Median Postoperative Length Of Stay Research Articles

Contemporary perioperative outcomes after total abdominal colectomy for ulcerative colitis in a tertiary referral centre.

Colectomy for ulcerative colitis (UC) is common despite therapeutic advances. Post-operative morbidity and mortality demonstrate an association between hospital volumes and outcomes. This single-centre retrospective study examines outcomes after emergency colectomy for UC. Patient demographics, perioperative variables and outcomes were collected in Beaumont Hospital between 2010 and 2023. Univariant analysis was used to assess relationships between perioperative variables and morbidity and length of stay (LOS). A total of 115 patients underwent total abdominal colectomy with end ileostomy for UC, 8.7 (±3.8) per annum. Indications were refractory acute severe colitis (88.7%), toxic megacolon (6.1%), perforation (4.3%), or obstruction (0.9%). Over 80% of cases were performed laparoscopically. Pre-operative steroid (93%) and biologic (77.4%) use was common. Median post-operative LOS was 8 days (interquartile range 6-12). There were no 30-day mortalities, and 30-day post-operative morbidity was 38.3%. There was no association between time to colectomy ( P = 0.85) or biologic use ( P = 0.24) and morbidity. Increasing age was associated with prolonged LOS ( P = 0.01). Laparoscopic approach (7 vs. 12 days P =0.01, 36.8% vs. 45% P = 0.66) was associated with reduced LOS and morbidity. This study highlights contemporary outcomes after emergency colectomy for UC at a specialist high-volume, tertiary referral centre, and superior outcomes after laparoscopic surgery in the biologic era.

Factors influencing the length of stay (LOS) undergoing robot-assisted thoracoscopic lung surgery in the setting of enhanced recovery after surgery (ERAS) protocol for pediatric patients: a retrospective study.

A prolonged length of stay (LOS) after surgery may result in higher hospital costs and hospital-acquired complications. This study aims to identify the risk factors associated with a prolonged hospital stay after robot-assisted thoracoscopic lung surgery for pediatric patients in the context of enhanced recovery after surgery. The data for this retrospective study were collected from pediatric patients undergoing robot-assisted thoracoscopic lung surgery. Patients were divided into two subgroups based on median postoperative LOS (Group I: LOS > median 5 days and Group II: LOS ≤ median 5 days). Logistic regression analysis was used to identify the potential factors associated with increased LOS. This study included 241 patients, 71 (29.46%) with an LOS of >5 days. The proportion of older children was significantly higher in Group I than that in Group II (P=0.004). Patients in Group I were more likely to experience a longer duration of anesthesia and surgery (P<0.001). They also had significantly higher rates of pneumonia, pleural effusion, and liver function damage (P<0.05). Several factors were identified to be associated with an increased LOS after robot-assisted thoracoscopic lung surgery: age >6 years [odds ratio (OR) =3.214, 95% confidence interval (CI): 1.464-7.502, P=0.004], surgery duration >100 min (OR =2.138, 95% CI: 1.296-4.387, P=0.005), intra-albumin (OR =13.778, 95% CI: 1.470-129.116, P=0.022), and blood loss >5 mL (OR =2.184, 95% CI: 1.082-4.409, P=0.029). The results revealed that older age, longer surgery duration, use of intra-albumin, and more blood loss predict longer postoperative hospital stay in pediatric patients with congenital lung lesions after robot-assisted thoracoscopic lung surgery.

MULTIMODAL PREHABILITATION MAY IMPROVE SURGICAL OUTCOMES FOR PATIENTS WITH INFLAMMATORY BOWEL DISEASE

Abstract BACKGROUND Surgery is associated with loss of lean body mass and physical deconditioning, which can delay healing and lead to complications. Multimodal prehabilitation (PH) with nutrition optimization and physical therapy improves outcomes after cancer surgery. However, the effects of prehabilitation for inflammatory bowel disease (IBD) surgery are not established. We aimed to assess surgical outcomes among IBD patients exposed to prehabilitation relative to no prehabilitation. METHODS We conducted a case-controlled study of the impact of prehabilitation in patients with IBD who underwent major abdominal surgery for Crohn’s disease (CD) or ulcerative colitis (UC) between May 1st, 2022 and June 6th, 2023 at a tertiary care center. Cases were defined as those who participated in a multimodal PH program that included nutrition counseling (weight optimization, preoperative carbohydrate loading and perioperative immunonutrition), medication management, physical therapy, and psychosocial evaluation beginning 4 weeks prior to surgery; controls received standard of care (SOC) written preoperative surgical instructions without PH. We assessed postoperative complications (defined by the comprehensive complications index (CCI)), severe complications (CCI&amp;gt;20), reoperation rate, 30-day readmission, post operative length of stay (LOS) and post-operative opioid use (defined by daily morphine milligram equivalents (MME)). Statistical tests included linear and logistic regression, Mann-Whitney U test, Chi-Square test, and Fisher’s exact test, as appropriate. RESULTS A total of 68 patients were identified, including 20 PH (cases) and 48 SOC (controls). Among PH, 75% had CD with the remainder UC; surgeries included ileocecal resection (45%), colectomy with ileostomy (25%), ileal pouch-anal anastomosis (25%), and small bowel resection (5%). Among SOC, 31% had CD with the remainder UC, and surgeries included colectomy with ileostomy (60%), stage 2 IPAA (29%), and small bowel (6%) or ileal (4%) resections. Age, sex, race, and ethnicity was similar between groups. Overall and severe complication rates were similar between PH and SOC (mean CCI scores 13.42 PH vs 11.25 SOC (p = 0.58), and CCI &amp;gt; 20 in 40% PH patients vs 29% SOC (p = 0.56)). Median post-operative LOS was shorter among PH vs SOC (3.0 vs 3.5d, p=0.02), and median post-operative opioid use was lower among PH vs SOC (19.5 vs 20.8 MME, p = 0.04). Readmission within 30 days occurred in 30% of PH and 17% of SOC (p = 0.22). Reoperation within 30 days occurred in 5% of PH and 17% of SOC (p = 0.37). CONCLUSION: Multimodal prehabilitation may improve select surgical outcomes in IBD, including length of stay and opioid use after surgery. Larger, prospective, controlled studies may help to further clarify the impact of PH on surgical outcomes for IBD, including complications, readmissions, and functional status. Table 1. Patient Characteristics and Outcomes by Prehabilitation Exposure Status

Predictors of Post-Operative Hospital Length of Stay Following Complete Repair of Tetralogy of Fallot in a Pediatric Cohort in the North of England

We sought to estimate the median post-operative length of stay (PLOS) and predictors of PLOS following tetralogy of Fallot (ToF) repair at a specialist surgical center in the North of England. The local National Congenital Heart Disease Audit dataset was used to identify patients aged < 2 years who underwent surgical repair for ToF between 1 January 1986 and 13 May 2022. Coefficients representing the median change in PLOS (days) according to predictors were estimated using Quantile regression. There were 224 patients (59.4% male, median age = 9 months, interquartile range (IQR) 5–13 months) with a median PLOS of 9 days (IQR 7–13). In the univariable regression, age (months) and weight (kg) at operation (β = − 0.17, 95% CI: − 0.33, − 0.01) and (β = − 0.53, 95% CI: − 0.97, − 0.10), previous (cardiac or thoracic) procedure (β = 5, 95% CI:2.38, 7.62), procedure urgency (elective vs urgent) (β = 2.8, 95% CI:0.39, 5.21), bypass time (mins) (β = 0.03, 95% CI:0.01, 0.05), cross-clamp time (mins) (β = 0.03, 95% CI:0.01, 0.06) and duration of post-operative intubation (days) (β = 0.81, 95% CI:0.67, 0.96), were significantly associated with PLOS. Previous procedure and intubation time remained significant in multivariable analyses. Some patient and operative factors can predict PLOS following complete ToF repair. Information on PLOS is important for health professionals to support parents in preparing for their child's discharge and to make any necessary practical arrangements. Health commissioners can draw on evidence-based guidance for resource planning. The small sample size may have reduced the power to detect small effect sizes, but this regional study serves as a foundation for a larger national study.

Cost Impact of an Enhanced Recovery Program for Lower Extremity Bypass

Enhanced recovery programs (ERPs) have significant potential patient benefits. However, implementation can also lead to increased cost of care with addition of standardized practices such as dedicated wound closure trays and increased use of regional anesthesia. This study's aim was to examine the impact of ERP implementation on cost of care for lower extremity bypass (LEB). A retrospective analysis was performed on LEB patients treated before (n = 145) and after (n = 171) ERP implementation in May 2018. Trauma, patients with concomitant suprainguinal bypass, and length of stay (LOS) outliers were excluded. Clinical data and McKesson-derived variable cost (volume dependent—supplies, nurse labor, medications), fixed cost (volume independent—overhead, admin staff, building maintenance and utilities), and total costs data were analyzed over the entire hospital encounter. Claudication, rest pain, or tissue loss were similar between pre-ERP and ERP patients (P = .335). Pre-ERP patients had similar total cost compared to ERP ($28,881 vs $29,230; P = .381). Overall median (interquartile range [IQR]) postoperative LOS decreased from 6 (IQR, 4-7 days) to 4 days (IQR, 3-7 days) (P < .001). Costs differed by indication, but there was no difference in pre-ERP vs ERP cohorts (Table). When comparing cost centers, we observed significant pre-ERP vs ERP cost declines in nursing (−16.0%; P = .032), intensive care unit (−56.5%; P = .021), and therapy categories (−17.5%; P = .015) but an increase in surgical (14.6%; P = .008) and anesthesia costs (14.8%; P = .004) (Figure). Overall cost of care remained stable with LEB-ERP. ERP implementation was associated with increased surgical and anesthesia costs, likely owing to additional elements of care such as standardized wound dressings, dedicated closure trays, and increased regional block utilization, but these costs overall appear offset by decreased LOS.TablePre-enhanced recovery program (ERP) and ERP costsCostPre-ERP (n = 145)ERP (n = 171)ERP/Pre-ERP differencePercent changeTotal costa$28,881 ± 1,3571$29,230 ± 15,359$3491.2By indication Claudication$21,210 ± 6585$23,149 ± 10,496$19399.1 Rest pain$29,359 ± 14516$29,194 ± 15,082$ (165)−0.6 Tissue loss$36,591 ± 13431$36,483 ± 17,812$ (107)−0.3Intensive care unit cost outliers and patients with a postoperative length of stay >90th percentile were excluded.aFixed and variable costs were also analyzed and found to follow similar trends. Open table in a new tab

Hypertrophic Pyloric Stenosis Protocol: A Single Center Study.

Initial treatment of hypertrophic pyloric stenosis (HPS) is correction of electrolyte disturbances with fluid resuscitation. In 2015, our institution implemented a fluid resuscitation protocol based on previous data that focused on minimizing blood draws and allowing immediate ad libitum feeds postoperatively. Our aim was to describe the protocol and subsequent outcomes. We conducted a single-center retrospective review of patients diagnosed with HPS from 2016 to 2023. All patients were given ad libitum feeds postoperatively and discharged home after tolerating three consecutive feeds. The primary outcome was the postoperative hospital length of stay (LOS). Secondary outcomes included the number of preoperative labs drawn, time from arrival to surgery, time from surgery to initiation of feeds, time from surgery to full feeds, and re-admission rate. The study included 333 patients. A total of 142 patients (42.6%) had electrolytic disturbances that required fluid boluses in addition to 1.5x maintenance fluids. The median number of lab draws was 1 (IQR 1,2), with a median time from arrival to surgery of 19.5hours (IQR 15.3,24.9). The median time from surgery to first and full feed was 1.9hours (IQR 1.2,2.7) and 11.2hours (IQR 6.4,18.3), respectively. Patients had a median postoperative LOS of 21.8hours (IQR 9.7,28.9). Re-admission rate within the first 30 postoperative days was 3.6% (n = 12) with 2.7% of re-admissions occurring within 72hours of discharge. One patient required re-operation due to an incomplete pyloromyotomy. This protocol is a valuable tool for perioperative and postoperative management of patients with HPS while minimizing uncomfortable intervention.

Is atelectasis related to the development of postoperative pneumonia? a retrospective single center study

BackgroundAtelectasis may play a substantial role in the development of pneumonia. However, pneumonia has never been evaluated as an outcome of atelectasis in surgical patients. We aimed to determine whether atelectasis is related to an increased risk of postoperative pneumonia, intensive care unit (ICU) admission and hospital length of stay (LOS).MethodsThe electronic medical records of adult patients who underwent elective non-cardiothoracic surgery under general anesthesia between October 2019 and August 2020 were reviewed. They were divided into two groups: one who developed postoperative atelectasis (atelectasis group) and the other who did not (non-atelectasis group). The primary outcome was the incidence of pneumonia within 30 days after the surgery. The secondary outcomes were ICU admission rate and postoperative LOS.ResultsPatients in the atelectasis group were more likely to have risk factors for postoperative pneumonia including age, body mass index, a history of hypertension or diabetes mellitus and duration of surgery, compared with those in the non-atelectasis. Among 1,941 patients, 63 (3.2%) developed postoperative pneumonia; 5.1% in the atelectasis group and 2.8% in the non-atelectasis (P = 0.025). In multivariable analysis, atelectasis was associated with an increased risk of pneumonia (adjusted odds ratio, 2.33; 95% CI: 1.24 – 4.38; P = 0.008). Median postoperative LOS was significantly longer in the atelectasis group (7 [interquartile range: 5–10 days]) than in the non-atelectasis (6 [3–8] days) (P < 0.001). Adjusted median duration was also 2.19 days longer in the atelectasis group (β, 2.19; 95% CI: 0.821 – 2.834; P < 0.001). ICU admission rate was higher in the atelectasis group (12.1% vs. 6.5%; P < 0.001), but it did not differ between the groups after adjustment for confounders (adjusted odds ratio, 1.52; 95% CI: 0.88 – 2.62; P = 0.134).ConclusionAmong patients undergoing elective non-cardiothoracic surgery, patients with postoperative atelectasis were associated with a 2.33-fold higher incidence of pneumonia and a longer LOS than those without atelectasis. This finding alerts the need for careful management of perioperative atelectasis to prevent or reduce the adverse events including pneumonia and the burden of hospitalizations.Trial registrationNone.

Optimal discharge planning for esophagectomy patients with enhanced recovery after surgery: Recommendations.

Studies have suggested that the postoperative length of stay (PLOS) of esophagectomy patients under the enhanced recovery after surgery (ERAS) pathway should be >10 days as against the previously recommended 7 days. We investigated the distribution and influencing factors of PLOS in the ERAS pathway in order to recommend an optimal planned discharge time. This was a single-center retrospective study of 449 patients with thoracic esophageal carcinoma who underwent esophagectomy and perioperative ERAS between January 2013 and April 2021. We established a database to prospectively document the causes of delayed discharge. The mean and median PLOS were 10.2 days and 8.0 days (range: 5-97), respectively. Patients were divided into four groups: group A (PLOS ≤ 7 days), 179 patients (39.9%); group B (8 ≤ PLOS ≤ 10 days), 152 (33.9%); group C (11 ≤ PLOS ≤ 14 days), 68 (15.1%); group D (PLOS > 14 days), 50 patients (11.1%). The main cause of prolonged PLOS in group B was minor complications (prolonged chest drainage, pulmonary infection, recurrent laryngeal nerve injury). Severely prolonged PLOS in groups C and D were due to major complications and comorbidities. On multivariable logistic regression analysis, open surgery, surgical duration >240 min, age >64 years, surgical complication grade >2, and critical comorbidities were identified as risk factors for delayed discharge. The optimal planned discharge time for patients undergoing esophagectomy with ERAS should be 7-10 days with a 4-day discharge observation window. Patients at risk of delayed discharge should be managed adopting PLOS prediction.

FEASIBILITY OF A NURSE AND DIETITIAN-LED IBD SURGICAL PREHABILITATION PROGRAM

Abstract BACKGROUND Surgery activates catabolic pathways that lead to loss of lean body mass and physical deconditioning, which can predispose to complications and delayed healing. Prehabilitation addresses modifiable risk factors, provides nutrition and functional status optimization, and has been shown to optimize surgical outcomes after cancer and/or orthopedic surgery. This includes decreased hospital length of stay (LOS), postoperative complications, readmission rates, and accelerated return to pre-surgical functional capacity. We assessed the feasibility of a structured, multidisciplinary prehabilitation program for patients with inflammatory bowel disease (IBD) undergoing abdominal surgery. METHODS We developed a nurse-practitioner and dietitian-led IBD prehabilitation program for patients undergoing ileal-cecal resection (ICR) or colectomy. Perioperative nutrition and medications were addressed during two clinic visits (4 weeks before and after surgery). The Global Leadership Initiative on Malnutrition (GLIM) criteria were used to define malnutrition. Sarcopenia was defined as either (1) two standard deviations below the norm for age and gender as assessed by dynamometry or (2) skeletal muscle index (SMI) &amp;lt;55 cm2/m2 for males and &amp;lt;39 cm2/m2 for females at the L3 region as assessed by computerized tomography. Micronutrients (iron profile, vitamin D, B6, zinc) were assessed and corrected if a deficiency was found. Patients were provided personalized diet recommendations for optimizing nutrition and were counseled on preoperative carbohydrate loading, and pre- and post-operative immunonutrition (IN). We assessed post-operative outcomes including post-operative length-of-stay (LOS), 30-day readmission, and perioperative complications of infection, abscess, and leak. RESULTS Ten patients (70% female, mean age 41 years) completed the program between 3/2021 and 5/2022. 9 underwent ICR and 1 underwent colectomy. 9 completed IN pre-operatively (90%); 9 (90%) completed carbohydrate loading pre-operatively, and 4 (40%) completed IN post-operatively. Upon initial assessment, 6 patients (60%) had malnutrition, and among the 4 patients with sarcopenia assessments, all 4 met criteria for sarcopenia. Forty percent had at least one micronutrient deficiency. Median post-operative LOS was 3.5 days. There were no readmissions within 30 days, and one patient had a postoperative infection. CONCLUSION A nurse practitioner- and dietician-led structured prehabilitation program is feasible. We hypothesize that low compliance with post-operative IN was due to formula not being available for inpatients at our facility; the impact of IN on post-operative outcomes should be evaluated in future studies. Further evaluation of outcomes associated with structured, multidisciplinary prehabilitation in IBD relative to usual care is warranted.

Qualitative Analysis of Length of Stay and Readmission after Carotid Endarterectomy

Length of stay (LOS) and readmissions are common measures to evaluate quality of health care. The objective of this study was to evaluate factors related to hospital LOS and readmission within 90days following carotid endarterectomy (CEA) in patients who have not had a stroke. Using a single institution database, patients who underwent CEA for carotid stenosis between 2014 and 2019 were identified. Asymptomatic carotid stenosis (no history of any stroke or transient ischemic attack (TIA) within 6months prior to CEA), and patients who had a TIA without stroke were included. Demographic and perioperative factors were collected. Primary outcomes analyzed were increased LOS (>1day) and readmission within 90days after surgery. There were 125 patients identified who underwent CEA for 133 carotid stenosis, and 8 patients had bilateral CEA; of which 36.8% were asymptomatic carotid stenosis with the remaining being operated on for TIA without any stroke. The mean age was 68years old and 36.1% of cases were female. The median postoperative LOS was 2days. Increased LOS occurred in 81 cases (60.9%). Increased LOS, compared to no increased LOS, occurred more often in patients with diabetes (48.1% vs. 30.8%, P=0.047), in those with operations starting after 12:00 pm (45.7% vs. 21.2%, P=0.004) and those with any minor complications such as neck swelling, neck pain, and urinary retention (30.9% vs. 15.4%, P=0.044). Readmission within 90days after CEA occurred in 24 (18%) of cases. Readmission within 90days, compared to no readmission within 90days, occurred more often in patients with a history of coronary artery disease (58.3% vs. 27.5%, P=0.004), congestive heart failure (37.5% vs. 11%, P=0.001), and atrial fibrillation (29.2% vs. 8.3%, P=0.004). More than half of patients undergoing CEA for carotid stenosis were discharged after postoperative day 1. Interventions on modifiable clinical risk factors, such as morning CEA scheduling and management of comorbidities, may decrease LOS and 90-day readmission rates.

A Retrospective Study of the Role of Perioperative Serum Albumin and the Albumin-Bilirubin Grade in Predicting Post-Liver Transplant Length of Stay.

Serum albumin's association with liver transplant outcomes has been investigated with mixed findings. This study aimed to evaluate perioperative albumin level, independently and as part of the albumin-bilirubin (ALBI) grade, as a predictor of post-liver transplant hospital and intensive care unit (ICU) length of stay (LOS). Adult liver-only transplant recipients at our institution from September 2011 to May 2019 were included in this retrospective study. Repeat transplants were excluded. Demographic, laboratory, and hospital course data were extracted from an institutional data warehouse. Negative binomial regression was used to assess the association of LOS with ALBI grade, age, BMI, ASA score, Elixhauser comorbidity index, MELD-Na, warm ischemia time, units of platelets and cryoprecipitate transfused, and preoperative serum albumin. Six hundred and sixty-three liver transplant recipients met inclusion criteria. The median preoperative serum albumin was 3.1 [2.6-3.6] g/dL. The median postoperative ICU and hospital LOS were 3.8 [2.4-6.8] and 12 [8-20] days, respectively. Preoperative serum albumin predicted hospital but not ICU LOS (ratio .9 [95% confidence interval (CI) .84-.99], P = .03, hospital LOS vs ratio .92 [95% CI 0.84-1.02], P = .10, ICU LOS). For patients with MELD-Na ≤ 20, ALBI grade-3 predicted longer hospital and ICU LOS (ratio 1.40 [95% CI 1.18-1.66], P < .001, hospital LOS vs ratio 1.62 [95% CI 1.32-1.99], P < .001, ICU LOS). These associations were not significant for patients with MELD-Na > 20. Serum albumin predicted post-liver transplant hospital LOS. ALBI grade-3 predicted increased hospital and ICU LOS in low MELD-Na recipients.

Does size matter? Comparing robotic versus open radical nephrectomy for very large renal masses.

We evaluated perioperative and mortality outcomes of robotic-assisted radical nephrectomy (RRN) vs. open radical nephrectomy (ORN) for very large renal cell carcinomas (RCC). Adult patients with non-metastatic RCC >10 cm in size (pT2b) were identified from the National Cancer Database (2010-2017). Mixed-effects multivariable logistic regression adjusting for patient, tumor, and facility characteristics were used to evaluate rates of positive margin, prolonged length of stay (LOS) (>75th percentile), 30-day readmission, and 30-day and 90-day mortality for RRN vs. ORN. Overall survival (OS) was evaluated using the Kaplan-Meier method and adjusted Cox proportional hazard modeling. Of the 2,977 patients who underwent radical nephrectomy, 492 (16.5%) underwent RRN. Factors associated with RRN included male gender, metro or urban locations, academic facilities, Charlson-Deyo score >2, private or Medicaid insurance, and surgery in a later year (all P < 0.05). Tumors ≥15.1cm in size were associated with a higher rate of conversion to open surgery (P < 0.001). ORN was associated with increased median postoperative LOS (4d [interquartile range; IQR 3-6] vs. 3d, [IQR 2-4]; P < 0.01). RRN demonstrated no significant difference in the risk of positive margin, 30-day readmission, 30-day mortality, or 90-day mortality. RRN was associated with a decreased risk of prolonged LOS (OR 0.38; 95%CI [0.28-0.53]). There was no difference in long-term OS observed in patients treated with ORN vs. RRN. Very large, non-metastatic RCC can be safely and effectively treated with RRN. Rates of conversion to open were higher for tumors ≥15.1 cm. RRN has comparable long-term OS and improved LOS compared to ORN.

151. Factors causing delay in discharge in patients eligible for ambulatory lumbar fusion surgery

<h3>BACKGROUND CONTEXT</h3> Assessing postoperative system inefficiencies and implementing process-improvement measures are vital to increase the feasibility of ambulatory lumbar fusion. <h3>PURPOSE</h3> Primary objective was to identify patients who would have been eligible for same-day discharge following minimally invasive elective lumbar fusion and then analyze the limiting factors in their postoperative pathway that led to a delay in discharge. Secondary objective was to assess if patient characteristics and operative variables had an impact on postoperative parameters influencing discharge. <h3>STUDY DESIGN/SETTING</h3> Retrospective review of prospectively collected data. <h3>PATIENT SAMPLE</h3> Consecutive patients undergoing primary single-level minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for degenerative conditions of the lumbar spine who would have been eligible for ambulatory lumbar fusion. <h3>OUTCOME MEASURES</h3> Postoperative in-hospital variables including 1) length of stay (LOS), 2) time in post-anesthesia recovery unit (PACU), 3) alertness check, neurological exam and pain scores at 3 hours and 6 hours, 4) type of analgesia, 5) time to physical therapy (PT) visit and clearance, 6) reasons for PT non-clearance, 7) time to per-oral (PO) intake, 8) time to voiding, 9) time to readiness for discharge, and 10) complications. <h3>METHODS</h3> Eligibility criteria for ambulatory lumbar fusion and discharge criteria were determined a priori based on a review of the literature and the authors' experience. Preoperative, surgical and postoperative in-hospital data were analyzed. Time taken to meet each discharge criterion was calculated. Time of discharge readiness was taken as the point when the patient had fulfilled all the criteria. The percentage of patients meeting each discharge criterion at 3 hours and 6 hours post-surgery was calculated. Correlation and regression analyses were performed to study the effect of postoperative variables on LOS. Multiple linear and logistic regression analyses were performed to study the effect of preoperative and operative variables on postoperative parameters influencing discharge. <h3>RESULTS</h3> A total of 71 patients were included of which only 4% were discharged on the same day. Most (69%) patients were discharged on postoperative day one. PT clearance, voiding and PO intake were the last-met discharge criterion in 93%, 6% and 1% of patients respectively. A total of 66% of patients did not get a PT evaluation on the day of surgery. Intravenous (IV) opioids for pain control (average of 2 doses) were required for 76% of patients. Less than 60% of patients had adequate pain control at 3 hours and 6 hours after the surgery. Orthostatic intolerance was seen in 27% of patients. The median postoperative LOS was 26.9 hours, time in PACU was 4.2 hours, time to PO intake was 6.5 hours, time to first void was 6.3 hours, time to first PT visit was 17.7 hours, time to PT clearance was 21.8 hours, and time to discharge readiness was 21.9 hours. Regression analyses showed that postoperative variables (time to PT clearance, time to PO intake, time to voiding, time in PACU, and pain score at 3 hours) had a significant effect on LOS. There was no effect of preoperative and operative variables on postoperative parameters influencing discharge. <h3>CONCLUSIONS</h3> Unavailability of PT, orthostatic intolerance, inadequate pain control, prolonged PACU stay, and long feeding and voiding times were identified as modifiable factors preventing same-day discharge in patients eligible for ambulatory lumbar fusion. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Naloxegol versus Alvimopan for Enhancing Postoperative Recovery following Radical Cystectomy for Bladder Cancer.

µ-Opioid-receptor antagonists are a standard component of enhanced recovery after surgery (ERAS) pathways following radical cystectomy (RC) as they reduce ileus and shorten length of stay (LOS). Prior studies have used alvimopan; however, naloxegol is a less expensive medication in the same class. We compared differences in postoperative outcomes between patients receiving alvimopan or naloxegol following RC. We retrospectively reviewed all patients undergoing RC over 20 months at an academic center during which standard practice transitioned from using alvimopan to naloxegol, while maintaining all other components of our ERAS pathway. We utilized bivariate comparisons as well as negative binomial and logistic regression to compare return of bowel function, rates of ileus and LOS following RC. Of 117 eligible patients, 59 (50%) received alvimopan and 58 (50%) received naloxegol. There were no differences in baseline clinical, demographic or perioperative factors. Median postoperative LOS was 6 days in each group (p=0.3). Time to flatus (2 versus 2 days, p=0.2) and ileus (14% versus 17%, p=0.6) were similar between the alvimopan and naloxegol groups, respectively. In multivariable models controlling for patient and surgical factors, µ-opioid antagonist agent was associated with neither LOS nor ileus. Cost difference was -$344.20/day, equivalent to a $2,065.20 savings over a 6-day hospital stay with naloxegol. In patients undergoing RC managed with a standard ERAS pathway, there were no differences in postoperative recovery based on the use of alvimopan versus naloxegol. Substitution of naloxegol for alvimopan may allow for significant cost savings without compromising outcomes.

Factors Causing Delay in Discharge in Patients Eligible for Ambulatory Lumbar Fusion Surgery.

Retrospective review of prospectively collected data. To analyze the postoperative factors that led delayed discharge in patients who would have been eligible for ambulatory lumbar fusion (ALF). Assessing postoperative inefficiencies is vital to increase the feasibility of ALF. Patients who underwent single-level minimally invasive transforaminal lumbar interbody fusion and would have met the eligibility criteria for ALF were included. Length of stay (LOS); time in postanesthesia recovery unit (PACU); alertness and neurological examination, and pain scores at three and six hours; type of analgesia; time to physical therapy (PT) visit; reasons for PT nonclearance; time to per-oral (PO) intake; time to voiding; time to readiness for discharge were assessed. Time taken to meet each discharge criterion was calculated. Multiple regression analyses were performed to study the effect of variables on postoperative parameters influencing discharge. Of 71 patients, 4% were discharged on the same day and 69% on postoperative day 1. PT clearance was the last-met discharge criterion in 93%. Sixty-six percent did not get PT evaluation on the day of surgery. Seventy-six percent required intravenous opioids and <60% had adequate pain control. Twenty-six percent had orthostatic intolerance. The median postoperative LOS was 26.9 hours, time in PACU was 4.2 hours, time to PO intake was 6.5 hours, time to first void was 6.3 hours, time to first PT visit was 17.7 hours, time to PT clearance was 21.8 hours, and time to discharge readiness was 21.9 hours. Regression analysis showed that time to PT clearance, time to PO intake, time to voiding, time in PACU, and pain score at three hours had a significant effect on LOS. Unavailability of PT, surgery after 1 pm , orthostatic intolerance, inadequate pain control, prolonged PACU stay, and long feeding and voiding times were identified as modifiable factors preventing same-day discharge. 4.

MP39-09 COMPARISON OF ALVIMOPAN VERSUS NALOXEGOL FOR ENHANCING POSTOPERATIVE RECOVERY FOLLOWING RADICAL CYSTECTOMY FOR BLADDER CANCER

You have accessJournal of UrologyCME1 May 2022MP39-09 COMPARISON OF ALVIMOPAN VERSUS NALOXEGOL FOR ENHANCING POSTOPERATIVE RECOVERY FOLLOWING RADICAL CYSTECTOMY FOR BLADDER CANCER Peter Kirk, Austin Wang, Dima Raskolnikov, Sarah Psutka, George Schade, John Gore, Yaw Nyame, Janet Kelly, and Jonathan Wright Peter KirkPeter Kirk More articles by this author , Austin WangAustin Wang More articles by this author , Dima RaskolnikovDima Raskolnikov More articles by this author , Sarah PsutkaSarah Psutka More articles by this author , George SchadeGeorge Schade More articles by this author , John GoreJohn Gore More articles by this author , Yaw NyameYaw Nyame More articles by this author , Janet KellyJanet Kelly More articles by this author , and Jonathan WrightJonathan Wright More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002599.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Opioid-receptor antagonists reduce the occurrence of postoperative ileus and shorten length of stay following radical cystectomy (RC), and are a standard component of enhanced recovery after surgery (ERAS) pathways. Although most prior data have studied the use of alvimopan for this indication, naloxegol is a less expensive alternative within the same medication class. We compared differences in postoperative outcomes between patients receiving alvimopan and naloxegol following RC. METHODS: We retrospectively reviewed all patients undergoing RC (open and robotic) and urinary diversion for bladder cancer at an urban, academic cancer center during which the standard practice transitioned from alvimopan to naloxegol without any other changes to our ERAS pathway (November 2019 through July 2021). We utilized bivariate comparisons as well as negative binomial and logistic regression to compare return of bowel function, rates of ileus, and length of stay (LOS) following RC. RESULTS: There were 86 patients eligible for inclusion, of whom 52 (60.5%) received alvimopan and 34 (39.5%) received naloxegol. There were no significant differences in baseline clinical or demographic characteristics, nor in perioperative factors (Table). Median postoperative LOS was six days with no significant differences between medication groups. There were also no significant differences between alvimopan and naloxegol in time to return of bowel function (3 versus 2 days to flatus, respectively, p =0.09) or rates of postoperative ileus (13 versus 24 percent, respectively, p =0.26). In multivariable models controlling for patient and surgical factors, choice of medication was not a significant predictor of LOS or ileus. Mean cost difference between alvimopan and naloxegol was -$328.22 per day in favor of naloxegol, equivalent to a reduction of $1,969.32 over a six-day hospital stay. CONCLUSIONS: In patients undergoing RC, there were no significant differences in postoperative recovery based on the use of alvimopan versus naloxegol. Substitution of naloxegol for alvimopan may allow for significant cost savings without compromising outcomes. Source of Funding: This work was supported by intramural funding through the University of Washington Urology Department © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e668 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Peter Kirk More articles by this author Austin Wang More articles by this author Dima Raskolnikov More articles by this author Sarah Psutka More articles by this author George Schade More articles by this author John Gore More articles by this author Yaw Nyame More articles by this author Janet Kelly More articles by this author Jonathan Wright More articles by this author Expand All Advertisement PDF DownloadLoading ...

Routine laboratory parameters in patients with necrotizing pancreatitis by the time of operative pancreatic debridement: Food for thought.

BACKGROUNDTiming of invasive intervention such as operative pancreatic debridement (OPD) in patients with acute necrotizing pancreatitis (ANP) is linked to the degree of encapsulation in necrotic collections and controlled inflammation. Additional markers of these processes might assist decision-making on the timing of surgical intervention. In our opinion, it is logical to search for such markers among routine laboratory parameters traditionally used in ANP patients, considering simplicity and cost-efficacy of routine laboratory methodologies.AIMTo evaluate laboratory variables in ANP patients in the preoperative period for the purpose of their use in the timing of surgery.METHODSA retrospective analysis of routine laboratory parameters in 53 ANP patients undergoing OPD between 2017 and 2020 was performed. Dynamic changes of routine hematological and biochemical indices were examined in the preoperative period. Patients were divided into survivors and non-survivors. Survivors were divided into subgroups with short and long post-surgery length of stay (LOS) in hospital. Correlation analysis was used to evaluate association of laboratory variables with LOS. Logistic regression was used to assess risk factors for patient mortality.RESULTSSeven patients (15%) with severe acute pancreatitis (SAP) and 46 patients (85%) with moderately SAP (MSAP) were included in the study. Median age of participants was 43.2 years; 33 (62.3%) were male. Pancreatitis etiology included biliary (15%), alcohol (80%), and idiopathic/other (5%). Median time from diagnosis to OPD was ≥ 4 wk. Median postoperative LOS was at the average of 53 d. Mortality was 19%. Progressive increase of platelet count in preoperative period was associated with shortened LOS. Increased aspartate aminotransferase and direct bilirubin (DB) levels the day before the OPD along with weak progressive decrease of DB in preoperative period were reliable predictors for ANP patient mortality.CONCLUSIONMultifactorial analysis of dynamic changes of routine laboratory variables can be useful for a person-tailored timing of surgical intervention in ANP patients.

Association of Operative Day of the Week with the Length of Stay and Total Hospitalization Costs in Patients with Partial Mastectomy: A Nationwide Database Study in Japan.

Introduction: Length of stay (LOS) is a major concern while optimizing medical resources and costs. Hence, factors influencing LOS should be investigated. In Japan, breast cancer surgery generally involves several days of hospitalization for observation, despite few complications. We hypothesized that the day of surgery (weekday; Monday-Friday) affects LOS. Methods: Using a Japanese nationwide database, we retrospectively identified 146,610 patients who underwent partial mastectomy for stage 0-III breast cancer from July 2010 to March 2017. We conducted multivariable linear and logistic regression analyses adjusting for background characteristics (such as comorbidities and hospital characteristics) with a generalized estimating equation for within-hospital clustering to compare postoperative and total LOS, total hospitalization costs, and postoperative complications between the groups for whom the surgery was performed on different days of the week. Results: In total, whereas the median postoperative LOS was 4 days (interquartile range, 3-6 days), the median total LOS was 6 days (5-8 days). The median total hospitalization cost was 6,189 US dollars (5,609-6,668 US dollars), and postoperative complications occurred in 3.3% of cases. Despite no significant difference in postoperative complications, Monday-Wednesday surgeries showed significantly shorter postoperative LOS than Friday surgeries (−0.11 days [95% confidence interval, −0.14 to −0.07] on Monday with reference to Friday). Nevertheless, Monday surgeries showed significantly increased total LOS (0.69 days [0.64-0.74]) and hospitalization costs (93 US dollars [71-116]) in comparison with Friday surgeries. Conclusions: The operative day of the week was associated with increased LOS and cost, with no difference in postoperative complications after partial mastectomy. Surgeries on Monday involved longer preoperative hospital stays and higher total hospitalization costs than those on other weekdays.

Postoperative Early Lumbar Drainage Can Reduce the Duration of Fever or Infection in Patients with Complicated Intracranial Tumors after a Long Operation Time.

Intracranial fever or infection is one of the common complications after craniotomy, especially for complicated intracranial tumors such as deep skull base tumors. We used early cerebrospinal fluid (CSF) drainage with a preplaced lumbar drainage (LD) tube after surgery and observed whether this procedure could reduce the rate and duration of fever or infection. The authors conducted a retrospective study of 142 patients who underwent complicated intracranial tumor surgery with no less than four hours of dural opening at the Center of Neurosurgery of Tangdu Hospital. The LD group underwent preoperative LD placement, intraoperative CSF release and postoperative continuous drainage, but the control group received routine craniotomy without preoperative LD. The primary outcomes included the rate, duration, and hospital length of stay (LOS) for patients with fever or infection after surgery, as compared between the two groups. The second outcome included complications related to LD and the rate of postoperative CSF leakage. There were 22 patients in the LD group and 23 patients in the control group who presented with delayed fever, which was supposed to be caused by intracranial infection or aseptic inflammation. The median duration of delayed fever in the LD group was obviously lower than that in the control group (7.762 ± 3.129 days vs 11.73 ± 5.239 days), and there was a statistically significant difference (P = 0.0046). In addition, there was a significant reduction in the median postoperative LOS (12 [8,10,15,21] days in the LD group vs 15 [9,13,20,28] days in the controls). Moreover, there was no significant difference in complications related to LD between the two groups. Three patients with brain herniation were observed in the LD group compared with one patient in the control group. All four patients had contemporary mild-to-moderate neurologic disorders after surgery or conservative treatment. Additionally, the rate of CSF leakage in the LD group was 5.41% (4/74), which was lower than that in the control group (8/68, [11.76%]), although there was no significant difference (P = 0.174). For patients receiving complicated intracranial lesions following a long operation time, postoperative early LD was beneficial for the treatment of patients with fever or infection. It not only reduced the duration of infection or fever in postoperative patients but also decreased the postoperative LOS. We should minimize the complications related to LD by careful and standardized LD and management processes, and ensure the effectiveness and safety of this treatment.

Risk factors associated with postoperative complications and prolonged postoperative length of stay after laparoscopic liver resection.

IntroductionLaparoscopic liver resection (LLR) has expanded rapidly. Previously published studies are limited to small samples and selected patients. Comprehensive data that may significantly influence the incidence of perioperative complications and postoperative length of stay (PLOS) are lacking.AimTo characterize complications after LLR and to identify risk factors associated with postoperative complications and prolonged PLOS.Material and methodsThis study was carried out at a high-volume HPB centre and included all patients who underwent LLRs between 2015 and 2018. Postoperative complications were analysed in detail. Logistic regression was used to identify independent risk factors. The primary outcome was postoperative complications with a comprehensive complication index (CCI) ≥ 26.2. The second outcome was prolonged length of stay.ResultsWe identified 938 patients who underwent LLR. In the full cohort, 79 (8.4%) patients experienced major complications with a CCI ≥ 26.2, with postoperative mortality in 4 (0.4%) patients. On multivariate analysis, the diagnosis of primary (OR = 8.97, 95% CI: 2.54–43.74, p = 0.001) and metastatic liver tumours (OR = 5.74, 95% CI: 1.20–30.90, p = 0.028), infectious liver disease (OR = 24.04, 95% CI: 5.30–129.53, p < 0.001), difficult liver resection (OR = 2.77, 95% CI: 1.29–6.69, p = 0.014), and intraoperative bleeding > 1000 ml (OR = 9.29, 95% CI: 3.40–26.43, p < 0.001) were independent factors that increased the odds of major complications. The median PLOS after the operation was 5 days (range: 2–35 days). Factors that independently influenced prolonged PLOS on multivariate analysis were age over 70 years, metastatic liver tumour, difficult liver resection, liver cirrhosis, and right hepatectomy.ConclusionsLLR remains safe for most liver space-occupying lesions. Several preoperative and intraoperative factors associated with the risk of complications and prolonged PLOS were identified. These factors should be considered during patient selection and perioperative management.