Paracolostomy hernia repair: who and when?

BACKGROUND: Paracolostomy hernia repair (PHR) can be a challenging procedure associated with significant morbidity and high recurrence rates. We sought to analyze the complication rate and 30-day mortality among patients undergoing PHR. STUDY DESIGN: This is a retrospective analysis of patients with PHR, based on Current Procedural Terminology code 44346, using the NSQIP database from 2005 to 2008. Univariate analysis of 30-day outcomes after both emergent and nonemergent PHR in patients greater than or less than 70 years old was completed. RESULTS: There were 519 patients who underwent PHR (mean age, 63.9 years old, female, 55.9%). Emergency PHR, performed in 59 patients (11.4%), was associated with increased rates of organ space surgical site infection (SSI) (8.5% vs 0.9%, p = 0.0014), pneumonia (18.6% vs 2.6%, p ≤ 0.0001), septic shock (13.6% vs 2.6%, p = 0.0007), total morbidity (50.8% vs 2.6%, p ≤ 0.0001), and death (10.2% vs 0.9%; p = 0.0002). In patients older than 70 years, emergent PHR amplified these differences: organ space SSI (13.8% vs 1.2%, p = 0.0054); pneumonia (27.6% vs 3.7%; p = 0.0002), septic shock (17.2% vs 4.3%; p = 0.02), and mortality (20.7% vs 1.9%; p = 0.0005). CONCLUSIONS: This study revealed that most PHRs are performed electively. Although elective repair remains a relatively safe procedure, even in the elderly, emergency PHR is associated with increased morbidity, especially pulmonary and septic complications, and higher mortality. These results are amplified among patients older than 70 years undergoing emergent repair. These findings suggest that greater consideration should be given to elective repair of paracolostomy hernias in the elderly because emergency repair is associated with considerable risk and worse outcomes.

Transfer status is a risk factor for increased in-hospital mortality in patients with diverticular hemorrhage.

PURPOSE: Gastrointestinal tract hemorrhage is a common problem accounting for approximately 1 % of hospital admissions. It is estimated that one third of the episodes of lower gastrointestinal hemorrhage are secondary to diverticular disease. Inter-institutional transfer has been associated with delay in care and increased in-hospital mortality. We hypothesized that patients with diverticular hemorrhage that were transferred from an acute care hospital to tertiary care institutions have increased in-hospital morbidity and mortality when compared to primarily admitted patients. MATERIALS AND METHODS: We performed a retrospective analysis of the Nationwide Inpatient Sample for the year 2008. Patients with a primary discharge diagnosis of diverticular hemorrhage were selected. Multivariate logistic regression was used to identify the relationship between transfer status and in-hospital mortality. RESULTS: A total of 99,415 hospitalizations for diverticular hemorrhage were identified. Transferred patients had higher in-hospital mortality rates compared to primarily admitted patients (3.5 vs. 1.8 %, p < 0.001), as well as increased length of stay (8.4 vs. 5.4 days, p < 0.001) and a higher rate of total abdominal colectomy (1.2 vs. 0.6 %, p < 0.001). Multivariate analysis indicated that transfer status was associated with increased in-hospital mortality [OR 1.8, 95 % CI 1.5-2.8, p < 0.001]. CONCLUSIONS: Inter-institutional transfer for diverticular bleeding is associated with increased in-hospital mortality, increased total abdominal colectomy rate, as well as increased economic burden including mean length of stay and total hospital charges. Further prospective studies are needed to analyze the clinical information of patients requiring transfer to another hospital in order to identify those patients who would truly benefit from inter-institutional transfer.