Preventing Isolated Perioperative Reintubation: Who is at highest risk?

Objectives: 1. We aim to characterize IPR nationally through a retrospective review of the National Surgical Quality Improvement Program participant user file (NSQIP PUF). 2.Identify risk factors for IPR including analysis of procedure type and preoperative characteristics.https://jdc.jefferson.edu/patientsafetyposters/1041/thumbnail.jp

Outcomes after resection of leiomyosarcomas of the inferior vena cava: a pooled data analysis of 377 cases.

BACKGROUND: Primary leiomyosarcomas of the inferior vena cava (IVC) pose unique surgical challenges. Due to the rarity of the disease, little definitive data exists on prognosis and treatment options. METHODS: A pooled data analysis was performed on all cases of initial IVC leiomyosarcoma resection identified by literature search (n = 371) and our institutional database (n = 6). Kaplan-Meier and Cox regression analyses were performed to identify factors associated with disease-free survival (DFS) and overall survival (OS). RESULTS: Patients were predominantly female (76%, n = 286); the median age of presentation was 55 years. Five-year DFS and OS were 6% and 55%, respectively. Preoperative factors independently associated with decreased OS included older age (HR:1.05, 95% CI:1.00-1.09), larger tumor size (HR:1.14, 95% CI:1.04-1.24), resection of adjacent organ(s) (HR:3.62, 95% CI:1.34-9.77), and R2 resection (HR:7.80, 95% CI:1.94-32.05). Isolated involvement of the suprarenal infrahepatic IVC was associated with longer OS (HR:0.22, 95% CI:0.06-0.78). A scoring system incorporating independent predictors of OS stratified outcomes: score 4-5 (n = 10, median OS 6 months), score 2-3 (n = 88, median OS 23 months) compared to a score of 0-1 (n = 44, median OS 29 months). CONCLUSIONS: Following resection of IVC leiomyosarcomas, recurrence is a near certainty; long-term survival, however is possible. The dominant predictors of survival include margin status, tumor size and radical resection. These can be combined into a risk score that has prognostic value

National trends in admissions, repair, and mortality for thoracic aortic aneurysm and type B dissection in the National Inpatient Sample.

OBJECTIVE: The advent of endovascular repair for both thoracic aortic aneurysm and type B dissection has transformed the management of these disease processes. This study was undertaken to better define, compare, and contrast the national trends in hospital admissions, invasive treatments, and inpatient mortality of patients with thoracic aortic aneurysm and type B dissection in the National Inpatient Sample. METHODS: The cohort was derived from International Classification of Diseases, Ninth Revision diagnosis codes for thoracic aortic dissection and thoracic aortic or thoracoabdominal aortic aneurysm. Patients receiving type A dissection or ascending aortic repair during their index admission were excluded using International Classification of Diseases, Ninth Revision procedure codes. A total of 155,187 patients were available for analysis from 2000 to 2012. RESULTS: Admissions for thoracic aortic aneurysm outnumbered the admissions for type B dissection (69.8% vs 30.2%; P \u3c .001), and the number of admissions for aneurysm grew more rapidly during this time (132% vs 63%; P \u3c .001). Thoracic endovascular aortic repair (TEVAR) for aneurysm experienced an increase in 2005, concordant with Food and Drug Administration approval of TEVAR for thoracic aortic aneurysm indication, then superseded open repair for thoracic aortic aneurysm from 2006 onward. Despite this, the rate of thoracic aortic aneurysm repair has remained relatively stable over time. TEVAR for dissection increased in 2006, superseded open repair in 2010, and continues to account for 50.5% of all dissection repairs. Overall, the number of type B dissection repairs has increased (P \u3c .001), over and above the increase in number of admissions for type B dissection. Despite the increased trends of utilization of TEVAR for both aneurysm and type B dissection, the overall in-hospital mortality rate among patients admitted for either disease state has decreased steadily over time (P \u3c .001). CONCLUSIONS: Whereas admissions for thoracic aortic aneurysm disease have increased over time, the rate of aneurysm repair has been stable, although TEVAR has supplanted a proportion of open repairs. In contrast, whereas admissions for type B dissection have experienced a more modest increase, there has been a disproportionate increase in type B dissection repair, largely due to increased use of TEVAR. These results show embracing of endovascular technology for dissection through expansion of indication. Despite the increase in rate of repair for type B dissection, inpatient mortality rate was reduced in both aneurysm and dissection patients, influenced by appropriate selection of patients for intervention

Length of Stay after Thoracic Endovascular Aortic Repair Depends on Indication and Acuity.

BACKGROUND: Length of stay (LOS) is a commonly used metric to optimize value in medical care. Although pathways have been developed for some procedures in vascular surgery to reduce LOS, they do not yet exist for thoracic endovascular aortic repair (TEVAR). The purpose of this study is to identify and define the risk factors for prolonged LOS in patients undergoing TEVAR to facilitate pathway development. METHODS: We included TEVAR patients in the National Surgical Quality Improvement Program database from 2005 to 2015. Prolonged LOS was defined as LOS \u3e 75th percentile of the overall cohort (11 days). Because initial analysis revealed the distinct clinical differences between dissection and aneurysm patients, further analysis was stratified by aortic pathology. Student\u27s t-test and Chi-square tests were used to compare demographic and perioperative variables between dissection and aneurysm patients, respectively. Multivariable logistic regression was used to evaluate the predictors for prolonged LOS. RESULTS: A total of 3,021 patients underwent TEVAR, with 858 patients (28.4%) undergoing TEVAR for dissection and 2,163 (71.6%) undergoing TEVAR for aneurysm. An initial analysis with logistic regression identified dissection indication (odds ratio [OR], 2.87; 95% confidence interval [CI], 1.1-7.3) as an independent predictor of prolonged LOS. Further analysis for prolonged LOS was subsequently performed separating dissection and aneurysm patients. Aneurysm patients were older (71.2 ± 11.7 vs. 63.1 ± 13.6 years, P \u3c 0.001), more often Caucasian (76.8% vs. 61.8%, P \u3c 0.001), and had more medical comorbidities (chronic obstructive pulmonary disease, cardiac history, diabetes, peripheral vascular disease, transient ischemic attack [TIA], P \u3c 0.001). In contrast, dissection patients had higher American Society of Anesthesiology (ASA) classification score (58.5% had \u3e3 ASA vs. 45.5%, P \u3c 0.001), longer hospitalizations (10.2 ± 9.3 vs. 8.5 ± 10.4 days, P \u3c 0.001), were more likely to have been transferred from another hospital or emergency room (58.4% vs. 48.3%, P \u3c 0.001), and were more often emergent (32.4% vs. 15.4%, P \u3c 0.001). In dissection patients, ASA classification score (OR, 1.49; 95% CI, 1.1-2.1) and dialysis (OR, 1.98; 95% CI, 1.0-3.9) were independent predictors for prolonged LOS. In aneurysm patients, dependent functional status (OR, 2.03; 95% CI, 1.4-2.8), diabetes (OR, 1.75; 95% CI, 1.1-2.8), cardiac history (OR, 1.37; 95% CI, 1.0-1.9), emergency status (OR, 1.98; 95% CI, 1.4-2.8), and dialysis (OR, 2.08; 95% CI, 1.2-3.7) predicted prolonged LOS. Postoperative complications including stroke/TIA; failure to wean from ventilator, sepsis, and pneumonia; and need for reoperation similarly increased LOS in both dissection and aneurysm patients. CONCLUSIONS: Dissection and aneurysm patients undergoing TEVAR are comprised of different patient populations, with dissection patients more often enduring prolonged hospitalizations. In contrast, TEVAR performed for nonemergent aneurysm repair had the shortest LOS. These data support the development of separate pathways defined by indication and acuity for patients undergoing TEVAR

Omission of adjuvant therapy after gastric cancer resection: development of a validated risk model.

NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Gastric Cancer recommend adjuvant chemotherapy with or without radiotherapy following after resection of gastric adenocarcinoma (GA) for patients who have not received neoadjuvant therapy. Despite frequent noncompliance with NCCN Guidelines nationally, risk factors underlying adjuvant therapy omission (ATom) have not been well characterized. We developed an internally validated preoperative instrument stratifying patients by incremental risk of ATom. The National Cancer Data Base was queried for patients with stage IB-III GA undergoing gastrectomy; those receiving neoadjuvant therapy were excluded. Multivariable models identified factors associated with ATom between 2006 and 2011. Internal validation was performed using bootstrap analysis; model discrimination and calibration were assessed using k-fold cross-validation and Hosmer-Lemeshow procedures, respectively. Using weighted β-coefficients, a simplified Omission Risk Score (ORS) was created to stratify ATom risk. The impact of ATom on overall survival (OS) was examined in ORS risk-stratified cohorts. In 4,728 patients (median age, 70 years; 64.8% male), 53.7% had ATom. The bootstrap-validated model identified advancing age, comorbidity, underinsured/uninsured status, proximal tumor location, and clinical T1/2 and N0 tumors as independent ATom predictors, demonstrating good discrimination. The simplified ORS, stratifying patients into low-, moderate-, and high-risk categories, predicted incremental risk of ATom (30% vs 53% vs 80%, respectively) and progressive delay to adjuvant therapy initiation (median time, 51 vs 55 vs 61 days, respectively). Patients at moderate/high-risk of ATom demonstrated worsening risk-adjusted mortality compared with low-risk patients (median OS, 26.4 vs 29.2 months). This ORS may aid in rational selection of multimodality treatment sequence in GA

Omission of Adjuvant Therapy After Gastric Cancer Resection: Development of a Validated Risk Model

NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Gastric Cancer recommend adjuvant chemotherapy with or without radiotherapy following after resection of gastric adenocarcinoma (GA) for patients who have not received neoadjuvant therapy. Despite frequent noncompliance with NCCN Guidelines nationally, risk factors underlying adjuvant therapy omission (ATom) have not been well characterized. We developed an internally validated preoperative instrument stratifying patients by incremental risk of ATom. The National Cancer Data Base was queried for patients with stage IB-III GA undergoing gastrectomy; those receiving neoadjuvant therapy were excluded. Multivariable models identified factors associated with ATom between 2006 and 2011. Internal validation was performed using bootstrap analysis; model discrimination and calibration were assessed using k-fold cross-validation and Hosmer-Lemeshow procedures, respectively. Using weighted β-coefficients, a simplified Omission Risk Score (ORS) was created to stratify ATom risk. The impact of ATom on overall survival (OS) was examined in ORS risk-stratified cohorts. In 4,728 patients (median age, 70 years; 64.8% male), 53.7% had ATom. The bootstrap-validated model identified advancing age, comorbidity, underinsured/uninsured status, proximal tumor location, and clinical T1/2 and N0 tumors as independent ATom predictors, demonstrating good discrimination. The simplified ORS, stratifying patients into low-, moderate-, and high-risk categories, predicted incremental risk of ATom (30% vs 53% vs 80%, respectively) and progressive delay to adjuvant therapy initiation (median time, 51 vs 55 vs 61 days, respectively). Patients at moderate/high-risk of ATom demonstrated worsening risk-adjusted mortality compared with low-risk patients (median OS, 26.4 vs 29.2 months). This ORS may aid in rational selection of multimodality treatment sequence in GA