A Medium-Term Comparison of Quality of Life and Pain After Robotic or Laparoscopic Cholecystectomy.

INTRODUCTION: We sought to compare medium-term outcomes between robotic-assisted cholecystectomy (RC) and laparoscopic cholecystectomy (LC) using validated quality of life (QoL) and pain assessments. MATERIALS AND METHODS: Patients who underwent RC or LC between 2012 and 2017 at a single academic institution were examined. Cases converted to open were excluded. Patients were contacted by telephone in 2019 and completed two standardized surveys to rate their QoL and pain. RESULTS: Of those screened, 122 (35.8%) completed both surveys. Ninety three (76.2%) underwent RC and 29 (23.8%) underwent LC. The groups (RC versus LC) were similar based on mean age (47.9 versus 45.5 y, P = 0.48), gender (66.7% versus 72.4% female, P = 0.56), race (86.0% White/5.4% Black versus 72.4% White/13.8% Black, P = 0.2), insurance status (98.9% versus 100.0% insured, P = 0.58), median body mass index (31.8 versus 31.3, P = 0.43), and median Charlson Comorbidity Index (1 versus 0, P = 0.14). Fewer RC patients had a history of steroid use compared to LC (16.1% versus 34.5%, P = 0.03). No overall significant difference in QoL was demonstrated. LC group had higher severity of "tiring-exhausting pain" (P = 0.04), "electric-shock pain" (P = 0.003), and "shooting pain" (P = 0.05). The "overall intensity" of pain in the "gallbladder region" between the groups was similar at the time of follow-up (P = 0.31). CONCLUSIONS: QoL over 2-7 y following time of surgery is comparable for robotic-assisted versus conventional laparoscopic cholecystectomies. The laparoscopic approach may be associated with a higher severity of subset categories of pain, but overall pain between the two approaches is comparable.

Paving a Path to Gender Parity: Recent Trends in Participation of Women in an Academic Surgery Society (Society for Surgery of the Alimentary Tract).

INTRODUCTION: The proportion of women surgeons is increasing, although women in surgical leadership and research has not kept pace. The Society for Surgery of the Alimentary Tract (SSAT) pledged its commitment to diversity and inclusion in 2016. Our study sought to evaluate the temporal trend of gender representation in leadership, speakership, and research at SSAT. METHODS: Publicly available SSAT meeting programs from 2010 to 2022 were reviewed to assess gender proportions within leadership positions (officers and committee chairs); invited speakerships, multidisciplinary symposia, and committee panel session moderators and speakers; and contributions to scientific sessions (moderator, first author and senior author). Verified individual professional profiles were analyzed to categorize gender as woman, man, or unavailable. Descriptive and trend analyses using linear regression and chi-squared testing were performed. RESULTS: A total of 5506 individuals were reviewed; 1178 (21.4%) were identified as women and 4328 (78.6%) as men or did not have available data. The absolute proportion of total female participation increased by 1.05% per year (R2=0.82). There was a statistically significant difference in the total proportion of women participation before and after 2016 (18.5% vs. 27.1%, p<0.01). Increases in the proportion of women were demonstrated in leadership, invited speakerships, multidisciplinary symposia, committee panel sessions, research session moderators, and abstract first authors. The proportion of women senior authors remained stagnant. CONCLUSION: Though this upward trajectory in SSAT women participation is encouraging, current trends predict that gender parity will not be reached until 2044.

Prospective Assessment of Social Determinants of Health and Length of Stay Among Emergency General Surgery and Trauma Patients.

BACKGROUND: Social determinants of health (SDOH) including insurance and substance use affect 50-90% of health outcomes, yet there remains no standard means to quantify or predict their impact. We prospectively evaluated the effects of SDOH on length of stay (LOS) and readmissions among emergency general surgery (EGS) and trauma patients. We compared these outcomes with Medicare Diagnosis Related Group (DRG) data to better quantify the impact of SDOH. METHODS: Adult (≥18 years old) EGS/trauma patients admitted July 7-28, 2020 at a Level 1 trauma center were prospectively enrolled. Primary outcomes were overall LOS, one-year readmissions, and excess LOS (eLOS), defined as days beyond DRG mean LOS. RESULTS: Assessment of SDOH among the 52 patients enrolled revealed that 5.8% of patients were homeless; 26.9% experienced substance abuse; 13.5% were uninsured on admission; and 7.7% on discharge. Mean LOS was 5 ± 4 days; 1-year readmission rate 25.0%; eLOS mean 1.75 ± 2.4 days. LOS was associated with substance use (OR 70.6 95% CI 11.7-160.4). eLOS was associated with substance use (OR 6.1, 95% CI 1.5-25.1) and public or no insurance (OR 26.0, 95% CI 4.9-138.1). No correlations were found between SDOH and readmission rates. DISCUSSION: EGS and trauma patients experience high rates of negative SDOH which affect clinical outcomes including LOS and readmissions. Medicare DRG determined eLOS is a fiscally relevant measure of the impact of SDOH and differs from LOS and readmissions. Further investigation is required to determine if eLOS can delineate the effects of other SDOH on admission outcomes for this patient population.

Identification of Populations at Risk for "Choosing Un-Wisely": A SEER Population-Based Study.

BACKGROUND: Since 2016, the Choosing Wisely campaign has recommended against routine axillary surgery in elderly patients with early stage, hormone receptor positive (ER+) breast cancer. The objective was to evaluate factors associated with axillary surgery in breast cancer patients meeting criteria for sentinel lymph node biopsy (SLNB) omission and identify potential disparities. METHODS: Female patients age ≥70 years with cT1-2N0M0, ER+, HER2-negative breast cancer diagnosed after publication of the Choosing Wisely recommendations, between 2016 and 2019, were identified from the Surveillance, Epidemiology, and End Results (SEER) database. Patient demographics and tumor characteristics associated with axillary surgery were analyzed. RESULTS: Of the 31 756 patients meeting omission criteria, 25 771 (81.2%) underwent axillary surgery. Hispanic ethnicity, median household income between $35,000 and $70,000, treatment in rural areas, poor differentiation, lobular and mixed lobular with ductal histology, T2 tumors, radiation therapy, and systemic therapy were factors associated with receiving axillary surgery on multivariable analysis. In the axillary surgery cohort, a median of 2 (IQR = 2) nodes were examined and 529 (2.1%) patients were found to have 1 or more positive lymph nodes. DISCUSSION: Among elderly patients meeting Choosing Wisely criteria for SLNB omission, particular racial, ethnic, socioeconomic, and geographic populations may be at increased risk for potential over treatment. Identification of these factors provides specific opportunities for education and implementation of de-escalation of unnecessary procedures.

Disruption of National Cancer Database Data Models in the First Year of the COVID-19 Pandemic.

Importance: Each year, the National Cancer Database (NCDB) collects and analyzes data used in reports to support research, quality measures, and Commission on Cancer program accreditation. Because data models used to generate these reports have been historically stable, year-to-year variances have been attributed to changes within the cancer program rather than data modeling. Cancer submissions in 2020 were anticipated to be significantly different from prior years because of the COVID-19 pandemic. This study involved a validation analysis of the variances in observed to expected 2020 NCDB cancer data in comparison with 2019 and 2018. Observations: The NCDB captured a total of 1 223 221 overall cancer cases in 2020, a decrease of 14.4% (Δ = -206 099) compared with 2019. The early months of the COVID-19 pandemic (March-May 2020) coincided with a nadir of cancer cases in April 2020 that did not recover to overall prepandemic levels through the remainder of 2020. In the early months of the COVID-19 pandemic, the proportion of early-stage disease decreased sharply overall, while the proportion of late-stage disease increased. However, differences in observed to expected stage distribution in 2020 varied by primary disease site. Statistically significant differences in the overall observed to expected proportions of race and ethnicity, sex, insurance type, geographic location, education, and income were identified, but consistent patterns were not evident. Conclusions and Relevance: Historically stable NCDB data models used for research, administrative, and quality improvement purposes were disrupted during the first year of the COVID-19 pandemic. NCDB data users will need to carefully interpret disease- and program-specific findings for years to come to account for pandemic year aberrations when running models that include 2020.

Operating Room Lockers and Gender Equity in the Surgical Workforce.

This study assesses gender parity in operating room locker room conditions.

Evaluating information loss in the National Cancer Database from cases lost to follow-up.

BACKGROUND AND OBJECTIVES: Cancer registries must focus on data capture which returns value while reducing resource burden with minimal loss of data. Identifying the optimum length of follow-up data collection for patients with cancer achieves this goal. METHODS: A two-step analysis using entropy calculations to assess information gain for each follow-up year, and second-order differences to compare survival outcomes between the defined follow-up periods and lifetime follow-up. A total of 391 567 adult cases, deidentified in the National Cancer Database and diagnosed in 1989. Comparisons examined a subset of 61 908 lung cancer cases, 48 387 colon and rectal cancer cases, and 64 134 breast cancer cases in adults. A total of 4133 pediatric cases were diagnosed in 1989 examining 1065 leukemia cases and 494 lymphoma cases. RESULTS: Annual increases in information gain fell below 1% after 16 years of follow-up for adult cases and 9 years for pediatric cases. Comparison of second-order differences showed 62% of the comparisons were similar between 15 years and lifetime follow-up when examining restricted mean survival time. In addition, 90% of the comparisons were statistically similar when comparing hazard ratios. CONCLUSIONS: Survival analysis using 15 years postdiagnosis follow-up showed minimal differences in information gain compared to lifetime follow-up.

Omission of Radiation in Conservative Treatment for Breast Cancer: Opportunity for De-escalation of Care.

INTRODUCTION: De-escalation of breast cancer treatment aims to reduce patient and financial toxicity without compromising outcomes. Level I evidence and National Comprehensive Cancer Network guidelines support omission of adjuvant radiation in patients aged >70 y with hormone-sensitive, pT1N0M0 invasive breast cancer treated with endocrine therapy. We evaluated radiation use in patients eligible for guideline concordant omission of radiation. METHODS: Subgroup analysis of patients eligible for radiation omission from two pooled randomized controlled trials, which included stage 0-III breast cancer patients undergoing breast conserving surgery, was performed to evaluate factors associated with radiation use. RESULTS: Of 631 patients, 47 (7.4%) met radiation omission criteria and were treated by 14 surgeons at eight institutions. The mean age was 75.3 (standard deviation + 4.4) y. Majority of patients identified as White (n = 46; 97.9%) and non-Hispanic (n = 44; 93.6%). The mean tumor size was 1.0 cm; 37 patients (88.1%) had ductal, 4 patients (9.5%) had lobular, and 17 patients (40.5%) had low-grade disease. Among patients eligible for radiation omission, 34 (72.3%) patients received adjuvant radiation. Those who received radiation were significantly younger than those who did not (74 y, interquartile range = 4 y, versus 78 y, interquartile range = 11 y, P = 0.03). There was no difference in radiation use based on size (P = 0.4), histology (P = 0.5), grade (P = 0.7), race (P = 1), ethnicity (P = 0.6), institution (P = 0.1), gender of the surgeon (P = 0.7), or surgeon (P = 0.1). CONCLUSIONS: Fewer than 10% of patients undergoing breast conservation met criteria for radiation omission. Nearly three-quarters received radiation therapy with younger age being a driver of radiation use, suggesting ample opportunity for de-escalation, particularly among younger eligible patients.

Twenty-Five Years of Cancer Follow-Up; Is the Data Worth the Effort?

BACKGROUND: Substantial resources are dedicated to long-term follow-up within cancer registries; however, the completeness of these data is poorly characterized. Our objectives were to quantify long-term cancer follow-up data completeness and the effort required to collect these data using the National Cancer Database (NCDB). METHODS: To quantify data completeness, patients diagnosed with cancer in 1989 were identified in the NCDB and loss to follow-up rates were assessed for 25 years after diagnosis. To quantify data collection effort, patients diagnosed from 1989 to 2014 who were alive and eligible for follow-up in 2014 were identified and the effort to perform patient follow-up was obtained via a survey of tumor registrars. The effort to perform follow-up beyond various intervals after diagnosis was calculated. RESULTS: In total, 484,201 patients at 958 hospitals were diagnosed with cancer in 1989. After 5 years, 6.5% of patients were lost to follow-up (13.1% of living patients), 50.3% were deceased, and 43.2% had ongoing follow-up. After 15 years, 22.9% were lost to follow-up (68.7% of living patients), 66.7% were deceased, and 10.5% had ongoing follow-up. By 25 years, loss to follow-up increased to 28.6% (93.7% of living patients), 69.5% were deceased, and 1.9% had ongoing follow-up. In 2014, 522,838 h were spent performing follow-up for 2,091,353 patients at 1456 hospitals who were >15 years from their initial cancer diagnosis. CONCLUSIONS: While 5-year follow-up is excellent in the NCDB, loss to follow-up increases over time. The impact of curtailing data collection is under investigation and follow-up duration requirements will be re-evaluated.

Recovery of Screening Mammogram Cancellations During COVID-19.

BACKGROUND: In response to the COVID-19 pandemic, the American Society of Breast Surgeons and American College of Radiology released a joint statement recommending that all breast screening studies be postponed effective March 26, 2020. STUDY DESIGN: A retrospective review of all canceled mammograms at a single tertiary care institution from January 1-August 31, 2020 was performed to evaluate the effect of this recommendation by quantifying both the number and reason for mammogram cancellations before and after March 26, 2020. Utilization of the electronic patient portal for appointment cancellation as a surrogate for telehealth uptake was noted. RESULTS: During the study period, 5340 mammogram appointments were kept and 2784 mammogram appointments were canceled. From a baseline of 30 (10.8%) canceled mammograms in January, cancellations peaked in March (576, 20.6%) and gradually decreased to a low in August (197, 7%). Reasons for cancellations varied significantly by month (P < .0001) and included COVID-19 related (236, 8.5%), unspecified patient reasons (1,210, 43.5%), administrative issues (147, 5.3%), provider requests (46, 1.7%), sooner appointments available (31, 1.1%), and reasons not given (486, 17.5%). In addition, compared to a baseline in January (51, 16.5%), electronic patient portal access peaked in August (67, 34.0%). CONCLUSION: Screening mammogram cancellations have gradually recovered after early COVID-19 restrictions were lifted and increasing use of electronic patient access appears to be sustained. Consequences for future staging at the time of diagnosis remain unknown. Understanding to what extent the pandemic affected screening may help surgeons plan for post-pandemic breast cancer care.

Improvement in Breast Reconstruction Disparities following Medicaid Expansion under the Affordable Care Act.

BACKGROUND:  Under the Affordable Care Act, Medicaid expansion effective 1 January 2014 aimed to increase access to health care. We sought to determine the association of Medicaid expansion with disparities in utilization of breast reconstruction. METHODS: Non-Hispanic Black (NHB) and White (NHW) breast cancer patients undergoing mastectomy +/- reconstruction between 2010 and 2017 were selected from the National Cancer Database. Annual trends for utilization of breast reconstruction by race, income, and education were evaluated by Medicaid expansion status using difference-in-differences regression analyses. Medicaid expansion was categorized by expansion date as early (2010-2013), 2014 (1/2014), late (after 1/2014), or no expansion. RESULTS: Of 443,607 patients, 36.3% (n = 161,128) underwent reconstruction, 13.1% (n = 58,249) were NHB, 16.8% (n = 74,430) had median income < $40,227, and 17.1% (n = 75,718) were in the lowest education quartile. In non-expansion states, lower proportions of NHB patients underwent reconstruction than NHW patients in all years, with the smallest disparity (NHB% - NHW%) (- 6.4%) in 2017. Decreases in disparities between NHB and NHW patients were seen with the smallest difference observed in 2014 (- 2.5%) in early-expansion states, in 2017 (- 0.7%) in 1/2014 expansion states, and in 2017 (- 4.5%) in late-expansion states. Similar findings for convergence of reconstruction utilization rates for the lowest two education levels and lowest two income quartiles were found with Medicaid expansion, with no convergence seen in non-expansion states over the study period. CONCLUSIONS: Some improvement in breast reconstruction disparities followed Medicaid expansion. Failure to improve parity without Medicaid expansion should be a consideration with any modifications to Medicaid access.

Compliance With Surgical Oncology Specialty Care at a Safety Net Facility.

BACKGROUND: Social determinants of health challenge in at-risk patients seen in safety net facilities. STUDY DESIGN: We performed a retrospective review of surgical oncology specialty clinic referrals at a safety net institution evaluating referral compliance and times to first appointment and initiation of definitive treatment. Main outcomes measured included completion of initial visit, initiation of definitive treatment, time from referral to first appointment, and time from first appointment to initiation of definitive treatment. RESULTS: Of 189 new referrals, English was not spoken by 52.4% and 69.4% were Hispanic. Patients presented without insurance in 39.2% of cases. Electronic patient portal was accessed by 31.6% of patients. Of all new referrals, 55.0% arrived for initial consultation and 53.4% initiated definitive treatment. Malignant diagnosis (P < .0001) and lack of insurance (P = .01) were associated with completing initial consultation. Initiation of definitive treatment was associated with not speaking English (P = .03), malignant diagnosis (P < .0001), and lack of insurance (P = .03). Times to first appointment and initiation of definitive treatment were not significantly affected by race/ethnicity, language, insurance, treatment recommended, or electronic patient portal access. CONCLUSION: Access to surgical oncology care for at-risk patients at a safety net facility is not adversely affected by lack of insurance, primary spoken language, or race/ethnicity. However, a significant proportion of all patients fail to complete the initial consultation and definitive treatment. Lessons learned from safety net facilities may help to inform disparities in health care found elsewhere.

Resection of Cavity Shave Margins in Stage 0-III Breast Cancer Patients Undergoing Breast Conserving Surgery: A Prospective Multicenter Randomized Controlled Trial.

OBJECTIVE: Single-center studies have demonstrated that resection of cavity shave margins (CSM) halves the rate of positive margins and re-excision in breast cancer patients undergoing partial mastectomy (PM). We sought to determine if these findings were externally generalizable across practice settings. METHODS: In this multicenter randomized controlled trial occurring in 9 centers across the United States, stage 0-III breast cancer patients undergoing PM were randomly assigned to either have resection of CSM ("shave" group) or not ("no shave" group). Randomization occurred intraoperatively, after the surgeon had completed their standard PM. Primary outcome measures were positive margin and re-excision rates. RESULTS: Between July 28, 2016 and April 13, 2018, 400 patients were enrolled in this trial. Four patients (2 in each arm) did not meet inclusion criteria after randomization, leaving 396 patients for analysis: 196 in the "shave" group and 200 to the "no shave" group. Median patient age was 65 years (range; 29-94). Groups were well matched at baseline for demographic and clinicopathologic factors. Prior to randomization, positive margin rates were similar in the "shave" and "no shave" groups (76/196 (38.8%) vs. 72/200 (36.0%), respectively, P = 0.604). After randomization, those in the "shave" group were significantly less likely than those in the "no shave" group to have positive margins (19/196 (9.7%) vs. 72/200 (36.0%), P < 0.001), and to require re-excision or mastectomy for margin clearance (17/196 (8.7%) vs. 47/200 (23.5%), P < 0.001). CONCLUSION: Resection of CSM significantly reduces positive margin and re-excision rates in patients undergoing PM.

Impact of Robotic Surgery on Residency Training for Herniorrhaphy and Cholecystectomy.

Robotic surgery has increased for common general surgery procedures. This study evaluates how robotic use affects the case distributions of herniorrhaphy and cholecystectomy for general surgery residents according to postgraduate year (PGY). We reviewed Accreditation Council for Graduate Medical Education (ACGME) biliary or hernia cases logged by surgical residents in the academic year 2017-2018. Operative reports were reviewed to compare approaches (robotic, laparoscopic, and open) by resident role and PGY level. Open cholecystectomies were excluded. Overall, 470 hernia and 657 cholecystectomy cases were logged. Hernia repairs were performed robotically in 15.9%, laparoscopically in 9.5%, and open in 74.7%. Cholecystectomies were performed robotically in 16.4% and laparoscopically in 83.6%. Residents were teaching assistants in 1.8% of hernia repairs and 1.5% of cholecystectomies. Distribution of cases by technique and PGY level was significantly different for both procedures, with chief residents performing the majority of robotic cholecystectomies (52.6%, P < .0001) and hernia repairs (59.7%, P < .0001). Migration of robotic cases to senior resident level and low percentage of teaching assistant roles held by residents suggest exposure to common operations may be delayed during general surgery residency training. Introduction of new technology in surgical training should be carefully reviewed and may benefit from a structured curriculum.

Do Better Operative Reports Equal Better Surgery? A Comparative Evaluation of Compliance With Operative Standards for Cancer Surgery.

To improve the quality of cancer operations, the American College of Surgeons published Operative Standards for Cancer Surgery, which has been incorporated into Commission on Cancer (CoC) accreditation requirements. We sought to determine if compliance with operative standards was associated with technical surgical outcomes. Oncologic operative reports from 2017 at a CoC and non-CoC institution were examined for documentation of Operative Standards essential steps. Lymph node (LN) yield for lung and colon cases and re-excision rates for breast cases were recorded. Correct documentation was poor for colon, breast, and lung cases with numerous elements documented in <10% of operative reports at both centers. For lung cases, there was no significant difference in meeting ≥10 LN benchmark or average LN yield between the 2 institutions. For colon cases, average lymph node yield was lower in the non-CoC facility, but there was no significant difference in meeting ≥12 LN benchmark. For breast cases, re-excision rates were similar in both programs. Many essential steps in Operative Standards were poorly documented in operative reports, regardless of CoC status. Achieving benchmark technical surgical outcomes was not associated with documented compliance with these standards. Whether improved documentation leads to better surgical outcomes requires further investigation.

Has Breast Surgery Shattered the Glass Ceiling? Trends in Female Representation at The American Society of Breast Surgeons Annual Meeting 2009-2019.

BACKGROUND: Our study sought to evaluate gender representation and the impact of gender on the large volume of research presented at The American Society of Breast Surgeons (ASBrS) Annual Meeting, the largest breast surgery meeting in the United States. METHODS: Publicly available ASBrS meeting programs and proceedings from 2009 to 2019 were reviewed to ascertain proportions of female engagement in society positions, contributions to scientific sessions, and subsequent manuscript publications. Trend analyses for temporal changes in gender representation and univariate tests of associations between authorship gender and publication success were performed. RESULTS: Women comprised 44.8% of members of the board of directors, 41.7% of committee chairs, and 54.8% of committee members. There were significant annual increased proportions of female committee members (3.2% per year, p = 0.01) and chairs (6.0% per year, p = 0.03). Women represented > 50% of all speakership positions, except keynote (42.2%). For oral, quickshot, and poster scientific presentations, > 70% of first authors and > 60% of senior authors were women. The meeting-related publication rate with female senior authorship was higher than that with male senior authorship (41.0% vs. 36.3%, p = 0.04). CONCLUSIONS: Although female surgeons remain a minority at most conferences, women have represented the majority of participants in committees, speakership, and scientific presentations at the ASBrS Annual Meeting over the past 10 years. The glass ceiling in breast surgery has been shattered, but efforts to improve gender equity must continue, not only in breast surgery, but all surgical specialties.