Exploring the paradigm of robotic surgery and its contribution to the growth of surgical volume.

Background: Robotic surgery is an appealing option for both surgeons and patients. The question around the introduction of new surgical technology, such as robotics, with the potential link to increased procedure-specific volume has not been addressed. We hypothesize that hospital adoption of robotic technology increases the total volume of specific procedures as compared to nonrobotic hospitals. Methods: The 2010-2020 Florida Agency for Health Care Administration Inpatient database was queried for open, laparoscopic, and robotic colectomy, lobectomy, gastric bypass, and antireflux procedures. International Classification of Diseases, 9th and 10th Revisions, codes were used. Difference in difference method was used to evaluate the impact of robotics on total procedure-specific volume of robotic hospitals versus nonrobotic hospitals before and after adopting robotic technology. Incident rate ratios from the difference in difference analysis determined the significance of adding robotics. Patient demographics were evaluated using χ2 test. Results: A total of 291,826 procedures were performed at 217 hospitals, 151 with robotic capabilities. Robotic hospitals experienced a 37% increase in surgical volume due to robotic technology (incident rate ratio 1.37, P < .05), which was consistent for each surgery except antireflux procedures (incident rate ratio 0.95). Robotic procedures had significantly higher charges for medical/surgical supplies; however, the mean length of stay for robotic procedures was significantly shorter than that of laparoscopic and open cases. Conclusion: Hospital adoption of robotic technology significantly increases surgical volume for select procedures. Hospitals should consider the benefits of introducing robotic technology which leads to higher volume and decreased length of stay, benefitting both hospital systems and patients.

Impact of sociodemographic factors on outcomes in patients with peritoneal malignancies following cytoreduction and chemoperfusion.

BACKGROUND AND OBJECTIVES: Sociodemographic factors have been shown to impact surgical outcomes. However, the effects of these factors on patients undergoing cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) are not well known. This study aims to evaluate the impact of sociodemographic factors on patients undergoing CRS/HIPEC. METHODS: Adult patients at a tertiary center who underwent CRS/HIPEC were evaluated. Perioperative variables were collected and analyzed. A national database was also used to evaluate patients undergoing CRS/HIPEC. RESULTS: There were 90 patients who underwent CRS/HIPEC (32% non-White). There was no statistically significant difference in postoperative complications, length of stay, or discharge disposition based upon race (white vs. non-White patients), socioeconomic status (SES), or insurance type. Nationally, we found that Black and Hispanic patients were less likely to undergo CRS/HIPEC than Non-Hispanic white patients (Black: odds ratio [OR]: 0.60, [confidence interval {CI}: 0.39-0.94]; Hispanic: OR: 0.52, [CI: 0.28-0.98]). However, there were no significant differences in postoperative complications based upon race/ethnicity. CONCLUSION: Sociodemographic factors including race, SES, and insurance status did not impact postoperative outcomes in patients undergoing CRS/HIPEC at our single institution. On a national level, Black and Hispanic patients underwent CRS/HIPEC at lower rates compared to white patients.

Medical Students from Socioeconomically Disadvantaged Backgrounds are Less Likely to Match into Surgery.

BACKGROUND: This study aims to understand the demographic and academic characteristics that play a role in enrollment in surgical residency programs as well as any racial or socioeconomic disparities that may exist for medical students entering surgical specialties at the Loyola University Chicago Stritch School of Medicine (LUC-SSOM). METHODS: Demographic data for 993 medical students graduating between 2013 and 2019 from LUC-SSOM were compared using a series of t tests, Chi-square tests, and logistic regression models. RESULTS: Students entering surgical residency programs had two times greater odds of coming from a family with a median family income greater than $75,000 than those entering non-surgical residencies (OR 2.19, 95% CI [1.35, 3.53]). Students from disadvantaged backgrounds had 50% decreased odds of going into surgery when compared to those not entering surgery (OR 0.50, 95% CI [0.28, 0.90]). CONCLUSIONS: Students from low socioeconomic status backgrounds face more barriers in pursuing surgical subspecialties.

Adopting robotic thoracic surgery impacts hospital overall lung resection case volume.

PURPOSE: We sought to evaluate the role of robotic-assisted lung surgery on hospital volume using difference in difference (DID). We propose hospital adoption of robotic thoracic technology increases total volume of specific procedures as compared to non-robotic hospitals. METHODS: The 2010-2015 Florida Agency for Health Care Administration dataset was queried for open, video-assisted thoracoscopic, and robotic-assisted thoracic surgeries. Incident Rate Ratios (IRR) from DID analysis determined the significance of robotic technology. For each technique, length of stay and elements of charges were compared to determine statistical significance. RESULTS: A total of 28,484 lung resection procedures performed at 162 hospitals, 65 of which had robotic capabilities were included. Robotic hospitals experienced an 85% increase in total lung surgical volume (IRR 1.85, p-value <0.001). This increase in volume was consistent for each lung resection procedure separately. CONCLUSION: Hospital adoption of robotic technology significantly increases the overall lung surgical volume for select lung resection procedures.

Does adoption of new technology increase surgical volume? The robotic inguinal hernia repair model.

Robotic Inguinal Hernia repair has been associated with higher costs but shorter length of stay. Robotic surgery is an appealing option for patients undergoing elective hernia surgery however given the high startup, maintenance and operating costs, the adoption of robotic technology may not guarantee increased profitability. Our hypothesis is that the introduction of robotic technology increases the overall surgical volume of inguinal hernia repairs within a hospital as compared to non-robotic hospitals. The 2010-2018 Florida Agency for Health Care Administration Ambulatory Patient data were queried for Open, Laparoscopic and Robotic inguinal hernia repairs using ICD9, ICD10 and CPT codes. Using a difference in difference (DID) technique, we determined the difference of the total hernia volume of robotic hospitals pre- and post-adoption of robotic technology. In addition, selected hospitals which were early adopters of robotic technology were compared to with their surrounding non-robotic competitor hospitals. Incident Rate Ratios-IRR, from the difference in difference analysis determined the significance of robotic technology. Hospital and patient demographic data were evaluated, and chi square test were used to determine statistical significance. p < 0.05 was considered significant. There were a total of 258,785 inguinal hernia repairs (5774 Robotic, 88,265 Laparoscopic and 164,746 Open) performed at 398 hospitals, 94 of which had robotic capabilities. Of all the procedure types, around 90% were primary inguinal hernia repairs. The majority of patients in this cohort were white non-Hispanic or Latino males (85%, 84%, 92%), age group 51-70 (46%), holding commercial health insurance (43%) and belonged to the lowest Charlson comorbidity index level (82%). Facility types designation for almost all robotic hospitals was hospital (99%), whereas 65% of non-robotic hospitals were ambulatory surgery centers and all other hospitals. Robotic hospitals experienced a 9.5% increase in total volume of inguinal hernia repairs after introduction of robotic technology (Incident Rate Ratios-IRR 1.095, p value < 0.0001). A significant increase in total hernia volume was observed for the early adopter hospitals with the IRR(s) ranging 1.20-2.51 (all p values < 0.0001), implying that adoption of robotic technology can in fact lead to very significant increase in total hernia volume for a hospital. The introduction of robotic technology leads to an increase in the overall volume of inguinal hernia repairs performed at a given hospital. To further evaluate the impact of robotic technology and significance of this methodology, additional work is underway using additional procedures and data from other states.

Introduction of transcatheter aortic valve replacement technology increases overall aortic valve surgical volume: Evaluating the Florida experience.

OBJECTIVE: Transcatheter aortic valve replacement technology is increasingly used for aortic valve stenosis. We sought to evaluate the adoption of transcatheter aortic valve replacement technology with respect to overall surgical aortic valve replacement volume in Florida. METHODS: The 2010-2019 Florida Agency for Health Care Administration data set was queried. Difference-in-difference analysis was used to evaluate the impact of transcatheter aortic valve replacement on the total aortic valve surgical volume of transcatheter aortic valve replacement versus nonperforming hospitals. Length of stay and elements of charges were compared for the raw and 1:1 propensity matched data. RESULTS: A total of 46,032 surgical aortic valve procedures were performed at 88 hospitals. Transcatheter aortic valve replacement performing hospitals experienced a 21% increase in total aortic valve surgical volume. Length of stay was significantly less for patients undergoing transcatheter aortic valve replacement. Propensity matched transcatheter aortic valve replacement patients had less gross total charges. CONCLUSION: Introduction of transcatheter aortic valve replacement technology significantly increased overall surgical aortic valve volume and may be associated with less gross total hospital charges.

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.

Impact of angiotensin system inhibitors on esophageal cancer survival.

INTRODUCTION: Angiotensin system inhibitors are associated with improved prognosis in patients with gastrointestinal and hepatobiliary cancers. Data suggest that renin-angiotensin system signaling stimulates the tumor's immune microenvironment to impact overall survival. The goal of this study is to investigate the role of angiotensin system inhibitor use on the overall survival and disease-free survival of esophageal cancer patients. METHODS: Retrospective review of esophagectomy patients with esophageal adenocarcinoma and squamous cell cancer at a single institution tertiary care center from 2007 to 2018 was performed. Outcomes include overall survival and disease-free survival. Patient characteristics were compared with t test and χ2 test. Survival was analyzed with Kaplan-Meier and Cox proportional-hazards regression. RESULTS: One hundred seventy-one patients were identified and 123 underwent esophagectomy for cancer. No significant differences in patient demographics were found between angiotensin system inhibitor users and non-angiotensin system inhibitor users except for the rates of hypertension (40% vs 94%, P < .01) and diabetes (16% vs 47%, P < .01). Distributions of tumor neoadjuvant therapy, adjuvant therapy, pathology, staging, margins, and surgical approach were similar. Postoperatively, there was no difference in major adverse cardiovascular events or infection rates. This study did not find any differences in overall survival and disease-free survival between angiotensin system inhibitor users and non-angiotensin system inhibitor users. CONCLUSION: Angiotensin system inhibitors have been shown to improve survival and decrease relative risk for several types of cancers; however, our data do not support the same effect on esophageal cancer patients undergoing curative intent surgery. Further research is needed to investigate potential nuances in angiotensin system inhibitor dose, chronicity of use, esophageal pathology, and applicability to nonsurgical candidates.

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.

Pancreatic neuroendocrine tumors: Surgical outcomes and survival analysis.

BACKGROUND: Pancreatic neuroendocrine tumors are rare, with rising incidence and limited clinicopathological studies. METHODS: Adult patients with pNET at a single tertiary care center were retrospectively evaluated. RESULTS: In total, 87 patients with histologically confirmed pNET who underwent resection were evaluated. 11% of patients had functioning pNETs: 9 insulinoma and 1 VIPoma. The majority (88.5%) were nonfunctioning. The most common surgical procedure performed was distal pancreatectomy with splenectomy (36.8%). 35.6% of cases were performed with minimally invasive surgery (MIS). MIS patients had fewer postoperative complications, shorter length of stay, and fewer ICU admissions.Disease-free survival (DFS) was unaffected by tumor size (p = 0.5) or lymph node status (p = 0.62). Patients with high-grade (G3) tumors experienced significantly shorter DFS (p = 0.02). CONCLUSIONS: This series demonstrates that survival in patients with pNET is driven mostly by tumor grade, though overall most have long-term survival after surgical resection. Additionally, an MIS approach is efficacious in appropriately selected cases.

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.

Non-Hispanic Blacks undergoing distal pancreatectomy have higher risk-adjusted rates of morbidity and are more likely to be high-cost outliers.

BACKGROUND: Few studies evaluate racial disparities in costs and clinical outcomes for patients undergoing distal pancreatectomy (DP). METHODS: We queried the Healthcare Cost and Utilization Project State Inpatient Databases to identify patients undergoing DP. Multivariable regression (MVR) was used to evaluate the association between race and postoperative outcomes. RESULTS: 2,493 patients underwent DP; 265 (10%) were black, and 221 (8%) were of Hispanic ethnicity. On MVR, black and Hispanic patients were less likely than whites to undergo surgery in high volume centers (OR 0.53, 95% CI [0.40, 0.71]; OR 0.45, 95% CI [0.32, 0.62]). Black patients had a greater risk of postoperative complication (OR 1.40, 95% CI [1.07, 1.83]), 90-day readmission (OR 1.53, 95% CI [1.15, 2.02]), prolonged length of stay (OR 1.74, 95% CI [1.25-2.44]), and of being a high cost outliers (OR 1.40, 95% CI [1.02, 1.91]) compared to white patients. CONCLUSION: Black patients have increased risk of having a postoperative complication, prolonged hospitalization, and of being a high-cost outlier than non-Hispanic whites.

A Needs Assessment for Incoming Surgical Interns: Communication Effectiveness Is the Most Important Skill.

INTRODUCTION: Medical schools and surgical programs have implemented a "boot camp" to assist medical students' transition into surgical interns and help them contend with a deluge of new responsibilities. This study aims to determine what faculty, residents, and medical students identify as the most critical topics for a surgical boot camp curriculum. METHODS: Forty-five-question survey was developed through an iterative review with multiple surgical colleagues in conjunction with the American College of Surgeons/Association of Program Directors/the Association of Surgical Education resident prep curricular modules. The questions were grouped into 3 broad categories, which included technical skills, practical knowledge, and clinical knowledge. Data were analyzed by a chi-squared test for proportions and continuous variables were compared using t test or ANOVA tests, when appropriate. RESULTS: There was a total of 62 participants, 19 (31%) were attending surgeons, 28 (45%) were general surgery residents, and 15 (24%) were fourth-year medical students (MS4). The response rate for attendings was 45%, residents was 72%, and fourth-year medical students was 43%. Practical knowledge was the most important skill by all participants, followed by clinical knowledge and technical skills (mean score 4.4 vs 3.9 vs 3.2, p < 0.001). The top 5 most important practical knowledge skills to have according to all participants included: how to communicate with senior residents/attendings/nurses, how to use the electronic medical record, how to perform effective handoffs, and how to write orders. CONCLUSIONS: Our study demonstrates that communication skills are the most important according to attendings, residents, and medical students. This study has implications for prioritizing the curricular components of an often tightly scheduled surgical boot camp.

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.

ACCESS TO HEALTHCARE INSURANCE INCREASES THE RATES OF SURGERY FOR DIVERTICULITIS.

OBJECTIVE: The goal of this study was to examine the effect of the Affordable Care Act Medicaid expansion on rates of hospitalization and surgery for diverticulitis. STUDY SETTINGS: Data were obtained from the Healthcare Cost and Utilization Project State Inpatient Databases from 2010 to 2014. STUDY DESIGN: Retrospective cohort study analyzing adult patients undergoing surgery for diverticulitis in the expansion and nonexpansion states, pre (2010-2013) and post (2014) Medicaid expansion. FINDINGS: There were a total of 159,419 patients in our cohort analysis. 75,575 (49%) in expansion states and 81,844 (51%) in non-expansion states. In multivariable Poisson regression, the rate of surgical procedures for diverticular disease increased among Medicaid patients (IRR 1.80; p<.01) whereas surgery rates in self-pay patients decreased (IRR 0.67; p<.01) in expansion states compared to non-expansion states. CONCLUSIONS: In states that expanded Medicaid coverage under the Affordable Care Act, the rate of surgery for diverticular disease in Medicaid patients increased. Therefore, legislation that increases healthcare access may increase the utilization of surgical care for diverticular disease.

Do high-volume centers mitigate complication risk and reduce costs associated with performing pancreaticoduodenectomy in ethnic minorities?

INTRODUCTION: Few studies examine the impact of ethnicity on post-operative outcomes and costs associated with pancreaticoduodenectomy (PD). METHODS: Multivariable regression (MVR) was used to perform a risk-adjusted comparison of patients within the Healthcare Cost and Utilization Project Databases undergoing PD. RESULTS: 4742 patients underwent PD. 3871 (81%) were white, 456 (10%) black, and 415 (9%) Hispanic. Black and Hispanics were less likely than whites to undergo PD in high volume centers. Blacks and Hispanics had a higher risk of select post-operative complications, prolonged lengths of stay, and high-cost outliers. When PDs done in high volume centers were evaluated separately, blacks and Hispanics had a lower adjusted-risk of any serious morbidity (OR 0.44, 95% CI [0.33, 0.57], OR 0.56, 95% CI [0.43, 0.73]) than whites but costs for PD among the three ethnic groups were statistically identical. CONCLUSION: Racial and ethnic minorities undergoing PD are less likely to receive care at high-volume centers, are at an increased risk of post-operative morbidity, and have higher odds of being high-cost outliers than NHW.

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.

Adjuvant systemic therapy for small bowel gastrointestinal stromal tumor (GIST): Is there a survival benefit after R0 resection?

BACKGROUND: The utility of adjuvant systemic therapy in small bowel gastrointestinal stromal tumor remains unclear. METHODS: We queried the National Cancer Data Base for individuals having enterectomy to negative margins for small bowel gastrointestinal stromal tumor between 2010 and 2015. Subjects were categorized by tumor size (2.1-5 cm, 5.1-10 cm, >10 cm) and histologic grade (≤5 mitoses/50 high-power field and >5 mitoses/50 high-power field). Cox proportional hazard analysis was performed to evaluate the association between adjuvant therapy and overall survival. RESULTS: One thousand five hundred fifty-nine patients met the inclusion criteria. On univariate comparison to resection alone, adjuvant therapy was associated with improved overall survival for individuals with high-grade tumors of intermediate and large size (85% vs 48%, P = .010; 75% vs 47%, P = .003) but not for those with high-grade tumors of small size or low-grade tumors of any size. On multivariable analysis adjusted for age, comorbid disease state, and tumor size, adjuvant therapy was independently associated with reduced risk of mortality for high-grade (hazard ratio 0.37, 95% confidence interval: 0.21-0.64) but not low-grade tumors. CONCLUSION: Adjuvant therapy after R0 resection for small bowel gastrointestinal stromal tumor should be administered after careful consideration of the size and grade of a patient's tumor.

Antimicrobial susceptibility of biliary stents do not predict infectious complications after whipple.

BACKGROUND: Postoperative infectious complications after a pancreaticoduodenectomy remain a significant cause of morbidity. Studies have demonstrated that a preoperative biliary stent increases the risk of postoperative infectious complications. Few studies have investigated the specific preoperative biliary stent bacterial sensitivities to preoperative antibiotics and the effect on infectious complications. The goal of this study was to investigate if the presence of a preoperative biliary stent increases the risk of postoperative infectious complications in patients undergoing a pancreaticoduodenectomy. Additionally, we aimed to investigate biliary stent culture sensitivities to preoperative antibiotics and determine if those sensitivities impacted postoperative infectious complications after a pancreaticoduodenectomy. METHODS: A retrospective chart review of patients who had undergone a pancreaticoduodenectomy at a single institution tertiary care center from 2007 to 2018 was performed. Perioperative variables including microbiology cultures from biliary stents were collected and analyzed. RESULTS: A total of 244 patients underwent a pancreaticoduodenectomy. A preoperative biliary stent was present in 45 (18%) patients. Infectious complications occurred in 25% of those patients with a preoperative biliary stent, and 19% of those without (P = .37). Of those patients with a stent that was cultured intraoperatively, 92% grew bacteria and 61% of those were resistant to the preoperative antibiotics administered. Of the patients with a preoperative biliary stent and bacteria resistant to the preoperative antibiotics, 17% developed a postoperative infectious complication, compared with 20% if the bacteria cultured was susceptible to the preoperative antibiotics (P = .64). CONCLUSION: Infectious complications after pancreaticoduodenectomy are a significant cause of morbidity. Stent bacterial sensitivities to preoperative antibiotics did not reduce the postoperative infectious complications in the preoperative biliary stent group suggesting a multifactorial cause of infections.

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.