ACS NSQIP Research Articles

Impact of Age on 30-day Complications After Adult Deformity Surgery.

A retrospective analysis. The aim of this study was to identify whether age is a risk factor for postoperative complications after adult deformity surgery (ADS). Spinal deformity is a prevalent cause of morbidity in the elderly population, occurring in as many as 68% of patients older than 60 years. Given the increasing prevalence of adult spinal deformities and an aging population, understanding the safety of ADS in elderly patients is becoming increasingly important. A retrospective cohort analysis was performed on the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2010 to 2014. Patients (≥18 years of age) from the NSQIP database undergoing ADS were separated into age-based cohorts (≤52, 53-61, 62-69, and ≥70 years of age). Age groups were determined by interquartile analysis. Chi-squared, t tests, and multivariate logistic regression models were used to identify independent risk factors. A total of 5805 patients met the inclusion criteria. Age groups 1, 2, 3, and 4 contained 1518 (26.1%), 1478 (25.4%), 1451 (25.0%), and 1358 (23.4%) patients, respectively. Multivariate logistic regression analysis revealed increasing age (relative to age group 1) to be an independent risk factor for prolonged length of stay [odds ratio (OR) 1.39, confidence interval (CI) 1.12-1.69], all complications (OR 1.64, CI 1.35-2.00), renal complications (OR 3.45, CI 1.43-8.33), urinary tract infection (OR 2.70, CI 1.49-4.76), postoperative transfusion (OR 1.47, CI 1.20-1.82), and unplanned readmission (OR 1.64, CI 1.18-2.23). Gradations in ORs existed between the different cohorts, such that the deleterious effect of age was less pronounced in cohort 3 compared with cohort 4, and even more less so between cohort 2 and cohort 4. Age has been shown to be an independent risk factor for increased length of stay, all complications, renal complications, urinary tract infection, transfusion, and unplanned readmission. 3.

Trends in urinary diversion after radical cystectomy for urothelial carcinoma.

To assess how trends in urinary diversion (UD) type following radical cystectomy (RC) have changed in recent years and investigate pre-operative predictors of UD type. Data were abstracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2011 to 2015. We quantified the percentages of continent diversions (CD) versus incontinent diversions (ID) completed over this time frame. Using univariate and multivariable logistic regression analyses, we compared UD type across year of operation as well as predictors of type of diversion. We identified 4790 patients in the cohort, of which 81% underwent an incontinent diversion. Patients undergoing incontinent diversions were older (p<0.001), more likely to be female (p<0.001), had higher American Society of Anesthesiologists (ASA) classification (p<0.001) and had more comorbidities with worse preoperative lab values. On multivariable analysis, the odds of incontinent diversion increased per year (OR 1.16, 95% CI 1.06-1.26; p=0.001). Neoadjuvant chemotherapy (NAC) was associated with lower odds of receiving an ID (OR 0.33, 95% CI 0.17-0.64; p=0.001). Being male, healthy and young were associated with higher odds of CD. We demonstrate that there has been a decrease in continent diversion use in recent years. Neoadjuvant chemotherapy, proxies of life expectancy and gender are significant predictors of continent diversion. Further investigation to determine the underlying cause of decreased utilization of CD is warranted.

Predicting complications of major head and neck oncological surgery: an evaluation of the ACS NSQIP surgical risk calculator

BackgroundThe American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) universal surgical risk calculator is an online tool intended to improve the informed consent process and surgical decision-making. The risk calculator uses a database of information from 585 hospitals to predict a patient’s risk of developing specific postoperative outcomes.MethodsPatient records at a major Canadian tertiary care referral center between July 2015 and March 2017 were reviewed for surgical cases including one of six major head and neck oncologic surgeries: total thyroidectomy, total laryngectomy, hemiglossectomy, partial glossectomy, laryngopharyngectomy, and composite resection. Preoperative information for 107 patients was entered into the risk calculator and compared to observed postoperative outcomes. Statistical analysis of the risk calculator was completed for the entire study population, for stratification by procedure, and by utilization of microvascular reconstruction. Accuracy was assessed using the ratio of predicted to observed outcomes, Receiver Operating Characteristics (ROC), Brier score, and the Wilcoxon signed–ranked test.ResultsThe risk calculator accurately predicted the incidences for 11 of 12 outcomes for patients that did not undergo free flap reconstruction (NFF group), but was less accurate for patients that underwent free flap reconstruction (FF group). Length of stay (LOS) analysis showed similar results, with predicted and observed LOS statistically different in the overall population and FF group analyses (p = 0.001 for both), but not for the NFF group analysis (p = 0.764). All outcomes in the NFF group, when analyzed for calibration, met the threshold value (Brier scores < 0.09). Risk predictions for 8 of 12, and 10 of 12 outcomes were adequately calibrated in the FF group and the overall study population, respectively. Analyses by procedure were excellent, with the risk calculator showing adequate calibration for 7 of 8 procedural categories and adequate discrimination for all calculable categories (6 of 6).ConclusionThe NSQIP-RC demonstrated efficacy for predicting postoperative complications in head and neck oncology surgeries that do not require microvascular reconstruction. The predictive value of the metric can be improved by inclusion of several factors important for risk stratification in head and neck oncology.

Addition of clinical risk scores improves prediction performance of American Society of Anesthesiologists (ASA) physical status classification for postoperative mortality in older patients: a pilot study.

Many methods for preoperative risk stratifications used in everyday practice do not take into account all of the comorbidities and complex physiological status of older patients. Therefore, anaesthesiologists and surgeons must consider multiple ways of preoperative diagnostics. Determining which of the preoperative clinical risk scores [Revised Lee score, the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) calculator and Surgical Outcome Risk Tool (SORT)] best improves routinely used American Society of Anaesthesiologists (ASA) physical status classification. The prospective pilot study included 78 patients who were being prepared for extensive non-cardiac surgeries under general anaesthesia. Preoperatively, anaesthesiologist determined ASA score according to guidelines. Then, the data of patients have been processed on the interactive calculators of Revised Lee score, ACS NSQIP and SORT. Mean age of included patients was 71.4±6.9years. When it comes to postoperative mortality prediction, three risk scores (ASA, ACS NSQIP and SORT) have been statistically significant, respectively, P=0.016, P<0.0001, P<0.0001. Results showed that AUC being higher in ACS NSQIP and SORT (0.813; 0.797). Out of all three additional risk scores, ACS NSQIP showed to add the most to the specificity and sensitivity of ASA score, with combined AUC=0.841. ACS NSQIP and SORT increase the accuracy of ASA score. Revised Lee score cannot be considered a good indicator of postoperative mortality risk since it is primarily the score which indicates risk for cardiovascular complications. Further studies, with a greater number of patients, are needed.

Do-Not-Resuscitate status as an independent risk factor for patients undergoing surgery for hip fracture.

AIMTo determine morbidity and mortality in hip fracture patients and also to assess for any independent associations between Do-Not-Resuscitate (DNR) status and increased post-operative morbidity and mortality in patients undergoing surgical repair of hip fractures.METHODSWe conducted a propensity score matched retrospective analysis using de-identified data from the American College of Surgeons’ National Surgical Quality Improvement Project (ACS NSQIP) for all patients undergoing hip fracture surgery over a 7 year period in hospitals across the United States enrolled in the ACS NSQIP with and without DNR status. We measured patient demographics including DNR status, co-morbidities, frailty and functional baseline, surgical and anaesthetic procedure data, post-operative morbidity/complications, length of stay, discharge destination and mortality.RESULTSOf 9218 patients meeting the inclusion criteria, 13.6% had a DNR status, 86.4% did not. Mortality was higher in the DNR compared to the non-DNR group, at 15.3% vs 8.1% and propensity score matched multivariable analysis demonstrated that DNR status was independently associated with mortality (OR = 2.04, 95%CI: 1.46-2.86, P < 0.001). Additionally, analysis of the propensity score matched cohort demonstrated that DNR status was associated with a significant, but very small increased likelihood of post-operative complications (0.53 vs 0.43 complications per episode; OR = 1.21; 95%CI: 1.04-1.41, P = 0.004). Cardiopulmonary resuscitation and unplanned reintubation were significantly less likely in patients with DNR status.CONCLUSIONWhile DNR status patients had higher rates of post-operative complications and mortality, DNR status itself was not otherwise associated with increased morbidity. DNR status appears to increase 30-d mortality via ceilings of care in keeping with a DNR status, including withholding reintubation and cardiopulmonary resuscitation.

National Analysis of Unplanned Readmissions After Thoracoscopic Versus Open Lung Cancer Resection

Hospital readmissions are viewed as a mark of inferior health care quality and are penalized. Unplanned postoperative readmission reason and timing after lung resection are not well understood. We examine related, unplanned readmissions after thoracoscopic versus open anatomic lung resections to identify opportunities to improve patient care. We analyzed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data set, 2012 to 2015, characterizing 30-day related, unplanned postoperative readmissions after anatomic lung resections for primary lung cancer. Risk-adjusted comparison of readmission after thoracoscopic and open resection was performed using propensity matching. Patients (n= 9,510) underwent anatomic lung resections; 4,935 (51.9%) were thoracoscopic resections and 4,575 (48.1%) were open resections. Of the thoracoscopic patients, 10.9% experienced one or more complications, versus 19.4% of patients with open resection (p < 0.0001). Of the thoracoscopic patients 5.5% experienced related, unplanned readmissions versus 7.2% of the patients with open resection (p < 0.001). 24.8% of complications after thoracoscopic approach occurred after discharge, versus 15.5% after open approach (p < 0.0001). Timing of unplanned readmission was similar for both groups. The propensity-matched odds ratio of risk of readmission after thoracoscopic versus open resection was 1.16 (95% confidence interval, 0.949 to 1.411, p= 0.15). Open anatomic lung resections for primary lung cancer had nearly twice the complication rate but only a slightly higher readmission rate than thoracoscopic resection. More complications occurred after discharge after thoracoscopic than open resections. Most readmissions occurred within 2 weeks after both thoracoscopic and open resections. Risk-adjusted comparison identified no statistically significant difference in risk of related, unplanned readmission after thoracoscopic versus open resections. Future studies should focus on identification of processes of care to decrease complications and unplanned readmissions after lung cancer resection.

MS 03.04 Technical Aspects of Limited Resection

Since its first report by Churchill and Belsey in 1939, and its evolution in lung cancer management described by Jensik in 1973 (Figure), pulmonary segmentectomy use for early lung cancer diagnosis and treatment has remained controversial. Definitive answers must wait regarding the results of the JCOG and Alliance randomized trials before true standards for surgical care for the lung cancer less than 2 cm are determined. Nevertheless, sublobar resections including wedge resection and segmentectomy are being adopted at an increasing rate compared to its use in previously published large databases (SEER, 5%; ACS NSQIP, 4%). Proper preoperative teaching and intraoperative performance of the technical aspects of sublobar resection are now becoming priorities for general thoracic resident and fellow training in an era where minimally invasive techniques are becoming increasingly the standard of care. General thoracic surgeons must have meticulous attention to detail in performing these resections in order to decrease the likelihood of collateral damage to neighboring segments as well as to minimize local recurrence whether there are performing the operation open, hybrid, standard VATS, uniportal VATS, or robotic. The technical aspects of sublobar resection begin before the patient goes to the operating room, and prime objectives in planning these resections include: 1) expertise in the segmental anatomy for that particular patient, 2) location and size of the nodule with relation to adjoining segmental bronchovascular components, 3) careful study and possible supplementation of high resolution computerized tomography with newer 3-D methods to define the spatial relationships of the nodule and segments, 4) pre- and intraoperative methods for locating the nodule if there is suspicion that parenchymal palpation will fail, 5) whether to perform wedge resection first or proceed directly to anatomic segmentectomy, 6) defining and managing the fissure between segments and recognizing when extended segmentectomy is possible or whether to convert to lobectomy and, 7) to use other intraoperative strategies to avoid technique related complications. Preoperative planning includes careful examination of the CT scan in the axial, coronal and sagittal plans in order to get a first appreciation of the depth, size, segmental anatomy and relationship of the nodule bronchovascular elements. Three-dimensional reconstruction can be as simple as navigational bronchoscopy planning images, or newer techniques for total 3-D pulmonary reconstruction which are in development.1 When there is a question of whether up front segmentectomy is to be performed and a part solid or non-solid nodule may not be palpable, intraoperative localization techniques such as navigation bronchoscopy2 or placement of fiducials/microcoils3 can be very useful. When there is no preoperative histologic diagnosis, whether a wedge or segmentectomy is performed initially will depend on the location and depth of the lesion as well as the fitness of the patient. Segmentectomy for initial diagnosis with intraoperative frozen section of both the primary lesion and suspicious level 13 and 14 stations can be prudent, especially if wedge resection could compromise performing the segmentectomy.4 In order to avoid positive margins, meticulous attention to detail with compulsive dissection and skeletonizing of the bronchovascular elements must be performed. If it is difficult to preserve the margin in a single segment resection, an extended resection of the parenchyma of adjacent segments or bisegmentectomy can be performed.5 There is controversy regarding the chance for loco-regional recurrence for segmentectomy especially in cases of pure solid lesions or segmentectomies which involve portions of the basilar segments or right upper lobe.6-8 Defining the fissure and the method with which it is divided can be one of the most important yet challenging portions of the operation. A variety of methods to define the fissure have evolved including inflation of the residual lung after segment occlusion, selective inflation of the segment to be removed, or the use of indocyanine green to define the intersegmental vein,4,5 and the fissure can be divided either with stapling alone or in combination with harmonic scalpel.9 A variety of fibrin sealants are available to decrease postoperative fistulae. With regard to the optimal approach, to date there have been no studies which show any superiority regarding conventional VATs or uniportal VATs for segmental resection, or any difference between the VATs approaches and robotic segmentectomy (10). A recent meta-analysis of over 7438 patients revealed a trend towards increased conversion to open with VATs, while postoperative complications, operation time, length of stay, chest tube duration, and number of lymph nodes were comparable.11

Perioperative outcomes after reoperative carotid endarterectomy are worse than expected

ObjectiveReoperative carotid endarterectomy (CEA) can be technically challenging because of significant scarring as a consequence of the initial CEA procedure. There are limited data that describe outcomes after reoperative CEA, and as such, our goal was to determine the effect of reoperative CEA on perioperative outcomes. MethodsThe American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients undergoing index and reoperative CEA between 2005 and 2014. Multivariate analysis was performed to assess the effect of reoperative CEA on outcomes including stroke, major adverse cardiovascular event, and procedure time. ResultsThere were 75,943 index and 140 reoperative CEAs identified. No differences were found in baseline demographics or comorbidities except that the reoperative group had a higher incidence of patients with end-stage renal disease (3.6% vs 1.1%; P = .004). Prior stroke with deficit (20.8% vs 15.4%; P = .137) and without deficit (11.5% vs 9.1%; P = .43) were similar between reoperative and index CEA groups. Both the reoperative and index initial CEA cohorts had comparable rates of surgical site infection (0.7% vs 0.3%; P = .462), return to the operating room (3.6% vs 4%; P = .816), readmission with 30 days (2.1% vs 6.9%; P = .810), myocardial infarction (2.1% vs 0.9%; P = .125), and perioperative death (0.7% vs 0.9%; P = .853). The reoperative cohort had a significantly higher rate of perioperative stroke (5.0% vs 1.6%; P = .002) and a longer operative duration (137 ± 54 vs 116 ± 49 minutes; P < .001). Multivariate analysis revealed that reoperative CEA was an independent factor for postoperative stroke (odds ratio, 3.71; 95% confidence interval [CI], 1.61-8.57; P = .002), major adverse cardiovascular event (odds ratio, 2.76; 95% CI, 1.32-5.78; P = .007), and longer procedure time (means ratio, 1.21; 95% CI, 1.12-1.30; P < .001). ConclusionsReoperative carotid surgery is associated with a longer operative time and higher risk for perioperative stroke compared with index CEA. This information informs the risk-benefit analysis for reoperation.

This Month in Adult Urology

No AccessJournal of UrologyThis Month in Adult Urology1 Oct 2017This Month in Adult Urology Joseph A. Smith Joseph A. SmithJoseph A. Smith More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.07.012AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "This Month in Adult Urology." The Journal of Urology, 198(4), pp. 715–716 References 1 : Surgical treatment of female stress urinary incontinence: AUA/SUFU guideline. J Urol2017; 198: 875. Link, Google Scholar 2 : AUA policy statement on use of multiparametric magnetic resonance imaging in the diagnosis, staging and management of prostate cancer. J Urol2017; 198: 832. Abstract, Google Scholar 3 : Predictive nomogram for recurrence following surgery for nonmetastatic renal cell cancer with tumor thrombus. J Urol2017; 198: 810. Abstract, Google Scholar 4 : Predicting complications following robot-assisted partial nephrectomy with the ACS NSQIP® universal surgical risk calculator. J Urol2017; 198: 803. Link, Google Scholar 5 : Effects of withdrawing α1-blocker from combination therapy with α1-blocker and 5α-reductase inhibitor in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia: a prospective and comparative trial using urodynamics. J Urol2017; 198: 905. Abstract, Google Scholar 6 : Focal laser ablation of prostate cancer: feasibility of magnetic resonance imaging-ultrasound fusion for guidance. J Urol2017; 198: 839. Link, Google Scholar 7 : Dietary and lifestyle risk factors associated with incident kidney stones in men and women. J Urol2017; 198: 858. Link, Google Scholar 8 : Severity of preoperative proteinuria is a risk factor for overall mortality in patients undergoing nephrectomy. J Urol2017; 198: 795. Link, Google Scholar 9 : Characteristics associated with treatment response and satisfaction in women undergoing onabotulinumtoxinA and sacral neuromodulation for refractory urgency urinary incontinence. J Urol2017; 198: 890. Abstract, Google Scholar © 2017 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 198Issue 4October 2017Page: 715-716 Advertisement Copyright & Permissions© 2017 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph A. Smith More articles by this author Expand All Advertisement PDF downloadLoading ...

Resident Training in Hysterectomy and Patient Morbidity: Interrogating the Association

BACKGROUND: Concern regarding resident inexperience as a contributing factor toward unfavorable surgical outcomes is often claimed but has been inadequately explored. METHODS: Data were abstracted from American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) on 33,278 benign hysterectomies performed from January 2005–December 2012. Associations between resident participation and morbidity were examined using multivariate-adjusted regression, adjusting for age, BMI, race, ethnicity, year of surgery, smoking, diabetes, hypertension, steroid use, ASA physical classification, uterine size, and postoperative diagnosis. Cases without resident involvement (63.4%) were used as the referent. RESULTS: Resident involvement was associated with significantly longer operative times regardless of surgical approach and year of training (all P&lt;.0001). Odds of blood transfusion were increased with resident participation in abdominal (OR 1.74; 95% CI 1.40–2.17) and laparoscopic hysterectomy (OR 1.87; 95% CI 1.33–2.64), while odds of sepsis were increased in abdominal (OR 2.29; 95% CI 1.37–3.83) and vaginal hysterectomy (OR 2.49; 95% CI 1.24–5.00). Odds of urinary tract infections were uniformly higher with resident participation (all P&lt;.001). When stratified by level of training, these associations only remained significant in hysterectomies involving senior residents. All associations were significantly attenuated or absent when operative time was included in the model. DISCUSSION: Resident involvement is associated with modest increases in the odds of blood transfusion and infectious morbidity after hysterectomy. These associations are likely driven by prolonged operative times with resident participation.

Multifactorial risk index for prediction of intraoperative blood transfusion in endovascular aneurysm repair

BackgroundIn some institutions, the current blood ordering practice does not discriminate minimally invasive endovascular aneurysm repair (EVAR) from open procedures, with consequent increasing costs and likelihood of blood product wastage for EVARs. This limitation in practice can possibly be addressed with the development of a reliable prediction model for transfusion risk in EVAR patients. We used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to create a model for prediction of intraoperative blood transfusion occurrence in patients undergoing EVAR. Afterward, we tested our predictive model on the Vascular Study Group of New England (VSGNE) database. MethodsWe used the ACS NSQIP database for patients who underwent EVAR from 2011 to 2013 (N = 4709) as our derivation set for identifying a risk index for predicting intraoperative blood transfusion. We then developed a clinical risk score and validated this model using patients who underwent EVAR from 2003 to 2014 in the VSGNE database (N = 4478). ResultsThe transfusion rates were 8.4% and 6.1% for the ACS NSQIP (derivation set) and VSGNE (validation) databases, respectively. Hemoglobin concentration, American Society of Anesthesiologists class, age, and aneurysm diameter predicted blood transfusion in the derivation set. When it was applied on the validation set, our risk index demonstrated good discrimination in both the derivation and validation set (C statistic = 0.73 and 0.70, respectively) and calibration using the Hosmer-Lemeshow test (P = .27 and 0.31) for both data sets. ConclusionsWe developed and validated a risk index for predicting the likelihood of intraoperative blood transfusion in EVAR patients. Implementation of this index may facilitate the blood management strategies specific for EVAR.

Low mortality rates after endovascular aortic repair expand use to high-risk patients

ObjectiveThe 2010 endovascular aneurysm repair (EVAR) trial 2 (EVAR 2) reported that patients with comorbidity profiles rendering them unfit for open aneurysm repair who underwent EVAR did not experience a survival advantage compared with those who did not undergo intervention. These patients experienced a 30-day mortality of 7.3%, whereas reports from similar cohorts reported far lower mortality rates. The primary objective of our study was to compare the incidence of 30-day mortality in low- and high-risk patients undergoing EVAR in a contemporary data set, using patient risk stratification criteria from EVAR 2. Secondarily, we sought to identify risk factors associated with a disproportionate contribution to 30-day mortality risk. MethodsData were obtained from the 2005 to 2013 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data Files (N = 24,813). Patients were included in the high-risk cohort with the presence of renal, respiratory, or cardiac preoperative criteria alone or in combination. Renal impairment criteria were defined as dialysis and creatinine concentration >2.26 mg/dL. Respiratory impairment criteria included history of chronic obstructive pulmonary disease and preoperative ventilator support. Cardiac impairment criteria included history of myocardial infarction, congestive heart failure, angina, and prior coronary intervention. Patient and procedural characteristics and 30-day postoperative outcomes were compared using Pearson χ2 tests for categorical variables and Wilcoxon rank sum tests for continuous variables. ResultsAmong 24,813 patients undergoing EVAR, 12,043 (48%) patients were characterized as high risk (at least one impairment criterion); 12,770 (52%) patients were stratified as low risk. The 30-day mortality rate was 1.9% in the high-risk cohort compared with the 7.3% reported by EVAR 2, and it was higher in the high-risk cohort compared with the low-risk cohort (1.9% vs 0.9%; P < .001). Whereas the presence of each comorbidity increased the odds of 30-day mortality (respiratory odds ratio [OR], 1.62; 95% confidence interval [CI], 1.16-2.26; P = .005; cardiac OR, 1.55; 95% CI, 1.14-2.10; P = .005), the presence of renal criteria disproportionately increased the odds of mortality threefold (OR, 3.42; 95% CI, 2.31-5.09; P < .001). ConclusionsContemporary 30-day mortality after EVAR in high-risk patients is substantially lower than that reported in the EVAR 2 trial. Whereas low- and high-risk stratification by current comorbidity criteria is appropriate, attention needs to be paid to disproportionate risk contribution from renal disease to mortality compared with cardiac and pulmonary comorbidities. Given the lower mortality risk than previously described, patients stratified as high risk should be thoughtfully considered for definitive EVAR.

Nutritional Status as an Adjunct Risk Factor for Early Postoperative Complications Following Posterior Cervical Fusion.

Retrospective study on prospectively collected data. The aim of this study was to study the impact of nutritional status, as measured by serum albumin level, on patient outcomes following posterior cervical fusion (PCF) surgery. Malnutrition is a potential modifiable risk factor that has garnered an increasing amount of attention within orthopedics in recent years. There is evidence to suggest the role of nutritional status in lumbar and ACDF surgery, yet the data for PCF are still lacking. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was queried by current procedure terminology (CPT) from 2010 to 2014. Bivariate analyses were performed to compare the preoperative characteristics between those with normal albumin and hypoalbuminemia. Postoperative complications and outcomes were similarly analyzed for those with and without low albumin levels. Stepwise multivariate logistic regression models were employed to determine whether hypoalbuminemia was an independent risk factor for short-term patient outcomes and complications. There were 1573 cases with measured albumin levels (42.4%). The mean (standard deviation) serum albumin level was 3.9 (0.6). Among these patients, 265 (16.8%) cases had hypoalbuminemia. The adjusted analyses demonstrated that patients with hypoalbuminemia had a significantly higher risk for length of stay >5 days (odds ratio [OR] = 3.8; 95% confidence interval [CI] = 2.8-5.1; P < 0.0001). In addition, hypoalbuminemia was an independent risk factor for any complications (OR = 2.7; 95% CI = 1.9-3.7; P < 0.0001), pulmonary complications (OR = 2.3; 95% CI = 1.2-4.5; P = 0.010), intra/postoperative blood transfusions (OR = 3.2; 95% CI = 2.1-4.9; P < 0.0001), sepsis (OR = 4.0; 95% CI = 1.7-9.2; P = 0.001), and venous thromboemoblism (OR = 3.6; 95% CI = 1.5-8.5; P = 0.004). These findings implicate that a baseline serum albumin <3.5 g/dL may serve as a valuable prognostic measure for the development of several complications following PCF surgery. 3.

Significant Differences Exist in Patient Demographics of Foot and Ankle Surgeries between High Quality Prospective Studies and National Databases

Category: Trauma Introduction/Purpose: Several high profile studies have compared surgical and non-operative treatments in specific types of major foot and ankle surgeries and serve as management guidelines for many Orthopaedic surgeons. However, the external validity of these studies has not been examined and should be confirmed in order to confidently apply the study conclusions to the national population and modify clinical practice. The purpose of the current study was to compare patient demographic information collected from major high quality, prospective studies in foot and ankle surgeries and from same surgical procedures recorded in a nationwide database of the United States patient population. Methods: Patient demographic information from surgical procedures for achilles tendon rupture, syndesmotic injury, calcaneal fracture, and lisfranc injury were pulled from American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database between 2005 – 2014 by using CPT codes listed in Table I. The same information was collected from several randomized control or prospective cohort studies identified for each type of procedure (Table I). Patient age and body mass index (BMI) were compared by using two sample T-test, while Fisher’s exact test was used to compare patient sex. Study data on age and BMI that did not provide both mean and standard deviation were not included in analysis. Results: In the NSQIP database, 1,633 achilles tendon repair and 8,852 syndesmotic injury cases were identified, but few calcaneal fracture surgeries and no lisfranc injury cases were found. For surgical cases with syndesmotic injury repair, age, sex and BMI all differed significantly between NSQIP data and the aggregate values of published studies, with the NSQIP patients being older and have more females and larger BMI (Tables II-IV). By comparing individual study data with NSQIP, 1 of 3 studies showed the same trend in age, 2 of 3 in sex, and 1 of 1 in BMI. For cases with Achilles tendon rupture repair, both aggregate and individual comparisons with 2 studies showed statistical difference on age, with NSQIP patients being older (Table II). Conclusion: Although the results were somewhat mixed, statistical significance did exist in patient demographic characteristics between published clinical data and a national database in the same foot and ankle surgeries. Caution should be warranted when interpreting clinical studies and before generalizing it onto the national population.

The criteria of "inoperability".

In the literature, the term "inoperable" mainly refers to two specific clinical aspects: cancer staging and technical difficulty/impossibility in performing. In light of this clarification, the statement "the patient cannot be anesthetized" has no medical foundation. On the contrary, the physicians have to carefully stratify the perioperative risk and optimize the patients' preoperative clinical status. In order to perform a precise risk stratification, the European Society of Cardiology and the European Society of Anaesthesiology have joined and published the guidelines for the perioperative cardiovascular management of patients scheduled to undergo non-cardiac surgery. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) represents the most complete and accurate prediction tool so far. It includes 21 preoperative factors relating to demographics, comorbidities and procedures able to predict outcomes based on preoperative risk factors such as death, cardiac complications, pneumonia, and acute kidney injury. The present article will address aspects related to common aspects concerning modifiable and non-modifiable that should be addressed in every patient to whom elective surgery has been scheduled.

Comparison of 30-Day Morbidity and Mortality After Arthroscopic Bankart, Open Bankart, and Latarjet-Bristow Procedures: A Review of 2864 Cases.

Background:Surgical intervention for anterior shoulder instability is commonly performed and is highly successful in reducing instances of recurrent instability.Purpose:To determine and compare the incidence of 30-day complications and patient and surgical risk factors for complications for arthroscopic Bankart, open Bankart, and Latarjet-Bristow procedures.Study Design:Cohort study; Level of evidence, 3.Methods:All arthroscopic Bankart, open Bankart, and Latarjet-Bristow procedures from 2005 to 2014 from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) prospective database were analyzed. Baseline patient variables were assessed, including the Charlson Comorbidity Index (CCI). Outcomes measures included length of operation, length of hospital stay, need for hospital admission, 30-day readmission, and 30-day return to the operating room. Binary logistic regression was performed for the presence of any complications after all 3 procedures.Results:There were 2864 surgical procedures (410 open Bankart, 163 Latarjet-Bristow, and 2291 arthroscopic Bankart) included. There was no significant difference with regard to age (P = .11), body mass index (P = .17), American Society of Anesthesiologists class (P = .423), or CCI (P = .479) for each group. The Latarjet-Bristow procedure had the highest overall complication rate (5.5%) compared with open (1.0%) and arthroscopic (0.6%) Bankart repairs. The Latarjet-Bristow procedure had significantly longer mean operative times (P < .001) in addition to the highest 30-day return rate to the operating room (4.3%; 95% confidence interval, 1.2%-7.4%). Smoking status was an independent predictor of a postoperative complication (P = .05; odds ratio, 8.0) after Latarjet-Bristow.Conclusion:Surgical intervention for anterior shoulder instability has a low rate of complication (arthroscopic Bankart, 0.6%; open Bankart, 1.0%; Latarjet-Bristow, 5.5%) in the early postoperative period, with the most common being surgical site infection, deep vein thrombosis, and return to the operating room.

Nutritional Insufficiency as a Predictor for Adverse Outcomes in Adult Spinal Deformity Surgery.

Study Design:Retrospective analysis of prospectively collected data.Objective:The effect of malnutrition on outcomes after general surgery has been well reported in the literature. However, there is a paucity of data on the effect of malnutrition on postoperative complications during adult deformity surgery. The study attempts to explore and quantify the association between hypoalbuminemia and postoperative complications.Methods:A retrospective cohort analysis was performed on the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2010 to 2014. Patients (≥18 years of age) from the NSQIP database undergoing adult deformity surgery were separated into cohorts based serum albumin (<3.5 or >3.5 g/dL). Chi-square and multivariate logistic regression models were used to identify independent risk factors.Results:A total of 2236 patients met the inclusion criteria for the study, of which 2044 (91.4%) patients were nutritionally sufficient while 192 (8.6%) patients were nutritionally insufficient. Multivariate logistic regressions revealed nutritional insufficiency as a risk factors for mortality (odds ratio [OR] = 15.67, 95% confidence interval [CI] = 6.01-40.84, P < .0001), length of stay ≥5 days (OR = 2.22, 95% CI = 1.61-3.06, P < .0001), any complications (OR = 1.82, 95% CI = 1.31-2.51, P < .0001), pulmonary complications (OR = 2.29, 95% CI = 1.29-4.06, P = .005), renal complications (OR = 2.71, 95% CI = 1.05-7.00, P = .039), and intra-/postoperative red blood cell transfusion (OR = 1.52, 95% CI = 1.08-2.12, P = .015).Conclusions:This study demonstrates that preoperative hypoalbuminemia is a significant and independent risk factor for postoperative complications, 30-day mortality, and increased length of hospital in patients undergoing adult deformity surgery surgery. Nutritional status is a modifiable risk factor that can potentially improve surgical outcomes after adult deformity surgery.

Outcomes of endovascular and open surgical repair of ruptured abdominal aortic aneurysms in elderly patients

BackgroundEndovascular aneurysm repair (EVAR) is becoming the preferred treatment modality for patients with a ruptured abdominal aortic aneurysm (rAAA). Although the survival advantage of EVAR over open aortic repair (OAR) has been shown in some studies, it is unclear whether this benefit extends to elderly patients. We sought to evaluate the outcomes of rAAA repair in octogenarians. MethodsWe reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data set (2005-2014) to identify patients older than 80 years who were treated with EVAR and OAR for rAAA. Procedural trends were evaluated during the course of the study period. Perioperative outcomes including mortality, morbidity, and hospital length of stay (LOS) were compared. Multivariable regression models were used to identify predictors of perioperative mortality and morbidity. ResultsAmong 1048 elderly patients who underwent rAAA repair, 450 (43%) and 598 (57%) were treated with EVAR and OAR, respectively. The use of EVAR to treat rAAA had increased significantly in this population of patients (0% in 2005 vs 56% in 2014; P < .001). The overall 30-day mortality rate among octogenarians was 41%. The mortality rate was significantly higher among those treated with OAR compared with EVAR (47% vs 33%; P < .001). Pneumonia (21% vs 10%; P < .001), reintubation (14% vs 9%; P < .001), and >48-hour ventilator dependence (43% vs 21%; P < .001) were significantly higher in patients undergoing OAR. Hospital LOS (13 vs 10 days; P < .001) was also longer in the OAR cohort. Compared with EVAR, OAR was independently predictive of 30-day mortality (adjusted odds ratio [AOR], 1.7; 95% confidence interval [CI], 1.3-2.2; P < .001), pneumonia (AOR, 2.4; 95% CI, 1.7-3.6; P < .001), >48-hour ventilator dependence (AOR, 2.5; 95% CI, 1.8-3.3; P < .001), and longer LOS (adjusted mean ratio, 1.4; 95% CI, 1.2-1.6; P < .001). ConclusionsElderly patients have significant but acceptable perioperative mortality and morbidity after rAAA repair. Use of endovascular repair in the elderly population has increased and is associated with better perioperative survival and 30-day outcomes compared with traditional open repair in this study.

The effect of age on microsurgical free flap outcomes: An analysis of 5,951 cases.

The growing elderly population necessitates a greater number of aging patients requiring complex reconstructive surgery involving free tissue transfer. The purpose of this study was to assess the safety, efficacy, and outcomes of microsurgical free tissue transfer in elderly patients using a national multi-institutional database. We performed a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patients undergoing free tissue transfer. We stratified cohorts based on ages 18-49, 50-59, 60-69, 70-79, and 80+ years and analyzed primary outcomes of surgical complications, medical complications, mortality, and flap failure. A total of 5,951 patients were identified for inclusion in the analysis. Univariate analysis demonstrated progressively increasing surgical (P = .001) and medical (P < .001) complication rates with increasing age. After controlling for confounding variables, age was not significantly associated with rates of surgical (OR 1.00, 95% CI 0.99-1.01, P = .737) or medical (OR 1.01, 95% CI 0.99-1.03, P = .209) complications, flap failure (OR 1.00, 95% CI 1.00-1.02, P = .689), or reoperation (OR 1.01, 95% CI 1.00-1.03, P = 0.165). Factors associated with surgical complications included BMI (OR 1.03, 95% CI 1.00-1.05, P = .031), prolonged operative time (OR 1.001, 95% CI 1.000-1.002, P = .002), American Society of Anesthesiologists (ASA) classification of 3 or greater (OR 1.62, 95% CI 1.17-2.23, P = .003), and prolonged hospitalization (OR 1.03, 95% CI 1.02-1.04, P < .001). ASA classification of 3 or greater (OR 2.57, 95% CI 1.48-4.45, P = .001), renal history (OR 10.13, 95% CI 1.57-65.55, P = .015), and prolonged hospitalization (OR 1.06, 95% CI 1.04-1.08, P < .001) were associated with medical complications. Age was associated with increased mortality (OR 1.06, 95% CI 1.00-1.13, P = .048). Age alone should not be used as an absolute or even relative contraindication in patient assessment. Rather, preoperative assessment should focus on comorbidities and assessment of physiologic age instead of chronologic age. Optimization of these comorbidities is key to sustaining favorable outcomes in microsurgical free flap reconstruction in the elderly population.

Risk factors for surgical site infection after ovarian cancer debulking: An ACS NSQIP analysis

Risk factors for surgical site infection after ovarian cancer debulking: An ACS NSQIP analysis