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Enhanced recovery protocols (ERPs) have the potential to streamline care and improve short-term outcomes for surgical patients. However, for patients undergoing modern iterations of complex abdominal wall reconstruction (AWR), little literature exists on the effectiveness of these protocols.In this retrospective study we reviewed our institutional experience with complex AWR throughout a 2-year period with 1 year immediately before and 1 year after implementation of our ERP. Patients undergoing primarily minimally invasive complex AWR who were compliant with 11 elements of our ERP were compared with patients who received surgery before implementation of the protocol or did not meet these criteria. Baseline patient characteristics and patient outcomes including hospital length of stay, narcotic usage, and readmission were compared across groups. Multivariable regression models were used to estimate the associations of our ERP protocol with outcomes adjusting for surgical approach.Median length of stay for the overall cohort (n = 132) was 3 days (interquartile range 1 to 4). Morbidity and mortality rates were 22.6% and 0.7%, respectively. ERP patients were less likely to have a complication (ERP compliant 8.7% [n = 46] vs non-ERP 30.2% [n = 86], plt; 0.01), had a shorter median postoperative length of stay (median 1 vs 3 days, plt; 0.01), and received fewer morphine equivalents (median 30.8 vs 45 mg, plt; 0.01). Readmission rate for ERP patients did not differ significantly vs non-ERP patients (6.5% vs 11.8%, p = 0.34).Use of ERPs in patients undergoing complex AWR may provide benefits for both patients and hospitals.

The COVID-19 pandemic possessed far-reaching health implications beyond the public health impact that have yet to be fully elucidated. We hypothesized that the COVID-19 pandemic led to an increase in biliary disease complexity and incidence of emergency cholecystectomy.We reviewed our institutional experience with cholecystectomy from February 2019-February 2021, n = 912. Pre COVID-19 pandemic patients were compared to patients after the onset of the pandemic. Baseline characteristics were compared between groups. A Cochran-Armitage test for trend assessed the temporal impact of COVID-19 on emergency presentation and gallbladder disease complexity.We identified 442 patients pre-pandemic and 470 patients during the pandemic. No significant differences were noted in demographics. COVID-19 significantly impacted emergency presentation (43.2% vs. 56.8%, p=0.01), cholecystitis (53.2% vs 61.8%; p=0.01), and gangrenous cholecystitis (2.8% vs 6.1%; p=0.01). Both groups had similar clinical outcomes.The COVID-19 pandemic affected an increased incidence of emergency presentation and complexity of gallbladder disease but did not significantly impact clinical outcomes. These findings may have broader implications for other diseases possibly affected by COVID-19.

Background Critical perspectives on the informed consent process for inguinal hernia surgery are lacking. Methods We conducted focus group interviews of patients who have undergone inguinal hernia surgery and nurses/medical assistants. Individual phone interviews were also conducted with surgeons sampled from the International Hernia Collaboration. Interviews were transcribed for coding and qualitative thematic analysis performed using NVivo 12 Plus. Themes were compiled to develop a decision aid. Results Sixteen patients, 6 support staff members, and 12 surgeons participated. Multiple themes were identified. Patients, nurses, and medical assistants identified barriers to asking questions in the current clinic setup, patient stress, and time constraints, while surgeons identified strategies to implement decision aids. All participants agreed that decision aids improve the informed consent process. Conclusion Key stakeholders identified barriers to the informed consent process and provided input on necessary components of a decision aid. Opportunities exist to address these barriers and improve the consent process.

Purpose: No consensus exists regarding the most effective form of pancreaticojejunostomy (PJ) following pancreaticoduodenectomy (PD). Methods: Data were gathered through the American College of Surgeons-National Surgical Quality Improvement Program, Pancreatectomy Demonstration Project. A total of 1781 patients underwent a PD at 43 institutions. After appropriate exclusions, 890 patients were analyzed. Patients were divided into duct-to-mucosa (n = 734, 82%) and invagination (n = 156, 18%) groups and were compared by unadjusted analysis. Type of PJ was included in eight separate morbidity and mortality multivariable analyses. Results: Invagination patients had higher serum albumin (p

Introduction: There is controversy regarding preoperative weight loss and its impact on the outcomes of bariatric surgery. We used a prospectively collected database to determine the association be...

Gastric ischemic conditioning prior to esophagectomy can increase neovascularization of the new conduit. Prior studies of ischemic conditioning have only investigated reductions in anastomotic leaks. Our aim was to analyze the association between gastric conditioning and all anastomotic outcomes as well as overall morbidity in our cohort of esophagectomy patients. We performed a retrospective review of patients undergoing esophagectomy from 2010 to 2015 in a National Cancer Institute designated center. Ischemic conditioning (IC) was performed on morbidly obese patients, those with cardiovascular disease or uncontrolled diabetes, and those requiring feeding jejunostomy and active tobacco users. IC consisted of transection of the short gastric vessels and ligation of the left gastric vessels. Primary outcomes consisted of all postoperative anastomotic complications. Secondary outcomes were overall morbidity. Two-hundred and seven esophagectomies were performed with an average follow-up of 19 months. Thirty-eight patients (18.4%) underwent conditioning (IC). This group was similar to patients not conditioned (NIC) in age, preoperative pathology, and surgical approach. Five patients in the ischemic conditioning group (13.2%) and 57 patients (33.7%) in the NIC experienced anastomotic complications (p = 0.011). Ischemic conditioning significantly reduced the postoperative stricture rate fourfold (5.3 vs. 20.7% p = 0.02). IC patients experienced significantly fewer complications overall (36.8 vs. 56.2% p = 0.03). Gastric ischemic conditioning is associated with fewer overall anastomotic complications, fewer strictures, and less morbidity. Randomized studies may determine optimal selection criteria to determine whom best benefits from ischemic conditioning.

Background: For pancreatectomy patients, mortality increases with increasing age. Our study evaluated the relative contribution of overall postoperative complications and failure to rescue rates on the observed increased mortality in older patients undergoing pancreatic resection at specialized centers. Methods: We identified 2694 patients who underwent pancreatic resection from the American College of Surgeons’ National Surgical Quality Improvement Pancreatectomy Demonstration Project at 37 high-volume centers. Overall morbidity and in-hospital mortality were determined in patients younger than 80 years (N = 2496) and 80 years or older (N = 198). Failure to rescue was the number of deaths in patients with complications divided by the total number of patients with postoperative complications. Results: No significant differences were observed between patients younger than 80 years and those 80 years or older in the rates of overall complications (41.4% vs 39.4%, P = 0.58). In-hospital mortality increased in patients 80 years or older compared to patients younger than 80 years (3.0% vs 1.1%, P = 0.02). Failures to rescue rates were higher in patients 80 years or older (7.7% vs 2.7%, P = 0.01). Across 37 high-volume centers, unadjusted complication rates ranged from 25.0% to 72.2% and failure to rescue rates ranged from 0.0% to 25.0%. Among patients with postoperative complications, comorbidities associated with failure to rescue were ascites, chronic obstructive pulmonary disease, and diabetes. Complications associated with failure to rescue included acute renal failure, septic shock, and postoperative pulmonary complications. Conclusions: In experienced hands, the rates of complications after pancreatectomy in patients 80 years or older compared to patients younger than 80 years were similar. However, when complications occurred, older patients were more likely to die. Interventions to identify and aggressively treat complications are necessary to decrease mortality in vulnerable older patients.

Over the past two decades, as experience with advanced laparoscopy has increased, surgeons have increasingly adopted laparoscopic antireflux surgery as the gold standard approach to gastroesophageal reflux disease. However, with the expansive implementation of these techniques, a concomitant increased incidence of complications from antireflux surgery has also been observed. In this milieu, foregut surgeons are increasingly called upon to care for patients who have previously undergone an antireflux operation. This chapter addresses the epidemiology of reoperative surgery of the hiatus, the optimal clinical evaluation and management prior to operative intervention, and the technical approach to caring for these patients.

Optimal pain management in the perioperative period is essential to improving patient quality of life, preventing postoperative complications, and ensuring improved surgical outcomes.1 This review discusses the optimal clinical approach to pain management in the acute setting, centering on the concept of multimodal analgesia. Various opioid and nonopioid medications available for treating acute pain are discussed, with a focus on the “pain ladder,” adverse effects of pain medications, epidural and regional anesthetic techniques, and common pitfalls to avoid when managing postoperative pain. This review does not discuss chronic pain management.

Objective and background Minimally invasive breast biopsy (MIBB) rates remain well below guideline recommendations of more than 90% and vary across geographic areas. Our aim was to determine the variation in use attributable to the surgeon and facility and determine the patient, surgeon, and facility characteristics associated with the use of MIBB. Methods We used 100% Texas Medicare claims data (2000-2008) to identify women older than 66 years with a breast biopsy (open or minimally invasive) and subsequent breast cancer diagnosis/operation within 1 year. The percentage of patients undergoing MIBB as the first diagnostic modality was estimated for each surgeon and facility. Three-level hierarchical generalized linear models (patients clustered within surgeons within facilities) were used to evaluate variation in MIBB use. Results A total of 22,711 patients underwent a breast cancer operation by 1226 surgeons at 525 facilities. MIBB was the initial diagnostic modality in 62.4% of cases. Only 7.0% of facilities and 12.9% of surgeons used MIBB for more than 90% of patients. In 3-level models adjusted for patient characteristics, the percentage of patients who received MIBB ranged from 7.5% to 96.0% across facilities (mean = 50.1%, median = 49.2%) and from 8.0% to 87.0% across surgeons (mean = 50.3%, median = 50.9%). The variance in MIBB use was attributable to facility (8.8%) and surgeon (15.4%) characteristics. Lower surgeon and facility volume, longer surgeon years in practice, and smaller facility bed size were associated with lower rates of MIBB use. Conclusions Identification of surgeon and facility characteristics associated with low use of MIBB provides potential targets for interventions to improve MIBB rates and decrease variation in use. Type of study Retrospective cohort.

The decision regarding elective cholecystectomy in older patients with symptomatic cholelithiasis is complicated. We developed and validated a prognostic nomogram to guide shared decision making for these patients.We used Medicare claims (1996-2005) to identify the first episode of symptomatic cholelithiasis in patients older than 65 years who did not undergo hospitalization or elective cholecystectomy within 2.5 months of the episode. We described current patterns of care and modeled their risk of emergent gallstone-related hospitalization or cholecystectomy at 2 years. Model discrimination and calibration were assessed using a random split sample of patients.We identified 92,436 patients who presented to the emergency department (8.3%) or physician's office (91.7%) and who were not immediately admitted. The diagnosis for the initial episode was biliary colic/dyskinesia (65.3%), acute cholecystitis (26.6%), choledocholithiasis (5.7%), or gallstone pancreatitis (2.4%). The 2-year emergent gallstone-related hospitalization rate was 11.1%, with associated in-hospital morbidity and mortality rates of 56.5% and 6.5%. Factors associated with gallstone-related acute hospitalization included male sex, increased age, fewer comorbid conditions, complicated biliary disease on initial presentation, and initial presentation to the emergency department. Our model was well calibrated and identified 51% of patients with a risk less than 10% for 2-year complications and 5.4% with a risk more than 40% (C statistic, 0.69; 95% confidence interval, 0.63-0.75).Surgeons can use this prognostic nomogram to accurately provide patients with their 2-year risk of developing gallstone-related complications, allowing patients and physicians to make informed decisions in the context of their symptom severity and its impact on their quality of life.

We recently developed and validated a prognostic model that accurately predicts the 2-year risk of emergent gallstone-related hospitalization in older patients presenting with symptomatic gallstones.We used 100% Texas Medicare data (2000 to 2011) to identify patients aged 66 years and older with an initial episode of symptomatic gallstones not requiring emergency hospitalization. At presentation, we calculated each patient's risk of 2-year gallstone-related emergent hospitalization using the previously validated model. Patients were placed into the following risk groups based on model estimates:30%, 30% to60%, and ≥ 60%. Within each risk group, we calculated the percent of elective cholecystectomies (≤ 2.5 months from initial episode) performed.In all, 161,568 patients had an episode of symptomatic gallstones. Mean age was 76.5 ± 7.3 years and 59.9% were female. The 2-year risk of gallstone-related hospitalizations increased from 15.9% to 41.5% to 65.2% across risk groups. For the overall cohort, 22.3% in the low-risk group, 20.9% in the moderate-risk group, and 23.2% in the high-risk group underwent elective cholecystectomy in the 2.5 months after the initial symptomatic episode. In patients with no comorbidities, elective cholecystectomy rates decreased from 34.2% in the low-risk group to 26.7% in the high-risk group. Of patients who did not undergo cholecystectomy, only 9.5% were seen by a surgeon in the 2.5 months after the initial episode.The risk of recurrent acute biliary symptoms requiring hospitalization has no influence, or even a paradoxical negative influence, on the decision to perform elective cholecystectomy after an initial symptomatic episode. Translation of the risk prediction model into clinical practice can better align treatment with risk and improve outcomes in older patients with symptomatic gallstones.

Bariatric tourism is defined as the travel of an individual to another region to pursue a bariatric operation. This chapter will focus on bariatric tourism related to the United States. As such, bariatric tourism can be considered as outbound (outside the United States), inbound (into the United States), or intrabound (within the United States). Bariatric tourism presents a complex clinical, societal, and international issue that is multifaceted both at the patient level and at the population level. The decision for a patient to pursue bariatric care outside of their healthcare region can have multiple implications for their own safety as well as the well-being of the populations they visit. In addition, the management of the bariatric meditourist poses a unique clinical challenge for surgeons who are tasked with managing complications. We present the known literature on bariatric tourism, including the estimated scope of the issue, current guidelines, the outcomes and international standards of care, cost considerations, and ethical issues.

Implanting a magnetic lower esophageal sphincter augmentation device (LINX, Torax Medical) has become an increasingly common option in the surgical management of gastroesophageal reflux disease. As the enthusiasm for placing this device increases, experience in the management of device-related complications-including erosion-is necessary.We report a staged approach to LINX removal in a 64-year-old female with symptoms of odynophagia secondary to partial erosion of a LINX device into the esophagus.The patient had a 12-bead LINX device placed in 2011 at an outside, international facility. In late 2013, she began experiencing symptoms of odynophagia. An esophagogastroduodenoscopy at our institution in October 2015 demonstrated two metallic beads eroding through the distal esophageal lumen. An elective endoscopic removal of the two visible beads was performed. A postoperative esophagram confirmed that there was no resulting esophageal perforation. The patient noted mild improvement in her symptoms. After a 12-week period to allow for complete healing, the remaining 10 beads of the LINX device were explanted laparoscopically without complication. No further procedures were undertaken. At 2 months' follow-up, the patient noted complete resolution of her symptoms.Transmural erosion of the LINX device into the esophageal lumen is a rare occurrence, with only five such complications reported in the published literature. We present the first account of LINX explantation for esophageal erosion in the United States. We demonstrated that a staged laparoendoscopic approach to LINX removal in these cases is feasible with minimal morbidity.

There is a paucity of data on the current management and outcomes of liver-directed therapy (LDT) in older patients presenting with stage IV colorectal cancer (CRC). The aim of the study was to evaluate treatment patterns and outcomes in use of LDT in the setting of improved chemotherapy.We used Cancer Registry and linked Medicare claims to identify patients aged ≥66 y undergoing surgical resection of the primary tumor and chemotherapy after presenting with stage IV CRC (2001-2007). LDT was defined as liver resection and/or ablation-embolization.We identified 5500 patients. LDT was used in 34.9% of patients; liver resection was performed in 1686 patients (30.7%), and ablation-embolization in 554 patients (10.1%), with 322 patients having both resection and ablation-embolization. Use of LDT was negatively associated with increasing year of diagnosis (odds ratio [OR] = 0.96, 95% confidence interval [CI] 0.93-0.99), age85 y (OR = 0.61, 95% CI 0.45-0.82), and poor tumor differentiation (OR = 0.73, 95% CI 0.64-0.83). LDT was associated with improved survival (median 28.4 versus 21.1 mo, P 0.0001); however, survival improved for all patients over time. We found a significant interaction between LDT and period of diagnosis and noted a greater survival improvement with LDT for those diagnosed in the late (2005-2007) period.Older patients with stage IV CRC are experiencing improved survival over time, independent of age, comorbidity, and use of LDT. However, many older patients deemed to be appropriate candidates for resection of the primary tumor and receipt of systemic chemotherapy did not receive LDT. Our data suggest that improved patient selection may be positively impacting outcomes. Early referral and optimal selection of patients for LDT has the potential to further improve survival in older patients presenting with advanced colorectal cancer.

Improvements in the ability to predict pancreatic fistula could enhance patient outcomes. Previous studies demonstrate that drain fluid amylase on postoperative day 1 (DFA1) is predictive of pancreatic fistula. We sought to assess the accuracy of DFA1 and to identify a reliable DFA1 threshold under which pancreatic fistula is ruled out.Patients undergoing pancreatic resection from November 1, 2011 to December 31, 2012 were selected from the American College of Surgeons-National Surgical Quality Improvement Program Pancreatectomy Demonstration Project database. Pancreatic fistula was defined as drainage of amylase-rich fluid with drain continuation7 days, percutaneous drainage, or reoperation for a pancreatic fluid collection. Univariate and multi-variable regression models were utilized to identify factors predictive of pancreatic fistula.DFA1 was recorded in 536 of 2,805 patients who underwent pancreatic resection, including pancreaticoduodenectomy (n = 380), distal pancreatectomy (n = 140), and enucleation (n = 16). Pancreatic fistula occurred in 92/536 (17.2%) patients. DFA1, increased body mass index, small pancreatic duct size, and soft texture were associated with fistula (p 0.05). A DFA1 cutoff value of90 U/L demonstrated the highest negative predictive value of 98.2%. Receiver operating characteristic (ROC) curve confirmed the predictive relationship of DFA1 and pancreatic fistula.Low DFA1 predicts the absence of a pancreatic fistula. In patients with DFA1 90 U/L, early drain removal is advisable.

The impact of neoadjuvant therapy on postpancreatectomy complications is inadequately described. Data from the NSQIP Pancreatectomy Demonstration Project (11/2011 to 12/2012) was used to identify patients with pancreatic adenocarcinoma who did and did not receive neoadjuvant therapy. Neoadjuvant therapy was classified as chemotherapy alone or radiation ± chemotherapy. Outcomes in the neoadjuvant vs. surgery first groups were compared. Of 1,562 patients identified at 43 hospitals, 199 (12.7 %) received neoadjuvant therapy (99 chemotherapy alone and 100 radiation ± chemotherapy). Preoperative biliary stenting (57.9 vs. 44.7 %, p = 0.0005), vascular resection (41.5 vs. 17.3 %, p

Multimodality therapy with chemotherapy and operative resection is recommended for patients with locoregional pancreatic cancer but is not received by many patients.To evaluate patterns in the use and timing of chemotherapy and resection and factors associated with receipt of multimodality therapy in older patients with locoregional pancreatic cancer.We used Surveillance, Epidemiology, and End Results-linked Medicare data (1992-2007) to identify patients with locoregional pancreatic adenocarcinoma. Multimodality therapy was defined as receipt of both chemotherapy and pancreatic resection. Logistic regression was used to determine factors independently associated with receipt of multimodality therapy. Log-rank tests were used to identify differences in survival for patients stratified by type and timing of treatment.We identified 10,505 patients with pancreatic adenocarcinoma. 5,358 patients (51.0%) received either chemotherapy or surgery, with 1,166 patients (11.1%) receiving both modalities. Resection alone was performed in 1,138 patients (10.8%), and chemotherapy alone was given to 3,054 (29.1%) patients. In patients undergoing resection as the initial treatment modality, 49.4% never received chemotherapy; 97.4% of patients who underwent chemotherapy as the initial treatment modality never underwent resection. The use of multimodality therapy increased from 7.4% of patients in 1992-1995 to 13.8% of patients in 2004-2007 (P.0001). The 2-year survival was 41.0% for patients receiving multimodality therapy, 25.1% with resection alone, and 12.5% with chemotherapy alone (P.0001). Of the patients receiving multimodality therapy, chemotherapy was delivered in the adjuvant setting in 93.1% and in the neoadjuvant setting in 6.9%, with similar 2-year survival with either approach (neoadjuvant vs adjuvant, 46.9% vs 40.6%; P = .16). Year of diagnosis, white race, less comorbidity, and no vascular invasion were independently associated with receipt of multimodality therapy.Only half of older patients with locoregional pancreatic cancer receive any treatment, and fewer than one quarter of treated patients receive multimodality therapy. Nearly all patients receiving chemotherapy as the initial treatment modality did not undergo resection, whereas half of those undergoing resection first received chemotherapy. When multimodality therapy is used, the vast majority of patients had chemotherapy in the adjuvant setting with a similar survival, regardless of approach.

Our objective was to determine the probability threshold for recurrent symptoms at which elective cholecystectomy compared to observation in older patients with symptomatic cholelithiasis is the more effective and cost-effective option. We built a decision model of elective cholecystectomy versus observation in patients >65 presenting with initial episodes of symptomatic cholelithiasis that did not require initial hospitalization or cholecystectomy. Probabilities for subsequent hospitalization, emergency cholecystectomy, and perioperative complications were based on previously published probabilities from a 5 % national sample of Medicare patients. Costs were estimated from Medicare reimbursements and from the Healthcare Cost and Utilization Project. Utilities (quality-adjusted life years, QALYs) were obtained from established literature estimates. Elective cholecystectomy compared to observation in all patients was associated with lower effectiveness (−0.10 QALYs) and had an increased cost of $3,422.83 per patient at 2-year follow-up. Elective cholecystectomy became the more effective option when the likelihood for continued symptoms exceeded 45.3 %. Elective cholecystectomy was both more effective and less costly when the probability for continued symptoms exceeded 82.7 %. An individualized shared decision-making strategy based on these data can increase elective cholecystectomy rates in patients at high risk for recurrent symptoms and minimize unnecessary cholecystectomy for patients unlikely to benefit.

Trends in the use of modern chemotherapeutic regimens, primary tumor resection, and the timing of chemotherapy and resection in older patients with stage IV colorectal cancer have not been evaluated. We used Cancer Registry- and Medicare-linked data (2000–2009) to describe time trends in resection of the primary tumor and receipt of chemotherapy in patients ≥66 presenting with stage IV colorectal cancer (N = 16,168). The mean age was 77.8 ± 7.3 years; 53.8 % were women and 82.9 % were white. Primary cancer sites were colon in 83.4 % and rectum in 16.6 %. Resection of the primary tumor decreased from 64.6 to 57.1 % (P

BACKGROUND A previous observational study reported that endoscopic ultrasound (EUS) is associated with improved survival in older patients with pancreatic cancer. The objective of this study was to reevaluate this association using different statistical methods to control for confounding and selection bias. METHODS Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data (1992-2007) was used to identify patients with locoregional pancreatic cancer. Two-year survival in patients who did and did not receive EUS was compared by using standard Cox proportional hazards models, propensity score methodology, and instrumental variable analysis. RESULTS EUS was associated with improved survival in both unadjusted (hazard ratio [HR] = 0.67, 95% confidence interval [CI] = 0.63-0.72) and standard regression analyses (HR = 0.78, 95% CI = 0.73-0.84) which controlled for age, sex, race, marital status, tumor stage, SEER region, Charlson comorbidity, year of diagnosis, education, preoperative biliary stenting, chemotherapy, radiation, and pancreatic resection. Propensity score adjustment, matching, and stratification did not attenuate this survival benefit. In an instrumental variable analysis, the survival benefit was no longer observed (HR = 1.00, 95% CI = 0.73-1.36). CONCLUSIONS These results demonstrate the need to exercise caution in using administrative data to infer causal mortality benefits with diagnostic and/or treatment interventions in cancer research. Cancer 2013;119:3861–3869. © 2013 American Cancer Society.

Background Surgeon and hospital volume are both known to affect outcomes for patients undergoing pancreatic resection. The objective was to evaluate the relative effects of surgeon and hospital volume on 30-d mortality and 30-d complications after pancreatic resection among older patients. Materials and methods The study used Texas Medicare data (2000-2012), identifying high-volume surgeons as those performing ≥4 pancreatic resections/year, and high-volume hospitals as those performing ≥11 pancreatic resections/year, on Medicare patients. Three-level hierarchical logistic regression models were used to evaluate the relative effects of surgeon and hospital volumes on mortality and complications, after adjusting for case mix differences. Results There were 2453 pancreatic resections performed by 490 surgeons operating in 138 hospitals. Of the total, 4.5% of surgeons and 6.5% of hospitals were high volume. The overall 30-d mortality was 9.0%, and the 30-d complication rate was 40.6%. Overall, 8.9% of the variance in 30-d mortality was attributed to surgeon factors and 9.8% to hospital factors. For 30-d complications, 4.7% of the variance was attributed to surgeon factors and 1.2% to hospital factors. After adjusting for patient, surgeon, and hospital characteristics, high surgeon volume (odds ratio [OR] = 0.54, 95% confidence interval [CI], 0.33-0.87) and high hospital volume (OR = 0.52; 95% CI, 0.30-0.92) were associated with lower risk of mortality; high surgeon volume (OR = 0.71, 95% CI, 0.55-0.93) was also associated lower risk of 30-d complications. Conclusions Both hospital and surgeon factors contributed significantly to the observed variance in mortality, but only surgeon factors impacted complications.

BACKGROUND Serial computed tomography (CT) imaging of blunt splenic injury can identify the latent formation of splenic artery pseudoaneurysms (PSAs), potentially contributing to improved success in nonoperative management. However, it remains unclear whether the delayed appearance of such PSAs is truly pathophysiologic or attributable to imaging quality and timing. The objective of this study was to evaluate the influence of recent advancements in imaging technology on the incidence of the latent PSA. METHODS Consecutive patients with blunt splenic injury over 4.5 years were identified from our trauma registry. Follow-up CT was performed for all but low-grade injuries 24 hours to 48 hours after initial CT. Incidences of both early and latent PSA formation were reviewed and compared with respect to imaging technology (4-slice vs. >or=16-slice). RESULTS A total of 411 patients were selected for nonoperative management of blunt splenic injury. Of these, 135 had imaging performed with 4-slice CT, and 276 had imaging performed with CTs of >=16-slice. Mean follow-up was 75 days (range, 1-1178 days) and 362 patients (88%) had follow-up beyond 7 days. Comparing 4-slice CT with >or=16-slice CT, there were no significant differences in the incidence of early PSA (3.7% vs. 4.7%; p = 0.91) or latent PSA (2.2% vs. 2.9%; p = 0.90). In both groups, latent PSAs accounted for approximately 38% of all PSAs observed. Splenic injury grade on initial CT was not associated with latent PSA (p = 0.54). Overall, the failure rate of nonoperative management was 7.3%. Overall mortality was 4.6%. No mortalities were related to splenic or other intra-abdominal injury. CONCLUSIONS The incidences of both early and latent PSA have remained remarkably stable despite advances in CT technology. This suggests that latent PSA is not a result of imaging technique but perhaps a true pathophysiologic phenomenon. Injury grade is unhelpful concerning the prediction of latent PSA formation.

Pancreatic cancer is considered a systemic disease at presentation. Therefore, multimodality therapy with surgical resection and chemotherapy is the standard of care for locoregional disease. We described treatment patterns and time trends with regard to age and treatment center in the receipt of multimodality therapy.We used the National Cancer Data Base to identify patients ≥18 years old with stage I and II pancreatic adenocarcinoma. Treatment was defined as no treatment, resection only, chemotherapy only, or multimodality therapy, which consisted of both chemotherapy (neoadjuvant or adjuvant) and resection. Trends in the receipt and type of treatment were compared.Of 39,441 patients, 22.8% of patients received no treatment, 18.5% received chemotherapy only, 23.0% underwent surgical resection alone, and 35.8% of patients received multimodality therapy. Receipt of multimodality therapy increased from 31.3% in 2004 to 37.9% in 2011 (p 0.0001). Patients55 years were less likely to receive multimodality therapy (56-64 years: OR 0.83, 95% CI 0.78-0.89; 65-75: OR 0.60, 95% CI 0.55-0.65; ≥76: OR 0.17, 95% CI 0.16-0.19 compared to patients 18-55). Compared to community hospitals, patients treated at an NCI-designated center were more likely to receive multimodality therapy (OR 1.62, 95% CI 1.46-1.81) and, if they received multimodality therapy, delivery of chemotherapy in the neoadjuvant compared to adjuvant setting (OR 2.82, 95% CI 2.00-3.98).Despite increased use of multimodality therapy, it remains underutilized in all patients and especially in older patients. Receipt of multimodality therapy and neoadjuvant therapy is highly dependent on treatment at NCI-designated cancer centers.

While there are many reported advantages to laparoscopic surgery compared to open surgery, the impact of a laparoscopic approach on postoperative morbidity in obese patients undergoing rectal surgery has not been studied. Our goal was to determine whether obese patients undergoing laparoscopic rectal surgery experienced the same benefits as non-obese patients. We identified patients undergoing rectal resections using the National Surgical Quality Improvement Project Participant Use Data File. We performed multivariable analyses to determine the independent association between laparoscopy and postoperative complications. A total of 26,437 patients underwent rectal resection. The mean age was 58.5 years, 32.6 % were obese, and 47.2 % had cancer. Laparoscopic procedures were slightly less common in obese patients compared to non-obese patients (36.0 vs. 38.2 %, p = 0.0006). In unadjusted analyses, complications were lower with the laparoscopic approach in both obese (18.9 vs. 32.4 %, p

Routine drainage of the operative bed following elective pancreatectomy remains controversial. Data specific to distal pancreatectomy (DP) have not been examined in a multi-institutional collaborative. : Data from the American College of Surgeons-National Surgical Quality Improvement Program Pancreatectomy Demonstration Project were utilized. The impact of drain placement on development of pancreatectomy-related and overall morbidity were analyzed. Propensity scores for drain placement were calculated, and nearest neighbor matching was used to create a matched cohort. Groups were compared using bivariate and logistic regression analyses. : Over 14 months, 761 patients undergoing DP were accrued; 606 were drained. Propensity score matching was possible in 116 patients. Drain and no drain groups were not different with respect to multiple preoperative and operative variables. All pancreatic fistulas (p

Intrahepatic cholangiocarcinoma (ICC) is a rare tumor, with an increasing incidence worldwide and an overall poor prognosis. Symptoms are usually nonspecific, contributing to an advanced tumor stage at diagnosis. The staging system for ICC has recently been updated and is based on number of lesions, vascular invasion, and lymph node involvement. Complete surgical resection to negative margins remains the only potentially curable treatment for ICC. Gemcitabine-based adjuvant therapy can be offered based on limited data from patients with unresectable ICC. Overall 5-year survivals after resection range from 17% to 44%, with median survivals of 19 to 43 months.

BackgroundThe factors associated with delayed gastric emptying (DGE) after a pancreaticoduodenectomy (PD) are not definitively known.MethodsFrom November 2011 through to May 2012, data were prospectively collected on 711 patients undergoing a pancreaticoduodenectomy or total pancreatectomy as part of the American College of Surgeons‐National Surgical Quality Improvement Program Pancreatectomy Demonstration Project. Bivariate and multivariate models were employed to determine the factors that predicted DGE.ResultsIn the 711 patients, the overall rate of DGE was 20.1%. In a bivariate analysis, intra‐operative factors such as pylorus‐preservation (47.1% versus 43.7%, P = 0.40), intra‐operative drain placement (85.5%, versus 85.1%, P = 0.91) and an antecolic compared with a retrocolic gastrojejunostomy (60.1% versus 65.1%, P = 0.26) were not different between the DGE and no DGE groups. Pancreatic fistula formation (31.2% versus 10.1%), post‐operative sepsis (21.7% versus 7.0%), organ space surgical site infection (SSI) (23.9% versus 7.9%), need for percutaneous drainage (23.0% versus 10.6%) and reoperation (10.6% versus 3.1%) were higher in patients with DGE (P < 0.0001). In a multivariable model, only pancreatic fistula, post‐operative sepsis and reoperation were independently associated with DGE.DiscussionIn this multicentre study, only post‐operative complications were associated with DGE. Neither pylorus preservation nor route of enteric reconstruction (antecolic versus retrocolic) was associated with delayed gastric emptying.

Guidelines for post resection surveillance of colorectal cancer recommend a collection of the patient's history and physical examination, testing for carcinoembryonic antigen (CEA), and colonoscopy. No consistent guidelines exist for the use of abdominal computed tomography (CT) and position emission tomography (PET)/PET-CT. The goal of our study was to describe current trends, the impact of oncologic follow-up on guideline adherence, and the patterns of use of nonrecommended tests.We used Texas Cancer Registry-Medicare-linked data (2000-2009) to identify physician visits, CEA testing, colonoscopy, abdominal CT, and PET/PET-CT scans in patients ≥ 66 years old with stage I-III colorectal cancer who underwent curative resection. Compliance with guidelines was assessed with a composite measure of physician visits, CEA tests, and colonoscopy use from start of surveillance.In patients who survived 3 years, the overall compliance with guidelines was 25.1%. In patients seen regularly by a medical oncologist, compliance with guidelines increased to 61.5% compared with 8.8% for those not seen by a medical oncologist regularly (P.0001). The use of abdominal CT and PET/PET-CT increased from 57.5% and 9.5%, respectively, in 2001 to 65.8% and 24.6% (P.0001) in 2006. Patients who saw a medical oncologist were more likely to get cross-sectional imaging than those who did not (P.0001).Compliance with current minimum guidelines for post treatment surveillance of colorectal cancer is low and the use of nonrecommended testing has increased over time. Both compliance and use of nonrecommended tests are markedly increased in patients seen by a medical oncologist. The comparative effectiveness of CT and PET/PET-CT in the surveillance of colorectal cancer patients needs further examination.

Only annual mammography and physical examination are recommended for the post-treatment surveillance of early stage breast cancer.We used Texas Cancer Registry-Medicare linked data (2001-2007) to identify physician visits and use of mammography, magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET) CT in patients ≥ 66 years old with ductal carcinoma in situ and stage I-III ductal carcinoma who underwent curative-intent operations. We also evaluated the trends in use of recommended and nonrecommended tests.We identified 8,598 patients with resected ductal carcinoma in situ (37.3%) or invasive ductal cancer (62.7%). Breast-conserving therapy was performed in 59%. Only 55% saw a physician twice a year for 2 years and underwent annual mammography for 2 consecutive years in the surveillance period. Mammography use decreased from 81% in 2001 to 75% in 2007 (P.0001), and breast MRI use rose from 0.5% to 7.0% (P.0001). For asymptomatic patients, the use of CT/MRI of the abdomen, chest, and head was 27%, 23%, and 22%, and this slightly increased during the study period. There was a significant increase in PET/PET CT use, from 2% in 2001 to 9% in 2007 (P.0001). There was a concomitant decrease in bone scan use from 21% in 2001 to 13% in 2007 (P.0001).Adherence to evidence-based guidelines has been substandard and the use of nonrecommended tests has persisted over the study period. The rise in PET use and attendant decrease in bone scan implicates a population receiving PET scan in lieu of bone scan for surveillance of asymptomatic metastatic disease. In an elderly population of breast cancer patients in Texas, these findings imply both underuse and overuse.