Introduction: Patients who undergo emergency surgery represent a high-risk population and have been shown to have poor outcomes. However, little is known about the variability in the quality of emergency general surgical care across hospitals. The objectives of this study were to compare 30-day outcomes after three common emergency general surgery procedures and to determine whether the quality of emergency surgical care is procedure-dependent or intrinsic to other aspects of the hospital environment. Methods: Patients who underwent emergency appendectomy, cholecystectomy, or colectomy at 95 hospitals that reported at least 20 of each procedure were identified in the 2005-2008 American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database. Outcomes of interest included 30-day overall morbidity and serious morbidity/mortality. Forward step-wise multivariable logistic regression models identified variables included in hierarchical models. Based upon the expected probabilities of the outcome derived from the hierarchical model, observed to expected (O/E) ratios for each outcome after the three procedures were calculated for each hospital. Hospitals were divided into three roughly equal groups based upon O/E ratios (Figure). Agreements on hospital outcomes for overall morbidity and serious morbidity/mortality after appendectomy, cholecystectomy, and colectomy were assessed using the kappa statistic and the Kendall's coefficient of concordance. Results: Of the 30,788 appendectomies, 1,984 (6.4%) patients had any morbidity, and 1,143 (3.7%) patients had a serious morbidity or died. Of the 5,824 cholecystectomies, 503 (8.6%) patients had any morbidity, and 369 (6.3%) patients had a serious morbidity or died. Of the 8,992 colectomies, 4,200 (46.7%) patients had any morbidity, and 3,737 (41.6%) patients had a serious morbidity or died. For overall morbidity, O/E ratios for appendectomy ranged from 0.31 to 2.52; O/E ratios for cholecystectomy ranged from 0 to 3.2; O/E ratios for colectomy ranged from 0.43 to 1.53. For serious morbidity/mortality, O/E ratios for appendectomy ranged from 0.21 to 2.93: O/E ratios for cholecystectomy ranged from 0 to 4.32; O/E ratios for colectomy ranged from 0.6 to 1.63. Hospitals outcomes based upon tercile rank after one procedure were not similar to those after the other procedures for either overall morbidity (kappa=0.13) or serious morbidity/mortality (kappa=0.16). Only nine (9.4%) hospitals for overall morbidity and nine (9.4%) hospitals for serious morbidity/mortality were rated in the highest tercile for all procedures. Four (4.2%) hospitals for overall morbidity and seven (7.4%) hospitals for serious morbidity/mortality were rated in the lowest tercile for all procedures. Conclusion: All three emergency general surgery procedures were associated with substantial 30-day overall morbidity and serious morbidity/mortality. Most hospitals did not have uniform outcomes across all three procedures. Individual hospitals should examine their procedure-specific outcomes after emergency general surgeries to focus quality improvement initiatives appropriately.

BackgroundFor chronic pancreatitis, European prospective trials have concluded that duodenum-preserving head resections (DPHR) are associated with less morbidity and similar pain relief and quality of life (QoL) outcomes compared with pancreaticoduodenectomy (PD). However, DPHR procedures are seldom performed in North America.MethodsPatients undergoing PD or DPHR for unremitting pain secondary to chronic pancreatitis were retrospectively identified. Quality of life was assessed cross-sectionally using the European Organization for Research and Treatment of Cancer (EORTC) Quality-of-Life Questionnaire (QLQ-C30) and pancreatic cancer-specific supplemental module (QLQ-PAN26).ResultsEighty-one patients underwent either a Whipple PD (n= 59) or a DPHR (Bern, Beger or Frey procedure, n= 22) for the treatment of pain caused by chronic pancreatitis over a 5-year period. The characteristics of patients undergoing DPHR and PD procedures were similar. Duration of procedure (360 min vs. 245 min), duration of hospital stay (12.0 days vs. 9.5 days) and estimated blood loss (535 ml vs. 214 ml) were all significantly less for DPHR patients (P < 0.05). Thirty-day morbidity and mortality, postoperative pain relief and QoL scores did not differ significantly between groups.ConclusionsDuodenum-preserving head resection is equally as effective as PD in relieving pain and improving QoL in chronic pancreatitis patients, and involves a shorter hospital stay and less blood loss.