Outcomes of Patients Undergoing Segmentectomy for Occult Node-Positive Clinical Stage IA Lung Cancer.

BACKGROUND: Results of recent clinical trials suggest that segmentectomy may be an acceptable alternative to lobectomy for selected patients with early-stage non-small cell lung cancer (NSCLC). Increased use of segmentectomy may result in a concomitant increase in occult node-positive (N+) disease on surgical pathology examination. The optimal management for such patients remains unknown. METHODS: Clinicopathologic data were abstracted from a prospective institutional database to identify patients with pathologic N+ disease after segmentectomy for cT1 N0 M0 NSCLC. Propensity score matching identified a comparable lobectomy cohort for assessment of cumulative incidence of recurrence and overall survival (OS). RESULTS: Of 759 included patients, 27 (4%) had nodal upstaging on the final pathology report. Of these 27 patients, 4 (15%) had skip metastasis to N2 stations, and 20 (74%) received adjuvant therapy; no completion lobectomies were performed. Ten patients (37%) had disease recurrence: 3 isolated locoregional (11%) and 7 distant (26%). The median time to recurrence among patients with recurrence was 1.8 years; OS after recurrence was 3.4 years. After 5:1 matching with 109 patients who underwent lobectomy, all variables were balanced between the groups, except pathologic N2 stage and open surgical approach. The 5-year cumulative incidence of recurrence was not significantly different between segmentectomy and lobectomy (42% vs 52%, respectively; Gray's P = .1). The 5-year OS (63% and 50%) and rate of locoregional recurrence (12% vs 13%) were not statistically different between the groups. CONCLUSIONS: Patients with occult N+ disease after segmentectomy for cT1 N0 M0 NSCLC had limited isolated locoregional recurrences and outcomes similar to those in patients who underwent lobectomy. Lobectomy may not provide an advantage in these patients.

Improved Preoperative Risk Assessment Tools Are Needed to Guide Informed Decision Making before Esophagectomy.

OBJECTIVE: We sought to evaluate the performance of 2 commonly used prediction models for postoperative morbidity in patients undergoing open and minimally invasive esophagectomy. SUMMARY BACKGROUND DATA: Patients undergoing esophagectomy have a high risk of postoperative complications. Accurate risk assessment in this cohort is important for informed decision-making. METHODS: We identified patients who underwent esophagectomy between January 2016 and June 2018 from our prospectively maintained database. Predicted morbidity was calculated using the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator (SRC) and a 5-factor National Surgical Quality Improvement Programderived frailty index. Performance was evaluated using concordance index (C-index) and calibration curves. RESULTS: In total, 240 consecutive patients were included for analysis. Most patients (85%) underwent Ivor Lewis esophagectomy. The observed overall complication rate was 39%; the observed serious complication rate was 33%.The SRC did not identify risk of complications in the entire cohort (C-index, 0.553), patients undergoing open esophagectomy (C-index, 0.569), or patients undergoing minimally invasive esophagectomy (C-index, 0.542); calibration curves showed general underestimation. Discrimination of the SRC was lowest for reoperation (C-index, 0.533) and highest for discharge to a facility other than home (C-index, 0.728). Similarly, the frailty index had C-index of 0.513 for discriminating any complication, 0.523 for serious complication, and 0.559 for readmission. CONCLUSIONS: SRC and frailty index did not adequately predict complications after esophagectomy. Procedure-specific risk-assessment tools are needed to guide shared patient-physician decision-making in this high-risk population.

Early Ambulation is Associated with Improved Outcomes Following Colorectal Surgery.

BACKGROUND: The Enhanced Recovery After Surgery (ERAS) society lists early mobilization as one of their recommendations for improving patient outcomes following colorectal surgery. The level of supporting evidence, however, is relatively weak, and furthermore, the ERAS guidelines do not clearly define "early" mobilization. In this study, we define mobilization in terms of time to first ambulation after surgery and develop an outcome-based cutoff for early mobilization. METHODS: This is a retrospective cohort study comprised of 291 patients who underwent colorectal operations at a large, academic medical center from June to December 2019. Three cutoffs (12 hours, 24 hours, and 48 hours) were used to divide patients into early and late ambulation groups for each cutoff, and statistical analysis was performed to determine differences in postoperative outcomes between the corresponding groups. RESULTS: Multivariate analysis showed no difference between the early and late ambulation groups for the 12-hour and 48-hour cutoffs; however, ambulation before 24 hours was associated with a decreased rate of severe complications as well as fewer adverse events overall. Patients who ambulated within 24 hours had a 4.1% rate of severe complications and a 22.1% rate of experiencing some adverse event (complication, return to the emergency department, and/or readmission). In comparison, 11.8% of patients who ambulated later experienced a severe complication (P = 0.026), while 36.1% of patients experienced some adverse event (P = 0.011). CONCLUSIONS: Ambulation within 24 hours after colorectal surgery is associated with improved postoperative outcomes, particularly a decreased rate of severe complications.

Surgeon Bias in Postoperative Opioid Prescribing.

BACKGROUND: The misuse of opioids is a serious national crisis that is fueled by prescriptions medications. Opioid prescribing habits are known to be highly varied amongst providers. The purpose of this study is to identify patient and surgeon characteristics that predict postoperative opioid prescribing patterns. METHODS: This is a serial cross-sectional analysis of 20,497 patients who underwent general surgical procedures at a large academic center. Our primary outcome was the total amount of opioids prescribed within 30 days of the surgery. Univariate and multivariate linear regression models were used to identify patient and provider characteristics that were associated with increased opioids prescribed. RESULTS: Among patient characteristics studied, patient age, sex, ethnicity, and insurance status were found to have a significant association with the amount of opioids prescribed. Younger patients and male patients received higher morphine milligram equivalents (MMEs) on discharge (p < 0.05). Patients of Hispanic background were prescribed significantly lower opioids compared to Non-Hispanic patients (p < 0.0001). Among the provider characteristics studied, surgeon sex and years in practice were significantly predictive of the amount of opioids prescribed, with surgeons in practice for <15 years prescribing the highest MMEs (p < 0.0001). CONCLUSION: While opioid prescribing habits after surgery seem highly varied and arbitrary, we have identified key predictors that highlight biases in surgeon opioid prescribing patterns. Surgeons tend to prescribe significantly larger amounts of opioids to younger, male patients and those of certain ethnic backgrounds, and surgeons with fewer years in practice are more likely to prescribe more opioids.

Oligometastases After Curative Esophagectomy Are Not One Size Fits All.

BACKGROUND: More than one-half of patients treated with esophagectomy for esophageal cancer experience recurrence. Oligometastasis, a proposed intermediate state of isolated local or solid organ recurrence that occurs before widespread systemic disease, is a potential target for aggressive local intervention. This study investigated presentation and prognosis among solid organ recurrence sites. METHODS: Patients with isolated solid organ recurrence at the liver, lung, or brain who underwent R0 esophagectomy from 1995 to 2016 were identified. Clinicopathologic characteristics and outcomes were compared among sites of recurrence. Overall survival was quantified using the Kaplan-Meier approach and Cox proportional hazards models. RESULTS: In total, 104 patients were included (site: brain, 37; lung, 27; liver, 40). Eighty percent of liver, 51% of brain, and 44% of lung oligometastases occurred in the first 12 months after esophagectomy. Despite the limited use of aggressive therapy, patients with lung oligometastasis had significantly longer median overall survival (2.41 years; 95% confidence interval [CI], 1.58 to 3.31) than did patients with brain (0.95 years; 95% CI, 0.62 to 1.49) or liver (0.95 years; 95% CI, 0.82 to 1.41) oligometastasis (P < .001). This difference remained after patient and tumor characteristics were adjusted for (brain: hazard ratio, 4.48; 95% CI, 2.24 to 8.99; liver: hazard ratio, 2.94; 95% CI, 1.48 to 5.82). CONCLUSIONS: Presentations and prognoses differ by site of esophageal cancer recurrence. Lung oligometastases are associated with a more indolent course, and patients with these lesions may benefit from more aggressive treatment to improve their more favorable outcomes further. These differences by site of recurrence advocate for moving beyond a standardized palliative approach to all esophageal cancer recurrences.

Primary lung cancer in women after previous breast cancer.

BACKGROUND: Breast cancer is the most common malignancy among women in the USA. Improved survival has resulted in increasing incidence of second primary malignancies, of which lung cancer is the most common. The United States Preventive Services Task Force (USPSTF) guidelines for lung-cancer screening do not include previous malignancy as a high-risk feature requiring evaluation. The aim of this study was to compare women undergoing resection for lung cancer with and without a history of breast cancer and to assess whether there were differences in stage at diagnosis, survival and eligibility for lung-cancer screening between the two groups. METHODS: Women who underwent lung-cancer resection between 2000 and 2017 were identified. Demographic, clinicopathological, treatment and outcomes data were compared between patients with a history of breast cancer (BC-Lung) and patients without a history of breast cancer (P-Lung) before lung cancer. RESULTS: Of 2192 patients included, 331 (15.1 per cent) were in the BC-Lung group. The most common method of lung-cancer diagnosis in the BC-Lung group was breast-cancer surveillance or work-up imaging. Patients in the BC-Lung group had an earlier stage of lung cancer at the time of diagnosis. Five-year overall survival was not statistically significantly different between groups (73.3 per cent for both). Overall, 58.4 per cent of patients (1281 patients) had a history of smoking, and 33.3 per cent (731 patients) met the current criteria for lung-cancer screening. CONCLUSION: Differences in stage at diagnosis of lung cancer and treatment selection were observed between patients with and without a history of breast cancer. Overall, there were no statistically significant differences in genomic or oncogenic pathway alterations between the two groups, which suggests that lung cancer in patients who previously had breast cancer may not be affected at the genomic level by the previous breast cancer. The most important finding of the study was that a high percentage of women with lung cancer, regardless of breast-cancer history, did not meet the current USPSTF criteria for lung-cancer screening.

Variations in postoperative opioid prescribing by day of week and duration of hospital stay.

BACKGROUND: Studies demonstrate wide variation in postoperative opioid prescribing and that patients are at risk of chronic opioid abuse after surgery. The factors that influence prescribing, however, remain obscure. This study investigates whether day of the week or the postoperative day at the time of discharge impacts prescribing patterns. METHODS: We identified patients who underwent commonly performed procedures at our institution from January 2014 through April 2019 and analyzed the relationship between postoperative opioids prescribed (oral morphine milligram equivalents) and both the day of the week and the postoperative day at discharge. RESULTS: In ambulatory operations (n = 13,545), each day progressing from Monday was associated with increased morphine milligram equivalents prescribed on discharge (P = .0080). For inpatient cases (n = 10,838), surgeons prescribed more morphine milligram equivalents at discharge in the latter half of the week and during the weekend (P = .0372). Every additional postoperative day at discharge was associated with a +19.25 morphine milligram equivalent prescribed (P < .0001). CONCLUSION: More opioids were prescribed on discharges later in the week and after prolonged hospital stays perhaps to avoid patients running out of medication. Providers may unintentionally allow such non-clinical factors to influence postoperative opioid prescribing. Increased awareness of these inadvertent biases may help decrease excess prescribing of potentially addicting opioids after an operation.

Disparities in mortality-to-incidence ratios by race/ethnicity for female breast cancer in New York City, 2002-2016.

BACKGROUND: Racial disparities in New York City (NYC) breast cancer incidence and mortality rates have previously been demonstrated. Disease stage at diagnosis and mortality-to-incidence ratio (MIR) may present better measures of differences in screening and treatment access. Racial/ethnic trends in NYC MIR have not previously been assessed. METHODS: Mammogram rates were compared using the NYC Community Health Survey, 2002-2014. Breast cancer diagnosis, stage, and mortality were from the New York State Cancer Registry, 2000-2016. Primary outcomes were MIR, the ratio of age-adjusted mortality to incidence rates, and stage at diagnosis. Joinpoint regression analysis identified significant trends. RESULTS: Mammogram rates in 2002-2014 among Black and Latina women ages 40 and older (79.9% and 78.4%, respectively) were stable and higher than among White (73.6%) and Asian/Pacific-Islander women (70.4%) (P < .0001). There were 82 733 incident cases of breast cancer and 16 225 deaths in 2000-2016. White women had the highest incidence, however, rates among Black, Latina, and Asian/Pacific Islander women significantly increased. Black and Latina women presented with local disease (Stage I) less frequently (53.2%, 57.6%, respectively) than White (62.5%) and Asian/Pacific-Islander women (63.0%). Black women presented with distant disease (Stage IV) more frequently than all other groups (Black 8.7%, Latina 5.8%, White 6.0%, and Asian 4.2%). Black women had the highest breast cancer mortality rate and MIR (Black 0.25, Latina 0.18, White 0.17, and Asian women 0.11). CONCLUSIONS: More advanced disease at diagnosis coupled with a slower decrease in breast cancer mortality among Black and Latina women may partially explain persistent disparities in MIR especially prominent among Black women. Assessment of racial/ethnic differences in screening quality and access to high-quality treatment may help identify areas for targeted interventions to improve equity in breast cancer outcomes.

Higher clinical suspicion is needed for prompt diagnosis of esophageal adenocarcinoma in young patients.

BACKGROUND: Esophageal cancer is considered a disease of the elderly. Although the incidence of esophageal adenocarcinoma in young patients is increasing, current guidelines for endoscopic evaluation of gastroesophageal reflux disease and Barrett's esophagus include age as a cutoff. There is a paucity of data on the presentation and treatment of esophageal cancer in young patients. Most studies are limited by small sample sizes, and conflicting findings are reported regarding delayed diagnosis and survival compared with older patients. METHODS: A retrospective cohort study was performed using the National Cancer Database between 2004 and 2015. Patients with esophageal adenocarcinoma were divided into quartiles by age (18-57, 58-65, 66-74, 75+ years) for comparison. Clinicopathologic and treatment factors were compared between groups. RESULTS: A total of 101,596 patients were identified with esophageal cancer. The youngest patient group (18-57 years) had the highest rate of metastatic disease (34%). No difference in tumor differentiation was observed between age groups. Younger patient groups were more likely to undergo treatment despite advanced stage at diagnosis. Overall 5-year survival was better for younger patients with local disease, but the difference was less pronounced in locoregional and metastatic cases. CONCLUSIONS: In this study, young patients were more likely to have metastatic disease at diagnosis. Advanced stage in young patients may reflect the need for more aggressive clinical evaluation in high-risk young patients.

Risk of Chronic Opioid Use in Opioid-Naïve and Non-Naïve Patients after Ambulatory Surgery.

BACKGROUND: Chronic postoperative opioid use has been demonstrated after surgery, but there is a paucity of data on whether the amount of opioids given at discharge is a significant contributor to the risk of prolonged use. The purpose of this study was to determine if higher amounts of opioids prescribed after ambulatory surgery increases chronic opioid use in opioid-naïve and non-naïve patients. METHODS: Using the Institutional Data Warehouse, 15,220 adult patients were identified who underwent ambulatory elective surgeries at our institution between January 2014 and July 2018 and received a perioperative opioid prescription. Multivariate logistic regression was used to characterize the relationship between amount of perioperative opioids prescribed and chronic opioid use. RESULTS: The study population consisted of 14,378 (94%) opioid-naïve and 842 (6%) non-naïve patients. Seven hundred fifty-seven (5%) patients received a new opioid prescription 90 to 365 days after surgery. Patients that had a lower amount of total perioperative opioids (0-150MMEs, 151-300MMEs, or 301-450MMEs) had 44-54% lower risk of persistent opioid use after surgery compared to those who received > 450 MMEs or > 60 pills of 5 mg oxycodone (p < 0.0001). This relationship was especially prominent on subset analysis of opioid non-naïve patients, a group that has thus far been left out of opioid-related studies. CONCLUSION: Persistent opioid use is a known complication after surgery. A higher number of opioid pills on discharge after ambulatory surgery is associated with increased risk of chronic opioid use. Surgeons should consider limiting the number of opioid pills prescribed after ambulatory surgery for both opioid-naïve and non-naïve patients.

Unique Considerations for Females Undergoing Esophagectomy.

OBJECTIVE: To improve understanding of sex differences in clinicopathologic characteristics, treatment and outcomes between male and female patients undergoing esophagectomy for esophageal cancer. SUMMARY BACKGROUND DATA: Esophageal cancer is a male predominant disease, and sex has not been considered in previous studies as an important factor in diagnosis or management. Sex differences in demographics, clinicopathologic characteristics, and postoperative outcomes remain largely undefined. METHODS: Retrospective review of 1958 patients (21% female) with esophageal cancer who underwent esophagectomy at a single institution between 1995 and 2017. RESULTS: Most patients had adenocarcinoma (83%); however, the rate of squamous cell carcinoma was significantly higher in females (35% vs 11%, respectively; P < .0001). Females had a lower rate of smoking (62 vs 73%) and heavy alcohol use (12 vs 19%) but a higher rate of previous mediastinal radiation (8.4 vs 1.8%) (P < 0.001). Postoperative mortality and overall survival (OS) were similar between sexes. However, subanalysis of patients with locoregional disease (clinical stage II/III) demonstrated that females received neoadjuvant therapy less frequently than males and had worse OS (median OS 2.56 yrs vs 2.08; P = 0.034). This difference remained significant on adjusted analysis (HR 1.24, 95% CI 1.06-1.46). CONCLUSIONS: Female patients had higher incidence of squamous cell carcinoma despite lower prevalence of behavioral risk factors. Among patients with locoregional disease, undertreatment in females may reflect treatment bias and history of previous mediastinal radiation. Esophageal cancer in females should be considered a unique entity as compared with the presentation and treatment of males.

Incidence and Risk Factors for Isolated Esophageal Cancer Recurrence to the Brain.

BACKGROUND: Recurrence of esophageal cancer in the brain is rare but associated with a poor prognosis. Identification of risk factors for isolated brain metastasis of esophageal cancer (iBMEC) after surgical treatment may guide surveillance recommendations to enable early identification and intervention before widespread metastasis. METHODS: Patients with iBMEC (n = 38) were identified from a prospective database of patients with esophageal cancer who underwent esophagectomy. Risk factors for iBMEC were identified using competing risk regression analysis. RESULTS: In a cohort of 1760 patients, 39% recurred and iBMEC developed in 2% by the end of the study. Survival in patients with iBMEC was similar to survival in patients with distant recurrence (median overall survival, 0.95 years; 95% confidence interval, 0.6-1.5 years). More than half of patients with iBMEC were diagnosed within 1 year postoperatively. All 38 patients with iBMEC had received neoadjuvant therapy before surgery. Pathologic complete response (PCR) to neoadjuvant therapy was associated with improved survival after brain recurrence (median overall survival, 1.56 vs 0.66 years; P = .019). CONCLUSIONS: In patients with PCR, iBMEC may represent true isolated recurrence, whereas in those with residual nodal disease, iBMEC may actually be the first observed site of widespread metastasis. Patients who receive neoadjuvant therapy, especially with PCR, may benefit from brain imaging, both preoperatively and with routine surveillance.

Surveillance Implications of Recurrence Patterns in Early Node-Negative Esophageal Adenocarcinoma.

BACKGROUND: There are limited data regarding optimal surveillance after curative resection for esophageal cancer. Once disease recurrence is diagnosed, the prognosis is poor. The purpose of this article was to characterize disease recurrence in patients with early esophageal adenocarcinoma. METHODS: Two hundred sixty patients were identified from a prospective institutional database with pathologic T1 and T2 node-negative disease therapy treated with curative esophagectomy alone for esophageal adenocarcinoma between 1995 and 2017. Competing risk analysis was used to analyze factors associated with recurrence. RESULTS: The 5-year cumulative incidence of recurrence was 12%. Predictive factors for increased risk of recurrence included increasing tumor size, poor differentiation, and pathologic T2 disease (P < .05), whereas presence of Barrett's esophagus on pathology was protective. Recurrence within 2 years was 2.5%, 6.1%, and 12% for T1a, T1b, and T2 disease, respectively. At 5 years cumulative incidence of recurrence was 8.2%, 11.5% and 22.2%, respectively. Median overall survival after recurrence was 1.04 years (95% confidence interval, 0.7-2.4). There were 14 subclinical and 13 symptomatic recurrences; patients with symptomatic recurrence had a significantly shorter overall survival after recurrence occurred (0.31 vs 0.71 years, P = .018). CONCLUSIONS: Among early node-negative patients with esophageal cancer undergoing curative resection, 5-year recurrence was 12%. Survival after recurrence was poor, and only a few patients had isolated locoregional recurrence at time of diagnosis, suggesting that scheduled surveillance may have an important role.

Ongoing Challenges with Clinical Assessment of Nodal Status in T1 Esophageal Adenocarcinoma.

BACKGROUND: Endoscopic mucosal resection (EMR) has emerged as an esophageal-preserving treatment for T1 esophageal adenocarcinoma (EAC); however, only patients with negligible risk of lymph node metastasis (LNM) are eligible. Reliable clinical diagnostic tools for LNM are lacking, as such, several risk assessment scores have been developed. The purpose of this study was to externally validate 2 previously published risk scores (Lee and Weksler) for clinical prediction of LNM in T1 EAC patients. METHODS: In adherence with the Lee and Weksler scores, esophagectomy patients with pathologic T1 EAC were identified. Sub-analysis was performed in patients with clinical T1 based on EMR. Predictive accuracy of the scores was evaluated by calculating the area under the curve of the receiver operating characteristic curve and calibration plots. The areas under the curves were compared using Venkatraman's test for paired receiver operating characteristic curves. RESULTS: Of 233 patients identified who met study criteria for external validation, 3 T1a and 32 T1b patients had LNM. The receiver operating characteristic curves demonstrated comparable high predictive and discriminatory capabilities with areas under the curves of 0.832 and 0.824 for the Lee and Weksler scores, respectively (p = 0.750). Results were more variable for the EMR cohort. Based on the risk thresholds defined by each score, the false-positive rate compared against the pathologic LNM status were 73% and 56% for Lee and Weksler, with 3% false negatives in the latter. On EMR, the false-positive rates were 70% and 50% for Lee and Weksler, with no false negatives. CONCLUSIONS: Both scoring systems demonstrated good discriminatory ability and predictive accuracy for LNM, but the defined thresholds resulted in a high false-positive rate. A better scoring system based on clinical characteristics is needed to better identify patients with local disease.

Outcomes of Radiation-Associated Esophageal Squamous Cell Carcinoma: The MSKCC Experience.

OBJECTIVE: Esophageal squamous cell carcinoma (ESCC-R) is a rarely encountered sequela of chest radiation. Treatment is limited by toxicity with reirradiation and complex surgical dissection in a previously radiated field. The clinical presentation, prognosis, and treatment selection of ESCC-R remain undefined. METHODS: A retrospective review of patients with esophageal squamous cell carcinoma at a single institution between 2000 and 2017 was performed to identify patients with previous radiation therapy (≥ 5 years delay). Clinicopathologic characteristics, treatment, and outcomes of ESCC-R (n = 69) patients were compared to patients with primary esophageal squamous cell carcinoma (ESCC) (n = 827). Overall survival (OS) and cumulative incidence of recurrence (CIR) were compared using log-rank and Gray's tests, respectively. RESULTS: Median time from radiation to ESCC-R was 18.2 years. The majority of ESCC-R patients were female and presented with earlier disease and decreased behavioral risk factors. ESCC-R treated with surgery alone had worse OS than ESCC (5-year 15 vs 33%; p = 0.045). Patients with ESCC-R who received neoadjuvant treatment had higher risk of postoperative in-house mortality (16.7 vs 4.2%; p = 0.032). Patients with ESCC-R treated with surgery alone and definitive chemoradiation had higher recurrence risk than those with neoadjuvant + surgery (5-year recurrence 55 and 45 vs 15%; p = 0.101). CONCLUSION: Neoadjuvant chemotherapy or chemoradiation should be used whenever possible for ESCC-R as it is associated with lower risk of recurrence. The improved survival benefits of aggressive treatment must be weighed against the higher associated postoperative risks.

Temporal trends in opioid prescribing for common general surgical procedures in the opioid crisis era.

BACKGROUND: Recent data has demonstrated that postoperative patients are at risk of chronic opioid abuse. It is unknown whether surgeon postoperative opioid prescribing changed as the opioid crisis entered its peak. METHODS: The Institutional Data Warehouse was queried to identify patients who underwent three common elective ambulatory procedures between 2014 and 2018 (n = 3495), including: laparoscopic cholecystectomy, laparoscopic inguinal hernia repair (IHR), and open IHR. The main outcome of interest was opioid pills prescribed, converted to an equianalgesic pill number (1 pill = 5 mg oxycodone). RESULTS: Postoperative opioid prescribing was stable from 2014 to 2016 then decreased significantly in 2017 and 2018 (p < 0.0001). While the median number of pills prescribed remained stable at 30 between 2014 and 2018, the frequency of patients receiving 30 pills decreased significantly. Multivariate analysis demonstrated significantly fewer pills prescribed postoperatively after 2016. CONCLUSIONS: Reductions in postoperative pills prescribed over time as the opioid crisis worsened suggests that surgeons may be considering the potential for opioid abuse and diversion. Persistently high median number of pills prescribed and continued variation in number of pills prescribed suggests room for further improvement.