American College Of Surgeons National Surgical Quality Improvement Program Research Articles

Not all operative time is created equal: operative time in relation to 30-day complications in benign laparoscopic hysterectomies

STUDY OBJECTIVE: To assess the relationship between operative time and specific 30-day postoperative complications across different intervals of operation duration in total laparoscopic hysterectomies (TLHs).DESIGN: A retrospective cohort study.SETTING: American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2011 to 2020.PATIENTS: 131,146 TLH cases.INTERVENTIONS: Eligible cases included benign laparoscopic hysterectomies with operative times between 20 and 499 min. We excluded cases involving disseminated cancer, emergency surgery, supracervical approaches, or concomitant procedures.MEASUREMENTS: Multivariable logistic regression analysis was used to evaluate the relationship between specific postoperative complications and operative time. Spline regression was used to analyze differences in the association between postoperative complications and operative time across different tertiles of operative duration.MAIN RESULTS: Multivariable logistic regression analysis demonstrated a significant association between operative time and complication occurrence for each complication type investigated, including unplanned readmission, urinary tract infections, superficial surgical site infections, blood transfusion administration, return to the operating room, and deep organ space infections. Multivariable logistic spline regression demonstrated that operative time contributed more strongly to the odds of a complication for shorter procedures than longer procedures. This relationship was more pronounced for major complications than minor complications.CONCLUSION: Operative time is a stronger risk factor for developing complications for shorter duration procedures than longer procedures. This is especially evident in major complications such as return to the operating room and deep organ space infections. Our results suggest that longer procedure duration may not affect the likelihood of a complication as much as previously thought, and operative times should not be a primary factor in deciding to convert to laparotomy or alter post-operative management.

Evaluation of the American College of Surgeons risk calculator in hepatectomy for metastatic colorectal cancer in a Southeast Asian population.

This study evaluated the accuracy of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) calculator in predicting outcomes after hepatectomy for colorectal cancer (CRC) liver metastasis in a Southeast Asian population. Predicted and actual outcomes were compared for 166 patients undergoing hepatectomy for CRC liver metastasis identified between 2017 and 2022, using receiver operating characteristic curves with area under the curve (AUC) and Brier score. The ACS-NSQIP calculator accurately predicted most postoperative complications (AUC > 0.70), except for surgical site infection (AUC = 0.678, Brier score = 0.045). It also exhibited satisfactory performance for readmission (AUC = 0.818, Brier score = 0.011), reoperation (AUC = 0.945, Brier score = 0.002), and length of stay (LOS, AUC = 0.909). The predicted LOS was close to the actual LOS (5.9 vs. 5.0days, P = 0.985). The ACS-NSQIP calculator demonstrated generally accurate predictions for 30-day postoperative outcomes after hepatectomy for CRC liver metastasis in our patient population.

Racial Disparities in Outcomes Following Surgical Fixation of Traumatic Thoracolumbar Fractures: A National Database Analysis

This study aims to assess race as an independent risk factor for postoperative complications after surgical fixation of traumatic thoracolumbar fractures for African American and Asian American patients compared with white patients. The 2011-2021 American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) dataset was used to identify patients undergoing fusion surgeries for thoracolumbar spine fractures. Patient comorbidity burden was assessed using a modified 5-item frailty index score (mFI-5). Chi-squared and ANOVA tests were used to compare baseline clinical characteristics between groups. Multivariate analysis was performed to compare African American and Asian American patients with white patients controlling for age, BMI, and American Society of Anesthesiologists (ASA) score. African American patients experienced longer operative times compared to Asian American and white patients (3.74 ± 1.87 hours versus 3.04 ± 1.71 hours and 3.48 ± 1.81 hours, p<0.001). African American and Asian American patients demonstrated higher comorbidity burden with mFI-5>2 compared to white patients (30.7 % and 25.6% versus 19.9%, p<0.001). African American and Asian American patients had a higher risk of postoperative complications than white patients (22.4% and 20% versus 19.7%, p<0.001). African American race was an independent risk factor of postoperative 30-day morbidity (OR 1.19, CI 1.11 - 1.28, p<0.001). African American and Asian American patients undergoing thoracolumbar fusion surgeries exhibit disproportionate comorbidity burden, longer LOS, and greater postoperative complications compared with white patients. Furthermore, the African American race was associated with an increased rate of 30-day postoperative complications.

Modified 5-Item Frailty Index: A Useful Tool for Assessing the Impact of Frailty on Postoperative Morbidity and Mortality Following Surgical Fixation of Thoracolumbar Fractures

The modified 5-item frailty index (mFI-5) is a comorbidity-based risk stratification tool to predict adverse events following various neurological surgeries. This study aims to quantify the association between increased mFI-5 and postoperative complications and mortality following surgical fixation of traumatic thoracolumbar fractures. The 2011-2021 American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) dataset was used to identify patients undergoing fusion surgeries for thoracolumbar spine fractures. The mFI-5 score was calculated based on the presence of five major comorbidities: congestive heart failure within 30 days before surgery, insulin-dependent or noninsulin-dependent diabetes mellitus, chronic obstructive pulmonary disease, partially dependent or totally dependent functional health status at the time of surgery, and hypertension requiring medication. Multivariate analysis assessed the independent impact of increasing mFI-5 scores on postoperative 30-day morbidity and mortality while controlling for baseline clinical characteristics. A total of 66,904 patients were included in our analysis (54.2% female, mean age 62.27 ± 12.93 years). On univariate analysis, higher mFI-5 score was significantly associated with increased risks of superficial surgical site infection, deep surgical site infection, wound dehiscence, unplanned reoperation, pneumonia, unplanned intubation, postoperative ventilator use, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke, myocardial infarction, cardiac arrest, pulmonary embolism, deep vein thrombosis, bleeding requiring transfusion, sepsis, septic shock, and longer hospital length of stay (LOS). On multivariate logistic regression, increasing mFI-5 score versus a mFI-5 score of zero was associated with higher odds of overall complications (mFI-5 ≥2: odds ratio [OR] 1.38 CI: 1.24 - 1.54, p<0.001; mFI-5 = 1: OR 1.18 CI: 1.11 - 1.24, p<0.001) and 30-day mortality (mFI-5 ≥2: OR 2.33 CI: 1.60 - 3.38, p<0.001). This study demonstrates that frailty, when measured using the mFI-5, independently predicts postoperative complications, hospital LOS, and 30-day mortality after surgical repair of thoracolumbar fractures. These findings are important for risk stratification in patients undergoing thoracolumbar fusion surgery and for standardization in reporting outcomes after those procedures.

Contemporary morbidity and mortality of open versus robotic cystectomy for bladder cancer: An analysis of the National Surgical Quality Improvement Program (NSQIP) procedure targeted cystectomy database

ObjectivesTo evaluate the association between surgical modality (RARC vs. ORC) and the risk of 30-day complications. Materials and MethodsWe utilized the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) Cystectomy-Targeted database from 2019 to 2021. The primary outcome was a composite of major complications including 30-day mortality, reoperation, cardiac events, and stroke. Secondary outcomes included individual major and cystectomy-specific complications. Propensity score matching (PSM) was employed to minimize inherent differences within our cohort. We performed logistic regression to assess the association between outcomes of interest and operative modality. ResultsWe found no difference between operative modality and the primary outcome, however, RARC was associated with a 70% lower risk of 30-day mortality (OR 0.30, 95% CI 0.13-0.70) and had favorable outcomes with respect to respiratory, deep venous thrombosis, wound complications, and length of stay. Limitations are related to residual confounding given the observational methodology. ConclusionsRARC was associated with reduced risk of multiple 30-day complications, including mortality, as well as organ system and cystectomy-specific outcomes. These data support the clinical benefit of increased adoption of RARC.

Supervised machine learning to predict non-home discharge following surgical treatment of pelvic fractures

Background: Decision-tree-based machine learning (ML) algorithms such as random forest (RF) are useful for their ability to predict outcomes and rank variables according to their utility in the decision-making process. This study utilizes RF to identify important predictors of discharge to facility following surgical stabilization of pelvis fractures, a traumatic injury that often precludes mortality and diminished quality of life. Methods: The American College of Surgeons national surgical quality improvement program (ACS-NSQIP) database was queried for patients aged 16 to 70 undergoing surgical fixation of pelvis fractures between 2008 and 2018. Outcome of interest was discharge home versus to facility. RF was trained with surgical variables, comorbidities, and other patient factors and tasked with predicting discharge location. Permutation feature importance (PFI) was then generated to identify important variables. Results: Out of 492 patients, 184 patients were discharged to facility, and 308 patients were discharged home. RF identified age, American Society of Anesthesiologists (ASA) classification, and preoperative hematocrit as top predictors for discharge to facility. Patients being discharged home were younger, had lower ASA scores, and had higher preoperative hematocrit. Conclusions: RF identified age, ASA classification, and preoperative hematocrit as top predictors for discharge destination following pelvic surgery. Knowledge of the impact of these variables can inform preoperative planning for both patients and their care team, while highlighting the opportunity to address preoperative hematocrit to both reduce cost and improve quality of care.

299 Predictors of Unplanned Readmission in Patients Undergoing Intracranial Tumor Resection: A Multi-center Analysis of 31,776 Patients

INTRODUCTION: Although unplanned readmission is a postoperative outcome metric associated with significant morbidity and financial burden, precise assessment tools for its prediction are yet to be developed. The Revised Risk Analysis Index (RAI) has been recently endorsed as a robust frailty index for predicting surgical outcomes. Hence, the RAI could potentially be utilized to help improve prediction unplanned readmission in patients undergoing intracranial tumor resection (ITR). METHODS: Data of patients undergoing ITR were obtained from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database from the years 2012-2019 using the ICD-9 and ICD-10 codes, indicating ITR. Baseline characteristics, preoperative clinical status, and outcomes were compared between patients with and without unplanned readmission. Frailty, as a measure of baseline physiological reserve, was calculated using the RAI. Univariate and multivariate logistic regression analyses were performed to identify independent associations between unplanned readmissions and patient characteristics. RESULTS: The unplanned readmission rate of this cohort (N = 31,776) was 10.8% (N = 3,420). Among the readmitted patients, 958 required unplanned reoperation. Multiple characteristics were significantly different between the readmitted and non-readmitted patients, including age, BMI, comorbidities, and RAI groups (p &lt; 0.05). The most common causes of unplanned readmission were infection (9.4%), seizures (6%), and pulmonary embolism (4%). Patient characteristics identified as reliable predictors of unplanned readmission, included age, body mass index (BMI), functional status, diabetes, hypertension, hyponatremia, and their RAI score (p &lt; 0.05). In multivariate analysis, RAI “frail” patients had an unplanned readmission odds ratio (OR) of 1.3(95%CI; 1.2-1.4), and RAI “severely frail” patients had an OR of 1.6 (95%CI; 1.3-2.1) (p &lt; 0.001). CONCLUSIONS: The RAI is a reliable pre-operative frailty index for predicting unplanned readmission following ITR. Utilizing the RAI to identify high risk patients may decrease unplanned readmission through implementation of appropriate management guidelines.

276 Outpatient Versus Inpatient Laminoplasty for Cervical Spondylosis: A Non-inferiority Analysis of Surgical Outcomes

INTRODUCTION: A rising trend of outpatient spinal procedures has been observed recently due to increasing evidence of lower risk of hospital-associated risks and better value-based healthcare delivery. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients undergoing cervical laminoplasty for spinal spondylosis. Patients with a hospital stay of more than 48 hours were excluded from the comparative analysis to increase baseline comparability between the two groups. Patients undergoing other spinal procedures during the same hospital stay were also excluded. The outcomes of interest were postoperative complications, nonroutine discharge, readmissions, and reoperations within 30 days after surgery. The non-inferiority of outpatient compared with inpatient surgery was defined as a risk difference of &lt;10.0% at a one-sided 97.5% confidence interval. RESULTS: A total of 808 cervical laminoplasty surgeries were identified. The study cohorts consisted of 107 and 701 patients in outpatient and inpatient groups, respectively. All recorded baseline characteristics, except age (58.3 ± 10.6 vs. 61.4 ± 11.5, p=0.01), were similar between the two groups. The incidences of postoperative complications were 2.8% and 3.4% for the outpatient and inpatient groups, respectively, while the non-routine discharge rates were 6.5% and 3.5%. Both groups had a 30-day readmission rate of 3.7%. In addition, the 30-day reoperation rates were 2.8 % and 1.4% for the outpatient and inpatient groups, respectively. Noninferiority of outpatient surgery was documented at a risk difference of 10% for postoperative complications, non-routine discharge, and readmission and reoperation rates. CONCLUSIONS: Outpatient cervical laminoplasty demonstrated similar early postoperative outcomes compared to inpatient surgery. Noninferiority in surgical outcomes after surgery was documented for outpatient compared with inpatient cervical laminoplasty surgery.

361 The Frailty-Driven Predictive Model for Failure to Rescue After Cervical Decompression and Fusion: An ACS-NSQIP Analysis of 3,632 Cases (2011-2020)

INTRODUCTION: Cervical decompression &amp; fusion (CDF) outcome prognostication relies on preoperative risk factors to predict complications and outcomes in order to help guide pre- and perioperative decision-making. METHODS: CDF cases were queried from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database 2011-2020. Patients who underwent CDF and experienced a major complication were identified. Within this cohort, FTR was calculated as death or hospice within 30 days of a major complication. Frailty was measured by the Risk Analysis Index-Revised (RAI-Rev). Demographics and baseline characteristics of patients were compared by FTR. Significant factors were assessed by univariate and multivariable regression for the development of a frailty-driven predictive model for FTR. The discriminative ability of the predictive model was assessed using a receiving operating characteristic curve analysis. RESULTS: There were 3,632 patients who suffered a major complication from CDF, and 7.6% (277 patients) experienced FTR. Independent predictors of FTR were non-elective surgery, frailty status, preoperative intubation, thrombosis or embolism complication, unplanned intubation, prolonged ventilator use (&gt;48 hours), cardiac arrest, and septic shock. Frailty, and a combination of preoperative and postoperative risk factors in a predictive model for FTR achieved outstanding discriminatory accuracy (C-statistic = 0.901, CI: 0.883-0.919). CONCLUSIONS: Preoperative and postoperative risk factors yield a highly accurate predictive model for FTR in CDF patients. Our model may guide surgical management and/or prognostication following the development of a major complication. Future studies may determine the predictive ability of this model in other neurosurgical patient populations. Our predictive model may be deployed by-the-beside here: https://nsgyfrailtyoutcomeslab.shinyapps.io/FailureToRescueCervicalFusion/

373 Modified 5-Item Frailty Index: A Useful Tool for Assessing the Impact of Frailty on Postoperative Morbidity and Mortality Following Surgical Fixation of Thoracolumbar Fractures

INTRODUCTION: The modified 5-item frailty index (mFI-5) is a comorbidity-based risk stratification tool that has been shown to predict adverse events following various neurological surgeries. METHODS: The 2011-2021 American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) dataset was used to identify patients undergoing fusion surgeries for thoracolumbar spine fractures. The mFI-5 score was calculated based on the presence of the 5 comorbidities: congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease, partially dependent or totally dependent functional health status, and hypertension. Multivariate analysis was used to assess the independent impact of increasing mFI-5 score on postoperative 30-day morbidity and mortality while controlling for baseline clinical characteristics. RESULTS: A total of 66,904 patients were included in our analysis (54.2% female, mean age 62.27 ± 12.93 years). On univariate analysis, higher mFI-5 score was significantly associated with increased risks of superficial surgical site infection(SSI), deep SSI, wound dehiscence, unplanned reoperation, pneumonia, unplanned intubation, postoperative ventilator use, progressive renal insufficiency, acute renal failure, urinary tract infection, stroke, myocardial infarction, cardiac arrest, pulmonary embolism, deep vein thrombosis, bleeding requiring transfusion, sepsis, septic shock, and longer hospital length of stay (LOS). On multivariate logistic regression, increasing mFI-5 score versus mFI-5 = 0 was associated with higher odds of overall complications (mFI-5 =2: odds ratio [OR] 1.44 CI: 1.35–1.52, p &lt; 0.001; mFI-5 = 1: OR 1.18 CI: 1.12–1.24, p &lt; 0.001) and 30-day mortality (mFI-5 =2: OR 2.32 CI: 1.60–3.37, p &lt; 0.001). CONCLUSIONS: This study demonstrates that frailty, when measured using the mFI-5, independently predicts postoperative complications, hospital LOS, and 30-day mortality after surgical repair of thoracolumbar fractures. These findings are important for risk stratification in patients undergoing thoracolumbar fusion surgery and for standardization in reporting outcomes after those procedures.

The Utilization of Laparoscopic Ventral Hernia Repair (LVHR) in Incarcerated and Strangulated Cases: A National Trend in Outcomes.

Early after its adoption, minimally invasive surgery had limited usefulness in emergent cases. However, with improvements in equipment, techniques, and skills, laparoscopy in complex and emergency operations expanded substantially. This study aimed to examine the trend of laparoscopy in incarcerated or strangulated ventral hernia repair (VHR) over time. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for laparoscopic repair of incarcerated and strangulated hernias (LIS-VHR) and compared over 2 time periods, 2014-2016 and 2017-2019. The utilization of laparoscopy in all incarcerated or strangulated VHR increased over time (2014-2016: 39.9% (n = 14 075) vs 2017-2019: 46.3% (n = 18 369), P < .001). Though likely not clinically significant, demographics and comorbidities statistically differed between groups (female: 51.7% vs 50.0%, P = .003; age 54.5 ± 13.7 vs 55.4 ± 13.8years, P < .001; BMI 34.9 ± 8.0 vs 34.6 ± 7.8kg/m2, P < .001). Patients from 2017 to 2019 were less comorbid (18.9% vs 16.8% smokers, P < .001; 18.2% vs 17.3% diabetic, P = .036; 4.6% vs 4.1% COPD, P = .021) but had higher ASA classification (III: 43.3% vs 45.7%; IV: 2.5% vs 2.7%, P < .001). Hernia types (primary, incisional, recurrent) were similar in each group. Operative time (89.7 ± 59.3 vs 97.4 ± 63.4min, P < .001) became longer but length-of-stay (1.4 ± 3.3 vs 1.1 ± 2.6days, P < .001) decreased. There was no statistical difference in surgical complications, medical complications, reoperation, or readmission rates between periods. Laparoscopic VHR has become a routine method for treating incarcerated and strangulated hernias, and its utilization continues to increase over time. Clinical outcomes have remained the same while hospital stays have decreased.

NSQIP 5-factor modified frailty index and complications after ileal anal pouch anastomosis for ulcerative colitis

BackgroundFrailty has been associated with worse postoperative outcomes. The 5-factor modified frailty index (mFI-5) is an objective measure although its validity in measuring frailty in patients undergoing ileal pouch-anal anastomosis (IPAA) for chronic ulcerative colitis (CUC) has not been reported. MethodsThis study used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted proctectomy database. The mFI-5 was calculated by five preoperative diagnoses: insulin-dependent or noninsulin-dependent diabetes, congestive heart failure, hypertension, chronic obstructive pulmonary disease, and dependent or partially dependent functional status. The impact of mFI-5 on minor and major postoperative morbidity in CUC patients undergoing IPAA was analyzed. ResultsThe cohort included 1454 patients (median age 38 years, median body mass index [BMI] 26 kg/m2) of which 87 % had a mFI-5 = 0, 11 % had a mFI-5 = 1, and 2.5 % a mFI-5 ≥ 2. In multivariable logistic regression, mFI-5 ≥ 2 was significantly associated with minor complications (OR = 2.29, 95 % CI [1.00–5.22], p = 0.049), but not with major complications (p = 0.860). ConclusionIPAA for CUC is associated with high postoperative morbidity, however, the mFI-5 alone has limited utility in determining which patients are at a higher risk of complications due to frailty. These observations suggest there is a need for more relevant instruments to measure frailty in this patient cohort.

Outpatient surgery benchmarks and practice variation patterns: Case controlled study.

Despite numerous potential benefits of outpatient surgery, there is currently a lack of national benchmarking data available for hospitals and surgeons to compare their own outcomes as they transition toward outpatient surgery. Patients who underwent 14 common general surgery operations from 2016-2020 were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Operations were selected based on frequency and the ability to be performed both in- and outpatient. Postoperative complications and readmissions were compared between patients who underwent inpatient vs outpatient surgery. After adjusting for patient comorbidities, multivariable models assessed the effect of patient characteristics on the odds of experiencing postoperative complications. A separate multiinstitutional study of 21 affiliated hospitals assessed practice variation. In 13 of the 14 studied procedures, complications were lower for patients who were selected for outpatient surgery (all P<0.01); minimally invasive (MIS) adrenalectomy showed no difference (P=0.61). Multivariable analysis confirmed these findings; the odds of experiencing any adverse events were lower following outpatient surgery in all operations but MIS adrenalectomy (OR 0.97; 95% CI 0.47-2.02). Analysis of institutional practices demonstrated variation in the rate of outpatient surgery in certain breast, endocrine, and hernia repair operations. Institutional practice patterns may explain the national variation in the rate of outpatient surgery. While the present data does not support the adoption of outpatient surgery to less optimal candidates, addressing unexplained practice variations could result in improved utilization of outpatient surgery.

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 .

The death of laparoscopy.

The introduction of laparoscopy in 1989 revolutionized surgical practices, reducing post-operative complications, and enhancing outcomes. Despite its benefits, limitations in laparoscopic tools have led to continued use of open surgery. Robotic-assisted surgery emerged to address these limitations, but its adoption trends and potential impact on open and laparoscopic surgery require analysis. A retrospective analysis used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases from 2012 to 2021. The study encompassed various abdominal procedures, employing Vector Autoregressive (VAR) models to analyze the dynamic relationships between surgical techniques. The models predicted future trends in open, laparoscopic, and robotic surgery until Q2 of 2025. The analysis included 360,171 patients across diverse procedures. In urology, robotic surgery dominated prostatectomies (83.1% in 2021) and nephrectomies (55.1% in 2021), while the open approach remained the predominant surgical technique for cystectomies (72.5% in 2021). In general surgery, robotic colectomies were forecasted to surpass laparoscopy, becoming the primary approach by 2024 (45.7% in 2025). Proctectomies also showed a shift towards robotic surgery, predicted to surpass laparoscopy and open surgery by 2025 (32.3%). Pancreatectomies witnessed a steady growth in robotic surgery, surpassing laparoscopy in 2021, with forecasts indicating further increase. While hepatectomies remained predominantly open (70.0% in 2025), esophagectomies saw a rise in robotic surgery, predicted to become the primary approach by 2025 (52.3%). The study suggests a transformative shift towards robotic-assisted surgery, poised to dominate various minimally invasive procedures. The forecasts indicate that robotic surgery may surpass laparoscopy and open surgery in colectomies, proctectomies, pancreatectomies, and esophagectomies by 2025. This anticipated change emphasizes the need for proactive adjustments in surgical training programs to align with evolving surgical practices. The findings have substantial implications for future healthcare practices, necessitating a balance between traditional laparoscopy and the burgeoning role of robotic-assisted surgery.

Do Patients With Insulin-Dependent and Non-Insulin-Dependent Diabetes Have Different Risks for Complications After Total Ankle Arthroplasty?

Patients with diabetes undergoing total ankle arthroplasty tend to be at greater risk for complications than those without diabetes. However, the effect of diabetes severity and how it impacts the risk for perioperative complications is less clear. The purpose of this study was to compare (1) complications, (2) length of hospital stay, and (3) readmissions within 30 days for total ankle arthroplasty (TAA) patients without diabetes, patients with non-insulin-dependent diabetes, and patients with insulin-dependent diabetes. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, a total of 1803 patients undergoing TAA between 2007 and 2019 were collected. The relationship between diabetes status (no diabetes [n = 1,589], insulin-dependent [n = 169], and non-insulin-dependent [n = 45]) and outcomes were compared. Multivariate linear regression models were used to adjust for confounding variables such as age, sex, race, body mass index, smoking, steroid use, hypertension, chronic obstructive pulmonary disease, anesthesia type, dyspnea, and outpatient status. Statistical significance was set at P <.05. Insulin-dependent diabetes was an independent risk factor for increased odds of infection within 30 days (odds ratio 6.47, 95% CI 0.79-33.66; P = .043). Hospital length of stay was also increased in patients with non-insulin-dependent diabetes (β = 0.21, 95% CI 0.02-0.40; P = .031) and insulin-dependent diabetes (β = 0.40, 95% CI 0.04-0.76; P = .028). However, neither diabetic state demonstrated a statistically significant increase in readmissions or wound complications within 30 days. Patients with insulin-dependent diabetes included in this cohort were at increased risk of having an infection within 30 days after TAA. Additionally, patients with diabetes status had an increased hospital length of stay. These results can inform patients on their potential outcomes after total ankle arthroplasty based on their diabetes status. Level III, retrospective comparative study.

Impact of Drain Placement on Postoperative Complications after Thyroidectomy for Substernal Goiter

Abstract Introduction Despite the evidence against drain placement after thyroidectomy, there is a lack of consensus on drain use in patients with substernal goiter. Objective To assess the factors that increase the likelihood of drain placement and its impact on postoperative hematoma and other 30-day complications among adult patients undergoing thyroidectomy for substernal goiter. Methods A retrospective cohort study that used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Adult patients (aged ≥ 18 years) who underwent elective thyroidectomy for substernal goiter from 2016 to 2020 were included. Cases with closed suction neck drains placed upon completion of surgery were included in the drain group, and the remaining cases formed the nondrain group. Results A total of 1,229 patients were included (46.5% with drain placement). The factors that increased the likelihood of drain placement included body mass index (BMI) ≥ 30 kg/m2, score between 3 and 5 on the American Society of Anesthesiologists (ASA) physical status classification, sternal split/transthoracic surgical approach, operative time ≥ 90 minutes, and surgery conducted by otolaryngologists. Patients with clean-contaminated or contaminated wound classifications were less likely to be submitted to drain placement. In addition, drain use had no impact on postoperative hematoma formation but was found to independently increase the risk of prolonged length of hospital stay. Conclusion Thyroidectomy without drain placement might be safe for substernal goiter. However, this decision should be individualized for each patient.Level Of Evidence: 3

Restoration of intestinal continuity following emergency sigmoid colectomy for sigmoid volvulus: An American College of Surgeons National Surgical Quality Improvement Program analysis using coarsened exact matching.

There is limited data to guide decision-making between performing a primary anastomosis and fashioning an end colostomy following emergency sigmoid colectomy for patients with sigmoid volvulus. The aim of this study was to compare the outcomes of these two approaches. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2006 to 2021 was retrospectively analyzed. Missing data were multiply imputed, and coarsened exact matching was performed to generate matched cohorts. Rates of major complications and other postoperative outcomes were evaluated among patients who had a primary anastomosis as compared with matched controls who had an end colostomy following emergency sigmoid colectomy. Overall, 4041 patients who had a primary anastomosis and 1240 who had an end colostomy met the inclusion criteria. After multiple imputation and coarsened exact matching, 895 patients who had a primary anastomosis had a matched control. The rate of major complications was lower in patients who had an end colostomy (33.2% vs. 36.7%), but this difference was not statistically significant (OR 0.86, 95% CI 0.70-1.05). Results were similar in subgroup analyses of higher-risk patients. There were no significant differences in overall complication rate, mortality, length of hospital stay, or readmission rate. Patients with a colostomy were more likely to be discharged to a care facility (OR 1.35, 95% CI 1.09-1.67). Differences in rates of major complications and many other outcomes after primary anastomosis as compared with end colostomy were not statistically significant following emergency sigmoid colectomy for sigmoid volvulus.

Risk Factors for Unexpected Admission Following Lumbar Spine Laminectomy: A National Database Study.

Introduction Laminectomy is one of the most common orthopedic spine surgeries performed in the United States. Compared to other spine operations such as fusions, laminectomies in isolation are of lower morbidity. However, complications may arise that result in readmission to an inpatient healthcare facility.The purpose of this study is to identify the demographics and risk factors associated with unplanned 30-day readmission following a laminectomy. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients who underwent a laminectomy procedure from 2015 to 2019 using CPT code 63030. This query yielded 61,708 cases. Demographic, lifestyle, comorbidity, and peri-operative factors were recorded. Independent samples Student's t-tests, chi-squared, and, where appropriate, Fisher's exact tests were used in univariate analyses to identify demographic, lifestyle, and peri-operative variables related to 30-day readmission following a laminectomy procedure. Multivariate logistic regression modeling was subsequently performed. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated and reported. Results Of the 61,708 patients included in our sample, 2,359 were readmitted within 30 days of surgery, corresponding to a readmission rate of 3.82%. Results of the univariate analysis revealed statistically significant relationships between readmission status and the following patient variables: patient age, sex, BMI, ASA classification, race, bleeding disorder, chronic obstructive pulmonary disease (COPD), diabetes, hypertension, congestive heart failure (CHF), chronic steroid use, total operative time, and tobacco use (p < 0.05). Multivariate logistic regression modeling confirmed that the following patient variables were associated with statistically significantly increased odds of readmission: age greater than 65 (p < 0.05), female sex (p = 0.013), bleeding disorder (p = 0.011), diabetes (p = 0.006), current smoker (p = 0.010), COPD (p < 0.001), steroid use (p = 0.006), ASA Class II or above (p < 0.05), and total operative time (p < 0.001). Conclusion Unplanned 30-day readmission after laminectomy is infrequent. However, increasing age, female sex, steroid use, current smokers, bleeding disorders, diabetes, COPD, CHF, a higher ASA classification, and longer operative times are independent risk factors for readmission following laminectomy.

A component-based analysis of metabolic syndrome's impact on 30-day outcomes after hip fracture: reduced mortality in obese patients.

Hip fractures are a common injury associated with significant morbidity and mortality. In the United States, there has been a rapid increase in the prevalence of metabolic syndrome (MetS), a condition comprised several common comorbidities, including obesity, diabetes mellitus, and hypertension, that may worsen perioperative outcomes. This article assesses the impact of MetS and its components on outcomes after hip fracture surgery. Patients who underwent nonelective operative treatment for traumatic hip fractures were identified in the 2015-2020 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Baseline characteristics between groups were compared, and significant differences were included as covariates. Multivariate regression was performed to assess the impact of characteristics of interest on postoperative outcomes. Patients with MetS, or a single one of its constitutive components-hypertension, diabetes, and obesity-were compared with metabolically healthy cohorts. In total 95,338 patients were included. Patients with MetS had increased complications (OR 1.509; P < 0.001), but reduced mortality (OR 0.71; P < 0.001). Obesity alone was also associated with increased complications (OR 1.14; P < 0.001) and reduced mortality (OR 0.736; P < 0.001). Both hypertension and diabetes alone increased complications (P < 0.001) but had no impact on mortality. Patients with MetS did, however, have greater odds of adverse discharge (OR 1.516; P < 0.001), extended hospital stays (OR 1.18; P < 0.001), and reoperation (OR 1.297; P = 0.003), but no significant difference in readmission rate. Patients with MetS had increased complications but decreased mortality. Our component-based analysis showed had obesity had a similar effect: increased complications but lower mortality. These results may help surgeons preoperatively counsel patients with hip fracture about their postoperative risks.