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  • Author or Editor: Duncan Neuhauser x
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Andreea Seicean, Prateek Kumar, Sinziana Seicean, Duncan Neuhauser and Robert J. Weil

OBJECTIVE

The goal of this study was to compare outcomes of carotid endarterectomy performed by neurological, general, and vascular surgeons.

METHODS

The authors identified 80,475 patients who underwent carotid endarterectomy between 2006 and 2015 in the National Surgical Quality Improvement Program, a prospectively collected, national clinical database with established reproducibility and validity. Nine hundred forty-three patients were operated on by a neurosurgeon; 75,649 by a vascular surgeon; and 3734 by a general surgeon. Preoperative and intraoperative characteristics and 30-day outcomes were stratified by the surgeon’s primary specialty. Using propensity scores, comprising pre- and intraoperative characteristics as well as procedure and diagnostic codes, the authors matched 203 neurosurgery (NS) patients to 203 vascular surgery (VS) patients and 203 NS patients to 203 general surgery (GS) patients. No pre- or intraoperative factors were significantly different between specialties in the matched sample. Regular logistic regression and conditional logistic regression were used to predict postoperative complications in the full sample and in the matched sample.

RESULTS

In the complete population sample, NS patients, when compared to patients of general and vascular surgeons, were less likely to be admitted from home and more likely to have carotid artery occlusion or stenosis with cerebral infarction, to be a current smoker, to have had recent chemo- or radiotherapy, to have surgery under general anesthesia, to undergo multiple procedures, and to have longer surgery times. In unadjusted analyses, NS patients were more likely to experience major complications (NS vs VS: odds ratio 1.3, 95% CI 1.1–1.6; NS vs GS: odds ratio 1.3, 95% CI 1.0–1.7); minor complications (NS vs VS: odds ratio 2.9, 95% CI 2.0–4.1; NS vs GS: odds ratio 2.7, 95% CI 1.7–4.2); intra- or postoperative transfusions (NS vs VS: odds ratio 1.6, 95% CI 1.4–1.9; NS vs GS: odds ratio 1.9, 95% CI 1.6–2.3); prolonged hospitalization (NS vs VS: odds ratio 3.0, 95% CI 2.6–3.5; NS vs GS: odds ratio 2.6, 95% CI 2.2–3.0); and discharge to skilled care facilities (NS vs VS: odds ratio 2.8, 95% CI 2.3–3.4; NS vs GS: odds ratio 3.1, 95% CI 2.4–4.1). In adjusted, propensity-matched analyses, however, patients’ outcome with carotid endarterectomy performed by NS was comparable with those completed by GS and VS.

CONCLUSIONS

Patients who undergo carotid endarterectomy performed by a neurosurgeon tend to have a greater preoperative disease burden than do those treated by a general or vascular surgeon, which contributes significantly to more morbid postoperative courses. In patients matched carefully on the basis of health status at the time of surgery and intraoperative variables that affect results, patients’ outcomes after carotid endarterectomy do not appear to depend on the attending surgeon’s primary specialty.

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Andreea Seicean, Nicholas K. Schiltz, Sinziana Seicean, Nima Alan, Duncan Neuhauser and Robert J. Weil

Object

The utility of preoperative hemostasis screening to predict complications is uncertain. The authors quantified the screening rate in US neurosurgery patients and evaluated the ability of abnormal test results as compared with history-based risk factors to predict hemostasis-related and general outcomes.

Methods

Eleven thousand eight hundred four adult neurosurgery patients were identified in the 2006–2009 American College of Surgeons National Surgical Quality Improvement Program database. Multivariate logistic regression modeled the ability of hemostatic tests and patient history to predict outcomes, that is, intra- and postoperative red blood cell [RBC] transfusion, return to the operating room [OR], and 30-day mortality. Sensitivity analyses were conducted using patient subgroups by procedure.

Results

Most patients underwent all 3 hemostatic tests (platelet count, prothrombin time/international normalized ratio [INR], activated partial thromboplastin time), but few had any of the outcomes of interest. The number of screening tests undergone was significantly associated with intraoperative RBC transfusion, a return to the OR, and mortality; an abnormal INR was associated with postoperative RBC transfusion. However, all tests had low sensitivity (0.09–0.2) and platelet count had low specificity (0.04–0.05). The association between patient history and each outcome was approximately the same across all tests, with higher sensitivity but lower specificity. Combining abnormal tests with patient history accounted for 50% of the mortality and 33% of each of the other outcomes.

Conclusions

This is the first study focused on assessing preoperative hemostasis screening as compared with patient history in a large multicenter sample of adult neurosurgery patients to predict hemostasis-related outcomes. Patient history was as predictive as laboratory testing for all outcomes, with higher sensitivity. Routine laboratory screening appears to have limited utility. Testing limited to neurosurgical patients with a positive history would save an estimated $81,942,000 annually.

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Nima Alan, Andreea Seicean, Sinziana Seicean, Duncan Neuhauser and Robert J. Weil

Object

The objective of this study was to assess whether preoperative anemia in patients undergoing elective cranial surgery influences outcomes in the immediate perioperative period (≤ 30 days).

Methods

The National Surgical Quality Improvement Program (NSQIP) was used to identify 6576 patients undergoing elective cranial surgery between 2006 and 2011. Propensity scores were used to match patients with moderate to severe anemia (moderate-severe) or mild anemia with patients without anemia. Logistic regression analysis was used to predict the outcomes of interest. Sensitivity analyses were used to limit the sample to patients without perioperative transfusion as well as those who underwent craniotomy for definitive resection of a malignant brain tumor.

Results

A total of 6576 patients underwent elective cranial surgery, of whom 175 had moderate-severe anemia and 1868 had mild anemia. Patients with moderate-severe (odds ratio 1.8, 95% CI 1.1–2.8) and mild (odds ratio 1.5, 95% CI 1.3–1.7) anemia were more likely to have prolonged length of stay (LOS) in the hospital compared to those with no anemia. Similarly, in patients who underwent craniotomy for a malignant tumor resection (n = 2537), anemia of any severity was associated with prolonged LOS, but not postoperative complications nor death.

Conclusions

Anemia is not associated with an overall increased risk for adverse outcomes in patients undergoing elective cranial surgery. However, patients with anemia are more likely to experience prolonged hospitalization postoperatively, resulting in increased resource utilization.

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Andreea Seicean, Nima Alan, Sinziana Seicean, Duncan Neuhauser, Warren R. Selman and Nicholas C. Bambakidis

OBJECT

Preoperative anemia may be treated with a blood transfusion. Both are associated with adverse outcomes in various surgical procedures, but this has not been clearly elucidated in surgery for cerebral aneurysms. In this study the authors assessed the association of preoperative anemia and perioperative blood transfusion, separately, on 30-day morbidity and mortality in patients undergoing open surgery for ruptured and unruptured intracranial aneurysms.

METHODS

The authors identified 668 cases (including 400 unruptured and 268 unruptured intracranial aneurysms) of open surgery for treatment of intracranial aneurysms in the 2006–2012 National Surgical Quality Improvement Program, a validated and reproducible prospective clinical database. Anemia was defined as a hematocrit level less than 39% in males and less than 36% in females. Perioperative transfusion was defined as at least 1 unit of packed or whole red blood cells given at any point between the start of surgery to 72 hours postoperatively. The authors separately compared surgical outcome between patients with (n = 198) versus without (n = 470) anemia, and those who underwent (n = 78) versus those who did not receive (n = 521) a transfusion, using a 1:1 match on propensity score.

RESULTS

In the matched cohorts, all observed covariates were comparable between anemic (n = 147) versus nonanemic (n = 147) and between transfused (n = 67) versus nontransfused patients (n = 67). Anemia was independently associated with prolonged hospital length of stay (LOS; odds ratio [OR] 2.5, 95% confidence interval [CI] 1.4–4.5), perioperative complications (OR 1.9, 95% CI 1.1–3.1), and return to the operating room (OR 2.1, 95% CI 1.1–4.5). Transfusion was also independently associated with perioperative complications (OR 2.4, 95% CI 1.1–5.3).

CONCLUSIONS

Preoperative anemia and transfusion are each independent risk factors for perioperative complications in patients undergoing surgery for cerebral aneurysms. Perioperative anemia is also associated with prolonged hospital LOS and 30-day return to the operating room.

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Nima Alan, Andreea Seicean, Sinziana Seicean, Nicholas K. Schiltz, Duncan Neuhauser and Robert J. Weil

Object

The goal in this study was to assess whether a current or prior history of smoking and the number of smoking pack years affect the risk for adverse outcomes in the 30-day postoperative period in patients who undergo elective cranial surgery.

Methods

Data from the 2006–2011 American College of Surgeons' National Surgical Quality Improvement Project were used in this study. The authors identified 8296 patients who underwent elective cranial surgery, of whom 1718 were current smokers, 854 were prior smokers, and 5724 were never smokers. Using propensity scores and age, the authors matched current and prior smokers to never smokers. Odds ratios for adverse postoperative outcomes were predicted with logistic regression. The relationship between number of pack years and poor outcomes was also examined.

Results

In unadjusted analyses, prior and current smokers did not differ from never smokers for having poor outcomes postoperatively. Similarly, in matched analyses, no association was found between smoking and adverse outcomes. Number of pack years in propensity-matched analyses did not predict worse outcomes in prior or current smokers versus never smokers.

Conclusions

The authors did not find smoking to be associated with 30-day postoperative morbidity or mortality. Although smoking cessation is beneficial for overall health, it may not improve the short-term (≤ 30 days) outcome of elective cranial surgery. Thus postponement of elective cranial cases only for smoking cessation may not be necessary.