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Lower socioeconomic status (SES) is associated with shorter overall survival (OS) in patients with locoregional colon cancer. We aimed to estimate: (1) the proportion of SES-based OS disparities mediated by disparities in the quality and location of surgical treatment in patients with resected stage I–III colon cancer and (2) the relative importance of components of surgical quality. We examined patients ages 18–80 years with resected stage I–III colon adenocarcinoma using the 2010–2016 National Cancer Database. SES was defined at the zip code level. Inverse odds weighting mediation analysis was used to estimate the proportion mediated (PM) for nine treatment quality-related and facility-related factors and composite PMs in models including all nine mediators. Models compared high SES patients with each lower SES stratum. Among 171,009 patients, 5-year OS increased from 70.4% in low SES patients to 78.1% in high SES. When high SES patients were compared with low, lower-middle, and upper-middle SES patients, PM ranges among lower SES strata were: minimally invasive surgery 16.0–16.6%, lymph nodes examined 7.7–9.6%, positive margins 3.8–6.5%, length of stay 16.7–28.1%, readmissions insignificant to 3.7%, treatment at > 1 CoC facility 2.7–3.1%, facility type insignificant to 7.3%, facility volume 2.9–8.2%, and adjusted facility 90-day mortality rates 33.2–42.8%. Composite PMs were 76.9% (95% CI 61.3%, 92.4%) for low SES, 68.7% (95% CI 56.4%, 81.1%) for lower-middle SES, and 60.9% (95% CI 43.1%, 78.6%) for upper-middle SES. These data suggest that improving the quality of the surgical episode for disadvantaged patients undergoing resection for locoregional colon cancer could decrease SES-based survival disparities by over half.

Higher socioeconomic status (SES) and non-Hispanic White (NHW) race/ethnicity are associated with higher treatment rates and longer overall survival (OS) among US patients with stage I–II pancreatic ductal adenocarcinoma. The proportion of OS disparities mediated through treatment disparities (PM) and the proportion predicted to be eliminated (PE) if treatment disparities were eliminated are unknown. We analyzed 2007–2015 data from the Surveillance, Epidemiology, and End Results (SEER) census tract-level database and the National Cancer Database (NCDB) using causal mediation analysis methods to understand the extent to which treatment disparities mediate OS disparities. In the first set of decompositions, race/ethnicity was controlled for as a covariate proximal to SES, and lower SES strata were compared with the highest SES stratum. In the second set, an intersectional perspective was taken and each SES-race/ethnicity combination was compared with highest SES-NHW patients, who had the highest treatment rates and longest OS. The SEER and NCDB cohorts contained 16,921 patients and 44,638 patients, respectively. When race/ethnicity was controlled for, PMs ranged from 43 to 48% and PEs ranged from 46 to 50% for various lower SES strata. When separately comparing each SES-race/ethnicity combination with the highest SES-NHW patients, results were similar for lower SES-NHW patients but differed markedly for non-Hispanic Black and Hispanic patients, for whom PMs ranged from 60 to 80% and PEs ranged from 55 to 75% for most lower SES strata. These results suggest that efforts to reduce treatment disparities are worthwhile, particularly for NHB and Hispanic patients, and simultaneously point to the importance of non-treatment-related causal pathways.

Background and objectives The relatively recent availability of effective systemic therapies for metastatic melanoma necessitates reconsideration of current surveillance patterns. Evidence supporting surveillance guidelines for resected Stage II melanoma is lacking. Prior reports note routine imaging detects only 21% of recurrent disease. This study aims to define recurrence patterns for Stage II melanoma to inform future surveillance guidelines. Methods This is a retrospective study of patients with Stage II melanoma. We analyzed risk factors for recurrence and methods of recurrence detection. We also assessed survival. Yearly hazards of recurrence were visualized. Results With a median follow-up of 4.9 years, 158 per 580 patients (27.2%) recurred. Overall, most recurrences were patient-detected (60.7%) or imaging-detected (27.3%). Routine imaging was important in detecting recurrence in patients with distant recurrences (adjusted rate 43.1% vs. 9.4% for local/in-transit; p = .04) and with Stage IIC melanoma (42.5% vs. 18.5% for IIA; p = .01). Male patients also self-detected recurrent disease less than females (52.1% vs. 76.8%; p Conclusions Routine imaging surveillance played a larger role in detecting recurrent disease for select groups in this cohort than noted in prior studies. In an era of effective systemic therapy, routine imaging should be considered for detection of asymptomatic relapse for select, high-risk patient groups.

There is increasing need to avoid excess opioid prescribing after surgery. We prospectively assessed overprescription in our hospital system and used these data to design a quality improvement intervention to reduce overprescription.Beginning in January 2017, an e-mail-based survey to assess the quantity of opioids used postoperatively as well as patient-reported pain control was sent to all surgical patients in a 23-hospital system. In January 2018, as a quality improvement initiative, guidelines were given to surgeons based on patient consumption data. Prescription and consumption were then tracked prospectively. Wilcoxon signed-rank, analysis of variance, and Cuzick trend tests were used to assess for overprescription and changes over time in opioid prescribing and consumption.We included 2239 patients in our cohort. The amount prescribed (median [IQR]: 30 [24-45] versus 18 [12-30], P 0.001) and consumed (median [IQR]: 12 [7-20] versus 8 [3-15], P 0.001) each decreased between the first and last quarter studied. Academic hospitals prescribed fewer opioids than nonacademic hospitals (median [IQR]: 24[15-40] versus median [IQR]: 30 [20-45], P 0.001). There was no difference in the quantity of opioids consumed between patients treated at academic and nonacademic facilities (median [IQR]: 10[3-19] versus 10.5 [4-20], P = 0.08). Patients consumed a median of 42% of the opioids prescribed, and there was no significant trend in the percent consumed over time (P = 0.8).Patients used far fewer opioids than prescribed after common adult general surgery procedures. When surgeons were provided with patient consumption data, the number of opioids prescribed decreased significantly.

Background Utilization of multimodality therapy for clinical stage I-II pancreatic ductal adenocarcinoma is associated with meaningful prolongation of survival. Although the qualitative existence of disparities in treatment utilization by socioeconomic status and race/ethnicity is well documented, the absolute magnitudes of these disparities have not been previously quantified. Methods The exposures in this retrospective cohort study of the 2010–2015 National Cancer Database were a 7-value area-level socioeconomic status index and race/ethnicity. Main outcomes were surgery, chemotherapy, and multimodality therapy (surgery and chemotherapy). Adjusted rate differences were calculated after logistic regression. Models excluded intermediate variables. Overall survival was evaluated in unadjusted and adjusted analyses. Results Of 43,760 patients, 63.4% underwent surgery. Of 39,808 patients without chemotherapy contraindications, refusal, or missing data, 75.1% received chemotherapy and 51.4% received multimodality therapy. Adjusted rate differences for utilization of surgery, chemotherapy, and multimodality therapy in the lowest socioeconomic status patients were –10.0 (95% confidence interval [CI] –12.4 to –7.5), –12.7 (95% CI –16.3 to –9.1), and –15.4 (95% CI –18.8 to –12.0), respectively, versus the highest socioeconomic status patients. Adjusted rate differences for multimodality therapy utilization in non-Hispanic Black and Hispanic patients were –10.1 (95% CI –13.6 to –6.7) and –11.8 (95% CI –14.3 to –9.2), respectively, versus non-Hispanic White patients. Median overall survival increased in a graded fashion from 14.1 (95% CI 13.4–14.8) months in the lowest socioeconomic status patients to 20.2 months (95% CI 19.6–20.8) in the highest socioeconomic status patients. Survival differences were attenuated but not eliminated in multivariable Cox models. Conclusion Socioeconomic status and race/ethnicity are more powerful determinants of whether patients receive treatment for clinical stage I-II pancreatic ductal adenocarcinoma than previously appreciated. Nationwide quality improvement efforts aimed at addressing these inequities are warranted.

Neoadjuvant therapy (NT) is the standard of care for clinical stage II-III rectal adenocarcinoma, but utilization remains suboptimal. We aimed to determine the underlying reasons for omission of local staging and NT. We conducted a retrospective study of patients with clinical stage II-III or undocumented clinical stage/pathologic stage II-III rectal adenocarcinoma who were treated in 2010–2016 in one of nine Intermountain Healthcare hospitals. The outcomes of omission of local staging and NT were examined with multivariable models. Risk- and reliability-adjusted rates of local staging and NT were calculated for surgeons who treated ≥ 3 patients. Pathologic and long-term outcomes were examined after excluding patients who were not resected or who underwent local excision (N = 11). Local staging was omitted in 43/240 (17.9%) patients and NT was omitted in 41/240 (17.1%). The strongest risk factors for local staging and NT omission were upper rectal tumors and surgeons who treated ≤ 3 cases/year. Thirty-six of 41 (87.8%) cases of omitted NT had local staging omitted. Adjusted surgeon-specific local staging rates varied 1.6-fold (56.3–92.4%) and NT rates varied 2.8-fold (34.1–97.1%). Surgeon local staging and NT rates were strongly correlated (r = 0.92). NT was associated with lower rates of positive circumferential radial margins (7.9 vs. 20.0%; P = 0.02), node positivity (33.3 vs. 55.0%; P = 0.01), and local recurrences (7.6 vs. 14.9% at 5 years; P = 0.0176). NT omission should be understood as a consequence of surgeon failure to perform local staging in most cases. Quality improvement efforts should focus on improving utilization of local staging.

To (1) evaluate rates of surgery for clinical stage I-II pancreatic ductal adenocarcinoma (PDAC), (2) identify predictors of not undergoing surgery, (3) quantify the degree to which patient- and hospital-level factors explain differences in hospital surgery rates, and (4) evaluate the association between adjusted hospital-specific surgery rates and overall survival (OS) of patients treated at different hospitals.Curative-intent surgery for potentially resectable PDAC is underutilized in the United States.Retrospective cohort study of patients ≤85 years with clinical stage I-II PDAC in the 2004 to 2014 National Cancer Database. Mixed effects multivariable models were used to characterize hospital-level variation across quintiles of hospital surgery rates. Multivariable Cox proportional hazards models were used to estimate the effect of adjusted hospital surgery rates on OS.Of 58,553 patients without contraindications or refusal of surgery, 63.8% underwent surgery, and the rate decreased from 2299/3528 (65.2%) in 2004 to 4412/7092 (62.2%) in 2014 (P0.001). Adjusted hospital rates of surgery varied 6-fold (11.4%-70.9%). Patients treated at hospitals with higher rates of surgery had better unadjusted OS (median OS 10.2, 13.3, 14.2, 16.5, and 18.4 months in quintiles 1-5, respectively, P0.001, log-rank). Treatment at hospitals in lower surgery rate quintiles 1-3 was independently associated with mortality [Hazard ratio (HR) 1.10 (1.01, 1.21), HR 1.08 (1.02, 1.15), and HR 1.09 (1.04, 1.14) for quintiles 1-3, respectively, compared with quintile 5] after adjusting for patient factors, hospital type, and hospital volume.Quality improvement efforts are needed to help hospitals with low rates of surgery ensure that their patients have access to appropriate surgery.

Background Significant overtreatment of intraductal papillary mucinous neoplasms can be attributed to low specificity of the current International Consensus Guidelines as well as nonconformity with the guidelines. We compare the ability of the 2012 and revised 2017 intraductal papillary mucinous neoplasms International Consensus Guidelines to predict high-grade dysplasia/invasive cancer and to determine the preoperative variables that predict resection of benign or low-grade dysplasia in tertiary care centers. Methods Clinical, radiographic, and pathologic data for resected intraductal papillary mucinous neoplasms at 3 high-volume National Cancer Institute Cancer Centers were reviewed and the 2012 and 2017 consensus criteria were retrospectively applied. When International Consensus Guidelines were not met, clinical decision analysis was used to determine the primary indication for resection. Logistic regression identified variables associated with pathologic grade. Results Records for a total of 251 patients were reviewed, 129 of whom (52%) had low-grade dysplasia. The revised 2017 International Consensus Guidelines had high sensitivity (98.4%) and negative predicted value (96.1%), and all high-risk stigmata predicted high-grade dysplasia/invasive cancer; however, specificity remained low (14.8%). Nonconformity with International Consensus Guidelines was the most powerful predictor of low-grade dysplasia on final pathologic examination (9.5; 2.12–40.78). Independent predictors of low-grade dysplasia included age younger than 50 (2.46; 1.08–5.62), fine-needle aspiration without epithelial cells (2.6; 1.43–4.72), and normal duct diameter (3.07; 1.99–4.75). Diabetes developed in 30% of patients after resection. Conclusion Management of intraductal papillary mucinous neoplasms remains clinically challenging. Low specificity of the International Consensus Guidelines and nonconformity with the guidelines continue to contribute to unnecessary pancreatic resections. Improved tools for disease classification as well as a better understanding of the natural history, biology, and rates of progression of intraductal papillary mucinous neoplasms are needed to avoid surgical overtreatment of low-grade intraductal papillary mucinous neoplasms.

Objective To quantify risk for CRI based on PABX use in CVAP placement for cancer patients. Summary background data : Central venous access ports (CVAP) are totally implanted devices used for chemotherapy. There is a temporal risk for catheter related infection (CRI) to insertion and perioperative prophylactic antibiotics (PABX) use is a contested issue among practitioners. Methods Data was collected from a single center, academic oncology center. Treatment with a perioperative PABX was compared to non-treatment, to examine the incidence of 14-day CRI. Propensity scores with matched weights controlled for confounding, using 15 demographic, procedural and clinical variables. Results From 2007 to 2012, 1,091 CVAP were placed, where 59.7 % received PABX. The 14-day CRI rate was 0.82%, with 78% of those not receiving PABX. While results did not achieve statistical significance, use of PABX was associated with a 58% reduction in the odds of a 14-day CRI (OR = 0.42, 95% CI: 0.08-2.24, p = 0.31). Conclusion The findings suggest a reduction in early CRI with the use of PABX. Since CRI treatment can range from a course of oral antibiotics, port removal, to hospital admission, we suggest clinicians consider these data when considering PABX in this high-risk population.

Guidelines recommend neoadjuvant therapy (NT) for clinical stage II–III (locally advanced) rectal adenocarcinoma, but utilization remains suboptimal. The causes of NT omission remain poorly understood. The main outcomes in this study of patients with resected clinically non-metastatic rectal adenocarcinoma in the 2010–2015 National Cancer Database were local staging utilization in patients with non-metastatic tumors (i.e., undocumented clinical stage/pathologic stage I–III) and NT utilization for locally advanced tumors. Multivariable regression was used to examine predictors of these outcomes. Facility-specific risk- and reliability-adjusted local staging and NT rates were calculated. Positive margins and overall survival (OS) were examined as secondary outcomes. Local staging was omitted in 7737/43,819 (17.7%) patients with clinically non-metastatic tumors and NT was omitted in 5199/31,632 (16.4%) patients with locally advanced tumors. NT was utilized in 24,826 (91.1%) locally advanced patients who had local staging vs. 1607 (36.6%) patients who did not; 2785 (53.6%) locally advanced patients with NT omitted also had local staging omitted. Treatment at facilities with lowest quintile local staging rates was associated with NT omission (relative risk 2.41, 95% confidence interval 2.11, 2.75). Adjusted facility local staging rates varied sixfold (16.1–98.0%), facility NT rates varied twofold (43.9–95.9%), and they were correlated (r = 0.58; P

Background Time-to-surgery from cancer diagnosis has increased in the United States. We aimed to determine the association between time-to-surgery and oncologic outcomes in patients with resectable pancreatic ductal adenocarcinoma undergoing upfront surgery. Methods The 2004–2012 National Cancer Database was reviewed for patients undergoing curative-intent surgery without neoadjuvant therapy for clinical stage I–II pancreatic ductal adenocarcinoma. A multivariable Cox model with restricted cubic splines was used to define time-to-surgery as short (1–14 days), medium (15–42), and long (43–120). Overall survival was examined using Cox shared frailty models. Secondary outcomes were examined using mixed-effects logistic regression models. Results Of 16,763 patients, time-to-surgery was short in 34.4%, medium in 51.6%, and long in 14.0%. More short time-to-surgery patients were young, privately insured, healthy, and treated at low-volume hospitals. Adjusted hazards of mortality were lower for medium (hazard ratio 0.94, 95% confidence interval, .90, 0.97) and long time-to-surgery (hazard ratio 0.91, 95% confidence interval, 0.86, 0.96) than short. There were no differences in adjusted odds of node positivity, clinical to pathologic upstaging, being unresectable or stage IV at exploration, and positive margins. Medium time-to-surgery patients had higher adjusted odds (odds ratio 1.11, 95% confidence interval, 1.03, 1.20) of receiving an adequate lymphadenectomy than short. Ninety-day mortality was lower in medium (odds ratio 0.75, 95% confidence interval, 0.65, 0.85) and long time-to-surgery (odds ratio 0.72, 95% confidence interval, 0.60, 0.88) than short. Conclusion In this observational analysis, short time-to-surgery was associated with slightly shorter OS and higher perioperative mortality. These results may suggest that delays for medical optimization and referral to high volume surgeons are safe.

The objective of this study is to assess the accuracy of the American College of Surgeons National Surgical Quality Improvement Program online risk calculator for estimating risk after operation for gastric cancer using the United States Gastric Cancer Collaborative. Nine hundred and sixty-five patients who underwent resection of gastric adenocarcinoma between January 2000 and December 2012 at seven academic medical centers were included. Actual complication rates and outcomes for patients were compared. Most of the patients underwent total gastrectomy with Roux-en-Y reconstruction (404, 41.9%) and partial gastrectomy with gastrojejunostomy (239, 24.8%) or Roux-en-Y reconstruction (284, 29.4%). The C-statistic was highest for venous throm-boembolism (0.690) and lowest for renal failure at (0.540). All C-statistics were less than 0.7. Brier scores ranged from 0.010 for venous thromboembolism to 0.238 for any complication. General estimates of risk for the cohort were variable in terms of accuracy. Improving the ability of surgeons to estimate preoperative risk for patients is critically important so that efforts at risk reduction can be personalized to each patient. The American College of Surgeons National Surgical Quality Improvement Program risk calculator is a rapid and easy-to-use tool and validation of the calculator is important as its use becomes more common.

Clinical trials play an important role in establishing the efficacy of different surgical interventions. It is important to understand the methodological considerations that are inherent to the design, analysis, and reporting of surgical trials. This chapter reviews the essentials that surgical investigators need to know in order to handle data from clinical trials.

The size and importance of socioeconomic status (SES)-based disparities in use of surgery for non-advanced stage gastrointestinal (GI) cancers have not been quantified. The exposure in this study of patients age 18–80 with one of nine non-advanced stage GI cancers in the 2007–2015 SEER database was a census tract-level SES composite. Multivariable models assessed associations of SES with use of surgery. Causal mediation analysis was used to estimate the proportion of survival disparities in SES quintiles 1 versus 5 that were mediated by disparities in use of surgery. Lowest SES quintile patients underwent surgery at significantly lower rates than highest quintile patients in each cancer. SES-based disparities in use of surgery were large and graded in esophagus adenocarcinoma, intrahepatic and extrahepatic cholangiocarcinoma, and pancreatic adenocarcinoma. Smaller but clinically relevant disparities were present in stomach, ampulla, and small bowel adenocarcinoma, whereas disparities were small in colorectal adenocarcinoma. Five-year all-stage overall survival (OS) was correlated with the size of disparities in use of surgery in SES quintiles 1 versus 5 (r = − 0.87; p = 0.003). Mean OS was significantly longer (range 3.5–8.9 months) in SES quintile 5 versus 1. Approximately one third of SES-based survival disparities in poor prognosis GI cancers were mediated by disparities in use of surgery. The size of disparities in use of surgery in SES quintiles 1 versus 5 was correlated with the proportion mediated (r = 0.98; p

OBJECTIVE The aim of the study was to describe county-level variation in use of surgery for stage I-II pancreatic ductal adenocarcinoma (PDAC) and the association between county surgery rates and cancer-specific survival (CSS). BACKGROUND The degree of small geographic area variation in use of surgery for stage I-II PDAC and the association between area surgery rates and CSS remain incompletely defined. METHODS This is a retrospective cohort study of patients aged 18 to 80 years in the 2007 to 2015 Surveillance, Epidemiology, and End Results database with stage I-II PDAC without contraindications to surgery or refusal. Multilevel models were used to characterize county-level variation in use of surgery and CSS. County-specific risk- and reliability-adjusted surgery rates and CSS rates were calculated. RESULTS Of 18,100 patients living in 581 counties, 10,944 (60.5%) underwent surgery. Adjusted county-specific surgery rates varied 1.5-fold from 49.9% to 74.6%. Median CSS increased in a graded fashion from 13 months [interquartile range (IQR) 13-14] in counties with surgery rates of 49.9% to 56.9% to 18 months (IQR 17-19) in counties with surgery rates of 68.0% to 74.6%. Results were similar in multivariable analyses. Adjusted county 18-month CSS rates varied 1.6-fold from 32.7% to 53.7%. Adjusted county surgery and 18-month CSS rates were correlated (r = 0.54; P < 0.001) and county surgery rates explained approximately half of county-level variation in CSS. Only 18 (3.1%) counties had adjusted surgery rates of 68.0% to 74.6%, which was associated with the longest CSS. CONCLUSIONS County-specific rates of surgery varied substantially, and patients living in areas with higher surgery rates lived longer. These data suggest that increasing use of surgery in stage I-II PDAC could lead to improvements in survival.

Pancreatic ductal adenocarcinoma (PDAC) has a poor prognosis, with a 5-year survival rate of 7.7%. Most patients are diagnosed at an advanced stage not amenable to potentially curative resection. A substantial portion of this review is dedicated to reviewing the current literature on carbohydrate antigen (CA 19-9), which is currently the only guideline-recommended biomarker for PDAC. It provides valuable prognostic information, can predict resectability, and is useful in decision making about neoadjuvant therapy. We also discuss carcinoembryonic antigen (CEA), CA 125, serum biomarker panels, circulating tumor cells, and cell-free nucleic acids. Although many biomarkers have now been studied in relation to PDAC, significant work still needs to be done to validate their usefulness in the early detection of PDAC and management of patients with PDAC.

13 Background: Non-Hispanic Black patients (NHBs) and low socioeconomic status (SES) non-Hispanic White patients (NHWs) have worse cancer outcomes. In most cancers, the relative importance of treatment disparities vs. other pathways are undefined. We estimated the proportion of overall survival (OS) disparities mediated by treatment disparities in NHBs and NHWs with stage IV CRC. Methods: We queried the National Cancer Database for NHBs and NHBs (aged 18-80) diagnosed with stage IV CRC in 2010-16. Zip code SES was defined as low (quartile 1 income and education), high (quartile 4 income and education), and middle. Exclusions were missing SES, chemotherapy contraindications/refusal, unknown treatment, and < 60 days follow-up. From available variables, we examined 3 plausible treatment mediators of OS: chemotherapy, metastatectomy, and treatment at > 1 CoC facility. Primary tumor resection was not analyzed to avoid immortal time bias. We used inverse odds ratio weighting (IORW) to estimate the proportion mediated ( PM) while adjusting for sex, age, cancer history, comorbidities, year, tumor location, grade, LVI, CEA, and KRAS status. Results: Among 70,773 patients, the rate of low SES was 3.6-fold higher among NHBs than NHWs. There were graded associations between higher SES and rates of each mediator (Cuzick trend tests, all p ⩽ 0.01). Furthermore, low and middle SES NHB and NHWs all had significantly lower rates of each mediator than high SES NHWs (Table, part A). 5-yr OS ranged from 14.5% in low SES NHBs to 21.9% in high SES NHWs. Low and middle SES NHWs and all NHBs had shorter adjusted OS than high SES NHWs (Table, part B). PMs were higher for low and middle SES NHBs vs. NHWs (27-28% vs. 19-22%). PMs were largest for metastasectomy (9.9-16.1%) and smallest for chemotherapy (5.0-7.9%). Conclusions: Treatment disparities mediate at least 20-30% of OS disparities in NHBs and NHWs with stage IV CRC. These estimates may represent the lower bound of true PMs since many aspects of treatment quality were unmeasured. These findings imply that policies addressing treatment disparities are projected to partially close survival gaps. [Table: see text]

Background In the setting of a national opioid epidemic there are concerns about routine overprescription of opioids postoperatively in both children and adults, which introduces excess opioids into the community. Purpose We sought to examine current opioid prescribing practices by surgeons and consumption of prescribed opioids by pediatric surgical patients following discharge. Methods Starting in January 2017 we began an emailed survey for all postoperative patients in a 23-hospital system about the opioids they were prescribed and consumed following discharge. They were then asked if their pain was controlled. Responses of pediatric patients (age 10–18) were examined. Findings Data from 277 patients were analyzed. After surgical procedures, patients were prescribed significantly more opioids (given in hydrocodone 5 mg equivalents) than they consumed: for appendectomy (median 10 vs. 2) cholecystectomy (12 vs. 5), hernia repair (20 vs. 14), tonsillectomy (30 vs. 17), sinus surgery (30 vs. 5), septoplasty (27 vs. 9.5), knee arthroscopy (30 vs. 12.5), open reduction and internal fixation (ORIF) of the hand and wrist (20 vs. 8.5), and ORIF of the foot and ankle (27 vs. 13.5). The majority (84%) of patients agreed or strongly agreed with the statement that their pain was controlled. Of patients with excess opioids, 64% reported keeping them in their home. Conclusions Providers prescribed more opioid tablets than were used by patients. Despite using fewer tablets, patients reported good pain control. Current prescribing practices contribute to excess opioids in the community and represent an opportunity to alter the current epidemic. Level of evidence III.

Pelvic sentinel lymph nodes (SLNs) are commonly identified during inguinal SLN biopsy for melanoma, but retrieval is not uniform among surgeons/centers. Few studies have assessed rates of micrometastases in pelvic versus superficial inguinal SLNs. Previous studies suggested that presence of pelvic SLNs was predicted by aggressive pathologic features and that their presence portended a worse prognosis. The objectives of this study were to examine presurgical predictors of pelvic SLNs among patients undergoing inguinal SLN biopsy, assess rates of micrometastases in superficial inguinal versus pelvic SLNs, and determine whether presence of pelvic SLNs was associated with long-term outcomes. Multivariable regression was used to assess presurgical factors associated with presence of pelvic SLNs. Rates of micrometastases in superficial inguinal versus pelvic SLNs in patients who had a pelvic SLN were compared with McNemar's test. Groin recurrence, disease-free survival (DFS), and disease-specific survival were analyzed by Kaplan-Meier method. A multivariable Cox model for DFS was performed. Pelvic SLNs were retrieved in 100/537 (18.6%) superficial inguinal SLN biopsies and no preoperative factors predicted their presence. In patients with a pelvic SLN, micrometastases were present in 3.0% of pelvic versus 34.0% of superficial inguinal SLN biopsies (P0.001). There were no differences in groin recurrence, DFS, and disease-specific survival for patients with/without pelvic SLNs in univariate analyses (all P0.2) or in the multivariable Cox model for DFS (hazard ratio: 1.1, 95% confidence interval: 0.6-2.1). In conclusion, pelvic SLNs harbor micrometastases less frequently than superficial inguinal SLNs do, suggesting that omission of pelvic SLN biopsy may be reasonable.

This population-based study investigates the survival and causes of death in patients with pancreatic adenocarcinoma to 21 years after diagnosis.

Care coordination for patients with chronic disease commonly involves multiple transitions between primary care and surgical providers. These transitions often cross healthcare settings, providers, and information systems. We performed a cross-sectional qualitative study to gain a better understanding of the factors that influence how patients and caregivers perceive care coordination during transitions of surgical care. Eight focus groups were conducted among individuals from three different U.S. states who had experienced an episode of surgical care within the past year. We included patients who had undergone major surgery for a chronic condition, as well as caregivers. We used Atlas.ti qualitative software and engaged in an iterative process of thematic analysis of focus group transcripts. After five-rounds of review, five main themes emerged that define chronic care coordination for surgical patients and caregivers: (a) Care coordination is embedded in the unwritten social con tract patients share with their surgical providers; (b) Patients expect all surgical and nonsurgical healthcare providers to be "on the same page"; (c) Patients are frightened and vulnerable during surgical care transitions; (d) Patients need to have accurate expectations of the processes associated with care coordination; and (e) Care coordination relies upon establishing patient trust with their surgical team and needs to be continually reaffirmed. Surgical patients and caregivers expect care coordination processes to involve informatics infrastructure, patient education, and information exchange between providers. Unfortunately, these aspects of care coordination are often lacking during transitions. These findings have implications for designing patient-centered interventions to improve coordination of chronic care.

Single-center studies in pancreatic adenocarcinoma have suggested that preoperative chemotherapy (PCT) is associated with higher lymph node ratio (LNR) than preoperative chemoradiation (PCRT). The association of postoperative chemotherapy with overall survival (OS) in patients treated with PCT and PCRT remains unclear. Our objectives were to investigate whether (1) PCT is associated with higher LNR than PCRT and (2) postoperative chemotherapy is associated with longer OS after PCT and PCRT in LNR-stratified cohorts. A retrospective cohort study was performed of patients with pancreatic adenocarcinoma treated with PCT or PCRT followed by resection between 2006 and 2014 in the National Cancer Database. Temporal trends were evaluated with Cuzick’s test. OS was evaluated with multivariable Cox regression and inverse probability weighted (IPW) Cox regression. Of 4187 patients, 1993 (47.6%) received PCT. PCT rates were stable at approximately 30% in 2006–2010 (p = 0.33) but increased to 64.9% by 2014 (p

Background The impact of insurance on outcomes in the modern era of evidence-based guidelines is unclear. We sought to examine differences in receipt of therapy and outcomes for early stage, non-small cell lung cancer patients by insurance coverage. Method Clinical T1-3 N0-1 non-small cell lung cancer cases were identified in the 2004 to 2014 National Cancer Database and compared across 4 groups: private, Medicare, Medicaid, and uninsured. A multivariable, linear regression model was used to examine the effects of insurance status on time to curative surgical therapy, adjusting for patient and facility characteristics. Receipt of different therapies was examined with multivariable logistic regression. Survival analysis was conducted with Cox regression. Results A total of 240,361 patients presented with early stage non-small cell lung cancer (60,532 private, 164,377 Medicare, 11,001 Medicaid, and 4,451 uninsured). After adjustment, Medicaid and uninsured patients received surgical therapy later than privately insured patients (9.5 days and 7.0 days, respectively, P 8 weeks (odds ratio 1.64, 95% confidence interval 1.55–1.73 and odds ratio 1.46, 95% confidence interval 1.34–1.58), and were significantly less likely to receive surgery (odds ratio 0.53, 95% confidence interval 0.50–0.56 and odds ratio 0.50, 95% confidence interval 0.47–0.55). Uninsured patients were more likely to receive no treatment (odds ratio 2.15, 95% confidence interval 1.92–2.41), followed by Medicaid patients (odds ratio 1.66, 95% confidence interval 1.53–1.80). The 5-year overall survival was significantly worse in the Medicaid and uninsured populations. Conclusion Even in the modern era, uninsured and Medicaid early stage non-small cell lung cancer patients have decreased odds of receiving a potentially curative operation and experience inferior outcomes. Given substantial expenditures on the Medicaid program, strategies for increasing utilization of curative surgery in Medicaid patients with lung cancer are needed.

Background A 5 cm margin is advocated for distal gastric adenocarcinoma (GAC). The optimal proximal resection margin (PM) length for proximal GAC is not established. Methods Patients who underwent curative-intent resection for proximal GAC from 2000 to 2012 at 7 centers in the US Gastric Cancer Collaborative were included. PM length was sequentially dichotomized and analyzed at 0.5 cm increments (0.5–6.5 cm). Outcomes after negative margin (R0) and positive microscopic margin (R1) resections were compared. Primary endpoints were local recurrence (LR) and overall survival (OS). Results All patients (n = 162) had R0 distal margins. 151 (93.2%) had an R0-PM with mean length of 2.6 cm (median:1.7 cm; range:0.1–15 cm). A greater PM distance was not associated with LR or OS. An R1-PM was associated with higher N-stage (N3:73% vs. 26%; P = 0.007) and increased LR (HR6.1; P = 0.009) but not associated with decreased OS. On multivariate analysis, an R1-PM was also not independently associated with LR. Conclusions For resection of proximal gastric adenocarcinoma, proximal margin length is not associated with local recurrence or overall survival. An R1 margin is associated with advanced N-stage but is not independently associated with recurrence or survival. When performing resection of proximal gastric adenocarcinoma, efforts to achieve a specific margin distance, especially if it necessitates an esophagectomy, should be abandoned. J. Surg. Oncol. 2015 111:203–207. © 2015 Wiley Periodicals, Inc.

Many patients with stage I-II pancreatic adenocarcinoma do not undergo resection. We hypothesized that (1) clinical staging underestimates nodal involvement, causing stage IIB to have a greater percent of resected patients and (2) this stage-shift causes discrepancies in observed survival.The Surveillance, Epidemiology, and End Results (SEER) research database was used to evaluate cause-specific survival in patients with pancreatic adenocarcinoma from 2004-2012. Survival was compared using the log-rank test. Single-center data on 105 patients who underwent resection of pancreatic adenocarcinoma without neoadjuvant treatment were used to compare clinical and pathologic nodal staging.In SEER data, medium-term survival in stage IIB was superior to IB and IIA, with median cause-specific survival of 14, 9, and 11 months, respectively (P .001). Seventy-two percent of stage IIB patients underwent resection vs 28% in IB and 36% in IIA (P .001). In our institutional data, 12.4% of patients had clinical evidence of nodal involvement vs 69.5% by pathologic staging (P .001). Among clinical stage IA-IIA patients, 71.6% had nodal involvement by pathologic staging.Both SEER and institutional data support substantial underestimation of nodal involvement by clinical staging. This finding has implications in decisions regarding neoadjuvant therapy and analysis of outcomes in the absence of pathologic staging.

Cardiac arrest (CA) is a rare but recognized complication of emergency airway management. Our aim was to measure the incidence of peri-intubation CA during emergency intubation and identify factors associated with this complication.Retrospective cohort study of emergency endotracheal intubations performed in a large, urban emergency department over a one-year period. Patients were included if they were18 years old and not in CA prior to intubation. Multiple logistic regression modeling was used to define factors independently associated with CA.A total 542 patients underwent emergency intubation during the study period and 410 met inclusion criteria for this study. CA occurred in 17/410 (4.2%) at a median of 6 min post-intubation. Nearly two-thirds of CA events occurred within 10 min of drug induction; early peri-intubation CA rate 2.4% (95% CI: 1.3-4.5%). Pulseless electrical activity was the initial rhythm in the majority of cases. More than half of CA events were successfully resuscitated but CA was associated with increased odds of hospital death (OR 14.8; 95% CI: 4.2-52). Pre-intubation hemodynamic and oximetry variables were associated with CA. CA was more common in patients experiencing pre intubation hypotension (12% vs 3%; p0.002). Pre RSI shock index (SI) and weight were independently associated with CA.In this series, 1 in 25 emergency intubations was associated with the complication of CA. Peri-intubation CA is associated with increased mortality. Pre-intubation patient characteristics are associated with this complication.

It is estimated that 37 % of the U.S. population is obese. It is unknown how obesity influences the operative and survival outcomes of cytoreductive surgery (CRS)/hyperthermic intraperitoneal chemotherapy (HIPEC) procedures. A retrospective analysis of a prospective database of 1,000 procedures was performed. Type of malignancy, performance status, resection status, hospital and intensive care unit stay, comorbidities, morbidity, mortality, and survival were reviewed. A total of 246 patients with body mass index (BMI) of >30 kg/m2 underwent 272 CRS/HIPEC procedures. Ninety-five (38.6 %) were severely obese (BMI > 35 kg/m2). A total of 135 (49.6 %) procedures were performed for appendiceal and 60 (22.1 %) for colon cancer. Median follow-up was 52 months. Both major and minor morbidity were similar for obese and non-obese patients. The 30-day mortality rates for obese and non-obese patients were 1.5 and 2.5 %, respectively. Median intensive care unit and hospital stay were 1 and 9 days, regardless of BMI. The 30-day readmission rate was similar between obese and non-obese patients (24.8 vs. 19.4 %, p = 0.11). Median survival for low-grade appendiceal cancer (LGA) was 76 months for obese patients and 107 months for non-obese patients (p = 0.32). Survival was worse for severely obese patients (median survival 54 months) versus non-obese patients with LGA (p = 0.04). Survival was similar for obese and non-obese patients with peritoneal surface disease (PSD) from colon cancer or high-grade appendiceal cancer. Obesity does not influence postoperative morbidity or mortality of patients with PSD, regardless of primary tumor. Severe obesity is associated with decreased long-term survival only in patients with LGA primary disease; however, application of CRS/HIPEC still offers meaningful prolongation of life. Obesity should not be considered a contraindication for CRS/HIPEC procedures.

404 Background: Guidelines for adjuvant chemotherapy in patients with resected pancreatic adenocarcinoma (PDAC) who received neoadjuvant chemotherapy are equivocal. A lymph node ratio (LNR) ≥ 0.15 may predict lack of benefit, but conflicting results are reported. Methods: The National Cancer Database was searched to identify patients who were resected after neoadjuvant chemotherapy in 2006-2013. Exclusions: metastases at surgery, 90-day postoperative mortality, adjuvant radiation, and outlier interval from diagnosis to surgery (10 months). The association between adjuvant chemotherapy and overall survival (OS) from diagnosis was examined using multivariable Cox regression and inverse propensity of treatment weighted (IPTW) Cox regression. An IPTW based estimator of the average treatment effect (ATE) was used to quantify the population average survival benefit of treatment. Outcomes were examined in all patients and in those with LNR < 0.15 and ≥ 0.15. Results: 681/2488 patients (27%) received adjuvant chemotherapy. In multivariable Cox regression, adjuvant chemotherapy was associated with improved OS in the overall cohort and in patients with LNR < 0.15. A trend towards improved OS was also observed for those with LNR ≥ 0.15. After accounting for indication bias using IPTW, a significant survival benefit for was observed only for patients with LNR < 0.15. The ATE among LNR < 0.15 patients was 3.3 (95% CI 1.0, 5.7) months, indicating that the average survival of the population would be 3.3 months longer if all received treatment. Conclusions: Adjuvant chemotherapy in resected PDAC patients who received neoadjuvant therapy appears to be beneficial in patients with negative lymph nodes or minimal nodal burden. High LNR after neoadjuvant therapy may be an indicator of adverse tumor biology that is less likely to derive a therapeutic benefit. [Table: see text]

Limited data exist on the prognosis of preoperative Helicobacter pylori (H. pylori) infection in gastric adenocarcinoma (GAC). Patients who underwent curative-intent resection for GAC from 2000 to 2012 at seven academic institutions comprising the United States Gastric Cancer Collaborative were included in the study. The primary end points of the study were overall survival (OS), recurrence-free survival (RFS), and disease-specific survival (DSS). Of 559 patients, 104 (18.6 %) who tested positive for H. pylori were younger (62.1 vs 65.1 years; p = 0.041), had a higher frequency of distal tumors (82.7 vs 71.9 %; p = 0.033), and had higher rates of adjuvant radiation therapy (47.0 vs 34.9 %; p = 0.032). There were no differences in American Society of Anesthesiology (ASA) class, margin status, grade, perineural invasion, lymphovascular invasion, nodal metastases, or tumor-node-metastasis (TNM) stage. H. pylori positivity was associated with longer OS (84.3 vs 44.2 months; p = 0.008) for all patients. This relationship with OS persisted in the multivariable analysis (HR 0.54; 95 % CI 0.30–0.99; p = 0.046). H. pylori was not associated with RFS or DSS in all patients. In the stage 3 patients, H. pylori was associated with longer OS (44.5 vs 24.7 months; p = 0.018), a trend of longer RFS (31.4 vs 21.6 months; p = 0.232), and longer DSS (44.8 vs 27.2 months; p = 0.034). Patients with and without preoperative H. pylori infection had few differences in adverse pathologic features at the time of gastric adenocarcinoma resection. Despite similar disease presentations, preoperative H. pylori infection was independently associated with improved OS. Further studies examining the interaction between H. pylori and tumor immunology and genetics are merited.

Delay in diagnosis of pancreatic ductal adenocarcinoma (PDAC) is associated with decreased survival. The effect of an initial misdiagnosis on delay in diagnosis and stage of PDAC is unknown. This study is a retrospective review (2000–2010) from a University-based cancer center of new diagnoses of proximal PDAC. Of 313 patients, 98 (31.3 %) had an initial misdiagnosis. Misdiagnosed patients were younger, 62.8 ± 12.6 vs. 68.0 ± 10.1 (p

Conflicting data exist on the prognostic implication of signet-ring cell (SRC) histology in gastric adenocarcinoma (GAC). All patients who underwent curative-intent resection of GAC from the seven institutions of the U.S. Gastric Cancer Collaborative between 2000 and 2012 were included. Primary end points were recurrence-free survival (RFS) and overall survival (OS). Stage-specific analyses were performed. A total of 768 patients met the inclusion criteria. SRC was present in 40.6 % of patients and was associated with female sex (52.9 vs. 38.6 %; p

The effect of routine drainage after abdominal surgery with enteric anastomoses is controversial. In particular, the role of peritoneal drain (PD) placement after total gastrectomy for adenocarcinoma is not well established. Patients who underwent total gastrectomy for gastric adenocarcinoma (GAC) at seven institutions from the US Gastric Cancer Collaborative, from 2000 to 2012, were identified. The association of PD placement with postoperative outcomes was analyzed. Overall, 344 patients were identified and 253 (74 %) patients received a PD. The anastomotic leak rate was 9 %. Those with PD placement had similar American Society of Anesthesiologists score, tumor size, TNM stage, and the need for additional organ resection when compared with their counterparts. No difference was observed in the rate of any complication (54 vs. 48 %; p = 0.45), major complication (25 vs. 24 %; p = 0.90), or 30-day mortality (7 vs. 4 %; p = 0.51) between the two groups. In addition, no difference in anastomotic leak (9 vs. 10 %; p = 0.90), the need for secondary drainage (10 vs. 9 %; p = 0.92), or reoperation (13 vs. 8 %; p = 0.28) was identified. On multivariate analysis, PD placement was not associated with decreased postoperative complications. Subset analysis, stratified by patients who did not undergo concomitant pancreatectomy (n = 319) or those who experienced anastomotic leak (n = 31), similarly demonstrated no association of PD placement with reduced complications or mortality. PD placement after total gastrectomy for GAC is associated with neither a decrease in the frequency and severity of adverse postoperative outcomes, including anastomotic leak and mortality, nor a decrease in the need for secondary drainage procedures or reoperation. Routine use of PDs is not warranted.

Total body surface area (TBSA) burned is a powerful descriptor of burn severity and influences the volume of resuscitation required in burn patients. The incidence and severity of TBSA overestimation by referring institutions (RIs) in children transferred to a burn center (BC) are unclear. The association between TBSA overestimation and overresuscitation is unknown as is that between TBSA overestimation and outcome. The trauma registry at a BC was queried over 7.25 years for children presenting with burns. TBSA estimate at RIs and BC, total fluid volume given before arrival at a BC, demographic variables, and clinical variables were reviewed. Nearly 20 per cent of children arrived from RIs without TBSA estimation. Nearly 50 per cent were overestimated by 5 per cent or greater TBSA and burn sizes were overestimated by up to 44 per cent TBSA. Average TBSA measured at BC was 9.5 ± 8.3 per cent compared with 15.5 ± 11.8 per cent as measured at RIs ( P < 0.0001). Burns between 10 and 19.9 per cent TBSA were overestimated most often and by the greatest amounts. There was a statistically significant relationship between overestimation of TBSA by 5 per cent or greater and overresuscitation by 10 mL/kg or greater ( P = 0.02). No patient demographic or clinical factors were associated with TBSA overestimation. Education efforts aimed at emergency department physicians regarding the importance of always calculating TBSA as well as the mechanics of TBSA estimation and calculating resuscitation volume are needed. Further studies should evaluate the association of TBSA overestimation by RIs with adverse outcomes and complications in the burned child.

Use of perioperative chemotherapy (CTx) alone versus chemoradiation therapy (cXRT) in the treatment of resectable gastric cancer remains varied. We sought to define the utilization and effect of CTx alone versus cXRT on patients having undergone curative-intent resection for gastric cancer.Using the multi-institutional US Gastric Cancer Collaborative database, we identified 505 gastric cancer patients between 2000 and 2012 who received perioperative therapy in addition to curative-intent resection. The impact of perioperative therapy on survival was analyzed by the use of propensity-score matching of clinicopathologic factors among patients who received CTx alone versus cXRT.Median patient age was 62 years, and most patients were male (58.2 %). Most patients had a T3 (38.7 %) or T4 (36.8 %) lesion and lymph node metastasis (73.4 %). A total of 211 (42.8 %) patients received perioperative CTx alone, whereas the remaining 294 (58.2 %) patients received cXRT. Factors associated with receipt of cXRT were younger age (odds ratio, 1.93) and lymph node metastasis (odds ratio, 4.02; both P 0.05). At a median follow-up of 28 months, the median overall survival (OS) was 33.4 months, and the 5-year OS was 36.7 %. Factors associated with worse overall survival included large tumor size [hazard ratio (HR), 1.83], T3 (HR 2.96) or T4 (HR 4.02) tumors, and lymph node metastasis (HR 1.57; all P 0.05). In contrast, receipt of cXRT was associated with improved long-term OS (CTx alone, 20.9 months; cXRT, 46.7 months; HR 0.51; P 0.001).cXRT was utilized in 58 % of patients undergoing curative-intent resection for gastric cancer. With propensity score-matched analysis, cXRT was an independent factor associated with improved recurrence-free survival and OS.

Objective Arterial hypotension is a recognized complication of emergency intubation that is independently associated with increased morbidity and mortality. Our aim was to identify factors associated with postintubation hypotension after emergency intubation. Methods Retrospective cohort study of tracheal intubations performed in a large, urban emergency department over a 1-year period. Patients were included if they were older than 17 years and had no systolic blood pressure measurements below 90 mm Hg for 30 consecutive minutes before intubation. Patients were analyzed in 2 groups, those with postintubation hypotension (PIH), defined as any recorded systolic blood pressure less than 90 mm Hg within 60 minutes of intubation, and those with no PIH. Multiple logistic regression modeling was used to define predictors of PIH. Results A total 465 patients underwent emergency intubation during the study period, and 300 met inclusion criteria for this study. Postintubation hypotension occurred in 66 (22%) of 300 patients, and these patients experienced significantly higher in-hospital mortality (35% vs 20%; odds ratio [OR] 2.1; 95% confidence interval [CI], 1.2-3.9). Multiple logistic regression analysis demonstrated that preintubation shock index (SI), chronic renal disease, intubation for acute respiratory failure, and age were independently associated with PIH. Of these, SI was the most strongly associated factor (OR, 55; 95% CI, 13-232). Receiver operating characteristic plot showed optimized SI 0.8 or higher predicting PIH with 67% sensitivity and 80% specificity. Rapid sequence intubation paralysis was associated with a lower incidence of PIH (OR, 0.04; 95% CI, 0.003-0.4). Conclusions Preintubation and peri-intubation factors predict the complication of PIH. Elevated SI strongly and independently forewarned of cardiovascular deterioration after emergency intubation with pre-RSI SI 0.8 or higher as the optimal threshold to identify patients at risk.

Arterial hypotension is a recognized complication of emergency intubation, but the consequence of this event is poorly described. Our aim was to identify the incidence of postintubation hypotension (PIH) after emergency intubation and to determine its association with inhospital mortality.Retrospective cohort study of tracheal intubations performed in a large, urban emergency department over a 1-year period. Patients were included if they were older than 17 years and had no systolic blood pressure measurements less than 90 mm Hg for 30 consecutive minutes before intubation. Patients were analyzed in 2 groups, those with PIH, defined as any recorded systolic blood pressure less than 90 mm Hg within 60 minutes of intubation, and those with no PIH. The primary outcome was inhospital mortality.Of 465 patients who underwent emergency intubation, 336 met inclusion criteria and were analyzed. Postintubation hypotension occurred in 79 (23%) of 336 patients. Patients with PIH had significantly higher inhospital mortality (33% vs 21%; 95% confidence interval for 12% difference, 1%-23%) and longer mean intensive care length of stay (LOS) (9.7 vs 5.9 days, P.01) and hospital LOS (17.0 vs 11.4 days, P.01). Postintubation hypotension remained a significant predictor of inhospital mortality after adjusting for confounding using multivariable logistic regression analysis (odds ratio, 1.9; 95% confidence interval, 1.1-3.5).Postintubation hypotension occurs in almost one quarter of normotensive patients undergoing emergency intubation. Postintubation hypotension is independently associated with higher inhospital mortality and longer intensive care unit and hospital LOS.

Arterial hypotension is known to follow emergency intubation but the significance of this event is poorly described. We aimed to measure the incidence of post-intubation hypotension (PIH) following emergency intubation and determine its association with in-hospital mortality.