Days Of Index Surgery Research Articles

Encephalography guidance of anesthesia to alleviate geriatric syndromes (Engages-Canada) study in cardiac surgery patients: a pragmatic, randomized clinical trial

Introduction Postoperative delirium (POD) is a syndrome characterized by an acute onset of fluctuating confusion, disorganization and inattention. POD is frequent in the cardiac surgery population (incidence between 11-50%), and associated to complications such as increased risk of falls, prolonged hospital stay, functional decline and increased morbidity and mortality. Risk factors for POD are often non-modifiable, such as age, male sex, underlying cognitive or psychiatric conditions, while risk factors more specific to the cardiac surgery population include the type of surgery, cardiopulmonary bypass time, transfusions, and mechanical ventilation time15-18. Recent studies suggest that the use of a processed EEG for titration of anesthesia may reduce the incidence of POD. Burst suppression, or the pathological patterns of high-voltage electrical activity alternating with periods of quiescence may be associated with POD. Our primary objective is to demonstrate whether guiding anesthesia depth using an EEG monitor to avoid episodes burst suppression can result in a decreased incidence and severity of delirium in the cardiac surgery population. Secondly, we want to examine contributing risk factors and sequelae of delirium. Methods ENGAGES-Canada is an ongoing multi-center, double-blinded, randomized controlled trial across 4 Canadian sites. Patients included are those over the age of 60 scheduled for elective cardiac surgery with cardiopulmonary bypass. Exclusion criteria are pre-operative delirium, illiteracy, history of awareness, and planned surgery within five days of index surgery. Using an anesthesia protocol for EEG-guided anesthesia to avoid burst suppression, patients are randomized to the intervention or the control group (non-utilization of the monitor). The primary outcome is defined as the incidence of postoperative delirium, assessed using the Confusion Assessment Method (CAM) or CAM-ICU, coupled with chart review from day 1 to 5. Secondary outcomes include the effect of known risk factors on the incidence of delirium and 30-day and 1-year patient-reported outcomes of health-related quality of life and prevention of falls. Results Current enrollment includes 600 patients, out of a target population of 1200. An interim analysis was performed at 570 patients. The incidence of delirium across all subjects was 17.5% when considering CAM alone. Patients in the EEG-blinded group spent more cumulative time in burst suppression than those guided by EEG: median 317 seconds versus 136 seconds in the blind and guided groups respectively. Discussion ENGAGES-CANADA is the first RCT to examine whether avoidance of burst suppression using EEG guidance can decrease the incidence and severity of delirium in a cardiac surgery population.

Complications of Spine Surgery in Elderly Japanese Patients: Implications for Future of World Population Aging.

ObjectiveTo analyze the relationship between age and perioperative complications of spine surgery in a Japanese cohort with the longest average life expectancy in the world. MethodsPatients with spinal stenosis who underwent standard spine surgery without instrumented fusion were divided into 4 groups: adults (20–64 years), the young-old (65–74), the middle old (75–84), and the oldest-old (≥85). Data on medical complications, surgical complications, and deaths within 30 days of index surgery were compared across the groups. Risk factors for complications were identified through multivariate analysis. ResultsA total of 584 patients underwent 673 operations: 35% were performed on adult patients, 33% on the young-old, 27% on the middle old, and 5% on the oldest-old. The rates of total or [major] medical complications significantly increased with age (8% [0.8%], 11% [0.9%], 27% [3.9%], 45% [9.1%], respectively; p<0.001 [p=0.003]), whereas those of surgical complications did not differ (11%, 8.1%, 14%, 9.1%, respectively; p=0.25). Independent risk factors for medical complications were an age of 75 years or older (75–84: odds ratio [OR], 5.1; ≥85: OR, 6.2) and American Society of Anesthesiologists (ASA) physical status classification III (OR, 5.4). Two patients older than 85 years died from medical complications. ConclusionThe complications of spine surgery increased in the middle and oldest-old patients because of medical complications; however, most were minor and treatable. Major complications were associated with preoperative medical comorbidities and their severities; therefore, most elderly patients with low ASA physical status classification (≤II) may benefit from spine surgery.

Perioperative complications and Intensive Care Unit utilization in super-superobese patients undergoing laparoscopic bariatric surgery.

Objective:Anesthetic management for super-superobese (SSO) patients (body mass index [BMI] ≥60 kg/m2) presents a challenge for anesthesiologists. This study aimed at characterizing the early complications and Intensive Care Unit (ICU) utilization in SSO patients receiving laparoscopic bariatric surgery.Materials and Methods:Totally, 25 SSO patients receiving laparoscopic bariatric surgery between June 2006 and December 2011 were reviewed. The data collected included patient demographics, preoperative comorbidities, anesthetic techniques, airway management, perioperative adverse events, ICU utilization, and early complications occurring within 30 days of index surgery. Early complications were defined as the adverse events that led to permanent detrimental effects or required significant additional intervention.Results:A retrospective analysis was performed on data from 25 consecutive SSO patients (age: 31.2 ± 11.1 years; BMI: 64.9 ± 4.7 kg/m2). Tracheal intubation was attempted successfully in all patients but was difficult in two cases when using laryngoscopy. Bronchospasm was observed in five cases (20%) after tracheal intubation. Postoperative ICU utilization was required in five cases (20%). Early complications occurred in two cases during their stay in postanesthesia care unit (including one case of respiratory failure and one case of hyperkalemia) and in two cases during their stay in ICU (both with respiratory failure). The incidence of early complications was 16%. All patients were discharged from the hospital without sequelae.Conclusions:It is imperative to anticipate the potential for developing perioperative adverse events and postoperative complications in SSO patients after bariatric surgery. Appropriate utilization of ICU resources may enhance patient safety.

Mini-Sternotomy Versus Conventional Sternotomy for Aortic Valve Replacement: Results from the MAVRIC Randomised Controlled Trial

Background: While Aortic Valve Replacement (AVR) outcomes have improved, morbidity remains significant. Need for transfusion is a key indicator of quality; transfusions are linked to prolonged hospital stay and increased mortality. Over one third of patients undergoing AVR via conventional median sternotomy require post-operative red-cell transfusion. Methods: MAVRIC was a single centre, single blind, randomised controlled trial, comparing AVR via manubrium-limited mini-sternotomy (intervention) and conventional median sternotomy (usual care) to assess the impact on post-operative red-cell transfusion. Patients were stratified by baseline logistic EuroSCORE and haemoglobin and followed for 12 weeks. The primary outcome was proportion of patients receiving red-cell transfusion within 7 days of index surgery. Findings: 271 patients were randomised using a central computer system with concealed allocation; 270 received surgery and contributed to the intention to treat analysis. No difference between intervention and usual care in red-cell transfusion within 7 days was found; 23/135 patients in each arm received a transfusion, odds ratio 1·0 (95% CI: 0·5, 2·0) and risk difference 0·0 (95% CI: -0·1, 0·1). Intervention reduced chest drain losses (mean 181·6ml (SD 138·7) vs usual care mean 306·9ml (SD 348·6)); this did not reduce red-cell transfusions. Mean valve size and postoperative valve function were comparable between intervention and usual care; 23mm vs 24mm, and 6/134 moderate or severe aortic regurgitation vs 3/130, respectively. Mini-sternotomy resulted in longer bypass times (82·7 minutes (SD 23·5) vs 59·6 minutes (SD 15·1)) and cross clamp times (64·1 minutes (SD 17·1) vs 46·3 minutes (SD 10·7)). Conventional sternotomy was more cost-effective with only a 5·8% probability of ministernotomy being cost-effective at a willingness to pay of £20,000/QALY. Interpretation: AVR via manubrium-limited mini-sternotomy did not reduce red blood cell transfusion within 7 days following index surgery when compared to conventional sternotomy. Clinical Trial Number: International Standard Randomised Controlled Trial Number (ISRCTN) ISRCTN29567910. Registered on 3 February 2014. Funding Statement: The trial was funded by the NIHR Research for Patient Benefit Programme (grant number PB-PG-1112-29035). GJM is supported by the British Heart Foundation (CH/12/1/29419) and the NIHR Leicester Biomedical Research Centre. Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: This protocol and all trial-related documents were originally approved by the National Research Ethics Service Committee, North East - Newcastle & North Tyneside 1 in March 2014 (IRAS Project 137295; REC Reference 14/NE/0005). Since initial approval, three amendments have been made and approved; thus, this is version 5 of the protocol. Written informed consent will be obtained from all participants. The trial will be run according to the principles of ICH-GCP and in accordance with relevant UK legislation and the protocol.

Complications and reoperations after surgery for 647 patients with spine metastatic disease

Background ContextPostoperative morbidity may offset the potential benefits of surgical treatment for spine metastatic disease; hence, risk factors for postoperative complications and reoperations should be taken into considerations during surgical decision-making. In addition, it remains unknown whether complications and reoperations shorten these patients' survival. PurposeWe aimed to describe and identify factors associated with having a complication within 30 days of index surgery as well as factors associated with having a subsequent reoperation. Furthermore, we assessed the effect of 30-day complications and reoperations on the patients' postoperative survival, as well as described neurologic changes after surgery. Study DesignRetrospective cohort study. Patient SampleWe included 647 patients 18 years and older who had surgery for metastatic disease in the spine between January 2002 and January 2014 in one of two affiliated tertiary care centers. Outcome MeasuresOur primary outcomes were complications within 30 days after surgery and reoperations until final follow-up or death. MethodsWe used multivariate logistic regression to identify risk factors for 30-day complications and reoperations. We used the Cox regression analysis to assess the effect of postoperative complications and reoperations on survival. ResultsFrom 647 included patients, 205 (32%) had a complication within 30 days. The following variables were independently associated with 30-day complications: lower albumin levels (odds ratio [OR]: 0.69, 95% confidence interval [CI]=0.49–0.96, p=.021), additional comorbidities (OR=1.42, 95% CI=1.00–2.01, p=.048), pathologic fracture (OR=1.41, 95% CI=0.97–2.05, p=.031), three or more spine levels operated upon (OR=1.64, 95% CI=1.02–2.64, p=.027), and combined surgical approach (OR=2.44, 95% CI=1.06–5.60, p=.036). One hundred and fifteen patients (18%) had at least one reoperation after the initial surgery; prior radiotherapy (OR=1.56, 95% CI=1.07–2.29, p=.021) to the spinal tumor was independently associated with reoperation. 30-day complications were associated with worse survival (hazard ratio [HR]=1.40, 95% CI=1.17–1.68, p<.001), and reoperation was not significantly associated with worse survival (HR=0.80, 95% CI=0.09–1.00, p=.054). Neurologic status worsened in 42 (6.7%), remained stable in 445 (71%), and improved in 140 (22%) patients after surgery. ConclusionsThree or more spine levels operated upon and prior radiotherapy should prompt consideration of a preoperative plastic surgery consultation regarding soft tissue coverage. Furthermore, if time allows, aggressive nutritional supplementation should be considered for patient with low preoperative serum albumin levels. Surgeons should be aware of the increase in complications in patients presenting with pathologic fracture, undergoing a combined approach, and with any additional preoperative comorbidities. Importantly, 30-day complications were associated with worsened survival.

Predictors of venous thromboembolism in patients with primary sarcoma of bone

Venous thromboembolism (VTE) is known to be independently associated with both orthopaedic surgery and malignancy. Patients undergoing surgery for musculoskeletal malignancies are at an increased risk for thromboembolic events. Although VTE can lead to serious morbidity and mortality, the potential complications of prophylactic anticoagulation call for a greater understanding of a patient's risk factors, as well as more rigorous guidelines for prophylactic anticoagulation regimens. The aims of this study were to 1) Analyze the rate of VTE in patients surgically treated for primary bone sarcoma; 2) Identify risk factors for VTE in patients with primary bone sarcoma; 3) Discuss the complications associated with prophylactic anticoagulation in patients with primary bone sarcoma. MethodsThis retrospective study identified all patients 18 years and older treated surgically at our institution for a primary bone sarcoma between 1990 and 2015. All patients with at least 90 days of post-operative follow-up from the index surgery were analyzed for occurrence of VTE. Those with an event were compared to those without to identify predictors of VTE. Results21 patients (5.5%) had a clinically symptomatic, radiographically confirmed VTE within 90 days of index surgery (12 DVT, 9 PE). Higher preoperative white blood cell count (OR 1.15, 95% CI 1.01–1.29) and post-operative wound complications (OR 5.01, 95% CI 1.93–13.55) were found to be independent risk factors for VTE. No differences in terms of efficacy were found among medications. The risk of wound complications increased significantly in patients who received chemical prophylaxis (OR 2.21, 95% CI 1.00–4.87). ConclusionsOur patient population had a relatively low rate of VTE as compared to the literature. Preoperative white blood cell count (WBC) and post-operative wound complications were both found to be independently associated predictors for VTE in patients with primary bone sarcoma. An elevated WBC may reflect hemoconcentration which per se is prothrombotic in nature. Aggressive DVT prophylaxis may, counter intuitively, increase the risk of thromboembolic events due to prolonged immobilization and additional surgeries that usually occur when addressing postoperative wound complications such as postoperative hematoma and wound dehiscence that may relate to overanticoagulation. Prospective randomized trials comparing different medications in combination with compressive devices are needed to assess efficacy with the lowest complication profile. Simpler protocols may increase patient compliance to prophylactic treatment.

17 - Early readmission, delayed discharge, and reoperation after lumbar discectomy discectomy: an analysis from a multicenter, prospective, randomized study

BACKGROUND CONTEXT: Readmissions and reoperations within the first few months of surgery are major factors driving negative clinical and financial outcomes. Providers are increasingly being asked to bear the financial burden of hospital admissions that occur within 90 days of index surgery. Same-level reherniation and progressive degeneration are the main causes of poor outcome after lumbar discectomy and often require early readmission and reoperation.

Low Risk for Local and Systemic Complications After Primary Repair of 1626 Achilles Tendon Ruptures.

Historically, Achilles tendon repairs and other surgeries about the hindfoot have demonstrated a significantly higher rate of wound healing complications and surgical site morbidity. The purpose of this study was to evaluate the comprehensive complication profile and risk factors for adverse short-term, clinical outcomes after primary repair of Achilles tendon ruptures. Between the years 2005 and 2014, all cases of primary Achilles tendon repair (Current Procedural Terminology code 27650) entered into the National Surgical Quality Improvement Project (NSQIP) database were extracted for analysis. Primary outcomes of interest were rates of total complication, reoperation, and rerupture within 30 days of index surgery. Independent risk factors associated with these selected endpoints were assessed with chi-square and logistic regression analysis and odds ratios with 95% confidence intervals were used to express relative risk. Of 1626 patients with an average age of 44 years (SD 13.3), the average ASA classification was 1.69 and hypertension (20.7%), morbid obesity (8.3%), and diabetes (4.9%) were among the most common medical comorbidities. A total of 28 (1.7%) patients sustained perioperative complications, including 1.3% with local complications (0.7% superficial wound infection, 0.4% wound disruption) and no cases of peripheral nerve injury or early repair failure. Systemic complications occurred in 0.4%, most commonly with deep venous thrombosis or nonfatal thromboembolism. Preoperative albumin was independently associated with an increased risk of local wound complications (odds ratio [OR] 28.67; 95% CI 1.42-579.40; P = .029). Chronic obstructive pulmonary disease (OR 22.33, 95% CI 2.49-199.81; P = .006) and bleeding disorder (OR 14.83, 95% CI 1.70-129.50; P = .015) were more likely to result in a systemic complication, and preoperative creatinine correlated with an increased risk of any complication (OR 6.11, 95% CI 1.15-32.34; P = .033). In total there were 5 (0.3%) readmissions with 2 (0.1%) unplanned reoperations attributed to local wound complications. Among a broad-based demographic of the United States, the rate of local wound complications was exceedingly low in the short-term perioperative period, although this risk may be significantly magnified with subtle decreases in albumin levels. Preoperative risk stratifications should carefully scrutinize for subtle abnormalities in nutritional parameters and renal function prior to undergoing Achilles surgery. Therapeutic, Level II: Prospective, comparative trial.

PMS39 - Direct Medical Resource Utilization For Reoperation After Intramedullary Fixation of Pertrochanteric HIP Fractures

To assess patient survival, reoperation rates, and direct medical resource utilization after reoperation subsequent to intramedullary fixation for patients with pertrochanteric femur fractures. This study used a retrospective cohort design with the United States Centers for Medicare and Medicaid (CMS) Standard Analytic File (5%) sample. Patients aged 65+ who received an ORIF with intramedullary fixation in 2013 were included in the cohort. Overall survival, reoperation events, and direct medical resource utilization (claim payments) across multiple settings of care were explored for the 90-day period after index hospitalization and for the subset of patients who underwent reoperation. Patient survival through 365 days of index surgery was analyzed using Kaplan-meier methods with stratification for baseline Charlson Comorbidity Index (CCI). 3,175 patients underwent index surgery during 2013. Patients had mean (SD) age of 83.4 (7.7), 74.1% were female, and 85.2% had a primary International Classification of Disease, 9th revision (ICD-9-CM) diagnosis code of 820.21: Closed fracture of intertrochanteric section of neck of femur. A total of 131 patients (4.1%) had a second hip surgery within 365 days after their index procedure: 51 (38.9%) contralateral, 35 (26.7%) ipsilateral and 45 (34.3%) of unknown laterality. Overall survival among the full cohort was 72.8% at 365 days, and differed across baseline CCI categories: 0-1: 83.2%; 2-3: 75.7%; 4-5: 69.5%; 6+: 58.3% (log-rank test; p <0001). For patients with ipsilateral hip reoperation, mean (SD) Medicare payments from index through the 90-day window totaled $46,577 ($26,607), and comprised the following: index hospitalization-$14,785 ($4,542); physician-$5,159 ($3,925); durable medical equipment-$203 ($536); home health-$2,936 ($3,802); skilled nursing facility-$12,002 ($11,656); inpatient rehab-$4,206 ($11,904); hospice-$326 ($1,365); and other inpatient admissions- $6,960 ($15,127). Mortality for patients with intramedullary fixation varies inversely with baseline CCI, and post-acute care accounts for nearly 60% of 90-day episode costs for patients requiring reoperation.

Patient Body Mass Index is an Independent Predictor of 30-Day Hospital Readmission After Elective Spine Surgery

Hospital readmission within 30 days of index surgery is receiving increased scrutiny as an indicator of poor quality of care. Reducing readmissions achieves the dual benefit of improving quality and reducing costs. With the growing prevalence of obesity, understanding its impact on 30-day unplanned readmissions and patients' perception of health status is important for appropriate risk stratification of patients. The aim of this study was to determine if obesity is an independent risk factor for unplanned 30-day readmissions after elective spine surgery. The medical records of 500 patients (nonobese, n= 281; obese, n= 219) undergoing elective spine surgery at a major academic medical center were reviewed. Preoperative body mass index (BMI) was measured on all patients. BMI that was ≥30 kg/m2 was classified as obese. Patient demographics, comorbidities, and postoperative complication rates were collected. The primary outcome investigated was unplanned all-cause 30-day hospital readmission. The association between preoperative obesity and 30-day readmission rate was assessed via multivariate logistic regression analysis. Baseline characteristics and operative variables and complication profiles were similar between both cohorts. Overall, 8.6% of patients were readmitted within 30 days of discharge; obese patients experienced a 2-fold increase in 30-day readmission rates (obese 12.33% vs. nonobese 5.69%, P= 0.01). In a multivariate logistic regression analysis, preoperative obesity (BMI ≥30 kg/m2) was found to be an independent predictor of 30-day readmission after elective spine surgery (P= 0.001). Preoperative obesity is an independent risk factor for readmission within 30 days of discharge after elective spine surgery. In a cost-conscious health care climate, preoperative BMI can identify patients at risk for early unplanned hospital readmission.

Beyond the Hospital Gates: Elucidating the Interactive Association of Social Support, Depressive Symptoms, and Physical Function with 30-Day Readmissions.

The aims of this study were to design patient-oriented risk models that elucidate the interactions among depressive symptoms, physical function, and sociodemographic markers and delineate the association of these indicators with 30-day readmissions. This prospective longitudinal study examined readmissions within 30 days of an index operation among adults (>18 yrs) undergoing outpatient surgery. The primary exposures were measures of physical function, depression, and sociodemographic factors. Multivariable logistic regression and hierarchical generalized linear mixed models with fixed and random effects tested interactions and association of these factors with 30-day readmissions. Adjusting for covariates and interaction terms, depressive symptoms (adjusted odds ratio, 2.50; 95% confidence interval, 1.45-4.29) and low physical function (adjusted odds ratio, 1.68; 95% confidence interval, 1.15-2.13) increased the odds of 30-day readmissions. Stratified by socioeconomic status (SES), those in the lowest SES group with depressive symptoms had a 73% increase in probability of readmissions (adjusted odds ratio, 2.67; 95% confidence interval, 1.10-4.07). Stratified by depressive symptom severity, being married or having a life partner lowered the readmission odds (adjusted odds ratio, 0.52; 95% confidence interval, 0.31-0.88). Final models had good discrimination and fitness (area under the curve, 0.710; corrected Akaike Information Criterion, 541.1). Within 30 days of index surgery, depressive symptom severity moderated the association of sociodemographic, social support and physical function indicators with 30-day readmissions.

Evaluation of 30-day hospital readmission after surgery for advanced-stage ovarian cancer in a medicare population.

To analyze rate, risk factors, and costs associated with 30-day readmission after ovarian cancer surgery. The SEER-Medicare linked database (1992 to 2010) was used to evaluate readmission rates within 30 days of index surgery in patients with stage IIIC/IV ovarian, primary peritoneal, or fallopian tube cancer. Multivariable logistic regression was used to identify factors associated with readmission. Of 5,152 eligible patients, 1,003 (19.5%) were readmitted within 30 days of discharge. Mean patient age was 75 years. Diagnoses associated with readmission included infection (34.7%), dehydration (34.3%), ileus/obstruction (26.2%), metabolic/electrolyte derangements (23.1%), and anemia (12.3%). In multivariable analysis, year of discharge was significantly associated with 30-day readmission (1996 to 2000: odds ratio [OR], 1.32; 95% CI, 1.01 to 1.71; 2001 to 2005: OR, 1.58; 95% CI, 1.24 to 2.0; 2006 to 2010: OR, 1.73; 95% CI, 1.35 to 2.21; referent years 1992 to 1995), as were length of index hospital stay more than 8 days (OR, 1.39; 95% CI, 1.18 to 1.64) and discharge to a skilled nursing facility (OR, 1.3; 95% CI, 1.04 to 1.63). Patients readmitted within 30 days had a significantly greater 1-year mortality rate compared with patients not readmitted (41.1% v 25.1%, respectively; P < .001). The median cost of readmission hospital stay was $9,220 in year 2010 dollars, with a total cost of $9.3 million over the study period. Early readmission after surgery for ovarian cancer is common. There is a significant association between 30-day readmission and 1-year mortality. These findings may catalyze development of targeted interventions to decrease early readmission, improve patient outcomes, and control health care costs.

Gentamicin-collagen sponge reduces sternal wound complications after heart surgery: A controlled, prospectively randomized, double-blind study

Prophylactic retrosternal placement of a gentamicin-collagen sponge has been the subject of several recent clinical studies and is a matter of controversy. The present study is the first controlled, prospective, randomized, double-blind, single-center study to investigate the efficacy of a retrosternal gentamicin-collagen sponge in reducing sternal wound complications after heart surgery. From June 2009 to June 2010, 720 consecutive patients who underwent median sternotomy were assigned to a control placebo group (collagen sponge) or an intervention group (gentamicin-collagen sponge). All patients received guideline-compliant perioperative antibiotic prophylaxis. The primary end point was the occurrence of deep sternal wound infections within 30 days of index surgery (follow-up period). Secondary end points were the occurrence of superficial sternal wound infections requiring treatment, as well as further clinical parameters, including revision, bleeding volume, and need for transfusions during the follow-up period. A total of 720 of 994 patients (72.4%) were enrolled (control group: n=367 vs intervention group: n=353). Risk factors for sternal wound infection and demographic variables were comparable in the 2 groups. The incidence of deep sternal wound infections was 13 of 367 (3.52%) in the control group versus 2 of 353 (0.56%) in the intervention group (P=.014; adjusted odds ratio, 0.15; 95% confidence interval, 0.02-0.69). The numbers needed to treat relation for all sternal wound infections and deep sternal wound infections were 26 and 33, respectively. No statistically significant differences were demonstrated concerning secondary end points, such as postoperative bleeding and transfusion of red cell units, thrombocytes, and fresh-frozen plasma. Routine prophylactic retrosternal use of a gentamicin-collagen sponge in patients undergoing cardiac surgery significantly reduces deep sternal wound infections.

Complication and Revision Rates Following Total Elbow Arthroplasty

To determine the complication rates after total elbow arthroplasty (TEA) in a large and diverse patient population. We identified patients undergoing TEA as inpatients in the years 1995 to 2005 using California's Discharge Database. Short-term outcomes of interest included rates of infection or wound complications, revision, reoperation, and pulmonary embolism that were diagnosed during an inpatient hospital admission and mortality within 90 days of index surgery. Longer-term outcomes analyzed included rates of revision, amputation, and conversion to fusion. We used regression models to estimate the role of patient and provider characteristics in predicting the rates of adverse outcomes. We identified 1,625 patients undergoing TEA. Early complications, defined as those requiring inpatient re-admission within the first 90 days after index surgery, were identified in 170 patients, and 132 patients required reoperation. Eighty one patients required revision in 90 days, and 48 underwent revision within one year. Early infections and wound complications requiring readmission occurred in 88 patients. In the 90 days after surgery, 4 patients had a pulmonary embolism and 10 patients died. One-hundred and twenty-one patients required revision, amputation, or fusion during the observation period, with a mean follow-up of 4 years. Hospital volume was not associated with increased risk of adverse outcomes. We analyzed a large and diverse patient population undergoing TEA. The overall rate of short-term complications requiring inpatient treatment was high, at over 10% (170 patients), with almost 8% (132 patients) requiring reoperation within the first 90 days. Although population-based studies have shortcomings, they can add to the body of knowledge of less frequent procedures such as TEA. Therapeutic IV.

Obesity and spine surgery: reassessment based on a prospective evaluation of perioperative complications in elective degenerative thoracolumbar procedures

Background Context The correlation between obesity and incidence of complications in spine surgery is unclear, with some reports suggesting linear relationships between body mass index (BMI) and complication incidence and others noting no relationship. Purpose The purpose of this article was to assess the relationship between obesity and occurrence of perioperative complications in an elective thoracolumbar surgery cohort. Study Design/Setting Prospective observational cohort study at a tertiary care facility. Patient Sample Cohort of 87 consecutive patients undergoing elective surgery for degenerative thoracolumbar pathologies over a 6-month period (May to December 2008). Outcome Measures Incidence of perioperative complications (those occurring within 30 days of surgery). Methods A prospective assessment of perioperative spine surgery complications was completed, and data were prospectively entered into a central database. Two independent auditors assessed for the presence and severity of perioperative complications. Previously validated binary definitions of major and minor complications were used. Patient data and early complications (those occurring within 30 days of index surgery) were analyzed using multivariate regression. Results Mean BMI in this cohort was 31.3; 40.8% of patients were obese (BMI>30) and 10 patients (11.5%) were morbidly obese (BMI>40). The overall complication incidence was 67%. Minor complications occurred in 50% of patients, and major complications occurred in 17.8% of patients. No positioning palsies occurred in this series. Age correlated with an increase in complication risk (p=.006) as did hypertension (p=.004) and performance of a fusion (p<.0001). BMI did not correlate with the incidence of minor, major, or any complications (p=.58). Conclusions This prospective assessment of perioperative complications in elective degenerative thoracolumbar procedures shows no relationship between patient BMI and the incidence of perioperative minor or major complications. Specific care in perioperative positioning may limit the risk of perioperative positioning palsies in obese patients.