Lower-extremity pressure, staging, and grading thresholds to identify chronic limb-threatening ischemia.

INTRODUCTION: The Society for Vascular Surgery Threatened Limb Classification System ('WIfI') is used to predict risk of limb loss and identify peripheral artery disease in patients with foot ulcers or gangrene. We estimated the diagnostic sensitivity of multiple clinical and noninvasive arterial parameters to identify chronic limb-threatening ischemia (CLTI). METHODS: We performed a single-center review of 100 consecutive patients who underwent angiography for foot gangrene or ulcers. WIfI stages and grades were determined for each patient. Toe, ankle, and brachial pressure measurements were performed by registered vascular technologists. CLTI severity was characterized using Global Limb Anatomic Staging System (GLASS stages) and angiosomes. Medial artery calcification in the foot was quantified on foot radiographs. RESULTS: GLASS NA (not applicable), I, II, and III angiographic findings were seen in 21, 21, 23, and 35 patients, respectively. A toe-brachial index < 0.7 and minimum ipsilateral ankle-brachial index < 0.9 performed well in identifying GLASS II and III angiographic findings, with sensitivity rates 97.8% and 91.5%, respectively. The diagnostic accuracy rates of noninvasive measures peaked at 74.7% and 89.3% for identifying GLASS II/III and GLASS I+ angiographic findings, respectively. The presence of medial artery calcification significantly diminished the sensitivity of most noninvasive parameters. CONCLUSIONS: The use of alternative noninvasive arterial testing parameters improves sensitivity for detecting PAD. Abnormal noninvasive results should suggest the need for diagnostic angiography to further characterize arterial anatomy of the affected limb. Testing strategies with better accuracy are needed.

Outcomes after ruptured abdominal aortic aneurysm repair in the era of centralized care.

OBJECTIVE: Little is known about the relationship between case volume and patient outcomes of those treated for ruptured abdominal aortic aneurysm (rAAA) after either endovascular aneurysm repair (EVAR) or open aneurysm repair (OAR). This study evaluated the impact of hospital case volume on outcomes after rAAA. METHODS: Patients with rAAA were identified in the Society for Vascular Surgery Vascular Quality Initiative database from 2003 to 2017, excluding patients from years in which a limited number of hospitals were included (2003-2009, 2017). Patients were stratified according to type of aneurysm repair and further stratified according to aortic surgical volume of the treating facility. Univariate and multivariable analyses were performed. RESULTS: Between 2010 and 2016, of 2895 patients who presented emergently with rAAA, 1246 underwent ruptured OAR (rOAR) and 1649 underwent ruptured EVAR (rEVAR). Before adjustment for demographics, comorbidities, and clinical characteristics, there were no differences in 1-year patient survival based on hospital OAR or EVAR volumes among patients undergoing rOAR or rEVAR. After adjustment for confounding variables, patients treated with rOAR at the highest volume OAR hospitals had a 33% lower hazard of mortality at 1 year relative to patients treated with rOAR at the lowest volume OAR hospitals. Preoperative interfacility transfer was associated with a 27% lower hazard of mortality after rOAR. There was no significant difference in hazard of mortality among patients undergoing rEVAR when they were stratified according to hospital EVAR volumes after adjustment for all other covariates. CONCLUSIONS: Outcomes after rAAA repair are associated with hospital volume among patients undergoing rOAR but not among patients undergoing rEVAR. Thus, centralization of care may have an important impact on outcomes when OAR is indicated, suggesting a benefit for preoperative interfacility transfer of care when it is feasible.

Thirty-day Readmission Rates for Carotid Endarterectomy Versus Carotid Artery Stenting.

BACKGROUND: Because of the emergence of readmission-related Medicare penalties, efforts are being made to identify and reduce patient readmissions. The purpose of this study was to compare rates and risk factors for 30-d readmission and hospital length of stay (LOS) after carotid endarterectomy (CEA) and carotid artery stenting (CAS) among patients treated for carotid artery stenosis in Pennsylvania. MATERIALS AND METHODS: Data were from the Pennsylvania Health Care Cost Containment Council (PHC4). We identified 15,966 patients who underwent CEA (n = 13,557) or CAS (n = 2409) in Pennsylvania between 2011 and 2014. Logistic regression was used to determine risk factors for 30-d readmission, whereas linear regression was used to model factors influencing LOS. Propensity score analysis was used to control for imbalanced covariates between procedures. RESULTS: Thirty-day readmission rates in Pennsylvania after CEA and CAS for carotid artery stenosis were similar (9.8% and 9.6%, respectively; P = 0.794). Not home discharge destination, Charlson comorbidity index ≥2, and LOS >1 d were all significantly associated with readmission risk. Procedure type (CEA or CAS) did not significantly influence risk. A significant difference in LOS was found between CEA and CAS, but the magnitude of the difference was small (2.38 for CAS versus 2.59 for CEA; P = 0.007). Black race, urgent and emergent cases, and not home discharges significantly increased LOS by notable amounts (1, 1.5, 3.9, and 1.9 d, respectively). CONCLUSIONS: Carotid artery stenosis patients in Pennsylvania undergoing CEA or CAS had similar 30-d readmission rates. Although LOS was significantly different, the magnitude of the difference was not large.

Neck hematoma after major head and neck surgery: Risk factors, costs, and resource utilization.

BACKGROUND: Postoperative cervical hematoma after major head and neck surgery is a feared complication. However, risk factors for developing this complication and attributable costs are not well-established. METHODS: The Nationwide Inpatient Sample database was utilized compare patients with and without postoperative cervical hematoma. Logistic regression was used to analyze risk factors for hematoma formation and 30-day mortality. Total inpatient length of stay (LOS) and costs were fit to generalized linear models. RESULTS: Of 32 071 patients, 1098 (3.4%) experienced a postoperative cervical hematoma. Male sex (odds ratio [OR] 1.38; P < .0001), black race (OR 1.35; P = .010), 4 or more comorbidities (OR 1.66; P < .0001), or presence of a preoperative coagulopathy (OR 6.76; P < .0001) were associated. Postoperative cervical hematoma was associated with 540% increased odds of death (P < .0001). The LOS and total excess costs were 5.14 days (P < .0001) and $17 887.40 (P < .0001), respectively. CONCLUSION: Although uncommon, postoperative cervical hematoma is a life-threatening complication of head and neck surgery with significant implications for outcomes and resource utilization.

Correlation of clinical and pathological staging and response to neoadjuvant therapy in resected pancreatic cancer.

BACKGROUND: Neoadjuvant therapy (NAT) has been increasingly employed to optimize outcomes in pancreatic cancer; however, little is known about its pathologic impact. METHODS: The National Cancer Data Base (2003-2011) was retrospectively reviewed for patients with pancreatic carcinoma who underwent initial surgery or NAT followed by resection. Response to NAT, determined by comparing clinical and pathologic stage, and survival were evaluated. RESULTS: 16,087 patients underwent initial pancreatectomy and 2307 patients received NAT. Clinical stage correlated poorly with pathological stage in patients who received initial surgery (κ = 0.2865, p < 0.001). With NAT, 21.9% were downstaged, 47.9% had no stage change, and 30.3% progressed. In clinical stage II disease, patients downstaged with neoadjuvant chemotherapy or multimodality therapy demonstrated improved survival over patients who did not respond or who progressed (P = 0.0022, P = 0.0012, respectively). This benefit was not preserved in stage III disease (P = 0.7380, P = 0.0726, respectively). In multivariable analysis, downstage in disease was associated with a 19% lower hazard of mortality (HR 0.81, 95% CI: 0.7-0.92, P = 0.002). CONCLUSIONS: Clinical stage correlates poorly with pathological stage in resectable pancreatic cancer. The majority of patients do not experience a change in stage with NAT. Those with early stage disease, responsive to NAT, experience a survival benefit.

Cost-effectiveness of per oral endoscopic myotomy relative to laparoscopic Heller myotomy for the treatment of achalasia.

BACKGROUND: Per oral endoscopic myotomy (POEM) has recently emerged as a viable option relative to the classic approach of laparoscopic Heller myotomy (LHM) for the treatment of esophageal achalasia. In this cost-utility analysis of POEM and LHM, we hypothesized that POEM would be cost-effective relative to LHM. METHODS: A stochastic cost-utility analysis of treatment for achalasia was performed to determine the cost-effectiveness of POEM relative to LHM. Costs were estimated from the provider perspective and obtained from our institution's cost-accounting database. The measure of effectiveness was quality-adjusted life years (QALYs) which were estimated from direct elicitation of utility using a visual analog scale. The primary outcome was the incremental cost-effectiveness ratio (ICER). Uncertainty was assessed by bootstrapping the sample and computing the cost-effectiveness acceptability curve (CEAC). RESULTS: Patients treated within an 11-year period (2004-2016) were recruited for participation (20 POEM, 21 LHM). During the index admission, the mean costs for POEM ($8630 ± $2653) and the mean costs for LHM ($7604 ± $2091) were not significantly different (P = 0.179). Additionally, mean QALYs for POEM (0.413 ± 0.248) were higher than that associated with LHM (0.357 ± 0.338), but this difference was also not statistically significant (P = 0.55). The ICER suggested that it would cost an additional $18,536 for each QALY gained using POEM. There was substantial uncertainty in the ICER; there was a 48.25% probability that POEM was cost-effective at the mean ICER. At a willingness-to-pay threshold of $100,000, there was a 68.31% probability that POEM was cost-effective relative to LHM. CONCLUSIONS: In the treatment of achalasia, POEM appears to be cost-effective relative to LHM depending on one's willingness-to-pay for an additional QALY.

Minimally invasive surgical approaches offer earlier time to adjuvant chemotherapy but not improved survival in resected pancreatic cancer.

BACKGROUND: Pancreatic surgery encompasses complex operations with significant potential morbidity. Greater experience in minimally invasive surgery (MIS) has allowed resections to be performed laparoscopically and robotically. This study evaluates the impact of surgical approach in resected pancreatic cancer. METHODS: The National Cancer Data Base (2010-2012) was reviewed for patients with stages 1-3 resected pancreatic carcinoma. Open approaches were compared to MIS. A sub-analysis was then performed comparing robotic and laparoscopic approaches. RESULTS: Of the 9047 patients evaluated, surgical approach was open in 7511 (83%), laparoscopic in 992 (11%), and robotic in 131 (1%). The laparoscopic and robotic conversion rate to open was 28% (n = 387) and 17% (n = 26), respectively. Compared to open, MIS was associated with more distal resections (13.5, 24.3%, respectively, p < 0.0001), shorter hospital length of stay (LOS) (11.3, 9.5 days, respectively, p < 0.0001), more margin-negative resections (75, 79%, p = 0.038), and quicker time to initiation of chemotherapy (TTC) (59.1, 56.3 days, respectively, p = 0.0316). There was no difference in number of lymph nodes obtained based on surgical approach (p = 0.5385). When stratified by type of resection (head, distal, or total), MIS offered significantly shorter LOS in all types. Multivariate analysis demonstrated no survival benefit for any MIS approach relative to open (all, p > 0.05). When adjusted for patient, disease, and treatment characteristics, TTC was not an independent prognostic factor (HR 1.09, p = 0.084). CONCLUSION: MIS appears to offer comparable surgical oncologic benefit with improved LOS and shorter TTC. This effect, however, was not associated with improved survival.

Resource utilization associated with cervical hematoma after thyroid and parathyroid surgery.

BACKGROUND: Postoperative cervical hematoma (PCH) after thyroid and parathyroid surgery is a well-known complication. This study used data from the Nationwide Inpatient Sample to identify risk factors, estimate mortality, length of stay (LOS), and total costs attributable to PCH in patients undergoing procedures for thyroid and parathyroid diseases. METHODS: Patients aged >18 y who underwent thyroid or parathyroid surgery between 2001 and 2011 were identified and stratified by the occurrence of PCH. Univariate analyses of patient demographics, clinical and hospital characteristics were performed. Multivariable logistic regression was used to determine risk factors for hematoma formation. LOS and costs were fit to linear regression models to determine the effect of PCH after adjusting for patient and hospital characteristics. RESULTS: Of patients who underwent thyroid or parathyroid surgery, 619 patients (0.8%) had a PCH. Predisposing factors included nonelective admission (emergent: OR = 2.01, P < 0.0001; urgent: OR = 1.47, P = 0.003), diagnosis of Graves' disease (OR = 1.90, P < 0.0001), or other benign pathology (OR = 1.43, P = 0.011) and having ≥2 comorbidities (2-3 comorbidities, OR = 1.24; P = 0.036 and ≥ 4 comorbidities, OR = 2.28; P < 0.0001). After adjusting for those characteristics, the total excess LOS and costs attributable to PCH were 2.1 d (P < 0.0001) and $7316 (P < 0.0001), respectively. In addition, after risk adjustment, odds of mortality more than tripled (P < 0.0001) in the setting of PCH. CONCLUSIONS: Because risk for PCH is largely driven by preoperative patient risk factors, five clinicians have an opportunity to stratify patients accordingly and thereby minimize the resource utilization and health care spending among those with lowest risk.

Minimally invasive surgery for gastric cancer: the American experience.

BACKGROUND: Minimally invasive surgical techniques are increasingly being implemented in oncologic care. This study assesses the impact of minimally invasive surgery on oncologic and perioperative outcomes in the management of gastric cancer in the USA. METHODS: From the American College of Surgeons and American Cancer Society National Cancer Data Base, we identified 6427 patients who underwent gastrectomy for cancer from 2010 to 2012. Treatment groups were categorized with an intention-to-treat paradigm as robotic, laparoscopic, and open surgery. Univariate and multivariate analyses were performed to estimate the impact of the surgical approach on oncologic and perioperative outcomes. RESULTS: Of patients undergoing definitive surgical intervention, 3.5 % (n = 223) underwent robotic gastrectomy, 23.1 % (n = 1487) underwent laparoscopic gastrectomy, and 73.4 % (n = 4717) underwent open surgery. Minimally invasive gastrectomy was more frequently performed on white (P = 0.018), privately insured patients (P = 0.049) treated at academic centers (P < 0.0001) in the eastern USA (P < 0.0001). After demographics, comorbidities, and tumor-related factors had been controlled for, patients who underwent laparoscopic gastrectomy had the postoperative length of stay decreased by 1.08 days (P < 0.0001) and greater odds of having at least 15 lymph nodes resected (odds ratio 1.16, P = 0.023). Use of robotic surgery did not have a statistically significant effect on the postoperative length of stay relative to open surgery (P = 0.222) but the patients so treated had greater odds of having at least 15 lymph nodes resected (odds ratio 1.51, P = 0.005). There were no differences in R0 resection rates or perioperative mortality on the basis of the surgical approach alone. CONCLUSIONS: These findings suggest that use of minimally invasive surgery for gastric cancer in the USA is impacting the adequacy of oncologic resection but is not yet having a clinically significant impact on perioperative outcomes relative to a conventional open approach.

Operative Autonomy among Senior Surgical Trainees during Infrainguinal Bypass Operations Is Not Associated with Worse Long-term Patient Outcomes.

BACKGROUND: In an era of rapidly evolving surgical training, intraoperative teaching remains paramount to the education of surgical trainees. The impact of surgical trainees' level of expertise on outcomes after infrainguinal bypass surgery, a technically demanding operation, remains unknown. The purpose of this study was to explore the effects of surgical residents' experience on outcomes after infrainguinal bypass surgery. METHODS: Using the American College of Surgeons National Surgical Quality Improvement Program database, we identified patients who underwent infrainguinal bypass from 2005 to 2012. Patients were stratified according to the training level of the most senior operating trainee. Univariate and multivariate analyses, as well as propensity score matched analysis, were performed to compare patient cohorts on operative time, length of hospital stay (LOS), bleeding, early graft failure, unplanned readmission, and 30-day mortality. RESULTS: A total of 19,579 patients were identified, of which 35.6% were female and 64.4% were male; mean age was 67.6 years. A PGY1 (postgraduate year) was the highest level trainee operating on 2.5%, a PGY2-4 for 26.2%, and a PGY5+ (postgraduate year 5 or greater) for 37.1%. Attending surgeons operated without trainees on 34.2%. PGY5+s were more likely to operate on patients who were younger, non-White, male, and on dialysis. In multivariable analysis, involvement of any surgical trainee was associated with procedures that took a greater length of time, had a greater odds of blood transfusion, and necessitated a longer hospital LOS relative to procedures performed by an attending surgeon alone. Only bypasses wherein PGY5+s were involved were associated with greater odds of early graft failure, unplanned readmission, and 30-day mortality when compared with procedures done without trainee involvement. After excluding lower extremity bypasses in which an attending surgeon operated without a trainee, propensity score matching analysis showed that patients operated on by PGY5+s had longer operative time (4.11 vs. 3.96 hr, P < 0.0001) and greater rates of postoperative bleeding (9.77% vs. 8.15%, P = 0.004) relative to patients operated on by attendings assisted by PGY1-4s, but no statistically significant difference in LOS, early graft failure, unplanned readmission, and perioperative mortality. CONCLUSIONS: Operative involvement of senior trainees was associated with worse outcomes during infrainguinal bypass, potentially reflecting a lesser extent of attending surgeon involvement, but no difference in patient outcomes after bypass procedure.

Timing of Adjuvant Chemotherapy and Impact on Survival for Resected Gastric Cancer.

BACKGROUND: Because postoperative convalescence often prolongs the interval between surgery and chemotherapy in patients undergoing treatment for advanced gastric cancer, this study assesses the survival impact of timing of adjuvant chemotherapy (AC) in patients undergoing curative resection for gastric cancer. METHODS: The 2003-2012 ACS NCDB was analyzed for patients treated with gastrectomy for stages 1-3 gastric cancer. Treatment groups were stratified by time to initiation of AC: initiation of chemotherapy within 8 weeks postoperatively, between 8 and 12 weeks postoperatively, after 12 weeks postoperatively, and no chemotherapy. Univariate and multivariate analyses were performed. RESULTS: Of 7942 patients undergoing gastrectomy, 29 % received AC. Of those who received AC, 58 % initiated AC within 8 weeks, 28 % initiated AC between 8 and 12 weeks, and 14 % received AC after 12 weeks. Among patients who received AC, median survival was not significantly different between time cohorts, even when stratified by pathologic stage. Median survival was longer for chemotherapy cohorts when compared with the no chemotherapy cohort, specifically in patients with pathologic stages 2 and 3 disease. In multivariable analysis, patients who received AC had a 27-29 % lower hazard of death (p < .0001), with administration of AC at any time, compared with patients who did not receive AC, but had no difference in hazard when comparing delayed AC to earlier administration of AC. CONCLUSIONS: Time to initiation of AC does not impact survival. With improved survival over patients who did not receive AC, even delayed initiation of chemotherapy should be offered, when appropriate.

Time to the initiation of adjuvant chemotherapy does not impact survival in patients with resected pancreatic cancer.

BACKGROUND: Surgical resection with adjuvant chemotherapy is the standard of care for patients with pancreatic cancer, but to the authors' knowledge, little is known regarding the temporal relationship between chemotherapy initiation and survival. The current study analyzed the impact of time to the initiation of adjuvant chemotherapy. METHODS: The National Cancer Data Base (2003-2011) was retrospectively reviewed for patients with clinical American Joint Committee on Cancer stages I to III resected pancreatic carcinoma. Time to chemotherapy was stratified at the 12-week postoperative time point. Univariate and multivariate analyses were performed. RESULTS: The current study included 6706 patients who underwent surgical resection alone, 3723 patients who initiated adjuvant chemotherapy at ≤12 weeks, and 669 patients who initiated adjuvant chemotherapy at >12 weeks. Patients who received chemotherapy at >12 weeks were older and had greater comorbidities. Those undergoing a Whipple resection or total pancreatectomy were more likely to initiate chemotherapy later compared with those patients undergoing a distal surgical resection. Adjuvant chemotherapy conferred a survival benefit over surgical resection alone (P<.0001). There was no overall survival benefit observed for patients receiving adjuvant chemotherapy at ≤12 weeks compared with at >12 weeks (P =.5301). When stratified by pathological stage of disease, there was no survival benefit noted for the earlier initiation of chemotherapy: stage I: P =.2783; stage II: P =.0708; and stage III: P =.0778. After controlling for patient, disease, and surgery characteristics, both patients who initiated adjuvant chemotherapy at ≤12 weeks and at >12 weeks were found to have a 35% lower odds of mortality versus those who underwent surgical resection alone (P<.0001 for both). CONCLUSIONS: The earlier initiation of adjuvant chemotherapy does not appear to significantly impact long-term survival in patients with resected pancreatic cancer. Because adjuvant chemotherapy confers a survival benefit, delayed chemotherapy should be offered when appropriate. Cancer 2016;122:2979-2987. © 2016 American Cancer Society.

Tumor regression grade in gastric cancer: Predictors and impact on outcome.

BACKGROUND: The clinical value and prognostic implications of histologic response to neoadjuvant chemotherapy in gastric cancer is unknown. METHODS: Tumor regression grade (TRG) was recorded in 58 gastric cancer patients identified from two institutional surgical databases. TRG 1a/b represented histologic responders (<10% viable tumor), while TRG 2/3 represented non-responders (>10% viable tumor). RESULTS: TRG 1a/b was recorded in 10 patients (17%), while 48 patients (83%) had a TRG 2/3 response. Larger tumor size (OR 0.24; 95%CI 0.09, 0.64; P = 0.004) and clinical downstaging (OR 30.0; 95%CI 3.26, 276; P = 0.003) were the only factors predictive of histologic response. TRG 1a/b responders had 3-year survival of 70.0% and an estimated overall survival of >69.8 months compared to 38.2% and 22.8 months in non-responders; however, this trend was not statistically significant (P = 0.535). While TRG could not predict survival (OR 2.40; 95%CI 0.46, 12.57; P = 0.300), patient age (OR 1.06; 95%CI 1.00, 1.11; P = 0.035), and the number of positive lymph nodes (≥7; OR 0.05; 95%CI 0.07, 0.27; P < 0.001) were independent predictors of survival. CONCLUSIONS: Few gastric cancers demonstrate histologic response to neoadjuvant chemotherapy. While TRG may be a valid marker for treatment response, its predictive value and clinical application in gastric cancer remains unclear. J. Surg. Oncol. 2016;114:434-439. © 2016 Wiley Periodicals, Inc.

Marital Status and Survival in Patients with Carcinoid Tumors.

BACKGROUND: Marital status is a known prognostic factor in overall and disease-specific survival in several types of cancer. The impact of marital status on survival in patients with carcinoid tumors remains unknown. We hypothesized that married patients have higher rates of survival than similar unmarried patients with carcinoid tumors. METHODS: Using the Surveillance, Epidemiology, and End Results database, we identified 23,126 people diagnosed with a carcinoid tumor between 2000 and 2011 and stratified them according to marital status. Univariate and multivariable analyses were performed to compare the characteristics and outcomes between patient cohorts. Overall and cancer-related survival were analyzed using the Kaplan-Meier method. Multivariable survival analyses were performed using Cox proportional hazards models (hazards ratio [HR]), controlling for demographics and tumor-related and treatment-related variables. Propensity score analysis was performed to determine surgical intervention distributions among married and unmarried (ie, single, separated, divorced, widowed) patients. RESULTS: Marital status was significantly related to both overall and cancer-related survival in patients with carcinoid tumors. Divorced and widowed patients had worse overall survival (HR, 1.33 [95% confidence interval {CI}, 1.08-1.33] and 1.34 [95% CI, 1.22-1.46], respectively) and cancer-related survival (HR, 1.15 [95% CI, 1.00-1.31] and 1.15 [95% CI, 1.03-1.29], respectively) than married patients over five years. Single and separated patients had worse overall survival (HR, 1.20 [95% CI, 1.08-1.33] and 1.62 [95% CI, 1.25-2.11], respectively) than married patients over five years, but not worse cancer-related survival. Unmarried patients were more likely than matched married patients to undergo definitive surgical intervention (62.67% vs 53.11%, respectively, P < 0.0001). CONCLUSIONS: Even after controlling for other prognostic factors, married patients have a survival advantage after diagnosis of any carcinoid tumor, potentially reflecting better social support and financial means than patients without partners.

Trends in the use and impact of neoadjuvant chemotherapy on perioperative outcomes for resected gastric cancer: Evidence from the American College of Surgeons National Cancer Database.

BACKGROUND: Standard of care for patients with advanced gastric cancer includes administration of neoadjuvant chemotherapy (NAC) before resection. This study assesses the pattern of use and impact of NAC on perioperative outcomes in US medical centers. METHODS: Using the American College of Surgeons National Cancer Database, 16,128 patients underwent gastrectomy for cancer from 2003 to 2012. Treatment groups were categorized as NAC or no NAC (ie, adjuvant chemotherapy and surgery only). Univariate and multivariate analyses were performed to estimate trends in utilization and impact of treatment on perioperative outcomes. RESULTS: Of patients undergoing gastrectomy, 36.6% received NAC and 63.4% did not receive chemotherapy in the neoadjuvant setting. Patients who received NAC were more frequently younger, male, white, privately insured, with fewer comorbidities, and treated at an academic center (all P < .0001). After controlling for demographics, comorbidities, and tumor-related factors, patients who received NAC had a postoperative duration of stay 0.43 days shorter than patients who did not receive chemotherapy (5.79 vs 6.22 days; P = .050). They had a 36% lower odds of 30-day mortality (odds ratio, 0.64, P < .0001) but nonsignificant lower odds of 90-day mortality. Use of NAC increased annually, with the greatest increases seen in academic facilities and in the Northeast and North Central United States. CONCLUSION: With concerns regarding the toxicity of NAC, these findings suggest that NAC is not associated with worse postoperative outcomes. In light of evidence touting the benefits of NAC, its adoption as a component in the multimodality care of gastric cancer is slowly increasing, although use of NAC remains poor overall.

Carotid Endarterectomy versus Carotid Artery Stenting: No Difference in 30-Day Postprocedure Readmission Rates.

BACKGROUND: In the United States, ischemic stroke is a major cause of morbidity and mortality, precipitated by carotid artery stenosis in 1 of every 5 individuals who suffer a stroke. Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are 2 proven means of intervening on this disease process, with similar patient outcomes. Little is known about the burden of readmission after each of these procedures. We hypothesized that no difference in readmission rates within 30 days would exist for these 2 procedures, in spite of baseline differences that might exist between the 2 patient populations. METHODS: Using the Pennsylvania Health Care Cost Containment Council database, we identified 4,319 people who underwent CEA (n = 3,640) or CAS (n = 679) in Pennsylvania in 2011. Univariate analyses were performed to compare patient characteristics and outcomes, including reasons for readmission, between patients who underwent CEA and those who underwent CAS. Logistic regression was used to estimate the effect of intervention on 30-day readmission, after controlling for potential confounders. Time to readmission was analyzed using the Kaplan-Meier method. RESULTS: Patients who underwent CEA and CAS differed in a few notable ways, including age, race, admission type, and comorbid conditions such as congestive heart failure, hemiplegia and paraplegia, and renal disease. The unadjusted rate of 30-day readmission was 9.37% for CEA and 10.75% for CAS (P = 0.26). After controlling for patient and procedure characteristics, differences between 30-day readmission rates were still not statistically significant (odds ratio = 1.13; P = 0.39). Finally, time to readmission was similar for those who underwent CEA and those who underwent CAS (P = 0.19). Complications associated with surgery comprised less than 10% of primary readmission diagnoses for both groups. CONCLUSIONS: Readmission rates after CEA and CAS for carotid artery stenosis are approximately 10%. In spite of differences between patients with carotid stenosis who are selected for endarterectomy and stenting, the choice of procedure does not appear to be associated with different readmission rates or time to readmission, even after controlling for patient characteristics.

Attributable cost of obesity in breast surgery: a matched cohort analysis.

BACKGROUND: The purpose of this study was to determine the economic impact of obesity on patients undergoing mastectomy and breast conservation (BC) for breast cancer. METHODS: An analysis of female patients greater than or equal to 18 years undergoing mastectomy and BC for breast cancer between 2004 and 2010 using the Nationwide Inpatient Sample was conducted. RESULTS: Of 55,903 patients in our study (49,985 mastectomy, 5,918 BC), 3,308 patients (5.92%) were obese. After propensity score matching, the cost for obese patients was higher at $1,826 (P < .0001) for mastectomy and $1,702 for BC (P < .0001). These costs were not significantly associated with overall complications and length of stay for mastectomy in the matched comparison group and not associated with overall complications and minimally associated with longer length of stay in the BC group. CONCLUSION: By controlling for other patient factors, this study shows that obesity is attributable to a significantly higher cost for both BC (29%) and mastectomy (23%).