Contemporary predictors of extended postoperative hospital length of stay after carotid endarterectomy

IntroductionHospital length of stay (LOS) contributes to costs. Carotid endarterectomy (CEA) is performed frequently by vascular surgeons, making contemporary CEA LOS rates and predictors vital knowledge for quality evaluation and cost containment initiatives.MethodsUsing a prospective single-institution database, we retrospectively identified consecutive patients undergoing CEA from 2001 to 2011. Demographic and perioperative factors were prospectively collected. The primary end point was extended postoperative LOS (ELOS), defined as postoperative LOS ≥2 days. Factors associated with ELOS were analyzed in a multivariable logistic regression model. Rates of 1-year readmission and death were compared with the Kaplan-Meier method (log-rank test).ResultsEight hundred forty patients underwent 897 CEAs with 39% of procedures among females and 35% for symptomatic disease. One hundred two (11.4%) patients were inpatients prior to the day of CEA (“preadmitted”); their preoperative days by definition are not included in ELOS. Median postoperative LOS was 1 day (interquartile range, 1-2). Four hundred fourteen patients (46.2%) had ELOS. Preadmission was associated with ELOS (72% vs 41%; P < .01) and ELOS patients were less likely to be discharged home (11.9% vs 1.5%; P < .01). There was no association between ELOS and unplanned 30-day postdischarge readmission (6.0% vs 7.0%; P = .59). On multivariable analysis, preoperative factors significantly associated with ELOS included preadmission (adjusted odds ratio [OR], 3.3; 95% confidence interval [CI], 1.9-5.7; P < .001), history of congestive heart failure (OR, 2.1; 95% CI, 1.1-4.2; P = .03), female gender (OR, 1.9; 95% CI, 1.4-2.6; P < .001), and history of chronic obstructive pulmonary disease (OR, 1.7; 95% CI, 1.0-2.9; P = .04). Operative factors included electroencephalography change (OR, 1.9; 95% CI, 1.2-3.2; P = .01), operating room start time after 12:00 pm (OR, 1.7; 95% CI, 1.2-2.4; P < .01), and total operating room time (OR, 1.5 per hour; 95% CI, 1.2-2.9; P < .01). Postoperative factors included transfer to intensive care unit (OR, 5.4; 95% CI, 3.1-9.4; P < .01), number of in-hospital postoperative complications (OR, 3.7; 95% CI, 2.2-6.5; P < .01), and Foley catheter placement (OR, 2.1; 95% CI, 1.3-3.4; P < .01). Over 1 year, ELOS was associated with increased hospital readmission (93.6% vs 84.7%; log-rank test, P < .01) and decreased survival (95.1% vs 98.3%; log-rank test, P < .01).ConclusionsNearly half of CEA patients were discharged on or after postoperative day 2. Interventions on modifiable risk factors, such as early Foley catheter placement to prevent urinary retention and morning CEA scheduling, may decrease LOS. ELOS may identify a subset of patients at increased risk for long-term readmission and mortality

Mineralocorticoid receptor expression in human venous smooth muscle cells: a potential role for aldosterone signaling in vein graft arterialization

Experimental studies have suggested a role for the local renin-angiotensin-aldosterone system in the response to vascular injury. Clinical data support that aldosterone, via activation of the mineralocorticoid receptor (MR), is an important mediator of vascular damage in humans with cardiovascular disease. In mineralocorticoid-sensitive target tissue, aldosterone specificity for MR is conferred enzymatically by the cortisol-inactivating enzyme 11β-hydroxysteroid-dehydrogenase-2 (11βHSD2). However, the role of MR/aldosterone signaling in the venous system has not been explored. We hypothesized that MR expression and signaling in venous smooth muscle cells contributes to the arterialization of venous conduits and the injury response in vein bypass grafts. MR immunostaining was observed in all samples of excised human peripheral vein graft lesions and in explanted experimental rabbit carotid interposition vein grafts, with minimal staining in control greater saphenous vein. We also found upregulated transcriptional expression of both MR and 11βHSD2 in human vein graft and rabbit vein graft, whereas control greater saphenous vein expressed minimal MR and no detectable 11βHSD2. The expression of MR and 11βHSD2 was confirmed in cultured human saphenous venous smooth muscle cells (hSVSMCs). Using an adenovirus containing a MR response element-driven reporter gene, we demonstrate that MR in hSVSMCs is capable of mediating aldosterone-induced gene activation. The functional significance for MR signaling in hSVSMCs is supported by the aldosterone-induced increase of angiotensin II type-1 receptor gene expression that was inhibited by the MR antagonist spironolactone. The upregulation of MR and 11βHSD2 suggests that aldosterone-mediated tissue injury plays a role in vein graft arterialization

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research