Preoperative Steroid Use Research Articles

Chronic steroid use and readmission following total shoulder arthroplasty.

BackgroundDegenerative arthritis is a major indication for both anatomic and reverse total shoulder arthroplasty (TSA). Degenerative arthritis is an age-related process that can be secondary to mechanical wear or inflammatory or autoimmune diseases, such as rheumatoid arthritis or systemic lupus erythematosus. Management of these diseases can include chronic corticosteroid for their anti-inflammatory and immunosuppressive effects. Given the well-known complications of chronic steroid use on other surgical procedures, investigation into postoperative complications specific to TSA will assist physicians in risk stratification and preoperative planning. The purpose of this study was to investigate the association between chronic preoperative steroid use and postoperative complications following TSA.MethodsThe American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent TSA between 2015 and 2020. Patient demographics, comorbidities, surgical characteristics, and 30-day postoperative complication data were collected. Multivariate logistic regression was used to identify postoperative complications associated with chronic preoperative steroid use. Reasons and risk factors for readmission among chronic steroid users were subsequently identified, as well.ResultsA total of 26,669 patients were included in this study: 25,376 (95.2%) were included in the nonsteroid cohort and 1293 (4.8%) were included in the chronic steroid cohort. The postoperative complications that were significantly associated with chronic preoperative steroid use were septic shock (P = .007), urinary tract infection (P = .016), myocardial infarction (P = .022), ventilator >48 hours (P = .028), readmission (P < .001), nonhome discharge (P < .001), and mortality (P = .007). The only postoperative complication independently associated with chronic preoperative steroid use was readmission (odds ratio, 1.36; 95% confidence interval, 1.04-1.79; P = .027).ConclusionPreoperative chronic steroid use is an independent predictor for readmission following TSA. As procedural improvement increases surgical volume for TSA, a better understanding of preoperative risk factors can improve perioperative risk stratification and help to minimize adverse outcomes.

High Rates of Recurrent Revascularization in Acute Limb Ischemia – A National Surgical Quality Improvement Program Study

We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to review outcomes of acute limb ischemia (ALI) patients following open surgical intervention for ALI. A previously validated tool was used to identify ALI patients in NSQIP undergoing open surgical revascularization from 2012 to 2017. Multivariable analysis was performed for the primary outcome of reoperation and secondary outcome of readmission and infection. A total of 2,878 ALI patients underwent open revascularization; 35.7% were transfers from another acute care hospital. A total of 13.8% required reoperation and 7.9% required readmission within 30days. A total of 32% of reoperations were recurrent revascularization, representing 4.4% of all ALI patients. A total of 58.7% of patients were female and either overweight or obese. Younger age (odds ratio OR 0.991 [0.984-0.999], P=0.02), underweight patients (OR 1.159 [0.667-2.01], P=0.05), pre-operative steroid use (OR 1.61 [1.07-2.41], P=0.02), and perioperative transfusion (OR 2.02 [1.04-3.95], P=0.04) predicted reoperations. This registry series demonstrates all-cause ALI patients are a different population than PAD with different risk factors. Despite being a time-critical condition, ALI has higher interhospital transfer rates than ACS or ruptured aneurysm. Following open revascularization, ALI outcomes are worse than ACS but better than ruptured AAA. These outcomes do not appear related to patient factors in contrast to revascularization for chronic PAD.

The Effect of Steroid Use on Complications after Distal Radius Fracture Repair.

Background Distal radius fractures (DRFs) are the most common fracture of the upper extremity. Given that steroids are one of the most commonly prescribed drugs and are usually prescribed for chronic conditions, steroid use represents a key factor to consider in how to optimize perioperative outcomes. Questions/Purposes The purpose of this study was to investigate if there are differences in perioperative outcomes for patients undergoing DRF open reduction and internal fixation based on preoperative steroid use. Patients and Methods Adult patients who underwent operative treatment for DRF from 2007 to 2018 were identified in a national database. Patients were divided into two cohorts as follows: (1) no steroid usage and (2) preoperative steroid usage. In this analysis, various postoperative complications, as well as extended length of stay and reoperation, were assessed. Bivariate analyses and multivariable logistical regression were performed. Results Among a total of 16,505 patients undergoing operative treatment for DRF, 16,145 patients (97.8%) did not have steroid usage and 360 (2.2%) had steroid usage. Following adjustment, an increased risk of extended length of hospital stay greater than 3 days (odds ratio [OR] = 1.646; p = 0.012) was seen in the steroid usage group compared with those who did not use steroids within 30 days of surgery. Conclusion Preoperative steroid use is associated with increased length of stay over 3 days after DRF open reduction and internal fixation surgery but is not associated with any of the other complications that were assessed in this study. Level of Evidence This is a Level III, retrospective study.

Erector spinae muscle radiographic density is associated with survival after lung transplantation

The study objective was to verify whether low preoperative radiographic density of erector spinae muscles is associated with poor prognosis after lung transplantation. Preoperative chest computed tomography scans for patients who underwent deceased-donor lung transplantation between 2013 and 2019 at Kyoto University Hospital were retrospectively retrieved. The radiographic density of erector spinae muscles was quantitatively evaluated as the mean attenuation of erector spinae muscles, and low mean radiographic density of the erector spinae muscles was defined as a mean radiographic density of the erector spinae muscles value below the median value for all patients. Overall survival and chronic lung allograft dysfunction-free survival with high and low mean radiographic density of the erector spinae muscles were estimated using the Kaplan-Meier method and evaluated by the log-rank test, as well as by univariate and multivariate Cox proportional hazard analyses. Of the 107 adult patients who underwent primary transplantation, 96 underwent at least 1 chest computed tomography scan within 24hours before lung transplantation. The median mean radiographic density of the erector spinae muscles in these 96 patients was 49.2 Hounsfield units. A low mean radiographic density of the erector spinae muscles value was significantly associated with decreased overall survival (hazard ratio, 4.50; P=.030) and chronic lung allograft dysfunction-free survival (hazard ratio, 3.18; P=.028) in the multivariate analysis. Additionally, patients with preoperative steroid use and a low mean radiographic density of the erector spinae muscles value had a worse overall survival (P<.001) and chronic lung allograft dysfunction-free survival (P<.001) than patients with preoperative steroid use and a high mean radiographic density of the erector spinae muscles value and those without preoperative steroid use. Low mean radiographic density of the erector spinae muscles was closely associated with a poor prognosis after lung transplantation. The prognosis was particularly poor in patients with preoperative steroid use and a low mean radiographic density of the erector spinae muscles. These results may be useful when considering the indications for lung transplantation or preoperative interventions. VIDEO ABSTRACT.

Simple Prediction Score for Developing Surgical Site Infection after Clean Neck Operation.

Background: Clean neck operations (thyroidectomies, parathyroidectomies, and lymph node resection) are among the most common procedures performed in the United States. Surgical site infections (SSIs) after clean neck operations are rare, but the consequences are devastating and often life-threatening. The aim of this study was to develop a score that will identify patients at high risk for developing a SSI after a clean neck procedure. Materials and Methods: Patients with either thyroidectomies, parathyroidectomies, or lymph node resection of the neck were identified from the 2016 and 2017 databases of the American College of Surgeons National Surgical Quality Improvement Program and were used for this analysis. Our primary goal was to build a scoring system with which we will be able to identify patients at high risk for SSI after a clean neck operation. Results: Of a total of 99,877 patients, 72,719 patients had a thyroidectomy, 22,043 patients had parathyroidectomy, and 5,115 patients had lymph node resection of the neck. Multivariable logistic regression identified the following independent risk factors associated with post-operative SSI: male gender (adjusted odds ratio [aOR], 1.25; 95% confidence interval [CI], 1.03-1.51), diabetes mellitus (aOR, 1.34; 95% CI, 1.07-1.67), smoking (aOR, 1.66; 95% CI, 1.36-2.04), pre-operative steroid use (aOR, 1.75; 95% CI, 1.21-2.53), cancer diagnosis (aOR, 1.44; 95% CI, 1.17-1.77), radical lymphadenectomies (aOR, 2.94; 95% CI, 2.16-4), and total operative time ≥198 minutes (aOR, 2.25; 95% CI, 1.82-2.78). Afterward, we developed a prognostic score for calculating the odds of having post-operative SSI. One point was allotted for each of the aforementioned factors, except lymphadenectomies where two points were allotted, and operative time was excluded. Our score was associated with a stepwise higher risk of post-operative SSI after a clean neck operation. Conclusions: Pre-operative and intra-operative factors can predict which patients undergoing a clean neck surgery may develop SSI. Our prognostic score may help guide surgeons identify patients at high-risk for SSI after clean neck surgery and these patients might benefit from prophylactic use of antibiotic agents.

Significant Reduction in Short-Term Complications Following Unicompartmental Versus Total Knee Arthroplasty: A Propensity Score Matched Analysis

BackgroundTotal knee arthroplasty (TKA) is a gold standard surgical treatment for end-stage arthritis and unicompartmental knee arthroplasty (UKA) is an alternative for localized disease in appropriate patients. Both have been shown to have equivalent complications in the short-term period. We aimed to explore the differences in 30-day complication rates between UKA and TKA using recent data. MethodsCurrent Procedural Terminology codes identified patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent primary TKA or UKA from 2014 to 2018. Propensity score matching addressed demographic differences. Rate of any adverse event (AAE) and complications were compared. ResultsWe identified 279,852 patients with 270,786 and 9,066 undergoing TKA and UKA. No significant difference was observed in baseline demographics after matching. The AAE rate differed significantly between TKA (5.07%) and UKA (2.38%) cohorts (P < .001). TKA group experienced more wound dehiscence, cerebrovascular accident, postoperative blood transfusion, deep vein thrombosis, and requirement for postoperative intubation. Rate of extended length of stay differed between the TKA (11.35%) and UKA (4.89%) cohorts (P < .001). Accounting for all other variables, preoperative corticosteroid use, bleeding disorder, and chronic obstructive pulmonary disease increased the risk for AAE for both groups. Increasing American Society of Anesthesiologists class also increased the odds for complication proportionally with increasing age and operative time. ConclusionContrary to previous data, we found a significantly higher 30-day complication rate in TKA patients. TKA patients had a higher likelihood of having an extended length of stay. Multivariable analysis identified preoperative steroid use, bleeding disorder, and chronic obstructive pulmonary disease as risk factors for developing adverse events for both groups. Level of EvidenceLevel III.

Prospective Cohort Study to Investigate the Safety of Preoperative Tumor Necrosis Factor Inhibitor Exposure in Patients With Inflammatory Bowel Disease Undergoing Intra-abdominal Surgery

Whether preoperative treatment of inflammatory bowel disease (IBD) with tumor necrosis factor inhibitors (TNFis) increases the risk of postoperative infectious complications remains controversial. The primary aim of this study was to determine whether preoperative exposure to TNFis is an independent risk factor for postoperative infectious complications within 30 days of surgery. We conducted a multicenter prospective observational study of patients with IBD undergoing intra-abdominal surgery across 17 sites from the Crohn's & Colitis Foundation Clinical Research Alliance. Infectious complications were categorized as surgical site infections (SSIs) or non-SSIs. Current TNFi exposure was defined as use within 12 weeks of surgery, and serum was collected for drug-level analyses. Multivariable models for occurrence of the primary outcome, any infection, or SSI were adjusted by predefined covariates (age, sex, preoperative steroid use, and disease type), baseline variables significantly associated (P < .05) with any infection or SSI separately, and TNFi exposure status. Exploratory models used TNFi exposure based on serum drug concentration. A total of 947 patients were enrolled from September 2014 through June 2017. Current TNFi exposure was reported by 382 patients. Any infection (18.1% vs 20.2%, P= .469) and SSI (12.0% vs 12.6%, P= .889) rates were similar in patients currently exposed to TNFis and those unexposed. In multivariable analysis, current TNFi exposure was not associated with any infection (odds ratio, 1.050; 95% confidence interval, 0.716-1.535) or SSI (odds ratio, 1.249; 95% confidence interval, 0.793-1.960). Detectable TNFi drug concentration was not associated with any infection or SSI. Preoperative TNFi exposure was not associated with postoperative infectious complications in a large prospective multicenter cohort.

Late is too late? Surgical timing and postoperative complications after primary ileocolic resection for Crohn’s disease

BackgroundDespite the recent advances in medical therapy, the majority of patients with Crohn’s disease (CD) still require surgery during the course of their life. While a correlation between early primary surgery and lower recurrence rates has been shown, the impact of surgical timing on postoperative complications is unclear. The aim of this study is to assess the impact of surgical timing on 30-day postoperative morbidity.MethodsThis is a retrospective analysis of a prospectively collected database of 307 consecutive patients submitted to elective primary ileocolic resection for CD at our institution between July 1994 and July 2018. The following variables were considered: age, gender, year of treatment, smoking habits, preoperative steroid therapy, presence of fistula or abscess, type of anastomosis, and time interval between diagnosis of CD and surgery. Univariate and multivariate logistic regressions were performed to examine the association between risk factors and complications.ResultsMajor complications occurred in 29 patients, while anastomotic leak was observed in 16 patients. Multivariate logistic regression analysis showed that surgical timing in years (OR 1.10 p = 0.002 for a unit change), along with preoperative use of steroids (OR 5.45 p < 0.001) were independent risk factors for major complications. Moreover, preoperative treatment with steroids (6.59 p = 0.003) and surgical timing (OR 1.10 p = 0.023 for a unit change) were independently associated with anastomotic leak, while handsewn anastomosis (OR 2.84 p = 0.100) showed a trend.ConclusionsOur results suggest that the longer is the time interval between diagnosis of CD and surgery, the greater is the risk of major surgical complications and of anastomotic leak.

Association between Preoperative Steroids and Outcomes in Patients Undergoing Pancreaticoduodenectomy using the National Surgical Quality Improvement Program

BackgroundA national study analyzing the association between preoperative steroid use and outcomes after pancreatic resections is lacking. The purpose of this study is to evaluate the association between preoperative steroids and outcomes after pancreaticoduodenectomy using a national database. Materials and MethodsA retrospective analysis of patients undergoing pancreaticoduodenectomy was performed using the National Surgical Quality Improvement Program (NSQIP) database (2014–2019). In addition, we utilized propensity score matching to compare patients on preoperative steroids to those who were not. Outcomes measured included 30-day complications and mortality, need for readmission, a prolonged hospital length of stay, delayed gastric emptying, and pancreatic fistula. ResultsAfter propensity score matching, there were 438 patients in the steroid group and 876 patients in the no steroid group. There was no difference in pancreatic fistula (23.8% vs. 21.7%; p-0.3), delayed gastric emptying (21.1% vs.20.1%; p-0.06), major complications (31.8% vs. 30.1%; p-0.1), and mortality (3.5% vs. 3.2%; p-0.6) between the two groups. ConclusionGlucocorticoids did not reduce the incidence of overall complications, postoperative fistula, and delayed gastric emptying following pancreaticoduodenectomy.

Operative Autonomy: Assessing Resident Impact on Surgical Outcomes In Below The Knee Amputations

INTRODUCTION AND OBJECTIVES Gradual increases in autonomy with attending physician oversight are consider crucial to successful training in surgery as well as safe patient care. The Veterans Affairs Surgical Quality Improvement Program (VASQIP) follows patient outcomes and has yet to be examined for outcomes of specialty and includes information about attending surgeon oversight in the operation room (OR). We set forth to examine VASQIP database to determine the frequency of resident operative independence during below the knee amputations (BKA). METHODS All VASQIP records for BKA from 1990 to 2018 were examined and categorized based on if the attending was scrubbed during case. Case matching was performed based on gender, diabetes, preoperative renal failure, smoking status, steroid use, CHF, COPD, and open wound infections. Comorbidities, pre- and postoperative outcomes for each procedure within 30 days were tabulated. 30 day post-operative outcomes including return to the operating room, wound infections mortality were assessed in addition to operative time, hospital length of stay and transfusion requirements. Student t-test* and Fisher's Exact Test⁎⁎ were utilized. RESULTS A total of 28,768 BKA VASQIP records were obtained. After case control matching, 5,234 cases remained. Cases were identified with the attending surgeon noted as being scrubbed during the case (n=2617), or not scrubbed (n=2617). Patients were similar in comorbidities across both. CONCLUSIONS Increased resident independence during BKA at VA hospitals is associated with a statistically significant length of stay, return to OR, blood transfusion, and sepsis. There was no statistically significant increase in operative time, 30-day mortality, wound infection, or total complication. Further research is required in assessing the risks associated with surgical training, resident supervision, and resident preparedness for independent practice. Gradual increases in autonomy with attending physician oversight are consider crucial to successful training in surgery as well as safe patient care. The Veterans Affairs Surgical Quality Improvement Program (VASQIP) follows patient outcomes and has yet to be examined for outcomes of specialty and includes information about attending surgeon oversight in the operation room (OR). We set forth to examine VASQIP database to determine the frequency of resident operative independence during below the knee amputations (BKA). All VASQIP records for BKA from 1990 to 2018 were examined and categorized based on if the attending was scrubbed during case. Case matching was performed based on gender, diabetes, preoperative renal failure, smoking status, steroid use, CHF, COPD, and open wound infections. Comorbidities, pre- and postoperative outcomes for each procedure within 30 days were tabulated. 30 day post-operative outcomes including return to the operating room, wound infections mortality were assessed in addition to operative time, hospital length of stay and transfusion requirements. Student t-test* and Fisher's Exact Test⁎⁎ were utilized. A total of 28,768 BKA VASQIP records were obtained. After case control matching, 5,234 cases remained. Cases were identified with the attending surgeon noted as being scrubbed during the case (n=2617), or not scrubbed (n=2617). Patients were similar in comorbidities across both. Increased resident independence during BKA at VA hospitals is associated with a statistically significant length of stay, return to OR, blood transfusion, and sepsis. There was no statistically significant increase in operative time, 30-day mortality, wound infection, or total complication. Further research is required in assessing the risks associated with surgical training, resident supervision, and resident preparedness for independent practice.

P399 C-Reactive Protein Values After Surgery for Inflammatory Bowel Disease: Is It Still A Good Marker For Intra-Abdominal Complication? A Retrospective Cohort Study of, 347 procedures

Abstract Background C-reactive protein (CRP) is a useful predictive test to early detect abdominal complication after colorectal surgery. Inflammatory bowel disease (IBD) is responsible of chronic inflammation and abnormal basal CRP that could influence the interest of its management after abdominal surgery. The aim of this study was to evaluate CRP as an indicator of postoperative complication in a specific IBD population. Methods Retrospective study of patients undergoing ileocolic resection or ileal pouch-anal anastomosis for IBD between, 2012 and 2019. Intra-abdominal complication was defined as any intra-abdominal event, infectious or otherwise, occurring during the immediate postoperative period. The early postoperative period was defined as post-operative days (POD), 1 and, 2 and late postoperative period as POD, 3 and 4. Results Ileocolic resection represented, 242 patients and ileal pouch-anal anastomosis, 105 patients. Intra-abdominal complications occured in, 18.1% of patients (ICR=40, 16.5% and IPAA=23, 21.9%). Pre-operative CRP (48 hours before surgery) was available for, 96 patients (29.8%). Among them, 64 had an abnormal CRP value (median:, 13±45.4). No relation was found between a preoperative abnormal CRP value and post-operative intra-abdominal complications. CRP was significantly higher at an early (105.2±56.0 vs, 128.1±69.8; p=0.008) and late stage (112.9±72.8 vs, 185.3±111.5; p &amp;lt;, 0.0001) for patients having an intra-abdominal complication. The best sensitivity and specificity values were obtained at POD, 3–4 with a CRP cut-off of, 75 with an area under the curve of, 0.71. The ability to rule out an intra-abdominal complication with a CRP Value &amp;lt;75 mg/L was good with, at POD, 1–2 NPV=86.4% and PPV=19.9% and, at POD, 3 an NPV=90.3% and PPV=22.2%. A BMI &amp;gt;25kg/m2 (p=0.04) and an open surgical approach (p=0.009) were associated with higher CRP levels in the first POD. In multivariate analysis, pre-operative steroid use (p=0.03), CRP at POD, 3 &amp;gt;, 100mg/L (p=0.002) and a rise between CRP values more than, 50 mg/L (p=0.005) or, 100 mg/L (p &amp;lt;, 0.0001) at, 48 hours were significantly associated with intra-abdominal complication. A CRP at POD, 1 &amp;lt;75mg/L was associated with a lower rate of intra-abdominal complication (p=0.01). A score using these, 4 independent factors was created and showed significant differences in intra-abdominal complication, anastomotic leakage and readmission rate. Conclusion CRP is a useful predictive marker to detect abdominal complication after surgery in IBD population. Measurement of CRP can help to reduce hospitalization stay and orientate towards complementary examinations.

Impact of Preoperative Steroid Use on Pancreaticoduodenectomy Outcomes: Analysis of the NSQIP Database

Introduction: While preoperative steroid use is frequently cited as a risk factor for postoperative morbidity, the impact of steroid use on the outcomes of patients undergoing pancreaticoduodenectomy has not been previously quantified. Methods: The National Surgical Quality Improvement Program (NSQIP) database from 2005-2019 was utilized. All patients who underwent pancreaticoduodenectomy were included in the analysis. Patient characteristics and unadjusted outcomes were described, and multivariate logistic regression was used to assess the impact of steroid use on postoperative outcomes. Results: A total of 49,672 patients were identified of whom 1,293 (2.6%) were taking steroids preoperatively. Complication rates were higher in patients on steroid therapy – 3.2% vs 2.2% (p=0.01) 30-day mortality, 16.1% vs 13.7% (p=0.02) 30-day readmissions, 7.7% vs 6.1% (p=0.02) 30-day reoperation rate, and 36% vs 31% (p<0.01) infectious complications. On multivariate logistic regression, steroid use was significantly associated with any complication (OR [95% CI]) 1.2 [1.1-1.3], reoperation 1.3 [1.03-1.6], postoperative infectious complications 1.2 [1.1-1.4], pancreatic fistula 1.3 [1.1-1.6] and prolonged postoperative hospitalization 1.3 [1.1-1.5]. Steroid use was not found to be a significant risk factor for 30-day mortality, readmission, or wound complications after controlling for patient characteristics. Conclusions: Preoperative steroid use has a negative impact on overall complication rates, reoperations, and infectious complications. This is important information when weighing treatment options and counseling patients preoperatively as well as treating patients postoperatively.

Updates of Risk Factors for Anastomotic Leakage after Colorectal Surgery.

Anastomotic leakage is a potentially severe complication occurring after colorectal surgery and can lead to increased morbidity and mortality, permanent stoma formation, and cancer recurrence. Multiple risk factors for anastomotic leak have been identified, and these can allow for better prevention and an earlier diagnosis of this significant complication. There are nonmodifiable factors such as male gender, comorbidities and distance of tumor from anal verge, and modifiable risk factors, including smoking and alcohol consumption, obesity, preoperative radiotherapy and preoperative use of steroids or non-steroidal anti-inflammatory drugs. Perioperative blood transfusion was shown to be an important risk factor for anastomotic failure. Recent studies on the laparoscopic approach in colorectal surgery found no statistical difference in anastomotic leakage rate compared with open surgery. A diverting stoma at the time of primary surgery does not appear to reduce the leak rate but may reduce its clinical consequences and the need for additional surgery if anastomotic leakage does occur. It is still debatable if preoperative bowel preparation should be used, especially for left colon and rectal resections, but studies have shown similar incidence of postoperative leak rate.

Risk Factors for Gastrointestinal Leak after Perforated Peptic Ulcer Disease Operative Repair.

There are limited studies regarding the impact of post-operative leak on perforated peptic ulcer disease (PPUD) and conflicting results regarding routine drain placement in operative repair of PPUD. This study aims to identify risk factors for gastrointestinal leak after operative repair of PPUD to better guide intra-operative decisions about drain placement. We performed a retrospective cohort study at a tertiary care center from 2008 to 2019, identifying 175 patients who underwent operative repair of PPUD. Patients who developed a leak (17%) were compared to patients who did not. Both hypoalbuminemia (albumin < 3.5g/dL) (P = .03) and duodenal ulcers (P < .01) were identified as significant risk factors for leak. No significant difference was found between leak and no leak groups for AAST disease severity grade, repair technique, or pre-operative use of tobacco, alcohol, or steroids. Post-operative leaks were associated with prolonged hospital stay (29days compared to 10, P < .01), increased complication rates (77% compared to 48%, P < .01), and increased re-operation rates (73% compared to 26%, <0.01). No difference was identified in patient characteristics or operative leak rates between patients who had drains placed at the index operation and those that did not. Leak after operative PPUD repair is associated with significant post-operative morbidity. Hypoalbuminemia and duodenal perforations are significant risk factors for post-operative leaks.

Impact of Preoperative Steroids Administration on Endoscopic Sinus Surgery: Systematic Review of Literature, and a Survey in Saudi Arabia.

There is limited knowledge in the literature and lack of clear protocols among practitioners regarding preoperative steroids administration for patients undergoing endoscopic sinus surgery (ESS). This study aimed to identify the practice patterns of rhinologists in Saudi Arabia as well as systematically review all health-related evidence regarding the use of preoperative steroids for ESS. A previously used questionnaire was modified and distributed in Saudi Arabia among rhinologists who finished their residency training. It entailed questions about their qualifications and preoperative steroids use, preferred regimen, and possible benefits. Also, a systematic literature review using four major databases was conducted to build a scoping view of the current evidence. A total of 94 subjects responded to the mailed survey. Of them, 72(76.6%) used preoperative steroids; 40 subjects believed that there is a strong supporting evidence while 32 reported that there is no solid evidence. The commonest indication was chronic rhinosinusitis with nasal polyp followed by allergic fungal rhinosinusitis. More than half of subjects (54.2%) preferred medium-dose prednisone (30-40mg/day). A considerable number believed that steroids decreased surgical bleeding (n = 57, 79.2%), improved surgical field visualization (77.8%), decreased surgical time (77.8%), and decreased mucosal inflammation (61.1%). Thirteen studies including 1028 patients were eligible for the systematic review. Only three studies reported a statistically significant effect of steroids in reducing intraoperative hemorrhage, while only two studies revealed that steroids significantly improved surgical field quality. In two studies, steroids showed a significant effect in reducing eosinophil infiltration. There is a major number of rhinology experts using preoperative steroids for patients undergoing ESS but there is a wide variation among their practice patterns. The current potential advantages of steroids need to be supported by further large randomized clinical trials to establish clear guidelines.

Resident Involvement in Hip Arthroscopy Procedures Does Not Affect Short-Term Surgical Outcomes

PurposeTo evaluate whether the presence of residents in hip arthroscopy (HA) procedures affects short-term surgical outcomes.MethodsThe American College of Surgeons National Surgical Quality Improvement Program Database was used to identify patients who underwent HA from 2006 to 2012. Demographic and 30-day outcome variables were compared between cohorts of patients with and without residents. Multivariate logistic regression was used to identify whether resident involvement was an independent risk factor for adverse outcomes. Propensity score matching was performed to control for all demographic and intraoperative variables.ResultsA total of 869 patients (59.7% female) were included in this study, 626 of which reported data on resident involvement. Patients were mostly White (73.4% of cases without a resident, 51.8% with a resident, P < .05). Those with residents were younger (P = .016), had lower modified 5-item frailty index (mFI-5) scores (P = .028), and had fewer cardiac comorbidities (P = .008). There was no difference in diabetic status, dyspnea symptoms, history of chronic obstructive pulmonary disease, renal comorbidity, neurologic comorbidity, cumulative comorbidities, history of bleeding disorders, inpatient vs. outpatient treatment, preoperative functional status, smoking history, and steroid use for chronic conditions. There was no difference in all complications, operative time, length of stay, reoperation, readmission, wound complication, venous thromboembolism, blood transfusions, or sepsis. Propensity score match for demographic and intraoperative differences found no association between resident involvement and increased complications. Resident involvement was not an independent risk factor for all complications studied.ConclusionResident involvement in HA procedures was not a risk factor for 30-day complications between 2006 and 2012. Resident involvement did not increase the risk of adverse outcomes, readmission, reoperation, or length of stay, nor did it significantly increase operative times.

Impact of steroid use and glucose control on surgical outcomes in diabetic gynecologic oncology patients

<h3>Objectives:</h3> The objective of this study was to assess the impact of preoperative steroid use and glucose control on postoperative outcomes for diabetes mellitus (DM) gynecologic oncology patients undergoing surgery. <h3>Methods:</h3> This retrospective cohort study included all gynecologic oncology patients admitted for inpatient surgery on an enhanced recovery protocol (ERP) between 10/2016 and 12/2018 with the addition of further patients with DM until 9/2019. The utilization of preoperative steroids has largely been adopted in most ERP patients. At our institution, 8mg intravenous dexamethasone is frequently used. Individual chart review was completed to identify the primary outcome of postoperative complications including: DKA, surgical site infection, ileus, DVT/PE, CVA, MI, AKI, unplanned ICU admission, pulmonary complications, and blood transfusions. Secondary outcomes included length of hospital stay (LOS) and readmission rate. SPSS v. 25 was used for statistical analysis. <h3>Results:</h3> 684 patients were identified and 184 (26.9%) had coexisting type I or II DM. Demographics including CCI, race, diagnosis, and surgical complexity were similar between groups. Patients with DM tended to be older, have a larger body mass index (BMI), and longer operative times. The overall complication rate was 32.5%. Patients with DM were more likely to have postoperative complications (77.5% vs. 15.9%, P=0.0001), increased LOS (4.0±4.6 vs. 3.1±1.9 days, P=0.001), though no difference in readmission rate was observed (10.3% vs. 7.6%, P=0.25). Patients were more likely to have postoperative complications if they had at least one documented serum glucose greater than 300 (74.1% vs 26.8%, P=0.0001) or an average serum glucose greater than 180mg/dL in the first 24 hours (80.0% vs 24.8%, P=0.0001). 54.3% of DM patients got preoperative steroids with no difference in complication or readmission rates seen (p=0.1; p=0.7). <h3>Conclusions:</h3> Diabetic patients are at a much higher risk for postoperative complications after gynecologic oncology surgery. There was no increased risk for postoperative complications in DM patients who received steroids as part of the ERP. However, poorly controlled glucose levels in the immediate postoperative period were associated with a higher rate of complications. Adequate blood glucose control perioperatively for these high-risk patients undergoing surgery is vital given the increased risk of postoperative complications and length of stay.

Muscle Flap Closures in Spine Surgery: Predictors of Usage Patterns and Factors Associated With Postoperative Complications From the NSQIP Database.

Retrospective cohort study using the National Surgical Quality Improvement Program. The objective of this study was to identify preoperative factors that impact the decision to perform prophylactic muscle flap closure and assess risk factors for wound healing complications in patients undergoing spinal procedures with and without muscle flap closure. Prior studies suggest that muscle flap closure following complex spine surgery results in a lower risk of wound healing complications. However, these studies have been limited to single institutions and/or surgeons. The National Surgical Quality Improvement Program database was queried for all patients undergoing spine surgery between 2005 and 2017 with and without concomitant muscle flaps. Preoperative and perioperative variables were extracted. Univariate and multivariate analyses were performed to assess risk factors influencing surgical site infection (SSI) and wound disruption, as well as to delineate which preoperative factors increased the likelihood of patients receiving flap closures a priori. Concomitant muscle flaps were performed on 758 patients; 301,670 patients did not receive a flap. Overall 29 (3.83%) patients in the flap group experienced SSI compared to 5154 (1.71%) in the nonflap group (P<0.0001). Preoperative steroid use [odds ratio (OR) 0.5; P<0.0001], wound infection (OR 0.24; P<0.0001), elevated white blood cell count (OR 1.034; P<0.0001), low hematocrit (OR 0.94; P<0.0001), preoperative transfusion (OR 0.22; P=0.0068) were significantly associated with utilization of muscle flaps. Perioperative factors including a contaminated wound (OR 4.72; P<0.0001), the American Society of Anesthesiologists classification of severe disease (OR 1.92; P=0.024), and longer operative time (OR 1.001; P=0.0024) were significantly associated with postoperative wound disruption. In addition, after propensity score matching for these factors that increase risk of wound complications, there was no difference in the rates of SSI between the flap and nonflap group. Our results suggest that patients with a higher burden of illness preoperatively are more likely to receive prophylactic paraspinal flaps which can reduce the rates of wound-related complications.

Postoperative complications in pediatric patients with cerebral palsy

Background/PurposeTo assess surgical outcomes of patients with cerebral palsy (CP) and if they differ from patients without CP. MethodsThe NSQIP-Pediatric database from 2012 to 2019 was used to compare differences in presenting characteristics and outcomes between patients with and without CP. Chi-square tests and multivariable logistic regression analysis were used to determine significance. Results119,712 patients, 433 (0.4%) with CP, 119,279 (99.6%) without, were identified. Patients with CP had more postoperative complications (19.4% vs. 6.9%, p < 0.001) with an OR of 3.2, (95%CI 2.5–4.1, p < 0.001) on univariable analysis. They underwent fewer laparoscopic procedures (79.1% vs. 90.8%, p < 0.001), had more readmissions (10.2% vs. 3.8%, p < 0.001), reoperations (5.1% vs. 1.2%, p < 0.001), and longer length of stays (LOS) (median 3 versus 1 day, p < 0.001). On multivariable analysis, having CP did not increase the odds of postoperative morbidity (OR 0.99, 95% CI 0.7–1.3), but higher ASA class, congenital lung malformation, gastrointestinal disease, coagulopathy, preoperative inotropic support, oxygen use, nutritional support, and steroid use significantly increase the odds of morbidity, all of which were more common in patients with CP. ConclusionPatients with CP have more postoperative complications, open procedures, and longer LOS. Patient complexity may account for these differences and risk-directed perioperative planning may improve outcomes. Level of EvidenceLevel IV.

P598 Previous Intestinal Resection Is Associated with Postoperative Complications in Crohn’s Disease: A Cohort Study

Abstract Background To assess the influence of a previous intestinal resection on postoperative complications for Crohn’s disease (CD). Methods Data on patients with CD undergoing surgery in our department from January 2016 through December 2019 were retrospectively reviewed. Information collected included demographic details, surgical data, and postoperative outcome. A cross- sectional study design was employed. Associations between postoperative complications and preoperative clinical indicators were further analyzed. Results Of the 129 patients with CD studied, 62 patients (48.06%) underwent previous resection. These patients were more likely to be older (P=0:031), have longer disease duration (P=0:025), use less 5-aminosalicylic acid/sulfasalazine preoperatively (P = 0:013), have lower body mass index (P = 0:003), and have a higher American Society of Anesthesiologists (ASA) Physical Status Classification System score (P = 0:043). Patients who had previous surgery had a longer duration of operation (P = 0:003), greater estimated blood loss (P = 0:001), and longer hospital stay (P &amp;lt; 0:001) and were more inclined to develop postoperative complications (P=0:047), particularly anastomotic leak (P=0:021) and severe (Clavien– Dindo grade III/IV) complications (P = 0:038). After multivariate analysis, previous intestinal resection (P = 0:019), preoperative use of steroids (P = 0:026), and ASA score of more than II (P &amp;lt; 0:001) were determined to be the independent prognostic risk factors for postoperative complications. During the 30-day follow-up period, there was no postoperative mortality or readmission. Conclusion Previous intestinal resection in patients with CD is an independent predictor of overall postoperative complications.