Evaluation of traditional targeted axillary dissection eligibility criteria for node-positive breast cancer after neoadjuvant chemotherapy in a prospective multicenter registry.

INTRODUCTION: Targeted axillary dissection (TAD) is performed after neoadjuvant systemic therapy (NST) to decrease the rate of non-therapeutic axillary dissection (ALND) for patients with node-positive breast cancer. In order to ensure the oncologic safety of TAD, eligibility criteria resulting in a low false negative rate (FNR) have been proposed. The purpose of this study was to evaluate the utility of the traditional criteria. METHODS: Data was collected from a prospective multicenter registry. In order to ascertain FNRs, pathologic findings in the sentinel lymph nodes (LN)s, malignant clipped LN, and axillary contents were determined. The FNRs within TAD eligibility criterion groups were compared. RESULTS: A total of 110 patients underwent TAD and ALND, and were therefore eligible for analysis. TAD retained a low FNR in advanced clinical T-N stage compared with earlier disease (T stage: 95% CI 0.00-11.93, p = 0.42; N stage: 95% CI 0.00-8.76, p = 0.31). Presentation with ≥4 abnormal LNs on axillary ultrasound did not predict a high TAD FNR (95% CI 0.00-5.37, p = 0.16). No significant differences were noted in TAD FNR when single was compared with dual tracer (blue dye vs dual tracer 95% CI 0.72-52.49, p = 0.13; radiotracer vs dual tracer 0.04-20.11, p = 0.51). Excision of the clipped LN and only one SLN was as accurate as excision of the clipped LN and ≥2 SLNs (95% CI 0.00-10.61, p = 0.38). CONCLUSIONS: TAD retained a low FNR among patients traditionally considered ineligible for this technique. However, excision of the clipped LN and at least one SLN remained essential to a low FNR.

An exploratory metabolomic comparison of participants with fast or absent functional progression from 2CARE, a randomized, double-blind clinical trial in Huntington's disease.

Huntington's disease (HD) is increasingly recognized for diverse pathology outside of the nervous system. To describe the biology of HD in relation to functional progression, we previously analyzed the plasma and CSF metabolome in a cross-sectional study of participants who had various degrees of functional impairment. Here, we carried out an exploratory study in plasma from HD individuals over a 3-year time frame to assess whether differences exist between those with fast or absent clinical progression. There were more differences in circulating metabolite levels for fast progressors compared to absent progressors (111 vs 20, nominal p < 0.05). All metabolite changes in faster progressors were decreases, whereas some metabolite concentrations increased in absent progressors. Many of the metabolite levels that decreased in the fast progressors were higher at Screening compared to absent progressors but ended up lower by Year 3. Changes in faster progression suggest greater oxidative stress and inflammation (kynurenine, diacylglycerides, cysteine), disturbances in nitric oxide and urea metabolism (arginine, citrulline, ornithine, GABR), lower polyamines (putrescine and spermine), elevated glucose, and deficient AMPK signaling. Metabolomic differences between fast and absent progressors suggest the possibility of predicting functional decline in HD, and possibly delaying it with interventions to augment arginine, polyamines, and glucose regulation.

Medicare Reimbursement in Hand and Upper Extremity Procedures: A 20-Year Analysis.

PURPOSE: Concern exists that Medicare physician fees for procedures have decreased over the past 20 years. The Centers for Medicare & Medicaid Services (CMS) is set to re-evaluate these physician fees in the near future for concern that these procedures are overvalued. Our study sought to analyze trends in Medicare reimbursement rates from 2000 to 2019 for the top 20 most billed hand and upper extremity surgical procedures at our institution. METHODS: The financial database of a single academic tertiary care center was queried to identify the Current Procedural Terminology codes most frequently utilized in orthopedic hand and upper extremity procedures in 2019. The Physician Fee Schedule Look-Up Tool from the CMS was queried for annual physician fee data. Monetary data were adjusted for inflation using the consumer price index of Urban Research Series (CPI-U-RS) and expressed in 2019 constant US dollars (USD). The average annual and total percent change in reimbursement were calculated via linear regression for all procedures (P < .05). RESULTS: Accounting for inflation, the total average physician reimbursement decreased by 20.9% from 2000 to 2019, with 12 of 20 codes decreasing by more than 20%. The greatest decrease pertained to arthrodesis of the wrist at 33.9%. Upon linear regression, all procedures were found to decrease annually, with arthrodesis of the wrist decreasing by an average of 2.3% annually over this period. CONCLUSIONS: Over the past 2 decades, physician reimbursement for hand and upper extremity procedures has significantly decreased.

Socioeconomic Influence on Speech Rehabilitation After Total Laryngectomy.

OBJECTIVE: Speech rehabilitation following a total laryngectomy significantly impacts the quality of life. Indwelling prosthetic voice restoration provides optimal outcomes; however, the long-term maintenance of these devices carries considerable financial costs, which are not universally covered by insurance. This investigation aimed to analyze associations between socioeconomic factors and outcomes in postlaryngectomy speech rehabilitation. STUDY DESIGN: Retrospective cohort analysis. SETTING: Academic tertiary-care center from May 2014 to September 2021. METHODS: In patients undergoing total laryngectomy, the incidence of tracheoesophageal puncture with indwelling vocal prostheses (TEP-VP) placement within the first postoperative year was compared among household income, demographic factors, and disease characteristics. Functional and maintenance outcomes served as secondary endpoints. RESULTS: Seventy-seven patients were included. Forty-five (58%) underwent indwelling TEP-VP (41 primaries). Eighty-nine percent of patients with annual incomes greater than $50k underwent TEP-VP compared to only 35% with incomes less than $50k/year. TEP-VP was performed in 85% of patients with commercial insurance, 70% with Medicare, 42% with Medicaid, and 0% with no insurance. On multivariate analysis, annual household incomes greater than $50k were predicted for TEP-VP placement (odds ratio: 12.7 [2.45-65.8], p = .002). The utilization of postoperative speech therapy and functional communication outcomes were similar among socioeconomic groups. Twelve patients were unable to afford supplies within the first year, with differences noted among insurance (p = .015) and income status (p = .003). CONCLUSION: Disparities in vocal and speech rehabilitation following laryngectomy may disproportionally affect underserved patients.

Features of mixed medullary thyroid tumors: An NCDB analysis of clinicopathologic characteristics and survival.

BACKGROUND: Mixed medullary-papillary thyroid carcinoma (MMPTC) and mixed medullary-follicular thyroid carcinoma (MMFTC) are rare variants with little known regarding behavior and prognosis. METHODS: Using the National Cancer Database (NCDB), demographics, clinicopathologic features, treatment, and overall survival (OS) from patients with MMPTC and MMFTC were compared to more prevalent subtypes. RESULTS: There were 296,101 patients: 421 MMPTC (0.14%), 133 MMFTC (0.04%), 263,140 PTC (88.87%), 24,208 FTC (8.18%) and 8,199 MTC (2.77%). Compared to PTC, MMPTC and MMFTC patients were older (p < 0.001) with a higher Charlson-Deyo comorbidity index (p < 0.001). Mixed tumors exhibited lower rates of nodal disease but more distant metastases compared to PTC (p < 0.001). MMPTC demonstrated lower estimated 10-year OS than PTC and FTC (76.04%vs 89.04% and 81.95%,p < 0.001), yet higher than MTC (70.29%,p < 0.001). MMFTC had a worse OS compared to all groups (63.32%,p < 0.001). CONCLUSION: Patients with MMFTC had significantly worse OS compared to DTC, portending a worse prognosis.

Improving Outpatient Follow-Up Rates for New In-Hospital Consults.

OBJECTIVE(S): This investigation aimed to define the rate of outpatient follow-up after in-hospital consultation, identify factors associated with establishing care, and evaluate an alternative scheduling process to improve outpatient adherence. METHODS: Two-phase, prospective study at an academic, tertiary-care institution from March 2020 to August 2022. First, all patients not previously known to our practice encountered via inpatient consult who warranted outpatient follow-up were prospectively captured. Logistic regression analysis was used to identify demographic, disease, and practice factors predictive of follow-up. Second, a randomized control trial was performed to validate the effects of pre-assigning appointments prior to discharge. RESULTS: Six hundred subjects were included in the final study cohort; 500 in phase-one, and 100 randomized during phase-two. In the phase-one cohort, 54% (n = 272) were lost to follow-up. Multivariate analysis showed increased odds of outpatient follow-up when appointments were pre-assigned before discharge (odds ratio [OR]: 3.69 [95% confidence interval [CI]: 2.29-5.96], p < 0.001), the primary reason for hospitalization was ENT and consult-related (OR: 3.29 [1.92-5.64], p < 0.001), and the diagnosis was one of Oncology (OR: 1.93 [1.02-3.69], p = 0.045) or Pediatrics (OR: 3.36 [1.41-7.98], p = 0.006) subspecialties. During phase-two, subjects randomized for pre-assigned appointments had higher outpatient follow-up (82%) compared to the control group (20%) (p < 0.001). CONCLUSION: Hospital-based consultations represent an important referral pathway for new patients. Disease characteristics may identify patients less likely to follow-up upon discharge. Appointment scheduling protocols, including pre-assigning appointments, are modifiable targets for improving adherence to care. Laryngoscope, 133:2540-2545, 2023.

Gastric Neuroendocrine Tumor Treatment and Survival Outcome Depends on Facility Type.

BACKGROUND: Gastric neuroendocrine tumors (gNETs) are rare cancers for which surgery may improve survival. We aim to determine if facility type affects treatment and survival outcomes. METHODS: The NCDB was queried for patients with gNET from 2004-2016 and stratified into Academic/Research Program (ARP), Community Cancer Program (CCP), Comprehensive Community Cancer Program (CCCP), or Integrated Network Cancer Program (INCP). Overall survival along with clinical and demographic features was compared. RESULTS: Median survival was improved in patients treated at an academic program: 137.3 months versus 88.0, 96.3, and 100.2 for CCP, CCCP, INCP, respectively (P < .0001). Patients treated at academic centers were more likely to have surgery (64.2% vs 59.1%, 57.5%, 51.4%, P < .0001). After propensity matching for age, race, grade, stage, insurance status, and comorbidity score, survival benefit from treatment at an academic center remained (P = .03), particularly for patients undergoing surgery (P < .0001) and chemotherapy (P = .04). CONCLUSION: Patients with gNET treated at an academic hospital had improved median survival after propensity matching and may benefit from treatment at academic rather than community medical centers.

Is Calcium Score in the Abdominal Aorta or Renal Arteries Predictive of Acute Kidney Injury After Cardiopulmonary Bypass: An Exploratory Study.

Introduction Acute kidney injury (AKI) remains a serious complication after surgery with cardiopulmonary bypass (CPB). A relationship similar to the one between coronary artery calcification and increased incidence of cardiac complications is hypothesized to exist for aortic calcification and the development of AKI. Elevated pulse pressure (PP) hypertension has been shown to be a predictor of AKI-CPB (AKI after CPB surgery), and calcium deposition and stiffening of the body's conduit arteries may be part of this process. We hypothesized that calcium scores obtained from non-contrast computed tomography (CT) scans of the infrarenal aorta and renal arteries would be independently and significantly associated with AKI-CPB. Methods We conducted a retrospective study of 65 subjects who underwent non-emergent open heart surgery with CPB in a tertiary healthcare center. AKI-CPB was diagnosed using the Acute Kidney Injury Network criteria. Aortic and renal artery calcium (Agatston) scores were obtained and entered into a multivariable logistic regression model alongside other significant predictors of AKI-CPB from a univariable analysis. Results Pulse pressure, body surface area, and pre-operative serum creatinine were significantly associated with the development of AKI-CPB, but the calcium scores were not. For PP, the odds ratio (OR) was 1.062, (95% Wald confidence interval {CI}=1.012 - 1.114). The OR for the calcium score in the aorta was 1.0000 (95% CI=1.0 - 1.0). Conclusions Agatston calcium scores in the renal arteries and infrarenal aorta were not independently associated with AKI-CPB, but arterial stiffening, as indicated by elevated pulse pressure, was predictive of AKI-CPB.

Trunk Range of Motion and Patient Outcomes After Anterior Vertebral Body Tethering Versus Posterior Spinal Fusion: Comparison Using Computerized 3D Motion Capture Technology.

BACKGROUND: Anterior vertebral body tethering (AVBT) for adolescent idiopathic scoliosis (AIS) is postulated to preserve motion compared with traditional posterior spinal fusion (PSF), but few studies exist to date. We used a validated computerized 3D model to compare trunk motion between patients treated with PSF and AVBT, and analyzed trunk motion in relation to the lowest instrumented vertebra (LIV). METHODS: This was a single-center retrospective review of a consecutive series of skeletally immature patients with AIS who underwent motion analysis prior to PSF (n = 47) or AVBT (n = 65) and 2 years postoperatively. Patients were divided into 4 groups on the basis of the LIV (≤L1, L2, L3, L4). Computerized 3D kinematic evaluations included thoracic and lumbar flexion, extension, side-bending, and rotation. Patient outcomes were assessed using the Scoliosis Research Society (SRS)-22 questionnaire. RESULTS: The LIV was ≤L1 in 48 patients treated with AVBT and 23 treated with PSF, L2 in 4 AVBT and 8 PSF patients, L3 in 10 AVBT and 8 PSF patients, and L4 in 3 AVBT and 8 PSF patients. PSF patients had a significant loss of motion in all 4 directions at 2 years postoperatively (e.g., flexion loss was 11° for ≤L1 to 30° for L4; p < 0.001). This equated to a 7° loss of trunk flexion per additional LIV level included in the fusion. AVBT patients only demonstrated loss of flexion and side-bending at 2 years postoperatively (e.g., flexion loss of 11° for L1 to 17° for L4; p < 0.001). Preoperative curve size and flexibility did not have any significant impact on differences in trunk motion between AVBT and PSF. SRS-22 scores were predominantly similar for AVBT versus PSF preoperatively and at 2 years postoperatively. CONCLUSIONS: Patients treated with AVBT experienced predominantly less motion loss compared with PSF patients at 2 years postoperatively. Patients treated with PSF demonstrated loss of motion in all planes that increased with each additional LIV from ≤L1 to L4, with 7° loss of flexion per additional LIV. However, the differences in total trunk motions were relatively modest for PSF and AVBT with an LIV of ≤L1. Preoperative curve magnitude and flexibility had no significant impact on trunk motion in either group. SRS-22 scores were similar for both groups at 2 years postoperatively. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Assessment of Gender Disparities and Geographic Variations in Payments from Industry among Plastic Surgeons in the United States.

BACKGROUND: Various medical specialties have demonstrated gender disparities involving industry-supported payments. The authors sought to determine whether such disparities exist within plastic surgery. METHODS: Industry contributions to plastic surgeons practicing in the United States were extracted from the Centers for Medicare and Medicaid Services Open Payments 2013 to 2017 databases. Specialists' gender was obtained through online searches. Kruskal-Wallis tests compared payments (in U.S. dollars) by gender (overall and by payment category). Linear regression estimated the independent association of female gender with increased/reduced payments while controlling for state-level variations. RESULTS: Of 1518 plastic surgeons, 13.4 percent were female. Of $44.4 million total payments from the industry, $3.35 million were made to female plastic surgeons (p < 0.01). During the study period, female plastic surgeons received lower overall payments than male plastic surgeons [median, $3500 (interquartile range, $800 to $9500) versus $4160.60 (interquartile range, $1000 to $19,728.20); p < 0.01]. This trend persisted nationwide after normalizing for year [$2562.50/year (interquartile range, $770 to $5916.25/year) versus $3200/year (interquartile range, $955 to $8715.15/year); p = 0.02] and at the state level in all 38 states where there was female representation. Analysis of payment categories revealed that honoraria payments were significantly higher for male plastic surgeons [$4738 (interquartile range, $1648 to $16,100) versus $1750 (interquartile range, $750 to $4100); p = 0.02]. Within risk-adjusted analysis, female plastic surgeons received $3473.21/year (95 percent CI, $671.61 to $6274.81; p = 0.02) less than male plastic surgeons. CONCLUSIONS: Gender disparities involving industry payments exist in plastic surgery at both national and state levels. Factors contributing to this phenomenon must be explored to understand implications of this gap.

Whole Blood in Trauma Resuscitation: What Is the Real Cost?

INTRODUCTION: Whole blood (WB) has gained popularity in trauma resuscitation within the past 5 y. Previously, its civilian use was limited due to advances in blood component fractionation and fears of hemolysis and infectious disease transmission. Although there are studies and review articles on the efficacy of WB, the analysis of cost pertaining to the use of WB is limited. MATERIALS AND METHODS: We performed a retrospective 1:1 propensity-matched analysis of 280 subjects comparing trauma patients receiving resuscitation with blood component therapy (BCT) to those receiving WB plus BCT between January 2014 and July 2019. WB was used for patients who arrived in hemorrhagic shock with systolic blood pressure <90 mmHg due to either penetrating or blunt trauma. Endpoints included the number of units of WB, packed red blood cells (PRBCs), fresh frozen plasma (FFP), platelets, and cryoprecipitate each patient received. Institution costs for each component were compared in the form of price ratios. Comparisons were made using Wilcoxon rank-sum tests with a P value of ≤0.05 considered statistically significant. RESULTS: The use of WB was associated with a statistically significant decrease in the number of PRBCs used when compared to BCT. This holds true with the cost of PRBCs being lower among the WB group when the price is controlled. Similarly, a trend was found where FFP, platelets, and cryoprecipitate use and cost showed an absolute decrease between WB and BCT groups. The use of WB is associated with decreased total cost as well (P = 0.1660), although not statistically significant. CONCLUSIONS: Adding WB to BCT for trauma resuscitation was associated with lower red blood cell use and cost. A similar trend was found that absolute total cost and absolute cost of FFP, platelets, and cryoprecipitate use was lower when WB was added. WB wastage was minimized due to repurposing WB into PRBCs when WB lifespan ended.

Delayed symptomatic hyponatremia in transsphenoidal surgery: Systematic review and meta-analysis of its incidence and prevention with water restriction.

BACKGROUND: Delayed symptomatic hyponatremia (DSH) is an unpredictable postoperative complication after transsphenoidal pituitary surgery. Universal postoperative sodium screening and water restriction are two strategies to detect or prevent the development of DSH. We performed a meta-analysis of studies characterizing the rate of DSH using sodium screening and water restriction protocols. METHODS: Literature search was done using MEDLINE/PUBMED, EMBASE, and Cochrane databases. Inclusion criteria are (1) development of DSH after endoscopic or microscopic transsphenoidal, sellar surgery, and (2) reporting of a standardized postoperative sodium screening protocol for monitoring or prevention of DSH. RESULTS: A total of 23 publications fulfilled the inclusion criteria resulted in a total of 5870 patients. Two meta-analyses were conducted. Of the 19 studies (N = 4488 patients) examining rate of DSH after sodium screening, DSH rates ranged from 0% to 19.7%. In the first meta-analysis, using a random-effect estimate of the combined proportions, the overall rate of DSH was 5.60% (4.0%-7.1%, I2 = 96.54%, T2 = 0.0007). In the second meta-analysis, a fixed-effect model of four studies consisted of 1382 patients. Eight hundred fifty-two patients were included prior to and 530 were included after water restriction protocol. Meta-analysis showed an odds ratio (OR) of 5.02 (95% CI: 2.16-11.65) favoring water restriction. CONCLUSION: This meta-analysis summarized rates of DSH with sodium screening protocol to be 5.60% (4.0%-7.1%) and showed a decreased risk of DSH after implementation of a water restriction protocol. The results are limited due to few studies examining fluid restriction (N = 4) and heterogeneity in water restriction protocols. No adverse events were seen with fluid restriction protocol. Prospective and multicenter studies should be conducted to further investigate the utility of water restriction following transsphenoidal pituitary surgery.

Medicaid expansion is associated with earlier diagnosis of gastric cancer.

INTRODUCTION: The 2014 Medicaid expansion was intended to improve access to care. We hypothesized that Medicaid expansion would be associated with improved gastric cancer (GC) outcomes. METHODS: We selected patients with a new primary diagnosis of GC from the National Cancer Database. We compared states that expanded Medicaid in 2014 to those that did not. We compared pre-and post-expansion intervals 2012-2013 and 2015-2016. RESULTS: There was an increase in patients diagnosed with stage 0-2 GC from 38% to 41.5% [p < 0.01] in expansion states (ES), but no change at 38.9% in non-expansion states (NES). Uninsured and Medicaid patients diagnosed with stages 0-2 GC increased in ES from 32.4% to 37.8% [p = 0.01] and decreased in NES from 29.7% to 27.3% [p = n.s.]. Uninsured and Medicaid patients receiving treatment rose from 87.0% to 90.3% in ES [p < 0.01] and in NES 83.9%-84.9% [p = n.s.]. Twelve-month survival for ES rose from 68.1% to 70.6% [p = 0.03] and in NES decreased 65.2%-65.1% [p = n.s.]. CONCLUSION: Increased healthcare access may be related to earlier diagnosis and improved outcomes in GC.

Reliability and accuracy in radiographic measurements of musculoskeletal tumors.

Tumor size and growth are important parameters when evaluating bone and soft tissue neoplasms. There are no reports comparing the intra- and interobserver reliability among physicians in their evaluation of musculoskeletal (MSK) tumor imaging. This study investigates the accuracy and precision of measurements made by orthopedic and radiology physicians in different stages of training. Blinded magnetic resonance imaging (MRI) scans from six patients, three soft tissue, and three bone tumors were selected: each case included an "old" and "new" scan that was performed at least 3 months apart. Fourteen participants were selected, representing varying levels of education and experience, including two of each of the following: medical students, orthopedic and radiology residents, oncology and nononcologic orthopedic attendings, and MSK and non-MSK radiology attendings. Participants compared the old and new studies, recording tumor size in the transverse, cranial-caudal, and anterior-posterior dimensions, and determined if the tumor was stable or unstable. The MRI's official report served as the "gold standard." Average intraobserver variability (|Trial 1 - Trial 2|/[(Trial 1 + Trial 2)/2])) in size measurements was 11.08% (0.00%-68.62%). The lowest variability was recorded by the MSK radiologist 1 (6.16%), and the greatest variability by Orthopedic Surgery Resident 1 (16.70%). Participants correctly determined stability 82% of the time (71%-100%). Only MSK radiologists correctly determined stability in over 90% of cases. There is considerable variability and inaccuracy in MRI-based measurements of MSK tumors. These findings motivate opportunities for improving MSK imaging education of radiology and orthopedic residents. Physicians ordering MRI scans should evaluate them themselves, instead of relying on the radiology report alone, to inform clinical decision-making.

Incidence and patient characteristics of venous thromboembolism during neoadjuvant chemotherapy for ovarian cancer.

There is paucity of data on venous thromboembolism (VTE) in patients receiving neoadjuvant chemotherapy (NACT) for advanced stage ovarian cancer. We explored the incidence and predictors of VTE in this patient population. We performed a retrospective review of women with primary ovarian, fallopian tube or peritoneal cancer who received NACT between January 2012 and October 2018 at Cooper University Hospital. Patients with history of VTE, heparin therapy or direct oral anticoagulant use prior to cancer diagnosis were excluded. The primary outcome was incidence of deep vein thrombosis (DVT) or pulmonary embolism (PE) after cancer diagnosis. We explored demographic and clinical variables associated with VTE. Of 90 patients included, 25 (28%) were diagnosed with VTE and 16 (64%) had PE. Eight patients were diagnosed after cancer diagnosis prior to the start of chemotherapy and 17 patients during NACT. Most patients had stage III disease and serous adenocarcinoma. There was a trend towards increased risk of VTE for Black patients (OR 3.22; CI 0.997-10.42; P = 0.051). Significantly fewer patients with VTE had debulking surgery (60% vs. 88%, P = 0.005). The risk of DVT increased by 8.7% per year of age (OR 1.087; 95% CI 1.01-1.17). Obesity, smoking status, medical comorbidities, disease stage, histology, invasive diagnostic surgery, and length of NACT were not associated with VTE. The incidence of VTE during neoadjuvant chemotherapy is high. Older age and Black race may increase the risk of VTE, and this morbid complication may adversely impact cancer treatment.

Paediatric dental outcomes among children exposed to chemotherapy in utero.

AIM: Our study prospectively evaluated dental development in children exposed to chemotherapy in utero compared with unexposed controls. DESIGN: Women who received chemotherapy while pregnant were enrolled in a research registry. After age two, each child's dentist was asked to complete a questionnaire about dental abnormalities and malformations, as well as for their unexposed siblings. Multivariate linear regression adjusting for age was used to compare the groups. RESULTS: Dental information was received for 67 exposed children and 59 controls. The majority of mothers were treated for breast cancer (79.1%) and primarily received doxorubicin (89.6%) and cyclophosphamide (80.6%). Mean gestational age at first exposure was 20.7 (±5.7) weeks. Mean age at dental evaluation was 8.0 (±4.3) years for exposed and 10.4 (±5.1) years for controls (P < .01). Missing teeth, tooth size, shape, and color did not differ significantly between groups. There was no statistical difference in dental caries, facial abnormalities, or abnormalities of enamel or gingiva. There was no association between any chemotherapy agent or regimen and increased risk of dental abnormalities. CONCLUSIONS: Overall, there was no difference in dental abnormalities between groups. These negative findings may be because no one received chemotherapy prior to 14 weeks when formation of primary teeth was beginning.

Cost-Benefit Analysis of Robotic vs. Laparoscopic Hepatectomy: A Propensity-Matched Retrospective Cohort Study of American College of Surgeons National Surgical Quality Improvement Program Database.

BACKGROUND: Robotic and laparoscopic hepatectomies having increased utilization as minimally invasive techniques are explored for hepatobiliary malignancies. Although the data on outcomes from these 2 approaches are emerging, the cost-benefit analysis of these approaches remains sparse. This study compares the costs associated with robotic vs. laparoscopic liver resections, taking into account 30-day complications. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, a propensity-matched cohort of patients with laparoscopic or robotic liver resections between 2014 and 2017 was identified. Costs were assigned to perioperative variables, including operating room (OR) time, length of stay, blood transfusions, and 30-day complications. Cost estimates were obtained from the Centers for Medicare and Medicaid Services billing data (2017), American Hospital Association data (2017), relevant literature, and local institutional cost data. RESULTS: In our matched cohort of 454 patients (227 per group), total costs associated with laparoscopic liver resections were estimated at $5.5 M ($24 K per patient) vs. $6.8 M ($29.8 K per patient) for robotic liver resections (21.3% difference, P < .001). The higher cost associated with robotic hepatectomies was related to blood transfusions ($22.0 K vs. $12.1 K, P = .02), length of stay ($2.05 M vs. $1.76 M, P = .046), and OR time ($4.01 M vs. $3.24 M, P < .0001). DISCUSSION: Robotic hepatectomies were associated with higher costs compared to laparoscopic hepatectomies. The 2 major contributors to the cost disparity were increased OR time and increased length of stay. Future studies are warranted to analyze high-volume Minimally Invasive Surgery surgeons' impact in specialty centers on potentially mitigating this current cost disparity.

Preoperative high-resolution esophageal manometry and postoperative symptoms in patients undergoing bariatric surgery: a retrospective cohort study.

BACKGROUND: The increasing incidence of obesity has led to a rise in bariatric surgeries. Obesity can be associated with various gastrointestinal symptoms as well as abnormal findings on high-resolution esophageal manometry (HRM). Bariatric procedures have variable effects on esophageal function and may contribute to postoperative symptoms. Preoperative HRM is not performed routinely on patients undergoing bariatric surgery but may identify patients likely to experience postoperative esophageal symptoms via delineation of structural or functional abnormalities. OBJECTIVES: To evaluate whether prebariatric surgery HRM could predict persistent or de novo postoperative esophageal symptoms. SETTING: Academic tertiary care hospital, United States. METHODS: Retrospective data were collected for 20 patients undergoing HRM and 100 controls 18 years and older from May 2012 to May 2015. Propensity score matching was performed to adjust for baseline differences between the 2 groups. Preoperative and postoperative esophageal symptoms (reflux, dysphagia, nausea/vomiting, bloating, fullness, early satiety, pain, and intolerance) were compared between HRM and control patients, and associations among HRM findings, Chicago Classification, and symptoms were analyzed. All included patients had follow-up beyond 3 months postoperatively. Data were analyzed with 2-tailed Fisher's exact test, Wilcoxon rank-sum test, and odds ratio. RESULTS: Compared to controls, patients undergoing preoperative HRM had a higher rate of postoperative chronic intolerance (25% versus 8%, P = .041). This difference was not observed in propensity score matching analysis. Identification of elevated integrated relaxation pressure and esophagogastric junction outflow obstruction predicted chronic intolerance (odds ratio = 21.0; 95% confidence interval: 1.40-314; P = .027 for each). CONCLUSIONS: Preoperative HRM abnormalities were associated with postoperative symptoms in patients undergoing bariatric surgery. HRM can identify patients who are more likely to experience postoperative esophageal symptoms and may aid in discussion of suitability for surgery and selection of bariatric intervention.

Effect of preoperative radiation on free flap outcomes for head and neck reconstruction: An updated systematic review and meta-analysis.

BACKGROUND: There is an ongoing debate about whether neoadjuvant radiation therapy is associated with higher rates of postoperative complications after head and neck reconstruction. Herle et al. conducted a systematic review in 2014 of 24 studies, finding higher complication rates in irradiated fields. We sought to perform an exhaustive updated systematic review and meta-analysis. METHODS: We conducted an updated systematic review of the literature, as outlined in our protocol, which was registered on PROSPERO. Databases included Medline, Embase, Cochrane Central, and Web of Science. There were no limits placed on the date range, place of publication, or origin. Exclusion criteria included patients less than 18 years of age, studies with less than 20 participants (n < 20), case studies, skull base reconstructions, and local tissue rearrangements. The combined results of the studies and relative risks (RR) were calculated. RESULTS: 53 studies were included for analysis, including 5,086 free flaps in an irradiated field, and 9,110 free flaps in a non-irradiated field. Of the 53 studies, 21 studies overlapped with those discussed in Herle et al.'s study, with a total of 32 additional studies. Neoadjuvant radiation was found to be a statistically significant risk factor for postoperative complications (RR 1.579, P < 0.001), total flap failure (RR, 1.565; P < 0.001), and fistula (RR, 1.810; P < 0.001). Our work reaffirmed the findings of the Herle et al. CONCLUSION: Preoperative radiation was associated with a statistically significant increase in the risk of total flap failure, fistula, and total complications but not partial flap failure. These high-morbidity complications must be taken into consideration when determining which patients should receive neoadjuvant radiation therapy.

Panniculectomy Performed in Conjunction With Gynecologic Surgery in Obese and Morbidly Obese Patients: A National Surgical Quality Improvement Program Analysis and Systematic Review of the Literature.

INTRODUCTION: Panniculectomy is a common procedure in plastic surgery, often performed after massive weight loss and in morbidly obese patients. It is also performed in combination with various gynecologic procedures based on the rational that it will reduce complication rates and benefit the patient (Am J Obstet Gynecol, 2000. 182, 1502-1505; J Gynecol Technol, 1997;3:9-16; J Am Coll Surg, 1995). These and other studies fail to provide proof of these claims for a number of reasons, including study design, lack of a control group and the inclusion of nonmorbidly obese patients (J Am Coll Surg, 1995; Gynecol Oncol, 1998, 70, 80-86; Int J Gynecol Cancer, 2015;25(8):1503-1512). Recent medical practice has focused increasingly on minimizing patient morbidity and trends in reimbursement are moving toward penalizing practices, which increase complications. The aim of this study was to evaluate the premise that the addition of panniculectomy to gynecologic surgery in the obese and morbidly obese patient population results in a statistically significant improvement in measureable outcomes. METHODS/RESULTS: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was reviewed to assess the association of complications with panniculectomy combined with gynecologic surgery in the morbidly obese patient population. The query identified 296 patients with a body mass index greater than 30 who had panniculectomy concomitant with gynecologic surgery. The results demonstrated a statistically significant relationship (P < 0.05) of these concomitant procedures with superficial infection, wound infection, pulmonary embolism, systemic sepsis, return to operating room, length of operation and length of stay. A systematic review of the literature was then performed which identified only 5 studies that included comparative cohorts of those with gynecologic surgery, with and without panniculectomy. There was no significant benefit across the studies in measured paramters. CONCLUSIONS: This NSQIP study and systematic review of the existing literature does not support the premise that there is a statistically significant benefit associated with performing panniculectomy in conjunction with gynecologic surgery in the morbidly obese patient population. The NSQIP data demonstrate significant elevation of negative outcomes in morbidly obese patients undergoing combined procedures. In the light of the risks to patients and current direction of medical practice the addition of elective panniculectomy to gynecologic surgery should be reevaluated in the a patient population with a body mass index greater than 30.