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Considerable variability exists between surgeons' assessments of a patient's individual pre-operative surgical risk. Surgical risk calculators are not routinely used despite their validation. We sought to compare thoracic surgeons' prediction of patients' risk of postoperative adverse outcomes versus a surgical risk calculator, the Surgical Risk Preoperative Assessment System (SURPAS). We developed vignettes from 30 randomly selected patients who underwent thoracic surgery in the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database. Twelve thoracic surgeons estimated patients' preoperative risks of postoperative morbidity and mortality. These were compared to SURPAS estimates of the same vignettes. C-indices and Brier scores were calculated for the surgeons' and SURPAS estimates. Agreement between surgeon estimates was examined using intraclass correlation coefficients (ICCs). Surgeons estimated higher morbidity risk compared to SURPAS for low-risk patients (ASA classes 1-2, 11.5% vs. 5.1%, p=

Background The universal Surgical Risk Preoperative Assessment System (SURPAS) prediction models for postoperative adverse outcomes have good accuracy for estimating risk in broad surgical populations and for surgical specialties. The accuracy in individual operations has not yet been assessed. The objective of this study was to evaluate the Surgical Risk Preoperative Assessment System in predicting adverse outcomes for selected individual operations. Methods The SURPAS models were applied to the top 2 most frequent common procedural terminology codes in 9 surgical specialties and 5 additional common general surgical operations in the 2009 to 2018 database of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Goodness of fit statistics were estimated, including c-indices for discrimination, Hosmer-Lemeshow graphs and P values for calibration, overall observed versus expected event rates, and Brier scores. Results The total sample size was 2,020,172, which represented 29% of the 6.9 million operations in the ACS NSQIP database. Average c-indices across 12 outcomes were acceptable (≥0.70) for 13 (56.5%) of the 23 operations. Overall observed-to-expected rates were similar for mortality and overall morbidity across the 23 operations. Hosmer-Lemeshow graphs over quintiles of risk comparing observed-to-expected rates of mortality and overall morbidity were similar for 52% and 70% of operations, respectively. Model performance was better in less complex operations and those done in patients with lower preoperative risk. Conclusion SURPAS displayed accuracy in estimating postoperative adverse events for some of the 23 operations studied, but not all. In the procedures where SURPAS was not accurate, developing disease or operation-specific risk models might be appropriate.

Background The Surgical Risk Preoperative Assessment System (SURPAS) uses eight variables to accurately predict postoperative complications but has not been sufficiently studied in emergency surgery. We evaluated SURPAS in emergency surgery, comparing it to the Emergency Surgery Score (ESS). Methods SURPAS and ESS estimates of 30-day mortality and overall morbidity were calculated for emergency operations in the 2009–2018 ACS-NSQIP database and compared using observed-to-expected plots and rates, c-indices, and Brier scores. Cases with incomplete data were excluded. Results In 205,318 emergency patients, SURPAS underestimated (8.1%; 35.9%) while ESS overestimated (10.1%; 43.8%) observed mortality and morbidity (8.9%; 38.8%). Each showed good calibration on observed-to-expected plots. SURPAS had better c-indices (0.855 vs 0.848 mortality; 0.802 vs 0.755 morbidity), while the Brier score was better for ESS for mortality (0.0666 vs. 0.0684) and for SURPAS for morbidity (0.1772 vs. 0.1950). Conclusions SURPAS accurately predicted mortality and morbidity in emergency surgery using eight predictor variables.

The objective of this study was to evaluate the educational impact following the implementation of a robotic thoracic surgery program on cardiothoracic (CT) surgery trainees. We hypothesized that the introduction of a robotic thoracic surgery program would adversely affect the CT surgery resident experience, decreasing operative involvement and subsequent competency of surgical procedures. CT surgery residents and thoracic surgery attendings from a single academic institution were administered a recurring, electronic survey from September 2019 to September 2020 following each robotic thoracic surgery case. Surveys evaluated resident involvement and operative performance. This study was exempt from review by our Institutional Review Board. Attendings and residents completed surveys for 86 and 75 cases, respectively. Residents performed > 50% of the operation independently at the surgeon console in 66.2 and 73.3% of cases according to attending and resident responses, respectively. The proportion of trainees able to perform > 75% of the operation increased with each increasing year in training (p = 0.002). Based on the Global Evaluative Assessment of Robotic Skills grading tool, third-year residents averaged higher scores compared to first-year residents (22.9 versus 17.4 out of 30 possible points, p

Background Postoperative complications, length of index hospital stay, and unplanned hospital readmissions are important metrics reflecting surgical care quality. Postoperative infections represent a substantial proportion of all postoperative complications. We examined the relationships between identification of postoperative infection prehospital and posthospital discharge, length of stay, and unplanned readmissions in the American College of Surgeons National Surgical Quality Improvement Program database across nine surgical specialties. Methods The 30-day postoperative infectious complications including sepsis, surgical site infections, pneumonia, and urinary tract infection were analyzed in the American College of Surgeons National Surgical Quality Improvement Program inpatient data during the period from 2012 to 2017. General, gynecologic, vascular, orthopedic, otolaryngology, plastic, thoracic, urologic, and neurosurgical inpatient operations were selected. Results Postoperative infectious complications were identified in 5.2% (137,014/2,620,450) of cases; 81,929 (59.8%) were postdischarge. The percentage of specific complications identified postdischarge were 73.4% of surgical site infections (range across specialties 63.7–93.1%); 34.9% of sepsis cases (27.4–58.1%); 26.5% of pneumonia cases (18.9%–36.3%); and 53.2% of urinary tract infections (48.3%–88.0%). The relative risk of readmission among patients with postdischarge versus predischarge surgical site infection, sepsis, pneumonia, or urinary tract infection was 5.13 (95% confidence interval: 4.90–5.37), 9.63 (8.93–10.40), 10.79 (10.15–11.45), and 3.32 (3.07–3.60), respectively. Over time, mean length of stay decreased but postdischarge infections and readmission rates significantly increased. Conclusion Most postoperative infectious complications were diagnosed postdischarge. These were associated with an increased risk of readmission. The trend toward shorter length of stay over time was observed along with an increase both in the percentage of infections detected after discharge and the rate of unplanned related postoperative readmissions over time. Postoperative surveillance of infections should extend beyond hospital discharge of surgical patients.

Rectal prolapse is relatively uncommon in male patients. The aim of this study was to compare males and females who underwent rectal prolapse surgery.Retrospective analysis of the ACS NSQIP public use file.Among 12,220 patients, 978 (8%) were male and 11,242 (92%) were female. Males were younger, 56 (38-73) vs. 71 (58-83) years, less often white (83% vs. 71%), had lower ASA scores, and underwent more laparoscopic (33% vs. 27%), more open (33% vs. 29%), and less perineal (33% vs 44%) procedures (all p 0.05). Morbidity (9.9% vs. 10.0%), reoperation (3.4% vs. 3.1%), and readmission (5.7% vs. 6.0%) were not different for males and females. In subgroup analysis by surgical procedure type, there remained no outcome differences. Propensity matched analysis revealed no difference in the use of laparoscopic, open, or perineal procedures.Males with rectal prolapse are younger, have a different racial distribution, a lower surgical risk profile, and undergo different surgical procedures than females, which appears to be driven by patient age and surgical risk assessment.

The extraordinary demands of managing the COVID-19 pandemic has disrupted the world's ability to care for patients with thoracic malignancies. As a hospital's COVID-19 population increases and hospital resources are depleted, the ability to provide surgical care is progressively restricted, forcing surgeons to prioritize among their cancer populations. Representatives from multiple cancer, surgical, and research organizations have come together to provide a guide for triaging patients with thoracic malignancies as the impact of COVID-19 evolves as each hospital.

Background Informed consent is an ethical imperative of surgical practice. This requires effective communication of procedural risks to patients and is learned during residency. No systematic review has yet examined current risk disclosure. This systematic review aims to use existing published information to assess preoperative provision of risk information by surgeons. Methods Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses as a guide, a standardized search in Ovid MEDLINE, Embase, CINHAL, and PubMed was performed. Three reviewers performed the study screening, with 2-reviewer consensus required at each stage. Studies containing objective information concerning preoperative risk provision in adult surgical patients were selected for inclusion. Studies exclusively addressing interventions for pediatric patients or trauma were excluded, as were studies addressing risks of anesthesia. Results The initial search returned 12,988 papers after deduplication, 33 of which met inclusion criteria. These studies primarily evaluated consent through surveys of providers, record reviews and consent recordings. The most ubiquitous finding of all study types was high levels of intra-surgeon variation in what risk information is provided to patients preoperatively. Studies recording consents found the lowest rates of risk disclosure. Studies using multiple forms of investigation corroborated this, finding disparity between verbally provided information vs chart documentation. Conclusions The wide variance in what information is provided to patients preoperatively inhibits the realization of the ethical and practical components of informed consent. The findings of this review indicate that significant opportunities exist for practice improvement. Future development of surgical communication tools and techniques should emphasize standardizing what risks are shared with patients.

Background The novel Surgical Risk Preoperative Assessment System (SURPAS) requires entry of five predictor variables (the other three variables of the eight-variable model are automatically obtained from the electronic health record or a table look-up), provides patient risk estimates compared to national averages, is integrated into the electronic health record, and provides a graphical handout of risks for patients. The accuracy of the SURPAS tool was compared to that of the American College of Surgeons Surgical Risk Calculator (ACS-SRC). Methods Predicted risk of postoperative mortality and morbidity was calculated using both SURPAS and ACS-SRC for 1,006 randomly selected 2007–2016 ACS National Surgical Quality Improvement Program (NSQIP) patients with known outcomes. C-indexes, Hosmer-Lemeshow graphs, and Brier scores were compared between SURPAS and ACS-SRC. Results ACS-SRC risk estimates for overall morbidity underestimated risk compared to observed postoperative overall morbidity, particularly for the highest risk patients. SURPAS accurately estimates morbidity risk compared to observed morbidity. Conclusions SURPAS risk predictions were more accurate than ACS-SRC's for overall morbidity, particularly for high risk patients. Summary The accuracy of the SURPAS tool was compared to that of the American College of Surgeons Surgical Risk Calculator (ACS-SRC). SURPAS risk predictions were more accurate than those of the ACS-SRC for overall morbidity, particularly for high risk patients.

BACKGROUND: The Esophageal Complications Consensus Group (ECCG) recommends that readmission to a primary or secondary hospital within 30 days of discharge after esophagectomy is an important quality outcome indicator for esophagectomy. This retrospective study was performed to investigate the incidence and risk factors for readmission after esophagectomy. METHODS: We retrospectively reviewed 291 patients who received an esophagectomy and mediastinal lymphadenectomy for curative purposes from January 2006 to June 2017. RESULTS: The mean age was 63.02±8.02 years, and there were 264 (90.7%) male patients. Thirty-nine (13.4%) patients were re-admitted within 30 days after discharge. The mean interval from discharge to the readmission was 13.46±9.36. Common causes of readmission were anastomotic stricture that required ballooning (12, 30.7%), wound problem (7, 17.9%), pneumonia (6, 15.4%), and poor oral intake (4, 10.2%). Other causes of readmission were delayed gastric emptying [3], jejunostomy tube problem [2], ileus [2], pain [1], pneumothorax [1], and pleural effusion [1]. On multivariable analysis, anastomotic leakage (odd ratio =2.884, P=0.026) was significantly related to readmission, whereas age, pathologic stage, vocal cord palsy, and neoadjuvant therapy were not related to readmission. CONCLUSIONS: Readmission within 30 days after esophagectomy was determined to be related to postoperative anastomotic leakage and wound problems whereas the vocal cord palsy was not.

Background: Formal surgical risk assessment tools have been developed to predict risk of adverse postoperative patient outcomes. Such tools accurately predict common postoperative complications, inform patients and providers of likely perioperative outcomes, guide decision making, and improve patient care. However, these are underutilized. We studied the attitudes towards and techniques of how surgeons preoperatively assess risk.Methods: 108 surgical faculty, 95 surgical residents, and 58 affiliate surgeons at a large academic tertiary referral hospital and affiliate community hospitals were emailed a 16-question survey between 8/2019-6/2020. Surveys were analyzed using descriptive statistics (frequency distributions and percentages for categorical variables, means, and standard deviations for continuous variables), and Fisher’s exact test and unpaired t-tests comparing responses by surgical attendings vs. residents.Results: Overall response rates were 50.0% for faculty surgeons, 47.4% for residents, and 36.2% for affiliate surgeons. Only 20.8% of surgeons used risk calculators most or all of the time. Attending surgeons were more likely to use prior experience and current literature while residents used risk calculators more frequently. Risk assessment tools were more likely to be used when predicting major complications and death in older patients with significant risk factors. Greatest barriers for use of risk assessment tools included time, inaccessibility, and trust in accuracy.Conclusions: Even though risk assessment tools are available, few surgeons use them as part of their routine practices. Developers of the tools need to design the tools to better promote the positive features and to avoid the burdens commonly reported by users.

The objectives were to determine factors associated with conversion to open surgery in patients with esophageal cancer who underwent minimally invasive esophagectomy (MIE, including laparo-thoracoscopic and robotic) and the impact of conversion to open surgery on patient outcomes. We included patients from the National Cancer Database with esophageal and gastroesophageal junction cancer who underwent MIE from 2010 to 2015. Patient-, tumor-, and facility-related characteristics as well as short-term and oncologic outcomes were compared between patients who were converted to open surgery and those who underwent successful MIE without conversion to open surgery. Multivariable logistic regression models were used to analyze risk factors for conversion to open surgery from attempted MIE. 7306 patients underwent attempted MIE. Of these patients, 82 of 1487 (5.2%) robotic-assisted esophagectomies were converted to open, compared to 691 of 5737 (12.0%) laparo-thoracoscopic esophagectomies (p

Introduction The Surgical Risk Preoperative Assessment System is a parsimonious, universal surgical risk calculator integrated into our local electronic health record. We determined how many of its eight preoperative risk predictor variables could be automatically obtained from the electronic health record. This has implications for the usability and adoption of Surgical Risk Preoperative Assessment System, serving as an example of use of electronic health record data for populating clinical decision support tools. Methods We quantified the availability and accuracy in the electronic health record of the eight Surgical Risk Preoperative Assessment System predictor variables (patient age, American Society of Anesthesiology physical status classification, functional health status, sepsis, work Relative Value Unit, in-/outpatient operation, surgeon specialty, emergency status) at the patient’s preoperative encounter of 5205 patients entered into the American College of Surgeons National Surgical Quality Improvement Program. Accuracy was determined by comparing the electronic health record data to the same patient’s National Surgical Quality Improvement Program data, used as the “gold standard.” Acceptable accuracy was defined as a Kappa statistic or Pearson correlation coefficient ≥0.8 when comparing electronic health record and National Surgical Quality Improvement Program data. Acceptable availability was defined as presence of the variable in the electronic health record at the preoperative encounter ≥95% of the time. Results Of the eight predictor variables, six had acceptable accuracy. Only preoperative sepsis and functional health status had Kappa statistics Conclusions Processes need to be developed to populate more of the Surgical Risk Preoperative Assessment System preoperative predictor variables in the patient’s electronic health record prior to the preoperative visit to lessen the burden on the busy surgeon and encourage more widespread use of Surgical Risk Preoperative Assessment System.

The morbidity and mortality benefits of performing high-risk operations in high-volume centers by high-volume surgeons are evident. Regionalization is a proposed strategy to leverage high-volume centers for esophagectomy to improve quality outcomes. Internationally, regionalization occurs under national mandates. Those mandates do not exist in the United States and spontaneous regionalization of esophagectomy has only modestly occurred in the U.S. Regionalization must strike a careful balance and not limit access to optimal oncologic care to our most vulnerable cancer patient populations in rural and disadvantaged socioeconomic areas. We reviewed the recent literature highlighting: the justification of hospital and surgeon annual esophagectomy volumes for regionalization; how safety performance metrics could influence regionalization; whether regionalization is occurring in the US; what impact regionalization may have on esophagectomy costs; and barriers to patients traveling to receive oncologic treatment at regionalized centers of excellence.

Background Our objective was to evaluate the association of bridge to transplant (BTT) extracorporeal membrane oxygenation (ECMO) on survival after lung transplantation (LTx) and determine the degree to which transplant center volume affects this relationship. Methods Using the United Network for Organ Sharing database, we performed a retrospective cohort study evaluating the survival of patients undergoing LTx between 2005 and 2017. On the basis of previous literature, LTx centers were classified into 3 groups using their average annual LTx volume over the preceding 5 years: less than 25, 25 to 49, and more than 50. Survival of BTT ECMO and non-ECMO patients was analyzed using a log-rank test. Propensity scores for BTT ECMO were calculated, and a weighted proportional hazards model was used to compare BTT ECMO and non-ECMO patients by center volume. Results There were 20,976 patients who met inclusion criteria, with 611 (2.9%) undergoing BTT ECMO. Overall, BTT ECMO was associated with increased posttransplantation hazard of mortality (hazard ratio, 1.37; 95% confidence interval, 1.14 to 1.64). Kaplan-Meier plots by center volume suggest that BTT ECMO–associated mortality may be mitigated at high-volume LTx centers. In the propensity score–weighted proportional hazards model, we determined that when centers perform more than 35 LTxs per year, the increased hazard of BTT ECMO on mortality is no longer observed. Conclusions BTT ECMO can be performed as a bridge to LTx without significantly increasing patient mortality in high-volume centers. Patients undergoing BTT ECMO at LTx centers that perform more than 35 LTxs annually have equivalent mortality to those who do not require ECMO before transplantation.

Background Defining a “high risk” surgical population remains challenging. Using the Surgical Risk Preoperative Assessment System (SURPAS), we sought to define “high risk” groups for adverse postoperative outcomes. Materials and Methods We retrospectively analyzed the 2009-2018 American College of Surgeons National Surgical Quality Improvement Program database. SURPAS calculated probabilities of 12 postoperative adverse events. The Hosmer Lemeshow graphs of deciles of risk and maximum Youden index were compared to define “high risk.” Results Hosmer-Lemeshow plots suggested the “high risk” patient could be defined by the 10th decile of risk. Maximum Youden index found lower cutoff points for defining “high risk” patients and included more patients with events. This resulted in more patients classified as “high risk” and higher number needed to treat to prevent one complication. Some specialties (thoracic, vascular, general) had more “high risk” patients, while others (otolaryngology, plastic) had lower proportions. Conclusions SURPAS can define the “high risk” surgical population that may benefit from risk-mitigating interventions.

Introduction: The impact of radiation prescription dose on postoperative complications during standard of care trimodality therapy for operable stage II-III esophageal and gastroesophageal junction cancers has not been established.Methods: We retrospectively reviewed 82 patients with esophageal or gastroesophageal junction cancers treated between 2004 and 2016 with neoadjuvant chemoradiation followed by resection at a single institution. Post-operative complications within 30 days were reviewed and scored using the Comprehensive Complication Index (CCI). Results were compared between patients treated with Results: Twenty-nine patients were treated with Conclusions: In selected esophageal and gastroesophageal junction cancer patients, radiation doses ≥ 50 Gy do not appear to increase 30 day post-operative complication rates. These findings suggest that the use of definitive doses of radiotherapy (50–50.4 Gy) in the neoadjuvant setting may not increase post-operative complications.

Background Pulmonary segmentectomy provides an anatomic lung resection while avoiding removal of excess normal lung tissue. This may be beneficial in patients with minimal pulmonary reserve who present with early-stage non-small cell lung cancer (NSCLC). However, the operative performance of a segmentectomy using a video-assisted thoracoscopic approach can be technically challenging. We hypothesized that introduction of the robotic surgical system would facilitate the performance of a segmentectomy as measured by an increase in the proportion of segmentectomies being pursued. Methods We completed a retrospective analysis of thoracoscopic and robotic anatomic lung resections, including lobectomies and segmentectomies, performed in patients with primary lung cancer from the time of initiation of the robotic thoracic surgery program in November 2017 to November 2019. We compared the proportion of thoracoscopic and robotic segmentectomies performed during the first year compared to the second year of the data collection period. Results A total of 138 thoracoscopic and robotic anatomic lung resections were performed for primary lung cancer. Types of lung cancer resected (adenocarcinoma, squamous cell carcinoma, or other), tumor size based on clinical T staging (T1-T4), and tumor location were not significantly different between years (P=0.44, P=0.98, and P=0.26, respectively). The proportion of segmentectomies increased from 8.6% during the first year to 25.0% during the second year (P=0.01). One out of 6 (16.7%) segmentectomies were performed using the robot during the first year versus 15 out of 17 (88.2%) during the second year (P=0.003). Conclusions Use of the robot led to a significant increase in the number of segmentectomies performed in patients undergoing anatomic lung resection. With increasing lung cancer awareness and widely available screening, a greater number of small, early-stage tumors suitable for segmentectomy will likely be detected. We conclude that robotic-assisted surgery may facilitate the challenges of performing a minimally invasive segmentectomy.

Background Risk assessment is essential to informed decision making in surgery. Preoperative use of the Surgical Risk Preoperative Assessment System (SURPAS) providing individualized risk assessment, may enhance informed consent. We assessed patient and provider perceptions of SURPAS as a risk assessment tool. Methods A convergent mixed-methods study assessed SURPAS’s trial implementation, concurrently collecting quantitative and qualitative data, separately analyzing it, and integrating the results. Patients and providers were surveyed and interviewed on their opinion of how SURPAS impacted the preoperative encounter. Relationships between patient risk and patient and provider assessment of SURPAS were examined. Results A total of 197 patients were provided their SURPAS postoperative risk estimates in nine surgeon’s clinics. Of the total patients, 98.8% reported they understood their surgical risks very or quite well after exposure to SURPAS; 92.7% reported SURPAS was very helpful or helpful. Providers shared that 83.4% of the time they reported SURPAS was very or somewhat helpful; 44.7% of the time the providers reported it changed their interaction with the patient and this change was beneficial 94.3% of the time. As patient risk increased, providers reported that SURPAS was increasingly helpful (p Conclusions Patients and providers reported the use of SURPAS helpful and informative during the preoperative risk assessment of patients, thus improving the surgical decision making process. Patients thought that SURPAS was helpful regardless of their risk level, whereas providers thought that SURPAS was more helpful in higher risk patients.

Background The objective of this study was to evaluate the impact of unplanned conversion to open esophagectomy during minimally invasive esophagectomy (MIE) on postoperative morbidity and mortality for patients with esophageal cancer, as well as to evaluate the variables that influence the need for conversion. Methods This study was a retrospective analysis of patients with esophageal cancer who underwent open esophagectomy or MIE by either a laparothoracoscopic approach or a robotic approach from 2016 to 2018 by using the esophagectomy-specific American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. Poisson regression models were used to analyze 30-day outcomes and risk factors for conversion to open esophagectomy during attempted MIE. Results A total of 2616 patients were identified. The overall conversion rate for MIE was 6.3%. Compared with completed MIE, patients requiring conversion to open esophagectomy had a significantly increased risk of 30-day mortality (risk ratio, 2.63; 95% confidence interval, 1.03 to 6.69) and experienced a variety of other postoperative complications. Patients requiring conversion to open esophagectomy during MIE also experienced worse perioperative outcomes when compared to patients who underwent planned open esophagectomy. Estimated surgical risk on the basis of the ACS NSQIP Surgical Risk Calculator was the only variable found to be independently associated with conversion from minimally invasive to open esophagectomy (risk ratio, 1.03; 95% confidence interval, 1.01 to 1.04, for each 10% increase in risk score). Conclusions Unplanned conversion to open esophagectomy during MIE is associated with significantly greater morbidity and a 2.6-fold increased risk of death when compared with both completed MIE and planned open esophagectomy. The ACS NSQIP Surgical Risk Calculator may help identify patients preoperatively who are at higher risk for conversion to open esophagectomy during MIE.

BACKGROUND: Neoadjuvant chemotherapy with concurrent radiotherapy (nCRT) is an accepted treatment regimen for patients with potentially curable esophageal and gastroesophageal junction (GEJ) adenocarcinoma. The purpose of this study was to evaluate if induction chemotherapy (IC) before nCRT is associated with improved pathologic complete response (pCR) and overall survival (OS) when compared with patients who received nCRT alone for esophageal and GEJ adenocarcinoma. METHODS: Using the National Cancer Database (NCDB), patients who received nCRT and curative intent esophagectomy for esophageal or GEJ adenocarcinoma from 2006–2015 were included. Chemotherapy and radiation therapy start dates were used to define cohorts who received IC before nCRT (IC + nCRT) versus those who only received concurrent nCRT before surgery. Propensity weighting was conducted to balance patient, disease, and facility covariates between groups. RESULTS: 12,460 patients met inclusion criteria. 11,880 (95%) patients received nCRT and 580 (5%) patients received IC + nCRT. Following propensity weighting, OS was significantly improved among patients who received IC + nCRT versus nCRT (HR 0.82; 95% CI 0.74–0.92; p

Background Risk assessment is essential to informed decision making in surgery. Preoperative use of the Surgical Risk Preoperative Assessment System (SURPAS) providing individualized risk assessment, may enhance informed consent. We assessed patient and provider perceptions of SURPAS as a risk assessment tool. Methods A convergent mixed-methods study assessed SURPAS’s trial implementation, concurrently collecting quantitative and qualitative data, separately analyzing it, and integrating the results. Patients and providers were surveyed and interviewed on their opinion of how SURPAS impacted the preoperative encounter. Relationships between patient risk and patient and provider assessment of SURPAS were examined. Results 197 patients were provided their SURPAS postoperative risk estimates in nine surgeon’s clinics. 98.8% of patients reported they understood their surgical risks very or quite well after exposure to SURPAS; 92.7% reported SURPAS was very helpful or helpful. 83.4% of the time providers reported SURPAS was very or somewhat helpful; 44.7% of the time the providers reported it changed their interaction with the patient and this change was beneficial 94.3% of the time. As patient risk increased, providers reported that SURPAS was increasingly helpful (pConclusions Patients and providers reported the use of SURPAS helpful and informative during the preoperative risk assessment of patients, thus improving the surgical decision making process. Patients thought that SURPAS was helpful regardless of their risk level, whereas providers thought that SURPAS was more helpful in higher risk patients.

Background The Surgical Risk Preoperative Assessment System accurately predicts postoperative complications in elective surgery using only 8 preoperative variables, but its performance in emergency surgery has not been evaluated. We hypothesized that the Surgical Risk Preoperative Assessment System accurately predicts postoperative complications in emergency surgery and compared its performance to that of the American College of Surgeons Surgical Risk Calculator. Methods We calculated the Surgical Risk Preoperative Assessment System and the American College of Surgeons Surgical Risk Calculator risk estimates in a random sample of 1,010 emergency surgery cases from the American College of Surgeons National Surgical Quality Improvement Program 2014 to 2017 database. Risk estimates were compared with known outcomes. Analyses included the Hosmer-Lemeshow goodness of fit graphs and P values, c-indexes, and Brier scores. Results Results were similar between the Surgical Risk Preoperative Assessment System and the American College of Surgeons Surgical Risk Calculator for mortality, urinary tract infection, cardiac, venous thromboembolism, and renal complications. The American College of Surgeons Surgical Risk Calculator underestimated morbidity compared with the Surgical Risk Preoperative Assessment System (16.04% American College of Surgeons Surgical Risk Calculator vs 24.88% Surgical Risk Preoperative Assessment System vs 24.3% observed). Both calculators overestimated readmission (7.67% American College of Surgeons Surgical Risk Calculator vs 5.18% Surgical Risk Preoperative Assessment System vs 4.1% observed). Conclusion Both calculators predicted mortality, urinary tract infection, cardiac, venous thromboembolism, and renal complications well, but readmissions relatively poorly. The Surgical Risk Preoperative Assessment System estimated overall morbidity accurately, while the American College of Surgeons Surgical Risk Calculator underestimated this risk.

Background The objective of this study was to develop an algorithm for identifying surgical site infections (SSIs) using independent variables from electronic health record data and outcomes from the American College of Surgeons National Surgical Quality Improvement Program to supplement manual chart review. Methods We fit 3 models to data from patients undergoing operations at the University of Colorado Hospital between 2013 and 2015: a similar model reported previously in the literature, a comprehensive model with 136 possible predictors, and a combination of those. All models used a generalized linear model with a lasso penalty. Several techniques for handling imbalance in the outcome were also used: Youden's J statistic to optimize the probability cutoff and sampling techniques combined with Youden's J. The models were then tested on data from patients undergoing operations during 2016. Results Two hundred thirty of 6,840 patients (3.4%) had an SSI. The comprehensive model fit to the full set of training data performed the best, achieving 90% specificity, 80% sensitivity, and an area under the receiver operating characteristic curve of 0.89. Conclusions We identified a model that accurately identified SSIs. The framework presented can be easily implemented by other American College of Surgeons National Surgical Quality Improvement Program-participating hospitals to develop models for enhancing surveillance of SSIs.

Background Risk assessment in surgery is essential to guide treatment decisions but is highly variable in practice. Providing formal preoperative risk assessment to surgical teams and patients may optimize understanding of risk. Implementation of the Surgical Risk Preoperative Assessment System (SURPAS), an innovative real time, universal, preoperative tool providing individualized risk assessment, may enhance informed consent and reduce adverse outcomes. To ensure optimal development and implementation of SURPAS we performed an in-depth pre-implementation evaluation of SURPAS at an academic tertiary referral center in Colorado. Methods Four focus groups with 24 patients, three focus groups with 29 surgical providers and clinic administrators, and five individual interviews with administrative officials were conducted to elicit their perspectives about the development and implementation of SURPAS. Qualitative data collection and analyses, utilizing a Matrix Analysis approach were used to explore insights regarding SURPAS. Results Participants were positive about SURPAS and provided suggestions to improve and address concerns regarding it. For healthcare personnel three major themes emerged: 1) The SURPAS tool - Important work especially for high risk patients, yet not a substitute for clinical judgment; 2) Benefits of SURPAS to the risk assessment process - Improves the processes, enhances patients’ participation in shared decision-making process, and creates a permanent record; and 3) Facilitators and barriers of implementation of SURPAS - Easy to incorporate into clinical practice in spite of surgical providers’ resistance to adoption of new technology. For patients three major themes emerged: 1) Past experience of preoperative risk assessment discussions – Patients were not made aware of possible complications that occurred; 2) The SURPAS tool - All patients liked SURPAS and believed having printed material would be useful to guide discussions and facilitate remembering conversations with the providers; and 3) Potential concerns with having risk assessment information – Patients were mixed in deciding to have an operation with high risks. Conclusions Systematically capturing data from the beginning of the implementation process from key stakeholders (patients, surgical providers, clinical staff, and administrators) that includes adaptations to the tool and implementation process will help to inform pragmatic approaches for implementing the SURPAS tool in various settings, scaling-up, and sustaining it.

Objective Interest in humanitarian surgery is high among surgical and obstetric residents. The Colorado Humanitarian Surgical Skills Workshop is an annual 2-day course exposing senior residents to surgical techniques essential in low- and middle-income countries but not traditionally taught in US residencies. We evaluated the course’s ability to foster resident comfort, knowledge, and competence in these skills. Design The cohort of course participants was studied prospectively. Participants attended didactic sessions followed by skills sessions using cadavers. Sample areas of focus included general surgery (mesh-free hernia repair), orthopedics (powerless external fixation), and neurosurgery (powerless craniotomy). Before and after the course, participants answered a questionnaire assessing confidence with taught skills; took a knowledge-based test composed of multiple choice and open-ended questions; and participated in a manual skills test of tibial external fixation. Setting The Center for Surgical Innovation, University of Colorado School of Medicine. Participants A total of 12 residents (11 general surgical and 1 obstetric) from ten US institutions. Results After the course, participants perceived increased confidence in performing all 27 taught procedures and ability to practice in low- and middle-income countries. In knowledge-based testing, 10 of 12 residents demonstrated improvement on multiple choice questioning and 9 of 12 residents demonstrated improvement on open-ended questioning with structured scoring. In manual skills testing, all external fixator constructs demonstrated objective improvement on structured scoring and subjective improvement on stability assessment. Conclusions For senior residents interested in humanitarian surgery, a combination of skills-focused teaching and manual practice led to self-perceived and objective improvement in relevant surgical knowledge and skills. The Colorado Humanitarian Surgical Skills Workshop represents an effective model for transmitting essential surgical principles and techniques of value in low-resource settings.

Hospital readmissions are viewed as a mark of inferior health care quality and are penalized. Unplanned postoperative readmission reason and timing after lung resection are not well understood. We examine related, unplanned readmissions after thoracoscopic versus open anatomic lung resections to identify opportunities to improve patient care.We analyzed the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data set, 2012 to 2015, characterizing 30-day related, unplanned postoperative readmissions after anatomic lung resections for primary lung cancer. Risk-adjusted comparison of readmission after thoracoscopic and open resection was performed using propensity matching.Patients (n = 9,510) underwent anatomic lung resections; 4,935 (51.9%) were thoracoscopic resections and 4,575 (48.1%) were open resections. Of the thoracoscopic patients, 10.9% experienced one or more complications, versus 19.4% of patients with open resection (p0.0001). Of the thoracoscopic patients 5.5% experienced related, unplanned readmissions versus 7.2% of the patients with open resection (p0.001). 24.8% of complications after thoracoscopic approach occurred after discharge, versus 15.5% after open approach (p0.0001). Timing of unplanned readmission was similar for both groups. The propensity-matched odds ratio of risk of readmission after thoracoscopic versus open resection was 1.16 (95% confidence interval, 0.949 to 1.411, p = 0.15).Open anatomic lung resections for primary lung cancer had nearly twice the complication rate but only a slightly higher readmission rate than thoracoscopic resection. More complications occurred after discharge after thoracoscopic than open resections. Most readmissions occurred within 2 weeks after both thoracoscopic and open resections. Risk-adjusted comparison identified no statistically significant difference in risk of related, unplanned readmission after thoracoscopic versus open resections. Future studies should focus on identification of processes of care to decrease complications and unplanned readmissions after lung cancer resection.

Objective Although previous studies have identified variation in quality lung cancer care, existing quality metrics may not fully capture the complexity of cancer care. The Thoracic Surgery Outcomes Research Network recently developed quality measures to address this. We evaluated baseline adherence to these measures and identified factors associated with adherence. Methods Patients with pathologic stage I and II non–small cell lung cancer from 2010 to 2015 were identified in the National Cancer Database. Patient-level and hospital-level adherence to 7 quality measures was calculated. Goal hospital adherence threshold was 85%. Factors influencing adherence were identified using multilevel logistic regression. Results We identified 253,182 patients from 1324 hospitals. Lymph node sampling was performed in 91% of patients nationally, but only 76% of hospitals met the 85% adherence mark. Similarly, 89% of T1b (seventh edition staging) tumors had anatomic resection, with 69% hospital-level adherence. Sixty-nine percent of pathologic stage II patients were recommended chemotherapy, with only 23% hospitals adherent. Eighty-three percent of patients had biopsy before primary radiation, with 64% hospitals adherent. Higher volume and academic institutions were associated with nonadherence to adjuvant chemotherapy and radiation therapy measures. Conversely, lower volume and nonacademic institutions were associated with inadequate nodal sampling and nonanatomic resection. Conclusions Significant gaps continue to exist in the delivery of quality care to patients with early-stage lung cancer. High-volume academic hospitals had higher adherence for surgical care measures, but lower rates for coordination of care measures. This requires further investigation, but suggests targets for quality improvement may vary by institution type.

Purpose There is marked variability in the behavior of different transplant centers regarding utilization of ex vivo lung perfusion (EVLP) for donation after circulatory death (DCD) lung donors. While interest in utilization of DCD lungs is growing as a means to expand the lung donor pool, the utility and indications for EVLP of DCD lungs is not well defined. Our objectives were to determine the baseline differences between DCD lungs that received EVLP and those that did not as well as the effect of EVLP on survival following DCD LTx. Methods Using the United Network for Organ Sharing (UNOS) database, we retrospectively reviewed all adult patients undergoing first-time isolated LTx between 2015 and 2017. Chi-squared tests and Wilcoxon-Mann-Whitney tests were used to investigate the differences in baseline characteristics between DCD and EVLP-DCD donors. Survival of DCD and EVLP-DCD transplants was analyzed using Kaplan Meier curves with a log rank test and a Cox proportional hazards model. Results A total of 5,866 patients met inclusion criteria and 218 (3.7%) LTx recipients received a DCD LTx. Of those receiving DCD lungs, 30 (13.7%) underwent EVLP prior to transplantation. Centers performing DCD LTx utilized EVLP-DCD with great variability; EVLP-DCD rates ranged from 0%-53.8% by center. Compared to DCD donors without EVLP, EVLP-DCD donors did not differ significantly by cause of death, age, gender, history of cigarette use, or PaO2/FiO2 ratio (Figure A). Recipients of EVLP-DCD lungs had equivalent survival to those who received DCD lungs as well as non-DCD lungs (Figure B). Conclusion DCD donation alone should not be an indication for EVLP. DCD and EVLP-DCD lungs were nearly identical in terms of donor lung characteristics including PaO2/FiO2 ratio. DCD donor lungs, which provide equivalent survival to conventional LTx, should undergo EVLP selectively.

Introduction: The relationship between altitude during treatment and common postoperative infections remains to be established. Based on the inverse relationship between oxygen partial pressure and...

Background The Surgical Risk Preoperative Assessment System (SURPAS) is a parsimonious set of models providing accurate preoperative prediction of common adverse outcomes for individual patients. However, focus groups with surgeons and patients have developed a list of questions about and recommendations for how to further improve SURPAS’s usability and usefulness. Eight issues were systematically evaluated to improve SURPAS. Methods The eight issues were divided into three groups: concerns to be addressed through further analysis of the database; addition of features to the SURPAS tool; and the collection of additional outcomes. Standard multiple logistic regression analysis was performed using the 2005–2015 American College of Surgeons National Surgical Quality Improvement Participant Use File (ACS NSQIP PUF) to refine models: substitution of the preoperative sepsis variable with a procedure-related risk variable; testing of an indicator variable for multiple concurrent procedure codes in complex operations; and addition of outcomes to increase clinical applicability. Automated risk documentation in the electronic health record and a patient handout and supporting documentation were developed. Long term functional outcomes were considered. Results Model discrimination and calibration improved when preoperative sepsis was replaced with a procedure-related risk variable. Addition of an indicator variable for multiple concurrent procedures did not significantly improve the models. Models were developed for a revised set of eleven adverse postoperative outcomes that separated bleeding/transfusion from the cardiac outcomes, UTI from the other infection outcomes, and added a predictive model for unplanned readmission. Automated documentation of risk assessment in the electronic health record, visual displays of risk for providers and patients and an “About” section describing the development of the tool were developed and implemented. Long term functional outcomes were considered to be beyond the scope of the current SURPAS tool. Conclusion Refinements to SURPAS were successful in improving the accuracy of the models, while reducing manual entry to five of the eight variables. Adding a predictor variable to indicate a complex operation with multiple current procedure codes did not improve the accuracy of the models. We developed graphical displays of risk for providers and patients, including a take-home handout and automated documentation of risk in the electronic health record. These improvements should facilitate easier implementation of SURPAS. Electronic supplementary material The online version of this article (10.1186/s13037-019-0208-2) contains supplementary material, which is available to authorized users.

Background Using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) complication status of patients who underwent an operation at the University of Colorado Hospital, we developed a machine learning algorithm for identifying patients with one or more complications using data from the electronic health record (EHR). Methods We used an elastic-net model to estimate regression coefficients and carry out variable selection. International classification of disease codes (ICD-9), common procedural terminology (CPT) codes, medications, and CPT-specific complication event rate were included as predictors. Results Of 6840 patients, 922 (13.5%) had at least one of the 18 complications tracked by NSQIP. The model achieved 88% specificity, 83% sensitivity, 97% negative predictive value, 52% positive predictive value, and an area under the curve of 0.93. Conclusions Using machine learning on EHR postoperative data linked to NSQIP outcomes data, a model with 163 predictors from the EHR identified complications well at our institution.

Despite progress in many different domains of surgical care, we are still striving toward practices which will consistently lead to the best care for an increasingly complex surgical population. Thoracic surgical patients, as a group, have multiple medical co-morbidities and are at increased risk for developing complications after surgical intervention. Our healthcare systems have been focused on treating complications as they occur in the hopes of minimizing their impact, as well as aiding in recovery. In recent years there has emerged a body of evidence outlining opportunities to optimize patients and likely prevent or decrease the impact of many complications. The purpose of this review article is to summarize four major domains—optimal pain control, nutritional status, functional fitness, and smoking cessation—all of which can have a substantial impact on the thoracic surgical patient’s course in the hospital—as well as to describe opportunities for improvement, and areas for future research efforts.

Background: Improving surgical outcomes is important to patients, providers, and healthcare systems. Understanding best methods to ensure evidence based practices are successfully implemented and sustained in clinical practices leads to improved care. Dissemination and implementation (D&I) science facilitates the successful pathway from clinical trials to sustained implementation. Methods: We describe D&I science, introduce the consolidated framework for implementation research (CFIR), a D&I framework, and provide an example of how CFIR was utilized to facilitate the translational process from design adaptations to implementation, broad utilization by clinicians, and sustainability of the SUrgical Risk Preoperative Assessment System (SURPAS) tool into regular clinical practice. SURPAS creates data-driven individualized risk assessments of common adverse postoperative outcomes to enhance the informed consent process, shared decision making, and consequently improved surgical outcomes. The CFIR provided a structured systematic way to identify constructs influencing the D&I of SURPAS, including adaptations for the process and tool. Results: We identified three domains, each with specific constructs, that participants believed would strongly influence effectiveness of SURPAS implementation efforts: the importance of patients’ perspectives (outer setting); the quality of SURPAS (intervention characteristic); and integration of SURPAS into the electronic health record (inner setting). Additionally, providers’ positive attitudes toward and support of SURPAS (characteristics of individuals); and the ease of integration of SURPAS into the workflow (process), were also identified. Tension emerged between patients’ preference of the provision of risk information and providers’ concern about additional clinic time required for formal risk discussion with low-risk patients. Conclusions: Systematically identifying constructs from the beginning of the design through the implementation process can guide design of a multi-component strategy for future large-scale implementation by assessing the relative impact of factors on implementation using the CFIR framework. In the example studied, this allows key stakeholders to ensure success of D&I of SURPAS at multiple levels and times, continuously optimizing the process.

Patients express strong opinion regarding discharge destination, preferring discharge home vs elsewhere. As focus on patient satisfaction increases, we sought to understand differences in postoperative discharge destination after minimally invasive vs open anatomic lung resection for lung cancer to guide patient education and management and better understand the postoperative patient experience.Procedures were identified by Current Procedural Terminology and International Classification of Diseases codes using the 2012-2017 American College of Surgeons National Surgical Quality Improvement Program dataset. Propensity score analysis was used to assess the relationship between the surgical approach and nonhome discharge destination (primary outcome) and postoperative complications; related, unplanned readmission; and mortality (secondary outcomes).A total of 17,303 patients underwent anatomic lung resection for lung cancer, including 10,121 (58.5%) minimally invasive and 7182 (41.5%) open resections. Patients undergoing open resection had 60% greater odds of nonhome discharge (P.001), 58% greater odds of postoperative mortality (P = .003), 36% greater odds of postoperative complication (P.001), and 17% greater odds of readmission (P = .04) compared with patients undergoing minimally invasive resection.The minimally invasive approach to lung resection for lung cancer offers patients a more desirable patient-centered postoperative experience, as well as more favorable clinical outcomes, and should be favored when feasible.

Background Sarcopenia may be an important predictive factor of outcomes after lung transplantation (LTx). Serum albumin and the 6-minute walk distance (6MWD) have been shown to be a marker of LTx outcomes. We measured sarcopenia, albumin, and 6MWD in a cohort of LTx patients and analyzed the utility of these as markers of outcomes for LTx patients. Methods We retrospectively identified LTx recipients from 2013-2018 at our institution who underwent computed tomographic imaging during their listing evaluation. From that image, we measured skeletal muscle cross-sectional surface area at the third lumbar vertebral level, and sarcopenia was diagnosed by established cutoffs. Associations between sarcopenia, albumin, 6MWD, and survival, and hospital length of stay, complications, readmissions, and discharge destination were evaluated. Results Sarcopenia was found in 72% (95 of 132) of patients, 18% (24 of 131) of patients were hypoalbuminemic, and 41% had a low 6MWD. Survival was not associated with presence of sarcopenia (hazard ratio [HR], 1.06; 95% confidence interval [CI], 0.46-2.42) or low 6MWD (HR, 0.86; 95% CI, 0.410-1.83). Hospital length of stay, complications, readmissions, and discharge destination were not influenced by sarcopenia or 6MWD. In contrast, hypoalbuminemia was independently associated with decreased survival (HR, 2.25; 95% CI, 1.04-4.85) and a higher grade of postoperative complications (P = .04). Conclusions Sarcopenia is prevalent in LTx patients. Neither sarcopenia nor 6MWD predicted mortality or short-term outcomes after LTx. This is in contrast to albumin levels, which were inversely associated with survival and complications. Albumin shows promise as an important predictor of mortality and short-term outcomes after LTx.

Tracheal laceration is a known complication of endotracheal intubation. This rare complication remains a diagnostic and management challenge for today’s practitioners. This clinical challenge report highlights current surgical and anesthetic management strategies.

Leaks from intrathoracic esophagogastric anastomosis are thought to be associated with higher rates of morbidity and mortality than leaks from cervical anastomosis. We challenge this assumption and hypothesize that there is no significant difference in mortality based on the location of the esophagogastric anastomosis. A systematic literature search was conducted using PubMed and Embase databases on all studies published from January 2000 to June 2015, comparing transthoracic (TTE) and transhiatal (THE) esophagectomies. Studies using jejunal or colonic interposition were excluded. Outcomes analyzed were leak rate, leak-associated mortality, overall 30-day mortality, and overall morbidity. Meta-analyses were performed using Mantel–Haenszel statistical analyses on studies reporting leak rates of both approaches. Nominal data are presented as frequency and interquartile range (IQR); measures of the association between treatments and outcomes are presented as odds ratio (OR) with 95 % confidence interval. Twenty-one studies (3 randomized controlled trials) were analyzed comprising of 7167 patients (54 % TTE). TTE approach yields a lower anastomotic leak rate (9.8 %; IQR 6.0–12.2 %) than THE (12 %; IQR 11.6–22.1 %; OR 0.56 [0.34–0.92]), without any significant difference in leak associated mortality (7.1 % TTE vs. 4.6 % THE: OR 1.83 [0.39–8.52]). There was no difference in overall 30-day mortality (3.9 % TTE vs. 4.3 % THE; OR 0.86 [0.66–1.13]) and morbidity (59.0 % TTE vs. 66.6 % THE; OR 0.76 [0.37–1.59]). Based on meta-analysis, TTE is associated with a lower leak rate and does not result in higher morbidity or mortality than THE. The previously assumed higher rate of transthoracic anastomotic leak-associated mortality is overstated, thus supporting surgeon discretion and other factors to influence the choice of thoracic versus cervical anastomosis.

OBJECTIVE To develop parsimonious prediction models for postoperative mortality, overall morbidity, and 6 complication clusters applicable to a broad range of surgical operations in adult patients. SUMMARY BACKGROUND DATA Quantitative risk assessment tools are not routinely used for preoperative patient assessment, shared decision making, informed consent, and preoperative patient optimization, likely due in part to the burden of data collection and the complexity of incorporation into routine surgical practice. METHODS Multivariable forward selection stepwise logistic regression analyses were used to develop predictive models for 30-day mortality, overall morbidity, and 6 postoperative complication clusters, using 40 preoperative variables from 2,275,240 surgical cases in the American College of Surgeons National Surgical Quality Improvement Program data set, 2005 to 2012. For the mortality and overall morbidity outcomes, prediction models were compared with and without preoperative laboratory variables, and generic models (based on all of the data from 9 surgical specialties) were compared with specialty-specific models. In each model, the cumulative c-index was used to examine the contribution of each added predictor variable. C-indexes, Hosmer-Lemeshow analyses, and Brier scores were used to compare discrimination and calibration between models. RESULTS For the mortality and overall morbidity outcomes, the prediction models without the preoperative laboratory variables performed as well as the models with the laboratory variables, and the generic models performed as well as the specialty-specific models. The c-indexes were 0.938 for mortality, 0.810 for overall morbidity, and for the 6 complication clusters ranged from 0.757 for infectious to 0.897 for pulmonary complications. Across the 8 prediction models, the first 7 to 11 variables entered accounted for at least 99% of the c-index of the full model (using up to 28 nonlaboratory predictor variables). CONCLUSIONS Our results suggest that it will be possible to develop parsimonious models to predict 8 important postoperative outcomes for a broad surgical population, without the need for surgeon specialty-specific models or inclusion of laboratory variables.