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Holland AM, Lorenz WR, Mead BS, Scarola GT, Augenstein VA, Kercher KW, Heniford BT. The Utilization of Laparoscopic Ventral Hernia Repair (LVHR) in Incarcerated and Strangulated Cases: A National Trend in Outcomes. Am Surg 2024:31348241241692. [PMID: 38557282 DOI: 10.1177/00031348241241692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Early after its adoption, minimally invasive surgery had limited usefulness in emergent cases. However, with improvements in equipment, techniques, and skills, laparoscopy in complex and emergency operations expanded substantially. This study aimed to examine the trend of laparoscopy in incarcerated or strangulated ventral hernia repair (VHR) over time. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for laparoscopic repair of incarcerated and strangulated hernias (LIS-VHR) and compared over 2 time periods, 2014-2016 and 2017-2019. RESULTS The utilization of laparoscopy in all incarcerated or strangulated VHR increased over time (2014-2016: 39.9% (n = 14 075) vs 2017-2019: 46.3% (n = 18 369), P < .001). Though likely not clinically significant, demographics and comorbidities statistically differed between groups (female: 51.7% vs 50.0%, P = .003; age 54.5 ± 13.7 vs 55.4 ± 13.8 years, P < .001; BMI 34.9 ± 8.0 vs 34.6 ± 7.8 kg/m2, P < .001). Patients from 2017 to 2019 were less comorbid (18.9% vs 16.8% smokers, P < .001; 18.2% vs 17.3% diabetic, P = .036; 4.6% vs 4.1% COPD, P = .021) but had higher ASA classification (III: 43.3% vs 45.7%; IV: 2.5% vs 2.7%, P < .001). Hernia types (primary, incisional, recurrent) were similar in each group. Operative time (89.7 ± 59.3 vs 97.4 ± 63.4 min, P < .001) became longer but length-of-stay (1.4 ± 3.3 vs 1.1 ± 2.6 days, P < .001) decreased. There was no statistical difference in surgical complications, medical complications, reoperation, or readmission rates between periods. CONCLUSION Laparoscopic VHR has become a routine method for treating incarcerated and strangulated hernias, and its utilization continues to increase over time. Clinical outcomes have remained the same while hospital stays have decreased.
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Affiliation(s)
- Alexis M Holland
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - William R Lorenz
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Brittany S Mead
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Gregory T Scarola
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Vedra A Augenstein
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - Kent W Kercher
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
| | - B Todd Heniford
- Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Atrium Health Carolinas Medical Center, Charlotte, NC, USA
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Ottaviano KE, Palange DC, Hill SS, Ata A, Chismark AD, Canete JJ, Valerian BT, Lee EC. Use of a 5-Item Modified Frailty Index for Assessing Outcomes After Hartmann's Reversal: An ACS-NSQIP Study. Am Surg 2024; 90:875-881. [PMID: 37978813 DOI: 10.1177/00031348231216483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
BACKGROUND Half of all patients with an end colostomy after sigmoid colectomy (Hartmann's procedure) never undergo Hartmann's reversal, frequently secondary to frailty. This retrospective cohort study evaluates the utility of a five-item modified frailty index (mFI-5) in predicting post-operative outcomes after Hartmann's reversal. METHODS The National Surgery Quality Improvement Program (NSQIP) database captured patients with elective Hartmann's reversals from 2011 to 2020. Clinical covariates were evaluated with univariate analysis and modified Poisson regression to determine association with overall morbidity, overall mortality, and extended length of stay (eLOS) when categorized by mFI-5 score. RESULTS 15,172 patients underwent elective Hartmann's reversal (91.6% open and 8.4% laparoscopic). Patients were grouped by mFI-5 score (0: 48.7%, 1: 38.2%, ≥ 2: 13.1%). Adjusted multivariable analysis showed frail patients (mFI-5≥2) had increased overall mortality (OR 2.23, 95% CI 1.21-4.11), morbidity (OR 1.23, 95% CI 1.12-1.35), and eLOS (OR 1.12, 95% 1.02-1.23). Among frail patients, a laparoscopic approach was associated with decreased overall morbidity (OR .64, 95% CI 0.56-.73) and decreased eLOS (OR .46, 95% CI 0.39-.54) when compared to open approach. DISCUSSION An mFI-5 of ≥2 was associated with greater morbidity, mortality, and eLOS following Hartmann's reversal. However, there were no mortality or eLOS differences in patients with an mFI-5 of 1 and only a 14% increase in any morbidity, making these patients potentially good candidates for Hartmann's reversal. Furthermore, laparoscopic surgery was associated with a protective effect for overall morbidity and eLOS, potentially mitigating some of the risk associated with higher frailty scores.
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Affiliation(s)
| | | | - Susanna S Hill
- University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Ashar Ata
- Albany Medical Center, Albany, NY, USA
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Khan M, Patnaik R, Lue M, Dao Campi H, Montorfano L, Sarmiento Cobos M, Valera RJ, Rosenthal RJ, Wexner SD. Modified Frailty Index Predicts Postoperative Complications Following Parastomal Hernia Repair. Am Surg 2024; 90:207-215. [PMID: 37632725 DOI: 10.1177/00031348231198102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/28/2023]
Abstract
BACKGROUND The 5-factor frailty index (5-mFI), validated frailty index with Spearmen rho correlation of .95 and C statistic >.7 for predicting postoperative complications, can be preoperatively used to stratify patients prior to parastomal hernia repairs. METHODS Retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database identified patients from 2015 to 2020. 5-mFI scores were calculated by adding one point for each comorbidity present: diabetes mellitus, congestive heart failure (CHF), hypertension requiring medication, severe chronic obstructive pulmonary disease (COPD), non-independent functional status. Primary endpoint was 30-day overall complications; secondary endpoints were 30-day readmission, reoperation, and discharge to care facility. RESULTS 2924 (52.2% female) patients underwent elective parastomal hernia repair. Univariate analysis showed 5-mFI > 2 had higher rates of overall (P = .008), pulmonary (P = .002), cardiovascular (P = .003)), hematologic (P = .003), and renal (P = .002) complications and higher rates of readmission (P = .009), reoperation (P = .001), discharge to care facility (P < .001), and death (P < .001). Multivariate analysis identified a 5-mFI of 2 or more as an independent risk factor for overall complications [OR: 1.40, 1.03-1.78; P = .032], pulmonary complications [2.97, 1.63-5.39; P < .001], hematological complications [1.60, 1.03-2.47; P = .035], renal complications [2.04, 1.19-3.46; P = .009], readmission [1.54, 1.19-1.99; P < .001], and discharge to facility [2.50, 1.66-3.77; P < .001]. Reoperation was not signification on multivariate analysis. CONCLUSIONS Parastomal hernia repair patients with 5-mFI score of >2 had higher risk of renal, cardiovascular, pulmonary, and hematologic complications, readmissions, longer hospitalization, discharge to care facility, and mortality, and can be useful during preoperative risk stratification.
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Affiliation(s)
- Mustafa Khan
- Department of General Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Ronit Patnaik
- Department of General Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Melinda Lue
- Department of General Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Haisar Dao Campi
- Department of General Surgery, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Lisandro Montorfano
- Department of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | | | - Roberto J Valera
- Department of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Raul J Rosenthal
- Department of Minimally Invasive Surgery, Cleveland Clinic Florida, Weston, FL, USA
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center, Cleveland Clinic Florida, Weston, FL, USA
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Mirzaie AA, Ueland WR, Lambert KA, Delgado AM, Rosen JW, Valdes CA, Scali ST, Huber TS, Upchurch GR, Shah SK. Appraising the Quality of Reporting of Vascular Surgery Studies That Use the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Database. Vasc Endovascular Surg 2024; 58:76-84. [PMID: 37452561 DOI: 10.1177/15385744231189771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVE The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) is an important data source for observational studies. While there are guides to ensure appropriate study reporting, there has been no evaluation of NSQIP studies in vascular surgery. We sought to evaluate the adherence of vascular-surgery related NSQIP studies to best reporting practices. METHODS In January 2022, we queried PubMed for all vascular surgery NSQIP studies. We used the REporting of studies Conducted using Observational Routinely-collected Health Data (RECORD) statement and the JAMA Surgery (JAMA-Surgery) checklist to assess reporting methodology. We also extracted the Journal Impact Factor (IF) of each article. RESULTS One hundred and fifty-nine studies published between 2002 and 2022 were identified and analyzed. The median score on the RECORD statement was 6 out of 8. The most commonly missed RECORD statement items were describing any validation of codes and providing data cleaning information. The median score on the JAMA-Surgery checklist was 2 out of 7. The most commonly missed JAMA-Surgery checklist items were identifying competing risks, using flow charts to help visualize study populations, having a solid research question and hypothesis, identifying confounders, and discussing the implications of missing data. We found no difference in the reporting methodology of studies published in high vs low IF journals. CONCLUSION Vascular surgery studies using NSQIP data demonstrate poor adherence to research reporting standards. Critical areas for improvement include identifying competing risks, including a solid research question and hypothesis, and describing any validation of codes. Journals should consider requiring authors use reporting guides to ensure their articles have stringent reporting methodology.
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Affiliation(s)
- Amin A Mirzaie
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | - Walker R Ueland
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Amanda M Delgado
- Office of Academic Affairs, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Jordan W Rosen
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | - Carlos A Valdes
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | - Thomas S Huber
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | - Gilbert R Upchurch
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL, USA
| | - Samir K Shah
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL, USA
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Kooragayala K, Lou J, Butchy V, Balakrishnan A, Sandilos G, Kwiatt M, Giugliano D, McClane S. Impact of Frailty on Patient Outcomes after Hartmann's Reversal: A NSQIP Analysis. Am Surg 2023; 89:5459-5465. [PMID: 36787880 DOI: 10.1177/00031348231156785] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND Colostomy reversal is a common procedure. Patients often have baseline comorbidities associated with postoperative morbidity. We utilized a modified frailty index (mFI-5) to predict postoperative complications. METHODS Patients who underwent elective, open Hartmann's reversal were queried from the National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified to low, medium, or high frailty groups. Statistical analysis was performed using chi-squared, ANOVA, and logistic regression. RESULTS There were 9272 patients with Hartmann's reversal. 48.78%, 30.31%, and 12.89% had low, moderate, or high frailty, respectively. High frailty was associated with cardiac arrest, myocardial infarction, reintubation, prolonged intubation, early reoperation, and mortality. After multivariate analysis, high frailty was associated with prolonged intubation (OR 3.147, P = .001), reintubation (OR 2.548, P = .002), and reoperation (OR 1.67, P < .001). CONCLUSIONS Frailty was associated with greater risk of postoperative complications in patients undergoing Hartmann's reversal. Frailty may be a useful adjunct to stratify for patients who are at risk for postoperative complications.
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Affiliation(s)
- Keshav Kooragayala
- Department of Surgery, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Johanna Lou
- Department of Surgery, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Virginia Butchy
- Department of Surgery, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Archana Balakrishnan
- Department of Palliative Medicine, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Georgianna Sandilos
- Department of Surgery, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Michael Kwiatt
- Department of Surgery, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Danica Giugliano
- Department of Surgery, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Steven McClane
- Department of Surgery, Cooper Medical School of Rowan University, Camden, NJ, USA
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Rich MD, Jungbauer WN, Schubert W. 30-Day Post-Operative Complications of Facial Fracture Repairs: A United States Database Study. Craniomaxillofac Trauma Reconstr 2023; 16:239-244. [PMID: 37975030 PMCID: PMC10638977 DOI: 10.1177/19433875221128535] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023] Open
Abstract
Study Design Cross-sectional database analysis. Objective To define post-operative complication rates in facial fracture repair and to assess this data for patient characteristics which may be associated with post-operative complications. Methods We performed a retrospective cohort analysis of the National Surgical Quality Improvement Program (NSQIP) database between January 1, 2015, and December 31, 2019. All patients included in this study sample must have (a) been ≥18 years old and (b) underwent surgical repair of a facial fracture during the study period by a plastic surgeon or otolaryngologist. Adverse outcomes at 30 days were characterized into four groups: superficial surgical site infection (SSI), deep SSI, organ space infection, and wound disruption. Results In total, 2481 patients met the primary outcome of facial fracture. Among the four fracture types assessed, 1090 fractures (43.9%) were mandibular, 721 were zygomatic (29.1%), 638 were orbital (25.7%), and 32 (1.3%) were Lefort. Of the entire cohort, 25 patients (1.01%) experienced a superficial SSI, 14 patients (.56%) presented with a deep SSI, 25 fractures (1.01%) returned with an organ space infection, and 23 patients (.93%) experienced some type of wound disruption. Smokers had a significantly higher risk of superficial SSIs (P < .05) and organ space infections (P < .05). Conclusions The majority of facial fracture patients do not experience post-operative complications. However, smokers and patients with diabetes mellitus were shown to be at an elevated risk of developing complications. Future research should further investigate this relationship and focus on developing interventions to improve post-operative outcomes.
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Affiliation(s)
- Matthew D. Rich
- Division of Plastic Surgery, University of Minnesota, Minneapolis, MN, USA
| | | | - Warren Schubert
- Division of Plastic Surgery, University of Minnesota, Minneapolis, MN, USA
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Abstract
Patients with class III obesity are often excluded from surgery in ambulatory surgery centers (ASCs). We hypothesize that class III obesity is not a risk factor for serious post-operative complications following outpatient operations. ACS-NSQIP database from 2012 to 2018 was queried. Patients undergoing outpatient inguinal hernia repair (IHR) and laparoscopic cholecystectomy (LC) were grouped by BMI. Baseline characteristics and 30-day outcomes were compared using univariate and multivariate analyses. Of these, 79,916 patients underwent IHR and 107,471 patients underwent LC. Multivariable analysis in IHR showed increased odds of superficial SSIs in all classes of obesity compared to normal weight (P < .0001). In the LC group, there were higher rates of SSIs with obesity (P < .0001). For both surgeries, a higher rate of readmissions to the hospital were observed in class II and IIIa obesity (both P < .0001), although rates were relatively low (<3%). Class III obesity demonstrates a statistically significant increase in SSI following IHR and LC. Severe complications requiring readmission are not mirrored, suggesting the morbidly obese patients should be considered for routine surgical procedures in outpatient settings.
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Affiliation(s)
- Mariana E Tumminello
- Department of Surgery, MedStar Georgetown Washington Hospital Center, Washington, DC, USA
| | - Matthew G Hogan
- Department of Surgery, LSU Health Sciences Center, New Orleans, LA, USA
| | - Claudia Leonardi
- Behavioral and Community Health Sciences, School of Public Health, LSU Health Sciences Center, New Orleans, LA, USA
| | - Jeffrey S Barton
- Surgery, Section of Colorectal Surgery, Kaiser Permanente Northwest, Clackamas, OR, USA
| | - Michael W Cook
- Department of Surgery, LSU Health Sciences Center, New Orleans, LA, USA
| | - Kurt G Davis
- Department of Surgery, LSU Health Sciences Center, New Orleans, LA, USA
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Findlay MC, Kim RB, Warner WS, Sherrod BA, Park S, Mazur MD, Mahan MA. Identification of an Operative Time Threshold for Substantially Increased Postoperative Complications Among Elderly Spine Surgery Patients. Global Spine J 2023:21925682221149390. [PMID: 36623932 DOI: 10.1177/21925682221149390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES To identify whether thresholds exist beyond which operative duration or age increases risks for complications among patients ≥65 years undergoing elective spine surgery. METHODS Elective inpatient spine procedures unrelated to infection/trauma/tumor diagnoses in patients <65 years recorded in the 2006-2019 American College of Surgeons National Surgical Quality Improvement database were identified. Univariate analyses was used to compare 30 day complication rates among 5 operative duration and age-stratified groups. To quantify the risk of prolonged operative duration on complications, multivariate analyses were performed controlling for confounders. A generalized linear model was used to assess the individual and combined effect strength of age and operative duration on complication rates. RESULTS Among 87,705 patients stratified by operative duration, 30 day complication rates rose nonlinearly as operative duration increased, with a sharp rise after 4.0-4.9 hours (28.3% at 4.0-4.9 hours, 51.7% at ≥5 hours, P < .001). Multivariate analysis found operative duration was independently associated with increased risk of overall complications (odds ratio 1.10→1.69, P < .001) and medical complications (odds ratio 1.19→1.98, P < .001). Although complication rates rose by age (all P < .001), age was not independently predictive of overall complications within any operative duration group on multivariate analysis. Operative duration had a greater effect (η2P = .067) than age (η2P = .003) on overall complication rates. CONCLUSIONS Increased operative duration was strongly associated with 30 day complication rates, particularly beyond a threshold of 5 hours. Furthermore, operative duration had a notably larger effect on overall complication rates than age.
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Affiliation(s)
- Matthew C Findlay
- School of Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - Robert B Kim
- Department of Neurosurgery, University of Utah Health, Salt Lake City, UT, USA
| | - Wesley S Warner
- Department of Neurosurgery, University of Utah Health, Salt Lake City, UT, USA
| | - Brandon A Sherrod
- Department of Neurosurgery, University of Utah Health, Salt Lake City, UT, USA
| | | | - Marcus D Mazur
- Department of Neurosurgery, University of Utah Health, Salt Lake City, UT, USA
| | - Mark A Mahan
- Department of Neurosurgery, University of Utah Health, Salt Lake City, UT, USA
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Hunsaker J, Khan M, Makarenko S, Evans J, Couldwell W, Karsy M. Prediction of Readmission and Complications After Pituitary Adenoma Resection via the National Surgical Quality Improvement Program (NSQIP) Database. Cureus 2021; 13:e14809. [PMID: 34123604 PMCID: PMC8191857 DOI: 10.7759/cureus.14809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2021] [Indexed: 02/07/2023] Open
Abstract
Introduction Pituitary adenomas are common intracranial tumors (incidence 4:100,000 people) with good surgical outcomes; however, a subset of patients show higher rates of perioperative morbidity. Our goal was to identify risk factors for postoperative complications or readmission after pituitary adenoma resection. Methods We undertook a retrospective cohort study of patients who underwent surgery for pituitary adenoma in 2006-2018 by using the National Surgical Quality Improvement Program database. The main outcome measures were patient complications and the 30-day readmission rate. Results Among the 2,292 patients (mean age 53.3±15.9 years), there were 491 complications in 188 patients (8.2%). Complications and 30-day readmission have remained stable over time rather than declined. Unplanned readmission was seen in 141 patients (6.2%). Multivariable analysis demonstrated that hypertension (OR=1.6; 95% CI= 1.1, 2.1; p=0.005) and high white blood cell count (OR=1.08; 95% CI=1.03, 1.1; p=0.0001) were independent predictors of complications. Return to the operating room (OR=5.9, 95% CI=1.7, 20.2, p=0.0005); complications (OR=4.1, 95% CI=1.6, 10.6, p=0.004); and blood urea nitrogen (OR=1.08, 95% CI=1.02, 1.2, p=0.02) were independent predictors of 30-day readmission. Conclusion Using one of the largest datasets of pituitary adenoma patients, we identified perioperative factors most critical for patient outcome. One strength of this study is adjusting for cofactors that predict outcomes, which has not been done previously. Several patient biomarkers, namely white blood cell count and blood urea nitrogen, may serve as preoperative markers that might identify patients at higher risk. Control of blood pressure and renal disease may be perioperative management strategies that can impact the outcome.
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Affiliation(s)
- Joshua Hunsaker
- Neurological Surgery, University of Utah, Salt Lake City, USA
| | - Majid Khan
- Medicine, Reno School of Medicine, University of Nevada, Reno, USA
| | - Serge Makarenko
- Neurological Surgery, University of Utah, Salt Lake City, USA
| | - James Evans
- Neurosurgery, Thomas Jefferson Medical College, Philadelphia, USA
| | | | - Michael Karsy
- Neurological Surgery, University of Utah, Salt Lake City, USA
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Abstract
The rate of postoperative morbidity and mortality after subdural hematoma (SDH) evacuation is high. The aim of this study was to compare mortality statistics from a high-volume database to historical figures and determine the most significant preoperative predictors of mortality and length of stay (LOS). The National Surgical Quality Improvement Program registry was searched (2005-2016) for patients with operatively treated SDHs, of which 2709 were identified for univariate analysis. After exclusion for missing data, 2010 individuals were analyzed with multivariable logistic regression. Primary outcome was 30-day mortality. The average patient age was 68.8 ± 14.9 years, and 64.1% were males. Upon multivariate analysis, nine variables were found to be associated with increased mortality: platelet count < 135,000 (OR 2.04, 95% CI 1.39-2.99), INR >1.2 (OR 1.87, 95% CI 1.34-2.6), bleeding disorder (OR 1.80, 95% CI 1.32-2.46), need for dialysis within two weeks preoperatively (OR 5.69, 95% CI 3.15-10.27), ventilator dependence in the 48 hours preceding surgery (OR 3.99, 95% CI 2.82-5.63), disseminated cancer (OR 2.95, 95% CI 1.34-6.47), WBC count >10,000 (OR 1.55, 95% CI 1.15-2.08), totally dependent functional status (OR 1.84, 95% CI 1.2-2.8), and each increasing year of age (OR 1.04, 95% CI 1.031-1.05). It is not surprising that chronic conditions and functional status were associated with increased mortality. However, specific laboratory abnormalities were also associated with increased mortality at levels generally considered within normal limits. More studies are needed to determine if correcting lab abnormalities preoperatively can improve outcomes in patients with intrinsic coagulopathy.
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Affiliation(s)
- Tyler Ball
- Neurological Surgery, University of Louisville School of Medicine, Louisville, USA
| | - Brent G Oxford
- Neurological Surgery, University of Louisville School of Medicine, Louisville, USA
| | - Ahmad Alhourani
- Neurological Surgery, University of Louisville School of Medicine, Louisville, USA
| | - Beatrice Ugiliweneza
- Neurological Surgery, University of Louisville School of Medicine, Louisville, USA
| | - Brian J Williams
- Neurological Surgery, University of Louisville School of Medicine, Louisville, USA
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Neary PM, Aiello AC, Stocchi L, Shawki S, Hull T, Steele SR, Delaney CP, Holubar SD. High-Risk Ileocolic Anastomoses for Crohn's Disease: When Is Diversion Indicated? J Crohns Colitis 2019; 13:856-863. [PMID: 31329836 DOI: 10.1093/ecco-jcc/jjz004] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Patients with Crohn's disease undergoing ileocolectomy and primary anastomosis are often at increased risk of anastomotic leak. We aimed to determine whether diverting ileostomy was protective against anastomotic leak after ileocolic resection for Crohn's disease using a large international registry. METHODS We analysed the National Surgical Quality Improvement Program Colectomy Module from 2012 to 2016. Multivariable logistic regression analysis and propensity-score matching were used to identify independent risk factors for leak, and to test the hypothesis that diverting ileostomy was protective against anastomotic leakage. RESULTS A total of 4172 [92%] patients underwent primary anastomosis, and 365 [8%] underwent anastomosis plus ileostomy. The leak rates in the two groups were 4.5% and 2.7%, [p = 0.12], respectively. Multivariate analysis indicated ileostomy omission, emergency surgery, smoking, inpatient status, wound classification 3 or 4, weight loss, steroid use, and prolonged operative time were independently associated with leak. Patients with 0-6 risk factors had leak rates of 1.6%, 2.7%, 4.3%, 6.7%, 8.8%, 11.5%, and 14.3% [p ≤ 0.001], respectively. Following propensity-score matching, ileostomy reduced the risk of leak rate by 55% [p = 0.005]. Patients with primary anastomosis who leaked most frequently required reoperation [57.8%], but anastomosis plus ileostomy patients who leaked most frequently were managed by percutaneous drainage [70%], p = 0.04. CONCLUSIONS After ileocolic resection for Crohn's disease, anastomotic leak may be predicted by simple addition of risk factors. We found that diverting ileostomy mitigated against leak, reducing both the leak rate and the likelihood of unplanned reoperations. Faecal diversion should be considered when ≥3 risk factors are present.
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Affiliation(s)
- Peter M Neary
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Academic Surgery, University Hospital Waterford.,University College Cork, Ireland
| | | | - Luca Stocchi
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sherief Shawki
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tracy Hull
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Scott R Steele
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Conor P Delaney
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Bernstein DN, Keswani A, Ring D. Perioperative Risk Adjustment for Total Shoulder Arthroplasty: Are Simple Clinically Driven Models Sufficient? Clin Orthop Relat Res 2017; 475:2867-74. [PMID: 27905060 DOI: 10.1007/s11999-016-5147-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is growing interest in value-based health care in the United States. Statistical analysis of large databases can inform us of the factors associated with and the probability of adverse events and unplanned readmissions that diminish quality and add expense. For example, increased operating time and high blood urea nitrogen (BUN) are associated with adverse events, whereas patients on antihypertensive medications were more likely to have an unplanned readmission. Many surgeons rely on their knowledge and intuition when assessing the risk of a procedure. Comparing clinically driven with statistically derived risk models of total shoulder arthroplasty (TSA) offers insight into potential gaps between common practice and evidence-based medicine. QUESTIONS/PURPOSES (1) Does a statistically driven model better explain the variation in unplanned readmission within 30 days of discharge when compared with an a priori five-variable model selected based on expert orthopaedic surgeon opinion? (2) Does a statistically driven model better explain the variation in adverse events within 30 days of discharge when compared with an a priori five-variable model selected based on expert orthopaedic surgeon opinion? METHODS Current Procedural Terminology codes were used to identify 4030 individuals older than 17 years of age who had TSA in which osteoarthritis was the primary etiology. A logistic regression model for adverse event and unplanned readmission within 30 days was constructed using (1) five variables chosen a priori based on clinic expertise (age, American Society of Anesthesiologists classification ≥ 3, body mass index, smoking status, and diabetes mellitus); and (2) by entering all variables with p < 0.10 in bivariate analysis. We then excluded 870 patients (22%) based on preoperative factors felt to make large discretionary surgery unwise to focus our research on appropriate procedures. Infirm patients have more pressing needs than alleviation of shoulder pain and stiffness. Among the remaining 3160 patients, logistic regression models for adverse event and unplanned readmission within 30 days were constructed in a similar manner to the complete models. The five a priori risk factors used in each model based on clinical expertise were selected by consensus of an expert orthopaedic surgeon panel. RESULTS When patients unfit for discretionary surgery were excluded, the clinically driven model found no risk factors and accounted for 1.4% of the variation in unplanned readmission. In contrast, the statistically driven model explained 4.6% of the variation and found operating time (hours) (odds ratio [OR], 1.26; 95% confidence interval [CI], 1.04-1.53) and hypertension requiring medications (OR, 1.95; 95% CI, 1.01-3.76) were associated with unplanned readmission accounting for all other factors. However, neither the clinically driven model (pseudo R2, 1.4%) nor statistically driven model (pseudo R2, 4.6%) provided much explanatory power. When patients unfit for discretionary surgery were excluded, no factors in the clinically driven model were significant and the model accounted for 0.95% of the variation in adverse events. In the statistically driven model, age (OR, 1.03; 95% CI, 1.01-1.06), men (OR, 1.64; 95% CI, 1.05-2.57), operating time (hours) (OR, 1.27; 95% CI, 1.07-1.52), and high BUN (OR, 3.12; 95% CI, 1.35-7.21) were associated with adverse events when accounting for all other factors, explaining 3.3% of the variation. However, neither the clinically driven model (pseudo R2, 0.95%) nor the statistically driven model (pseudo R2, 3.3%) provided much explanatory power. CONCLUSIONS The observation that a statistically derived risk model performs better than a clinically driven model affirms the value of research based on large databases, although the models derived need to be tested prospectively. CLINICAL RELEVANCE Clinicians can utilize our results to understand that clinician intuition may not always offer the best risk adjustment and that factors impacting TSA unplanned readmission and adverse events may be best derived from large data sets. However, because current analyses explain limited variation in outcomes, future studies might look to better define what factors drive the variation in unplanned readmission and adverse events.
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Baker D, Sherrod B, McGwin G Jr, Ponce B, Gilbert S. Complications and 30-day Outcomes Associated With Venous Thromboembolism in the Pediatric Orthopaedic Surgical Population. J Am Acad Orthop Surg 2016; 24:196-206. [PMID: 26855119 DOI: 10.5435/JAAOS-D-15-00481] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The risk of morbidity associated with venous thromboembolism (VTE) after pediatric orthopaedic surgery remains unclear despite increased use of thromboprophylaxis measures. METHODS The American College of Surgeons National Surgical Quality Improvement Program, Pediatric database was queried for patients undergoing an orthopaedic surgical procedure between 2012 and 2013. Upper extremity and skin/subcutaneous surgeries were excluded. Associations between VTE and procedure, demographics, comorbidities, preoperative laboratory values, and 30-day postoperative outcomes were evaluated. RESULTS Of 14,776 cases, 15 patients (0.10%) experienced postoperative VTE. Deep vein thrombosis (DVT) occurred in 13 patients (0.09%), and pulmonary embolism developed in 2 patients (0.01%). The procedure with the highest VTE rate was surgery for infection (1.2%). Patient factors associated with the development of VTE included hyponatremia (P = 0.003), abnormal partial thromboplastin time (P = 0.046), elevated aspartate transaminase level (P = 0.004), and gastrointestinal (P = 0.011), renal (P = 0.016), and hematologic (P = 0.019) disorders. Nearly half (46.2%) of DVTs occurred postdischarge. Complications associated with VTE included prolonged hospitalization (P < 0.001), pneumonia (P < 0.001), unplanned intubation (P = 0.003), urinary tract infection (P = 0.003), and central line-associated bloodstream infection (P < 0.001). Most of the postoperative complications (66.7%) occurred before VTE diagnosis, and no patients with VTE died. CONCLUSION In the absence of specified risk factors, thromboprophylaxis may be unnecessary for this population.
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Murphy M, Gilder H, McCutcheon BA, Kerezoudis P, Rinaldo L, Shepherd D, Maloney P, Snyder K, Carlson ML, Carter BS, Bydon M, Van Gompel JJ, Link MJ. Increased Operative Time for Benign Cranial Nerve Tumor Resection Correlates with Increased Morbidity Postoperatively. J Neurol Surg B Skull Base 2016; 77:350-7. [PMID: 27441161 DOI: 10.1055/s-0036-1572508] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 01/09/2016] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVES Operative time, previously identified as a risk factor for postoperative morbidity, is examined in patients undergoing benign cranial nerve tumor resection. DESIGN/SETTING/PARTICIPANTS This retrospective cohort analysis included patients enrolled in the ACS-NSQIP registry from 2007 through 2013 with a diagnosis of a benign cranial nerve neoplasm. MAIN OUTCOME MEASURES Primary outcomes included postoperative morbidity and mortality. Readmission and reoperation served as secondary outcomes. RESULTS A total of 565 patients were identified. Mean (median) operative time was 398 (370) minutes. The 30-day complication, readmission, and return to the operating room rates were 9.9%, 9.9%, and 7.3%, respectively, on unadjusted analyses. CSF leak requiring reoperation or readmission occurred at a rate of 3.1%. On multivariable regression analysis, operations greater than 413 minutes were associated with an increased odds of overall complication (OR 4.26, 95% CI 2.08-8.72), return to the operating room (OR 2.65, 95% CI 1.23-5.67), and increased length of stay(1.6 days, 95% CI 0.94-2.23 days). Each additional minute of operative time was associated with an increased odds of overall complication (OR 1.004, 95% CI 1.002-1.006) and increased length of stay (0.006 days, 95% CI 0.004-0.008). CONCLUSION Increased operative time in patients undergoing surgical resection of a benign cranial nerve neoplasm was associated with an increased rate of complications.
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Affiliation(s)
- Meghan Murphy
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Hannah Gilder
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Brandon A McCutcheon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | | | - Lorenzo Rinaldo
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Daniel Shepherd
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Patrick Maloney
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Kendall Snyder
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Matthew L Carlson
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota, United States
| | - Bob S Carter
- Department of Neurologic Surgery University of California, San Diego, United States
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Jamie J Van Gompel
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael J Link
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States
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