Association Between Coronavirus Disease 2019 Vaccination and Mortality After Major Operations.

OBJECTIVE: The objective of this study was to compare postoperative 90-day mortality between (1) fully vaccinated patients with COVID-19-positive and negative diagnosis, and (2) vaccinated and unvaccinated patients with COVID-19 positive diagnosis. BACKGROUND: Societal guidelines recommend postponing elective operations for at least 7 weeks in unvaccinated patients with preoperative coronavirus disease 2019 (COVID-19) infection. The role of vaccination in this infection-operation time risk is unclear. METHODS: We conducted a national US multicenter retrospective, matched cohort study spanning July 2021 to October 2022. Participants were included if they underwent a high-risk general, vascular, orthopedic, neurosurgery, or genitourinary surgery. All-cause mortality occurring within 90 days of the index operation was the primary outcome. Inverse probability treatment weighted propensity scores were used to adjust logistic regression models examining the independent and interactive associations between mortality, exposure status, and infection proximity. RESULTS: Of 3401 fully vaccinated patients in the 8-week preoperative period, 437 (12.9%) were COVID-19-positive. Unadjusted mortality rates were not significantly different between vaccinated patients with COVID-19 (22, 5.0%) and vaccinated patients without COVID-19 (99, 3.3%; P = 0.07). After inverse probability treatment weighted adjustment, mortality risk was not significantly different between vaccinated COVID-19-positive patients compared to vaccinated patients without COVID-19 (adjusted odds ratio = 1.38, 95% CI: 0.70, 2.72). The proximity of COVID-19 diagnosis to the index operation did not confer added mortality risk in either comparison cohort. CONCLUSIONS: Contrary to risks observed among unvaccinated patients, postoperative mortality does not differ between patients with and without COVID-19 when vaccinated against the severe acute respiratory syndrome coronavirus 2 virus and receiving a high-risk operation within 8 weeks of the diagnosis, regardless of operation timing relative to diagnosis.

Timing of a Major Operative Intervention After a Positive COVID-19 Test Affects Postoperative Mortality: Results From a Nationwide, Procedure-matched Analysis.

BACKGROUND: Studies indicate that coronavirus disease 2019 (COVID-19) infection before or soon after operations increases mortality, but they do not comment on the appropriate timing for interventions after diagnosis. OBJECTIVE: We sought to determine what the safest time would be for COVID-19 diagnosed patients to undergo major operative interventions. METHODS: High-risk operations, between January 2020 and May 2021, were identified from the Veterans Affairs COVID-19 Shared Data Resource. Current Procedural Terminology (CPT) codes were used to exact match COVID-19 positive cases (n=938) to negative controls (n=7235). Time effects were calculated as a continuous variable and then grouped into 2-week intervals. The primary outcome was 90-day, all-cause postoperative mortality. RESULTS: Ninety-day mortality in cases and controls was similar when the operation was performed within 9 weeks or longer after a positive test; but significantly higher in cases versus controls when the operation was performed within 7 to 8 weeks (12.3% vs 4.9%), 5 to 6 weeks (10.3% vs 3.3%), 3 to 4 weeks (19.6% vs 6.7%), and 1 to 2 weeks (24.7% vs 7.4%) from diagnosis. Among patients who underwent surgery within 8 weeks from diagnosis, 90-day mortality was 16.6% for cases versus 5.8% for the controls ( P <0.001). In this cohort, we assessed interaction between case status and any symptom ( P =0.93), and case status and either respiratory symptoms or fever ( P =0.29), neither of which were significant statistically. CONCLUSIONS: Patients undergoing major operations within 8 weeks after a positive test have substantially higher postoperative 90-day mortality than CPT-matched controls without a COVID-19 diagnosis, regardless of presenting symptoms.

Two-year Outcomes of Prehabilitation Among Obese Patients With Ventral Hernias: A Randomized Controlled Trial (NCT02365194).

OBJECTIVE: To determine if preoperative nutritional counseling and exercise (prehabilitation) improve outcomes in obese patients seeking ventral hernia repair (VHR)? SUMMARY BACKGROUND DATA: Obesity and poor fitness are associated with complications following VHR. It is unknown if preoperative prehabilitation improves outcomes of obese patients seeking VHR. METHODS: This is the 2-year follow-up of a blinded randomized controlled trial from 2015 to 2017 at a safety-net academic institution. Obese patients (BMI 30-40) seeking VHR were randomized to prehabilitation versus standard counseling. Elective VHR was performed once preoperative requirements were met: 7% total body weight loss or 6 months of counseling and no weight gain. Primary outcome was percentage of hernia-free and complication-free patients at 2 years. Complications included recurrence, reoperation, and mesh complications. Primary outcome was compared using chi-square. We hypothesize that prehabilitation in obese patients with VHR results in more hernia- and complication-free patients at 2-years. RESULTS: Of the 118 randomized patients, 108 (91.5%) completed a median (range) follow-up of 27.3 (6.2-37.4) months. Baseline BMI (mean±SD) was similar between groups (36.8 ±â€Š2.6 vs 37.0 ±â€Š2.6). More patients in the prehabilitation group underwent emergency surgery (5 vs 1) or dropped out of the program (3 vs 1) compared to standard counseling (13.6% vs 3.4%, P = 0.094). Among patients who underwent surgery, there was no difference in major complications (10.2% vs 9.1%, P = 0.438). At 2-years, there was no difference in percentage of hernia-free and complication-free patients (72.9% vs 66.1%, P = 0.424, 1.14, 0.88-1.47). CONCLUSION: There is no difference in 2-year outcomes of obese patients seeking VHR who undergo prehabilitation versus standard care. Prehabilitation may not be warranted in obese patients undergoing elective VHR.Clinical Trial Registration: This trial was registered with clinicaltrials.gov (NCT02365194).

A Statistical Model-driven Surgical Case Scheduling System Improves Multiple Measures of Operative Suite Efficiency: Findings From a Single-center, Randomized Controlled Trial.

OBJECTIVE: We sought to determine whether a data-driven scheduling approach improves Operative Suite (OS) efficiency. BACKGROUND: Although efficient use of the OS is a critical determinant of access to health care services, OS scheduling methodologies are simplistic and do not account for all the available characteristics of individual surgical cases. METHODS: We randomly scheduled cases in a single OS by predicting their length using either the historical mean (HM) duration of the most recent 4 years; or a regression modeling (RM) system that accounted for operative and patient characteristics. The primary endpoint was the imprecision in prediction of the end of the operative day. Secondary endpoints included measures of OS efficiency; personnel burnout captured by the Maslach Burnout Inventory; and a composite endpoint of 30-day mortality, myocardial infarction, wound infection, bleeding, amputation, or reoperation. RESULTS: Two hundred and seven operative days were allocated to scheduling with either the RM or the HM methodology. Mean imprecision in predicting the end of the operative day was higher with the HM approach (30.8 vs 7.2 minutes, P = 0.024). RM was associated with higher throughput (379 vs 356 cases scheduled over the course of the study, P = 0.04). The composite rate of adverse 30-day events was similar (2.2% vs 3.2%, P = 0.44). The mean depersonalization score was higher (3.2 vs 2.0, P = 0.044), and mean personal accomplishment score was lower during HM weeks (37.5 vs 40.5, P = 0.028). CONCLUSIONS: Compared to the HM scheduling approach, the proposed data-driven RM scheduling methodology improves multiple measures of OS efficiency and OS personnel satisfaction without adversely affecting clinical outcomes.

Modifying Risks in Ventral Hernia Patients With Prehabilitation: A Randomized Controlled Trial.

OBJECTIVE: The aim of this study was to determine whether preoperative nutritional counseling and exercise (prehabilitation) in obese patients with ventral hernia repair (VHR) results in more hernia-free and complication-free patients. BACKGROUND: Obesity and poor fitness are associated with complications following VHR. These issues are prevalent in low socioeconomic status patients. METHODS: This was a blinded, randomized controlled trial at a safety-net academic institution. Obese patients (BMI 30 to 40) seeking VHR were randomized to prehabilitation versus standard counseling. VHR was performed once preoperative requirements were met: 7% total body weight loss or 6 months of counseling and no weight gain. Primary outcome was the proportion of hernia-free and complication-free patients. Secondary outcomes were wound complications at 1 month postoperative and weight loss measures. Univariate analysis was performed. RESULTS: Among 118 randomized patients, prehabilitation was associated with a higher percentage of patients who lost weight and achieved weight loss goals; however, prehabilitation was also associated with a higher dropout rate and need for emergent repair. VHR was performed in 44 prehabilitation and 34 standard counseling patients. There was a trend toward less wound complication in prehabilitation patients (6.8% vs 17.6%, P = 0.167). The prehabilitation group was more likely to be hernia-free and complication-free (69.5% vs 47.5%, P = 0.015). CONCLUSIONS: It is feasible to implement a prehabilitation program for obese patients at a safety-net hospital. Prehabilitation patients have a higher likelihood of being hernia-free and complication-free postoperatively. Although further trials and long-term outcomes are needed, prehabilitation may benefit obese surgical patients, but there may be increased risks of dropout and emergent repair. CLINICAL TRIAL REGISTRATION: This trial was registered with clinicaltrials.gov (NCT02365194).

Variation in postacute care utilization after complex surgery.

BACKGROUND: Variation in use of postacute care (PAC), including skilled nursing facilities and inpatient rehabilitation, accounts for 73% of regional variation in Medicare spending. Studies of hospital variation in PAC use have typically focused on nonsurgical patients or have been limited to Medicare data. Consequently, there is no nationally representative data on how rates of postoperative discharge to PAC differ between hospitals. The purpose of this study was to explore hospital-level variation in PAC utilization after cardiovascular and abdominal surgery. MATERIALS AND METHODS: We evaluated 3,487,365 patients from the Nationwide Inpatient Sample and 60,666 from the Veterans Affairs health system, who had colorectal surgery, hepatectomy, pancreatectomy, coronary bypass, aortic aneurysm repair, and peripheral vascular bypass from 2008 to 2011. For each hospital, we calculated unadjusted and risk-adjusted observed-to-expected ratios for discharge to PAC facilities (skilled nursing or inpatient rehabilitation). RESULTS: A total of 631,199 (18%) non-veterans and 4744 (8%) veterans were discharged to PAC facilities. For veterans, 32% were ≥70 y old, and 98% were men. For non-veterans, 39% were ≥70, and 60% were men. Hospital rates of discharge to PAC facilities varied from 1% to 36% for veterans hospitals and from 1% to 59% for non-veteran hospitals. Risk-adjusted observed-to-expected ratios ranged from 0.10 to 4.15 for veterans and from 0.11 to 4.3 for non-veteran hospitals. CONCLUSIONS: There is substantial variation in PAC utilization and rates of home discharge after abdominal and cardiovascular surgery. To reduce variation, further research is needed to understand health systems factors that influence PAC utilization.

Variation and Impact of Multiple Complications on Failure to Rescue After Inpatient Surgery.

OBJECTIVE: To examine the extent to which multiple, sequential complications impacts variation in institutional postoperative mortality rates. BACKGROUND: Failure to rescue (FTR) has been proposed as an underlying factor in hospital variation in surgical mortality. However, little is currently known about hospital variation in FTR after multiple complications or the contribution of sequential complications to variation. METHODS: Retrospective cohort study of 266,101 patients within the Veterans Affairs Surgical Quality Improvement Program (2000-2014) who underwent a subset of high-mortality inpatient general, vascular, or thoracic procedures. The association between number of postoperative complications (0, 1, 2, or ≥3) and 30-day mortality across quintiles of hospital risk-adjusted mortality was evaluated with multivariable, multilevel mixed-effects models. RESULTS: Among patients who had a complication, over half (60.9%) had 1, but those with more than 1 accounted for the majority of the deaths (63.1%). Across hospital quintiles, there were no differences in complications (23.5% very low mortality vs 23.6% very high mortality; trend test P = 0.15). FTR increased significantly (12.0% vs 18.1%; trend test P < 0.001) with an incremental impact as complications accrued (6.7% 1 complication vs 26.1% ≥3, lowest quintile; 11.7% 1 complication vs 33.0% ≥3, highest quintile). However, the risk of FTR associated with increasing complications remained relatively constant across hospital quintiles and was not explained by differences in patients presenting with multiple complications on the index complicated day. CONCLUSIONS: FTR occurs predominantly among patients who have more than 1 complication with a dose-response relationship as complications accrue. As this dose-response relationship is observed across hospitals, surgical quality improvement efforts may benefit by shifting focus to broader interventions designed to prevent subsequent complications at all hospitals.

Postacute Care and Recovery After Cancer Surgery: Still a Long Way to Go.

OBJECTIVE: To determine whether postacute care (PAC) facilities can compensate for increased mortality stemming from a complicated postoperative recovery (complications or deconditioning). BACKGROUND: An increasing number of patients having cancer surgery rely on PAC facilities including skilled nursing and rehabilitation centers to help them recover from postoperative complications and the physical demands of surgery. It is currently unclear whether PAC can successfully compensate for the adverse consequences of a complicated postoperative recovery. METHODS: We combined data from the Veterans Affairs Cancer Registry with the Surgical Quality Improvement Program to identify veterans having surgery for stage I-III colorectal cancer from 1999 to 2010. We used propensity matching to control for comorbidity, functional status, postoperative complications, and stage. RESULTS: We evaluated 10,583 veterans having colorectal cancer surgery, and 765 veterans (7%) were discharged to PAC facilities whereas 9818 veterans (93%) were discharged home. Five-year overall survival after discharge to PAC facilities was 36% compared with 51% after discharge home. Stage I patients discharged to PAC facilities had similar survival (45%) as stage III patients who were discharged home (44%). Patients discharged to PAC facilities had worse survival in the first year after surgery (hazard ratio 2.0, 95% confidence interval 1.7-2.4) and after the first year (hazard ratio 1.4, 95% confidence interval 1.2-1.5). CONCLUSIONS: Discharge to PAC facilities after cancer surgery is not sufficient to overcome the adverse survival effects of a complicated postoperative recovery. Improvement of perioperative care outside the acute hospital setting and development of better postoperative recovery programs for cancer patients are needed to enhance survival after surgery.

National Quality Forum Colon Cancer Quality Metric Performance: How Are Hospitals Measuring Up?

OBJECTIVE: To evaluate the impact of care at high-performing hospitals on the National Quality Forum (NQF) colon cancer metrics. BACKGROUND: The NQF endorses evaluating ≥12 lymph nodes (LNs), adjuvant chemotherapy (AC) for stage III patients, and AC within 4 months of diagnosis as colon cancer quality indicators. Data on hospital-level metric performance and the association with survival are unclear. METHODS: Retrospective cohort study of 218,186 patients with resected stage I to III colon cancer in the National Cancer Data Base (2004-2012). High-performing hospitals (>75% achievement) were identified by the proportion of patients achieving each measure. The association between hospital performance and survival was evaluated using Cox shared frailty modeling. RESULTS: Only hospital LN performance improved (15.8% in 2004 vs 80.7% in 2012; trend test, P < 0.001), with 45.9% of hospitals performing well on all 3 measures concurrently in the most recent study year. Overall, 5-year survival was 75.0%, 72.3%, 72.5%, and 69.5% for those treated at hospitals with high performance on 3, 2, 1, and 0 metrics, respectively (log-rank, P < 0.001). Care at hospitals with high metric performance was associated with lower risk of death in a dose-response fashion [0 metrics, reference; 1, hazard ratio (HR) 0.96 (0.89-1.03); 2, HR 0.92 (0.87-0.98); 3, HR 0.85 (0.80-0.90); 2 vs 1, HR 0.96 (0.91-1.01); 3 vs 1, HR 0.89 (0.84-0.93); 3 vs 2, HR 0.95 (0.89-0.95)]. Performance on metrics in combination was associated with lower risk of death [LN + AC, HR 0.86 (0.78-0.95); AC + timely AC, HR 0.92 (0.87-0.98); LN + AC + timely AC, HR 0.85 (0.80-0.90)], whereas individual measures were not [LN, HR 0.95 (0.88-1.04); AC, HR 0.95 (0.87-1.05)]. CONCLUSIONS: Less than half of hospitals perform well on these NQF colon cancer metrics concurrently, and high performance on individual measures is not associated with improved survival. Quality improvement efforts should shift focus from individual measures to defining composite measures encompassing the overall multimodal care pathway and capturing successful transitions from one care modality to another.

Ventral Hernia Management: Expert Consensus Guided by Systematic Review.

OBJECTIVE: To achieve consensus on the best practices in the management of ventral hernias (VH). BACKGROUND: Management patterns for VH are heterogeneous, often with little supporting evidence or correlation with existing evidence. METHODS: A systematic review identified the highest level of evidence available for each topic. A panel of expert hernia-surgeons was assembled. Email questionnaires, evidence review, panel discussion, and iterative voting was performed. Consensus was when all experts agreed on a management strategy. RESULTS: Experts agreed that complications with VH repair (VHR) increase in obese patients (grade A), current smokers (grade A), and patients with glycosylated hemoglobin (HbA1C) ≥ 6.5% (grade B). Elective VHR was not recommended for patients with BMI ≥ 50 kg/m (grade C), current smokers (grade A), or patients with HbA1C ≥ 8.0% (grade B). Patients with BMI= 30-50 kg/m or HbA1C = 6.5-8.0% require individualized interventions to reduce surgical risk (grade C, grade B). Nonoperative management was considered to have a low-risk of short-term morbidity (grade C). Mesh reinforcement was recommended for repair of hernias ≥ 2 cm (grade A). There were several areas where high-quality data were limited, and no consensus could be reached, including mesh type, component separation technique, and management of complex patients. CONCLUSIONS: Although there was consensus, supported by grade A-C evidence, on patient selection, the safety of short-term nonoperative management, and mesh reinforcement, among experts; there was limited evidence and broad variability in practice patterns in all other areas of practice. The lack of strong evidence and expert consensus on these topics has identified gaps in knowledge where there is need of further evidence.

Ileostomy creation in colorectal cancer surgery: risk of acute kidney injury and chronic kidney disease.

BACKGROUND: Ileostomy creation is associated with postoperative dehydration and readmission; however, the effect on renal function is unknown. Our goal was to characterize the impact of ileostomy creation on acute and chronic renal function. MATERIALS AND METHODS: A retrospective cohort study with patients undergoing colorectal cancer surgery at a tertiary referral institution (2005-2011). The relationship between ileostomy creation and acute kidney injury (AKI)-related readmission, severe chronic kidney disease (CKD) at 12 mo (glomerular filtration rate <30 mL/min/1.73 m2), and onset of severe CKD over time was evaluated using multivariable logistic and Cox regression and adjusted using propensity score stratification. RESULTS: Among 619 patients, 84 (13%) had ileostomy. AKI-related readmission and severe CKD at 12 mo were more common among ileostomy patients (17% versus 2%, P < 0.01 and 13.3% versus 5%, P = 0.02, respectively). After propensity score adjustment, ileostomy was a significant predictor of AKI-related readmissions (odds ratio: 10.3; 95% confidence interval [CI], 3.9-27.2), severe CKD at 12 mo (odds ratio: 4.1; 95% CI, 1.4-11.9), and onset of severe CKD over time (hazard ratio: 4.2; 95% CI, 2.3-6.6). CONCLUSIONS: Ileostomy creation is associated with increased risk of AKI-related readmissions and development of severe CKD. Future studies must focus on strategies to minimize kidney injury when ileostomy is a necessary component of colorectal cancer surgery and revisiting current indications for ileostomy creation.

Primary Tumor Resection and Multimodality Treatment for Patients with Metastatic Colon Cancer.

BACKGROUND: Although controversial, recent data suggest a benefit associated with primary tumor resection (PTR) in metastatic colon cancer (mCC) patients. However, utilization of the various management strategies over time relative to surgery, in particular multimodality treatment (MMT), as well as the impact of age on treatment remains unclear. STUDY DESIGN: Historical cohort study of mCC patients in the National Cancer Data Base (1998-2009). Temporal trends in treatment utilization (chemotherapy, PTR alone, MMT) were evaluated. Using a landmark approach, the association between treatment, age, and risk of death was evaluated with multivariable Cox regression, including interaction. RESULTS: Among 103,100 mCC patients, PTR decreased 50.1 % during the study period, whereas MMT and chemotherapy increased 27.4 and 104.8 %, respectively (trend test, p < 0.001). Patients aged ≥75 years were the only group for whom PTR alone was the most common intervention over time and performed more commonly (33.8 %) than MMT (23.8 %) in the most recent study year. Relative to MMT, risk of death was higher for all other management strategies. The sequence of PTR and chemotherapy (reference-surgery first) did not affect risk of death (chemotherapy first-1.05 [0.95-1.15]), as long resection was a part of MMT (PTR alone-1.16 [1.08-1.23]). Patient age did not impact the relative benefit associated with competing management strategies. CONCLUSIONS: Although the benefit associated with PTR in mCC patients is a function of MMT, PTR alone remains a common management strategy among older patients. Given the aging U.S. population, exploring provider biases and patient preferences may be necessary to optimize management of mCC patients.

Use of simulation to assess a statistically driven surgical scheduling system.

BACKGROUND: To maximize operating room (OR) utilization, better estimates of case duration lengths are needed. We used computerized simulation to determine whether scheduling OR cases using a statistically driven system that incorporates patient and surgery-specific factors in the process of case duration prediction improves OR throughput and utilization. METHODS: We modeled surgical and anesthetic length of vascular surgical procedures as a function of patient and operative characteristics using a multivariate linear regression approach (Predictive Modeling System [PMS]). Mean historical operative time per surgeon (HMS) and mean anesthetic time were also calculated for each procedure type. A computerized simulation of scheduling in a single OR performing vascular operations was then created using either the PMS or the HMS. RESULTS: Compared to HMS, scheduling the operating room using the PMS increased throughput by a minimum of 15% (99.8% cumulative probability, P < 0.001). The PMS was slightly more likely to lead to overtime (mean 13% versus 11% of operative days during a calendar year, P < 0.001). However, the overtime lasted longer in the HMS group (mean 140 versus 95 min per day of overtime, P < 0.001). PMS was associated with lower OR underutilization rate (mean 23% versus 34% of operative days, P < 0.001) and less lengthy OR underutilization (mean 120 versus 193 min per day of underutilization, P < 0.001). CONCLUSIONS: This computerized simulation demonstrates that using the PMS for scheduling in a single operating room increases throughput and other measures of surgical efficiency.

Preoperative cancer cachexia and short-term outcomes following surgery.

BACKGROUND: Cancer cachexia is an important measure of physiologic reserve associated with worse survival and represents an actionable factor for the cancer population. However, the incidence of cachexia in surgical cancer patients and its impact on postoperative outcomes are currently unknown. METHODS: A prospective cohort study enrolling patients having elective cancer surgery (2012-2014) at a Veterans Affairs tertiary referral center. Preoperative cancer cachexia (weight loss ≥5% over 6-mo period before surgery) was the predictor of interest. The primary outcome was 60-d postoperative complications (VA Surgical Quality Improvement Program). Patients were grouped by body mass index (BMI) category (<25, 25-29.9, ≥30), and interaction between cachexia and BMI was tested for the primary outcome. Multivariate logistic regression was used to examine the association between preoperative cachexia and postoperative complications. RESULTS: Of 253 patients, 16.6% had preoperative cachexia, and 51.8% developed ≥ 1 postoperative complications. Complications were more common in cachectic patients (64.3% versus 49.3%, P = 0.07). This association varied by BMI category, and interaction analysis was significant for those with normal or underweight BMI (BMI < 25, P = 0.03). After multivariate modeling, in patients with normal or underweight BMI, preoperative cachexia was associated with higher odds of postoperative complications (odds ratios, 5.08 [95% confidence intervals, 1.18-21.88]; P = 0.029). Additional predictors of complications included major surgery (3.19 [1.24-8.21], P = 0.01), ostomy (4.43 [1.68-11.72], P = 0.003), and poor baseline performance status (2.31 [1.05-5.08], P = 0.03). CONCLUSIONS: Cancer cachexia is common in surgical patients, and is an important predictor of postoperative complications, though its effect varies by BMI. As a modifiable predictor of worse outcomes, future studies should examine the role of cachexia treatment before cancer surgery.

Ninety-day readmission after colorectal cancer surgery in a Veterans Affairs cohort.

BACKGROUND: Readmissions following colorectal surgery are common. However, there are limited data examining unplanned readmissions (URs) after colorectal cancer (CRC) surgery. The goal of this study was to identify reasons and predictors of UR, and to examine their clinical impact on CRC patients. METHODS: A retrospective cohort study using a prospective CRC surgery database of patients treated at a VA tertiary referral center was performed (2005-2011). Ninety-day URs were recorded and classified based on reason for readmission. Clinical impact of UR was measured using a validated classification for postoperative complications. Multivariate logistic regression analyses were performed to identify predictors of UR. RESULTS: 487 patients were included; 104 (21%) required UR. Although the majority of UR were due to surgical reasons (n = 72, 69%), medical complications contributed to 25% of all readmission events. Nearly half of UR (n = 44, 40%) had significant clinical implications requiring invasive interventions, intensive care unit stays, or led to death. After multivariate logistic regression, the following independent predictors of UR were identified: African-American race (odds ratio [OR] 0.47 [0.27-0.88]), ostomy creation (OR 2.50 [1.33-4.70]), and any postoperative complication (OR 4.36 [2.48-7.68]). CONCLUSIONS: Ninety-day URs following colorectal cancer surgery are common, and represent serious events associated with worse outcomes. In addition to postoperative complications, surgical details that can be anticipated (i.e., ileostomy creation) and medical events unrelated to surgery, both contribute as important and potentially preventable reasons for UR. Future studies should focus on developing and examining interventions focused at improving the process of perioperative care for this high-risk population.

Infectious postoperative complications decrease long-term survival in patients undergoing curative surgery for colorectal cancer: a study of 12,075 patients.

OBJECTIVE: We sought to characterize the effect of postoperative complications on long-term survival after colorectal cancer (CRC) resection. BACKGROUND: The impact of early morbidity on long-term survival after curative-intent CRC surgery remains controversial. METHODS: The Veterans Affairs Surgical Quality Improvement Program and Central Cancer Registry databases were linked to acquire perioperative and cancer-specific data for 12,075 patients undergoing resection for nonmetastatic CRC (1999-2009). Patients were categorized by presence of any complication within 30 days and by type of complication (noninfectious vs infectious). Univariate and multivariate survival analyses adjusted for patient, disease, and treatment factors were performed, excluding early deaths (<90 days). Subset analysis was performed to determine the specific impact of severe postoperative infections. RESULTS: The overall morbidity and infectious complication rates were 27.8% and 22.5%, respectively. Patients with noninfectious postoperative complications were older, had lower preoperative serum albumin, had worse functional status, and had higher American Society of Anesthesiologists scores than patients with infectious complications and without complications (all P < 0.001). The presence of any complication was independently associated with decreased long-term survival [hazard ratio, 1.24; 95% confidence interval (1.15-1.34)]. Multivariate analysis by complication type demonstrated increased risk only with infectious complications [hazard ratio, 1.31; 95% confidence interval (1.21-1.42)]. Subset analysis demonstrated this effect predominantly in patients with severe infections [hazard ratio, 1.41; 95% confidence interval (1.15-1.73)]. CONCLUSIONS: The presence of postoperative complications after CRC resection is associated with decreased long-term survival, independent of patient, disease, and treatment factors. The impact on long-term outcome is primarily driven by infectious complications, particularly severe postoperative infections.

Postoperative transitional care needs in the elderly: an outcome of recovery associated with worse long-term survival.

OBJECTIVE: To characterize transitional care needs (TCNs) after colorectal cancer (CRC) surgery and examine their association with age and impact on overall survival (OS). BACKGROUND: TCNs after cancer surgery represent additional burden for patients and are associated with higher short-term mortality. They are not well-characterized in CRC patients, particularly in the context of a growing elderly population, and their effect on long-term survival is unknown. METHODS: A retrospective cohort study of CRC patients (N = 486) having curative surgery at a tertiary referral center (2002-2011) was conducted. Outcomes included TCNs (home health or nonhome destination at discharge) and OS. Patients were compared on the basis of age: young (<65 years), old (65-74 years), and oldest (≥75 years). Multivariate logistic regression models were used to examine the association of age with TCNs, and OS was compared on the basis of TCNs and stage, using the Kaplan-Meier method. RESULTS: TCNs were required by 130 patients (27%). The oldest patients had highest TCNs (49%) compared with the other age groups (P < 0.01), with rehabilitation services as their primary TCNs (80%). After multivariate analysis, patients 75 years or older had significantly increased TCN risk (odds ratio, 4.7; 95% confidence interval, 2.6-8.5). TCN was associated with worse OS for patients with early- and advanced stage CRC (P < 0.001). CONCLUSIONS: TCNs after CRC surgery are common and significantly increased in patients 75 years or older, represent an outcome of postoperative recovery, and are associated with worse long-term survival. Preoperative identification of higher risk populations should be used for patient counseling, advanced preoperative planning, and to implement strategies targeted at minimizing TCNs.

Sphincter preservation rates after radical resection for rectal cancer in the United States veteran population: opportunity for improvement in early disease.

BACKGROUND: Sphincter preservation (SP) is an important goal of rectal cancer surgery. We hypothesized that SP rates among veteran patients have increased and are comparable to national rates, and that a subset of patients with early disease still undergo non-SP procedures. METHODS: Patients with nonmetastatic primary rectal adenocarcinoma who underwent curative-intent rectal resection were identified from the Veterans Affairs Central Cancer Registry (VACCR) database (1995-2010). SP trends over time were described and compared to the Surveillance, Epidemiology, and End-Results (SEER) population. Subset analysis was performed in patients with nonirradiated, pathologic stage 0-I rectal cancers, a population that may qualify for novel SP strategies. RESULTS: Of 5,145 study patients, 3,509 (68 %) underwent SP surgery. The VACCR SP rate increased from 59.9 % in 1995-1999 to 79.3 % in 2005-2010, when it exceeded that of SEER (76.9 %, p = 0.023). On multivariate analysis, recent time period was independently associated with higher likelihood of SP (odds ratio [OR] 2.64, p < 0.001). Preoperative radiotherapy (OR 0.51, p < 0.001) and higher pathologic stage (OR 0.37, stage III, p < 0.001) were negative predictors. In patients with nonirradiated pathologic stage 0-I cancers, SP rates also increased, but 25 % of these patients underwent non-SP procedures. Within this subset, patients with clinical stage 0 and I disease still had significant rates of abdominoperineal resection (7.7 and 17.0 %, respectively). CONCLUSIONS: SP rates among veterans have increased and surpass national rates. However, an unacceptable proportion of patients with stage 0-I rectal cancers still undergo non-SP procedures. Multimodal treatment with local excision may further improve SP rates in this subset of patients.

Comparison of domain-specific cognitive function after carotid endarterectomy and stenting.

BACKGROUND: Observational data indicate that carotid artery stenting (CAS) is associated with higher incidence of subclinical cerebral microemboli than carotid endarterectomy (CEA). We hypothesized that CEA would be associated with superior performance on detailed domain-specific cognitive testing compared with CAS. METHODS: Patients with >80% asymptomatic carotid artery stenosis were randomized to CEA or CAS with side of stenosis balanced across condition. A robust battery of tests was used to assess the cognitive domains of attention, memory, mood, visual-spatial skills, motor ability, processing speed, and executive functioning ≤10 days preoperatively and postoperatively at 6 weeks and 6 months. Tests were administered using standardized conditions and were scored by individuals blinded to treatment allocation. RESULTS: Baseline cognitive performance was similar between CAS (n = 29) and CEA (n = 31) groups (P > .05). Relative to baseline, verbal and visual memory and attention functions substantially improved in the CAS and CEA groups at 6 months (multiple cognitive tests achieved statistical significance). Compared with CEA, cognitive processing speed (Stroop Color test: 9.0 vs 7.3, P = .04; and Stroop Word test: 9.0 vs 7.4, P = .05) was superior in the CAS group at 6 weeks. Executive functioning (phonemic verbal fluency: 10.6 vs 8.4, P = .043) and motor function (Grooved Pegboard of nondominant extremity: 45.7 vs 38.9, P = .022) were also superior in the CAS group at 6 months. Tests of attention, memory, and visual-spatial skills were similar between CAS and CEA patients at 6 weeks and 6 months. CONCLUSIONS: Carotid revascularization improves memory and attention within the first 6 postoperative months. Compared with CEA, CAS produces improvements in cognitive processing speed, executive functioning, and motor function.

Surgical follow-up costs disproportionately impact low-income patients.

BACKGROUND: Surgical procedures have significant costs at the national level, but the financial burden on patients is equally important. Patients' out-of-pocket costs for surgery and surgical care include not only direct medical costs but also the indirect cost of lost wages and direct nonmedical costs including transportation and childcare. We hypothesized that the nonmedical costs of routine postoperative clinic visits disproportionately impact low-income patients. MATERIALS AND METHODS: This was a cross-sectional study performed in the postoperative acute care surgery clinic at a large, urban county hospital. A survey containing items about social, demographic, and financial data was collected from ambulatory patients. Nonmedical costs were calculated as the sum of transportation, childcare, and lost wages. Costs and cost to income ratios were compared between income strata. RESULTS: Ninety-seven patients responded to the survey of which 59 reported all items needed for cost calculations. The median calculated cost of a clinic visit was $27 (interquartile range $18-59). Components of this cost were $16 ($14-$20) for travel, $22 ($17-$50) for childcare among patients requiring childcare, and $0 ($0-$30) in lost wages. Low-income patients had significantly higher (P = 0.0001) calculated cost to income ratios, spending nearly 10% of their monthly income on these costs. CONCLUSIONS: The financial burden of routine postoperative clinic visits is significant. Consistent with our hypothesis, the lowest income patients are disproportionately impacted, spending nearly 10% of their monthly income on costs associated with the clinic visit. Future cost-containment efforts should examine alternative, lower cost methods of follow-up, which reduce financial burden.