Aksharananda Rambachan

Surgical Duration and Risk of Venous Thromboembolism

IMPORTANCE There is a paucity of data assessing the effect of increased surgical duration on the incidence of venous thromboembolism (VTE). OBJECTIVE To examine the association between surgical duration and the incidence of VTE. DESIGN, SETTINGS, AND PARTICIPANTS Retrospective cohort of 1,432,855 patients undergoing surgery under general anesthesia at 315 US hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2011. EXPOSURE Duration of surgery. MAIN OUTCOMES AND MEASURES The rates of deep vein thrombosis (DVT), pulmonary embolism (PE), and VTE within 30 days of the index operation. Surgical duration was standardized across Current Procedural Terminology codes using a z score. Outcomes were compared across quintiles of the z score. Multiple logistic regression models were developed to examine the association while adjusting for patient demographics, clinical characteristics, and comorbidities. RESULTS The overall VTE rate was 0.96% (n = 13,809); the rates of DVT and PE were 0.71% (n = 10,198) and 0.33% (n = 4772), respectively. The association between surgical duration and VTE increased in a stepwise fashion. Compared with a procedure of average duration, patients undergoing the longest procedures experienced a 1.27-fold (95% CI, 1.21-1.34; adjusted risk difference [ARD], 0.23%) increase in the odds of developing a VTE; the shortest procedures demonstrated an odds ratio of 0.86 (95% CI, 0.83-0.88; ARD, -0.12%). The robustness of these results was substantiated with several sensitivity analyses attempting to minimize the effect of outliers, concurrent complications, procedural differences, and unmeasured confounding variables. CONCLUSIONS AND RELEVANCE Among patients undergoing surgery, an increase in surgical duration was directly associated with an increase in the risk for VTE. These findings may help inform preoperative and postoperative decision making related to surgery.

Impact of resident involvement on urological surgery outcomes: An analysis of 40,000 patients from the ACS NSQIP database

PURPOSE In addition to excellent patient care, the focus of academic medicine has traditionally been resident training. The changing landscape of health care has placed increased focus on objective outcomes. As a result, the surgical training process has come under scrutiny for its influence on patient care. We elucidated the effect of resident involvement on patient outcomes. MATERIALS AND METHODS We retrospectively analyzed data from the 2005 to 2011 NSQIP® participant use database. Patients were separated into 2 cohorts by resident participation vs no participation. The cohorts were compared based on preoperative comorbidities, demographic characteristics and intraoperative factors. Confounders were adjusted for by propensity score modification and complications were analyzed using perioperative variables as predictors. RESULTS A total of 40,001 patients met study inclusion criteria. Raw data analysis revealed that cases with resident participation had a higher rate of overall complications. However, after propensity score modification there was no significant difference in overall, medical or surgical complications in cases with resident participation. Resident participation was associated with decreased odds of overall complications (0.85). Operative time was significantly longer in cases with resident participation (159 vs 98 minutes). CONCLUSIONS Urology resident involvement is not associated with increased overall and surgical complications. It may even be protective when adjusted for appropriate factors such as case mix, complexity and operative time.

Predictors of Readmission following Outpatient Urological Surgery

PURPOSE The Patient Protection and Affordable Care Act increases oversight of surgical outcomes and ties hospital readmissions to Medicare reimbursement. Given the increasing volume of outpatient urological procedures, to our knowledge this study provides the first multi-institutional multivariate analysis of patient factors that contribute to readmission. MATERIALS AND METHODS Using the 2011 National Surgical Quality Improvement Program database we identified 7,795 patients. Multiple logistic regression was used to predict 30-day unplanned hospital readmissions controlling for demographics, clinical characteristics and comorbidities. Readmission rates of the 5 most common procedures were calculated along with the rate of postoperative complications associated with readmission. RESULTS Outpatient urological surgery had an overall 3.7% readmission rate. The 5 most common procedures were cystourethroscopy and resection of bladder tumor (readmission rate 4.97%), laser prostatectomy (4.27%), transurethral resection of prostate (4.24%), hydrocele excision (1.92%) and sling surgery for urinary incontinence (0.85%). The most common comorbidities in readmitted patients were hypertension, diabetes and smoking. Risk adjusted multiple regression indicated that cancer history (OR 3.48), bleeding disorder (OR 2.03), male gender (OR 1.38), ASA(®) level 3 or 4 (OR 1.34) and age (OR 1.01) were significant predictors of readmission. Readmitted patients also had a higher 30-day complication rate. CONCLUSIONS Readmission after outpatient urological surgery occurs at a rate of 3.7%. A history of cancer, bleeding disorder, male gender, ASA level 3 or 4 and age were associated with readmission along with greater rates of medical and surgical complications. Our results may help guide risk reduction initiatives and prevent costly readmissions.

Reasons for readmission after carotid endarterectomy

OBJECTIVE With increasing oversight of postoperative outcomes with the Patient Protection and Affordable Care Act, the reduction of readmissions is necessary to avoid financial penalties. This article provides a multi-institutional, multivariate analysis of the pre- and postoperative patient factors associated with readmission after carotid endarterectomy (CEA). METHODS Using the National Surgical Quality Improvement Program from 2011, we considered 8456 patients. The primary outcome variable was 30-day unplanned readmission. Multiple logistic regression was used, and we controlled for preoperative demographic variables, comorbidities and clinical characteristics, and postoperative medical and surgical complications. RESULTS Patients with CEA had a 6.0% unplanned readmission rate. The most common comorbidities in the readmitted patients included hypertension, diabetes, and bleeding disorder. Risk-adjusted multiple regression indicated that preoperative bleeding disorder (odds ratio [OR] 1.62), diabetes (OR 1.46), history of a cerebrovascular accident/stroke (OR 1.46), and increasing age (OR 1.01) were statistically significant predictors for readmission. Postoperatively, surgical-site infection (OR 21.90), myocardial infarction (OR 10.35), sepsis/septic shock (OR 7.79), cerebrovascular accident/stroke (OR 6.58), pneumonia (OR 4.37), and urinary tract infection (OR 3.21) were associated with a greater rate of readmission. CONCLUSIONS Readmission after CEA occurs at a comparatively high rate. Preoperative bleeding disorders, diabetes, cerebrovascular accidents, and age and postoperative surgical-site infection, myocardial infarction, sepsis/septic shock, pneumonia, and cerebrovascular accident were associated with readmission. These findings may help guide the surgical management of patients and prevent costly readmissions.

Robot-Assisted Laparoscopic Ipsilateral Ureteroureterostomy for Ectopic Ureters in Children: Description of Technique

PURPOSE We report our experience and present our technique with the robot-assisted laparoscopic ipsilateral ureteroureterostomy (IUU) in the management of ureteral duplication with ectopia in children. PATIENTS AND METHODS We reviewed our institutional experience for all patients who underwent a robot-assisted laparoscopic IUU at the University of Minnesota Amplatz Childrens Hospital between December 2010 and October 2011. An intraoperative, three-port technique was used after a ureteral stent was placed into the ipsilateral lower pole. Demographic information, diagnosis, operative time, hospital course, complications, and follow-up were all evaluated. RESULTS Our series included four female patients and one male patient with a mean age of 61 months (6 to 182 mos). All five had a diagnosis of upper pole ectopic ureters, one of which was associated with an ureterocele. Mean total operative time was 225 minutes (181 to 253 min), and mean hospital stay was 1.2 days (1-2 days). There were no intraoperative complications. In follow-up, at the time of ureteral stent removal, pyelonephritis developed in one patient, but all patients had resolution of their presenting symptoms including urinary tract infections and incontinence. A significant reduction in upper pole hydronephrosis was seen in all patients. CONCLUSIONS Our experience indicates that robot-assisted laparoscopic IUU is safe and effective in the management of ureteral duplication anomalies in children.

Predictors of readmission after outpatient plastic surgery

Background: Hospital readmissions have become a topic of focus for quality care measures and cost-reduction efforts. However, no comparative multi-institutional data on plastic surgery outpatient readmission rates currently exist. The authors endeavored to investigate hospital readmission rates and predictors of readmission following outpatient plastic surgery. Methods: The 2011 National Surgical Quality Improvement Program database was reviewed for all outpatient procedures. Unplanned readmission rates were calculated for all 10 tracked surgical specialties (i.e., general, thoracic, vascular, cardiac, orthopedics, otolaryngology, plastics, gynecology, urology, and neurosurgery). Multivariate logistic regression models were used to determine predictors of readmission for plastic surgery. Results: A total of 7005 outpatient plastic surgery procedures were isolated. Outpatient plastic surgery had a low associated readmission rate (1.94 percent) compared with other specialties. Seventy-five patients were readmitted with a complication. Multivariate regression analysis revealed obesity (body mass index ≥30), wound infection within 30 days of the index surgery, and American Society of Anesthesiologists class 3 or 4 physical status as significant predictors for unplanned readmission. Conclusions: Unplanned readmission after outpatient plastic surgery is infrequent and compares favorably to rates of readmission among other specialties. Obesity, wound infection within 30 days of the index operation, and American Society of Anesthesiologists class 3 or 4 physical status are independent predictors of readmission. As procedures continue to transition into outpatient settings and the drive to improve patient care persists, these findings will serve to optimize outpatient surgery use. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

A systematic review of single-stage augmentation-mastopexy.

Background: The safety of single-stage augmentation-mastopexy remains controversial given the dual purpose of increasing breast volume and decreasing the skin envelope. Currently, the literature is relatively sparse and heterogeneous. This systematic review considered complication profiles and pooled summary estimates in an attempt to guide surgical decision-making. Methods: Multiple databases were queried for combined augmentation-mastopexy outcomes. Whenever possible, meta-analysis of complication rates was performed. Results: Twenty-three studies met inclusion criteria. Average follow-up varied from 16 to 173 weeks, with a majority under 1 year. The pooled total complication rate was 13.1 percent (95 percent CI, 6.7 to 21.3 percent). The most common individual complication was recurrent ptosis, with an incidence of 5.2 percent (95 percent CI, 3.1 to 7.8 percent), followed by poor scarring (3.7 percent; 95 percent CI, 1.9 to 6.1 percent). The pooled incidences of capsular contracture and tissue-related asymmetry were 3.0 percent (95 percent CI, 1.4 to 5.0 percent) and 2.9 percent (95 percent CI, 1.2 to 5.4 percent), respectively. Infection, hematoma, and seroma were rare, with pooled incidences of less than 2 percent each. Three published studies reported data on patient satisfaction. The reoperation rate obtained from 13 studies was 10.7 percent (95 percent CI, 6.7 to 15.4 percent). Conclusions: This meta-analysis encompassed 4856 cases of simultaneous augmentation-mastopexy. Study heterogeneity was high because of differences in surgical techniques, outcome definitions, and follow-up durations. This review suggests that with careful patient selection, pooled complication and reoperation rates for single-stage augmentation-mastopexy are acceptably low.

Increased anaesthesia duration increases venous thromboembolism risk in plastic surgery: A 6-year analysis of over 19,000 cases using the NSQIP dataset

Abstract Background: Venous thromboembolism (VTE) is a significant cause of morbidity and mortality, particularly in the postoperative setting. Various risk stratification schema exist in the plastic surgery literature, but do not take into account variations in procedure length. The putative risk of VTE conferred by increased length of time under anaesthesia has never been rigorously explored. Aim: The goal of this study is to assess this relationship and to benchmark VTE rates in plastic surgery. Methods: A large, multi-institutional quality-improvement database was queried for plastic and reconstructive surgery procedures performed under general anaesthesia between 2005–2011. In total, 19,276 cases were abstracted from the database. Z-scores were calculated based on procedure-specific mean surgical durations, to assess each case’s length in comparison to the mean for that procedure. A total of 70 patients (0.36%) experienced a post-operative VTE. Patients with and without post-operative VTE were compared with respect to a variety of demographics, comorbidities, and intraoperative characteristics. Potential confounders for VTE were included in a regression model, along with the Z-scores. Results: VTE occurred in both cosmetic and reconstructive procedures. Longer surgery time, relative to procedural means, was associated with increased VTE rates. Further, regression analysis showed increase in Z-score to be an independent risk factor for post-operative VTE (Odds Ratio of 1.772 per unit, p-value < 0.001). Subgroup analyses corroborated these findings. Conclusions: This study validates the long-held view that increased surgical duration confers risk of VTE, as well as benchmarks VTE rates in plastic surgery procedures. While this in itself does not suggest an intervention, surgical time under general anaesthesia would be a useful addition to existing risk models in plastic surgery.

Supply of neuraminidase inhibitors related to reduced influenza A (H1N1) mortality during the 2009-2010 H1N1 pandemic: an ecological study.

Background The influenza A (H1N1) pandemic swept across the globe from April 2009 to August 2010 affecting millions. Many WHO Member States relied on antiviral drugs, specifically neuraminidase inhibitors (NAIs) oseltamivir and zanamivir, to treat influenza patients in critical condition. Such drugs have been found to be effective in reducing severity and duration of influenza illness, and likely reduced morbidity during the pandemic. However, it is less clear whether NAIs used during the pandemic reduced H1N1 mortality. Methods Country-level data on supply of oseltamivir and zanamivir were used to predict H1N1 mortality (per 100,000 people) from July 2009 to August 2010 in forty-two WHO Member States. Poisson regression was used to model the association between NAI supply and H1N1 mortality, with adjustment for economic, demographic, and health-related confounders. Results After adjustment for potential confounders, each 10% increase in kilograms of oseltamivir, per 100,000 people, was associated with a 1.6% reduction in H1N1 mortality over the pandemic period (relative rate (RR) = 0.84 per log increase in oseltamivir supply). While the supply of zanamivir was considerably less than that of oseltamivir in each Member State, each 10% increase in kilogram of active zanamivir, per 100,000, was associated with a 0.3% reduction in H1N1 mortality (RR = 0.97 per log increase). Conclusion While there are limitations to the ecologic nature of these data, this analysis offers evidence of a protective relationship between antiviral drug supply and influenza mortality and supports a role for influenza antiviral use in future pandemics.

Intractable hemorrhagic cystitis after hematopoietic stem cell tranplantation - Is there a role for early urinary diversion in children?

PURPOSE Severe hemorrhagic cystitis is a major complication in the pediatric population undergoing hematopoietic stem cell transplantation. Percutaneous nephrostomy tube drainage as a treatment for severe hemorrhagic cystitis has rarely been investigated. We examined children undergoing hematopoietic stem cell transplantation for risk factors associated with severe hemorrhagic cystitis, as well as our experience with percutaneous nephrostomy tube placement as an adjunctive management strategy. MATERIALS AND METHODS Using prospectively collected data from the Blood and Marrow Transplant Database at the University of Minnesota, we reviewed 40 pediatric patients with severe hemorrhagic cystitis from 1996 to 2010. Specific treatment for each patient was administered at the discretion of the attending physician and generally included bladder irrigation before bladder fulguration or percutaneous nephrostomy tube placement. A percutaneous nephrostomy tube was placed in 11 patients due to the intractable nature of the hemorrhagic cystitis. RESULTS Of the 11 patients who underwent percutaneous nephrostomy tube drainage 5 (45%) had improvement of the hemorrhagic cystitis within 30 days and the same number had long-term resolution. Among the patients with long-term resolution hemorrhagic cystitis resolved an average of 12.4 days after percutaneous nephrostomy tube placement, and the tubes were removed an average of 8.8 weeks after placement. Through September 2011 mortality among patients with percutaneous nephrostomy tubes was 55% (6 of 11 patients), which was identical to the overall mortality in the severe hemorrhagic cystitis group (22 of 40). No death could be directly attributed to hemorrhagic cystitis or percutaneous nephrostomy tube placement. CONCLUSIONS Placement of percutaneous nephrostomy tubes for treatment of severe hemorrhagic cystitis results in long-term improvement in intractable hemorrhagic cystitis, and is a safe and viable option for the majority of patients.