Quality Improvement Program Research Articles

Is it time to Reassess The Role of Preoperative HypoalbuminemiaAmong Geriatric Distal Femur Fracture Patients?

Hypoalbuminemia, blanketly defined as Albumin < 3.5g/dL, is often utilized as a threshold associated with postoperative complications and mortality among orthopedic and non-orthopedic surgical procedures. Albumin level is influenced by a myriad of factors including liver function, malnutrition, and inflammation. This study evaluates the role preoperative albumin as an independent risk factor for mortality and increased length of stay (LOS) among distal femur fracture (DFF) patients. Between 2010 and 2019, the National Surgical Quality Improvement Program (NSQIP) identified isolated closed distal femur fractures preoperative albumin levels using International Classification of Diseases 9th and 10th revisions (ICD9/ICD10) codes [S72.4*; 821.2*]. Albumin was categorized as both continuous and categorical variables: marked hypoalbuminemia (< 2.5g/dL), mild hypoalbuminemia (2.5-3.5g/dL), normal albuminemia (3.5-4.5g/dL) or hyperalbuminemia (> 4.5g/dL). Primary outcomes included in-hospital mortality and LOS. The incidence rate of hypoalbuminemia was 54.6% (419/767). Multivariable logistic regression analysis demonstrated that when compared to patients with baseline marked hypoalbuminemia, patients with mild hypoalbuminemia and normal serum albumin reported a respective 82% (OR 0.18, 95% CI [0.04, 0.71], p = 0.014) and 80% (OR: 0.20, 95% CI [0.05, 0.89], p = 0.034) decreased odds of in-hospital mortality. Similarly, a 53.7% (OR 0.46, 95% CI [0.23, 0.94], p = 0.033), 71.1% (OR 0.29, 95% CI [0.14, 0.60], p = 0.001), and 82.8% (OR 0.17, 95% [0.04, 0.75], p = 0.020) decreased odds of exceeding mean LOS was observed among mild hypoalbuminemic, normal, and hyperalbuminemic patients compared to patients with baseline marked hypoalbuminemia. Preoperative hypoalbuminemia is an independent risk factor for increased LOS and mortality among DFFs, controlling for confounding factors. Prospective investigation of albumin risk stratification is warranted to differentiate contributable effects of chronic malnutrition and traumatic inflammatory albumin downregulation among geriatric trauma patients. Prognostic Level III.

Prospective analysis of preoperative C-reactive protein and neutrophil-to-lymphocyte ratio as predictors of postoperative complications in bile duct injury repair.

The role of inflammation in the bile duct injury has been suggested. Regarding, this study aims to determine the relationship between preoperative White Blood Cell count (WBC), C-reactive protein (CRP), and neutrophil-lymphocyte ratio (pNLR) with post-operative short- and long-term outcomes in patients undergoing a hepaticojejunostomy (HJ) for a bile duct injury (BDI) repair. This prospective longitudinal study (R-2022-3001-127) enrolled fifty patients. pNLR, WBC, and CRP were determined from preoperative laboratory analysis. Morbidity/Mortality, Accordion and National Surgical Quality Improvement Program (NSQIP), primary HJ patency and actual primary patency rate were registered. Perioperative morbidity and mortality were 34% and 2%. Primary patency was 92%. Median CRP and pNLR were statistically significantly higher in patients with Accordion > 3, NSQIP any complication, and biliary complications. CRP cut-off was consistent (6.3-6.6mg/dl) with area under curve (AUC) 0.8, in all post-operative complications. pNLR had a good AUC (0.7; 2.7-3.1 cut-off value) in any complication and biliary complications. Preoperative inflammatory biomarkers of patients who underwent a HJ for BDI repairs were associated with post-operative complications.

Increased risk of adverse events following the treatment of associated versus elementary acetabular fractures: a matched analysis of short-term complications

PurposeThis retrospective cohort study aims to compare short-term complication rates between patients receiving open reduction and internal fixation (ORIF) for associated versus elementary acetabular fractures, with a secondary objective of identifying independent risk factors for adverse outcomes.MethodsThe American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database was queried using current procedural terminology (CPT) codes to identify patients that underwent ORIF for associated acetabular (CPT 27228) or elementary acetabular fractures (CPT 27226, 27227) from 2010 to 2021. Propensity score matching was employed to account for baseline differences and the short-term complication rates were compared between the cohorts.ResultsWe identified 1,330 patients who underwent ORIF for an acetabular fracture between 2010 and 2021, including 868 patients with elementary fractures and 462 with associated fractures. After matching, there were 462 patients in each cohort. The matched associated acetabular fracture group experienced higher rates of any adverse event (AAE, p = 0.029), transfusion (p = 0.010), and reoperation (p = 0.049). Increased age, increased operative time, higher body mass index (BMI), and prolonged hospital length of stay (LOS) augmented the risk of any complication.ConclusionThe findings of this study identify areas of greater risk of postoperative complications after ORIF in individuals with associated versus elementary acetabular fractures. Discussion of these heightened risks is critical to appropriate patient care. Understanding these risks plays an important role in the clinical decision-making process and may identify areas to monitor patients postoperatively.

Association of obesity and thyroidectomy-specific perioperative outcomes.

There is limited large-scale data on the effect of obesity on thyroidectomy-specific outcomes. To fill this gap in the literature, this study evaluates the association between obesity and thyroidectomy-specific outcomes using a large real-world surgical outcomes dataset. The 2016-2019 American College of Surgeons National Surgical Quality Improvement Program Targeted Thyroidectomy dataset (ACS NSQIP) was queried. Using an inverse probability weighted (IPW) model, the impact of BMI on the primary (postoperative voice hoarseness, neck hematoma, and hypocalcemia.) and secondary outcomes (operative time and postoperative length of stay) were estimated. BMI was evaluated as per the WHO obesity categories. Sensitivity analysis was performed. 24,370 patients were evaluated with an average BMI of 30.6, a mean age of 51.8years, 77.5% were female, and 7.9 % were Hispanic. In univariate analysis, patients with BMI >30 had a higher risk of postoperative voice hoarseness (6.7 vs. 5.8% and p=0.005) and neck hematoma (2.1 vs. 1.7% and p=0.014) and a lower risk in hypocalcemia rates (3.6% vs. 4.6 % and p<0.001). In the fully adjusted multivariable IPW models, BMI >30 was associated with a higher rate of postoperative voice hoarseness (RR 1.12 and p=0.031) and neck hematoma (RR 1.25 and p=0.024) but a lower rate of hypocalcemia (RR 0.81 and p=0.001). Also, patients with BMI >30 had longer OR time (adjusted difference: 6.33min and p<0.001) and length of stay (adjusted difference: 1.36h and p=0.002). In this national cohort of patients undergoing thyroidectomy, obesity was associated with a decreased rate of hypocalcemia but an increased rate of postoperative voice hoarseness and neck hematoma.

An Analysis of 24-Hour Survival Based on Arrival by Atypical Ground Transport Versus Ground Emergency Medical Services

Objectives Studies comparing police, privately owned vehicle (POV), and ground Emergency Medical Services (GEMS) trauma transports reveal mixed results. It remains unclear whether using nonstandard transport methods may be beneficial in the setting of certain injuries. We sought to determine 24-h survival after transport by police or POV when compared to GEMS. Methods We analyzed data from the Trauma Quality Improvement Program datasets from 2020 to 2022 for patients arriving from scene by POV, police, or GEMS. The primary outcome was 24-h survival. Multivariable logistic regression models were used to adjust for confounders. Further stratification was performed by mechanism. We used abbreviated Injury Severity Score (ISS) by body region to assess those with and without penetrating torso trauma. Results Patients arriving by POV had a lower median age than those arriving by GEMS and a higher proportion of pediatric patients. This group exhibited a lower incidence of blunt trauma but a higher incidence of penetrating trauma, along with fewer serious injuries across all body regions. Across all adjusted models, arrival by POV was associated with higher odds of 24-h survival, except for cases of penetrating torso trauma among pediatric patients. Patients arriving by police also had a lower median age but a reduced proportion of pediatric patients. This group showed a higher proportion of penetrating trauma and serious injuries to the thorax and abdomen. Police arrivals with blunt trauma had higher odds of 24-h survival, while those with penetrating trauma had lower odds of 24-h survival, a pattern consistent when stratifying by ISS greater than 15. Conclusions This study highlights a survival advantage for trauma patients transported by POV compared to GEMS. Limitations include a lack of prehospital transport time and intervention data. While police transport showed improved survival for blunt trauma, it was associated with worse outcomes for penetrating trauma. These findings suggest that nontraditional transport methods may be beneficial in certain scenarios. Future research should aim to refine transport protocols, investigate the impact of nontraditional methods on transport time, and better understand the impact of prehospital interventions on patient outcomes.

Racial and ethnic disparities in short-stay primary total shoulder arthroplasty.

There is a paucity of literature evaluating the utilization of short-stay total shoulder arthroplasty (TSA) in different racial groups. The purpose of this study is to compare short-stay TSA utilization and postoperative outcomes across racial groups. The National Surgical Quality Improvement Program (NSQIP) database was queried from 2010 to 2018 to identify patients who underwent primary short-stay TSA, defined as a length of stay of less than 2 midnights. Annual proportions of short-stay TSA, demographic variables, preoperative comorbidities, and postoperative complications were compared across groups. All racial groups showed increases in the proportion of short-stay TSA cases over time, but this increase was most evident in Whites. Hispanics had increased rates of pneumonia (0.8% vs. 0.2%; p = 0.002) and transfusion (2.0% vs 1.0%; p = 0.015) compared to Whites, but no other differences in outcomes were observed between groups. Postoperative outcomes were similar across groups despite differing comorbidity profiles, suggesting that short-stay TSA is being implemented appropriately based on perceived preoperative risk. However, differences in utilization across groups suggest that underlying disparities may exist. Given the continued increase in short-stay TSA procedures, opportunities to resolve racial disparities are essential in mitigating the effects of social determinants of health in minority patient groups.

IVC filter use in patients with a history of venous thromboembolism undergoing bariatric surgery: a MBSAQIP study.

Research on the use of prophylactic inferior vena cave filter (IVCF) placement prior to metabolic and bariatric surgery (MBS) in high risk patients has yielded conflicting results. We evaluated thrombotic events and mortality in patients with a history of venous thromboembolism (VTE) who underwent IVCF placement in anticipation of MBS. We queried the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for all patients undergoing primary sleeve gastrectomy or Roux-en-Y gastric bypass from 2015 to 2019 with a history of VTE. We tabulated yearly IVCF use and compared 30-day rates of deep venous thrombosis (DVT), pulmonary embolism (PE), readmission, mortality, and serious adverse events in patients with and without prophylactic IVCF placement. Multivariate logistic regression was used to assess the relationship between preoperative placement of an IVCF and postoperative outcomes. Of 754,397 patients undergoing MBS, 16,683 (2.2%) had a prior VTE. Placement of IVCF in anticipation of MBS decreased from 285/2245 (10.4%) in 2015 to 85/3750 (2.2%) in 2019 (p < 0.01). The incidence of PE did not differ significantly between patients with prophylactic IVCF vs. those without (0.1% vs 0.5%, p = 0.13). Postoperative DVT was more common in patients who underwent IVCF placement (1.7% vs. 0.8%, p < 0.01). No significant differences were observed in mortality. Preoperative placement of an IVCF was an independent risk factor for development of a postoperative DVT (OR 2.45; 95% CI 1.39-4.32). These data do not support a history of VTE as an indication for prophylactic IVCF placement in anticipation of MBS.

Influential Factors in the Decision to Pursue a Bachelor’s Degree in Computer Engineering and Artificial Intelligence at the School of Engineering and Technology, Walailak University

Background and Objectives: University education is essential for empowering individuals and fostering economic, social, and intellectual growth. In Thailand, fair and competitive university admissions are ensured across 75 institutions by the Thai University Center Admission System (TCAS). At the same time, each individual’s decision to pursue higher education is influenced by the quality of program’s curriculum and academic reputation, along with geographical considerations and parental guidance. This study investigates factors influencing the decision to pursue a bachelor's degree in Computer Engineering and Artificial Intelligence (CEAI) at Walailak University, focusing in particular on their revised curriculum. Insights gained aim to enhance curriculum alignment, boost recruitment, and meet the diverse needs of students. Methodology: This study employed an exploratory approach, using descriptive statistics and multiple regression analysis. The population consisted of 126 students enrolled in the CEAI program at Walailak University in 2022. A sample of 96 participants were randomly selected and voluntarily completed an online questionnaire. The questionnaire, distributed via academic platforms and social media, elicited demographic information and explored factors influencing participants’ decision to pursue this degree. Main Results: The results showed that curriculum factors had the greatest impact on the decision to pursue the program, followed by financial factors, educational institution factors, and personal reasons. The t-test results indicated that gender impacted decision regarding course enrollment and the total monthly income of the family affected the decision as to whether or not to enroll at a particular institution. Discussions: This study revealed key factors influencing enrollment decisions for CEAI students at Walailak University. Curriculum relevance, faculty expertise, and financial considerations emerged as their primary concerns. Notably, female students valued curriculum aspects more highly than their male counterparts, yet they remain underrepresented, highlighting persistent gender stereotypes in engineering. Income-related differences significantly impacted perceptions of financial factors. To address these findings, we recommend: (1) curriculum-focused marketing emphasizing industry relevance, (2) targeted outreach to female students, (3) expanded financial support and transparency, and (4) enhanced public relations leveraging social media and outreach programs. These strategies aim to create a more diverse and inclusive program, aligning with global trends in STEM education and workforce development. Conclusions: The study reveals that curriculum factors, particularly job market relevance and faculty expertise, are most important to students in Walailak University's CEAI program. Gender and income related differences significantly influence student perspectives. These insights can help improve program quality, develop targeted admission strategies, and better serve diverse student needs.

Racial and Ethnic Disparities in Failure-to-Rescue After Postoperative Sepsis After Noncardiac Surgery.

Sepsis disproportionately affects marginalized communities. This study aims to evaluate racial and ethnic disparities in failure-to-rescue (FTR) after postoperative sepsis. This cross-sectional study used data from the American College of Surgeons National Surgical Quality Improvement Program for patients who underwent inpatient noncardiac surgery between 2018 and 2021. Patients were categorized as non-Hispanic White (hereafter, White), non-Hispanic Black (hereafter, Black), Asian, and Hispanic individuals. The association between (1) FTR after sepsis and (2) FTR after septic shock and race and ethnicity was evaluated using multivariable logistic regression. Failure-to-rescue was defined as 30-day mortality among patients who developed postoperative sepsis or postoperative septic shock. Among the 1388,977 patients (mean [SD] age 60.5 [16]); 783,056 (56.4%) were female, 1017,875 (73%) were White, 171,774 (12%) were Black, 138,457 (10%) were Hispanic, and 60,871 (4%) were Asian. Compared to White individuals, Black (adjusted odds ratio [aOR], 1.29; 95% CI, 1.23-1.35, P < .001) and Hispanic individuals (aOR, 1.15; 95% CI, 1.09-1.21, P < .001) were more likely to develop sepsis; Black individuals were more likely to develop septic shock (aOR, 1.28; 95% CI, 1.21-1.36; P < .001), and Asians were less likely to develop septic shock (aOR 0.84; 95% CI, 0.75-0.93, P = .002). Black individuals experienced lower rates of FTR after sepsis [Black: (aOR, 0.71; 95% CI, 0.54-0.94; P = .017), while Black (aOR, 0.93; 95% CI, 0.80-1.08; P = .35)], Hispanic (aOR, 0.87; 95% CI, 0.72-1.06; P = .16) and Asian Individuals (aOR, 1.06; 95% CI, 0.8-1.37; P = .67) experienced similar rates of FTR after septic shock compared to White individuals. Black and Hispanic individuals experienced higher rates of postoperative sepsis but did not experience higher rates of failure-to-rescue. Reducing inequity in surgical care should focus on efforts to prevent postoperative sepsis.

Development and internal validation of time-to-event risk prediction models for major medical complications within 30 days after elective colectomy.

Patients undergoing colectomy are at risk of numerous major complications. However, existing binary risk stratification models do not predict when a patient may be at highest risks of each complication. Accurate prediction of the timing of complications facilitates targeted, resource-efficient monitoring. We sought to develop and internally validate Cox proportional hazards models to predict time-to-complication of major complications within 30 days after elective colectomy. We studied a retrospective cohort from the multicentered American College of Surgeons National Surgical Quality Improvement Program procedure-targeted colectomy dataset. Patients aged 18 years or above, who underwent elective colectomy between January 1, 2014 and December 31, 2019 were included. A priori candidate predictors were selected based on variable availability, literature review, and multidisciplinary team consensus. Outcomes were mortality, hospital readmission, myocardial infarction, cerebral vascular events, pneumonia, venous thromboembolism, acute renal failure, and sepsis or septic shock within 30 days after surgery. The cohort consisted of 132145 patients (mean ± SD age, 61 ± 15 years; 52% females). Complication rates ranged between 0.3% (n = 383) for cardiac arrest and acute renal failure to 5.3% (n = 6986) for bleeding requiring transfusion, with readmission rate of 8.6% (n = 11415). We observed distinct temporal patterns for each complication: the median [quartiles] postoperative day of complication diagnosis ranged from 1 [0, 2] days for bleeding requiring transfusion to 12 [6, 18] days for venous thromboembolism. Models for mortality, myocardial infarction, pneumonia, and renal failure showed good discrimination with a concordance > 0.8, while models for readmission, venous thromboembolism, and sepsis performed poorly with a concordance of 0.6 to 0.7. Models exhibited good calibration but ranges were limited to low probability areas. We developed and internally validated time-to-event prediction models for complications after elective colectomy. Once further validated, the models can facilitate tailored monitoring of high risk patients during high risk periods. Clinicaltrials.gov (NCT05150548; Principal Investigator: Janny Xue Chen Ke, M.D., M.Sc., F.R.C.P.C.; initial posting: November 25, 2021).

Similar Associated Risk of Complications and Death for Adolescent Gunshot Wounds Treated at Pediatric Only Hospitals when Compared to Combined Pediatric and Adult Centers.

Adult trauma centers, including combined pediatric/adult centers (CPACs), see high volumes of penetrating trauma. Few studies have compared outcomes of adolescents presenting with gunshot wounds (GSWSs) at CPACs vs. pediatric only hospitals (POHs). This study aimed to compare injury patterns, complications, and mortality for adolescents sustaining GSWs presenting to CPACs vs POHs, hypothesizing decreased associated risk of complications and mortality at CPACs. The 2017-2021 Trauma Quality Improvement Program database was queried for adolescents (aged 12-17) with isolated GSWs. Patients transferred or with brain injury were excluded. CPACs included centers with adult and pediatric ACS-verification while POHs only had pediatric ACS-verification. Multivariable logistic regression analysis was performed to identify risk factors associated with in-hospital complications and mortality, controlling for age, injury severity score (ISS), vitals, surgery, and blood transfusions. Of 3,064 adolescents presenting with GSWs, 1,512 (49.3%) presented to CPACs. When compared to POH, CPAC patients were slightly older (median, 16 vs. 15 years old, p<0.001) had increased ISS (median: 9 vs. 4, p<0.001), and injuries to the spine (9.3% vs. 5.7%, p<0.001), heart (2.3% vs. 0.7%, p<0.001), lung (19.1% vs. 10.6%, p<0.001), liver (8.5% vs. 4.8%, p<0.001), and spleen (3.2% vs. 1.5%, p=0.002). CPAC adolescents also had increased rates of emergent operations (31.9% vs. 23.5%, p<0.001). However, on multivariable analysis, CPAC adolescents had a similar associated risk of in-hospital complications (OR 0.91, CI 0.59-1.41, p=0.68) and mortality (OR 0.76, CI 0.40-1.48, p=0.42). Adolescent GSW patients had similar associated risk of mortality and complications when comparing POHs to CPACs. This suggests that adolescents with GSWs receive similar care at both CPACs and POHs. Additional research is warranted to corroborate these findings.

The impact of metabolic syndrome on short term radical cystectomy complications

PurposeRadical cystectomy is a highly morbid procedure with short term perioperative complications rates cited to be as high as 60%. Short term perioperative complications have been demonstrated to be more frequent in underweight and overweight patients. We sought to evaluate the impact of metabolic syndrome on surgical outcomes. Materials and methodsWe identified 19,071 eligible patients who underwent radical cystectomy for nonmetastatic bladder cancer using the American College of Surgeons National Surgical Quality Improvement Program database between the years 2014 to 2021. The primary exposure was the presence of metabolic syndrome (body mass index >30, hypertension, diabetes) and included 1,566 patients. Our primary outcome was the development of a post operative surgical complication with secondary outcomes of the impact on length of stay, return to operating room, readmission, and 30 day mortality. ResultsMetabolic syndrome was associated with an increased rate of complications following radical cystectomy (P < 0.001). Complications were demonstrated in 68% of patients with metabolic syndrome in comparison to 60% of those without. Following multivariable adjustment for relevant demographic, comorbidity, and treatment factors, compared to patients without metabolic syndrome, patients with metabolic syndrome were significantly more likely to experience a complication in the 30 days following cystectomy. Among the secondary outcomes, on multivariable analysis significant differences were found in the risk of readmission and extended length of stay. Critically, the risk of 30 day morbidity was associated with a 1.8 fold increase in those with metabolic syndrome. ConclusionsMetabolic syndrome demonstrates significantly worse perioperative outcomes following radical cystectomy for bladder cancer.

Impact of islet autotransplantation on 30-day post-operative outcomes in patients undergoing Total Pancreatectomy: A NSQIP retrospective cohort analysis of 584 patients

BackgroundTotal pancreatectomy (TP) offers a surgical option for refractory pancreatitis, yet confers substantial long-term morbidity associated with resultant diabetes. While total pancreatectomy with islet autotransplantation (TPIAT) offers an intuitive solution, data evaluating its safety have been limited to single-center studies. The aim of this study is to evaluate whether the addition of islet autotransplantation to TP confers additional post-operative morbidity within the 30-day post-operative period. MethodsThis is a retrospective cohort study of prospectively collected cases from the National Surgical Quality Improvement Program (NSQIP) database. Cases of TP with or without islet autotransplantation from 2016 – 2021 were included. Baseline demographics, and a comprehensive list of 30-day postoperative outcomes were evaluated. Multivariable logistic regression models were constructed to evaluate the impact of each factor on 30-day complications. ResultsA total of 584 cases were included with 171 (29.2%) patients undergoing TPIAT. TPIAT patients were younger (58.8 vs. 39.5; p < 0.0001), and had lower incidences of pre-existing diabetes (41.4% vs. 19.9%; p < 0.0001) and hypertension (48.2% vs. 24.6%; p <0.0001). TPIAT cohort had longer length of stay (10.3 days vs.12.2 days; p = 0.0006). There was no difference in overall rates of serious complications between the two cohorts (50.1% vs. 45.0%; p = 0.263). After adjusting for demographic differences between cohorts using multivariable logistic regression models, TPIAT was not associated with serious complications (OR 0.71; p=0.168) compared to TP alone. ConclusionThe results from this study suggest that TPIAT does not appear to be associated with increased 30-day morbidity, and should be considered in patients to mitigate the long-term morbidity associated with diabetes mellitus post TP.

Hygiene Factors and Motivation Factors towards Job Satisfaction in Malaysia Healthcare Sector

Healthcare professionals' job satisfaction is a measure that should be included in quality improvement programmes for healthcare services. It significantly affects how productive and effective healthcare facilities are. The most valuable resource in the healthcare system is its human resources, which also serve as the driving force behind the delivery of sustainable services (Saari and Judge, 2004). The effectiveness of health services is impacted by employee turnover and absenteeism, which are both linked to poorer job satisfaction among these competent health professionals. The WHO has determined that the threshold of the health workforce density is currently below expectations in several developing nations. The goal of this study is to have a better awareness and knowledge of the motivational factors that influence job satisfaction in Malaysia's healthcare industries. Many academic researchers have studied motivational factors causing job satisfaction in different populations. The scope of this study will be focused on the Malaysian healthcare industry, and the respondents will be Malaysian healthcare professionals. This study concentrates on the national level of job satisfaction and motivational factors among healthcare professionals. The findings of the study help the Malaysian Ministry of Health, regional health bureaus, and other stakeholders who invest in the Malaysian health sector plan appropriate interventions to promote healthcare professionals' retention in public health sectors.

Prediction of Two Year Survival Following Elective Repair of Abdominal Aortic Aneurysms at A Single Centre Using A Random Forest Classification Algorithm

The decision to electively repair an abdominal aortic aneurysm (AAA) involves balancing the risk of rupture, periprocedural mortality, and life expectancy. Random forest classifiers (RFCs) are powerful machine learning algorithms. The aim of this study was to construct and validate a random forest machine learning tool to predict two year survival following elective AAA repair. All patients who underwent elective open or endovascular repair of AAA from 1 January 2008 to 31 March 2021 were reviewed. They were assessed using the Vascular Surgery Quality Improvement Program pathway involving cardiopulmonary exercise testing, contrast enhanced computerised tomography scan, and multidisciplinary assessment. Patients were followed up for at least two years. A RFC was developed using 70% of the dataset and validated using 30% to predict survival for at least two years following AAA repair. A total of 925 patients (n = 836 men; n = 89 women) underwent elective repair of AAA; 126 (13.6%) died during the first two years; 11 (1.2%) died from periprocedural mortality. Variable importance analysis suggested that anaerobic threshold, pre-operative haemoglobin, maximal O2 consumption, body mass index, risk category, and forced expiratory volume in 1 second - forced vital capacity ratio were the most important contributors to the model. Sensitivity and specificity of the RFC for prediction of two year survival following surgery was 96.7% (95% CI 94.4 - 99%) and 67.1% (95% CI 61 - 72%); overall accuracy: 92.6% (95% CI 88 - 95%) (positive predictive value: 0.93, negative predictive value: 0.80); 10-fold cross validation revealed area under the receiver operator characteristic curve of 0.88. RFCs based on readily available clinical data can successfully predict survival in the first two years following elective repair of AAA. Such information can contribute to the risk benefit assessment when deciding to electively repair AAAs.

A Comparative Analysis of Open Versus Minimally Invasive Pancreatoduodenectomies

ABSTRACTBackground and ObjectivesPancreatoduodenectomy (PD) has been associated with significant morbidity and mortality. To reduce morbidity, minimally invasive pancreatoduodenectomies (MIPD) have become more prevalent. We aimed to compare short‐term survival and complications for open (OPD) versus MIPD and to assess the relationship between operative approach and operative time on outcomes.MethodsPatients undergoing PD between 2017 and 2020 were identified within the National Surgical Quality Improvement Program (NSQIP). The primary outcome was operative time, and the secondary outcomes were death at 30 days, reoperation, readmission, and NSQIP‐identified 30‐day postoperative complications. A multivariable logistic regression was performed.ResultsA total of 14 977 PDs were performed from 2017 to 2020. MIPD increased from less than 8% of pancreatoduodenectomies performed in 2017 to over 10% of PD by 2020. Of the MIPD cohort, 62% were robotic, and 38% were laparoscopic, with robotic surgery becoming most prevalent by the end of the study period. MIPD was associated with significantly longer operative times than OPD (p &lt; 0.01). MIPD was associated with decreased odds of postoperative bleeding and surgical site infection (p &lt; 0.01), but higher odds of death at 30 days.ConclusionsMIPD has been shown to have improved postoperative outcomes compared to OPD but is associated with longer operative times, which can be associated with increased complications.

HoLEP Safety and Efficacy in Octogenarians: A Retrospective ACS-NSQIP Analysis (2011-2020)

ObjectiveTo evaluate the safety of Holmium laser enucleation of the prostate (HoLEP) in octogenarian compared to non-octogenarian patients. MethodsA retrospective cohort analysis was performed using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2011 to 2020. We assessed baseline demographic data, American Society of Anesthesiologists (ASA) score, functional status, and medical comorbidities. Our primary outcome was the incidence of postoperative complications, the need for re-operation, and re-admission within 30 days following the procedure between octogenarians and non-octogenarians. A multivariate logistic model was utilized to identify predictors for postoperative complications. ResultsA total of 5305 patients were included. Octogenarians had higher rates of hypertension (69.9% vs. 55.5%, p < 0.001), and bleeding disorders (5.1% vs. 2.6%, p < 0.001). The absolute risk for postoperative complications was low in the two groups. However, the octogenarians had higher rates for readmitted (6.1% vs 3.6% p = 0.006) and to receive perioperative blood transfusion (3.3% vs 0.9% p-value <0.001). Multivariable regression analysis showed a significantly lower odds ratio to develop complications in non-octogenarians (OR: 0.698) [95% CI: 0.537, 0.908, (p=0.007)]. ConclusionThere was a significant association between octogenarians and the risk of post-operative complications of HoLEP however the absolute risk remained low. We believe that operative outcomes for octogenarians can be optimized with careful selection given the low incidence of complications.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) in penetrating abdominal vascular injuries is associated with worse outcomes

BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) may benefit patients with severe subdiaphragmatic traumatic hemorrhage. This study compares outcomes in patients with penetrating abdominal vascular injury treated with REBOA versus those managed without REBOA. MethodsUsing the Trauma Quality Improvement Program (TQIP) database, we identified adult patients with penetrating abdominal vascular injury from 2017 to 2022. Propensity scores matched REBOA patients 1:3 with non-REBOA patients. The primary outcome was in-hospital mortality, with secondary outcomes including 24-h mortality, transfusion needs, and complications such as acute kidney injury (AKI), deep vein thrombosis (DVT), pulmonary embolism (PE), lower extremity compartment syndrome, fasciotomy, amputation, and femoral artery repair. ResultsTwo hundred ninety-three REBOA patients were matched with 879 non-REBOA patients. REBOA patients had higher in-hospital mortality (46.8 ​% vs 36.3 ​%, p ​= ​0.002), packed-red blood cell (PRBC) transfusion requirements within 4 ​h (median 15.3 vs 8.2, p ​< ​0.001), AKI (8.5 ​% vs 4.7 ​%, p ​= ​0.013), fasciotomy (6.5 ​% vs 3.6 ​%, p ​= ​0.039), amputation (3.4 ​% vs 1.4 ​%, p ​= ​0.025), and femoral artery repair (3.4 ​% vs 0.6 ​%, p ​< ​0.001). In a subgroup analysis of patients without severe extra-abdominal injuries, REBOA was associated with higher in-hospital mortality (49.7 ​% vs. 38.2 ​%, p ​= ​0.013) and increased packed red blood cell (PRBC) transfusion requirements (median 14.1 vs. 8.3 units, p ​< ​0.001). ConclusionsIn penetrating abdominal vascular injuries, REBOA was associated with worse outcomes.

Higher complication and readmission rates after total knee arthroplasty with discharge to inpatient facility vs. home: a propensity score matched analysis

IntroductionThe purpose of this retrospective cohort study was to assess differences in complication rates, early readmission rates, and reasons for readmission following TKA based on discharge destination. Secondarily, we aimed to identify independent risk factors for developing any adverse event (AAE) in the 30-day postoperative period.MethodsThe American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) was filtered using current procedural terminology (CPT) codes to identify patients undergoing TKA from 2015 to 2020. Patients were divided into three cohorts based on discharge destination: home, skilled nursing facility (SNF), or inpatient rehabilitation facility (IRF). Propensity score matching was used to account for confounding variables. Statistical analysis was conducted using one-way analysis of variance (ANOVA), Chi-square tests, and multivariable logistic regression.Results352,824 patients were initially identified with 303,375 discharged home, 31,635 discharged to SNF, and 17,814 discharged to IRF. Following propensity score matching, there were 5,000 patients in each cohort. Regarding postoperative complications, the home cohort had significantly a lower readmission rate (p = 0.01) and rate of any adverse event (p < 0.001) when compared to the IRF and SNF cohorts. The IRF cohort had a significantly higher rate of AAE than the SNF cohort or the home cohort. On multivariable analysis, increasing age, increasing BMI, increasing length of hospital stay, male sex, American Society of Anesthesiologists (ASA) classification four, and history of COPD were all found to be independent risk factors for developing AAE.ConclusionsThis study demonstrates that patients who are discharged to a rehabilitation facility or SNF following TKA experienced significantly higher rates of readmission and postoperative complications than patients discharged home, even after controlling for baseline demographic differences and comorbidities. Given the high financial burden associated with these facilities, it is important for physicians to consider these potential impacts on outcomes when determining patient disposition following TKA.

Oncoplastic Surgery with Volume Replacement versus Mastectomy with Implant-Based Breast Reconstruction: Early Post-operative Complications in Patients with Breast Cancer.

Two common surgical approaches for breast cancer are breast-conserving surgery and mastectomy with implant-based breast reconstruction (MIBR). However, for large tumors, an alternative to MIBR is oncoplastic surgery with volume replacement (OPSVR). We performed a comprehensive analysis comparing OPSVR with MIBR, with our aim to focus on the 30-days post-operative complications between these two techniques. We conducted a retrospective cohort study using the National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2020. Only breast cancer patients were included and were divided according to the surgical technique: OPSVR and MIBR. Logistic regression analysis was used to assess independent risk factors for total, surgical, and wound complications. A cohort of 8,403 breast cancer patients was analyzed. 683 underwent OPSVR and 7,720 underwent MIBR. From 2005 to 2020, the adoption of OPSVR gradually increased over the years (p<0.001), whereas MIBR decreased. OPSVR patients were older (57.04 vs. 51.89 years, p<0.001), exhibited a higher BMI (31.73 vs. 26.93, p<0.001), had a greater prevalence of diabetes mellitus (11.0% vs. 5.0%, p<0.001). They also had a higher ASA classification (2.33 vs. 2.15, p<0.001), shorter operative time (173.39 vs. 216.20 min, p<0.001), and a higher proportion of outpatient procedures (83.7% vs 39.5%, p<0.001). Outcome analysis demonstrated fewer total complications in the OPSVR patients, (4.2% vs. 10.9%, p<0.001), including lower rates of surgical complications (2.2% vs 8.0%, p<0.001) and wound complications (1.9% vs. 4.8%, p=0.005) compared to MIBR patients. Multivariate analysis identified OPSVR as an independent protective factor for total, surgical, and wound complications. OPSVR has become a favorable technique for patients with breast cancer. Even in patients with higher comorbidities, OPSVR demonstrates safe and better outcomes when compared to MIBR. It should be considered a reasonable and safe breast surgical option in the appropriate patient.