Introduction Surgical site infections (SSIs) continue to be a challenging issue among patients undergoing pancreatectomy. Anecdotally, the use of negative pressure wound therapy (NPWT) following pancreatectomy for cancer has been associated with decreased SSIs. The objective of this study was to compare the postoperative outcomes of NPWT and non-NPWT for incisional wound care following distal pancreatectomy or pancreatoduodenectomy for pancreatic diagnoses using a national surgical database. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried from 2005 to 2019 for patients undergoing distal pancreatectomy or pancreaticoduodenectomy for pancreatic diagnoses using primary Current Procedural Terminology (CPT) codes. The primary outcome was surgical site infection rates between NPWT and non-NPWT patient groups. Secondary outcomes include sepsis, septic shock, readmission, and reoperation. Outcomes of interest were compared using multivariate logistic regression. Results A total of 54,457 patients underwent pancreatectomy with 131 receiving NPWT. Multivariate analysis, while accounting for patient characteristics, including wound classification, showed no difference in postoperative superficial SSI, deep SSI, sepsis, septic shock, or readmission between the NPWT and non-NPWT groups. Organ space SSI was higher in the NPWT group (21% vs 12%, p=0.001). Reoperation related to procedure was also high in the NPWT group (14% vs 4.3%, p<0.001). Conclusion The use of NPWT in distal pancreatectomies and pancreatoduodenectomies is associated with increased organ space SSIs and reoperation rates, with no difference in superficial SSI, deep SSI, or readmission. This large sample study shows no significant benefit of using NPWT incisional wound care after pancreatectomy.

UNASSIGNED: There is paucity of studies on preoperative risk assessment tools in patients undergoing emergency surgery. The present study evaluated the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II, American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) surgical risk calculator and American Society of Anesthesiologists (ASA) physical status (PS) classification system in patients undergoing emergency exploratory laparotomy.
UNASSIGNED: This retrospective study included 60 adult patients who underwent emergency exploratory laparotomy for perforation peritonitis. The clinical details, ASA PS classification, laboratory investigations and postoperative course of patients were retrieved from their medical records. Based on these details, APACHE II and ACS-NSQIP were calculated for the patients. The study\'s primary outcome was the accuracy of the preoperative APACHE II, ACS-NSQIP risk calculator and ASA PS class in predicting the postoperative 30-day mortality of patients.
UNASSIGNED: The area under the curve (AUC) of APACHE II, ACS-NSQIP score, and ASA PS classification for mortality 30 days after surgery was 0.737, 0.694 and 0.601, respectively. The P value for the Hosmer-Lemeshow (H-L) test of scoring systems was 0.05, 0.25 and 0.05, respectively. AUC for postoperative complications was 0.799 for APACHE II, 0.683 for ACS-NSQIP and 0.601 for ASA PS classification. H-L test of these scoring systems for complications after surgery revealed P values of 0.62, 0.36 and 0.53, respectively.
UNASSIGNED: Compared to the ACS-NSQIP and ASA PS classification system, the APACHE II score has a better discriminative ability for postoperative complications and mortality in adult patients undergoing emergency exploratory laparotomy.

Introduction It has been suggested that hernia repair with concomitant cholecystectomy increases the risk of postoperative complications due to potential mesh contamination. This study compares postoperative outcomes and complications between patients who underwent ventral hernia repair (VHR) with and without concomitant cholecystectomy (CCY). Methods Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, from 2005 to 2019, we queried patients who underwent ventral hernia repairs using the current procedural terminology (CPT) codes 49652-49657 (laparoscopic) and 49560-49566 (open), with or without cholecystectomy. The ACS NSQIP is a prospective, systematic study of patients who underwent major general surgical procedures aggregating data from over 200 hospitals. Cases involving additional concomitant procedures were excluded. Primary outcomes of interest were 30-day mortality, length of stay, readmission, return to operating room (OR), and postoperative complications. The odds ratio for primary outcomes was calculated using multivariable binomial logistic regression to control for patient risk factors. Results In total, 167586 cases were identified, 165,758 ventral hernia repairs alone, and 1,828 ventral hernia repairs with concomitant cholecystectomy. There was no difference in 30-day mortality, length of stay, readmission, return to the operating room, or postoperative complications between groups. Patients who underwent simultaneous VHR/CCY when compared to those who had VHR alone, had no differences in the rate of surgical site infections (1.86% vs. 1.97%, P = 0.57) or sepsis (0.82% vs. 0.41%, P = 0.10).  Conclusion In a large national sample, there is no significant difference in postoperative outcomes, specifically infection-related complications, when comparing VHR along with concurrent VHR/CCY. Our findings suggest no increased risks for patients undergoing concurrent ventral hernia repair and cholecystectomy. Hence, surgeons might consider this combined approach to offer the best value-based care, especially when it could eliminate the need for a second operation and the risk of infection is low. Prospective studies with more procedural-specific information for hernia repairs and indications for cholecystectomy are needed however it is likely safe to perform both procedures during the same setting in cholecystectomy cases lacking signs of acute infection.

Introduction Lumbar spine interbody fusions have been performed to relieve back pain and improve stability due to various underlying pathologies. Anterior interbody fusion and posterior interbody fusion approaches are two main approaches that are classically compared. In an attempt to compare these two approaches to the spine, large retrospective national database reviews have been performed to compare and predict 30-day postoperative outcomes; however, they have conflicting findings. Obesity, defined as having a body mass index (BMI) over 30 kg/m2, may also contribute to the extent of spine pathology and is associated with increased rates of postoperative complications. Complication rates in patients who are obese have yet to be thoroughly investigated using a large national database. Our present investigation aims to make this comparison using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. The goal of the present study is to utilize a nationwide prospective database to determine short-term differences in postoperative outcomes between posterior and anterior lumbar fusion in patients with obesity and relate these findings to previous studies in the general population. Methods A retrospective cohort analysis was conducted on 9,021 patient data from the ACS-NSQIP database from 2015 to 2019 who underwent an elective, single-level fusion via anterior or posterior surgical approach. This database captures over 150 clinical variables on individual patient cases, including demographic data, preoperative risk factors and laboratory values, intraoperative data, and significant events up to postoperative day 30. All outcome measures were included in this analysis with special attention to rates of deep venous thrombosis (DVT) and pulmonary embolism (PE), prolonged length of stay (LOS), reoperation, and operation time. Results Multivariable analysis controlling for age, BMI, sex, race, functional status, American Society of Anesthesiologists (ASA) class, and selected comorbidities with P < 0.05 demonstrated that the anterior approach was an independent predictor for all significant outcomes except prolonged length of stay. Compared to the posterior approach, the anterior approach had a shorter total operation time (B = -13.257, 95% confidence interval (CI) [-17.522, -8.992], P < 0.001), higher odds of deep vein thrombosis (odds ratio (OR) = 2.210, 95% CI [1.211, 4.033], P= 0.010), and higher odds of pulmonary embolism (OR = 2.679, 95% CI [1.311, 5.477], P = 0.007) and was protective against unplanned reoperation (OR = 0.702, 95% CI [0.548, 0.898], P = 0.005). Conclusions The obese population makes up a large and growing demographic of those undergoing spine surgery, and as such, it is pertinent to investigate the differences, advantages, and disadvantages of lumbar fusion approaches in this group. While anterior approaches may be protective of longer operation time and unplanned reoperation, this benefit may not be clinically significant when considering an increased risk of DVT and PE. Given the short-term nature of this dataset and the limitations inherent in large de-identified retrospective database studies, these findings are interpreted with caution. Longer-term follow-up studies accounting for confounding variables with spine-centered outcomes will be necessary to further elucidate these nuances.

The American College of Surgeons National Surgical Quality Improvement Program surgical risk calculator (ACS-NSQIP SRC) has been designed to predict morbidity and mortality and help stratify surgical patients. This study evaluates the performance of the SRC for patients undergoing surgery for colorectal liver metastases (CRLM).
SRC was retrospectively computed for patients undergoing liver or simultaneous colon and liver surgery for colorectal cancer (CRC) in two high tertiary referral centres from 2011 to 2020. C-statistics and Brier score were calculated as a mean of discrimination and calibration respectively, for both group and for every level of surgeon adjustment score (SAS) for liver resections in case of simultaneous liver-colon surgery. An AUC ≥ 0.7 shows acceptable discrimination; a Brier score next to 0 means the prediction tool has good calibration.
Four hundred ten patients were included, 153 underwent simultaneous resection, and 257 underwent liver-only resections. For simultaneous surgery, the ACS-NSQIP SRC showed good calibration and discrimination only for cardiac complication (AUC = 0.720, 0.740, and 0.702 for liver resection unadjusted, SAS-2, and SAS-3 respectively; 0.714 for colon resection; and Brier score = 0.04 in every case). For liver-only surgery, it only showed good calibration for cardiac complications (Brier score = 0.03). The SRC underestimated the incidence of overall complications, pneumonia, cardiac complications, and the length of hospital stay.
ACS-NSQIP SRC showed good predicting capabilities only for 1 out of 5 evaluated outcomes; therefore, it is not a reliable tool for patients undergoing liver surgery for CRLM, both in the simultaneous and staged resections.

OBJECTIVE: To investigate the impact of race/ethnicity on surgical outcomes following pancreaticoduodenectomy for pancreatic cancer.
METHODS: A retrospective review of patients undergoing pancreaticoduodenectomy for adenocarcinoma in the National Surgical Quality Improvement Program (NSQIP) database from 2014 to 2019. Patient and tumor characteristics and 30-day postoperative outcomes were compared. Multivariable logistic and linear regression models were conducted to investigate the relationship between race/ethnicity and surgical outcomes.
RESULTS: Six thousand five hundred and sixty-two patients were included (84.5% White, 7.9% Black, 3% Hispanic, 4.6% Asian). Larger proportions of Blacks had preoperative American Society of Anesthesiologists class 3 or 4. There were no significant differences in tumor characteristics or operative techniques. A smaller proportion of Asians and Hispanics received neoadjuvant chemotherapy and/or radiation than Blacks and Whites. Relative to White, the Black race was independently associated with postoperative sepsis and reoperation. Both Black and Hispanic race/ethnicity were associated with prolonged intubation and delayed gastric emptying, and minorities races/ethnicities were associated with longer length of hospital stay. Relative to White, Hispanic, and Asian race/ethnicity were independently associated with a lower likelihood of neoadjuvant therapy (NAT) receipt.
CONCLUSIONS: In ACS-NSQIP participating hospitals, non-White race/ethnicity was independently associated with adverse outcomes after pancreatic cancer resection. A possible disparity in NAT receipt may exist in Asian and Hispanic patients undergoing surgical resection.

OBJECTIVE: To evaluate the rate of perioperative venous thromboembolism (VTE) among patients undergoing common benign urologic reconstructive cases. We hypothesize that this rate will be lower than previously described.
METHODS: We utilized the American College of Surgeons National Surgical Quality Improvement Project database from 2015 to 2019 to evaluate 30-day perioperative risk of VTE. Patients ≥ 18 years old undergoing benign urologic reconstructive cases were selected using Current Procedural Terminology (CPT) codes. Demographic, comorbidity, and operative variables were captured. The primary outcome was VTE within the 30-day postoperative period.
RESULTS: We identified 8467 patients who met inclusion criteria. The majority of patients were male (> 95%) with an average age of 65 and BMI of 29.6. There were 23 VTE events (0.27%) within the 30-day perioperative period. Fourteen (14/59) procedures had a perioperative VTE. Many of the traditional factors for VTE including operative time and obesity significantly increased risk of VTE in univariate analysis. In multivariate analysis, only BMI (OR 1.09; 95% CI 1.01-1.12) and inpatient status (OR 4.42; 95% CI 1.9-10.2) were correlated with increased perioperative VTE.
CONCLUSIONS: The rate of VTE among patients undergoing benign urologic reconstructive cases is low. Providers should continue to have high index of suspicion particularly for inpatients with high BMI in addition to other known risk factors for VTE.

UNASSIGNED: Various scoring systems help in classifying the patient\'s risk preoperatively and hence to decide the best available treatment option. ACS-NSQIP score has been introduced in clinical practice for few years. This study was done to find out whether there is any difference between predicted mortality from ACS-NSQIP score and observed mortality in Saudi population.
UNASSIGNED: This prospective observational study was conducted at Security Forces Hospital, Riyadh, Kingdom of Saudi Arabia. We included patients undergoing elective and emergency surgical procedures in our hospital. Thirty days mortality data was collected and then observed to expected (O/E) mortality ratio was calculated. The sample size for our study was nine hundred and three (903) patients.
UNASSIGNED: The mean ACS-NSQIP mortality risk score (%) for the study was 0.49. Expected number of mortalities was 4.42 while observed mortalities were 11, yielding an O/E ratio of 2.48 (p-value 0.000). We did not find a significant difference between expected and observed mortalities except for ASA class 3 and 4 patients where expected numbers of mortalities were lower than observed (p-value < 0.05).
UNASSIGNED: ACS-NSQIP can be reliably used for postoperative mortality prediction especially in lower risk groups.

BACKGROUND: Diabetes is a recognised risk for several chronic and acute illnesses, including increased complications in surgery for oesophageal cancer. Our primary aim is to determine the impact of diabetes on postoperative surgical and medical complications after oesophagectomy.
METHODS: All oesophagectomies for malignancy as reflected in the 2016-2018 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) datasets were extracted and analysed. Current Procedural Terminology (CPT) codes used were 1) open procedures (43107, 43108, 43112, 43113, 43116, 43117, 43118, 43121, 43122, and 43123) and 2) hybrid procedures (43186, 43287, and 43288). Logistic regression models examined associations between diabetic status and adverse outcomes. The associations were adjusted for sex, race, age group, operation year, CPT code, body mass index (BMI), smoking, congestive heart failure, antihypertensives, renal failure, and dyspnoea.
RESULTS: Two thousand five hundred and thirty-eight oesophagectomies were identified. 86.45% (n=2,194) underwent open procedures and 13.55% (n=344) had hybrid procedures. There were 177 insulin-dependent diabetics (IDDM) and 320 (12.61%) non-insulin-dependent diabetics (NIDDM). 84.14% were male and 77.74% were Caucasian. 89.48% of the patients were between 50 and 79 years of age. 40.27% experienced postoperative complications. Medical complications (odds ratio [OR]: 1.7, p-value: 0.002), surgical complications (OR: 1.9, p-value: <0.001), wound complications (OR: 2.9, p-value: <0.001), and anastomotic leaks (OR: 2.4, p-value: <0.001) were more common in diabetic patients. Subgroup analysis showed that in hybrid procedures, there is a statistically significant increase in the OR of surgical complications (OR: 3.61, p-value: 0.05), medical complications (OR: 3.76, p-value: 0.04), and anastomotic leak (OR: 3.49, p-value: 0.27) in IDDM as compared to NIDDM.
CONCLUSIONS: Insulin-dependent diabetes doubles the risk of all major complications compared to nondiabetics. When considering surgical approach and diabetic status (IDDM vs nondiabetics, NIDDM vs nondiabetics), the risk of complications further doubles for hybrid oesophagectomies compared to open procedures.

BACKGROUND: Patient selection for outpatient total joint arthroplasty (TJA) is important for optimizing patient outcomes. This study develops machine learning models that may aid in patient selection for outpatient TJA based on medical comorbidities and demographic factors.
METHODS: This study queried elective total knee arthroplasty (TKA) and total hip arthroplasty (THA) cases during 2010-2018 in the American College of Surgeons National Surgical Quality Improvement Program. Artificial neural network models predicted same-day discharge and length of stay (LOS) fewer than 2 days (short LOS). Multiple linear and logistic regression analyses were used to identify variables significantly associated with predicted outcomes.
RESULTS: A total of 284,731 TKA cases and 153,053 THA cases met inclusion criteria. For TKA, prediction of short LOS had an area under the receiver operating characteristic curve (AUC) of 0.767 and accuracy of 84.1%; prediction of same-day discharge had an AUC of 0.802 and accuracy of 89.2%. For THA, prediction of short LOS had an AUC of 0.757 and accuracy of 70.6%; prediction of same-day discharge had an AUC of 0.814 and accuracy of 78.8%.
CONCLUSIONS: This study developed machine learning models for aiding patient selection for outpatient TJA, through accurately predicting short LOS or outpatient vs inpatient cases. As outpatient TJA expands, it will be important to optimize preoperative patient selection and effectively screen surgical candidates from a broader patient population. Incorporating models such as these into electronic medical records could aid in decision-making and resource planning in real time.