Unplanned reoperations: is emergency surgery a risk factor? A cohort study

Risk Factors for Unplanned Returns to the Operating Room in Pediatric Trauma Patients

BACKGROUND

Unplanned returns to the operating room (uROR) are associated with worse outcomes including increased complications and length of stay (LOS) in adults. However, the incidence and predictors of uROR for pediatric trauma patients (PTPs) are unknown. This study aimed to identify predictors of uROR for PTPs.

METHODS

The 2017-2019 Trauma Quality Improvement Program database was queried for PTPs 1-16 years-old to compare patients with uROR to those without uROR. Multivariable logistic regression analysis was performed.

RESULTS

From 44 711 PTPs identified, 299 (.7%) underwent uROR. Pediatric trauma patients requiring uROR were older (14 vs 8 years old, P < .001), had a higher rate and associated risk of mortality (8.7% vs 1.4%, P < .001) (OR 6.67, CI 4.43-10.05, P < .001) as well as increased complications including surgical infection (16.4% vs .2%, P < .001) and compartment syndrome (4.7% vs .1%, P < .001). Patients undergoing uROR had increased LOS (18 vs 2 days, P < .001) and intensive care unit LOS (9 vs 3 days, P < .001). Independent associated risk factors for uROR included rectal injury (OR 4.54, CI 2.28-9.04, P < .001), brain injury (OR 3.68, CI 2.71-5.00, P < .001), and gunshot wounds (OR 2.55, CI 1.83-3.56, P < .001).

DISCUSSION

The incidence of uROR was <1% for PTPs. However, patients requiring uROR had increased LOS and associated risk of death compared to those without uROR. Predictors of uROR included gunshot wounds and injuries to the rectum and brain. Patients with these risk factors should be counseled with efforts made to improve care for these high-risk populations.

Understanding unplanned return to theatre in rural South Australia general surgery: review of four major hospitals over a six-year period

BACKGROUND

Unplanned return to theatre (URTT) is associated with longer hospital stay and higher mortality rates, placing extra burden on hospital resources. There is a lack of literature analysing causes of URTT in a rural general surgery department. This knowledge may be important to help identify patients at risk of URTT. This study aims to identify causes of URTT in rural general surgical patients.

METHODS

This is a retrospective multicenter cohort involving four rural South Australian (SA) hospitals: Mount Gambier (MGH), Whyalla (WH), Port Augusta (PAH), and Port Lincoln (PLH). All general surgical inpatients admitted from February 2014 to March 2020 were analysed to identify all-cause of URTT.

RESULTS

Of the 44 191 surgical procedures performed, there were 67 (0.15%) URTT. The most common surgical subspecialty cases that resulted in URTT were Colorectal (47.1%), General surgery (33.2%) Plastics (9.8%), and Hepatopancreatico-biliary (3.9%). The three commonest operations during URTT were washouts 22 (32.8%), interventions for haemostasis 11 (16.4%) and bowel resections 9 (13.4%). Sixteen (24%) of URTT followed emergency surgery. When comparing between elective and emergency admissions needing URTT, there were no statistical difference in age, gender, speciality type, types of surgery performed, and median number of days until URTT.

CONCLUSION

Rates of URTT are low in South Australian rural hospitals when compared to our overseas counterpart. A wide range of surgery is being performed in rural centres, further supporting the need for rural surgical trainees to have a tailored curriculum encompassing subspecialities and being competent in managing any potential complications.

Preoperative Prediction of Unplanned Reoperation in a Broad Surgical Population

INTRODUCTION

Unplanned reoperation is an undesirable outcome with considerable risks and an increasingly assessed quality of care metric. There are no preoperative prediction models for reoperation after an index surgery in a broad surgical population in the literature. The Surgical Risk Preoperative Assessment System (SURPAS) preoperatively predicts 12 postoperative adverse events using 8 preoperative variables, but its ability to predict unplanned reoperation has not been assessed. This study's objective was to determine whether the SURPAS model could accurately predict unplanned reoperation.

METHODS

This was a retrospective analysis of the American College of Surgeons' National Surgical Quality Improvement Program adult database, 2012-2018. An unplanned reoperation was defined as any unintended operation within 30 d of an initial scheduled operation. The 8-variable SURPAS model and a 29-variable "full" model, incorporating all available American College of Surgeons' National Surgical Quality Improvement Program nonlaboratory preoperative variables, were developed using multiple logistic regression and compared using discrimination and calibration metrics: C-indices (C), Hosmer-Lemeshow observed-to-expected plots, and Brier scores (BSs). The internal chronological validation of the SURPAS model was conducted using "training" (2012-2017) and "test" (2018) datasets.

RESULTS

Of 5,777,108 patients, 162,387 (2.81%) underwent an unplanned reoperation. The SURPAS model's C-index of 0.748 was 99.20% of that for the full model (C = 0.754). Hosmer-Lemeshow plots showed good calibration for both models and BSs were similar (BS = 0.0264, full; BS = 0.0265, SURPAS). Internal chronological validation results were similar for the training (C = 0.749, BS = 0.0268) and test (C = 0.748, BS = 0.0250) datasets.

CONCLUSIONS

The SURPAS model accurately predicted unplanned reoperation and was internally validated. Unplanned reoperation can be integrated into the SURPAS tool to provide preoperative risk assessment of this outcome, which could aid patient risk education.

Risk Factors for 30-Day Unplanned Re-Operation in Pediatric Upper Extremity Surgery: A National Surgical Quality Improvement Program (NSQIP)-Pediatric Analysis

Introduction The unplanned re-operation rate has been used as one marker of procedure quality in numerous surgical sub-fields. The purpose of this study was to determine independent risk factors for unplanned re-operations within 30 days following pediatric upper extremity surgery. Methods Pediatric patients who had a primary upper extremity procedure from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. The procedures included percutaneous fixation of supracondylar humerus fractures, open treatment of humeral condylar fractures, tendon sheath incision, repair of syndactyly, and reconstruction of polydactyly. Patients were categorized by those who had unplanned return to the operating room within 30 days and patients who did not. Patient demographics, clinical characteristics, and medical co-morbidities were evaluated for their association with re-operation using bivariate and multivariate analysis. Results A total of 27,536 pediatric patients underwent primary upper extremity surgeries; of these, 290 (1.1%) required an unplanned re-operation. After controlling for potential confounding variables on multivariable regression analysis, American Society of Anesthesiologists (ASA) class III-V (OR 15.89; p<0.001), inpatient procedure (OR 1.29; p=0.044), emergent/urgent triage (OR 3.75; p<0.001), longer operative time (OR 1.01; p<0.001), and prolonged hospital stay (OR 1.01; p=0.010) were independent predictors for re-operation. Conclusion This study demonstrates that the national rate of 30-day unplanned re-operation in pediatric upper extremity surgeries is low overall. The greatest risk factors for unplanned re-operation were ASA class III-V, inpatient setting, emergent/urgent triage, longer operative time, and prolonged hospital stay. This knowledge can help further improve patient outcomes through risk stratification and preoperative planning.

Thirty-day unplanned reoperations of thoracic spine surgery: 10 years of data from a single center with 3,242 patients

BACKGROUND CONTEXT

Unplanned reoperation is a useful quality indicator for spine surgery. However, the rates of a 30-day unplanned reoperation in patients undergoing thoracic spinal surgery are not well established.

PURPOSE

To assess the rates, reasons, and risk factors of 30-day unplanned reoperations for thoracic spine surgeries in a single center study.

STUDY DESIGN

A retrospective observational study.

PATIENT SAMPLE

3,242 patients who underwent thoracic spinal surgery at our institution in the past decade were included.

OUTCOME MEASURES

The incidence, chief reasons, and risk factors for unplanned reoperations within 30 days after thoracic spinal surgery.

METHODS

We retrospectively analyzed the data of all patients who underwent thoracic spinal surgery between January 2012 and December 2021. Statistical methods, including univariate and multivariate analyses, were performed to assess the incidence, reasons, and risk factors for thoracic degenerative diseases, spinal tumors, kyphosis deformity, and spinal trauma.

RESULTS

Of the 3,242 patients who underwent thoracic spinal surgery, 107 (3.30%) required unplanned reoperations within 30 days due to epidural hematoma (1.17%), wound complications (0.80%), implant complications (0.43%), inadequate decompression (0.25%), and other causes (0.65%). Patients with degenerative disease (3.88%), spinal tumor (2.98%), and kyphosis deformity (3.33%) had significantly higher incidences of reoperation than those with spinal trauma (1.47%). Unplanned reoperations were classified as hyperacute (30.84%), acute (31.76%), and subacute (37.38%). After univariate analysis, several factors were associated with unplanned reoperation in the 4 cohorts of thoracic spine diseases (p<.05). Multivariate logistic regression analysis revealed that upper thoracic spine surgery (p=.001), concomitant dekyphosis (p=.027), and longer activated partial thromboplastin time (p=.025) were risk factors of unplanned reoperation for thoracic degenerative disease. Whereas American Society of Anesthesiologists (ASA) grade III (p=.015), combined approach (p=.016), and operation time longer than 420 min (p=.042) for spinal tumor, and similar ankylosing spondylitis (p=.023) and operation time longer than 340 min (p=.041) were risk factors of unplanned reoperation for kyphosis deformity.

CONCLUSIONS

The unplanned reoperation rate for thoracic spine surgery was 3.30%, with epidural hematoma and wound complications being the most common reasons. However, upper thoracic spine surgery, concomitant dekyphosis, underlying coagulation disorder, longer operation time, higher ASA grade, and comorbidities of ankylosing spondylitis led to an increased risk of unplanned reoperation within 30 days of thoracic spine surgery.

Incidences, causes and risk factors of unplanned reoperations within 30 days of spine surgery: a single-center study based on 35,246 patients

BACKGROUND CONTEXT

Unplanned reoperation, a quality indicator in spine surgery, has not been sufficiently investigated in a large-scale, single-center study.

PURPOSE

To assess the incidences, causes, and risk factors of unplanned reoperations within 30 days of spine surgeries in a single-center study.

STUDY DESIGN

Retrospective observational study.

PATIENT SAMPLE

A cohort of 35,246 patients who underwent spinal surgery in our hospital were included.

OUTCOME MEASURES

The rates, chief reasons, and risk factors for unplanned reoperations within 30 days of spine surgery.

METHODS

We retrospectively analyzed the data for patients who underwent spine surgeries for degenerative spinal disorders, tumor, or deformity and had subsequent unplanned operations within 30 days at a single tertiary academic hospital from January 2016 to July 2021. Univariate and multivariate analyses were performed to assess the incidences, causes, and risk factors.

RESULTS

Out of 35,246 spinal surgery patients, 297 (0.84%) required unplanned reoperations within 30 days of spine surgery. Patients with a thoracic degenerative disease (3.23%), spinal tumor (1.63%), and spinal deformity (1.50%) had significantly higher rates of reoperation than those with atlantoaxial (0.61%), cervical (0.65%), and lumbar (0.82%) degenerative disease. The common causes for reoperation included epidural hematoma (0.403%), wound infections (0.148%), neurological deficit (0.108%), and pedicle screw malposition (0.077%). Unplanned reoperations were classified as hyperacute (45.45%), acute (30.98%), subacute (15.82%), or chronic (7.74%). Univariate analysis indicated that 20 clinical factors were associated with unplanned reoperation (p<.05). Multivariate Poisson regression analysis revealed that anemia (p<.001), osteoporosis (p=.048), ankylosing spondylitis (p=.008), preoperative foot drop (p=.011), deep venous thrombosis (p<.001), and previous surgical history (p<.001) were independent risk factors for unplanned spinal reoperation.

CONCLUSIONS

The incidence of unplanned spinal reoperations was 0.84%. The chief common causes were epidural hematoma, wound infections, neurological deficit, and pedicle screw malposition. Anemia, osteoporosis, ankylosing spondylitis, preoperative foot drop, deep venous thrombosis, and previous surgical history led to an increased risk of unplanned reoperation within 30 days of spine surgery.

Is Elective Nighttime Operation Associated With Adverse Outcomes? Analysis in Immediate Tissue Expander-Based Breast Reconstruction

BACKGROUND

Despite the long-standing presumption that nighttime surgery could affect adverse outcomes, its association independent of patient's general condition and disease severity remains unclear. We hypothesized that conducting elective surgery for subjects with good physical status at nighttime was not associated with increased risks of postoperative complications and aimed to examine it in tissue-expander-insertion (TEI) operation for breast reconstruction.

METHOD

Patients who underwent immediate unilateral TEI-based breast reconstruction between 2014 and 2019 were enrolled. They were categorized into 3 groups based on the starting time of the TEI operation: 8 am to 6 pm (group 1), 6 pm to 8 pm (group 2), and after 8 pm (group 3). The postoperative complication rates were compared among the groups. The independent associations of each variable, including the operation starting time and adverse outcomes, were analyzed.

RESULTS

In total, 1458 patients were analyzed, including 970 in group 1, 358 in group 2, and 130 in group 3. The groups showed similar baseline characteristics regarding comorbidities and the American Society of Anesthesiologists classification. Compared with group 1, group 3 was associated with significantly increased rates of overall complications including infection, reoperation, and premature removal of the tissue expander. These differences retained influences in the multivariable analyses. Group 3 showed a significantly longer hospitalization period than the other 2 groups. The complication rates did not differ between groups 1 and 2.

CONCLUSIONS

Conducting TEI operation at nighttime seems to be associated with increased risks of adverse postoperative outcomes compared with conducting it during regular working hours.

Unplanned Return to the Operating Room after Elective Oncologic Thoracic Surgery: A Further Quality Indicator in Surgical Oncology

Background: An unplanned return to the operating room (UROR) is defined as a readmission to the operating room because of a complication or an untoward outcome related to the initial surgery. The aim of the present report is to evaluate the role of URORs after elective oncologic thoracic surgery. Methods: In the study, 4012 consecutive patients were enrolled; among them, 71 patients (1.76%) had an unplanned return to the operating room. Age, sex, Charlson comorbidity index, induction treatments, type of the first operation, indication to readmission to the operating room and type of second operation, length of stay, complication after reoperation and outcomes were collected. Results: The mean age was 63.3 (SD: 13.0); there were 53 male patients (74.6%); the type of the first procedure was: lower lobectomy (11.3%), middle lobectomy (1.4%), upper lobectomy (22.5%), metastasectomy (5.6%), extrapleural pneumonectomy (4.2%), pneumonectomy (40.9%), pleural biopsy (5.6%) and other procedures (8.5%). Patients presenting complications after UROR had undergone a significantly longer first procedure (p < 0.02), had a longer length of stay (p < 0.001) and had higher post-operative mortality (p < 0.001). Conclusions: The patients experiencing UROR after elective oncologic thoracic surgery have significantly higher morbidity and mortality rates when compared to standard thoracic surgery. Bronchopleural fistula remains the most lethal complication in patients undergoing UROR.

Risk Factors and Outcomes of Redo Craniotomy: A Tertiary Care Center Analysis

Background and aim

Reoperation rate is defined as the percentage of patients returning to the operating room (OR) within 30 days of an initial craniotomy and undergoing a repeat (redo) craniotomy procedure. It is a key factor of quality-of-care assessments and has implications for outcomes, especially in oncological cases. Redo craniotomies are associated with improvement in neurological status and decreased mortality rate compared to non-surgical interventions but are associated with higher costs and risk of complications. It is important to gauge the indications and frequency of redo craniotomies as an index of quality of healthcare to improve patient outcomes. This study aimed to identify the indications, frequency, and outcomes of reoperation following an initial craniotomy in neurosurgical patients at a tertiary care hospital.

Methods

This retrospective cohort study was conducted at a tertiary care center in Pakistan and included all patients who underwent unplanned reoperation within 30 days of initial craniotomy from January 1, 2010, to December 31, 2017. Demographics, indications for index surgery as well as reoperation, and outcomes in the form of complications, neurological status, and mortality were collected from medical charts and analyzed.

Results

The study comprised 111 patients who underwent reoperations. Median age of the patients was 36 years (interquartile range {IQR}: 33 years). From a total of more than 1900 annual cases, the frequency of unplanned reoperations was 3.5%. The most common indication of unplanned reoperation based on MRI/CT was hemorrhage (40%, subdural hemorrhage was most common), followed by hydrocephalus (22%), cerebral edema (13%), and residual tumor (13%). The most common clinical reason for unplanned reoperation was a drop in Glasgow Coma Scale (GCS) (59%), whereas anisocoria was seen in 10.8% of patients. The highest mortality rate was observed in patients who were reoperated from post-operative day two to post-operative day seven (56%). Hypertension (p=0.014) and thrombocytopenia (p<0.001) showed significant associations with developing intracranial hemorrhage. Seventy-eight percent of patients showed significant improvement in their Karnofsky Performance Score (KPS) whereas 22% showed deterioration in their KPS.

Conclusion

The delivery of consistent quality healthcare relies on early detection and intervention in at-risk patients. Our center’s reoperation rate is consistent with the average range among other centers globally. Hypertension, anticoagulation, and antiplatelet therapy were common risk factors for redo craniotomies within 30 days. Patients with these conditions need special care to prevent returns to the operating room. Patients also need to be monitored for hemorrhage in the short term (one to two days) and hydrocephalus in the long term (two to 30 days) to intervene early if needed.

The Incidence and Causes of Unplanned Reoperations as a Quality Indicator in Pediatric Surgery

Background: Unplanned return to the operating room (uROR) within the 30-day postoperative period can be used as a quality indicator in pediatric surgery. The aim of this study was to investigate and evaluate uROR as a quality indicator. Methods: The case records of pediatric patients who underwent reoperation within the 30-day period after primary surgery, from 1 January 2018 to 31 December 2020 were retrospectively reviewed. The primary outcome of the study was the rate of uROR as a quality indicator in pediatric surgery. Secondary outcomes were indications for primary and secondary surgery, types and management of complications, factors that led to uROR, length of hospital stay, duration of surgery and anesthesia, and starting time of surgery. Results: A total of 3982 surgical procedures, under general anesthesia, were performed during the three-year study period (2018, n = 1432; 2019, n = 1435; 2020, n = 1115). Elective and emergency surgeries were performed in 3032 (76.1%) and 950 (23.9%) patients, respectively. During the study period 19 (0.5%) pediatric patients, with the median age of 11 years (IQR 3, 16), underwent uROR within the 30-day postoperative period. The uROR incidence was 6 (0.4%), 6 (0.4%), and 7 (0.6%) for years 2018, 2019, and 2020, respectively (p = 0.697). The incidence of uROR was significantly higher in males (n = 14; 73.7%) than in females (n = 5; 26.3%) (p = 0.002). The share of unplanned reoperations in studied period was 4.5 times higher in primarily emergency surgeries compared to primarily elective surgeries (p < 0.001). The difference in incidence was 0.9% (95% CI, 0.4–1.4). Out of children that underwent uROR within the 30-day period after elective procedures, 50% had American Society of Anesthesiologists (ASA) score three or higher (p = 0.016). The most common procedure which led to uROR was appendectomy (n = 5, 26.3%) while the errors in surgical technique were the most common cause for uROR (n = 11, 57.9%). Conclusion: Unplanned reoperations within the 30-day period after the initial surgical procedure can be a good quality indicator in pediatric surgery. Risk factors associated with uROR are emergency surgery, male gender, and ASA score ≥3 in elective pediatric surgery.

Analysis of neurosurgical procedures with unplanned reoperation for quality improvement: A 5-year single hospital study

The unplanned return to the operating room rate is a quality metric for assessing hospital performance. This study aimed to evaluate the cause, incidence, and time interval of unplanned returns in index neurosurgical procedures within 30 days of the initial surgery as an internal audit. We retrospectively analyzed neurosurgical procedures between January 2015, and December 2019, in a single regional hospital. The definition of an unplanned return to the operating room was a patient who underwent two operations within 30 days when the second procedure was not planned, staged, or related to the natural course of the disease.A total of 4365 patients were identified in our analysis, of which 93 (2%) had an unplanned return to the operating room within 30 days of their initial surgery during admission. The most common reason for an unplanned return to the operating room for a cranial procedure was hemorrhage, followed by hydrocephalus and subdural effusion, which accounted for 49.5%(46/93), 12%(11/93), and 5.4%(5/93) of cases, respectively. In spinal procedures, the most common cause of return was a residual disc, followed by surgical site infection, which accounted for 5.4%(5/93) and 4.3%(4/93) of cases, respectively. The overall median time interval for unplanned returns to the operating room was 3 days (interquartile range, 1-9).Lowering the rate of postoperative hemorrhage in cranial surgery and postoperative residual disc in spine surgery was crucial as an internal audit in a 5-year single institute follow-up. However, the unplanned reoperation rate is less helpful in benchmarking because of the heterogeneity of patients between hospitals.

Risk factors for unplanned return to the operating room within 24 hours: A 9-year single-center observational study

The purpose of the retrospective case-control study was to identify the causes of and risk factors for unplanned return to the operating room (uROR) within 24 hours in surgical patients.We examined 275 cases of 24-hour uROR in our hospital from January 2010 to December 2018. The reasons for 24-hour uROR were classified into several categories. Controls were randomly matched to cases in a 1:1 ratio with the selection criteria set for the same surgeon and operation code in the same corresponding year.The mortality rate was significantly higher in patients with 24-hour uROR (11.63% vs 5.23%). Bleeding was the most common etiology (172/275; 62.55%) and technical error (14.5%) also contributed to 24-hour uROR. The clinical factors that led to bleeding included a history of liver disease (P = .032), smoking (P = .002), low platelet count in preoperative screening (P = .012), and preoperative administration of antiplatelet or anticoagulant agents (P = .014).Clinicians should recognize the risk factors for bleeding and minimize errors to avoid the increase in patient morbidity and mortality that is associated with 24-hour uROR.Level of Evidence: Level IV.

Unplanned Reoperation Following Gynaecological Surgeries: A report from Jordan

Objectives

Unplanned return to the operating theatre refers to an unplanned reoperation following a primary surgical procedure and can result in serious complications. The rate of unplanned reoperations is often used as a measure of in-hospital quality monitoring and improvement. This study aimed to review the prevalence rate and features of unplanned gynaecological reoperations at a major general hospital in Jordan.

Methods

This retrospective study took place between January 2011 and January 2018 at The Specialty Hospital in Amman, Jordan. The medical records of all women who underwent unplanned reoperations following a primary gynaecological procedure during this period were reviewed.

Results

A total of 4,895 primary gynaecological procedures were performed during the study period, of which 4,175 (85.3%) were elective and 720 (14.7%) were emergency operations. There were 15 unplanned reoperations (0.3%); of these, 14 (93.3%) followed elective procedures and one (6.7%) followed an emergency surgery. Most reoperations were performed following hysterectomies (53.3%). Bleeding was the predominant reason for reoperation (93.3%), with the source of the bleeding successfully identified in 71.3% of cases. In terms of outcome, none of the cases required a subsequent reoperation and there were no mortalities.

Conclusion

The rate of unplanned reoperation at a hospital in Jordan was 0.3%. Unplanned reoperations occurred primarily as a result of bleeding following hysterectomies. Development of care pathways may reduce surgical complications and rates of unplanned reoperation.

Unplanned surgical reoperations as a quality indicator in pediatric tertiary general surgical specialties: Associated risk factors and hospitalization, a retrospective case-control analysis

Unplanned reoperations have not been studied extensively in pediatric patients, especially concerning risk factors. We aim to estimate the rate of unplanned reoperations and to determine the associated factors in pediatric general surgical specialties.This analysis included a retrospective case-control study of unplanned reoperations from July 1, 2010 to June 30, 2017 in the general surgical specialties. For each case, we identified approximately 2 randomly selected controls who underwent the same type of operation. The factors involved in the unplanned reoperations were investigated using univariate and multivariate analysis.Of the 3263 patients who underwent surgery, unplanned reoperations were performed in 139 patients (4.3%). The main indications for unplanned reoperations were wound complications (n = 52, 42.6%), followed by postoperative ileus (n = 12, 9.8%), postoperative bleeding (n = 8, 6.6%), and intraabdominal infection (n = 13, 10.7%). Following multivariate analysis, 2 factors remained significantly associated with unplanned reoperation: higher initial surgery-related risk level (P = .007, risk ratio (RR) = 0.48; 95% confidence interval (CI) = 0.27-0.82) and operation performed outside working hours (P = .031, RR = 0.52; 95% CI = 0.30-0.89).Various patient- and procedure-related factors were associated with unplanned reoperations. This information might be helpful for the optimization of treatment planning and resource allocation.

Risk factors of emergency reoperations

Background

Emergency reoperation is considered to be a quality indicator in surgery. We analyzed the risk factors for emergency reoperations.

Methods

Patients who underwent emergency operations from January 1, 2017, to December 31, 2017, at our hospital were reviewed in this retrospective study. Multivariate logistic regression was performed for the perioperative risk factors for emergency reoperation.

Results

A total of 1,481 patients underwent emergency operations during the study period. Among them, 79 patients received emergency reoperations. The variables related to emergency reoperation included surgeries involving intracranial and intraoral lesions, highest mean arterial pressure ≥ 110 mmHg, highest heart rate ≥ 100 beats/min, anemia, duration of operation >120 min, and arrival from the intensive care unit (ICU).

Conclusions

The type of surgery, hemodynamics, hemoglobin values, the duration of surgery, and arrival from ICU were associated with emergency reoperations.

The rise of quality indicators in neurosurgery: 30-day unplanned reoperation rate evaluated in 3760 patients-a single-center experience

OBJECTIVE

Quality indicators are emerging as tools to evaluate health care outcomes. Few studies have evaluated indicators suitable for neurosurgery so far. Among others, reoperation rate has been suggested as a possible indicator. We aimed to evaluate the reoperation rate in a large neurosurgery adult collective.

METHODS

In this exploratory post hoc analysis, we evaluated all patients operated in our service for elective and emergency surgery between January 2014 and May 2016. Planned and unplanned reoperations were filtered and a quantitative analysis, including uni- and multivariate analyses, was performed.

RESULTS

A total of 3760 patients were included in this evaluation. From 378 reoperated patients within 30 days (10.1%), 51 underwent planned procedures (1.4%). Three hundred twenty-seven patients (8.7%) represented the analyzed collective of patients having undergone unplanned surgical procedures, causing a total of 409 from 4268 additional procedures (9.6%). Early unplanned 7-day reoperation rate was 4.5% (n = 193), occurring in 4.5% of patients (n = 193). Postoperative hemorrhage (n = 107, 26.2%) and external ventricle drainage-associated infections or dislocation (n = 105, 25.7 %) were the most common indication for unplanned surgery.

CONCLUSION

Unplanned re-operation rate of a neurosurgical service can help to internally evaluate health care outcome and improve quality of care. Benchmarking with this indicator however is not recommendable as results can vary distinctly due to the heterogenic patient collective of each institution. We expect unplanned reoperation rates to be higher in large university hospitals and tertiary centers with complex cases, as compared to center with less complex cases treating patients with lower morbidity. In this study, we deliver an authentic portrait of a large neurosurgical center in Germany.

Returns to the operating room after breast surgery at a tertiary care medical center

BACKGROUND

Evaluation of returns to the operating room (RORs) may spur practice modifications to improve patient outcomes and hospital practices. We determined the frequency and indications for RORs after breast operations.

METHODS

We identified patients ≥18 years who underwent a breast operation at our institution 1/1/14-1/13/17 and assessed ROR within 45-days. RORs were categorized as unplanned/planned, staged/unstaged, or unrelated procedures. Univariate and multivariable analyses compared variables between patients who did and did not have an ROR.

RESULTS

2,914 patients underwent a breast operation of whom 117 (4.0%) had 121 RORs. Planned staged procedures accounted for 48 RORs (39.7%), while unplanned complications accounted for 65 (53.7%). On multivariable analysis, ROR was more common among patients undergoing total, skin-sparing, or nipple-sparing mastectomy (versus lumpectomy) all p < 0.03, while immediate breast reconstruction did not increase RORs.

CONCLUSIONS

RORs following breast operations occurred in 4% of patients, with approximately one-third for a staged oncologic procedure. Implementation of ROR documentation tools should be encouraged, as these data provide benchmarks for clinical practice improvement initiatives to improve the quality of patient care.

Analysis of trauma patients with unplanned returns to the operating room

Objectives

Trauma patients undergoing damage-control surgery may have a planned return to the operating room. In contrast, little is known about unplanned returns to the operating room (uROR) in trauma. The aim of this study was to identify risk factors for uROR in trauma patients. It is hypothesized that blunt trauma patients with uROR have higher mortality when compared to penetrating trauma patients with uROR. Additionally, it is hypothesized that trauma patients with uROR after thoracotomy have higher mortality than patients with uROR after laparotomy.

Material and Methods

A retrospective analysis of the National Trauma Data Bank from 2011-2015 including any adult patient with an uROR was performed.

Results

From 3.447.320 patients, 9.269 (0.2%) were identified to have uROR. In a multivariable logistic regression analysis, 27 independent predictors were identified for risk of uROR with the strongest independent risk factor being compartment syndrome (OR= 10.50, CI= 9.35-11.78, p <0.001). Blunt (compared to penetrating) mechanism was associated with higher risk for mortality in patents with uROR (OR= 1.69, CI= 1.14-2.51, p <0.001) as was re-incision thoracotomy (RT) compared to re-incision laparotomy (RL) (OR= 2.22, CI= 1.29-3.84, p <0.001).

Conclusion

The strongest risk factor for uROR in trauma is compartment syndrome. Both a blunt (compared to penetrating) mechanism and RT (compared to RL) are independent risk factors for mortality in patients undergoing an uROR.

Comprehensive characterization of perioperative reoperation following radical cystectomy

INTRODUCTION

To examine the nature, timing, and risk factors underlying return to the operating room (ROR) following radical cystectomy (RC). ROR has been proposed as a surgical quality metric based on data from the general surgery literature, but ROR has not been comprehensively characterized following RC.

PATIENTS AND METHODS

We queried our institutional Cystectomy Registry from 2000 to 2016 to identify patients with ROR within 90 days of RC. Multivariable logistic regression was used to examine associations between patient features and ROR. Survival outcomes were studied based on whether ROR was necessary.

RESULTS

Of 1968 patients treated with RC, 112 (5.7%) underwent 125 reoperations within 90 days of RC, of which 93% were unanticipated and due to postsurgical complications. The most common reasons for ROR were facial dehiscence (29%), bowel obstruction (21%), and enteric anastomotic leak (8%). On multivariable analysis, increasing body mass index (odds ratio 1.04, 95% confidence interval (CI) 1.01-1.08, P = 0.045) and albumin <3.5 g/dl (odds ratio 2.15, 95% CI 1.28-3.59, P = 0.004) were associated with greater odds of ROR. Patients with a ROR had significantly decreased 5-year overall survival compared to patients who did not undergo ROR (43% vs. 55%; P = 0.003), and ROR was associated with increased all-cause mortality after multivariable adjustment (hazard ratio 1.33, 95% CI 1.01-1.74, P = 0.04).

CONCLUSION

ROR principally occurred due to unanticipated complications and was associated with increased mortality after RC. These data suggest ROR may be a useful metric by which urological programs can track the efficacy of interventions aimed at improving perioperative care for RC patients.

Log-transformed B-type natriuretic peptide as a prognostic predictor in patients undergoing cardiovascular surgery

Objective

This study was performed to explore the association between circulating B-type natriuretic peptide (BNP) and other mortality-related factors in patients undergoing cardiovascular surgery.

Methods

In this observational study, multilevel linear regression analysis and multilevel survival analysis were performed to measure the log-transformed BNP (lnBNP) value at four time points in 197 patients with 788 repeated data measurements. Effects of the interaction between the time points and the two intervention groups (cardiac surgery and vascular surgery) were also investigated. Six models were evaluated to identify the best fit for the data. Stata/MP® version 14.2 (Stata Corp., College Station, TX, USA) was used to analyze the two-level variance component model fitting.

Results

There were significant differences in the fixed-effect parameters of lnBNP, such as the time point, age, body mass index, emergency operation, prognostic nutritional index, and estimated glomerular filtration rate. According to the multilevel survival analysis for all-cause death and vascular death, lnBNP significantly differed and was a common prognostic marker.

Conclusion

As lnBNP increased by 1 point, all-cause death increased 2.07 times and vascular death increased 3.10 times. lnBNP is an important prognostic predictor and quantitative biochemical marker in patients undergoing cardiovascular surgery.

Monitoring excess unplanned return to theatre following colorectal cancer surgery

BACKGROUND

To develop a risk-adjustment model for unplanned return to theatre (URTT) outcomes following colorectal surgeries in Australia and New Zealand hospitals and apply top-down and bottom-up statistical process control methods for fair comparison of hospitals and surgeons' URTT rates.

METHODS

We analysed URTT outcomes from hospitals contributing data to the Bi-National Colorectal Cancer Audit clinical registry between 2007 and 2016. Preoperative and intraoperative covariates were considered for risk adjustment. A risk-adjusted rate funnel plot was prepared for between-hospital comparisons and identification of outlying hospitals with unusually high rates of URTT. Cumulative observed-minus-expected charts with cumulative sum signals were then presented for surgeons within an outlying hospital.

RESULTS

The study included 15 134 patients and 166 surgeons across 70 hospitals. The weighted average URTT rate was 5.2%. The risk-adjustment model identified 12 preoperative and intraoperative variables that significantly raise the risk of URTT: male sex, American Society of Anesthesiologists score, emergency admissions, conversion entry, left hemicolectomy, total colectomy, proctocolectomy, lower anterior resection, ultra-low anterior resection, abdominoperineal resection, organ resection and excess lymph nodes harvested. Right hemicolectomy significantly reduced risk of URTT. URTT rates were not found to significantly vary across seniority of operator; however, comparisons were limited by lack of data on junior operators. The funnel plot identified five hospitals as 'possible outliers' and hospital T was identified as a 'definite outlier'. The cumulative observed-minus-expected charts with cumulative sum signals showed that within hospital T, one surgeon among three had a particularly bad run of URTTs.

CONCLUSION

Feedback from aggregated URTT outcomes using a risk-adjusted rate funnel plot is enhanced when follow-up examination of outlying hospitals is conducted with concurrent application of cumulative observed-minus-expected charts with cumulative sum signals.

Preventable Complications and Deaths after Emergency Nontrauma Surgery

The objective of this study was to investigate the frequency and cause of preventable and potentially preventable complications on an emergency nontrauma surgical service. The study is a retrospective review conducted at an academic teaching hospital. All patients were assessed (January 2010–June 2012) for emergency general surgical conditions, excluding trauma. The main outcome measures were preventable and potentially preventable complications and deaths, treatments, loop closure mechanisms, and impact on outcomes. The results showed that of 9078 nontrauma emergency surgical admissions and consultations, 194 patients (2.1%) had 261 complications. One hundred and ten (42.1% of total complications) were preventable. The most common causes of preventable complications were delay in management or diagnosis (n = 45, 41% of all preventable complications), technical/iatrogenic (n = 28, 25%), and infectious (n = 18, 16%). The most common nonpreventable complication was infectious (n = 84, 82% of all complications). The most common diagnoses associated with preventable complications were acute cholecystitis (n = 27, 25%), acute appendicitis (n = 25, 23%), and small bowel obstruction (n = 7, 6%). Preventable complications changed management in 80 per cent of cases. Of three (0.01%) mortalities, two were preventable. The mortality rate in emergency nontrauma surgery is low. A significant burden of complications remains. A large proportion are preventable or potentially preventable, with many changing management. These preventable errors are important targets for quality improvement efforts as the specialty of acute care surgery evolves.

The impact of unplanned reoperations in head and neck cancer surgery on survival

OBJECTIVES

Unplanned reoperation causes physical and psychological stress in patients and it costs more in terms of medical, economic and social resource. The purpose of the study was to evaluate the incidence, risk factors and clinical significance of unplanned reoperation (any unscheduled surgery within 30 days from the initial surgery) in patients who had undergone head and neck cancer (HNC) surgery.

MATERIALS AND METHODS

A total of 574 consecutive patients who had received surgery for HNC with or without flap reconstruction from 2010 to 2015 were analyzed. Clinical and biochemical characteristics, cause of unplanned reoperation, cancer subsites, and previous treatment history were compared between unplanned reoperation group (n = 60) and control group (n = 514). Multivariable analyses were performed to identify risk factors for unplanned reoperation. Clinical significance was evaluated by multivariable survival analyses using Cox proportional hazard model.

RESULTS

Overall rate of unplanned reoperation was 10.5%. Flap complication (40.0%) was the most common cause, followed by infection (16.7%), necrosis (11.7%), and bleeding (8.3%). Higher N (N2) classification, long operation time and previous treatment before surgery were identified as risk factors for unplanned reoperation. Based on multivariable survival analyses, recurrence-free survival was significantly decreased in unplanned reoperation group (Hazard ratio = 1.85, 95% confidence interval [1.23-2.80]), but not overall survival.

CONCLUSION

Unplanned reoperation significantly decreased recurrence-free survival in patients with HNC surgery. Thus, careful surgical/ perioperative management is needed to reduce unplanned reoperation in HNC patients with advanced nodal disease, long operation time or previous treatment history.

Returns to Operating Room After Colon and Rectal Surgery in a Tertiary Care Academic Medical Center: a Valid Measure of Surgical Quality?

INTRODUCTION

Returns to the operating room (ROR) have been suggested as a marker of surgical quality. Increasingly, quality and value metrics are utilized for reimbursement as well as public reporting to inform health care consumers. We sought to understand the etiology of ROR and assess the validity of simple ROR as a quality metric.

METHODS

This was a single referral center retrospective review of all colon and rectal operations between January 1, 2014 and December 31, 2014. Surgical Systems Nurse + was constructed and validated at our institution for classifying ROR as either an unplanned return to the OR, planned return due to complications, planned staged return, or an unrelated return. The primary outcome was the classification of ROR and total number of ROR within 30 days.

RESULTS

Of the 2389 colorectal patients who underwent surgery between January 1, 2014 and December 31, 2014; 214 returned to the operating room within 30 days (9.0%). Among the 214 patients, there were a total of 232 ROR with an average of 1.1 ROR per patient (range 1-4); 90 (38.8%) were unplanned ROR, 49 (21.1%) were planned returns due to complications, 92 (39.7%) were planned staged returns, and 1 (0.4%) were unrelated ROR. The most common reason for an unplanned ROR was an anastomotic leak (n = 21; 9.1%). Overall, unplanned reoperations were rare events (n = 90/2389; 3.8%), largely comprised of patients experiencing an anastomotic abscess or leak (n=21/2389; 0.9%).

CONCLUSIONS

In a high volume and complexity academic colon and rectal surgery practice, RORs within 30 days occurred after 10.4% of cases. Unplanned ROR were relatively rare and most commonly associated with an anastomotic leak. Since the majority of ROR were planned-staged returns, overall rate of ROR should be questioned as a metric of surgical quality. Perhaps, the anastomotic leak rate may be a better metric to monitor for quality improvement efforts.

Risk Factors of Reoperation After Pancreatic Resection

BACKGROUND

Pancreatic resection is associated with a high incidence of postoperative complications, some of which require reoperation.

AIMS

To analyze the incidence of and risk factors for reoperation following pancreatectomy.

METHODS

Pre- and postoperative information and procedure characteristics of 15,549 patients having undergone pancreatectomy in 435 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2014 were analyzed.

RESULTS

A total of 773 (5.0%) patients required reoperation within 30 days of their index pancreatectomy. Patients requiring reoperation were more likely to be younger (mean ± standard deviation, 62.6 ± 13.2 vs. 64.1 ± 12.2 years, p < 0.001), male (60 vs. 49%, p < 0.001), to have respiratory comorbidities, lower preoperative serum albumin (3.7 ± 0.68 vs. 3.8 ± 0.62 mg/dl, p < 0.001), higher total bilirubin (1.7 ± 2.7 vs. 1.5 ± 2.4 mg/dl, p = 0.02), and higher American Society of Anesthesiologists (ASA) class than those who did not undergo reoperation. Other factors associated with increased incidence of reoperation included longer mean operative duration at the index procedure, postoperative transfusion requirement, wound complications, and cardiorespiratory, renal, thromboembolic, and infectious events. Multivariate regression analysis identified male sex, preoperative serum albumin <3.5 mg/dl, ASA class of 3 or 4, pancreaticoduodenectomy, and total pancreatectomy as the strongest predictors for reoperation after index pancreatic resection. Complication and readmission rates were significantly higher for those undergoing reoperation.

CONCLUSION

Patient characteristics and procedural factors contribute to reoperation after pancreatectomy in this largest and most diverse sample to date. Further investigation to identify perioperative strategies for mitigating this risk is required to improve the safety of pancreatic resection.

Quality Indicators in Cranial Neurosurgery: Which Are Presently Substantiated? A Systematic Review

BACKGROUND

Owing to the rising costs of health care delivery, the quality of delivered care has become a central issue across all medical specialties. Consequently, there is increasing pressure to create standardized frameworks for measuring quality of care. In the field of cranial neurosurgery, health care administrators have begun applying quality measures that are easily available but might be inaccurate in measuring the quality of care.

METHODS

We performed a systematic literature review on quality indicators (QIs) that are presently used in this field, aiming to elucidate which QIs are scientifically founded and thus potentially justifiable as measures of quality. We found a total of 8 QIs, and methodologically evaluated published studies according to the AIRE (Appraisal of Indicators through Research and Evaluation) criteria. These criteria include length of hospital stay, all-cause readmission rate, and unplanned reoperation rate.

RESULTS

Our review indicates that these presently used or proposed QIs for neurosurgery lack scientific rigor and are restricted to rudimentary measures, and that further research is necessary.

CONCLUSIONS

Neurosurgeons need to define their own QIs and actively participate in the validation of these QIs to provide the best possible patient outcomes. More reliable clinical registries, obligatory for all neurosurgical services, should be established as a basis for establishing such indicators, with risk adjustment being an important element of any such indicators.

An institutional analysis of unplanned return to the operating room to identify areas for quality improvement

BACKGROUND

Unplanned return to the operating room (uROR) has been suggested as a hospital quality indicator. The purpose of this study was to determine reasons for uROR to identify opportunities for patient care improvement.

METHODS

uROR reported by our institution's American College of Surgeons National Surgical Quality Improvement Program underwent secondary review.

RESULTS

The uROR rate reported by clinical reviewers was 4.3%. Secondary review re-categorized 64.7% as "true uROR" with the most common reasons for uROR being infection (30.9%) and bleeding (23.6%). Remaining cases were categorized as "false uROR" with the most common reasons being inadequate documentation (60.0%) and not directly related to index procedure (16.7%).

CONCLUSIONS

Strict adherence to NSQIP definitions results in misidentification of true uROR. This raises concerns for using NSQIP-identified uROR as a hospital quality metric. Improved processes of care to prevent infection and hemorrhage at our institution could reduce the rate of true uROR.

Nonelective surgery at night and in-hospital mortality: Prospective observational data from the European Surgical Outcomes Study

BACKGROUND

Evidence suggests that sleep deprivation associated with night-time working may adversely affect performance resulting in a reduction in the safety of surgery and anaesthesia.

OBJECTIVE

Our primary objective was to evaluate an association between nonelective night-time surgery and in-hospital mortality. We hypothesised that urgent surgery performed during the night was associated with higher in-hospital mortality and also an increase in the duration of hospital stay and the number of admissions to critical care.

DESIGN

A prospective cohort study. This is a secondary analysis of a large database related to perioperative care and outcome (European Surgical Outcome Study).

SETTING

Four hundred and ninety-eight hospitals in 28 European countries.

PATIENTS

Men and women older than 16 years who underwent nonelective, noncardiac surgery were included according to time of the procedure.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Primary outcome was in-hospital mortality; the secondary outcome was the duration of hospital stay and critical care admission.

RESULTS

Eleven thousand two hundred and ninety patients undergoing urgent surgery were included in the analysis with 636 in-hospital deaths (5.6%). Crude mortality odds ratios (ORs) increased sequentially from daytime [426 deaths (5.3%)] to evening [150 deaths (6.0%), OR 1.14; 95% confidence interval 0.94 to 1.38] to night-time [60 deaths (8.3%), OR 1.62; 95% confidence interval 1.22 to 2.14]. Following adjustment for confounding factors, surgery during the evening (OR 1.09; 95% confidence interval 0.91 to 1.31) and night (OR 1.20; 95% confidence interval 0.9 to 1.6) was not associated with an increased risk of postoperative death. Admittance rate to an ICU increased sequentially from daytime [891 (11.1%)], to evening [347 (13.8%)] to night time [149 (20.6%)].

CONCLUSION

In patients undergoing nonelective urgent noncardiac surgery, in-hospital mortality was associated with well known risk factors related to patients and surgery, but we did not identify any relationship with the time of day at which the procedure was performed.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT01203605.

Unplanned Reoperations in Neurosurgical Patients Due to Postoperative Bleeding: A Single-Center Experience and Literature Review

The aim of this study is to investigate the incidence of unplanned reoperations from all causes due to bleeding in neurosurgical patients. The medical records of patients who received neurosurgical procedures at our hospital were retrospectively reviewed and data of patients who received reoperations were extracted and summarized. A literature review was conducted of the Medline, Cochrane, EMBASE, and Google Scholar databases up to November 2013. The main outcome measure was the rate of unplanned reoperations due to bleeding. At our hospital, 68 patients with a mean age of 41.5 ± 21.5 years (range, 7 months to 76 years) received an unplanned reoperation. More than 70% of the patients were older than 18 years, 64.7% were males, and 94.1% had cranial surgery. Almost 60% of the patients received >1 blood transfusion (58.8%) after the first surgery. Of the 68 patients, 35 (51.5%) received a second operation due to bleeding. Univariate logistic regression analysis only showed that an increasing time interval between the first and second surgery was associated with a decreased chance of the reoperation being performed due to bleeding (odds ratio [OR] = 0.843, 95% confidence interval [CI]: 0.720-0.987; P = .033). Of 229 studies identified, 5 retrospective reports with a total of 1375 patients were included in the analysis. The rate of reoperations for bleeding in the 5 studies ranged from 4.2% to 31.5%. Employing measures to reduce postoperative bleeding may help reduce the rate of unplanned neurosurgical reoperations.

Assessing early unplanned reoperations in neurosurgery: opportunities for quality improvement

OBJECT

Review of morbidities and mortality has been the primary method used to assess surgical quality by physicians, hospitals, and oversight agencies. The incidence of reoperation has been proposed as a candidate quality indicator for surgical care. The authors report a comprehensive assessment of reoperations within a neurosurgical department and discuss how such data can be integrated into quality improvement initiatives to optimize value of care delivery.

METHODS

All neurosurgical procedures performed in the main operating room or the outpatient surgery center at the Ronald Reagan UCLA Medical Center and UCLA Santa Monica Medical Center from July 2008 to December 2012 were considered for this study. Interventional radiology and stereotactic radiosurgery procedures were excluded. Early reoperations within 7 days of the index surgery were reviewed and their preventability status was evaluated.

RESULTS

The incidence of early unplanned reoperation was 2.6% (occurring after 183 of 6912 procedures). More than half of the patients who underwent early unplanned reoperation initially had surgery for shunt-related conditions (34.4%) or intracranial tumor (23.5%). Shunt failure was the most common indication for early unplanned reoperation (34.4%), followed by postoperative bleeding (20.8%) and postoperative elevated intracranial pressure (9.8%). The average time interval (± SD) between the index surgery and reoperation was 3.0 ± 1.9 days. The average length of stay following reoperation was 12.1 ± 14.4 days.

CONCLUSIONS

This study enabled an in-depth assessment of reoperations within an academic neurosurgical practice and identification of strategic opportunities for department-wide quality improvement initiatives. The authors provide a nuanced discussion regarding the use of absolute reoperations as a quality indicator for neurosurgical patient populations.