Risk Of Postoperative Adverse Events Research Articles

Chemotherapy and adverse cardiovascular events in colorectal cancer patients undergoing surgical resection

BackgroundColorectal cancer patients undergoing surgical resection are at increased short-term risk of post-operative adverse events. However, specific predictors for long-term major adverse cardiac and cerebrovascular events (MACCE) are unclear. We hypothesised that patients who receive chemotherapy are at higher risk of MACCE than those who did not.MethodsIn this retrospective study, 412 patients who underwent surgical resection for newly diagnosed colorectal cancer from January 2013 to April 2015 were grouped according to chemotherapy status. MACCE was defined as a composite of cardiovascular death, myocardial infarction, stroke, unplanned revascularisation, hospitalisation for heart failure or angina. Predictors of MACCE were identified using competing risks regression, with non-cardiovascular death a competing risk.ResultsThere were 200 patients in the chemotherapy group and 212 patients in the non-chemotherapy group. The overall prevalence of prior cardiovascular disease was 20.9%. Over a median follow-up duration of 5.1 years from diagnosis, the incidence of MACCE was 13.3%. Diabetes mellitus and prior cardiovascular disease were associated with an increased risk of MACCE (subdistribution hazard ratio, 2.56; 95% CI, 1.48-4.42) and 2.38 (95% CI, 1.36-4.18) respectively. The chemotherapy group was associated with a lower risk of MACCE (subdistribution hazard ratio, 0.37; 95% CI, 0.19-0.75) compared to the non-chemotherapy group.ConclusionsAmongst colorectal cancer patients undergoing surgical resection, there was a high incidence of MACCE. Diabetes mellitus and prior cardiovascular disease were associated with an increased risk of MACCE. Chemotherapy was associated with a lower risk of MACCE, but further research is required to clarify this association.

Discharge Destination After Shoulder Arthroplasty: An Analysis of Discharge Outcomes, Placement Risk Factors, and Recent Trends.

Rates of shoulder arthroplasty continue to increase. Factors influencing disposition and the effect discharge destination may have on perioperative outcomes are currently unknown. This study (1) investigates patients undergoing total shoulder arthroplasty subsequently discharged to home, skilled nursing facilities, and or independent rehabilitation facilities; (2) identifies differences in perioperative outcomes; and (3) investigates the risk of adverse events and readmission after nonhome disposition. The American College of Surgeons National Surgical Quality Improvement Program database was queried for patients undergoing total shoulder arthroplasty from 2013 to 2018. Bivariate and multivariate analyses were conducted to determine the relationship between patient characteristics and risks of discharge to a non-home destination, discharge to an independent rehabilitation facility as opposed to a skilled nursing facility, severe postdischarge adverse events, and unplanned readmission. Factors associated with discharge to a non-home facility included those older than 85 years of age (odds ratio [OR], 14.38), dialysis requirement (OR, 4.16), transfer from a non-home facility (OR, 3.69), dependent functional status (OR, 3.17), female sex (OR, 2.78), history of congestive heart failure (2.05), American Society of Anesthesiologists class >2 (OR, 1.97), longer length of stay (OR, 1.47), and body mass index >35 (OR, 1.29) (P < 0.05). Patients discharged to a non-home facility had an approximately quadrupled rate of both major adverse events (8.6% vs 2.4%, P < 0.001) and minor adverse events (6.1% vs 1.4%, P < 0.001). Discharge to a non-home facility had a higher likelihood of a severe adverse event (OR, 1.82, P = 0.029) or unplanned readmission (OR, 1.60, P = 0.001). Non-home discharge destination demonstrated a notable negative impact on postoperative outcomes independent of medical complexity. Preoperative management of modifiable risk factors may decrease length of inpatient stay, rates of disposition to non-home facilities, and total cost of care. The benefit of more intense postoperative management at a non-home discharge destination must be carefully weighed against the independent risk of postoperative adverse events and readmissions.

Adverse outcomes after major surgery in children with intellectual disability.

To evaluate outcomes after major surgery in children and adolescents with intellectual disability. We used 2004 to 2013 claims data from Taiwan's National Health Insurance programme to conduct a nested cohort study, which included 220292 surgical patients aged 6 to 17years. A propensity score matching procedure was used to select 2173 children with intellectual disability and 21730 children without intellectual disability for comparison. Logistic regression was used to calculate the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of the postoperative complications and 30-day mortality associated with intellectual disability. Children with intellectual disability had a higher risk of postoperative pneumonia (OR 2.16, 95% CI 1.48-3.15; p<0.001), sepsis (OR 1.67, 95% CI 1.28-2.18; p<0.001), and 30-day mortality (OR 2.04, 95% CI 1.05-3.93; p=0.013) compared with children without intellectual disability. Children with intellectual disability also had longer lengths of hospital stay (p<0.001) and higher medical expenditure (p<0.001) when compared with children with no intellectual disability. Children with intellectual disability experienced more complications and higher 30-day mortality after surgery when compared with children without intellectual disability. There is an urgent need to revise the protocols for the perioperative care of this specific population. Surgical patients with intellectual disability are at increased risk of postoperative pneumonia, sepsis, and 30-day mortality. Intellectual disability is associated with higher medical expenditure and increased length of stay in hospital after surgical procedures. The influence of intellectual disability on postoperative outcomes is consistent in both sexes and those aged 10 to 17 years. Low income and a history of fractures significantly impacts postoperative adverse events for patients with intellectual disability.

Outcomes Associated With Fibrin Sealant Use in Lateral Neck Dissections.

ObjectiveTo determine whether the use of fibrin sealant tissue adhesives during lateral neck dissections is associated with a change in postoperative outcomes.Study DesignRetrospective cohort.SettingInstitutionally affiliated tertiary care center.MethodsVarious demographic, disease, and surgical data were collected for patients who underwent lateral neck dissections. Univariate regression analysis was performed with the following outcomes: total drain output and duration of drain placement, as well as incidence of postoperative infection, hematoma, seroma, chyle leak, and salivary leak.ResultsA total of 133 patients underwent lateral neck dissections. Fibrin sealant was used in 35% of cases (n = 46). Its use was not associated with differences in total drain output (P = .77) or the number of days that the drains were in place (P = .83). On secondary analysis, the use of fibrin sealant was not associated with a difference in postoperative incidence of hematoma (P = .65), seroma (P = .68), chyle leak (P = .42), or salivary leak (P = .73). These results were consistent when stratified by the presence of intraoperative complications. Its use accompanied an average cost of $674 per case.ConclusionsFibrin sealant use during lateral neck dissections was not associated with a reduction in drain output or days that the drains remained in situ. Although the current study was limited by sample size, fibrin sealant use was not associated with a decreased risk of postoperative adverse events. The evidence in this report suggests that the routine use of these products adds cost without clear benefit.

Underwater reopenable clip closure of mucosal defects after duodenal endoscopic submucosal dissection.

Closing mucosal defects after duodenal endoscopic submucosal dissection (ESD) decreases the risk of postoperative adverse events.1 Although various methods for closure have been proposed,2,3 a single reliable and safe method has not yet been established. Herein, we propose the underwater reopenable clip closure (U-REC), a novel technique for closing mucosal defects after duodenal ESD.

Comparison of Outcomes between Obese and Non-Obese Patients in a Colorectal Enhanced Recovery After Surgery (ERAS) Program: A Single-Center Cohort Study

Introduction: Obese patients are considered at increased risk of postoperative adverse events after colorectal surgery. Objective: The objective of the present study was to compare postoperative outcomes between obese and non-obese patients undergoing elective colorectal surgery in an Enhanced Recovery After Surgery (ERAS) program. Methods: A retrospective analysis of a prospective cohort including patients who underwent elective colorectal surgery and were included in an ERAS protocol between February 2014 and December 2017 at Geneva University Hospital, Geneva, Switzerland, was performed. Postoperative outcomes of obese and non-obese patients were compared. Results: Data of 460 patients were analyzed, including 374 (81%) non-obese and 86 (19%) obese patients. Overall, there was no difference in postoperative outcomes between the 2 groups. Among patients undergoing oncologic surgery, obese subjects had a significantly higher rate of conversion to laparotomy (11.9 vs. 2.1%, p = 0.01) and longer time until return of bowel function (2.38 vs. 1.98 days, p = 0.03), without increased morbidity or longer length of stay. Conclusion: Obese and non-obese patients had similar postoperative outcomes after elective colorectal surgery with ERAS management. ERAS can potentially reduce the increased morbidity usually observed in obese patients following elective colorectal surgery.

Abstract P1-13-04: Prevention of shoulder problems trial (UK-PROSPER): Exercise to prevent shoulder problems in patients undergoing breast cancer treatment

Abstract Aim: To investigate the clinical and cost-effectiveness of early structured exercise on functional and health-related outcomes in women at high risk of developing shoulder problems after breast cancer treatment. Methods: The UK-PROSPER was a pragmatic, multicentre, randomised controlled trial comparing a structured exercise programme with best practice usual care (information leaflet). Women at high-risk (planned axillary node clearance, planned radiotherapy to the axilla and/or supraclavicular area, existing shoulder problems and BMI &amp;gt;30) of postoperative shoulder problems with a confirmed invasive or non-invasive primary breast cancer scheduled for surgery were included. We aimed to randomise 350 women from 17 centres across England, with postoperative follow-up at 6 weeks, 6 and 12 months post-randomisation. The PROSPER exercise intervention was developed from evidence, clinical experts and patients; the final intervention consisted of exercise, behavioural strategies and physical activity. Women were offered a minimum of three face-to-face appointments with a physiotherapist, starting 7 to 10 days postoperatively with three optional appointments. The control group received written leaflets containing information on exercises after surgery. The primary outcome was the Disabilities of the Arm Shoulder and Hand (DASH) score at 12 months. Secondary outcomes included DASH subscales, postoperative pain, complications and health-related quality of life. Results: 392 women were recruited, 196 randomised to each treatment arm. Mean age was 58.1 years, mean BMI was 30.2. Groups were similar for socioeconomic characteristics at baseline. Of 191 women allocated to exercise intervention, 142/191 (74%) received three or more PT sessions, 38/191 (20%) received up to three sessions and 11/191 (6%) no treatment. Those randomised to exercise had better arm, shoulder and hand function compared to usual care at 12 months (mean DASH score 16.4 versus 23.9 respectively; adjusted mean difference (MD) -7.42; 95% CI -12.34 to -2.50; p=0.003). DASH subscales for activity limitations, participation restriction and impairment improved over time in women receiving exercise compared to usual care. A lower rate of neuropathic pain at 12 months was reported by treatment arm (23% control vs 16% exercise). Conclusions: Early structured postoperative exercise was beneficial on functional and other health-related outcomes at 12 months in women undergoing surgery for breast cancer treatment. Early postoperative exercise was safe and did not increase risk of postoperative adverse events. Citation Format: Julie Bruce, Bruno Mazuquin, Pankaj Mistry, Esther Williamson, Ranjit Lall, Raghavan Vidya, Emma Withers, Sophie Rees, Alastair Canaway, Stavros Petrou, Sarah E Lamb, Alastair M Thompson. Prevention of shoulder problems trial (UK-PROSPER): Exercise to prevent shoulder problems in patients undergoing breast cancer treatment [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P1-13-04.

An audit and evaluation of appropriateness of perioperative allogenic red blood cell transfusion in liver surgery

Presenter: Laura Baker MD | University of Ottawa Background: Red blood cell (RBC) transfusion in liver surgery is common and associated with post-operative morbidity. Knowledge of appropriateness of administered transfusions in this patient population is lacking. The objective of this study is to (1) evaluate the appropriateness of perioperative transfusions, (2) identify prescriber-associated characteristics associated with inappropriate transfusions, and (3) determine if patients deemed inappropriately transfused are at increased risk of post-operative adverse events in comparison to patients not transfused. Methods: A retrospective review of patients undergoing hepatectomy at a tertiary care liver surgery unit from March 2011 to April 2018 was preformed. Patient demographics, operative details, clinical variables surrounding transfusion events, and information pertaining to patients post-operative course were collected. Appropriateness of RBC transfusions was determined via application of three distinct tools, independently, in duplicate. Results: A cohort of 489 patients underwent liver resection during the study period, of which 19% (n=91) received a total of 241 RBC transfusions in the perioperative period. Forty-one percent of patients underwent a major liver resection. Ninety percent of cases were preformed open. The primary indication for hepatectomy was colorectal liver metastases (52%); 22% of patients underwent resection for primary liver malignancy. Median preoperative hemoglobin was 132g/L; 19% of patients were anemic at the time of surgery. Between 22% to 63% of transfusions administered during the intraoperative period were considered inappropriate based on the three different appropriateness tools. Thirty-eight to 67% of transfusions administered during the post-operative period were considered inappropriate. Patients were at increased risk of being inappropriately transfused in the immediate postoperative period while in the post-operative recovery unit while their care was being overseen by anesthesiologist, compared to later in the postoperative period (OR18.6; 95% CI 2.3-151.5). Prescriber experience (junior versus senior resident versus attending physician), time of transfusion (evenings and weekends versus business hours) and method through which transfusion order was delivered (written versus verbal order) did not influence appropriateness of the transfusion. Patients considered to have been inappropriately transfused during the intraoperative period were at increased risk of developing a major post-operative adverse event (Clavien-Dindo≥grade 3) compared to those who did not receive a transfusion (OR 4.2; 95% CI 1.1-15.6). Conclusion: Despite trends towards reductions in perioperative transfusions in patients undergoing hepatectomy, this work highlights that a significant proportion of patients are being exposed to unnecessary transfusion. There is substantial variability in the estimates provided by the three appropriateness tools, with the incidence of inappropriate RBC transfusion ranging between 22-67%. This study identified the immediate post-operative period as a particularly vulnerable period for patients being transfused unnecessarily. Furthermore, the association identified between development of major post-operative adverse events in patients identified as inappropriately transfused compared to those not transfused further supports the described deleterious effects of blood transfusions in surgical patients. Further work in this area is warranted to minimize the administration of unnecessary, and potentially harmful RBC transfusions.

Neonatal intensive care unit patients recovering in the post anesthesia care unit: An observational analysis of postextubation complications.

Neonatal patients are at higher risk in the perioperative period than older infants and children. Extubation as an early goal for noenatal intensive careunitpatients presenting for surgery is undergoing a renaissance period, and an exploration of adverse events following selection for extubation immediately after general anesthesia has not specifically been undertaken in this population. The objective of this study is to determine the adverse events most commonly encountered in neonatal intensive care unitpatients recovering from anesthesia in the post anesthesia care unit, quantify the risk of event occurrence, and identify risk factors that may increase the risk of postoperative adverse events. All neonatal intensive care unitpatients presenting to the operating room6/1/2014-5/31/2018 who recovered in thepost anesthesia care unit were included for analysis. Univariate analyses were conducted utilizing the Wilcoxon rank-sum test or Fisher exact test. Due to the low event rate, a small-sample generalized estimating equation model was created with a major event composite as the outcome and explanatory variables with P values<.1 on univariate analysis. Statistically significant continuous variables were then dichotomized based on Youden index. There were 707 operative cases in 607 patients. There were 81 total events recorded, and 64/81 were considered to be major events; all of which were respiratory. The risk of any postoperative event was 11.5%, major respiratory event requiring intervention by a nurse or provider was 9.1%, and reintubation was 0.8%. Birth weight<1.58kg (OR 3.71; 95% CI 2.11-6.53; P<.001) and postmenstrual age at surgery <41weeks (OR 3.20; 95% CI 1.54-6.63; P<.001) were strongly associated with an increased risk of a major postoperative respiratory event. The most important factors associated with major events in the post anesthesia care unitfollowing extubation of neonatal intensive care unitpatients were birth weight<1.58kg and postmenstrual age at surgery<41weeks. A patient with both features has a 7-fold increase in the odds of a major respiratory event in the post anesthesia care unit. Careful consideration of the postoperative ventilation and monitoring strategy must be given to patients with low birth weight (<1.58kg) or who are <41weeks postmenstrual age at the time of surgery.

The influence of age on the peri- and postoperative clinical course in patients undergoing minimally invasive transforaminal lumbar interbody fusion techniques of the lumbar spine

ObjectiveAs a result of continuously increasing life expectancy, the number of requests for surgery to treat degenerative diseases of the spine in the elderly population will increase. Since older age is associated with the occurrence of medical comorbidities, the demand for less extensive surgical approaches is growing. The aim of this study is to establish whether minimally invasive fusion techniques are a safe and adequate tool for use in elderly patients. Patients and methodsWe analyzed 187 patients who underwent minimally invasive surgery (MIS) in the form of one- to four-level fusion procedures. In 146 patients, additional widening of the spinal canal was performed. The subjects were grouped into four age categories of approximately equal size (33–56, 56–66, 66–74 and 74–85). The effect of age on the incidence of peri- and postoperative complications was investigated and compared between the age groups. ResultsOlder age was not associated with the occurrence of perioperative complications, which include wound healing disorders, hematomas, wound traction-blisters and cerebrospinal fluid leakage. Fourteen patients (7.49%) encountered distinct surgical technique related complications, making surgical revision necessary in eight patients (4.28%). Furthermore, increasing age didn’t elevate the risk of postoperative adverse events, i.e. pulmonary embolism, ischemic heart attack or pneumonia, among others. However, older patients were found to stay in hospital longer than younger patients, especially when more than one level was fused. ConclusionsMinimally invasive surgery techniques are safe in elderly patients. The small-scale surgical approach guarantees a low incidence of infections and wound healing disorders. However, a longer hospital stay must be expected in older patients.

Association of Plasma Branched Amino Acid with Surgical Adverse Events in Type A Aortic Dissection

Background: Type A aortic dissection (AAD) is associated with substantial perioperative mortality and morbidity. Methods: We conducted a study of the concentrations of plasma amino acid metabolites by ultraperformance liquid chromatography mass spectrometry to identify patients at high risk of major adverse events (MAEs) in-hospital in 391 patients undergoing surgical repair, including 111 participants in a retrospective discovery set and 280 patients in a prospective validation set. Results: In the discovery set, 31 patients (27.9%) experienced MAEs in hospital, of whom 4 (12.9%) died. Metabolite factor 3, composed of branched-chain amino acids (BCAA), including valine, isoleucine, and leucine, was associated with MAEs. Median BCAA levels in patients with and without MAEs were 267.18 pg/mL (222.06-312.93 pg/mL) and 236.72 pg/mL (200.19-274.62 pg/mL), respectively. The adjusted odds ratio (OR) for increasing tertiles of BCAA compared with the lowest tertiles was 3.259 (95% confidence interval (CI) 1.018-10.431; P = 0.047). In the validation set, the adjusted OR for the increasing tertiles of BCAA compared with the lowest tertiles was 5.82 (95% CI 2.74-12.38; P < 0.001), indicating a significant association between the preoperative BCAA levels and outcome. Conclusions: Our study shows that in patients with AAD, the pre-operative plasma BCAA level was associated with the risk of post-operative adverse events of AAD in hospital. Funding Statement: This study was supported by the Ministry of Science and Technology of China (Key Projects of Precision Medicine Program, grant no. 2016YFC0903000 and 2017YFC0908400) and the Beijing Municipal Science and Technology Commission (Z171100000417002), NSFC (Natural Science Foundation of China) (81870341) Declaration of Interests: On behalf of all authors, the corresponding author states that there is no conflict of interest. Ethics Approval Statement: The study was designed as an observational study, including consecutive patients undergoing surgical repair for nontraumatic AAD (from July 2016 to November 2018) in the DPANDA registry study for aortic aneurysm and/or dissection (NCT03233087 in ClinicalTrials.gov), which was approved by the Beijing Anzhen Hospital Ethics Review Board. All patients provided written informed consent.

Management of Degenerative Spondylolisthesis: Analysis of a Questionnaire Study, Correlation With a National Sample, and Perioperative Outcomes of Treatment Options.

Surgical treatment for lumbar degenerative spondylolisthesis has been shown to provide better long-term outcomes than conservative treatment. However, there is variation in surgical approaches employed by surgeons. This study investigates current surgical practice patterns and compares perioperative outcomes of 3 common surgical treatments for this pathology. A survey was administered to surgeons who attended the Lumbar Spine Research Society (LSRS) meeting in 2014. Data were extracted from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) from 2005 to 2014 to characterize the same responses. The 2 data sets were compared. Perioperative outcomes of those in the ACS-NSQIP posterior fusion subcohorts were characterized and compared. Posterior surgical approaches utilized by surgeons who responded to the LSRS survey were similar to those captured by ACS-NSQIP where 72% of those with degenerative spondylolisthesis were fused. Of those that were fused, 8% had an uninstrumented posterior fusion, 33% had an instrumented posterior fusion, and 59% had an instrumented posterior fusion with interbody. On multivariate analysis, there was no difference in risk of postoperative adverse events, readmission, or length of stay between these 3 common types of fusion. Practice patterns for the posterior management of lumbar degenerative spondylolisthesis were similar between LSRS survey responses and ACS-NSQIP data. The ACS-NSQIP perioperative outcome measures assessed were similar regardless of surgical technique. These findings highlight that cost-benefit considerations and longer-term outcomes have to be the measures by which surgical technique is chosen for degenerative spondylolisthesis.

Impact of postoperative acute kidney failure in long-term survival after heart valve surgery.

We investigated the impact of acute kidney failure after a heart valve procedure among patients with or without chronic kidney disease (CKD). All patients who had undergone a surgical valve procedure between 2005 and 2017 at our institution were divided into 2 groups depending on whether they had previous history of CKD (estimated glomerular filtration rate <60 ml/min/1.73 m2) or not. Homogeneous groups were obtained by propensity score matching. Long-term mortality was compared between the 2 groups and according to the occurrence of postoperative acute kidney failure. Level of significance was set at P-value <0.008 for multiple comparison tests. From the 3907 patients included to this study, 1476 (37.78%) had previous history of CKD. After adjusting for propensity score 1:1, patients with preoperative impaired renal function were at a higher risk of acute kidney failure (26.83% vs 10.16%, P < 0.001) and postoperative mortality (8.48% vs 5.17%, P = 0.001). In the follow-up, they had a poorer survival at 1, 5 and 10 years as compared to patients with normal renal function (88% vs 91.95%, 78.29% vs 81.11% and 56.13% vs 66.29%, respectively; P < 0.001). Patients without postoperative kidney failure had similar survival whether they had preoperative CKD or not [hazard ratio (HR) 1.16, 99.2% confidence interval (CI) 0.87-2.52; P = 0.142]. As compared to patients with postoperative preserved renal function, those with postoperative kidney failure had a higher long-term mortality either if they had previous kidney disease or not [(HR 2.18, 99.2% CI 1.75-2.72; P < 0.001) and (HR 1.48, 99.2% CI 1.33-1.65; P < 0.001), respectively]. Preoperative CKD was the strongest predictor of acute kidney failure (odds ratio 4.45; 95% CI 3.59-5.53; P < 0.001). Patients with CKD are at higher risk of postoperative adverse events and have poorer long-term outcomes. Postoperative acute kidney failure increases long-term mortality.

Prediction of Complications, Readmission, and Revision Surgery Based on Duration of Preoperative Opioid Use: Analysis of Major Joint Replacement and Lumbar Fusion.

Preoperative opioid use results in adverse outcomes and higher costs after elective surgery. However, duration thresholds for higher risk are not entirely known. Therefore, the purpose of our study was to determine the number and duration of preoperative opioid prescriptions in order to estimate the risk of postoperative adverse events after major joint replacement and lumbar fusion. National insurance claims data (2007 to September 30, 2015) were used to identify primary total knee arthroplasties (TKAs), total hip arthroplasties (THAs), and 1 or 2-level posterior lumbar fusions (PLFs) performed for degenerative disease. The effect of preoperative opioid burden (naive, ≤3 months, >3 to 6 months, >6 months but stopped 3 months before surgery, and >6 months of continuous use) on the risks of various adverse outcomes was studied using Cox proportional hazards analysis with adjustment for demographic and clinical covariates. A total of 58,082 patients stratified into 3 cohorts of 32,667 with TKA, 14,734 with THA, and 10,681 with 1 or 2-level PLF were included for this analysis. A duration of preoperative opioids of >3 months was associated with a higher risk of 90-day emergency department (ED) visits for all causes and readmission after TKA. Preoperative opioid prescription for >6 months was associated with a higher risk of all-cause and pain-related ED visits, wound dehiscence/infection, and hospital readmission within 90 days as well as revision surgery within 1 year after TKA, THA, and PLF. Stopping the opioid prescription 3 months preoperatively for chronic users resulted in a significant reduction in the risk of adverse outcomes, with the greatest impact seen after THA and PLF. Patients with a preoperative opioid prescription for up to 3 months before a major arthroplasty or a 1 or 2-level lumbar fusion had a similar risk of adverse outcomes as opioid-naive patients. While >6 months of opioid use was associated with a higher risk of adverse outcomes, a 3-month prescription-free period before the surgery appeared to mitigate this risk for chronic users. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Postoperative Complications and Impact of Diabetes Mellitus Severity on Revision Total Knee Arthroplasty.

Total knee arthroplasty (TKA) is a common and effective treatment of knee osteoarthritis. As the amount of TKAs performed increases, so does the number of TKA failures and subsequent revisions. Diabetes mellitus (DM) has been shown to increase complications following orthopaedic procedures. For these reasons, it is important to understand the association between severity of DM and the risk of postoperative adverse events following revision TKA. A retrospective cohort study was conducted using the American College of Surgeons' National Surgical Quality Improvement Program database. Patients who underwent revision TKAs between 2007 and 2016 were identified and recorded as having noninsulin-dependent DM (NIDDM), insulin-dependent DM (IDDM), or no DM. Univariate and multivariate analysis were used to evaluate the incidence of multiple adverse events within 30 days after revision TKA. A total of 13,246 patients who underwent revision TKA were selected (without DM = 10,381 [78.4%]; NIDDM = 1,890 [14.3%]; IDDM = 975 [7.4%]). Patients with NIDDM were found to have an increased risk of developing renal insufficiency and urinary tract infection (UTI) compared with patients without DM, while patients with IDDM were found to have an increased risk of developing 10 of 20 adverse events compared with patients without DM. NIDDM is an independent risk factor for UTI and IDDM is an independent factor for development of three complications compared with no DM. Insulin dependency is an independent factor for septic shock, postoperative blood transfusion, and extended postoperative hospital stay. Relative to patients with NIDDM, those with IDDM have a greater likelihood of developing more adverse perioperative outcomes than patients without DM. Although complication rates remain relatively low, orthopaedic surgeons must consider the implications of diabetes and insulin dependence on patient selection, preoperative risk stratification, and postoperative outcomes.

Impact of Cardiac Risk Factors in the Postsurgical Outcomes of Patients With Cleft Palate: Analysis of the 2012-2014 NSQIP Database.

To assess the risk of complication in patients undergoing cleft palate repair with congenital cardiac comorbidities in a large, national cohort. Retrospective review. Using the 2012-2014 National Surgical Quality Improvement Program (NSQIP) Pediatric database, patients undergoing cleft palate repair were selected for analysis. Patients with cleft palate repairs were stratified based on the presence or absence congenital cardiac comorbidities. Univariate and stepwise forward logistic regression were conducted. It is hypothesized that risk of postoperative adverse events in patients with congenital cardiac comorbidities is higher than in patients without cardiac disease. Nationally, between 2012 and 2014, 3240 patients underwent cleft palate repair, 422 (13.0%) with cardiac disease, and 2818 (87.0%) without cardiac disease. Patients with cardiac disease were smaller (10.5 [6.6] kg vs 11.6 [8.6] kg, P < .01) and more likely to be premature (4.6% vs 13.0%, P < .01) compared to those without cardiac disease. Postoperatively, patients with cardiac conditions were more likely to experience an adverse event (8.8% vs 4.2%, P < .01). Specifically, they were more likely to experience reintubation (1.7% vs 0.4%, P < .01), reoperation (2.1% vs 0.6%, P < .01), and longer length of stay (2.7 [7.0] vs 1.6 [2.8] days, P < .01). Rates of surgical site infection and dehiscence were not different. Cleft palate repair in patients with concurrent congenital cardiac defects is a safe procedure but carries elevated risk in the postoperative period as demonstrated in this analysis of the NSQIP-Pediatric database. Technical risks are equivalent. Additional anesthesia and surgical awareness of these potential complications is essential to minimize perianesthesia risks.

Validated Risk Stratification System for Prediction of Adverse Events Following Open Reduction and Internal Fixation of the Ankle

Category: Ankle Introduction/Purpose: As orthopaedic surgery moves towards bundled payments, there is growing interest in identifying patients at high risk for postoperative adverse events. The purpose of this study is to develop and validate a risk stratification system for the occurrence of adverse events following open reduction and internal fixation (ORIF) of the ankle. Methods: Patients undergoing ORIF of closed ankle fractures as part of the National Surgical Quality Improvement Program (NSQIP) were identified. For patients undergoing surgery during 2006-2014, multivariate Cox proportional hazards modeling was used to identify factors that were independently associated with the occurrence of adverse events (including events such as surgical site infection, myocardial infarction, and pulmonary embolism). Based on these results, a nomogram was used to generate a point-scoring system for risk stratification. To evaluate the validity of the point-scoring system, the system was applied to patients undergoing ankle ORIF during 2015-2016. Results: Of the 6,140 patients undergoing surgery during 2006-2014, 5.8% developed an adverse event. Based on the Cox proportional hazards regression, patients were assigned points for each of the following statistically significant risk factors: anemia (+2 points), insulin-dependent diabetes (+2 points), age=65 (+1 point), dependent functional status (+1 point), chronic obstructive pulmonary disease (COPD; +1 point), and hypertension (+1 point; Figure 1A). 4,702 patients were identified in the 2015-2016 validation cohort. Among these patients, the risk-stratification system was found to strongly predict the risk for adverse events (p&lt;0.001, Figure 1B). Conclusion: The occurrence of adverse events following ankle ORIF is associated with anemia, insulin-dependent diabetes, age=65, dependent functional status, COPD, and hypertension. We present and validate a simple point-scoring risk stratification system to predict the risk of adverse events. Future systems of bundled payments for ankle ORIF should exclude high-risk patients from the bundling systems, or make appropriate adjustments in reimbursement based on risk.

Treatment Outcomes and Adverse Events Following In-Office Angiolytic Laser With or Without Concurrent Polypectomy for Vocal Fold Polyps

In-office angiolytic laser procedures have been used successfully as an alternative treatment for vocal fold polyps; little is known in detail about the treatment outcomes and adverse events. To examine the outcomes and incidence rates of adverse events associated with in-office angiolytic laser procedures with or without concurrent polypectomy as an alternative treatment for vocal fold polyps. Retrospective cohort study at a tertiary medical center. We identified 114 consecutive patients with vocal polyps who underwent in-office angiolytic laser treatments between January 1, 2014, and August 31, 2016. After the exclusion of 17 with missing or incomplete data, 97 were enrolled. In-office 532-nm laser procedures with or without concurrent polypectomy. Between 1 and 2 months after the surgical procedures, we collected the following outcome data: videolaryngostroboscopy, perceptual rating of voice quality, acoustic analysis, maximal phonation time, and subjective rating of voice quality using a visual analogue scale and 10-item voice handicap index. This study enrolled 97 patients (mean [SD] age, 45.6 [11.3] years; 48 [49%] male). The mean duration of symptoms was 10.1 months (range, 1-60 months). Twenty-nine patients (30%) had angiolytic laser procedures only, while 68 (70%) received laser with concurrent polypectomy. Both treatment modalities offered significant improvements. Only 1 patient (1%) receiving angiolytic laser with concurrent polypectomy underwent another treatment session, so this group had significantly less need for multiple treatments than those receiving laser treatment alone (6 [21%]; effect size, -1.57; 95% CI, -2.77 to -0.36). We identified 8 adverse events (8% of the cases): vocal fold edema (n = 5), vocal hematoma (n = 2), and vocal ulceration (n = 1). Patients treated with laser plus concurrent polypectomy had significantly fewer adverse events than those treated with angiolytic laser alone (2 [3%] vs 6 [21%]; effect size, 1.20; 95% CI, 0.26 to 2.13). In-office angiolytic laser procedures can be an effective alternative treatment for vocal polyps, although with possible need for multiple treatment sessions and occasional occurrence of minor postoperative adverse events. Concurrent polypectomy following laser coagulation allows less laser energy delivery and reduces the risk of postoperative adverse events and the need for additional treatment sessions.

Association of STOP-Bang Questionnaire as a Screening Tool for Sleep Apnea and Postoperative Complications: A Systematic Review and Bayesian Meta-analysis of Prospective and Retrospective Cohort Studies.

The risk of postoperative complications increases with undiagnosed obstructive sleep apnea (OSA). The high-risk OSA (HR-OSA) patients can be easily identified using the STOP-Bang screening tool. The aim of this systematic review and meta-analysis is to determine the association of postoperative complications in patients screened as HR-OSA versus low-risk OSA (LR-OSA). The following data bases were searched from January 1, 2008, to October 31, 2016, to identify the eligible articles: Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Cochrane Databases of Systematic Reviews, Medline-in-Process & other nonindexed citations, Google Scholar, Embase, Web of Sciences and Scopus. The search included studies with adult surgical patients screened for OSA with STOP-Bang questionnaire that reported at least 1 cardiopulmonary or any other complication requiring intensive care unit admission as diagnosis of outcome. We used a Bayesian random-effects analysis to evaluate the existing evidence of STOP-Bang in relation to OSA and to assess the association of postoperative complications with the identified HR-OSA patients by study design and methodologies. This systematic review and meta-analysis was conducted using 10 cohort studies: 23,609 patients (HR-OSA, 7877; LR-OSA, 15,732). The pooled odds of perioperative complications were higher in the HR-OSA versus LR-OSA patients (odds ratio 3.93, 95% credible interval, 1.85-7.77, P= .003; 6.86% vs 4.62%). The length of hospital stay was longer in HR-OSA by 2 days when compared with LR-OSA (5.0 ± 4.2 vs 3.4 ± 2.8 days; mean difference 2.01; 95% credible interval, 0.77-3.24; P= .005). Meta-regression to adjust for baseline confounding factors and subgroup analysis did not materially change the results. This systematic review and meta-analysis suggests that HR-OSA is related with higher risk of postoperative adverse events and longer length of hospital stay when compared with LR-OSA patients. Our findings support the implementation of the STOP-Bang screening tool for perioperative risk stratification.

Hospitalization in the Year Preceding Major Oncologic Surgery Increases Risk for Adverse Postoperative Events.

Hospitalization is associated with negative clinical effects that last beyond discharge. This study aimed to determine whether hospitalization in the year before major oncologic surgery is associated with adverse outcomes. Patients 18years of age or older with stomach, pancreas, colon, or rectal cancer who underwent resection in California and New York (2008-2010) were included in the study. Patients with hospitalization in the year prior to oncologic resection (HYPOR) were identified. Multivariable logistic regression was used to examine the association of prior hospitalization with the following adverse outcomes: inpatient mortality, complications, complex discharge needs, and 90-day readmission. Subset analysis by cancer type was performed. Outcomes based on temporal proximity of hospitalization to month of surgical admission were evaluated. Of 32,292 patients, 16.3% (n=5276) were HYPOR. Patients with prior hospitalization were older (median age, 72 vs 67years; p<0.001) and had more comorbidities (Elixhauser Index ≥3, 86.5 vs 75.3%; p<0.001). In the multivariable analysis, HYPOR was associated with complications (odds ratio [OR], 1.28; 95% confidence interval [CI] 1.18-1.40), complex discharge (OR, 1.44; 95% CI 1.34-1.55), and 90-day readmission (OR, 1.45; 95% CI 1.35-1.56). The interval from HYPOR to resection was not associated with adverse outcomes. Patients hospitalized in the year before oncologic resection are at increased risk for postoperative adverse events. Recent hospitalization is a risk factor that is easily ascertainable and should be used by clinicians to identify patients who may need additional support around the time of oncologic resection.