Surgical Quality Research Articles

Application of Multimodal Reconstruction Technology and 3D Printing Technology in MVD Surgery.

Microvascular decompression (MVD) plays a pivotal role in the treatment of cranial neurovascular compression syndromes, yet the safety and precision of the surgery remain a focus of clinical attention. This article delves into the application of multimodal reconstruction and 3D printing technologies in MVD surgeries, evaluating their effectiveness in preoperative planning. Multimodal reconstruction, by integrating various imaging techniques such as magnetic resonance imaging (MRI) and computed tomography (CT), provides high-resolution anatomical information, offering comprehensive data support for preoperative planning and intraoperative navigation. Complementing this, 3D printing technology presents patients' anatomical structures as individualized physical models, enabling surgeons to fabricate corresponding skin templates for surgical needs, offering intuitive and practical references. Case studies presented in this article demonstrate the application and efficacy of these technologies in actual MVD surgeries. The results suggest that multimodal reconstruction and 3D printing technologies aid surgical teams in better understanding patients' anatomical structures during preoperative planning, enhancing surgical accuracy, reducing operative time, and shortening hospital stays. Despite notable advancements in MVD surgeries, challenges such as data accuracy, technological complexity, and cost persist. Future research should aim to address these issues, further optimizing the technologies and promoting their widespread application in neurosurgical procedures. Through in-depth investigation and understanding of these advanced technologies, we hope to pave new paths for improving surgical outcomes and patients' quality of life.

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<0.0001). No association was found between actual 30-dm and predicted NELA 30-dm, R²=0.01; p<0.0001 or ACS-NSQIP, R²=0.01; p<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 >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<0.0001. Both NELA and ACS-NSQIP predicted 30-dm showed a significant positive correlation with actual 30-dm: R²=0.33, p<0.0001; and R²=0.41, p<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 >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<0.0001 and R²=0.09, p<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<0.0001), but a weak one between a-30-dm and NELA (R²=0.04, p<0.0001) or ACS-NSQIP (R²=0.02, p<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<0.0001) with only NELA showing a strong positive correlation with a-30-dm (R²=0.31, p<0.0001); and not ACS-NSQIP (R²=0.05, p<0.0001). Conclusion NELA can accurately predict 30-day mortality in patients aged <70 undergoing EL but not >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.].

Geographic and racial disparities in the quality of surgical care among patients with nonmetastatic uterine cancer

BackgroundWhile utilization of minimally invasive surgery and sentinel lymph node biopsy have increased considerably over time for surgical management of early-stage uterine cancer, practice varies significantly in the United States, with disparities among low-volume centers and patients of Black race. A significant number of counties in the US are without a gynecologic oncologist, and almost half of counties with the highest gynecologic cancer rates lack a local gynecologic oncologist. ObjectiveTo evaluate relationships of distance traveled and proximity to gynecologic oncologists with receipt of and racial disparities in the quality of surgical care in patients undergoing hysterectomy for nonmetastatic uterine cancer. Study designPatients who underwent hysterectomy for nonmetastatic uterine cancer in Kentucky, Maryland, Florida, and North Carolina were identified in 2012-2018 State Inpatient Database and State Ambulatory Surgery Services Database files. County-to-county distances were used for distances traveled and to nearest gynecologic oncologist. Factors associated with receipt of minimally invasive surgery and lymph node dissection were analyzed using multivariable logistic regression models including assessment for interactions of travel for surgery with patient race. ResultsAmong 21,837 cases, 45.5% lived in a county without a gynecologic oncologist; 55.5% overall traveled to another county for surgery, including 88% of those lacking a local gynecologic oncologist. Patients lacking local access to a gynecologic oncologist in their county who did not travel for surgery were more likely to receive open surgery and no lymph node dissection, and those in counties without access in any surrounding county were even more likely. Among patients in counties without a gynecologic oncologist, those who traveled for surgery had similar likelihood of minimally invasive surgery (71%) but greater likelihood of lymph node dissection (64.7% vs 57.2%) compared to non-travelers. Among counties without a gynecologic oncologist, longer distance traveled was associated with receipt of lymph node assessment. Compared to non-Black patients, Black patients were less likely to undergo minimally invasive surgery (57.0% vs 74.1%). In adjusted regression models controlling for a diagnosis of fibroids, Black race was an independent risk factor for receipt of open surgery. There was a significant interaction of Black race and travel for surgery, with Black patients who lived in counties without a gynecologic oncologist who did not travel facing incrementally lower likelihood of receiving minimally invasive surgery (OR=0.57 vs non-Black patients who traveled for surgery; OR=0.60 as interaction term; p<0.001 for both). Similar disparities in surgical quality by race were noted for Black patients who lived in counties with a gynecologic oncologist who traveled out of county for surgery. ConclusionsPatients, particularly those of Black race, who lack local access to gynecologic oncologist specialty care benefit from traveling to specialty centers to ensure access to high-quality surgery for nonmetastatic uterine cancer. Further work is needed to ensure equitable and universal access to high-quality care through patient travel or specialist outreach.

Risk factors and outcomes after surgery for malignant neoplasm of the parotid gland: An ACS-NSQIP study

BackgroundMalignant neoplasms of the parotid gland (MPG) are clinically challenging due to aggressive growth and metastasis. Despite tumor resection being the primary treatment, there is a paucity of studies on post-surgical outcomes and pre-operative risk factors for MPG. Materials and MethodsWe queried the American College of Surgeons National Surgical Quality Improvement Program database to identify patients who underwent MPG surgery between 2008 and 2021. 30-day postoperative outcomes and risk factors predisposing to the occurrence of complications were assessed. ResultsThe study population included 3,052 patients, the majority of whom were males (n=1,842; 60%) and White (n=2,017; 66%). The average age was 63 ± 16 years. The most common comorbidities were obesity (n=1,182; 39%) and hypertension (n=1,533; 50%). Surgical procedures were performed predominantly in the inpatient setting (n=1,773; 58%) by ENT surgeons (n=2,767; 91%). Overall, complications were reported in 6.8% (n=209) of patients. Inpatient setting (p<0.001), renal failure (p<0.001), smoking (p=0.012), as well as increased creatinine (p<0.001) and blood urea nitrogen (BUN) levels (p=0.001) were identified as risk factors for complications. In addition, concurrent microsurgical procedures such as flap surgery and/or nerve grafting significantly increased the risk of postoperative adverse events (p<0.001). ConclusionsOur analysis revealed that complication rates were associated with high creatinine and BUN levels, inpatient surgery, renal failure, higher ASA classes and smoking. We also found that concurrent microsurgical procedures were predictive factors for complications. These findings can inform patient counseling, preoperative planning, and risk stratification.

Within-hospital Temporal Clustering of Postoperative Complications and Implications for Safety Monitoring and Benchmarking Using ACS-NSQIP Data.

To determine the extent to which within-hospital temporal clustering of postoperative complications is observed in the American College of Surgeons, National Surgical Quality Improvement Program (ACS-NSQIP). ACS-NSQIP relies on periodic and on-demand reports for quality benchmarking. However, if rapid increases in postoperative complication rates (clusters) are common, other reporting methods might be valuable additions to the program. This article focuses on estimating the incidence of within-hospital temporal clusters. ACS-NSQIP data from 1,547,440 patients, in 425 hospitals, over a 2-year period was examined. Hospital-specific Cox proportional hazards regression was used to estimate the incidence of mortality, morbidity, and surgical site infection (SSI) over a 30-day postoperative period, with risk adjustment for patient and procedure and with additional adjustments for linear trend, day-of-week, and season. Clusters were identified using scan statistics, and cluster counts were compared, using unpaired and paired t tests, for different levels of adjustment and when randomization of cases across time eliminated all temporal influences. Temporal clusters were rarely observed. When clustering was adjusted only for patient and procedure risk, an annual average of 0.31, 0.85, and 0.51 clusters were observed per hospital for mortality, morbidity, and SSI, respectively. The number of clusters dropped after adjustment for linear trend, day-of-week, and season (0.31-0.24; P = 0.012; 0.85-0.80; P = 0.034; and 0.51-0.36; P < 0.001; using paired t tests) for mortality, morbidity, and SSI, respectively. There was 1 significant difference in the number of clusters when comparing data with all adjustments and after data were randomized (0.24 and 0.25 for mortality; P = 0.853; 0.80 and 0.82 for morbidity; P = 0.529; and 0.36 and 0.46 [randomized data had more clusters] for SSI; P = 0.001; using paired t tests) for mortality, morbidity, and SSI, respectively. Temporal clusters of postoperative complications were rarely observed in ACS-NSQIP data. The described methodology may be useful in assessing clustering in other surgical arenas.

Surgical Risk, Operative Time, and Anesthesia Time Associated With Combining Tracheostomy and Gastrostomy Tube Placement Under a Single Anesthetic

IntroductionPediatric patients may need both tracheostomy and gastrostomy tube (G-tube) placement to satisfy both oxygen and nutritional requirements for sustaining life. It is unclear if combining both procedures under one anesthetic is associated with reductions in total operative time or surgical risk, compared to performing the two procedures separately. MethodsOur study used the 2016–2021 National Surgical Quality Improvement Program-Pediatric Participant Use Files. Patients age 0–2 years were included if they underwent elective tracheostomy or G-tube placement and no concomitant procedures other than direct laryngoscopy or bronchoscopy. The initial cohort included 14,047 patients undergoing G-tube placement only, 571 undergoing tracheostomy only, and 236 undergoing both procedures concurrently. Multivariable analysis used propensity score matching to compare combined procedures to matched synthetic controls, created by combining data from patients undergoing each procedure independently (N = 180 matched pairs). ResultsAfter matching, combined procedures were associated with lower complication risk (odds ratio: 0.42; 95% confidence interval [CI]: 0.27, 0.65) and reduced anesthesia time (mean difference: 57 min; 95% CI: 47, 68) when compared to synthetic controls, but did not differ on total operative time (mean difference: −4.5 min; 95% CI: −12.6, +3.6). ConclusionCombined procedures are theorized to reduce risks associated with prolonged exposure to anesthesia. We found a reduction in total anesthesia time associated with combining tracheostomy and G-tube placement under one anesthetic, and lower risk of complications, but no change in total operative time relative to performing 2 separate surgeries. Level of EvidenceIII.

Surgical Intelligence Can Lead to Higher Adoption of Best Practices in Minimally Invasive Surgery.

To examine the use of surgical intelligence for automatically monitoring critical view of safety (CVS) in laparoscopic cholecystectomy (LC) in a real-world quality initiative. Surgical intelligence encompasses routine, artificial intelligence-based capture and analysis of surgical video, and connection of derived data with patient and outcomes data. These capabilities are applied to continuously assess and improve surgical quality and efficiency in real-world settings. Laparoscopic cholecystectomies conducted at 2 general surgery departments between December 2022 and August 2023 were routinely captured by a surgical intelligence platform, which identified and continuously presented CVS adoption, surgery duration, complexity, and negative events. In March 2023, the departments launched a quality initiative aiming for 75% CVS adoption. Two hundred seventy-nine procedures were performed during the study. Adoption increased from 39.2% in the 3 preintervention months to 69.2% in the final 3 months ( P < 0.001). Monthly adoption rose from 33.3% to 75.7%. Visualization of the cystic duct and artery accounted for most of the improvement; the other 2 components had high adoption throughout. Procedures with full CVS were shorter ( P = 0.007) and had fewer events ( P = 0.011) than those without. OR time decreased following intervention ( P = 0.033). Surgical intelligence facilitated a steady increase in CVS adoption, reaching the goal within 6 months. Low initial adoption stemmed from a single CVS component, and increased adoption was associated with improved OR efficiency. Real-world use of surgical intelligence can uncover new insights, modify surgeon behavior, and support best practices to improve surgical quality and efficiency.

Using machine learning to identify risk factors for short-term complications following thumb carpometacarpal arthroplasty

BackgroundThumb carpometacarpal (CMC) joint osteoarthritis is among the most common degenerative hand diseases. Thumb CMC arthroplasty, or trapeziectomy with or without tendon augmentation, is the most frequently performed surgical treatment and has a strong safety profile. Though adverse outcomes are infrequent, the ability to predict risk for complications has substantial clinical benefits. In the present study, we evaluated a well-known surgical database with machine learning (ML) techniques to predict short-term complications and reoperations after thumb CMC arthroplasty. MethodsA retrospective study was conducted using data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) years 2005–2020. Outcomes were 30-day wound and medical complications and 30-day return to the operating room. We used three ML algorithms — a Random Forest (RF), Elastic-Net Regression (ENet), and Extreme Gradient Boosted Tree (XGBoost), and 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 7711 cases. The RF was the best performing algorithm for all outcomes, with an AUC score of 0.61±0.03 for reoperations, 0.55±0.04 for medical complications, and 0.59±0.03 for wound complications. On feature importance analysis, procedure duration was the highest weighted predictor for reoperations. In all outcomes, procedure duration, older age, and female sex were consistently among the top five predictors. ConclusionsWe successfully developed ML algorithms to predict reoperations, wound complications, and medical complications. RF models had the highest performance in all outcomes.

266. NSQIP 5-FACTOR MODIFIED FRAILTY INDEX PREDICTS MORBIDITY BUT NOT MORTALITY AFTER ESOPHAGECTOMY

Abstract Background Frailty is a source of morbidity in esophagectomy patients. To aid clinical decision making, it is important to determine if the simplified 5-factor modified frailty index (mFI-5) retains the same associations between frailty and adverse outcomes as its 11-factor predecessor. Methods Patients undergoing esophagectomy for esophageal cancer or dysplasia from 2016-2018 were identified using National Surgical Quality Improvement Program (NSQIP). The mFI-5 was used to determine association between frailty and post-esophagectomy morbidity and mortality. Results In total, 2,567 patients were included. No patients had a mFI-5 score higher than 3/5 and the score distribution was wide: mFI0 = 1103 (43%), mFI1 = 982 (38.3%), mFI2 = 435 (16.9%), mFI3 = 47 (1.8%). Clavien-Dindo grade IV complications increased with mFI score: mFI0 (11.2%), mFI1 (15.6%), mFI2 (19.8%), mFI3 (25.5%), as did mortality: mFI0 (1.9%), mFI1 (3%), mFI2 (3.4%), mFI3 (4.3%). Multivariate logistic regression analyses controlling for age, sex, body mass index, American Society of Anesthesiology classification, operative duration, emergency surgery status, and neoadjuvant therapy status showed increasing frailty score was associated with Clavien-Dindo grade IV complications (p=0.01), but not mortality (p=0.13). Conclusions The mFI-5 is associated with morbidity but not mortality in patients who have undergone esophagectomy for esophageal cancer. Compared to the mFI-11, the mFI-5 may not be nuanced enough in the assessment of frailty specific to this patient population.

The Open Abdomen After Intra-abdominal Contamination in Emergency General Surgery

IntroductionDelayed fascial closure (DFC) is an increasingly utilized technique in emergency general surgery (EGS), despite a lack of data regarding its benefits. We aimed to compare the clinical outcomes of DFC versus immediate fascial closure (IFC) in EGS patients with intra-abdominal contamination. MethodsThis retrospective study was conducted using the 2013-2020 American College of Surgeons National Surgical Quality Improvement Program database. Adult EGS patients who underwent an exploratory laparotomy with intra-abdominal contamination [wound classification III (contaminated) or IV (dirty)] were included. Patients with agreed upon indications for DFC were excluded. A propensity-matched analysis was performed. The primary outcome was 30-d mortality. ResultsWe identified 36,974 eligible patients. 16.8% underwent DFC, of which 51.7% were female, and the median age was 64 y. After matching, there were 6213 pairs. DFC was associated with a higher risk of mortality (15.8% versus 14.2%, P = 0.016), pneumonia (11.7% versus 10.1%, P = 0.007), pulmonary embolism (1.9% versus 1.6%, P = 0.03), and longer hospital stay (11 versus 10 d, P < 0.001). No significant differences in postoperative sepsis and deep surgical site infection rates between the two groups were observed. Subgroup analyses by preoperative diagnosis (diverticulitis, perforation, and undifferentiated sepsis) showed that DFC was associated with longer hospital stay in all subgroups, with a higher mortality rate in patients with diverticulitis (8.1% versus 6.1%, P = 0.027). ConclusionsIn the presence of intra-abdominal contamination, DFC is associated with longer hospital stay and higher rates of mortality and morbidity. DFC was not associated with decreased risk of infectious complications. Further studies are needed to clearly define the indications of DFC.

Low Rates of 30-Day Postoperative Complications After Meniscal Allograft Transplantation: A Retrospective Study Using the National Surgical Quality Improvement Program Database

PurposeThe purpose of this study is to determine the short-term (30-day) postoperative complication rates in patients undergoing meniscus allograft transplantation (MAT). MethodsAmerican College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients who had undergone MAT from 2014 to 2021 using Current Procedural Terminology (CPT) codes. Patients were excluded if they did not have sufficient demographic data – namely those without data for age, sex, BMI, preoperative functional status, ASA classification, operative time, and length of hospital stay. Post-operative complications within 30 days were identified and rates of complications were examined as the primary outcome of this study. As a secondary outcome, multivariate logistic regression was used to identify risk factors associated with the thirty-day incidence of post-operative complications. Subgroup analysis was performed to analyze differences in postoperative outcomes following isolated MAT versus MAT with concomitant ligament reconstruction/repair, cartilage preservation, or realignment osteotomy. ResultsA total of 396 meniscal transplants were identified, with mean age of 35.2 ± 14.9, mean body mass index (BMI) of 29.6 ± 6.7, mean length of stay of 0.5 ± 1.8 days. 11 patients experienced any adverse event (AAE), Specific complications included surgical site infections (5), deep vein thrombosis (DVT) (1), urinary tract infection (UTI) (3), and return to the operating room (OR) (2). On subgroup analysis, there was no significant difference between AAE rates in patients undergoing MAT with concomitant procedures compared to patients undergoing isolated MAT (7 vs 4, p=0.5). ConclusionPatients who underwent MAT had an overall complication rate of 2.8% in the short-term postoperative period (≤30 days). Patients undergoing MAT with concomitant ligament reconstruction/repair, cartilage preservation, and realignment osteotomy had similar rates of all postoperative complications when compared to patients undergoing isolated MAT. Level of EvidenceLevel IV, therapeutic case series.

369. IMPACT OF THE COVID-19 PANDEMIC ON ESOPHAGEAL CANCER PATIENTS UNDERGOING ESOPHAGECTOMY: AN ACS-NSQIP DATABASE ANALYSIS

Abstract Background To cope with the increasing number of infected patients, medical access was restricted, and public facilities were closed throughout the COVID-19 pandemic. Early detection and treatment of esophageal cancer is critical for improved prognosis. However, the impact of pandemic-related medical access restrictions has not be evaluated to date for esophageal cancer. Therefore, the purpose of this research is to determine how the lockdown policy affected the surgical outcome of patients with esophageal cancer. Methods We analyzed patients who underwent esophagectomy for esophageal cancer between 2016-2022 using data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), including the procedure targeted esophagectomy database. The patients were stratified into two groups based on their operation date relative to pandemic (BEFORE COVID group: 2016-2019 vs AFTER COVID group: 2020-2022). Demographic data and perioperative outcomes were compared between the two groups. Statistical analysis included Chi-square tests for categorical variables and independent student T-tests for continuous data, with a significance threshold set at p &amp;lt; 0.05. Results Between 2016-2022, 7,198 esophageal cancer patients underwent esophagectomy. Clinical T4 increased significantly, but clinical N and pathologic T and N stages showed no impact. PET scan imaging, neoadjuvant chemotherapy and radiotherapy remained unchanged. The utilization of a minimally invasive approach rose substantially from 32.6% to 47.2% (p &amp;lt; 0.001). Positive margin rates increased from 7.5% to 9% (p = 0.03), and anastomotic leak rates increased from 14.1% to 17.2% (p &amp;lt; 0.001). Operative time, blood loss, and conversion rate showed no significant differences. Perioperative complications, including organ space surgical site infections and myocardial infarctions, significantly increased after COVID-19. Conclusion The COVID-19 pandemic altered the clinical staging of esophageal cancer patients undergoing esophagectomy, but it did not disrupt access to essential investigations and treatment. A notable increase in the implementation of minimally invasive techniques was observed after the pandemic. However, significant impacts were noticed on operative outcomes, including positive margin and leak rates.

Recent patterns in minimally invasive colectomies: Where are we now?

ObjectiveMinimally invasive surgery (MIS) techniques such as laparoscopy and robotic surgery for colorectal resection have been cited as superior to traditional open surgery because of their associations with decreased operating room time, hospital stay length, and postoperative morbidity. Despite these benefits, the open approach remains a common surgical method for colorectal resection procedures. We aim to evaluate the most recent yearly trends in open, laparoscopic, and robotic approaches to provide insight into uptake and present the status of MIS in the field of colorectal surgery. MethodsData were collected from the American College of Surgeons National Surgical Quality Improvement Program targeted colectomy database for the years 2014–2020. The surgical approach was classified as either open, laparoscopic, or robotic. Analysis was performed to identify trends in colorectal surgery categorized by year, patient age, American Society of Anesthesiologists (ASA) classification, body mass index (BMI), and emergency status. ResultsThere was an overall decline in both open and laparoscopic surgery cases (from 38.4% to 34.4% and from 57.4% to 50.8%, respectively) and an overall increase in robotic surgery cases (from 4.2% to 14.8%) from 2014 through 2020. Open surgery was the most common approach for the lowest BMI category (<18.5), highest risk ASA classes (4–5) and most emergent surgeries, whereas robotic surgery rates were negligible for these groups. Laparoscopy was the most prevalent approach for all other categories. ConclusionLaparoscopy was the most prevalent approach in colorectal surgery, although the total case proportions generally tended to decrease. While open surgery remains the approach of choice for emergent procedures, laparoscopic case proportions increased marginally in this category, likely owing to increases in surgeon comfort and continued expansion of laparoscopic training efforts. Importantly, the total prevalence of robotic surgery increased significantly between 2014 and 2020, which may be attributable to advancements in the robotic platform and increases in familiarity and competence with the technology. We anticipate a continuation of these trends in the future and recommend the creation of a national robotic surgery training standard.

Trends and predictors of laparoscopic compared with open emergent inguinal hernia repair

BackgroundLaparoscopic emergent inguinal hernia repair remains controversial despite studies suggesting it is safe and feasible. Variables associated with laparoscopic compared with open emergent inguinal hernia repair are currently not well described. This study aims to investigate patient characteristics and risk factors associated with laparoscopic emergent inguinal hernia repair. MethodsThe American College of Surgeons National Surgical Quality Improvement database was queried for adult patients (age ≥18 years) who had undergone emergent inguinal hernia repair between 2015 and 2021. The relationships between demographic variables and laparoscopic compared with open emergent inguinal hernia repair were evaluated using univariate and multivariate analyses. ResultsA total of 8,215 patients were included in this analysis. Use of laparoscopic emergent inguinal hernia repair increased from 9% in 2015 to 23% in 2021. Female patients (odds ratio, 1.84, P < .001) and patients aged ≤65 years (odds ratio, 1.25, P = .005) were more likely to undergo laparoscopic repair. Black (odds ratio, 0.73, P = .003) and Hispanic (odds ratio, 0.72, P = .006) patients and patients with greater American Society of Anesthesiologists classification (odds ratio, 0.86, P = .037), ascites (odds ratio, 0.39, P = .039), and preoperative dialysis requirement (odds ratio, 0.45, P = .017) were less likely to undergo laparoscopic repair. Aside from a decreased likelihood of readmission in patients who underwent laparoscopic surgery (odds ratio, 0.696, P = .024), there was no difference in other postoperative outcomes, despite a laparoscopic approach being associated with greater rates of concomitant procedures compared with an open approach (24% vs 18%, P < .001). ConclusionsFemale sex, younger age, and lower American Society of Anesthesiologists class were associated with a greater likelihood of laparoscopic surgery. Black and Hispanic patients and patients with ascites and dialysis requirements were less likely to undergo laparoscopic repair. Laparoscopic inguinal hernia repair can be safely performed in an emergent setting.