Recurrent Nerve Injury After Total Thyroidectomy: Risk Factor Analysis of a Targeted NSQIP Data Set.

BACKGROUND: Recurrent laryngeal nerve (RLN) injury is a significant complication after thyroidectomy. Understanding risk factors for RLN injury and the associated postoperative complications may help inform quality improvement initiatives. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) thyroidectomy-targeted database was utilized for patients undergoing total thyroidectomy between 2016 and 2017. Univariable and multivariable regression were used to identify factors associated with RLN injury. RESULTS: A total of 6538 patients were identified. The overall rate of RLN injury was 7.1% (467/6538). Of these, 4129 (63.1%) patients had intraoperative neuromonitoring (IONM), with an associated RLN injury rate of 6.5% (versus 8.2% without). African American and Asian race, non-elective surgery, parathyroid auto-transplantation, and lack of RLN monitoring were all significantly associated with nerve injury on multivariable analysis (P<.05). Patients with RLN injury were more likely to experience cardiopulmonary complications, re-intubation, longer length of stay, readmission, and reoperation. Patients who had IONM and sustained RLN injury remained at risk for developing significant postoperative complications, although the extent of cardiopulmonary complications was less severe in this cohort. DISCUSSION: Recurrent laryngeal nerve injury is common after thyroidectomy and is associated with significant morbidity, despite best practices. Attention to preoperative characteristics may help clinicians to further risk stratify patients prior to thyroidectomy. While IONM does not mitigate all complications, use of this technology may decrease severity of postoperative complications.

Socioeconomic Disparities in Pancreas Cancer Resection and Survival in the Veterans Health Administration.

BACKGROUND: Disparities based on socioeconomic factors such as race, ethnicity, marital status, and insurance status are associated with pancreatic cancer resection, but these disparities are usually not observed for survival after resection. It is unknown if there are disparities when patients undergo their treatment in a non-fee-for-service, equal-access healthcare system such as the Veterans Health Administration (VHA). METHODS: Patients having T1-T3 M0 pancreatic adenocarcinoma diagnosed between 2006 and 2017 were identified from the VHA Corporate Data Warehouse. Socioeconomic, demographic, and tumor variables associated with resection and survival were assessed. RESULTS: In total, 2580 patients with early-stage pancreatic cancer were identified. The resection rate was 36.5%. Surgical resection was independently associated with younger age [odds ratio (OR) 0.94, p < 0.001], White race (OR 1.35, p = 0.028), married status (OR 1.85, p = 0.001), and employment status (retired vs. unemployed, OR 1.41, p = 0.008). There were no independent associations with Hispanic ethnicity, geographic region, or Social Deprivation Index. Resection was associated with significantly improved survival (median 21 vs. 8 months, p = 0.001). Among resected patients, survival was independently associated with younger age (HR 1.019, p = 0.002), geographic region (South vs. Pacific West, HR 0.721, p = 0.005), and employment (employed vs. unemployed, HR 0.752, p = 0.029). Race, Hispanic ethnicity, marital status, and Social Deprivation Index were not independently associated with survival after resection. CONCLUSIONS: Race, marital status, and employment status are independently associated with resection of pancreatic cancer in the VHA, whereas geographic region and employment status are independently associated with survival after resection. Further studies are warranted to determine the basis for these inequities.

Associations of gender, race, and ethnicity with disparities in short-term adverse outcomes after pancreatic resection for cancer.

BACKGROUND: Several studies have identified disparities in pancreatic cancer treatment associated with gender, race, and ethnicity. There are limited data examining disparities in short-term adverse outcomes after pancreatic resection for cancer. The aim of this study is to evaluate associations of gender, race, and ethnicity with morbidity and mortality after pancreatic resection for malignancy. METHODS: The American College of Surgeons National Surgical Quality Improvement database was retrospectively reviewed. The χ2 test and Student's t-test were used for univariable analysis and hierarchical logistic regression for multivariable analysis. RESULTS: Morbidity and major morbidity after pancreaticoduodenectomy are associated with male gender, Asian race, and Hispanic ethnicity, whereas 30-day mortality is associated with the male gender. Morbidity and major morbidity after distal pancreatectomy are associated with the male gender. Morbidity after pancreaticoduodenectomy is independently associated with male gender, Asian race, and Hispanic ethnicity; major morbidity is independently associated with male gender and Asian race, and mortality is independently associated with Hispanic ethnicity. CONCLUSIONS: Gender, race, and ethnicity are independently associated with morbidity after pancreaticoduodenectomy for cancer; gender and race are independently associated with major morbidity; and ethnicity is independently associated with mortality. Further studies are warranted to determine the basis of these associations.

The improvement in post-operative mortality following pancreaticoduodenectomy between 2006 and 2016 is associated with an improvement in the ability to rescue patients after major morbidity, not in the rate of major morbidity.

BACKGROUND: The postoperative mortality rate of pancreaticoduodenectomy is decreasing over time. It is unknown whether this is related to reduction in incidence of major morbidity or failure to rescue. We aimed to make this determination. METHODS: ACS-NSQIP was retrospectively reviewed from 2006 to 2016. Comparisons were assessed with Spearman's rank-order correlation test, chi-square test with linear-by-linear association, and multivariable hierarchical logistic regression. RESULTS: Mortality decreased significantly from 2.9% to 1.5% (p < 0.001). This decrease was independent of preoperative variables on multivariable analysis (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.55-5.21, p < 0.001). In contrast, no change in incidence of major morbidity was seen on univariable (26.8% to 25.9%, p = 1.00) or multivariable analysis (OR 1.22, 95% CI 1.03-1.45, p = 0.060). Failure to rescue was observed to decrease on univariable (9.8% to 4.1%, p < 0.001) and multivariable analysis (OR 3.65, 95% CI 2.07-6.76, p < 0.001). CONCLUSION: There has been a sizeable reduction in the mortality rate after pancreaticoduodenectomy from 2006 to 2016. This predominantly results from a reduction in failure to rescue rate rather than a decrease in incidence of major morbidity.

Relationship Between Newly Established Perioperative DNR Status and Perioperative Outcomes in the Elderly Population: A NSQIP Database Analysis.

BACKGROUND: Health care practitioners have developed complex algorithms to numerically calculate surgical risk. We examined the association between the initiation of a new do-not-resuscitate (DNR) status during hospitalization and postoperative outcomes, including mortality. We hypothesized that new DNR status would be associated with similar complication rates, even though mortality rates may be higher. METHODS: A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Geriatric Surgery Research File. Two cohorts were defined by the presence of a new DNR status during the hospitalization that was not present on hospital admission. Multivariable logistic regression was used to control for differences between the DNR and non-DNR cohorts. The primary outcome was 30-day mortality. Secondary outcomes included rates of postoperative complications, including returning to the operating room, reintubation, failure to wean from ventilation, surgical site infections, dehiscence, pneumonia, acute kidney injury, renal failure, stroke, cardiac arrest, acute myocardial infarction, transfusion requirements, sepsis, urinary tract infections, venous thromboembolisms, total number of complications for each patient, and hospital length of stay. RESULTS: In our geriatric population with a newly established DNR status, the mortality rate was 39.29%, significantly greater than the non-DNR population after multivariable regression. Secondary outcomes also occurred at an increased rate in the DNR cohort including surgical site infections (8.29% vs 4.04%), pneumonia (18% vs 2.26%), renal insufficiency (2.43% vs 0.35%), acute renal failure (5% vs 0.19%), stroke (3% vs 0.36%), acute myocardial infarction (6.29% vs 0.95%), and cardiac arrest (5.86% vs 0.51%). CONCLUSIONS: The initiation of a new DNR status during hospitalization is associated with a significantly higher burden of both morbidity and mortality. This contrasts with prior studies that did not show an increased rate of adverse outcomes and suggests that a new DNR status in postoperative patients may reflect a consequence of adverse postoperative events. The informed consent process in older patients at risk for adverse outcomes after surgery should include discussions regarding goals of care and acceptable risk.

Epidural Analgesia in Ventral Hernia Repair: An Analysis of 30-day Outcomes.

Background: Ventral hernia repair (VHR) is a common procedure associated with significant postoperative morbidity and prolonged hospital length of stay (LOS). The use of epidural analgesia in VHR has not been widely evaluated. Purpose: To compare the outcomes of general anesthesia plus epidural analgesia (GA + EA) versus general anesthesia alone (GA) in patients undergoing ventral hernia repair. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was used to identify elective cases of VHR. Propensity score-matched analysis was used to compare outcomes in GA vs GA + EA groups. Cases receiving transverse abdominus plane blocks were excluded. Results: A total of 9697 VHR cases were identified, resulting in two matched cohorts of 521 cases each. LOS was significantly longer in the GA + EA group (5.58 days) vs the GA group (5.20 days, p = 0.008). No other statistically significant differences in 30-day outcomes were observed between the matched cohorts. Conclusion: Epidural analgesia in VHR is associated with statistically significant, but not clinically significant increase in LOS and may not yield any additional benefit in cases of isolated, elective VHR. Epidural analgesia may not be beneficial in this surgical population. Future studies should focus on alternative modes of analgesia to optimize pain control and outcomes for this procedure.

Discharge destination following rectal cancer resection: an analysis of preoperative and intraoperative factors.

PURPOSE: Rectal cancer resections can be associated with long and complicated postoperative recoveries. Many patients undergoing these operations are discharged to rehabilitation or skilled nursing facilities. The purpose of this study was to identify preoperative and intraoperative factors associated with increased risk for non-home discharge after rectal cancer resection. METHODS: Rectal cancer resections were identified in the National Surgical Quality Improvement Program Targeted Proctectomy Dataset (years 2016 through 2017) by ICD code. Patients with unknown discharge destination or who experienced in-hospital mortality were excluded. Univariate and multivariate logistic regression analyses were performed to identify preoperative and intraoperative variables associated with non-home discharge destination. Multiple imputation was used to account for missing values. RESULTS: Among the 3637 patients comprising the study sample, 292 (8.0%) patients were discharged to rehabilitation, skilled care, or acute care facilities. Preoperative factors associated with non-home discharge on multivariate analysis included older age, non-independent functional status, insulin-dependent diabetes, and hypoalbuminemia (all p < 0.05). Having received neoadjuvant chemotherapy was associated with home discharge (OR 0.625, 95% CI 0.427-0.914, p = 0.015). Intraoperative factors associated with non-home discharge on multivariate analysis were concurrent cystectomy (p = 0.004) and myocutaneous flap reconstruction (p < 0.001). Patients discharged to non-home facilities had longer initial lengths of stay (14.1 versus 7.0 days, p < 0.001) and higher reoperation rates (12.7 versus 5.0%, p < 0.001), but similar readmission rates (14.7 versus 15.0%, p = 1.0). CONCLUSION: Several preoperative and intraoperative factors are associated with increased risk for non-home discharge after rectal cancer resection. These data can aid in perioperative planning and discharge optimization.

Risk factors and reasons for reoperation after radical cystectomy.

PURPOSE: Reoperation after radical cystectomy (RC) is common but the types of reoperation after RC and associated risk factors have not been fully characterized. Here, we provide a detailed, contemporary account of the factors that drive surgical reoperation within the first 30-days after surgery, identify at risk patient populations, and describe common reoperations. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program database (2012-2017) was analyzed to identify 30-day reoperation rates after RC. Captured variables included demographic, preoperative, operative, and postoperative characteristics. Postoperative characteristics included complications, including types of reoperation, length of stay, unplanned readmissions, and discharge destination. Pearson chi-squared and multivariable logistic regression models were used for analysis. RESULTS: A total of 10,848 patients underwent RC and there were 633 (5.84%) unplanned reoperations. On multivariable logistic regression, patient factors associated with increased risk of reoperation included longer operative times at index procedure (>90th percentile operative time) (OR1.41 [1.08-1.83], P = 0.02), smoking (OR1.34 [1.11-1.63], P < 0.01), obesity (BMI≥30) (OR 1.29 [1.04-1.60], P = 0.02) and chronic obstructive pulmonary disease (OR1.74 [1.36-2.3], P < 0.01). Other significant factors included clinically significant hypertension, perioperative blood transfusion, and male sex. The most common reoperation procedures were those performed on the gastrointestinal tract, accounting for 60.59% (349) of all reoperations, followed by skin/subcutaneous procedures 14.76% (85), followed by Genitourinary procedures at 8.16% (47). Patients who underwent reoperation were at higher risk for readmission, discharge to a facility, and death (P < 0.01). CONCLUSION: Reoperation after RC is associated with approximately 5% rate of reoperation within 30 days of surgery. The most common reason for reoperation was related to the gastrointestinal tract, accounting for more than 60% of all reoperations. Risk factors for reoperation included longer surgical times, smoking, obesity, chronic obstructive pulmonary disease, perioperative blood transfusion, and clinically significant hypertension. Knowledge of these factors can aid in operative planning and counseling and lead to possible strategies to reduce reoperations in the early perioperative setting.

Twenty-Three-Hour-Stay Colectomy Without Increased Readmissions: An Analysis of 1905 Cases from the National Surgical Quality Improvement Program.

BACKGROUND: Isolated case series from highly specialized centers suggest the feasibility of a 23-h hospital stay after colectomy. We sought to determine preoperative variables associated with discharge within 23 h after colectomy to identify patients best suited for a short-stay model. METHODS: The American College of Surgeons NSQIP Colectomy-Targeted database was used to identify patients who underwent elective colectomy from 2012 to 2017. All cases with missing length of stay or inpatient death were excluded. Patients with a postoperative hospital stay ≤1 day were identified. Univariate and multivariate analyses were conducted to identify factors associated with early discharge. RESULTS: A total of 1905 patients were discharged within 23 h after surgery (1.6%). These patients were noted to be younger (59 versus 61 years, p < 0.001) and less likely to have insulin-dependent diabetes (3.0 versus 4.4%, p < 0.001), preoperative dyspnea (2.2 versus 6.0%, p < 0.001), COPD (3.0 versus 4.2%, p = 0.011), and hypertension (40.7 versus 46.9%, p < 0.001) than patients who stayed longer. Shorter operative time (OR 0.986, 95% CI 0.985-0.987, p < 0.001), minimally invasive techniques (OR 2.969, 95% CI 2.686-3.282, p < 0.001), lack of ostomy (OR 0.614, 95% CI 0.478-0.788, p < 0.001), and lack of ureteral stenting (OR 0.641, 95% CI 0.500-0.821, p < 0.001) were associated with early discharge in multivariable analysis. There was no increased incidence of readmission in patients discharged within 23 h. CONCLUSIONS: Twenty-three-hour-stay colectomy is feasible on a national level and does not result in an increased incidence of readmission. Patients undergoing elective procedures without significant medical comorbidities may be eligible for early discharge. Preoperative factors may be used to select patients best suited for this short-stay model.

The Association Between Potential Opioid-Related Adverse Drug Events and Outcomes in Colorectal Surgery.

Introduction: Major colorectal surgery procedures are complex operations that can result in significant postoperative pain and complications. More evidence is needed to demonstrate how opioid-related adverse drug events (ORADEs) after colorectal surgery can affect hospital length of stay (LOS), hospital revenue, and what their association is with clinical conditions. By understanding the clinical and economic impact of potential ORADEs within colorectal surgery, we hope to further guide approaches to perioperative pain management in an effort to improve patient care and reduce hospital costs. Materials and Methods: We conducted a retrospective study utilizing the Centers for Medicare and Medicaid Services (CMS) Administrative Database to analyze Medicare discharges involving three colorectal surgery diagnosis-related groups (DRGs) to identify potential ORADEs. The impact of potential ORADEs on mean hospital LOS and hospital revenue was analyzed. Results: The potential ORADE rate in patients undergoing colorectal surgery was 23.92%. The mean LOS for discharges with a potential ORADE was 5.35 days longer than without an ORADE. The mean hospital revenue per day with a potential ORADE was $418 less than without an ORADE. Any type of open surgery had a statistically significant higher potential ORADE rate than the matched laparoscopic case (P < .001). Clinical conditions most strongly associated with ORADEs in colorectal surgery included septicemia, pneumonia, shock, and fluid and electrolyte disorders. Conclusion: The incidence of ORADEs in colorectal surgery is high and is associated with longer hospital stays and reduced hospital revenue. Reducing the use of opioids in the perioperative setting, such as using multimodal analgesia strategies, may lead to positive outcomes with shorter hospital stays, increased hospital revenue, and improved patient care.

Prediction of Discharge Destination Following Major Hepatectomy.

BACKGROUND: Anatomic hepatectomies can be associated with complicated post-operative recoveries, often with discharge to post-acute care facilities. This study identifies preoperative and intraoperative factors associated with increased risk for non-home discharge destination after major hepatectomy. METHODS: Patients undergoing major hepatectomy were identified in the NSQIP Targeted Hepatectomy Dataset (2014-2016). Multivariable logistic regression was performed. Patients from 2014 to 2015 were used for training cohort with nomogram generation and 2016 for validation cohort. RESULTS: Overall, 226 of 3750 patients (6.0%) were discharged to rehab, skilled care, or acute care facilities. Preoperative factors associated with non-home discharge on multivariable analysis were outside patient transfers, older age, presence of ascites, ASA physical status 3 or higher, and low preoperative hematocrit (all p < 0.05). Intraoperative factors significantly predictive were concurrent lysis of adhesions, Pringle maneuver, and biliary reconstruction (all p < 0.05). Predictors from testing cohort were validated in validation cohort. Nomograms based on preoperative variables alone and both preoperative and intraoperative variables were generated. CONCLUSION: We identify several preoperative and intraoperative factors that are associated with increased risk for non-home discharge after major hepatectomy. Preoperative anemia represents a potentially modifiable risk factor. Nomograms for preoperative planning as well as immediately following surgery were generated.

Fast-Track Pancreaticoduodenectomy: Factors Associated with Early Discharge.

BACKGROUND: Pancreaticoduodenectomy is a complex surgery frequently associated with prolonged hospitalizations. However, there are a subset of patients discharged within 5 days from surgery; the preoperative and intraoperative characteristics of this subset are unknown. METHODS: The NSQIP Targeted Pancreatectomy Dataset was used from 2014 to 2016. Patients who died within 30 days were excluded. A total of 10,741 patients undergoing pancreaticoduodenectomy were identified. Univariable and multivariable logistic regression analyses were performed for preoperative and intraoperative ACS-NSQIP variables to identify predictors of early discharge. Early discharge was defined as discharge 3-5 days after surgery. RESULTS: A total of 1105 patients (10.3%) were discharged within 5 days following pancreaticoduodenectomy. On multivariable analysis, preoperative factors associated with early discharge included younger age (OR 0.988, p < 0.001), non-obesity (OR 0.737, p = 0.001), those receiving neoadjuvant chemotherapy (OR 1.424, p < 0.001), and lack of COPD (OR 0.489, p = 0.005) or hypertension (OR 0.805, p = 0.007). Intraoperative factors associated with early discharge on multivariable analysis were shorter operation duration (OR 0.999, p = 0.002), minimally invasive surgery (OR 3.537, p < 0.001), and hard pancreatic texture (OR 1.480, p < 0.001). Intraoperative factors associated with non-early discharge were epidural placement (OR 0.485, p < 0.001), drain placement (OR 0.308, p < 0.001), and jejunostomy tube placement (OR 0.278, p < 0.001). Patients discharged within 5 days had a 14.7% readmission rate compared to 17.0% for later discharges (p = 0.047). CONCLUSIONS: Multiple preoperative and intraoperative factors, including some that are potentially modifiable, were significantly associated with early discharge after pancreaticoduodenectomy. Patients with these characteristics may benefit from enhanced recovery after surgery programs and expedited disposition planning postoperatively.

National Surgical Quality Improvement Program analysis of unplanned reoperation in patients undergoing low anterior resection or abdominoperineal resection for rectal cancer.

BACKGROUND: The rate of unplanned reoperation for rectal cancer can provide information about surgical quality. We sought to determine factors associated with unplanned reoperation after low anterior resection and abdominoperineal resection for patients with rectal cancer and outcomes after these reoperations. METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was used to conduct this retrospective study. Patients who underwent elective low anterior resection and abdominoperineal resection for rectal cancer from 2012-2014 were identified. The primary outcomes were 30-day reoperation rates and postoperative complications. RESULTS: A total of 454 low anterior resection patients (5.9%) and 289 abdominoperineal resection patients (8.1%) required reoperation within 30 days of their index operation. The most common reasons for reoperation were infection, bleeding, and bowel obstruction. Multivariate analysis revealed that male sex (odds ratio: 1.5, P = .001), poor functional status (odds ratio: 2.2, P = .04), operative time (odds ratio: 1.001, P = .01), low preoperative albumin (odds ratio: 0.79, P = .04), and lack of ostomy (odds ratio, 0.66, P = .005) were independent risk factors for reoperation after low anterior resection. Smoking (odds ratio: 1.7, P = .001), chronic obstructive pulmonary disease (odds ratio: 1.8, P = .03), poor functional status (odds ratio: 2.1, P = .032), operative time (odds ratio: 1.003, P < .001), low preoperative albumin (odds ratio: 0.69, P = .007), and open approach (odds ratio: 1.5, P = .02) were independent risk factors for reoperation after abdominoperineal resection. Postoperative complication rates are high for those undergoing reoperation, often leading to non-home discharge (P < .001) after reoperation. CONCLUSION: Reoperation after low anterior resection and abdominoperineal resection for rectal cancer is not uncommon. This study highlights the indications for reoperation, potentially modifiable preoperative risk factors for reoperation, and the morbidity associated with such operations.