National Surgical Quality Improvement Program Database Research Articles

Postoperative venous thromboembolism risk in patients with vulvar carcinoma: An analysis of the National surgical Quality Improvement Program (NSQIP) database

ObjectivesDue to low incidence of vulvar cancer (VC), incidence and predictors for development of venous thromboembolism (VTE) are poorly understood. We examined incidence and risk factors associated with VTE in patients undergoing surgery for VC. MethodsWe included patients who underwent surgery for VC from the National Surgical Quality Improvement Program database. VTE within the 30-day postoperative period was captured with Current Procedural Terminology codes. Baseline demographics and clinical characteristics were compared between patients with and without VTE. Univariable and multivariable-adjusted exact logistic regression models were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between risk factors and VTE. ResultsWe identified 1414 patients undergoing procedures for VC from the NSQIP database. Overall, 11 (0.8 %) patients developed VTE. Univariable predictors of VTE included surgery type [compared with simple vulvectomy: radical vulvectomy only (OR = 7.97, 95 % CI = 1.44, infinity) and radical vulvectomy plus unilateral IFN (OR = 15.98, 95 % CI = 2.70, infinity)], unplanned readmission (OR = 11.56, 95 % CI = 2.74, 46.38), deep surgical site infection (OR = 16.05, 95 % CI = 1.59–85.50), and preoperative thrombocytosis (OR = 6.53, 95 % CI = 0.00, 34.86). In a multivariable-adjusted model, longer operative time (≥72 min OR = 11.33, 95 % CI = 1.58–499.03) and preoperative functional status [compared with complete independence: total dependence (OR = 53.88, 95 % CI = 0.85, infinity) and partial dependence (OR = 53.88, 95 % CI = 0.85, infinity)] were associated with VTE. ConclusionIn this cohort of patients with VC undergoing radical vulvectomy, VTE incidence was low. Surgery type, longer operative time, dependent functional status, and wound disruption were identified as risk factors. Our findings highlight opportunities for prophylactic intervention in certain patients.

Acute cholecystitis, obesity, and steatohepatitis constitute the lethal triad for bile duct injury (BDI) during laparoscopic cholecystectomy.

The most feared complication during laparoscopic cholecystectomy remains a bile duct injury (BDI). Accurately risk-stratifying patients for a BDI remains difficult and imprecise. This study evaluated if the lethal triad of acute cholecystitis, obesity, and steatohepatitis is a prognostic measure for BDI. A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) registry was performed. All laparoscopic cholecystectomy cases within the main NSQIP database for 2012-2019 were queried. Two study cohorts were constructed. One with the lethal triad of acute cholecystitis, BMI ≥ 30, and steatohepatitis. The other cohort did not have the full triad present. Multivariate analysis was performed via logistic regression modeling with calculation of odds ratios (OR) to identify independent factors for BDI. An uncontrolled and controlled propensity score match analysis was performed. A total of 387,501 cases were analyzed. 36,887 cases contained the lethal triad, the remaining 350,614 cases did not have the full triad. 860 BDIs were identified resulting in an overall incidence rate 0.22%. There were 541 BDIs within the lethal triad group with 319 BDIs in the other cohort and an incidence rate of 1.49% vs 0.09% (P < 0.001). Multivariate analysis identified the lethal triad as an independent risk factor for a BDI by over 15-fold (OR 16.35, 95%CI 14.28-18.78, P < 0.0001) on the uncontrolled analysis. For the controlled propensity score match there were 29,803 equivalent pairs identified between the cohorts. The BDI incidence rate remained significantly higher with lethal triad cases at 1.65% vs 0.04% (P < 0.001). The lethal triad was an even more significant independent risk factor for BDI on the controlled analysis (OR 40.13, 95%CI 7.05-356.59, P < 0.0001). The lethal triad of acute cholecystitis, obesity, and steatohepatitis significantly increases the risk of a BDI. This prognostic measure can help better counsel patients and potentially alter management.

Disparities in Demographics in Hip Arthroplasty Between U.S. Active Duty Military and the ACS-NSQIP Clinical Registry.

Patient demographics, such as sex and age, are known risk factors for undergoing revision following primary total hip arthroplasty (THA). The military population is unique because of the increased rates of primary and secondary osteoarthritis of the hip. Treatment options are limited for returning patients to their line of duty; however, THA has been shown to be an effective option. The primary purpose of this study was to evaluate and contrast the demographic differences of patients undergoing primary THA between the U.S. active duty military population and the general population. The secondary goal was to identify the proportion of primary THA performed at the MTF within the military health system (MHS). This was an exempt study determined by the local institutional review board. A retrospective analysis of the MHS Data Repository (MDR) and the National Surgical Quality Improvement Program (NSQIP) was performed. The databases were used to identify the patients who underwent THA from January 1, 2015 to December 31, 2020. The MDR was used to identify demographics such as sex, age, setting of surgery, geographic location, previous military deployments, history of deployment-related injuries, branch of service, and rank. The NSQIP database was queried for sex and age. The median age of the population was compared using the Mann-Whitney U test and gender was compared using the Chi-square test. The MDR was used to evaluate 2,734 patients, whereas the NSQIP database was used to evaluate 223,832 patients. In the military population, patients who underwent THA were 87.7% male with an average age of 45 years, whereas in the general population as measured via the NSQIP database, 45.2% patients were male with an average age of 66.0 years. Comparing the two groups, we demonstrated that the military patients were significantly more likely to be younger (P < .001) and males (P < .001). Only 29.6% of primary THAs were performed within the MTF. Patients in the MHS are undergoing THA at a younger age and are more likely to be male compared to the general population. A significant portion of primary THAs in the MHS are also being performed at civilian institutions. These demographics may result in increased risk of revision; however, long-term studies are warranted to evaluate survivorship in this unique population.

Surgical techniques and outcomes of thyroid chondroplasty in transfeminine individuals: A systematic review

Thyroid chondroplasty (TC) in facial gender affirming surgery (FGAS) is aimed at modifying the thyroid cartilage to achieve a more feminine laryngeal appearance. This study evaluated open versus endoscopic techniques to thyroid chondroplasty and associated outcomes and complications. A systematic review (SR) according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines for articles pertaining to TC was conducted. Data from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) was reviewed for individuals who underwent “cervical tracheoplasty” for gender dysphoria. In the SR, 12 articles representing 368 patients were included for analysis. Nine articles described open approaches and three articles described endoscopic techniques. Rate of total complications was found to be 4.3% (n=12) in the open approach compared to 15% (n=13) in the endoscopic approach. Reports of positive aesthetic results was 92% for the open approach and 90% for the endoscopic approach. In the open approach, seven (2.5%) patients requested additional removal of cartilage and three (1.1%) requested scar revision. In the endoscopic approach, three (3.7%) patients requested additional cartilage removal in the endoscopic approach. NSQIP database found no incidence of wound or major complications among patients who underwent tracheoplasty alone. While the advantage of the endoscopic approach is a scarless neck incision, the rate of complications for endoscopic thyroid chondroplasty is higher than the open approach. Endoscopic approaches are still not widely used and continued investigations are warranted to improve familiarity of this approach and reduce postoperative complications.

Perioperative Vision Loss Following Prone Spine Surgery: A Case-Control Study

PurposePerioperative vision loss (POVL) is a rare and devastating complication following prone spine surgery. Due to the rare nature of this complication, there is limited research available about patient and surgical risk factors that increase the risk of POVL. Study DesignThis study utilized a case-control secondary data analysis methodology that included 5 cases of POVL and 250 controls from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database who all underwent prone spine surgery between 2010-2020. MethodsEach POVL case was matched to 50 randomly selected controls (n = 250) based on type and year of surgery. Demographics and variables of interest were compared among the POVL cases, among POVL cases and the aggregate control group (n = 250), and POVL cases against their matched control group. Univariate and multivariate conditional logistic regression were then used to estimate the odds of developing POVL in relation to potential patient and surgical risk factors. FindingsWhen POVL cases were compared to the 250 control cases using univariate analysis, patients who developed POVL were more likely to have received a blood transfusion within 72 hours of surgery (p < 0.0001). and have longer operative times (OR =1.01, 95% CI [1.003, 1.017], p = 0.003). ConclusionsTwo surgical risk factors were determined to be statistically significant, including the need for perioperative blood transfusion and prolonged operative time. These findings support previous research on POVL which often identified blood loss and prolonged operative times as surgical risk factors. The narrow patient population used in this project may have limited the ability to perform a more robust study on POVL. Therefore, further research on POVL using the NSQIP database is strongly encouraged.

Safety and utility of panniculectomy in renal transplant candidates and end stage renal disease patients.

As the obesity crisis in the United States continues, some renal transplantation centers have liberalized their BMI criteria necessary for transplant eligibility. More individuals with larger body-habitus related comorbidities with End-Stage Renal Disease (ESRD) now qualify for renal transplantation (RT). Surgical modalities from other fields also interact with this patient population. In order to assess surgical outcomes of panniculectomy in the context of renal transplantation and ESRD, the authors performed a systematic review following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) 2020 guidelines. Due to a paucity of existing primary studies, we retrospectively collected data on patients with ESRD undergoing panniculectomy from the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) to evaluate outcomes of body contouring in this patient population. From the systematic review, a total of 783 ESRD patients underwent panniculectomy among the studies identified. Of these, 91 patients underwent panniculectomy simultaneously to RT while 692 had their pannus resected prior to kidney transplant. The most common complication was hematoma followed by wound dehiscence. From the NSQIP database, 24868 patients met the inclusion criteria for analysis. In the setting of renal transplant status, patients with diabetes, hypertension requiring medication, and requiring dialysis were more likely to suffer postoperative complications (OR 1.31, 1.15, and 2.2, respectively). However, upon sub-analysis of specific types of complications, the only retained association was between diabetes and wound complication. Preliminary data show that panniculectomy in ESRD patients appears to be safe, though with a nominal increased risk for complications. Pannus resection does not appear to impact post-transplantation outcomes, including long-term allograft survival. Larger, higher powered, randomized studies are needed to confirm the safety, utility, and medical benefit of panniculectomy in the context of renal transplantation.

Anticoagulation prophylaxis patterns following retroperitoneal lymph node dissection for testis cancer

IntroductionRetroperitoneal lymph node dissection (RPLND) is the standard of care for testicular cancer in various disease settings. Deep vein thrombosis (DVT) complications have been reported to occur in <1% of primary RPLND cases and up to 3% of postchemotherapy (PC-RPLND) cases. While prophylactic anticoagulation (AC) has been well-documented to reduce DVT rates in patients undergoing surgery in general, the benefit of prophylactic AC in RPLND has not been assessed. In this retrospective cohort study, we seek to address this unmet need by evaluating the rates and associated risk factors of DVT and pulmonary embolism (PE) with a national and institutional database, assess the changing patterns in DVT prophylaxis with postoperative AC following RPLND, and quantify the potential benefit of prophylactic AC in patients who have undergone RPLND using a risk-stratified approach. MethodsThe National Surgical Quality Improvement Program (NSQIP) database was queried for patients who underwent RPLND during the 10-year period from 2011 to 2021. An institutional database was queried for all patients undergoing RPLND from 2013 to 2022. Patient characteristics and operative outcomes were compared between the NSQIP and the institutional database. The institutional database was stratified by prior oncologic treatment (i.e., primary RPLND vs. PC-RPLND) and outcomes were compared. Postoperative AC rate was determined and trended by year. The use of postoperative AC and PE events were stratified by clinical stage. The absolute risk reduction (ARR) of AC prophylaxis on PE events and the number needed to treat (NNT) with AC prophylaxis to prevent a single PE event was determined. ResultsIn total, the NSQIP database query resulted in 779 patients and our institutional database query resulted in 188 patients. The rate of DVT and PE was 1.2% and 0.5% vs. 2.1% and 1.6% in the NSQIP and institutional cohort, respectively. The rate of postoperative AC following RPLND in patients from the institutional database increased from 5% in 2013 to 43% in 2022 (P = 0.01). There were no statistically significant differences in complication rates, including bleeding events, chyle leaks, or hospital readmissions amongst patients who were prescribed AC at discharge and those who were not. No stage I patients developed PEs and no stage I patients were prescribed AC. The ARR for AC prophylaxis for development of PE was found to be 0.023 for the clinical stage II and stage III cohorts. The NNT to prevent a single PE with AC was 44 and 43 for the stage II and stage III cohorts, respectively. ConclusionsAC appears beneficial with minimal risk of harm after RPLND, especially in patients with higher risk of developing DVT/PE, highlighting the safety and efficacy of this regimen. There was a significant increase in the rate of AC prophylaxis at discharge amongst patients undergoing RPLND in the institutional database from 2013 to 2022. A risk-stratified protocol of postoperative AC following RPLND appears reasonable, and further prospective trials are warranted to formally confirm this recommendation.

Preoperative COVID-19 infection status negatively impacts postoperative outcomes of geriatric hip fracture surgery

ObjectivesCompare outcomes for patients with recently diagnosed COVID-19 infection to those without COVID-19 infection undergoing operative treatment of hip fractures using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. DesignRetrospective propensity score matched cohort. MethodsPatients who received surgery for an acute hip fracture (intramedullary nail (IMN), open reduction internal fixation (ORIF) or hemiarthroplasty) in 2021 were identified from the NSQIP database. Propensity score matching was implemented using patient demographics and preoperative medical conditions to compare outcomes for COVID-19-positive and COVID-19-negative cohorts. ResultsAfter matching, COVID-19-positive patients exhibited a higher risk of 30-day mortality (Odds ratio (OR) 1.48, 95 % confidence interval (CI) 1.01 – 2.04), pneumonia (OR 2.90, 95 % CI: 1.91 – 4.33), unplanned intubation (OR 2.53, 95 % CI: 1.39 – 4.39), and septic shock (OR 2.51, 95 % CI: 1.10 – 4.67). COVID-19-positive patients were also more likely to have a longer length of hospital stay (Hazard Ratio 1.3, 95 % CI: 1.20 – 1.41) and were more likely to be discharged to an acute care hospital (OR 1.90, 95 % CI: 1.03 – 3.06). ConclusionsActive COVID-19 infection is an independent risk factor for complications as well as increased resource utilization in patients undergoing surgical treatment of acute hip fracture. Using the results of this multicenter study, quantification of these risks can help inform practice and treatment protocols for this population. Level of EvidenceIII.

A Lack of Generalizability—Total Knee Demographics in the Active Duty Population

ABSTRACT Introduction Age and sex are known demographic risk factors for requiring revision surgery following primary total knee arthroplasty (TKA). Military service members are a unique population with barriers to long-term follow up after surgery. This study aims to compare demographic data between active duty military personnel and a nationwide sample to identify differences that may impact clinical and economic outcomes. Methods A retrospective observational analysis was performed using the Military Health System Data Repository (MDR) and the National Surgical Quality Improvement Program (NSQIP). Databases were queried for patients undergoing primary TKA between January 1, 2015 and December 31, 2020. The MDR was queried for demographic data including age, sex, duty status, facility type, geographic region, history of prior military deployment, history of deployment-related health condition, branch of military service, and military rank. National Surgical Quality Improvement Program was queried for age and sex. Median age between populations was compared with the Mann–Whitney U test, and gender was compared with a chi-squared test. Results During the study period, 2,094 primary TKA patients were identified from the MDR, and 357,865 TKA patients were identified from the NSQIP database. Military TKA patients were 79.4% male with a median age of 49.0, and NSQIP TKA patients were 38.9% were male, with a median age of 67. Military TKA patients were significantly more likely to be male (P &amp;lt; .001) and younger (P &amp;lt; .001). Conclusion Patients undergoing TKA in the military are younger and more likely to be male compared to national trends. Current evidence suggests these factors may place them at a significant revision risk in the future. The application of quality metrics based on nationwide demographics may not be applicable to military members within the Military Health System.

Increased Age, Operative Time, American Society of Anesthesiologists Classification, Functional Dependency, and Comorbidity Burden Are Risk Factors for Adverse Events After Meniscectomy and Meniscus Repair: 10-Year Analysis of 64,223 Patients

To use the NSQIP database to identify risk factors for 30-day adverse events and hospital readmission following isolated and unilateral meniscectomy or meniscus repair. A retrospective review of the National Surgical Quality Improvement Program (NSQIP) database from the years 2012 to 2021 identified all patients undergoing isolated, unilateral meniscectomy or meniscus repair. Multivariable analyses were performed for each procedure to identify patient characteristics associated with any adverse event (AAE) or unplanned hospital readmission within 30 days of surgery. From 2012 to 2021, 59,450 (93%) patients underwent meniscectomy, and 4,773 (7%) patients underwent meniscus repair. Overall adverse event rate was 0.95% after meniscectomy and 1.40% after repair. Risk factors for AAE after meniscectomy included increased age (OR= 1.010; P= .009), increased operative time (OR= 1.003; P= 0.011), ASA Class IV (OR= 2.048; P= .045), functional dependency (OR= 3.527; P= .001), and current smoking (OR= 1.308; P= .018). Risk factors for AAE after meniscus repair included age (OR= 1.024; P= .016), operative time (OR= 1.004; P= .038), and bleeding disorders (OR= 7.000; P=.014). ASA Class III increased risk of hospital readmission after both procedures (OR=1.906; P= .008; OR= 4.101; P= .038), while medical comorbidities of heart failure (OR= 3.924; P=.016), hypertension (OR= 1.412; P= .011), and COPD (OR=2.350; P < .001) increased readmission risk after meniscectomy only. Per analysis of the ACS-NSQIP database, surgical treatment of meniscal tears in the knee has been performed frequently over the past 10 years, with meniscectomies comprising over 90% of cases. Increased age and operative time were associated with a modest risk of adverse events after both meniscectomy and meniscus repair. Increased comorbidity burden, evidenced by ASA class, dependent functional status, current smoking, and systemic medical conditions, such as heart failure, hypertension, COPD, and bleeding disorders, greatly increased rates of unfavorable outcomes within 30 days of meniscus surgery. Level III, retrospective prognostic comparative investigation.

Assessing the mFI-5 frailty score and functional status in geriatric patients undergoing inguinal hernia repairs.

The modified 5-factor frailty index (mFI-5) is a prognostic tool based on five comorbidities from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database-hypertension, congestive heart failure, chronic obstructive pulmonary disease (COPD), diabetes, and non-independent functional status. Our study investigates the mFI-5 index's ability to predict morbidity, length of stay (LOS), and discharge destination in geriatric patients undergoing inguinal hernia repairs, as well as assesses the interplay of baseline functional status. Patients aged ≥ 65years who underwent inguinal or femoral hernia repairs from the 2018-2020 NSQIP database were studied. Separate analyses were performed for emergent and elective cohorts. Stratification was performed according to the sum of mFI-5 variables: mFI = 0, mFI = 1, mFI ≥ 2. A total of 41,897 consisted of 92.9% elective and 7.1% emergent cases. The sample was 37.8% mFI = 0, 47.2% mFI = 1, and 15.0% mFI ≥ 2. Median age was 73 (IQR 68-78). Of emergent mFI ≥ 2 cases, 24.2% had non-independent functional status, versus only 4.8% in elective cases. Area under the curve was calculated for emergent and elective groups, including mortality (0.86, 0.80), pneumonia (0.82, 0.77), discharge destination not home (0.78, 0.73), prolonged LOS (0.69, 0.66), and infection (0.71, 0.62). Of index variables, dependent functional status was correlated with increased complications in elective and emergent cohorts, while COPD was significant in elective cases (OR > 2.0, p < 0.05). The mFI-5 is predictive of complications in geriatric inguinal hernia repairs, especially in emergent cases. Frail patients with non-independent functional status are most at risk and, thusrequire proactive and watchful perioperative care.

Validation of the American College of Surgeons National Surgical Quality Improvement Program risk predictor in an Australian general surgical cohort.

The National Surgical Quality Improvement Program (NSQIP) Surgical Risk Calculator from the American College of Surgeons is a widely available tool for peri-operative risk prediction. This study investigates its predictive performance in an Australian setting. A single-centre retrospective external validation study was conducted at a tertiary referral centre in New South Wales, Australia. Data from a general surgical cohort in a 2-year period from 2020 to 2021 was collected from the NSQIP database and entered into the NSQIP calculator. The predictive performance of the calculator was analysed across the standard 14 NSQIP postoperative outcome measures at 30 days. There were 2121 patient records analysed using tests of accuracy and in the discrimination and calibration domains. The overall predictive performance of the NSQIP calculator was reasonable. There was greater accuracy at lower-risk predictions. At higher-risk predictions, Readmission, Death, and Discharge to Nursing or Rehab Facility, and Length of Stay were overestimated, whilst other outcomes were underestimated. This study demonstrates reasonable overall performance of the NSQIP calculator in the context of this cohort and provides data to support the need for locally adapted and validated risk prediction tools for use by Australian perioperative physicians.

Outcomes and Predictors of Morbidity after Carotid Body Tumor Resection

Carotid body tumors (CBTs) are uncommon neuroendocrine tumors at the carotid bifurcation treated with resection. The goal of this study was to examine patient outcomes after CBT resection and establish predictors of morbidity. Patients undergoing CBT resection were identified from the National Surgical Quality Improvement Program (NSQIP) database over 11years. Demographics, past medical history, preoperative labs, procedural details, morbidity and mortality were recorded. Multivariable logistic regression (MLR) analysis was performed to determine independent predictors of morbidity. From 2010 to 2020, 668 CBT resections were identified. The majority of patients were female (65%) and White (72%) with a mean age of 56 (standard deviation [SD]±16). Average body mass index (BMI) was 29.9 (SD±7.1). Arterial resection occurred in 81 patients (12%). 6% of patients experienced morbidity, most commonly re-operation (2.4%). Morbidity was more common in patients with higher BMI (33.1 vs. 29.7, P=0.005), chronic obstruction pulmonary disease (10% vs. 1.9%, P=0.012), higher American Society of Anesthesiologists (P=0.005), and lower albumin (3.7 vs. 4, P=0.016). Morbidity was not increased with arterial resection (P=1) or based on length of operation (P=0.169). Morbidity did not impact mortality (P=0.06) though led to longer length of stay [LOS] (8days vs. 2.4, P<0.001). On MLR, preoperative BMI was the only risk factor for morbidity (odds ratio 1.06, 95% confidence interval 1.02-1.1, P=0.005). CBT resection is very well tolerated with low stroke rates, morbidity, and mortality. Arterial resection leads to increased transfusion requirements and LOS but did not increase stroke rates, mortality, or overall morbidity. Within the NSQIP database, preoperative BMI was the only predictor of postoperative morbidity, which leads to significantly longer LOS.

Relevance of Uterine Weight for Predicting Surgical Complications in Minimally Invasive Benign Hysterectomy

To describe the uterine weight threshold for increasing risk of complications after a laparoscopic hysterectomy using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. Cross-sectional analysis using the American College of Surgeons NSQIP database from 2016 to 2021. American College of Surgeons NSQIP database. Patients undergoing minimally invasive hysterectomy for benign indications (N=64289). None. Uterine weight was entered in grams and 30-day complications were abstracted from patient charts. In the analytic sample, median uterine weight was 135 grams (interquartile range, 90-215) and 6% of patients (n=4085) experienced complications. Uterine weight performed very poorly in predicting complications on bivariate analysis (area under the receiver operating characteristics curve, 0.53; 95% confidence interval, 0.53-0.54). On multivariable analysis, a uterine weight cutoff of 163 grams was associated with higher odds of complications (odds ratio, 1.11; 95% confidence interval, 1.03-1.19; p=.003), but this threshold achieved only a 43% sensitivity and 62% specificity for predicting complications. Uterine weight alone possessed negligible utility for predicting the risk of perioperative complications in minimally invasive hysterectomy.

Baseline frailty status, not advanced patient age, predicts epilepsy surgery outcomes: An analysis of 696 patients from the NSQIP database

ObjectivePreoperative risk stratification of patients undergoing epilepsy surgery remains challenging. Recently, the efforts to look beyond age alone as an outcomes predictor has resulted in the development of measures of physiological reserve, or ‘frailty indices.’ The most frequently cited index in neurosurgery is the 11-item or 5-item modified frailty index (mFI11 or mFI-5). The present study aimed to use a large national registry to evaluate the effect of frailty (as measured by mFI-5 versus age on postoperative outcomes of patients undergoing epilepsy surgery. MethodsThe National Surgical Quality Improvement Program (NSQIP) database, overseen by the American College of Surgeons (ACS), was used to extract data for patients undergoing epilepsy surgery from 2015 to 2019. Univariate and multivariate analyses for age and mFI-5 were performed for the following 30-day outcomes of extended length of hospital stay (eLOS) and non-home discharge (NHD). The effect sizes were summarized by odds ratio and associated 95 % confidence intervals. Receiver operating characteristic (ROC) curve analysis, including area under the curve (AUC), was used to quantify the discrimination. ResultsUnivariate and multivariate analyses demonstrated that frailty statuses from mFI-5, not age, were significantly predictive of eLOS and NHD. On ROC curve analysis, mFI-5 was a stronger predictor of eLOS (C = 0.59, 95 % CI 0.54–0.64, p < 0.001) and NHD (C = 0.69, 95 % CI 0.64–0.76, p < 0.001) than age (C = 0.53, 95 % CI 0.48–0.58, p = 0.21 and C = 0.53, 95 % CI 0.46–0.59, p = 0.44, respectively). ConclusionFrailty, not age, is an independent risk factor for poor postoperative outcomes, particularly eLOS and NHD, in patients undergoing epilepsy surgery. Usage of mFI-5 for preoperative risk stratification of epilepsy surgery patients can help in prognostication.

Comparing surgeon perception of complication rates to publicly reported data using NSQIP

BackgroundPast studies have demonstrated that surgeons' perceptions of their own postsurgical complications may not be accurate. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database is a nationally validated, risk-adjusted, outcomes-based program created to measure and improve the quality of surgical care. Using information acquired through survey data, the purpose of this study is to determine how surgeons' perceptions of their own postoperative complications rates compare to the NSQIP database that tracks these outcome metrics. Hypothesis/purposeWe hypothesize that surgeons underestimate their rates of morbidity, readmission, and reoperation within thirty days postoperatively when compared to NSQIP data. Study designData elements such as perceived morbidity, readmission, and reoperation were collected through surveys distributed at a large level one trauma center. Survey respondents were asked how their rates compared to their peers and physician survey responses were then compared to institutional NSQIP data. Results87.5% of surgeons underestimated their rates of morbidity, 35.4% underestimated their rates of readmission, 22.9% underestimated their rates of reoperation. When comparing themselves to their departmental averages, 57.78% accurately estimated their morbidity rates, 75.56% accurately estimated readmission rates, and 86.67% accurately estimated reoperation rates. ConclusionSurgeons are poor predictors of individual 30-day postoperative complication rates including morbidity, readmission, and reoperation. However, surgeons are more accurate in estimating these same outcomes when asked to compare to the average of their department.

Local/Regional Anesthesia Versus General Anesthesia in Phalanx Fractures/Dislocations

Background: Traditionally, surgical repair of phalanx fractures was performed under general anesthesia. However, the emergence of regional and local anesthesia, otherwise known as Wide-awake Local Anesthesia No Tourniquet, provides an alternative approach where general anesthesia is undesirable. The choice of anesthetic approach resides with clinicians, though it is important to factor in the evidence that regional/local provides not only an alternative anesthesia approach but also potentially avoids comorbidities associated with general anesthesia. This study hypothesizes that the use of local/regional anesthesia for phalanx fracture/dislocation has comparable outcomes to general anesthesia and provides for fewer adverse events. Methods: To answer the research purpose, the investigators designed and implemented a retrospective cohort study of consecutive cases reported to the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database between January 1, 2015, and December 31, 2019. The study population included patients in the NSQIP database who underwent operative fixation of a phalanx fracture or dislocation in 2 cohorts, those with local/regional anesthesia or general anesthesia. The predictor variables were preoperative patient demographic data, including age, gender, surgical specialty, elective surgery, diabetes, smoking, hypertension, and open wound. Results: A total of 2831 patients were identified in the NSQIP database between January 1, 2015, and December 31, 2019. Local/regional anesthesia was performed in 13% of patients with the remaining 87% receiving general anesthesia. Surgical site occurrences were not clinically significant between the 2 groups. Overall, 30-day post-operative complications in the local/regional cohort included one patient with a deep vein thrombosis (0.03%) and pulmonary embolus (0.02%). Overall, 30-day post-operative complications in the general anesthesia cohort included pneumonia (0.12%) and stroke (0.08%). Conclusions: Surgery using the regional/local anesthesia techniques for patients with phalanx fractures or dislocations is safe and can be used in situations where general anesthesia is undesirable as post-operative 30-day complications are similar to those with general anesthesia.

(033) Analyzing Patient-Specific Predictors of Surgical Risk and Outcomes Following Gender-Affirming Surgery

Abstract Introduction Gender affirming surgery (GAS) has seen dramatic advances in phalloplasty and vaginoplasty for gender dysphoria. However, there is still need for better characterization of patient demographics and surgical outcomes. Recent interest has emerged in predictors of post-surgical complications, such as patient frailty and comorbidities for preoperative risk assessment. Better understanding factors predicting outcomes can help with patient selection, patient counseling, and quality improvement. Objective To evaluate phalloplasty and vaginoplasty outcomes and predictors of complications utilizing the National Surgical Quality Improvement Program (NSQIP) database. Methods CPT codes were utilized to identify phalloplasty (59980) and vaginoplasty (59970, 57335) cases recorded in NSQIP from 2006-2020. Descriptive statistics were calculated for baseline patient characteristics, operative parameters, and 30-day complications. Frailty was calculated using the modified frailty index (NSQIP-mFI-5), a previously validated 5-item score including points for diabetes, impaired functional status, COPD, CHF, and hypertension. Pre-operative morbidity probabilities were derived from the “MORBPROB” variable, which is the NSQIP morbidity probability, which uses hierarchical regression analysis on patient-specific factors. Univariate logistic regression, ANOVA, and t-test analyses were performed as appropriate to identify predictors of surgical complications, operative time, and hospital length of stay (LOS). Results Out of 9,637,305 patients in the NSQIP database, 58 underwent phalloplasty and 485 underwent vaginoplasty. For phalloplasty and vaginoplasty, the mean patient age was 38.4±11.8 and 36.6±12.6 years, respectively. The average operative time for phalloplasty and vaginoplasty was 331 minutes and 263 minutes respectively, and the average LOS was 5.1 days and 4.3 days, respectively. The overall 30-day complication rate for phalloplasty was 26%, with 17% of all patients experiencing minor complications, including urinary tract infections, superficial wound infections, pneumonia, and peri-operative bleeding requiring transfusion, and 16% of all patients experiencing major complications including occurrences of sepsis, DVT, stroke, reintubation, renal failure, myocardial infarction, pulmonary embolism, septic shock, would dehiscence, deep wound infections, and cardiac arrest. The overall, minor, and major complications rates for vaginoplasties were 14%, 7%, and 9%. Unplanned readmissions and reoperations each occurred in 7% phalloplasty and 5% vaginoplasty patients. In either cohort, no deaths occurred within 30 days post-operation. Upon logistic regression, NSQIP-mFI-5 scores ≥0.2 versus a score of 0 were not predictive of 30-day complications, operative time, or LOS for either procedure. Notably, for vaginoplasties, higher NSQIP-mFI-5 scores were numerically associated with higher complication rates (OR 2.02, 95% CI 0.94-4.09, p=0.072). When comparing NSQIP preoperative morbidity probabilities of ≥10% versus &amp;lt;10%, this score was predictive of 30-day complications for both phalloplasty (OR 4.0, 95% CI 1.1-19.6, p=0.038) and vaginoplasty (OR 2.46, 95% CI 1.4-4.3, p&amp;lt;0.001). NSQIP morbidity probability ≥10% was also predictive of extended LOS for phalloplasty patients (6.3±1.3 vs. 2.9±0.8, p=0.03). Conclusions This study described the complication rates of phalloplasty and vaginoplasty using the NSQIP database which are largely aligned with previously published studies. The NSQIP preoperative morbidity probability is an effective predictor of surgical complications and is a better predictor than the modified NSQIP frailty index. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Paul Chung - Consultant for Boston Scientific and Coloplast.

Generic versus disease-specific adverse event reporting: a comparison of the NSQIP and SAVES databases for the identification of acute care adverse events in adult spine surgery.

The accurate identification and reporting of adverse events (AEs) is crucial for quality improvement. A myriad of AE systems are utilized. There is a lack of understanding of the differences between prospective versus retrospective, disease-specific versus generic, and point-of-care versus chart-abstracted systems. The objective of this study was to compare the benefits and limitations between the prospective, disease-specific, point-of-care Spine Adverse Events Severity System (SAVES) and the retrospective, generic, and chart-abstracted National Surgical Quality Improvement Program (NSQIP) for the identification and reporting of AEs in adult patients undergoing spinal surgery. The authors conducted an observational ambidirectional cohort study of adult patients undergoing spine surgery other than for trauma between 2011 and 2019 in a quaternary spine center. Patients were identified using Current Procedural Terminology codes in the NSQIP database and matched using unique medical record numbers to their corresponding record in SAVES. The incidence of AEs and per-patient AEs as recorded in NSQIP and SAVES was the primary outcome of interest. Comparable AEs were identified by matching NSQIP AEs to equivalent ones in SAVES. Chi-square tests were used to test for significant differences in the incidence of overall and comparable AEs between the databases. There were 2198 patients identified in NSQIP, of whom 2033 also had complete records in SAVES. SAVES identified 5342 individual AEs in 1484 patients (73%) compared with 1291 individual AEs in 807 patients (39.7%) with the NSQIP database (p < 0.001). SAVES identified 250 intraoperative and 422 postoperative spine-specific AEs that NSQIP did not record. NSQIP captured a greater number of AEs beyond 30 days, including prolonged length of stay > 30 days, unplanned readmission, unplanned reoperation, and death later than 30 days after surgery compared with SAVES. SAVES captures a greater incidence of peri- and intraoperative spine-specific AEs than NSQIP, while NSQIP identifies a greater number of AEs beyond 30 days. While a prospective, disease-specific, point-of-care AE system such as SAVES is specific for guiding quality improvement in spine surgery, it incurs greater time and financial costs. Conversely, a retrospective, generic, and chart-abstracted system such as NSQIP provides equivocal cross-institutional comparability with reduced time and financial costs. Specific contextual and aim-specific needs should guide the choice and implementation of an AE system.

Outcome of Difficult Pelvis Surgeries done by Gynecologist versus General Surgeons

Objective: To evaluate the outcomes of difficult pelvis surgeries done by gynecologist versus general surgeons. Study Design: Retrospective study Place and Duration of Study: Department of Surgery, CMH Kharian Medical College, Kharian, Department of Surgery, Wah Medical College POF Hospital, Wah Cantt and Ghulam Muhammad Mahar Medical College, Teaching Hospital, Sukkur from 1st August 2015 to 31st July 2018. Methodology: Fifty professionals (who conducted 500 pelvic surgeries) were included either from the surgery or obstetrics gynecology departments. The study was initiated post-consent of each participant. Surgeons National Surgical Quality Improvement Program (NSQIP) data base software was applied for designing the questionnaire. The NSQIP database collects information from 10 perioperative-variables, as well as preoperative-comorbidities, parity, previous history of pelvic surgery, ureteral obstruction and vesico-vaginal fistula, intraoperative-variables, as well as 30-day mortality and morbidity outcomes including the rate of reoperation and re-admission. Other information regarding ASA classification and malignancy were also collected. Result: There were 341 procedures performed by surgeons while 159 procedures were conducted obstetrics gynecologists’ surgeons. The mean age of the patients was 62.5±11.5 years. The ASA classification presented higher number of surgeries in class 1 and 2 of the ASA class. The apical procedures as Sacrospinous and Sacrocolpopexy were performed highest by obstetrics gynecologists. The 30 days postoperative complication rate was increased significantly in the obstetrics gynecologists group than the surgeons. Conclusion: Prolapse surgery completed by a surgeon is linked with lower odds of 30-day postoperative-complications than the one performed by the obstetrician-gynecologist. Keywords: Outcome, Pelvis surgery, Prolapse surgery, Complication