Umang Jain

ASA class is a reliable independent predictor of medical complications and mortality following surgery

METHODS The American Society of Anesthesiologists Physical Status classification system (ASA PS) is a method of characterizing patient operative risk on a scale of 1-5, where 1 is normal health and 5 is moribund. Every anesthesiologist is trained in this measure, and it is performed before every procedure in which a patient undergoes anesthesia. We measured the independent predictive value of ASA-PS for complications and mortality in the ACS-NSQIP database by multivariate regression. We conducted analogous regressions after standardizing ASA-PS to control for interprocedural variations in risk in the overall model and sub-analyses by surgical specialty and the most common procedures. RESULTS For 2,297,629 cases (2005-2012; median age 55, min = 16, max > 90 [90 and above are coded as 90+]), at increasing levels of ASA-PS (2-5), odds ratios (ORs) from 2.05 to 63.25 (complications, p < 0.001) and 5.77-2011.92 (mortality, p < 0.001) were observed, with non-overlapping 95% confidence intervals. Standardization of ASA-PS (OR = 1.426 [per standard deviation above the mean ASA-PS per procedure], p < .001) and subgroup analyses yielded similar results. DISCUSSION ASA PS was not only found to be associated with increased morbidity and mortality, but independently predictive when controlling for other comorbidities. Even after standardization based on procedure type, increases in ASA predicted significant increases in complication rates for morbidity and mortality post-operatively. CONCLUSIONS ASA PS has strong, independent associations with post-operative medical complications and mortality across procedures. This capability, along with its simplicity, makes it a valuable prognostic metric.

National Multi-Institutional Comparison of 30-Day Postoperative Complication and Readmission Rates Between Open Retropubic Radical Prostatectomy and Robot-Assisted Laparoscopic Prostatectomy Using NSQIP

BACKGROUND Many American hospitals will soon face readmission penalties deducted from Medicare reimbursements, which will place further scrutiny on techniques that may offer reduced postoperative morbidity. We aimed to perform the first multi-institutional study using the National Surgical Quality Improvement Program (NSQIP) database, to compare predictors of readmission within cohorts of open radical retropubic prostatectomy (RRP) and robot-assisted laparoscopic radical prostatectomy (RALRP) in a contemporary nationwide series of radical prostatectomy. METHODS All patients who underwent radical prostatectomy in 2011 were identified in the NSQIP database using procedural codes. As no patients in the analysis underwent LRP, patients were grouped as RRP or RALRP for analysis. Perioperative variables were analyzed using chi-squared and Students t-tests as appropriate. Multiple logistic regression was used to identify readmission risk factors. RESULTS Of 5471 patient cases analyzed, 4374 (79.9%) and 1097 (20.1%) underwent RALRP and RRP, respectively. RRP and RALRP cohorts experienced different readmission rates (5.47% vs 3.48%, respectively; p=0.002). In addition, RRP experienced a higher rate of overall complications than RALRP (23.25% vs 5.62%, respectively; p<0.001), but not higher rates of reoperation (1.09% vs 0.96%, respectively; p=0.689). Overall predictors of readmission included operative time, dyspnea, and RRP or RALRP procedure type. Current smoking and patient age were predictive of readmission for RRP only, while dyspnea was predictive of readmission following RALRP only. CONCLUSION This is the first multi-institutional retrospective study that examines readmission rates and procedural intracohort predictors of readmission for RRP in the contemporary United States. We report a significant difference in postoperative complication and readmission rates in RRP compared with RALRP. Further prospective analysis is warranted.

Predictors of readmission after outpatient otolaryngologic surgery

Hospital readmissions increase costs to hospitals and patients. There is a paucity of data on benchmark rates of readmission for otolaryngological surgery. Understanding the risk factors that increase readmission rates may help enhance patient education and set system‐wide expectations. We aimed to provide benchmark data on causes and predictors of readmission following outpatient otolaryngological surgery.

Predictors and causes of unplanned re-operations in outpatient plastic surgery: a multi-institutional analysis of 6749 patients using the 2011 NSQIP database

Abstract Unplanned re-operations carry significant implications for healthcare services, surgical outcomes, and patient safety. However, there has been a paucity of large scale, multi-centre studies that evaluate the predictors and causes of unplanned re-operation in outpatient plastic surgery. This study retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) and identified all plastic surgery outpatient cases performed in 2011. Multiple logistic regression analysis was utilised to identify independent risk factors and causes of unplanned reoperations. Of the 6749 outpatient plastic surgery cases identified, there were 125 (1.9%) unplanned re-operations (UR). Regression analysis demonstrated that body mass index (BMI, OR = 1.041, 95% CI = 1.019–1.065), preoperative open wound/wound infection (OR = 3.498, 95% CI = 1.593–7.678), American Society of Anesthesiologists (ASA) class 3 (OR = 2.235, 95% CI = 1.048–4.765), and total work relative value units (RVU, OR = 1.014, 95% CI = 1.005–1.024) were significantly predictive of UR. Additionally, the presence of any complication was significantly associated with UR (OR = 15.065, 95% CI = 5.705–39.781). In an era of outcomes-driven medicine, unplanned re-operation is a critical quality indicator for ambulatory plastic surgery facilities. The identified risk factors will aid in surgical planning and risk adjustment.

Venous thromboembolism in reconstructive pelvic surgery

OBJECTIVE We sought to determine the incidence and risk factors for venous thromboembolism (VTE) in women undergoing reconstructive pelvic surgery (RPS). STUDY DESIGN Using the American College of Surgeons National Surgical Quality Improvement Program registry, we identified patients who underwent RPS from 2006 through 2010 based on Current Procedural Terminology codes. We defined 2 cohorts: women with any RPS performed, with concomitant surgery from other specialties allowed (RPS + other), and women whose only procedure was RPS. VTE was defined as deep vein thrombosis or pulmonary embolism diagnosed within 30 days of surgery. Demographic characteristics, comorbidities, and operative characteristics were extracted from the database. Variables were analyzed using χ(2) tests and Student t tests for categorical and continuous variables. We performed a multiple logistic regression to control for confounding variables. RESULTS In all, 20,687 women underwent RPS + other, with 69 cases of VTE for a rate of 0.3%. Multivariate analysis demonstrated predictors for postoperative VTE including inpatient hospital status (odds ratio [OR], 7.69; P < .001), higher American Society of Anesthesiology Physical Status classification (OR, 2.70; P < .001), and emergency intervention (OR, 3.65; P = .008). When women undergoing only RPS were analyzed, there were 14 cases of VTE, with an incidence of 0.1% and the only specific predictor for postoperative VTE was length of stay (P < .037). CONCLUSION The incidence of VTE following RPS is very low, but it is increased in women undergoing concomitant surgeries. Patients undergoing inpatient surgery with higher American Society of Anesthesiology Physical Status classifications and requiring emergency intervention were at highest risk for VTE.

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.