Postoperative Emergency Room Visits Research Articles

Influence of Economic Connectedness on Pediatric Obstructive Sleep Apnea Severity and Adenotonsillectomy Outcomes.

To examine the influence of economic connectedness (EC), a measure of social capital, on obstructive sleep apnea (OSA) severity and adenotonsillectomy outcomes in children. Retrospective study. Single tertiary medical center. The study population included 286 children who were referred for full-night polysomnography for OSA and underwent adenotonsillectomy. The primary outcome was the relationship between EC and the presence of severe OSA, and secondary outcomes included postoperative emergency room visits and residual OSA after adenotonsillectomy. Linear regression, Kruskal-Wallis test, Pearson's χ2 test, and multiple logistic regression were used for categorical and continuous data as appropriate. In this population, the median age was 9.0 (interquartile range [IQR] = 6.9-11.7) and 144 (50.3%) were male. The majority were white (176, 62.0%), black (60, 21.1%), and/or of Hispanic ethnicity (173, 60.9%). The median EC of this population was 0.64 (IQR = 0.53-0.86). Higher EC was associated with decreased odds of having severe OSA (odds ratio: 0.17, 95% confidence interval = 0.05-0.61). However, EC was not associated with either postoperative emergency room visits or residual OSA. EC was significantly associated with severe OSA (ie, apnea-hypopnea index ≥ 10) but not with postoperative emergency room visits or residual OSA after adenotonsillectomy. Further research is needed to understand the effects of various social capital measures on pediatric OSA and adenotonsillectomy outcomes.

Safety and efficacy of ambulatory tubeless mini-percutaneous nephrolithotomy in the management of 10-25 mm renal calculi A retrospective study.

This study aimed to assess the safety and efficacy of ambulatory minipercutaneous nephrolithotomy (mini-PCNL) in a totally tubeless exit (without a nephrostomy tube or an internal stent) and tubeless exit (without a nephrostomy tube but with an internal stent) for the treatment of renal calculi 10-25 mm in size. We conducted a retrospective analysis of patients who underwent mini-PCNL at our institution between September 2018 and September 2022. The study included a cohort of 95 patients diagnosed with renal calculi measuring 10-25 mm. All patients underwent a computed tomography (CT) renal colic scan preoperatively, on postoperative day one (POD 1), and at three-month followup. Patient demographics and outcome parameters were recorded, including stone characteristics, operative time, hospital stay, stone-free rate (SFR), complication rates, and subsequent emergency room (ER) visits. Patients were considered stone-free if they had no fragments or residual fragments measuring <4 mm. The median maximum stone diameter was 16 mm (10-25 mm). Twenty-nine patients (30.5%) had multiple renal calculi. The median operative time was 64 (38-135) minutes. Eighty-six patients (90.5%) underwent a totally tubeless procedure, without a nephrostomy tube or an internal stent. All patients were discharged home on the same operative day with a median hospitalization time of six hours. Seven (7.4%) postoperative ER visits were recorded, and two (2.1%) led to hospital readmission. The frequency of grade I, II, and III Clavien-Dindo complications were 18 (18.9%), one (1.1%), and one (1.1%), respectively. The SFR on POD 1 and three-month followup was 73.7% and 92.6%, respectively. Two patients in the study required retreatment. Ambulatory tubeless mini-PCNL is a safe and effective treatment option for 10-25 mm renal stones. Experienced institutions can safely adopt ambulatory mini-PCNL as a treatment option without an increased risk of postoperative complications, ER visits, or hospital readmissions.

Does resident involvement in tonsillectomy affect outcomes?

ObjectiveTonsillectomy is essentially a solo surgery with a well-described complication profile. It may serve as a good benchmark to evaluate the resident-as-surgeon. This study examined complications such as post-tonsillectomy bleeding in children undergoing tonsillectomy by attending surgeons (AS) or pediatric otolaryngologist-supervised residents. MethodsCharts were reviewed of all children aged 12 and under who had tonsillectomy +/− adenoidectomy at a children's hospital between Jan 2019 and Dec 2020. Patient age, gender, BMI, indication for surgery, surgical technique, presence of a resident surgeon, primary bleeding, secondary bleeding, treatment of bleeding, other Emergency Room (ER) visits, and clinic phone calls were recorded. Binary logistic regression was performed. Results2051 total children (1092 (53.2 %) males and 956 (46.6 %) females) with a mean age of 6.1 years (95 % CI 6.0–6.2) were included. 1910 (93.0 %) underwent surgery for tonsillar obstruction. 1557 (75.9 %) underwent monopolar cautery tonsillectomy. 661 (32.2 %) had a resident surgeon. 274 (13.4 %) had a related ER visit within 15 days. 18 (0.9 %) had a primary bleed and 155 (7.6 %) had a secondary bleed. Binary logistic regression showed that significant predictors of postoperative ER visits were patient age (OR = 1.101, 95 % CI = 1.050–1.154, p < .001) and resident involvement (OR = 0.585, 95 % CI = 0.429-,797, p < .001). Only age was associated with overall postoperative bleeding incidence (OR = 1.131, 95 % CI = 1.068–1.197, p < .001), as well as secondary bleeding (OR = 1.128, 95 % CI = 1.063–1.197, p < .001). There were no significant predictors of primary bleeding. ConclusionResident involvement in pediatric tonsillectomy is associated with decreased postoperative ER utilization and does not appear to increase common postoperative complications including bleeding and dehydration.

Routine history and physical examinations prior to cataract surgery are not beneficial

ObjectifDéterminer l'innocuité d'une politique éliminant la prise des antécédents préopératoires et la réalisation d'un examen physique avant une chirurgie de la cataracte. NatureÉtude rétrospective de population. MéthodesÉtant donné que les antécédents préopératoires et l'examen physique n’étaient plus nécessaires en Alberta après le 1er avril 2017, on a réalisé une étude rétrospective des données issues des demandes de remboursement auprès du régime provincial d'assurance maladie afin de déterminer s'il était sécuritaire d’éliminer ces 2 exigences. Les données provenant d'Albertains qui ont subi une chirurgie de la cataracte et qui ont fait l'objet d'un examen médical préopératoire entre avril 2014 et mars 2017 ont été comparées à celles de patients qui ont subi une chirurgie de la cataracte entre avril 2017 et mai 2020 sans avoir subi d'examen médical préalable. La survenue d'effets médicaux indésirables (soit une visite au service des urgences, une admission à l'hôpital ou le décès dans les 30 jours suivant la chirurgie de la cataracte) tenait lieu de paramètre principal. RésultatsUn total de 236 046 chirurgies de la cataracte ont été réalisées pendant la période à l’étude. La probabilité d'une visite au service des urgences en période postopératoire était plus grande (rapport de cotes [RC] = 1,04; intervalle de confiance [IC] à 95 % : 1,01–1,08) dans le groupe examen préopératoire (n = 112 806 yeux), soit 4,8 % des patients, comparativement à 4,7 % des patients du groupe sans examen préopératoire (n = 123 240 yeux; p = 0,03). De même, les admissions à l'hôpital étaient plus susceptibles de se produire dans le groupe examen préopératoire (RC = 1,26; IC à 95 % : 1,18–1,34) et ont touché 1,8 % de ces patients, comparativement à 1,5 % des patients du groupe sans examen préopératoire (p < 0,0001). Le taux de décès s'est élevé à 0,09 % dans les 2 groupes (p = 0,992). ConclusionsLe taux de visites au service des urgences et d'admissions à l'hôpital dans les 30 jours suivant la chirurgie de la cataracte étaient pour ainsi dire identiques, ce qui donne à penser que les examens préopératoires, qui étaient jusqu'alors réalisés pour réduire le taux de morbi-mortalité postopératoire, offrent peu d'avantages pour les patients.

Elective joint surgeries were safe and effective during the COVID-19 pandemic: a retrospective cohort study in Washington State

Introduction The cancelation of elective joint procedures left patients affected with debilitating osteoarthritis unsure of when their joint replacement operation would take place. Our primary aim in this study was to assess the safety of total hip and knee arthroplasty (THA, TKA) during an active pandemic and to determine if patient outcomes changed after a State of Emergency declaration. Methods This retrospective cohort study evaluated the outcomes of patients who received a THA or TKA in Yakima County, a region in Washington State which had the most COVID-19 infections per capita at the time of the initial surge in 2020. Patients were stratified between a control group and COVID-19 group depending on if their surgery was before or after the cancellation of all elective surgeries on March 19th, 2020. Demographics, surgical notes, COVID-19 test status, functional outcomes, and adverse events were collected. Chi-square and t-tests were utilized to analyze differences between categorical and continuous variables, respectively. Results Inclusion criteria was met for 90 patients for the control group and 490 patients for the COVID-19 group. There were no differences between the cohorts in age, BMI, ethnicity, Charlson Comorbidity Index scores, insurance status, or procedure type. There were four recorded COVID-19 infections from patients in the COVID-19 group (p=0.39); zero of which had complications related to their postoperative care. In comparing our control group to COVID-19 group, no significant differences were observed in postoperative emergency room visits (2.2% vs 6.3% respectively (p=0.126)), hospital readmissions ( 2.2% vs 3.9% respectively (p=0.447)), or any adverse events ( 5.6% vs 7.3% respectively (p=0.073)). Visual analogue pain scores, Lower Extremity Functional scores, and range of motion at one week and three months postoperative were not significantly different between either group. Discussion Our comparison between these patient cohorts showed no significant differences in the rate of postoperative adverse events, functional outcome scores, or complications from COVID-19 infections. Thus, with the proper precautions, elective joint replacement surgery may be done safely during a State of Emergency declaration for an active pandemic.

Socioeconomic Influence on Cervical Fusion Outcomes.

A retrospective observational study. The aim of this study was to compare postoperative outcomes following cervical fusion based on socioeconomic status (SES) variables including race, education, net worth, and homeownership status. Previous studies have demonstrated the effects of patient race and income on outcomes following cervical fusion procedures. However, no study to date has comprehensively examined the impact of multiple SES variables. We hypothesized that race, education, net worth, and homeownership influence important outcomes following cervical fusion. Optum's de-identified Clinformatics Data Mart (CDM) database was queried for patients undergoing first-time inpatient cervical fusion from 2003 to 2021. Patient demographics, SES variables, and the Charlson comorbidity index were obtained. Primary outcomes were hospital length of stay and 30-day rates of reoperation, readmission, and postoperative complications. Secondary outcomes included postoperative emergency room visits, discharge status, and total hospital charges. A total of 111,914 patients underwent cervical spinal fusion from 2003 to 2021. Multivariate analysis revealed that after controlling for age, sex, and Charlson comorbidity index, Black race was associated with a higher rate of 30-day readmissions [odds ratio (OR): 1.11, 95% CI: 1.03-1.20]. Lower net worth (vs. >$500K) and renting (vs. owning a home) were significantly associated with both higher rates of 30-day readmissions (OR: 1.29, 95% CI: 1.17-1.41; OR: 1.34, 95% CI: 1.22-1.49), and emergency room visits (OR: 1.29, 95% CI: 1.18-1.42; OR: 1.11, 95% CI: 1.00-1.23). Lower net worth (vs. >$500K) was also associated with increased complications (OR: 1.22, 95% CI: 1.14-1.31). Socioeconomic variables, including patient race, education, and net worth, influence postoperative metrics in cervical spinal fusion surgery. Future studies should focus on developing and implementing targeted interventions based on patient SES to reduce disparity.

Socioeconomic Effects on Lumbar Fusion Outcomes.

Recent studies suggest that socioeconomic status (SES) influences outcomes after spinal fusion. The influence of SES on postoperative outcomes is increasingly relevant as rates of lumbar fusion rise. To determine the influence of SES variables including race, education, net worth, and homeownership on postoperative outcomes. Optum's deidentified Clinformatics Data Mart Database was used to conduct a retrospective review of SES variables for patients undergoing first-time, inpatient lumbar fusion from 2003 to 2021. Primary outcomes included hospital length of stay (LOS) and 30-day reoperation, readmission, and postoperative complication rates. Secondary outcomes included postoperative emergency room visits, discharge status, and total hospital charges. In total, 217 204 patients were identified. On multivariate analysis, Asian, Black, and Hispanic races were associated with increased LOS (Coeff. [coefficient] 0.92, 95% CI 0.68-1.15; Coeff. 0.61, 95% CI 0.51-0.71; Coeff. 0.43, 95% CI 0.32-0.55). Less than 12th grade education (vs greater than a bachelor's degree) was associated with increased odds of reoperation (OR [odds ratio] 1.88, 95% CI 1.03-3.42). Decreased net worth was associated with increased odds of readmission (OR 1.32, 95% CI 1.25-1.40) and complication (OR 1.14, 95% CI 1.10-1.20). Renting a home (vs homeownership) was associated with increased LOS, readmissions, and total charges (Coeff. 0.30, 95% CI 0.17-0.43; OR 1.19, 95% CI 1.11-1.30; Coeff. 13 200, 95% CI 9000-17 000). Black race, less than 12th grade education, <$25K net worth, and lack of homeownership were associated with poorer postoperative outcomes and increased costs. Increasing perioperative support for patients with these sociodemographic risk factors may improve postoperative outcomes.

New findings regarding the influence of assistants on surgical outcomes in penile prosthesis implantation.

Penile prosthesis implantation is the definitive treatment for refractory erectile dysfunction, yet exposure to this procedure during training of urology residents is often limited. To assess the effects of resident participation in penile prosthesis surgery, we compared surgical outcomes in a retrospective case series of 253 penile prosthesis surgeries by a single surgeon at the same institution between 2017 and 2020 with the assistance of either a registered nurse first assistant (RNFA) or a resident. Pertinent patient characteristics and surgical complications including device complications, surgical site infection, postoperative bleeding, iatrogenic injury, cardiovascular events, pulmonary events, and urinary retention were documented. Measured outcomes included operative time, Emergency Room (ER) visits, unplanned postoperative visits, pain medication refills, and surgicalcomplications. Compared to RFNAs, resident-assisted penile prosthesis surgery was associated with significant increase in mean operative time (71.4 min vs. 87.9 min, p < 0.01) and postoperative ER visits (3.0% vs. 10.6%, p = 0.03) but not surgical complications (19.7% vs. 20.8%, OR 1.03, 95% CI [0.46 -2.30]) or other measured outcomes. Compared to a dedicated RFNA, Resident assistance increased operative time by approximately 17 min, but did not increase post-operative surgical complications, supporting the notion that resident assistance in these procedures may be appropriate as an integral part of training.

Visual guidelines and tutoring in pediatric urological surgery.

The aim of this prospective randomized study was to evaluate the impact of visual guidelines (picture book) and parents tutoring on pediatric urological surgery on parent's stress and anxiety, the number of postoperative contacts, and complications. Following institutional ethical committee approval, a special picture book reflecting different stages of the convalescent period following multiple types of pediatric urological surgery was developed. Parents were randomly divided into 2 groups in which 33 parents in Group 1 received the picture book in addition to routine instructions prior to the surgery and 31 in Group 2 received only routine postoperative instructions. The parents were asked to answer a questionnaire (Amsterdam Preoperative Anxiety and Information Scale) regarding the level of anxiety before surgery and immediately after surgery in the recovery room. The number of postoperative parent's calls, nonplaned emergency room visits, and complications were recorded. No statistically significant difference in perioperative parental anxiety was found (p = 0.88). The visual tutoring group had a significantly lower rate of emergency room admissions (6.6% vs. 18.6%, p = 0.0433), however parents from this group made a higher number of postoperative calls (9.9% vs. 3.1%, p = 0.38). Two (6.6%) from the tutoring group expressed their desire to omit visual counseling in future surgical preparation and 4 (13.2%) did not have an opinion. Overall satisfaction with regards to the preoperative counseling and information and the number of postoperative complications was similar in both groups. Visual tutoring does not add any value to parental anxiety but seems helpful in reducing postoperative emergency room visits. Some parents preferred to exclude visual information from future preoperative counseling.

Household Income as a Predictor for Surgical Outcomes and Opioid Use After Spine Surgery in the United States.

Cross-Sectional Study. Socioeconomic status (SES) is a fundamental root of health disparities, however, its effect on surgical outcomes is often difficult to capture in clinical research, especially in spine surgery. Here, we present a large single-center study assessing whether SES is associated with cause-specific surgical outcomes. Patients undergoing spine surgery between 2015 and 2019 were assigned income in accordance with the national distribution and divided into quartiles based on the ZIP code-level median household income. We performed univariate, chi-square, and Analysis of Variance (ANOVA) analysis assessing the independent association of SES, quantified by household income, to operative outcomes, and multiple metrics of opioid consumption. 1199 patients were enrolled, and 1138 patients were included in the analysis. Low household income was associated with the greatest rates of 3-month opioid script renewal (OR:1.65, 95% CI:1.14-2.40). In addition, low-income was associated with higher rates of perioperative opioid consumption compared to higher income including increased mean total morphine milligram equivalent (MME) 252.25 (SD 901.32) vs 131.57 (SD 197.46) (P < .046), and inpatient IV patient-controlled analgesia (PCA) MME 121.11 (SD 142.14) vs 87.60 (SD 86.33) (P < .023). In addition, household income was independently associated with length of stay (LOS), and emergency room (ER) revisits with low-income patients demonstrating significantly longer postop LOS and increasing postoperative ER visits. Considering the comparable surgical management provided by the single institution, the associated differences in postoperative outcomes as defined by increased morbidities and opioid consumption can potentially be attributed to health disparities caused by SES.

0908 The Impact Of Adenotonsillectomy On Obstructive Sleep Apnea In Children With Trisomy 21: A Retrospective Cohort Study

Abstract Introduction Obstructive sleep apnea (OSA) has a prevalence of 1 - 5.7% in the general pediatric population. In children with Trisomy 21 (T21), OSA is estimated to be much higher, at 30-60%. The medical consequences of untreated OSA may be significant, therefore it is worthwhile to explore treatment options. Adenotonsillectomy (AT) is often the first line treatment in children, including those with T21. However, success rates of AT in patients with T21 is more variable, and postoperative complications can be higher. The aim of this study was to determine the impact of AT on the apnea hypopnea index (AHI) in patients with Trisomy 21. Methods A retrospective cohort study was conducted by reviewing children with T21 and the following criteria: 1) 0 to 18 years of age, 2) AT completed between January 2010 to December 2015, 3) pre- and post-operative polysomnogram (PSG). Data extraction included demographics, details of PSG both prior to and after surgery including severity of sleep apnea and oxygen levels, type of surgery, and surgical complications. Results Our sample consisted of 64 subjects. Mean pre-operative AHI was 32.2, while mean post-operative AHI was 8.0, for a difference of 21.7 (p = 0.0001). Mean pre-operative oxygen saturation was 92.5, while mean post-operative oxygen saturation was 93.7, for a difference of 1.2 (p = 0.01). There were 10 post-operative emergency room visits (15.3%), 2 admissions to hospital (3.1%) and 2 repeat surgeries for post-operative bleeding (3.1%). Conclusion Preliminary findings of this study show a statistically significant improvement in OSA severity as determined by change in AHI and mean oxygen saturations post AT in children with T21. Complication rates were low. Further data collection and analysis is underway. Support None.

The synergistic effect of preoperative opioid use and many associated preoperative predictors of poor outcome in the trauma patient population

ObjectiveThe purpose of this study is to investigate if preoperative opioid use is associated with other predictors of poor outcome and the effect of these factors on complications. We hypothesized that preoperative opioid use (POU) is associated with increased rates of postoperative complications. DesignRetrospective case control study. SettingAcademic level-1 trauma center. Patients/participantsPatients with long bone, lower extremity fractures requiring operative fixation. InterventionN/A. Main outcome measuresPostoperative hospital admissions, emergency room (ER) visits, and reoperations. Results399 patients (opioid naïve [ON] 80.2%, Age 38, 95% CI 35.9–39.6) were reviewed. Patients who had POU were older (P = 0.004), had higher BMI (P = 0.03), proportion of females (P < 0.001), tobacco use (P < 0.001), proportion of American Society of Anesthesiologist (ASA) class ≥ 3 (P < 0.001), and rates of substance use disorder (SUD) (P < 0.001). POU was associated with prolonged opiate use at 6 months (60.8%), 1 year (43.0%), higher rates of postoperative readmissions (18.1%), ER visits (17.2%), reoperations (17.5%), and complications (Odds Ratio [OR]: 2.4, P < 0.01). The risk of complication increased synergistically with the addition of other predictors: less than a high school education (OR: 4.6, P = 0.001); ASA class ≥3 (OR: 5.6, P < 0.001). All three factors combined also increased risk of complication synergistically (OR: 9.1, P = 0.003). ConclusionsOur study demonstrates that many predictors of poor outcome frequently accompany POU. POU combined with many of these predictors synergistically increases the risk of complication. Outcomes-based payment models should reflect this expected rate of readmissions, ER visits and complications in this group. Patients with POU should be targeted with multi-disciplinary interventions aimed to modify these risk factors.

2487 Same-Day Discharge after Hysterectomy: Identifying Reasons for Unplanned Admissions and Evaluating Institutional Compliance with a Standardized Protocol

Study Objective Same-day discharge (SDD) has been the goal of most of minimally invasive hysterectomies. Our institution adopted a standardized operating procedure (SOP) for planned SDD in 2013. The aims of this study were to identify the reasons for unplanned admissions after minimally invasive hysterectomies at our institution and critically review the SDD SOP. Design Quality assurance, retrospective cohort study Setting Single academic institution Patients or Participants We reviewed charts of 74 patients between January to June 2017 and from June to December 2018 who underwent minimally invasive hysterectomy for benign gynecologic indications. Urogynecology patients were excluded. Interventions No interventions, descriptive study. Measurements and Main Results The peri-operative hospital course our sample was compared to our institution's SOP for same-day discharge. The average age of our cohort was 44 with an average body mass index of 27. Mean post-operative acute care unit stay was 4.7 hours (range 2.5 - 11.1 hours); 34% of patients stayed less than the 4 hours required in the SDD SOP, but none of these patients had post-operative emergency room visits or hospital re-admissions. Documentation of SDD SOP-recommended pre-operative counseling (43%) and intra-operative bladder backfilling (8%) was poor. Unplanned admissions on the day of surgery occurred in 17 (22.9%): 9 (52.9%) were for medical (23.5%) or surgical (29) complications, while 2 (12%) had voiding dysfunction and 2 (12%) had pain. Age, hysterectomy route, length of surgery, and estimated blood loss were not associated with these unplanned admissions. Conclusion Our quality assurance project identified that our unplanned admissions for nausea and pain could potentially be avoided with implementation of enhanced recovery after surgery protocol, including pre-operative counseling of expectations and same-day discharge information. Voiding dysfunction requiring admission could be decreased by performing active voiding trials in recovery area. Consider creating a protocol for goals at recovery room before discharge instead of a time frame to discharge.

Safety of Thyroid Surgery in the Elderly: A Propensity Score Matched Cohort Study

BackgroundThyroid surgery is becoming more common in the elderly as elderly population continues to grow. We aim to evaluate the relative risk of morbidity from thyroidectomy in patients greater than 75 y of age. MethodsA retrospective analysis was performed for patients who were undergoing thyroidectomy between 2001 and 2018 in a multihospital network. A matched control group was selected with use of a propensity score, which was based on gender, ethnicity, type of surgery, insurance status, and comorbidities. The Charlson Comorbidity Index was used to quantify comorbidities. Total complications included both thyroid-specific and systemic complications. ResultsWe identified 313 patients over the age of 75 y with a propensity score matched group of 313 patients. There was no difference between the percent female (73% versus 73%, P = 0.92), race composition (P = 0.91), insurance status (P = 0.99), percent undergoing total thyroidectomy (84% versus 84%, P = 0.91), and Charlson Index (2.6 versus 2.69, P = 0.70) of the two groups. Overall complications (4.8% versus 1.9%, P = 0.05) and thrombotic events (1.2 versus 0%, P = 0.04) were significantly higher but there was no statistically significant difference between postoperative emergency room visits (7% versus 6%, P = 0.61), readmissions (11.5% versus 8.6%, P = 0.18), cardiovascular (1.3 versus 0.6%, P = 0.61), pulmonary (3.2 versus 0.9%, P = 0.07), or neurologic complications (1.0 versus 0.3%, P = 0.34). No reoperations were noted in either group. Elder patients did have a longer length of stay (2.64 versus 1.29 d, P < 0.01). ConclusionsElderly patients did have a longer length of stay when compared to a matched younger population. Although there was a trend with higher complication rates in the elderly, those differences did not reach statistical significance.

Same day discharge after thyroidectomy is safe and effective

Historically, thyroidectomies have been performed as inpatient operations due to concerns of postoperative bleeding and symptomatic hypocalcemia. We aim to demonstrate that outpatient thyroidectomy can be performed safely. MethodsThis report outlines a 7-year retrospective analysis (2009-2016) of outpatient vs inpatient thyroidectomies, with outcomes including hematoma, blood loss, recurrent laryngeal nerve injury, symptomatic hypocalcemia, and postoperative emergency room (ER) visits. ResultsA total of 1460 thyroidectomies were performed: 1272 (87%) outpatient and 188 (13%) inpatient. Five outpatients: 4 total thyroidectomies (TT), 1 TT with a central lymph node dissection (CLND), and 1 partial thyroidectomy (PT) developed postoperative hematomas (0.34%) at post-discharge hour 3, 9, 10, 13, and 42. Average time to discharge was 2 hours and 37 minutes. Hematomas were evacuated successfully in the operating room under local anesthesia with a 2-day average hospital stay. There were no differences between TT, thyroid lobectomy (TL), and PT procedures for postoperative hematoma (p=0.17). Outpatient compared to inpatient thyroidectomy was more likely to have been performed in patients with lower American Society of Anesthesia scores (2.3 vs 2.9, p<0.0001), less mean blood loss (74 vs 227 ml, p<0.0001), lesser age (52 vs 56 years, p=0.0012), less extensive dissection (p<0.0001), and fewer RLN injuries (2.4% vs 8.5%, p<0.0001). There was no difference between outpatient and inpatient symptomatic hypocalcemia (6.3% vs 9.6%, p=0.09), 30-day postoperative ER visits (8.8% vs 9.6%, p=0.73), and postoperative hematoma (0.39% vs 0%, p=0.39). There was one inpatient mortality from stroke. ConclusionPostoperative hematomas can be managed safely without life-threatening complications suggesting outpatient thyroidectomy can be performed safely by an experienced surgeon, and adverse sequelae dealt with in a safe and effective manner.

MP89-20 POST-OPERATIVE EMERGENCY ROOM VISITS AFTER URINARY STONE SURGERY: VARIATION BASED ON SURGICAL MODALITY

You have accessJournal of UrologyStone Disease: Surgical Therapy VI1 Apr 2018MP89-20 POST-OPERATIVE EMERGENCY ROOM VISITS AFTER URINARY STONE SURGERY: VARIATION BASED ON SURGICAL MODALITY Abhinav Khanna, Manoj Monga, Tianming Gao, Andrew Nguyen, Paurush Babbar, Jesse Schold, and Robert Abouassaly Abhinav KhannaAbhinav Khanna More articles by this author , Manoj MongaManoj Monga More articles by this author , Tianming GaoTianming Gao More articles by this author , Andrew NguyenAndrew Nguyen More articles by this author , Paurush BabbarPaurush Babbar More articles by this author , Jesse ScholdJesse Schold More articles by this author , and Robert AbouassalyRobert Abouassaly More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2960AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Urinary stone disease is responsible for over 1 million emergency room (ER) visits annually. There is increasing regulatory and cost pressure to reduce unplanned episodes of care, particularly following elective surgery. However, the frequency of ER visits in the early post-operative period after different modalities of stone surgery is not well characterized. We aim to describe rates of post-operative ER visits following percutaneous nephrolithotomy (PCNL), ureteroscopy (URS), and extracorporeal shockwave lithotripsy (ESWL). METHODS The Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project (HCUP) State Inpatient and Ambulatory Surgery Databases for California (2010-2011), Florida, Iowa (2010-2012), and New York (2006-2012) were used to identify patients undergoing PCNL, URS, or ESWL. The HCUP State Emergency Department Database was used to identify post-operative ER visits in the first 30 days after surgery (or after hospital discharge for inpatient procedures). Baseline clinical and demographic characteristics were compared among groups using chi-square, ANOVA, and Kruskal-Wallis tests. Post-operative ER visits were compared across surgery types with chi-square. Multivariate logistic regression was used to identify predictors of post-operative ER visits. RESULTS A total of 321,899 patients undergoing stone surgery during the study period were identified, including 128,040 (39.8%) ESWL, 42,853 (13.3%) PCNL, and 151,006 (46.9%) URS. PCNL had the highest rate of 30-day post-op ER visits (13.2%), followed by URS (10.6%) and ESWL (7.5%) (p<.0001). Table 1 highlights the most common causes of post-op ER visits by surgery type. On multivariate logistic regression adjusting for baseline clinical and sociodemographic characteristics, PCNL (OR 1.62, 95% 1.56-1.69) and URS (OR 1.33, 95% 1.30-1.37) were both independent predictors of post-op ER visit when compared to ESWL. CONCLUSIONS Among kidney stone surgeries, PCNL has the highest rate of 30-day post-operative ER visits, while ESWL has the lowest. Post-operative ER visits are an important outcome for both patients and surgeons, and differences between surgery types should be factored into the pre-operative shared decision making process. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1213 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Abhinav Khanna More articles by this author Manoj Monga More articles by this author Tianming Gao More articles by this author Andrew Nguyen More articles by this author Paurush Babbar More articles by this author Jesse Schold More articles by this author Robert Abouassaly More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Readmissions, unplanned emergency room visits, and surgical retreatment rates after anti-reflux procedures

The choice between endoscopic injection (EI) and ureteroneocystotomy (UNC) for surgical correction of vesicoureteral reflux (VUR) is controversial. To compare postoperative outcomes of EI vs UNC. This study reviewed linked inpatient (SID), ambulatory surgery (SASD), and emergency department (SEDD) data from five states in the United States (2007-10) to identify pediatric patients with primary VUR undergoing EI or UNC as an initial surgical intervention. Unplanned readmissions, additional procedures, and emergency room (ER) visits were extracted. Statistical analysis was performed using multivariate logistic regression using generalized estimating equation (GEE) to adjust for hospital-level clustering. The study identified 2556 UNC and 1997 EI procedures. Compared with patients undergoing EI, those who underwent UNC were more likely to be younger (4.6 vs 6.0 years, P<0.001), male (30 vs 20%, P<0.001), and publicly insured (34 vs 29%, P<0.001). As shown in Summary Figure, compared with EI, UNC patients had lower rates of additional anti-reflux procedures within 12 months (25 (1.0) vs 121 (6.1%), P<0.001), but a higher rate of 30-day and 90-day readmissions and ER visits. On multivariate analysis, patients treated by UNC remained at higher odds of being readmitted (OR=4.45; 2.69 in 30 days; 90 days, P<0.001) and to have postoperative ER visits (OR=3.33; 2.26 in 30 days; 90 days, P<0.001); however, EI had significantly higher odds of repeat anti-reflux procedures in the subsequent year (OR=7.12, P<0.001). Endoscopic injection constituted nearly half of initial anti-reflux procedures in children. However, patients treated with UNC had significantly lower odds of requiring re-treatment in the first year relative to those treated with EI. By contrast, patients treated with UNC had more than twice the odds of being readmitted or visiting an ER postoperatively. Although the available data were amongst the largest and most well validated, the major limitation was the retrospective nature of the administrative database. The practice setting may not be generalizable to states not included in the analysis. Postoperative readmissions and ER visits were uncommon after any surgical intervention for VUR, but were more common among children undergoing UNC. The EI patients had a more than seven-fold increased risk of surgical re-treatment within 1 year.

Postoperative Urinary Retention and Urinary Tract Infections Predict Midurethral Sling Mesh Complications

To determine if postoperative urinary retention and urinary tract infections (UTIs) were predictors of future mesh complications requiring surgical intervention after midurethral sling (MUS). Administrative data in Ontario, Canada, between 2002 and 2013 were used to identify all women who underwent a mesh-based MUS. The primary outcome was revision of the transvaginal mesh sling (including mesh removal/erosion/fistula, or urethrolysis). Two potential risk factors were analyzed: postoperative retention (within 30 days of procedure) and number of postoperative emergency room visits or hospital admissions for UTI symptoms. A total of 59,556 women had a MUS, of which 1598 (2.7%) required revision surgery. Of the 2025 women who presented to the emergency room or were admitted to hospital for postoperative retention, 212 (10.5%) required operative mesh revision. Of the 11,747 patients who had at least one postoperative UTI, 366 (3.1%) patients required operative mesh revision. In adjusted analysis, postoperative retention was significantly predictive of future reoperation (hazard ratio [HR] 3.46, 95% confidence interval [CI] 2.97-4.02), and this difference persisted when urethrolysis was excluded as a reason for sling revision (HR 3.08, 95% CI 2.62-3.63). Similarly, in adjusted analysis, each additional postoperative hospital visit for UTI symptoms increased the risk for surgical intervention for mesh complications (HR 1.74, 95% CI 1.61-1.87). Postoperative urinary retention and hospital presentation for UTI symptoms are associated with an increased risk of reoperation for MUS complications. These patients should be followed and investigated for mesh complications when appropriate.

Abstract: Same-Day Discharge for Women Undergoing Implant-Based Breast Reconstruction Using an Enhanced Recovery after Surgery Model Is Safe

PURPOSE: To compare enhanced recovery after surgery (ERAS) with traditional recovery after surgery (TRAS) for patients undergoing implant-based breast reconstruction. MATERIALS AND METHODS: A retrospective chart review of two patient groups (ERAS and TRAS) was performed. Data from patients undergoing implant-based breast reconstruction (immediate and delayed) from a single reconstructive surgeon working with three general surgeons was collected from February 2012 - October 2013 for the TRAS group and September 2013–2015 for the ERAS group. The ERAS protocol included day surgery, multimodal analgesia, and preoperative anti-emetic prophylaxis. The TRAS pathway involved overnight admission, narcotic-based analgesia, and no preoperative anti-emetic. Demographics, operative variables, and complication rates were compared between groups. RESULTS: Sixty-three ERAS patients and 78 TRAS patients were included in the study. Follow-up was reported for 100% of patients, and included antibiotic use and complications rates up to 30 days post-reconstruction. Length of stay was shorter for ERAS patients compared to TRAS patients (0.31 nights vs. 1.45 nights, p=0.00). No differences were observed between groups in the frequency of preoperative radiation (6% vs. 5%, p=0.70) or immediate reconstruction (97% vs. 89%, p=0.09). The ERAS patients underwent more bilateral mastectomies (83% vs. 55%, p=0.00) and direct-to-implant (vs. expander) reconstructions (65% vs. 24%, p=0.00). Despite the increased risk for the ERAS group due to more implant-based and bilateral reconstructions, there was no significant difference in major complications [repeat surgery, readmission, or IV antibiotics (13% vs. 9%, p=0.48)], minor complications such as seroma or partial tissue necrosis (29% vs. 27%, p=0.83), or number of postoperative emergency room visits (10% vs. 15%, p=0.3) within 30 days compared to the TRAS group. CONCLUSION: ERAS protocol for implant-based breast reconstruction is safe, without increased readmission rates or emergency room visits compared to TRAS, and significantly decreased length of stay. DISCLOSURE/FINANCIAL SUPPORT:None of the authors have a financial interest in any of the products, devices, or drugs mentioned in this manuscript.