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Background: The influence of surgical margin status on long-term outcomes of patients undergoing adrenal resection for ACC remains not well defined. We studied the impact of surgical tumor margin status on recurrence-free survival (RFS) and overall survival (OS) of patients undergoing resection for ACC. Methods: A total of 165 patients who underwent adrenal resection for ACC and met inclusion criteria were identified form a multi-institutional database. Clinicopathological data, pathologic margin status, and long-term outcomes were assessed. Patients were stratified into two groups based on margin status: R0 (margin >1 mm) versus R1. Results: R0 resection was achieved in 126 patients (76.4 %), whereas 39 patients (23.6 %) had an R1 resection. Median and 5-year OS for patients undergoing R0 resection were 96.3 months and 64.8 % versus 25.1 months and 33.8 % for patients undergoing an R1 resection (both p

Competing Interests: Disclosure: Kazunari Sasaki, Jane Wang, Carsten Kamphues, Stefan Buettner, Johan Gagniere, Victoria Ardilles, Katsunori Imai, Doris Wagner, Ioannis Pozios, Dimitris Papakonstantinou, Emmanouil Pikoulis, Efstathios Antoniou, Daisuke Morioka, Inger Marie Løes, Per Eystein Lønning, Peter Kornprat, Federico N. Aucejo, Hideo Baba, Eduardo de Santibañes, Klaus Kaczirek, Richard Burkhart, Itaru Endo, Katharina Beyer, Martin E Kreis, Timothy M. Pawlik, and Georgios Antonios Margonis have no conflicts of interest/competing interests to declare.

Competing Interests: Disclosure: The authors have no conflicts of interest to report.

Background: Recent studies have suggested that certain combinations of KRAS or BRAF biomarkers with clinical factors are associated with poor outcomes and may indicate that surgery could be "biologically" futile in otherwise technically resectable colorectal liver metastasis (CRLM). However, these combinations have yet to be validated through external studies., Patients and Methods: We conducted a systematic search to identify these studies. The overall survival (OS) of patients with these combinations was evaluated in a cohort of patients treated at 11 tertiary centers. Additionally, the study investigated whether using high-risk KRAS point mutations in these combinations could be associated with particularly poor outcomes., Results: The recommendations of four studies were validated in 1661 patients. The first three studies utilized KRAS, and their validation showed the following median and 5-year OS: (1) 30 months and 16.9%, (2) 24.3 months and 21.6%, and (3) 46.8 months and 44.4%, respectively. When analyzing only patients with high-risk KRAS mutations, median and 5-year OS decreased to: (1) 26.2 months and 0%, (2) 22.3 months and 15.1%, and (3) not reached and 44.9%, respectively. The fourth study utilized BRAF, and its validation showed a median OS of 10.4 months, with no survivors beyond 21 months., Conclusion: The combinations of biomarkers and clinical factors proposed to render surgery for CRLM futile, as presented in studies 1 (KRAS high-risk mutations) and 4, appear justified. In these studies, there were no long-term survivors, and survival was similar to that of historic cohorts with similar mutational profiles that received systemic therapies alone for unresectable disease., Competing Interests: Disclosure. None to report., (© 2024. Society of Surgical Oncology.)

Background: Regular surveillance imaging is commonly used after curative-intent resection of most solid-organ cancers to enable prompt diagnosis and management of recurrent disease. Given the fear of cancer recurrence, surveillance may lead to distress and anxiety ("scanxiety") but its frequency, severity, and management among cancer survivors are poorly understood., Methods: A systematic review of the PubMed, Embase, CINAHL, and PsycINFO databases was conducted to evaluate existing literature on anxiety and emotional experiences associated with surveillance after curative-intent cancer surgery as well as interventions aimed at reducing scanxiety., Results: Across the 22 included studies encompassing 8693 patients, reported rates of scanxiety varied significantly, but tended to decrease as time elapsed after surgery. Qualitative studies showed that scanxiety arises from various factors innate to the surveillance experience and is most prevalent in the scan-to-results waiting period. Common risk factors for scanxiety included sociodemographic and cancer-related characteristics, low coping self-efficacy, pre-existing anxiety, and low patient well-being. Conversely, reassurance was a positive aspect of surveillance reported in several studies. Trials evaluating the impact of interventions all focused on modifying the surveillance regimen compared with usual care, but none led to reduced rates of scanxiety., Conclusions: Although scanxiety is nearly universal across multiple cancer types and patient populations, it is transient and generally limited in severity. Because existing trials evaluating interventions to reduce scanxiety have not identified effective strategies to date, future research is needed to identify interventions aimed at reducing their impact on high-risk individuals., Competing Interests: Disclosure: There are no conflict of interest., (© 2024. The Author(s).)

Background: Benzodiazepines are the third most misused medication, with many patients having their first exposure during a surgical episode. We sought to characterize factors associated with new persistent benzodiazepine use (NPBU) among patients undergoing cancer surgery., Patients and Methods: Patients who underwent cancer surgery between 2013 and 2021 were identified using the IBM-MarketScan database. NPBU was defined as one prescription filled during the 90-180 days period after surgery by patients who were previously benzodiazepine naïve. The association of variables with perioperative benzodiazepine use and NPBU was assessed using multivariable regression., Results: Among 34,637 patients with cancer (breast: n = 5460, 15.8%; lung: n = 3479, 10.0%; esophagus: n = 384, 1.1%; gastric: n = 852, 2.5%; liver: n =502, 1.4%; biliary: n = 268, 0.8%; pancreas: n = 1290, 3.7%; colon: n = 10,838, 31.3%; rectum: n = 2566, 7.4%; prostate: n = 8998, 26.0%), most were male (n = 19,687, 56.8%) with a median age of 57 years (IQR 51-61 years). Overall, 8.8% of patients had perioperative benzodiazepine use and 7.5% of patients developed NPBU following surgery. On multivariable analyses, perioperative benzodiazepine exposure (ref. no perioperative exposure: OR 2.00, 95% CI 1.68-2.38) and higher perioperative dose of > 32.0 lorazepam milligram equivalents (LME) (ref. < 10 LME: OR 2.42, 95% CI 2.01-2.92) were independently associated with higher odds of NPBU. Notably, male patients had lower odds of NPBU versus female patients (OR 0.80, 95% CI 0.68-0.94)., Conclusions: Roughly 1 in 13 commercially insured patients developed NPBU following surgery for cancer. Judicious use of benzodiazepines among patients with high risk of misuse can mitigate NPBU to help avoid benzodiazepine-related complications such as overdose or accidental deaths., Competing Interests: Disclosures: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors declare no funding or financial support. The authors declare no conflict of interest., (© 2024. Society of Surgical Oncology.)

Background: We sought to define whether and how hepatic ischemia/reperfusion (I/R) as manifested by perioperative aspartate aminotransferase (AST) and alanine aminotransaminase (ALT) levels impact long-term outcomes after curative-intent resection of hepatocellular carcinoma (HCC)., Patients and Methods: Intrasplenic injection of HCC cells was used to establish a murine model of HCC recurrence with versus without I/R injury. Patients who underwent curative resection for HCC were identified from a multi-institutional derivative cohort (DC) and separate external validation (VC) cohort. Perioperative changes of transaminase levels were examined relative to the recurrence-free (RFS) and overall survival (OS) among patients following HCC resection., Results: Mice exposed to hepatic I/R injury were more likely to experience tumor recurrence, as well as higher luminescence signal intensity (all p < 0.05) versus mice with no I/R injury. Relative changes between AST and ALT (sum of AST/ALT ratios, SAAR) on postoperative day (POD) 1 and POD 3 AST 1 ALT 1 and AST 3 ALT 3 were calculated using the formula: SAAR = 1 2 AST 1 ALT 1 + AST 3 ALT 3 via Fourier transform theory. Among 734 patients in DC, the median SAAR was 2.1. After adjusting for other competing risk factors, SAAR ≥ 2.0 remained strongly associated with risk of postoperative recurrence (ref. SAAR < 2.0, HR 1.32, p = 0.03), whereas SAAR ≥ 3.5 was associated with risk of postoperative mortality (ref. SAAR < 3.5, HR 1.86, p < 0.01). SAAR demonstrated good accuracy to predict postoperative recurrence (c-index 0.724, 0.731) and mortality (c-index 0.655, 0.765) in DC and VC, respectively., Conclusions: Use of routine labs such as AST and ALT can help identify patients at high risk of recurrence and mortality following HCC resection., Competing Interests: Disclosure: The authors declare no conflict of interest., (© 2024. Society of Surgical Oncology.)

Background: Poor infrastructure in deprived areas may hinder access to health care, and a lack of socioeconomic resources can prevent patients from remaining at home after discharge. This study sought to assess the association between the Area Deprivation Index (ADI) and days at home within 90 days (DAH-90) after a complex operative procedure., Methods: Patients who underwent an elective operation for a gastrointestinal cancer between 2016 and 2020 were identified from the Medicare Standard Analytic Files. County-level ADI was calculated using a weighted average of ADI percentiles for each census block within a county. The association between ADI and DAH-90 and the impact of DAH-90 on 1-year expenditures and 1-year mortality were evaluated., Results: Among 72,452 patients who underwent a surgical procedure, median patient age was 75 years (interquartile range [IQR] 71-81) and 54.3% of patients had a Charlson Comorbidity Index higher than 2. A +0.2 increase in ADI was associated with 12.6% lower odds of achieving high DAH-90 (adjusted odds ratio [aOR], 0.874; 95% confidence interval [CI], 0.845-0.903) compared with low DAH-90. Notably, high DAH-90 (mean difference, -55,614$; 95% CI, -56,540$ to -54,687$) and medium DAH-90 (mean difference, -39,538$; 95% CI, -40,194$ to -38,882$) were associated with markedly decreased 1-year total expenditures, as well as lower 1-year mortality compared with patients who spent fewer days at home after surgery., Conclusions: Increasing area deprivation was associated with higher likelihood of spending fewer days at home after a complex cancer surgical procedure. Patients spending fewer days at home were far more likely to die within 1 year and experienced higher health care costs., Competing Interests: Disclosure: There are no conflicts of interest., (© 2024. Society of Surgical Oncology.)

Competing Interests: Disclosure: The authors declare no conflicts of interest.

Background: US News and World Report (USNWR) hospital rankings influence patient choice of hospital, but their association with surgical outcomes remains ill-defined. We sought to characterize clinical outcomes and costs of surgery for colon cancer among USNWR top ranked and unranked hospitals., Methods: Using Medicare Standard Analytic Files, patients aged ≥65 years undergoing surgery for colon cancer were identified. Hospitals were categorized as 'ranked' or 'unranked' based on USNWR cancer hospital rankings. One-to-one matching was performed between patients treated at ranked and unranked hospitals, and clinical outcomes and costs of surgery were compared., Results: Among 50 ranked and 2522 unranked hospitals, 13,650 patient pairs were compared. Overall, 30-day mortality was 2.13% in ranked hospitals versus 3.68% in unranked hospitals (p < 0.0001), and the overall paired cost difference was $8159 (p < 0.0001). As patient risk increased, 30-day mortality differences became larger, with the ranked hospitals having 30-day mortality of 7.59% versus 11.84% for unranked hospitals among the highest-risk patients (p < 0.0001). Overall paired cost differences also increased with increasing patient risk, with cost of care being $72,229 for ranked hospitals versus $56,512 for unranked hospitals among the highest-risk patients (difference = $14,394; p = 0.02). The difference in cost per 1% reduction in 30-day mortality was $9009 (95% confidence interval [CI] $6422-$11,597) for lowest-risk patients, which dropped to $3387 (95% CI $2656-$4119) for highest-risk patients (p < 0.0001)., Conclusion: Treatment at USNWR-ranked hospitals, particularly for higher-risk patients, was associated with better outcomes but higher-cost care. The benefit of being treated at highly ranked USNWR hospitals was most pronounced among high-risk patients., (© 2024. The Author(s).)

Background: Racial and sex disparities in the incidence and outcomes of patients with intrahepatic cholangiocarcinoma (iCCA) exist, yet potential genomic variations of iCCA based on race and sex that might be contributing to disparate outcomes have not been well studied., Methods: Data from the American Association for Cancer Research Project GENIE registry (version 15.0) were analyzed to assess genetic variations in iCCA. Adult patients (age >18 years) with histologically confirmed iCCA who underwent next-generation sequencing were included in the analytic cohort. Racial and sex variations in genomic profiling of iCCA were examined., Results: The study enrolled 1068 patients from 19 centers (White, 71.9%; Black, 5.1%; Asian, 8.4%, other, 14.6%). The male-to-female ratio was 1:1. The majority of the patients had primary tumors (73.7%), whereas 23.0% had metastatic disease sequenced. While IDH1 mutations occurred more frequently in White versus Black patients (20.8% vs. 5.6%; p = 0.021), FGFR2 mutations tended to be more common among Black versus White populations (27.8% vs. 16.1%; p = 0.08). Males were more likely to have TP53 mutations than females (24.3% vs. 18.2%, p = 0.016), whereas females more frequently had IDH1 (23.3% vs 16.0 %), FGFR2 (21.0% vs. 11.3%), and BAP1 (23.4% vs. 14.5%) mutations than males (all p < 0.05). Marked variations in the prevalence of other common genomic alterations in iCCA were noted across different races and sexes., Conclusion: Distinct genomic variations exist in iCCA across race and sex. Differences in mutational profiles of iCCA patients highlight the importance of including a diverse patient population in iCCA clinical trials as well as the importance of recognizing different genetic drivers that may be targetable to treat distinct patient cohorts., (© 2024. The Author(s).)

Competing Interests: Ethics approval and consent to participate: This study was performed in accordance with the Declaration of Helsinki and was approved by the Institutional Review Boards of all participating hospitals.

Introduction: Despite cost-standardization efforts, significant variations in hospital costs persist in insurance claims. We sought to identify and quantify factors driving cost variability at hospital and cost center levels following a complex gastrointestinal surgical procedure., Methods: Individuals who underwent pancreatectomy (PA), colectomy (CO), and proctectomy (PR) were identified from the Surveillance, Epidemiology, and End Results database. Index surgery costs across 1,262 hospitals were compared, adjusting for clinical, demographic, and geographic factors. Multilevel regression modeling identified factors associated with variability in charges., Results: Among 35,908 individuals (PA: 8.2%; CO: 79.4%; PR: 12.4%), the median age was 78 years (interquartile range [IQR] 72-84), with 56.1% male. Median Medicare payments varied significantly by cancer type (CO: $21,704, PA: $26,709, PR: $21,228; p < 0.001). Operating room ($6,891, 23.82%), hospital stay ($5,931, 20.9%), and professional fees ($4,352, 15.35%) were the top cost centers, comprising 60% of total costs. Surgeons had the highest charges (PA: $2,037; CO: $2,131; PR: $2,243), followed by anesthesiologists (PA: $622; CO: $431; PR: $480). Charges for critical care specialists and pathologists were relatively low. Multilevel modeling demonstrated total charge variability was primarily influenced by patient factors (83%), followed by surgeon factors (9%) and hospital factors (8%)., Conclusions: There was marked variation in spending at the cost center level in the surgical treatment of gastrointestinal cancers. Patient factors demonstrated the greatest variability, followed by hospital and surgeon-level factors. Implementing value-based healthcare and standardized surgical protocols may improve both care quality and cost-effectiveness., Competing Interests: Disclosure The authors declare no conflict of interest., (© 2024. Society of Surgical Oncology.)

Competing Interests: Disclosure Giovanni Catalano and Timothy M. Pawlik declare no conflicts of interest that may be relevant to the contents of this article.

Competing Interests: Disclosures None.

Competing Interests: Disclosure The authors have no conflict of interests to declare.

Background: Lymph node metastasis (LNM) is among the most important predictors of poor prognosis after surgery for gallbladder cancer (GBC). Traditionally, staging has been based on the raw count of LNM, with a high risk of understaging patients who undergo inadequate lymph node dissection (LND). The log odds of metastatic lymph nodes (LODDS) may represent an alternative staging approach to stratify patients more accurately after resection of GBC., Patients and Methods: In this cross-sectional study, patients who underwent curative-intent surgery with LND for GBC were identified from an international database. Two predictive models were built and compared, each integrating a different lymph nodes status indicator [i.e., American Joint Committee on Cancer (AJCC) and LODDS]., Results: Among 199 patients, the median number of lymph nodes examined was 5 [interquartile range (IQR): 3.0, 8.0]; most patients had T1 (n = 26, 13.1%) or T2 (n = 97, 48.7%) disease, and a subset had LNM (n = 87, 44.0%). Multivariable Cox analysis demonstrated LODDS was an independent predictor of overall survival [hazard ratio (HR) 1.84, 95% confidence interval (CI) 1.5-2.3; p < 0.001]. The LODDS model demonstrated better performance compared with a traditional model that utilized the AJCC N category [concordance (C) index: 0.814 versus 0.763; p < 0.001]. Patients classified as high- versus low-risk based on LODDS had much worse overall survival (OS) (4.9% versus 83.7%, respectively; p < 0.001). The LODDS model performance remained high even among patients with inadequate LND (< 6 LN) (C index: 0.87). An online calculator was developed ( https://catalano-giovanni.shinyapps.io/LoddsGBC/ )., Conclusions: A novel prognostic model based on LODDS may overcome the inherent limitations of the current AJCC staging system, reducing understaging among patients with fewer than six total lymph nodes evaluated., Competing Interests: Disclosure The authors declare no conflicts of interest., (© 2024. Society of Surgical Oncology.)

Background: The prognostic role of the fibrosis-4 (FIB-4) index relative to intrahepatic cholangiocarcinoma (ICC) after hepatectomy remains unclear. This study sought to characterize the impact of the FIB-4 index and tumor burden score (TBS) on recurrence and overall survival (OS)., Methods: ICC patients undergoing hepatectomy (2000-2020) were identified using a multi-institutional database. Patients were categorized as low (low TBS/low FIB-4 index), intermediate (low TBS/high FIB-4 index or high TBS/low FIB-4 index), and high (high TBS/high FIB-4 index)., Results: Among 1168 patients in different TBS and FIB-4 index cohorts, 3-year recurrence varied considerably. For instance, among the patients with low TBS, individuals with a high FIB-4 index had a greater risk of recurrence than patients with a low FIB-4 index (59.9 vs. 47.7%; P = 0.01). Among patients with a high TBS, individuals with a high versus a low FIB-4 index had a higher incidence of recurrence (76.8 vs. 69.0%; P = 0.04). A similar pattern was observed among patients with both a low FIB-4 index (low [47.7%] vs. high [69.0%] TBS) and a high FIB-4 index (low [59.9%] vs. high [76.8%] TBS; both P < 0.001). Patients with a high [27.5%] versus a low [48.8%] TBS; P < 0.001) and patients with a high [34.2%] versus a low [43.5%] FIB-4 index; P = 0.01) had a worse OS. The multivariable analysis demonstrated an increasing risk of recurrence in the intermediate-index (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.20-2.16; P = 0.001) and high-index (HR, 2.13; 95% CI 1.45-3.13; P < 0.001) groups versus the low-index group., Conclusions: Both tumor-related and non-tumorous characteristics should be used to predict risk of recurrence and survival more accurately among patients with ICC following hepatic resection., (© 2024. Society of Surgical Oncology.)

Background: Historically, housing policies have perpetuated the marginalization and economic disinvestment of redlined neighborhoods. Residential segregation persists nowadays in the form of contemporary redlining, promoting healthcare disparities. The current study sought to assess the effect of redlining on oncological outcomes of patients with gastrointestinal cancer and identify mediators of the association., Methods: Patients with colorectal or hepatobiliary cancer were identified from the linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2007-2019). The contemporary redlining index, a measure of mortgage lending bias, was assessed relative to disease stage at diagnosis, receipt of appropriate treatment, textbook outcome, and mortality. Mediation analysis was used to identify socioeconomic, structural, and clinical mediating factors., Results: Among 94,988 patients, 32.2% resided in high (n = 23,872) and highest (n = 6,791) redlining census tracts compared with 46.2% in neutral and 21.6% in low redlining tracts. The proportion of Black, Hispanic, and White patients experiencing high and highest redlining was 65.9%, 41.6%, and 27.9%, respectively. Highest redlining was associated with 18.2% higher odds of advanced disease at diagnosis, greater odds of not undergoing surgery for localized disease (adjusted odds ratio [aOR] 1.363, 95% confidence interval [CI] 1.219-1.524) or not receiving chemotherapy for advanced disease (aOR 1.385, 95% CI 1.216-1.577), and 26.7% lower odds of textbook outcome achievement. Mediation analysis for appropriate treatment quantified the proportion of the association driven by socioeconomic status, racial/ethnic minority status, racial/economic segregation, primary care shortage, and housing/transportation., Conclusions: Contemporary redlining contributed both directly, and via downstream factors, to disparities in oncological care and outcomes of patients with gastrointestinal cancer., (© 2024. The Author(s).)

Background: Primary care (PC) is essential to overall wellness and management of comorbidities. In turn, patients without adequate access to PC may face healthcare disparities. We sought to characterize the impact of established PC on postoperative outcomes among patients undergoing a surgical procedure for a digestive tract cancer., Methods: Medicare beneficiaries with a diagnosis of hepatobiliary, pancreas, and colorectal cancer between 2005 and 2019 were identified within the Surveillance, Epidemiology, and End Results program and Medicare-linked database. Individuals who did versus did not have PC encounters within 1-year before surgery were identified. A postoperative textbook outcome (TO) was defined as the absence of complications, no prolonged hospital stay, no readmission within 90 days, and no mortality., Results: Among 63,177 patients, 50,974 (80.7%) had at least one established PC visit before surgery. Patients with established PC were more likely to achieve TO (odds ratio [OR], 1.14; 95% confidence interval [CI], 1.09-1.19) with lower odds for complications (OR, 0.85; 95% CI, 0.72-0.89), extended hospital stay (OR, 0.86; 95% CI, 0.81-0.94), 90-day readmission (OR, 0.94; 95% CI, 0.90-0.99), and 90-day mortality (OR, 0.87; 95% CI, 0.79-0.96). In addition, patients with established PC had a 4.1% decrease in index costs and a 5.2% decrease in 1-year costs. Notably, patients who had one to five visits with their PC in the year before surgery had improved odds of TO (OR, 1.21; 95% CI, 1.16-1.27), whereas individuals with more than 10 visits had lower odds of a postoperative TO (OR, 0.91; 95% CI, 0.84-0.98)., Conclusion: Most Medicare beneficiaries with digestive tract cancer had established PC within the year before their surgery. Established PC was associated with a higher probability of achieving ideal outcomes and lower costs. In contrast, patients with more than 10 PC appointments, which was likely a surrogate of overall comorbidity burden, experienced no improvement in postoperative outcomes., (© 2024. The Author(s).)

Background: Liver metastasis impacts survival in patients with gastroenteropancreatic neuroendocrine tumors (GEP-NETs); however, current guidelines lack consensus on post-resection surveillance and adjuvant therapy. A comprehensive risk stratification tool is needed to guide personalized management., Objective: We aimed to develop and validate a predictive model for liver metastasis risk after surgical resection of GEP-NETs that incorporates pathological factors and adjuvant therapy., Methods: Patients with GEP-NETs who underwent surgical resection with curative intent at three major Chinese hospitals (2010-2022) were identified. Univariable and multivariable Cox regression analysis identified independent risk factors of liver metastasis. The liver metastasis score (LMS) was developed using weighted risk factors and validated by tenfold cross-validation., Results: Among the 724 patients included in the analytic cohort, liver metastasis occurred in 66 patients (9.1%) at a median of 36 months; patients with liver metastasis had a worse 5-year overall survival (no liver metastasis 63.6% vs. liver metastasis 95.8%; p < 0.001). Independent predictors were Ki-67 index (hazard ratio [HR] 10.36 for Ki-67 3-20%, HR 18.30 for Ki-67 >20%, vs. <3%), vascular invasion (HR 5.03), lymph node metastases (HR 2.24), and lack of adjuvant therapy (HR 3.03). The LMS demonstrated excellent discrimination (C-index 0.888) and stratified patients into low, intermediate, and high-risk relative to 5-year risk of liver metastasis: 2.9%, 20.8%, and 49.7%, respectively (p < 0.001)., Conclusions: The novel LMS effectively predicted the risk of liver metastasis after surgical resection of GEP-NETs. This validated model can help guide personalized surveillance and adjuvant treatment strategies, potentially improving outcomes for high-risk patients., (© 2024. Society of Surgical Oncology.)

Background: New persistent opioid use (NPOU) after surgery has been identified as a common complication. This study sought to assess the long-term health outcomes among patients who experienced NPOU after gastrointestinal (GI) cancer surgery., Methods: Patients who underwent surgery for hepato-pancreato-biliary and colorectal cancer between 2007 and 2019 were identified using the Surveillance, Epidemiology, and End Results (SEER)-Medicare-linked database. Mixed-effect multivariable logistic regression and Cox proportional hazard models were used to estimate the risk of mortality and hospital visits related to falls, respiratory events, or pain symptoms., Results: Among 15,456 patients who underwent GI cancer surgery, 967(6.6%) experienced NPOU. Notably, the patients at risk for the development of NPOU were those with a history of substance abuse (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.14-1.84), moderate social vulnerability (OR, 1.26; 95% CI, 1.06-1.50), an advanced disease stage (OR, 4.42; 95% CI, 3.51-5.82), or perioperative opioid use (OR, 3.07; 95% CI, 2.59-3.63. After control for competing risk factors, patients who experienced NPOU were more likely to visit a hospital for falls, respiratory events, or pain symptoms (OR, 1.45, 95% CI 1.18-1.78). Moreover, patients who experienced NPOU had a greater risk of death at 1 year (hazard ratio [HR], 2.15; 95% CI, 1.74-2.66)., Conclusion: Approximately 1 in 15 patients experienced NPOU after GI cancer surgery. NPOU was associated with an increased risk of subsequent hospital visits and higher mortality. Targeted interventions for individuals at higher risk for NPOU after surgery should be used to help mitigate the harmful effects of NPOU., (© 2024. The Author(s).)

Introduction: The growing burden of an aging population has raised concerns about demands on healthcare systems and resources, particularly in the context of surgical and cancer care. Delirium can affect treatment outcomes and patient recovery. We sought to determine the prevalence of postoperative delirium among patients undergoing digestive tract surgery for malignant indications and to analyze the role of delirium on surgical outcomes., Methods: Medicare claims data were queried to identify patients diagnosed with esophageal, gastric, hepatobiliary, pancreatic, and colorectal cancers between 2018 and 2021. Postoperative delirium, occurring within 30 days of operation, was identified via International Classification of Diseases, 10th edition codes. Clinical outcomes of interested included "ideal" textbook outcome (TO), characterized as the absence of complications, an extended hospital stay, readmission within 90 days, or mortality within 90 days. Discharge disposition, intensive care unit (ICU) utilization, and expenditures also were examined., Results: Among 115,654 cancer patients (esophageal: n = 1854, 1.6%; gastric: n = 4690, 4.1%; hepatobiliary: n = 6873, 5.9%; pancreatic: n = 8912, 7.7%; colorectal: n = 93,325, 90.7%), 2831 (2.4%) were diagnosed with delirium within 30 days after surgery. On multivariable analysis, patients with delirium were less likely to achieve TO (OR 0.27 [95% CI 0.25-0.30]). In particular, patients who experienced delirium had higher odds of complications (OR 3.00 [2.76-3.25]), prolonged length of stay (OR 3.46 [3.18-3.76]), 90-day readmission (OR 1.96 [1.81-2.12]), and 90-day mortality (OR 2.78 [2.51-3.08]). Furthermore, patients with delirium had higher ICU utilization (OR 2.85 [2.62-3.11]). Upon discharge, patients with delirium had a decreased likelihood of being sent home (OR 0.40 [0.36-0.46]) and instead were more likely to be transferred to a skilled nursing facility (OR 2.17 [1.94-2.44]). Due to increased utilization of hospital resources, patients with delirium incurred in-hospital expenditures that were 55.4% higher (no delirium: $16,284 vs. delirium: $28,742) and 90-day expenditures that were 100.7% higher (no delirium: $2564 vs. delirium: $8226) (both p < 0.001). Notably, 3-year postoperative survival was adversely affected by delirium (no delirium: 55.5% vs. delirium: 37.3%), even after adjusting risk for confounding factors (HR 1.79 [1.70-1.90]; p < 0.001)., Conclusions: Postoperative delirium occurred in one in 50 patients undergoing surgical resection of a digestive tract cancer. Delirium was linked to a reduced likelihood of achieving an optimal postoperative outcome, increased ICU utilization, higher expenditures, and a worse long-term prognosis. Initiatives to prevent delirium are vital to improve postoperative outcomes among cancer surgery patients., (© 2024. Society of Surgical Oncology.)

Background: Practice patterns and potential quality differences among surgical oncology fellowship graduates relative to years of independent practice have not been defined., Methods: Medicare claims were used to identify patients who underwent esophagectomy, pancreatectomy, hepatectomy, or rectal resection for cancer between 2016 and 2021. Surgical oncology fellowship graduates were identified, and the association between years of independent practice, serious complications, and 90-day mortality was examined., Results: Overall, 11,746 cancer operations (pancreatectomy [61.2%], hepatectomy [19.5%], rectal resection [13.7%], esophagectomy [5.6%]) were performed by 676 surgical oncology fellowship graduates (females: 17.7%). The operations were performed for 4147 patients (35.3%) by early-career surgeons (1-7 years), for 4104 patients (34.9%) by mid-career surgeons (8-14 years), and for 3495 patients (29.8%) by late-career surgeons (>15 years). The patients who had surgery by early-career surgeons were treated more frequently at a Midwestern (24.9% vs. 14.2%) than at a Northeastern institution (20.6% vs. 26.9%) compared with individuals treated by late-career surgeons (p < 0.05). Surgical oncologists had comparable risk-adjusted serious complications and 90-day mortality rates irrespective of career stage (early career [13.0% and 7.2%], mid-career [12.6% and 6.3%], late career [12.8% and 6.5%], respectively; all p > 0.05). Surgeon case-specific volume independently predicted serious complications across all career stages (high vs. low volume: early career [odds ratio {OR}, 0.80; 95% confidence interval {CI}, 0.65-0.98]; mid-career [OR, 0.81; 95% CI, 0.66-0.99]; late career [OR, 0.78; 95% CI, 0.62-0.97])., Conclusion: Among surgical oncology fellowship graduates performing complex cancer surgery, rates of serious complications and 90-day mortality were comparable between the early-career and mid/late-career stages. Individual surgeon case-specific volume was strongly associated with postoperative outcomes irrespective of years of independent practice or career stage., (© 2024. The Author(s).)

Background: The association of hospital market competition, financial costs, and quality of oncologic care has not been well-defined. This study sought to evaluate variations in patient outcomes and financial expenditures after complex cancer surgery across high- and low-competition markets., Methods: Medicare 100% Standard Analytic Files were used to identify patients with lung, esophageal, gastric, hepatopancreaticobiliary, or colorectal cancer who underwent surgical resection between 2018 and 2021. Data were merged with the annual hospital survey database, and the hospital market Herfindahl-Hirschman index was used to categorize hospitals into low- and high-concentration markets. Multi-level, multivariable regression models adjusting for patient characteristics (i.e., age, sex, comorbidities, and social vulnerability), year of procedure, and hospital factors (i.e., case volume, nurse-bed ratio, and teaching status) were used to assess the association between hospital market competition and outcomes., Results: Among 117,641 beneficiaries who underwent complex oncologic surgery, the mean age was 73.8 ± 6.1 years, and approximately one-half of the cohort was male (n = 56,243, 47.8%). Overall, 63.8% (n = 75,041) of the patients underwent care within a high-competition market. Notably, there was marked geographic variation relative to market competition. High versus low market-competition hospitals were more likely to be in high social vulnerability areas (35.1 vs 27.5%; p < 0.001), as well as care for racial/ethnic minority individuals (13.8 vs 7.7%; p < 0.001), and patients with more comorbidities (≥ 2 Elixhauser comorbidities: 63.1 vs 61.1%; p < 0.001). In the multivariable analysis, treatment at hospitals in high- versus low-competition markets was associated with lower odds of achieving a textbook outcome (odds ratio, 0.95; 95% confidence interval, 0.91-0.99; p = 0.009). Patients at high-competition hospitals had greater mean index hospitalization costs ($19,462.2 [16211.9] vs $18,844.7 [14994.7]) and 90-day post-discharge costs ($7807.8 [15431.3] vs $7332.8 [14038.2]) (both p < 0.001) than individuals at low-competition hospitals., Conclusions: Hospital market competition was associated with poor achievement of an optimal postoperative outcome and greater hospitalization costs., (© 2024. The Author(s).)

Introduction: Although up to 50-70% of patients with intrahepatic cholangiocarcinoma (ICC) recur following resection, data to predict post-recurrence survival (PRS) and guide treatment of recurrence are limited., Methods: Patients who underwent resection of ICC between 2000 and 2020 were identified from an international, multi-institutional database. Data on primary disease as well as laboratory and radiologic data on recurrent disease were collected. Factors associated with PRS were examined and a novel scoring system to predict PRS (PRS score) was developed and internally validated., Results: Among 986 individuals who underwent resection for ICC, 588 (59.6%) patients developed recurrence at a median follow up of 20.3 months. Among patients who experienced a recurrence, 97 (16.5%) underwent re-resection/ablation for recurrent ICC; 88 (15.0%) and 403 (68.5%) patients received intra-arterial treatment or systemic chemotherapy/supportive therapy, respectively. Patient American Society of Anesthesiologists (ASA) class > 2 (1 point), primary tumor N1/Nx status (1 point), primary R1 resection margin (1 point), primary tumor G3/G4 grade (1 point), carbohydrate antigen (CA) 19-9 > 37 UI/mL (2 points) at recurrence and carcinoembryonic antigen (CEA) > 5 ng/mL (2 points) at recurrence, as well as recurrent bilateral disease (1 point) and early recurrence (1 point) were included in the PRS score. The PRS score successfully stratified patients relative to PRS and demonstrated strong discriminatory ability (C-index 0.70, 95% confidence interval 0.68-0.72). While a PRS score of 0-3 was associated with a 3-year PRS of 62.5% following resection/ablation for recurrent ICC, a PRS score > 3 was associated with a low 3-year PRS of 35.5% (p = 0.03)., Conclusions: The PRS score demonstrated strong discriminatory ability to predict PRS among patients who had developed recurrence following initial resection of ICC. The PRS score may be a useful tool to guide treatment among patients with recurrent ICC., (© 2024. Society of Surgical Oncology.)