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Background Quality measurement has become a priority for national healthcare reform, and valid measures are necessary to discriminate hospital performance and support value‐based healthcare delivery. The Commission on Cancer (CoC) is the largest cancer‐specific accreditor of hospital quality in the United States and has implemented Quality of Care Measures to evaluate cancer care delivery. However, none has been formally tested as a valid metric for assessing hospital performance based on actual patient outcomes. Methods Eligibility and compliance with the Quality of Care Measures are reported within the National Cancer Database, which also captures data for robust patient‐level risk adjustment. Hospital‐level compliance was calculated for the core measures, and the association with patient survival was tested using Cox regression. Results Seven hundred sixty‐eight thousand nine hundred sixty‐nine unique cancer cases were included from 1323 facilities. Increasing hospital‐level compliance was associated with improved survival for only two measures, including a 35% reduced risk of mortality for the gastric cancer measure G15RLN (HR 0.65, 95% CI 0.58–0.72) and a 19% reduced risk of mortality for the colon cancer measure 12RLN (HR 0.81, 95% CI 0.77–0.85). For the lung cancer measure LNoSurg, increasing compliance was paradoxically associated with an increased risk of mortality (HR 1.14, 95% CI 1.08–1.20). For the remaining measures, hospital‐level compliance demonstrated no consistent association with patient survival. Conclusion Hospital‐level compliance with the CoC’s Quality of Care Measures is not uniformly aligned with patient survival. In their current form, these measures do not reliably discriminate hospital performance and are limited as a tool for value‐based healthcare delivery., The Commission on Cancer is the largest cancer‐specific accreditor of hospital quality in the United States and has implemented Quality of Care Measures to evaluate quality cancer care delivery. This study represents the first comprehensive evaluation of the Quality of Care Measures as valid metrics for assessing hospital performance based on actual patient outcomes.

Reduced surgical site infection (SSI) rates have been reported with use of closed incision negative pressure therapy (ciNPT) in high-risk patients.A deep learning-based, risk-based prediction model was developed from a large national database of 72,435 patients who received infrainguinal vascular surgeries involving upper thigh/groin incisions. Patient demographics, histories, laboratory values, and other variables were inputs to the multilayered, adaptive model. The model was then retrospectively applied to a prospectively tracked single hospital data set of 370 similar patients undergoing vascular surgery, with ciNPT or control dressings applied over the closed incision at the surgeon's discretion. Objective predictive risk scores were generated for each patient and used to categorize patients as "high" or "low" predicted risk for SSI.Actual institutional cohort SSI rates were 10/148 (6.8%) and 28/134 (20.9%) for high-risk ciNPT versus control, respectively (P 0.001), and 3/31 (9.7%) and 5/57 (8.8%) for low-risk ciNPT versus control, respectively (P = 0.99). Application of the model to the institutional cohort suggested that 205/370 (55.4%) patients were matched with their appropriate intervention over closed surgical incision (high risk with ciNPT or low risk with control), and 165/370 (44.6%) were inappropriately matched. With the model applied to the cohort, the predicted SSI rate with perfect utilization would be 27/370 (7.3%), versus 12.4% actual rate, with estimated cost savings of $231-$458 per patient.Compared with a subjective practice strategy, an objective risk-based strategy using prediction software may be associated with superior results in optimizing SSI rates and costs after vascular surgery.

Due to conflicting study results on the effect of laterality on overall survival in primary colon cancers, we sought to examine the impact of left compared to right-sided primary tumors on overall survival for stage I–III colon cancer using the largest dataset to date. The 2006–2013 NCDB was queried for patients with single primary, stage I–III colon adenocarcinoma and grouped by stage and tumor location. For stage I–II tumors, 114,839 patients had resection (62% right:38% left). After adjustment, patients with right-sided tumors had superior survival ([HR right as reference]: 1.13, 95% CI 1.09–1.17, p

BACKGROUND Although surgery remains the cornerstone of gastric cancer therapy, the use of radiation therapy (RT) is increasingly being employed to optimize outcomes. We sought to assess outcomes following use of RT for the treatment of gastric adenocarcinoma. METHODS Using the National Cancer Data Base (NCDB) from 1998 to 2012, all patients with resected gastric adenocarcinoma were identified. Patients were stratified into four groups based on preoperative therapy: RT alone, chemotherapy only, chemoradiotherapy (CRT), and no preoperative therapy. Overall survival was estimated using multivariate Cox proportional hazards model. Adjusted secondary outcomes include margin positivity, lymph node harvest, LOS, 30-day readmission and mortality. RESULTS A total of 10 019 patients met study criteria. In the unadjusted analysis, patients undergoing CRT compared to chemotherapy alone had fewer positive margins (7.9% vs 15.9%; P

Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare tumor in children, with current evidence limited to single-center studies. We examined treatment and clinical outcomes for pediatric and adult SPN with a national data set.The 2004 to 2013 National Cancer Data Base was queried to identify all patients diagnosed with SPN. The cohort was stratified by age (pediatric and adult) defined as below 18 years and 18 years and above, respectively. Baseline characteristics and unadjusted outcomes were compared.We identified 21 pediatric and 348 adult patients with SPN. Both groups displayed similar demographic composition. Patients were commonly female (90.5% [pediatric] vs. 85.9% [adult], P=0.56) and white (66.7% vs. 68.3%, P=0.74). Tumor location was similar between adults and children. Median tumor size was similar between children and adults (5.9 vs. 4.9 cm, P=0.41). Treatment strategies did not vary between groups. Partial pancreatectomy was the most common resection strategy (71.4% vs. 53.1%, P=0.80). Both groups experienced low mortality (0.0% vs. 0.7% at 5 y, P=0.31).This study provides the largest comparison of pediatric and adult SPN to date. Children with SPN have similar disease severity at presentation, receive similar treatments, and demonstrate equivalent postoperative outcomes compared with their adult counterparts.

Adjuvant chemotherapy after resection is the standard of care for stage III colon cancer, yet many patients omit chemotherapy. We aimed to describe the impact of delayed chemotherapy on overall survival across multiple time points.The 2006 to 2014 National Cancer Data Base (NCDB) was queried for patients with single primary stage III adenocarcinoma of the colon. Patients were grouped by receipt and timing of chemotherapy from resection date: chemotherapy omitted,6 weeks, 6 to 8 weeks, 8 to 12 weeks, 12 to 24 weeks, and24 weeks. Subgroup analyses were performed for those with comorbidities and those who had postoperative complications. Overall survival was compared using Cox proportional hazard modeling, adjusting for patient, tumor, and facility characteristics.In total, 72,057 patients were included; 20,807 omitted chemotherapy, 22,705 received it at6 weeks, 15,412 between 6 and 8 weeks, 9,049 between 8 and 12 weeks, 3,595 between 12 and 24 weeks, and 489 at24 weeks after resection. Compared with patients who omitted chemotherapy, patients who received chemotherapy at6 weeks (hazard ratio [HR] 0.44), 6 to 8 weeks (HR 0.45), 8 to 12 weeks (HR 0.52), 12 to 24 weeks (HR 0.61), and24 weeks (HR 0.68) had superior overall survival (p0.001). This survival benefit was preserved across subgroups (p0.001).After resection of stage III colon cancer, patients should receive adjuvant chemotherapy within 6 to 8 weeks for maximal benefit. However, chemotherapy should be offered to patients who are outside the optimal window, who have significant comorbidities, or who have had a complication more than 24 weeks from resection to improve the overall survival compared with omitting chemotherapy.

Background Our study compares 30-day vs. 90-day mortality following colorectal cancer surgery (CRS), and examines hospital performance ranking based on this assessment. Methods Mortality rates were compared between 30 vs. 90 days following CRS for patients with stage I-III colorectal cancers from the National Cancer Database (2004–2012). Risk-adjusted hierarchical regression models evaluated hospital performance based on mortality. Hospitals were ranked into top (10%), middle (80%), and lowest (10%) performance groups. Results Among 185,464 patients, 90-day mortality was nearly double the 30-day mortality (4.4% vs. 2.5%). Following risk adjustment 176 hospitals changed performance ranking: 39% in the top 30-day mortality group changed ranking to the middle group; 37% of hospitals in the lowest 30-day group changed ranking to the middle 90-day group. Conclusions Evaluation of hospital performance based on 30-day mortality is associated with misclassification for 15% of hospitals. Ninety-day mortality may be a better quality metric in oncologic CRS.

Aim To examine the overall survival differences of neoadjuvant therapy modalities: no therapy, chemotherapy alone, radiation alone, and chemoradiation in a large cohort of patients with locally advanced rectal cancer. Method Adults with clinical stage II and III rectal adenocarcinoma were selected from the National Cancer Database and grouped by type of neoadjuvant therapies received: no therapy, chemotherapy only, radiotherapy only, or chemoradiation. Multivariable regression methods were used to compare adjusted differences in perioperative outcomes and overall survival. Results Among 32978 patients included, 9714 (29.5%) received no neoadjuvant therapy, 890 (2.7%) chemotherapy only, 1170 (3.5%) radiotherapy only, and 21204 (64.3%) chemoradiation. Compared to no therapy, chemotherapy or radiotherapy alone was not associated with any adjusted differences in surgical margin positivity, permanent colostomy rate, or overall survival (all p > 0.05). With adjustment, neoadjuvant chemoradiation vs. no therapy was associated with a lower likelihood of surgical margin positivity (OR 0.74, p < 0.001), decreased rate of permanent colostomy (OR 0.77, p < 0.001), and overall survival (HR 0.79, p < 0.001). When compared to chemotherapy or radiotherapy alone, chemoradiation remain associated with improved overall survival (vs. chemotherapy alone: HR 0.83, p = 0.04; vs. radiotherapy alone: HR 0.83, p < 0.019). Conclusions Neoadjuvant chemoradiation, not chemotherapy or radiotherapy alone, is important for sphincter preservation, R0 resection, and survival for patients with locally advanced rectal cancer. Despite this finding, one-third of patients in the United States with locally advanced rectal cancer fail to receive stage-appropriate chemoradiation. This article is protected by copyright. All rights reserved.

This study compares outcomes following pancreaticoduodenectomy (PD) for patients treated at local, low-volume centers and those traveling to high-volume centers.Although outcomes for PD are superior at high-volume institutions, not all patients live in proximity to major medical centers. Theoretical advantages for undergoing surgery locally exist.The 1998 to 2012 National Cancer Data Base was queried for T1-3N0-1M0 pancreatic adenocarcinoma patients who underwent PD. Travel distances to treatment centers were calculated. Overlaying the upper and lower quartiles of travel distance with institutional volume established short travel/low-volume (ST/LV) and long travel/high-volume (LT/HV) cohorts. Overall survival was evaluated.Of 7086 patients, 773 ST/LV patients traveled ≤6.3 (median 3.2) miles to centers performing ≤3.3 PDs yearly, and 758 LT/HV patients traveled ≥45 (median 97.3) miles to centers performing ≥16 PDs yearly. LT/HV patients had higher stage disease (P0.001), but lower margin positivity (20.5% vs 25.9%, P = 0.01) and improved lymphadenectomy (16 vs 11 nodes, P0.01). Moreover, LT/HV patients had shorter hospitalizations (9 vs 12 days, P0.01) and lower 30-day mortality (2.0% vs 6.3%, P0.01) with similar 30-day readmission rates (10.1% vs 9.8%, P = 0.83). Despite more advanced disease, LT/HV patients had superior unadjusted survival (20.3 vs 15.7 months). After adjustment, travel to a high-volume center remained associated with reduced long-term mortality (hazard ratio 0.75, P0.01).Despite an increased travel burden, patients treated at high-volume centers had improved perioperative outcomes, short-term mortality, and overall survival. These data support ongoing efforts to centralize care for patients undergoing PD.

OBJECTIVES The purpose of this study was to determine the optimal timing of surgical resection of oesophageal adenocarcinoma following neoadjuvant chemoradiotherapy (nCRT). METHODS nCRT before resection of oesophageal adenocarcinoma yields improved overall and progression-free survival. Despite the wide acceptance of tri-modal therapy, the optimal timing of surgical resection after nCRT is not well defined and existing studies are limited. Adults with Stage II/III oesophageal adenocarcinoma undergoing nCRT before surgery were identified from the National Cancer Database. Multivariable analysis using restricted cubic splines was used to identify an inflection point in clinical outcomes as a function of time between nCRT and surgery, dividing the cohort into short- and long-interval treatment groups, which were then compared. Adjusted rates of survival and margin status were compared between groups using multivariable analysis. RESULTS Among 2444 patients, restricted cubic splines identified an inflection point at 56 days, dividing our cohort into 1533 short-interval and 911 long-interval patients. Long-interval patients had a higher adjusted incidence of pathologic downstaging (odds ratio 1.38, confidence interval 1.02-1.85, P = 0.04) but no difference in margin positivity compared with short-interval patients (odds ratio 0.91, confidence interval 0.56-1.47, P = 0.69). Worse overall survival was noted in the long-interval subgroup (hazard ratio 1.44, confidence interval 1.22-1.71, P

Objective:To determine the impact of race and insurance on use of minimally invasive (MIS) compared with open techniques for rectal cancer in the United States.Background:Race and socioeconomic status have been implicated in disparities of rectal cancer treatment.Methods:Adults undergoing MIS (lapar

Hypoalbuminemia is associated with adverse surgical outcomes. A minimum threshold and the impact of incrementally decreasing albumin remain undefined for colorectal surgery patients. The 2011–2013 National Surgical Quality Improvement Program (NSQIP) dataset was queried for patients undergoing elective colorectal surgery. Multivariable regression analyses with restricted cubic splines (RCS) were used to examine the adjusted association between preoperative serum albumin level and the incidence of complications and to establish an optimal threshold. RCS allows for flexible evaluation in multivariable models without having to assume a specific relationship a priori. Sixteen thousand one hundred forty-five patients met study criteria. RCS analysis demonstrated an inflection point at serum albumin level of 3.9 mg/dL. Patients with preoperative albumin

Background/purpose There are limited data identifying risk factors for nodal metastasis in children with differentiated thyroid cancer. Methods The 1998–2011 Surveillance, Epidemiology, and End Results Program database was queried for patients ≤18years of age diagnosed with differentiated thyroid cancer who underwent nodal examination. Patients were grouped by absence or presence of nodal metastasis. Multivariable logistic regression methods were used to identify independent risk factors for nodal metastasis. Results In total, 1075 children met study criteria: 734 (68%) had nodal metastases, while 341 (32%) did not. After adjustment, risk factors for nodal metastasis included larger tumor size (1.1–2cm: odds ratio [OR] 2.02, 95% confidence interval [CI] 1.22–3.34, p=0.006; 2.1–4cm: OR 3.37, 95% CI 2.03–5.60, p 4cm: OR 3.39, 95% CI 1.69–6.81, p=0.001), extrathyroidal extension (OR 7.28, 95% CI 4.07–13.01, p Conclusions Increasing tumor size, extrathyroidal extension, and multifocal disease are independent factors associated with nodal metastases in pediatric differentiated thyroid cancer. If these risk factors are present, children with differentiated thyroid cancer should undergo careful preoperative evaluation for evidence of lateral cervical lymph node metastases, and the central compartment should be evaluated intraoperatively, with consideration of central lymphadenectomy. Level of evidence Level III.

This study aimed to define morbidities and costs related to modern-day medical care for children with vascular anomalies. We reviewed the 2003–2009 Kids’ Inpatient Database for pediatric patients (age

BackgroundPrevious studies have identified risk factors for femoral arterial thrombosis after paediatric cardiac catheterisation, but none of them have evaluated the clinical and economic significance of this complication at the population level. Therefore, we examined the national prevalence and economic impact of femoral arterial thrombosis after cardiac catheterisation in children.MethodsPatients⩽18 years of age who underwent cardiac catheterisation were identified in the 2003–2009 Kids’ Inpatient Database. Patients were stratified by age as follows: ResultsAmong the 11,497 paediatric cardiac catheterisations identified, 4558 catheterisations (39.6%) were performed in children ConclusionsFemoral arterial thrombosis is especially prevalent in children

The use of intensity-modulated radiation therapy (IMRT) in rectal cancer has steadily increased over traditional 3D conformal radiotherapy (3D-CRT) due to perceived benefit of delivering higher treatment doses while minimizing exposure to surrounding tissues. However, IMRT is technically challenging and costly, and its effects on rectal cancer outcomes remain unclear.Adults with clinical stage II and III rectal adenocarcinoma who underwent neoadjuvant chemoradiotherapy with 45-54 Gy of radiation and surgery were included from the 2006-2013 National Cancer Data Base. Patients were grouped based the modality of radiation received: IMRT or 3D-CRT. Multivariable regression modeling adjusting for demographic, clinical, and treatment characteristics was used to examine the impact of IMRT vs. 3D-CRT on pathologic downstaging, resection margin positivity, sphincter loss surgery, 30-day unplanned readmission and mortality after surgery, and overall survival.Among 7386 patients included, 3330 (45 %) received IMRT and 4056 (55 %) received 3D-CRT. While the mean radiation dose delivered was higher with IMRT (4735 vs. 4608 cGy, p 0.001), it was associated with higher risks of positive margins (adjusted odds ratio (OR) 1.57; p 0.001) and sphincter loss surgery (OR 1.32; p 0.001). There were no differences between IMRT and 3D-CRT in the likelihood of pathologic downstaging (OR 0.89, p = 0.051), unplanned readmission (OR 0.79; p = 0.07), or 30-day mortality (OR 0.61; p = 0.31) after surgery. Additionally, there were no differences in overall survival at 8 years (IMRT vs. 3D-CRT: 64 vs. 64 %; adjusted hazard ratio 1.06, p = 0.47).IMRT is associated with worse local tumor control without any long-term survival benefit for patients with locally advanced rectal cancer. Given the lack of significant advantage and the higher cost of IMRT, caution should be exercised when using IMRT instead of traditional 3D-CRT for rectal cancer.

To examine the impact of alvimopan on outcomes and costs in a rigorous enhanced recovery colorectal surgery protocol.Postoperative ileus remains a major source of morbidity and costs in colorectal surgery. Alvimopan has been shown to reduce incidence of postoperative ileus in enhanced recovery colorectal surgery; however, data are equivocal regarding its benefit in reducing length of stay and costs.Patients undergoing major elective enhanced recovery colorectal surgery were identified from a prospectively-collected database (2010-2013). Multivariable analyses were employed to compare outcomes and hospital costs among patients who had alvimopan versus no alvimopan by adjusting for demographic, clinical, and treatment characteristics.A total of 660 patients were included; 197 patients received alvimopan and 463 patients had no alvimopan. In unadjusted analysis, the alvimopan group had a faster return of bowel function, shorter length of stay, and lower rates of ileus, Foley re-insertion, and urinary tract infection (all P 0.01). After adjustment, alvimopan was associated with a faster return of bowel function by 0.6 day (P = 0.0006), and lower incidence of postoperative ileus (odds ratio 0.23, P = 0.0002). With adjustment, alvimopan was associated with a shorter length of stay by 1.6 days (P = 0.002), and a hospital cost savings of $1492 per patient (P = 0.01).Alvimopan administration as an element of enhanced recovery colorectal surgery is associated with faster return of bowel function, lower incidence of postoperative ileus, shorter hospitalization, and a significant cost savings. These results suggest that alvimopan is cost-effective in the setting of enhanced recovery colorectal surgery protocols, and should therefore be considered in these programs.

Background/Purpose Sentinel lymph node biopsy (SLNB)-based management has been shown to improve disease-free survival in adult melanoma, but there is scant evidence regarding the utility of SLNB in pediatric melanoma. Methods The 2004–2011 Surveillance, Epidemiology, and End Results database was queried for patients with primary cutaneous melanoma of Breslow depth>0.75mm and clinically negative nodes. Pediatric patients, defined as less than 20years of age, were grouped by whether they underwent SLNB or not. Kaplan–Meier analysis was performed to compare melanoma-specific survival (MSS) in propensity-matched groups. Results 310 pediatric patients met study criteria: 261 (84%) underwent SLNB, while 49 (16%) did not. There was no difference in MSS between matched children who received SLNB and those who did not (p=0.36). Among children who received SLNB, a positive SLNB was associated with worse MSS compared to a negative SLNB (89% vs. 100% at 84months, p=0.04). However, children with a positive SLNB had more favorable survival compared to patients >20years of age (88% vs. 66% at 84months, p=0.02). Conclusions SLNB does not confer a survival benefit to children with melanoma, but it provides valuable prognostic information regarding MSS.

To examine survival of patients who underwent minimally invasive versus open low anterior resection (LAR) for rectal cancer.Utilization of laparoscopic and robotic LAR for rectal cancer has steadily increased. Short-term outcomes between these techniques and open surgery have shown equivalent results; however, survival outcomes are unknown.Adults from the National Cancer Data Base undergoing LAR for rectal adenocarcinoma were identified. Patients were stratified by intent-to-treat into open (OLAR) or minimally invasive LAR (MI-LAR). Multivariable modeling was used to compare short-term outcomes and survival between MI-LAR and OLAR and between laparoscopic (LLAR) and robotic LAR (RLAR).Among 14,033 patients included, 57.8% underwent OLAR and 42.2% MI-LAR. After adjustment, MI-LAR was associated with shorter length of stay (P 0.001), but similar rates of positive margins, 30-day readmission, 30-day mortality, and use of adjuvant therapies (all P 0.05). At 36 months, there was no difference in adjusted risk of mortality between MI-LAR and OLAR (hazard ratio [HR] 0.88, P = 0.089). In a subgroup analysis of LLAR versus RLAR, there were no differences in lymph node harvest, margin positivity, length of stay, readmission rate, 30-day mortality, or overall survival after adjustment (all P 0.05).Minimally invasive LAR for rectal cancer is associated with similar overall survival with the benefit of shorter hospitalization. Although the conversion rate is lower, robotic LAR is not associated with superior oncologic outcomes compared to laparoscopic LAR. Our findings support the ongoing adoption of minimally invasive techniques for rectal adenocarcinoma.

Controversy exists over whether resection of the primary tumor in stage IV colorectal cancer with inoperable metastases improves patient outcomes.The purpose of this study was to evaluate whether resection of the primary tumor without metastasectomy in patients with stage IV colorectal cancer is associated with improved overall survival compared with patients undergoing chemotherapy and/or radiation therapy alone.This was a retrospective review of a multi-institutional dataset.This study was conducted in all participating commission on cancer (CoC)-accredited facilities.The 2003-2006 National Cancer Data Base was reviewed to identify patients with stage IV adenocarcinoma of the colon or rectum who underwent palliative treatment without curative intent, either in the form of surgical resection of the primary tumor without metastasectomy consisting of a colectomy or rectal resection with or without chemotherapy and/or radiation or chemotherapy and/or radiation alone.Groups were compared for baseline characteristics. Overall survival was compared using Kaplan-Meier analysis before and after propensity matching with a 1:1 nearest-neighbor algorithm.Of the 1446 patients included in the analysis, 231 (16%) underwent surgical resection of the primary tumor without metastasectomy. Surgical resection was associated with a significant survival benefit on unadjusted analysis (median survival, 9.2 vs. 7.6 months; p0.01). After propensity matching to adjust for nonrandom treatment selection, surgical resection continued to be associated with a significant survival benefit (median survival, 9.2 vs. 7.3 months; p0.01).This study was limited by the potential for selection bias regarding which patients received surgical resection. There was also a lack of data regarding the indication for operation, specifically whether a patient was symptomatic or asymptomatic before resection. The inability to account for tumor size or grade among patients who did not receive surgical resection was another limitation.Surgical resection of the primary tumor without metastasectomy in patients with metastatic colorectal cancer is associated with improved survival as compared with chemotherapy/radiation therapy alone. Additional research is necessary to determine which patients may benefit from this intervention.

Improvements in diagnosis and treatment have resulted in significant improvement in survival rates for rectal cancer. This has led to increasing focus on post-treatment quality of life. One common sequela of treatment for rectal cancer is urinary dysfunction, defined as either difficulty voiding or incontinence. This consists of multiple clinical syndromes of distinct etiologies, most commonly dysfunction of the pelvic autonomic nerves or pelvic floor instability. This can vary in both duration and severity, with some patients experiencing transient and mild symptoms, while others experience prolonged functional impairment. A number of treatment options exist, including behavioral, pharmacologic, and surgical interventions. Because of the multifaceted nature of this process, optimal symptom relief requires careful evaluation of the severity and etiology of a patient’s complaints. Ultimately post-treatment urinary dysfunction can have a significant impact on quality of life, and it is important for clinicians to understand both the causes and management of this process.

Previous studies have raised concerns that video-assisted thoracoscopic (VATS) lobectomy may compromise nodal evaluation. The advantages or limitations of robotic lobectomy have not been thoroughly evaluated.Perioperative outcomes and survival of patients who underwent open versus minimally-invasive surgery (MIS [VATS and robotic]) lobectomy and VATS versus robotic lobectomy for clinical T1-2, N0 non-small cell lung cancer from 2010 to 2012 in the National Cancer Data Base were evaluated using propensity score matching.Of 30,040 lobectomies, 7,824 were VATS and 2,025 were robotic. After propensity score matching, when compared with the open approach (n = 9,390), MIS (n = 9,390) was found to have increased 30-day readmission rates (5% versus 4%, p0.01), shorter median hospital length of stay (5 versus 6 days, p0.01), and improved 2-year survival (87% versus 86%, p = 0.04). There were no significant differences in nodal upstaging and 30-day mortality between the two groups. After propensity score matching, when compared with the robotic group (n = 1,938), VATS (n = 1,938) was not significantly different from robotics with regard to nodal upstaging, 30-day mortality, and 2-year survival.In this population-based analysis, MIS (VATS and robotic) lobectomy was used in the minority of patients for stage I non-small cell lung cancer. MIS lobectomy was associated with shorter length of hospital stay and was not associated with increased perioperative mortality, compromised nodal evaluation, or reduced short-term survival when compared with the open approach. These results suggest the need for broader implementation of MIS techniques.

Symptomatic hemorrhoid disease is one of the most prevalent ailments associated with significant impact on quality of life. Management options for hemorrhoid disease are diverse, ranging from conservative measures to a variety of office and operating-room procedures. In this review, the authors will discuss the anatomy, pathophysiology, clinical presentation, and management of hemorrhoid disease.

Several reports suggest that the efficacy of adjuvant chemotherapy on survival diminishes over time for colon cancer; however, precise timing of its loss of benefit has not been established.This study aimed to determine the relationship between time to adjuvant chemotherapy and survival and to identify a threshold for increased risk of mortality.This was a retrospective study. Multivariable Cox proportional hazard modeling with restricted cubic splines was used to evaluate the adjusted association between time to adjuvant chemotherapy and overall survival and to establish an optimal threshold for the initiation of therapy.Data were collected from the National Cancer Data Base.Adults who received adjuvant chemotherapy following resection of stage II to III colon cancers were selected.The primary outcome measured was overall survival.A total of 7794 patients were included. After adjusting for clinical, tumor, and treatment characteristics, our model determined a critical threshold of chemotherapy initiation at 44 days from surgery, after which there was an increase in the overall mortality. At a median follow-up of 61 months, the risk of mortality was increased in those who received adjuvant chemotherapy after 44 days from surgery (adjusted HR, 1.14; 95% CI, 1.05-1.24; p = 0.002), but not in those who received chemotherapy before 44 days from surgery (p = 0.11). Each additional week of delay was associated with a 7% decrease in survival (HR, 1.07; 95% CI, 1.04-1.10; p0.001).This study was limited by selection bias and the inability to compare specific chemotherapy regimens.This study objectively determines the optimal timing of adjuvant chemotherapy for patients with resected colon cancer. Delay beyond 6 weeks is associated with compromised survival. These findings emphasize the importance of the timely initiation of therapy, and suggest that efforts to enhance recovery following surgery have the potential to improve survival by decreasing delay to adjuvant chemotherapy.

Feeding tube placement is common among patients undergoing gastrectomy, and national guidelines currently recommend consideration of a feeding jejunostomy tube (FJT) for all patients undergoing resection for gastric cancer. However, data are limited regarding the safety of FJT placement at the time of gastrectomy for gastric cancer.The 2005-2011 American College of Surgeons National Surgical Quality Improvement Program Participant User Files were queried to identify patients who underwent gastrectomy for gastric cancer. Subjects were classified by the concomitant placement of an FJT. Groups were then propensity matched using a 1:1 nearest neighbor algorithm, and outcomes were compared between groups. The primary outcomes of interest were overall 30-d overall complications and mortality. Secondary end points included major complications, surgical site infection, and early reoperation.In total, 2980 subjects underwent gastrectomy for gastric cancer, among whom 715 (24%) also had an FJT placed. Patients who had an FJT placed were more likely to be male (61.6% versus 56.6%, P = 0.02), have recent weight loss (21.0% versus 14.8%, P 0.01), and have undergone recent chemotherapy (7.9% versus 4.2%, P 0.01) and radiation therapy (4.2% versus 1.3%, P 0.01). They were also more likely to have undergone total (compared with partial) gastrectomy (66.6% versus 28.6%, P 0.01) and have concomitant resection of an adjacent organ (40.4 versus 24.1%, P 0.01). After adjustment with propensity matching, however, all baseline characteristics and treatment variables were highly similar. Between groups, there were no statistically significant differences in 30-d overall complications (38.8% versus 36.1%, P = 0.32) or mortality (5.8 versus 3.7%, P = 0.08). There were also no differences in major complications, surgical site infection, or early reoperation. Operative time was slightly longer among patients with feeding tubes placed (median, 248 versus 233 min, P = 0.01), but otherwise there were no significant differences in any outcomes between groups.Concomitant placement of FJT at the time of gastrectomy may result in slightly increased operative times but does not appear to lead to increased perioperative morbidity or mortality. Further investigation is needed to identify the patients most likely to benefit from FJT placement.

Background While enhanced recovery protocols (ERPs) reduce physiologic stress and improve outcomes in general, their effects on postoperative renal function have not been directly studied. Methods Patients undergoing major colorectal surgery under ERP (February 2010 to March 2013) were compared with a traditional care control group (October 2004 October 2007) at a single institution. Multivariable regression models examined the association of ERP with postoperative creatinine changes and incidence of postoperative acute kidney dysfunction (based on the Risk, Injury, Failure, Loss, and End-stage renal disease criteria). Results Included were 1054 patients: 590 patients underwent surgery with ERP and 464 patients without ERP. Patient demographics were not significantly different. Higher rates of neoplastic and inflammatory bowel disease surgical indications were found in the ERP group (81 vs. 74%, p = 0.045). Patients in the ERP group had more comorbidities (ASA ≥ 3) (62 vs. 40%, p

Practice guidelines differ in their support of adjuvant chemotherapy use in patients who received preoperative chemoradiation for rectal cancer.The purpose of this study was to evaluate the impact of adjuvant chemotherapy among patients with locally advanced rectal cancer who received neoadjuvant chemoradiation and surgery.This was a retrospective study. Multivariable Cox proportional hazard modeling was used to evaluate the adjusted survival differences.Data were collected from the National Cancer Database.Adults with pathologic stage II and III rectal adenocarcinoma who received neoadjuvant chemoradiation and surgery were included.Overall survival was measured.Among 12,696 patients included, 4023 (32%) received adjuvant chemotherapy. The use of adjuvant chemotherapy increased over the study period from 23% to 36%. Although older age and black race were associated with a lower likelihood of receiving adjuvant chemotherapy, patients with higher education level and stage III disease were more likely to receive adjuvant chemotherapy (all p0.05). At 7 years, overall survival was improved among patients who received adjuvant chemotherapy (60% vs. 55%; p0.001). After risk adjustment, the use of adjuvant chemotherapy was associated with improved survival (HR = 0.81 (95% CI, 0.72-0.91); p0.001). In the subgroup of patients with stage II disease, survival was also improved among patients who received adjuvant chemotherapy (68% vs 58% at 7 y; p0.001; HR = 0.70 (95% CI, 0.57-0.87); p = 0.002). Among patients with stage III disease, the use of adjuvant chemotherapy was associated with a smaller but persistent survival benefit (56% vs 51% at 7 y; p = 0.017; HR = 0.85 (95% CI, 0.74-0.98); p = 0.026).The study was limited by its potential for selection bias and inability to compare specific chemotherapy regimens.The use of adjuvant chemotherapy among patients with rectal cancer who received preoperative chemoradiation conferred a survival benefit. This study emphasizes the importance of adjuvant chemotherapy in the management of rectal cancer and advocates for its increased use in the setting of neoadjuvant therapy. See Video Abstract at http://link.lww.com/DCR/A428.

BACKGROUND: Our study aims to identify the minimum number of lymph nodes (LN) associated with improved survival in patients who underwent NRT for stage II-III rectal cancer. METHODS: Adults with clinical stage II and III rectal adenocarcinoma in the National Cancer Data Base were stratified by NRT. Multivariable Cox regression modeling with restricted cubic splines was used to determine the minimum number of LNs associated with improved survival. RESULTS: Of 38,363 patients, 76% received NRT. After adjustment, a LNY≥12 was associated with improved survival among patients receiving NRT (HR 0.79, p < 0.0001) and those without NRT (HR 0.88, p = 0.04). Among patients receiving NRT, factors independently associated with LNY≥12 were younger age, private insurance, low comorbidity score, a recent year of diagnosis, higher T stage and grade, APR resection, and academic institution. CONCLUSIONS: A minimum LNY of 12 confers a survival benefit for rectal cancer patients regardless of receiving neoadjuvant radiation therapy.

Gallbladder cancer (GBC) is the most common biliary tract malignancy. Because it commonly metastasizes via lymphatics, portal lymphadenectomy should be included in oncologic resections. This study aimed to compare the oncologic equivalence of the laparoscopic versus open technique by evaluating lymph node (LN) yield.The 2010-2012 National Cancer Data Base identified patients who underwent laparoscopic or open resection of GBC with dedicated lymphadenectomy. LN yield was compared by resection method. Variables associated with LN yield ≥3 were identified.Of 1524 patients identified, 52% were intended to undergo laparoscopic surgery, with 20% of these patients converted to open. Collection of ≥3 LNs following open resection (47%) was higher than for laparoscopic resection (34%), p 0.001. Operations performed at high-volume (aOR:1.74, p 0.001) and/or academic centers (aOR:1.70, p = 0.024) had superior LN yield. LN yield was not associated with overall survival (aHR:0.93, p = 0.493).In this analysis of national data, LN yield following laparoscopic resection for GBC was significantly lower than following open resection. Open resection is more frequently performed at academic centers, possibly to assure adequate oncologic resection. Enforcing consensus guidelines for lymphadenectomy in gallbladder cancer will optimize outcomes as minimally invasive approaches evolve.

Hand-assisted laparoscopic surgery (HALS) is often used in procedures too complex for completely minimally invasive approaches. However, there are concerns for whether this hybrid approach abrogates perioperative benefits of the completely minimally invasive technique. We queried the 2012–2013 National Surgery Quality Improvement Program for adults undergoing elective HALS or open colectomy (OC). After propensity matching, short-term outcomes were compared. Subset analysis was performed for segmental resections. Multivariate analysis was used to determine predictors of utilizing either approach. This query included 8791 patients (OC 2707, HALS 6084). Predictors of HALS included male sex (OR 1.17, p = 0.006), increasing BMI (OR 1.01, p = 0.02), benign indication (OR 1.48, p

Metachromatic leukodystrophy (MLD) is a lysosomal storage disease that leads to neurological deterioration and visceral involvement, including sulphatide deposition in the gallbladder wall. Using our institution's extensive experience in treating MLD, we examined the incidence of gallbladder abnormalities in the largest cohort of children with MLD to date.We conducted a retrospective review of all children with MLD, adrenoleukodystrophy (ALD), or Krabbe disease who underwent hematopoietic stem cell transplantation (HSCT) at our institution between 1994 and 2015. Baseline characteristics and unadjusted outcomes were compared using the Kruskal-Wallis test for continuous variables and Pearson χIn total, 87 children met study criteria: 29 children with MLD and 58 children with ALD or Krabbe disease. Children with MLD were more likely to demonstrate gallbladder abnormalities on imaging, both before HSCT (41.4% versus 5.2%, P 0.001) and after HSCT (75.9% versus 41.4%, P = 0.002). Consequently, a larger proportion of children with MLD underwent surgical or interventional management of biliary disease (10.3% versus 3.4%, P = 0.03).Children with MLD have a significantly greater incidence of gallbladder abnormalities than children with other lysosomal storage diseases. Biliary disease should be considered in children with MLD who develop abdominal pain, and cholecystectomy should be considered for persistent, symptomatic gallbladder abnormalities.

HAL colectomy is a technique perceived to provide the benefits of laparoscopic surgery while improving tactile feedback and operative time. Published data are largely limited to small, single-institution studies. The 2012-2013 National Surgical Quality Improvement Program Participant Data Use File was queried for patients undergoing elective SL or HAL colectomy. Patients underwent 1:1 propensity matching and had outcomes compared. An additional subgroup analysis was performed for patients undergoing segmental resections only. 13,949 patients were identified, of whom 6084 (43.6 %) underwent HAL colectomy. Patients undergoing HAL versus SL colectomy had higher rates of postoperative ileus (8.7 vs. 6.3 %, p

Interest in robotic technology is burgeoning within the field of colorectal surgery. However, benefits of robotic-assisted colectomy (RAC) compared with laparoscopic colectomy (LC) remain ambiguous.Patients who underwent minimally invasive colectomy during 2012-2013 were identified from the National Surgical Quality Improvement Program (NSQIP) database. Short-term perioperative outcomes were compared between 1:1 propensity-matched groups. A subset analysis was performed among patients who underwent segmental resections.Among the 15,976 patients included, 498 (3.1 %) colectomies were performed with robotic assistance. After matching for demographic, clinical, and treatment characteristics, there were no differences between RAC and LC in complications such as wound infection, urinary tract infection, cardiopulmonary or thromboembolic events, renal insufficiency, anastomotic leaks, transfusions, readmissions, or 30-day mortality (all p 0.05). However, operative time was markedly higher for RAC (196 vs. 166 min, p 0.001). Among segmental resections, operative time remained significantly longer for RAC (190 vs. 153 min, p 0.001) without differences in perioperative outcomes (all p 0.05).In this early experience, RAC resulted in similar perioperative outcomes when compared to LC but was associated with longer operative time. Given the focus on value-based healthcare, utilizing RAC in straightforward colectomies may not be financially justifiable at this stage of adoption.

Limited data exist regarding the effect of conversion from laparoscopic to open colectomy on perioperative and oncologic outcomes in colon cancer.The National Cancer Data Base was used to identify patients who underwent colectomy for non-metastatic colon cancer (2010-2012). Patients were stratified into three groups: laparoscopic/robotic-assisted colectomy (MIC), converted colectomy (CC), and open colectomy (OC). Multivariable modeling was applied to compare outcomes from CC and MIC to OC while adjusting for patient, clinical, and tumor characteristics.Of 104,400 patients, 40,328 (38.6 %) underwent MIC, 57,928 (55.5 %) OC, and 6144 (5.9 %) CC. After adjustment, the rate of positive surgical margins was not significantly different between CC and OC (p = 0.44). However, with adjustment, CC versus OC was associated with shorter hospital length of stay (4 % decrease, 95 % CI 2-5 %, p 0.0001) and lower odds of 30-day mortality (OR 0.77, 95 % CI 0.64-0.94, p = 0.0112). Adjusted overall survival was similar between CC and OC (p = 0.34).Conversion from laparoscopic to open colectomy was not associated with compromised oncologic outcomes, while maintaining improved short-term outcomes despite being attempted in only 45 % of patients. This data suggests that utilization of laparoscopic colectomy should be attempted for patients with colon cancer.

Neoadjuvant chemoradiotherapy (nCRT) has demonstrated proven benefit in tumor regression and improved long-term local control for patients with locally advanced rectal cancer. However, precise analysis of the optimal waiting time that maximizes oncologic benefits of nCRT has not been established.The 2006-2012 National Cancer Data Base was queried for patients with stage II and III rectal adenocarcinoma who underwent nCRT followed by surgical resection. Time to surgery was defined as the difference between last date of radiotherapy and date of surgery. Primary study endpoints included resection margin positivity and pathologic downstaging. Multivariable regression modeling with restricted cubic splines was used to evaluate the adjusted association between time to surgery and our study endpoints, and to establish an optimal time threshold for surgery.A total of 11,760 patients were included. Median time to surgery was 53 days (interquartile range [IQR] 43 to 63 days). After adjusting for patient demographic, clinical, tumor, and treatment characteristics, our model determined an inflection point at 56 days after end of radiotherapy associated with the highest likelihood of complete resection and pathologic downstaging. With adjustment, the risk of margin positivity was increased in those who underwent surgery after 56 days from end of radiotherapy (odds ratio [OR] 1.40, 95% CI 1.21 to 1.61, p0.001). The likelihood of downstaging was increasing up to 56 days after radiotherapy (≥56 days vs56 days, OR 1.2, 95% CI 1.02 to 1.23, p = 0.01).This study objectively determined the optimal time for surgery after completion of nCRT for rectal cancer based on completeness of resection and tumor downstaging. Eight weeks appears to be the critical threshold for optimal tumor response.

Background The objective of this study was to evaluate outcomes of minimally invasive approaches to esophagectomy using population-level data. Methods Multivariable regression modeling was used to determine predictors associated with the use of minimally invasive approaches for patients in the National Cancer Data Base who underwent resection of middle and distal clinical T13N03M0 esophageal cancers from 2010 to 2012. Perioperative outcomes and 3-year survival were compared between propensity-matched groups of patients with esophageal cancer who underwent minimally invasive esophagectomy (MIE) or open esophagectomy (OE). A subgroup analysis was performed to evaluate the impact of using robotic-assisted operations as part of the minimally invasive approach. Results Among 4,266 patients included, 1,308 (30.6%) underwent MIE. It was more likely to be used in patients treated at academic (adjusted odds ratio [OR], 10.1; 95% confidence interval [CI], 4.2–33.1) or comprehensive cancer facilities (adjusted OR, 6.4; 95% CI, 2.6–21.1). Compared with propensity-matched patients who underwent OE, patients who underwent MIE had significantly more lymph nodes examined (15 versus 13; p = 0.016) and shorter hospital lengths of stay (10 days versus 11 days; p = 0.046) but similar resection margin positivity, readmission, and 30-day mortality (all p > 0.05). Survival was similar between the matched groups at 3 years for both adenocarcinoma and squamous cell carcinoma ( p > 0.05). Compared with MIE without robotic assistance, use of a robotic approach was not associated with any significant differences in perioperative outcomes ( p > 0.05). Conclusions The use of minimally invasive techniques to perform esophagectomy for esophageal cancer is associated with modestly improved perioperative outcomes without compromising survival.

Failing to complete chemotherapy adversely affects survival in patients with colorectal cancer. However, the effect of incomplete delivery of neoadjuvant radiotherapy is unclear.To determine whether incomplete radiotherapy delivery is associated with worse clinical outcomes and survival.Data on 17 600 patients with stage II to III rectal adenocarcinoma from the 2006-2012 National Cancer Database who received neoadjuvant chemoradiotherapy followed by surgical resection were included. Multivariable regression methods were used to compare resection margin positivity, permanent colostomy rate, 30-day readmission, 90-day mortality, and overall survival between patients who received complete (45.0-50.4 Gy) and incomplete (45.0 Gy) doses of radiation as preoperative therapy.The primary outcome measure was overall survival; short-term perioperative and oncologic outcomes encompassing margin positivity, permanent ostomy rate, postoperative readmission, and postoperative mortality were also assessed.Among 17 600 patients included, 10 862 were men, with an overall median age of 59 years (range, 51-68 years). Of these, 874 patients (5.0%) received incomplete doses of neoadjuvant radiation. The median radiation dose received among those who did not achieve complete dosing was 34.2 Gy (interquartile range, 19.8-40.0 Gy). Female sex (adjusted odds ratio [OR] 0.69; 95% CI, 0.59-0.81; P .001) and receiving radiotherapy at a different hospital than the one where surgery was performed (OR, 0.72; 95% CI, 0.62-0.85; P .001) were independent predictors of failing to achieve complete dosing; private insurance status was predictive of completing radiotherapy (OR, 1.60; 95% CI, 1.16-2.21; P = .004). At 5-year follow-up, overall survival was improved among patients who received a complete course of radiotherapy (3086 [estimated survival probability, 73.2%] vs 133 [63.0%]; P .001). After adjustment for demographic, clinical, and tumor characteristics, patients receiving a complete vs incomplete radiation dose had a similar resection margin positivity (OR, 0.99; 95% CI, 0.72-1.35; P = .92), permanent colostomy rate (OR, 0.96; 95% CI, 0.70-1.32; P = .81), 30-day readmission rate (OR, 0.92; 95% CI, 0.67-1.27; P = .62), and 90-day mortality (OR, 0.72; 95% CI, 0.33-1.54; P = .41). However, a complete radiation dose had a significantly lower risk of long-term mortality (adjusted hazard ratio, 0.70; 95% CI, 0.59-0.84; P .001).Achieving a target radiation dose of 45.0 to 50.4 Gy is associated with a survival benefit in patients with locally advanced rectal cancer. Aligning all aspects of multimodal oncology care may increase the probability of completing neoadjuvant therapy.

Minimally invasive (MI) gastrectomy has become increasingly common as a resection technique for gastric cancer; however, data are limited regarding peri-operative morbidity, oncologic outcomes and long-term survival, particularly in the Western patient population.The 2010-2012 National Cancer Data Base was queried for adult patients who underwent gastrectomy for localized, intestinal-type gastric adenocarcinoma. Patients were classified by surgical approach (MI vs. open gastrectomy) on an intent-to-treat basis. Groups were propensity score matched using a 1:1 nearest neighbor algorithm, and outcomes were compared. Survival was estimated using the Kaplan-Meier method.Among 5420 patients, 1423 (26%) underwent MI gastrectomy. Following adjustment with propensity matching, all baseline characteristics were highly similar between 1175 patients in each treatment group. Between propensity-matched groups, MI gastrectomy patients had similar rates of margin-negative resections (91 vs. 90%, p = 0.447), median lymph node harvest (16 vs. 15, p = 0.104), and utilization of adjuvant therapies (28 vs. 28%, p = 0.748). MI gastrectomy was associated with shorter hospital stay (8 vs. 9 days, p 0.001) without an increase in unplanned readmissions (7 vs. 6%, p = 0.456) or 30-day mortality (2 vs. 3%, p = 0.655). There was no difference in 3-year overall survival (50 vs. 55%, p = 0.359).On a national level, MI gastrectomy for gastric cancer appears to be associated with similar perioperative and long-term outcomes compared to the traditional open approach. While prospective studies remain essential, these data provide greater equipoise for ongoing trials and institutional efforts to further implement and evaluate this technique.

Background: Venous thromboembolism (VTE) is an uncommon but clinically significant postoperative complication in children. Incidence of VTE in pediatric patients ranges from 34-58 per 10,000 hospitalized children1. Due to rarity of these events, there is limited information about the factors predisposing children to VTE after surgery. We queried a national surgical database to identify risks and outcomes associated with VTE in pediatric surgical patients. Methods: The National Surgical Quality Improvement Program-Pediatric (NSQIP) is a prospectively collected database that records pediatric surgical information, surgical approaches, and 30 day patient outcomes. The database was queried for the years 2012-2013 to identify pediatric patients (age < 18) who had received surgical intervention and were diagnosed with postoperative VTE. Because of their separate coding in NSQIP, we defined VTE as including venous thromboembolism, or pulmonary embolism (PE) diagnosed radiographically within 30 days of operation. To reduce non-random differences between patients we used propensity scores based on age, sex, race, BMI, and ASA classification to match patients in a 1:2 ratio using the nearest neighbor method. Using univariate and multivariate analysis, we identified preoperative risk factors associated with VTE. Results: In total, 130 patients were identified who developed VTE postoperatively (VTE n=122, PE n=7, BOTH PE + VTE n= 1) from this database of 114,395 patients. There were 104 patients with VTE that also had complete entries and were subsequently analyzed in this study. Surgical specialties treating patients in this analysis included cardiothoracic surgery, general surgery, neurosurgery, orthopedic surgery, otolaryngology, plastic surgery, and urology. Eighty-one unique operative CPT codes were identified for patients with VTE. Patients who developed VTE had increased operative time, anesthesia time, and total length of stay (all p < 0.001). Multivariate analysis demonstrated that pneumonia (odds ratio [OR] 1.73, 95% confidence interval [CI] 1.3 - 2.29), Central Line Associated Bloodstream Infection (CLABSI) (OR 1.69, 95% CI 1.18 - 2.42), sepsis (OR 1.47, 95% CI 1.18 - 1.82), septic shock (OR 1.36, 95% CI 1.06 - 1.75), and current solid or hematologic malignancy or active treatment of malignancy (OR 1.30, 95% CI 1.08 - 1.58) were all statistically significant risk factors associated with development of VTE (all p < 0.05). Conclusions: Postoperative VTE risk is significantly increased in children with malignancy or severe infections. Further research is needed to understand the mechanism between malignancy, systemic inflammation, and VTE risk in children. These findings may help to identify patients in need of prophylactic treatment in order to reduce postoperative thrombotic risk in pediatric patients. References: 1. Raffini L, Huang YS, Witmer C, Feudtner C. Dramatic increase in venous thromboembolism in children's hospitals in the United States from 2001 to 2007. Pediatrics. 2009;124(4):1001-1008. Disclosures No relevant conflicts of interest to declare.