j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e9
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Q1 16 17 18 Q14 19 20 21 Q2 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Pulmonary complications after major abdominal surgery: National Surgical Quality Improvement Program analysis Chun Kevin Yang, MD,* Annabelle Teng, MD, David Y. Lee, MD, and Keith Rose, MD Department of Surgery, Mount Sinai St. Luke’s Hospital and Mount Sinai Roosevelt Hospital, New York
article info
abstract
Article history:
Background: Postoperative pulmonary complications (PPCs) after major abdominal surgery
Received 29 December 2014
are common and associated with significant morbidity and high cost of care. The objective
Received in revised form
of this study was to identify the risk factors for PPCs after major abdominal surgery.
3 March 2015
Materials and methods: The American College of Surgeons’ National Surgical Quality
Accepted 12 March 2015
Improvement Program database from 2005e2012 was queried for patients who underwent
Available online xxx
major abdominal surgery (esophagectomy, gastrectomy, pacnreatectomy, enterectomy, hepatectomy, colectomy, and proctectomy). Predictors of PPCs were identified using
Keywords:
multivariate logistic regression.
ACS-NSQIP
Results: Of 165,196 patients who underwent major abdominal surgery 9595 (5.8%) suffered
Complications
PPCs (pneumonia 3.2%, prolonged ventilator support 48 h 3.0%, and unplanned intubation
Pneumonia
2.8%). On multivariate analysis, significant predictors of overall and individual PPCs include
Intubation
esophagectomy, advanced American Society of Anesthesiology Classification System,
Ventilation
dependent functional status, prolonged operative time, age 80 y, severe chronic
Postoperative
obstructive pulmonary disease, preoperative shock, ascites, and smoking. Obesity was not a risk factor. Female gender was overall protective for PPCs. Conclusions: PPCs after abdominal procedures are associated with a number of clinical variables. Esophageal operations and American Society of Anesthesiology Classification System were the strongest predictors. These results provide a framework for identifying patients at risk for developing pulmonary complications after major abdominal surgery. ª 2015 Elsevier Inc. All rights reserved.
1.
Introduction
After wound infections, postoperative pulmonary complications (PPCs) are the second-most common type of postoperative complication with an incidence estimated to range from 2.0%e5.6% [1,2]. PPCs have been shown to be one of the most significant factors associated with poor patient outcomes, leading to a longer hospital stay, increased likelihood
of rehospitalization, and increased mortality [3]. PPCs are also associated with significant additional costs with estimates ranging anywhere from 2- to 12-fold increases in estimated expenditures and reported excess costs-per-procedure of up to $120,000 [4,5]. Since the late 1990s, many PPC prediction calculators have been developed to assess patients at risk for these complications. Most of the models are based on retrospective,
* Corresponding author. Department of Surgery, Mount Sinai St. Luke’s Hospital and Mount Sinai Roosevelt Hospital, 1000 10th Avenue Suite 2B, New York, NY 10019.Tel: ---; fax: ---. Q3 E-mail address: [email protected] (C.K. Yang). 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2015.03.028
5.2.0 DTD YJSRE13207_proof 1 April 2015 3:27 pm ce
66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130
2
131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e9
single-institution data taken from cohorts of either broad surgical specialties or surgeries limited to one organ system. Furthermore, they have either defined a composite PPC outcome as a dependent variable or focused on singular pulmonary complications [1,3,6e9]. Additionally, large multicenter studies from Veterans Affairs have either excluded women or reviewed Veterans Affairs exclusive data and thus may not reflect the general population [10,11]. The aim of this study is to investigate the incidence of pulmonary complications after major abdominal surgeries, using the highly standardized American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) database. We specifically analyze three of the most significant pulmonary complications included under the PPC designation: pneumonia, unplanned intubations, and respiratory failure (failure to wean from the ventilator at 130 preoperative, intraoperative, and postoperative clinical variables. Additionally, 30d postoperative mortality and morbidity data are collected in the database. Currently, there are >300 hospitals that participate in this program [12]. The ACS-NSQIP Participant User File database was queried from 2005e2012 for major abdominal surgeries using current procedural terminology codes (Table 1). Major abdominal surgeries were categorized by system into the following: esophagectomy, gastrectomy, hepatectomy, pancreatectomy, enterectomy, colectomy, and proctectomy. We excluded emergent cases and patients with preoperative pulmonary complications including ventilator dependence and pneumonia from our analysis. Clinically relevant preoperative, intraoperative, and postoperative events were noted and reviewed. Because our study design was to cover all major abdominal surgeries, regardless of
organ system, our selection of variables was chosen to be generic rather than disease-specific. Variables were selected based on clinical relevance and were largely limited by the variable availability within the ACS-NSQIP database. All clinical variables in the ACS-NSQIP database are defined in the user guide [13]. Categorical variables were analyzed between the group with PPCs (PPCs present) and the group without PPCs (PPCs absent) using chi-square tests. Continuous variables were analyzed with Student’s t-test and the ManneWhitney U-test, where appropriate. A univariate binomial logistic regression analysis was performed for all factors studied. Additionally, a multivariate stepwise logistic regression analysis was used to generate odds ratios (ORs) for factors associated with PPCs. A P value 35 (kg/m2) >10% weight loss in last 6 mo Do not resuscitate status No Yes Cancer history Chemotherapy Radiotherapy Disseminated cancer Cardiovascular history Angina CHF MI PCI Cardiac surgery Pulmonary history No dyspnea Dyspnea at rest Dyspnea with exertion Severe COPD Renal history Preoperative AKI Preoperative dialysis dependent Endocrine history Non-insulin dependent diabetes Insulin dependent diabetes Chronic steroid use Gastrointestinal history Ascites CNS comorbidities Impaired sensorium Preoperative septic shock Smoking status 0 packs/y 1e20 packs/y 21e40 packs/y 41e60 packs/y
With PPCs (n ¼ 9565)
Without PPCs (n ¼ 155,631)
P Value
66.9 14.1 30.77% (2944) 49.06% (4693) 20.15% (1928)
60.4 15.4 48.01% (74,728) 41.40% (64,481) 10.55% (16,422)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Q1 16 17 18 Q14 19 20 21 Q2 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Pulmonary complications after major abdominal surgery: National Surgical Quality Improvement Program analysis Chun Kevin Yang, MD,* Annabelle Teng, MD, David Y. Lee, MD, and Keith Rose, MD Department of Surgery, Mount Sinai St. Luke’s Hospital and Mount Sinai Roosevelt Hospital, New York
article info
abstract
Article history:
Background: Postoperative pulmonary complications (PPCs) after major abdominal surgery
Received 29 December 2014
are common and associated with significant morbidity and high cost of care. The objective
Received in revised form
of this study was to identify the risk factors for PPCs after major abdominal surgery.
3 March 2015
Materials and methods: The American College of Surgeons’ National Surgical Quality
Accepted 12 March 2015
Improvement Program database from 2005e2012 was queried for patients who underwent
Available online xxx
major abdominal surgery (esophagectomy, gastrectomy, pacnreatectomy, enterectomy, hepatectomy, colectomy, and proctectomy). Predictors of PPCs were identified using
Keywords:
multivariate logistic regression.
ACS-NSQIP
Results: Of 165,196 patients who underwent major abdominal surgery 9595 (5.8%) suffered
Complications
PPCs (pneumonia 3.2%, prolonged ventilator support 48 h 3.0%, and unplanned intubation
Pneumonia
2.8%). On multivariate analysis, significant predictors of overall and individual PPCs include
Intubation
esophagectomy, advanced American Society of Anesthesiology Classification System,
Ventilation
dependent functional status, prolonged operative time, age 80 y, severe chronic
Postoperative
obstructive pulmonary disease, preoperative shock, ascites, and smoking. Obesity was not a risk factor. Female gender was overall protective for PPCs. Conclusions: PPCs after abdominal procedures are associated with a number of clinical variables. Esophageal operations and American Society of Anesthesiology Classification System were the strongest predictors. These results provide a framework for identifying patients at risk for developing pulmonary complications after major abdominal surgery. ª 2015 Elsevier Inc. All rights reserved.
1.
Introduction
After wound infections, postoperative pulmonary complications (PPCs) are the second-most common type of postoperative complication with an incidence estimated to range from 2.0%e5.6% [1,2]. PPCs have been shown to be one of the most significant factors associated with poor patient outcomes, leading to a longer hospital stay, increased likelihood
of rehospitalization, and increased mortality [3]. PPCs are also associated with significant additional costs with estimates ranging anywhere from 2- to 12-fold increases in estimated expenditures and reported excess costs-per-procedure of up to $120,000 [4,5]. Since the late 1990s, many PPC prediction calculators have been developed to assess patients at risk for these complications. Most of the models are based on retrospective,
* Corresponding author. Department of Surgery, Mount Sinai St. Luke’s Hospital and Mount Sinai Roosevelt Hospital, 1000 10th Avenue Suite 2B, New York, NY 10019.Tel: ---; fax: ---. Q3 E-mail address: [email protected] (C.K. Yang). 0022-4804/$ e see front matter ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2015.03.028
5.2.0 DTD YJSRE13207_proof 1 April 2015 3:27 pm ce
66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130
2
131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195
j o u r n a l o f s u r g i c a l r e s e a r c h x x x ( 2 0 1 5 ) 1 e9
single-institution data taken from cohorts of either broad surgical specialties or surgeries limited to one organ system. Furthermore, they have either defined a composite PPC outcome as a dependent variable or focused on singular pulmonary complications [1,3,6e9]. Additionally, large multicenter studies from Veterans Affairs have either excluded women or reviewed Veterans Affairs exclusive data and thus may not reflect the general population [10,11]. The aim of this study is to investigate the incidence of pulmonary complications after major abdominal surgeries, using the highly standardized American College of Surgeons’ National Surgical Quality Improvement Program (ACS-NSQIP) database. We specifically analyze three of the most significant pulmonary complications included under the PPC designation: pneumonia, unplanned intubations, and respiratory failure (failure to wean from the ventilator at 130 preoperative, intraoperative, and postoperative clinical variables. Additionally, 30d postoperative mortality and morbidity data are collected in the database. Currently, there are >300 hospitals that participate in this program [12]. The ACS-NSQIP Participant User File database was queried from 2005e2012 for major abdominal surgeries using current procedural terminology codes (Table 1). Major abdominal surgeries were categorized by system into the following: esophagectomy, gastrectomy, hepatectomy, pancreatectomy, enterectomy, colectomy, and proctectomy. We excluded emergent cases and patients with preoperative pulmonary complications including ventilator dependence and pneumonia from our analysis. Clinically relevant preoperative, intraoperative, and postoperative events were noted and reviewed. Because our study design was to cover all major abdominal surgeries, regardless of
organ system, our selection of variables was chosen to be generic rather than disease-specific. Variables were selected based on clinical relevance and were largely limited by the variable availability within the ACS-NSQIP database. All clinical variables in the ACS-NSQIP database are defined in the user guide [13]. Categorical variables were analyzed between the group with PPCs (PPCs present) and the group without PPCs (PPCs absent) using chi-square tests. Continuous variables were analyzed with Student’s t-test and the ManneWhitney U-test, where appropriate. A univariate binomial logistic regression analysis was performed for all factors studied. Additionally, a multivariate stepwise logistic regression analysis was used to generate odds ratios (ORs) for factors associated with PPCs. A P value 35 (kg/m2) >10% weight loss in last 6 mo Do not resuscitate status No Yes Cancer history Chemotherapy Radiotherapy Disseminated cancer Cardiovascular history Angina CHF MI PCI Cardiac surgery Pulmonary history No dyspnea Dyspnea at rest Dyspnea with exertion Severe COPD Renal history Preoperative AKI Preoperative dialysis dependent Endocrine history Non-insulin dependent diabetes Insulin dependent diabetes Chronic steroid use Gastrointestinal history Ascites CNS comorbidities Impaired sensorium Preoperative septic shock Smoking status 0 packs/y 1e20 packs/y 21e40 packs/y 41e60 packs/y
With PPCs (n ¼ 9565)
Without PPCs (n ¼ 155,631)
P Value
66.9 14.1 30.77% (2944) 49.06% (4693) 20.15% (1928)
60.4 15.4 48.01% (74,728) 41.40% (64,481) 10.55% (16,422)
