Is Esophagectomy for Benign Conditions Benign?

BACKGROUND: Outcomes data on esophagectomy performed for benign conditions is scarce. Using the National Surgical Quality Improvement Program database, we sought to analyze outcomes of esophagectomy performed for benign conditions. METHODS: The National Surgical Quality Improvement Program database was queried for all esophagectomies performed from 2005 to 2015. Outcomes for benign conditions were analyzed and compared with outcomes for malignant conditions. RESULTS: Esophagectomy was performed in 7,477 patients during the study period. Of those, 6,762 underwent esophagectomy for malignant conditions and 715 for benign conditions. For patients with benign conditions, reconstruction was performed using gastric conduit in 631 and colon/intestine in 84. The anastomosis was intrathoracic in 420 and cervical in 295. Benign esophagectomies were more likely to be emergent (10.1% vs 0.4%, p \u3c 0.001). In addition, these patients had a longer hospital length of stay (17.2 days vs 14.5 days, p \u3c 0.001) and higher occurrence of Clavien-Dindo grade IV complications (25% vs 20%, p = 0.003). Mortality was similar at 4%. In patients with benign conditions, reconstruction with colon/intestine had higher occurrence of Clavien-Dindo Grade IV complications (37% vs 23%, p = 0.006), surgical wound infections (33% vs 16%, p \u3c 0.001), and death (10% vs 4%, p = 0.017) compared with gastric reconstruction. Site of anastomosis did not affect outcomes. CONCLUSIONS: Benign esophagectomies are associated with significant morbidity. Although the site of the anastomosis does not alter outcomes, use of colon/intestine conduit should be pursued with caution

Cholecystectomy Is Risker in Male Patients

Introduction: While cholecystitis has a female preponderance, some observe a trend towards more challenging disease in male patients. The confluence of sex and patient acuity has not been thoroughly investigated. We hypothesize that men present with worse disease compared with women, as evidenced by higher rates of open surgery and higher resource consumption. Methods: An inpatient registry from a 5-hospital system was queried for cholecystectomy procedures not associated with neoplasm or malignancy. Cases from 2015 to 2021 were included. Demographics, clinical and outcome variables were analyzed. Univariate analysis and multivariate logistic regression were performed. The data were de-identified before analysis and deemed exempt from IRB review, and were analyzed using R within R-Studio. Results: There were 2789 cholecystectomy patients, 1616 (58%) were women and 1173 (42%) were men. Demographics and baseline health characteristics differed across sex. Univariate analysis highlighted that males experienced more harms (1.35 vs 1.14; p = 0.002), more open approaches (18% vs 11%; p \u3c 0.001), longer inpatient lengths of stays (median: 4 vs 3 days; p \u3c 0.001), higher hospital cost ($15,694 vs$13,173; p \u3c 0.001), increased laboratory orders (37.65 vs 30.01; p \u3c 0.001), higher MS-DRG weight (2.104 vs 1.842; p \u3c 0.001) and greater mortality risk (56% vs 36%; p \u3c 0.001). Further, multivariate analysis found male cholecystectomy patients were correlated with higher instances of open surgical approach (OR: 1.80; p \u3c 0.001), hospital readmission (OR: 1.50; p = 0.008), and higher cost (β: $981; R2: 0.27; p = 0.006). Conclusion: Inpatient male cholecystectomy patients present with worse disease and require more hospital resources

Perioperative outcomes for the emergent Whipple operation in the United States: An analysis of the American College of Surgeons National Surgical Quality Improvement Program

INTRODUCTION: Emergent pancreaticoduodenectomy (EMPD) has been safely performed for acute pancreaticoduodenal surgical situations. It is unclear whether the morbidity associated with EMPD is due to technical complexities of the surgery or the surgical situation. METHODS: We sought to compare outcomes of all patients undergoing elective (ELPD) and EMPD between 2005 and 2014 utilizing the American College of Surgeons NSQIP database. Univariate and multivariable analyses were performed to identify the impact on perioperative outcomes. RESULTS: There were 24, 328 ELPD and 194 EMPD identified. Patients with EMPD had worse functional status and American So-ciety of Anesthesiologists, and more often, acute renal failure and dialysis requirements (3.6% vs 0.1%, p \u3c 0.001 and 5.2% vs 0.4%, p \u3c 0.001). Additionally, EMPD had higher rates of ventilator \u3e 48 hours (4.9% vs 15.5%,), Clavien 4 and higher complications (10.3% vs 28.9%), and death (3.2% vs 10.8%), p \u3c 0.001. There were no differences in superficial incisional surgical site infections (SSI) (9.6% vs 8.8% p = 0.785) or organ/space SSI (11.9% vs 16.0%, p = 0.106). On multivariable analysis, EMPD was an independent risk factor for death (odds ratio [OR] 2.21, p = 0.00173), Clavien 4 complication (OR 2.38, p \u3c 0.001), but not for organ space SSI (OR 1.38, p = 0.1094), renal failure (OR 1.129, p = 0.791), or MI (OR 1.506, p = 0.492). CONCLUSIONS: EMPD has a worse complication profile than ELPD. The lack of significance in organ space SSI suggests that the high morbidity of EMPD is more likely associated with the inciting surgical event rather than the technical complexity of the surgery

Analysis of risk factors for readmission after hysterectomy: Use of a national database.

Study Objective: There is a paucity of predictive work done to help risk assess and stratify patients potential for readmission hysterectomy. We sought to further explore the risk of readmission after hysterectomy. Design: Retrospective review of database. Setting: National Surgical Quality Improvement Project database ( NSQIP) Patients: Women who had undergone hysterectomy for non-cancer indications, 2005 and 2015. Intervention: Hysterectomy (any approach). Measurements and Main Results: We queried 11 years of the National Surgical Quality Improvement Project ( NSQIP)Participant Use File (PUF), 2005-2015. CPT codes for hysterectomy were chosen. Data was analyzed in R with univariate followed by multivariate analysis. There were 2636 readmissions and 81322 non-readmitted patients (rate of 3.1%). There were significant differences based on route of surgery (p \u3c .001), with the majority 51.4% being open, and least after vaginal route ( 13.9%). Readmissions were younger (mean age 47.1 vs 48.0, p \u3c .001), had more associated procedures based on work rvu (mean 16.9.1 vs 17.2, P \u3c .001), were more likely to be diabetic (5.1% Insulin and 6.9% oral hypoglycemic, vs 2.0% and 5.7 % in non readmitted, P \u3c .001), they also had higher ASA scores. Similar patterns were noted with hypertension, COPD, CHF, smoking history, dyspnea, functional status, steroid use, operative times, wound class. By multivariate logistic regression the most powerful independent predictors or readmission were: frailty (OR \u3e 500), functional status (OR 1.64), steroid use (OR 1.65), ASA class (OR 1.47), COPD (OR 1.26), wound class (OR 1.25) and diabetes (OR 1.23). Conclusion: Improved prediction of readmission risk will facilitate discussion and informed consent with families, as well as empower quality improvement projects targeted on risk factor modification or escalation of readmission prevention interventions

Use of a simplified frailty index to predict Clavien 4 complications and mortality after hepatectomy: analysis of the National Surgical Quality Improvement Project database

BACKGROUND: An aging surgical population places an increasing burden on surgeons to accurately risk stratify and counsel patients. Preoperative frailty assessments are a promising new modality to better evaluate patients but can often be time consuming. Data regarding frailty and hepatectomy outcomes have not been published to date. METHOD: Using the National Surgical Quality Improvement Project database, we examined hepatectomy patients 2005 to 11 and correlated frailty scores with outcomes of major morbidity, mortality, and extended length of stay, using a previously validated modified frailty index score. Frailty was compared against age, American Society of Anesthesiologists class, and other common risk variables. RESULTS: Multivariate regression identified frailty as the strongest predictor of Clavien 4 complications (OR = 40.0, 95% CI = 15.2 to 105.0), and mortality (OR = 26.4, 95% CI = 7.7 to 88.2). As the frailty score increased, there was a statistically significant increase in Clavien 4 complications, mortality, and extended length of stay (P \u3c .001 for all). CONCLUSIONS: Frailty is a significant factor in morbidity and mortality after hepatectomy. Use of the modified frailty index allows for feasibility of data collection in a busy clinical setting

A retrospective study of the effects of minimally invasive colorectal surgery on Patient Safety Indicators across a five-hospital system

BACKGROUND: The Agency for Healthcare Research and Quality uses Patient Safety Indicators (PSI) to gauge quality of care and patient safety in hospitals. PSI 90 is a weighted combination of several PSIs that primarily comprises perioperative events. This score can affect reimbursement through Medicare and hospital quality ratings. Minimally invasive surgery (MIS) has been shown to decrease adverse events and outcomes. We sought to evaluate individual PSI and PSI 90 outcomes of minimally invasive versus open colorectal surgeries using a large medical database from 5 hospitals. METHODS: A health system administrative database including all inpatients from 5 acute care hospitals was queried based on ICD 10 PC codes for colon and rectal surgery procedures performed between January 2, 2018 and December 31, 2019. Surgeries were labeled as MIS (laparoscopic) or open colorectal resection surgery. Patient demographics, health information, and case characteristics were analyzed with respect to surgical approach and PSI events. Statistical relationships between surgical approach and PSI were investigated using univariate methods and multivariate logarithmic regression analysis. PSIs of interest were PSI 8, PSI 9 PSI 11, PSI 12, and PSI 13. RESULTS: There were 1382 operations identified, with 861 (62%) being open and 521 (38%) being minimally invasive. Logistic modeling showed no significant difference between the 2 groups for PSI 3, 6, or 8 through 15. CONCLUSION: Understanding PSI 90 and its components is important to enhance perioperative patient care and optimize reimbursement rates. We showed that MIS, despite providing known clinical benefits, may not affect scores in the PSI 90. Surgical approach may have little effect on PSIs, and other patient and system components that are more important to these outcome measures should be pursued

Vaginal hysterectomy outcomes; Complications and analysis of risk factors for 30-day readmission.

Study Objective: Vaginal hysterectomy is the preferred minimally invasive route for hysterectomy. Literature suggests low infectious morbidity. We sought to analyze our outcomes and assess risk factors for readmission. Design: Retrospective review of database. Setting: National Surgical Quality Improvement Project database ( NSQIP) Patients:Women who underwent vaginal hysterectomy, between 2005 and 2015. Intervention: Vaginal hysterectomy. Measurements and Main Results: We queried 11 years of the National Surgical Quality Improvement Project ( NSQIP)Participant Use File (PUF), 2005-2015. CPT codes for vaginal, including laparoscopic assisted vaginal hysterectomy were chosen. Data was analyzed in R with univariate followed by multivariate analysis. There were 17646 cases with 466 readmissions (2.6%). Complication rate was low (0.01%) with low rates for pulmonary embolism ( 0.01%) and wound infection ( 0.02%). The mean total length of stay was 1.35 days with 1.7% of patients returning to the operating room. Readmissions were younger were more likely to be diabetic (p \u3c .001), they also had higher ASA scores (p \u3c .001). Similar patterns were noted with smoking history, dyspnea and fraility index. Conclusion: Vaginal hysterectomy demonstrates low complication rates. Wound infection is not a significant contributor to readmission in these patients unlike in other routes of hysterectomy. Preoperative optimization of functional status and medical conditions like diabetes will further reduce readmission risk in women undergoing vaginal hysterectomy

Impact of extremes of BMI on perioperative complications in complex pancreatic resections

INTRODUCTION: Pancreaticoduodenectomy offers the best chance for long-term survival and cure for patients with pancreatic malignancy. These complex resections are associated with a high perioperative morbidity. We hypothesized that BMI extremes (low\u3c18, high 35-50, ultrahigh\u3e50) would represent risk factors for perioperative complications in complex pancreatic surgery. METHODS: All patients undergoing elective complex pancreatectomy (N=24,522) from 2005 to 2014 were identified utilizing the American College of Surgeons (ACS) NSQIP database. Univariate and multivariable analyses were performed to identify the impact of BMI on perioperative outcomes. RESULTS: Patients with BMI extremes had a higher incidence of unplanned intubation (ultrahigh/high/low/normal, %: 8.3/7.0/ 5.8/4.8; p\u3c0.001), prolonged mechanical ventilation (\u3e48 hours) (%: 5.5/8.1/6.2/4.6; p\u3c0.001), Clavien 4 or higher complication (%: 12.8/15.0/10.7/10.0; p\u3c0.001) and length of hospital stay (days: 13.19/14.03/14.87/12.86; p\u3c0.001), organ/space SSI (12.8/17.0/8.2/11.5; p\u3c0.001) and death (%: 4.6/4.2/2.7/3.1; p\u3c0.034). On multivariable analyses, adjusting for comorbidity status, high BMI represented an independent risk factor for reintubation (odds ratio [OR] 1.68; p\u3c0.001), failure to wean (OR 1.91; p\u3c0.001), Clavien 4 complication (OR 1.65; p\u3c0.001), death (OR 1.43; p=0.002). When adjusting for comorbidity status low and ultrahigh BMI did not represent risk factors for complications. CONCLUSIONS: BMI extremes have less impact on perioperative outcomes after pancreaticoduodenectomies than previously thought when adjusting for comorbidity status. While selection bias is possible, it appears that the perioperative complication risk is not higher than the general population. This may have implications for preoperative patient counselling, treatment sequencing and preoperative nutrition optimization. In addition, better identification of patients who are at low risk of having perioperative complications in the setting of complex oncologic procedures may facilitate patient selection for future fast-track postoperative pathways