Disparities in Breast Cancer Screening Rates Among Adults With and Without Intellectual and Developmental Disabilities.

BACKGROUND: Individuals with intellectual and developmental disabilities may face barriers in accessing healthcare, including cancer screening and detection services. We sought to assess the association of intellectual and developmental disabilities (IDD) with breast cancer screening rates. METHODS: Data from 2018 to 2020 was used to identify screening-eligible individuals from Medicare Standard Analytic Files. Adults aged 65-79 years who did not have a previous diagnosis of breast cancer were included. Multivariable regression was used to analyze the differences in breast cancer screening rates among individuals with and without IDD. RESULTS: Among 9,383,349 Medicare beneficiaries, 11,265 (0.1%) individuals met the criteria for IDD. Of note, individuals with IDD were more likely to be non-Hispanic White (90.5% vs. 87.3%), have a Charlson Comorbidity Index score ≤ 2 (66.2% vs. 85.5%), and reside in a low social vulnerability index neighborhood (35.7% vs. 34.4%). IDD was associated with reduced odds of undergoing breast cancer screening (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.74-0.80; p < 0.001). Breast cancer screening rates in individuals with IDD were further influenced by social vulnerability and belonging to a racial/ethnic minority. CONCLUSIONS: Individuals with IDD may face additional barriers to breast cancer screening. The combination of IDD and social vulnerability placed patients at particularly high risk of not being screened for breast cancer.

Sepsis and Septic Shock in Patients Undergoing Thyroidectomy: Incidence, Risk Factors, and Outcomes.

INTRODUCTION: Postoperative sepsis represents a rare complication following thyroidectomy. We aimed to explore the incidence, risk factors, sources, and outcomes of postoperative sepsis and septic shock among adult patients undergoing thyroidectomy. METHODS: Data from the American College of Surgeons National Surgical Quality Improvement Program were used in this retrospective cohort study. Patients aged ≥18 y who underwent elective thyroidectomy between 2005 and 2019 were included. Multivariable binary logistic regression models were computed to explore risk factors and outcomes of 30-d sepsis and septic shock. RESULTS: Among the 180,373 included patients, 0.1% developed sepsis or septic shock. Male gender, low body mass index, American Society of Anesthesiologists classes 3-5, functional dependence, smoking, diabetes mellitus, pulmonary disease, inpatient surgery, malignant indication, clean-contaminated wound classification, and operation time ≥150 min were significant risk factors for development of sepsis or septic shock. Common infectious sources of sepsis included surgical site infections (29.6%), pneumonia (18.6%), urinary tract infections (16.2%), and multiple infections (6.9%). Patients with postoperative sepsis or septic shock were significantly more likely to develop complications, including wound disruption, stroke, cardiac and renal complications, thromboembolism, prolonged length of stay, unplanned reoperation, and mortality. CONCLUSIONS: Sepsis is rare following thyroidectomy. Our study provides insight into risk factors and procedural characteristics which may contribute to the development of postoperative sepsis or septic shock in this population.

Sex differences in altmetric attention scores and traditional impact metrics of top-cited general surgery literature: Cracks in the ceiling?

BACKGROUND: Sex disparities have previously been identified in surgical academia. This study examines sex differences in the top-cited contemporary general surgery articles and compares Altimetric Attention Score (AAS) and other impact metrics between male and female corresponding authors (CAs). METHODS: We conducted a bibliometric analysis of the 100 most cited articles published between 2019 and 2021 in each of the top 10 general surgery journals based on the 2021 Journal Impact Factor. Impact metrics included AAS, citation count, and H-index of the CA. We used multivariable regression analyses to investigate whether the sex of the CA or first author (FA) was independently associated with AAS and citation count. RESULTS: Among 1000 articles, 23.1% had female CAs and 27.4% female FAs. Female CA articles had higher AAS (13.0 [2.0-63.0] vs. 8.0 [1.0-28.5]; p < 0.001) and lower H-indices (24.0 [11.0-45.0] vs. 31.0 [17.0-50.0]; p = 0.015). Although median citation count did not differ by CA sex, articles with Level 1 evidence and a female CA were cited more often (35.5 [24.0-85.0] vs. 25.0 [16.0 vs. 46.0]; p < 0.05). In multivariable regression, female CA articles had higher AAS (OR: 1.002 [95% CI: 1.001-1.004]) and lower H-index (OR: 0.987 [95% CI: 0.977-0.997]). CONCLUSION: Despite having similar citation counts, articles authored by female CAs exhibit higher AAS scores compared to those authored by their male counterparts. While it is heartening that research authored by female surgeons achieves significant visibility, it remains to be understood how this translates into academic impact and scholarly recognition.

Postoperative complications among dialysis-requiring patients undergoing splenectomy.

BACKGROUND: Dialysis patients are at high risk for surgery, but their outcomes after splenectomy are unclear. We compared postoperative complications between dialysis and non-dialysis patients. METHODS: Data were retrieved from the National Surgical Quality Improvement Program for this retrospective cohort. Adult patients undergoing elective splenectomy between 2005 and 2020 were included. RESULTS: Among 10,339 included patients, 143(1.4%) were on chronic dialysis. Postoperative mortality was higher in dialysis vs. non-dialysis patients (9.1% vs. 1.8%). Dialysis patients were more likely to have 30-day major morbidity, infectious and non-infectious complications, reoperation, and prolonged hospital stay. On multivariable regression, dialysis dependence significantly increased odds of mortality, major morbidity, blood transfusion, prolonged length of stay, reoperation, and failure-to-rescue (FTR). CONCLUSION: Dialysis patients were at higher risk of postoperative morbidity following splenectomy. Additionally, the risk of FTR in this patient population is also significantly more compared to non-dialysis patients.

Training in cardiothoracic surgery: The role for simulation.

Adequate cardiothoracic surgical training is essential for provision of quality care to patients. In recent years, simulation-based training has been advocated as an adjunct to traditional surgical training. Advances in simulation technology has resulted in many low- and highfidelity simulators being employed in cardiothoracic surgical training. Such models allow trainees to practice an array of realistic full-length procedures in a safe and controlled environment, with the window to make mistakes and consider them learning points. There is significant evidence to demonstrate the effectiveness of cardiothoracic surgery simulation in improving surgical skills and operating room performances in addition to building confidence among trainees. However, owing to the high financial cost of arranging it, simulation-based training is not widespread in low- and middle-income countries, including Pakistan. More work is warranted on the cost effectiveness of implementing simulation-based learning, which, in turn, would increase the uptake of simulation to enhance cardiothoracic surgical training in Pakistan.

Persistent poverty impacts access to minimally invasive surgery among patients with hepatopancreatobiliary cancer.

BACKGROUND AND OBJECTIVES: Minimally invasive surgery (MIS) has been successfully adopted in hepatopancreatobiliary (HPB) cancer, and has been associated with improved perioperative and comparable oncological outcomes. We sought to define the impact of county-level duration of poverty on access to MIS and clinical outcomes among patients with HPB cancer undergoing surgical treatment. MATERIALS AND METHODS: Data on patients diagnosed with HPB cancer were obtained from the Surveillance, Epidemiology, and End Results (SEER)-Medicare data (2010-2016). County-level poverty data were obtained from the American Community Survey and the U.S. Department of Agriculture, and categorized into three groups: never high poverty (NHP), intermittent high poverty (IHP), and persistent poverty (PP). Multivariable regression was used to assess the relationship between PP and MIS. RESULTS: Among 8098 patients, 82% (n = 664) resided in regions with NHP, 13.6% (n = 1104) resided in regions with IHP, and 4.4% (n = 350) resided in regions with PP. Median age at the diagnosis was 71 years (interquartile range [IQR]: 67-77). Patients from IHP and PP counties had lower odds of undergoing MIS (IHP/PP vs. NHP, odds ratio [OR]: 0.59, 95% confidence interval [CI]: 0.36-0.96, p = 0.034) and being discharged home (IHP/PP vs. NHP, OR: 0.64, 95% CI: 0.43-0.99, p = 0.043), as well as a higher risk of 1-year mortality (IHP/PP vs. NHP, HR: 1.51, 95% CI: 1.036-2.209, p = 0.032) compared with patients residing in NHP counties. CONCLUSIONS: Duration of county-level poverty was associated with lower receipt of MIS and unfavorable clinical and survival outcomes among patients with HPB cancer. There is a need to improve access to modern surgical treatment options among vulnerable, PP populations.

Association of Metabolic Syndrome with Stroke, Myocardial Infarction, and Other Postoperative Complications Following Carotid Endarterectomy: A Multicenter, Retrospective Cohort Study.

BACKGROUND: Metabolic syndrome (MetS) is a constellation of hypertension, insulin resistance, obesity, and dyslipidemia and is known to increase the risk of postoperative morbidity. This study aimed to assess the impact of MetS on stroke, myocardial infarction, mortality, and other complications following carotid endarterectomy (CEA). METHODS: We analyzed data from the National Surgical Quality Improvement Program. Patients undergoing elective CEA between 2011 and 2020 were included. Patients with American Society of Anesthesiologists status 5, preoperative length of stay (LOS) > 1 day, ventilator dependence, admission from nonhome location, and ipsilateral internal carotid artery stenosis of < 50% or 100% were excluded. A composite cardiovascular outcome for postoperative stroke, myocardial infarction, and mortality was generated. Multivariable binary logistic regression analyses were used to assess the association of MetS with the composite outcome and other perioperative complications. RESULTS: We included 25,226 patients (3,613, 14.3% with MetS). MetS was associated with postoperative stroke, unplanned readmission, and prolonged LOS on bivariate analysis. On multivariable analysis, MetS was significantly associated with the composite cardiovascular outcome (1.320 [1.061-1.642]), stroke (1.387 [1.039-1.852]), unplanned readmission (1.399 [1.210-1.619]), and prolonged LOS (1.378 [1.024-1.853]). Other clinico-demographic factors associated with the cardiovascular outcome included Black race, smoking status, anemia, leukocytosis, physiologic risk factors, symptomatic disease, preoperative beta-blocker use, and operative time ≥ 150 min. CONCLUSIONS: MetS is associated with cardiovascular complications, stroke, prolonged LOS, and unplanned readmissions following CEA. Surgeons should provide optimized care to this high-risk population and strive to reduce operative durations.

Disparities in access to quality surgical care for women in resource-constrained settings: Bottlenecks and the way forward.

Women seeking surgical care are burdened with gender disparities, particularly in resource-limited settings. Such disparities can lead to women often presenting late with advanced disease and poor prognoses. The current narrative review was planned to find evidence for gender disparities, their implications, challenges faced by women seeking surgical care, and strategies to address them. Potentiating from interplay between various societal, sociocultural, and economic barriers, the main challenges included inadequate autonomy, financial constraints, transport and referral issues, lack of experienced women surgeons, privacy concerns, surgeon distrust, and higher thresholds for seeking care. While research revealed these underlying causes, much work remains for governmental healthcare bodies, the international community, surgical leadership, policymakers, surgeons, and family members of patients to act on the highlighted issues. Unrestricted access to quality surgical care for everyone is of vital importance, and can translate into a significant decrease in preventable disabilities and deaths among women in resource-constrained settings.

Perioperative registries in resource-limited settings: The way forward for Pakistan.

Capable of improving surgical quality, perioperative registries can allow performance benchmarking, reliable reporting and the development of risk-prediction models. Well established in high-income countries, perioperative registries remain limited in lower- and middle-income countries due to several challenges. First, ensuring comprehensive data entry forums to power the registries is difficult because of limited electronic medical records requiring sustained efforts to develop and integrate these into practice. Second, lack of adequate expertise and resources to develop and maintain registry software necessitates the involvement of software developers and information technology personnel. Third, case ascertainment and item completion are challenging secondary to poor-quality medical records and high loss-to-follow-up rates, requiring telemedicine initiatives as an adjunct to existing care for the assessment of post-discharge outcomes. Lastly, standardised coding of clinical terminology is warranted for ensuring interoperability of the registries for which adaptation of the existing disease and procedural codes can be a sustainable and cost-effective alternative to the development of new codes.

Path to publication: A peer mentorship model for student-lead surgical research.

Early and sustained involvement in research is imperative for medical students to ensure better career prospects in addition to provision of high-quality, evidence-based care to patients. However, involvement of students in surgical research still remains limited, owing to inadequate research training. The current paper was planned to describe the structure of the "Path to Publication" series, incorporating peer mentorship with capacity-building research workshops for medical students. A total of 25 students were grouped into 8 surgical subspecialty groups to conduct research, supervised by experienced student research and faculty mentors. In addition, a series of research workshops were organized in synchronization with the different phases of research for all groups, equipping medical students with the necessary skills needed for each phase. This initiative has successfully equipped medical students with research skills in addition to involving them in surgical research, helping to advance their research careers and promote evidence-based surgery in Pakistan.

PakSurg: The first trainee-lead model for multicenter surgical research collaboration in Pakistan.

We describe creation and piloting of the PakSurg Collaborative, devised via integration of existing trainee-led collaborative models in the United Kingdom with the resource-limited surgical care in Pakistan. This is the first trainee-lead surgical research collaborative in Pakistan, established by the student-lead Surgery Interest Group from the Aga Khan University. The project involved creation of a model that included a steering committee comprising of five teams which worked in conjunction with collaborators from multiple hospitals. To facilitate this collaboration, a comprehensive and cost-efficient study management pathway was developed. The PakSurg Collaborative has the potential to deliver methodologically robust, high-quality, multicenter surgical evidence from Pakistan. This nationally representative data could inform evidence-based surgical guidelines, potentially translating into improved outcomes for patients undergoing surgery.

Risk factors for intensive care unit admission and mortality among adult meningitis patients.

OBJECTIVE: To assess the risk factors for intensive care unit admission and inpatient all-cause mortality among adult meningitis patients. METHODS: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised of patients of either gender aged ≥18 years diagnosed with bacterial, viral, or tuberculous meningitis between July 2010 and June 2019. Multivariable logistic regression analyses were used to explore independent predictors of inpatient mortality and intensive care unit admission. Data was analysed using SPSS 24. RESULTS: Of the 929 patients with suspected meningitis, 506(54.5%) had confirmatory diagnosis. Of them, 303(59.9%) were males. The overall median age of the sample was 47.0 years (interquartile range: 33.0 years). The most common aetiology was bacterial meningitis 324(64%), followed by viral meningitis 141(27.9%). Incidence of inpatient mortality was 53(10.5%), while 75(14.8%) patients required intensive care unit admission. Tuberculous aetiology, intensive care unit admission, concurrent encephalitis, hydrocephalus, inpatient neurosurgery, and longer length of hospital stay were predictors of mortality (p<0.05). Non-indication of blood culture was found to be associated with reduced risk of mortality (p<0.05). For intensive care unit admission, diabetes mellitus, presentation with seizure, imaging suggestive of meningitis, and inpatient neurosurgery were associated with higher risk of admission, while hypertension, presentation with headache, viral aetiology and non-indication of blood culture reduced the risk (p<0.05). CONCLUSIONS: Adult meningitis patients tend to have poor expected outcomes, and their management strategies should be planned accordingly.

Factors Affecting 30-Day Outcomes in Patients Undergoing Nontraumatic Upper Extremity Amputation: A Retrospective Descriptive Longitudinal Study.

BACKGROUND: Current literature concerning upper extremity amputations (UEAs) is very sparse. In this study, we conducted the first multicenter retrospective analysis aiming to identify risk factors associated with unfavorable outcomes in patients undergoing nontraumatic UEAs. METHODS: A retrospective cohort study was conducted using the National Surgical Quality Improvement Program database. Adult patients who underwent nontraumatic UEAs between 2005 and 2021 were divided into two cohorts based on whether they experienced 30-day major morbidity (MM). Thereafter, multivariable binary logistic regression analysis was used to identify risk factors of MM. RESULTS: From a total of 2984 cases, MM was observed in 8.7% of patients. Factors associated with MM included American Society of Anesthesiologists classes 3 (odds ratio [OR], 2.974 [1.862 to 4.748]) and 4 (OR, 4.736 [2.857 to 7.848]), being underweight (OR, 2.370 [1.251 to 4.491]), and suffering from insulin-dependent diabetes (OR, 1.390 [1.018 to 1.898]). In addition, an infectious surgical indication was associated with an increased risk of MM compared with having a benign (OR, 0.648 [0.488 to 0.682]) or malignant (OR, 0.205 [0.091 to 0.462]) indication. Moreover, patients undergoing shoulder amputations were at an increased risk of MM compared with those undergoing amputations of the forearm/wrist (OR, 0.243 [0.072 to 0.819]) and hands/fingers (OR, 0.286 [0.095 to 0.861]). CONCLUSION: The risk factors identified for MM after nontraumatic UEAs should guide surgeons toward appropriately identifying high-risk patients and adequately counseling them preoperatively.

Medicaid expansion and palliative care for advanced-stage liver cancer.

BACKGROUND: Medicaid expansion (ME) has contributed to transforming the United States healthcare system. However, its effect on palliative care of primary liver cancers remains unknown. This study aimed to evaluate the association between ME and the receipt of palliative treatment in advanced-stage liver cancer. METHODS: Patients diagnosed with stage IV hepatocellular carcinoma or intrahepatic cholangiocarcinoma were identified from the National Cancer Database and divided into pre-expansion (2010-2013) and postexpansion (2015-2019) cohorts. Logistic regression identified predictors of palliative treatment. Difference-in-difference (DID) analysis assessed changes in palliative care use between patients living in ME states and patients living in non-ME states. RESULTS: Among 12,516 patients, 4582 (36.6%) were diagnosed before expansion, and 7934 (63.6%) were diagnosed after expansion. Overall, rates of palliative treatment increased after ME (18.1% [pre-expansion] vs 22.3% [postexpansion]; P < .001) and are more pronounced among ME states. Before expansion, only cancer type and education attainment were associated with the receipt of palliative treatment. Conversely, after expansion, race, insurance, location, cancer type, and ME status (odds ratio [OR], 1.23; 95% CI, 1.06-1.44; P = .018) were all associated with palliative care. Interestingly, the odds were higher if treatment involved receipt of pain management (OR, 2.05; 95% CI, 1.23-2.43; P = .006). Adjusted DID analysis confirmed increased rates of palliative treatment among patients living in ME states relative to non-ME states (DID, 4.4%; 95% CI, 1.2-7.7; P = .008); however, racial disparities persist (White, 5.6; 95% CI, 1.4-9.8; P = .009; minority, 2.6; 95% CI, -2.5 to 7.6; P = .333). CONCLUSION: The implementation of ME contributed to increased rates of palliative treatment for patients residing in ME states after expansion. However, racial disparities persist even after ME, resulting in inequitable access to palliative care.

Impact of Drain Placement on Postoperative Complications after Thyroidectomy for Substernal Goiter.

Introduction Despite the evidence against drain placement after thyroidectomy, there is a lack of consensus on drain use in patients with substernal goiter. Objective To assess the factors that increase the likelihood of drain placement and its impact on postoperative hematoma and other 30-day complications among adult patients undergoing thyroidectomy for substernal goiter. Methods A retrospective cohort study that used data from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Adult patients (aged ≥ 18 years) who underwent elective thyroidectomy for substernal goiter from 2016 to 2020 were included. Cases with closed suction neck drains placed upon completion of surgery were included in the drain group, and the remaining cases formed the nondrain group. Results A total of 1,229 patients were included (46.5% with drain placement). The factors that increased the likelihood of drain placement included body mass index (BMI) ≥ 30 kg/m 2 , score between 3 and 5 on the American Society of Anesthesiologists (ASA) physical status classification, sternal split/transthoracic surgical approach, operative time ≥ 90 minutes, and surgery conducted by otolaryngologists. Patients with clean-contaminated or contaminated wound classifications were less likely to be submitted to drain placement. In addition, drain use had no impact on postoperative hematoma formation but was found to independently increase the risk of prolonged length of hospital stay. Conclusion Thyroidectomy without drain placement might be safe for substernal goiter. However, this decision should be individualized for each patient. Level Of Evidence: 3.

Assessing Risk Factors for Prolonged Intensive Care Unit Stay After Surgery for Adult Congenital Heart Disease: A Study From a Lower-Middle-Income Country.

Background Prolonged post-surgery intensive care unit (ICU) stay for congenital heart disease (CHD) has been explored in the pediatric population. However, there is limited data for adult CHD (ACHD), also called grown-up congenital heart (GUCH) disease, especially in low-resource countries where intensive care beds are scarce. This study identifies factors associated with prolonged ICU stay following surgery for ACHD in Pakistan, a lower-middle-income country (LMIC). Methods This retrospective study included all adult patients (⩾18 years) who underwent cardiac surgery with cardiopulmonary bypass for their CHD from 2011-2016 at a tertiary-care private hospital in Pakistan. Prolonged ICU stay was defined as stay >6 days (75th percentile). Regression analysis was used to explore risk factors of prolonged ICU stay. Results A total of 166 patients (53.6% males) with a mean age of 32.05 ± 12.11 years were included. Atrial septal defect repair was the most common surgery (42.2%). Most patients were categorized as Risk Adjustment for Congenital Heart Surgery 1 (RACHS-1) Category 1 (51.8%) and Category 2 (30.1%). Forty-three of 166 patients (25.9%) experienced prolonged ICU stay. Complications occurred in 38.6% of patients postoperatively, with the most common being acute kidney injury (29.5%). On multivariable logistic regression adjusted for age, gender, and RACHS-1 categories, intraoperative inotrope score, cardiopulmonary bypass time, aortic cross-clamp time duration of mechanical ventilation, and postoperative acute kidney injury (AKI) were associated with prolonged ICU stay. Conclusion Surgeons managing ACHD in LMICs must strive for shorter operative durations and the judicious use of intraoperative inotropes in addition to anticipating and promptly managing postoperative complications such as AKI, to minimize ICU stay in countries where intensive care beds are a scarce resource.

The effect of preoperative steroids for at least 10 days on complications following craniotomy for tumor resection: A database, retrospective cohort study.

Introduction: The effect of chronic steroid therapy on postoperative outcomes after craniotomy for tumor resection remains understudied. Research question: This study aimed to fill this gap and to identify risk factors of postoperative morbidity and mortality among patients on chronic steroid use undergoing craniotomy for tumor resection. Materials and methods: Data from the American College of Surgeons National Surgical Quality Improvement Program were used. Patients who underwent craniotomy for tumor resection between 2011 and 2019 were included. Perioperative characteristics and complications were compared among patients with and without chronic steroid therapy, defined as steroid use for at least 10 days. Multivariable regression analyses were conducted to assess the impact of steroid therapy on postoperative outcomes. Subgroup analyses involving patients on steroid therapy were conducted to explore risk factors of postoperative morbidity and mortality. Results: Of 27,037 patients, 16.2% were on steroid therapy. On regression analyses, steroid use was significantly associated with any postoperative complication, infectious complication, urinary tract infection, septic shock, wound dehiscence, pneumonia, non-infectious, pulmonary, and thromboembolic complications, cardiac arrest, blood transfusion, unplanned reoperation, readmission, and mortality. On subgroup analysis, risk factors for postoperative morbidity and mortality among patients on steroid therapy included older age, higher American Society of Anesthesiology physical status, functional dependence, pulmonary and cardiovascular comorbidities, anemia, dirty/infected wounds, prolonged operative time, disseminated cancer, and a diagnosis of meningioma. Discussion and conclusion: Preoperative brain tumor patients on steroids for 10 or more days are at a relatively high risk of postoperative complications. We recommend a judicious use of steroids in brain tumor patients, both in terms of dosage and duration of treatment.

Survival Benefit Relative to Treatment Modalities Among Patients with Very Early Intrahepatic Cholangiocarcinoma: an Analysis of the National Cancer Database.

BACKGROUND: Liver transplantation (LT) has been considered a potential curative treatment for patients with very early intrahepatic cholangiocarcinoma (ICC) and cirrhosis, yet the survival benefit of LT has not been well defined. This study aimed to compare the long-term survival outcomes of patients who underwent LT with that of individuals who received resection and non-curative intent treatment (non-CIT). METHODS: Patients who underwent LT, hepatectomy, and non-CIT between 2004 and 2018 were included in the National Cancer Database. Survival benefits of LT over resection and non-CIT were analyzed relative to overall survival (OS). RESULTS: Among 863 patients, 54 (6.3%) underwent LT, while 342 (39.6%) underwent surgical resection, and 467 (54.1%) received non-CIT, respectively. While the rates of non-CIT increased over time, the percentages of LT remained consistent during the study period. LT patients had similar 5-year OS to individuals who underwent resection (referent, resection: LT, HR 0.95, 95%CI 0.84-1.58, p=0.84). In contrast, 5-year OS was better among patients who underwent LT versus individuals who had non-CIT after controlling other variables using propensity score overlapping weighting (5-year OS, LT 57.1% vs. LR 25.8%, p<0.001). CONCLUSIONS: The outcomes of very early ICC patients who underwent LT were similar to individuals who underwent hepatectomy, but better than patients treated with non-CIT. LT should be may be a consideration as a treatment option for patients with early stage ICC who are unsuitable candidates for resection.

Association of County-Level Food Deserts and Food Swamps with Hepatopancreatobiliary Cancer Outcomes.

BACKGROUND: Malnutrition has been linked to the development of hepatopancreatobiliary (HPB) cancer. We sought to examine the association between food swamps and food deserts on surgical outcomes of patients with HPB cancer. METHODS: Patients who underwent surgery for HPB cancer between 2014 and 2020 were identified from the Medicare Standard Analytic Files. Patient-level data were linked to the United States Department of Agriculture data on food swamps and deserts. Multivariable regression was performed to examine the association between the food environment and outcomes. RESULTS: Among 53,426 patients, patients from the worse food environment were more likely to be Black, have a higher Charlson Comorbidity Index, and reside in areas with high social vulnerability. Following surgery, the overall incidence of textbook outcome (TO) was 41.6% (n = 22,220). Patients residing in the worse food environments less often achieved a TO versus individuals residing in the healthiest food environments (food swamp: 39.4% vs. 43.9%; food desert: 38.5% vs 42.2%; p < 0.05). On multivariable analysis, individuals residing in the poorest food environments were associated with lower odds of achieving TO compared with individuals living in healthiest food environments (food swamp: OR 0.83, 95%CI 0.75-0.92, food desert: OR 0.86, 95%CI 0.76-0.97; both p < 0.05). CONCLUSION: The surrounding food environment of patients may serve as a modifiable socio-demographic risk factor that contributes to disparities in surgical outcomes of HPB cancer.

Disparities in Liver Transplantation Rates and Outcomes Among Adults with and without Mental Illnesses.

BACKGROUND: Patients with mental illnesses face unique disparities in access to liver transplantation. We sought to compare rates of evaluation, transplantation, and post-transplant outcomes among patients with and without mental illnesses. METHODS: Patients aged 18-75 with decompensated cirrhosis or hepatocellular carcinoma were identified from the Medicare Standard Analytic Files from 2014-2020. Regression analyses were used to examine the association between mental illness and evaluation by a transplant surgeon, receipt of transplant, and post-transplant outcomes. RESULTS: Among 274,252 liver transplant candidates, 34,269 (12.5%) patients had depression and/or anxiety disorders and 8,184 (3.0%) had severe mental illnesses. The proportion of patients evaluated by a transplant surgeon was lower among patients with severe mental illnesses (14.1%), as well as individuals with depression and/or anxiety disorders (16.0%) versus the general population (18.5%) (p < 0.001). Similarly, utilization of transplantation rates was lower among patients with severe mental illness (1.1%) compared with depression and/or anxiety disorders (2.0%), as well as individuals without mental illnesses (3.8%) (p < 0.001). On multivariable regression analyses, mental illness remained independently associated with lower odds of evaluation and transplantation among patients with mental illnesses. In contrast, on adjusted analyses there were no differences in postoperative outcomes including perioperative complications, biliary complications, graft rejection, graft failure, and overall survival. CONCLUSION: Despite lower rates of evaluation and transplant, patients with mental illnesses did not experience differences in most postoperative outcomes compared with patients without a mental illness.