Identification of risk categories for in pancreaticoduodenectomy based on diagnosis

BackgroundUtilization of large-volume clinical registries for observational research has gained popularity in orthopaedic literature. However, concerns exist regarding inadequate reporting of methodology in this type of research. Despite these concerns, the reproducibility of such studies has not been adequately assessed in existing literature. This study aims to assess the reproducibility of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) arthroplasty studies on smoking as a risk factor for poor surgical outcomes by employing identical datasets and statistical methods.MethodsA systematic PubMed search between 2013 and 2023 identified ACS-NSQIP studies involving hip or knee arthroplasty and smoking as a potential risk factor for poor surgical outcomes. Each study’s methods were reproduced by a trained statistician based on the reported methodology. In cases where certain steps were not explicitly stated, the statistician made informed decisions to reproduce those steps. Adjusted odds ratios (aORs) and p-values (α = 0.05) were compared between the original and reanalyzed datasets.ResultsThe initial search yielded 43 studies, with 11 meeting inclusion criteria resulting in the reanalysis of 268 aORs. Upon reanalysis, 12.69% of the original studies’ aORs changed in interpretation, while 13.43% experienced a change in statistical significance. The average magnitude change of each aOR across all studies was 17.22%, and the sample size (N) in reanalysis varied by up to 47.84%. Among the 11 commonly cited studies, approximately one in eight objective conclusions changed in interpretation or statistical significance.ConclusionInconsistent reproducibility exists across many arthroplasty studies that utilize the ACS-NSQIP database. These findings highlight the importance of rigorous reporting of study methodology, data collection, and statistical analyses when utilizing large-volume databases in orthopaedic research. This burden of responsibility should be shared among authors, peer reviewers, and orthopaedic journals to confirm the accuracy and validity of published database research.Level of evidenceThis study systematically reviewed and analyzed, in attempt to reproduce, published arthroplasty studies utilizing ACS-NSQIP database to assess smoking as a potential risk factor for poor surgical outcomes. All analyzed studies included Level III Evidence, therefore this current study compares reproduced Level III Evidence to the original Level III Evidence.

Several single-center reports suggest that vascular resection (VR) during pancreaticoduodenectomy (PD) for patients with pancreatic adenocarcinoma is feasible without affecting early postoperative mortality or morbidity. Our objective is to review the outcomes associated with VR during PD using a large multicenter data source. A retrospective cohort analysis was performed using the National Surgical Quality Improvement Program Participant User Files for 2005-2009. All patients undergoing PD for a postoperative diagnosis of malignant neoplasm of the pancreas were included. Forward stepwise multivariate regression analysis was used to determine the association between VR during PD and 30-day postoperative mortality and morbidity after adjustment for patient demographics and comorbidities. 3,582 patients were included for analysis, 281 (7.8 %) of whom underwent VR during PD. VR during PD was associated with significantly greater risk-adjusted 30-day postoperative mortality [5.7 % with VR versus 2.9 % without VR, adjusted odds ratio (AOR) 2.1, 95 % confidence interval (CI) 1.22-3.73, P = 0.008] and overall morbidity (39.9 % with VR versus 33.3 % without VR, AOR 1.36, 95 % CI 1.05-1.75, P = 0.02). There was no significant difference in risk-adjusted postoperative mortality or morbidity between those patients undergoing VR by the primary surgical team versus those patients undergoing VR by a vascular surgical team. Contrary to the findings of several previously published single-center analyses, the current study demonstrates increased 30-day postoperative morbidity and mortality in PD with VR when compared with PD alone.

There is paucity of studies on preoperative risk assessment tools in patients undergoing emergency surgery. The present study evaluated the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II, American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator and American Society of Anesthesiologists (ASA) physical status (PS) classification system in patients undergoing emergency exploratory laparotomy. This retrospective study included 60 adult patients who underwent emergency exploratory laparotomy for perforation peritonitis. The clinical details, ASA PS classification, laboratory investigations and postoperative course of patients were retrieved from their medical records. Based on these details, APACHE II and ACS-NSQIP were calculated for the patients. The study's primary outcome was the accuracy of the preoperative APACHE II, ACS-NSQIP risk calculator and ASA PS class in predicting the postoperative 30-day mortality of patients. The area under the curve (AUC) of APACHE II, ACS-NSQIP score, and ASA PS classification for mortality 30 days after surgery was 0.737, 0.694 and 0.601, respectively. The P value for the Hosmer-Lemeshow (H-L) test of scoring systems was 0.05, 0.25 and 0.05, respectively. AUC for postoperative complications was 0.799 for APACHE II, 0.683 for ACS-NSQIP and 0.601 for ASA PS classification. H-L test of these scoring systems for complications after surgery revealed P values of 0.62, 0.36 and 0.53, respectively. Compared to the ACS-NSQIP and ASA PS classification system, the APACHE II score has a better discriminative ability for postoperative complications and mortality in adult patients undergoing emergency exploratory laparotomy.

Multiple models have attempted to predict morbidity of liver resection (LR). This study aims to determine the efficacy of American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator and the Physiological and Operative Severity Score in the enUmeration of Mortality and Morbidity (POSSUM) in predicting post-operative morbidity in patients who underwent LR. A retrospective analysis was conducted on patients who underwent elective LR. Morbidity risk was calculated with the ACS-NSQIP surgical risk calculator and POSSUM equation. Two models were then constructed for both ACS-NSQIP and POSSUM-(1) the original risk probabilities from each scoring system and (2) a model derived from logistic regression of variables. Discrimination, calibration, and overall performance for ACS-NSQIP and POSSUM were compared. Sub-group analysis was performed for both primary and secondary liver malignancies. Two hundred forty-five patients underwent LR. Two hundred twenty-three (91%) had malignant liver pathologies. The post-operative morbidity, 90-day mortality, and 30-day mortality rate were 38.3%, 3.7%, and 2.4% respectively. ACS-NSQIP showed superior discriminative ability, calibration, and performance to POSSUM (p = 0.03). Hosmer-Lemeshow plot demonstrated better fit of the ACS-NSQIP model than POSSUM in predicting morbidity. In patients undergoing LR, the ACS-NSQIP surgical risk calculator was superior to POSSUM in predicting morbidity risk.

Background:Cardiac surgery prediction models and outcomes from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) have not been reported. The authors sought to develop preoperative prediction models and estimates of postoperative outcomes for cardiac surgery using the ACS-NSQIP and compare these to the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD).Methods:In a retrospective analysis of the ACS-NSQIP data (2007–2018), cardiac operations were identified using cardiac surgeon primary specialty and sorted into cohorts of coronary artery bypass grafting (CABG) only, valve surgery only, and valve+CABG operations using CPT codes. Prediction models were created using backward selection of the 28 non-laboratory preoperative variables in ACS-NSQIP. Rates of nine postoperative outcomes and performance statistics of these models were compared to published STS 2018 data.Results:Of 28 912 cardiac surgery patients, 18 139 (62.8%) were CABG only, 7872 (27.2%) were valve only, and 2901 (10.0%) were valve+CABG. Most outcome rates were similar between the ACS-NSQIP and STS-ACSD, except for lower rates of prolonged ventilation and composite morbidity and higher reoperation rates in ACS-NSQIP (all P<0.0001). For all 27 comparisons (9 outcomes × 3 operation groups), the c-indices for the ACS-NSQIP models were lower by an average of ~0.05 than the reported STS models.Conclusions:The ACS-NSQIP preoperative risk models for cardiac surgery were almost as accurate as the STS-ACSD models. Slight differences in c-indexes could be due to more predictor variables in STS-ACSD models or the use of more disease- and operation-specific risk variables in the STS-ACSD models.

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was used to establish predictors for 30-day postoperative complications following spine and cranial neurosurgery. The ACS-NSQIP participant use files were queried for neurosurgical cases between 2005 and 2015. Prevalence of postoperative complications following neurosurgery was determined. Nested multivariable logistic regression analysis was used to identify demographic, comorbidity, and perioperative characteristics associated with any complication and mortality for spine and cranial surgery. There were 175,313 neurosurgical cases (137,029 spine, 38,284 cranial) identified. A total of 23,723 (13.5%) patients developed a complication and 2588 (1.5%) patients died. Compared with spine surgery, cranial surgery had higher likelihood of any complication (22.2% vs. 11.1%; P<0.001) and mortality (4.8% vs. 0.5%; P<0.001). In multivariable analysis, cranial surgery had 2.73 times higher likelihood for mortality compared with spine surgery (95% confidence interval, 2.46-3.03; P<0.001), but demonstrated lower odds of any complication (odds ratio, 0.93; 95% confidence interval, 0.90-0.97; P<0.001). There were 6 predictors (race, tobacco use, dyspnea, chronic obstructive pulmonary disease, chronic heart failure, and wound classification) significantly associated with any complication, but not mortality. Paradoxically, tobacco use had an unexplained protective effect on at least one complication or any complication. Similarly, increasing body mass index was protective for any complication and mortality, which suggests there may be a newly observed "obesity paradox" in neurosurgery. After controlling for demographic characteristics, preoperative comorbidities, and perioperative factors, cranial surgery had higher risk for mortality compared with spine surgery despite lower risk for other complications. These findings highlight a discrepancy in the risk for postoperative complications following neurosurgical procedures that requires emphasis within quality improvement initiatives.

Background Emergency laparotomy (EL) is common, with &amp;gt;30,000 performed annually in the UK. EL has a high 30-day mortality of 9.2%, especially in the elderly. Reliable preoperative risk assessment is essential to aid decision-making and perioperative care arrangements. NELA and ACS-NSQIP risk calculators can both be used to assess risk, and both can under or over-predict mortality. Methods This is a multi-center, retrospective, observational, cohort study investigating the correlation between actual 30-dm (a-30-dm) and predicted 30-dm (p-30-dm) following EL using NELA and ACS-NSQIP in adults over and under 70, over 2-years, in two UK centres. Sample size was calculated at 385 cases. Statistical analysis was carried out using GraphPad Prism 10.1.1. Results 626 cases were analyzed. A-30-dm, NELA, and ACS-NSQIP p-30-dm in the under 70s subgroup were 5.78%, 5.53%, and 3.41% respectively, with NELA and ACS-NSQIP correlating positively with a-30-dm: R²=0.12, p&amp;lt;0.0001 and R²=0.09, p&amp;lt;0.0001. In over 70s, a-30-dm was 13.96%, NELA p-30-dm 14.02% and ACS-NSQIP 9.76%, with a positive correlation between the latter two (R²=0.56, p&amp;lt;0.0001), but a weak one between a-30-dm and NELA (R²=0.04, p&amp;lt;0.0001) or ACS-NSQIP (R²=0.02, p&amp;lt;0.0001). For the entire cohort a-30-dm, NELA and ACS-NSQIP p-30-dm were 9.74%, 9.8%, and 6.59% respectively. NELA and ACS-NSQIP p-30-dm showed a strong positive correlation (R²=0.89; p&amp;lt;0.0001) with only NELA showing a strong positive correlation with a-30-dm (R²=0.31, p&amp;lt;0.0001); and not ACS-NSQIP (R²=0.05, p&amp;lt;0.0001). Conclusion NELA can accurately predict 30-day mortality in patients aged &amp;lt;70 undergoing EL but not &amp;gt;70. ACS-NSQIP and a-30-dm correlated in a very weak manner.

National databases are increasingly being used for research in spine surgery; however, one limitation of such databases that has received sparse mention is the frequency of missing data. Studies using these databases often do not emphasize the percentage of missing data for each variable used and do not specify how patients with missing data are incorporated into analyses. This study uses the American College of Surgeons National SurgicalQuality Improvement Program (ACS-NSQIP) database to examine whether different treatments of missing data can influence the results of spine studies. (1) What is the frequency of missing data fields for demographics, medical comorbidities, preoperative laboratory values, operating room times, and length of stay recorded in ACS-NSQIP? (2) Using three common approaches to handling missing data, how frequently do those approaches agree in terms of finding particular variables to be associated with adverse events? (3) Do different approaches to handling missing data influence the outcomes and effect sizes of an analysis testing for an association with these variables with occurrence of adverse events? Patients who underwent spine surgery between 2005 and 2013 were identified from the ACS-NSQIP database. A total of 88,471 patients undergoing spine surgery were identified. The most common procedures were anterior cervical discectomy and fusion, lumbar decompression, and lumbar fusion. Demographics, comorbidities, and perioperative laboratory values were tabulated for each patient, and the percent of missing data was noted for each variable. These variables were tested for an association with "any adverse event" using three separate multivariate regressions that used the most common treatments for missing data. In the first regression, patients with any missing data were excluded. In the second regression, missing data were treated as a negative or "reference" value; for continuous variables, the mean of each variable's reference range was computed and imputed. In the third regression, any variables with >10% rate of missing data were removed from the regression; among variables with ≤10% missing data, individual cases with missing values were excluded. The results of these regressions were compared to determine how the different treatments of missing data could affect the results of spine studies using the ACS-NSQIP database. Of the 88,471 patients, as many as 4441 (5%) had missing elements among demographic data, 69,184 (72%) among comorbidities, 70,892 (80%) among preoperative laboratory values, and 56,551 (64%) among operating room times. Considering the three different treatments of missing data, we found different risk factors for adverse events. Of 44 risk factors found to be associated with adverse events in any analysis, only 15 (34%) of these risk factors were common among the three regressions. The second treatment of missing data (assuming "normal" value) found the most risk factors (40) to be associated with any adverse event, whereas the first treatment (deleting patients with missing data) found the fewest associations at 20. Among the risk factors associated with any adverse event, the 10 with the greatest effect size (odds ratio) by each regression were ranked. Of the 15 variables in the top 10 for any regression, six of these were common among all three lists. Differing treatments of missing data can influence the results of spine studies using the ACS-NSQIP. The current study highlights the importance of considering how such missing data are handled. Until there are better guidelines on the best approaches to handle missing data, investigators should report how missing data were handled to increase the quality and transparency of orthopaedic database research. Readers of large database studies should note whether handling of missing data was addressed and consider potential bias with high rates or unspecified or weak methods for handling missing data.

Carpometacarpal (CMC) joint arthroplasty is a common procedure performed by both orthopedic and plastic surgeons to address arthritis of the thumb CMC joint. The purpose of this study was to (1) compare the postoperative outcomes between orthopedic and plastic surgeons and (2) determine how surgeon specialty impacts rates of postoperative complications following CMC arthroplasty. All adult patients (&gt;18 years) undergoing CMC arthroplasty were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2020. Patient demographic data and medical comorbidities were examined. Patients were classified as having a procedure by either an orthopedic surgeon or a plastic surgeon. Univariate analysis and multivariate logistic regression were used to assess the risk of postoperative complications and 30-day readmission based on surgeon specialty. A total of 5,162 patients undergoing CMC arthroplasty were included in our study, with 83.7% of procedures performed by orthopedic surgeons versus 16.3% performed by plastic surgeons. The incidence of surgical complications (p &lt; 0.001), wound complications (p &lt; 0.001), and superficial surgical site infections (SSIs; p &lt; 0.001) was significantly higher when performed by plastic surgery. Additionally, operative time was significantly higher in cases performed by plastic surgeons (p = 0.001). On multivariate logistic regression, plastic surgery was independently associated with an increased risk of all complications (adjusted odds ratio [AORs] 2.70, 95% confidence interval [CI] 1.71–4.26), over four-fold increase in the risk of wound complications (AOR 4.49, 95% CI 2.53–7.97) and superficial SSI (AOR 5.06, 95% CI 2.72–9.39) when compared with orthopedic surgery. Despite similar patient demographics, CMC arthroplasty performed by plastic surgeons is independently associated with an increased risk of total postoperative complications, wound complications, and superficial infections when compared with orthopedic surgeons. Further investigation into perioperative and specialty-specific factors that contribute to discrepancies is warranted to improve outcomes and guide surgeon training. Level III, retrospective cohort study.

Preoperative anemia and 30-day postoperative outcomes among women undergoing laparoscopic myomectomy

General Versus Locoregional Anesthesia in TEVAR: An NSQIP Analysis

Accurate risk estimation is essential when benchmarking surgical outcomes for reimbursement and engaging in shared decision-making. The greater complexity of emergency surgery patients may bias outcome comparisons between elective and emergency cases. To test whether an established risk modelling tool, the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) predicts mortality comparably for emergency and elective cases. From the ACS-NSQIP 2011-2012 patient user files, we selected core emergency surgical cases also common to elective scenarios (gastrointestinal, vascular, and hepato-biliary-pancreatic). After matching strategy for Common Procedure Terminology (CPT) and year, we compared the accuracy of ACS-NSQIP predicted mortality probabilities using the observed-to-expected ratio (O:E), c-statistic, and Brier score. In all, 56,942 emergency and 136,311 elective patients were identified as having a common CPT and year. Using a 1:1 matched sample of 37,154 emergency and elective patients, the O:E ratios generated by ACS-NSQIP models differ significantly between the emergency [O:E = 1.031; 95% confidence interval (CI) = 1.028-1.033] and elective populations (O:E = 0.79; 95% CI = 0.77-0.80, P < 0.0001) and the c-statistics differed significantly (emergency c-statistic = 0.927; 95% CI = 0.921-0.932 and elective c-statistic = 0.887; 95% CI = 0.861-0.912, P = 0.003). The Brier score, tested across a range of mortality rates, did not differ significantly for samples with mortality rates of 6.5% and 9% (eg, emergency Brier score = 0.058; 95% CI = 0.048-0.069 versus elective Brier score = 0.057; 95% CI = 0.044-0.07, P = 0.87, among 2217 patients with 6.5% mortality). When the mortality rate was low (1.7%), Brier scores differed significantly (emergency 0.034; 95% CI = 0.027-0.041 versus elective 0.016; 95% CI = 0.009-0.023, P value for difference 0.0005). ACS-NSQIP risk estimates used for benchmarking and shared decision-making appear to differ between emergency and elective populations.

Although gender-affirming vaginoplasty (GAV) has become more common, optimal postoperative length of stay (LOS) remains unclear, with recommendations ranging from 3 to 9 days. As the transgender population grows, establishing standardized care is critical. Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, this study examines predictors of prolonged LOS in GAV and evaluates the safety of discharging patients within 2 days. The ACS-NSQIP identified patients who underwent GAV from 2012 to 2022 and were grouped based on LOS: early (≤2 d) and prolonged (>2 d). Categorical variables were analyzed using the χ2 or Fisher exact tests, and continuous variables with Student t test or Wilcoxon rank-sum. Logistic regression with propensity adjustment was used for multivariate analysis. Significance threshold was set at P<0.05. A total of 663 patients were included. Significant differences between groups were observed for age, race, surgical specialty, and American Society of Anesthesiologists (ASA) classification (P=0.03, 0.03, 0.001, and 0.02, respectively). Patients with prolonged LOS had higher preoperative hematocrit values (P=0.01) and longer operative times (P<0.0001). Early discharge had fewer complications (P=0.03), readmissions (2 vs. 25), and reoperations (4 vs. 25), although the latter were not statistically significant. Although univariate logistic regression identified preoperative hematocrit, operative time, and surgical specialty as predictors of prolonged LOS, only operative time remained significant after multivariate adjustment. Among patients undergoing GAV, operative time was the strongest predictor of prolonged LOS. Significant associations with age, race, surgical specialty, ASA classification, and hematocrit levels highlight areas for targeted intervention. Discharge by 2 days was associated with significantly fewer complications, with trends toward lower readmission and reoperation rates, supporting early discharge as a safe option in selected patients.

MP65-11 FRAILTY AMONG BLADDER AUGMENTATION PATIENTS: HEALTH CARE UTILIZATION AND PERIOPERATIVE OUTCOMES

Umbilical hernias present commonly during pregnancy secondary to increased intra-abdominal pressure. As a result, umbilical hernia incarceration or strangulation may affect pregnant females. The purpose of this study is to detail the operative management and 30-day outcomes of umbilical hernias in pregnant patients using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). All female patients undergoing umbilical hernia repair during pregnancy were identified within the ACS-NSQIP. Preoperative patient variables, intraoperative variables, and 30-day patient morbidity and mortality outcomes were investigated using a variety of statistical tests. A total of 126 pregnant patients underwent umbilical hernia repair from 2005 to 2014; 73 (58%) had incarceration or strangulation at the time of surgical intervention. The majority of patients (95%) underwent open umbilical hernia repair. Superficial surgical site infection was the most common morbidity in patients undergoing open umbilical hernia repair. Based on review of the ACS-NSQIP database, the incidence of umbilical hernia repair during pregnancy is very low; however, the majority of patients required repair for incarceration of strangulation. When symptoms develop, these hernias can be repaired with minimal 30-day morbidity to the mother. Additional studies are needed to determine the long-term recurrence rate of umbilical hernia repairs performed in pregnant patients and the effects of surgical intervention and approach on the fetus.