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Harris J, Ahluwalia V, Xu K, Romeo D, Fritz C, Rajasekaran K. The efficacy of the National Surgical Quality Improvement Program surgical risk calculator in head and neck surgery: A meta-analysis. Head Neck 2024; 46:1718-1726. [PMID: 38576311 DOI: 10.1002/hed.27765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/16/2024] [Accepted: 03/26/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND The National Surgical Quality Improvement Program surgical risk calculator (SRC) estimates the risk for postoperative complications. This meta-analysis assesses the efficacy of the SRC in the field of head and neck surgery. METHODS A systematic review identified studies comparing the SRC's predictions to observed outcomes following head and neck surgeries. Predictive accuracy was assessed using receiver operating characteristic curves (AUCs) and Brier scoring. RESULTS Nine studies totaling 1774 patients were included. The SRC underpredicted the risk of all outcomes (including any complication [observed (ob) = 35.9%, predicted (pr) = 21.8%] and serious complication [ob = 28.7%, pr = 17.0%]) except mortality (ob = 0.37%, pr = 1.55%). The observed length of stay was more than twice the predicted length (p < 0.02). Discrimination was acceptable for postoperative pneumonia (AUC = 0.778) and urinary tract infection (AUC = 0.782) only. Predictive accuracy was low for all outcomes (Brier scores ≥0.01) and comparable for patients with and without free-flap reconstructions. CONCLUSION The SRC is an ineffective instrument for predicting outcomes in head and neck surgery.
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Affiliation(s)
- Jacob Harris
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vinayak Ahluwalia
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Katherine Xu
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dominic Romeo
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christian Fritz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Chandna M, Kumar A, Crippen M, Sakkal M, Guler M, Garg N, Tekumalla S, Barbarite E, Krein H, Heffelfinger R. Factors Predicting Discharge Disposition Following Head and Neck Free Flap Reconstruction. Laryngoscope 2024; 134:2721-2725. [PMID: 38098138 DOI: 10.1002/lary.31202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 09/12/2023] [Accepted: 10/17/2023] [Indexed: 05/09/2024]
Abstract
OBJECTIVES Patients undergoing head and neck free flap reconstruction (HNFFR) may have significant change to their baseline functional status requiring inpatient rehabilitation (IPR) after discharge. We sought to identify patient/procedure characteristics predictive of discharge destination. METHODS Patients undergoing elective HNFFR between July 2017 and July 2022 were reviewed for discharge destination. Those discharged to IPR versus home were compared across patient/procedure characteristics and physical/occupational therapy metrics. Significance was assessed via bivariate and multivariable analyses. RESULTS Of the 531 patients, 102 (19.2%) required IPR postoperatively. Patients discharged to IPR versus home were significantly older (70.1 [11.6] vs. 64.1 [13.1] years; p < 0.001) and more likely to lack family assistance (26.5% vs. 8.6%; p < 0.001), require baseline assistance for activities of daily living (ADLs) (31.4% vs. 9.8%; p < 0.001), have baseline cognitive dysfunction (15.7% vs. 6.1%; p = 0.001), were more likely to have neoplasm as the surgical indication for HNFFR (89.2% vs. 80.0%; p = 0.033) and more likely to have a tracheostomy postop (62.7% vs. 51.7%), and had a significantly longer length of stay (11.2 [8.0] vs. 6.8 [8.3] days; p < 0.001). There was no significant difference in gender, donor site, use of tube feeds, and use of assistive devices between the two groups. Following logistic regression, the strongest predictors of discharge to IPR include lack of family assistance (OR = 3.8; p < 0.001) and baseline assistance for ADLs (OR = 4.0, p < 0.001). CONCLUSION Certain patient factors predict the need for discharge to rehab after HNFFR. Perioperative identification of these factors may facilitate patient counseling and discharge planning with potential to reduce hospital length of stay and further optimize patient care. LEVEL OF EVIDENCE III Laryngoscope, 134:2721-2725, 2024.
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Affiliation(s)
- Megha Chandna
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Ayan Kumar
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Meghan Crippen
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Marah Sakkal
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Meryam Guler
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Neha Garg
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Sruti Tekumalla
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
- Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Eric Barbarite
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Howard Krein
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
| | - Ryan Heffelfinger
- Department of Otolaryngology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A
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Namavarian A, Gabinet-Equihua A, Deng Y, Khalid S, Ziai H, Deutsch K, Huang J, Gilbert RW, Goldstein DP, Yao CMKL, Irish JC, Enepekides DJ, Higgins KM, Rudzicz F, Eskander A, Xu W, de Almeida JR. Length of Stay Prediction Models for Oral Cancer Surgery: Machine Learning, Statistical and ACS-NSQIP. Laryngoscope 2024. [PMID: 38651539 DOI: 10.1002/lary.31443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 03/17/2024] [Accepted: 03/27/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Accurate prediction of hospital length of stay (LOS) following surgical management of oral cavity cancer (OCC) may be associated with improved patient counseling, hospital resource utilization and cost. The objective of this study was to compare the performance of statistical models, a machine learning (ML) model, and The American College of Surgeons National Surgical Quality Improvement Program's (ACS-NSQIP) calculator in predicting LOS following surgery for OCC. MATERIALS AND METHODS A retrospective multicenter database study was performed at two major academic head and neck cancer centers. Patients with OCC who underwent major free flap reconstructive surgery between January 2008 and June 2019 surgery were selected. Data were pooled and split into training and validation datasets. Statistical and ML models were developed, and performance was evaluated by comparing predicted and actual LOS using correlation coefficient values and percent accuracy. RESULTS Totally 837 patients were selected with mean patient age being 62.5 ± 11.7 [SD] years and 67% being male. The ML model demonstrated the best accuracy (validation correlation 0.48, 4-day accuracy 70%), compared with the statistical models: multivariate analysis (0.45, 67%) and least absolute shrinkage and selection operator (0.42, 70%). All were superior to the ACS-NSQIP calculator's performance (0.23, 59%). CONCLUSION We developed statistical and ML models that predicted LOS following major free flap reconstructive surgery for OCC. Our models demonstrated superior predictive performance to the ACS-NSQIP calculator. The ML model identified several novel predictors of LOS. These models must be validated in other institutions before being used in clinical practice. LEVEL OF EVIDENCE Level 3 Laryngoscope, 2024.
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Affiliation(s)
- Amirpouyan Namavarian
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Yangqing Deng
- Department of Biostatistics, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
| | - Shuja Khalid
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada
| | - Hedyeh Ziai
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Konrado Deutsch
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jingyue Huang
- Department of Biostatistics, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
| | - Ralph W Gilbert
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
| | - David P Goldstein
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
| | - Christopher M K L Yao
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
| | - Jonathan C Irish
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
| | - Danny J Enepekides
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Kevin M Higgins
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Frank Rudzicz
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada
- International Centre for Surgical Safety, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Vector Institute for Artificial Intelligence, Toronto, Ontario, Canada
| | - Antoine Eskander
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Wei Xu
- Department of Biostatistics, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
- Department of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - John R de Almeida
- Department of Otolaryngology-Head & Neck Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Princess Margaret Cancer Center-University Health Network, Toronto, Ontario, Canada
- Department of Otolaryngology-Head & Neck Surgery, Sinai Health System, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Ronen O, Robbins KT, Shaha AR, Kowalski LP, Mäkitie AA, Florek E, Ferlito A. Emerging Concepts Impacting Head and Neck Cancer Surgery Morbidity. Oncol Ther 2023; 11:1-13. [PMID: 36565427 PMCID: PMC9935772 DOI: 10.1007/s40487-022-00217-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/01/2022] [Indexed: 12/25/2022] Open
Abstract
All treatment modalities for head and neck cancer carry with them a risk of adverse events. Head and neck surgeons are faced with significant challenges to minimize associated morbidity and manage its sequelae. Recognizing situations in which a surgical complication is an adverse event inherent to the procedure can alleviate the psychologic impact a complication might have on the treatment team and minimize external and internal pressures. Focusing on the complications that can be effectively modified, future complications can be avoided. Also, some surgical morbidities may not be preventable, necessitating the option to reconsider whether the incidents should be labeled toxic reactions rather than a complication. This discussion highlights some of the areas in which additional research is needed to achieve the goal of minimizing the impact of surgical morbidity.
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Affiliation(s)
- Ohad Ronen
- Head and Neck Surgery Unit, Department of Otolaryngology-Head and Neck Surgery, Affiliated With Azrieli Faculty of Medicine, Galilee Medical Center, Bar-Ilan University, POB 21, Nahariya, Safed, 2210001, Israel.
| | - K Thomas Robbins
- Department of Otolaryngology-Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Ashok R Shaha
- Head and Neck Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Luiz P Kowalski
- Department of Otorhinolaryngology-Head and Neck Surgery, A.C. Camargo Cancer Center, São Paulo, Brazil
- Department of Head and Neck Surgery, University of São Paulo Medical School, São Paulo, Brazil
| | - Antti A Mäkitie
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ewa Florek
- Laboratory of Environmental Research, Department of Toxicology, Poznan University of Medical Sciences, Poznan, Poland
| | - Alfio Ferlito
- Coordinator of International Head and Neck Scientific Group, Padua, Italy
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Basta MN, Rao V, Paiva M, Liu PY, Woo AS, Fischer JP, Breuing KH. Evaluating the Inaccuracy of the National Surgical Quality Improvement Project Surgical Risk Calculator in Plastic Surgery: A Meta-analysis of Short-Term Predicted Complications. Ann Plast Surg 2022; 88:S219-S223. [PMID: 35513323 DOI: 10.1097/sap.0000000000003189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Preoperative surgical risk assessment is a major component of clinical decision making. The ability to provide accurate, individualized risk estimates has become critical because of growing emphasis on quality metrics benchmarks. The American College of Surgeons National Surgical Quality Improvement Project (NSQIP) Surgical Risk Calculator (SRC) was designed to quantify patient-specific risk across various surgeries. Its applicability to plastic surgery is unclear, however, with multiple studies reporting inaccuracies among certain patient populations. This study uses meta-analysis to evaluate the NSQIP SRC's ability to predict complications among patients having plastic surgery. METHODS OVID MEDLINE and PubMed were searched for all studies evaluating the predictive accuracy of the NSQIP SRC in plastic surgery, including oncologic reconstruction, ventral hernia repair, and body contouring. Only studies directly comparing SCR predicted to observed complication rates were included. The primary measure of SRC prediction accuracy, area under the curve (AUC), was assessed for each complication via DerSimonian and Laird random-effects analytic model. The I2 statistic, indicating heterogeneity, was judged low (I2 < 50%) or borderline/unacceptably high (I2 > 50%). All analyses were conducted in StataSE 16.1 (StataCorp LP, College Station, Tex). RESULTS Ten of the 296 studies screened met criteria for inclusion (2416 patients). Studies were classified as follows: (head and neck: n = 5, breast: n = 1, extremity: n = 1), open ventral hernia repair (n = 2), and panniculectomy (n = 1). Predictive accuracy was poor for medical and surgical complications (medical: pulmonary AUC = 0.67 [0.48-0.87], cardiac AUC = 0.66 [0.20-0.99], venous thromboembolism AUC = 0.55 [0.47-0.63]), (surgical: surgical site infection AUC = 0.55 [0.46-0.63], reoperation AUC = 0.54 [0.49-0.58], serious complication AUC = 0.58 [0.43-0.73], and any complication AUC = 0.60 [0.57-0.64]). Although mortality was accurately predicted in 2 studies (AUC = 0.87 [0.54-0.99]), heterogeneity was high with I2 = 68%. Otherwise, heterogeneity was minimal (I2 = 0%) or acceptably low (I2 < 50%) for all other outcomes. CONCLUSIONS The NSQIP Universal SRC, aimed at offering individualized quantifiable risk estimates for surgical complications, consistently demonstrated poor risk discrimination in this plastic surgery-focused meta-analysis. The limitations of the SRC are perhaps most pronounced where complex, multidisciplinary reconstructions are needed. Future efforts should identify targets for improving SRC reliability to better counsel patients in the perioperative setting and guide appropriate healthcare resource allocation.
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Affiliation(s)
- Marten N Basta
- From the Plastic Surgery Department, Brown University, Providence, RI
| | - Vinay Rao
- From the Plastic Surgery Department, Brown University, Providence, RI
| | - Marcelo Paiva
- From the Plastic Surgery Department, Brown University, Providence, RI
| | - Paul Y Liu
- From the Plastic Surgery Department, Brown University, Providence, RI
| | - Albert S Woo
- From the Plastic Surgery Department, Brown University, Providence, RI
| | - John P Fischer
- Plastic Surgery Division, University of Pennsylvania, Philadelphia, PA
| | - Karl H Breuing
- From the Plastic Surgery Department, Brown University, Providence, RI
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Yung AE, Wong G, Pillinger N, Wykes J, Haddad R, McInnes S, Palme CE, Hubert Low TH, Clark JR, Sanders R, Ch'ng S. Validation of a risk prediction calculator in Australian patients undergoing head and neck microsurgery reconstruction. J Plast Reconstr Aesthet Surg 2022; 75:3323-3329. [PMID: 35768291 DOI: 10.1016/j.bjps.2022.04.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 04/16/2022] [Accepted: 04/26/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND The American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) surgical risk calculator (SRC) is an open access calculator predicting patients' risk of postoperative complications. This study aims to assess the validity of the SRC in patients undergoing microsurgical free flap reconstruction at an Australian tertiary referral centre. METHODS This is a retrospective cohort study of 200 consecutive patients treated up to November 2020. SRC-predicted rates of postoperative complications and hospital length of stay (LOS) were compared to those observed for the ablative and reconstructive components of the procedure. The performance of the SRC was assessed using Brier scores, area under the receiver operating characteristic (ROC) curve (AUC), and the Hosmer-Lemeshow test. RESULTS For both ablative and reconstructive components, the SRC discriminates well for pneumonia and urinary tract infection, and it is calibrated well for readmission and sepsis, but it does not discriminate and calibrate well for any single outcome. SRC-predicted hospital LOS and actual LOS did not correlate well for the reconstructive component, but they correlated strongly for the ablative component. CONCLUSIONS The SRC is a poor predictor of postoperative complication rates and hospital LOS in patients undergoing head and neck microsurgical reconstruction.
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Affiliation(s)
- Amanda E Yung
- The University of Sydney Sydney Medical School, Sydney, Australia; The Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health Distrinct, Sydney, Australia
| | - Gerald Wong
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, Australia
| | - Neil Pillinger
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, Australia
| | - James Wykes
- Department of Head and Neck Surgery, Chris O'Brien Lifehouse Cancer Centre, Sydney, Australia
| | - Roger Haddad
- Department of Plastics and Reconstructive Surgery, Royal Prince Alfred Hospital, Sydney, Australia
| | - Stephanie McInnes
- Department of Anaesthetics, Chris O'Brien Lifehouse Cancer Centre, Sydney, Australia
| | - Carsten E Palme
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Department of Head and Neck Surgery, Chris O'Brien Lifehouse Cancer Centre, Sydney, Australia
| | - Tsu-Hui Hubert Low
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Department of Head and Neck Surgery, Chris O'Brien Lifehouse Cancer Centre, Sydney, Australia
| | - Jonathan R Clark
- The Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health Distrinct, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Department of Head and Neck Surgery, Chris O'Brien Lifehouse Cancer Centre, Sydney, Australia
| | - Robert Sanders
- The Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health Distrinct, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney, Australia
| | - Sydney Ch'ng
- The Royal Prince Alfred Institute of Academic Surgery, Sydney Local Health Distrinct, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Department of Plastics and Reconstructive Surgery, Royal Prince Alfred Hospital, Sydney, Australia; Melanoma Institute of Australia, Sydney, Australia.
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Christou CD, Naar L, Kongkaewpaisan N, Tsolakidis A, Smyrnis P, Tooulias A, Tsoulfas G, Papadopoulos VN, Velmahos GC, Kaafarani HMA. Validation of the Emergency Surgery Score (ESS) in a Greek patient population: a prospective bi-institutional cohort study. Eur J Trauma Emerg Surg 2021; 48:1197-1204. [PMID: 34296323 PMCID: PMC8297717 DOI: 10.1007/s00068-021-01734-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 06/19/2021] [Indexed: 02/05/2023]
Abstract
Purpose The Emergency Surgery Score (ESS) is a reliable point-based score that predicts mortality and morbidity in emergency surgery patients. However, it has been validated only in the U.S. patients. We aimed to prospectively validate ESS in a Greek patient population. Methods All patients who underwent an emergent laparotomy were prospectively included over a 15-month period. A systematic chart review was performed to collect relevant preoperative, intraoperative, and postoperative variables based on which the ESS was calculated for each patient. The relationship between ESS and 30-day mortality, morbidity (i.e., the occurrence of at least one complication), and the need for intensive care unit (ICU) admission was evaluated and compared between the Greek and U.S. patients using the c-statistics methodology. The study was registered on "Research Registry" with the unique identifying number 5901. Results A total of 214 patients (102 Greek) were included. The mean age was 64 years, 44% were female, and the median ESS was 7. The most common indication for surgery was hollow viscus perforation (25%). The ESS reliably and incrementally predicted mortality (c-statistics = 0.79 [95% CI 0.67–0.90] and 0.83 [95% CI 0.74–0.92]), morbidity (c-statistics = 0.83 [95% CI 0.76–0.91] and 0.79 [95% CI 0.69–0.88]), and ICU admission (c-statistics = 0.88 [95% CI 0.81–0.96] and 0.84 [95% CI 0.77–0.91]) in both Greek and U.S. patients. Conclusion The correlation between the ESS and the surgical outcomes was statistically significant in both Greek and U.S. patients undergoing emergency laparotomy. ESS could prove globally useful for preoperative patient counseling and quality-of-care benchmarking.
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Affiliation(s)
- Chrysanthos Dimitris Christou
- First General Surgery Department, School of Medicine, Faculty of Medical Sciences, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Leon Naar
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Napaporn Kongkaewpaisan
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Alexandros Tsolakidis
- First General Surgery Department, School of Medicine, Faculty of Medical Sciences, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis Smyrnis
- First General Surgery Department, School of Medicine, Faculty of Medical Sciences, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Andreas Tooulias
- First General Surgery Department, School of Medicine, Faculty of Medical Sciences, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Tsoulfas
- First General Surgery Department, School of Medicine, Faculty of Medical Sciences, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasileios Nikolaos Papadopoulos
- First General Surgery Department, School of Medicine, Faculty of Medical Sciences, Papageorgiou General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Constantinos Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA
| | - Haytham Mohamed Ali Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Harvard Medical School, Massachusetts General Hospital, 165 Cambridge Street, Suite 810, Boston, MA, 02114, USA.
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Mantelakis A, Assael Y, Sorooshian P, Khajuria A. Machine Learning Demonstrates High Accuracy for Disease Diagnosis and Prognosis in Plastic Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3638. [PMID: 34235035 PMCID: PMC8225366 DOI: 10.1097/gox.0000000000003638] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 04/14/2021] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Machine learning (ML) is a set of models and methods that can detect patterns in vast amounts of data and use this information to perform various kinds of decision-making under uncertain conditions. This review explores the current role of this technology in plastic surgery by outlining the applications in clinical practice, diagnostic and prognostic accuracies, and proposed future direction for clinical applications and research. METHODS EMBASE, MEDLINE, CENTRAL and ClinicalTrials.gov were searched from 1990 to 2020. Any clinical studies (including case reports) which present the diagnostic and prognostic accuracies of machine learning models in the clinical setting of plastic surgery were included. Data collected were clinical indication, model utilised, reported accuracies, and comparison with clinical evaluation. RESULTS The database identified 1181 articles, of which 51 articles were included in this review. The clinical utility of these algorithms was to assist clinicians in diagnosis prediction (n=22), outcome prediction (n=21) and pre-operative planning (n=8). The mean accuracy is 88.80%, 86.11% and 80.28% respectively. The most commonly used models were neural networks (n=31), support vector machines (n=13), decision trees/random forests (n=10) and logistic regression (n=9). CONCLUSIONS ML has demonstrated high accuracies in diagnosis and prognostication of burn patients, congenital or acquired facial deformities, and in cosmetic surgery. There are no studies comparing ML to clinician's performance. Future research can be enhanced using larger datasets or utilising data augmentation, employing novel deep learning models, and applying these to other subspecialties of plastic surgery.
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Affiliation(s)
| | | | | | - Ankur Khajuria
- Kellogg College, University of Oxford
- Department of Surgery and Cancer, Imperial College London, UK
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9
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Naar L, El Hechi M, Kokoroskos N, Parks J, Fawley J, Mendoza AE, Saillant N, Velmahos GC, Kaafarani HMA. Can the Emergency Surgery Score (ESS) predict outcomes in emergency general surgery patients with missing data elements? A nationwide analysis. Am J Surg 2020; 220:1613-1622. [PMID: 32102760 DOI: 10.1016/j.amjsurg.2020.02.034] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/09/2020] [Accepted: 02/17/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Emergency Surgery Score (ESS) is an accurate mortality risk calculator for emergency general surgery (EGS). We sought to assess whether ESS can accurately predict 30-day morbidity, mortality, and requirement for postoperative Intensive Care Unit (ICU) care in patients with missing data variables. METHODS All EGS patients with one or more missing ESS variables in the 2007-2015 ACS-NSQIP database were included. ESS was calculated assuming that a missing variable is normal (i.e. no additional ESS points). The correlation between ESS and morbidity, mortality, and postoperative ICU level of care was assessed using the c-statistics methodology. RESULTS Out of a total of 4,456,809 patients, 359,849 were EGS, and of those 256,278 (71.2%) patients had at least one ESS variable missing. ESS correlated extremely well with mortality (c-statistic = 0.94) and postoperative requirement of ICU care (c-statistic = 0.91) and well with morbidity (c-statistic = 0.77). CONCLUSION ESS performs well in predicting outcomes in EGS patients even when one or more data elements are missing and remains a useful bedside tool for counseling EGS patients and for benchmarking the quality of EGS care.
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Affiliation(s)
- Leon Naar
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Majed El Hechi
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Nikolaos Kokoroskos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Parks
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Jason Fawley
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Noelle Saillant
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery & Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
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Goshtasbi K, Birkenbeuel JL, Abouzari M, Lehrich BM, Yasaka TM, Abiri A, Muhonen EG, Hsu FPK, Kuan EC. Short-Term Morbidity and Predictors of Adverse Events Following Esthesioneuroblastoma Surgery. Am J Rhinol Allergy 2020; 35:500-506. [PMID: 33121257 DOI: 10.1177/1945892420970468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The short-term adverse events and predictors of morbidity in surgical resection of esthesioneuroblastoma (ENB) are largely unknown, and investigating these variables can help direct planning for at-risk patients. METHODS The 2005-2017 National Surgical Quality Improvement Program database was queried to identify patients with a diagnosis of ENB undergoing skull base surgery for tumor resection. Information regarding demographics, patient morbidity score, pre-operative and intra-operative data, and post-operative outcomes were extracted. Cox proportional hazard analysis was utilized to assess complication and readmission/reoperation rates. RESULTS A total of 95 patients undergoing skull base surgery for resection of ENB were included. Mean age, BMI, operation time, and post-operative length of stay (LOS) of the cohort were 53.6 ± 16.2 years, 29.1 ± 6.5, 392.0 ± 204.6 minutes, and 5.8 ± 4.6 days, respectively. In total, 31 patients (32.6%) experienced at least one 30-day adverse event, which included blood transfusion intra-operatively or within 72 hours from the operation (22.1%), readmission (10.7%), intubation >48 hours (7.4%), reintubation (4.2%), organ or space infection (4.2%), reoperation (4.0%), superficial or deep surgical site infection (2.1%), sepsis (2.1%), pulmonary embolism (1.1%), and myocardial infarction (1.1%). Patients who experienced at least one adverse event had significantly higher operation time (486.8 ± 230.4 vs. 347.5 ± 176.2 minutes, p = 0.002), LOS (9.2 ± 5.6 days vs. 4.2 ± 3.0, p < 0.001), and lower hematocrit (37.3 ± 5.9 vs. 41.2 ± 3.8, p < 0.001) and albumin levels (3.8 ± 0.6 vs. 4.2 ± 0.3, p = 0.009). Patients with a higher American Society of Anesthesiologists (ASA) score (HR = 2.39; p = 0.047) or longer operation time (HR = 1.004; p = 0.001) had a significantly higher risk for experiencing adverse events. Obesity was not associated with different intra- or post-operative outcomes, but older patients had shorter operations (p = 0.002) and LOS (p = 0.0014). CONCLUSION Longer operation time and lower pre-operative hematocrit and albumin levels may all increase complication rates in ENB resection. Patients with high ASA score or more advanced age may have different short-term outcomes.
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Affiliation(s)
- Khodayar Goshtasbi
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
| | - Jack L Birkenbeuel
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
| | - Mehdi Abouzari
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
| | - Brandon M Lehrich
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
| | - Tyler M Yasaka
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
| | - Arash Abiri
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
| | - Ethan G Muhonen
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
| | - Frank P K Hsu
- Department of Neurological Surgery, University of California, Irvine, California
| | - Edward C Kuan
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, California
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