ACS-NSQIP Database Research Articles

Risk factors associated with 30-day complications following lower extremity sarcoma surgery: A national surgical quality improvement project analysis.

Our study aims to identify risk factors associated with complications in lower extremity (LE) sarcoma surgery, as well as the prevalence and complications associated with concurrent plastic surgery procedures (CPSP). ACS-NSQIP database was accessed to identify patients treated for LEsarcoma (2010-2019). Patient demographics, preoperative lab, comorbidities, tumor type, location, principle procedure, and presence/characteristics of CPSPs were recorded. Thirty-day soft tissue complications were analyzed. Bivariate and multivariate logistic regression was performed on IBM SPSS.™ RESULTS: Nine hundred eighteen patients were included (483 males and 435 females), average age and body mass index(BMI) of 57 and 27.4 kg/m,2 respectively. Comorbidities included smoking (13.9%, 128), hypertension (37.3%, 342), and insulin-dependent diabetes(3.7%, 34). Preoperative lab values included albumin <3.5 (6.8%, 63), hematocrit <30% (8.2%, 75), and platelet count <150 000 (5.9%, 54). Thirty-day soft tissue complication rate was 5.7% (52 of 918). On multivariate logistic regression, increased age (p = 0.039), higher BMI (p = 0.017), and longer operative times (p = 0.002) were significant risk factors independently associated with soft tissue complications. Soft tissue complications within 30 days occur in 6% of patients. Graft procedures carry a 20% risk of complications. Risk factors independently associated with complications include increased age, increased BMI, and longer operative times.

Association Between Pre-operative BUN and Post-operative 30-Day Mortality in Patients Undergoing Craniotomy for Tumors: Data From the ACS NSQIP Database.

ObjectiveThere is limited evidence to clarify the specific relationship between pre-operative blood urea nitrogen (BUN) and post-operative 30-day mortality in patients undergoing craniotomy for tumors. Therefore, we aimed to investigate this relationship in detail.MethodsElectronic medical records of 18,642 patients undergoing craniotomy for tumors in the ACS NSQIP from 2012 to 2015 were subjected to secondary retrospective analysis. The principal exposure was pre-operative BUN. Outcome measures were post-operative 30-day mortality. We used binary logistic regression modeling to evaluate the association between them and conducted a generalized additive model and smooth curve fitting (penalized spline method) to explore the potential relationship and its explicit curve shape. We also conducted sensitivity analyses to ensure the robustness of the results and performed subgroup analyses.ResultsA total of 16,876 patients were included in this analysis. Of these, 47.48% of patients were men. The post-operative 30-day mortality of the included cases was 2.49% (420/16,876), and the mean BUN was 16.874 ± 6.648 mg/dl. After adjusting covariates, the results showed that pre-operative BUN was positively associated with post-operative 30-day mortality (OR = 1.020, 95% CI: 1.004, 1.036). There was also a non-linear relationship between BUN and post-operative 30-day mortality, and the inflection point of the BUN was 9.804. For patients with BUN < 9.804 mg/dl, a 1 unit decrease in BUN was related to a 16.8% increase in the risk of post-operative 30-day mortality (OR = 0.832, 95% CI: 0.737, 0.941); for patients with BUN > 9.804 mg/dl, a 1 unit increase in BUN was related to a 2.8% increase in the risk of post-operative 30-day mortality (OR = 1.028, 95% CI: 1.011, 1.045). The sensitivity analysis proved that the results were robust. The subgroup analysis revealed that all listed subgroups did not affect the relationship between pre-operative BUN and post-operative 30-day mortality (P > 0.05).ConclusionOur study demonstrated that pre-operative BUN (mg/dl) has specific linear and non-linear relationships with post-operative 30-day mortality in patients over 18 years of age who underwent craniotomy for tumors. Proper pre-operative management of BUN and maintenance of BUN near the inflection point (9.804 mg/dl) could reduce the risk of post-operative 30-day mortality in these cases.

Safety of Laparoscopic Appendectomy in the Setting of Coagulopathy: An ACS-NSQIP Study.

Patients with coagulopathy requiring emergent appendectomy constitute a challenging patient population. It is unclear whether laparoscopic appendectomy (LA) is as safe as open appendectomy (OA) in these patients. We queried the ACS-NSQIP database for adults with coagulopathy undergoing emergent appendectomy from 2014 to 2017. Demographic characteristics and operative outcomes were compared between the two groups. Propensity weighting for LA versus OA was estimated using augmented inverse probability of treatment weights (AIPW). A total of 137,429 patients were included, of which 7049 (5%) had coagulopathy. In patients with coagulopathy, LA was the most common approach (89%). After AIPW, there was no difference in the adjusted risk of either postoperative transfusion or 30-day reoperation between OA and LA. LA was associated with reduced operative time (56 versus 75min), length of stay (3.5 versus 7.0d), and surgical site infection rate (6% versus 13%) compared to OA. Patients with coagulopathy represent a significant proportion of those undergoing an appendectomy. The majority of patients with coagulopathy who require appendectomy undergo LA, and this approach appears to be safe with regard to transfusion requirement and reoperation.

Associations Between Preoperative Risk, Postoperative Complications, and 30-Day Mortality.

Comorbidities and postoperative complications increase mortality, making early recognition and management critical. It is useful to understand how they are associated with one another. This study assesses associations between comorbidities, complications, and mortality. We calculated associations between comorbidities, complications, and 30-day mortality using the 2012-2018 ACS-NSQIP database. We examined the association between mortality and number of complications which complications were most associated with mortality. 5,777,108 patients were included. 30-day mortality was 0.95%. For most comorbidities or postoperative complications, patients with these had higher mortality than patients without. Having ≥ 1 complication increased mortality risk by 32.5-fold (6.5% vs. 0.2%). Mortality rate significantly increased with increasing number of complications, particularly after two or more complications. Bleeding and sepsis were associated with the most deaths. The 30-day mortality rate was < 1% but was 32-fold higher in patients with complications and increased rapidly for patients with ≥ 2 complications. Bleeding and sepsis were the most prominent complications associated with mortality.

Postsplenectomy morbidity and mortality in patients with immune thrombocytopenic purpura: A national cohort study

We sought to identify factors associated with 30-day morbidity, and their impact on 30-day mortality, among patients undergoing splenectomy for immune thrombocytopenic purpura (ITP). Using the ACS-NSQIP database, patients undergoing splenectomy for ITP were identified (2005-2019), and those with and without postoperative complications within 30 days of surgery were compared. Of 2483 patients evaluated, 280 (11.3%) developed 30-day morbidity: infection (n= 145 [5.8%]), venous thromboembolism (n = 71 [2.9%]), acute renal failure (n = 7 [0.3%]), respiratory failure (n = 40 [1.6%]), cardiac arrest/myocardial infarction (n = 16 [0.6%]), cerebrovascular accident (n = 4 [0.2%]), or postoperative blood transfusion (n = 62 [2.5%]). Risk-factors for 30-day morbidity included age ≥50 years (odds ratio [OR] 1.50, p = 0.020), body mass index ≥30 kg/m2 (OR 1.45, p = 0.023), functional dependence (OR 2.90, p = 0.009), preoperative albumin <3.5 g/dL (OR 2.10, p < 0.001), preoperative platelets <30 000/μL (OR 1.54, p = 0.020), open surgical approach (OR 2.32, p < 0.001), and inpatient status before surgery (OR 1.85, p = 0.040). Among patients at low-risk for 30-day morbidity (no risk-factors present), the 30-day morbidity rate was 5.0% versus 41.5% for ≥5 risk-factors (p < 0.001). Thirty-day mortality was 1.2%. Thirty-day morbidity and mortality are low with splenectomy for ITP. Select patients have particularly low perioperative risk and may benefit from early splenectomy if initial medical therapy fails.

Total Psoas Area is a Measure for Deconditioning in Colorectal Surgery Patients.

Physical fitness is an important prognostic indicator for surgical outcomes. An objective measure of deconditioning is needed to determine patient fitness. This study aims to describe a methodology to standardize psoas measurements and correlate them with postoperative outcomes. After obtaining IRB approval, the ACS-NSQIP database was queried for patients over 18years, undergoing colectomies for non-trauma indications from 1/1/2013 to 12/31/2018. Upon CT imaging, the psoas muscle was identified at the lumbosacral joint. Imaging software calculated the total cross-sectional area of the left and right psoas muscle and was normalized by dividing by height squared to achieve our Total Psoas Index (TPI) in cm2/m2. 1173 patients met study criteria; all had TPI calculated. A TPI equal to or below the gender-specific 25th percentile defined sarcopenia. In total, 151 females (24.6%) and 137 males (24.5%) were classified as sarcopenic. TPI was significantly associated with multiple NSQIP 30-day outcomes and mortality in our study population. Measuring TPI at the lumbosacral joint is an appropriate method for determining sarcopenia.

Effect of age and gender on pre-operative cardiovascular risk assessment

BackgroundThe AUB-HAS2 Cardiovascular Risk Index is a recently published tool for pre-operative cardiovascular evaluation. It is based on six data elements: history of heart disease, symptoms of angina or dyspnea, age ≥ 75 years, hemoglobin < 12 mg/dl, vascular surgery, and emergency surgery. The objective of this study is to study the effect of age and gender on the performance of the AUB-HAS2 Index in pre-operative cardiovascular risk assessment.MethodsThe study population consisted of 1,167,414 non-cardiac surgeries registered in the ACS NSQIP database. The population was stratified by age (≥ 40 and < 40 years old) and by gender (men and women). Each patient was given an AUB-HAS2 score of 0, 1, 2, 3, or > 3 based on the number of data elements s/he has. The outcome measure was all-cause mortality, myocardial infarction (MI), or stroke at 30 days after surgery.ResultsThe overall 30-day event rate was higher in patients ≥ 40 years compared to those < 40 years (2.5% vs 0.3%, P < 0.0001) and in men compared to women (2.7% vs 1.8%, P < 0.0001). In both age and gender subgroups, there was a gradual and significant increase in the outcome measure (death, MI, or stroke) as the AUB-HAS2 score increased: from ≤ 0.5% in those with a score of 0 to more than 15% in those with a score > 3 (P < 0.0001). The AUB-HAS2 Index was able to stratify risk in all subgroups into low, intermediate, and high (P < 0.0001). Receiver operating characteristic curves showed the AUB-HAS2 Index has very good discriminatory power in both age (area under the curve (AUC) of 0.81 and 0.78) and gender (AUCs of 0.79 and 0.84) subgroups.ConclusionThis study extends the validation of the newly derived AUB-HAS2 Cardiovascular Risk Index to different age and gender subgroups with very good discriminative power.

Morbid Obesity Not a Risk for Serious Complications Following Outpatient Surgery.

Patients with class III obesity are often excluded from surgery in ambulatory surgery centers (ASCs). We hypothesize that class III obesity is not a risk factor for serious post-operative complications following outpatient operations. ACS-NSQIP database from 2012 to 2018 was queried. Patients undergoing outpatient inguinal hernia repair (IHR) and laparoscopic cholecystectomy (LC) were grouped by BMI. Baseline characteristics and 30-day outcomes were compared using univariate and multivariate analyses. Of these, 79,916 patients underwent IHR and 107,471 patients underwent LC. Multivariable analysis in IHR showed increased odds of superficial SSIs in all classes of obesity compared to normal weight (P < .0001). In the LC group, there were higher rates of SSIs with obesity (P < .0001). For both surgeries, a higher rate of readmissions to the hospital were observed in class II and IIIa obesity (both P < .0001), although rates were relatively low (<3%). Class III obesity demonstrates a statistically significant increase in SSI following IHR and LC. Severe complications requiring readmission are not mirrored, suggesting the morbidly obese patients should be considered for routine surgical procedures in outpatient settings.

Increased 30-Day Postoperative Readmission and Medical Complication Rates Among Patients 65 Years and Older Following Arthroscopic Rotator Cuff Repair

PurposeThe purpose of this study is to use a large national database to assess short-term adverse events following arthroscopic rotator cuff repair in patients 65 years and older.MethodsThe ACS NSQIP database was queried to identify patients that underwent arthroscopic rotator cuff repair between December 31, 2015, and January 1, 2017. Patients were split into two groups: 1) between 40-65 years old and 2) 65+ years old. Cases involving open rotator cuff repair, total shoulder arthroplasty, hemiarthroplasty, and emergency surgery were excluded. Exact matching was used to control for confounding variables, including sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, operative time, and several medical comorbidities. After matching, the incidence of several 30-day patient complication measures was compared between the groups. Binary logistic regression was used to identify covariates associated with various 30-day complications.ResultsA total of 17,880 patients were included in the study. 69.4% (n = 12,404) patients were between 40 and 65 years old and 30.6% (n = 5,476) patients were 65+ years old. After matching, 9,210 patients were included in the final analysis. After matching, patients 65 years and older were more likely to experience 30-day unplanned readmission (P = .035) and overall medical complications (P = .036). There were no significant differences in most 30-day complication measures, including mortality (P = .250), reoperation (P = .449), non-home discharge (P = .255), surgical complications (P = .146), and several medical complications, including myocardial infarction (P = .165), deep venous thromboembolism (P = .206), pulmonary embolism (P = .196), and cerebrovascular accident (P > .999) between the two age groups.ConclusionsIn this matched cohort study, patients 65 years and older experienced a higher rate of 30-day unplanned readmission and overall medical complications following elective arthroscopic rotator cuff repair relative to patients under 65. However, these older patients did not have significantly worse rates of other 30-day complication measures, including mortality, reoperation, return to the OR, and non-home discharge.

Open and Closed Approaches to Skin Closure After Nonelective Open Colorectal Operations.

Optimal wound management strategies to reduce surgical site infections (SSIs) in nonelective open colorectal surgery (NOCS) remain controversial and variable. Our aim is to describe SSI and other 30-day outcome measures among patients with varying wound management techniques undergoing NOCS. All NOCS patients were extracted from the 2016 to 2018 ACS-NSQIP database. Outcomes of patients managed with all layers closed (ALC) were compared to patients managed with skin open (SO), using propensity score matching (PSM) to control for significant confounding risk factors for SSI. A total of 40,820 patients were included; 4622 patients managed with SO and 36,198 managed with ALC. Patients in the SO group were more likely to have a history of hypertension, renal failure, chronic obstructive pulmonary disease, smoking, obesity, and sepsis on presentation (P < .001). After PSM, no differences in risk factors remained; 4622 and 4344 patients were included in the SO and ALC cohorts, respectively. While ALC patients experienced a higher rate of superficial SSI (1.4% vs 7.3%, P < .001) and any wound complications (6.8% vs 10.8%, P < .001), the SO group had higher wound dehiscence (4.4% vs 2.8%, P < .001). There were no significant differences in deep wound infection. The SO group had longer average length of stay (14.7 vs 13.1days, P < .001), higher non-wound-related complications, discharge to SNF, and in-hospital mortality. Significant differences in SSI rates among NOCS patients with differing wound management techniques were observed. More notably, other important quality measures, such as length of stay, disposition, mortality, and non-wound-related complications were also significantly impacted by wound management strategy.

Complicated Abdominal Wall Hernias in the Elderly: Time Is Life and Comorbidities Matter.

Abdominal wall hernias represent a common problem that can present as surgical emergencies with increased morbidity and mortality. The data examining outcomes in elderly patients with hernia emergencies is scant. The 2007-2017 ACS-NSQIP database was queried. Patients ≥65years old with a diagnosis of acute complicated abdominal wall hernia were included. Univariable and multivariable analyses were used to identify independent predictors of 30-day mortality and surgical site infection (SSI). Main predictors of 30-day mortality were admission from nursing home or chronic care facility (OR = 1.62, 95% CI: 1.10-2.38, P = .014), transfer from outside ED (OR = 1.81, 95% CI: 1.31-2.51, P < .001), days from admission to operation (OR = 1.05, 95% CI: 1.02-1.08, P = .002), recent significant weight loss (OR = 1.95, 95% CI: 1.12-3.37, P = .018), pre-operative septic shock (OR = 4.13, 95% CI: 2.44-6.99, P < .001), ventilator dependence (OR = 2.50, 95% CI: 1.29-4.81, P = .006), and ASA status. When compared to open repair, laparoscopic repair emerged as protective against SSI (OR = .34, 95% CI: .17-.66, P = .001). Bowel resection (OR = 2.15, 95% CI: 1.63-2.84, P < .001) and increasing wound class were risk factors for SSI. In the elderly patient presenting with an acute complicated abdominal wall hernia, time to surgery is crucial for survival, and comorbidities influence outcome. Laparoscopy is an option in management due to its decreased risk of surgical site infection without increased mortality, whenever patient factors are favorable for this approach.

MP01-15 SEDATION AS AN ALTERNATIVE ANESTHETIC TECHNIQUE FOR FRAGILE PATIENTS IN TRANSURETHRAL RESECTION OF THE PROSTATE

You have accessJournal of UrologyCME1 May 2022MP01-15 SEDATION AS AN ALTERNATIVE ANESTHETIC TECHNIQUE FOR FRAGILE PATIENTS IN TRANSURETHRAL RESECTION OF THE PROSTATE Christian Ayoub, Nassib Abou Heidar, Adnan El-Achkar, Hani Tamim, and Albert El Hajj Christian AyoubChristian Ayoub More articles by this author , Nassib Abou HeidarNassib Abou Heidar More articles by this author , Adnan El-AchkarAdnan El-Achkar More articles by this author , Hani TamimHani Tamim More articles by this author , and Albert El HajjAlbert El Hajj More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002513.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Although novel treatments have been introduced to treat benign prostatic hyperplasia, TURP remains the gold standard. TURP is mostly performed using general (genTURP) or spinal (spTURP) anesthesia. Monitored Anesthesia Care MAC/Sedation (macTURP) anesthesia is a safer and infrequently used anesthesia technique reserved for high-risk patients. The aim of this study is to compare 30-day post-operative outcomes of TURP using the three types of anesthesia techniques from the ACS-NSQIP database. METHODS: The ACS-NSQIP database was queried for male patients who underwent TURP for BPH treatment between the years 2005-2017. Demographics, clinical, operative characteristics, and 30-day outcomes were compared. Univariate and multivariate regression models were constructed for selected outcomes. RESULTS: 37,410 patients underwent TURP for BPH treatment of which 73.3% underwent genTURP, 24% spTURP and 2.4% macTURP anesthesia. Older patients (73) with hypertension (64%), history of COPD (8.1%) and of ASA II/III (51.2%, 6.3% respectively) were more likely to undergo macTURP as compared to genTURP (p-value <0.013). Regarding postoperative outcomes, macTURP showed lower rates of readmission (4.7%) as compared to spTURP and genTURP (p-value= 0.06). MacTURP also showed shorter operative times (50 min) and was more likely to be used in emergency cases (2.3%) as compared to genTURP but longer operative times as compared to spTURP (48 min) (p-value <0.01). MacTURP showed shorter length of hospital stay (2.15 days) as compared to spTURP (2.67 days), but longer length of hospital stays as compared to genTURP (1.85 days) (p-value <0.01). In terms of return to operative room, occurrence of pneumonia, urinary tract infection, sepsis and bleeding requiring transfusion there was no significant difference between the 3 anesthetic techniques. Multivariate analysis showed macTURP had lower operative time by 4 mins and spTURP by 2.7 mins as compared to genTURP. No other significant difference was seen in the multivariate analysis. CONCLUSIONS: TURP under sedation was found to be feasible with a good safety profile. Sedation could be used in elderly, fragile and co-morbid patients providing them less post-operative complications and shorter operative times as compared to more invasive anesthetic techniques. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e7 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christian Ayoub More articles by this author Nassib Abou Heidar More articles by this author Adnan El-Achkar More articles by this author Hani Tamim More articles by this author Albert El Hajj More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP16-20 PREDICTORS OF DISCHARGE TO HOME FOLLOWING MAJOR SURGERY FOR UROLOGIC MALIGNANCIES

You have accessJournal of UrologyCME1 May 2022MP16-20 PREDICTORS OF DISCHARGE TO HOME FOLLOWING MAJOR SURGERY FOR UROLOGIC MALIGNANCIES Nehizena Aihie, Deukwoo Kwon, Matthew Mason, Helen Yang Hougen, Dimple Chananmolu, Sanoj Punnen, Bruno Nahar, Dipen Parekh, Mark Gonzalgo, and Chad Ritch Nehizena AihieNehizena Aihie More articles by this author , Deukwoo KwonDeukwoo Kwon More articles by this author , Matthew MasonMatthew Mason More articles by this author , Helen Yang HougenHelen Yang Hougen More articles by this author , Dimple ChananmoluDimple Chananmolu More articles by this author , Sanoj PunnenSanoj Punnen More articles by this author , Bruno NaharBruno Nahar More articles by this author , Dipen ParekhDipen Parekh More articles by this author , Mark GonzalgoMark Gonzalgo More articles by this author , and Chad RitchChad Ritch More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002549.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Discharge to home is a measurable patient outcome used to assess quality of care for hospitals. The 2021 US news and world report (USNWR) uses this metric to rate patient outcomes when calculating Urology hospital rankings. Our objective was to identify patient risk factors that predict non-home discharge after surgery for urologic malignancies. METHODS: The ACS-NSQIP database was queried using urology specific Current Procedural Terminology (CPT) codes to retrospectively identify patients who had undergone open, laparoscopic, or robotic surgery for urologic malignancies including prostate, bladder, kidney, or upper tract urothelial cancer from 2011-2019. Descriptive statistics were used to compare patients who were discharged to home versus non-home discharges. Univariable and multivariable logistic regression analysis were performed to identify patient characteristics that were associated with non-home discharges. All tests were two-sided and statistical significance was considered when p<0.05. RESULTS: Non-home discharge occurred in 3.03% of the 103,244 patients in our study. In our study population 91.7% were male while 8.3% were female. Women were more likely to have non-home discharges (male:female OR 0.62 p<0.0001). As expected, non-home discharge was more common in patients who underwent cystectomy when compared to nephrectomy (OR 1.51 p=0.016) or prostatectomy (OR 1.56 p=0.002). Those with elevated BMI were less likely to experience non-home discharge (OR 0.85 p=0.002) while patients who were identified as underweight and those with unexpected weight loss prior to surgery were more likely to have non-home discharges (OR 1.90 p<0.0001, OR 2.02, p<0.0001). Comorbidities including diabetes and cardiopulmonary disease were also found to be significant independent predictors of non-home discharges. CONCLUSIONS: Patient factors including age, gender, weight, comorbidities, and site of procedure were found to be independent predictors of non-home discharge following surgery for urologic malignancies. Patients with these risk factors should be counseled pre-operatively on the likelihood of requiring a non-home discharge to help manage expectations and create a standardized transition of care pathway following surgery. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e283 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nehizena Aihie More articles by this author Deukwoo Kwon More articles by this author Matthew Mason More articles by this author Helen Yang Hougen More articles by this author Dimple Chananmolu More articles by this author Sanoj Punnen More articles by this author Bruno Nahar More articles by this author Dipen Parekh More articles by this author Mark Gonzalgo More articles by this author Chad Ritch More articles by this author Expand All Advertisement PDF DownloadLoading ...

A dynamic risk factor assessment for myocardial infarction and cardiac arrest in patients undergoing pancreatectomy

To identify pancreatectomy specific risk factors for myocardial infarction and cardiac arrest (MICA) and to assess whether addition of new information obtained during the hospitalization changes these risk factors. Analysis was performed on elective pancreatectomy data from the ACS-NSQIP database (2014-2019). Risk factors were grouped into pre-operative, intra-operative, and postoperative phases. Factors were selected using a bootstrap resampling procedure to determine MICA association. Independent significance was assessed by logistic regression. In the first 30 days post-op, 650 of 39779 patients (1.88%) developed MICA. Some of the surgery specific, intra- and post-operative factors that were identified are: delayed gastric emptying (OR: 2.61; 95% CI: 2.12-3.21), total pancreatectomy (OR: 2.16; 95% CI: 1.29-3.42), pancreatic fistula (OR: 1.54; 95% CI: 1.25-1.90), post-operative transfusion (OR: 1.28; 95% CI: 1.03-1.58), and open approach (OR: 1.36; 95% CI: 1.05-1.77). Adding new variables improved statistical model performance and the c-statistic improved from 0.69 to 0.76 in the final analysis. Surgery specific, intra-, and post-operative factors were associated with MICA. Addition of new information during the hospital course changed risk factors and the statistical prediction of MICA risk improved.

Body Mass Index Has a Nonlinear Association With Postoperative 30-Day Mortality in Patients Undergoing Craniotomy for Tumors in Men: An Analysis of Data From the ACS NSQIP Database.

BackgroundThe association between body mass index (BMI) and mortality is controversial. Thus, the purpose of our research was to survey the association between BMI and postoperative 30-day mortality in brain tumor patients undergoing craniotomy.MethodsThis study analyzed data collected in a multicenter, cross-sectional study that consecutively and nonselectively collected data from a total of 18,642 patients undergoing craniotomy for tumors in the ACS NSQIP from 2012 to 2015. We constructed three linear and non-linear binomial logistic models (the inflection point was set at 18.5) to evaluate the association between BMI and postoperative 30-day mortality, respectively. We also conducted subgroup analyses. Additionally, we compared non-linear models with vs. without interaction with sex.ResultsA total of 17,713 patients were included in this analysis. Of these, 47.38% were male. The postoperative 30-day mortality of the included cases was 2.39% (423/17,713), and the mean BMI was 28.41 ± 6.05 kg/m2. The linear logistic models suggested that after adjusting for the covariates, BMI was not associated with postoperative 30-day mortality (OR=0.999; 95% CI: 0.981, 1.017). The non-linear binomial logistic models suggested a nonlinear relationship between BMI and postoperative 30-day mortality. When BMI was < 18.5, we observed a stronger negative association between them after adjusting for covariates; the OR and 95% CI were 0.719, 0.576-0.896. When BMI was > 18.5, the relationship between them was not significant. We also found that a one-unit decrease in BMI for male patients with BMI < 18.5 kg/m2 was related to a 34.6% increase in the risk of postoperative 30-day mortality (OR=0.654, 95% CI (0.472, 0.907). There was no significant association between them in male patients with BMI > 18.5 kg/m2 or female patients.ConclusionsThis study demonstrates a non-linear relationship between BMI and the risk of postoperative death. Preoperative underweight (BMI < 18.5 kg/m2) would increase the risk of postoperative death in male patients (> 18 years old) undergoing craniotomy for brain tumors. Appropriate nutritional management prior to craniotomy for brain tumors may reduce the risk of postoperative 30-day mortality in underweight men.

Current Trends in Breast Reconstruction following Bilateral Prophylactic Mastectomy.

Background:Individuals with genetic susceptibility to breast cancer may pursue bilateral prophylactic mastectomy (BPM) and subsequent breast reconstruction. This study aimed to characterize immediate reconstructive trends following BPM.Methods:The ACS-NSQIP database (2010 -2019) was used to examine differences in demographics and operative outcomes based on breast reconstruction technique following BPM and factors predicting reconstruction type.Results:Of 1945 patients (mean age, 43.8 ± 11.3 years), implant-based reconstruction (IBR) was most frequently (71.8%) performed following BPM. Patients who underwent IBR (n = 1396) were younger (42.6 years, P < 0.001), more likely to be White (P < 0.05), and more likely to have a BMI less than 25 (P < 0.001). Patients who underwent autologous reconstruction (AR) (n = 186, 45.8 years) were more likely to be Black or African American and have a BMI of 25–30. Patients who underwent mastectomy only (MO) without immediate reconstruction (n = 363) were older (47.6 years), more likely to be Asian, and more likely to have a BMI greater than 35. The MO cohort had the highest frequency of diabetes or smoking history. AR was associated with longer operations, longer lengths of stay, and increased complications. Increasing age and BMI were predictive of AR or MO compared to IBR. Smoking was predictive of MO.Conclusion:This is the first large-scale study of genetically susceptible patients who underwent BPM demonstrating a significant relationship between patient demographics, operative outcomes, and immediate reconstruction technique. These results provide valuable insight for surgeons and patients during the shared decision-making process.

Frailty as a Predictor of Surgical Outcomes Following Femoral Hernia Repair.

Femoral hernias are associated with significant morbidity and mortality due to risk of strangulation. Frailty has shown to be strongly associated with adverse outcomes. A modified five-factor frailty index (mFI-5) is a simple validated predictor of postoperative complications and mortality within the ACS-NSQIP® database. This study aims to evaluate the impact of frailty and age on 30-day outcomes after femoral hernia repair. Patients who underwent femoral hernia repair were queried using the ACS-NSQIP database (2017) and divided into two groups based on frailty score (FS): Frail (FS = 1-5) and Non-frail (FS = 0). We evaluated the association between postoperative outcomes and frailty, age, sex, presentation, ASA class, timing of surgery, and surgical approaches. Univariate analysis followed by a multivariable logistic regression model was performed to evaluate postoperative morbidity. Of a total of 1,295 patients, 540 (42.7%) were in the Frail group. No differences in sex and race proportions were observed between groups. The Frail group had a higher rate of serious morbidity (4.4% vs 1.9%, P < .001), overall morbidity (7.8% vs 3.4%, P < .010), readmission rate (5.4% vs 2.3%, P = .003), and median (IQR) hospital length of stay (1 [0, 4] vs 0 [0, 1] days, P < .001). In multivariable analysis, male sex, presentation with complication, emergency surgery, and FS were associated with increased odds of overall morbidity. All deaths were in the Frail group. Frailty, male sex, presentation with obstruction/strangulation, and emergency surgery are independent predictors of increased 30-day morbidity. Thirty-day mortality was noted in the Frail group.

Impact of Obesity and Diabetes on Postoperative Outcomes Following Surgical Treatment of Nontraumatic Subarachnoid Hemorrhage: Analysis of the ACS-NSQIP Database

Nontraumatic subarachnoid hemorrhage (SAH) refers to high pressure extravasation of blood into the subarachnoid space that typically occurs spontaneously from rupture of cerebral aneurysm. The purpose of this study was to identify postoperative complications requiring increased surveillance in obese, diabetic, and hypertensive patients. Patients who underwent surgical treatment for nontraumatic SAH were queried in the American College of Surgeons National Surgical Quality Improvement Program database from the years 2012-2018. Cases were identified using International Classification of Diseases codes and then classified independently by 3 dichotomous diagnoses: obesity, diabetes, and hypertension. Among 1002 patients meeting inclusion criteria, 311 (31%) were obese (body mass index >30), 86 (9%) had diabetes treated with insulin or noninsulin agents, and 409 (41%) required medication for hypertension. There was a statistically significant association between diabetes and postoperative pneumonia (odds ratio [OR]=1.694; 95% confidence interval [CI]= 0.995-2.883; P=0.050), prolonged ventilator dependence (OR=1.700; 95% CI= 1.087-2.661; P=0.019), and death (OR=1.846; 95% CI= 1.071-3.179; P=0.025). Medication-dependent hypertension was statistically associated with incidence of stroke/cerebrovascular accident (OR=1.763; 95% CI=1.056-2.943; P=0.023). Obesity was not associated with adverse outcomes in this population. In patients undergoing surgical management of SAH, hypertensive and diabetic patients had poorer outcomes, including prolonged ventilator dependence, pneumonia, stroke/cerebrovascular accident, and death. Surprisingly, preexisting obesity was not associated with poor outcomes. In fact, overweight body mass index, class I obesity, and class II obesity had decreased need for transfusion in the 30-day postoperative period.

Novel Calculator to Estimate the Risk of Clinically Relevant Postoperative Pancreatic Fistula Following Distal Pancreatectomy

BackgroundDrain management algorithms are based on studies that predict clinically relevant postoperative pancreatic fistula (CR-POPF) using drain fluid amylase level on POD1 (DFA1). These studies are focused on pancreaticoduodenectomy which is inherently different than distal pancreatectomy. Moreover, the change of DFA between POD1 and POD3 (ΔDFA) is underutilized despite its importance in predicting CR-POPF. We sought to generate a calculator that estimates the risk of CR-POPF following distal pancreatectomy. MethodsThe 2014–2018 pancreas-targeted ACS-NSQIP database was used to identify patients who underwent elective distal pancreatectomy. Models to predict CR-POPF were constructed using DFA1 with/without ΔDFA. The fittest model was used to construct a calculator. ResultsOut of 12,042 distal pancreatectomies, 692 patients met the study’s inclusion criteria. The risk of CR-POPF was 15.9% in the included cohort versus 14.8% in the excluded one (P = 0.421). The predictors of the CR-POPF were age, operative time, DFA1, and ΔDFA. Adding ΔDFA decreased the Akaike’s information criterion of the model (507.7 vs 544.7)—indicating a significantly better model fit—and improved the cross-validated area under the curve from 0.731 to 0.791. An easy-to-use calculator was created for surgeons to estimate the risk of CR-POPF based on the abovementioned variables. A sensitivity/specificity table was created at various cutoffs to direct clinical decision-making with respect to early drain removal. ConclusionsThis study highlights the importance of ΔDFA, in addition to DFA1, in predicting CR-POPF. The provided calculator will facilitate predicting CR-POPF and postoperative drain management following distal pancreatectomy.

Impact of preoperative smoking on patients undergoing right hemicolectomies for colon cancer

PurposeThe tobacco epidemic is one of the biggest global public health issues impacting quality of life and surgical outcomes. Although 30% of colon cancers warrant a right hemicolectomy (RH), there is no specific data on the influence of smoking on postoperative complications following RH for cancer. The aim of this study was to determine its effect on post-surgical outcomes.MethodsPatients who underwent elective RH for colon cancer between 2016 and 2019 were identified from the ACS-NSQIP database. Propensity score matching (PSM) was used with a maximum absolute difference of 0.05 between propensity scores. Primary outcome was to assess the 30-day complication risk profile between smokers and non-smokers. Secondary outcomes included smoking impact on wound and major medico-surgical complication rates, as well as risk of anastomotic leak (AL) using multivariable logistic regression models.ResultsFollowing PSM, 5652 patients underwent RH for colon cancer with 1,884 (33.3%) identified as smokers. Smokers demonstrated a higher rate of organ space infection (4.1% vs 3.1%, p = 0.034), unplanned return to theatre (4.8% vs 3.7%, p = 0.045) and risk of AL (3.5% vs 2.1%, p = 0.005). Smoking was found to be an independent risk factor for wound complications (OR 1.32, 95% CI 1.03–1.71, p = 0.032), primary pulmonary complications (OR 1.50, 95% CI 1.06–2.13, p = 0.024) and AL (OR 1.66, 95% CI 1.19–2.31, p = 0.003).ConclusionSmokers have increased risk of developing major post-operative complications compared to non-smokers. Clinicians and surgeons must inform smokers of these surgical risks and potential benefit of smoking cessation prior to undergoing major colonic resection.