Characteristics of early complications in isolated primary anterior cruciate ligament reconstruction surgery.

PURPOSE: The early complications of isolated anterior cruciate ligament reconstruction surgery (ACLR) have not been well characterized using large databases. This study aims to characterize incidence, impact, and risk factors for short-term operative complications following elective, isolated ACLR surgery. We hypothesize that demographic and perioperative factors may predict 30-day complications after isolated ACLR. METHODS: This case-control analysis of the American College of Surgeons National Surgical Quality Improvement Program Database (2005-2017) used Current Procedural Terminology codes to identify elective, isolated ACLR patients. Patients undergoing concomitant procedures were excluded. Complications were analyzed using bivariate analysis against demographic variables. Multiple stepwise logistic regression was used to identify independent risk factors for morbidity after ACLR. RESULTS: A total 12,790 patients (37.0% female, p = 0.674) were included with a mean age of 32.2 years old (SD 10.7 years, p < 0.001). Mean BMI was 27.8 kg/m2 (6.5) where 28.9% of patients had a BMI > 30 (p = 0.064). The most common complications were wound-related (0.57%). In cases with complications, there were higher rates of (1.3% vs 0.8%, p = 0.004) prolonged operation (> 1.5 h), higher rate (2.9% vs 1.8%, p = 0.004) of extended length of stay (≥ 1 day), unplanned reoperation (15.8% vs 0.3%, p < 0.001), and unplanned readmission (17.5% vs 0.3%, p < 0.001). Multivariate analysis showed prolonged operative time (p = 0.001), dyspnea (p = 0.008), and non-ambulatory surgery (p = 0.034) to be predictive of any complication. Dependent functional status (p = 0.091), mFI-5 > 0.2 (= 0.173), female sex (p = 0.191), obesity (p = 0.101), and smoking (p = 0.113) were not risk factors for complications. CONCLUSION: ACLR is associated with low rates of morbidity and readmissions. The most common comorbidities, complications, and predictors of morbidities were identified to aid surgeons in further reducing adverse outcomes of ACLR. Operative time > 1.5 h, dyspnea, and non-ambulatory surgery are predictive of complications.

Restorative surgery for ulcerative colitis in the elderly: an analysis of ileal pouch-anal anastomosis procedures from the American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND: Ileal pouch-anal anastomosis (IPAA) for ulcerative colitis (UC) can be performed as either 2- or 3-stage procedure. IPAA in the elderly has been reported as safe and feasible, but little work to date has assessed outcomes by procedure. The aim of our study was to assess use and short-term outcomes of 2- and 3-stage IPAA in older adults. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Database was searched for ≥ 65-year-old patients who underwent IPAA for UC in 2- or 3-stage from 2012 to 2016. The primary endpoint was the rate and trends of the two approaches over time. Secondary endpoints included 30-day adverse events and complication-associated costs. RESULTS: Overall, 123 patients were included: 77.5% (n = 83) 2-stage and 40 (32.5%) 3-stage IPAA. Mean age was 68.7 ± 3.9 years, with 43 (34.9%) women. The use of the 3-stage IPAA increased over time (18.8% in 2012 vs. 33.3% in 2016), with decreasing use of 2-stage IPAA (81.3% vs. 66.7%, p < 0.001). The morbidity associated with the procedures decreased over time, overall (81.3% in 2012 and 51.5% in 2016, p < 0.001) and in each group individually. No differences were observed in postoperative complications across groups (45.8% 2-stage, 32.5% 3-stage). The overall mean costs of care when no postoperative complications occurred was $25,910, vs. $38,577 when any complication occurred (p < 0.001), but no differences were observed between groups. CONCLUSION: In a national analysis, there was a trend of increasing 3-stage vs. 2-stage IPAA for UC in older Americans. Complications and complication-associated costs were comparable across approaches, suggesting that the choice of procedure type should be based on the specific patient comorbidities and surgeon preferences.

Restorative surgery for ulcerative colitis in the elderly: an analysis of ileal pouch-anal anastomosis procedures from the American College of Surgeons National Surgical Quality Improvement Program.

BACKGROUND: Ileal pouch-anal anastomosis (IPAA) for ulcerative colitis(UC) can be performed as either 2- or 3-stage procedure. IPAA in the elderly has been reported as safe and feasible, but little work to date has assessed outcomes by procedure. The aim of our study was to assess use and short-term outcomes of 2- and 3-stage IPAA in older adults. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was searched for ≥ 65-year-old patients who underwent IPAA for UC in 2- or 3-stage from 2012 to 2016. The primary endpoint was the rate and trends of the two approaches over time. Secondary endpoints included 30-day adverse events and complication-associated costs. RESULTS: Overall, 123 patients were included: 77.5% (n = 83) 2-stage and 40 (32.5%) 3-stage IPAA. Mean age was 68.7 ± 3.9 years, with 43 (34.9%) women. The use of the 3-stage IPAA increased over time (18.8% in 2012 vs. 33.3% in 2016), with decreasing use of 2-stage IPAA(81.3% vs. 66.7%, p < 0.001). The morbidity associated with the procedures decreased over time, overall (81.3% in 2012 and 51.5% in 2016, p < 0.001) and in each group individually. No differences were observed in postoperative complications across groups (45.8% 2-stage, 32.5% 3-stage). The overall mean costs of care when no postoperative complications occurred was $25,910, vs. $38,577 when any complication occurred (p < 0.001), but no differences were observed between groups. CONCLUSIONS: In a national analysis, there was a trend of increasing 3-stage vs. 2-stage IPAA for UC in older Americans. Complications and complication-associated costs were comparable across approaches, suggesting that the choice of procedure type should be based on the specific patient comorbidities and surgeon preferences.

General Anesthesia Leads to Increased Adverse Events Compared With Spinal Anesthesia in Patients Undergoing Unicompartmental Knee Arthroplasty.

BACKGROUND: The volume of unicompartmental knee arthroplasty (UKA) has increased dramatically in recent years with good reported long-term outcomes. UKA can be performed under general or neuraxial (ie, spinal) anesthesia; however, little is known as to whether there is a difference in outcomes based on anesthesia type. The purpose of the present study is to compare perioperative outcomes between anesthesia types for patients undergoing primary elective UKA. METHODS: Patients who underwent primary elective UKA from 2007 to 2017 were identified from the American College of Surgeons-National Surgical Quality Improvement Program Database. Operating room times, length of stay (LOS), 30-day adverse events, and readmission rates were compared between patients who received general anesthesia and those who received spinal anesthesia. Propensity-adjusted multivariate analysis was used to control for selection bias and baseline patient characteristics. RESULTS: A total of 8639 patients underwent UKA and met the inclusion criteria for this study. Of these, 4728 patients (54.7%) received general anesthesia and 3911 patients (45.3%) received spinal anesthesia. On propensity-adjusted multivariate analyses, general anesthesia was associated with increased operative time (P < .001) and the occurrence of any severe adverse event (odds ratio [OR], 1.39; 95% confidence interval [95% CI], 1.04-1.84; P = .024). In addition, general anesthesia was associated with higher rates of deep venous thrombosis (OR, 2.26; 95% CI, 1.11-4.6; P = .024) and superficial surgical site infection (OR, 1.04; 95% CI, 0.6-1.81; P < .001). Finally, general anesthesia was also associated with a reduced likelihood of discharge to home (OR, 0.72; 95% CI, 0.59-0.88; P < .001). No difference existed in postoperative hospital LOS or readmission rates among cohorts. CONCLUSION: General anesthesia was associated with an increased rate of adverse events and increased operating room times as well as a reduced likelihood of discharge to home. There was no difference in hospital LOS or postoperative readmission rates between anesthesia types.

Minimally Invasive Surgical Site Infection in Procedure-Targeted ACS NSQIP Pancreaticoduodenectomies.

BACKGROUND: Pancreaticoduodenectomy (PD) incurs a surgical site infection rate of up to 18%. Published rates after minimally invasive PD are comparable or superior to open, but data are limited to high-volume, single-institution series. This study aimed to determine national outcomes. We hypothesized nationwide infections would be reduced with a minimally invasive approach. MATERIALS AND METHODS: Using the newly available pancreatectomy-specific outcomes in National Surgical Quality Improvement Project, data on surgical site infection in PD were extracted from the procedure-targeted participant user file from 2014 to 2015. χ2 test determined correlation of infection with approach. Linear regression determined correlation of known parameters with infection rate. RESULTS: Overall infection rate was 24%. Compared with open, laparoscopic rates were lower (P = 0.001), but robotic rates were comparable with open. Stenting, longer operative times, and soft gland texture were associated with increased infection rates, whereas larger duct size and drains were associated with decreased rates (all P < 0.01). CONCLUSIONS: Laparoscopic PD is associated with decreased surgical site infection on a national level. This represents the first procedure-targeted National Surgical Quality Improvement Project report on this endpoint. Despite greater infection rates than previously reported, these data support previous institutional reports of decreased infection rates with laparoscopic approach.

Current Quality Measurement Tools Are Insufficient to Assess Complications in Orthopedic Surgery.

PURPOSE: The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) is a clinically-derived, validated tool to track outcomes in surgery. The Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) are a set of computer algorithms run on administrative data to identify adverse events. The purpose of this study is to compare complications following orthopedic surgery identified by ACS-NSQIP and AHRQ-PSI. METHODS: Patients between 2010 and 2012 who underwent orthopedic procedures (arthroplasty, spine, trauma, foot and ankle, hand, and upper extremity) at our tertiary-care, academic institution were identified (n = 3,374). Identification of inpatient adverse events by AHRQ-PSI in the cohort was compared with 30-day events identified by ACS-NSQIP. Adverse events common to both AHRQ-PSI and ACS-NSQIP were infection, sepsis, venous thromboembolism, bleeding, respiratory failure, wound disruption, and renal failure. Concordance between AHRQ-PSI and ACS-NSQIP for identifying adverse events was examined. RESULTS: A total of 729 adverse events (21.6%) were identified in the cohort using ACS-NSQIP methodology and 35 adverse events (1.0%) were found using AHRQ-PSI. Only 12 events were identified by both methodologies. The most common complication was bleeding in ACS-NSQIP (18.1%) and respiratory failure in AHRQ-PSI (0.53%). The overlap was highest for venous thromboembolic events. There was no overlap in adverse events for 5 of the 7 categories of adverse events. CONCLUSIONS: A large discrepancy was observed between adverse events reported in ACS-NSQIP and AHRQ-PSI. A large percentage of clinically important adverse events identified in ACS-NSQIP were missed in AHRQ-PSI algorithms. The ability of AHRQ-PSI for detecting adverse events varied widely with ACS-NSQIP. CLINICAL RELEVANCE: AHRQ-PSI algorithms currently are insufficient to assess the quality of orthopedic surgery.

Factors associated with increased 30-day re-operation risk in anterior cruciate ligament reconstruction.

BACKGROUND: Revision surgery following isolated anterior cruciate ligament reconstruction (ACLR) has often focused on mid- to long-term revisions due to re-rupture, while short-term 30-day revision is a rare, but underappreciated entity. This study aims to characterize incidence and risk factors for reoperations following isolated ACLR. METHODS: This is a retrospective case-control analysis of the American College of Surgeons National Surgical Quality Improvement Program Database (NSQIP) database from 2005 to 2017. Current Procedural Terminology codes were used to identify elective isolated ACLR patients. Patients undergoing reoperations were analyzed using bivariate analysis against their respective perioperative variables. Multivariate stepwise logistic regression was used to identify independent risk factors for reoperations after ACLR. RESULTS: 12,790 patients were included in the study. 37.0% of patients were female. Mean age was 32.2+/-10.7 years and mean body mass index (BMI) was 27.8+/-6.5 kg/m2, with 28.9% of patients with BMI > 30. The most frequently reported reason for reoperation based on CPT and ICD-9/10 codes was postoperative infection (0.5%). Overall reoperation rate was approximately 0.5%. Multivariate analysis identified operative time >1.5 h (OR 2.6 [95% CI; 1.5-4.4]), dependent functional status (OR 14.0 [1.4-141.6]), and adjunctive anesthesia (OR 2.4 [95% CI; 1.1-5.0]) as independent risk factors for reoperation. Female sex was a protective factor against reoperations (OR 0.6 [0.3-0.98]). CONCLUSION: Primary, isolated ACLR is associated with extremely low rates of short-term reoperations. Operative time >1.5 h, dependent functional status, and adjunctive anesthesia were independent risk factors for reoperation and female sex was a protective factor against reoperation. LEVEL OF EVIDENCE: Level III. Retrospective cohort study.

Surgical care improvement project and surgical site infections: can integration in the surgical safety checklist improve quality performance and clinical outcomes?

INTRODUCTION: The World Health Organization Surgical Safety Checklist (SSC) has been shown to decrease surgical site infections (SSI). The Surgical Care Improvement Project (SCIP) SSI reduction bundle (SCIP Inf) contains elements to improve SSI rates. We wanted to determine if integration of SCIP measures within our SSC would improve SCIP performance and patient outcomes for SSI. METHODS: An integrated SSC that included perioperative SCIP Inf measures (antibiotic selection, antibiotic timing, and temperature management) was implemented. We compared SCIP Inf compliance and patient outcomes for 1-y before and 1-y after SSC implementation. Outcomes included number of patients with initial post-anesthesia care unit temperature <98.6°F and SSI rates according to our National Surgical Quality Improvement Program data. RESULTS: Implementation of a SCIP integrated SSC resulted in a significant improvement in antibiotic infusion timing (92.7% [670/723] versus 95.4% [557/584]; P < 0.05), antibiotic selection (96.2% [707/735] versus 98.7% [584/592]; P < 0.01), and temperature management (93.8% [723/771] versus 97.7% [693/709]; P < 0.001). Furthermore, we found a significant reduction in number of patients with initial post-anesthesia care unit temperature <98.6°F from 9.7% (982/10,126) to 6.9% (671/9676) (P < 0.001). Institutional SSI rates decreased from 3.13% (104/3319) to 2.96% (107/3616), but was not significant (P = 0.72). SSI rates according to specialty service were similar for all groups except colorectal surgery (24.1% [19/79] versus 11.5% [12/104]; P < 0.05). CONCLUSION: Implementation of an integrated SSC can improve compliance of SSI reduction strategies such as SCIP Inf performance and maintenance of normothermia. This did not, however, correlate with an improvement in overall SSI at our institution. Further investigation is required to determine other factors that may influence SSI at an institutional level.

Cervical Total Disc Replacement and Anterior Cervical Discectomy and Fusion: Comparison of 30-Day Population Comorbidities and Perioperative Complications Using 6 Years of American College of Surgeons National Surgical Quality Improvement Program Participant Use File Data.

OBJECTIVE: American College of Surgeons National Surgical Quality Improvement Program Participant Use File data from 2014 through 2019 were used to compare 1- and 2-level anterior cervical discectomy and fusion (ACDF) and cervical total disc replacement (cTDR) with respect to: patient demographics, comorbidities, adverse events, and 30-day morbidity rates. METHODS: One- and 2-level ACDF and cTDR patients were identified by current procedural terminology codes. Demographics, comorbidities, and adverse events were summarized. Unmatched cohorts were compared using Wilcoxon Rank Sum test for continuous variables, Pearson χ2 test for categorical variables, and 30-day morbidity using inverse probability of treatment weighted log-binomial regression. RESULTS: American College of Surgeons National Surgical Quality Improvement Program 2014 through 2019 Participant Use File datasets represent 4,862,497 unique patients, identifying 13,347 1-level, 6933 2-level ACDF, 3114 1-level, and 862 2-level cTDR patient cohorts. Statistically significant differences between cohorts are extensive: age, sex, race, admission status, patient origin, discharge disposition, emergent surgery, surgical specialty, American Society of Anesthesiologists classification, wound class, operative time, hospital LOS, BMI, functional status, smoking, diabetes, dyspnea, chronic obstructive pulmonary disease, congestive heart failure, hypertension, renal failure, dialysis, cancer, steroid use, anemia, bleeding disorders, systemic sepsis, and number of concurrent comorbid conditions. Inverse probability of treatment weighted log-binomial models, demonstrated increased risk of deep venous thrombosis/thrombophlebitis, pulmonary embolism, deep incisional surgical site infection, pneumonia, and unplanned return to operating room associated with ACDF while increased risk of cerebral vascular accident/stroke with neurological deficit and myocardial infarction associated with cTDR. The composite complications outcome favors cTDR over ACDF for 30-day morbidity. No mortalities occurred within the cTDR cohort. CONCLUSIONS: Adjusting for demographics and comorbidities; ACDF has a higher average risk of adverse event. When ACDF and cTDR are equipoise, consideration for cTDR may be indicated in populations with higher rates of comorbid conditions.

Frailty Status Is a More Robust Predictor Than Age of Spinal Tumor Surgery Outcomes: A NSQIP Analysis of 4,662 Patients.

OBJECTIVE: The present study aimed to evaluate the effect of baseline frailty status (as measured by modified frailty index-5 [mFI-5]) versus age on postoperative outcomes of patients undergoing surgery for spinal tumors using data from a large national registry. METHODS: The National Surgical Quality Improvement Program database was used to collect spinal tumor resection patients' data from 2015 to 2019 (n = 4,662). Univariate and multivariate analyses for age and mFI-5 were performed for the following outcomes: 30-day mortality, major complications, unplanned reoperation, unplanned readmission, hospital length of stay (LOS), and discharge to a nonhome destination. Receiver operating characteristic (ROC) curve analysis was used to evaluate the discriminative performance of age versus mFI-5. RESULTS: Both univariate and multivariate analyses demonstrated that mFI-5 was a more robust predictor of worse postoperative outcomes as compared to age. Furthermore, based on categorical analysis of frailty tiers, increasing frailty was significantly associated with increased risk of adverse outcomes. 'Severely frail' patients were found to have the highest risk, with odds ratio 16.4 (95% confidence interval [CI],11.21-35.44) for 30-day mortality, 3.02 (95% CI, 1.97-4.56) for major complications, and 2.94 (95% CI, 2.32-4.21) for LOS. In ROC curve analysis, mFI-5 score (area under the curve [AUC] = 0.743) achieved superior discrimination compared to age (AUC = 0.594) for mortality. CONCLUSION: Increasing frailty, as measured by mFI-5, is a more robust predictor as compared to age, for poor postoperative outcomes in spinal tumor surgery patients. The mFI-5 may be clinically used for preoperative risk stratification of spinal tumor patients.

Racial disparities in short-term outcomes after breast reduction surgery-A National Surgical Quality Improvement Project Analysis with 23,268 patients using Propensity Score Matching.

BACKGROUND: Evidence of widespread disparities in healthcare for racial and ethnic minorities is well documented. This study aims to evaluate differences in surgical outcomes after breast reduction surgery (BRS) according to patients' ethnicities. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database (2005-2018) was utilized to analyze two propensity score matched patient cohorts-White and non-White-that underwent BRS. Preoperative variables assessed included demographic data and comorbidities such as diabetes mellitus, hypertension, and obesity. Postoperative outcomes assessed were medical complications, minor and major surgical complications, as well as mortality. RESULTS: In total, 23268 patients underwent BRS and met the inclusion criteria. After propensity score matching, the two cohorts were matched with respect to these preoperative variables, and 7187 patients were included in each cohort of White and non-White patients (total 14374). After matching, overall 30-day major complications were not significantly different between White and non-White cohort (2.25% vs 2.14%, p=0.65). After accounting for differences in confounding variables at the patient and socioeconomic level, racial and ethnic minorities who underwent breast reduction were found to experience fewer minor surgical complications. The analysis of temporal trends identified an overall rise in the number of patients seeking BRS, with a higher increase noted in the non-White population. CONCLUSION: Overall, our findings are reassuring exemptions to prevalent racial and ethnic health inequalities and can serve as a positive example for adequate and fair provision of surgical care.

Protocol-driven prevention of perioperative hypothermia in the pediatric neurosurgical population.

OBJECTIVE: Perioperative hypothermia (PH) is a preventable, pathological, and iatrogenic state that has been shown to result in increased surgical blood loss, increased surgical site infections, increased hospital length of stay, and patient discomfort. Maintenance of normothermia is recommended by multiple surgical quality organizations; however, no group yet provides an ergonomic, evidence-based protocol to reduce PH for pediatric neurosurgery patients. The authors' aim was to evaluate the efficacy of a PH prevention protocol in the pediatric neurosurgery population. METHODS: A prospective, nonrandomized study of 120 pediatric neurosurgery patients was performed. Thirty-eight patients received targeted warming interventions throughout their perioperative phases of care (warming group-WG). The remaining 82 patients received no extra warming care during their perioperative period (control group-CG). Patients were well matched for age, sex, and preparation time intraoperatively. Hypothermia was defined as < 36°C. The primary outcome of the study was maintenance of normothermia preoperatively, intraoperatively, and postoperatively. RESULTS: WG patients were significantly warmer on arrival to the operating room (OR) and were 60% less likely to develop PH (p < 0.001). Preoperative forced air warmer use both reduced the risk of PH at time 0 intraoperatively and significantly reduced the risk of any PH intraoperatively (p < 0.001). All patients, regardless of group, experienced a drop in core temperature until a nadir occurred at 30 minutes intraoperatively for the WG and 45 minutes for the CG. At every time interval, from preoperatively to 120 minutes intraoperatively, CG patients were between 2 and 3 times more likely to experience PH (p < 0.001). All patients were warm on arrival to the postanesthesia care unit regardless of patient group. CONCLUSIONS: Preoperative forced air warmer use significantly increases the average intraoperative time 0 temperature, helping to prevent a fall into PH at the intraoperative nadir. Intraoperatively, a strictly and consistently applied warming protocol made intraoperative hypothermia significantly less likely as well as less severe when it did occur. Implementation of a warming protocol necessitated only limited resources and an OR culture change, and was well tolerated by OR staff.

Frailty and Polypharmacy in Older Patients with Otolaryngologic Diseases.

Frailty and Polypharmacy commonly impact disease processes and treatment of patients with otolaryngologic disorders. Although well known to geriatricians, the 2 concepts often elude other physicians, including otolaryngologists. This article reviews the common manifestations likely to be encountered in otolaryngology patients, reviews frailty measures in surgical patients, and makes recommendations regarding education of nongeriatricians.

Early Complications and Outcomes in Adult Spinal Deformity Surgery: An NSQIP Study Based on 5803 Patients.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: The purpose of this study is to determine the incidence, impact, and risk factors for short-term postoperative complications following elective adult spinal deformity (ASD) surgery. METHODS: Current Procedural Terminology codes were used to query the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) for adults who underwent spinal deformity surgery from 2010 to 2014. Patients were separated into groups of those with and without complications. Univariate analysis and multivariate logistic regression were used to assess the impact of patient characteristics and operative features on postoperative outcomes. RESULTS: In total, 5803 patients were identified as having undergone ASD surgery in the NSQIP database. The average patient age was 59.5 (±13.5) years, 59.0% were female, and 81.1% were of Caucasian race. The mean body mass index was 29.5(±6.6), with 41.9% of patients having a body mass index of 30 or higher. The most common comorbidities were hypertension requiring medication (54.5%), chronic obstructive pulmonary disease (4.9%), and bleeding disorders (1.2%). Nearly a half of the ASD patients had an operative time >4 hours. The posterior fusion approach was more common (56.9%) than an anterior one (39.6%). The mean total relative value unit was 73.4 (±28.8). Based on multivariate analyses, several patient and operative characteristics were found to be predictive of morbidity. CONCLUSION: Surgical correction of ASD is associated with substantial risk of intraoperative and postoperative complications. Preoperative and intraoperative variables were associated with increased morbidity and mortality. This data may assist in developing future quality improvement activities and saving costs through measurable improvement in patient safety.

Use of free tissue transfer in head and neck cancer surgery and risk of overall and serious complication(s): An American College of Surgeons-National Surgical Quality Improvement Project analysis of free tissue transfer to the head and neck.

BACKGROUND: The purpose of this article was to assess the rates of head and neck free tissue transfer and variables available in the American College of Surgeons - National Surgical Quality Improvement Project (ACS-NSQIP) dataset to predict overall and serious complications. METHODS: We conducted a data analysis from 2005 to 2014 on free tissue cases in the head and neck with descriptive and cross-sectional analysis to examine correlation of NSQIP variables with complications (p < .05). RESULTS: Of 1643 flaps, 906 complications occurred, such as blood transfusion, return to the operating room, extended ventilator support, pneumonia, and superficial surgical site infection. Insulin-dependent diabetes, operative time, age, white blood cell (WBC) count, and smoking correlated with overall complications. Five hundred one patients experienced 859 serious complications: return to the operating room, pneumonia, deep surgical site infection, sepsis, and unplanned intubation. Operative time, clean contaminated wound status, dirty wound classification, and history of congestive heart failure were predictive. CONCLUSION: Identification of risks for complications is an opportunity for improvement. Extended operative time consistently predicts for both overall and serious complications, suggesting long surgery within contaminated sites risks complication. © 2016 Wiley Periodicals, Inc. Head Neck 39: 702-707, 2017.

Risk factors associated with venous thromboembolism in patients undergoing spine surgery.

OBJECTIVE Patients undergoing spinal surgery are at risk for developing venous thromboembolism (VTE). The authors sought to identify risk factors for VTE in these patients. METHODS The American College of Surgeons National Surgical Quality Improvement Project database for the years 2006-2010 was reviewed for patients who had undergone spinal surgery according to their primary Current Procedural Terminology code(s). Clinical factors were analyzed to identify associations with VTE. RESULTS Patients who underwent spinal surgery (n = 22,434) were identified. The rate of VTE in the cohort was 1.1% (pulmonary embolism 0.4%; deep vein thrombosis 0.8%). Multivariate binary logistic regression analysis revealed 13 factors associated with VTE. Preoperative factors included dependent functional status, paraplegia, quadriplegia, disseminated cancer, inpatient status, hypertension, history of transient ischemic attack, sepsis, and African American race. Operative factors included surgery duration > 4 hours, emergency presentation, and American Society of Anesthesiologists Class III-V, whereas postoperative sepsis was the only significant postoperative factor. A risk score was developed based on the number of factors present in each patient. Patients with a score of ≥ 7 had a 100-fold increased risk of developing VTE over patients with a score of 0. The receiver-operating-characteristic curve of the risk score generated an area under the curve of 0.756 (95% CI 0.726-0.787). CONCLUSIONS A risk score based on race, preoperative comorbidities, and operative characteristics of patients undergoing spinal surgery predicts the postoperative VTE rate. Many of these risks can be identified before surgery. Future protocols should focus on VTE prevention in patients who are predisposed to it.

Thirty day postoperative outcomes following anterior lumbar interbody fusion using the National Surgical Quality Improvement Program database.

OBJECTIVE: Anterior lumbar interbody fusion (ALIF) is a common procedure used to treat various lumbar degenerative pathologies. The purpose of this study is to describe 30-day postoperative outcomes following ALIF on a national scale. METHODS: The American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) was searched for ALIF patients between 2005 and 2011. The top preoperative diagnoses were determined using ICD-9 codes. All available 30-day complications were grouped as overall composite morbidity and were compared between preoperative diagnosis groups by univariable and multivariable analyses. RESULTS: There were a total of 1352 ALIF patients. Overall, 6.73% of patients experienced a postoperative complication. Unplanned reoperations (2.48%), urinary tract infection (1.55%), superficial surgical site infection (1.41%), and sepsis (1.11%) were the most common morbidity events. The morbidity rates for each sub-group were: intervertebral disc degeneration (4.41%), spondylosis (6.72%), lumbosacral spinal stenosis(8.21%), and spondylolisthesis (8.41%). After extensive adjustment for patient characteristics and preoperative morbidities, multivariable analysis revealed spondylolisthesis (OR=3.29; 95% CI:1.04-10.46) and spinal stenosis (OR=3.76; 95% CI:1.33-10.63) to be associated with significantly higher overall morbidity odds when compared with lumbar disc degeneration. Lumbosacral spondylosis was associated with similar outcomes as degenerative disc disease (OR =1.70; 95% CI:0.48-6.06). CONCLUSIONS: Diverse postoperative complications need to be managed following ALIF. Patients with spondylolisthesis and spinal stenosis may carry increased 30-day postoperative morbidity profiles in ALIF when compared to those with degenerative disc disease. Prospective studies are needed to better delineate the outcomes of ALIF procedures, particularly in the spondylolisthesis and spinal stenosis patient populations.

Use of a simplified frailty index to predict Clavien 4 complications and mortality after hepatectomy: analysis of the National Surgical Quality Improvement Project database.

BACKGROUND: An aging surgical population places an increasing burden on surgeons to accurately risk stratify and counsel patients. Preoperative frailty assessments are a promising new modality to better evaluate patients but can often be time consuming. Data regarding frailty and hepatectomy outcomes have not been published to date. METHOD: Using the National Surgical Quality Improvement Project database, we examined hepatectomy patients 2005 to 11 and correlated frailty scores with outcomes of major morbidity, mortality, and extended length of stay, using a previously validated modified frailty index score. Frailty was compared against age, American Society of Anesthesiologists class, and other common risk variables. RESULTS: Multivariate regression identified frailty as the strongest predictor of Clavien 4 complications (OR = 40.0, 95% CI = 15.2 to 105.0), and mortality (OR = 26.4, 95% CI = 7.7 to 88.2). As the frailty score increased, there was a statistically significant increase in Clavien 4 complications, mortality, and extended length of stay (P < .001 for all). CONCLUSIONS: Frailty is a significant factor in morbidity and mortality after hepatectomy. Use of the modified frailty index allows for feasibility of data collection in a busy clinical setting.

Patient factors associated with 30-day morbidity, mortality, and length of stay after surgery for subdural hematoma: a study of the American College of Surgeons National Surgical Quality Improvement Program.

OBJECTIVE: Surgery for subdural hematoma (SDH) is a commonly performed neurosurgical procedure. This study identifies patient characteristics associated with adverse outcomes and prolonged length of stay (LOS) in patients who underwent surgical treatment for SDH. METHODS: All patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) who were treated via craniotomy or craniectomy for SDH between 2005 and 2012 were identified. Patient demographics, comorbidities, and 30-day outcomes were described. Multivariate regression was used to identify predictors of adverse events. RESULTS: A total of 746 surgical procedures performed for SDH were identified and analyzed. Patients undergoing this procedure were 64% male with an average age (± SD) of 70.9 ± 14.1 years. The most common individual adverse events were death (17%) and intubation for more than 48 hours (19%). In total, 34% experienced a serious adverse event other than death, 8% of patients returned to the operating room (OR), and the average hospital LOS was 9.8 ± 9.9 days. In multivariate analysis, reduced mortality was associated with age less than 60 years (relative risk [RR] = 0.47, p = 0.017). Increased mortality was associated with gangrene (RR = 3.5, p = 0.044), ascites (RR = 3.00, p = 0.006), American Society of Anesthesiologists (ASA) Class 4 or higher (RR = 2.34, p = 0.002), coma (RR = 2.25, p < 0.001), and bleeding disorders (RR = 1.87, p = 0.003). Return to the OR was associated with pneumonia (RR = 3.86, p = 0.044), male sex (RR = 1.85, p = 0.015), and delirium (RR = 1.75, p = 0.016). Serious adverse events were associated with ventilator dependence preoperatively (RR = 1.86, p < 0.001), dialysis (RR = 1.44, p = 0.028), delirium (RR = 1.40, p = 0.005), ASA Class 4 or higher (RR = 1.36, p = 0.035), and male sex (RR = 1.29, p = 0.037). Similarly, LOS was increased in ventilator dependent patients by 1.56-fold (p = 0.002), in patients with ASA Class 4 or higher by 1.30-fold (p = 0.006), and in delirious patients by 1.29-fold (p = 0.008). CONCLUSIONS: Adverse outcomes are common after surgery for SDH. In this study, 18% of the patients died within 30 days of surgery. Factors associated with adverse outcomes were identified. Patients and families should be counseled about the serious risks of morbidity and death associated with acute traumatic SDH requiring surgery.

Comparison of the lumbar disc herniation patients randomized in SPORT to 6,846 discectomy patients from NSQIP: demographics, perioperative variables, and complications correlate well.

BACKGROUND CONTEXT: The Spine Patient Outcomes Research Trial (SPORT) is a highly referenced clinical trial that randomized patients with lumbar pathology to receive surgery or continued conservative treatment. PURPOSE: The purpose of this study was to compare the SPORT lumbar disc herniation cohort and an analogous cohort from the National Surgical Quality Improvement Program (NSQIP) database. STUDY DESIGN/SETTING: This is a retrospective cohort study comparing a national database population to a randomized clinical trial. PATIENT SAMPLE: Elective lumbar discectomies from NSQIP between 2010 and 2012 were used. OUTCOME MEASURES: Demographics were compared between the randomized SPORT cohorts (surgical and nonoperative) and NSQIP. Perioperative factors and complications were then compared between SPORT discectomy patients and NSQIP. METHODS: Using current procedural terminology and International Classification of Diseases, ninth revision codes, all elective lumbar discectomies from NSQIP between 2010 and 2012 were identified. Where possible based on the published data and variables available in each cohort, the two populations were compared. RESULTS: A total of 6,846 NSQIP discectomy patients were compared with the randomized SPORT surgical and nonoperative cohorts. Demographic comparisons showed that NSQIP patients were older (average age 48.2±14.5 years [mean±standard deviation] vs. 41.7±11.8 and 43.0±11.3 years, respectively [p<.001]) and had higher body mass index (29.6±6.2 kg/m(2) vs. 27.8±5.6 and 28.2±5.4 kg/m(2), respectively [p<.001]). No statistical differences existed for gender or race. Smoking status was not different between the SPORT nonoperative group and NSQIP but was higher in NSQIP compared with SPORT surgical patients (p=.020 by 7%). Comparisons of perioperative factors and complications between the SPORT surgical cohort and NSQIP showed no statistical difference in average operative time, length of stay, deep wound infections, wound dehiscence, total wound complications, or blood transfusions. Spine Patient Outcomes Research Trial superficial wound infection rates were higher than NSQIP (p=.029 by 1.4%). As expected, SPORT 1-year reoperation rates were higher than NSQIP 30-day rates (7% vs. 2%, p<.001). CONCLUSIONS: Spine Patient Outcomes Research Trial lumbar disc herniation results are similar to those from a large national patient sample. Even statistically significant differences would be considered clinically similar. These findings support the generalizability of the SPORT lumbar disc herniation results.