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Failure to rescue (FTR) is a quality metric defined as mortality after potentially preventable complications after surgery. Predicting patients who are at the highest risk of mortality after a complication may aid in preventing deaths. Thirty-day follow-up period inadequately captures postoperative deaths; alternatively, a 90-day follow-up period has been advocated. This study aimed to examine the association of a validated frailty metric, the risk analysis index (RAI), with 90-day FTR (FTR-90). Patients aged ≥65 years who underwent a major abdominal operation between 2014 and 2020 at a quaternary care center were abstracted. Institutional data were merged with the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Geriatric Surgery Research File variables. The association between RAI and FTR-90 was evaluated using multivariable logistic regression. A total of 398 patients with postoperative complications were included. Fifty-two patients (13.1%) died during the 90-day follow-up. The FTR-90 group was older (median age: 76 vs 73 years, respectively; P =.002), had a greater preoperative American Society of Anesthesiologists classification score (P <.001), and had a higher ACS NSQIP estimated risk of morbidity (0.33% vs 0.20%, P <.001) and mortality (0.067% vs 0.012%, P <.001). The FTR-90 group had a greater median RAI score (23 vs 19; P =.002). The RAI score was independently associated with FTR-90 (odds ratio, 1.04; 95% CI, 1.0042-1.0770; P =.028) but not with FTR-30 (P =.13). Preoperative frailty, as defined by RAI, is independently associated with FTR at 90-day follow-up. FTR-90 captured nearly 60% more deaths than did FTR-30. Frailty has major implications beyond the typical 30-day follow-up period, and a longer follow-up period must be considered. [ABSTRACT FROM AUTHOR]

The risk of venous thromboembolism (VTE) after hepatopancreatobiliary (HPB) surgery is high. Extended postdischarge prophylaxis in this patient population has been controversial. This study aimed to examine the safety of postdischarge extended VTE prophylaxis in patients at high risk of VTE events after HPB surgery. Adult patients risk stratified as very high risk of VTE who underwent HPB operations between 2014 and 2020 at a quaternary care center were included. Patients were matched 1:2 extended VTE prophylaxis to the control group (patients who did not receive extended prophylaxis). Analyses compared the proportions of adverse bleeding events between groups. A total of 307 patients were included: 103 in the extended prophylaxis group and 204 in the matched control group. Demographics were similar between groups. More patients in the extended VTE prophylaxis group had a history of VTE (9% vs 3%; P =.045). There was no difference in bleeding events between the extended VTE prophylaxis and the control group (6% vs 2%; P =.091). Of the 6 patients with bleeding events in the VTE prophylaxis group, 5 had gastrointestinal (GI) bleeding, and 1 had hemarthrosis. Of the 4 patients with bleeding events in the control group, 1 had intra-abdominal bleeding, 2 had GI bleeding, and 1 had intra-abdominal and GI bleeding. Patients discharged with extended VTE prophylaxis after HPB surgery did not experience more adverse bleeding events compared with a matched control group. Routine postdischarge extended VTE prophylaxis is safe in patients at high risk of postoperative VTE after HPB surgery. [ABSTRACT FROM AUTHOR]

Traditional surgical outcomes are measured retrospectively and intermittently, limiting opportunities for early intervention. The objective of this study was to use risk-adjusted cumulative sum (RA-CUSUM) to track perioperative surgical outcomes for laparoscopic gastric bypass. We hypothesized that RA-CUSUM could identify performance variations between surgeons. Two mid-Atlantic quaternary care academic centers. Patient-level data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) were abstracted for laparoscopic gastric bypasses performed by 3 surgeons at 2 high-volume centers from 2014 to 2021. Estimated probabilities of serious complications, reoperation, and readmission were derived from the MBSAQIP risk calculator. RA-CUSUM curves were generated to signal observed-to-expected odds ratios (ORs) of 1.5 (poor performance) and.5 (superior performance). Control limits were set based on a false positive rate of 5% (α =.05). We included 1192 patients: Surgeon A = 767, Surgeon B = 188, and Surgeon C = 237. Overall rates of serious complications, 30-day reoperations, and 30-day readmissions were 3.9%, 2.5%, and 5.2% respectively, with expected rates of 4.7%, 2.2%, and 5.8%. RA-CUSUM signaled lower-than-expected (OR <.5) rates of readmission and serious complication in Surgeon A, and higher-than-expected (OR > 1.5) readmission rate in Surgeon C. Surgeon A further demonstrated an early period of higher-than-expected (OR > 1.5) reoperation rate before April 2015, followed by superior performance thereafter (OR <.5). Surgeon B's performance generally reflected expected standards throughout the study period. RA-CUSUM adjusts for clinical risk factors and identifies performance outliers in real-time. This approach to analyzing surgical outcomes is applicable to quality improvement, root-cause analysis, and surgeon incentivization. • Risk-adjusted cumulative sum (RA-CUSUM) adjusts for clinical risk factors to identify performance outliers in real-time. • RA-CUSUM is applicable to quality improvement/root-cause analysis in bariatric surgery. [ABSTRACT FROM AUTHOR]

Preoperative geriatric-specific variables (GSV) influence short-term morbidity in surgical patients, but their impact on long-term survival in elderly patients with cancer remains undefined. This observational cohort study included patients ≥65 years who underwent hepatopancreatobiliary or colorectal operations for malignancy between 2014 and 2020. Individual patient data included merged ACS NSQIP data, Procedure Targeted, and Geriatric Surgery Research variables. Patients were stratified by age: 65–74, 75–84, and ≥85 and presence of these GSVs: mobility aid, preoperative falls, surrogate signed consent, and living alone. Bivariable and multivariable analyses were used to evaluate 1-year mortality and postoperative discharge to facility. 577 patients were included: 62.6 % were 65–74 years old, 31.7 % 75–84, and 5.7 % ≥ 85. 96 patients were discharged to a facility with frequency increasing with age group (11.4 % vs 22.4 % vs 42.4 %, respectively, p < 0.001). 73 patients (12.7 %) died during 1-year follow-up, 32.9 % from cancer recurrence. One-year mortality was associated with undergoing hepatopancreatobiliary operations (p = 0.017), discharge to a facility (p = 0.047), and a surrogate signing consent (p = 0.035). Increasing age (p < 0.001), hepatopancreatobiliary resection (p = 0.002), living home alone (p < 0.001), and mobility aid use (p < 0.001) were associated with discharge to a facility. Geriatric-specific variables, living alone and use of a mobility aid, were associated with discharge to a facility. A surrogate signing consent and discharge to a facility were associated with 1-year mortality. These findings underscore the importance of preoperative patient selection and optimization, efficacious discharge planning, and informed decision-making in the care of elderly cancer patients. [ABSTRACT FROM AUTHOR]

Background: Medical errors were largely concealed prior to the landmark report "To Err Is Human". The purpose of this systematic scoping review was to determine the extent pediatric surgery defines and studies errors, and to explore themes among papers focused on errors in pediatric surgery. Methods: The methodological framework used to conduct this scoping study has been outlined by Arksey and O'Malley. In January 2020, PubMed, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched. Oxford Level of Evidence was assigned to each study; only studies rated Level 3 or higher were included. Results: Of 3,064 initial studies, 12 were included in the final analysis: 4 cohort studies, and 8 outcome/audit studies. This data represented 5,442,000 aggregate patients and 8,893 errors. There were 6 different error definitions and 5 study methods. Common themes amongst the studies included a systems-focused approach, an increase in errors seen with increased complexity, and studies exploring the relationship between error and adverse events. Conclusions: This study revealed multiple error definitions, multiple error study methods, and common themes described in the pediatric surgical literature. Opportunities exist to improve the safety of surgical care of children by reducing errors. Original Scientific Research Type of Study: Systematic Scoping Review Level of Evidence Rating: 1 [ABSTRACT FROM AUTHOR]

Botulinum toxin A (BoNT-A) injection is one of the most frequently undertaken procedures in aesthetic medicine. The Medicines & Healthcare products Regulatory Agency (MHRA) is the government body in the United Kingdom (UK) mandated to ensure that the provision and administration of medicines is safe. We analyzed adverse events of facial cosmetic BoNT-A injections reported to the MHRA and assessed whether the incidence of reported adverse events in this government registry is comparable to published retrospective and prospective studies. A freedom of information (FOI) request was submitted to the MHRA to obtain recorded complications of BoNT- A. Complications reported to the MHRA between 1991 and 2020 were analyzed. Only cases with BoNT-A where the indication was specified as for facial cosmetics were included in the analysis. Additionally, the literature was reviewed on adverse events of facial cosmetic BoNT- A injections, and a statistical meta-analysis of complication rates was carried out. A total of 188 adverse events of aesthetic BoNT-A injections were reported to the MHRA. The literature search resulted in 30 studies and a total of 17,352 injection sessions, where the complication rate was 16% (95% CI = 8% to 25%). Frequent adverse events included localized skin reactions such as bruising with an incidence of 5% (95% CI = 3% to 7%), headache in 3% (95% CI = from 1% to 5%), and facial paresis in 2% (95% CI = 1% to 3%) of injection sessions. This is the first paper to obtain and evaluate data on adverse events of BoNT-A from the MHRA. An estimate of the likely complication rate of aesthetic BoNT-A in the UK, according to the MHRA database, is significantly lower than the rate recorded from our meta-analysis of the international literature. This suggests that the MHRA may be underestimating the adverse events of aesthetic BoNT-A treatment, which would have implications for patient safety and informed consent. Therefore, legislative changes may be required to ensure more robust reporting of aesthetic BoNT-A in the UK. [ABSTRACT FROM AUTHOR]

Background: Readmissions are costly and inconvenient for patients, and occur frequently in hepatopancreatobiliary (HPB) surgery practice. Readmission prediction tools exist, but most have not been designed or tested in the HPB patient population. Methods: Pancreatectomy and hepatectomy operation–specific readmission models defined as subspecialty readmission risk assessments (SRRA) were developed using clinically relevant data from merged 2014-15 ACS NSQIP Participant Use Data Files and Procedure Targeted datasets. The two derived procedure-specific models were tested along with 6 other readmission models in institutional validation cohorts in patients who had pancreatectomy or hepatectomy, respectively, between 2013 and 2017. Models were compared using area under the receiver operating characteristic curves (AUC). Results: A total of 16,884 patients (9169 pancreatectomy and 7715 hepatectomy) were included in the derivation models. A total of 665 patients (383 pancreatectomy and 282 hepatectomy) were included in the validation models. Specialty-specific readmission models outperformed general models. AUC characteristics of the derived pancreatectomy and hepatectomy SRRA (pancreatectomy AUC=0.66, hepatectomy AUC=0.74), modified Readmission After Pancreatectomy (AUC=0.76), and modified Readmission Risk Score for hepatectomy (AUC=0.78) outperformed general models for readmission risk: LOS/2 + ASA integer-based score (pancreatectomy AUC=0.58, hepatectomy AUC=0.66), LACE Index (pancreatectomy AUC=0.54, hepatectomy AUC=0.62), Unplanned Readmission Nomogram (pancreatectomy AUC=0.52, hepatectomy AUC=0.55), and institutional ARIA (pancreatectomy AUC=0.46, hepatectomy AUC=0.58). Conclusion: HPB readmission risk models using 30-day subspecialty-specific data outperform general readmission risk tools. Hospitals and practices aiming to decrease readmissions in HPB surgery patient populations should use specialty-specific readmission reduction strategies. [ABSTRACT FROM AUTHOR]

The impact of obesity on postoperative outcomes after pancreatoduodenectomy remains insufficiently studied. All pancreatoduodenectomy patients were abstracted from the 2014 to 2018 American College of Surgeons National Surgical Quality Improvement Program data sets and were stratified into the following 3 body mass index categories: non-obese (body mass index 18.5–29.9), class 1/2 obesity (body mass index 30–39.9), and class 3 severe obesity (body mass index ≥ 40). Analyses tested associations between patient factors and four 30-day postoperative outcomes: mortality, composite morbidity, delayed gastric emptying, and postoperative pancreatic fistula. Multivariable logistic regression models tested independent associations between patient factors and these 4 outcome measures. A total of 16,823 patients were included in the study: 12,234 (72.7%) non-obese, 4,030 (24%) obese, and 559 (3.3%) with severe obesity. Bivariable analyses demonstrated significant associations between obesity, severe obesity, and greater proportions of numerous preoperative comorbidities as well as a greater likelihood of postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, composite morbidity, and mortality (all P ≤.001). After adjusting for significant covariates, obesity was independently associated with postoperative pancreatic fistula (odds ratio 1.49, 95% confidence interval: 1.33–1.67, P <.001), delayed gastric emptying (odds ratio 1.16, 95% confidence interval: 1.05–1.28, P =.004), composite morbidity (odds ratio 1.28, 95% confidence interval: 1.18–1.38, P <.001), and mortality (odds ratio 1.79, 95% confidence interval: 1.36–2.36, P <.001). Obesity and severe obesity are significantly associated with worse short-term outcomes after pancreatoduodenectomy. Preoperative considerations, such as weight management strategies during individualized treatment planning, could improve outcomes in this population. [ABSTRACT FROM AUTHOR]

Perioperative efficiency has been studied, although little is known about patient and personnel factors associated with a timely operating room start. We hypothesize that patient, personnel factors, and induction-order decisions are associated with anesthesia induction time. An institutional database was used to identify the anesthesia induction time of adults undergoing first-start, elective operations from January 2014 to May 2017 at an academic quaternary care center. Data included patient demographics; surgeon and anesthesiologist, as well as their seniority (years since initial board certification); certified registered nurse anesthetist versus anesthesia resident staffing; and use of neuraxial anesthesia. Times were measured as minutes from scheduled start to induction. Univariate and multivariate analyses were performed to identify factors associated with induction time. We identified 15,823 cases. Predictors of later induction included add-on cases (1,224 cases were add-ons, 7.73%), American Society of Anesthesiologists classification ≥ 3, neuraxial anesthesia, and certified registered nurse anesthetist staffing. Surgeon seniority—but not gender—affected induction time. In 11,093 cases (70.1%), the anesthesiologist was scheduled for multiple first starts with a choice of which patient to induce first. Surgeon gender was predictive of induction order, with cases of male surgeons induced first more frequently than female surgeons' (47.0% vs 44.1%, P =.02). Cases staffed by anesthesiology residents were more likely to be induced first compared with those staffed by certified registered nurse anesthetists (52.1% vs 41.5%, P <.01). Patient and personnel factors affect the order of case induction, but induction time is most dependent on patient factors. Hospitals should focus on improving preparedness and limiting bias to create a more equitable and efficient perioperative process. [ABSTRACT FROM AUTHOR]

Spinal cord injuries (SCI) lead to major disabilities affecting > 2.5 million people worldwide. Major shortcomings in clinical translation result from multiple factors, including species differences, development of moderately predictive animal models, and differences in methodologies between preclinical and clinical studies. To overcome these obstacles, we first conducted a comparative neuroanatomical analysis of the spinal cord between mice, Microcebus murinus (a nonhuman primate), and humans. Next, we developed and characterized a new model of lateral spinal cord hemisection in M. murinus. Over a 3-month period after SCI, we carried out a detailed, longitudinal, behavioral follow-up associated with in vivo magnetic resonance imaging (1H-MRI) monitoring. Then, we compared lesion extension and tissue alteration using 3 methods: in vivo 1H-MRI, ex vivo 1H-MRI, and classical histology. The general organization and glial cell distribution/morphology in the spinal cord of M. murinus closely resembles that of humans. Animals assessed at different stages following lateral hemisection of the spinal cord presented specific motor deficits and spinal cord tissue alterations. We also found a close correlation between 1H-MRI signal and microglia reactivity and/or associated post-trauma phenomena. Spinal cord hemisection in M. murinus provides a reliable new nonhuman primate model that can be used to promote translational research on SCI and represents a novel and more affordable alternative to larger primates. [ABSTRACT FROM AUTHOR]

Background: Despite technical advances, bile leak remains a significant complication after hepatectomy. The current study uses a targeted multi-institutional dataset to characterize perioperative factors that are associated with bile leakage after hepatectomy to better understand the impact of bile leak on morbidity and mortality.Methods: Adult patients in the 2014-2015 ACS NSQIP targeted hepatectomy dataset were linked to the ACS NSQIP PUF dataset. Bivariable and multivariable regression analyses were used to assess the associations between clinical factors and post-hepatectomy bile leak.Results: Of 6859 patients, 530 (7.7%) had a postoperative bile leak. Proportion of bile leaks was significantly greater in patients after major compared to minor hepatectomy (12.6 vs. 5.1%, p < 0.001). The proportion of patients with bile leak was significantly greater in patients after major hepatectomy who had concomitant enterohepatic reconstruction (31.8 vs. 10.1%, p < 0.001). Postoperative mortality was significantly greater in patients with bile leaks (6.0 vs. 1.7%, p < 0.001). After adjusting for significant covariates, bile leak was independently associated with increased risk of postoperative morbidity (OR = 4.55; 95% CI 3.72-5.56; p < 0.001). After adjusting for significant effects of postoperative complications, liver failure, and reoperation (all p<0.001), bile leak was not independently associated with increased risk of postoperative mortality (p = 0.262).Conclusion: Major hepatectomy and enterohepatic biliary reconstruction are associated with significantly greater rates of bile leak after liver resection. Bile leak is independently associated with significant postoperative morbidity. Mitigation of bile leak is critical in reducing morbidity and mortality after liver resection. [ABSTRACT FROM AUTHOR]

Plastic is now one among one of the most pervasive pollutants on the planet, and ocean circulation models predict that the Arctic will become another accumulation zone. As solutions to address marine plastic emerge, is essential that baselines are available to monitor progress towards targets. The northern fulmar ( Fulmarus glacialis ), a widely-distributed seabird species, has been used as a biological monitor for plastic pollution in the North Sea, and could be a useful monitoring species elsewhere. We quantified plastic ingested by northern fulmars from the southeastern Canadian waters of the Labrador Sea with the objective of establishing a standardized baseline for future comparisons. Over two years we sampled 70 fulmars and found that 79% had ingested plastic, with an average of 11.6 pieces or 0.151 g per bird. Overall, 34% of all fulmars exceeded the Ecological Quality Objective for marine litter, having ingested > 0.1 g of plastic. [ABSTRACT FROM AUTHOR]

Aim: Prior studies have demonstrated a reoperation rate ranging from 5.8 to 7.6% following colorectal surgery. However, the indications for reoperation have not been extensively evaluated. We aimed to describe the indications for reoperation and associated procedures following colorectal resection.Methods: This is a retrospective cohort study of all patients undergoing colorectal resection at a single institution from 2003 to 2013. For patients who returned to the operating room, the primary indication was categorized into mutually exclusive categories and all procedures performed within 30 days of the initial operation were indexed. Univariate and multivariate analyses were performed.Results: We identified 2793 patients who underwent colorectal operations, of which 407 (14.6%) were emergent. A total of 178 (6.7%) patients returned to the operating room. On multivariate analysis, emergent operation, malnutrition, corticosteroid use, and operative duration were independently associated with reoperation; independent functional status was protective. The most common indications for reoperation were anastomotic leak and bowel obstruction. The most common procedures performed were ostomy creation, bowel resection, and adhesiolysis.Conclusions: Reoperation after colorectal surgery is a relatively common occurrence for which we have identified the risk factors, most common indications, and specific procedures performed. This knowledge will help identify areas for improvement. [ABSTRACT FROM AUTHOR]

Plastic debris has become a major pollutant in the world's oceans and is found in many seabird species from low to high latitudes. Here we compare levels of plastic ingestion from two surface feeders, northern fulmars ( Fulmarus glacialis ) and black-legged kittiwakes ( Rissa tridactyla ), and two pursuit diving species, thick-billed murres ( Uria lomvia ) and black guillemots ( Cepphus grylle ) in the Canadian high Arctic. This is the first report quantifying plastic ingestion in kittiwakes in this region, and as predicted, kittiwakes and fulmars had higher frequency of plastic ingestion than guillemots and murres. Despite this, amounts of plastic ingested by birds remain lower than regions farther south. [ABSTRACT FROM AUTHOR]

Background: Morbidity after gastrectomy remains high. The potentially modifiable risk factors have not been well described. This study considers a series of potentially modifiable patient-specific and perioperative characteristics that could be considered to reduce morbidity and mortality after gastrectomy.Methods: This retrospective cohort study includes adults in the ACS NSQIP PUF dataset who underwent gastrectomy between 2011 and 2013. Sequential multivariable models were used to estimate effects of clinical covariates on study outcomes including morbidity, mortality, readmission, and reoperation.Results: Three thousand six hundred and seventy-eight patients underwent gastrectomy. A majority of patients had distal gastrectomy (N = 2,799, 76.1 %) and had resection for malignancy (N = 2,316, 63.0 %). Seven hundred and ninety-eight patients (21.7 %) experienced a major complication. Reoperation was required in 290 patients (7.9 %). Thirty-day mortality was 5.2 %. Age (OR = 1.01, 95 % CI = 1.01-1.02, p = 0.001), preoperative malnutrition (OR = 1.65, 95 % CI = 1.35-2.02, p < 0.001), total gastrectomy (OR = 1.63, 95 % CI = 1.31-2.03, p < 0.001), benign indication for resection (OR = 1.60, 95 % CI = 1.29-1.97, p < 0.001), blood transfusion (OR = 2.57, 95 % CI = 2.10-3.13, p < 0.001), and intraoperative placement of a feeding tubes (OR = 1.28, 95 % CI = 1.00-1.62, p = 0.047) were independently associated with increased risk of morbidity. Association between tobacco use and morbidity was statistically marginal (OR = 1.23, 95 % CI = 0.99-1.53, p = 0.064). All-cause postoperative morbidity had significant associations with reoperation, readmission, and mortality (all p < 0.001).Conclusions: Mitigation of perioperative risk factors including smoking and malnutrition as well as identified operative considerations may improve outcomes after gastrectomy. Postoperative morbidity has the strongest association with other measures of poor outcome: reoperation, readmission, and mortality. [ABSTRACT FROM AUTHOR]

Background: Congestive heart failure (CHF) predicts surgical morbidity and mortality. However, few studies evaluate CHF's impact on noncardiac operations. Because of CHFs serious threat to health and survival, surgeons must understand risks CHF poses to patients undergoing a diverse array of operations.Study Design: We used 2009 to 2013 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Files to estimate the risk of serious morbidity, reoperation, readmission, mortality, and other postoperative complications associated with preoperative diagnosis of CHF. Multivariable logistic regression analysis provided odds ratios (OR) and 95% confidence intervals (CI) for outcomes in 34 ACS NSQIP procedure groups, controlling for age, sex, race, emergency surgery status, American Society of Anesthesiologists Classification, body mass index, and selected laboratory values.Results: Unadjusted ORs indicate adverse effects of CHF on surgical outcomes for most procedures considered. When adjusted for age and other confounders, CHF persists with adverse effects on most outcomes, including serious morbidity (OR 1.52, 95% CI, 1.44 to 1.61; p < 0.001); reoperation (OR 1.29, 95% CI, 1.17 to 1.42; p < 0.001); readmission (OR 1.39, 95% CI, 1.29 to 1.50; p < 0.001); and 30-day mortality (OR 1.96, 95% CI 1.80 to 2.13; p < 0.001). The impact of CHF on morbidity and mortality substantially affected those undergoing carotid endarterectomy and lower extremity endovascular repair. Cardiac arrest, mortality, unplanned intubation, and ventilator > 48 hours were complications most affected by CHF.Conclusions: Congestive heart failure strongly predicts serious morbidity, unplanned reoperation, readmission, and surgical mortality for noncardiac operations. Surgeons must pay particular attention to recognizing CHF and optimizing perioperative management when considering surgery. [ABSTRACT FROM AUTHOR]

Background The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) risk-adjustment model for patients who require hepatic resection does not include metrics of underlying chronic liver disease. The applicability of the current risk adjustment model is under debate. This study aims to assess the impact of chronic liver disease on the ACS NSQIP estimates of postoperative morbidity and mortality. Study design This retrospective cohort study included all cases of hepatic resection at our quaternary referral institution between 2006 and 2013. Metrics of chronic liver disease were abstracted and linked with the ACS NSQIP risk-adjustment model estimated probabilities of morbidity and mortality for each case. Sequential general linear models were used to estimate differences in ACS NSQIP probabilities of morbidity and mortality associated with measures of underlying chronic liver disease. Results A total of 522 hepatic resections were performed during the study period. The patient cohort included 91 patients with fibrosis (17%) and 38 patients with cirrhosis (7%). The mean ACS NSQIP estimated probability of morbidity was 0.24 ± 0.11 and probability of mortality was 0.02 ± 0.02. Fibrosis was associated with increased probability of morbidity (0.26 ± 0.11; P = .019); cirrhosis was also associated with increased probability of morbidity (0.27 ± 0.10; P = .059). Parenchymal liver disease was not associated with increased probability of mortality (all P ≥ .62). Increased probabilities of mortality were associated with diagnosis and extent of resection (both P < .001). Conclusions In patients selected for hepatectomy, metrics of chronic liver disease were associated with differences in ACS NSQIP estimated probability of morbidity. Incorporation of metrics of chronic liver disease into the ACS NSQIP targeted hepatectomy modules should improve estimates of risk after hepatic resection. [ABSTRACT FROM AUTHOR]

Background The long-term durability of Roux-en-Y gastric bypass (RYGB) remains ill-defined in the American population secondary to poor follow-up after bariatric surgery. Objectives This study evaluated the population lost to follow-up to better define the long-term durability of RYGB for weight loss and co-morbidity amelioration. Methods All patients (n = 1087) undergoing RYGB at a single institution between 1985 and 2004 were evaluated. Univariate differences in preoperative co-morbidities, postoperative complications, annual weight loss, and 10-year co-morbidities were analyzed to compare outcomes between patients with routine follow-up and those without. Using electronic medical record review for all encounters at our academic medical center and telephone survey, we obtained data for patients lost to follow-up. Results Among 1087 RYGB patients, 151 (14%) had consistent 10-year follow-up in our prospectively collected database, with yearly clinic visits beyond 2 years postoperatively. Electronic medical record review and telephone survey data were collected on an additional 500 (46%) patients, resulting in 60% of patients having 10-year follow-up after RYGB. There was no statistical difference in any preoperative or postoperative variables between the 2 groups. We found no difference in co-morbidity prevalence preoperatively or at 10 years between groups. Examination of percent excess body mass index lost at yearly intervals revealed no difference between the groups at each interval up to 10 years ( P = .36). Conclusion We found no difference in 10-year outcomes, including weight loss and co-morbidity reduction, between patients with routine clinic visits and those lost to follow-up. These 10-year data address the gap in knowledge resulting from poor long-term follow-up after bariatric surgery. [ABSTRACT FROM AUTHOR]

Background Effective collaboration among healthcare providers is an essential component of high-quality patient care. Interprofessional education is foundational to ensuring that students are prepared to engage in optimal collaboration once they enter clinical practice particularly in the care of complex geriatric patients undergoing surgery. Study Design To enhance interprofessional education between nursing students and medical students in a clinical environment, we modeled the desired behavior and skills needed for interprofessional preoperative geriatric assessment for students, then provided an opportunity for students to practice skills in nurse/physician pairs on standardized patients. This experience culminated with students performing skills independently in a clinic setting. Results Nine nursing students and six medical students completed the pilot project. At baseline and after the final clinic visit we administered a ten question geriatric assessment test. Post-test scores (M = 90.33, SD = 11.09) were significantly higher than pre-test scores (M = 72.33, SD = 12.66, t(14) = − 4.50, p < 0.001. Nursing student post-test scores improved a mean of 22.0 points and medical students a mean of 11.7 points over pre-test scores. Analysis of observational notes provided evidence of interprofessional education skills in the themes of shared problem solving, conflict resolution, recognition of patient needs, shared decision making, knowledge and development of one's professional role, communication, transfer of interprofessional learning, and identification of learning needs. Conclusions Having nursing and medical students “learn about, from and with each other” while conducting a preoperative geriatric assessment offered a unique collaborative educational experience for students that better prepares them to integrate into interdisciplinary clinic teams. [ABSTRACT FROM AUTHOR]

Résumé Le modèle de Denver (Early Start Denver Model [ESDM]) est une approche qui intègre des concepts développementaux, relationnels, comportementaux et d’apprentissage, afin de proposer une intervention particulièrement adaptée aux très jeunes enfants, dès l’âge de 12 mois. En partenariat avec les parents, l’ESDM vise à sortir l’enfant avec TSA ou « risque autistique » de sa « privation sociale » et à relancer les processus de développement altérés. Conçu comme un modèle naturaliste, transposable dans tous les environnements naturels, il vise à stimuler de manière intensive l’engagement social, l’imitation et la communication. Sur la base d’une évaluation trimestrielle du profil de développement de chaque enfant, un programme d’intervention individualisé est élaboré. L’ESDM est une des seules approches validées par une étude randomisée et contrôlée et recommandée par la Haute Autorité de la santé. Les questions en suspens concernent : (1) le nombre d’heures hebdomadaires nécessaire pour une application efficace de l’ESDM ; (2) les modalités d’application (en individuel/en petit groupe) ; (3) et le profil d’enfants pouvant bénéficiant au mieux de cette approche. À titre d’exemple, nous rapportons ici les résultats d’une étude portant sur 16 enfants avec troubles autistiques intégrés pendant au moins un an dans un programme d’intervention précoce basé sur les principes de l’ESDM. Nous avons observé des améliorations significatives dans des domaines pivots de l’autisme (l’attention conjointe, la communication, la relation affective, l’expression émotionnelle…) et globalement une homogénéisation de leurs compétences. Cependant, les profils évolutifs diffèrent d’un enfant à l’autre, notamment en fonction du retard de développement initialement présent. The Early Start Denver Model for young children with autism (ESDM) is an early intervention program that integrates developmental, relationship-based, behavioral and learning concepts emerging from research on autism spectrum disorder (ASD), in order to provide a comprehensive intervention in particular for the very young children, from the age of 12 months on. In close collaboration with parents and family, the ESDM aims to decrease the child's ‘social deprivation’ and its perpetuating impact on the neuronal and psychological development, in order to rekindle the altered developmental processes during this period of maximal brain plasticity. Designed as a naturalistic model that can be transposed into different contexts, the EDSM aims to stimulate in an intensive manner previously deficient functions such as social engagement, imitation, communication etc., through play sequences based on the child's interests. Following a precise evaluation of each child's developmental profile every three months, an individual intervention program is elaborated through a highly structured and standardized procedure using the ESDM curriculum. The ESDM is one of the only treatment approaches that have been scientifically validated in a randomized controlled trial, and it is one of the major programs recommended by the French High Authority of Health (HAS) for the treatment of children with ASD (since 2012). Questions remain regarding the necessary treatment intensity in order to obtain satisfying results with the ESDM (20–25 hours per week or less), especially within the context of the French public health system, regarding its treatment modalities (one-on-one or small group settings) and regarding the profile of children that would benefit most from this intervention (e.g. ASD with or without associated developmental delay). As an example, we report here the results of a study on 16 children with ASD participating over at least one year in an early intervention program with flexible treatment hours based on ESDM principles. [ABSTRACT FROM AUTHOR]

Background There is limited outcome data for super-super-obese (SSO) patients, those with Body Mass Index (BMI) ≥ 60 kg/m 2 , who seek surgical treatment with Laparoscopic Roux-en-Y Gastric Bypass (LRYGB). A large single center LRYGB experience was reviewed to compare the safety and efficacy of LRYGB in SSO patients to the standard obese population undergoing this procedure. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database and an Institutional Review Board approved prospective database was used to identify all patients undergoing LRYGB by multiple surgeons at a single institution between 1/1/1994 and 11/15/2013. Preoperative co-morbidities, postoperative complications, 30-day outcomes, and weight loss at yearly intervals were analyzed to determine difference between SSO patients and NonSSO patients (BMI<60 kg/m 2 ). Results Of the 2009 patients undergoing LRYGB over the past 20 years; 328 had BMI≥60 kg/m 2 . Preoperative co-morbidities, conversion to open, and length of stay were significantly increased among SSO patients; however there was no significant difference in postoperative outcomes or complications. Percent reduction of excess BMI beyond 12 months was significantly improved among NonSSO patients with less than 30% follow-up beyond 2 years. Conclusions LRYGB appears well tolerated for super-super-obese patients with BMI≥60 kg/m 2 in experienced centers. These patients still have significant reduction in excess BMI despite being less than NonSSO patients undergoing RYGB. The ACS NSQIP database provides excellent tracking of institutional progress with bariatric surgical outcomes to facilitate the improvement of best practice techniques. [ABSTRACT FROM AUTHOR]

Background Health policy experts have proposed a framework defining value as outcomes achieved per dollar spent on health care. However, few institutions quantify their delivery of care along these dimensions. Our objective was to measure the value of our surgical services over time. Study Design We reviewed the data of patients undergoing general and vascular surgery from 2002 through 2012 at a tertiary care university hospital as abstracted by the American College of Surgeons NSQIP. Morbidity and mortality data from the American College of Surgeons NSQIP database were risk adjusted to calculate observed-to-expected ratios, which were then inverted into a numerator as a surrogate for quality. Costs, the denominator of the value equation, were determined for each patient's hospitalization. The ratio was then transformed by a constant and analyzed with linear regression to analyze and compare values from 2002 through 2012. Results A total of 25,453 patients met criteria for inclusion. Overall, the value of surgical services increased from 2002 through 2012. The observed increase in value was greater in general surgery than in vascular surgery, and value actually decreased in vascular procedures. Although there was a similar increase in outcomes in vascular surgery compared with general surgery, costs rose significantly higher ($474/year vs −$302/year; p < 0.001). These increased costs were mostly observed from 2006 through 2010 with the adoption of endovascular technology. Conclusions Despite the challenges posed by current information systems, calculating risk-adjusted value in surgical services represents a critical first step for providers seeking to improve outcomes, avoid ill-advised cost containment, and determine the costs of innovation. [ABSTRACT FROM AUTHOR]

Background Unplanned hospital readmissions among surgical patients are the target of multiple efforts to improve patient outcomes and to decrease avoidable costs. This study presents an analysis of unplanned readmissions for adult patients who undergo major surgery and the associated risk presented by clinical characteristics of the individual patients known before discharge. Methods Multivariable logistic regression analysis was used to develop and validate a model for estimating risk of readmission using data from the participant use data file of the American College of Surgeons National Surgical Quality Improvement Program. Results Unplanned readmission occurred in 5.3% of major surgery cases for patients who were discharged alive. A total of 48 candidate predictors of unplanned readmission were evaluated. A reduced model was developed that included the 10 covariates that provide the greatest contributions to the full model. The reduced model demonstrated good statistical performance (validated C statistic = 0.70) and demonstrated excellent calibration in an independent dataset of patients undergoing major surgery in 2012. The predictive equation from the reduced model is presented as a nomogram and formula for calculating individual patient risk of unplanned readmission. Conclusion Accurate identification of patients at high risk for unplanned readmission can be conducted using selected patient characteristics known before discharge. A nomogram reflecting the effects of these key patient characteristics can be used to calculate accurately a patient's individual risk of readmission. The availability of these estimates before discharge could improve the efficacy of discharge planning efforts and related programs coordinating care seeking to prevent avoidable readmission. [ABSTRACT FROM AUTHOR]

Background Anastomotic leak, a potentially deadly postoperative occurrence, particularly interests surgeons performing gastrointestinal procedures. We investigated incidence, cost, and impact on survival of anastomotic leak in gastrointestinal surgical procedures at an academic center. Study Design We conducted a chart review of American College of Surgeons NSQIP operative procedures with gastrointestinal anastomosis from January 1, 2003 through April 30, 2006. Each case with an American College of Surgeons NSQIP 30-day postoperative complication was systematically reviewed for evidence of anastomotic leak for 12 months after the operative date. We tracked patients for up to 10 years to determine survival. Morbidity, mortality, and cost for patients with gastrointestinal anastomotic leaks were compared with patients with anastomoses that remained intact. Results Unadjusted analyses revealed significant differences between patients who had anastomotic leaks develop and those who did not: morbidity (98.0% vs 28.4%; p < 0.0001), length of stay (13 vs 5 days; p ≤ 0.0001), 30-day mortality (8.4% vs 2.5%; p < 0.0001), long-term mortality (36.4% vs 20.0%; p ≤ 0.0001), and hospital costs (chi-square [2] = 359.8; p < 0.0001). Multivariable regression demonstrated that anastomotic leak was associated with congestive heart failure (odds ratio [OR] = 31.5; 95% CI, 2.6–381.4; p = 0.007), peripheral vascular disease (OR = 4.6; 95% CI, 1.0–20.5; p = 0.048), alcohol abuse (OR = 3.7; 95% CI, 1.6–8.3; p = 0.002), steroid use (OR = 2.3; 95% CI: 1.1–5.0; p = 0.027), abnormal sodium (OR = 0.4; 95% CI, 0.2–0.7; p = 0.002), weight loss (OR = 0.2; 95% CI, 0.06–0.7; p = 0.011), and location of anastomosis: rectum (OR = 14.0; 95% CI, 2.6–75.5; p = 0.002), esophagus (OR = 13.0; 95% CI, 3.6–46.2; p < 0.0001), pancreas (OR = 12.4; 95% CI, 3.3–46.2; p < 0.0001), small intestine (OR = 6.9; 95% CI, 1.8–26.4; p = 0.005), and colon (OR = 5.2; 95% CI, 1.5–17.7; p = 0.009). Conclusions Significant morbidity, mortality, and cost accompany gastrointestinal anastomotic leaks. Patients who experience an anastomotic leak have lower rates of survival at 30 days and long term. [ABSTRACT FROM AUTHOR]

Background The 30-day readmission rate is a quality metric under the Affordable Care Act. Readmission rates after thyroidectomy and parathyroidectomy and associated factors remain ill-defined. We evaluated patient and perioperative factors for association with readmission after thyroidectomy and parathyroidectomy. Methods The American College of Surgeons National Surgical Quality Improvement Program Participant Use File (2011) data for thyroid ( n = 3,711) and parathyroid ( n = 3,358) resections were analyzed. Patient- and operation-related factors were assessed by univariate and multivariate analyses. Results Among 7,069 patients, 30-day readmission rate was 4.0%: 4.1% after thyroidectomy and 3.8% after parathyroidectomy. Significant associations for 30-day readmission included declining functional status (odds ratio [OR], 6.4–10.1), preoperative hemodialysis (OR, 2.6; 95% CI, 1.5–4.7), malnutrition (OR, 3.4; 95% CI, 1.2–10.1), increasing American Society of Anesthesiologists class (OR 1.3–4.7), unplanned reoperation (OR, 61.6), and length of stay (LOS) <24 hours (OR, 0.61; 95% CI, 0.45–0.85; all P < .05). Readmission was associated with greater total and postoperative LOS and major postoperative complications, including renal insufficiency (all P < .01). Conclusion Thirty-day readmission after cervical endocrine resection occurs in 4% of patients. Discharge within 24 hours of operation does not affect the likelihood of readmission. Risk factors for readmission are multifactorial and driven by preoperative conditions. Decreasing the index hospital stay and preventing major postoperative complications may decrease readmissions and improve quality metrics. [ABSTRACT FROM AUTHOR]

Objective: To develop a research productivity scoring program within an academic department of surgery that would help realign incentives to encourage and reward research. Although research is highly valued in the academic mission, financial incentives are generally aligned to reward clinical productivity. Methods: A formula assigning points for publications and extramural grants was created and used to award a research incentive payment proportional to the research productivity score, beginning July 2007. Publication points reflect journal impact factor, author role, and manuscript type. Grant points reflect total funding and percentage of effort. Publication data were gathered from Web of Science/PubMed/Medline and grants data from the departmental grants office. An annual award is presented to the person with the greatest improvement. The research productivity score data after July 2007 were compared with control data for the 2 preceding years. A 33-question survey to 28 clinical faculty was conducted after the first year to measure satisfaction and solicit constructive feedback. Results: The mean annual point scores increased from the preresearch productivity score to the postresearch productivity score academic years (2180 vs 3389, respectively, P = .08), with a significant change in the grant component score (272 vs 801, P = .03). Since research productivity score implementation, the operative case volumes increased 4.3% from 2006 to 2011. With a response rate of 89%, the survey indicated that 76% of the faculty wished to devote more time to research and 52% believed 1 or more research-related behaviors would change because of the research productivity score program. Conclusions: An objective, transparent research incentive program, through both monetary incentives and recognition, can stimulate productivity and was well-received by faculty. [ABSTRACT FROM AUTHOR]

Background: Semiannually, the National Surgical Quality Improvement Program (NSQIP) provides its participating sites with observed-to-expected (O/E) ratios for 30-day postoperative mortality and morbidity. At each reporting period, there is typically a small group of hospitals with statistically significantly high O/E ratios, meaning that their patients have experienced more adverse events than would be expected on the basis of the population characteristics. An important issue is to determine which actions a surgical service should take in the presence of a high O/E ratio. Study Design: This article reviews case studies of how some of the Department of Veterans Affairs and private-sector NSQIP participating sites used the clinically rich NSQIP database for local quality improvement efforts. Data on postoperative adverse events before and after these local quality improvement efforts are presented. Results: After local quality improvement efforts, wound complication rates were reduced at the Salt Lake City Veterans Affairs medical center by 47%, surgical site infections in patients undergoing intraabdominal surgery were reduced at the University of Virginia by 36%, and urinary tract infections in vascular patients were reduced at the Massachusetts General Hospital by 74%. At some sites participating in the NSQIP, notably the Massachusetts General Hospital and the University of Virginia, the NSQIP has served as the basis for surgical service-wide outcomes research and quality improvement programs. Conclusions: The NSQIP not only provides participating sites with risk-adjusted surgical mortality and morbidity outcomes semiannually, but the clinically rich NSQIP database can also serve as a catalyst for local quality improvement programs to significantly reduce postoperative adverse event rates. [Copyright &y& Elsevier]

Background: Data from the Patient Safety in Surgery Study were used to compare preoperative risk factors, intraoperative variables, and surgical outcomes of adrenalectomy procedures performed in 81 Veterans Affairs (VA) hospitals with those performed in 14 private-sector (PS) hospitals. Study Design: This study is a retrospective review of prospectively collected data on all patients undergoing adrenalectomy in the VA and PS for fiscal years 2002 through 2004. Bivariate analysis compared VA and PS preoperative risk factors, intraoperative variables, and 30-day morbidity and mortality. Regression risk-adjustment analysis was used to compare 30-day postoperative morbidity in the VA and PS. Results: During the 3 years studied, 178 VA patients and 371 PS patients underwent adrenalectomy procedures with a median per site of 2 (range 1−9) and 21 (range 8−70) procedures per VA and PS hospital, respectively. The VA patients had considerably more comorbidities than PS patients. The unadjusted 30-day morbidity rate was significantly higher in VA (16.29%) than PS (6.74%) hospitals (p = 0.0003); after controlling for the higher rate of comorbidities, the adjusted odds ratio for morbidity in the VA versus the PS hospitals was no longer significant (odds ratio = 1.328; 95% CI, 0.488−3.613). Unadjusted mortality rate was VA 2.81%, PS 0.27%, p = 0.0074. The low event rate overall precluded risk adjustment for mortality. Conclusions: The VA adrenalectomy population has more preoperative risk factors and substantially higher unadjusted 30-day postoperative morbidity and mortality rates than the PS population. After risk adjustment, there is no significant difference in morbidity between the VA and the PS. A larger study population is needed to compare risk-adjusted mortality between the VA and PS. [Copyright &y& Elsevier]

Background: The aging population of the United States results in increasing numbers of surgical operations on elderly patients. This study observed aging related to morbidity, mortality, and their risk factors in patients undergoing major operations. Study design: We reviewed our institution’s American College of Surgeons National Surgical Quality Improvement Program database from February 24, 2002, through June 30, 2005, including standardized preoperative, intraoperative, and 30-day postoperative data points. This required review and analysis of the prospectively collected data. We examined patient demographics, preoperative risk factors, intraoperative risk factors, and 30-day outcomes with a focus on those aged 80 years and older. Results: A total of 7,696 surgical procedures incurred a 28% morbidity rate and 2.3% mortality rate, although those older than 80 years of age had a morbidity of 51% and mortality of 7%. Hypertension and dyspnea were the most frequent risk factors in those aged 80 years and older. Preoperative transfusion, emergency operation, and weight loss best predicted morbidity for those 80 years of age and older. Operative duration predicted “other” postoperative occurrences and emergent case status predicted respiratory occurrences across all age groups. Preoperative impairment of activities of daily living, emergency operation, and increased American Society of Anesthesiology classification predicted mortality across all age groups. A 30-minute increment of operative duration increased the odds of mortality by 17% in patients older than 80 years. Postoperative morbidity and mortality increased progressively with increasing age. Age was statistically significantly associated with morbidity (wound, p = 0.021; renal, p = 0.001; cardiovascular, p = 0.0004; respiratory, p < 0.0001) and mortality (p = 0.001). Conclusions: Although several risk factors for postoperative morbidity and mortality increase with age, increasing age itself remains an important risk factor for postoperative morbidity and mortality. [Copyright &y& Elsevier]

Background: Elderly patients (65 years of age and older) undergo an increasing number of operations performed annually in the US and they present with unique healthcare needs. Preventing postoperative readmission remains an important challenge to improving surgical care. This study examined whether geriatric-specific variables were independently associated with postoperative readmissions of elderly patients.Methods: The American College of Surgeons (ACS) Geriatric Surgery Research File (GSRF) was joined with the ACS NSQIP Participant Use Data Files for 2014 to 2016. This data set included 13 GSRF variables and 26 ACS NSQIP variables. Associations between clinically relevant variables and readmission were tested with multivariable logistic regression.Results: The data represented 6,039 general surgery patients age 65 years and older. Fifty-eight percent of patients had colorectal operations, 19% pancreatic or hepatobiliary, 15% hernia, 4% thyroid or esophageal, and 3% had appendix operations. Twenty-four percent of patients experienced an NSQIP-defined 30-day postoperative complication and 3% died within 30 days after operation. Eleven percent of patients had unplanned 30-day readmission. Standard NSQIP variables, including 30-day composite morbidity (odds ratio [OR] 5.11; 95% CI, 4.24 to 6.16; p < 0.001), reoperation (OR 2.8; 95% CI, 2.07 to 3.79; p < 0.001), and steroid use (1.42; 95% CI, 1.03 to 1.96; p = 0.03) were associated with readmission. In addition, GSRF variables, including incompetent on admission (OR 1.63; 95% CI, 1.11 to 2.38; p = 0.01), fall risk at discharge (OR 1.42; 95% CI, 1.11 to 1.82; p = 0.005), use of mobility aid (OR 1.26; 95% CI, 1.02 to 1.56; p = 0.03), and discharged home with skilled care (OR, 1.22; 95% CI, 1.0 to 1.49; p = 0.04) were associated with readmission.Conclusions: Four GSRF and 3 current standard ACS NSQIP variables were important in the evaluation of postoperative readmission of elderly patients. Geriatric-specific variables contributed to the explanation of the relationship between clinical variables and readmissions in elderly surgical patients. [ABSTRACT FROM AUTHOR]