Insulin dependence as an independent predictor of perioperative morbidity after ventral hernia repair: a National Surgical Quality Improvement Program analysis of 45,759 patients.

BACKGROUND: Although diabetes mellitus has been identified as a predictor of perioperative morbidity after ventral hernia repair (VHR), it is unclear whether insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) confer the same degree of risk. We examined the variable effect of IDDM and NIDDM on 30-day medical and surgical complications after VHR. METHODS: We performed a retrospective analysis of patients in the National Surgical Quality Improvement Program database from 2005 to 2012 undergoing VHR. After perioperative variable comparison, regression analysis was performed to determine whether IDDM and/or NIDDM independently predicted increased complications after proper risk adjustment. RESULTS: A total of 45,759 patients were identified to have undergone VHR. Of these, 38,026 patients (83.1%) were not diabetic, 5,252 (11.5%) were NIDDM patients, and 2,481 (5.4%) were IDDM patients. After controlling for other risk factors, we found that IDDM independently predicted increased rates of overall, surgical, and medical complications (odds ratio, 1.284, 1.251, 1.263, respectively) in open repair. IDDM independently predicted increased overall and medical complications (odds ratio, 1.997, 1.889, respectively) but not surgical complications in laparoscopic repair. NIDDM was not significantly associated with any complication type in either procedure type. CONCLUSIONS: Our present study suggests that much of the perioperative risk associated with diabetes is attributable to IDDM. The effect of IDDM on laparoscopic and open repair is subtly different. IDDM demonstrates increased overall and medical complications in laparoscopic repair and increased overall, medical, and surgical complications in open repair. Of note, IDDM does not independently predict increased risk for surgical complications in laparoscopic repair.

Assessing Outcomes and Safety of Inpatient Versus Outpatient Tissue Expander Immediate Breast Reconstruction.

BACKGROUND: With the rising cost of healthcare delivery and bundled payments for episodes of care, there has been impetus to minimize hospitalization and increase utilization of outpatient surgery mechanisms. Given the increase in outpatient mastectomy and immediate tissue expander (TE)-based reconstruction and the paucity of data on its comparative safety to inpatient procedures, we sought to understand the risk for early postoperative complications in an outpatient model compared with more traditional inpatient status using the National Surgical Quality Improvement Program database. METHODS: NSQIP data files from 2005 to 2012 were queried to identify patients undergoing immediate TE-based breast reconstruction after mastectomy. Patients were stratified by whether they received outpatient or inpatient care and then propensity score matched based on preoperative baseline characteristics to produce matched cohorts. Multivariate regression analysis was used to determine whether outpatient versus inpatient status conferred differing risk for 30-days complications. RESULTS: Of the 2014 patients who met criteria, 1:1 propensity matching yielded 634 patients in each of the matched cohorts. Overall complications (5.2 vs. 5.4 %), overall surgical complications (4.3 vs. 3.9 %), overall medical complications (1.3 vs. 2.1 %), and return to the operating room (6.6 vs. 7.3 %) were similar between outpatient and inpatients cohorts (p > .2), respectively. There was a small, but significant increased risk of organ/space SSI in outpatients (1.9 vs. 0.5 %, p = .02) and trend for increased risk for pulmonary embolus (PE) and urinary tract infection (UTI) in inpatients (0.3 vs. 0 %, p = .16; 0.3 vs. 0 %, p = .16). CONCLUSIONS: Our studies suggest that outpatient TE confers similar safety profiles to inpatient TE with regards to 30-day postoperative overall complications, medical and surgical morbidity, and return to the operating room. A slightly increased risk for surgical site infection must be balanced against potential risk for known inpatient-related complications such as UTI and PE.

Open vs Minimally Invasive Partial Nephrectomy: Assessing the Impact of BMI on Postoperative Outcomes in 3685 Cases from National Data.

PURPOSE: Previous studies analyzing the relationship between Body Mass Index (BMI) and complications after partial nephrectomy have been underpowered. We use a national surgical database to explore the association of BMI with postoperative outcomes for Open Partial Nephrectomy (OPN) and Minimally Invasive Partial Nephrectomy (MIPN). PATIENTS AND METHODS: Years 2005-2012 of the National Surgical Quality Improvement Program (NSQIP) were queried for OPN and MIPN. Postoperative complications were organized according to Clavien Grades and compared across normal weight (BMI kg/m(2)=18.5-<25.0), overweight (BMI=25.0-<30.0), and obese (BMI≥30.0) patients using standard descriptive statistics and multivariate regression modeling. RESULTS: Of 1667 OPNs and 2018 MIPNs, 46.2% of patients were obese. Operative time was 16.91 minutes longer on average for obese patients (p<0.001). The overall complication rate after OPN was 17.9%, 17.2%, and 17.9% (p=0.945) for normal weight, overweight, and obese patients, respectively; while the overall complication rate after MIPN was 6.9%, 6.3%, and 8.7% (p=0.147). Multivariate regression analysis demonstrated that overweight and obese patients were not at increased risk for any complication grade after OPN and MIPN compared to normal weight patients. When comparing procedures, MIPN had a lower complication rate compared to OPN for obese (8.7% vs 17.9%, p<0.001) and morbidly obese patients (9.2% vs 22.2%, p=0.001). CONCLUSIONS: Although surgery in obese patients is longer compared to normal weight patients, it does not appear to increase the likelihood of 30-day postoperative complications for OPN or MIPN. However, obese patients undergoing MIPN had lower complication rates than those undergoing OPN.

Advanced age as an independent predictor of perioperative risk after laparoscopic sleeve gastrectomy (LSG).

BACKGROUND: While the safety of many bariatric procedures has been previously studied in older patients, we examine the effect of advancing age on medical/surgical complications in laparoscopic sleeve gastrectomy, a relatively unstudied procedure but that is trending upwards in use. METHODS: Patients undergoing laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (RYGB) were extracted from the National Surgical Quality Improvement Program 2005-2012 database. Pre- and postoperative variables were analyzed using chi-square and student t test as appropriate to determine the comparative safety of LSG to RYGB in the elderly. Multivariate regression modeling was used to evaluate whether age is associated with adverse 30-day events following LSG. RESULTS: Of the patients that met the inclusion criteria, 56,664 (84 %) patients underwent RYGB and 10,835 (16 %) underwent LSG. In the LSG cohort, incidence of overall complications, medical complications, and death significantly increased with increasing age (p < 0.05). No statistically significant differences in rates of 30-day complications, return to the OR, and mortality exist between RYGB and LSG cohorts in patients older than 65 years. The age group of over 65 years independently predicted increased risk for overall and medical complications (OR, 1.748; OR, 2.027). Notably, age was not significantly associated with surgical complications in LSG. CONCLUSION: In this large, multi-institutional study, advanced age was significantly associated with overall and medical complications but not surgical complications in LSG. Our findings suggest that the risk conferred by advancing age in LSG is predominantly for medical morbidity and advocate for improved perioperative management of medical complications. LSG may be the preferable option to RYGB for elderly patients as neither procedure is riskier with regards to 30-day morbidity while LSG has been shown to be safer with regards to long-term reoperation and readmission risk.

Resident involvement and plastic surgery outcomes: an analysis of 10,356 patients from the American College of Surgeons National Surgical Quality Improvement Program database.

BACKGROUND: Intraoperative experience is an essential component of surgical training. The impact of resident involvement in plastic surgery has not previously been studied on a large scale. METHODS: The authors retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program database from 2006 to 2010 for all reconstructive plastic surgery cases. Resident involvement was tracked as an individual variable to compare outcomes. RESULTS: A total of 10,356 cases were identified, with 43 percent noted as having resident involvement. The average total relative value units, a proxy for surgical complexity, and operative time were higher for procedures with residents present. When balanced by baseline characteristics using propensity score stratification into quintiles, no differences in graft, prosthesis, or flap failure or mortality were observed. Furthermore, there were no differences in overall complications or wound infection with resident involvement for a majority of the quintiles. Multivariable logistic regression analysis revealed that resident involvement was a significant predictor of overall morbidity, but not associated with increased odds of wound infection, graft, prosthesis or flap failure, or overall mortality. CONCLUSIONS: Residency has the dual mission of training future physicians and also providing critical support for academic medical centers. Using a large-scale, multicenter database, the authors were able to confirm that well-matched cohorts with-and without-resident presence had similar complication profiles. Moreover, even when residents were involved in comparably more complex cases with longer operative times, infection, graft and flap failure, and mortality remained similar.

The relationship between relative value units and outcomes: a multivariate analysis of plastic surgery procedures.

INTRODUCTION: Relative value units (RVUs) were developed as a quantifier of requisite training, knowledge, and technical expertise for performing various procedures. In select procedures, increasing RVUs have been shown to substitute well for increasing surgical complexity and have been linked to greater risk of complications. The relationship of RVU to outcomes has yet to be examined in the plastic surgery population. METHODS: This study analyzed nearly 15,000 patients from a standardized, multicenter database to better define the link between RVUs and outcomes in this surgical population. The American College of Surgeons' National Surgical Quality Improvement Program was retrospectively reviewed from 2006 to 2010. RESULTS: A total of 14,936 patients undergoing primary procedures of plastic surgery were identified. Independent risk factors for complications were analyzed using multivariable logistic regression. A unit increase in RVUs was associated with a 1.7% increase in the odds of overall complications and 1.0% increase in the odds of surgical site complications but did not predict mortality or reoperation. A unit increase in RVUs was also associated with a prolongation of operative time by 0.41 minutes, but RVUs only accounted for 15.6% of variability in operative times. CONCLUSIONS: In the plastic surgery population, increasing RVUs correlates with increased risks of overall complications and surgical site complications. While increasing RVUs may independently prolong operative times, they only accounted for 15.6% of observed variance, indicating that other factors are clearly involved. These findings must be weighed against the benefits of performing more complex surgeries, including time and cost savings, and considered in each patient's risk-benefit analysis.