The Resource Costs of Maintaining Learner Utilization of a Simulation Center During the COVID-19 Pandemic.

BACKGROUND: Despite advances in online education during the COVID-19 pandemic, its impact on surgical simulation remains unclear. The aim of this study was to compare the costs and resources required to maintain simulation training in the pandemic and to evaluate how it affected exposure of medical students to simulation during their surgical clerkship. METHODS: The number of learners, contact hours, staff hours, and costs were collected from a multi-departmental simulation center of a single academic institution in a retrospective fashion. Utilization and expenditure metrics were compared between the first quarter of academic years 2018-2020. Statistical analysis was performed to evaluate potential differences between overall resource utilization before and during the pandemic, and subgroup analysis was performed for the resources required for the training of the third-year medical students. RESULTS: The overall number of learners and contact hours decreased during the first quarter of the academic year 2020 in comparison with 2019 and 2018. However, the staff hours increased. In addition, the costs for PPE increased for the same periods of time. In the subgroup analysis of the third-year medical students, there was an increase in the number of learners, as well as in the staff hours and in the space required to perform the simulation training. DISCUSSION: Despite an increase in costs and resources spent on surgical simulation during the pandemic, the utilization by academic entities has remained unaffected. Further studies are required to identify potential solutions to lower simulation resources without a negative impact on the quality of surgical simulation.

Body mass index and risk of mortality in patients undergoing bariatric surgery.

BACKGROUND: Prior literature has demonstrated that bariatric surgery is a safe approach for patients with morbid obesity. However, the relationship between body mass index (BMI) and risk of mortality in these patients has not been fully elucidated. Primary objective of this study was to evaluate the relationship between BMI and risk of mortality using data obtained from a national database, with a special focus on patients with BMI ≥ 70.0 kg/m2. METHODS: A retrospective cohort study of patients with morbid obesity (BMI ≥ 40 kg/m2) undergoing first-time bariatric surgery between 2015 and 2018 was performed using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program. Primary outcome was intra-operative death or death within 30 days post-operatively. Patients were categorized into quartiles according to BMI. Multivariable analysis was performed to evaluate the association of BMI with risk of mortality. Relative risk (RR) and 95% confidence interval (CI) are provided as measures of strength of association and precision, respectively. RESULTS: A total of 463, 436 patients were included with a 30-day mortality rate of 0.11%. Mean BMI (SD) was 48.2 (7.3) kg/m2; 1.5% of patients had BMI ≥ 70.0 kg/m2. On multivariable analysis, highest quartile patients had a significantly higher risk of mortality than lowest quartile patients. For patients with BMI ≥ 70.0 kg/m2, the risk of mortality was more pronounced with an eightfold increase compared to the lowest quartile. In patients with BMI ≥ 70.0 kg/m2, although sleeve gastrectomy (SG) was the most common procedure, the risk of mortality was significantly higher in patients undergoing Roux-en-Y gastric bypass (RYGB). CONCLUSIONS: BMI is associated with increased risk of 30-day mortality. The effect of BMI is more pronounced in patients with BMI ≥ 70.0 kg/m2. In these patients, RYGB is associated with increased risk of mortality compared to SG.

The association of health insurance and race with treatment and survival in patients with metastatic colorectal cancer.

BACKGROUND: Black patients and underinsured patients with colorectal cancer (CRC) present with more advanced disease and experience worse outcomes. The study aim was to evaluate the interaction of health insurance status and race with treatment and survival in metastatic CRC. MATERIALS AND METHODS: Patients diagnosed with metastatic CRC within NCDB from 2006-2016 were included. Primary outcomes included receipt of chemotherapy and 3-year all-cause mortality. Multivariable logistic regression and Cox-regression (MVR) including a two-way interaction term of race and insurance were performed to evaluate the differential association of race and insurance with receipt of chemotherapy and mortality, respectively. RESULTS: 128,031 patients were identified; 70.6% White, 14.4% Black, 5.7% Hispanic, and 9.3% Other race. Chemotherapy use was higher among White compared to Black patients. 3-year mortality rate was higher for Blacks and lower for Hispanics, in comparison with White patients. By MVR, Black patients were less likely to receive chemotherapy. When stratified by insurance status, Black patients with private and Medicare insurance were less likely to receive chemotherapy than White patients. All-cause mortality was higher in Black patients and lower in Hispanic patients, and these differences persisted after controlling for insurance and receipt of chemotherapy. CONCLUSION: Black patients and uninsured or under-insured patients with metastatic CRC are less likely to receive chemotherapy and have increased mortality. The effect of health insurance among Blacks and Whites differs, however, and improving insurance alone does not appear to fully mitigate racial disparities in treatment and outcomes.

Improvement in Surgical Quality Following Pancreaticoduodenectomy With Increasing Case Volume in a Rural Hospital.

BACKGROUND: The literature is replete with studies that define the nexus of quantity and quality in complex surgical operations. These observations have heralded a call for centralization of care to high-volume centers. The purpose of this study was to chronicle improvements in quality associated with pancreaticoduodenectomy (PD) as a rural hospital matures from a low- to very high-volume center. METHODS: A retrospective review of a prospective pancreatic surgery database was undertaken from July 2007 to June 2020. Annual periods were characterized as low (≤12/year), high (13-29/year), and very high volume (≥30/year). Data for the following quality benchmarks were aggregated and compared: length of stay (LOS), 30-day readmissions, 30-day mortality, and 1- and 3-year survival. A subgroup analysis was undertaken in those patients undergoing PD for adenocarcinoma detailing margin status and number of lymph nodes harvested. Outcomes were compared using the Fisher's exact and Student's t-test. RESULTS: 375 PD were completed over the 13-year period; 62.1% were undertaken for ductal adenocarcinoma. There was a significant decrease in LOS and 30-day readmissions as the institution matured toward very high volume. There were no significant differences in 30-day mortality, 1- and 3-year survival, or margin negativity rates associated with volume. Extent of lymph node harvest significantly improved as institutional experience increased. DISCUSSION: Our pancreatic surgery program matured rapidly from low to very high volume with institutional commitment and dedicated resources. As the institution matured, operational efficiencies and surgical quality improved. Not unexpectedly, biology trumped volume as reflected in 1- and 3-year survival rates.

Thirty-day complication rates do not differ by race among patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma.

BACKGROUND AND OBJECTIVES: Black patients with pancreatic ductal adenocarcinoma (PDAC) are less likely to receive multimodality treatment and have worse survival compared to White patients. However, little is known regarding racial differences in postoperative outcomes. The primary aim of this study was to determine if 30-day complication rates following pancreaticoduodenectomy (PD) differ by race. METHODS: A retrospective cohort study of patients who underwent PD for PDAC from 2014 to 2016 within the ACS-NSQIP pancreatectomy-specific data set was performed. Primary outcomes were 30-day pancreas-specific and overall major complications. RESULTS: A total of 6936 patients were identified, including 91.4% (N = 6337) White and 8.6% (N = 599) Black. Pathologic stage and rates of neoadjuvant therapy were similar among Whites and Blacks. Rates of pancreas-specific (23.9% vs. 23.1%, p = .88) and major postoperative complications (39.2% vs. 39.9%, p = .55) were similar between Whites and Blacks. By multivariable regression analysis, there was no association between race and odds of pancreas-specific complications (odds ratio [OR] 1.10, 95% confidence interval [CI] 0.89-1.37) or overall major complications (OR 1.13, 95% CI 0.95-1.36). CONCLUSIONS: Among patients undergoing PD for PDAC, Black race is not associated with increased pancreas-specific or overall 30-day postoperative complications. Short-term postoperative outcomes do not appear to explain the increase in pancreatic cancer mortality among Black patients.

When Is It Safe to Proceed With Pancreaticoduodenectomy Without Biliary Decompression?

BACKGROUND: An absolute bilirubin level where preoperative biliary decompression (PBD) is indicated before pancreaticoduodenectomy has been elusive. Our goal was to identify a total bilirubin level whereby biliary decompression provides clear benefit, despite associated expenses and potential complications. MATERIALS AND METHODS: We reviewed a prospectively collected database of patients undergoing pancreaticoduodenectomy at the Vidant Medical Center between 2007 and 2016. Patients were arbitrarily subdivided into 3 groups based on presenting bilirubin level (≤10 mg/dL, 10.1-14.9 mg/dL, and ≥15 mg/dL) to determine the presence of overall complications, severe complications (Clavien-Dindo classification ≥3), prolonged length of stay (>1 SD), readmissions, or mortality. RESULTS: Common bile duct stenting independently predicted a higher incidence of complications in patients presenting with bilirubin ≤10 mg/dL (P = .03) vs. those patients going directly to surgery. No differences were observed for patients with bilirubin between 10.1 mg/dL and 14.9 mg/dL. Biliary decompression in patients with bilirubin ≥15 mg/dL independently predicted fewer overall (73.8% vs. 100%, P = .0082) and less severe complications (14.3% vs. 44.5%, P = .03) and lower readmission rates (15.8% vs. 55.6%, P = .03) vs. those going directly to surgery. Patients not undergoing biliary decompression underwent pancreaticoduodenectomy sooner than those decompressed (4.7 days vs. 17.2 days, P = .01). DISCUSSION: All patients presenting with bilirubin ≥15 mg/dL should undergo PBD, while those with bilirubin ≤10 mg/dL should forego stent placement to avoid stent-related complications. The decision to stent between 10.1 and 14.9 mg/dL should be made on a case-by-case basis keeping in mind timeliness to definitive cancer treatment.

Predictive Value of Preoperative Serum CA19-9 on Margin Status.

Serum carbohydrate antigen (CA19-9) is known to correlate with stage, resectability, and prognosis of pancreatic cancer. The goal of pancreaticoduodenectomy is to achieve an R0 resection because worse outcomes are reported in the presence of positive margins. The purpose of this study was to evaluate the predictive utility of CA19-9 for pancreaticoduodenectomy margin status. A retrospective review of patients with pancreatic adenocarcinoma undergoing pancreaticoduodenectomy between October 2007 and November 2018 at our institution was performed. Patient demographics, preoperative CA19-9, and tumor characteristics were analyzed. Univariate and multivariate logistic regression was performed to determine factors associated with positive margins. A total of 184 patients were included. The mean age was 65 years; most patients were male and white. Majority had a positive preoperative CA19-9 (69%). There were nearly twice as many patients with negative as positive margins. Groups had similar demographics and preoperative CA19-9. A greater proportion of patients with negative margins had smaller tumors and early disease. On univariate and multivariate analysis, larger and higher stage tumors had greater odds of positive margins (P < 0.05). There was no significant association between margin status and preoperative CA19-9. Preoperative CA19-9 is not predictive of margin status. These results suggest that although preoperative CA19-9 values are associated with both resectability and prognosis, positive margins may not be a contributing mechanism.