Obesity and perioperative outcomes in older surgical patients undergoing elective spine and major arthroplasty surgery

Preoperative nutritional status and postoperative health outcomes in older adults undergoing spine surgery: Electronic health records analysis

AIM

To examine whether a high nutritional risk status, assessed via the Geriatric Nutritional Risk Index (GNRI), is independently associated with postoperative health outcomes, including unplanned intensive care unit (ICU) admissions, infectious complications, and prolonged length of stay in older patients undergoing spine surgery.

METHODS

We conducted a retrospective descriptive study analyzing electronic health records from a tertiary hospital, including data from 1,014 patients aged ≥70 undergoing elective spine surgery between February 2013 and March 2023.

RESULTS

High nutritional risk patients had significantly higher odds of unplanned ICU admission, infectious complications, and prolonged length of stay compared to low-risk patients. For each one-point increase in GNRI, there was a significant 0.91- and 0.95-fold decrease in the odds of unplanned ICU admission and infectious complications, respectively.

CONCLUSION

GNRI screening in older patients before spine surgery may have potential to identify those at elevated risk for postoperative adverse outcomes.

Cost Benefit of Implementation of Risk Stratification Models for Adult Spinal Deformity Surgery

STUDY DESIGN/SETTING

Retrospective cohort study.

OBJECTIVE

Assess the extent to which defined risk factors of adverse events are drivers of cost-utility in spinal deformity (ASD) surgery.

METHODS

ASD patients with 2-year (2Y) data were included. Tertiles were used to define high degrees of frailty, sagittal deformity, blood loss, and surgical time. Cost was calculated using the Pearl Diver registry and cost-utility at 2Y was compared between cohorts based on the number of risk factors present. Statistically significant differences in cost-utility by number of baseline risk factors were determined using ANOVA, followed by a generalized linear model, adjusting for clinical site and surgeon, to assess the effects of increasing risk score on overall cost-utility.

RESULTS

By 2 years, 31% experienced a major complication and 23% underwent reoperation. Patients with ≤2 risk factors had significantly less major complications. Patients with 2 risk factors improved the most from baseline to 2Y in ODI. Average cost increased by $8234 per risk factor (R2 = .981). Cost-per-QALY at 2Y increased by $122,650 per risk factor (R2 = .794). Adjusted generalized linear model demonstrated a significant trend between increasing risk score and increasing cost-utility (r2 = .408, P < .001).

CONCLUSIONS

The number of defined patient-specific and surgical risk factors, especially those with greater than two, were associated with increased index surgical costs and diminished cost-utility. Efforts to optimize patient physiology and minimize surgical risk would likely reduce healthcare expenditures and improve the overall cost-utility profile for ASD interventions.Level of evidence: III.

Obesity Does Not Increase Perioperative Outcomes in Older Patients Undergoing Thoracoscopic Anatomic Lung Cancer Surgery

Objectives

To investigate the relationship between obesity status and perioperative outcomes in elderly patients undergoing thoracoscopic anatomic lung cancer surgery.

Methods

From January 2016 to December 2018, we performed a monocentric retrospective cohort study among 4164 consecutive patients aged 65 years or older who underwent thoracoscopic anatomic lung cancer surgery at Shanghai Chest Hospital. Two groups were stratified by body mass index (BMI): nonobese (BMI<28kg/m²) and obese status (BMI≥28kg/m²). Using a 1:1 propensity score matching (PSM) analysis to compare perioperative outcomes between two groups.

Results

4035 older patients were eventually enrolled, with a mean age of 69.8 years (range: 65-87), and 305 patients were eligible for obese status, with a mean BMI of 29.8 ± 1.7kg/m². Compared with nonobese patients, obese patients were more likely to have higher rates of intraoperative hypoxemia (1.2% vs 3.9%, P=0.001) and new-onset arrhythmia (2.3% vs 4.3%, P=0.034). The difference in intraoperative transfusion and conversion rates and postoperative outcomes regarding pulmonary complications, new-onset arrhythmia, transfusion, length of hospital stay, 30-day readmission and hospitalization costs between two groups were not significant (P>0.05). After a 1:1 PSM analysis, the difference in both intraoperative and postoperative complications among two groups were not significant (P>0.05). In subgroup analysis, patients with BMI≥30kg/m² had a similar incidence of perioperative complications compared to patients with BMI between 28 and 30 kg/m² (P>0.05).

Conclusions

Our research data support evidence for “obesity paradox” and also contribute the growing body of evidence that obesity in older patients should not exclude candidates for thoracoscopic anatomic lung cancer surgery.

Predictors of post-hip fracture knee pain in hospitalized older adults with intertrochanteric femoral fracture

BACKGROUND

Post-hip fracture knee pain (PHFKP) is an important issue that contributes to reduced gait speed and prolonged hospitalization. Femoral morphology has been reported to contribute to the development of PHFKP, but an independent association has not been confirmed and clinically applicable cutoffs for predicting the development of PHFKP remain unclear.

OBJECTIVE

To determine whether femoral morphology and knee extension range of motion limitation are independent factors in PHFKP and to determine cutoffs for predicting the development of PHFKP.

DESIGN

Retrospective chart review study.

SETTING

Convalescent inpatient rehabilitation hospital.

PARTICIPANTS

Patients in a convalescent ward after intertrochanteric femoral fracture surgery.

MAIN OUTCOME MEASURES

PHFKP development, radiographic femoral morphology (leg length discrepancy and neck-shaft angle), and knee extension range of motion limitation.

RESULTS

PHFKP developed in 36 (35%) of the 103 patients enrolled. The PHFKP group had a longer hospital stay (p = .029), greater weight (p = .031), greater knee extension range of motion limitation (p = .001), and more varus neck-shaft angle (p < .001) compared to the non-PHFKP group. Varus neck-shaft angle (odds ratio, 0.85; 95% confidence interval [CI], 0.78-0.92; p < .001) and knee extension range of motion limitation (odds ratio, 1.18; 95% CI, 1.07-1.30; p = .001) were significant factors for PHFKP development. Neck-shaft angle discrepancy and knee extension range of motion limitation demonstrated moderate accuracy in discriminating development of PHFKP according to receiver operating characteristic analysis, with cutoffs of 9.6° and 7.5°, respectively. Areas under the receiver operating characteristic curve were 0.77 (95% CI, 0.66-0.88; p < .001) for neck-shaft angle discrepancy and 0.67 (95% CI, 0.56-0.79; p = .004) for knee extension range of motion limitation.

CONCLUSIONS

Varus neck-shaft angle and knee extension range of motion limitation were identified as independent predictors of PHFKP. The cutoff for neck-shaft angle may be useful for predicting PHFKP development and to define an acceptable angle of fracture reduction to prevent PHFKP.

Preoperative and Perioperative Predictors of Length of Hospital Stay after Primary Total Hip Arthroplasty-Our Experience on 743 Cases

The aim of this retrospective investigation is to evaluate the correlation between several preoperative and perioperative factors and the length of hospital stay in patients that underwent elective total hip arthroplasty with overnight admission. Medical records of patients that underwent THA from the beginning of 2016 to the end of 2018 were retrospectively screened. Demographics, comorbidities, whole blood count, intraoperative details, and length of postoperative stay were retrieved. The association between clinical, laboratory and surgical factors and the length of hospital stay was explored by means of negative binomial and logistic regression models. The median length of postoperative hospital stay was four days (Inter Quartile Range, IQR 3, 5). After univariate regression a stepwise multivariate regression showed that operative time (p = 0.001), the preoperative serum creatinine (p < 0.001), the intraoperative blood loss (p = 0.04) and the use of an anterolateral approach (p < 0.001) were found to correlate significantly with the increase of the hospitalization length, while no significant correlation was found for all the other features. Multivariable model fitted through logistic regression (LOS below or over the median value of four days) had an Area Under the Curve (AUC) of 0.748. Our analysis suggests a significant role played by different preoperative and perioperative variables in influencing the length of hospital stay.