The PrEDICT-DGE score as a simple preoperative screening tool identifies patients at increased risk for delayed gastric emptying after pancreaticoduodenectomy.

BACKGROUND: Morbidity after Pancreaticoduodenectomy (PD) has remained unchanged over the past decade. Delayed Gastric Emptying (DGE) is a major contributor with significant impact on healthcare-costs, quality of life and, for malignancies, even survival. We sought to develop a scoring system to aid in easy preoperative identification of patients at risk for DGE. METHODS: The ACS-NSQIP dataset from 2014 to 2018 was queried for patients undergoing PD with Whipple or pylorus preserving reconstruction. 15,154 patients were analyzed using multivariable logistic regression to identify risk factors for DGE, which were incorporated into a prediction model. Subgroup analysis of patients without SSI or fistula (primary DGE) was performed. RESULTS: We identified 9 factors independently associated with DGE to compile the PrEDICT-DGE score: Procedures (Concurrent adhesiolysis, feeding jejunostomy, vascular reconstruction with vein graft), Elderly (Age>70), Ductal stent (Lack of biliary stent), Invagination (Pancreatic reconstruction technique), COPD, Tobacco use, Disease, systemic (ASA>2), Gender (Male) and Erythrocytes (preoperative RBC-transfusion). PrEDICT-DGE scoring strongly correlated with actual DGE rates (R2 = 0.95) and predicted patients at low, intermediate, and high risk. Subgroup analysis of patients with primary DGE, retained all predictive factors, except for age>70 (p = 0.07) and ASA(p = 0.30). CONCLUSION: PrEDICT-DGE scoring accurately identifies patients at high risk for DGE and can help guide perioperative management.

Impact of preoperative biliary drainage on 30 Day outcomes of patients undergoing pancreaticoduodenectomy for malignancy.

BACKGROUND: Preoperative biliary drainage (PBD) has been advocated to address the plethora of physiologic derangements associated with cholestasis. However, available literature reports mixed outcomes and is based on largely outdated and/or single-institution studies. METHODS: Patients undergoing PBD prior to pancreaticoduodenectomy (PD) for periampullary malignancy between 2014-2018 were identified in the ACS-NSQIP pancreatectomy dataset. Patients with PBD were propensity-score-matched to those without PBD and 30-day outcomes compared. RESULTS: 8,970 patients met our inclusion criteria. 4,473 with obstruction and PBD were matched to 829 with no preoperative drainage procedure. In the non-jaundiced cohort, 711 stented patients were matched to 2,957 without prior intervention. PBD did not influence 30-day mortality (2.2% versus 2.4%) or major morbidity (19.8% versus 20%) in patients with obstructive jaundice. Superficial surgical site infections (SSIs) were more common with PBD (6.8% versus 9.2%), however, no differences in deep or organ-space SSIs were found. Patients without obstruction prior to PBD exhibited a 3-fold increase in wound dehiscence (0.5% versus 1.5%) additionally to increased superficial SSIs. CONCLUSION: PBD was not associated with an increase in 30-day mortality or major morbidity but increased superficial SSIs. PBD should be limited to symptomatic, profoundly jaundiced patients or those with a delay prior to PD.

Travel patterns of cancer surgery patients in a regionalized system.

BACKGROUND: Regionalization of complex surgeries has increased patient travel distances possibly leaving a substantial burden on those at risk for poorer surgical outcomes. To date, little is known about travel patterns of cancer surgery patients in regionalized settings. To inform this issue, we sought to assess travel patterns of those undergoing a major cancer surgery within a regionalized system. MATERIALS AND METHODS: We identified 4733 patients who underwent lung, esophageal, gastric, liver, pancreatic, and colorectal resections from 2002-2014 within a multihospital system in the Mid-Atlantic region of the United States. Patient age, race and/or ethnicity, and insurance status were extracted from electronic health records. We used Geographical Information System capabilities in R software to estimate travel distance and map patient addresses based on cancer surgery type and these characteristics. We used visual inspection, analysis of variance, and interaction analyses to assess the distribution of travel distances between patient populations. RESULTS: A total of 48.2% of patients were non-white, 49.9% were aged >65 y, and 54.9% had private insurance. Increased travel distance was associated with decreasing age and those undergoing pancreatic and esophageal resections. Also, black patients tend to travel shorter distances than other racial and/or ethnic groups. CONCLUSIONS: These maps offer a preliminary understanding into variations of geospatial travel patterns among patients receiving major cancer surgery in a Mid-Atlantic regionalized setting. Future research should focus on the impact of regionalization on timely delivery of surgical care and other quality metrics.

Colloid Carcinoma of the Pancreas: A Rare Initial Presentation of Lynch Syndrome.

Patients with Lynch syndrome, most commonly associated with colorectal cancer, have an increased risk of developing other tumors including pancreatic ductal adenocarcinoma and precursor lesions, such as intraductal papillary mucinous neoplasms. Here, we present a case of a man in his early 20s who presented with a retroperitoneal mass involving the head of the pancreas. Following a pancreaticoduodenectomy combined with para-aortic lymphadenectomy, a pathologic diagnosis of colloid carcinoma, also known as mucinous noncystic carcinoma, of the pancreas was reported. Further testing established the diagnosis of Lynch syndrome. This case is unique because colloid carcinoma of the pancreas is rare and has never been reported as an initial presentation of Lynch syndrome.

Persistent disparities in liver transplantation for patients with hepatocellular carcinoma in the United States, 1998 through 2007.

BACKGROUND: Prior studies have demonstrated that among patients with hepatocellular carcinoma (HCC), African Americans (AAs) and Asian/Pacific Islanders (APIs) are substantially less likely to undergo liver transplantation (LT) compared with whites. The authors examined whether disparities in the receipt of LT among LT-eligible HCC patients changed over a 10-year time period, and whether the disparities might be explained by sociodemographic or clinical factors. METHODS: The National Cancer Data Base, a national hospital-based cancer registry, was used to study 7707 adults with small (≤ 5 cm), nonmetastatic HCC diagnosed between 1998 and 2007. Racial/ethnic patterns in the use of LT were compared during 2 periods of 5 years each: 1998 through 2002 (n = 2412 patients) and 2003 through 2007 (n = 5295 patients). Data regarding comorbid medical conditions were only available during the later time period. RESULTS: Large and persistent racial/ethnic differences in the probability of receiving LT were observed. Compared with whites, hazard ratios (HRs) and associated 95% confidence intervals (95% CIs) for receiving LT from 1998 through 2002 were 0.64 (95% CI, 0.46-0.89) for AA patients, 1.01 (95% CI, 0.79-1.29) for Hispanic patients, and 0.52 (95% CI, 0.39-0.68) for API patients. Analogous results for 2003 through 2007 were 0.64 (95% CI, 0.54-0.76) for AA patients, 0.86 (95% CI, 0.75-0.99) for Hispanic patients, and 0.58 (95% CI, 0.49-0.69) for API patients. AA patients were less likely than whites to undergo any form of surgery, and API patients were more likely than whites to undergo surgical resection. Adjustment for sociodemographic and clinical factors produced only small changes in these HRs. CONCLUSIONS: Between 1998 and 2007, there were large and persistent racial/ethnic disparities noted in the receipt of LT among patients with HCC. These disparities were not explained by sociodemographic or clinical factors.

Medicaid Expansion and Disparity Reduction in Surgical Cancer Care at High-Quality Hospitals.

BACKGROUND: The Affordable Care Act's Medicaid expansion has been heavily debated due to skepticism about Medicaid's ability to provide high-quality care. Particularly, little is known about whether Medicaid expansion improves access to surgical cancer care at high-quality hospitals. To address this question, we examined the effects of the 2001 New York Medicaid expansion, the largest in the pre-Affordable Care Act era, on this disparity measure. STUDY DESIGN: We identified 67,685 nonelderly adults from the New York State Inpatient Database who underwent select cancer resections. High-quality hospitals were defined as high-volume or low-mortality hospitals. Disparity was defined as model-adjusted difference in percentage of patients receiving operations at high-quality hospitals by insurance type (Medicaid/uninsured vs privately insured) or by race (African American vs white). Levels of disparity were calculated quarterly for each comparison pair and then analyzed using interrupted time series to evaluate the impact of Medicaid expansion. RESULTS: Disparity in access to high-volume hospitals by insurance type was reduced by 0.97 percentage points per quarter after Medicaid expansion (p < 0.0001). Medicaid/uninsured beneficiaries had similar access to low-mortality hospitals as the privately insured; no significant change was detected around expansion. Conversely, racial disparity increased by 0.87 percentage points per quarter (p < 0.0001) in access to high-volume hospitals and by 0.48 percentage points per quarter (p = 0.005) in access to low-mortality hospitals after Medicaid expansion. CONCLUSIONS: Pre-Affordable Care Act Medicaid expansion reduced the disparity in access to surgical cancer care at high-volume hospitals by payer. However, it was associated with increased racial disparity in access to high-quality hospitals. Addressing racial barriers in access to high-quality hospitals should be prioritized.

The Affordable Care Act's Medicaid expansion and utilization of discretionary vs. non-discretionary inpatient surgery.

BACKGROUND: While pre-Affordable Care Act expansions in Medicaid eligibility led to increased utilization of elective inpatient procedures, the impact of the Affordable Care Act on such preference-sensitive procedures (also known as discretionary procedures) versus time-sensitive non-discretionary procedures remains unknown. As such, we performed a hospital-level quasi-experimental evaluation to measure the differential effects of the Affordable Care Act's Medicaid expansion on utilization of discretionary procedures versus non-discretionary procedures. METHODS: The State Inpatient Database (2012-2014) yielded 476 hospitals providing selected discretionary procedures or non-discretionary procedures performed on 288,446 non-elderly, adult patients across 3 expansion states and 2 non-expansion control states. Discretionary procedures included non-emergent total knee and hip arthroplasty, while non-discretionary procedures included nine cancer surgeries. Mixed Poisson interrupted time series analyses were performed to determine the impact of the Affordable Care Act's Medicaid expansion on the number of discretionary procedures versus non-discretionary procedures provided among non-privately insured patients (Medicaid and uninsured patients) and privately insured patients. RESULTS: Analysis of the number of non-privately insured procedures showed an increase in discretionary procedures of +15.1% (IRR 1.15, 95% CI:1.11-1.19) vs -4.0% (IRR 0.96, 95% CI:0.94-0.99) and non-discretionary procedures of +4.1% (IRR 1.04, 95% CI:1.0-1.1) vs -5.3% (IRR 0.95, 95% CI:0.93-0.97) in expansion states compared to non-expansion states, respectively. Analysis of privately insured procedures showed no statistically meaningful change in discretionary procedures or non-discretionary procedures in either expansion or non-expansion states. CONCLUSION: In this multi-state evaluation, the Affordable Care Act's Medicaid expansion preferentially increased utilization of discretionary procedures versus non-discretionary procedures in expansion states compared to non-expansion states among non-privately insured patients. These preliminary findings suggest that increased Medicaid coverage may have contributed to the increased use of inpatient surgery for discretionary procedures.

Primary Epidermoid Cyst of Biliary Duct Presenting as Choledochal Cyst.

Choledochal cyst is a cystic dilation of the biliary tree that can increase the risk of malignancy in bile ducts and the gallbladder. These are usually lined by bile duct epithelium, which may undergo intestinal and squamous metaplasia. This is the first report of clinically diagnosed type II choledochal cyst that is entirely lined by metaplastic stratified squamous epithelium, unlike most other cysts, which are histologically lined by bile duct epithelium. This observation can potentially explain the underlying pathogenic mechanism of rare reports of squamous cell carcinomas arising in bile duct systems.

Why Do Long-Distance Travelers Have Improved Pancreatectomy Outcomes?

BACKGROUND: Centralization of complex surgical care has led patients to travel longer distances. Emerging evidence suggested a negative association between increased travel distance and mortality after pancreatectomy. However, the reason for this association remains largely unknown. We sought to unravel the relationships among travel distance, receiving pancreatectomy at high-volume hospitals, delayed surgery, and operative outcomes. STUDY DESIGN: We identified 44,476 patients who underwent pancreatectomy for neoplasms between 2004 and 2013 at the reporting facility from the National Cancer Database. Multivariable analyses were performed to examine the independent relationships between increments in travel distance mortality (30-day and long-term survival) after adjusting for patient demographics, comorbidity, cancer stage, and time trend. We then examined how additional adjustment of procedure volume affected this relationship overall and among rural patients. RESULTS: Median travel distance to undergo pancreatectomy increased from 16.5 to 18.7 miles (p for trend < 0.001). Although longer travel distance was associated with delayed pancreatectomy, it was also related to higher odds of receiving pancreatectomy at a high-volume hospital and lower postoperative mortality. In multivariable analysis, difference in mortality among patients with varying travel distance was attenuated by adjustment for procedure volume. However, longest travel distance was still associated with a 77% lower 30-day mortality rate than shortest travel among rural patients, even when accounting for procedure volume. CONCLUSIONS: Our large national study found that the beneficial effect of longer travel distance on mortality after pancreatectomy is mainly attributable to increase in procedure volume. However, it can have additional benefits on rural patients that are not explained by volume. Distance can represent a surrogate for rural populations.

Do hospital factors impact readmissions and mortality after colorectal resections at minority-serving hospitals?

BACKGROUND: Minority-serving hospitals have greater readmission rates after operative procedures including colectomy; however, little is known about the contribution of hospital factors to readmission risk and mortality in this setting. This study evaluated the impact of hospital factors on readmissions and inpatient mortality after colorectal resections at minority-serving hospitals in the context of patient- and procedure-related factors. METHODS: More than 168,000 patients who underwent colorectal resections in 374 California hospitals (2004-2011) were analyzed using the State Inpatient Database and American Hospital Association Hospital Survey data. Sequential logistic regression analyses were performed to determine the associations between minority-serving hospital status and 30-day, 90-day, and repeated readmissions. RESULTS: Thirty-day, 90-day, and repeated readmission rates were 11.2%, 16.9%, and 2.9%, respectively. Odds for 30-day, 90-day, and repeated readmissions after colorectal resections were 19%, 20%, and 38% more likely at minority-serving hospitals versus non-minority-serving hospitals, respectively (P < .01), after controlling for age, sex, comorbidities, year, and procedure type. Patient factors accounted for up to 65% of the observed increase in odds for readmission at minority-serving hospitals while hospital-level factors contributed roughly 40%. Inpatient mortality was significantly greater at minority-serving hospitals versus non-minority-serving hospitals (4.9% vs 3.8%; P < .001). Risk factors significantly associated with readmissions and inpatient mortality included Medicaid/Medicare primary insurance, emergent operation, and ostomy creation. Low procedure volume was significantly associated with increased odds for inpatient mortality. CONCLUSION: Patient-level factors seemed to dominate the increased readmission risk after colorectal resections at minority-serving hospitals while hospital factors were less contributory. These findings need to be further validated to shape quality improvement interventions to decrease readmissions.

Did Pre-Affordable Care Act Medicaid Expansion Increase Access to Surgical Cancer Care?

BACKGROUND: Although the Affordable Care Act (ACA) expanded Medicaid access, it is unknown whether this has led to greater access to complex surgical care. Evidence on the effect of Medicaid expansion on access to surgical cancer care, a proxy for complex care, is sparse. Using New York's 2001 statewide Medicaid expansion as a natural experiment, we investigated how expansion affected use of surgical cancer care among beneficiaries overall and among racial minorities. STUDY DESIGN: From the New York State Inpatient Database (1997 to 2006), we identified 67,685 nonelderly adults (18 to 64 years of age) who underwent cancer surgery. Estimated effects of 2001 Medicaid expansion on access were measured on payer mix, overall use of surgical cancer care, and percent use by racial/ethnic minorities. Measures were calculated quarterly, adjusted for covariates when appropriate, and then analyzed using interrupted time series. RESULTS: The proportion of cancer operations paid by Medicaid increased from 8.9% to 15.1% in the 5 years after the expansion. The percentage of uninsured patients dropped by 21.3% immediately after the expansion (p = 0.01). Although the expansion was associated with a 24-case/year increase in the net Medicaid case volume (p < 0.0001), the overall all-payer net case volume remained unchanged. In addition, the adjusted percentage of ethnic minorities among Medicaid recipients of cancer surgery was unaffected by the expansion. CONCLUSIONS: Pre-ACA Medicaid expansion did not increase the overall use or change the racial composition of beneficiaries of surgical cancer care. However, it successfully shifted the financial burden away from patient/hospital to Medicaid. These results might suggest similar effects in the post-ACA Medicaid expansion.

Biliary-colonic fistula: a case report and literature review.

We report the occurrence of common bile duct obstruction and biliary-colonic fistula after open cholecystectomy. Although it is a very unusual complication after cholecystectomy, biliary-colonic fistula should be part of the differential diagnosis for patients presenting with sepsis after open or laparoscopic cholecystectomy. After confirmation and characterization of the injury by endoscopic retrograde cholangiopancreatography and cholangiogram, assessment for undrained collections by computed tomography scan, control of sepsis and coagulopathy, and nutritional support, surgical repair was undertaken. The patient underwent fistula take-down between the common bile duct and the colon at the hepatic flexure, primary closure of the colon enterotomy, and a Roux-en-Y end-to-side hepaticojejunostomy at the confluence of the right and left hepatic ducts. Recovery was uneventful and the patient was doing well at the 6-month follow-up. Surgical repair should be undertaken by surgeons with extensive experience in hepatobiliary reconstruction.

Vulnerable Hospitals and Cancer Surgery Readmissions: Insights into the Unintended Consequences of the Patient Protection and Affordable Care Act.

BACKGROUND: Penalties from the Hospital Readmission Reduction Program can push financially strained, vulnerable patient-serving hospitals into additional hardship. In this study, we quantified the association between vulnerable hospitals and readmissions and examined the respective contributions of patient- and hospital-related factors. METHODS: A total of 110,857 patients who underwent major cancer operations were identified from the 2004-2011 State Inpatient Database of California. Vulnerable hospitals were defined as either self-identified safety net hospitals (SNHs) or hospitals with a high percentage of Medicaid patients (high Medicaid hospitals [HMHs]). We used multivariable logistic regression to determine the association between vulnerable hospitals and readmission. Patient and hospital contributions to the elevation in odds of readmission were assessed by comparing estimates from models with different subsets of predictors. RESULTS: Of the 355 hospitals, 13 were SNHs and 31 were HMHs. After adjusting for Hospital Readmission Reduction Program variables, SNHs had higher 30-day (odds ratio [OR] = 1.32; 95% CI, 1.18-1.47), 90-day (OR = 1.28; 95% CI, 1.18-1.38), and repeated readmissions (OR = 1.33; 95% CI, 1.18-1.49); HMHs also had higher 30-day (OR = 1.18; 95% CI, 1.05-1.32), 90-day (OR = 1.28; 95% CI, 1.16-1.42), and repeated readmissions (OR = 1.24; 95% CI, 1.01-1.54). Compared with patient characteristics, hospital factors accounted for a larger proportion of the increase in odds of readmission among SNHs (60% to 93% vs 24% to 39%), but a smaller proportion among HMHs (9% to 15% vs 60% to 115%). CONCLUSIONS: Vulnerable status of hospitals is associated with higher readmission rates after major cancer surgery. These findings reinforce the call to account for socioeconomic variables in risk adjustments for hospitals who serve a disproportionate share of disadvantaged patients.

Medicaid beneficiaries undergoing complex surgery at quality care centers: insights into the Affordable Care Act.

BACKGROUND: Medicaid beneficiaries do not have equal access to high-volume centers for complex surgical procedures. We hypothesize there is a large Medicaid Gap between those receiving emergency general vs complex surgery at the same hospital. METHODS: Using the Nationwide Inpatient Sample, 1998 to 2010, we identified high-volume pancreatectomy hospitals. We then compared the percentage of Medicaid patients receiving appendectomies vs pancreatectomies at these hospitals. Hospital characteristics associated with increased Medicaid Gap were evaluated using generalized estimating equation models. RESULTS: A total of 602 hospital-years of data from 289 high-volume pancreatectomy hospitals were included. Median percentages of Medicaid appendectomies and pancreatectomies were 12.1% (interquartile range: 5.8% to 19.8%) and 6.7% (interquartile range: 0% to 15.4%), respectively. Hospitals that performed greater than or equal to 40 pancreatic resections per year had higher odds of having significant Medicaid Gap (odds ratio 2.3, 95% confidence interval 1.1 to 5.0). CONCLUSIONS: Gaps exist between the percentages of Medicaid patients receiving emergency general surgery vs more complex surgical care at the same hospital and may be exaggerated in hospitals with very high volume of complex elective surgeries.

Fragmentation of Care after Surgical Discharge: Non-Index Readmission after Major Cancer Surgery.

BACKGROUND: Despite national emphasis on care coordination, little is known about how fragmentation affects cancer surgery outcomes. Our study examines a specific form of fragmentation in post-discharge care-readmission to a hospital different from the location of the operation-and evaluates its causes and consequences among patients readmitted after major cancer surgery. STUDY DESIGN: We used the State Inpatient Database of California (2004 to 2011) to identify patients who had major cancer surgery and their subsequent readmissions. Logistic models were used to examine correlates of non-index readmissions and to assess associations between location of readmission and outcomes, measured by in-hospital mortality and repeated readmission. RESULTS: Of 9,233 readmissions within 30 days of discharge after major cancer surgery, 20.0% occurred in non-index hospitals. Non-index readmissions were associated with emergency readmission (odds ratio [OR] = 2.63; 95% CI, 2.26-3.06), rural residence (OR = 1.81; 95% CI, 1.61-2.04), and extensive procedures (eg hepatectomy vs proctectomy; OR = 2.77; CI, 2.08-3.70). Mortality was higher during non-index readmissions than index readmissions independent of patient, procedure, and hospital factors (OR = 1.31; 95% CI, 1.03-1.66), but was mitigated by adjusting for conditions present at readmission (OR = 1.24; 95% CI, 0.98-1.58). Non-index readmission predicted higher odds of repeated readmission within 60 days of discharge from the first readmission (OR = 1.16; 95% CI, 1.02-1.32), independent of all covariates. CONCLUSIONS: Non-index readmissions constitute a substantial proportion of all readmissions after major cancer surgery. They are associated with more repeated readmissions and can be caused by severe surgical complications and increased travel burden. Overcoming disadvantages of non-index readmissions represents an opportunity to improve outcomes for patients having major cancer surgery.

Pancreaticoduodenectomy hospital resource utilization in octogenarians.

BACKGROUND: Although pancreaticoduodenectomy (PD) is feasible in patients greater than or equal to 80 years, little is known about the potential strain on resource utilization. METHODS: Outcomes and inpatient charges were compared across age cohorts (I: ≤70, II: 71 to 79, III: ≥80 years) in 99 patients who underwent PD (2005 to 2013) at our institution. The generalized linear modeling approach was used to estimate the impact of age. RESULTS: Perioperative complications were equivalent among cohorts. Increasing age was associated with intensive care unit use, increased length of stay (LOS), and the likelihood of discharge to a skilled facility. After controlling for covariates, hospital charges were significantly higher in Cohort III (P = .006) and Cohort II (P = .035) when compared with Cohort I. However, hospital charges between Cohorts II and III were equivalent (P = .374). Complications (P = .005) and LOS (P < .001) were associated with higher hospital charges. CONCLUSIONS: Increasing age was associated with increased intensive care unit, LOS, and discharge to skilled facilities. However, octogenarians had equivalent PD charges and outcome measures when compared with septuagenarians and future studies should validate these findings in larger national studies.