Successful de-implementation of an ineffective practice: The fall of docusate.

BACKGROUND: Reducing wasteful practices optimizes value in medicine. Docusate lacks treatment efficacy yet is widely prescribed. This quality improvement project aimed to de-implement docusate in place of a new evidence-based order set. METHODS: This is an ambidirectional study of inpatient laxative orders from 2018 to 2022 â€‹at one institution. We stratified docusate data by service/unit to target prospective deimplementation initiatives. A new evidence-based constipation order set was embedded in Cerner. RESULTS: There were 701,732 docusate orders across 75 services on 68 units. Top docusate ordering services were Trauma, Obstetrics and Hospitalist. Docusate administration rates were higher than for other laxatives. Our efforts reduced docusate orders by 44% over 4 months. PEG and senna orders increased by 58% and 35%. CONCLUSION: Docusate has no efficacy yet is widely prescribed. A structured de-implementation strategy can drive systematic change by leveraging technology and applying multidisciplinary improvement efforts. Our work removed docusate from the inpatient formulary.

Surgeon perspectives on the STITCH trial: a mixed methods study.

BACKGROUND: Incisional hernia prevention strategies related to fascial closure technique during laparotomy are well described yet poorly implemented in practice. The factors hindering the surgeon's adoption of evidence-based techniques for fascial closure are poorly understood and characterized. METHODS: Using an exploratory sequential mixed methods design, we first collected 139 responses to a validated quantitative survey based on a Theoretical Domain Framework for adoption of healthcare practices. Mean scores from survey responses were tabulated, and the findings were used to develop an interview guide for subsequent qualitative individual semi-structured phone interviews. Fourteen practicing surgeons were purposively sampled from social media outlets and our institution. The interviews were recorded and transcribed verbatim for coding and thematic analysis using NVivo 12 Plus. Data from the surveys and interviews were integrated using joint displays. RESULTS: Quantitative and qualitative analyses from surveys and semi-structured interviews revealed various themes related to surgeon decision-making related to fascial closure technique. Surgeons cited limitations of prior studies, applicability of findings, anecdotal experiences, and situation-specific environments that influence their decision-making. Peer influence and lack of training also affected surgeons' perspectives on integrating small bite technique into practice. CONCLUSION: Trial design limitations, peer influence, and patient-specific factors impacted surgeon decision-making in the choice of fascial closure technique. Future clinical trials in diverse patient populations may improve surgeons' confidence in implementing technique for fascial closure.

Towards identifying a learning curve for robotic abdominal wall reconstruction: a cumulative sum analysis.

INTRODUCTION: Over the past decade, an increase has been seen in robotics used for hernia repair, specifically robotic abdominal wall reconstruction (rAWR). However, the learning curve for rAWR can be steep and presently, little is understood regarding the optimal case volume required to achieve proficiency. The aim of our study was to review skill acquisition and describe the learning curve for rAWR. METHODS: A retrospective, single-surgeon case series of consecutive patients who underwent rAWR from 2018 to 2022. The primary outcome was operative time, obtained from console time identified through the MyIntutive application. A one-sided cumulative sum analysis (CUSUM) curve for the total operative time was derived based on the mean operative time of chronological procedures (207 min). RESULTS: 185 patients underwent rAWR between 2018 and 2022. These patients were more likely to be female, Caucasian, and have undergone two previous hernia repairs. ASA complexity increased over time with ASA 3 being predominant from 2020 onwards. The median hernia length was 15.0 cm and the median width was 7 cm. Average operative time was 207.8 min and decreased over time. The CUSUM analysis identified four phases of skill acquisition with the following case volumes: Initial Learning Curve (0-20), Stabilization Phase (21-55), Second Learning Curve (56-70), 4) Skill Proficiency (> 70). CONCLUSION: In the early learning curve of rAWR, operative time decreased consistently after 70 cases, with an initial inflection after 20 cases. We identified varying stages of skill acquisition that are likely typical of a surgeon as they would progress through the learning curve of advanced robotic surgery. Future studies are needed to confirm the optimal case volume for determining the skill level for the performance of rAWR.

A retrospective single-institution review of the impact of COVID-19 on severity of biliary disease.

BACKGROUND: The COVID-19 pandemic possessed far-reaching health implications beyond the public health impact that have yet to be fully elucidated. We hypothesized that the COVID-19 pandemic led to an increase in biliary disease complexity and incidence of emergency cholecystectomy. METHODS: We reviewed our institutional experience with cholecystectomy from February 2019-February 2021, n = 912. Pre COVID-19 pandemic patients were compared to patients after the onset of the pandemic. Baseline characteristics were compared between groups. A Cochran-Armitage test for trend assessed the temporal impact of COVID-19 on emergency presentation and gallbladder disease complexity. RESULTS: We identified 442 patients pre-pandemic and 470 patients during the pandemic. No significant differences were noted in demographics. COVID-19 significantly impacted emergency presentation (43.2% vs. 56.8%, p= <0.01), cholecystitis (53.2% vs 61.8%; p=<0.01), and gangrenous cholecystitis (2.8% vs 6.1%; p=<0.01). Both groups had similar clinical outcomes. CONCLUSIONS: The COVID-19 pandemic affected an increased incidence of emergency presentation and complexity of gallbladder disease but did not significantly impact clinical outcomes. These findings may have broader implications for other diseases possibly affected by COVID-19.

The formaldehyde treated guar meal and prill fat, agro industrial by-products as dietary rumen protected protein and energy source: improves growth performance, feed conversion, nutrient utilization, microbial protein synthesis, blood metabolites and economic efficiency in growing dairy buffalo (Bubalus bubalis) calves.

The study investigated the effects of protein replacement with formaldehyde-treated guar meal (FTGM) and prill fat (PF) in the diet on performance of growing dairy buffalo calves. Thirty-two feedlots Surti breed dairy buffalo calves (age, 7.31 ± 0.34 months and body weight, 90.69 ± 6.19 kg) were assigned into four dietary treatments (n-8 calves/each): (1) control group, supplied basal diet as per ICAR (2013) nutrient requirements; (2) FTGM group, 30% crude protein (CP) requirement of concentrate mixture (dry matter basis (DMB)) replaced with FTGM in basal diet; (3) PF group, supplied basal diet + 100 g PF; and (4) FTGM + PF group, 30% CP requirement of concentrate mixture (DMB) replaced with FTGM in the basal diet + 100 g PF for 280 days. All the treatment diets were isonitrogenous. Growth performance was improved in FTGM + PF and FTGM groups. Apparent digestibility (%) of CP was increased in FTGM and FTGM + PF diet, while digestibility (%) of ether extract (EE) was increased in PF group. Serum total protein, albumen, urea nitrogen, and creatinine concentrations were higher in FTGM + PF and FTGM groups, whereas total cholesterol and triglycerides levels were greater in FTGM + PF and PF groups. Calculated methane emission had a discernible influence of treatment in FTGM and FTGM + PF. The overall cost of feeding per kilogram gain was lowest in FTGM and FTGM + PF groups. In conclusion, 30% CP replacement with FTGM with or without PF improved the growth performance, feed conversion ratio, and nutrient utilization; supported efficient utilization of resources; and economized the rearing of growing dairy buffalo calves.

Retrospective Evaluation of Short-Term Outcomes of an Enhanced Recovery Protocol for Patients Undergoing Complex Abdominal Wall Reconstruction.

BACKGROUND: Enhanced recovery protocols (ERPs) have the potential to streamline care and improve short-term outcomes for surgical patients. However, for patients undergoing modern iterations of complex abdominal wall reconstruction (AWR), little literature exists on the effectiveness of these protocols. STUDY DESIGN: In this retrospective study we reviewed our institutional experience with complex AWR throughout a 2-year period with 1 year immediately before and 1 year after implementation of our ERP. Patients undergoing primarily minimally invasive complex AWR who were compliant with 11 elements of our ERP were compared with patients who received surgery before implementation of the protocol or did not meet these criteria. Baseline patient characteristics and patient outcomes including hospital length of stay, narcotic usage, and readmission were compared across groups. Multivariable regression models were used to estimate the associations of our ERP protocol with outcomes adjusting for surgical approach. RESULTS: Median length of stay for the overall cohort (n = 132) was 3 days (interquartile range 1 to 4). Morbidity and mortality rates were 22.6% and 0.7%, respectively. ERP patients were less likely to have a complication (ERP compliant 8.7% [n = 46] vs non-ERP 30.2% [n = 86], p < 0.01), had a shorter median postoperative length of stay (median 1 vs 3 days, p < 0.01), and received fewer morphine equivalents (median 30.8 vs 45 mg, p < 0.01). Readmission rate for ERP patients did not differ significantly vs non-ERP patients (6.5% vs 11.8%, p = 0.34). CONCLUSIONS: Use of ERPs in patients undergoing complex AWR may provide benefits for both patients and hospitals.

Comparative clinical evaluation of a self-adhering flowable composite with conventional flowable composite in Class I cavity: An in vivo study.

Context: The purpose of this study was to evaluate the efficiency of self-adhering flowable composite with that of a time-tested conventional flowable composite. Since the self-adhering composite reduces chair time and is convenient to use, its clinical behavior was monitored for a year. Aim: This study aimed to evaluate the clinical behavior of self-adhering flowable composite - Fusio Liquid Dentin - in small-sized Class I cavities and also to compare it with conventional flowable composite - Tetric N-Flow - bonded to the tooth structure with fifth-generation two-step-etch-and-rinse adhesive. Subjects and Methods: A total of 60 cavities were restored using flowable composite materials (30 cavities in each group) and evaluated at baseline, 1 month, 3 months, 6 months, and 1 year with modified United States Public Health Service criteria. The statistical analysis for the study was done using Fisher's exact test for intergroup comparison and Chi-square test for intragroup comparison. P < 0.05 was considered statistically significant. Results: Statistically no significant differences were observed in Fusio Liquid Dentin restorations during the recall visits. Statistically significant differences were found in color match evaluated for Tetric restorations during the recall visits. Conclusion: Based on the data acquired, the novel self-adhering composite material demonstrated good clinical behavior. As a result, at this point in the prospective clinical study, the use of Fusio Liquid Dentin to repair Class I cavities is acceptable.

Patient, Nurse, Medical Assistant, and Surgeon Perspectives Inform the Development of a Decision Support Tool for Inguinal Hernia Surgery: A Qualitative Analysis.

BACKGROUND: Critical perspectives on the informed consent process for inguinal hernia surgery are lacking. METHODS: We conducted focus group interviews of patients who have undergone inguinal hernia surgery and nurses/medical assistants. Individual phone interviews were also conducted with surgeons sampled from the International Hernia Collaboration. Interviews were transcribed for coding and qualitative thematic analysis performed using NVivo 12 Plus. Themes were compiled to develop a decision aid. RESULTS: Sixteen patients, 6 support staff members, and 12 surgeons participated. Multiple themes were identified. Patients, nurses, and medical assistants identified barriers to asking questions in the current clinic setup, patient stress, and time constraints, while surgeons identified strategies to implement decision aids. All participants agreed that decision aids improve the informed consent process. CONCLUSION: Key stakeholders identified barriers to the informed consent process and provided input on necessary components of a decision aid. Opportunities exist to address these barriers and improve the consent process.

A case report on endodontic management of the rarest Vertucci's Type VIII configuration in maxillary second molar with three mesiobuccal canals.

Anatomic variations in mesiobuccal root (MBR) of maxillary molars are common. This variation is found to be more common in maxillary first molars as compared to second molars. However, finding three independent mesiobuccal (MB) canals in the MBR of maxillary molars is clinically a rare entity. With the use of magnification, illumination, and cone-beam computed tomography, combined with the skill of the operator, there is an increased possibility of detecting such additional canals. The present case report describes the successful clinical management of a second molar in a 58-year-old female patient having three MBR canals (MB1, MB2, and MB3) with a Vertucci's Type VIII canal configuration and an almost obliterated pulp chamber. The canals were prepared using hand and rotary instruments, followed by obturation. Very few such cases have been documented clinically in the literature.

Effect of chemical cross-linkers on surface topography and microtensile bond strength of sound dentin: An in vitro study.

AIM AND OBJECTIVES: The aim of the study was to investigate the effect of two different collagen cross-linking agents proanthocyanidin (Grape seed extract [GSE] and 1-Ethyl-3-(3-dimethylaminopropyl) carbodiimide) on the surface topography of etched dentin and microtensile bond strength (µTBS) of resin dentin bond. MATERIALS AND METHODS: Fifty-two sound human 3rd molars were collected, and their occlusal surfaces were ground flat to expose dentin. Dentin surfaces were etched using phosphoric acid and then teeth were randomly divided into four groups, according to the dentin treatment: Group 1: wet bonding technique, Group 2: dry bonding technique, Group 3: 6.5% proanthocyanidin, and Group 4: 0.1M carbodiimide. Scanning electron microscope analysis was done for twenty specimens (n = 5 per group) at ×10,000 and ×30,000 magnification. Remaining 32 specimens were restored with TETRIC N-Bond adhesive systems and resin composite. After 24 h, teeth were sectioned to produce a cross-sectional surface area of 1.0 mm2 and tested for µTBS. STATISTICAL ANALYSIS: Data were statistically analyzed using ANOVA and post hoc least significant difference test (P < 0.05). CONCLUSION: When acid-etched dentin is treated by 6.5% proanthocyanidin (GSE) and 0.1M carbodiimide, followed by application of adhesives, it results in increased µTBS due to cross-linking of collagen fibrils.

Comparative evaluation of different direct pulp capping agents in carious tooth: An in vivo study.

BACKGROUND: The success of direct pulp capping (DPC) depends on the preoperative assessment of pulpal status, intraoperative judgment after pulp exposure, and the biomaterials used to cap the pulp. AIM: The study aims to compare the clinical and radiographic responses of the pulp-dentin complex after DPC with TheraCal LC, Biodentine, and current gold standard mineral trioxide aggregate (MTA) Plus. MATERIALS AND METHODS: Ninety vital permanent teeth with Class I deep carious lesions were randomly divided into three different groups. After the caries excavation, hemostasis was established using sodium hypochlorite at the site of pulp exposure on which the material was placed. Clinical and radiographic follow-ups were performed at 1-, 3-, and 6-month intervals. RESULTS: Overall success rates of MTA Plus, Biodentine, and TheraCal LC were statistically insignificant. CONCLUSIONS: TheraCal LC and Biodentine showed similar success rates when compared to MTA Plus and can be used as an agent in DPC.

Standoff pump-probe photothermal detection of hazardous chemicals.

A novel pump-probe Photothermal methodology using Quartz Tuning Fork (QTF) detector has been demonstrated for the first time. A tunable mid-IR Quantum Cascade Laser (QCL) and a CW fixed wavelength visible laser have been used as the pump and probe beam respectively. The developed Photothermal (PT) technique is based on Quartz Tuning Fork (QTF) detector for the detection of hazardous/explosive molecules adsorbed on plastic surface and also in aerosols form. PT spectra of various trace molecules in the fingerprinting mid- infrared spectral band 7-9 µm from distance of 25 m have been recorded. The PT spectra of explosives RDX, TNT and Acetone have been recorded at very low quantities. Acetone is the precursor of explosive Tri-Acetone Tri-Phosphate (TATP). The experimentations using pump and probe lasers, exhibit detection sensitivity of less than 5 µg/cm2 for RDX, TNT powders and of ~ 200 nl quantity for Nitrobenzene (NB) and Acetone (in liquid form) adsorbed on surfaces, from a distance of ~ 25 m. The sensitivity of the same order achieved from a distance of 15 m by using only a mid-IR tunable pump laser coupled to QTF detector. Thus the pump-probe PT technique is more sensitive in comparison to single tunable QCL pump beam technique and it is better suited for standoff detection of hazardous chemicals for homeland security as well as for forensic applications.

Evaluation of cell viability of Human Dental Pulp Stem Cells in Two dimensional and Three dimensional Fibrin Glue Scaffold.

CONTEXT: Regenerative endodontics uses the concept of tissue engineering to restore the diseased immature tooth, allowing for continued development of the root to a healthy state. For regenerative endodontics, the use of human dental pulp stem cells (HDPSCs) with appropriate scaffolds and growth factors is imperative. AIMS: The aim of the study was to evaluate the human dental pulp cell viability in two-dimensional (2D) and 3D fibrin glue scaffold to be used in regenerative endodontics. SUBJECTS AND METHODS: Regenerative potential of HDPSCs was comparatively assessed usings 2D and 3D fibrin glue scaffold. 3D scaffold was made with different concentrations of fibrinogen. Cell morphology was studied under inverted phase-contrast microscopy, and cell proliferation was assessed using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay at various time intervals. STATISTICAL ANALYSIS USED: Collected data underwent a two-way ANOVA test. The P value of the study was kept 0.05 according to the sample size. RESULTS: Study revealed a significant increase in the proliferation of HDPSCs in fibrin glue precoated wells of 2D fibrin glue compared to preseeded cells on day 1 and day 3. The concentration of fibrinogen has a major role in cell viability in 3D fibrin glue scaffold. Homing of HDPSCs in the 3D scaffold improves with time. CONCLUSIONS: This study concludes that the concentration of fibrin glue has a significant role in HDPSC Viability in 3D scaffold.

Gastric Ischemic Conditioning Prior to Esophagectomy Is Associated with Decreased Stricture Rate and Overall Anastomotic Complications.

BACKGROUND: Gastric ischemic conditioning prior to esophagectomy can increase neovascularization of the new conduit. Prior studies of ischemic conditioning have only investigated reductions in anastomotic leaks. Our aim was to analyze the association between gastric conditioning and all anastomotic outcomes as well as overall morbidity in our cohort of esophagectomy patients. METHODS: We performed a retrospective review of patients undergoing esophagectomy from 2010 to 2015 in a National Cancer Institute designated center. Ischemic conditioning (IC) was performed on morbidly obese patients, those with cardiovascular disease or uncontrolled diabetes, and those requiring feeding jejunostomy and active tobacco users. IC consisted of transection of the short gastric vessels and ligation of the left gastric vessels. Primary outcomes consisted of all postoperative anastomotic complications. Secondary outcomes were overall morbidity. RESULTS: Two-hundred and seven esophagectomies were performed with an average follow-up of 19 months. Thirty-eight patients (18.4%) underwent conditioning (IC). This group was similar to patients not conditioned (NIC) in age, preoperative pathology, and surgical approach. Five patients in the ischemic conditioning group (13.2%) and 57 patients (33.7%) in the NIC experienced anastomotic complications (p = 0.011). Ischemic conditioning significantly reduced the postoperative stricture rate fourfold (5.3 vs. 20.7% p = 0.02). IC patients experienced significantly fewer complications overall (36.8 vs. 56.2% p = 0.03). CONCLUSIONS: Gastric ischemic conditioning is associated with fewer overall anastomotic complications, fewer strictures, and less morbidity. Randomized studies may determine optimal selection criteria to determine whom best benefits from ischemic conditioning.

Leakage of an Invagination Pancreaticojejunostomy May Have an Influence on Mortality.

Purpose: No consensus exists regarding the most effective form of pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD). Methods: Data were gathered through the American College of Surgeons-National Surgical Quality Improvement Program, Pancreatectomy Demonstration Project. A total of 1781 patients underwent a PD at 43 institutions. After appropriate exclusions, 890 patients were analyzed. Patients were divided into duct-to-mucosa (n = 734, 82%) and invagination (n = 156, 18%) groups and were compared by unadjusted analysis. Type of PJ was included in eight separate morbidity and mortality multivariable analyses. Results: Invagination patients had higher serum albumin (p < 0.01) and lower body mass index (p < 0.01), were less likely to have a preoperative biliary stent (p < 0.01), and were more likely to have a soft gland (p < 0.01). PJ anastomosis type was not associated with morbidity but was associated with mortality (duct-to-mucosa vs. invagination, odds ratio = 0.22, p < 0.01). Among patients who developed a clinically relevant pancreatic fistula, none of the 119 duct-to-mucosa, compared with 5 of 21 invagination, patients died (p < 0.01). Conclusion: Patients who undergo a PJ by duct-to-mucosa or invagination differ with respect to preoperative and intraoperative variables. When an invagination PJ leaks, there may be a greater influence on mortality than when a duct-to-mucosa PJ leaks.

Two-Stage Explantation of a Magnetic Lower Esophageal Sphincter Augmentation Device Due to Esophageal Erosion.

INTRODUCTION: Implanting a magnetic lower esophageal sphincter augmentation device (LINX, Torax Medical) has become an increasingly common option in the surgical management of gastroesophageal reflux disease. As the enthusiasm for placing this device increases, experience in the management of device-related complications-including erosion-is necessary. METHODS: We report a staged approach to LINX removal in a 64-year-old female with symptoms of odynophagia secondary to partial erosion of a LINX device into the esophagus. RESULTS: The patient had a 12-bead LINX device placed in 2011 at an outside, international facility. In late 2013, she began experiencing symptoms of odynophagia. An esophagogastroduodenoscopy at our institution in October 2015 demonstrated two metallic beads eroding through the distal esophageal lumen. An elective endoscopic removal of the two visible beads was performed. A postoperative esophagram confirmed that there was no resulting esophageal perforation. The patient noted mild improvement in her symptoms. After a 12-week period to allow for complete healing, the remaining 10 beads of the LINX device were explanted laparoscopically without complication. No further procedures were undertaken. At 2 months' follow-up, the patient noted complete resolution of her symptoms. CONCLUSION: Transmural erosion of the LINX device into the esophageal lumen is a rare occurrence, with only five such complications reported in the published literature. We present the first account of LINX explantation for esophageal erosion in the United States. We demonstrated that a staged laparoendoscopic approach to LINX removal in these cases is feasible with minimal morbidity.

Relative impact of surgeon and hospital volume on operative mortality and complications following pancreatic resection in Medicare patients.

BACKGROUND: Surgeon and hospital volume are both known to affect outcomes for patients undergoing pancreatic resection. The objective was to evaluate the relative effects of surgeon and hospital volume on 30-d mortality and 30-d complications after pancreatic resection among older patients. MATERIALS AND METHODS: The study used Texas Medicare data (2000-2012), identifying high-volume surgeons as those performing ≥4 pancreatic resections/year, and high-volume hospitals as those performing ≥11 pancreatic resections/year, on Medicare patients. Three-level hierarchical logistic regression models were used to evaluate the relative effects of surgeon and hospital volumes on mortality and complications, after adjusting for case mix differences. RESULTS: There were 2453 pancreatic resections performed by 490 surgeons operating in 138 hospitals. Of the total, 4.5% of surgeons and 6.5% of hospitals were high volume. The overall 30-d mortality was 9.0%, and the 30-d complication rate was 40.6%. Overall, 8.9% of the variance in 30-d mortality was attributed to surgeon factors and 9.8% to hospital factors. For 30-d complications, 4.7% of the variance was attributed to surgeon factors and 1.2% to hospital factors. After adjusting for patient, surgeon, and hospital characteristics, high surgeon volume (odds ratio [OR] = 0.54, 95% confidence interval [CI], 0.33-0.87) and high hospital volume (OR = 0.52; 95% CI, 0.30-0.92) were associated with lower risk of mortality; high surgeon volume (OR = 0.71, 95% CI, 0.55-0.93) was also associated lower risk of 30-d complications. CONCLUSIONS: Both hospital and surgeon factors contributed significantly to the observed variance in mortality, but only surgeon factors impacted complications.

Trends in Receipt and Timing of Multimodality Therapy in Early-Stage Pancreatic Cancer.

INTRODUCTION: Pancreatic cancer is considered a systemic disease at presentation. Therefore, multimodality therapy with surgical resection and chemotherapy is the standard of care for locoregional disease. We described treatment patterns and time trends with regard to age and treatment center in the receipt of multimodality therapy. METHODS: We used the National Cancer Data Base to identify patients ≥18 years old with stage I and II pancreatic adenocarcinoma. Treatment was defined as no treatment, resection only, chemotherapy only, or multimodality therapy, which consisted of both chemotherapy (neoadjuvant or adjuvant) and resection. Trends in the receipt and type of treatment were compared. RESULTS: Of 39,441 patients, 22.8% of patients received no treatment, 18.5% received chemotherapy only, 23.0% underwent surgical resection alone, and 35.8% of patients received multimodality therapy. Receipt of multimodality therapy increased from 31.3% in 2004 to 37.9% in 2011 (p < 0.0001). Patients >55 years were less likely to receive multimodality therapy (56-64 years: OR 0.83, 95% CI 0.78-0.89; 65-75: OR 0.60, 95% CI 0.55-0.65; ≥76: OR 0.17, 95% CI 0.16-0.19 compared to patients 18-55). Compared to community hospitals, patients treated at an NCI-designated center were more likely to receive multimodality therapy (OR 1.62, 95% CI 1.46-1.81) and, if they received multimodality therapy, delivery of chemotherapy in the neoadjuvant compared to adjuvant setting (OR 2.82, 95% CI 2.00-3.98). CONCLUSION: Despite increased use of multimodality therapy, it remains underutilized in all patients and especially in older patients. Receipt of multimodality therapy and neoadjuvant therapy is highly dependent on treatment at NCI-designated cancer centers.

Laparoscopy decreases complications for obese patients undergoing elective rectal surgery.

INTRODUCTION: While there are many reported advantages to laparoscopic surgery compared to open surgery, the impact of a laparoscopic approach on postoperative morbidity in obese patients undergoing rectal surgery has not been studied. Our goal was to determine whether obese patients undergoing laparoscopic rectal surgery experienced the same benefits as non-obese patients. METHODS: We identified patients undergoing rectal resections using the National Surgical Quality Improvement Project Participant Use Data File. We performed multivariable analyses to determine the independent association between laparoscopy and postoperative complications. RESULTS: A total of 26,437 patients underwent rectal resection. The mean age was 58.5 years, 32.6 % were obese, and 47.2 % had cancer. Laparoscopic procedures were slightly less common in obese patients compared to non-obese patients (36.0 vs. 38.2 %, p = 0.0006). In unadjusted analyses, complications were lower with the laparoscopic approach in both obese (18.9 vs. 32.4 %, p < 0.0001) and non-obese (15.6 vs. 25.3 %, p < 0.0001) patients. In a multivariable analysis controlling for potential confounders, the risk of postoperative complications increased as the degree of obesity worsened. The likelihood of experiencing a postoperative complication increased by 25, 45, and 75 % for obese class I, obese class II, and obese class III patients, respectively. A laparoscopic approach was associated with a 40 % decreased odds of a postoperative complication for all patients (OR 0.60, 95 % CI 0.56-0.64). CONCLUSION: Laparoscopic rectal surgery is associated with fewer complications when compared to open rectal surgery in both obese and non-obese patients. Obesity was an independent risk factor for postoperative complications. In appropriately selected patients, rectal surgery outcomes may be improved with a minimally invasive approach.

Relative Contributions of Complications and Failure to Rescue on Mortality in Older Patients Undergoing Pancreatectomy.

BACKGROUND: For pancreatectomy patients, mortality increases with increasing age. Our study evaluated the relative contribution of overall postoperative complications and failure to rescue rates on the observed increased mortality in older patients undergoing pancreatic resection at specialized centers. METHODS: We identified 2694 patients who underwent pancreatic resection from the American College of Surgeons' National Surgical Quality Improvement Pancreatectomy Demonstration Project at 37 high-volume centers. Overall morbidity and in-hospital mortality were determined in patients younger than 80 years (N = 2496) and 80 years or older (N = 198). Failure to rescue was the number of deaths in patients with complications divided by the total number of patients with postoperative complications. RESULTS: No significant differences were observed between patients younger than 80 years and those 80 years or older in the rates of overall complications (41.4% vs 39.4%, P = 0.58). In-hospital mortality increased in patients 80 years or older compared to patients younger than 80 years (3.0% vs 1.1%, P = 0.02). Failures to rescue rates were higher in patients 80 years or older (7.7% vs 2.7%, P = 0.01). Across 37 high-volume centers, unadjusted complication rates ranged from 25.0% to 72.2% and failure to rescue rates ranged from 0.0% to 25.0%. Among patients with postoperative complications, comorbidities associated with failure to rescue were ascites, chronic obstructive pulmonary disease, and diabetes. Complications associated with failure to rescue included acute renal failure, septic shock, and postoperative pulmonary complications. CONCLUSIONS: In experienced hands, the rates of complications after pancreatectomy in patients 80 years or older compared to patients younger than 80 years were similar. However, when complications occurred, older patients were more likely to die. Interventions to identify and aggressively treat complications are necessary to decrease mortality in vulnerable older patients.