title: Risk factors associated with the surgical management of craniopharyngiomas in pediatric patients: analysis of 1961 patients from a national registry database.
abstract: OBJECTIVE Patient demographic characteristics, hospital volume, and admission status have been shown to impact surgical outcomes of sellar region tumors in adults; however, the data available following the resection of craniopharyngiomas in the pediatric population remain limited. The authors sought to identify potential risk factors associated with outcomes following surgical management of pediatric craniopharyngiomas. METHODS The Nationwide Inpatient Sample database and Kids' Inpatient Database were analyzed to include admissions for pediatric patients (≤ 18 years) who underwent a transcranial or transsphenoidal craniotomy for resection of a craniopharyngioma. Patient-level factors, including age, race, comorbidities, and insurance type, as well as hospital factors were collected. Outcomes analyzed included mortality rate, endocrine and nonendocrine complications, hospital charges, and length of stay. A multivariate model controlling for variables analyzed was constructed to examine significant independent risk factors. RESULTS Between 2000 and 2011, 1961 pediatric patients were identified who underwent a transcranial (71.2%) or a transsphenoidal (28.8%) craniotomy for resection of a craniopharyngioma. A major predilection for age was observed with the selection of a transcranial (23.4% in < 7-year-olds, 28.1% in 7- to 12-year-olds, and 19.7% in 13- to 18-year-olds) versus transphenoidal (2.9% in < 7-year-olds, 7.4% in 7- to 12-year-olds, and 18.4% in 13- to 18-year-olds) approach. No significant outcomes were associated with a particular surgical approach, except that 7- to 12-year-old patients had a higher risk of nonendocrine complications (relative risk [RR] 2.42, 95% CI 1.04-5.65, p = 0.04) with the transsphenoidal approach when compared with 13- to 18-year-old patients. The overall inpatient mortality rate was 0.5% and the most common postoperative complication was diabetes insipidus (64.2%). There were no independent factors associated with inpatient mortality rates and no significant differences in outcomes among groups based on sex and race. The average length of stay was 11.8 days, and the mean hospital charge was $116,5 22. Hospitals with medium and large bed capacity were protective against nonendocrine complications (RR 0.53, 95% CI 0.3-0.93, p = 0.03 [medium]; RR 0.45, 95% CI 0.25-0.8, p < 0.01 [large]) and total complications (RR 0.73, 95% CI 0.55-0.97, p = 0.03 [medium]; RR 0.68, 95% CI 0.51-0.9, p < 0.01 [large]) when compared with hospitals with small bed capacity (< 200 beds). Patients admitted to rural hospitals had an increased risk for nonendocrine complications (RR 2.56, 95% CI 1.11-5.9, p = 0.03). The presence of one or more medical comorbidities increased the risk of higher total complications (RR 1.38, 95% CI 1.14-1.68), p < 0.01 [1 comorbidity]; RR 2.37, 95% CI 1.98-2.84, p < 0.01 [≥ 2 comorbidities]) and higher total hospital charges (RR 2.9, 95% CI 1.08-7.81, p = 0.04 [1 comorbidity]; RR 9.1, 95% CI 3.74-22.12, p < 0.01 [≥ 2 comorbidities]). CONCLUSIONS This analysis identified patient age, comorbidities, insurance type, hospital bed capacity, and rural or nonteaching hospital status as independent risk factors for postoperative complications and/or increased hospital charges in pediatric patients with craniopharyngioma. Transsphenoidal surgery in younger patients with craniopharyngioma was a risk factor for nonendocrine complications.
authors.affiliation: Department of Neurological Surgery.
authors.forename: Joshua
authors.initials: J
authors.lastname: Bakhsheshian
authors.affiliation: Keck School of Medicine.
authors.forename: Diana L
authors.initials: DL
authors.lastname: Jin
authors.affiliation: Department of Neurological Surgery.
authors.forename: Ki-Eun
authors.initials: KE
authors.lastname: Chang
authors.affiliation: Department of Neurological Surgery.
authors.forename: Ben A
authors.initials: BA
authors.lastname: Strickland
authors.affiliation: Department of Neurological Surgery.
authors.forename: Dan A
authors.initials: DA
authors.lastname: Donoho
authors.affiliation: Department of Neurology; and.|Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California.
authors.forename: Steven
authors.initials: S
authors.lastname: Cen
authors.affiliation: Department of Neurological Surgery.
authors.forename: William J
authors.initials: WJ
authors.lastname: Mack
authors.affiliation: Department of Neurological Surgery.
authors.forename: Frank
authors.initials: F
authors.lastname: Attenello
authors.affiliation: Department of Neurological Surgery.
authors.forename: Eisha A
authors.initials: EA
authors.lastname: Christian
authors.affiliation: Department of Neurological Surgery.
authors.forename: Gabriel
authors.initials: G
authors.lastname: Zada
mesh_terms: D000293:Adolescent; D002648:Child; D015331:Cohort Studies; D003397:Craniopharyngioma / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*; D016208:Databases, Factual / Q000639:trends*; D019468:Disease Management; D005260:Female; D006742:Hospital Bed Capacity; D006801:Humans; D007902:Length of Stay / Q000639:trends; D008297:Male; D010911:Pituitary Neoplasms / Q000175:diagnosis / Q000453:epidemiology / Q000601:surgery*; D011183:Postoperative Complications / Q000175:diagnosis / Q000453:epidemiology; D012042:Registries; D012307:Risk Factors; D014481:United States / Q000453:epidemiology
keywords: DI = diabetes insipidus; HCUP = Healthcare Cost and Utilization Project; ICD-9-CM = International Classification of Diseases, Ninth Revision; Clinical Modification; KID = Kids' Inpatient Database; Kids' Inpatient Database; LOS = length of stay; NIS = Nationwide Inpatient Sample; National (Nationwide) Inpatient Sample; RR = relative risk; craniopharyngioma; oncology; parasellar; sellar; transsphenoidal