Does Chronic Kidney Disease Affect Outcomes after Major Abdominal Surgery? Results from the National Surgical Quality Improvement Program

Introduction

The impact of chronic kidney disease (CKD) and end-stage renal disease on outcomes following major abdominal surgery is not well defined.

Materials and Methods

The 2008 NSQIP database was queried to identify adult patients undergoing complex abdominal surgery (major colorectal, hepatobiliary, pancreatic, gastric, and esophageal operations). Thirty-day morbidity and mortality in patients on hemodialysis (HD) versus patients not on HD were compared. The impact of preoperative renal insufficiency, measured by glomerular filtration rate (GFR), on morbidity and mortality was then assessed in non-dialysis patients.

Results

Of 24,572 patients who underwent major abdominal operations, excluding emergency cases, only 149 (0.6 %) were on HD preoperatively. Thirty-day mortality in the HD group was 12.8 % compared to 1.8 % for those not on HD (p?<?0.0001). Overall complication rate was 23.5 versus 12.3 % (p?<?0.0001). In particular, rates of pneumonia (6.7 vs 3.0 %, p?<?0.05) and sepsis (12.8 vs 5.3 %, p?<?0.001) were higher in patients on HD. In patients not on HD, GFR was significantly predictive of postoperative mortality after controlling for age, gender, race, emergency status, and comorbidities. Compared to patients with normal preoperative kidney function (GFR, 75–90 ml/min/1.73 m²), even modest CKD (GFR, 45–60 ml/min/1.73 m²) was associated with increased postoperative mortality (odds ratio (OR), 1.62). With greater impairment in kidney function, postoperative mortality was even more marked (GFR, 30–45 ml/min/1.73 m² and OR, 2.84; GFR, 15–30 ml/min/1.73 m² and OR, 5.56). In addition, CKD was independently associated with increased postoperative complications.

Conclusion

Any degree of preoperative kidney impairment, even mild asymptomatic disease, is associated with clinically significant increases in 30-day postoperative morbidity and mortality following major abdominal surgery.     

Patient and Peri-operative Predictors of Morbidity and Mortality After Esophagectomy: American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), 2005–2008

Purpose  

Our aim was to determine what specific patient and peri-operative factors contribute to major complications after esophagectomy.     

A predictive model of complications after spine surgery: the National Surgical Quality Improvement Program (NSQIP) 2005–2010

Background contextThere is increasing scrutiny by several regulatory bodies regarding the complications of spine surgery. Precise delineation of the risks contributing to those complications remains a topic of debate.PurposeWe attempted to create a predictive model of complications in patients undergoing spine surgery.Study design/settingRetrospective cohort study.Patient sampleA total of 13,660 patients registered in the American College of Surgeons National Quality Improvement Project (NSQIP) database.Outcome measuresThirty-day postoperative risks of stroke, myocardial infarction, death, infection, urinary tract infection (UTI), deep vein thrombosis (DVT), pulmonary embolism (PE), and return to the operating room.MethodsWe performed a retrospective cohort study involving patients who underwent spine surgery between 2005 and 2010 and were registered in NSQIP. A model for outcome prediction based on individual patient characteristics was developed.ResultsOf the 13,660 patients, 2,719 underwent anterior approaches (19.9%), 565 corpectomies (4.1%), and 1,757 fusions (12.9%). The respective 30-day postoperative risks were 0.05% for stroke, 0.2% for MI, 0.25% for death, 0.3% for infection, 1.37% for UTI, 0.6% for DVT, 0.29% for PE, and 3.15% for return to the operating room. Multivariate analysis demonstrated that increasing age, more extensive operations (fusion, corpectomy), medical deconditioning (weight loss, dialysis, peripheral vascular disease, coronary artery disease, chronic obstructive pulmonary disease, diabetes), increasing body mass index, non-independent mobilization (preoperative neurologic deficit), and bleeding disorders were independently associated with a more than 3 days' length of stay. A validated model for outcome prediction based on individual patient characteristics was developed. The accuracy of the model was estimated by the area under the receiver operating characteristic curve, which was 0.95, 0.82, 0.87, 0.75, 0.74, 0.78, 0.76, 0.74, and 0.65 for postoperative risk of stroke, myocardial infarction, death, infection, DVT, PE, UTI, length of stay of 3 days or longer, and return to the operating room, respectively.ConclusionsOur model can provide individualized estimates of the risks of postoperative complications based on preoperative conditions, and can potentially be used as an adjunct in decision-making for spine surgery.     

Early Results from a Novel Quality Outcomes Program: The American Society of Breast Surgeons’ Mastery of Breast Surgery

Background

In 2008, the American Society for Breast Surgeons launched its Mastery in Breast Surgery Pilot Program to demonstrate feasibility of a Web-based tool for breast surgeons to document and monitor quality outcomes.

Methods

Participating surgeons report performance of three quality measures for breast procedures: Was a needle biopsy performed to evaluate the breast lesion before the procedure? Was the surgical specimen oriented? For nonpalpable lesions localized with image guidance, was there intraoperative confirmation of removal? Data are collected through the American Society for Breast Surgeons’ Web-based software using a secure server and encrypted identification numbers. Surgeon demographic/practice characteristic data were collected, and logistic regression models were used to identify factors that affected quality measures.

Results

From October 2008 to December 2009, a total of 696 surgeons entered data for 28,798 breast procedures. Participants were diverse in years in practice, geographic location, practice setting and type, and proportion of practice made up of breast procedures. Delivery of “optimal care” (defined as delivery of all quality measures for which there was no valid clinical reason for nonperformance) was high for all surgeon demographic/practice characteristics, ranging from 81% to 94%. Statistically significant differences in delivery of quality measures were observed within all physician demographic/practice characteristic variables, but many absolute differences were small.

Conclusions

The high level of participation and volume of breast procedures for which quality measure data was entered demonstrate this is a feasible means of collecting quality performance data. Future development will include identifying/developing additional quality measures and establishing evidence-based benchmarks for care on the basis of data collected.

     

Body Mass Index and Major Cancer Surgery Outcomes: Lack of Association or Need for Alternative Measurements of Obesity?

Background  

Although surgical studies have reported inconsistent associations between increased body mass index (BMI) and operative outcomes, the accuracy of BMI for measuring obesity has been questioned in previous epidemiologic studies. Simultaneously, BMI has known comorbidities, which may mediate the effect of BMI if included in multivariable models. We sought to examine the effect of BMI on operative outcomes after adjusting for preoperative factors.     

Effect of Donor Body Mass Index on the Outcome of Donation After Cardiac Death Kidneys: How Big is Too Big?

Introduction

Morbid obesity (MO) has become an epidemic in the United Sates and is associated with adverse effects on health. The purpose of this study was to examine the effects of MO on the short-term outcomes of kidneys transplanted from donation after cardiac death (DCD) donors.

Patients and Methods

Using a prospectively collected database, we reviewed 467 kidney transplantations performed at a single center between January 2008 and June 2011 to identify 67 recipients who received transplants from 40 DCD donors. The outcomes of 14 MO DCD donor kidneys were compared with 53 non-MO DCD grafts. MO was defined as a body mass index ≥35. Mean patient follow-up was 16 months.

Results

The MO and non-MO DCD donor groups were similar with respect to donor and recipient age, gender, race, cause of death and renal disease, time from withdrawal of life support to organ perfusion, mean human leukocyte antigen (HLA) mismatch, and overall recipient survival. Organs from MO DCD donors also had comparable rates of delayed graft function (21.4% vs 20.0%; P = not significant [NS]). At 1 year post-transplantation, a small but statistically insignificant difference was observed in the graft survival rates of MO and non-MO donors (87% vs. 96%; P = NS). One MO kidney had primary nonfunction.

Conclusions

These data demonstrate that kidneys procured from MO DCD donors have equivalent short-term outcomes compared with non-MO grafts and should continue to be used. Further investigation is needed to examine the effect of MO on long-term renal allograft survival.     

Does accreditation matter? An analysis of complications of bariatric cases using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program and National Quality Improvement Program databases

BackgroundTwo large nationwide databases collect data on common operations in the United States. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) collects bariatric data, whereas the National Quality Improvement Program (NSQIP) gathers details on a broader range of general surgical cases.ObjectiveEvaluate the differences in rates of complications between both databases regarding Roux-en-Y gastric bypass and sleeve gastrectomy.SettingNational databases, United States.MethodsWe evaluated the MBSAQIP and NSQIP from 2017 to 2019 using the procedure codes 43644 and 43775. Fifteen common complications were evaluated. Propensity-matched analyses (PMAs) were done to control for differences across databases. Significantly different variables after a PMA were included in multivariable models. The data were examined for differences between the 2 databases before and after the PMA, with and without adjustment for operation type.ResultsThere were 483,361 cases reported in the MBSAQIP and 57,598 in the NSQIP. PMA matched 57,479 cases for each database. Seven complications were different, with higher rates reported in the NSQIP than in the MBSAQIP: myocardial infarction, sepsis, organ/space surgical site infections, deep vein thrombosis, urinary tract infections, pulmonary embolism, ventilator dependence >48 hours, and pneumonia. When adjusting for the procedure performed, sleeve gastrectomy in the NSQIP had higher rates of organ/space surgical site infections, deep vein thrombosis, sepsis, and death. Roux-en-Y gastric bypass in the NSQIP had higher rates of organ/space surgical site infections, ventilator dependence >48 hours, urinary tract infections, myocardial infarction, deep vein thrombosis, and sepsis.ConclusionWhen compared with the MBSAQIP, the NSQIP reports higher rates of bariatric complications. Further studies are needed to confirm the reasons behind this.     

What Is the Effect of Stoma Construction on Surgical Site Infection After Colorectal Surgery?

Introduction

The aim of our study was to evaluate the effect of stoma creation on deep and superficial surgical site infections after an index colorectal surgical procedure.

Methods

We designed a retrospective cohort study from the National Surgical Quality Improvement Program. We evaluated all patients who underwent colorectal surgery procedures from January 2005 to December 2009 with or without creation of a stoma and sought to identify the effect of stoma creation on deep and superficial surgical site infections.

Results

A total of 79,775 patients underwent colorectal procedures (laparoscopic 30.7 %, open 69.3 %), while 8,113 patients developed a surgical site infection (10.2 %). The univariate analysis revealed that surgical site infections were much more common in patients with a stoma compared to those with no stoma (11.8 % vs. 9.5 %, p?<?0.0001). On multivariate analysis, stoma construction during the index colorectal procedure (OR 1.3, CI 1.2 to 1.4), ASA class ≥2, smoking, and abnormal body mass index were associated with surgical site infection.

Conclusions

The construction of a stoma with colorectal procedures is associated with a higher risk of surgical site infection. Although the stoma effect on surgical site infection is attenuated with laparoscopic techniques, the association remained statistically significant.     

Monitoring the Practice of Vascular Surgery: Findings from a National Registry (1996–2011)

Background

The goal of this article is to present for the first time to the international community the detailed findings and outcomes of the Spanish Vascular Registry (SVR) after 16 years of experience.

Methods

We examined the nationwide registry promoted by the Spanish Society of Angiology and Vascular Surgery (1996–2011). The changes in vascular surgical activity in Spain during the period of study were examined. We evaluated the number of services, medical specialists, consultations, admissions, and operations that occurred in Spain. We also assessed the trends in therapeutic activity and the medical and social impact of vascular pathology.

Results

A mean of 60 centers (range = 32–83) participated in the SVR (79.3 % of the total). In the last year of the study period, 94.3 % centers (100 % of teaching centers) participated. The mean number of activities per hospital per year was 5,298 consultations, 2,625 vascular explorations, 630 hospital admissions (61 % elective and 31 % emergency), and 742 surgical procedures. A total of 29,289 carotid stenosis procedures had been registered over 16 years. Both carotid endarterectomy (CEA) and carotid artery stenting (CAS) procedures have increased in frequency over time. In 2011, CAS constituted 19.3 % of all carotid procedures. A total of 31,703 abdominal aortic aneurysm (AAA) operations were registered during the study period. Surgery for ruptured AAA remained stable over time. Since its appearance in the year 2000, endovascular treatment (EVAR) increased steadily over time. Currently, EVAR represents about half of all AAA surgery (50.2 %). The total rate of in-hospital operative deaths was 1.1 %, but in-hospital mortality for open arterial surgery was 4 %. Mortality has decreased of late.

Conclusions

The SVR has enabled us to understand the development and implementation of vascular surgery throughout Spain and to note the increased healthcare activity and the better overall results obtained as a consequence.     

Safety of same-day discharge after laparoscopic sleeve gastrectomy: propensity score–matched analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program Registry

BackgroundInformation on the safety of outpatient sleeve gastrectomy is sparse.ObjectiveThis study aimed to assess the safety of sleeve gastrectomy as a day case surgery.SettingUniversity health network, United States.MethodsPatients who underwent primary sleeve gastrectomy were identified in the 2015–2017 MBSAQIP database. Day case surgery procedure was defined as having a hospital length of stay of 0 days. Day case surgery patients were matched with inpatient controls using propensity score matching. The primary outcome was 30-day mortality.ResultsA total of 271,658 sleeve gastrectomy patients met the inclusion criteria. Of these, only 7825 (2.88 %) were day case surgery procedures. There was no mortality in the group. Day case surgery, compared with inpatient sleeve gastrectomy, was associated with a similar risk of a leak (.56% versus .40%; relative risk [RR], 1.419; 95% CI, .896–2.245; P = .133), bleeding (.38% versus .31%; RR, 1.250; 95% CI, .731–2.138; P = .414), 30-day reoperation (.81% versus .56%; RR, 1.432; 95% CI, .975–2.104; P = .066), and 30-day morbidity (1.15% versus 1.01%; RR, 1.139; 95% CI, .842–1.541; P = .397). Outpatients’ SG increased the risk for 30-day readmission (3.35% versus 2.79%; RR, 1.202; 95% CI, 1.009–1.432; P = .039).ConclusionsSleeve gastrectomy in the outpatient setting as a day case surgery was associated with no mortality and no statistically significant risk of reoperation, leakage, or bleeding compared with patients admitted to inpatient units. The readmission rate was higher in the day case surgery group.     

The Results of a Surgical Complication Protection Program (BLIS, Inc.) for Private Pay Bariatric Patients in the U.S.: 2006–2011

Background

Bariatric surgery is the most effective treatment for morbid obesity and associated medical co morbidities. There is currently minimal surgical treatment penetration of this widespread disease. BLIS has been able to improve the access to bariatric surgery for cash-pay patients by alleviating concern about the costs of post-surgical complications. Recently, there has become an ability to attract payor groups by offering a “bundled” payment which includes BLIS complication protection.

Methods

A total of 5,364 self-pay patients underwent laparoscopic adjustable gastric banding, laparoscopic vertical sleeve gastrectomy, or laparoscopic Roux-en-Y gastric bypass with BLIS complication insurance.

Results

Of the overall 5,364 patients, the 30-day mortality rate was 0.04 % and 1-year mortality rate was 0.06 %. The frequency of complications was 5.4 % in the gastric banding group, 6.5 % in the sleeve gastrectomy group, and 9.7 % in the gastric bypass group.

Conclusions

The results for mortality and complications in the BLIS data set compares very well with other large data sets in bariatric surgery. BLIS complication insurance improves the access to bariatric surgery in patients who self-pay.