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Background: The objective of this study was to review the long-term efficacy of a post-operative venous thromboembolism (VTE) prevention program at our institution., Methods: We performed a review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data at our hospital from January 2008-December 2022. The primary outcome was risk-adjusted VTE events., Results: In 2009, a postoperative general surgery patient was three times more likely to have a postoperative VTE event than predicted (O/E ratio 3.02, 95% CI 1.99-4.40). After implementing a mandatory VTE risk assessment model and a risk-commensurate prophylaxis protocol in the electronic medical record in 2011, the odds ratio of a patient developing a postoperative VTE declined to 0.70 by 2014 (95% CI 0.40-1.23). This success persisted through 2022., Conclusions: Since the implementation of a standardized postoperative VTE prevention program in 2011, our institution has sustained a desirably low likelihood of VTE events in general surgery patients., Competing Interests: Declaration of competing interest Authors have no conflict of interest to disclose, (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Appropriate follow-up of incidental adrenal masses (IAMs) is infrequent. We implemented a quality improvement (QI) program to improve management of IAMs., Study Design: This system-wide initiative targeted primary care providers (PCPs) after IAM detection. It incorporated (1) chart-based messages and emails to PCPs, (2) an evidence-based IAM evaluation algorithm, (3) standardized recommendations in radiology reports, and (4) access to a multispecialty adrenal clinic. Patients diagnosed with an IAM from January 1, 2018, to December 31, 2019, were prospectively included (the "QI cohort") and compared with a historical, preintervention cohort diagnosed with IAMs in 2016. The primary outcomes were the initiation of an IAM investigation by the PCP, defined as relevant clinical history-taking, laboratory screening, follow-up imaging, or specialist referral., Results: The QI cohort included 437 patients and 210 in the historical cohort. All patients had 12 months or more of follow-up. In the QI cohort, 35.5% (155 of 437) met the primary endpoint for PCP-initiated evaluation, compared with 27.6% (58 of 210) in the historical cohort (p = 0.0496). Among the subgroup with a documented PCP working within our health system, 46.3% (74 of 160) met the primary endpoint in the QI cohort vs 33.3% (38 of 114) in the historical cohort (p = 0.035). After adjusting for insurance status, presence of current malignancy, initial imaging setting (outpatient, inpatient, or emergency department), and having an established PCP within our health system, patients in the QI cohort had 1.70 times higher odds (95% CI 1.16 to 2.50) of undergoing a PCP-initiated IAM evaluation. Adrenal surgery was ultimately performed in 2.1% (9 of 437) of QI cohort patients and 0.95% (2 of 210) of historical cohort patients (p = 0.517)., Conclusions: This simple, moderately labor-intensive QI intervention was associated with increased IAM evaluation initiated by PCPs., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Decision-making regarding definitive therapy for Graves' disease requires effective patient-provider communication. We investigated whether patients with limited English proficiency have differences in thyroidectomy outcomes or perioperative management when compared to English proficient (EP) patients at a safety net hospital with high-volume endocrine surgery practice., Methods: Retrospective study of patients who underwent thyroidectomy (2012-2021) for Graves' disease within a tertiary referral system. Demographics, preoperative factors, and postoperative outcomes were abstracted via chart review and compared between EP and limited English proficient (LEP) patients in univariate analyses. Odds of postoperative complications were assessed via multivariable logistic regression. Time metrics such as time from endocrinology consultation to surgery were compared via Kaplan-Meier analysis and adjusted Cox proportional regression models., Results: Of 236 patients, 85 (36%) had LEP. Low and equivalent complication rates occurred across language groups (<1% permanent). LEP patients had similar odds of thyroidectomy-specific complications (odds ratio = 1.2; 95% confidence interval 0.6-2.4). Adjusted Cox proportional hazards ratios showed that LEP patients experienced significantly shorter time from endocrinology consultation to surgery compared to EP patients [hazard ratio = 0.7; 95% confidence interval 0.5-0.9]., Conclusions: Thyroidectomy-specific complication rate for patients with Graves' disease was low, and we detected no independent association between complications and English language proficiency. Non-English primary language was independently associated with reduced time from endocrinology consultation to surgery. This finding must be interpreted with nuance and is likely multifactorial. It may reflect a well-organized, efficient system for under-resourced patients, or it may derive from communication barriers that limit robust shared decision-making, thus accelerating time to surgery., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Minimally invasive pancreaticoduodenectomy (MIPD), including robotic (RPD) and laparoscopy (LPD), is becoming more frequently employed in the management of pancreatic ductal adenocarcinoma (PDAC), though the majority of operations are still performed via open approach (OPD). Access to technologic advances often neglect the underserved. Whether disparities in access to MIPD exist, remain unclear., Methods: The National Cancer Database (NCDB) was queried (2010-2020) for patients who underwent pancreatoduodenectomy for PDAC. Cochran-Armitage tests assessed for trends over time. Social determinants of health (SDH) were compared between approaches. Multinomial logistic models identified predictors of MIPD., Results: Of 16,468 patients, 80.03 % underwent OPD and 19.97 % underwent MIPD (22.60 % robotic; 77.40 % laparoscopic). Black race negatively predicted LPD (vs white (OR 0.822; 95 % CI 0.701-0.964)). Predictors of RPD included Medicare/other government insurance (vs uninsured or Medicaid (OR 1.660; 95 % CI 1.123-2.454)) and private insurance (vs uninsured or Medicaid (OR 1.597; 95 % CI 1.090-2.340)). Early (2010-2014) vs late (2015-2020) diagnosis, stratified by race, demonstrated an increase in Non-White patients undergoing OPD (13.15 % vs 14.63 %; p = 0.016), but not LPD (11.41 % vs 13.57 %;p = 0.125) or RPD (14.15 % vs 15.23 %; p = 0.774)., Conclusion: SDH predict surgical approach more than clinical stage, facility type, or comorbidity status. Disparities in race and insurance coverage are different between surgical approaches., (Copyright © 2023 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Introduction: Patients with pancreatic cancer can present with a variety of insidious abdominal symptoms, complicating initial diagnosis. Early symptoms of pancreatic cancer often mirror those associated with gallstone disease, which has been demonstrated to be a risk factor for this malignancy. This study aims to compare the incidence of gallstone disease in the year before diagnosis of pancreatic ductal adenocarcinoma (PDAC) as compared to the general population, and evaluate the association of gallstone disease with stage at diagnosis and surgical intervention., Methods: Patients with PDAC were identified from SEER-Medicare (2008-2015). The incidence of gallstone disease (defined as cholelithiasis, cholecystitis and/or cholecystectomy) in the 1 year before cancer diagnosis was compared to the annual incidence in an age-matched, sex-matched, and race-matched noncancer Medicare cohort., Results: Among 14,654 patients with PDAC, 4.4% had gallstone disease in the year before cancer diagnosis. Among the noncancer controls (n = 14,654), 1.9% had gallstone disease. Both cohorts had similar age, sex and race distributions. PDAC patients with gallstone disease were diagnosed at an earlier stage (stage 0/I-II, 45.8% versus 38.1%, P < 0.0001) and a higher proportion underwent resection (22.7% versus 17.4%, P = 0.0004) compared to patients without gallstone disease., Conclusions: In the year before PDAC diagnosis, patients present with gallstone disease more often than the general population. Improving follow-up care and differential diagnosis strategies may help combat the high mortality rate in PDAC by providing an opportunity for earlier stage of diagnosis and earlier intervention., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: In early-stage hepatocellular carcinoma (HCC), the receipt of recommended care is critical for long-term survival. Unfortunately, not all patients decide to undergo therapy. We sought to identify factors associated with the decision to decline recommended intervention among patients with early-stage HCC., Methods: The National Cancer Database was queried for patients diagnosed with clinical stages I and II HCC (2004-2017). Cohorts were created based on the receipt or decline of recommended interventions-hepatectomy, liver transplantation, and ablation. Multivariable logistic regression identified predictors for declining intervention, and propensity score analysis was used to calculate the respective odds. Survival analysis was performed using the Kaplan-Meier method., Results: Of 20,863 patients, 856 (4.1%) declined intervention. Patients who were documented as having declined intervention were more often Black (vs. other: OR, 1.3; 95% CI, 1.1-1.6; p = 0.0038), had Medicaid or no insurance (vs. Private, Medicare, or other government insurance): OR, 1.9; 95% CI, 1.6-2.3; p < 0.0001), lived in a low-income area (vs. other: OR, 1.4; 95% CI, 1.2-1.7; p < 0.0001), and received treatment at a non-academic center (vs. academic: OR, 2.1; 95% CI, 1.9-2.5; p < 0.0001). Patients who declined recommended interventions had worse survival compared to those who received treatment (22.9 vs. 59.2 months; p < 0.0001, respectively)., Conclusions: Racial and socioeconomic disparities persist in the decision to undergo recommended treatment. Underutilization of treatment acts as a barrier to addressing racial and socioeconomic disparities in early-stage HCC outcomes., (© 2023. The Author(s) under exclusive licence to Société Internationale de Chirurgie.)

Objective: To determine the effect of persistent poverty on the diagnosis, surgical resection and survival of patients with non-small cell lung (NSCLC), breast, and colorectal cancer., Background: Disparities in cancer outcomes exist in counties with high levels of poverty, defined as ≥20% of residents below the federal poverty level. Despite this well-established association, little is known about how the duration of poverty impacts cancer care and outcomes. One measure of poverty duration is that of "persistent poverty," defined as counties in high poverty since 1980., Methods: In this retrospective cohort study, patients with NSCLC, breast and colorectal cancer were identified from SEER (2012-2016). County-level poverty was obtained from the American Community Survey (1980-2015). Outcomes included advanced stage at diagnosis (stage III-IV), resection of localized disease (stage I-II) and cancer-specific survival. Hierarchical generalized linear models and accelerated failure time models with Weibull distribution were used, adjusted for patient-level covariates and region., Results: Overall, 522,514 patients were identified, of which 5.1% were in persistent poverty. Patients in persistent poverty were more likely to present with advanced disease [NSCLC odds ratio (OR): 1.12, 95% confidence interval (CI): 1.06-1.18; breast OR: 1.09, 95% CI: 1.02-1.17; colorectal OR: 1.00, 95% CI: 0.94-1.06], less likely to undergo surgery (NSCLC OR: 0.81, 95% CI: 0.73-0.90; breast OR: 0.82, 95% CI: 0.72-0.94; colorectal OR: 0.84, 95% CI: 0.70-1.00) and had increased cancer-specific mortality (NSCLC HR: 1.09, 95% CI: 1.06-1.13; breast HR: 1.18, 95% CI: 1.05-1.32; colorectal HR: 1.09, 95% CI: 1.03-1.17) as compared with those without poverty. These differences were observed to a lesser magnitude in counties with current, but not persistent, poverty and disappeared in counties no longer in poverty., Conclusions: The duration of poverty has a direct impact on cancer-specific outcomes, with the greatest effect seen in persistent poverty and resolution of disparities when a county is no longer in poverty. Policy focused on directing resources to communities in persistent poverty may represent a possible strategy to reduce disparities in cancer care and outcomes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Rationale: Incidental radiographic findings are common, and primary care providers (PCPs) are often charged with the conducting or initiating an appropriate evaluation. Clinical guidelines are available for management of common 'incidentalomas' including lung and adrenal nodules, but guidelines-adherent evaluations are not always performed; for example, in the setting of incidental adrenal masses (IAMs), recent literature suggests that an evidence-based evaluation occurs in <25% of patients for whom it is warranted-a quality and safety concern., Aims and Objectives: The objective of this study was to examine whether point-of-care access to concise clinical guidelines would promote appropriate evaluations of two common incidentalomas: IAMs and lung nodules., Method: This study was a survey-based, single-blinded, randomized experiment of decision-making within clinical vignettes. Respondents were PCPs in a variety of clinical practice settings, and half were randomly assigned to surveys that included concise clinical guidelines while the other half served as controls without access to guidelines. Scenarios involved patients with IAMs and lung nodules, and the scenarios included both higher-risk and lower-risk lesions. Our primary analysis examined safe versus inappropriate clinical decisions, while a secondary analysis compared guidelines-concordant versus guidelines-discordant responses., Results: For both the higher-risk IAM and higher-risk lung nodule scenarios, safe answer choices were selected at a similar rate by respondents regardless of whether they had access to guidelines or not. However, for the lower risk scenarios, inappropriate answer choices were chosen substantially more frequently by respondents without access to guidelines compared to those with the guidelines (lung: 29.3% vs. 4.5%, p = 0.003, adrenal: 31.6% vs. 7.0%, p = 0.01). There was less variation in the secondary analysis., Conclusion: Survey respondents were significantly more likely to make safe management decisions in lower-risk clinical scenarios when clinical guidelines were available. Point-of-care access to clinical guidelines for incidentalomas is an intervention that may reduce management errors and improve patient safety., (© 2023 John Wiley & Sons Ltd.)

Background and Objectives: Studies have reported ambiguous results regarding the efficacy of ablation for early-stage hepatocellular carcinoma (HCC). Our study compared outcomes of ablation versus resection for HCC ≤50 mm to identify tumor sizes that would most benefit from ablation in terms of long-term survival., Methods: The National Cancer Database was queried for patients with stage I and II HCC ≤50 mm who underwent ablation or resection (2004-2018). Three cohorts were created based on tumor size: ≤20, 21-30, and 31-50 mm. A propensity score-matched survival analysis was performed using the Kaplan-Meier method., Results: In total, 36.47% (n = 4263) and 63.53% (n = 7425) of patients underwent resection and ablation, respectively. After matching, resection was associated with a significant survival benefit compared to ablation (3-year survival: 78.13% vs. 67.64%; p < 0.0001) in patients with HCC of ≤20 mm. The impact of resection was even more striking among patients with HCC of 21-30 mm (3-year survival: 77.88% vs. 60.53%; p < 0.0001) and 31-50 mm (3-year survival: 67.21% vs. 48.55%; p < 0.0001)., Conclusions: While resection offers a survival benefit over ablation in the treatment of early-stage HCC ≤50 mm, ablation may provide a feasible bridging strategy in patients awaiting transplantation., (© 2023 Wiley Periodicals LLC.)

Purpose: Incidental adrenal masses (IAMs) are common but rarely evaluated. To improve this, we developed a standardized radiology report recommendation template and investigated its implementation and effectiveness., Methods: We prospectively studied implementation of a standardized IAM reporting template as part of an ongoing quality improvement initiative, which also included primary care provider (PCP) notifications and a straightforward clinical algorithm. Data were obtained via medical record review and a survey of radiologists. Outcomes included template adoption rates and acceptability (implementation measures), as well as the proportion of patients evaluated and time to follow-up (effectiveness outcomes)., Results: Of 4,995 imaging studies, 200 (4.0%) detected a new IAM. The standardized template was used in 54 reports (27.0%). All radiologists surveyed were aware of the template, and 91% affirmed that standardized recommendations are useful. Patients whose reports included the template were more likely to have PCP follow-up after IAM discovery compared with those with no template (53.7% versus 36.3%, P = .03). After adjusting for sex, current or prior malignancy, and provider ordering the initial imaging (PCP, other outpatient provider, or emergency department or inpatient provider), odds of PCP follow-up remained 2.0 times higher (95% confidence interval 1.02-3.9). Patients whose reports included the template had a shorter time to PCP follow-up (log-rank P = .018). PCPs ultimately placed orders for biochemical testing (35.2% versus 18.5%, P = .01), follow-up imaging (40.7% versus 23.3%, P = .02), and specialist referral (22.2% versus 4.8%, P < .01) for a higher proportion of patients who received the template compared with those who did not., Conclusions: Use of a standardized template to communicate IAM recommendations was associated with improved IAM evaluation. Our template demonstrated high acceptability, but additional strategies are necessary to optimize adoption., (Copyright © 2022 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: The COVID-19 pandemic profoundly impacted the delivery of care and timing of elective surgical procedures. Most endocrine-related operations were considered elective and safe to postpone, providing a unique opportunity to assess clinical outcomes under protracted treatment plans., Methods: American Association of Endocrine Surgeon members were surveyed for participation. A Research Electronic Data Capture survey was developed and distributed to 27 institutions to assess the impact of COVID-19-related delays. The information collected included patient demographics, primary diagnosis, resumption of care, and assessment of disease progression by the surgeon., Results: Twelve out of 27 institutions completed the survey (44.4%). Of 850 patients, 74.8% (636) were female; median age was 56 (interquartile range, 44-66) years. Forty percent (34) of patients had not been seen since their original surgical appointment was delayed; 86.2% (733) of patients had a delay in care with women more likely to have a delay (87.6% vs 82.2% of men, χ 2  = 3.84, P = .05). Median duration of delay was 70 (interquartile range, 42-118) days. Among patients with a delay in care, primary disease site included thyroid (54.2%), parathyroid (37.2%), adrenal (6.5%), and pancreatic/gastrointestinal neuroendocrine tumors (1.3%). In addition, 4.0% (26) of patients experienced disease progression and 4.1% (24) had a change from the initial operative plan. The duration of delay was not associated with disease progression (P = .96) or a change in operative plan (P = .66)., Conclusion: Although some patients experienced disease progression during COVID-19 delays to endocrine disease-related care, most patients with follow-up did not. Our analysis indicated that temporary delay may be an acceptable course of action in extreme circumstances for most endocrine-related surgical disease., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Preoperative decision-making in patients who speak a primary language other than English is understudied. We investigated whether patient primary language is associated with differences in immediate breast reconstruction (IBR) after mastectomy., Patients and Methods: This retrospective observational study analyzed female patients undergoing mastectomy in the New Jersey State Inpatient Database (2009-2014). The primary outcome was the odds of IBR with a prespecified subanalysis of autologous tissue-based IBR. We used multivariable logistic regression and hierarchical generalized linear mixed models to control for patient characteristics and nesting within hospitals., Results: Of 13,846 discharges, 12,924 (93.3%) specified English as the patient's primary language, while 922 (6.7%) specified a language other than English. Among English-speaking patients, 6178 (47.8%) underwent IBR, including 2310 (17.9%) autologous reconstructions. Among patients with a primary language other than English, 339 (36.8%) underwent IBR, including 93 (10.1%) autologous reconstructions. Unadjusted results showed reduced odds of IBR overall [odds ratio (OR) 0.64, 95% CI 0.55-0.73], and autologous reconstruction specifically (OR 0.52, 95% CI 0.41-0.64) among patients with a primary language other than English. After adjustment for patient factors, this difference persisted among the autologous subgroup (OR 0.64, 95% CI 0.51-0.80) but not for IBR overall. A hierarchical model incorporating both patient characteristics and hospital-level effects continued to show a difference among the autologous subgroup (OR 0.75, 95% CI 0.58-0.97)., Conclusions: Primary language other than English was an independent risk factor for lower odds of autologous IBR after adjustments for patient and hospital effects. Focused efforts should be made to ensure that patients who speak a primary language other than English have access to high-quality shared decision-making for postmastectomy IBR., (© 2022. Society of Surgical Oncology.)

Introduction: Routine screening plays a critical role in the diagnosis of hepatocellular carcinoma (HCC), but not all patients undergo consistent surveillance. This study aims to evaluate surveillance patterns and their association with diagnosis stage and survival among Medicare patients at risk for HCC., Patients and Methods: Patients with HCC and guideline-based screening eligibility who underwent imaging with ultrasound or abdominal magnetic resonance imaging (MRI) in the 2 years prior to diagnosis were identified from SEER-Medicare (2008-2015). Three surveillance cohorts were created: diagnostic (imaging only within 3 months prior), intermittent (imaging only once within 2 years prior, excluding diagnostic), and routine (at least two imaging encounters within 2 years prior, excluding diagnostic). Multivariable logistic regression was used to predict early-stage diagnosis (stage I-II), and 5-year survival was evaluated using the accelerated failure time method with Weibull distribution., Results: Among 2261 eligible patients, 26.1% were classified as diagnostic, 15.8% as intermittent, and 58.1% as routine surveillance. The median age was 74 years (IQR 70-78 years). The majority of patients had a preexisting cirrhosis diagnosis (81.5%). Routine and intermittent, compared with diagnostic, surveillance were predictive of early-stage disease (routine: OR 2.05, 95% CI 1.64-2.56; intermittent: OR 1.43, 95% CI 1.07-1.90). Patients who underwent routine surveillance had significantly lower risk of mortality (HR 0.84, 95% CI 0.75-0.94) compared with the diagnostic group., Conclusions: A large proportion of screening-eligible patients do not undergo routine surveillance, which is associated with late-stage diagnosis and higher risk of mortality. These findings demonstrate the impact of timely and consistent healthcare access and can guide interventions for promoting surveillance among these patients., (© 2022. Society of Surgical Oncology.)

Background: Medicaid expansion has led to earlier stage diagnoses in several cancers but has not been studied in hepatocellular carcinoma (HCC), a disease with complex risk factors. We examined the effect of Medicaid expansion on the diagnosis of HCC and associations with county-level social vulnerability., Methods: Patients with HCC <65 years of age were identified from the SEER database (2010-2016). County-level social vulnerability factors were obtained from the CDC SVI and BRFSS. A Difference-in-Difference analysis evaluated change in early-stage diagnoses (stage I-II) between expansion and non-expansion states. A Difference-in-Difference-in-Difference analysis evaluated expansion impact among counties with higher proportions of social vulnerability., Results: Of 19,751 patients identified, 81.5% were in expansion states. Uninsured status decreased in expansion states (6.3%-2.4%, p < 0.0001) and remained unchanged in non-expansion states (12.7%-14.8%, p = 0.43). There was no significant difference in the incidence of early-stage diagnoses between expansion states and non-expansion states. Results were consistent when accounting for social vulnerability., Conclusion: Medicaid expansion was not associated with earlier stage diagnoses in patients with HCC, including those with higher social vulnerability. Unlike other cancers, expanded access did not translate into higher utilization of care in HCC, suggesting barriers on a multitude of levels., (Copyright © 2021. Published by Elsevier Ltd.)

Background: Current AJCC guidelines recommend evaluating ≥6 lymph nodes during gallbladder cancer resection but real world data suggest this is rarely achieved. We evaluated the extent of lymphadenectomy and survival among patients with gallbladder adenocarcinoma., Methods: Patients with resected pT1b-T3 gallbladder adenocarcinoma were identified from the NCDB (2004-2017). Propensity scores were created for the odds of sufficient lymphadenectomy (≥6 nodes), patients were matched 1:1 and survival was analyzed using the Kaplan-Meier method., Results: Overall, 4760 patients were identified: 16.7% underwent sufficient lymphadenectomy, which was predictive of nodal disease (OR 1.77, 95%CI 1.51-2.08) and demonstrated a survival benefit in N0 (median OS 140.8 versus 44.4 months; p < 0.0001) and N1-2 disease (median OS 27.7 versus 17.7 months; p < 0.0001) after matching., Conclusions: The majority of patients with gallbladder adenocarcinoma do not undergo the recommended nodal dissection, resulting in a survival disadvantage, likely due to understaging, decisions regarding adjuvant therapy and local tumor recurrence., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Patients undergoing pancreaticoduodenectomy (PD) at low volume PD hospitals with high volume for other complex operations have comparable outcomes to high volume PD centers. We evaluated the impact of upper gastrointestinal operations (UGI) hospital volume on the outcomes of elderly, high risk patients undergoing PD., Methods: Patients >65 years old who underwent PD for pancreatic adenocarcinoma were identified from SEER-Medicare (2008-2015). Four volume cohorts were created using PD tertiles and UGI median: low (1st tertile PD), mixed-low (2nd tertile PD, low UGI), mixed-high (2nd tertile PD, high UGI) and high (3rd tertile PD). Multivariable logistic and negative binomial regression assessed short-term complications., Results: In total, 2717 patients were identified with a median age of 74.5 years. Patients treated at low, mixed-low and mixed-high volume hospitals, versus high volume, had higher risk of short-term complications, including major complications (low: OR 1.441, 95%CI 1.165-1.783; mixed-low: OR 1.374, 95%CI 1.085-1.740; mixed-high: OR 1.418, 95%CI 1.098-1.832) and 90-day mortality (low: OR 2.16, 95%CI 1.454-3.209; mixed-low: OR 2.068, 95%CI 1.347-3.175; mixed-high: OR 1.96, 95%CI 1.245-3.086)., Conclusion: Patients with pancreatic adenocarcinoma who are older and more medically complex benefit from undergoing surgery at high volume PD centers, independent of the operative experience of that center., (Copyright © 2021 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Postoperative urinary tract infections (UTIs) are associated with increased lengths of stay, inpatient costs, and mortality. Review of institutional data from the American College of Surgeons (ACS) NSQIP revealed opportunities to improve practices with respect to urinary catheter (Foley) insertion, catheter care, adherence to diagnosis and prevention protocols, and ACS NSQIP reporting., Study Design: A multidisciplinary quality improvement team convened and implemented interventions based on a literature review and analysis of institutional drivers of postoperative UTI. The team educated the ACS NSQIP surgical clinical reviewers and clinical teams about UTI diagnostic criteria and prevention, trained staff in proper catheterization technique, and provided performance feedback. The team also developed kits with supplies and instructions for patients who were discharged home with catheters, along with an instructional video. The investigators evaluated project effectiveness by comparing pre- and postintervention process measures and rates of postoperative UTI., Results: After interventions, compliance rates improved for hand hygiene (62% to 83%, p = 0.04), precleansing of the periurethral area (66% to 97%, p = 0.001), and catheter positioning (41% to 93%, p < 0.001), and the composite performance (10% to 73%, p < 0.001). Surgery residents' scores on a UTI knowledge assessment improved from 71% to 81% (p = 0.005). The majority of residents and staff strongly agreed that the training sessions would change their practice (57% and 69%, respectively). The unadjusted rate of postoperative UTIs at our institution decreased from 1.55% to 0.69% (p = 0.016), corresponding to an improvement in the ACS NSQIP odds ratio from 1.51 to 0.86., Conclusions: A series of interventions, including provider training, patient education, and audits of practice with performance feedback, are associated with improvements in both practice and the incidence of postoperative UTI., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Centralization for complex cancer surgery may not always be feasible owing to socioeconomic disparities, geographic constraints, or patient preference. The present study investigates how the combined volume of complex cancer operations impacts postoperative outcomes at hospitals that are low-volume for a specific high-risk cancer operation., Study Design: Patients who underwent pneumonectomy, esophagectomy, gastrectomy, hepatectomy, pancreatectomy, or proctectomy were identified from the National Cancer Database (2004-2017). For every operation, 3 separate cohorts were created: low-volume hospitals (LVH) for both the individual cancer operation and the total number of those complex operations, mixed-volume hospital (MVH) with low volume for the individual cancer operation but high volume for total number of complex operations, and high-volume hospitals (HVH) for each specific operation., Results: LVH was significantly (all p ≤ 0.01) predictive for 30-day mortality compared with HVH across all operations: pneumonectomy (9.5% vs 7.9%), esophagectomy (5.6% vs 3.2%), gastrectomy (6.8% vs 3.6%), hepatectomy (5.9% vs 3.2%), pancreatectomy (4.7% vs 2.3%), and proctectomy (2.4% vs 1.3%). Patients who underwent surgery at MVH and HVH demonstrated similar 30-day mortality: esophagectomy (3.2 vs 3.2%; p = 0.993), gastrectomy (3.2% vs 3.6%; p = 0.637), hepatectomy (3.8% vs 3.2%; p = 0.233), pancreatectomy (2.8% vs 2.3%; p = 0.293), and proctectomy (1.2% vs 1.3%; p = 0.843). Patients who underwent pneumonectomy at MVH demonstrated lower 30-day mortality compared with HVH (5.4% vs 7.9%; p = 0.045)., Conclusion: Patients who underwent complex operations at MVH had similar postoperative outcomes to those at HVH. MVH provide a model for the centralization of complex cancer surgery for patients who do not receive their care at HVH., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: The volume-outcome relationship has been well-established for pancreaticoduodenectomy (PD). It remains unclear if this is primarily driven by hospital volume or individual surgeon experience., Objective: This study aimed to determine the relationship of hospital and surgeon volume on short-term outcomes of patients with pancreatic adenocarcinoma undergoing PD., Methods: Patients >65 years of age who underwent PD for pancreatic adenocarcinoma were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2008-2015). Analyses were stratified by hospital volume and then surgeon volume, creating four volume cohorts: low-low (low hospital, low surgeon), low-high (low hospital, high surgeon), high-low (high hospital, low surgeon), high-high (high hospital, high surgeon). Propensity scores were created for the odds of undergoing surgery with high-volume surgeons. Following matching, multivariable analysis was used to assess the impact of surgeon volume on outcomes within each hospital volume cohort., Results: In total, 2450 patients were identified: 54.3% were treated at high-volume hospitals (27.0% low-volume surgeons, 73.0% high-volume surgeons) and 45.7% were treated at low-volume hospitals (76.9% low-volume surgeons, 23.1% high-volume surgeons). On matched multivariable analysis, there were no significant differences in the risk of major complications, 90-day mortality, and 30-day readmission based on surgeon volume within the low and high hospital volume cohorts., Conclusion: Compared with surgeon volume, hospital volume is a more significant factor in predicting short-term outcomes after PD. This suggests that a focus on resources and care pathways, in combination with volume metrics, is more likely to achieve high-quality care for patients undergoing PD across all hospitals., (© 2021. Society of Surgical Oncology.)

Background: The "I COUGH" protocol is associated with improved postoperative pulmonary outcomes, and ambulation is an essential component. I COUGH is an acronym for Incentive spirometry, Coughing, Oral care, Understanding (patient and staff education), Getting-out-of-bed, and Head-of-bed elevation. This trial sought to enhance one component, specifically ambulation after operations., Methods: Randomized trial of inpatients in a safety-net, academic medical center. The intervention group received standard I COUGH education along with text message reminders to ambulate postoperatively, whereas the control group received standard education alone. Postoperative walking frequency was compared to each participant's ambulation on the day prior to enrollment., Results: The intervention group had an average improvement of 1.8 ± 1.8 walks per day per patient, while the average change for the control group was 0.2 ± 1.0 walks per day per patient. This represents a 9-fold increase in ambulation for the intervention group (p = 0.03)., Conclusions: Implementation of text message reminders increased ambulation and improved adherence to the I COUGH protocol following operations. This system should be further investigated as an adjunct to postoperative care., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Incidental adrenal masses (IAMs) are common. Primary care providers (PCPs) are frequently responsible for incidentaloma evaluations. We evaluated whether PCPs view this paradigm effective, barriers faced, and strategies to optimize care delivery., Methods: This is a sequential explanatory study, comprised of surveys followed by focus groups of PCPs. Because lung nodules are another type of common incidental finding, we compared PCP views on management of lung nodules to their views on IAMs., Results: For IAMs, 22.3% of PCPs "always refer" to specialists, but for lung nodules this was 11.5% (p = 0.026). For lung nodules, the most significant barrier was insufficient time/support to longitudinally follow results (69%), but for IAMs it was uncertainty about which tests to order (68%). Fear of litigation was equal (lung = 22.5%, IAMs = 21.3%). Consistent themes regarding the "ideal" system included specific recommendations in radiology reports; automation of orders for follow-up tests; longitudinal tracking tools; streamlined consultations; and decision guides embedded within the electronic health record., Conclusions: Respondents are more comfortable with lung nodules than IAMs. Management of "incidentalomas" is within their scope of practice, but the current system can be optimized., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The Caprini risk assessment model is a well-validated tool that identifies patients who would benefit from extended venous thromboembolism (VTE) prophylaxis beyond hospital discharge. VTE, particularly portal mesenteric vein thrombosis (PMVT), is a potentially devastating complication of laparoscopic sleeve gastrectomy (LSG); therefore, we sought to examine whether the model can be safely applied to LSG patients. We hypothesized that its use can minimize the incidence of postoperative VTE, including PMVT, without increasing the likelihood of bleeding complications., Materials and Methods: We conducted a retrospective chart review of those patients who underwent LSG at our institution from 2010 and 2018, at which time the Caprini risk assessment model was already our institutional standard. We determined the patients' Caprini scores at the time of discharge and whether patients at high risk of VTE were discharged from hospital on extended courses of VTE prophylaxis. We also recorded if bleeding complications or VTE events occurred in the first 180 days after LSG., Results: Six hundred thirty-eight patients underwent LSG, including 521 (81.7%) women, with an average preoperative body mass index (BMI) of 44.4 kg/m 2 (SD 6.8). One hundred fifty-eight (24.8%) patients had Caprini scores that warranted extended courses of VTE prophylaxis beyond hospital discharge. Three patients (0.47%) developed a postoperative VTE, but no patient developed PMVT. No bleeding complications were observed among patients who received extended VTE prophylaxis., Conclusion: The Caprini risk assessment model can effectively identify patients after LSG who might benefit from extended courses of VTE prophylaxis. Extended VTE prophylaxis does not seem to confer increased bleeding risk in this patient population., (© 2021. The Society for Surgery of the Alimentary Tract.)

Objective: Incidental adrenal masses (IAMs) are detected in approximately 1%-2% of abdominal computed tomography (CT) scans. Recent estimates suggest that more than 70-million relevant CT scans are performed annually in the United States; thus, IAMs represent a significant clinical entity. Most clinical guidelines recommend an initial follow-up evaluation that includes imaging and biochemical testing after index IAM detection., Methods: Systematic review of literature in the PubMed, EMBASE and Web of Science databases to determine whether guidelines regarding IAM evaluation are followed and to identify effective management strategies. Our initial search was in January 2018 and updated in November, 2019., Results: 31 studies met inclusion criteria. In most institutions, only a minority of patients with IAMs undergo initial follow-up imaging (median 34%, IQR 20%-50%) or biochemical testing (median 18%, IQR 15%-28%). 2 interventions shown to improve IAM evaluation are IAM-specific recommendations in radiology reports and dedicated multi-disciplinary teams. Interventions focused solely on alerting the ordering clinician or primary care provider to the presence of an IAM have not demonstrated effectiveness. Patients who are referred to an endocrinologist are more likely to have a complete IAM evaluation, but few are referred., Discussion: Most patients with an IAM do not have an initial evaluation. The radiology report has been identified as a key component in determining whether IAMs are evaluated appropriately. Care teams dedicated to management of incidental radiographic findings also improve IAM follow-up. Although the evidence base is sparse, these interventions may be a starting point for further inquiry into optimizing care in this common clinical scenario., Competing Interests: Conflict of Interest The authors declare that there are no conflicts of interest., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Choledochal cysts (CC) are often diagnosed during the first few decades of life, when, due to the risk of malignancy, resection is advised. With an increasing number of patients undergoing abdominal imaging, many older patients have recently been radiographically diagnosed with biliary duct enlargement that meets the criteria of choledochal cysts. The management in these patients is less well defined, but resection is often recommended as it is for younger patients. We sought to better understand the significance of these biliary duct anomalies in adults., Methods: We retrospectively reviewed all patients 18 years and older at our institution, who were given a radiographic diagnosis of choledochal cyst during the interval 2006-2019. Demographics, comorbidities, complications, readmissions, and follow-up imaging were evaluated., Results: We identified 22 patients, of whom 40.9% (n = 9) underwent an operation. The remainder was observed. Median duct size was 15 mm (range 2-25 mm). There were no significant differences in demographics between the two cohorts. Of those who underwent resection, none had evidence of high-grade dysplasia or invasive carcinoma upon final pathology. However, 33.3% (n = 3) had subsequent readmissions for complications, including post-operative nausea and vomiting, cholangitis, and anastomotic stenoses that required stenting. In the observation group, there was no obvious growth of the cysts or development of worrisome features to suggest malignant degeneration (median follow-up = 68 months)., Conclusion: A radiographic diagnosis of choledochal cyst in older adults is likely a different entity than those diagnosed in childhood. Close surveillance of these biliary duct anomalies in older adults may be a better option than resection and reconstruction with the associated risks of long-term morbidity., (© 2021. The Society for Surgery of the Alimentary Tract.)

Objectives: To prospectively characterise: (1) postoperative opioid analgesic prescribing practices; (2) experience of patients undergoing elective ambulatory surgeries and (3) impact of patient risk for medication misuse on postoperative pain management., Design: Longitudinal survey of patients 7 days before and 7-14 days after surgery., Setting: Academic urban safety-net hospital., Participants: 181 participants recruited, 18 surgeons, follow-up data from 149 participants (82% retention); 54% women; mean age: 49 years., Interventions: None., Primary and Secondary Outcome Measures: Total morphine equivalent dose (MED) prescribed and consumed, percentage of unused opioids., Results: Surgeons postoperatively prescribed a mean of 242 total MED per patient, equivalent to 32 oxycodone (5 mg) pills. Participants used a mean of 116 MEDs (48%), equivalent to 18 oxycodone (5 mg) pills (~145 mg of oxycodone remaining per patient). A 10-year increase in patient age was associated with 12 (95% CI (-2.05 to -0.35)) total MED fewer prescribed opioids. Each one-point increase in the preoperative Graded Chronic Pain Scale was associated with an 18 (6.84 to 29.60) total MED increase in opioid consumption, and 5% (-0.09% to -0.005%) fewer unused opioids. Prior opioid prescription was associated with a 55 (5.38 to -104.82) total MED increase in opioid consumption, and 19% (-0.35% to -0.02%) fewer unused opioids. High-risk drug use was associated with 9% (-0.19% to 0.002%) fewer unused opioids. Pain severity in previous 3 months, high-risk alcohol, use and prior opioid prescription were not associated with postoperative prescribing practices., Conclusions: Participants with a preoperative history of chronic pain, prior opioid prescription, and high-risk drug use were more likely to consume higher amounts of opioid medications postoperatively. Additionally, surgeons did not incorporate key patient-level factors (eg, substance use, preoperative pain) into opioid prescribing practices. Opportunities to improve postoperative opioid prescribing include system changes among surgical specialties, and patient education and monitoring., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Clinical staging guides decisions about optimal treatment sequence in patients with gastric cancer, although the preoperative accuracy is not strongly established. This study investigates concordance of clinical and pathologic stage as well as its impact on the survival of patients with gastric adenocarcinoma., Methods: Patients with clinical stage T2-4, N0, M0 gastric adenocarcinoma who underwent surgery without neoadjuvant therapy were identified from the National Cancer Database (2010-2015). The primary outcome was up-staging, defined as cT < pT, pN1-3, and/or pM1 (AJCC 7 th edition). Multivariable logistic regression analysis was performed to predict up-staging. Survival analysis was performed using the Kaplan-Meier method., Results: In total, 2254 patients were identified. cTNM staging was discordant with pTNM staging in 65.6% of cases, with 50.4% up-staged and 15.2% down-staged. On multivariable logistic regression, younger age (OR 0.991, 95% CI 0.984-0.999, p=0.0188), male sex (versus female; OR 1.392, 95% CI 1.158-1.673, p=0.0004), poor or undifferentiated tumor grade (versus well differentiated or moderately differentiated; OR 2.399, 95% CI 1.987-2.896; p<0.0001), positive margin status (versus negative; OR 4.575, 95% CI 3.360-6.230; p<0.0001), and days from diagnosis to surgery (15-32 days versus ≤ 14 days; OR 1.411, 95% CI 1.098-1.814, p=0.0072) were predictive of up-staging. Patients who were up-staged had a decreased survival compared to patients who were accurately staged (median survival 27.9 months versus 67.6 months; log-rank p<0.0001)., Conclusion: This study found a substantial discordance between clinical and pathologic staging of resectable locally advanced gastric adenocarcinoma. These data support that patients may have more advanced disease at presentation than reflected in clinical staging and may benefit from improved diagnostic modalities and neoadjuvant chemotherapy.

Background: The relationship between hospital volume and surgical outcomes is well-established; however, considerable socioeconomic and geographic barriers to high-volume care persist. This study assesses how the overall volume of hepatopancreaticobiliary (HPB) cancer operations impacts outcomes of liver resections (LRs)., Study Design: The National Cancer Database (2004-2014) was queried for patients who underwent LR for hepatocellular carcinoma. Hospital volume was determined separately for all HPB operations and LRs. Centers were dichotomized as low and high volume based on the median number of operations. The following study cohorts were created: low-volume hospitals (LVHs) for both LRs and HPB operations, mixed-volume hospitals (MVHs) with low-volume LRs but high-volume HPB operations, and high-volume LR hospitals (HVHs) for both LRs and HPB operations., Results: Of 7,265 patients identified, 37.5%, 8.8%, and 53.7% were treated at LVHs, MVHs, and HVHs, respectively. On multivariable analysis, patients treated at LVHs had higher 30-day mortality compared with patients treated at HVHs (odds ratio 1.736; p < 0.001). However, patients treated at MVHs experienced 30-day mortality comparable with patients treated at HVHs (odds ratio 0.789; p = 0.318). Similar results were found for positive margin status, prolonged hospital stay, and overall survival., Conclusions: LR outcomes at low-volume LR centers that have substantial experience with HPB cancer operations are similar to those at high-volume LR centers. Our results demonstrate that the volume to outcomes curve for HPB operations should be assessed more holistically and that patients can safely undergo liver operations at low-volume LR centers if HPB volume criteria are met., (Copyright © 2021 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: A subset of encapsulated/circumscribed follicular variant of papillary thyroid carcinoma (FVPTC) was reclassified as noninvasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) in 2016 to reduce overtreatment of a low-risk tumor. Study objectives were to describe the epidemiology and long-term outcomes of NIFTP in a high-volume, urban, tertiary referral center. Methods: Among patients enrolled in the Boston Medical Center (BMC) Thyroid Cancer Registry, 110 cases of FVPTC underwent index thyroid surgery at BMC between 2000 and 2016. Historically, BMC pathologists assess all malignant nodules using sections ≤0.3 cm with evaluation of the entire nodule and capsule. After review of pathology reports to identify potential NIFTPs, slides were rereviewed using criteria established by the NIFTP Working Group in 2016 and 2018. We evaluated interobserver reliability using Cohen's Kappa coefficient. Results: Among 110 FVPTCs, 15 (13%) met NIFTP criteria; 11 women and 4 men, age range 31-64 (mean 47.5) years. Mean tumor diameter was 1.7 cm (compared with 2.2 cm for FVPTC). Among NIFTP cases, there were no lymph node metastases, distant metastases, or tumor recurrences. All NIFTP cases were American Thyroid Association (ATA) low risk compared with only 68% of FVPTC ( p  = 0.011). Among FVPTCs, 14% had positive lymph nodes at index operation. Four patients (4%) had distant metastases. Mean follow-up time was 46 and 69 months for FVPTC and NIFTP, respectively. Among FVPTCs with an excellent response to therapy (2015 ATA guidelines), there were no recurrences. Just over half ( n  = 8) of patients with NIFTP received postoperative radioactive iodine (RAI) therapy. Concordance between pathologists was high for ruling out NIFTP (75%), but only 36% for ruling in NIFTP. Overall, for NIFTP designation, Cohen's Kappa was 0.39, which is considered fair. Conclusions: Although this is a relatively small cohort, all NIFTP specimens underwent updated pathology review consistent with current guidelines; mean follow-up was nearly 6 years. NIFTP represents a small fraction of the total papillary neoplasia diagnosed at this tertiary referral center (2.3%). None of the NIFTP cohort experienced an adverse oncologic event, and there were no regional or distant metastases. Over 50% of patients with NIFTP received RAI. Thus, the NIFTP reclassification may substantially reduce the number of patients who require adjuvant therapies, such as completion surgery or RAI.

Background: The purpose of this study was to determine whether racial or other demographic characteristics were associated with declining surgery for early stage gastric cancer., Methods: Patients with clinical stage I-II gastric adenocarcinoma were identified from the NCDB. Multivariable logistic models identified predictors for declining resection. Patients were stratified based on propensity scores, which were modeled on the probability of declining. Overall survival was evaluated using the Kaplan-Meier method., Results: Of 11,326 patients, 3.68% (n = 417) declined resection. Patients were more likely to refuse if they were black (p < 0.001), had Medicaid or no insurance (p < 0.001), had shorter travel distance to the hospital (p < 0.001) or were treated at a non-academic center (p = 0.001). After stratification, patients who declined surgery had worse overall survival (all strata, p < 0.001)., Conclusions: Racial and sociodemographic disparities exist in the treatment of potentially curable gastric cancer, with patients who decline recommended surgery suffering worse overall survival., Competing Interests: Declaration of competing interest The authors have no related conflicts of interest or financial support to declare. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Fine-needle biopsy (FNB) predicts benign or malignant thyroid nodules. For indeterminate (ITN) FNBs, commercial molecular tests may improve the diagnostic accuracy and reduce the number of operations. These tests have had limited independent implementation studies in routine clinical practice. This is a prospective observational study. At Boston Medical Center, the 1,316 consecutive FNBs were classified to one of the six categories in the Bethesda classification system. Those ITN samples were submitted for ThyroSeqV.2 next generation sequencing panel analysis. The performance of ThyroSeqV.2 to predict "neoplasm requiring surgery" (NRS) was evaluated. ThyroSeqV.2 assay was performed in 398 FNBs on 384 cytologically ITN nodules (308 Bethesda III, 47 Bethesda IV and 29 Bethesda V). The first evaluable ThyroSeq result for each nodule was used for final analysis. Seventy-seven (72.0%) of 107 patients with a high risk molecular test underwent thyroid surgery resulting in 41 NRS (53.2%) and 36 benign nodules (46.8%). Of the 249 patients with a low risk or negative molecular analysis, 51 (20.5%) had surgery revealing 47 benign nodules (92.2%) and 4 NRS (7.8%). Based on surgical outcome of 128 ITN with evaluable ThyroSeq results, this molecular test had a sensitivity of 91% (95% CI: 79%-98%), specificity of 56% (45%-67%), positive predictive value (PPV) of 53% (42%-65%), negative predictive value (NPV) of 92% (81%-98%), and an overall accuracy of 69% (55%-85%) with a prevalence of NRS of 35% (27%-44%). ThyroSeqV.2 in this clinical use study in ITN nodules provided a similar NPV but a lower PPV than expected compared to published studies due to the detection of an array of mutations in benign nodules. The NPV of 92.0% for ITN cytology confirmed its utility as a "rule-out" test to exclude NRS., Competing Interests: None., (AJCR Copyright © 2020.)

Background: Postoperative venous thromboembolism (VTE) is usually preventable with adequate prophylaxis. In an institutional study, patients with emergency operations (EO), multiple operations (MO), and perioperative sepsis (PS) were more likely to develop VTE despite standard prophylaxis., Methods: General surgery patients in the NSQIP database from 2011 to 2014 were stratified into VTE and non-VTE groups, and statistical analyses were performed., Results: Among 1,610,086 patients, 13,673 (0.8%) were diagnosed with VTE. The VTE odds ratios for patients with EO, MO and PS were 1.4 (95%CI:1.3-1.5), 1.9 (95%CI:1.7-2.0), and 2.4 (95%CI:2.2-2.5), respectively. VTE odds ratios increased with concurrence of two factors (EO+PS: 2.0 (95%CI:1.9-2.2)) (EO+MO: 2.3 (95%CI:1.9-2.7)) (MO+PS: 2.5 (95%CI:2.2-2.7)) and further still for patients with all three factors (2.7, 95%CI:2.4-3.0)., Conclusion: General surgery patients with EO, MO, or PS have a greater likelihood of developing postoperative VTE. These factors are not necessarily captured in contemporary risk assessment models that guide chemoprophylaxis, and so these high-risk patients may receive insufficient prophylaxis., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: This study analyzed independent factors associated with post-thyroidectomy Emergency Room (ER) visits and Hospital Readmissions (HR)., Methods: This is a retrospective review from the CESQIP registry of 8381 thyroidectomy patients by 173 surgeons at 46 institutions. A total of 7142 ER visits and 7265 HR were analyzed. Multivariable logistic regression analysis was performed to determine the risk factors for an ER visit or HR., Results: Within 30-days of surgery, rates of all ER visits were 3.4% (n = 250) and all HR were 2.3% (n = 170). Hypocalcemia was the reason for 21.9% of ER encounters and 36.4% of HR. BMI >40 kg/m 2 was a risk factor for both ER visit (OR1.86) and HR (OR1.94). Surgical duration >3 h (OR2.63), and transection of recurrent laryngeal nerve (OR4.58) were risk factors for HR., Conclusions: Strategies to decrease hypocalcemia and improve perioperative care of patients with BMI >40 kg/m 2 may improve post-thyroidectomy outcome., Competing Interests: Declaration of competing interest Julie Ann Sosa is a member of the Data Monitoring Committee of the Medullary Thyroid Cancer Consortium Registry supported by GlaxoSmithKline, Novo Nordisk, Astra Zeneca and Eli Lilly., (Copyright © 2020 Elsevier Inc. All rights reserved.)