Role of mFI-5 in predicting geriatric outcomes in laparoscopic cholecystectomy.

BACKGROUND: Frailty is the age-related decline contributing to adverse outcome vulnerability. This study assesses the modified 5-factor frailty index's (mFI-5) ability to predict geriatric cholecystectomy outcomes. METHODS: Laparoscopic cholecystectomy patients ages ≥65 were identified from the American College of Surgeons' National Surgical Quality Improvement Program database (2018-2020). MFI-5 variables include hypertension, congestive heart failure, chronic obstructive pulmonary disease, diabetes, and functional status. Groups were stratified according to the number of comorbidities: mFI â€‹= â€‹0, mFI â€‹= â€‹1, mFI≥2. RESULTS: 32,481 cases included 27.6% mFI â€‹= â€‹0, 46.4% mFI â€‹= â€‹1, 26.0% mFI≥2. Highest frailty correlated with increased discharges to not home (OR 1.88, p â€‹< â€‹0.01). Non-independent functional status was associated with mortality (OR 7.32), prolonged length of stay (LOS) (5.69), pneumonia (4.90), sepsis (3.78), readmission (2.60) (p â€‹< â€‹0.01). AUCs were calculated for prolonged LOS (0.89), discharges to not home (0.85), mortality (0.83), pneumonia (0.76), sepsis (0.76). CONCLUSIONS: Healthcare teams can use mFI-5 to target at-risk cholecystectomy patients and proactively intervene to avoid complications.

Surgery Improves Patient-Reported Outcomes in Patients with Intestinal and Pancreatic NETs: A Prospective Analysis.

BACKGROUND: Incorporation of patient-reported outcomes such as health-related quality of life has become increasingly important in the management of chronic diseases such as cancer. In this prospective study, we examined the effect of surgical resection on quality of life in patients with intestinal and pancreatic neuroendocrine tumors (NETs). METHODS: Thirty-two patients underwent NET resection at our institution from January 2020 to January 2022. All patients completed the 12-item short-form quality-of-life survey prior to surgery, as well as at the 3-, 6-, and 12-month postoperative time points. The presence and severity of specific carcinoid syndrome symptoms (diarrhea, flushing, and abdominal pain) were also recorded during pre- and postoperative appointments. RESULTS: Patients experienced significant increases in both mental and physical health after surgery. Mental health scores significantly increased at all three time points (baseline: 51.33; 3-month: 53.17, p = 0.02; 6-month: 57.20, p < 0.001; 12-month: 57.34, p = 0.002), and physical health scores increased at 6 and 12 months (baseline: 50.39; 6-month: 53.16, p = 0.04; 12-month: 55.02, p = 0.003). Younger patients benefited more in terms of physical health, while older patients had more significant increases in mental health. Patients with metastatic disease, larger primary tumors, and those receiving medical therapy had lower baseline quality-of-life scores and greater improvements after surgery. The vast majority of patients in this study also experienced alleviation of carcinoid syndrome symptoms. CONCLUSIONS: In addition to prolonging survival, resection of intestinal and pancreatic NETs leads to significantly improved patient-reported quality of life.

Expert Consensus for Key Features of Operative Reports of Ventral Hernia.

BACKGROUND: Operative reports are important documents; however, standards for critical elements of operative reports are general and often vague. Hernia surgery is one of the most common procedures performed by general surgeons, so the aim of this project was to develop a Delphi consensus on critical elements of a ventral hernia repair operative report. STUDY DESIGN: The Delphi method was used to establish consensus on key features of operative reports for ventral hernia repair. An expert panel was selected and questionnaires were distributed. The first round of voting was open-ended to allow participants to recommend what details should be included. For the second round the questionnaire was distributed with the items that did not have unanimous responses along with free text comments from the first round. RESULTS: Eighteen surgeons were approached, of which 11 completed both rounds. Twenty items were on the initial questionnaire, of which 11 had 100% agreement. Of the remaining 9 items, after the second questionnaire an additional 7 reached consensus. CONCLUSION: Ventral hernia repairs are a common and challenging problem and often require reoperations. Surgeons frequently refer to previous operative notes to guide future procedures, which requires detailed and comprehensive operative reports. This Delphi consensus was able to identify key components needed for an operative report describing ventral hernia repair.

Diabetes as a Risk Factor for Perforated Appendicitis: A National Analysis.

BACKGROUND: A few important risk factors play into rates of perforation following acute appendicitis. Diabetes may be an additional risk factor due to various systemic complications that may contribute to perforation and additional adverse outcomes following acute appendicitis, all of which currently remains unknown in the United States. METHODS: Adult patients with acute appendicitis under 65 years of age were identified from the National Inpatient Sample between 2012 and 2014 and the distribution of baseline variables was examined across diabetic status using Rao-Scott chi square and student's t-test. A propensity score match was implemented for a conditional logistic regression that assessed differences in rates of perforation, outcomes, as well as postoperative complications. RESULTS: Among all patients with acute appendicitis, approximately 7% had diabetes. Diabetics were more likely to experience perforated appendicitis (odds ratio 95% confidence interval 1.093 (1.029, 1.160); P = .0036), experience a longer length of stay (1.540 (1.434, 1.654); P < .0001), receive an open appendectomy (1.139 (1.05, 1.236); P = .0018), and experience postoperative cardiovascular complications (2.103 (1.325, 3.340)); P = .0016). DISCUSSION: Diabetic adult patients under 65 years of age with acute appendicitis experience higher rates in perforation, a longer length of stay, more open surgical approach, and cardiovascular postoperative complications. Diabetes should be one of many risk factors considered in the evaluation and management of perforation following acute appendicitis.

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.

Resection Prolongs Overall Survival for Nonmetastatic Midgut Small Bowel Neuroendocrine Tumors: A National Cancer Data Base Study.

OBJECTIVES: This study aimed to understand if resection (RS) for nonmetastatic small bowel neuroendocrine tumors (SBNETs) prolongs 5-year overall survival. METHODS: Patients from National Cancer Data Base with primary histologically confirmed SBNETs from 2007 to 2016 were included. Patients younger than 18 years, with the disease in the duodenum/Meckel diverticulum or metastatic disease were excluded. We assessed 5-year survival rates using Kaplan-Meier curves and multivariate Cox proportional hazards regression after RS, nonresection surgical management (NRS), or no resection (NR). Multivariate models were adjusted with age, sex, race, insurance, Charlson-Deyo comorbidity score, academic facility, primary tumor location, clinical T, clinical N, stage, and grade. RESULTS: We identified 4180 patients. On average, patients were 64 years old (standard deviation, 12 years), male (53%), and White (84%). The majority received RS (91.8%) as opposed to NRS (4.0%) or NR (4.2%). Patients who received RS versus NR had increased survival rates (84.2% vs 73.9%; univariate log-rank, P < 0.0001; multivariate hazard ratio, 0.73; 95% confidence interval, 0.53-0.99; P = 0.04). No statistical difference in survival was observed for NRS versus NR. CONCLUSIONS: To our knowledge, this is the first national study to evaluate survival after RS for nonmetastatic SBNETs. Results suggest that RS of SBNETs may prolong 5-year survival.

Emotional Regulation in Surgery: Fostering Well-Being, Performance, and Leadership.

Emotional regulation is increasingly gaining acceptance as a means to improve well-being, performance, and leadership across high-stakes professions, representing innovation in thinking within the field of surgical education. As one part of a broader cognitive skill set that can be trained and honed, emotional regulation has a strong evidence base in high-stress, high-performance fields. Nevertheless, even as Program Directors and surgical educators have become increasingly aware of this data, with emerging evidence in the surgical education literature supporting efficacy, hurdles to sustainable implementation exist. In this white paper, we present evidence supporting the value of emotional regulation training in surgery and share case studies in order to illustrate practical steps for the development, adaptation, and implementation of emotional regulation curricula in three key developmental contexts: basic cognitive skills training, technical skills acquisition and performance, and preparation for independence. We focus on the practical aspects of each case to elucidate the challenges and opportunities of introducing and adopting a curricular innovation into surgical education. We propose an integrated curriculum consisting of all three applied contexts for emotional regulation skills and advocate for the dissemination of such a longitudinal curriculum on a national level.

The 5-Factor Modified Frailty Index in the Geriatric Surgical Population.

BACKGROUND: The modified frailty index (mFI-11) is a National Surgical Quality Improvement Program (NSQIP)-based 11-factor index that has been proven to adequately reflect frailty and predict mortality and morbidity. In the past years, certain NSQIP variables have been removed from the database; as of 2015, only 5 out of the original 11 factors remain. While the predictive power and usefulness of this 5-factor index (mFI-5) has been proven in previous work, it has yet to be studied in the geriatrics population. The goal of our study was to compare the mFI-5 to the mFI-11 in terms of value and predictive ability for mortality, postoperative infection, and unplanned 30-day readmission for patients aged 65 years and older. METHODS: Spearman's Rho was calculated to compare the value, and unadjusted and adjusted logistic regressions were created for three outcomes in nine surgical subspecialties. Correlation coefficients were above .86 across all surgical specialties except for cardiac surgery. Adjusted and unadjusted models showed similar C-statistics for mFI-5 and 11. RESULTS: Overall predictive values of geriatric mFI-5 and mFI-11 were lower than those for the general population but still had effective predictive value for mortality and post-operative complications (C-Stat ≥ .7) and weak predictive value for 30-day readmission. CONCLUSIONS: The mFI-5 is an equally effective predictor as the mFI-11 in all subspecialties and an effective predictor of mortality and postoperative complication in the geriatric population. This index has credibility for future use to study frailty within NSQIP, within other databases, and for clinical assessment and use.

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.

Is preoperative anemia a significant risk factor for splenectomy patients? A NSQIP analysis.

BACKGROUND: Prior literature has examined the association between preoperative anemia and complications across surgical settings; however, evidence is lacking for splenectomy patients. We investigated the association between preoperative hematocrit and 30-day postoperative outcomes in this population using a national database. METHODS: Patients who underwent splenectomy (2012-2017) were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Analyses were performed for the overall cohort and elective versus emergent subsets, adjusting for transfusion among other covariates. RESULTS: Our sample included 5,580 patients. As hematocrit decreased, complication rates increased incrementally in both the univariate and multivariate analyses. Adjusted odds ratios (and 95% confidence intervals) for moderate anemia (26% ≤ hematocrit < 30%) as compared to no anemia (hematocrit ≥ 38%) were readmission = 1.5 (1.1-1.8), sepsis = 2.2 (1.6-3.0), and composite outcome = 1.8 (1.0-3.2). Parameter estimates (standard error, P value) for the moderate versus no anemia group were length of stay = 3.0 (0.5, P < .001) and days to discharge = 1.2 (0.3; P < .001). CONCLUSION: Our results demonstrate a dose-response relationship between increasing degree of anemia and odds of various postoperative adverse outcomes after adjusting for several potential confounders. The subset analysis further suggests that elective splenectomy cases are more likely to have poor outcomes when in the presence of anemia or when transfusions are performed as compared to emergent cases. This suggests that the harm associated with transfusion may offset the benefit of optimizing anemia in an elective splenectomy case.

Do Socioeconomic Disparities Exist in Postoperative Opioid Prescription and Consumption?

BACKGROUND: Since 1999, >200 000 people in the United States have died from a prescription opioid overdose. Lower socioeconomic status (SES) is one important risk factor. This study investigates socioeconomic disparities in postoperative opioid prescription and consumption. METHODS: September 2018-April 2019, 128 patients were surveyed postoperatively regarding opioid consumption. The neighborhood disadvantage was calculated using area deprivation index (ADI). The top 3 quartiles were "high SES" and the bottom quartile "low SES." RESULTS: The study population included 96 high SES patients, median ADI 6 (2-12.3) and 32 low SES, median ADI 94.5 (81.3-97.3). For both, median Oxycodone 5 mg prescribed was 20 pills. 29.2% of high SES consumed 0 pills, 40.6% consumed 1-9 pills, and 27.1% consumed 10+ pills. 25.0% of low SES consumed 0 pills, 46.9% consumed 1-9 pills, and 18.8% consumed 10+ pills. No significant difference in opioid prescription (P = .792) or consumption (P = .508) between SES groups. DISCUSSION: Patients of all SES are prescribed and consumed opioids in similar patterns with no significant difference in postoperative pain following ambulatory surgery.

Prognostic Factors Associated With Progression for Advanced-Stage/G1 and G2 Small-Bowel Neuroendocrine Tumors After Multimodal Therapy: Experience From a Tertiary Referral Center.

OBJECTIVES: Neuroendocrine tumors represent approximately 40% of primary small bowel malignancies. However, factors predictive of progression after multimodal surgical therapy have not been well described. We evaluated the characteristics of small bowel neuroendocrine tumor patients associated with progression after multimodal surgical resection. METHODS: A retrospective chart review identified 99 stage III and stage IV small bowel neuroendocrine tumor patients at Mount Sinai diagnosed and treated with surgery between 2005 and 2019. Progression-free survival (PFS) was defined as time from surgery until progression in surveillance radiologic imaging. Kaplan-Meier method was used to calculate PFS. Cox proportional hazard models were used to study the prognostic factors for PFS. RESULTS: Of 99 patients, 48 had tumor progression during the follow-up period. Median PFS was 5.7 years (95% confidence interval [CI], 3.73-8.66) for the entire cohort. Prognostic factors for PFS were age at diagnosis (hazard ratio [HR], 1.04; 95% CI, 1.01-1.07), perineural invasion (HR, 2.19; 95% CI, 1.13-4.23), and elevated preoperative chromogranin level (HR, 2.31; 95% CI, 1.01-5.27). CONCLUSIONS: Age at diagnosis, perineural invasion, and elevated preoperative chromogranin level may play a prognostic role in PFS.

Pre-operative endovascular occlusion for unresectable metastatic carcinoid tumor: technique and initial results.

PURPOSE: Surgery is the only curative therapy for carcinoid patients; however, many are unresectable due to direct involvement of the superior mesenteric artery (SMA) branches. In these patients, we sought to improve surgical outcomes via arterial skeletonization of the SMA prior to surgical resection. MATERIALS AND METHODS: After left radial access, the SMA was catheterized, angiography was performed, and balloon occlusion was achieved in the tumor vessel. Following balloon occlusion of the affected artery, patients were assessed for symptoms of ischemia and angiographic evidence of distal perfusion via collaterals. If patients tolerated occlusion, an endovascular plug was deployed in the affected artery; if not, the procedure was terminated. The next day, all patients underwent exploratory laparotomy and surgical resection of tumor and bowel. RESULTS: The procedure was performed 15 times on 14 patients. 13 out of 15 procedures went to embolization, while the other 2 proceeded to surgery without plug deployment. One of the embolized patients had serious post-surgical complications, while both non-embolized patients developed complications including short bowel syndrome and ischemic colitis. Length of stay between embolized and non-embolized patients was equal, but re-admittance within 30 days was 7.7% in the embolized group and 100% in the non-embolized group. DISCUSSION: Our initial experience demonstrates feasibility and safety of deploying plugs within branches of the SMA prior to surgical resection and improved surgical outcomes. Palpation of the plug assisted in surgical resection. We have demonstrated that pre-operative endovascular occlusion is a safe, practical procedure, which aids surgical resection of mesenteric carcinoid disease.

A Predictive Nomogram for Small Intestine Neuroendocrine Tumors.

OBJECTIVE: There is a scarcity of prognostic tools for small intestine neuroendocrine tumors (SI-NETs) and inconsistencies in currently available grading and staging systems. Nomograms are being proposed to address these limitations. However, none is specific to the US population. This study proposed a concise nomogram for SI-NETs using US population-based data. METHODS: Patients with SI-NETs (2004-2015) were selected from the Surveillance, Epidemiology, and End Results database. Variables selected were age, sex, race, tumor grade, primary tumor size, and TNM staging. Cox regression parameter estimates were used to generate nomogram scores. RESULTS: A total of 2734 patients were selected: 2050 for nomogram development and 684 for internal validation. Prognosticators, age (P < 0.0001), primary tumor size >3 cm (P < 0.0022), tumor grade (P < 0.0001), depth of invasion ≥T3 (P < 0.0280), and distant metastasis (P < 0.0001) were used to develop the nomogram. Nomogram scores ranges from 10 to 80 points with an area under the curve of 0.76, which remained consistently high during internal validation (area under the curve, 0.75). CONCLUSIONS: This Surveillance, Epidemiology, and End Results database nomorgram is a concise prognostic tool that demonstrated high predictive accuracy.

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.