The Effect of Obesity on Postoperative Analgesia Practices and Complications Following Endoscopic Sinus Surgery: A Propensity Score-Matched Cohort Study

BACKGROUND

Despite growing concern regarding over-prescription of narcotic pain medication following ambulatory surgery, little is known about the analgesic prescribing practices following endoscopic sinus surgery (ESS) in obese patients in comparison to non-obese patients.

OBJECTIVE

To compare the rates of opioid versus non-opioid prescriptions, the need for steroids, and post-operative adverse events between obese and non-obese adult patients undergoing ESS.

METHODS

Using TriNetX Live database, we identified all patients aged ≥18 years who underwent ESS (n = 1303) between 2014 and 2022 across several healthcare institutions across the state of Tennessee. We 1:1 propensity score-matched obese (BMI ≥ 30 kg/m2) and non-obese (18.5 kg/m2 ≤ BMI < 30 kg/m2) cohorts for age, gender, race, and comorbidities including asthma, nicotine dependence, and sleep apnea. Rates of prescriptions and post-operative adverse events between cohorts were analyzed using risk ratios (RR) and confidence intervals (CI).

RESULTS

A toal of 532 obese patients were compared to 532 propensity score-matched non-obese patients in the first 14 post-operative days following ESS. The obese cohort was significantly more likely to be prescribed analgesics generally (RR = 1.72; 95% CI = 1.20-2.47), non-opioid analgesics (RR = 1.73; 95% CI = 1.19-2.50), and opioid analgesics (RR = 1.64; 95% CI = 1.14-2.36) than non-obese patients. There was no difference in rates of antibiotic or antiemetic prescription, prednisone/methylprednisolone, dexamethasone, ED visits, critical care service, epistaxis, transfusion, anemia, revision sinus surgery, mechanical ventilation, CPAP, or inhalation airway treatments.

CONCLUSION

Obese patients undergoing ESS were significantly more likely to be prescribed non-opioid and opioid analgesia in the first 14 days post-operatively compared to non-obese patients. There were no differences in post-operative adverse events or other prescriptions. Otolaryngologists should be aware that obese patients are at increased risk of opioid induced airway obstruction and steroid induced hyperglycemia, especially in patients with comorbid sleep apnea or diabetes. Emphasis on non-opioid analgesics and multimodal pain management should be advocated for this population.

Effect of obesity on outcomes after open laryngeal surgery including total laryngectomy: A NSQIP database analysis

BACKGROUND

The impact of obesity on outcomes after open laryngeal surgery has not been well-described.

METHODS

The NSQIP database was queried for all open laryngeal surgeries including total laryngectomies between 2005 and 2018. Outcomes of patients identified as obese or nonobese by BMI were compared.

RESULTS

Of 1865 patients, 20.1% classified as obese. The most common operation performed was total laryngectomy with or without radical neck dissection (73.2%). Operation time and length of hospital stay were significantly less for obese patients. On multivariate analysis, obesity was associated with less bleeding transfusions occurrences (aOR, 0.395, p = 0.0052), surgical complications (aOR, 0.604, p < 0.001), and any complication (aOR, 0.730, p = 0.0019).

CONCLUSION

Though there may be an inverse association of obesity with complications and bleeding transfusion occurrences, as well as decreased operation time and length of hospital stay, several confounders and bias may exist; therefore, it is difficult to conclude that the obesity paradox is present.

The Effect of Diabetes Mellitus on Post-Operative Outcomes in Patients Undergoing Endoscopic Sinus Surgery

BACKGROUND

Diabetes Mellitus (DM) and its associated immune dysfunction are well-studied risk factors for adverse surgical outcomes. The literature regarding endoscopic sinus surgery (ESS) is less robust and there have been conflicting reports on post-operative complications and surgical results in this patient population. The purpose of this study was to analyze the impact of diabetes mellitus on outcomes after ESS via rates of post-operative medical intervention in the first 6 months after surgery.

METHODS

This was a retrospective cohort study of 176 subjects who underwent ESS from 2015 to 2019 at a single institution by 2 fellowship-trained rhinologists. Subjects were divided into 2 groups, those with a documented Hemoglobin A1c (HbA1c) >6.5 or diagnosis of DM and those with HbA1C < 6.5. Patient age, demographics, 6-month preoperative HbA1c, surgical status and extent, and 6-monthpostoperative need for steroids and/or antibiotics were collected.

RESULTS

Out of n = 176 total patients, n = 39 (22.2%) were categorized into the DM group, which were older (46.4 vs 53.8 years, P = .004) and higher proportion of white patients (89.7% vs 68.6%, P = .008). There were no significant differences between the 2 groups in proportion of revision surgery, surgical extent, and post-operative use of antibiotics or steroids. When including all variables in binary logistic regression for use of postoperative antibiotics or steroids, the only significant variable predicting these outcomes was the extent of surgical resection including sphenoid sinus (P = .001, OR [95% CI] = 4.02 [1.73-9.34]) or frontal sinus (P < .001, OR [95% CI = 9.86 [4.00-24.33]).

CONCLUSIONS

Patients with DM do not appear to have worse post-operative outcomes outside of the initial 6-month postoperative period.

Frailty, Age, ASA Classification, and BMI on Postoperative Morbidity in Mandibular Fracture ORIF

OBJECTIVE

To assess how traditional, simple markers of health independently affect postoperative morbidity of mandibular fracture open reduction-internal fixations (ORIFs).

STUDY DESIGN

Cohort study.

SETTING

National Surgical Quality Improvement Project (NSQIP) Database.

METHODS

The 2005 to 2017 NSQIP database was queried for patients who underwent mandibular ORIF. To control for the severity of the trauma, an additional "concurrent surgery" variable was created. A modified 5-item frailty index was calculated based on the following: presurgery-dependent functional status, chronic hypertension, diabetes mellitus, history of chronic obstructive pulmonary disease, and history of congestive heart failure.

RESULTS

Among 1806 patients with mandibular ORIFs (mean age 34.8 ± 15.4 years), modified frailty index (mFI) was associated with 30-day medical complications (p < .001), reoperation (p < .001), and readmission (p = .005) on univariate analysis. Increased age was associated with prolonged hospitalization (p < .001) and medical complications (p < .001). The increased American Society of Anesthesiologists (ASA) score was associated with all endpoints (p ≤ .003), while increased body mass index (BMI) was associated with none. On multivariate analysis, only increased ASA was associated with any adverse event (reference: ASA 1; ASA 2, odds ratio [OR]: 2.17 [95% confidence interval, CI: 2.17-3.71], p = .004; ASA 3-4, OR: 3.63 [95% CI: 1.91-6.91], p < .001). Similarly, mFI and BMI were not independently associated with prolonged hospitalization (≥2 days) (p ≥ .015), but 65+ age (reference: 18-49; OR: 2.33 [95% CI: 1.40-3.86], p = .001) and ASA 3 to 4 groups (reference: ASA 1; OR: 3.26 [95% CI: 2.06-5.14], p < .001) were.

CONCLUSION

ASA status and age are more useful modalities than mFI or BMI in predicting poor postoperative morbidity in mandibular ORIF. These simple metrics can assist with managing surgeons' expectations for mandibular ORIF patients.

Utility of Preoperative Laboratory Testing for Ambulatory Endoscopic Sinonasal Surgery in Low-Risk Patients

Background

Preoperative laboratory tests (PLTs) are often obtained prior to outpatient surgical procedures. The objective of this study is to examine the current practice of routine PLT in low-risk patients undergoing ambulatory endoscopic sinonasal surgery (ESS) and to assess whether such testing impacts surgical outcomes.

Methods

Patients undergoing ambulatory ESS were identified from the 2011 to 2018 NSQIP database. Low-risk patients were defined as American Society of Anesthesiologist class 1 or 2. PLTs were grouped into hematologic, chemistry, coagulation, and liver function tests. Chi-square analyses and independent samples t-tests were conducted to compare categoric and continuous variables, respectively.

Results

A total of 664 cases met the inclusion criteria, of which 419 (62.1%) underwent at least one PLT. Of these, the most frequent PLT obtained was a complete blood cell count (92.4%). Major complications occurred in 1.5% of patients. There were no statistically significant differences in overall postoperative complications between those with and without PLT ( P = .264). Specifically, no significant difference was seen in the incidence of postoperative bleeding ( P = .184), urinary tract infection ( P = .444), pulmonary embolism ( P = .444), or wound infection ( P = .701). On multivariable analyses, PLT status was not significantly associated with any complication ( P = .097) or unplanned readmission ( P = .898).

Conclusions

Our analysis did not reveal an association between the use of PLT and postoperative morbidity or unplanned readmission in low-risk patients undergoing outpatient ESS.

Length of Stay in Patients Undergoing Tracheoplasty: A NSQIP Study

BACKGROUND

Prolonged length of stay (LOS) has been associated with increased morbidity and resource utilization in various surgical procedures. We aim to determine factors associated with increased hospital stay in patient undergoing tracheoplasty.

METHODS

The 2012-2018 National Surgical Quality Improvement Program (NSQIP) database was queried for patients undergoing tracheoplasty. Patient LOS was the primary clinical outcome. A LOS >75th percentile was considered as prolonged and was utilized for bivariate analysis of demographic, comorbidity, and operative characteristics. LOS was utilized as a continuous variable for multivariate linear regression analysis.

RESULTS

A total of 252 patients were queried. The majority of patients were female (67.5%), white (82.4%), and over the age of 65 (77.0%). Patients had a median LOS of 7 days with the 75th percentile cutoff being defined at 10 days. On bivariate analysis of associated comorbidities, patients with prolonged LOS were more commonly obese (72.4% vs. 53.1%, p = 0.009), diabetic (37.9% vs. 16.5%, p < 0.001), dyspneic (58.6% vs. 40.7%, p = 0.016), and had chronic steroid use (25.9% vs. 12.9%, p = 0.018). Multivariable logistic regression analysis demonstrated significant associations between prolonged LOS and both chronic obstructive pulmonary disorder (COPD) (OR: 3.43, p = 0.020) and chronic steroid use (OR: 3.81, p = 0.018).

CONCLUSIONS

This study elucidates factors associated with prolonged LOS in patients undergoing tracheoplasty. Patients with COPD and chronic steroid use were significantly associated with prolonged LOS.

LEVEL OF EVIDENCE

4 Laryngoscope, 2022.

Factors Associated With Unanticipated Admission After Outpatient Endoscopic Sinonasal Surgery

OBJECTIVES/HYPOTHESIS

To identify factors that may increase the risk of unplanned admission following elective outpatient endoscopic sinonasal surgery (ESS).

STUDY DESIGN

Retrospective analysis of the National Surgical Quality Improvement Program (NSQIP).

METHODS

All cases of ESS were extracted from the 2010 to 2018 NSQIP database using Current Procedural Terminology codes. Only cases coded as outpatient, elective, and nonemergent procedures were included. Unplanned admissions were defined as cases with a total hospital stay of 1 day or more. Univariate and multivariate analyses were performed to identify variables that independently predicted unanticipated admission.

RESULTS

A total of 971 cases met inclusion criteria, of which 274 (28.2%) were unanticipated admissions. Patients in the unplanned admission group were more likely to be older (46.8 vs. 41.1 years, P < .001), male (57.7% vs. 48.4%, P = .009), obese (54.8% vs. 43.8%, P = .003), and have hypertension (35.0% vs. 25.0%, P = .002). Unplanned admitted patients were also more likely to be included under American Society of Anesthesiologists (ASA) classification III-IV (43.1% vs. 27.2%, P < .001). There were no significant differences in race, smoking, diabetes, or chronic steroid use. Unplanned admitted patients had a higher rate of surgical complications (2.9% vs. 1.0%, P = .041). Upon multivariate analysis, independent preoperative risk factors for unplanned admission included age (OR: 1.018, P = .002), male gender (OR: 1.415, P = .025), obesity (OR: 1.527, P = .008), and ASA III-IV (OR 1.501, P = .018).

CONCLUSIONS

Factors independently associated with unplanned admission following outpatient ESS were older age, male gender, obesity, and higher ASA. Identification of patients at risk may reduce unanticipated hospital admission after ESS.

LEVEL OF EVIDENCE

4 Laryngoscope, 132:518-522, 2022.

Obesity as a Risk Factor for Postoperative Adverse Events in Skull Base Surgery

OBJECTIVE

To determine the implications of obesity on postoperative adverse events following skull base surgery.

METHODS

The 2005-2017 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for adverse events in skull base surgery cases. Patients were stratified by body mass index (BMI) into normal weight (18.5 ≤ BMI < 25), overweight (25 ≤ BMI < 30), and obese (BMI ≥ 30) cohorts. Logistic regression was used to assess the association of overweight or obese BMI with various 30-day postoperative adverse events.

RESULTS

A total of 2305 patients were included for analysis, of which 732 (31.8%) and 935 (40.6%) were overweight or obese, respectively. The mean age was 53.8 ± 15.3 years and 1214 (52.7%) patients were female. Obese patients were younger (P = .033) and possessed higher frailty (P < .001) and ASA scores (P < .001). Operation times and lengths of hospitalization were not significantly different across patient cohorts (all P > .05). On propensity score-adjusted multivariable analysis, only bleeding (OR = 0.42, P < .001) and deep vein thrombosis (OR = 6.46, P = .015) were significantly associated with obesity. There were no significant differences in rates of readmission, reoperation, or mortality between normal weight and obese patients (all P > .05).

CONCLUSIONS

Obesity was associated with decreased postoperative bleeding and increased deep vein thromboses. Obese patients were otherwise at no higher risk for medical or surgical complications. Elevated BMI did not confer an increased risk for readmission, reoperation, or death. Thus, patient obesity should not be a major determinant in offering skull base surgery in individuals who would otherwise benefit from treatment.

Association between modified frailty index and surgical outcomes in intradural skull base surgery

The objective of this study is to evaluate the impact of preoperative frailty on short-term outcomes following intradural resection of skull base lesions. The 2005-2017 ACS-NSQIP database was queried for 30-day post-operative outcomes of patients undergoing intradural resection of the skull base, extracted by CPT codes 61601, 61606, 61608, and 61616. Five-item modified frailty index (mFI) was calculated based on the history of diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, chronic hypertension, and functional status. A total of 701 patients (58.8% female, 72.0% white) were included with a mean age of 51.8 ± 14.7 years. Compared to patients with mFI = 0 (n = 403), patients with mFI ≥ 1 (n = 298) were more likely to have higher rates of reoperation (13.4% vs. 8.7%, p = 0.045), medical complications (20.5% vs. 9.2%, p < 0.001), surgical complications (13.8% vs. 8.4%, p = 0.024), discharge to non-home facility (DNHF) (24.8% vs. 13.3%, p < 0.001), and prolonged length of hospitalization (7.3 ± 6.8 days vs. 5.6 ± 5.0, p = 0.003). Moreover, mFI = 1-3 was also associated with higher BMI, non-white race, high ASA, and older age (all p < 0.05). Upon adjusting for age, BMI, race, ASA score, and surgical site, multivariate regression analysis demonstrated that higher mFI (treated as a continuous variable) was associated with higher odds of medical complications (OR = 1.630, CI = 1.153-2.308, p = 0.006), surgical complications (OR = 1.594, CI = 1.042-2.438, p < 0.031), and LOS ≥ 10 days (OR = 1.609, CI = 1.176-2.208, p = 0.003). In conclusion, the 5-item mFI can be an independent predictor of several important short-term surgical outcomes following intradural resection of skull base lesions, warranting further investigations into its clinical utility.

Association Between 5-Item Modified Frailty Index and Short-term Outcomes in Complex Head and Neck Surgery

OBJECTIVES

To evaluate the impact of preoperative frailty on short-term outcomes following complex head and neck surgeries (HNSs).

STUDY DESIGN

Cross-sectional database analysis.

SETTING

American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

METHODS

The 2005 to 2017 ACS-NSQIP was queried for patients undergoing complex HNS. Five-item modified frailty index (mFI) was calculated based on functional status and history of diabetes, chronic obstructive pulmonary disease, congestive heart failure, and chronic hypertension.

RESULTS

A total of 2786 patients (73.1% male) with a mean age of 62.0 ± 11.6 years were included. Compared to nonfrail patients (41.2%), patients with mFI ≥1 (58.8%) had shorter length of operation (P = .021), longer length of stay (LOS) (P < .001), and higher rates of 30-day reoperation (P = .009), medical complications (P < .001), discharge to nonhome facility (DNHF) (P < .001), and mortality (P = .047). These parameters remained statistically significant when compared across all individual mFI scores (all P < .05). After adjusting for age, sex, race, body mass index, smoking, and American Society of Anesthesiologists score via multivariate logistic regression, patients with mFI ≥1 were significantly more likely to undergo reoperation (odds ratio [OR], 1.39), surgical complications (OR, 1.19), medical complications (OR, 1.55), prolonged LOS (OR, 1.29), and DNHF (OR, 1.56) (all P < .05). Multivariate logistic regression also demonstrated that after adjusting for confounders, compared to patients with mFI = 1, patients with mFI = 2-5 (18.7%) were more likely to undergo shorter operations (OR, 0.74), have medical (OR, 1.46) or any complications (OR, 1.27), and have DNHF (OR, 1.62) (all P < .05).

CONCLUSION

The 5-point mFI can independently predict short-term surgical outcomes following complex HNS. This simple and reliable metric can potentially lead to improved preoperative counseling and postoperative planning for complex HNS patients.