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Introduction: Increasing health-care costs in the United States have not translated to superior outcomes in comparison to other developed countries. The implementation of physician-targeted interventions to reduce costs may improve value-driven health outcomes. This study aimed to evaluate the effectiveness of physician-targeted interventions to reduce surgical expenses and improve care for patients undergoing total thyroidectomies., Methods: Two separate face-to-face interventions with individual surgeons focusing on surgical expenses associated with thyroidectomy were implemented in two surgical services (endocrine surgery and otolaryngology) by the surgical chair of each service in Jun 2016. The preintervention period was from Dec 2014 to Jun 2016 (19 mo, 352 operations). The postintervention period was from July 2016 to January 2018 (19 mo, 360 operations). Descriptive statistics were utilized, and differences-in-differences were conducted to compare the pre and postintervention outcomes including cost metrics (total costs, fixed costs, and variable costs per thyroidectomy) and clinical outcomes (30-d readmission rate, days to readmission, and total length of stay)., Results: Patient demographics and characteristics were comparable across pre- and post-intervention periods. Post-intervention, both costs and clinical outcomes demonstrated improvement or stability. Compared to otolaryngology, endocrine surgery achieved additional savings per surgery post-intervention: mean total costs by $607.84 (SD: 9.76; P < 0.0001), mean fixed costs by $220.21 (SD: 5.64; P < 0.0001), and mean variable costs by $387.82 (SD: 4.75; P < 0.0001)., Conclusions: Physician-targeted interventions can be an effective tool for reducing cost and improving health outcomes. The effectiveness of interventions may differ based on specialty training. Future implementations should standardize these interventions for a critical evaluation of their impact on hospital costs and patient outcomes., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Drain fluid amylase (DFA) levels have been used to predict clinically relevant postoperative pancreatic fistula (CR-POPF) and guide postoperative drain management. Optimal DFA cutoff thresholds vary between studies, thereby prompting investigation of an alternative assessment technique. As DFA measurements could, in theory, be distorted by variations in ascites fluid production, we hypothesized that adjusting DFA for volume corrected drain fluid amylase (vDFA) would improve CR-POPF predictive models., Methods: A single-institution retrospective cohort study of patients, who underwent pancreatoduodenectomies (PD) and distal pancreatectomies (DP) between 2013 and 2019, was performed. DFAs and vDFAs were measured on postoperative day (POD) 3. Clinicopathologic variables were compared between cohorts by univariable and multivariable analyses and Receiver operating characteristic (ROC) curves., Results: Patients developing a CR-POPF were more likely to be male and have elevated DFA, vDFA, and body mass index (BMI). vDFA use did not contribute to a superior CR-POPF predictive model compared to DFA-a finding consistent on subanalysis of surgery type PD versus DP. In CR-POPF predictive models, DFA, vDFA, and male sex significantly improved CR-POPF predictive models when considering both surgery subtypes, while only DFA and vDFA significantly improved models when cohorts were segregated by surgery type., Conclusions: Postoperative DFA remains a preferred method of predicting CR-POPF as the proposed vDFA assessment technique only adds complexity without increased discriminability., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Despite aggressive surgical care and systemic therapy, patients with pancreatic ductal adenocarcinoma (PDAC) have a poor prognosis. Recent studies show that racial disparities in outcome also exist. We sought to investigate the association lymph node (LN) metastases had with survival between Black and White patients with PDAC after resection., Methods: Retrospective analysis of 226 PDAC patients who underwent resection at a single institution from 2010 to 2018 was performed with attention to LN metastasis and patient race. The number of patients who received chemotherapy was also evaluated., Results: One Hundred Seventy Five (77.4%) PDAC patients were White and 51 (22.6%) were Black. 130 (59.3%) patients had LN metastasis (LN+). LN+ and LN- groups were similar in race (P = 0.93), sex (P = 0.10) and age at the time of diagnosis (P = 0.45). Patients with LN + disease were more likely to present with larger tumors (3.4 versus 2.8 cm, P = 0.02) and higher T status (P = 0.001). White and Black patients had similar rates of LN metastasis (59% versus 58.8%, P = 1.0). The median survival for LN- Black and White patients were similar (43.2 versus 30.2 mo, P = 0.82). LN + Black patients trended towards receiving more systemic therapy than White LN + patients (55% versus 42%, P = 0.10). The median survival for LN + Black patients was significantly less than LN + White patients (17.5 versus 24.6 mo, P = 0.04)., Conclusions: Black LN + PDAC patients have an inferior survival rate after resection when compared to their White counterparts. Our disparity in outcome cannot be solely explained by a difference in systemic treatment. Further investigation is warranted to determine racial differences in tumor biology or response to chemotherapy., (Copyright © 2022. Published by Elsevier Inc.)

Background: Many surgical departments in the United States lack endocrine surgery faculty. Although endocrine surgeons can provide worthwhile clinical services, it is unclear how they contribute to the overall academic mission of the department. The present study aims to evaluate the academic productivity of endocrine surgeons, as defined by the American Association of Endocrine Surgeons (AAES) membership, when compared with other academic surgical faculty., Materials and Methods: An established database of 4081 surgical department faculty was used for this study. This database includes surgical faculty of the top 50 National Institutes of Health (NIH) funded universities and faculty from five outstanding hospital-based surgical departments. Academic metrics including publication, citations, H-index, and NIH funding were obtained using publically available data from websites. The AAES membership status was gathered from the online membership registry., Results: A total of 110 AAES members were identified in this database, accounting for 2.7% of this population. Overall, the AAES members outperformed other academic surgical faculty with respect to publications (66 ± 94 versus 28 ± 91, P < 0.001), publication citations (1430 ± 3432 versus 495 ± 2955, P < 0.001), and H-index (19 ± 18 versus 10 ± 13, P < 0.001). In addition, the AAES members were more likely to have former/current NIH funding and hold divisional or departmental leadership positions than their non-AAES member colleagues., Conclusions: Based on these data, the AAES members excelled with respect to publications, citations, and research funding compared with nonendocrine surgical faculty. These results demonstrate that endocrine surgeons can contribute enormously to the overall academic mission. Therefore, more surgical departments in the United States should consider establishing an endocrine surgery program., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Operating room efficiency can be compromised because of surgical instrument processing delays. We observed that many instruments in a standardized tray were not routinely used during thyroid and parathyroid surgery at our institution. Our objective was to create a streamlined instrument tray to optimize operative efficiency and cost., Materials and Methods: Head and neck surgical instrument trays were evaluated by operating room team leaders. Instruments were identified as either necessary or unnecessary based on use during thyroidectomies and parathyroidectomies. The operating room preparation time, tray weights, number of trays, and number of instruments were recorded for the original and new surgical trays. Cost savings were calculated using estimated reprocessing cost of $0.51 per instrument., Results: Three of 13 head and neck trays were converted to thyroidectomy and parathyroidectomy trays. The starting head and neck surgical set was reduced from two trays with 98 total instruments to one tray with 36 instruments. Tray weight decreased from 27 pounds to 10 pounds. Tray preparation time decreased from 8 min to 3 min. The new tray saved $31.62 ($49.98 to $18.36) per operation in reprocessing costs. Projected annual savings with hospitalwide implementation is over $28,000.00 for instrument processing alone. Unmeasured hospital savings include decreased instrument wear and replacement frequency, quicker operating room setup, and decreased decontamination costs., Conclusions: Optimizing surgical trays can reduce cost, physical strain, preparation time, decontamination time, and processing times, and streamlining trays is an effective strategy for hospitals to reduce costs and increase operating room efficiency., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Human CC chemokine Macrophage Inflammatory Protein-3alpha (MIP-3alpha) directs inflammatory cell migration through its binding to the transmembrane receptor CCR6. MIP-3alpha has recently been shown to promote tumor cell migration in pancreatic adenocarcinoma by up-regulation of matrix metalloproteinases (MMPs). We hypothesized that MIP-3alpha promotes pancreatic cancer invasion through the up-regulation of MMP-9, a Type 4 collagenase., Materials, Methods, and Results: Immunohistochemistry and RT-PCR confirmed the presence of MIP-3alpha in PANC-1 cells, a human pancreatic adenocarcinoma cell line. MIP-3alpha stimulated the production of both latent and active forms of MMP-9 in PANC-1 by Western analysis. Tumor cell invasion was then evaluated using a modified Boyden chamber invasion assay. MIP-3alpha promoted a dose-dependent increase in pancreatic cancer cell invasion (P < 0.05) at 100 ng/ml. The activity at the putative MIP-3alpha receptor, CCR6, was demonstrated by receptor blockade. Anti-CCR6 antibody and anti-MMP-9 antibody inhibited MIP-3alpha-stimulated PANC-1 cell invasion of collagen to 37% and 35% of control, respectively (P < 0.05)., Conclusions: MIP-3alpha, through its CCR6 receptor, promotes tumor cell invasion by the up-regulation of MMP-9. Molecular based therapy aimed at the inhibition of MIP-3alpha activity through the CCR6 receptor may serve as a future target to prevent tumor cell invasion in pancreatic adenocarcinoma.

Evidence suggests that thrombospondin-1 (TSP-1), a 450-kDa glycoprotein in platelets and extracellular matrix, is involved in angiogenesis. However, the mechanisms by which TSP-1 regulates angiogenesis are unknown, and the exact role of TSP-1 in angiogenesis has been controversial: both stimulatory and inhibitory effects of TSP-1 have been reported. In this study, we evaluated the effect of TSP-1 on the capacity of bovine aortic endothelial (BAE) cells to both invade and form microvessel-like tubes in collagen gels. BAE cell tube formation was enhanced by exogenous TSP-1 at relatively low concentrations (1-10 microg/ml) but inhibited at higher concentrations of TSP-1 (>15 microg/ml). In addition, we correlated this biphasic effect on tube formation with the capacity of TSP-1 to stimulate the activity of a matrix metalloproteinase-9 (MMP-9) in BAE cell collagen gel cultures. The TSP-1-mediated stimulation of MMP-9 activity was specific and dose- and time-dependent. Furthermore, TSP-1-stimulated BAE cell invasion and tube formation were reversed by antibodies against both TSP-1 and MMP-9, suggesting that TSP-1 modulates endothelial cell invasion and morphogenesis in vitro by a mechanism involving the regulation of MMP-9 activity. These findings support the conclusion that TSP-1 is a multifunctional modulator of angiogenesis and are consistent with the dynamic presence of TSP-1 in remodeling tissues in which matrix degradation is required.

TSP-1 is a matrix-bound adhesive glycoprotein, which plays a role in tumor cell proliferation and tumor angiogenesis. The purpose of this study was to investigate the effect of TSP-1 on breast tumor cell invasion. Tumor cell invasion assays were performed using a modified Boyden chamber apparatus with collagen-coated membranes. Four breast cell lines were studied in serum-free media: the malignant MDA-MB-231, SKBR-3, and MCF-7 cell lines, and the benign MCF-10A cell line. Invasion was measured as the summation of the number of cells in five representative high power fields (400x) traversing the collagen barrier after a 3-hr incubation period. The effect of an anti-TSP-1 antibody (100 microgram/ml) was also evaluated in the malignant cell lines. Statistical analysis was performed by ANOVA and Student's unpaired t test. TSP-1 promoted a dose-dependent increase in invasion as compared to buffer controls in all three malignant cell lines. TSP-1 (100 nM) promoted a greater than five-fold increase over controls in tumor cell invasion for MDA-MB-231, SKBR-3, and MCF-7 cell lines (P < 0.005). TSP-1 had no effect on the invasiveness of the benign cell type MCF-10A. Anti-TSP-1 antibody inhibited TSP-1 promoted invasion in the MDA-MB-231, SKBR-3, and MCF-7 cell lines by 45, 48, and 39%, respectively (P = 0.003, 0.044, 0.047). TSP-1 promotes tumor cell invasion of collagen by breast cancer cells. Therapy designed to inhibit TSP-1 may prevent invasion and metastasis in breast cancer.