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Background: Esophagectomy in locally advanced esophageal adenocarcinoma is challenging and carries risk. The value of esophagectomy in locally advanced esophageal adenocarcinoma is not well-defined., Study Design: The National Cancer Database was used to identify patients with cT4 esophageal adenocarcinoma from 2004 to 2020. Multivariable regression was used to identify factors associated with use of esophagectomy. Cox modeling was used to identify factors associated with all-cause mortality. Patients undergoing esophagectomy were 1:1 propensity score-matched to patients treated nonsurgically. Kaplan-Meier analysis was used to compare 5-year overall survival (OS)., Results: A total of 3,703 patients met inclusion criteria. Of those, 541 (15%) underwent esophagectomy, and 3,162 (85%) did not. Age 65 years or less (adjusted odds ratio [aOR] 1.69, 95% CI 1.33 to 2.14), White race (aOR 2.98, 95% CI 2.24 to 3.96), treatment in academic centers (aOR 1.64, 95% CI 1.33 to 2.02), private insurance (aOR 1.88, 95% CI 1.50 to 2.36), and tumors less than 6 cm (aOR 1.86, 95% CI 1.44 to 2.40) were associated with use of esophagectomy. Government of lack of insurance (hazard ratio [HR] 1.23, 95% CI 1.12 to 1.35), income <$46,000 (HR 1.11, 95% CI 1.03 to 1.20), treatment in nonacademic centers (HR 1.16, 95% CI 1.07 to 1.25), Charlson-Deyo Comorbidity Index 1 or more (HR 1.22, 95% CI 1.12 to 1.32), and tumors 6 cm or more (HR 1.20, 95% CI 1.09 to 1.32) were associated with risk of all-cause mortality. Esophagectomy (HR 0.50, 95% CI 0.44 to 0.56) and systemic therapy (HR 0.40, 95% CI 0.37 to 0.43) were associated with decreased risk of all-cause mortality. Patients undergoing esophagectomy had higher rates of 5-year OS (27.4% vs 13.2%, p < 0.0001) and longer median OS (24.71 vs 10.09 months, p < 0.0001). Among cT4b patients, those who underwent esophagectomy had higher rates of 5-year OS (24.5% vs 12.3%, p < 0.0001) and longer median OS (25.53 vs 11.01 months, p < 0.0001)., Conclusions: In cT4 esophageal adenocarcinoma, esophagectomy is associated with improved rates of 5-year OS compared with nonsurgical treatment., (Copyright © 2024 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: We seek to determine the association between COVID-19 diagnosis and postoperative outcomes following bariatric surgery., Methods: Using the Metabolic and Bariatric Surgery Accreditation Quality Improvement Project (MBSAQIP) database, patients undergoing sleeve gastrectomy and gastric bypass without a COVID-19 diagnosis were 2:1 propensity-score matched to those with COVID-19 infection pre or postoperatively., Results: 1369 (0.74 ​%) and 1331 (0.72 ​%) patients had a COVID-19 diagnosis within 14 days prior to or 30 days after their operation, respectively. Patients with preoperative COVID-19 infection had equivalent outcomes to COVID-19 negative patients (all p ​> ​0.05). Postoperative COVID-19 diagnosis was associated with worse outcomes including increased risk of anastomotic/staple line leak (1.1 ​% vs 0.1 ​%, p ​< ​0.001), postoperative pneumonia (2.9 ​% vs 0.1 ​%, p ​< ​0.001), and 30-day reoperation (2.1 ​% vs 0.9 ​%, p ​= ​0.002)., Conclusions: Postoperative diagnosis of COVID-19 after bariatric surgery is associated with worse outcomes; however, it is safe to perform these procedures on patients recently convalesced from COVID-19 infection., Competing Interests: Declaration of competing interest All authors have no conflicts of interest to disclose for this research paper., (Copyright © 2023. Published by Elsevier Inc.)

Background: The value of palliative surgery in pancreatic cancer is not well-defined., Methods: We queried the National Cancer Database for patients undergoing curative-intent resection, palliative surgery or medical palliation for clinical stage cT4N0-2M0 pancreatic cancer. Cohorts were 1:1:1 propensity-score-matched for comorbidities and stage. Kaplan-Meier method was used to compare overall survival for matched cohorts., Results: 9,107 patients met inclusion criteria: 3,567 (39 ​%) underwent curative intent surgery, 1608 (18 ​%) surgical palliation, 3932 (43 ​%) medical palliation. Patients undergoing resection and surgical palliation had significant hospitalizations (11.0 ​± ​0.4 vs. 10.0 ​± ​0.3 days; p ​= ​0.821) and rates of readmission (8.1 ​% vs. 2.0 ​%; p ​< ​0.001). Patients undergoing surgical palliation demonstrated marginal increases in survival relative to those undergoing medical palliation (8.54 vs. 7.36 months; p ​< ​0.0001)., Conclusion: In patients undergoing care for locally advanced pancreatic cancer, palliative surgery is associated with marginal improvement in survival but significant lengths of hospitalization and risk of readmission., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier Inc.)

Background: Prior studies evaluating the efficacy of local excision compared to radical resection in the treatment of rectal adenocarcinoma lacked sufficient power to identify differences in outcomes for patients with cT2 disease but low-risk histopathology. We compared the outcomes of local excision and radical resection for low-risk histopathology and high-risk histology of patients with cT2N0M0 rectal adenocarcinoma to assess their outcomes., Methods: We queried the National Cancer Database for patients presenting with cT2N0M0 rectal adenocarcinoma between 2004 and 2019 and categorized them as low-risk histopathology or high-risk histology. We used the Cox proportional hazards model to identify factors associated with the risk of all-cause mortality. We 1:1 propensity-matched patients who underwent local excision to patients who underwent radical resection and used the Kaplan-Meier method to compare overall survival for matched cohorts., Results: Of the 4,446 patients selected, we classified 1,206 (27%) as high-risk histology and 3,240 (73%) as low-risk histopathology. Among the patients with high-risk histology, 121 (10%) underwent local excision and 1,085 (90%) underwent radical resection. Among the patients with low-risk histopathology, 340 (10%) underwent local excision and 2,900 (90%) radical resections. Whereas radical resection was associated with decreased risk of all-cause mortality and increased overall survival for patients with high-risk histology, it was not for patients with low-risk histopathology., Conclusion: The overall survival of patients with low-risk histopathology with cT2N0M0 rectal adenocarcinoma who undergo local excision is similar to those of patients with low-risk histopathology who undergo radical resection, suggesting local excision is a reasonable approach for these patients. In contrast, radical resection provides a significant survival advantage for patients with high-risk histology and should remain their treatment of choice., (Copyright © 2023. Published by Elsevier Inc.)

Background: Pretreatment clinical staging is used to decide the course of treatment in early-stage esophageal cancer. Few studies assess the effect of inaccurate clinical staging on oncologic outcomes., Methods: We queried the National Cancer Database to identify patients undergoing esophagectomy for clinical stage cT1bN0 esophageal carcinoma between 2010 and 2019. Patients were categorized as being upstaged if, on final pathology, they had histopathologic disease that would have warranted treatment with neoadjuvant therapy. The textbook oncologic outcome was defined as margin-negative resection, 15 lymph nodes examined, a hospital stay of <21 days, no unplanned 30-day readmission or mortality, and stage-appropriate use of neoadjuvant therapy., Results: In total, 916 patients met inclusion criteria; 378 (41.2%) had a pathologic stage that differed from their pretreatment clinical stage. By multivariable regression, factors associated upstaging included: presentation between 2015 and 2019 (odds ratio 1.92 95% confidence interval [1.19, 3.13]), delay to esophagectomy of >30 days (odds ratio 2.38 95% confidence interval [1.13, 5.57]), larger tumor size (>2 cm relative to <2 cm, odds ratio 2.73 95% confidence interval [1.72, 4.39]), and poorly differentiated histology (odds ratio 2.79 95% confidence interval [1.75, 4.49]). The rate of textbook oncologic outcome assuming reliable clinical staging was 43.8%; accounting for upstaging, the rate of textbook oncologic outcome was 22.5% (P < .001)., Conclusion: In patients with cT1bN0 esophageal cancer, tumor size and histology are associated with the risk of inaccurate pretreatment clinical staging. Inaccuracies in clinical staging impact the rate at which providers achieve optimal oncologic outcomes., (Copyright © 2023. Published by Elsevier Inc.)

Background: Studies comparing approaches to managing rectal neuroendocrine tumors are underpowered by institutional series. The efficacy of expectant management relative to local excision and radical resection is poorly defined., Methods: We queried the National Cancer Database to identify patients presenting with non-metastatic rectal neuroendocrine tumors between 2004 and 2019. Multivariable regression was used to identify factors associated with expectant management. Cox modeling was used to identify factors associated with all-cause mortality. Patients undergoing expectant management were 1:1:1 propensity score matched for demographics and comorbid disease to those undergoing radical resection and local excision. The Kaplan-Meier method was used to compare overall survival profiles for matched cohorts., Results: A total of 6,316 patients met the inclusion criteria. Of these, 5,211 (83%) underwent local excision, 600 (9.5%) radical resection, and 505 (8%) expectant management. On multivariable regression, factors associated with expectant management included Black race, government insurance, and tumor size <2.0 centimeters. On Cox modeling, factors associated with mortality included age >65 years, male sex, government insurance, comorbidity score >0, tumor size >2 centimeters, and poorly differentiated histology. On comparison of matched cohorts: patients undergoing radical resection had longer hospitalizations and higher readmission rates than those undergoing local excision; there was no difference in overall survival between cohorts in patients with stage 1 disease; in stage 2 and 3 diseases, patients undergoing local excision and radical resection demonstrated improved rates of overall survival relative to those undergoing expectant management., Conclusion: Expectant management is a reasonable approach for patients with stage 1 rectal neuroendocrine tumors. Local excision should be the preferred treatment option for those presenting with stage 2/3 disease., (Copyright © 2023. Published by Elsevier Inc.)

Background: The efficacy of local excision (transduodenal or endoscopic ampullectomy) in treating early-stage ampullary cancer has not been well defined., Study Design: We queried the National Cancer Database to identify patients undergoing either local tumor excision or radical resection for early-stage (cTis-T2, N0, M0) ampullary adenocarcinoma between 2004 and 2018. Cox modeling was used to identify factors associated with overall survival. Patients undergoing local excision were then 1:1 propensity score-matched for demographics, hospital level, and histopathological factors to those undergoing radical resection. The Kaplan-Meier method was used to compare overall survival (OS) profiles for matched cohorts., Results: A total of 1,544 patients met inclusion criteria. A total of 218 (14%) underwent local tumor excision, and 1,326 (86%) radical resection. On propensity score matching, 218 patients undergoing local excision were successfully matched to 218 patients undergoing radical resection. On comparison of matched cohorts, those undergoing local excision had lower rate of margin-negative (R0) resection (85.1% vs 99%, p < 0.001) and lower median lymph node count (0 vs 13, p < 0.001) but had significantly shorter length of initial hospitalization (median days: 1 vs 10 days, p < 0.001), lower rate of 30-day readmission (3.3% vs 12.0%, p = 0.001), and lower rate of 30-day mortality (1.8% vs 6.5%, p = 0.016) than patients undergoing radical resection. There was no statistically significant difference in OS between the matched cohorts (46.9% vs 52.0%, p = 0.46)., Conclusions: In patients presenting with early-stage ampullary adenocarcinoma, local tumor excision is associated with higher rate of R1 resection but accelerated postprocedure recovery and patterns of OS comparable with those after radical resection., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Despite surgical advances, rates of paraesophageal hernia recurrence remain high. We evaluate outcomes of paraesophageal hernia repair in United States veterans, safety of robotic technology, and risk factors for reoperation for recurrence., Methods: The Veterans Affairs Surgical Quality Improvement Program database was queried for patients undergoing laparoscopic or robotic paraesophageal hernia repair from 2010 to 2021. The effect of patient and operative characteristics on outcomes was evaluated., Results: 2,444 patients underwent paraesophageal hernia repair. 62 (2.5%) had a reoperation for recurrence. Emergent priority (aOR 18.3 [5.9-56.2]) and younger age (aOR 0.7 [0.5-0.9]) were associated with increased risk of reoperation. On comparison of propensity matched cohorts, repairs done robotically took longer (4.17 vs. 3.57 h, p < 0.001) but had 30-day outcomes and rates of reoperation for recurrence equivalent to laparoscopic repairs (p > 0.05)., Conclusion: Emergent priority and younger age are associated with increased risk of reoperation for recurrent paraesophageal hernia. Robotic approaches take longer but are safe., Competing Interests: Declaration of competing interest The authors have no financial or other conflicts of interest to disclose. This study was not funded., (Copyright © 2022. Published by Elsevier Inc.)

Background: Studies evaluating endoscopic resection for early-stage (cT1N0M0) esophageal adenocarcinoma include small numbers of patients with T1b tumors. The role of endoscopic resection in esophageal adenocarcinoma remains incompletely defined., Methods: We queried the National Cancer Database to identify patients presenting with esophageal adenocarcinoma between 2010 and 2017. Those treated with neoadjuvant chemoradiotherapy and endoscopic ablation were excluded. Patients undergoing endoscopic resection for cT1a and cT1b tumors were separately 1:1 propensity matched for relevant demographic and tumor factors to those undergoing esophagectomy for disease of like clinical stage. The Kaplan-Meier method was used to compare 5-year overall survival for matched cohorts., Results: A total of 3,157 patients met the inclusion criteria. Of these patients, 2,024 (64.1%) had cT1a and 1133 (35.9%) had cT1b disease. Among those with cT1a tumors, 461 (22.8%) underwent esophagectomy, 1,357 (67.0%) endoscopic resection, and 206 (10.2%) treatment with chemoradiotherapy alone. Among those with cT1b tumors, 649 (57.3%) underwent esophagectomy, 293 (25.9%) endoscopic resection, and 191 (16.8%) chemoradiotherapy. On unadjusted comparison, patients treated for esophageal adenocarcinoma with chemoradiotherapy had a lower rate of overall survival than those treated with endoscopic resection or esophagectomy (26.1% vs 73.1% vs 75.5%, P < .001). On comparison of matched cohorts, patients undergoing endoscopic resection for cT1b tumors demonstrated lower rates of overall survival than those undergoing esophagectomy (60.6% vs 74.1%, P = .0013), whereas those undergoing endoscopic resection for cT1a tumors demonstrated rates of overall survival statistically similar to those undergoing esophagectomy (77.8% vs 80.2%, P = .75)., Conclusion: Esophagectomy is associated with improved overall survival relative to endoscopic resection in patients presenting with cT1bN0M0 but not in those with cT1a esophageal adenocarcinoma., (Published by Elsevier Inc.)

Background: The efficacy of endoscopic resection in early-stage esophageal squamous cell carcinoma has not been defined., Methods: We queried the National Cancer Database to identify patients presenting with cT1N0M0 esophageal squamous cell cancer between 2004 and 2017. Transitive match methods were used to 1:1:1 propensity match patients undergoing endoscopic resection to patients undergoing esophagectomy and those undergoing definitive chemoradiotherapy. Kaplan Meier method was used to compare 5-year overall survival profiles for matched cohorts., Results: 301 patients (19%) underwent endoscopic resection; 497 (32%) esophagectomy; 767 (49%) chemoradiation. On comparison of matched cohorts, patients undergoing chemoradiation demonstrated lower rates of survival than those undergoing esophagectomy (32% vs. 59%, p < 0.0001) while those undergoing endoscopic resection demonstrated rates comparable to patients undergoing esophagectomy (53% vs. 59%, p = 0.77)., Conclusions: For cT1N0M0 esophageal squamous cell cancer, endoscopic resection is associated with rates of survival similar to those following esophagectomy and better than those following definitive chemoradiation., Competing Interests: Declaration of competing interest The authors of this paper have no conflicts of interest to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Prior studies evaluating the safety and efficacy of local excision relative to surgical resection in early-stage rectal adenocarcinoma have primarily included low rectal cancers treated with abdominoperineal resection as control comparison cohorts. The role of local excision in early-stage rectal adenocarcinoma is incompletely defined., Methods: We queried the National Cancer Database to identify patients with cT1 N0 M0 rectal adenocarcinoma between 2004 and 2019. Patients undergoing abdominoperineal resection were excluded. Multivariable regression was used to identify factors associated with use of local excision instead of low anterior resection. Patients undergoing local excision were propensity score matched for age, sex, demographic characteristics, Charlson-Deyo comorbidity class score, and tumor grade and size to those undergoing low anterior resection. Short-term clinical outcomes and 5-year overall survival for matched cohorts were compared by standard methods., Results: A total of 5,693 patients met inclusion criteria; 1,973 patients underwent local excision and 3,720 low anterior resection. Age (adjusted odds ratio 1.26; 95% confidence interval, 1.17-1.37), tumor histology (poorly differentiated histology: adjusted odds ratio 0.66; 95% confidence interval, 0.51-0.86), and size (>4 cm: adjusted odds ratio 0.20; 95% confidence interval, 0.16-0.25) were associated with choice of intervention. On comparison of matched cohorts, patients undergoing LE demonstrated shorter hospital stay (2.4 ±9.8 vs 5.6 ±8.1 days; P < .001) and lower readmission rate (4% vs 7%; P = .002) but higher margin-positive resection rates (8% vs 2%; P < .001). Overall survival profiles for patients undergoing local excision were comparable with those for low anterior resection., Conclusion: In patients with cT1 N0 M0 rectal adenocarcinoma, local excision is associated with a higher margin-positive resection rate than low anterior resection but affords accelerated postprocedure recovery and comparable rates of overall survival., (Published by Elsevier Inc.)

Background: Quality assessment in oncologic surgery has traditionally involved reporting discrete metrics that may be difficult for patients and referring providers to interpret. We define a composite quality metric (CQM) for resection in rectal cancer., Methods: We queried the National Cancer Database to identify patients undergoing low anterior resection for clinical stage II-III rectal adenocarcinoma between 2010 and 2017. CQM was defined as appropriate neoadjuvant therapy, margin-negative resection, appropriate lymph node assessment, postoperative length of stay (LOS) < 75th percentile, and no 30-day readmission or mortality., Results: 19,721 patients met inclusion criteria; 8,083 (41%) had a CQM. The most common reasons for failure to achieve CQM: inadequate node assessment (27%), prolonged LOS (26%). On Cox modeling, CQM (aHR 0.70, 95% CI [0.66, 0.75]) was associated with improved overall survival., Conclusion: CQM is independently associated with improved survival in rectal cancer and may be an effective measure of quality., Competing Interests: Declaration of competing interest Dr. Singer has associations with Ethicon Inc., Intuitive Surgical Inc., Merck & Co. Inc., and Nestle. The remaining authors have no financial disclosures., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Published studies examining the efficacy of liver transplantation in patients presenting with hepatocellular cancer beyond the traditional Milan criteria for liver transplantation have primarily been single institution series with limited ability to compare outcomes to alternative methods of management., Methods: We queried the National Cancer Database to identify patients presenting between 2004 and 2016 with histologically confirmed clinical stage III and IVA hepatocellular cancer. Multivariable regression was used to identify factors associated with liver transplantation. Patients undergoing liver transplantation were 1:1 propensity score-matched for age, demographics, comorbid disease, clinical stage, and histologic resection margin to those undergoing surgical resection. The Kaplan-Meier method was used to compare overall survival profiles for matched cohorts., Results: Seven hundred and ninety-two patients met inclusion criteria-590 (74.5%) underwent surgical resection and 202 (25.5%) liver transplantation. On adjusted analysis, patients undergoing liver transplantation were less likely to have advanced age (>60 years; odds ratio 0.39, 95% confidence interval [0.21-0.71]) and to be of Black race (odds ratio 0.42, 95% confidence interval [0.23-0.73]) or Asian (odds ratio 0.25, 95% confidence interval [0.11-0.53]) ethnicity but were more likely to have advanced (Charlson score >2) comorbidity scores, (odds ratio 2.48, 95% confidence interval [1.58-3.90]) and more likely to have private health insurance (odds ratio 4.17, 95% confidence interval [1.31-18.66]) than those undergoing surgical resection. On Kaplan-Meier analysis of matched cohorts, patients undergoing liver transplantation demonstrated significantly better rates of 5-year overall survival (65.3% vs 26.3%, P < .0001) and longer median overall survival times than those undergoing resection (53.1 ± 2.78 vs 26.9 ± 1.20 months, P < .0001)., Conclusion: Liver transplantation offers the potential to be an effective treatment modality in select patients presenting with stage III and IVA hepatocellular cancer., (Published by Elsevier Inc.)

Outcomes after cancer resection are traditionally measured individually. Composite metrics, or textbook outcomes, bundle outcomes into a single value to facilitate assessments of quality. We propose a composite outcome for non-small cell lung cancer resections, examine factors associated with the outcome, and evaluate its effect on overall survival. We queried the National Cancer Database for patients with stage I/II non-small cell lung cancer who underwent sublobar resection, lobectomy, or pneumonectomy from 2010 to 2016. We defined the metric as margin-negative resection, sampling of ≥10 lymph nodes, length of stay <75th percentile, no 30-day mortality, no readmission, and receipt of indicated adjuvant therapy. Multivariable logistic regression, Cox proportional hazards modeling, survival analyses, and propensity score matching were used to identify factors associated with the outcome and overall survival. Of 88,208 patients, 70,149 underwent lobectomy, 14,922 underwent sublobar resection, and 3,137 underwent pneumonectomy. Textbook outcome was achieved in 26.3% of patients. Failure to achieve the outcome was most commonly driven by inadequate nodal assessment. Textbook outcome was more likely after minimally invasive surgical approaches (aOR = 1.47; P< 0.001) relative to open resection and less likely after sublobar resection (aOR = 0.20; P< 0.001) relative to lobectomy. Achievement of textbook outcome was associated with an 9.6% increase in 5-year survival (P< 0.001), was independently associated with improved survival (aHR = 0.72; P < 0.001), and remained strongly associated with survival independent of resection extent after propensity matching. One in 4 patients undergoing non-small cell lung cancer resection achieve textbook outcome. Textbook outcome is associated with improved survival and has value as a quality metric., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Diaphragmatic hernia repair is a common operation performed at all types of hospitals. The variation in costs and repeat episodes of care after this operation is not known., Study Design: The Healthcare Cost and Utilization Project State Inpatient and State Ambulatory Surgery and Services Databases for Florida were queried to identify patients undergoing diaphragmatic hernia repair between 2011 and 2018 and the associated inpatient and outpatient encounters within 12 months postoperatively. Hospitals were ranked by cost and grouped into quintiles. All costs and charges were reliability and case-mix adjusted with the use of hierarchical multivariable regression., Results: In total, 8,848 patients underwent diaphragmatic hernia operations at 158 hospitals. The most expensive hospital quintile had lower surgical volume, location in rural settings, and fewer than 100 beds. There was a wide variation in costs after diaphragmatic hernia repair. On unadjusted comparison, index costs were $23,041 more expensive in hospitals in the highest quintile than in the lowest quintile. Cost differences were persistent even after case-mix and reliability adjustment. The variation in adjusted aggregate charges for associated outpatient and inpatient encounters in the first year after the index operation was considerably lower than that of the index hospitalization., Conclusion: There is nearly a 2-fold variation in the cost of a diaphragmatic hernia repair across hospitals. Most of the variation occurs during the index surgical encounter and not for repeat encounters during the first postoperative year. As bundled payment models mature, hospitals and payers will need to target this variation to ensure cost-efficiency., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background and Objectives: Few empiric studies evaluate the effects of regionalization on pancreatic cancer care., Methods: We queried the National Cancer Database to identify patients undergoing pancreaticoduodenectomy for clinical stage I/II pancreatic adenocarcinoma between 2006 and 2015. Facilities were categorized by annual pancreatectomy volume. Textbook oncologic outcome was defined as a margin negative resection, appropriate lymph node assessment, no prolonged hospitalization, no 30-day readmission, no 90-day mortality, and timely receipt of adjuvant chemotherapy. Multivariable regression adjusted for comorbid disease, pathologic stage, and facility characteristics was used to evaluate the relationship between facility volume and textbook outcome., Results: Sixteen thousand six hundred and two patients underwent pancreaticoduodenectomy; 3566 (21.5%) had a textbook outcome. Operations performed at high volume centers increased each year (45.8% in 2006 to 64.2% in 2015, p < 0.001) as did textbook outcome rates (14.3%-26.2%, p < 0.001). Surgical volume was associated with textbook outcome. High volume centers demonstrated higher unadjusted rates of textbook outcome (25.4% vs. 11.8% p < 0.01) and increased adjusted odds of textbook outcome relative to low volume centers (odds ratio: 2.39, [2.02, 2.85], p < 0.001). Textbook outcome was associated with improved overall survival independent of volume., Conclusions: Regionalization of care for pancreaticoduodenectomy to high volume centers is ongoing and is associated with improved quality of care., (© 2021 Wiley Periodicals LLC.)

Background: Prior studies evaluating the effect of margin status on clinical outcome in patients undergoing resection for intrahepatic and extrahepatic hilar cholangiocarcinoma include small numbers of patients with histologically positive margins. The value of margin negative resection in these cases remains unclear., Methods: We queried the National Cancer Database to identify patients undergoing resection for clinical stage I to III intrahepatic and extrahepatic hilar between 2004 and 2015. Patients receiving neoadjuvant therapy and those having <3 lymph nodes examined were excluded. Patients undergoing positive resection were 1:1 propensity matched to those undergoing negative resection. Kaplan-Meier methods were used to compare overall survival for the matched cohorts., Results: In the study, 3,618 patients met the inclusion criteria, and 3,018 (83.4%) underwent negative resection; 600 (16.6%) positive resection. Patients undergoing negative resection had smaller tumors (2.97 ± 0.07 cm vs 3.49 ± 0.15 cm), were less likely to have stage 3 disease (16.7% vs 25.7%) and to receive adjuvant radiation (27.1% vs 45.7%) and chemotherapy (49.4% vs 61.0%) than those undergoing positive resection (all P < .05). On comparison of matched cohorts, patients undergoing negative resection had longer median overall survival (24.5 ± 0.02 vs 19.1 ± 0.02 months) and higher rates of 5-year overall survival (24.5% vs 16.7%) than those undergoing positive resection (P < .01)., Conclusion: In patients presenting with resectable intrahepatic and extrahepatic hilar, negative resection is associated with improved overall survival. Extended resections performed in an effort to clear surgical margins are warranted in patients fit for such procedures., (Copyright © 2021. Published by Elsevier Inc.)

Background: Few studies evaluate the efficacy of adjuvant radiotherapy (aXRT) in patients with retroperitoneal liposarcoma undergoing resection to histologically positive (R1) margins., Methods: We queried the National Cancer Database to identify patients undergoing R1 resection for localized, large (>5 cm) low and moderate grade retroperitoneal liposarcoma between 2004 and 2016. Kaplan Meier method was used to compare overall survival (OS) for patients receiving aXRT to a 1:2 propensity-matched cohort of patients undergoing resection alone., Results: A total of 322 (76.5%) patients underwent R1 resection alone, while 99 (23.5%) underwent resection followed by aXRT. The 99 receiving aXRT were successfully 1:2 propensity-score matched to 198 undergoing resection alone. There was no difference in 5-year OS between matched cohorts (69.7% vs 76.2%, p = 0.40)., Conclusions: In patients undergoing R1 resection of moderate- and well-differentiated retroperitoneal liposarcoma, use of aXRT is not associated with an improvement in OS., (Published by Elsevier Inc.)

Background: Liver transplantation offers a potential for curative-intent treatment in patients presenting with non-metastatic intrahepatic cholangiocarcinoma that is not amenable to partial hepatectomy. There is little empiric evidence evaluating the efficacy of liver transplantation in patients with intrahepatic cholangiocarcinoma., Methods: We queried the National Cancer Database to identify patients presenting with histologically confirmed clinical stage I to III intrahepatic cholangiocarcinoma between 2004 and 2016. Propensity scoring was used to develop matched cohorts of patients undergoing treatment with liver transplantation, surgical resection, or chemotherapy alone. Kaplan Meier methods were used to compare rates of overall survival., Results: One thousand four hundred and eleven patients met inclusion criteria. Of these, 66 (4.7%) underwent liver transplantation, 461 (32.7%) underwent surgical resection, and 884 (62.6%) were treated with chemotherapy alone. On adjusted analysis, patients undergoing liver transplantation were more likely to be male (odds ratio 4.35, 95% confidence interval [0.12, 0.42]), have a Charlson Comorbidity Score ≥2 (odds ratio 3.11, 95% confidence interval [1.44, 6.57]), and to receive both neoadjuvant (odds ratio 2.78, 95% confidence interval [1.36,5.75], and adjuvant (odds ratio 1.94, 95% confidence interval [0.97, 3.87]) systemic therapy than those undergoing resection. On Kaplan Meier analysis, patients undergoing liver transplantation demonstrated rates of 5-year overall survival (36.1% vs 34.7%, P = .53) that were statistically identical to those for stage-matched and margin-matched patients undergoing resection but significantly better than those for stage-matched patients treated with systemic therapy alone (36.1% vs 5.3%, P < .0001)., Conclusion: Patients undergoing liver transplantation for intrahepatic cholangiocarcinoma demonstrate overall survival profiles similar to stage-matched and margin-matched patients undergoing surgical resection. Liver transplantation is an effective treatment modality in select patients presenting with localized intrahepatic cholangiocarcinoma., (Published by Elsevier Inc.)

Objectives: Stereotactic body radiation therapy (SBRT) is an established primary treatment modality in patients with lung cancer who have multiple comorbidities and/or advanced-stage disease. However, its role in otherwise healthy patients with stage I lung cancer is unclear. In this context, we compared the effectiveness of SBRT versus surgery on overall survival using a national database., Methods: We identified all patient with clinical stage I non-small cell lung cancer from the National Cancer Database from 2004 to 2016. We defined otherwise healthy patients as those with a Charlson-Deyo comorbidity index of 0 and whose treatment plan included options for either SBRT or surgery. We further excluded patients who received SBRT due to a contraindication to surgery. We first used propensity score matching and Cox proportional hazard models to identify associations. Next, we fit 2-stage residual inclusion models using an instrumental variables approach to estimate the effects of SBRT versus surgery on long-term survival. We used the hospital SBRT utilization rate as the instrument., Results: Of 25,963 patients meeting all inclusion/exclusion criteria, 5465 (21%) were treated with SBRT. On both Cox proportional hazards modeling and propensity-score matched Kaplan-Meier analysis, surgical resection was associated with improved survival relative to SBRT. In the instrumental-variable-adjusted model, SBRT remained associated with decreased survival (hazard ratio, 2.64; P  < .001). Both lobectomy (hazard ratio, 0.17) and sublobar resections (hazard ratio, 0.28) were associated with improved overall survival compared with SBRT ( P  < .001)., Conclusions: In otherwise healthy patients with stage I NSCLC, surgical resection is associated with a survival benefit compared with SBRT. This is true for both lobar and sublobar resections.

Background: Achieving microscopically negative (R0) surgical margins in gallbladder cancer often requires a partial hepatectomy with associated risk of morbidity and potential to delay adjuvant therapy. Prior studies on the importance of margin status in resectable gall bladder cancer include small numbers of patients with positive (R1) resection margins and are underpowered., Methods: We queried the National Cancer Database to identify patients undergoing resection of gallbladder adenocarcinoma between 2004 and 2015. Patients presenting with metastatic disease, those who received neoadjuvant therapy, and those with fewer than 3 lymph nodes assessed were excluded. 1:1 propensity score matching was used to develop cohorts undergoing either R0 or R1 resection, matched for demographic, pathologic, and facility characteristics. Kaplan-Meier analysis was used to assess the association between margin status and overall survival., Results: A total of 1,439 patients met inclusion criteria; 1,285 underwent R0 and 154 underwent R1 resection. On Kaplan-Meier analysis of propensity-matched cohorts, patients undergoing R0 resection had a median overall survival that was 18 months longer than those undergoing R1 resection (34.6 ± 2.0 months vs 16.3 ± 1.7 months, P < .001)., Conclusion: In patients presenting with resectable gallbladder adenocarcinoma, margin-negative resection is associated with significant improvement in overall survival., (© 2021 Published by Elsevier Inc.)

Background: Published studies evaluating the effect of robotic assistance on clinical outcomes and costs of care in diaphragmatic hernia repair (DHR) have been limited., Study Design: The Healthcare Cost and Utilization Project State Inpatient and State Ambulatory Surgery and Services Databases for Florida were queried to identify patients undergoing transabdominal DHR between 2011 and 2018 and associated inpatient and outpatient encounters within 12 months after the index operation. Patients undergoing robotic DHR were 1:1:1 propensity score-matched for age, sex, race, Elixhauser comorbidity score, case priority, payer, and facility volume with patients undergoing open and laparoscopic DHR., Results: There were 5,962 patients (67.3%) who underwent laparoscopic DHR, 1,520 (17.2%) who underwent open DHR, and 1,376 (15.5%) who underwent robotic DHR. On comparison of matched cohorts, median index length of stay (3 days; interquartile range [IQR] 2 to 5 days vs 2 days; IQR 1 to 4 days; p < 0.001) and index hospitalization costs ($17,236; IQR $13,231 to $22,183 vs $12,087; IQR $8,881 to $17,439; p < 0.001) for robotic DHR were greater than for laparoscopic DHR. Median length of stay for open DHR (6 days; IQR 4 to 10 days) was longer than that for both laparoscopic and robotic DHR. Median index hospitalization costs for open DHR ($16,470; IQR $11,152 to $23,768) were greater than those for laparoscopic DHR, but less than those for robotic DHR. There were no significant differences between cohorts in the overall rate of post-index care., Conclusions: Laparoscopic DHR is the most cost-effective approach to DHR. Robotic assistance provides clinical outcomes comparable with laparoscopic DHR, but is associated with increased index cost., (Copyright © 2021 American College of Surgeons. All rights reserved.)

Background: Mangled extremities are one of the most difficult injuries for trauma surgeons to manage. We compare limb salvage rates for a limb-threatening lower extremity injuries managed at Level I vs Level II trauma centers (TCs)., Study Design: We identified all adult patients with a limb-threatening injury who underwent primary amputation or limb salvage (LS) using the American College of Surgeons (ACS) Trauma Quality Improvement Program database at ACS Level I vs II TCs between 2007 and 2017. A limb-threatening injury was defined as an open tibial fracture with concurrent arterial injury (Gustilo type IIIc). Multivariable analysis and propensity score matching were performed to minimize confounding by indication., Results: There were 712 records for analysis; 391 (54.9%) LS performed and 321 (45.1%) underwent amputation. The rate of LS was statistically higher among patients treated at Level I TCs vs those treated at Level II TCs (47.4% vs 34.8%; p = 0.01). Patients with penetrating injuries (13% vs 9.5%; p = 0.046) and tibial/peroneal artery injury (72.9% vs 50.4%; p < 0.001), as opposed to popliteal artery injury (30.8% vs 58.8%; p < 0.001), were more likely to have LS. The risk-adjusted odds of LS was 3.13 times higher at Level I TCs vs Level II TCs (95% CI, 1.59 to 6.34; p = 0.001). Limb salvage rates were significantly higher at Level I TCs compared with Level II TCs (53.0% vs 34.8%; p = 0.004), even after propensity matching., Conclusions: In patients with a mangled extremity, limb salvage rates are 50% higher at Level I TCs compared with Level II TCs, independent of case mix and injury severity., (Copyright © 2021 American College of Surgeons. All rights reserved.)

Background: The use of whole-body computed tomography (WBCT) in awake, clinically stable injured patients is controversial. It is associated with unnecessary radiation exposure and increased cost. We evaluate use of computed tomography (CT) imaging during the initial evaluation of injured patients at American College of Surgeons Levels I and II trauma centers (TCs) after blunt trauma., Methods: We identified adult blunt trauma patients after motor vehicle crash (MVC) from the American College of Surgeons Trauma Quality Improvement Program (TQIP) database between 2007 and 2016 at Level I or II TCs. We defined awake clinically stable patients as those with systolic blood pressure of 100 mm Hg or higher with a Glasgow Coma Scale score of 15. Computed tomography imaging had to have been performed within 2 hours of arrival. Whole-body computed tomography was defined as simultaneous CT of the head, chest and abdomen, and selective CT if only one to two aforementioned regions were imaged. Patients were stratified by Injury Severity Score (ISS)., Results: There were 217,870 records for analysis; 131,434 (60.3%) had selective CT, and 86,436 (39.7%) had WBCT. Overall, there was an increasing trend in WBCT utilization over the study period (p < 0.001). In patients with ISS less than 10, WBCT was utilized more commonly at Level II versus Level I TCs in patients discharged from the emergency department (26.9% vs. 18.3%, p < 0.001), which had no surgical procedure(s) (81.4% vs. 80.3%, p < 0.001) and no injury of the head (53.7% vs. 52.4%, p = 0.008) or abdomen (83.8% vs. 82.1%, p = 0.001). The risk-adjusted odds of WBCT was two times higher at Level II TC vs. Level I (odds ratio, 1.88; 95% confidence interval 1.82-1.94; p < 0.001)., Conclusion: Whole-body computed tomography utilization is increasing relative to selective CT. This increasing utilization is highest at Level II TCs in patients with low ISSs, and in patients without associated head or abdominal injury. The findings have implications for quality improvement and cost reduction., Level of Evidence: Care management, Level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Few studies evaluate the impact of unhealthy alcohol and drug use on the risk and severity of postoperative outcomes after upper gastrointestinal and pancreatic oncologic resections., Methods: The National Inpatient Sample was queried to identify patients undergoing total gastrectomy, esophagectomy, total pancreatectomy, and pancreaticoduodenectomy between 2012 and 2015. Unhealthy alcohol and drug use was assessed by the International Classification of Diseases, Ninth Revision, and National Inpatient Sample coder designation. Multivariable regression was used to identify associations between alcohol and drug use and postoperative complication, duration of stay, hospital cost, and mortality., Results: In the study, 59,490 patients met inclusion criteria; 2,060 (3.5%) had unhealthy alcohol use; 1,265 (2.1%) had unhealthy drug use. Postoperative complication rates were higher in patients with alcohol and drug use than in abstainers (67.5% vs 62.8% vs 57.2%; P < .01). On multivariable regression, alcohol use was independently associated with increased risk of a nonwithdrawal complication (odds ratio 1.33 [1.05, 1.68]), and alcohol and drug use were independently associated with increased length of stay (1.54 [0.12, 2.96]) and 2.22 [0.90, 3.55] days) and cost ($5,471 [$60, $10,881] and $4,022 [$402, $7,643]), but not mortality., Conclusion: Unhealthy substance use is associated with increased rates of postoperative complications, prolonged length of stay, and costs in patients undergoing major upper gastrointestinal and pancreatic oncologic resections. Screening and abstinence interventions should be incorporated into the preoperative care pathways for these patients., (Published by Elsevier Inc.)

Background: Prior studies evaluating the impact of adjuvant or neoadjuvant radiotherapy on clinical outcomes in retroperitoneal liposarcoma have been underpowered., Methods: We queried the National Cancer Database for patients undergoing resection of retroperitoneal liposarcoma from 2004 to 2016. Cox proportional hazards modeling stratified by tumor size was used to identify factors associated with overall survival., Results: 4018 patients met inclusion criteria. 251 had small (<5 cm), 574 intermediate (5-10 cm), and 3193 large (>10 cm) tumors. Positive surgical margins were correlated with risk of death across all tumor size categories (<5 cm HR 2.33, CI [1.20, 4.55]; 5-10 cm HR 1.49, CI [1.03, 2.14]; >10 cm HR 1.30, CI [1.12, 1.51]). Adjuvant radiotherapy was associated with improved survival for patients with large tumors only (HR 0.75, CI [0.64, 0.89])., Conclusions: In retroperitoneal liposarcoma, adjuvant radiation is associated with improved survival only for patients with tumors larger than 10 cm. Radiation should be used sparingly in patients with smaller tumors., Summary: The use of radiotherapy in the management of retroperitoneal sarcoma remains controversial. We isolated retroperitoneal liposarcomas only and identified a survival benefit from radiotherapy treatment only in tumors larger than 10 cm and only in the adjuvant setting., (Published by Elsevier Inc.)

Background: Prior studies evaluating the impact of adjuvant or neoadjuvant radiation on clinical outcomes of patients with non-lipomatous retroperitoneal sarcoma have been underpowered., Methods: We queried the National Cancer Database to identify patients undergoing surgical resection of retroperitoneal sarcoma with non-lipomatous histology from 2004 to 2016. Multivariable logistic regression and Cox proportional hazards modelling with patients stratified by tumor size were used to identify factors associated with overall survival., Results: 3,394 patients met inclusion criteria. 592 had small (<5 cm), 1,186 had intermediate (5-10 cm), and 1,616 had large (>10 cm) tumors. Use of either neoadjuvant or adjuvant radiotherapy was associated with improved survival for patients with intermediate (neoadjuvant HR 0.67, CI [0.46, 0.98]; adjuvant HR 0.61, CI [0.50, 0.76]) and large (neoadjuvant HR 0.50, CI [0.37, 0.68]; adjuvant HR 0.56, CI [0.47, 0.69]) tumors, while adjuvant radiation therapy was associated with a survival benefit for small-sized tumors (HR 0.67, CI [0.46, 0.99])., Conclusions: Radiation therapy is associated with an overall survival benefit in patients presenting undergoing resection of non-lipomatous retroperitoneal sarcoma., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Bile duct injury (BDI) during cholecystectomy requiring biliary enteric reconstruction (BER) is associated with increased risk of postoperative mortality and substantive increases in costs of care. The impact of the timing of repair on overall costs of care is poorly understood., Materials and Methods: The Healthcare Cost and Utilization Project Florida State databases (2006-2015) were queried to identify patients undergoing BER within 1-y of cholecystectomy performed for benign biliary disease. Patients were then categorized by the time interval between cholecystectomy to BER: early (≤3 d), intermediate (4 d to 6 wk), or delayed (>6 wk). By repair timing strategy, 1-y outcomes were aggregated, including charges, inpatient costs, aggregate length of stay, and inpatient mortality., Results: Of 563,887 patients undergoing cholecystectomy, 1168 required a BER (0.21%) within 1-y of cholecystectomy. Early BER was performed in 560 patients (47.9%), intermediate BER in 439 patients (37.6%), and delayed BER in 169 (14.5%) patients. On multivariable analysis adjusting for patient, procedure, and facility factors, intermediate BER demonstrated an increased risk of mortality (odds ratio 2.04, 95% confidence interval [CI]: 1.16-3.56) and increased aggregate inpatient cost (+$12,472; 95% CI: $6421-$18,524) relative to early BER. There was no notable difference in adjusted risk of inpatient mortality between the early and delayed BER cohorts (odds ratio 0.90; 95% CI: 0.32-1.25), but delayed BER was associated with increased aggregate inpatient costs (+$45,111; 95% CI: $36,813-$53,409)., Conclusions: When compared with delayed BER, early repair was associated with shorter aggregate inpatient hospitalization without increased postoperative mortality. Intermediate timing of repair is associated with increased costs and risk of mortality., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Health care spending is driven by a very small percentage of Americans, many of whom are patients with prolonged durations of stay. The objective of this study was to characterize superusers in the trauma population., Methods: The National Trauma Data Bank for 2008-2012 was queried. Superusers were defined as those with a duration of stay in the top 0.06% of the population and were compared with the remainder of the population to determine differences in demographic characteristics, comorbidities, prehospital factors, and outcomes. Multivariate analysis was used to determine independent predictors of being classified as a superuser., Results: A total of 3,617,261 patients met inclusion criteria, with 34,728 qualifying as superusers. Mean duration of stay for superusers was 58.7 days compared with the average 4.6 days (P < .001). Superusers were more likely to be male, black, Medicaid insured, and have a higher Injury Severity Score and lower Glasgow Coma Scale score. The hospital course of superusers was likely to be complicated by pneumonia, acute respiratory distress syndrome, decubitus ulcer, and acute kidney injury., Conclusion: Age, sex, race, and insurance were associated with prolonged use of inpatient care in the trauma patient population. Specific comorbidities and complications are associated with being a superuser. This subset of the trauma population confers a disproportionate burden on the health care system and can serve as a potential target for intervention., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: To describe the long-term incidence of adhesive bowel obstruction following major urologic surgery, and the effect of early surgery on perioperative outcomes., Methods: The Healthcare Cost and Utilization Project State Inpatient Databases for California and Florida (2006-2011) were used to identify major urologic oncologic surgery patients. Subsequent adhesive bowel obstruction admissions were identified and Kaplan-Meier time-to-event analysis was performed. Early surgery for bowel obstruction was defined as occurring on-or-before hospital-day four. The effects of early surgery on postoperative minor/moderate complications (wound infection, urinary tract infection, deep vein thrombosis, and pneumonia), major complications (myocardial infarction, pulmonary embolism, and sepsis), death, and postoperative length-of-stay were assessed., Results: Major urologic surgery was performed on 104,400 patients, with subsequent 5-year cumulative incidence of adhesive bowel obstruction admission of 12.4% following radical cystectomy, 3.3% following kidney surgery, and 0.9% following prostatectomy. During adhesive bowel obstruction admission, 71.6% of patients were managed conservatively and 28.4% surgically. Early surgery was performed in 65.4%, with decreased rates of minor/moderate complications (18 vs. 30%, p = 0.001), major complications (10 vs. 19%, p = 0.002), and median postoperative length of stay (8 vs. 11 days, p < 0.001) compared with delayed surgery. On multivariate analysis early surgery decreased the odds of minor/ moderate complications by 43% (p = 0.01), major complications by 45% (p = 0.03), and postoperative length of stay by 3.1 days (p = 0.01)., Conclusion: Adhesive bowel obstruction is a significant long-term sequela of urologic surgery, for which early surgical management may be associated with improved perioperative outcomes.

Background: The fastest growing segment of the American population is the elderly (>65 years). This change in demographics also is being seen in trauma centers. Emergency department thoracotomy is utilized in an attempt to restore circulation for patients arriving in extremis. The purpose of this study was to investigate the relationship between clinical variables, particularly age, and outcomes for injured patients receiving an emergency department thoracotomy., Methods: Using the National Trauma Data Bank for years 2008-2012, observations with International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes for exploratory thoracotomy were identified. Emergency department thoracotomy was defined as any observation that occurred at a time to thoracotomy less than the total time spent in the emergency department thoracotomy, and within 15 minutes of arrival. Mechanisms of injury, demographic data, and injuries were analyzed for predictors of survival and mortality rates. Mortality rates were determined for each decade and year of life., Results: There were 11,380 observations for thoracotomy identified. Of these, 2,519 were emergency department thoracotomy, with the majority (n= 2,026, 80% observations) performed for penetrating wounds. Mortality rates ranged from 80% to 100% for each decade of life. Mortality was 100% for patients >57 years old with either penetrating or blunt mechanisms of injury., Conclusion: Emergency department thoracotomy offered no survival benefit for patients older than 57 years of age. These data suggest that emergency department thoracotomy performed in elderly patients may be futile., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The role of cervical spine magnetic resonance imaging (MRI) in the evaluation of clinically unevaluable blunt trauma patients has been called into question by several recent studies., Methods: A PubMed search was performed for all studies comparing computed tomography and MRI in the assessment of the cervical spine in patients who cannot be evaluated clinically. The radiologic findings and clinical outcomes from each study were collated for analysis., Results: Data for 1,714 patients were available. All patients had a negative computed tomography scan and then underwent an MRI. There were 271 (15.8%) patients who had a previously undocumented finding on MRI with the majority (98.2%) being a ligamentous injury. Only 5 injuries (1.8%) resulted in surgical intervention., Conclusions: MRI identifies additional injuries; however, the vast majority are of minor clinical significance. Routine MRI after a negative computed tomography of the cervical spine is not supported by the current literature., (Published by Elsevier Inc.)

Background: The purpose of this study was to measure how the duration of nonoperative intervention for intestinal obstruction impacted patient outcomes and whether hospital characteristics influenced the timing of operative intervention., Methods: The State Inpatient Database (Florida) of the Health Care Utilization Project and the Annual Survey database of the American Hospital Association were linked from 2006 to 2011. Included were patients ≥18 years of age with a primary diagnosis of intestinal obstruction. Patient factors included age, sex, socioeconomic factors, and comorbid conditions., Results: A total of 116,195 patients met our inclusion criteria, and 43,079 underwent operative intervention (37.1%). Patients who required operative correction of the intestinal obstruction after the fifth day of hospitalization, compared with patients who underwent an operation on the day of admission, had increases in mortality (6.1% vs 1.8%, P < .001), complication rates (15.4% vs 4.0%, P < .001), and postoperative hospital stay (9 vs 5 days, P < .001). Patients cared for at a large teaching facility (with surgery residents) had increased odds of early operative intervention by 23% (odds ratio 1.23, [1.20-1.28]), whereas patients at low-volume hospitals had decreased odds of early intervention (odds ratio 0.88, [0.73-0.91])., Conclusion: Initial nonoperative treatment in patients with uncomplicated intestinal obstruction is an important strategy, but the odds of having an adverse event increase as intestinal obstruction is delayed. Importantly, the presence of surgery residents and increasing bed size are hospital characteristics associated with earlier operative intervention, suggesting a quality benefit for care at large teaching hospitals., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Incisional hernia recurrence after repair continues to be a persistent complication. The purpose of this study was to investigate the association between patient-specific factors, surgeon-specific factors, and hernia recurrence in patients undergoing repair of an incisional hernia in whom the component separation technique was used., Methods: All patients undergoing incisional herniorrhaphy with component separation from October 2006 to May 2013 were reviewed. Data collected included demographics, comorbidities, postoperative complications, and factors related to mesh implantation. Computed tomography images were used to evaluate the size of the hernia and dimensions of the linea alba., Results: The 85 patients were followed for a mean of 14.4 months, and 12 (14.1%) recurrent hernias were diagnosed. More than 91% of the herniorrhaphies were performed after a previous repair failed. The recurrence rate decreased to 11.1% when, in addition to the component separation, a mesh was used to reinforce the repair. There were no differences between the group who developed a recurrence and those who did not in terms of sex, age, race, body mass index, preoperative comorbidities, or type of mesh used., Conclusion: In this case series of complex abdominal wall herniorrhaphies using component separation, the recurrence rate was 14.1% overall and 11.1% when a mesh was used to reinforce the repair. Recurrent hernia was not associated with patient demographics, comorbidities, thickness or width of the linea alba, presence of a contaminated wound, or postoperative surgical-site occurrences., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Thoracic injury is currently the second leading cause of trauma-related death and rib fractures are the most common of these injuries. Flail chest, as defined by fracture of three or more ribs in two or more places, continues to be a clinically challenging problem. The underlying pulmonary contusion with subsequent inflammatory reaction and right-to-left shunting leading to hypoxia continues to result in high mortality for these patients. Surgical stabilization of the fractured ribs remains controversial. We review the history of management for flail chest alone and when combined with pulmonary contusion. Finally, we propose an algorithm for nonoperative and surgical management.

Purpose: Biliary dyskinesia (BD) is described as biliary colic in the absence of gallstones. The diagnosis relies on imaging studies and decreased excretion of bile in response to cholecystokinin during quantitative cholescintigraphy. The purpose of this study was to evaluate the success of laparoscopic cholecystectomy (LC) for relieving symptoms in patients diagnosed with BD and correlate gallbladder ejection fraction (EF) with symptom relief., Methods: A retrospective review was performed at a single institution of all patients who underwent LC for BD from January 2005 through January 2012. The diagnosis of BD was determined by a normal gallbladder as viewed with ultrasonography and cholescintigraphy with a gallbladder EF less than or equal to 45%. Data collection included demographics, results of imaging studies, pathologic diagnosis, and early postoperative pain relief. Patients were contacted by phone after being discharged from the surgeon's care for evaluation of symptom relief. Data were analyzed with nonparametric statistical methods, including Mann-Whitney U test, receiver operator characteristic, Fisher exact test, and χ(2) test. All data are expressed as median and 25th and 75th percentile range., Results: There were 126 patients who had a LC for BD during the study period. The median biliary EF was 20% (10-29%). The most common pathologic finding was chronic cholecystitis (n = 95; 75%). Median length of follow-up in the perioperative period was 11 days (8-17), during which time 98 patients (78%) had relief of symptoms. Phone interviews (n = 53; 42%) confirmed 66% (n = 35) of patients remained free of pain. There was no difference in the mean EF among those with resolution of pain 20% (10-29%) compared with patients with persistent pain 23% (11-29%), P = .62. Obese patients were more likely to have persistent symptoms in the perioperative period with a shift to lower body mass index at the time of the phone survey. Receiver operator characteristic characteristic for the association between scintigraphic EF and resolution of postoperative pain demonstrated no association, with the area under the curve equal to 0.47., Conclusion: The majority of patients in this series with BD had resolution of symptoms with LC. However, cholescintigraphy EF did not correlate with outcome. Further studies are needed to better identify patients diagnosed with BD who will benefit from LC., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Background: The purpose of this study was to evaluate the outcomes of various surgeon strategies used to evaluate and treat common duct stones (CDSs) in patients presenting with mild to moderate gallstone pancreatitis (GP)., Methods: We performed a retrospective review of patients admitted for mild to moderate GP. Data variables included laboratory values and radiology images, indications for and findings of intraoperative cholangiogram (IOC) and endoscopic retrograde cholangiopancreatography (ERCP), length of stay (LOS), and hospital charges. Data were stratified by 2 different management strategies: preoperative ERCP and then laparoscopic cholecystectomy (LC) or LC with IOC followed by selective postoperative ERCP., Results: During this time period, 80 patients met the study criteria, 56 were treated by LC with IOC, and 24 had a preoperative ERCP performed. The incidence of CDS was 33% (n = 26). The presence of CDSs correlated with an elevated total bilirubin at admission (CDSs 3.5 mg/dL vs 2.1 mg/dL no CDSs, P < .01) and 24 hours after admission (CDS 3.2 mg/dL vs 1.5 mg/dL no CDS, P < .01). Patients who had an IOC compared with those who had preoperative ERCP had a shorter LOS (4.6 vs 5.9 days, P = .04) and lower hospital charges (US $28,510 vs US $38,620; P < .01)., Conclusions: Elevated total bilirubin at admission and 24 hours after admission may predict a patient's risk for CDS. We found that the management of uncomplicated GP with early LC and IOC results in decreased LOS and total hospital charges when compared with preoperative ERCP., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: Surgical education is changing owing to workforce and economic demands. Simulation and other technical teaching methods are used to acquire skills transferable to the operating room. Operative management of traumatic injuries has declined, making it difficult to acquire and maintain competence. The ASSET course was developed by the Committee on Trauma's Surgical Skills Committee to fill a surgical skills need in resident and fellow education. Using a human cadaver, standardized rapid exposure of vital structures in the extremities, neck, thorax, abdomen, retroperitoneum, and pelvis is taught., Methods: A retrospective analysis of 79 participants in four ASSET courses was performed. Operative experience data were collected, and self-efficacy questionnaires (SEQs) were administered before and after the course. Course evaluations and instructor evaluation data were analyzed. Student's and paired samples t tests as well as analysis of variance and Spearman ρ correlation coefficient analysis were performed using α at p < 0.05. We hypothesized that the ASSET course would teach new surgical techniques and that learner self-assessed ability would improve., Results: Participants included 27 PGY-4, 20 PGY-5, 24 PGY-6 or PGY-7 and PGY-8 at other levels of training. Self-assessed confidence improved in all body regions (p < 0.001), with the greatest increase in upper extremity and chest. Pre- and post-SEQ scores correlated with trauma operative experience. Precourse SEQ scores differed by level of training. Instructor evaluations correlated with previous experience on a trauma service. Program evaluations averaged 4.73 on a 5-point scale, with gaining new knowledge rated at 4.8 and learning new techniques at 4.72., Conclusion: A standardized cadaver-based surgical exposures course offered to senior surgical residents adds new surgical skills and improves participant self-assessed ability to perform emergent surgical exposure of vital structures.

Rhabdomyolysis is a clinical syndrome defined by muscle breakdown and subsequent release of intracellular contents. There are many etiologies of rhabdomyolysis, classified here as congenital and acquired; compartment syndrome secondary to trauma with reperfusion injury is one common precipitating factor. Regardless of the underlying etiology, the pathophysiology follows a similar pathway via myocyte destruction and release of myoglobin into the systemic circulation. Rhabdomyolysis-induced renal failure is caused by the precipitation of myoglobin in the renal tubules which is enhanced under acidic conditions. A high index of clinical suspicion is required to promptly recognize rhabdomyolysis, especially in the unconscious patient. Presenting symptoms include tea-colored urine and muscle weakness or fatigue. The diagnosis is confirmed most reliably with the finding of elevated serum creatine kinase levels. Early, aggressive resuscitation with either normal saline or lactated Ringer's solution to maintain an adequate urine output is the most important intervention in preventing the development of acute renal failure. There is insufficient clinical evidence supporting the routine administration of diuretics and bicarbonate to protect against the development of acute renal failure.

Background: The use of prophylactic antibiotics in penetrating abdominal trauma has resulted in decreased infection rates. The Eastern Association for the Surgery of Trauma (EAST) first published its practice management guidelines (PMGs) for the use of prophylactic antibiotics in penetrating abdominal trauma in 1998. During the next decade, several new prospective studies were published on this topic. In addition, the practice of damage control laparotomy became widely used, and additional questions arose as to the role of prophylactic antibiotics in this setting. Thus, the EAST Practice Management Guidelines Committee set out to update the original PMG., Methods: A search of the National Library of Medicine and the National Institutes of Health MEDLINE databases was performed using PubMed (www.pubmed.gov) and specific key words. The search retrieved English language articles regarding the use of antibiotics in penetrating abdominal trauma published from 1973 to 2011. The topics investigated were the need for perioperative antibiotics, the duration of antibiotic therapy, the dose of antibiotics in patients presenting in hemorrhagic shock, and the appropriate duration of antibiotic therapy in the setting of damage control laparotomy., Results: Forty-four articles were identified for inclusion in this review., Conclusion: There is evidence to support a Level I recommendation that prophylactic antibiotics should only be administered for 24 hours in the presence of a hollow viscus injury. In addition, there are no data to support continuing prophylactic antibiotics longer than 24 hours in damage control laparotomy.

Background: In the aftermath of a devastating earthquake in early 2011, Haiti fell victim to an outbreak of cholera that claimed thousands of lives and affected populations in nearby Dominican Republic, Venezuela, and even the United States. This was the first time cholera had been reported in Haiti in more than 100 years. The sudden appearance of cholera, a pathogen with no known non-human host, raised the question of how it was introduced to an island that has long been spared this disease. The purpose of this review is to provide an overview of the history of cholera, its pathophysiology and virulence factors, and current recommendations for treatment., Methods: Articles published in the past 10 years were identified by a search of the medical literature using PUBMED and reviewed. Bibliographies of each article also were reviewed for additional pertinent articles., Results: The recent epidemic was caused by a strain that has been responsible for disease in South Asia since 1961, the seventh and most recent strain identified since 1900. It is transmitted by the fecal-oral route. Once infected, the patient develops a rapidly dehydrating diarrheal illness caused by the cholera toxin, which activates cytoplasmic adenylate cyclase of the intestinal epithelial cells by adenosine diphosphate (ADP)-ribosylation of the stimulatory G protein. The high cyclic adenosine monophosphate (cAMP) concentrations activate the cystic fibrosis transmembrane conductance regulator, causing a dramatic efflux of ions and water from infected enterocytes and leading to watery diarrhea. The first line of therapy is oral hydration with intravenous fluids; antibiotics are reserved for patients with severe dehydration. Spread of cholera is preventable with simple modifications of hygiene and water preparation., Conclusions: Cholera has re-emerged as a major infectious disease in the recent past, with a global increase in its incidence. Vaccination should be considered as an adjunct for controlling the epidemics and also for volunteer health care workers who provide services to underdeveloped nations. During an epidemic such as occurred in Haiti, use of antibiotics should be considered for all hospitalized patients. These endeavors should proceed in concert with much-needed improvements in sanitation and accessibility of potable water.