The impact of surgeon experience on perioperative complications and operative measures following thoracolumbar 3-column osteotomy for adult spinal deformity: overcoming the learning curve

2020 ◽  
Vol 32 (2) ◽  
pp. 207-220 ◽  
Author(s):  
Darryl Lau ◽  
Vedat Deviren ◽  
Christopher P. Ames
Keyword(s):  
Blood Loss ◽  
Operative Time ◽  
Surgical Complication ◽  
Perioperative Complications ◽  
Adult Spinal Deformity ◽  
Neurological Deficits ◽  
Complication Rates ◽  
Years Of Experience ◽  
Surgeon Experience ◽  
Operative Measures

OBJECTIVEPosterior-based thoracolumbar 3-column osteotomy (3CO) is a formidable surgical procedure. Surgeon experience and case volume are known factors that influence surgical complication rates, but these factors have not been studied well in cases of adult spinal deformity (ASD). This study examines how surgeon experience affects perioperative complications and operative measures following thoracolumbar 3CO in ASD.METHODSA retrospective study was performed of a consecutive cohort of thoracolumbar ASD patients who underwent 3CO performed by the senior authors from 2006 to 2018. Multivariate analysis was used to assess whether experience (years of experience and/or number of procedures) is associated with perioperative complications, operative duration, and blood loss.RESULTSA total of 362 patients underwent 66 vertebral column resections (VCRs) and 296 pedicle subtraction osteotomies (PSOs). The overall complication rate was 29.4%, and the surgical complication rate was 8.0%. The rate of postoperative neurological deficits was 6.2%. There was a trend toward lower overall complication rates with greater operative years of experience (from 44.4% to 28.0%) (p = 0.115). Years of operative experience was associated with a significantly lower rate of neurological deficits (p = 0.027); the incidence dropped from 22.2% to 4.0%. The mean operative time was 310.7 minutes overall. Both increased years of experience and higher case numbers were significantly associated with shorter operative times (p < 0.001 and p = 0.001, respectively). Only operative years of experience was independently associated with operative times (p < 0.001): 358.3 minutes from 2006 to 2008 to 275.5 minutes in 2018 (82.8 minutes shorter). Over time, there was less deviation and more consistency in operative times, despite the implementation of various interventions to promote fusion and prevent construct failure: utilization of multiple-rod constructs (standard, satellite, and nested rods), bone morphogenetic protein, vertebroplasty, and ligament augmentation. Of note, the use of tranexamic acid did not significantly lower blood loss.CONCLUSIONSSurgeon years of experience, rather than number of 3COs performed, was a significant factor in mitigating neurological complications and improving quality measures following thoracolumbar 3CO for ASD. The 3- to 5-year experience mark was when the senior surgeon overcame a learning curve and was able to minimize neurological complication rates. There was a continuous decrease in operative time as the surgeon’s experience increased; this was in concurrence with the implementation of additional preventative surgical interventions. Ongoing practice changes should be implemented and can be done safely, but it is imperative to self-assess the risks and benefits of those practice changes.

scholarly journals The Effect of Systemic Tranexamic Acid on Hypercoagulable Complications and Perioperative Outcomes Following Three-Column Osteotomy for Adult Spinal Deformity

2020 ◽  
pp. 219256822095381
Author(s):  
Alexander F. Haddad ◽  
Christopher P. Ames ◽  
Michael Safaee ◽  
Vedat Deviren ◽  
Darryl Lau
Keyword(s):  
Blood Loss ◽  
Tranexamic Acid ◽  
Spinal Deformity ◽  
Operative Time ◽  
Adult Spinal Deformity ◽  
High Volume ◽  
Perioperative Outcomes ◽  
Surgeon Experience ◽  
Volume Blood ◽  
High Doses

Study Design: Retrospective cohort study. Objective: Thoracolumbar 3-column osteotomy (3CO) is a powerful technique for correction of rigid adult spinal deformity (ASD). However, it can be associated with high-volume blood loss. This study seeks to investigate the efficacy and safety of tranexamic acid (TXA) in 3CO ASD patients. Methods: ASD patients who underwent 3CO from 2006 to 2019 were retrospectively reviewed. Outcomes were compared between TXA and non-TXA patients, and TXA doses. Results: A total of 365 ASD patients were included: 181 TXA and 184 non-TXA. The mean age was 64.6 years and 60.5% were female. Operative time was shorter in the TXA group (295.6 vs 320.2 minutes, P < .001). However, TXA was not associated with shorter operative time (β = −6.5 minutes, 95% CI −29.0 to 15.9, P = .567) after accounting for surgeon experience. There was no difference in blood loss (2020.2 vs 1914.1 mL, P = .437) between groups. Overall complications (37.0% vs 33.2%, P = .439), including hypercoagulable (2.2% vs 3.8%, P = .373) and cardiac (13.3% vs 7.1%, P = .050) complications were similar between groups. TXA was not independently associated with blood loss or TXA-related complications. Both groups had comparable intensive care unit (2.5 vs 2.0 days, P = .060) and hospital (8.9 vs 8.2 days, P = .190) stays. There were no differences in outcomes between TXA dosing subgroups. Conclusions: Systemic TXA use during 3CO for ASD surgery was not associated with decreased blood loss. TXA patients had shorter operative times, but this was driven mainly by surgeon experience on multivariate analysis. Routine use of TXA is safe and does not increase the incidence of hypercoagulable complications even at high doses.

scholarly journals Predictors for Unfavorable Early Outcomes in Elective Total Hip Arthroplasty: Does Extreme Body Mass Index Matter?

2019 ◽  
Vol 2019 ◽  
pp. 1-8
Author(s):  
Chun-Yu Hung ◽  
Chih-Hsiang Chang ◽  
Yu-Chih Lin ◽  
Shen-Hsun Lee ◽  
Szu-Yuan Chen ◽  
...  
Keyword(s):  
Body Mass Index ◽  
Total Hip Arthroplasty ◽  
Blood Loss ◽  
Operative Time ◽  
Perioperative Complications ◽  
Length Of Hospital Stay ◽  
Normal Weight ◽  
Morbidly Obese ◽  
Complication Rates ◽  
Cardiovascular Comorbidities

Background. Studies of previous cohorts have demonstrated a controversial association between extreme body mass index (BMI) and complication rates following total hip arthroplasty (THA). The purpose of this study was to compare 30-day perioperative complications in underweight (BMI <18.50 kg/m2), normal-weight (BMI 18.50–24.99 kg/m2), overweight (BMI 25.00–29.99 kg/m2), class I obesity (BMI 30.00–34.99 kg/m2), and morbidly obese (BMI ≥35.00 kg/m2) groups. Methods. We performed a cohort study including patients who underwent unilateral primary THA by a single surgeon between January 2010 and December 2015 at our institution. We assessed 30-day complications, operation time, operative blood loss, and length of hospital stay. Results. We identified 1565 primary THAs that were performed in patients with varying BMI levels. Compared with the normal-weight patients, the morbidly obese group had a higher 30-day complication rate (8.9% vs. 2.4%), longer operative time (79 minutes vs. 70 minutes), and more blood loss (376 mL vs. 302 mL). Underweight patients did not present any 30-day complications, and there were no differences among underweight and normal-weight patients regarding complication rates, operative time, or blood loss. The mean length of hospital stay was comparable among the different BMI groups. In the multivariate regression model, higher BMI was not associated with a higher risk of 30-day complications. Independent risk factors for 30-day complications were advanced age, prolonged operative time, and cardiovascular comorbidities. Conclusion. Although increased operative time, blood loss, and perioperative complications were seen in the morbidly obese patients, BMI alone was not an independent risk factor for a higher 30-day complication rate. Therefore, our data suggest clinicians should make elderly patients aware of increased 30-day complications before the procedure, particularly those with cardiovascular comorbidities. Withholding THA solely on the basis of BMI is not justified.

STANDARD OPEN MICRODISCECTOMY VERSUS MINIMAL ACCESS TROCAR MICRODISCECTOMY

Neurosurgery ◽  
2008 ◽  
Vol 62 (1) ◽  
pp. 174-182 ◽  
Author(s):  
Yu-Mi Ryang ◽  
Markus F. Oertel ◽  
Lothar Mayfrank ◽  
Joachim M. Gilsbach ◽  
Veit Rohde
Keyword(s):  
Blood Loss ◽  
Visual Analog Scale ◽  
Oswestry Disability Index ◽  
Operative Time ◽  
Short Form ◽  
Lumbar Disc ◽  
Complication Rates ◽  
Minimal Access ◽  
Analog Scale ◽  
Short Form 36

Abstract OBJECTIVE Minimal access surgery as a less invasive alternative to standard macro- and microsurgical approaches is becoming increasingly popular in the management of traumatic and degenerative spine diseases. However, data is lacking if minimal access spine surgery is indeed beneficial. This prospective randomized study was conducted to compare efficiency, safety, and outcome of standard open microsurgical discectomy (SOMD) for lumbar disc herniation with microsurgical discectomy using an 11.5 mm trocar system for minimal access to the spine. METHODS Sixty patients were randomized to two groups of 30 patients each. Group 1 was treated by SOMD, and Group 2 was treated by minimal access microsurgical discectomy (MAMD). Perioperative parameters and pre- and postoperative clinical findings including sensory or motor deficits and pain according to the visual analog scale, Oswestry Disability Index scores, and Short Form-36 results were assessed. All patients were followed for at least 6 months postoperatively (mean, 16 mo). RESULTS Preoperatively, no statistically significant intergroup differences could be detected proving the comparability of both groups. Postoperatively, significant improvement of neurological symptoms and pain as measured by the visual analog scale, Oswestry Disability Index, and Short Form-36 scores could be achieved in both groups. In regard to operative time, intraoperative blood loss, and complication rate, slightly better results were observed in the MAMD group. CONCLUSION SOMD and MAMD allow achievement of significant improvement of pain and neurological deficits in patients with lumbar disc herniations. Differences in operative time, blood loss, and complication rates were statistically not significant in MAMD compared with SOMD, indicating that, at least in lumbar disc surgery, minimal access trocar techniques are a viable alternative to standard spinal approaches.

scholarly journals Surgical Outcomes for Minimally Invasive vs Open Transforaminal Lumbar Interbody Fusion

Neurosurgery ◽  
2015 ◽  
Vol 77 (6) ◽  
pp. 847-874 ◽  
Author(s):  
Nickalus R. Khan ◽  
Aaron J. Clark ◽  
Siang Liao Lee ◽  
Garrett T. Venable ◽  
Nicholas B. Rossi ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Blood Loss ◽  
Minimally Invasive ◽  
Radiation Exposure ◽  
Interbody Fusion ◽  
Operative Time ◽  
Meta Analysis ◽  
Transforaminal Lumbar Interbody Fusion ◽  
Complication Rates ◽  
Lumbar Interbody Fusion

BACKGROUND: Minimally invasive transforaminal lumbar interbody fusion (TLIF)—or MI-TLIF—has been increasing in prevalence compared with open TLIF (O-TLIF) procedures. The use of MI-TLIF is an evolving technique with conflicting reports in the literature about outcomes. OBJECTIVE: To investigate the impact of MI-TLIF in comparison with O-TLIF for early and late outcomes by using the Visual Analog Scale for back pain (VAS-back) and the Oswestry Disability Index (ODI). Secondary end points include blood loss, operative time, radiation exposure, length of stay, fusion rates, and complications between the 2 procedures. METHODS: During August 2014, a systematic literature search was performed identifying 987 articles. Of these, 30 met inclusion criteria. A random-effects meta-analysis was performed by using both pooled and subset analyses based on study type. RESULTS: Our meta-analysis demonstrated that MI-TLIF reduced blood loss (P &lt; .001), length of stay (P &lt; .001), and complications (P = .001) but increased radiation exposure (P &lt; .001). No differences were found in fusion rate (P = .61) and operative time (P = .34). A decrease in late VAS-back scores was demonstrated for MI TLIF (P &lt; .001), but no differences were found in early VAS-back, early ODI, and late ODI. CONCLUSION: MI-TLIF is associated with reduced blood loss, decreased length of stay, decreased complication rates, and increased radiation exposure. The rates of fusion and operative time are similar between MI-TLIF and O-TLIF. Differences in long-term outcomes in MI-TLIF vs O-TLIF are inconclusive and require more research, particularly in the form of large, multi-institutional prospective randomized controlled trials.

Role of Frameless Stereotaxy in the Surgical Treatment of Cerebral Arteriovenous Malformations: Technique and Outcomes in a Controlled Study of 44 Consecutive Patients

Neurosurgery ◽  
2002 ◽  
Vol 51 (5) ◽  
pp. 1108-1118 ◽  
Author(s):  
Stephen M. Russell ◽  
Henry H. Woo ◽  
Seth S. Joseffer ◽  
Jafar J. Jafar
Keyword(s):  
Blood Loss ◽  
Arteriovenous Malformations ◽  
Operative Time ◽  
Controlled Study ◽  
Frameless Stereotaxy ◽  
Complication Rates ◽  
Cerebral Arteriovenous Malformations ◽  
Estimated Blood Loss ◽  
Group 2 ◽  
Group 1

Abstract OBJECTIVE To describe a frameless stereotactic technique used to resect cerebral arteriovenous malformations (AVMs) and to determine whether frameless stereotaxy during AVM resection could decrease operative times, minimize intraoperative blood losses, reduce postoperative complications, and improve surgical outcomes. METHODS Data for 44 consecutive patients with surgically resected cerebral AVMs were retrospectively reviewed. The first 22 patients underwent resection without stereotaxy (Group 1), whereas the next 22 patients underwent resection with the assistance of a frameless stereotaxy system (Group 2). RESULTS The patient characteristics, AVM morphological features, and percentages of preoperatively embolized cases were statistically similar for the two treatment groups. The mean operative time for Group 1 was 497 minutes, compared with 290 minutes for Group 2 (P = 0.0005). The estimated blood loss for Group 1 was 657 ml, compared with 311 ml for Group 2 (P = 0.0008). Complication rates, residual AVM incidences, and clinical outcomes were similar for the two groups. CONCLUSION Frameless stereotaxy allows surgeons to 1) plan the optimal trajectory to an AVM, 2) minimize the skin incision and craniotomy sizes, and 3) confirm the AVM margins and identify deep vascular components during resection. These benefits of stereotaxy were most apparent for small, deep AVMs that were not visible on the surface of the brain. Frameless stereotaxy reduces the operative time and blood loss during AVM resection.

scholarly journals Bone cutter versus plastibell device in neonatal circumcision: A randomized trial

2020 ◽  
Vol 9 ◽  
pp. 24
Author(s):  
Ademola Olusegun Talabi ◽  
Gabriel Unimke Udie ◽  
Oludayo Adedapo Sowande ◽  
Owolabi Oni ◽  
Olusanya Adejuyigbe
Keyword(s):  
Blood Loss ◽  
Randomized Trial ◽  
Complication Rate ◽  
Operative Time ◽  
Urban Setting ◽  
Complication Rates ◽  
Estimated Blood Loss ◽  
Tertiary Teaching ◽  
Neonatal Circumcision ◽  
Perception Score

Background: Several techniques and devices have been described for circumcision each with its own pros and cons. The objective of this study was to compare the outcome of neonatal circumcision between bone-cutter and plastibell devices at our institution. Methods: This is a randomized trial (unregistered) conducted at the Pediatric Surgical Unit of a tertiary teaching hospital situated in a semi-urban setting, between January 2019 and December 2019. The uncircumcised neonates underwent circumcision by either bone-cutter or plastibell device. Demographic characteristics, operative time, estimated blood loss, and postoperative complications were compared. A p-value of <0.05 was considered significant. Results: The age ranged between 7 days and 30 days with a mean of 15.9±5.5 days. The mean age and weight of both groups were well matched (p >0.05). The operative time in the bone cutter technique was 4.2±0.9 minutes compared to 5.8±1.2 minutes in the plastibell device method (p <0.001). Blood loss was lesser with bone cutter (0.27 ±0.32mls versus 0.51 ±0.44mls in the plastibell device, p <0.001). The complication rates were comparable in both study groups (p =1.000). The overall complication rate was 5.8%. The penile perception score and the Hollander wound evaluation score for bone-cutter were 15.7±0.8 and 5.7±0.84 while in the plastibell device were 15.4±1.1 and 5.4±1.1, respectively (p >0.05). Conclusion: Operative time and blood loss were less with bone cutter compared to plastibell device. However, the complication rate, penile perception score, and Hollander wound evaluation scores were similar.

Single Incision Laparoscopic Cholecystectomy Performed via the “Marionette” Technique Shows Equivalence in Outcome and Cost to Standard Four Port Laparoscopic Cholecystectomy in a Selected Patient Population

2015 ◽  
Vol 81 (10) ◽  
pp. 1015-1020 ◽  
Author(s):  
Maryam N. Saidy ◽  
Sunal S. Patel ◽  
Mark W. Choi ◽  
Mohammed Al-Temimi ◽  
Deron J. Tessier
Keyword(s):  
Multivariate Analysis ◽  
Laparoscopic Cholecystectomy ◽  
Blood Loss ◽  
Hospital Stay ◽  
Operative Time ◽  
Single Incision ◽  
Univariate Analysis ◽  
Operating Time ◽  
Complication Rates ◽  
Single Incision Laparoscopic Cholecystectomy

The aim of our study is to compare single incision laparoscopic cholecystectomy (SILC) performed using the “marionette” technique (m-SILC), to the standard four-port technique [four-port laparoscopic cholecystectomy (4PLC)]. Patient information was extracted from a prospectively maintained database (n = 188). Our primary endpoint was operative costs (determined by operating time and instruments used). Secondary endpoints were length of stay, operative time, blood loss, and postoperative complication rates. Univariate and adjusted multivariate analysis was used to compare the outcomes. There were a total of 188 patients for this study. Gender, body mass index, American Society of Anesthesiologists class, and resident participation were similar. Patients undergoing m-SILC were younger (43.8 vs 49.8 years old), less likely to have cholangiogram (32% vs 54%), and were more likely to undergo cholecystectomy for chronic cholecystitis (73.3% vs 52%). In univariate analysis, cholecystectomy performed by the “marionette method” as compared with the 4PLC was associated with shorter operative time (67 vs 59 minutes respectively) and shorter hospital stay (1.2 vs 2.08 days respectively). In multivariate analysis, SILC was associated with shorter hospital stay and comparable operative time, blood loss, and postoperative complications. Instrumentation cost was less in SILC (by $94). SILC done by an experienced surgeon with the “marionette” technique on a carefully selected population shows a statistically significant cost benefit while maintaining clinically comparable outcomes to the standard 4PLC.

Robotic-assisted laparoscopic prostatectomy in obese patients: The Columbia University experience

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 14619-14619
Author(s):  
A. W. Levinson ◽  
D. B. Samadi ◽  
S. M. Collins ◽  
A. E. Urdaneta ◽  
E. T. Goluboff ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
Blood Loss ◽  
Operative Time ◽  
Perioperative Complications ◽  
Obese Patients ◽  
Columbia University ◽  
Robotic Assisted ◽  
Laparoscopic Prostatectomy ◽  
Trocar Placement ◽  
Significant Difference

14619 Background: In addition to being more likely to be found with more aggressive prostate cancer (PCa), obese patients (OPs) face challenges with treatment options for localized PCa. Several studies have shown that open radical retropubic prostatectomy, pure laparoscopic, and robotic-assisted laparoscopic prostatectomy (RALP) may be associated with increased operative times, blood loss, and even a higher rate of capsular incision. We examined our own experience with the surgical and pathologic outcomes of OPs undergoing transperitoneal RALP at our institution. Methods: We queried the Columbia University IRB approved database for transperitoneal RALPs performed by a single fellowship trained laparoscopic oncologist (DS) for which body mass index (BMI) data was available. We identified patients who met the CDC definition of obese (BMI > or = 30 kg/m2) at the time of surgery. We compared surgical and pathologic outcomes between these OPs and NOPs. Of note, operative time was defined as the time from initial trocar placement to skin closure, and does not include robotic set-up time. Results: BMI data was available for 78% of RALP patients in the database. We identified 22 OPs (mean BMI 32.7 (30.1 to 46.7)) and 112 NOPs (mean BMI 25.6). One patient in each group was converted to open. There were no statistically significant differences in the surgical outcomes of mean blood loss, operative time or length of stay for the OPs vs. NOPs (179cc v. 191cc, 213min v. 221min, and 1.4d vs. 1.7d, respectively). There was no significant difference in preoperative PSA, pre-treatment MSKCC 5yr progression-free probability, pre or post-operative Gleason sum, margin status, or perioperative complications. There was a trend towards increased prostatic volume in OPs vs NOPs (51cc vs 44cc, p = 0.10). Conclusions: Unlike a prior robotic, pure laparoscopic and ORRP series, OPs who received transperitoneal RALP at our institution had no statistically significant increases in blood loss, operative time or perioperative complications when compared to their non-obese cohorts. We believe RALPs may be safely recommended to OPs as an option for treatment of localized prostate cancer. No significant financial relationships to disclose.

scholarly journals Prospective multicenter assessment of perioperative and minimum 2-year postoperative complication rates associated with adult spinal deformity surgery

2016 ◽  
Vol 25 (1) ◽  
pp. 1-14 ◽  
Author(s):  
Justin S. Smith ◽  
Eric Klineberg ◽  
Virginie Lafage ◽  
Christopher I. Shaffrey ◽  
Frank Schwab ◽  
...  
Keyword(s):  
Patient Care ◽  
Spinal Deformity ◽  
Perioperative Complications ◽  
Adult Spinal Deformity ◽  
Vena Cava ◽  
Complication Rates ◽  
Inclusion Criteria ◽  
Patient Counseling ◽  
Delayed Complications

OBJECTIVE Although multiple reports have documented significant benefit from surgical treatment of adult spinal deformity (ASD), these procedures can have high complication rates. Previously reported complications rates associated with ASD surgery are limited by retrospective design, single-surgeon or single-center cohorts, lack of rigorous data on complications, and/or limited follow-up. Accurate definition of complications associated with ASD surgery is important and may serve as a resource for patient counseling and efforts to improve the safety of patient care. The authors conducted a study to prospectively assess the rates of complications associated with ASD surgery with a minimum 2-year follow-up based on a multicenter study design that incorporated standardized data-collection forms, on-site study coordinators, and regular auditing of data to help ensure complete and accurate reporting of complications. In addition, they report age stratification of complication rates and provide a general assessment of factors that may be associated with the occurrence of complications. METHODS As part of a prospective, multicenter ASD database, standardized forms were used to collect data on surgery-related complications. On-site coordinators and central auditing helped ensure complete capture of complication data. Inclusion criteria were age older than 18 years, ASD, and plan for operative treatment. Complications were classified as perioperative (within 6 weeks of surgery) or delayed (between 6 weeks after surgery and time of last follow-up), and as minor or major. The primary focus for analyses was on patients who reached a minimum follow-up of 2 years. RESULTS Of 346 patients who met the inclusion criteria, 291 (84%) had a minimum 2-year follow-up (mean 2.1 years); their mean age was 56.2 years. The vast majority (99%) had treatment including a posterior procedure, 25% had an anterior procedure, and 19% had a 3-column osteotomy. At least 1 revision was required in 82 patients (28.2%). A total of 270 perioperative complications (145 minor; 125 major) were reported, with 152 patients (52.2%) affected, and a total of 199 delayed complications (62 minor; 137 major) were reported, with 124 patients (42.6%) affected. Overall, 469 complications (207 minor; 262 major) were documented, with 203 patients (69.8%) affected. The most common complication categories included implant related, radiographic, neurological, operative, cardiopulmonary, and infection. Higher complication rates were associated with older age (p = 0.009), greater body mass index (p ≤ 0.031), increased comorbidities (p ≤ 0.007), previous spine fusion (p = 0.029), and 3-column osteotomies (p = 0.036). Cases in which 2-year follow-up was not achieved included 2 perioperative mortalities (pulmonary embolus and inferior vena cava injury). CONCLUSIONS This study provides an assessment of complications associated with ASD surgery based on a prospective, multicenter design and with a minimum 2-year follow-up. Although the overall complication rates were high, in interpreting these findings, it is important to recognize that not all complications are equally impactful. This study represents one of the most complete and detailed reports of perioperative and delayed complications associated with ASD surgery to date. These findings may prove useful for treatment planning, patient counseling, benchmarking of complication rates, and efforts to improve the safety and cost-effectiveness of patient care.

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