Trends and disparities in access to minimally invasive distal pancreatectomy (midp): an eight-year analysis from the national cancer database.

Laparoscopic and robotic approaches to distal pancreatectomy are becoming the standard of care. The aim of our study was to evaluate the trends of utilization and disparities in access to minimally invasive approaches in distal pancreatectomy. We queried the National Cancer Database (NCDB) and analyzed all the patients who underwent distal pancreatectomy from 2010 to 2017. Patients were divided into groups of those with open distal pancreatectomy (ODP) and those with laparoscopic or robotic distal pancreatectomy (MIDP = minimally invasive distal pancreatectomy). Our outcome measures were trends of MIDP and disparities in access to MIDP. Cochran Armitage trend analysis and multivariate regression analysis were used to evaluate outcomes. A total of 13,537 patients with distal pancreatectomy were identified in the NCDB from 2010 to 2017. 7548 (55.8%) underwent ODP, while 5989 (44.2%) underwent MIDP. The MIDP rates increased from 25% in 2010 to 52% in 2017 (p < 0.01). On regression analysis, when controlled for age, gender, diagnosis, tumor size, grade, staging, and chemoradiotherapy, African American patients were 30% less likely to undergo MIDP than White (OR 0.7, 95% CI [0.5-0.8], p < 0.01). Similarly, Hispanic patients were 25% less likely to undergo MIDP than non-Hispanic patients OR 0.75, 95% CI [0.6-0.9], p = 0.02). Compared to Medicare/private insured patients, uninsured patients were 50% less likely to undergo MIDP (OR 0.5, 95% CI [0.4-0.7], p < 0.01). Based on the medium household income, compared to patients in the fourth quartile, patients in the third quartile OR 0.9, 95% CI [0.3-0.9], p = 0.03). Second OR 0.8, 95%CI [0.5-0.9], p < 0.01), first quartile OR 0.7, 95% CI [0.5-0.8], p < 0.01) were less likely to undergo MIPD as well. Utilization of MIDP has increased from one in every four patients in 2010 to every other patient in 2017. However, African Americans, Hispanics, the uninsured, and those from low-income quartiles are less likely to undergo MIDP. Efforts should be made to ensure access to minimally invasive approches are available to minorities.

Analysis of Conflicts of Interest in Studies Related to Robotics in Gastrointestinal and Abdominal Wall Surgery.

BACKGROUND: Industry payments to physicians represent a potential conflict of interest (COI) and can influence the study conclusions. This study aimed to evaluate the accuracy of the COIs reported in major surgical journals. STUDY DESIGN: Studies with at least one American author published between 2016 and 2021 that discussed observational and intervention studies assessing robotic surgery were included in the analysis. The Centers for Medicare & Medicaid Services' Open Payments database was used to collect the industry payments. A COI is defined as receiving funding from a robotics company while publishing research directly related to the company's products. A COI statement was defined as disclosed (or accurate) if the disclosure statement for the study in question acknowledged funding from the robotics companies. A COI was defined as undisclosed (or inaccurate) if the disclosure statement for the study in question did not acknowledge funding from the robotics companies. RESULTS: A total of 314 studies and 1978 authors were analyzed. Only 13.6% of the studies had accurate COI statements, whereas the majority (86.4%) had inaccurate COI disclosures. Additionally, 48.9% of the authors who received funding of $10,000 to $100,000 failed to report this amount in their disclosures, and 18% of the authors who received funding of $100,000 or more did not report it in their disclosures. CONCLUSIONS: There was a significant discordance between the self-reported COI in gastrointestinal and abdominal wall surgeries. This study calls for continued efforts to improve the definitions of what constitutes a relevant COI and encourages a standardized reporting process. It is imperative for investigators to make accurate disclosure statements.

Financial Relationships in General Surgery Education: Recent Trends in Industry Payments to General Surgery Residency Leadership.

INTRODUCTION: Residency programs and their directors frequently receive funding from industry payers. Both general surgery residency program directors (PDs) and assistant program directors (APDs) receive industry funding for various reasons, including educational advancement. This study investigates recent trends in industry payments to both PDs and APDs to better understand the financial relationships among leaders in residency education. METHODS: We compared industry payments to general surgery residency PDs and APDs from 2019 to 2021 utilizing the U.S. Centers for Medicare & Medicaid Services (CMS) open payments database. In addition, secondary analyses were performed among PDs to assess differences based on gender, practicing surgical specialty, and geographical region. RESULTS: During the study period (2019-2021), PDs received payments amounting to 2,882,821 USD. PDs were found to receive more funding than APDs, with each receiving average funding of 10,045 vs. 323 USD (p < 0.01), respectively, over the study period. There was a significant decrease in total payments from 2019 to 2020 (1,512,190 vs. 868,811 USD; p < 0.01). Total payments made in 2021 were similar compared to 2020 (905,836 vs. 868,811 USD; p = 0.1). We found that male PDs received significantly more in-industry payments when compared to female PDs (11,702 USD per PD vs. 3971 USD per PD, p < 0.01). CONCLUSION: This study presents initial data that residency program leadership has robust biomedical industry relationships, and further research is warranted to investigate the impacts of these payments on program resources, educational opportunities for residents, and program outcomes. Male PDs received significantly more industry payments when compared to female PDs. Leaders in the surgical training community must cautiously ensure that these industry relationships are appropriately navigated.

Impact of Medicaid Expansion on the Treatment and Outcomes of Intrahepatic Cholangiocarcinoma.

INTRODUCTION: The Affordable Care Act increased insurance coverage for patients residing in states that expanded Medicaid coverage, but its impact on the outcomes of intrahepatic cholangiocarcinoma (ICC) is not clear. Therefore, we examine the impact of Medicaid expansion (ME) on access to treatment and outcomes of ICC. METHODS: We queried the National Cancer Database (NCDB) data for patients with a diagnosis of ICC (2010-2018). Difference-in-difference (DID) analysis was performed to assess the impact of January 2014 ME on curative-intent surgical resection, multimodal therapy, neoadjuvant chemotherapy, 30-day mortality, and overall survival (OS). RESULTS: Of the 2150 patients included in the study,1574 (73.2%) and 576 (26.8%) patients lived in non-ME and ME states, respectively. On adjusted DID, ME was independently associated with receipt of curative-intent surgical resection (DID coefficient: 0.05, 95% confidence interval [95% CI]: 0.04-0.06, p = 0.002) and multimodal therapy (DID coefficient: 0.08, 95% CI: 0.06-0.10, p = 0.004). In addition, ME was associated with improved OS in ME states (hazard ratio [HR]: 0.73, 95% CI: 0.62-0.87, p = 0.001) but not in non-ME states (HR: 0.95, 95% CI: 0.80-1.12, p = 0.536). CONCLUSION: ME status consistently predicted increased utilization of care processes that improved ICC outcomes, including greater rates of curative-intent surgery and multimodal therapy.

The undisclosed disclosures: Conflicts of interest in studies related to robotics in hepatobiliary and pancreatic surgery.

BACKGROUND: The use of robotics in hepatobiliary and pancreatic surgery has increased. With this increased collaboration, there has also been a push toward improving the transparency of conflicts of interest in terms of funding provided by robotics companies. METHODS: Studies with ≥1 American author published between 2016 and 2020 discussing robotic hepatobiliary and pancreatic surgery were included in the analysis. The Centers for Medicare and Medicaid Services Open Payments Program was used to evaluate the accuracy of industry payment disclosures. Conflict of interest was defined as a lack of disclosure of ≥$100 funding from any robotics company in the United States. The primary outcome of this study was to determine the efficacy of the current standard conflict of interest reporting in surgery. RESULTS: A total of 355 studies (2,413 authors) were included. Of the studies that received robotics funding (n = 133), 20.3% did not disclose their conflicts of interest, whereas 79.7% had a conflict of interest disclosure. However, most of the disclosures (76.5%) were inaccurate. CONCLUSION: The findings of this study require an update in journal policies to ensure the accurate disclosure of conflicts of interest in robotic hepatobiliary and pancreatic surgery studies. Similarly, the investigators should ensure that their disclosures are accurate. Finally, surgeons must be more on top of their relationships with these companies and consider their vulnerability to bias.

Should Radiological Assessment be Part of Core General Surgery Competency? A Survey of the General Surgery Residents.

BACKGROUND: Radiological assessment is an important skill to develop in general surgery training. Therefore, we aimed to determine general surgery residents' points of view on receiving formal radiology didactics. METHODS: We performed an anonymous survey of general surgery residents throughout the USA. The survey queried the residents' postgraduate year, training program type, diagnostic radiology education in their training program, as well as the residents' comfort level in interpreting various imaging modalities, followed by a series of images to assess the residents' ability to interpret images showing various surgical disease processes. RESULTS: A total of 365 residents responded to the survey. In total, 76.6% of the respondent states that there is no structured didactic session in their program on radiological studies. However, 66.3% felt that interpretation of radiological images should be used to determine surgical competency and promotion to the next academic year. In terms of accurately reading images-68.7% of the residents were able to read an X-ray showing cecal volvulus correctly, 51.9% were able to read a cholangiogram correctly, and 95.3% were correctly read an X-ray showing free under the diaphragm. CONCLUSION: Most residents favored having radiological assessments as part of the competency evaluation. Furthermore, a curriculum and inbuilt training structure that aims to ensure residents develop competent clinical image interpretation abilities may enhance the development and retention of such skills, ultimately influencing patient outcomes.

Hospitalization Costs and Outcomes of Open, Laparoscopic, and Robotic Liver Resections.

INTRODUCTION: Most liver resections performed in the United States are open. With the ever-increasing role of robotic surgery, our study's role is to assess national outcomes based on the surgical approach. METHODS: We performed a retrospective analysis of the 2015 National Readmission Database (NRD). We selected patients undergoing open, laparoscopic, and robotic hepatectomy. Propensity score matching was performed to match the three groups in terms of demographics, hospital characteristics, and resection type. Our primary outcome was 6-month readmission rates and associated costs. RESULTS: 3,872 patients were included in the analysis (open = 3,420, laparoscopic = 343, and robotic = 109). Robotic liver resection has lower 6-month readmission rates (18.3%) than the laparoscopic (26.7%) and open (30%) counterparts. The robotic approach was more cost-effective ($127,716.56 ± 12,567.31) than the open ($157,880.82 ± 18,560.2) and laparoscopic approach ($152,060.78 ± 8,890.13) in terms of the total cost which includes cost per readmission. CONCLUSIONS: There is a financial benefit of using robotics in terms of cost, hospital length of stay, and readmission rates in patients undergoing liver resection, cost.

Cancer Care in the Incarcerated Population: Barriers to Quality Care and Opportunities for Improvement.

Importance: Cancer is the leading cause of mortality in incarcerated individuals older than 45 years and the fourth leading cause of mortality overall. Health care professionals face increasing challenges to provide high-quality care under the confines of prison regulations and procedures. Observations: Adjusted for age, race, sex, and year of diagnosis, the standardized incidence ratio for all cancers is more than 2-fold higher in incarcerated vs general populations. Among deaths occurring in state and federal prison systems, cancer is the overall leading cause of mortality with lung cancer being the leading cause of cancer-related mortality followed by liver, colon, and pancreatic cancers, respectively. Access to high-quality oncological services remains variable; however, cost of care represents about a fifth of overall annual prison expenditures. Given the enormous patient burden, coupled with the rushed discretionary screenings performed by jail and prison nursing staff, early cancer symptoms are often missed altogether or misdiagnosed as a chronic illness or as acute infections. As such, many incarcerated individuals present with more advanced cancer stage. Incarcerated individuals have limited, if any, access to the internet, social media, and other sources of information, which severely limits their ability to research treatment options. Within the prison setting, access to professionals with special skills in assisting with social and spiritual concerns is also generally limited, and less than 4% of prisons have hospice programs. There are no uniform quality-of-care monitoring standards for correctional systems and facilities, nor are there mechanisms for reporting comparable performance data to enforce quality control within correctional health care systems. Conclusions and Relevance: There is a growing trend in cancer incidence among incarcerated patients, which is multifactorial including barriers in access to care, increased burden of chronic medical conditions, and decreased screening tests. Efforts are needed to ensure quality health care outcomes for incarcerated patients with cancer.

Neoadjuvant Chemoradiation Therapy Is Associated with Adverse Outcomes in Patients Undergoing Pancreaticoduodenectomy for Pancreatic Cancer.

The use of neoadjuvant chemoradiation therapy in patients with pancreatic adenocarcinoma is emerging as an acceptable therapy option. The effects of neoadjuvant therapy on 30 days' outcomes in patients with pancreatic cancer are not well defined in the literature. NSQIP (2009-2012) was used. Only patients with a diagnosis of pancreatic cancer and those who underwent a Whipple were included in the analysis. Patient who underwent neoadjuvant chemoradiation therapy were compared with those who did not receive therapy. Main outcome measures were as follows: complications, ≥2 units of blood transfusions, length of stay, readmission rates, return to the operating room, and 30-day mortality. A total of 1445 patients (395: neoadjuvant chemoradiation and 1050: no neoadjuvant therapy) were identified. The mean age was 67 ± 12 years, and 51 per cent of the patients were male. Neoadjuvant chemoradiation therapy was associated with increase in readmission rates (18% vs 12.2%, P 0.02), unanticipated return to the operating room (2.3% vs 1.1%, P 0.03) with no difference in mortality rates. Neoadjuvant chemoradiation therapy is associated with increase in inhospital complications. These differences in outcomes may be explained by the more advance stage of pancreatic cancer in these subsets of patients. Resource utilization and preoperative rehabilitation are of utmost significance to overcome this rise in complications associated with neoadjuvant chemoradiation therapy.

The Role of Genetic Testing in Patients With Breast Cancer: A Review.

Importance: In the United States from 2009 to 2013, the incidence of breast cancer was the highest of any cancer and the death rate was second to that of lung cancer. Approximately 5% to 10% of breast cancers are inheritable. Observations: BRCA1 and BRCA2 germline mutations account for up to 30% of inheritable breast cancers and are the most commonly assessed mutations in patients presenting with early-onset breast cancer, triple-negative breast cancer, bilateral breast cancer, and a family history of breast cancer. Less common non-BRCA mutations have also been identified and contribute to hereditary breast cancer syndromes. Although established in BRCA mutations, indications and interpretations of genetic testing in non-BRCA mutations are not well defined. Furthermore, costs associated with genetic testing are highly variable and dependent on laboratory pricing, insurance coverage, and individual risk factors. Conclusions and Relevance: Genetic testing is a powerful tool that allows for the detection of BRCA and non-BRCA germline mutations in individuals with high risks of breast cancer, which in turn aids in the individualization of treatment. Given the magnitude of this disease, it is of great benefit for physicians, including general surgeons, to understand the indications, interpretations, and costs associated with genetic testing in patients with breast cancer. Cost is an especially important part of the genetic testing process and point of discussion with patients.

Improving Hospital Quality and Costs in Nonoperative Traumatic Brain Injury: The Role of Acute Care Surgeons.

IMPORTANCE: The role of acute care surgeons is evolving; however, no guidelines exist for the selective treatment of patients with traumatic brain injury (TBI) exclusively by acute care surgeons. We implemented the Brain Injury Guidelines (BIG) for managing TBI at our institution on March 1, 2012. OBJECTIVE: To compare the outcomes in patients with TBI before and after implementation of the BIG protocol. DESIGN, SETTING, AND PARTICIPANTS: We conducted a 2-year analysis of our prospectively maintained database of all patients with TBI (findings of skull fracture and/or intracranial hemorrhage on an initial computed tomographic scan of the head) who presented to our level I trauma center. The pre-BIG group included patients with TBI from March 1, 2011, through February 29, 2012, and the post-BIG group included patients from July 1, 2012, through June 30, 2013. MAIN OUTCOMES AND MEASURES: The primary outcome measures were patients with repeated computed tomography of the head and neurosurgical consultations. Secondary outcome measures were findings of progression of intracranial hemorrhage on repeated computed tomographic scans, neurosurgical intervention, hospital admission, intensive care unit admission, hospital and intensive care unit length of stay, 30-day readmission rate, and hospital costs per patient. RESULTS: A total of 796 patients (415 in the pre-BIG group and 381 in the post-BIG group) were included. There was a significant reduction (19.0%) in the rate of neurosurgical consultation (post-BIG group, 273 patients [71.7%]; pre-BIG group, 376 [90.6%]; P < .001), repeated computed tomography of the head (post-BIG group, 255 patients [66.9%]; pre-BIG group, 381 patients [91.8%]; P < .001), hospital (post-BIG group, 330 [86.6%]; pre-BIG group, 398 [95.9%]; P < .001) and intensive care unit admission (post-BIG group, 202 [53.0%]; pre-BIG group, 257 [61.9%]; P = .01), hospital length of stay (post-BIG group, 5.4 [4.5] days; pre-BIG group, 6.1 [4.8] days; P = .03), and hospital costs per patient ($4772 per patient; P = .03) with implementation of BIG. There was no difference in the in-hospital mortality rate (post-BIG group, 62 patients [16.3%]; pre-BIG group, 69 patients [16.6%]; P = .89), progression of intracranial hemorrhage on repeated scans (post-BIG group, 41 patients [10.8%]; pre-BIG group, 59 patients [14.2%]; P = .14), neurosurgical intervention (post-BIG group, 61 patients [16.0%]; pre-BIG group, 59 patients [14.2%]; P = .48), and 30-day readmission rate (post-BIG group, 31 patients [8.1%]; pre-BIG group, 37 patients [8.9%]; P = .69) after implementation of BIG. CONCLUSIONS AND RELEVANCE: Implementation of BIG is safe and cost-effective. BIG defines the management of TBI without the need for neurosurgical consultation and unnecessary imaging. Establishing a national, multi-institutional study implementing the BIG protocol is warranted.

Management of Conjunctival Melanoma: Critical Assessment of Sentinel Lymph Node Biopsy.

Conjunctival melanoma (CoM) is a rare and aggressive form of melanoma. There is a lack of consensus on a unified management plan for this disease. Recently, a few centers have adopted the regional sentinel lymph node biopsy into the staging process of CoM. This study presents a critical assessment of the role of sentinel lymph node biopsy in CoM and presents a simplified management algorithm based on high-risk clinical and pathological features.

Prothrombin complex concentrate use in coagulopathy of lethal brain injuries increases organ donation.

Coagulopathy is a defined barrier for organ donation in patients with lethal traumatic brain injuries. The purpose of this study was to document our experience with the use of prothrombin complex concentrate (PCC) to facilitate organ donation in patients with lethal traumatic brain injuries. We performed a 4-year retrospective analysis of all patients with devastating gunshot wounds to the brain. The data were analyzed for demographics, change in international normalized ratio (INR), and subsequent organ donation. The primary end point was organ donation. Eighty-eight patients with lethal traumatic brain injury were identified from the trauma registry of whom 13 were coagulopathic at the time of admission (mean INR 2.2 ± 0.8). Of these 13 patients, 10 patients received PCC in an effort to reverse their coagulopathy. Mean INR before PCC administration was 2.01 ± 0.7 and 1.1 ± 0.7 after administration (P < 0.006). Correction of coagulopathy was attained in 70 per cent (seven of 10) patients. Of these seven patients, consent for donation was obtained in six patients and resulted in 19 solid organs being procured. The cost of PCC per patient was $1022 ± 544. PCC effectively reveres coagulopathy associated with lethal traumatic brain injury and enabled patients to proceed to organ donation. Although various methodologies exist for the treatment of coagulopathy to facilitate organ donation, PCC provides a rapid and cost-effective therapy for reversal of coagulopathy in patients with lethal traumatic brain injuries.

Retinoblastoma treatment burden and economic cost: impact of age at diagnosis and selection of primary therapy.

PURPOSE: To follow the treatment history of patients with retinoblastoma to identify the trends in the number of hospital visits over time and the direct cost of medical care as determined by age at diagnosis and selected primary treatment modality. DESIGN: An Institutional Review Board (IRB) approved consecutive retrospective case series. MATERIALS AND METHODS: Records from the Bascom Palmer Eye Institute were reviewed to identify 115 eligible patients (176 eyes) with retinoblastoma who underwent treatment at the Ocular Oncology Service between 1995 and 2010 and were available for extended follow-up evaluation. RESULTS: Bilateral disease was present in 53% (N = 61) of all patients, and 79% (N = 90) of patients were diagnosed in the first six months of life. Chemotherapy was used to treat 75% (N = 86) of all patients and 95% (N = 36) of patients diagnosed in the first six months of life. 100% (N = 4) of patients presenting between the age of five and nine were enucleated. Per episode of care, the lowest-cost treatment strategy was enucleation, followed by focal laser therapy, systemic chemotherapy with planned enucleation, systemic chemotherapy, and lastly, intra-arterial melphalan chemotherapy. CONCLUSION: Age at diagnosis is directly associated with the type of treatment chosen for retinoblastoma. The burden of retinoblastoma treatment on children and families is significant. The direct medical cost of intra-arterial chemotherapy per episode of care is comparable to systemic chemotherapy, but current strategies utilizing multiple planned episodes of intra-arterial chemotherapy are significantly more costly and may be associated with less systemic side effects and similar favorable outcomes. At the Bascom Palmer Eye Institute, intra-arterial chemotherapy has quickly become the treatment of choice for globe conserving therapy of retinoblastoma.