Preoperative Hospital Research Articles

Laparoscopic simple prostatectomy: a large single-center prospective cohort study.

BACKROUND The aim of our study was to analyze outcomes and safety of laparoscopic simple prostatectomy (LSP) in a high-volume center. METHODS A consecutive series of men with lower urinary tract symptoms and large prostates (>80 cc) prospectively enrolled between November 2015 and December 2017 in one center. All patients underwent laparoscopic simple prostatectomy. Outcomes were evaluated considering the trifecta favorable outcome which was defined as a combination of the following items: 1) no perioperative complications; 2) postoperative IPSS max >15 mL/s. Complications were evaluated according to the modified Clavien classification system. Univariate and multivariate binary logistic regression was performed to identify predictors of a positive trifecta outcome. RESULTS Overall 272 patients were enrolled. At three months after surgery median IPSS total score was 4 (IQR: 3-7), median IPSS QoL was 1 (IQR:1-2), median prostate-specific antigen was 0.53 (IQR: 0.33-1.00) ng/ml and median Q max was 23 (IQR: 17-30) mL/s. All these parameters improved statistically when compared to baseline (P<0.001). The overall complication rate was 21% however most of the complications were low grade complications according to modified Clavien-Dindo classification (grade ≤2). Overall, 68% of the patients presented a positive trifecta outcome. On multivariate analysis only preoperative hemoglobin and hospital stay were confirmed predictors of positive trifecta outcome. CONCLUSIONS LSP represents a safe and effective procedure in the treatment of large adenomas. Although RCTs are needed before reaching definitive conclusions, LSP is a promising technique for patients with LUTS and large prostates.

Adolescent Disc Disease: Risk Factors and Treatment Success-Related Factors

A paucity of literature is available discussing the associated risk factors, treatment options (including the use of minimally invasive surgery), and outcomes related to lumbar disc herniation (LDH) in children. We have discussed the risk factors for disc disease among pediatric patients and evaluated the efficacy of the minimally invasive approach. A retrospective review of pediatric patients with lumbar disc disease who had undergone microdiscectomy at our institution from 2005 to 2016 was conducted. The preoperative presentation, hospital course, postoperative course, and follow-up data (≥3 years) were reviewed. We evaluated the risk factors for LDH and the surgical outcomes for both groups. A total of 52 pediatric patients had undergone 61 lumbar disc surgeries for LDH in our department from 2005 to 2016. Their average age at surgery was 16.65 years. Of the 61 procedures, 48 (78.7%) had been performed via the minimally invasive spine microdiscectomy approach and 13 (21.3%) via the open microdiscectomy approach. The average body mass index for all cases was 29.3 kg/m2. The average interval to diagnosis was 7.9 months. Of the 61 cases, 21 (34.4%) had been required for patients who were competitive athletes. In addition, 15 had been for LDH related to trauma (24.6%). In 46 of the 61 cases, complete resolution of the symptoms had occurred at the 1-year follow-up visit (79.2% of minimally invasive spine microdiscectomy vs 61.5% of open microdiscectomy). Risk factors similar to those for adult LDH, such as an elevated body mass index, can be seen in the pediatric population. However, some unique risk factors such as post-traumatic LDH were found in the pediatric age group. Minimally invasive techniques are demonstrably safe and useful in this patient population.

Evaluation of post-surgical site infection wounds in a tertiary care hospital of Central India

Introduction: Surgical site infections (SSIs) are one of the commonest hospital-acquired infections globally. Materials and Methods: A total of 2083 cases were included in the study; surgical sites were graded in accordance to the set of clinical criteria recommended by the CDC’s NNIS system. We graded the wounds on the basis of culture positive with respect to age and sex, pre-operative hospitalization, duration of surgery, duration of drain, hemoglobin levels, random blood sugar, and smoking. Results: The total males and females included were 1561 and 522, respectively. The age group of 40–50 years was the highest operated group, whereas the 12–21 age group was with least surgeries. The numbers of SSI were higher in subjects with longer pre-operative hospital stay. The occurrence of SSIs was higher in surgeries with longer duration. Patients with drain of longer duration had higher number of SSIs when compared with subjects with no drain in wounds. The hemoglobin pattern suggested that anemic subjects were more susceptible to SSIs when compared with non-anemic subjects. Diabetic patients were more prone to SSI when compared with non-diabetic subjects. Smokers were more prone to SSIs when compared with non-smokers. Conclusion: The study established a relationship between SSI and various factors, which would help clinicians in handling cases of post-operative SSIs.

Hospital Course and outcome for patients with Anorectal malformations (Bucket-handle deformity), a 3-year experience from Khartoum north teaching hospital (2016 -2019)

Introduction: Anorectal malformations are some of the most common structural congenital malformations treated by pediatric surgeons globally. A bucket-handle deformity is a subtype of it characterized by a subepithelial midline raphe fistula. The etiology has not been fully understood but it is more likely to be multifactorial; genetic and environmental factors implicated. The outcome of surgery depends on the clinical presentation, early diagnosis, other associated malformations, surgeon’s expertise and a post-operative follow up care. Objectives: To analyze and evaluate pediatric patients with Bucket-handle deformity in terms of their hospital course (insight into the pre, peri and post-operative course). Methodology: This study was done at Khartoum North Teaching Hospital in Khartoum; Sudan. The targeted population were all pediatric patients with this deformity in our pediatric surgery department. Data was collected using a data collection sheet filled by the in-charge surgeon in the period from (March 2016 - March 2019). Results: In 72 pediatric patients with Bucket-handle deformity included, 39 (54.2%) were males and 33 (45.8%) were females. The mean age for patients was 2.28 years and 2.3 years at the time of surgery. When it comes to their gestational age at time of delivery, almost of them (82%) were born at term and about (16.7%) were preterm and only a small fraction (1.4%) were post-term. Ten patients (13.9%) have other anomalies that mainly cardiac and only 3 (4.2%) have an associated family history of congenital anomalies. Only 9.7% of patients were septic on admission and they had a slightly longer pre-operative and post-operatively hospital course when compared to non-septic patients. The average number of days patients stayed in hospital pre-operatively was 6.56 days and 10.72 days post-operatively. Overall, there was no post-operative complications of urinary or fecal incontinence and there was no constipation in the 6 months period following the surgery. Conclusion: This study showed that all pediatric patients with Bucket-handle deformity in our pediatric surgery department had good surgical outcome with no post-operative complications despite having a relatively long pre-operative and post-operative hospital course. Recommendations: Although results were excellent regarding the surgery, further studies should be carried out to expand the literature regarding evaluation of pediatric patients with Bucket-handle deformity in terms of their hospital course. More efforts need to be put to optimize pediatric patients for surgery even before referring them to a specialized pediatric surgery unit for the goal of minimizing the duration of their admission course.

Factors Associated with 30-Day Mortality in Patients after Percutaneous Endoscopic Gastrostomy.

Introduction:Percutaneous endoscopic gastrostomy (PEG) is the main accepted method for long-term tube feeding. The aim of this study is to investigate the risk factors associated with early mortality after PEG.Methods:It is a retrospective survival analysis in a tertiary-level hospital. We reviewed the medical records of 277 patients with PEG placement. The data were analyzed by the Kaplan-Meier method. Multivariable Cox proportional regression models were also built to test the effects of PEG on mortality.Results:A total of 277 patients who submitted to PEG were studied. One-hundred and sixty (58%) were female, mean age of 73.3 ± 15.7 years. Ninety-three patients (33.6%) had diabetes mellitus and 165 (59.6%) had blood hypertension. The indications for PEG placement were chronic neurologic dysphagia in 247 (89.5%) patients and tumors and other diseases in 29 (10.5%). The 30 days proportional mortality probability rate was 13%. In a multivariate Cox proportional regression model, preoperative ICU hospitalization (HR 1.79, 95% CI 1.36–2.36, P = 0.000) and hemoglobin (HR 0.91, 95% CI 0.85–0.98, P = 0.015) were predictors of early mortality.Conclusion:In patients who had underwent PEG tube insertion for long-term nutrition, anemia and previous ICU admission were predictors of mortality at four weeks. These factors may guide physicians to discourage the indication for PEG.

Population-Based Study on Practice Variation Regarding Preoperative Systemic Chemotherapy in Patients with Colorectal Liver Metastases and Impact on Short-Term Outcomes

Introduction: Indications for preoperative chemotherapy for colorectal liver metastases (CRLM) vary. Use of preoperative chemotherapy may influence postoperative outcomes. This study assesed variation in use of preoperative chemotherapy for CRLM and related postoperative outcomes in the Netherlands. Methods: All patients who underwent liver resection for CRLM in the Netherlands between 2014 and 2018 were included from a national auditing database. Case-mix factors contributing to use of preoperative chemotherapy, hospital variation and postoperative outcomes were assessed using multivariable logistic regression. Postoperative outcomes were postoperative complicated course (PCC), 30-day morbidity and 30-day mortality. Results: In total, 4323 (69.6%) patients were included of whom 1314 (31.1%) patients received preoperative chemotherapy and 3009 patients did not. Patients receiving chemotherapy were younger (mean (+SD) 63.3 (10.2) versus 67.1 (10.3) p< 0.01) and had less comorbidity (Charlson scores 2+ (18% versus 27%, p< 0.01). Unadjusted hospital variation concerning administration of preoperative chemotherapy ranged between 4% and 100%. After adjusting for case-mix factors, three hospitals administered significantly more preoperative chemotherapy than expected and six administered significantly less preoperative chemotherapy than expected. PCC was 12.1%, 30-day morbidity was 8.8% and 30-day mortality was 1.5%. No association between preoperative chemotherapy and PCC (OR 1.22, 0.97 - 1.53, p = 0.09), 30-day morbidity (OR 1.16, 0.90 - 1.48, p = 0.25) or 30-day mortality (OR 1.18, 0.68 - 2.01, p = 0.55) was observed. Conclusions: Significant hospital variation in use of preoperative chemotherapy for CRLM was present in the Netherlands. No association between postoperative outcomes and preoperative chemotherapy was observed.

ALCOHOLIC VS. NON-ALCOHOLIC CHRONIC PANCREATITIS: SURGEONS’ PERSPECTIVE FROM A TERTIARY CENTRE IN INDIA

ABSTRACT Background:Although alcohol is the most common cause for chronic pancreatitis worldwide, idiopathic type is prevalent in India. Natural history and disease progression are different between these two groups. There is paucity of data comparing surgical outcome and quality of life in these patients. Aim:To evaluate clinical features, surgical outcome and quality of life between these two groups of patients. Method:All patients with chronic pancreatitis who underwent surgery were prospectively reviewed. Results:From 98 patients, 42 were alcoholic. Number of male and the mean age at the time of operation was significantly more in alcoholic patients. Smoking, preoperative hospital admission rate and the prevalence of local complications like inflammatory pancreatic head mass, biliary stricture and left sided portal hypertension were distinctly more common in alcoholic group. Frey procedure was required more commonly in alcoholic group. Mean postoperative hospital stay and overall postoperative complication rate were comparable between the two groups. Over a median follow up of 18 months there was significant improvement in quality of life and pain score in both the groups. Improvement of physical functioning score at follow-up was significantly more in alcoholic group but the requirement for analgesic medications were significantly more in alcoholic group. However, appetite loss was more perceived by non-alcoholic group. Conclusion:Alcoholic chronic pancreatitis presents with more local complications associated with chronic pancreatitis. Frey procedure is a safe and well accepted surgery in this group. Though they required more analgesic requirement in short term follow up, other aspects of quality of life are similar to non-alcoholic group.

892. Meningitis after Ventricular Shunt Operations: Multicenter Study to Identify Etiology, Incidence and Risk Factors

BackgroundA Ventriculoperitoneal shunt is the main treatment for communicating hydrocephalus. Surgical site infection associated with the shunt device is the most common complication and an expressive cause of morbidity and mortality of the treatment.The objective of our study is to answer three questions: a)What is the risk of meningitis after ventricular shunt operations? b) What are the risk factors for meningitis? c) What are the main microorganisms causing meningitis?MethodsA retrospective cohort study assessed meningitis and risk factors in patients undergoing ventricular shunt operations between 2015/Jul and 2018/Jun from 12 hospitals at Belo Horizonte, Brazil. Data were gathered by standardized methods defined by the National Healthcare Safety Network (NHSN)/CDC procedure-associated protocols for routine SSI surveillance. Sample size = 926.26 variables were evaluated by univariate and multivariate analysis (logistic regression).Results71 patients were diagnosed with meningitis which represent a risk of 7.7% (C.I.95%= 6.1%; 9.6%). From the 26 variables, three were acknoleged as risk factors: age < two years old (OR = 3.20; p < 0.001), preoperative hospital length of stay > four days (OR = 2.02; p = 0.007) and more than one surgical procedure (OR = 3.23; p = 0.043). Patients two or more years old, who had surgery four days after hospital admission, had increased risk of meningitis from 4% to 6% (p = 0.140). If a patient < two years had surgery four days post hospital admission, the risk is increased from 9% to 18% (p = 0.026). 71 meningitis = > 45 (63%) the etiologic agent identified: Staphylococcus aureus (33%), Staphylococcus epidermidis (22%), Acinetobacter sp (7%), Enterococcus sp (7%), Pseudomonas sp (7%), and other (18%). Hospital length of stay in non-infected patients (days): mean = 21 (sd = 28), median = 9; hospital stay in infected patients: mean = 34 (sd = 37), median = 27 (p=0.025). Mortality rate in patients without infection was 10% while hospital death of infected patients was 13% (p=0.544).ConclusionTwo intrinsic risk factors for meningitis post ventricular shunt, age under two years old and multiple surgeries, and one extrinsic risk factor, preoperative length of hospital stay, were identified. Incidence of meningitis post VP shunt decreases with urgent surgical treatment.Disclosures All Authors: No reported disclosures

SURGICAL SITE INFECTION FOLLOWING CESAREAN SECTION AND ITS ASSOCIATED RISK FACTORS AT A TERTIARY CARE HOSPITAL IN CHITWAN

Background: Surgical site infection following Cesarean Section is one of the major potential surgical complications with its incidence ranging from 3-15%. Morbidity and mortality are considerably in­creased after a surgical site infection placing a significant physical, emotional and economic burden on the patient herself. This study is aimed to identify the associated risk factors for postcesarean surgical site infection at a tertiary care hospital in Chitwan. Methods: A descriptive cross-sectional study of 186 women who underwent a cesarean section was carried out in Chitwan Medical College Teaching Hospital, Chitwan, Nepal from 27thDecember 2019 to 19th February 2020. Data were collected from patients using a self-constructed questionnaire and their risk factors were studied. Results: A total of 186 cases were studied and the incidence rate of surgical site infection was 13 (6.99%). The mean age was 26.13±4.94. Among the total cases, 87.10% of cases were literate while 12.90% of cases were illiterate. Out of total surgical site infection cases, infection was more prevalent (84.62%) among those with preoperative hospitalization of ≤ 24 hours and (53.85%) among those who stayed in the hospital for &lt; 5 days. Conclusions: Education level, duration of preoperative hospitalization and total hospital stay were found to be significant risk factors associated with surgical site infection and appropriate measures to address these risk factors help to lower the rate of surgical site infection.

Antimicrobial Prophylaxis for Postoperative Urinary Tract Infections in Transurethral Resection of Bladder Tumors: A Systematic Review and Meta-Analysis.

The administration of antimicrobial prophylaxis for postoperative urinary tract infections following transurethral resection of bladder tumors is controversial. We aimed to systematically review evidence on the potential effect of antimicrobial prophylaxis on postoperative urinary tract infections and asymptomatic bacteriuria. We conducted a systematic search in Embase®, Medline® and the Cochrane Central Register of Controlled Trials. Randomized controlled trials and nonrandomized controlled trials assessing the effect of any form of antimicrobial prophylaxis in patients with transurethral resection of bladder tumors on postoperative urinary tract infections or asymptomatic bacteriuria were included. Risk of bias was assessed using RoB 2.0 or the Newcastle-Ottawa Scale. Fixed and random effects meta-analyses were conducted. As a potential basis for a scoping review, we exploratorily searched Medline for risk factors for urinary tract infections after transurethral resection of bladder tumors. The protocol was registered on PROSPERO (CRD42019131733). Of 986 screened publications, 7 studies with 1,725 participants were included; the reported effect sizes varied considerably. We found no significant effect of antimicrobial prophylaxis on urinary tract infections: the pooled odds ratio of the random effects model was 1.55 (95% CI 0.73-3.31). The random effects meta-analysis examining the effect of antimicrobial prophylaxis on asymptomatic bacteriuria showed an OR of 0.43 (0.18-1.04). Risk of bias was moderate. Our exploratory search identified 3 studies reporting age, preoperative pelvic radiation, preoperative hospital stay, duration of operation, tumor size, preoperative asymptomatic bacteriuria and pyuria as risk factors for urinary tract infections following transurethral resection of bladder tumors. We observed insufficient evidence supporting routine antimicrobial prophylaxis in patients undergoing transurethral resection of bladder tumors for the prevention of postoperative urinary tract infections; our findings may inform harmonization of international guidelines.

Sense of coherence, mental well-being and perceived preoperative hospital and surgery related stress in surgical patients with malignant, benign, and no neoplasms

BackgroundThis prospective, cross-sectional, observational study examined associations between sense of coherence (SOC), mental well-being, and perceived preoperative hospital and surgery related stress of surgical patients with malignant, benign, and no neoplasms. The objective was to assess a putative association between SOC and preoperative stress, and to test for a statistical mediation by mental well-being.MethodThe sample consisted of 4918 patients from diverse surgical fields, of which 945 had malignant neoplasms, 333 benign neoplasms, and 3640 no neoplasms. For each subsample, we conducted simple mediation analyses to test an indirect effect of SOC on preoperative stress mediated by mental well-being. The models were adjusted for age, gender, and essential medical factors.ResultsPatient groups did not differ significantly regarding degrees of SOC and mental well-being (SOC, M [SD]: 12.31 [2.59], 12.02 [2.62], 12.18 [2.57]; mental well-being M [SD]: 59.26 [24.05], 56.89 [22.67], 57.31 [22.87], in patients with malignant, benign, and without neoplasms, respectively). Patients without neoplasms reported significantly lower stress (4.19 [2.86], M [SD]) than those with benign (5.02 [3.03], M [SD]) and malignant neoplasms (4.99 [2.93], M [SD]). In all three mediation models, SOC had significant direct effects on stress, with higher SOC being associated with lower stress (− 0.3170 [0.0407], − 0.3484 [0.0752], − 0.2919 [0.0206]; c’ [SE], p < 0.001 in patients with malignant, benign, and without neoplasms, respectively). In patients with malignant neoplasms and without neoplasms, SOC showed small indirect effects on stress that were statistically mediated by well-being. Higher SOC was related to higher well-being, which in turn was related to lower stress. In patients with benign neoplasms, however, no significant indirect effects of SOC were found.ConclusionsSOC was directly associated with lower perceived hospital and surgery related stress, over and above the direct and mediation effects of mental well-being. Because the data are cross-sectional, conclusions implying causality cannot be drawn. Nevertheless, they indicate important relationships that can inform treatment approaches to reduce elevated preoperative stress by specifically addressing low SOC.Trial registrationclinicaltrials.gov Identifier: NCT01357694. Registered 18 May 2011

Effect of Hospital and Surgeon Procedure Volumes on the Incidence of Intraoperative Conversion During Off-Pump Coronary Artery Bypass Grafting

Intraoperative conversion to cardiopulmonary bypass with its subsequent high mortality is a major concern associated with off-pump coronary artery bypass grafting (OPCAB). The impact of procedure volume on the incidence of intraoperative conversion, however, is poorly defined. This study therefore evaluated the effect of procedure volume on the incidence of conversion in OPCAB using nationwide data. We analyzed 31,361 patients who underwent primary, nonemergent, isolated OPCAB during 2013-2016 reported in the Japan Cardiovascular Surgery Database. Hospitals (n = 548) and surgeons (n = 1315) were divided into tertile categories (low-, medium-, and high volumes) based on the total number of isolated coronary artery bypass grafting (CABG). Hierarchical logistic regression analysis, including 22 preoperative factors and hospital and surgeon CABG volumes, was used to assess the relation between procedure volume and the risk of conversion due to bleeding/hemodynamic instability. There were 797 (2.5%) intraoperative conversions due to bleeding/hemodynamic instability. Risk-adjusted odds ratios for conversion were significantly lower in some combined hospital/surgeon CABG volume categories than in the reference category. Hospital/surgeon volumes and their odds ratio (95% confidence interval) were as follows: low/low 1.00 (reference); medium/low 0.62 (0.39-0.96); high/low 0.47 (0.27-0.81); high/high 0.58 (0.38-0.89). There was a lower risk of conversion in medium- and high-volume than low-volume hospitals, especially among low-volume surgeons. Procedure volume is associated with the incidence of conversion during OPCAB. Among low-volume surgeons, hospital CABG volume significantly reduces conversion in a volume-dependent manner. These findings will be useful for safety training of OPCAB surgeons.

Association of Preoperative Geriatric Assessment With Length of Stay After Combined Cardiac Surgery

For older patients undergoing cardiac surgery, geriatric factors are known to increase postoperative complications and prolong length of stay (LOS). Comprehensive geriatric assessment (CGA) is an evidence-based method for geriatric evaluation to develop an individualized-care plan to optimize physical, functional, and social issues. This study analyzed the association between preoperative CGA and hospital LOS after combined cardiac surgery. This retrospective monocentric study included all patients aged 75 years and greater who underwent combined cardiac surgery between 2014 and 2017. Hospital LOS, intensive care unit LOS, and postoperative complications were compared between patients with or without preoperative CGA before and after propensity-score matching. Mean age of the 407 patients was 79.6 years; 114 underwent a preoperative CGA (28%). For 305 patients (74.9%), coronary artery bypass was associated with aortic valve replacement. After propensity-score matching, a significant difference was found between the 2 groups (preoperative CGA versus none) for in-hospital LOS (12 versus 13 days; P= .04) and intensive care unit LOS (3 versus 4 days; P= .01). In multivariable analysis, a significant association remained between hospital LOS and CGA (P= .02), renal function (P= .02), mitral replacement (P= .001), and complications (P= .001). Our results favor the use of systematic preoperative CGA. These encouraging results need to be validated by prospective studies that assess the impact of individualized-care plan established after CGA on postoperative outcomes. With an aging population, efforts are required to determine how to implement preoperative individualized-care plans to improve postoperative outcomes for vulnerable patients undergoing cardiac surgery.

Costs Associated With Lobectomy for Lung Cancer: An Analysis Merging STS and Medicare Data

Costs related to care of patients who undergo lobectomy for lung cancer may vary depending on patient, disease, and treating facility characteristics. We aimed to identify underlying case mix factors that contribute to variability of 90-day costs of lobectomy for early-stage lung cancer. The Society of Thoracic Surgeons General Thoracic Surgery Database was queried for lobectomy for clinical stage I lung cancer (2008-2013). Demographics, clinical outcomes, and 90-day episode-of-care costs across all care settings were analyzed for patients successfully linked to Medicare data. Hospital costs were estimated from charges using cost-to-charge ratios. Comprehensive regression models were created to identify impact of preoperative patient factors and hospital characteristics on costs, and to delineate additive costs due to perioperative outcomes and complications. The mean 90-day cost for lobectomy was $45,080 ± $38,239. Variables associated with significant additive costs were age greater than or equal to 75 years, American Society of Anesthesiologists classification III or IV, forced expiratory volume in 1 second less than 80% predicted, body mass index less than 18.5 or greater than 35, current or past smoker, cerebrovascular disease, chronic kidney disease, impaired functional status, open thoracotomy, prolonged operative time, government hospitals, metropolitan setting, and geographic location. Patients with 1 or more postoperative complication resulted in an overall mean added cost of $27,259. Added costs increased with the number of complications; isolated recurrent laryngeal nerve paresis ($3,911) and respiratory failure ($35,011) were associated with the least and most additive cost, respectively. Lobectomy is associated with substantial variability of episode-of-care costs. Variability is driven by patient demographic and clinical factors, hospital characteristics, and the occurrence and severity of complications.

What Factors Predict Adverse Discharge Disposition in Patients Older Than 60 Years Undergoing Lower-extremity Surgery? The Adverse Discharge in Older Patients after Lower-extremity Surgery (ADELES) Risk Score.

Adverse discharge disposition, which is discharge to a long-term nursing home or skilled nursing facility is frequent and devastating in older patients after lower-extremity orthopaedic surgery. Predicting individual patient risk allows for preventive interventions to address modifiable risk factors and helps managing expectations. Despite a variety of risk prediction tools for perioperative morbidity in older patients, there is no tool available to predict successful recovery of a patient's ability to live independently in this highly vulnerable population. In this study, we asked: (1) What factors predict adverse discharge disposition in patients older than 60 years after lower-extremity surgery? (2) Can a prediction instrument incorporating these factors be applied to another patient population with reasonable accuracy? (3) How does the instrument compare with other predictions scores that account for frailty, comorbidities, or procedural risk alone? In this retrospective study at two competing New England university hospitals and Level 1 trauma centers with 673 and 1017 beds, respectively; 83% (19,961 of 24,095) of patients 60 years or older undergoing lower-extremity orthopaedic surgery were included. In all, 5% (1316 of 24,095) patients not living at home and 12% (2797 of 24,095) patients with missing data were excluded. All patients were living at home before surgery. The mean age was 72 ± 9 years, 60% (11,981 of 19,961) patients were female, 21% (4155 of 19,961) underwent fracture care, and 34% (6882 of 19,961) underwent elective joint replacements. Candidate predictors were tested in a multivariable logistic regression model for adverse discharge disposition in a development cohort of all 14,123 patients from the first hospital, and then included in a prediction instrument that was validated in all 5838 patients from the second hospital by calculating the area under the receiver operating characteristics curve (ROC-AUC).Thirty-eight percent (5360 of 14,262) of patients in the development cohort and 37% (2184 of 5910) of patients in the validation cohort had adverse discharge disposition. Score performance in predicting adverse discharge disposition was then compared with prediction scores considering frailty (modified Frailty Index-5 or mFI-5), comorbidities (Charlson Comorbidity Index or CCI), and procedural risks (Procedural Severity Scores for Morbidity and Mortality or PSS). After controlling for potential confounders like BMI, cardiac, renal and pulmonary disease, we found that the most prominent factors were age older than 90 years (10 points), hip or knee surgery (7 or 8 points), fracture management (6 points), dementia (5 points), unmarried status (3 points), federally provided insurance (2 points), and low estimated household income based on ZIP code (1 point). Higher score values indicate a higher risk of adverse discharge disposition. The score comprised 19 variables, including socioeconomic characteristics, surgical management, and comorbidities with a cutoff value of ≥ 23 points. Score performance yielded an ROC-AUC of 0.85 (95% confidence interval 0.84 to 0.85) in the development and 0.72 (95% CI 0.71 to 0.73) in the independent validation cohort, indicating excellent and good discriminative ability. Performance of the instrument in predicting adverse discharge in the validation cohort was superior to the mFI-5, CCI, and PSS (ROC-AUC 0.72 versus 0.58, 0.57, and 0.57, respectively). The Adverse Discharge in Older Patients after Lower Extremity Surgery (ADELES) score predicts adverse discharge disposition after lower-extremity surgery, reflecting loss of the ability to live independently. Its discriminative ability is better than instruments that consider frailty, comorbidities, or procedural risk alone. The ADELES score identifies modifiable risk factors, including general anesthesia and prolonged preoperative hospitalization, and should be used to streamline patient and family expectation management and improve shared decision making. Future studies need to evaluate the score in community hospitals and in institutions with different rates of adverse discharge disposition and lower income. A non-commercial calculator can be accessed at www.adeles-score.org. Level III, diagnostic study.

Association Between Preoperative Blood Glucose Level and Hospital Length of Stay for Patients Undergoing Appendectomy or Laparoscopic Cholecystectomy.

OBJECTIVETo evaluate the effect of preoperative blood glucose (POBG) level on hospital length of stay (LOS) in patients undergoing appendectomy or laparoscopic cholecystectomy.RESEARCH DESIGN AND METHODSWe conducted a retrospective cohort study of patients aged ≥18 years who had undergone appendectomy or laparoscopic cholecystectomy procedures between 2005 and 2016 at a tertiary medical center in Taiwan. The association between POBG level and LOS was evaluated using a multivariable quasi-Poisson regression with robust variance. Multiple imputations were performed to replace missing values.RESULTSWe included 8,291 patients; 4,025 patients underwent appendectomy (appendectomy group) and 4,266 underwent laparoscopic cholecystectomy (laparoscopic cholecystectomy group). In the appendectomy group, patients with POBG levels of ≥123 mg/dL (adjusted relative risk [aRR] 1.19; 95% CI 1.06–1.33) had a 19% higher risk of having a LOS of >3 days than did those with POBG levels of <106 mg/dL. In the laparoscopic cholecystectomy group, patients with POBG levels of ≥128 mg/dL also had a significantly higher risk of having a LOS of >3 days (aRR 1.17; 95% CI 1.07–1.29) than did those with POBG levels of <102 mg/dL. A positive dose–response curve between POBG and an adjusted risk of a LOS of >3 days was observed, although the curve starts to flatten at a POBG level of ∼130 mg/dL.CONCLUSIONSWe demonstrated that a higher POBG level was significantly associated with a prolonged LOS for patients undergoing appendectomy or laparoscopic cholecystectomy. The optimal POBG level may be lower than that commonly perceived.

Impacts of incomplete revascularization following off-pump coronary artery bypass grafting on perioperative outcomes in octogenarians

Objective: To assess the impacts of incomplete revascularization following off-pump coronary artery bypass grafting (OPCABG) on perioperative outcomes in octogenarians. Methods: A retrospective analysis of 242 octogenarian patients with coronary artery disease (CAD) hospitalized in Beijing Anzhen Hospital from June 2008 to July 2016 was performed. These patients were divided into the complete revascularization group (n=181) and the incomplete revascularization group (n=61) depending on whether they underwent complete revascularization. The impacts of incomplete revascularization following OPCABG on perioperative outcomes were summarized and compared between the two groups. Results: Among the 242 patients over 80 years who received OPCABG, there were 198 males (81.8%). Compared to the complete revascularization group, those in the incomplete revascularization group were older [(83.2±1.5) vs (81.5±1.1) years old, P=0.03], with more carotid stenosis (44.3% vs 25.4%, P=0.01), more involved in the diagonal and circumflex branch of coronary artery (49.2% vs 17.1%, P=0.01; 83.6% vs 70.2%, P=0.03), shorter operative time [(4.1±1.7) h vs (4.7±1.2) h, P=0.03), longer preoperative [(7.1±2.3) d vs (5.2±2.0) d, P=0.01] and total hospitalization time [(16.3±6.8) d vs (12.5±4.2) d, P=0.01], however, the differences of the in-hospital mortality and incidence of other perioperative complications were not statistically significant between the two groups (all P>0.05). Conclusion: Compared with complete revascularization, incomplete revascularization following OPCABG in CAD patients over 80 years old does not increase the perioperative mortality and the incidence of other complications, and it reduces the operative time. However, it increases the time of preoperative and total hospital stay.

Health care costs of endovascular compared with open thoracoabdominal aortic aneurysm repair

ObjectiveTo compare 1-year health care costs between endovascular and open thoracoabdominal aortic aneurysm (TAAA). MethodsPopulation-based administrative health databases were used to capture TAAA repairs performed in Ontario, Canada, between January 2006 and February 2017. All health care costs incurred by the Ministry of Health from a single-payer universal health care system were included. Costs of the aortic endografts and ancillary devices for the index procedure were estimated as C$44,000 per endovascular case vs C$1000 for open cases, based on previous reports. Costs (2017 Canadian dollars) were calculated in phases (1, 1-3, 3-6, and 6-12 months from surgery) with censoring for death. For each phase, propensity score matching of endovascular and open cases based on preoperative patient and hospital characteristics was used. The association between preoperative characteristics (including repair approach) and the first month postprocedure cost was characterized through multivariable analysis. ResultsOverall 664 TAAA repairs were identified (open, n = 361 [54.5%] and endovascular, n = 303 [45.6%]). At 1 month, the median cost was higher for endovascular TAAA repair in the prematching cohort (C$64,892 vs C$36,647; P < .01). Similarly, in 241 well-balanced endovascular/open patient pairs after propensity score matching, the median health care costs were higher in endovascular TAAA cases during the first month (C$62,802 vs C$33,605; P < .01). The 1- to 3-month median cost was not statistically different between endovascular and open TAAA cases either before matching (C$2781 vs C$2618; P = .71) or after matching (C$2762 vs C$2092; P = .58). Likewise, in the 3- to 6-month and 6- to 12-month postprocedure intervals, there were no significant differences in the median health care costs between groups. On multivariable analysis, older age (5-year increments) (relative change [RC] in mean cost, 1.05; 95% confidence interval [CI], 1.04-1.06; P = .01), urgent procedures (RC, 1.29; 95% CI, 1.10-1.52; P < .01), and history of stroke (RC, 1.34; 95% CI, 1.00-1.78; P = .05) were associated with higher costs in the first postoperative month, whereas open relative to endovascular TAAA repair was associated with a decreased 1-month cost (RC, 0.65; 95% CI, 0.56-0.74; P < .01). ConclusionsTAAA repair is expensive regardless of technique. Compared with open TAAA repair, endovascular repair was associated with a higher early cost, owing to the upfront cost of the endograft and aortic ancillary devices. There was no difference in cost from 1 to 12 months after repair. A decrease in the cost of endovascular devices might allow equivalent costs between endovascular and open TAAA repair.

Pulmonary function in preoperative, postoperative and post hospital discharge after heart surgery: controlled clinical study

Background: Cardiac surgery may influence respiratory function at different times, such as before and after surgery, and after hospitaldischarge. Objective: Evaluate the respiratory functionality (respiratory muscle strength and peak expiratory flow-PEF) of pre, postoperativeand post-hospital discharge of cardiac surgery patients at a Regional Hospital in the south of Minas Gerais. Methods: The sample consisted of11 subjects: 6 women (54.4%) and 5 men (45.46%), with mean age of ± 60 years. The mean height, weight and BMI were respectively: ±1.61m,±71.08kg and ±26.89. Results: The values of the functional variables were lower than expected; men had the highest values of maximalinspiratory pressure (MIP), maximal expiratory pressure (MEP) and PEF at the 3 moments; there was correlation rs &lt; 1 p &lt; 0.01 of PRE MIP andPOS MIP; PRE MIP and POS MEP; third day MIP and PRE MIP; and POS MEP and PRE MEP. Conclusion: men had the highest values ofrespiratory functional variables. The analysis of the variables at the 3 moments showed that after hospital discharge most of them reduced theirvalues. The post hospital discharge should be a concern of professionals assisting cardiac surgery patients.

A Fall Within 3 Months Before Total Joint Arthroplasty is Associated With Adverse Outcomes in Elderly Patients

BackgroundFalls are associated with morbidity and death in the elderly. The consequences of falls after total joint arthroplasty (TJA) are known, but the consequences of preoperative falls are unclear. We assessed associations between preoperative fall history and hospital readmission rates and discharge disposition after primary TJA. MethodsWe queried the National Surgical Quality Improvement Program Geriatric Pilot Project for cases of primary total hip arthroplasty (THA) (n = 3671) and total knee arthroplasty (TKA) (n = 6194) performed between 2014 and 2018 for patients aged ≥65 years. Patient characteristics, comorbidities, functional status indicators, and 30-day outcomes were compared among patients with falls occurring within 3 months, from >3 to 6 months, and from >6 to 12 months before surgery, and patients with no falls in the year before surgery. The timing of falls was assessed for independent associations with hospital readmission and discharge to a skilled care facility (SCF). Alpha = 0.05. ResultsPatients who fell within 3 months before surgery had greater odds of SCF discharge (for THA, odds ratio [OR] 2.5, 95% confidence interval [CI] 1.8-3.4; for TKA, OR 1.8, 95% CI 1.4-2.3) and hospital readmission (for THA, OR 1.8, 95% CI 1.1-3.0; for TKA, OR 2.4, 95% CI 1.6-3.5) compared with the no-fall cohort. No such associations were observed for the other two fall cohorts. ConclusionFalls within 3 months before primary TJA are associated with SCF discharge and readmission for patients aged ≥65 years. Fall history screening should be included in preoperative evaluation. Level of EvidenceIII.