Surgical Quality Improvement Program Dataset Research Articles

General Complications after Endoscopic Sinus Surgery in Smokers: A 2005-2016 NSQIP Analysis.

Exposure to cigarette smoke has been associated with a higher incidence of postoperative complications across a variety of surgical specialties. However, it is unclear if smoking increases this risk after endoscopic sinus surgery (ESS). Because complication rates after ESS are relatively low, a large national database allows for a statistically meaningful study of this topic. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) dataset from 2005 to 2016 was analyzed. Patients who underwent ESS were identified. Thirty-day postoperative complication rates between smokers and nonsmokers were compared. Complications included infection, thromboembolic events, reintubation, readmission, acute renal failure, and cardiovascular events. 921 patients who underwent ESS were identified. 182 (20%) were smokers and 739 (80%) were nonsmokers. 609 patients underwent outpatient ESS, while 312 patients underwent inpatient ESS. A total of 12 patients experienced postoperative surgical site infections involving the deeper tissues beyond the wound (organ/space SSI). On univariate analysis, smoking was associated with a higher incidence of organ/space SSI (P = .0067) and pulmonary embolism (P = .0321) after ESS. On multivariate logistic regression, smoking was associated with increased odds (4.495, 1.11- 8.17, P = .0347) of organ/space SSI after ESS. This study demonstrates an association between exposure to cigarette smoke and potentially serious surgical site infections in the 30-day postoperative period after ESS. Our findings may help when counseling smokers who are considering ESS. Further study is required to understand the nature of these infections and ways to prevent them.Level of Evidence: 2c ("health outcomes").

Unanticipated Admission Following Outpatient Ligament Reconstruction and Tendon Interposition: An Analysis of 3966 Cases.

Background: Hand surgeons in the United States commonly perform ligament reconstruction and tendon interposition (LRTI) to address debilitating thumb carpometacarpal arthritis. The objective of this investigation was to examine the characteristics that place patients at risk for unanticipated inpatient admission after a planned outpatient LRTI. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) datasets from years 2009 to 2016 were used to identify patients with a primary Current Procedural Terminology code for LRTI (25445, 25447). Only outpatient, nonemergent, and elective procedures were considered. Univariable and multivariable regression were used to determine risk factors and postoperative complications associated with increased likelihood of unanticipated admission, defined as length of initial hospital stay greater than 0 days. Statistical significance was set at P < .05. Results: Of 3966 patients who underwent outpatient LRTI, 134 (3.4%) had unplanned admission. On multivariable regression, age ≥ 65 years (odds ratio [OR] = 1.50), white race (OR = 4.44), and chronic steroid use (OR = 2.42) were significant predictors of unplanned admission. History of smoking, obesity, hypertension, diabetes, American Society of Anesthesiologists classification, and anesthesia method were not associated with admission. Patients who had unplanned admission had increased rate of reoperation (2.5% vs 0.3%) compared with nonadmitted patients. There was no difference in rate of postoperative infection, deep vein thrombosis, wound dehiscence, or 30-day mortality. Conclusions: Age ≥ 65 years, chronic steroid use, and white race were significant predictors of unplanned admission following LRTI. Identifying patients with these characteristics will be critical in risk adjusting the anticipated cost of the episode of care in outpatient LRTI.

Bowel resection or repair at the time of cytoreductive surgery for ovarian malignancy is associated with increased complication rate: An ACS-NSQIP study

ObjectivesBowel procedures are commonly performed as part of ovarian cancer cytoreduction. The aim of this study was to assess the postoperative complication rates among women with an ovarian malignancy undergoing bowel resection/repair at the time of cytoreductive surgery compared with a control group (cytoreductive surgery without bowel resection or repair). MethodsAnalysis of 4965 cytoreductive surgeries for suspected ovarian malignancies recorded in the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) datasets (2006–2017) was performed. One-way ANOVA, Kruskal-Wallis H and Chi-squared tests were used to evaluate and compare baseline characteristics between the groups and controls. Postoperative surgical site infection rates and other 30-day post-operative outcomes were assessed with multivariable logistic and linear regressions. Results8.3% (413/4965) of cytoreductive procedures had an associated repair of enterotomy (small or large bowel), 10.9% (541/4947) had an associated colectomy with primary anastomosis, and 2.1% (104/4965) had an associated colectomy with colostomy. Surgical site infections (SSI, either superficial incisional, deep incisional, organ space or wound dehiscence) were significantly more prevalent in the bowel resection/repair group (16.9% vs 5.7%, p < 0.0001). The odds of surgical infections were 2.67 times higher in patients who underwent a bowel resection or repair after controlling for age, BMI, ASA status, pre-operative weight loss, hypoalbuminemia, NSQIP morbidity score, length and complexity of surgical procedure. ConclusionPatients undergoing bowel resection/repair at the time of cytoreductive surgery are at increased risk of surgical site infections, without increased risk of 30-day mortality. Interventions to mitigate the risk of infectious complications in these patients should be evaluated in a prospective fashion.

Transmetatarsal and Minor Amputation Versus Major Leg Amputation: 30-Day Readmissions, Reamputations, and Complications

AimsThe optimal level of lower-extremity amputation, particularly in diabetic patients with ulceration, is debated. Proximal amputations more greatly decrease function versus distal amputations, but healing and complication rates may differ between the 2 types. This study compares early postoperative outcomes after transmetatarsal and other partial foot amputations and major leg amputations. MethodsData were derived from National Surgical Quality Improvement Program datasets covering 2012 to 2014. Outcomes studied include 30-day rates of readmission to hospital for wound complications. We matched the 2 types of amputation patients by propensity score to fairly compare between levels of amputation when either type of amputation might be indicated. The same analysis was then performed with emphasis on diabetic patients. ResultsMajor amputation patients were more likely to have dependent functional status, although their surgeries tended to be more complicated. Minor amputation patients had 2.5 times the odds of irrigation and debridement compared with major amputation patients, but only 0.49 and 0.47 times the odds of urinary tract infection or transfusion, respectively. ConclusionsAlthough short-term complications, readmissions, and reoperations were more common in distal amputation, UTI and the need for transfusion were higher in major amputation.

The Effect of Regional Anesthesia on Outcomes After Minimally Invasive Ivor Lewis Esophagectomy

The objective of the present study was to determine whether regional anesthesia in addition to general anesthesia was associated with improved outcomes compared with general anesthesia alone in minimally invasive Ivor Lewis esophagectomy. Retrospective cohort study. This study examined patients across multiple hospital institutions using the American College of Surgeons National Surgical Quality Improvement Program dataset. Patients who underwent minimally invasive Ivor Lewis esophagectomy were identified and grouped according to general plus regional anesthesia versus general anesthesia alone. Using multivariate logistic regression, outcomes, including 30-day mortality, respiratory complications, infection, blood clots, reintubation, return to the operating room, and length of hospital stay, were examined. Of the 463 patients who underwent minimally invasive Ivor Lewis esophagectomy, 398 met study inclusion criteria. General and regional anesthesia were administered to 108 patients in the study, with the remainder receiving only general anesthesia. Multivariate regression demonstrated no difference in the primary outcome of 30-day mortality (0.93% for regional and general anesthesia, 2.07% for general anesthesia alone [odds ratio 0.49; p = 0.534]). There was no significant difference for any secondary outcome including return to the operating room, failure to wean from the ventilator, reintubation, surgical site infection, pneumonia, renal insufficiency and failure, cardiac arrest, acute myocardial infarction, transfusion, venous thromboembolism, urinary tract infection, length of hospital stay, or total number of complications per patient. Despite potential benefits of regional anesthesia for minimally invasive Ivor Lewis esophagectomy, the present study did not show significant differences in any outcomes between regional and general anesthesia versus general anesthesia alone.

Risk Factors for Early Periprosthetic Fracture after Primary Total Hip Arthroplasty

AbstractPeriprosthetic fracture (PPF) after total hip arthroplasty (THA) is associated with adverse outcomes. Many studies have sought to determine risk factors for PPF, though controversy exists regarding several variables. This study sought to determine risk factors for early PPF using the National Surgical Quality Improvement Program (NSQIP) dataset. Patients with a primary current procedural terminology for THA were identified. The primary outcome was reoperation/readmission for PPF within 30 days. Multivariable logistic regression was utilized to adjust for confounding factors. A total of 159,234 patients were included in the study, of whom 195 patients (0.12%) had a PPF within 30 days, with a mean day of reoperation/readmission of 14.6 (standard deviation 7.7). A total of 68 patients (34.9% of those fractured) underwent one or more reoperations. In multivariable analysis, risk factors for PPF were higher body mass index (BMI; odds ratio [OR] 1.03 per mg/kg2, 95% confidence interval [CI] 1.0–1.05) and higher preoperative leukocyte count (OR 1.04 per 103/mL, 95% CI 1.01–1.06). Among females, age (OR 1.05 per year, 95% CI 1.04–1.07) was significantly associated with PPF, but a similar difference was not observed among males (OR 1.01, 95% CI 0.98–1.04). Controlling for patient age, there was no significant difference in risk of PPF for females versus males (p = 0.2213). PPF was associated with the development of additional complications (OR 4.10, 95% CI 2.68–6.27). This study identified risk factors for PPF after primary THA. These results have implications for preoperative planning and postoperative precautions among patients with particularly elevated risk of PPF.

A Simple Risk Score to Predict Clavien-Dindo Grade IV and V Complications After Non-elective Cholecystectomy

BackgroundNon-elective cholecystectomies can lead to severe postoperative complications and mortality. Existing risk prediction tools do not meet the need to reliably predict these complications. MethodsUsing the 2011–2016 American College of Surgeons National Surgical Quality Improvement Program datasets, we identified patients undergoing non-elective cholecystectomy with primary ICD 9/10 codes indicating the following diagnoses: symptomatic cholelithiasis, acute cholecystitis, choledocholithiasis, gallstone pancreatitis, and cholangitis. We randomly allocated patients to derivation and validation cohorts (80/20 split). Severe complications (Clavien-Dindo grades IV and V) included unplanned intubation, prolonged mechanical ventilation, pulmonary embolism, acute renal failure requiring dialysis, stroke, myocardial infarction, cardiac arrest, septic shock, and mortality. Logistic regression using backward selection identified predictors of severe complications and a risk score was generated based on this model. ResultsOf 68,953 patients in the derivation cohort, 1.7% (N = 1157) suffered severe complications. The final multivariable risk score model included the following predictors: age (0–12 points), preoperative sepsis (5 points), planned open procedure (5 points), estimated glomerular filtration rate (0–13 points), and preoperative albumin level (0–8 points). The associated risk-score model yielded scores from 0 to 43 with 0.1–59.4% predicted probability of severe complications and had a C-statistic of 0.845 (95% CI 0.834, 0.857) in the derivation cohort and 0.870 (95% CI 0.851, 0.889) in the validation cohort. ConclusionA simple risk-score model predicts severe complications in patients undergoing unplanned cholecystectomy for common indications encountered in an acute care surgery service and identifies high-risk patients.

Acute Complications in Total Wrist Arthroplasty: A National Surgical Quality Improvement Program Review.

Background The study sought to assess the patient-based variables, surgical risk factors, and postoperative conditions associated with readmission after total wrist arthroplasty (TWA). Materials and Methods All patients undergoing TWA were identified from the National Surgical Quality Improvement Program dataset from 2005 to 2016. Patient demographics, medical comorbidities, surgical characteristics, and outcomes were examined to isolate predictors for readmission within 30 days postoperatively. Results A total of 57 patients were identified to have undergone TWA. The average patients were 62.3 (13.8) years old, female (57.7%), and most were treated in the outpatient setting (67.3%). Comorbid conditions included smoking (17.3%), diabetes (15.4%), and chronic steroid therapy (15.4%). No complications were identified in the 30-day postoperative period. There was a trend for increasing utilization of TWA over the years included. Conclusion TWA is a safe procedure with low complication rates in the acute postoperative period. Increasing utilization is likely a result of improved outcomes and cost-effectiveness of TWA. Level of Evidence This is a Level II, prognostic study.

Use of neuraxial anesthesia for hybrid lower extremity revascularization is associated with reduced perioperative morbidity

ObjectiveRecent advances in endovascular technology have allowed complex peripheral arterial disease (PAD) to be treated with less invasive hybrid procedures under neuraxial anesthesia. This study investigates the perioperative outcomes of hybrid lower extremity revascularization (LER) performed under neuraxial anesthesia (NAA) vs general anesthesia (GA). We hypothesize that the use of NAA is associated with improved outcomes. MethodsThe 2005-2017 American College of Surgeons National Surgical Quality Improvement Program dataset was used to identify patients who underwent hybrid LER for PAD. Based on the primary anesthetic technique, patients were divided into two groups: GA and NAA, which included spinal or epidural anesthesia. Baseline characteristics of the two groups were compared. A group of patients treated under GA were matched (2:1) to patients in the NAA group based on gender, age, race, functional status, transfer status, chronic obstructive pulmonary disease, wound infection, American Society of Anesthesiologists classification, emergent surgery, preoperative sepsis, indication, and type of hybrid procedure. Patient characteristics and 30-day outcomes were compared. ResultsOf 9430 patients who underwent hybrid LER, only 452 (4.8%) received NAA. Patients who received NAA were older (mean age, 68 ± 8.4 vs 72.3 ± 9.2; P = .004) and were more likely to be white (70.9% vs 85.6%; P < .0001), have dependent functional status (7.6% vs 13.1%; P < .0001), chronic obstructive pulmonary disease (24.3% vs 17.5%; P = .001), and a diagnosis of wound infection (15% vs 23.5%; P < .0001). After propensity matching, 904 patients in the GA group were compared with 452 patients in the NAA group with no difference in baseline characteristics. NAA was associated with reduced rate of more than 48 hours' ventilator requirement (2.4% vs 0.2%; P = .0014), bleeding requiring transfusion (17.5% vs 8%; P < .0001), and overall morbidity (29.3% vs 19%; P < .0001), as well as shorter length of hospital stay (6.8 ± 9.3 vs 5.3 ± 6.1 days; P = .0026) and total operating time (237.8 ± 109 vs 202.4 ± 113 minutes; P < .0001) compared with GA. ConclusionsNAA is an infrequently used anesthesia technique during hybrid LER and is primarily used for older patients with chronic obstructive pulmonary disease. NAA is associated with decreased perioperative morbidity and length of hospital stay compared with GA and may be considered in this sicker patient population.

Accurate Preoperative Prediction of Discharge Destination Using 8 Predictor Variables: A NSQIP Analysis

With inpatient length of stay decreasing, discharge destination after surgery can serve as an important metric for quality of care. Additionally, patients desire information on possible discharge destination. Adequate planning requires a multidisciplinary approach, can reduce healthcare costs and ensure patient needs are met. The Surgical Risk Preoperative Assessment System (SURPAS) is a parsimonious risk assessment tool using 8 predictor variables developed from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) dataset. SURPAS is applicable to more than 3,000 operations in adults in 9 surgical specialties, predicts important adverse outcomes, and is incorporated into our electronic health record. We sought to determine whether SURPAS can accurately predict discharge destination. A "full model" for risk of postoperative "discharge not to home" was developed from 28 nonlaboratory preoperative variables from ACS NSQIP 2012-2017 dataset using logistic regression. This was compared with the 8-variable SURPAS model using the C index as a measure of discrimination, the Hosmer-Lemeshow observed-to-expected plots testing calibration, and the Brier score, a combined metric of discrimination and calibration. Of 5,303,519 patients, 447,153 (8.67%) experienced a discharge not to home. The SURPAS model's C index, 0.914, was 99.24% of that of the full model's (0.921); the Hosmer-Lemeshow plots indicated good calibration and the Brier score was 0.0537 and 0.0514 for the SUPAS and full model, respectively. The 8-variable SURPAS model preoperatively predicts risk of postoperative discharge to a destination other than home as accurately as the 28 nonlaboratory variable ACS NSQIP full model. Therefore, discharge destination can be integrated into the existing SURPAS tool, providing accurate outcomes to guide decision-making and help prepare patients for their postoperative recovery.

Association of Hospital Altitude and Postoperative Infectious Complications After Major Operations.

Introduction: The relationship between altitude during treatment and common postoperative infections remains to be established. Based on the inverse relationship between oxygen partial pressure and altitude, we hypothesized that hospital elevation would correlate positively with postoperative infectious complication rates, including surgical site infection (SSI), urinary tract infection (UTI), and pneumonia. Methods: We used an event-enriched population of general, urologic, vascular, plastic-reconstructive, orthopedic, and thoracic patients within the 2016 ACS National Surgical Quality Improvement Program (NSQIP) dataset who underwent procedures with high risk of infectious complications. This yielded 82,172, 175,409, and 88,856 patients from 571, 577, and 570 hospitals for the study of 30-day postoperative SSI, UTI, and pneumonia outcomes respectively. Hospital altitudes were determined using Google Maps. Data were analyzed using univariate (altitude) and multivariate logistic regression, with altitude forced into the model, and forward-selection of NSQIP variables, with adjustment for clustering by hospital. Results: When compared in 1000-foot increments above sea level, hospital altitude had no significant effect on SSI or UTI (odds ratio [OR] = 1.0, p > 0.05). The risk of postoperative pneumonia decreased with increased altitude (OR = 0.93, 95% confidence interval: 0.87-0.99, p = 0.03). Conclusions: Patients and providers should be reassured that there is no increased risk of SSI or UTI at higher altitudes. The decreased risk of postoperative pneumonia was surprising and there exist potential explanations warranting future investigation.

Analysis of Discharge Destination After Open Versus Minimally Invasive Surgery for Lung Cancer

Patients express strong opinion regarding discharge destination, preferring discharge home vs elsewhere. As focus on patient satisfaction increases, we sought to understand differences in postoperative discharge destination after minimally invasive vs open anatomic lung resection for lung cancer to guide patient education and management and better understand the postoperative patient experience. Procedures were identified by Current Procedural Terminology and International Classification of Diseases codes using the 2012-2017 American College of Surgeons National Surgical Quality Improvement Program dataset. Propensity score analysis was used to assess the relationship between the surgical approach and nonhome discharge destination (primary outcome) and postoperative complications; related, unplanned readmission; and mortality (secondary outcomes). A total of 17,303 patients underwent anatomic lung resection for lung cancer, including 10,121 (58.5%) minimally invasive and 7182 (41.5%) open resections. Patients undergoing open resection had 60% greater odds of nonhome discharge (P < .001), 58% greater odds of postoperative mortality (P= .003), 36% greater odds of postoperative complication (P < .001), and 17% greater odds of readmission (P= .04) compared with patients undergoing minimally invasive resection. The minimally invasive approach to lung resection for lung cancer offers patients a more desirable patient-centered postoperative experience, as well as more favorable clinical outcomes, and should be favored when feasible.

Comprehensive Review of Cranial Chordomas Using National Databases in the USA

AimsThe management of cranial chordomas is controversial. We provide a comprehensive review of the evolving patterns of care of cranial chordomas in the USA. Materials and methodsWe analysed the National Cancer Database (NCDB) and the Surveillance, Epidemiology, and End Results (SEER) database between 2004 and 2014 for clinical characteristics and long-term survival, and the National Surgical Quality Improvement Program (NSQIP) dataset between 2005 and 2016 for perioperative characteristics and surgical morbidity. ResultsIn total, 936 patients were identified from the NCDB, 405 patients from SEER and 64 patients from the NSQIP. Most patients were men (56.2, 54.8 and 57.8% in NCDB, SEER and NSQIP, respectively) and White (80.9 and 83.2% in NCDB and SEER, respectively). Surgery was the preferred treatment modality (87.3% in NCDB and 86.2% in SEER). Surgery was carried out alone (41.8% in NCDB and 40.7% in SEER) or in combination with radiation (42.1% in NCDB and 45.4% in SEER). Proton therapy was the most common type of radiation (32.2% in NCDB), particularly after 2011. The median operative time, median hospital length and postoperative morbidity were significantly higher in chordoma patients compared with patients who underwent other skull-base procedures. The 5-year survival rate was 79.8% in NCDB and 76.9% in SEER. There was a trend towards longer survival in patients receiving surgery and radiation, which has been increasingly used since 2004. Patients younger than 60 years had a decreased risk of mortality. ConclusionsOur analysis reflects patterns of care in the USA. The use of surgery and radiation is increasing, with a trend towards longer survival. Surgery is complicated with long operative time, hospital stay and a higher rate of complications.

Accurate preoperative prediction of unplanned 30-day postoperative readmission using 8 predictor variables

BackgroundUnplanned postoperative readmissions are associated with high costs, may indicate poor care quality, and present a substantial opportunity for healthcare quality improvement. Patients want to know their risk of unplanned readmission, and surgeons need to know the risk to adequately counsel their patients. The Surgical Risk Preoperative Assessment System tool was developed from the American College of Surgeons National Surgical Quality Improvement Program dataset and is a parsimonious model using 8 predictor variables. Surgical Risk Preoperative Assessment System is applicable to >3,000 operations in 9 surgical specialties, predicts 30-day postoperative mortality and morbidity, and is incorporated into our electronic health record. MethodsA Surgical Risk Preoperative Assessment System model was developed using logistic regression. It was compared to the 28 nonlaboratory variables model from the American College of Surgeons National Surgical Quality Improvement Program 2012 to 2017 dataset using the c-index as a measure of discrimination, the Hosmer-Lemeshow observed-to-expected plots testing calibration, and the Brier score, a combined metric of discrimination and calibration. ResultsOf 4,861,370 patients, 188,150 (3.98%) experienced unplanned readmission related to the index operation. The Surgical Risk Preoperative Assessment System model’s c-index, 0.728, was 99.3% of that of the full model’s, 0.733; the Hosmer-Lemeshow plots indicated good calibration; and the Brier score was 0.0372 for Surgical Risk Preoperative Assessment System and 0.0371 for the full model. ConclusionThe 8 variable Surgical Risk Preoperative Assessment System model detects patients at risk for postoperative unplanned, related readmission as accurately as the full model developed from all 28 nonlaboratory preoperative variables in the American College of Surgeons National Surgical Quality Improvement Program dataset. Therefore, unplanned readmission can be integrated into the existing Surgical Risk Preoperative Assessment System tool providing moderately accurate prediction of postoperative readmission.

Effect of operative duration on infectious complications and mortality following hepatectomy

BackgroundTo study mortality and infectious complications (IC) risk relative to operative duration in a large and contemporary cohort of patients undergoing hepatectomy. MethodsA retrospective cohort study of 21,443 patients from the National Surgical Quality Improvement Program dataset of patients who underwent liver resection from 2012 to 2016. ResultsPatients undergoing hepatectomy during the study period (N = 21,443) had a mean operative duration of 243.5 min of which 16.6% (3533) developed at least one IC. The overall 30-day mortality was 1.6%. A significant increase in mortality and IC was demonstrated from 3 h of operating time (OR: 1.99 and OR: 1.94, respectively), peaking at 8 h (OR: 7.15 and OR: 6.37, respectively). Pneumonia, sepsis/septic shock, and SSI presented high prevalence and were linked to significant mortality. After case-matching, elective hepatectomy was associated with a 4-fold increased risk of infectious complications. ConclusionsOperative duration was associated with a linear increased risk of mortality and IC after hepatectomy. The most critical determinants of IC were ASA class, COPD, CHF, and type of hepatectomy.

The association of body mass index with same-day hospital admission, postoperative complications, and 30-day readmission following day-case eligible joint arthroscopy: A national registry analysis

Study objectiveWe examined the association of body mass index (BMI) with hospital admission, same-day complications, and 30-day hospital readmission following day-case eligible joint arthroscopy. DesignRetrospective cohort study. SettingMulti-institutional. PatientsAdult patients undergoing arthroscopy of the knee, hip or shoulder in the outpatient setting. InterventionNone. MeasurementsUsing the American College of Surgeons National Surgical Quality Improvement Program dataset from 2012 to 2016, we examined seven BMI ranges: normal BMI (≥20 kg/m2 and <25 kg/m2), underweight (<20 kg/m2), overweight (≥25 kg/m2 and <30 kg/m2), Class 1 and 2 obese (≥30 kg/m2 and <40 kg/m2, reference variable), and severe obesity, which we divided into the following BMI ranges: ≥40 kg/m2 and <50 kg/m2, ≥50 kg/m2 and <60 kg/m2, and ≥60 kg/m2. The primary outcome was hospital admission. Secondary outcomes included same-day postoperative complications and 30-day hospital readmission. We performed multivariable logistic regression and reported odds ratios (OR) and their associated 95% confidence interval (CI) and considered a p-value of <0.05 as statistically significant. Main resultsThere were a total of 99,410 patients included in the final analysis, in which there was a 2.6% rate of hospital admission. When compared to class 3 obesity, only those with BMI ≥50 kg/m2(OR 1.55, 95% CI 1.18–2.01, p = 0.005) had increased odds of hospital admission. There were no differences in 30-day hospital readmission or same-day postoperative complications. ConclusionWe found that only patients with BMI ≥50 kg/m2 had increased odds for same-day hospital admission even when patient's comorbid conditions are optimized, suggesting that a BMI ≥50 kg/m2 may be used as a sole factor for patient selection in patients undergoing joint arthroscopy. For patients with BMI <50 kg/m2, we recommend that BMI alone should not be solely used to exclude patients from having joint arthroscopies performed in an outpatient setting, especially since this patient group makes up a significant proportion of joint arthroscopy.

Latent tuberculosis progression within a collective of human immunodeficiency virus infected patients

We examined the association of body mass index (BMI) with hospital admission, same-day complications, and 30-day hospital readmission following day-case eligible joint arthroscopy.Retrospective cohort study.Multi-institutional.Adult patients undergoing arthroscopy of the knee, hip or shoulder in the outpatient setting.None.Using the American College of Surgeons National Surgical Quality Improvement Program dataset from 2012 to 2016, we examined seven BMI ranges: normal BMI (≥20 kg/m2 and <25 kg/m2), underweight (<20 kg/m2), overweight (≥25 kg/m2 and <30 kg/m2), Class 1 and 2 obese (≥30 kg/m2 and <40 kg/m2, reference variable), and severe obesity, which we divided into the following BMI ranges: ≥40 kg/m2 and <50 kg/m2, ≥50 kg/m2 and <60 kg/m2, and ≥60 kg/m2. The primary outcome was hospital admission. Secondary outcomes included same-day postoperative complications and 30-day hospital readmission. We performed multivariable logistic regression and reported odds ratios (OR) and their associated 95% confidence interval (CI) and considered a p-value of <0.05 as statistically significant.There were a total of 99,410 patients included in the final analysis, in which there was a 2.6% rate of hospital admission. When compared to class 3 obesity, only those with BMI ≥50 kg/m2 (OR 1.55, 95% CI 1.18–2.01, p = 0.005) had increased odds of hospital admission. There were no differences in 30-day hospital readmission or same-day postoperative complications.We found that only patients with BMI ≥50 kg/m2 had increased odds for same-day hospital admission even when patient's comorbid conditions are optimized, suggesting that a BMI ≥50 kg/m2 may be used as a sole factor for patient selection in patients undergoing joint arthroscopy. For patients with BMI <50 kg/m2, we recommend that BMI alone should not be solely used to exclude patients from having joint arthroscopies performed in an outpatient setting, especially since this patient group makes up a significant proportion of joint arthroscopy.

The Impact of Current Smoking on Wound Complications, A Review of the ACS NSQIP Dataset [11Q

INTRODUCTION: Smoking is a modifiable risk factor that is associated with cardiac, respiratory, and wound postoperative complications. We investigate the impact of smoking on postoperative wound complications. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) dataset was queried for patient who underwent hysterectomy by primary CPT code from 2011 to 2014. CPT codes used included laparoscopic hysterectomy (58570-58573), laparoscopic assisted vaginal hysterectomy (58550-58554), abdominal hysterectomy (58150), vaginal hysterectomy (58260, 58261, 58290, 58291). Smoking was defined by the ACS NSQIP as individuals who have smoked cigarettes within the previous twelve months leading up to surgery. Univariate analysis was used to assess 30 day postoperative wound complications. Wound complications included: superficial surgical site infection (SSI), deep SSI, organ space SSI and wound disruption. RESULTS: There were significant differences between number of wound complications and relative risk for smokers compared to non-smokers undergoing hysterectomy. The relative risk for superficial wound complication is 1.5 (p<0.05), deep surgical site infection is 1.89 (P<0.05), organ space infection is 1.59 (p<0.05), and wound disruption 1.61 (p <0.05) for smokers compared to non-smokers undergoing hysterectomy. The risk of a single complication increases by 1.56 (p<0.001) with smoking, risk of two complications increases by 2.12 (p<0.001), and the risk of having three complications increases by 4.88 (p<0.001). CONCLUSION: Smoking at the time of hysterectomy greatly increased the risk of wound complications. Future studies should investigate the amount of time from smoking cessation to surgery required to decrease the risk of wound complications.

Factors Associated with Wound Complications after Open Femoral Artery Exposure for Elective Endovascular Abdominal Aortic Aneurysm Repair.

We identified factors that would lead to wound complications after open femoral exposure for endovascular abdominal aortic aneurysm repair (oEVAR). Using the National Surgical Quality Improvement Program dataset (2005-2014), we examined the patients who underwent oEVAR. Patients were stratified on whether they developed postoperative wound complications. Comparisons were made between group with wound complications and those without and adjusted analyses performed to identify variables that independently increased the risk of wound complications. There were 14,868 patients in the study cohort and 2.6% (384 patients) developed wound complications after EVAR. Among those with wound complications, 94% (360 patients) of patients had superficial and deep surgical site infection. Patients who had wound complication were likely to be younger (72.6 vs. 73.7 years old ( p = 0.02), functionally dependent (5.4 vs. 2.5%) ( p < 0.05), smoker (3 vs. 2.4%, p =0.03), female (4 vs. 2.2%), with significantly higher body mass index (31 vs. 28), and more commonly had diabetes (4 vs. 2.4%, p < 0.001) or renal failure (12 vs. 3%, p < 0.001). Although perioperative survival was similar, patients who had wound complications had significantly longer hospital length of stay (LOS) (7.3 ± 12 vs. 3.4 ± 5 days, p < 0.001). Up to 3% patients developed wound complications after open femoral exposure during EVAR with significantly higher LOS and therefore cost utilization.

Comparison of open and endovascular procedures in patients with critical limb ischemia on dialysis

ObjectivePeripheral artery disease is a common comorbidity in patients with end-stage renal disease (ESRD), but there is a paucity of data comparing outcomes of different interventions in this group of patients. In this study, we examined perioperative outcomes of lower extremity endovascular revascularization (ER) and open revascularization (OR) in dialysis patients with critical limb ischemia (CLI). MethodsPatients on dialysis and undergoing ER and OR for CLI from 2011 to 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program dataset. Patient demographics, comorbidities, anatomic features, and perioperative outcomes were compared between ER and OR procedures. ResultsFrom 2011 to 2015, 1021 lower extremity revascularizations were performed in dialysis patients with CLI. In this group, 535 were ER (53%) and 486 were OR (47%) procedures. Although demographic characteristics such as age and gender were similar between the two groups, there was a higher proportion of Caucasians and African Americans in the OR group. Patients undergoing open and endovascular procedures had similar rates of hypertension, congestive heart failure, diabetes, chronic obstructive pulmonary disease, and bleeding disorders. A minority of procedures (4%) were emergencies, which were distributed equally between the two groups. Preoperative aspirin usage was higher in the ER group (84% vs 78%; P = .024), beta-blocker use was higher in the OR group (79% vs 74%; P = .08), and statin use was similar between the two groups (72% in OR and 70% in ER; P = .54). On risk-adjusted multivariate analysis, OR was associated with a lower rate of major amputation (5.97% vs 11.78%; odds ratio, 0.48; 95% confidence interval [CI], 0.26-0.85), but a higher rate of postoperative bleeding (29.6% vs 8.97%; odds ratio, 2.86; 95% CI, 1.8-4.35) and wound complications (15% vs 3%; odds ratio, 4.5; 95% CI, 2.38-8.3). The 30-day mortality and cardiovascular morbidity were similar between the two groups. ConclusionsIn patients with ESRD with CLI, OR is associated with a lower risk of major limb amputation but a higher rate of postoperative wound complications and bleeding, compared with ER. Cardiovascular complications, 30-day mortality, reinterventions and readmissions were similar between the two groups. In patients with ESRD with CLI, OR should be considered as an option for limb salvage if feasible. Long-term outcomes comparing the two types of procedures are needed.