Surgeons National Surgical Quality Improvement Research Articles

Complication Rates and Variability in Gastrojejunostomy Tube Usage in Infants and Children

BackgroundGastrojejunostomy tube (GJT) placement is commonly performed for enteral access and post-pyloric feeding in children with gastric feeding intolerance. Prior studies have suggested the risk of surgical complications is elevated in infants compared to older children. We aim to characterize GJT usage in children and investigate the risk factors for postoperative complications through two national databases. MethodsWe performed a multi-institutional retrospective cohort study on children who underwent GJT placement utilizing two national databases, the Pediatric American College of Surgeons National Surgical Quality Improvement Program (Ped-NSQIP) and the Pediatric Health Information System (PHIS). Analyses were performed within each cohort separately to determine differences in outcomes between infants (<1 year of age) and non-infants (≥ 1 year of age). Multivariable logistic regression was performed to determine associations with postoperative complications. ResultsInfants did not have an increased rate of surgical complications compared to non-infants in the Ped-NSQIP cohort (26.9% vs. 29.0%, p = 0.84) or PHIS cohort (35.3% vs. 30.7%, p = 0.07). There was an increased risk of complications in African American infants (OR 1.93, 95% CI 1.01-3.67) and non-infants (OR 1.64, 95% CI 1.27-2.10) and for urgent procedures or emergent procedures in both infants and non-infants (OR 5.42-6.46 and OR 2.12-2.61, respectively). GJT placement and complication rates significantly varied across institutions. ConclusionWe demonstrate substantial but similar overall complication rates of GJT placement between infants and non-infants. These findings suggest age alone should not negate placement of GJTs when indicated for enteral access in children. Level of Evidence3 Type of StudyMulti-institutional, retrospective, cohort study

Popliteal-Distal Bypass Affords Better Limb Salvage than Tibial Angioplasty for Chronic Limb-Threatening Ischemia

ObjectiveChronic limb-threatening ischemia (CLTI) due to isolated tibial occlusive disease is treated by either popliteal distal bypass or tibial angioplasty, although there is limited data directly comparing efficacy and outcomes between these two treatment modalities. This study compares 30-day mortality and major adverse limb events following infrapopliteal bypass and tibial angioplasty in patients with CLTI. MethodsPatients who underwent popliteal distal bypass for CLTI were extracted from American College of Surgeons National Surgical Quality Improvement Program targeted lower extremity open database, whereas patient with CLTI who underwent isolated tibial angioplasty were identified in the targeted lower extremity endovascular database. Any case with more proximal angioplasty such as femoral/pop/iliac was excluded. The time interval was 2011-2022. The two groups were comparable in demographics and pre-operative comorbidities were obtained using propensity matching. Mortality, systemic complications, and major adverse limb events were measured. Multivariable logistic regression was used for data analysis. To obtain granular data on the angiographic characteristics of patients undergoing popliteal-distal bypass or tibial angioplasty, The George Washington University institutional data from 2014 to 2019 was used as supplement to the database. ResultsThere were 1,947 and 3,423 cases identified in the bypass and endovascular groups, respectively. After propensity matching for all preoperative variables, 1,747 cases remained in each group. Although bypass was associated with higher major adverse cardiovascular events, pulmonary, renal, and wound complications, bypass had significantly better 30-day limb salvage when compared to tibial angioplasty (major amputation rate 3.32% vs. 6.12%; p<0.01). Institutional data identified 69 patients with CLTI due to isolated tibial occlusive disease; 25 (36.2%) underwent popliteal-distal bypass and 44 (63.8%) underwent tibial angioplasty. Reviewing of angiographic details revealed patients who underwent popliteal-distal bypass had better pedal targets (inframalleolar/pedal score of P0 [24.0% vs 15.9%] or P1 [68.0% vs 61.3%]) than tibial angioplasty patients (inframalleolar/pedal score of P2 [22.7% vs 8.0%]). ConclusionPopliteal-distal bypass was associated with higher morbidity but better limb salvage than endovascular interventions. However, this could be explained by the association with better pedal targets in patients who underwent popliteal-tibial bypass. Prospective studies should be done comparing popliteal distal bypasses and tibial angioplasty in cases with similar pedal targets.

Using machine and deep learning to predict short-term complications following trigger digit release surgery

BackgroundTrigger finger is a common disorder of the hand characterized by pain and locking of the digits during flexion or extension. In cases refractory to nonoperative management, surgical release of the A1 pulley can be performed. This study evaluates the ability of machine learning (ML) techniques to predict short-term complications following trigger digit release surgery. MethodsA retrospective study was conducted using data for trigger digit release from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) years 2005–2020. Outcomes of interest were 30-day complications and 30-day return to the operating room. Three ML algorithms were evaluated — a Random Forest (RF), Elastic-Net Regression (ENet), and Extreme Gradient Boosted Tree (XGBoost), along with a deep learning Neural Network (NN). Feature importance analysis was performed in the highest performing model for each outcome to identify predictors with the greatest contributions. ResultsWe included a total of 1209 cases of trigger digit release. The best algorithm for predicting wound complications was the RF, with an AUC of 0.64 ± 0.04. The XGBoost algorithm was best performing for medical complications (AUC: 0.70 ± 0.06) and reoperations (AUC: 0.60 ± 0.07). All three models had performance significantly above the AUC benchmark of 0.50 ± 0.00. On our feature importance analysis, age was distinctively the highest contributing predictor of wound complications. ConclusionsMachine learning can be successfully used for risk stratification in surgical patients. Moving forwards, it is imperative for hand surgeons to continue evaluating applications of ML in the field.

Acquired buried penis: an observational study characterizing the variability in procedural codes reported during surgery.

Adult acquired buried penis (ABP) is a heterogenous condition and surgical treatment typically includes several steps. Additionally, there is no consensus on which current procedural terminology (CPT) codes to utilize for these steps. Our objective is to characterize the variability in CPT codes reported for ABP surgeries. We hypothesize that the heterogeneous disease process combined with a lack of consensus on appropriate CPT codes will result in marked variability in CPT codes reported during surgery for ABP. Data was collected from American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) between 2007-2020. We included adults undergoing surgery for ABP. All CPT codes were grouped into different anatomic categories: penile procedures, scrotal procedures, pannus-related procedures, urethral procedures, tissue transfers, and skin grafts. Codes not fitting these categories were labeled "Other". Our study included 146 patients. There were 413 total CPT codes reported with 82 unique codes in our cohort. The average number of codes per patient was 2.8, with a range from 1 to 9. There were many unique codes in each anatomic category: 18 different codes within penile procedures, 7 within pannus procedures, 8 within skin grafting, 4 within scrotal procedures, 7 within tissue transfers, and 19 within urethral. There was marked variability in individual code use with each code being reported anywhere from 1 to 58 times. Urologists were the primary surgeons in 69% (n=101). We found marked variability in CPT codes reported during surgery for ABP. This suggests the need for our stakeholder organizations to support efforts that would allow consensus on which codes should be utilized for this increasingly recognized condition.

Trends in the use of immediate postoperative intravesical chemotherapy following transurethral resection of bladder tumors

PurposeThe use of immediate postoperative intravesical chemotherapy (IVC) following transurethral resection of bladder tumor (TURBT) has been shown to reduce the rate of recurrence of nonmuscle invasive bladder cancer. Historically, utilization of IVC following TURBT has been low. We sought to determine the rate of immediate postoperative IVC following TURBT, as well as assess factors that may influence its use. MethodsWe utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to assess the rates of IVC between the years 2016 to 2021. All patients who underwent TURBT based on appropriate procedure codes were initially included. Patients with an additional procedure code for the administration of IVC were identified. ResultsFrom 2016 to 2021, 50,295 patients underwent TURBT for bladder cancer. There were 21,544 (43%) small, 18,135 (36%) medium, and 10,616 (21%) large tumors treated. In total, 2,833 (5.6%) patients received IVC. Use of IVC was associated with surgery performed in an elective setting, those who did not receive preoperative blood transfusion, and shorter operative time. Receipt of chemotherapy was more common in the later years examined. ConclusionsThe rate of use of IVC remains very low. Ongoing study and improvement initiatives are in place, though these predominantly are assessing academic centers. Further study and quality improvement should be performed and include community practice settings.

Obesity is an independent risk factor for postoperative pulmonary embolism after anterior cervical discectomy and fusion

BACKGROUNDOver the past decade, the prevalence of obesity has risen in the United States, in parallel with the demand for anterior cervical discectomy with fusion (ACDF). Prior studies have evaluated the role of obesity classes in cervical spine surgery in smaller patient populations. We aimed to evaluate any potential correlation to a national population sample by utilizing a large multicenter database. PURPOSEThe purpose of this study was to analyze obesity level's influence on perioperative complication rates in patients undergoing ACDF. STUDY DESIGN/SETTINGA retrospective cohort, large multicenter database study. PATIENT SAMPLEThe American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify patients who had undergone an elective ACDF procedure between 2011 and 2020 using Current Procedural Terminology (CPT) code 22551. OUTCOME MEASURESMedical and surgical complications within thirty days of operation. METHODSPatients were categorized into four BMI groups: nonobese (BMI 18.5−29.9 kg/m2), obese class I (BMI 30−34.9 kg/m2), obese class II (BMI 35−39.9 kg/m2), and obese class III (BMI ≥40 kg/m2). A univariate analysis conducted for demographic variables and preoperative comorbidities identified age, sex, race, smoking status, hypertension requiring medication, diabetes, history of congestive heart failure, history of bleeding disorder, and chronic obstructive pulmonary disease as risk factors. Chi-square test was used to compare incidence of complications among groups. A multivariable logistic regression analysis was subsequently performed to adjust for these preoperative risk factors and compare obesity classes I-III to nonobese patients. RESULTSAbout 64,718 patients were identified of whom 33,365 were nonobese, 17,190 were obese class I, 8,608 were obese class II, and 5,555 were obese class III. Obese classes I-III patients had a higher incidence of surgical site infections (0. 33%, 0.36%, 0.41%, vs. 0.24%, p=.039) and pulmonary embolism (PE) (0.25%, 0.31, 0.29 vs. 0.15%, p=.003). Obese classes I-III had a lower incidence of blood transfusion (0.23%, 0.17%, 0.27% vs. 0.4%, p<.001) obese class I, obese class II, and obese class III independently increased the risk for PE (OR: 1.716, 95% CI (1.129−2.599); OR: 2.213, 95% CI (1.349−3.559); OR: 2.207, 95% CI (1.190--3.892), respectively). CONCLUSIONSRisk for postoperative PEs after an ACDF was significantly higher for obese classes I-III compared to nonobese patients. These findings may further support the use of additional prophylaxis measures and precaution in the perioperative setting.

Using the modified frailty index as a predictor of complications in adults undergoing transforaminal interbody lumbar fusion

ObjectiveTo correlate the operative characteristics and complications of transforaminal lumbar interbody fusion (TLIF) to patient frailty status for the first time in a multicenter study. MethodsUsing the American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database, all patients who underwent TLIF in 2015–2020 were filtered for their demographics, operative characteristics, and 30-day complication outcomes. Patients were stratified into 2 cohorts, low and high frailty, based on their modified frailty index 5 score. Univariate analysis was performed between the 2 cohorts for each collected variable, and multivariable analysis was performed to observe adjusted odds ratios (OR). ResultsThe frail cohort experienced more unplanned readmission (4.3 vs 6.6 %, p < 0.001). During hospital stays, the frail cohort experienced more overall complications (9.8 vs 13.8 %, p < 0.001). In contrast to the low frailty cohort, the high frailty patients saw longer hospital stays (3.27 vs. 3.69 days, p < 0.001). The high frailty group saw more discharges to an institution beside their home (89.6 vs 77.9 %, p < 0.001). Rates of superficial and deep surgical site infection, organ space infection, wound dehiscence, reintubation, renal insufficiency, urinary tract infection, stroke, cardiac arrest, DVT, sepsis, and septic shock were not significantly different. Multivariable analyses showed high frailty status as an independent predictor of unplanned readmissions, major complications, and preventing discharge to home. ConclusionsmFI-5 serves as an effective predictor of surgical outcomes following TLIF and independently predicts unplanned readmission, discharge to home, and major complications. Noninfectious outcomes were more likely to be significantly different between the high- and low frailty groups, while all infectious outcomes apart from superficial surgical site infection and pneumonia were not significantly different between the cohorts.

Predicting extended hospital stay following revision total hip arthroplasty: a machine learning model analysis based on the ACS-NSQIP database.

Prolonged length of stay (LOS) following revision total hip arthroplasty (THA) can lead to increased healthcare costs, higher rates of readmission, and lower patient satisfaction. In this study, we investigated the predictive power of machine learning (ML) models for prolonged LOS after revision THA using patient data from a national-scale patient repository. We identified 11,737 revision THA cases from the American College of Surgeons National Surgical Quality Improvement Program database from 2013 to 2020. Prolonged LOS was defined as exceeding the 75th value of all LOSs in the study cohort. We developed four ML models: artificial neural network (ANN), random forest, histogram-based gradient boosting, and k-nearest neighbor, to predict prolonged LOS after revision THA. Each model's performance was assessed during training and testing sessions in terms of discrimination, calibration, and clinical utility. The ANN model was the most accurate with an AUC of 0.82, calibration slope of 0.90, calibration intercept of 0.02, and Brier score of 0.140 during testing, indicating the model's competency in distinguishing patients subject to prolonged LOS with minimal prediction error. All models showed clinical utility by producing net benefits in the decision curve analyses. The most significant predictors of prolonged LOS were preoperative blood tests (hematocrit, platelet count, and leukocyte count), preoperative transfusion, operation time, indications for revision THA (infection), and age. Our study demonstrated that the ML model accurately predicted prolonged LOS after revision THA. The results highlighted the importance of the indications for revision surgery in determining the risk of prolonged LOS. With the model's aid, clinicians can stratify individual patients based on key factors, improve care coordination and discharge planning for those at risk of prolonged LOS, and increase cost efficiency.

Ranking the Orthopedic Procedures With the Highest Morbidity and Mortality.

Musculoskeletal conditions currently affect more than one-third of the US population and orthopedic procedures play a pivotal role in managing them. Like any invasive intervention, these carry a wide spectrum of risk, necessitating a comprehensive understanding of the associated morbidity and mortality. This study sought to provide a global perspective of the risks and complications associated with these procedures to establish an easy to understand risk stratification tool for both patients and providers. Current Procedural Terminology codes associated with orthopedic surgery were identified in the American College of Surgeons National Surgical Quality Improvement Program database from 2018 to 2020. Each code was associated with its rate of 30-day mortality as well as any adverse event (AAE) and then ranked for descriptive analysis. In total, there were 698,549 patients who underwent orthopedic procedures associated with 94 CPT codes with at least 1 morbidity event and 144 CPT codes with at least 1 AAE. The CPT code associated with the highest mortality was 27590 or above knee amputation. The CPT code associated with the highest rate of AAE was 27507 or open treatment of femoral shaft fracture with plate and screws. This is the first study to compare the rates of morbidity and mortality in all patients with orthopedic procedures. There was a strong bias toward increased risk associated with lower extremity surgery and surgery most often performed in the geriatric population. [Orthopedics. 202x;4x(x):xx-xx.].

Racial disparity in peripheral nerve block usage in breast reconstruction: A nationwide analysis

Peripheral nerve block (PNB) usage in plastic surgery is associated with reduction in post-operative opioid consumption and pain demonstrating benefits in breast reconstruction (BR). This retrospective study explored whether racial-ethnic disparities exist with PNB use for postoperative analgesia in patients undergoing BR. Using the American College of Surgeons National Surgical Quality Improvement Program database, women who underwent BR from 2012-2021 and received "regional" in addition to general anesthesia were included in the study. Patients without race and ethnicity dataand who received other additional anesthesia were excluded. Unweighted rates of PNB use were compared between racial-ethnic groups and BR modality. Multivariate logistic regression assessed whether race and ethnicity were independently associated with receiving PNBs. A total of 25,188 patients underwent BR and 9429 patients (37.4%) received PNB for postoperative analgesia. Patient demographics reached statistical, but not clinical, significance in age and BMI. Comorbidities were not significantly different between groups. Black patients were less likely to receive PNBs (p<0.001), while Asian and Other patients were more likely to receive PNBs compared to White patients (p<0.001). Black patients were less likely to receive PNB in immediate implant-based and autologous BR, as well as delayed autologous (p<0.05). Asian patients were more likely to receive PNB for all implant-based BR compared to White patients (p<0.001). Ethnicity had no significant impact on receipt of PNB. As a conclusion, racial disparity exists in use of PNBs for postoperative analgesia in BR. Equitable access to PNBs should be championed to not augment baseline racial disparity in BR.

Predicting prolonged length of stay following revision total knee arthroplasty: A national database analysis using machine learning models

BackgroundAs the number of revision total knee arthroplasty (TKA) continues to rise, close attention has been paid to factors influencing postoperative length of stay (LOS). The aim of this study is to develop generalizable machine learning (ML) algorithms to predict extended LOS following revision TKA using data from a national database. Methods23,656 patients undergoing revision TKA between 2013 and 2020 were identified using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients with missing data and those undergoing re-revision or conversion from unicompartmental knee arthroplasty were excluded. Four ML algorithms were applied and evaluated based on their (1) ability to distinguish between at-risk and not-at-risk patients, (2) accuracy, (3) calibration, and (4) clinical utility. ResultsAll four ML predictive algorithms demonstrated good accuracy, calibration, clinical utility, and discrimination, with all models achieving a similar area under the curve (AUC) (AUCLR=AUCRF=AUCHGB=0.75, AUCANN=0.74). The most important predictors of prolonged LOS were found to be operative time, preoperative diagnosis of sepsis, and body mass index (BMI). ConclusionsML models developed in this study demonstrated good performance in predicting extended LOS in patients undergoing revision TKA. Our findings highlight the importance of utilizing nationally representative patient data for model development. Prolonged operative time, preoperative sepsis, BMI, and elevated preoperative serum creatinine and BUN were noted to be significant predictors of prolonged LOS. Knowledge of these associations may aid with patient-specific preoperative planning, discharge planning, patient counseling, and cost containment with revision TKA.

Association between hypertension requiring medication and postoperative 30-day mortality in adult patients with tumor craniotomy: an analysis of data using propensity score matching.

Reliable quantification of the association between hypertension requiring medication and postoperative 30-day mortality in adult patients who undergo craniotomy for tumor resection is limited. We aimed to explore the associations between these factors. This work was a retrospective cohort study that used propensity score matching (PSM) among 18,642 participants from the American College of Surgeons National Surgical Quality Improvement Program database between 2012 and 2015. Hypertension requiring medication and postoperative 30-day mortality were the independent and dependent target variables, respectively. PSM was conducted via nonparsimonious multivariate logistic regression to balance the confounders. Robust estimation methods were used to investigate the association between hypertension requiring medication and postoperative 30-day mortality. A total of 18,642 participants (52.6% male and 47.4% female) met our inclusion criteria; 7,116 (38.17%) participants with hypertension required medication and had a 3.74% mortality rate versus an overall mortality rate of 2.46% in the adult cohort of patients who underwent craniotomy for tumor resection. In the PSM cohort, the risk of postoperative 30-day mortality significantly increased by 39.0% among patients with hypertension who required medication (OR = 1.390, 95% confidence interval (CI): 1.071-1.804, p = 0.01324) after adjusting for the full covariates. Compared with participants without hypertension requiring medication, those with hypertension requiring medication had a 34.0% greater risk of postoperative 30-day mortality after adjusting for the propensity score (OR = 1.340, 95% CI: 1.040-1.727, p = 0.02366) and a 37.6% greater risk of postoperative 30-day mortality in the inverse probability of treatment weights (IPTW) cohort (OR = 1.376, 95% CI: 1.202, 1.576, p < 0.00001). Among U.S. adult patients undergoing craniotomy for tumor resection, hypertension requiring medication is a notable contributor to 30-day mortality after surgery, with odds ratios ranging from 1.34 to 1.39.

Robotic compared with laparoscopic cholecystectomy: A National Surgical Quality Improvement Program comparative analysis

BackgroundData demonstrating the clinical benefit of robotic cholecystectomy over the laparoscopic approach are lacking. Herein, we aim to evaluate whether robotic cholecystectomy is associated with improved surgical outcomes compared with laparoscopic cholecystectomy. Study DesignThis is a retrospective cohort study that used the American College of Surgeons National Surgical Quality Improvement Program to compare the outcomes of patients who underwent robotic or laparoscopic cholecystectomy for benign indications in 2022. ResultsOf the 59,216 patients identified, 53,746 underwent laparoscopic cholecystectomy and 5,470 robotic. Compared with the robotic cohort, the patients in the laparoscopic cholecystectomy group were older (50.4 vs 49.7 years), were of the male sex (32.7% vs 29.7%), and comprised a greater percentage of other races than White, African American, and Asian (28.6% vs 14.8%). Multivariable logistic regression revealed that robotic cholecystectomy compared with the laparoscopic approach was independently associated with a lower risk of Clavien-Dindo complications grade 3 or 4 (odds ratio, 0.82; 95% confidence interval, 0.69–0.98), a lower rate of conversion to open (odds ratio, 0.44; 95% confidence interval, 0.32–0.61), and lower odds of requiring hospitalization ≥24 hours (odds ratio, 0.76; 95% confidence interval, 0.71–0.81). There were no significant differences between the 2 approaches in terms of reoperation (odds ratio, 0.69; 95% confidence interval, 0.47–1.00) and readmission (odds ratio, 0.94; 95% confidence interval, 0.82–1.10). ConclusionRobotic cholecystectomy was independently associated with a lower risk of serious complications, lower rate conversion to open, and hospitalization ≥24 hours compared with laparoscopic cholecystectomy. These findings suggest that new technologies might enhance the safety of minimally invasive surgery.

SP2.9 - National Emergency Laparotomy Audit (NELA) and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) risk prediction calculators are not accurate in predicting 30-day mortality in patients aged 80 and above

Abstract Background 30- to 50000 Emergency Laparotomies (EL) are performed annually in the UK. More than half of patients are aged 70 or over and have a high post-operative complication rate along with a 16-20% risk of 30-day mortality (30-dm). To date, the literature lacks a dedicated risk prediction tool for mortality and morbidity following EL in the elderly population. Methods A multi-center, retrospective study of patients aged ≥80 undergoing EL examined the correlation between predicted 30-dm using NELA and ACS-NSQIP and actual 30-dm. This occurred in two UK centers over a 2-year period. The primary outcome was defined as the correlation between actual 30-dm and NELA or ACS-NSQIP predicted 30-dm. GraphPad Prism 10.1.1. was used for statistical analysis. Results 141 cases were included in the final analysis (Table 1). The actual 30-dm was 17.73%, NELA predicted 30-dm 13.07% (7.21;27.84), and ACS-NSQIP 9.4% (3.8;20.6). NELA correlated positively with ACS-NSQIP predicted 30-dm (R²=0.79; p&amp;lt;0.0001). No association was found between actual 30-dm and predicted NELA 30-dm, R²=0.01; p&amp;lt;0.0001 or ACS-NSQIP, R²=0.01; p&amp;lt;0.0001. All data is expressed as Median + IQR. Conclusion In octo- and nonagenarians, following an emergency laparotomy, both NELA and ACS-NSQIP are not accurate in predicting 30-day mortality.Table 1Male/female ratio0.63Age (years)84 (81;87)BMI (kg/m²)24.27 (21.43;27)Lactate (most recent preoperative value) mmol/L1.7 mmol/L (1.14;3.01)ASA grade3 (2;4)Clinical frailty score3 (3;5)Charlson Comorbidity Index4 (2;5)

FP7.8 - Perioperative risk prediction for Emergency Laparotomy in Adults, using the National Emergency Laparotomy Audit (NELA) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) risk prediction tools – an Eastern European perspective

Abstract Background Worldwide, emergency laparotomy (EL) is one of the most common procedures. Having an actual 30-day mortality (30-dm) of 10 to 15%, EL has a high mortality rate, particularly in patients &amp;gt;70 years old. Preoperative risk assessment and stratification can improve outcomes. The American-College-of-Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) and the National Emergency Laparotomy Audit (NELA) risk prediction tools are the most used risk calculators, but both can under or overpredict. Methods This is a single-center, retrospective, cohort study that looked at the correlation between actual and predicted 30-dm using NELA and ACS-NSQIP in adults ≥18, following EL, over 2 years, in a single-tertiary-center from Romania. The primary outcome was defined as the correlation between actual 30-dm and NELA or ACS-NSQIP predicted 30-dm. Statistical analysis was performed using GraphPad-Prism 10.1.1. and Stata18. Results 207 cases were analyzed. Male/female ratio was 1.49; age 65 years (50;77); BMI 26.25kg/m² (23.01;28.35); preoperative lactate 1.8 mmol/L (1.5;3.4); ASA grade 3 (2;4) clinical frailty score 4 (3;4); and Charlson Comorbidity Index 5 (3;8). Actual 30-dm was 31.4% with NELA and ACS-NSQIP predicted 30-dm of 5.78% (1.84;21.48) and 5.5% (1.2;24.2) respectively. NELA and ACS-NSQIP predicted 30-dm expressed a strong positive correlation, R²=0.88; p&amp;lt;0.0001. Both NELA and ACS-NSQIP predicted 30-dm showed a significant positive correlation with actual 30-dm: R²=0.33, p&amp;lt;0.0001; and R²=0.41, p&amp;lt;0.0001 respectively. All data is presented as Median + IQR. Conclusion In a Romanian setting both ACS-NSQIP and NELA risk calculators underpredicted 30-dm, despite expressing a strong positive correlation with actual 30-dm.

NELA 1 - Actual and predicted 30-day mortality following emergency laparotomy using National Emergency Laparotomy Audit (NELA) and American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) risk prediction tools

Abstract Background Emergency laparotomy (EL) is common, with &amp;gt;30,000 performed annually in the UK. EL has a high 30-day mortality of 9.2%, especially in the elderly. Reliable preoperative risk assessment is essential to aid decision-making and perioperative care arrangements. NELA and ACS-NSQIP risk calculators can both be used to assess risk, and both can under or over-predict mortality. Methods This is a multi-center, retrospective, observational, cohort study investigating the correlation between actual 30-dm (a-30-dm) and predicted 30-dm (p-30-dm) following EL using NELA and ACS-NSQIP in adults over and under 70, over 2-years, in two UK centres. Sample size was calculated at 385 cases. Statistical analysis was carried out using GraphPad Prism 10.1.1. Results 626 cases were analyzed. A-30-dm, NELA, and ACS-NSQIP p-30-dm in the under 70s subgroup were 5.78%, 5.53%, and 3.41% respectively, with NELA and ACS-NSQIP correlating positively with a-30-dm: R²=0.12, p&amp;lt;0.0001 and R²=0.09, p&amp;lt;0.0001. In over 70s, a-30-dm was 13.96%, NELA p-30-dm 14.02% and ACS-NSQIP 9.76%, with a positive correlation between the latter two (R²=0.56, p&amp;lt;0.0001), but a weak one between a-30-dm and NELA (R²=0.04, p&amp;lt;0.0001) or ACS-NSQIP (R²=0.02, p&amp;lt;0.0001). For the entire cohort a-30-dm, NELA and ACS-NSQIP p-30-dm were 9.74%, 9.8%, and 6.59% respectively. NELA and ACS-NSQIP p-30-dm showed a strong positive correlation (R²=0.89; p&amp;lt;0.0001) with only NELA showing a strong positive correlation with a-30-dm (R²=0.31, p&amp;lt;0.0001); and not ACS-NSQIP (R²=0.05, p&amp;lt;0.0001). Conclusion NELA can accurately predict 30-day mortality in patients aged &amp;lt;70 undergoing EL but not &amp;gt;70. ACS-NSQIP and a-30-dm correlated in a very weak manner.

Periprocedural clinical outcomes of revision hip arthroplasty: a multi-centric comparison of current strategies based on the NSQIP.

Recent projections suggest a substantial rise in demand for revision total hip arthroplasties, emphasizing the need for optimized perioperative care. Various revision techniques, such as isolated acetabular or femoral component revisions and total replacements, have garnered attention. Further research is needed to establish the most effective strategies for improving clinical outcomes. This retrospective analysis utilized data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use File from 2016 to 2021. The study aimed to compare clinical characteristics and 30-day outcomes among patients undergoing combined acetabular and femoral (A + F) revision, acetabulum-only (A) revision, and femoral side-only (F) revision surgeries. The analysis of 18,888 patients revealed crucial differences in preoperative and postoperative outcomes among various revision strategies. Specifically, there were notable variations in patient demographics, comorbidities, and emergency procedures. Postoperative data showed distinct rates of mortality, complications, and readmissions across the groups. Notably, femoral component revisions were associated with increased risks of mortality, transfusion, and urinary tract infections, underscoring the need for careful evaluation and consideration when opting for this revision approach. The study's significance lies in its extensive patient cohort and multifaceted evaluation of revision strategies. Although consensus is lacking on single-component revisions, targeting the acetabulum component appears relatively safer. Continued research and individualized evaluations are crucial for refining revision strategies and optimizing outcomes in THA revisions.

The effect of high-normal preoperative international normalized ratios on postoperative outcomes and complications following posterior cervical spine surgery

IntroductionCurrent guidelines recommend that the International Normalized Ratio (INR) be less than 1.5 prior to spine intervention. Recent studies have shown that an INR > 1.25 is associated worse outcomes following anterior cervical surgery. We sought to determine the risk of complications associated with an INR > 1.25 following elective posterior cervical surgery.MethodsThe American College of Surgeons National Surgical Quality Improvement Program database was queried. Patients undergoing elective posterior cervical surgery from 2012 to 2016 with an INR level within 24 h of surgery were included. Primary outcomes were hematoma requiring surgery, 30-day mortality, and transfusions within 72-hours. There were 815 patients in the INR ≤ 1 cohort (Cohort A), 410 patients in the 1 < INR ≤ 1.25 cohort (Cohort B), and 33 patients in the 1.25 < INR ≤ 1.5 cohort (Cohort C).ResultsCohort C had a higher rate of transfusion (4% Cohort A; 6% Cohort B; 12% Cohort C; p = 0.028) and the rate of mortality within 30 days postoperatively trended toward significance (0.4% Cohort A; 0.5% Cohort B; 3% Cohort C; p = 0.094). There was no significant difference in the rate of postoperative hematoma formation requiring surgery (0.2% Cohort A; 0% Cohort B; 0% Cohort C; p = 0.58). On multivariate analysis, increasing INR was not associated with an increased risk of developing a major complication.ConclusionAn INR > 1.25 but ≤ 1.5 may be safe for posterior cervical surgery. An INR > 1.25 but ≤ 1.5 was associated with a significantly higher rate of transfusions. However, increasing INR was not significantly associated with increased risk of any of the major complications.

Predictors of Prolonged Hospital Stay After Microsurgery for Vestibular Schwannoma: Analysis of a Decade of Data.

Microsurgical resection is one of the treatments for vestibular schwannomas (VS). While several factors have been linked to increased length of stay (LOS) for VS patients undergoing microsurgery, a better understanding of these factors is important to provide prognostic information for patients. Determine predictors of increased LOS for VS patients undergoing microsurgical resection. Retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2010 to 2020. Database review. All patients who underwent microsurgery (CPT codes 61520, 61526/61596) for the management of vestibular schwannoma (ICD9 and ICD10 codes 225.1, D33.3) were included. Analyzing perioperative factors that can predict prolonged hospital stay. A total of 2096 cases were identified and 1,188 (57%) of these patients were female. The mean age was 51.0 ± 14.0 years. Factors contributing to prolonged LOS included African American race (OR = 2.11, 95% CI: 1.32-3.36, p = 0.002), insulin-dependent diabetes mellitus (OR = 2.12, 95% CI: 1.09-4.4.11, p = 0.026), hypertension (OR = 1.26, 95% CI: 1-1.58, p = 0.046), functional dependency (OR = 5.22, 95% CI: 2.31-11.79, p = 0.001), prior steroid use (OR = 1.96, 95% CI: 1.18-3.15, p = 0.009), ASA class III (OR = 2.06, 95% CI: 1.18-3.6, p < 0.011), ASA class IV (OR = 6.34, 95% CI: 2.62-15.33, p < 0.001), and prolonged operative time (OR = 2.14, 95% CI: 1.76-2.61). Microsurgery by a translabyrinthine (TL) approach compared to a retrosigmoid (RSG) approach had lower odds of prolonged LOS (OR = 0.67, 95% CI: 0.54-0.82, p < 0.001). In a separate analysis regarding patients receiving reoperation, operative time was the only predictor of prolonged LOS (OR = 2.77, 95% CI: 1.39-5.53, p = 0.004.). Our analysis offers an analysis of the factors associated with a prolonged LOS for the surgical management of VS. By identifying healthcare disparities, targeting modifiable factors, and applying risk stratification based on demographics and comorbidities, we can work toward reducing disparities in LOS and enhancing patient outcomes.

Impact of Obesity, Smoking, and Age on 30-Day Postoperative Outcomes of Patients Undergoing Arthroscopic Meniscus Surgery.

The purpose of this study was to evaluate the impact that obesity, smoking, and older age have on 30-day postoperative complications, reoperations, and readmissions of patients undergoing arthroscopic meniscectomy or meniscus repair. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried to identify meniscus surgeries and operative outcomes between 2008 and 2016. Controlled regression analysis was then performed to evaluate for an association between obesity, age, and smoking and these outcomes. While obesity showed no influence on adverse postoperative complications or reoperations, class I obesity was associated with a lower rate of readmission. Older age, smoking, and comorbidity burden were significant predictors of postoperative complications, reoperations, and/or readmissions. Age 80 years or older was particularly predictive of 30-day complications (odds ratio, 3.5; P<.001) and readmissions (odds ratio, 2.5; P=.004). Obesity is not a major risk factor for complications when undergoing meniscus surgery, while age older than 70 years predicts negative short-term postoperative outcomes. [Orthopedics. 20XX;4X(X):XXX-XXX.].