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Patel AA, Kennedy D, Dupuis G, Levi JR, Weber PC. Determining the Impact of Preoperative Psychiatric Comorbidities on Readmission After Resection of Vestibular Schwannoma. Otol Neurotol 2024; 45:e602-e606. [PMID: 39142317 DOI: 10.1097/mao.0000000000004277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
OBJECTIVE To determine the impact of comorbid depression on readmission after vestibular schwannoma resection. STUDY DESIGN Retrospective database analysis. SETTING National database of readmitted patients. PATIENTS The Nationwide Readmission Database (NRD) was retrospectively reviewed for patients with history of vestibular schwannoma, identified by International Classification of Disease, Ninth Revision (ICD-9) code 225.1 and ICD-10 code D33.3, who underwent surgical resection (ICD-9 04.01, ICD-10-PCS 00BN0ZZ) in 2020. INTERVENTIONS Therapeutic. MAIN OUTCOME MEASURES Need for rehabilitation, need for procedures, length of stay, cost of readmission, and insurance status. RESULTS A total of 1997 patients were readmitted after resection of vestibular schwannoma in 2020. Of these patients, 290 had history of a comorbid depressive disorder.A significantly higher proportion of patients with history of comorbid depression were transferred to a rehabilitation facility after readmission (11.30% versus 4.30%, p < 0.001). Length of stay (p = 0.227) and total readmission cost (p = 0.723) did not differ significantly, but a significantly lower proportion had private insurance (55.40% versus 64.40%, p = 0.027). CONCLUSION Depression is associated with higher utilization of postoperative rehabilitation services and higher rates of medical comorbidities, and should be considered during preoperative evaluation.
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Affiliation(s)
| | | | - Genevieve Dupuis
- Boston University School of Public Health, Boston, Massachusetts
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Heman-Ackah SM, Blue R, Quimby AE, Abdallah H, Sweeney EM, Chauhan D, Hwa T, Brant J, Ruckenstein MJ, Bigelow DC, Jackson C, Zenonos G, Gardner P, Briggs SE, Cohen Y, Lee JYK. A multi-institutional machine learning algorithm for prognosticating facial nerve injury following microsurgical resection of vestibular schwannoma. Sci Rep 2024; 14:12963. [PMID: 38839778 PMCID: PMC11153496 DOI: 10.1038/s41598-024-63161-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 05/26/2024] [Indexed: 06/07/2024] Open
Abstract
Vestibular schwannomas (VS) are the most common tumor of the skull base with available treatment options that carry a risk of iatrogenic injury to the facial nerve, which can significantly impact patients' quality of life. As facial nerve outcomes remain challenging to prognosticate, we endeavored to utilize machine learning to decipher predictive factors relevant to facial nerve outcomes following microsurgical resection of VS. A database of patient-, tumor- and surgery-specific features was constructed via retrospective chart review of 242 consecutive patients who underwent microsurgical resection of VS over a 7-year study period. This database was then used to train non-linear supervised machine learning classifiers to predict facial nerve preservation, defined as House-Brackmann (HB) I vs. facial nerve injury, defined as HB II-VI, as determined at 6-month outpatient follow-up. A random forest algorithm demonstrated 90.5% accuracy, 90% sensitivity and 90% specificity in facial nerve injury prognostication. A random variable (rv) was generated by randomly sampling a Gaussian distribution and used as a benchmark to compare the predictiveness of other features. This analysis revealed age, body mass index (BMI), case length and the tumor dimension representing tumor growth towards the brainstem as prognosticators of facial nerve injury. When validated via prospective assessment of facial nerve injury risk, this model demonstrated 84% accuracy. Here, we describe the development of a machine learning algorithm to predict the likelihood of facial nerve injury following microsurgical resection of VS. In addition to serving as a clinically applicable tool, this highlights the potential of machine learning to reveal non-linear relationships between variables which may have clinical value in prognostication of outcomes for high-risk surgical procedures.
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Affiliation(s)
- Sabrina M Heman-Ackah
- Department of Neurosurgery, Perelman Center for Advanced Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 15th Floor, Philadelphia, PA, 19104, USA.
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA.
| | - Rachel Blue
- Department of Neurosurgery, Perelman Center for Advanced Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 15th Floor, Philadelphia, PA, 19104, USA
| | - Alexandra E Quimby
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Otolaryngology and Communication Sciences, SUNY Upstate Medical University Hospital, Syracuse, NY, USA
| | - Hussein Abdallah
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Elizabeth M Sweeney
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Daksh Chauhan
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Tiffany Hwa
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jason Brant
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA
| | - Michael J Ruckenstein
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
| | - Douglas C Bigelow
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
| | - Christina Jackson
- Department of Neurosurgery, Perelman Center for Advanced Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 15th Floor, Philadelphia, PA, 19104, USA
| | - Georgios Zenonos
- Center for Cranial Base Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Paul Gardner
- Center for Cranial Base Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Selena E Briggs
- Department of Otolaryngology, MedStar Washington Hospital Center, Washington, DC, USA
- Department of Otolaryngology, Georgetown University, Washington, DC, USA
| | - Yale Cohen
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - John Y K Lee
- Department of Neurosurgery, Perelman Center for Advanced Medicine, University of Pennsylvania, 3400 Civic Center Boulevard, 15th Floor, Philadelphia, PA, 19104, USA
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
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Bridgham K, Shikara M, Ludeman E, Eisenman DJ. Impact of Obesity on Postoperative Complications after Lateral Skull Base Surgery: A Systematic Review. ORL J Otorhinolaryngol Relat Spec 2023; 85:264-274. [PMID: 37604124 DOI: 10.1159/000531531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 06/05/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION The relationship between obesity and complications after lateral skull base tumor resection is not clear. There is conflicting evidence regarding the incidence of postoperative complications in this patient population. The purpose of this study is to examine the relationship between obesity and outcomes following lateral skull base tumor resection. DATA SOURCES Data were extracted from PubMed, Embase, CINAHL, and Cochrane CENTRAL. METHODS Included studies assessed the relationship between obesity and outcomes following lateral skull base tumor removal. Studies with ≤5 patients, pediatric patients, duplicate patient populations, or insufficient data were excluded. Two independent investigators reviewed each study for inclusion. A third reviewer served as a tie-breaker for any conflicts. Extracted data includes patient demographics, tumor pathology, surgical approach, and postoperative outcomes including incidence of cerebrospinal fluid (CSF) leak and other postoperative complications, length of stay (LOS), and readmission and reoperation rates. Descriptive statistics were used to compare postoperative outcomes for obese and nonobese controls. RESULTS 14 studies met final inclusion criteria. Nine studies evaluated the relationship between obesity and CSF leaks. Four studies found a significant increase in postoperative CSF leak in obese patients compared to nonobese controls. The remaining studies trended toward an increased incidence of CSF leak in the obese population but did not reach statistical significance. One out of seven studies found that obesity increased postoperative LOS, and one out of five studies found that obesity increased reoperation rates following tumor resection. CONCLUSIONS Based on the results, obesity does not appear to increase LOS, readmission, or reoperation rates after lateral skull base tumor resection. The relationship between obesity and postoperative CSF leak, however, warrants further analysis.
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Affiliation(s)
- Kelly Bridgham
- University of Maryland School of Medicine, Baltimore, Maryland, USA,
- Department of Otorhinolaryngology, Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA,
| | - Meryam Shikara
- Department of Otorhinolaryngology- Head and Neck Surgery, University of Maryland Medical System, Baltimore, Maryland, USA
| | - Emilie Ludeman
- University of Maryland Baltimore Graduate School, Baltimore, Maryland, USA
| | - David J Eisenman
- University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Otorhinolaryngology- Head and Neck Surgery, University of Maryland Medical System, Baltimore, Maryland, USA
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Rimmer R, Lilly G, Gupta S, Ciporen J, Detwiller K, Cetas J, Dogan A, Geltzeiler M. Endoscopic Endonasal Eustachian Tube Obliteration for Cerebrospinal Fluid Rhinorrhea: A Case Series and Scoping Review. Oper Neurosurg (Hagerstown) 2022; 22:345-354. [DOI: 10.1227/ons.0000000000000158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/15/2021] [Indexed: 11/19/2022] Open
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Totten DJ, Manzoor NF, Yancey KL, Yawn RJ, Haynes DS, Rivas A. Comparison of Small Intestinal Submucosal Graft and Autologous Tissue in Prevention of CSF leak after Posterior Fossa Craniotomy. J Neurol Surg B Skull Base 2021; 82:695-699. [PMID: 34745839 DOI: 10.1055/s-0040-1713772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 04/27/2020] [Indexed: 10/21/2022] Open
Abstract
Objective To compare the use of porcine small intestinal submucosal grafts (SISG) and standard autologous material (fascia) in prevention of cerebrospinal fluid (CSF) leak and pseudomeningocele formation after translabyrinthine resection. Setting Set at the tertiary skull base center. Methods This is a retrospective chart review. After Institutional Review Board approval, we performed a retrospective cohort study evaluating CSF leak in patients who underwent resection of lateral skull base defects with multilayered reconstruction using either fascia autograft or porcine SISGs. Demographics were summarized with descriptive statistics. Logistic regression was used to compare autograft and xenograft cohorts in terms of CSF complications. Results Seventy-seven patients underwent lateral skull base resection, followed by reconstruction of the posterior cranial fossa. Of these patients, 21 (27.3%) underwent multilayer repair using SISG xenograft. There were no significant differences in leak-associated complications between autograft and xenograft cohorts. Ventriculoperitoneal shunt was necessary in one (1.8%) autograft and one (4.8) xenograft cases ( p = 0.49). Operative repair to revise surgical defect was necessary in three (5.4%) autograft cases and none in xenograft cases. Conclusion The use of SISG as a component of complex skull base reconstruction after translabyrinthine tumor resection may help reduce CSF leak rates and need for further intervention.
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Affiliation(s)
- Douglas J Totten
- Vanderbilt University School of Medicine, Nashville, Tennessee, United States
| | - Nauman F Manzoor
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Kristen L Yancey
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Robert J Yawn
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - David S Haynes
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
| | - Alejandro Rivas
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States
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Investigating Predictors of Increased Length of Stay After Resection of Vestibular Schwannoma Using Machine Learning. Otol Neurotol 2021; 42:e584-e592. [PMID: 33443974 DOI: 10.1097/mao.0000000000003042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the predictors of prolonged length of stay (LOS) after vestibular schwannoma resection. STUDY DESIGN Retrospective chart review. SETTING Tertiary referral center. PATIENTS Patients who underwent vestibular schwannoma resection between 2008 and 2019. INTERVENTIONS Variables of interest included age, body mass index, comorbidities, symptoms, previous intervention, microsurgical approach, extent of resection, operative time, preoperative tumor volume, and postoperative complications. Predictive modeling was done through multivariable linear regression and random forest models with 80% of patients used for model training and the remaining 20% used for performance testing. MAIN OUTCOME MEASURES LOS was evaluated as the number of days from surgery to discharge. RESULTS Four hundred one cases from 2008 to 2019 were included with a mean LOS of 3.0 (IQR = 3.0-4.0). Postoperatively, 14 (3.5%) of patients had LOS greater than two standard deviations from the mean (11 days). In a multivariate linear regression model (adjusted R2 = 0.22; p < 0.001), preoperative tumor volume (p < 0.001), coronary artery disease (p = 0.002), hypertension (p = 0.029), and any major complication (p < 0.001) were associated with increased LOS (by 0.12, 3.79, 0.87, and 3.20 days respectively). A machine learning analysis using a random forest identified several potential nonlinear relationships between LOS and preoperative tumor dimensions (length, volume) and operative time that were not captured on regression. The random forest model had lower prediction error compared to the regression model (RMSE 5.67 vs. 44.59). CONCLUSIONS Tumor volume, coronary artery disease, hypertension, and major complications impact LOS. Machine learning methods may identify nonlinear relationships worthy of targeted clinical investigation and allow for more accurate patient counseling.
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Guo X, Zhu Y, Wang X, Xu K, Hong Y. Peritumoral Edema Is Associated With Postoperative Hemorrhage and Reoperation Following Vestibular Schwannoma Surgery. Front Oncol 2021; 11:633350. [PMID: 33767998 PMCID: PMC7985450 DOI: 10.3389/fonc.2021.633350] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 02/15/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Postoperative hemorrhage (POH) is a severe complication following vestibular schwannoma surgery that may require surgical treatment. The purpose of our study is to identify risk factors associated with POH and reoperation following the resection of vestibular schwannoma. Methods: We retrospectively recruited 452 vestibular schwannoma patients treated with retrosigmoid approach. The primary outcome was POH, and the secondary outcome was reoperation for POH. Clinical and radiographic data were compared by performing univariate analysis and logistic regression analysis. Results: Among the 452 patients, 37 patients (8.2%) presented with POH and14 patients (3.1%) required reoperation within a 30-day hospitalization period. The univariate analysis showed that peritumoral edema, tumor diameter >30 mm, severe postoperative hypertension, and length of hospital stay were associated with POH and reoperation for POH. Logistic regression analysis showed that peritumoral edema [odds ratio (OR) 4.042, 95% confident interval (CI) 1.830–8.926, P = 0.001] and tumor diameter >30 mm (OR 3.192, 95% CI 1.421–7.168, P = 0.005) were independent predictive factors for POH. Peritumoral edema (OR 7.071, 95% CI 2.342–21.356, P = 0.001) was an independent predictive factor for reoperation by using logistic regression analysis. Further analysis revealed that larger tumor and incomplete tumor resection were both associated with a higher incidence of peritumoral edema. Conclusion: Peritumoral edema and tumor size are independent risk factors for POH following vestibular schwannoma surgery. And larger hematoma occurs more commonly in tumors with peritumoral edema which may require reoperation. Tumor size and extent of tumor resection are associated with peritumoral edema. Close attention should be paid to high-risk patients especially for those who presented with severe postoperative hypertension.
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Affiliation(s)
- Xiaoming Guo
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Neurosurgery, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Yueli Zhu
- Department of Geriatrics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoyu Wang
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ke Xu
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuan Hong
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Rinaldo L, Rabinstein AA, Lanzino G. Increased Body Mass Index Associated With Reduced Risk of Delayed Cerebral Ischemia and Subsequent Infarction After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2020; 84:1035-1042. [PMID: 29659999 DOI: 10.1093/neuros/nyy104] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 03/02/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Increased body mass index (BMI) may be protective against cerebral ischemia in certain clinical contexts. OBJECTIVE To investigate whether increased BMI was associated with delayed cerebral ischemia (DCI) and subsequent infarction after aneurysmal subarachnoid hemorrhage (aSAH). METHODS We retrospectively reviewed the clinical course of patients presenting to our institution for management of aSAH. Patient were segregated according to BMI< or ≥29.4, a value determined by Classification and Regression Tree analysis. Predictors of DCI and delayed infarction were identified using stepwise multivariate logistic regression analysis. RESULTS There were 161 patients included for analysis. Average BMI within our patient cohort was 28.9, with 67 patients presenting with a BMI of ≥29.4 on admission. DCI occurred in 50 patients (31.1%) and was complicated by delayed infarction in 15 patients (9.3%). On stepwise multivariate analysis, BMI ≥ 29.4 was independently associated with reduced likelihood of DCI (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.18-0.92) and delayed infarction (OR 0.13, 95% CI 0.02-0.61; P = .008). Increasing maximum flow velocity on transcranial Doppler ultrasound was independently associated with increased odds of both DCI (Unit OR 1.19, 95% CI 1.09-1.30; P < .001) and delayed infarction (Unit OR 1.31, 95% CI 1.13-1.56; P < .001), while intracerebral hemorrhage was independently associated with increased odds of delayed infarction (OR 6.99, 95% CI 1.82-30.25; P = .005). CONCLUSION We report an association between elevated BMI and reduced incidence of DCI and delayed infarction, suggesting a protective effect of increasing BMI on the risk of ischemic complications after aSAH.
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Affiliation(s)
- Lorenzo Rinaldo
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | | | - Giuseppe Lanzino
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.,Department of Neurointerventional Radiology, Mayo Clinic, Rochester, Minnesota
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Obesity Is Not Associated With Postoperative Complications After Vestibular Schwannoma Surgery in a Large Single Institution Series. Otol Neurotol 2019; 40:1373-1377. [DOI: 10.1097/mao.0000000000002397] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Patel VA, Dunklebarger M, Banerjee K, Shokri T, Zhan X, Isildak H. Surgical Management of Vestibular Schwannoma: Practice Pattern Analysis via NSQIP. Ann Otol Rhinol Laryngol 2019; 129:230-237. [DOI: 10.1177/0003489419882044] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective:Characterize current perspectives in the surgical management of vestibular schwannoma (VS) to guide otolaryngologists in understanding United States practice patterns.Methods:A retrospective analysis of ACS-NSQIP database was performed to abstract all patients from 2008 to 2016 who underwent VS resection using ICD-9/10 codes 225.1 and D33.3, respectively. The specific surgical approach employed was identified via CPT codes 61520, 61526/61596, and 61591, which represent retrosigmoid (RS), translabyrinthine (TL) and middle cranial fossa (MCF) approaches, respectively. Analyzed outcomes include general surgical complications, total length of stay, and reoperation.Results:A total of 1671 VS cases were identified, 1266 (75.7%) were RS, 292 (17.5%) were TL, and 114 (6.8%) were MCF. The annual number of cases increased over the study period from 15 to 375, which is chiefly attributed to increased institutional participation in ACS-NSQIP. Perioperative variables including BMI ( P < .001), ASA class ( P = .004), ethnicity ( P = .008), operative time ( P < .001), and reoperation ( P < .001) were found to be statistically significant between cohorts. Increased utilization of RS approach was consistent over the entire study period, with significantly more RS performed than either TL or MCF. Finally, a statistically significant difference with respect to general surgical complication rates was not noted between surgical approaches.Conclusions:There is increased employment of RS approach for the operative management of VS, which likely is the result of increased reliance on both stereotactic radiosurgery and observation as alternative treatment strategies.
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Affiliation(s)
- Vijay A. Patel
- Department of Otolaryngology—Head and Neck Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | | | - Kalins Banerjee
- College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Tom Shokri
- Department of Otolaryngology—Head and Neck Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Xiang Zhan
- Department of Public Health Sciences, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
| | - Huseyin Isildak
- Department of Otolaryngology—Head and Neck Surgery, College of Medicine, The Pennsylvania State University, Hershey, PA, USA
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Yolcu Y, Wahood W, Alvi MA, Kerezoudis P, Habermann EB, Bydon M. Reporting Methodology of Neurosurgical Studies Utilizing the American College of Surgeons-National Surgical Quality Improvement Program Database: A Systematic Review and Critical Appraisal. Neurosurgery 2019; 86:46-60. [DOI: 10.1093/neuros/nyz180] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 01/27/2019] [Indexed: 12/12/2022] Open
Abstract
AbstractBACKGROUNDUse of large databases such as the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) has become increasingly common in neurosurgical research.OBJECTIVETo perform a critical appraisal and evaluation of the methodological reporting for studies in neurosurgical literature that utilize the ACS-NSQIP database.METHODSWe queried Ovid MEDLINE, EMBASE, and PubMed databases for all neurosurgical studies utilizing the ACS-NSQIP. We assessed each study according to number of criteria fulfilled with respect to Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement, REporting of studies Conducted using Observational Routinely-collected Health Data (RECORD) Statement, and Journal of American Medical Association–Surgical Section (JAMA-Surgery) Checklist. A separate analysis was conducted among papers published in core and noncore journals in neurosurgery according to Bradford's law.RESULTSA total of 117 studies were included. Median (interquartile range [IQR]) scores for number of fulfilled criteria for STROBE Statement, RECORD Statement, and JAMA-Surgery Checklist were 20 (IQR:19-21), 9 (IQR:8-9), and 6 (IQR:5-6), respectively. For STROBE Statement, RECORD Statement, and JAMA-Surgery Checklist, item 9 (potential sources of bias), item 13 (supplemental information), and item 9 (missing data/sensitivity analysis) had the highest number of studies with no fulfillment among all studies (56, 68, 50%), respectively. When comparing core journals vs noncore journals, no significant difference was found (STROBE, P = .94; RECORD, P = .24; JAMA-Surgery checklist, P = .60).CONCLUSIONWhile we observed an overall satisfactory reporting of methodology, most studies lacked mention of potential sources of bias, data cleaning methods, supplemental information, and external validity. Given the pervasive role of national databases and registries for research and health care policy, the surgical community needs to ensure the credibility and quality of such studies that ultimately aim to improve the value of surgical care delivery to patients.
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Affiliation(s)
- Yagiz Yolcu
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Waseem Wahood
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mohammed Ali Alvi
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Panagiotis Kerezoudis
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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12
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Perry A, Kerezoudis P, Graffeo CS, Carlstrom LP, Peris-Celda M, Meyer FB, Bydon M, Link MJ. Little Insights from Big Data: Cerebrospinal Fluid Leak After Skull Base Surgery and the Limitations of Database Research. World Neurosurg 2019; 127:e561-e569. [PMID: 30928599 DOI: 10.1016/j.wneu.2019.03.207] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 03/19/2019] [Accepted: 03/20/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cerebrospinal fluid (CSF) leak is a frustrating complication of skull base surgery. Published methodologies using national surgical databases to assess CSF leak have not accounted for variability between skull base operations. OBJECTIVE Our goal was to attempt the development of a novel framework for adapting big data techniques to skull base surgery and assess the reliability of corresponding data manipulations. METHODS A retrospective nested case-control analysis was performed using patients from the National Surgical Quality Improvement Program (NSQIP) registry, 2012-2015. Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes identified possible skull base operations, which were systematically grouped by anatomic location. Meningioma, schwannoma, pituitary adenoma, and trigeminal neuralgia (TN) were included. RESULTS Of 2918 patients, 84 (2.9%) were readmitted/reoperated on within 30 days for CSF leak. Operations involving the anterior fossa, both middle/posterior fossas in 1 approach, or the orbitocranial zygomatic approach were significantly associated with CSF leak, as were schwannomas and meningiomas in any location (8.5%, 3.1%, 10.2%, 4.1%, and 3.0%; all P < 0.0001). Multivariate analysis of only middle/posterior fossa lesions identified schwannoma (odds ratio [OR], 2.7; 95% confidence interval [CI], 1.3-5.6; P = 0.008), TN (OR, 5.4; 95% CI, 2-14.7; P = 0.008), chronic obstructive pulmonary disease (OR, 3.9; 95% CI, 1.1-14; P = 0.03), and increased operative time (OR, 4.0; 95% CI, 1.7-9.5; P = 0.009) as significant CSF leak risk factors. CONCLUSIONS Based on NSQIP data analyzed using a rational skull base/anatomic framework, risk factors for postoperative CSF leak include chronic obstructive pulmonary disease, operative time, anterior fossa meningioma, and middle/posterior fossa schwannoma or TN. Although databases such as NSQIP can be extensively manipulated to generate surrogate results that may provide limited insight, applications beyond their design should be approached carefully.
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Affiliation(s)
- Avital Perry
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Panagiotis Kerezoudis
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Lucas P Carlstrom
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Maria Peris-Celda
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Fredric B Meyer
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael J Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA.
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Bi WL, Mooney MA, Yoon S, Gupta S, Lawton MT, Almefty KK, Corrales CE, Dunn IF. Variation in Coding Practices for Vestibular Schwannoma Surgery. J Neurol Surg B Skull Base 2019; 80:96-102. [PMID: 30733907 DOI: 10.1055/s-0038-1667124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Accepted: 06/10/2018] [Indexed: 10/28/2022] Open
Abstract
Introduction Nationwide databases are frequently used resources for assessing practice patterns and clinical outcomes. However, analyses based on billing codes may be limited by the inconsistent application of current procedural terminology (CPT) codes to specific operations. We investigated the variability among commonly used CPT codes for vestibular schwannomas resection and sought to identify factors that underlie this variation. Methods The surgical procedure for 274 cases of vestibular schwannoma resections from two institutions was reviewed and classified as retrosigmoid, translabyrinthine, or middle fossa approaches. We then assessed the CPT codes assigned to each case and analyzed their association with surgical approach, surgeons involved, the coding specialty, and year of surgery. We further compared the incidence of CPT codes assigned for vestibular schwannoma surgeries in the American College Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2010 to 2014. Results The majority (65%) of vestibular schwannoma resections within the institutional cohort were billed with skull base approach and/or excision codes, whereas 76% of cases in NSQIP were associated with a single craniotomy for tumor code. The use of skull base codes over the past decade increased within our institutional cohort but remained relatively stable within NSQIP. CPT codes did not consistently reflect the operative approaches for vestibular schwannomas. Conclusion We observed significant variability in coding patterns for vestibular schwannoma surgeries within institutions, surgical practices, and national databases. These results call for discretion in interpretation of data from aggregated billing code-based nationwide databases and suggests a role for institutional standardization of CPT assignments for the same approaches.
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Affiliation(s)
- Wenya Linda Bi
- Department of Neurosurgery, Center for Skull Base and Pituitary Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Michael A Mooney
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Seungwon Yoon
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Saksham Gupta
- Department of Neurosurgery, Center for Skull Base and Pituitary Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Kaith K Almefty
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - C Eduardo Corrales
- Division of Otolaryngology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Ian F Dunn
- Department of Neurosurgery, Center for Skull Base and Pituitary Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States
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Gupta S, Ahmed AK, Bi WL, Dawood HY, Iorgulescu JB, Corrales CE, Dunn IF, Smith TR. Predicting Readmission and Reoperation for Benign Cranial Nerve Neoplasms: A Nationwide Analysis. World Neurosurg 2018; 121:e223-e229. [PMID: 30261394 DOI: 10.1016/j.wneu.2018.09.081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/07/2018] [Accepted: 09/11/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Readmission and reoperation are risks in the resection of benign cranial nerve tumors (BCNTs). This report analyzes the impact of patient-level and surgical factors on these adverse outcomes. METHODS This retrospective cohort review comprised patients with a diagnosis of BCNT enrolled in the American College of Surgeons National Surgical Quality Improvement Program registry from 2011 to 2015. Multivariate logistic regression was used to determine the impact of select medical and operative factors on the primary outcomes of readmission and reoperation within 30 days, adjusted for relevant covariates. RESULTS We identified 996 patients who underwent resection of a BCNT. The most frequent major complications were readmission (11%), reoperation (8%), surgical site infections (2.6%), and venous thromboembolism (1.5%). The most frequent indications for readmission were management of infection (2.5%), cerebrospinal fluid leak (2.3%), and hydrocephalus (0.5%). Repair of cranial and meningeal defects (3.0%), correction of lagophthalmos (1.2%), and repair of middle ear defects (1.0%) were the most common indications for reoperation. Logistic regression revealed that extremes of age were associated with readmission, whereas preoperative steroid usage, long operative time, and postoperative length of stay >3 days were associated with reoperation (P < 0.05). Obesity trended toward an association with readmission and reoperation. CONCLUSIONS Extremes of age were associated with readmission; preoperative steroid use, long operative time, and postoperative length of stay >3 days were associated with reoperation. Surgeons should consider these factors when assessing risk of postoperative complications for BCNTs.
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Affiliation(s)
- Saksham Gupta
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Abdul-Kareem Ahmed
- Department of Neurosurgery, University of Maryland Medical College, Baltimore, Maryland, USA
| | - Wenya Linda Bi
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hassan Y Dawood
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - J Bryan Iorgulescu
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - C Eduardo Corrales
- Department of Otolaryngology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ian F Dunn
- Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Timothy R Smith
- Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Rinaldo L, Hughes JD, Rabinstein AA, Lanzino G. Effect of body mass index on outcome after aneurysmal subarachnoid hemorrhage treated with clipping versus coiling. J Neurosurg 2017; 129:658-669. [PMID: 29027862 DOI: 10.3171/2017.4.jns17557] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE It has been suggested that increased body mass index (BMI) may confer a protective effect on patients who suffer from aneurysmal subarachnoid hemorrhage (aSAH). Whether the modality of aneurysm occlusion influences the effect of BMI on patient outcomes is not well understood. The authors aimed to compare the effect of BMI on outcomes for patients with aSAH treated with surgical clipping versus endovascular coiling. METHODS The authors retrospectively reviewed the outcomes for patients admitted to their institution for the management of aSAH treated with either clipping or coiling. BMI at the time of admission was recorded and used to assign patients to a group according to low or high BMI. Cutoff values for BMI were determined by classification and regression tree analysis. Predictors of poor functional outcome (defined as modified Rankin Scale score > 2 measured ≥ 90 days after the ictus) and posttreatment cerebral hypodensities detected during admission were then determined separately for patients treated with clipping or coiling using stepwise multivariate logistic regression analysis. RESULTS Of the 469 patients admitted to the authors' institution with aSAH who met the study's inclusion criteria, 144 were treated with clipping and 325 were treated with coiling. In the clipping group, the frequency of poor functional outcome was higher in patients with BMI ≥ 32.3 kg/m2 (47.6% vs 19.0%; p = 0.007). In contrast, in the coiling group, patients with BMI ≥ 32.3 kg/m2 had a lower frequency of poor functional outcome at ≥ 90 days (5.8% vs 30.9%; p < 0.001). On multivariate analysis, high BMI was independently associated with an increased (OR 3.92, 95% CI 1.20-13.41; p = 0.024) and decreased (OR 0.13, 95% CI 0.03-0.40; p < 0.001) likelihood of poor functional outcome for patients treated with clipping and coiling, respectively. For patients in the surgical group, BMI ≥ 28.4 kg/m2 was independently associated with incidence of cerebral hypodensities during admission (OR 2.44, 95% CI 1.16-5.25; p = 0.018) on multivariate analysis. For patients treated with coiling, BMI ≥ 33.2 kg/m2 was independently associated with reduced odds of hypodensities (OR 0.45, 95% CI 0.21-0.89; p = 0.021). CONCLUSIONS The results of this study suggest that BMI may differentially affect functional outcomes after aSAH, depending on treatment modality. These findings may aid in treatment selection for patients with aSAH.
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Affiliation(s)
| | | | | | - Giuseppe Lanzino
- Departments of1Neurosurgery.,3Neurointerventional Radiology, Mayo Clinic, Rochester, Minnesota
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Sergesketter A, Elsamadicy AA, Gottfried ON. Impact of Obesity on Complications and 30-Day Readmission Rates After Cranial Surgery: A Single-Institutional Study of 224 Consecutive Craniotomy/Craniectomy Procedures. World Neurosurg 2017; 100:244-249. [PMID: 28093346 DOI: 10.1016/j.wneu.2017.01.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 01/04/2017] [Accepted: 01/05/2017] [Indexed: 01/18/2023]
Abstract
BACKGROUND The prevalence of obesity is increasing at a disparaging rate in the United States. Although previous studies have associated obesity with increased surgical complications and readmission rates, the impact of obesity on surgical outcomes after cranial surgery remains understudied. The aim of this study is to assess the effect of obesity on complication and 30-day readmission rates after cranial surgery. METHODS The medical records of 224 consecutive patients (nonobese, n = 164; obese, n = 60) undergoing either craniotomy or craniectomy at a major academic institution in 2011 were reviewed. Preoperative body mass index equal to or greater than 30 kg/m2 was classified as obese. The primary outcome investigated in this study was the rate of intraoperative and postoperative complications and 30-day readmissions after craniectomy/craniotomy. RESULTS Baseline patient characteristics and comorbidities were similar between the cohorts. The mean body mass indexes for both cohorts were significantly different (nonobese, 22.8 ± 4.2 kg/m2 vs. obese, 45.1 ± 15.9 kg/m2; P < 0.0001). Most patients underwent tumor excision in both cohorts (nonobese, 64.0% vs. obese, 66.7%; P = 0.75). Compared with the nonobese cohort, the obese cohort had significantly higher estimated blood loss (nonobese, 209.9 ± 201.3 mL vs. obese, 284.9 ± 250.0 mL; P = 0.04), but similar length of operation (nonobese, 187.3 ± 89.4 minutes vs. obese, 209.6 ± 100.5; P = 0.14). Length of hospital stay and rate of postoperative complications were similar between both cohorts. Obese patients had increased rate of 30-day readmission, but this was not statistically significant (nonobese, 3.1% vs. obese, 6.7%; P = 0.25). CONCLUSIONS Our study suggests that obesity may not have a significant impact on surgical outcomes after cranial surgery.
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Affiliation(s)
- Amanda Sergesketter
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Oren N Gottfried
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.
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