Differences In 30-day Outcomes Research Articles

Impact of head and neck radiation on long-term outcomes after carotid revascularization

ObjectiveRadiation-induced carotid artery stenosis (RICS) is a well-described phenomenon seen after head and neck cancer radiation. Previously published literature suggests that, compared with atherosclerotic disease, RICS may result in worse long-term outcomes and early restenosis. This study aims to evaluate the effect of radiation on long-term outcomes after various carotid revascularization techniques using a multi-center registry database. MethodsPatients in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI) registry for carotid artery intervention (carotid endarterectomy [CEA]; transfemoral carotid artery stenting [CAS]; transcarotid artery revascularization [TCAR]), who are 65 years or older were included in the study. VQI Vascular Implant Surveillance and Interventional Outcomes Network (VISION) Medicare-linked database was used to obtain long-term procedure-specific outcomes. Primary endpoints were 3-year death, stroke, and reintervention. We performed propensity matching between patients with prior radiation and those without. Kaplan-Meier analysis and a multivariate logistic regression model were used to analyze the outcome variables. ResultsA total of 56,472 patients had undergone carotid revascularization (CEA, n = 48,307; TCAR, n = 4593; CAS, n = 3572), 1244 patients with prior radiation and 54,925 patients without prior radiation. The prior radiation group was more likely to be male (71.9% vs 60.3%; P < .01), to receive a stent (47.5% vs 13.5%; P < .01), and to be on P2Y12 inhibitor (55.2% vs 38.3%; P < .01). Propensity matching was performed on 1223 patients (CEA, n = 655; TCAR, n = 292; CAS, n = 287). There were no significant differences in 30-day outcomes for death, stroke, or major adverse cardiovascular events for all three procedures. The prior radiation group had higher rates of cranial nerve injury (3.7% vs 1.8%; P = .04) and 90-day readmission (23.5% vs 18.3%; P = .01) after CEA. For long-term outcomes, prior radiation significantly increased mortality risk for CEA and CAS (hazard ratio [HR], 1.77; 95% confidence interval [CI], 1.38-2.27 and HR, 1.56; 95% CI, 1.02-2.36, respectively). The 3-year risk of stroke for CEA in radiated patients was also significantly higher (HR, 1.47; 95% CI, 1.03-2.09) compared with non-radiated patients. Prior radiation did not significantly affect death and stroke in patients undergoing TCAR. Prior radiation also did not impact the rates of short and long-term reintervention after CEA, CAS, or TCAR. ConclusionsPrior head and neck radiation significantly increases the risk for mortality and stroke for CEA and the risk for mortality after CAS. Long-term outcomes for TCAR are not significantly affected by prior radiation. TCAR may be the preferred treatment modality for patients with radiation-induced carotid stenosis.

Young and resilient: Unraveling papillary thyroid cancer outcomes in males under 40.

While males present with more adverse clinicopathologic features in papillary thyroid carcinoma (PTC), younger age has previously been shown to be a favorable prognostic factor. We examined the combined effect of male sex and young age on PTC outcomes. We conducted a retrospective analysis of a prospectively maintained database of thyroid cancer surgery patients (2000-2020) at a single quaternary care institution. We included papillary thyroid carcinoma cases and excluded those with prior cancer-related thyroid surgery. We examined demographics, cancer stage, surgical outcomes, and complications by age and sex, analyzing groups below and above the age of 40years. A total of 680 patients with PTC were included. Females constituted 68% (age ≥40years: 44% and <40years: 24%) and males 32% (≥40years: 24% and <40years: 8%). A significant difference (p<0.001) of N1 disease distribution was found between the groups. N1a metastasis was greater in patients younger than 40 regardless of sex ((M<40 (15%), F<40 (15%), M≥40 (12%), and F≥40 (9%)). While, M<40 had greater N1b metastasis (36%) than all other groups (M≥40 (28%), F<40 (22%), and F≥40 (10%)). There was no significant difference in the distribution ofT stages between groups. Groups showed no differences in 30-day outcomes, recurrence at 1year, reoperation, mortality, nerve injury, or hypocalcemia. Young males with PTC face increased occurrence of nodal metastasis yet experience similar recurrence rates as their female and older counterparts. Subgroup analysis underscores the predictive role of sex and age in advanced PTC cases.

P526 Handsewn versus Stapled Ileocolic Anastomosis for Crohn's: Comparable Outcomes Despite More Severe Disease Profile in the Handsewn Group

Abstract Background Stapled anastomosis is the most common anastomotic method after ileocolic resection for Crohn's disease, whereas handsewn end-to-end (HS-ETE) anastomosis is less frequently performed. The optimal technique for ileocolic anastomosis in Crohn's patients remains controversial. Some studies have suggested potential benefits of HS-ETE over SSTS, including lower recurrence rates, whereas others have found no difference. We aimed to compare short-term postoperative outcomes and long-term recurrence-free survival between the HS-ETE and SSTS groups at our center. Methods This retrospective study included consecutive patients who underwent ileocolic resection for Crohn's disease between 2012-2022 with either HS-ETE or SSTS anastomosis. The primary outcomes were perianastomotic recurrence and need for surgical/endoscopic intervention. Cox regression and Kaplan-Meier curves were used to compare recurrence-free survival. Results A total of 764 patients were included: 162 (21%) with HS-ETE and 602 (79%) with SSTS anastomosis. The median age of the HS-ETE and SSTS groups was 39 and 38 years, respectively. Males comprised 43% of the HS-ETE group and 51% of the SSTS group. The median BMI was 24 kg/m2 in both groups. The HS-ETE group had a longer median disease duration (10 vs. 7 years, p=0.02) and a higher rate of previous abdominal surgery (35% vs. 22%, p=0.01) than the SSTS group did. The ileocolonic location (78% vs. 66%, p=0.03) and perforating disease (45% vs. 35%, p=0.04) were also more common in the HS-ETE group. The median operative time (207 min vs. 147 min, p&amp;lt;0.001) and estimated blood loss (150 mL vs. 75 mL, p&amp;lt;0.001) were greater in the HS-ETE group. There were no differences in 30-day outcomes between the groups. Perianastomotic recurrence rates were similar between the HS-ETE and SSTS groups (29.6% vs. 28.9%, p=0.93). The 5-year recurrence-free survival rates were also comparable (HS-ETE, 56.4% vs. SSTS, 59%; p=0.94). Also, we found that the risk of requiring surgical or endoscopic intervention for recurrence between HS-ETE and SSTS was comparable (HS-ETE, 65.2% vs. SSTS, 74.2%; p=0.273) Conclusion Although the HS-ETE group had worse baseline disease characteristics, including longer disease duration, higher previous surgery rates, and more aggressive disease location and behavior, HETE and SSTS anastomosis after ileocolic resection for Crohn’s disease yielded comparable perioperative and long-term outcomes in our patient cohort.

First Assistant In Bariatric Surgery: A Comparison Between Laparoscopic And Robotic Approaches: A 4-Year Analysis of the MBSAQIP Database (2016-2019).

The first assistant (FA) plays an important role in the operating room for bariatric surgery. The aim of this study was to examine the relationship between the type of FA and operative time (OT) and postoperative outcomes comparing robotic and laparoscopic approaches in bariatric surgery. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) data for 2016-2019 was queried. Log-normal regression was performed to evaluate the association of FAs and OT variations within and between groups. We used logistic regression to examine the relationship between the type of FA and 30-day outcomes across all procedures and approaches. A total of 691,789 patients who underwent robotic (R), and laparoscopic (L) sleeve gastrectomy (SG), Roux-en-Y gastric-bypass (RYGB), and duodenal switch (DS) were included. The percentage variation of OT was higher in the laparoscopic group (L-SG: 8.18%, L-RYGB: 9.88%, and L-DS: 15.00%) compared to the robotic group (R-SG: 2.43%, R-RYGB: 5.76%, and R-DS: 0.80%). There was not a significant difference in 30-day outcomes between laparoscopic and robotic approaches for the same procedures. The FA was associated with a decreased variability in OT in the robotic cohort compared to the laparoscopic group with no significant difference in complication rates. These results suggest that the robotic approach may decrease the need for skilled FAs in bariatric procedures.

MELD score predicts short-term outcomes after surgical management of proximal humerus fractures: a matched analysis.

We aimed to evaluate the difference in 30-day outcomes after surgical management of proximal humerus fractures (PHFs) between patients with and without chronic liver disease as defined by a MELD score greater than 10. This was a retrospective database review. All centers participating in the American College of Surgeons National Surgical Quality Improvement Program database were included. Patients with proximal humerus fractures who (1) underwent ORIF, HA, or SA and (2) had calculable MELD scores were included. Open reduction and internal fixation, hemiarthroplasty, or shoulder arthroplasty was used for treatment. Thirty-day complications, mortality, readmission, and reoperation rates were measured. Of the total 1732 PHF patients identified, 300 had a MELD score higher than 10. After propensity matching by significant covariates, MELD score higher than 10 was found to be significantly associated with higher rates of 30-day mortality, 30-day readmission, transfusion within 72 hours, and systemic complications. Among patients with a MELD score higher than 10, treatment with SA or HA instead of ORIF was associated with a higher rate of transfusion and longer operative time. There were no significant differences between treatment cohorts regarding mortality, reoperation, readmission, or complications. A MELD score higher than 10 is associated with higher risk of surgical complications, transfusion, and death in patients undergoing surgery for proximal humerus fractures. Among patients with a MELD score higher than 10, ORIF was associated with a lower transfusion rate and shorter operative time than arthroplasty or hemiarthroplasty. Prognostic Level III.

Prevalence and outcomes of acute coronary syndrome patients with and without standard modifiable risk factors undergoing percutaneous coronary intervention

Abstract Background Prevention strategies in acute coronary syndrome (ACS) have focused on patients with standard modifiable risk factors (SMuRFs; diabetes, hypercholesterolaemia, hypertension, and current smoking). There is increasing awareness that SMuRF-less patients may represent a unique subset of patients experiencing ACS. Purpose To investigate the prevalence, characteristics, and outcomes of SMuRF-less ACS patients compared to those with SMuRFs undergoing percutaneous coronary intervention (PCI) in a major city in Australia. Methods We analysed data from adult (≥18 years) ACS patients receiving PCI between 2005 and 2020 using a PCI Registry which contains data for all patients undergoing coronary intervention at one of six major hospitals. Patients with a known history of coronary artery disease were excluded. Overall clinical characteristics and outcomes for those with and without SMuRFs were examined. The primary outcome was 30-day all-cause mortality. Secondary outcomes included in-hospital outcomes, myocardial infarction (MI), revascularisation, and major adverse cardiovascular and cerebrovascular (MACCE) events at 30 days. Long-term mortality was investigated using Cox-proportional hazards regression. Results From 1 January 2005 to 31 December 2020, 2,727 (14.4%) of 18,988 patients were SMuRF-less. Mean (± standard deviation [SD]) age was similar between patients with and without SMuRFs (63±13 vs 63±12 years) and there were more females with SMuRFs (25% vs 20%, p&amp;lt;0.001). SMuRF-less patients were less likely to have a history of cerebrovascular disease (1.2% vs 4.2%, p&amp;lt;0.001), peripheral vascular disease (0.6% vs 3.0%, p&amp;lt;0.001), and chronic lung disease (8.6% vs 10.1%, p=0.014). They were more likely to present with out-of-hospital cardiac arrest (6.6% vs 3.9%, p&amp;lt;0.001) and ST-elevation MI (59% vs 51%, p&amp;lt;0.001). The left anterior descending artery was the target lesion in 46% of SMuRF-less patients compared to 39% of those with SMuRFs. During hospital stay, SMuRF-less patients were more likely to experience post-procedural cardiogenic shock (4.5% vs 3.6%, p=0.019) and arrhythmia (11.2% vs 9.9%, p=0.029). At 30 days, all-cause mortality did not differ between those with and without SMuRFs (3.2% vs 3.6%, p=0.290). Similarly, there were no differences in 30-day MI, revascularisation, and MACCE. During mean follow-up of approximately 7 years, being SMuRF-less was associated with a 12% decreased rate of mortality (adjusted Hazard Ratio 0.88 [95% confidence interval 0.78, 0.99], p=0.035). Conclusions Despite differences in characteristics (rates of cardiac arrest and ST-elevation MI), no difference in 30-day outcomes was observed among those with and without SMuRFs. However, SMuRF-less patients had lower hazard for long-term mortality. These findings suggest SMuRF-less patients may have novel risk factors and improved long-term outcome warranting further research.

Early postoperative outcomes in stent vs stent-less ileal conduits after radical cystectomies.

e16612 Background: Placing stents at the ureteroileal anastomosis for radical cystectomy with ileal conduit (RCIC) diversion has been common practice for the vast majority of urologists. Recently, the practice has been called into question, as some institutions have shifted to not stenting their ileal conduits for patient comfort and convenience. In this study, we aim to investigate the difference in 30-day outcomes between patients who did and did not receive ureteroileal stents after RCIC. Methods: RCs performed between 2019-2020 were identified in NSQIP and the corresponding cystectomy-targeted database. Baseline demographics, comorbidities, and operative parameters were compared via Pearson’s chi-square and t-tests between stented and stent-less RCICs. Outcomes of interest included rates of urinary tract infections (UTIs), acute kidney injury (AKI), renal failure requiring dialysis, anastomotic leaks, ureteral obstruction, ureteral fistula formation, need for reoperation, and 30-day hospital readmissions. Outcomes were compared using Pearson’s chi-square. All statistical tests were two tailed, p&lt;0.05 considered significant. Results: 3,865 RCICs were identified, of which 446 (11.5%) were stent-less. There was no difference in baseline demographics, comorbidities, or operative parameters between the stented and stent-less group, with the notable exceptions that significantly more stent-less patients had robotic-assisted instead of open RCs compared to the stented group (33% vs 21%, p&lt;0.001), and significantly more stent-less patients were preoperatively on dialysis compared to the stented group (4.9% vs 0.5%, p&lt;0.001). There was no significant difference in 30-day rates of UTIs, AKIs, renal failure, anastomotic leaks, ureteral obstruction, ureteral fistula formation, need for reoperation, and readmissions between the stented and stent-less cohorts. Conclusions: Stent-less ileal conduits have recently emerged in popularity. This study represents the largest multi-institutional analysis comparing outcomes between traditionally stented and stent-less RCICs, and shows that there is no significant difference in outcomes. Given the added cost and patient discomfort of ureteroileal stents, this study may indicate that these stents may not play as significant of a role in preventing early complications as previously thought. These findings warrant further investigation.

Impact of Head and Neck Radiation on Long-term Outcomes After Carotid Revascularization

Radiation-induced carotid artery stenosis is a well-described phenomenon seen after treatment for head and neck cancer. Previously published literature suggests that compared to atherosclerotic disease, radiation-induced carotid artery stenosis may result in poorer long-term outcomes and early restenosis. The study aims to evaluate the effect of radiation on long-term outcomes after various carotid revascularization techniques using a multicenter registry database. Patients in the Society for Vascular Surgery Vascular Quality Initiative registry for carotid artery intervention (carotid endarterectomy, CEA; transfemoral carotid artery stenting, CAS; transcarotid artery revascularization, TCAR), who are 65 years or older were included in the study. Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network Medicare-linked database was used to obtain long-term procedure-specific outcomes. Primary end points were 3-year death, stroke, and reintervention. We performed propensity matching between patients with prior radiation and those without. Kaplan-Meier analysis and a multivariate logistic regression model were used to analyze the outcome variables. There were 1244 patients with prior radiation and 54,925 patients without prior radiation. Prior radiation group was more likely to be male (71.9% vs 60.3%; P ≤ .01), more likely to receive a stent (47.5% vs 13.5%; P < .01), and more likely to be on P2Y12 inhibitor (55.2% vs 38.3%; P < .01). Propensity matching was performed on 1223 patients (CEA, n = 655; TCAR, n = 292; CAS, n = 287). There were no significant differences in 30-day outcomes for death, stroke, or major adverse cardiovascular events for all three procedures (Table). The prior radiation group had higher rates of cranial injury (3.7% vs 1.8%; P = .04) and 90-day readmission (23.5% vs 18.3%; P = .01) after CEA. For long-term outcomes, prior radiation significantly increased mortality risk for CEA and CAS (hazard ratio [HR], 1.77; 95% confidence interval [CI], 1.38-2.27 and HR, 1.56; 95% CI, 1.02-2.36, respectively). The 3-year risk of stroke for CEA in radiated patients was also significantly higher (HR, 1.47; 95% CI, 1.03-2.09) compared to nonradiated patients. Prior radiation did not significantly affect death and stroke in patients undergoing TCAR. Prior radiation also did not impact the rates of short and long-term reintervention after CEA, CAS, or TCAR. Prior head and neck radiation significantly increases the risk for mortality and stroke for CEA and the risk for mortality after CAS. Long-term outcomes for TCAR are not significantly affected by prior radiation. TCAR may be the preferred treatment modality for patients with radiation-induced carotid stenosis.TableHR95% CIP valueCEA Death1.771.38-2.27<.01 Stroke1.471.03-2.09.03 Reintervention1.260.87-1.82.21CAS Death1.561.02-2.36.04 Stroke0.910.56-1.46.68 Reintervention1.710.86-3.38.13TCAR Death1.100.60-2.03.76 Stroke1.470.66-3.31.35 Reintervention0.980.54-1.79.96All Death1.371.12-1.68<.01 Stroke0.980.75-1.27.85 Reintervention1.240.94-1.64.13CAS, Carotid artery stenting; CEA, carotid endarterectomy; CI, confidence interval; HR, hazard ratio; TCAR, transcarotid artery revascularization. Open table in a new tab

MP56-18 STENT VS STENT-LESS ILEAL CONDUITS AFTER RADICAL CYSTECTOMIES: IS THERE DIFFERENCE IN EARLY POSTOPERATIVE OUTCOMES

You have accessJournal of UrologyCME1 Apr 2023MP56-18 STENT VS STENT-LESS ILEAL CONDUITS AFTER RADICAL CYSTECTOMIES: IS THERE DIFFERENCE IN EARLY POSTOPERATIVE OUTCOMES Rishabh Simhal, Yash Shah, Kerith Wang, Daniel Simon, James Mark, Zachary Prebay, Costas Lallas, Leonard Gomella, and Mihir Shah Rishabh SimhalRishabh Simhal More articles by this author , Yash ShahYash Shah More articles by this author , Kerith WangKerith Wang More articles by this author , Daniel SimonDaniel Simon More articles by this author , James MarkJames Mark More articles by this author , Zachary PrebayZachary Prebay More articles by this author , Costas LallasCostas Lallas More articles by this author , Leonard GomellaLeonard Gomella More articles by this author , and Mihir ShahMihir Shah More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003309.18AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Placing stents at the ureteroileal anastomosis for radical cystectomy with ileal conduit (RCIC) diversion has been common practice for the vast majority of urologists. Recently, the practice has been called into question, as some institutions have shifted to not stenting their ileal conduits for patient comfort and convenience. In this study, we aim to investigate the difference in 30-day outcomes between patients who did and did not receive ureteroileal stents after RCIC. METHODS: RCs performed between 2019-2020 were identified in NSQIP and the corresponding cystectomy-targeted database. Baseline demographics, comorbidities, and operative parameters were compared via Pearson’s chi-square and t-tests between stented and stent-less RCICs. Outcomes of interest included rates of urinary tract infections (UTIs), acute kidney injury (AKI), renal failure requiring dialysis, anastomotic leaks, ureteral obstruction, ureteral fistula formation, need for reoperation, and 30-day hospital readmissions. Outcomes were compared using Pearson’s chi-square. All statistical tests were two tailed, p<0.05 considered significant. RESULTS: 3,865 RCICs were identified, of which 446 (11.5%) were stent-less. There was no difference in baseline demographics, comorbidities, or operative parameters between the stented and stent-less group, with the notable exceptions that significantly more stent-less patients had robotic-assisted instead of open RCs compared to the stented group (33% vs 21%, p<0.001), and significantly more stent-less patients were preoperatively on dialysis compared to the stented group (4.9% vs 0.5%, p<0.001). There was no significant difference in 30-day rates of UTIs, AKIs, renal failure, anastomotic leaks, ureteral obstruction, ureteral fistula formation, need for reoperation, and readmissions between the stented and stent-less cohorts. CONCLUSIONS: Stent-less ileal conduits have recently emerged in popularity. This study represents the largest multi-institutional analysis comparing outcomes between traditionally stented and stent-less RCICs, and shows that there is no significant difference in outcomes. This study shows no difference in significant perioperative complications in patients without stents compared to those with stents. Therefore this needs to be investigated further given the overall cost, patient discomfort and concern for stent related infectious complications. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e782 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rishabh Simhal More articles by this author Yash Shah More articles by this author Kerith Wang More articles by this author Daniel Simon More articles by this author James Mark More articles by this author Zachary Prebay More articles by this author Costas Lallas More articles by this author Leonard Gomella More articles by this author Mihir Shah More articles by this author Expand All Advertisement PDF downloadLoading ...

Asian race is not associated with increased 30-day serious complications or mortality: a MBSAQIP analysis of 594,837 patients.

With expansion of bariatric surgery indications to include Asian patients with diabetes and body mass index (BMI) ≥ 27.5, or BMI ≥ 32.5, it is important to characterize Asian patient population undergoing bariatric surgery and assess their postoperative outcomes. This retrospective study analyzed the 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database. All patients undergoing Roux-en-Y gastric bypass (RYGB) and laparoscopic sleeve gastrectomy (LSG) who self-reported as Asian or White race were included. The primary outcomes were to characterize the Asian race population in North American and to identify if Asian race was associated with serious complications or mortality at 30days. Overall, 594,837 patients met inclusion, with 4229 self-reporting Asian racial status. Patients of Asian race were younger (41.8 vs 45.5years, p < 0.001) and had a lower BMI (42.8 vs 44.7kg/m2 p < 0.001) than White patients. They were also more likely to have insulin dependent diabetes (10.9% vs 8.2%, p < 0.001), have received prior cardiac surgery (10.0% vs 1.2% p < 0.001), and suffer from renal insufficiency (1.0% vs 0.5%, p < 0.001). There were no significant differences between rates of RYGB (28.3% vs 28.9%, p = 0.4) and mean operative duration (87.7 vs 87.5min, p = 0.7). Additionally, there were no differences in 30day outcomes including leak (0.5% vs 0.5%, p = 0.625), bleeding (1.2% vs 1.0%, p = 0.1), serious complications (3.4% vs 3.5%, p = 0.6), or mortality (0.1% vs 0.1%, p = 0.7) and after confounder control, Asian race was not independently associated with serious complications (OR 1.0, CI 0.9-1.2, p = 0.7), or mortality (OR 1.1, CI 0.3-3.3, p = 0.1). Despite the increased metabolic burden of Asian patients, no differences in 30-day outcomes compared to White patients occurs. This data supports evidence suggesting these patients may safely undergo bariatric surgery independent of their increased metabolic burden.

Posterior Cervical Fusion for Fracture Is Not the Same as Fusion for Degenerative Cervical Spine Disease: Implications for a Bundled Payment Model.

Retrospective. To understand differences in 30-day outcomes between patients undergoing posterior cervical fusion (PCF) for fracture versus degenerative cervical spine disease. Current bundled payment models for cervical fusions, such as the Bundled Payments for Care Improvement revolve around the use of diagnosis-related groups to categorize patients for reimbursement purposes. Though a PCF performed for a fracture may have a different postoperative course of care as compared with a fusion being done for degenerative cervical spine pathology, the current DRG system does not differentiate payments based on the indication/cause of surgery. The 2012-2017 American College of Surgeons-National Surgical Quality Improvement Program was queried using Current Procedural Terminology code 22600 to identify patients receiving elective PCFs. Multivariate analyses were used to compare rates of 30-day severe adverse events, minor adverse events, readmissions, length of stay, and nonhome discharges between the 2 groups. A total 2546 (91.4%) PCFs were performed for degenerative cervical spine pathology and 240 (8.6%) for fracture. After adjustment for differences in baseline clinical characteristics, patients undergoing a PCF for a fracture versus degenerative pathology had higher odds of severe adverse events [18.8% vs. 10.6%, odds ratio (OR): 1.65 (95% CI, 1.10-2.46); P =0.015], prolonged length of stay >3 days [54.2% vs. 40.5%, OR: 1.93 (95% CI, 1.44-2.59); P <0.001], and nonhome discharges [34.2% vs. 27.6%, OR: 1.54 (95% CI, 1.10-2.17); P =0.012]. Patients undergoing PCFs for fracture have significant higher rates of postoperative adverse events and greater resource utilization as compared with individuals undergoing elective PCF for degenerative spine pathology. The study calls into question the need of risk adjustment of bundled prices based on indication/cause of the surgery to prevent the creation of a financial disincentive when taking care/performing surgery in spinal trauma patients.

Short-term outcomes of robotic inguinal hernia repair during robotic prostatectomy – An analysis of the Abdominal Core Health Quality Collaborative

BackgroundConcomitant robotic-assisted laparoscopic prostatectomy (RALP) and robotic inguinal hernia repair (RIHR) has been reported. Nevertheless, data on its safety is lacking and some surgeons avoid performing both operations concurrently due to the potential risk of mesh related complications in the setting of a fresh vesicourethral anastomosis. We aimed to investigate differences in 30-day outcomes between patients undergoing RALP+RIHR and those undergoing RIHR alone. MethodsPatients who have undergone concomitant RALP and RIHR with 30-day follow-up available were identified within the Abdominal Core Health Quality Collaborative. Using a propensity score algorithm, they were matched with a cohort of patients undergoing RIHR alone based on confounders such as body mass index, age, ASA class, smoking, hernia size and recurrent status and prior pelvic operation. The groups were compared for 30-day rates of surgical site infection (SSI), surgical site occurrences (SSO), surgical site occurrences requiring operative intervention (SSOPI) and hernia recurrence. Results24 patients underwent RALP + RIHR and were matched to 72 patients who underwent RIHR alone (3:1). Median age was 64 years, 33% were obese and 17% smokers. No significant differences were found on 30-day rates of overall complications (21% RALP + RIHR vs. 15% RIHR, p = 0.53) and surgical site occurrences (12% RALP + RIHR vs.11% RIHR, p = 0.85). No patient in the RALP + RIHR group had a 30-day SSI, SSOPI or early recurrence. ConclusionRALP+RIHR appears not to result in increased rates of wound complications, overall complications or early recurrence when compared to patient undergoing RIHR alone. Prospective, controlled studies with larger number of patients are needed to confirm our findings.

Completely intracorporeal anastomosis in robotic left colonic and rectal surgery: technique and 30-day outcomes.

As robotic surgery continues to disseminate into the field of colon and rectal surgery, there is a growing interest in the utilization of intracorporeal anastomosis to potentially improve surgical outcomes. The purpoe of this study was to compare feasibility, safety, and short-term outcomes of robotic sigmoid and low anterior resections performed with completely intracorporeal anastomosis (CICA) technique to the traditional extracorporeal assisted anastomosis (ECAA) technique. Consecutive series of patients who underwent elective robotic sigmoid or low anterior resections for benign or malignant disease utilizes either CICA or ECAA between August 2017 and November 2019. Surgical complications were assessed until 30 postoperative days and compared between the two groups. A total of 160 patients were identified; 73 (45.6%) in the CICA group and 87 (54.4%) in the ECAA group. Most of the procedures were performed for malignancy (76%). Estimated blood loss was lower in the CICA group (80.7mL vs. 110.2mL; p = 0.048), while operative times were longer (5.9 ± SD hours vs. 4.9 ± SD hours; p = < 0.001). Overall conversion rate was 1.9%, with no conversions in the CICA group. Overall complications occurred in 54 patients (33.8%) with 13 (8.3%) representing major complications. There were no significant differences in 30day outcomes between the two groups. This study demonstrates the feasibility and safety of robotic sigmoid and low anterior resections with CICA. Outcomes for robotic sigmoid and low anterior resections are encouraging regardless of anastomotic technique (CICA vs ECAA).

Fellowship training influences learning curves for laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric surgical procedure. Little is known about how surgeon training background influences the learning curve of this procedure. We examined operating times (OT), weight loss outcomes, and 30-day complications between surgeons with and without fellowship training in LSG. We hypothesize that post-residency training specific to LSG influences learning curves. Surgeons from a single institution were split into two groups: those who had not completed fellowship training in LSG (NF, n = 3), and those who had completed LSG specific training in fellowship (SGF, n = 3). OTs, BMI changes at 1year, and 30-day readmissions, reoperations, and complications were extracted for the first 100 LSG cases of each surgeon. Data were analyzed in bins of 20 cases. Comparisons were made between cohorts within a bin and between adjacent bins of the same surgeon cohort. Logistic regression analyses were performed of OT and weight loss outcomes. SGF surgeons showed no difference in OTs over their first 100 cases. NF surgeons had statistically significant increased OTs compared to SGF surgeons during their first 60 cases and progressively shortened OTs during that interval (109min to 78min, p < 0.001 for NF surgeons vs. 73min to 69min, SGF surgeons). NF surgeons had a significantly steeper slope for improvement in OT over case number. There was no correlation between case number and weight loss outcomes in either group, and no differences in 30-day outcomes between groups. Surgeons who trained to perform LSG in fellowship demonstrate faster and consistent OR times on their initial independent LSG cases compared to surgeons who did not, with no correlation between case number and weight loss outcomes or safety profiles for either group. This suggests that learning curves for LSG are achieved during formal case-specific fellowship training.

Severe Upper Gastrointestinal Hemorrhage Caused by Reflux Esophagitis.

There are few reports about reflux esophagitis (RE) as a cause of severe upper gastrointestinal bleeding (UGIB). This study aims to evaluate (1) changes in its prevalence over the last three decades and (2) clinical and endoscopic characteristics and 30-day outcomes among RE patients with and without focal esophageal ulcers (EUs) and stigmata of recent hemorrhage (SRH). A retrospective study of prospectively collected data of esophagitis patients hospitalized with severe UGIB between 1992 and 2020. Descriptive analysis and statistical comparisons were performed. Of 114 RE patients, the mean age was 61.1years and 76.3% were males. 38.6% had prior gastroesophageal reflux disease (GERD) symptoms; overall 36% were on acid suppressants. Over three consecutive decades, the prevalence of RE as a cause of severe UGIB increased significantly from 3.8 to 16.7%. 30-day rebleeding and all-cause mortality rates were 11.4% and 6.1%. RE patients with focal EUs and SRH (n = 23) had worse esophagitis than those with diffuse RE (n = 91) (p = 0.012). There were no differences in 30-day outcomes between RE patients with and without EUs and SRH. For patients with severe UGIB caused by RE, (1) the prevalence has increased significantly over the past three decades, (2) the reasons for this increase and preventive strategies warrant further study, (3) most patients lacked GERD symptoms and did not take acid suppressants, and (4) those with focal ulcers and SRH had more severe esophagitis and were treated endoscopically.

Is the current referral trend a threat to the Military Health System? Perioperative outcomes and costs after colorectal surgery in the Military Health System versus civilian facilities

BackgroundTRICARE military beneficiaries are increasingly referred for major surgeries to civilian hospitals under “purchased care.” This loss of volume may have a negative impact on the readiness of surgeons working in the “direct-care” setting at military treatment facilities and has important implications under the volume-quality paradigm. The objective of this study is to assess the impact of care source (direct versus purchased) and surgical volume on perioperative outcomes and costs of colorectal surgeries. MethodsWe examined TRICARE claims and medical records for 18- to 64-year-old patients undergoing major colorectal surgery from 2006 to 2015. We used a retrospective, weighted estimating equations analysis to assess differences in 30-day outcomes (mortality, readmissions, and major or minor complications) and costs (index and total including 30-day postsurgery) for colorectal surgery patients between purchased and direct care. ResultsWe included 20,317 patients, with 24.8% undergoing direct-care surgery. Mean length of stay was 7.6 vs 7.7 days for direct and purchased care, respectively (P = .24). Adjusted 30-day odds between care settings revealed that although hospital readmissions (odds ratio 1.40) were significantly higher in direct care, overall complications (odds ratio 1.05) were similar between the 2 settings. However, mean total costs between direct and purchased care differed ($55,833 vs $30,513, respectively). Within direct care, mean total costs ($50,341; 95% confidence interval $41,509–$59,173) were lower at very high-volume facilities compared to other facilities ($54,869; 95% confidence interval $47,822–$61,916). ConclusionDirect care was associated with higher odds of readmissions, similar overall complications, and higher costs. Contrary to common assumptions regarding volume and quality, higher volume in the direct-care setting was not associated with fewer complications.

Hepatectomy type determines long term outcomes in patients with T1/T2 gladder bladder cancer

Presenter: Muhammad Khan MD | University of Southern California, Westchester Medical center Background: Optimal surgical treatment for T1 and T2 gallbladder cancer is not well defined in the literature. We utilized a national database to assess clinical outcomes based on the hepatectomy strategy - segment IVb and V resection versus wedge resection, in patients with T1 and T2 gallbladder cancer. Methods: We utilized the 2004-2017 national cancer database to select patients with T1 and T2 gallbladder cancer. We then stratified them based on the type of the hepatectomy – wedge resection vs segment 4b and 5 resections. The two groups were assessed for differences in 30-day outcomes, and 5-year survival rates. Results: A total of 5,047 patients were included in the analysis. T1 and T2 stage gallbladder cancer patients were more likely to have a wedge resection than a segment IVb & V liver resection (94.8% vs 5.3%: p-0.01). We found no difference in 30-day mortality and readmission rates based on the surgical approach. Segment IVb & V liver resection was associated with improved 5-year survival in T1 (92 months vs 74; p-0.01) and T2 disease (75 months vs 55; p-.001). Conclusion: T1 and T2 gallbladder cancer patients undergoing segment IVb and V resection rather than wedge resection have improved 5-year survival.

Differences in 30-day outcomes between inpatient and outpatient total elbow arthroplasty (TEA)

As the health care system in the United States shifts towardvalue-based care, there has been increased interest in performing total joint arthroplastyin the outpatient setting to optimize costs, outcomes, and patient satisfaction. Several studies have demonstrated success in performing ambulatory total knee and hip arthroplasty. The purpose of this study was to compare short-term outcomes and complications after total elbow arthroplasty (TEA) across the inpatient and outpatient operative settings. The American College of Surgeons National Quality Improvement Programdatabase was queried to identify 575 patients undergoing primary TEA using the Current Procedural Terminology code 24363. Of this sample, 458 were inpatient and 117 were outpatient procedures. Propensity score matching using a 3:1 inpatient-to-outpatient ratio was performed to account for baseline differences in several variables-age, sex, body mass index class, American Society of Anesthesiologists class, and various comorbidities-between the inpatient and outpatient groups. After matching, the rates of various short-term outcomes and complications were compared between the inpatient and outpatient groups. Inpatient TEA was associated with a higher rate of complications relative to outpatient TEA, including non-home discharge (14.9% vs. 7.5%, P = .05), unplanned hospital readmission (7.4% vs. 0.9%, P= .01), surgical complications (7.6% vs. 2.6%, P= .04), and medical complications (3.6% vs. 0.0%, P= .04). Outpatient TEA has a lower short-term complication rate than inpatient TEA. Outpatient TEA should be considered for patients for whom such a discharge pathway is feasible. Future research should focus on risk stratification of patients and specific criteria for deciding when to pursue outpatient TEA.

3:09 PM Abstract No. 309 Differences in 30-day outcomes of endovascular lower extremity interventions performed by interventional radiology and vascular surgery

Studies comparing outcomes of endovascular interventions performed by interventional radiologists versus vascular surgeons have found conflicting results. This study aims to identify and correct for any differences in patient population treated by each specialty and compare short-term outcomes. The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database (2011 to 2016) was queried to identify all patients who had undergone an endovascular lower extremity intervention (eLEI) for peripheral artery disease by interventional radiologists (IR, n = 299) or vascular surgeons (VS, n = 18,906). Significantly different demographic factors and preoperative comorbidities between IR and VS treated patients were controlled for with 1:2 propensity matching. Multivariate analyses on outcomes between the cohorts were subsequently performed utilizing Pearson’s chi-squared tests and Fisher’s exact tests for categorical variables and one-way analyses of variance (ANOVA) for continuous variables. Significant differences were observed in preoperative and perioperative variables between the two cohorts. For example, IR favored use of intravenous sedation whereas VS tended to utilize general anesthesia (P < 0.001). Propensity matching successfully corrected for most of these differences. The cohort of propensity matched patients that were treated by VS that required a blood transfusion in the 30 days following operation was significantly greater than those patients treated by IR (P = 0.006). No other short-term postoperative complications were found to be significantly different. While transfusion rates are higher in patients treated by VS, specialist training and execution in eLEIs overall leads to comparable rates of short-term complications when covariates are minimized. One limitation with the NSQIP database is that institution identifiers, which may have provided for a more comprehensive comparison, are not included. Further studies are indicated to analyze the independent impact of perioperative factors such as selection of anesthesia use on outcomes, as well as the long-term efficacy of endovascular interventions performed by IR and VS.

Preservation of pelvic perfusion with iliac branch devices does not decrease ischemic colitis compared with hypogastric embolization in endovascular abdominal aortic aneurysm repair

ObjectiveIschemic colitis is a rare but devastating complication of endovascular repair of infrarenal abdominal aortic aneurysms. Although it is rare (0.9%) in standard endovascular aneurysm repair (EVAR), the incidence increases to 2% to 3% in EVAR with hypogastric artery embolization (HAE). This study investigated whether preservation of pelvic perfusion with iliac branch devices (IBDs) decreases the incidence of ischemic colitis. MethodsWe used the targeted EVAR module in the American College of Surgeons National Surgical Quality Improvement Program database to identify patients undergoing EVAR of infrarenal abdominal aortic aneurysm from 2012 to 2017. The cohort was further stratified into average-risk and high-risk groups. Average-risk patients were those who underwent elective repair for sizes of the aneurysms, whereas high-risk patients were repaired emergently for indications other than asymptomatic aneurysms. Within these groups, we examined the 30-day outcomes of standard EVARs, EVAR with HAE, and EVAR with IBDs. The primary outcome was the incidence of ischemic colitis. Secondary outcomes included mortality, major organ dysfunction, thromboembolism, length of stay, and return to the operating room. The χ2 test, Fisher exact test, Kruskal-Wallis test, and multivariate regression models were used for data analysis. ResultsThere were 11,137 patients who had infrarenal EVAR identified. We designated this the all-risk cohort, which included 9263 EVAR, 531 EVAR-HAE, and 1343 EVAR-IBD procedures. These were further stratified into 9016 cases with average-risk patients and 2121 cases with high-risk patients. In the average-risk group, 7482 had EVAR, 411 had EVAR-HAE, and 1123 had EVAR-IBD. In the high-risk group, 1781 had EVAR, 120 had EVAR-HAE, and 220 had EVAR-IBD. There was no significant difference in 30-day outcomes (including ischemic colitis) between EVAR, EVAR-HAE, and EVAR-IBD in the all-risk and high-risk groups. In the average-risk cohort, EVAR-HAE was associated with a higher mortality rate than EVAR (2.2% vs 1.0%; adjusted odds ratio, 2.58; P = .01). Although EVAR-IBD was not superior to EVAR-HAE in 30-day mortality, major organ dysfunction, or ischemic colitis in this average-risk cohort, EVAR-IBD exhibited a trend toward lower mortality compared with EVAR-HAE in this cohort, but it was not statistically significant (1.0% vs 2.2%; adjusted odds ratio, 0.42; P = .07). ConclusionsIschemic colitis is a rare complication of EVAR. HAE does not appear to increase the risk of ischemic colitis, and preservation of pelvic perfusion with IBDs does not decrease its incidence. Although HAE is associated with significantly higher mortality than standard EVAR in average-risk patients, the preservation of pelvic perfusion with IBDs does not appear to improve mortality over HAE.