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Emergency general surgery (EGS) patients are at increased risk for postoperative morbidity and mortality. Obesity is a risk factor for poor outcomes in this population. Our study aimed to explore the association of body mass index (BMI) with postoperative outcomes in patients requiring common EGS procedures. A retrospective review of the 2018-2020 National Surgical Quality Improvement Program database identified patients undergoing four common EGS procedures: large bowel resection, small bowel resection, cholecystectomy, and appendectomy. Patients were classified by BMI: normal weight (18.5-24.9 kg/m2), obesity classes I (30-34.9 kg/m2), II (35-39.9 kg/m2), III (40-49.9 kg/m2), and IV (≥50 kg/m2). Main outcomes of interest were major adverse event (MAE) and mortality. From 2018 to 2020, a total of 82,540 patients underwent one of four common EGS procedures. On unadjusted analysis, obesity class IV had higher mortality rates compared to classes I-III (6.2% vs 3.1%, P < 0.001). Patients in obesity classes I-III had lower odds of MAE and death relative to those of normal weight. Compared to other patients with obesity, those in obesity class IV were at increased risk of MAE (odds ratio 1.27; 95% confidence interval 1.13-1.44) and death (odds ratio 1.69; 95% confidence interval 1.34-2.13). Patients with varying degrees of obesity have different risk profiles following common EGS procedures. While patients in lower obesity classes had reduced odds of adverse outcomes, those with BMI ≥50 kg/m2 were particularly at greater risk for postoperative morbidity and mortality. This vulnerable population warrants further investigation and increased vigilance to ensure high-quality care. [ABSTRACT FROM AUTHOR]

Background: Malignant peritoneal mesothelioma is a rare disease with poor outcomes. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy is the cornerstone of therapy. We aim to compare outcomes of malignant peritoneal mesothelioma treated at academic versus community hospitals. Methods: This was a retrospective cohort study using the National Cancer Database to identify patients with malignant peritoneal mesothelioma from 2004 to 2016. Patients were divided according to treating facility type: academic or community. Outcomes were assessed using log-rank tests, Cox proportional-hazard modeling, and Kaplan-Meier survival statistics. Results: In total, 2682 patients with malignant peritoneal mesothelioma were identified. A total of 1272 (47.4%) were treated at an academic facility and 1410 (52.6%) were treated at a community facility. Five hundred forty-six (42.9%) of patients at academic facilities underwent debulking or radical surgery compared to 286 (20.2%) at community facilities. Three hundred sixty-six (28.8%) of patients at academic facilities received chemotherapy on the same day as surgery compared to 147 (10.4%) of patients at community facilities. Unadjusted 5-year survival was 29.7% (95% CI 26.7–32.7) for academic centers compared to 18.3% (95% CI 16.0–20.7) for community centers. In multivariable analysis, community facility was an independent predictor of increased risk of death (HR: 1.19, 95% CI 1.08–1.32, p = 0.001). Conclusions: We demonstrate better survival outcomes for malignant peritoneal mesothelioma treated at academic compared to community facilities. Patients at academic centers underwent surgery and received chemotherapy on the same day as surgery more frequently than those at community centers, suggesting that malignant peritoneal mesothelioma patients may be better served at experienced academic centers. [ABSTRACT FROM AUTHOR]

Results Colon Cancer A total of 33,038 colon cancer patients with isolated liver metastases were included (31.3% academic, 68.7% community). Keywords: Colorectal cancer; Liver metastases; Survival EN Colorectal cancer Liver metastases Survival 209 213 5 01/17/22 20220101 NES 220101 Introduction Colorectal cancer is the third leading cause of cancer-related deaths in the USA. Recurrence and outcomes following hepatic resection, radiofrequency ablation, and combined resection/ablation for colorectal liver metastases. [Extracted from the article]

The incidence of anal squamous cell carcinoma (SCC) is rising, despite the introduction of a vaccine against human papillomavirus (HPV), the most common etiology of anal SCC. The rate of anal SCC is higher among women and sex-based survival differences may exist. We aimed to examine the association between sex and survival for stage I-IV anal SCC. The National Cancer Database was used to identify patients with stage I-IV anal SCC from 2004-2016. Outcomes were assessed utilizing log rank tests, Kaplan-Meier statistics, and Cox proportional-hazard modeling. Subgroup analyses by disease stage and by HPV status were performed. Outcomes of interest were median, 1-, and 5-year survival by sex. There were 31,185 patients with stage I-IV anal SCC. 10,714 (34.3%) were male and 20,471 (65.6%) were female. 1- and 5- year survival was 90.2% (95% CI 89.8 – 90.7) and 67.7% (95% CI 66.9 – 68.5) for females compared to 85.8% (95% CI 85.1 – 86.5) and 55.9% (95% CI 54.7 – 57.0) for males. In subgroup analysis, females demonstrated improved unadjusted and adjusted survival for all stages of disease. Female sex was an independent predictor of improved survival (HR 0.68, 95% CI 0.65 – 0.71, P < 0.001). We demonstrate better overall survival for females compared to males for stage I-IV anal SCC. It is not clear why women have a survival advantage over men, though exposure to prominent risk factors may play a role. High-risk men may warrant routine screening for anal cancer. [ABSTRACT FROM AUTHOR]

Background: The evaluation of lymph nodes in rectal cancer dictates treatment. The goals of this study are to characterize the contemporary rate of lymph node metastasis in early stage rectal cancer and to re-investigate histologic factors that predict positive lymph nodes. Materials and Methods: Using the National Cancer Database, we identified patients with clinical stage I rectal adenocarcinoma. Multivariable logistic regression was used to determine risk factors for lymph node positivity. Results: 12.2% of patients with T1 tumors and 18.0% of patients with T2 tumors had positive lymph nodes. For T1 tumors, positive lymph nodes were present in 9.3% with neither poor differentiation nor lymphovascular invasion (LVI), 17.3% with poor differentiation alone, 34.7% with LVI alone, and 45.0% with both poor differentiation and LVI. For T2 tumors, positive lymph nodes were present in 11.7% with neither poor differentiation nor LVI, 25.3% with poor differentiation alone, 47.3% with LVI alone, and 41.5% with both poor differentiation and LVI. LVI was an independent predictor of positive lymph nodes (OR;4.75,95%CI;3.17–7.11,p < 0.001) for T1 and (OR;6.20,95%CI;4.53–8.51,p < 0.001) T2 tumors. Conclusions: T1/T2 tumors have higher rates of positive lymph nodes when poor differentiation and LVI are present. These results should be taken into consideration prior to surgical treatment. [ABSTRACT FROM AUTHOR]

Background: Primary small bowel non-Hodgkin's lymphoma is a rare disease representing 2% of small intestine malignancies. There is limited data delineating the optimal treatment for these heterogeneous tumors. We aim to examine relationships between different treatment modalities and surgical outcomes in patients with small bowel lymphoma. Materials and Methods: Patients diagnosed with stage I–III small bowel lymphoma in 2004–2015 who underwent surgery were identified in the National Cancer Database. Two cohorts were created based on systemic chemotherapy treatment status. The primary outcome was overall survival. An adjusted Cox proportional hazards model was used to evaluate the impact of treatment strategy on survival. Results: 2283 patients met inclusion criteria Of these patients, 826 patients (36%) underwent surgical resection alone, and 1457 patients (64%) underwent resection with systemic chemotherapy. Chemotherapy was associated with improved overall survival in unadjusted (5-year overall survival, 55% versus 70%) and adjusted analysis (HR 0.54, 95% CI 0.47–0.63, p < 0.001). Discussion: Patients with small bowel lymphoma have a low five-year overall survival after surgery. Chemotherapy is associated with improved survival, although one third of patients do not receive this therapy. Several other clinical factors are identified that are also associated with overall survival, including histology subtype, margin status, age, and medical comorbidities. This information can help with prognostication and potentially aid in treatment decision-making. [ABSTRACT FROM AUTHOR]

Purpose: Small bowel leiomyosarcoma (SB LMS) is a rare disease with few studies characterizing its outcomes. This study aims to evaluate surgical outcomes for patients with SB LMS. Methods: The National Cancer Database was queried from 2004 to 2016 to identify patients with SB LMS who underwent surgical resection. The primary outcome was overall survival. Results: A total of 288 patients with SB LMS who had undergone surgical resection were identified. The median age was 63, and the majority of patients were female (56%), White (82%), and had a Charlson comorbidity score of zero (76%). Eighty-one percent of patients had negative margins following surgical resection. Fourteen percent of patients had metastatic disease at the time of diagnosis. Nineteen percent of patients received chemotherapy and 3% of patients received radiation. One-year overall survival was 77% (95% CI: 72–82%) and 5-year overall survival was 43% (95% CI: 36–49%). Higher grade (HR: 1.98, 95% CI: 1.10–3.55, p = 0.02) and metastatic disease at diagnosis (HR: 2.57, 95% CI: 1.45–4.55, p = 0.001) were independently associated with higher risk of death. Conclusion: SB LMS is a rare disease entity, with treatment centering on complete surgical resection. Our results demonstrate that overall survival is higher than previously thought. Timely diagnosis to allow for complete surgical resection is key, and investigation into the possible role of chemotherapy or radiation therapy is needed. [ABSTRACT FROM AUTHOR]

Background: Enhanced recovery after surgery (ERAS) is a multimodal perioperative care pathway designed to achieve early recovery by preserving preoperative organ function and minimizing the stress response following surgery. Few studies have assessed the association between ERAS and postoperative cardiac complications. The goal of this study is to evaluate the impact of ERAS on postoperative cardiac complications.Materials and Methods: A retrospective review of a prospectively maintained database of colorectal patients who underwent surgery at a tertiary colorectal cancer referral center was carried out. Preoperative, intraoperative, and postoperative factors including demographics, comorbidities, medications, and fluid administration were recorded. The primary outcome was postoperative cardiac arrhythmia, and secondary outcomes included other postoperative complications.Results: A total of 800 patients who underwent elective colorectal surgery were identified. Four hundred seventeen patients (52%) were in the control group and 383 patients (48%) were in the ERAS group. Patients in both groups were similar with regard to demographics and clinical characteristics. There were significantly higher rates of cardiac arrhythmia in the control group (5.3%) compared with the ERAS group (1.8%), p = 0.009. Multivariable analysis revealed that ERAS was an independent predictor of decreased postoperative cardiac arrhythmia (OR 0.30, 95%CI 0.17-0.55, p < 0.001) while older age was an independent predictor of increased postoperative cardiac arrhythmia (OR 1.08, 95%CI 1.02-1.13, p = 0.008). Patients receiving lower amounts of intravenous fluids had significantly decreased postoperative cardiac arrhythmia (OR = 0.25, 95%CI 0.09-0.67, p = 0.006).Conclusions: ERAS and goal-directed fluid therapy are associated with significant reductions in postoperative cardiac arrhythmias. [ABSTRACT FROM AUTHOR]

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have historically been associated with high morbidity given the physiologic insult of an extensive operation. Enhanced Recovery after Surgery (ERAS) pathways have been successful in improving postoperative outcomes for many procedures but have not been well studied in these cases. We examined the feasibility and effect of ERAS pathway implementation for patients undergoing CRS/HIPEC. Patients with peritoneal carcinomatosis who underwent CRS/HIPEC between October 2015 to September 2018 were identified. Patient characteristics, disease pathology, and perioperative outcome data were obtained. Primary outcomes were hospital length of stay (LOS), 30-d readmissions, renal dysfunction, and complications. Of the 31 patients who were included, 11 (35.5%) patients underwent CRS/HIPEC prior to the implementation of the ERAS pathway, and 20 (64.5%) patients underwent CRS/HIPEC according to the ERAS guidelines. There were no significant differences in the baseline clinical or pathologic characteristics between groups. There was a significant decrease in LOS with ERAS pathway management from 9 d to 6 d (P = 0.002). No patients from either cohort experienced acute kidney injury. There was no significant difference in 30-d readmission rates or complications. In this feasibility study, ERAS pathway utilization significantly decreased postoperative LOS for patients undergoing CRS/HIPEC, without evidence of increased complications or readmissions. ERAS programs should be considered for integration into future CRS/HIPEC protocols. [ABSTRACT FROM AUTHOR]

Background: Enhanced recovery after surgery (ERAS) programs are now standard of care for colorectal surgery. Efforts have been aimed at decreasing postoperative opioid consumption. The goal of this study is to evaluate the effect of liposomal bupivacaine transversus abdominis plane (TAP) blocks on opioid use and its downstream effect on rates of ileus and hospital length of stay (LOS). Methods: We performed a retrospective pre- and postintervention time-trend analysis (2016–2018) of ERAS patients undergoing laparoscopic colorectal surgery at two academic medical centers within the same hospital system. The intervention was liposomal bupivacaine TAP blocks versus standard local infiltration with bupivacaine with a primary outcome of total morphine milligram equivalents (MME) administered within 72 h of surgery. Secondary outcomes included hospital LOS and rate of postoperative ileus. Results: There were 556 patients included at the control hospital, and 384 patients were included at the treatment hospital. Patients at both hospitals were similar with regard to age, body mass index, comorbidities, and surgical indication. In an adjusted time-trend analysis, the treatment hospital was associated with a significant decrease in MME administered (– 15.9 mg, p = 0.04) and hospital LOS (– 0.8 days, p < 0.001). There was no significant decrease in the rate of ileus at the treatment hospital (– 6.9%, p = 0.08). Conclusions: In a time-trend analysis, the addition of liposomal bupivacaine TAP blocks into the ERAS protocol resulted in significantly reduced opioid use and shorter hospital LOS for patients undergoing surgery at the treatment hospital. Liposomal bupivacaine TAP blocks should be considered for inclusion in the standard ERAS protocol. [ABSTRACT FROM AUTHOR]

Background: Following abdominoperineal resection (APR) for rectal cancer, perineal wound complications are common. Omental flap creation may allow for decreased morbidity. The aim of this study was to assess wound complications in rectal cancer patients undergoing APR with and without the addition of an omental flap. Methods: The National Surgical Quality Improvement Program Proctectomy targeted database from 2016 to 2017 was used to identify all patients undergoing APR for rectal cancer. The primary outcomes were wound complications such as superficial site infection, deep wound infection, organ space infection, and wound dehiscence. Results: There were 3063 patients identified. One hundred seventy-three (5.6%) patients underwent APR with an omental flap repair while 2890 (94.4%) patients underwent APR without an omental flap repair. Patients in both groups were similar with regard to age, gender, body mass index, American Society of Anesthesia class, and neoadjuvant cancer treatment (all p > 0.05). Patients who underwent an omental flap repair were significantly more likely to have a postoperative organ space infection (10.4% vs. 6.5%, p = 0.04). There was no significant difference in rates of superficial site infection, deep wound infection, wound dehiscence, or reoperation between the two patient groups. In multivariable analysis, omental flap creation was independently associated with organ space infection (OR 1.72, 95%CI 1.02–2.90, p = 0.04). Conclusions: This is the largest study to evaluate omental flap use in rectal cancer patients undergoing APR. Omental flaps are independently associated with organ space infection. [ABSTRACT FROM AUTHOR]

Purpose: Low anterior resection with coloanal anastomosis (CAA) for low rectal cancer is a technically difficult operation with limited data available on oncologic outcomes. We aim to investigate overall survival and operative oncologic outcomes in patients who underwent CAA compared to abdominoperineal resection (APR). Methods: The National Cancer Database (2004–2013) was used to identify patients with non-metastatic rectal adenocarcinoma who underwent CAA or APR. Patients were 1:1 matched on age, gender, Charlson score, tumor size, tumor grade, pathologic stage, and radiation treatment with propensity scores. The primary outcome was overall survival. Secondary outcomes included 30-day mortality and resection margins. Results: Following matching, 3536 patients remained in each group. No significant differences in matched demographic, treatment, or tumor variables were seen between groups. There was no significant difference in 30-day mortality (1.24% vs. 1.39%, p = 0.60). Following resection, margins were more likely to be negative after CAA compared with APR (5.26% vs. 8.14%, p < 0.001). When stratified by pathologic stage, there was a significant survival advantage for individuals undergoing CAA compared to APR (stage 1 HR 0.72, [95% CI 0.62–0.85], p < 0.001; stage 2 HR 0.76, [95% CI 0.65–0.88], p < 0.001; stage 3 HR 0.76, [95% CI 0.67–0.85], p < 0.001). Conclusions: Patients undergoing CAA compared with APR for rectal cancer have better overall survival and are less likely to have positive margins despite the technically challenging operation. [ABSTRACT FROM AUTHOR]

Background: Anti-tumor necrosis factor (TNF) agents have been an integral part in the treatment of inflammatory bowel disease. However, a subset of inflammatory bowel disease patients ultimately requires surgery and up to 30 % of them have undergone treatment with anti-TNF agents. Studies assessing the effect of anti-TNF agents on postoperative outcomes have been inconsistent. The aim of this study is to assess postoperative morbidity in inflammatory bowel disease patients who underwent surgery with anti-TNF therapy prior to surgery.Methods: This is a retrospective review of 282 patients with inflammatory bowel disease undergoing intestinal surgery between 2013 and 2015 at the Mount Sinai Hospital. Patients were divided into two groups based on treatment with anti-TNF agents (infliximab, adalimumab, certolizumab) within 8 weeks of surgery. Thirty-day postoperative outcomes were recorded. Univariate and multivariate statistical analyses were carried out.Results: Seventy-three patients were treated with anti-TNF therapy within 8 weeks of surgery while 209 patients did not have exposure. Thirty-day anastomotic leak, intra-abdominal abscess, wound infection, extra-abdominal infection, readmission, and mortality rates were not significantly different between the two groups.Conclusions: The use of anti-TNF medications in inflammatory bowel disease patients within 2 months of intestinal surgery is not associated with an increased risk of 30-day postoperative complications. [ABSTRACT FROM AUTHOR]

Emergency general surgery is a risk factor for postoperative morbidity and mortality. Patients with obesity are at greater risk for complications following ventral hernia repair (VHR). Our study aimed to determine the association of obesity with postoperative outcomes in patients requiring emergency VHR. Our retrospective study used the 2016-2020 National Surgical Quality Improvement Program database to identify patients undergoing emergency VHR. Patients were classified by body mass index (BMI): normal weight 18.5-24.9 kg/m2, overweight 25-29.9 kg/m2, obesity 30-39.9 kg/m2, morbid obesity 40-49.9 kg/m2, and super morbid obesity (SMO) ≥50 kg/m2. The primary outcome of interest was surgical site infection (SSI). From 2016 to 2020, a total 11,593 patients underwent emergency VHR. Patients with higher BMI had increased incidences of postoperative complications. Compared to other patients with obesity, SMO patients had higher rates of SSI (11.5% versus 5.5%, P < 0.001), prolonged ventilatory support (4.0% versus 1.5%, P < 0.001), length of stay ≥4 d (52.7% versus 42.2%, P < 0.001), reoperation (6.4% versus 3.4%, P < 0.001), and readmission (11.3% versus 7.2%, P < 0.001). Super morbid obesity (SMO) patients had increased odds of SSI (odds ratio [OR] 5.55, 95% confidence interval [CI] 3.47-8.88), prolonged ventilatory support (OR 1.92, 95% CI 1.07-3.45), and reoperation (OR 1.97, 95% CI 1.26-3.09) compared to normal weight patients. Patients with BMI ≥50 kg/m2 undergoing emergency VHR have increased overall incidences of SSIs, prolonged mechanical ventilation, reoperation, and readmission, and this remains significant when compared to other patients with obesity. This population is at significant risk for postoperative morbidity, and increased vigilance in perioperative management is imperative to ensure safe, high-quality care. [ABSTRACT FROM AUTHOR]

Background: The value of drain placement in hepatic surgery has not been conclusive. The aim of this study was to determine whether drain placement during major hepatectomy was associated with negative postoperative outcomes and whether its placement reduced the need for secondary procedures. Methods: The American College of Surgeons National Surgical Quality Improvement Program Procedure-Targeted Hepatectomy Database was used to identify patients who underwent major hepatectomy. Patients were divided into two groups based on the placement of a drain during the procedure. Propensity score-matched cohorts of patients who underwent major hepatic resection with or without drain placement were created accounting for patient characteristics. The primary outcomes were 30-day postoperative complications including bile leak, post-hepatectomy liver failure, and invasive intervention as well as mortality and readmission. Results: A total of 1005 patients underwent major hepatectomy; 500 patients (49.8 %) had prophylactic drains placed at the conclusion of the procedure. Drain placement was associated with any complication ( p < 0.001), blood transfusion ( p < 0.001), renal insufficiency ( p = 0.02), bile leak ( p < 0.001), invasive intervention ( p = 0.02), length of stay ( p = 0.001), and readmission ( p < 0.001). In the matched cohort, drain placement was associated with any complication ( p < 0.001), blood transfusion ( p < 0.001), superficial surgical site infection (SSI) ( p = 0.028), bile leak ( p < 0.001), and longer length of stay (0.03). In addition, placement of a prophylactic drain did not decrease the rate of postoperative bile leaks requiring therapeutic intervention ( p = 0.21) (Table 2). In multivariate analysis, drain placement was independently associated with any complication ( p < 0.001), blood transfusion ( p = 0.02), bile leak ( p < 0.001), invasive intervention ( p = 0.011), superficial surgical site infection (SSI) ( p = 0.039), and hospital readmission ( p = 0.005) (Table 3). Placement of a prophylactic drain did not decrease the rate of postoperative bile leaks requiring therapeutic intervention ( p = 0.15). Conclusion: Drain placement after major hepatectomy may lead to increased postoperative complications including bile leak, superficial surgical site infection, and hospital length of stay and does not decrease the need for secondary procedures in patients with bile leaks. [ABSTRACT FROM AUTHOR]

Background Laparoscopic ventral hernia repair (LVHR) is associated with considerable postoperative pain. Transversus abdominis plane (TAP) blocks have proven effective in controlling postoperative pain in a variety of laparoscopic abdominal operations. To date, no studies have focused on TAP blocks in LVHR. Our goal was to assess whether TAP blocks reduce opioid requirements and pain scores after LVHR. Study Design Patients undergoing LVHR were randomly assigned to receive a TAP block or placebo injection. The primary end points were cumulative opioid use at 1, 3, 6, 12, 18, and 24 hours postoperatively and pain scores recorded at 1 and 24 hours postoperatively. Results Patients in the experimental TAP group (n = 52) and control group (n = 48) were comparable with respect to patient demographics and clinical characteristics. In the postanesthesia care unit, the TAP group had significantly lower pain scores than the control group (p < 0.05). Patients in the TAP group used less opioids than the control group at each time point assessed after 6 hours postoperatively (p < 0.05). There was no significant difference in pain scores at 24 hours postoperatively (p > 0.05). Conclusions Transversus abdominis plane blocks given during LVHR significantly decrease both short-term postoperative opioid use and pain experienced by patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: Poorer surgical outcomes in black compared with white patients have been reported, but it remains unclear if race independently predicts worse outcomes. We investigated if blacks have poorer outcomes than whites following abdominal surgery at quality-seeking hospitals. METHODS: Using the American College of Surgeons' National Surgical Quality Improvement Program database, patients who were black or white and underwent common abdominal surgery procedures were identified. A total of 19,326 (10%) blacks and 167,140 (90%) whites undergoing abdominal surgery were analyzed. Statistical analyses were performed using SPSS v20. RESULTS: Thirty-day mortality for blacks compared with whites was not statistically significant for any procedures reviewed (all P > .05). Thirty-day morbidity for blacks was slightly higher in appendectomy (P < .0001), small bowel resection (P < .0001), and partial colectomy (P < .0001). CONCLUSION: Black compared with white patients did not have increased mortality following abdominal surgery but had minor, clinically insignificant, increased morbidity in appendectomy, small bowel resection, and partial colectomy. [ABSTRACT FROM AUTHOR]

Background: Spinal anaesthesia when compared to general anaesthesia has been shown to decrease postoperative morbidity in orthopaedic surgery. The aim of the present study was to assess the differences in thirty-day morbidity and mortality for patients undergoing hip fracture surgery with spinal versus general anaesthesia.Methods: The American College of Surgeons National Surgical Quality and Improvement Program (NSQIP) database was used to identify patients who underwent hip fracture surgery with general or spinal anaesthesia between 2010 and 2012 using CPT codes 27245 and 27244. Patient characteristics, complications, and mortality rates were compared. Univariate analysis and multivariate logistic regression were used to identify predictors of thirty-day complications. Stratified propensity scores were employed to adjust for potential selection bias between cohorts.Results: 6133 patients underwent hip fracture surgery with spinal or general anaesthesia; 4318 (72.6%) patients underwent fracture repair with general anaesthesia and 1815 (27.4%) underwent fracture repair with spinal anaesthesia. The spinal anaesthesia group had a lower unadjusted frequency of blood transfusions (39.34% versus 45.49%; p<0.0001), deep vein thrombosis (0.72% versus 1.64%; p=0.004), urinary tract infection (8.87% versus 5.76%; p<0.0001), and overall complications (45.75% versus 48.97%; p=0.001). The length of surgery was shorter in the spinal anaesthesia group (55.81 versus 65.36 min; p<0.0001). After multivariate logistic regression was used to adjust for confounders, general anaesthesia (odds ratio, 1.29; 95% confidence interval, 1.14-1.47; p=0.0002) was significantly associated with increased risk for complication after hip fracture surgery. Age, female sex, body mass index, hypertension, transfusion, emergency procedure, operation time, and ASA score were risk factors for complications after hip fracture repair (all p<0.05).Conclusions: Patients who underwent hip fracture surgery with general anaesthesia had a higher risk of thirty-day complications as compared to patients who underwent hip fracture repair with spinal anaesthesia. Surgeons should consider using spinal anaesthesia for hip fracture surgery. [ABSTRACT FROM AUTHOR]

This JAMA Insights Clinical Update summarizes current guidelines for prevention of surgical site infections and discusses emerging prevention strategies, such as preoperative bowel preparation and negative-pressure wound therapy, that are challenging longstanding surgical practices. [ABSTRACT FROM AUTHOR]

Background: Racial disparities exist in patients with rectal cancer with respect to both treatment and survival. Minority-serving hospitals (MSHs) provide healthcare to a disproportionately large percent of minority patients in the USA. We examined the effects of rectal cancer treatment at MSH to understand drivers of these disparities. Methods: The NCDB was queried (2004–2015), and patients diagnosed with stage II or III rectal adenocarcinoma were identified. Racial case mix distribution was calculated at the institutional level, and MSHs were defined as those within the top decile of Black and Hispanic patients. Logistic regression was used to identify predictors of receipt of standard of care treatment. Survival was assessed using the Kaplan-Meier method, and Cox proportional hazards models were used to evaluate adjusted risk of death. Analyses were clustered by facility. Results: A total of 68,842 patients met the inclusion criteria. Of these patients, 63,242 (91.9%) were treated at non-MSH, and 5600 (8.1%) were treated at MSH. In multivariable analysis, treatment at MSH (OR 0.70 95%CI 0.61–0.80 p < 0.001) and Black race (OR 0.75 95%CI 0.70–0.81 p < 0.001) were associated with significantly lower odds of receiving standard of care. In adjusted analysis, Black patients had a significantly higher risk of mortality (HR 1.20 95%CI 1.14–1.26 p < 0.001). Conclusions: Treatment at MSH institutions and Black race were associated with significantly decreased odds of receipt of recommended standard therapy for locally advanced rectal adenocarcinoma. Survival was worse for Black patients compared to White patients despite adjustment for receipt of standard of care. [ABSTRACT FROM AUTHOR]

There are various racial, socioeconomic, and tumor-specific factors that can impact rectal cancer outcomes. The current systematic review and meta-analysis evaluate the effect socioeconomic and racial variables on overall survival of rectal cancer patients after surgical resection. A literature search was performed via electronic databases according to Systematic Reviews and Meta-Analyses and Meta-analysis Of Observational Studies in Epidemiology guidelines. All studies were evaluated by three authors and validated for data extraction. Predictive variables and survival profiles (1-, 5-, and 10-y survival and overall survival) reported by the studies were recorded for the systematic review. Hazard ratios, odds ratios, and 95% confidence intervals were extracted for meta-analysis. Forest plots were used to interpret the results. The primary outcome was the effect size of the predictive variables on overall survival after surgical resection. Of the 265 articles collected, 22 met inclusion criteria. Sixteen studies were used for the systematic review, and 17 studies were considered for meta-analysis. Overall, 662,053 subjects with rectal cancer were studied (439,766 with race reported), of which 344,193 (78.3%) were White and 60,283 (13.7%) were Black. The median survival was 56.8% for White patients and 47.9% for Black patients. Meta-analysis revealed that race, socioeconomic variables (education level, income level, and insurance status), and facility characteristics (type and volume) were significantly associated with overall survival in rectal cancer. Racial and socioeconomic disparities are present in outcomes for rectal cancer patients undergoing surgical resection. It is important to consider these disparities in the management of patients with rectal cancer to minimize any consequent disparities in surgical outcomes. [ABSTRACT FROM AUTHOR]

Surgical resection is a mainstay of colorectal cancer treatment, and prior studies have shown improved outcomes in patients undergoing surgery for colorectal cancer by colorectal surgical specialists compared with nonspecialized surgeons. Here, we examine the geographic distribution of colorectal surgeons in the United States and its relationship with sociodemographic characteristics of the served population. The Area Health Resource File from 2017 to 2018 was used to identify the number and location of colorectal surgeons practicing throughout the United States and sociodemographic characteristics at the county and hospital referral region (HRR) level. The main outcomes of interest were the density of colorectal surgeons per 100,000 population and associations with sociodemographic characteristics at the county and HRR level based on multivariable linear regression. In multivariable analysis, regions with higher proportion of nonwhite individuals and college-educated individuals had significantly more colorectal surgeons per 100,000 population, whereas regions with higher proportions of uninsured individuals had significantly fewer colorectal surgeons per 100,000 population at both the county and HRR levels. Geographic and sociodemographic variability exists in the distribution of colorectal surgeons in the United States. Such variability may be contributing to disparities in access to specialized colorectal care. [ABSTRACT FROM AUTHOR]

Physician burnout is a highly prevalent issue in the surgical community. Burnout is associated with poor career satisfaction; female gender, and younger age place surgeons at higher risk for burnout. Here, we examined drivers behind burnout and career dissatisfaction in female and junior surgical faculty, with specific attention paid to gender-based differences. Participants included full-time surgery faculty members at a single academic surgery center. Both male and female faculty members were included, at ranks ranging from instructor to associate professor. Semistructured interviews were conducted by a faculty member at the institution until thematic saturation was reached. Field notes were compiled from each interview, and these data were coded thematically. Fourteen female faculty and nine male faculty members were interviewed. For both female and male faculty, lack of control with work life was a significant theme contributing to burnout. Positive factors contributing to career satisfaction for both genders included enjoyment of patient care and teaching, teamwork and collegiality, and leadership support. For female faculty, the major theme of gender bias in the workplace as a risk factor for burnout was prominent. Male faculty struggled more than their female counterparts with guilt over complications and second victim syndrome. Gender differences driving career dissatisfaction and burnout exist between female and male surgical faculty. Acknowledging these differences when designing efforts to address physician wellness and decrease burnout is critical. [ABSTRACT FROM AUTHOR]

Anatomic hepatectomies can be associated with complicated post-operative recoveries, often with discharge to post-acute care facilities. This study identifies preoperative and intraoperative factors associated with increased risk for non-home discharge destination after major hepatectomy. Patients undergoing major hepatectomy were identified in the NSQIP Targeted Hepatectomy Dataset (2014–2016). Multivariable logistic regression was performed. Patients from 2014 to 2015 were used for training cohort with nomogram generation and 2016 for validation cohort. Overall, 226 of 3750 patients (6.0%) were discharged to rehab, skilled care, or acute care facilities. Preoperative factors associated with non-home discharge on multivariable analysis were outside patient transfers, older age, presence of ascites, ASA physical status 3 or higher, and low preoperative hematocrit (all p < 0.05). Intraoperative factors significantly predictive were concurrent lysis of adhesions, Pringle maneuver, and biliary reconstruction (all p < 0.05). Predictors from testing cohort were validated in validation cohort. Nomograms based on preoperative variables alone and both preoperative and intraoperative variables were generated. We identify several preoperative and intraoperative factors that are associated with increased risk for non-home discharge after major hepatectomy. Preoperative anemia represents a potentially modifiable risk factor. Nomograms for preoperative planning as well as immediately following surgery were generated. [ABSTRACT FROM AUTHOR]

Introduction: The outcomes for enhanced recovery after surgery (ERAS) have yet to be thoroughly studied in minimally invasive esophageal surgery. In this review, we examine the literature to provide an overview of the current state of ERAS in minimally invasive esophageal surgery.Methods: We searched the PubMed database up to January 2018 for relevant literature. We reviewed two randomized controlled trials, one Cochrane Review, two meta-analyses, three systematic reviews, three prospective cohort studies, three retrospective case-control studies, one consecutive series, and several other studies pertaining to ERAS in minimally invasive esophageal surgery.Results: Compared with conventional perioperative care, ERAS pathways after minimally invasive esophageal procedures reduce postoperative hospital length of stay, encourage earlier return of bowel function, increase cost savings, and do not significantly change perioperative complication rates.Conclusions: We recommend that patients undergoing minimally invasive esophageal surgery enter a postoperative ERAS pathway to maximize recovery. ERAS pathways offer the best opportunity for successful postoperative recovery without negatively impacting patient safety. [ABSTRACT FROM AUTHOR]

Introduction: In the modern era of minimally invasive colorectal surgery and enhanced recovery pathways, the value of preoperative bowel preparation remains debated. In this review, we evaluate evidence regarding the use of mechanical bowel preparation (MBP) and oral antibiotic bowel preparation to make recommendations for their application in contemporary practice.Methods: We searched the PubMed database through December 2017 for relevant randomized controlled trials, Cochrane Reviews, American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database studies, and other reviews pertaining to MBP and oral antibiotic bowel preparation in elective colorectal surgery and conducted a narrative review.Results: The combination of MBP and oral antibiotics reduces the incidence of surgical site infection, anastomotic leak, and postoperative sepsis. MBP improves laparoscopic surgical viewing and facilitates intraoperative manipulation of the bowel in minimally invasive surgery.Conclusion: Based on existing data, we recommend that preoperative care includes MBP and oral antibiotics in elective minimally invasive colorectal surgery. [ABSTRACT FROM AUTHOR]

Individual participants expressed overlapping leadership styles, with I servant i and I transformational i leadership expressed by all 20 participants. I Leadership training i emerged as an additional theme, characterized by descriptions of formal and informal leadership training and by timing of leadership experiences, as either "early" or "late", that promoted leadership development. Women remain under-represented in academic surgery leadership positions, as is evidenced by the declining proportion of female faculty in ascending academic ranks, distributed as follows as of 2020: 60.7% of instructors, 30.2% of assistant professors, 23.1% of associate professors, and 13.5% of professors.[1] In 2020, women represented 8.7% of surgical department chairs in the USA.[2] We aimed to identify leadership styles and characteristics among female surgical chairs. [Extracted from the article]

One promising avenue toward a better understanding of the pathophysiology of positive emotional disturbances is to examine high-frequency heart rate variability (HRV-HF), which has been implicated as a potential physiological index of disturbances in positive emotional functioning. To date, only a few psychopathology relevant studies have systematically quantified HRV-HF profiles using more ecologically valid methods in everyday life. Using an experience-sampling approach, the present study examined both mean levels and intra-individual variability of HRV-HF – as well as comparison measures of cardiovascular arousal, sympathetic activity, and gross somatic movement – in everyday life, using ambulatory psychophysiological measurement across a six-day consecutive period among a spectrum of community adult participants with varying degrees of positive valence system disturbance, including adults with bipolar I disorder (BD; n = 21), major depressive disorder (MDD; n = 17), and healthy non-psychiatric controls (CTL; n = 28). Groups did not differ in mean HRV-HF, but greater HRV-HF instability (i.e., intra-individual variation in HRV-HF) was found in the BD compared to both MDD and CTL groups. Subsequent analyses suggested that group differences in HRV-HF variability were largely accounted for by variations in clinician-rated manic symptoms. However, no association was found between HRV-HF variability and dimensional measures of positive affectivity. This work provides evidence consistent with a quadratic relationship between HRV-HF and positive emotional disturbance and represents a valuable step toward developing a more ecologically valid model of positive valence system disturbances and their underlying psychophysiological mechanisms within an RDoC framework. [ABSTRACT FROM AUTHOR]

Background: Prior studies assessing colorectal cancer survival have reported better outcomes when operations are performed at high-volume centers. These studies have largely been cross-sectional, making it difficult to interpret their estimates. We aimed to assess the effect of facility volume on survival following proctectomy for rectal cancer. Methods: Using data from the National Cancer Database, we included all patients with complete baseline information who underwent proctectomy for non-metastatic rectal cancer between 2004 and 2016. Facility volume was defined as the number of rectal cancer cases managed at the treating center in the calendar year prior to the patient's surgery. Overall survival estimates were obtained for facility volumes ranging from 10 to 100 cases/year. Follow-up began on the day of surgery and continued until loss to follow-up or death. Results: A total of 52,822 patients were eligible. Patients operated on at hospitals with volumes of 10, 30, and 50 cases/year had similar distributions of grade, clinical stage, and neoadjuvant therapies. 1-, 3-, and 5-year survival all improved with increasing facility volume. One-year survival was 94.0% (95% CI: 93.7, 94.3) for hospitals that performed 10 cases/year, 94.5% (95% CI: 94.2, 94.7) for 30 cases/year, and 94.8% (95% CI: 94.5, 95.0) for 50 cases/year. Five-year survival was 68.9% (95% CI: 68.0, 69.7) for hospitals that performed 10 cases/year, 70.8% (95% CI: 70.1, 71.5) for 30 cases/year, and 72.0% (95% CI: 71.2, 72.8) for 50 cases/year. Conclusions: Treatment at a higher volume facility results in improved survival following proctectomy for rectal cancer, though the small benefits are less profound than previously reported. [ABSTRACT FROM AUTHOR]

Background: The incidence of colorectal cancer (CRC) is increasing in many low- to middle-income countries, including Ukraine. Ukraine reports high mortality rates in CRC patients. To identify potential areas for targeted interventions to improve CRC care in Ukraine, we investigated Ukrainian clinician perspectives on evidence-based CRC treatment guidelines. Methods: An explanatory sequential mixed-methods study design was used. A survey was administered to attendees of a regional surgical conference. Semi-structured interviews were subsequently performed with practicing clinicians in Ukraine. Interviews were coded to identify prominent themes. Results: Quantitative: 105 clinicians completed the survey. 76% of respondents reported using guidelines in daily practice. Lack of English proficiency was cited by 28.6% of respondents as a barrier to guideline use. Improved knowledge and additional financial resources were reported as factors that would be helpful in providing evidence-based care. Quantitative: 15 clinicians were interviewed. Two major themes were identified: limitations in access to the medical literature resources (language barriers and financial barriers), and sense of clinician initiative and willingness to learn despite hardships. Conclusions: Clinicians in Ukraine have positive perspectives on utilization of evidence-based CRC treatment guidelines. However, they face major barriers in accessing resources needed to keep up-to-date on the current literature. Fortunately, there exists both willingness and initiative on the clinician level to pursue continuing education. Efforts should be made on the international society level to improve open-access and foreign language translation availability to support physicians in Ukraine and other low- to middle-income countries. [ABSTRACT FROM AUTHOR]

Background: There is controversy regarding the widespread uptake of robotic surgery across several surgical disciplines. While it has been shown to confer clinical benefits such as decreased blood loss and shorter hospital stays, some argue that the benefits of this technology do not outweigh its high cost. We performed a retrospective insurance-based analysis to investigate how undergoing robotic surgery, compared to open surgery, may impact the time in which an employed individual returns to work after undergoing major surgery. Methods: We identified a cohort of US adults with employer-sponsored insurance using claims data from the MarketScan database who underwent either open or robotic radical prostatectomy, hysterectomy/myomectomy, and partial colectomy from 2012 to 2016. We performed multiple regression models incorporating propensity scores to assess the effect of robotic vs. open surgery on the number of absent days from work, adjusting for demographic characteristics and baseline absenteeism. Results: In a cohort of 1157 individuals with employer-sponsored insurance, those undergoing open surgery, compared to robotic surgery, had 9.9 more absent workdays for radical prostatectomy (95%CI 5.0 to 14.7, p < 0.001), 25.3 for hysterectomy/myomectomy (95%CI 11.0–39.6, p < 0.001), and 29.8 for partial colectomy (95%CI 14.8–44.8, p < 0.001) Conclusion: For the three major procedures studied, robotic surgery was associated with fewer missed days from work compared to open surgery. This information helps payers, patients, and providers better understand some of the indirect benefits of robotic surgery relative to its cost. [ABSTRACT FROM AUTHOR]

Background: In Ukraine, the 1-year mortality for colorectal cancer is much higher than that seen in high-income countries. We investigated practice patterns of colorectal cancer treatment in a region of Ukraine to account for high mortality rates. Methods: An explanatory sequential mixed methods design was used. Data from patients who underwent surgery for colorectal cancer in Ivano-Frankivsk from 2011 to 2015 were collected via retrospective chart review, and descriptive statistics were calculated. Semi-structured interviews were performed with local practicing surgeons and oncologists until thematic saturation was reached. Results: A total of 960 patients who underwent surgery were identified in the Ivano-Frankivsk region with colon (689) or rectal (271) cancer. 11.7% of patients underwent preoperative CT of the abdomen and pelvis, and only 1.7% underwent CT of the chest. 4.1% of patients underwent a complete preoperative colonoscopy, while 31.0% had incomplete colonoscopies. Postoperatively, 31.1% of patients with stage II colon cancer and 43.9% of patients with stage III colon cancer underwent adjuvant chemotherapy. For patients with stage II and III rectal cancers, 20.9% and 33.3% underwent chemotherapy, while 68.4% and 66.7% underwent radiation therapy, respectively. Fifteen physicians completed interviews. Two major themes emerged regarding physician perceptions on providing colorectal cancer care: lack of resources and systems level issues negatively impacting patient care. Conclusion: In this region in Ukraine, staging practices for colorectal malignancies are inconsistent and inadequate, and adjuvant treatments are varied. This is likely attributable to the lack of resources facing providers and the prohibitively high cost of care to patients. [ABSTRACT FROM AUTHOR]

PURPOSE: There is limited knowledge of the long-term health effects of the Chernobyl nuclear power plant accident that occurred more than 30 years ago in Ukraine. This study describes trends in the incidence of solid organ malignancy in Ukraine and the five regions most affected by the radioactive fallout. METHODS: The National Cancer Registry of Ukraine was queried for age-standardized incidence rates (ASIRs) of solid organ malignancy in Ukraine and the regions of Kyiv, Chernihiv, Zhytomyr, Rivne, and Volyn covering the period of 1999 to 2016. Joinpoint analysis was used to calculate the average annual percentage of change. RESULTS: The highest burdens of cancer incidence in Ukraine were seen in the lung, stomach, breast, and prostate. We observed significant increases in the ASIRs of colon (average annual percentage of change, 1.5 [95% CI, 1.3 to 1.7]), rectal (0.9 [95% CI, 0.6 to 1.2]), kidney (2.3 [95% CI, 1.8 to 2.9]), thyroid (4.2 [95% CI, 3.1 to 5.3]), breast (1 [95% CI, 0.6 to 1.4]), cervical (0.7 [95% CI, 0.3 to 1.2]), and prostate (3.9 [95% CI, 3.6 to 4.2]) cancers, with decreases in stomach (−2.4 [95% CI, −2.5 to −2.3]) and lung (−1.8 [95% CI, −2.1 to −1.5]) cancers. ASIRs in the affected regions were similar to nationwide rates, with the exception of those for Kyiv. CONCLUSION: The incidence rates of many solid organ malignancies in Ukraine are rising. However, the rates of solid organ malignancy in the five regions most affected by fallout did not substantially differ from national patterns, with the exception of those for Kyiv. Ongoing monitoring of cancer incidence in Ukraine is necessary to understand how best to decrease disease burden nationwide and to elucidate the causes of regional variations in ASIRs, such as access to diagnostics and environmental exposures. [ABSTRACT FROM AUTHOR]

We present a deterministic process-machine interaction (PMI) model that can associate different complex time-frequency patterns, including nonlinear dynamic behaviors that manifest in vibration signals measured during a chemical mechanical planarization (CMP) process for polishing blanket copper wafer surfaces to near-optical finish (Ra\sim 5~nm) to specific process mechanisms. The model captures the effects of the nonuniform structural properties of the polishing pad, pad asperities, and machine kinematics on CMP dynamics using a deterministic 2^\circ of freedom nonlinear differential equation. The model was validated using a Buehler (Automet 250) bench top CMP machine instrumented with a wireless (XBee IEEE 802.15.4 RF module) multi-sensor unit that includes a MEMS 3-axis accelerometer (Analog Devices ADXL 335). Extensive experiments suggest that the deterministic PMI model can capture such significant signal patterns as aperiodicity, broadband frequency spectra, and other prominent manifestations of process nonlinearity. Remarkably, the deterministic PMI model was able to explain not just the physical sources of various time-frequency patterns observed in the measured vibration signals, but also, their variations with process conditions. The features extracted from experimental vibration data, such as power spectral density over the 115–120 Hz band, and nonlinear recurrence measures were statistically significant estimators (R^2\sim 75\%) of process parameter settings. The model together with sparse experimental data was able to estimate process drifts resulting from pad wear with high fidelity (R^2\sim 85\%). The signal features identified using the PMI model can lead to effective real-time in-situ monitoring of wear and anomalies in the CMP process. [ABSTRACT FROM AUTHOR]

Wound healing is a complex process initiated by the formationoffibrin fibers and endothelialization. Normally, this process is triggeredin a wound by thrombin cleavage of fibrinopeptides on fibrinogen molecules,which allows them to self spontaneously-assemble into large fibersthat provide the support structure of the clot and promote healing.We have found that the fibrous structures can also form without thrombinon most polymer or metal surfaces, including those commonly used forstents. We show that the relatively hydrophobic E and D regions ofthe fibrinogen molecule are adsorbed on these surfaces, exposing theαC domains, which in turn results in the formation of largefiber structures that promote endothelial cell adhesion. We show thatthe entire process can be suppressed when stents or other substratesare coated with polymers that are functionalized to bind the αCdomains, leading to the development of potentially nonthrombogenicimplant materials. [ABSTRACT FROM AUTHOR]

Background: Colorectal cancer is one of the most common cancers worldwide and is associated with high mortality when detected at a later stage. There is a paucity of studies from low and middle income countries to support the cost-effectiveness of colorectal cancer screening. We aim to analyze the cost-effectiveness of colorectal cancer screening compared to no screening in Ukraine, a lower-middle income country. Methods: We developed a deterministic Markov cohort model to assess the cost-effectiveness of three colorectal cancer screening strategies [fecal occult blood test (FOBT) every year, flexible sigmoidoscopy with FOBT every 5 years, and colonoscopy every 10 years] compared to no screening. We modeled outcomes in terms of cost per quality-adjusted life-years (QALYs) over a lifetime time horizon. We performed sensitivity analyses on treatment adherence, test characteristics and costs. Analyses were conducted from the perspective of the Ministry of Health of Ukraine. Results: The base-case lifetime cost-effectiveness analysis showed that all three screening strategies were cost saving compared to no screening, and among the three strategies, colonoscopy every 10 years was the dominant strategy compared to no screening with standard adherence to treatment. When decreased adherence to treatment was modeled, colonoscopy every 10 years was the most cost-effective strategy with an incremental cost-effectiveness ratio of $843 per QALY compared with no screening. Conclusion: Our findings indicate that colorectal cancer screening can save money and improve health compared to no screening in Ukraine. Colonoscopy every 10 years is superior to the other screening modalities evaluated in this study. This knowledge can be used to concentrate efforts on developing a national screening program in Ukraine. [ABSTRACT FROM AUTHOR]