American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

New Crucial Literature: The Science You Need to Know

Literature selections curated by Lewis Flint, MD, FACS, and reviewed by the Bulletin Brief editorial board.

Pair of JACS

Time from Admission to Operation Strongly Predictive of Mortality Risk in Trauma Laparotomy

Marsden MER, Vulliamy PED, Carden R, et al. Trauma Laparotomy in the UK: A Prospective National Service Evaluation. J Am Coll Surg. May 17, 2021 [Epub ahead of print].

Bagaria D, Gupta A. Key Performance Indicators: Satisfying Quest for Quality. J Am Coll Surg. July 8, 2021 [Epub ahead of print].

Marsden and coauthors reported outcomes for patients who required laparotomy for abdominal injury within the first 24 hours following admission in 34 U.K. trauma centers over a six-month interval in 2019. The study cohort included 363 patients; overall mortality rate was 9 percent. Blood transfusion was required in 154 patients, and 97 percent of deaths occurred in this group. The data suggested that time from admission to operation was strongly predictive of mortality risk; the analysis disclosed that patients requiring transfusion who underwent computed tomography imaging prior to operation experienced elevated mortality risk. The authors recommended that time from admission to operation be considered as a quality measure and that delay due to imaging represented an opportunity for quality improvement.

In the letter from Bagaria and Gupta, the authors stressed the importance of prolonged pre-hospital transport time as a significant risk factor for mortality, especially in low-resource settings. Reduction of time spent in all phases of early trauma care, especially in patients requiring transfusion, could potentially reduce mortality risk.

Comparing State-Level Outcomes and Costs of Open, Laparoscopic, and Robotic Repair of Diaphragmatic Hernia

Kulshrestha S, Janjua HM, Bunn C, et al. State-Level Examination of Clinical Outcomes and Costs for Robotic and Laparoscopic Approach to Diaphragmatic Hernia Repair. J Am Coll Surg. 2021;233(1):9-19.e2.

This study used data from a state health care cost and utilization database to compare outcomes and costs for open, laparoscopic, and robotic repair of diaphragmatic hernia in adult patients. Data from a seven-year interval were collected, and the study cohort consisted of 5,962 patients. Laparoscopic hernia repair was used in 67.3 percent of patients; robotic repair was used in 15.5 percent of the cohort.

When outcomes for laparoscopic and robotic repairs were compared, there was no difference in overall mortality or complication rates. The analysis showed that median length of stay was longest for open repairs; median length of stay for laparoscopic repair was one day shorter than for robotic repairs. Of interest was the observation that postoperative endoscopy was required in significantly fewer patients treated with open repairs. Hospital costs were highest for robotic repairs even though hospital days for robotic repairs were shorter compared with open repairs and were only one day longer than laparoscopic repairs. The authors suggested that costs of equipment required for robotic repairs explained the cost differential. Unfortunately, data on surgeon/hospital experience with robotic repairs were not available; it is possible that greater experience might lead to reduced costs. Patient-reported outcomes and patient satisfaction data also were not available. Additional research will be needed to determine pathways to reduced costs for robotic repairs.

Other Article

Society for Perioperative Assessment and Quality Improvement Guidelines for Preoperative Management of Endocrine, Hormonal, and Urologic Medications

Pfeifer KJ, Selzer A, Mendez CE, et al. Preoperative Management of Endocrine, Hormonal, and Urologic Medications: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement. Mayo Clin Proc. 2021;96(6):1655-1669.

Pfeifer and coauthors reported recommendations for preoperative management of chronically administered medications that are frequently used in patients undergoing elective surgical procedures. Categories of medications included in the recommendations included insulins, oral antidiabetic medications, thyroid hormone and anti-thyroid drugs, agents for urologic conditions such as prostatic hypertrophy, and hormonal agents used for breast diseases and other conditions. The article emphasized that most agents can be continued on the day of surgery, but dosages may need adjustment. Insulin dosages, in particular, require adjustment based on risk for hyper- or hypoglycemia. Recommendations for each major group of drugs were summarized in clear, informative tables. An example is the table summarizing recommendations for preoperative management of urologic medications, which can be viewed online. Surgeons are encouraged to review the full article content.