Risk associated with perioperative red blood cell transfusion in cranial surgery.

We assessed the impact of intra- and postoperative RBC transfusion on postoperative morbidity and mortality in cranial surgery. A total of 8924 adult patients who underwent cranial surgery were identified in the 2006-2011 American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Patients undergoing a biopsy, radiosurgery, or outpatient surgery were excluded. Propensity scores were calculated according to demographic variables, comorbidities, and preoperative laboratory values. Patients who had received RBC transfusion were matched to those who did not, by propensity score, preoperative hematocrit level, and by length of surgery, as an indirect measure of potential intraoperative blood loss. Logistic regression was used to predict adverse postoperative outcomes. A total of 625 (7%) patients were transfused with one or more units of packed RBCs. Upon matching, preoperative hematocrit, length of surgery, and emergency status were no longer different between transfused and non-transfused patients. RBC transfusion was associated with prolonged length of hospitalization (OR 1.6, 95% CI 1.2-2.2), postoperative complications (OR 2.8, 95% CI 2.0-3.8), 30-day return to operation room (OR 2.0, 95% CI 1.3-3.2), and 30-day mortality (OR 4.3, 95% CI 2.4-7.6). RBC transfusion is associated with substantive postoperative morbidity and mortality in patients undergoing both elective and emergency cranial surgery. These results suggest judicious use of transfusion in cranial surgery, consideration of alternative means of blood conservation, or pre-operative restorative strategies in patients undergoing elective surgery, when possible.

Effect of a randomized controlled trial on the surgical treatment of spinal metastasis, 2000 through 2010: a population-based cohort study.

BACKGROUND: The effect of randomized controlled trials (RCT) on clinical practice patterns and patient outcomes is understudied. A 2005 RCT by Patchell et al demonstrated benefit for surgical decompression in patients with spinal metastasis (SpM). We examined trends in spinal surgery for patients with SpM before and after publication of the Patchell RCT. METHODS: The Nationwide Inpatient Sample (NIS) was used to identify a 20% stratified sample of surgical SpM admissions to nonfederal United States hospitals from 2000 to 2004 and 2006 to 2010, excluding 2005 when the RCT was published. Propensity scores were generated and logistic regression analysis was performed to compare outcomes in pre- and post-RCT time periods. RESULTS: A total of 7404 surgical admissions were identified. The rate of spine surgery increased post-RCT from an average of 3.8% to 4.9% surgeries per metastatic admission per year (P = .03). Admissions in the post-RCT group were more likely to be non-Caucasian, lower income, Medicaid recipients, and have more medical comorbidities and a greater metastatic burden (P < .001). Logistic regression of the propensity-matched sample showed increased odds post-RCT for expensive hospital stay (2.9; 95% confidence interval [CI] = 2.6-3.4) and some complications, including neurologic (1.7; 95% CI = 1.1-2.8), venous thromboembolism (2.8; 95% CI = 1.9-4.2), and decubitis ulcers (15.4; 95% CI = 6.7-34.5). However, odds for in-hospital mortality decreased (0.6; 95% CI = 0.5-0.8). CONCLUSIONS: Surgery for SpM increased after publication of a positive RCT. A significantly greater proportion of patients with lower socioeconomic status, more comorbidities, and greater metastatic burden underwent surgery post-RCT. These patients experienced more postoperative complications and higher in-hospital charges but less in-hospital mortality.

Short-term outcomes of craniotomy for malignant brain tumors in the elderly.

BACKGROUND: Disparity in resection rates for malignant brain tumors in elderly patients is partially attributed to a belief that advanced age is associated with an increased risk of postoperative morbidity and mortality. The objective of this study was to investigate the effect of advanced age (≥75 years) on 30-day outcomes in patients with primary and metastatic brain tumors who underwent craniotomy for definitive resection of a malignant brain tumor. METHODS: The authors conducted prospective analyses of the American College of Surgeons' National Surgical Quality-Improvement Project (NSQIP) database from 2006 to 2010 of 970 patients aged ≥40 years who underwent craniotomy for definitive resection of neoplasm. Preoperative and intraoperative characteristics and 30-day outcomes were stratified by age. By using propensity scores, 134 patients (aged ≥75 years) were matched to 134 patients ages 40 to 74 years. Logistic regression was used to predict adverse postoperative outcomes. RESULTS: The median length of hospital stay was 5 days; the rate of minor and major complications were 5.9% and 13.1%, respectively; 5.7% of patients returned to the operating room; and 4.3% of patients died within 30 days. Advanced age did not increase the odds for poorer short-term outcomes. CONCLUSIONS: Advanced age did not increase the risk of poor outcomes after surgical resection of primary or metastatic intracranial tumors when analyses were controlled for other risk factors. These results suggest that age should not be used, in isolation, as an a priori factor to discourage pursuing craniotomy.

Sepsis after elective neurosurgery: Incidence, outcomes, and predictive factors.

Sepsis is a life-threatening condition resulting from systemic infection, with mortality rates approaching 30%. Most neurological surgeries are now performed electively, which permits medical optimization preoperatively. We performed a retrospective cohort analysis of 122,466 adult elective neurosurgical patients from 2012 to 2018 in the National Surgical Quality Improvement Program database. To select for a medically optimized population, patients were included if they arrived from home on the day of surgery, were not pregnant or puerperium, and had no documented evidence of preexisting infection. We analyzed demographic, comorbidity, and operative information; performed multivariate logistic regression to explore factors predictive of postoperative sepsis; and evaluated outcomes for patients who developed sepsis. Overall, 0.87% of patients developed postoperative sepsis (n = 1,067). The rate of sepsis was higher in the cranial subpopulation (1.21%; n = 330) and lower in the spinal subpopulation (0.77%; n = 733). The overall sepsis cohort was older, had more males, was more functionally dependent, had longer operation durations, and had higher rates of medical comorbidities. Minority race and smoking were not associated with sepsis. The sepsis cohort fared worse than the control cohort across all outcome measures, including prolonged length-of-stay (≥90th percentile), discharge anywhere but home, 30-day readmission, 30-day reoperation, and 30-day mortality. Results for the cranial and spine subpopulations follow similar trends. In summary, sepsis in the elective neurosurgical population is an uncommon but devastating cause of excess morbidity and mortality.

Platelet count abnormalities and peri-operative outcomes in adults undergoing elective, non-cardiac surgery.

BACKGROUND: Anemia and transfusion of blood in the peri-operative period have been shown to be associated with increased morbidity and mortality across a wide variety of non-cardiac surgeries. While tests of coagulation, including the platelet count, have frequently been used to identify patients with an increased risk of peri-operative bleeding, results have been equivocal. The aim of this study was to assess the effect of platelet level on outcomes in patients undergoing elective surgery. MATERIALS AND METHODS: Retrospective cohort analysis of prospectively-collected clinical data from American College of Surgeons National Surgical Quality Improvement Program (NSQIP) between 2006-2016. RESULTS: We identified 3,884,400 adult patients who underwent elective, non-cardiac surgery from 2006-2016 at hospitals participating in NSQIP, a prospectively-collected, national clinical database with established reproducibility and validity. After controlling for all peri- and intraoperative factors by matching on propensity scores, patients with all levels of thrombocytopenia or thrombocytosis had higher odds for perioperative transfusion. All levels of thrombocytopenia were associated with higher mortality, but there was no association with complications or other morbidity after matching. On the other hand, thrombocytosis was not associated with mortality; but odds for postoperative complications and 30-day return to the operating room remained slightly increased after matching. CONCLUSIONS: These findings may guide surgeons in the appropriate use and appreciation of the utility of pre-operative screening of the platelet count prior to an elective, non-cardiac surgery.

The posteromedial neurovascular bundle of the ankle: an anatomic study using plastinated cross sections.

PURPOSE: The aim of this study was to evaluate the topography of the posteromedial neurovascular bundle of the ankle. The anatomic relation of the posteromedial neurovascular bundle at different levels of the ankle was studied as an aid in planning minimally invasive surgery. A thorough knowledge of the local anatomy is a prerequisite before attempting release of the tibial nerve or when using the posteromedial portal for ankle arthroscopy. METHODS: A slice anatomy study was performed on 12 intact right male cadaveric lower limbs. The distal third of each limb was cut and the foot positioned in the neutral position. The measurements were performed at the level of the tibiotalar joint, at the tip of the medial malleolus, and at the sustentaculum tali. RESULTS: The tibial nerve is predicted to be 11.8 +/- 2.4 mm and the posterior tibial artery 16.7 +/- 3.8 mm anterior from the calcaneal tendon at the level of the tibiotalar joint. At the tip of the malleolus medialis, the tibial nerve is 14.3 +/- 2.5 mm and the posterior tibial artery 22.1 +/- 4.1 mm anterior to the Achilles tendon. The medial plantar nerve is situated at the sustentaculum tali level 8.4 +/- 3.4 mm and the lateral plantar nerve 16.1 +/- 3.1 mm posterior to the sustentaculum. CONCLUSIONS: On the basis of our anatomic data, a posteromedial portal made at the level of the tip of the medial malleolus seems to be safe, effective, and reproducible. Therefore a portal at this level would be advantageous for an endoscopic tarsal tunnel release or when using the posteromedial portal for ankle arthroscopy. Anatomic characteristics should be kept in mind when ankle surgery is performed, thereby reducing the risk of injury to the medial neurovascular bundle and offering easy access inside the posterior compartment of the ankle. CLINICAL RELEVANCE: This cadaveric study suggests that, by placing the posteromedial ankle portal at the tip of the medial malleolus, the risk of neurovascular injuries could be reduced.

Surgeon specialty and patient outcomes in carotid endarterectomy.

OBJECTIVE: The goal of this study was to compare outcomes of carotid endarterectomy performed by neurological, general, and vascular surgeons. METHODS: The authors identified 80,475 patients who underwent carotid endarterectomy between 2006 and 2015 in the National Surgical Quality Improvement Program, a prospectively collected, national clinical database with established reproducibility and validity. Nine hundred forty-three patients were operated on by a neurosurgeon; 75,649 by a vascular surgeon; and 3734 by a general surgeon. Preoperative and intraoperative characteristics and 30-day outcomes were stratified by the surgeon's primary specialty. Using propensity scores, comprising pre- and intraoperative characteristics as well as procedure and diagnostic codes, the authors matched 203 neurosurgery (NS) patients to 203 vascular surgery (VS) patients and 203 NS patients to 203 general surgery (GS) patients. No pre- or intraoperative factors were significantly different between specialties in the matched sample. Regular logistic regression and conditional logistic regression were used to predict postoperative complications in the full sample and in the matched sample. RESULTS: In the complete population sample, NS patients, when compared to patients of general and vascular surgeons, were less likely to be admitted from home and more likely to have carotid artery occlusion or stenosis with cerebral infarction, to be a current smoker, to have had recent chemo- or radiotherapy, to have surgery under general anesthesia, to undergo multiple procedures, and to have longer surgery times. In unadjusted analyses, NS patients were more likely to experience major complications (NS vs VS: odds ratio 1.3, 95% CI 1.1-1.6; NS vs GS: odds ratio 1.3, 95% CI 1.0-1.7); minor complications (NS vs VS: odds ratio 2.9, 95% CI 2.0-4.1; NS vs GS: odds ratio 2.7, 95% CI 1.7-4.2); intra- or postoperative transfusions (NS vs VS: odds ratio 1.6, 95% CI 1.4-1.9; NS vs GS: odds ratio 1.9, 95% CI 1.6-2.3); prolonged hospitalization (NS vs VS: odds ratio 3.0, 95% CI 2.6-3.5; NS vs GS: odds ratio 2.6, 95% CI 2.2-3.0); and discharge to skilled care facilities (NS vs VS: odds ratio 2.8, 95% CI 2.3-3.4; NS vs GS: odds ratio 3.1, 95% CI 2.4-4.1). In adjusted, propensity-matched analyses, however, patients' outcome with carotid endarterectomy performed by NS was comparable with those completed by GS and VS. CONCLUSIONS: Patients who undergo carotid endarterectomy performed by a neurosurgeon tend to have a greater preoperative disease burden than do those treated by a general or vascular surgeon, which contributes significantly to more morbid postoperative courses. In patients matched carefully on the basis of health status at the time of surgery and intraoperative variables that affect results, patients' outcomes after carotid endarterectomy do not appear to depend on the attending surgeon's primary specialty.

Impact of Resident Involvement in Neurosurgery: An American College of Surgeons' National Surgical Quality Improvement Program Database Analysis of 33,977 Patients.

OBJECTIVE: There is conflicting and limited literature on the effect of intraoperative resident involvement on surgical outcomes. Our study assessed effects of resident involvement on outcomes in patients undergoing neurosurgery. METHODS: We identified 33,977 adult neurosurgical cases from 374 hospitals in the 2006-2012 National Surgical Quality Improvement Program, a prospectively collected national database with established reproducibility and validity. Outcomes were compared according to resident involvement before and after 1:1 matching on procedure and perioperative risk factors. RESULTS: Resident involvement was documented in 13,654 cases. We matched 10,170 resident-involved cases with 10,170 attending-alone. In the matched sample, resident involvement was associated with increased surgery duration (average, 34 minutes) and slight increases in odds for prolonged hospital stay (odds ratio, 1.2; 95% confidence interval [CI], 1.2-1.3) and complications (odds ratio, 1.2; 95% CI, 1.1-1.3) including infections (odds ratio, 1.4; 95% CI, 1.2-1.7). Increased risk for infections persisted after controlling for surgery duration (odds ratio, 1.3; 95% CI, 1.1-1.5). The majority of cases were spine surgeries, and resident involvement was not associated with morbidity or mortality for malignant tumor and aneurysm patients. Training level of residents was not associated with differences in outcomes. CONCLUSION: Resident involvement was more common in sicker patients undergoing complex procedures, consistent with academic centers undertaking more complex cases. After controlling for patient and intraoperative characteristics, resident involvement in neurosurgical cases continued to be associated with longer surgical duration and slightly higher infection rates. Longer surgery duration did not account for differences in infection rates.

Impact of Platelet Transfusion on Intracerebral Hemorrhage in Patients on Antiplatelet Therapy-An Analysis Based on Intracerebral Hemorrhage Score.

OBJECTIVE: Platelet transfusions for patients with intracerebral hemorrhage (ICH) on antiplatelet therapy (APT) remain controversial. Diverging past research and differences in platelet preparation warrant further investigation of this topic. In this study, the association between platelet transfusion and clinical outcomes of ICH is investigated in patients matched by ICH score, a validated predictor of mortality. METHODS: A consecutive review of all patients from 2012 to 2015 with nontraumatic ICH was performed. Risk factors including demographics, medical comorbidities, APT use, and ICH score were reviewed. Standardized differences were used to assess baseline characteristics; logistic regression models were performed to determine whether platelet transfusions were associated with adverse outcomes, both before and after matching for ICH score. RESULTS: A total of 538 patients with nontraumatic ICH were investigated. Of these, 168 were on APT; 71 were excluded. Thirty-nine patients (40%) received platelet transfusions and 58 (60%) did not. An overall mortality of 9.3% was measured, with 29.9% of patients enduring complications. In the unmatched cohort, patients who received platelet transfusions were more likely to deteriorate (odds ratio [OR], 4.7), undergo surgical intervention during their hospital stay (OR, 7.2), be discharged with a worse modified Rankin Scale score (OR, 3.6), or die (OR, 6.1). After matching by ICH score, platelet transfusion was not a significant predictor for any negative outcome. CONCLUSIONS: This is the first analysis of platelet transfusions in patients with ICH based on ICH score. For patients on APT, platelet transfusion is not associated with clinical outcomes in an ICH score-matched sample.

The Influence of Race on Short-term Outcomes After Laminectomy and/or Fusion Spine Surgery.

STUDY DESIGN: A retrospective cohort analysis of prospectively collected clinical data. OBJECTIVE: The aim of this study was to assess the effect of race on outcomes in patients undergoing elective laminectomy and/or fusion spine surgery. SUMMARY OF BACKGROUND DATA: Studies that have looked at the effect of race on spine surgery outcomes have failed to take into account baseline risk factors that may influence peri-operative outcomes. METHODS: We identified 48,493 adult patients who underwent elective spine surgery consisting of elective laminectomy and/or fusion, from 2006 to 2012, at hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), a prospectively collected, national clinical database with established reproducibility and validity. Pre- and intraoperative characteristics and 30-day outcomes were stratified by race. We used propensity scores to match African-American and Caucasian patients on all pre- and intraoperative factors, including by principal diagnosis leading to surgery as well as surgery performed. We used regular and conditional logistic regression to predict the effect of race on adverse postoperative outcomes in the full sample and matched sample. RESULTS: Caucasians comprised 82% of our sample. We found no differences in the incidence of pre- and intraoperative factors when comparing Caucasian patients with all minority patients, and only minimal increased odds for prolonged length of length of hospitalization (LOS) and discharge with continued care. However, African-American patients, who comprised 39% of our minority sample, had more preoperative comorbidities than Caucasian patients. Even after eliminating all differences between pre- and intraoperative factors between Caucasian and African-American patients, African-American patients continued to have LOS that was, on average, one day longer than Caucasian patients. African-American patients also had higher odds for major complications [odds ratio (OR) = 1.3; 95% confidence interval (95% CI) 1.1-1.6], and to be discharged requiring continued care (OR = 2.3; 95% CI 1.8-2.8). CONCLUSION: African-American race is independently associated with prolonged LOS, major complications, and a need to be discharged with continued care in patients undergoing elective spine surgery. LEVEL OF EVIDENCE: 3.

A pilot study investigating the effect of parathyroidectomy on arterial stiffness and coronary artery calcification in patients with primary hyperparathyroidism.

BACKGROUND: Arterial stiffness (AS) and coronary artery calcification (CAC) are predictors of cardiovascular risk and can be measured noninvasively. The aim of this study was to analyze the effects of parathyroidectomy on AS and CAC in patients with primary hyperparathyroidism (PHP). METHODS: This prospective, institutional review board-approved study included 21 patients with PHP, who underwent parathyroidectomy. Before and 6 months after parathyroidectomy, AS was assessed by measuring central systolic pressure (CSP), central pulse pressure, augmentation pressure (AP), and augmentation index (AIx); the CAC score (Agatston) was calculated on noncontrast computed tomography. AS parameters were compared with unaffected controls from donor nephrectomy database. RESULTS: Preoperative CSP and AIx parameters in PHP patients were higher than those in donor nephrectomy patients (P = .004 and P = .039, respectively). Preoperative total CAC score was zero in 15 patients (65%) and ranged from the 72nd to the 99th percentile in 6 patients (26%). Although there were no changes in CAC or AS after parathyroidectomy on average, there was variability in individual patient responses on AS. CONCLUSION: This pilot study demonstrates that CAC is not altered in PHP patients at short-term follow-up after parathyroidectomy. The heterogeneous changes in AS after parathyroidectomy warrant further investigation in a larger study with longer follow-up.

Screening via CT angiogram after traumatic cervical spine fractures: narrowing imaging to improve cost effectiveness. Experience of a Level I trauma center.

OBJECT: Screening for vertebral artery injury (VAI) following cervical spine fractures is routinely performed across trauma centers in North America. From 2002 to 2007, the total number of neck CT angiography (CTA) studies performed in the Medicare population after trauma increased from 9796 to 115,021. In the era of cost-effective medical care, the authors aimed to evaluate the utility of CTA screening in detecting VAI and reduce chances of posterior circulation strokes after traumatic cervical spine fractures. METHODS: A retrospective review of all patients presenting with cervical spine fractures to Northeast Ohio's Level I trauma institution from 2002 to 2012 was performed. RESULTS: There was a total of 1717 cervical spine fractures in patients presenting to Northeast Ohio's Level I trauma institution between 2002 and 2012. CTA screening was performed in 732 patients, and 51 patients (0.7%) were found to have a VAI. Fracture patterns with increased odds of VAI were C-1 and C-2 combined fractures, transverse foramen fractures, and subluxation of adjacent vertebral levels. Ten posterior circulation strokes were identified in this patient population (0.6%) and found in only 4 of 51 cases of VAI (7.8%). High-risk fractures defined by Denver Criteria, VAI, and antiplatelet treatment of VAI were not independent predictors of stroke. CONCLUSIONS: Cost-effective screening must be reevaluated in the setting of blunt cervical spine fractures on a case-by-case basis. Further prospective studies must be performed to elucidate the utility of screening for VAI and posterior circulation stroke prevention, if identified.

Relation of Echocardiographic Characteristics of the Right-Sided Heart With Incident Heart Failure and Mortality in Patients With Sleep-Disordered Breathing and Preserved Left Ventricular Ejection Fraction.

Sleep-disordered breathing (SDB) has been associated with right-sided heart dysfunction and adverse cardiovascular outcomes. Longitudinal data are sparse in terms of understanding the prognostic implications of right ventricular remodeling in SDB on cardiovascular risk. We therefore investigated the predictive value of right-sided cardiac functional alterations on incident heart failure (HF) or death in SDB. Patients with SDB who underwent echocardiography within 1 month of index polysomnogram from January 2002 to July 2011 with normal left ventricular ejection fraction were included. Cox proportional prognostic hazard models predicting HF or death were used. Of a potential 375 subjects, 202 fulfilled the inclusion criteria (58 ± 14 years; 50% men). Subjects were followed for 3.1 ± 2.4 years with a total of 34 (16.8%) developing HF or death. Right ventricular end-systolic area (hazard ratio [HR] 1.3, 95% CI 1.01 to 1.6, p = 0.038), pulmonary vascular resistance (PVR; HR 1.4, 95% CI 1.1 to 1.7, p = 0.005) and also left atrial volume index (HR 1.7, 95%, CI 1.3 to 2.3, p <0.001) and E/A ratio (HR 1.4, 95% CI 1.1 to 1.7, p <0.001), were predictive of HF or death. Patients with increased PVR had significantly shorter event-free survival than without increased PVR (p = 0.04). In sequential Cox models, a model based on clinical data and left ventricular ejection fraction (χ2, 5.4) was improved by left atrial volume index (χ2, 12.7; p = 0.011) and further increased by PVR (χ2, 19.7; p = 0.015). In conclusion, right-sided heart dysfunction provides important prognostic information in SDB and may aid in identifying those at highest risk to target for closer follow-up.

The Impact of Laparoscopic Approaches on Short-term Outcomes in Patients Undergoing Liver Surgery for Metastatic Tumors.

PURPOSE: To compare the perioperative outcomes associated with open and laparoscopic (LAP) surgical approaches for liver metastases. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify all adult patients who underwent surgical therapy for metastatic liver tumors between 2006 and 2012 (N=7684). Patients who underwent >1 procedure were excluded. Logistic regression after matching on propensity scores was used to assess the association between surgical approaches and perioperative outcomes. RESULTS: A total of 4555 patients underwent open resection, 387 LAP resection, 297 open radiofrequency ablation (RFA), and 265 LAP RFA. In propensity-matched samples (over 95% of patients successfully matched), there was no significant difference between LAP resection and LAP RFA in perioperative complications and length of stay and both compared favorably with their open counterparts. DISCUSSION: Minimally invasive approaches for secondary hepatic malignancies were associated with improved postoperative morbidity and length of stay and should be preferred in appropriate patients.

Use and Utility of Hemostatic Screening in Adults Undergoing Elective, Non-Cardiac Surgery.

INTRODUCTION: One view of value in medicine is outcome relative to cost of care provided. With respect to operative care, increased attention has been placed on evaluation and optimization of patients prior to undergoing an elective surgery. We examined more than 2 million patients having elective, non-cardiac surgery to assess the incidence and utility of pre-operative hemostatic screening, compared with a composite of history variables that may indicate a propensity for bleeding, to assess several important outcomes of surgery. MATERIALS & METHODS: We queried the NSQIP database to identify 2,020,533 patients and compared hemostatic tests (PT, aPTT, platelet count) and history covariables indicative of potential for abnormal hemostasis. We compared outcomes across predictor values; used Person's chi-square tests to compare differences, and logistic regression to model outcomes. RESULTS: Approximately 36% of patients had all three tests pre-operatively while 16% had none of them; 11.2% had a history predictive of potential abnormal bleeding. Outcomes of interest across the cohort included death in 0.7%, unplanned return to the operating room or re-admission within 30 days in 3.8% and 6.2% of patients; 5.3% received a transfusion during or after surgery. Sub-analyses in each of the nine surgical specialties' most common procedures yielded similar results. CONCLUSION: The limited predictive value of each hemostatic screening test, as well as excess costs associated with them, across a broad spectrum of elective surgeries, suggests that limiting pre-operative testing to a more select group of patients may be reasonable, equally efficacious, efficient, and cost-effective.

Risks associated with preoperative anemia and perioperative blood transfusion in open surgery for intracranial aneurysms.

OBJECT: Preoperative anemia may be treated with a blood transfusion. Both are associated with adverse outcomes in various surgical procedures, but this has not been clearly elucidated in surgery for cerebral aneurysms. In this study the authors assessed the association of preoperative anemia and perioperative blood transfusion, separately, on 30-day morbidity and mortality in patients undergoing open surgery for ruptured and unruptured intracranial aneurysms. METHODS: The authors identified 668 cases (including 400 unruptured and 268 unruptured intracranial aneurysms) of open surgery for treatment of intracranial aneurysms in the 2006-2012 National Surgical Quality Improvement Program, a validated and reproducible prospective clinical database. Anemia was defined as a hematocrit level less than 39% in males and less than 36% in females. Perioperative transfusion was defined as at least 1 unit of packed or whole red blood cells given at any point between the start of surgery to 72 hours postoperatively. The authors separately compared surgical outcome between patients with (n = 198) versus without (n = 470) anemia, and those who underwent (n = 78) versus those who did not receive (n = 521) a transfusion, using a 1:1 match on propensity score. RESULTS: In the matched cohorts, all observed covariates were comparable between anemic (n = 147) versus nonanemic (n = 147) and between transfused (n = 67) versus nontransfused patients (n = 67). Anemia was independently associated with prolonged hospital length of stay (LOS; odds ratio [OR] 2.5, 95% confidence interval [CI] 1.4-4.5), perioperative complications (OR 1.9, 95% CI 1.1-3.1), and return to the operating room (OR 2.1, 95% CI 1.1-4.5). Transfusion was also independently associated with perioperative complications (OR 2.4, 95% CI 1.1-5.3). CONCLUSIONS: Preoperative anemia and transfusion are each independent risk factors for perioperative complications in patients undergoing surgery for cerebral aneurysms. Perioperative anemia is also associated with prolonged hospital LOS and 30-day return to the operating room.

Preoperative steroid use and the incidence of perioperative complications in patients undergoing craniotomy for definitive resection of a malignant brain tumor.

We studied the impact of preoperative steroids on 30 day morbidity and mortality of craniotomy for definitive resection of malignant brain tumors. Glucocorticoids are used to treat peritumoral edema in patients with malignant brain tumors, however, prolonged (⩾ 10 days) use of preoperative steroids as a risk factor for perioperative complications following resection of brain tumors has not been studied comprehensively. Therefore, we identified 4407 patients who underwent craniotomy to resect a malignant brain tumor between 2007 and 2012, who were reported in the National Surgical Quality Improvement Program, a prospectively collected clinical database. Metastatic brain tumors constituted 37.5% (n=1611) and primary malignant gliomas 62.5% (n=2796) of the study population. We used logistic regression to assess the association between preoperative steroid use and perioperative complications before and after 1:1 propensity score matching. Patients who received steroids constituted 22.8% of the population (n=1009). In the unmatched cohort, steroid use was associated with decreased length of hospitalization (odds ratio [OR] 0.7; 95% confidence interval [CI] 0.6-0.8), however, the risk for readmission (OR 1.5; 95% CI 1.2-1.8) was increased. In the propensity score matched cohort (n=465), steroid use was not statistically associated with any adverse outcomes. Patients who received steroids were less likely to stay hospitalized for a protracted period of time, but were more likely to be readmitted after discharge following craniotomy. As an independent risk factor, preoperative steroid use was not associated with any observed perioperative complications. The findings of this study suggest that preoperative steroids do not independently compromise the short term outcome of craniotomy for resection of malignant brain tumors.

Impact of age on 30-day postoperative outcome of surgery for ruptured and unruptured intracranial aneurysms.

OBJECTIVE: To assess in a retrospective analysis of a prospectively collected database, the impact of increased age on 30-day postoperative outcomes of surgery for intracranial aneurysms (ICAs). METHODS: 721 adult patients who underwent surgery for ICA were identified in the 2006-2012 American College of Surgeons' National Surgical Quality Improvement Program. Baseline characteristics and 30-day outcomes were stratified by age: <50 years (n=221), 50-60 years (n=221), and >60 years (n=266). Patients <50 and 50-60 years old were propensity score-matched to those aged >60 years. Logistic regression was used to examine the relationship between increased age and surgical outcome. RESULTS: In unadjusted analyses, age <50 years was associated with fewer postoperative complications (OR=0.5, 95% CI 0.3 to 0.7) and lower mortality (OR=0.4, 95% CI 0.2 to 0.9) compared with those aged >60 years. Patients aged between 50 and 60 years were less likely to have complications (OR=0.6, 95% CI 0.4 to 0.8) in unadjusted analyses. Upon propensity score matching, covariate balance was achieved for all age strata. In adjusted analyses, patients <50 years (OR=0.4, 95% CI 0.2 to 0.7) and 50-60 years (OR=0.5, 95% CI 0.3 to 0.8) of age continued to have fewer complications than those aged >60. CONCLUSIONS: Age >60 is independently associated with 30-day postoperative morbidity in patients undergoing surgery for ICA. The results of this study suggest age >60 should be considered an a priori risk factor in surgical management of ICA, regardless of associated comorbidities often associated with increased age.

National Trends and In-hospital Complication Rates in More Than 1600 Hemispherectomies From 1988 to 2010: A Nationwide Inpatient Sample Study.

BACKGROUND: Anatomic and functional hemispherectomies are relatively infrequent and technically challenging. The literature is limited by small samples and single institution data. OBJECTIVE: We used the Nationwide Inpatient Sample (NIS) database to report on a large population of hemispherectomy patients and their in-hospital complication rates over a 23-year period. METHODS: Between 1988 and 2010, we identified 304 pediatric hospitalizations in the NIS database where hemispherectomy was performed. Using the NIS weighting scheme, this inferred an estimated 1611 hospitalizations nationwide during this time period. Descriptive statistics were calculated on this inferred sample for patient and hospital characteristics and stratified by the presence of in-hospital complications. The adjusted odds of in-hospital complications and nonroutine discharge were estimated using multivariable models. RESULTS: The mean age of the patients was 5.9 years; 46% were female, and 54% were white. In the inferred series, 909 hospitalizations (56%) encountered at least 1 in-hospital complication; 42% were surgery related, and 25% were related to the hospitalization itself. For every 1-year increase in age, there was a corresponding 8% increase in the odds of a nonroutine discharge, adjusting for other potential confounders (95% confidence interval: 1.01-1.16). The most common in-hospital complication was the need for a blood transfusion (30%), followed by meningitis (10%), hydrocephalus (8%), postoperative hematoma/stroke (8%), and adverse pulmonary event (8%). Thirty-three mortalities (2%) were inferred from this series. CONCLUSION: This is the largest study to date examining hemispherectomy and associated in-hospital complication rates. This study supports early surgery in patients with medically intractable epilepsy and severe hemispheric disease.

Impact of preoperative anemia on outcomes in patients undergoing elective cranial surgery.

OBJECT: The objective of this study was to assess whether preoperative anemia in patients undergoing elective cranial surgery influences outcomes in the immediate perioperative period (≤ 30 days). METHODS: The National Surgical Quality Improvement Program (NSQIP) was used to identify 6576 patients undergoing elective cranial surgery between 2006 and 2011. Propensity scores were used to match patients with moderate to severe anemia (moderate-severe) or mild anemia with patients without anemia. Logistic regression analysis was used to predict the outcomes of interest. Sensitivity analyses were used to limit the sample to patients without perioperative transfusion as well as those who underwent craniotomy for definitive resection of a malignant brain tumor. RESULTS: A total of 6576 patients underwent elective cranial surgery, of whom 175 had moderate-severe anemia and 1868 had mild anemia. Patients with moderate-severe (odds ratio 1.8, 95% CI 1.1-2.8) and mild (odds ratio 1.5, 95% CI 1.3-1.7) anemia were more likely to have prolonged length of stay (LOS) in the hospital compared to those with no anemia. Similarly, in patients who underwent craniotomy for a malignant tumor resection (n = 2537), anemia of any severity was associated with prolonged LOS, but not postoperative complications nor death. CONCLUSIONS: Anemia is not associated with an overall increased risk for adverse outcomes in patients undergoing elective cranial surgery. However, patients with anemia are more likely to experience prolonged hospitalization postoperatively, resulting in increased resource utilization.