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OBJECTIVE When indicated, patients with symptomatic Chiari malformation type I (CM-I) may benefit from suboccipital decompression (SOD). Although SOD is considered a lower-risk neurosurgical procedure, preoperative risk assessment and careful surgical patient selection remain critical. The objectives of the present study were twofold: 1) describe 30-day SOD outcomes for CM patients with attention to the impact of preoperative frailty and 2) design a predictive model for the primary endpoint of nonhome discharge (NHD). METHODS There were 1015 CM-I patients who underwent SOD in the 2011–2020 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, as specified by diagnostic and procedural codes (Current Procedural Terminology code 61343). Descriptive statistics were used to analyze total cohort baseline demographics, preoperative comorbidities, and postoperative outcomes within 30 days of surgery. Univariate cross-tabulation was used to compare baseline demographics and preoperative characteristics across the NHD and home discharge (HD) cohorts. Receiver operating characteristic (ROC) curve analysis was used to assess the discriminative ability of the revised Risk Analysis Index (RAI-rev) on NHD. RESULTS The study cohort had a median age of 36 years, and 80.6% of patients were female. Race distribution was categorized as White (69.9%), Black (16.6%), and other groups (13.6%). The most common preoperative comorbidities were active smoking (24.4%), hypertension (19.2%), and diabetes mellitus (4.7%). The primary outcome of NHD occurred in 4.6% of patients (n = 47). Increasing frailty (measured by the RAI-rev) was associated with a stepwise increase in the rate of NHD: 2.3% for RAI-rev scores 0–10, 5.8% for RAI-rev scores 11–15, 7.6% for RAI-rev scores 16–20, 18.2% for RAI-rev scores 21–25, and 77.8% for RAI-rev scores ≥ 26 (p < 0.001). Other preoperative factors associated with NHD included older age, nonelective surgery, diabetes, hypertension, and elevated creatinine (all p < 0.01). The other most common 30-day complications included unplanned readmission (9.3%), unplanned reoperation (5.3%), return to the operating room (5.8%), Clavien-Dindo grade IV (life-threatening) (1.5%), organ space surgical site infection (SSI) (1.5%), superficial SSI (1.4%), and reoperation for a CSF leak (1.1%). Surgical mortality (within 30 days) was extremely rare (1/1015, 0.1%). ROC curve analysis demonstrated that RAI-rev predicted NHD with significant discriminatory accuracy among CM-I patients who received SOD treatment (C-statistic 0.731, 95% CI 0.648–0.814). CONCLUSIONS This decade-long analysis of a multicenter surgical registry provides internationally representative, modern rates of 30-day outcomes after suboccipital decompression (with or without duraplasty) for adult CM-I patients. Preoperative frailty assessment with the RAI-rev may help identify higher-risk surgical candidates.

Readmission is an important metric for surgical quality of care. This study aimed to develop a validated risk model that reliably predicts readmission after panniculectomy using the American College of Surgeons National Surgical Quality Improvement Program database.The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify all patients who had undergone panniculectomy from 2005 to 2018. The outcome of interest was 30-day readmission. The cohort was divided randomly into 70 percent development and 30 percent validation groups. Independent predictors of 30-day readmission were identified using multivariable logistic regression on the development group. The predictors were weighted according to beta coefficients to generate an integer-based clinical risk score predictive of readmission, which was validated against the validation group.For the model selection, 22 variables were identified based on criteria of p0.05 percent and complete data availability. Variables included in the development model included inpatient surgery, hypertension, obesity, functional dependence, chronic obstructive pulmonary disease, wound class greater than or equal to 3, American Society of Anesthesiologists class greater than 3, and liposuction. Receiver operating characteristic curve analysis of the validation group rendered an area under the curve of 0.710, which demonstrates the accuracy of this prediction model. The predicted incidence within each risk stratum was statistically similar to the observed incidence in the validation group ( p0.01), further highlighting the accuracy of the model.The authors present a validated risk stratification model for readmission following panniculectomy. Prospective studies are needed to determine whether the implementation of the authors' clinical risk score optimizes safety and reduces readmission rates.Risk, III.

Increasing patient age has been associated with worse outcomes after pituitary adenoma resection in previous studies, but the prognostic value of frailty compared with advancing age on pituitary adenoma resection outcomes has not been clearly evaluated.The National Surgical Quality Improvement Program from 2015 to 2019 was queried for data for patients aged18 years who underwent pituitary adenoma resection (n = 1454 identified patients). Univariate and multivariate analyses of age and frailty (5-factor modified frailty index [mFI-5]) were performed on 30-day mortality, major complications, extended length of stay (eLOS), discharge destination, and readmission and reoperation. The receiver operating characteristic curve analysis was performed to compare effect of age and mFI-5.On univariate analysis, increasing frailty was significantly associated with greater risk of unplanned readmission (frail: odds ratio [OR], 1.9; 95% confidence interval [CI], 1.2-3.2; severely frail: OR, 6.9; 95% CI, 2.4-19.8) and a major complication (frail: OR, 3.6; 95% CI, 2.1-6.1). Severe frailty was also associated with nonhome discharge (OR, 10.6; 95% CI, 3.2-35.8) and eLOS (OR, 4.5; 95% CI, 1.5-13.4). Increasing age was not associated with any of these outcome measures. Multivariate analysis also demonstrated similar trends. In receiver operating characteristic curve analysis, the mFI-5 score showed higher discrimination for major complications compared with age (area under the curve: 0.624 vs. 0.503; P0.001).Increasing frailty, and not advancing age, was an independent predictor for major complications, unplanned readmissions, eLOS, and nonhome discharge after pituitary adenoma resection, suggesting frailty to be superior to age in preoperative risk stratification in this patient population.

Frailty lacks a universal definition. The modified Frailty Index (mFI) using patient comorbidities can be used to measure frailty. We hypothesized that mFI predicts 30-day complications after microsurgical breast reconstruction. American College of Surgeons' (ACS) National Surgical Quality Improvement Project (NSQIP) was investigated to identify patients undergoing microsurgical breast reconstruction between 2005-2014 using Current Procedure Terminology (CPT) code, 19364. We used mFI as a measure of frailty. The patients were assigned a frailty score based on the number of preoperative comorbid conditions as defined by the mFI. Other risk indices used include age, BMI, wound class, ASA class. Stratification was performed in ascending order for each. The outcome measure was aggregate 30-day complications. Regression analysis was performed followed by Receptor Operating Characteristic (ROC) curve to determine the accuracy of each risk index in predicting 30-day complications. Of the 3237 patients 24% experienced complications. Univariate logistic regression analysis found odds ratio of complications for frailty score 1 = 22.1 (CI = 17.9-27.3, p < 0.01), and 2 = 28 (CI = 18.3-43, p < 0.01) compared to frailty score = 0. ROC curve demonstrated mFI with the highest concordance score (c-score = 0.816). Multivariable logistic regression found frailty as the strongest independent predictor of 30-day aggregate complications adjusted OR = 22.24, CI = 17.77-27.82, p < 0.01 when compared to other risk indices. The modified Frailty Index is a simple, reliable, and objective tool that can be used to predict postoperative complications after microsurgical breast reconstruction. The application of this tool can help microsurgeons preoperatively identify patients who are at high risk. Abbreviations: ACS: American College of Surgeons; ASA: American Society of Anesthesiologists; BMI: body mass index; CHF: congestive heart failure; CPT: current procedural terminology; COPD: chronic obstructive pulmonary disease; CVA: cerebrovascular accident; DM: diabetes mellitus; IRB: institutional review board; mfi: modified frailty index; MI: myocardial infarction; NSQIP: national surgical quality improvement program; PVD: peripheral vascular disease; ROC: receptor operating characteristic; TIA: transient ischemic attach.