Greater Operative Time Research Articles

Prospective Validation of the Spinal Cord Shape Classification System in the Prediction of Intraoperative Neuromonitoring Data Loss: Assessing the Risk of Spinal Cord Data Loss During Spinal Deformity Correction.

The Spinal Cord Shape Classification System (SCSCS) class has been associated with spinal cord monitoring data loss during spinal deformity surgery. The objective of the current study was to prospectively validate the SCSCS as a predictor of spinal cord monitoring data loss during spinal deformity surgery. A prospective cohort study of consecutive patients who were undergoing primary deformity surgery at a single institution from 2018 to 2023 and whose major curve was in the spinal cord region was undertaken. Spinal cord morphology at the apex of the major curve on preoperative axial T2-weighted magnetic resonance imaging was used to categorize patients into 3 spinal cord shape types based on the SCSCS. The primary outcome was intraoperative neuromonitoring (IONM) data loss related to spinal cord dysfunction. Demographics and surgical and radiographic variables were compared between patients with IONM data loss and those without loss. Predictors of IONM loss were determined using bivariate and multivariable logistic regression analyses. A total of 256 patients (168 adult, 88 pediatric) were included and were separated into 3 SCSCS types: 110 (43.0%) with Type I, 105 (41.0%) with Type II, and 41 (16.0%) with Type III. IONM loss was observed in 30 (11.7%) of the 256 patients, including 7 (6.4%) of 110 with SCSCS Type I, 7 (6.7%) of 105 with Type II, and 16 (39.0%) of 41 with Type III. IONM loss was associated with SCSCS Type III, the preoperative deformity angular ratio, performance of 3-column osteotomies, greater operative time, greater transfusion volume, and greater postoperative sagittal corrections. SCSCS type was the strongest independent predictor of IONM data loss. SCSCS Type III had the greatest odds of IONM loss (odds ratio [OR] = 6.68, 95% confidence interval [CI] = 2.45 to 18.23 compared with Types I and II combined). The overall predictive performance with respect to IONM loss (area under the receiver operating characteristic curve = 0.827) was considered excellent. This prospective cohort study of patients undergoing spinal deformity correction confirmed that patients with a Type-III spinal cord shape had greater odds of IONM loss. Inclusion of the SCSCS in preoperative risk stratification and intraoperative management of spinal deformity corrective surgery is recommended. Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Oxytocin Infusion versus Vaginal Misoprostol in Reducing Blood Loss during Abdominal Myomectomy: A Randomized Controlled Trial

Background Uterine myomas are most prevalent benign tumors in reproductive-aged women. Myomectomy is an alternative to hysterectomy for women who wish to retain their uterus but it is associated with higher risk of blood loss, greater operative time and need for blood transfusion. Knowledge of the effectiveness of the interventions to reduce bleeding during myomectomy is essential to enable evidence-based clinical decisions. Aim of the Work The aim of the study is to compare between the efficacy of intraoperative oxytocin infusion and preoperative vaginal misoprostol in reducing blood loss during abdominal myomectomies. Methods In a prospective randomized controlled trial which was conducted at Ain shams maternity Hospital in Cairo from July 2017 to May 2021.100 women who had abdominal myomectomy for symptomatic leiomyomas were enrolled. Patients were randomly assigned to 2 groups. Group O (Oxytocin group) patients (n = 50) received 30 U oxytocin in 500 ml normal saline infusion intraoperative and Group M (Misoprostol group) An hour before the operation, patients (n = 50) received a single dose of vaginal misoprostol (400 μg). The primary outcome was the operative blood loss. The secondary outcomes were the need for blood transfusion, change in hemoglobin (Hb) and hematocrit (Hct) levels 24 h after operation, conversion to hysterectomy, hospitalization and the prevalence of side effects. Results Intra-operative blood loss was significantly lower in those women randomized to receive vaginal misoprostol versus the oxytocin infusion group (458.5 ± 115.4 mL vs 618.8 ± 115.1 ml {P = < 0.001}). Misoprostol group showed lower mean blood loss by – 160.3 ml (95% CI -206.0 to -114.6) and reduced need for blood transfusion (RR 0.22, 95% CI 0.005 to 0.98) {P = 0.025}. Additionally, there was a highly significant statistical difference between Misoprostol group and Oxytocin group as regards the postoperative hemoglobin, hematocrit concentration, operative time as Misoprostol group showed a higher postoperative hemoglobin and hematocrit concentration, and less operative time. There was no difference in the patient demographics, intraoperative characteristics, postoperative stay, complications, and the side effects between the two groups. Conclusion As evident from the current study, pre-operative misoprostol in abdominal myomectomy is a safe and reliable method that offers some practical advantages, such as reducing intra-operative blood loss and blood transfusion needs

Comparison of titanium elastic nailing and spica casting outcomes in preschool children following femoral diaphyseal fractures

BACKGROUND & OBJECTIVE: Pediatric femoral diaphyseal fractures are common fractures in preschool children. The titanium elastic nailing technique is becoming prevalent in developed and developing countries. To compare the frequency of efficacy, safety and mean surgical fixation outcomes among patients who underwent titanium elastic nailing versus spica casting in diaphyseal femur fractures
 METHODOLOGY: A prospective study was conducted at department of orthopedics, Pakistan Ordinance Factory (POF) hospital. The study duration was 2 years (March 2018-March 2020). A sample size of 42 children was calculated using WHO calculator. Children selection was made on the basis of non-probability (consecutive) sampling. Group TEN underwent titanium elastic nailing, while group SPICA underwent hip spica casting. Patients were followed for six months. We used SPSS version 24 for the analysis of data. Fisher exacts and independent T-test were applied for measuring associations and comparisons of two groups. P-value ≤0.05 was considered significant.
 RESULTS: Total of 42 patients were included in the study. The mean age of patients was 3.4 years±1.4SD. The TEN group showed satisfactory results in malalignment (p=0.000) and complications (p=0.000). SPICA group showed significantly high assisted weight bearing duration (p=0.000), full weight bearing duration (p=0.000), greater operative time (p=0.000), lower range of motion (p=0.000) and less patient satisfaction (p=0.000) as compared to TEN group.
 CONCLUSION: Titanium elastic nailing is safe, effective, and allows faster recovery in pediatric patients with diaphyseal femoral fractures. We recommend titanium elastic nailing as a valid treatment option for femur fractures in preschool children.

Critical Analysis of Radiographic and Patient-Reported Outcomes Following Anterior/Posterior Staged Versus Same-Day Surgery in Patients Undergoing Identical Corrective Surgery for Adult Spinal Deformity.

A retrospective cohort study of a prospectively collected multicenter adult spinal deformity (ASD) database. The aim of this study was to compare staged procedures to same-day interventions and identify the optimal time interval between staged surgeries for the treatment of ASD. Surgical intervention for ASD is an invasive and complex procedure that surgeons often elect to perform on different days (staging). Yet, there remains a paucity of literature on the timing and effects of the interval between stages. ASD patients with 2-year data undergoing an anterior/posterior (A/P) fusion to the ilium were included. Propensity score matching was performed for the number of levels fused, number of interbody devices, surgical approaches, number of osteotomies/three-column osteotomy, frailty, Oswestry Disability Index, Charlson Comorbidity Index, revisions, sagittal vertical axis, pelvic incidence-lumbar lordosis, and upper instrumented vertebrae to create balanced cohorts of same-day and staged surgical patients. Staged patients were stratified by intervening time-period between surgeries, using quartiles. A total of 176 propensity score-matched patients were included. The median interval between A/P staged procedures was 3 days. Staged patients had greater operative time and lower intensive care unit stays postoperatively ( P <0.05). At 2 years, staged compared with same-day showed a greater improvement in T1 slope-cervical lordosis, C2 sacral slope, and SRS-Schwab sagittal vertical axis ( P <0.05). Staged patients had higher rates of minimal clinically important difference for 1-year SRS-Appearance and 2-year Physical Component Summary scores. Assessing different intervals of staging, patients at the 75th percentile interval showed greater improvement in 1-year SRS-Pain and SRS-Total postoperative as well as SRS-Activity, Pain, Satisfaction, and Total scores ( P <0.05) compared with patients in lower quartiles. Compared with the 25th percentile, patients reaching the 50th percentile interval were associated with increased odds of improvement in Global Alignment and Proportion score proportionality [9.3 (1.6-53.2), P =0.01]. This investigation is among the first to compare multicenter staged and same-day surgery A/P ASD patients fused to ilium using propensity matching. Staged procedures resulted in significant improvement radiographically, reduced intensive care unit admissions, and superior patient-reported outcomes compared with same-day procedures. An interval of at least 3 days between staged procedures is associated with superior outcomes in terms of Global Alignment and Proportion score proportionality.

The impact of body mass index on oncoplastic breast surgery: A multicenter analysis.

Obesity has nearly tripled in the last 50 years. During the last decades, oncoplastic breast surgery has become an important choice in the surgical treatment of breast cancer. An association exists between higher body mass index (BMI) and wound complications for major operations, but there is scarce literature on oncoplastic surgery. Hence, our aim was to compare the complication rates among patients who underwent oncoplastic surgery, stratified by BMI. Patient data were analyzed from the National Surgical Quality Improvement Program database (NSQIP) for oncoplastic breast procedures (2005-2020). Patients were stratified according to World Health Organization obesity classifications. Multivariate logistic regression was performed to assess risk factors for complications (overall, operative, and wound-related). From a total of 6887 patients who underwent oncoplastic surgery, 4229 patients were nonobese, 1380 had Class 1 obesity (BMI: 30 to <35 kg/m2 ), 737 Class 2 obesity (BMI: 35 to <40 kg/m2 ), and 541 Class 3 obesity (BMI: ≥ 40 kg/m2 ). Greater operative time was found according to higher BMI (p < 0.001). Multivariate analysis adjusted for baseline characteristics showed that patients with obesity Class 2 (odds ratio [OR] = 1.51, 95% confidence interval [CI]: 1.03-2.23, p = 0.037) and 3 (OR = 1.87, 95% CI 1.24-2.83, p = 0.003) had increased risk of overall and wound complications compared with Nonobese patients. Comparing obese with nonobese patients, there were no differences in rates of deep SSI, organ/space SSI, pneumonia, reintubation, pulmonary embolism, deep vein thrombosis, urinary tract infection, stroke, bleeding, postoperative sepsis, length of stay, and readmission. Oncoplastic surgery is a safe procedure for most patients. However, caution should be exercised when performing oncoplastic surgery for patients with Class 2 or 3 obesity (BMI ≥ 35 kg/m2 ), given there was a higher rate of overall and wound-specific complications, compared with patients who were not obese or had Class 1 obesity.

Immediate Plastic Surgery Intervention after Soft Tissue Sarcoma Resection: Examining Wound Healing, Readmission, and Reoperation.

Adult patients who underwent index STS resection between 2005 and 2018 were queried from an institutional database. Main outcomes analyzed were 90-day same-site reoperation, any-cause readmission, and wound healing complications. Univariate and multivariate logistic regression were used to identify risk factors. Additional evaluation was then performed for the following two cohorts: patients with and without plastic surgeon involvement. In total, 228 cases were analyzed. Multivariate regression demonstrated the following predictors for 90-day wound-healing complications: plastic surgery intervention [OR = 0.321 (0.141-0.728), P = 0.007], operative time [OR = 1.003 (1.000-1.006), P = 0.039], and hospital length of stay [OR = 1.195 (1.004-1.367), P = 0.010]. For 90-day readmission, operative time [OR = 1.004 (1.001-1.007), P = 0.023] and tumor stage [OR = 1.966 (1.140-3.389), P = 0.015] emerged as multivariate predictors. Patients whose resection included a plastic surgeon experienced similar primary outcomes despite these patients having expectedly longer operative times (220 ± 182 versus 108 ± 67 minutes, P < 0.001) and hospital length of stay (3.99 ± 3.69 versus 1.36 ± 1.97 days, P < 0.001). Plastic surgeon involvement emerged as a significant protector against 90-day wound healing complications. Cases that included plastic surgeons achieved similar complication rates in all categories relative to cases without plastic surgery intervention, despite greater operative time, hospital length of stay, and medical complications.

Automation of order costing analysis by using Visual Basic for applications in Microsoft Excel

In the modern world of technologies (sciences of arts), optimum operation time is the prime consideration. Technologies with greater operation time are needed to be modified or replaced as per the requirement of the current scenario. In small and medium enterprises of developing countries, almost all the reporting activities are conducted in Microsoft Excel. The manual operation in Microsoft Excel takes a long time (17.37 minutes, only if there was one order of only one article with one color) of the users; furthermore, there can also be a greater chance of error in the report. In the same way, the order costing report at the ABC footwear company of Lahore is prepared manually in Microsoft Excel which used to take a long time to be prepared along with the greater probability of errors in the report. Because of the above-mentioned reasons, the order costing report was decided to be automated with the help of visual basic for applications (VBA) in Microsoft Excel. The manual procedure including all the activities was collected from the planning and costing department of ABC Company. Moreover, all the activities were listed down and their time study was conducted. VBA macros were programmed with the objectives of automating all the manual tasks of the order costing report in Microsoft Excel and eliminating the chance of error (calculation error made by the employee). Macros, were programmed by the use of conditional statements, (i.e. if and else conditions) and various types of loops, (i.e. Do while loop and for loop). Automated decisions were made with the help of conditional statements during the operation and the conditional statements were circulated with the help of loops across the whole worksheet. Two userforms were designed for the execution of macros by the click of command buttons (having macros at their back). Total eight worksheets were incorporated into the automated template. All the programmed VBA macros were explained with the help of flowcharts made in the Microsoft Visio. After the report was automated, a time study of operations performed after each click was conducted with the help of stop watch. The data obtained by the time study was entered into Microsoft Excel so that the time of old and suggested methods could be compared. Comparison of both methods indicated that the suggested method took 85.92% less time as compared to the old method of preparing the order costing report. At the same time, the report made by the suggested method was free of errors and the workload of employees was also reduced.

What is a better value for your time? Anterior cervical discectomy and fusion versus cervical disc arthroplasty.

IntroductionCompared to anterior cervical discectomy and fusion (ACDF), the motion preservation of cervical disc arthroplasty (CDA) provides an attractive alternative with similar short-term results. However, there is a paucity of the economics of performing CDA over ACDF.Study Design:This was retrospective study.Objective:The objective of this study is to evaluate relative-value-units (RVUs), operative time, and RVUs-per-minute between single-level ACDF and CDA. Secondary outcomes included 30-day readmission, reoperation, and morbidity.Methods:Adults who underwent ACDF or CDA in 2011–2019 National Surgical Quality Improvement Program database datasets. Multivariate quantile regression was utilized.Results:There were 26,595 patients (2024 CDA). ACDF patients were older, more likely to be female, discharged to inpatient rehabilitation, and have a history of obesity, smoking, diabetes, steroid use, and the American Society of Anesthesiologists-class ≥3. ACDF had greater median RVUs-per-case (41.2 vs. 24.1) and RVUs-per-minute (0.36 vs. 0.27), despite greater operative-time (109 min vs. 92 min) (P < 0.001). ACDF predicted a 16.9 unit increase in median RVUs per case (P < 0.001, confidence interval [CI]95: 16.3–17.5), an 8.81 min increase in median operative time per case (P < 0.001, CI95: 5.69–11.9), and 0.119 unit increase in median RVUs-per-minute (P < 0.001, CI95: 0.108–0.130). ACDF was associated with greater unadjusted rates of readmission (3.2% vs. 1.4%) morbidity (2.3% vs. 1.1%) (P < 0.001), but similar rates of reoperation (1.3% vs. 0.8%, P = 0.080). After adjusting for significant patient-related and procedural factors, readmission (odds ratio [OR] = 0.695, P = 0.130, CI95: 0.434–1.113) and morbidity (OR = 1.102, P = 0.688, CI95: 0.685–1.773) was similar between ACDF and CDA.Conclusions:Median RVUs-per-minute increased by 0.119 points for ACDF over CDA, or $257.7/h for each additional-hour of surgery. Adjusted 30-day outcomes were similar between procedures. Reimbursement for CDA does not appear to be in line with ACDF and may be a barrier to widespread usage.

Impact of Navigation on 30-Day Outcomes for Adult Spinal Deformity Surgery.

Retrospective database study. Navigation has been increasingly used to treat degenerative disease, with positive radiographic and clinical outcomes and fewer adverse events and reoperations, despite increased operative time. However, short-term analysis on treating adult spinal deformity (ASD) surgery with navigation is limited, particularly using large nationally represented cohorts. This is the first large-scale database study to compare 30-day readmission, reoperation, morbidity, and value-per-operative time for navigated and conventional ASD surgery. Adults were identified in the National Surgical Quality Improvement Program (NSQIP) database. Multivariate regression was used to compare outcomes between navigated and conventional surgery and to control for predictors and baseline differences. 3190 ASD patients were included. Navigated and conventional patients were similar. Navigated cases had greater operative time (405 vs 320min) and mean RVUs per case (81.3 vs 69.7), and had more supplementary pelvic fixations (26.1 vs 13.4%) and osteotomies (50.3 vs 27.7%) (P <.001).In univariate analysis, navigation had greater reoperation (9.9 vs 5.2%, P = .011), morbidity (57.8 vs 46.8%, P = .007), and transfusion (52.2 vs 41.8%, P = .010) rates. Readmission was similar (11.9 vs 8.4%). In multivariate analysis, navigation predicted reoperation (OR = 1.792, P = .048), but no longer predicted morbidity or transfusion. Most reoperations were infectious and hardware-related. Despite controlling for patient-related and procedural factors, navigation independently predicted a 79% increased odds of reoperation but did not predict morbidity or transfusion. Readmission was similar between groups. This is explained, in part, by greater operative time and transfusion, which are risk factors for infection. Reoperation most frequently occurred for wound- and hardware-related reasons, suggesting navigation carries an increased risk of infectious-related events beyond increased operative time.

The impact of synchronous liver resection on the risk of anastomotic leakage following elective colorectal resection. A propensity score match analysis on behalf of the iCral study group

Introductionhow best to manage patients with colorectal cancer and synchronous liver metastasis is still controversial, with specific concerns of increased risk of postoperative complications following combined resection. We aimed at analyzing the influence of combined liver resection on the risk of anastomotic leak (AL) following colorectal resection. Methodswe reviewed the iCral prospectively maintained database to compare the relative risk of AL of patients undergoing colorectal resection for cancer to that of patients receiving simultaneous liver and colorectal resection for cancer with isolated hepatic metastases. The incidence of AL was the primary outcome of the analysis. Perioperative details and postoperative complications were also appraised. Resultsout of a total of 996 patients who underwent colorectal resection for cancer, 206 receiving isolated colorectal resection were compared with a matched group of 53 patients undergoing simultaneous liver and colorectal resection. Combined surgery had greater operative time and resulted in longer postoperative hospitalization compared to colorectal resection alone. The proportion of overall morbidity following combined resection was significantly higher than after isolated colorectal resection (56.6% vs. 37.9%, p = 0.021). Overall, the two groups of patients did not differ neither on the rate of major postoperative complications, nor in terms of AL (9.4% vs. 6.3%, p = 0.381). At specific multivariate analysis, the duration of surgery was the only risk factor independently associated with the likelihood of AL. Conclusionscombining hepatic with colorectal resection for the treatment of synchronous liver metastasis from colorectal cancer does not increase significantly the incidence of AL.

Sarcopenia is associated with blood transfusions in head and neck cancer free flap surgery.

ObjectiveTo determine if sarcopenia is a predictor of blood transfusion requirements in head and neck cancer free flap reconstruction (HNCFFR).MethodsA single‐institution, retrospective review was performed of HNCFFR patients with preoperative abdominal imaging from 2014 to 2019. Demographics, comorbidities (modified Charlson Comorbidity Index [mCCI]), skeletal muscle index (cm2/m2), oncologic history, intraoperative data, and 30‐day postoperative complications (Clavien‐Dindo score [CD]) were collected. Binary logistic regression was performed to determine predictors of transfusion.ResultsEighty (33.5%), 66 (27.6%), and 110 (46.0%) of n = 239 total patients received an intraoperative, postoperative, or any perioperative blood transfusion, respectively. Sixty‐two (25.9%) patients had sarcopenia. Patients receiving intraoperative transfusions had older age (P = .035), more frequent alcoholism (P = .028) and sarcopenia (P < .001), greater mCCI (P < .001), lower preoperative hemoglobin (P < .001), reconstruction with flaps other than forearm (P = .003), and greater operative times (P = .001), intravenous fluids (P < .001), and estimated blood loss (EBL, P < .001). Postoperative transfusions were associated with major complications (CD ≥ 3; P < .001). Multivariate regression determined sarcopenia (P = .023), mCCI (P = .013), preoperative hemoglobin (P = .002), operative time (P = .036), and EBL (P < .001) as independent predictors of intraoperative transfusion requirements. Postoperative transfusions were predicted by preoperative hemoglobin (P = .007), osseous flap (P = .036), and CD ≥ 3 (P < .001). A perioperative transfusion was predicted by sarcopenia (P = .021), preoperative hemoglobin (P < .001), operative time (P = .008), and CD ≥ 3 (P = .018).ConclusionSarcopenia is associated with increased blood transfusions in HNCFFR. Patients should be counseled preoperatively on the associated risks, and the increased blood product requirement should be accounted in resource‐limited scenarios.Level of Evidence4.

Clinical impact of creatine phosphokinase and c-reactive protein as predictors of postgastrectomy complications in patients with gastric cancer

BackgroundPostoperative complications have been linked to the morbidity and mortality of several cancers. However, predicting whether complications will occur in the early period after surgery or not is challenging. Hence, this study aimed to examine the diagnostic accuracy of serum creatine phosphokinase (CPK) and c-reactive protein (CRP) in predicting the development of postgastrectomy complications.MethodsWe retrospectively analyzed 188 patients with gastric cancer (GC) who underwent gastrectomy. The diagnostic accuracy of serum CPK and CRP was investigated using the areas under the curves (AUC). The CPK ratio was defined as the CPK on postoperative day (POD) 1 to the CPK on a preoperative day.ResultsOut of 188 patients, 48 (25.5%) developed postoperative complications. The complications group had a greater operative time (p = 0.037), higher CPK ratio on POD1 (p < 0.0001), and a higher serum CRP level on POD3 (p = 0.001). The AUC for the CPK ratio was 0.772, with an optimal cutoff value of 7.05, whereas that for CRP was 0.659, with an optimal cutoff value of 11.4 mg/L. The CPK ratio on POD1 (p < 0.0001) and the CRP on POD3 (p = 0.007) were independent factors for predicting the development of postgastrectomy complications. The CPK ratio on POD1 and the CRP on POD3 predicted postgastrectomy complications in 41 patients (85.4%). According to combined value of both CPK ratio and CRP level, the positive predictive value and the negative predictive value was 0.70 and 0.829. And sensitivity and specificity were 0.438 and 0.936.ConclusionThe CPK ratio on POD1 and the CRP on POD3 after gastrectomy for GC were predictive factors for complication development and may be employed to prevent the development of such complications and improve the prognosis of patients with GC.

Extent of hepatic resection impacts expense of care at no extra physiologic cost

Purpose: We sought to publish the differences in perioperative outcomes and costs in patients undergoing major and minor hepatectomy for liver tumors at a tertiary hepatobiliary center. Method: Patients undergoing hepatectomy were classified as major (≥3 segments) and minor (<3 segment) resections. Perioperative, cost and charge variables were tabulated. Statistically significant differences, defined as p<0.05, were determined by Student’s t-test. Results: 217 and 153 patients underwent major and minor hepatectomy respectively. There were no differences in age, gender, BMI or ASA score between the two groups. Estimated blood loss (p=0.0008), operative time (p=0.0001) and lesion size (p=0.0001) were significantly greater in patients with major hepatectomy vs minor hepatectomy. Length of stay (p=1.00), in hospital mortality (p=0.2) and 30 day mortality (p=0.54) were not significantly different between the two groups. Intraoperative (p=0.001), variable (p=0.002) and total costs (p=0.01) were significantly greater for patients undergoing major hepatectomy, but not postoperative (p=0.49), fixed (p=0.18) nor fixed indirect costs (p=0.09). Total hospital charges were significantly greater in patients undergoing major hepatectomy (p=0.001), but payments received was not (p=0.38). Conclusion: Major hepatectomy resulted in greater operative time, blood loss and total costs, surrogates of a technically more challenging resection than minor hepatectomy. Major hepatectomy led to greater hospital charges but not payments received. Mortality and length of stay are equivalent between major and minor hepatectomy.Tabled 1VID067MajorMinorTotal| p-ValuePatients (n)217153370EBL (mL)200(319±368.4)100(196±308.4)p=0.0008*Operative Time (minutes)289(300±116.6)216(240±121.7)p=0.0001*Size of Lesion (cm)5(6±3.9)3(4±3.3)p=0.0001*Length of Stay (days)4(5±3.9)3(5±5.1)p=1.0030 Day Mortality8 (4%)3 (2%)p=0.54Total Hospital Charges$187,286($201,749 ± $125,487.0)$144,944($162,294 ± $94,436.4)p=0.001*Total Cost$30,622($34,710 ± $29,055.5)$24,588($27,855 ± $17,673.7)p=0.01*Payments Received$19,508($42,993 ± $44,704.0)$18,037($38,620 ± $44,296.4)p=0.38 Open table in a new tab

93. Cost utility analysis of a combined approach for surgical correction of adult spinal deformity

BACKGROUND CONTEXT With the increasing emphasis on value-based outcomes in health care, there has been an increased focus on the cost of surgical intervention in patients with adult spinal deformity (ASD). However, there is a paucity of literature on the economic impact of a surgeon's surgical approach for corrective ASD surgery. PURPOSE To investigate the cost-utility associated with surgical approach. STUDY DESIGN/SETTING Retrospective cohort study of a prospective multicenter ASD database. PATIENT SAMPLE This study included 208 ASD patients. OUTCOME MEASURES Oswestry Disability Index (ODI), SF-6D, cost per quality adjusted life years (QALY). METHODS ASD patients with no previous history of fusions, complete radiographic, and HRQL data at baseline and 2 years were included. Patients were propensity score matched for age, CCI, levels fused, frailty, SVA, PI-LL and osteotomies. Means comparison tests and ANOVA chi-squared analyses assessed differences in baseline demographic and clinical data between cohorts. Utility data were calculated using ODI converted to SF-6D using published conversion methods. QALYs utilized a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs were calculated using the PearlDiver database incorporating complications, comorbidities (CC), major complications, and comorbidities (MCC) were assessed according to CMS.gov manual definitions. Two-year reimbursement consisted of a standardized estimate using regression analysis of Medicare pay-scales for all services rendered within a 30-day window, including estimates regarding costs of postoperative complications, outpatient health care encounters, revisions and medical related readmissions. After accounting for CC, MCC, length of stay (LOS), revisions, and death, cost per QALY at 2 years and life expectancy were calculated for surgical approach. RESULTS A total of 208 PSM ASD patients were included (62.2yrs, 84% F, 26.9 kg/m2). Patients undergoing a combined approach had a longer LOS (6.55 vs 8.15), greater operative time, and experienced significantly greater blood loss (all p 0.05). Despite initial higher costs of a combined approach, the average cost of ASD surgery at 2 years follow-up for posterior-only approach was greater compared to a combined approach ($72,749 vs $65,073). Furthermore, the cost per QALY was higher for posterior-only patients at 2 years compared to patients undergoing a combined approach ($363,910 vs $333,981). If utility gained is sustained to life expectancy, the cost per QALY was $54,027 for posterior-only and $49,584 for combined. CONCLUSIONS In a matched cohort of adult spinal deformity patients, a combined approach trended toward a lower average cost of surgery at 2 years, lower cost per QALY, significantly lower rates of operative complications and revisions. Although improvement after surgical intervention was similar between the two approaches, cost per QALY of posterior-only approach was slightly greater primarily driven by increased operative complications and rates of revisions. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Short-Term Outcomes of Staged Versus Same-Day Surgery for Adult Spinal Deformity Correction

Study DesignRetrospective cohort study. ObjectivesAssess differences between staged (≤3 days) and same-day surgery in perioperative factors, radiographic measures, and complications. Summary of Background DataSurgical adult spinal deformity correction may require combined anterior and posterior approaches. To modulate risk, some surgeons perform surgery that is expected to be longer and/or more complex in two stages. Prior studies comparing staged (≥7 days) and same-day surgery demonstrated mixed results and none have examined results with shorter staging intervals. MethodsRetrospective review of adults undergoing combined anterior/posterior approaches for spinal deformity over a 3-year period at a single institution (n=92). Univariate differences between staged and same-day surgery were assessed with chi-squared, Fisher exact, and Mann-Whitney U tests. Generalized estimating equations assessed whether differences in perioperative outcomes between groups remained after adjusting for differences in demographic and surgical characteristics. ResultsIn univariate analyses, staged surgery was associated with a length of stay (LOS) 3 days longer than same-day surgery (9.2 vs. 6.3 days, p < .001), and greater operative time, blood loss, transfusion requirement, and days in intensive care unit (p < .001 for each). Staged surgery had a higher rate of thrombotic events (p = .011) but did not differ in readmission rates or other complications. Radiographically, improvements in Cobb angle (average 13° vs. 17°, p = .028), lumbar lordosis (average 14° vs. 23°, p = .019), and PI-LL mismatch (average 10° vs. 2° p = .018) were greater for staged surgery, likely related to more extensive use of osteotomies in the staged group.After risk adjustment, taking into account the procedural specifics including longer fusion constructs and greater number of osteotomies, LOS no longer differed between staged and same-day surgery; however, the total operative time was 98 minutes longer for staged surgery (p < .001). Differences in blood loss between groups was accounted for by differences in operative time and patient and surgical characteristics. ConclusionsAlthough univariate analysis of our results were in accordance with previously published works, multivariate analysis allowing individual case risk adjustment revealed that LOS was not significantly increased in the staged group as reported in previous studies. There was no difference in infection rates as previously described but an increase in thrombotic events was observed. Level of EvidenceLevel III.

Speeding Up the Write Operation for Multi-Level Cell Phase Change Memory with Programmable Ramp-Down Current Pulses.

Multi-level cell (MLC) phase change memory (PCM) can not only effectively multiply the memory capacity while maintaining the cell area, but also has infinite potential in the application of the artificial neural network. The write and verify scheme is usually adopted to reduce the impact of device-to-device variability at the expense of a greater operation time and more power consumption. This paper proposes a novel write operation for multi-level cell phase change memory: Programmable ramp-down current pulses are utilized to program the RESET initialized memory cells to the expected resistance levels. In addition, a fully differential read circuit with an optional reference current source is employed to complete the readout operation. Eventually, a 2-bit/cell phase change memory chip is presented with a more efficient write operation of a single current pulse and a read access time of 65 ns. Some experiments are implemented to demonstrate the resistance distribution and the drift.

Longer Operative Time Is Independently Associated With Surgical Site Infection and Wound Dehiscence Following Open Reduction and Internal Fixation of the Ankle.

Background: Little is known regarding the association of operative time with adverse events following foot and ankle surgery. This study tests whether greater operative time is associated with the occurrence of adverse events following open reduction and internal fixation (ORIF) of the ankle. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for cases of ankle ORIF (primary CPT codes 27766, 27769, 27792, 27814, 27822, 27823) performed during 2005-2016. Operative time was tested for association with the occurrence of adverse events with controls for baseline characteristics and primary CPT code. Results: A total of 20 591 procedures met inclusion/exclusion criteria. The average (±SD) operative time was 75.7 (±37.3) minutes and varied by baseline characteristics and primary CPT code. After controlling for these factors, a 15-minute increase in operative time was associated with an 11% increase in risk for developing surgical site infection (SSI; relative risk [RR]: 1.11; 95% CI: 1.06-1.16), 20% for wound dehiscence (RR: 1.20; 95% CI: 1.11-1.29), 10% for anemia requiring transfusion (RR: 1.10; 95% CI: 1.04-1.17), 60% for cerebrovascular accident (RR: 1.60; 95% CI: 1.17-2.18), 14% for unplanned intubation (RR: 1.14; 95% CI: 1.03-1.26), and 7% for extended length of hospital admission (RR: 1.07; 95% CI: 1.05-1.09). Conclusion: Operative time is linearly and independently associated with the risks for SSI, wound dehiscence, and other adverse events following ORIF of the ankle. Efforts should be implemented to safely minimize operative duration without compromising the technical components of the procedure. Levels of Evidence: Therapeutic, Level IV.

Approach-based Comparative and Predictor Analysis of 30-day Readmission, Reoperation, and Morbidity in Patients Undergoing Lumbar Interbody Fusion Using the ACS-NSQIP Dataset

A retrospective cohort study. The aim of this study was to determine the difference in 30-day readmission, reoperation, and morbidity for patients undergoing either posterior or anterior lumbar interbody fusion. Despite increasing utilization of lumbar interbody fusion to treat spinal pathology, few studies compare outcomes by surgical approach, particularly using large nationally represented cohorts. Patients who underwent lumbar interbody fusion were identified using the NSQIP database. Rates of readmission, reoperation, morbidity, and associated predictors were compared between posterior/transforaminal (PLIF/TLIF) and anterior/lateral (ALIF/LLIF) lumbar interbody fusion using multivariate regression. Bonferroni-adjusted alpha-levels were utilized whereby variables were significant if their P values were less than the alpha-level or trending if their P values were between 0.05 and the alpha-level. We identified 26,336 patients. PLIF/TLIF had greater operative time (P = 0.015), transfusion (P < 0.001), UTI (P = 0.008), and stroke/CVA (P = 0.026), but lower prolonged ventilation (P < 0.001) and DVT (P = 0.002) rates than ALIF/LLIF. PLIF/TLIF independently predicted greater morbidity on multivariate analysis (odds ratio: 1.155, P = 0.0019).In both groups, experiencing a complication and, in PLIF/TLIF, ASA-class ≥3 predicted readmission (P < 0.001). Increased age trended toward readmission in ALIF/LLIF (P = 0.003); increased white cell count (P = 0.003), dyspnea (P = 0.030), and COPD (P = 0.005) trended in PLIF/TLIF. In both groups, increased hospital stay and wound/site-related complication predicted reoperation (P < 0.001). Adjunctive posterolateral fusion predicted reduced reoperation in ALIF/LLIF (P = 0.0018). ASA-class ≥3 (P = 0.016) and age (P = 0.021) trended toward reoperation in PLIF/TLIF and ALIF/LLIF, respectively. In both groups, age, hospital stay, reduced hematocrit, dyspnea, ASA-class ≥3, posterolateral fusion, and revision surgery and, in PLIF/TLIF, bleeding disorder predicted morbidity (P < 0.001). Female sex (P = 0.010), diabetes (P = 0.042), COPD (P = 0.011), and disseminated cancer (P = 0.032) trended toward morbidity in PLIF/TLIF; obesity trended in PLIF/TLIF (P = 0.0022) and ALIF/LLIF (P = 0.020). PLIF/TLIF was associated with a 15.5% increased odds of morbidity; readmission and reoperation were similar between approaches. Older age, higher ASA-class, and specific comorbidities predicted poorer 30-day outcomes, while procedural-related factors predicted only morbidity. These findings can guide surgical approach given specific factors. 3.

Evacuation of postoperative hematomas after thyroid and parathyroid surgery: An analysis of the CESQIP Database

A feared complication after thyroid and parathyroid operations is postoperative hematoma that threatens the airway. The aim of this study was to identify factors associated with postoperative hematoma. Patients undergoing thyroidectomy or parathyroidectomy were evaluated for postoperative hematoma requiring operative intervention using the database of the Collaborative Endocrine Surgery Quality Improvement Program. Associations between perioperative factors and postoperative hematoma were evaluated with bivariate methodologies and multivariable logistic regression. Among 19,356 patients, 60.4% underwent thyroidectomy ± lymph node dissection, 34.9% parathyroidectomy, and 4.7% concurrent thyroidectomy/parathyroidectomy. Postoperative hematoma occurred in 0.6% overall: 0.7% of thyroidectomies, 0.3% of parathyroidectomies, and 1.3% of combined thyroid/parathyroid operations (P < .001). The incidence of postoperative hematoma was greater among men (P < .001) and after greater operative times (P < .001) but was not influenced by body mass index, prior neck surgery, or reoperations. Multivariable logistic regression determined that operative complexity, operation >1 hour, male sex, and age were independently associated with postoperative hematoma. Postoperative hematoma were associated with greater rates of other complications as well. Large databases such as Collaborative Endocrine Surgery Quality Improvement Program are useful to evaluate rare complications. The risk of postoperative hematoma is associated with extent of operation, greater operative times, age, and male sex. These data may be beneficial in counseling patients and may serve as a benchmark for surgeons to evaluate their practices.

Meta-analysis of Robot-assisted Versus Laparoscopic Surgery for Rectal Cancer.

A meta-analysis was conducted to evaluate and compare the short- and long-term outcomes of robot-assisted (RAS) and conventional laparoscopic surgery (LAS) for rectal cancer. We searched MEDLINE for relevant papers published between 2010 and December 2017 by using specific search terms. We analyzed outcomes over short- and long-term periods. We identified 23 papers reporting results that compared RAS for rectal cancer with LAS. Our meta-analysis included 4,348 patients with rectal cancer; 2,068 had undergone RAS, and 2,280 had undergone LAS. In the short- and long-term period, 27 and 7 outcome variables were examined, respectively. RAS for rectal cancer was significantly associated with a greater operative time and a lower conversion rate to open surgery in the short-term, and results in almost similar outcomes in the long-term, compared to LAS. RAS may be an acceptable surgical treatment option compared to LAS for rectal cancer.