificity, 97% vs. 94%; positive predictive value, 97% vs. 89%; accuracy, 96% vs. 92%; P<.0001) than with oral contrast. CONCLUSIONS: Noncontrast CT techniques to diagnose appendicitis showed equivalent or better diagnostic performance compared with CT scanning with oral contrast. A prospective comparative trial of CT with and without oral contrast for appendicitis should be performed to assess the adequacy of this modality.
Appendicitis↗
Are bariatric surgical outcomes worth their cost? A systematic review.
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Cost-Benefit Analysis↗
Evaluating diagnostic accuracy in appendicitis using administrative data.
BACKGROUND: Research techniques using administrative data have been used to assess quality of care in the management of appendicitis, but their validity has not been assessed. This study assessed the validity of a research technique using administrative data to determine whether patients undergoing an appendectomy actually had appendicitis or if they had a negative appendectomy (NA). MATERIALS AND METHODS: A retrospective study of patients at Group Health Cooperative of Puget Sound undergoing appendectomy from 1991-1999 was conducted to compare the accuracy of administrative codes with data abstracted from medical records. RESULTS: Of 1823 nonincidental appendectomies (mean age 31 +/- 18.6 years, 49.6% female), 280 did not have appendicitis by criteria applied to administrative data (15.4%). The accuracy of this method for determining appendicitis was determined by medical record evaluation revealing sensitivity (98.6%), specificity (48.6%), positive predictive value for appendicitis (83.8%), and negative predictive value for NA (70.4%). When the administrative-data technique did not classify a patient as having had appendicitis, chart-abstracted data indicated appendicitis in 6.4%, and an incorrectly labeled incidental appendectomy in 23.2%. The administrative-data technique for detecting NA erroneously included many cases of incidental appendectomy and missed many cases of clinically confirmed NA. More than half of clinical NAs were missed by the administrative technique. CONCLUSIONS: In this setting, the sensitivity of administrative-data techniques for the detection of appendicitis was excellent, but their adequacy for identifying patients undergoing NA was limited. The use of this technique as a quality measure should be reconsidered.
Adolescent↗
Temporal changes in the management of diverticulitis.
PURPOSE: This study was designed to evaluate temporal trends in the use and type of operative and non-operative interventions in the management of diverticulitis. METHODS: A retrospective cohort using a statewide administrative database was used to identify all patients hospitalized for diverticulitis in the state of Washington (1987-2001). Poisson and logistic regression were used to calculate changes in the frequency of hospitalization, operative and percutaneous interventions, and colostomy over time. RESULTS: Of the 25,058 patients hospitalized non-electively with diverticulitis (mean age 69 +/- 16, 60% female) there were only minimal changes in the frequency of admissions over time (0.006% increase per year-IRR 1.00006 95% CI 1.00004, 1.00008). The odds of an emergency colectomy at initial hospitalization decreased by 2% each year (OR 0.98 95% CI 0.98, 0.99) whereas the odds of percutaneous abscess drainage increased 7% per year (OR 1.07 95% CI 1.05, 1.1). Among patients undergoing percutaneous drainage, the odds of operative interventions decreased by 9% compared to patients who did not have a percutaneous intervention (OR 0.91 95% CI 0.87, 0.94). The proportion of patients undergoing colostomy during emergency operations remained essentially stable over time (range 49-61%), as did the proportion of patients undergoing prophylactic colectomy after initial non-surgical management (approximately 10%). CONCLUSIONS: There was a minimal increase in the frequency of diverticulitis admissions over time. A rise in percutaneous drainage procedures was associated with a decrease in emergency operative interventions. The proportion of patients undergoing colostomy remained stable, and there does not seem to be a significant increase in the use of one-stage procedures for diverticulitis.
Aged↗
Washington State's approach to variability in surgical processes/Outcomes: Surgical Clinical Outcomes Assessment Program (SCOAP).
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General Surgery↗
Perioperative rofecoxib plus local anesthetic field block diminishes pain and recovery time after outpatient inguinal hernia repair.
In this study, we compared pain scores after inguinal herniorrhaphy in patients treated by preincisional local anesthetic field block (PL), or PL combined with perioperative rofecoxib, with controls who received standard care. Seventy-five patients having herniorrhaphy under general anesthesia were randomly assigned to receive a placebo pill preoperatively, and for 5 days postoperatively (CONT); preoperative bupivacaine field block and perioperative placebo (PL); preoperative field block plus rofecoxib, 50 mg preoperatively and for 5 days postoperatively (PLR). Bupivacaine infiltration in the wound at closure, IV fentanyl and acetaminophen/oxycodone were administered postoperatively to all. Discharge time, pain scores (0-10), analgesic use, and satisfaction scores (1-6) were compared using analysis of variance. PLR patients had lower maximum pain scores (worst pain) in the postanesthesia care unit (3.7 versus 5.3, P = 0.02) and at 24 h (5.3 versus 6.8, P = 0.03), were discharged 38 min sooner (P = 0.01), required 28% less oxycodone 0-24 h after discharge (P = 0.04), and reported higher satisfaction scores compared with CONT. Pain in PL was less than CONT for 30 min. There were no differences among the 3 groups after 24 h postoperatively. We conclude that perioperative rofecoxib with PL reduces in-hospital recovery time, decreases pain scores and opioid use, and improves satisfaction scores in the first 24 h after surgery.
Adolescent↗
Primary operative versus nonoperative therapy for pediatric empyema: a meta-analysis.
OBJECTIVE: The optimal treatment of children with empyema remains controversial. The purpose of this review was to compare reported results of nonoperative and primary operative therapy for the treatment of pediatric empyema. METHODS: A systematic comprehensive review of the scientific literature was conducted with the PubMed (National Library of Medicine) database for the period from 1981 to 2004. This reproducible search identified all publications dealing with treatment of empyema in the pediatric population (<18 years of age). A meta-analysis was performed with studies with adequate data summaries for > or =1 of the outcomes of interest for both treatment groups. RESULTS: Sixty-seven studies were reviewed. Data were aggregated from reports of children initially treated nonoperatively (3418 cases from 54 studies) and of children treated with a primary operative approach (363 cases from 25 studies). The populations were similar in age. Patients who underwent primary operative therapy had a lower aggregate in-hospital mortality rate (0% vs 3.3%), reintervention rate (2.5% vs 23.5%), length of stay (10.8 vs 20.0 days), duration of tube thoracostomy (4.4 vs 10.6 days), and duration of antibiotic therapy (12.8 vs 21.3 days), compared with patients who underwent nonoperative therapy. In 8 studies for which meta-analysis was possible, patients who received primary operative therapy were found to have a pooled relative risk of failure of 0.09, compared with those who did not. Meta-analysis could not be performed for any of the other outcome measures investigated in this review. Similar complication rates were observed for the 2 groups (5% vs 5.6%). CONCLUSIONS: These aggregate results suggest that primary operative therapy is associated with a lower in-hospital mortality rate, reintervention rate, length of stay, time with tube thoracostomy, and time of antibiotic therapy, compared with nonoperative treatment. The meta-analysis demonstrates a significantly reduced relative risk of failure among patients treated operatively.
Adolescent↗
Impact of surgical clipping on survival in unruptured and ruptured cerebral aneurysms: a population-based study.
BACKGROUND AND PURPOSE: The management of aneurysms is controversial because little is known about the impact of clipping on long-term outcome. This study was designed to evaluate long-term survival of patients with aneurysms undergoing clipping in a statewide population. METHODS: We used a retrospective design using an administrative database to identify patients hospitalized with aneurysms (1987 to 2001). Time-to-event analysis was used to determine the risk of death from all causes and from neurological causes. RESULTS: 4619 patients (mean age 54.7+/-15.3, 66.3% female) were hospitalized with cerebral aneurysms. Survival among patients with ruptures was significantly lower compared with patients with unruptured aneurysm (P<0.001) with adjusted hazard ratio (HR) of death after clipping 40% higher (HR: 1.4; 95% CI: 1.2, 1.7) in patients with rupture compared with those that were unruptured. Survival estimates for unruptured patients who underwent clipping were significantly higher than among those unruptured patients who did not undergo clipping (P<0.001), with adjusted HR of death 30% higher in patients with unruptured aneurysm that were not clipped compared with unruptured patients who were clipped (HR: 1.3; 95% CI: 1.1, 1.6). Patients with unruptured aneurysm who underwent clipping and survived beyond the 30-day postoperative period were less likely to die from neurologically related causes (5.6 versus 2.3%, P<0.001). Patients with ruptures and aneurysms who underwent clipping have a higher rate of death compared with the general population in the long-term. CONCLUSIONS: Short-term and long-term mortality after clipping of cerebral aneurysms is higher than previously reported. Patients with unruptured aneurysms who undergo clipping have improved survival compared with those who do not undergo clipping. This study supports the use of early intervention in the management of patients with unruptured aneurysms.
Aneurysm, Ruptured↗
Primary anastomosis or Hartmann's procedure for patients with diverticular peritonitis? A systematic review.
PURPOSE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.
Anastomosis, Surgical↗
The impact of low health literacy on surgical practice.
BACKGROUND: We sought to determine the prevalence of low health literacy (LHL) among patients in a preoperative clinic, the characteristics associated with LHL, and the association between LHL and adherence to preoperative instructions. METHODS: We conducted a cohort study and interviewed patients at a VA preoperative clinic. We administered a health literacy test and collected sociodemographic information. When patients returned for their scheduled surgical procedures, adherence to preoperative instructions was assessed. RESULTS: Of 332 participants, 12% (n = 40) had LHL. Low health literacy was more prevalent among older adults (more than 65 years) compared with those under age 65. Patients with LHL were more likely to be nonadherent to preoperative medication instructions (odds ratio = 1.9; 95% confidence interval: 0.8 to 4.8), but this was of borderline statistical significance. CONCLUSIONS: Low health literacy was common among older patients and appeared to be associated with lower adherence to preoperative medication instructions.
Adolescent↗