Use of neoadjuvant paclitaxel in breast angiosarcoma-Impact on surgical resection and response rates.

OBJECTIVE: Breast angiosarcoma is a tumor that can arise as a primary breast tumor or in association with prior radiation therapy. Angiosarcomas are uniquely sensitive to paclitaxel. This study evaluated the impact neoadjuvant paclitaxel (NAC) therapy has on surgical outcomes, tumor recurrence, and survival in breast angiosarcomas. METHODS: Patients with angiosarcoma of the breast, either primary or radiation-associated, were identified from a prospective institutional database. Patients receiving NAC were compared to those treated with upfront surgery. Clinical and pathological variables were compared using Student's t-test or Fisher's exact test, differences in survival were calculated using Kaplan-Meier methods. RESULTS: Twenty-four patients with angiosarcoma of the breast were identified, 10 with primary angiosarcoma and 14 with radiation-associated angiosarcoma. Twelve patients received NAC, 6 of each with primary angiosarcoma or radiation-associated angiosarcoma. Of these 12 patients, 11 had a margin negative resection (91%) of which, nine had a complete pathological response on surgical pathology. Of the 12 surgery-first patients, four (n = 4/12, 33%) had positive surgical margins, two of the four underwent reoperation. With a median follow-up of 16 months, four NAC patients had recurrence (33%) compared to six patients in the surgery-first group (58%) (p = 0.41). While not statistically significant, NAC patients had a 33% less risk of recurring compared to surgery-first patients ([hazard ratio =0.67 (95% confidence interval 0.16-2.72; p = 0.6]). CONCLUSION: NAC for breast angiosarcoma may be associated with high rates of complete pathological response and margin-negative resection. However, this did not impact overall survival. Future prospective control studies and longer follow-up periods are warranted to understand the impact on recurrence and survival.

Adjuvant Palbociclib May be Associated with Delayed Recurrence in Completely Resected Retroperitoneal Liposarcoma: Results of a Single-Institution Retrospective Cohort Study.

BACKGROUND: Retroperitoneal liposarcomas are locally aggressive and frequently recur following complete surgical resection. Palbociclib, a cyclin-dependent kinase (CDK) 4/CDK6 inhibitor, is effective in the treatment of metastatic or unresectable liposarcoma. OBJECTIVE: The purpose of this study was to describe our initial experience using adjuvant palbociclib to delay recurrence. METHODS: Patients with resected RPS were identified from a prospectively maintained institutional database. In 2017, we began offering adjuvant palbociclib to patients following complete gross resection. Treatment interval, defined as the time between surgical resection and re-resection or change in systemic therapy, was compared between patients selected for adjuvant palbociclib or observation. RESULTS: Between 2017 and 2020, 12 patients underwent a total of 14 operations (14 patient cases) and were selected for adjuvant palbociclib for recurrence prevention. These patients were compared with 14 patients who, since 2010, underwent a total of 20 operations (20 patient cases) and were selected for observation. Histology was primarily dedifferentiated liposarcoma for both groups (observation: 70% [14/20]; adjuvant palbociclib: 64% [9/14]). All patients underwent complete gross resection. Neither age, number of previous surgeries, histologic grade, or Eastern Cooperative Oncology Group (ECOG) performance status differed between groups (p > 0.05 for all). Patients selected for adjuvant palbociclib experienced a longer treatment interval than those selected for observation, although it did not reach statistical significance (20.5 months vs. 13.1 months, p = 0.08, log rank). CONCLUSION: Adjuvant palbociclib may be associated with a prolonged interval between liposarcoma resection and the need for re-resection or other systemic therapy. Palbociclib may be effective in delaying liposarcoma recurrence, and its use for this indication warrants prospective study.

All Politics Are Local: A Single Institution Investigation of the Educational Impact of Residents and Fellows Working Together.

BACKGROUND: Most general surgery residents pursue fellowship; there is limited understanding of the impact residents and fellows have on each other's education. The goal of this exploratory survey was to identify these impacts. MATERIALS AND METHODS: Surgical residents and fellows at a single academic institution were surveyed regarding areas (OR assignments, the educational focus of the team, roles and responsibilities on the team, interpersonal communication, call, "other") hypothesized to be impacted by other learners. Impact was defined as "something that persistently affects the clinical learning environment and a trainee's education or ability to perform their job". Narrative responses were reviewed until dominant themes were identified. RESULTS: Twenty-three residents (23/45, 51%) and 12 fellows (12/21, 57%) responded. Responses were well distributed among resident year (PGY-1:17% [4/23], PGY-2, 35% [8/23], PGY-3 26% [6/23], PGY-4 9% [2/23%], PGY-5 13% [3/23]). Most residents reported OR assignment (14/23, 61%) as the area of primary impact, fellows broadly reported organizational categories (Roles and responsibilities 33%, educational focus 16%, interpersonal communication 16%). Senior residents reported missing out on operations to fellows while junior residents reported positive impacts of operating directly with fellows. Residents of all levels reported that fellows positively contributed to their education. Fellows, senior residents, and junior residents reported positive experiences when residents and fellows operated together as primary surgeon and assistant. CONCLUSIONS: Residents and fellows impact one another's education both positively and negatively. Case allocation concerns senior residents, operating together may alleviate this, providing a positive experience for all trainees. Defining a unique educational role for fellows and delineating team expectations may maximize the positive impacts in this relationship.

Robotic Gastrectomy for Gastric Adenocarcinoma in the USA: Insights and Oncologic Outcomes in 220 Patients.

BACKGROUND: While multiple Asian and a few Western retrospective series have demonstrated the feasibility and safety of robotic-assisted gastrectomy for gastric cancer, its reliability for thorough resection, especially for locoregional disease, has not yet been firmly established, and reported learning curves vary widely. To support wider implementation of robotic gastrectomy, we evaluated the learning curve for this approach, assessed its oncologic feasibility, and created a selection model predicting the likelihood of conversion to open surgery in a US patient population. PATIENTS AND METHODS: We retrospectively reviewed data on all consecutive patients who underwent robotic gastrectomy at a high-volume institution between May 2012 and March 2019. RESULTS: Of the 220 patients with gastric cancer selected to undergo curative-intent robotic gastrectomy, surgery was completed using robotics in 159 (72.3%). The median number of removed lymph nodes was 28, and ≥ 15 lymph nodes were removed in 94% of procedures. Surgical time decreased steadily over the first 60-80 cases. Complications were generally minor: 7% of patients experienced complications of grade 3 or higher, with an anastomotic leak rate of 2% and mortality rate 0.9%. Factors predicting conversion to open surgery included neoadjuvant chemotherapy, BMI ≥ 31 kg/m2, and tumor size ≥ 6 cm. CONCLUSIONS: These findings support the safety and oncologic feasibility of robotic gastrectomy for selected patients with gastric cancer. Proficiency can be achieved by 20 cases and mastery by 60-80 cases. Ideal candidates for this approach are patients with few comorbidities, BMI < 31 kg/m2, and tumors < 6 cm.

Cancer surveillance imaging: Does repeated iodinated contrast exposure impact long-term kidney function?

BACKGROUND: Contrast-induced nephropathy is a well-recognized acute complication in cancer patients, but the long-term effects of repeated contrast exposure are not known. We analyzed the association of the number of contrast-enhanced computed tomography (CECT) examinations and other clinical factors with decline in estimated glomerular filtration rate (eGFR) in colorectal cancer survivors. MATERIALS AND METHODS: We retrospectively queried a prospective surgical colorectal cancer database to identify patients with stage I or II cancer who underwent resection in 2007 - 2013 and were alive for at least 3 years. eGFR was calculated before and 3 years after the surgery with ≥ 20% decline relative to baseline defined as significant and used as the primary outcome. The association of clinical factors with the primary outcome was analyzed using logistic regression. RESULTS: Only 256 patients with the median follow-up of 65 months had sufficient clinical data for analysis. Median eGFR decline at follow-up was 3.0 mL/min/1.73m2 or 4% change from baseline. 47 patients (18%) had ≥ 20% reduction in eGFR, which was not associated with the number of CECT examinations. Multivariable analysis demonstrated that increasing age (OR, 1.03; 95% CI, 1.00 - 1.06), presence of diabetes (OR, 2.33; 95% CI, 1.18 - 4.61), and longer operation time (OR, 1.04; 95% CI, 1.01 - 1.07) were independently associated with a higher likelihood of ≥ 20% eGFR decline at 3 years. CONCLUSION: Older age, diabetes, and longer operating time, but not cumulative contrast exposure were found to be associated with worse long-term renal outcomes following surgical resection in patients with early-stage colorectal cancer who survived 3 years.

The academic tweet: Twitter as a tool to advance academic surgery.

Social media, Twitter in particular, has emerged as an essential tool for surgeons. In the realm of academic surgery, it enables surgeons to advance the core values of academic surgery, as outlined by the Association for Academic Surgery: inclusion, leadership, innovation, scholarship, and mentorship. This article details the ways in which surgeons are using Twitter to embody these values and how the Twitter account for the Association of Academic Surgeons accomplishes its goal of inspiring and developing young academic surgeons.

Total Gastrectomy for Hereditary Diffuse Gastric Cancer at a Single Center: Postsurgical Outcomes in 41 Patients.

OBJECTIVE: The aim of this study was to describe postoperative outcomes of total gastrectomy at our institution for patients with hereditary diffuse gastric cancer (HDGC). BACKGROUND: HDGC, which is mainly caused by germline mutations in the E-cadherin gene (CDH1), renders a lifetime risk of gastric cancer of up to 70%, prompting a recommendation for prophylactic total gastrectomy. METHODS: A prospective gastric cancer database identified 41 patients with CDH1 mutation who underwent total gastrectomy during 2005 to 2015. Perioperative, histopathologic, and long-term data were collected. RESULTS: Of the 41 patients undergoing total gastrectomy, median age was 47 years (range 20 to 71). There were 14 men and 27 women, with 25 open operations and 16 minimally invasive operations. Median length of stay was 7 days (range 4 to 50). In total, 11 patients (27%) experienced a complication requiring intervention, and there was 1 peri-operative mortality (2.5%). Thirty-five patients (85%) demonstrated 1 or more foci of intramucosal signet ring cell gastric cancer in the examined specimen. At 16 months median follow-up, the median weight loss was 4.7 kg (15% of preoperative weight). By 6 to 12 months postoperatively, weight patterns stabilized. Overall outcome was reported to be "as expected" by 40% of patients and "better than expected" by 45%. Patient-reported outcomes were similar to those of other patients undergoing total gastrectomy. CONCLUSION: Total gastrectomy should be considered for all CDH1 mutation carriers because of the high risk of invasive diffuse-type gastric cancer and lack of reliable surveillance options. Although most patients have durable weight loss after total gastrectomy, weights stabilize at about 6 to 12 months postoperatively, and patients report outcomes as being good to better than their preoperative expectations. No patients have developed gastric cancer recurrence after resections.

Evolving application of minimally invasive cancer operations at a tertiary cancer center.

BACKGROUND: Patients and providers are increasingly interested in the utilization, safety, and efficacy of minimally invasive surgery (MIS). We reviewed 11 years of MIS resections (laparoscopic and robotic) for intra-abdominal malignancies. METHODS: Patients who underwent gastrectomy, distal pancreatectomy, hepatic resection, and colorectal resection between 2004 and 2014 were identified. Cases were categorized as open, laparoscopic, and robotic based on the initial operation approach. Diagnostic laparoscopies were excluded. RESULTS: Of the 10 039 patients who underwent the above procedures, between 2004 and 2014, 2832 (28%) were MIS. In 2004, 12% (100/826) of all resections were performed with MIS approaches, rising to 23% (192/821) of all resections by 2009 and 44% (484/1092) in 2014. The number of open resections has remained largely stable: 726 (88% of all resections) in 2004 and 608 (56% of all resections) in 2014. Initially, laparoscopy experienced incremental adoption. Robotic surgery was implemented in 2009 and is currently the dominant MIS approach, accounting for 76% (368/484) of all MIS resections in 2014. Overall mortality has remained less than 1%. CONCLUSIONS: While maintaining patient safety, utilization of MIS techniques has increased substantially since 2004, particularly for gastric and colorectal resections. Since 2009 robotic surgery is the predominant MIS approach.

Patterns and Predictors of Weight Loss After Gastrectomy for Cancer.

BACKGROUND: Weight loss following gastrectomy for patients with gastric cancer has not been well characterized. We assessed the impact of patient and procedure-specific variables on postoperative weight loss following gastrectomy for cancer. METHODS: A prospectively maintained gastric cancer database identified patients undergoing gastrectomy for cancer. Clinical and pathologic characteristics, baseline body mass index (BMI), and postoperative weights were extracted. Change in weight was analyzed by percent change in weight and absolute change in BMI. Random coefficients models were used to test whether the rate of change in weight over time differed by factors of interest. RESULTS: Of 376 consecutive patients who underwent resection for gastric adenocarcinoma, 55 % were male, median age 66 years, and mean preoperative BMI 27.1 (range 16.2-45.6). Total gastrectomy was associated with more weight loss than subtotal gastrectomy at 1 year (15 vs. 6 %, early stage; 17 vs. 7 %, late stage). Maximum weight change was observed at 6-12 months after operation and remained stable or improved at 2 years. For early- and late-stage patients, median percent weight loss at 1 year was greater for BMI ≥ 30 versus BMI < 30 (14 vs. 8 %, early stage; 15 vs. 9 %, late stage). CONCLUSIONS: The extent of weight loss after gastrectomy for gastric cancer is dependent on preoperative BMI and extent of gastric resection. Maximum weight change is expected by 12 months after operation and will stabilize or improve over time.

Risk factors for recurrence in T1-2N0 gastric cancer in the United States and China.

INTRODUCTION: Recurrence patterns after curative intent gastrectomy for T1-2N0 gastric adenocarcinoma are poorly defined. We sought to assess timing, patterns, and risk factors for recurrence in patients treated at two high-volume gastric cancer centers in the United States and China. METHODS: Between 1995 and 2011, 1,058 patients underwent curative intent gastrectomy. Recurrences were classified as locoregional, distant, or peritoneal. Univariate and multivariate analyses were performed to identify risk factors for recurrence. RESULTS: Overall, 7% (76) of our 1,058 patients from the United States (n = 414) and China (n = 644) recurred. Liver (43%) was the most common site of recurrence in both countries (US: 24%, China: 52%), followed by peritoneum (16%), lymph nodes (10%), and anastomosis (8%). Median time to recurrence was 23 months (US: 30 months, China: 23 months), which decreased with increasing T-stage (T1a: 27 months, T1b: 24 months, T2: 22 months). Tumor size (P = 0.001), depth of invasion (P = 0.010), histological type (P = 0.022) and lymphovascular invasion (P = 0.001) were independently associated with recurrence. CONCLUSION: Patients infrequently recur following curative intent gastrectomy for T1-2N0 gastric adenocarcinoma. Almost all recurrences occur between six months and 3 years post-operatively, most frequently in distant anatomic locations; selective followup during this time period is recommended. J. Surg. Oncol. 2016;113:745-749. © 2016 Wiley Periodicals, Inc.

Development and assessment of Memorial Sloan Kettering Cancer Center's Surgical Secondary Events grading system.

BACKGROUND: Studying surgical secondary events is an evolving effort with no current established system for database design, standard reporting, or definitions. Using the Clavien-Dindo classification as a guide, in 2001 we developed a Surgical Secondary Events database based on grade of event and required intervention to begin prospectively recording and analyzing all surgical secondary events (SSE). METHODS: Events are prospectively entered into the database by attending surgeons, house staff, and research staff. In 2008 we performed a blinded external audit of 1,498 operations that were randomly selected to examine the quality and reliability of the data. RESULTS: Of 4,284 operations, 1,498 were audited during the third quarter of 2008. Of these operations, 79 % (N = 1,180) did not have a secondary event while 21 % (N = 318) had an identified event; 91 % of operations (1,365) were correctly entered into the SSE database. Also 97 % (129 of 133) of missed secondary events were grades I and II. There were 3 grade III (2 %) and 1 grade IV (1 %) secondary event that were missed. There were no missed grade 5 secondary events. CONCLUSIONS: Grade III-IV events are more accurately collected than grade I-II events. Robust and accurate secondary events data can be collected by clinicians and research staff, and these data can safely be used for quality improvement projects and research.

Comparing surgical infections in National Surgical Quality Improvement Project and an Institutional Database.

BACKGROUND: Surgical quality improvement requires accurate tracking and benchmarking of postoperative adverse events. We track surgical site infections (SSIs) with two systems; our in-house surgical secondary events (SSE) database and the National Surgical Quality Improvement Project (NSQIP). The SSE database, a modification of the Clavien-Dindo classification, categorizes SSIs by their anatomic site, whereas NSQIP categorizes by their level. Our aim was to directly compare these different definitions. MATERIALS AND METHODS: NSQIP and the SSE database entries for all surgeries performed in 2011 and 2012 were compared. To match NSQIP definitions, and while blinded to NSQIP results, entries in the SSE database were categorized as either incisional (superficial or deep) or organ space infections. These categorizations were compared with NSQIP records; agreement was assessed with Cohen kappa. RESULTS: The 5028 patients in our cohort had a 6.5% SSI in the SSE database and a 4% rate in NSQIP, with an overall agreement of 95% (kappa = 0.48, P < 0.0001). The rates of categorized infections were similarly well matched; incisional rates of 4.1% and 2.7% for the SSE database and NSQIP and organ space rates of 2.6% and 1.5%. Overall agreements were 96% (kappa = 0.36, P < 0.0001) and 98% (kappa = 0.55, P < 0.0001), respectively. Over 80% of cases recorded by the SSE database but not NSQIP did not meet NSQIP criteria. CONCLUSIONS: The SSE database is an accurate, real-time record of postoperative SSIs. Institutional databases that capture all surgical cases can be used in conjunction with NSQIP with excellent concordance.

Differences in gastric cancer survival between the U.S. and China.

BACKGROUND: Previous comparisons of gastric cancer between the West and the East have focused predominantly on Japan and Korea, where early gastric cancer is prevalent, and have not included the Chinese experience, which accounts for approximately half the world's gastric cancer. METHODS: Patient characteristics, surgical procedures, pathologic information, and survival were compared among gastric cancer patients who underwent curative intent gastrectomy at two large volume cancer centers in China and the US between 1995 and 2005. RESULTS: Median age and body mass index were significantly higher in US patients. The proportion of proximal gastric cancer was comparable. Gastric cancer patients in China had larger tumors and a later stage at presentation. The median number of positive lymph nodes was higher (5 vs 4, P < 0.02) despite a lower lymph node retrieval (16 vs 22, P < 0.001) in Chinese patients. The probability of death due to gastric cancer in Chinese patients was 1.7 fold of that in the US (P < 0.0001) after adjusting for important prognostic factors. CONCLUSIONS: Even after adjusting for important prognostic factors Chinese gastric cancer patients have a worse outcome than US gastric cancer patients. The differences between Chinese and US gastric cancer are a potential resource for understanding the disease.

Beyond Training the Next Generation of Physicians: The Unmeasured Value Added by Residents to Teaching Hospitals and Communities.

Following medical school, most newly graduated physicians enter residency training. This period of graduate medical education (GME) is critical to creating a physician workforce with the specialized skills needed to care for the population. Completing GME training is also a requirement for obtaining medical licensure in all 50 states. Yet, crucial federal and state funding for GME is capped, creating a bottleneck in training an adequate physician workforce to meet future patient care needs. Thus, additional GME funding is needed to train more physicians. When considering this additional GME funding, it is imperative to take into account not only the future physician workforce but also the value added by residents to teaching hospitals and communities during their training. Residents positively affect patient care and health care delivery, providing intrinsic and often unmeasured value to patients, the hospital, the local community, the research enterprise, and undergraduate medical education. This added value is often overlooked in decisions regarding GME funding allocation. In this article, the authors underscore the value provided by residents to their training institutions and communities, with a focus on current and recent events, including the global COVID-19 pandemic and teaching hospital closures.

Surgeons Underestimate the Importance of Surgical Topics for Non-Surgeons: Results of a National Survey.

OBJECTIVE: To determine if surgeons and non-surgeons agree on the importance of surgical topics covered in the surgical clerkship to the daily practice of non-surgeons. DESIGN: An IRB-approved anonymous survey ranking the relative importance of 35 topics drawn from surgical clerkship curricula asking physicians to rank the relative importance of each topic, using a five-point Likert scale, to the daily practice of non-surgeons. SETTING: Online anonymous survey. PARTICIPANTS: Convenience sample of practicing physicians and trainees. The survey was offered to physicians in all specialties via social media and professional connections, responders identified their practice specialty. RESULTS: 295 physicians completed the survey. Two hundred thirty-one (85%) were from non-surgical specialties: emergency medicine (EM, n = 100); primary care (PC, n = 71 - included internal medicine, family medicine, and pediatrics); a variety of others (n = 60).  Surgeons and non-surgeons agreed on the relative importance of the acute abdomen, breast disease, inguinal hernias, inflammatory bowel disease, morbid obesity, sinusitis, thyroid and parathyroid disease, and wound care; surgeons believed colorectal cancer and diverticulitis to be more important. Surgeons rated all other topics as less important to non-surgeons than non-surgeons. EM rated most acute problems more important that PC; both groups ranked most topics higher importance to the practice of a non-surgeon than surgeons (p < 0.05). CONCLUSIONS: Surgeons consistently underestimate the importance non-surgeons place on surgical topics in their practice.  These results reinforce the perceived importance of a wide exposure to surgery in the surgical clerkship to all medical students - but topics could be focused differently depending on acute or non-acute non-surgical care career plans.

Surgical Management of Breast Cancer Liver Metastasis.

Hepatic resection for patients with isolated breast cancer liver metastases (BCLM) is associated with prolonged disease-free interval and better overall survival in highly selected patients. Patients with limited disease who are not candidates for surgery benefit from ablative therapies for isolated breast cancer metastasis in addition to systemic chemotherapy. In the era of modern effective systemic chemotherapy for BCLM, local regional therapies are warranted, yet only in well-selected patients following discussion in a multidisciplinary setting. This article reviews data related to hepatic resection and ablative therapies of BCLM, as well as long-term outcomes of women treated with these approaches.

Association Between Anesthesia Delivered During Tumor Resection and Cancer Survival: a Systematic Review of a Mixed Picture with Constant Themes.

BACKGROUND: Surgery is required for cure of most solid tumors, and general anesthesia is required for most cancer surgery. The vast majority of cancer surgery is facilitated by general anesthesia using volatile inhalational agents such as isoflurane and sevoflurane. Only recently have the immunologic and oncologic effect of inhalational agents, and their alternative, propofol-based total intravenous anesthesia (TIVA), come under investigation. METHODS: Between January 2019 and June 2020, English language articles on PubMed were searched for the keywords "Propofol" "TIVA" or "IV anesthesia" and either "cancer surgery" or "surgical oncology." Duplicates were removes, manuscripts classified as either in vitro, animal, translational, or clinical studies, and their results summarized within these categories. RESULTS: In-vitro and translational data suggest that inhalational anesthetics are potent immunosuppressive and tumorigenic agents that promote metastasis, while propofol is anti-inflammatory, anti-tumorigenic, and prevents metastasis development. Clinically there is a recurring association, based largely on retrospective, single institution series, that TIVA is associated with significant improvements in disease-free interval and overall survival in a number of, but not all, solid tumors. The longer the surgery is, the more intense the surgical trauma is, the more aggressive the malignancy is, and the higher likelihood of an association is. DISCUSSION: Prospective randomized trials, coupled with basic science and translational studies, are needed to further define this association.

When a Patient Regrets Having Undergone a Carefully and Jointly Considered Treatment Plan, How Should Her Physician Respond?

Shared decision making is best utilized when a decision is preference sensitive. However, a consequence of choosing between one of several reasonable options is decisional regret: wishing a different decision had been made. In this vignette, a patient chooses mastectomy to avoid radiotherapy. However, postoperatively, she regrets the more disfiguring operation and wishes she had picked the other option: lumpectomy and radiation. Although the physician might view decisional regret as a failure of shared decision making, the physician should reflect on the process by which the decision was made. If the patient's wishes and values were explored and the decision was made in keeping with those values, decisional regret should be viewed as a consequence of decision making, not necessarily as a failure of shared decision making.

Autonomous detection, grading, and reporting of postoperative complications using natural language processing.

INTRODUCTION: Natural language processing, a computer science technique that allows interpretation of narrative text, is infrequently used to identify surgical complications. We designed a natural language processing algorithm to identify and grade the severity of deep venous thrombosis and pulmonary embolism (together: venous thromboembolism). METHODS: Patients from our 2011-2014 American College of Surgeons National Surgical Quality Improvement Project cohorts with a duplex ultrasound or a computerized tomography angiography of the chest performed within 30 days of surgery were divided into training and validation datasets. A "bag of words" approach classified the reports; other electronic health record data classified the venous thromboembolism's severity. RESULTS: Of the 10,295 American College of Surgeons National Surgical Quality Improvement Project patients, 251 were used in our deep venous thromboses validation cohort (273 total ultrasounds) and 506 in our pulmonary embolisms cohort (552 total computerized tomography angiographies). For deep venous thromboses the sensitivity and specificity were 85.1% and 94.6%, while for pulmonary embolisms they were 90% and 98.7%. Most discordances were due to lack of imaging documentation of a deep venous thrombosis (28/41, 68.3%) or pulmonary embolism (6/6, 100%). Most deep venous thromboses (28 patients, 54.6%) and pulmonary embolisms (25 patients, 75.8%) required administration of therapeutic intravenous or subcutaneous anticoagulation. CONCLUSION: Natural language processing can reliably detect the presence of postoperative venous thromboembolisms, and its use should be expanded for the detection of other conditions from narrative documentation.

Association of Hospital Costs With Complications Following Total Gastrectomy for Gastric Adenocarcinoma.

IMPORTANCE: Postoperative complications are associated with increased hospital costs following major surgery, but the mechanism by which they increase cost and the categories of care that drive this increase are poorly described. OBJECTIVE: To describe the association of postoperative complications with hospital costs following total gastrectomy for gastric adenocarcinoma. DESIGN, SETTING, AND PARTICIPANTS: This retrospective analysis of a prospectively collected gastric cancer surgery database at a single National Cancer Institute-designated comprehensive cancer center included all patients undergoing curative-intent total gastrectomy for gastric adenocarcinoma between January 2009 and December 2012 and was conducted in 2015 and 2016. MAIN OUTCOMES AND MEASURES: Ninety-day normalized postoperative costs. Hospital accounting system costs were normalized to reflect Medicare reimbursement levels using the ratio of hospital costs to Medicare reimbursement and categorized into major cost categories. Differences between costs in Medicare proportional dollars (MP $) can be interpreted as the amount that would be reimbursed to an average hospital by Medicare if it paid differentially based on types and extent of postoperative complications. RESULTS: In total, 120 patients underwent curative-intent total gastrectomy for stage I through III gastric adenocarcinoma between 2009 and 2012. Of these, 79 patients (65.8%) were men, and the median (interquartile range) age was 64 (52-70) years. The 51 patients (42.5%) who underwent an uncomplicated total gastrectomy had a mean (SD) normalized cost of MP $12 330 (MP $2500), predominantly owing to the cost of surgical care (mean [SD] cost, MP $6830 [MP $1600]). The 34 patients (28.3%) who had a major complication had a mean (SD) normalized cost of MP $37 700 (MP $28 090). Surgical care was more expensive in these patients (mean [SD] cost, MP $8970 [MP $2750]) but was a smaller contributor to total cost (24%) owing to increased costs from room and board (mean [SD] cost, MP $11 940 [MP $8820]), consultations (mean [SD] cost, MP $3530 [MP $2410]), and intensive care unit care (mean [SD] cost, MP $7770 [MP $14 310]). CONCLUSIONS AND RELEVANCE: Major complications were associated with tripled normalized costs following curative-intent total gastrectomy. Most of the excess costs were related to the treatment of complications. Interventions that decrease the number or severity of postoperative complications could result in substantial cost savings.