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Chen VW, Portuondo J, Massarweh NN. Association between type of index complication and outcomes after noncardiac surgery. Surgery 2024:S0039-6060(24)00285-X. [PMID: 38862281 DOI: 10.1016/j.surg.2024.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 04/19/2024] [Accepted: 04/23/2024] [Indexed: 06/13/2024]
Abstract
BACKGROUND Failure to rescue, or the death of a patient after a surgical complication, largely occurs in patients who develop a cascade of postoperative complications. However, it is unclear whether there are specific types of index complications that are more strongly associated with failure to rescue, additional secondary complications, or other types of postoperative outcomes. This is a national cohort study of veterans who underwent noncardiac surgery at Veterans Affairs hospitals using data from the Veterans Affairs Surgical Quality Improvement Program (January 1, 2016 to September 30, 2021). Index complications were grouped into categories (cardiovascular, venous thromboembolism, pulmonary, bleeding/transfusion, renal, central nervous system, wound, sepsis, Clostridium difficile colitis, graft, or minor [defined as complications having an associated mortality rate <1%]). The association between type of index complication and failure to rescue, secondary complications, reoperation, and postoperative length of stay was evaluated with multivariable, hierarchical regression, and risk of death assessed with shared frailty modeling. RESULTS Among 574,195 patients, 5.3% had at least 1 complication (of which 26.1% had secondary complications, and 8.2% had failure to rescue), and 4.5% had a reoperation. Secondary complication (5.0%-61.4%) and failure to rescue (0.8%-34.2%) rates varied by the type of index complication. Relative to index minor complications, index bleeding was most associated with secondary complication (subdistribution hazard ratio 1.4, 95% confidence interval [1.1-1.8]), index cardiac complications were most associated with failure to rescue (odds ratio 45.4 [34.5-59.7]), index graft complications were most associated with reoperation (odds ratio 96.0 [79.5-115.8]), and index pulmonary complications were associated with 2.6 times longer length of stay (incident rate ratio 2.6 [2.6-2.7]). Index cardiac and central nervous system complications were most strongly associated with risk of death (cardiac-hazard ratio 2.45, 95% confidence interval [2.14-2.81]; central nervous system-hazard ratio 1.84 [1.49-2.27]). CONCLUSION Different types of index complications are associated with different outcome profiles. This suggests surgical quality improvement efforts should be tailored not only to the type of index complication to be addressed but also to the desired outcome to improve.
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Affiliation(s)
- Vivi W Chen
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.
| | - Jorge Portuondo
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Nader N Massarweh
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, GA; Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, GA; Department of Surgery, Morehouse School of Medicine, Atlanta, GA
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2
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Knoedler L, Knoedler S, Alfertshofer M, Hansen FJ, Schenck T, Sofo G, Obed D, Hollmann K, Siegwart LC, Vollbach FH, Bigdeli AK, Kauke-Navarro M, Pomahac B. Gynecomastia Surgery in 4996 Male Patients Over 14 Years: A Retrospective Analysis of Surgical Trends, Predictive Risk Factors, and Short-Term Outcomes. Aesthetic Plast Surg 2024:10.1007/s00266-024-03927-0. [PMID: 38528130 DOI: 10.1007/s00266-024-03927-0] [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: 12/12/2023] [Accepted: 02/09/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND The high prevalence of benign male breast tissue enlargement (gynecomastia) has resulted in a marked increase of gynecomastia cases. While about one third of male adults experience some form of gynecomastia, gynecomastia surgery (GS) outcome research is limited to small study populations and single-center/-surgeon databases. In this study, we aimed to access the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify preoperative risk factors for complications and investigate postoperative outcomes of GS. METHODS In this retrospective study, we queried the ACS-NSQIP database from 2008 to 2021 to identify male adult patients who underwent GS. Postoperative outcomes involved the occurrence of any, surgical and medical complications, as well as reoperation, readmission, and mortality within a 30-day postoperative time period. Univariable and multivariable assessment were performed to identify risk factors for complications while adjusting for possible confounders. RESULTS The study included 4,996 GS patients with a mean age of 33.7 ± 15 years and BMI of 28.2 ± 5.1 kg/m2. White patients constituted 54% (n = 2713) of the cohort, and 27% (n = 1346) were obese. Except for 2020, there was a steady increase in GS cases over the study period. Outpatient surgeries were most common at 95% (n = 4730), while general surgeons performed the majority of GS (n = 3580; 72%). Postoperatively, 91% (n = 4538) of patients were discharged home; 4.4% (n = 222) experienced any complications. Multivariable analysis identified inpatient setting (p < 0.001), BMI (p = 0.023), prior sepsis (p = 0.018), and bleeding disorders (p = 0.047) as independent risk factors for complications. CONCLUSION In this study, we analyzed 4996 male adult GS patients from the ACS-NSQIP database, revealing an increased caseload and significant general surgeon involvement. Risk factors like bleeding disorders, inpatient status, and prior sepsis were linked to postoperative complications, while BMI was crucial for predicting adverse events. Overall, our findings may aid in enhancing patient care through advanced preoperative screening and closer perioperative management. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Leonard Knoedler
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Samuel Knoedler
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA
- Instituto Ivo Pitanguy, Hospital Santa Casa de Misericórdia Rio de Janeiro, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeriro, Brazil
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Frederik J Hansen
- Department of Surgery, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | | | - Giuseppe Sofo
- Instituto Ivo Pitanguy, Hospital Santa Casa de Misericórdia Rio de Janeiro, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeriro, Brazil
| | - Doha Obed
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, 30625, Hannover, Germany
| | - Katharina Hollmann
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Laura C Siegwart
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Felix H Vollbach
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Amir K Bigdeli
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA.
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3
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Kougias P, Sharath SE. At the Edge of a New Frontier in Quality Measures. JAMA Surg 2024; 159:322. [PMID: 38150236 DOI: 10.1001/jamasurg.2023.6525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Affiliation(s)
- Panos Kougias
- Department of Surgery, College of Medicine, State University of New York, Downstate Health Sciences University, New York
- VA New York Harbor Healthcare System, Operative Care Line/Research Service Line, Brooklyn
| | - Sherene E Sharath
- Department of Surgery, College of Medicine, State University of New York, Downstate Health Sciences University, New York
- VA New York Harbor Healthcare System, Operative Care Line/Research Service Line, Brooklyn
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4
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Roshanov PS, Chan MTV, Borges FK, Conen D, Wang CY, Xavier D, Berwanger O, Marcucci M, Sessler DI, Szczeklik W, Spence J, Alonso-Coello P, Fernández C, Pearse RM, Malaga G, Garg AX, Srinathan SK, Jacka MJ, Tandon V, McGillion M, Popova E, Sigamani A, Abraham V, Biccard BM, Villar JC, Chow CK, Polanczyk CA, Tiboni M, Whitlock R, Ackland GL, Panju M, Lamy A, Sapsford R, Williams C, Wu WKK, Cortés OL, MacNeil SD, Patel A, Belley-Côté EP, Ofori S, McIntyre WF, Leong DP, Heels-Ansdell D, Gregus K, Devereaux PJ. One-year Outcomes after Discharge from Noncardiac Surgery and Association between Predischarge Complications and Death after Discharge: Analysis of the VISION Prospective Cohort Study. Anesthesiology 2024; 140:8-24. [PMID: 37713506 DOI: 10.1097/aln.0000000000004763] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023]
Abstract
BACKGROUND In previous analyses, myocardial injury after noncardiac surgery, major bleeding, and sepsis were independently associated with most deaths in the 30 days after noncardiac surgery, but most of these deaths occurred during the index hospitalization for surgery. The authors set out to describe outcomes after discharge from hospital up to 1 yr after inpatient noncardiac surgery and associations between predischarge complications and postdischarge death up to 1 yr after surgery. METHODS This study was an analysis of patients discharged after inpatient noncardiac surgery in a large international prospective cohort study across 28 centers from 2007 to 2013 of patients aged 45 yr or older followed to 1 yr after surgery. The study estimated (1) the cumulative postdischarge incidence of death and other outcomes up to a year after surgery and (2) the adjusted time-varying associations between postdischarge death and predischarge complications including myocardial injury after noncardiac surgery, major bleeding, sepsis, infection without sepsis, stroke, congestive heart failure, clinically important atrial fibrillation or flutter, amputation, venous thromboembolism, and acute kidney injury managed with dialysis. RESULTS Among 38,898 patients discharged after surgery, the cumulative 1-yr incidence was 5.8% (95% CI, 5.5 to 6.0%) for all-cause death and 24.7% (95% CI, 24.2 to 25.1%) for all-cause hospital readmission. Predischarge complications were associated with 33.7% (95% CI, 27.2 to 40.2%) of deaths up to 30 days after discharge and 15.0% (95% CI, 12.0 to 17.9%) up to 1 yr. Most of the association with death was due to myocardial injury after noncardiac surgery (15.6% [95% CI, 9.3 to 21.9%] of deaths within 30 days, 6.4% [95% CI, 4.1 to 8.7%] within 1 yr), major bleeding (15.0% [95% CI, 8.3 to 21.7%] within 30 days, 4.7% [95% CI, 2.2 to 7.2%] within 1 yr), and sepsis (5.4% [95% CI, 2.2 to 8.6%] within 30 days, 2.1% [95% CI, 1.0 to 3.1%] within 1 yr). CONCLUSIONS One in 18 patients 45 yr old or older discharged after inpatient noncardiac surgery died within 1 yr, and one quarter were readmitted to the hospital. The risk of death associated with predischarge perioperative complications persists for weeks to months after discharge. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Pavel S Roshanov
- Department of Medicine, Western University, London, Canada; Population Health Research Institute, Hamilton, Canada
| | - Matthew T V Chan
- Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong and Prince of Wales Hospital, Hong Kong, Hong Kong
| | - Flavia K Borges
- Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - David Conen
- Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - C Y Wang
- Honorary Professor; Department of Anesthesiology, University of Malaya, Kuala Lumpur, Malaysia
| | - Denis Xavier
- St. John's Medical College Hospital, Bangalore, India
| | - Otavio Berwanger
- George Institute for Global Health, London, United Kingdom; Imperial College London, London, United Kingdom
| | - Maura Marcucci
- Clinical Epidemiology and Research Centre (CERC), Department of Biomedical Sciences, Humanitas University and IRCCS Humanitas Research Hospital, Milan, Italy; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Daniel I Sessler
- Department of Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Jessica Spence
- Anesthesia and Critical Care, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Center, Hospital Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red (CIBER) de Epidemiología y Salud Pública, Madrid, Spain
| | - Carmen Fernández
- Department of Anesthesiology and Intensive Care Medicine, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rupert M Pearse
- Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, United Kingdom
| | - German Malaga
- Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Amit X Garg
- Department of Medicine, University of Western Ontario, London, Canada
| | | | - Michael J Jacka
- Department of Critical Care and Anesthesia, University of Alberta, Edmonton, Canada
| | - Vikas Tandon
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Michael McGillion
- School of Nursing, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Ekaterine Popova
- IIB Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Barcelona, Spain; Centro Cochrane Iberoamericano, Barcelona, Spain
| | - Alben Sigamani
- Numen Health, Bangalore, India; Narayana Hrudayalaya Health City Bangalore, Bangalore, India
| | - Valsa Abraham
- Christian Medical College and Hospital Ludhiana, Ludhiana, India
| | - Bruce M Biccard
- Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, University of Cape Town, Observatory, South Africa
| | | | - Clara K Chow
- Westmead Applied Research Centre, University of Sydney, Sydney, Australia; Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - Carísi A Polanczyk
- Graduate Program in Epidemiology and Cardiovascular Science, Federal University of Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil; Institute for Health Technology Assessment, Porto Alegre, Rio Grande do Sul, Brazil
| | - Maria Tiboni
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Richard Whitlock
- Department of Surgery, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Gareth L Ackland
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Mohamed Panju
- Department of Medicine, McMaster University, Hamilton, Canada
| | - André Lamy
- Department of Surgery, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Robert Sapsford
- Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Colin Williams
- Royal Liverpool University Hospital, Liverpool, United Kingdom
| | - William Ka Kei Wu
- Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, New Territories, Hong Kong
| | - Olga L Cortés
- Research Department and Nursing Department, Fundación Cardioinfantil-Instituto de Cardiología, Bogotá DC, Colombia
| | - S Danielle MacNeil
- Schulich School of Medicine and Dentistry, Western University, London, Canada; Otolaryngology-Head & Neck Surgery, London Health Sciences Centre, London, Canada
| | - Ameen Patel
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Emilie P Belley-Côté
- Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Sandra Ofori
- Population Health Research Institute, Hamilton, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - William F McIntyre
- Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Darryl P Leong
- Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada
| | | | - P J Devereaux
- Department of Medicine, McMaster University, Hamilton, Canada; Population Health Research Institute, Hamilton, Canada
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Clausen J, Boesen V, Gögenur I, Watt T. A Content Framework of a Novel Patient-Reported Outcome Measure for Detecting Early Adverse Events After Major Abdominal Surgery. World J Surg 2023; 47:2676-2687. [PMID: 37610468 PMCID: PMC10545596 DOI: 10.1007/s00268-023-07143-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Systematic health monitoring with patient-reported outcome instruments may predict post-discharge complications after major surgery. The objective of this study was to conceptualize a novel patient-reported outcome instrument for detecting early adverse events within two weeks of discharge after major emergency abdominal surgery and colorectal cancer surgery. METHODS This study was conducted in two phases. (1) An exhaustive health concept pool was generated using systematic content analysis of existing patient-reported outcome measures (N = 31) and semi-structured interviews of readmitted patients (N = 49) and health professionals (N = 10). Concepts were categorized into three major domains: 'Symptoms,' 'functional status,' and 'general health perception.' We calculated the frequency of each health concept as the proportion of patients, who experienced the respective concept prior to readmission. (2) Colorectal cancer surgeons (N = 13) and emergency general surgeons (N = 12) rated the relevance of each health concept (1 = irrelevant, 5 = very relevant) in the context of detecting post-discharge adverse events. We selected concepts with either a high mean relevance score (≥ 4) or a combination of moderate mean relevance score and high patient-reported frequency (≥ 3 and ≥ 20% or ≥ 2.5 and ≥ 50%, respectively). RESULTS Content analysis of existing items with additions from patients and experts resulted in 58 health concepts, of which the majority were distinct symptoms (N = 40). The selection procedure resulted in 29 patient-reported health concepts relevant for detecting adverse events after discharge. CONCLUSION The outlined framework provides content validity for future patient-reported outcome instruments detecting adverse events in the early post-discharge period after major emergency abdominal surgery and colorectal cancer surgery.
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Affiliation(s)
- Johan Clausen
- Center for Surgical Science, Surgical Department, Zealand's University Hospital, Lykkebaekvej 1, 4600, Koege, Denmark.
| | - Victor Boesen
- Department of Endocrinology, Gentofte and Herlev Hospital, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Surgical Department, Zealand's University Hospital, Lykkebaekvej 1, 4600, Koege, Denmark
| | - Torquil Watt
- Department of Endocrinology, Gentofte and Herlev Hospital, Borgmester Ib Juuls Vej 1, 2730, Herlev, Denmark
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Portuondo JI, Whitlock RS, Mehl SC, Massarweh NN. Variation in Resident Operative Autonomy at Veterans Affairs Hospitals. JAMA Surg 2023; 158:321-323. [PMID: 36576814 PMCID: PMC9857278 DOI: 10.1001/jamasurg.2022.4791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/14/2022] [Indexed: 12/29/2022]
Abstract
This cohort study examines resident involvement in the care of US veterans who underwent noncardiac surgery.
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Affiliation(s)
- Jorge I. Portuondo
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs (VA) Medical Center, Houston, Texas
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Richard S. Whitlock
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Steven C. Mehl
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Pediatric Surgery, Texas Children’s Hospital, Houston
| | - Nader N. Massarweh
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, Georgia
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
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Intraoperative Assessment of Surgical Stress Response Using Nociception Monitor under General Anesthesia and Postoperative Complications: A Narrative Review. J Clin Med 2022; 11:jcm11206080. [PMID: 36294399 PMCID: PMC9604770 DOI: 10.3390/jcm11206080] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 11/16/2022] Open
Abstract
We present a narrative review focusing on the new role of nociception monitor in intraoperative anesthetic management. Higher invasiveness of surgery elicits a higher degree of surgical stress responses including neuroendocrine-metabolic and inflammatory-immune responses, which are associated with the occurrence of major postoperative complications. Conversely, anesthetic management mitigates these responses. Furthermore, improper attenuation of nociceptive input and related autonomic effects may induce increased stress response that may adversely influence outcome even in minimally invasive surgeries. The original role of nociception monitor, which is to assess a balance between nociception caused by surgical trauma and anti-nociception due to anesthesia, may allow an assessment of surgical stress response. The goal of this review is to inform healthcare professionals providing anesthetic management that nociception monitors may provide intraoperative data associated with surgical stress responses, and to inspire new research into the effects of nociception monitor-guided anesthesia on postoperative complications.
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Whitlock RS, Portuondo JI, Commander SJ, Ha TA, Zhu H, Goss JA, Kukreja KU, Leung DH, Terrada DL, Masand PM, Nguyen HN, Nuchtern JG, Wesson DE, Heczey AA, Vasudevan SA. Integration of a dedicated management protocol in the care of pediatric liver cancer: From specialized providers to complication reduction. J Pediatr Surg 2022; 57:1544-1553. [PMID: 34366130 DOI: 10.1016/j.jpedsurg.2021.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/15/2021] [Accepted: 07/20/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Up to a third of children undergoing partial hepatectomy for primary hepatic malignancies experience at least one perioperative complication, with a presumed deleterious effect on both short- and long-term outcomes. We implemented a multidisciplinary treatment protocol in the management of these patients in order to improve complication rates following partial hepatectomy. METHODS A retrospective chart review was completed for all patients < 18 years of age who underwent liver resection at our institution between 2002 and 2019 for primary hepatic cancer. Demographic, intraoperative, postoperative, pathologic, and outcome data were analyzed for perioperative complications using the CLASSIC and Clavien-Dindo (CD) scales, event-free survival (EFS) and overall survival (OS). RESULTS A total of 73 patients were included in the analysis with 33 prior-to and 40 after dedicated provider protocol implementation. Perioperative complication rates decreased from 52% to 20% (p = 0.005) with major complications going from 18% to 10% (p = 0.31). On multivariable logistic regression, protocol implementation was associated with a reduction in any (OR 0.29 [95% CI 0.09 - 0.89]) but not major complications. On multivariate cox models, post protocol implementation was associated with improved event free survival (EFS) (HR 0.19 (0.036 - 0.195). Among patients with a diagnosis of hepatoblastoma (n = 62), the occurrence of a major perioperative complication was associated with a worse EFS (HR=5.45, p = 0.03) on multivariate analysis, however this did not translate into an impact on overall survival. CONCLUSIONS Our results demonstrate that, for children with primary liver malignancies, a dedication of patients to high-volume surgeons can improve rates of complications of liver resections and may improve the oncological outcome of hepatoblastoma.
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Affiliation(s)
- Richard S Whitlock
- Division of Pediatric Surgery, Texas Children's Surgical Oncology Program, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, United States
| | - Jorge I Portuondo
- Division of Pediatric Surgery, Texas Children's Surgical Oncology Program, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, United States
| | - Sarah J Commander
- Department of Surgery, Duke University Medical Center, Durham, NC, United States
| | - Tu-Anh Ha
- Division of Pediatric Surgery, Texas Children's Surgical Oncology Program, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, United States
| | - Huirong Zhu
- Outcomes and Impact Service, Texas Children's Hospital, Houston, TX, United States
| | - John A Goss
- Division of Abdominal Transplantation, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, United States
| | - Kamlesh U Kukreja
- Division of Interventional Radiology, Singleton Department of Pediatric Radiology, Texas Children's Liver Tumor Program, Baylor College of Medicine, Houston, TX, United States; Singleton Department of Pediatric Radiology, Texas Children's Liver Tumor Program, Baylor College of Medicine, Houston, TX, United States
| | - Daniel H Leung
- Division of Gastroenterology, Hepatology and Nutrition, Texas Children's Liver Tumor Program, Department of Pediatrics, Baylor College of Medicine, Houston, TX, United States
| | - Dolores Lopez Terrada
- Departmant of Pathology, Texas Children's Liver Tumor Program, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, United States
| | - Prakash M Masand
- Singleton Department of Pediatric Radiology, Texas Children's Liver Tumor Program, Baylor College of Medicine, Houston, TX, United States
| | - HaiThuy N Nguyen
- Singleton Department of Pediatric Radiology, Texas Children's Liver Tumor Program, Baylor College of Medicine, Houston, TX, United States
| | - Jed G Nuchtern
- Division of Pediatric Surgery, Texas Children's Surgical Oncology Program, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, United States
| | - David E Wesson
- Division of Pediatric Surgery, Texas Children's Surgical Oncology Program, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, United States
| | - Andras A Heczey
- Texas Children's Cancer and Hematology Center, Texas Children's Liver Tumor Program, Department of Pediatrics, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX, United States
| | - Sanjeev A Vasudevan
- Division of Pediatric Surgery, Texas Children's Surgical Oncology Program, Texas Children's Liver Tumor Program, Michael E. DeBakey Department of Surgery, Dan L. Duncan Cancer Center, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, United States.
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Madsen HJ, Henderson WG, Bronsert MR, Dyas AR, Colborn KL, Lambert-Kerzner A, Meguid RA. Associations Between Preoperative Risk, Postoperative Complications, and 30-Day Mortality. World J Surg 2022; 46:2365-2376. [PMID: 35778512 DOI: 10.1007/s00268-022-06638-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Comorbidities and postoperative complications increase mortality, making early recognition and management critical. It is useful to understand how they are associated with one another. This study assesses associations between comorbidities, complications, and mortality. METHODS We calculated associations between comorbidities, complications, and 30-day mortality using the 2012-2018 ACS-NSQIP database. We examined the association between mortality and number of complications which complications were most associated with mortality. RESULTS 5,777,108 patients were included. 30-day mortality was 0.95%. For most comorbidities or postoperative complications, patients with these had higher mortality than patients without. Having ≥ 1 complication increased mortality risk by 32.5-fold (6.5% vs. 0.2%). Mortality rate significantly increased with increasing number of complications, particularly after two or more complications. Bleeding and sepsis were associated with the most deaths. CONCLUSION The 30-day mortality rate was < 1% but was 32-fold higher in patients with complications and increased rapidly for patients with ≥ 2 complications. Bleeding and sepsis were the most prominent complications associated with mortality.
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Affiliation(s)
- Helen J Madsen
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA. .,Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Denver, Anschutz Medical Campus, 12631 E. 17th Avenue, C-310, Room 6602, Aurora, CO, 80045, USA.
| | - William G Henderson
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam R Dyas
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kathryn L Colborn
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Anne Lambert-Kerzner
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert A Meguid
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
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10
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Portuondo JI, Farjah F, Massarweh NN. Association Between Hospital Perioperative Quality and Long-term Survival After Noncardiac Surgery. JAMA Surg 2022; 157:258-268. [PMID: 35044437 PMCID: PMC8771439 DOI: 10.1001/jamasurg.2021.6904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE There is known variation in perioperative mortality rates across hospitals. However, the extent to which this variation is associated with hospital-level differences in longer-term survival has not been characterized. OBJECTIVE To evaluate the association between hospital perioperative quality and long-term survival after noncardiac surgery. DESIGN, SETTING, AND PARTICIPANTS This national cohort study included 654 093 US veterans who underwent noncardiac surgery at 98 hospitals using data from the Veterans Affairs Surgical Quality Improvement Program from January 1, 2011, to December 31, 2016. Data were analyzed between January 1 and November 1, 2021. EXPOSURES Hospitals were stratified separately into quintiles of reliability-adjusted failure to rescue (FTR) and mortality rates. Patients were further categorized as having a complicated or uncomplicated postoperative course. MAIN OUTCOMES AND MEASURES The association between hospital FTR or mortality performance quintile (with quintile 1 representing low FTR or mortality and quintile 5 representing very high FTR or mortality) and overall risk of death was evaluated separately using multivariable shared frailty modeling among patients with a complicated and uncomplicated postoperative course. RESULTS For the overall cohort of 654 093 patients, the mean (SD) age was 61.1 (13.2) years; 597 515 (91.4%) were men and 56 578 (8.7%) were women; 111 077 (17.0%) were Black, 5953 (0.9%) were Native American, 467 969 (71.5%) were White, 42 219 (6.5%) were missing a racial category, and 26 875 (4.1%) were of another race; and 37 538 (5.7%) were Hispanic. Hospital-level 5-year survival for patients with a complicated course ranged from 42.7% (95% CI, 38.1%-46.9%) to 82.4% (95% CI, 59.0%-93.2%) and from 76.2% (95% CI, 74.4%-78.0%) to 95.2% (95% CI, 92.5%-97.7%) for patients with an uncomplicated course. Overall, 47 (48.0%) and 83 (84.7%) of 98 hospitals were either in the same or within 1 performance quintile for FTR and mortality, respectively. Among patients who had a postoperative complication, there was a dose-dependent association between care at hospitals with higher FTR rates and risk of death (compared with quintile 1: quintile 2 hazard ratio [HR], 1.05 [95% CI, 0.99-1.12]; quintile 3 HR, 1.17 [95% CI, 1.10-1.26]; quintile 4 HR, 1.30 [95% CI, 1.22-1.38]; and quintile 5 HR, 1.34 [95% CI, 1.22-1.43]). Similarly, increasing hospital FTR rates were associated with increasing risk of death among patients without complications (compared with quintile 1: quintile 2 HR, 1.07 [95% CI, 1.01-1.14]; quintile 3 HR, 1.10 [95% CI, 1.04-1.16]; quintile 4 HR, 1.15 [95% CI, 1.09-1.21]; and quintile 5 HR, 1.10 [95% CI, 1.05-1.19]). These findings were similar across hospital mortality quintiles for patients with complicated and uncomplicated courses. CONCLUSIONS AND RELEVANCE The findings of this cohort study suggest that the structures, processes, and systems of care that underlie the association between FTR and worse short-term outcomes may also have an influence on long-term survival through a pathway other than rescue from complications. A better understanding of these differences could lead to strategies that address variation in both perioperative and longer-term outcomes.
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Affiliation(s)
- Jorge I. Portuondo
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Farhood Farjah
- Department of Surgery, University of Washington, Seattle
| | - Nader N. Massarweh
- Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston, Texas,Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas,Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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11
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Patel AB, Weber V, Gourine AV, Ackland GL. The potential for autonomic neuromodulation to reduce perioperative complications and pain: a systematic review and meta-analysis. Br J Anaesth 2022; 128:135-149. [PMID: 34801224 PMCID: PMC8787777 DOI: 10.1016/j.bja.2021.08.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/09/2021] [Accepted: 08/25/2021] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Autonomic dysfunction promotes organ injury after major surgery through numerous pathological mechanisms. Vagal withdrawal is a key feature of autonomic dysfunction, and it may increase the severity of pain. We systematically evaluated studies that examined whether vagal neuromodulation can reduce perioperative complications and pain. METHODS Two independent reviewers searched PubMed, EMBASE, and the Cochrane Register of Controlled Clinical Trials for studies of vagal neuromodulation in humans. Risk of bias was assessed; I2 index quantified heterogeneity. Primary outcomes were organ dysfunction (assessed by measures of cognition, cardiovascular function, and inflammation) and pain. Secondary outcomes were autonomic measures. Standardised mean difference (SMD) using the inverse variance random-effects model with 95% confidence interval (CI) summarised effect sizes for continuous outcomes. RESULTS From 1258 records, 166 full-text articles were retrieved, of which 31 studies involving patients (n=721) or volunteers (n=679) met the inclusion criteria. Six studies involved interventional cardiology or surgical patients. Indirect stimulation modalities (auricular [n=23] or cervical transcutaneous [n=5]) were most common. Vagal neuromodulation reduced pain (n=10 studies; SMD=2.29 [95% CI, 1.08-3.50]; P=0.0002; I2=97%) and inflammation (n=6 studies; SMD=1.31 [0.45-2.18]; P=0.003; I2=91%), and improved cognition (n=11 studies; SMD=1.74 [0.96-2.52]; P<0.0001; I2=94%) and cardiovascular function (n=6 studies; SMD=3.28 [1.96-4.59]; P<0.00001; I2=96%). Five of six studies demonstrated autonomic changes after vagal neuromodulation by measuring heart rate variability, muscle sympathetic nerve activity, or both. CONCLUSIONS Indirect vagal neuromodulation improves physiological measures associated with limiting organ dysfunction, although studies are of low quality, are susceptible to bias and lack specific focus on perioperative patients.
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Affiliation(s)
- Amour B.U. Patel
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Valentin Weber
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK
| | - Alexander V. Gourine
- Centre for Cardiovascular and Metabolic Neuroscience, Neuroscience, Physiology and Pharmacology, University College London, London, UK
| | - Gareth L. Ackland
- Translational Medicine and Therapeutics, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, London, UK,Corresponding author.
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