The effect of frailty and age on outcomes in elective paraesophageal hernia repair.

INTRODUCTION: Paraesophageal hernia repair (PEHR) is a safe and effective operation. Previous studies have described risk factors for poor peri-operative outcomes such as emergent operations or advanced patient age, and pre-operative frailty is a known risk factor in other major surgery. The goal of this retrospective cohort study was to determine if markers of frailty were predictive of poor peri-operative outcomes in elective paraesophageal hernia repair. METHODS: Patients who underwent elective PEHR between 1/2011 and 6/2022 at a single university-based institution were identified. Patient demographics, modified frailty index (mFI), and post-operative outcomes were recorded. A composite peri-operative morbidity outcome indicating the incidence of any of the following: prolonged length of stay (≥ 3 days), increased discharge level of care, and 30-day complications or readmissions was utilized for statistical analysis. Descriptive statistics and logistic regression were used to analyze the data. RESULTS: Of 547 patients who underwent elective PEHR, the mean age was 66.0 ± 12.3, and 77.1% (n = 422) were female. Median length of stay was 1 [IQR 1, 2]. ASA was 3-4 in 65.8% (n = 360) of patients. The composite outcome occurred in 32.4% (n = 177) of patients. On multivariate analysis, increasing age (OR 1.021, p = 0.02), high frailty (OR 2.02, p < 0.01), ASA 3-4 (OR 1.544, p = 0.05), and redo-PEHR (OR 1.72, p = 0.02) were each independently associated with the incidence of the composite outcome. On a regression of age for the composite outcome, a cutoff point of increased risk is identified at age 72 years old (OR 2.25, p < 0.01). CONCLUSION: High frailty and age over 72 years old each independently confer double the odds of a composite morbidity outcome that includes prolonged post-operative stay, peri-operative complications, the need for a higher level of care after elective paraesophageal hernia repair, and 30-day readmission. This provides additional information to counsel patients pre-operatively, as well as a potential opportunity for targeted pre-habilitation.

Early postoperative telehealth visit protocol implementation reduces emergency department utilization following benign foregut procedures.

INTRODUCTION: Emergency department (ED) visits and readmissions following benign foregut surgery (BFS) represent a burden on patients and the health care system. The objective of this study was to identify differences in ED visits and readmissions before and after implementation of an early postoperative telehealth visit protocol for BFS. We hypothesized that utilization of telehealth visits would be associated with reduced post-operative ED and hospital utilization. METHODS: An early postoperative telehealth protocol was initiated in 2020 at an academic medical center to provide a video conference within the first postoperative week. Consecutive elective BFS including fundoplication, Linx, paraesophageal hernia repair, and Heller myotomy performed between 2018 and 2022 were included. Outcomes included ED visits and 30-day readmission. Bivariate analyses were performed using Chi-squared testing for categorical variables. The association between telehealth visits and outcomes were evaluated using multivariable logistic regression. RESULTS: 616 patients underwent BFS during the study period. 310 (50.3%) were performed prior to the implementation of telehealth visits and 306 (49.7%) were after. 241 patients in the telehealth visit group (78.8%) completed their telehealth visit. A total of 34 patients (5.5%) had ED visits without readmission while 38 patients (6.2%) were readmitted within the first 30 days. The most common cause of ED visits and readmissions included pain (n = 18, 25%) and nausea/vomiting (n = 12, 16%). There was a significant reduction in ED visits without admission following telehealth visit implementation (7.4% vs 3.6%; OR 2.20, 95% CI 1.04-4.65, p = 0.04). There was no difference in readmission rates (6.1% versus 6.5%; OR 0.89, 95% CI 0.46-1.73, p = 0.73). The telehealth cohort had significantly lower ED visits for pain (31% vs 16.7%, p = 0.04) and nausea/vomiting (23.8% vs 6.7%, p = 0.02). DISCUSSION: Early telehealth follow-up was associated with a significant decrease in ED visits following BFS. The majority of this was attributable to a reduction in ED visits for pain, nausea, and vomiting. These results provide a possible avenue for improving quality and cost-effectiveness within this patient population.

Assessing the effects of smoking status on outcomes of elective minimally invasive paraesophageal hernia repair.

BACKGROUND: Patients are often advised on smoking cessation prior to elective surgical interventions, but the impact of active smoking on paraesophageal hernia repair (PEHR) outcomes is unclear. The objective of this cohort study was to evaluate the impact of active smoking on short-term outcomes following PEHR. METHODS: Patients who underwent elective PEHR at an academic institution between 2011 and 2022 were retrospectively reviewed. The National Surgical Quality Improvement Program (NSQIP) database from 2010 to 2021 was queried for PEHR. Patient demographics, comorbidities, and 30-day post-operative data were collected and maintained in an IRB-approved database. Cohorts were stratified by active smoking status. Primary outcomes included rates of death or serious morbidity (DSM) and radiographically identified recurrence. Bivariate and multivariable regressions were performed, and p value < 0.05 was considered statistically significant. RESULTS: 538 patients underwent elective PEHR in the single-institution cohort, of whom 5.8% (n = 31) were smokers. 77.7% (n = 394) were female, median age was 67 [IQR 59, 74] years, and median follow-up was 25.3 [IQR 3.2, 53.6] months. Rates of DSM (non-smoker 4.5% vs smoker 6.5%, p = 0.62) and hernia recurrence (33.3% vs 48.4%, p = 0.09) did not differ significantly. On multivariable analysis, smoking status was not associated with any outcome (p > 0.2). On NSQIP analysis, 38,284 PEHRs were identified, of whom 8.6% (n = 3584) were smokers. Increased DSM was observed among smokers (non-smoker 5.1%, smoker 6.2%, p = 0.004). Smoking status was independently associated with increased risk of DSM (OR 1.36, p < 0.001), respiratory complications (OR 1.94, p < 0.001), 30-day readmission (OR 1.21, p = 0.01), and discharge to higher level of care (OR 1.59, p = 0.01). No difference was seen in 30-day mortality or wound complications. CONCLUSION: Smoking status confers a small increased risk of short-term morbidity following elective PEHR without increased risk of mortality or hernia recurrence. While smoking cessation should be encouraged for all active smokers, minimally invasive PEHR in symptomatic patients should not be delayed on account of patient smoking status.

Patient perspectives on post-bariatric surgery nutritional supplementation.

BACKGROUND: Bariatric procedures increase patient risk of long-term metabolic complications primarily due to nutrient deficiencies. The mainstay of prevention includes routine vitamin and mineral supplementation; however, patient-reported barriers to daily compliance are poorly understood. METHODS: Post-bariatric surgery patients electively participated in an 11-point outpatient survey at a single academic institution. Surgical procedures included either laparoscopic sleeve gastrectomy (SG) or gastric bypass (GB). At the time of survey, patients ranged from 1-month to 15 years from surgery. Survey items consisted of dichotomous (yes/no), multiple choice, and open-ended free response questions. Descriptive statistics were evaluated. RESULTS: Two hundred and fourteen responses were collected, 116 (54%) underwent SG and 98 (46%) underwent GB. Of these, 49% of samples were during short-term postoperative follow-up visits (0-3 months), 34% intermediate follow-up (4-12 months), and 17% long-term follow-up (> 1 year). A total of 98% of patients reported that insurance did not cover their supplement cost. Most patients reported current vitamin use (95%), with 87% reporting daily compliance. Daily compliance was observed in 94%, 79%, and 73% of SG patients at short-, intermediate-, and long-term follow-up visits, respectively. While GB patients reported daily compliance in 84%, 100%, and 92% of short, intermediate, and long-term responses. Of those who were unable to take vitamins daily, non-compliance was attributed most to forgetting (54%), and less often to side effects (11%), or taste (11%). Patient-reported strategies for remembering to take vitamins included tying into daily routine (55%), use of a pill box (7%), and alarm reminders (7%). CONCLUSIONS: Daily compliance with post-bariatric surgery vitamin supplementation does not appear to vary based on postoperative time-period or surgical procedure. While a minority of patients struggle with daily compliance, factors associated with non-compliance include patient forgetting, side effects, and taste. Widespread utilization of patient-reported daily reminder strategies may lead to improved overall compliance and reduce incidence of nutritional deficiencies.

Textbook Outcomes in Liver Surgery: a Systematic Review.

BACKGROUND: Assessment of the quality of care among patients undergoing hepatectomy may be inadequate using traditional "siloed" postoperative surgical outcome metrics. In turn, the combination of several quality metrics into a single composite Textbook Outcome in Liver Surgery (TOLS) may be more representative of "ideal" surgical care. METHODS: Adhering to PRISMA guidelines, a search for primary articles on post-operative TOLS evaluation after hepatectomy was performed. Studies that did not present hepatectomy outcomes, pediatric or transplantation populations, duplicated series, and editorials were excluded. Studies were evaluated in aggregate for methodological variation, TOLS rates, factors associated with TOLS, hospital variation, and overall findings. RESULTS: Among 207 identified publications, 32 observational cohort studies were selected for inclusion in the review. There was a total of 90,077 hepatic resections performed from 1993 to 2020 in the analytic cohort. While TOLS definitions varied widely, all studies used an "all-or-none" composite structure combining a median of 5 (range: 4-7) discrete parameters. Observed TOLS rates varied in the different reported populations from 11.2 to 77.0%. TOLS was associated with patient, hospital, and operative factors. CONCLUSIONS: This systematic review summarizes the contemporary international experience with TOLS to assess surgical performance following hepatobiliary surgery. TOLS is a single composite metric that may be more patient-centered, as well as better suited to quantify "optimal" care and compare performance among centers performing liver surgery.

Does size matter? Comparing robotic versus open radical nephrectomy for very large renal masses.

INTRODUCTION: We evaluated perioperative and mortality outcomes of robotic-assisted radical nephrectomy (RRN) vs. open radical nephrectomy (ORN) for very large renal cell carcinomas (RCC). MATERIALS AND METHODS: Adult patients with non-metastatic RCC >10 cm in size (pT2b) were identified from the National Cancer Database (2010-2017). Mixed-effects multivariable logistic regression adjusting for patient, tumor, and facility characteristics were used to evaluate rates of positive margin, prolonged length of stay (LOS) (>75th percentile), 30-day readmission, and 30-day and 90-day mortality for RRN vs. ORN. Overall survival (OS) was evaluated using the Kaplan-Meier method and adjusted Cox proportional hazard modeling. RESULTS: Of the 2,977 patients who underwent radical nephrectomy, 492 (16.5%) underwent RRN. Factors associated with RRN included male gender, metro or urban locations, academic facilities, Charlson-Deyo score >2, private or Medicaid insurance, and surgery in a later year (all P < 0.05). Tumors ≥15.1cm in size were associated with a higher rate of conversion to open surgery (P < 0.001). ORN was associated with increased median postoperative LOS (4d [interquartile range; IQR 3-6] vs. 3d, [IQR 2-4]; P < 0.01). RRN demonstrated no significant difference in the risk of positive margin, 30-day readmission, 30-day mortality, or 90-day mortality. RRN was associated with a decreased risk of prolonged LOS (OR 0.38; 95%CI [0.28-0.53]). There was no difference in long-term OS observed in patients treated with ORN vs. RRN. CONCLUSIONS: Very large, non-metastatic RCC can be safely and effectively treated with RRN. Rates of conversion to open were higher for tumors ≥15.1 cm. RRN has comparable long-term OS and improved LOS compared to ORN.

Textbook oncologic outcome in pancreaticoduodenectomy: Do regionalization efforts make sense?

BACKGROUND AND OBJECTIVES: Few empiric studies evaluate the effects of regionalization on pancreatic cancer care. METHODS: We queried the National Cancer Database to identify patients undergoing pancreaticoduodenectomy for clinical stage I/II pancreatic adenocarcinoma between 2006 and 2015. Facilities were categorized by annual pancreatectomy volume. Textbook oncologic outcome was defined as a margin negative resection, appropriate lymph node assessment, no prolonged hospitalization, no 30-day readmission, no 90-day mortality, and timely receipt of adjuvant chemotherapy. Multivariable regression adjusted for comorbid disease, pathologic stage, and facility characteristics was used to evaluate the relationship between facility volume and textbook outcome. RESULTS: Sixteen thousand six hundred and two patients underwent pancreaticoduodenectomy; 3566 (21.5%) had a textbook outcome. Operations performed at high volume centers increased each year (45.8% in 2006 to 64.2% in 2015, p < 0.001) as did textbook outcome rates (14.3%-26.2%, p < 0.001). Surgical volume was associated with textbook outcome. High volume centers demonstrated higher unadjusted rates of textbook outcome (25.4% vs. 11.8% p < 0.01) and increased adjusted odds of textbook outcome relative to low volume centers (odds ratio: 2.39, [2.02, 2.85], p < 0.001). Textbook outcome was associated with improved overall survival independent of volume. CONCLUSIONS: Regionalization of care for pancreaticoduodenectomy to high volume centers is ongoing and is associated with improved quality of care.

Does minimally invasive pancreaticoduodenectomy increase the chance of a textbook oncologic outcome?

BACKGROUND: Textbook oncologic outcome has been described in an effort to improve upon traditional outcomes defining care after pancreaticoduodenectomy for adenocarcinoma. We sought to examine whether minimally invasive pancreaticoduodenectomy increased the likelihood of an optimal textbook oncologic outcome. METHODS: Patients undergoing open pancreaticoduodenectomy or minimally invasive pancreaticoduodenectomy between 2010 and 2015 were identified in the National Cancer Database. Textbook oncologic outcome was defined as R0 resection with American Joint Committee on Cancer compliant lymphadenectomy, no prolonged duration of stay, no 30-day readmission/mortality, and receipt of adjuvant chemotherapy. Propensity score matching was employed to evaluate adjusted rates of textbook oncologic outcome, in addition to overall survival. RESULTS: Among 12,854 patients who underwent pancreaticoduodenectomy, 48.3% were female, and the median patient age was 66 years; 87.5% underwent open pancreaticoduodenectomy, and 12.5% underwent whether minimally invasive pancreaticoduodenectomy. After propensity score matching, there were no noted differences in the likelihood of R0 resection, adequate lymphadenectomy, nonprolonged duration of stay, no readmission, no 30-day mortality, adjuvant chemotherapy, or textbook oncologic outcome among open pancreaticoduodenectomy versus minimally invasive pancreaticoduodenectomy (P > .05). Textbook oncologic outcome was associated with an improved median overall survival (negative textbook oncologic outcome: 21.3 months vs positive textbook oncologic outcome: 27.6 months, P < .001). CONCLUSION: Although textbook oncologic outcome was associated with a survival advantage, it was only achieved in 1 in 4 patients undergoing pancreaticoduodenectomy for adenocarcinoma. Achievement of textbook oncologic outcome was equivalent among patients who underwent minimally invasive pancreaticoduodenectomy compared with open pancreaticoduodenectomy after propensity score matching.

Laparoscopic partial hepatectomy is cost-effective when performed in high volume centers: A five state analysis.

BACKGROUND: Prior studies comparing the efficacy of laparoscopic (LHR) and open hepatic resection (OHR) have not evaluated inpatient costs. METHODS: We conducted a retrospective cohort study using the Healthcare Cost and Utilization Project State Inpatient Databases to identify patients undergoing hepatic resection between 2010 and 2014. RESULTS: 10,239 patients underwent hepatic resection. 865 (8%) underwent LHR and 9374 (92%) underwent OHR. On adjusting for hospital volume, patients undergoing LHR had a lower risk of respiratory (OR 0.64, 95% CI [0.52, 0.78]), wound (OR 0.48; 95% CI [0.29, 0.79]) and hematologic (OR 0.57; 95% CI [0.44, 0.73]) complication as well as a lower risk of being in the highest quartile of cost (0.58; 95% CI [0.43, 0.77]) than those undergoing OHR. Patients undergoing LHR in very high volume (>314 hepatectomies/year) centers had lower risk-adjusted 90-day aggregate costs of care than those undergoing OHR (-$8022; 95% CI [-$11,732, -$4311). DISCUSSION: Laparoscopic partial hepatectomy is associated with lower risk of postoperative complication than OHR. This translates to lower aggregate costs in very high-volume centers.

Assessment of Cancer Center Variation in Textbook Oncologic Outcomes Following Colectomy for Adenocarcinoma.

BACKGROUND: Traditional metrics may inadequately represent rates of attaining optimal oncologic care. We evaluated a composite "textbook oncologic outcome" (TOO) to assess the incidence of achieving an "optimal" clinical result after colon adenocarcinoma (CA) resection. METHODS: The National Cancer Database (NCDB) was queried to identify patients undergoing colectomy for non-metastatic CA between 2010 and 2015. TOO was defined as a margin negative resection with an AJCC compliant lymph node evaluation, no prolonged length of stay (LOS) or 30-day readmission/mortality, as well as receipt of stage appropriate adjuvant chemotherapy. RESULTS: Among 170,120 patients who underwent colectomy at 1315 hospitals, 93,204 (54.8%) achieved TOO with large variations observed among facilities. While certain factors were achieved nearly universally (R0 margin, 95.6%; no 30-day mortality, 97.2%), avoidance of prolonged LOS (77.3%) and appropriate adjuvant chemotherapy (83.0%) were achieved less consistently. On multivariable analysis, Black race/ethnicity (OR 0.82, 95% CI 0.80-0.85), Medicaid insurance (OR 0.64, 0.61-0.68), and low-volume facility (< 50/year) (OR 0.83, 0.77-0.89) were associated with decreased likelihood of TOO. Achievement of TOO was associated with improved long-term survival (HR 0.45; 95% CI 0.44-0.46). CONCLUSIONS: Roughly one-half of patients undergoing resection of CA achieved an optimal clinical outcome. TOO may be a more useful quality metric to assess patient-centric composite outcomes following surgical procedures.

Biliary Enteric Reconstruction After Biliary Injury: Delayed Repair Is More Costly Than Early Repair.

BACKGROUND: Bile duct injury (BDI) during cholecystectomy requiring biliary enteric reconstruction (BER) is associated with increased risk of postoperative mortality and substantive increases in costs of care. The impact of the timing of repair on overall costs of care is poorly understood. MATERIALS AND METHODS: The Healthcare Cost and Utilization Project Florida State databases (2006-2015) were queried to identify patients undergoing BER within 1-y of cholecystectomy performed for benign biliary disease. Patients were then categorized by the time interval between cholecystectomy to BER: early (≤3 d), intermediate (4 d to 6 wk), or delayed (>6 wk). By repair timing strategy, 1-y outcomes were aggregated, including charges, inpatient costs, aggregate length of stay, and inpatient mortality. RESULTS: Of 563,887 patients undergoing cholecystectomy, 1168 required a BER (0.21%) within 1-y of cholecystectomy. Early BER was performed in 560 patients (47.9%), intermediate BER in 439 patients (37.6%), and delayed BER in 169 (14.5%) patients. On multivariable analysis adjusting for patient, procedure, and facility factors, intermediate BER demonstrated an increased risk of mortality (odds ratio 2.04, 95% confidence interval [CI]: 1.16-3.56) and increased aggregate inpatient cost (+$12,472; 95% CI: $6421-$18,524) relative to early BER. There was no notable difference in adjusted risk of inpatient mortality between the early and delayed BER cohorts (odds ratio 0.90; 95% CI: 0.32-1.25), but delayed BER was associated with increased aggregate inpatient costs (+$45,111; 95% CI: $36,813-$53,409). CONCLUSIONS: When compared with delayed BER, early repair was associated with shorter aggregate inpatient hospitalization without increased postoperative mortality. Intermediate timing of repair is associated with increased costs and risk of mortality.

Analysis of adjuvant chemotherapy in patients undergoing curative-intent resection of localized adrenocortical carcinoma.

BACKGROUND: Studies evaluating the role of adjuvant chemotherapy (ACT) in Adrenocortical Carcinoma (ACC) are limited due to its rarity. The objective of this study was to evaluate if ACT provides a survival benefit in patients who underwent curative-intent resection of localized ACC and to determine factors associated with receipt of ACT. METHODS: The National Cancer Data Base was queried to identify patients (2010-2016) with curative-intent resection of localized ACC (T1-T3, N0, M0). RESULTS: Of 577 patients with adrenalectomy, 389 (67%) had adrenalectomy alone, and 188 (33%) received ACT. Private insurance, lymphovascular invasion, stage II, and radiotherapy were predictors of ACT (P < 0.05). Advanced (T3) stage lymphovascular invasion, and being uninsured were associated with decreased OS (P < 0.05). There was no association between ACT and OS. CONCLUSIONS: For patient who underwent curative-intent resection of localized ACC, there was no association between ACT and OS. Private insurance, lymphovascular invasion, stage II disease, and radiotherapy were associated with receipt of ACT.

Weekend readmissions associated with mortality following pancreatic resection for cancer.

BACKGROUND: The weekend effect is associated with an increased risk of adverse events, with complex patient populations especially susceptible to its impact. The objective of this study was to determine if outcomes for patients readmitted following pancreas resection differed on the weekend compared to weekdays. METHODS: The Healthcare Cost and Utilization State Inpatient Database for Florida was used to identify patients undergoing pancreas resection for cancer who were readmitted within 30 days of discharge following surgery. Measured outcomes (for readmission encounters) included inpatient morbidity and mortality. RESULTS: Patients with weekend readmissions had an increased odds of inpatient mortality (aOR 2.7, 95% C.I.: 1.1-6.6) compared to those with weekday readmissions despite having similar index lengths of stay (15.9 vs. 15.5 days, P = .73), incidence of postoperative inpatient complications (22.4% vs. 22.3%, P = .98), reasons for readmission, and baseline comorbidity. DISCUSSION: Weekend readmissions following pancreatic resection are associated with increased risk of mortality. This is not explained by measured patient factors or clinical characteristics of the index hospital stay. Developing strategies to overcome the weekend effect can result in improved care for patients readmitted on the weekend.

Does resection improve overall survival for intrahepatic cholangiocarcinoma with nodal metastases?

BACKGROUND: The potential benefit of surgical resection of intrahepatic cholangiocarcinoma in patients with locoregionally advanced disease has not been definitively determined. METHODS: The National Cancer Database was queried to identify patients with clinical evidence of node-positive intrahepatic cholangiocarcinoma. Resected patients were stratified by margin status and lymph node ratio (nodes positive to nodes harvested). Risk of death was determined using Cox regression models and Kaplan-Meier survival functions. RESULTS: A total of 1,425 patients with T(any)N1M0 intrahepatic cholangiocarcinoma were identified. Two hundred twelve (14.9%) underwent surgical resection. On multivariable Cox regression, R0 resection afforded a survival benefit regardless of lymph node ratio (lymph node ratio > 0.5: hazard ratio 0.466, 95% confidence interval 0.304-0.715; lymph node ratio ≤ 0.5: hazard ratio 0.444, 95% confidence interval 0.322-0.611), whereas a survival benefit was only seen in R1 patients with lymph node ratio ≤ 0.5 (hazard ratio 0.470, 95% confidence interval 0.316-0.701). On Kaplan-Meier, median survival was 11.6 months with chemotherapy, 15.7 months with R0 resection in lymph node ratio > 0.5, and 22.2 months with R0 resection in lymph node ratio ≤ 0.5 (P < .001). DISCUSSION: Margin negative resection is associated with a risk-adjusted survival benefit for patients with clinically N1 intrahepatic cholangiocarcinoma regardless of the degree of regional lymph node involvement.

Textbook oncologic outcome is associated with increased overall survival after esophagectomy.

BACKGROUND: Assessment of quality in oncologic operations traditionally involves use of discrete metrics reported individually. Such metrics have limited value to payers and patients making broad comparisons of clinical programs. We define a composite textbook oncologic outcome for esophagectomy. METHODS: The National Cancer Database was queried to identify patients presenting with clinically resectable esophageal cancer between 2004 and 2015. Textbook oncologic outcome was defined as stage-appropriate use of neoadjuvant chemoradiation followed by margin negative esophagectomy with formal lymph node assessment and having no prolonged hospitalization, readmission, or 30-day mortality. RESULTS: Fourteen thousand nine hundred and sixty-nine patients underwent esophagectomy. Of those, 5,561 (37.2%) had textbook oncologic outcome. The overall survival of patients having textbook oncologic outcome was significantly longer than those who did not (52.1 (95% confidence interval [49.0-58.8]) vs 29.1 months (95% confidence interval [29.1-32.3]). On multivariable modeling adjusted for age, comorbid conditions, demographics, treatment characteristics, and esophagectomy volume, volume (odds ratio 1.38, 95% confidence interval [1.16-1.65]) and minimally invasive approach were independently associated with textbook oncologic outcome (odds ratio 1.15, 95% confidence interval [1.02-1.30]), and textbook oncologic outcome was independently associated with improved overall survival (hazard ratio 0.74, 95% confidence interval [0.68-0.80]). CONCLUSION: Textbook oncologic outcome is achieved in a minority of patients undergoing esophagectomy. Textbook oncologic outcome is independently associated with improved overall survival.

Optimal Cystectomy Outcome: A Composite Measurement Evaluating Quality of Care and Mortality Benefit.

OBJECTIVES: To evaluate the incidence and impact of an "optimal cystectomy outcome" (OCO), a simplified performance metric that encompasses multiple patient-centered outcomes. METHODS: We identified patients in the National Cancer Center Database undergoing radical cystectomy for stage cT2-cT3 urothelial carcinoma (2006-2014). OCO was defined as negative resection margin, adequate lymphadenectomy (>10 nodes), no prolonged length-of-stay (<75th percentile), no 30-day-readmission, and no 30-day-mortality. We used multivariable logistic regression and Cox proportional-hazards models to identify factors associated with OCO and overall survival (OS). RESULTS: Among 12,997 patients who fit the inclusion criteria, individual OCO components were attained at a relatively high rate; however, only 37.6% of patients met all 5 OCO criteria. Patients who underwent surgery at a high-volume (OR 2.45) academic facility (OR 1.60) using a minimally-invasive approach (OR 1.32) were more likely to receive an OCO. Patients were less likely to receive an OCO if they were older (OR 0.98), African American (OR 0.71), had Medicaid insurance (OR 0.66), or more comorbidities (OR 0.48) (all P <0.05). Patients who received an OCO were found to have a significantly lower risk of overall mortality (HR 0.69, P <0.05). CONCLUSION: Various patient- and hospital-specific factors affect a system's ability to achieve OCO in patients undergoing radical cystectomy. OCO is directly associated with improved OS and has the potential to function as a composite performance metric for the quality of care in bladder cancer.

Association of obesity with postoperative outcomes after proctectomy.

BACKGROUND: Prior efforts evaluating obesity as a risk factor for postoperative complications following proctectomy have been limited by sample size and uniform outcome classification. METHODS: The ACS NSQIP was queried for patients with non-metastatic rectal adenocarcinoma who underwent elective proctectomy. After stratification by BMI classification, multivariable modeling was used to identify the effect of BMI class on adjusted risk of 30-day outcomes controlling for patient, procedure, and tumor factors. RESULTS: Of 2241 patients identified, 33.4% had a normal BMI, 33.5% were overweight, 21.1% were obese, and 12.0% were morbidly obese. Increased risk of superficial surgical site infection (SSI) was observed in obese (OR 2.42, 95%CI:[1.36-4.29]) and morbidly obese (OR 3.29, 95%CI:[1.77-6.11]) patients when compared to normal BMI. Morbid obesity was associated with increased risk of any complication (OR 1.44, 95%CI:[1.05-1.96]). BMI class was not associated with risk adjusted odds of anastomotic leak. CONCLUSIONS: Morbid obesity is independently associated with an increased composite odds risk of short-term morbidity following elective proctectomy for cancer primarily due to increased risk of superficial SSI.

Assessment of textbook oncologic outcomes following pancreaticoduodenectomy for pancreatic adenocarcinoma.

BACKGROUND: Composite outcomes may more accurately reflect patient and provider expectations around optimal care. We sought to determine the impact of achieving a so-called "textbook oncologic outcome" (TOO) among patients undergoing resection of pancreatic adenocarcinoma (PDAC). METHODS: Patients undergoing pancreaticoduodenectomy (PD) for PDAC between 2006 and 2016 were identified in the National Cancer Database (NCDB). TOO was defined by: margin negative resection, compliant lymph node evaluation, no prolonged length-of-stay, no 30-day readmission/mortality, and receipt of adjuvant chemotherapy. Factors associated with TOO and overall survival (OS) were evaluated using multivariable logistic and Cox regression models, respectively. RESULTS: Among 18 608 patients who underwent PD at 782 hospitals, many patients successfully achieved certain TOO factors such as R0 margin (77.9%) and no 30-day mortality (96.9%), while other TOO criteria such as receipt of adjuvant therapy (48.2%) were achieved less frequently. Overall, only 3124 (16.8%) patients achieved a TOO. Factors associated with lower odds of TOO included: older age, Black race, Medicaid insurance, Community facility, and low PD facility (<20 PD/y) (all P < .05). Achievement of a TOO was associated with lower risk of mortality (HR 0.74; 95% CI, 0.70-0.77). CONCLUSIONS: While TOO was associated with improved long-term survival, TOO was only achieved in 16.8% of patients undergoing PD.

Impact of general surgery rotation exposure on surgery clerkship performance.

BACKGROUND: Medical students often have variable exposures to general surgery (GS) and subspecialty surgery (SS) during their surgical clerkship. We will evaluate the relationship between clinical exposure to GS and performance on the NBME Subject Examination in Surgery. METHODS: Student data was collected retrospectively from 2015 to 2018 at a single academic institution. Students were categorized based on their clinical clerkship exposure to GS. A linear model was used to estimate the mean difference in NBME performance between GS and strictly SS exposed students while controlling for prior standardized examination scores and completion of an internal medicine clerkship prior to surgery. RESULTS: 365 (67%) of 547 students were exposed to a GS rotation prior to their NBME exam. Performance on the NBME exam was comparable between GS versus SS students (µdiff = 0.37, 95% CI: -0.73 to 1.48; p = .51). CONCLUSIONS: Exposure to a GS rotation is not advantageous on the NBME surgery examination. Students who completed the medicine clerkship prior to surgery demonstrated superior performance on the NBME surgery examination.

The impact of the affordable care act (ACA) Medicaid Expansion on access to minimally invasive surgical care.

INTRODUCTION: This study aims to evaluate the effect of the ACA Medicaid expansion on the utilization of minimally invasive (MIS) approaches to common general surgical procedures. METHODS: We queried five Healthcare Cost and Utilization Project State Inpatient Databases to evaluate rates of utilization and costs of MIS and open approaches pre and post Medicaid expansion. RESULTS: 117,241 patients met the inclusion criteria. Following the enactment of the ACA, use of both laparoscopic gastric bypass (IRR 1.08; 95% CI: [1.02, 1.15]) and Nissen fundoplication (IRR 1.17; 95% CI [1.09, 1.26]) increased in Medicaid patients treated in expansion states than in those treated in non-expansion states. Simultaneously, the costs reported for self-pay patients increased in expansion states more than in non-expansion states (+$1669; 95% CI [$655, $2682]). CONCLUSIONS: Medicaid expansion was associated with increased rates of utilization of MIS approaches to several surgical procedures and a shifting of costs toward patients who were self-insured.