Sujata Saha

Operative duration as an independent risk factor for postoperative complications in single-level lumbar fusion: an analysis of 4588 surgical cases.

Study Design. Multicenter retrospective cohort study. Objective. To estimate the impact of increasing surgical duration on outcomes after single-level lumbar fusion. Summary of Background Data. Lumbar fusion is a widely used practice for the treatment of disability and chronic low back pain. Longer operative duration is shown to correlate with increased morbidity and mortality in various surgical disciplines, but no large-scale study has been performed to validate this relationship in lumbar spine surgery. Methods. The American College of Surgeons National Surgical Quality Improvement Program was retrospectively reviewed to identify all patients who underwent lumbar fusion procedures during 2006 to 2011. Thirty-day morbidity and mortality rates were reported on the basis of operative time, whereas multivariate logistic regression model was used to examine operative duration as an independent risk factor for outcomes. Results. A total of 4588 patients were included in the analysis. The mean operative duration for all patients was 197 ± 105 minutes. Our multivariate risk-adjusted regression models demonstrated that increasing operative time was associated with step-wise increase in risk for overall complications (odds ratio [OR], 2.09–5.73), medical complications (OR, 2.18–6.21), surgical complications (OR, 1.65–2.90), superficial surgical site infection (OR, 2.65–3.97), and postoperative transfusions (OR, 3.25–12.19). Operative duration of 5 hours or more was also associated with increased risk of reoperation (OR, 2.17), organ/space surgical site infection (OR, 9.72), sepsis/septic shock (OR, 4.41), wound dehiscence (OR, 10.98), and deep vein thrombosis (OR, 17.22). Conclusion. Our data suggest that increasing operative duration is associated with a wide array of complications. Operative duration is, therefore, an important quality metric in the performance of lumbar fusion. Strategies to reduce operative time and further research to identify risk factors that are associated with longer surgical duration are needed for improved patient outcomes. Level of Evidence: 3

Impact of Resident Involvement on Orthopaedic Surgery Outcomes: An Analysis of 30,628 Patients from the American College of Surgeons National Surgical Quality Improvement Program Database

BACKGROUND Operative procedural training is a key component of orthopaedic surgery residency. The influence of intraoperative resident participation on the outcomes of surgery has not been studied extensively using large, population-based databases. METHODS We identified 30,628 patients who underwent orthopaedic procedures from the 2011 American College of Surgeons National Surgical Quality Improvement Program. Outcomes as measured by perioperative complications, readmission rates, and mortality within thirty days were compared for cases with and without intraoperative resident involvement. RESULTS Logistic regression with propensity score analysis revealed that intraoperative resident participation was associated with decreased rates of overall complications (odds ratio, 0.717 [95% confidence interval, 0.657 to 0.782]), medical complications (odds ratio, 0.723 [95% confidence interval, 0.661 to 0.790]), and mortality (odds ratio, 0.638 [95% confidence interval, 0.427 to 0.951]). Resident presence in the operating room was not predictive of wound complications (odds ratio, 0.831 [95% confidence interval, 0.656 to 1.053]), readmission (odds ratio, 0.962 [95% confidence interval, 0.830 to 1.116]), or reoperation (odds ratio, 0.938 [95% confidence interval, 0.758 to 1.161]). A second analysis by propensity score stratification into quintiles grouped by similar probability of intraoperative resident presence showed resident involvement to correlate with decreased rates of overall and medical complications in three quintiles, but increased rates of overall and medical complications in one quintile. All other outcomes were equivalent across quintiles. CONCLUSIONS Orthopaedic resident involvement during surgical procedures is associated with lower risk of perioperative complications and mortality in the National Surgical Quality Improvement Program database. The results support resident participation in the operative care of orthopaedic patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

The Effect of Operative Time on Perioperative Morbidity After Laparoscopic Hysterectomy

INTRODUCTION: We aimed to determine the effect of operative time on the risk of perioperative morbidity after laparoscopic hysterectomy. METHODS: Deidentified data from the National Surgical Quality Improvement Program Database were reviewed for patients undergoing total or subtotal laparoscopic hysterectomy from 2006 to 2011. Robotic and traditional laparoscopy data were pooled. Primary outcomes were 30-day complication rates in relation to operative time. Demographics, comorbidities, and complications were compared using bivariate and multivariate regression analysis. RESULTS: Nine thousand sixty-four women underwent laparoscopic hysterectomy during the study period. Medical, surgical, and overall complications increased significantly with increasing operative time (Fig. 1). On bivariate analysis, operative times over 240 minutes were associated with significant increases in composite morbidity (13.3% compared with 4.7%, P<.001), surgical complications (4.1% compared with 1.6%, P<.001), medical complications (10.7% compared with 3.3%, P<.001), and reoperation (2.6% compared with 1.2%, P=.013) as well as venous thromboembolis, urinary tract infection, and blood transfusion. These associations remained statistically significant on multivariate analysis. For each additional 10 minutes of operative time, the odds of overall, medical, and surgical complications increased by 5.1%, 6.2%, and 4.1%, respectively, and the odds of reoperation, venous thromboembolism, urinary tract infection, and transfusion increased by 5.1%, 6.2%, 4.1%, and 8.3%, respectively. Fig. 1. Rates of overall, surgical, and medical complications and reoperation stratified by 60-minute intervals of surgical duration. CONCLUSIONS: We demonstrated a direct, independent correlation between increased operative time during laparoscopic hysterectomy and perioperative morbidity. Operating time exceeding 4 hours was associated with a nearly threefold increase in overall complications. Patients considering laparoscopic hysterectomy who are at risk for excessive operating time may benefit from an alternative surgical approach.

Surgical Risk after Unilateral Lobectomy versus Total Thyroidectomy: A Review of 47,434 Patients

Background: We reviewed the 2005-2012 ACS-NSQIP Databases to evaluate factors associated with adverse events (AE) after unilateral thyroid lobectomy (UL) and total thyroidectomy (TT). Methods: All unilateral lobectomies and total thyroidectomies performed from 2005 to 2012 were identified for analysis. The cohort was characterized with respect to preoperative and demographic characteristics, complications, reoperation, and mortality. Results: 47,434 patients were identified, of which 17,584 underwent unilateral lobectomy and 29,850 underwent total thyroidectomy. On multivariable regression analysis, UL was associated with a 2.786 greater risk of returning to the OR, and a 1.377 risk of surgical complications. The increased risk of return to the OR was eliminated when controlling for patients returning to the OR for completion thyroidectomy after UL. Conclusion: NSQIP is the only dataset that is able to discern between unilateral lobectomy and total thyroidectomy to make viable comparisons in outcomes.The NSQIP dataset may be imperfect, as pertinent details of chemotherapy and radiation, and procedure-specific complications, including hematoma and airway compromise, are not tracked. In spite of this, our findings suggest avenues for improvement in the care of thyroidectomy patients, and suggest directions for a thyroidectomy-specific outcomes database.

Oropharyngeal Contamination Predisposes to Complications after Neck Dissection An Analysis of 9462 Patients

Objective While neck dissection is important in the treatment of head and neck cancer, there is a paucity of studies evaluating outcomes. We sought to compare preoperative variables and outcomes between clean and contaminated neck dissections, using the 2006-2011 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data sets. Study Design Retrospective review of prospectively maintained database. Setting Multicenter (university hospitals; tertiary referral centers). Subjects and Methods A retrospective review was performed of the NSQIP database to identify patients undergoing neck dissection in clean vs oropharyngeal contaminated cases. Clinical factors, comorbidities, epidemiologic factors, and procedural characteristics were analyzed to identify factors associated with 30-day postoperative adverse events, including medical and surgical complications, unplanned reoperation, and mortality. Bivariate and multivariable analyses were performed for the outcome of one or more adverse events. Results In total, 8890 patients had clean neck dissections, while 572 patients had neck wound contamination with oropharyngeal flora. On multivariable regression analysis, oropharyngeal contamination was a significant risk factor for surgical complications (odds ratio [OR], 3.42; 95% confidence interval [CI], 1.96-5.96; P < .001). However, medical complications and mortality were not significantly different between the 2 cohorts. This finding persisted after subgroup analysis, with removal of all thyroidectomy patients from analysis (OR, 2.33; 95% CI, 1.25-4.36; P = .008). Conclusion Using the ACS-NSQIP data set, this study found an increased risk of surgical complications in the setting of contaminated neck dissections. These data should be used for patient risk stratification, informed consent, and to guide further research.

Predictors of Adverse Events after Neck Dissection: An Analysis of the 2006 to 2011 NSQIP Data Sets

Objectives: Studies evaluating complications after neck dissection alone or in conjunction with other procedures are sparse. We looked for predictors of adverse events after neck dissection using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), which tracks 30-day complication rates in patients undergoing surgery at participating centers. Methods: In this retrospective review, 619 patients were identified using CPT codes specific for neck dissection. Clinical factors, comorbidities, epidemiologic factors, and procedure characteristics were analyzed with multiple regression to evaluate relationship to complication rates. Results: Twenty-three percent of patients (142 of 619 patients) underwent neck dissection and experienced either a medical or surgical complication. Factors associated with adverse events included previous cardiac surgery (odds ratio [OR] 3.376, 95% confidence interval [CI] 1.084-10.516, P = .036), dyspnea (OR 2.568, 95% CI 1.06-6.22, P = .037), total work RVUs (OR 1.085, OR 1.041–1.131, P = .001), and anesthesia time (OR 1.005, 95% CI 1-1.009, P = .036). Importantly, smoking, age, ASA class, and prior radiation or chemotherapy were not significant. Injury to accessory nerve and chyle leak are not specifically tracked in NSQIP. Conclusions: This study presents important benchmarks for medical and surgical complication rates, reoperation, and mortality observed with neck dissection in a large nationally abstracted patient sample. Cardiorespiratory morbidity and surgical complexity were found to be major drivers of complications. The true complication rates may be underrepresented due to inadequate tracking of procedure specific complications in NSQIP.