Immediate preoperative hyperglycemia correlates with complications in non-cardiac surgical cases.

STUDY OBJECTIVE: Assess for a relationship between immediate preoperative glucose concentrations and postoperative complications. DESIGN: Retrospective cohort study. SETTING: Single large, tertiary care academic medical center. PATIENTS: A five-year registry of all patients at our hospital who had a glucose concentration (plasma, serum, or venous/capillary/arterial whole blood) measured up to 6 h prior to a non-emergent surgery. INTERVENTIONS: The glucose registry was cross-referenced with a database from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). We applied an outcomes review to the subset of patients for whom we had data from both registries (n = 1774). MEASUREMENTS: Preoperative glucose concentration in the full population as well as the subgroups of patients with or without diabetes were correlated with adverse postsurgical outcomes using 1) univariable analysis and 2) full multivariable analysis correcting for 27 clinical factors available from the ACS NSQIP database. Logistic regression analysis was performed using glucose level either as a continuous variable or as a categorical variable according to the following classifications: mild (≥140 mg/dL; ≥7.8 mmol/L), moderate (≥180 mg/dL; ≥10 mmol/L), or severe (≥250 mg/dL; ≥13.9 mmol/L) hyperglycemia. A third analysis was performed correcting for 7 clinically important factors (age, BMI, predicted duration of procedure, sex, CKD stage, hypoalbuminemia, and diabetic status) identified by anesthesiologists and surgeons as immediately available and important for decision making. MAIN RESULTS: Univariable analysis of all patients and the subgroups of patients without diabetes or with diabetes showed that immediate preoperative mild or moderate hyperglycemia correlates with postoperative complications. Statistical significance was lost in most groups using full multivariable analysis, but not when correcting for the 7 factors available immediately preoperatively. However, for all patients with diabetes, moderate hyperglycemia (≥180 mg/dL; ≥10 mmol/L) continued to significantly correlate with complications even in the full multivariable analysis [odds ratio (OR) 1.79; 95% Confidence Intervals (CI) 1.10, 2.92], and with readmission/reoperation within 30 days [OR 1.93; 95% CI 1.18, 3.13]. CONCLUSIONS: Preoperative hyperglycemia within 6 h of surgery is a marker of adverse postoperative outcomes. Among patients with diabetes in our study, a preoperative glucose level ≥ 180 mg/dL (≥10 mmol/L) independently correlates with risk of postoperative complications and readmission/reoperation. These results should encourage future work to determine whether addressing immediate preoperative hyperglycemia can improve complication rates, or simply serves as a marker of higher risk.

Racial disparities in comorbid conditions among patients undergoing thyroidectomy for Graves' disease: An ACS-NSQIP analysis.

BACKGROUND: Studies indicate that racial disparities exist in the presentation and outcomes of patients undergoing thyroidectomy for cancer and benign disease. We examined the relationship between race, pre-operative characteristics and outcomes in patients undergoing thyroidectomy for GD. METHODS: Patients were identified from the 2013-2016 American College of Surgeons NSQIP database using ICD-9/10 codes consistent with diffuse toxic goiter. RESULTS: AA patients were more likely to have an ASA classification of ≥3 (41% vs 30%, p < 0.001), a higher rate of CHF (2.1% vs 0.5%, p = 0.01), hypertension (46% vs 32%, p < 0.001) and dyspnea (10% vs 5%, p < 0.001) compared to Non-Hispanic Caucasians (NH-C) patients. Complications were higher in patients with ASA≥3 and CHF but not affected by race. CONCLUSIONS: Analysis of a national database of thyroidectomy for GD revealed a higher burden of preoperative comorbidities in AA patients compared to other races, although race was not an independent predictor of outcomes.

Practice Patterns and Outcomes of Pediatric Thyroid Surgery: An NSQIP Analysis.

BACKGROUND: Pediatric thyroid cancer rates are rising. The aim of this study was to determine the state of current practice and outcomes for pediatric thyroidectomies using the pediatric National Surgical Quality Improvement Program (NSQIP-P) with specific attention to differences based on surgeon type/specialty. METHODS: All cases of pediatric thyroidectomies and neck dissections within the NSQIP-P database were identified from 2015 to 2017. Patient, disease, and treatment-related factors affecting 30-day outcomes were analyzed using univariate and multivariate analyses. RESULTS: A total of 1300 cases were identified. Mean age at time of surgery was 14.0 (SD 3.5) years. The majority of patients were female (78%) and Caucasian (72%). Pediatric general surgeons performed the largest proportion of cases (42%) followed by pediatric otolaryngologists (33%). Malignancies were present in 29% of cases. The overall rate of complications was 3.0%. On multivariate analysis, non-pediatric surgeons were more likely to operate on Caucasian children, malignant pathology, and perform modified radical neck dissections. Pediatric surgeons were more likely to have longer operative times, have specialized in otolaryngology, and operate on sicker children (ASA>2). There were no differences in length of stay or overall complications rates. CONCLUSIONS: This study shows that pediatric surgeons currently perform the majority of thyroid surgeries in children. While unable to assess surgeon volume, our data show that thyroid surgery is being safely performed at NSQIP-affiliated hospitals by both non-pediatric and pediatric surgeons. Further studies are needed to determine if there are differences in specific procedure-related complications and long-term outcomes between surgeon types.

Impact of urinary tract infection definitions on colorectal outcomes.

BACKGROUND: Hospital-acquired urinary tract infections (UTIs) significantly impact hospital outcomes. Colorectal surgery is inherently high risk for postoperative infections including UTI, and these patients may have unique outcomes as compared to other medical and surgical hospitalizations. We aim to assess the impact of the differing definitions of UTI captured by our hospital quality measures on hospital charges, length of stay (LOS), and mortality after colorectal resections at our institution. MATERIALS AND METHODS: Existing hospital quality surveillance was used to retrospectively identify postcolorectal resection UTI, as defined by the National Surgical Quality Improvement Program (NSQIP), and the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN)-defined catheter-associated UTIs (CAUTI), from 2006-2012. Both groups were compared to colorectal resections performed during the same period that did not develop a UTI. Groups were compared for differences in 30-d surgical outcomes with multivariate analysis of total hospital charges and LOS. RESULTS: During our study period, we identified 18 CAUTIs and 42 NSQIP-UTI, and 1064 other colorectal resections (UTI rate, 5.3%). Our overall mortality rate was 4.4% and was not associated with CAUTI or NSQIP-UTI on univariate analysis. CAUTI, but not NSQIP-UTI, was associated with a 73% increase in LOS and 70% increase in total hospital charges on multivariate analysis. CONCLUSIONS: By reviewing quality outcomes surveillance modalities at our hospital, we identified postcolorectal resection CAUTI, but not NSQIP-UTI, to be associated with increased total hospital charges and LOS. Neither was associated with mortality.

Morbidity and mortality following elective splenectomy for benign and malignant hematologic conditions: analysis of the American College of Surgeons National Surgical Quality Improvement Program data.

IMPORTANCE: Splenectomy is a commonly performed operation; however, data from large series regarding operative outcomes to help guide decision making and informed consent are lacking. OBJECTIVE: To evaluate clinical and pathologic variables associated with morbidity and mortality following elective splenectomy for benign and malignant hematologic conditions in the United States. DESIGN, SETTING, AND PARTICIPANTS: A review of the American College of Surgeons National Surgical Quality Improvement Program data for elective splenectomy between January 1, 2005, and December 31, 2011, was performed, and 1715 eligible individuals were identified. INTERVENTION: Elective splenectomy for hematologic conditions. MAIN OUTCOMES AND MEASURES: Complications and operative mortality were evaluated for the entire cohort and compared between patients with benign vs malignant diseases. Multivariable logistic regression was used to evaluate factors predictive of operative complications and death. RESULTS: Splenectomy was performed in 1344 patients (78.4%) for benign disease and in 371 patients (21.6%) for malignant disease. Two hundred ninety-one patients (17.0%) had a complication, and operative mortality occurred in 27 patients (mortality rate, 1.6%). Patients treated for malignant disease had a higher rate of overall complications (27.2%) compared with patients treated for benign disease (14.1%) (P < .001). Several variables were independent predictors of complications, including malignant disease (vs benign) (Odds Ratio [OR], 1.86; 95% CI, 1.23-2.80; P = .003), independent performance status (vs dependent) (OR, 0.33; 95% CI, 0.07-1.52; P = .02), and increasing albumin level (OR, 0.75; 95% CI, 0.66-0.86; P < .001). Increasing age (OR, 1.03; 95% CI, 1.00-1.06; P = .05) was an independent predictor of mortality while increasing albumin level (OR, 0.63; 95% CI, 0.46-0.86; P = .003) predicted lower risk of operative death. From these data, a patient older than 60 years with a low preoperative albumin level has a predicted probability for operative death as high as 10.0%. CONCLUSIONS AND RELEVANCE: Preoperative performance and nutritional status are significant risk factors for complications and mortality following elective splenectomy. Although operative mortality continues to decrease over time, specific preoperative variables may help with patient selection before elective splenectomy for certain patients.