Does Speed Matter? A Look at NSQIP-P Outcomes based on Operative Time.
Background: Appendicitis is a common pediatric surgical condition, comprising a large burden of healthcare costs. We aimed to determine if prolonged operative times are associated with increased 30-day complication rates when adjusting for pre-operative risk factors.
Methods: Patients <18 years old, diagnosed intraoperatively with acute uncomplicated appendicitis and undergoing laparoscopic appendectomy were identified from the NSQIP-Pediatric 2012-2018 databases. The primary outcome, “post-operative complications”, is a composite of sepsis, deep incisional surgical site infections, wound disruptions, superficial, and organ space infections within 30-days of the operation. Secondary outcomes included return to the operating room and unplanned readmissions within 30 days. Logistic regression models were used to assess associations between operative time and each outcome.
Results: Between 2012-2018, 27,763 pediatric patients with acute uncomplicated appendicitis underwent a laparoscopic appendectomy. Over half the population was male (61%) with a median operative time of 39 minutes (IQR 29-52 minutes). Post-operative complication rate was 2.8% overall and was highest (8%) among patients with operative time ≥ 90 minutes (Figure 1). Unplanned readmission occurred in 2.9% of patients, with less than 1% (0.7%) returning to the operating room. Each 30-minute increase in operating time was associated with a 24% increase in odds of a post-operative complication (OR=1.24, 95% CI=1.17-1.31) in adjusted models. Longer operative times were associated with higher odds of unplanned readmission (OR=1.11, 95% CI=1.05-1.18) and return to the operating room (OR=1.13, 95% CI=1.02-1.24) in adjusted models.
Conclusion: There is a risk-adjusted association between prolonged operative time and the occurrence of postoperative complications. Postoperative complications are known to increase healthcare spending and is a current area of focus in healthcare value models. Future studies evaluating factors that contribute to longer operative times, such as surgeon experience, involvement of trainees, operative technique, or difficult anatomy may help improve outcomes following surgical management of acute uncomplicated appendicitis.