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Introduction: The management of many patients with early-stage melanoma includes sentinel lymph node (SLN) biopsy for prognostic and treatment planning purposes. While the minimum necessary number of SLNs to examine has been determined for patients with other malignancies, it has not been delineated in melanoma. The current study evaluates risk factors for SLN positivity and the associated number of SLNs that are necessary to examine for appropriate staging., Materials and Methods: The National Cancer Database participant user file from 2018 to 2020 was queried for clinically node-negative patients who underwent SLN biopsy. Descriptive statistics were obtained. Analysis of variance statistical analyses were performed., Results: Eight thousand forty eight melanoma patients out of 48,748 were identified from 2018 to 2020 that had lymph node positivity on SLN biopsy. The median age of patients was 64. The male-to-female ratio was 1.47. Chi-squared analysis revealed that there was a statistically significant difference in positivity rate between at least two groups (P = 0.006) for primary melanoma site, male sex (P < 0.01), race, age, histologic type, Breslow thickness, and lymphovascular invasion (P < 0.001). SLN positivity rate increased with the number of SLNs examined until plateauing at 4 SLNs. There was no statistical difference between positivity for 3 SLNs and larger numbers of SLNs examined. Propensity matching revealed no statistically significant difference in positive rate when more than 2 SLNs were biopsied., Conclusions: SLN positivity is proportionally related to the number of SLNs examined, suggesting that surgeons should attempt to remove a minimum of 2 SLNs for the optimal staging of patients with melanoma., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: A hospital's approach (volume of cancer treatment services provided) to treating metastatic colorectal cancer influences a patient's treatment as strongly as patient disease status. The implications of hospital-level treatment approaches across disease stages remain understudied. We sought to determine if hospital service volume (SV) for metastatic colorectal cancer could be predictive of nonstandard treatment patterns in stages I-III colon cancer., Materials and Methods: Using the National Cancer Database, we examined rates of nonstandard treatment patterns among patients with colon cancer between 2010 and 2017. After adjusting for clinicopathological characteristics using multivariable logistic regression, we evaluated the relationship between hospital-level SV for metastatic colorectal cancer and nonstandard treatment approaches for patients with stages I-III colon cancer., Results: There were significant associations between hospital-level SV for metastatic colorectal cancer and the odds of chemotherapy overtreatment among patients with stage I-III colon cancer, as well as undertreatment among patients with stages II-III disease after adjusting for hospital-, patient-, and tumor-level covariates. Patients at the highest-level SV hospitals for metastatic disease had 1.29 higher odds (95% CI = 1.18-1.41; P < 0.0001) of receiving overtreatment compared to patients from lowest SV hospitals. The odds ratio of undertreatment in highest SV compared to lowest SV was 0.64 (95% CI 0.56-0.72; P< 0.0001)., Conclusions: Hospital-level SV of patients with metastatic colon cancer is a significant indicator of nonstandard treatment patterns among patients with stage I-III colon cancer. Hospitals with the highest volume of cancer treatments have higher odds of providing overtreatment, while low SVs are associated with higher odds of undertreatment., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The role of systemic therapy in the management of ampullary (AA) and duodenal adenocarcinoma (DA) remains poorly understood. This study sought to synthesize current evidence supporting the use of neoadjuvant therapy (NAT) in AA and DA., Methods: The study searched PubMed, Cochrane Library (Wiley), Embase (Elsevier), CINAHL (EBSCO), and ClinicalTrials.gov databases for observational or randomized studies published between 2002 and 2022 evaluating survival outcomes for patients with non-metastatic AA or DA who received systemic therapy and surgical resection. The data extracted included overall survival, progression-free survival, and pathologic response (PR) rate., Results: From the 347 abstracts identified in this study, 29 reports were reviewed in full, and 15 were included in the final review. The selected studies published from 2007 to 2022 were retrospective. Eight were single-center studies; five used the National Cancer Database (NCDB); and two were European multicenter/national studies. Overall, no studies identified survival differences between NAT and upfront surgery (with or without adjuvant therapy). Two NCDB studies reported longer survival with NAT/AT than with surgery. Five single-center studies reported a significant portion of NAT patients who achieved PR, and one study identified major PR as an independent predictor of survival. Other outcomes associated with NAT included conversion from unresectable to resectable disease, reduced lymph node positivity, and decreased local recurrence rate., Conclusion: Evidence supporting the use of NAT in AA and DA is weak. No randomized studies exist, and observational data show mixed results. For patients with DA and AA, NAT appears safe, but better evidence is needed to understand the preferred multidisciplinary management of DA and AA periampullary malignancies., (© 2023. Society of Surgical Oncology.)

Patients who undergo resection for non-invasive IPMN are at risk for long-term recurrence. Further evidence is needed to identify evidence-based surveillance strategies based on the risk of recurrence. We performed a systematic review of the current literature regarding recurrence patterns following resection of non-invasive IPMN to summarize evidence-based recommendations for surveillance. Among the 61 studies reviewed, a total of 8779 patients underwent resection for non-invasive IPMN. The pooled overall median follow-up time was 49.5 months (IQR: 38.5-57.7) and ranged between 14.1 months and 114 months. The overall median recurrence rate for patients with resected non-invasive IPMN was 8.8% (IQR: 5.0, 15.6) and ranged from 0% to 27.6%. Among the 33 studies reporting the time to recurrence, the overall median time to recurrence was 24 months (IQR: 17, 46). Existing literature on recurrence rates and post-resection surveillance strategies for patients with resected non-invasive IPMN varies greatly. Patients with resected non-invasive IPMN appear to be at risk for long-term recurrence and should undergo routine surveillance.

Objective: To establish the association between bactibilia and postoperative complications when stratified by perioperative antibiotic prophylaxis., Background: Patients undergoing pancreatoduodenectomy experience high rates of surgical site infection (SSI) and clinically relevant postoperative pancreatic fistula (CR-POPF). Contaminated bile is known to be associated with SSI, but the role of antibiotic prophylaxis in mitigation of infectious risks is ill-defined., Methods: Intraoperative bile cultures (IOBCs) were collected as an adjunct to a randomized phase 3 clinical trial comparing piperacillin-tazobactam with cefoxitin as perioperative prophylaxis in patients undergoing pancreatoduodenectomy. After compilation of IOBC data, associations between culture results, SSI, and CR-POPF were assessed using logistic regression stratified by the presence of a preoperative biliary stent., Results: Of 778 participants in the clinical trial, IOBC were available for 247 participants. Overall, 68 (27.5%) grew no organisms, 37 (15.0%) grew 1 organism, and 142 (57.5%) were polymicrobial. Organisms resistant to cefoxitin but not piperacillin-tazobactam were present in 95 patients (45.2%). The presence of cefoxitin-resistant organisms, 92.6% of which contained either Enterobacter spp. or Enterococcus spp., was associated with the development of SSI in participants treated with cefoxitin [53.5% vs 25.0%; odds ratio (OR)=3.44, 95% CI: 1.50-7.91; P =0.004] but not those treated with piperacillin-tazobactam (13.5% vs 27.0%; OR=0.42, 95% CI: 0.14-1.29; P =0.128). Similarly, cefoxitin-resistant organisms were associated with CR-POPF in participants treated with cefoxitin (24.1% vs 5.8%; OR=3.45, 95% CI: 1.22-9.74; P =0.017) but not those treated with piperacillin-tazobactam (5.4% vs 4.8%; OR=0.92, 95% CI: 0.30-2.80; P =0.888)., Conclusions: Previously observed reductions in SSI and CR-POPF in patients that received piperacillin-tazobactam antibiotic prophylaxis are potentially mediated by biliary pathogens that are cefoxitin resistant, specifically Enterobacter spp. and Enterococcus spp., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Importance: Despite improvements in perioperative mortality, the incidence of postoperative surgical site infection (SSI) remains high after pancreatoduodenectomy. The effect of broad-spectrum antimicrobial surgical prophylaxis in reducing SSI is poorly understood., Objective: To define the effect of broad-spectrum perioperative antimicrobial prophylaxis on postoperative SSI incidence compared with standard care antibiotics., Design, Setting, and Participants: Pragmatic, open-label, multicenter, randomized phase 3 clinical trial at 26 hospitals across the US and Canada. Participants were enrolled between November 2017 and August 2021, with follow-up through December 2021. Adults undergoing open pancreatoduodenectomy for any indication were eligible. Individuals were excluded if they had allergies to study medications, active infections, chronic steroid use, significant kidney dysfunction, or were pregnant or breastfeeding. Participants were block randomized in a 1:1 ratio and stratified by the presence of a preoperative biliary stent. Participants, investigators, and statisticians analyzing trial data were unblinded to treatment assignment., Intervention: The intervention group received piperacillin-tazobactam (3.375 or 4 g intravenously) as perioperative antimicrobial prophylaxis, while the control group received cefoxitin (2 g intravenously; standard care)., Main Outcomes and Measures: The primary outcome was development of postoperative SSI within 30 days. Secondary end points included 30-day mortality, development of clinically relevant postoperative pancreatic fistula, and sepsis. All data were collected as part of the American College of Surgeons National Surgical Quality Improvement Program., Results: The trial was terminated at an interim analysis on the basis of a predefined stopping rule. Of 778 participants (378 in the piperacillin-tazobactam group [median age, 66.8 y; 233 {61.6%} men] and 400 in the cefoxitin group [median age, 68.0 y; 223 {55.8%} men]), the percentage with SSI at 30 days was lower in the perioperative piperacillin-tazobactam vs cefoxitin group (19.8% vs 32.8%; absolute difference, -13.0% [95% CI, -19.1% to -6.9%]; P < .001). Participants treated with piperacillin-tazobactam, vs cefoxitin, had lower rates of postoperative sepsis (4.2% vs 7.5%; difference, -3.3% [95% CI, -6.6% to 0.0%]; P = .02) and clinically relevant postoperative pancreatic fistula (12.7% vs 19.0%; difference, -6.3% [95% CI, -11.4% to -1.2%]; P = .03). Mortality rates at 30 days were 1.3% (5/378) among participants treated with piperacillin-tazobactam and 2.5% (10/400) among those receiving cefoxitin (difference, -1.2% [95% CI, -3.1% to 0.7%]; P = .32)., Conclusions and Relevance: In participants undergoing open pancreatoduodenectomy, use of piperacillin-tazobactam as perioperative prophylaxis reduced postoperative SSI, pancreatic fistula, and multiple downstream sequelae of SSI. The findings support the use of piperacillin-tazobactam as standard care for open pancreatoduodenectomy., Trial Registration: ClinicalTrials.gov Identifier: NCT03269994.

Background: Patients with pancreas cancer may undergo palliative gastrointestinal or biliary bypass. Recent comparisons of post-operative outcomes following such procedures are lacking., Methods: We analyzed patients undergoing exploration, gastrojejunostomy, biliary bypass or double bypass for pancreatic cancer using data from the 2005-2019 American College of Surgeons National Surgical Quality Improvement Program. We compared 30-day mortality and complications across procedures and over time periods (2005-10, 2011-14, 2015-19) using multivariable regression models. Factors associated with postoperative mortality were identified., Results: Of 43,525 patients undergoing surgery with a postoperative diagnosis of pancreatic cancer, 5572 met inclusion criteria. Palliative operations included 1037 gastrojejunostomies, 792 biliary bypasses, 650 double bypasses, and 3093 explorations. The proportion of biliary and double bypass procedures decreased from 2005-10 to 2015-19. Gastrojejunostomy had higher 30-day mortality rate (11.5%) than other operations (p < 0.001). Adjusted 30-day mortality rates remained stable over time (7.8% vs 6.3%, p = 0.095), while rates of serious complications decreased over time (23.2% vs 17.1%, p < 0.001)., Conclusions: Palliative bypass for pancreatic cancer has not become safer over time, and 30-day mortality and complications remain high., Competing Interests: Declaration of competing interest None Declared for all authors., (Published by Elsevier Inc.)

Background: Recent literature suggests wide variations exist in the international management of locally advanced pancreatic cancer. This study sought to evaluate how geography contributes to variations in management of locally advanced pancreatic cancer., Methods: An electronic survey investigating preferences for the evaluation and management of locally advanced pancreatic cancer was distributed to an international cohort of pancreatic surgeons. Surgeons were classified according to geographic location of practice, and survey responses were compared across locations., Results: A total of 153 eligible responses were received from 4 continents: North and South America (n = 94, 61.4%), Europe (n = 25, 16.3%), and Asia (n = 34, 22.2%). Preferences for the use and duration of neoadjuvant chemotherapy and radiotherapy varied widely. For example, participants in Asia commonly preferred 2 months of neoadjuvant chemotherapy (61.8%), whereas North and South American participants preferred 4 months (52.1%), and responses in Europe were mixed (P = .006). Participants in Asia were less likely to consider isolated liver or lung metastases contraindications to exploration and consequently had a greater propensity to consider exploration in a vignette of oligometastatic disease (56.7% vs North and South America: 25.6%, Europe: 43.5%; P = .007)., Conclusion: In an international survey of pancreatic surgeons, attitudes regarding locally advanced pancreatic cancer and metastatic disease management varied widely across geographic locations. Better evidence is needed to define optimal management of locally advanced pancreatic cancer., (© 2022 The Authors.)

Background: In borderline resectable and locally advanced (BRLA) pancreatic cancer patients, the role of adjuvant therapy (AT) after neoadjuvant therapy (NAT) and curative-intent resection is poorly understood., Methods: Using the National Cancer Database (NCDB) between 2011 and 2017, we identified BRLA patients who received NAT and resection. Kaplan-Meier analysis and multivariable Cox proportional hazards (PH) regression were performed to examine the association between AT and overall survival (OS)., Results: Of 17,905 BRLA patients identified, 764 received NAT and resection, of which 203 received AT. Median age was 63 years, and 53.1% were female. Kaplan Meier analysis revealed no differences in median OS between AT vs non-AT groups (28.9 vs 30.1months, p = 0.498). In the multivariable Cox PH model, after adjusting for other factors, when margin was positive, AT was associated with an improved survival (HR 0.54, 95%CI 0.32-0.90, p = 0.031)., Conclusion: AT was not associated with survival in BRLA patients who received NAT and resection except in patients with positive margins. Further research is necessary to better understand the role of AT following NAT in patients with BRLA., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Radiation therapy (RT) has a suboptimal effect in patients with pancreatic ductal adenocarcinoma (PDAC) due to intrinsic and acquired radioresistance (RR). Comprehensive bioinformatics and microarray analysis revealed that cholesterol biosynthesis (CBS) is involved in the RR of PDAC. We now tested the inhibition of the CBS pathway enzyme, farnesyl diphosphate synthase (FDPS), by zoledronic acid (Zol) to enhance radiation and activate immune cells., Methods: We investigated the role of FDPS in PDAC RR using the following methods: in vitro cell-based assay, immunohistochemistry, immunofluorescence, immunoblot, cell-based cholesterol assay, RNA sequencing, tumouroids (KPC-murine and PDAC patient-derived), orthotopic models, and PDAC patient's clinical study., Findings: FDPS overexpression in PDAC tissues and cells (P < 0.01 and P < 0.05) is associated with poor RT response and survival (P = 0.024). CRISPR/Cas9 and pharmacological inhibition (Zol) of FDPS in human and mouse syngeneic PDAC cells in conjunction with RT conferred higher PDAC radiosensitivity in vitro (P < 0.05, P < 0.01, and P < 0.001) and in vivo (P < 0.05). Interestingly, murine (P = 0.01) and human (P = 0.0159) tumouroids treated with Zol+RT showed a significant growth reduction. Mechanistically, RNA-Seq analysis of the PDAC xenografts and patients-PBMCs revealed that Zol exerts radiosensitization by affecting Rac1 and Rho prenylation, thereby modulating DNA damage and radiation response signalling along with improved systemic immune cells activation. An ongoing phase I/II trial (NCT03073785) showed improved failure-free survival (FFS), enhanced immune cell activation, and decreased microenvironment-related genes upon Zol+RT treatment., Interpretation: Our findings suggest that FDPS is a novel radiosensitization target for PDAC therapy. This study also provides a rationale to utilize Zol as a potential radiosensitizer and as an immunomodulator in PDAC and other cancers., Funding: National Institutes of Health (P50, P01, and R01)., Competing Interests: Declaration of interests Dr. Surinder K. Batra is one of the co-founders of Sanguine Diagnostics and Therapeutics, Inc. All other authors disclosed no potential conflicts of interest., (Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: The utilization of cancer-directed treatment for patients with all stages of pancreatic cancer in the USA is unknown. This study sought to examine national practice patterns and identify patient, hospital, regional, and other factors associated with disparities in the use of guideline-concordant cancer-directed therapy., Methods: Patients diagnosed with PDAC between 2004 and 2015 were queried from the National Cancer Data Base. Standard of care cancer-directed treatment was defined as surgical resection plus chemotherapy or chemoradiation for patients with stage 1 and 2 disease, chemotherapy for patients with metastatic disease (stage 4), and chemotherapy with or without surgery or chemoradiation for patients with locally advanced stage 3 disease., Results: A total of 336,629 patients with stage 1 (n = 38,443, 11.4%), stage 2 (n = 93,923, 27.9%), stage 3 (n = 37,492, 11.1%), or stage 4 metastatic (n = 166,771, 49.5%) disease were identified. Adherence with stage-specific standard of care treatment occurred in only 45.3% (n = 152,560) of patients among the entire cohort and varied by stage of disease (stage 1: 14.6% vs. stage 2: 39.9% vs. stage 3: 67.6%, vs. stage 4: 50.9%). Older age (OR 0.95, 95%CI 0.94-0.95; p < 0.001), female sex (OR 0.94, 95%CI 0.943-0.97; p < 0.001), African Americans (OR 0.89, 95%CI 0.87-0.91; P < 0.001), and increasing comorbidity burden (Charlson-Deyo score ≥3: OR 0.52, 95%CI 0.50-0.55; P < 0.001) were associated with a lower likelihood of receiving stage-specific standard of care treatment. Conversely, treatment at a high-volume center (quartile 4: OR: 1.13, 95%CI 1.10-1.16; P < 0.001) and higher education level (OR 1.32, 95%CI 1.28-1.36; p < 0.001) was associated with higher likelihood of receiving stage-specific standard of care treatment. Patients who received standard of care treatment had a 47% lower risk of death compared with patients who did not receive standard of care treatment (HR 0.53, 95%CI 0.52-0.53; P < 0.001)., Conclusion: Pancreatic adenocarcinoma is a complex disease requiring a multi-disciplinary approach for optimal outcomes. Receipt of stage-specific standard of care treatment for PDAC is associated with improved long-term oncological outcomes, but is only achieved in less than half of patients. Further studies are needed to evaluate interventions to address these treatment disparities for patients with PDAC., (© 2021. The Society for Surgery of the Alimentary Tract.)

Background and Purpose: There is limited high-level evidence to guide locally advanced pancreas cancer (LAPC) management. Recent work shows that surgeons' preferences in LAPC management vary broadly. We sought to examine whether surgeon volume was associated with attitudes regarding LAPC management., Methods: An electronic survey was distributed by email to an international cohort of pancreas surgeons to evaluate practice patterns regarding LAPC management. Clinical vignette-based questions evaluated surgeons' attitudes regarding patient eligibility and the proclivity to offer exploration. Surgeons were classified into "low-" or "high-volume" categories according to thresholds of self-reported annual pancreatectomy volume. Surgeon's attitudes regarding LAPC management and inclination to consider exploration were compared across annual volume categories., Results: A total of 153 eligible responses were received from 4 continents, for an estimated response rate of 10.6%. Median duration of practice was 12 years (IQR 6-20). Most respondents reported >25 cases/year (89, 58.2%), of which 34 (22.2%) reported >50. Compared to surgeons with <25 cases/year, surgeons with >25 cases/year practiced longer (median 15 vs. 7.5 years, P<0.001) and were more likely to "always" recommend neoadjuvant chemotherapy (83.2% vs. 56.3%, P=0.001). Surgeons performing >50 cases/year were more likely to offer arterial resection (70.6% vs. 43.7%, P=0.006). The willingness to offer (or defer) exploration did not differ across any categories of surgeons' annual case volume., Conclusions: In an international survey of pancreas surgeons, the proclivity to consider exploration for LAPC was not associated with multiple categories of surgeon volume. Better evidence is needed to define the optimal management approach to LAPC., (© 2021. The Society for Surgery of the Alimentary Tract.)

Background: The use of neoadjuvant therapy (NAT) for pancreatic ductal adenocarcinoma (PDAC) is increasing. While there is an association between NAT and improved post-pancreatectomy complication rates in limited patient populations, the strength of the relationship and its applicability to a broader and modern pancreatectomy cohort remains unclear., Methods: We used the 2014-2018 American College of Surgeons National Surgical Quality Improvement Project to evaluate NAT use for PDAC patients undergoing pancreatectomy. We also used propensity score matching techniques to compare 30-day postoperative outcomes, including clinically relevant postoperative pancreatic fistula (CR-POPF) and delayed gastric emptying (DGE), between patients selected for NAT versus upfront surgery., Results: Patients receiving NAT were more likely to undergo vascular resections (33% vs. 16%, p < 0.001), have perioperative transfusions (18% vs. 12%, p < 0.001), and undergo longer procedures. Rates of CR-POPF (6%, vs. 10%, p < 0.001), DGE (11% vs. 13%, p = 0.016), postoperative percutaneous drainage (9% vs. 12%, p < 0.001), and SSI (15% vs. 18%, p < 0.001) were lower for patients selected for NAT. The association of NAT with CR-POPF remained statistically significant (adjusted odds ratio 0.52, 95% CI 0.42-0.66) after adjustment for operative technique, gland texture, and need for vascular resection for patients undergoing pancreaticoduodenectomy, but not for patients undergoing distal pancreatectomy., Conclusions: Among PDAC patients undergoing resection, selection for NAT is associated with fewer CR-POPFs, postoperative procedural interventions, and infectious complications, particularly for patients undergoing pancreaticoduodenectomy. These associations should be considered in discussions of multidisciplinary treatment sequencing for patients with PDAC.

Objective: The aim of this study was to investigate surgeon preferences for the management of patients with locally advanced pancreatic cancer (LAPC)., Background: Select patients with LAPC may become candidates for curative resection following neoadjuvant therapy, and recent reports of survival are encouraging. Yet the optimal management approach remains unclear., Methods: An extensive electronic survey was systematically distributed by email to an international cohort of pancreas surgeons. Data collected included practice characteristics, management preferences, attitudes regarding contraindications to surgery, and 6 clinical vignettes of patients that ultimately received a margin negative resection (with detailed videos of post-neoadjuvant imaging) to assess propensity for surgical exploration if resection status is not known., Results: A total of 153 eligible responses were received from 4 continents. Median duration of practice is 12 years (interquartile range 6-20) and 77% work in a university setting. Most surgeons (86%) are considered high volume (>10 resections/yr), 33% offer a minimally-invasive approach, and 50% offer arterial resections in select patients. Most (72%) always recommend neoadjuvant chemotherapy, and 65% prefer FOLFIRINOX. Preferences for the duration of chemotherapy varied widely: 39% prefer ≥2 months, 43% prefer ≥4 months, and 11% prefer ≥6 months. Forty-one percent frequently recommend neoadjuvant radiotherapy, and 53% prefer 5 to 6 weeks of chemoradiation. The proportion of surgeons favoring exploration following neoadjuvant varied extensively across 5 vignettes of LAPC, from 14% to 53%. In a vignette of oligometastatic liver metastases, 31% would offer exploration if a favorable therapy response is observed., Conclusions: In an international cohort of pancreas surgeons, there is substantial variation in management preferences, perceived contraindications to surgery, and the propensity to consider exploration in LAPC. These results emphasize the importance of a robust and nuanced multidisciplinary discussion for each patient, and suggest an evolving concept of "resectability.", Competing Interests: All authors have no conflicts of interest to declare., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Stereotactic Radiotherapy (SRT) over 5-15 days can be interdigitated without delaying chemotherapy. Bridging chemotherapy may allow for extended intervals to surgery, potentially improving sterilization of surgical margins and overall survival. SRT for pancreatic adenocarcinoma should not be limited to the tumor, and should consider hypofractionated approaches to regional nodes., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Hall’s department receives research and travel support from Elekta AB, Stockholm, Sweden. All other authors declare no conflicts of interest., (© 2021 The Author(s). Published by Elsevier B.V. on behalf of European Society for Radiotherapy and Oncology.)

Background: The optimal type of operative drainage following pancreaticoduodenectomy (PD) remains unclear. Our objective is to investigate risk associated with closed drainage techniques (passive [gravity] vs. suction) after PD., Methods: We assessed operative drainage techniques utilized in patients undergoing PD in the ACS-NSQIP pancreas-targeted database from 2016 to 2018. Using multivariable logistic regression to adjust for characteristics of the patient, procedure, and pancreas, we examined the association between use of gravity drainage and postoperative outcomes., Results: We identified 9665 patients with drains following PD from 2016 to 2018, of which 12.7% received gravity drainage. 61.0% had a diagnosis of adenocarcinoma or pancreatitis, 26.5% had a duct <3 mm, and 43.5% had a soft or intermediate gland. After multivariable adjustment, gravity drainage was associated with decreased rates of postoperative pancreatic fistula (odds ratio [OR] 0.779, 95% confidence interval [CI] 0.653-0.930, p=0.006), delayed gastric emptying (OR 0.830, 95% CI 0.693-0.988, p=0.036), superficial SSI (OR 0.741, 95% CI 0.572-0.959, p=0.023), organ space SSI (OR 0.791, 95% CI 0.658-0.951, p=0.012), and readmission (OR 0.807, 95% CI 0.679-0.958, p=0.014) following PD., Conclusions: Gravity drainage is independently associated with decreased rates of CR-POPF, DGE, SSI, and readmission following PD. Additional prospective research is necessary to better understand the preferred drainage technique following PD.

Approximately one third of cancer patients die due to complexities related to cachexia. However, the mechanisms of cachexia and the potential therapeutic interventions remain poorly studied. We observed a significant positive correlation between SIRT1 expression and muscle fiber cross-sectional area in pancreatic cancer patients. Rescuing Sirt1 expression by exogenous expression or pharmacological agents reverted cancer cell-induced myotube wasting in culture conditions and mouse models. RNA-seq and follow-up analyses showed cancer cell-mediated SIRT1 loss induced NF-κB signaling in cachectic muscles that enhanced the expression of FOXO transcription factors and NADPH oxidase 4 (Nox4), a key regulator of reactive oxygen species production. Additionally, we observed a negative correlation between NOX4 expression and skeletal muscle fiber cross-sectional area in pancreatic cancer patients. Knocking out Nox4 in skeletal muscles or pharmacological blockade of Nox4 activity abrogated tumor-induced cachexia in mice. Thus, we conclude that targeting the Sirt1-Nox4 axis in muscles is an effective therapeutic intervention for mitigating pancreatic cancer-induced cachexia., Competing Interests: Disclosures: D.A. Tuveson reported "other" from Surface Oncology, Leap Therapeutics, and Cygnal Therapeutics; grants from ONO and Fibrogen; personal fees from Chugai and Merck outside the submitted work; SAB, stock from Surface Oncology, Leap Therapeutics, and Cygnal Therapeutics; sponsored research from ONO and Fibrogen; and honoraria from Chugai and Merck. No other disclosures were reported., (© 2020 Dasgupta et al.)

Background: Anastomotic leak is the most common major complication after esophagectomy. We investigated the 2016 American College of Surgeons National Surgical Quality Improvement Program esophagectomy targeted database to identify risk factors for anastomotic leak., Methods: Patients who underwent esophagectomy for cancer were included. Patients experiencing an anstomotic leak were identified, and univariate and multivariable logistic regression was performed to identify variables independently associated with anastomotic leak., Results: Of 915 patients included, 83% were male and the median age was 64 years. Patients with anastomotic leak more frequently had additional complications (87% vs 36%, P < .001). Rates of reoperation (64% vs 11%, P < .001) and mortality (8% vs 2%, P = .001) were higher in patients with anastomotic leak. After adjusting for patient and procedure characteristics, prolonged operative time (for each additional 30-minutes; adjusted odds ratios (AOR) 1.068, 95% CI, 1.022-1.115, P = .003), increased preoperative WBC count (for each 3000/µL increase; AOR 1.323, 95% CI, 1.048-1.670, P = .019), pre-existing diabetes (AOR 1.601, 95% CI, 1.012-2.534, P = .045), and perioperative transfusion (AOR 1.777, 95% CI, 1.064-2.965, P = .028) were independently associated with anastomotic leak., Conclusion: Both patient and procedure-related factors are associated with anastomotic leak. Though frequently non-modifiable, these findings could facilitate risk stratification and early detection of anastomotic leak to reduce associated morbidity., (© 2019 Wiley Periodicals, Inc.)

Background: Liver resection in patients with neuroendocrine liver metastasis (NELM) provides a survival benefit, yet the optimal extent of resection remains unknown. We sought to examine outcomes of patients undergoing non-anatomic (NAR) versus anatomic liver resection (AR) for NELM using a large international cohort of patients., Methods: Two hundred and fifty-eight patients who underwent curative intent liver resection from January 1990 to December 2016 were identified from eight institutions. Patients were excluded if they underwent concurrent ablation, had extrahepatic disease, underwent a debulking operation, or had mixed anatomic and non-anatomic resections. Overall (OS) and recurrence-free (RFS) survival were compared among patients based on the extent of liver resection (AR vs. NAR)., Results: Most primary tumors were located in the pancreas (n = 117, 45.4%) or the small intestine (n = 65, 25.2%). Liver resection consisted of NAR (n = 126, 48.8%) or AR (n = 132, 51.2%) resection. The overwhelming majority of patients who underwent NAR had an estimated liver involvement of < 50% (NAR 109, 97.3% vs. AR n = 82, 65.6%; P < 0.001). Patients who underwent NAR also had higher rates of primary tumor lymph node metastasis (NAR n = 79, 71.2% vs. AR n = 37, 33.6%; P < 0.001) and microscopically positive margins (R1) (NAR n = 29, 25.7% vs. AR n = 16, 12.5%; P = 0.009). After a median follow-up of 47.7 months, 48 (18.6%) patients died and 37.0% (n = 95) had evidence of disease recurrence. Patients who underwent AR had both longer median OS (not reached) and RFS (not reached) versus patients who underwent NAR (median OS 138.3 months; median RFS 31.3 months) (both P < 0.01). After controlling for patient and disease-related factors, extent of liver resection was independently associated with an increased risk of recurrence (HR 2.39, 95% CI 1.04-5.48; P = 0.04) but not death (HR 1.92, 95% CI 0.40-9.28; P = 0.42)., Conclusion: NAR was independently associated with a higher incidence of recurrence versus patients who undergo a formal anatomic hepatectomy among patients with NELM.

Background and Objectives: Gastrointestinal stromal tumors (GIST) are the most common sarcoma arising from the gastrointestinal tract. Data regrading long-term prognosis based on tumor location (stomach vs small intestine) are mixed, so we aimed to analyze their outcomes using a large national oncology database., Methods: The National Cancer Database was queried for cases of stomach and small intestine GIST between the years 2004 and 2014. Survival analysis was performed using the Kaplan-Meier method, and factors related to survival were compared using the Cox proportional hazards model., Results: Of 18 900 total patients, those with small intestine GIST had larger median tumor size (6.2 cm; interquartile range [IQR], 3.8 to 10.0 vs stomach: 5.0 cm; IQR, 3.0 to 9.0; P < 0.001) and a higher incidence of tumors with ≥5 mitoses/50 HPF (29.3% vs stomach: 24.2%; P < 0.001). Unadjusted median overall survival (OS) was longer for patients with stomach GIST (10.3 years) as compared to small intestine GIST (9.4 years) (P = 0.01). After controlling for patient and tumor-related factors, however, OS did not differ between stomach and small intestine GIST (hazard ratio, 1.19; 95% confidence interval, 0.88 to 1.61; P = 0.26)., Conclusions: Patients with small intestine GIST more commonly have larger, high mitotic rate tumors, but despite these worse prognostic features, tumor location did not independently impact OS., (© 2018 Wiley Periodicals, Inc.)

Background: Margin negative resection offers the best chance of long-term survival in retroperitoneal sarcoma (RPS). En-bloc resection of adjacent structures, including the inferior vena cava (IVC), is often required to achieve negative margins. We review our 20-year experience of en-bloc IVC and RPS resection., Methods: Retrospective review of patients with RPS resection involving the IVC were matched 1:3 by age and histology to RPS without IVC resection. Prognostic factors for overall survival (OS) and disease free survival (DFS) were assessed., Results: Thirty-two patients underwent RPS resection en-bloc with IVC. They were matched with 96 cases of RPS without IVC resection. Median OS of 59 months and DFS 18 months in IVC resection group was comparable to RPS resection without vascular involvement: median OS 65 months, DFS 18 months (P = 0.519, P = 0.604). On multivariate analyses, R2 margin (OS: HR = 6.52 [95%CI: 1.18-36.09], P = 0.032) was associated with inferior OS. R2 margin and increased number of organs resected (DFS: HR = 5.07, [1.15-22.27], P = 0.031, HR = 1.28 [1.01-1.62], P = 0.014) were associated with inferior DFS. Reconstructions included graft (n = 19, 59%), patch (n = 4, 13%), primary repair (n = 6, 19%), and ligation (n = 4, 13%)., Conclusions: RPS resection en-bloc with IVC can achieve equivalent rates of DFS and OS to patients without vascular involvement., (© 2018 Wiley Periodicals, Inc.)

Background: Management of neuroendocrine liver metastasis (NELM) in the setting of unresectable disease is poorly defined and the role of debulking remains controversial. The objective of the current study was to define outcomes following non-curative intent liver-directed therapy (debulking) among patients with NELM., Methods: 612 patients were identified who underwent liver-directed therapy of NELM from a multi-institutional database. Outcomes were stratified according to curative (R0/R1) versus non-curative ≥ 80% debulking (R2)., Results: 179 (29.2%) patients had an R2/debulking procedure. Patients undergoing debulking more commonly had more aggressive high-grade tumors (R0/R1: 12.8% vs. R2: 35.0%; P < 0.001) or liver disease burden that was bilateral (R0/R1: 52.8% vs. R2: 75.6%; P < 0.001). After a median follow-up of 51 months, median (R0/R1: not reached vs. R2: 87 months; P < 0.001) and 5-year survival (R0/R1: 85.2% vs. R2: 60.7%; P < 0.001) was higher among patients who underwent an R0/R1 resection compared with patients who underwent a debulking operation. Among patients with ≥50% NELM liver involvement, median and 5-year survival following debulking was 55.4 months and 40.6%, respectively., Conclusion: Debulking operations for NELM provided reasonable long-term survival. Hepatic debulking for patients with NELM is a reasonable therapeutic option for patients with grossly unresectable disease that may provide a survival benefit., (Copyright © 2017. Published by Elsevier Ltd.)

Resection with clean margin (R0 resection) is associated with better survival in patients with pancreatic cancer. Over the last decade, advancements in preoperative chemotherapy and radiation therapy in pancreatic cancer have led to expansion of indications for surgical resection. Current guidelines define pancreatic cancer with unreconstructable vascular involvement as locally advanced, or surgically unresectable. We present our experience in managing patients with locally advanced pancreatic cancer with a very unique series of patients who achieved R0 resection despite "unresectable" vascular involvement. Additionally, we review current guidelines, the ability to predict venous resection by imaging, outcomes after venous resection and reconstruction, published patency rates of venous reconstructions, and potential future implications of this novel technique.

Introduction: Management of neuroendocrine liver metastasis (NELM) in the presence of extrahepatic disease (EHD) is controversial. We sought to examine outcomes of patients undergoing liver-directed therapy (resection, ablation, or both) for NELM in the presence of EHD using a large international cohort of patients., Methods: 612 patients who underwent liver-directed therapy were identified from eight institutions. Postoperative outcomes, as well as and overall (OS) were compared among patients with and without EHD., Results: Most primary tumors were located in the pancreas (N = 254;41.8%) or the small bowel (N = 188;30.9%). Patients underwent surgery alone (N = 471;77.0%), ablation alone (N = 15;2.5%), or a combined approach (N = 126;20.6%). Patients with EHD had more high-grade tumors (EHD: 44.4% vs no EHD: 16.1%; P < 0.001). EHD was often the peritoneum (N = 29;41.4%) or lung (N = 19;27.1%). Among 70 patients with EHD, 20.0% (N = 14) underwent concurrent resection for EHD. After median follow-up of 51 months, 174 (28.4%) patients died with a median OS of 140.4 months. Patients with EHD had a shorter median OS versus patients who did not have EHD (EHD: 87 months vs no EHD: not reached; P = 0.002). EHD was independently associated with an increased risk of death (HR: 2.56, 95%CI 1.16-5.62; P = 0.02)., Conclusion: Patients with NELM and EHD had more aggressive tumors, conferring a twofold increased risk of death. Surgical treatment of NELM among patients with EHD should be individualized., (© 2017 Wiley Periodicals, Inc.)

Background: The benefit of adjuvant chemotherapy for resected intrahepatic cholangiocarcinoma (ICC) is unclear. The aim of the current study was to investigate the impact of adjuvant chemotherapy on survival among patients undergoing resection of ICC using a multi-institutional database., Methods: 1154 ICC patients undergoing curative-intent hepatectomy between 1990 and 2015 were identified from 14 institutions. Cox proportional hazard modeling was used to determine the impact of adjuvant chemotherapy on overall survival (OS)., Results: Following resection, 347 (30%) patients received adjuvant chemotherapy, most commonly a gemcitabine-based regimen (n = 184, 52%). Patients with T2/T3/T4 disease were more likely to receive adjuvant therapy compared with patients with T1a/T1b disease (OR 2.5, 95%CI 1.89-3.23; P < 0.001). Among patients who did and did not receive adjuvant therapy, patients with T2/T3/T4 tumors had a 5-year OS of 37% (95%CI 28.9-44.4) versus 30% (95%CI 23.8-35.6), respectively (p = 0.006). Similarly patients with N1 disease who received adjuvant chemotherapy tended to have improved 5-year OS (18.3%, 95%CI 9.0-30.1 vs. no adjuvant therapy 12%, 95%CI 3.9-24.4; P = 0.050)., Conclusions: While adjuvant chemotherapy did not influence the prognosis of all ICC patients following surgical resection, it was associated with a potential survival benefit in subgroups of patients at increased risk for recurrence, such as those with advanced tumors., (Copyright © 2017 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Major vascular involvement (IVC or portal vein) for intrahepatic cholangiocarcinoma (ICC) has traditionally been considered a contraindication to resection. We sought to define perioperative outcomes and survival of ICC patients undergoing hepatectomy with major vascular resection in a large international multi-institutional database., Methods: A total of 1087 ICC patients who underwent curative-intent hepatectomy between 1990 and 2016 were identified from 13 institutions. Multivariable logistic and cox regressions were used to determine the impact of major vascular resection on perioperative and survival outcomes., Results: Of 1087 patients who underwent resection, 128 (11.8%) also underwent major vascular resection (21 [16.4%] IVC resections, 98 [76.6%] PV resections, 9 [7.0%] combined resections). Despite more advanced disease, major vascular resection was not associated with the risk of any complication (OR = 0.68, 95%CI 0.32-1.45) or major complications (OR = 0.95, 95%CI 0.49-2.00). Post-operative mortality was also comparable between groups (OR = 1.05, 95%CI 0.32-3.47). In addition, median recurrence-free (14.0 vs 14.7 months, HR = 0.737, 95%CI 0.49-1.10) and overall (33.4 vs 40.2 months, HR = 0.71, 95%CI 0.359-1.40) survival were similar among patients who did and did not undergo major vascular resection (both P > 0.05)., Conclusion: Among patients with ICC, major vascular resection was not associated with worse perioperative or oncologic outcomes. Concurrent major vascular resection should be considered in appropriately selected patients with ICC undergoing hepatectomy., (© 2017 Wiley Periodicals, Inc.)

Background: Patients with painful varicose veins and venous insufficiency can be treated by eliminating axial reflux only or by eliminating axial reflux plus phlebectomy with transilluminated powered phlebectomy. This study was undertaken with the aim of determining and improving signs and symptoms of venous disease (measured by venous clinical severity score) and complications (by routine surveillance ultrasound and long-term post-operative follow up) for each treatment strategy., Methods: We performed a retrospective evaluation of prospectively collected data from 979 limbs undergoing procedures for significant varicose veins and venous insufficiency from March 2008 until June 2014 performed at a single tertiary referral hospital. Patient demographics, Clinical Etiology Anatomy and Pathophysiology classification, venous clinical severity scores pre- and post-procedure, treatment chosen, and peri-operative complications were collected; descriptive statistics were calculated and unadjusted surgical outcomes for patients stratified by the procedure performed. Multivariable logistic regression was used to evaluate the relationship between procedure type and thrombotic complications after adjusting for patient characteristics, severity of disease, pre-operative anticoagulation, and post-operative compression., Result: Venous clinical severity scores improved more with radiofrequency ablation + transilluminated powered phlebectomy as compared to radiofrequency ablation alone (3.8 ± 3.4 vs. 3.2 ± 3.1, p = 0.018). Regarding deep venous thrombosis, there was no significant difference between radiofrequency ablation + transilluminated powered phlebectomy vs. radiofrequency ablation alone. There was no statistical difference in asymptomatic endovenous heat-induced thrombosis or infection, although there were slightly more hematomas and cases of asymptomatic superficial thrombophlebitis with combined therapy. On multivariable analysis, only procedure type predicted thrombotic complications., Conclusion: Ablation of axial reflux plus transilluminated powered phlebectomy produces improved outcomes as measured by venous clinical severity score, with slight increases in minor post-operative complications and should be strongly considered as initial therapy when patients present with significant symptomatic varicose veins and superficial venous insufficiency. Implementation of a standardized thromboprophylaxis protocol with individual risk assessment results in few significant thrombotic complications amongst high-risk patients, thus potentially obviating the need for routine post-operative duplex., (© The Author(s) 2015.)

Background: Management of cystic lesions of the pancreas (CLP) is controversial. In this study, we sought to evaluate national changes in the resection of CLP over time, to better understand the impact of evolving guidelines on CLP management., Methods: We used Medicare data to examine CLP resection among patients undergoing pancreatic resection between 2001 and 2012. Patients with a diagnosis of CLP were identified and compared to patients with non-CLP indications. We then examined changes over time in patient and hospital characteristics and outcomes among patients with a CLP diagnosis., Results: We identified 56,419 Medicare patients undergoing pancreatic resection, of which 2129 had a CLP diagnosis. The annual number of CLP resections, and proportion of all resections performed for CLP increased significantly during the period, from 2.1% (65/3072) resections in 2001, to 4.5% (286/6348) in 2012 (p < 0.001). The proportion of CLP resections with a malignant diagnosis did not change (15.5% in 2001-2003 vs. 13.1% in 2010-2012, p = 0.4). Overall rates of 30-day mortality decreased significantly during the period (9.6% in 2001-2003 vs. 5.5% in 2010-2012, p < 0.001)., Discussion: CLP resections were performed with increasing frequency in Medicare patients between 2001 and 2012, but this did not correspond to increased diagnosis of malignancy. Additional research is needed to understand the influence of recent guidelines on management of CLP., (Copyright © 2016 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Objective: Although it has been suggested that social-networking services such as Twitter could be used as a tool for medical education, few studies have evaluated its use in this setting. We sought to evaluate the use of Twitter as a novel educational tool in a medical school surgery clerkship. We hypothesized that Twitter can enhance the educational experience of clerkship students., Design: We performed a prospective observational study. We created a new Twitter account, and delivered approximately 3 tweets per day consisting of succinct, objective surgical facts. Students were administered pre- and postclerkship surveys, and aggregate test scores were obtained for participating students and historical controls., Setting: Required third-year medical school surgery clerkship at the University of Michigan large tertiary-care academic hospital., Participants: Third-year medical students., Results: The survey response rate was 94%. Preclerkship surveys revealed that most (87%) students have smartphones, and are familiar with Twitter (80% have used before). Following completion of the clerkship, most students (73%) reported using the Twitter tool, and 20% used it frequently. Overall, 59% believed it positively influenced their educational experience and very few believed it had a negative influence (2%). However, many (53%) did not believe it influenced their clerkship engagement. Aggregate mean National Board of Medical Examiners Shelf Examination scores were not significantly different in an analysis of medical student classes completing the clerkship before or after the Twitter tool (p = 0.37)., Conclusions: Most of today's learners are familiar with social media, and own the technology necessary to implement novel educational tools in this platform. Applications such as Twitter can be facile educational tools to supplement and enhance the experience of students on a medical school clerkship., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The development of operative skills during general surgery residency depends largely on the resident surgeons' (residents) ability to accurately self-assess and identify areas for improvement. We compared evaluations of laparoscopic skills and comfort level of residents from both the residents' and attending surgeons' (attendings') perspectives., Design: We prospectively observed 111 elective cholecystectomies at the University of Michigan as part of a larger quality improvement initiative. Immediately after the operation, both residents and attendings completed a survey in which they rated the residents' operative proficiency, comfort level, and the difficulty of the case using a previously validated instrument. Residents' and attendings' evaluations of residents' performance were compared using 2-sided t tests., Setting: The University of Michigan Health System in Ann Arbor, MI. Large academic, tertiary care institution., Participants: All general surgery residents and faculty at the University of Michigan performing laparoscopic cholecystectomy between June 1 and August 31, 2013. Data were collected for 28 of the institution's 54 trainees., Results: Attendings rated residents higher than what residents rated themselves on a 5-point Likert-type scale regarding depth perception (3.86 vs. 3.38, p < 0.005), bimanual dexterity (3.75 vs. 3.36, p = 0.005), efficiency (3.58 vs. 3.18, p < 0.005), tissue handling (3.69 vs. 3.23, p < 0.005), and comfort while performing a case (3.86 vs. 3.38, p < 0.005). Attendings and residents were in agreement on the level of autonomy displayed by the resident during the case (3.31 vs. 3.34, p = 0.85), the level of difficulty of the case (2.98 vs. 2.85, p = 0.443), and the degree of teaching done by the attending during the case (3.61 vs. 3.54, p = 0.701)., Conclusions: A gap exists between residents' and attendings' perception of residents' laparoscopic skills and comfort level in performing laparoscopic cholecystectomy. These findings call for improved communication between residents and attendings to ensure that graduates are adequately prepared to operate independently. In the context of changing methods of resident evaluations that call for explicitly defined competencies in surgery, it is essential that residents are able to accurately self-assess and be in general agreement with attendings on their level of laparoscopic skills and comfort level while performing a case., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Surgical resection is underutilized for patients with colorectal liver metastases (CLM). Although the causes of underutilization are poorly understood, provider attitudes towards surgical referral may be contributory. We sought to understand medical oncologists' perspectives on referral for CLM., Methods: Medical oncologists who treat colorectal cancer in the US state of Michigan were surveyed. We characterized respondents' attitudes regarding clinical and tumor-related contraindications to liver resection for CLM, as well as referral and treatment preferences using case-based scenarios. We then evaluated practice characteristics and treatment preferences between physicians., Results: A total of 112 eligible responses were received (46 % response rate). Nearly 40 % of respondents reported having no liver surgeons in their practice area. Commonly perceived contraindications to liver resection included extrahepatic disease (80.3 %), poor performance status (77.7 %), the presence of >4 metastases (62.5 %), bilobar metastases (43.8 %), and metastasis size >5 cm (40.2 %). Compared with high-referring physicians, low-referring physicians were just as likely to refer a patient with very low recurrence risk (89.3 vs. 98.3 %; p = 0.099), but much less likely to refer a patient with moderate risk (0 vs. 82.8 %; p < 0.001). High-referring physicians were more likely to consider resection for scenarios consistent with higher recurrence risk (31.0 vs. 10.7 %; p = 0.05)., Conclusions: We found wide variation in surgical referral patterns for CLM. Many felt that bilobar disease and tumor size were contraindications to liver-directed therapy despite a lack of supporting data. These findings suggest an urgent need to increase dissemination of evidence and guidance regarding management for CLM, perhaps through increased specialist participation in tumor boards.

Background: Sequential compression devices (SCDs) reduce deep venous thrombosis in postsurgical patients, but the use is hindered by poor compliance., Methods: General and orthopedic surgery patients (n = 67) were randomized to standard- or battery-powered SCDs. Compliance was documented hourly. Nurses and patients were issued a survey to assess barriers to compliance and device satisfaction., Results: Compliance with standard SCDs was 47% compared with 85% with battery-powered SCDs (P < .001). The most common barriers identified by nurses and patients were ambulation and transfers, which were mitigated with the battery-powered device. A majority (79%) of those issued a battery-powered device reported no major problems compared with only 14% of patients issued a standard device (P < .005)., Conclusions: The dual venous thromboembolism prevention strategies of early mobilization and SCD utilization can be met with the appropriate equipment., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Over the past decade, there has been a rapid decline in adverse events after bariatric surgery. As a result, it is possible that the influence of hospital volume on outcomes has attenuated over time. The objective of the present study was to examine whether the relationship between hospital volume and adverse events has persisted in the era of laparoscopic surgery. This study is based on analysis of State Inpatient Databases (SID) for 12 states from 2006 through 2011, which included 446,127 patients., Methods: Using hospital discharge data, changes in serious complications, reoperations and mortality over time, and the impact of hospital volume on outcomes among patients undergoing laparoscopic adjustable gastric band (LAGB) and laparoscopic Roux-en-Y gastric bypass (LRYGB) were studied. Hospitals were stratified by operative volume, and using multivariable logistic regression to adjust for patient characteristics and procedure-type, the relationships between hospital volume and outcomes during 3 2-year periods were examined: 2006-2007, 2008-2009, and 2010-2011., Results: The rate of reoperations and mortality were low, and there were no significant differences between the highest (>125 cases/yr) and lowest (<50 cases/yr) volume hospitals for both LAGB and LRYGB. The volume-outcome relationship was most prominent when examining rates of adjusted odds ratios for serious complications at the lowest volume hospitals compared with the highest volume hospitals (LAGB: 1.65 [CI: 1.18, 2.30] for 2006-2007, 1.81 [CI: 1.36, 2.41] for 2008-2009, and 2.08 [CI:1.40, 3.09] for 2010-2011; LRYGB: 1.55 [CI:1.23, 1.95] for 2006-2007, 1.39 [CI:1.09, 1.76], and 1.39 [CI:1.07, 1.80] for 2010-2011)., Conclusions: Outcomes improved over the study period at both high- and low-volume volume hospitals. There remain significant differences in serious complications between the highest and lowest volume hospitals for both stapled and nonstapled procedures., (Copyright © 2015 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Importance: Previous studies of checklist-based quality improvement interventions have reported mixed results., Objective: To evaluate whether implementation of a checklist-based quality improvement intervention--Keystone Surgery--was associated with improved outcomes in patients in a large statewide population undergoing general surgery., Design, Setting, and Exposures: A retrospective longitudinal study examined surgical outcomes in 64,891 Michigan patients in 29 hospitals using Michigan Surgical Quality Collaborative clinical registry data from 2006 through 2010. Multivariable logistic regression and difference-in-differences analytic approaches were used to evaluate whether Keystone Surgery program implementation was associated with improved surgical outcomes following general surgery procedures, apart from existing temporal trends toward improved outcomes during the study period., Main Outcomes and Measures: Risk-adjusted rates of superficial surgical site infection, wound complication, any complication, and 30-day mortality., Results: Implementation of Keystone Surgery in 14 participating centers was not associated with improvements in surgical outcomes during the study period. Adjusted rates of superficial surgical site infection (3.2% vs 3.2%, P=.91), wound complication (5.9% vs 6.5%, P=.30), any complication (12.4% vs 13.2%, P=.26), and 30-day mortality (2.1% vs 1.9%, P=.32) at participating hospitals were similar before and after implementation. Difference-in-differences analysis accounting for trends in 15 nonparticipating centers and sensitivity analysis excluding patients receiving surgery in the first 6 or 12 months after program implementation yielded similar results., Conclusions and Relevance: Implementation of a checklist-based quality improvement intervention did not affect rates of adverse surgical outcomes among patients undergoing general surgery in participating Michigan hospitals. Additional research is needed to understand why this program was not successful prior to further dissemination and implementation of this model to other populations.

Background: Increasing pressures to provide high-quality evidence-based cancer care have driven the rapid proliferation of clinical practice guidelines (CPGs). The quality and validity of CPGs have been questioned, and adherence to guidelines is relatively low. The purpose of this study was to critically evaluate the development process and scientific content of CPGs., Methods: CPGs addressing management of rectal cancer were evaluated. We quantitatively assessed guideline quality with the validated Appraisal of Guidelines Research & Evaluation (AGREE II) instrument. We identified 21 independent processes of care using the nominal group technique. We then compared the evidence base and scientific agreement for the management recommendations for these processes of care., Results: The quality and content of rectal cancer CPGs varied widely. Mean overall AGREE II scores ranged from 27% to 90%. Across the 5 CPGs, average scores were highest for the clarity of presentation domain (85%; range, 58% to 99%) and lowest for the applicability domain (21%; range, 8% to 56%). Randomized controlled trials represented a small proportion of citations (median, 18%; range, 13%-35%), 78% of the recommendations were based on low- or moderate-quality evidence, and the CPGs only had 11 references in common with the highest-rated CPG. There were conflicting recommendations for 13 of the 21 care processes assessed (62%)., Conclusions: There is significant variation in CPG development processes and scientific content. With conflicting recommendations between CPGs, there is no reliable resource to guide high-quality evidence-based cancer care. The quality and consistency of CPGs are in need of improvement., (© 2014 American Cancer Society.)

Background: Evidence suggests that prolonged operative time adversely affects surgical outcomes. However, whether faster surgeons have better outcomes is unclear, as a surgeon׳s speed could reflect skill and efficiency, but may alternatively reflect haste. This study evaluates whether median surgeon operative time is associated with adverse surgical outcomes after laparoscopic Roux-en-Y gastric bypass., Methods: We performed a retrospective cohort study using statewide clinical registry data from the years 2006 to 2012. Surgeons were ranked by their median operative time and grouped into terciles. Multivariable logistic regression with robust standard errors was used to evaluate the influence of median surgeon operative time on 30-day surgical outcomes, adjusting for patient and surgeon characteristics, trainee involvement, concurrent procedures, and the complex interaction between these variables., Results: A total of 16,344 patients underwent surgery during the study period. Compared to surgeons in the fastest tercile, slow surgeons required 53 additional minutes to complete a gastric bypass procedure (median [interquartile range] 139 [133-150] versus 86 [69-91], P<.001). After adjustment for patient characteristic only, slow surgeons had significantly higher adjusted rates of any complication, prolonged length of stay, emergency department visits or readmissions, and venous thromboembolism (VTE). After further adjustment for surgeon characteristics, resident involvement, and the interaction between these variables, slow surgeons had higher rates of any complication (10.5% versus 7.1%, P=.039), prolonged length of stay (14.0% versus 4.4%, P=.002), and VTE (0.39% versus .22%, P<.001)., Conclusion: Median surgeon operative duration is independently associated with adjusted rates of certain adverse outcomes after laparoscopic Roux-en-Y gastric bypass. Improving surgeon efficiency while operating may reduce operative time and improve the safety of bariatric surgery., (Copyright © 2015 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Surgical checklists are increasingly used to improve compliance with evidence-based processes in the perioperative period. Although enthusiasm exists for using checklists to improve outcomes, recent studies have questioned their effectiveness in large populations., Objective: We sought to examine the association of Keystone Surgery, a statewide implementation of an evidence-based checklist and Comprehensive Unit-based Safety Program, on surgical outcomes and health care costs., Methods: We performed a study using national Medicare claims data for patients undergoing general and vascular surgery (n=1,002,241) from 2006 to 2011. A difference-in-differences approach was used to evaluate whether implementation was associated with improved surgical outcomes and decreased costs when compared with a national cohort of nonparticipating hospitals. Propensity score matching was used to select 10 control hospitals for each participating hospital. Costs were assessed using price-standardized 30-day Medicare payments for acute hospitalizations, readmissions, and high-cost outliers., Results: Keystone Surgery implementation in participating centers (N=95 hospitals) was not associated with improved outcomes. Difference-in-differences analysis accounting for trends in nonparticipating hospitals (N=950 hospitals) revealed no differences in adjusted rates of 30-day mortality [relative risk (RR)=1.03; 95% confidence intervals (CI), 0.97-1.10], any complication (RR=1.03; 95% CI, 0.99-1.07), reoperations (RR=0.89; 95% CI, 0.56-1.22), or readmissions (RR=1.01; 95% CI, 0.97-1.05). Medicare payments for the index admission increased following implementation ($516 average increase in payments; 95% CI, $210-$823 increase), as did readmission payments ($564 increase; 95% CI, $89-$1040 increase). High-outlier payments ($965 increase; 95% CI, $974decrease to $2904 increase) did not change., Conclusions: Implementation of Keystone Surgery in Michigan was not associated with improved outcomes or decreased costs in Medicare patients.