Surgeons-National Quality Improvement Project Research Articles

Comparing Total Laparoscopic Hysterectomy (TLH) Versus Total Vaginal Hysterectomy (TVH) in Large Uteri

Study Objective To compare surgical outcomes between total laparoscopic (TLH) and total vaginal (TVH) hysterectomy with uterine weight (UW) ≥250 grams Design Retrospective cohort study using 1:2 propensity score (PS) matching. PS was calculated using preoperative characteristics and UW. Pairwise analysis was performed using Wilcoxon rank-sum and Fisher's exact tests as appropriate. Multivariable logistic regression was performed to identify the independent impact of TVH on surgical outcomes. Setting American College of Surgeons National Quality Improvement Project Hysterectomy Specific Database. Patients or Participants Women undergoing benign hysterectomy for UW ≥250g. Interventions TLH or TVH. Measurements and Main Results There were 1,870 TVH that met all criteria for inclusion and matched to 3,740 TLH. There were no differences in preoperative demographics and comorbidities. UW was similar for both groups 376 g (IQR: 293-501) for TVH and 384 g (IQR 302-515) for TLH, p=0.07. TVH was completed in less time than TLH, 77 (IQR: 56-111) versus 122 (IQR: 91-164) minutes, p Conclusion In patients with similar preoperative characteristics and uterine weight TVH is not associated with an increased risk of major surgical morbidity or other adverse surgical outcomes.

Delayed gastric emptying in diabetic patients undergoing pancreaticoduodenectomy: A procedure-targeted nsqip analysis

Presenter: Alissa Greenbaum MD | Rutgers University Background: Delayed gastric emptying (DGE) is a major source of morbidity after pancreaticoduodenctomy (PD), occurring in up to 20% of patients. Patients with type I or II diabetes mellitus (DM) have a propensity for gastric dysmotility, however the exact relationship between DGE and DM is not clearly established. The aim of this study was to determine the incidence of DGE in patients with and without DM after PD. Methods: The American College of Surgeons National Quality Improvement Project (ACS-NSQIP) procedure-targeted pancreatectomy database was queried from 2014 to 2017 for patients undergoing PD and combined with the main ACS-NSQIP database. Patient demographic, clinical and perioperative variables were compared by DM status. The primary outcome was rate of DGE. A subset analysis of insulin-dependent DM (IDDM) and non-insulin-dependent DM (non-IDDM) patients was also performed. Statistical analyses were performed using chi-square, Mann Whitney-U tests, and logistic regression. Results: A total of 14,735 patients met inclusion criteria, including 10,930 non-DM patients (74.2%) and 3805 DM patients (25.8%). Median cohort age was 66 years and 53.7% were male (n=7918). DGE occurred in 17.1% of patients overall (n=2519); 17.2% in non-DM and 16.8% in DM patients (p=0.60). DM patients had a higher ASA class, increased rates of hypertension, increased proportion of pancreatic adenocarcinoma, larger duct size, harder gland texture, and required more frequent vascular resection (p<0.001). DM patients had equivalent rates compared to non-DM patients of post-operative superficial surgical site infection (7.8% in both; p=0.89), deep surgical site infection (1.4 vs 1.5%; p=0.56), urinary tract infection (3.2 vs 2.8%; p=0.23) and pneumonia (4.3 vs 3.6%; p=0.19), and lower rates of organ space infection (11.5 vs 14.0%; p<0.001) and pancreatic fistula (14.9 vs 19.0%; p<0.001). On subset analysis, IDDM had better outcomes compared to non-IDDM patients in organ space infections (8.8 vs 14.2%; p<0.001) and pancreatic fistula (11.7 vs 18.3%; p<0.001). Rates of DGE were 18.0% (n=337) in non-IDDM and 15.7% in IDDM patients (p=0.162). There were no significant differences in rates of reoperation, hospital length of stay, readmission rates or 30-day mortality. On multivariable logistic regression, male sex, advanced age, history of smoking, pancreatic fistula, and organ space infection were associated with DGE. DM status was not predictive of DGE. Conclusion: No differences in rates of DGE between DM and non-DM patients after PD were found, strengthening the hypothesis that DGE is a separate physiologic entity from diabetic gastroparesis. IDDM patients demonstrated better postsurgical outcomes compared to non-IDDM patients in terms of intra-abdominal infection and pancreatic fistula, suggesting a potential role of monitored insulin or hyperglycemia regulation in the development of these complications.

Risk of Venous Thromboembolism and Operative Duration in Patients Undergoing Neurosurgical Procedures.

The association of operative duration with the risk of venous thromboembolism (VTE) has not been quantified in neurosurgery. To investigate the association of surgical duration for several neurosurgical procedures and the incidence of VTE. We performed a retrospective cohort study involving patients who underwent neurosurgical procedures from 2005 to 2012 and were registered in the American College of Surgeons National Quality Improvement Project registry. In order to control for confounding, we used multivariable regression models, and propensity score conditioning. During the study period, there were 94 747 patients, who underwent neurosurgical procedures, and met the inclusion criteria. Of these, 1358 (1.0%) developed VTE within 30 days postoperatively. Multivariable logistic regression demonstrated an association of longer operative duration with higher 30-day incidence of VTE (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.19-1.25). Compared with procedures of moderate duration (third quintile, 40-60th percentile), patients undergoing the longest procedures (>80th percentile) had higher odds (OR, 3.15; 95% CI, 2.49-3.99) of developing VTE. The shortest procedures (<20th percentile) were associated with a decreased incidence of VTE (OR, 0.51; 95% CI, 0.27-0.76) in comparison to those of moderate duration. The same associations were present in propensity score-adjusted models, and models stratified by subgroups of cranial, spinal, peripheral nerve, and carotid procedures. In a cohort of patients from a national prospective surgical registry, increased operative duration was associated with increased incidence of VTE for neurosurgical procedures. These results can be used by neurosurgeons to inform operative management, and to stratify patients with regard to VTE risk.

Operative Duration and Risk of Surgical Site Infection in Neurosurgery

The association of surgical duration with the risk of surgical site infection (SSI) has not been quantified in neurosurgery. We investigated the association of operative duration in neurosurgical procedures with the incidence of SSI. We performed a retrospective cohort study involving patients who underwent neurosurgical procedures from 2005 to 2012 and were registered in the American College of Surgeons National Quality Improvement Project registry. To control for confounding, we used multivariable regression models and propensity score conditioning. During the study period there were 94,744 patients who underwent a neurosurgical procedure and met the inclusion criteria. Of these patients, 4.1% developed a postoperative SSI within 30 days. Multivariable logistic regression showed an association between longer operative duration with higher incidence of SSI (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.16-1.20). Compared with procedures of moderate duration (third quintile, 40th-60th percentile), patients undergoing the longest procedures (>80th percentile) had higher odds (OR, 2.07; 95% CI, 1.86-2.31) of developing SSI. The shortest procedures (<20th percentile) were associated with decreased incidence of SSI (OR, 0.72; 95% CI, 0.61-0.83) compared with those of moderate duration. The same associations were present in propensity score adjusted models and models stratified by subgroups of cranial, spinal, peripheral nerve, and carotid procedures. In a cohort of patients from a national prospective surgical registry, longer operative duration was associated with increased incidence of SSI for neurosurgical procedures. These results can be used by neurosurgeons to inform operative management and to stratify patients with regard to SSI risk.

A predictive model of complications after spine surgery: the National Surgical Quality Improvement Program (NSQIP) 2005–2010

Background contextThere is increasing scrutiny by several regulatory bodies regarding the complications of spine surgery. Precise delineation of the risks contributing to those complications remains a topic of debate. PurposeWe attempted to create a predictive model of complications in patients undergoing spine surgery. Study design/settingRetrospective cohort study. Patient sampleA total of 13,660 patients registered in the American College of Surgeons National Quality Improvement Project (NSQIP) database. Outcome measuresThirty-day postoperative risks of stroke, myocardial infarction, death, infection, urinary tract infection (UTI), deep vein thrombosis (DVT), pulmonary embolism (PE), and return to the operating room. MethodsWe performed a retrospective cohort study involving patients who underwent spine surgery between 2005 and 2010 and were registered in NSQIP. A model for outcome prediction based on individual patient characteristics was developed. ResultsOf the 13,660 patients, 2,719 underwent anterior approaches (19.9%), 565 corpectomies (4.1%), and 1,757 fusions (12.9%). The respective 30-day postoperative risks were 0.05% for stroke, 0.2% for MI, 0.25% for death, 0.3% for infection, 1.37% for UTI, 0.6% for DVT, 0.29% for PE, and 3.15% for return to the operating room. Multivariate analysis demonstrated that increasing age, more extensive operations (fusion, corpectomy), medical deconditioning (weight loss, dialysis, peripheral vascular disease, coronary artery disease, chronic obstructive pulmonary disease, diabetes), increasing body mass index, non-independent mobilization (preoperative neurologic deficit), and bleeding disorders were independently associated with a more than 3 days' length of stay. A validated model for outcome prediction based on individual patient characteristics was developed. The accuracy of the model was estimated by the area under the receiver operating characteristic curve, which was 0.95, 0.82, 0.87, 0.75, 0.74, 0.78, 0.76, 0.74, and 0.65 for postoperative risk of stroke, myocardial infarction, death, infection, DVT, PE, UTI, length of stay of 3 days or longer, and return to the operating room, respectively. ConclusionsOur model can provide individualized estimates of the risks of postoperative complications based on preoperative conditions, and can potentially be used as an adjunct in decision-making for spine surgery.

Outcome prediction in intracranial tumor surgery: the National Surgical Quality Improvement Program 2005–2010

Accurate knowledge of individualized risks is crucial for decision-making in the surgical management of patients with brain tumors. Precise delineation of those risks remains a topic of debate. We attempted to create a predictive model of outcomes in patients undergoing craniotomies for tumor resection (CTR). We performed a retrospective cohort study involving patients who underwent CTR from 2005 to 2010 and were registered in the American College of Surgeons National Quality Improvement Project database. A model for outcome prediction based on individual patient characteristics was developed. Of the 1,834 patients, 457 had meningiomas (24.9 %) and 1377 had non-meningioma tumors (75.1 %). The respective 30-day postoperative risks were 2.1 % for stroke, 1.3 % for MI, 2.7 % for death, 2.4 % for deep surgical site infection, and 6.6 % for return to the OR. Multivariate analysis demonstrated that pre-operative tumor-related neurologic deficit, stroke, altered mental status, and weight loss, were independently associated with most outcomes, including post-operative MI, death, and deep surgical site infection. An additive effect of the variables on the risk of all outcomes was observed. A validated model for outcome prediction based on individual patient characteristics was developed. The accuracy of the model was estimated by the area under the receiver operating characteristic curve, which was 0.687, 0.929, 0.749, 0.746, and 0.679 for postoperative risk of stroke, MI, death, infection, and return to the OR, respectively. Our model can provide individualized estimates of the risks of post-operative complications based on pre-operative conditions, and can potentially be utilized as an adjunct in the decision-making for surgical intervention in brain tumor patients.

A Risk Factor-based Predictive Model of Outcomes in Carotid Endarterectomy

Accurate knowledge of individualized risks and benefits is crucial to the surgical management of patients undergoing carotid endarterectomy (CEA). Although large randomized trials have determined specific cutoffs for the degree of stenosis, precise delineation of patient-level risks remains a topic of debate, especially in real world practice. We attempted to create a risk factor-based predictive model of outcomes in CEA. We performed a retrospective cohort study involving patients who underwent CEAs from 2005 to 2010 and were registered in the American College of Surgeons National Quality Improvement Project database. Of the 35 698 patients, 20 015 were asymptomatic (56.1%) and 15 683 were symptomatic (43.9%). These patients demonstrated a 1.64% risk of stroke, 0.69% risk of myocardial infarction, and 0.75% risk of death within 30 days after CEA. Multivariate analysis demonstrated that increasing age, male sex, history of chronic obstructive pulmonary disease, myocardial infarction, angina, congestive heart failure, peripheral vascular disease, previous stroke or transient ischemic attack, and dialysis were independent risk factors associated with an increased risk of the combined outcome of postoperative stroke, myocardial infarction, or death. A validated model for outcome prediction based on individual patient characteristics was developed. There was a steep effect of age on the risk of myocardial infarction and death. This national study confirms that that risks of CEA vary dramatically based on patient-level characteristics. Because of limited discrimination, it cannot be used for individual patient risk assessment. However, it can be used as a baseline for improvement and development of more accurate predictive models based on other databases or prospective studies.

Carotid Endarterectomy in Asymptomatic Patients With Limited Life Expectancy

Conclusion: Carotid endarterectomy (CEA) is commonly performed in asymptomatic patients with life-limiting conditions. The net benefit of CEA in this population is uncertain. Summary: Numerous guidelines are in place regarding which patients with asymptomatic carotid stenosis should be considered for prophylactic CEA. The Society for Vascular Surgery guidelines indicate that asymptomatic patients with ≥60% carotid artery stenosis can be considered for CEA when life expectancy is >3 years and the perioperative stroke and death risk is <3% (Ricotta JJ et al, J Vasc Surg 2011;54e1-e31). Other societies have more strict indications and assert that appropriate candidates should have a life expectancy >5 years (Goldstein LB et al, Stroke 2011;42:517-84; and Chaturvedi S et al, Neurology 2005;65:794-801). The American Academy of Neurology (Chaturvedi S et al, reference) supports CEA for asymptomatic disease only if patients are aged <75 years. However, anecdotally, it appears many patients undergo CEA outside of societal guidelines. The authors sought to examine how commonly CEA was performed in asymptomatic patients with limited life expectancy. They used the American College of Surgeons National Quality Improvement Project data to identify eight conditions associated with limited life expectancy based on survival estimates using external sources: disseminated cancer, advanced liver disease, symptomatic congestive heart failure, dialysis dependence, severe chronic obstructive pulmonary disease, age >90 years, American Society of Anesthesiologist class 4, and do-not-resuscitate (DNR) status as indicators of limited life expectancy. The predicted 5-year mortality in all but the DNR group varies from 46% to 83%. Comparisons were then made of 30-day stroke rate, death, and myocardial infarction after CEA between asymptomatic patients with and without life-limiting conditions. There were 12,631 CEAs performed in asymptomatic patients, of which 2,525 (20%) were performed in patients with life-limiting conditions or diagnoses. The most common conditions were severe chronic obstructive pulmonary disease and American Society of Anesthesiologist class 4 designation. Patients with life-limiting conditions had higher rates of perioperative complications, including stroke, (1.8% vs 0.9%, P < .01), death (1.4% vs 0.3%, P < .01), and stroke/death (2.9% vs 1.1%, P < .001). After adjustment for other comorbidities, patients with life-limiting conditions were still nearly three times more likely to experience perioperative stroke or death than those without these conditions (odds ratio, 2.1; 95% confidence interval, 2.1-3.8; P < .001). The incidence of myocardial infarction was 1%. Comment: The data as presented in the original abstract are a bit misleading. Of the nearly 13,000 patients undergoing prophylactic CEA, the very large majority deemed to have life threatening conditions had severe chronic obstructive pulmonary disease or American Society of Anesthesiologist class 4. Only 10 patients had advanced liver disease, 21 had advanced cancer, 25 patients had a DNR status, 108 were aged >90 years, and 110 were dialysis-dependent. The decision to perform surgery is an individual one between the physician and the patient. Data such as this are never privy to individual circumstances surrounding operative decisions. For example, clearly not all 90-year-old patients and not all dialysis-dependent patients are the same. Conversely, as pointed out by the authors, the National Quality Improvement Project database may underestimate perioperative myocardial infarction and stroke. Nevertheless, although prophylactic CEA may be an overused procedure, the stroke and death rates in the patients with so-called limited life expectancy were actually less than those advocated by the American Heart Association for patients with asymptomatic carotid stenosis. Without actual survival data on the so-called patients with limited life expectancy, the report can be considered a bit more inflammatory than informative.

Carotid endarterectomy in asymptomatic patients with limited life expectancy.

Data from randomized trials assert that asymptomatic patients undergoing carotid endarterectomy (CEA) must live 3 to 5 years to realize the benefit of surgery. We examined how commonly CEA is performed among asymptomatic patients with limited life expectancy. Within the American College of Surgeons National Quality Improvement Project we identified 8 conditions associated with limited life expectancy based on survival estimates using external sources. We then compared rates of 30-day stroke, death, and myocardial infarction after CEA between asymptomatic patients with and without life-limiting conditions. Of 12,631 CEAs performed in asymptomatic patients, 2525 (20.0%) were in patients with life-limiting conditions or diagnoses. The most common conditions were severe chronic obstructive pulmonary disease and American Society of Anesthesiologists Class IV designation. Patients with life-limiting conditions had significantly higher rates of perioperative complications, including stroke (1.8% versus 0.9%, P<0.001), death (1.4% versus 0.3%, P<0.001), and stroke/death (2.9% versus 1.1%, P<0.001). Even after adjustment for other comorbidities, patients with life-limiting conditions were nearly 3 times more likely to experience perioperative stroke or death than those without these conditions (OR, 2.8; 95% CI, 2.1-3.8; P<0.001). CEA is performed commonly in asymptomatic patients with life-limiting conditions. Given the high rates of postoperative stroke/death in these patients as well as their limited life expectancy, the net benefit of CEA in this population remains uncertain. Health policy research examining the role of CEA in asymptomatic patients with life-limiting conditions is necessary and may serve as a potential source for significant healthcare savings in the future.