Prolonged Postoperative Length Of Stay Research Articles

The impact of preoperative nutritional status on postoperative outcomes: an insight from Geriatric Nutritional Risk Index in elderly pancreaticoduodenectomy patients

BackgroundMalnutrition is not uncommon among the elderly undergoing pancreatoduodenectomy (PD) and is related to increased complications. Previous studies have shown that the Geriatric Nutritional Risk Index (GNRI) predicts outcomes in various populations. Nevertheless, the research exploring the correlation between GNRI and postoperative outcomes in PD is scarce. This study aimed to investigate the preoperative malnutrition, as measured by GNRI, on outcomes in elderly patients undergoing PD.Materials and MethodsThis retrospective analysis enrolled 144 elderly patients underwent PD for periampullary tumors from November 2016 to December 2021. Patients were stratified based on the GNRI value: high/moderate nutrition risk (GNRI ≤ 92, N = 54), low nutrition risk (92 < GNRI ≤ 98, N = 35), and no nutrition risk (GNRI > 98, N = 55). Perioperative outcomes and postoperative surgical complications were compared between these groups. Univariate and multivariate analyses were performed on major postoperative complications and prolonged postoperative length of stay (PLOS).ResultsPatients in the high/moderate risk group were significantly older, with lower BMI (P = 0.012), higher mortality rate (11.1%, P = 0.024), longer PLOS (P < 0.001), and higher incidence of over grade IIIB complications (37.0%, P = 0.001), Univariate and multivariate analyses showed the high/moderate risk GNRI group (OR 3.61, P = 0.032), increased age (OR 1.11, P = 0.014) and operative time over 8 h (OR 3.04, P = 0.027) were significantly associated with increased major postoperative complications. The high/moderate risk GNRI group was also a significant predictor for prolonged PLOS (OR 3.91, P = 0.002).ConclusionsPreoperative GNRI has the potential to be a predictive tool for identifying high-risk elderly patients and monitoring nutritional status preoperatively to improve postoperative surgical outcomes following PD.

So many measures in ERAS protocol: Which matters most?

ObjectivesEnhanced recovery after surgery (ERAS), which includes multiple measures, has gradually become the standard perioperative management in pediatric surgery. However, it is still unclear which of its many measures affects the outcomes more. MethodsWe retrospectively analyzed the medical records of children with congenital choledochal cysts who underwent surgical treatment in a specialized children's hospital from January 2019 to December 2022. Data including baseline factors, implementation of ERAS interventions, postoperative complications, and postoperative length of stay (PLOS) were collected. Univariate and multivariate analyses were performed to identify the association between PLOS and baseline factors or specific ERAS measures. ResultsThe implementation rate of ERAS measures ranged from 5.02% to 100% in 219 cases who underwent 3 to 14 ERAS measures. Univariate analysis showed that body mass index-for-age z-scores, liver function indicators, and postoperative complications were the significant baseline factors for PLOS. At the same time, the measures with the greatest effect on PLOS were early postoperative feeding and early removal of tubes. Multivariate analysis with different models revealed that postoperative complications, early postoperative feeding, and early catheter removal influenced the PLOS the most. ConclusionsA prolonged PLOS was associated with poor preoperative nutritional status, elevated liver function indexes, and postoperative complications. Early postoperative feeding and removal of tubes appeared more likely with a reduced PLOS than other measures, requiring more attention when implementing the ERAS protocol.

Development and validation of a novel nomogram to predict the risk of the prolonged postoperative length of stay for lumbar spinal stenosis patients

BackgroundLumber spinal stenosis (LSS) is the increasingly reason for spine surgery for elder patients since China is facing the fastest-growing aging population. The aim of this research was to create a model to predict the probabilities of requiring a prolonged postoperative length of stay (PLOS) for lumbar spinal stenosis patients, minimizing the healthcare burden.MethodsA total of 540 LSS patients were enrolled in this project. The outcome was a prolonged PLOS after spine surgery, defined as hospitalizations ≥ 75th percentile for PLOS, including the day of discharge. The least absolute shrinkage and selection operator (LASSO) was used to identify independent risk variables related to prolonged PLOS. Multivariable logistic regression analysis was utilized to generate a prediction model utilizing the variables employed in the LASSO approach. The receiver operating characteristic (ROC) curve’s area under the curve (AUC) and the calibration curve’s respective curves were used to further validate the model’s calibration with predictability and discriminative capabilities. By using decision curve analysis, the resulting model’s clinical effectiveness was assessed.ResultsAmong 540 individuals, 344 had PLOS that was within the usual range of P75 (8 days), according to the interquartile range of PLOS, and 196 had PLOS that was above the normal range of P75 (prolonged PLOS). Four variables were incorporated into the predictive model, named: transfusion, operation duration, blood loss and involved spine segments. A great difference in clinical scores can be found between the two groups (P < 0.001). In the development set, the model’s AUC for predicting prolonged PLOS was 0.812 (95% CI: 0.768–0.859), while in the validation set, it was 0.830 (95% CI: 0.753–0.881). The calibration plots for the probability showed coherence between the expected probability and the actual probability both in the development set and validation set respectively. When intervention was chosen at the potential threshold of 2%, analysis of the decision curve revealed that the model was more clinically effective.ConclusionsThe individualized prediction nomogram incorporating five common clinical features for LSS patients undergoing surgery can be suitably used to smooth early identification and improve screening of patients at higher risk of prolonged PLOS and minimize health care.

Optimal discharge planning for esophagectomy patients with enhanced recovery after surgery: Recommendations.

Studies have suggested that the postoperative length of stay (PLOS) of esophagectomy patients under the enhanced recovery after surgery (ERAS) pathway should be >10 days as against the previously recommended 7 days. We investigated the distribution and influencing factors of PLOS in the ERAS pathway in order to recommend an optimal planned discharge time. This was a single-center retrospective study of 449 patients with thoracic esophageal carcinoma who underwent esophagectomy and perioperative ERAS between January 2013 and April 2021. We established a database to prospectively document the causes of delayed discharge. The mean and median PLOS were 10.2 days and 8.0 days (range: 5-97), respectively. Patients were divided into four groups: group A (PLOS ≤ 7 days), 179 patients (39.9%); group B (8 ≤ PLOS ≤ 10 days), 152 (33.9%); group C (11 ≤ PLOS ≤ 14 days), 68 (15.1%); group D (PLOS > 14 days), 50 patients (11.1%). The main cause of prolonged PLOS in group B was minor complications (prolonged chest drainage, pulmonary infection, recurrent laryngeal nerve injury). Severely prolonged PLOS in groups C and D were due to major complications and comorbidities. On multivariable logistic regression analysis, open surgery, surgical duration >240 min, age >64 years, surgical complication grade >2, and critical comorbidities were identified as risk factors for delayed discharge. The optimal planned discharge time for patients undergoing esophagectomy with ERAS should be 7-10 days with a 4-day discharge observation window. Patients at risk of delayed discharge should be managed adopting PLOS prediction.

Predicting prolonged postoperative length of stay risk in patients undergoing lumbar fusion surgery: Development and assessment of a novel predictive nomogram.

ObjectiveThe purpose of this study was to develop and internally validate a prediction nomogram model in patients undergoing lumbar fusion surgery.MethodsA total of 310 patients undergoing lumbar fusion surgery were reviewed, and the median and quartile interval were used to describe postoperative length of stay (PLOS). Patients with PLOS > P75 were defined as prolonged PLOS. The least absolute shrinkage and selection operator (LASSO) regression was used to filter variables for building the prolonged PLOS risk model. Multivariable logistic regression analysis was applied to build a predictive model using the variables selected in the LASSO regression model. The area under the ROC curve (AUC) of the predicting model was calculated and significant test was performed. The Kappa consistency test between the predictive model and the actual diagnosis was performed. Discrimination, calibration, and the clinical usefulness of the predicting model were assessed using the C-index, calibration plot, and decision curve analysis. Internal validation was assessed using the bootstrapping validation.ResultsAccording to the interquartile range of PLOS in a total of 310 patients, the PLOS of 235 patients was ≤P75 (7 days) (normal PLOS), and the PLOS of 75 patients was > P75 (prolonged PLOS). The LASSO selected predictors that were used to build the prediction nomogram included BMI, diabetes, hypertension, duration of surgery, duration of anesthesia, anesthesia type, intraoperative blood loss, sufentanil for postoperative analgesia, and postoperative complication. The model displayed good discrimination with an AUC value of 0.807 (95% CI: 0.758–0.849, P < 0.001), a Kappa value of 0.5186 (cutoff value, 0.2445, P < 0.001), and good calibration. A high C-index value of 0.776 could still be reached in the interval validation. Decision curve analysis showed that the prolonged PLOS nomogram was clinically useful when intervention was decided at the prolonged PLOS possibility threshold of 3%.ConclusionsThis study developed a novel nomogram with a relatively good accuracy to help clinicians access the risk of prolonged PLOS in lumbar fusion surgery patients. By an estimate of individual risk, surgeons and anesthesiologists may shorten PLOS and accelerate postoperative recovery of lumbar fusion surgery through more accurate individualized treatment.

Predictive factors of prolonged postoperative length of stay after anatomic pulmonary resection

IntroductionThe objective of this study is to create a predictive model of prolonged postoperative length of stay (PLOS) in patients undergoing anatomic lung resection, to validate it in an external series and to evaluate the influence of PLOS on readmission and 90-day mortality. MethodsAll patients registered in the GEVATS database discharged after the intervention were included. We define PLOS as the postoperative stay in days above the 75th percentile of stay for all patients in the series. A univariate and multivariate analysis was performed using logistic regression and the model was validated in an external cohort. The possible association between PLOS and readmission and mortality at 90 days was analyzed. Results3473 patients were included in the study. The median postoperative stay was 5 days (IQR: 4–7). 815 patients had PLOS (≥8 days), of which 79.9% had postoperative complications. The final model included as variables: age, BMI, male sex, ppoFEV1%, ppoDLCO% and thoracotomy; the AUC in the referral series was 0.684 (95% CI: 0.661–0.706) and in the validation series was 0.73 (95% CI: 0.681–0.78). A significant association was found between PLOS and readmission (p < .000) and 90-day mortality (p < .000). ConclusionsThe variables age, BMI, male sex, ppoFEV1%, ppoDLCO% and thoracotomy affect PLOS. PLOS is associated with an increased risk of readmission and 90-day mortality. 20% of PLOS are not related to the occurrence of postoperative complications.

The Impact of Nutritional Status and Sarcopenia on the Outcomes of Lung Transplantation

<h3>Purpose</h3> Malnutrition and sarcopenia have been widely reported to negatively influence patients' outcomes in different clinical settings, but information is lacking about their impact on short and long-term outcomes after lung transplantation (LT). The aim of this study was to investigate which nutritional and sarcopenia indices independently predict prolonged post-operative invasive mechanical ventilation (IMV), intensive care unit (ICU) and hospital length of stay (LOS), re-intubation and rejection after LT. <h3>Methods</h3> Observational, retrospective study on patients undergoing LT in a single University Hospital was conducted between February 2016 and November 2020. Within 6 months before LT, the following data were collected: a) nutritional indices (Body Mass Index (BMI), serum albumin concentration, Prognostic Nutritional Index (PNI), Mini Nutritional Assessment Short-Form (MNA-SF)); b) sarcopenia indices (Creatinine Height Index (CHI), Skeletal Muscle Index (SMI) and densitometry of paravertebral muscles at chest CT-scan); c) postoperative clinical data related to the outcomes of interest. Univariable logistic regression models were used for binary outcomes and univariable gamma models for continuous outcomes. <h3>Results</h3> 108 of 114 patients were enrolled after excluding 6 patients for incomplete records. Seventy-two patients (67%) were male, median age was 52 [43-60] years. The main indications for BLT were interstitial (46%), septic (22%) and obstructive (19%) diseases. The IMV duration was non-linearly associated with pre-operative serum albumin (range 30-35 g/L: effect -1.67 [-2.45 - -0.89] hours, p<0.01). The ICU LOS was non-linearly correlated to albumin (range 30-35 g/L: effect -0.84 [-1.23 - -0.45] days, p<0.01) and PNI (range 25-40: effect -1.79 [-3.09 - -0.50] days, p=0.01), but linearly associated to BMI (range 20.7-27.4 kg/m²: effect +0.34 [0.03 - 0.68] days, p=0.04). No nutritional or muscle parameters predicted the need for re-intubation, the presence of rejection at 30 days and hospital LOS. <h3>Conclusion</h3> Pre-operative low serum albumin independently predicts prolonged IMV after LT, while pre-transplant low albumin, low PNI and high BMI values are associated with prolonged postoperative ICU LOS. Further studies are needed to identify the most appropriate nutritional and muscular assessment tools in BLT recipients.

Outcomes of Minimally Invasive Distal Pancreatectomy in the Octogenarian Population: An ACS NSQIP Analysis

Introduction: Minimally invasive distal pancreatectomy (MIDP) has become increasingly used in practice. Multiple studies have shown improvements in estimated blood loss (EBL), length of stay (LOS) and decreased complication rates. We aim to evaluate the impact of operative approach on postoperative outcomes in octogenarians undergoing distal pancreatectomy. Method: Elective non-emergent distal pancreatectomies (DPs) were identified from the 2014–2019 ACS-NSQIP Procedure Targeted Pancreatectomy Participant Use Data Files. Outcomes examined included: mortality, major complications, minor complications, postoperative pancreatic fistula (POPF), clinically relevant postoperative pancreatic fistula (CR-POPF), prolonged postoperative length-of-stay (P-LOS), and Non-home discharge (NHD). Outcomes were compared between open (ODP) and MIDP groups. Multivariable logistic regression models were constructed to examine the risk-adjusted impact of approach on outcomes. Results: Of 9,681 elective DPs, only 634 were octogenarians. Of these, 330 were ODP and 332 MIDP (87, 26.2% were robotic). The MIDP group was less likely to have greater than 10% weight loss (5.12% vs 11.33%, p=0.015), to have received preoperative chemotherapy (6.93% vs 15%, p=0.02), preoperative radiation (1.81% vs 7%, p=0.03) and to have had pancreatic adenocarcinoma (51.81% vs 54.33%, p<0.001). On univariable analysis, MIDP had lower incidence of major complications (5.52% vs 8.33%, p=0.02) and P-LOS (19.58% vs 36.67%, p<0.001). On multivariable analysis, MIDP remained independently predictive of a lesser rate of P-LOS (OR: 0.39, P<0.001). Conclusions: MIPD was independently predictive of shorter LOS in octogenarians. MIDP is a safe and effective approach in this frail population.Tabled 1Table 1. Multivariable Model for Prolonged Length of Stay (>7days)PredictorOdds Ratio95% C.I.P-valueMIDP0.390.27-0.57<0.001COPD2.891.25-6.670.01310% Weight Loss0.80.41-1.550.517Preoperative Chemotherapy0.750.38-1.510.431Preoperative Radiotherapy1.310.48-3.540.585Pancreatic adenocarcinoma1.360.93-1.970.104 Open table in a new tab

Risk factors associated with postoperative complications and prolonged postoperative length of stay after laparoscopic liver resection.

IntroductionLaparoscopic liver resection (LLR) has expanded rapidly. Previously published studies are limited to small samples and selected patients. Comprehensive data that may significantly influence the incidence of perioperative complications and postoperative length of stay (PLOS) are lacking.AimTo characterize complications after LLR and to identify risk factors associated with postoperative complications and prolonged PLOS.Material and methodsThis study was carried out at a high-volume HPB centre and included all patients who underwent LLRs between 2015 and 2018. Postoperative complications were analysed in detail. Logistic regression was used to identify independent risk factors. The primary outcome was postoperative complications with a comprehensive complication index (CCI) ≥ 26.2. The second outcome was prolonged length of stay.ResultsWe identified 938 patients who underwent LLR. In the full cohort, 79 (8.4%) patients experienced major complications with a CCI ≥ 26.2, with postoperative mortality in 4 (0.4%) patients. On multivariate analysis, the diagnosis of primary (OR = 8.97, 95% CI: 2.54–43.74, p = 0.001) and metastatic liver tumours (OR = 5.74, 95% CI: 1.20–30.90, p = 0.028), infectious liver disease (OR = 24.04, 95% CI: 5.30–129.53, p < 0.001), difficult liver resection (OR = 2.77, 95% CI: 1.29–6.69, p = 0.014), and intraoperative bleeding > 1000 ml (OR = 9.29, 95% CI: 3.40–26.43, p < 0.001) were independent factors that increased the odds of major complications. The median PLOS after the operation was 5 days (range: 2–35 days). Factors that independently influenced prolonged PLOS on multivariate analysis were age over 70 years, metastatic liver tumour, difficult liver resection, liver cirrhosis, and right hepatectomy.ConclusionsLLR remains safe for most liver space-occupying lesions. Several preoperative and intraoperative factors associated with the risk of complications and prolonged PLOS were identified. These factors should be considered during patient selection and perioperative management.

Factores predictores de estancia hospitalaria prolongada tras resección pulmonar anatómica

IntroductionThe objective of this study is to create a predictive model of prolonged postoperative length of stay (PLOS) in patients undergoing anatomic lung resection, to validate it in an external series and to evaluate the influence of PLOS on readmission and 90-day mortality. MethodsAll patients registered in the GEVATS database discharged after the intervention were included. We define PLOS as the postoperative stay in days above the 75th percentile of stay for all patients in the series. A univariate and multivariate analysis was performed using logistic regression and the model was validated in an external cohort. The possible association between PPE and readmission and mortality at 90 days was analyzed. Results3473 patients were included in the study. The median postoperative stay was 5 days (IQR: 4–7). 815 patients had PLOS (≥8 days), of which 79.9% had postoperative complications. The final model included as variables: age, BMI, male sex, ppoFEV1%, ppoDLCO% and thoracotomy; the AUC in the referral series was 0.684 (95% CI: 0.661–0.706) and in the validation series was 0.73 (95% CI: 0.681–0.78). A significant association was found between PLOS and readmission (p<.000) and 90-day mortality (p<.000). ConclusionsThe variables age, BMI, male sex, ppoFEV1%, ppoDLCO% and thoracotomy affect PLOS. PLOS is associated with an increased risk of readmission and 90-day mortality. 20% of PLOS are not related to the occurrence of postoperative complications.

Improved Retinal Microcirculation After Cardiac Surgery in Patients With Congenital Heart Disease

Background: Microcirculatory changes in congenital heart disease (CHD) patients undergoing cardiac surgery are not fully understood. We aimed to investigate the changes of retinal microcirculation in CHD patients after cardiac surgery by optical coherence tomography angiography (OCTA) and explore the association between retinal microcirculation and surgical outcome.Methods: This prospective observational study consisted of 71 CHD patients aged ≥6 years undergoing cardiac surgery including 19 cyanotic CHD (CCHD) and 52 acyanotic CHD (ACHD). Optical coherence tomography angiography (OCTA) was used to measure vessel density (VD) and capillary density (CD) of radial peripapillary capillary (RPC) and peripapillary, VD of superficial capillary plexus (SCP) and deep capillary plexus (DCP), thickness of retinal nerve fiber layer (RNFL) and ganglion cell complex (GCC) preoperatively and 1 month postoperatively. Transthoracic echocardiography was conducted to measure macrocirculation.Results: In CCHD patients, VD and CD of RPC and peripapillary increased postoperatively (all P < 0.05). In ACHD patients, VD of peripapillary, CD of RPC and peripapillary, and RNFL thickness increased postoperatively (all P < 0.05). VD of SCP and DCP, and GCC thickness did not change significantly in CHD patients after surgery. Lower preoperative retinal microvascular density was associated with longer cardiopulmonary bypass (CPB) time and postoperative length of stay (PLOS). No correlation was found between microcirculatory and macrohemodynamic parameters (all P > 0.05).Conclusions: Improved retinal microcirculation was observed after congenital cardiac surgery and impaired preoperative retinal microvasculature was associated with prolonged CPB time and PLOS, which might provide potential information about the outcome of congenital cardiac surgery.

Perioperative Outcomes for Centers Routinely Admitting Postoperative Endovascular Aortic Aneurysm Repair to the ICU

Intensive care unit (ICU) admission after endovascular aortic aneurysm repair (EVAR) varies across medical centers. We evaluated the association of postoperative ICU use with perioperative and long-term outcomes after EVAR. The Vascular Quality Initiative (2003-2019) was queried for index elective EVARs. Included centers were categorized by percentage of patients with EVARs postoperatively admitted to the ICU; routine ICU (rICU) centers as ≥80% ICU admissions and nonroutine ICU (nrICU) centers as ≤20% ICU admissions. Patients admitted preoperatively or with same day discharge were excluded. Perioperative outcomes and survival were compared between rICU and nrICU centers. Of 45,310 EVARs in the database, 35,617 were performed at rICU or nrICU centers - 5,443 (15.3%) at 71 rICU centers and 30,174 (84.7%) at 200 nrICU centers. Overall, mean age was 73.4 years and 81.6% were male. Postoperative myocardial infarction, pulmonary complications, stroke, leg ischemia, and in-hospital mortality were similar between rICU and nrICU centers (all p > 0.05). Postoperative length of stay (LOS) was prolonged at rICU centers (mean) (2.2 ± 3.6 vs 2 ± 4.2 days, p < 0.001). One-year survival was similar between rICU and nrICU centers, respectively, (94.9% vs 95.4%, p= 0.085). When compared with nrICU centers, rICU centers had similar 1-year mortality risk (hazard ratio [HR] 1.15, 95% CI 0.99-1.34, p= 0.076), but were associated with longer postoperative LOS (means ratio 1.1, 95% CI 1.08-1.13, p < 0.001). Routine ICU use after EVAR was associated with prolonged postoperative LOS, without improved perioperative/long-term morbidity or mortality. Updated care pathways to include postoperative admission to lower acuity care units may reduce costs without compromising care.

Comparison on short-term safety outcomes between off-pump and on-pump coronary artery bypass grafting by experienced surgeons: a single center study with 31 075 cases

Objective: To compare the short-term outcomes between off-pump and on-pump coronary artery bypass graft (CABG) by experienced surgeons with similar surgical team in a single large-volume cardiac surgery center. Methods: A total of 31 075 patients with multivessel coronary disease who underwent isolated off-pump or on-pump CABG between January 1, 2009 and December 31, 2019 by experienced surgeons in Fuwai hospital were enrolled in this retrospective study. Patients was divided into on-pump CABG group and on-pump CABG group on an intention-to treat basis. Short term safety endpoints, including 30 days mortality, composite endpoint of major morbidity or mortality, prolonged postoperative length of stay (PLOS), and prolonged ICU length of stay (PICULOS), and distal anastomosis were compared between the two groups. Mortality was evaluated on 30 days post operation, other endpoints were collected before discharge. After 1∶1 propensity-score matching of baseline characteristics for on-pump and off-pump CABG, postoperative endpoints were compared with use of McNemar's test and further adjusted with the use of a logistic regression model. Results: After propensity-score matching, 10 243 matched pairs of patients were included in the final analysis, there were 4 605(22.5%) females and mean age was (60.7±8.6) years. The standardized differences were less than 5% for all baseline variables in matched cohort. Univariate analysis indicated lower risk of 30 days mortality (0.2% vs. 0.7%, P<0.001), major morbidity or mortality (5.7% vs. 8.8%, P<0.001), PLOS (3.2% vs. 4.9%, P<0.001), PICULOS (9.4% vs. 12.2, P<0.001), and lower number of distal anastomosis ((3.3±0.8) vs. (3.6±0.8), P<0.001) in off-pump CABG group than in on-pump CABG group. After adjustment of cofounders, multivariate analysis showed that off-pump CABG was still associated with a lower risk of 30 days mortality (OR=0.29, 95%CI: 0.09-0.87, P=0.027), composite endpoint of major morbidity or mortality (OR=0.60, 95%CI: 0.53-0.68, P<0.001), PLOS (OR=0.64, 95%CI 0.54-0.75, P<0.001), PICULOS (OR=0.76, 95%CI: 0.69-0.84, P<0.001). Conclusions: Off-pump CABG is related with superior short-term safety outcomes than on-pump CABG by experienced surgeons in our center.

Risk Factors for Prolonged Length of Stay and Readmission After Parathyroidectomy for Renal Secondary Hyperparathyroidism.

Population-based analyses of 30-day outcomes after parathyroidectomy for renal secondary hyperparathyroidism are limited. We sought to identify risk factors associated with prolonged length of stay (LOS) and readmission in this patient population. Patients with secondary hyperparathyroidism who underwent parathyroidectomy were reviewed in the ACS-NSQIP database (2011-2016). Patients were identified by ICD codes specific to secondary hyperparathyroidism of renal origin and the ACS-NSQIP variable for current preoperative dialysis. Multivariable logistic regression was used to identify independent factors associated with prolonged LOS and 30-day readmission after parathyroidectomy. The cohort included 1846 patients with secondary hyperparathyroidism on dialysis who underwent parathyroidectomy. There were 416 (22.5%) patients classified under the prolonged LOS group. On multivariable analysis, factors associated with prolonged LOS included elevated preoperative alkaline phosphatase [OR 3.13 (95%-CI 2.09-4.70), p < 0.001], decreased preoperative hematocrit [OR 1.83 (95%-CI 1.25-2.68), p = 0.002], unplanned reoperation (OR 5.02 [95%-CI 2.22-11.3], p < 0.001) and any postoperative complication [OR 6.12 (95%-CI 3.31-11.3), p < 0.001]. The overall 30-day readmission rate was 15.0%. Hypocalcemia and hungry bone syndrome accounted for 47.0% (n = 93/198) of readmissions. On multivariable analysis, patients with a history of hypertension and those undergoing unplanned reoperation were at risk of readmission [2.16 (95%-CI 1.21-3.87), p = 0.009, and 2.40 (95%-CI 1.15-5.02), p = 0.020, respectively], whereas reoperative parathyroidectomy was inversely associated with readmission (OR 0.24, 95%-CI 0.07-0.80, p = 0.021). In patients undergoing parathyroidectomy for renal secondary hyperparathyroidism, several readily available preoperative biochemical markers, including those of increased bone turnover and anemia, are associated with prolonged postoperative LOS. Unplanned reoperation was predictive of both increased LOS and readmission.

Risk factors associated with prolonged postoperative length of stay of patients with gastric cancer

Objective: To investigate the risk factors of prolonged postoperative length of stay (LOS) in patients with gastric cancer. Methods: A retrospective study was performed on 2033 patients who underwent curative surgery in Department of Pancreatic-gastric, Cancer Hospital, Chinese Academy of Medical Sciences. Eightieth percentile of postoperative hospital stay for all patients was taken as the cutoff, the patients were divided into the normal group (1 532 patients) and the extended group (501 patients). Logistic regression model was used to determine the risk factors related to prolonged postoperative LOS in gastric cancer. Results: A total of 417 cases with postoperative complications were recruited in extended group. The five highest complications accounting for prolonged LOS were: abdominal infection in 69 cases (13.77%), pleural effusion in 60 cases (11.98%), anastomotic leakage in 43 cases (8.58%), poor wound healing in 34 cases (6.79%), and bleeding in 25 cases (4.99%). Logistic regression analysis showed that age (OR=1.348, P=0.013), surgical procedure (OR=2.712, P<0.001), extent of resection (OR=2.035, P<0.001), degree of incision healing(OR=4.867, P<0.001), and perioperative blood transfusion (OR=1.711, P<0.001) were independent risk factors for prolonged postoperative LOS. Conclusions: The most common complication associated with prolonged postoperative LOS for gastric cancer patients is abdominal infection. Age, surgical procedure, extent of resection, degree of incision healing, and perioperative blood transfusion are the independent risk factors for prolonged postoperative LOS.

Computed Tomography-Determined Muscle Quality Rather Than Muscle Quantity Is a Better Determinant of Prolonged Hospital Length of Stay in Patients Undergoing Transcatheter Aortic Valve Implantation

Computed tomography (CT)-determined skeletal muscle measures have been used for predicting postoperative outcomes in patients undergoing transcatheter aortic valve implantation (TAVI). We investigated the impact of CT-determined muscle quantity (measured as psoas muscle area [PMA] and psoas muscle index [PMI]) and quality (measured as psoas muscle density [PMD]) on hospital length of stay (LOS) after TAVI. We retrospectively identified 182 consecutive patients who underwent TAVI between March 2013 and August 2017 with adequate preprocedural CT imaging. Baseline demographic and clinical data, the Society of Thoracic Surgeons score, the essential frailty toolset (EFT) frailty rating, and precontrast PMD, PMA, and PMI were obtained in all study patients. The primary outcome was prolonged postoperative LOS defined as greater than 14 days. Patients with prolonged LOS had a significantly higher Society of Thoracic Surgeons score (p < 0.001) and significantly lower PMD (p < 0.001) than those with LOS ≤14 days. More patients with prolonged LOS had concomitant peripheral vascular disease (p = 0.001), had undergone percutaneous coronary interventions (p = 0.022), and had an EFT score ≥4 (p < 0.001) compared to those without prolonged LOS. Neither PMA (p = 0.123) nor PMI (p = 0.271) were associated with prolonged LOS. Multivariate analysis identified EFT score ≥4, the presence of peripheral vascular disease, and PMD as independent predictors of prolonged LOS. The precontrast CT-determined muscle quality measurement PMD is a simple and objective predictor of prolonged LOS after TAVI.

Impact of preoperative cachexia on postoperative length of stay in elderly patients with gastrointestinal cancer.

The aim of the present study was to investigate the impact of preoperative cachexia on postoperative length of stay (LOS) in elderly patients with gastrointestinal cancer. This prospective cohort study enrolled 98 patients (≥60 y of age) with gastric or colorectal cancer who were scheduled to undergo curative surgery and were categorized as either having cachexia or as being in a non-cachexia group. The definition of cachexia was patients with >5% loss of stable body weight over the previous 6 mo, a body mass index (BMI) <20 kg/m2 and ongoing weight loss >2%, or sarcopenia and ongoing weight loss >2%. Multivariable Poisson regression analysis was performed with postoperative LOS as the dependent variable and the presence of cachexia as the independent variable, and age, sex, Eastern Cooperative Oncology Group performance status, education, cancer type, clinical stage, surgical approach, and the Charlson Comorbidity Index as confounding variables. Twenty-two patients (22.4%) were diagnosed with cachexia. Postoperative LOS was 17.1 ± 8.7 d in the non-cachexia group and 20.6 ± 10.8 d in the cachexia group. Multivariable Poisson analysis showed that preoperative cachexia was significantly associated with prolonged postoperative LOS after adjustment (2.41 d; 95% confidence interval, 0.28to4.55; P = 0.027). Our results suggested that preoperative cachexia prolongs postoperative LOS in elderly patients with gastrointestinal cancer, implying that cachexia should be assessed and treated before surgery.

Performance of The Society of Thoracic Surgeons 2008 Cardiac Risk Models for Major Postoperative Complications after Heart Valve Surgery in a Chinese Population: A Multicenter Study

To evaluate the performance of Society of Thoracic Surgeons (STS) 2008 cardiac surgery risk scores for postoperative complications in Chinese patients undergoing single valve surgery at multicenter institutions. From January 2009 through December 2012, 4493 consecutive patients older than 16 years who underwent single valve surgery at 4 cardiac surgical centers were collected and scored according to the STS 2008 risk scores. The final research population included the following isolated heart valve surgery types: aortic valve replacement, mitral valve replacement, and mitral valve repair. Calibration of the risk scores was assessed by the Hosmer–Lemeshow (H-L) test. Discrimination was tested by calculating the area under the receiver operating characteristic (ROC) curve. The observed incidence rate for cerebrovascular accident (CVA), renal failure (RF), prolonged ventilation (Vent), reoperation (Reop), prolonged postoperative length of stay (PLOS), and short postoperative LOS (SLOS) was 0.90%, 1.32%, 4.18%, 2.43%, 3.64%, and 1.65%, respectively. The predicted incidence rate for CVA, RF, Vent, Reop, PLOS, and SLOS was 0.76%, 1.55%, 4.94%, 6.69%, 3.92%, and 2.54%, respectively. The STS 2008 risk scores give an accurate calibration for individual postoperative risk in CVA, RF, Vent, and PLOS (Hosmer–Lemeshow: P = .052, P = .474, P = .468, and P = .712, respectively). The area under the ROC curve of the STS 2008 risk scores for the above 4 postoperative complications were 0.714, 0.724, 0.727%, and 0.713, respectively. The STS 2008 risk scores were suitable for major postoperative complications in patients undergoing single valve surgery, except for Reop and SLOS.

680 - Development of an Objective Prediction Model for Prolonged Postoperative Length of Stay in Crohn's Disease Patients Undergoing Major Abdominal Surgery

680 - Development of an Objective Prediction Model for Prolonged Postoperative Length of Stay in Crohn's Disease Patients Undergoing Major Abdominal Surgery

Factors influencing postoperative length of stay in an enhanced recovery after surgery program for primary total knee arthroplasty

BackgroundHospital length of stay (LOS) after primary total knee arthroplasty (TKA) has decreased obviously following the implementation of enhanced recovery after surgery (ERAS) program in the last few years. However, there are still some patients that cannot be discharged at early time for a variety of reasons, and it is necessary to explore factors leading to prolonged LOS. Therefore, the purpose of this study was to identify the complete preoperative, perioperative, and postoperative factors associated with prolonged postoperative LOS (PLOS) after primary TKA in a detailed ERAS program.MethodsIn a consecutive series from July 2015 to March 2017, all patients who underwent unilateral elective primary TKA were included in the retrospective study. A PLOS greater than 3 days was considered a prolonged PLOS. Multivariable logistic regression analysis was performed to identify patient characteristics and relevant preoperative, perioperative, and postoperative variables that were associated with prolonged PLOS and postoperative complications.ResultsA total of 241 patients were included with a mean PLOS of 3.8 days. Prolonged PLOS was significantly associated with preoperative valgus deformity of the knee (OR 4.95, 95%CI 1.56–15.77, P = 0.007), increased serum level of interleukin-6 on postoperative day 1 (OR 1.01, 95%CI 1.00–1.03, P = 0.039), increased visual analogue scale pain score and serum level of C-reactive protein on postoperative day 3 (OR 2.56, 95%CI 1.28–5.13, P = 0.008; OR 1.01, 95%CI 1.00–1.03, P = 0.019), increased day to achieve 90° active knee flexion after surgery (OR 2.19, 95%CI 1.27–3.79, P = 0.005), and postoperative wound complications (OR 8.58, 95%CI 2.10–35.03, P = 0.003) and other minor complications (OR 6.04, 95%CI 2.40–15.19, P < 0.001). Preoperative pulmonary infection (OR 2.75, 95%CI 1.20–6.28, P = 0.016), American Society of Anesthesiologists score 3/4 (OR 2.14, 95%CI 1.01–4.52, P = 0.046), and utilization of catheter after surgery (OR 2.53, 95%CI 1.23–5.19, P = 0.012) were significantly associated with postoperative complications.ConclusionsMultiple factors were associated with prolonged PLOS and postoperative complications after TKA in the ERAS program. It is important to recognize all the factors to try to maximize the use of medical resources and ultimately optimize the care of our patients.