Race Does Not Affect Rates of Surgical Complications at Military Treatment Facility.

INTRODUCTION: Racial minorities have been found to have worse health care outcomes, including perioperative adverse events. We hypothesized that these racial disparities may be mitigated in a military treatment facility, where all patients have a military service connection and are universally insured. MATERIALS AND METHODS: This is a single institution retrospective review of American College of Surgeons National Surgical Quality Improvement Program data for all procedures collected from 2017 to 2020. The primary outcome analyzed was risk-adjusted 30-day postoperative complications compared by race. RESULTS: There were 6,941 patients included. The overall surgical complication rate was 6.9%. The complication rate was 7.3% for White patients, 6.5% for Black patients, 12.6% for Asian patients, and 3.4% for other races. However, after performing patient and procedure level risk adjustment using multivariable logistic regression, race was not independently associated with surgical complications. CONCLUSIONS: Risk-adjusted surgical complication rates do not vary by race at this military treatment facility. This suggests that postoperative racial disparities may be mitigated within a universal health care system.

Does Liposomal Bupivacaine Decrease Postoperative Opioid Use in Conjunction with an Enhanced Recovery After Bariatric Surgery Pathway? A Prospective, Double-blind, Randomized Controlled Trial.

BACKGROUND: Minimization of opiate use is an important focus in the setting of the severe national opioid crisis. This study evaluated the role of liposomal bupivacaine (LB) in decreasing postoperative opioid use before and after implementation of a bariatric enhanced recovery after surgery (ERAS) program. METHODS: We performed an IRB-approved, prospective, double-blind, randomized controlled trial of LB versus plain bupivacaine (PB) in patients undergoing elective, minimally invasive, weight loss surgery at a comprehensive metabolic and bariatric surgery program from November 2017 to December 2019. Primary outcomes were postoperative morphine milligram equivalents per day (MME/day) and average subjective inpatient pain level. Secondary outcomes were length of hospital stay (LOS) and adverse events (AEs). RESULTS: Of the 100 patients enrolled, 78 were randomly assigned to LB (42) or PB (36). Thirty-four received the ERAS protocol, and 44 did not. The mean MME/day use did not differ significantly by the bupivacaine group [median, IQR PB: 20.3 (40.95); LB: 33.0 (42.9); p = .314], but it did differ by the ERAS group [median, IQR no ERAS 33.2 (47.1), ERAS 24.0 (34.0); p = .049]. Length of stay, inpatient pain score, and AEs did not differ significantly by either the bupivacaine or the ERAS group. CONCLUSIONS: In our study, liposomal bupivacaine did not significantly decrease postoperative opioid use either before implementation of ERAS or as part of an enhanced recovery after surgery program for minimally invasive bariatric surgery procedures.

The Quality of Otolaryngology- Head and Neck Surgery Literature over the Last Decade.

OBJECTIVE: To describe the changes in the quality of the Otolaryngology-Head and Neck Surgery (OTOHNS) literature over the last decade, and compare it to other surgical-based fields. METHODS: Based on impact factors, the top eight clinical U.S. OTOHNS journals were selected, and articles were analyzed from 2020 (Oto 2020) and compared to 2010 (Oto 2010). This was done similarly for Neurosurgery, Orthopedic, Ophthalmology, and General Surgery journals in 2020 (non-Oto). To limit bias and account for random variability, the first 10 research articles from each journal in each group were included. Data regarding the study type, level of evidence, use of confidence intervals, and funding source were collected. RESULTS: Based on an a priori power analysis, 160 articles were analyzed for Oto 2010 and Oto 2020. Compared to Oto 2020, Oto 2010 had more level 1 and 2 evidence (12 vs. 4; p = 0.032) and less reporting of confidence intervals (10 vs. 32; p < 0.001). Comparing the top 160 articles from 2020 from Non-Oto and OTOHNS (Oto), Non-Oto had more level 1 and 2 evidence (19 vs. 6; p = 0.0047), more randomized controlled trials (8 vs. 1; p = 0.016), and less reporting of confidence intervals (42 vs. 58; p = 0.009). CONCLUSION: High quality studies remain relatively scarce in the OTOHNS literature. Although reporting of confidence intervals has improved over the last decade, aggregate levels of evidence and extramurally funded studies lag behind other surgical-based fields. Better study design will provide stronger evidence basis, in hopes of improving clinical care. LEVEL OF EVIDENCE: N/A Laryngoscope, 133:1853-1856, 2023.

Mifepristone Combination Therapy Compared With Misoprostol Monotherapy for the Management of Miscarriage: A Cost-Effectiveness Analysis.

OBJECTIVE: To assess whether mifepristone pretreatment adversely affects the cost of medical management of miscarriage. METHODS: Decision tree analyses were constructed, and Monte Carlo simulations were run comparing costs of combination therapy (mifepristone and misoprostol) with monotherapy (misoprostol alone) for medical management of miscarriage in multiple scenarios weighing clinical practice, patient income, and surgical evacuation modalities for failed medical management. Rates of completed medical evacuation for each were obtained from a recent randomized controlled trial. RESULTS: In every scenario, combination therapy offered a significant cost advantage over monotherapy. Using a Monte Carlo analysis, cost differences favoring combination therapy ranged from 6.3% to 19.5% in patients making federal minimum wage. The cost savings associated with combination therapy were greatest in scenarios using a staged approach to misoprostol administration and in scenarios using in-operating room dilation and curettage as the only modality for uterine evacuation, a savings of $190.20 (99% CI 189.35-191.07) and $217.85 (99% CI 217.19-218.50) per patient in a low-income wage group, respectively. A smaller difference was seen in scenarios using in-office manual vacuum aspiration to complete medical management failures. As patients' wages increased, the difference in cost between combination therapy and monotherapy increased. CONCLUSION: Mifepristone combined with misoprostol is, overall, more cost effective than monotherapy, and therefore cost should not be a deterrent to its adoption in the management of miscarriage.

Tympanoplasty following Blast Injury.

Objectives To assess outcomes following tympanoplasty for blast-induced tympanic membrane perforations in a military population. Study Design Case series with chart review. Setting Tertiary care medical centers. Subjects and Methods Military personnel (N = 254) undergoing tympanoplasty for blast-related tympanic membrane perforations sustained between April 2005 and July 2014 were identified from the Expeditionary Medical Encounter Database. Descriptive statistics were obtained regarding demographics, primary and revision surgery success rates, hearing status pre- and postsurgery, and frequency of ossicular reconstruction. Rates of successful perforation closure were assessed against perforation size and character (central vs marginal) and time to surgery. Rates and types of complications were additionally explored. Results There were a total of 352 operations among 254 subjects, with an 82.1% rate of successful closure following primary surgery. For successful primary tympanoplasty, the mean improvement in pure tone average was 11.7 ± 12.1 dB. Ossiculoplasty was performed in 9.1% (32 of 352) of cases. There was no significant relationship between successful perforation closure and perforation size, perforation character, or time between injury and surgery. Cholesteatoma complicated 4.3% (15 of 352) of cases. A significant relationship was identified between risk of cholesteatoma development and increasing perforation size and marginal perforations. Conclusion Tympanoplasty success rates for blast-induced tympanic membrane perforations are lower than for other common injury mechanisms. Due to appreciable rates of postoperative cholesteatoma development, close clinical surveillance is recommended.