High Community-Level Social Vulnerability is Associated with Worse Recurrence-Free Survival (RFS) After Resection of Extremity and Truncal Soft Tissue Sarcoma.

BACKGROUND: Although social vulnerability has been associated with worse postoperative and oncologic outcomes in other cancer types, these effects have not been characterized in patients with soft tissue sarcoma. This study evaluated the association of social vulnerability and oncologic outcomes. METHODS: The authors conducted a single-institution cohort study of adult patients with primary and locally recurrent extremity or truncal soft tissue sarcoma undergoing resection between January 2016 and December 2021. The social vulnerability index (SVI) was measured on a low (SVI 1-39%, least vulnerable) to high (60-100%, most vulnerable) SVI scale. The association of SVI with overall survival (OS) and recurrence-free survival (RFS) was evaluated by Kaplan-Meier analysis and Cox proportional hazard regression. RESULTS: The study identified 577 patients. The median SVI was 44 (interquartile range [IQR], 19-67), with 195 patients categorized as high SVI and 265 patients as low SVI. The median age, tumor size, histologic subtype, grade, comorbidities, stage, follow-up time, and perioperative chemotherapy and radiation utilization were similar between the high and low SVI cohorts. The patients with high SVI had worse OS (p = 0.07) and RFS (p = 0.016) than the patients with low SVI. High SVI was independently associated with shorter RFS in the multivariate analysis (hazard ratio, 1.64; 95% confidence interval, 1.06-2.54) but not with OS (HR, 1.47; 95% CI 0.84-2.56). CONCLUSION: High community-level social vulnerability appears to be independently associated with worse RFS for patients undergoing resection of extremity and truncal soft tissue sarcoma. The effect of patient and community-level social risk factors should be considered in the treatment of patients with extremity sarcoma.

Development of an Electronic Health Record Registry to Facilitate Collection of Commission on Cancer Metrics for Patients Undergoing Surgery for Breast Cancer.

PURPOSE: Accurate and efficient data collection is a challenge for quality improvement initiatives and clinical research. We describe the development of a custom electronic health record (EHR)-based registry to automatically extract structured Commission on Cancer axillary surgery-specific metrics from a custom synoptic note template included in the operative reports for patients with breast cancer undergoing surgery. METHODS: The smart functionality of our enterprise-based EHR system was leveraged to create a custom smart phrase to capture axillary surgery-specific variables. A multidisciplinary team developed structured data elements correlating to each axillary surgery-specific variable. These data elements were then included in a note template for the operative report. Each variable could be aggregated and converted into a single flat database through the EHR's reporting workbench and serve as a live, prospective registry for all users within the EHR. RESULTS: The final axillary surgery-specific note template in a synoptic format allowed for efficient and easy entry and automatic collection of breast cancer-specific metrics. From initial adoption in February 2021-December 2021, there were 1,254 patients who underwent breast surgery with axillary surgery. The operative notes allowed for automatic capture of metrics from 60.5% (n = 759) of patients. Data capture improved from 37.6% in the initial adoption period of 6 months to 86.2% in the last 5 months. CONCLUSION: We were able to demonstrate successful implementation of provider-driven structured data entry into EHR systems that permits automatic data capture. The end result is a custom synoptic note template and a real-time, prospective registry of breast cancer-specific Commission on Cancer metrics that are robust enough to use for quality improvement initiatives and clinical research.

Gender Disparities in Presentations at the Society of Surgical Oncology (SSO) Meetings From 2014 to 2019.

BACKGROUND: Participation in surgical society meetings serves as a proxy for academic success and is important for career development. This study aimed to investigate and report the gender breakdown of presenters at recent Society of Surgical Oncology (SSO) meetings. METHODS: Genders of presenters for poster, parallel, plenary, and video sessions at SSO meetings from 2014 through 2019 were collected. These data were broken down to first-last authorship relationships including female-female, female-male, male-female, and male-male. The proportions of female-to-male presenters were compared for each session type. Statistical significance was set at p value lower than 0.05. RESULTS: From 2014 through 2019, the SSO had 2920 presenters, and 47% were female. Women were listed as first authors more often for the poster session (48%) than for other sessions (parallel, plenary, and video) (p = 0.003). Women also were listed more often as senior authors for the poster session (31%) than for other sessions (p = 0.004). Female senior authors were fewer than male senior authors across all session types. Female first authors had the highest representation in breast (75%), endocrine (48%), and cutaneous (46%) specialties (p < 0.001). The most common combination of first and senior authors was male-male (43%), followed by female-male (28%), female-female (19%), and male-female (10%). CONCLUSION: Overall, female presentation at SSO is comparable with society demographics, and female first authorship is relatively equal to male first authorship in poster sessions. Whereas female first authorship improved over time, female senior authorship remained relatively flat. Opportunities to improve gender equality in senior authorship positions should be explored.

The Current Landscape of Staging and Treatment of Colorectal Cancer in a Region of Ukraine: a Mixed Methods Study.

BACKGROUND: In Ukraine, the 1-year mortality for colorectal cancer is much higher than that seen in high-income countries. We investigated practice patterns of colorectal cancer treatment in a region of Ukraine to account for high mortality rates. METHODS: An explanatory sequential mixed methods design was used. Data from patients who underwent surgery for colorectal cancer in Ivano-Frankivsk from 2011 to 2015 were collected via retrospective chart review, and descriptive statistics were calculated. Semi-structured interviews were performed with local practicing surgeons and oncologists until thematic saturation was reached. RESULTS: A total of 960 patients who underwent surgery were identified in the Ivano-Frankivsk region with colon (689) or rectal (271) cancer. 11.7% of patients underwent preoperative CT of the abdomen and pelvis, and only 1.7% underwent CT of the chest. 4.1% of patients underwent a complete preoperative colonoscopy, while 31.0% had incomplete colonoscopies. Postoperatively, 31.1% of patients with stage II colon cancer and 43.9% of patients with stage III colon cancer underwent adjuvant chemotherapy. For patients with stage II and III rectal cancers, 20.9% and 33.3% underwent chemotherapy, while 68.4% and 66.7% underwent radiation therapy, respectively. Fifteen physicians completed interviews. Two major themes emerged regarding physician perceptions on providing colorectal cancer care: lack of resources and systems level issues negatively impacting patient care. CONCLUSION: In this region in Ukraine, staging practices for colorectal malignancies are inconsistent and inadequate, and adjuvant treatments are varied. This is likely attributable to the lack of resources facing providers and the prohibitively high cost of care to patients.

Gender Disparity in Awards in General Surgery Residency Programs.

IMPORTANCE: Women are disproportionately underrecognized as award winners within medical societies. The presence of this disparity has not been investigated in training programs. OBJECTIVE: To determine the presence of a gender disparity in award winners in general surgery residency programs. DESIGN, SETTING, AND PARTICIPANTS: In this retrospective survey study, 32 geographically diverse academic and independent general surgery residency programs were solicited for participation. The 24 participating programs (75.0%) submitted deidentified data regarding the gender distribution of residents and trainee award recipients for the period from July 1, 1996, to June 30, 2017. Data were analyzed from September 11, 2017, to December 21, 2018. EXPOSURES: Time and the proportion of female trainees. MAIN OUTCOMES AND MEASURES: The primary outcome was the percentage of female award winners. A multilevel logistic regression model accounting for the percentage of female residents in each program compared the odds of a female resident winning an award relative to a male resident. This analysis was repeated for the first and second decades of the study. Award winners were further analyzed by type of award (clinical excellence, nonclinical excellence, teaching, or research) and selection group (medical students, residents, or faculty members). RESULTS: A total of 5030 of 13 760 resident person-years (36.6%) and 455 of 1447 award winners (31.4%) were female. Overall, female residents were significantly less likely to receive an award compared with male residents (odds ratio [OR], 0.44; 95% CI, 0.37-0.54; P < .001). During the first decade of the study, female residents were 70.8% less likely to receive an award compared with male residents (OR, 0.29; 95% CI, 0.19-0.45; P < .001); this improved to 49.9% less likely in the second decade (OR, 0.50; 95% CI, 0.42-0.61; P < .001). Female residents were less likely to receive an award for teaching (OR, 0.33; 95% CI, 0.26-0.42; P < .001), clinical excellence (OR, 0.44; 95% CI, 0.31-0.61; P < .001), or nonclinical excellence (OR, 0.69; 95% CI, 0.48-0.98; P = .04). No statistical difference was observed for research award winners (OR, 0.76; 95% CI, 0.42-1.12; P = .17). The largest discrepancies were observed when award recipients were chosen by residents (OR, 0.23; 95% CI, 0.14-0.39; P < .001) and students (OR, 0.32; 95% CI, 0.25-0.42; P < .001) compared with faculty members (OR, 0.52; 95% CI, 0.42-0.66; P < .001). CONCLUSIONS AND RELEVANCE: This study found that female residents were significantly underrepresented as award recipients. These findings suggest the presence of ongoing implicit bias in surgery departments and training programs.

Surgical Informatics: Defining the Role of Informatics in the Current Surgical Training Paradigm.

OBJECTIVE: Clinical Informatics is a large part of the current surgical practice, yet, there is no formal curriculum to teach residents about informatics. The purpose of this article is to describe the field of clinical informatics, describe the potential of informatics to improve surgical care, and propose a framework to train surgical informaticians. DESIGN: This is a perspective summarizing the role of clinical informatics in current surgical training. CONCLUSIONS: The manuscript concisely discusses the potential impact of novel technologies and information systems on surgical care delivery. We demonstrate the importance of informatics training for surgeons and describe the relatively new fellowship program as well as the various pathways to obtain board certification in clinical informatics.

Outcomes of a low-osmolar water-soluble contrast pathway in small bowel obstruction.

BACKGROUND: Adhesive small-bowel obstruction (SBO) is a common surgical condition accounting for a significant proportion of acute surgical admissions and surgeries. The implementation of a high-osmolar water-soluble contrast challenge has repeatedly been shown to reduce hospital length of stay and possibly the need for surgery in SBO patients. The effect of low-osmolar water-soluble contrast challenge however, is unclear. The aim of this study is to evaluate the outcomes of an SBO pathway including a low-osmolar water-soluble contrast challenge. METHODS: A prospective cohort of patients admitted for SBO were placed on an evidence-based SBO pathway including low-osmolar water-soluble contrast between January 2017 and October 2018 and were compared with a historical cohort of patients prior to the implementation of the pathway from September 2013 through December 2014. The primary outcome was length of stay less than 4 days with a secondary outcome of failure of nonoperative management. RESULTS: There were 140 patients enrolled in the SBO pathway during the study period and 101 historic controls. The SBO pathway was independently associated with a length of stay less than 4 days (odds ratio, 1.76; 95% confidence interval, 1.03-3.00). Median length of stay for patients that were successfully managed nonoperatively was lower in the SBO pathway cohort compared with controls (3 days vs. 4 days, p = 0.04). Rates of readmission, surgery, and bowel resection were not significantly different between the two cohorts. CONCLUSION: Implementation of an SBO pathway using a low-osmolarity contrast is associated with decreased hospital length of stay. Rates of readmission, surgery, and need for bowel resection for those undergoing surgery were unchanged. An SBO pathway utilizing low-osmolarity water-soluble contrast is safe and effective in reducing length of stay in the nonoperative management of adhesive small-bowel obstructions. LEVEL OF EVIDENCE: Therapeutic study, level IV.

The opportunities and shortcomings of using big data and national databases for sarcoma research.

The rarity and heterogeneity of sarcomas make performing appropriately powered studies challenging and magnify the significance of large databases in sarcoma research. Established large tumor registries and population-based databases have become increasingly relevant for answering clinical questions regarding sarcoma incidence, treatment patterns, and outcomes. However, the validity of large databases has been questioned and scrutinized because of the inaccuracy and wide variability of coding practices and the absence of clinically relevant variables. In addition, the utilization of large databases for the study of rare cancers such as sarcoma may be particularly challenging because of the known limitations of administrative data and poor overall data quality. Currently, there are several large national cancer databases, including the Surveillance, Epidemiology, and End Results database, the National Cancer Data Base of the American College of Surgeons and the American Cancer Society, and the National Program of Cancer Registries of the Centers for Disease Control and Prevention. These databases are often used for sarcoma research, but they are limited by their dependence on administrative or billing data, the lack of agreement between chart abstractors on diagnosis codes, and the use of preexisting documented hospital diagnosis codes for tumor registries, which lead to a significant underestimation of sarcomas in large data sets. Current and future initiatives to improve databases and big data applications for sarcoma research include increasing the utilization of sarcoma-specific registries and encouraging national initiatives to expand on real-world, evidence-based data sets.

Association of Domestic Responsibilities With Career Satisfaction for Physician Mothers in Procedural vs Nonprocedural Fields.

Importance: Physicians who are mothers face challenges with equal distribution of domestic duties, which can be an obstacle in career advancement and achieving overall job satisfaction. Objectives: To study and report on the association between increased domestic workload and career dissatisfaction and if this association differed between proceduralists and nonproceduralists. Design, Setting, and Participants: Data for this study were gathered from April 28 to May 26, 2015, via an online survey of 1712 attending physician mothers recruited from the Physician Moms Group. Statistical analysis was performed from August 25, 2017, to November 20, 2018. Main Outcomes and Measures: Univariate analysis was performed for respondents who reported sole responsibility for 5 or more vs fewer than 5 main domestic tasks. Independent factors associated with career dissatisfaction or a desire to change careers were identified using a multivariate logistic regression model. Results: Of the 1712 respondents, most were partnered or married (1698 [99.2%]), of which 458 (27.0%) were in procedural specialties. Overall, respondents reported having sole responsibility for most domestic tasks, and there were no statistically significant differences between procedural and nonprocedural groups. Physician mothers in procedural specialties primarily responsible for 5 or more domestic tasks reported a desire to change careers more often than those responsible for fewer than 5 tasks (105 of 191 [55.0%] vs 114 of 271 [42.1%]; P = .008). This difference was not noted in physician mothers in nonprocedural specialties. In multivariate analysis of the proceduralist cohort, primary responsibility for 5 or more tasks was identified as a factor independently associated with the desire to change careers (odds ratio, 1.5; 95% CI, 1.0-2.2; P = .05). Conclusions and Relevance: Physician mothers report having more domestic responsibilities than their partners. For proceduralist mothers, self-reported higher levels of domestic responsibility were associated with career dissatisfaction. Increasing numbers of mothers in the medical workforce may create a demand for more equitable distribution and/or outsourcing of domestic tasks.

Female Representation and Implicit Gender Bias at the 2017 American Society of Colon and Rectal Surgeons' Annual Scientific and Tripartite Meeting.

BACKGROUND: Women surgeons are underrepresented in academic surgery and may be subject to implicit gender bias. In colorectal surgery, women comprise 42% of new graduates, but only 19% of Diplomates in the United States. OBJECTIVE: We evaluated the representation of women at the 2017 American Society of Colon and Rectal Surgeons Scientific and Tripartite Meeting and assessed for implicit gender bias. DESIGN: This was a prospective observational study. SETTING: The study occurred at the 2017 Tripartite Meeting. MAIN OUTCOME MEASURES: The primary outcome measured was the percentage of women in the formal program relative to conference attendees and forms of address. METHODS: Female program representation was quantified by role (moderator or speaker), session type, and topic. Introductions of speakers by moderators were classified as formal (using a professional title) or informal (using name only), and further stratified by gender. RESULTS: Overall, 31% of meeting attendees who are ASCRS members were women, with higher percentages of women as Candidates (44%) and Members (35%) compared with Fellows (24%). Women comprised 28% of moderators (n = 26) and 28% of speakers (n = 80). The highest percentage of women moderators and speakers was in education (48%) and the lowest was in techniques and technology (17%). In the 41 of 47 sessions evaluated, female moderators were more likely than male moderators to use formal introductions (68.7% vs 54.0%, p = 0.02). There was no difference when female moderators formally introduced female versus male speakers (73.9% vs 66.7%, p = 0.52); however, male moderators were significantly less likely to formally introduce a female versus male speaker (36.4% vs 59.2%, p = 0.003). LIMITATIONS: Yearly program gender composition may fluctuate. Low numbers in certain areas limit interpretability. Other factors potentially influenced speaker introductions. CONCLUSIONS: Overall, program representation of women was similar to meeting demographics, although with low numbers in some topics. An imbalance in the formality of speaker introductions between genders was observed. Awareness of implicit gender bias may improve gender equity and inclusiveness in our specialty. See Video Abstract at http://links.lww.com/DCR/A802.

Past, present, and future of Emergency General Surgery in the USA.

Emergency General Surgery (EGS) patients represent a unique group of acutely ill surgical patients at high risk for death and complications. Since the inception of EGS as a surgical subspecialty in the early 2000s, there have been significant developments to further define the scope of EGS as well as to advance data collection, performance measurement, and quality improvement. This includes defining the EGS cohort by diagnosis and procedure and by overall burden, benchmarking of EGS outcomes, and creation of quality improvement programs aimed at reducing the excess morbidity and mortality associated with EGS. Going forward there exists a need for a more modern approach to quality improvement. This may include the creation of an EGS data registry, the use of electronic medical records data, wearable device technology, and a focus on patient reported outcomes.

Unplanned reoperation after hepatectomy: an analysis of risk factors and outcomes.

BACKGROUND/PURPOSE: Reoperation is being increasingly utilized as a metric for surgical care quality. The aim of this study was to identify the incidence of and risk factors for unplanned reoperation following index hepatectomy. METHODS: Pre, intra- and post-operative information of patients who underwent partial hepatectomy in 435 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2013 were analyzed. RESULTS: 343 (4%) of 9195 patients required reoperation within 30 days of index hepatectomy. The index procedures with the highest incidence of reoperation (%) were trisectionectomy (7%) and right hepatectomy (5%). Patients who underwent reoperation had increased index operative duration (323 ± 174 min versus 243 ± 125 min, p < 0.001), postoperative transfusion (57% versus 23%, p < 0.001), wound complications, cardiorespiratory, renal, thromboembolic, and infectious events. Hemorrhage was the most common indication for reoperation (10%). Male gender, ASA class 4, and right hepatectomy or trisectionectomy were independent predictors of reoperation (OR 1.4 [1.1-1.7], p = 0.007; 2.0 [1.3-3.1], p = 0.003; 1.6 [1.2-2.0], p = 0.001 and 2.5 [1.8-3.4], p < 0.001, respectively). All reoperations occurred during index hospitalization and resulted in longer mean length of stay (19 ± 17 days versus 7 ± 7 days, p < 0.001). CONCLUSION: Reoperation is associated with several patient characteristics and procedural factors in this national sample. Knowledge of these factors can increase awareness of patients at risk for reoperation.

Risk Factors of Reoperation After Pancreatic Resection.

BACKGROUND: Pancreatic resection is associated with a high incidence of postoperative complications, some of which require reoperation. AIMS: To analyze the incidence of and risk factors for reoperation following pancreatectomy. METHODS: Pre- and postoperative information and procedure characteristics of 15,549 patients having undergone pancreatectomy in 435 hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2014 were analyzed. RESULTS: A total of 773 (5.0%) patients required reoperation within 30 days of their index pancreatectomy. Patients requiring reoperation were more likely to be younger (mean ± standard deviation, 62.6 ± 13.2 vs. 64.1 ± 12.2 years, p < 0.001), male (60 vs. 49%, p < 0.001), to have respiratory comorbidities, lower preoperative serum albumin (3.7 ± 0.68 vs. 3.8 ± 0.62 mg/dl, p < 0.001), higher total bilirubin (1.7 ± 2.7 vs. 1.5 ± 2.4 mg/dl, p = 0.02), and higher American Society of Anesthesiologists (ASA) class than those who did not undergo reoperation. Other factors associated with increased incidence of reoperation included longer mean operative duration at the index procedure, postoperative transfusion requirement, wound complications, and cardiorespiratory, renal, thromboembolic, and infectious events. Multivariate regression analysis identified male sex, preoperative serum albumin <3.5 mg/dl, ASA class of 3 or 4, pancreaticoduodenectomy, and total pancreatectomy as the strongest predictors for reoperation after index pancreatic resection. Complication and readmission rates were significantly higher for those undergoing reoperation. CONCLUSION: Patient characteristics and procedural factors contribute to reoperation after pancreatectomy in this largest and most diverse sample to date. Further investigation to identify perioperative strategies for mitigating this risk is required to improve the safety of pancreatic resection.