ACS NSQIP Research Articles

Enhanced recovery after surgery in colorectal surgery: Impact of protocol adherence on patient outcomes

Study objectivesThere is growing evidence internationally to support Enhanced Recovery After Surgery (ERAS) pathways. The impact of pathway compliance and the relative importance of individual components, however, remains less clear. Our institution implemented a multimodal ERAS protocol for elective colorectal surgery in November 2013. The objectives of this study were to investigate the impact of the introduction of the pathway, the relationship between pathway adherence and patient outcomes, and the relative importance of individual components. DesignThis was a single-center, observational cohort study of elective colorectal surgical patients. SettingA tertiary care and academic teaching hospital in Canada. PatientsProspective data was collected from 495 consecutive major colorectal surgical patients following the ERAS launch. Retrospective data was also collected from a pre-ERAS cohort of 99. MeasurementsAdherence to 12 ERAS components were measured, along with American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) defined patient complications and hospital length of stay (LOS). Post-ERAS patients were divided in to two groups: high compliance (≥75% process adherence) and low compliance (<75% adherence). Outcomes were compared between groups. Main resultsThere was a significant reduction in both complication rate (31.5% vs 14.6%; p ≤0.05) and hospital mean LOS (10.1 vs 6.9 days; p ≤0.05) following introduction of the ERAS pathway. The high adherence group had a shorter mean LOS (5.7 vs 8.6 days; p ≤0.01) and lower rate of complications (11.2% vs 19.6%; p = 0.02) compared with the low compliance group. ConclusionsHigher adherence to the standardized ERAS protocol was associated with improved patient outcomes, including reduced pulmonary complications. The cause-effect relationship is complex and likely influenced by confounding factors. Our data provides feedback to aid ongoing innovation of our pathway locally and adds to the growing body of evidence supporting the value of ERAS in general.

The Effect of Obesity on Achilles Rupture Repair.

Introduction. Obesity is an increasingly common comorbidity that may negatively affect outcomes following orthopaedic surgery. It is valuable to determine whether obese patients are vulnerable for postoperative complications. The purpose of this study was to analyze data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) to determine the effect of obesity on surgical treatment of Achilles tendon ruptures. Methods. Patients who underwent a surgical repair of the Achilles tendon were retrospectively identified through the ACS NSQIP. The patients were divided into 2 cohorts (obese and nonobese), then perioperative and postoperative factors were evaluated for association with obesity. Results. A total of 2128 patients were identified, of whom 887 (41.7%) were classified as obese. Obesity correlated with an increased operative time, 60.9 versus 56.1 minutes. The only postoperative complication associated with obesity was wound dehiscence. Logistic regression adjusted for comorbid conditions demonstrated that obesity was not associated with an increased risk of wound dehiscence. Conclusion. A large segment of the patient population undergoing Achilles tendon repair is obese. Obesity was found to have an increased association with wound dehiscence, likely related to comorbid conditions, following Achilles tendon repair. Obesity was not significantly associated with any other complication. Levels of Evidence: III, Retrospective Cohort Study.

Cardiac biomarkers improve prediction performance of the combination of American Society of Anesthesiologists physical status classification and Americal College of Surgeons National Surgical Quality Improvement Program calculator for postoperative mortality in elderly patients: a pilot study.

Our previous research has shown American Society of Anaesthesiologists physical status classification (ASA) score and Americal College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) calculator to have the most accuracy in the prediction of postoperative mortality. The aim of our research was to define the most reliable combination of cardiac biomarkers with ASA and ACS NSQIP. We have included a total of 78 patients. ASA score has been determined in standard fashion, while we used the available interactive calculator for the ACS NSQIP score. Biomarkers BIRC5, H-FABP, and hsCRP have been measured in specialized laboratories. All of the deceased patients had survivin (BIRC5) > 4.00pg/ml, higher values of H-FABP and hsCRP and higher estimated levels of ASA and ACS NSQIP (P = 0.0001). ASA and ACS NSQIP alone had AUC of, respectively, 0.669 and 0.813. The combination of ASA and ACS NSQIP had AUC = 0.841. Combination of hsCRP with the two risk scores had AUC = 0.926 (95% CI 0.853-1.000, P < 0.0001). If we add three cardiac biomarkers to this model, we get AUC as high as 0.941 (95% CI 0.876-1.000, P < 0.0001). The correction of statistical models with comorbidities (CIRS-G score) did not change the accuracy of prediction models that we have provided. Addition of ACS NSQIP and biomarkers adds to the accuracy of ASA score, which has already been proved by other authors. Cardiac biomarker hsCRP can be used as the most reliable cardiac biomarker; however, the "multimarker approach" adds the most to the accuracy of the combination of clinical risk scores.

The impact of surgical duration on complications after transurethral resection of the prostate: an analysis of NSQIP data.

Transurethral resection of the prostate is the most commonly performed procedure for the management of benign prostatic obstruction. However, little is known about the effect surgical duration has on complications. We assess the relationship between operative time and TURP complications using a modern national surgical registry. We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2006 to 2016 for patients undergoing TURP. Patients were separated into five groups based on operative time: 0-30 min, 30.1-60 min, 60.1-90 min, 90.1-120 min, and greater than 120 min. Standard statistical analysis, including multivariate regression, was performed to determine factors associated with complications. 31,813 patients who underwent TURP were included. The overall complication rate was 9.0% and increased significantly with longer surgical duration (p < 0.001). Longer operative time was associated with a greater risk of postoperative sepsis or shock, transfusion, reoperation, and deep vein thrombus or pulmonary embolism. Longer surgical duration was associated with increased odds of any complication and, specifically, blood transfusion after controlling for age, race, comorbidities, American Society of Anesthesia (ASA) class, type of anesthesia administered, and trainee involvement. The adjusted risk of each of the above complications remained significantly increased for surgeries lasting longer than 120 min. As surgical duration increases, there is a significant increase in the rate of complications after TURP. These data demonstrate that this procedure is safest when performed in under 90 min.

Thirty-Day Perioperative Complications, Prolonged Length of Stay, and Readmission Following Elective Posterior Lumbar Fusion Associated With Poor Nutritional Status.

Study Design:Retrospective study.Objective:To determine the rates of early postoperative mortality and morbidity in adults with hypoalbuminemia undergoing elective posterior lumbar fusion (PLF).Methods:The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was examined from 2005 to 2012. Current Procedural Terminology (CPT) codes were used to query the database for adults (≥18 years) who underwent PLF and/or posterior/transforaminal lumbar interbody fusion (PLIF/TLIF). Patients were divided into those with normal albumin concentration (≥3.5g/dL) and those with hypoalbuminemia (<3.5 g/dL). Both univariate and multivariate analyses were performed.Results:A total of 2410 patients were included, of whom 2251 (93.4%) were normoalbuminemic and 159 (6.6%) were hypoalbuminemic. Patients with preoperative serum albumin levels <3.5 g/dL were older with a higher American Society of Anesthesiologists (ASA) score, and more comorbidities, including anemia, diabetes, dependent functional status, and preoperative history of chronic steroid therapy. Hypoalbuminemic patients had higher rates of any 30-day perioperative complication (P < .001), unplanned readmission (P = .019), and prolonged length of stay (LOS) >5 days (P < .001). However, hypoalbuminemia was not significantly associated with any specific perioperative complication. On multivariate analysis, preoperative hypoalbuminemia was found to be an independent predictor of prolonged LOS (OR 2.4, 95% CI 1.7-3.5; P < .001) and unplanned readmission (OR 2.7, 95% CI 1.1-6.3; P = .023).Conclusion:Hypoalbuminemia was found to be an important predictor of patient outcomes in this population. This study suggests that clinicians should consider nutritional screening and optimization as part of the preoperative risk assessment algorithm.Level of Evidence:III

Outcomes of Ileal Pouch Excision: an American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Analysis

BackgroundThis study aimed to define the incidence and risk factors of postoperative morbidity and mortality after pouch excision (PE). MethodsACS-NSQIP database was queried for patients who underwent PE between 2005 and 2015. Main outcome measures were 30-day mortality, major morbidity, overall surgical site infections (SSI), reoperation, and length of stay (LOS). Risk factors associated with these outcomes were assessed using multivariate logistic or quantile regression. ResultsThree hundred eighty-one patients underwent PE (mean age 47.7(±15.3) years; 51.7% female). Mean body mass index (BMI) was 24.6(±5.7) kg/m2, 55.4% were ASA class 1–2 and 18.4% were immunosuppressed. Mean operative time was 252(±112.7) min, 98% were elective cases, and median LOS was 7(5–11) days. Twenty-eight percent experienced major morbidity, including SSIs (21.5% overall, 9.2% superficial, 3.7% deep, 10.3% organ space), sepsis (9.5%), urinary tract infection (5.8%), and postoperative pneumonia (2.4%). The observed venous thromboembolism rate was low, with 0.5 and 0.8% of patients suffering pulmonary embolism and deep vein thrombosis, respectively; 5.5% required reoperation. Postoperative mortality was 0.8%. On multivariate logistic regression, smoking (OR 3.03 [95% CI 1.56, 5.88]) and operative time (OR 1.003 [95% CI 1.0003, 1.0005) were associated with increased odds of major morbidity. Smoking (OR 3.29 [95% CI 1.65, 6.54]) and operative time (OR 1.002 [95% CI 1.000, 1.004]) were independent risk factors for overall SSI. LOS was significantly increased in patients with major morbidity (3.29 days [95% CI 1.60, 4.99]) and increased operative time (0.013 days [95% CI 0.007, 0.018]). ConclusionsPE is an operation with significant risk of morbidity. However, mortality was low in the present cohort of patients. Patients who were smokers and had longer operative time had increased risk of overall infectious complications and major morbidity. Furthermore, major morbidity and operative time were associated with increased hospital length of stay following PE.

30-Day readmission following outpatient rotator cuff repair: an analysis of 18,061 cases

ABSTRACTObjectives: The purpose of this study is to identify patient characteristics that increase risk for unplanned readmission within 30 days of an initial hospital stay after outpatient rotator cuff repair (RCR).Methods: A retrospective cohort study was performed utilizing the National Surgical Quality Improvement Program (ACS NSQIP) datasets from 2012 to 2015. Patients were preliminarily included in the study based on the presence of a primary Common Procedural Terminology code for RCR (23410, 23412, 23420, and 29827). Only non-emergent, outpatient, and elective procedures performed on patients with American Society of Anesthesiologists (ASA) ≤4 were considered. The primary outcome variables were 30-day unplanned readmission after outpatient surgery. Secondary analyses were implemented to establish reason and timing of readmission.Results: A total of 18,061 cases were reviewed, and 199 (1%) patients experienced 30-day unplanned readmission. Age ≥80 (OR = 2.13, p = 0.0276), COPD (OR = 1.75, p = 0.0354), hypertension requiring medication (OR = 1.67, p = 0.0027), dialysis (OR = 13.46, p < 0.0001) and an ASA classification of 3 (OR = 2.78, p = 0.0143) or ASA 4 (OR = 6.15, p = 0.0012) were identified as major prognosticators for readmission. Female sex was associated with lower odds of readmission (OR = 0.54, p = 0.0001). The most common complications associated with readmission were cardiovascular (29%), infection (19%), and respiratory (17%).Conclusions: The rate of 30-day unplanned inpatient readmission following outpatient RCR using the NSQIP data was found to be 1%, with advanced age and preexisting medical comorbidities contributing to the highest odds of readmission. Cardiovascular, infectious, and respiratory complications contributed to the majority of readmissions. The ability to identify patients with these risk factors will be of utility in optimizing outcomes and cost-effectiveness of RCR.Level of evidence: Level III

Surgical repair of perforated peptic ulcers: laparoscopic versus open approach.

Perforated peptic ulcers are a surgical emergency that can be repaired using either laparoscopic surgery (LS) or open surgery (OS). No consensus has been reached on the comparative outcomes and safety of each approach. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, we conducted a 12-year retrospective review (2005-2016) and identified 6260 adult patients who underwent either LS (n = 616) or OS (n = 5644) to repair perforated peptic ulcers. To mitigate selection bias and adjust for the inherent heterogeneity between groups, we used propensity-score matching with a case (LS):control (OS) ratio of 1:3. We then compared intraoperative outcomes such as operative time, and 30-day postoperative outcomes including infectious and non-infectious complications, and mortality. Propensity-score matching created a total of 2462 matched pairs (616 in the LS group, 1846 in the OS group). Univariate analysis demonstrated successful matching of patient characteristics and baseline clinical variables. We found that OS was associated with a shorter operative time (67.0 ± 28.6min, OS versus 86.9 ± 57.5min, LS; P < 0.001) but a longer hospital stay (8.6 ± 6.2days, OS versus 7.8 ± 5.9days, LS; P = 0.001). LS was associated with a lower rate of superficial surgical site infections (1.5%, LS versus 4.2%, OS; P = 0.032), wound dehiscence (0.3%, LS versus 1.6%, OS; P = 0.030), and mortality (3.2%, LS versus 5.4%, OS; P = 0.009). Fewer than 10% of patients with perforated peptic ulcers underwent LS, which was associated with reduced length of stay, lower rate of superficial surgical site infections, wound dehiscence, and mortality. Given our results, a greater emphasis should be provided to a minimally invasive approach for the surgical repair of perforated peptic ulcers.

Could sodium imbalances predispose to postoperative venous thromboembolism? An analysis of the NSQIP database

BackgroundHyponatremia is common among patients with pulmonary embolism, while hypernatremia increases the risk of venous thromboembolism (VTE). Our objective was to evaluate the association between sodium imbalances and the incidence of VTE and other selected perioperative outcomes.MethodsWe conducted a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and identified 1,108,704 patients undergoing major surgery from 2008 to 2012. We evaluated 30-day perioperative outcomes, including mortality and cardiac, respiratory, neurological, urinary, wound, and VTE outcomes. Multivariate logistic regressions were used to estimate the odds of 30-day perioperative outcomes.ResultsCompared with the normal sodium group, in which VTE occurred in 1.0% of patients, 1.8% of patients in the hyponatremia group (unadjusted odds ratio (OR) 1.84) and 2.4% of patients in the hypernatremia group (unadjusted OR 2.49) experienced VTE. Crude mortality was 1.3% in the normal sodium group, 4.9% in the hyponatremia group (unadjusted OR 3.93) and 8.4% in the hypernatremia group (unadjusted OR 7.01). Crude composite morbidity was 7.1% for the normal sodium group, 16.7% for the hyponatremia group (unadjusted OR 2.63) and 20.6% for the hypernatremia group (unadjusted OR 3.43). After adjusting for potential confounders, hyponatremia and hypernatremia remained significantly and independently associated with an increased risk of VTE (adjusted OR 1.43 and 1.56, respectively), mortality (adjusted OR 1.39 and 1.39, respectively) and composite morbidity (adjusted OR 2.15 and 3.34, respectively).ConclusionsPre-operative hyponatremia and hypernatremia are potential prognostic markers for perioperative 30-day morbidity, mortality and VTE.

Postoperative Delirium as a Target for Surgical Quality Improvement.

To explore hospital-level variation in postoperative delirium using a multi-institutional data source. Postoperative delirium is closely related to serious morbidity, disability, and death in older adults. Yet, surgeons and hospitals rarely measure delirium rates, which limits quality improvement efforts. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Geriatric Surgery Pilot (2014 to 2015) collects geriatric-specific variables, including postoperative delirium using a standardized definition. Hierarchical logistic regression models, adjusted for case mix [Current Procedural Terminology (CPT) code] and patient risk factors, yielded risk-adjusted and smoothed odds ratios (ORs) for hospital performance. Model performance was assessed with Hosmer-Lemeshow (HL) statistic and c-statistics, and compared across surgical specialties. Twenty thousand two hundred twelve older adults (≥65 years) underwent inpatient operations at 30 hospitals. Postoperative delirium occurred in 2427 patients (12.0%) with variation across specialties, from 4.7% in gynecology to 13.7% in cardiothoracic surgery. Hierarchical modeling with 20 risk factors (HL = 9.423, P = 0.31; c-statistic 0.86) identified 13 hospitals as statistical outliers (5 good, 8 poor performers). Per hospital, the median risk-adjusted delirium rate was 10.4% (range 3.2% to 27.5%). Operation-specific risk and preoperative cognitive impairment (OR 2.9, 95% confidence interval 2.5-3.5) were the strongest predictors. The model performed well across surgical specialties (orthopedic, general surgery, and vascular surgery). Rates of postoperative delirium varied 8.5-fold across hospitals, and can feasibly be measured in surgical quality datasets. The model performed well with 10 to 12 variables and demonstrated applicability across surgical specialties. Such efforts are critical to better tailor quality improvement to older surgical patients.

Risk Factors for Deep Vein Thrombosis or Pulmonary Embolus Following Anterior Cruciate Ligament Reconstruction

Background:Nearly 350,000 Americans develop a deep venous thromboembolism (DVT) or pulmonary embolism (PE) annually, and nearly 100,000 Americans die from these events. To date, little research has investigated patient-specific risk factors that increase the rate of DVT/PE following anterior cruciate ligament reconstruction (ACLR).Purpose:To determine relevant patient risk factors for the development of DVT/PE following ACLR.Study Design:Case-control study; Level of evidence, 3.Methods:All instances of ACLR from 2005 to 2014 within the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) prospective database were analyzed. Both univariate analysis and binary logistic regression were performed to determine which patient demographics and surgical factors were associated with DVT or PE following surgery.Results:Of the 9146 patients who underwent ACLR, 46 (0.5%) developed postoperative DVT, 8 (0.1%) developed PE, and 5 (0.05%) developed both. The following variables were associated with the development of DVT or PE on univariate analysis: increased age, a high tibial osteotomy (HTO) performed at the time of ACLR, microfracture performed, the presence of hypertension requiring medical therapy, and the presence of an active wound infection. Independent predictors of DVT or PE on multivariate analysis included HTO (odds ratio [OR], 22.7), the presence of an active wound infection (OR, 11.0), or hypertension requiring medication (OR, 2.2). Meniscal repair was not a risk factor for DVT or PE on univariate or multivariate analysis.Conclusion:In a review of 9146 patients undergoing ACLR, 46 (0.5%) developed DVT in the 30-day postoperative period. Increasing age over 30 years, concomitant HTO or microfracture, hypertension requiring medication, and presence of wound infection were all associated with an increased risk of DVT. The annual incidence of DVT/PE following ACLR reconstruction is low (<1%) and has not changed over time.

Do preoperative oral antibiotics increase Clostridium difficile infection rates? An analysis of 13959 colectomy patients.

The aim of this study was to determine whether or not preoperative oral antibiotic preparation (POAP) increases the rate of Clostridium difficile colitis (CDC) in patients undergoing colectomy. In 2015, data for colectomies had been collected prospectively and recorded in the targeted colectomy option of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). This was available for retrospective analysis. Data available for analysis included elective and emergency status, POAP, surgical approach, primary anastomosis and CDC status. The effect of POAP on CDC was analysed and risk adjusted for 14 separate preoperative variables. In all, 13959 adult patients underwent a colectomy in 2015 (POAP group 5311 and non- POAP group 8648). The overall rate of CDC in colectomy patients was 1.6% (227/13959). On univariate analysis, CDC was significantly less common in the POAP group than in the non-POAP group (1.2% vs 1.9%, P=0.003). Univariate analysis of a further 41 preoperative variables revealed 14 to be associated with CDC. However, after risk adjustment with these 14 variables, POAP lost its statistical significance (adjusted OR 0.902, 95% CI 0.584-1.486, P=0.685). Only patients with pre-existing systemic inflammatory response syndrome appeared to be at increased risk of CDC (adjusted OR 2.154, 95% CI 1.139-4.074, P=0.018). At the very least this study suggests it is safe to use POAP in colectomy patients without increasing the rate of CDC unless they have pre-existing systemic inflammatory response syndrome.

Standardisation of perioperative urinary catheter use to reduce postsurgical urinary tract infection: an interrupted time series study.

Prevention of healthcare-associated urinary tract infection (UTI) has been the focus of a national effort, yet appropriate indications for insertion and removal of urinary catheters (UC) among surgical patients remain poorly defined. We developed and implemented a standardised approach to perioperative UC use to reduce postsurgical UTI including standard criteria for catheter insertion, training of staff to insert UC using sterile technique and standardised removal in the operating room and surgical unit using a nurse-initiated medical directive. We performed an interrupted time series analysis up to 2 years following intervention. The primary outcome was the proportion of patients who developed postsurgical UTI within 30 days as measured by the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Process measures included monthly UC insertions, removals in the operating room and UC days per patient-days on surgical units. At baseline, 22.5% of patients were catheterised for surgery, none were removed in the operating room and catheter-days per patient-days were 17.4% on surgical units. Following implementation of intervention, monthly catheter removal in the operating room immediately increased (range 12.2%-30.0%) while monthly UC insertion decreased more slowly before being sustained below baseline for 12 months (range 8.4%-15.6%). Monthly catheter-days per patient-days decreased to 8.3% immediately following intervention with a sustained shift below the mean in the final 8 months. Postsurgical UTI decreased from 2.5% (95% CI 2.0-3.1%) to 1.4% (95% CI 1.1-1.9; p=0.002) during the intervention period. Standardised perioperative UC practices resulted in measurable improvement in postsurgical UTI. These appropriateness criteria for perioperative UC use among a broad range of surgical services could inform best practices for hospitals participating in ACS NSQIP.

Postoperative outcomes in patients with a do-not-resuscitate (DNR) order undergoing elective procedures

Study objectiveDo-not-resuscitate (DNR) status has been shown to be an independent risk factor for mortality in the post-operative period. Patients with DNR orders often undergo elective surgeries to alleviate symptoms and improve quality of life, but there are limited data on outcomes for informed decision making. DesignRetrospective cohort study. SettingA multi-institutional setting including operating room, postoperative recovery area, inpatient wards, and the intensive care unit. PatientsA total of 566 patients with a DNR status and 316,431 patients without a DNR status undergoing elective procedures using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) from 2012. InterventionsPatients undergoing elective surgical procedures. MeasurementsWe analyzed the risk-adjusted 30-day morbidity and mortality outcomes for the matched DNR and non-DNR cohorts undergoing elective surgeries. Main resultsDNR patients had significantly increased odds of 30-day mortality (OR 2.51 [1.55–4.05], p < 0.001) compared with non-DNR patients. In the DNR versus non-DNR cohort there was no significant difference in the occurrence of a number of 30-day complications, the rate of resuscitative measures undertaken, including cardiac arrest requiring CPR, reintubation, or return to the OR. The most common complications in both DNR and non-DNR patients undergoing elective procedures were transfusion, urinary tract infection, reoperation, and sepsis. Finally, the DNR patients had a significantly increased total length of hospital stay (7.65 ± 9.55 vs. 6.87 ± 9.21 days, p = 0.002). ConclusionsDNR patients, as compared with non-DNR patients, have increased post-operative mortality but not morbidity, which may arise from unmeasured severity of illness or transition to comfort care in accordance with a patient's wishes. The informed consent process for elective surgeries in this patient population should include a discussion of acceptable operative risk.

Impact of Synchronous Liver Resection on the Perioperative Outcomes of Patients Undergoing CRS-HIPEC

BackgroundWhile liver resection (LR) and cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) are commonly performed for hepatic and peritoneal metastases, respectively, the safety of synchronous LR and CRS-HIPEC has not been established. MethodsThe American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) databases from 2005 to 2016 were used to identify patients who underwent CRS-HIPEC. Demographic, clinical, and perioperative outcomes were compared among patients who underwent CRS-HIPEC with and without synchronous LR. ResultsAmong 1168 patients who underwent CRS-HIPEC, 100 (8.6%) underwent synchronous LR and 1068 (91.4%) did not. The most common primary diagnosis was unspecified (65.3%) followed by appendix (16.0%) and colorectal (12.5%). Among patients who underwent CRS-HIPEC plus LR, the majority had a partial hepatectomy (96.0%), while a small subset underwent trisegmentectomy (2.0%) or hemihepatectomy (2.0%). Patients who underwent CRS-HIPEC plus LR underwent a greater number of operative procedures (8.3±2.5 vs 6.7 ± 2.5, p < 0.001), had a longer operative time (520.7±155.3 vs 454.6±160.7 min, p = 0.001), had a longer hospital length of stay (16.7±15.6 vs 11.1±11.5 days, p < 0.001), were more likely to require reoperation (13.0 vs 6.9%, p = 0.03), and experienced greater 30-day morbidity (47.0 vs 27.4%, p < 0.001), but not mortality (3.0 vs 1.4%, p = 0.22). On multivariate logistic regression, LR was strongly associated with increased risk of postoperative morbidity even after controlling for potential confounders (OR 1.65, 95% CI 1.03–2.64). ConclusionsSimultaneous LR and CRS-HIPEC was associated with increased operative time, length of hospital stay, reoperation, and postoperative morbidity compared to CRS-HIPEC alone. For patients with synchronous hepatic and peritoneal metastases, a staged operative approach should be considered.

Timing of complications following posterior cervical fusion

Study designRetrospective cohort study. ObjectiveTo characterize the timing of complications after posterior cervical fusion. Summary of background dataUnderstanding the expected timing of postoperative complications facilitates early diagnosis of potential adverse events and is important for optimizing postoperative care. Though studies have examined the incidence of complications after posterior cervical fusion, no study has characterized the timing of these complications. MethodsPatient data in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset with a primary CPT code 22600, corresponding to posterior cervical fusion, was analyzed for demographics, comorbidities, and ten specific complications. Complication timing was assessed, and univariate analysis was performed to investigate the relationship of patient demographic and clinical variables on the development of postoperative complications. ResultsA total of 2517 patients with a mean age of 59.3 ± 12.5 met inclusion criteria. The overall complication rate was 12.4%. The median day of diagnosis and interquartile range for each complication was: blood transfusion (0.0, 0-0), myocardial infarction (3, 2–7), reintubation (3, 1–9), pneumonia (4, 3–10), deep venous thrombosis (7, 5–16), urinary tract infection (11.5, 5–17.5), sepsis (14, 7–20), pulmonary embolism (14, 8–21), surgical site infection (15, 9–21), and wound dehiscence (15.5, 9–25). Less than 50% deep venous thromboses were diagnosed before discharge, and less than 30% of pulmonary emboli were diagnosed before discharge. On univariate analysis, increased age, decreased functional status, fusing more than one level, current smoker status, diabetes, and CHF were associated with increased complications. ConclusionsThis timing data is useful to the practicing spine surgeon as it provides a guide for when to expect and investigate for specific complications after posterior cervical procedures. It may aid in the early diagnosis of complications and may also assist in healthcare reimbursement negotiations.

The effect of smoking on 30-day outcomes in elective hernia repair

BackgroundAdverse postoperative outcomes related to smoking are well established, yet current smokers continue to be offered elective surgery in the US. It is unknown whether patients undergoing low-risk, elective procedures, who actively smoke experience increased risk of complications. We sought to determine the increased burden of complications following elective hernia repair procedures in patients identified as current smokers. MethodsWe identified patients undergoing elective incisional, inguinal, umbilical, or ventral hernia repair from 2011 to 2014 using the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database. Multivariable logistic regression analysis was used to examine the association between current smoking and 30-day postoperative outcomes, adjusting for demographics and comorbidities. ResultsOf 220,629 patients who underwent elective hernia repair, 40,446 (18.3%) self-identified as current smokers within the past 12 months. Current smokers experienced an increased likelihood (Odds Ratio [95% Confidence interval]) of reoperation (OR 1.23 [95% CI 1.11–1.36]), readmission (OR 1.24 [95% CI 1.16–1.32]), and death (OR 1.53 [95% CI 1.06–2.22]). Furthermore, smokers experienced an increased risk of postoperative pulmonary, infectious, and wound complications, but there was no increased risk of requiring transfusion or of postoperative cardiac or thromboembolic events. ConclusionsCurrent smokers were more likely to experience serious postoperative complications within 30 days. Given the volume of elective hernia surgery performed in the US, encouraging smoking cessation prior to offering elective repair could reduce postoperative complications, reoperation, readmission, and mortality.

Multi-institutional Analysis of Surgical Management and Outcomes of Mandibular Fracture Repair in Adults

Mandibular fractures are rare, most commonly occurring in young male patients who present with facial trauma. The etiology, incidence, and presentation vary among previous publications depending on cultural and socioeconomic factors of the region of origin. This multi-institutional study aims to present demographic characteristics, surgical treatment, and clinical outcomes of surgical repair of mandible fractures in the United States. An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) adult databases of the years 2006 through 2014 was performed identifying 940 patients with an International Classification of Diseases, version 9 (ICD-9) diagnosis of either closed or open fracture of the mandible. Preoperative, perioperative, and postoperative details were categorized and evaluated for these two cohorts. Multivariate analysis was performed to detect risk factors related to any complications. Patients were predominantly male (85.7%), young with a mean age of 34.0 ± 14.8 years, and relatively healthy with body mass index of 23.6 ± 8.2 and an American Society of Anesthesiologists (ASA) class of 1 or 2 (84.4%). However, more than half were regular smokers (51.1%). The top five most frequent procedures performed for mandibular repair were exclusively open surgical approaches with internal, external, or interdental fixation in both cohorts. Patients with open fractures were more often admitted as emergencies, treated inpatient, required longer operative times, and presented with more contaminated wounds ( p < 0.05). Overall, medical (1.7%) and surgical complications (3.7%) were low. A high ASA class 3 or above and emergency operations were identified as risk factors for medical adverse events. Despite frequent concomitant injuries after trauma and a diverse array of mandibular injury types, our patient sample demonstrated favorable outcomes and low complication rates. Open surgical techniques were the most common procedures in this study representing the American population.

The Impact of Resident Involvement in Elective Posterior Cervical Fusion.

Retrospective study of prospectively collected data OBJECTIVE.: The aim of this study was to assess the impact of resident surgeon involvement on patient outcomes following posterior cervical fusion (PCF) surgery. Recently, there has been a significant uptrend in the number of PCF performed in the United States. Prior studies have investigated patient outcomes after cervical arthrodesis. Despite the heightened concern for patient safety and quality improvement, the data on the safety of resident participation in PCF is sparse. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was examined from 2005 to 2012. Current Procedural Terminology codes were used to query the database for adults (≥18 years) who underwent PCF. Multivariate logistic regression models were employed on data adjusted by propensity scores to determine whether resident involvement was an independent predictor for the outcomes of interest. A total of 448 cases were assessed in NSQIP. Less than half of these cases involved residents (224, 43.1%). Resident involvement was found to be a significant predictor for blood transfusions [odds ratio (OR) = 1.7, confidence interval (CI) = 1.1-2.6, P = 0.010], length of stay of more than 5 days (OR = 1.6, CI = 1.0-2.6, P = 0.040), and operative time more than 4 hours (OR = 3.6, CI = 1.7-7.4, P = 0.0007). Other independent risk factors for prolonged length of stay included age 81 years or older versus 50 years or younger (OR = 4.7, CI = 1.7-12.6, P = 0.016) and diabetes (OR = 2.3, CI = 1.3-4.1, P = 0.006). In addition, multifusion was identified as a significant risk factor for extended operative time (OR = 1.8, CI = 1.1-2.9, P = 0.023). The present study used a large, nationwide sample to assess the impact of resident involvement in PCF. Resident participation was not associated with mortality, but had a minimal association with morbidity. 3.

Accuracy of the ACS NSQIP Online Risk Calculator Depends on How You Look at It: Results from the United States Gastric Cancer Collaborative

The objective of this study is to assess the accuracy of the American College of Surgeons National Surgical Quality Improvement Program online risk calculator for estimating risk after operation for gastric cancer using the United States Gastric Cancer Collaborative. Nine hundred and sixty-five patients who underwent resection of gastric adenocarcinoma between January 2000 and December 2012 at seven academic medical centers were included. Actual complication rates and outcomes for patients were compared. Most of the patients underwent total gastrectomy with Roux-en-Y reconstruction (404, 41.9%) and partial gastrectomy with gastrojejunostomy (239, 24.8%) or Roux-en-Y reconstruction (284, 29.4%). The C-statistic was highest for venous thromboembolism (0.690) and lowest for renal failure at (0.540). All C-statistics were less than 0.7. Brier scores ranged from 0.010 for venous thromboembolism to 0.238 for any complication. General estimates of risk for the cohort were variable in terms of accuracy. Improving the ability of surgeons to estimate preoperative risk for patients is critically important so that efforts at risk reduction can be personalized to each patient. The American College of Surgeons National Surgical Quality Improvement Program risk calculator is a rapid and easy-to-use tool and validation of the calculator is important as its use becomes more common.