Patient-Reported Quality of Recovery after Sedation for Endoscopy in the Elderly

INTRODUCTION

Although sedation is critical in minimizing discomforts in patients, conflicting data regarding the safety of sedation among the elderly population exist. This prospective study aimed to compare the quality of recovery (QoR) from gastrointestinal endoscopy performed under sedation between elderly and younger patients.

METHODS

We included 177 patients aged 40-64 (group 1, n = 66), 65-79 (group 2, n = 76), and ≥80 (group 3, n = 35) years. QoR was assessed 1 day after the procedure using the quality of recovery 15 (QoR-15) questionnaire, which is a 15-item questionnaire with scores ranging from 0 to 150. Patient demographic, procedural, and sedation data were collected, and neurocognitive function was assessed before and a day after sedation.

RESULTS

Groups 1 and 3 differed according to the Mini-Cog test and 3-word memory test performed before the procedure (p < 0.001). QoR-15 scores between groups were not different (139 ± 19 group 1, 141 ± 17 group 2, and 147 ± 26 group 3; p > 0.05). Patients in groups 3 and 2 were administered lower doses of propofol and midazolam than those in group 1. The incidence of oxygen desaturation (SaO2 <90% for >30 s) was lower in groups 1 and 2 than in group 3 (p = 0.01).

CONCLUSIONS

As indicated by the QoR-15 questionnaire, the QoR from sedation was not significantly different between the study groups.

Analyzing the impact of preoperative interrogation of cardiac implantable electronic devices

Background

Cardiac implantable electronic devices (CIED) are becoming more common for the management of underlying of cardiac dysrhythmias, and more patients with these devices are presenting for cardiac and noncardiac procedures.

Methods

We performed a retrospective, cohort, single-center study at a tertiary teaching medical center, gathering 151 patients with CIED undergoing elective and emergent surgeries for the time period between November 2013 and December 2016. We aimed to determine whether patients with CIED had the device interrogated before surgery as recommended by the Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) consensus, whether this lack of compliance led to delay in the holding area before surgery and determine the presence of intra- or postoperative cardiac events in these patients.

Results

A total of 76% of patients had interrogation of the device before surgery. Emergent cases were not interrogated as much as elective cases preoperatively (43% vs. 18%, respectively; P < 0.05). In total, 6% of cases had a CIED-related average holding area delay time of 54 minutes. Patients without preoperative device interrogation had more perioperative cardiac events than those who had the device checked (25% vs. 8%, respectively; odds ratio [OR] 0.26; 95% CI, 0.09-0.7, P < 0.013).

Conclusions

Our findings suggest that preoperative interrogation of the device plays a significant role to minimize the incidence of perioperative cardiac adverse events. Institutional providers show a lack of compliance with HRS/ASA recommendations for preoperative CIED management. Further research is required to determine if improved compliance to recommendations will lead to enhanced outcomes.

American Society of Anesthesiologists physical status score as a predictor of long-term outcome in women with endometrial cancer

OBJECTIVE

To study the association of the American Society of Anesthesiologists (ASA) physical status score with long-term outcome in endometrial cancer.

METHODS

Overall, disease-specific and non-cancer-related survival were estimated using simple and multivariable Cox regression analyses and the Kaplan-Meier method.

RESULTS

A total of 1166 patients were included in the study. Median follow-up time was 76 (range 1-136) months. All-cause and non-cancer-related mortality were increased in patients whose ASA physical status score was III (HRs 2.5 and 8.0, respectively) or IV (HRs 5.7 and 25, respectively), and cancer-related mortality was increased in patients whose score was IV (HR 2.7). Kaplan-Meier analyses demonstrated a worse overall, disease-specific and non-cancer-related survival for patients whose score was ≥III (p<0.0001 for all). Disease-specific survival was also separately analyzed for patients with stage I and stage II-IV cancer. Compared with patients whose score was ≤II, the survival was worse for patients whose score was ≥III in both subgroups of stages (p=0.003 and p=0.017 for stage I and stages II-IV, respectively). ASA physical status score remained an independent predictor of all-cause mortality (HR 2.2 for scores ≥III), cancer-related mortality (HRs 1.7 and 2.2 for scores ≥III and IV, respectively) and non-cancer related mortality (HR 3.1 for scores ≥III) after adjustment for prognostically relevant clinicopathologic and blood-based covariates. ASA physical status score also remained an independent predictor of cancer-related mortality after exclusion of patients who were at risk for nodal involvement based on features of the primary tumor but who did not undergo lymphadenectomy, and patients with advanced disease who received suboptimal chemotherapy (HRs 1.6 and 2.5 for scores ≥III and IV, respectively).

CONCLUSIONS

ASA physical status score independently predicts overall survival, disease-specific survival, and non-cancer-related survival in endometrial cancer.

ASA Classification as a Risk Stratification Tool in Adult Spinal Deformity Surgery: A Study of 5805 Patients

STUDY DESIGN

Retrospective analysis of prospectively collected data.

OBJECTIVES

Adult spinal deformity (ASD) surgery is a highly complex procedure that has high complication rates. Risk stratification tools can improve patient management and may lower complication rates and associated costs. The goal of this study was to identify the independent association between American Society of Anesthesiologists (ASA) class and postoperative outcomes following ASD surgery.

METHODS

The 2010-2014 American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology and International Classification of Diseases, Ninth Revision, codes relevant to ASD surgery. Patients were divided based on their ASA classification. Bivariate and multivariate logistic regression analyses were employed to quantify the increased risk of 30-day postoperative complications for patients with increased ASA scores.

RESULTS

A total of 5805 patients met the inclusion criteria, 2718 (46.8%) of which were ASA class I-II and 3087 (53.2%) were ASA class III-IV. Multivariate logistic regression revealed ASA class to be a significant risk factor for mortality (odds ratio [OR] = 21.0), reoperation within 30 days (OR = 1.6), length of stay ≥5 days (OR = 1.7), overall morbidity (OR = 1.4), wound complications (OR = 1.8), pulmonary complications (OR = 2.3), cardiac complications (OR = 3.7), intra-/postoperative red blood cell transfusion (OR = 1.3), postoperative sepsis (OR = 2.7), and urinary tract infection (OR = 1.6).

CONCLUSIONS

This is the first study evaluating the role of ASA class in ASD surgery with a large patient database. Use of ASA class as a metric for preoperative health was verified and the association of ASA class with postoperative morbidity and mortality in ASD surgery suggests its utility in refining the risk stratification profile and improving preoperative patient counseling for those individuals undergoing ASD surgery.

Patient survival and surgical re-intervention predictors for intracapsular hip fractures

BACKGROUND

Choosing between total hip replacement (THR) and partial hip replacement (PHR) for patients with intracapsular hip fractures is often based on subjective factors. Predicting the survival of these patients and risk of surgical re-intervention is essential to select the most adequate implant.

METHODS

We conducted a retrospective cohort study on mortality of patients over 70 years with intracapsular hip fractures who were treated between January 2010 and December 2013, with either PHR or THR. Patients' information was withdrawn from our local computerized database. The age-adjusted Charlson comorbidity index (ACCI) and American Society of Anesthesiologists (ASA) score were calculated for all patients. The patients were followed for 2 years after surgery. Survival and surgical re-intervention rates were compared between the two groups using a Multivariate Cox proportional hazard model.

RESULTS

A total of 356 individuals were included in this study. At 2 years of follow-up, 221 (74.4%) of the patients with ACCI score≤7 were still alive, in contrast to only 20 (29.0%) of those with ACCI score>7. In addition, 201 (76.2%) of the patients with ASA score≤3 were still alive after 2 years, compared to 30 (32.6%) of individuals with ASA >3. Patients with the ACCI score>7, and ASA score>3 had a significant increase in all-cause 2-year mortality (adjusted hazard ratio of 3.2, 95% CI 2.2-4.6; and 3.12, 95% CI 2.2-4.5, respectively). Patients with an ASA score>3 had a quasi-significant increase in the re-intervention risk (adjusted hazard ratio 2.2, 95% CI 1.0-5.1). The sensitivity, specificity, positive predictive value and negative predictive values of ACCI in predicting 2-year mortality were 39.2%, 91.1%, 71%, and 74.4%, respectively. On the other hand, the sensitivity, specificity, positive predictive value and negative predictive values of ASA score in predicting 2-year mortality were 49.6%, 79.1%, 67.4%, and 76.1%, respectively.

CONCLUSIONS

Both ACCI and ASA scales were able to predict the 2-year survival of patients with intracapsular hip fractures. The ASA scale was also able to predict the risk of re-intervention in these patients.

Fitness plus American Society of Anesthesiologists grade improve outcome prediction after endovascular aneurysm repair

BACKGROUND

Although the American Society of Anesthesiologists (ASA) grade was established for statistical purposes, it is often used prognostically. However, older patients undergoing elective surgery are typically ASA III, which limits patient stratification. We look at the prognostic effect on early complications and survival of using ASA and self-reported physical fitness to stratify patients undergoing endovascular repair of abdominal aortic aneurysms.

METHODS

Data were extracted from a trial database. All patients were assigned a fitness level (A (fit) or B (unfit)) based on their self-reported ability to walk briskly for 1 km or climb two flights of stairs. Fitness was used to stratify ASA III patients, with fitter patients assigned ASA IIIA and less fit patients ASA IIIB. Outcomes assessed included survival, reinterventions, endoleak, all early and late complications and early operative complications.

RESULTS

A combined ASA/fitness scale (II, IIIA, IIIB and IV) correlated with 1- and 3-year survival (1-year P = 0.001, 3-year P = 0.001) and early and late complications (P = 0.001 and P = 0.05). On its own, ASA predicted early complications (P = 0.0004) and survival (1-year P = 0.01, 3-year P = 0.01). Fitness alone was predictive for survival (1-year P = 0.001, 3-year P = 0.001) and late complications (P = 0.009).

CONCLUSION

This study shows that even a superficial assessment of fitness is reflected in surgical outcomes, with fitter ASA III patients showing survival patterns similar to ASA II patients. Physicians should be alert to differences in fitness between patients in the ASA III group, despite similarities based on preexisting severe systemic disease.

Comparative study for better adjuvant with ropivacaine in epidural anesthesia

BACKGROUND

Better adjuvants for epidural analgesia are still evolving. Dexmedetomidine that is alpha-2 agonist can be used as an adjuvant in epidural analgesia and anesthesia.

AIMS

The aim of this study was to compare the effect of dexmedetomidine versus clonidine in combination with ropivacaine in epidural anesthesia on intraoperative and postoperative analgesia, to find out the better adjuvant for regional anesthesia.

SETTINGS AND DESIGN

Randomized control trial.

MATERIALS AND METHODS

Sixty adult patients (18-60 years) with American Society of Anesthesiologists (ASA) 1/ASA 2 grade and undergoing lower abdominal and lower limbs surgeries were included and randomized into three groups of 20 patients each. Group 1 - received ropivacaine with normal saline. Group 2 - received ropivacaine with dexmedetomidine. Group 3 - received ropivacaine with clonidine.

STATISTICAL ANALYSIS

Mean and Standard deviation were calculated. All the data were analyzed using analysis of variance and Chi-square test. The value of P< 0.05 was considered significant.

RESULTS

All the three groups were comparable with respect to age, sex, and ASA grade. There was statistically significant mean time to reach T10 sensory block level (15.8, 5.7, 9.6 min in Groups 1, 2, and 3, respectively). The maximum duration of analgesia was statistically higher in Group 2 patients (383.7 vs. 365.3 and 280.5 min in Group 3 and Group 1, respectively). The mean time to reach motor block was significantly shorter in Group 2. Side effects were comparable in all groups with statistically insignificant fall in mean arterial pressure and hypotension was noted with Group 2.

CONCLUSION

We concluded that the patients receiving the addition of dexmedetomidine to ropivacaine in epidural anesthesia had a faster onset and longer duration of sensory and motor blockade. Dexmedetomidine in comparison to clonidine had acceptable sedation and hemodynamic stability and minimal dose requirement make very effective adjuvant in epidural anesthesia with comparable side effects.

Laparoscopic gastrectomy for gastric cancer in the elderly patients

BACKGROUND

This study aimed to investigate the short-term surgical outcomes of laparoscopic gastrectomy for gastric cancer in elderly patients in order to determine the safety, feasibility, and risk factors for postoperative complications associated with this procedure.

METHODS

We retrospectively investigated 208 patients who underwent laparoscopic gastrectomy for gastric cancer between January 2007 and September 2014. After excluding 15 patients with unusual medical histories or surgical treatments, 193 were selected for this cohort study. We divided the patients into two cohorts: elderly patients (≥75 years old) and non-elderly patients (<74 years old). We compared these cohorts with respect to clinicopathological characteristics and intraoperative and postoperative parameters.

RESULTS

The overall complication rates were 11.4% (8 of 70 patients) in the elderly cohort and 8.1% (10 of 123 patients) in the non-elderly cohort (P = 0.449). In a univariate analysis, Charlson comorbidity index (CCI) of ≥3, American Society of Anesthesiologists (ASA) score of 3, operative time of ≥330 min, and intraoperative blood loss of ≥50 ml were found to correlate significantly with postoperative complications. In a multivariate analysis, CCI of ≥3 (P = 0.034), ASA score of 3 (P = 0.019), and intraoperative blood loss of ≥50 ml (P = 0.016) were found to be independent risk factors of postoperative complications. In contrast, age was not found to significantly affect the risk of postoperative complications.

CONCLUSIONS

Laparoscopic gastrectomy for gastric cancer can be successfully performed in elderly patients with an acceptable complication rate. This study suggested that high CCI, ASA score, and intraoperative blood loss volume were identified as independent predictors of postoperative complications after laparoscopic gastrectomy for gastric cancer.

Endoscopic hemostasis is rarely used for hematochezia: a population-based study from the Clinical Outcomes Research Initiative National Endoscopic Database

BACKGROUND

Data on the use of endoscopic hemostasis performed during colonoscopy for hematochezia are primarily derived from expert opinion and case series from tertiary care settings.

OBJECTIVES

To characterize patients with hematochezia who underwent in-patient colonoscopy and compare those who did and did not receive endoscopic hemostasis.

DESIGN

Retrospective analysis.

SETTING

Clinical Outcomes Research Initiative National Endoscopic Database, 2002 to 2008.

PATIENTS

Adults with hematochezia.

INTERVENTIONS

None.

MAIN OUTCOME MEASUREMENTS

Demographics, comorbidities, practice setting, adverse events, and colonoscopy procedural characteristics and findings.

RESULTS

We identified 3151 persons who underwent in-patient colonoscopy for hematochezia. Endoscopic hemostasis was performed in 144 patients (4.6%). Of those who received endoscopic hemostasis, the majority were male (60.3%), white (83.3%), and older (mean age 70.9 ± 12.3 years); had a low-risk American Society of Anesthesiologists classification (53.9%); and underwent colonoscopy in a community setting (67.4%). The hemostasis-receiving cohort was significantly more likely to be white (83.3% vs 71.0%, P = .02), have more comorbidities (classes 3 and 4, 46.2% vs 36.0%, P = .04), and have the cecum reached (95.8% vs 87.7%, P = .003). Those receiving hemostasis were significantly more likely to have an endoscopic diagnosis of arteriovenous malformations (32.6% vs 2.6%, P = .0001) or a solitary ulcer (8.3% vs 2.1%, P < .0001).

LIMITATIONS

Retrospective database analysis.

CONCLUSIONS

Less than 5% of persons presenting with hematochezia and undergoing inpatient colonoscopy received endoscopic hemostasis. These findings differ from published tertiary care setting data. These data provide new insights into in-patient colonoscopy performed primarily in a community practice setting for patients with hematochezia.

Comparison of prospective risk estimates for postoperative complications: human vs computer model

BACKGROUND

Surgical quality improvement tools such as NSQIP are limited in their ability to prospectively affect individual patient care by the retrospective audit and feedback nature of their design. We hypothesized that statistical models using patient preoperative characteristics could prospectively provide risk estimates of postoperative adverse events comparable to risk estimates provided by experienced surgeons, and could be useful for stratifying preoperative assessment of patient risk.

STUDY DESIGN

This was a prospective observational cohort. Using previously developed models for 30-day postoperative mortality, overall morbidity, cardiac, thromboembolic, pulmonary, renal, and surgical site infection (SSI) complications, model and surgeon estimates of risk were compared with each other and with actual 30-day outcomes.

RESULTS

The study cohort included 1,791 general surgery patients operated on between June 2010 and January 2012. Observed outcomes were mortality (0.2%), overall morbidity (8.2%), and pulmonary (1.3%), cardiac (0.3%), thromboembolism (0.2%), renal (0.4%), and SSI (3.8%) complications. Model and surgeon risk estimates showed significant correlation (p < 0.0001) for each outcome category. When surgeons perceived patient risk for overall morbidity to be low, the model-predicted risk and observed morbidity rates were 2.8% and 4.1%, respectively, compared with 10% and 18% in perceived high risk patients. Patients in the highest quartile of model-predicted risk accounted for 75% of observed mortality and 52% of morbidity.

CONCLUSIONS

Across a broad range of general surgical operations, we confirmed that the model risk estimates are in fairly good agreement with risk estimates of experienced surgeons. Using these models prospectively can identify patients at high risk for morbidity and mortality, who could then be targeted for intervention to reduce postoperative complications.

Development and validation of a risk calculator for predicting postoperative pneumonia

OBJECTIVE

To identify preoperative factors associated with an increased risk of postoperative pneumonia and subsequently develop and validate a risk calculator.

PATIENTS AND METHODS

The American College of Surgeons' National Surgical Quality Improvement Program, a multicenter, prospective data set (2007-2008) was used. Univariate and multivariate logistic regression analyses were performed. The 2007 data set (N=211,410) served as the training set, and the 2008 data set (N=257,385) served as the validation set.

RESULTS

In the training set, 3825 patients (1.8%) experienced postoperative pneumonia. Patients who experienced postoperative pneumonia had a significantly higher 30-day mortality (17.0% vs 1.5%; P<.001). On multivariate logistic regression analysis, 7 preoperative predictors of postoperative pneumonia were identified: age, American Society of Anesthesiologists class, chronic obstructive pulmonary disease, dependent functional status, preoperative sepsis, smoking before operation, and type of operation. The risk model based on the training data set was subsequently validated on the validation data set, with model performance being very similar (C statistic: 0.860 and 0.855, respectively). The high C statistic indicates excellent predictive performance. The risk model was used to develop an interactive risk calculator.

CONCLUSION

Preoperative variables associated with an increased risk of postoperative pneumonia include age, American Society of Anesthesiologists class, chronic obstructive pulmonary disease, dependent functional status, preoperative sepsis, smoking before operation, and type of operation. The validated risk calculator provides a risk estimate for postoperative pneumonia and is anticipated to aid in surgical decision making and informed patient consent.

Preoperative pelvic radiation increases the risk for ileal pouch failure in patients with colitis-associated colorectal cancer

BACKGROUND AND AIMS

To evaluate the impact of preoperative radiation on pouch outcomes in patients with colitis-associated cancer (CAC).

METHODS

CAC patients who underwent restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) from 1984 to 2009 were identified from our registry. The impact of preoperative pelvic radiation for CAC or other pelvic cancer on pouch related outcomes was evaluated.

RESULTS

Sixty-three pouch patients with confirmed CAC were included (37 male, 58.7%). The mean age at pouch construction was 46.9±10.6 years. Seven patients were excluded due to the presence of persistent diverting ileostomy (n=2) or no follow-up (n=5). The remaining 56 patients were analyzed, including 9 who received pelvic radiation prior to IPAA creation for CRC or other cancers. Preoperative pelvic radiation was significantly associated with chronic pouchitis (P=0.024). There was, however, no correlation between pelvic radiation and pouch/anal transitional zone neoplasia, pouch stricture, pelvic abscess and pouch fistula/sinus. Pouch failure occurred in 13 patients after a median follow-up of 66.4 (range: 2.7-322.2) months. Although a simple statistical analysis based on the number of patients with pouch failure did not achieve significance (4/9 vs. 9/47, P=0.19), Kaplan-Meier analysis showed a strong association between preoperative pelvic radiation and the risk for pouch failure (P<0.001). A subgroup analysis of rectal cancer patients revealed that 3/7 patients (42.9%) with radiation and 3/17 (17.6%) without had pouch failure (P=0.31). Again, the association between pelvic radiation and pouch failure was confirmed using Kaplan-Meier analysis (P=0.02).

CONCLUSIONS

Pelvic radiation administered prior to IPAA creation appears to be associated with poor pouch outcomes. Oncological benefits and pouch functional outcomes should be carefully balanced before pelvic radiation is considered prior to restorative proctocolectomy.

Risk analysis and stratification of surgical morbidity after immediate breast reconstruction

BACKGROUND

Surgical complications after breast reconstruction can be associated with significant morbidity, dissatisfaction, and cost. We used the ACS-NSQIP datasets from 2005 to 2011 to derive predictors of morbidity and to stratify risk after immediate breast reconstruction (IBR).

STUDY DESIGN

Surgical complications after implant and autologous reconstruction were assessed using the ACS-NSQIP 2005 to 2011 datasets. Patient demographics, clinical characteristics, and operative factors were associated with the likelihood of experiencing a surgical complication. A "model cohort" of 12,129 patients was randomly selected from the study cohort to derive predictors. Weighted odds ratios derived from logistic regression analysis were used to create a composite risk score and to stratify patients. The remaining one-third of the cohort (n = 6,065) were used as the "validation cohort" to assess the accuracy value of the risk model.

RESULTS

On adjusted analysis, autologous reconstruction (odds ratio [OR] 1.41, p < 0.001), American Society of Anesthesiologists physical status ≥ 3 (OR 1.25, p = 0.004), class I obesity (OR 1.38, p < 0.001), class II obesity (OR 1.91, p < 0.001), class III obesity (OR 1.70, p < 0.001), and active smoking (OR 1.46, p < 0.001) were associated with complications. Risk factors were weighted and patients were stratified into low (0 to 2, n = 9,133, risk = 7.14%), intermediate (3 to 4, n = 1,935, risk = 10.90%), high (5 to 7, n = 1,024, risk = 16.70%), and very high (8 to 9, n = 37, risk = 27.02%) risk categories based on their total risk score (p < 0.001). Internal validation of the "model cohort" using the "validation cohort" was performed demonstrating accurate prediction of risk across groups: low (7.1% vs 7.1%, respectively, p = 0.9), intermediate (10.9% vs 12.0%, respectively, p = 0.38), high (16.7% vs 16.8%, respectively, p = 0.95), and very high (27.0% vs 30.0%, respectively, p = 1.0).

CONCLUSIONS

Surgical complications after IBR are related to preoperatively identifiable factors that can be used to accurately risk stratify patients, which may assist with counseling, selection, and perioperative decision-making.

Development and validation of a risk-stratification score for surgical site occurrence and surgical site infection after open ventral hernia repair

BACKGROUND

Current risk-assessment tools for surgical site occurrence (SSO) and surgical site infection (SSI) are based on expert opinion or are not specific to open ventral hernia repairs. We aimed to develop a risk-assessment tool for SSO and SSI and compare its performance against existing risk-assessment tools in patients with open ventral hernia repair.

STUDY DESIGN

A retrospective study of patients undergoing open ventral hernia repair (n = 888) was conducted at a single institution from 2000 through 2010. Rates of SSO and SSI were determined by chart review. Stepwise regression models were built to identify predictors of SSO and SSI and internally validated using bootstrapping. Odds ratios were converted to a point system and summed to create the Ventral Hernia Risk Score (VHRS) for SSO and SSI, respectively. Area under the receiver operating characteristic curve was used to compare the accuracy of the VHRS models against the National Nosocomial Infection Surveillance Risk Index, Ventral Hernia Working Group (VHWG) grade, and VHWG score.

RESULTS

The rates of SSO and SSI were 33% and 22%, respectively. Factors associated with SSO included mesh implant, concomitant hernia repair, dissection of skin flaps, and wound class 4. Predictors of SSI included concomitant repair, dissection of skin flaps, American Society of Anesthesiologists class ≥ 3, wound class 4, and body mass index ≥ 40. The accuracy of the VHRS in predicting SSO and SSI exceeded National Nosocomial Infection Surveillance and VHWG grade, but was not better than VHWG score.

CONCLUSIONS

The VHRS identified patients at increased risk for SSO/SSI more accurately than the National Nosocomial Infection Surveillance scores and VHWG grade, and can be used to guide clinical decisions and patient counseling.

Wound classification in pediatric general surgery: significant variation exists among providers

BACKGROUND

Risk-adjusted rates of surgical site infections (SSI) are used as a quality metric to facilitate improvement within a hospital system and allow comparison across institutions. The NSQIP-Pediatric, among others, uses surgical wound classification as a variable in models designed to predict risk-adjusted postoperative morbidity, including SSI rates. The purpose of this study was to measure the level of agreement in wound classification assignment among 3 providers: surgeons, operating room (OR) nurses, and NSQIP surgical clinical reviewers (SCR).

STUDY DESIGN

An analysis was performed of pediatric general surgery operations from 2010 to 2011. Wound classification was assigned at the time of operation by the OR nurse and surgeon, and by the NSQIP SCR postoperatively, according to NSQIP methodology. Disagreement was defined as any discrepancy in classification among the 3 providers, and the level of agreement was determined using the kappa statistic.

RESULTS

For the 374 procedures reviewed, there was an overall disagreement of 48% among all providers, kappa 0.48 (95% CI 0.43 to 0.53). When comparing wound classification by surgeon and NSQIP SCR, 23% of cases were in disagreement, kappa 0.74 (95% CI 0.68 to 0.78). Disagreement between OR nurse and either surgeon or NSQIP SCR was higher: 38%, kappa 0.45 (95% CI 0.38 to 0.53) and 40%, kappa 0.44 (95% CI 0.37 to 0.51). Fundoplication, appendectomy, and cholecystectomy demonstrated the highest overall disagreement (73%, 71%, and 60%, respectively).

CONCLUSIONS

There is significant variation in assigning surgical wound classification among health care providers. For future SSI comparative analyses, it will be critical to improve uniformity and understanding of wound class assignment among providers and institutions.

Risk-scoring model for prediction of non-home discharge in epithelial ovarian cancer patients

BACKGROUND

Identification of preoperative factors predictive of non-home discharge after surgery for epithelial ovarian cancer (EOC) may aid counseling and optimize discharge planning. We aimed to determine the association between preoperative risk factors and non-home discharge.

STUDY DESIGN

Patients who underwent primary surgery for EOC at Mayo Clinic between January 2, 2003 and December 29, 2008 were included. Demographic, preoperative, and intraoperative factors were retrospectively abstracted. Logistic regression models were fit to identify preoperative factors associated with non-home discharge. Multivariable models were developed using stepwise and backward variable selection. A risk-scoring system was developed for use in preoperative counseling.

RESULTS

Within our cohort of 587 EOC patients, 12.8% were not discharged home (61 went to a skilled nursing facility, 1 to a rehabilitation facility, 1 to hospice, and there were 12 in-hospital deaths). Median length of stay was 7 days (interquartile range [IQR] 5, 10 days) for patients dismissed home compared with 11 days (IQR 7, 17 days) for those with non-home dismissals (p < 0.001). In multivariable analyses, patients with advanced age (odds ratio [OR] 3.75 95% CI [2.57, 5.48], p < 0.001), worse Eastern Cooperative Oncology Group (ECOG) performance status (OR 0.92 [95% CI 0.43, 1.97] for ECOG performance status 1 vs 0 and OR 5.40 (95% CI 2.42, 12.03) for score of 2+ vs 0; p < 0.001), greater American Society of Anesthesiologists (ASA) score (OR 2.03 [95% CI 1.02, 4.04] for score ≥3 vs < 3, p = 0.04), and higher CA-125 (OR 1.28 [95% CI 1.12, 1.46], p < 0.001) were less likely to be discharged home. The unbiased estimate of the c-index was excellent at 0.88, and the model had excellent calibration.

CONCLUSIONS

Identification of preoperative factors associated with non-home discharge can assist patient counseling and postoperative disposition planning.

Abdominal aortic aneurysms: endovascular options and outcomes - proliferating therapy, but effective?

Abdominal aortic aneurysm (AAA) has a reported prevalence rate of 1.4% in the US. AAA rupture accounts for an estimated 15,000 deaths per year, rendering it the 10th leading cause of death in men over the age of 55. Endovascular repair (EVR) has proliferated in the last two decades as an increasingly popular alternative to traditional open surgery, and is now the default treatment in the majority of centres worldwide. This review article outlines the evidence supporting this stance. The development of EVR is reviewed, alongside trends in utilisation of this therapy over time. The evidence for the relative short-term and long-term outcomes of EVR and open AAA repair is discussed, and ongoing controversies surrounding the use of EVR are considered.

Evaluation of the reliability of clinical staging of T2 N0 esophageal cancer: a review of the Society of Thoracic Surgeons database

BACKGROUND

Clinical staging of esophageal cancer has improved with positron-emission tomography/computed tomography and endoscopic ultrasound imaging. Despite such progress, small single-center studies have questioned the reliability of clinical staging of T2 N0 esophageal cancer. This study broadly examines the adequacy of clinical staging of T2 N0 disease using The Society of Thoracic Surgeons database.

METHODS

We retrospectively studied 810 clinical stage T2 N0 patients from 2002 to 2011, with 58 excluded because of incomplete pathologic staging data. Clinical stage, pathologic stage, and preoperative characteristics were recorded. Logistic regression analysis was used to identify factors associated with upstaging at the time of surgical intervention.

RESULTS

Among 752 clinical stage T2 N0 patients, 270 (35.9%) received induction therapy before the operation. Of 482 patients who went directly to surgical intervention, 132 (27.4%) were confirmed as pathologic T2 N0, 125 (25.9%) were downstaged (ie, T0-1 N0), and 225 (46.7%) were upstaged at the operation (T3-4 N0 or Tany N1-3). Exclusive tumor upstaging (ie, pathologic T3-4 N0) accounted for 41 patients (18.2%), whereas exclusive nodal upstaging (ie, pathological T1-2 N1-3) accounted for 100 (44.5%). Combined tumor and nodal upstaging (ie, pathological T3-4 N1-3) accounted for 84 patients (37.3%). Among patients who received induction therapy, 103 (38.1%) were upstaged vs 225 (46.7%) without induction therapy (p = 0.026). Comparing the induction therapy group and the primary surgical group, postoperative 30-day mortality (3.7% vs 3.7%, p > 0.99) and morbidity (46.3% vs 45%, p = 0.76) were similar.

CONCLUSIONS

Despite advances in staging techniques, clinical staging of T2 N0 esophageal cancer remains unreliable. Recognizing T2 N0 as a threshold for induction therapy in esophageal cancer, many surgeons have opted to treat T2 N0 disease with induction therapy, even though one-quarter of these patients will be pathologic T1 N0. Although this study demonstrated similar perioperative morbidity and mortality with and without induction therapy, further study is needed to examine the effect of upstaging on long-term survival.

Do not resuscitate orders--managing the dilemma

The status of DNR orders (or equivalent declarations) in patients undergoing surgery will continue to present considerable challenges for both healthcare providers and patients, or their alternate decision makers. It is essential that all parties understand the specifics of each DNR order, focusing not only on the actual content of the order or declaration but also on the context in terms of location, timing and circumstance. The principle of "respect for persons" should guide, inform and shape the approach followed with each patient. Meaningful dialogue and "negotiation" will be required. Make no assumptions! The "required reconsideration" of pre-existing DNR orders should be the basic approach followed. There is no single "solution" for all DNR-related issues in the peri-operative period. What may appear obvious to the anaesthetist may be viewed entirely differently by the patient, or even by other members of the care giving team. There is no justification for either the automatic suspension or the automatic continuation of DNR orders in patients undergoing surgery. A patient-specific and situation-specific approach and "solution" is required. Similar principles will apply in acute care settings other than the operating room. Full engagement by health care workers in the processes addressing these issues should be a personally enriching experience.