Open Versus Minimally Invasive Approach for Craniosynostosis: Analysis of the National Surgical Quality Improvement Program-Pediatric

Abstract

Objective This multicenter study aimed to compare demographic, operative, and short-term outcomes data between open and minimally invasive surgical approaches for craniosynostosis repair utilizing the American College of Surgeon’s National Surgical Quality Improvement Program Pediatric (NSQIP-P) database and highlight surgical disparities among races and ethnicities. Design Retrospective review of large multicenter database. Setting Freestanding general acute care children's hospitals, children's hospitals within a larger hospital, specialty children's hospitals, or general acute care hospitals with a pediatric wing. Patients and Participants A total of 4931 pediatric patients underwent craniosynostosis correction within the NSQIP-P database from 2013 to 2019. Interventions None. Main Outcome Measure(s) Demographic information included age at surgery, sex, race, and ethnicity. Operative and outcomes measures included operative time, anesthesia time, days until discharge, postoperative complications, blood transfusions, 30-day readmission, and 30-day unplanned return to operating room. Results Patients who underwent minimally invasive surgery had significantly shorter operative and anesthesia times ( p < .001; p < .001), fewer days until discharge ( p < .001), fewer postoperative complications ( p < .05), and less blood transfusions ( p < .001). The proportion of White patients was significantly higher in the minimally invasive surgery group ( p < .01), whereas Black and Hispanic patients had a significantly higher proportion in the open surgery group ( p < .001; p < .001). Additionally, the percentage of patients undergoing minimally invasive surgery increased from 3.8% in 2014 to over 13% in 2019. Conclusions This study adds to a growing consensus that minimally invasive surgery has significantly decreased operative time, anesthesia time, transfusion rates, length of hospital stay, and postoperative complications compared to open surgery. Racial and ethnic surgical disparities showed larger proportions of Black and Hispanic populations undergoing open procedures.

Scoping Review of Healthcare Disparities in Treatment of Craniosynostosis: Assessing Impacts of Race, Insurance, and Socioeconomic Status

“…Two of the 3 studies found that more patients undergoing open procedures experienced complications than those receiving closed procedures. 23,25 The third study found no significant difference between the 2 types of operations. 24 Twelve studies examined hospital LOS.…”

“…Seven of these 9 studies found that Black and Hispanic patients were more likely to be treated via an open approach, whereas White patients were more likely to receive endoscopic repairs. 4,[13][14][15][16]20,23 Two retrospective national database reviews found no associations between race or ethnicity and treatment type. 22,24 Insurance status impacted surgical approach selection in 7 studies (4 national database reviews, 2 single-institution cohort reviews, and one dual-institution cohort review), showing that patients covered by Medicaid were more likely to receive the open CVR approach.…”

“…Surgical approach was also largely found to impact LOS; 6 studies showed that patients who underwent open surgeries had a lengthier hospital stay than those who received closed procedures. 14,18,[22][23][24][25] However, Wallace et al found that the average LOS was shorter for patients that received an open procedure. Two studies also found that treatment at a high-volume center was associated with a shorter time spent in the hospital than in low-volume centers.…”

“…Two studies also found that treatment at a high-volume center was associated with a shorter time spent in the hospital than in low-volume centers. 14,21 Four studies assessed 30-day readmission rates following craniosynostosis surgery, 19,23,28,29 and two studies analyzed reoperation rates. 6,28 In their regional database review, Xu et al found that Black race and Hispanic ethnicity were associated with more frequent post-discharge hospital-based acute encounters.…”

“…9 When comparing the 2 procedures, a significant body of literature supports that limited incision procedures had improved safety and morbidity compared to open procedures. 17,23,24,36 Endoscopic repairs generally require shorter operation time, thus less time under anesthesia and lower blood transfusion rates. 23,27 Differences in perioperative complication rates and long-term neurological outcomes between the 2 types of operations is an ongoing area of study with conflicting evidence however, given the possible ramifications of long-term cognitive deficits, it is important area for continued investigation.…”