Longer Postoperative Length Of Stay Research Articles

Impact of frailty on outcomes following emergency laparotomy: a retrospective analysis across diverse clinical conditions.

Emergency laparotomy (EL) encompasses procedures of varying complexity and urgency, undertaken in different clinical scenarios, leading to different risks of morbidity and mortality. We hypothesized that the increased mortality and longer postoperative length of stay (LoS) observed in frail patients are related to differences in indication for operation, a higher rate of sepsis, worse intraperitoneal soiling, and more advanced malignancy in this group. This retrospective cohort study analysed patients entered into the National Emergency Laparotomy Audit database between January 1, 2018, and June 15, 2021, in Oxford. The primary outcome was 180-day survival analysed using multivariable Cox regression. The secondary outcomes, delay to surgery (DtS) and postoperative LoS, were analysed using logarithmically transformed multivariable linear regression. Of the 803 patients analysed, 396 (49.3%) were male. The median age was 66, and 337 (42%) were living with at least very mild frailty. Mortality hazard ratios for Clinical Frailty Scale grades 4 (3.93, 95% CI 1.89-8.20), 5 (5.86, 95% CI 2.87-11.97), and 6-7 (14.17, 95% CI 7.33-27.40) were not confounded by indication, sepsis, intraperitoneal soiling, or malignancy status. Frail patients experienced a 1.38-fold longer DtS and a 1.24-fold longer postoperative LoS, even after adjusting for indication, sepsis, intraperitoneal soiling, malignancy status, and DtS. Our results indicate that frail patients have a poorer prognosis and longer postoperative LoS, independent of DtS, indication, sepsis, intraperitoneal soiling, and malignancy status. Patient frailty is also associated with longer DtS.

Association of Postoperative Atrial Fibrillation Duration after Coronary Artery Bypass Grafting with Poor Postoperative Outcomes.

Postoperative atrial fibrillation (POAF) has long been associated with poor perioperative outcomes after coronary artery bypass grafting (CABG). In this study, we aimed to investigate the effect of prolonged POAF durations on perioperative outcomes of CABG. This retrospective cohort study examined CABG patients enrolled at Beijing Anzhen Hospital from January 2018 to September 2021. We compared patients with POAF durations 48 hours to patients with POAF durations 48 hours. Primary outcomes were in-hospital mortality, stroke, acute respiratory failure (ARF), acute kidney injury (AKI), and significant gastrointestinal bleeding (GIB); secondary outcomes were postoperative length of stay (LOS) and intensive care unit (ICU) duration. Associations between primary outcomes and POAF duration were determined using logistic regression and restricted cubic spline analyses. Differences in baseline characteristics were controlled using propensity score matching (PSM) and inverse probability of treatment weighting (IPTW). Out of 11,848 CABG patients, 3604 (30.4%) had POAF, while 1131 (31.4%) had it for a duration of 48 hours. ARF (adjusted odds ratio [OR]: 2.96, 95% confidence interval [CI]: 1.47-6.09), AKI (adjusted OR: 2.37, 95% CI: 1.42-3.99), and significant GIB (adjusted OR: 2.60, 95% CI: 1.38-5.03) were associated with POAF durations 48 hours; however, neither in-hospital mortality (adjusted OR: 1.60, 95% CI: 0.97-2.65) nor stroke (adjusted OR: 1.28, 95% CI: 0.71-2.34) was. These results remained even following PSM and IPTW analyses. POAF durations longer than 48 hours were independently associated with poorer perioperative recovery from CABG, with respect to the occurrence of ARF, AKI, and GIB, as well as a longer postoperative LOS and ICU duration. However, it was not associated with greater in-hospital mortality or stroke occurrence. All these findings suggest that postoperative monitoring of POAF and positive intervention after detection may be more helpful in optimizing post-CABG patient outcomes.

Abstract 12010: Duration of Postoperative Atrial Fibrillation After Coronary Artery Bypass Graft Surgery is Associated With Poor Perioperative Outcomes

Background: Postoperative atrial fibrillation (POAF) is one of the most common complications after coronary artery bypass graft surgery (CABG). It has long been associated with poor perioperative outcomes, but few studies have been carried out regarding the effect of POAF duration on those outcomes. Research Questions: Does prolonged duration of POAF have an adverse effect on perioperative outcomes of CABG? Methods: This retrospective cohort study examined CABG patients enrolled at Beijing Anzhen Hospital from January 2018 to September 2021. We compared POAF duration ≥48 hours patients with POAF duration <48 hours patients. Primary outcomes examined were in-hospital mortality, stroke, acute respiratory failure (ARF), acute kidney injury (AKI), as well as significant gastrointestinal bleeding (GIB); secondary outcomes were postoperative length of stay (LOS), intensive care unit (ICU) stay. Associations between primary outcomes and POAF duration were determined using logistic regression and restricted cubic spline analyses. Results: Out of 11 848 CABG patients, 3604 (30.4%) had POAF; 1131 (31.4%) of POAF patients had it for duration ≥48 hours. ARF (adjusted odds ratio [OR]: 2.96, 95% confidence interval [CI]: 1.47 - 6.09), AKI (adjusted OR: 2.37, 95% CI: 1.42 - 3.99), and significant GIB (adjusted OR: 2.60, 95% CI: 1.38 - 5.03), but not in-hospital mortality (adjusted OR: 1.56, 95% CI: 0.92 - 2.65) or stroke (adjusted OR: 1.29, 95% CI: 0.70 - 2.33) was associated with POAF duration ≥48 hours. These findings were still applicable, even after conducting propensity score matching and inverse probability of treatment weighting analyses. Conclusions: POAF duration longer than 48 hours was independently associated with poorer perioperative recovery from CABG, with respect to the occurance of AFR, AKI and GIB, as well as longer postoperative LOS and ICU stay. However, it was not associated with greater in-hospital mortality or stroke occurrence. All these findings suggest that postoperative monitoring of POAF and positive intervention after detection could optimize post-CABG patient outcomes.

Redo laparoscopic pyeloplasty for recurrent ureteropelvic junction obstruction: Propensity score matched analyses of a high-volume center.

PurposeReview the experience of redo laparoscopic pyeloplasty (RLP) in patients with recurrent ureteropelvic junction obstruction (UPJO) in comparison to primary laparoscopic pyeloplasty (PLP) and redo open pyeloplasty (ROP), and determine the feasibility and effectiveness of RLP for recurrent UPJO in children.MethodsWe retrospectively reviewed the clinical data of patients treated with transperitoneal PLP, RLP, and ROP for UPJO from December 2015 to December 2022. The Propensity score matching (PSM) was used to balance confounding variables. RLP patients were 1:4 matched with PLP and 1:3 matched with ROP. The primary outcomes were failure and post-operative complications. Complications were classified according to the Clavien-Dindo grading system.ResultsThe study included ten patients who underwent RLP, 43 patients who underwent ROP, and 412 patients who underwent PLP. The follow-up time ranged from 6 to 36 months in the RLP group, 12 to 60 months in the PLP group, and 24 to 54 months in the ROP group. In the RLP group, no failure but three post-operative complications (Clavien grade II) were observed during the follow-up. Compared with the PLP group, the older age, higher weight, larger pre-operative anteroposterior diameter (APD) and APD/cortical thickness (P/C ratio), longer operation time, and post-operative length of stay (LOS) in the RLP group (P < 0.05). After PSM, longer operation time and post-operative LOS were observed in the RLP group (P < 0.05). Compared with the ROP group, the older age, higher weight, and longer post-operative LOS in the RLP group (P < 0.05). After PSM, longer post-operative LOS was observed in the ROP group (P < 0.05). The failure and complication rates were comparable between RLP and PLP or RLP and ROP (P > 0.05).ConclusionsOur result demonstrated that RLP performed as well as PLP except for a longer operation time. Compared with ROP, RLP has the advantages of a clearer surgical view, sufficient exposure, clearer anatomical landmark position, and minor trauma with a comparable clinical outcome. On experienced hands, RLP for recurrent UPJO after is a safe and effective procedure and should be considered an excellent alternative to the more commonly recommended ROP in select patients.

Is it safe to administer neoadjuvant chemotherapy to patients undergoing hepatectomy for intrahepatic cholangiocarcinoma? ACS-NSQIP propensity-matched analysis.

The use of neoadjuvant chemotherapy (NAC) in patients with intrahepatic cholangiocarcinoma (iCCA) is increasing. The objective of this study was to compare the 30-day post-operative complications and length-of-stay (LOS) between patients undergoing hepatectomy for iCCA with and without NAC. A retrospective study was conducted using the ACS-NSQIP database queried from 2014 to 2018. Patients with NAC receipt were propensity-score matched into 1:3 ratio with controls using the greedy-matching algorithm and a caliper of 0.2. Logistic and Poisson regression models were used to estimate the effect sizes. A total of 1508 patients who underwent hepatectomy for iCCA were included. 706 patients remained after matching and balance were achieved. The NAC group had 110 (60.1%) complications vs. 289 (55.3%) complications in the non-NAC group (p=0.29). NAC was not associated with worse 30-day postoperative complications [OR 1.24, 95% CI: 0.87-1.76; p=0.24]. Post-operative LOS in the NAC group was 8.56 days (mean, SD 7.4) vs. non-NAC group 9.27 days (mean, SD 8.41, p=0.32). NAC was not associated with longer post-operative LOS [RR 0.93, 95% CI:0.80, 1.08; p=0.32]. NAC may be safely administered without increasing the risk of 30-day complications or post-operative hospital LOS.

Appendectomy and Cholecystectomy Outcomes for Pediatric Cancer Patients with Leukopenia: A NSQIP-Pediatric Study

BackgroundChildren with cancer often develop leukopenia which may impair wound healing and increase surgical complication rates. When leukopenic children with cancer develop an acute surgical condition, the optimal management strategy remains unclear. This study examined the effect of preoperative leukopenia on postoperative outcomes in children with cancer who underwent an appendectomy or cholecystectomy. MethodsWe retrospectively identified cancer patients undergoing an appendectomy or cholecystectomy from the National Surgical Quality Improvement Program-Pediatric database from 2012-2018. Demographics and perioperative characteristics were compared by leukopenia status (WBC <4 vs. ≥4 × 10^3/mL). Postoperative length of stay (LOS) and 30-day composite complications, including infections, reoperations, and readmissions, were analyzed for each procedure using multivariate regression. ResultsThere were 227 children who underwent an appendectomy and 101 children who underwent a cholecystectomy. Leukopenia was seen in 93 (41.0%) appendectomy and 57 (56.4%) cholecystectomy cases. Nineteen (8.4%) appendectomy patients and six (5.9%) cholecystectomy patients developed a postoperative complication. The median postoperative LOS was 2 days (IQR 1-6 days) for appendectomy and 1 day (IQR 1-2.5 days) for cholecystectomy cases. After multivariate analyses, leukopenia was not associated with increased postoperative complications after an appendectomy (OR 0.55, P = 0.36) or cholecystectomy (OR 0.39, P = 0.37). There was no significant difference in postoperative LOS based on leukopenia status for children who underwent an appendectomy (P = 0.82) or cholecystectomy (P = 0.37). ConclusionIn pediatric cancer patients, leukopenia was not associated with increased short-term postoperative complications or longer postoperative LOS after either an appendectomy or cholecystectomy. These results support that operative management can be performed safely in pediatric appendicitis and cholecystitis in leukopenic cancer patients.

Perioperative Outcomes for Centers Routinely Admitting Postoperative Endovascular Aortic Aneurysm Repair to the ICU

Intensive care unit (ICU) admission after endovascular aortic aneurysm repair (EVAR) varies across medical centers. We evaluated the association of postoperative ICU use with perioperative and long-term outcomes after EVAR. The Vascular Quality Initiative (2003-2019) was queried for index elective EVARs. Included centers were categorized by percentage of patients with EVARs postoperatively admitted to the ICU; routine ICU (rICU) centers as ≥80% ICU admissions and nonroutine ICU (nrICU) centers as ≤20% ICU admissions. Patients admitted preoperatively or with same day discharge were excluded. Perioperative outcomes and survival were compared between rICU and nrICU centers. Of 45,310 EVARs in the database, 35,617 were performed at rICU or nrICU centers - 5,443 (15.3%) at 71 rICU centers and 30,174 (84.7%) at 200 nrICU centers. Overall, mean age was 73.4 years and 81.6% were male. Postoperative myocardial infarction, pulmonary complications, stroke, leg ischemia, and in-hospital mortality were similar between rICU and nrICU centers (all p > 0.05). Postoperative length of stay (LOS) was prolonged at rICU centers (mean) (2.2 ± 3.6 vs 2 ± 4.2 days, p < 0.001). One-year survival was similar between rICU and nrICU centers, respectively, (94.9% vs 95.4%, p= 0.085). When compared with nrICU centers, rICU centers had similar 1-year mortality risk (hazard ratio [HR] 1.15, 95% CI 0.99-1.34, p= 0.076), but were associated with longer postoperative LOS (means ratio 1.1, 95% CI 1.08-1.13, p < 0.001). Routine ICU use after EVAR was associated with prolonged postoperative LOS, without improved perioperative/long-term morbidity or mortality. Updated care pathways to include postoperative admission to lower acuity care units may reduce costs without compromising care.

Tourniquet use in routine primary total knee arthroplasty is associated with a higher transfusion rate and longer postoperative length of stay: a real-world study

BackgroundIn an enhanced recovery after surgery program, a growing number of orthopedists are reconsidering the necessity of tourniquet use in total knee arthroplasty (TKA). However, the impact of tourniquet use on transfusion rate and postoperative length of stay (PLOS) in TKA remains controversial. Therefore, we carried out a study to investigate the effect of tourniquet application in routine primary TKA on transfusion rate and PLOS.MethodsWe analyzed data from 6325 patients who underwent primary unilateral TKA and divided them into two groups according to whether a tourniquet was applied during the procedure, and a tourniquet was used in 4902 and not used in 1423. The information for transfusion and PLOS was extracted from patients’ electronic health records, and the data were analyzed with logistic and linear regression analyses.ResultsFollowing TKA, the transfusion rate and PLOS were 14.52% and 7.72 ± 3.54 days, respectively, in the tourniquet group, and 6.47% and 6.44 ± 3.48 days, respectively, in the no-tourniquet group. After adjusting for the different related variables, tourniquet use was significantly correlated with a higher transfusion rate (risk ratio = 1.888, 95% confidence interval (CI) 1.449–2.461, P < 0.001) and a longer PLOS (partial regression coefficient (B) = 0.923, 95%CI 0.690–1.156, P < 0.001).ConclusionsOur findings suggested that tourniquet use in routine primary TKA was related to a higher transfusion rate and a longer PLOS. The impact of tourniquet use on transfusion rate and PLOS should be taken into account in clinical practice.

Post-operative delirium in older patients following cancer related and other high-risk surgeries.

e24024 Background: Older adults are at increased risk for postoperative delirium (POD). This risk might be higher in patients with cancer as underlying malignancy and its complications predispose individuals to develop delirium. Therefore, it is important to evaluate the onset of delirium in this patient population especially as POD is associated with increased risk of rehospitalization, decline in cognitive function, morbidity and mortality. Methods: We performed a retrospective review of patients aged ≥ 70 years admitted January 2017 through July 2019 to a tertiary care referral center for a high-risk surgery, defined as associated with a mortality risk greater than 1%. Cancer related surgeries (CRS) were identified through cross matching with Cancer Registry. Patients who had delirium assessment in the postoperative setting using the Confusion Assessment Method (CAM) were included. Chi-square tests of proportion, Wilcoxon Ranked Sum and multivariate logistic regression analyses were conducted. Results: A total of 2340 patients were included in this analysis, 315 of whom had (CRS). Overall, the age (median, IQR) of patients at surgery was 76 years (72-80) and the length of stay (LOS) was 7 (4-11) days. Patients receiving CRS were younger (75, 72-79) than those with non-CRS (76, 72-81) (p = 0.022); had a shorter post-operative LOS (4, 2-7 vs. 5, 3-8; p &gt; 0.001), and were less likely to develop POD (7.6% vs. 16.1%; p &lt; 0.001). Among patients receiving CSR, those who developed POD were older (78 vs. 74; p = 0.008) and had longer post-operative LOS (14.0 vs. 4.0; p &lt; 0.001). Those having experienced radiotherapy (RT) for cancer within the year before the surgery, were more likely to develop POD (40.0% vs. 6.6% p. &lt; 0.001). Chemotherapy in the year prior to surgery did not increase the risk of POD (6.1% vs. 7.8%; p = 0.721). Among those having non-CRS, a cancer diagnosis did not affect POD. A logistic regression predicting POD indicated that the lower likelihood of POD following CRS was independent of age or gender (OR = 0.40; p &lt; .001); RT within one year prior was independent predictor of higher POD (OR = 5.48; p = 0.003). Our data presentation will include further analysis of POD risk factors. Conclusions: Although older adults receiving CRS were significantly less likely to develop delirium than patients with other high-risk surgeries, it is still important to evaluate POD in this population due to its impact of patients’ outcomes. Further understanding of POD risk factors, such as preoperative RT, would allow the development of targeted interventions that might lessen the risk.

Delay in coronary artery bypass grafting for STEMI patients improves hospital morbidity and mortality

ObjectivesThe optimal timing of coronary artery bypass grafting (CABG) in patients with ST elevated acute myocardial infarction (STEMI) is unclear. The purpose of the study is to evaluate and compare the outcomes in STEMI patients who underwent CABG within the various time intervals within the first 7 days of either emergent or urgent hospital admission.MethodsPatients aged 30 years old and older diagnosed with STEMI who underwent CABG within first 7 days after non-elective hospital admission were selected from the National Inpatient Sample 2010–2014 using the appropriate ICD-9-CM diagnosis and procedure codes. These patients were divided into 3 cohorts based on timing of surgery: within 24 h (group A), 2nd-3rd day (group B), and 4th–7th day (group C). The rates of postoperative complications, mortality, and postoperative hospital length of stay (LOS) were compared using the Chi-square test, multivariable logistic regression analysis, and Wilcoxon rank sum test.ResultsA total of 5963 patients were identified: group A = 28.5%, group B = 36.1%, group C = 35.4%. Mean age overall was 63.1 ± 11.1 years; 76.9% were males and 72.9% were whites. Compared to groups B and C, patients in group A were more likely to develop cardiac complications (OR [odds ratio] =1.33, 95%CI [confidence interval] 1.12–1.59 and OR = 1.39, 95%CI 1.17–1.67, respectively) and respiratory complications (OR = 1.31, 95%CI 1.13–1.51 and OR = 1.53, 95%CI 1.32–1.78, respectively). They were also more likely to have renal complications (OR = 1.31, 95%CI 1.11–1.54) and bleeding (OR = 1.20, 95%CI 1.05–1.37) than patients in group B and had a similar tendency compared to group C. We did not find significant differences in the above complications between groups B and C. Postoperative stroke and sternal wound infection rates were similar between all three groups. In-hospital mortality was also higher in group A (8.2%) compared to group B (3.5%) and group C (2.9%, P < 0.0001 for both); differences between groups B and C were not significant. This was confirmed in the multivariable logistic regression analysis with controlling for age, gender, race, the Elixhauser Comorbidity Index, and complications (group A vs B: OR = 1.85, 95%CI 1.52–2.25; group A vs C: OR = 2.21; 95%CI 1.82–2.68). Patients in group A had a significantly longer postoperative LOS (median 7 days with IQR [interquartile range] 5–10 days) compared to those in group B (median 6 days, IQR 5–8 days) and group C (median 6 days, IQR 4–8 days; P < 0.0001 for both).ConclusionsThe results of this study show that despite the urgency and severity of STEMI, patients who undergo CABG within the first 24 h after non-elective hospital admission have increased hospital morbidity and mortality. These findings suggest that a delay in surgery beyond the first 24 h may be beneficial to patient outcomes. Furthermore, there is a significant cost effectiveness when the patients delay surgery because the hospital length of stay is reduced as well as the subsequent hospital costs.

Impact of nutritional status/risk and post-operative nutritional management on clinical outcomes in patients undergoing gastrointestinal surgery: a prospective observational study.

Malnutrition is prevalent in patients undergoing gastrointestinal (GI) surgery and has been linked to adverse outcomes. The present study aimed to determine the association between early post-operative nutritional status/risk, post-operative nutritional management and clinical outcomes. A prospective observational study was conducted in GI surgical patients with a minimum 3-day post-operative length of stay (LOS). Data on patient demographics, nutritional status/risk, post-operative nutritional management and clinical outcomes were collected. Four markers of nutritional status and risk were assessed: preoperative weight loss, nutrition risk, malnutrition status and hand grip strength. Clinical outcomes included: post-operative LOS, complication and readmissions rates. Multivariate linear and logistic regression were used to test for associations with clinical outcomes. One hundred and fifteen patients (55% female) with mean (SD) age of 60.8 (16.2) years were included. Median (IQR) post-operative LOS was 8.0days (4.5-11.5), 37% of participants developed at least one complication post-operatively and 24% were readmitted within 30-days of discharge. Mean number of nil-by mouth (NBM) days post-operatively was 0.7 (1.2) and the average time to commence feeding was 3.3 (2.2)days after surgery. Poor nutritional status/risk between days 3-5post-operatively assessed through all four markers was associated with longer post-operative LOS (all P<0.05). No association was found between number of NBM days, time to feeding and clinical outcomes. Poor early post-operative nutritional status/risk is associated with longer post-operative LOS in patients undergoing GI surgery, which may facilitate simple identification of patients at high priority for nutritional intervention. The present study highlights the heterogeneity in post-operative nutritional management practices.

Genetic abnormalities/syndromes significantly impact perioperative outcomes of conotruncal heart defects.

Objectives:The main objective of the study is to characterize the effects of genetic abnormalities/syndromes (GA/S) on perioperative outcomes of cardiac surgeries involving repair of conotruncal heart defects (CTHD).Design:The study involves a single-center retrospective analysis of patients who underwent complete repair of CTHDs (tetralogy of Fallot [TOF], truncus arteriosus, interrupted aortic arch, and ventricular septal defect with coarctation) between January 2000 and December 2015. The primary outcome was the post operative length of stay (PLOS). The secondary outcomes were mortality, cardiac complications, hematologic complications, infections, and number of medications-at-discharge.Setting:Cardiac intensive care unit in a tertiary pediatric hospital in South Florida that performs around 300 open-heart surgeries a year.Subjects:A total of 177 patients with CTHDs who underwent cardiac surgeries in the stated time period were included in the final study cohort.Measurements and Main Results:Majority of patients had TOF (72.5%) and 46 (26%) had GA/S. The most common GA/S was 22q11 deletion (37%). PLOS was significantly increased in patients with GA/S (P < 0.05). Patients with GA/S were 4.5 times more likely to have a postoperative cardiac complication, 4.2 times more likely to have a postoperative infection, and received 1.6 times more medications at discharge than those without GA/S. However, GA/S was not associated with increased perioperative mortality. Black patients were three times more likely to have a longer PLOS than White patients.Conclusions:Perioperative outcomes in patients with GA/S suggested an increased residual cardiovascular disease and increased resource usage. Notably, this is the first study demonstrating the effect of race and ethnicity on PLOS in CTHD patients.

Effect of Trisomy 21 on Postoperative Length of Stay and Non-cardiac Surgery After Complete Repair of Tetralogy of Fallot

Trisomy 21 (T21) is the most common chromosomal abnormality, and is frequently associated with congenital heart disease. Results of previous studies evaluating the effect of T21 on postoperative outcomes and complications following heart surgery have been mixed. Our goal was to determine if T21 is associated with higher frequency of adverse postoperative outcomes following repair of tetralogy of Fallot (TOF). A query of the Pediatric Health Information System was performed for patients who underwent complete repair of TOF from 2004 to 2015. Patients with a genetic syndrome other than T21 and tracheostomy and/or gastrostomy prior to heart surgery were excluded. Two groups were created on the basis of whether patients received a diagnostic code for T21. The adverse outcomes of interest were postoperative mortality, postoperative length of stay (LOS), postoperative gastrostomy, and postoperative tracheostomy. Univariate and Kaplan-Meier analysis were performed to evaluate outcomes. There were a total of 4790 patients; 430 (9%) patients had T21, and 4360 (91%) patients without a genetic diagnosis. There was no significant difference in mortality before discharge between those with and without T21 (2.3% vs 1.4%; p = 0.155). Patients with T21 had longer postoperative LOS (mean of 19.8days vs 12.4days; p < 0.001), and higher rates of postoperative gastrostomy (13.3% vs 5.3%; p < 0.02). There was no significant difference between groups for rates of postoperative tracheostomy (1.9% vs 1.2%; p = 0.276). Kaplan-Meier analysis confirmed that patients with T21 had longer postoperative LOS and greater incidence of gastrostomy.

Closed suction drainage following routine primary total joint arthroplasty is associated with a higher transfusion rate and longer postoperative length of stay: a retrospective cohort study

BackgroundIn an enhanced recovery after surgery program, not placing a closed suction drain following routine primary total joint arthroplasty (TJA) is becoming more acceptable. However, the influence of drain use on transfusion rate and postoperative length of stay (PLOS) in TJA remains controversial. Therefore, we aimed to compare drain use with no drain in routine primary TJA to determine the differences in transfusion rate and PLOS.MethodsWe analyzed the data from 12,992 patients undergoing primary unilateral TJA: 6325 total knee arthroplasties (TKA) and 6667 total hip arthroplasties (THA). Patients were divided into two groups according to whether they received a drain postoperatively following TKA and THA. We extracted information for transfusion and PLOS from patients’ electronic health records and analyzed the data by logistic and linear regression analyses.ResultsThe transfusion rate and PLOS were 15.07% and 7.75 ± 3.61 days, respectively, in the drain group and 6.72% and 6.54 ± 3.32 days, respectively, in the no-drain group following TKA. The transfusion rate and PLOS were 20.53% and 7.00 ± 3.35 days, respectively, in the drain group and 13.57% and 6.07 ± 3.06 days, respectively, in the no-drain group following THA. After adjusting for the following variables: age, gender, body mass index, orthopedic diagnoses, hypertension, type 2 diabetes, coronary heart disease, chronic obstructive pulmonary disease, preoperative hemoglobin, albumin, analgesic use, anesthesia, American Society of Anesthesiologists class, tranexamic acid use, intraoperative bleeding, operative time, and tourniquet use (for TKA), drain use correlated significantly with a higher transfusion rate (risk ratio = 2.812, 95% confidence interval (CI) 2.224–3.554, P < 0.001 for TKA and risk ratio = 1.872, 95% CI 1.588–2.207, P < 0.001 for THA) and a longer PLOS (partial regression coefficient (B) = 1.099, 95% CI 0.879–1.318, P < 0.001, standard regression coefficient (B′) = 0.139 for TKA; B = 0.973, 95% CI 0.695–1.051, P < 0.001, and B′ = 0.115 for THA). Two groups showed no significant difference in wound complications.ConclusionsOur findings indicated that drain use was associated with a higher transfusion rate and a longer PLOS in patients undergoing routine primary TJA. The routine use of postoperative drainage is not recommended in primary unilateral TJA.

Preoperative Clinical and Echocardiographic Factors Associated with Surgical Timing and Outcomes in Primary Repair of Common Atrioventricular Canal Defect.

In complete atrioventricular canal defect (CAVC), there are limited data on preoperative clinical and echocardiographic predictors of operative timing and postoperative outcomes. A retrospective, single-center analysis of all patients who underwent primary biventricular repair of CAVC between 2006 and 2015 was performed. Associated cardiac anomalies (tetralogy of Fallot, double outlet right ventricle) and arch operation were excluded. Echocardiographic findings on first postnatal echocardiogram were correlated with surgical timing and postoperative outcomes using bivariate descriptive statistics and multivariable logistic regression. 153 subjects (40% male, 84% Down syndrome) underwent primary CAVC repair at a median age of 3.3 (IQR 2.5-4.2) months. Median postoperative length of stay (LOS) was 7 (IQR 5-15) days. Eight patients (5%) died postoperatively and 24 (16%) required reoperation within 1year. On multivariable analysis, small aortic isthmus (z score < -2) was associated with early primary repair at < 3months (OR 2.75, 95% CI 1.283-5.91) and need for early reoperation (OR 3.79, 95% CI 1.27-11.34). Preoperative ventricular dysfunction was associated with higher postoperative mortality (OR 7.71, 95% CI 1.76-33.69). Other factors associated with mortality and longer postoperative LOS were prematurity (OR 5.30, 95% CI 1.24-22.47 and OR 5.50, 95% CI 2.07-14.59, respectively) and lower weight at surgery (OR 0.17, 95% CI 0.04-0.75 and OR 0.55, 95% CI 0.35-0.85, respectively). Notably, preoperative atrioventricular valve regurgitation and Down syndrome were not associated with surgical timing, postoperative outcomes or reoperation, and there were no echocardiographic characteristics associated with late reoperation beyond 1 year after repair. Key preoperative echocardiographic parameters helped predict operative timing and postoperative outcomes in infants undergoing primary CAVC repair. Aortic isthmus z score < -2 was associated with early surgical repair and need for reoperation, while preoperative ventricular dysfunction was associated with increased mortality. These echocardiographic findings may help risk-stratified patients undergoing CAVC repair and improve preoperative counseling and surgical planning.

Pre- and intra-operative predictors of postoperative hospital length of stay in patients undergoing radical prostatectomy for prostate cancer in China: a retrospective observational study

BackgroundHospital length of stay (LOS) has recently been receiving increasing attention as a marker of medical resource consumption. Identifying predictors of longer LOS can better equip doctors to counsel patients and facilitate more efficient patient flow and utilization of medical resources. The objective of this study was to identify pre- and intra-operative risk factors for postoperative hospital LOS in patients who had undergone radical prostatectomy in China.MethodsWe retrospectively analyzed data of 793 eligible patients with prostate cancer who had undergone radical prostatectomy in our institution between January 2011 and March 2016. Relevant preoperative variables, including patient characteristics, medical comorbidities, prostate cancer disease-specific variables, urinary tract symptoms, preoperative laboratory values, and intraoperative variables including operation type, operation duration, and blood loss, were analyzed. The outcome was postoperative length of stay which was calculated as the time from the date of operation to the date of discharge. Multiple linear regression analysis was used to identify predictors of this outcome.ResultsThe mean postoperative LOS was 11.7 days (±4.6 days) and the median 10 days (range, 5–46 days). According to univariate and multivariate analysis, operation type (open or laparoscopic), blood loss, Gleason score (≥8) and preoperative laboratory values of white blood count (WBC) were found to be the main explanatory predictors of postoperative LOS of patients with prostate cancer in our institution. Additionally, open surgery was the strongest significant predictor of longer LOS according to the standardized coefficients in this model.ConclusionsOur findings indicate that significant predictors of longer postoperative LOS in patients who have undergone radical prostatectomy in China include both preoperative variables of Gleason score, WBC and intraoperative variables of operation type (open or laparoscopic), blood loss. To shorten hospital LOS in patients with prostate cancer and optimize utilization of Chinese medical resources, efforts should be made to improve the intraoperative process and reduce the prevalence of preoperative risk factors.

Association of Preoperative Cell Counts With Outcomes After Operation for Congenital Heart Disease

We examined the association of preoperative cell count abnormalities, which have been shown to be associated with outcomes in adult cardiac patients, with morbidity and mortality after operation for congenital heart disease (CHD) in children. We performed a retrospective cohort studyon 4,865 children undergoing cardiac operation from 2004 to 2014. Our exposures of interest were presence ofpreoperative lymphopenia (lymphocyte count ≤3,000cells/μL), thrombocytopenia (platelet count <150× 103/μL), and neutrophilia (neutrophil count ≥7,000 cells/μL). Our outcomes of interest were mortality status, postoperative length of stay (LOS), and occurrence of postoperative complications. We performed logistic and linear regressions to determine the associations of preoperative cell counts with mortality, LOS, and complications, adjusting for age, sex, race or ethnicity, presence of a genetic syndrome, and Society of Thoracic Surgeons and European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality category. Overall mortality was 2.8%, median LOS was 6days, and 7.6% of patients had postoperative complications. Lymphopenia was associated with increased odds of postoperative mortality (odds ratio 1.67, 95% confidence interval: 1.15 to 2.43, p= 0.007). Lymphopenia, thrombocytopenia, and neutrophilia were all associated with longer postoperative LOS. Lymphopenia and thrombocytopenia were associated with increased occurrence of postoperative sepsis, and neutrophilia was associated with need for postoperative mechanical circulatory support. In children undergoing CHD operation, preoperative lymphopenia is associated with increased in-hospital mortality postoperatively. Preoperative lymphopenia, neutrophilia, and thrombocytopenia are associated with longer postoperative LOS and with development of postoperative complications. Preoperative cell counts may serve as important prognostic markers in preoperative planning for patients with CHD.

Machine learning algorithm for predicting longer postoperative length of stay among older cancer patients.

e21536 Background: To predict longer postoperative length of stay (LLOS) among older cancer patients, we have used a novel method to assess factors associated with this outcome. Methods: Our study was based on 47-item electronic Rapid Fitness Assessment (eRFA) data presented last year (Shahrokni, et al. (J Clin Oncol 34, 2016 (suppl; abstr 10011). LLOS was defined as LOS ≥8days.We used machine learning model to explore the relationship between &gt; 70 pre, intra, and postoperative variables with LLOS. A filter-based variable selection algorithm was utilized to only identify the most important variables as defined by information gain. We computed the mutual information between each variable and the LOS, and ranked them from high to low gain. To create an interpretable machine learning model, we used decision tree classifier. The tree started with the most informative variable as the root and branches based on a threshold value such that the entropy decreases by most. Results: In a cohort of 492 postoperative older cancer patients (median age 80), the variable selection algorithm showed that only 5 variables are sufficient for predicting LLOS with an accuracy of 77.2%, sensitivity 81.6% and specificity 61.31% in all patients. The algorithm started with operation time (OT) of &lt; or &gt; 4 hrs. For example, patients with OT &gt; 4 hours and social activity limitation (SAL) &gt; 7 were 78% likely to have LLOS. Patients with SAL ≤ 7 and OT &gt; 5 hours were 75% likely to have LLOS. Patients were 71% likely not to have LLOS if OT &lt; 4 hours and SAL ≤ 7. To avoid the effect of potential data collection errors and increase the accuracy of the model, we used the Bootstrap Aggregating (bagging) method which ensembles the decision of a set small trees. Particularly, we generated 3 datasets from randomly sampling patients from current dataset with replacement and built 3 different trees. As a result of combining 3 short trees we reach the accuracy of 83.2% with sensitivity 83.9% and specificity 82.4%. Conclusions: Machine learning model could be helpful for predicting LLOS among older cancer patients. Prospective studies are needed to validate this method in different academic and community settings.

Prolonged air leak after video-assisted thoracic surgery lung cancer resection: risk factors and its effect on postoperative clinical recovery.

Prolonged air leak (PAL) is one of the most common postoperative complications after pulmonary resection. The aim of this study was to reveal the incidence and risk factors of PAL in video-assisted thoracic surgery (VATS) lung cancer resection, and to evaluate the effect of PAL on postoperative complications, postoperative length of stay (PLOS), and medical costs. Continuous patients who underwent VATS major pulmonary resection for lung cancer between January 2014 and December 2015 were studied. Clinical data of these patients were obtained from the Western China Lung Cancer Database. PAL was defined as air leak more than 5 days after surgery. The risk factors for PAL were analyzed, as well as the effect of PAL on postoperative clinical recovery. A total of 1,051 patients were enrolled in this study. The incidence of PAL was 10.6% (111/1,051). Pleural adhesion [odds ratio (OR), 2.38 for extensive vs. none, P=0.001] was identified as the only independent risk factors for PAL through multivariate analysis. The incidence of overall complications and pneumonia were significantly higher in patients with PAL (PAL group) than those without PAL (non-PAL group) (OR, 6.77, P=0.000; OR, 2.41, P=0.010, respectively). PAL was found to be associated with longer PLOS (11.7±6.6 vs. 6.5±3.6 days; P=0.000) and higher medical costs (¥62,042.5±18,072.0 vs. ¥52,291.3±13,845.5, P=0.000). Pleural adhesion was associated with increased risk of PAL after VATS lung cancer resection. Those patients with PAL had more postoperative complications, stayed longer in the hospital after surgery, and paid higher medical costs.

Contemporary outcomes of complete atrioventricular septal defect repair: Analysis of the Society of Thoracic Surgeons Congenital Heart Surgery Database

Contemporary outcomes data for complete atrioventricular septal defect (CAVSD) repair are limited. We sought to describe early outcomes of CAVSD repair across a large multicenter cohort, and explore potential associations with patient characteristics, including age, weight, and genetic syndromes. Patients in the Society of Thoracic Surgeons Congenital Heart Surgery Database having repair of CAVSD (2008-2011) were included. Preoperative, operative, and outcomes data were described. Univariate associations between patient factors and outcomes were described. Of 2399 patients (101 centers), 78.4% had Down syndrome. Median age at surgery was 4.6 months (interquartile range, 3.5-6.1 months), with 11.8% (n = 284) aged ≤ 2.5 months. Median weight at surgery was 5.0 kg (interquartile range, 4.3-5.8 kg) with 6.3% (n = 151) < 3.5 kg. Pulmonary artery band removal at CAVSD repair was performed in 122 patients (4.6%). Major complications occurred in 9.8%, including permanent pacemaker implantation in 2.7%. Median postoperative length of stay (PLOS) was 8 days (interquartile range, 5-14 days). Overall hospital mortality was 3.0%. Weight < 3.5 kg and age ≤ 2.5 months were associated with higher mortality, longer PLOS, and increased frequency of major complications. Patients with Down syndrome had lower rates of mortality and morbidities than other patients; PLOS was similar. In a contemporary multicenter cohort, most patients with CAVSD have repair early in the first year of life. Prior pulmonary artery band is rare. Hospital mortality is generally low, although patients at extremes of low weight and younger age have worse outcomes. Mortality and major complication rates are lower in patients with Down syndrome.