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Background: We sought to define individual contributions at the patient, surgeon, pathologist, and hospital levels on lymph node assessment after pancreatic cancer resection., Methods: SEER-Medicare beneficiaries who underwent pancreatic cancer resection were identified. Multi-level multivariable regression was performed to assess the proportion of variance explained by patient, surgeon, pathologist, and hospitals on lymph node assessment (≥12 versus <12)., Results: 2872 patients underwent pancreaticoduodenectomy by 646 distinct surgeons and 1063 distinct pathologists across 308 hospitals. Patient-related characteristics contributed the most to the variance in adequate lymph node assessment (71.0 ​%). After accounting for all explanatory variables in the full model, 5.5 ​% of the residual provider-level variation was attributed to the pathologist, 35.2 ​% to the surgeon, and 59.3 ​% to the hospital., Conclusions: Patient-to-patient variation was the greatest underlying contributor to variations in adequate lymph node assessment related to pancreatic cancer surgery. Variation among hospitals was greater than among surgeons or pathologists., Competing Interests: Declaration of interest All authors agree to the contents and publication of this work into the American Journal of Surgery. Below are the individual contributions of each author., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: As there is limited literature evaluating food insecurity status (FI) and surgical outcomes, we sought to assess the association between county-level FI and outcomes following cardiac surgery., Methods: In a retrospective cohort, patients who underwent coronary artery bypass grafting between 2016 and 2020 were identified utilizing the Medicare Standard Analytic Files. Using County-level FI, patients were stratified into low, moderate, and high cohorts. The primary outcome was textbook outcomes, a measure of "optimal" post-operative outcomes. Adjusted multiple logistic regression and Cox regression models were utilized to evaluate outcomes and survival., Results: Among 267,914 patients, patients residing in high FI regions were less likely to achieve textbook outcomes (OR: 0.94, 95 ​% CI: 0.90-0.99). When evaluating individual post-operative outcomes of interest, patients residing in high FI regions also had a greater odd of 90-day mortality (OR: 1.24, 95 ​% CI: 1.12-1.36) and extended LOS (OR: 1.07, 95 ​% CI: 1.01-1.14) (all p ​< ​0.0001). Moreover, this population was also at greater risk of 5-year mortality (HR: 1.11, 95 ​% CI: 1.06-1.17) compared with their counterparts from low food insecurity regions. Racial disparities persisted in high FI counties as Black patients had a greater risk of 5-year mortality (HR: 1.27, 95 ​% CI: 1.17-1.38, p ​< ​0.0001) compared with White patients within the same FI level., Conclusions: County-level FI was associated with worse outcomes following cardiac surgery., Competing Interests: Declaration of competing interest The authors do not have any financial or personal relationships with other people or organizations to disclose that would impact the integrity of this research study., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: We sought to investigate the association between surgical opioid prescriptions and the risk of opioid initiation among opioid-naive spouses., Methods: Patients who underwent surgery for breast or gastrointestinal cancer were identified from the IBM Marketscan database. Multivariable regression analysis was performed to examine the association between surgical opioid prescription and opioid initiation among opioid-naïve patient spouses., Results: Among the 9365 individuals included in the analytic cohort, 77.9 ​% (n ​= ​7300) filled a perioperative opioid prescription. Of note, spouses of patients who received a surgical opioid prescription (6.7 ​% vs. 4.5 ​%; p ​< ​0.001) were more likely to begin using opioids. On multivariable analysis, surgical opioid prescription was associated with 61 ​% (1.61, 95%CI 1.28-2.03) higher odds of opioid initiation among opioid-naïve spouses., Conclusion: Surgical opioid prescriptions are associated with an increased risk of opioid initiation among opioid-naive spouses. These findings underscore the importance of counseling on safe opioid use, storage, and disposal for the family., Competing Interests: Declaration of competing interest The authors do not have any financial or personal relationships with other people or organizations to disclose that would impact the integrity of this research study., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: This study sought to quantify the direct and indirect effects of race on postoperative outcomes after complex surgery., Methods: Medicare patients who underwent abdominal aortic aneurysm (AAA) repair, coronary artery bypass grafting (CABG), lung resection or colectomy were identified (2014-2018). Generalized structural equation modelling was utilized to quantify the direct and indirect effects of race on Textbook outcome (TO)., Results: Among 930,033 patients, 46.8% of patients achieved a TO, with Black patients less likely to achieve a TO (referent: White; Black: OR 0.72, 95% CI 0.70-0.73). Notably, 32.3% of the disparities in TO were attributable to race itself, while 67.7% was explained by other factors. Specifically, residential segregation accounted for 39.4% of the lower TO rates among Black patients, while 21.0% was attributable to a high comorbidity burden., Conclusions: These data highlight the need to target structural racism as a policy priority to promote a more equitable healthcare system., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: We sought to determine the association of persistent poverty on patient outcomes relative to US News World Report (USNWR) rankings among individuals undergoing common major surgical procedures., Methods: Medicare beneficiaries who underwent AAA repair, CABG, colectomy, or lung resection were identified. Multivariable logistic regression was used to evaluate the relationship between care at USNWR hospitals, county-level duration of poverty (never-high poverty (NHP); intermittent high poverty (IHP): persistent-poverty (PP)) and 30-day mortality., Results: Among 916,164 beneficiaries, individuals residing in PP neighborhoods who received surgical care at ranked hospitals had lower risk-adjusted 30-day mortality (5.89% vs 8.89%; p ​< ​0.001). On multivariable analysis, 30-day mortality was lower at ranked hospitals across all poverty categories with greatest decrease among patients from PP regions (NHP: OR-0.91, 95%CI0.87-0.95; IHP: OR-0.78, 95%CI0.69-0.88; PP: OR-0.69, 95%CI0.57-0.83; p ​< ​0.001)., Conclusion: Receipt of surgical care at top-ranked hospitals was associated with improvement in postoperative mortality, especially among patients residing in persistent poverty.., Competing Interests: Declaration of competing interest All authors agree to the contents and publication of this work into the American Journal of Surgery. Below are the individual contributions of each author., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: As leaders strive to create equitable surgical pipelines, one process under scrutiny is letters of recommendation (LORs). We sought to review the Colon and Rectal Surgery (CRS) Resident Candidate Assessment questionnaire and LORs for gendered differences., Methods: This retrospective observational study of letters of recommendation to CRS fellowship during the 2018-2019 application cycle utilized linguistic Inquiry and Word Count (LIWC2015) software to assess letter length and themes comparing differences by applicant and referee gender., Results: 103 applicants (35 ​% women) with 363 LORs (16 ​% written by women) were included. Short answer responses were longer for women applicants, while LORs were longer for men applicants (368 vs 325 words p ​= ​0.03). Men applicants' strengths had more technical skill descriptors, while women applicants' strengths had more emotional language and cognitive and perceptual words., Conclusions: This study found significant differences between LORs written for CRS fellowship applicants based on gender., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The interplay of patient-, procedural, and provider-level factors on the ability to achieve a textbook outcome(TO) remain poorly defined., Methods: The Medicare Standard Analytical Files from 2013 to 2017 were used to identify beneficiaries who underwent pancreatic surgery. Multivariable logistic regression with mixed effects was used to examine the role of the individual surgeon relative to patient- and procedural-factors to achieve a TO., Results: Among 20,902 patients who underwent pancreatic resection, median age was 72 years (IQR:68-77); roughly one-half of the cohort was female(47,4%) and the majority was White (89.3%). After controlling for patient- and procedure-related characteristics, there was 35% variation in odds of experiencing a TO relative to the specific individual surgeon who performed the operation (OR:1.35, 95%CI:1.29-1.41). Patients who underwent pancreatectomy by a bottom TO quartile surgeon had a higher observed/expected ratio for each component of TO including post-operative complication (OR:2.62, 95%CI:2.11-3.25), prolonged LOS (OR:3.36, 95%CI:2.67-4.22), 90-day readmission (OR:2.08, 95%CI:1.68-2.56), and 90-day mortality (OR:3.29, 95% CI:2.35-4.63) compared with patients treated by a high TO quartile surgeon., Conclusion: The likelihood of achieving a TO after pancreatic resection was markedly influenced by the individual treating surgeon even after controlling for patient- and procedure-level factors., Competing Interests: Declaration of competing interest The authors have no personal conflicts of interest to declare., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: While disadvantaged neighborhoods may be associated with worse outcomes and earlier death, the relationship between economic opportunity and surgical outcomes remains unexplored., Methods: Medicare beneficiaries who underwent AAA, CABG, colectomy or cholecystectomy were identified and stratified into quintiles based on upward economic mobility. Risk-adjusted probability of adverse postoperative outcomes were examined relative to economic mobility., Results: Among 1,081,745 Medicare beneficiaries (age: 75.5 years, female: 43.0%, White: 91.3%), risk-adjusted 30-day postoperative mortality decreased in a stepwise fashion from 6.0%(5.9-6.1) in the lowest quintile of upward economic mobility to 5.3%(5.2-5.4) in highest upward economic mobility (lowest vs. highest economic mobilityobility OR:1.14 (95%CI:1.11-1.17)). Similar associations were noted for postoperative complications (OR:1.04, 95%CI:1.02-1.06), extended length-of-stay (OR:1.07, 95%CI:1.06-1.09), and 30-day readmission (OR:1.04, 95%CI:1.02-1.05). Black beneficiaries had a higher risk of post-operative mortality across upward economic mobility quintiles except within the highest upward mobility group (referent, White patients, OR:0.93, 95%CI:0.79-1.09, p=0.355)., Conclusion: Economic upward mobility was associated with post-operative outcomes. Race-based differences were mitigated at the highest levels of upward economic mobility, highlighting the importance of socioeconomics as a health equity lever., Competing Interests: Declaration of competing interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Quality assessment in oncologic surgery has traditionally involved reporting discrete metrics that may be difficult for patients and referring providers to interpret. We define a composite quality metric (CQM) for resection in rectal cancer., Methods: We queried the National Cancer Database to identify patients undergoing low anterior resection for clinical stage II-III rectal adenocarcinoma between 2010 and 2017. CQM was defined as appropriate neoadjuvant therapy, margin-negative resection, appropriate lymph node assessment, postoperative length of stay (LOS) < 75th percentile, and no 30-day readmission or mortality., Results: 19,721 patients met inclusion criteria; 8,083 (41%) had a CQM. The most common reasons for failure to achieve CQM: inadequate node assessment (27%), prolonged LOS (26%). On Cox modeling, CQM (aHR 0.70, 95% CI [0.66, 0.75]) was associated with improved overall survival., Conclusion: CQM is independently associated with improved survival in rectal cancer and may be an effective measure of quality., Competing Interests: Declaration of competing interest Dr. Singer has associations with Ethicon Inc., Intuitive Surgical Inc., Merck & Co. Inc., and Nestle. The remaining authors have no financial disclosures., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: In order to investigate the optimal approach for synchronous colorectal liver metastases (sCRLM), we sought to use the "win ratio" (WR), a novel statistical approach, to assess the relative benefit of simultaneous versus staged surgical treatment., Methods: Patients who underwent hepatectomy for sCRLM between 2008 and 2020 were identified from a multi-institutional database. The WR approach was utilized to compare composite outcomes of patients undergoing simultaneous versus staged resection., Results: Among 1116 patients, 642 (57.5%) presented with sCRLM; 290 (45.2%) underwent simultaneous resection, while 352 (54.8%) underwent staged resection. In assessing the composite outcome, staged resection yielded a WR of 1.59 (95%CI 1.47-1.71) over the simultaneous approach for sCRLM. The highest WR occurred among patients requiring major hepatectomy (WR = 1.93, 95%CI 1.77-2.10) compared with patients who required minor liver resection (WR = 1.55, 95%CI 1.44-1.70)., Conclusions: Staged resection was superior to simultaneous resection for sCRLM based on a WR assessment., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The aim of the current study was to determine the impact of neighborhood characteristics on textbook outcome (TO) following surgery., Methods: Medicare beneficiaries undergoing AAA repair, CABG, colectomy, or lung resection. Neighborhood characteristics associated with TO were identified., Results: Among 852,128 Medicare beneficiaries, a 10% increase in the mean percentage of college or advanced degree residents (OR:1.04, 95% CI = 1.04-1.05) was associated with 4% greater odds of a TO, whereas 2% lower odds of TO were noted with a 10% increase in the mean percentage of single-parent households (OR: 0.98, 95% CI = 0.97-0.99). Of note, the highest odds of an extended LOS (OR:1.06, 95% CI: 1.05-1.06) and 90-d mortality (OR: 1.05, 95% CI: 1.04-1.06) were observed with single-parent households., Conclusions: Among patients undergoing a range of common surgical procedures, increases in college or advanced degrees residents and a decrease in single-parent households led to significantly higher odds of achieving a TO., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Care patterns among patients diagnosed with pancreatic adenocarcinoma remain poorly defined., Methods: Cluster analysis was performed on patients with pancreatic adenocarcinoma to assess time from diagnosis to death spent in different care settings (home self-care-dominant[HSC], acute in-hospital care-dominant[ACS], hospice care-dominant[HC] or mixed home and hospice care[MHH])., Results: Among 32,816 patients, most belonged to the HSC group (n = 13,459, 41%), followed by MHH (n = 9,091, 28%), ACS (n = 5,737, 18%) and HC (n = 4,529, 14%). Only about 1 in 3 patients in the HSC (n = 4,028, 30%) or ACS (n = 2,206, 35%) received hospice services for at least one week before death. 16% of patients (n = 5,188) died in the hospital, which was most common among ACS patients (n = 1,640, 29%). Median daily expenditures varied according to health care utilization (HSC, $44.6, IQR 12.3-130.1 vs MHH, $162.3, IQR 60.5-351.9 vs ACS, $489.7, IQR 243.2-856.8 vs HC, $306.1, IQR 132.3-580.0; p < 0.001)., Conclusions: Pancreatic adenocarcinoma patients differed with regards to health care utilization, hospice use and expenditures following diagnosis., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Social vulnerability is an important driver of disparate surgical outcomes, however the extent to which certain types of vulnerability impact outcomes is poorly understood., Methods: Medicare beneficiaries 65 years or older who underwent one of four operations were identified. Multivariable mixed-effects logistic regression was used to measure the association of four social vulnerability subthemes from the social vulnerability index (SVI) were assessed relative to the likelihood to achieve a textbook outcome (TO)., Results: Among 579,846 Medicare beneficiaries, median age was 74 years and most patients (536,455,92.5%) were White/non-Hispanic. On multivariable analysis, the overall impact of the composite SVI metric on the odds to achieve a postoperative TO was lower among White/non-Hispanic patients (Δ25%ile SVI:OR:0.98,95%CI:0.97-0.98) compared with ethnic/minority patients (Δ25%ile SVI:OR:0.93,95%CI:0.91-0.94). Increasing vulnerability in the subthemes of socioeconomic status (Δ25%ile SVI:ethnic/minority:OR:0.92, 95%CI:0.91-0.94) and household composition (Δ25%ile SVI:ethnic/minority:OR:0.92,95%CI:0.91-0.94) was associated with a greater likelihood not to achieve a TO among minority patients., Conclusions: Worsening SES and household compositions & disability had a detrimental effect on odds of TO following surgery with the most pronounced effect on non-White minority patients., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: To examine whether pregnant patients have higher risk of major 30-day postoperative complications compared with their non-pregnant counterparts after non-obstetric surgery., Methods: A secondary analysis of the prospective National Surgical Quality Improvement Program (NSQIP) from 2005 to 2012 of pregnant patients 18-51 years old, without surgery in the preceding 30 days, and who underwent a non-obstetrical operation. The primary outcome was composite 30-day major postoperative complications. We used modified Poisson regression., Results: Among 354,251 assessed patients, 3655 (1%) were pregnant. The overall incidence of 30-day major postoperative complication was 6%, and did not vary by pregnancy status. Pregnant patients were not at higher risk of 30-day major postoperative complications compared to non-pregnant patients following non-obstetric surgery. This held for most procedures, except pregnant patients were at a higher risk of complications with colorectal and hernia surgeries. Secondarily, pregnant patients were at higher risk of transfusion., Conclusions: Pregnant patients are generally not at higher risk of major postoperative complications following non-obstetric surgery. This information can be used when counseling pregnant patients about the risks versus benefits of non-obstetric surgery., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: We aimed to predict practicing surgeon workforce size across ten specialties to provide an up-to-date, national perspective on future surgical workforce shortages or surpluses., Methods: Twenty-one years of AMA Masterfile data (1997-2017) were used to predict surgeons practicing from 2030 to 2050. Published ratios of surgeons/100,000 population were used to estimate the number of surgeons needed. MGMA median wRVU/surgeon by specialty (2017) was used to determine wRVU demand and capacity based on projected and needed number of surgeons., Results: By 2030, surgeon shortages across nine specialties: Cardiothoracic, Otolaryngology, General Surgery, Obstetrics-Gynecology, Ophthalmology, Orthopedics, Plastics, Urology, and Vascular, are estimated to increase clinical workload by 10-50% additional wRVU. By 2050, shortages in eight specialties are estimated to increase clinical workload by 7-61% additional wRVU., Conclusions: If historical trends continue, a majority of surgical specialties are estimated to experience workforce deficits, increasing clinical demands substantially., (Copyright © 2021. Published by Elsevier Inc.)

Background: We sought to assess variations in outcomes among patients undergoing resection for hepatocellular carcinoma (HCC) at centers with varied accreditation status., Methods: Patients undergoing resection for HCC from 2004 to 2016 were identified from the linked SEER-Medicare database. Short- and long-term outcomes as well as expenditures associated with receipt of surgery were examined based on cancer center accreditation., Results: Among 1390 patients, 46.1% (n = 641) were treated at unaccredited centers, 39.3% (n = 546) at CoC-accredited and 14.6% (n = 203) at NCI-designated centers. Patients undergoing resection of HCC at NCI-designated hospitals had lower odds of complications (OR = 0.66, 95%CI: 0.45-0.98) and 90-day mortality (OR = 0.31, 95%CI: 0.11-0.85) after major liver resection compared with individuals treated at CoC-accredited centers. Receipt of surgery at NCI-designated hospitals (ref: CoC-accredited; HR = 0.81, 95%CI: 0.66-0.99) was an independent predictor of improved survival. Medicare payments for liver resection were comparable at different accreditation status centers (NCI: $21,760 vs CoC: $24,059 vs unaccredited: $24,724, p = 0.18)., Conclusion: Patients undergoing resection of HCC at NCI-designated hospitals had improved outcomes for the same level of Medicare expenditure compared with patients treated at CoC-accredited centers., Competing Interests: Declaration of competing interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The objective of this study was to define the relative impact of alcohol and/or hepatitis-related HCC etiology on the outcomes of patients who underwent resection or transplantation for HCC., Methods: The SEER-Medicare database was used to identify patients with HCC between 2004 and 2015. Patients with history of alcohol abuse or hepatitis were identified. Overall survival (OS) and cancer-specific survival (CSS) were calculated using the Kaplan-Meier method and multivariable Cox regression analysis., Results: Among 1140 patients, 11.9% (n = 136) of patients had alcohol-related HCC, 30.0% (n = 342) hepatitis-related HCC, and 58.1% (n = 662) had other cause-related HCC. On multivariable analysis, patients with alcohol-related HCC (HR:1.06, 95%CI:0.82-1.35) or hepatitis-related HCC (HR:1.05, 95%CI:0.88-1.26) had similar hazards of death compared with patients who had non-alcohol/non-hepatitis-related HCC. Patients who had tumor size ≤5 cm had lower hazards of death (HR:0.81, 95%CI:0.68-0.97), while individuals who underwent liver resection (vs. transplantation) had almost a two-fold higher hazards of death (HR:1.99, 95%CI:1.47-2.69)., Conclusion: Tumor specific factors (i.e. tumor size and stage) and operative approach (i.e. resection vs. transplantation) -rather than HCC etiology- dictated both OS and CSS., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Mental illness and depression can be associated with increased risk of suicidal ideation (SI). We sought to determine the association between mental illness and SI among cancer surgical patients., Methods: Medicare beneficiaries who underwent resection of lung, esophageal, pancreatic, colon, or rectal cancer were analyzed. Patients were categorized as no mental illness, anxiety and/or depression disorders or bipolar/schizophrenic disorders., Results: Among 211,092 Medicare beneficiaries who underwent surgery for cancer, the rate of suicidal ideation was 270/100,000 patients. Antecedent mental health diagnosis resulted in a marked increased SI. On multivariable analysis, patients with anxiety alone (OR 1.49, 95%CI 1.04-2.14), depression alone (OR 2.60, 95%CI 1.92-3.38), anxiety + depression (OR 4.50, 95%CI 3.48-5.86), and bipolar/schizophrenia (OR 7.30, 95%CI 5.27-10.30) had increased odds of SI., Conclusions: Roughly 1 in 370 Medicare beneficiaries with cancer who underwent a wide range of surgical procedures had SI. An antecedent mental health diagnosis was a strong risk factor for SI., Competing Interests: Declaration of competing interest None to report., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: We sought to determine the impact of payer-mix on post-operative outcomes among Medicare beneficiaries following hepatopancreatic surgery., Methods: Medicare beneficiaries who underwent hepatopancreatic surgery were identified. Hospital quality markers were obtained from the Hospital General Information dataset. Hospitals were dichotomized (low/average vs. high) based on Medicare patient days versus all patient days irrespective of payer type., Results: High Medicare patient-mix hospitals were more likely to be ranked higher than the national average relative to safety of care (29.4% vs. 38.1%) and timeliness of care (15.4% vs. 26.3%) versus low burden Medicare hospitals (both p < 0.001). However, Medicare beneficiaries who had hepatopancreatic surgery at a high Medicare patient-mix hospital were at higher risk of a complication (OR = 1.13, 95%CI 1.04-1.22), and death within 30-days (OR = 1.37, 95%CI 1.23-1.53) following surgery., Conclusion: While hospitals caring for higher numbers of Medicare beneficiaries generally performed better on CMS quality indicators, these rankings did not equate to improved post-operative outcomes., Competing Interests: Declaration of competing interest WE HAVE NO CONFLICTS OF INTEREST., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Females comprise 1/3 of general surgery residents, 1/4 of surgical faculty and 10% of full professors. Inadequate sponsorship is one proposed mechanism for this decline. This study evaluated letters of recommendation (LOR) among applicants applying to a complex general surgical oncology (CGSO) fellowship., Methods: Linguistic analysis of LOR for CGSO applicants was conducted. Demographics of authors and features of the LOR were extracted. Differences by gender of the applicant were analyzed., Results: Among 340 letters, 67% were written for male and 33% written for female applicants. Males authored 84% of letters reviewed. Female authors used more grindstone adjectives than males (3.61 v 2.90). However, this difference was seen only among letters written for male applicants (3.82 v. 2.73). All other linguistic features were similar, aside from mention of physical appearance which was significantly more common in letters written about female applicants (4% v. 1%)., Conclusions: Female authors write substantively different letters than males. Physical appearance is a small but important difference in letters for female applicants., Competing Interests: Declaration of competing interest The authors have no financial conflict of interest to disclose., (Copyright © 2020. Published by Elsevier Inc.)

Competing Interests: Declaration of competing interest None.

Introduction: The impact of safety net (SN) hospitals relative to racial and healthcare disparities remains largely unknown., Methods: Using the Nationwide Inpatient Sample, adults undergoing coronary artery bypass grafting, colectomy, or total hip arthroplasty were identified. Multivariable regression analysis was performed to determine association between SN burden and outcomes. Within each SN burden tier, the association between race/ethnic group and outcomes was defined., Results: Overall 865,648 patients were identified. After adjustment for potential confounders, patients operated at the highest SN burden hospitals had increased odds of complications (OR 1.14, 95%CI 1.10-1.18), death (OR 1.41, 95%CI 1.31-1.52), FTR (OR 1.36, 95%CI 1.25-1.47) and a never event (OR 1.57, 95%CI 1.47-1.68). Irrespective of hospital SN burden, racial minorities had greater odds of a complication, and prolonged LOS compared to whites (p < 0.05)., Conclusion: While overall degree of safety net burden was associated with worse overall outcomes, SN hospitals did not mitigate racial disparities experienced by minority patients., Competing Interests: Declaration of competing interest None Declared., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: In the United States, 5% of patients represent up to 55% of all health care costs. This study sought to define healthcare utilization patterns among super-utilizers, as well as assess possible variation in patient outcomes., Methods: Medicare super-utilizers undergoing either a total hip or knee arthroplasty were identified and entered into a cluster analysis using annual preoperative charges to identify distinct patterns of utilization., Results: Among 19,522 super-utilizers who underwent THA or TKA, there was a marked heterogeneity in overall utilization with 5 distinct clusters of utilization patterns. Of note, comorbidity burden was similar among the 5 clusters. Patient outcomes also varied by Cluster type, ranging from 6.9% to 16.5% experiencing complications and 1.0%-3.2% experiencing 90-day mortality., Conclusion: While previous studies have suggested that super-utilizers are a homogenous group of patients, the current study demonstrated a large degree of heterogeneity within super-utilizers. Variations in utilization patterns were associated with postoperative outcomes and subsequent health care costs., Competing Interests: Declaration of competing interest None., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Hospital ranking systems are often used by individuals to inform choice around which healthcare system may be best equipped to manage their care., Methods: The 2013-2015 100% Medicare Inpatient and Outpatient SAFs was utilized to identify patients who underwent surgery (AAA repair, CABG, THA, TKA and lung resection) at one of the top-20 hospitals ranked by USNWR., Results: On multivariable linear regression analysis, after controlling for clinical and hospital level factors, rank position among the top 20 USNWR hospitals was not associated with the proportion of patients who experienced a complication (β = 0.167), failure-to-rescue (β = 0.277), 90-day readmission (β = 0.186) and 90-day mortality (β = 0.033)(all p > 0.05). Similar trends were observed among each surgical procedure type, as well as even among all top 50 USNWR ranked hospitals (all p > 0.05)., Conclusion: Rank position among hospitals within the USNWR "honor roll" was not associated with differences in patient outcomes following surgical intervention. Patients and hospitals need to exercise caution when placing weight on rank-position among hospitals as a means to discriminate clinical outcomes and quality of actual patient care., Competing Interests: Declaration of competing interest All authors declare that they have no disclosures to report., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: The Affordable Care Act introduced restrictions on the creation of new physician-owned hospitals (POH). We sought to define whether POH status was associated with differences in care., Methods: Patients undergoing one of ten surgical procedures were identified using Medicare Standard Analytic Files. Patient and hospital-level characteristics and outcomes between POH and non-POH were compared., Results: Among 1,255,442 patients identified, 14,560 (1.2%) were treated at POH. A majority of POHs were in urban areas (n = 30, 90.9%) and none were in low socioeconomic status areas. Patients at POH were slightly younger (POH:72, IQR:68-77 vs. non-POH:73, IQR:69-79) and healthier (CCI; POH:2; IQR: 1-3 vs. non-POH: 3; IQR: 1-4). Patients at non-POH had higher odds of postoperative complications (OR:1.67, 95%CI:1.55-1.80) and slightly higher medical expenditures (POH:$11,347, IQR:$11,139-$11,936 vs. non-POH:$13,389, IQR:$11,381-$19,592)., Conclusions: POH were more likely to be located in socioeconomic advantaged areas, treat healthier patients and have lower associated expenditures., Competing Interests: Declaration of competing interest None., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an increasingly utilized strategy for patients with peritoneal surface malignancies (PSM)., Methods: The US HIPEC Collaborative was retrospectively reviewed to compare the indications and perioperative outcomes of patients who underwent CRS ± HIPEC between 2000 and 2012 (P1) versus 2013-2017 (P2)., Results: Among 2,364 patients, 39% were from P1 and 61% from P2. The most common primary site was appendiceal (64%) while the median PCI was 13 and most patients had CCR 0 (60%) or 1 (25%). Over time, median estimated blood loss, need for transfusion, and length of hospital stay decreased. While the incidence of any (55% vs. 57%; p = 0.426) and Clavien III/IV complications did not change over time, there was a decrease in 90-day mortality (5% vs. 3%; p = 0.045)., Conclusion: CRS-HIPEC is increasingly performed for PSM at high-volume centers. Despite improvements in some perioperative outcomes and a reduction in postoperative mortality, morbidity rates remain high., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Considered the top 5% of healthcare utilizers, "super-utilizers" are estimated to consume as much as 40-55% of all healthcare costs. The aim of this study was to identify factors associated with switching between low- and super-utilization., Methods: Low and super-utilizers who underwent abdominal aortic aneurysm (AAA) repair, coronary artery bypass graft (CABG), colectomy, total hip arthroplasty (THA), total knee arthroplasty (TKA), or lung resection between 2013 and 2015 were identified from 100% Medicare Inpatient Standard Analytic Files., Results: Among 1,049,160 patients, 788,488 (75.1%) and 21,700 (2.1%) patients were low- or super-utilizers prior to surgery, respectively. Among patients who were super-utilizers before surgery, 23% remained super-utilizers post-operatively, yet 26.8% patients became low-utilizers after surgery. Factors associated with moving from low-to super-utilization in the pre-versus post-operative setting included AAA repair, higher Charlson, and pulmonary failure. In contrast, pre-operative super-utilizers who became low-utilizers in the post-operative setting were less likely to be African American or have undergone CABG., Conclusion: While 3% of pre-operative low-utilizers became super-utilizers likely due to complications, nearly one quarter of all pre-operative super-utilizers became low-utilizers following surgery suggesting success of the surgery to resolve underlying conditions associated with preoperative super-utilization., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Administration of blood products may be associated with increased morbidity and perioperative mortality in surgical patients., Methods: Patients aged 18 + who underwent gastrointestinal surgery at the Ohio State University Wexner Medical Center 9/10/2015-5/9/2018 were identified. Multivariable logistic regression models were used to evaluate impact of blood product use on survival and complications, as well as to identify factors associated with receipt of transfusions., Results: Among 10,756 patients, 35,517 units of blood products were transfused. Preoperative nadir hemoglobin was associated with receipt of blood product transfusion (OR 0.55, 95% CI 0.53, 0.68). After adjusting for patient and procedural characteristics, patients undergoing transfusion of blood products had an increased risk of perioperative mortality (OR 7.80, 95% CI 6.02, 10.10)., Conclusions: The use of blood products was associated with increased risk of complication and death. Patient blood management programs should be implemented to provide rational criteria and guidance for the transfusion of blood products., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The objective of this study was to examine risk factors and outcomes of hospital readmission following complex hepatopancreatobiliary (HPB) surgery among the elderly., Methods: The Nationwide Readmissions Database was queried for patients ≥ 60 years who underwent HPB surgery during 2010-2015., Results: The incidence of 30- and 90-day readmission was similar among patients 60-74 vs. ≥75 (P > 0.05). Patients age 60-74 years with ≥2 comorbidities had an increased odds of 30-day (OR 1.13, p = 0.021) and 90-day (OR 1.13, p = 0.005) readmission. Patients ≥75 years with ≥2 comorbidities had the highest in-hospital mortality (5%) whereas patients 60-74 years with 0 or 1 comorbidity had the lowest in-hospital mortality on readmission (3%)., Conclusion: Following an HPB procedure, roughly 1 in 7 elderly patients were readmitted within 30 days and 1 in 4 patients within 90 days. Elderly patients with multiple comorbidities were more likely to be readmitted at non-index hospitals., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Conversations around surgical goals of care should focus on relational (e.g., empathy, trust, understanding) instead of transactional processes (e.g., communication). Rather than reducing the patient-surgeon relationship to isolated variables such as "communication," a "relational lens" that considers all the aspects of the patient-surgeon relationship and its dynamic processes is needed., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Our objective was to determine the association between indicators of surgical quality - incidence of major complications and failure-to-rescue - and hospital market concentration in light of differences in costs of care., Methods: Patients undergoing coronary artery bypass graft (CABG), colon resection, pancreatic resection, or liver resection in the 2008-2011 Nationwide Inpatient Sample were identified. The effect of hospital market concentration on major complications, failure-to-rescue, and inpatient costs was estimated at the lowest and highest mortality hospitals using multivariable regression techniques., Results: A weighted total of 527,459 patients were identified. Higher market concentration was associated with between 4% and 6% increased odds of failure-to-rescue across all four procedures. Across procedures, more concentrated markets had decreased inpatient costs (average marginal effect ranging from -$3064 (95% CI: -$5812 - -$316) for CABG to -$4876 (-$7773 - -$1980) for liver resection., Conclusion: In less competitive (more concentrated) hospital markets, higher overall risk of failure-to-rescue after complications was accompanied by lower inpatient costs, on average. These data suggest that market controls may be leveraged to influence surgical quality and costs., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Shared decision-making (SDM) is a process that respects the rights of patients to be fully involved in decisions about their care. By evaluating all available healthcare options and weighing patients' personal values and preferences against available unbiased evidence, patients and healthcare professionals can make health-related decisions together, as partners. We sought to evaluate the impact of perceived SDM on patient-reported outcomes, healthcare quality, and healthcare utilization., Methods: Patients were identified from the 2010-2014 Medical Expenditure Panel Survey (MEPS) cohort. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey was levied to create a weighted composite score of satisfaction with SDM on a 12-point scale, and then categorized as optimal, average or poor SDM based on weighted scores. Weighting and variance techniques were applied to assure results were representative of the U.S. civilian population. Chi-square analysis was used to estimate differences across SDM groupings and multivariate logistic regression was performed to generate odds ratios (OR) and confidence intervals (CI)., Results: The study cohort included 63,931 responses to the survey tool. Results of SDM satisfaction across the three categories were skewed, with 46.6% (n = 29,807) of the respondents reporting optimal SDM, 42.1% (n = 26,887) reporting average scores and only 11.3% (n = 7237) reporting poor perceived SDM. Non-white race, lower educational level, low socioeconomic status, non-married status, and uninsured or underinsured status were all associated with higher incidence of poor perceived SDM (p < .05). Poor SDM was associated with increased odds of poor physical health scores (OR: 1.17; 95% CI 1.01-1.36) and poor mental health scores (OR: 1.53; 95% CI 1.25-1.86). Poor SDM was associated with lower use of statins (OR: 0.77; 95% CI 0.68-0.87) and aspirin (OR: 0.86; 95% CI 0.77-0.95), both of which are established quality of care metrics. Poor SDM was also associated with increased emergency department (ED) utilization, with an increased likelihood of 2 or more ED visits associated with poor SDM (OR: 1.25; 95% CI 1.06-1.49)., Conclusions: Poor SDM was associated with worse patient-reported health outcomes, worse established quality indicators, and higher healthcare utilization. While increasing physician education may help optimize SDM, differences in patient-perceived SDM were also strongly driven by inherent patient characteristics., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Increasing hospital market concentration (with concomitantly decreasing hospital market competition) may be associated with rising hospital prices. Hospital markup - the relative increase in price over costs - has been associated with greater hospital market concentration., Methods: Patients undergoing a cardiothoracic or gastrointestinal procedure in the 2008-2011 Nationwide Inpatient Sample (NIS) were identified and linked to Hospital Market Structure Files. The association between market concentration, hospital markup and hospital for-profit status was assessed using mixed-effects log-linear models., Results: A weighted total of 1,181,936 patients were identified. In highly concentrated markets, private for-profit status was associated with an 80.8% higher markup compared to public/private not-for-profit status (95%CI: +69.5% - +96.9%; p < 0.001). However, private for-profit status in highly concentrated markets was associated with only a 62.9% higher markup compared to public/private not-for-profit status in unconcentrated markets (95%CI: +45.4% - +81.1%; p < 0.001)., Conclusion: Hospital for-profit status modified the association between hospitals' market concentration and markup. Government and private not-for-profit hospitals employed lower markups in more concentrated markets, whereas private for-profit hospitals employed higher markups in more concentrated markets., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Increasingly, patients with multiple co-morbidities undergo surgery for rectal cancer. We aimed to evaluate if decreased psoas muscle area and volume, as measures for sarcopenia, were associated with postoperative morbidity., Methods: Retrospective review of patients undergoing rectal cancer resection at a tertiary medical center (2007-2015). Variables included demographics, co-morbidities, preoperative psoas muscle area and volume, and postoperative complications., Results: Among 180 patients (58% male, mean age 62.7 years), 44% experienced complications (n = 79), of which 38% (n = 30) were major complications. Malnourished patients had smaller height-adjusted total psoas area than non-malnourished patients (6.4 vs. 9.5 cm 2 /m 2 , p = 0.004). Among patients with imaging obtained within 90 days of surgery, major morbidity was associated with smaller total psoas area (6.7 vs. 10.5 cm 2 /m 2 , p = 0.04) and total psoas volume (26.7 vs. 42.2 cm 3 /m 2 , p = 0.04) compared to those with minor complications., Conclusion: Preoperative cross-sectional imaging may help surgeons anticipate postoperative complications following rectal cancer surgery., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Little is known about how information available at discharge affects decision-making and its effect on readmission. We sought to define the association between information used for discharge and patients' subsequent risk of readmission., Methods: 2009-2014 patients from a tertiary academic medical center's surgical services were analyzed using a time-to-event model to identify criteria that statistically explained the timing of discharges. The data were subsequently used to develop a time-varying prediction model of unplanned hospital readmissions. These models were validated and statistically compared., Results: The predictive discharge and readmission regression models were generated from a database of 20,970 patients totaling 115,976 patient-days with 1,565 readmissions (7.5%). 22 daily clinical measures were significant in both regression models. Both models demonstrated good discrimination (C statistic = 0.8 for all models). Comparison of discharge behaviors versus the predictive readmission model suggested important discordance with certain clinical measures (e.g., demographics, laboratory values) not being accounted for to optimize discharges., Conclusions: Decision-support tools for discharge may utilize variables that are not routinely considered by healthcare providers. How providers will then respond to these atypical findings may affect implementation., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Reducing unwanted variations has been identified as an avenue for cost containment. We sought to characterize variations in hospital costs after major surgery and quantitate the variability attributable to the patient, procedure, and provider., Methods: A total of 22,559 patients undergoing major surgical procedure at a tertiary-care center between 2009 and 2013 were identified. Hierarchical linear regression analysis was performed to calculate risk-adjusted fixed, variable and total costs., Results: The median cost of surgery was $23,845 (interquartile ranges, 13,353 to 43,083). Factors associated with increased costs included insurance status (Medicare vs private; coefficient: 14,934; 95% CI = 12,445.7 to 17,422.5, P < .001), preoperative comorbidity (Charlson Comorbidity Index = 1; coefficient: 10,793; 95% CI = 8,412.7 to 13,174.2; Charlson Comorbidity Index ≥2; coefficient: 24,468; 95% CI = 22,552.7 to 26,383.6; both P < .001) and the development of a postoperative complication (coefficient: 58,624.1; 95% CI = 56,683.6 to 60,564.7; P < .001). Eighty-six percent of total variability was explained by patient-related factors, whereas 8% of the total variation was attributed to surgeon practices and 6% due to factors at the level of surgical specialty., Conclusions: Although inpatient costs varied markedly between procedures and providers, the majority of variation in costs was due to patient-level factors and should be targeted by future cost containment strategies., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Most studies on readmission only report data on first readmission within 30 days. These data may underestimate the true impact of readmission, as recurrent readmissions are common among patients undergoing major surgery. We therefore sought to define characteristics and readmission patterns of patients recurrently readmitted after major surgery., Methods: A total of 81,769 patients discharged after 10 major surgical procedures (coronary artery bypass graft, abdominal aortic aneurysm, carotid endarterectomy, aortic valve replacement, esophagectomy, gastrectomy, pancreatectomy, pulmonary resection, hepatectomy, and colorectal resection) between 2010 and 2012 were identified from a large employer-provided health plan. Maximum number of unplanned readmissions experienced within 365 days of discharge was measured., Results: Median patient age was 55 years, and a slight majority (55.4%) was male. Comorbidities were common as 36.9% had a Charlson comorbidity index (CCI) of ≥2. Median length of stay was 5 (interquartile range, 3 and 8) days. Among 24,344 (29.8%) patients who experienced readmission, 64.0% experienced 1 readmission, whereas 36.0% experienced recurrent readmissions within 365 day of a prior discharge. Compared with patients experiencing 1 readmission, patients with ≥2 readmissions were more likely to be female (47.3% vs 44.2%) and have more comorbidities (Charlson comorbidity index ≥2, 49.5% vs 42.5%; both P < .001). Complications during the index hospitalization were more common among patients experiencing recurrent readmissions (35.5% vs 30.7%, P < .001). Although median length of stay during index hospitalization was longer among patients with recurrent readmissions (6 vs 7 days), median time to first readmission was shorter (97 vs 40 days, both P < .001). Among study cohort, 4.5% experienced 3 or more readmissions; these patients accounted for 14.8% of all admissions and 13.7% of hospital charges for the study cohort during the entire follow-up period., Conclusions: Among patients who underwent major surgery, 3 in 10 patients experienced readmission of which 1 in 10 patients experienced recurrent readmission within 1 year after surgery. Overall 4.5% of patients with ≥3 readmissions accounted for 14.8% of total admission during the study period. Assessment of only first rehospitalization may not fully capture the long-term outcomes after major surgery., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Data on the hemoglobin (Hb) after transfusion, or the "target," which reflects the "dose" of blood given are not well studied. We sought to examine the incidence and causes of "over transfusion" of red blood cells after surgery., Methods: Data on blood utilization including Hb triggers and targets were obtained for patients undergoing colorectal, pancreas, or liver surgery between 2010 and 2013., Results: A total of 2,905 patients were identified, of which 895 (31%) were transfused (median age 64, interquartile range: 53 to 72; 51% men; median American Society of Anesthesiologists class 3, interquartile range: 3-3; 51% pancreatic, 14% hepatobiliary, 21% colorectal, and 14% other). Among these, 512 (57%) were overtransfused (final Hb target after transfusion ≥9.0 g/dL). Among patients who were overtransfused, 171 (33%) were transfused at too high an initial trigger (>8.0 g/dL), whereas 304 (59%) had an appropriate trigger but received ≥2 packed red blood cell (PRBC) units, suggesting an opportunity to have transfused fewer units. There was significant variation in overtransfusion among surgeons (range 0% to 80%, P = .003)., Conclusions: Excess use of blood transfusion is common and was due to PRBC utilization for too high a transfusion trigger, as well as too many units transfused., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: We sought to define the impact of cortisol-secreting status on outcomes after surgical resection of adrenocortical carcinoma (ACC)., Methods: The U.S ACC group database was queried to identify patients who underwent ACC resection between 1993 and 2014. The short-term and long-term outcomes were assessed., Results: The incidence of all functional and cortisol-secreting tumors was 40.6% and 22.6%, respectively. On multivariable analysis, cortisol secretion remained associated with an increased risk of postoperative complications (odds ratio = 2.25, 95 % confidence interval = 1.04 to 4.88; P = .04). At a median follow-up of 17.6 months, 118 patients (50.4%) had developed a recurrence. On multivariable analysis, after adjusting for patient and disease-related factors cortisol secretion independently predicted shorter recurrence-free survival (Hazard ratio = 2.05, 95% confidence interval = 1.16 to 3.60; P = .01)., Conclusions: Cortisol secretion was associated with an increased risk of postoperative morbidity. Recurrence remains high among patients with ACC after surgery; cortisol secretion was independently associated with a shorter recurrence-free survival. Tailoring postoperative surveillance of ACC patients based on their cortisol secreting status may be important., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to investigate the prognostic significance of early (30-day) hospital readmission (EHR) on mortality after pancreatectomy., Methods: Using a prospectively collected institutional database linked with a statewide dataset, we evaluated the association between EHR and overall mortality in all patients undergoing pancreatectomy at our tertiary institution (2005 to 2010)., Results: Of 595 pancreatectomy patients, EHR occurred in 21.5%. Overall mortality was 29.4% (median follow-up 22.7 months). Patients with EHR had decreased survival compared with those who were not readmitted (P = .011). On multivariate analysis adjusting for baseline group differences, EHR for gastrointestinal-related complications was a significant independent predictor of mortality (hazard ratio 2.30, P = .001)., Conclusions: In addition to known risk factors, 30-day readmission for gastrointestinal-related complications following pancreatectomy independently predicts increased mortality. Additional studies are necessary to identify surgical, medical, and social factors contributing to EHR, as well as interventions aimed at decreasing postpancreatectomy morbidity and mortality., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: We sought to define trends in the use of epidural analgesia (EA) for hepatopancreatic procedures, as well as to characterize inpatient outcomes relative to the use of EA., Methods: The Nationwide Inpatient Sample database was queried to identify all elective hepatopancreatic surgeries between 2000 and 2012. In-hospital outcomes were compared among patients receiving EA vs conventional analgesia using propensity matching., Results: EA utilization was 7.4% (n = 3,961). The use of EA among minimally invasive procedures increased from 3.8% in 2000 to 9.1% in 2012. The odds of sepsis (odds ratio [OR] .72, 95% confidence interval [CI] .56 to .93), respiratory failure (OR .79, 95% CI .69 to .91), and postoperative pneumonia (OR .77, 95% CI .61 to .98), as well as overall in-hospital mortality (OR .72, 95% CI .56 to .93) were lower in the EA cohort (all P < .05). In contrast, no association was noted between EA and postoperative hemorrhage (OR .81, 95% CI .65 to 1.01, P = .06)., Conclusions: EA use among patients undergoing hepatopancreatic procedures remains low. After controlling for confounding factors, EA remained associated with a reduction in specific pulmonary-related complications, as well as in-hospital mortality., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: We sought to identify differences among black and white Medicare-insured patients with colorectal cancer who underwent resection., Methods: Surveillance, Epidemiology and End Results-Medicare (SEER-Medicare) linked inpatient data from 1986 to 2005 were examined. Differences in short- and long-term outcomes among black vs white patients were investigated., Results: There were 125,676 (92.4%) white and 9,891 (7.6%) black patients who met the criteria. Black patients were younger (75.5 vs 77.2 years; P < .001) but had more comorbidities than did white patients (mean Charlson comorbidity index score 3.99 vs 3.87; P < .001). Black patients demonstrated greater odds of in-hospital mortality (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.30 to 1.56) and readmission within 30 days (OR, 1.26; 95% CI, 1.18 to 1.34). Comparing 1986 to 1990 vs 2001 to 2005, black patients had greater odds of 30-day readmission (OR, 1.12 vs 1.31) but reduced odds of index in-hospital mortality (OR, 1.84 vs 1.28). Black patients had worse long-term survival after colorectal surgery (hazard ratio [HR], 1.21; 95% CI, 1.17 to 1.25; P < .001)., Conclusions: Black patients with colorectal cancer demonstrated increased risk of mortality and readmission after controlling for age, sex, and comorbidities. Although black vs white differences in perioperative mortality decreased over time, disparities in readmission and long-term survival persisted., (Copyright © 2013 Elsevier Inc. All rights reserved.)

It is highly unusual for a 20-cm retroperitoneal teratoma to present as a subhepatic abscess with septic shock in a postpartum woman. We present a case of a multilocular cystic teratoma densely adherent to adjacent viscera and vessels. Because of the complexity of the case and the clinical condition of the patient, a 2-stage operation was employed for this special case. An initial emergency drainage effectively relieved symptoms of acute infection and facilitated the 2nd-stage resection of the tumor., (Copyright 2010 Elsevier Inc. All rights reserved.)