ACS-NSQIP Database Research Articles

Early drain removal after hepatectomy: an underutilized management strategy

BackgroundRecent data suggest that routine drainage is unnecessary in patients undergoing hepatectomy, but many surgeons continue to utilize drains. We compared the outcomes of patients undergoing early versus routine drain removal after hepatectomy. MethodsPatients having drains placed during major (≥3 segments) or partial hepatectomy (≤2 segments) were identified in the 2014-16 ACS-NSQIP database. Propensity matching between early (POD 0–3) and routine (POD 4–7) drain removal and multivariable regressions were performed. ResultsEarly drain removal was performed in 661 (40%) of patients undergoing a partial hepatectomy and 211 (22%) of major hepatectomy patients. After matching, 719 early and 719 routine drain removal patients were compared. Early drain removal patients had lower overall (12 vs 19%, p < 0.001) and serious (9 vs 13%, p < 0.03) morbidity as well as fewer bile leaks (2.1% vs 5.0%, p < 0.003). Length of stay was two days shorter (4 vs 6 days, p < 0.01) and readmissions were less frequent (5.4 vs 8.1%, p = 0.02) for patients undergoing early drain removal. ConclusionEarly drain removal is associated with fewer overall and serious complications, shorter length of stay and fewer readmissions. Early drain removal after hepatectomy is an underutilized management strategy.

Obesity and unanticipated hospital admission following outpatient laparoscopic cholecystectomy.

Compared to other common outpatient operations, laparoscopic cholecystectomy has higher rates of unanticipated hospital admission with reports ranging from 1.0 to 39.5%. Identification of simple preoperative risk factors for admission can aid appropriate patient selection. The aim of this study was to evaluate the association of obesity with need for hospital admission and day of surgery postoperative complications. The ACS NSQIP database from 2007 to 2016 was used to evaluate patients ≥ 18years old who had undergone outpatient laparoscopic cholecystectomy. The primary outcome was hospital admission,defined as hospital length of stay ≥ 24h. The secondary endpoint was postoperative complications on day of surgery. A multivariable logistic regression was used to evaluate the association of body mass index (BMI) and the outcomes of interest. Odds ratio (OR) and their 95% confidence interval (CI) were reported. 192,750 patients underwent laparoscopic cholecystectomy in the outpatient setting. 38,945 (20.20%) required hospital admission. 89 (0.05%) had postoperative complications on the day of surgery. On multivariable logistic regression analysis, when compared to the baseline cohort of BMI ≥ 30 and < 40kg/m2, patients with a BMI ≥ 50kg/m2 had a 10% increased odds of hospital admission (OR 1.10, CI 1.02-1.19, p < 0.001). BMI ≥ 40kg/m2 and < 50kg/m2 was not associated with increased odds of hospital admission (OR 0.99, CI 0.95-1.03, p 0.725). There was no increased odds of postoperative complications for patients with higher BMI (OR 1.35, CI 0.32-3.89, p < 0.623). Patients with super obesity have a 10% increased odds of hospital admission following laparoscopic cholecystectomy. Obesity is not associated with increased odds of same-day postoperative complications. Ambulatory laparoscopic cholecystectomy for the morbidly obese is safe; however, those with BMI > 50kg/m2 should be considered on a case-by-case basis.

Commentary: Reporting Methodology of Neurosurgical Studies Utilizing the ACS-NSQIP Database: A Systematic Review and Critical Appraisal.

Commentary: Reporting Methodology of Neurosurgical Studies Utilizing the ACS-NSQIP Database: A Systematic Review and Critical Appraisal.

Post-operative outcomes for patients with liver-related ascites undergoing non-emergent laparoscopic cholecystectomy

Surgical procedures in patients with cirrhosis and associated ascites carry significant morbidity and mortality. However, these patients often undergo non-emergent but necessary procedures such as laparoscopic cholecystectomy. The purpose of this study is to determine the impact of cirrhosis with ascites on non-emergent laparoscopic cholecystectomy. The ACS-NSQIP database was queried from 2005 to 2017 for patients undergoing non-emergent laparoscopic cholecystectomy with or without intra-operative cholangiogram. Groups were propensity score matched for age, sex, BMI, smoking, inpatient status, ASA Class, presence of pre-operative SIRS/sepsis, and the individual components of the 5-item modified frailty index. 346,105 patients were identified, 591 of which who had liver-related ascites. Patients without ascites were matched at a 5:1 ratio, producing 2955 controls. Patients with ascites had significantly higher rates of overall morbidity (15.6% vs. 11.3%, p = 0.0039), mortality (3.6% vs. 1.5%, p = 0.0020), and longer hospitalizations (7.4 vs. 4.4days, p < 0.0001). Patients with ascites and a MELD score less than or equal to 9 had no difference in morbidity (p = 0.1124) or mortality (p = 0.6021) when compared to patients without ascites. Patients with ascites and a MELD score greater than 9 had significantly higher rates of both morbidity (25.8%, p = 0.0056) and mortality (7.1%, p = 0.0333). Patients with cirrhosis and ascites have many comorbidities in addition to their liver disease. These patients are at significant risk for both morbidity and mortality related to non-emergent laparoscopic cholecystectomy. Surgeons should proceed with caution for patients with ascites and MELD scores greater than 9. These cases should only be performed by surgeons comfortable with difficult gallbladders at facilities equipped to take care of cirrhotic patients.

Can the Emergency Surgery Score (ESS) predict outcomes in emergency general surgery patients with missing data elements? A nationwide analysis

BackgroundThe Emergency Surgery Score (ESS) is an accurate mortality risk calculator for emergency general surgery (EGS). We sought to assess whether ESS can accurately predict 30-day morbidity, mortality, and requirement for postoperative Intensive Care Unit (ICU) care in patients with missing data variables. MethodsAll EGS patients with one or more missing ESS variables in the 2007–2015 ACS-NSQIP database were included. ESS was calculated assuming that a missing variable is normal (i.e. no additional ESS points). The correlation between ESS and morbidity, mortality, and postoperative ICU level of care was assessed using the c-statistics methodology. ResultsOut of a total of 4,456,809 patients, 359,849 were EGS, and of those 256,278 (71.2%) patients had at least one ESS variable missing. ESS correlated extremely well with mortality (c-statistic = 0.94) and postoperative requirement of ICU care (c-statistic = 0.91) and well with morbidity (c-statistic = 0.77). ConclusionESS performs well in predicting outcomes in EGS patients even when one or more data elements are missing and remains a useful bedside tool for counseling EGS patients and for benchmarking the quality of EGS care.

The effect of operative time on complication profile and length of hospital stay in autologous and implant-based breast reconstruction patients: An analysis of the 2007–2012 ACS-NSQIP database

It is a generally accepted relationship that an increase in operative time results in an increase in postoperative morbidity. However, few studies have investigated the minute by minute effect of increased operation time on outcomes in reconstructive breast surgery. The authors examined the association between operation time and postoperative outcomes for autologous and implant-based breast reconstructions. Data used in these analyses were extracted from all plastic surgery procedures identified in the 2007-2012 ACS-NSQIP datasets. Logistic regression models were used to examine associations between operation time and adverse outcomes. Generalized linear models using a Poisson distribution and a logarithmic link function were used to examine the association between the two continuous variables of operating time and the length of hospital admission. The results drawn from the database show a statistically significant association between operating length for autologous breast reconstructions and both surgical and medical complications. The OR of 1.0018 and 1.0015 for surgical and medical complications, respectively, reflects a minute by minute increase. For implant-based reconstructions, a similar association was seen with surgical complications with an OR of 1.004. Across both subgroups of breast reconstruction, there was a significant association between an increase in OR time and the length of hospital stay. We have shown a linear relationship that conveys a minute by minute increase in the complication profile and the chance of a longer hospital stay for breast reconstruction patients with regard to operative time.

Is resident assistance equivalent to fellows during hepatectomy?

Hepatectomy is a complex operative procedure frequently performed at academic institutions with trainee participation. The aim of this study was to determine the effect of assistant's training level on outcomes following hepatectomy. A retrospective review of a prospective, single-institution ACS-NSQIP database was performed for patients that underwent hepatectomy (2013-2016). Patients were divided by trainee assistant level: hepatopancreatobiliary (HPB) fellow versus general surgery resident (PGY 4-5). Demographic, perioperative, and 30-day outcome variables were compared using Chi-Square/Fisher's exact, Mann-Whitney U test, and multivariable regression. Cases involving a senior-level general surgery resident or HPB fellow as first assistant were included (n = 352). Those with a second attending, junior-level resident, or no documented assistant were excluded (n = 39). Patients undergoing hepatectomy with an HPB fellow as primary assistant had more frequent preoperative biliary stenting, longer operative time, and more concomitant procedures including biliary reconstruction, resulting in a higher rate of post-hepatectomy liver failure (PHLF) (15% vs. 8%, P = 0.044). However, trainee level did not impact PHLF on multivariable analysis (OR 0.60, 95% CI [0.29-1.25], P = 0.173). Fellows assisted with proportionally more major hepatectomies (45% vs. 31%; P = 0.010) and resections for hepatobiliary cancers (31% vs. 19%, P = 0.014). On stratified analysis of major and minor hepatectomies, outcomes were similar between trainee groups. Fellows performed higher complexity cases with longer operative time. Despite these differences, outcomes were similar regardless of assistant training level. Resident and HPB fellow participation in operations requiring liver resection provide comparable quality of care.

Racial disparities after stoma construction in colorectal surgery.

Racial disparities are under-recognized among patients undergoing colorectal surgery. The purpose of this study was to determine the complication rates and surgical outcomes stratified by race and ethnicity among patients undergoing colorectal surgery with intestinal stoma creation. The ACS NSQIP database from 2013 to 2016 was used. Colon, rectum and small bowel cases requiring intestinal stoma creation were selected. Both African-American and other groups of minority patients were compared with Caucasian patients using a complex multivariable analysis model. Primary outcomes of interest were complication rates, mortality and extended hospital length of stay. The study included 38088 admissions. After multivariable analysis, African-American patients still had a prolonged length of hospital stay and higher complication rates. Other minorities also had a prolonged length of hospital stay and higher complication rates. Both African-American and other groups of minority patients requiring an ostomy suffer significantly higher postoperative complication rates and a prolonged hospital length of stay, even after comorbidity adjustment. Access to care, socioeconomic status and comorbid disease management are all important factors for minority patients who undergo colorectal surgery requiring intestinal stoma construction.

Ivor Lewis vs Mckeown esophagectomy: analysis of operative outcomes from the ACS NSQIP database

Ivor Lewis and McKeown esophagectomy are common techniques to treat esophageal cancer. In this study, we aim to compare these two approaches. We used the American College of Surgeons National Surgical Quality Improvement Project database (2005-2017) to compare both techniques using bivariate analysis after propensity matching. We identified 6136 patients with esophagectomy and divided them into 2 groups based on whether they received a McKeown (1676; 27.31%) or an Ivor Lewis (4460; 70.14%) esophagectomy. McKeown esophagectomy was associated with higher rates of superficial surgical site infections (8.02% vs 3.67%, p < 0.001), anastomotic leaks (9.12% vs 7.71%, p = 0.02), prolonged intubation (15.06% vs 10.10%, p < 0.001), re-intubation (15.30% vs 10.34%, p ≤ 0.001), and return to the OR (16.46% vs 11.32%, p < 0.001). The McKeown esophagectomy patients also had longer hospital length of stay (14.5 ± 11.99 vs 13.37 ± 11.8, p = 0.002), higher re-admission rate (21.56% vs 16.87%, p = 0.002), and higher discharges to nursing/rehabilitation institutions (14.06% vs 11.99%, p = 0.004).The mortality rate and positive resection margins were not significantly different. There was a trend toward more utilization of Ivor Lewis esophagectomy over years. When compared to Ivor Lewis esophagectomy, McKeown esophagectomy is associated with more unplanned intubation, increased difficulty weaning from the ventilator, incisional surgical site infections, anastomotic leak, and higher length of stay.

The Effect of Immunosuppression on Emergency Colectomy Outcomes: A Nationwide Retrospective Analysis.

The impact of immunosuppression on the outcomes of emergent surgery remains poorly described. We aimed to quantify the impact of chronic immunosuppression on outcomes of patients undergoing emergent colectomy (EC). The Colectomy-Targeted ACS-NSQIP database 2012-2016 was queried for patients who underwent colectomy for an emergent indication. As per NSQIP, chronic immunosuppression was defined as the use of corticosteroid or immunosuppressant medication within the prior 30days. Patients undergoing EC for any indication were divided into two groups: immunosuppressant use (IMS) and no immunosuppressant use (NIS). Patients were propensity-score-matched on demographics, comorbidities, preoperative laboratory values, and operative variables in a 1:1 ratio to control for confounding factors. The primary outcome was 30-day mortality. Secondary outcomes included overall 30-day morbidity, individual postoperative complications (e.g., wound dehiscence, anastomotic leak, and sepsis), and hospital length of stay. Out of a total of 130,963 patients, 17,707 patients underwent an EC, of which 15,422 were NIS and 2285 were IMS. Totally, 2882patients were matched (1441 NIS; 1441 IMS). The median age was 66 [IQR 56-76]; 56.8% were female; patients more frequently underwent a diversion procedure rather than primary anastomosis (68.4% vs 31.6%). Overall, as compared to NIS, IMS patients had higher 30-day mortality (21.4% vs 18.5%, p = 0.045) and overall morbidity (79.7% vs 75.7%, p = 0.011). Particularly, IMS patients had increased rates of unplanned intubations (11.5% vs 7.9%, p = 0.001), wound dehiscence (5.7% vs 3.5%, p = 0.006), progressive renal insufficiency 2.2% vs 1.2%, p = 0.042), pneumonia (12.6% vs 10.0%, p = 0.029), and longer median hospital length of stay [12.0 (8.0-21.0) vs 11.0 (7.0-19.0), p < 0.001] as compared to NIS patients. Chronic immunosuppression is independently associated with a significant and quantifiable increase in 30-day mortality and complications for patients undergoing EC. Our results provide the emergency surgeon with quantifiable risk estimates that can help guide better patient counseling while setting reasonable expectations.

Vascular resection in minimally invasive vs open pancreaticoduodenectomy

Presenter: Roheena Panni MD, MPHS | Washington University, St. Louis Background: Pancreaticoduodenectomy is associated with high morbidity and the complexity of the procedure increases with vascular resection. Vascular resection during pancreaticoduodenectomy is associated with increased operative time, perioperative transfusion, DVT, septic shock, and length of stay, but the overall mortality is similar. With the advancement in minimally invasive surgical techniques, laparoscopic and robotic pancreatic surgery is becoming more common. A growing body of evidence exists demonstrating the equivalence or benefit of minimally invasive pancreaticoduodenectomy (MIPD) when compared to open pancreaticoduodenectomy (OPD) regarding the short term outcomes and safety. The purpose of this study is to determine the postoperative outcomes of patients undergoing vascular resection with OPD or MIPD approach using a large, multicenter cohort. Methods: All patients undergoing elective pancreaticoduodenectomy, including OPD and MIPD (robotic and laparoscopic, including open-assisted and unplanned open conversion), with vascular resection in the ACS NSQIP database were included in the study. Patients were stratified into those who underwent OPD vascular resection and those who underwent MIPD vascular resection. Patient covariates and outcomes were compared using standard statistical methods. Results: 2233 patients underwent OPD with vascular resection (17.8%) and 149 patients underwent MIPD with vascular resection (13.8%). The frequency of artery, vein, and combined artery and vein resection was (10.3%, 69.9%, and 19.6%) in OPD and (16.1%, 62.4%, and 21.47%) in MIPD, respectively. Patients undergoing MIPD vascular resection were more likely to have BMI < 25 (34.2% vs 42.5%, p-value 0.0143). The mean OR time was significantly longer in patients undergoing MIPD and vascular resection compared to OPD and vascular resection (485.4 ± 13.30 vs. 427 ± 152.90, p-value < 0.0001). We next compared postoperative complications and found that patients undergoing OPD vascular resection were more likely to have postoperative sepsis compared to MIPD vascular resection (10.17% vs. 4.70%, p-value= 0.0299). There was a trend towards a decrease in superficial surgical site infection, organ space infection and length of stay and an increase in 30-day readmission in the MIPD vascular resection group; however, these differences were not statistically significant. On multivariate analysis, postoperative sepsis was independently associated with OPD (p-value= 0.0446). Conclusion: MIPD with vascular resection is safe and feasible. Future studies are needed to determine the effect of MIPD with vascular resection on long term outcomes and survival.

Surgery for the Very Old: Are Nonagenarians Different?

Octogenarians and nonagenarians are considered the "very old" and are often viewed as one group. Americans are aging, with the proportion of the very old expected to increase from 1.9 per cent of the population to 4.3 per cent in 2050. This study aimed to underscore the differences in surgical trends, demographics, and outcomes between octogenarians and nonagenarians. The ACS-NSQIP database (2007-2012) was used to derive the type of surgeries, demographics, and outcomes of octogenarian and nonagenarians undergoing nonemergent vascular, orthopedic, and general surgery procedures. Between 2007 and 2012, nonagenarians accounted for an increasing percentage of surgeries (85 to 121 per 10,000 surgeries, relative risk = 1.42; 95% CI: 1.30-1.54) across surgical specialties, including vascular, general, and orthopedic surgery, whereas the percentage of octogenarians undergoing surgery remained unchanged. Nonagenarians had a higher 30-day perioperative mortality and a longer hospital stay than octogenarians after vascular, orthopedic, and general surgery procedures. Nonagenarians are a rapidly growing group of surgical patients with significantly higher perioperative mortality and longer postoperative hospital stay. The impact of surgery on the quality of life of nonagenarians needs to be studied to justify the increasing healthcare costs.

Construction of nomogram to predict postoperative pancreatic fistula after distal pancreatectomy utilizing the ACS-NSQIP pancreatectomy targeted database

Presenter: Jonathan Pastrana Del Valle MD | Beth Israel Deaconess Medical Center Background: Distal pancreatectomy is widely employed in the treatment of benign and malignant conditions of the body and tail of the pancreas. Postoperative pancreatic fistula is a frequent and potentially morbid complication after this operation, occurring in up to 20% of distal pancreatectomy patients. Effective methods for predicting and preventing postoperative pancreatic fistula are still sought. While effective risk assessment models have been developed for postoperative pancreatic fistula after pancreaticoduodenectomy, to our knowledge, a similar model for distal pancreatectomy does not exist. The aim of this study was to investigate factors associated with postoperative pancreatic fistula following distal pancreatectomy and to create a risk model to predict this complication using data from the ACS-NSQIP database. Methods: Patients who underwent distal pancreatectomy from 2014 to 2017 were selected from the ACS-NSQIP pancreatectomy targeted database. Clinically relevant (grade B or C) fistulas were identified using the 2016 ISGPS definitions. We utilized chi square tests on categorical variables and logistic regression on continuous variables to assess associations of preoperative and intraoperative variables with postoperative fistula. Variables with a p<0.10 on univariable analysis were then included in a multivariable logistic regression model, and a nomogram was constructed from this model. The predictive ability of the nomogram was assessed using the concordance statistic (c-statistic), and its calibration was tested using the Hosmer-Lemeshow test. Results: A total of 7,088 patients who underwent distal pancreatectomy from 2014 to 2017 were identified in the ACS-NSIQP database. Clinically relevant postoperative pancreatic fistula were identified in 1,174 (16.6%) of the patients. Univariable analysis identified male sex, higher BMI, smoking history, congestive heart failure, disseminated cancer, low pre-operative albumin, chemotherapy within 90 days of surgery, radiation within 90 days of surgery, intra-operative drain placement, vascular resection, and histology were associated with pancreatic fistula (all p<0.05). Gland texture, pancreatic duct size, and presence of chronic pancreatitis were not significantly associated with fistula. Variables independently associated with pancreatic fistula in the multivariable model were male sex, higher BMI, smoking history, congestive heart failure, higher preoperative platelet count, intraoperative drain placement, vascular resection, and histology (all p<0.01). The nomogram constructed from this analysis is shown in panel A. The concordance statistic of the nomogram is 0.625 (ROC curve shown in panel B). The nomogram appeared well calibrated (panel C) with a Hosmer-Lemeshow p=0.723 consistent with a good fit. Conclusion: Male sex, higher BMI, smoking history, congestive heart failure, higher pre-operative platelet count, intra-operative drain placement, vascular resection, and histology are independently associated with risk of developing postoperative pancreatic fistula after distal pancreatectomy. A nomogram based on these risk factors yielded a c- statistic of 0.625 suggesting that other variables not accounted for may contribute to the risk of pancreatic fistula and/or there is some inherent unpredictability in the development of this complication. The nomogram does provide a well calibrated prediction of risk based on easily determined pre-operative and intra-operative variables, and thus may be useful in post-operative management. Further study to externally validate this nomogram is warranted.

A Nomogram for Predicting 30-day Mortality in Elderly Patients Undergoing Hemiarthroplasty for Femoral Neck Fractures

Introduction:Femoral neck fractures in the elderly are increasingly common as a result of a growing geriatric population with 1-year mortality rates approaching 35%. While preoperative medical optimization and early time to surgery have reduced morbidity and mortality, patients with numerous medical comorbidities remain high risk for death in the perioperative period. Identifying those with greatest risk with a scoring system or nomogram may assist multidisciplinary teams in reducing mortality following hemiarthroplasty.Purpose:Identify predictors of 30-day mortality in elderly patients who underwent hemiarthroplasty for a femoral neck fracture to generate a predictive nomogram to determine the probability of post-operative mortality.Methods:Retrospective evaluation using data from the ACS-NSQIP database from 2005 to 2014 with CPT code 27125 for hip hemiarthroplasty. Multiple factors including demographics and comorbidities were compared in patients who experienced 30-day mortality and those who did not. T-test and chi-square tests were used to analyze data and a multivariate model was generated using logistic regression.Results:Advanced age (odds ratio (OR) 1.04), underweight BMI (OR 1.55), male sex (OR 1.80), reduced functional status (OR 2.04), heart failure within 30 days prior to surgery (OR 2.22), American Society of Anesthesiologists grade > 2 (OR > 2.50), disseminated cancer (OR 3.43) were all found to have statistically significant odds ratios for 30-day mortality following hemiarthroplasty.Conclusion:A tool based on easily identifiable risk factors, demographics, and comorbidities was developed that can help predict elderly patients who will experience mortality within 30 days of following hemiarthroplasty. In addition to identifying high risk patients, the nomogram can serve as a counseling tool for physicians to use with patients and their families to assist with better understanding of perioperative mortality risk.

30-Day outcomes and predictors of complications after Puestow procedure

BackgroundA lateral pancreaticojejunostomy, or a Puestow procedure, is used in chronic pancreatitis with ductal dilation and pain. The current literature on the Puestow is sparse. This study examines outcomes of Puestow procedures nationwide. MethodsUsing ACS-NSQIP database, patients who underwent a Puestow procedure from 2010 to 2016 were identified. Univariate analysis and multivariable regression models were used to identify predictors of mortality and morbidities. Covariates included in the regression models were chosen based on clinical significance. ResultsThe cohort included 524 patients. The 30-day mortality rate was 1.2%(n = 6). At least one major complication occurred in 19.1% of patients including death (1.2%), major organ dysfunction (8.2%), pulmonary embolism (1.3%), and surgical site infections (13.0%). Diabetes, COPD, and transfusions were the strongest predictors of complications. ConclusionsThe Puestow procedure is an acceptable treatment modality with low rates of morbidity and mortality. Minimizing transfusions and optimizing pulmonary status may improve 30-day outcomes.

Association of metabolic syndrome with morbidity and mortality in emergency general surgery

BackgroundMetabolic syndrome (MetS) is defined by numerous comorbidities. We sought to assess MetS’s effect on the 7 main emergency general surgery (EGS) procedures that constitute 80% of EGS procedures, mortalities, complications, and costs. MethodsData were acquired from the ACS-NSQIP database from 2005 to 2017. Current procedural terminology (CPT) codes were utilized to identify cases. Patients with obesity, diabetes, and hypertension were defined as having MetS. MetS and non-MetS cohorts were propensity score matched, compared by outcomes, and assessed with multivariate logistic regression to attain odds ratios (OR). ResultsOf 752,023 cases, 41,788 (5.6%) MetS cases were identified. Significant outcomes included superficial infection (OR: 1.51), pulmonary complications (OR: 1.17), renal complications (OR: 1.82), cumulative morbidity (OR: 1.22), and hospital readmission (OR: 1.41). ConclusionsFor patients undergoing these procedures, MetS increased risk for comorbidities and hospital readmission. MetS had a significant impact on mortality only for appendectomy.

A significant proportion of venous thromboembolism events in general surgical patients occurs after discharge: analysis of the ACS-NSQIP Essentials database

BackgroundVenous thromboembolism (VTE) is a major cause of morbidity and mortality in general surgical patients.MethodsThe ACS-NSQIP database was queried and VTE data were collected and analyzed to assess the incidence of VTE at a 500-bed, non-profit, teaching, inner city, community hospital and similar peer institutions from January 1, 2006 to December 31, 2011.ResultsPost-discharge VTE events accounted for 40% of all VTE events within 30 days of discharge. Data show a significant proportion of post-discharge VTE events that may be preventable with extending VTE prophylaxis in the post-discharge period.ConclusionThis is the first paper to report on this high post-discharge incidence of VTE in general surgical patients and to recommend continuation of VTE prophylaxis in the post-discharge period.

High Compliance to an Enhanced Recovery Pathway for Patients ≥65 Years Undergoing Major Small and Large Intestinal Surgery Is Associated With Improved Postoperative Outcomes.

This study was performed to evaluate compliance to an Enhanced Recovery Pathway (ERP) among patients ≥65 years and determine the effect of compliance on postoperative outcomes. ERPs improve postoperative outcomes in patients undergoing major surgery. Given the inherent decline of the older surgical patient, the benefit of an ERP in this population has been questioned. Patients undergoing major small and large intestinal surgery prior to and following ERP implementation at the Johns Hopkins Medical Institutions were entered into the ACS-NSQIP database. Outcomes included ERP compliance rates, complications, length of stay (LOS), and 30-day readmission rates were determined for older patients. Nine hundred seventy-four patients (693 < 65 yrs and 281 ≥ 65 yrs) were included. Of those ≥ 65 years, 142 (51%) were entered prior to and 139 (49%) were entered following ERP implementation. More ERP than pre-ERP patients underwent laparoscopic procedures (45.3% vs. 32.4%, P = 0.02), had disseminated malignancies (9.4% vs. 2.8%, P = 0.03), and smoked (14.4% vs. 4.9%, P = 0.01). Overall compliance was 74.5%, and 47% of older ERP patients achieved high compliance (≥75% compliance with ERP variables). High compliance was associated with a 30% decrease LOS (IRR: 0.7 P = 0.001) and 60% decrease in major (CD ≥ II) complications (OR: 0.4 P = 0.05). LOS and complication rates following implementation of an ERP were significantly improved in highly compliant elderly patients. Interventions to further improve outcomes should target decreasing variability by increasing individual compliance with an effective clinical pathway.

Utilization and Outcomes of Local Anesthesia and Peripheral Nerve Block for Hybrid Lower Extremity Revascularization

Purpose: To investigate the utilization of local anesthesia or peripheral nerve block with monitored anesthesia care (LPMAC) and its impact on the perioperative outcomes of hybrid lower extremity revascularization (LER) compared with general anesthesia (GA). Materials and Methods: A search of the ACS-NSQIP database between 2005 and 2017 identified 9430 patients who underwent hybrid LER for peripheral artery disease. Excluding 449 ineligible cases left 8981 hybrid LER patients for analysis. The patients were dichotomized based on the anesthetic technique: 8631 (96.1%) GA and 350 (3.9%) LPMAC. The GA patients were matched 3:1 based on propensity scores to patients in the LPMAC group based on gender, age, race, functional status, transfer status, chronic obstructive pulmonary disease (COPD), dialysis status, American Society of Anesthesiologists (ASA) class, emergent surgery, preoperative sepsis, indication, and type of open and endovascular procedure. Outcomes including complications, mortality, procedure time, and hospital length of stay were compared between the matched groups (801 GA vs 267 LPMAC). Results: Comparing the unmatched groups, those treated under LPMAC were older (72.7±9 vs 68±8.4 years, p<0.001) and had higher rates of COPD (24.3% vs 17%, p=0.001), dialysis dependence (8.1% vs 4.2%, p=0.002), preoperative sepsis (6.6% vs 4.2%, p=0.029), and ASA class ≥IV (29.1% vs 24.1%, p=0.036) than in the unmatched GA cohort. In the matched comparison, LPMAC was associated with lower overall morbidity (25.5% vs 32.3%, p=0.042) and shorter operating time (202.7±98 vs 217.7±102 minutes, p=0.034) compared with GA. The rate of myocardial infarction was lower (1.1% vs 2.4%) and ventilator use for >48 hours was less frequent (0.4% vs 2.6%) for LPMAC patients, though statistical significance was not reached. There was no difference in mortality or hospital length of stay. Conclusion: LPMAC is an infrequent anesthetic technique for hybrid LER and is primarily used for patients with a high burden of comorbidities. LPMAC is associated with reduced overall morbidity and operating time. Further studies are needed to identify which patients undergoing hybrid LER benefit most from LPMAC.

Parathyroidectomy is Safe in Elderly Patients: A National Surgical Quality Improvement Program Study.

With increasing age, the incidence of hyperparathyroidism is increased. This study evaluates parathyroidectomy outcomes in elderly patients. Primary hyperparathyroidism patients having parathyroidectomy as listed in the 2005-2017 ACS-NSQIP database were separated by age: ≤60, 61-79 and ≥80. Outcomes included complications, 30-day mortality, return to the OR, operating times, and hospital length of stay (LOS). Multivariable logistic regression was used to compare patients 61-79 and ≥80 to those ≤60. Patients ≤60 and ≥80 were propensity score matched using gender, race, BMI, smoking status, steroid use, modified frailty index (mFI), ASA class, procedure, setting, anesthesia, and wound class. Morbidity and mortality were compared to ACS-NSQIP database patients having elective inguinal hernia repair. Of 47,701 patients: 22,220 were ≤60, 22,683 were 61-79, and 2798 were ≥80. Patients ≥80 had more complications (2.3% vs. 1.5% for 61-79 and 1.0% for ≤60, p < 0.01), LOS > 1day (10.3% vs. 5.8% and 6.7%, p < 0.01), and mortality (0.21% vs. 0.11% and 0.03%, p < 0.01). On multivariable analysis of the overall population, older age, male gender, steroid use, high mFI, outpatient procedure, and general anesthesia increased the risk of complications. On propensity score matched analysis, there was no difference in complications (1.5% vs. 2.2%, p = 0.06) or mortality (0.04% vs. 0.23%, p = 0.12) between patients ≤60 and ≥80. Parathyroidectomy morbidity and mortality was lower than that for elective inguinal hernia repair in patients ≥80 (2.3% vs. 10% and 0.21% vs. 1.1%, p < 0.01). Parathyroidectomy is a safe operation, offering lower morbidity and mortality than elective hernia repair in all age groups including octogenarians.