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Medical errors were largely concealed prior to the landmark report "To Err Is Human". The purpose of this systematic scoping review was to determine the extent pediatric surgery defines and studies errors, and to explore themes among papers focused on errors in pediatric surgery.The methodological framework used to conduct this scoping study has been outlined by Arksey and O'Malley. In January 2020, PubMed, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched. Oxford Level of Evidence was assigned to each study; only studies rated Level 3 or higher were included.Of 3,064 initial studies, 12 were included in the final analysis: 4 cohort studies, and 8 outcome/audit studies. This data represented 5,442,000 aggregate patients and 8,893 errors. There were 6 different error definitions and 5 study methods. Common themes amongst the studies included a systems-focused approach, an increase in errors seen with increased complexity, and studies exploring the relationship between error and adverse events.This study revealed multiple error definitions, multiple error study methods, and common themes described in the pediatric surgical literature. Opportunities exist to improve the safety of surgical care of children by reducing errors. Original Scientific Research Type of Study: Systematic Scoping Review Level of Evidence Rating: 1.

The impact of obesity on postoperative outcomes after pancreatoduodenectomy remains insufficiently studied.All pancreatoduodenectomy patients were abstracted from the 2014 to 2018 American College of Surgeons National Surgical Quality Improvement Program data sets and were stratified into the following 3 body mass index categories: non-obese (body mass index 18.5-29.9), class 1/2 obesity (body mass index 30-39.9), and class 3 severe obesity (body mass index ≥ 40). Analyses tested associations between patient factors and four 30-day postoperative outcomes: mortality, composite morbidity, delayed gastric emptying, and postoperative pancreatic fistula. Multivariable logistic regression models tested independent associations between patient factors and these 4 outcome measures.A total of 16,823 patients were included in the study: 12,234 (72.7%) non-obese, 4,030 (24%) obese, and 559 (3.3%) with severe obesity. Bivariable analyses demonstrated significant associations between obesity, severe obesity, and greater proportions of numerous preoperative comorbidities as well as a greater likelihood of postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, composite morbidity, and mortality (all P ≤ .001). After adjusting for significant covariates, obesity was independently associated with postoperative pancreatic fistula (odds ratio 1.49, 95% confidence interval: 1.33-1.67, P.001), delayed gastric emptying (odds ratio 1.16, 95% confidence interval: 1.05-1.28, P = .004), composite morbidity (odds ratio 1.28, 95% confidence interval: 1.18-1.38, P .001), and mortality (odds ratio 1.79, 95% confidence interval: 1.36-2.36, P .001).Obesity and severe obesity are significantly associated with worse short-term outcomes after pancreatoduodenectomy. Preoperative considerations, such as weight management strategies during individualized treatment planning, could improve outcomes in this population.

Background Preoperative assessment of geriatric-specific determinants of health may enhance perioperative risk stratification among elderly patients. This study examines effects of geriatric-specific variables on postoperative outcomes in patients undergoing elective major abdominal operations. Methods Patients included in the ACS NSQIP pilot Geriatric Surgery Research File program who underwent elective pancreatic, liver, and colorectal operations between 2014 and 2016 were examined. Multivariable analyses were performed to evaluate associations between patient-specific geriatric variables and risk of death, morbidity, readmission, and discharge destination. Results A total of 4165 patients were included. Patients ≥85 years were more likely to die, experience postoperative morbidity, and be discharged to a facility (all p ≤ 0.039) than younger patients. Preoperatively, patients ≥85 years were more likely to use a mobility aid, have a prior fall, have consent signed by a surrogate, and to live alone at home prior to operation (all p 0.055). Patients 75–84 and ≥85 years were more likely to be discharged to facility (OR 2.33 and 4.75, respectively, both p

Efficacy of single-shot opioid spinal analgesia after pancreatoduodenectomy remains understudied and lacks comparison to standard continuous thoracic epidural analgesia (TEA).Pancreatoduodenectomy patients who underwent TEA or opioid spinal for postoperative pain management from 2015 to 2020 were included in this observational cohort study. Primary outcome was patient-reported mean daily pain scores. Secondary outcomes included postoperative morphine milligram equivalents (MMEs) and length of stay (LOS). Multivariable linear regression models were constructed to compare risk-adjusted outcomes.180 patients were included: 56 TEA and 124 opioid spinal. Compared to epidural patients, opioid spinal patients were more likely to be older (67.0 vs. 64.6, p=0.045), have greater BMI (26.5 vs. 24.4, p=0.02), and less likely to be smokers (19.4% vs. 41.1%, p=0.002). Opioid spinal, compared to TEA, was associated with lower intraoperative MMEs (0.25 vs. 22.7, p0.001) and postoperative daily MMEs (7.9 vs. 10.3, p=0.03) on univariate analysis. However, after multivariable adjustment, there was no difference in average pain scores across the postoperative period (spinal vs. epidural: 4.18 vs. 4.14, p=0.93), daily MMEs (p=0.50), or LOS (p=0.23).There was no significant difference in postoperative pain scores, opioid use, or LOS between patients managed with TEA or opioid spinal after pancreatoduodenectomy.

Background Perioperative efficiency has been studied, although little is known about patient and personnel factors associated with a timely operating room start. We hypothesize that patient, personnel factors, and induction-order decisions are associated with anesthesia induction time. Methods An institutional database was used to identify the anesthesia induction time of adults undergoing first-start, elective operations from January 2014 to May 2017 at an academic quaternary care center. Data included patient demographics; surgeon and anesthesiologist, as well as their seniority (years since initial board certification); certified registered nurse anesthetist versus anesthesia resident staffing; and use of neuraxial anesthesia. Times were measured as minutes from scheduled start to induction. Univariate and multivariate analyses were performed to identify factors associated with induction time. Results We identified 15,823 cases. Predictors of later induction included add-on cases (1,224 cases were add-ons, 7.73%), American Society of Anesthesiologists classification ≥ 3, neuraxial anesthesia, and certified registered nurse anesthetist staffing. Surgeon seniority—but not gender—affected induction time. In 11,093 cases (70.1%), the anesthesiologist was scheduled for multiple first starts with a choice of which patient to induce first. Surgeon gender was predictive of induction order, with cases of male surgeons induced first more frequently than female surgeons’ (47.0% vs 44.1%, P = .02). Cases staffed by anesthesiology residents were more likely to be induced first compared with those staffed by certified registered nurse anesthetists (52.1% vs 41.5%, P Conclusion Patient and personnel factors affect the order of case induction, but induction time is most dependent on patient factors. Hospitals should focus on improving preparedness and limiting bias to create a more equitable and efficient perioperative process.

BACKGROUND Delayed initiation of adjuvant chemotherapy negatively impacts long-term survival in patients with colorectal cancer. Colorectal enhanced recovery protocols result in decreased complications and length of stay; however, the impact of enhanced recovery on the timing of adjuvant chemotherapy remains unknown. OBJECTIVE This study aimed to identify factors associated with on-time delivery of adjuvant chemotherapy after colorectal cancer surgery, hypothesizing that implementation of an enhanced recovery protocol would result in more patients receiving on-time chemotherapy. DESIGN This was a retrospective cohort study comparing the rate of on-time adjuvant chemotherapy delivery after colorectal cancer resection before and after implementation of an enhanced recovery protocol. SETTINGS The study was conducted at a large academic medical center. PATIENTS All of the patients who underwent nonemergent colorectal cancer resections for curative intent from January 2010 to June 2017, excluding patients who had no indication for adjuvant chemotherapy, had received preoperative systemic chemotherapy, or did not have medical oncology records available were included. MAIN OUTCOME MEASURES Patients before and enhanced recovery were compared, with the rate of on-time adjuvant chemotherapy delivery as the primary outcome. Adjuvant chemotherapy delivery was considered on time if initiated ≤8 weeks postoperatively, and treatment was considered delayed or omitted if initiated >8 weeks postoperatively (delayed) or never received (omitted). Multivariable logistic regression identified predictors of on-time chemotherapy delivery. RESULTS A total of 363 patients met inclusion criteria, with 189 patients (52.1%) undergoing surgery after enhanced recovery implementation. Groups differed in laparoscopic approach and median procedure duration, both of which were higher after enhanced recovery. Significantly more patients received on-time chemotherapy after enhanced recovery implementation (p = 0.007). Enhanced recovery was an independent predictor of on-time adjuvant chemotherapy (p = 0.014). LIMITATIONS The study was limited by its retrospective and nonrandomized before-and-after design. CONCLUSIONS Enhanced recovery was associated with receiving on-time adjuvant chemotherapy. As prompt initiation of adjuvant chemotherapy improves survival in colorectal cancer, future investigation of long-term oncologic outcomes is necessary to evaluate the potential impact of enhanced recovery on survival. See Video Abstract at http://links.lww.com/DCR/B21. LA IMPLEMENTACION DE UN PROTOCOLO DE RECUPERACION ACELERADA SE ASOCIA CON EL INICIO A TIEMPO DE QUIMIOTERAPIA ADYUVANTE EN CANCER COLORRECTAL:: El inicio tardio de la quimioterapia adyuvante afecta negativamente la supervivencia a largo plazo en pacientes con cancer colorrectal. Los protocolos de recuperacion acelerada colorrectales dan lugar a una disminucion de las complicaciones y la duracion de estancia hospitalaria; sin embargo, el impacto de la recuperacion acelerada en el momento de inicio de quimioterapia adyuvante sigue siendo desconocido.Este estudio tuvo como objetivo identificar los factores asociados con la administracion a tiempo de la quimioterapia adyuvante despues de la cirugia de cancer colorrectal, con la hipotesis de que la implementacion de un protocolo de recuperacion acelerada daria lugar a que mas pacientes reciban quimioterapia a tiempo.Estudio de cohorte retrospectivo que compara la tasa de administracion de quimioterapia adyuvante a tiempo despues de la reseccion del cancer colorrectal antes y despues de la implementacion de un protocolo de recuperacion acelerada.Centro medico academico grande.Todos los pacientes que se sometieron a resecciones de cancer colorrectal no emergentes con intencion curativa desde enero de 2010 hasta junio de 2017, excluyendo a los pacientes que no tenian indicacion de quimioterapia adyuvante, que recibieron quimioterapia sistemica preoperatoria o no tenian registros medicos de oncologia disponibles.Los pacientes se compararon antes y despues de la implementacion de la recuperacion acelerada, con la tasa de administracion de quimioterapia adyuvante a tiempo como el resultado primario. La administracion de quimioterapia adyuvante se considero a tiempo si se inicio ≤8 semanas despues de la operacion, y el tratamiento se considero retrasado / omitido si se inicio> 8 semanas despues de la operacion (retrasado) o nunca fue recibido (omitido). La regresion logistica multivariable identifico predictores de administracion de quimioterapia a tiempo.363 pacientes cumplieron con los criterios de inclusion, con 189 (52.1%) pacientes sometidos a cirugia despues de la implementacion de recuperacion acelerada. Los grupos difirieron en el abordaje laparoscopico y la duracion media del procedimiento; ambos factores fueron mayores despues de la recuperacion acelerada. Significativamente mas pacientes recibieron quimioterapia a tiempo despues de la implementacion de recuperacion acelerada (p = 0.007). La recuperacion acelerada fue un factor predictivo independiente de quimioterapia adyuvante a tiempo (p = 0.014).Diseno retrospectivo, tipo ¨antes y despues¨ no aleatorizado.La recuperacion acelerada se asocio con la recepcion de quimioterapia adyuvante a tiempo. Debido a que el inicio rapido de la quimioterapia adyuvante mejora la supervivencia en el cancer colorrectal, en el futuro sera necesario investigar los resultados oncologicos a largo plazo para evaluar el impacto potencial de la recuperacion acelerada en la supervivencia. Vea el Resumen en Video en http://links.lww.com/DCR/B21.

Background In North America, the prevalence of gastroesophageal reflux disorder ranges from 18.1% to 27.8%. We measured the risk posed by preoperative esophageal disease for patients undergoing abdominal operations. Method American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP; 2005-2015) data were merged with institutional clinical data repository records to identify esophageal disease in surgical patients undergoing intra-abdominal procedures. Patients with esophageal disease were classified as gastroesophageal reflux disorder (GERD) or other, which included patients with esophageal stricture, spasm, ulcer, or diverticuli, achalasia, esophagitis, reflux esophagitis, Barrett's esophagus, and multiple esophageal diagnoses, excluding GERD. ACS NSQIP–targeted procedure groups included were colectomy, proctectomy, ventral hernia repair, bariatric surgery, hepatectomy, appendectomy, abdominal aortic aneurysm repair, open aortoiliac repair, hysterectomy, myomectomy, and oophorectomy. Multivariable logistic regression was used to model postoperative complication rates, adjusting for ACS NSQIP risk of morbidity, demographic factors, ACS NSQIP–targeted procedure groups, and open versus laparoscopic surgery. Results Of 9172 intra-abdominal cases, 21.3% had preoperative esophageal disease (19.6% GERD and 1.7% other). After adjustment, patients with GERD were at higher risk for experiencing a number of complications, including all-cause 30-d complication (odds ratio [OR] = 1.21, 95% confidence interval [CI] 1.05-1.41, P = 0.044), renal complication (OR = 1.43, 95% CI 1.09-1.87, P = 0.036), wound complication (OR = 1.40, 95% CI 1.10-1.79, P = 0.028), and readmission within 30 d (OR = 1.66, 95% CI 1.35-2.04, P Conclusions Preoperative GERD is associated with increased postoperative complication rate. Surgeons should consider assessing GERD in patients undergoing abdominal operations.

This study aims to test associations between perioperative blood transfusion and postoperative morbidity and mortality after major abdominal operations.The 2014 ACS NSQIP dataset was queried for all patients who underwent one of the ten major abdominal operations. Separate multivariable regression models, were developed to evaluate the independent effects of perioperative blood transfusion on morbidity and mortality.Of 48,854 patients in the study cohort, 4887 (10%) received a blood transfusion. Rates of transfusion ranged from 4% for laparoscopic gastrointestinal resection to 58% for open AAA. After adjusting for significant effects of NSQIP-estimated probabilities, transfusion was independently associated with morbidity and mortality after open AAA repair (OR = 1.99/14.4 respectively, p ≤ 0.010), esophagectomy (OR = 2.80/3.0, p 0.001), pancreatectomy (OR = 1.88/3.01, p 0.001), hepatectomy (OR = 2.82/5.78, p 0.001), colectomy (OR = 2.15/3.17, p 0.001), small bowel resection (OR = 2.81/3.83, p ≤ 0.004), and laparoscopic gastrointestinal operations (OR = 2.73/4.05, p 0.001).Perioperative blood transfusion is independently associated with an increased risk of morbidity and mortality after most major abdominal operations.

Estimating surgeon-level value in health care remains relatively unexplored. American College of Surgeons National Surgical Quality Improvement Program Participant Use Files (2005-2013) were linked with total costs at a single institution. Random intercepts in 3-level random effects logistic regression models predicted 30-day postoperative mortality or morbidity for each surgeon each year. Value was defined as quality (morbidity or mortality) divided by costs for surgeons performing general surgery and vascular procedures. Forty-four surgeons performed 11 965 surgeries. Risk-adjusted costs trended down over time. For all surgeries, mortality value increased by 3.27 per year (95% confidence interval = 2.54-4.01; P < .001) on a 100-point scale, while morbidity value did not change. Of 21 surgeons with data for 5 years or longer, mortality value increased for all surgeons except one. Continuous increase in complication rates from 2008 contributed to decreased morbidity value. Value may assist surgeons in exploring performance opportunities better than morbidity or mortality alone.

BACKGROUND: Surgical site infection is a frequent cause of morbidity after colorectal resection, and is a quality measure for hospitals and surgeons. In an effort to reduce the risk of postoperative infections, many wounds are left open at the time of surgery for secondary or delayed primary wound closure. OBJECTIVE: Evaluate the impact of delayed wound closure on the rate of surgical infections and resource utilization. DESIGN: This retrospective propensity matched study compared colorectal surgery patients with wounds left open with a cohort of patients with primary skin closure. SETTINGS: The American College of Surgeons National Quality Improvement Program Participant Use file for 2014 was queried. PATIENTS: 50,212 patients who underwent elective or emergent colectomy, proctectomy, and stoma creation were included. MAIN OUTCOME MEASURES: Rates of postoperative infections and discharge to medical facilities. RESULTS: Surgical wounds were left open in 2.9% of colorectal cases (n=1,466). Patients with skin left open were broadly higher-risk, as evident by a significantly higher median estimated probability of 30-day mortality (3.4% vs 0.45%, p0.05). Resource utilization was higher for patients with incisions left open including longer length of stay (11 vs 10 days, p=0.006) and higher rates of discharge to a facility (34% vs 27%, p

BACKGROUND: Despite technical advances, bile leak remains a significant complication after hepatectomy. The current study uses a targeted multi-institutional dataset to characterize perioperative factors that are associated with bile leakage after hepatectomy and to better understand the impact of bile leak on morbidity and mortality. METHODS: Adult patients in the 2014–2015 ACS NSQIP targeted hepatectomy dataset were linked to the ACS NSQIP PUF dataset. Bivariable and multivariable regression analyses were used to assess the associations between clinical factors and post-hepatectomy bile leak. RESULTS: Of 6,859 patients, 530 (7.7%) had a postoperative bile leak. Proportion of bile leaks was significantly higher in patients after major compared to minor hepatectomy (12.6% vs 5.1%, p

Prior studies have demonstrated a reoperation rate ranging from 5.8 to 7.6% following colorectal surgery. However, the indications for reoperation have not been extensively evaluated. We aimed to describe the indications for reoperation and associated procedures following colorectal resection. This is a retrospective cohort study of all patients undergoing colorectal resection at a single institution from 2003 to 2013. For patients who returned to the operating room, the primary indication was categorized into mutually exclusive categories and all procedures performed within 30 days of the initial operation were indexed. Univariate and multivariate analyses were performed. We identified 2793 patients who underwent colorectal operations, of which 407 (14.6%) were emergent. A total of 178 (6.7%) patients returned to the operating room. On multivariate analysis, emergent operation, malnutrition, corticosteroid use, and operative duration were independently associated with reoperation; independent functional status was protective. The most common indications for reoperation were anastomotic leak and bowel obstruction. The most common procedures performed were ostomy creation, bowel resection, and adhesiolysis. Reoperation after colorectal surgery is a relatively common occurrence for which we have identified the risk factors, most common indications, and specific procedures performed. This knowledge will help identify areas for improvement.

BACKGROUND: Independent associations between chronic liver disease, MELD, and postoperative outcomes among patients selected for liver resection have not been completely established. We hypothesized independent associations between MELD, cirrhosis, and postoperative mortality. METHODS: Patient-level data from the targeted hepatectomy module and ACS NSQIP PUF during 2014–2015 were merged. Multivariable regression models with interaction effect between MELD and liver texture (normal vs congested/fatty vs cirrhotic) tested the independent effects of covariates on mortality and morbidity. RESULTS: 3,530 patients were included, of whom 668 patients (19%) had cirrhosis. ACS NSQIP defined mortality (3.9%vs1.1%) and morbidity (23.5%vs15.8%) were higher in patients with cirrhosis (both p

Monitoring and prevention of long-term nutrient deficiency after laparoscopic Roux-en-Y gastric bypass (LRYGB) remains ill defined due to limited surgical follow-up after bariatric surgery. This study compared nutrient supplementation as well as surgeon and primary care physician (PCP) follow-up between patients with short-term versus long-term follow-up. All patients undergoing LRYGB at a single institution in 2004 (long-term group, n = 281) and 2012–2013 (short-term group, n = 149) were evaluated. Prospectively collected database, electronic medical record (EMR) review and telephone survey were used to obtained follow-up for both cohorts. Multivariate logistic regression was used to assess factors independently predicting multivitamin use. Complete follow-up was achieved in 172 (61 %) long-term and 107 (72 %) short-term patients. We demonstrate a significant difference (p

The Hospital Value-Based Purchasing Program measures value of care provided by participating Medicare hospitals and creates financial incentives for quality improvement and fosters increased transparency. Limited information is available comparing hospital performance across health care business models.The 2015 Hospital Value-Based Purchasing Program results were used to examine hospital performance by business model. General linear modeling assessed differences in mean total performance score, hospital case mix index, and differences after adjustment for differences in hospital case mix index.Of 3,089 hospitals with total performance scores, categories of representative health care business models included 104 physician-owned surgical hospitals, 111 University HealthSystem Consortium, 14 US NewsWorld Report Honor Roll hospitals, 33 Kaiser Permanente, and 124 Pioneer accountable care organization affiliated hospitals. Estimated mean total performance scores for physician-owned surgical hospitals (64.4; 95% CI, 61.83-66.38) and Kaiser Permanente (60.79; 95% CI, 56.56-65.03) were significantly higher compared with all remaining hospitals, and University HealthSystem Consortium members (36.8; 95% CI, 34.51-39.17) performed below the mean (p0.0001). Significant differences in mean hospital case mix index included physician-owned surgical hospitals (mean 2.32; p0.0001), US NewsWorld Report honorees (mean 2.24; p = 0.0140), and University HealthSystem Consortium members (mean 1.99; p0.0001), and Kaiser Permanente hospitals had lower case mix value (mean 1.54; p0.0001). Re-estimation of total performance scores did not change the original results after adjustment for differences in hospital case mix index.The Hospital Value-Based Purchasing Program revealed superior hospital performance associated with business model. Closer inspection of high-value hospitals can guide value improvement and policy-making decisions for all Medicare Value-Based Purchasing Program Hospitals.

Morbidity after gastrectomy remains high. The potentially modifiable risk factors have not been well described. This study considers a series of potentially modifiable patient-specific and perioperative characteristics that could be considered to reduce morbidity and mortality after gastrectomy.This retrospective cohort study includes adults in the ACS NSQIP PUF dataset who underwent gastrectomy between 2011 and 2013. Sequential multivariable models were used to estimate effects of clinical covariates on study outcomes including morbidity, mortality, readmission, and reoperation.Three thousand six hundred and seventy-eight patients underwent gastrectomy. A majority of patients had distal gastrectomy (N = 2,799, 76.1 %) and had resection for malignancy (N = 2,316, 63.0 %). Seven hundred and ninety-eight patients (21.7 %) experienced a major complication. Reoperation was required in 290 patients (7.9 %). Thirty-day mortality was 5.2 %. Age (OR = 1.01, 95 % CI = 1.01-1.02, p = 0.001), preoperative malnutrition (OR = 1.65, 95 % CI = 1.35-2.02, p 0.001), total gastrectomy (OR = 1.63, 95 % CI = 1.31-2.03, p 0.001), benign indication for resection (OR = 1.60, 95 % CI = 1.29-1.97, p 0.001), blood transfusion (OR = 2.57, 95 % CI = 2.10-3.13, p 0.001), and intraoperative placement of a feeding tubes (OR = 1.28, 95 % CI = 1.00-1.62, p = 0.047) were independently associated with increased risk of morbidity. Association between tobacco use and morbidity was statistically marginal (OR = 1.23, 95 % CI = 0.99-1.53, p = 0.064). All-cause postoperative morbidity had significant associations with reoperation, readmission, and mortality (all p 0.001).Mitigation of perioperative risk factors including smoking and malnutrition as well as identified operative considerations may improve outcomes after gastrectomy. Postoperative morbidity has the strongest association with other measures of poor outcome: reoperation, readmission, and mortality.

Roux-en-Y Gastric Bypass (RYGB) is well known to ameliorate type 2 diabetes mellitus (T2DM), and recent work suggests that the preoperative DiaREM model predicts successful remission up to 1 year post-RYGB. However, no data exist for long-term validity. Therefore, we sought to determine the utility of this score on long-term RYGB effectiveness for T2DM resolution at 2 and 10 years, respectively. T2DM patients (Age: 48, BMI: 49, HbA1C: 8.1) undergoing RYGB at the University of Virginia between 2004–2006 (n = 42) and 2012–2014 (n = 59) were evaluated prospectively to assess preoperative DiaREM score, defined from insulin use, age, HbA1C, and type of antidiabetic medication. T2DM partial remission status was based on the American Diabetes Association guidelines (HbA1C

Background Safety of pancreaticoduodenectomy has improved significantly in the past 3 decades. Current inpatient and 30-d mortality rates are low. However, incidence and causes of 90-d and 1-y mortality are poorly defined and largely unexplored. Methods All patients who had pancreaticoduodenectomy between 2007 and 2016 were included in this single institution, retrospective cohort study. Distributions of pancreaticoduodenectomy-specific morbidity and cause-specific mortality were compared between early (within 90 d) and late (91-365 d) postoperative recovery periods. Results A total of 551 pancreaticoduodenectomies were performed during the study period. Of these, 6 (1.1%), 20 (3.6%), and 91 (16.5%) patients died within 30, 90, and 365 d after pancreaticoduodenectomy, respectively. Causes of early and late mortality varied significantly (all P ≤ 0.032). The most common cause of death within 90 d was due to multisystem organ failure from sepsis or aspiration in 9 (45%) patients, followed by post-pancreatectomy hemorrhage in 5 (25%) patients, and cardiopulmonary arrest from myocardial infarction or pulmonary embolus in 3 (15%) patients. In contrast, recurrent cancer was the most common cause of death in 46 (65%) patients during the late postoperative period between 91 and 365 d. Mortality from failure to thrive and debility was similar between early and late postoperative periods (15% versus 19.7%, P = 0.76). Conclusions Most quality improvement initiatives in patients selected for pancreaticoduodenectomy have focused on reduction of technical complications and improvement of early postoperative mortality. Further reduction in postoperative mortality after pancreaticoduodenectomy can be achieved by improving patient selection, mitigating postoperative malnutrition, and optimizing preoperative cancer staging and management strategies.

Objective The purpose of this study is to determine if patient selection varies based on years of surgical practice. Background The impact of hospital and surgeon volume as a marker of experience has demonstrated an inverse association with surgical outcomes. However, temporal measures of experience often demonstrate no effect. Additionally, a self-reporting survey demonstrated decreasing case complexity over time, suggesting that changes in patient selection may account for some of these observed discrepancies. Methods General surgery cases at a single tertiary care center reported to the American College of Surgeons National Surgical Quality Improvement Program over a 10-year period were identified. Additionally general surgery cases from the ACS NSQIP 2008 PUF data were used to create risk models for any complications, 30-day mortality, or a composite complication or mortality outcome. These models then estimated risk for our local data. Years of experience after American Board of Surgery certification were calculated for each surgeon for each case. Multivariate linear regression, controlling for surgeon clustering, was used to determine the association between years of surgical experience and preoperative risk of complications and mortality. Results Eighteen thousand six hundred and eighty eight cases were identified from our institution. Surgeons selected patients of increasing operative risk until 15 years of practice before selecting lower risk patients throughout the rest of their career. After adjusting for risk, no association was observed between years from board certification and mortality. However, there was a trend toward decreasing complication rates with increasing experience. Conclusions Surgical experience significantly impacts patient selection. Surgeons with over 25 years of experience had lower complication rates. Experience had no impact on mortality.

Objective To develop a research productivity scoring program within an academic department of surgery that would help realign incentives to encourage and reward research. Although research is highly valued in the academic mission, financial incentives are generally aligned to reward clinical productivity. Methods A formula assigning points for publications and extramural grants was created and used to award a research incentive payment proportional to the research productivity score, beginning July 2007. Publication points reflect journal impact factor, author role, and manuscript type. Grant points reflect total funding and percentage of effort. Publication data were gathered from Web of Science/PubMed/Medline and grants data from the departmental grants office. An annual award is presented to the person with the greatest improvement. The research productivity score data after July 2007 were compared with control data for the 2 preceding years. A 33-question survey to 28 clinical faculty was conducted after the first year to measure satisfaction and solicit constructive feedback. Results The mean annual point scores increased from the preresearch productivity score to the postresearch productivity score academic years (2180 vs 3389, respectively, P = .08), with a significant change in the grant component score (272 vs 801, P = .03). Since research productivity score implementation, the operative case volumes increased 4.3% from 2006 to 2011. With a response rate of 89%, the survey indicated that 76% of the faculty wished to devote more time to research and 52% believed 1 or more research-related behaviors would change because of the research productivity score program. Conclusions An objective, transparent research incentive program, through both monetary incentives and recognition, can stimulate productivity and was well-received by faculty.

BACKGROUND:Pancreatic fistula remains a morbid complication after pancreatectomy. Since the proposed mechanism of pancreatic fistula is different between pancreaticoduodenectomy and distal pancreatectomy, we hypothesized that pancreatic gland texture and duct size are not associated with pancreatic fistula after distal pancreatectomy. METHODS:All patients ≥18 years in the 2014-15 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) targeted pancreatectomy dataset were linked with the ACS NSQIP Public Use File (PUF). Pancreatic duct size (6 mm) and pancreatic gland texture (hard, intermediate, soft) were categorized. Separate multivariable analyses were performed to evaluate associations between pancreatic duct size and gland texture after pancreaticoduodenectomy and distal pancreatectomy. RESULTS:A total of 9366 patients underwent pancreaticoduodenectomy or distal pancreatectomy during the study period. Proportion of pancreatic fistula was similar after distal pancreatectomy (606 of 3132, 19.4%) and pancreaticoduodenectomy (1163 of 6335, 18.4%, p = 0.245). Both pancreatic gland texture and duct size were significantly associated with pancreatic fistula after pancreaticoduodenectomy (p

Background Previous studies have indicated that blood transfusion is associated with increased risk of worse outcomes among patients selected for hepatectomy. However, the independent effect of transfusion has not been confirmed. We hypothesize that blood transfusion is an independent factor that affects outcomes in patients undergoing hepatectomy. Materials and methods Patients at tertiary care center who underwent hepatectomy between 2006 and 2013 were identified and linked with the American College of Surgeons National Surgical Quality Improvement Program PUF data set. Multivariable logistic regression analysis was used to estimate the effect of blood transfusion on 30-d mortality and morbidity, adjusted for differences in extent of resection and estimated probabilities of morbidity and mortality. Results Among 522 patients in the study, 48 (9.2%) patients required perioperative blood transfusion within 72 h of resection, and 172 (33%) underwent major hepatectomy. Indications for hepatectomy included metastatic neoplasm ( n = 229, 44%), primary hepatic neoplasm ( n = 108, 21%), primary extra-hepatic biliary neoplasm ( n = 23, 4%), and nonmalignant indications ( n = 162, 31%). Eighty-eight (17%) patients had a postoperative morbidity. Blood transfusion was significantly associated with postoperative morbidity (odds ratio [OR] = 4.18, 95% CI = 2.18-8.02, P = 0.0001) and mortality (OR = 14.5, 95% CI = 3.08-67.8, P = 001), after adjustment for the concurrent effect of National Surgical Quality Improvement Program estimated probability of morbidity (OR = 1.15, 95% CI = 0.11-12.2, P = 0.042). The extent of resection was not significantly associated with morbidity (OR = 1.30, 95% CI, 0.74-2.28, P = 0.366) or mortality (OR = 1.14, 95% CI = 0.24-5.50, P = 0.870). Conclusions Blood transfusion is a highly statistically significant independent predictor of morbidity and mortality after hepatectomy. Judicious use of perioperative transfusion is indicated in patients with benign and malignant indications for liver resection.

Background The long-term durability of Roux-en-Y gastric bypass (RYGB) remains ill-defined in the American population secondary to poor follow-up after bariatric surgery. Objectives This study evaluated the population lost to follow-up to better define the long-term durability of RYGB for weight loss and co-morbidity amelioration. Methods All patients (n = 1087) undergoing RYGB at a single institution between 1985 and 2004 were evaluated. Univariate differences in preoperative co-morbidities, postoperative complications, annual weight loss, and 10-year co-morbidities were analyzed to compare outcomes between patients with routine follow-up and those without. Using electronic medical record review for all encounters at our academic medical center and telephone survey, we obtained data for patients lost to follow-up. Results Among 1087 RYGB patients, 151 (14%) had consistent 10-year follow-up in our prospectively collected database, with yearly clinic visits beyond 2 years postoperatively. Electronic medical record review and telephone survey data were collected on an additional 500 (46%) patients, resulting in 60% of patients having 10-year follow-up after RYGB. There was no statistical difference in any preoperative or postoperative variables between the 2 groups. We found no difference in co-morbidity prevalence preoperatively or at 10 years between groups. Examination of percent excess body mass index lost at yearly intervals revealed no difference between the groups at each interval up to 10 years ( P = .36). Conclusion We found no difference in 10-year outcomes, including weight loss and co-morbidity reduction, between patients with routine clinic visits and those lost to follow-up. These 10-year data address the gap in knowledge resulting from poor long-term follow-up after bariatric surgery.

Authors of recent studies have championed the importance of maintaining cerebral perfusion pressure (CPP) to prevent secondary brain injury following traumatic head injury. Data from these studies have provided little information regarding outcome following severe head injury in patients with an intracranial pressure (ICP) greater than 40 mm Hg, however, in July 1997 the authors instituted a protocol for the management of severe head injury in patients with a Glasgow Coma Scale score lower than 9. The protocol was focused on resuscitation from acidosis, maintenance of a CPP greater than 60 mm Hg through whatever means necessary as well as elevation of the head of the bed, mannitol infusion, and ventriculostomy with cerebrospinal fluid drainage for control of ICP. Since the institution of this protocol, nine patients had a sustained ICP greater than 40 mm Hg for 2 or more hours, and five of these had an ICP greater than 75 mm Hg on insertion of the ICP monitor and later experienced herniation and expired within 24 hours. Because of the severe nature of the injuries demonstrated on computerized tomography scans and their physical examinations, these patients were not aggressively treated under this protocol. The authors vigorously attempted to maintain a CPP greater than 60 mm Hg with intensive fluid resuscitation and the administration of pressor agents in the four remaining patients who had developed an ICP higher than 40 mm Hg after placement of the ICP monitor. Two patients had an episodic ICP greater than 40 mm Hg for more than 36 hours, the third patient had an episodic ICP greater than of 50 mm Hg for more than 36 hours, and the fourth patient had an episodic ICP greater than 50 mm Hg for more than 48 hours. On discharge, all four patients were able to perform normal activities of daily living with minimal assistance and experience ongoing improvement. Data from this preliminary study indicate that intense, aggressive management of CPP can lead to good neurological outcomes despite extremely high ICP. Aggressive CPP therapy should be performed and maintained even though apparently lethal ICP levels may be present. Further study is needed to support these encouraging results.

Given the current climate of outcomes-driven quality reporting, it is critical to appropriately risk stratify patients using standardized metrics.To elucidate the risk associated with urgent surgery on complications and mortality after general surgical procedures.This retrospective review used the American College of Surgeons National Surgery Quality Improvement Program database to capture all general surgery cases performed at 435 hospitals nationwide between January 1, 2013, and December 31, 2013. Data analysis was performed from November 11, 2015, to February 16, 2017.Any operations coded as both nonelective and nonemergency were designated into a novel category titled urgent.The primary outcome was 30-day mortality; secondary outcomes included 30-day rates of complications, reoperation, and readmission in urgent cases compared with both elective and emergency cases.Of 173 643 patients undergoing general surgery (101 632 females and 72 011 males), 130 235 (75.0%) were categorized as elective, 22 592 (13.0%) as emergency, and 20 816 (12.0%) as nonelective and nonemergency. When controlling for standard American College of Surgeons National Surgery Quality Improvement Program preoperative risk factors, with elective surgery as the reference value, the 3 groups had significantly distinct odds ratios (ORs) of experiencing any complication (urgent surgery: OR, 1.38; 95% CI, 1.30-1.45; P .001; and emergency surgery: OR, 1.65; 95% CI, 1.55-1.76; P .001) and of mortality (urgent surgery: OR, 2.32; 95% CI, 2.00-2.68; P .001; and emergency surgery: OR, 2.91; 95% CI, 2.48-3.41; P .001). Surgical procedures performed urgently had a 12.3% rate of morbidity (n = 2560) and a 2.3% rate of mortality (n = 471).This study highlights the need for improved risk stratification on the basis of urgency because operations performed urgently have distinct rates of morbidity and mortality compared with procedures performed either electively or emergently. Because we tie quality outcomes to reimbursement, such a category should improve predictive models and more accurately reflect the quality and value of care provided by surgeons who do not have traditional elective practices.

To examine the relationship between body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) and 30-day mortality risk among patients in the participant use data file database of the American College of Surgeons National Surgical Quality Improvement Program. Obesity is a prevalent chronic disease in the United States, and general and vascular surgeons are caring for an increasing population of obese patients.Multivariable logistic regression analysis was used to assess the statistical significance of the relationship between BMI and mortality, with adjustments for patient-level differences in overall mortality risk and principal operating procedures. Odds ratios with 95% CIs were calculated to measure the relative difference in mortality by BMI quintile, with reference to the middle quintile of the BMI. The overall significance of the BMI and of the other covariates was measured using the Wald χ(2) test statistic. A separate multivariable logistic regression model was developed to assess the significance of the interaction between BMI and primary procedure.A total of 183 sites.Patients with major surgical procedures reported in the participant use data file database of the American College of Surgeons National Surgical Quality Improvement Program.The data included 189 533 cases of general and vascular surgical procedures reported in 2005 and 2006 for patients with known overall probabilities of death. Among these, 3245 patients died within 30 days of their surgery (1.7%). Patients with a BMI of less than 23.1 demonstrated a significant increased risk of death, with 40% higher odds compared with patients in the middle range for BMI (26.3 to29.7). Important differences in the association between BMI and mortality risk occur by type of primary procedure.Body mass index is a significant predictor of mortality within 30 days of surgery, even after adjusting for the contribution to mortality risk made by type of surgery and for a specific patient's overall expected risk of death.