Generalizability of COBRA: A Parsimonious Perioperative Venous Thromboembolism Risk Assessment Model.

INTRODUCTION: Standardized use of venous thromboembolism (VTE) risk assessment models (RAMs) in surgical patients has been limited, in part due to the cumbersome workflow addition required to use available models. The COBRA score-capturing cancer diagnosis, (old) age, body mass index, race, and American Society of Anesthesiologists Physical Status score-has been reported as a potentially automatable VTE RAM that circumvents the cumbersome workflow addition that most RAMs represent. We aimed to test the ability of the COBRA model to effectively risk-stratify patients across various populations. METHODS: Patients were included from the 2014-2019 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Participant Use Data File for two hospitals, representing colorectal, endocrine, breast, transplant, plastic, and general surgery services. COBRA score was calculated for each patient using preoperative characteristics. We calculated negative predictive value (NPV) for VTE outcomes and compared the COBRA score to NSQIP's expected VTE rate for all patients, between the two hospitals, and between subspecialty service lines. RESULTS: Of the 10,711 patients included, those with COBRA <4 (31%) had projected median VTE rate of 0.21% (interquartile range, 0.09-0.68%; mean, 0.54%). Patients with higher scores (69%) had median rate of 0.88% (0.26-2.07%; 1.46%); relative rate 2.7. The median projected VTE rates for patients identified as low risk were 0.21% and 0.16% and as high risk were 0.87% and 0.89% at hospitals one and 2, respectively. The median projected VTE rates for patients identified as low risk were 0.17%, 0.61%, and 0.08% and as high risk were 0.52%, 1.43%, and 0.18% among general, colorectal, and endocrine surgery patients, respectively. COBRA had NPV of 0.995 and sensitivity of 0.871 as compared to NPV 0.997 and sensitivity 0.857 of the NSQIP model. CONCLUSIONS: The COBRA score is concordant with the traditional gold standard NSQIP VTE RAM and demonstrates interhospital and service-specific generalizability, although performance was limited in especially low-risk patients. The model adequately risk-stratifies surgical patients preoperatively, potentially providing clinical decision support for perioperative workflows.

The financial impact of the COVID-19 pandemic on sleeve gastrectomy at a major academic institution.

INTRODUCTION: The COVID-19- pandemic significantly impacted metabolic and bariatric surgery (MBS) practices due to large-scale surgery cancellations along with staff and supply shortages. We analyzed sleeve gastrectomy (SG) hospital-level financial metrics before and after the COVID-19 pandemic. METHODS: Hospital cost-accounting software (MicroStrategy, Tysons, VA) was reviewed for revenues, costs, and profits per SG at an academic hospital (2017-2022). Actual figures were obtained, not insurance charge estimates or hospital projections. Fixed costs were obtained through surgery-specific allocation of inpatient hospital and operating-room costs. Direct variable costs were analyzed with sub-components including: (1) labor and benefits, (2) implants, (3) drug costs, and 4) medical/surgical supplies. The pre-COVID-19 period (10/2017-2/2020) and post-COVID-19 period (5/2020-9/2022) financial metrics were compared with student's t-test. Data from 3/2020 to 4/2020 were excluded due to COVID-19-related changes. RESULTS: A total of 739 SG patients were included. Average length of stay (LOS), Center for Medicaid and Medicare Case Mix Index (CMI), and percentage of patients with commercial insurance were similar pre vs. post-COVID-19 (p > 0.05). There were more SG performed per quarter pre-COVID-19 than post-COVID-19 (36 vs. 22; p = 0.0056). Pre-COVID-19 and post-COVID-19 financial metrics per SG differed significantly for, respectively, revenues ($19,134 vs. $20,983) total variable cost ($9457 vs. $11,235), total fixed cost ($2036 vs. $4018), total profit ($7571 vs. $5442), and labor and benefits cost ($2535 vs. $3734; p < 0.05). CONCLUSIONS: The post-COVID-19 period was characterized by significantly increased SG fixed cost (i.e., building maintenance, equipment, overhead) and labor costs (increased contract labor), resulting in precipitous profit decline that crosses the break-even in calendar year quarter (CQ) 3, 2022. Potential solutions include minimizing contract labor cost and decreasing LOS.

Implications of leukocytosis following distal pancreatectomy splenectomy (DPS) and association with postoperative complications.

BACKGROUND: Early identification of complications after distal pancreatectomy splenectomy (DPS) poses challenges, as white blood cell count (WBC) is confounded by physiologic leukocytosis. We examined WBC patterns associated with complications after DPS. METHODS: Clinicopathologic data were collected for patients who underwent DPS in our system from 2009 to 2016. We examined WBC, temperature, platelet count (PC), and ratios of these variables as potential early indicators of patients at risk of infections or major complications (MCs). RESULTS: 348 patients met study inclusion, of whom 206 (59%) were women and the median patient age was 59 ± 15 years. Infectious and MC rates were 11% and 16%, respectively, with <1% 30-day mortality. Postoperative WBC peaks were higher in patients with infections and MCs compared with no complication (23 vs. 17, p < 0.0001). WBC peak timing occurred postoperative day (POD) 2-3 for uncomplicated cases while peaks occurred POD9 for patients with infections and MCs. DISCUSSION: These data define patterns of leukocytosis following DPS. Although differences in infection markers were identified for patients with and without complications, no obvious thresholds were identified. Clinical suspicion for complications after DPS remains our best tool for early identification.

A scalable tool for adjudication of time sensitive cases during COVID-19 pandemic.

BACKGROUND: During the COVID-19 pandemic, prioritization of care and utilization of scarce resources are daily considerations in healthcare systems that have never experienced these issues before. Elective surgical cases have been largely postponed, and surgery departments are struggling to correctly and equitably determine which cases need to proceed. A resource to objectively prioritize and track time sensitive cases would be useful as an adjunct to clinical decision-making. METHODS: A multidisciplinary working group at Emory Healthcare developed and implemented an adjudication tool for the prioritization of time sensitive surgeries. The variables identified by the team to form the construct focused on the patient's survivability according to actuarial data, potential impact on function with delay in care, and high-level biology of disease. Implementation of the prioritization was accomplished with a database design to streamline needed communication between surgeons and surgical adjudicators. All patients who underwent time sensitive surgery between 4/10/20 and 6/15/20 across 5 campuses were included. RESULTS: The primary outcomes of interest were calculated patient prioritization score and number of days until operation. 1767 cases were adjudicated during the specified time period. The distribution of prioritization scores was normal, such that real-time adjustment of the empiric algorithm was not required. On retrospective review, as the patient prioritization score increased, the number of days to the operating room decreased. This confirmed the functionality of the tool and provided a framework for organization across multiple campuses. CONCLUSIONS: We developed an in-house adjudication tool to aid in the prioritization of a large cohort of canceled and time sensitive surgeries. The tool is relatively simple in its design, reproducible, and data driven which allows for an objective adjunct to clinical decision-making. The database design was instrumental in communication optimization during this chaotic period for patients and surgeons.

Diabetes development after distal pancreatectomy: results of a 10 year series.

BACKGROUND: Limited literature is available on the postoperative development of impaired glucose tolerance (IGT) and new-onset diabetes mellitus (NODM) following Distal Pancreatectomy (DP). We aimed to study the post-surgical clinical evolution of IGT/DM and its association with preoperative glycemic profiles of patients undergoing DP. METHODS: Pre- and postoperative glycemic laboratories were measured in patients undergoing DP by the senior author from 2007-2017. Multivariate risk factor analysis was performed to determine risk factors for new-onset IGT/DM after DP. Kaplan-Meier curves were constructed for development of NODM postoperatively. RESULTS: Of 216 included patients, n = 63, n = 68 and n = 85 were preoperatively diagnosed with no-diabetes (No-DM), pre-diabetes (Pre-DM), and diabetes (DM), respectively. At 2-year follow-up, n = 37, n = 80 and n = 99 were classified as No-DM, Pre-DM or DM, respectively. Pre-diabetics had a higher risk of developing postoperative dysglycemia (RR 2.230, 95% CI 1.732-2.870, p = 0.001). Preoperative OGTT>130, HbA1c >6.0, and chronic pancreatitis were risk factors for postoperative DM. CONCLUSION: 40% of patients undergoing DP were unaware of their dysglycemic status (pre-DM or DM) pre-operatively. At 2-year follow-up, 36% non-diabetic and 57% pre-diabetic patients had developed NODM. Appropriate pre-operative diabetic assessment is warranted for all patients undergoing pancreatic resections.

Standardization of operative technique in minimally invasive right hepatectomy: improving cost-value relationship through value stream mapping in hepatobiliary surgery.

BACKGROUND: With current emphasis on improving cost-quality relationship in medicine, it is imperative to evaluate cost-value relationships for surgical procedures. Previously the authors demonstrated comparable clinical outcomes for minimally invasive right hepatectomy (MIRH) and open right hepatectomy (ORH). MIRH had significantly higher intraoperative cost, though overall costs were similar. METHODS: MIRH was decoded into its component critical steps using value stream mapping, analyzing each associated cost. MIRH technique was prospectively modified, targeting high cost steps and outcomes were re-examined. Records were reviewed for elective MIRH before (pre-MIRH n = 50), after (post MIRH n = 25) intervention and ORH (n = 98), between January 1, 2008 and November 30, 2016. RESULTS: Average overall cost was significantly lower for post-standardization MIRH (post-MIRH $21 768, pre-MIRH $28 066, ORH $33 020; p < 0.001). Average intraoperative blood loss was reduced with MIRH (167, 292 and 509 mL p < 0.001). Operative times were shorter (147, 190 and 229 min p < 0.001) and LOS was reduced for MIRH (3, 4, 7 days p < 0.002). CONCLUSIONS: Using a common quality improvement tool, the authors established a model for cost effective clinical care. These tools allow surgeons to overcome personal or traditional biases such as stapler choices, but most importantly eliminate non-value added interventions for patients.

Frailty and one-year mortality in major intra-abdominal operations.

BACKGROUND: Frailty is an objective measurement capable of preoperatively identifying patients with increased risk of 30-d morbidity and mortality, though less is known about its utility beyond that timeframe. We hypothesized that preoperative frailty is associated with an increased risk of 1-y mortality in patients undergoing major intra-abdominal surgery. MATERIALS AND METHODS: Demographics, laboratory values, and traditional surgical risk assessments (American Society of Anesthesiologists scale, Eastern Cooperative Oncology Group Performance Status, Charlson Comorbidity Index) were collected prospectively. Preoperative frailty was evaluated using Fried criteria. Postoperative complications were defined by Clavien-Dindo Classification. One-year mortality data were gathered from phone calls, medical records, and the National Death Index. RESULTS: This study included 189 patients with a mean age of 62 years. Of the total, 59.8% were male and 71.4% were Caucasian. At enrollment, 139 (73.5%) patients were considered "not frail", whereas 50 (26.5%) were considered "intermediately frail" or "frail". A total of 73 (38.6%) patients experienced a 30-d postoperative complication. At 1 y, 15 (7.9%) patients had died, 5 (3.6%) not frail and 10 (20.0%) intermediately frail/frail patients. Postoperative mortality occurred <30 d, between 31-100 d, and >100 d in 3, 4, and 8 patients, respectively. Malignant neoplasm was documented as the underlying cause of death in 12 patients. All 30-d mortalities occurred in frail patients who had a postoperative complication. CONCLUSIONS: Frailty status is predictive of 1-y postoperative mortality. The Fried Frailty Criteria has the potential to more accurately evaluate surgical patients' mortality risk beyond the immediate postoperative period, particularly when considered collectively with traditional surgical risk assessment tools.

The Readmission Event after Vascular Surgery: Causes and Costs.

BACKGROUND: The study evaluates the readmission diagnoses after vascular surgical interventions and the associated hospital costs. METHODS: Patients readmitted after undergoing carotid artery stenting (CAS), carotid endarterectomy (CEA), infrarenal endovascular abdominal aortic aneurysm repair (EVAR), open abdominal aortic aneurysm repair (OAAA), suprainguinal revascularization (SUPRA), or infrainguinal revascularization (INFRA) between January 1, 2008 and October 20, 2013 at a single academic institution were retrospectively identified. Demographic, preoperative, and postoperative event variables were obtained by chart review. The diagnoses and the costs of the readmission event were obtained by chart review and from hospital financial data. Readmission indications were grouped as unrelated or planned readmissions, procedure-specific complications, wound complications, cardiac causes, and other. Univariate analyses of categorical variables were performed with χ2 or Fisher exact test where appropriate. Continuous variables were analyzed using the Wilcoxon rank-sum test. RESULTS: A total of 1,170 patient records were identified. Thirty-day readmission occurred in 112 patients (9.6%). The readmission rate was significantly different between groups: 4.5% in CAS (n = 8/177), 8.5% in CEA (21/246), 5.8% in EVAR (18/312), 11.4% in OAAA (4/35), 15.6% in INFRA (33/212), 13.5% in SUPRA (24/178), and 40% in combined SUPRA and INFRA (4/10) (P < 0.0001). Readmissions were unrelated or planned in 19.6% of patients. Wound complications were the most common readmission diagnoses (36.6%, 41/112).There was a difference in the distribution of readmission indications among procedure groups, with wound complications being predominant in INFRA and SUPRA groups (60.6% and 58.3%, respectively), and cardiac events predominantly in EVAR patients (42%) (P < 0.001). In univariable analysis of predictors of readmission, significant preoperative factors were chronic obstructive pulmonary disease, renal insufficiency, and lower hematocrit. Significant postoperative predictors included any postoperative complication, number of complications, increased length of stay, wound complications, postoperative infections, blood transfusion, and reoperation. The median hospital cost for readmission for wound complications was 29,723 USD (interquartile range 23,841-36,878), and for cardiac complications was 39,784 USD (26,305-46,918). The median cost of readmission for bypass graft occlusion was 33,366 USD (20,530-43,170). The median length of stay also differed depending on the readmission diagnosis and was highest for bypass graft occlusion (8.5 days). CONCLUSIONS: Readmissions after vascular procedures are associated with high cost and hospital bed utilization. Wound complications continue to be the dominant readmission etiology. The characterization of these costs and risk factors in this study can allow for resource allocation to minimize preventable related readmissions. A significant proportion of readmissions after vascular interventions are planned or unrelated, which should be taken into consideration in metric benchmarking and performance comparisons.

Higher Quality and Lower Cost from Improving Hospital Discharge Decision Making.

This paper reports research on improving decisions about hospital discharges - decisions that are now made by physicians based on mainly subjective evaluations of patients' discharge status. We report an experiment on uptake of our clinical decision support software (CDSS) which presents physicians with evidence-based discharge criteria that can be effectively utilized at the point of care where the discharge decision is made. One experimental treatment we report prompts physician attentiveness to the CDSS by replacing the default option of universal "opt in" to patient discharge with the alternative default option of "opt out" from the CDSS recommendations to discharge or not to discharge the patient on each day of hospital stay. We also report results from experimental treatments that implement the CDSS under varying conditions of time pressure on the subjects. The experiment was conducted using resident physicians and fourth-year medical students at a university medical school as subjects.

Incentivizing Cost-Effective Reductions in Hospital Readmission Rates.

The recent regulatory changes enacted by the Centers for Medicare and Medicaid Services (CMS) have identified hospital readmission rates as a critical healthcare quality metric. This research focuses on the utilization of pay-for-performance (P4P) mechanisms to cost effectively reduce hospital readmission rates and meet the regulatory standards set by CMS. Using the experimental economics laboratory we find that both of the P4P mechanisms researched, bonus and bundled payments, cost-effectively meet the performance criteria set forth by CMS. The bundled payment mechanism generates the largest reduction in patient length of stay (LOS) without altering the probability of readmission. Combined these results indicate that utilizing P4P mechanisms incentivizes cost effective reductions in hospital readmission rates.

The Association Between Hospital Finances and Complications After Complex Abdominal Surgery: Deficiencies in the Current Health Care Reimbursement System and Implications for the Future.

OBJECTIVE: To determine the relationship between complications after 3 common general surgery procedures and per-episode hospital finances. BACKGROUND: With impending changes in health care reimbursement, maximizing the value of care delivered is paramount. Data on the relative clinical and financial impact of postoperative complications are necessary for directing surgical quality improvement efforts. METHODS: We reviewed the medical records of patients enrolled in the American College of Surgeons' National Surgical Quality Improvement Program who underwent pancreaticoduodenectomy, hepatectomy, and colectomy at a single academic institution between September 2009 and August 2012. Clinical outcomes data were subsequently linked with hospital billing data to determine hospital finances associated with each episode. We describe the association between postoperative complications, hospital length of stay, and different financial metrics. Multivariable linear regression modeling tested linear association between postoperative outcomes and cost data. RESULTS: There was a positive association between the number of surgical complications, payments, length of stay, total charges, total costs, and contribution margin for the three procedures. Multivariable models indicated that complications were independently associated with total cost among the selected procedures. Payments increased with complications, offsetting increased costs. CONCLUSIONS: In the current fee-for-service environment, the financial incentives are misaligned with quality improvement efforts. As we move to a value-driven method of reimbursement, administrators and health care providers alike will need to focus on improving the quality of patient care while remaining conscious of the cost of care delivered. Reducing complications effectively improves value.

Predicting Length of Stay Following Radical Nephrectomy Using the National Surgical Quality Improvement Program Database.

PURPOSE: Length of stay is frequently used to measure the quality of health care, although its predictors are not well studied in urology. We created a predictive model of length of stay after nephrectomy, focusing on preoperative variables. MATERIALS AND METHODS: We used the NSQIP database to evaluate patients older than 18 years who underwent nephrectomy without concomitant procedures from 2007 to 2011. Preoperative factors analyzed for univariate significance in relation to actual length of stay were then included in a multivariable linear regression model. Backward elimination of nonsignificant variables resulted in a final model that was validated in an institutional external patient cohort. RESULTS: Of the 1,527 patients in the NSQIP database 864 were included in the training cohort after exclusions for concomitant procedures or lack of data. Median length of stay was 3 days in the training and validation sets. Univariate analysis revealed 27 significant variables. Backward selection left a final model including the variables age, laparoscopic vs open approach, and preoperative hematocrit and albumin. For every additional year in age, point decrease in hematocrit and point decrease in albumin the length of stay lengthened by a factor of 0.7%, 2.5% and 17.7%, respectively. If an open approach was performed, length of stay increased by 61%. The R(2) value was 0.256. The model was validated in a 427 patient external cohort, which yielded an R(2) value of 0.214. CONCLUSIONS: Age, preoperative hematocrit, preoperative albumin and approach have significant effects on length of stay for patients undergoing nephrectomy. Similar predictive models could prove useful in patient education as well as quality assessment.

Association between hospital finances, payer mix, and complications after hyperthermic intraperitoneal chemotherapy: deficiencies in the current healthcare reimbursement system and future implications.

BACKGROUND: Despite increasing implementation of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC), there are little data on its financial implications. We analyzed hospital cost and reimbursement data within the context of insurance provider type and postoperative complications. METHODS: Clinicopathologic variables, hospital costs, and reimbursement for all patients undergoing CRS/HIPEC at a single institution from 2009 to 2013 were analyzed. RESULTS: A total of 64 patients underwent CRS/HIPEC. Median PCI score was 19, and average operative time was 550 min. Tumor histology included appendiceal (n = 40; 62 %), colorectal (n = 16; 25 %), goblet cell (n = 5; 8 %), and mesothelioma (n = 3; 5 %). Median length-of-stay was 13 days. Complications occurred in 42 patients (66 %), including 13 (20 %) with major (Clavien grade III-IV) complications. Payer mix included 42 private insurance and 22 Medicare/Medicaid. Financial data was available for 56 patients: average total hospital cost was $49,248 and reimbursement was $63,771, for a hospital profit of $14,523/patient. Despite similar costs between Medicare/Medicaid and private-insurance patients, Medicare/Medicaid reimbursed much less ($30,713 vs $80,747; p < 0.001), resulting in a net loss of $17,342 per patient. For private-insured patients, major complications were associated with increased cost and increased reimbursement, resulting in a net profit of $36,285, compared with a net loss of $54,274 in Medicare/Medicaid patients. CONCLUSIONS: CRS/HIPEC is profitable in privately insured patients, even for those with major complications, but loses money in patients with Medicare/Medicaid. Under a future bundled-reimbursement system, complications will be negatively associated with profit. With these impending changes, hospitals must place emphasis on value, recalculate the reimbursement necessary for financial viability, and focus on decreasing costs and minimizing complications.

Medical students impact laparoscopic surgery case time.

BACKGROUND: Medical students (MS) are increasingly assuming active roles in the operating room. Laparoscopic cases offer unique opportunities for MS participation. The aim of this study was to examine associations between the presence of MS in laparoscopic cases and operation time and postoperative complication rates. MATERIALS AND METHODS: Data from the American College of Surgeons National Surgical Quality Improvement Program were linked to operative records for nonemergent, inpatient, and laparoscopic general surgery cases at our institution from January, 2009-January, 2013. Cases were grouped into eight distinct procedure categories. Hospital records provided information on the presence of MS. Demographics, comorbidities, intraoperative variables, and postoperative complication rates were analyzed. RESULTS: Seven hundred laparoscopic cases were included. Controlling for wound class, procedure group, and surgeon, MS were associated with an additional 28 min of total operative time. The most significant increase occurred between the skin incision and skin closure. No significant association between the presence of MS and postoperative complications was observed. CONCLUSIONS: This is the first retrospective analysis to examine the effect of MS presence during laparoscopic procedures. Increase in the operation time associated with the presence of MS should be examined further, to optimize the educational experience without incurring increased cost due to increased operation time.

Combining laparoscopic giant paraesophageal hernia repair with sleeve gastrectomy in obese patients.

BACKGROUND: Surgical treatment for giant paraesophageal hernias (PEH) in morbidly obese patients (BMI > 35) continues to be a difficult problem. Prior studies have demonstrated recurrence rates of up to 40% with higher rates in morbidly obese patients. Reports have shown success combining repair with a bariatric procedure to decrease recurrence rates while achieving weight loss. We report mid-term results from a larger series with combining laparoscopic giant PEH repair with sleeve gastrectomy (SG). METHODS: We reviewed all combined cases of PEH repairs with SG done at a single institution from 2008 to 2013. The surgical technique was standardized and absorbable bio-prosthetic buttress crural closure reinforcement was used selectively. Yearly upper gastrointestinal radiographic (UGI) studies and postoperative Gastroesophageal Reflux Disease Health-Related Quality of Life questionnaires were completed. 33 patients were enrolled; 18 patients (55%) completed the study RESULTS: No 30-day morbidity or mortality occurred. 16 patients were female; the average age was 55.3 ± 11.4 years (30-72) with follow-up from surgery of 19.9 ± 16.7 months (6-66). The average weight loss was 23.5 ± 12.7 kg (8-57); excess body weight loss was 46 ± 25.8% (18-112). Based on the UGIs, 9/18 (50%) had no evidence of hernia recurrence, while 6/18 (33%) demonstrated a small (<2 cm) recurrence. 3/18 (17%) patients had evidence of moderate recurrence (3-5 cm). Postoperative GERD-HRQL scores revealed an average score of 10 ± 7 (2-26). All patients reported being "satisfied" with their operation and weight loss and also had a significant improvement in foregut symptoms. No patient has required surgical revision and residual symptoms responded to conservative management. CONCLUSIONS: PEH in morbidly obese patients remain a complex surgical problem. Our case series shows that combination with SG may decrease recurrence rates but more importantly leads to lower rates of reoperation for symptomatic recurrence. Patients also garner the added medical benefits of weight loss.

Can we become better robot surgeons through simulator practice?

INTRODUCTION: There is significant growth in the use of the robotic surgery platform in the general surgery community. Current pre-requisites for robot surgery training include performing basic tasks on a simulator and achieving a minimum overall score for each task. However, there is limited information about these tasks related to performance and time required to become proficient. We focused on critical tasks that have the highest potential for preventing inadvertent injuries, and constructed models to predict how many attempts would be needed to master the tasks depending on the user's initial attempt. METHODS AND PROCEDURES: This study was conducted using de-identified data collected over 12 months from the dV-Trainers® simulator at our institution. We analyzed tasks used in institutional surgical robot credentialing that focused on camera manipulation and energy use. Data were extracted from the Camera Targeting, Energy Dissection, and Energy Switching exercises focusing on individual metrics such as Time to Complete Exercise, Economy of Motion, Misapplied Energy Time, and Blood Volume Loss. Mixed linear models looking at sequential attempts and specific performance metrics were constructed using IBM SPSS Statistics version 20. RESULTS: Over 26,000 overall minutes of recorded use was logged in our simulator by more than 30 unique users across all exercises. An average of 15 users performed each of the analyzed exercises, with an average of eight attempts per exercise. Based on our models, on average most users would need four to five attempts to achieve 80 % proficiency for any given metric. CONCLUSION: Virtual reality robotic simulators such as the dv-Trainer® can be used by general surgeons to become better robotic surgeons. Our data suggests that it can be used by a surgeon to predict how much time and effort one would need to spend on the simulator in order to become proficient with the robot, especially in critical metrics such as camera manipulation and energy application. Surgeons who require more attempts to successfully complete tasks may want to consider additional training methods, such as proctoring or hands-on laboratories, to improve robot surgery proficiency.

Postoperative complications in bariatric surgery using age and BMI stratification: a study using ACS-NSQIP data.

BACKGROUND: Bariatric surgery results in long-term weight loss and significant morbidity reduction. Morbidity and mortality following bariatric surgery remain low and acceptable. This study looks to define the trend of morbidity and mortality as it relates to increasing age and body mass index (BMI) in patients undergoing bariatric surgery. METHODS: We queried the ACS/NSQIP 2010-2011 Public Use File for patients who underwent elective laparoscopic adjustable banding (LAGB), sleeve gastrectomy (LSG) and gastric bypass (LGBP). Total morbidity and 30-day mortality were evaluated. Logistic regression models were created to estimate the effect of increasing age and BMI on morbidity for these bariatric procedures. RESULTS: A total of 20,308 laparoscopic bariatric procedures were reviewed (11617 LGBP, 3069 LSG and 5622 LAGB). Overall mortality and morbidity rates were 0.11 and 3.84%, respectively. The odds of postoperative complications increased by 2% with each additional year of age (OR 1.02, 95% CI 1.02-1.03) and every point increase in BMI (OR 1.02, 95% CI 1.01-1.03). Multiple logistic regression identified COPD, Diabetes, Hypertension, and Dyspnea as major risk factors for postoperative morbidity. Postoperative complications were three times more likely after LGBP (OR 2.87, 95% CI 2.31-3.57) and two times more likely after LSG (OR 2.06, 95% CI 1.57-2.72) when compared to patients undergoing LAGB. CONCLUSION: Morbidity and mortality increase on a predictable trend with increasing age and BMI. There is increased risk of morbidity for stapling procedures when compared to gastric banding, but this must be considered in context of surgical efficacy when choosing a bariatric procedure. These data can be used in preoperative counseling and evaluation of surgical candidacy of bariatric surgical patients.

Neurocognitive, psychological and behavioral correlates of binge drinking and use of alcohol with caffeinated beverages in college-aged adults.

BACKGROUND: We examined event-related potential (ERP), behavioral and psychological correlates of binge drinking and the use of alcohol mixed with caffeinated beverages (AmCBs) in college-aged (18-26 years) adults. OBJECTIVE: Our objective was to delineate the neurocognitive correlates of different patterns of risky alcohol use in this population. METHODS: We collected ERP data while an initial sample of 60 participants completed visual oddball and go/no-go tasks. We also collected self-report data measuring levels of sensation seeking, impulsivity, and drinking-induced disinhibition. In our primary analyses between binge drinker (N = 17) and comparison participants (N = 29), we used analysis of covariance (ANCOVA) to control for monthly marijuana usage and excluded participants who reported using other illicit drugs. As separate, exploratory analyses, we compared participants who reported using AmCBs (n = 14) and those who did not (n = 46), co-varying for monthly marijuana and recreational drug use. RESULTS: We found that binge drinkers and AmCB users reported significantly higher levels of sensation seeking and drinking-induced disinhibition. In addition, we found that binge drinkers exhibited greater P3a/b amplitudes in the oddball task. In contrast, AmCB users exhibited significantly attenuated P3a amplitudes to distracter stimuli in the oddball task. However, we found no statistically significant differences in the amplitudes of P2(00) or N2(00) components between binge drinkers and comparison participants or between AmCB users and nonusers. CONCLUSIONS: Overall, these data suggest that binge drinking and AmCB use are associated with P3 alterations, but the specific effects may differ for individuals with different patterns of risky alcohol use.

Cost comparison analysis of open versus laparoscopic distal pancreatectomy.

BACKGROUND: In comparison with open distal pancreatectomy (ODP), laparoscopic distal pancreatectomy (LDP) is associated with fewer complications and shorter hospital stays, but comparative cost data for the two approaches are limited. METHODS: Records of all distal pancreatectomies carried out from January 2009 to June 2013 were reviewed and stratified according to operative complexity. Patient factors and outcomes were recorded. Total variable costs (TVCs) were tabulated for each patient, and stratified by category [e.g. 'floor', 'operating room' (OR), 'radiology']. Costs for index admissions and 30-day readmissions were compared between LDP and ODP groups. RESULTS: Of 153 procedures, 115 (70 LDP, 45 ODP) were selected for analysis. The TVC of the index admission was US$3420 less per patient in the LDP group (US$10 480 versus US$13 900; P = 0.06). Although OR costs were significantly greater in the LDP cohort (US$5756 versus US$4900; P = 0.02), the shorter average hospitalization in the LDP group (5.2 days versus 7.7 days; P = 0.01) resulted in a lower overall cost. The total cost of index hospitalization combined with readmission was significantly lower in the LDP cohort (US$11 106 versus US$14 803; P = 0.05). CONCLUSIONS: In appropriately selected patients, LDP is more cost-effective than ODP. The increased OR cost associated with LDP is offset by the shorter hospitalization. These data clarify targets for further cost reductions.