The impact of gender, race, and ethnicity on bariatric surgery outcomes

BACKGROUND

The rates of postoperative complications can vary among specific patient populations.

OBJECTIVES

The aim of this study is to examine how gender, race, and ethnicity can affect short-term postoperative complications in bariatric surgery patients.

SETTING

United States.

METHODS

Patients who underwent bariatric surgery between the years 2016 and 2021 were included and stratified based on gender, race/ethnicity, and procedure type. The 30-day outcomes were assessed using Clavien-Dindo (CD) classification of III-V. Wilcoxon rank-sum test was performed to compare continuous variables among groups and Chi-squared test for categorical variables. Logistic regression was performed to examine the effects of gender, race/ethnicity on CD classification ≥ III complications by the procedure type.

RESULTS

A total of 975,642 bariatric surgery patients were included. Descriptive univariate analysis showed that CD ≥ III complications were higher among non-Hispanic blacks (NHB) and lowest in Hispanic patients, regardless of their gender, except in the duodenal switch DS group, where non-Hispanic whites (NHW) had the lowest complication rate. There was no difference between male and female patients with regards to postoperative complications, except in the sleeve gastrectomy (SG) group, where NHW males had more complications than NHW females. Sleeve gastrectomy showed the lowest complication rates followed by gastric bypass and DS in all groups. In multivariate logistic regression model, for both females and males NHBs had higher odds of postoperative complications compared to NHWs in sleeve gastrectomy (Female aOR:1.31, 95% CI: [1.23-1.40]; Male aOR:1.24, 95% CI: [1.08-1.43], P < .001) and gastric bypass (Female aOR:1.24, 95% CI: [1.16-1.33]; Male aOR:1.25, 95% CI: [1.06-1.48], P < .01).

CONCLUSIONS

Non-Hispanic Black patients are at a higher rate of developing CD ≥ III complications compared to non-Hispanic Whites after bariatric surgery. The male gender was not a significant risk factor for serious postoperative complications. Among the different types of bariatric procedures, sleeve gastrectomy has the lowest rates of severe complications, followed by gastric bypass and duodenal switch. These results highlight the significance of considering gender, race, ethnicity, and procedure type during preoperative evaluation, surgical planning, and postoperative care.

Development of ethnicity-adjusted global alignment and proportion score to predict the risk of mechanical complications following corrective surgery for adult spinal deformity

BACKGROUND CONTEXT

Surgery for degenerative scoliosis (DS) is a complex procedure with high complication and revision rates. Based on the concept that pelvic incidence (PI) is a constant parameter, the global alignment and proportional (GAP) score was developed from sagittal alignment data collected in the Caucasian populations to predict mechanical complications. However, the PI varies among different ethnic groups, and the GAP score may not apply to Chinese populations. Thus, this study aims to assess the predictability of the GAP score for mechanical complications in the Chinese populations and develop an ethnicity-adjusted GAP score.

PURPOSE

To test the predictability of the original GAP score in the Chinese population and develop a Chinese ethnicity-tailored GAP scoring system.

STUDY DESIGN/SETTINGS

Retrospective cohort study.

PATIENT SAMPLE

A total of 560 asymptomatic healthy volunteers were enrolled to develop Chinese ethnicity-tailored GAP (C-GAP) score and a total of 114 DS patients were enrolled to test the predictability of original GAP score and C-GAP score.

OUTCOME MEASURES

Demographic information, sagittal spinopelvic parameters of healthy volunteers and DS patients were collected. Mechanical complications were recorded at a minimum of 2-year follow-up after corrective surgery for DS patients.

METHODS

A total of 560 asymptomatic healthy volunteers with a mean age of 61.9±14.1 years were enrolled to develop ethnicity-adjusted GAP score. Besides, 114 surgically trated DS patients (M/F=10/104) with a mean age of 60.7±7.1 years were retrospectively reviewed. Demographic data and radiological parameters of both groups, including PI, lumbar lordosis (LL), sacral slope (SS), the sagittal vertical axis (SVA), and global tilt (GT) were collected. Ideal LL, SS, and GT were obtained by calculating their correlation with PI of healthy volunteers using linear regression analysis. Relative pelvic version (RPV), relative lumbar lordosis (RLL), lordosis distribution index (LDI), and relative spinopelvic alignment (RSA) were obtained using the ideal parameters, and the Chinese population adjusted GAP score (C-GAP) was developed based on these values. The predictability of original and C-GAP for mechanical failure was evaluated using clinical and radiological data of DS patients by evaluating the area under the curve (AUC) using receiver operating characteristic curve. This study was supported the National Natural Science Foundation of China (NSFC) (No. 82272545), ($ 8,000-10,000) and the Jiangsu Provincial Key Medical Center, and the China Postdoctoral Science Foundation (2021M701677), Level B ($ 5,000-7,000).

RESULTS

Ideal SS=0.53×PI+9 (p=.002), ideal LL=0.48×PI+22 (p=.023) and ideal GT=0.46 × PI-9 (p=.011). were obtained by correlation analysis using sagittal parameters from those healthy volunteers, and RPV, RLL, RSA, and LDI were calculated accordingly. Then, the ethnicity-adjusted C-GAP score was developed by summing up the numeric value of calculated RPV, RLL, RSA, and LDI. The AUC was classified as ''no or low discriminatory power'' for the original GAP score in predicting mechanical complications (AUC=0.592, p=.078). Similarly, the original GAP score did not correlate with mechanical complications in DS patients. According to the C-GAP score, the sagittal parameters were proportional in 25 (21.9%) cases, moderately disproportional in 68 (59.6%), and severely disproportional in 21% (18.5%) cases. The incidence of mechanical complications was statistically different among proportioned and moderately disproportional and severely disproportional portions of the C-GAP score (p=.03). The predictability of the C-GAP score is high with an AUC=0.773 (p<.001). In addition, there is a linear correlation between mechanical complication rate and C-GAP score (χ=0.102, p=.02).

CONCLUSION

The Ethnicity-adjusted C-GAP score system developed in the current study provided a more accurate and reliable for predicting the risk of mechanical complications after corrective surgery for adult spinal deformity.

Are There Racial and Ethnic Disparities in Management and Outcomes of Surgically Treated Distal Radius Fractures?

BACKGROUND

Racial/ethnic disparities have been demonstrated across multiple orthopedic sub-specialties. There is a paucity of literature examining disparities in distal radius fracture (DRF) management.

METHODS

Using the National Surgical Quality Improvement Program database, we analyzed 15 559 non-Hispanic (NH) White, NH Black, NH Asian, and Hispanic adults who underwent open reduction and internal fixation for DRF from 2013 to 2019. We evaluated time from hospital admission to surgery and length of stay using Poisson regression. Deep venous thrombosis, pulmonary embolism (PE), and wound complications were reported using descriptive statistics. Thirty-day reoperation and readmission were analyzed using binary logistic regression.

RESULTS

Wait time to surgery was longer for Hispanic patients than NH White patients (incidence rate ratio [IRR]: 2.54, P < .001); this narrowed over time (IRR: 0.944, P = .047). Length of stay was longer for NH Black (IRR: 1.78, P < .001) and Hispanic patients (IRR: 1.83, P < .001), but shorter for NH Asian (IRR: 0.715, P = .019) than NH White patients; this temporally narrowed for NH Black patients (IRR: 0.908, P = .001). Deep venous thrombosis, PE, and wound complications occurred at a rate less than 0.30% across all groups. Hispanic patients were less likely to undergo reoperation than NH White patients (odds ratio [OR]: 0.254, P = .003). While there was no difference in readmission between groups in the aggregated study period, NH Black patients experienced a temporal increase in readmissions relative to NH White patients (OR: 1.40, P = .038).

CONCLUSIONS

Racial and ethnic disparities exist in DRF management. Further investigation on causes for and solutions to combat these disparities in DRF care may help improve the inequities observed.

Race Associated With Increased Complication Rates After Total Knee Arthroplasty

BACKGROUND

Racial and ethnic disparities have been suggested to be associated with poor outcomes after total knee arthroplasty (TKA). While socioeconomic disadvantage has been studied, analyses of race as the primary variable are lacking. Therefore, we examined the potential differences between Black and White TKA recipients. Specifically, we assessed 30-day and 90-day, as well as 1 year: (1) emergency department visits and readmissions; (2) total complications; (3) as well as risk factors for total complications.

METHODS

A consecutive series of 1,641 primary TKAs from January 2015 to December 2021 at a tertiary health care system were reviewed. Patients were stratified according to race, Black (n = 1,003) and White (n = 638). Outcomes of interest were analyzed using bivariate Chi-square and multivariate regressions. Demographic variables such as sex, American Society of Anesthesiologists classification, diabetes, congestive heart failure, chronic pulmonary disease, and socioeconomic status based on Area Deprivation Index were controlled for across all patients.

RESULTS

The unadjusted analyses found that Black patients had an increased likelihood of 30-day emergency department visits and readmissions (P < .001). However, in the adjusted analyses, Black race was demonstrated to be a risk factor for increased total complications at all-time points (P ≤ .0279). Area Deprivation Index was not a risk for cumulative complications at these time points (P ≥ .2455).

CONCLUSION

Black patients undergoing TKA may be at increased risk for complications with more risk factors including higher body mass index, tobacco use, substance abuse, chronic obstructive pulmonary disease, congestive heart failure, hypertension, chronic kidney disease, and diabetes and were thus, "sicker" initially than the White cohort. Surgeons are often treating these patients at the later stages of their diseases when risk factors are less modifiable, which necessitates a shift to early, preventable public health measures. While higher socioeconomic disadvantage has been associated with higher rates of complications, the results of this study suggest that race may play a greater role than previously thought.

The Impact of Race on Perioperative and Patient-Reported Outcomes following Autologous Breast Reconstruction

BACKGROUND

Racial disparities are evident in multiple aspects of the perioperative care of breast cancer patients, but data examining whether such differences translate to clinical and patient-reported outcomes are limited. This study examined the impact of race on perioperative outcomes in autologous breast reconstruction.

METHODS

A retrospective cohort study including all breast cancer patients who underwent immediate autologous breast reconstruction at a single institution from 2010 to 2017 was conducted. Self-reported race was used to classify patients into three groups: white, African American, and other. The primary and secondary endpoints were occurrence of any major complications within 30 days of surgery and patient-reported outcomes (measured with the BREAST-Q), respectively. Regression models were constructed to identify factors associated with the outcomes.

RESULTS

Overall, 404 patients, including 259 white (64 percent), 63 African American (16 percent), and 82 patients from other minority groups (20 percent), were included. African American patients had a significantly higher proportion of preoperative comorbidities. Postoperatively, African American patients had a higher incidence of 30-day major complications (p = 0.004) and were more likely to return to the operating room (p = 0.006). Univariable analyses examining complications demonstrated that race was the only factor associated with 30-day major complications (p = 0.001). Patient-reported outcomes were not statistically different at each time point through 3 years postoperatively.

CONCLUSIONS

African American patients continue to present with increased comorbidities and may be more likely to experience major complications following immediate autologous breast reconstruction. However, patient-reported satisfaction or physical well-being outcomes may not differ between groups.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Racial and ethnic differences in reconstructive surgery for apical vaginal prolapse

BACKGROUND

There is limited literature identifying racial and ethnic health disparities among surgical modalities and outcomes in the field of urogynecology and specifically pelvic organ prolapse surgery.

OBJECTIVE

This study aimed to evaluate the differences in surgical approach for apical vaginal prolapse and postoperative complications by race and ethnicity.

STUDY DESIGN

This is a retrospective cohort study of women undergoing surgical repair for apical vaginal prolapse between 2014 and 2017 using data from the American College of Surgeons National Surgical Quality Improvement Program. Patients were eligible for inclusion if they underwent either vaginal colpopexy or abdominal sacrocolpopexy. Abdominal sacrocolpopexy cases were further divided into those performed by laparotomy and those performed by laparoscopy. Multivariable logistic regression models that controlled for age, comorbidities, American Society of Anesthesiologists physical status classification, and concurrent surgery were used to determine whether race and ethnicity are associated with the type of colpopexy (vaginal vs abdominal) or the surgical route of abdominal sacrocolpopexy. Similar models that also controlled for surgical approach were used to assess 30-day complications by race and ethnicity.

RESULTS

A total of 22,861 eligible surgical cases were identified, of which 12,337 (54%) were vaginal colpopexy and 10,524 (46%) were abdominal sacrocolpopexy. Among patients who had an abdominal sacrocolpopexy, 2262 (21%) were performed via laparotomy and 8262 (79%) via laparoscopy. The study population was 70% White, 9% Latina, 6% African American, 3% Asian, 0.6% Native Hawaiian or Pacific Islander, 0.4% American Indian or Alaska Native, and 11% unknown. In multivariable analysis, Asian and Native Hawaiian or Pacific Islander women were less likely to undergo abdominal sacrocolpopexy compared with White women (odds ratio, 0.82; 95% confidence interval, 0.68-0.99, and odds ratio, 0.56; 95% confidence interval, 0.39-0.82, respectively). Among women who underwent an abdominal sacrocolpopexy, Latina women and Native Hawaiian or Pacific Islander women were less likely to undergo a laparoscopic approach compared with White women (odds ratio, 0.68; 95% confidence interval, 0.58-0.79, and odds ratio, 0.31; 95% confidence interval, 0.1-0.56, respectively). Complication rates also differed by race and ethnicity. After a colpopexy, African American women were more likely to need a blood transfusion (odds ratio, 3.04; 95% confidence interval, 1.95-4.73; P≤.001) and have a deep vein thrombosis or pulmonary embolus (odds ratio, 2.46; 95% confidence interval, 1.10-5.48; P=.028), but less likely to present with postoperative urinary tract infections (odds ratio, 0.68; 95% confidence interval, 0.49-0.96; P=.028) than White women in multivariable regression models. Using the Clavien-Dindo classification system, Latina women had higher odds of developing grade II complications than White women in multivariable models (odds ratio, 1.25; 95% confidence interval, 1.04-1.51; P=.02).

CONCLUSION

There are racial and ethnic differences in the type and route of surgical repair for apical vaginal prolapse. In particular, Latina and Pacific Islander women were less likely to undergo a laparoscopic approach to abdominal sacrocolpopexy compared with White women. Although complications were uncommon, there were several complications including blood transfusions that were higher among African American and Latina women. Additional studies are needed to better understand and describe associated factors for these differences in care and surgical outcomes.

Incidence, Determinants and Mortality of Heart Failure Associated With Medical-Surgical Procedures in Patients ≥ 65 Years of Age (from the Cardiovascular Health Study)

Heart failure (HF) and myocardial infarction are serious complications of major noncardiac surgery in older adults. Many factors can contribute to the development of HF during the postoperative period. The incidence of, and risk factors for, procedure-associated heart failure (PHF) occurring at the time of, or shortly after, medical procedures in a population-based sample ≥ 65 years of age have not been fully characterized, particularly in comparison with HF not proximate to medical procedures. This analysis comprises 5,121 men and women free of HF at baseline from the Cardiovascular Health Study who were followed up for 12.0 years (median). HF events were documented by self-report at semi-annual contacts and confirmed by a formal adjudication committee using a review of the participants' medical records and standardized criteria for HF. Incident HF events were additionally adjudicated as either being related or unrelated to a medical procedure (PHF and non-PHF, respectively). We estimated cause-specific hazards ratios for the association of covariates with PHF and non-PHF. There were 1,728 incident HF events in the primary analysis: 168 (10%) classified as PHF, 1,526 (88%) as non-PHF, and 34 unclassified (2%). For those 1,045 participants in whom LV ejection fraction was known at the time of the HF event, it was ≥45% in 89 of 118 participants (75%) with PHF, compared to 517 of 927 participants (55%) with non-PHF (p < 0.001). Increased age, male gender, diabetes, and angina at baseline were associated with both PHF and non-PHF (range of hazard ratios (HR): 1.04-2.05]. Being Black was inversely associated with PHF [HR: 0.46, 95% confidence interval: 0.25-0.86]. Participants with increased age, without baseline angina, and with baseline LVEF<55% were at a significantly lower risk for PHF compared to non-PHF. Among those with PHF, surgical procedures-including cardiac, orthopedic, gastrointestinal, vascular, and urologic-comprised 83.3%, while percutaneous procedures comprised 8.9% (including 6.5% represented by cardiac catheterizations and pacemaker placements). Another group composed of a variety of procedures commonly requiring large fluid volume administration comprised 7.7%. There was a lower all-cause 30-day mortality in the PHF versus the non-PHF group (2.2% vs 5.7%), with a nonsignificant odds ratio of 0.39 in a minimally adjusted model. When individuals with prior myocardial infarction (MI) were excluded in a sensitivity analysis, the proportion of incident HF with concurrent MI was greater for PHF (32.9%) than for non-PHF (19.8%). In conclusion, PHF in older adults is a common entity with relatively low 30-day mortality. Baseline angina, lower age, and LVEF ≥ 55% were associated with a higher risk of PHF compared to non-PHF. Being Black was associated with a lower risk of PHF and PHF as a proportion of HF was lower in Black than in non-Black participants. Compared to non-PHF, PHF more frequently presented with concurrent MI and with preserved LV ejection fraction.

Risk of adverse events due to high volumes of local anesthesia during Mohs micrographic surgery

General guidelines for the maximum amounts of locally injected lidocaine exist; however, there is a paucity of data in the Mohs micrographic surgery (MMS) literature. This study aimed to determine the safety and adverse effects seen in patients that receive larger amounts of locally injected lidocaine. A retrospective chart review of 563 patients from 1992 to 2016 who received over 30 mL of locally injected lidocaine was conducted. Patient records were reviewed within seven postoperative days for complications. The average amount of anesthesia received was 40 mL, and the average patient weight was 86.69 kg. 1.4% of patients had a complication on the day of surgery, and 4.4% of patients had a complication within 7 days of the surgery. The most common complications were excessive bleeding/hematoma formation and wound infection. Only two complications could be attributable to local anesthetics. Gender, heart disease, hypertension, diabetes, and smoking were not significant risk factors for the development of complications. MMS is a safe outpatient procedure for patients that require over 30 mL of locally injected anesthesia. The safety of high volumes of lidocaine extends to patients with risk factors such as heart disease, hypertension, diabetes, and smoking.

Risk of complication at the time of laparoscopic hysterectomy: a prediction model built from the National Surgical Quality Improvement Program database

BACKGROUND

Although laparoscopic hysterectomy is well established as a favorable mode of hysterectomy owing to decreased perioperative complications, there is still room for improvement in quality of care. Previous studies have described laparoscopic hysterectomy risk, but there is currently no tool for predicting risk of complication at the time of laparoscopic hysterectomy.

OBJECTIVE

This study aimed to create a prediction model for complications at the time of laparoscopic hysterectomy for benign conditions.

STUDY DESIGN

This is a retrospective cohort study that included patients who underwent laparoscopic hysterectomy for benign indications between 2014 and 2017 in US hospitals contributing to the American College of Surgeons - National Surgical Quality Improvement Program database. Data about patient baseline characteristics, perioperative complications (intraoperative complications, readmission, reoperation, need for transfusion, operative time greater than 4 hours, or postoperative medical complication), and uterine weight at the time of pathologic examination were collected retrospectively. Postoperative uterine weight was used as a proxy for preoperative uterine weight estimate. The sample was randomly divided into 2 patient populations, one for deriving the model and the other to validate the model.

RESULTS

A total of 33,123 women met the inclusion criteria. The rate of composite complication was 14.1%. Complication rates were similar in the derivation and validation cohorts (14.1% [2306 of 14,051] vs 13.9% [2289 of 14,107], P=.7207). The logistic regression risk prediction tool for hysterectomy complication identified 7 variables predictive of complication: history of laparotomy (21% increased odds of complication), age (2% increased odds of complication per year of life), body mass index (0.2% increased odds of complication per each unit increase in body mass index), parity (7% increased odds of complication per delivery), race (when compared with white women, black women had 34% increased odds and women of other races had 18% increased odds of complication), and American Society of Anesthesiologists score (when compared with American Society of Anesthesiologists 1, American Society of Anesthesiologists 2 had 31% increased odds, American Society of Anesthesiologists 3 had 62% increased odds, and American Society of Anesthesiologists 4 had 172% increased odds of complication). Predicted preoperative uterine weight also had a statistically significant nonlinear relationship with odds of complication. The c-statistics for the derivation and validation cohorts were 0.62 and 0.62, respectively. The model is well calibrated for women at all levels of risk.

CONCLUSION

The laparoscopic hysterectomy complication predictor model is a tool for predicting complications in patients planning to undergo hysterectomy.

Portending Influence of Racial Disparities on Extended Length of Stay after Elective Anterior Cervical Discectomy and Interbody Fusion for Cervical Spondylotic Myelopathy

OBJECTIVE

The aim of this study was to investigate whether race is an independent predictor of extended length of stay (LOS) after elective anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM).

METHODS

A retrospective cohort study was performed using the National Inpatient Sample database from 2016 to 2017. All adult patients undergoing ACDF for CSM were identified using the International Classification of Diseases, Tenth Revision, Clinical Modification coding system.

RESULTS

A total of 15,400 patients were identified, of whom 13,250 (86.0%) were Caucasian (C) and 2150 (14.0%) were African American (AA). The C cohort tended to be older, whereas the AA cohort had 2 times as many patients in the 0-25th income quartile. The prevalence of comorbidities was greater in the AA cohort. Intraoperative fusion levels were similar between the cohorts, whereas the AA cohort had a higher rate of cerebrospinal fluid leak/dural tear. In relation to the number of complications, the C cohort had a lower rate compared with the AA cohort (P = 0.006), including no complication (89.4% vs. 85.3%), 1 complication (9.9% vs. 12.8%), and >1 complication (0.7% vs. 1.9%). The AA cohort experienced significantly longer hospital stays (C, 1.9 ± 2.3 days vs. AA, 2.7 ± 3.5; P < 0.001), greater proportion of extended LOS (C, 17.5% vs. AA, 29.1%; P < 0.001) and nonroutine discharges (C, 16.1% vs. AA, 28.6%; P < 0.001). AA race was a significant independent risk factor for extended LOS (odds ratio, 1.98; 95% confidence interval, 1.50-2.61; P < 0.001).

CONCLUSIONS

Our study suggests that AA patients have a significantly higher risk of prolonged LOS after elective ACDF for CSM compared with C patients.

Elucidation of the novel role of ethnicity and diabetes in poorer outcomes after cardiac surgery in a multiethnic Southeast Asian cohort

BACKGROUND

Although diabetes is associated with ethnicity and worse cardiac surgery outcomes, no research has been done to study the effect of both diabetes and ethnicity on cardiac surgery outcomes in a multiethnic Southeast Asian cohort. Hence, this study aimed to delineate the association of ethnicity on outcomes after cardiac surgery among diabetics in a multiethnic Southeast Asian population.

METHODS

Perioperative data from 3008 adult patients undergoing elective cardiac surgery from 2008 to 2011 at the two main heart centers in Singapore was analyzed prospectively, and confirmatory analysis was conducted with the generalized structural equation model.

RESULTS

Diabetes was significantly associated with postoperative acute kidney injury (AKI) and postoperative hyperglycemia. Postoperative AKI, Malay ethnicity, and blood transfusion were associated with postoperative dialysis. Postoperative AKI and blood transfusion were also associated with postoperative arrhythmias. In turn, postoperative dialysis and arrhythmias increased the odds of 30-day mortality by 7.7- and 18-fold, respectively.

CONCLUSIONS

This study identified that diabetes is directly associated with postoperative hyperglycemia and AKI, and indirectly associated with arrhythmias and 30-day mortality. Further, we showed that ethnicity not only affects the prevalence of diabetes, but also postoperative diabetes-related outcomes.

Contributors to Racial Disparities in Minimally Invasive Hysterectomy in the US Department of Veterans Affairs

BACKGROUND

Minimally invasive hysterectomy for fibroids decreases recovery time and risk of postoperative complications compared with abdominal hysterectomy. Within Veterans Affair (VA), black women with uterine fibroids are less likely to receive a minimally invasive hysterectomy than white women.

OBJECTIVE

To quantify the contributions of patient, facility, temporal and geographic factors to VA black-white disparity in minimally invasive hysterectomy.

RESEARCH DESIGN

A cross-sectional study.

SUBJECTS

Veterans with fibroids and hysterectomy performed in VA between October 1, 2012 and September 30, 2015.

MEASURES

Hysterectomy mode was defined using ICD-9 codes as minimally invasive (laparoscopic, vaginal, or robotic-assisted) versus abdominal. The authors estimated a logistic regression model with minimally invasive hysterectomy modeled as a function of 4 sets of factors: sociodemographic characteristics other than race, health risk factors, facility, and temporal and geographic factors. Using decomposition techniques, systematically substituting each white woman's characteristics for each black woman's characteristics, then recalculating the predicted probability of minimally invasive hysterectomy for black women for each possible combination of factors, we quantified the contribution of each set of factors to observed disparities in minimally invasive hysterectomy.

RESULTS

Among 1255 veterans with fibroids who had a hysterectomy at a VA, 61% of black women and 39% of white women had an abdominal hysterectomy. Our models indicated there were 99 excess abdominal hysterectomies among black women. The majority (n=77) of excess abdominal hysterectomies were unexplained by measured sociodemographic factors beyond race, health risk factors, facility, and temporal or geographic trends.

CONCLUSION

Closer examination of the equity of VA gynecology care and ways in which the VA can work to ensure equitable care for all women veterans is necessary.

Impact of diabetes on outcomes of cardiac surgery in a multiethnic Southeast Asian population

Although diabetes is rapidly increasing in Asia and has been shown to be associated with worse cardiac surgery outcomes, no research has been done to study the impact of diabetes on cardiac surgery outcomes in a Southeast Asian cohort. Hence, this study aims to delineate the predictors and impact of diabetes after cardiac surgery in a multi-ethnic Southeast Asian cohort. We analysed data from 2831 adult patients undergoing elective cardiac surgery, from 2008 to 2010 in Singapore. Diabetes was found to significantly increase the odds of intensive care unit readmission by 1.70 (95% confidence interval 1.171-2.480, p = 0.005), postoperative infection by 1.73 (95% confidence interval 1.003-2.976, p = 0.049), acute kidney injury by 1.36 (95% confidence interval 1.137-1.626, p = 0.001), postoperative hyperglycaemia by 6.00 (95% confidence interval 4.893-7.348, p < 0.001), and new need for dialysis by 1.71 (95% 1.086-5.360, p = 0.021). In conclusion, diabetes is associated with increased risk for renal dysfunction, hyperglycaemia, and infection after cardiac surgery, similar to the relative risks of diabetes patients observed in Western populations.

Risk Factors Associated with Persistent Anterior Uveitis after Cataract Surgery

PURPOSE

To identify risk factors for the development of persistent anterior uveitis (PAU) following uncomplicated phacoemulsification cataract extraction in patients without histories of uveitis or autoimmune diseases.

DESIGN

Retrospective cohort study.

METHODS

Medical records were reviewed of patients who underwent phacoemulsification cataract extraction with intraocular lens implantation between January 1, 2014, and December 31, 2016, at the University of Colorado Hospital. Exclusion criteria included patient history of autoimmune disease and/or uveitis, cataract surgery combined with another intraocular surgery, and complicated cataract surgery. Patients with PAU were identified according to Standardization of Uveitis Nomenclature Working Group criteria. Data including sex, race/ethnicity, surgery length and cumulative dissipated energy (CDE), and postoperative visual acuity (VA) and intraocular pressure (IOP) were obtained. Main outcome measurements were risk factors for the development of PAU.

RESULTS

The charts of 3,013 eyes from 2,019 patients were reviewed. A total of 61 eyes (2.0%) from 48 patients developed PAU. African Americans were more likely than whites to develop PAU (relative risk = 11.3; P < 0.0001). Age, sex, surgery length, and CDE were not risk factors. Patients with PAU did not have worse VA than those without PAU, and African Americans with PAU did not have worse VA or IOP than the other races with PAU. Eighteen of the 61 eyes (29.5%) also developed cystoid macular edema.

CONCLUSIONS

African Americans have a higher risk of developing PAU after uncomplicated phacoemulsification cataract extraction. The mechanism leading to this is unclear. Although PAU requires prolonged treatment, it does not appear to lead to worse visual outcomes.

Racial Disparities and Outcomes After Left Ventricular Assist Device Implantation as Bridge to Transplantation or Destination Therapy

OBJECTIVE

We sought to investigate outcomes after left ventricular assist device (LVAD) implantation in advanced heart failure patients stratified by race.

METHODS

Patients who had LVADs inserted at a single center as a bridge to transplant (BTT) or destination therapy (DT) were divided into 3 groups based on race: Caucasian, African American (AA), and Hispanic. Postoperative outcomes including complications, discharge disposition, and survival at defined time points were compared. Cox proportional hazards were used to identify factors associated with 1-year all-cause survival.

RESULTS

A total of 158 patients who had LVADs as BTT (n = 63) and DT (n = 95) were studied. Of these, 56% (n = 89) were Caucasians, 35% (n = 55) were AA, and 9% (n = 14) were Hispanics. AA patients had higher BMI and lower socioeconomic status and educational level, and were more likely to be single or divorced. Operative outcomes were similar among all 3 groups. Unadjusted 30-day, 6-month, 1-year, and 2-year survival rates for Caucasians versus AA versus Hispanics were 82% versus 89% versus 93%, P = 0.339; 74% versus 80% versus 71%, P = 0.596; 67% versus 76% versus 71%, P = 0.511; and 56% versus 62% versus 68%, P = 0.797. On multivariate analysis, device-related infection, malfunction, and abnormal rhythm were factors associated with overall all-cause mortality.

CONCLUSION

AA patients who undergo LVAD implantation as BTT or DT have lower socioeconomic status and educational level compared to their Caucasian or Hispanic counterparts. These differences, however, do not translate into postimplant survival outcomes.

Comparison of a Potential Hospital Quality Metric With Existing Metrics for Surgical Quality-Associated Readmission

Importance

The existing readmission quality metric does not meaningfully distinguish readmissions associated with surgical quality from those that are not associated with surgical quality and thus may not reflect the quality of surgical care.

Objective

To compare a quality metric that classifies readmissions associated with surgical quality with the existing metric of any unplanned readmission in a surgical population.

Design, Setting, and Participants

Cohort study using US nationwide administrative data collected on 4 high-volume surgical procedures performed at 103 Veterans Affairs hospitals from October 1, 2007, through September 30, 2014. Data analysis was conducted from October 1, 2017, to January 24, 2019.

Main Outcomes and Measures

Hospital-level rates of unplanned readmission (existing metric) and surgical readmissions associated with surgical quality (new metric) in the 30 days following hospital discharge for an inpatient surgical procedure.

Results

The study population included 109 258 patients who underwent surgery at 103 hospitals. Patients were majority male (94.1%) and white (78.2%) with a mean (SD) age of 64.0 (10.0) years at the time of surgery. After case-mix adjustment, 30-day surgical readmissions ranged from 4.6% (95% CI, 4.5%-4.8%) among knee arthroplasties to 11.1% (95% CI, 10.9%-11.3%) among colorectal resections. The new surgical readmission metric was significantly correlated with facility-level postdischarge complications for all procedures, with ρ coefficients ranging from 0.33 (95% CI, 0.13-0.51) for cholecystectomy to 0.52 (95% CI, 0.38-0.68) for colorectal resection. Correlations between postdischarge complications and the new surgical readmission metric were higher than correlations between complications and the existing readmission metric for all procedures examined (knee arthroplasty: 0.50 vs 0.48; hip replacement: 0.44 vs 0.18; colorectal resection: 0.52 vs 0.42; and cholecystectomy: 0.33 vs 0.10). When compared with using the existing readmission metric, using the new surgical readmission metric could change hip replacement-associated payment penalty determinations in 28.4% of hospitals and knee arthroplasty-associated penalties in 26.0% of hospitals.

Conclusions and Relevance

In this study, surgical quality-associated readmissions were more correlated with postdischarge complications at a higher rate than were unplanned readmissions. Thus, a metric based on such readmissions may be a better measure of surgical care quality. This work provides an important step in the development of future value-based payments and promotes evidence-based quality metrics targeting the quality of surgical care.

Persistent disparities in breast cancer surgical outcomes among hispanic and African American patients

BACKGROUND

Racial disparities among patients who receive breast mastectomy and reconstruction have not been well characterized.

METHODS

Records of patients undergoing breast extirpative and reconstructive surgery at a high-volume university-affiliated hospital over 5 consecutive years were reviewed. Patient demographics, breast cancer profiles, reconstructive modality, and outcomes were compared by race.

RESULTS

A total of 1045 patients underwent 1678 breast reconstructions during the five-year period. Mean age and standard deviation was 49.8 ± 10.6 years with a BMI of 27.9 ± 6.5. Hispanic and African American patients had significantly higher BMIs (p < 0.001), higher rates of ASA class III or IV (p = 0.025), obesity, diabetes, hypertension (p < 0.001 for these three comparisons), and smoking (p = 0.003), and had more prior abdominal surgeries (p = 0.007). Comparing oncologic characteristics, this population subset had higher rates of neoadjuvant chemotherapy (p = 0.036), history of radiation (p = 0.016), and were more likely to undergo modified radical mastectomy (p = 0.002) over nipple-sparing mastectomy (p = 0.035). Reconstructive complications revealed a higher overall complication rate (p = 0.023), higher rates of partial mastectomy flap necrosis (p = 0.043), as well as arterial (p = 0.009) and venous insufficiency (p = 0.026) during microvascular reconstruction among Hispanic and African American patients.

CONCLUSIONS

Compared to other patients, the present study identifies higher comorbidity burdens, higher rates of prior radiation and neoadjuvant chemotherapy, and higher post-surgical complication rates among Hispanic and African American patients with breast cancer.

A comparison of the risk of postoperative recurrence between African-American and Caucasian patients with Crohn's disease

BACKGROUND

Many patients with Crohn's disease will develop complications that require surgery. Recurrence after surgery is common.

AIM

To assess racial differences in postoperative recurrence between African-Americans and Caucasians.

METHODS

Medical records of Crohn's disease patients who underwent surgery (ileal, colonic, or ileocolonic resection) between June 2014 and June 2016 were reviewed. The primary endpoints were clinical and endoscopic remission at 6-12 months after a Crohn's disease surgery. Secondary outcomes included biological and histologic remission. Risks of recurrence were assessed by univariate, multivariate, and propensity score-matched analysis.

RESULTS

Thirty-six African-American and 167 Caucasian patients with Crohn's disease were included for analysis. There was no difference in disease location, disease behaviour, type of surgery performed, and pre- or postoperative medication use between the two groups. The rate of endoscopic remission did not differ between African-American and Caucasian patients (50% vs 42%, P = 0.76), and race did not influence the risk of endoscopic recurrence on univariate, multivariate, or propensity score-matched analysis. The rate of clinical remission was significantly lower in African-American patients compared to Caucasian patients (36% vs. 63%, P = 0.008). African-American race was significantly associated with clinical recurrence on univariate (odds ratio (OR) 6.76, 95% CI 1.50-30.40; P = 0.01), multivariate (OR 5.02, 95% CI 1.60-15.80; P = 0.006), and propensity-matched analysis (68% vs. 32% in Caucasians, P = 0.005). Rates of biologic and histologic remission were similar between the two groups on all analyses.

CONCLUSIONS

We found that African-American patients with Crohn's disease have a similar degree of objective measures of mucosal inflammation after surgery including endoscopic recurrence as compared to Caucasian patients. However, African-American race was significantly associated with clinical recurrence, suggesting the presence of ethnic variation in postoperative presentation in Crohn's disease.

The Presence of an Advanced Gastrointestinal (GI)/Minimally Invasive Surgery (MIS) Fellowship Program Does Not Impact Short-Term Patient Outcomes Following Fundoplication or Esophagomyotomy

INTRODUCTION

The current surgical landscape reflects a continual trend towards sub-specialization, evidenced by an increasing number of US surgeons who pursue fellowship training after residency. Despite this growing trend, however, the effect of advanced gastrointestinal (GI)/minimally invasive surgery (MIS) fellowship programs on patient outcomes following foregut/esophageal operations remains unclear. This study looks at two representative foregut surgeries (laparoscopic fundoplication and esophagomyotomy) performed in New York State (NYS), comparing hospitals which do and do not possess a GI/MIS fellowship program, to examine the effect of such a program on perioperative outcomes. We also aimed to identify any patient or hospital factors which might influence perioperative outcomes.

METHODS

The SPARCS database was examined for all patients who underwent a foregut procedure (specifically, either an esophagomyotomy or a laparoscopic fundoplication) between 2012 and 2014. We compared the following outcomes between institutions with and without a GI/MIS fellowship program: 30-day readmission, hospital length of stay (LOS), and development of any major complication.

RESULTS

There were 3175 foregut procedures recorded from 2012 to 2014. Just below one third (n = 1041; 32.8%) were performed in hospitals possessing a GI/MIS fellowship program. Among our entire included study population, 154 patients (4.85%) had a single 30-day readmission, with no observed difference in readmission between hospitals with and without a GI/MIS fellowship program, even after controlling for potential confounding factors (p = 0.6406 and p = 0.2511, respectively). Additionally, when controlling for potential confounders, the presence/absence of a GI/MIS fellowship program was found to have no association with risk of having a major complication (p = 0.1163) or LOS (p = 0.7562). Our study revealed that postoperative outcomes were significantly influenced by patient race and payment method. Asians and Medicare patients had the highest risk of suffering a severe complication (10.00 and 7.44%; p = 0.0311 and p = 0.0036, respectively)-with race retaining significance even after adjusting for potential confounders (p = 0.0276). Asians and uninsured patients demonstrated the highest readmission rates (15.00 and 12.50%; p = 0.0129 and p = 0.0012, respectively)-with both race and payment method retaining significance after adjustment (p = 0.0362 and p = 0.0257, respectively). Lastly, payment method was significantly associated with postoperative LOS (p < 0.0001), with Medicaid patients experiencing the longest LOS (mean 3.99 days) and those with commercial insurance experiencing the shortest (mean 1.66 days), a relationship which retained significance even after adjusting for potential confounders (p < 0.0001).

CONCLUSION

The presence of a GI/MIS fellowship program does not impact short-term patient outcomes following laparoscopic fundoplication or esophagomyotomy (two representative foregut procedures). Presence of such a fellowship should not play a role in choosing a surgeon. Additionally, in these foregut procedures, patient race (particularly Asian race) and payment method were found to be independently associated with postoperative outcomes, including postoperative LOS.

Racial and Ethnic Postoperative Outcomes After Surgery: The Hispanic Paradox

BACKGROUND

The Hispanic population in the United States have previously been shown to have, in some cases, better health outcomes than non-Hispanic whites (NHWs) despite having lower socioeconomic status and higher frequency of comorbidities. This epidemiologic finding is coined as the Hispanic Paradox (HP). Few studies have evaluated if the HP exists in surgical patients. Our study aimed to examine postoperative complications between Hispanic and NHW patients undergoing low- to high-risk procedures.

MATERIALS AND METHODS

We conducted a retrospective cohort study analyzing adult patients who underwent high-, intermediate-, and low-risk procedures. The Healthcare Cost and Utilization Project California State Inpatient Database between 2006 and 2011 was used to identify the patient cohort. Candidate variables for the adjusted model were determined a priori and included patient demographics with the ethnic group as the exposure of interest.

RESULTS

The median age for Hispanics was 52 (SD 19.3) y, and 38.8% were male (n = 87,837). A higher proportion of Hispanics had Medicaid insurance (23.9% versus 3.8%) or were self-pay (14.2% versus 4.5%) compared with NHWs. In adjusted analysis, Hispanics had a higher odds risk for postoperative complications across all risk categories combined (OR 1.06, 95% CI 1.04-1.09). They also had an increased in-hospital (OR 1.38, 95% CI 1.14-1.30) and 30-d mortality in high-risk procedures (OR 1.34, 95% CI 1.19-1.51).

CONCLUSIONS

Hispanics undergoing low- to high-risk surgery have worse outcomes compared with NHWs. These results do not support the hypothesis of an HP in surgical outcomes.

Comparison of patellar tracking according to different angles of external rotation of femoral component in varus knee of Asians

PURPOSE

Racial difference in the femoral geometry may exist. Asian femurs may be more externally rotated. If anatomical differences in distal femur had existed between Caucasians and Asians, the group with 5° external rotation of the femoral component should have shown better results than the group with 3° external rotation of the femoral component have.

METHODS

598 patients underwent total knee arthroplasty in our institution, among whom 83 patients (115 knees) who had postoperative computed tomography (CT) were studied retrospectively. Sixty-two knees were set in 5° of external rotation of femoral component relative to the posterior condylar axis (group A) while the others (53 knees) were set in 3° (group B). The femoral component rotation (FCR) was measured and compared using CT. The patellar tilting (PT) and the lateral patellar displacement (LPD) were measured to evaluate the patellar tracking using Merchant view. And postoperative clinical scores were compared.

RESULTS

The mean FCRs showed no significant difference between two groups ( p > 0.05). The mean PT and LPD showed no statistically significant difference either ( p > 0.05). There were no statistical differences in clinical scores.

CONCLUSION

The difference in the patellar tracking between the two groups could not be demonstrated. There were no statistical differences in clinical scores either. We concluded there is no need to adhere to 5° external rotation.

Does Race Influence Risk Assessment and Recommendations for Lung Resection? A Randomized Trial

BACKGROUND

Racial disparities in use of surgical therapy for lung cancer exist in the United States. Videos of standardized patients (SPs) can help identify factors that influence physicians' surgical risk estimation. We hypothesized that physician race and SP race in videos influence surgeon decision making.

METHODS

Four race-neutral clinical vignettes representing lung resection candidates were paired with risk-level concordant short silent videos of SPs. Vignette/video combinations were classified as low or high risk. Trainees and practicing thoracic surgeons read a race-neutral vignette, provided an initial estimate of the percentage risk of major surgical complications, viewed a video randomized to a black or white SP, provided a final estimate of risk, and scored the likelihood that they would recommend operative therapy. Changes in risk estimates were assessed.

RESULTS

Participants included 113 surgeons (38 practicing surgeons, 75 trainees); of these, 76 were white non-Hispanic (67%), and 37 were other self-identified racial categories. Percentage changes between initial and final risk estimates were not significantly related to patient race (p = 0.11) or surgeon race (white versus other; p = 0.52). Videos of black SPs were associated with a similar likelihood of recommending an operation compared with that of videos of white SPs (p = 0.90). Physician race (white versus other) was not related to the likelihood of recommending surgical intervention (p = 0.79).

CONCLUSIONS

Neither patient nor physician race was significantly associated with risk estimation or surgical recommendations. These findings do not provide an explanation for documented racial disparities in lung cancer therapy. Further investigation is needed to identify the mechanism underlying these disparities.

Ethnicity, Race, and Postoperative Stroke Risk Among 53,593 Patients with Asymptomatic Carotid Stenosis Undergoing Revascularization

BACKGROUND

The incidence of postoperative stroke after carotid endarterectomy is an uncommon event, and differences by racial and ethnic subgroups are not described fully in the literature.

OBJECTIVE

To investigate the impact of race and ethnicity on postoperative stroke risk among patients with asymptomatic carotid stenosis undergoing carotid endarterectomy.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was searched for patients between the dates 2008 and 2015 to identify patients undergoing carotid endarterectomy with no history of stroke. Four racial and ethnic subgroups were included: non-Hispanic white, Hispanic white, non-Hispanic back, and non-Hispanic Asian. In addition to a descriptive statistical analysis, univariate and multivariate regression models were created to adjust for cardiovascular and perioperative risk factors and corrected for multiple comparisons.

RESULTS

Among the 53,593 patients identified meeting the inclusion criteria, 788 (1.45%) patients experienced a stroke within 30 days. The non-Hispanic white group compared with the minority subgroups had a lower risk of postoperative stroke (1.43% vs. 1.67%, P = 0.18). The greatest difference was between the non-Hispanic white and Hispanic white groups, but this was not significant on multivariable analysis (odds ratio 1.40, 95% confidence interval 0.97-2.02, P = 0.08) after adjustment for risk stroke factors. The strongest predictors of postoperative stroke were perioperative blood transfusion, dependent functional status, and longer operative time.

CONCLUSIONS

There was no difference between the racial and ethnic groups and the proportion of postoperative stroke among patients undergoing revascularization for asymptomatic carotid stenosis.

Racial Disparities in Above-knee Amputations After TKA: A National Database Study

BACKGROUND

Above-knee amputation (AKA) is a rare but devastating complication of TKA. Although racial disparities have been previously reported in the utilization of TKA, it is unclear whether disparities exist in the rates of AKA after TKA.

QUESTIONS/PURPOSES

(1) Which gender-racial group has the highest rate of AKA from septic and aseptic complications of TKA? (2) Which age groups have higher rates of AKA from septic and aseptic complications of TKA?

METHODS

Using National Inpatient Sample data from 2000 to 2011, AKAs resulting from complications of TKA were identified using a combination of International Classification of Diseases, 9th Revision procedure and diagnosis codes. Of the 341,954 AKAs identified, 9733 AKAs were the result of complications of TKA (septic complications = 8104, aseptic complications = 1629). Standardized AKA rates were calculated for different age and gender- racial groups by dividing the number of AKAs in each group with the corresponding number of TKAs. Standardized rate ratios were calculated after adjusting for demographics and comorbidities.

RESULTS

After adjusting for age and comorbidities, black men had the highest rate of AKA after TKA (adjusted rate in black men = 578 AKAs per 100,000 TKAs, standardized rate ratio [SRR] = 4.32 [confidence interval {CI}, 3.87-4.82], p < 0.001). Black men also had the highest rate of AKA after septic complications of TKA (p < 0.001). The adjusted rates of AKA were higher in patients younger than 50 years (adjusted rate = 473, SRR = 3.14 [CI, 2.94-3.36], p < 0.001) and older than 80 years (adjusted rate = 297, SRR = 1.85 [CI, 1.76-1.95], p < 0.001).

CONCLUSIONS

The rising demand for TKA has led to an increase in the number of AKAs performed for complications of TKA in the United States. Although we did not find an increase in the rate of AKA during the study period, certain populations, including black men and patients older than 80 years and younger than 50 years, had higher rates of AKA. Further studies are required to understand the reasons for these disparities and measures should be undertaken to eliminate these disparities.

LEVEL OF EVIDENCE

Level III, therapeutic study.

African Americans and Short-Term Outcomes after Surgery for Crohn's Disease: An ACS-NSQIP Analysis

BACKGROUND

Previous reports on racial disparities in the treatment of Crohn's disease [CD] in African American [AA] patients have shown differences in both medical and surgical treatments in this population. No study thus far has examined the effect of AA race on outcomes after surgery for CD.

METHODS

Utilizing the National Surgical Quality Improvement Program [NSQIP] Participant User File [PUF] for the years 2005-2013, we examined the effect of AA race on postoperative complications in patients with CD undergoing intestinal surgery.

RESULTS

AA patients had a significantly higher rate of complications overall compared to non-AA patients [23.5% vs 18.9%, p = 0.002]. Postoperative sepsis [10.9% vs 6.6%, p < 0.001] and surgical site infection [17.6% vs 14.8%, p = 0.037] were most significant. After adjustment for age, sex, preoperative disease severity and lifestyle factors [smoking], race remained a statistically significant factor in postoperative complication rate. Only after additional adjustment was made for comorbidities and American Society of Anesthesiologists class did race lose significance within our model.

CONCLUSION

African Americans experience a greater amount of postoperative complications following surgery for Crohn's disease. Preoperative disease management, addressing smoking status and control of comorbid disease are important factors in addressing the racial disparities in the surgical treatment of Crohn's disease.

Characterizing Short-Term Outcomes Following Surgery for Rectal Cancer: the Role of Race and Insurance Status

BACKGROUND

There is a paucity of data demonstrating the effect race and insurance status have on postoperative outcomes for patients with rectal cancer. We evaluated factors impacting short-term outcomes following rectal cancer surgery.

DESIGN

Patients who underwent surgery for rectal cancer using the University Health System Consortium database from 2011 to 2012 were studied. Univariate and multivariable analyses were used to identify patient related risk factors for 30-day outcomes after proctectomy: complication rate, 30-day readmission, ICU stay, and length of hospital stay (LOS).

RESULTS

A total of 9272 proctectomies were identified in this cohort. After adjustment for potential confounders, black patients were more likely to have 30-day readmissions (OR 1.51, 95 % CI 1.26-1.81), ICU stays (OR 1.25, 95 % CI 1.03-1.51), and longer LOS (+1.67 days, 95 % CI 1.21-2.13) when compared to whites. Compared to those with private insurance, patients with public or military insurance or who were self-pay had a higher likelihood of having postoperative complications.

CONCLUSIONS

In patients who undergo elective proctectomy for rectal cancer, non-white and non-privately insured status are associated with significantly worse short-term outcomes. Further studies are needed to determine the implications with respect to receipt of adjuvant therapy and survival.

Postsurgical Depressive Symptoms and Proinflammatory Cytokine Elevations in Women Undergoing Primary Treatment for Breast Cancer

OBJECTIVE

Depression and inflammation may independently promote breast cancer (BCa) disease progression and poorer clinical outcomes. Depression has been associated with increased levels of inflammatory markers in medically healthy individuals and patients with cancer. However, inconsistencies in study time frames complicate interpretation of results within specific cancer types. This study examined relationships between depressive symptoms and inflammation in women with early-stage BCa before beginning adjuvant treatment.

METHODS

Women with Stage 0-III BCa were recruited approximately 4 to 8 weeks after surgery. Depressive symptoms were assessed using the Hamilton Rating Scale for Depression, and blood samples were collected to quantify circulating levels of interleukin (IL)-1β, IL-6, and tumor necrosis factor α (TNF-α) by enzyme-linked immunosorbent assay. Analyses of covariance were used to test for group differences (elevated versus low depressive symptoms) in levels of cytokines. Multiple regression analyses were used to examine relationships between continuous severity of depressive symptoms and levels of cytokines adjusting for relevant biobehavioral covariates.

RESULTS

Thirty-six (40%) of 89 patients showed elevated levels of depressive symptoms and, in adjusted models, had marginally higher levels of IL-1β (mean [M] = 14.49 [95% confidence interval {CI} = 6.11-32.65] versus M = 4.68 [95% CI = 1.96-9.86] and IL-6 [M = 88.74 {95% CI = 33.28-233.96} versus M = 61.52 {95% CI = 27.44-136.40}]) significantly higher levels of TNF-α (M = 17.07 [95% CI = 8.27-34.32] versus M = 6.94 [95% CI = 3.58-12.80]) than did women with low depressive symptoms. Across the spectrum of depressive symptoms, greater magnitude of depressive symptoms was related to greater levels of IL-1β (β = 0.06, p = .006, R = 0.25) and TNF-α (β = 0.06, p = .003, R = 0.27).

CONCLUSIONS

Postsurgery and preadjuvant treatment for early-stage BCa, depressive symptoms covary with elevated levels of multiple proinflammatory cytokines. Findings have implications for psychosocial and biological interventions concurrently focusing on depression and inflammation.

TRIAL REGISTRATION

NCT01422551.

A preoperative personalized risk assessment calculator for elderly ovarian cancer patients undergoing primary cytoreductive surgery

OBJECTIVE

Cytoreductive surgery for ovarian cancer has higher rates of postoperative complication than neoadjuvant chemotherapy followed by surgery. If patients at high risk of postoperative complication were identified preoperatively, primary therapy could be tailored. Our objective was to develop a predictive model to estimate the risk of major postoperative complication after primary cytoreductive surgery among elderly ovarian cancer patients.

METHODS

Patients who underwent primary surgery for ovarian cancer between 2005 and 2013 were identified from the National Surgical Quality Improvement Project. Patients were selected using primary procedure CPT codes. Major complications were defined as grade 3 or higher complications on the validated Claviden-Dindo scale. Using logistic regression, we identified demographic and clinical characteristics predictive of postoperative complication.

RESULTS

We identified 2101 ovarian cancer patients of whom 35.9% were older than 65. Among women older than 65, the rate of major postoperative complication was 16.4%. Complications were directly associated with preoperative laboratory values (serum creatinine, platelets, white blood cell count, hematocrit), ascites, white race, and smoking status, and indirectly associated with albumin. Our predictive model had an area under receiver operating characteristic curve of 0.725. In order to not deny patients necessary surgery, we chose a 50% population rate of postoperative complication which produced model sensitivity of 9.8% and specificity of 98%.

DISCUSSION

Our predictive model uses easily and routinely obtained objective preoperative factors to estimate the risk of postoperative complication among elderly ovarian cancer patients. This information can be used to assess risk, manage postoperative expectations, and make decisions regarding initial treatment.

Laparoscopic gastric bypass vs sleeve gastrectomy in obese Korean patients

AIM: To compare the mid-term outcomes of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) in obese Korean patients.

METHODS: All consecutive patients who underwent either LSG or LRYGB with primary to treat morbid obesity between January 2011 and December 2012 were retrospectively reviewed. Patients with a body mass index (BMI) ≥ 30 kg/m² with inadequately controlled obesity-related comorbidities (e.g., diabetes, obstructive sleep apnea, hypertension, or obesity-related arthropathy) or BMI ≥ 35 kg/m² were considered for bariatric surgery according to the International Federation for the Surgery of Obesity-Asia Pacific Chapter Consensus statements in 2011. The decision regarding the procedure type was made on an individual basis following extensive discussion with the patient about the specific risks associated with each procedure. All operative procedures were performed laparoscopically by a single surgeon experienced in upper gastrointestinal surgeries. Baseline demographics, perioperative surgical outcomes, and postoperative anthropometric data from a prospectively established database were thoroughly reviewed and compared between the two surgical approaches.

RESULTS: One hundred four patients underwent LSG, and 236 underwent LRYGB. Preoperative BMI in the LSG group was significantly higher than that of the LRYGB group (38.6 kg/m²vs 37.2 kg/m², P = 0.024). Patients with diabetes were more prevalent in the LRYGB group (18.3% vs 35.6%, P = 0.001). Operating time and hospital stay were significantly shorter in the LSG group compared with the LRYGB group (100 min vs 130 min, P < 0.001; 1 d vs 2 d, P = 0.003), but the incidence of perioperative complications was similar between the groups (P = 0.351). The mean percentage of excess weight loss (%EWL) was 71.2% for LRYGB, while it was 63.5% for LSG, at mean follow-up periods of 18.0 and 21.0 mo, respectively (P = 0.073). The %EWL at 1, 3, 6, 12, 18, 24, and 36 mo was equivalent between the groups. Four patients required surgical revision after LSG (4.8%), while revision was only required in one case following LRYGB (0.4%; P = 0.011).

CONCLUSION: Both LSG and LRYGB are effective procedures that induce comparable weight loss in the mid-term and similar surgical risks, except for the higher revision rate after LSG.

Impact of body mass index on complications following pancreatectomy: Ten-year experience at National Cancer Center in China

AIM: To examine the impact of body mass index (BMI) on outcomes following pancreatic resection in the Chinese population.

METHODS: A retrospective cohort study using prospectively collected data was conducted at the Cancer Hospital of the Chinese Academy of Medical Sciences, China National Cancer Center. Individuals who underwent pancreatic resection between January 2004 and December 2013 were identified and included in the study. Persons were classified as having a normal weight if their BMI was < 24 kg/m² and overweight/obese if their BMI was ≥ 24 kg/m² as defined by the International Life Sciences Institute Focal Point in China. A χ² test (for categorical variables) or a t test (for continuous variables) was used to examine the differences in patients’ characteristics between normal weight and overweight/obese groups. Multiple logistic regression models were used to assess the associations of postoperative complications, operative difficulty, length of hospital stay, and cost with BMI, adjusting for age, sex, and type of surgery procedures.

RESULTS: A total of 362 consecutive patients with data available for BMI calculation underwent pancreatic resection for benign or malignant disease from January 1, 2004 to December 31, 2013. Of the 362 patients, 156 were overweight or obese and 206 were of normal weight. One or more postoperative complications occurred in 35.4% of the patients following pancreatic resection. Among patients who were overweight or obese, 42.9% experienced one or more complications, significantly higher than normal weight (29.6%) individuals (P = 0.0086). Compared with individuals who had normal weight, those with a BMI ≥ 24.0 kg/m² had higher delayed gastric emptying (19.9% vs 5.8%, P < 0.0001) and bile leak (7.7% vs 1.9%, P = 0.0068). There were no significant differences seen in pancreatic fistula, gastrointestinal hemorrhage, reoperation, readmission, or other complications. BMI did not show a significant association with intraoperative blood loss, operative time, length of hospital stay, or cost.

CONCLUSION: Higher BMI increases the risk for postoperative complications after pancreatectomy in the Chinese population. The findings require replication in future studies with larger sample sizes.

Prevalence of suicidality among Hispanic and African American veterans following surgery

OBJECTIVES

We evaluated factors associated with suicidal behavior and ideation (SBI) during 3 years of follow-up among 89,995 Veterans Health Administration (VHA) patients who underwent major surgery from October 2005 to September 2006.

METHODS

We analyzed administrative data using Cox proportional hazards models. SBI was ascertained by International Classification of Disease, 9th Revision codes.

RESULTS

African Americans (18% of sample; 16,252) were at an increased risk for SBI (hazard ratio [HR] = 1.21; 95% confidence interval [CI]  = 1.10, 1.32), whereas Hispanics were not (HR = 1.10; 95% CI = 0.95, 1.28). Other risk factors included schizophrenia, bipolar disorder, depression, posttraumatic stress disorder, pain disorders, postoperative new-onset depression, and postoperative complications; female gender and married status were protective against SBI.

CONCLUSIONS

The postoperative period might be a time of heightened risk for SBI among minority patients in the VHA. Tailored monitoring and postoperative management by minority status might be required to achieve care equity.

The impact of Hispanic ethnicity and race on post-surgical complications in patients with inflammatory bowel disease

BACKGROUND

Surgery for inflammatory bowel disease (IBD) is common and represents a large portion of the cost of IBD treatment. There are multiple risk factors for post-operative complications after IBD surgery, but the role of ethnicity remains unclear. The aim of our study was to compare the rate of post-operative complications in Hispanic and non-Hispanic patients with equal access to health care.

METHODS

We designed a case-control study including patients enrolled in a health plan available to uninsured patients at Jackson Memorial Hospital (Miami, FL, USA) who had access to health care for at least 24 consecutive months prior to surgery. Sixty-seven Hispanic patients (cases) and 75 non-Hispanic patients (controls) met criteria and were compared with respect to demographics, type of surgery, disease phenotype, and laboratory markers. Primary outcome was the development of a medical or surgical complication.

RESULTS

A slight numerical increase in post-operative complications was seen in Hispanic patients; this did not reach statistical significance [1.06 (95 % CI 0.48-2.36; p = 0.88)]. Factors independently associated with post-operative complications included diagnosis of ulcerative colitis [OR 5.4 (95 % CI 1.67-20.58; p = 0.004)], pre-operative albumin levels <3 mg/dL [OR: 8.2 (95 % CI 2.3-35.5; p < 0.001)], smoking [OR 15.7 (95 % CI 4.2-72.35; p < 0.001)], and use of ≥20 mg of prednisone [OR 6.7 (95 % CI 2.15-24.62; p < 0.001)].

CONCLUSIONS

In a group of patients with equal access to medical care and follow-up, Hispanics and non-Hispanics with IBD that underwent surgery had no significant differences in types of IBD surgeries or post-surgical outcomes.

Variations in postoperative complications according to race, ethnicity, and sex in older adults

OBJECTIVES

To explore differences in the incidence of postoperative complications between three racial and ethnic groups (white, black, Hispanic) before and after taking into account potentially confounding patient and hospital characteristics.

DESIGN

Cross-sectional study using 2006 to 2007 administrative discharge data from hospitals in four states (CA, PA, NJ, FL) linked to American Hospital Association Annual Survey data and data from the U.S. Census. Risk-adjusted logistic regression models were used in the analyses.

SETTING

Six hundred U.S. adult nonfederal acute care hospitals.

PARTICIPANTS

Individuals aged 65 and older undergoing general, orthopedic, or vascular surgery (N = 587,314; 86% white, 6% black, 8% Hispanic).

MEASUREMENTS

Thirteen frequent postoperative complications.

RESULTS

When considered without controls, black patients had significantly greater odds than white patients of developing 12 of the 13 complications, by factors (ORs) ranging from 1.09 to 2.69. Hispanic patients had significantly greater odds than white patients in nine of the 13 complications (ORs = 1.11-1.82) and significantly lower odds than white patients on two of the other four (ORs both = 0.84). The fully adjusted models that accounted for hospital and especially patient characteristics substantially diminished the number of complications for which black and Hispanic patients had significantly greater odds than white patients. Many of the significant differences between black, Hispanic, and white patients that persisted after controls were different for men and women.

CONCLUSION

Older black and Hispanic individuals have greater odds than white individuals of developing a vast majority of postoperative complications. Procedure type and health status largely explained differences in postoperative complication risk, which are frequently conditional on sex.

Trends in use of total knee arthroplasty in Korea from 2001 to 2010

BACKGROUND

The use of total knee arthroplasty (TKA) has increased substantially in most Western countries. However, the trends in TKA use and changes in demographic characteristics of patients having TKA in Korea remain unclear.

QUESTIONS/PURPOSES

We documented the trends in TKA use and in the demographics of patients undergoing TKA in Korea over the past decade and determined whether current TKA use in Korea corresponds to worldwide trends.

METHODS

Using the Health Insurance Review and Assessment Service of Korea database, we analyzed TKA records (n = 398,218) from 2001 to 2010 in Korea. Trends in TKA use and demographics, including numbers and rates of primary and revision TKA, growth rate and the revision burden, and age- and sex-specific rates, were estimated. They were compared with nationwide TKA registry reports from other countries, and a systematic review was performed.

RESULTS

Over the past decade, the primary and revision TKA rates increased by 407% and 267%, respectively. However, the revision burden remained 2%. The highest proportion was observed in 65 to 74 years old and the greatest increase in 75 to 84 years old, but a decrease was observed in those 55 to 64 years old. Women consistently had a ninefold higher TKA rate. The primary TKA rate was comparable with that of other countries, but the revision burden remained lower. In addition, old and female patients comprised considerably higher proportions in Korea.

CONCLUSIONS

During the past decade, TKA use in Korea has markedly increased and caught up with the use levels of most developed Western countries. Trends toward consistent growth in elderly patients and higher rates in females were observed. Appropriate healthcare strategies reflecting these trends in demographics are urgently needed in Korea.

Patient race and surgical outcomes after total knee arthroplasty: an analysis of a large regional database

OBJECTIVE

To examine racial differences in surgical complications, mortality, and revision rates after total knee arthroplasty.

METHODS

We studied patients undergoing primary total knee arthroplasty using 2001-2007 Pennsylvania Health Care Cost Containment Council data. We conducted bivariate analyses to assess the risk of complications such as myocardial infarction, venous thromboembolism, wound infections, and failure of prosthesis, as well as 30-day and 1-year overall mortality after elective total knee arthroplasty, between racial groups. We estimated Kaplan-Meier 1- and 5-year surgical revision rates, and fit multivariable Cox proportional hazards models to compare surgical revision by race, incorporating 5 years of followup. We adjusted for patient age, sex, length of hospital stay, surgical risk of death, type of health insurance, hospital surgical volume, and hospital teaching status.

RESULTS

In unadjusted analyses, there were no significant differences by racial group for either overall 30-day or in-hospital complication rates, or 30-day and 1-year mortality rates. Adjusted Cox models incorporating 5 years of followup showed an increased risk of revisions for African American patients (hazard ratio [HR] 1.39, 95% confidence interval [95% CI] 1.08-1.80), younger patients (HR 2.30, 95% CI 1.96-2.69), and lower risk for female patients (HR 0.81, 95% CI 0.71-0.92).

CONCLUSION

In this sample of patients who underwent knee arthroplasty, we found no significant racial differences in major complication rates or mortality. However, African American patients, younger patients, and male patients all had significantly higher rates of revision based on 5 years of followup.

Racial disparities in voice outcomes after thyroid and parathyroid surgery

BACKGROUND

There is evidence that the outcomes of head and neck surgery may differ across racial and ethnic groups. Vocal changes related to the operation are an anticipated risk of thyroidectomy and parathyroidectomy. Race-specific voice outcomes after thyroid and parathyroid operations have not been reported. Therefore, our aim was to examine the potential disparity in voice outcomes between white and black patients after thyroid or parathyroid operations.

PATIENTS AND METHODS

Eighty-seven patients (59 white and 28 black) were included in a prospective observational trial. Subjects were evaluated before operation, and 2 weeks, 3 months, and 6 months postoperatively using a comprehensive battery of functional voice assessments of voice characteristics. The association of race with voice outcomes over time was evaluated with generalized linear models.

RESULTS

Aside from volume of pathologic specimen (black, 117.5 cm3 vs. white, 43.2 cm3; P = .004), presence of multinodular goiter (black, 32.1% vs. white, 6.8%; P = .004) or Hashimoto's thyroiditis (black, 3.6% vs. white, 28.8%; P = .009), there were no differences between racial groups. Blacks were more likely than whites to have negative voice outcomes (odds ratio, 2.6; 95% confidence interval, 1.1-6.2; P = .034] throughout the postoperative period, especially at 6 months (black, 25% vs. white, 4%; P = .018). This finding was related principally to divergent scores on the voice-related quality-of-life scale, the voice handicap index.

CONCLUSION

We observed greater rates of self-reported, negative voice outcomes among blacks than whites after thyroid or parathyroid operations. The precise mechanism for this disparity has not been described. The observed racial disparity in self-perceived voice impairment in this study merits further investigation.

Patient satisfaction and complications following laser hair removal in ethnic skin

BACKGROUND

Laser hair removal (LHR) is increasingly popular for the treatment of unwanted hair. To date, there have been few studies to evaluate patient satisfaction and complications after LHR among people of color.

OBJECTIVES

To determine patient satisfaction and complications with long-pulsed Nd:YAG laser assisted hair removal in dark-complexioned skin individuals from the patient's point of view.

PATIENTS/METHODS

A survey questionnaire was administered to subjects with Fitzpatrick skin type VI between the ages of 21-70 years who had been treated with long-pulsed Nd:YAG for unwanted hair. Questions were comprised of those related to satisfaction and complications from treatment with LHR. Satisfaction was recorded on a linear analogue scale (LAS=not at all satisfied; 100=extremely satisfied).

RESULTS

Fifty patients (female 41, male 9) completed the survey. All patients were satisfied with Nd:YAG LHR treatment with the mean satisfaction score of 84.2. All patients favor LHR treatment as compared to alternative methods. The majority of patients (79.3%) who had completed six or more LHR treatments were removing their hair less frequently than before LHR treatment. Hyperpigmentation after treatment was noted in three patients (6%), which lasted for 3-10 days. No hypopigmentation, blistering, or scarring was observed. All patients completing the study would recommend LHR for patients with unwanted hair with the mean recommendation score of 91.5.

CONCLUSIONS

Nd:YAG laser-assisted hair removal gives a high rate of patient satisfaction in terms of hair reduction with minimal complication among subjects of color.

Contribution of body mass index to postoperative outcome in minority patients

OBJECTIVE

The purpose of this investigation was to examine the association of body mass index (BMI) category with short-term outcomes in minority surgical patients-a relationship that previously has not been well characterized.

METHODS

Data from the National Surgical Quality Improvement Program were used to calculate the BMI of minority patients undergoing surgery from 2005 to 2008. Patients were stratified into 5 BMI classes. Stepwise logistic regression was used to calculate odds ratios for mortality after controlling for known clinically relevant covariates.

MAIN OUTCOME MEASURES

Morbidity and mortality at 30 days, across all 5 BMI classes.

RESULTS

Among 119,619 minority patients studied, 50% were African American, 36% Hispanic, 10% Asian and Pacific Islanders, and 4% American Indian and Alaskan natives. Seventy percent were overweight or obese. Women were more likely to be obese or severely obese. The overall mortality rate was 1.5%, and this varied significantly by BMI class. Distribution of 30-day mortality demonstrated a progressive decrease, with the highest risk of death in the underweight class, and the lowest risk of death in the severely obese class. This relationship was maintained, even in patients with at least 1 major postoperative complication.

CONCLUSION

The prevalence of being overweight or obese was high in this nationally representative cohort of minority surgical patients. Although BMI class is a significant predictor of 30-day mortality, the effect appeared paradoxical. The poorest outcomes were in the underweight and normal BMI patients. Severely obese patients had the lowest risk of mortality, even after experiencing a major postoperative complication.

The impact of high body mass index on postoperative complications and resource utilization in minority patients

BACKGROUND

Obesity is disproportionately prevalent among minority patients, yet very little has been written about its effect on surgical outcome in this group.

OBJECTIVE

We investigated the association of body mass index (BMI) category with perioperative complications and resource utilization.

METHODS

Data from the American College of Surgeons National Surgical Quality improvement Program Participant Use Data File was used to calculate the BMI (kg/m2) of all minority patients undergoing inpatient surgery from 2005 to 2008. Patients were stratified into 4 BMI classes, ranging from normal weight to severely obese. Postoperative length of stay (LOS) was used as the main proxy for resource utilization. Stepwise logistic regression was used to calculate odds ratios for prolonged LOS after controlling for clinically relevant cofactors.

RESULTS

Among 73978 patients, 28% were in the normal BMI category, 28.9% were overweight, 28.2% were obese, and 14.9% were severely obese. Morbidity and mortality distribution varied significantly by BMI category, with the highest proportion of cases occurring in the normal-BMI group and the lowest in the severely obese patients. Postoperative LOS was longer for patients in the normal-BMI group than for severely obese patients. Other markers of resource utilization also followed the same pattern with progressive decrease from normal-BMI patients to the severely obese group.

CONCLUSION

Postoperative morbidity and mortality and markers of hospital resource consumption were highest in the normal-BMI patients and decreased progressively to the severely obese group. This group appears to enjoy a paradoxical protection from perioperative complications and so utilize fewer hospital resources.

Ethnic variation in cholecystectomy rates and outcomes, Manitoba, Canada, 1972-84

We used population-based data from the Province of Manitoba's universal health insurance plan to compare the cholecystectomy experience of Native Americans and non-Natives from 1972 to 1984. The age-adjusted cholecystectomy rates for Native females were higher than for non-Native females with the peak rate occurring at age 30-39 for Native Americans and at age 60-69 for non-Natives. The rates for males were three times lower than for females and did not differ between Natives and non-Natives. Native Americans were more likely readmitted to hospital for surgical complications than non-Natives and this held true after controlling for age, sex, rural versus urban residence, teaching versus non-teaching hospital, multiple discharge diagnoses or complex versus simple cholecystectomy (relative odds 1.46, 95 per cent confidence interval 1.17, 1.18). The explanation for the relatively high rates of cholecystectomy among Native American females may be related to high rates of known risk factors for gallstone disease (such as obesity and high parity). However, the higher rates of surgical complications require further study.