Procedure-specific Risk Factors Research Articles

Risk Factors for Rescue Opioid Prescription After Cubital Tunnel Surgery.

Concerns regarding the ongoing opioid epidemic have led to heightened scrutiny of postoperative opioid prescribing patterns for common orthopedic surgical procedures. This study investigated patient- and procedure-specific risk factors for additional postoperative opioid rescue prescriptions following ambulatory cubital tunnel surgery. A retrospective review was performed of patients who underwent cubital tunnel surgery at 2 academic medical centers between June 1, 2015 and March 1, 2020. Patient demographics, comorbidities, prior opioid history, and surgical variables were recorded. The primary outcome was postoperative rescue opioid prescription. Univariate and bivariate statistical analyses were performed. Two hundred seventy-four patients were included, of whom 171 (62%) underwent in situ ulnar nerve decompression and 103 (38%) underwent ulnar nerve decompression with anterior transposition. The median postoperative opioid prescription amount was 90 morphine equivalent units (MEU) for the total cohort, 77.5 MEU for in situ ulnar nerve decompression, and 112.5 MEU for ulnar nerve decompression with transposition. Twenty-two patients (8%) required additional rescue opioid prescriptions postoperatively. Female sex, fibromyalgia, chronic opioid use, chronic pain diagnosis, and recent opioid were associated with the need for additional postoperative rescue opioid prescriptions. While most patients do not require additional rescue opioid prescriptions after cubital tunnel surgery, chronic pain patients and patients with pain sensitivity syndromes are at risk for requiring additional rescue opioid prescriptions. For these high-risk patients, preoperative collaboration of a multidisciplinary team may be beneficial for developing a perioperative pain management plan that is both safe and effective.

Patient and Surgical Risk Factors for Surgical Site Infection in Lower-Extremity Oncological Endoprosthetic Reconstruction: A Secondary Analysis of the PARITY Trial Data.

The specific risk factors for surgical site infection (SSI) in orthopaedic oncology patients undergoing endoprosthetic reconstruction have not previously been evaluated in a large prospective cohort. In the current study, we aimed to define patient- and procedure-specific risk factors for SSI in patients who underwent surgical excision and endoprosthetic reconstruction for lower-extremity bone or soft-tissue tumors using the prospectively collected data of the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial. PARITY was a multicenter, blinded, randomized controlled trial with a parallel 2-arm design that aimed to determine the effect of a long duration (5 days) versus short duration (24 hours) of postoperative prophylactic antibiotics on the rate of SSI in patients undergoing surgical excision and endoprosthetic reconstruction of the femur or tibia. In this secondary analysis of the PARITY data, a multivariate Cox proportional hazards regression model was constructed to explore predictors of SSI within 1 year postoperatively. A total of 96 (15.9%) of the 604 patients experienced an SSI. Of the 23 variables analyzed in the univariate analysis, 4 variables achieved significance: preoperative diagnosis, operative time, volume of muscle excised, and hospital length of stay (LOS). However, only hospital LOS was found to be independently predictive of SSI in the multivariate regression analysis (hazard ratio per day = 1.03; 95% confidence interval = 1.01 to 1.05; p < 0.001). An omnibus test of model coefficients demonstrated that the model showed significant improvement over the null model (χ2 = 78.04; p < 0.001). No multicollinearity was found. This secondary analysis of the PARITY study data found that the only independent risk factor for SSI on multivariate analysis was hospital LOS. It may therefore be reasonable for clinicians to consider streamlined discharge plans for orthopaedic oncology patients to potentially reduce the risk of SSI. Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Clinical Considerations for Patients Experiencing Acute Kidney Injury Following Percutaneous Nephrolithotomy.

Acute kidney injury (AKI) is a common postoperative outcome in urology patients undergoing surgery for nephrolithiasis. The objective of this study was to determine the prevalence of postoperative AKI and its degrees of severity, identify risk factors, and understand the resultant outcomes of AKI in patients with nephrolithiasis undergoing percutaneous nephrolithotomy (PCNL). A cohort of patients admitted between 2012 and 2019 to a single tertiary-care institution who had undergone PCNL was retrospectively analyzed. Among 417 (n = 326 patients) encounters, 24.9% (n = 104) had AKI. Approximately one-quarter of AKI patients (n = 18) progressed to Stage 2 or higher AKI. Hypertension, peripheral vascular disease, chronic kidney disease, and chronic anemia were significant risk factors of post-PCNL AKI. Corticosteroids and antifungals were associated with increased odds of AKI. Cardiovascular, neurologic complications, sepsis, and prolonged intensive care unit (ICU) stay percentages were higher in AKI patients. Hospital and ICU length of stay was greater in the AKI group. Provided the limited literature regarding postoperative AKI following PCNL, and the detriment that AKI can have on clinical outcomes, it is important to continue studying this topic to better understand how to optimize patient care to address patient- and procedure-specific risk factors.

Factors Associated With Spinal Cord Ischemia After Thoracic, Abdominal, and Thoracoabdominal Endovascular Aortic Repairs

Spinal cord ischemia (SCI) is a challenging complication after endovascular aortic repair throughout the full extent of the aorta. However, data on factors associated with postoperative SCI development that are specific to the treatment extent are scarce. Therefore, we examined factors associated with SCI after thoracic endovascular aortic repair (TEVAR), complex endovascular aortic repair (cEVAR), and thoracoabdominal endovascular repairs (TAARs). All patients who underwent thoracic, abdominal, or TAAR from 2014 to 2019 were identified in the Vascular Quality Initiative linked with Medicare Claims. Procedures were classified into three subgroups based on repair extent: descending thoracic aortic repair (TEVAR), paravisceral segment of the abdominal aorta grouped as cEVAR, and TAAR. Logistic regression was used to identify factors associated with SCI within each group. Cox regression was used to evaluate the impact of SCI on 5-year survival. A total of 6591 patients were included (50% TEVAR, 42% cEVAR, and 8% TAAR). SCI incidence rates were 3.6%, 2.5%, and 11% for TEVAR, cEVAR, and TAAR, respectively. After TEVAR, preoperative renal dysfunction (odds ratio [OR]: 2.5, 95% confidence interval [CI]: 1.6-3.9; P < .001), ruptured presentation (OR: 3.9, 95% CI: 2.0-7.2; P < .001), and more extensive coverage (for each zone covered: OR: 1.5, 95% CI: 1.1-2.1; P = .008) were associated with higher odds of SCI. Left subclavian artery revascularization was associated with lower odds of SCI (OR: 0.48, 95% CI: 0.23-0.95; P = .041) (Table I). After cEVAR, patients with prior open (OR: 2.5, 95% CI: 1.1-5.1; P = .012) and endovascular (OR: 2.3, 95% CI: 1.1-4.8; P = .020) aortic surgery, longer operative times (for each hour: OR: 1.4, 95% CI: 1.2-1.5; P < .001), and more extensive coverage (for each zone covered: OR: 1.2, 95% CI: 1.0-1.4; P = .025) had higher odds of SCI (Table II). Notably, coverage extent and staged repair were not found to be significantly associated with SCI after TAAR (Table III). SCI was associated with higher 5-year mortality among all repairs (TEVAR: adjusted hazard ratio [aHR]: 2.1, CI: 1.6-2.9; P < .001; cEVAR: aHR: 3.4, CI: 2.4-4.7; P < .001; and TAAR: aHR: 2.1, CI: 1.3-3.2; P < .001). The extent of aortic zone coverage was associated with SCI after TEVAR and cEVAR, whereas prior aortic surgery was associated with SCI after cEVAR. Notably, left subclavian artery revascularization was associated with lower odds of SCI after TEVAR. In contrast to previous reports, staged repair was not associated with lower SCI risk after TAAR. Future studies should focus on procedure-specific risk factors to identify patients at higher risk of SCI and understand the optimal preventive strategy within specific procedures.Table ILogistic regression analysis for factors associated with SCI after TEVAR, cEVAR, or TAAACharacteristicTEVARcEVARTAAROR95% CIP valueOR95% CIP valueOR95% CIP valueAge1.000.98-1.0.901.00.99-1.0.111.00.95-1.0.9Gender (female)0.900.59-1.3.600.950.52-1.6.900.660.34-1.2.2White0.910.58-1.4.700.690.37-1.3.200.820.39-1.8.6Hypertension1.80.77-5.1.201.20.51-3.5.700.860.28-3.3.8Smoking history1.30.83-2.2.202.20.84-7.7.151.60.65-4.6.3Prior aortic surgery NoneRef.Ref.Ref.Ref.Ref.Ref.Ref.Ref.Ref. Open0.590.28-1.1.122.51.1-5.1.0121.30.61-2.8.30 Endovascular0.440.17-0.97.0672.31.1-4.8.0200.510.18-1.2.20 Both1.70.41-5.3.401.60.25-6.5.501.10.29-3.6.80COPD1.40.89-2.2.141.10.67-1.9.601.70.90-3.3.10Prior MI1.20.72-2.0.400.840.43-1.5.601.10.46-2.5.80Baseline eGFR <60 mL/min/1.73 m22.51.6-3.9<.0010.960.56-1.6.901.20.67-2.4.40Pathology TAARef.Ref.Ref.Ref.Ref.Ref.Ref.Ref.Ref. Accute dissection1.70.94-3.1.077–––––– CTBAD + PDA1.60.74-3.2.20–––––– Traumatic––––––––– PAU + IMH + (PAU + IMH)1.20.65-2.1.60–––––– Other–––1.40.33-4.6.501.10.50-2.6.70Presentation AsymptomaticRef.Ref.Ref.Ref.Ref.Ref.Ref.Ref.Ref. Symptomatic1.30.77-2.3.301.00.49-2.1.90.830.39-1.7.60 Rupture3.92.0-7.2<.0011.10.26-3.6.82.00.56-6.4.20Total procedure time, hours1.10.99-1.2.0671.41.2-1.5<.0011.00.95-1.2.20Estimated blood loss, 100 mL1.00.98-1.0.201.00.99-1.0.31.041.0-1.08.026Left subclavian artery treatment NoneRef.Ref.Ref.–––Ref.Ref.Ref. Occlusion0.830.43-1.5.50–––0.290.04-1.1.12 Revascularization0.480.23-0.95.041–––0.810.34-1.8.6Celiac involvement Infraceliac sealingRef.Ref.Ref.Ref.Ref.Ref. Supraceliac sealing1.60.90-3.1.110.790.38-1.6.5Hypogastric involvement None–––Ref.Ref.Ref.––– Hypogastric artery involvement–––0.710.14-2.6.6–––Staged aortic treatment––––––0.880.45-1.7.70Length of coverage (zones)1.51.1-2.1.0081.21.0-1.4.0251.050.89-1.2.6cEVAR, Complex endovascular aortic repair; CI, confidence interval; COPD, chronic obstructive pulmonary disease; CTBAD, complicated type B aortic dissection; eGFR, estimated glomerular filtration rate; IMH, intramural hematoma; MI, myocardial infarction; OR, odds ratio; PAU, penetrating aortic ulcer; PDA, patent ductus arteriosus; TAA, thoracic aortic aneurysm; TAAR, thoracoabdominal endovascular repair; TEVAR, thoracic endovascular aortic repair.Boldface P values represent statistical significance. Open table in a new tab

Predictors of antiplatelet cessation in a real-world patient population undergoing non-cardiac surgery after PCI

BackgroundThe optimal perioperative management of antiplatelet therapy (APT) therapy in patients undergoing noncardiac surgery (NCS) following percutaneous coronary intervention (PCI) is unclear. We sought to identify predictors of APT cessation in a real-world cohort of patients undergoing NCS within 1 year of PCI. MethodsConsecutive patients undergoing PCI at a tertiary center between 2011 and 2018 were prospectively enrolled. Perioperative interruption of APT was defined as cessation of either aspirin or P2Y12 inhibitor between 1 and 14 days prior to NCS. Predictors of APT discontinuation were identified by multivariable Cox regression with stepwise selection of candidate variables. ResultsA total of 1092 surgeries corresponding to 747 patients were identified. Overall, there were 487 (44.6%) preoperative antiplatelet interruptions: discontinuation of either P2Y12 inhibitors only (47.4%), aspirin only (7.9%), or both agents (44.7%). Both patient-specific risk factors (prior stroke, lower BMI, anemia, MI) and procedure specific risk factors (chronic total occlusions, multivessel disease, drug-eluting stent use) affected decisions regarding APT cessation. Likelihood of APT cessation increased in higher-risk surgeries and in patients on more potent P2Y12 inhibitors (ticagrelor/prasugrel vs clopidogrel) whereas those undergoing NCS <90 days post PCI were less likely to have cessation of APT. ConclusionIn this contemporary cohort of post-PCI patients undergoing NCS, patient-, angiographic- and surgery-specific factors all affected decision-making regarding APT cessation. Our findings reflective of real-world practice, highlight the importance of a multidisciplinary team approach to individualize decision making in these patients.

Mortality Prediction After Cardiac Surgery in Children: An STS Congenital Heart Surgery Database Analysis

BackgroundThe Society of Thoracic Surgeons (STS) Congenital Heart Surgery Database (CHSD) provides risk-adjusted operative mortality rates to approximately 120 North American congenital heart centers. Optimal case-mix adjustment methods for operative mortality risk prediction in this population remain unclear. MethodsA panel created diagnosis-procedure combinations of encounters in the CHSD. Models for operative mortality using the new diagnosis-procedure categories, procedure-specific risk factors, and syndromes or abnormalities included in the CHSD were estimated using Bayesian additive regression trees and least absolute shrinkage and selector operator (lasso) models. Performance of the new models was compared with the current STS CHSD risk model. ResultsOf 98 825 operative encounters (69 063 training; 29 762 testing), 2818 (2.85%) STS-defined operative mortalities were observed. Differences in sensitivity, specificity, and true and false positive predicted values were negligible across models. Calibration for mortality predictions at the higher end of risk from the lasso and Bayesian additive regression trees models was better than predictions from the STS CHSD model, likely because of the new models’ inclusion of diagnosis-palliative procedure variables affecting <1% of patients overall but accounting for 27% of mortalities. Model discrimination varied across models for high-risk procedures, hospital volume, and hospitals. ConclusionsOverall performance of the new models did not differ meaningfully from the STS CHSD risk model. Adding procedure-specific risk factors and allowing diagnosis to modify predicted risk for palliative operations may augment model performance for very high-risk surgical procedures. Given the importance of risk adjustment in estimating hospital quality, a comparative assessment of surgical program quality evaluations using the different models is warranted.

Reevaluating Congenital Heart Surgery Center Performance Using Operative Mortality

BackgroundThe Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) provides observed-to-expected (O/E) operative mortality ratios to more than 100 congenital heart centers in North America. We compared the current approach for estimating O/E ratios to approaches incorporating information on diagnosis as moderators of procedures, other unused risk factors, and additional variation in confidence interval construction to characterize center performance. MethodsBayesian additive regression trees (BART) and lasso models linked operative mortality to diagnosis-procedure categories, procedure-specific risk factors, and syndromes/abnormalities. Bootstrapping accounted for variation in the STS-CHSD (STS bootstrap) and lasso CIs. We compared O/E estimates, interquartile range of CI widths, and concordance of center performance categorizations (worse-than-, as-, or better-than-expected mortality) of the new approaches to the STS-CHSD. ResultsIn 110 surgical centers including 98,822 surgical operative encounters, there were 2818 (2.85%) operative mortalities (center range, 0.37%-10%). Compared with the STS-CHSD, BART- and lasso-estimated O/E ratios varied more and had narrower confidence intervals (interquartile range of confidence interval: STS-CHSD = 1.11, STS bootstrap = 0.98; lasso = 0.80; BART = 0.96). Concordance of performance categorization with the STS-CHSD ranged from 84% (lasso) to 91% (STS Bootstrap); more than 70% of discordant centers improved categories. Discordant centers had smaller volumes, fewer operative mortalities, and treated more patients with congenital lung abnormalities. ConclusionsRelative to the STS-CHSD, up to 16% of hospitals changed performance categories, most improving performance. Given the significance of quality reports for congenital heart centers, inclusion of additional risk factors and unaddressed variation should be considered.

Morbidity in Patients with Nasopharyngeal Carcinoma and Radiation-Induced Skin Lesions: Cause, Risk Factors, and Dermatitis Evolution and Severity.

Radiation-induced skin injuries such as lesions (RSLs) and dermatitis are the most common complication during radiotherapy (RT) for nasopharyngeal carcinoma, but little is known about risk factors unique to oncology. This study sought a greater understanding of these risk factors to stratify patients based on risk and guide clinical decision-making. Investigators analyzed the data of 864 consecutive patients referred to the RT center of the Southern Theater General Hospital for a new RSL from 2013 to 2019. These patients were followed up for an average of approximately 16 months until their death or March 30, 2020, whichever came first. Multivariate logistic regression analysis and Cox proportional hazards model were used to identify predictors of grade 3 or 4 dermatitis. The main causes of treatment interruption included dermatitis and oral mucositis. Significant patient-specific risk factors for RSLs included current smoking, current drinking, and lower Karnofsky Performance Scale score and significant procedure-specific risk factors included receiving intensity-modulated radiation therapy (IMRT), hyperfractionated RT, induction chemotherapy, multicycle chemotherapy, and taxol- and cisplatin-based drugs. The three factors that independently predicted risk of RSL were IMRT, lower Karnofsky Performance Scale score, and multicycle chemotherapy. Comparing predictive factors among patients with severe RSL revealed that patients who received IMRT were more likely to develop grade 3 or 4 dermatitis. Oncology providers should note that IMRT is an aggressive technique with a trend toward increased RSL. Providers should pay special attention to adverse effects to skin in patients with nasopharyngeal carcinoma.

Waking Up in Pain: a prospective unselected cohort study of pain in 3702 patients immediately after surgery in the Danish Realm

BackgroundAcute and persistent pain after surgery is well described. However, no large-scale studies on immediate postoperative pain in the operating room (OR) exist, hindering potential areas of research to improve...

Perioperative respiratory adverse events in children undergoing triple endoscopy.

Children with aerodigestive disorders often have many of the reported risk factors for development of perioperative respiratory adverse events. This study sought to evaluate the incidence of such events in this group of patients undergoing general anesthesia for "triple endoscopy" (flexible bronchoscopy with bronchoalveolar lavage, rigid laryngoscopy and bronchoscopy, and esophagogastroduodenoscopy) and to identify any patient-specific or procedure-specific risk factors associated with higher incidence of perioperative respiratory adverse events. We performed a retrospective chart review of children 18years or younger who underwent triple endoscopy as part of an aerodigestive evaluation. Data collected from medical records included: preoperative polysomnography, symptoms of acute respiratory illness, medical comorbidities, demographics, postoperative hospital or intensive care unit admission, and all respiratory events and interventions in the perioperative period. Patient-specific and procedure-specific factors were investigated via univariate analysis for any correlations with perioperative respiratory adverse events. Of the 122 patients undergoing triple endoscopy, 69 (57%) experienced a perioperative respiratory adverse event. We found no difference in the incidence of perioperative respiratory adverse events among children with documented lung disease compared with those with no lung disease (OR: 0.89, p=.8 95% CI: 0.43, 1.8), and no significant difference between those children who had a respiratory illness at the time of surgery, 1-2weeks prior, 3-4weeks prior, and those with no preceding respiratory illness. A higher percentage of males had a perioperative respiratory adverse event, compared with females (OR: 2.7, p=.01 95% CI: 1.3, 5.09). Patients undergoing triple endoscopy for evaluation of aerodigestive disorders at our institution experienced perioperative respiratory adverse events at a rate of 57%.

Complications after medullary thyroid carcinoma surgery: multicentre study of the SQRTPA and EUROCRINE® databases.

Surgery is the curative therapy for patients with medullary thyroid carcinoma (MTC). In determining the extent of surgery, the risk of complications should be considered. The aim of this study was to assess procedure-specific outcomes and risk factors for complications after surgery for MTC. Patients who underwent thyroid surgery for MTC were identified in two European prospective quality databases. Hypoparathyroidism was defined by treatment with calcium/active vitamin D. Recurrent laryngeal nerve (RLN) palsy was diagnosed on laryngoscopy. Complications were considered at least transient if present at last follow-up. Risk factors for at-least transient hypoparathyroidism and RLN palsy were identified by logistic regression analysis. A total of 650 patients underwent surgery in 69 centres at a median age of 56 years. Hypoparathyroidism, RLN palsy and bleeding requiring reoperation occurred in 170 (26·2 per cent), 62 (13·7 per cent) and 17 (2·6 per cent) respectively. Factors associated with hypoparathyroidism were central lymph node dissection (CLND) (odds ratio (OR) 2·20, 95 per cent c.i. 1·04 to 4·67), CLND plus unilateral lateral lymph node dissection (LLND) (OR 2·78, 1·20 to 6·43), CLND plus bilateral LLND (OR 2·83, 1·13 to 7·05) and four or more parathyroid glands observed (OR 4·18, 1·46 to 12·00). RLN palsy was associated with CLND plus LLND (OR 4·04, 1·12 to 14·58) and T4 tumours (OR 12·16, 4·46 to 33·18). After compartment-oriented lymph node dissection, N0 status was achieved in 248 of 537 patients (46·2 per cent). Complications after surgery for MTC are procedure-specific and may relate to the unavoidable consequences of radical dissection needed in some patients.

Incidence and predictors of early and delayed renal function decline after aortic aneurysm repair in the Vascular Quality Initiative database

BackgroundPostoperative acute kidney injury (AKI) may complicate both open and endovascular aortic aneurysm repair (EVAR) and is associated with substantial morbidity, mortality, and health care expense. We aim to evaluate the incidence of postoperative AKI and factors associated with its occurrence and the effects of postoperative AKI on long-term renal function and mortality after open and EVAR in the Society for Vascular Surgery Vascular Quality Initiative registry. MethodsElective aneurysm cases were identified including thoracic endovascular aortic aneurysm repair (TEVAR) and complex endovascular aortic aneurysm repair (cEVAR), infrarenal endovascular repair (EVAR) and infrarenal open repair (OAR) from 2003 to 2019. The preoperative estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease formula and stratified based on chronic kidney disease (CKD) grades. Postoperative AKI was defined per the Vascular Quality Initiative definition as a creatinine increase of 0.5 mg/dL or if postoperative dialysis was required. Patients on preprocedural hemodialysis and those with previous renal transplant were excluded. Demographics and procedural factors were evaluated for predicting in-hospital postoperative AKI (all approaches) and at 9 to 21 months of long-term follow-up (EVAR only) using logistic regression modeling. ResultsWe identified a total of 2813 cEVAR, 2995 TEVAR, 39,945 EVAR, and 8143 OAR patients. Of those, postoperative AKI occurred in 377 cEVAR (13.5%), 199 TEVAR (6.7%), 1099 EVAR (2.8%), and 1249 OAR (15.5%). Risk factors for postoperative AKI across all groups were worse preoperative eGFR, total number of blood transfusions, perioperative anemia, reinterventions, and postoperative respiratory complications. Additional procedure-specific risk factors of postoperative AKI were preoperative hemoglobin of less than 10 and contrast volume of 125 to 150 mL, hypertension, a low ejection fraction, and a history of percutaneous revascularization for EVAR; for both EVAR/cEVAR, renal artery coverage was a risk factor, whereas for OAR, male sex, non-White race, hypertension, suprarenal aortic cross-clamp, and increased renal ischemic time were risk factors. Among 8133 EVAR patients with long-term follow-up, a decrease in kidney function occurred in 56.7% of patients with postoperative AKI vs 19.9% without postoperative AKI (P < .001). The following risk factors were associated with a decrease in renal function at long-term follow-up: postoperative AKI, a preoperative eGFR of less than 90, and hypertension. A preoperative hemoglobin of greater than 12 was protective. Postoperative AKI was associated with significantly lower survival compared with no postoperative AKI across all procedures (log rank <0.001). ConclusionsPostoperative AKI occurs more often in patients with worse preoperative renal function, lower preoperative hemoglobin, and in open surgeries with inter-renal or suprarenal cross-clamping. Importantly, postoperative AKI is associated with increased mortality across all types of aortic repair. Given the long-term impact of postoperative AKI on outcomes for all aortic repairs and the limitations of current insensitive functional indices, there is a need to seek more sensitive indicators of decreases in early renal structural in this population.

Complications after medullary thyroid carcinoma surgery: multicentre study of the SQRTPA and EUROCRINE® databases.

Surgery is the curative therapy for patients with medullary thyroid carcinoma (MTC). In determining the extent of surgery, the risk of complications should be considered. The aim of this study was to assess procedure-specific outcomes and risk factors for complications after surgery for MTC. Patients who underwent thyroid surgery for MTC were identified in two European prospective quality databases. Hypoparathyroidism was defined by treatment with calcium/active vitamin D. Recurrent laryngeal nerve (RLN) palsy was diagnosed on laryngoscopy. Complications were considered at least transient if present at last follow-up. Risk factors for at-least transient hypoparathyroidism and RLN palsy were identified by logistic regression analysis. A total of 650 patients underwent surgery in 69 centres at a median age of 56 years. Hypoparathyroidism, RLN palsy and bleeding requiring reoperation occurred in 170 (26·2 per cent), 62 (13·7 per cent) and 17 (2·6 per cent) respectively. Factors associated with hypoparathyroidism were central lymph node dissection (CLND) (odds ratio (OR) 2·20, 95 per cent c.i. 1·04 to 4·67), CLND plus unilateral lateral lymph node dissection (LLND) (OR 2·78, 1·20 to 6·43), CLND plus bilateral LLND (OR 2·83, 1·13 to 7·05) and four or more parathyroid glands observed (OR 4·18, 1·46 to 12·00). RLN palsy was associated with CLND plus LLND (OR 4·04, 1·12 to 14·58) and T4 tumours (OR 12·16, 4·46 to 33·18). After compartment-oriented lymph node dissection, N0 status was achieved in 248 of 537 patients (46·2 per cent). Complications after surgery for MTC are procedure-specific and may relate to the unavoidable consequences of radical dissection needed in some patients.

Effect of length of surgery on the incidence of venous thromboembolism after benign hysterectomy

Venous thromboembolism is a leading cause of morbidity and mortality postoperatively. The current venous thromboembolism risk assessment tools have not been validated in gynecologic patients. Most patients undergoing hysterectomy for benign indications will receive mechanical or pharmacologic prophylaxis based on preoperative risk assessment. However, current guidelines do not incorporate newer data that indicate additional risk of venous thromboembolism with prolonged surgery times or mode of hysterectomy. This study aimed to determine the effect of length of surgery, or operative time, on the risk of venous thromboembolism within 30 days after hysterectomy and determine whether differences in the effect of operative time exist across age, body mass index, and surgical approach. We performed a secondary analysis of prospectively collected surgical quality improvement data using the American College of Surgeons National Surgical Quality Improvement Program database, which contains demographic and perioperative information and 30-day postoperative outcomes from >500 hospitals, and targeted data files including procedure-specific risk factors and outcomes for a subset of hospitals. We analyzed patients undergoing abdominal, vaginal, or laparoscopic hysterectomy for benign conditions from 2014 to 2017, identified by the Current Procedural Terminology codes. We excluded patients with cancer, patients whose surgery was not performed by a gynecologist, patients who were not in the targeted files, and patients with missing operative time or with an operative time of <30 minutes. Patients were compared with respect to the incidence of venous thromboembolism and operative time, stratified by age, body mass index, and surgical approach. Multivariable logistic regression was performed; operative time was treated as a continuous, linear variable. A total of 70,606 patients were included. The 30-day venous thromboembolism incidence was 0.4% (n=259). Patients with venous thromboembolism were more likely to be obese, have inpatient procedures, and had, on average, greater uterine weight. Hysterectomy approach was vaginal in 11,641 patients, laparoscopic in 41,557 patients, and abdominal in 17,408 patients. After adjustment, for each 60-minute increase in operative time, there was a 35% increase in the odds of venous thromboembolism (adjusted odds ratio, 1.35; 95% confidence interval, 1.25-1.45). Stratified by surgical approach, the odds of venous thromboembolism per 60-minute increase in operative time was greatest among abdominal hysterectomy (adjusted odds ratio, 1.49; 95% confidence interval, 1.35-1.65) compared with laparoscopic hysterectomy (adjusted odds ratio, 1.20; 95% confidence interval, 1.05-1.38) and vaginal hysterectomy (adjusted odds ratio, 1.27; 95% confidence interval, 0.97-1.66) (P=.01). Increasing body mass index and increasing age did not modify the impact of operative time on venous thromboembolism incidence (P=.66 and P=.58, respectively). Every 60-minute increase in operative time was independently associated with a 35% increased odds of venous thromboembolism within 30 days of hysterectomy, and this risk was cumulative. Minimally invasive hysterectomy had lower odds of venous thromboembolism than abdominal hysterectomy across all time points.

Risk Factors for Surgical Site Infection in Orthopaedic Oncology.

Surgical site infections (SSIs) are common complications after surgeries involving musculoskeletal tumors, but we know little about SSI risk factors unique to orthopaedic oncology. A greater understanding of these factors will help risk-stratify patients and guide surgical decision-making. A retrospective review at a single-institution identified 757 procedures done on 624 over 6 years. The patients had a preoperative diagnosis of a malignant or potentially malignant neoplasm of the bone or soft tissues. Patient-specific and procedure-specific variables and diagnosis of SSI were recorded for each case. Data were analyzed through univariate analysis and multiple logistic regression. On univariate analysis, significant patient-specific risk factors for SSI included malignancy (P < 0.001), smoking history (P = 0.041), and American Society of Anesthesiologists Score (P = 0.002). Significant procedure-specific risk factors for SSI on univariate analysis included surgery time (P < 0.001), estimated blood loss (P < 0.001), blood transfusion volume (P < 0.001), neoadjuvant chemotherapy (P < 0.001), neoadjuvant radiation therapy (P < 0.001), inpatient surgery (P < 0.001), and number of previous surgeries within the study period (P < 0.001). The two factors that independently predicted risk of SSI when controlling for all other variables in a multiple logistic regression were whether the surgery was done on an inpatient basis (P = 0.005) and the number of previous surgeries done on the same site (P = 0.001). We found a number of risk factors that correlate markedly with SSI after orthopaedic oncology surgery. The surgeon can use these risk factors to aid in surgical decision-making.

Intra-abdominal Pressure Changes During Hip Arthroscopy: A Prospective Multicenter Study

To evaluate intra-abdominal pressure changes during hip arthroscopy and define its relationship with other patient related variables. A prospective multicenter study evaluating intra-abdominal pressure (IAP) in patients undergoing arthroscopic treatment of femoroacetabular impingement was performed. The IAP was measured indirectly by a bladder catheter (AbViser Autovalve Intra-abdominal pressure monitor) and documented every 30 minutes during the entire procedure. The following risk factors were analyzed: traction time, duration surgery, previous abdominal surgery, capsule repair, psoas tenotomy, and surgical approach. One hundred and five patients with symptomatic femoroacetabular impingement that underwent hip arthroscopy met the inclusion criteria. There were significant differences in the IAP between the preoperative measurement of IAP and the IAP at different time points during surgery (P<.01). The IAP increased continuously from the commencement of surgery (considered as time point from portal establishment) until the first 60 minutes. After first 60 minutes of surgery, the IAP did not increase significantly. There were no significant associations between increased IAP and the risk factors analyzed. IAP increases significantly during the first 60 minutes of hip arthroscopy; it then stabilizes for the duration of surgery before decreasing just after the completion of surgery. The highest recorded IAP was not associated with additional complications. No symptomatic intra-abdominal hypertension was documented. Finally, patient- and procedure-specific risk factors did not predict changes in IAP. Systemic monitoring of IAP during the hip arthroscopy procedure can easily and effectively be done, allowing the surgeon to early detect any significant change. Level IV, therapeutic case series.

A Frailty-Based Risk Score Predicts Morbidity and Mortality After Elective Endovascular Repair of Descending Thoracic Aortic Aneurysms

Thoracic endovascular aortic repair (TEVAR) has expanded access to descending thoracic aortic aneurysm (DTAA) repair particularly for elderly and frail patients. This high-risk population has limited long-term overall survival, such that appropriate patient selection is required to optimize patient benefit and resource utilization. Our objective is to develop and validate a frailty-based, procedure-specific risk score for patients undergoing elective TEVAR for DTAA. Patients undergoing nonemergent TEVAR for DTAA during 2005-2016 were identified in the National Surgical Quality Improvement Program database. Those with concurrent cardiac or open aortic surgery, abdominal visceral intervention, or Zone 0 deployment were excluded. Patients were randomly divided between derivation and validation samples. The primary outcome was 30-day major adverse events (MAE), including mortality and major systemic complications. Using the derivation cohort, variables associated with MAE were identified by univariable analyses. Those with P<0.05 were included in multivariable logistic regression analysis. Independent procedure-specific and frailty-related risk factors for MAE were used to develop a pragmatic score to assess risk for TEVAR. Overall, 1,784 patients were included. 14% of the derivation patients had MAE (14% major complications, 4% mortality). Independent risk factors for MAE were primarily associated with markers of frailty and TEVAR extent and complexity and included functional dependence (OR 2.9, 95% CI 1.6-5.4), pulmonary disease (1.6, 1.1-2.4), thoracoabdominal extent (2.2 (1.4-3.4), need for iliac access (2.1, 1.1-3.8), and Zone I or II deployment (OR 1.7, 1.1-2.5). According to their respective beta coefficients, each variable was assigned a single point. Based on total points, patients were stratified as low- (0 points), intermediate- (1 point), or high-risk (≥2 points), with stepwise increases in mortality (0%, 4%, and 9%) and major complications (7%, 11%, and 23%) between strata. Validation patients had similar characteristics, risk strata distribution, and outcomes as the derivation patients, and the risk model had similar performance in both groups. Markers of frailty and procedure complexity strongly predict MAE after TEVAR for DTAA and can improve patient selection by enabling patient and procedure-specific risk stratification. While TEVAR is safe in low-risk patients, intermediate-risk patients warrant careful discussion of the risks and benefits of aortic intervention; under certain circumstances, high-risk patients may not benefit. Further study is required to define the association between frailty and long-term outcomes.

Effect of Length of Surgery on the Incidence of Venous Thromboembolism After Benign Hysterectomy

<h3>Study Objective</h3> Determine effect of length of surgery (LOS) on risk for venous thromboembolism (VTE) after hysterectomy and determine if differences exist based on age, body mass index (BMI), and surgical approach. <h3>Design</h3> Secondary analysis of prospectively-collected surgical quality improvement data. <h3>Setting</h3> American College of Surgeons National Surgical Quality Improvement Program database, containing demographic, perioperative information and 30-day postoperative outcomes from >500 hospitals, and targeted data files including procedure-specific risk factors and outcomes for a subset of hospitals. <h3>Patients or Participants</h3> Patients undergoing abdominal (AH), vaginal (VH), or laparoscopic hysterectomy (LH), identified with Current Procedural Terminology (CPT) codes, for benign indications from 2014-2016 were eligible. Patients with cancer, surgery not performed by a gynecologist, not in targeted files, missing LOS, or LOS <30 minutes were excluded. <h3>Interventions</h3> Patients were compared with respect to incidence of VTE and LOS, stratified by age, BMI, and surgical approach. <h3>Measurements and Main Results</h3> 48,813 patients were included. VTE incidence was 0.3%. Patients with VTE were obese, had greater uterine weight, and had inpatient procedures. Multivariable logistic regression was performed; LOS was treated as a continuous variable. Adjusting for confounders, for each 60 minute increase in LOS, there was a 41% increase in odds of VTE. Stratified by surgical approach, odds of VTE per 60 minute increase in LOS were greatest after AH (aOR 1.56, 95%CI 1.4, 1.75) compared to LH (aOR 1.19, 95%CI 0.76, 1.85) and VH (aOR 1.24, 95%CI 1.04, 1.47). As BMI increased, odds of VTE per 60 minutes increased: <30kg/m² (aOR 1.31, 95%CI 1.11, 1.55), 30-39kg/m² (aOR 1.43, 95%CI 1.24, 1.65), and ≥40kg/m² (aOR 1.46, 95%CI 1.23, 1.72). There was no modification of risk by age. <h3>Conclusion</h3> Our study suggests given the increased odds of VTE per 60 minute increase in LOS, the risk of VTE is cumulative. Prolonged LOS or obese patients may benefit from pharmacological and mechanical prophylaxis.

Can We Predict Incisional Hernia?: Development of a Surgery-specific Decision-Support Interface.

The aim of this study was to identify procedure-specific risk factors independently associated with incisional hernia (IH) and demonstrate the feasibility of preoperative risk stratification through the use of an IH risk calculator app and decision-support interface. IH occurs after 10% to 15% of all abdominal surgeries (AS) and remains among the most challenging, seemingly unavoidable complications. However, there is a paucity of readily available, actionable tools capable of predicting IH occurrence at the point-of-care. Patients (n = 29,739) undergoing AS from 2005 to 2016 were retrospectively identified within inpatient and ambulatory databases at our institution. Surgically treated IH, complications, and costs were assessed. Predictive models were generated using regression analysis and corroborated using a validation group. The incidence of operative IH was 3.8% (N = 1127) at an average follow-up of 57.9 months. All variables were weighted according to β-coefficients generating 8 surgery-specific predictive models for IH occurrence, all of which demonstrated excellent risk discrimination (C-statistic = 0.76-0.89). IH occurred most frequently after colorectal (7.7%) and vascular (5.2%) surgery. The most common occurring risk factors that increased the likelihood of developing IH were history of AS (87.5%) and smoking history (75%). An integrated, surgeon-facing, point-of-care risk prediction instrument was created in an app for preoperative estimation of hernia after AS. Operative IH occurred in 3.8% of patients after nearly 5 years of follow-up in a predictable manner. Using a bioinformatics approach, risk models were transformed into 8 unique surgery-specific models. A risk calculator app was developed which stakeholders can access to identify high-risk IH patients at the point-of-care.

Neurosurgical Infections.

Patients in the neurointensive care unit often undergo life-saving neurosurgical interventions that can be associated with serious complications. Infection is a common and sometimes fatal complication of such procedures. Infection may occur not only in the setting of major cranial and spinal surgery, but also with common minor procedures that utilize neurosurgical devices, such as placement of external ventricular drains, ventriculoperitoneal shunts, and deep brain stimulators. In this article, we review the epidemiology and microbiology of these infections, and discuss their general and procedure-specific risk factors and treatment options.