Relationship Between Availability of Urologists and Primary Care Providers and Stage of Diagnosis for Invasive Urinary Bladder Cancer.

INTRODUCTION: With no recommended screening approach, urinary bladder cancer patients rely on referral to urologists to ensure timely diagnosis of bladder cancer. This requires coordination between primary and specialty care. We provide estimates of the relative association between primary care physician and urologist density on stage of urinary bladder cancer diagnosis. METHODS: We used 2010 to 2016 Pennsylvania Cancer Registry data to identify all adult patients diagnosed with bladder cancer. Our primary outcome was locoregional stage of diagnosis, since treatment modality changes and prognosis worsens beyond this stage. Based on patient's residential location at the time of diagnosis we defined both density of urologists and number of primary care providers (defined as providers per population) within the patient's county. We used univariate and multivariate logistic regression to estimate the association between provider density and likelihood of locoregional stage of diagnosis. We also controlled for age, sex, race/ethnicity, insurance type, and year. RESULTS: Our sample included 11,771 urinary bladder cancer patients with 10,607 diagnosed at locoregional stage and 1164 at distant stage. Multivariate regression results show primary care density was associated with significantly higher odds of locoregional stage of diagnosis (odds ratio of 1.05 [95% CI: 1.02-1.08]) while urologist density was associated with significantly lower odds of locoregional stage (odds ratio of 0.65 [95% CI: 0.48-0.89]). CONCLUSIONS: We found primary care density but not urologist density was associated with earlier stage of diagnosis, highlighting the importance of access to primary care and need for timely referral to urologic care.

Gallbladder Cancer Incidentally Found at Cholecystectomy: Perioperative Risk Factors.

PURPOSE: Risk factors of gallbladder cancer (GBC) are not well-defined resulting in greater than 60% of GBCs being diagnosed incidentally following cholecystectomy performed for presumed benign indications. As most localized GBCs require more extensive oncologic surgery beyond cholecystectomy, this study aims to examine factors associated with incidentally found GBC to improve preoperative and intraoperative diagnoses. METHODS: The American College of Surgeons National Surgical Quality Improvement Program Database from 2007 to 2017 was used to identify cholecystectomies performed with and without a final diagnosis of GBC. Univariate and multivariable logistic regressions were used to compare demographic, intraoperative, and postoperative characteristics among those with and without a diagnosis of GBC. RESULTS: The incidence of GBC was observed to be 0.11% (441/403,443). Preoperative factors associated with risk of GBC included age > 60 (OR 6.51, p < .001), female sex (OR 1.75, p < .001), history of weight loss (2.58, p < .001), and elevated preoperative alkaline phosphatase level (OR 1.67, p = .001). Open approach was associated with 7 times increased risk of GBC compared to laparoscopic approach (OR 7.33, p < .001). In addition to preoperative factors and surgical approach, longer mean operative times (127 min vs 70.7 min, p < .001) were significantly associated with increased risk of GBC compared to benign final pathology. CONCLUSION: This study demonstrates that those with incidentally discovered GBC at cholecystectomy are unique from those undergoing cholecystectomy for benign indications. By identifying predictors of GBC, surgeons can choose high risk individuals for pre-operative oncologic evaluation and consider better tools for identifying GBC such as intraoperative frozen pathology.

Disparities in Surgical Treatment of Resectable Pancreatic Adenocarcinoma at Minority Serving Hospitals.

INTRODUCTION: Minority serving hospitals (MSH) are those serving a disproportionally high number of minority patients. Previous research has demonstrated that treatment at MSH is associated with worse outcomes. We hypothesize that patients treated at MSH are less likely to undergo surgical resection of pancreatic adenocarcinoma compared to patients treated at non-MSH. METHODS: Patients with resectable pancreatic cancer were identified using the National Cancer Database. Institutions treating Black and Hispanic patients in the top decile were categorized as an MSH. Factors associated with the primary outcome of definitive surgical resection were evaluated using multivariable logistic regression. Univariate and multivariable survival analysis was performed. RESULTS: Of the 75,513 patients included in this study, 7.2% were treated at MSH. Patients treated at MSH were younger, more likely to be uninsured, and higher stage compared to those treated at non-MSH (P < 0.001). Patients treated at MSH underwent surgical resection at lower rates (MSH 40% versus non-MSH 44.5%, P < 0.001). On multivariable logistic regression, treatment at MSH was associated with decreased likelihood of undergoing definitive surgery (odds ratio 0.91, P = 0.006). Of those who underwent surgical resection, multivariable survival analysis revealed that treatment at an MSH was associated with increased morality (hazard ratio 1.12, P < 0.001). CONCLUSIONS: Patients with resectable pancreatic adenocarcinoma treated at MSH are less likely to undergo surgical resection compared to those treated at non-MSH. Targeted interventions are needed to address the unique barriers facing MSH facilities in providing care to patients with pancreatic adenocarcinoma.

Management of Male Patients With Occult Breast Cancer: Analysis of the National Cancer Database.

INTRODUCTION: Occult breast cancer (OBC) consists of <0.1% of breast cancer cases in the United States. Male occult breast cancer (mOBC) has not been well-studied outside of case reports, and management is largely based on female OBC (fOBC) studies. We aim to examine the prevalence of mOBC among those in the National Cancer Database with breast cancer and describe treatment modalities received by mOBC compared to fOBC. METHODS: The National Cancer Database was queried for patients with OBC from 2004 to 2018. Chi-Square test and Fisher's exact tests compared patient, clinical, and facility characteristics by sex. Treatment modalities [systemic therapy, radiation therapy, axillary lymph node dissection, modified radical mastectomy (MRM)] were compared. A subgroup analysis examined pathologic upstaging in patients who underwent MRM. RESULTS: Of 23,374 male patients with breast cancer, 0.13% were identified to have mOBC [versus 0.09% in fOBC]. cN2/N3 disease was significantly more prevalent in the mOBC cohort (61.3%) than in the fOBC cohort (30.7%, P < 0.001). Receipt of axillary lymph node dissection or MRM was not significantly different by sex. Male OBC (mOBC) patients were less likely to receive trimodality treatment than fOBC patients. In patients who underwent MRM, more mOBC patients [75%] were pathologically upstaged as T+ after mastectomy than fOBC patients [30%, P < 0.001], questioning the adequacy of diagnostic workup for mOBC compared to fOBC. CONCLUSIONS: This review confirms mOBC as an extremely rare disease. Multimodal treatments have been highly utilized to optimize care in this patient population. Further investigation is warranted to examine the survival benefit of treatment regimens for mOBC.

The Association of Guideline-Concordant Sentinel Lymph Node Biopsy for Melanoma at Minority-Serving Hospitals.

BACKGROUND: Minority-serving hospitals (MSHs) have been associated with lower guideline adherence and worse outcomes for various cancers. However, the relationship among MSH status, concordance with sentinel lymph node biopsy (SLNB) guidelines, and overall survival (OS) for patients with cutaneous melanoma is not well studied. METHODS: The National Cancer Database was queried for patients diagnosed with T1a*, T2, and T3 melanoma between 2012 and 2017. MSHs were defined as the top decile of institutions ranked by the proportion of minorities treated for melanoma. Based on National Comprehensive Cancer Network guidelines, guideline-concordant care (GCC) was defined as not undergoing SLNB if thickness was < 0.76 mm without ulceration, mitosis ≥ 1/mm2, or lymphovascular invasion (T1a*), and performing SLNB for patients with intermediate thickness melanomas between 1.0 and 4.0 mm (T2/T3). Multivariable logistic regressions examined associations with GCC. The Kaplan-Meier method and log-rank tests were used to evaluate OS between MSH and non-MSH facilities. RESULTS: Overall, 5.9% (N = 2182/36,934) of the overall cohort and 37.8% of minorities (n = 199/527) were managed at MSHs. GCC rates were 89.5% (n = 33,065/36,934) in the overall cohort and 85.4% (n = 450/527) in the minority subgroup. Patients in the overall cohort (odds ratio [OR] 0.85; p = 0.02) and the minority subgroup (OR 0.55; p = 0.02) were less likely to obtain GCC if they received their care at MSHs compared with non-MSHs. Minority patients receiving care at MSHs had a decreased survival compared with those treated at non-MSHs (p = 0.002). CONCLUSIONS: Adherence to SLNB guidelines for melanoma was lower at MSHs. Continued focus is needed on equity in melanoma care for minority patients in the United States.

Unsuspected gastric glomus tumour.

Gastric glomus tumours (GGTs) are rare predominantly benign, mesenchymal neoplasms that commonly arise from the muscularis or submucosa of the gastric antrum and account for <1% of gastrointestinal soft-tissue tumours. Historically, GGT has been difficult to diagnose preoperatively due to the lack of unique clinical, endoscopic and CT features. We present a case of an incidentally identified GGT in an asymptomatic man that was initially considered a neuroendocrine tumour (NET) by preoperative fine-needle aspiration biopsy with focal synaptophysin reactivity. An elective robotic distal gastrectomy and regional lymphadenectomy were performed. Postoperative review by pathology confirmed the diagnosis of GGT. GGTs should be considered by morphology as a differential diagnosis of gastric NET on cytology biopsy, especially if there is focal synaptophysin reactivity. Additional staining for SMA and BRAF, if atypical/malignant, can help with this distinction. Providers should be aware of the biological behaviour and treatment of GGTs.

Outcomes after sublobar resection versus lobectomy in non-small cell carcinoma in situ.

OBJECTIVE: Guidelines for treatment of non-small cell lung cancer identify patients with tumors ≤2 cm and pure carcinoma in situ histology as candidates for sublobar resection. Although the merits of lobectomy, sublobar resection, and lymphoid (LN) sampling, have been investigated in early-stage non-small cell lung cancer, evaluation of these modalities in patients with IS disease can provide meaningful clinical information. This study aims to compare these operations and their relationship with regional LN sampling in this population. METHODS: The National Cancer Database was used to identify patients diagnosed with non-small cell lung cancer clinical Tis N0 M0 with a tumor size ≤2 cm from 2004 to 2017. The χ2 tests were used to examine subgroup differences by type of surgery. Kaplan-Meier method and Cox proportional hazard model were used to compare overall survival. RESULTS: Of 707 patients, 56.7% (401 out of 707) underwent sublobar resection and 43.3% (306 out of 707) underwent lobectomy. There was no difference in 5-year overall survival in the sublobar resection group (85.1%) compared with the lobectomy group (88.9%; P = .341). Multivariable survival analyses showed no difference in overall survival (hazard ratio, 1.044; P = .885) in the treatment groups. LN sampling was performed in 50.9% of patients treated with sublobar resection. In this group, LN sampling was not associated with improved survival (84.9% vs 85.0%; P = .741). CONCLUSIONS: We observed no difference in overall survival between sublobar resection and lobectomy in patients with cTis N0 M0 non-small cell lung cancer with tumors ≤2 cm. Sublobar resection may be an appropriate surgical option for this population. LN sampling was not associated with improved survival in patients treated with sublobar resection.

Esophagectomy vs Gastrectomy for Early Stage Adenocarcinoma of the Gastroesophageal Junction: What is the Optimal Oncologic Surgical Treatment?

Guidelines for the management of gastroesophageal junction (GEJ) adenocarcinoma recommend esophagectomy as the preferred surgical treatment. Gastrectomy has been proposed as an equivalent procedure. This study aims to compare the oncologic outcomes of these operations. The National Cancer Database was queried for patients with clinical T1N0M0 (all sizes) and T2N0M0 (≤2cm) GEJ adenocarcinoma from 2004-2017. Patients treated with surgery-only were included and were stratified by surgical treatment. Propensity-score matching (PSM) was used to create a balanced cohort. Multivariable logistic regression was performed to evaluate for factors predictive of treatment. Kaplan-Meier (KM) and Cox proportional hazards models were used to compare overall survival (OS). 2,446 patients were identified. 75.1% received esophagectomy, while 24.9% were treated with gastrectomy. Patients at high volume facilities were more likely to undergo esophagectomy (OR 1.750, P < 0.001). Factors associated with lower likelihood of undergoing esophagectomy included age ≥75 years (OR 0.588, P = 0.001), female sex (OR 0.706, P = 0.003), and non-White race (OR 0.430, P < 0.001), compared to age ≤50 years, male, and White race, respectively. In the unmatched cohort, gastrectomy was associated with a higher rate of positive margins (4.1% vs 2.3%, P = 0.022). PSM yielded 591 pairs. In the matched cohort, patients treated with esophagectomy had improved 5-year OS compared to gastrectomy (70.6% vs 66.5%, P = 0.030). Multivariable analysis showed improved OS in patients treated with esophagectomy compared to gastrectomy (HR 0.767, P = 0.010). Esophagectomy is associatedwith improved survival and a lower incidence of positive margins in patients with early-stage GEJ adenocarcinoma when compared to gastrectomy.

Association of Surgery and Chemotherapy in Stage IV Gastroenteropancreatic Neuroendocrine Carcinoma.

INTRODUCTION: The survival benefit of chemotherapy for patients with metastatic gastroenteropancreatic neuroendocrine carcinomas (GEP-NECs) is well established. However, reasons for underutilization of chemotherapy are unknown. METHODS: The National Cancer Database (NCDB) was queried for metastatic GEP-NECs from 2009 to 2016. The cohort was stratified by patients who had received chemotherapy and who did not receive chemotherapy. Demographic, socioeconomic, clinical, and treatment characteristics were captured. Multivariable logistic regression examined factors associated with chemotherapy utilization. RESULTS: Of the 2367 stage IV GEP-NECs patients identified, 1647 (69.6%) received chemotherapy. Patients with primary site at colon and small bowel, age ≥75, no insurance, and ≥2 comorbidities were less likely to receive chemotherapy than patients with other primary sites, age <75, private insurance, and no comorbidities (P < 0.005). The small bowel and colon were the primary sites with the greatest percentage of patients who received surgery (46.4% and 41.8%, respectively). In these subgroup of patients, surgical intervention was also associated with lower probability of receiving chemotherapy (odds ratio = 0.60, P < 0.005). CONCLUSIONS: About 30% of patients with metastatic GEP-NECs did not receive chemotherapy. Primary site location and receipt of surgery were significantly associated with receipt of chemotherapy, with NECs in small bowel and colon being more likely to receive surgery and less likely to receive chemotherapy. While surgery may be considered on an individual basis, increasing efforts to ensure patients with colon or small bowel NECs receive guideline-concordant chemotherapy will positively impact survival. In addition, interventions to improve health insurance coverage to increase receipt of chemotherapy are warranted.

Racial Differences in Bariatric Surgical Approach: a Cross-Sectional National Inpatient Sample Analysis.

PURPOSE: Although racial inequalities in referral and access to bariatric surgical care have been well reported, racial difference in the selection of surgical techniques is understudied. This study examined factors associated with the utilization of the two main bariatric surgical techniques: laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). MATERIALS AND METHODS: The National Inpatient Sample database was queried for patients who underwent elective LSG or LRYGB for the treatment of severe obesity. Chi-square tests and multivariable logistic regression assessed associations of surgical approach with patient and facility characteristics. Sensitivity analyses examined the following body mass index (BMI) subgroups: < 40.0 kg/m2, 40.0-44.9 kg/m2, 45.0-49.9 kg/m2, and ≥ 50.0 kg/m2. RESULTS: Within the final cohort (N = 86,053), 73.0% (N = 62,779) underwent LSG, and 27.0% (N = 23,274) underwent LRYGB. Patients with BMI 45.0-49.9 kg/m2 (OR = 0.85) and BMI ≥ 50.0 kg/m2 (OR = 0.80) were less likely to undergo LSG than patients with BMI 40.0-45.0 kg/m2 (all p < 0.001). However, Black (OR = 1.74) and White Hispanic patients (OR = 1.30) were more likely to undergo LSG than White non-Hispanic patients (all p < 0.005). In the BMI ≥ 50.0 kg/m2 group, Black patients were still more likely to undergo LSG compared to White non-Hispanic patients (OR = 1.69, p < 0.001), while Asians/Pacific Islanders were less likely to receive LSG than White non-Hispanic patients (OR = 0.41, p < 0.05). CONCLUSION: In this observational study, we identified racial differences in the selection of common bariatric surgical approaches across various BMI categories. Future investigations are warranted to study and to promote awareness of the racial/ethnic influence in attitudes on obesity, weight loss, financial support, and surgical risks during bariatric discussions with minorities.

Management of Clinical T2N0 Esophageal and Gastroesophageal Junction Adenocarcinoma: What Is the Optimal Treatment?

BACKGROUND: The current standard of care for locally advanced esophageal and gastroesophageal junction (GEJ) adenocarcinoma includes neoadjuvant chemoradiation and surgery. The optimal treatment for clinical T2N0M0 (cT2N0) disease is debated. This study aims to determine the optimal treatment in these patients. METHODS: The National Cancer Database was used to identify patients who underwent surgery for cT2N0 esophageal and GEJ adenocarcinoma from 2004 to 2017. Patients were grouped into surgery-alone, neoadjuvant therapy (NAT), and adjuvant therapy (AT) groups. Subgroups of high-risk patients (tumor ≥ 3 cm, poor differentiation, or lymphovascular invasion) and patients upstaged after upfront surgery were identified. Kaplan-Meier method and Cox proportional hazard ratios were used to compare overall survival. RESULTS: Of 2160 patients included, 957 (44.3%) underwent surgery-alone, 821 (38.0%) underwent NAT and surgery, and 382 (17.7%) underwent surgery and AT. One thousand six hundred nineteen (75.0%) patients had high-risk features. Six hundred fourteen (45.9%) patients were upstaged after upfront surgery. In the overall cohort, AT was associated with improved survival compared to NAT (HR 0.618, p < 0.001) and surgery-alone (HR 0.699, p < 0.001). There was no difference in survival between NAT and surgery-alone (HR 1.132, p = 0.112). Similar results were observed in high-risk patients. Patients upstaged after upfront surgery who received AT had improved survival compared to those initially treated with NAT (HR 0.613, p < 0.001). CONCLUSION: This analysis suggests that cT2N0 esophageal and GEJ adenocarcinomas may not benefit from the intensive multimodality therapy utilized in locally advanced disease. Selective use of AT for patients who are upstaged pathologically, or have high-risk features, is associated with improved outcomes.

The cost of treatments for retained traumatic hemothorax: A decision analysis.

INTRODUCTION: Early video-assisted thorascopic surgery (VATS) is the recommended intervention for retained hemothorax in trauma patients. Alternative options, such as lytic therapy, to avoid surgery remain controversial. The purpose of this decision analysis was to assess expected costs associated with treatment strategies. METHODS: A decision tree analysis estimated the expected costs of three initial treatment strategies: 1) VATS, 2) intrapleural tissue plasminogen activator (TPA) lytic therapy, and 3) intrapleural non-TPA lytic therapy. Probability parameters were estimated from published literature. Costs were based on National Inpatient Sample data and published estimates. Our model compared overall expected costs of admission for each strategy. Sensitivity analyses were conducted to explore the impact of parameter uncertainty on the optimal strategy. RESULTS: In the base case analysis, using TPA as the initial approach had the lowest total cost (U.S. $37,007) compared to VATS ($38,588). TPA remained the optimal initial approach regardless of the probability of complications after VATS. TPA was an optimal initial approach if TPA success rate was >83% regardless of the failure rate with VATS. VATS was the optimal initial strategy if its total cost of admission was <$33,900. CONCLUSION: Lower treatment costs with lytic therapy does not imply significantly lower total cost of trauma admission. However, an initial approach with TPA lytic therapy may be preferred for retained traumatic hemothorax to lower the total cost of admission given its high probability of avoiding the operating room with its resultant increased costs. Future studies should identify differences in quality of life after recovery from competing interventions.

Predictors of Conversion During Minimally Invasive Gastrectomy for Malignancy.

INTRODUCTION: Implementation of minimally invasive gastrectomy (MIG) for malignancy is increasing. However, risk factors for conversion to open surgery during laparoscopic and robotic gastrectomy are poorly understood. This study aimed to determine the risk factors for, and impact of, conversion during oncologic resection. METHODS: The National Cancer Database (NCDB) was used to identify patients with clinical stage I-III gastric cancer from 2010 to 2017. Chi-squared test and t-test were used to compare the robotic versus laparoscopic groups. Propensity score weighted multivariable logistic regression was used to evaluate factors associated with conversion to open surgery. RESULTS: Of 6990 patients identified, 5702 (81.6%) underwent a laparoscopic resection and 1288 (18.4%) underwent robotic-assisted resection. Conversion rates were 14.7% and 7.8% for laparoscopic and robotic gastrectomy, respectively. The robotic approach was associated with lower likelihood of conversion compared to laparoscopic approach (odds ratio [OR] = 0.470, P < 0.001). Other factors predictive of conversion included tumor size >5 cm compared to <2 cm (OR 1.714, P = 0.010), total gastrectomy compared to partial gastrectomy (OR 2.019, P < 0.001), antrum/pylorus (OR 2.345, P < 0.001), and body (OR 2.152, P < 0.001) tumors compared to cardia tumors. Compared to those treated with laparoscopic and robotic gastrectomy, patients who underwent conversion experienced significantly longer hospital length of stay and higher rates of positive surgical margins. CONCLUSIONS: Laparoscopic gastrectomy was associated with a higher conversion rate compared to robotic gastrectomy. Conversion to open surgery was associated with a significantly longer length of stay and higher rates of positive margins. Identification of risk factors for conversion can aid in appropriate modality selection.

Albumin-bilirubin score is superior to platelet-albumin-bilirubin score and model for end-state liver disease sodium for predicting posthepatectomy liver failure.

BACKGROUND: Risk stratification for patients undergoing hepatectomy can be attempted using established models. This study compares the platelet-albumin-bilirubin (PALBI) score with albumin-bilirubin (ALBI) and model for end-stage liver disease sodium (MELD-Na) for predicting posthepatectomy liver failure (PHLF) and 30-day mortality. METHODS: The 2014-2018 NSQIP database was queried for patients who underwent elective hepatectomy. Multivariable logistic regressions assessed associations of posthepatectomy outcomes with patient and clinical characteristics. Predictive accuracy of the grading systems was evaluated using receiver operator characteristic (ROC) curves and calculating area under the curve (AUC). RESULTS: Severe PHLF (Grade B/C) and mortality were present in 2.58% (N = 369) and 1.2% (N = 171) of patients who underwent hepatectomy (N = 13 925), respectively. ALBI Grade 2/3 had a stronger association with severe PHLF (odds ratio [OR] = 1.62, p < 0.01) and mortality (OR = 2.06, p < 0.005) than PALBI Grade 2/3 (OR = 1.14, p = 0.43 for PHLF and OR = 2.01, p < 0.005 for mortality) or MELD-Na ≥10 (OR = 1.29, p = 0.25 for PHLF and OR = 1.84, p < 0.03). ALBI had a higher AUC (0.671) than PALBI (0.625) and MELD-Na (0.627) for predicting severe PHLF. ALBI had a higher AUC (0.695) than PALBI (0.642) for predicting 30-day mortality. CONCLUSIONS: ALBI was a more accurate predictor of severe PHLF and 30-day mortality than MELD-Na and PALBI for patients who underwent hepatectomy.

Burden of cancer in the general surgical population in the eastern region of Ghana.

OBJECTIVE: To estimate the surgical burden of malignant disease in the Eastern Region of Ghana. DESIGN: Descriptive cross-sectional study. SETTING: Regional hospital in the eastern region of Ghana. PARTICIPANTS: Patients treated by the surgery department at Eastern Regional Hospital in Koforidua, Ghana. INTERVENTIONS: None. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcome was incidence of malignancy and secondary outcome descriptive differences between patients who had a benign indication for surgery compared with those with a malignant indication for surgery. RESULTS: A total of 1943 inpatient surgical procedures were performed from 2015 to 2017 with 13.4% (261) of all procedures ultimately performed for malignancy. Of all breast procedures performed, 95.2% of procedures resulted in a malignant diagnosis. The remaining subtypes of procedures had rates ranging from <1% to 41.2% of procedures performed for malignant disease. Additionally, this study found over 13% of patients admitted to the surgical service for breast cancer ultimately did not undergo a surgical procedure. CONCLUSION: This is the first study investigating the burden of malignant disease in the Eastern Region of Ghana. We found a substantial prevalence of malignant disease in the surgical population in this region. This information can be used to aid in future medical resource planning in this region.

Is preoperative biliary stenting associated with increased rate of postoperative complications for patients undergoing pancreatoduodenectomy? A review of national surgical quality improvement program data.

BACKGROUND: Jaundice in the setting of periampullary neoplasms is often treated with biliary stenting. Level 1 data demonstrated an increase in perioperative complications after pancreaticoduodenectomy in patients undergoing stent placement. However, the impact of this data on practice patterns in the US remains unknown. METHODS: The National Surgical Quality Improvement Program (NSQIP) Pancreatectomy Targeted Participant Use Data File was used to identify patients from 2014 to 2017 undergoing pancreatoduodenectomy. Chi-square test and multivariable logistic regression were used to compare outcomes between those with biliary stent and those without. RESULTS: Of the 5524 patients, 3321 (60.1%) had biliary stent placement. The stent group was older, had a higher ASA class, and had preoperative weight loss compared to the group without biliary stenting (all p < 0.05). When adjusting for demographic and operative characteristics, the non-stent group had lower associated overall complications and postoperative infections. There was no significant difference in mortality and pancreatic fistula rate between groups. CONCLUSION: Preoperative biliary stenting is still common prior to pancreaticoduodenectomy. With a trend toward increased utilization of neoadjuvant chemotherapy, stenting will likely remain a common practice. Recognition of increased rates of complications associated with stent placement allows for appropriate risk-benefit analysis.

Are pediatric surgery clinics LGBTQ+ inclusive?

PURPOSE: Creating inclusive LGBTQ+ environments is important in the provision of inclusive care. This cross sectional study assessed whether patient intake forms in pediatric surgery departments were LGBTQ+ inclusive (L-I). METHODS: North American pediatric surgery departments affiliated with pediatric surgery fellowships or general surgery residencies were contacted to retrieve patient intake forms. Forms were assessed for LGBTQ+ inclusivity using a novel L-I scoring system consisting of 6 criteria: preferred name, pronouns, preferred language, gender identity, sex assigned at birth, and l-I guardianship. Institutions without intake forms were invited to comment on their use of l-I intake questions. RESULTS: 59/125 programs responded to our query, 10 of which provided intake forms. Median l-I score was 2/6 points (range 1-4). l-I guardianship was the most common question asked. No intake form asked for pronouns. Of the 49 institutions without forms, 30.5% reported asking l-I questions during initial visits. Narratives from these institutions varied widely. Some institutions supported routine l-I questions while others stated l-I questions were unnecessary, irrelevant, and/or offensive. CONCLUSIONS: Few North American pediatric surgery departments consistently ask l-I questions during the intake process. Comments questioning the appropriateness and necessity of l-I questions highlight the need for LGBTQ+ education. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Cross sectional study.

Survival Benefit of Guideline-Concordant Postoperative Radiation for Local Merkel Cell Carcinoma.

BACKGROUND: Postoperative radiation therapy (RT) for early-stage Merkel Cell Carcinoma (MCC) decreases the risk of locoregional recurrence and improve overall survival. However, concordance with RT guidelines is unknown. MATERIALS AND METHODS: The National Cancer Database was queried for stage I/II MCC patients receiving surgical intervention from 2006-2017. The cohort was stratified by patients who had and did not have indication(s) for adjuvant RT of the primary tumor site based on National Comprehensive Cancer Network guidelines. We captured the use of RT, patient demographics, socioeconomic characteristics, and clinical characteristics. Logistic regression, Kaplan-Meier method, and propensity score weighted Cox proportional hazards model examined associations and survival benefits of RT. RESULTS: 2,330 stage I/II MCC patients underwent surgical intervention. 1,858 (79.7%) met National Comprehensive Cancer Network criteria for RT of the primary tumor site, of which 1,062 (57.2%) received RT. 472 (20.3%) did not meet criteria for RT, of which 203 (43.0%) received RT. Five-year overall survival advantage was identified for patients who received RT when it was indicated (P < 0.003). There was no evidence of overall survival advantage when patients received guideline-discordant RT (P = 0.478). CONCLUSIONS: Surgical resection with adjuvant RT of the primary tumor site has an overall survival benefit for local MCC when patients meet criteria for RT. This study found a group who received guideline-discordant RT with no survival advantage. Further investigation is warranted to identify the socio-demographic and oncologic reasons for guideline discordance in the treatment of MCC for both under- and over-treatment.