American College Of Surgeons National Surgical Quality Improvement Program Database Research Articles

In Patients with Heart Failure Undergoing Carotid Endarterectomy, Locoregional Anesthesia is Not Associated with Decreased Mortality, Stroke, or Myocardial Infarction Compared to General Anesthesia

ObjectiveWhile existing literature reports no benefit of locoregional anesthesia (LRA) over general anesthesia (GA) in patients undergoing carotid endarterectomy (CEA), the effect of LRA on patients with congestive heart failure (CHF) has not been explored. This study aims to assess whether the choice of anesthesia plays a role in influencing outcomes within this population. MethodsUsing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) files between 2005-2022 and the procedural targeted ACS-NSQIP database for CEA between 2011-2022, all patients receiving CEA were identified, and the subset of patients with CHF was included. Patient characteristics and 30-day outcomes were compared using χ2 or Fischer’s exact test as appropriate for categorical variables and the independent t-test or Mann-Whitney U test as appropriate for continuous variables. Mortality, stroke, myocardial infarction (MI), and major adverse cardiac events (MACE) were compared between patients receiving general anesthesia (GA) and locoregional anesthesia (LRA) using univariate analysis. ResultsA total of 3,040 patients (2,733 undergoing GA, 307 undergoing LRA) with a diagnosis of CHF undergoing CEA were identified. No difference in mortality (GA 3.1% vs LRA 4.6%, p=0.162), MI (GA 3.0% vs LRA 2.3%, p=0.478), stroke (2.4% vs 2.6%, p=0.805) or MACE (GA 7.4% vs LRA 8.1%, p=0.654) was observed. LRA patients had a significantly lower hospital stay compared to GA patients (1 day [IQR 1-3] vs 2 days [IQR 1-4], p<0.001). Shunt was more commonly used in patients receiving GA (32.9% vs 12.5%, p<0.001) compared to LRA. ConclusionWhile utilizing LRA compared to GA during carotid endarterectomy in patients with CHF is associated with a shorter hospital stay and less intraoperative shunting, the choice of anesthesia did not impact the outcomes of mortality, MI or stroke. Further research is needed to determine the effect of LRA on the outcomes of CEA among patients with different stages of heart failure.

Predicting Prolonged Length of Hospital Stay and Identifying Risk Factors Following Total Ankle Arthroplasty: A Supervised Machine Learning Methodology

Ankle osteoarthritis (OA) is a debilitating condition that arises as a result of trauma or injury to the ankle and often progresses to chronic pain and loss of function that may require surgical intervention. Total ankle arthroplasty (TAA) has emerged as a means of operative treatment for end-stage ankle OA. Increased hospital length of stay (LOS) is a common adverse postoperative outcome that increases both the complications and cost of care associated with arthroplasty procedures. The purpose of this study was to employ four machine learning (ML) algorithms to predict LOS in patients undergoing TAA using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The ACS-NSQIP database was queried to identify adult patients undergoing elective TAA from 2008 to 2018. Four supervised ML classification algorithms were utilized and tasked with predicting increased hospital length of stay (LOS). Among these variables, female sex, ASA Class III, preoperative sodium, preoperative hematocrit, diabetes, preoperative creatinine, other arthritis, BMI, preoperative WBC, and Hispanic ethnicity carried the highest importance across predictions generated by 4 independent ML algorithms. Predictions generated by these algorithms were made with an average AUC of 0.7257, as well as an average accuracy of 73.98% and an average sensitivity and specificity of 48.47% and 79.38%, respectively. These findings may be useful for guiding decision-making within the perioperative period and may serve to identify patients at increased risk for a prolonged LOS.

Gynecomastia Surgery in 4996 Male Patients Over 14 Years: A Retrospective Analysis of Surgical Trends, Predictive Risk Factors, and Short-Term Outcomes.

The high prevalence of benign male breast tissue enlargement (gynecomastia) has resulted in a marked increase of gynecomastia cases. While about one third of male adults experience some form of gynecomastia, gynecomastia surgery (GS) outcome research is limited to small study populations and single-center/-surgeon databases. In this study, we aimed to access the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify preoperative risk factors for complications and investigate postoperative outcomes of GS. In this retrospective study, we queried the ACS-NSQIP database from 2008 to 2021 to identify male adult patients who underwent GS. Postoperative outcomes involved the occurrence of any, surgical and medical complications, as well as reoperation, readmission, and mortality within a 30-day postoperative time period. Univariable and multivariable assessment were performed to identify risk factors for complications while adjusting for possible confounders. The study included 4,996 GS patients with a mean age of 33.7 ± 15 years and BMI of 28.2 ± 5.1 kg/m2. White patients constituted 54% (n = 2713) of the cohort, and 27% (n = 1346) were obese. Except for 2020, there was a steady increase in GS cases over the study period. Outpatient surgeries were most common at 95% (n = 4730), while general surgeons performed the majority of GS (n = 3580; 72%). Postoperatively, 91% (n = 4538) of patients were discharged home; 4.4% (n = 222) experienced any complications. Multivariable analysis identified inpatient setting (p < 0.001), BMI (p = 0.023), prior sepsis (p = 0.018), and bleeding disorders (p = 0.047) as independent risk factors for complications. In this study, we analyzed 4996 male adult GS patients from the ACS-NSQIP database, revealing an increased caseload and significant general surgeon involvement. Risk factors like bleeding disorders, inpatient status, and prior sepsis were linked to postoperative complications, while BMI was crucial for predicting adverse events. Overall, our findings may aid in enhancing patient care through advanced preoperative screening and closer perioperative management. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Risk Factors Associated with Postoperative Outcomes in Diverticular Disease Undergoing Elective Colectomy—A Retrospective Cohort Study from the ACS-NSQIP Database

Recommendations for elective colectomies after recovery from uncomplicated acute diverticulitis should be individualized. The kinds of associated risk factors that should be considered for this approach remain undetermined. The aim of this study was to identify the risk factors associated with postoperative outcomes in patients with diverticular disease after receiving an elective colectomy. This is a retrospective study using the multi-institutional, nationally validated database of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP). The patients who were diagnosed with diverticular disease and received an elective colectomy were included in our risk factor analyses. Postoperative mortality, morbidity, and overall complications were measured. Univariate and multivariate analyses were used to demonstrate the risk factors. We analyzed 30,468 patients with diverticular disease, 67% of whom received an elective colectomy. The rate of 30-day mortality was 0.2%, and superficial surgical site infection was the most common postoperative morbidity (7.2%) in the elective colectomies. The independent risk factors associated with overall complications were age ≥ 75, BMI ≥ 30, smoking status, dyspnea, hypertension, current kidney dialysis, chronic steroid use, ASA III, and open colectomy. In laparoscopic colectomy, 67.5% of the elective colectomies, the associated risk factors associated with overall complications still included age ≥ 75, smoking, hypertension, chronic steroid use, and ASA III. Identification of patient-specific risk factors may inform the decision-making process for elective colectomy and reduce the postoperative complications after mitigation of those risk factors.

Foot and Ankle Surgery Postoperative Complications with Regional vs General Anesthesia

Category: Trauma; Other Introduction/Purpose: Regional anesthesia has been increasingly used within orthopaedic surgery. It has been found to decrease opioid use and consumption and has been associated with decreased blood loss and clot formation in some lower extremity surgeries – specifically hip and knee arthroplasty surgery. General anesthesia is not without risks including malignant hyperthermia, laryngeal edema, vocal cord trauma, and delirium. This has led to increased utilization of regional anesthesia in foot and ankle surgery. However, there is a paucity of research that compares the postoperative outcomes in patients treated with regional compared to general anesthesia in these surgeries. We hypothesize the use of regional anesthesia in foot and ankle surgery leads to fewer short-term postoperative complications compared to general anesthesia. Methods: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried from 2006-2018 to identify patients undergoing foot and ankle surgery. Current Procedural Terminology (CPT) codes for all foot and ankle surgery were utilized to determine which participants to include in the analysis. The cohort was divided into patients who received regional anesthesia versus those who received general anesthesia, and comparisons were made on demographic characteristics, and comorbidities, using chi-squared and t-test analyses. Multivariate logistic regressions were performed to identify whether lack of regional anesthesia was an independent risk factor for infection, minor postoperative complications, and major postoperative complications. Major postoperative complications included any complication that had a long-term effect on someone’s life or led to reoperation, while minor postoperative complications included any event that needed medical intervention but did not impact a person’s health long-term. Results: Using the ACS-NSQIP database and CPT codes, there were 12,764 participants for regional anesthesia and 73,481 participants who had general anesthesia. Utilizing logistic regression, this study found that the absence of regional anesthesia was independently associated with an increased risk for minor complications in foot and ankle surgery (Odds Ratio (OR) 1.34, 95% Confidence Interval (CI) [1.25-1.44], p=0.00). The absence of regional anesthesia was not associated with increased risk of major complications in foot and ankle surgery (OR 1.04, CI [0.96-1.12], p=0.32). Patients who received regional anesthesia were older and had more comorbidities than those without regional anesthesia used which may be a reason for the findings for major complications. Conclusion: Regional anesthesia independently reduced the risk of minor postoperative complications up to 30-days following foot and ankle surgery in this study. Patients undergoing foot and ankle surgery may benefit from augmenting their anesthetic plan with regional anesthesia.

The Anterior Versus Posterior Approach for Interbody Fusion in Patients Who Are Classified as Obese: A Retrospective Cohort Study of 9,021 Patients From a National Database.

Introduction Lumbar spine interbody fusions have been performed to relieve back pain and improve stability due to various underlying pathologies.Anterior interbody fusion and posterior interbody fusion approaches are two main approaches that are classically compared.In an attempt to compare these two approaches to the spine, large retrospective national database reviews have been performed to compare and predict 30-day postoperative outcomes; however, they have conflicting findings.Obesity, defined as having a body mass index (BMI) over 30kg/m2, may also contribute to the extent of spine pathology and isassociated withincreased rates of postoperative complications. Complication rates in patients who are obese have yet to be thoroughly investigated using a large national database.Our present investigation aims to make this comparison using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.The goal of the present study is to utilize a nationwide prospective database to determine short-term differences in postoperative outcomes between posterior and anterior lumbar fusion in patients with obesity and relate these findings to previous studies in the general population. Methods A retrospective cohort analysis was conducted on 9,021 patientdata from the ACS-NSQIP database from 2015 to 2019 who underwent an elective, single-level fusion via anterior or posterior surgical approach. This database captures over 150 clinical variables on individual patient cases, including demographic data, preoperative risk factors and laboratory values, intraoperative data, and significant events up to postoperative day 30. All outcome measures were included in this analysis with special attentionto rates of deep venous thrombosis (DVT) and pulmonary embolism (PE), prolonged length of stay (LOS), reoperation, and operation time. Results Multivariable analysis controlling for age, BMI, sex, race, functional status, American Society of Anesthesiologists (ASA) class, and selected comorbidities with P < 0.05 demonstrated that the anterior approach was an independent predictor for all significant outcomes except prolonged length of stay. Compared to the posterior approach, the anterior approach had a shorter total operation time (B = -13.257, 95% confidence interval (CI) [-17.522, -8.992], P< 0.001), higher odds of deep vein thrombosis (odds ratio (OR) = 2.210, 95% CI [1.211, 4.033], P= 0.010), and higher odds of pulmonary embolism (OR = 2.679, 95% CI [1.311, 5.477], P= 0.007) and was protective against unplanned reoperation (OR = 0.702, 95% CI [0.548, 0.898],P= 0.005). Conclusions The obese population makes up a large and growing demographic of those undergoing spine surgery, and as such, it is pertinent to investigate the differences, advantages, and disadvantages of lumbar fusion approaches in this group. While anterior approachesmaybe protective of longer operation time and unplanned reoperation, this benefit may not be clinically significant when considering an increased risk of DVT and PE. Given the short-term nature of this dataset and the limitations inherent in large de-identified retrospective database studies, these findings are interpreted with caution. Longer-term follow-up studies accounting for confounding variables with spine-centered outcomes will be necessary to further elucidate these nuances.

Does a Modified Frailty Index Predict 30-day Complications After Long-Bone Nonunion or Malunion Surgery?

To assess the ability of a modified frailty index (mFI-5) score, which includes the presence of congestive heart failure, hypertension, chronic obstructive pulmonary disease, diabetes, and nonindependent functional status, and to identify patients at increased risk of complications after surgical treatment of long-bone nonunions/malunions. Retrospective. Hospitals participating in the 2005-2018 American College of Surgeons National Surgical Quality Improvement Program. Patients in the American College of Surgeons National Surgical Quality Improvement Program database with upper extremity and lower extremity fractures were enrolled. Surgical repair of nonunions/malunions of upper and lower extremity long bones. Postoperative complications after long-bone nonunion/malunion surgery. Respective univariate analysis of the 2964 UE [1786 (60.3%) with mFI-5 of 0 and 386 (13.0%) with mFI-5 ≥2] and 3305 LE [1837 (55.6%) with mFI-5 of 0 and 498 (15.1%) with mFI-5 ≥2] showed that increasing mFI-5 score was associated with medical complications, extended longer length of stay, adverse discharge, and readmission. Binomial logistic regression showed that UE patients with mFI-5 ≥2 had increased risk of wound complications [odds ratio (OR) 2.512, 95% (confidence interval) CI: 1.037-6.086, P = 0.041), adverse discharge (OR 1.735, 95% CI: 1.204-2.499, P = 0.003), and unplanned readmission (OR 2.102, 95% CI: 1.038-4.255, P = 0.039), while LE patients with mFI-5 ≥2 had an increased risk of medical complications (OR 1.847, 95% CI: 1.307-2.610, P = 0.001), cumulative morbidity (OR 1.835, 95% CI: 1.342-2.510, P < 0.001), extended longer length of stay (OR 1.809, 95% CI: 1.233-2.654, P = 0.002), and adverse discharge (OR 1.841, 95% CI: 1.394-2.432, P < 0.001). mFI-5 score ≥2 is associated with significant increase in postoperative complications after surgical repair of long-bone nonunions/malunions. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Body Mass Index (BMI) Cutoffs and Racial, Ethnic, Sex, or Age Disparities in Patients Treated With Total Ankle Arthroplasty.

The rising prevalence of obesity among American adults has disproportionately affected Black adults and women. Furthermore, body mass index (BMI) has historically been used as a relative contraindication to many total joint arthroplasty (TJA) procedures, including total ankle arthroplasty. The purpose of this study was to investigate potential disparities in patient eligibility for total ankle arthroplasty based on race, ethnicity, sex, and age by applying commonly used BMI cutoffs to the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients in the ACS-NSQIP database who underwent TAA from 2011 to 2020 were retrospectively reviewed in a cross-sectional analysis. BMI cutoffs of <50, <45, <40, and <35 were then applied. The eligibility rate for TAA was examined for each BMI cutoff, and findings were stratified by race, ethnicity, sex, and age. Independent t tests, chi-squared tests, and Fisher exact tests were performed to compare differences at an α = 0.05. A total of 1215 of 1865 TAA patients (65.1%) were included after applying the exclusion criteria. Black patients had disproportionately lower rates of eligibility at the most stringent BMI cutoff of <35 (P = .004). Hispanic patients had generally lower rates of eligibility across all BMI cutoffs. In contrast, Asian American and Pacific Islander patients had higher rates of eligibility at the BMI cutoffs of <35 (P = .033) and <40 (P = .039), and White non-Hispanic patients had higher rates of eligibility across all BMI cutoffs. Females had lower eligibility rates across all BMI cutoffs. Ineligible patients were also younger compared to eligible patients across all BMI cutoffs. Stringent BMI cutoffs may disproportionately disqualify Black, female, and younger patients from receiving total ankle arthroplasty. Level III, retrospective cross-sectional study.

Predicting early term complications of ORIF distal radius fracture in outpatient settings using NSQIP data

PurposeThere is no consensus on which risk factors are most predictive for complications following open reduction internal fixation of distal radius fractures (ORIF-DRF) in an outpatient setting. This study is a complication risk analysis for ORIF-DRF in outpatient settings based on data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). MethodsA nested, case-control study, was conducted in ORIF-DRF cases performed in outpatient settings from 2013 to 2019 obtained from the ACS-NSQIP database. Cases with documented local or systemic complications were age and gender-matched in a 1:3 ratio. The association between patient and procedure-dependent risk factors for systemic and local complications in general and for different subpopulations was examined. Bivariate and multivariable analyses were performed to evaluate the association between risk factors and complications. ResultsFrom a total of 18,324 ORIF-DRF, 349 cases with complications were identified and matched to 1047 Controls. Independent patient-related risk factors included a history of smoking, the American Society of Anesthesiologists (ASA) Physical Status Classification 3 and 4, and bleeding disorder. The intra-articular fracture with three or more fragments was found to be an independent risk factor of all procedure-related risk factors. History of smoking was found to be an independent risk factor for all gender populations, as well as for patients younger the 65 years old. For older patients (age ≥65) bleeding disorder was found to be an independent risk factor. ConclusionComplications of ORIF-DRF in outpatient settings have many risk factors. This study provides surgeons with specific risk factors for possible complications following ORIF-DRF.

Risk Factors for Acute Postoperative Complications Following Operative Management of Le Fort Fractures-A NSQIP Study.

Le Fort fractures comprise a pattern of complex midfacial fractures that arise secondarily to craniofacial trauma. Although management of these fractures has been detailed within the literature, there is a paucity of research examining postoperative outcomes after surgical repair. The primary aim of this study is to assess patient outcomes after operative management of Le Fort fractures, and examine factors influencing the risk for developing postoperative complications, through utilization of the ACS-NSQIP database. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for cases recorded between 2012 and 2019 with International Classification of Disease (ICD)-9 and ICD-10 codes corresponding to Le Fort fractures. Patient demographics, clinical variables, and postoperative variables were recorded. Logistic regression analysis was conducted to identify independent risk factors for postoperative complications. Identification of cases with appropriate ICD codes, and exclusion of those with missing data, yielded 562 patients for analysis. There were no cases of minor complications and 14 cases of severe complications (3 cases of wound dehiscence, 3 cases of transfusion requirement, 1 case of failure to wean from the ventilator for more than 48 h, 1 pulmonary embolism, and 8 cases of reoperation), corresponding to an overall complication rate of 2.49%. Logistic regression analysis revealed steroid use as an independent predictor of severe postoperative complications (OR =13.73, 95% CI: 1.08-128.02, P =0.02). The present study is the first to conduct a risk factor analysis of patients with Le Fort fractures using the ACS-NSQIP national database. The overall postoperative complication rate was 2.49%, with 14 cases of complications recorded in 8 years. Although this may suggest that surgical management of Le Fort fractures is generally well-tolerated, it should be noted that this problem is frequently associated with other severe injuries of the head and neck that may influence patient prognosis. Given this, further analysis would benefit from a larger patient cohort and longer postoperative data as the ACS-NSQIP database only records outcomes within 30 days.

Performance of General Surgical Procedures in Outpatient Settings Before and After Onset of the COVID-19 Pandemic

The American College of Surgeons (ACS) has advocated for the expansion of outpatient surgery to conserve limited hospital resources and bed capacity, while maintaining surgical throughput, during the COVID-19 pandemic. To investigate the association of the COVID-19 pandemic with outpatient scheduled general surgery procedures. This multicenter, retrospective cohort study analyzed data from hospitals participating in the ACS National Surgical Quality Improvement Program (ACS-NSQIP) from January 1, 2016, to December 31, 2019 (before COVID-19), and from January 1 to December 31, 2020 (during COVID-19). Adult patients (≥18 years of age) who underwent any 1 of the 16 most frequently performed scheduled general surgery operations in the ACS-NSQIP database were included. The primary outcome was the percentage of outpatient cases (length of stay, 0 days) for each procedure. To determine the rate of change over time, multiple multivariable logistic regression models were used to assess the independent association of year with the odds of outpatient surgery. A total of 988 436 patients were identified (mean [SD] age, 54.5 [16.1] years; 574 683 women [58.1%]), of whom 823 746 underwent scheduled surgery before COVID-19 and 164 690 had surgery during COVID-19. On multivariable analysis, the odds of outpatient surgery during COVID-19 (vs 2019) were higher in patients who underwent mastectomy for cancer (odds ratio [OR], 2.49 [95% CI, 2.33-2.67]), minimally invasive adrenalectomy (OR, 1.93 [95% CI, 1.34-2.77]), thyroid lobectomy (OR, 1.43 [95% CI, 1.32-1.54]), breast lumpectomy (OR, 1.34 [95% CI, 1.23-1.46]), minimally invasive ventral hernia repair (OR, 1.21 [95% CI, 1.15-1.27]), minimally invasive sleeve gastrectomy (OR, 2.56 [95% CI, 1.89-3.48]), parathyroidectomy (OR, 1.24 [95% CI, 1.14-1.34]), and total thyroidectomy (OR, 1.53 [95% CI, 1.42-1.65]). These odds were all greater than those observed for 2019 vs 2018, 2018 vs 2017, and 2017 vs 2016, suggesting that an accelerated increase in outpatient surgery rates in 2020 occurred as a consequence of COVID-19, rather than a continuation of secular trends. Despite these findings, only 4 procedures had a clinically meaningful (≥10%) overall increase in outpatient surgery rates during the study period: mastectomy for cancer (+19.4%), thyroid lobectomy (+14.7%), minimally invasive ventral hernia repair (+10.6%), and parathyroidectomy (+10.0%). In this cohort study, the first year of the COVID-19 pandemic was associated with an accelerated transition to outpatient surgery for many scheduled general surgical operations; however, the magnitude of percentage increase was small for all but 4 procedure types. Further studies should explore potential barriers to the uptake of this approach, particularly for procedures that have been shown to be safe when performed in an outpatient setting.

Early Outcomes and Risk Factors in Orthognathic Surgery for Mandibular and Maxillary Hypo- and Hyperplasia: A 13-Year Analysis of a Multi-Institutional Database

Orthognathic surgery (OS) is a frequently performed procedure for the correction of dentofacial deformities and malocclusion. Research on OS is mostly limited to single-surgeon experience or single-institutional reports. We, therefore, retrospectively analyzed a multi-institutional database to investigate outcomes of OS and identify risk factors for peri- and postoperative complications. We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2008-2020) to identify patients who underwent OS for mandibular and maxillary hypo- and hyperplasia. The postoperative outcomes of interest included 30-day surgical and medical complications, reoperation, readmission, and mortality. We also evaluated risk factors for complications. The study population included 674 patients, 48% of whom underwent single jaw surgery, 40% double jaw surgery, and 5.5% triple jaw surgery. The average age was 29 ± 11 years, with an equal gender distribution (females: n = 336; 50%, males: n = 338; 50%). Adverse events were relatively rare, with a total of 29 (4.3%) complications reported. The most common surgical complication was superficial incisional infection (n = 14; 2.1%). While the multivariable analysis revealed isolated single lower jaw surgery (p = 0.03) to be independently associated with surgical complication occurrence, it also identified an association between the outpatient setting and the frequency of surgical complications (p = 0.03) and readmissions (p = 0.02). In addition, Asian ethnicity was identified as a risk factor for bleeding (p = 0.003) and readmission (p = 0.0009). Based on the information recorded by the ACS-NSQIP database, our analysis underscored the positive (short-term) safety profile of OS. We found OS of the mandible to be associated with higher complication rates. The calculated risk role of OS in the outpatient setting warrants further investigation. A significant correlation between Asian OS patients and postoperative adverse events was found. Implementation of these novel risk factors into the surgical workflow may help facial surgeons refine their patient selection and improve patient outcomes. Future studies are needed to investigate the causal relationships of the observed statistical correlations.

Incidence and Risk Factors for 30 Day Reoperation in Benign Hysterectomy

<h3>Study Objective</h3> To determine the incidence and risk factors of 30-day reoperation in benign hysterectomy. <h3>Design</h3> The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2014 to 2020 was queried for all patients who underwent hysterectomy for benign indication. Our primary outcome was incidence of 30-day reoperation. Secondary outcomes included risk factors for reoperation such as route of surgery, body mass index (BMI), infection present at time of surgery, surgeon specialty, and preoperative comorbidities. <h3>Setting</h3> Hospitals participating in the NSQIP program. <h3>Patients or Participants</h3> Patients were identified in the ACS-NSQIP database using Current Procedural Terminology (CPT) codes. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> 334,756 hysterectomies were analyzed after incorporating inclusion and exclusion criteria. 4,988 patients (1.5%) underwent reoperation or died within 30 days of index procedure. The most common CPT codes for reoperation included exploratory laparotomy (12.3%), gynecologic repair (12.5%) and wound debridement/repair (9.2%). On multivariable analysis, ASA class 3 or higher (Class 3 vs. 2 OR 1.31, p<0.0001; Class 4 vs. 2 OR 2.49, p<0.0001), smoking (OR 1.17, p=.0006), hypertension requiring medication (OR 1.17, p=.0001), insulin dependent diabetes (OR 1.74, p=.0001), and surgical site infection present at the time of surgery (OR 8.39,p<.0001) were associated with an increased risk of the primary outcome. Vaginal approach to surgery was associated with an increased risk of 30-day reoperation when compared to laparoscopic approach (OR 1.47, p=.0001). Preoperative hematocrit, BMI, race, and surgeon specialty were not significant risk factors for 30-day reoperation. <h3>Conclusion</h3> This is the largest study in gynecologic surgery investigating the incidence and risk factors for 30-day reoperation in benign hysterectomy. The overall incidence of 30-day reoperation in benign hysterectomy is low. Certain preoperative comorbidities, infection present at time of surgery, and route of surgery are associated with increased risk of 30-day reoperation.

Utility of the Modified 5-Items Frailty Index to Predict Complications and Mortality After Elective Cervical, Thoracic and Lumbar Posterior Spine Fusion Surgery: Multicentric Analysis From ACS-NSQIP Database.

Retrospective review of multicentric data. The modified 5-item frailty index is a relatively new tool to assess the post-operative complication risks. It has been recently shown a good predictive value after posterior lumbar fusion. We aimed to compare the predictive value of the modified 5-item frailty index in cervical, thoracic and lumbar surgery. The American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) Database 2015-2020 was used to identify patients who underwent elective posterior cervical, thoracic, or lumbar fusion surgeries for degenerative conditions. The mFI-5 score was calculated based on the presence of 5 co-morbidities: congestive heart failure within 30days prior to surgery, insulin-dependent or noninsulin-dependent diabetes mellitus, chronic obstructive pulmonary disease or pneumonia, partially dependent or totally dependent functional health status at time of surgery, and hypertension requiring medication. Multivariate analysis was used to assess the independent impact of increasing mFI-5 score on the postoperative morbidity while controlling for baseline clinical characteristics. 53252 patients were included with the mean age of 64.2 ± 7.2. 7946 suffered medical complications (14.9%), 1565 had surgical complications (2.9%), and 3385 were readmitted (6.3%), 363 died (.68%) within 30days postoperative (6.3%). The mFI-5 items score was significantly associated with higher rates of complications, readmission, and mortality in cervical, thoracic, and lumbar posterior fusion surgery. The modified 5-item frailty score is a reliable tool to predict complications, readmission, and mortality in patients planned for elective posterior spinal fusion surgery.

A Tool to Estimate Risk of 30-day Mortality and Complications After Hip Fracture Surgery: Accurate Enough for Some but Not All Purposes? A Study From the ACS-NSQIP Database.

Surgical repair of hip fracture carries substantial short-term risks of mortality and complications. The risk-reward calculus for most patients with hip fractures favors surgical repair. However, some patients have low prefracture functioning, frailty, and/or very high risk of postoperative mortality, making the choice between surgical and nonsurgical management more difficult. The importance of high-quality informed consent and shared decision-making for frail patients with hip fracture has recently been demonstrated. A tool to accurately estimate patient-specific risks of surgery could improve these processes. With this study, we sought (1) to develop, validate, and estimate the overall accuracy (C-index) of risk prediction models for 30-day mortality and complications after hip fracture surgery; (2) to evaluate the accuracy (sensitivity, specificity, and false discovery rates) of risk prediction thresholds for identifying very high-risk patients; and (3) to implement the models in an accessible web calculator. In this comparative study, preoperative demographics, comorbidities, and preoperatively known operative variables were extracted for all 82,168 patients aged 18 years and older undergoing surgery for hip fracture in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2011 and 2017. Eighty-two percent (66,994 of 82,168 ) of patients were at least 70 years old, 21% (17,007 of 82,168 ) were at least 90 years old, 70% (57,260 of 82,168 ) were female, and 79% (65,301 of 82,168 ) were White. A total of 5% (4260 of 82,168) of patients died within 30 days of surgery, and 8% (6786 of 82,168) experienced a major complication. The ACS-NSQIP database was chosen for its clinically abstracted and reliable data from more than 600 hospitals on important surgical outcomes, as well as rich characterization of preoperative demographic and clinical predictors for demographically diverse patients. Using all the preoperative variables in the ACS-NSQIP dataset, least absolute shrinkage and selection operator (LASSO) logistic regression, a type of machine learning that selects variables to optimize accuracy and parsimony, was used to develop and validate models to predict two primary outcomes: 30-day postoperative mortality and any 30-day major complications. Major complications were defined by the occurrence of ACS-NSQIP complications including: on a ventilator longer than 48 hours, intraoperative or postoperative unplanned intubation, septic shock, deep incisional surgical site infection (SSI), organ/space SSI, wound disruption, sepsis, intraoperative or postoperative myocardial infarction, intraoperative or postoperative cardiac arrest requiring cardiopulmonary resuscitation, acute renal failure needing dialysis, pulmonary embolism, stroke/cerebral vascular accident, and return to the operating room. Secondary outcomes were six clusters of complications recently developed and increasingly used for the development of surgical risk models, namely: (1) pulmonary complications, (2) infectious complications, (3) cardiac events, (4) renal complications, (5) venous thromboembolic events, and (6) neurological events. Tenfold cross-validation was used to assess overall model accuracy with C-indexes, a measure of how well models discriminate patients who experience an outcome from those who do not. Using the models, the predicted risk of outcomes for each patient were used to estimate the accuracy (sensitivity, specificity, and false discovery rates) of a wide range of predicted risk thresholds. We then implemented the prediction models into a web-accessible risk calculator. The 30-day mortality and major complication models had good to fair discrimination (C-indexes of 0.76 and 0.64, respectively) and good calibration throughout the range of predicted risk. Thresholds of predicted risk to identify patients at very high risk of 30-day mortality had high specificity but also high false discovery rates. For example, a 30-day mortality predicted risk threshold of 15% resulted in 97% specificity, meaning 97% of patients who lived longer than 30 days were below that risk threshold. However, this threshold had a false discovery rate of 78%, meaning 78% of patients above that threshold survived longer than 30 days and might have benefitted from surgery. The tool is available here: https://s-spire-clintools.shinyapps.io/hip_deploy/ . The models of mortality and complications we developed may be accurate enough for some uses, especially personalizing informed consent and shared decision-making with patient-specific risk estimates. However, the high false discovery rate suggests the models should not be used to restrict access to surgery for high-risk patients. Deciding which measures of accuracy to prioritize and what is "accurate enough" depends on the clinical question and use of the predictions. Discrimination and calibration are commonly used measures of overall model accuracy but may be poorly suited to certain clinical questions and applications. Clinically, overall accuracy may not be as important as knowing how accurate and useful specific values of predicted risk are for specific purposes.Level of Evidence Level III, therapeutic study.

Preoperative hypoalbuminemia and dialysis increase morbidity/mortality after spine surgery for primary pyogenic spinal infections (ACS-NSQIP Study).

Background: We analyzed the role of hypoalbuminemia, dialysis, and other risk factors that increase morbidity/ mortality following surgery for primary pyogenic spinal infections (PSIs). The American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) that included 627 patients was utilized as our database.Methods: Primary spinal surgery for spondylodiscitis was evaluated in a ACS-NSQIP database involving 627 patients between 2010 and 2019. Outcome assessment included evaluation of 30-day postoperative morbidity, and mortality rates.Results: Within 30 postoperative days, complications occurred in 14.6% (92/627) of patients; 59 (9.4%) required readmission, and 39 (6.2%) required additional surgery. The most common complications were: wound infections, pneumonia, septic shock, and death (1.8%). Hypoalbuminemia (i.e., significantly associated with unplanned readmission and reoperation), and dialysis were the two major risk factors contributing to increased perioperative morbidity and mortality.Conclusion: Among 627 ACS-NSQIP patients undergoing primary surgery for PSIs, hypoalbuminemia and dialysis were associated with higher risks of major perioperative morbidity (i.e., within 30 postoperative days – mostly readmissions and reoperations) and mortality.

MP29-01 COMPARISON OF POSTOPERATIVE OUTCOMES OF TRANSURETHRAL RESECTION OF THE PROSTATE, LASER VAPORIZATION OR LASER ENUCLEATION FOR BENIGN PROSTATIC HYPERPLASIA TREATMENT USING THE AMERICAN COLLEGE OF SURGEONS NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM (ACS-NSQIP) DATASET

You have accessJournal of UrologyCME1 May 2022MP29-01 COMPARISON OF POSTOPERATIVE OUTCOMES OF TRANSURETHRAL RESECTION OF THE PROSTATE, LASER VAPORIZATION OR LASER ENUCLEATION FOR BENIGN PROSTATIC HYPERPLASIA TREATMENT USING THE AMERICAN COLLEGE OF SURGEONS NATIONAL SURGICAL QUALITY IMPROVEMENT PROGRAM (ACS-NSQIP) DATASET Christian Ayoub, Rachelle Haber, Reem Amine, Diana Mikati, and Albert El Hajj Christian AyoubChristian Ayoub More articles by this author , Rachelle HaberRachelle Haber More articles by this author , Reem AmineReem Amine More articles by this author , Diana MikatiDiana Mikati 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.0000000000002572.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Novel laser techniques for treating benign prostatic hyperplasia (BPH) are challenging gold standard techniques such as transurethral resection of the prostate (TURP). Comparing the outcomes of different techniques might serve in determining safety and efficacy compared to the current gold standard. The aim of this study is to compare the postoperative outcomes of three types of endourologic surgeries (TURP, laser vaporization (PVP) and laser enucleation (LEP)) for BPH treatment using the ACS-NSQIP database. METHODS: The ACS-NSQIP database was queried for men >50 years of age who underwent TURP, PVP and LEP for treatment of BPH from 2005 till 2017. Demographics, clinical, operative characteristics, and 30-day outcomes were compared. Univariate and multivariate regression models were performed for return to the operating room, morbidity, and length of hospital stay. RESULTS: 56,436 patients underwent endourologic surgeries for BPH, 64.0% had TURP, 31.1% PVP, and 4.9% LEP. Patients undergoing TURP were more likely to be smokers (11.2%, p-value<0.001), have diabetes (21.8%, p-value<0.001), with history of COPD (6.8%, p-value<0.001), disseminated cancer (1.5%, p-value<0.001), weight loss (0.6%, p-value 0.039), congestive heart failure (1%, p-value 0.02), and presenting as emergency cases (2.3%, p-value<0.001). Lower rates were seen in laser vaporization followed by laser enucleation with morcellation. After adjusting for covariates, PVP and LEP showed less return to the operating room with a 48.1% and 21.7% decrease in the odds as compared to TURP, respectively. PVP showed a significant 13.2% increase in the odds of experiencing morbidity as opposed to a decrease of 37.5% in LEP as compared to TURP. PVP and LEP showed a decrease in hospital stay by 0.988 and 0.305 days as compared to TURP, respectively. CONCLUSIONS: This study shows superiority of laser techniques in 30-day postoperative outcomes as compared to TURP. Further research is needed to account for longer duration of follow-up and patient-specific urologic outcomes, such as prostate size, urinary incontinence, erectile dysfunction, and retrograde ejaculation. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e469 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christian Ayoub More articles by this author Rachelle Haber More articles by this author Reem Amine More articles by this author Diana Mikati More articles by this author Albert El Hajj More articles by this author Expand All Advertisement PDF DownloadLoading ...

Development and validation of a risk-based algorithm for preoperative type and screen testing in spine surgery

BACKGROUND CONTEXTWith improvements in surgical techniques and perioperative management, transfusion rates after spine surgery have decreased over time. Given this trend, routine preoperative ABO/Rh type and antibody screen (T&S) laboratory testing may not be warranted in all patients undergoing spine surgery. PURPOSEThe aim of the current study is to evaluate risk factors for intra/postoperative transfusion in patients undergoing a variety of spine procedures and to develop an algorithm for selectively ordering preoperative T&S testing in appropriate patients. STUDY DESIGN/SETTINGThis is a single institution, retrospective observational study of patients undergoing emergent or elective spine surgery. External validation of the algorithm was performed on a national sample of patients undergoing spine surgery from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) national database. PATIENT SAMPLEA total of 5,947 surgeries from January 1, 2016 to December 31, 2019 at a single institution, and 166,113 surgeries from the 2016 to 2018 ACS-NSQIP database. OUTCOME MEASURESThe primary outcome measure was performance of intraoperative or postoperative transfusion. METHODSUsing the institutional sample, univariate statistics (chi-square tests, fisher's exact test, 2-sided independent sample tests) were performed to compare demographics, comorbidities, and surgical details (case type, number of levels treated, etc.) between patients who did and did not require intra- or postoperative transfusion. Transfusion rates were calculated and compared across procedure types. Multivariate logistic regression was performed to identify independent predictors of transfusion and the model's accuracy was evaluated using the area under the curve (AUC) of the receiver operating characteristics (ROC) curve. A risk-based algorithm suggesting no preoperative T&S in low transfusion risk procedures, routine preoperative T&S in high-risk procedures, and further assessment in medium risk thoracolumbar fusion procedures was created. The algorithm's sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were evaluated when it was applied to both the institutional and national samples. Potential cost savings from reducing T&S orders were calculated. RESULTSIn the institutional sample, 120 patients (2.0%) required intraoperative or postoperative transfusion. The highest rates of transfusion were found in corpectomy (10.5%) and anterior/posterior cervical fusion (6.9%) procedures. In the multivariate logistic regression model, the presence of a preoperative coagulation defect or hemorrhagic condition (OR: 7.149, p<.001) and 6+ level surgery (OR: 7.511, p<.001) were the strongest predictors of transfusion. Overall, the model generated an AUC of 0.882, indicating excellent predictive accuracy. When applied to the institutional cohort, the risk-based algorithm had a sensitivity of 78.3%, specificity of 80.5%, PPV of 7.6%, and NPV of 99.4% for evaluating likelihood of transfusion. Using the algorithm 4,717 T&S tests would have been eliminated (79.3%), resulting in a cost savings of $179,246. Application of the model to the ACS-NSQIP cohort resulted in a sensitivity of 61.9%, specificity of 84.6%, PPV of 15.6%, and NPV of 98.0%. CONCLUSIONSThe routine use of preoperative ABO/Rh type and antibody screen testing does not appear to be warranted in patients undergoing spine surgery. A risk-based approach to preoperative type and screen testing may eliminate unnecessary tests and generate significant cost savings with minimal disruption to clinical care.

Racial disparities in outcomes of arthroscopic rotator cuff repair: A propensity score matched analysis using multiple national data sets

BackgroundDisparities in access, utilization and outcomes exist throughout the healthcare system for minority groups, including racial and ethnic minorities; these disparities have wide-reaching implications for individuals as well as the healthcare system as a whole. This study will examine the impact of race on short and medium term outcomes for patients undergoing rotator cuff repair (RCR) using matched cohorts. MethodsPatients undergoing arthroscopic rotator cuff repair from 2016 to 2018 were extracted from two national databases: the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and TriNetX Research Network. Using the ACS-NSQIP database, univariate analysis was performed to identify differences in comorbidities between white and minority patients. Patients were propensity score matched based on significant differences between groups and 30-day postoperative outcomes were assessed. These comorbidities were then used to propensity score match white and minority patients in the TriNetX database and two-year postoperative outcomes were evaluated. ResultsFollowing propensity score matching, 3716 patients remained in each group from the ACS-NSQIP database and 4185 patients remained in each group from the TriNetX database. The OR time for minority patients was longer than white patient in the ACS-NSQIP database (92.2 vs. 87.6 min, p < .001). There was no difference in medium-term outcomes for repeat RCR, infection or frozen shoulder between white and minority patients in the TriNetX database. ConclusionAfter propensity score matching the only significant short-term outcome between white and minority patients undergoing RCR was a difference in OR time; there were no differences in medium-term outcomes. This may indicate that the source of racial disparities is one of access to healthcare rather than an innate difference in the patients’ outcomes. Further study is needed to elucidate this issue.

Inpatient versus outpatient shoulder arthroplasty outcomes: A propensity score matched risk-adjusted analysis demonstrates the safety of outpatient shoulder arthroplasty

ObjectivesBeginning January 1, 2021 total shoulder arthroplasty (TSA) was removed from the Medicare (U.S national healthcare for patients ≥ 65years of age) inpatient-only list. Furthermore, there is limited data comparing outpatient and inpatient TSA among recent contemporary large population databases. This study aimed to analyze shoulder arthroplasty outcomes between inpatient and outpatient procedures at the national level. MethodsThe American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was utilized (2015–2019). Cases with a current procedural terminology of 23472 indicative of primary TSA and reverse total shoulder arthroplasty were included (N = 22,452). Outcomes were then analyzed in two approaches: unmatched analysis and propensity score matched risk-adjusted analysis. ResultsOverall, 9.7% (N = 2,185) of cases were performed outpatient and 90.3% (N = 20,357) of cases were performed inpatient. The rate of outpatient procedures has been steadily increasing (2015: 8.3%, 2016: 14.7%, 2017: 15.8%, 2018: 26.5%, 2019: 34.6%; P < 0.001). Outpatients were more likely to be male (50.7% vs. 43.7%) and younger (age < 65; 37.0% vs. 27.9%) and less likely to be ASA class 3 or 4 (49.5% vs. 58.3%). Outpatients had fewer comorbidities including obesity (46.1% vs. 51.9%), hypertension (60.5% vs. 67.4%), diabetes (15.1 vs. 18.2%), chronic obstructive pulmonary disease (4.8% vs. 7.0%), bleeding disorders (1.3% vs. 2.5%), or chronic steroid use (3.5% vs. 5.0%; all P < 0.001). In a non-risk matched analysis of outcomes, outpatient procedures displayed lower rates of any adverse event (3.5% vs. 5.3%; P < 0.001), minor adverse events (1.5% vs. 3.0%; P = 0.001), and readmission (2.2% vs. 2.8%; P = 0.025). Following a propensity score matched analysis, two risk matched cohorts of outpatient (N = 2,172) and inpatient (N = 2,172) procedures were identified. Subsequent analysis of outcomes revealed no significant differences in outcome metrics between risk-matched outpatient and inpatient procedures. ConclusionsFrom 2015 to 2019, there has been a four-fold increase in the proportion of outpatient shoulder arthroplasty cases in the ACS-NSQIP database. This study shows that outpatient shoulder arthroplasty may be safely performed in a select cohort of patients without increased risk of adverse events. After adjusting for comorbidities, there were no differences in clinical outcomes or rates of adverse outcomes between inpatient and outpatient shoulder arthroplasty. Level of evidenceRetrospective Observational Study, Level IV.