National Surgical Quality Improvement Program Research Articles

An Assessment of Adverse Events in Patients with 22q11.2 Deletion Syndrome Undergoing Palatoplasty: An Analysis of the NSQIP Pediatric Database.

The National Surgical Quality Improvement Program (NSQIP) Pediatric database has been used to identify factors related to adverse surgical outcomes in pediatric and craniofacial surgical procedures. Focusing on a historically "higher-risk" population, our aim was to assess the impact of demographics, comorbidities, and 22q11.2 deletion syndrome (22QDS) diagnosis on 30-day postoperative complications in patients undergoing primary palatoplasty. We used the 2012-2020 NSQIP Pediatric database to identify patients ≤3 years with and without 22q11.2 deletion syndrome who underwent primary palatoplasty. Demographics, comorbidities, and perioperative characteristics were compared between those with and without 22QDS. Logistic regression was used to determine if children with 22QDS were more likely to experience a 30-day postoperative complication or readmission. There were 10,745 patients ≤3 years old who underwent primary palatoplasty; 83 (0.8%) of whom had 22QDS and 10,662 (99.8%) did not. Children with 22QDS were older when they underwent primary palatoplasty and more likely to have comorbidities. A total of 513 patients (4.8%) experienced a postoperative complication within 30 days and 255 were readmitted (2.4%). Of the 513, 8 (9.6%) had a 22QDS diagnosis and 505 (4.7%) did not. A diagnosis of 22QDS was not a significant independent risk factor for a complication (adjusted odds ratio (aOR) = 1.13; 95% confidence interval (CI): 0.50-2.54) or readmission (aOR = 1.74; 95% CI: 0.74-4.13) within 30 days. This study found that the diagnosis of 22QDS was not an independent predictor of post-palatoplasty complication risk, and in fact 30-day complications are rare for those patients undergoing cleft palate repair, even among those patients with 22QDS.

SP2.9 - National Emergency Laparotomy Audit (NELA) and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) risk prediction calculators are not accurate in predicting 30-day mortality in patients aged 80 and above

Abstract Background 30- to 50000 Emergency Laparotomies (EL) are performed annually in the UK. More than half of patients are aged 70 or over and have a high post-operative complication rate along with a 16-20% risk of 30-day mortality (30-dm). To date, the literature lacks a dedicated risk prediction tool for mortality and morbidity following EL in the elderly population. Methods A multi-center, retrospective study of patients aged ≥80 undergoing EL examined the correlation between predicted 30-dm using NELA and ACS-NSQIP and actual 30-dm. This occurred in two UK centers over a 2-year period. The primary outcome was defined as the correlation between actual 30-dm and NELA or ACS-NSQIP predicted 30-dm. GraphPad Prism 10.1.1. was used for statistical analysis. Results 141 cases were included in the final analysis (Table 1). The actual 30-dm was 17.73%, NELA predicted 30-dm 13.07% (7.21;27.84), and ACS-NSQIP 9.4% (3.8;20.6). NELA correlated positively with ACS-NSQIP predicted 30-dm (R²=0.79; p<0.0001). No association was found between actual 30-dm and predicted NELA 30-dm, R²=0.01; p<0.0001 or ACS-NSQIP, R²=0.01; p<0.0001. All data is expressed as Median + IQR. Conclusion In octo- and nonagenarians, following an emergency laparotomy, both NELA and ACS-NSQIP are not accurate in predicting 30-day mortality.Table 1Male/female ratio0.63Age (years)84 (81;87)BMI (kg/m²)24.27 (21.43;27)Lactate (most recent preoperative value) mmol/L1.7 mmol/L (1.14;3.01)ASA grade3 (2;4)Clinical frailty score3 (3;5)Charlson Comorbidity Index4 (2;5)

FP7.8 - Perioperative risk prediction for Emergency Laparotomy in Adults, using the National Emergency Laparotomy Audit (NELA) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) risk prediction tools – an Eastern European perspective

Abstract Background Worldwide, emergency laparotomy (EL) is one of the most common procedures. Having an actual 30-day mortality (30-dm) of 10 to 15%, EL has a high mortality rate, particularly in patients >70 years old. Preoperative risk assessment and stratification can improve outcomes. The American-College-of-Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) and the National Emergency Laparotomy Audit (NELA) risk prediction tools are the most used risk calculators, but both can under or overpredict. Methods This is a single-center, retrospective, cohort study that looked at the correlation between actual and predicted 30-dm using NELA and ACS-NSQIP in adults ≥18, following EL, over 2 years, in a single-tertiary-center from Romania. The primary outcome was defined as the correlation between actual 30-dm and NELA or ACS-NSQIP predicted 30-dm. Statistical analysis was performed using GraphPad-Prism 10.1.1. and Stata18. Results 207 cases were analyzed. Male/female ratio was 1.49; age 65 years (50;77); BMI 26.25kg/m² (23.01;28.35); preoperative lactate 1.8 mmol/L (1.5;3.4); ASA grade 3 (2;4) clinical frailty score 4 (3;4); and Charlson Comorbidity Index 5 (3;8). Actual 30-dm was 31.4% with NELA and ACS-NSQIP predicted 30-dm of 5.78% (1.84;21.48) and 5.5% (1.2;24.2) respectively. NELA and ACS-NSQIP predicted 30-dm expressed a strong positive correlation, R²=0.88; p<0.0001. Both NELA and ACS-NSQIP predicted 30-dm showed a significant positive correlation with actual 30-dm: R²=0.33, p<0.0001; and R²=0.41, p<0.0001 respectively. All data is presented as Median + IQR. Conclusion In a Romanian setting both ACS-NSQIP and NELA risk calculators underpredicted 30-dm, despite expressing a strong positive correlation with actual 30-dm.

NELA 1 - Actual and predicted 30-day mortality following emergency laparotomy using National Emergency Laparotomy Audit (NELA) and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) risk prediction tools

Abstract Background Emergency laparotomy (EL) is common, with >30,000 performed annually in the UK. EL has a high 30-day mortality of 9.2%, especially in the elderly. Reliable preoperative risk assessment is essential to aid decision-making and perioperative care arrangements. NELA and ACS-NSQIP risk calculators can both be used to assess risk, and both can under or over-predict mortality. Methods This is a multi-center, retrospective, observational, cohort study investigating the correlation between actual 30-dm (a-30-dm) and predicted 30-dm (p-30-dm) following EL using NELA and ACS-NSQIP in adults over and under 70, over 2-years, in two UK centres. Sample size was calculated at 385 cases. Statistical analysis was carried out using GraphPad Prism 10.1.1. Results 626 cases were analyzed. A-30-dm, NELA, and ACS-NSQIP p-30-dm in the under 70s subgroup were 5.78%, 5.53%, and 3.41% respectively, with NELA and ACS-NSQIP correlating positively with a-30-dm: R²=0.12, p<0.0001 and R²=0.09, p<0.0001. In over 70s, a-30-dm was 13.96%, NELA p-30-dm 14.02% and ACS-NSQIP 9.76%, with a positive correlation between the latter two (R²=0.56, p<0.0001), but a weak one between a-30-dm and NELA (R²=0.04, p<0.0001) or ACS-NSQIP (R²=0.02, p<0.0001). For the entire cohort a-30-dm, NELA and ACS-NSQIP p-30-dm were 9.74%, 9.8%, and 6.59% respectively. NELA and ACS-NSQIP p-30-dm showed a strong positive correlation (R²=0.89; p<0.0001) with only NELA showing a strong positive correlation with a-30-dm (R²=0.31, p<0.0001); and not ACS-NSQIP (R²=0.05, p<0.0001). Conclusion NELA can accurately predict 30-day mortality in patients aged <70 undergoing EL but not >70. ACS-NSQIP and a-30-dm correlated in a very weak manner.

Periprocedural clinical outcomes of revision hip arthroplasty: a multi-centric comparison of current strategies based on the NSQIP.

Recent projections suggest a substantial rise in demand for revision total hip arthroplasties, emphasizing the need for optimized perioperative care. Various revision techniques, such as isolated acetabular or femoral component revisions and total replacements, have garnered attention. Further research is needed to establish the most effective strategies for improving clinical outcomes. This retrospective analysis utilized data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use File from 2016 to 2021. The study aimed to compare clinical characteristics and 30-day outcomes among patients undergoing combined acetabular and femoral (A + F) revision, acetabulum-only (A) revision, and femoral side-only (F) revision surgeries. The analysis of 18,888 patients revealed crucial differences in preoperative and postoperative outcomes among various revision strategies. Specifically, there were notable variations in patient demographics, comorbidities, and emergency procedures. Postoperative data showed distinct rates of mortality, complications, and readmissions across the groups. Notably, femoral component revisions were associated with increased risks of mortality, transfusion, and urinary tract infections, underscoring the need for careful evaluation and consideration when opting for this revision approach. The study's significance lies in its extensive patient cohort and multifaceted evaluation of revision strategies. Although consensus is lacking on single-component revisions, targeting the acetabulum component appears relatively safer. Continued research and individualized evaluations are crucial for refining revision strategies and optimizing outcomes in THA revisions.

The effect of high-normal preoperative international normalized ratios on postoperative outcomes and complications following posterior cervical spine surgery

IntroductionCurrent guidelines recommend that the International Normalized Ratio (INR) be less than 1.5 prior to spine intervention. Recent studies have shown that an INR > 1.25 is associated worse outcomes following anterior cervical surgery. We sought to determine the risk of complications associated with an INR > 1.25 following elective posterior cervical surgery.MethodsThe American College of Surgeons National Surgical Quality Improvement Program database was queried. Patients undergoing elective posterior cervical surgery from 2012 to 2016 with an INR level within 24 h of surgery were included. Primary outcomes were hematoma requiring surgery, 30-day mortality, and transfusions within 72-hours. There were 815 patients in the INR ≤ 1 cohort (Cohort A), 410 patients in the 1 < INR ≤ 1.25 cohort (Cohort B), and 33 patients in the 1.25 < INR ≤ 1.5 cohort (Cohort C).ResultsCohort C had a higher rate of transfusion (4% Cohort A; 6% Cohort B; 12% Cohort C; p = 0.028) and the rate of mortality within 30 days postoperatively trended toward significance (0.4% Cohort A; 0.5% Cohort B; 3% Cohort C; p = 0.094). There was no significant difference in the rate of postoperative hematoma formation requiring surgery (0.2% Cohort A; 0% Cohort B; 0% Cohort C; p = 0.58). On multivariate analysis, increasing INR was not associated with an increased risk of developing a major complication.ConclusionAn INR > 1.25 but ≤ 1.5 may be safe for posterior cervical surgery. An INR > 1.25 but ≤ 1.5 was associated with a significantly higher rate of transfusions. However, increasing INR was not significantly associated with increased risk of any of the major complications.

Predictors of Prolonged Hospital Stay After Microsurgery for Vestibular Schwannoma: Analysis of a Decade of Data.

Microsurgical resection is one of the treatments for vestibular schwannomas (VS). While several factors have been linked to increased length of stay (LOS) for VS patients undergoing microsurgery, a better understanding of these factors is important to provide prognostic information for patients. Determine predictors of increased LOS for VS patients undergoing microsurgical resection. Retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2010 to 2020. Database review. All patients who underwent microsurgery (CPT codes 61520, 61526/61596) for the management of vestibular schwannoma (ICD9 and ICD10 codes 225.1, D33.3) were included. Analyzing perioperative factors that can predict prolonged hospital stay. A total of 2096 cases were identified and 1,188 (57%) of these patients were female. The mean age was 51.0 ± 14.0 years. Factors contributing to prolonged LOS included African American race (OR = 2.11, 95% CI: 1.32-3.36, p = 0.002), insulin-dependent diabetes mellitus (OR = 2.12, 95% CI: 1.09-4.4.11, p = 0.026), hypertension (OR = 1.26, 95% CI: 1-1.58, p = 0.046), functional dependency (OR = 5.22, 95% CI: 2.31-11.79, p = 0.001), prior steroid use (OR = 1.96, 95% CI: 1.18-3.15, p = 0.009), ASA class III (OR = 2.06, 95% CI: 1.18-3.6, p < 0.011), ASA class IV (OR = 6.34, 95% CI: 2.62-15.33, p < 0.001), and prolonged operative time (OR = 2.14, 95% CI: 1.76-2.61). Microsurgery by a translabyrinthine (TL) approach compared to a retrosigmoid (RSG) approach had lower odds of prolonged LOS (OR = 0.67, 95% CI: 0.54-0.82, p < 0.001). In a separate analysis regarding patients receiving reoperation, operative time was the only predictor of prolonged LOS (OR = 2.77, 95% CI: 1.39-5.53, p = 0.004.). Our analysis offers an analysis of the factors associated with a prolonged LOS for the surgical management of VS. By identifying healthcare disparities, targeting modifiable factors, and applying risk stratification based on demographics and comorbidities, we can work toward reducing disparities in LOS and enhancing patient outcomes.

Impact of Obesity, Smoking, and Age on 30-Day Postoperative Outcomes of Patients Undergoing Arthroscopic Meniscus Surgery.

The purpose of this study was to evaluate the impact that obesity, smoking, and older age have on 30-day postoperative complications, reoperations, and readmissions of patients undergoing arthroscopic meniscectomy or meniscus repair. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried to identify meniscus surgeries and operative outcomes between 2008 and 2016. Controlled regression analysis was then performed to evaluate for an association between obesity, age, and smoking and these outcomes. While obesity showed no influence on adverse postoperative complications or reoperations, class I obesity was associated with a lower rate of readmission. Older age, smoking, and comorbidity burden were significant predictors of postoperative complications, reoperations, and/or readmissions. Age 80 years or older was particularly predictive of 30-day complications (odds ratio, 3.5; P<.001) and readmissions (odds ratio, 2.5; P=.004). Obesity is not a major risk factor for complications when undergoing meniscus surgery, while age older than 70 years predicts negative short-term postoperative outcomes. [Orthopedics. 20XX;4X(X):XXX-XXX.].

Low Rates of 30-Day Postoperative Complications After Meniscal Allograft Transplantation: A Retrospective Study Using the National Surgical Quality Improvement Program Database

PurposeThe purpose of this study is to determine the short-term (30-day) postoperative complication rates in patients undergoing meniscus allograft transplantation (MAT). MethodsAmerican College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients who had undergone MAT from 2014 to 2021 using Current Procedural Terminology (CPT) codes. Patients were excluded if they did not have sufficient demographic data – namely those without data for age, sex, BMI, preoperative functional status, ASA classification, operative time, and length of hospital stay. Post-operative complications within 30 days were identified and rates of complications were examined as the primary outcome of this study. As a secondary outcome, multivariate logistic regression was used to identify risk factors associated with the thirty-day incidence of post-operative complications. Subgroup analysis was performed to analyze differences in postoperative outcomes following isolated MAT versus MAT with concomitant ligament reconstruction/repair, cartilage preservation, or realignment osteotomy. ResultsA total of 396 meniscal transplants were identified, with mean age of 35.2 ± 14.9, mean body mass index (BMI) of 29.6 ± 6.7, mean length of stay of 0.5 ± 1.8 days. 11 patients experienced any adverse event (AAE), Specific complications included surgical site infections (5), deep vein thrombosis (DVT) (1), urinary tract infection (UTI) (3), and return to the operating room (OR) (2). On subgroup analysis, there was no significant difference between AAE rates in patients undergoing MAT with concomitant procedures compared to patients undergoing isolated MAT (7 vs 4, p=0.5). ConclusionPatients who underwent MAT had an overall complication rate of 2.8% in the short-term postoperative period (≤30 days). Patients undergoing MAT with concomitant ligament reconstruction/repair, cartilage preservation, and realignment osteotomy had similar rates of all postoperative complications when compared to patients undergoing isolated MAT. Level of EvidenceLevel IV, therapeutic case series.

Loss of Functional Independence after Plastic Surgery in Older Patients: American College of Surgeons National Surgical Quality Improvement Program Database.

Maintenance of functional independence is an important patient-centered outcome. As the evidence on loss of independence (LOI) in older patients undergoing plastic surgery is lacking, this study investigates the extent of LOI, identifying factors associated with LOI. The 2021-2022 American College of Surgeons National Surgical Quality Improvement Program database was searched to identify patients (>65 years old) who underwent plastic surgery and provided data on their functional independence. The primary outcome was LOI on discharge. Data on perioperative factors, including patient characteristics and comorbidities, surgical details, and outcome measures such as operation time, length of hospital stay, surgical and medical complications, mortality, and discharge destination were extracted. Of 2112 patients who underwent plastic surgery, most were independent on discharge (n = 1838, 87%). A total of 163 patients lost their independence (LOI rate: 7.7%). Patients discharged as dependent were more likely to have experienced surgical and medical complications, and less likely to be discharged home (all <0.0001). Factors independently associated with LOI included age (1.08, P = 0.0001), a history of a fall within the last 6 months (2.01, P = 0.03), inpatient setting (2.30, P = 0.0002), operation time (1.00, P = 0.01), and length of hospital stay (1.13, P = 0.0001). Approximately 8% of older patients undergoing plastic surgery are found to be at risk of postsurgical LOI. Future prospective and multicenter studies should evaluate the risks for short- and long-term LOI with the goal of developing interventions that optimize the care for this patient population.

Risk factors and outcomes after surgery for malignant neoplasm of the parotid gland: An ACS-NSQIP study

BackgroundMalignant neoplasms of the parotid gland (MPG) are clinically challenging due to aggressive growth and metastasis. Despite tumor resection being the primary treatment, there is a paucity of studies on post-surgical outcomes and pre-operative risk factors for MPG. Materials and MethodsWe queried the American College of Surgeons National Surgical Quality Improvement Program database to identify patients who underwent MPG surgery between 2008 and 2021. 30-day postoperative outcomes and risk factors predisposing to the occurrence of complications were assessed. ResultsThe study population included 3,052 patients, the majority of whom were males (n=1,842; 60%) and White (n=2,017; 66%). The average age was 63 ± 16 years. The most common comorbidities were obesity (n=1,182; 39%) and hypertension (n=1,533; 50%). Surgical procedures were performed predominantly in the inpatient setting (n=1,773; 58%) by ENT surgeons (n=2,767; 91%). Overall, complications were reported in 6.8% (n=209) of patients. Inpatient setting (p<0.001), renal failure (p<0.001), smoking (p=0.012), as well as increased creatinine (p<0.001) and blood urea nitrogen (BUN) levels (p=0.001) were identified as risk factors for complications. In addition, concurrent microsurgical procedures such as flap surgery and/or nerve grafting significantly increased the risk of postoperative adverse events (p<0.001). ConclusionsOur analysis revealed that complication rates were associated with high creatinine and BUN levels, inpatient surgery, renal failure, higher ASA classes and smoking. We also found that concurrent microsurgical procedures were predictive factors for complications. These findings can inform patient counseling, preoperative planning, and risk stratification.

Within-hospital Temporal Clustering of Postoperative Complications and Implications for Safety Monitoring and Benchmarking Using ACS-NSQIP Data.

To determine the extent to which within-hospital temporal clustering of postoperative complications is observed in the American College of Surgeons, National Surgical Quality Improvement Program (ACS-NSQIP). ACS-NSQIP relies on periodic and on-demand reports for quality benchmarking. However, if rapid increases in postoperative complication rates (clusters) are common, other reporting methods might be valuable additions to the program. This article focuses on estimating the incidence of within-hospital temporal clusters. ACS-NSQIP data from 1,547,440 patients, in 425 hospitals, over a 2-year period was examined. Hospital-specific Cox proportional hazards regression was used to estimate the incidence of mortality, morbidity, and surgical site infection (SSI) over a 30-day postoperative period, with risk adjustment for patient and procedure and with additional adjustments for linear trend, day-of-week, and season. Clusters were identified using scan statistics, and cluster counts were compared, using unpaired and paired t tests, for different levels of adjustment and when randomization of cases across time eliminated all temporal influences. Temporal clusters were rarely observed. When clustering was adjusted only for patient and procedure risk, an annual average of 0.31, 0.85, and 0.51 clusters were observed per hospital for mortality, morbidity, and SSI, respectively. The number of clusters dropped after adjustment for linear trend, day-of-week, and season (0.31-0.24; P = 0.012; 0.85-0.80; P = 0.034; and 0.51-0.36; P < 0.001; using paired t tests) for mortality, morbidity, and SSI, respectively. There was 1 significant difference in the number of clusters when comparing data with all adjustments and after data were randomized (0.24 and 0.25 for mortality; P = 0.853; 0.80 and 0.82 for morbidity; P = 0.529; and 0.36 and 0.46 [randomized data had more clusters] for SSI; P = 0.001; using paired t tests) for mortality, morbidity, and SSI, respectively. Temporal clusters of postoperative complications were rarely observed in ACS-NSQIP data. The described methodology may be useful in assessing clustering in other surgical arenas.

Using machine learning to identify risk factors for short-term complications following thumb carpometacarpal arthroplasty

BackgroundThumb carpometacarpal (CMC) joint osteoarthritis is among the most common degenerative hand diseases. Thumb CMC arthroplasty, or trapeziectomy with or without tendon augmentation, is the most frequently performed surgical treatment and has a strong safety profile. Though adverse outcomes are infrequent, the ability to predict risk for complications has substantial clinical benefits. In the present study, we evaluated a well-known surgical database with machine learning (ML) techniques to predict short-term complications and reoperations after thumb CMC arthroplasty. MethodsA retrospective study was conducted using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) years 2005–2020. Outcomes were 30-day wound and medical complications and 30-day return to the operating room. We used three ML algorithms — a Random Forest (RF), Elastic-Net Regression (ENet), and Extreme Gradient Boosted Tree (XGBoost), and a deep learning Neural Network (NN). Feature importance analysis was performed in the highest performing model for each outcome to identify predictors with the greatest contributions. ResultsWe included a total of 7711 cases. The RF was the best performing algorithm for all outcomes, with an AUC score of 0.61±0.03 for reoperations, 0.55±0.04 for medical complications, and 0.59±0.03 for wound complications. On feature importance analysis, procedure duration was the highest weighted predictor for reoperations. In all outcomes, procedure duration, older age, and female sex were consistently among the top five predictors. ConclusionsWe successfully developed ML algorithms to predict reoperations, wound complications, and medical complications. RF models had the highest performance in all outcomes.

266. NSQIP 5-FACTOR MODIFIED FRAILTY INDEX PREDICTS MORBIDITY BUT NOT MORTALITY AFTER ESOPHAGECTOMY

Abstract Background Frailty is a source of morbidity in esophagectomy patients. To aid clinical decision making, it is important to determine if the simplified 5-factor modified frailty index (mFI-5) retains the same associations between frailty and adverse outcomes as its 11-factor predecessor. Methods Patients undergoing esophagectomy for esophageal cancer or dysplasia from 2016-2018 were identified using National Surgical Quality Improvement Program (NSQIP). The mFI-5 was used to determine association between frailty and post-esophagectomy morbidity and mortality. Results In total, 2,567 patients were included. No patients had a mFI-5 score higher than 3/5 and the score distribution was wide: mFI0 = 1103 (43%), mFI1 = 982 (38.3%), mFI2 = 435 (16.9%), mFI3 = 47 (1.8%). Clavien-Dindo grade IV complications increased with mFI score: mFI0 (11.2%), mFI1 (15.6%), mFI2 (19.8%), mFI3 (25.5%), as did mortality: mFI0 (1.9%), mFI1 (3%), mFI2 (3.4%), mFI3 (4.3%). Multivariate logistic regression analyses controlling for age, sex, body mass index, American Society of Anesthesiology classification, operative duration, emergency surgery status, and neoadjuvant therapy status showed increasing frailty score was associated with Clavien-Dindo grade IV complications (p=0.01), but not mortality (p=0.13). Conclusions The mFI-5 is associated with morbidity but not mortality in patients who have undergone esophagectomy for esophageal cancer. Compared to the mFI-11, the mFI-5 may not be nuanced enough in the assessment of frailty specific to this patient population.

The Open Abdomen After Intra-abdominal Contamination in Emergency General Surgery

IntroductionDelayed fascial closure (DFC) is an increasingly utilized technique in emergency general surgery (EGS), despite a lack of data regarding its benefits. We aimed to compare the clinical outcomes of DFC versus immediate fascial closure (IFC) in EGS patients with intra-abdominal contamination. MethodsThis retrospective study was conducted using the 2013-2020 American College of Surgeons National Surgical Quality Improvement Program database. Adult EGS patients who underwent an exploratory laparotomy with intra-abdominal contamination [wound classification III (contaminated) or IV (dirty)] were included. Patients with agreed upon indications for DFC were excluded. A propensity-matched analysis was performed. The primary outcome was 30-d mortality. ResultsWe identified 36,974 eligible patients. 16.8% underwent DFC, of which 51.7% were female, and the median age was 64 y. After matching, there were 6213 pairs. DFC was associated with a higher risk of mortality (15.8% versus 14.2%, P = 0.016), pneumonia (11.7% versus 10.1%, P = 0.007), pulmonary embolism (1.9% versus 1.6%, P = 0.03), and longer hospital stay (11 versus 10 d, P < 0.001). No significant differences in postoperative sepsis and deep surgical site infection rates between the two groups were observed. Subgroup analyses by preoperative diagnosis (diverticulitis, perforation, and undifferentiated sepsis) showed that DFC was associated with longer hospital stay in all subgroups, with a higher mortality rate in patients with diverticulitis (8.1% versus 6.1%, P = 0.027). ConclusionsIn the presence of intra-abdominal contamination, DFC is associated with longer hospital stay and higher rates of mortality and morbidity. DFC was not associated with decreased risk of infectious complications. Further studies are needed to clearly define the indications of DFC.

369. IMPACT OF THE COVID-19 PANDEMIC ON ESOPHAGEAL CANCER PATIENTS UNDERGOING ESOPHAGECTOMY: AN ACS-NSQIP DATABASE ANALYSIS

Abstract Background To cope with the increasing number of infected patients, medical access was restricted, and public facilities were closed throughout the COVID-19 pandemic. Early detection and treatment of esophageal cancer is critical for improved prognosis. However, the impact of pandemic-related medical access restrictions has not be evaluated to date for esophageal cancer. Therefore, the purpose of this research is to determine how the lockdown policy affected the surgical outcome of patients with esophageal cancer. Methods We analyzed patients who underwent esophagectomy for esophageal cancer between 2016-2022 using data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), including the procedure targeted esophagectomy database. The patients were stratified into two groups based on their operation date relative to pandemic (BEFORE COVID group: 2016-2019 vs AFTER COVID group: 2020-2022). Demographic data and perioperative outcomes were compared between the two groups. Statistical analysis included Chi-square tests for categorical variables and independent student T-tests for continuous data, with a significance threshold set at p &amp;lt; 0.05. Results Between 2016-2022, 7,198 esophageal cancer patients underwent esophagectomy. Clinical T4 increased significantly, but clinical N and pathologic T and N stages showed no impact. PET scan imaging, neoadjuvant chemotherapy and radiotherapy remained unchanged. The utilization of a minimally invasive approach rose substantially from 32.6% to 47.2% (p &amp;lt; 0.001). Positive margin rates increased from 7.5% to 9% (p = 0.03), and anastomotic leak rates increased from 14.1% to 17.2% (p &amp;lt; 0.001). Operative time, blood loss, and conversion rate showed no significant differences. Perioperative complications, including organ space surgical site infections and myocardial infarctions, significantly increased after COVID-19. Conclusion The COVID-19 pandemic altered the clinical staging of esophageal cancer patients undergoing esophagectomy, but it did not disrupt access to essential investigations and treatment. A notable increase in the implementation of minimally invasive techniques was observed after the pandemic. However, significant impacts were noticed on operative outcomes, including positive margin and leak rates.

Recent patterns in minimally invasive colectomies: Where are we now?

ObjectiveMinimally invasive surgery (MIS) techniques such as laparoscopy and robotic surgery for colorectal resection have been cited as superior to traditional open surgery because of their associations with decreased operating room time, hospital stay length, and postoperative morbidity. Despite these benefits, the open approach remains a common surgical method for colorectal resection procedures. We aim to evaluate the most recent yearly trends in open, laparoscopic, and robotic approaches to provide insight into uptake and present the status of MIS in the field of colorectal surgery. MethodsData were collected from the American College of Surgeons National Surgical Quality Improvement Program targeted colectomy database for the years 2014–2020. The surgical approach was classified as either open, laparoscopic, or robotic. Analysis was performed to identify trends in colorectal surgery categorized by year, patient age, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), and emergency status. ResultsThere was an overall decline in both open and laparoscopic surgery cases (from 38.4% to 34.4% and from 57.4% to 50.8%, respectively) and an overall increase in robotic surgery cases (from 4.2% to 14.8%) from 2014 through 2020. Open surgery was the most common approach for the lowest BMI category (<18.5), highest risk ASA classes (4–5) and most emergent surgeries, whereas robotic surgery rates were negligible for these groups. Laparoscopy was the most prevalent approach for all other categories. ConclusionLaparoscopy was the most prevalent approach in colorectal surgery, although the total case proportions generally tended to decrease. While open surgery remains the approach of choice for emergent procedures, laparoscopic case proportions increased marginally in this category, likely owing to increases in surgeon comfort and continued expansion of laparoscopic training efforts. Importantly, the total prevalence of robotic surgery increased significantly between 2014 and 2020, which may be attributable to advancements in the robotic platform and increases in familiarity and competence with the technology. We anticipate a continuation of these trends in the future and recommend the creation of a national robotic surgery training standard.

Five steps in performing machine learning for binary outcomes

BackgroundThe use of machine learning (ML) in cardiovascular and thoracic surgery is evolving rapidly. Maximizing the capabilities of ML can help improve patient risk stratification and clinical decision making, improve accuracy of predictions, and improve resource utilization in cardiac surgery. The many nuances and intricacies of ML modeling need to be understood to appropriately implement these technologies in the clinical research setting. This primer provides an educational framework of ML for generating predicted probabilities in clinical research and illustrates it with a real-world clinical example. MethodsWe focus on modeling for binary classification and imbalanced classes, a common scenario in cardiothoracic surgery research. We present a 5-step strategy for successfully harnessing the power of ML and performing such analyses, and demonstrate our strategy using a real-world example based on data from the National Surgical Quality Improvement Program pediatric database. ConclusionsCollaboration among surgeons, care providers, statisticians, data scientists, and information technology professionals can help to maximize the impact of ML as a powerful tool in cardiac surgery.

Validation of the American College of Surgeons surgical risk calculator for thoracic surgery.

Advances in medicine and surgical techniques make it possible to operate on selected comorbid elderly patients for whom risk assessment is essential. We aimed to validate the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator specifically for thoracic surgery. This study retrospectively included 283 consecutive patients who all underwent various thoracic surgeries at our center. Considering "serious complication" as the most important outcome, we compared the predicted risk scores with the observed incidence of 30-day morbidity and mortality. We calculated the area under the receiver operating characteristic curve (AUROC) with 95% confidence intervals for each outcome and utilized the Brier score to check the calibration and complication odds ratios above vs. below average risk in all score outcomes with the number of occurred events. In our study population, most patients were <65 years old (48%), predominantly male (63%), and overweight or obese (48%). In addition, 13% had severe chronic obstructive pulmonary disease (COPD), and 75% were categorized as American Society of Anesthesiologists (ASA) class III or higher. For "serious complication", AUROC was 59%, and events were equal in patients with above or below average risk scores (P=0.96). AUROC was 67% for "any complication" and 58% for "return to OR", expressing no useful predictive value. The Brier score and odds ratios were low for all outcomes. Dyspnea, ASA class, COPD, and body mass index as single postoperative risk predictors significantly improved the basic model consisting of the logit of the risk calculator alone. Thus, the calculator alone did not perform as well as these single variables did. The ACS NSQIP surgical risk calculator exhibited low sensitivity, specificity, and low AUROC for postoperative 30-day morbidity and mortality in our study cohort. Therefore, we think it cannot be considered as valid risk estimation tool for general thoracic surgery.

Surgical Outcomes for Patients With Trisomy 21 and Hirschsprung's Disease: An NSQIP-Pediatric Study

IntroductionPrevious studies have demonstrated worse outcomes for Hirschsprung's disease (HD) procedures in Trisomy 21 (T21) patients. Using a large national database, we sought to investigate surgical outcomes in HD patients with T21 compared to non-T21 patients. MethodsWe utilized the deidentified National Surgical Quality Improvement Program Pediatric database from 2012 to 2021. Using International Classification of Diseases, Ninth Revision codes, children <18 y old with HD were included and stratified by T21 diagnosis. Demographics, Current Procedural Terminology codes, case characteristics, length of hospital stay, and postoperative complications were analyzed. ResultsOf 3456 HD patients, 12.0% (n = 413) patients had a concurrent diagnosis of T21. Pull-through (PT) procedures accounted for 54.9% of surgeries (n = 1896), of which 10.0% (n = 189) had T21. T21 patients who underwent PT had a younger gestational age (P < 0.0001), cardiac risk factors (P < 0.0001), hematologic disorders (P < 0.0001), higher American Society of Anesthesiologists class (P < 0.0001), and were older at their index operation (P = 0.03). Though operative times were similar, T21 patients had a longer total length of stay (P = 0.0263), postoperative length of stay (P = 0.0033), and more unplanned reoperations (P = 0.0094). Though only significant in unadjusted analyses, T21 patients had more postoperative complications after PT (P = 0.0034), specifically deep surgical site infections (P = 0.009), organ/space surgical site infections (P = 0.004), wound disruption (P < 0.001), and sepsis (P = 0.025). ConclusionsWe confirm significant differences exist between T21 and non-T21 patients undergoing HD procedures, particularly increased total length of stay, postoperative length of stay, and unplanned reoperations. Understanding these differences will lead to more optimal treatment plans for this unique patient population.