Continuous Wound Irrigation and Intraoperative Methadone Decreases Opioid Use and Shortens Length of Stay After CRS/HIPEC.

BACKGROUND: Epidural analgesia is resource and labor intense and may limit postoperative management options and delay discharge. This study compared postoperative outcomes after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) with epidural analgesia versus continuous wound infusion system (CWIS) with/without intraoperative methadone. METHODS: A single-institution, retrospective chart review was performed including all patients undergoing open CRS/HIPEC from 2018 to 2021. Patient demographics, surgical characteristics, length of stay, and in-hospital analgesic use were reviewed. In-hospital opioid exposure in morphine milligram equivalents (MME) was calculated. Multivariate analysis (MVA) for mean total and daily opioid exposure was conducted. RESULTS: A total of 157 patients were included. Fifty-three (34%) had epidural analgesia, 96 (61%) had CWIS, and 79 (50%) received methadone. Length of stay was significantly shorter with CWIS + methadone versus epidural (7 vs. 8 days, p < 0.01). MVA showed significantly lower mean total and daily opioid exposure with CWIS+methadone versus epidural (total: 252.8 ± 17.7 MME vs. 486.8 ± 86.6 MME; odds ratio [OR] 0.72, 95% confidence interval [CI] 0.52-0.98, p = 0.04; Daily: 32.8 ± 2.0 MME vs. 51.9 ± 5.7 MME, OR 0.72, 95% CI 0.52-0.99, p ≤ 0.05). The CWIS-only group (n = 17) had a significantly lower median oral opioid exposure versus epidural (135 MME vs. 7.5 MME, p < 0.001) and longer length of stay versus CWIS + methadone (9 vs. 7 days, p = 0.04), There were no CWIS or methadone-associated complications and one epidural abscess. CONCLUSIONS: CWIS + methadone safely offers better pain control with less in-hospital opioid use, shorter length of stay, and decreased resource utilization compared with epidural analgesia in patients undergoing CRS-HIPEC.

The Influence of Rural Healthcare Systems and Communities on Surgery and Recovery: A Qualitative Study.

INTRODUCTION: Successful recovery after surgery is complex and highly individual. Rural patients encounter greater barriers to successful surgical recovery than urban patients due to varying healthcare and community factors. Although studies have previously examined the recovery process, rural patients' experiences with recovery have not been well-studied. The rural socioecological context can provide insights into potential barriers or facilitators to rural patient recovery after surgery. METHODS: We conducted semi-structured qualitative interviews with a purposeful sample of 30 adult general surgery patients from rural areas in the Mountain West region of the United States. We used the socioecological framework to analyze their responses. Interviews focused on rural participants' experiences accessing healthcare and the impact of family and community support during postoperative recovery. Interviews were transcribed verbatim and coded using content and thematic analysis. RESULTS: All participants commented on the quality of their rural healthcare systems and its influence on postoperative care. Some enjoyed the trust developed through long-standing relationships with providers in their communities. However, participants described community providers' lack of money, equipment, and/or knowledge as barriers to care. Following surgery, participants recognized that there are advantages and disadvantages to receiving family and community support. Some participants worried about being stigmatized or judged by their community. CONCLUSIONS: Future interventions aimed at improving access to and recovery from surgery for rural patients should take into account the unique perspectives of rural patients. Addressing the socioecological factors surrounding rural surgery patients, such as healthcare, family, and community resources, will be key to improving postoperative recovery.

Implications of Tumor Characteristics and Treatment Modality on Local Recurrence and Functional Outcomes in Children With Chest Wall Sarcoma: A Pediatric Surgical Oncology Research Collaborative Study.

OBJECTIVE: To determine the impact of tumor characteristics and treatment approach on (1) local recurrence, (2) scoliosis development, and (3) patient-reported quality of life in children with sarcoma of the chest wall. SUMMARY OF BACKGROUND DATA: Children with chest wall sarcoma require multimodal therapy including chemotherapy, surgery, and/or radiation. Despite aggressive therapy which places them at risk for functional impairment and scoliosis, these patients are also at significant risk for local recurrence. METHODS: A multi-institutional review of 175 children (median age 13 years) with chest wall sarcoma treated at seventeen Pediatric Surgical Oncology Research Collaborative institutions between 2008 and 2017 was performed. Patient-reported quality of life was assessed prospectively using PROMIS surveys. RESULTS: The most common diagnoses were Ewing sarcoma (67%) and osteosarcoma (9%). Surgical resection was performed in 85% and radiation in 55%. A median of 2 ribs were resected (interquartile range = 1-3), and number of ribs resected did not correlate with margin status ( P = 0.36). Local recurrence occurred in 23% and margin status was the only predictive factor(HR 2.24, P = 0.039). With a median follow-up of 5 years, 13% developed scoliosis (median Cobb angle 26) and 5% required corrective spine surgery. Scoliosis was associated with posteriorrib resection (HR 8.43; P= 0.003) and increased number of ribs resected (HR 1.78; P = 0.02). Overall, patient-reported quality of life is not impaired after chest wall tumor resection. CONCLUSIONS: Local recurrence occurs in one-quarter of children with chest wall sarcoma and is independent of tumor type. Scoliosis occurs in 13% of patients, but patient-reported quality of life is excellent.

Patient-centered Opioid Prescribing: Breaking Away From One-Size-Fits-All Prescribing Guidelines.

BACKGROUND: Procedure-based opioid-prescribing guidelines have reduced the amount of opioids prescribed after surgery; however, many patients are still overprescribed opioids. The 24-h predischarge opioid consumption (PDOC) metric has been proposed to guide patient-centered prescribing. MATERIALS AND METHODS: This is a single-institution, retrospective study of patients who underwent major abdominal surgery. We assessed the correlation between inpatient opioid use and discharge prescriptions using morphine milligram equivalents (MMEs). The adequacy of discharge prescriptions for individual patients was assessed using 2 models, one assuming constant opioid use (based on 24-h PDOC) and the other assuming a linear taper. RESULTS: Of 596 included patients, gastric bypass and colectomy were the most common operations. Median length of stay was 3.5 d. Inpatient opioid use and discharge prescriptions were weakly correlated (r = 0.35). Patients with no opioid use 24 h before discharge (n = 133, 22.3%) were frequently discharged with opioid prescriptions. Patients with high opioid use (24-h PDOC >60 MME) were often discharged with prescriptions that would have lasted <48 h (164/200, 82%). Assuming constant opioid use, discharge prescriptions would have lasted patients a median of 5.1 d. With linear opioid tapering, 440 (72.9%) patients would have had leftover pills. A theoretical discharge prescription of 4 times 24-h PDOC would reduce the median prescription by 130 MMEs and allow a linear taper for 97.6% of patients. CONCLUSIONS: At our institution, opioid prescribing was rarely patient-centered, with little correlation between patient's inpatient opioid use and discharge prescriptions. This leads to overprescribing for most patients and underprescribing for others.

Drivers of Moral Distress in Surgical Intensive Care Providers: A Mixed Methods Study.

BACKGROUND: Moral distress is common among healthcare providers, leading to staff burnout and attrition. This study aimed to identify root causes of and potential solutions to moral distress experienced by surgical intensive care unit (SICU) providers. MATERIALS AND METHODS: This is a mixed methods study of physicians and nurses from a single, academic SICU. We obtained quantitative data from the Measures of Moral Distress for Healthcare Professionals (MMD-HP) survey and qualitative data from semi-structured interviews. The MMD-HP is a 27 question, validated survey on triggers of moral distress. Survey and interview data were analyzed to identify drivers of moral distress using a convergent design. RESULTS: 21 nurses and 25 physicians were surveyed and 17 providers interviewed. MMD-HP data demonstrated high levels of moral distress for nurses (mean total MMD-HP 132 ± 63.5) and physicians (121.7 ± 64.7), P = 0.68. The most frequent root cause of moral distress for all providers was participating in the delivery of aggressive care perceived to be futile. Nurses also reported caring for patients with unclear goals of care as a key driver of moral distress. Interview data supported these findings. Providers recommended improving access to palliative care to increase early communication on patient goals of care and end-of-life as a solution. Culture in the SICU often promotes supporting aggressive care however, acting as a potential barrier to increasing palliative resources. CONCLUSIONS: Providing aggressive care that is perceived as futile was the primary driver of moral distress in the SICU. Interventions to improve early communication and access to end-of-life care should be prioritized to decrease moral distress in staff.

Recurrence patterns in patients with Stage II melanoma: The evolving role of routine imaging for surveillance.

BACKGROUND AND OBJECTIVES: The relatively recent availability of effective systemic therapies for metastatic melanoma necessitates reconsideration of current surveillance patterns. Evidence supporting surveillance guidelines for resected Stage II melanoma is lacking. Prior reports note routine imaging detects only 21% of recurrent disease. This study aims to define recurrence patterns for Stage II melanoma to inform future surveillance guidelines. METHODS: This is a retrospective study of patients with Stage II melanoma. We analyzed risk factors for recurrence and methods of recurrence detection. We also assessed survival. Yearly hazards of recurrence were visualized. RESULTS: With a median follow-up of 4.9 years, 158 per 580 patients (27.2%) recurred. Overall, most recurrences were patient-detected (60.7%) or imaging-detected (27.3%). Routine imaging was important in detecting recurrence in patients with distant recurrences (adjusted rate 43.1% vs. 9.4% for local/in-transit; p = .04) and with Stage IIC melanoma (42.5% vs. 18.5% for IIA; p = .01). Male patients also self-detected recurrent disease less than females (52.1% vs. 76.8%; p < .01). CONCLUSIONS: Routine imaging surveillance played a larger role in detecting recurrent disease for select groups in this cohort than noted in prior studies. In an era of effective systemic therapy, routine imaging should be considered for detection of asymptomatic relapse for select, high-risk patient groups.

Prioritizing Surgical Care on National Health Agendas: A Qualitative Case Study of Papua New Guinea, Uganda, and Sierra Leone.

BACKGROUND: Little is known about the social and political factors that influence priority setting for different health services in low- and middle-income countries (LMICs), yet these factors are integral to understanding how national health agendas are established. We investigated factors that facilitate or prevent surgical care from being prioritized in LMICs. METHODS AND FINDINGS: We undertook country case studies in Papua New Guinea, Uganda, and Sierra Leone, using a qualitative process-tracing method. We conducted 74 semi-structured interviews with stakeholders involved in health agenda setting and surgical care in these countries. Interviews were triangulated with published academic literature, country reports, national health plans, and policies. Data were analyzed using a conceptual framework based on four components (actor power, ideas, political contexts, issue characteristics) to assess national factors influencing priority for surgery. Political priority for surgical care in the three countries varies. Priority was highest in Papua New Guinea, where surgical care is firmly embedded within national health plans and receives significant domestic and international resources, and much lower in Uganda and Sierra Leone. Factors influencing whether surgical care was prioritized were the degree of sustained and effective domestic advocacy by the local surgical community, the national political and economic environment in which health policy setting occurs, and the influence of international actors, particularly donors, on national agenda setting. The results from Papua New Guinea show that a strong surgical community can generate priority from the ground up, even where other factors are unfavorable. CONCLUSIONS: National health agenda setting is a complex social and political process. To embed surgical care within national health policy, sustained advocacy efforts, effective framing of the problem and solutions, and country-specific data are required. Political, technical, and financial support from regional and international partners is also important.

Generation of national political priority for surgery: a qualitative case study of three low-income and middle-income countries.

BACKGROUND: Surgical conditions exert a major health burden in low-income and middle-income countries (LMICs), yet surgery remains a low priority on national health agendas. Little is known about the national factors that influence whether surgery is prioritised in LMICs. We investigated factors that could facilitate or prevent surgery from being a health priority in three LMICs. METHODS: We undertook three country case studies in Papua New Guinea, Uganda, and Sierra Leone, using a qualitative process-tracing method. In total 72 semi-structured interviews were conducted between March and June, 2014, in the three countries. Interviews were designed to query informants' attitudes, values, and beliefs about how and why different health issues, including surgical care, were prioritised within their country. Informants were providers, policy makers, civil society, funders, and other stakeholders involved with health agenda setting and surgical care. Interviews were analysed with Dedoose, a qualitative data analysis tool. Themes were organised into a conceptual framework adapted from Shiffman and Smith to assess the factors that affected whether surgery was prioritised. FINDINGS: In all three countries, effective political and surgical leadership, access to country-specific surgical disease indicators, and higher domestic health expenditures are facilitating factors that promote surgical care on national health agendas. Competing health and policy interests and poor framing of the need for surgery prevent the issue from receiving more attention. In Papua New Guinea, surgical care is a moderate-to-high health priority. Surgical care is embedded in the national health plan and there are influential leaders with surgical interests. Surgical care is a low-to-moderate health priority in Uganda. Ineffectively used policy windows and little national data on surgical disease have impeded efforts to increase priority for surgery. Surgical care remains a low health priority in Sierra Leone. Resource constraints and competing health priorities, such as infectious disease challenges, prevent surgery from receiving attention. INTERPRETATION: Priority for surgery on national health agendas varies across LMICs. Increasing dialogue between surgical providers and political leaders can increase the power of actors who advocate for surgical care. Greater emphasis on the importance of surgical care in achieving national health goals can strengthen internal and external framing of the issue. Growing political recognition of non-communicable diseases provides a favourable political context to increase attention for surgery. Lastly, increasing internally generated issue characteristics, such as improved tracking of national surgical indicators, could increase the priority given to surgery within LMICs. FUNDING: The Bill & Melinda Gates Foundation, King's Health Partners/King's College London, and Lund University.

Improving pain management and safe opioid use after surgery: A DMAIC-based quality intervention.

Background: Multimodal perioperative patient education and expectation-setting can reduce post-operative opioid use while maintaining pain control and satisfaction. As part of a quality-improvement project, we developed a standardized model for perioperative education built upon the American College of Surgeons (ACS) Safe and Effective Pain Control After Surgery (SEPCAS) brochure to improve perioperative education regarding opioid use and pain control. Material and methods: Our study was designed within the Define, Measure, Analyze, Improve, Control (DMAIC) quality-improvement framework. Patients were surveyed about the adequacy of their perioperative education regarding pain control and use of prescription opioid medication. After gathering baseline data, a multimodal educational intervention based on the SEPCAS brochure was implemented. Survey responses were then compared between groups. Results: Twenty-seven subjects were included from the pre-intervention period, and thirty-nine were included from the post-intervention period (n = 66). Those in the post-intervention period were more likely to report receiving the appropriate amount of education regarding recognizing the signs of opioid overdose and how to safely store and dispose of opioid medications. The majority of patients who received the SEPCAS brochure reported that it was useful in their post-operative recovery and that it should be given to every patient undergoing surgery. Conclusions: The ACS SEPCAS brochure is an effective tool for improving patient preparation to safely store and dispose of their opioid medication and recognize the signs of opioid overdose. The brochure was also well received by patients and perceived as an effective educational material.

Naloxone co-prescriptions for surgery patients prescribed opioids: A retrospective cohort study.

Background: Surgeon-prescribed opioids contribute to 11% of prescription drug overdoses in the United States (US). With prescription opioids involved in 24% of all opioid-related overdose deaths in 2020, the US Centers for Disease Control and Prevention (CDC) recommends naloxone co-prescribing to patients at high-risk of overdose and death as a harm reduction strategy. We sought to 1) examine naloxone co-prescribing rates to surgical patients (using common post-surgical prescribing amounts) and those with potential risk factors for opioid-related overdoses or adverse events, and 2) identify the factors associated with patients receiving naloxone co-prescriptions. Methods: We conducted a single-institution, retrospective study using the electronic medical records of all patients undergoing surgery at an academic institution between August 2020 and May 2021. We included post-surgical adults prescribed opioids that were sent to a pharmacy in our health system. The primary outcome was the percentage of co-prescribed naloxone in patients prescribed opioids. Results: The overall naloxone co-prescription rate was low (1.7%). Only 14.6% of patients prescribed ≥350 morphine milligram equivalents (MME, equivalent to 46.7 oxycodone 5 mg tablets) and 8.6% of patients using illicit drugs were co-prescribed naloxone. On multivariable analysis, patients who were prescribed >350 MME, used illicit drugs or tobacco, underwent an elective or emergent general surgery procedure, self-identified as Hispanic, or had ASA scores of 2-4 were more likely to receive a naloxone co-prescription. Conclusions: Naloxone co-prescribing after surgery remains low, even for high-risk patients. Harm reduction strategies such as naloxone, safe storage, and disposal of leftover opioids could reduce surgeons' iatrogenic contributions to the worsening US opioid crisis.

Promoting Disposal of Left-Over Opioids After Surgery in Rural Communities: A Qualitative Description Study.

BACKGROUND: Patients rarely dispose of left-over opioids after surgery. Disposal serves as a primary prevention against misuse, overdose, and diversion. However, current interventions promoting disposal have mixed efficacy. Increasing disposal in rural communities could prevent or reduce the harms caused by prescription opioids. AIMS: Identify barriers and facilitators to disposal in the rural communities of the United States Mountain West region. METHODS: We conducted a qualitative description study with 30 participants from Arizona, Idaho, Montana, Nevada, Oregon, Utah, and Wyoming. We used a phronetic iterative approach combining inductive content and thematic analysis with deductive interpretation through the Precaution Adoption Process Model (PAPM). RESULTS: We identified four broad themes: (a) awareness, engagement, and education; (b) low perceived risk associated with nondisposal; (c) deciding to keep left-over opioids for future use; and (d) converting decisions into action. Most participants were aware of the importance of disposal but perceived the risks of nondisposal as low. Participants kept opioids for future use due to uncertainty about their recovery and future treatments, breakdowns in the patient-provider relationship, chronic illness or pain, or potential future injury. The rural context, particularly convenience, cost, and environmental contamination, contributes to decisional burden. CONCLUSIONS: We identified PAPM stage-specific barriers to disposal of left-over opioids. Future interventions should account for where patients are along the spectrum of deciding to dispose or not dispose as well as promoting harm-reduction strategies for those who choose not to dispose.

Surgical Trainee Perspectives on the Opioid Crisis: The Influence of Explicit and Hidden Curricula.

OBJECTIVE: In order to effectively create and implement an educational program to improve opioid prescribing practices, it is important to first consider the unique perspectives of residents on the frontlines of the opioid epidemic. We sought to better understand resident perspectives on opioid prescribing, current practices in pain management, and opioid education as a needs assessment for designing future educational interventions. DESIGN: This is a qualitative study using focus groups of surgical residents at 4 different institutions. SETTING: We conducted focus groups using a semistructured interview guide in person or over video conferencing. The residency programs selected for participation represent a broad geographic range and varying residency sizes. PARTICIPANTS: We used purposeful sampling to recruit general surgery residents from the University of Utah, University of Wisconsin, Dartmouth-Hitchcock Medical Center, and the University of Alabama at Birmingham. All general surgery residents at these locations were eligible for inclusion. Participants were assigned to focus groups by residency site and their status as junior (PGY-2, PGY-3) or senior resident (PGY-4, PGY-5). RESULTS: We completed 8 focus groups with a total of 35 residents included. We identified 4 main themes. First, residents relied on clinical and nonclinical factors when making decisions about opioid prescribing. However, hidden curricula based on unique institutional cultures and attending preferences heavily influenced residents' prescribing practices. Second, residents acknowledged that stigma and biases towards certain patient groups influenced opioid prescribing practices. Third, residents encountered barriers within their health systems to evidence-based opioid prescribing. Fourth, residents did not routinely receive formal education on pain management or opioid prescribing. Residents recommended several interventions to improve the current state of opioid prescribing, including standardized prescribing guidelines, improved patient education, and formal training during the first year of residency. CONCLUSIONS: Our study highlighted several areas of opioid prescribing that can be improved upon through educational interventions. These findings can be used to develop programs aimed at improving residents' opioid prescribing practices, both during and after training, and ultimately the safe care of surgical patients. ETHICS STATEMENT: This project was approved by the University of Utah Institutional Review Board, ID # 00118491. All participants provided written informed consent.

Evaluating a health system-wide opioid disposal intervention distributing home-disposal bags.

OBJECTIVE: To evaluate a health system-wide intervention distributing free home-disposal bags to surgery patients prescribed opioids. DATA SOURCES AND STUDY SETTING: We collected patient surveys and electronic medical record data at an academic health system. STUDY DESIGN: We conducted a prospective observational study. The bags were primarily distributed at pharmacies, though pharmacists delivered bags to some patients. The primary outcome was disposal of leftover opioids (effectiveness). Secondary outcomes were patient willingness to dispose and factors associated with disposal (effectiveness), recalling receipt of the bag (reach), and recalling receipt of bags and disposal over time (maintenance). We used a modified Poisson regression to evaluate the relative risk of disposal. Inverse probability of treatment weighting, based on propensity scores, was used to account for differences between survey responders and non-responders and reduce nonresponse bias. DATA COLLECTION/EXTRACTION METHODS: From August 2020 to May 2021, we surveyed patients 2 weeks after discharge (allowing for home opioid use). Eligibility criteria were age ≥18, English being primary language, valid email address, hospitalization ≤30 days, discharge home, and an opioid prescription sent to a system pharmacy. PRINCIPAL FINDINGS: We identified 5134 patients with 2174 completing the survey (response rate 42.3%). Among respondents, 1375 (63.8%) recalled receiving the disposal bag. Among 1075 respondents with leftover opioids, 284 (26.4%) disposed, 552 (51.3%) planned to dispose, 79 (7.4%) did not plan to dispose, 69 (6.4%) had undecided, and 91 (8.5%) had not considered disposal. Recalling receipt of the bag (incidence rate ratio [IRR] 1.25, 95% confidence interval [CI] 1.13-1.37) was positively associated with disposal. Patients who used opioids in the last year were less likely to dispose (IRR 0.82, 95% CI 0.73-0.93). Disposal rates remained stable over the study period while recalling receipt of bags trended up. CONCLUSIONS: A pragmatic implementation of a disposal intervention resulted in lower disposal rates than prior trials.

Multianalyte Serum Biomarker Panel for Early Detection of Pancreatic Adenocarcinoma.

PURPOSE: We determined whether a large, multianalyte panel of circulating biomarkers can improve detection of early-stage pancreatic ductal adenocarcinoma (PDAC). MATERIALS AND METHODS: We defined a biologically relevant subspace of blood analytes on the basis of previous identification in premalignant lesions or early-stage PDAC and evaluated each in pilot studies. The 31 analytes that met minimum diagnostic accuracy were measured in serum of 837 subjects (461 healthy, 194 benign pancreatic disease, and 182 early-stage PDAC). We used machine learning to develop classification algorithms using the relationship between subjects on the basis of their changes across the predictors. Model performance was subsequently evaluated in an independent validation data set from 186 additional subjects. RESULTS: A classification model was trained on 669 subjects (358 healthy, 159 benign, and 152 early-stage PDAC). Model evaluation on a hold-out test set of 168 subjects (103 healthy, 35 benign, and 30 early-stage PDAC) yielded an area under the receiver operating characteristic curve (AUC) of 0.920 for classification of PDAC from non-PDAC (benign and healthy controls) and an AUC of 0.944 for PDAC versus healthy controls. The algorithm was then validated in 146 subsequent cases presenting with pancreatic disease (73 benign pancreatic disease and 73 early- and late-stage PDAC cases) and 40 healthy control subjects. The validation set yielded an AUC of 0.919 for classification of PDAC from non-PDAC and an AUC of 0.925 for PDAC versus healthy controls. CONCLUSION: Individually weak serum biomarkers can be combined into a strong classification algorithm to develop a blood test to identify patients who may benefit from further testing.

American Indian/Alaska native access to colorectal cancer screening: Does gastroenterologist density matter?

BACKGROUND: American Indians/Alaska Natives (AI/AN) receive less colorectal cancer (CRC) screening than other populations. Using gastroenterologist (GI) locations as a measure of colonoscopy access, we correlate GI density and AI/AN CRC screening rates. METHODS: We identified GIs from the 2016 National Provider Identifier registry, and calculated GI density per 100,000 people. We identified screening, demographic, and socioeconomic variables from the 2016 Behavioral Risk Factor Surveillance System Survey. GI density and CRC screening rates were analyzed with Multivariable Poisson regression. RESULTS: In states with GI Density greater than 3.98/100,000, odds of AI/AN CRC screening are 1.27-1.37 times higher than in states below this threshold (p < 0.036). CONCLUSIONS: GI density has a limited association on CRC screening, with decrease impact beyond threshold of 3.98 GI/100,000. Minimal access to GIs is important in improving AI/AN CRC screening; however, further research is required to elucidate the most critical factors contributing to CRC screening.

Patient Perceptions of Decision-making and Quality-of-life Following Surgical Resection of Pancreatic Adenocarcinoma: A Mixed-methods Study.

Pancreatic adenocarcinoma (PDAC) remains a highly lethal disease, with surgery, the only opportunity for cure, accompanied by high rates of morbidity. Understanding patients' lived experiences after surgical resection of PDAC is critical to knowing whether the decision to undergo surgery was worth it for these patients. Methods: We performed a convergent, mixed-methods study with patients who underwent resection of PDAC between January 1, 2019, and January 8, 2020. Quantitative data (medical record review and 3 questionnaires) were analyzed using descriptive statistics. Qualitative data (semistructured interviews) were analyzed using the constant comparative method. Data were then compared for congruence. Results: Eighteen of 22 eligible participants completed interviews and 11 completed questionnaires. Data collection occurred at a median of 14.2 months (IQR 11.6-16.3) from surgery. We identified 4 main themes. First, persistent negative symptoms were common for patients, but patients adapt to these and are satisfied with their "new normal." Second, patients have varied and continually evolving mindsets throughout their cancer journey. Third, despite decreased quality-of-life, patients have a high degree of satisfaction with their decision to pursue surgery. Finally, patients were okay with a passive role in decision-making around surgery. Despite variable involvement in decision-making and outcomes, no participants reported regret over the decision to pursue surgery. Discussion: This nuanced account of patients' lived experiences following surgery for PDAC allows for an improved understanding of the impact of pancreatic resection on patients. Surgeons can use these data to improve preoperative counseling for patients with PDAC and help guide them to making the correct decisions about surgery.

Postoperative opioid prescribing, use and pain trends following general surgery procedures: a retrospective cohort study among veterans comparing non-opioid versus chronic opioid users.

INTRODUCTION: Understanding postoperative opioid use patterns among different populations is key to developing opioid stewardship programs. METHODS: We performed a retrospective cohort study on opioid prescribing, use, and pain after general surgery procedures for patients cared for by a transitional pain service at a veterans administration hospital. Discharge opioid prescription quantity, 90-day opioid prescription, and patient reported outcome pain measures were compared between chronic opioid users and non-opioid users (NOU). Additionally, 90-day total opioid use was evaluated for NOU. RESULTS: Of 257 patients, 34 (13%) were on chronic opioid therapy, over 50% had a mental health disorder, and 29% had a history and/or presence of a substance use disorder. NOU were prescribed a median (IQR) of 10 (7, 12) tablets at discharge, while chronic opioid users were prescribed 6 (0, 12) tablets (p<0.001). 90-day opioid prescription (not including baseline opioid prescription for chronic users) was 10 (7, 15) and 6 (0, 12) tablets, respectively (p=0.001). There were no differences in changes in pain intensity or pain interference scores during recovery between groups. Median 90-day opioid use post discharge for NOU was 4 (0, 10) pills. DISCUSSION: Non-opioid and chronic opioid users required very few opioid pills following surgery, and patients on chronic opioid therapy quickly returned to their baseline opioid use after a small opioid prescription at discharge. There was no difference in pain recovery between groups. Opioid prescribing guidelines should include patients on chronic opioid therapy and could consider recommending a more conservative prescribing approach.

Preoperative Advance Care Planning for Older Adults Undergoing Major Abdominal Surgery.

BACKGROUND: Advance care planning (ACP) is recommended for older patients undergoing surgery. ACP consists of creating advance directives (ADs), identifying surrogate decision makers (SDMs), and documenting goals of care. We identified factors associated with documentation of preoperative ACP to identify opportunities to optimize ACP for older surgical patients. METHODS: This was a retrospective study of surgical patients ≥70 years old who underwent elective, high-risk abdominal procedures between 01/2015-08/2019. Clinical data were obtained from our institution's National Surgical Quality Improvement Project database. ACP metrics were extracted from the electronic medical record. We analyzed the data to identify patient factors associated with ACP metrics. We also analyzed whether ACP was more frequent for patients who experienced postoperative complications or death. RESULTS: 267/1,651 patients were included. 97 patients (36%) had an AD available on the day of surgery, 57 (21%) had an SDM identified, and 31 (12%) had a documented goals of care conversation. On multivariable analysis, older age and white race were associated with an increased likelihood of having an AD available on the day of surgery. Women were 1.7 times more likely to have an SDM (p = 0.02). No patient or surgeon factors were significantly associated with goals of care documentation. ACP was not performed more frequently in patients who experienced postoperative complications or death. CONCLUSION: In this series, ACP was not routinely documented for older patients undergoing major surgery. ACP was not more frequent in patients who experienced complications or death, demonstrating the importance of universal preoperative ACP in older patients.

Who doesn't fit? A multi-institutional study using machine learning to uncover the limits of opioid prescribing guidelines.

BACKGROUND: Many U.S. institutions have adopted postsurgical opioid-prescribing guidelines to standardize prescribing practices, and yet there is inherent variability in patients' opioid consumption after surgery. The utility of these guidelines is limited by the fact that some patients' needs will inevitably exceed them, and yet there are no evidence-based tools to help providers identify these patients. In this study we aimed to maximize the value of these guidelines by training machine learning models to predict patients whose needs will be met by these smaller recommended prescriptions, and patients who may require an additional degree of personalization. The aim of the present study was to develop predictive models for determining whether a surgical patient's postdischarge opioid requirement will fall above or below common opioid prescribing guidelines. METHODS: We conducted a retrospective cohort study of surgical patients at one institution from 2017 to 2018. Patients were called after discharge to collect opioid consumption data. Machine learning models were used to identify outlier opioid consumers (ie, exceeding our institutional prescribing guidelines) using diagnosis codes, medical history, in-hospital opioid use, and perioperative factors as predictors. External validation was performed on opioid consumption data collected at a second institution from 2020 to 2021, and sensitivity analysis was performed using a third institution's prescribing guidelines. RESULTS: The development and external validation cohorts included 1,867 and 498 patients, respectively. Age, body mass index, tobacco use, preoperative opioid exposure, and in-hospital opioid consumption were the strongest predictors of postdischarge consumption. A lasso regression model exhibited an area under the receiver operating characteristic curve of 0.74 (95% confidence interval 0.67-0.81) in predicting postdischarge opioid consumption. External validation of a limited lasso model yielded an area under the receiver operating characteristic curve of 0.67 (0.60-0.74). Performance was preserved when evaluated on another institution's guidelines (area under the receiver operating characteristic curve 0.76 [0.72-0.80]). CONCLUSION: Patient characteristics reliably predict postdischarge opioid consumption in relation to prescribing guidelines for both opioid-naive and exposed populations. This model may be used to help providers confidently follow prescribing guidelines for patients with typical opioid responsiveness and correctly pursue more personalized prescribing for others.

Current Barriers in Robotic Surgery Training for General Surgery Residents.

OBJECTIVE: To assess the current barriers in robotic surgery training for general surgery residents. DESIGN: Multi-institutional web-based survey. SETTING: 9 academic medical centers with a general surgery residency. PARTICIPANTS: General surgery residents of at least PGY-3 training level. RESULTS: 163 general surgery residents were contacted with 80 responses (49.1%). The most common responders were PGY-3s (38.8%) followed by PGY-5s (27.5%). The Northeast represented 42.5% of responses. Colorectal cases were the most common robotic case residents were involved in (51.3%). Residents' typical roles were assisting at the bedside (31.3%) and splitting time between assisting at the bedside and operating at the surgeon console (31.3%). 43% report to be either extremely or somewhat dissatisfied with their robotic surgery experience. 62.5% report they do not intend to integrate robotic surgery into their future practice. 93.8% of residents have a standardized robotic curriculum. 47.5% report using the simulator only during required didactic time with 52.5% having the robotic simulator conveniently located. The majority of residents report that the presence of dual consoles and first-assists in robotic cases enhance their robotic training (93% - 62%, respectively). 72.5% felt like they had more autonomy during laparoscopic cases and 96.8% of residents felt that an attendings' lack of experience impacted their time operating at the surgeon console. CONCLUSIONS: General surgery residents report lack of effective OR teaching, real clinical experience, and simulated experience as main barriers in their robotic surgery training. Dual consoles and first-assistants are favorably looked upon. Lack of attending experience and comfort were universally negatively associated with resident participation. For residents interested in robotic surgery, advocating for more robust investment in dual consoles, first-assistants, and faculty development would likely improve their robotic surgery training experience. However, residency programs should consider whether robotic surgery should be a core competency of an already time restricted training paradigm.