Importance

Advances in perioperative cardiac management and an increase in the number of endovascular procedures have made significant contributions to patients and postoperative myocardial infarction (POMI) risk following high-risk vascular procedures. Whether these changes have translated into real-world improvements in POMI incidence remain unknown.

Objective

To examine the temporal trends of myocardial infarction (MI) following high-risk vascular procedures.

Design, setting, and participants

A retrospective cohort study was performed using data collected from January 1, 2005, to December 31, 2013, in the American College of Surgeons National Surgery Quality Improvement Program database, to which participating hospitals across the United States report their preoperative, operative, and 30-day outcome data. A total of 90 303 adults who underwent a high-risk vascular procedure-open aortic surgery or infrainguinal bypass-during the study period were identified. Patients were divided into cohorts based on their year of operation, and their baseline cardiac risk factors and incidence of POMI were compared. Cases from 2005 to 2014 in the database were eligible for inclusion if one of their Current Procedural Terminology codes matched any of the operations identified as a high-risk vascular procedure. Data analysis took place from August 1, 2016, to November 15, 2016.

Exposures

The main exposure was the year of the operation. Other variables of interest included demographics, comorbidities, and other risk factors for MI.

Main outcomes and measures

Primary outcome of interest was the incidence of POMI.

Results

Of the 90 303 patients included in the study, 22 836 (25.3%) had undergone open aortic surgery and 67 467 (74.7%) had had infrainguinal bypass. The open aortic cohort comprised 16 391 men (71.9%), had a mean (SD) age of 69.1 (11.5) years, and was predominantly white (18 440 patients [80.8%] self-identified as white race/ethnicity). The infrainguinal bypass cohort included 41 845 men (62.1%), had a mean (SD) age of 66.7 (11.7) years, and had 51 043 patients (75.7%) who self-identified as white race/ethnicity. During the study period, patients who underwent open aortic procedures were more likely to be classified as American Society of Anesthesiologists class IV (7426 patients [32.6%] vs 15 683 [23.3%] for the infrainguinal bypass cohort) or class V (1131 [5.0%] vs 206 [0.3%]; P < .001) and to undergo emergency procedures (4852 [21.3%] vs 4954 [7.3%]; P < .001). The open aortic procedure cohort also experienced significantly higher actual incidence of POMI (464 [3.0%] vs 1270 [1.9%]; P < .001). From 2009 to 2014, the incidence of POMI demonstrated no substantial temporal change (2.7% in 2009 to 3.1% in 2014; P = .64 for trend). Postoperative MI was consistently associated with poor prognosis, with a 3.62-fold (95% CI, 2.25-5.82) to 11.77-fold (95% CI, 6.10-22.72) increased odds of cardiac arrest and a 3.01-fold (95% CI, 2.08-4.36) to 6.66-fold (95% CI, 4.66-9.52) increased odds of mortality.

Conclusions and relevance

The incidence of MI did not significantly decrease in the past decade and has been consistently associated with worse clinical outcomes. Further inquiry into why advanced perioperative care did not reduce cardiac complications is important to quality improvement efforts.

This cohort study analyzes the cost and stabilization of disease in patients undergoing transcatheter and surgical aortic valve replacement.

Introduction

Cardiovascular complications are the leading cause of death after noncardiac surgery. Major abdominal operations represent the largest category of procedures considered to have an increased risk of cardiovascular complications. The current aim was to examine trends in the incidence of mortality, perioperative myocardial infarction, and cardiac arrest to determine the presence of potential volume-outcome relationships.

Methods

We performed a retrospective analysis of the Nationwide Inpatient Sample for patients undergoing elective, open abdominal esophagectomy, gastrectomy, pancreatectomy, nephrectomy, hepatectomy, splenectomy, and colectomy (major abdominal surgery) during 2008-2014. Univariate and multivariate analyses were performed to determine the impact of operative volume on rates of myocardial infarction, cardiac arrest, and mortality.

Results

Of the 962,754 elective admissions for major abdominal surgery, 1.4% experienced in-hospital mortality, 0.7% myocardial infarction, and 0.35% cardiac arrest. Myocardial infarction and cardiac arrest were associated with a 24-fold increase in risk of perioperative mortality. Compared with institutions that have a very low volume of operations, those hospitals with larger volumes of operations had a decreased risk of cardiac arrest and incident mortality after cardiovascular complications, but the odds of myocardial infarction were greatest at higher operative-volume hospitals. The annual all-cause mortality and myocardial infarction rates decreased over time, but the incidence of cardiac arrest increased.

Conclusion

Myocardial infarction or cardiac arrest after major abdominal surgery increased the odds of mortality with superior rescue after cardiovascular complications at higher volume institutions. Across all US hospitals performing major abdominal surgery, the rate of cardiac arrest increased without a concomitant increase in myocardial infarction or mortality. Novel targets for risk modification of myocardial infarction and cardiac arrest as well as investigation of processes that facilitate rescue after these complications at higher operative-volume hospitals are needed to delineate quality improvement opportunities.

Patients with renal dysfunction are at increased risk for developing aortic valve pathology. In the present era of value-based healthcare delivery, a comparison of transcatheter and surgical aortic valve replacement (SAVR) readmission performance in this population is warranted. All adult patients who underwent transcatheter or SAVR from 2011 to 2014 were identified using the Nationwide Readmissions Database, containing data for nearly 50% of US hospitalizations. Patients were further stratified as chronic kidney disease stage 1 to 5 as well as end-stage renal disease requiring dialysis. Kaplan-Meier, Cox Hazard, and multivariable regression models were generated to identify predictors of readmission and costs. Of the 350,609 isolated aortic valve replacements, 4.7% of patients suffered from chronic kidney disease stages 1 to 5 or end-stage renal disease. Transcatheter aortic valve patients with chronic kidney disease stages 1 to 5/or end-stage renal disease were older (81.9 vs 72.9 years, p <0.0001) with a higher prevalence of heart failure (15.2 vs 4.3%, p = 0.04), and peripheral vascular disease (31.1 vs 22.8%, p <0.0001) compared to their SAVR counterparts. Transcatheter aortic valve replacement in chronic kidney disease stage 1 to 3 patients had a higher rate of readmission due to heart failure and pacemaker placement than SAVR. Transcatheter aortic valve replacement was associated with increased costs compared with SAVR for all renal failure patients. In conclusion, in this national cohort of chronic and end-stage renal disease patients, transcatheter aortic valve implantation was associated with increased mortality, readmissions for chronic kidney disease stages1 to 3, and index hospitalization costs.

Background

Although it is well known that obesity is a risk factor for gastrointestinal (GI) cancer, it is not well established if obesity can cause earlier GI cancer onset.

Methods

A cross-sectional study examining the linked 2004-2008 California Cancer Registry Patient Discharge Database was performed to evaluate the association between obesity and onset age among four gastrointestinal cancers, including esophageal, gastric, pancreatic, and colorectal cancers. Regression models were constructed to adjust for other carcinogenic factors.

Results

The diagnosis of obesity (BMI > 30) was associated with a reduction in diagnosis age across all four cancer types: 3.25 ± 0.53 years for gastric cancer, 4.56 ± 0.18 years for colorectal cancer, 4.73 ± 0.73 years for esophageal cancer, and 5.35 ± 0.72 for pancreatic cancer. The diagnosis of morbid obesity (BMI > 40) was associated with a more pronounced reduction in the age of diagnosis: 5.48 ± 0.96 years for gastric cancer, 7.75 ± 0.30 years for colorectal cancer, 7.67 ± 1.26 years for esophageal cancer, and 8.19 ± 1.25 years for pancreatic cancer. Both morbid obesity and obesity remained strongly associated with earlier cancer diagnosis for all four cancer types even after adjusting for other available cancer risk factors.

Conclusions

The diagnosis of obesity, especially morbid obesity, was associated with a significantly earlier gastrointestinal cancer onset in California. Further research with prospective cohort data may be required to establish the causal relationship between obesity and cancer onset age.

Background

As the technology of ventricular assist devices continues to improve, the morbidity and mortality for patients with a ventricular assist device is expected to approach that of orthotopic heart transplantation. The present study was performed to compare perioperative outcomes, readmission, and resource utilization between ventricular assist device implantation and orthotopic heart transplantation, using a national cohort.

Methods

Patients who underwent either orthotopic heart transplantation or ventricular assist device implantation from 2010 to 2014 in the National Readmission Database were selected.

Results

Of the 12,111 patients identified during the study period, 5,440 (45%) received orthotopic heart transplantation, while 6,671 (55%) received ventricular assist devices. Readmissions occurred frequently after ventricular assist device implantation and orthotopic heart transplantation, with greater rates at 30 days (29% versus 24%, P=.005) and 6 months (62% versus 46%, P < .001) for the ventricular assist device cohort. Cost of readmission was greater among ventricular assist device patients at 30 days ($29,115 versus $21,586, P=.0002) and 6 months ($34,878 versus $20,144, P = .0106).

Conclusion

Readmission rates and costs for patients with a ventricular assist device remain greater than their orthotopic heart transplantation counterparts. Given the projected increases in ventricular assist device utilization and limited transplant donor pool, further emphasis on cost containment and decreased readmissions for patients undergoing a ventricular assist device is essential to the viability of such therapy in the era of value-based health care delivery.

Purpose

Over the past decade, an increasing number of bariatric surgeons are trained in fellowships annually despite only a modest increase in nationwide bariatric surgery volume. The study surveys the bariatric surgery job market trend in order to inform better career-choice decisions for trainees interested in this field.

Materials and methods

A national retrospective cohort survey over an 11-year period was conducted. Bariatric surgery fellowship graduates from 2008 to 2019 and program directors (PDs) were surveyed electronically. Univariate analysis was performed comparing responses between earlier (2008-2016) and recent graduates (2017-2019).

Results

We identified a total of 996 graduates and 143 PDs. Response rates were 9% and 20% respectively (n = 88, 29). Sixty-eight percent of graduates felt there are not enough bariatric jobs for new graduates. Seventy-nine percent of PDs felt that it is more difficult to find a bariatric job for their fellows now than 5-10 years ago. Forty-eight percent of PDs felt that we are training too many bariatric fellows. Seventy-seven percent of all graduates want the majority of their practice to be comprised bariatric cases; however, only 42% of them reported achieving this. In the univariate analysis, recent graduates were less likely to be currently employed as a bariatric surgeon (64% vs. 86%, p = 0.02) and were less satisfied with their current case volume (42% vs. 66%, p = 0.01).

Conclusions

The temporal increase in bariatric fellowship graduates over the past decade has resulted in a significant decline in the likelihood of employment in a full-time bariatric surgical practice and a decline in surgeons' bariatric case volumes.

As robotic surgery has increased in popularity, the lack of haptic feedback has become a growing issue due to the application of excessive forces that may lead to clinical problems such as intraoperative and postoperative suture breakage. Previous suture breakage warning systems have largely depended on visual and/or auditory feedback modalities, which have been shown to increase cognitive load and reduce operator performance. This work catalogues a new sensing technology and haptic feedback system (HFS) that can reduce instances of suture failure without negatively impacting performance outcomes including knot quality. Suture breakage is common in knot-tying as the pulling motion introduces prominent shear forces. A shear sensor mountable on the da Vinci robotic surgical system's Cadiere grasper detects forces that correlate to the suture's internal tension. HFS then provides vibration feedback to the operator as forces near a particular material's failure load. To validate the system, subjects tightened a total of four knots, two with the Haptic Feedback System (HFS) and two without feedback. The number of suture breakages were recorded and knot fidelity was evaluated by measuring knot slippage. Results showed that instances of suture failure were significantly reduced when HFS was enabled (p = 0.0078). Notably, knots tied with HFS also showed improved quality compared to those tied without feedback (p = 0.010). The results highlight the value of HFS in improving robotic procedure outcomes by reducing instances of suture failures, producing better knots, and reducing the need for corrective measures.