Time of day is associated with postoperative morbidity: an analysis of the national surgical quality improvement program data

Does Timing Matter? The Effect of Intensive Care Unit Arrival Timing on Elective Cardiac Surgery

BACKGROUND

Due to staffing changes at scheduled intervals and decreases in essential staff in the evenings, late intensive care unit (ICU) arrivals may be at risk for suboptimal outcomes. Utilizing a regional collaborative, we sought to determine the effect of ICU arrival timing on outcomes in elective isolated coronary artery bypass.

METHODS

Adults undergoing elective, isolated coronary artery bypass from 17 hospitals between 2013 and 2023 were identified. Patients with missing predicted risk of mortality or missing ICU arrival time were excluded. Late ICU arrival time was defined as between 6:00 pm and 6:00 am. Hierarchical logistic regression with appropriate predicted risk scores was utilized for outcome risk adjustment.

RESULTS

We identified 11,638 patients, with 972 (8.4%) experiencing late ICU arrival. Late ICU arrival patients had higher predicted risk of morbidity or mortality (8.2%; [interquartile range {IQR}, 5.6%, 12.0%] vs 7.7% [IQR, 5.5%, 11.5%], P = .048) compared with early ICU arrival patients with longer median cardiopulmonary bypass times (96 minutes [IQR, 78, 119] vs 93 [IQR, 73, 116], P < .001). Late ICU arrival patients experienced more unadjusted complications including prolonged ventilation (7.7% vs 4.2%, P < .001) and operative mortality (2.0% vs 1.1%, P = .02), although no difference in failure-to-rescue (11.0% vs 10.4%, P = .84). Logistic regression with risk adjustment demonstrated late ICU arrival as a predictor of prolonged ventilation (odds ratio, 1.49 [95% CI, 1.12-1.99], P = .006).

CONCLUSIONS

After adjustment, late ICU arrivals experienced higher rates of prolonged ventilation, although this did not translate to failure-to-rescue.

Is Night Surgery a Nightmare for Lung Transplantation?

Night work is frequently associated with sleep deprivation and is associated with greater surgical and medical complications. Lung transplantation (LT) is carried out both at night and during the day and involves many medical healthcare workers. The goal of the study was to compare morbidity and mortality between LT recipients according to LT operative time. We performed a retrospective, observational, single-center study. When the procedure started between 6 AM and 6 PM, the patient was allocated to the Daytime group. If the procedure started between 6 PM and 6 AM, the patient was allocated to the Nighttime group. Between January 2015 and December 2020, 253 patients were included. A total of 168 (66%) patients were classified into the Day group, and 85 (34%) patients were classified into the Night group. Lung Donors' general characteristics were similar between the groups. The 90-day and one-year mortality rates were similar between the groups (90-days: n = 13 (15%) vs. n = 26 (15%), p = 0.970; 1 year: n = 18 (21%) vs. n = 42 (25%), p = 0.499). Daytime LT was associated with more one-year airway dehiscence (n = 36 (21%) vs. n = 6 (7.1%), p = 0.004). In conclusion, among patients who underwent LT, there was no significant association between operative time and survival.

Adhesive surface electrodes versus needle-based neuromonitoring in lumbar spinal surgery

Background

The relative safety and more widespread utility of an adhesive surface electrode-based neuromonitoring (ABM) system may reduce the time and cost of traditional needle-based neuromonitoring (NBM).

Methods

This retrospective cohort review included one- and two-level transforaminal lumbar interbody fusion procedures (2019-2023). The primary variables studied included were time (in minutes) from patient entry into the operating room (OR) to incision, time from patient entry into the OR to closure, and time from incision to closure. Univariate and bivariate analyses were performed to compare the outcomes between the ABM (31 patients) and NBM (51 patients) modalities.

Results

We found no significant differences in the time from patient entry into the OR to incision (ABM: 71.8, NBM: 70.3, P = 0.70), time from patient entry into the OR to closure (ABM: 284.2, NBM: 301.7, P = 0.27), or time from incision to closure (ABM: 212.4, NBM: 231.4, P = 0.17) between the two groups. Further, no patients from either group required reoperation for mal-positioned instrumentation, and none sustained a new postoperative neurological deficit. The ABM approach did, however, allow for a reduction in neurophysiologist-workforce and neuromonitoring costs.

Conclusion

The introduction of the ABM system did not lower surgical time but did demonstrate similar efficacy and clinical outcomes, with reduced clinical invasiveness, neurophysiologist-associated workforce, and overall neuromonitoring cost compared to NBM.

Impact of Transplantation Timing on Renal Graft Survival Outcomes and Perioperative Complications

Nighttime organ transplantation aims to decrease cold ischemia duration, yet conflicting data exists on its impact on graft function and perioperative complications. This multicenter TRANSPLANT'AFUF study including 2,854 patients, transplanted between 1 January 2011, and 31 December 2022, investigated nighttime kidney transplantation's impact (8:00 p.m.-8:00 a.m.) versus daytime (8:00 a.m.-8:00 p.m.) on surgical complications and graft survival. Overall, 2043 patients (71.6%) underwent daytime graft, while 811 (28.4%) underwent nighttime graft. No impact was observed of timing of graft surgery on graft survival with a median survival of 98 months and 132 months for daytime and nightime grafting, respectively (p = 0.1749). Moreover, no impact was observed on early surgical complications (Clavien I-II = 20.95% for DG and 20.10% for NG; Clavien III-IV-V = 15.42% for DG and 12.94% for NG; p = 0.0889) and late complications (>30 days) (Clavien I-II = 6.80% for DG and 5.67% for NG; Clavien III-IV-V = 12.78% for DG and 12.82% for NG; p = 0.2444). Noteworthy, we found a significant increase in Maastricht 3 donors' rates in nighttime transplantation (5.53% DG vs. 21.45% NG; p < 0.0001). In conclusion, nighttime kidney transplantation did not impact early/late surgical complications nor graft survival.

Safety of nighttime elective hepatectomy for hepatocellular carcinoma patients: a retrospective study

Purpose

This study aimed to investigate whether nighttime elective surgery influenced the short-term outcomes and prognosis of hepatocellular carcinoma (HCC) patients.

Methods

The 1,339 HCC patients who underwent hepatectomy were divided into the daytime surgery group (8 a.m.-6 p.m., n = 1,105) and the nighttime surgery group (after 6 p.m., n = 234) based on the start time of surgery. The 1:2 propensity score matching (PSM) analysis was used to control confounding factors. The short-term outcomes of HCC patients in the 2 groups were compared before and after PSM. Factors associated with major complications (Clavien-Dindo grade, ≥III) and textbook oncologic outcomes (TOO) were separately identified by multivariable logistic regression based on variables screened via least absolute shrinkage and selection operator (LASSO). The Kaplan-Meier method was used to analyze overall survival (OS) and recurrence-free survival (RFS).

Results

TOO was achieved after surgery in 897 HCC patients. HCC patients in the nighttime surgery group had a higher body mass index (P = 0.010). After 1:2 PSM, the baseline characteristics of patients between the 2 groups were similar. Short-term outcomes in HCC patients were comparable both before and after PSM (all Ps > 0.05), as were TOO in the 2 groups before (P = 0.673) and after PSM (P = 0.333). In our LASSO-logistic regression, nighttime surgery was not an independent factor associated with major complications or TOO. Both groups also had similar OS (P = 0.950) and RFS (P = 0.740) after PSM.

Conclusion

Our study revealed the safety of nighttime elective hepatectomy for HCC patients.

Postoperative wound dehiscence in mandibular fractures

OBJECTIVE

To clarify the occurrence and causes of non-infection-related surgical wound dehiscence (SWD) in intraorally treated mandibular fractures.

MATERIAL AND METHODS

Patients with one or two fractures of the dentate part of the mandible treated surgically via an intraoral approach were included in this retrospective study. The primary outcome variable was SWD. Associations between patient-, fracture- and surgery-related variables and SWD were evaluated.

RESULTS

Altogether 232 patients with 270 mandibular angle, body, symphysis and/or parasymphysis fractures were included in the analysis. In all, 22 SWDs were detected. These occurred in 9.5% of patients and in 8.1% of fractures. Surgery performed at night-time showed a significantly higher SWD rate than daytime surgeries (p = .012). Additionally, a significantly greater SWD rate was found among smokers (p = .041). Other studied variables remained statistically non-significant for SWD. In a multivariate analysis, night-time was the only significant independent variable with an odds ratio of 3.297 (95% CI 1.238 - 8.780, p = .017) for SWD.

CONCLUSION

The approach or closure technique used and the fracture type had only a minor effect on non-infection-related SWD in patients with mandibular fractures. To avoid SWDs, mandibular fracture surgeries should be conducted during the daytime with adequate support from an experienced surgeon.

Surgical starting time of the day and survival in gastric cancer

Previous studies indicate differences in short-term postoperative outcomes depending on the surgical starting time of the day, but long-term data are lacking. The aim of this study was to clarify if surgical starting time of the day influences long-term survival in gastric cancer patients. This cohort study consecutively included 2728 patients who underwent curatively intended gastrectomy for gastric cancer in 2011-2015 at a high-volume hospital in China, with follow-up until June 2019. Cox regression provided hazard ratios (HRs) with 95% confidence intervals (CIs) for 3-year all-cause mortality, adjusted for age, sex, health insurance, pathological tumor stage, surgical approach, neoadjuvant therapy, and weekday of surgery. Compared with patients with early starting time of gastrectomy (08:00-09:29), the point estimates for 3-year all-cause mortality were modestly increased in patients with a starting time in the middle of day (09:30-13:29; HR 1.15, 95% CI 0.97 to 1.37) and later (13:30-21:25; HR 1.10, 0.91 to 1.32). The corresponding HRs were increased particularly in patients who underwent laparoscopic gastrectomy (HR 1.54, 1.10 to 2.14 and HR 1.59, 1.12 to 2.25, respectively) and in those with stage II tumors (HR 1.74, 1.11 to 2.73 and HR 1.60, 1.00 to 2.58, respectively). Our study indicated that in patients who underwent laparoscopic gastrectomy and in those who with stage II tumors, starting surgery in the early morning might be associated with better long-term survival.

After-hour elective total knee arthroplasty does not affect clinical outcomes but negatively affects alignment

INTRODUCTION

In cases of limited medical resources, elective total knee arthroplasty (TKA) sometimes needs to be performed after typical work hours. However, surgeon fatigue and logistical factors may potentially affect outcomes. This study aimed to detect whether after-hour procedures impair outcomes after TKA.

MATERIALS AND METHODS

Elective unilateral TKA from Jan 1, 2016 to Nov 31, 2018 was retrospectively selected and separated into two groups. Procedures started from 8:00 A.M. to 5:29 P.M. were identified as day-time surgeries, whereas those started from 5:30 P.M. to 11:59 P.M. were considered after-hour surgeries. Operative period, Knee Society Score (KSS), range of motion (ROM), total blood loss, length of hospital stay (LOS), and postoperative adverse events and complications were compared. Additionally, the components were evaluated radiologically.

RESULTS

A total of 321 patients were selected, including 258 (80.37%) patients in the day-time group and 63 (19.63%) patients in the after-hour group. Operative period, LOS, total blood loss were similar between groups. The overall and each specific incidence of postoperative complications were comparable between the two groups, but the incidence of postoperative vomiting (POV) was higher in the after-hour group. There was no significant difference in knee joint function as shown by the KSS and ROM, both on the 3rd day and at 2 years after surgeries. Radiologically, there were no significant differences between the two groups in the femoral notches (P = 0.592). However, better coronal alignment was detected in the day-time group (P = 0.002), consistent with which there were less outliers (P = 0.033).

CONCLUSION

After-hour TKA procedure does not exert an impact on clinical outcomes, but negatively affects lower limb alignment. Besides, after-hour TKA surgery impairs patients' comfort by increasing POV.

Late surgical start time is associated with increased blood transfusion following gastric bypass surgery

BACKGROUND

Surgical start time (SST) has demonstrated conflicting effects on perioperative outcomes due to confounding factors, such as increased acuity in later SST cases. This study investigated the effect of SST on blood transfusion after gastric bypass surgery, a complication-prone elective surgical procedure.

METHODS

This retrospective cohort study included all patients undergoing gastric bypass surgery at a single academic medical center from 2016 through 2021 (n = 299). The primary independent variable was SST (before vs. after 15:00). The primary outcome was blood transfusion. Secondary outcomes included postoperative respiratory failure, length of stay, acute kidney injury, and mortality. The associations between SST and outcomes were investigated with univariate analyses. Multivariate and receiver operating characteristic (ROC) analyses were applied to the primary outcome, adjusting for demographic and operative characteristics.

RESULTS

On univariate analysis, 15:00-18:43 SST was associated with an increased risk of blood transfusion (relative risk 4.32, 95% confidence interval 1.27 to 14.63, p = 0.032), but not postoperative respiratory failure, acute kidney injury, length of stay, or mortality. On multivariate analysis, the only independent predictor of postoperative blood transfusion was a 15:00-18:43 SST (adjusted odds ratio 4.32, 95% confidence interval 1.06 to 15.96, c-statistic = 0.638). ROC analysis demonstrated that compared to the 15:00 threshold, a 14:34 threshold predicted postoperative blood transfusion with better accuracy (sensitivity = 70.0%, specificity = 83.0%).

CONCLUSIONS

Despite having similar demographic and operative characteristics, gastric bypass patients in the late SST cohort had a greater incidence of postoperative blood transfusion in this single-center study.

Feasibility of two laparoscopic surgeries for colon cancer performed by the same surgeon on a single day

BACKGROUND

Although the proportion of laparoscopic colectomies (LCs) for colon cancer is increasing, the feasibility of the same surgeon performing two LCs on a single day remains unknown. This study was conducted to clarify the feasibility of this practice by evaluating short-term and long-term outcomes.

METHODS

This retrospective analysis enrolled patients with pathological stage I-III colon cancer who underwent LC at the Shizuoka Cancer Center between 2010 and 2020. Patients were divided into two groups based on the timing of the surgery for the surgeon. The first group (n = 1485) comprised patients who underwent LC as the first surgery of the day for the surgeon. The second group (n = 163) comprised patients who underwent LC as the second LC of the day for the surgeon. Propensity score matching was performed to balance the baseline characteristics of the first and second groups. The short-term and long-term outcomes of the two groups were compared.

RESULTS

After propensity score matching, there were no significant differences in the incidence of postoperative complications of Clavien-Dindo classification grade II or higher between the first (10.4%, 17/163) and second groups (5.5%, 9/163). There were no significant differences in other perioperative outcomes, including operative time, intraoperative blood loss, and incidence of conversion to open surgery, between the two groups. Regarding long-term outcomes, there were no significant differences in overall survival or relapse-free survival between the two groups both in the full cohort and in the propensity score-matched cohort. In the propensity score-matched cohort, 5-year overall survival was 92.7% in the first group and 94.4% in the second group; 5-year relapse-free survival was 87.1% and 90.3%, respectively.

CONCLUSION

Our results suggest that the same surgeon performing two LCs for colon cancer on a single day is feasible in terms of short-term and long-term outcomes.

Association of Surgical Start Time with Outcomes of Benign Hysterectomy

STUDY OBJECTIVE

To evaluate whether surgical start time is associated with clinical and financial outcomes of hysterectomies performed for benign indications.

DESIGN

Retrospective cohort study.

SETTING

University 5-hospital healthcare system.

PATIENTS

Women who underwent benign hysterectomy between 2014 and 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed demographic, operative, and financial data to evaluate the relationships between surgical start time and perioperative outcomes including operating room time, estimated blood loss, length of stay, same-day discharge, and adverse perioperative events. Additionally, we evaluated the impact of surgical start time on total hysterectomy charges. Descriptive statistics and multivariate logistic and linear regressions were performed adjusting for confounders. Our study identified 2894 women who underwent benign hysterectomy, with 1910 hysterectomies starting prior to 12 pm (am group) and 984 hysterectomies starting after 12 pm (pm group). A pm start time was associated with higher estimated blood loss (Median 100, interquartile range 50, 200 in the am group vs Median 125, interquartile range 75, 250), increased length of stay, and decreased likelihood of same-day discharge. No significant differences were noted in the rates of adverse perioperative events between the 2 groups. Surprisingly, an afternoon start time was associated with decreased total hospital charges (median am $14 055.30 versus median pm $11 724.80). These cost differences persisted after multivariate linear regression, and when stratified by hysterectomy surgical approach, remained significant in the open and laparoscopic cohorts.

CONCLUSION

Afternoon hysterectomy start time is associated with increased blood loss and length of stay with decreased rates of same-day discharge; however, there was no associated increase in perioperative adverse events or mortality. Awareness regarding surgical start time and outcomes can guide surgical scheduling and optimize same-day discharge.

Does the timing of appendectomy affect outcomes and postoperative complications?

PURPOSE

There is controversy about the necessity of nighttime appendectomy. The aim of this study was to determine whether timing of appendectomy performance plays a role on postoperative complications.

METHODS

A retrospective single-center comparative study was performed in children who underwent surgery for acute appendicitis between 2017 and 2021. Patients were divided into groups based on the time slot in which surgery was performed: morning (8:00 h-15:00 h), afternoon (15:00 h-22:00 h) and night (22:00 h-08:00 h). Demographics, intraoperative data, length of hospital stay, and postoperative complications were analyzed and compared.

RESULTS

A total of 1643 patients were included: 337 were operated in the morning, 751 in the afternoon and 555 at night. We found no demographic differences. When comparing the intraoperative data, no differences were observed in the percentage of complicated appendicitis. Night group patients presented a higher percentage of open appendectomies (64.5%) when compared to afternoon (49.6%) and morning (46.2%) groups (p < 0.001). Surgery time was also significantly shorter in the night group (45.2 min ± 18.9 min) (p < 0.001). There were no differences in length of hospital stay, postoperative complications rate or readmission rate.

CONCLUSION

These results show that in our institution time slot in which the appendectomy is performed has no consequences in postoperative outcomes and complications.

Clinical Impact of a Quality Improvement Program Including Dedicated Emergency Radiology Personnel on Emergency Surgical Management: A Propensity Score-Matching Study

Objective

To investigate the clinical impact of a quality improvement program including dedicated emergency radiology personnel (QIP-DERP) on the management of emergency surgical patients in the emergency department (ED).

Materials and Methods

This retrospective study identified all adult patients (n = 3667) who underwent preoperative body CT, for which written radiology reports were generated, and who subsequently underwent non-elective surgery between 2007 and 2018 in the ED of a single urban academic tertiary medical institution. The study cohort was divided into periods before and after the initiation of QIP-DERP. We matched the control group patients (i.e., before QIP-DERP) to the QIP-DERP group patients using propensity score (PS), with a 1:2 matching ratio for the main analysis and a 1:1 ratio for sub-analyses separately for daytime (8:00 AM to 5:00 PM on weekdays) and after-hours. The primary outcome was timing of emergency surgery (TES), which was defined as the time from ED arrival to surgical intervention. The secondary outcomes included ED length of stay (LOS) and intensive care unit (ICU) admission rate.

Results

According to the PS-matched analysis, compared with the control group, QIP-DERP significantly decreased the median TES from 16.7 hours (interquartile range, 9.4–27.5 hours) to 11.6 hours (6.6–21.9 hours) (p < 0.001) and the ICU admission rate from 33.3% (205/616) to 23.9% (295/1232) (p < 0.001). During after-hours, the QIP-DERP significantly reduced median TES from 19.9 hours (12.5–30.1 hours) to 9.6 hours (5.7–19.1 hours) (p < 0.001), median ED LOS from 9.1 hours (5.6–16.5 hours) to 6.7 hours (4.9–11.3 hours) (p < 0.001), and ICU admission rate from 35.5% (108/304) to 22.0% (67/304) (p < 0.001).

Conclusion

QIP-DERP implementation improved the quality of emergency surgical management in the ED by reducing TES, ED LOS, and ICU admission rate, particularly during after-hours.

Association Between Daytime vs Overnight Digit Replantation and Surgical Outcomes

Importance

Recent evidence suggests that select delayed replantation may not adversely affect digit survival; however, whether surgical timing (overnight or daytime) is associated with digit replantation outcomes is unknown.

Objective

To assess whether digit survival, complication rate, and duration of surgery are associated with time of replantation.

Design, Setting, and Participants

This retrospective case series study included all replantations performed at a single tertiary referral academic center between January 1, 2000, and August 1, 2021. Data were analyzed between October 2, 2021, and January 1, 2022. Four daytime surgery intervals were selected based on literature review. Daytime replantations started within the intervals whereas overnight replantations began outside the intervals. For each case, the procedure difficulty score and the attending surgeon expertise score were calculated. Logistic and linear regressions adjusting for confounders including procedure difficulty score and expertise score were used to assess surgical timing and outcomes. Participants were adults (aged ≥18 years) undergoing digit replantations between January 2000 and August 2021 with at least 1-month follow-up. Replantation was defined as the reattachment of a completely amputated digit that necessitated anastomosis of both artery and vein.

Exposures

Daytime or overnight digit replantation.

Main Outcomes and Measures

Viable replanted digit at 1-month follow-up, number of complications, and duration of surgery.

Results

A total of 98 patients (mean [SD] age, 39.5 [15.3] years; 136 [93%] men) and 147 digits met inclusion criteria. Overall success rate was 55%. Between 4 pm and 7 am, overnight replantations were associated with 0.4 fewer complications (β, -0.4; 95% CI, -0.8 to -0.1) and 90.7 minutes shorter operative time (β, -90.7; 95% CI, -173.6 to -7.7). A 1-point increase in surgeon expertise score was associated with 1.7 times increased odds of replantation success for all intervals (adjusted odds ratio, 1.7; 95% CI, 1.2 to 2.4; P = .002). There were no differences in digit survival by surgical time.

Conclusions and Relevance

In this case series study of digit replantations, time of operation was not associated with replantation success. Overnight replantation was associated with fewer complications and shorter duration of surgery compared with daytime surgery. Results of this study suggest that overnight replantations may be performed with outcomes comparable to daytime replantations at a tertiary care academic center.

'Out of hours' orthopaedics in an Irish regional trauma unit and the impact of COVID-19

Introduction

MRHT is the regional trauma service for the Midlands, providing 24/7 orthopaedic cover. ‘Out of hours’ surgery is reserved for those occasions where waiting for the next operating list during normal working hours would result in an unacceptable outcome for the patient.

Aims

To identify how many ‘out-of-hours’ surgeries were performed and what proportion of the total workload was made up by these cases.

Secondly, to identify the impact of COVID-19 on our workload as an acute trauma service.

Methods

We performed a retrospective analysis of all operations performed in the emergency orthopaedic theatre between January 2017 and October 2020. Included were all emergency orthopaedic procedures performed after 6 p.m. and before 8 a.m.

We compared this to the total number of trauma surgeries performed in the same time period to calculate the percentage of our total operations.

Results

There were a total of 7615 orthopaedic trauma operations performed in the 193 weeks. 164 of these were ‘out-of-hours’. This represents 2.2% of the total operations performed and is equal to 0.84 cases per week.

55 of the 164 (33.5%) were performed in children under the age of 18.

62 were performed between 6 and 8 p.m., 61 between 8 and 10 p. m., 31 between 10 p.m. and midnight, and the remaining 10 were performed between midnight and 3 a.m.

Conclusion

Surgery out of hours has been associated with increased complications, and so decisions to perform emergency surgery should not be made lightly. However, sometimes they are unfortunately necessary and are some of the most important operations we can perform as orthopaedic surgeons.

Absence of a weekday effect on short- and long-term oncologic outcomes of gastrectomy for gastric cancer: a propensity score matching analysis

BACKGROUND

Day of the week when elective gastrointestinal surgery is performed may be influenced by various background and tumor-related factors. Relationships between postoperative outcome and when in the week gastrectomy is performed remain controversial. We undertook this study to evaluate whether weekday of gastrectomy influenced outcomes of gastric cancer treatment ("weekday effect").

METHODS

Patients who underwent curative surgery for gastric cancer between 2004 and 2017 were included in this retrospective study. To obtain 2 cohorts well balanced for variables that might influence clinical outcomes, patients whose gastrectomy was performed early in the week (EW group) were matched 1:1 with others undergoing gastrectomy later in the week (LW group) by use of propensity scores.

RESULTS

Among 554 patients, 216 were selected from each group by propensity score matching. Incidence of postoperative complications classified as Clavien-Dindo grade II or higher was similar between EW and LW groups (20.4% vs. 24.1%; P = 0.418). Five-year overall and recurrence-free survival were 86.0% and 81.9% in the EW group, and 86.2% and 81.1% in the LW group (P = 0.981 and P = 0.835, respectively).

CONCLUSIONS

Short- and long-term outcomes were comparable between gastric cancer patients who underwent gastrectomy early and late in the week.

Defining the optimal time to appendectomy: A step toward precision surgery

BACKGROUND

We aimed to investigate the association between time from admission to appendectomy on perioperative outcomes in order to determine optimal time-to-surgery windows.

METHODS

We performed a retrospective review of all the appendectomies performed between July 2018 to May 2020. We first compared the perioperative outcomes using preselected time-to-surgery cut-offs, then determined optimal safe windows for surgery, and finally identified subgroups of patients who may require early intervention.

RESULTS

Six hundred twenty-one appendectomies were performed in the time period. The patients with a time-to-surgery of ≥12 hours had a significantly longer length of stay (median 2 days [interquartile range 1-3] vs 3 days [interquartile range 2-4], mean difference = 0.74 [95% confidence interval 0.32-1.17, P = .0006]) and higher 30-day readmission risk (odds ratio 2.58, 95% confidence interval 1.12-5.96, P = .0266) versus those with a time-to-surgery of <12 hours. These differences persisted when the time-to-surgery was dichotomized by <24 or ≥24 hours. A time-to-surgery beyond 25 hours was associated with a 3.34-fold increased odds of open conversion (P = .040), longer operation time (mean difference 15.8 mins, 95% confidence interval 3.4-28.3, P = .013) and longer postoperative length of stay (mean difference 10.3 hours, 95% confidence interval 3.4-20.2, P = .042) versus a time-to-surgery of <25 hours. The patients with time-to-surgery beyond 11 hours had a 1.35-fold increased odds of 30-day readmission (95% confidence interval 1.02-5.43, P = .046) compared with those who underwent appendectomy before 11 hours. Older patients, patients with American Society of Anesthesiologist score II to III, and individuals with long duration of preadmission symptoms had higher risk of prolonged operation time, open conversion, increased length of stay, and postoperative morbidity with increasing time-to-surgery.

CONCLUSION

This study identified the safe windows for appendectomy to be 11 to 25 hours from admission for most perioperative outcomes. However, certain patient subgroups may be less tolerant of surgical delays.

The impact of case order and intraoperative staff changes on spine surgical efficiency

BACKGROUND CONTEXT

Despite concerted efforts toward quality improvement in high-volume spine surgery, there remains concern that increases in case load may compromise the efficient and safe delivery of surgical care. There is a paucity of evidence to describe the effects of spine case order and operating room (OR) team structure on measures of intraoperative timing and OR efficiency.

PURPOSE

This study aims to determine if intraoperative staff changes and surgical case order independently predict extensions in intraoperative timing after spinal surgery for spondylotic diseases.

STUDY DESIGN/ SETTING

Retrospective cohort analysis PATIENT SAMPLE: All patients over age 18 who underwent primary or revision decompression and/or fusion for degenerative spinal diseases between 2017 to 2019 at a single academic institution were retrospectively identified. Exclusion criteria included absence of descriptive data and intraoperative timing parameters as well as surgery for traumatic injury, infection, and malignancy.

OUTCOME MEASURES

Intraoperative timing metrics including total theater time, wheels in to induction, induction start to cut, cut to close, and close to wheels out. Postoperative outcomes included length of hospital stay and 90-day hospital readmissions.

METHODS

Surgical case order and intraoperative changes in staff (circulator and surgical scrub nurse or technician) were determined. Patient demographics, surgical factors, intraoperative timing and postoperative outcomes were recorded. Extensions in each operative stage were determined as a ratio of the actual duration of the parameter divided by the predicted duration of the parameter. Univariate and multivariate analyses were performed to compare outcomes within case order and staff change groups.

RESULTS

A total of 1,108 patients met the inclusion criteria. First, second, and third start cases differed significantly in intraoperative extensions of total theater time, wheels in to induction, induction start to cut, cut to close, and close to wheels out. On regression, decreasing case order predicted extension in wheels in to induction time. Surgeries with intraoperative staff changes were associated with increases in total theater time, induction start to cut time, cut to close time, close to wheels out time, and length of hospital stay. Switch in primary circulator predicted extended theater time and cut to close time. Relief of primary circulator or scrub predicted extended total theater time, induction start to cut time, cut to close time, and close to wheels out time.

CONCLUSIONS

Intraoperative staff change in spine surgery independently predicted extended operative duration. However, higher case order was not significantly associated with procedural time.

Getting going on time: reducing neurophysiology set-up times in order to contribute to improving surgery start and finish times

At the Walton Centre we conduct a relatively large number of complex and lengthy elective (booked) spinal operations. Recently, we have had a particular problem with half or more of these sessions finishing late, resulting in staff discontent and greater use of on-call staff.These operations require patient monitoring by neurophysiology clinical scientists. Before the surgeon can start the operation, in-theatre neurophysiological measurements are required to establish a baseline. We reasoned that reducing this set-up time would reduce the risk of surgery starting late, and so the whole session finishing later than expected.In this project we redesigned the neurophysiology parts of in-theatre patient preparation. We conducted five Plan-Do-Study-Act cycles over 3 months, reducing the duration of pre-surgery preparation from a mean of 70 min to around 50 min. We saw improvements in surgical start times and session finish times (both earlier by roughly comparable amounts). The ultimately impact is that we saw on-time session finishes improve from around 50% to 100%. Following this project, we have managed to sustain the changes and the improved performance.The most impactful change was to conduct in-theatre neurophysiology patient preparation simultaneously with anaesthesia, rather than waiting for this to finish; when we performed this with a pair of clinical scientists, we were able to complete neurophysiology patient preparation by the time the anaesthetist was finished, therefore not introducing delays to the start of surgery. A final change was to remove a superfluous preparatory patient-baseline measurement.This is a very challenging and complex environment, with powerful stakeholders and many factors and unpredictable events affecting sessions. Nevertheless, we have shown that we can make improvements within our span of influence that improve the wider process. While using pairs of staff requires greater resource, we found the benefit to be worthwhile.

Impact of after-hours surgery on outcomes of acute type A aortic dissection repair

PURPOSE

To establish whether emergency surgery performed outside working hours (after hours) contributed to adverse outcomes for patients with acute type A aortic dissection (ATAAD).

METHODS

We reviewed the operation records of ATAAD repair in our institution from 2004 to 2019 (n = 187). Emergency surgery was performed by one of a few teams of experienced surgeons, regardless of the time of day. Patients were divided into two groups based on the surgery start time: during working hours (n = 65) and after hours (n = 122). A propensity score-matched analysis was performed for 58 pairs of patients.

RESULTS

The overall in-hospital mortality was 6.9% for the working-hours group and 13.8% for the after-hours group. There were no significant differences between the groups in the relatively limited study population (n = 187). Surgeon experience and aortic interventions did not differ remarkably between the groups. After-hours repair was not associated with postoperative complications. There were no significant differences in the long-term survival or aortic event-free rates between the groups.

CONCLUSIONS

After-hours surgery did not affect the short- or long-term outcomes of ATAAD repair under our backup system, which supports the recommendation of immediate surgical repair. Efforts to minimize the discrepancies between working hours and after hours could help to improve the surgical outcomes of patients undergoing ATAAD repair.

Consecutive Laparoscopic Colorectal Resections in a Single Workday by the Same Surgeon: Efficient or Risky?

Background: As laparoscopic colorectal surgery (LCS) continues increasing worldwide, surgeons may need to perform more than one LCS per day to accommodate this higher demand. We aimed to determine the safety of performing consecutive LCSs by the same surgeon in a single workday. Materials and Methods: Consecutive LCSs performed by the same surgeon from 2006 to 2019 were included. The sample was divided into two groups: patients who underwent the first (G1) and those who underwent the second and the third (G2) colorectal resections in a single workday. LCSs were stratified into level I (low complexity), level II (medium complexity), and level III (high complexity). Demographics, operative variables, and postoperative outcomes were compared between groups. Results: From a total of 1433 LCSs, 142 (10%) were included in G1 and 158 (11%) in G2. There was a higher rate of complexity level III LCS (G1: 23% versus G2: 6%, P < .0001) and a longer operative time (G1: 160 minutes versus G2: 139 minutes, P = .002) in G1. There were no differences in anastomotic leak, overall morbidity, or mortality rates. Mean length of hospital stay and readmission rates were similar between groups. Conclusion: Multiple consecutive laparoscopic colorectal resections can be safely performed by the same surgeon in a single workday. This efficient strategy should be encouraged at high-volume centers with experienced colorectal surgeons.

Preoperative neutrophil-to-lymphocyte ratio may contribute to the prediction of postoperative infectious complications in patients with acute appendicitis: a retrospective study

BACKGROUND

Several studies have assessed various clinical variables to identify risk factors for postoperative complications in patients with acute appendicitis. However, few studies have focused on the relationships between systemic inflammatory variables and postoperative complications in patients with acute appendicitis. We investigated the relationships between postoperative complications and systemic inflammatory variables, and assessed the clinical utility of these variables as predictors of postoperative complications in patients with acute appendicitis.

METHODS

We retrospectively reviewed 181 patients who underwent immediate appendectomy for acute appendicitis. All postoperative complications were classified as infectious or noninfectious, and we evaluated the relationships between postoperative complications and clinical factors including the preoperative neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio.

RESULTS

In total, 28 patients (15.5%) had postoperative Clavien-Dindo grade II-IV complications; 17 patients (9.4%) and 11 patients (6.1%) were categorized as the infectious and noninfectious complication groups, respectively. The cutoff value of the preoperative neutrophil-to-lymphocyte ratio for all complications was 11.3, and multivariate analysis revealed that the preoperative neutrophil-to-lymphocyte ratio was an independent predictor of any postoperative complication (odds ratio: 4.223, 95% confidence interval: 1.335-13.352; P = 0.014). The cutoff value of the preoperative neutrophil-to-lymphocyte ratio for infectious complications was 11.4, and multivariate analysis revealed that the preoperative neutrophil-to-lymphocyte ratio was an independent predictor of infectious complications (odds ratio: 4.235, 95% confidence interval: 1.137-15.776; P = 0.031).

CONCLUSIONS

In patients with acute appendicitis, the preoperative neutrophil-to-lymphocyte ratio may be a useful predictor of all postoperative complications, especially infectious complications.

Delayed extubation in spine surgery is associated with increased postoperative complications and hospital episode-based resource utilization

STUDY OBJECTIVE

To elucidate the association between delayed extubation, postoperative complications, and episode-based resource utilization.

DESIGN

Retrospective Propensity-Matched Cohort Study.

SETTING

Single Large Academic Medical Center.

PATIENTS

The computerized anesthetic records of 17,223 patients undergoing spine surgery from January 2006 through November 2016 were reviewed for this study. The records of 11,421 patients met inclusion criteria for final analysis, with 527 subjects who had delayed extubation following their procedure.

INTERVENTIONS

Delayed extubation, defined as patients not extubated prior to leaving the operating room.

MEASUREMENTS

Computerized anesthetic records of spine surgery patients were analyzed retrospectively. Corresponding Medicare Severity Diagnosis Related Group numbers (MS-DRGs) were then identified, as well as associated lengths of stay and costs of care. We compared hospital-acquired International Classification of Diseases-9 (ICD-9) and ICD-10 postoperative complication codes linked to each record to assess differences in outcome.

MAIN RESULTS

Increasing medical and surgical complexity is associated with delayed extubation. Using propensity score matching, delayed extubation was independently associated with a higher likelihood of any postoperative complication (Odds Ratio [OR]: 1.79; 95% Confidence Interval [CI]: 1.23-2.61); major complications (OR: 2.22; 95% CI: 1.31-3.76); prolonged length of hospital stay (Hazard Ratio [HR]: 0.82 (0.72, 0.95), p = 0.006); prolonged Intensive Care Unit (ICU) stay (HR: 0.68 (0.61, 0.76), p < 0.001); and were less likely to be discharged home (OR: 1.40 (1.02, 1.92), p = 0.036). Propensity score matching demonstrated that anesthesiologist handoff was not independently associated with any of the examined adverse outcomes.

CONCLUSIONS

Delayed extubation after spine surgery was associated with a statistically significant increased incidence of postoperative complications as well as increased hospital episode-based resource utilization in the form of increased hospital length of stay, ICU length of stay, post-acute care at a facility, and higher cost of hospitalization. Although anesthesiologist handoff was associated with delayed extubation, it was not independently associated with postoperative complications when propensity score matching was applied.

The Impact of Surgical Scheduling on Outcomes in Lumbar Laminectomy

Objective The purpose of this study was to determine whether surgical scheduling affected patient outcomes following lumbar laminectomy. Physician fatigue caused by prolonged work hours has been shown to worsen outcomes. Previous research has also established a relationship between surgical scheduling and outcomes. Methods This was a retrospective chart review of single-level lumbar laminectomy patients at the Penn State Milton S. Hershey Medical Center between 1992 and 2019. Patients who underwent a one-level laminectomy between 1992 and 2019 were included in the study. Patients with procedures defined as complex (>1 level, tumor or abscess removal, discectomy, implant removal) were excluded. The surgical complication rate [cerebrospinal fluid (CSF) leak, 30-day redo, 30-day ED visit, weakness, sensation loss, infection, urinary retention] was compared across surgical start times, day of the week, proximity to a holiday, and procedure length. Results Procedures that started between 9:01-11:00 were more likely to have a complication than those between 7:01-9:00 (p=0.04). For every 60-min increase in surgery length, odds of having a complication increased by 2.01 times (p=0.0041). Surgeries that started between 11:01-13:00 had a significantly longer median surgery length than those between 7:01-9:00. Conclusion The time of the day when the procedure was started was predictive of worse outcomes following laminectomy. This may be attributed to several factors, including fatigue and staff turnover. Additionally, increased surgical length was predictive of more complications. It remains unclear whether increased surgical time results from correction of noticed errors or a fatigue-related decline in speed and performance. These findings on one-level laminectomy warrant further investigations since they have implications for reducing systemic failures that impact patient outcomes.

Simplifying the Combined Use of Fibula Flap and Anterolateral Thigh Flap for Oromandibular Reconstruction

Although the preferred technique for reconstruction of extensive composite oromandibular defects involves the use of a fibula flap for the inner mucosal lining and mandibular bone reconstruction and an anterolateral thigh flap for outer skin coverage and soft tissue replenishment, this approach is complicated and manpower-dependent. It also often involves prolonged operations requiring nighttime surgery with insufficient manpower in an era of restricted working hours for residents, which can negatively affect the surgical outcomes. Traditionally, the mucosal defect is first defined and the fibula flap is then dissected to ensure a size-matching skin flap for the inner lining. This flap is transferred first after mandibulectomy is completed, but is delayed by the fibula bone shaping process. Finalizing the flap inset is a sophisticated process involving the fibula bone, fibula skin, and anterolateral thigh skin. Thus, we developed a strategy to overcome the late start of fibula flap harvest, the delayed initiation of defect-site reconstruction, and the troublesome flap inset. Briefly, we dissected both flaps sequentially or simultaneously from contralateral limbs before the mucosal defect was defined, so that the flaps were ready in the daytime. Once the mandibulectomy was completed, we transferred the anterolateral thigh flap first while the fibula bone was shaped, and simplified the flap inset by using the anterolateral thigh skin for the inner lining and outer coverage and the fibula skin as a monitoring flap. We employed this approach in five patients and completed postmandibulectomy reconstruction in as fast as 4 hours.

Laparoscopic delayed and interval appendectomy in the workstyle reform era

PURPOSE

Excessive working hours have been reported to contribute to burnout among surgeons. In Japan, work-style reform is a problem that needs immediate attention. Acute appendectomy, which often occurs at nighttime, is one of the most common emergency surgeries. The feasibility of delayed and interval appendectomy remains to be investigated.

METHODS

Two hundred forty-five consecutive patients who underwent laparoscopic appendectomy in our hospital were enrolled. They were divided into three groups: emergency appendectomy (immediate surgery, soon after the diagnosis [EA group], n = 153), delayed appendectomy (surgery during daytime the following day [DA group], n = 38) and interval appendectomy (antibiotics treatment followed by selective surgery three to four months later [IA group], n = 54). The clinical background and surgical outcomes were compared. Next, the residents' excess working time per month was calculated.

RESULTS

The surgical outcomes (operation time, blood loss, length of hospital stay, postoperative complications) were similar between the EA and DA groups. However, no DA was performed during nighttime hours whereas 15.7% of EA was performed during nighttime hours (p = 0.0007). The surgical outcomes of the IA group were also comparable. The residents' excess working time declined following the introduction of DA and workstyle reform.

CONCLUSION

Delayed and interval laparoscopic appendectomy are feasible, and can be performed to promote workstyle reform without impairing patient safety.

Outcomes of Rhegmatogenous Retinal Detachment Repair When Comparing Surgeon Continuity in a Team-Based Practice

BACKGROUND AND OBJECTIVE

To facilitate timely surgery and efficient use of operating room time, our practice uses a team-based approach so patients may undergo primary rhegmatogenous retinal detachment (RRD) surgery with a different surgeon instead of the diagnosing surgeon.

PATIENTS AND METHODS

This was a retrospective cohort study of 331 eyes that underwent RRD surgery. Patients were divided into two groups: RRD surgery performed by the diagnosing surgon, and RRD surgery performed by a different surgeon.

RESULTS

Of 331 eyes, 200 eyes (60.4%) were repaired by the diagnosing surgeon and 131 eyes (39.6%) were repaired by a different surgeon. Primary anatomic success (PAS) rates at 3 months postoperatively were equivalent between the two groups (87.0% and 87.8% in the diagnosing surgeon and different surgeon groups, respectively [P = .83]). There was no significant difference in preoperative (P = .08) or final (P = .28) visual acuity between the groups. Time between diagnosis and RRD repair was shorter in the different surgeon group (median of 1.5 days [IQR: 1.0-3.6] in the surgeon group versus 2.2 days [IQR: 0.8-5.7] in the diagnosing surgeon group) (P = .03). Logistic regression analysis gave no evidence to suggest that PAS rates depended on day of week, time of day surgery was performed, group, or the interaction between those factors (P = .93).

CONCLUSIONS

Visual and anatomic success in RRD repair are equivalent when surgery is performed by either the diagnosing surgeon or a surgical colleague because time to surgery is reduced. Neither time of day nor day of the week had any influence on the outcomes. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:560-566.].

The Impact of Surgery duration and Surgery End Time on Postoperative Sleep in Older Adults

Objectives/Background:

Sleep disruption is prevalent in older patients. No previous studies have considered the impact of surgery duration or surgery end time of day on postoperative sleep disruption. Accordingly, we examined the duration of surgery and surgery end times for associations with postoperative sleep disruption.

Methods:

Inclusion criteria were patients ≥ 65 years of age undergoing major, non-cardiac surgery. Sleep disruption was measured by wrist actigraphy and defined as wake after sleep onset (WASO) during the night, or inactivity/sleep time during the day. The sleep opportunity window was set from 22:00 to 06:00 which coincided with “lights off and on” in the hospital. WASO during this 8-hour period on the first postoperative day was categorized into one of three groups: ≤ 15%, 15–25%, and > 25%. Daytime sleep (inactivity) during the first postoperative day was categorized as ≤ 20%, 20–40%, and > 40%. Statistical analyses were conducted to test for associations between surgery duration, surgery end time and sleep disruption on the first postoperative day and following night.

Results:

For this sample of 156 patients, surgery duration ≥ 6 hours and surgery end time after 19:00 were not associated with WASO groups (p = 0.17, p = 0.94, respectively). Furthermore, daytime sleep was also not affected by surgery duration or surgery end time (p = 0.07, p = 0.06 respectively).

Conclusion:

Our hypothesis that patients with longer duration or later-ending operations have increased postoperative sleep disruption was not supported. Our results suggest the pathophysiology of postoperative sleep disruption needs further investigation.

Associations between surgical start time (regular vs after hours) and morbidity and mortality during hospitalization in dogs and cats

OBJECTIVE

To examine the relationship between after-hours (ie, nights and weekends) emergency general surgery and morbidity or mortality in dogs and cats during hospitalization.

DESIGN

Cross-sectional study from September 1, 2013 to May 31, 2017.

SETTING

University teaching hospital.

ANIMALS

Four hundred seventy-four dogs and 66 cats that underwent emergency general surgery (gastrointestinal, hepatobiliary, urogenital, soft tissue traumatic injury, splenectomy/excision of bleeding abdominal tumor, surgical revision, and negative exploratory categories) with the emergency surgery service. All patients were required to have complete medical records.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Study animals were grouped as exposed or not exposed to after-hours emergency surgery. They were further classified as either postoperatively dead or suffering morbidity (yes or no). Additional exposure factors (eg, age, sex, American Society of Anesthesiology [ASA] status) were investigated. Multivariable logistic regression was used to identify and quantify any associations with mortality or morbidity. In dogs, exposure to after-hours emergency general surgery was not associated with mortality or morbidity. In dogs, both mortality and morbidity were associated with ASA status. In cats, mortality was not examined because the number of dead cats was small (n = 5). The odds of morbidity were 3.4 times lower (1/0.29) in cats having emergency surgery after hours, compared to cats admitted during regular hours (odds ratio [OR], 0.29; 95% Confidence Interval (CI), 0.09-0.93; P = 0.03). No other investigated exposure factors were associated with morbidity in study cats.

CONCLUSIONS

After-hours emergency surgery in dogs was not associated with increased risk of mortality and morbidity at the study facility. Feline patients having emergency surgery during regular hospital hours had a higher risk of morbidity; further investigation of modifiable risk factors is warranted.

The Pull-through Anastomosis of Ureter to Enteric Conduit (PAUTEC): A Novel Technique for Urinary Diversion

OBJECTIVE

To describe and illustrate a novel technique of uretero-ileal anastomosis for use in urinary diversion - the Pull-through Anastomosis of Ureter To Enteric Conduit (PAUTEC). A second objective was to evaluate the surgical outcomes of the PAUTEC anastomosis.

MATERIALS AND METHODS

Our novel anastomotic technique was described step-by-step and visually depicted with illustrations and the accompanying narrated video. Additionally, to evaluate safety and efficacy, a retrospective review of a prospectively maintained database was performed. Patients who underwent radical cystectomy alone or during pelvic exenteration, with ileal conduit diversion incorporating PAUTEC, 2016-2020 with ≥6 months follow-up were included. Surgical outcomes and renal function were analysed.

RESULTS

PAUTEC anastomosis was performed on 43 ureters in 23 patients. Mean age was 66 years [50-80] and 21 of 23 patients were male. One patient had a conservatively-managed small urine leak. No ureteric strictures have been identified to date. Mean serum creatinine was 1.15 mg/dL [0.69-2.08] (102umol/L, range 61-184 umol/L) preoperatively, and 1.09 mg/dL [0.61-2.59] (96.3 umol/L, range 54-229 umol/L) at follow-up, demonstrating no significant change (P= .26, paired t-test). Mean follow-up was 15 months [6-44].

CONCLUSION

A PAUTEC technique of uretero-ileal anastomosis is feasible and technically straightforward, with satisfactory outcomes observed to date.

Revisiting delayed appendectomy in patients with acute appendicitis

Acute appendicitis (AA) is the most common acute abdomen, and appendectomy is the most common nonelective surgery performed worldwide. Despite the long history of understanding this disease and enhancements to medical care, many challenges remain in the diagnosis and treatment of AA. One of these challenges is the timing of appendectomy. In recent decades, extensive studies focused on this topic have been conducted, but there have been no conclusive answers. From the onset of symptoms to appendectomy, many factors can cause delay in the surgical intervention. Some are inevitable, and some can be modified and improved. The favorable and unfavorable results of these factors vary according to different situations. The purpose of this review is to discuss the causes of appendectomy delay and its risk-related costs. This review also explores strategies to balance the positive and negative effects of delayed appendectomy.

Effect of surgical start time on short- and long-term outcomes after minimally invasive esophagectomy: a propensity-score matching analysis

There is growing focus on the relationship between surgical start time and postoperative outcomes. However, the extent to which the operation start time affects the surgical and oncological outcomes of patients undergoing esophagectomy has not previously been studied. The purpose of this retrospective study was to investigate the potential effect of surgical start time on the short- and long-term outcomes for patients who underwent thoracoscopic-laparoscopic McKeown esophagectomy. From September 2009 to June 2019, a total of 700 consecutive patients suffering from esophageal cancer underwent thoracoscopic-laparoscopic McKeown esophagectomy in the Department of Thoracic Surgery at Daping Hospital. Among these patients, 166 esophagectomies were performed on the same day and were classified as the first- or second-start group. Patients in the first-start group were more likely to be older than those in the second-start group: (64.73 vs. 61.28, P = 0.002). In addition, patients with diabetes mellitus were more likely to be first-start cases (8.4 vs. 1.2%). After propensity score matching (52 matched patients in first-start cases and 52 matched patients in second-start cases), these findings were no longer statistically significant. There was no difference in the incidence rate of peri- or postoperative adverse events between the first- and second-start groups. The disease-specific survival rates and disease-free survival rates were comparable between the two groups (P = 0.236 and 0.292, respectively). On the basis of the present results, a later start time does not negatively affect the short- or long-term outcomes of patients undergoing minimally invasive McKeown esophagectomy.

A model-based validation study of postoperative complications with considerations on operative timing

Background

Surgery is a highly technical procedure relying on high mental acuity and manual dexterity. The possibility that surgical outcomes and post-operative complications could be subject to influence by fatigue and/or circadian rhythms in surgeons has been investigated with inconsistent results.

Methods

We conducted a retrospective study to assess the significance of operative timing on classifying surgical complications using an interpretable machine learning approach. We trained various linear, generative as well as tree models on the surgical record data collected from a university-affiliated, tertiary teaching hospital in China by performing parameter tuning using grid search cross-validation for optimizing the F1 score.

Results

The results indicated that XGBoost was the best-performing model overall and its feature importance was shown to provide insight into possible timing-related associations with postoperative complications. We observed that the duration of surgery acted as the strongest indicator, and while surgery initiated at night (between 9 pm and 7 am) also ranked higher on the feature importance scale, it bore less significance than other factors such as the patient's age, gender, and type of surgery performed.

Conclusions

We showed that surgical records could be used to demonstrate that operative timing might affect the occurrence of postoperative complications, but only in a relatively mild way while potentially entangling with multiple factors.

Surgical Start Time Is Not Predictive of Microdiscectomy Outcomes

STUDY DESIGN

Retrospective analysis of clinical data from a single institution.

OBJECTIVE

The objective of this study was to assess the time of surgery as a possible predictor for outcomes, length of stay, and cost following microdiscectomy.

SUMMARY OF BACKGROUND DATA

The volume of microdiscectomy procedures has increased year over year, heightening interest in surgical outcomes. Previous investigations have demonstrated an association between time of procedures and clinical outcomes in various surgeries, however, no study has evaluated its influence on microdiscectomy.

METHODS

Demographic and outcome variables were collected from all patients that underwent a nonemergent microdiscectomy between 2008 and 2016. Patients were divided into 2 cohorts: those receiving surgery before 2 pm were assigned to the early group and those with procedures beginning after 2 pm were assigned to the late group. Outcomes and patient-level characteristics were compared using bivariate, multivariable logistic, and linear regression models. Adjusted length of stay and cost were coprimary outcomes. Secondary outcomes included operative complications, nonhome discharge, postoperative emergency department visits, or readmission rates.

RESULTS

Of the 1261 consecutive patients who met the inclusion criteria, 792 were assigned to the late group and 469 were assigned to the early group. There were no significant differences in demographics or baseline characteristics between the 2 cohorts. In the unadjusted analysis, mean length of stay was 1.80 (SD=1.82) days for the early group and 2.00 (SD=1.70) days for the late group (P=0.054). Mean direct cost for the early cohort was $5088 (SD=$4212) and $4986 (SD=$2988) for the late cohort (P=0.65). There was no difference in adjusted length of stay or direct cost. No statistically significant differences were found in operative complications, nonhome discharge, postoperative emergency department visits, or readmission rates between the 2 cohorts.

CONCLUSION

The study findings suggest that early compared with late surgery is not significantly predictive of surgical outcomes following microdiscectomy.

After-hours esophagectomy may pose additional risk to patients with esophageal cancer

Background

The increase in the incidence of esophageal cancers (ECs) combined with fewer surgeons working at large centers will increase the likelihood of surgery for ECs being performed during later hours. This study aimed to compare esophagectomies’ operative outcomes for EC performed at different surgical starting times.

Methods

This was a single-center, retrospective study. Risk-adjusted cumulative sum curve analysis and Cox regression analysis were used to identify the potential change-point of surgical starting times. The participants were then divided into 2 groups according to the change-point time. Propensity score matching was used to control confounding factors between the 2 groups. We compared the short- and long-term outcomes in both groups.

Results

A total of 702 patients who underwent potentially radical esophagectomy from 7 May 2014 to 31 December 2017 in our institute were included. The 3-year all-cause mortality showed a significant change-point at 16:42, with an increment from 56.5% to 76.9% (P=0.043). Esophagectomy that commenced between 17:00–18:59 was associated with significantly lower overall survival (OS) [multivariate hazard ratio (HR): 2.47; 95% confidence interval (CI): 1.25 to 4.90; P=0.010] and disease-free survival (DFS) (multivariate HR: 2.14; 95% CI: 1.08 to 4.21; P=0.028). The participants were allocated to the during-hours group and the after-hours group according to the change-point of 17:00. A total of 84 participants in the during-hours group were matched to 33 participants in the after-hours group. The median operative time was shorter in the after-hours group [309 (during-hours) vs. 239 (after-hours) minutes, P=0.014); the after-hours group had a greater incidence of respiratory complications (22.63% vs. 45.45%, P=0.023) and 90-day mortality (0 vs. 9.09%, P=0.021). The 5-year OS (P=0.042) and DFS (P=0.030) were significantly higher in the during-hours group.

Conclusions

Esophagectomies started during after-hours are correlated with poorer surgical outcomes. It is recommended to cancel selective esophagectomies due to commence after 17:00.

Impact of surgeon work duration prior to distal pancreatectomy on perioperative outcomes: a propensity score matching analysis

BACKGROUND

Surgeons are likely to get progressively fatigued during the course of a normal workday. The objective of this study was to evaluate the impact of surgeon work duration prior to performing distal pancreatectomy (DP) on the perioperative outcome, especially frequency of grade II or higher grade postoperative complications.

METHODS

Patients undergoing DP for all causes were divided into two groups according to surgeon work hours prior to performing DP: group A (less than 5 h) and group B (5-10 h). Propensity score matching (PSM) analysis (1:1) were performed to balance the baseline characteristics between the two groups. Intraoperative complications were compared between the two groups. Postoperative complications and their severity were followed up for 60 days and mortality for 90 days. The study was powdered to identify a 15% difference in the incidence of grade II or higher grade complications.

RESULTS

By using PSM analysis, the patients in group A (N = 202) and group B (N = 202) were well matched regarding demographics, comorbidities, operative technique, pancreatic texture and pathology. There was no significant difference in the incidence of grade II or higher grade complications between the two groups. There was no difference in clinically relevant postoperative pancreatic fistula, percutaneous drainage, readmission, reoperation, or morality. Group B was associated with a higher incidence of intraoperative organ injury, which could be managed successfully during the operation.

CONCLUSION

The retrospective study demonstrated that the surgeon work duration did not significantly affect the clinical outcome of DP.

Creating a model to predict time intervals from induction of labor to induction of anesthesia and delivery to coordinate workload

BACKGROUND

Induction of labor continues to become more common. We analyzed induction of labor and timing of obstetric and anesthesia work to create a model to predict the induction-anesthesia interval and the induction-delivery interval in order to co-ordinate workload to occur when staff are most available.

METHODS

Patients who underwent induction of labor at a single medical center were identified and multivariable linear regression was used to model anesthesia and delivery times. Data were collected on date of birth, race/ethnicity, body mass index, gestational age, gravidity, parity, indication for labor induction, number of prior deliveries, time of induction, induction agent, cervical dilation, effacement, and fetal station on admission, date and time of anesthesia administration, date and time of delivery, and delivery type.

RESULTS

A total of 1746 women met inclusion criteria. Associations which significantly influenced time from induction of labor to anesthesia and delivery included maternal age (anesthesia P <0.001, delivery P =0.002), body mass index (both P <0.001), prior vaginal delivery (both P <0.001), gestational age (anesthesia P <0.001, delivery P <0.018), simplified Bishop score (both P <0.001), and first induction agent (both P <0.001). Induction of labor of nulliparous women at 02:00 h and parous women at 04:00 or 05:00 h had the highest estimated probability of the mother having her first anesthesia encounter and delivering during optimally staffed hours when our institution's specialty personnel are most available.

CONCLUSIONS

Time to obstetric and anesthesia tasks can be estimated to optimize induction of labor start times, and shift anesthesia and delivery workload to hours when staff are most available.

Daytime versus after-hours surgery outcomes in hip fracture patients: a systematic review and meta-analysis

BACKGROUND

Several studies found that hip fracture patient outcome is greatly influenced by the time from admission to surgery. To avoid surgical delay, surgery for hip fracture may be performed at night or weekends. However, after-hours surgery may lead to a reduction in support staff and to surgeon fatigue, which ultimately increases mortality and complications. Therefore, we wanted to compare the outcomes of daytime and after-hours surgery in hip fracture patients.

METHODS

A literature search was performed in the Cochrane Library, and the Web of Science, PubMed, Embase, and Springer databases from inception to December 2019. Relevant studies comparing the results of operations performed at different time periods were included. The main clinical outcomes included total complications, mortality, blood loss, surgical time, and length of hospitalization. Data were pooled, and a meta-analysis was completed.

RESULTS

Nine retrospective cohort studies and one randomized controlled trial met the inclusion criteria; the studies included a total of 583,290 patients. We found no significant differences in mortality, surgical time or blood loss between daytime and after-hours surgery in hip fracture patients (P > 0.05). Of note, the patients who underwent after-hours surgery had fewer surgical complications (P < 0.001) and a shorter length of hospitalization (P = 0.021) than those who underwent daytime surgery.

CONCLUSION

After-hours surgery for hip fracture is safe. To avoid surgical delay, after-hours surgery is still a viable and even necessary option.

Effects of night surgery on postoperative mortality and morbidity: a multicentre cohort study

Background

Surgery at night (incision time 17:00 to 07:00 hours) may lead to increased postoperative mortality and morbidity. Mechanisms explaining this association remain unclear.

Methods

We conducted a multicentre retrospective cohort study of adult patients undergoing non-cardiac surgery with general anaesthesia at two major, competing tertiary care hospital networks. In primary analysis, we imputed missing data and determined whether exposure to night surgery affects 30-day mortality using a mixed-effects model with individual anaesthesia and surgical providers as random effects. Secondary outcomes were 30-day morbidity and the mediating effect of blood transfusion rates and provider handovers on the effect of night surgery on outcomes. We further tested for effect modification by surgical setting.

Results

Among 350 235 participants in the primary imputed cohort, the mortality rate was 0.9% (n=2804/322 327) after day and 3.4% (n=940/27 908) after night surgery. Night surgery was associated with an increased risk of mortality (ORadj 1.26, 95% CI 1.15 to 1.38, p<0.001). In secondary analyses, night surgery was associated with increased morbidity (ORadj 1.41, 95% CI 1.33 to 1.48, p<0.001). The proportion of patients receiving intraoperative blood transfusion and anaesthesia handovers were higher during night-time, mediating 9.4% (95% CI 4.7% to 14.2%, p<0.001) of the effect of night surgery on 30-day mortality and 8.4% (95% CI 6.7% to 10.1%, p<0.001) of its effect on morbidity. The primary association was modified by the surgical setting (p-for-interaction<0.001), towards a greater effect in patients undergoing ambulatory/same-day surgery (ORadj 1.81, 95% CI 1.39 to 2.35) compared with inpatients (ORadj 1.17, 95% CI 1.02 to 1.34).

Conclusions

Night surgery was associated with an increased risk of postoperative mortality and morbidity. The effect was independent of case acuity and was mediated by potentially preventable factors: higher blood transfusion rates and more frequent provider handovers.

Time of day does not influence outcomes in acute type A aortic dissection: Results from the IRAD

BACKGROUND

Type A acute aortic dissection (TAAAD) represents a surgical emergency requiring intervention regardless of time of day. Whether such a "evening effect" exists regarding outcomes for TAAAD has not been previously studied using a large registry data.

METHODS

Patients with TAAAD were identified from the International Registry of Acute Aortic Dissections (1996-2019). Outcomes were compared between patients undergoing operative repair during the daytime (D), defined as 8 am-5 pm, versus the evening (N), defined as 5 pm-8 am.

RESULTS

Four thousand one-hundrd and ninety-seven surgically treated patients with TAAAD were identified, with 1824 patients undergoing daytime surgery (43.5%) and 2373 patients undergoing evening surgery (56.5%). Daytime patients were more likely to have undergone prior cardiac surgery (13.2% vs. 9.5%; p < .001) and have had a prior aortic dissection (4.8% vs. 3.4%; p = .04). Evening patients were more likely to have been transferred from a referring hospital (70.8% vs. 75.0%; p = .003). Daytime patients were more likely to undergo aortic valve sparing root procedures (23.3% vs. 19.2%; p = .035); however, total arch replacement was performed with equal frequency (19.4% vs. 18.8%; p = .751). In-hospital mortality (D: 17.3% vs. N. 16.2%; p = .325) was similar between both groups. Subgroup analysis examining the effect of weekend presentation revealed no significant mortality difference.

CONCLUSIONS

A majority of TAAAD patients underwent surgical repair at night. There were higher rates of postoperative tamponade in evening patients; however, mortality was similar. The expertise of cardiac-dedicated operative and critical care teams regardless of time of day as well as training paradigms may explain similar mortality outcomes in this high risk population.

Later Surgical Start Time Is Associated With Longer Length of Stay and Higher Cost in Cervical Spine Surgery

STUDY DESIGN

Retrospective study of a surgical cohort from a single, large academic institution.

OBJECTIVE

The aim of this study was to investigate associations between surgical start time, length of stay, cost, perioperative outcomes, and readmission.

SUMMARY OF BACKGROUND DATA

One retrospective study with a smaller cohort investigated associations between surgical start time and outcomes in spine surgery and found that early start times were correlated with shorter length of stay. No examinations of perioperative outcomes or cost have been performed.

METHODS

All patients undergoing anterior cervical discectomy and fusion (ACDF) and posterior cervical decompression and fusion (PCDF) were queried from a single institution from January 1, 2008 to November 30, 2016. Patients undergoing surgery that started between 12:00 AM and 6:00 AM were excluded due to their likely emergent nature. Cases starting before and after 2:00 PM were compared on the basis of length of stay and cost as the primary outcomes using multivariable logistic regression.

RESULT

The patients undergoing ACDF and PCDF were both similar on the basis of comorbidity burden, preoperative diagnosis, and number of segments fused. The patients undergoing ACDF starting after 2 PM had longer LOS values (adjusted difference of 0.65 days; 95% confidence interval [CI]: 0.28-1.03; P = 0.0006) and higher costs of hospitalization (adjusted difference of $1177; 95% CI: $549-$1806; P = 0.0002). Patients undergoing PCDF starting after 2 PM also had longer LOS values (adjusted difference of 1.19 days; 95% CI: 0.46-1.91; P = 0.001) and higher costs of hospitalization (adjusted difference of $2305; 95% CI: $826-$3785; P = 0.002).

CONCLUSION

Later surgical start time is associated with longer LOS and higher cost. These findings should be further confirmed in the spine surgical literature to investigate surgical start time as a potential cost-saving measure.

LEVEL OF EVIDENCE

3.

Factors Affecting Outcomes in Acute Type A Aortic Dissection: A Systematic Review

Acute type A aortic dissection is a clinical emergency and is associated with significant morbidity and mortality rates if not managed promptly in specialised and high-volume centres. The mortality rate is increased by 1% for each hour delay in management; however, with advancement in clinical practice, diagnostic imaging and clinician awareness, this has been dramatically reduced to below 30% in most international centres. Not only timing of recognition of the pathology, but also other factors can significantly affect outcomes of such critical pathology. This includes, but is not limited to, age, extent of the pathology, existence of connective tissue disorders, hypertension, diabetes mellitus and surgeon experience. This narrative review will focus on current clinical practice and the evidence behind optimising each factor to minimise adverse outcomes in such high-risk cohort.

Operative timing is associated with increased morbidity and mortality in patients undergoing emergency general surgery: a multisite study of emergency general services in a single academic network

Background

Despite the widespread implementation of the acute care surgery (ACS) model, limited access to operating room time represents a barrier to the optimal delivery of emergency general surgery (EGS) care. The objective of this study was to describe the effect of operative timing on outcomes in EGS in a network of teaching hospitals.

Methods

We conducted a retrospective review of EGS operations performed at 3 teaching hospitals in a single academic network. Time of operation was categorized as daytime (8 am to 5 pm), after hours (5 pm to 11 pm) or overnight (11 pm to 8 am). Time to operation was calculated as the interval from admission to operative start time and categorized as less than 24 hours, 24-72 hours and greater than 72 hours.

Results

After we excluded nonindex cases, trauma cases and cases occurring more than 5 days after admission, 1505 EGS cases were included. We found that 39.0% of operations were performed in the daytime, 46.3% after hours and 14.8% overnight. In terms of time to operation, 52.3% of operations were performed within 24 hours of admission, 33.4% in 24-72 hours and 14.3% in more than 72 hours. The overall complication rate was 20.6% (310 patients) and the overall mortality rate was 3.8% (57 patients). After multivariable analysis, time to operation more than 72 hours after admission was independently associated with increased odds of morbidity (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.09-2.47), while overnight operating was associated with increased odds of death (OR 3.15, 95% CI 1.29-7.70).

Conclusion

Increasing time from admission to operation and overnight operating were associated with greater morbidity and mortality, respectively, for EGS patients. Strategies to provide timely access to the operating room should be considered to optimize care in an ACS model.

Impact of time of day on radiology image interpretations

AIM

To examine the impact of the time of day on radiologists' mammography reading performance.

MATERIALS AND METHODS

Retrospective mammographic reading assessment data were collected from the BreastScreen Reader Assessment Strategy database and included timestamps of the readings and reader-specific demographic data of 197 radiologists. The radiologists performed the readings in a workshop setting with test case sets enriched with malignancies (one-third of cases were malignant). The collected data were evaluated with an analysis of covariance to determine whether time of day influenced radiologists' specificity, lesion sensitivity or the jackknife alternative free-response receiver operating characteristic (JAFROC).

RESULTS

After adjusting for radiologist experience and fellowship, specificity varied significantly by time of day (p=0.027), but there was no evidence of any significant impact on lesion sensitivity (p=0.441) or JAFROC (p=0.120). The collected data demonstrated that specificity during the late morning (10.00-12.00) was 71.7%; this was significantly lower than in the early morning (08.00-10.00) and mid-afternoon (14.00-16.00), which were 82.74% (p=0.003) and 81.39% (p=0.031), respectively. Specificity during the late afternoon (16.00-18.00) was 73.95%; this was significantly lower than in the early morning (08.00-10.00) and mid-afternoon (14.00-16.00), which were 82.74% (p=0.003) and 81.39% (p=0.031), respectively.

CONCLUSION

The results indicated that the time of day may influence radiologists' performance, specifically their ability to identify normal images correctly.

The start of gastrectomy at different time-of-day influences postoperative outcomes

Gastric cancer (GC) continues to be 1 of the malignant tumors with high morbidity and mortality worldwide. Although the improvements in targeted inhibitor therapy have promoted survival, the first choice for GC patients is still surgery. However, prolonged surgery may tire surgeons and affect surgical outcomes.To detect whether different time-of-day radical gastrectomy influenced short-term and long-term surgical outcomes.This study included 117 patients between 2008 and 2012 who underwent a radical gastrectomy. These patients were grouped into the morning (before 13:00) and afternoon (after 13:00) groups or divided into 2 groups according to the median operation start time (before or after 11:23). Then, the relevant influence of the surgical start time was analyzed.The morning group (before 13:00) and the front median group (before 11:23) showed longer operative time (P = .008 and P = .016, respectively), lower estimated blood loss (P < .001 and P = .158, respectively), and longer time before resuming oral intake (P < .001 and P < .173, respectively) than the afternoon group (after 13:00) or latter median group (after 11:23). Starting the operation in the morning had no effect on the rate of postoperative complications. The operation start time had no significant influence on the overall survival of patients who underwent a radical gastrectomy. However, in subgroup analysis, patients who underwent a distal gastrectomy faced poor prognosis when their surgery started after 13:00 (P = .030).The results suggest that the operation start time might be an indicator of total operative time, estimated blood loss, and the time to resuming oral intake. The operation start time may also influence the prognosis of radical gastrectomy in patients with GC.

Late Surgical Start Time and the Effect on Rates of Complications in a Neurosurgical Population: A Prospective Longitudinal Analysis

OBJECTIVE

The after-hours effect on postoperative complications has been poorly studied in the neurosurgical literature. A recent retrospective analysis showed that patients with a surgical start time (SST) between 09:01 pm and 07:00 am had a greater risk of complications. This study used a prospective registry to examine the relationship between SST and postoperative complications in a large neurosurgical population.

METHODS

We performed a prospective longitudinal cohort analysis of all consecutive adult patients admitted to our neurosurgery service between October 1, 2018 and May 1, 2019. Complications were prospectively recorded and classified as surgical or medical. Univariate and multivariate logistic regressions were used to analyze these data.

RESULTS

Eighty-five surgical complications (6.6%) and 110 medical complications (8.6%) resulted from 1285 operations on 1145 patients. Later SST was predictive of complications in the emergent population (odds ratio [OR], 2.28; 95% confidence interval [CI], 1.01-5.15; P = 0.048) but not in the elective population. Extubation in the neurosurgical intensive care unit (NICU) versus the operating room strongly predicted medical complications (OR, 6.91; 95% CI, 3.33-14.34; P < 0.0001). Patients with a later SST were significantly more likely to be extubated in the NICU (P < 0.0001).

CONCLUSIONS

Patients undergoing emergent operations with a later SST were significantly more likely to have a postoperative complication. Patients who were extubated in the NICU versus the operating room were significantly more likely to have a medical complication. Patients were more likely to be extubated in the NICU if they had a later SST; therefore, SST may indirectly be associated with an increase in medical complications.