Publications by authors named "Aziz M Merchant"

55 Publications

Socioeconomic risk factors for mortality and readmission after surgery for bowel obstruction: An analysis of the Nationwide Readmissions Database.

Am J Surg 2021 Apr 30. Epub 2021 Apr 30.

Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, 07103, USA. Electronic address:

Background: Small bowel obstructions (SBO) are one of the most common surgical emergencies, but they remain a major cause of high morbidity and mortality in patients with previous history of abdominal and pelvic surgery. Socioeconomic factors have not been extensively studied in surgical management of SBO.

Methods: We queried the 2016 NRD database for all surgically managed admissions ≥18 years of age with a primary diagnosis of SBO. The primary outcomes for this analysis were index admission mortality, 30-day mortality, and 30-day readmissions. Multivariate logistic regression models were utilized to examine the association between predictors and primary outcomes.

Results: Medicaid patients had a higher likelihood of index admission mortality. Medicare and Medicaid patients both had higher likelihoods of 30-day readmissions.results CONCLUSIONS: Careful consideration should be taken before deciding the optimal surgical approach in patients with SBO. Medicaid beneficiaries and those with existing comorbidities should receive careful post-operative follow-up to ensure optimal outcomes.

Conclusion:
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http://dx.doi.org/10.1016/j.amjsurg.2021.04.026DOI Listing
April 2021

A Resident-Driven Mobile Evaluation System Can Be Used to Augment Traditional Surgery Rotation Evaluations.

Am Surg 2021 Apr 21:31348211011130. Epub 2021 Apr 21.

Division of Trauma and Surgical Critical Care, Department of Surgery, 12286Rutgers - New Jersey Medical School, Newark, NJ, USA.

Background: The Accreditation Council for Graduate Medical Education requires residents to receive milestone-based evaluations in key areas. Shortcomings of the traditional evaluation system (TES) are a low completion rate and delay in completion. We hypothesized that adoption of a mobile evaluation system (MES) would increase the number of evaluations completed and improve their timeliness.

Methods: Traditional evaluations for a general surgery residency program were converted into a web-based form via a widely available, free, and secure application and implemented in August 2017. After 8 months, MES data were analyzed and compared to that of our TES.

Results: 122 mobile evaluations were completed; 20% were solicited by residents. Introduction of the MES resulted in an increased number of evaluations per resident ( = .0028) and proportion of faculty completing evaluations ( = .0220). Timeliness also improved, with 71% of evaluations being completed during one's clinical rotation.

Conclusions: A resident-driven MES is an inexpensive and effective method to augment traditional end-of-rotation evaluations.
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http://dx.doi.org/10.1177/00031348211011130DOI Listing
April 2021

Epidemiology of orthopaedic fractures due to firearms.

J Clin Orthop Trauma 2021 Jan 26;12(1):45-49. Epub 2020 Oct 26.

Department of Orthopaedic Surgery, Rutgers University, New Jersey Medical School, 140 Bergen Street, D-1610, Newark, NJ, 07103, USA.

The majority of firearm injuries involve the extremities and have concomitant orthopaedic injuries. National data on the epidemiology of wounds caused by firearms may better inform physicians and identify areas of public health intervention. We conducted an analysis of a national database to describe the epidemiology of orthopaedic firearm injuries in the United States. The Nationwide Inpatient Sample 2001-2013 database was queried for adult patients with fractures excluding those of the skull using injury billing codes. Characterization of injury was determined using External Cause of Injury billing codes. Sociodemographic and geographic variables were reported. Chi square and multinomial logistic regression analyses were performed to identify predictors of type of firearm implicated in injury. 334,212 firearm injuries were reported in the database and about half had concomitant orthopaedic fractures. Most patients were between the ages 19 and 29, were African American, and were male. The most frequent circumstance of injury was assault/homicide, the most common firearm used was a handgun, and the most common fracture site was the femur. Patients without insurance and patients of lower income were most commonly afflicted. Knowing this distribution of the burden of this class of injury provides the opportunity to identify and intervene on behalf of at-risk populations, potentially reducing injuries by promoting firearm safety to these groups and advocating sensible practices to reduce inequitable outcomes caused by these injuries.
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http://dx.doi.org/10.1016/j.jcot.2020.10.047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920201PMC
January 2021

Differences in the Predictive value of Elixhauser Comorbidity Index and the Charlson Comorbidity indices in patients with hand infections.

J Clin Orthop Trauma 2021 May 3;16:27-34. Epub 2020 Dec 3.

Rutgers New Jersey Medical School Department of Orthopaedics, 140 Bergen Street, ACC D1610, Newark, NJ 07103, USA.

Purpose: Hand infections are a common source of potentially debilitating morbidity, particularly in patients with comorbid disease. We hypothesize that there is a difference in predictive value between two commonly used comorbidity indices for the prognosis of hand infections, which may have clinical implications in the management of these conditions.

Methods: The Nationwide Inpatient Sample 2001-2013 database was queried for hand infections using International Classification of Diseases, Ninth Revision codes. The Elixhauser (ECI) and Charlson (CCI) comorbidity scores were calculated based on validated sets of ICD-9 codes. Primary outcomes included mortality, prolonged length of stay (LOS, defined as >95 percentile), discharge destination, and postoperative complications. Indices were compared using receiver operating characteristic (ROC) curves and the areas under the curve (AUC). If confidence intervals overlapped, significance was determined using the DeLong method for correlated ROC curves. This is a validated, non-parametric comparison used for the calculation of the difference between two AUCs.

Results: A weighted total of 1,511,057 patients were included in this study. The majority were Caucasian (57.1%) males (61.4%). Complication rates included 0.9% mortality, 5.3% prolonged length of stay, 25.3% discharges to non-home destinations, and 5.3% post-operative complications. The ECI and CCI each demonstrated good predictive value for mortality, but poor predictive value for non-routine discharge, prolonged LOS, and post-operative complications. There was a significantly increased likelihood of each complication with increasing comorbidity score for both indices, with the greatest odds ratio in the ECI ≥4 cohort.

Conclusions: The CCI was superior in predicting mortality while the ECI was superior in predicting non-routine discharge, prolonged length of stay, and postoperative complications, but these indices may not be clinically relevant. While both represent good predictive models, a score specifically designed for patients with hand infections may have superior prognostic value.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1016/j.jcot.2020.12.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7919929PMC
May 2021

A simplified preoperative risk assessment tool as a predictor of complications in the surgical management of forearm fractures.

J Clin Orthop Trauma 2021 Mar 18;14:121-126. Epub 2020 Jul 18.

Department of Orthopaedic Surgery, Rutgers University, New Jersey Medical School, 140 Bergen Street, D-1610, Newark, NJ, 07103, USA.

Purpose: Frailty is a well-known predictor of adverse postoperative outcomes and is often considered in the preoperative planning stage of surgery. In recent years, the modified frailty index (mFI), a novel metric used to quantify frailty, has become increasingly used in the orthopedic literature as a risk assessment tool. In this study, we analyze the utility of the mFI in predicting unplanned repeat operations and morbidity in the surgical treatment forearm fractures.

Methods: We used the American College of Surgeons National Surgical Quality Improvement Program 2006-2014 dataset to identify patients undergoing open fixation of forearm fractures. The mFI was calculated based on 5 possible comorbid conditions. Demographic and predictor variables were analyzed for associations with each outcome. In order to assess frailty in both the general and elderly population, two analyses were completed: one for the entire population and one for a population of age 65 or older. The primary outcome of interest was unplanned repeat operation. Secondary outcomes included discharge destination and major post-operative complications. Chi square and logistic regression analyses were used to identify associations.

Results: A total of 4641 patients were included in our final analysis. There was a higher prevalence of females and patients between the ages of 61 and 80 compared to other age groups. An mFI score ≥2 was a positively associated with unplanned repeat operation in the general population. An mFI score ≥2 was also positively associated with a discharge destination other than home and major post-operative complications. In the elderly population, mFI ≥2 was similarly associated with a discharge destination other than the patient's home.

Conclusions: Patients undergoing open treatment of forearm fractures were at an increased likelihood of having an unplanned repeat operation and having major complications as frailty score increased, demonstrating that the mFI may be clinically applicable risk assessment tool for these patients.
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http://dx.doi.org/10.1016/j.jcot.2020.07.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7919933PMC
March 2021

The Association of Chronic Opioid Use with Resource Utilization and Outcomes after Emergency General Surgery.

J Invest Surg 2020 Nov 24:1-6. Epub 2020 Nov 24.

Department of Surgery, Rutgers-New Jersey Medical School, Newark, NJ, USA.

Introduction: Chronic opioid use is prevalent among patients undergoing emergent surgery. We sought to understand it on the outcomes of the most common emergency surgery procedures, Appendectomy and Cholecystectomy.

Methods: We used the National Inpatient Sample to identify chronic opioid use in emergency appendectomies ( = 953) and cholecystectomies ( = 2826) from 2005 to 2014. Primary outcome was length of stay (LOS), and secondary outcomes included total charges and mortality. LOS was analyzed with multivariate Poisson regression, total charges with multivariate linear regression.

Results: For Appendectomy, the opioid abuse group was younger, had similar gender and racial demographics, had more Medicaid and private insurance and less self-pay, and had no clinically significant differences in comorbidities. Those with chronic opioid use had a 24% increased LOS (20-29%,  < .001) and $5532(±$881,  < .001) higher hospital charges. Mortality was very rare and not different (0.2% vs 0.6%, aOR 0.54 [0.11-2.58],  = .44). For Cholecystectomy, the opioid abuse group was similar in age and gender, had slightly more white individuals, had a slightly different payor mix including higher rate of private insurance, and had no clinically significant differences in comorbidities. Patients with preoperative chronic opioid abuse showed a 14% increased LOS (12-16%,  < .001) and $5352 (± $1065,  < .001) higher hospital charges, but no significant increase in mortality (0.7% vs 0.6%, aOR 1.58 [0.77-3.25],  = .22).

Conclusion: Patients with chronic opioid abuse did not have increased mortality following EGS but had increased resource utilization and LOS. These findings may help explore the impact of opioid abuse on hospital and societal cost.
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http://dx.doi.org/10.1080/08941939.2020.1839820DOI Listing
November 2020

The Use of Artificial Neural Network to Predict Surgical Outcomes After Inguinal Hernia Repair.

J Surg Res 2021 03 21;259:372-378. Epub 2020 Oct 21.

Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey. Electronic address:

Background: Inguinal hernia repair is one of the most commonly performed surgical procedures. We developed and validated an artificial neural network (ANN) model for the prediction of surgical outcomes and the analysis of risk factors for inguinal hernia repair.

Materials And Methods: The American College of Surgeons National Surgical Quality Improvement Program was used to find patients who underwent inguinal hernia repair. Using logistic regression and ANN models, we evaluated morbidity, readmission, and mortality using the area under the receiver operating characteristic curves, true-positive rate, true-negative rate, false-positive rate, and false-negative rates.

Results: There was no significant difference in the power of the ANN and logistic regression for predicting mortality, readmission, and all morbidities after inguinal hernia repair. Risk factors for morbidity, readmission, and mortality outcomes identified using ANN were consistent with logistic regression analysis.

Conclusions: ANNs perform comparably to logistic regression models in the prediction of outcomes after inguinal hernia repair. ANNs may be a useful tool in risk factor analysis of hernia surgery and clinical applications.
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http://dx.doi.org/10.1016/j.jss.2020.09.021DOI Listing
March 2021

Robotic Transthoracic Repair of a Right-Sided Traumatic Diaphragmatic Rupture.

Surg J (N Y) 2020 Jul 28;6(3):e164-e166. Epub 2020 Sep 28.

Division of Cardiothoracic Surgery, Rutgers New Jersey Medical School, Newark, New Jersey.

 Traumatic diaphragm rupture injury repairs are predominately performed through thoracotomy, laparotomy, or a combination of the two approaches. While open surgery is often necessary to follow the fundamentals of damage-control operations in unstable or polytrauma patients, minimally invasive surgery may be an alternative for those with a low injury burden to reduce the postoperative morbidities associated with open operations.  We describe the first case of a right-sided diaphragm rupture from blunt trauma that was repaired by a robotic transthoracic approach in the index admission.  Minimally invasive repair of an acute traumatic diaphragm rupture is feasible in selected trauma patients.
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http://dx.doi.org/10.1055/s-0040-1716330DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7521942PMC
July 2020

Low-molecular weight vs. unfractionated heparin for prevention of venous thromboembolism in general surgery: a meta-analysis.

Updates Surg 2021 Feb 3;73(1):75-83. Epub 2020 Sep 3.

Department of Surgery, Rutgers New Jersey Medical School, 185 South Orange Avenue, Suite MSB G530, Newark, NJ, 07103, USA.

To assess the association between low-molecular weight heparin (LMWH) and unfractionated heparin (UFH) in the prevention of venous thromboembolism (VTE) among participants undergoing general surgery. LMWH and UFH are the standard of practice in the prevention of VTE in surgery. However, in the context of general surgery, studies comparing the effectiveness of these treatments are limited. A systematic search was conducted to find studies which examined the comparative effectiveness between LMWH and UFH in the prophylaxis of VTE in the context of general surgery. The number of events of VTE in groups receiving LMWH or UFH was the primary outcome of interest, and was used to calculate odds-ratios. Amongst 33,068 participants pooled from twelve studies, the rate of VTE was 1.3% in those treated with LMWH, and 3.1% in those treated with UFH. Although there was a wide difference in rates due to clinical heterogeneity, there was no statistically significant difference between treatment effects [OR 0.77; 95% CI 0.58-1.03; p value = 0.0783; I= 62.3%; 12 studies]. In terms of the sensitivity analysis, sources overly contributing to heterogeneity were removed. The random-effects model continued to show insignificance between LMWH and UFH in the prevention of VTE in participants undergoing general surgery [OR 0.86; 95% CI 0.69-1.08; p value = 0.2005; I= 0%; 9 studies]. Results show an equal effectiveness in the prevention of VTE between participants undergoing general surgery in those allocated to receive LMWH to those allocated to receive UFH.
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http://dx.doi.org/10.1007/s13304-020-00872-wDOI Listing
February 2021

The Rare Middle Mesocolic Hernia.

Am Surg 2020 Aug 28:3134820945278. Epub 2020 Aug 28.

5751 Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.

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http://dx.doi.org/10.1177/0003134820945278DOI Listing
August 2020

High Acuity of Postoperative Consults to Emergency General Surgery at an Urban Safety Net Hospital.

J Surg Res 2021 01 17;257:50-55. Epub 2020 Aug 17.

Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey. Electronic address:

Background: Emergency general surgery (EGS) has high rates of morbidity, mortality, and readmission. Therefore, it might be expected that an EGS service fields many consultations for postoperative patients. However, with the known overutilization of emergency department visits for nonurgent conditions, we hypothesized most postoperative consults received by an EGS service would be nonurgent and could be appropriately managed as an outpatient.

Methods: We reviewed all EGS consults at a single urban safety net hospital over a 12-month period, screening for patients who had undergone surgery in the previous 12 mo. This included consultations from the emergency room and inpatient setting. Demographics, admission status, procedures performed, and other details were abstracted from the chart and Vizient reports. Consultation questions were categorized and then reviewed by an expert panel to determine if conditions could have been managed as an outpatient.

Results: The EGS service received a total of 1112 consults, with 99 (9%) for a postoperative condition. Overall, 85% of postoperative consults were admitted after consultation, 19% underwent surgery and 21% underwent a procedure with gastroenterology or interventional radiology. Expert review classified slightly over one-third (36%) of consults as nonurgent.

Conclusions: Most postoperative consults seen at our urban safety net hospital represent true morbidity that required admission, intervention, or surgery. Despite this high acuity, one-third of postoperative consults could have been managed as an outpatient. Efforts to improve discharge instructions and set patient expectations could limit unnecessary postoperative emergency department visits.
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http://dx.doi.org/10.1016/j.jss.2020.07.038DOI Listing
January 2021

Factors Contributing to Extended Hospital Length of Stay in Emergency General Surgery.

J Invest Surg 2020 Aug 14:1-8. Epub 2020 Aug 14.

Department of General Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA.

Background: Emergency general surgery (EGS) is a field characterized by disproportionately high costs, post-operative mortality, and complications. We attempted to identify independent factors predictive of an increased postoperative length of stay (LOS), a key contributor to economic burden and worse outcomes.

Methods: The ACS-NSQIP database was queried for data from2005 to 2017. Current procedural terminology (CPT) codes were used to identify the most commonly performed EGS procedures: appendectomy, bowel resection, colectomy, and cholecystectomy. Cohorts above and below 75 percentile LOS were determined, compared by preoperative variables, and evaluated with univariate and multivariate logistic regression to quantify risk.

Results: Of 267,495 cases, 70,703 cases were above the 75 percentile for LOS. A larger proportion of patients in the extended LOS group were 41 years or older (88.6% vs 45.7%). More Blacks (10.3% vs 6.7%) were observed in the extended LOS group. Age, race, cardiopulmonary, hepatic, and renal disease, diabetes, recent weight loss, steroid use, and sepsis history were significant factors on multivariate analysis but varied in terms of risk proportion by procedure. Age (61+), Black race, hypertension, sepsis, and cancer were significant for all 4 procedures.

Conclusions: Several factors are independently associated with extended LOS for those undergoing the most common EGS procedures. Five of these were associated with an increased LOS for all four procedures. These included, age (61+), hypertension, sepsis, cancer, and Black race.
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http://dx.doi.org/10.1080/08941939.2020.1805829DOI Listing
August 2020

Patient frailty as a risk assessment tool in surgical management of long bone fractures.

J Clin Orthop Trauma 2020 Jul 23;11(Suppl 4):S591-S595. Epub 2020 Jan 23.

Rutgers New Jersey Medical School Department of Orthopaedics, 140 Bergen Street, ACC D1610, Newark, NJ, 07103, United States.

Background: Frailty is an important predictor of surgical outcomes and has been quantified by several models. The modified frailty index (mFI) has recently been adapted from an 11-item index to a 5-item index and has promise to be a valuable risk assessment tool in orthopedic trauma patients. We perform a retrospective analysis of the 5-item mFI and evaluate its effectiveness in predicting outcomes in patients with long bone fractures.

Methods: The National Surgery Quality Improvement Program (NSQIP) 2006-2016 database was queried for surgical procedures in the treatment of long bone fractures by current procedural terminology (CPT) codes, excluding those performed on metacarpals and metatarsals. Cases were excluded if they were missing demographic, frailty, and variable data. The 5-item frailty index was calculated based on the sum of presence of 5 conditions: COPD/pneumonia, congestive heart failure, diabetes, hypertension, and impaired functional status. Chi square was used to determine variables significantly associated with each outcome. The significant variables were included in multivariate logistic regression along with the mFI. Significance was defined as  < 0.05.

Results: Of the 140,249 fixation procedures performed on long bone fractures in NSQIP, 109,423 cases remained after exclusion criteria were applied. The majority of patients were between the ages of 61 and 80 (34.0%), were female (65.6%) and Caucasian (86.3%). Multivariate analysis revealed that mFI scores ≥3 were predictive of unplanned reoperation (OR = 1.57), wound disruption (OR = 2.83), unplanned readmission (OR = 2.12), surgical site infection (OR = 1.90), major complications (OR = 3.04), and discharge destination (OR = 3.06).

Conclusions: Our study analyzed the relationship of frailty and postoperative complications in patients with long bone fractures. Patients had increased likelihood of morbidity, independent of other comorbidities and demographic factors. The mFI may have a role as a simple, easy to use risk assessment tool in cases of orthopedic trauma.
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http://dx.doi.org/10.1016/j.jcot.2020.01.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7394786PMC
July 2020

Laparoscopy improves failure to rescue compared to open surgery for emergent colectomy.

Updates Surg 2020 Sep 9;72(3):835-844. Epub 2020 Jun 9.

Rutgers New Jersey Medical School, 185 South Orange Avenue, Suite MSB G530, Newark, NJ, 07103, USA.

Emergent colectomy is performed in thousands of Americans each year and carries significant morbidity and mortality. Although laparoscopy has gained favor in the elective setting, its impact on failure to rescue has not been studied on a population level for emergent colectomy. The purpose of this study was to compare failure to rescue following laparoscopic versus open colectomy in the emergency setting. This was a retrospective cohort study of The American College of Surgeons National Surgical Quality Improvement Program. Adult patients undergoing emergent colectomy between 2005 and 2018 were selected and stratified into laparoscopic or open surgery groups using the Current Procedural Terminology codes. Propensity matching was performed based on the demographic and comorbidity data. Main outcomes were failure to rescue, mortality, overall morbidity, individual complications, and length of hospital stay. After matching, 11,484 cases were included for analysis, of which 3829 were laparoscopic. Overall, open colectomy conferred higher odds of failure to rescue (OR 1.71, 95% CI 1.42-2.08), mortality (OR 1.72, 95% CI 1.44-2.07), and morbidity (OR 1.73, 95% CI 1.60-1.88) vs laparoscopic cases. Open surgery significantly increased the risk of nearly all measured postoperative complications including return to operating room (OR 1.25, 95% CI 1.08-1.45), ventilator use > 48 h (OR 2.43, 95% CI 2.03-2.93), and septic shock (OR 2.34, 95% CI 1.97-2.80). Hospital length of stay was shorter for patients undergoing laparoscopic (10.4 days) vs open (12.3 days) colectomy (p < 0.0001). This study demonstrates the safety and efficacy of the laparoscopic approach for emergent colectomy vs open surgery. Laparoscopy was associated with improved complications rates, mortality, and failure to rescue, indicating that it is a promising option to improve patient outcomes during emergent colectomy.
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http://dx.doi.org/10.1007/s13304-020-00803-9DOI Listing
September 2020

Incidence and Cost of Deep Vein Thrombosis in Emergency General Surgery Over 15 Years.

J Surg Res 2020 08 9;252:125-132. Epub 2020 Apr 9.

Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey. Electronic address:

Background: Deep vein thromboses (DVTs) are a significant sequela of surgery and are associated with significant of morbidity and mortality in the United States. Operative emergency general surgery (EGS) cases have been demonstrated to have a greater burden of DVT than other types of surgery.

Materials And Methods: DVT in EGS cases were identified from the National Inpatient Sample-Healthcare Cost and Utilization Project database from 2001 to 2015 Q3 based on ICD-9 code specification. National incidence of DVT in EGS was calculated using the National Inpatient Sample-Healthcare Cost and Utilization Project sampling methodology, and propensity score matching was used to assess costs associated with DVT.

Results: Among 15,148,352 sample-weighted hospitalizations, 0.623% (94,392) experienced DVT. Incidence of DVT was greatest in GI ulcer surgery (1.705%) and lowest in appendectomy (0.095%). Patients with a perioperative DVT incurred $22,301 more in hospital-related costs than their counterparts who did not have a DVT. Although rates of DVT remained stable over the period analyzed, DVT-associated costs increased at a 2.09% annual rate in excess of inflation during the period analyzed. This increase in costs was most significant for laparotomy, which increased at a rate of 8.09% annually.

Conclusions: DVT continues to be a significant burden on resources in EGS in spite of efforts with DVT prophylaxis. Considering the increase in costs and little change in incidence, further research on cost-effective management of DVT in EGS is warranted.
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http://dx.doi.org/10.1016/j.jss.2020.03.022DOI Listing
August 2020

Association of metabolic syndrome with morbidity and mortality in emergency general surgery.

Am J Surg 2020 08 23;220(2):448-453. Epub 2019 Dec 23.

Department of General Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA. Electronic address:

Background: Metabolic syndrome (MetS) is defined by numerous comorbidities. We sought to assess MetS's effect on the 7 main emergency general surgery (EGS) procedures that constitute 80% of EGS procedures, mortalities, complications, and costs.

Methods: Data were acquired from the ACS-NSQIP database from 2005 to 2017. Current procedural terminology (CPT) codes were utilized to identify cases. Patients with obesity, diabetes, and hypertension were defined as having MetS. MetS and non-MetS cohorts were propensity score matched, compared by outcomes, and assessed with multivariate logistic regression to attain odds ratios (OR).

Results: Of 752,023 cases, 41,788 (5.6%) MetS cases were identified. Significant outcomes included superficial infection (OR: 1.51), pulmonary complications (OR: 1.17), renal complications (OR: 1.82), cumulative morbidity (OR: 1.22), and hospital readmission (OR: 1.41).

Conclusions: For patients undergoing these procedures, MetS increased risk for comorbidities and hospital readmission. MetS had a significant impact on mortality only for appendectomy.
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http://dx.doi.org/10.1016/j.amjsurg.2019.12.021DOI Listing
August 2020

Is Insurance Status Associated with the Likelihood of Operative Treatment of Clavicle Fractures?

Clin Orthop Relat Res 2019 Dec;477(12):2620-2628

D.V. Congiusta, K.M. Amer, M.M. Vosbikian, I.H. Ahmed, Department of Orthopaedic Surgery, Rutgers University New Jersey Medical School, Newark, NJ A.M. Merchant, Department of Surgery, Rutgers University New Jersey Medical School, Newark, NJ, USA.

Background: Most closed clavicle fractures are treated nonoperatively. Research during the past decade has reported differences in the treatment of clavicle fractures based on insurance status in the US and may highlight unmet needs in a vulnerable population, particularly because new data show that surgery may lead to improved outcomes in select populations. Large-scale, national data are needed to better inform this debate.

Questions/purposes: (1) Does the likelihood of operative fixation of closed clavicle fractures vary among patients with different types of insurance? (2) What demographic and socioeconomic factors are associated with the likelihood of clavicle fracture surgery? (3) Has the proportion of operative fixation of clavicle fractures changed over time?

Methods: A retrospective analysis of the Nationwide Inpatient Sample 2001-2013 database was performed. This database is the largest publicly available all-payer inpatient database in the US that provides pertinent socioeconomic data on a nationwide scale. Data were queried for patients with closed clavicle fractures using International Classification of Diseases, Ninth Revision (ICD-9) diagnostic codes, and surgery was determined using ICD-9 procedural codes. A total of 252,109 patients were included in the final analysis after 158,619 patients were excluded because of missing demographic or insurance data, ambiguous fracture location, or age younger than 19 years. Of the 252,109 included patients, 21,638 (9%) underwent surgical fixation of clavicle fractures. A chi-square analysis was performed to determine variables to be included in a multivariable analysis. A binary logistic regression analysis was used to examine demographic and other important variables, with a significance level of p < 0.01. Poisson's regression and a t-test were used to analyze trends over time. Results were recorded as odds ratios (OR) and incidence rate ratios.

Results: After controlling for demographic and potentially relevant variables, such as the median income and fracture location, we found that patients with Medicare, Medicaid, and no insurance had a lower likelihood of undergoing operative fixation of clavicle fractures than did those with private insurance. Patients without insurance were the least likely to undergo surgery (OR, 0.63; 95% CI, 0.60-0.66; p < 0.001), followed by those with Medicare (OR, 0.73; 95% CI, 0.70-0.78; p < 0.001) and those with Medicaid (OR, 0.74; 95% CI, 0.69-0.78; p < 0.001). Women, black, and Hispanic patients were also less likely to undergo surgery than men and white patients (OR, 0.95; p = 0.003; OR = 0.67; p < 0.001; and OR = 0.82; p < 0.001, respectively) There was an increase in the overall proportion of patients undergoing surgery, from 5% in 2001 to 11% in 2013 (incidence rate ratio, 2.99; p < 0.001).

Conclusions: We believe that the greater use of surgery among adult patients with clavicle fractures who have private insurance than among those with nonprivate or no insurance-as well as among men and white patients compared with women and patients of color-may be a manifestation of important health care disparities in the inpatient population. This may be owing to variable access to care or a difference in the likelihood that a surgeon will offer surgery based on a patient's insurance status. Because operative fixation of closed clavicle fractures increases in the adult population, future research should elucidate conscious and subconscious motivations of patients and surgeons to better inform the discussion of health care disparities in orthopaedics.

Level Of Evidence: Level III, therapeutic study.
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http://dx.doi.org/10.1097/CORR.0000000000000836DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6907309PMC
December 2019

The Impact of Chronic Liver Disease on Postoperative Outcomes and Resource Utilization.

J Invest Surg 2021 Jun 29;34(6):617-626. Epub 2019 Oct 29.

Division of General and Minimally Invasive Surgery, Department of Surgery, Rutgers, New Jersey Medical School, Newark, NJ, USA.

Background: Multiple studies have shown high rates of postoperative morbidity and mortality in individuals with chronic liver disease (CLD). However, analyses from comparisons with individuals without CLD are not available. Such analyses might provide opportunities to improve outcomes.

Methods: Data from The National Surgical Quality Improvement Program (NSQIP) from 2008 to 2011 were analyzed comparing CLD patients undergoing non-liver surgery propensity matched to those without CLD. Patients with CLD were stratified by Model of End Stage Liver Disease (MELD) scores <15 and ≥15. Primary outcome was all cause mortality, and secondary outcomes were composite and individual morbidity, hospital length of stay, readmission, reoperation, and discharge destination. Odds ratios (OR) were calculated, and length of hospital stay was estimated using Poisson regression.

Results: There were 6,209 patients with CLD (4,013 with low MELD, 2,196 with high MELD) matched to 18,627 patients without. Patients with CLD had 1.8- and 3.3-times higher odds of mortality (95% CI 1.6-2.1 for Low MELD (10.6%), 2.9-3.8 for high MELD (35.2%), and 1.8- and 2.2-times higher odds of any morbidity (1.6-1.9 and 1.9-2.4). Complications specific to CLD were increased based on MELD specifically coma (OR 1.6, 0.9-2.9 for Low MELD, 2.2, 1.5-3.2 for High MELD), renal failure (OR 1.4, 1.1-1.8 and 2.4, 2.0-2.9), and bleeding (OR 1.7, 1.5-1.9 and 2.0, 1.8-2.3). They also had a 20% and 80% longer length of stay, 2.2- and 3.4-times higher odds of being discharged somewhere other than home, 1.7- and 1.6-times higher odds of readmission, and 1.5- and 1.6-times higher odds of reoperation.

Conclusion: Patients with CLD have significantly higher odds of mortality and morbidity, which is increased with a higher MELD. Interventions that decrease those morbidities are needed and have the potential to decrease mortality and resource utilization.
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http://dx.doi.org/10.1080/08941939.2019.1676846DOI Listing
June 2021

Laparoscopic colectomy for diverticulitis in patients with pre-operative respiratory comorbidity: analysis of post-operative outcomes in the United States from 2005 to 2017.

Surg Endosc 2020 04 8;34(4):1665-1677. Epub 2019 Jul 8.

Department of Surgery, Rutgers New Jersey Medical School, 185 South Orange Avenue, Suite MSB G530, Newark, NJ, 07103, USA.

Background: Current studies suggest that laparoscopic colorectal surgery is an advantageous alternative to open surgery due to improved post-operative outcomes in high-risk patient groups. Limited data is currently available on the benefits of minimally invasive colectomy for diverticulitis in patients with significant pre-operative respiratory comorbidities.

Study Design: The NSQIP 2005-2017 datasets were used to identify patients that underwent partial colectomies due to diverticulitis. Partial colectomy cases were identified using CPT codes and then filtered to include only ICD 9 and 10 codes for diverticulitis. Pre-operative respiratory comorbidities included dyspnea, chronic obstructive pulmonary disease (COPD), and smoking status. Propensity matching was performed based on patient demographic and pre-operative risk factor data to create comparable groups for each respiratory comorbidity subset. Outcomes of interest were 30-day post-operative mortality and morbidity, incidence of return to operating room (ROR), and hospital length of stay (LoS). Laparoscopy and open surgery groups were compared using Chi square tests for categorical variables and t tests for continuous variables. A p value less than 0.05 was considered statistically significant.

Results: Among 70,420 cases with diverticulitis, 15,237 cases were identified as smokers, 3934 had dyspnea, and 3219 had COPD. Patients that had open procedures had significantly greater odds of mortality (OR 2.624 for smokers; OR 2.698 for dyspnea; OR 2.663 for COPD), morbidity (OR 2.590 for smokers; OR 2.344 for dyspnea; OR 2.883 for COPD), wound complication (OR 1.989 for smokers; OR 1.461 for dyspnea; OR 1.956 for COPD), and ROR (OR 1.184 for smokers; OR 1.634 for dyspnea; OR 1.975 for COPD). Laparoscopic procedures resulted in significantly lower average LoS (5.34 vs. 9.46 days for smokers; 6.84 vs. 11.06 days for dyspnea; 7.41 vs. 12.62 days for COPD; all p < .0001).

Conclusion: Laparoscopic colectomy for diverticulitis diagnosis for a matched cohort of patients with pre-operative respiratory comorbidities such as smoking status, dyspnea, and COPD resulted in significantly improved post-operative outcomes, lower odds of mortality and morbidity, and shorter LoS.
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http://dx.doi.org/10.1007/s00464-019-06943-3DOI Listing
April 2020

The Impact of Interdisciplinary Education on Skills and Attitudes of Surgery and Emergency Medicine Residents.

Surg J (N Y) 2019 Jan 20;5(1):e18-e24. Epub 2019 Mar 20.

Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey.

 Interdisciplinary education (IDE) has been proposed as a means to improve patient safety by enhancing the performance of diverse health care teams. The improved camaraderie between members of different specialties may enhance communication and can foster a more supportive and positive work environment.  This study was aimed to assess the effect of IDE on the procedural skills of general surgery (GS) and emergency medicine (EM), as well as the perceptions that GS and EM residents have of one another.  EM and GS residents participated in two separate IDE sessions (4 months apart) designed to teach extended focused assessment with sonography in trauma (e-FAST), tube thoracostomy, and complex wound closure. Surveys were administered to determine the effects that IDE had on confidence in performing bedside procedures, perceptions of IDE, and perceptions of one another's specialty. Survey responses were recorded using a 5-point Likert's scale.  Nine GS residents and 10 EM residents participated in the entire study. Significant improvements in the confidence levels of performing bedside procedures were noted among both groups of residents. We also report a significant improvement in the perceived respect and communication between EM and GS residents.  Although further studies with a larger sample size are required, we have shown that IDE can improve the confidence levels of EM and GS residents in performing tube thoracostomy, e-FAST, and complex wound closure. These IDE sessions also improve the perceptions that the residents have of one another. IDE is a useful tool and may translate into improved consultation, collaboration, and patient care.
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http://dx.doi.org/10.1055/s-0039-1681063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6426722PMC
January 2019

A Propensity Score-Matched Analysis of Laparoscopic versus Open Surgery in Patients with COPD.

J Invest Surg 2021 Jan 21;34(1):70-79. Epub 2019 Mar 21.

Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.

: This study aims to compare outcomes of laparoscopic surgery to the outcomes of open surgery in patients with chronic obstructive pulmonary disease (COPD). Plethora of studies compares laparoscopic and open surgery in the general population; however, there is a paucity of existing literature examining the optimal surgical techniques in the COPD population. : A propensity score-matched analysis using the 2012-2015 National Inpatient Sample (NIS) was conducted to match COPD patients undergoing the most common laparoscopic procedures to COPD patients undergoing the same procedures through an open approach. A multivariate logistic regression model was used to assess mortality and complications, and a multivariate linear regression model was used to compare the length of stay and total cost between open and laparoscopic surgery groups in COPD patients. In general, open surgeries in COPD patients had worse outcomes than laparoscopic surgeries. Laparoscopic cholecystectomies were 45% less likely, colectomies were 58% less likely, and diagnostic procedures were 44% less likely to result in mortality than their open counterparts. All surgical cohorts except incisional hernia repairs had higher complication rates with an open approach. Aggregate complication rate reduction among procedures ranged between 29% and 65%. Total costs were higher in all open surgical cohorts except for appendectomies ($3,424-8,455). All open surgeries were associated with a longer length of stay, ranging from an extra day to 3 days, depending on surgery type. Laparoscopic surgery should not be considered a contraindication in patients with COPD. Careful consideration of surgical technique can have significant implications on patient outcomes and hospital costs in the COPD population.
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http://dx.doi.org/10.1080/08941939.2019.1581307DOI Listing
January 2021

Outcomes of Ventral Hernia Repair in Solid Organ Transplant Patients: A Regression Analysis of the National Inpatient Sample.

J Surg Res 2019 07 18;239:284-291. Epub 2019 Mar 18.

Department of Surgery, Rutgers, New Jersey Medical School, Newark, New Jersey. Electronic address:

Background: Solid organ transplant has been identified as an independent risk factor in ventral hernia repair. Previous studies have generally focused on case studies or small samples. We sought to investigate the impact of liver or kidney transplant on ventral hernia repair outcomes using a nationally representative sample.

Methods: The National Inpatient Sample was used to identify ventral hernia repairs from years 2005 to 2014. We then divided them into two groups, patients with prior solid organ transplant and those without, and used logistic regression to analyze the effect of this variable on outcomes. We then investigated the relationship between various comorbidities and 30-d outcomes of surgery in both groups after adjusting for comorbidities. The primary outcome we looked at was mortality, with secondary outcomes such as length of stay and various surgical complications.

Results: We compared two groups consisting of patients with prior transplant (n = 3317) and patients without (n = 372,775) and found that patients with prior liver or kidney transplant did not have higher mortality rates and also did not have longer lengths of stay. In addition, in terms of preoperative variables, patients with transplant were more likely to have the following comorbidities: cardiac arrhythmia, chronic blood loss anemia, chronic pulmonary disease, congestive heart failure, depression, metastatic cancer, obesity, psychoses, solid tumor without metastasis, and weight loss. Diabetes was associated with higher mortality in transplant patients.

Conclusions: Patients without prior liver or kidney transplant did not have higher mortality rates or lengths of stay.
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http://dx.doi.org/10.1016/j.jss.2019.02.016DOI Listing
July 2019

The Cost of Surgical Site Infections after Colorectal Surgery in the United States from 2001 to 2012: A Longitudinal Analysis.

Am Surg 2019 Feb;85(2):142-149

Surgical site infections (SSIs) are among the most common types of postoperative complications in the United States and are associated with significant prevalence of morbidity and mortality in patients undergoing surgical interventions, especially in colorectal surgery (CRS) where SSI rates are significantly higher than those of similar operative sites. SSIs were identified from the National Inpatient Sample-Healthcare Cost and Utilization Project database from 2001 to 2012 based on the specification of an ICD-9 code. Propensity score matching was used to compare costs associated with SSI cases with those of non-SSI controls among elective and nonelective admissions. Results were projected nationally using Healthcare Cost and Utilization Project sampling methodology to evaluate the incidence of SSIs and ascertain the national cost burden retrospectively. Among 4,851,359 sample-weighted hospitalizations, 4.2 per cent (203,597) experienced SSI. Elective admissions associated with SSI-stayed hospitalized for an average of 7.8 days longer and cost $18,410 more than their counterparts who did not experience an SSI. Nonelective admissions that experienced an SSI had an 8.5-day longer hospital stay and cost $20,890 more than counterparts without perioperative infections. This represents a 3 per cent annual growth in costs for SSIs and seems to be largely driven by cost increases in treatment of SSIs for elective surgeries. Current efforts of SSI management after CRS focused on compliance with guidelines and tracking of infection rates would benefit from some improvements. Considering the growing costs and increase in resource utilization associated with SSIs from 2001 to 2012, further research on costs associated with management of SSIs specific to CRS is necessary.
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February 2019

Colonoscopy utilization in rural areas by general surgeons: An analysis of the National Ambulatory Medical Care Survey.

Am J Surg 2019 08 13;218(2):281-287. Epub 2019 Feb 13.

Department of Surgery, Rutgers-New Jersey Medical School, Newark, NJ, USA. Electronic address:

Background: One in three adults above 50 years old have not been screened for colorectal cancer as of 2013. Rural areas have even lower screening and have more general surgeons compared to gastroenterologists, offering surgeons as a reservoir for necessary services.

Methods: Public data from the 2006-2015 CDC National Ambulatory Medical Care Survey was analyzed using SAS. Number of colonoscopies performed by rural general surgeons, family medicine practitioners, and other specialties were compared to their urban counterparts.

Results: 21.91% of rural colonoscopies were performed by general surgeons, whereas 32.87% were performed by family medicine practitioners and 45.22% by other specialties including gastroenterologists. Rural general surgeons performed a greater percentage of annual rural colonoscopies than urban general surgeons (p < 0.05).

Conclusion: General surgeons are fulfilling the need for colonoscopy in rural areas. Improvements to current colonoscopy training guidelines are imperative, especially for physicians who practice in rural areas.
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http://dx.doi.org/10.1016/j.amjsurg.2019.02.009DOI Listing
August 2019

The role of socioeconomic disparity in colorectal cancer stage at presentation.

Updates Surg 2019 Sep 20;71(3):523-531. Epub 2019 Feb 20.

Department of Surgery, Rutgers-New Jersey Medical School, 185 South Orange Avenue, Suite MSB G530, Newark, NJ, USA.

Colorectal cancer, despite multiple screening measures being available, is the second leading cause of death due to cancer. Cancer stage at diagnosis is an important determinant of survival, where earlier stages have significantly increased rates of survival. By looking at various social health disparities (at a patient and geographic level) and their effect on stage at presentation, we will gain a better understanding of the effect they have on cancer outcomes. Data were collected from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database for the years 2007-2014. Covariates extracted were patient-level variables such as age, race, primary site, state/county, insurance status as well as county-level data which included percent urban population, median family income, rural-urban continuum code classification, percent of population that has not completed high school, percent of population below the poverty line, percent of population foreign-born, percent of language-isolated persons, and unemployment rate. The primary outcome analyzed was cancer staging at diagnosis. A χ analysis and multivariate binary logistic regression was modeled to elucidate the associations between study covariates and late stage of cancer presentation. Chi-squared analysis demonstrated significant associations (at p < 0.05) between stage of diagnosis with race, age, insurance status, location of primary site, percent of population below poverty line, percent of language-isolated persons, and percent of unemployed. To help reduce these disparities, community resources and increased screening and prevention techniques must be implemented to target the unique populations at greatest risk for developing the disease.
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http://dx.doi.org/10.1007/s13304-019-00632-5DOI Listing
September 2019

Association of Smoking Tobacco With Complications in Head and Neck Microvascular Reconstructive Surgery.

JAMA Facial Plast Surg 2019 Jan;21(1):20-26

Department of Otolaryngology-Head and Neck Surgery, Rutgers New Jersey Medical School, Newark.

Importance: Smoking is a highly prevalent risk factor among patients with head and neck cancer. However, few studies have examined the association of this modifiable risk factor on postoperative outcomes following microvascular reconstruction of the head and neck.

Objective: To analyze the risk associated with smoking in patients undergoing free flap surgery of the head and neck.

Design, Setting, And Participants: In this retrospective, population, database study, the National Quality Improvement Program data sets from 2005 to 2014 were queried for all cases of head and neck surgery involving free flap reconstruction in the United States. The 2193 cases identified were stratified into smoking and nonsmoking cohorts and compared using χ2 and binary logistic regression analyses. Pack-years of smoking data were used to assess the degree of risk associated with a prolonged history of smoking. All analyses were conducted between January 2018 and June 2018.

Main Outcomes And Measures: Smoking and nonsmoking cohorts were compared for rates of demographic characteristics, comorbidities, and complications. Following correction for differences in patient demographics and comorbidities, smoking and nonsmoking cohorts were compared for rates of postoperative complications. Complication rates were further assessed within the smoking cohort by number of pack years smoked.

Results: Of the 2193 patients identified as having undergone free flap reconstruction of the head and neck, 624 (28.5%) had a history of recent smoking. After accounting for differences in demographic variables and patient comorbidities using regression analyses, smoking status was found to be independently associated with wound disruption (odds ratio, 1.74; 95% CI, 1.17-2.59; P = .006) and unplanned reoperation (odds ratio, 1.50; 95% CI, 1.15-1.95; P = .003). An analysis by pack-years of smoking showed that a longer smoking history was significantly associated with higher rates of numerous comorbidities but not with a corresponding increase in rates of complications.

Conclusions And Relevance: Smokers undergoing free flap reconstruction of the head and neck may be at significantly higher risk of postoperative wound disruption and subsequent reoperation. These risks were independent of pack-years of smoking history, suggesting that both risks were associated with perioperative smoke exposure, and preoperative smoking cessation may be of benefit.

Level Of Evidence: NA.
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http://dx.doi.org/10.1001/jamafacial.2018.1176DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6439727PMC
January 2019

The Role of High-Fidelity Team-Based Simulation in Acute Care Settings: A Systematic Review.

Surg J (N Y) 2018 Jul 13;4(3):e136-e151. Epub 2018 Aug 13.

Division of General Surgery, Department of Surgery, Rutgers University, New Jersey Medical School, Newark, New Jersey.

 High-fidelity team-based simulation has been identified as an effective way of teaching and evaluating both technical and nontechnical skills. Several studies have described the benefits of this modality in a variety of acute care settings, but a lack of standardized methodologies has resulted in heterogeneous findings. Few studies have characterized high fidelity simulation across a broad range of acute care settings and integrated the latest evidence on its educational and patient impact.  The MEDLINE, EMBASE, Cochrane Library, and PsycINFO databases were searched for empirical studies from the last 10 years, investigating high fidelity team-based simulation in surgical, trauma, and critical care training curricula.  Seventeen studies were included. Interventions and evaluations were comprehensively characterized for each study and were discussed in the context of four overarching acute care settings: the emergency department/trauma bay, the operating room, the intensive care unit, and inpatient ad hoc resuscitation teams.  The use of high-fidelity team-based simulation has expanded in acute care and is feasible and effective in a wide variety of specialized acute settings, including the emergency department/trauma bay, the operating room, the intensive care unit, and inpatient ad hoc resuscitation teams. Training programs have evolved to emphasize team-based, multidisciplinary education models and are often conducted in situ to maximize authenticity. In situ simulations have also provided the opportunity for system-level improvement and discussions of complex topics such as social hierarchy. There is limited evidence supporting the impact of simulation on patient outcomes, sustainability of simulation efforts, or cost-effectiveness of training programs. These areas warrant further research now that the scope of utilization across acute care settings has been characterized.
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http://dx.doi.org/10.1055/s-0038-1667315DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6089798PMC
July 2018

The effect of pulmonary hypertension on inpatient outcomes of laparoscopic procedures.

Updates Surg 2018 Dec 27;70(4):521-528. Epub 2018 Jun 27.

Department of Surgery, Head and Neck Surgery, Rutgers New Jersey Medical School, 185 South Orange Avenue, Suite MSB G530, Newark, NJ, 07103, USA.

The purpose of our analysis was to assess the effects of pulmonary hypertension (PH) on clinical outcomes of patients undergoing laparoscopic procedures. Pulmonary hypertension alters physiologic patterns that has the potential to complicate laparoscopic procedures, however, an in-depth analysis evaluating survival outcomes, complications, and associated comorbidities has not been done before. Data from the National Inpatient Survey were used to identify 179,663 patients without PH and 1453 patients with PH undergoing laparoscopic procedures from the years 2003-2013. In patients with pulmonary hypertension, the presence of the following comorbidities, congestive heart failure (OR 3.56) diabetes with chronic complications (OR 3.74) fluid and electrolyte disorders (OR 7.34) metastatic cancer (OR 14.42) and peripheral vascular disease (OR 3.12) increased in-patient mortality. In regards to post-operative complications, patients with PH were more likely to have cardiac complications defined as cardiac arrest, cardiac insufficiency, cardiorespiratory failure, or heart failure (OR 3.74). Patients with PH were also more likely to develop iatrogenic pneumothorax (OR 4.13) iatrogenic pulmonary embolism (OR 7.65) and post-operative urinary complications (OR 1.92). Overall, the comorbidity with the highest association with in-patient mortality was metastatic cancer and of all complications, patients with PH were most likely to develop iatrogenic pulmonary embolism. Preparing for these adversities, notably in patients with certain associated conditions has the potential to improve patient outcome.
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http://dx.doi.org/10.1007/s13304-018-0556-yDOI Listing
December 2018

Comparison of outcomes following laparoscopic and open treatment of emergent small bowel obstruction: an 11-year analysis of ACS NSQIP.

Surg Endosc 2018 12 4;32(12):4900-4911. Epub 2018 Jun 4.

Department of Surgery, New Jersey Medical School, Rutgers University, Newark, NJ, USA.

Background: Small bowel obstruction (SBO) continues to be a common indication for acute care surgery. While open procedures are still widely used for treatment, laparoscopic procedures may have important advantages in certain patient populations. We aim to analyze differences in outcomes between the two for treatment of bowel obstruction.

Methods: The American College of Surgeons National Surgical Quality Improvement Program was used to find patients that underwent emergent or non-elective surgery for SBO. Propensity matching was used to create comparable groups. Logistic regression was used to assess differences in the primary outcome of interest, return to operating room, and morbidity and mortality outcomes. Logistic regression was also used to assess the contribution of various preoperative demographic and comorbidity characteristics to 30-day mortality.

Results: A total of 24,028 patients underwent surgery for SBO from 2005 to 2011. Of those, 3391 were laparoscopic. Propensity matching resulted in 6782 matched patients. Laparoscopic cases had significantly decreased odds of experiencing any morbidity and wound complications compared to open cases in bowel-resection and adhesiolysis-only cases. There was no significant difference found for odds of returning to operating room. Laparoscopic cases resulted in significantly shorter hospital stays than open cases (7.18 vs.10.84 days, p < 0.0001). Increasing age, American Society of Anesthesiologists class greater than three, and the presence of respiratory comorbidities resulted in increased odds of mortality. Underweight body mass index (BMI) (< 18.5) increased odds of mortality while greater than normal BMI (> 25) decreased odds of mortality.

Conclusions: Analysis of emergent SBO cases between 2005 and 2015 demonstrates that laparoscopy is not utilized as often as open approaches in surgical treatment. Laparoscopic surgery resulted in reduced postoperative morbidity and significantly shorter hospital stays compared to open intervention and was not associated with significant differences in odds of reoperation compared to open surgery.
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http://dx.doi.org/10.1007/s00464-018-6249-2DOI Listing
December 2018

Residency Training in Robotic General Surgery: A Survey of Program Directors.

Minim Invasive Surg 2018 8;2018:8464298. Epub 2018 May 8.

Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ 07103, USA.

Objective: Robotic surgery continues to expand in minimally invasive surgery; however, the literature is insufficient to understand the current training process for general surgery residents. Therefore, the objectives of this study were to identify the current approach to and perspectives on robotic surgery training.

Methods: An electronic survey was distributed to general surgery program directors identified by the Accreditation Council for Graduate Medical Education website. Multiple choice and open-ended questions regarding current practices and opinions on robotic surgery training in general surgery residency programs were used.

Results: 20 program directors were surveyed, a majority being from medium-sized programs (4-7 graduating residents per year). Most respondents (73.68%) had a formal robotic surgery curriculum at their institution, with 63.16% incorporating simulation training. Approximately half of the respondents believe that more time should be dedicated to robotic surgery training (52.63%), with simulation training prior to console use (84.21%). About two-thirds of the respondents (63.16%) believe that a formal robotic surgery curriculum should be established as a part of general surgery residency, with more than half believing that exposure should occur in postgraduate year one (55%).

Conclusion: A formal robotics curriculum with simulation training and early surgical exposure for general surgery residents should be given consideration in surgical residency training.
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http://dx.doi.org/10.1155/2018/8464298DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5964613PMC
May 2018