Reshma Brahmbhatt

Gender and frailty predict poor outcomes in infrainguinal vascular surgery

BACKGROUND Women have poorer outcomes after vascular surgery as compared to men as shown by studies recently. Frailty is also an independent risk factor for postoperative morbidity and mortality. This study examines the interplay of gender and frailty on outcomes after infrainguinal vascular procedures. MATERIALS AND METHODS The American College of Surgeons National Surgical Quality Improvement Program database was used to identify all patients who underwent infrainguinal vascular procedures from 2005-2012. Frailty was measured using a modified frailty index (mFI; derived from the Canadian Study of Health and Aging). Univariate and multivariate analysis were performed to investigate the association of preoperative frailty and gender, on postoperative outcomes. RESULTS Of 24,645 patients (92% open, 8% endovascular), there were 533 deaths (2.2%) and 6198 (25.1%) major complications within 30 d postoperatively. Women were more frail (mean mFI = 0.269) than men (mean mFI = 0.259; P < 0.001). Women and frail patients (mFI>0.25) were more likely to have a major morbidity (P < 0.001) or mortality (P < 0.001) with the highest risk in frail women. On multivariate logistic regression analysis, female gender and increasing mFI were independently significantly associated with mortality (P < 0.05) as well as major complications. The interaction of gender and frailty in multivariate analysis showed the highest adjusted 30-d mortality and morbidity in frail females at 2.8% and 30.1%, respectively and that was significantly higher (P < 0.001) than nonfrail males, nonfrail females and frail males. CONCLUSIONS Female gender and frailty are both associated with increased risk of complications and death following infrainguinal vascular procedures with the highest risk in frail females. Further studies are needed to explore the mechanisms of interaction of gender and frailty and its effect on long-term outcomes for peripheral vascular disease.

Improved trends in patient survival and decreased major complications after emergency ruptured abdominal aortic aneurysm repair

BACKGROUND Improved trends in patient survival and decreased major complications after emergency ruptured abdominal aortic aneurysm (AAA) repair. Emergency AAA repair carries a high risk of morbidity and mortality. This study seeks to examine morbidity and mortality trends from the National Surgical Quality Improvement Program (NSQIP) database, and identify potential risk factors. METHODS All emergency AAA repairs were identified using the NSQIP database from 2005 to 2011. Univariate analysis (using the Student t, χ(2), and Fishers exact tests) and multivariate logistic regression was performed to examine trends in mortality and morbidity. RESULTS Out of 2761 patients who underwent emergency AAA repair, 321 (11.6%) died within 24 hours of surgery. Of the remaining 2440 patients, 1133 (46.4%) experienced major complications and 459 (18.8%) died during the postoperative period. From 2005 to 2011, there was a significant decrease in patient mortality, particularly in patients who survived the perioperative period (P = .002). Total complications increased overall (P < .0001); however, major complications decreased from 58.7% in 2005 to 42.6% in 2011 (P < .0001) among patients who survived beyond 24 hours. The use of endovascular aortic repair (EVAR) increased over the study period (P < .0001). On multivariate analysis of patients who survived past the initial 24-hour period, advancing age (odds ratio [OR], 1.1; 95% confidence interval [CI], 1.0-1.1), chronic obstructive pulmonary disease (OR, 2.6; 95% CI, 1.7-4.1), dependent functional status (OR, 2.0; 95% CI, 1.2-3.2), and presence of a major complication (OR, 3.1; 95% CI, 2.0-5.0) were significantly associated with death, whereas presence of a senior resident (OR, 0.4; 95% CI, 0.3-0.6) or fellow (OR 0.3; 95% CI, 0.2-0.6) was inversely associated with death. EVAR was not associated with death, but was associated with 30-day complications (OR, 0.5; 95% CI, 0.3-0.6). CONCLUSIONS Patient survival has increased from 2005 to 2011 after emergency AAA repair, with a significant improvement particularly in patients who survive past the first 24 hours. EVAR was not associated with mortality, but was protective of 30-day complications. Although the total number of complications increased, the number of major complications decreased over the study period, suggesting that newer techniques and patient care protocols may be improving outcomes.

Identifying Risk Factors for Surgical Site Complications after Laparoscopic Ventral Hernia Repair: Evaluation of the Ventral Hernia Working Group Grading System

BACKGROUND In 2010, the Ventral Hernia Working Group (VHWG) published a grading system to assess the risk of surgical site complications in patients undergoing ventral hernia repair. This study evaluated the predictive value of the VHWG classification for the surgical outcomes of laparoscopic ventral hernia repair (LVHR) and identified independent factors associated with surgical site infection (SSI) and surgical site occurrence (SSO). METHODS A retrospective review was performed of all patients who underwent LVHR over a 10-year period at two institutions. The U.S. Centers for Disease Control and Prevention definition of SSI and the VHWG definition of SSO were used. Univariable analysis was performed using the Student t-test, analysis of variance, chi-square test, or Fisher exact test, as appropriate. Multivariable analysis was used to identify independent factors associated with SSI and SSO. RESULTS Differences in American Society of Anesthesiologists class, body mass index, diabetes mellitus, chronic obstructive pulmonary disease, tobacco use, hernia type, prior abdominal surgery, prior ventral hernia repair, hernia size, and total infections were identified by grade. There was no difference in SSI or SSO by grade. Multivariable analysis revealed institution and number of prior abdominal operations to be associated with SSI. Institution, prostate disease, and prior ventral hernia repair were associated with SSO. CONCLUSIONS The VHWG classification was unable to predict SSI and SSO and may not be applicable in LVHR. This study identified independent factors associated with SSI and SSO in LVHR. Although further study is warranted to validate these results, the factors presented may be a useful tool to stratify patient risk of SSI and SSO with LVHR.

Prevalence of surgical site infection at the stoma site following four skin closure techniques: a retrospective cohort study.

Background/Aims: Surgical site infection (SSI) is a common complication of stoma reversal. Studies have suggested that different skin closures affect SSI rates. Our aim was to determine which skin closure technique following stoma reversal leads to the lowest rate of SSI. Methods: We conducted a retrospective review of all adult patients undergoing stoma reversal at a single institution (2005-2011) and compared the rate of SSI following four skin closure techniques: primary closure (PC), secondary closure (SC), loose PC (LPC), and circular closure (CC). Univariate analysis included χ2 or Fishers exact test and ANOVA or Kruskal-Wallis H test for categorical and continuous data, respectively. A multivariate logistic regression model was created to identify predictors of SSI. Results: One hundred and forty-six patients were identified: 40 (27%) PC, 68 (47%) SC, 20 (14%) LPC, and 18 (12%) CC. CC was less likely to have SSI (6%) compared to PC (43%), SC (16%), and LPC (15%; p < 0.01). Increasing body mass index was a predictor of SSI (odds ratio 1.11, 95% confidence interval 1.04-1.12, p < 0.01). CC was associated with the lowest odds of developing SSI [0.07 (0.01-0.63), p = 0.02]. Conclusions: SSI rate was the lowest for stomas that were closed with CC.

Jumping the Gun? Evaluating the Evidence for Synthetic Mesh in Contaminated Hernia Repairs

ASA score 0.10 1 0 (0) 0 (0) 2 2 (5.3) 9 (23.1) 3 30 (78.9) 24 (61.5) 4 6 (15.8) 6 (15.4) BMI, kg/m 32.1 1.1 31.8 0.9 0.82 Benign prostatic hypertrophy 21 (55.3) 8 (20.5) <0.01 Abdominal aortic aneurysm 2 (5.3) 2 (5.1) 1.00 COPD 11 (28.9) 11 (28.2) 1.00 Coronary artery disease 27 (71.0) 19 (48.7) 0.06 Peripheral vascular disease 15 (39.5) 11 (28.2) 0.34 Steroid use 2 (5.3) 5 (12.8) 0.43 Immunosuppression 2 (5.3) 6 (15.4) 0.26 Diabetes mellitus 21 (55.3) 13 (33.3) 0.07 Current smoker 16 (42.1) 20 (51.3) 0.50 Alcohol use disorder 6 (15.8) 1 (2.6) 0.06

IP183. Analysis of Early Lower Extremity Reamputations

Objective: Lower extremity amputation is commonly performed nationwide. Whereas previous studies have reported modest rates of acute reoperation for lower extremity amputations, data are scarce regarding the need for early reamputation to a higher anatomic level. The goal of this study was to better define contemporary outcomes and risk factors associated with reamputation. Methods: Within the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Program database, patients who underwent primary major lower extremity amputation (below knee [BKA], above knee [AKA]) were identified by Current Procedural Terminology code. Patients undergoing concomitant procedures, those classified as American Society of Anesthesiologists class 5, and those without primary wound closure, including guillotine amputations, were excluded. Outcomes of patients undergoing early (within 30 days) reamputation to a higher anatomic level were compared with those of patients who did not, including length of stay, morbidity, and mortality. Demographic, clinical, and perioperative characteristics were compared, and those risk factors approaching significance were used in a multivariable logistic regression model to determine their association with early reamputation. Results: There were 14,673 patients identified for the 5-year period: 8306 BKAs and 6367 AKAs. Most patients were male (63%), white (62%), and diabetic (63%), with a median age of 67 years (interquartile range, 58-77 years). Most major amputations were performed by vascular surgeons (65%). Overall, lower level amputations were associated with a higher reamputation rate (BKA, 2.5%; AKA, 0.8%; P < .001). Reamputation was associated with increased length of stay (8 days vs 5 days; P < .001) and greater rates of readmission (64.9% vs 13.6%; P < .001). Reamputation was associated with greater rates of wound complications (40.8% vs 6.9%; P < .001), myocardial infarction (3.8% vs 1.7%; P 1⁄4 .027), pulmonary embolism (1.9% vs 0.4%; P 1⁄4 .004), sepsis (20.2% vs 5.0%; P < .001), and complications overall (69.5% vs 39.3%; P < .001). The 30-day mortality was not significantly different for the two groups (4.2% vs 6.3%; P 1⁄4 0.159). On multivariable analysis, advanced age (odds ratio [OR], 1.02; confidence interval [CI], 1.01-1.03), smoking (OR, 1.75; CI, 1.32-2.33), end-stage renal disease on dialysis (OR, 1.67; CI, 1.23-2.26), preoperative septic shock (OR, 2.53; CI, 1.29-4.97), and bleeding disorders (OR, 1.72; CI, 1.34-2.22) were associated with early reamputation. An open wound/wound infection (OR, 0.73; CI, 0.56-0.94) was found to be inversely associated with reamputation. Conclusions: Based on this study, early reamputation rates are low. Reamputation is associated with significant morbidity, prolonged hospitalization, and frequent readmissions. Patient-specific factors and comorbidities should be considered in selecting the appropriate anatomic level of amputation. Further studies are needed, particularly by vascular surgeons, to elucidate this population of patients and to minimize the risk of reamputation.

In Patients with Carotid Artery Dissection, Is Stenting Superior to Open Repair to Improve Clinical Outcomes?

Carotid artery dissection is a rare but potentially devastating entity. Clinical sequale can include stroke, cranial nerve dysfunction, carotid stenosis, and pseudoaneurym formation. Anticoagulation is the mainstay of treatment, but in patients who fail anticoagulation or have contraindications to anticoagulation, surgical therapy is often considered. Open surgical repair had historically been the traditional therapy of choice, but percutaneous therapy with stent placement has become increasingly commonplace. No randomized trials exist regarding optimal surgical management of carotid artery dissection. Current literature supports both open and endovascular treatment as safe and effective for carotid artery dissection.

Symptomatic Carotid Stenosis

Awoman in her early 60swith a history of hypertension and hyperlipidemiawas transferred toourhospital aftermultiple transient ischemicattacksand left internal carotidartery (ICA) stenosisduring thepast severalmonths.Hermost recentpresentationwas 1weekprior foraminor strokewith amaurosis fugax, slurred speech, rightsided weakness, and facial droop lasting longer than 24 hours. Magnetic resonance imaging of the brain demonstrated subacute infarctions involving the left frontal and parietal hemispheres. She was a current smokerandwas takingaspirinandstatinmedicationat the time of presentation. Workup at another facility prior to transfer included computedtomographicangiographyof theneck,whichshowedchronic occlusion of the right ICA and 95% stenosis of the left ICA. On examination, the patient was afebrile with a heart rate of 69 beats/min andbloodpressureof 134/69mmHg.Pertinent findings includedno carotid bruit, a regular cardiac rhythm, andequally palpable upper extremity pulses bilaterally. The patient was neurologically intact, save for 4/5 motor strength in her right upper extremity. Computed tomographic angiography of the head andneckwas performed (Figure 1). Quiz at jamasurgery.com A B