The association of body mass index with same-day hospital admission, postoperative complications, and 30-day readmission following day-case eligible joint arthroscopy: A national registry analysis

The Impact of Preoperative Risk Factors on Delayed Discharge in Day Surgery: A Meta-Analysis

OBJECTIVE

This study aims to evaluate and identify the main preoperative risk factors affecting the timely discharge of day surgery patients, offering evidence to enhance preoperative assessments and minimize delayed discharge.

BACKGROUND

With the widespread adoption of day surgery in global healthcare systems, ensuring timely discharge of patients post-surgery has become a critical challenge. Numerous studies have explored various preoperative risk factors influencing delayed discharge. This meta-analysis integrates existing evidence to clarify the primary preoperative risk factors.

METHODS

A systematic search was conducted across the PubMed, CINAHL, Scopus, Web of Science, Embase, Cochrane Library, and CNKI databases, including all clinical studies on preoperative risk factors for day surgery published until 15 October 2024. A systematic review and random effects model were employed to aggregate data and estimate the main preoperative risk factors for day surgery.

RESULTS

A total of nine studies involving 41,458 patients were included. The analysis revealed statistically significant differences in the following preoperative risk factors: age (MD = 1.33, 95% CI: 0.73-1.93, p < 0.0001), body mass index (BMI) (MD = 0.69, 95% CI: 0.18-1.20, p = 0.008), the presence of chronic comorbidities (OR = 3.62, 95% CI: 2.93-4.46, p < 0.00001), the type of anesthesia (OR = 15.89, 95% CI: 7.07-35.69, p < 0.00001), a history of cardiac disease (OR = 2.46, 95% CI: 1.71-3.53, p < 0.00001), gender (OR = 3.18, 95% CI: 2.03-4.99, p < 0.00001), the expected duration of surgery (MD = 0.18, 95% CI: 0.15-0.20, p < 0.00001), complex procedures (OR = 1.78, 95% CI: 1.47-2.16, p < 0.00001), a lack of social family support (OR = 2.42, 95% CI: 1.60-3.67, p < 0.0001), and inadequate preoperative assessment (OR = 3.64, 95% CI: 2.06-6.41, p < 0.00001). There were no statistically significant differences between the delayed discharge group and the non-delayed discharge group in terms of the American Society of Anesthesiologists (ASA) classification (p = 1.00) and preoperative anxiety (p = 0.08).

CONCLUSION

This study identifies the primary preoperative risk factors for delayed discharge in day surgery, including age, high BMI, the presence of chronic comorbidities, the type of anesthesia, a history of cardiac disease, gender, the duration of surgery, the complexity of the procedure, a lack of social family support, and inadequate preoperative assessment. These findings provide a reference for preoperative assessment, highlighting the need for clinical attention to these high-risk groups during preoperative screening and management to reduce the likelihood of delayed discharge and enhance surgical safety and success rates.

Association between obesity and risk of delayed discharge and unplanned readmission for day surgery: A systematic review and meta-analysis

AIMS

This work aims to investigate the association between obesity and risk of delayed discharge and unplanned readmission in day surgery patients.

BACKGROUND

Day surgeries are well received and developing rapidly. Associations between obesity and delayed discharge and unplanned readmission, which are clinically relevant outcomes in day surgeries, are complex.

DESIGN

A systematic review and meta-analysis was conducted.

DATA SOURCES

The PubMed, Web of Science, EMBASE, Cochrane Library, CNKI, VIP, and Wan Fang databases were comprehensively searched from inception until January 2021.

REVIEW METHODS

Two independent reviewers assessed the studies and extracted data. Pooled estimates were obtained using a random-effects model.

RESULTS

Eleven articles published between 2007 and 2020 were finally included. Obesity appeared not to increase the risk of delayed discharge. However, morbid obesity seemed to be associated with a higher risk of delayed discharge. The meta-analysis revealed no relationship between higher body mass index (BMI) and unplanned readmission for day surgery patients.

CONCLUSIONS

Obesity appeared not to increase the risk of delayed discharge except in patients with morbid obesity. Additionally, a higher BMI was not associated with increased risk of unplanned readmission after day surgery. Future studies are required to address this issue further in different types of surgery and areas.

Childhood obesity trends: Association with same-day hospital admission in a National Outpatient Surgical Population

BACKGROUND

Although the prevalence of obesity in the general population and its perioperative implications among children undergoing inpatient surgeries are well known, little is known about obesity prevalence among children scheduled for ambulatory surgery.

AIMS

Here, we report the trends of obesity and severe obesity among children who underwent ambulatory surgery across multiple centers in the United States and explore the association of obesity status with admission following elective ambulatory surgery.

MATERIALS AND METHODS

Using data from the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (2012-2019), we selected children 2-18 years old who underwent outpatient surgical procedures under general anesthesia and had documented height, weight, and body mass index (BMI) data. We estimated the prevalence of overweight, obesity (class 1), and severe obesity (class 2 and class 3) patients and explored their association with same-day hospital admission, defined as hospital length of stay ≥1 day.

RESULTS

Data from 152 918 children (mean age: 9.7 ± 4.7 years) were analyzed. Of these, 16.4% (n = 25 007) were overweight, 13.8% (n = 21 085) were class 1 obese, 5.2% (n = 7879) were class 2 obese, and 3.0% (n = 4623) were class 3 obese. From 2012 to 2019, class 2 or 3 obesity prevalence increased by 26.7% and 32.5%, respectively. Overweight and obese children had relatively higher odds of same-day hospital admission compared to healthy weight children (overweight odds ratio [95% confidence interval]: 1.05 [1.02, 1.08]; class 1 obesity: 1.04 [1.00, 1.07]; class 2 obesity: 1.09 [1.02, 1.16]; class 3 obesity: 1.20 [1.11, 1.30]).

DISCUSION AND CONCLUSION

The burden of obesity continues to increase in children scheduled for ambulatory surgery. Children with class 2 and class 3 obesity have higher rates of same-day hospital admission following elective ambulatory surgery compared to healthy weight children, a factor that should be considered in scheduling these patients.

Increased Readmission Rates but No Difference in Complication Rates in Patients Undergoing Inpatient Versus Outpatient Hip Arthroscopy: A Large Matched-Cohort Insurance Database Analysis

Purpose

Methods

Results

Conclusions

Level of Evidence

Does anterior cruciate ligament reconstruction increase venous thromboembolism risk compared with knee meniscectomy under arthroscopy?

Background

This study compared the incidence of postoperative venous thromboembolism (VTE) between meniscectomy and anterior cruciate ligament reconstruction (ACLR) under arthroscopy and assessed whether ACLR increases the VTE risk compared with meniscectomy.

Methods

A retrospective study of prospectively collected clinical data, including data on 436 patients ranging in age from 18 to 60 years who underwent ACLR or meniscectomy surgery, was performed between October 2018 and October 2019 in our hospital. All patients underwent routine VTE screening by venous ultrasonography in postoperative week 2 and then clinical follow-up at 4 and 6 weeks post-surgery. The incidence of VTE was calculated, and clinical factors such as age, sex, body mass index (BMI), smoking, concomitant procedure, Caprini score, and duration of tourniquet use were evaluated in relation to the risk factors for VTE.

Results

A total of 320 patients who underwent arthroscopic ACLR or meniscectomy were available for analysis. Of these patients, 130 (40.6%) underwent ACLR, and 190 (59.4%) underwent meniscectomy. No cases of pulmonary embolism (PE) or femoral deep vein thrombosis (DVT) were reported in either group. Fourteen patients (10.8%) developed VTE in the ACLR group compared with 10 (5.3%) in the meniscectomy group, with no significant difference (p = 0.066). Among these patients, 4 (3.1%) patients in the ACL reconstruction group and 2 (1.1%) patients in the meniscectomy group had DVT confirmed by Doppler ultrasound (p > 0.05). ACLR, age, and BMI (OR = 3.129; 1.061; 1.435) tended to increase the risk of VTE, but the results were not statistically significant (p = 0.056, 0.059, 0.054).

Conclusions

The incidence of VTE after ACLR and meniscectomy within 6 weeks post-surgery was 10.8 and 5.3%, respectively. ACLR, age, and BMI had a tendency to increase the risk of VTE.

First fully endoscopic metabolic procedure with NOTES gastrojejunostomy, controlled bypass length and duodenal exclusion: a 9-month porcine study

We conducted a pilot study of a potential endoscopic alternative to bariatric surgery. We developed a Natural Orifice Transluminal Endoscopic Surgery (NOTES) gastric bypass with controlled bypass limb length using four new devices including a dedicated lumen-apposing metal stent (GJ-LAMS) and pyloric duodenal exclusion device (DED). We evaluated procedural technical success, weight change from baseline, and adverse events in growing Landrace/Large-White pigs through 38 weeks after GJ-LAMS placement. Six pigs (age 2.5 months, mean baseline weight 26.1 ± 2.7 kg) had initial GJ-LAMS placement with controlled bypass limb length, followed by DED placement at 2 weeks. Technical success was 100%. GJ-LAMS migrated in 3 of 6, and DED migrated in 3 of 5 surviving pigs after mucosal abrasion. One pig died by Day 94. At 38 weeks, necropsy showed 100–240 cm limb length except for one at 760 cm. Weight gain was significantly lower in the pigs that underwent endoscopic bypass procedures compared to expected weight for age. This first survival study of a fully endoscopic controlled bypass length gastrojejunostomy with duodenal exclusion in a growing porcine model showed high technical success but significant adverse events. Future studies will include procedural and device optimizations and comparison to a control group.

Patient Selection for Adult Ambulatory Surgery: A Narrative Review

With migration of medically complex patients undergoing more extensive surgical procedures to the ambulatory setting, selecting the appropriate patient is vital. Patient selection can impact patient safety, efficiency, and reportable outcomes at ambulatory surgery centers (ASCs). Identifying suitability for ambulatory surgery is a dynamic process that depends on a complex interplay between the surgical procedure, patient characteristics, and the expected anesthetic technique (eg, sedation/analgesia, local/regional anesthesia, or general anesthesia). In addition, the type of ambulatory setting (ie, short-stay facilities, hospital-based ambulatory center, freestanding ambulatory center, and office-based surgery) and social factors, such as availability of a responsible individual to take care of the patient at home, can also influence patient selection. The purpose of this review is to present current best evidence that would provide guidance to the ambulatory anesthesiologist in making an informed decision regarding patient selection for surgical procedures in freestanding ambulatory facilities.

Early Postoperative Outcomes of Super Morbid Obese Compared to Morbid Obese Patients After Ambulatory Surgery Under General Anesthesia: A Propensity-Matched Analysis of a National Database

BACKGROUND

Patients with body mass index (BMI) ≥50 kg/m2, defined as super morbid obesity, represent the fastest growing segment of patients with obesity in the United States. It is currently unknown if super morbid obese patients are at greater odds than morbid obese patients for poor outcomes after outpatient surgery. The main objective of the current investigation is to assess if super morbid obese patients are at increased odds for postoperative complications after outpatient surgery when compared to morbid obese patients.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2017 to 2018 was queried to extract and compare patients who underwent outpatient surgery and were defined as either morbidly obese (BMI >40 and <50 kg/m2) or super morbidly obese (BMI ≥50 kg/m2). The primary outcome was the occurrence of medical adverse events within 72 hours of discharge. In addition, we also examine death and readmissions as secondary outcomes. A propensity-matched analysis was used to evaluate the association of BMI ≥50 kg/m2 versus BMI between 40 and 50 kg/m2 and the outcomes.

RESULTS

A total of 661,729 outpatient surgeries were included in the 2017-2018 NSQIP database. Of those, 7160 with a BMI ≥50 kg/m2 were successfully matched to 7160 with a BMI <50 and ≥40 kg/m2. After matching, 17 of 7160 (0.24%) super morbid obese patients had 3-day medical complications compared to 15 of 7160 (0.21%) morbid obese patients (odds ratio [OR; 95% confidence interval {CI}] = 1.13 [0.57-2.27], P = .72). The rate of 3-day surgical complications in super morbid obese patients was also not different from morbid obese patients. Thirty-five of 7160 (0.48%) super morbid obese patients were readmitted within 3 days, compared to 33 of 7160 (0.46%) morbid obese patients (OR [95% CI] = 1.06 [0.66-1.71], P = .80). When evaluated in a multivariable analysis as a continuous variable (1 unit increase in BMI) in all patients, BMI ≥40 kg/m2 was not significantly associated with overall medical complications (OR [95% CI] = 1.00 [0.98-1.04], P = .87), overall surgical complication (OR [95% CI] = 1.02 [0.98-1.06], P = .23), or readmissions (OR [95% CI] = 0.99 [0.97-1.02], P = .8).

CONCLUSIONS

Super morbid obesity is not associated with higher rates of early postoperative complications when compared to morbid obese patients. Specifically, early pulmonary complications were very low after outpatient surgery. Super morbid obese patients should not be excluded from outpatient procedures based on a BMI cutoff alone.

Should there be a body mass index eligibility cutoff for elective airway cases in an ambulatory surgery center? A retrospective analysis of adult patients undergoing outpatient tonsillectomy

STUDY OBJECTIVE

It is unclear what the body mass index (BMI) should be when performing surgery involving the airway at an outpatient surgery facility. The objective of this study was to evaluate the association of Class 3 obesity versus a composite cohort of Class 1 and 2 obesity with same-day hospital admission following outpatient tonsillectomy in adults.

DESIGN

Retrospective cohort study.

SETTING

Multi-institutional.

PATIENTS

Patients undergoing outpatient tonsillectomy.

INTERVENTION

None.

MEASUREMENTS

We used the National Surgical Quality Improvement Program (NSQIP) to analyze association of BMI to same-day admission and 30-day readmission following outpatient tonsillectomy from 2017 to 2019. We looked at six BMI cohorts: 1) ≥30 and < 40 kg/m² (reference cohort), 2) ≥20 and < 30 kg/m², 3) <20 kg/m², 4) ≥40 and < 50 kg/m², 5) ≥50 and < 60 kg/m², and 6) ≥60 kg/m². We used multivariable Poisson regression with robust standard errors and controlled for various confounders to calculate risk ratios (RR) and 99% confidence intervals (CI).

MAIN RESULTS

There were 12,287 patients included in the final analysis, at which 697 (5.7%) and 283 (2.3%) had a same-day admission or 30-day readmission, respectively. On Poisson regression with robust standard errors, the relative risks for BMI ≥40 kg/m² and < 50 kg/m², ≥50 kg/m² and < 60 kg/m², and ≥ 60 kg/m² (BMI ≥30 kg/m² and < 40 kg/m² was the reference group) were 1.31 (99% CI 1.03-1.65, p = 0.03), 1.99 (99% CI 1.43-2.78, p = 0.002), and 1.80 (99% CI 1.00-3.25, p = 0.07), respectively. Furthermore, Class 3 obesity was not associated with 30-day readmission.

CONCLUSION

These results contribute data that may help practices - especially freestanding ambulatory surgery centers - decide appropriate BMI cutoffs for surgery involving the airway. Whether this is considered clinically significant enough to rule out eligibility will differ from practice-to-practice and will depend on surgical volume, resources available and financial interests.

Risk factors for hospital admission in patients undergoing outpatient anterior cruciate ligament reconstruction: A national database study

INTRODUCTION

Anterior Cruciate Ligament Reconstructions (ACLR) are routinely performed in an outpatient setting with low 90-day readmission rates (2.3%); however, admissions rates in the immediate perioperative period have been previously reported as high as 13.1%. Despite the surprisingly high number of patients requiring immediate perioperative admission, there has been a lack of recent literature specifically examining the associated risk factors for admission.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, a query for patients who underwent ACLR from 2011 through 2018 was performed using Current Procedural Terminology codes. The following concomitant procedures were included: meniscectomy, meniscal repair, diagnostic arthroscopy, loose body removal, synovectomy, chondroplasty, abrasion chondroplasty, drilling for osteochondritis dissecans. Demographics including age, sex, race, body mass index (BMI) and comorbidities were collected. Perioperative factors collected were anesthesia type and operative times. Patient demographic and perioperative data were compared using Fisher's exact test and Pearson's chi-square test. Multivariate logistic regressions were used to calculate odds ratios (OR) and 95% confidence intervals (CI) of independent risk factors for postoperative admission. Holm-Bonferroni method yielded adjusted p-value thresholds for significance.

RESULTS

Of the 20,819 patients undergoing ACLR with and without concomitant procedures, 3.8% of patients were admitted to the hospital in the immediate postoperative period. Following multivariate regression analysis, increased odds of admission were demonstrated with the use of regional anesthesia alone (OR = 2.77, 95%CI: 2.22-3.44; p < 0.001), increasing concurrent procedures (Table 1), and obesity classes II (OR = 1.62, 95%CI: 1.26-2.10; p < 0.001) and III (OR = 1.81, 95%CI: 1.33-2.47; p < 0.001). Subsequent subgroup analysis of the isolated ACLR procedures (N = 9,423) demonstrated a 3.3% postoperative admission rate. Multivariate regressions demonstrated increased odds of admission with regional anesthesia use only (OR = 2.62, 95%CI: 1.90-3.60; p < 0.001), obesity class II (OR = 2.22, 95%CI: 1.51-3.26; p < 0.001), and increasing minutes of operative time (OR = 1.01, 95%CI: 1.01-1.01; p < 0.001). Table 2 demonstrates increasing rates and odds of admission with increasing operative time in hours.

CONCLUSION

Anterior Cruciate Ligament Reconstructions are routinely performed in an outpatient setting; nevertheless, a subset of ACLR patients is admitted postoperatively. We found an increased risk of admission with the use of regional anesthesia alone, increasing concurrent procedures and obesity classes II and III. A further understanding of patient risk factors for those undergoing ACLR allows orthopedic surgeons to better develop a preoperative plan and discuss patient expectations, which will lead to more efficient resource allocation and improved patient satisfaction.

Patient health status and case complexity of outpatient surgeries at various facility types in the United States: An analysis using the National Anesthesia Clinical Outcomes Registry

STUDY OBJECTIVE

Among the various types of outpatient surgery centers, there are differences in higher American Society of Anesthesiologists Physical Status (ASA PS) scores and surgical complexity among patients who are undergoing surgery. The primary objective of this study was to describe the differences performed at various types of outpatient surgery facilities.

DESIGN

We performed a retrospective analysis of the National Anesthesia Clinical Outcomes Registry (NACOR) data.

SETTING

NACOR from 2012 to 2017.

PATIENTS

From 2012 to 2017, there were a total of 13,053,115 outpatient surgeries in the database. After removing cases with unknown facility type, the final study sample was 9,217,336.

INTERVENTIONS

None.

MEASUREMENTS

To calculate the probability of either American Society of Anesthesiologists Physical Status (ASA PS) score ≥ 3 or physiologically complex cases (defined as Common Procedural Terminology start-up units ≥8), we performed mixed effects logistic regression for each institution per facility type, controlling for year and using facility identification as the random effect. We present the mean rate of these two classifications as case per 10,000 cases and report the 99.9% confidence interval (CI), to control for multiple comparisons.

MAIN RESULTS

Among all cases, 5,919,844 (64.2%) were classified as ASA PS 1 or 2 and 254,110 (2.8%) of surgical procedures were considered physiologically complex. The mean rate of cases with ASA PS ≥ 3in the university setting was 2982 per 10,000 cases [99.9% CI 2701-3278 per 10,000 cases]. Large community hospitals had a higher proportion of ASA PS ≥3 patients, medium-sized hospitals had no difference, and all other facility types had a decreased proportion. The mean rate of cases that were physiologically complex in the university setting was 133 per 10,000 cases [99.9% CI 117-151 per 10,000 cases]. Large community hospitals had a higher proportion of physiologically complex cases, medium-sized and small-sized hospitals had no difference, and all other facility types had a decreased proportion.

CONCLUSIONS

Freestanding and attached surgery centers exhibited smaller rates of patients that were ASA PS ≥ 3, as well as a decrease in surgically complex cases, when compared to university settings. This suggests that the level of conservativeness for patient and surgery appropriateness for outpatient surgery differs across various facility types.

Finding the body mass index cutoff for hospital readmission after ambulatory hernia surgery

BACKGROUND

The suitability of ambulatory surgery in obese patients remains controversial. This study aimed to investigate the "cutoff" value of body mass index (BMI) associated with increased likelihood of hospital readmissions within the first 24 hours of surgery in patients undergoing ambulatory hernia repair.

MATERIALS AND METHODS

The study used data from the 2012-2016 American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP). Cochran Armitage trend tests were conducted to assess progression in rates hospital readmissions across categories of patient BMI. The minimum p-value method, Kolmogorov-Smirnov goodness of fit tests, logistic regression, and receiver-operating characteristic (ROC) curve analyses were used to investigate the cutoff of patient BMI indicative of increased likelihood of readmissions.

RESULTS

A total of 214,125 ambulatory hernia repair cases were identified. Of those, 908 patients (0.42%) had an unexpected hospital admission within the first 24 hours after surgery. The readmission rates did not significantly increase across the categories of BMI. However, some of the reasons for readmission significantly differed by BMI category. Logistic regression analysis revealed no statistically significant association between BMI and hospital readmissions (odds ratio [95% Cl], 0.96 [0.91-1.02] P = .179). An optimal BMI threshold predictive of an increased likelihood of hospital readmissions was not identifiable by any of the statistical methods used.

CONCLUSIONS

Although reasons for readmission differed by BMI category, there is no clear cutoff value of BMI associated with increased hospital readmission within the first 24 hours after surgery.

Editorial Commentary: Readmission Rate After Hip Arthroscopy: Is There a Cause for Concern?

Readmission after hip arthroscopic surgery is an undesired and unusual event. The causes may range from wound-related issues, deep infection, increasing pain, complications of surgery, to medical events. It adds to the economic burden of the procedure and causes unnecessary anguish to the patients and indeed clinicians. It is also one of the less-studied areas of hip arthroscopic surgery because of its rarity. There would be benefit in being able to identify the risk factors of readmission such that pre-emptive measures can be put in place to prevent or indeed counsel the patients before the surgery. In certain cases, readmission may remain an unpreventable event. In our experience, the readmission rate after hip arthroscopy is 0.5%, whereas patients with elevated body mass index are at greater risk.