Safety and postoperative adverse events in pediatric airway reconstruction: Analysis of ACS-NSQIP-P 30-day outcomes

Revision surgery for laryngotracheal stenosis in children: A single center's 44 years experience

OBJECTIVES

Outcome measures of revision open airway surgery in pediatric laryngotracheal stenosis (LTS) are reported.

METHODS

Data on 46 pediatric LTS patients undergoing revision open airway surgery were collected retrospectively. The measured outcomes were decannulation rate, time to decannulation, postoperative complications, additional surgery to achieve decannulation, and functional results.

RESULTS

The most common revision surgery was partial cricotracheal resection (PCTR) in 21/46, followed by extended PCTR (ePCTR) in 20/46, and laryngotracheal reconstruction (LTR) in 5/46 patients. A 90.7% overall decannulation rate (ODR) and a 74.4% operation-specific decannulation rate (OSDR) were achieved. Delayed decannulation was identified in children aged 5 years or less (p = 0.038) and in patients with previous primary open airway surgery (p = 0.039). Complications were observed in 52.2% of patients. To achieve optimal airway patency, additional open or endoscopic airway surgeries were necessary in 30.4% and 47.7% of patients, respectively. Age 5 years or less (p = 0.034), multiple comorbidities (p = 0.044), revision ePCTR (p = 0.023), and laryngeal stenting (p = 0.018) were risk factors requiring additional open surgery to achieve age-appropriate airway. Failed primary open airway surgery (p = 0.034) and comorbidities (p = 0.044) were risk factors for a higher rate of additional endoscopic surgeries. Postoperatively 63.0% of patients achieved normal breathing, 82.2% were dysphonic and 91.1% were orally fed.

CONCLUSIONS

In this report, the patient's age under 5 years, previous primary open airway surgery, medical comorbidities, and laryngeal stenting had a significant negative impact on revision open airway surgery outcomes.

LEVEL OF EVIDENCE

Level 4 Laryngoscope, 133:3200-3207, 2023.

Surgical site infections after pediatric open airway reconstruction-A National Surgical Quality Improvement Program-Pediatric analysis

Objectives

To determine the rate of surgical site infections (SSI) after pediatric open airway reconstruction using a nationwide database.

Study Design

Cross-sectional study of the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS NSQIP-P) Database.

Methods

The ACS NSQIP-P was queried for open airway surgeries between 2013 and 2019 determining postoperative SSI and wound dehiscence with a random sample of non-airway cases serving as a control group.

Results

A total of 637 laryngotracheoplasties (LTP), 411 tracheal resections (TR) and 2100 control procedures were included. LTP and TR were both performed on younger children with more comorbidities than control surgeries (p < .05). Postoperative wound complications occurred more often after airway reconstructions than non-airway cases (6.4% vs. 2.9%, p < .001). Compared to non-airway procedures, LTP (OR: 2.42, 95% CI: 1.62-3.61) and TR (OR: 2.07, 95% CI: 1.28-3.66) developed increased SSI. Multiple logistic regression identified dirty or infected wounds (OR: 4.61, p < .001, 95% CI: 2.35-9.03) and American Society of Anesthesiologists (ASA) Class IV (OR: 3.19, p = .02, 95% CI: 1.12-8.39) as the strongest predictors of SSI after airway reconstruction.

Conclusions

SSI after pediatric airway reconstruction occur in 6% of cases and are increased in infected wounds and ASA Class IV surgeries. Recognizing common factors for these complications provide reliable benchmarking to design surgical quality improvement initiatives.

Level of Evidence

4.

Estimating perioperative outcomes after pediatric laryngotracheal reconstruction surgery in accordance with ACS-NSQIP-P reporting

BACKGROUND

The American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS-NSQIP-P) database monitors quality outcomes in pediatric surgery. However, the registry might underreport low-volume procedures. This review describes complications after laryngotracheal reconstruction (LTR) based on ACS-NSQIP-P reporting standards.

METHODS

A case series with chart review at a tertiary children's hospital included consecutive LTR procedures between 2010 and 2018. Surgical procedures were grouped into single- or double-stage for comparison of thirty-day complication rates.

RESULTS

Eighty-four procedures were reviewed with 70% (59/84) double-stage and 30% (25/84) single-stage. Children requiring double-stage procedures were younger (3.3 vs. 6.0 years, P = .002) and more often Black or African American (51% vs. 24%, P = .03). Double-stage LTR was frequently performed on children with grade 3 or 4 subglottic stenosis (90% vs. 52%, P < 001), with a tracheostomy (97% vs. 68%, P = .001) and with gastroesophageal reflux disease (93% vs. 67%, P = .004). Airway-related complications occurred in 19% (16/84) of children and non-airway complications occurred in 16% (13/84) with similar rates between groups. Unplanned reintubation (20% vs. 0%, P = .002), ventilator support longer than 48 hours (12% vs. 0%, P = .02), and total hospitalization lengths (15.6 vs. 6.5 days, P < .001) were increased after single-stage LTR. Children with non-airway complications had more central nervous system disorders (46% vs. 10%, P = .004).

CONCLUSION

Postoperative complications after pediatric LTR occur in nearly 20% of children and single-stage procedures have higher unplanned reintubations, prolonged ventilator support and hospitalization lengths. Surgeons should recognize that these typically minor events should be consistently monitored and reported after surgical expansion of the pediatric airway.

LEVEL OF EVIDENCE

IV.

Children Undergoing Laryngeal Surgery for Obstructive Sleep Apnea: NSQIP Analysis of Length of Stay, Readmissions, and Reoperations

OBJECTIVE

No national study to date has specifically evaluated the predictive variables associated with extended hospitalization and other postoperative complications following laryngeal surgery in children with obstructive sleep apnea (OSA). The goals of this study were to identify perioperative risk factors and provide a descriptive analysis of surgical outcomes in these children using the National Surgical Quality Improvement Program-Pediatrics (NSQIP-P) database.

METHODS

Patients aged 0 to 18 years who underwent laryngeal surgery with a postoperative diagnosis of OSA were queried via the 2014-2018 NSQIP-P database using Current Procedural Terminology code 31541. Variables collected included age, sex, ethnicity, body mass index (BMI), medical comorbidities, American Society of Anesthesiologists (ASA) physical classification, operative time, and concurrent procedures. Endpoints of interest were length of stay, unplanned reoperation, readmission, reintubation, and postoperative complications. Univariate and multivariate linear regression analyses were performed.

RESULTS

A total of 181 cases were identified (57.5% male and 42.5% female, mean age 4.36 years, range 14 days-17.7 years). Body mass index (P = .015, OR = 0.96), structural CNS abnormality (P = .034, OR = 1.95), preoperative oxygen supplementation (P = .043, OR = 1.28), operative time (P = .019, OR = 1.84, 95% CI = 1.28-2.54), and concurrent procedure (P < .001, OR = 2.21) were all independently associated with LOS. Postoperative complications had no significantly associated variables, with an overall low incidence of readmission (5.0%), reoperation (1.7%), and reintubation (1.1%).

CONCLUSION

In this data set, children with OSA undergoing laryngeal surgery experienced minimal postoperative complications. Recognition of the factors associated with increased LOS could lead to improvement in the quality of care for children with OSA.

Early Adverse Events Following Pediatric Mandibular Advancement: Analysis of the ACS NSQIP-Pediatric Database

OBJECTIVE

This study aims to assess early adverse events and patient factors associated with complications following mandible distraction osteogenesis (MDO).

MATERIALS AND METHODS

The American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-Pediatric) database, years 2012 to 2019, was queried for patients undergoing mandible advancement via relevant Current Procedural Terminology and postoperative diagnosis codes. Thirty-day adverse events and co-morbidities are assessed.

RESULTS

A total of 208 patients were identified with 17.3% (n = 36) experiencing an adverse event, reoperation (n = 14), and readmission (n = 11) being most common. Patients < 365 days old at the time of operation were more likely to experience an adverse event (26.1% vs 10.8%; P = .005). However, among patients less than 1 year of age, differences in the complication rates between patients  ≤ 28 days and >28 days (30.2% vs 22.2%; P = .47) and those weighing  ≤ 4 kg and >4 kg (31.7% vs 11.5%; P = .063) did not reach statistical significance.

CONCLUSIONS

Adverse events following mandible advancement are relatively common, though often minor. In our analysis of the NSQIP-Pediatric database, neonatal age ( ≤ 28 days) or weight  ≤ 4 kg did not result in a statistically significant increase in complications among patients less than 1 year of age. Providers should consider early intervention in patients who may benefit from MDO.

Complications and outcomes following open laryngotracheal reconstruction: A 15 year experience at an Australian paediatric tertiary referral centre

OBJECTIVE

To report on our experience with open pediatric laryngotracheal reconstruction (LTR) with cartilage interposition grafts over the past 15 years and document setbacks and factors that affect postoperative outcomes.

METHOD

A retrospective chart review was performed on all pediatric patients who underwent single and double-stage LTR at The Children's Hospital in Westmead between August 2004 and July 2019. The outcomes measured include the overall decannulation rate, rates of postoperative complications, need for subsequent procedures and postoperative functional results (dyspnea, stridor, voice impairment).

RESULTS

Between August 2004 and July 2019, a total of 51 open LTRs were performed on 46 patients, with mean age 3.9 years (range 1 month to 12.1 years), including 11 revision operations (11.8%). The most common indication for surgery was subglottic stenosis, followed by bilateral vocal cord motion impairment followed by anterior glottic web. 13 cases (25.5%) were complicated by ventilator associated pneumonia in the postoperative period and 11 patients (21.6%) experienced wound complications ranging from localised wound abscess to wound dehiscence and graft failure. Patients with viral infections had an increased risk of wound dehiscence and graft failure (OR 1.8, 95% CI 1.01 - 3.23). Patients with a greater decrease in albumin in the postoperative period were more likely to have wound complications (OR 1.8; 95% CI 1.17 -2.83). Ten patients failed extubation and required a subsequent tracheostomy. Severity of stenosis, age at time of surgery, history of prematurity and revision LTR were not predictors for need for reintubation and/or tracheostomy after surgery. 23 cases (45.1%) underwent subsequent endoscopic procedures such a balloon dilatation to manage restenosis following LTR. Though 45.7% had a very good outcome, a significant group of 21% had ongoing voice issues.

CONCLUSION

Good outcomes were achieved following open LTR for pediatric laryngotracheal stenosis despite postoperative complications. At final follow up, 33 patients (71.7%) had good exercise tolerance with no or mild stridor. Forty-one of the forty-six patients (89.1%) were successfully decannulated.

Barriers to Decannulation After Double-Stage Laryngotracheal Reconstruction

OBJECTIVES/HYPOTHESIS

To identify any potential barriers for decannulation in children undergoing double-staged laryngotracheal reconstruction (dsLTR) beyond the severity of disease itself.

STUDY DESIGN

Case series with chart review.

METHODS

We performed a retrospective chart review from 2008 to 2018 of 41 children who had undergone dsLTR as primary treatment for laryngotracheal stenosis at a stand-alone tertiary children's hospital. We examined the effect of demographic, medical, and surgical factors on successful decannulation and time to decannulation after dsLTR.

RESULTS

Of the 41 children meeting inclusion criteria who underwent dsLTR, 34 (82%) were decannulated. Age, gender, race, insurance status, medical comorbidity, and multilevel stenosis did not predict overall decannulation. Insurance status did not impact time to decannulation (P = .13, Log-rank). Factors that increased length of time to decannulation were the use of anterior and posterior cartilage grafts (P = .001, Log-rank), history of pulmonary disease (P = .05, Log rank), history of cardiac disease (P = .017, Log-rank), and race/ethnicity (P = .001 Log-rank).

CONCLUSION

In a cohort with a similar decannulation rates to previous dsLTR cohorts, we identified no demographic or medical factors that influenced overall decannulation. We did observe that pulmonary comorbidity, cardiac comorbidity, and race/ethnicity lengthens time to decannulation.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:2141-2147, 2021.

30-Day readmission rates, diagnoses, and risk factors following pediatric airway surgery

BACKGROUND

In the last few decades, the increased survival of premature infants and critically ill children have led to the increased frequency and complexity of pediatric airway procedures. Minimizing readmission rates following these procedures is important to maximize health outcomes and cost effectiveness. This study examines the incidence, reasons, and risk factors for hospital readmissions following pediatric airway surgeries in a large, nationally representative sample.

METHODS

Pediatric airway surgeries performed across 22 states in 2014 were identified using data from the Nationwide Readmissions Database (NRD). Airway surgeries were identified and categorized using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes into the following categories: tracheostomy, repair of larynx, repair of trachea, laryngeal excision, tracheal excision, bronchoscopy, laryngoscopy, laryngotracheal diagnostic procedures, other operations on larynx, and other operations on trachea. Univariate and multivariate analyses were used to identify factors significantly correlated with readmissions.

RESULTS

10,289 pediatric airway procedures over 7120 visits were identified. 954 readmissions were identified for an overall readmission rate of 13.4%. 613 of these readmissions were related to the initial procedure, yielding a relevant readmission rate of 8.6%. On univariate analysis, factors that varied significantly with readmission rates included number of diagnoses on record (OR 1.06), number of chronic conditions (OR 1.18), number of procedures (OR 1.07), public insurance status (OR 1.39), bottom quartile median household income in patient zip code (OR 1.29), teaching hospital status (OR 1.60), and chronic perinatal respiratory disease (OR 1.45). On multivariate analysis, significant predictors included number of diagnoses (OR 1.02), number of chronic conditions (OR 1.13), and bottom quartile median household income in patient zip code (OR 1.20). The most common categories for readmission were respiratory distress (36%), infection (24%), and pneumonia (14%). The top overall individual reasons for readmission were stenosis of larynx (7.3%) and pneumonia (5.9%).

CONCLUSIONS

Pediatric airway surgeries have relatively high rates of readmission. Strategies to reduce readmissions should involve addressing health disparities and employing a multidisciplinary approach to improve care for medically complex patients.

Best Practice Recommendations for Pediatric Otolaryngology during the COVID-19 Pandemic

Objective

To review the impact of coronavirus disease 2019 (COVID-19) on pediatric otolaryngology and provide recommendations for the management of children during the COVID-19 pandemic.

Data Sources

Clinical data were derived from peer-reviewed primary literature and published guidelines from national or international medical organizations. Preprint manuscripts and popular media articles provided background information and illustrative examples.

Methods

Included manuscripts were identified via searches using PubMed, MEDLINE, and Google Scholar, while organizational guidelines and popular media articles were identified using Google search queries. Practice guidelines were developed via consensus among all authors based on peer-reviewed manuscripts and national or international health care association guidelines. Strict objective criteria for inclusion were not used due to the rapidly changing environment surrounding the COVID-19 pandemic and a paucity of rigorous empirical evidence.

Conclusions

In the face of the COVID-19 pandemic, medical care must be judiciously allocated to treat the most severe conditions while minimizing the risk of long-term sequelae and ensuring patient, physician, and health care worker safety.

Implications for Practice

The COVID-19 pandemic will have a profound short- and long-term impact on health care worldwide. Although the full repercussions of this disease have yet to be realized, the outlined recommendations will guide otolaryngologists in the treatment of pediatric patients in the face of an unprecedented global health crisis.

A cross-sectional evaluation of outcomes of pediatric branchial cleft cyst excision

OBJECTIVE

To examine complications following pediatric branchial cleft cyst excision by surgical specialty, demographics, and comorbid conditions.

METHODS

A retrospective review of the National Surgical Quality Improvement Program database was performed. Pediatric cases from January 1, 2015 through May 1, 2017 with a current procedural terminology code of 42810 (excision branchial cleft cyst or vestige, confined to skin and subcutaneous tissues) or 42815 (excision branchial cleft cyst, vestige, or fistula, extending beneath subcutaneous tissues and/or into the pharynx) were included. Statistical analysis was performed to assess associations between complications and surgical specialty, demographics, and comorbidities.

RESULTS

Of the 895 cases that met inclusion criteria, the median age was two years and there was an approximately equal number of males (46.8%) and females (53.2%). Forty-five patients (5.0%) experienced at least one 30-day complication, the most predominant of which was superficial surgical site infection. There was no statistically significant difference between complications and surgical specialty, complications and patient demographics, or complications and depth of excision. There was a statistically significant difference (p = 0.05) in the percentage of patients with a past medical history of developmental delay between those with at least one complication (11.1%) compared to those without any complications (4.2%).

CONCLUSION AND RELEVANCE

Branchial cleft excision is a generally safe procedure across surgical specialties and patient demographics. There is an association between a history of developmental delay and 30-day postoperative complications.

Pediatric Rhinoplasty: A national surgical quality improvement program analysis

OBJECTIVES

Rhinoplasty is commonly performed in children with congenital anomalies and resultant nasal deformity causing airway obstruction. Little is known regarding patient factors or perioperative sequelae. We define demographic characteristics and perioperative complications for children undergoing rhinoplasty within a large national cohort.

STUDY DESIGN

Retrospective cohort study of children aged ≤ 18 years undergoing rhinoplasty utilizing data from the 2012 to 2015 American College of Surgeons National Surgery Quality Improvement Program-Pediatric public use file.

METHODS

All children who underwent rhinoplasty were identified. Postoperative complications were defined as 30-day postoperative infection, unplanned readmission and reoperation, and death. Multivariate logistic regression was used to identify predictors of complications. Subgroup analysis was performed based on child age (age < 5 years vs. 5-13 years vs. ≥ 14 years).

RESULTS

Of 1,378 children undergoing rhinoplasty, 21(1.52%) children experienced complications, with the most common being unplanned readmission. Younger children were more likely to experience complications (3.79% aged < 5 years vs. 0.66% aged ≥ 14 years; P = 0.001). Using multivariate logistic regression analysis, we observed a 61% decreased odds of complication with each age group (odds ratio 0.39, 95% confidence interval 0.19, 0.77; P = 0.007). Younger children were more likely to be male (56.2% male aged < 5 years vs. 46.6% male aged ≥ 14 years; P = 0.011), have developmental delay (11.7% aged < 5 years vs. 3.65% aged ≥ 14 years; P < 0.001), and have craniofacial abnormalities (73.2% aged < 5 years vs. 42.1% aged ≥ 14 years; P < 0.001).

CONCLUSION

Children undergoing rhinoplasty experience few major complications, with the most common being unplanned readmission. Younger children are at greater risk and are more likely to be male with craniofacial abnormalities.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:494-499, 2019.

Publicly Available Databases in Otolaryngology Quality Improvement

The historical context for quality improvement is provided. Important differences are described between the two overarching types of databases: clinical registries and administrative databases. The pros and cons of each are provided as are examples of their utilization in otolaryngology-head and neck surgery.

Analysis of risk factors for morbidity in children undergoing the Kasai procedure for biliary atresia

OBJECTIVE

To evaluate the perioperative risk factors for 30-day complications of the Kasai procedure in a large, cross-institutional, modern dataset.

STUDY DESIGN

The 2012-2015 National Surgical Quality Improvement Program Pediatric database was used to identify patients undergoing the Kasai procedure. Patients' characteristics were compared by perioperative blood transfusions and 30-day outcomes, including complications, reoperations, and readmissions. Multivariable logistic regression was used to identify risk factors predictive of outcomes. Propensity matching was performed for perioperative blood transfusions to evaluate its effect on outcomes.

RESULTS

190 children were included with average age of 62 days. Major cardiac risk factors were seen in 6.3%. Perioperative blood transfusions occurred in 32.1%. The 30-day post-operative complication rate was 15.8%, reoperation 6.8%, and readmission 15.3%. After multivariate analysis, perioperative blood transfusions (OR 3.94; p < 0.01) and major cardiac risk factors (OR 7.82; p < 0.01) were found to increase the risk of a complication. Perioperative blood transfusion (OR 4.71; p = 0.01) was associated with an increased risk of reoperation. Readmission risk was increased by prematurity (OR 3.88; p = 0.04) and 30-day complication event (OR 4.09; p = 0.01). After propensity matching, perioperative blood transfusion was associated with an increase in complications (p < 0.01) and length of stay (p < 0.01).

CONCLUSION

Major cardiac risk factors and perioperative blood transfusions increase the risk of post-operative complications in children undergoing the Kasai procedure. Further research is warranted in the perioperative use of blood transfusions in this population.

LEVEL OF EVIDENCE

IV.

Safety and postoperative adverse events in management of acute mastoiditis in children - 30 Day NSQIP outcomes

OBJECTIVE

To examine preoperative risk factors, postoperative 30-day outcomes and adverse events of acute mastoiditis using a national pediatric surgical database.

METHODS

We explored our objectives using a cross-sectional analysis of a hospital-based reporting system database. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) pediatric database was used to identify surgical encounters for the treatment of acute mastoiditis from 2012 to 2015. Patient demographics, co-morbidities, laboratory values, surgical details, complications, and outcomes were tabulated. Linear regression was used to determine predictors of prolonged hospital stay based on pre-operative, surgical and outcome variables.

RESULTS

113 patients with acute mastoiditis were identified from with mean age of 7.8 years. Mastoidectomy was the most common index procedure performed (44; 34%). Average hospital stay length was 5.2 days. No patients died within 30 days. 4 (3.1%) patients required readmission, and 9 (6.9%) required unplanned subsequent operative procedures. Pre-operative presence of sepsis or systemic inflammatory response syndrome (SIRS; p = 0.03), and unplanned additional procedures were associated with a prolonged hospital stay (p = 0.03), but age, gender, race, and pre-operative morbidities were not (p > 0.05).

CONCLUSIONS

Contemporary surgical management of acute mastoiditis in children appears to be safe. Mortality is rare and has been potentially eliminated as a complication. Rates of pre-operative systemic infection were very high, despite current antibiotic utilization trends. Opportunities for quality improvement exist to investigate how to decrease rates of preoperative sepsis, limit readmissions, and unplanned re-operations. The role of mastoidectomy appears prominent, as it was used in about two-thirds of cases.

LEVEL OF EVIDENCE

4.

Results of Database Studies in Spine Surgery Can Be Influenced by Missing Data

BACKGROUND

National databases are increasingly being used for research in spine surgery; however, one limitation of such databases that has received sparse mention is the frequency of missing data. Studies using these databases often do not emphasize the percentage of missing data for each variable used and do not specify how patients with missing data are incorporated into analyses. This study uses the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to examine whether different treatments of missing data can influence the results of spine studies.

QUESTIONS/PURPOSES

(1) What is the frequency of missing data fields for demographics, medical comorbidities, preoperative laboratory values, operating room times, and length of stay recorded in ACS-NSQIP? (2) Using three common approaches to handling missing data, how frequently do those approaches agree in terms of finding particular variables to be associated with adverse events? (3) Do different approaches to handling missing data influence the outcomes and effect sizes of an analysis testing for an association with these variables with occurrence of adverse events?

METHODS

Patients who underwent spine surgery between 2005 and 2013 were identified from the ACS-NSQIP database. A total of 88,471 patients undergoing spine surgery were identified. The most common procedures were anterior cervical discectomy and fusion, lumbar decompression, and lumbar fusion. Demographics, comorbidities, and perioperative laboratory values were tabulated for each patient, and the percent of missing data was noted for each variable. These variables were tested for an association with "any adverse event" using three separate multivariate regressions that used the most common treatments for missing data. In the first regression, patients with any missing data were excluded. In the second regression, missing data were treated as a negative or "reference" value; for continuous variables, the mean of each variable's reference range was computed and imputed. In the third regression, any variables with > 10% rate of missing data were removed from the regression; among variables with ≤ 10% missing data, individual cases with missing values were excluded. The results of these regressions were compared to determine how the different treatments of missing data could affect the results of spine studies using the ACS-NSQIP database.

RESULTS

Of the 88,471 patients, as many as 4441 (5%) had missing elements among demographic data, 69,184 (72%) among comorbidities, 70,892 (80%) among preoperative laboratory values, and 56,551 (64%) among operating room times. Considering the three different treatments of missing data, we found different risk factors for adverse events. Of 44 risk factors found to be associated with adverse events in any analysis, only 15 (34%) of these risk factors were common among the three regressions. The second treatment of missing data (assuming "normal" value) found the most risk factors (40) to be associated with any adverse event, whereas the first treatment (deleting patients with missing data) found the fewest associations at 20. Among the risk factors associated with any adverse event, the 10 with the greatest effect size (odds ratio) by each regression were ranked. Of the 15 variables in the top 10 for any regression, six of these were common among all three lists.

CONCLUSIONS

Differing treatments of missing data can influence the results of spine studies using the ACS-NSQIP. The current study highlights the importance of considering how such missing data are handled.

CLINICAL RELEVANCE

Until there are better guidelines on the best approaches to handle missing data, investigators should report how missing data were handled to increase the quality and transparency of orthopaedic database research. Readers of large database studies should note whether handling of missing data was addressed and consider potential bias with high rates or unspecified or weak methods for handling missing data.

Safety and Perioperative Adverse Events in Pediatric Endoscopic Sinus Surgery: An ACS-NSQIP-P Analysis

INTRODUCTION

This study describes safety outcomes of pediatric endoscopic sinus surgery (ESS) to identify risk factors for 30-day postoperative adverse events using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database.

METHODS

We performed a retrospective cohort study involving patients in the 2012-2015 NSQIP-P database who underwent ESS. Predictors included demographics, comorbidities and surgical acuity. Outcomes included 30-day complications, reoperations, and readmissions.

RESULTS

Among 2,061 ESS cases identified, 1,829 (88.7%) were elective and 232 (11.3%) were urgent/emergent. There were 92 (4.5%) readmissions, 54 (2.6%) unplanned reoperations, and 61 (3.0%) complications. On multivariate analysis, readmission was associated with urgent/emergent procedures (OR 2.31, CI 1.36-3.93, p<0.01) and history of bleeding disorder (OR 2.24, CI 1.12-4.44, p = 0.02), reoperation was associated with urgent/emergent procedures (OR 5.78, CI 3.24-10.34, p<0.01), and complications were associated with urgent/emergent procedures (OR 3.81, CI 2.13-6.82, p<0.01) and history of bleeding disorder (OR 5.30, CI 2.74-10.20, p<0.01). Bleeding requiring transfusion was associated with urgent/emergent procedures (OR 9.61, CI 2.90-31.80, p<0.01), history of bleeding disorder (OR 14.16, CI 4.41-45.45, p<0.01), and age <3 years (OR 3.92, CI 0.99-15.61, p = 0.05). Black children were significantly more likely to undergo urgent/emergent surgery than white children (19.7% vs. 9.6%, p<0.01).

CONCLUSIONS

This multi-institutional study confirms that while pediatric ESS is largely safe, urgent/emergent procedures carry the greatest risk of postoperative adverse events, and black children are significantly more likely to undergo higher acuity surgery than white children. Regardless of procedure acuity, young age and bleeding disorder are associated with higher risk of 30-day adverse events.