American College Of Surgeons National Surgical Quality Improvement Project Research Articles

Inter-rater Reliability of ACS-NSQIP Colorectal Procedure Coding in Canada

BackgroundThe American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) uses Current Procedural Terminology (CPT) codes for risk-adjusted calculations. This study evaluates the inter-rater reliability of coding colorectal resections across Canada by ACS-NSQIP surgical clinical nurse reviewers (SCNR) and its impact on risk predictions. MethodsSCNRs in Canada were asked to code simulated operative reports. Percent agreement and free-marginal kappa correlation were calculated. The ACS-NSQIP risk calculator was utilized to illustrate its impact on risk prediction. ResultsResponses from 44 of 150 (29.3%) SCNRs revealed 3 to 6 codes chosen per case, with agreement ranging from 6.7% to 62.3%. Free-marginal kappa correlation ranged from moderate agreement (0.53) to high disagreement (-0.17). ACS-NSQIP risk calculator predicted absolute differences in risk for serious complications (0.2% to 13.7%) and mortality (0.2% to 6.3%). ConclusionThis study demonstrated low inter-rater reliability in coding ACS-NSQIP colorectal procedures in Canada among SCNRs, impacting risk predictions.

MP07-04 OUTCOMES AND PATIENT CHARACTERISTICS FOR SACROCOLPOPEXIES PERFORMED BY UROLOGY VS GYNECOLOGY

You have accessJournal of UrologyCME1 Apr 2023MP07-04 OUTCOMES AND PATIENT CHARACTERISTICS FOR SACROCOLPOPEXIES PERFORMED BY UROLOGY VS GYNECOLOGY Rishabh Simhal, Kerith Wang, Maria D'Amico, Courtney Capella, Radhika Ragam, Yash Shah, Joon Yau Leong, Whitney Smith, Patrick Shenot, and Alana Murphy Rishabh SimhalRishabh Simhal More articles by this author , Kerith WangKerith Wang More articles by this author , Maria D'AmicoMaria D'Amico More articles by this author , Courtney CapellaCourtney Capella More articles by this author , Radhika RagamRadhika Ragam More articles by this author , Yash ShahYash Shah More articles by this author , Joon Yau LeongJoon Yau Leong More articles by this author , Whitney SmithWhitney Smith More articles by this author , Patrick ShenotPatrick Shenot More articles by this author , and Alana MurphyAlana Murphy More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003222.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Sacrocolpopexies (SCP) are performed by both urologists and gynecologists; however, the majority are performed by gynecologists. We aim to elucidate if there is a difference in patient demographics and surgical outcomes based on surgeon specialty. METHODS: Open and minimally invasive SCPs performed between 2006-2020 were identified in the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database using CPTs 57280 and 57425. Frailty was calculated using the NSQIP modified frailty index (mFI-5), a previously validated 5-item score including points for diabetes, functional status, chronic obstructive pulmonary disease, heart failure, and hypertension, and the revised surgical Risk Analysis Index (RAI-rev), a validated score which accounts for patient comorbidities, age, and functional status. Univariate analysis was performed using student’s t-test and Pearson’s chi-square to compare operative parameters, patient frailty and demographics, surgical outcomes, and mortality. RESULTS: We identified 8,944 SCPs from 2006-2020. Gynecology performed 81% of cases, and urology performed 19% (p<.001). Urologists tended to perform more minimally invasive cases compared to gynecologists (84% vs 77%, p<.001). Between urologists and gynecologists, there were no significant differences in surgical outcomes, minor complications (surgical site infection, pneumonia, urinary tract infection, bleeding, or acute kidney injury), major complications (deep vein thrombosis, stroke, renal failure, myocardial infarction, pulmonary embolism, septic shock, deep wound infections, or cardiac arrest), 30-day reoperations, 30-day hospital readmissions, nor 30-day mortality. However, urology patients tended to be older (65 vs 61 years, p<.001) and frailer by mFI-5 (0.7 vs 0.5, p<.001, higher score indicating more frailty) and RAI-rev (19.4 vs 17.1, p<.001, higher score indicating more frailty). CONCLUSIONS: We found no difference in 30-day surgical outcomes for SCPs performed by urologists compared to gynecologists. However, urologists tend to perform more minimally invasive procedures and operate on older, more frail patients. This finding highlights differences in practice patterns between two specialties and warrants further studies. Source of Funding: n/a © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e85 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rishabh Simhal More articles by this author Kerith Wang More articles by this author Maria D'Amico More articles by this author Courtney Capella More articles by this author Radhika Ragam More articles by this author Yash Shah More articles by this author Joon Yau Leong More articles by this author Whitney Smith More articles by this author Patrick Shenot More articles by this author Alana Murphy More articles by this author Expand All Advertisement PDF downloadLoading ...

IBCOx-15 Bariatric surgery in patients with BMI greater than 70: analysis of the ACSNSQIP database

Abstract Background Bariatric surgery offers patients short- and long-term benefits to their health and quality of life. Currently, we see more patients with superior body mass index (BMI) looking for these benefits. Evidence-based medicine is integral in the evaluation of risks versus benefit; however, data are lacking in this high-risk population. Objectives To assess the morbidity and mortality of patients with BMI 70 undergoing bariatric surgery. Setting University Hospital, Bronx, New York, USA using national database. Methods Using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database for years 2005 to 2016, we identified patients who underwent primary laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass. Patients with BMI ≥70 were assigned to the BMI ≥ 70 (BMI70+) cohort and less obese patients were assigned to the BMI &amp;lt; 70 (U70) cohort. Length of stay and 30-day morbidity and mortality were compared. Results A total of 163,413 patients underwent non-revisional bariatric surgery. Of those, 2322 had a BMI ≥ 70. BMI70+ was associated with increased mortality (0.4% versus 0.1%, P 5.0001), deep vein thrombosis (0.6% versus 0.3%, P 5.007), pulmonary (1.9% versus 0.5%, P 5.0001), renal (0.9% versus 0.2%, P 5.0001), and infectious complications (1.1% versus .4%, P 5 .0001). BMI 70+ patients had longer mean length of stay (2.6 versus 2.1 d, P 5.0001) and operative time (126.1 versus 114.5 min, P 5.0001). There was no statistically significant difference in the number of myocardial infarctions (0.1% versus 0.1%, P 5.319), pulmonary embolisms (0.3% versus 0.2%, P 5.596), and transfusion requirements (0.1% versus 0.1%, P 5.105) between groups. Conclusions Evaluation of risk and benefit is performed on a case-by-case basis, but evidence-based medicine is critical in empowering surgeons and patients to make informed decisions. The overall rate of morbidity and mortality for BMI 701+ patients undergoing bariatric surgery was increased over U70 patients but was still relatively low. Our study will allow surgeons to incorporate objective data into their assessment of risk for super-obese patients pursuing bariatric surgery.

First 30 Days Wound-Related Complications in Young Smokers Following Primary Achilles Repair

The Achilles tendon is frequently injured in the young to middle aged population. Previous studies have shown that there is an increased risk of delay in postsurgical wound healing amongst tobacco smoking patients with Achilles tendon injury.This study utilized the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. We included patients between the ages of 18 and 35 years who underwent primary Achilles tendon repair between years 2011 and 2020. The procedure type (with or without graft, CPT 27650 and 27652), patient demographics, and comorbidities were included. Primary outcomes of interest were 30-day readmission, minor complications, outcomes related to wound healing (wound disruption, superficial surgical site infection, deep incisional surgical site infection, organ-space site infections) and reoperations within 30 days of index surgery.A total of 1944 patients met the inclusion criteria for this study. One thousand six hundred and fifty-nine patients were nonsmokers, while 285 were smokers. Logistic regression showed no differences between smokers and nonsmokers (reference group) for 30-day readmission, reoperation, and minor complications. However, Black non-Hispanic patients were found to be 0.3 times (95% confidence interval: 0.1, 0.98) as likely to develop minor complications as compared to the White non-Hispanic patients.Wound-related complications after Achilles tendon repair remain low in younger (18-35 years) patients. When comparing clinical outcomes between nonsmokers and smokers, we found no statistically significant difference in this retrospective study.

Multi-Level Posterior Cervical Foraminotomy Associated With Increased Post-operative Infection Rates and Overall Re-Operation Relative to Anterior Cervical Discectomy With Fusion or Cervical Disc Arthroplasty.

Retrospective Cohort Study. Cervical radiculopathy meeting operative criteria has traditionally been managed using anterior cervical discectomy and fusion (ACDF). However, cervical disc arthroplasty (CDA) and posterior cervical foraminotomy (PCF) are also reasonable options. This study aimed to assess differences in postoperative outcomes among patients undergoing multi-level ACDF, CDA, or PCF comparing medical/surgical complications and healthcare utilization parameters. Patients who underwent multi-level ACDF, CDA, or PCF between 2012 and 2019 were identified from the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. Patients were stratified based on procedure type and propensity score matched to resolve baseline differences. ANOVA was performed to identify differences in medical complications, surgical complications, and healthcare utilization metrics. A total of 31344 patients who underwent an eligible procedure were identified (ACDF: n = 28089, CDA: n = 1748, PCF: n = 1507), and 684 patients remained in each group following propensity score matching. Patients undergoing multi-level PCF were found to experience longer lengths of hospital stay (PCF: 1.67 ± 1.61days, ACDF: 1.50 ± 1.32days, CDA: 1.27 ± 1.05days, P < .001), higher rates of reoperation (PCF: 3.2%, ACDF: 1.0%, CDA: .4%, P = .020), superficial infection (PCF: 1.3%, ACDF: .3%, CDA: .1%, P = .008) and deep infection (PCF: 1.2%, ACDF: 0%, CDA: 0%, P < .001). There were no outcome differences between multi-level ACDF and CDA. Patients undergoing multi-level PCF were at increased risk for longer hospital stay, re-operation, and infection relative to those undergoing ACDF and CDA. Future research should aim to uncover the precise mechanisms underlying these complications, as well as analyze long term outcomes. III.

Postoperative pneumonia after bariatric surgery during the COVID-19 pandemic: a National Surgical Quality Improvement Program study.

BackgroundDuring the COVID-19 pandemic, surgical centers had to weigh the benefits and risks of conducting bariatric surgery. Obesity increases the risk of developing severe COVID-19 infections, and therefore, bariatric surgery is beneficial. In contrast, surgical patients who test positive for COVID-19 have higher mortality rates.ObjectiveThis study investigates the national prevalence of postoperative pneumonia during the COVID-19 pandemic in the bariatric surgery population.SettingThe American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database.MethodsThis is a cross-sectional study using the ACS-NSQIP database. The population of concern included patients who underwent sleeve gastrectomy and Roux-en-Y gastric bypass procedures. Information was extracted on rate of postoperative pneumonia and other 30-day complications between 2018 and 2020.ResultsAll baseline characteristics were similar among patients who underwent bariatric surgery between 2018 and 2020. However, there was a 156% increase in postoperative pneumonia in 2020 compared with the previous year. Furthermore, despite the similar postoperative complication rates across the years, there was a statistically significant increase in all-cause mortality in 2020. The multivariate analysis showed that having surgery in 2020 was a statistically significant risk factor for pneumonia development postoperatively.ConclusionsThis study showed a statistically significant increase in the prevalence of postoperative pneumonia during the COVID-19 pandemic among bariatric surgery patients. Surgical centers must continuously evaluate the risks associated with healthcare-associated exposure to COVID-19 and weigh the benefits of bariatric surgery.

Risk Factors for Surgical Site Infection in the Undeserved Population After Ventral Hernia Repair: A 3936 Patient Single-Center Study Using National Surgical Quality Improvement Project

Background: Ventral hernia repair (VHR) is one of the most common surgical procedures performed in the United States. Surgical site infections (SSI) carry significant morbidity for the patient and pose a very challenging problem for the surgeon, associated with up to 6.6% of cases. Thus, surgeons should be well versed in the risk factors implicated in SSI after VHR. Given the high burden of diabetes, obesity, and smoking in our patient population, we sought to study the rate of SSI and the risk factors that led to SSI in our population. Study Design: This is a retrospective study using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database for the years 2014-2019. We identified patients who underwent VHR at a single institution in the Bronx, New York. The rate of SSI was calculated, and then, risk factors for SSI were identified using logistic regression analysis. Results: A total of 3936 patients underwent VHR. Incisional hernias made up 41% of the cohort, and there were 37.4% laparoscopic repairs. During the 30-day follow-up, SSI was identified in 101 patients (2.6%). Factors associated with SSI include emergent surgery (adjusted odds ratio [aOR] = 2.57), body mass index >35 kg/m2 (aOR = 2.38), insulin-dependent diabetes mellitus (aOR = 2.36), and incisional hernia (aOR = 1.81). In addition, a laparoscopic approach was found to be a protective factor (aOR = 0.43, 95% confidence interval 0.25-0.75). Surprisingly, different from other studies, smoking cigarettes was not associated with SSI in our cohort. Conclusions: The rate of SSI after VHR in our institution is 2.6%, which is within that reported in the literature. Most of the variables associated with SSI are modifiable and are similar to those previously reported. Laparoscopic repairs appear to be protective for its occurrence.

Surgical Outcomes in Canada and the United States: An Analysis of the ACS-NSQIP Clinical Registry.

There has been longstanding uncertainty over whether lower healthcare spending in Canada might be associated with inferior outcomes for hospital-based care. We hypothesized that mortality and surgical complication rates would be higher for patients who underwent four common surgical procedures in Canada as compared to the US. We conducted a retrospective cohort study of all adults who underwent hip fracture repair, colectomy, pancreatectomy, or spine surgery in 96 Canadian and 585 US hospitals participating in the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) between January 1, 2015 and December 31, 2019. We compared patients with respect to demographic characteristics and comorbidity. We then compared unadjusted and adjusted outcomes within 30-days of surgery for patients in Canada and the US including: (1) Mortality; (2) A composite constituting 1-or-more of the following complications (cardiac arrest; myocardial infarction; pneumonia; renal failure/; return to operating room; surgical site infection; sepsis; unplanned intubation). Our hip fracture cohort consisted of 21,166 patients in Canada (22.3%) and 73,817 in the US (77.7%), for colectomy 21,279 patients in Canada (8.9%) and 218,307 (91.1%), for pancreatectomy 873 (7.8%) in Canada and 12,078 (92.2%) in the US, and for spine surgery 14,088 (5.3%) and 252,029 (94.7%). Patient sociodemographics and comorbidity were clinically similar between jurisdictions. In adjusted analyses odds of death was significantly higher in Canada for two procedures (colectomy (OR 1.22; 95% CI 1.044-1.424; P = .012) and pancreatectomy (OR 2.11; 95% CI 1.26-3.56; P = .005)) and similar for hip fracture and spine surgery. Odds of the composite outcome were significantly higher in Canada for all 4 procedures, largely driven by higher risk of cardiac events and post-operative infections. We found evidence of higher rates of mortality and surgical complications within 30-days of surgery for patients in Canada as compared to the US.

Comparing Characteristics and Postoperative Outcomes of Hysterectomy for Endometriosis Versus Other Benign Indications: A NSQIP Study

<h3>Study Objective</h3> Endometriosis is known to cause mild to significant intra-abdominal adhesions, theoretically making surgical procedures more challenging. However, little comparative surgical outcomes data is available. <h3>Design</h3> The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database was searched from 2018 to 2019 for all total hysterectomies. Hysterectomies for malignant conditions, emergent cases, and cases with pre-operative morbidity were excluded. Univariate comparisons were made between patients with hysterectomies for endometriosis vs other benign indications (abnormal bleeding, leiomyoma, prolapse, and pelvic pain). Unadjusted and adjusted logistic regression models were used to investigate the association between primary outcomes and hysterectomy indication, with covariates in the adjusted model including age, race, ethnicity and surgical route. <h3>Setting</h3> Within 30 days post operative. <h3>Patients or Participants</h3> Patients undergoing hysterectomy 18-55 years old. <h3>Interventions</h3> Hysterectomy. <h3>Measurements and Main Results</h3> A total of 29,742 women underwent hysterectomies, of which 3,596 (12.1%) were performed for endometriosis. Patients undergoing hysterectomy for endometriosis were statistically likely to be younger, predominately white, and had lower BMI. They were also more likely to have had prior abdominal surgery, prior pelvic surgery, undergo a laparoscopic approach, and undergo lysis of adhesions (all p<0.001). Overall length of stay (1.1 vs 1.2 days, p<0.001) and operative time (130.8 vs 136.8 minutes, p<0.001) were lower in patients undergoing hysterectomy for endometriosis. Examining primary outcomes, patients with endometriosis were more likely to experience major morbidity (AOR 1.25, p=0.033), with no difference in minor morbidity (p=0.87). There were two mortalities. Endometriosis patients were more likely to develop deep surgical site infection (SSI) (OR 1.42, p=0.004), and less likely to receive blood transfusion (OR 0.58, p<0.001). There was no significant difference in occurrence of superficial SSI, sepsis, venous thromboembolism, readmission or re-operation between groups. <h3>Conclusion</h3> Patients undergoing hysterectomy for endometriosis were more likely to experience major morbidity and deep surgical site infection compared to patients with other benign indications.

Predictive validity of American College of Surgeons: National Surgical Quality Improvement Project risk calculator in patients with ovarian cancer undergoing interval debulking surgery

IntroductionIn gynecologic patients, few studies describe the accuracy of the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) pre-operative risk calculator for women undergoing surgery for ovarian cancer.ObjectiveTo determine...

The 5-Factor Modified Frailty Index as a Predictor of 30-day Complications in Pressure Ulcer Repair

The 5-item modified frailty index (mFI-5) is a validated tool to assess postoperative risks in older surgical candidates. We sought to compare the predictive ability of mFI-5 to its individual components and other established risk factors for complications in flap reconstruction of late-stage pressure ulcer repair. The 2012 to 2018 American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database was queried for pressure ulcer diagnosis and reconstructive flap repair procedures. Univariate and multivariate regression analysis models were used to assess how mFI-5, the components of the mFI-5 (functional status before surgery, diabetes, history of chronic obstructive pulmonary disease, history of congestive heart failure, and history of hypertension requiring medicine), and other factors commonly used to risk-stratify (age, obesity, ASA classification, and history of smoking) were associated with complications. 35.1% of the total 1254 flap reconstructive procedures for pressure ulcer repair experienced complications. Most cases had at least one of the five mFI-5 factors in both the complication (42.7%) and no complication (45.7%) cohorts. Compared with the factors making up the mFI-5 score and other common variables used to risk-stratify, mFI-5 was significantly associated with complications in the univariate (OR 1.17, CI 1.03 - 1.33; P=0.02) and multivariate analysis (OR 1.16, CI 1.02 - 1.34; P=0.043). The mFI-5 is a useful predictor of postoperative outcomes in patients undergoing reconstructive flap surgery for pressure ulcer injuries compared to other historically considered risk factors for surgical complications.

Abdominal Wall Thickness is a Predictor for Surgical Site Infections in Patients Undergoing Colorectal Operations.

Surgical site infections (SSIs) are an established complication following colorectal operations, with rates up to 30% reported in the literature. Obesity is a known risk factor for SSI; however, body mass index (BMI), body fat percentage, waist-hip ratio, or abdominal circumference are imperfect measures. The purpose of our study was to determine whether abdominal wall thickness (AWT) is predictive of SSI. We queried our American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database for patients (age ≥18years) undergoing a colectomy at the University of Kentucky (UK) from January 1, 2013 to December 31, 2018. The exclusion criteria included patients with open abdomens or the lack of preoperative computed tomography (CT) within 3months of their operation. AWT was measured at the level of the anterior superior iliac spine (ASIS) on abdominal CT. SSI was defined by superficial SSI, deep SSI, and wound dehiscence. Of 1261 patients enrolled, 52.2% were female, with an average age of 57.4years. More patients had laparoscopic operations (51%), and the median length of stay was 7days. Our study demonstrated an SSI rate of 9.4% and a 30-day readmission rate of 11%. The overall mean AWT was 2.6cm (range .1-13.1), and patients with the highest AWT quintile were more likely to develop an SSI than the lowest quintile (12% vs. 5%). After controlling for risk factors and confounders, the odds of an SSI were 3.6 times higher for patients with the highest AWT than patients with the lowest AWT. Among colorectal surgery patients, AWT is an independent risk factor predictive for SSI.

Development of a Risk Prediction Model With Improved Clinical Utility in Elective Cervical and Lumbar Spine Surgery

Retrospective cohort. We present a universal model of risk prediction for patients undergoing elective cervical and lumbar spine surgery. Previous studies illustrate predictive risk models as possible tools to identify individuals at increased risk for postoperative complications and high resource utilization following spine surgery. Many are specific to one condition or procedure, cumbersome to calculate, or include subjective variables limiting applicability and utility. A retrospective cohort of 177,928 spine surgeries (lumbar (L) Ln = 129,800; cervical (C) Cn = 48,128) was constructed from the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. Cases were identified by Current Procedural Terminology (CPT) codes for cervical fusion, lumbar fusion, and lumbar decompression laminectomy. Significant preoperative risk factors for postoperative complications were identified and included in logistic regression. Sum of odds ratios from each factor was used to develop the Universal Spine Surgery (USS) score. Model performance was assessed using receiver-operating characteristic (ROC) curves and tested on 20% of the total sample. Eighteen risk factors were identified, including sixteen found to be significant outcomes predictors. At least one complication was present among 11.1% of patients, the most common of which included bleeding requiring transfusion (4.86%), surgical site infection (1.54%), and urinary tract infection (1.08%). Complication rate increased as a function of the model score and ROC area under the curve analyses demonstrated fair predictive accuracy (lumbar = 0.741; cervical = 0.776). There were no significant deviations between score development and testing datasets. We present the Universal Spine Surgery score as a robust, easily administered, and cross-validated instrument to quickly identify spine surgery candidates at increased risk for postoperative complications and high resource utilization without need for algorithmic software. This may serve as a useful adjunct in preoperative patient counseling and perioperative resource allocation. 3.

Bariatric surgery in the super-super morbidly obese: outcome analysis of patients with BMI >70 using the ACS-NSQIP database.

Bariatric surgery offers patients short- and long-term benefits to their health and quality of life. Currently, we see more patients with superior body mass index (BMI) looking for these benefits. Evidence-based medicine is integral in the evaluation of risks versus benefit; however, data are lacking in this high-risk population. To assess the morbidity and mortality of patients with BMI ≥70 undergoing bariatric surgery. University Hospital, Bronx, New York, United States using national database. Using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database for years 2005 to 2016, we identified patients who underwent primary laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass. Patients with BMI ≥70 were assigned to the BMI >70 (BMI70+) cohort and less obese patients were assigned to the BMI <70 (U70) cohort. Length of stay and 30-day morbidity and mortality were compared. A total of 163,413 patients underwent non-revisional bariatric surgery. Of those, 2322 had a BMI ≥70. BMI70+ was associated with increased mortality (.4% versus .1%, P = .0001), deep vein thrombosis (.6% versus .3%, P = .007), pulmonary (1.9% versus .5%, P = .0001), renal (.9% versus .2%, P = .0001), and infectious complications (1.1% versus .4%, P = .0001). BMI70+ patients had longer mean length of stay (2.6 versus 2.1 d, P = .0001) and operative time (126.1 versus 114.5 min, P= .0001). There was no statistically significant difference in the number of myocardial infarctions (.1% versus .1%, P = .319), pulmonary embolisms (.3% versus .2%, P = .596), and transfusion requirements (.1% versus .1%, P = .105) between groups. Evaluation of risk and benefit is performed on a case-by-case basis, but evidence-based medicine is critical in empowering surgeons and patients to make informed decisions. The overall rate of morbidity and mortality for BMI70+ patients undergoing bariatric surgery was increased over U70 patients but was still relatively low. Our study will allow surgeons to incorporate objective data into their assessment of risk for super-obese patients pursuing bariatric surgery.

Impact of Preoperative Care for Rectal Adenocarcinoma on Pathologic Specimen Quality and Postoperative Morbidity: A NSQIP Analysis

Comprehensive and multidisciplinary care are critical in rectal cancer treatment. We sought to determine if completeness of preoperative care was associated with pathologic specimen quality and postoperative morbidity. Clinical stage I-III rectal adenocarcinoma patients who underwent elective low anterior resection or abdominoperineal resection were identified from the 2016-2017 American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) database. The 3 preoperative NSQIP variables (colonoscopy, stoma marking, and neoadjuvant chemoradiation) were used to divide patients into 2 cohorts: complete vs incomplete preoperative care. The primary outcome was a composite higher pathologic specimen quality score (>12 lymph nodes, negative circumferential, and negative distal margins). The secondary outcome was 30-day morbidity. Preoperative characteristics were compared with ANOVAs and chi-square tests. Outcomes measures were evaluated with logistic regression. We identified 1,125 patients: 591 (52.5%) complete and 534 (47.5%) incomplete. The complete group was younger, had more women, lower-third rectal tumors, clinical stage III disease, and neoadjuvant treatment. The complete group had higher odds of better pathologic specimen quality after adjusting for age, sex, tumor location, stage, and neoadjuvant therapy (adjusted odds ratio [aOR] 1.75, p= 0.001). The complete group had decreased rates of transfusions (odds ratio [OR] 0.47, p < 0.001), postoperative ileus (OR 0.67, p= 0.01), sepsis (OR 0.32, p= 0.01), and readmissions (OR 0.60, p= 0.003). Other complications did not statistically differ between groups. Complete preoperative care in rectal adenocarcinoma is associated with higher pathologic specimen quality and reduced postoperative morbidity. This highlights the importance of adherence to guideline-directed care.

The ACS National Surgical Quality Improvement Program-Inflammatory Bowel Disease Collaborative: Design, Implementation, and Validation of a Disease-specific Module.

Surgery for inflammatory bowel disease (IBD) involves a complex interplay between disease, surgery, and medications, exposing patients to increased risk of postoperative complications. Surgical best practices have been largely based on single-institution results and meta-analyses, with multicenter clinical data lacking. The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) has revolutionized the way in which large-volume surgical outcomes data have been collected. Our aim was to employ the ACS-NSQIP to collect disease-specific variables relevant to surgical outcomes in IBD. A collaborative of 13 high-volume IBD surgery centers was convened to collect 5 IBD-specific variables in NSQIP. Variables included biologic and immunomodulator medications usage, ileostomy utilization, ileal pouch anastomotic technique, and colonic dysplasia/neoplasia. A sample of the Surgical Clinical Reviewer collected data was validated by a colorectal surgeon at each institution, and kappa's agreement statistics generated. Over 1 year, data were collected on a total of 956 cases. Overall, 41.4% of patients had taken a biologic agent in the 60 days before surgery. The 2 most commonly performed procedures were laparoscopic ileocolic resections (159 cases) and subtotal colectomies (151 cases). Overall, 56.8% of cases employed an ileostomy, and 134 ileal pouches were constructed, of which 92.4% used stapled technique. A sample of 214 (22.4%) consecutive cases was validated from 8 institutions. All 5 novel variables were shown to be reliably collected, with excellent agreement for 4 variables (kappa ≥ 0.70) and very good agreement for the presence of colonic dysplasia (kappa = 0.68). We report the results of the initial year of implementation of the first disease-specific collaborative within NSQIP. The selected variables were demonstrated to be reliably collected, and this collaborative will facilitate high-quality, large case-volume research specific to the IBD patient population.

Analysis of Facial Reanimation Procedures Performed Concurrently With Total Parotidectomy and Facial Nerve Sacrifice.

Facial reanimation procedures share the same surgical field as a parotidectomy and are most easily accomplished at the time of facial nerve sacrifice. Early reanimation would also reduce the duration of paralysis and may lead to better functional outcomes. To assess the incidence and types of facial nerve reanimation performed concurrently with total parotidectomy and facial nerve sacrifice using the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. This cross-sectional study identified 285 patients who underwent total parotidectomy with facial nerve sacrifice (Current Procedural Terminology code 42425) and evaluated the various types of facial reanimation procedures performed concurrently. Patients were identified from the ACS-NSQIP database encompassing 603 community and academic hospitals and underwent treatment from January 1, 2010, through December 31, 2015. Data were analyzed from September 20, 2017, through February 21, 2018. Comparison of demographics in nonreanimation and reanimation groups and subgroups of nerve- and sling-type reanimation procedures. Of 285 patients who underwent total parotidectomy with facial nerve sacrifice (61.8% men; mean [SD] age, 64 [15] years), 89 (31.2%; 95% CI, 26.0%-37.0%) underwent at least 1 concurrent facial reanimation procedure. Of the facial nerve procedures performed, 41 (46.1%; 95% CI, 36.0%-56.0%) were nerve-type repairs, 31 (34.8%; 95% CI, 26.0%-45.0%) were sling-type repairs, and 17 (19.1%; 95% CI, 12.0%-29.0%) included both types. Patients treated with nerve-type repairs only were significantly younger than those treated with sling-type repairs only (mean [SD] age, 57.6 [16.0] vs 72.1 [13.8] years; P < .001). Forty-nine patients underwent free tissue reconstruction. Of those, 24 patients (49.0%) had concurrent facial reanimation procedure(s) performed; this proportion was significantly more than those who did not undergo free tissue reconstruction (65 of 236 [28.0%]; P = .003). In patients undergoing total parotidectomy with facial nerve sacrifice, many are not receiving a concurrent facial reanimation procedure at the time of their tumor resection. Those patients who underwent free tissue reconstruction were significantly more likely to receive a concurrent facial reanimation procedure. These findings may reveal an opportunity for earlier facial reanimation in this patient population. NA.

Using the National Surgical Quality Improvement Project (NSQIP) to Perform Clinical Research in Colon and Rectal Surgery.

The American College of Surgeons' National Surgical Quality Improvement Project (ACS-NSQIP) is probably the most well-known surgical database in North American and worldwide. This clinical database was first proposed by Dr. Clifford Ko, a colorectal surgeon, to the ACS, and NSQIP first started collecting data ca. 2005 with the intent of comparing hospitals (benchmarking) and for hospital-level quality improvement projects. Since then, its popularity has grown from just a few participating hospitals in the United States to more than 708 participating hospitals worldwide, and collaboration allows regional or disease-specific data sharing. Importantly, from a methodological perspective, as the number of hospitals has grown so has the hospital heterogeneity and thus generalizability of the results and conclusions of the individual studies. In this article, we will first briefly present the structure of the database (aka the Participant User File) and other important methodological considerations specific to performing clinical research. We will then briefly review and summarize the approximately 60 published colectomy articles and 30 published articles on proctectomy. We will conclude with future directions relevant to colorectal clinical research.

Thursday, September 27, 2018 1:05 PM–2:05 PM Lumbar Spine Surgery: What You Need to Know: 113. Routine microscope use does not increase operative time or affect short term outcomes in single-level lumbar microdecompression

BACKGROUND CONTEXT Lumbar microdecompression is one of the most common procedures in orthopedic spine surgery with an overall low complication and high satisfaction rate. The procedure is typically performed with visualization aids, either loupes or an operating room microscope. Several studies to date have investigated differences between these two magnification tools, with conflicting results. Some authors argue in favor of the microscope, citing improved visualization, better ergonomics and improved patient outcomes, while others argue that its use makes no clinical difference. These studies consist primarily of small patient cohorts numbering 50-100 subjects. PURPOSE The purpose of this study is to determine how the routine use of an operating room microscope during single level lumbar microdecompression impacts intraoperative and short-term surgical outcomes through an examination of the largest retrospective cohort to date. STUDY DESIGN/SETTING Retrospective review of American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. PATIENT SAMPLE A total of 43,948 patients who underwent single level lumbar microdecompression from 2005 to 2015. OUTCOME MEASURES Assessment of surgical benchmarks of operative time and length of hospital stay as well as differences in early (30 day) complication rates. The specific complications evaluated included the need for blood transfusion, return to the operating room, pulmonary embolism, deep venous thrombosis, sepsis, cerebrovascular accident, cardiac arrest, ventilator time greater than 48 hours, urinary tract infection, pneumonia, myocardial infarction, surgical site infections, and patient mortality. METHODS Using the ACS-NSQIP database, we identified all patients who underwent single level lumbar microdecompression (CPT 63030). They were divided into two cohorts, those cases that involved the use of an operating room microscope (CPT 69990), and those that did not. We compared intraoperative and postoperative procedural data as well as the incidences of local and systemic complications. RESULTS The ACS-NSQIP database identified 43,948 patients who underwent single level lumbar microdecompression from 2005 to 2015. Of that patient cohort 4,654 cases included the use of an operating room microscope. There were no clinically significant demographic differences between patient cohorts. We identified clinically important statistical differences in length of stay (1.37 vs. 1.75 days, p CONCLUSIONS The routine use of an operating room microscope in single level lumbar microdecompression does not affect short-term patient outcomes. Importantly, there is no difference in mean operative time or infection rate with the addition of a microscope. There is a statistically significant trend toward decreased length of stay and fewer blood transfusions in the microscope cohort; however, in the setting of a large database study and small absolute differences, the clinical implications of these findings are difficult to interpret. Based on these results, we conclude that the decision to use an operating room microscope in single level lumbar microdecompression should be left to the treating surgeon and based upon considerations of improvements in visualization, surgeon ergonomics and ability to educate surgical assistants. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Impact of Operative Times and Mesh Utilization on Paraesophageal Hernia Repair: Analysis of 30-Day Outcomes from the American College of Surgeons National Surgical Quality Improvement Project Database.

Using mesh to buttress the crural repair following a paraesophageal hernia repair remains controversial. This article evaluates recent trends in laparoscopic paraesophageal hernia repairs and analyzes the impact of mesh and operative time on postoperative morbidity. The 2013-2015 American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database was queried for elective laparoscopic paraesophageal hernia repair with and without mesh. Operative times were grouped into quartiles and statistical analysis was performed using analysis of variance univariate with post hoc testing and multivariate regression modeling. The outcomes of interest were composite morbidity scores and readmission rates within 30 days of surgery. The database identified a cohort of 6234 laparoscopic paraesophageal hernia repairs. Mesh was utilized in 42% of cases per year and did not change over the study period (P = .367). Mesh was used 37%, 40%, 43%, and 49% of the time within operative quartiles 1, 2, 3, and 4, respectively (P < .001). Postoperative morbidity and readmission rates for each operative time quartile were 2.8%, 4.1%, 5.42%, and 6.13% (P < .001) and 4.4%, 5%, 6.2%, and 7.6% (P = .001), respectively. Post hoc testing indicated statistically significant differences in postoperative morbidity and readmission rates between quartiles 1 and 3/4. Multivariate regression analysis documented operative time as a risk factor for postoperative morbidities and readmission. Simply using mesh was not directly associated with postoperative morbidity. Mesh utilization does not impact postoperative outcomes; however, as operative time increases, the incidence of postoperative morbidity also increases.