30-day Surgical Complications Research Articles

Iliac Artery Stenting Combined with Ipsilateral Open Femoro-Popliteal Revascularization and Its Effect on Bypass Patency

In cases of multilevel obstructive atherosclerotic disease, hybrid procedures of concomitant iliac artery stenting and femoro-popliteal bypass (IS-FPB) may represent a valid approach, but results are still unclear. The aim was to evaluate early and long-term outcomes of concurrent IS-FPB. This retrospective study included 75 patients (76 limbs) treated with concomitant IS-FPB between January 2010 and June 2016. All patients were prospectively enrolled in a dedicated database. Long-term patency and limb salvage rates were reported using Kaplan-Meier curves. Clinical presentation, lesion sites and extension, distal runoff, type of stent, and bypass were evaluated for their association with patency using univariate and multivariate analysis. Mean age was 72.2±9.4years; the Society for Vascular Surgery comorbidity score was 1.14±0.61. A covered stent (CS) was implanted in 41 (54%) iliac arteries and a bare-metal stent in 35 (46%); a polytetrafluoroethylene graft was used for bypass in 44 limbs (58%) while 32 limbs (42%) had great saphenous vein bypass. Technical success was 99%; the 30-day cumulative surgical complications rate was 6%, mortality 2%, and morbidity 1%. At 42months, primary patency of the entire ilio-femoral axis was 65.2% (95% confidence interval [CI], 53-86%). This finding was primarily related to femoro-popliteal bypass occlusion (primary patency, 69.5%), rather than iliac stent loss of patency (primary patency, 94.6%). Secondary patency was 77.6% and limb salvage 89.9%. Univariate analysis demonstrated that Rutherford category 5/6 was a negative predictor of FPB patency (P=0.04), whereas common femoral artery endarterectomy (P=0.03) and the use of a CS (P=0.02) were positive predictors. Multivariate analysis finally indicated that the use of CS to treat iliac obstructive disease was an independent predictor of patency (hazard ratio, 0.15; 95% CI, 0.03-0.64; P=0.01). Concurrent IS-FPB has acceptable early and long-term results. Even if further studies are needed, the use of a CS for the iliac obstruction seem to provide better outcomes in the hybrid treatment of these cases of multilevel disease.

Avascular Necrosis Is Associated With Increased Transfusions and Readmission Following Primary Total Hip Arthroplasty.

Avascular necrosis (AVN) may confer an increased risk of complications and readmission following total hip arthroplasty (THA). However, current risk-adjustment models do not account for AVN. A total of 1706 patients who underwent THA for AVN from 2011 to 2013 were selected from the American College of Surgeon's National Surgical Quality Improvement Program database and matched 1:1 to controls using a predetermined propensity score algorithm. Rates of 30-day medical and surgical complications, readmissions, and reoperations were compared between cohorts. Propensity-score logistic regression was used to determine independent associations between AVN and outcomes of interest. Patients with AVN had a higher rate of medical complications than those without AVN (20.3% vs 15.3%, respectively; P<.001). Bleeding transfusion was the most common medical complication, occurring at a significantly higher rate in patients with AVN than those without AVN (19.6% vs 13.9%, respectively; P<.001). Patients with AVN were also twice as likely to experience a readmission after THA (odds ratio, 2.093; 95% confidence interval, 1.385-3.164). Avascular necrosis of the femoral head is an independent risk factor for transfusion up to 72 hours postoperatively and readmission up to 30 days following total hip replacement. [Orthopedics. 2017; 40(3):171-176.].

Initial experience of restorative proctocolectomy for ulcerative colitis by transanal total mesorectal rectal excision and single-incision abdominal laparoscopic surgery.

Laparoscopic surgery is well established for colon cancer, with defined benefits. Use of laparoscopy for the performance of restorative proctocolectomy (RPC) with ileoanal anastomosis is more controversial. Technical aspects include difficult dissection of the distal rectum and a potentially increased risk of anastomotic leakage through multiple firings of the stapler. In an attempt to overcome these difficulties we have used the technique of transanal rectal excision to perform the proctectomy. This paper describes the technique, which is combined with an abdominal approach using a single-incision platform (SIP). Data were collected prospectively for consecutive operations between May 2013 and October 2015, including all cases of restorative proctocolectomy with ileoanal pouch anastomosis performed laparoscopically. Only patients having a transanal total mesorectal excision (TaTME) assisted by SIP were included. The indication for RPC was ulcerative colitis (UC) refractory to medical treatment. The procedure was performed on 16 patients with a median age of 46 (26-70) years. The male:female ratio was 5:3 and the median hospital stay was 6 (3-20) days. The median operation time was 247 (185-470) min and the overall conversion rate to open surgery was 18.7%. The 30-day surgical complication rate was 37.5% (Clavien-Dindo 1 in four patients, 2 in one patient and 3 in one patient). One patient developed anastomotic leakage 2weeks postoperatively. This initial study has demonstrated the feasibility and safety of TaTME combined with SIP when performing RPC with ileal pouch-anal anastomosis for UC.

Surgical resident involvement in foot and ankle surgery.

Surgical resident participation in the operating room is necessary for education and progression toward safe and independent practice. However, the impact of resident involvement on patient outcomes in foot and ankle surgery is unknown. The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database (2005-2012) was used to identify common foot and ankle procedures (by Current Procedural Taxonomy (CPT) code) performed by orthopedic surgeons. Resident participation was determined using the NSQIP-collected variable 'pgy'; cases missing the pgy variable were excluded. Multivariate regression models were constructed to determine an association between resident involvement and 30-day morbidity (total, medical, and surgical complications) and 30-day mortality, when controlling for patient demographics, comorbidities, American Society for Anesthesiologist (ASA) status, body mass index (BMI), and smoking status. A total of 13,685 cases were analyzed for 24 common foot and ankle operations. Overall mortality rate was 3.60%. Overall complication rate was 16.9%; 10.9% had medical and 8.3% had surgical complications. Residents were involved in 55.6% of cases. In unadjusted analyses, resident cases were less likely to be emergent, but were performed on more complicated patients (i.e. higher comorbidity burden, higher ASA scores). Resident cases had increased total morbidity (18.8% vs. 14.6%, p<0.001), medical complications (12.5% vs. 9.0%, p<0.001), and surgical complications (8.7% vs. 7.7%, p=0.03), but similar mortality frequency (3.8% vs. 3.3%, p=0.2). In multivariable analyses, resident cases did not correlate with 30-day mortality, 30-day total morbidity, or 30-day surgical complications; resident cases were, however, associated with increased medical complications [Odds Ratio (OR) 1.18 (95% Confidence Interval (CI) 1.02-1.37, p=0.03)] and longer length of stay [Coeff 2.38 (1.68-3.09), p<0.001]. Subgroup analyses of orthopedic-only cases demonstrated no statistical association between resident involvement and mortality, total morbidity, or medical complications; a decrease in surgical complications was observed for open reduction internal fixation cases [OR 0.23 (0.06-0.82), p=0.02]. Resident involvement in foot and ankle surgery is not associated with changes in 30-day mortality, 30-day total morbidity, or 30-day surgical complication rates. Residents operate on more medically complex patients who experience higher medical complication rates and longer postoperative length of stay; however, the cause and directionality of this relationship remains to be determined. Efforts to improve the quality of foot and ankle surgery with resident involvement should target reductions in post-operative medical complications. Prognostic study, Level II.

Nutritional route in oesophageal resection trial II (NUTRIENT II): study protocol for a multicentre open-label randomised controlled trial

IntroductionEarly start of an oral diet is safe and beneficial in most types of gastrointestinal surgery and is a crucial part of fast track or enhanced recovery protocols. However, the...

Insulin dependence as an independent predictor of perioperative morbidity after ventral hernia repair: a National Surgical Quality Improvement Program analysis of 45,759 patients

BackgroundAlthough diabetes mellitus has been identified as a predictor of perioperative morbidity after ventral hernia repair (VHR), it is unclear whether insulin-dependent diabetes mellitus (IDDM) and non–insulin-dependent diabetes mellitus (NIDDM) confer the same degree of risk. We examined the variable effect of IDDM and NIDDM on 30-day medical and surgical complications after VHR. MethodsWe performed a retrospective analysis of patients in the National Surgical Quality Improvement Program database from 2005 to 2012 undergoing VHR. After perioperative variable comparison, regression analysis was performed to determine whether IDDM and/or NIDDM independently predicted increased complications after proper risk adjustment. ResultsA total of 45,759 patients were identified to have undergone VHR. Of these, 38,026 patients (83.1%) were not diabetic, 5,252 (11.5%) were NIDDM patients, and 2,481 (5.4%) were IDDM patients. After controlling for other risk factors, we found that IDDM independently predicted increased rates of overall, surgical, and medical complications (odds ratio, 1.284, 1.251, 1.263, respectively) in open repair. IDDM independently predicted increased overall and medical complications (odds ratio, 1.997, 1.889, respectively) but not surgical complications in laparoscopic repair. NIDDM was not significantly associated with any complication type in either procedure type. ConclusionsOur present study suggests that much of the perioperative risk associated with diabetes is attributable to IDDM. The effect of IDDM on laparoscopic and open repair is subtly different. IDDM demonstrates increased overall and medical complications in laparoscopic repair and increased overall, medical, and surgical complications in open repair. Of note, IDDM does not independently predict increased risk for surgical complications in laparoscopic repair.

Safety of cochlear implantation before 12 months of age: Medical University of South Carolina and Pediatric American College of Surgeons-National Surgical Quality improvement program outcomes.

The primary objective of this study was to determine the safety profile of cochlear implantation (CI) in infants <12 months old. Retrospective review of institutional (Medical University of South Carolina [MUSC]) and national data (Pediatric American College of Surgeons-National Surgical Quality Improvement Program [ACS-NSQIP]). Cases were subdivided into two groups according to age at CI: <12 months and 12 to 18 months. The primary outcome measure of interest was occurrence of a postoperative medical or surgical complication. Operative time, anesthesia time, time in the postoperative anesthesia care unit, and length of stay were also assessed. In infants <12 months of age, the incidence of a 30-day postoperative surgical complication using the ACS-NSQIP database was 3.6%; this did not differ from the rate observed in the 12- to 18-month-old group (3.2%, P = 1.0). In the MUSC series, the occurrence of a 30-day postoperative complication in children <12 months old was comparable (2.7%). At longer-term follow-up (mean = 3.7 years), the incidence of a postoperative surgical complication in infants <12 months old using MUSC data was 13.5%. When compared to older children at longer-term follow-up, no difference was noted (12.7%, P = 1.0). The incidence of a postoperative medical or anesthetic complication in children <12 months of age was extremely rare in both MUSC and ACS-NSQIP series (0% and 1.3%, respectively). Institutional and national data demonstrate that CI in children <12 months of age is a safe procedure. Although infants <12 months old are at risk for postoperative complications, the rates of surgical and medical complications were no different compared to children 12 to 18 months of age. 4 Laryngoscope, 126:707-712, 2016.

Outcomes of polytetrafluoroethylene-covered stent versus bare-metal stent in the primary treatment of severe iliac artery obstructive lesions

This study compared early and midterm outcomes of polytetrafluoroethylene-covered stents (CSs) vs bare-metal stents (BMSs) in the primary treatment of severe TransAtlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) C and D iliac artery obstructive lesions. Between January 2009 and June 2014, 128 patients underwent stenting of 167 iliac arteries; CSs were implanted in 82 iliac arteries (49%) and BMSs in 85 (51%). All patients were prospectively enrolled in a dedicated database. Thirty-day outcomes, mid-term patency, limb salvage, and survival were compared, and follow-up results were analyzed with Kaplan-Meier curves. Clinical presentation, lesion site, extension, and laterality were evaluated for their association with patency in the two groups using multiple logistic regressions. Patients were a mean age of 70± 10.3years, The Society for Vascular Surgery comorbidity score was 0.89± 0.57, with no differences after stratification by CS and BMS (P= .17). Iliac lesions were classified by limb as TASC II C in 86 (51%) and D in 81 (49%). Comparing CS and BMS, technical success was 99% in both groups (P= 1.0); the 30-day cumulative surgical complications rate (7.3% vs 4.7%; P= .53), mortality (1.8% vs 0%; P= .45), and morbidity (1.8% vs 1.4%; P= .99) were equivalent. At 24months (average 22months; range, 30 days-56 months), primary patency of CS vs BMS was similar (93% vs 80%; P= .14), and this finding was maintained after stratification by TASC II C (97% vs 93%; P= .59) and D (88% vs 61%; P= .07); secondary patency was 98% vs 92% (P= .22), and limb salvage was 99% and 95% (P= .35) respectively. Multivariate analysis indicated that BMS in long-segment stenosis involving the common and external iliac arteries was a negative predictor of patency (odds ratio, 0.16; 95% confidence interval, 0.04-0.62; P= .007); within this subgroup of TASC II D lesions, primary patency at 24months was significantly higher for CS than for BMS (88% vs 57%; P= .03). Overall, the use of CSs for severe iliac lesions has similar early and midterm outcomes compared with BMS. In a subcategory of TASC II D lesions with long-segment severe stenosis of both the common and external iliac arteries, CS should be considered as the primary line of treatment.

Longer Operative Time During Benign Laparoscopic and Robotic Hysterectomy Is Associated With Increased 30-Day Perioperative Complications.

The relationship between operative time and perioperative morbidity has not been fully characterized in gynecology. We aimed to determine the impact of operative time on 30-day perioperative complications after laparoscopic and robotic hysterectomy. Patients undergoing laparoscopic and robotic hysterectomy for benign disease from 2006 to 2011 within the National Surgical Quality Improvement Program (NSQIP) database were identified by Current Procedural Terminology code. Operative times were stratified into 60-minute intervals and complication rates analyzed. Primary outcomes included 30-day overall, medical, and surgical complications. Bivariate analyses using χ(2), Fisher's exact, and one-way analysis of variance tests were performed to compare clinical and procedural characteristics associated with longer operative time and complications. Multivariable logistic regression analyses were then performed to determine the independent association between operative time and perioperative complications. Canadian Task Force classification II-2 (Evidence obtained from well-designed cohort or case-control studies preferably from more than 1 center or research group). American College of Surgeons NSQIP. Patients who underwent laparoscopic or robotic hysterectomy for benign disease from 2006 to 2011 at any institution participating in NSQIP. None, retrospective database study. Of the 7630 laparoscopic and robotic hysterectomies identified, 399 patients (5.2%) experienced complications, most commonly urinary tract infection (UTI; 2.1%), superficial surgical site infection (1.0%), and blood transfusion (1.0%). Return to the operating room was required in 97 patients (1.3%), and there were 4 deaths, for a mortality rate of .05%. Complications increased steadily with longer operative time. Operative time ≥ 240 minutes was associated with increased overall complications (13.8% vs 4.6%, p<.001), surgical complications (5.4% vs 1.5%, p<.001), medical complications (10.4% vs 3.2%, p<.001), return to the operating room (2.7% vs 1.2%, p = .002), deep venous thrombosis (.5% vs .06%, p = .011), pulmonary embolism (.7% vs .1%, p = .012), and blood transfusion (3.4% vs .8%, p<.001). These associations remained statistically significant after multivariable regression analysis. Based on continuous regression modeling, each additional hour of operative time would be expected to increase odds of overall complications (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.28-1.54; p<.001), medical complications (OR, 1.42; 95% CI, 1.28-1.57; p<.001), surgical complications (OR, 1.32; 95% CI, 1.17-1.49; p<.001), venous thromboembolism (OR, 1.47; 95% CI, 1.12-1.92; p = .005), UTI (OR, 1.20; 95% CI, 1.05-1.36; p = .006), blood transfusion (OR, 1.42; 95% CI, 1.18-1.71; p<.001), and return to the operating room (OR, 1.25; 95% CI, 1.08-1.45; p = .003). We demonstrated a direct, independent association between operative time and 30-day complications after laparoscopic and robotic hysterectomy. Future research should aim to further delineate risk factors for prolonged operative time and morbidity in laparoscopic hysterectomy to allow surgeons to maximize preoperative planning and optimize patient selection for minimally invasive hysterectomy.

PWE-263 Outcomes after colorectal resection in octogenarians and nonagenarians - results of a 10 year single surgeon series

<h3>Introduction</h3> Against the background of an ageing population, few data are available on surgical outcomes in the elderly. This study aimed to compare outcomes after colorectal resection for benign and malignant disease in patients aged 80 years and above and those under 80. <h3>Method</h3> Data were prospectively recorded in a single consultant surgeon database from 2004 to 2014. The primary endpoint was in-hospital mortality. Secondary endpoints were anastomotic leak, 30-day reoperation rate, general and surgical complications, length of stay, readmission rates within 30 days and overall survival. All data were analysed using SPSS. <h3>Results</h3> Eighty-eight of 534 patients were aged 80 years and above. Of this elderly cohort, 10 were aged 90 years and above. Median follow-up was 18 months in the elderly cohort vs. 25 months in the younger cohort (p = 0.07). Seventy-nine of 88 (89.8%) resections in the elderly cohort were for malignancy vs. 355 of 446 (79.6%) in the younger cohort (p = 0.04). A significantly higher proportion of patients in the elderly cohort had an ASA status of 3 to 5 (53/88 [60.2%] vs. 180/446 [40.4%] in the younger cohort, p &lt; 0.0001). In-hospital mortality was non-significantly higher in the elderly group (3 of 88 [3.4%] vs. 7 of 446 [1.6%] in the younger group, p = 0.46). Anastomotic leak rates were similar (5 of 88 [5.7%] in the elderly vs. 26 of 446 [5.8%] in the younger group, p = 0.95), as were the 30-day reoperation rate (6/88 [6.8%] vs. 30/446 [6.7%], p = 0.90), general complications (7 of 88 [8.0%] vs. 44/446 [9.9%], p = 0.57), and surgical complications (6/88 [6.8%] vs. 49/446 [11.0%], p = 0.58) respectively. The median length of stay was two days longer in the elderly (12.8 days vs. 10.8 days, p = 0.06). Readmission rates were similar (1/88 [1.2%] in the elderly vs. 18/446 [4.0%], p = 0.61). The overall mean survival time was significantly shorter in the elderly compared to the younger cohort (55 vs. 98 months, p &lt; 0.0001). <h3>Conclusion</h3> Elderly patients tended to have more comorbidities which were reflected in a longer hospital stay compared with the younger cohort and had poorer overall survival, which is expected in the over 80s. Other outcomes were not significantly different, suggesting that colorectal resection has acceptable outcomes in the elderly and should be considered in selected patients. <h3>Disclosure of interest</h3> None Declared.

Creation and validation of a condition-specific venous thromboembolism risk assessment tool for ventral hernia repair

We used the database of the American College of Surgeons National Surgical Quality Improvement Program to (1) identify risk factors for 30-day venous thromboembolism (VTE) after ventral hernia repair (VHR) and (2) to create and validate a condition-specific assessment tool for the risk of VTE. Open and laparoscopic VHR patients in the American College of Surgeons National Surgical Quality Improvement Program were identified using Current Procedural Terminology code. The occurrence of VTE, including deep-venous thrombosis (DVT) or pulmonary embolus, within 30 days postoperatively was the primary outcome. Regression-based analysis and subsequent bootstrap analysis created a weighted VTE risk assessment model (RAM) for ventral hernia repair. The weighted RAM was used to risk-stratify patients for both 30-day VTE risk and 30-day risk for medical and surgical complications. Data for 113,873 hernia repair patients were obtained; 30-day deep-venous thrombosis, pulmonary embolus, and VTE rates were 0.59%, 0.43%, and 0.92%, respectively. The average time to VTE was 10.8 days. A 14-factor, weighted RAM was created. The weighted risk score identified a 25-fold variability (from 0.20 to 4.97%) in VTE risk among the overall VHR population. Although created to risk-stratify for VTE, the risk score also risk-stratified for 30-day medical and surgical complications, inpatient duration of stay, and 30-day mortality. The 30-day VTE risk after VHR is 0.92%, but a 25-fold variability in VTE risk exists among the overall hernia population. We demonstrate that a weighted VTE RAM quantifies VTE risk among the population undergoing ventral hernia repair, and that VTE risk score can also be used to risk-stratify for 30-day medical and surgical complications as well as mortality.

Sustainability and long-term effectiveness of the WHO surgical safety checklist combined with pulse oximetry in a resource-limited setting: two-year update from Moldova.

Little is known about the sustainability and long-term effect of surgical safety checklists when implemented in resource-limited settings. A previous study demonstrated the marked, short-term effect of a structured hospital-wide implementation of a surgical safety checklist in Moldova, a lower-middle-income country, as have studies in other low-resource settings. To assess the long-term reduction in perioperative harm following the introduction of a checklist-based surgical quality improvement program in a resource-limited setting and to understand the long-term effects of such programs. Twenty months after the initial implementation of a surgical safety checklist and the provision of pulse oximetry at a referral hospital in Moldova, a lower-middle-income, resource-limited country in Eastern Europe, we conducted a prospective study of perioperative care and outcomes of 637 consecutive patients undergoing noncardiac surgery (the long-term follow-up group), and we compared the findings with those from 2106 patients who underwent surgery shortly after implementation (the short-term follow-up group). Preintervention data were collected from March to July 2010. Data collection during the short-term follow-up period was performed from October 2010 to January 2011, beginning 1 month after the implementation of the launch period. Data collection during the long-term follow-up period took place from May 25 to July 6, 2012, beginning 20 months after the initial intervention. The primary end points of interest were surgical morbidity (ie, the complication rate), adherence to safety process measures, and frequency of hypoxemia. Between the short- and long-term follow-up groups, the complication rate decreased 30.7% (P = .03). Surgical site infections decreased 40.4% (P = .05). The mean (SD) rate of completion of the checklist items increased from 88% (14%) in the short-term follow-up group to 92% (11%) in the long-term follow-up group (P < .001). The rate of hypoxemic events continued to decrease (from 8.1 events per 100 hours of oximetry for the short-term follow-up group to 6.8 events per 100 hours of oximetry for the long-term follow-up group; P = .10). Sustained use of the checklist was observed with continued improvements in process measures and reductions in 30-day surgical complications almost 2 years after a structured implementation effort that demonstrated marked, short-term reductions in harm. The sustained effect occurred despite the absence of continued oversight by the research team, indicating the important role that local leadership and local champions play in the success of quality improvement initiatives, especially in resource-limited settings.

Oropharyngeal Contamination Predisposes to Complications after Neck Dissection: An Analysis of 9462 Patients.

While neck dissection is important in the treatment of head and neck cancer, there is a paucity of studies evaluating outcomes. We sought to compare preoperative variables and outcomes between clean and contaminated neck dissections, using the 2006-2011 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data sets. Retrospective review of prospectively maintained database. Multicenter (university hospitals; tertiary referral centers). A retrospective review was performed of the NSQIP database to identify patients undergoing neck dissection in clean vs oropharyngeal contaminated cases. Clinical factors, comorbidities, epidemiologic factors, and procedural characteristics were analyzed to identify factors associated with 30-day postoperative adverse events, including medical and surgical complications, unplanned reoperation, and mortality. Bivariate and multivariable analyses were performed for the outcome of one or more adverse events. In total, 8890 patients had clean neck dissections, while 572 patients had neck wound contamination with oropharyngeal flora. On multivariable regression analysis, oropharyngeal contamination was a significant risk factor for surgical complications (odds ratio [OR], 3.42; 95% confidence interval [CI], 1.96-5.96; P < .001). However, medical complications and mortality were not significantly different between the 2 cohorts. This finding persisted after subgroup analysis, with removal of all thyroidectomy patients from analysis (OR, 2.33; 95% CI, 1.25-4.36; P = .008). Using the ACS-NSQIP data set, this study found an increased risk of surgical complications in the setting of contaminated neck dissections. These data should be used for patient risk stratification, informed consent, and to guide further research.

Operative Time Longer Than 180 Minutes in Abdominal Hysterectomy is Predictive of 30-Day Perioperative Complications

Objectives: Hysterectomy remains one of the most commonly performed procedures in women, but risk factors for complications are incompletely understood. We aimed to utilize the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to investigate the impact of operative time on 30-day complication rates after benign abdominal hysterectomy. Materials and Methods: Data from ACS-NSQIP were retrieved for patients undergoing benign abdominal hysterectomy from 2006 to 2011. Given utilization of de-identified data, our Institutional Review Board deemed that formal review was not necessary. Patients were selected using Current Procedural Terminology (CPT) codes for total and subtotal abdominal hysterectomy, namely, 58150 and 58180. Primary outcomes were 30-day rates of medical, surgical, and overall complications and reoperation in relation to operative time. Operative times were divided into 60-minute intervals and complication rates analyzed. Bivariate analysis and multivariate regression modeling were performed to assess the association between operative time and complications. Results: A total of 16,864 abdominal hysterectomy procedures were identified. Rates of 30-day overall, medical, surgical complications, and reoperation were 12.4%, 9.2%, 4.2%, and 1.7%, respectively. Complication rates increased significantly with increasing operative time, with an inflection point noted at 180 minutes. Patients with operative time R180 minutes were more likely to be >50 years old, obese, nonsmokers, diabetic, hypertensive, ASA class 3-4, and to have higher RVU coded for the procedure. On bivariate analysis, operative time R180 minutes was associated with increased overall complications (25% versus 10.4%, p 0.001), surgical complications (7.1 versus 3.1%, p 0.001), medical complications (19.9% versus 7.5%, p 0.001), reoperation (2.5% versus 1.6%, p = 0.001), blood transfusion (14.3% versus 4%, p 0.001), deep venous thrombosis (0.5% versus 0.2%, p = 0.002), pulmonary embolism (1.1% versus 0.3%, p 0.001), and urinary tract infection (3.8% versus 2.3%, p 0.001). Mortality was low in both groups at 0.1%. After multivariable regression analysis, operative time R180 minutes was independently predictive of overall complications (OR = 2.3, 95% CI = 2.0 to 2.5, p 0.001), medical complications (OR = 2.4, 95% CI = 2.1 to 2.8, p 0.001), surgical complications (OR = 1.6, 95% CI = 1.3 to 1.9, p 0.001), blood transfusion (OR = 3.0, 95% CI = 2.5 to 3.4, p 0.001), venous thromboembolism (OR = 2.6, 95% CI = 1.7 to 4.0, p 0.001), and urinary tract infection (OR = 1.5, 95% CI = 1.2 to 1.9, p = 0.002). Conclusion: We have demonstrated a direct, independent correlation between increased operative time during abdominal hysterectomy and increased 30-day overall complications, medical complications, surgical complications, reoperation, blood transfusion, venous thromboembolism, and urinary tract infection. Additional study is needed regarding risk factors for prolonged operative time in hysterectomy, the comparative advantages and morbidity of minimally invasive hysterectomy relative to abdominal hysterectomy, and the relationship of these differential risks to operative time. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS: Tatiana Catanzarite: Nothing to disclose Brittany Vieira: Nothing to disclose Sujata Saha: Nothing to disclose John Y. Kim: Nothing to disclose Magdy Milad: Nothing to disclose

Lessons learned from the American College of Surgeons National Surgical Quality Improvement Program Database: has centralized data collection improved immediate breast reconstruction outcomes and safety?

The American College of Surgeons National Surgical Quality Improvement Program database was implemented to longitudinally track surgical 30-day surgical outcomes and complications. The authors analyze the program-reported outcomes for immediate breast reconstruction from 2007 to 2011, to assess whether longitudinal data collection has improved national outcomes and to highlight areas in need of continued improvement. The authors reviewed the database from 2007 to 2011 and identified encounters for immediate breast reconstruction using Current Procedural Terminology codes for prosthetic and autologous reconstruction. Demographics and comorbidities were tabulated for all patients. Postoperative complications analyzed included surgical-site infection, wound dehiscence, implant or flap loss, pulmonary embolism, and respiratory infections. A total of 15,978 patients underwent mastectomy and immediate reconstruction. Fewer smokers underwent immediate reconstruction over time (p=0.126), whereas more obese patients (p=0.001) and American Society of Anesthesiologists class 3 and 4 patients (p<0.001) underwent surgery. An overall increase in superficial surgical-site infection was noted, from 1.7 percent to 2.3 percent (p=0.214). Wound dehiscence (p=0.036) increased over time, whereas implant loss (p=0.015) and flap loss (p=0.012) decreased over time. Mean operative times increased over the analyzed years, as did all complications for prosthetic and autologous reconstruction. The American College of Surgeons National Surgical Quality Improvement Program data set has shown an increase in complications for immediate breast reconstruction over time, because of a longitudinally higher number of comorbid patients and longer operative times. This knowledge allows plastic surgeons the unique opportunity to improve patient selection criteria and efficiency. Therapeutic, III.

Physician Social Networks and Variation in Rates of Complications After Radical Prostatectomy

ObjectivesVariation in care within and across geographic areas remains poorly understood. The goal of this article was to examine whether physician social networks—as defined by shared patients—are associated with rates of complications after radical prostatectomy. MethodsIn five cities, we constructed networks of physicians on the basis of their shared patients in 2004-2005 Surveillance, Epidemiology and End Results-Medicare data. From these networks, we identified subgroups of urologists who most frequently shared patients with one another. Among men with localized prostate cancer who underwent radical prostatectomy, we used multilevel analysis with generalized linear mixed-effect models to examine whether physician network structure—along with specific characteristics of the network subgroups—was associated with rates of 30-day and late urinary complications, and long-term incontinence after accounting for patient-level sociodemographic, clinical factors, and urologist patient volume. ResultsNetworks included 2677 men in five cities who underwent radical prostatectomy. The unadjusted rate of 30-day surgical complications varied across network subgroups from an 18.8 percentage-point difference in the rate of complications across network subgroups in city 1 to a 26.9 percentage-point difference in city 5. Large differences in unadjusted rates of late urinary complications and long-term incontinence across subgroups were similarly found. Network subgroup characteristics—average urologist centrality and patient racial composition—were significantly associated with rates of surgical complications. ConclusionsAnalysis of physician networks using Surveillance, Epidemiology and End Results-Medicare data provides insight into observed variation in rates of complications for localized prostate cancer. If validated, such approaches may be used to target future quality improvement interventions.

Is nighttime the right time? Risk of complications after laparoscopic cholecystectomy at night.

Laparoscopic cholecystectomies can be performed at night in high-volume acute care hospitals. We hypothesized that nonelective nighttime laparoscopic cholecystectomies are associated with increased postoperative complications. We conducted a single-center retrospective review of consecutive laparoscopic cholecystectomy patients between October 2010 and May 2011 at a safety-net hospital in Houston, Texas. Data were collected on demographics, operative time, time of incision, length of stay, 30-day postoperative complications (ie, bile leak/biloma, common bile duct injury, retained stone, superficial surgical site infection, organ space abscess, and bleeding) and death. Statistical analyses were performed using STATA software (version 12; Stata Corp). During 8 months, 356 patients had nonelective laparoscopic cholecystectomies. A majority were female (n = 289 [81.1%]) and Hispanic (n = 299 [84%]). There were 108 (30%) nighttime operations. There were 29 complications in 18 patients; there were fewer daytime than nighttime patients who had at least 1 complication (4.0% vs 7.4%; p = 0.18). On multivariate analysis, age (odds ratio = 1.06 per year; 95% CI, 1.02-1.10; p = 0.002), case duration (odds ratio = 1.02 per minute; 95% CI, 1.01-1.02; p = 0.001), and nighttime surgery (odds ratio = 3.33; 95% CI, 1.14-9.74; p = 0.001) were associated with an increased risk of 30-day surgical complications. Length of stay was significantly longer for daytime than nighttime patients (median 3 vs 2 days; p < 0.001). Age, case duration, and nighttime laparoscopic cholecystectomy were predictive of increased 30-day surgical complications at a high-volume safety-net hospital. The small but increased risk of complications with nighttime laparoscopic cholecystectomy must be balanced against improved efficiency at a high-volume, resource-poor hospital.

A Population-Level Analysis of Bilateral Breast Reduction: Does Age Affect Early Complications?

As the American population ages, a growing number of women may suffer from symptomatic macromastia in their later years. The authors analyzed population data from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program database to investigate effects of age on 30-day surgical outcomes for reduction mammaplasty with the hope of improving patient care, counseling, and risk stratification. Overall, 3537 patients were included in the analysis. Outcome variables included 30-day postoperative major surgical, medical, and wound complications. Patients were initially stratified into 2 groups: <60 years and ≥60 years. The World Health Organization defines age >60 years as elderly. The authors then performed a subgroup analysis, further stratifying the younger cohort into <50 years and 50-60 years of age. Univariate analysis was performed to assess the dependency of preoperative factors on surgical outcomes (P < .05). Of the 3547 patients, 3050 were <60 years of age (39.7 ± 11.8 years) and 487 were ≥60 years of age (65.1 ± 4.7 years). A total of 182 thirty-day postoperative surgical complications were documented. Stratifying patients into 2 age groups did not reveal an association between age and any surgical complication (P = .26). This population-level analysis of reduction mammaplasty indicated that, with proper patient selection, the procedure can be performed safely on older patients.

Surgical Quality Is More Than Volume: The Association between Changing Urologists and Complications for Patients with Localized Prostate Cancer

To examine the association of changing urologists on surgical complications in men with prostate cancer. Registry and administrative claims data from the Surveillance, Epidemiology, and End Results-Medicare database from 1995 to 2005. A cross-sectional observational study of men with prostate cancer who underwent radical prostatectomy. Subjects were classified as having "changed urologists" if they had a different urologist who diagnosed their cancer from the one who performed their surgery. "Doubly robust" propensity score weighted multivariable logistic regression models were used to investigate the effect of changing urologists on 30-day surgical complications, late urinary complications, and long-term incontinence. Men who changed urologists between diagnosis and treatment had significantly lower odds of 30-day surgical complications compared with men who did not change urologists (odds ratio: 0.82; 95 percent confidence interval: 0.76-0.89), after adjustment. Changing urologists was associated with lower risks of 30-day complications for both black and white men compared with staying with the same urologist for their diagnosis and surgical treatment. Urologist changing is associated with the observed variation in complications following radical prostatectomy. This may suggest that patients are responding to aspects of surgical quality not captured in surgical volume.

Hand-Assisted Laparoscopic Versus Open Donor Nephrectomy: A Retrospective Comparison of Perioperative and Functional Results in a Tertiary Care Center in Mexico

BackgroundLaparoscopic nephrectomy for living donors is the current procedure of choice. Hand-assisted laparoscopic donor nephrectomy (HALDN) is the variation of this technique currently used in our institution. Though the advantages and disadvantages have been described for this procedure, the graft function compared with open surgery has been shown to be equal. We compared the outcomes of patients undergoing the former standard open donor nephrectomy (ODN) versus the current HALDN technique. MethodsIn this retrospective, comparative, and analytic study we reviewed our institutional database of renal transplantation procedures from January 2005 to April 2011 for perioperative variables and 1-year follow-up data. Donor renal function was evaluated with serum creatinine concentrations and estimated glomerular filtration rates with the Chronic Kidney Disease–Epidemiology formula. Complications were reported with the Clavien-Dindo classification. ResultsThe 190 consecutive donors included 99 ODN and 91 HALDN, who did not show baseline differences. ODN had a shorter mean operative time (217 ± 57.5 vs 270 ± 60.1 minutes) and shorter warm ischemia time (2.12 ± 1.4 vs 4.62 ± 2.7 minutes). HALDN had less operative blood loss (274.4 ± 198.1 vs 202.99 ± 157.1 mL) and shorter in-hospital stay (5.58 ± 2.2 vs 4.23 ± 1.8 days). There were no significant differences in 30-day surgical complications or transfusion requirements. No graft loss was reported. No difference in renal function was observed between the groups at days 1–2 or months 1, 6, or 12 after nephrectomy. ConclusionsLaparoscopic surgery has replaced conventional open surgery for living renal donors. HALDN is a safe and successful procedure compared with ODN. It is now the procedure of choice in our institution.