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Background: Survival outcomes of never smokers with non-small cell lung cancer (NSCLC) who undergo surgery are poorly characterized. This investigation compared surgical outcomes of never and current smokers with NSCLC.Methods: This investigation was a single-institution retrospective study of never and current smokers with NSCLC from 1975 to 2004. From an analytic cohort of 4,546 patients with NSCLC, we identified 724 never smokers and 3,822 current smokers. Overall, 1,142 patients underwent surgery with curative intent. For survival analysis by smoking status, hazard ratios (HRs) were estimated using Cox proportional hazard modeling and then further adjusted by other covariates.Results: Never smokers were significantly more likely than current smokers to be women (P < .01), older (P < .01), and to have adenocarcinoma (P < .01) and bronchioloalveolar carcinoma (P < .01). No statistically significant differences existed in stage distribution at presentation for the analytic cohort (P = .35) or for the subgroup undergoing surgery (P = .24). The strongest risk factors of mortality among patients with NSCLC who underwent surgery were advanced stage (adjusted hazard ratio, 3.43; 95% CI, 2.32-5.07; P < .01) and elevated American Society of Anesthesiologists classification (adjusted hazard ratio, 2.18; 95% CI, 1.40-3.40; P < .01). The minor trend toward an elevated risk of death on univariate analysis for current vs never smokers in the surgically treated group (hazard ratio, 1.20; 95% CI, 0.98-1.46; P = .07) was completely eliminated when the model was adjusted for covariates (P = .97).Conclusions: Our findings suggest that smoking status at time of lung cancer diagnosis has little impact on the long-term survival of patients with NSCLC, especially after curative surgery. Despite different etiologies between lung cancer in never and current smokers the prognosis is equally dismal. [ABSTRACT FROM AUTHOR]

Objective: Delays to definitive surgery in esophageal cancer may be associated with disease progression and worsened survival. The objective of this study was to perform a national assessment for predictors of delay to esophagectomy and to assess for their impact on oncologic and survival outcomes., Methods: The National Cancer Database, 2010-2020, was queried for patients with locally advanced esophageal adenocarcinoma (Stage I-III). Patients were divided into upfront and post-neoadjuvant chemoradiation (nCRT) cohorts. The primary outcome was time-to-surgery. Time-to-surgery was examined as a continuous and categorical variable, where patients were divided into timely and delayed cohorts (96 days for upfront cohort; 56 days for post-nCRT cohort)., Results: Of 16,486 patients, 4,066 (24.7%) underwent upfront surgery and 12,420 (75.3%) post-nCRT surgery. In the upfront surgery group, median [interquartile range] time-to-surgery was 61 [40-96] days. Risk-adjusted predictors of delay included lack of insurance, lowest quartile of education, biopsy-based staging or surgical staging and robotic-assisted approach. In the post-nCRT cohort time-to-surgery was 55 [44-70] days. Risk-adjusted predictors of delay included Hispanic ethnicity, Medicaid or other government-based insurance, lowest quartile of educational status, and robotic approach. In the upfront surgery group, patients who had delayed surgery had increased odds of pathologic upstaging (1.31, 95% confidence interval 1.06-1.61). In the post-nCRT group, patients with surgical delay had increased odds of 90-day mortality (1.27, 95% confidence interval 1.06-1.51)., Conclusions: Following risk-adjustment for patient, oncologic, facility and surgical characteristics, there were several predictors of increased time to esophagectomy associated with consequences of upstaging and survival., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: The oncologic benefit of induction chemotherapy (IC) before chemoradiation (CRT) compared to CRT alone for locally advanced esophageal and gastroesophageal junction (GEJ) adenocarcinoma is not well defined. We hypothesized that IC with CRT would improve survival and pathologic complete response rate compared to CRT alone., Methods: A retrospective review of patients with biopsy proven esophageal or GEJ adenocarcinoma treated with preoperative CRT and IC + CRT and surgical resection from 2007 to 2023 at a single institution was performed. First order outcomes were overall survival and pathologic complete response rate; secondary outcomes included disease-free survival and distant metastasis failure. Subgroup analyses were conducted based on baseline characteristics and tumor-specific features. Survival analysis was performed with Kaplan-Meier curves with log-rank tests and Cox regression analysis., Results: Of 205 patients that met inclusion criteria, 76 (38%) patients underwent IC + CRT. There were no significant differences in demographic or tumor-specific characteristics between the two cohorts. There were no differences in the median overall survival between CRT and IC + CRT groups (47 months vs. not reached, p = 0.194). The rate of pathologic complete response in the overall cohort was 22%; IC + CRT was not associated with higher complete tumor response than CRT alone (20% vs. 23%, p = 0.557). There were no significant differences in any of the secondary outcomes between the two treatment paradigms., Conclusions: We could not detect added oncologic benefit in survival or pathologic complete response with IC over CRT alone for resectable esophageal and GEJ cancer. Biomarker driven prospective studies exploring the optimal perioperative treatment regimens are warranted., (© 2024 Wiley Periodicals LLC.)

Background: Precise estimates of risk-adjusted increases in postoperative length of stay (LOS) associated with postoperative complications across a range of complications and operations are not available in the existing literature., Methods: Associations between preoperative characteristics, postoperative complications and postoperative LOS were tested using medians, interquartile ranges, and nonparametric rank sum tests in a retrospective cohort study using the 2005-2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) dataset. A negative binomial model was used with postoperative LOS as the dependent variable and preoperative characteristics and postoperative complications as independent variables. The model was applied to estimate each patient's postoperative LOS with and without each postoperative complication to measure the association between each complication and risk-adjusted change in postoperative LOS., Results: A total of 4,495,582 patients were included. After risk-adjustment, occurrence of each postoperative complication was associated with significantly increased postoperative LOS (between + 3.9 and + 20.1 days, p < 0.0001). The longest risk-adjusted postoperative LOS increases were associated with prolonged ventilator use (+ 20.1 days), wound disruption (+ 19.4 days), and acute renal failure (+ 17.1 days)., Conclusion: Occurrence of any postoperative complication was associated with increased risk-adjusted postoperative LOS. Degree of increase varied by complication. These data could be useful for patient counseling, allocation of resources, discharge planning, and quality improvement efforts., (© 2024. The Author(s).)

Objective: Improvement of surgical care is dependent upon evidence-based practices (EBPs), policies, procedures, and innovations. The objective of this study was to understand and synthesize the use of implementation science (IS) in surgical care., Summary Background Data: This article summarizes the existing literature to identify the frequency and types of EBPs selected for surgical care, IS frameworks that guided the published research, and prominent facilitators and barriers., Methods: A modified version of the Arksey and O'Malley framework and the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews Checklist were used to provide the guidance and standards to conduct this scoping review. We queried: Ovid MEDLINE; American Psychological Association PsycINFO; Embase; Cumulated Index to Nursing and Allied Health Literature; Web of Science; and Google Scholar for manuscripts published January 2001 - June 2023., Results: The initial search found 3,674 citations of which 129 met inclusion criteria. The heterogeneity and volume of innovations within the surgical IS field were vast. The most frequent innovations were in peri-operative care, safety in surgery, and Enhanced Recovery After Surgery. Six constructs were identified as both major facilitators and barriers: support from leadership; surgeon and staff knowledge regarding EBPs; relationship/team building; environmental context; data; and resources., Conclusion: Identifying these implementation factors used in the surgical field enables us to determine variables that support and inhibit the adoption and implementation of new practices, support practice change, enhance quality and equity of surgical care, and identify research gaps for future IS in surgical care., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Prior publications about the association between participation in the American College of Surgeons National Surgical Quality Improvement Program and improved postoperative outcomes have reported mixed results. We aimed to perform a comprehensive analysis of preoperative characteristics and unadjusted and risk-adjusted postoperative complication rates over time in the American College of Surgeons National Surgical Quality Improvement Program dataset., Methods: We used the American College of Surgeons National Surgical Quality Improvement Program database, 2005 to 2018, to analyze preoperative patient characteristics and unadjusted and risk-adjusted rates of adverse postoperative outcomes by year. Expected events were calculated using multiple logistic regression, with each complication as the dependent variable and the 28 non-laboratory preoperative American College of Surgeons National Surgical Quality Improvement Program variables as the independent variables. Annual observed-to-expected ratios for each outcome were used to risk-adjust outcomes over time., Results: The analytic cohort included 7,474,298 operations across 9 surgical specialties. Both the preoperative patient risk and the unadjusted rate of postoperative complications decreased over time. While the observed-to-expected ratio for mortality remained around 1, the observed-to-expected ratios for the other outcomes decreased over time from 2005 to 2018, except for the following cardiac complications: overall morbidity 1.11 (95% confidence interval: 1.10-1.13) to 0.97 (0.96-0.98); pulmonary 1.18 (1.15-1.21) to 0.91 (0.89-0.92); infection 1.19 (1.16-1.21) to 1.01 (1.00-1.01); urinary tract infection 1.29 (1.23-1.34) to 0.87 (0.86-0.89); venous thromboembolism 1.10 (1.03-1.16) to 0.92 (0.90-0.94) ; cardiac 0.76 (0.70-0.81) to 1.04 (1.01-1.07); renal 1.14 (1.08-1.21) to 0.96 (0.93-0.99); stroke 1.12 (1.00-1.25) to 0.98 (0.94-1.03); and bleeding 1.35 (1.33-1.36) to 0.80 (0.79-0.81)., Conclusion: Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program have experienced a decrease in risk-adjusted postoperative surgical complications over time in all areas except for mortality and cardiac complications., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: Prior studies have associated morbidity following anatomic lung resection with prolonged postoperative length of stay; however, each complication's individual impact on length of stay as a continuous variable has not been studied. The purpose of this study was to determine the risk-adjusted increase in length of stay associated with each individual postoperative complications following anatomic lung resection., Methods: Patients who underwent anatomic lung resection cataloged in the prospectively collected American College of Surgeons National Surgical Quality Improvement Program participant use file, 2005-2018, were targeted. The association between preoperative characteristics, postoperative complications and length of stay in days was tested. A negative binomial model adjusting for the effect of preoperative characteristics and 18 concurrent postoperative complications was used to generate incidence rate ratios. This model was fit to generate risk-adjusted increases in length of stay by complication., Results: Of 32 133 patients, 5065 patients (15.8%) experienced at least one post-operative complication. The most frequent complications were pneumonia (n = 1829, 5.7%), the need for transfusion (n = 1794, 5.6%) and unplanned reintubation (n = 1064, 3.3%). The occurrence of each of the 18 individual complications was associated with significantly increased length of stay. This finding persisted after risk-adjustment, with the greatest risk-adjusted increases being associated with prolonged ventilation (+17.4 days), followed by septic shock (+17.2 days), acute renal failure (+16.5 days) and deep surgical site infection (+13.2 days)., Conclusions: All 18 postoperative complications studied following anatomic lung resection were associated with significant risk-adjusted increases in length of stay, ranging from an increase of 17.4 days with prolonged ventilation to 2.6 days following the need for transfusion., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: A significantly lower rate of non-small cell lung cancer (NSCLC) screening, greater health care avoidance, and changes to oncologic recommendations were some consequences of the Coronavirus disease 2019 (COVID-19) pandemic affecting the medical environment. We sought to determine how the health care environment during the COVID-19 pandemic affected the oncologic treatment of patients diagnosed with non-small cell lung cancer (NSCLC)., Methods: This was a retrospective cohort study evaluating patients with NSCLC in the National Cancer Database (2019-2020). Patients were divided into prepandemic (2019) and pandemic (2020) cohorts, and patient, oncologic, and treatment variables were compared. Multivariable logistic regression was performed to control for the impact of demographic characteristics on oncologic variables and the impact of oncologic variables on treatment variables., Results: The study population comprised 250,791 patients, including 114,533 patients (45.7%) in the pandemic cohort. There were 15% fewer new NSCLC diagnoses during the pandemic compared with prepandemic. Patients diagnosed during the pandemic had more advanced clinical TNM stage on presentation (P < .0001) and were more likely to have tumors in overlapping lobes or in a main bronchus (P = .0002). They were less likely to receive cancer treatment (P < .0001) and to undergo primary resection (P < .0001) and more likely to receive adjuvant systemic therapy (P = .004) and a combination of palliative treatment regimens (P < .0001). After risk adjustment, all these differences remained statistically significant (P < .05)., Conclusions: The COVID-19 pandemic was associated with increased clinical stage at presentation for patients with NSCLC, which impacted subsequent treatment strategies. However, treatment differed minimally when controlling for cancer stage. Future studies will examine the impact of these differences on overall survival and cancer-free survival., Competing Interests: Conflict of Interest Statement E.A.D. reports honoraria from Astra Zeneca. R.A.M. reports consulting fees from Medtronic (payments made to institution). The other authors have no conflicts of interest to report. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Benefits of thoracic enhanced recovery after surgery programs have been described. However, there is ongoing discussion on the importance of full protocol compliance. The objective of this study was to determine whether strict adherence to an enhanced recovery after surgery protocol leads to further improvement in outcomes compared with less strict compliance., Methods: This was a multihospital prospective cohort study of all consecutive anatomic lung resection patients on the thoracic enhanced recovery after surgery pathway from May 2021 to March 2023, with comparison with a historical control from January 2019 to April 2021. Compliance to 5 key protocol elements was tracked. Patients were grouped into high- and low-compliance cohorts, defined as adherence to 4-5/5 or 0-3/5 elements, respectively. The primary outcome was overall morbidity; secondary outcomes included cardiac, respiratory, and infectious morbidity and length of stay., Results: Of the 960 patients, 429 (44.7%) were enhanced recovery after surgery patients and 531 (55.3%) were in the historical control group. Across all patients, 250 (26.0%) were considered high compliance and 710 (74.0%) were considered low compliance. After adjustment for enhanced recovery after surgery status and confounders, the association between high compliance and improved outcomes persisted for all but infectious morbidity. Compared with low compliance, high compliance was associated with decreased odds of any morbidity (0.41 [95% CI, 0.22-0.77]), cardiac morbidity (0.31 [0.11-0.91]), respiratory morbidity (0.46 [0.23-0.90]) and decreased length of stay (0.38 [0.18-0.87])., Conclusion: Enhanced recovery after surgery protocols improve outcomes after anatomic lung resection. Increasing compliance to individual elements (>80%) further improves patient outcomes. Continued efforts should be directed at increasing compliance to individual protocol elements., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Parathyroidectomy remains the only definitive cure for primary hyperparathyroidism (PHPT). In rare cases, ectopic hyperfunctioning glands are located in the mediastinum, necessitating a thoracic surgical approach. The objective of this project was to review a single high-volume institutional experience of this presentation, with specific attention to the use of a robotic-assisted thoracic surgery (RATS) approach., Methods: This was a single-center, 5-year retrospective cohort study. All patients who underwent RATS mediastinal mass resection (MMR) for PHPT at the University of Colorado Anschutz Medical Campus were targeted for inclusion. Patient cases were reviewed for demographics, history, operative data, laboratory values, and postoperative course., Results: Eight patients underwent RATS-MMR for PHPT between 2018-2023. Median [interquartile range] operative time was 178 [138-213] minutes, and length of stay was 2.0 [1.5-2.0] days. One patient experienced post-operative chylothorax requiring dietary modification. There were no other 30-day complications or readmissions. Final pathology confirmed intrathymic parathyroid tissue in all patients. All patients achieved cure of PHPT., Conclusions: The robotic-assisted approach has low morbidity and associated hospital length of stay and can be safely used to cure PHPT. As this is a rare pathology with an infrequently utilized surgical approach, it is important to critically discuss the diagnostic evaluation and operative course, aimed at educating the thoracic surgeon who may encounter and assist in the management of these patients., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-1920/coif). J.D.M. serves as an unpaid editorial board member of Journal of Thoracic Disease from April 2022 to March 2024. J.D.M. reports that he consults for Intuitive, Inc. C.M.S. receives salary support, in part, by the National Institutes of Health, under Ruth L. Kirschstein National Research Service Award T32CA17468. R.A.M. reports that he consults for Medtronic, Inc. The other authors have no conflicts of interest to declare., (2024 Journal of Thoracic Disease. All rights reserved.)

Background: Benign anastomotic stricture is a recognized complication following esophagectomy. Laparoscopic gastric ischemic preconditioning (LGIP) prior to esophagectomy has been associated with decreased anastomotic leak rates; however, its effect on stricture and the need for subsequent endoscopic intervention is not well studied., Methods: This was a case-control study at an academic medical center using consecutive patients undergoing oncologic esophagectomies (July 2012-July 2022). Our institution initiated an LGIP protocol on 1 January 2021. The primary outcome was the occurrence of stricture within 1 year of esophagectomy, while secondary outcomes were stricture severity and frequency of interventions within the 6 months following stricture. Bivariable comparisons were performed using Chi-square, Fisher's exact, or Mann-Whitney U tests. Multivariable regression controlling for confounders was performed to generate risk-adjust odds ratios and to identify the independent effect of LGIP., Results: Of 253 esophagectomies, 42 (16.6%) underwent LGIP prior to esophagectomy. There were 45 (17.7%) anastomotic strictures requiring endoscopic intervention, including three patients who underwent LGIP and 42 who did not. Median time to stricture was 144 days. Those who underwent LGIP were significantly less likely to develop anastomotic stricture (7.1% vs. 19.9%; p = 0.048). After controlling for confounders, this difference was no longer significant (odds ratio 0.46, 95% confidence interval 0.14-1.82; p = 0.29). Of those who developed stricture, there was a trend toward less severe strictures and decreased need for endoscopic dilation in the LGIP group (all p < 0.20)., Conclusion: LGIP may reduce the rate and severity of symptomatic anastomotic stricture following esophagectomy. A multi-institutional trial evaluating the effect of LGIP on stricture and other anastomotic complications is warranted., (© 2024. Society of Surgical Oncology.)

Objective: The objective of this study was to examine representation of women on the editorial boards of cardiothoracic surgery-focused journals over the past 2 decades to identify changes over time compared with women cardiothoracic surgeon and trainee representation, and to highlight additional opportunities for improvement., Methods: The editorial boards of 2 high-impact cardiothoracic surgery journals were reviewed from 2000 to 2023. Data on editorial board positions, including editors-in-chief, associate/deputy editors, feature editors, and general members of the editorial board were abstracted. The proportion of women editors was assessed. Data were compared with publicly available information from the Association of American Medical Colleges on physician specialty by sex., Results: Of 3460 editorial positions, 332 (9.6%) were held by women. Women occupied 2.2% (1 out of 45) of editor-in-chief positions, 13.2% (78 out of 592) of senior editor positions, 11.5% (33 out of 287) of feature editor positions, and 8.3% (221 out of 2663) of general editorial board positions. The proportion of women holding any editorial board position significantly increased from 2.4% in 2000 to 18.2% in 2023 (P = .01). Overall, editorial board representation increased at a rate of 0.7% ± 1.3% per year, not significantly different from the growth of practicing women cardiothoracic surgeons at 0.3% ± 0.5% per year (P = .584)., Discussion: Representation of women on the editorial boards of cardiothoracic surgery-focused journals has increased commensurate with the increasing proportion of practicing women cardiothoracic surgeons, although remains at 16%. Work remains to continue the recruitment of women to cardiothoracic surgery as well as to identify the key elements that can support them in positions of leadership., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: We sought to evaluate how implementing a thoracic enhanced recovery after surgery (ERAS) protocol impacted surgical outcomes after elective anatomic lung resection., Background: The effect of implementing the ERAS Society/European Society of Thoracic Surgery thoracic ERAS protocol on postoperative outcomes throughout an entire health care system has not yet been reported., Methods: This was a prospective cohort study within one health care system (January 2019-March, 2023). A thoracic ERAS protocol was implemented on May 1, 2021 for elective anatomic lung resections, and postoperative outcomes were tracked using the electronic health record and Vizient data. The primary outcome was overall morbidity; secondary outcomes included individual complications, length of stay, opioid use, chest tube duration, and total cost. Patients were grouped into pre-ERAS and post-ERAS cohorts. Bivariable comparisons were performed using independent t -test, χ 2 , or Fisher exact tests, and multivariable logistic regression was performed to control for confounders., Results: There were 1007 patients in the cohort; 450 (44.7%) were in the post-ERAS group. Mean age was 66.2 years; most patients were female (65.1%), white (83.8%), had a body mass index between 18.5 and 29.9 (69.7%), and were ASA class 3 (80.6%). Patients in the postimplementation group had lower risk-adjusted rates of any morbidity, respiratory complication, pneumonia, surgical site infection, arrhythmias, infections, opioid usage, ICU use, and shorter postoperative length of stay (all P <0.05)., Conclusions: Postoperative outcomes were improved after the implementation of an evidence-based thoracic ERAS protocol throughout the health care system. This study validates the ERAS Society/European Society of Thoracic Surgery guidelines and demonstrates that simultaneous multihospital implementation can be feasible and effective., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Inadvertent perioperative hypothermia has been associated with poor surgical outcomes. The purpose of this study was to evaluate the incidence and associated postoperative complications of inadvertent perioperative hypothermia in patients undergoing robotic-assisted thoracic surgery lung resections., Methods: This was a single-center, retrospective cohort study evaluating all consecutive patients who underwent robotic-assisted thoracic surgery lung resection between January 1, 2021, and November 30, 2022. Temperatures were measured at 5 time points: preprocedure unit, anesthesia induction, 30 minutes postinduction, extubation, and recovery room arrival. Temperature changes were calculated at each interval. Adjusted and unadjusted comparison was performed between those who experienced varying levels of inadvertent perioperative hypothermia (Hypothermia I: <36 °C, Hypothermia II: <35.5 °C, and Hypothermia III: <35 °C) and those who did not., Results: A total of 313 patients were included, and 201 (64.2%) lobectomies, 50 (16.0%) segmentectomies, and 62 (19.8%) wedge resections were performed. Across all patients, 291 (93.0%) had a temperature less than 36 °C, 195 (62.3%) had a temperature less than 35.5 °C, and 100 (31.9%) had a temperature less than 35.0 °C. Patients experienced significant temperature change at all intervals (P < .001), with the greatest loss occurring during the preprocedure interval (between leaving preprocedure unit and anesthesia induction). On adjusted analysis, patients who experienced inadvertent perioperative hypothermia less than 35.5 °C were older (odds ratio, 1.03; 95% CI, 1.01-1.05), had lower body mass index (odds ratio, 0.95; 95% CI, 0.87-0.98), and had increasing operative time (odds ratio, 1.00; 95% CI, 1.00-1.01). Patients who experienced inadvertent perioperative hypothermia had higher risk-adjusted rates of overall morbidity and infectious postoperative complications., Conclusions: The majority of patients undergoing robotic-assisted thoracic surgery lung resections experience some degree of inadvertent perioperative hypothermia and have associated increased rates of 30-day morbidity. Structured and interval-specific interventions should be implemented to decrease rates of inadvertent perioperative hypothermia and subsequent complications., Competing Interests: Conflict of Interest Statement R.A.M. consults for Medtronic. J.D.M. consults for Intuitive. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: In 2012, the American Society of Anesthesiologists (ASA) published guidelines recommending against routine preoperative laboratory testing for low-risk patients to reduce unnecessary medical expenditures. The aim of this study was to assess the change in routine preoperative laboratory testing in low-risk versus higher-risk patients before and after release of these guidelines., Methods: The ACS-NSQIP database, 2005-2018, was separated into low-risk versus higher-risk patients based upon a previously published stratification. The guideline implementation date was defined as January 2013. Changes in preoperative laboratory testing over time were compared between low- and higher-risk patients. A difference-in-differences model was applied. The primary outcome included any laboratory test obtained ≤90 days prior to surgery., Results: Of 7,507,991 patients, 972,431 (13.0%) were defined as low-risk and 6,535,560 (87.0%) higher-risk. Use of any preoperative laboratory test declined in low-risk patients from 66.5% before to 59.6% after guidelines, a 6.9 percentage point reduction, versus 93.0%-91.9% in higher-risk patients, a 1.1 percentage point reduction (p < 0.0001, comparing percentage point reductions). After risk-adjustment, the adjusted odds ratio for having any preoperative laboratory test after versus before the guidelines was 0.77 (95% CI 0.76-0.78) in low-risk versus 0.93 (0.92-0.94) in higher-risk patients. In low-risk patients, lack of any preoperative testing was not associated with worse outcomes., Conclusions: While a majority of low-risk patients continue to receive preoperative laboratory testing not recommended by the ASA, there has been a decline after implementation of guidelines. Continued effort should be directed at the deimplementation of routine preoperative laboratory testing for low-risk patients., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

The downstream effects on healthcare delivery during the initial wave of the COVID-19 pandemic remain unclear. The purpose of this study was to determine how the healthcare environment surrounding the pandemic affected the oncologic care of patients diagnosed with esophageal cancer. This was a retrospective cohort study evaluating patients in the National Cancer Database (2019-2020). Patients with esophageal cancer diagnoses were divided into pre-pandemic (2019) and pandemic (2020) groups. Patient demographics, cancer-related variables, and treatment modalities were compared. Among 26,231 esophageal cancer patients, 14,024 patients (53.5%) were in the pre-pandemic cohort and 12,207 (46.5%) were in the pandemic cohort. After controlling for demographics, patients diagnosed during the pandemic were more likely to have poorly differentiated tumors (odds ratio [OR] 1.24, 95% confidence interval [CI] 1.08-1.42), pathologic T3 disease compared to T1 (OR 1.25, 95% CI 1.02-1.53), positive lymph nodes on pathology (OR 1.36, 95% CI 1.14-1.64), and to be pathologic stage IV (OR 1.51, 95% CI 1.29-1.76). After controlling for oncologic characteristics, patients diagnosed during the pandemic were more likely to require at least two courses of systemic therapy (OR 1.78, 95% CI 1.48-2.14) and to be offered palliative care (OR 1.13, 95% CI 1.04-1.22). While these patients were offered curative therapy at lower rates, this became non-significant after risk-adjustment (p = .15). The pandemic healthcare environment was associated with significantly increased risk-adjusted rates of patients presenting with advanced esophageal cancer. While this led to significant differences in treatment, most of these differences became non-significant after controlling for oncologic factors., (© 2023 UICC.)

Objective: To estimate preoperative risk of postoperative infections using structured electronic health record (EHR) data., Background: Surveillance and reporting of postoperative infections is primarily done through costly, labor-intensive manual chart reviews on a small sample of patients. Automated methods using statistical models applied to postoperative EHR data have shown promise to augment manual review as they can cover all operations in a timely manner. However, there are no specific models for risk-adjusting infectious complication rates using EHR data., Methods: Preoperative EHR data from 30,639 patients (2013-2019) were linked to the American College of Surgeons National Surgical Quality Improvement Program preoperative data and postoperative infection outcomes data from 5 hospitals in the University of Colorado Health System. EHR data included diagnoses, procedures, operative variables, patient characteristics, and medications. Lasso and the knockoff filter were used to perform controlled variable selection. Outcomes included surgical site infection, urinary tract infection, sepsis/septic shock, and pneumonia up to 30 days postoperatively., Results: Among >15,000 candidate predictors, 7 were chosen for the surgical site infection model and 6 for each of the urinary tract infection, sepsis, and pneumonia models. Important variables included preoperative presence of the specific outcome, wound classification, comorbidities, and American Society of Anesthesiologists physical status classification. The area under the receiver operating characteristic curve for each model ranged from 0.73 to 0.89., Conclusions: Parsimonious preoperative models for predicting postoperative infection risk using EHR data were developed and showed comparable performance to existing American College of Surgeons National Surgical Quality Improvement Program risk models that use manual chart review. These models can be used to estimate risk-adjusted postoperative infection rates applied to large volumes of EHR data in a timely manner., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The purpose of this study was to determine if an association between Social Vulnerability Index (SVI) and risk-adjusted complications exists in a broad spectrum of surgical patients., Summary Background Data: Growing evidence supports the impact of social circumstances on surgical outcomes. SVI is a neighborhood-based measure accounting for sociodemographic factors putting communities at risk., Methods: This was a multi-hospital, retrospective cohort study including a sample of patients within one healthcare system (2012-2017). Patient addresses were geocoded to determine census tract of residence and estimate SVI. Patients were grouped into low SVI (score<75) and high SVI (score≥75) cohorts. Perioperative variables and postoperative outcomes were tracked and compared using local ACS-NSQIP data. Multivariable logistic regression was performed to generate risk-adjusted odds ratios of postoperative complications in the high SVI cohort., Results: Overall, 31,224 patients from five hospitals were included. Patients with high SVI were more likely to be racial minorities, have 12/18 medical comorbidities, have high ASA class, be functionally dependent, be treated at academic hospitals, and undergo emergency operations (all p ​< ​0.05). Patients with high SVI had significantly higher rates of 30-day mortality, overall morbidity, respiratory, cardiac and infectious complications, urinary tract infections, postoperative bleeding, non-home discharge, and unplanned readmissions (all p ​< ​0.05). After risk-adjustment, only the associations between high SVI and mortality and unplanned readmission became non-significant., Conclusions: High SVI was associated with multiple adverse outcomes even after risk adjustment for preoperative clinical factors. Targeted preventative interventions to mitigate risk of these specific complications should be considered in this high-risk population., Competing Interests: Declaration of competing interest The authors report no conflicts of interest. The ACS-NSQIP and participating hospitals are the source of these data; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors. This work was supported by an internal grant from the Department of Surgery, University of Colorado School of Medicine. There was no external funding support for this work. Artificial Intelligence was not used in the preparation of this manuscript., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Surgical diagnostic lung biopsy (DLB) is performed to guide the management of pulmonary disease with unclear etiology. However, the utilization of surgical DLB in critically ill patients remains unclear. The purpose of this study was to determine if patient preoperative disposition impacts complication rates after DLB., Methods: This was retrospective cohort study using electronic health record (EHR) data at one academic institution [2013-2021]. Patients who underwent DLB were identified using current procedural terminology (CPT) codes and cohorted based on preoperative disposition. The primary outcome was 30-day mortality; secondary outcomes were overall morbidity, individual complications, and changes to medical therapy. Complication rates were compared using chi-squared tests, Fisher's exact tests, or analysis of variance (ANOVA). Multivariable logistic regression was performed to generate risk-adjusted odds ratios (ORs) for each complication., Results: Of 285 patients, 238 (83.5%) presented from home, 26 (9.1%) from inpatient floor units, and 21 (7.4%) from intensive care units (ICUs). Patients requiring ICU had the highest 30-day rates of mortality, overall morbidity, and all individual complications (all P<0.05). After risk adjustment, non-ICU inpatients had higher odds of postoperative ventilator use, prolonged ventilation, and ICU need than outpatients (all P<0.05). Preoperative ICU disposition was associated with increased OR of 30-day mortality [OR, 70.92; 95% confidence interval (CI): 5.55-906.32] and overall morbidity (OR, 7.27; 95% CI: 1.93-27.42) compared to patients with other preoperative dispositions. There were no differences in changes to medical therapy between the cohorts., Conclusions: Patients requiring ICU before DLB had significantly higher risk-adjusted rates of mortality and postoperative complications than outpatients and other inpatients. A clear benefit from tissue diagnosis should be defined prior to performing DLB on critically ill patients., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-1724/coif). The authors have no conflicts of interest to declare., (2024 Journal of Thoracic Disease. All rights reserved.)

Background: Cardiothoracic surgeons and general surgeons (including surgical oncologists) perform most esophagectomies. The purpose of this study was to explore whether specialty-driven differences in surgical techniques and the use of minimally invasive surgical approaches exist and are associated with postoperative outcomes after esophagectomy., Methods: This was a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program esophagectomy-targeted participant user file (2016-2018). Patients who underwent esophagectomy were sorted into cardiothoracic and general surgeon cohorts based on surgeon specialty. Perioperative characteristics and postoperative outcomes were compared using the χ 2 analysis or independent t test. Multivariable logistic regression controlling for perioperative variables was performed to generate risk-adjusted rates of postoperative outcomes compared by surgical specialty., Results: Of 3,247 patients included, 1,792 (55.2%) underwent esophagectomy by cardiothoracic surgeons and 1,455 (44.5%) by general surgeons as the primary surgeon. Cardiothoracic surgeons were more likely to use traditional minimally invasive surgical (P = .0004) or open approaches (P < .0001) and less likely to use robotic (P = .04) or a hybrid robotic and traditional approaches (P < .0001). Cardiothoracic surgeons performed more Ivor Lewis esophagectomies and fewer transhiatal and McKeown esophagectomies (P < .0001). After risk adjustment, there were no differences in rates of postesophagectomy complications, such as anastomotic leaks or positive margins, between cardiothoracic surgeons and general surgeons (all P > .05). However, cardiothoracic surgeons were more likely than general surgeons to treat anastomotic leaks with surgery rather than procedural interventions (odds ratio = 1.76; 95% confidence interval, 1.24-2.52)., Conclusion: Cardiothoracic surgeons and general surgeons use minimally invasive surgical subtypes differently when performing esophagectomy. However, there were no risk-adjusted differences in postoperative complications when compared by surgical subspecialty. Esophagectomy is being performed safely by surgeons with different specialties and training pathways., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: The Social Vulnerability Index (SVI) is a composite metric for social determinants of health. The objective of this study was to determine if SVI influences stage at presentation for non-small cell lung cancer (NSCLC) patients and subsequent therapies., Materials and Methods: NSCLC patients from our local contribution to the National Cancer Database (2011-2021) were grouped into low SVI (<75 %ile) and high SVI (>75 %ile) cohorts. Demographics, cancer-related variables, and treatment modalities were compared. Multivariable logistic regression was performed to control for the impact of demographics on cancer presentation and for the impact of oncologic variables on treatment outcomes., Results: Of 1,662 NSCLC patients, 435 (26 %) were defined as high SVI. Compared to the 1,227 (74 %) low SVI patients, highly vulnerable patients were more likely to be male (53.3 % vs 46.0 %, p = 0.009), non-White (17.2 % vs 9.7 %, p < 0.0001), have comorbidities (29.4 % vs 23.1 %, p = 0.009) and present at a higher AJCC clinical T, M and overall stage (all p < 0.05). These findings persisted on multivariable analysis, with highly vulnerable patients having 1.5x the odds (95 %CI: 1.23-1.86, p < 0.001) of presenting at more advanced stage. Patients with high SVI were less likely to be recommended for and receive surgery (40.9 % vs 53.2 %, p < 0.001), and this finding persisted after controlling for stage at presentation (OR 1.37, 95 %CI 1.04-1.80)., Conclusions: Highly vulnerable patients present at a more advanced clinical stage and are less likely to be recommended and receive surgery, even after controlling for stage at presentation. Further investigation into these findings is warranted to achieve more equitable oncologic care., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Christina M Stuart reports that this work was supported by the National Institutes of Health, under Ruth L. Kirschstein National Research Service Award T32CA17468., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Patient-reported outcomes (PROs) are an underreported aspect of surgical recovery. The purpose of our study was to track PROs after robotic anatomic lung to determine the timing to recovery of baseline patient baseline quality of life. This was a prospective cohort study at an academic medical center (4/2021-12/2022). Patients who underwent robotic anatomic lung resection were asked to complete PROMIS-29 surveys at the preoperative clinic visit, postoperative clinic visit, 30 days and 90 days postoperatively via in-person and email-based electronic surveys. The PROPr score, a summary of health-related quality of life, and mental and physical health z-scores were estimated for each patient using published methods and compared by postoperative timing. 75 patients completed the preoperative survey and at least one postoperative survey; 56 completed postoperative clinic surveys, 54 completed 30-day postoperative surveys, and 40 completed 90-day postoperative surveys. All three PROMIS scores decreased between the preoperative and first postoperative visit (all p < 0.05). PROPr scores increased over time but remained significantly worse than baseline by 90 days (-0.08 difference between 90 days and preoperative, p = 0.02). While PROMIS summary z-scores for physical health remained - 0.29 lower at 90 days postoperatively, this did not reach statistical significance (p = 0.06). Mental health scores returned to baseline by 90 days postoperatively (p = 0.41). While some PROs returned to baseline by 90 days postoperatively, overall quality-of-life scores remained significantly below preoperative baselines. These findings are important to share with patients during the informed consent process to achieve patient centered care more effectively., (© 2024. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Introduction: Compliance with thoracic Enhanced Recovery After Surgery (ERAS) protocols is critical to achieving their maximum benefits. We sought to examine utilization of quality review meetings as a method to improve protocol compliance through identification and resolution of barriers with compliance., Methods: A multidisciplinary committee implemented a thoracic ERAS protocol for anatomic lung resections across five hospitals within our health system. Compliance data at one institution were tracked for 4 mo after initiation of the ERAS protocol; a quality review meeting was held at one hospital, and two additional months of compliance data were recorded. Outcomes of interest were compliance changes to five protocol elements. Pathway elements deferred due to "mindful deviation" were excluded. Chi-square and Fisher's exact tests were used to compare compliance differences., Results: We included 81 patients: 53 patients before the quality review meeting and 28 after. There were 405 compliance opportunities; 68 (17%) were excluded for mindful deviation, leaving 337 (83%) for inclusion. Overall compliance improved from 53% before to 84% after the quality review meeting. Compliance to avoiding intraoperative urinary catheters, placing chest tubes to water seal in postanesthesia care unit, liberal chest tube removal, and postoperative multimodal pain regimen use improved after the quality review meeting (P values <0.05). Use of preoperative pain bundles was not significantly different (87% versus 96%, P = 0.25)., Conclusions: Conducting a quality review meeting significantly improved ERAS protocol element use at our intervention healthcare region. This methodology should be considered at other institutions implementing surgical protocols., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The social vulnerability index (SVI) is a neighborhood-based metric used to determine an individual's susceptibility to socioeconomic hardship, with high SVI indicating high susceptibility. SVI has previously been associated with surgical outcomes. We aimed to determine if SVI influences morbidity following robotic-assisted lung resection., Methods: This was a retrospective cohort study at one academic medical center (1/1/2021-11/30/2022). Patients undergoing robotic-assisted lung resection were grouped into low (<75 th percentile) and high (≥75 th percentile) SVI cohorts. The primary outcome was 30-day overall morbidity; secondary outcomes were individual 30-day post-operative outcomes. Univariate analysis was performed using Chi-squared or Mann-Whitney- U tests, and multivariable logistic regression was performed to generate risk-adjusted odds ratios (ORs) of postoperative complications., Results: We included 320 patients, of which 40 patients (12.5%) in the high-SVI group and 280 (87.5%) in the low-SVI group. High SVI patients were more likely to be non-Caucasian and of Hispanic ethnicity, but there were no other differences in perioperative characteristics (all P>0.05). High SVI patients were more likely to experience a post-operative complication (42.5% vs. 24.6%, P=0.017), surgical site infection (SSI) (12.5% vs. 4.3%, P=0.047), hemothorax (5.0% vs. 0.0%, P=0.015), intensive care need (15.0% vs. 4.6%, P=0.021), sepsis (10.0% vs. 1.1%, P=0.006) and unplanned reoperation (5.0% vs. 0.4%, P=0.042). After risk-adjustment, the association of increased overall morbidity with high SVI persisted (OR =2.53; 95% confidence interval: 1.19-5.35)., Conclusions: High SVI was associated with increased risk-adjusted odds of morbidity after robotic-assisted lung resection. Highly vulnerable patients should be allocated perioperative resources to help mitigate the increased risk of these complications., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-1122/coif). C.M.S. reports that she receives associated grant funding from the National Institutes of Health, under Ruth L. Kirschstein National Research Service Award T32CA17468. J.D.M. reports that he performs consulting for Intuitive Surgical, Inc. R.A.M. reports that he consults for Medtronic, Inc. The other authors have no conflicts of interest to declare., (2023 Journal of Thoracic Disease. All rights reserved.)

Objective: Donation after circulatory death (DCD) procurement and transplantation after thoracoabdominal normothermic regional perfusion (TA-NRP) remains a novel technique to improve cardiac and hepatic allograft preservation but may be complicated by lung allograft pulmonary edema. We present a single-center series on early implementation of a lung-protective protocol with strategies to mitigate posttransplant pulmonary edema in DCD lung allografts after TA-NRP procurement., Methods: Data from all lung transplantations performed using a TA-NRP procurement strategy from October 2022 to April 2023 are presented. Donor management consisted of key factors to reduce lung allograft pulmonary edema: aggressive predonation and early posttransplant diuresis, complete venous drainage at TA-NRP initiation, and early pulmonary artery venting upon initiation of systemic perfusion. Donor and recipient characteristics, procurement characteristics such as TA-NRP intervals, and 30-day postoperative outcomes were assessed., Results: During the study period, 8 lung transplants were performed utilizing TA-NRP procurement from DCD donors. Donor ages ranged from 16 to 39 years and extubation time to declaration of death ranged from 10 to 90 minutes. Time from declaration to TA-NRP initiation was 7 to 17 minutes with TA-NRP perfusion times of 49 to 111 minutes. Median left and right allograft warm ischemia times were 55.5 minutes (interquartile range, 46.5-67.5 minutes) and 41.0 minutes (interquartile range, 39.0-53.0 minutes, respectively, with 2 recipients supported with cardiopulmonary bypass or venoarterial extracorporeal membrane oxygenation during implantation. No postoperative extracorporeal membrane oxygenation was required. There were no pulmonary-related deaths; however, 1 patient died from complications of severe necrotizing pancreatitis with a normal functioning allograft. All patients were extubated within 24 hours. Index intensive care unit length of stay ranged from 3 to 11 days with a hospital length of stay of 13 to 37 days., Conclusions: Despite concern regarding quality of DCD lung allografts recovered using the TA-NRP technique, we report initial success using this procurement method. Implementation of strategies to mitigate pulmonary edema can result in acceptable outcomes following lung transplantation. Demonstration of short- and long-term safety and efficacy of this technique will become increasingly important as the use of TA-NRP for thoracic and abdominal allografts in DCD donors expands., Competing Interests: The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (© 2023 The Author(s).)

Background: Outcomes for patients undergoing emergency thoracic operations have not been well described. This study was designed to compare postoperative outcomes among patients undergoing emergency versus nonemergency thoracic operations., Methods: We retrospectively analyzed the American College of Surgeons National Surgical Quality Improvement Program database (2005-2018). We identified patients who underwent emergency thoracic operations using current procedural technology codes. Patients were then sorted into 1 of 4 cohorts: lung and chest wall, hiatal hernia, esophagus, and pericardium. Emergency versus nonemergency outcomes were compared. Univariate logistic regression was performed with "emergency status" as the independent variable and 30-day postoperative outcomes as the dependent variables. Multiple logistic regression models were performed to control for preoperative factors., Results: Of 90,398 thoracic operations analyzed, 4,044 (4.5%) were emergency. Common emergency operations were pericardial window (n = 580, 10.2%), laparoscopic hiatal hernia repair (n = 366, 8.9%), thoracoscopic partial lung decortication (n = 334, 8.1%), thoracoscopic wedge resection (n = 301, 7.3%), thoracoscopic total lung decortication (n = 256, 6.2%), and open repair of hiatal hernia without mesh (n = 254, 6.2%). In all 4 cohorts, 30-day postoperative complications occurred more frequently after emergency surgery. After controlling for patient characteristics, 8 complications were more frequent after emergency lung and chest wall surgery, 5 complications were more frequent after emergency hiatal hernia surgery, and 3 complications were more frequent after emergency pericardium surgery. Risk-adjusted complications were not different after emergency esophageal surgery., Conclusion: Patients undergoing emergency thoracic operations have worse risk-adjusted outcomes than those undergoing nonemergency thoracic operations. Subset analysis is needed to determine what factors contribute to increased adverse outcomes in specific patient populations., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: The effect of a patient's Social Vulnerability Index (SVI) on complication rates after esophagectomy remains unstudied. The purpose of this study was to determine how social vulnerability influences morbidity following esophagectomy., Methods: This was a retrospective review of a prospectively collected esophagectomy database at one academic institution, 2016 to 2022. Patients were grouped into low-SVI (<75%ile) and high-SVI (>75%ile) cohorts. The primary outcome was overall postoperative complication rate; secondary outcomes were rates of individual complications. Perioperative patient variables and postoperative complication rates were compared between the 2 groups. Multivariable logistic regression was used to control for covariates., Results: Of 149 patients identified who underwent esophagectomy, 27 (18.1%) were in the high-SVI group. Patients with high SVI were more likely to be of Hispanic ethnicity (18.5% vs 4.9%, P = .029), but there were no other differences in perioperative characteristics between groups. Patients with high SVI were significantly more likely to develop a postoperative complication (66.7% vs 36.9%, P = .005) and had greater rates of postoperative pneumonia (25.9% vs 6.6%, P = .007), jejunal feeding-tube complications (14.8% vs 3.3%, P = .036), and unplanned intensive care unit readmission (29.6% vs 12.3%, P = .037). In addition, patients with high SVI had a longer postoperative hospital length of stay (13 vs 10 days, P = .017). There were no differences in mortality rates. These findings persisted on multivariable analysis., Conclusions: Patients with high SVI have greater rates of postoperative morbidity following esophagectomy. The effect of SVI on esophagectomy outcomes warrants further investigation and may prove useful in identifying populations that benefit from interventions to mitigate these complications., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The gold standard for detecting postoperative complications uses databases like the American College of Surgeons National Surgical Quality Improvement Program, a multi-centered database based on manual chart review. However, their limitations and costs have led many centers to discontinue participation. Novel techniques to detect postoperative complications must be developed and implemented with surgeon involvement, which is paramount to their adoption. We sought to assess surgeons' opinions of a newly developed postoperative complication detection tool, the Automated Surveillance of Postoperative Infections, within the contextual clinical environment., Methods: This was a multi-site qualitative formative evaluation of surgeon perceptions of the Automated Surveillance of Postoperative Infections. We conducted semi-structured interviews and focus groups with surgeons and presented the Automated Surveillance of Postoperative Infections concept. Important domains and constructs, as categorized by Consolidated Framework for Implementation Research, were identified to support the successful adoption and implementation of the Automated Surveillance of Postoperative Infections., Results: Twenty-four surgeons with 10 surgical subspecialties were interviewed. The following 4 main themes were found: (1) perception of the Automated Surveillance of Postoperative Infections tool-to provide important data that can improve and support clinical outcomes; (2) environment for implementation-description of factors to support or impede implementation; (3) adaptability of the Automated Surveillance of Postoperative Infections-to work with the complexity of surgical cases; and (4) the Automated Surveillance of Postoperative Infections report format and details., Conclusions: We successfully captured the perspectives and suggestions of surgeons to improve the Automated Surveillance of Postoperative Infections and potential barriers during the initial development phase. Barriers included fear of punitive action from reports and complex surgical cases. Facilitators identified were the need to improve clinical outcomes and organizational support. The results of this formative evaluation will be used to further develop Automated Surveillance of Postoperative Infections, starting with a prototype, the Automated Surveillance of Postoperative Infections 1.0., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Open and robotic-assisted transthoracic approaches for diaphragm plication are accepted surgical interventions for diaphragm paralysis and eventration. However, long-term patient-reported symptom improvement and quality of life (QOL) remains unclear., Study Design: A telephone-based survey was developed focusing on postoperative symptom improvement and QOL. Patients who underwent open or robotic-assisted transthoracic diaphragm plication (2008-2020) across three institutions were invited to participate. Patients who responded and provided consent were surveyed. Likert responses on symptom severity were dichotomized and rates before and after surgery were compared using McNemar's test., Results: Forty-one percent of patients participated (43 of 105 responded, mean age 61.0 years, 67.4% male, 37.2% robotic-assisted surgery), with an average time between surgery and survey of 4.1 ± 3.2 years. Patients reported significant improvement in dyspnea while lying flat (67.4% pre- vs 27.9% postoperative, p < 0.001), dyspnea at rest (55.8% pre- vs 11.6% postoperative, p < 0.001), dyspnea with activity (90.7% pre- vs 55.8% postoperative, p < 0.001), dyspnea while bending over (79.1% pre- vs 34.9% postoperative, p < 0.001), and fatigue (67.4% pre- vs 41.9% postoperative, p = 0.008). There was no statistical improvement in chronic cough. 86% of patients reported improved overall QOL, 79% had increased exercise capacity, and 86% would recommend surgery to a friend with a similar problem. Analysis comparing open and robotic-assisted approaches found no statistically significant differences in symptom improvement or QOL responses between the groups., Conclusions: Patients report significantly improved dyspneic and fatigue symptoms after transthoracic diaphragm plication, regardless of open or robotic-assisted approach. The majority of patients report improved QOL and exercise capacity., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: After surgical resection of pancreatic ductal adenocarcinoma, 14% of patients have lung-only recurrence. We hypothesize that in patients with isolated lung metastases from pancreatic ductal adenocarcinoma, pulmonary metastasectomy offers a survival benefit with minimal additional morbidity after resection., Methods: This was a single-institution, retrospective study of patients who underwent definitive resection of pancreatic ductal adenocarcinoma and later developed isolated lung metastases between 2009 and 2021. Patients were included if they carried a diagnosis of pancreatic ductal adenocarcinoma, underwent pancreatic resection with curative intent, and subsequently developed lung metastases. Patients were excluded if they developed multiple sites of recurrence., Results: We identified 39 patients with pancreatic ductal adenocarcinoma and isolated lung metastases, 14 of whom underwent pulmonary metastasectomy. During the study period, 31 (79%) patients died. Across all patients, there was an overall survival of 45.9 months, a disease-free interval of 22.8 months, and survival after recurrence of 22.5 months. Survival after recurrence was significantly longer in patients who underwent pulmonary metastasectomy than those who did not (30.8 months vs 18.6 months, P < .01). There was no difference in overall survival between groups. However, patients who underwent pulmonary metastasectomy were significantly more likely to be alive 3 years after their diagnosis (100.0% vs 64%, P = .02) and 2 years after recurrence (79% vs 32%, P < .01) than those in who did not undergo pulmonary metastasectomy. No mortalities occurred related to pulmonary metastasectomy, and procedure-related morbidity was 7%., Conclusion: Patients who underwent pulmonary metastasectomy for isolated pulmonary pancreatic ductal adenocarcinoma metastases had significantly longer survival after recurrence and clinically meaningful survival benefit with minimal additional morbidity after pulmonary resection., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Thirty-day mortality after outpatient surgery is unexpected and undesired. We investigated preoperative risk factors, operative variables, and postoperative complications associated with 30-day death after outpatient surgery., Methods: Using the 2005 to 2018 American College of Surgeons National Surgical Quality Improvement Program database, we evaluated 30-day mortality rate trends over time after outpatient operations. We analyzed associations between 37 preoperative variables, operation time, hospital length of stay, and 9 postoperative complications with mortality rate using χ 2 analyses for categorical data and tests for continuous data. We used forward selection logistic regression models to determine the best predictors of mortality preoperatively and postoperatively. We also separately analyzed mortality by age group., Results: A total of 2,822,789 patients were included. The 30-day mortality rate did not change significantly over time (P = .34, Cochran-Armitage trend test), remaining steady at around 0.06%. The most significant preoperative predictors of mortality included the patient having disseminated cancer, decreased functional health status, increased American Society of Anesthesiology Physical Status classification, increased age, and ascites, accounting for 95.8% (0.837/0.874) of the full model c-index. The most significant postoperative complications associated with increased risk of mortality included having cardiac (26.95% yes vs 0.04% no), pulmonary (10.25% vs 0.04%), stroke (9.22% vs 0.06%), and renal (9.33% vs 0.06%) complications. Postoperative complications conferred a greater risk for mortality than preoperative variables. Mortality risk increased incrementally with age, particularly past age 80., Conclusion: The operative mortality rate after outpatient surgery has not changed over time. Patients over 80 years with disseminated cancer, decreased functional health status, or increased ASA class should generally be considered for inpatient surgery. However, there might be some circumstances where outpatient surgery could be considered., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Anastomotic leak after esophagectomy is associated with significant morbidity and mortality. Our institution began performing laparoscopic gastric ischemic preconditioning (LGIP) with ligation of the left gastric and short gastric vessels prior to esophagectomy in all patients presenting with resectable esophageal cancer. We hypothesized that LGIP may decrease the incidence and severity of anastomotic leak., Methods: Patients were prospectively evaluated following the universal application of LGIP prior to esophagectomy protocol in January 2021 until August 2022. Outcomes were compared with patients who underwent esophagectomy without LGIP from a prospectively maintained database from 2010 to 2020., Results: We compared 42 patients who underwent LGIP followed by esophagectomy with 222 who underwent esophagectomy without LGIP. Age, sex, comorbidities, and clinical stage were similar between groups. Outpatient LGIP was generally well tolerated, with one patient experiencing prolonged gastroparesis. Median time from LGIP to esophagectomy was 31 days. Mean operative time and blood loss were not significantly different between groups. Patients who underwent LGIP were significantly less likely to develop an anastomotic leak following esophagectomy (7.1% vs. 20.7%, p = 0.038). This finding persisted on multivariate analysis [odds ratio (OR) 0.17, 95% confidence interval (CI) 0.03-0.42, p = 0.029]. The occurrence of any post-esophagectomy complication was similar between groups (40.5% vs. 46.0%, p = 0.514), but patients who underwent LGIP had shorter length of stay [10 (9-11) vs. 12 (9-15), p = 0.020]., Conclusions: LGIP prior to esophagectomy is associated with a decreased risk of anastomotic leak and length of hospital stay. Further, multi-institutional studies are warranted to confirm these findings., (© 2023. Society of Surgical Oncology.)

Poorly differentiated esophageal adenocarcinoma (PDEAC) has a dismal prognosis. Glypican-1(GPC-1) is known to be upregulated in several cancer types in contrast to healthy tissues, rendering it as a biomarker. Nevertheless, the potential therapeutic targeting of GPC-1 has not been explored in PDEAC. There is accumulating evidence that GPC-1, via upregulation of PI3K/Akt/ERK signaling, plays a crucial role in the progression and chemoresistance in cancer. Pictilisib, a class I pan PI3K inhibitor, has shown promising antitumor results in clinical trials, however, has not gained widespread success due to acquired drug resistance. This study investigated the role of GPC-1 in chemo-resistant PDEAC and appraises the impact of targeted silencing of GPC-1 on the antitumor effects of Pictilisib in PDEAC cell lines. Immunohistochemistry assays in PDEAC tissue specimens demonstrated a pronounced intensity of staining with GPC-1. Upregulation of GPC-1 was found to be correlated with advanced stage and poor prognosis. In-vitro studies examined the influence of GPC-1 knockdown and Pictilisib, both as individual agents and in combination, on cytotoxicity, cell cycle distribution, apoptosis, and gene expression profiles. Silencing GPC-1 alone showed significantly reduced cell viability, migration, colony formation, epithelial-mesenchymal transition, and stemness in PDEAC cells. Significantly, knockdown of GPC-1 combined with low-dose Pictilisib led to enhancement of cytotoxicity, cell cycle arrest, and apoptosis in ESO-26 and OE-33 cells. In the xenograft mouse model, the combination of Pictilisib and GPC-1 knockdown exhibited synergy. These findings suggest that GPC-1 represents a promising target to augment chemosensitivity in esophageal adenocarcinoma., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2023 The Author(s). Published with license by Taylor & Francis Group, LLC.)

Diaphragm paralysis and eventration are rare conditions in adults. Symptomatic patients may benefit from surgical plication of the elevated hemidiaphragm. The objective of this study was to compare short-term outcomes and length of stay following robotic-assisted vs. open diaphragm plication. A multicenter retrospective study was conducted that identified patients undergoing unilateral hemidiaphragm plication from 5/2008 to 12/2020. The first RATS plication was performed in 11/2018. Electronic medical records were reviewed, and outcomes were compared between RATS and open approach. One hundred patients underwent diaphragm plication, including thirty-nine (39.0%) RATS and sixty-one (61.0%) open cases. Patients undergoing RATS diaphragm plication were older (64 years vs. 55 years, p = 0.01) and carried a higher burden of comorbidities (Charlson Comorbidity Index: 2.0 vs. 1.0, p = 0.02). The RATS group had longer median operative times (146 min vs. 99 min, p < 0.01), but shorter median hospital length of stays (3.0 days vs. 6.0 days, p < 0.01). There was a non-significant trend toward a decreased rate of 30-day postoperative complications (20.5% RATS vs. 32.8% open, p = 0.18) and 30-day unplanned readmissions (7.7% RATS vs. 9.8% open, p > 0.99). RATS is a technically feasible and safe option for performing diaphragm plications. This approach increases the surgical candidacy of older patients with a higher burden of comorbid disease without increasing complication rates, while reducing length of hospital stay., (© 2023. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Background/aim: The primary mode of therapy for individuals with locally advanced esophageal adenocarcinoma (EAC) is neoadjuvant chemotherapy, commonly 5-Fluorouracil (5-FU). However, approximately 30% of these patients develop resistance to therapy. Glypican-1 (GPC-1) has been identified as one of the key drivers of chemoresistance in cancer; however, its role in EAC cells has not been explored. The objective of the present study was to evaluate the role of GPC-1 in chemoresistance to 5-FU in EAC cells., Materials and Methods: Cell viability to 5-FU was measured with CCK-8 assay, and GPC-1 expression was validated using western blot. 5-FU resistant cell lines were generated. The effect of lentivirus-mediated GPC-1 knockdown on FLO-1 cell viability, cell cycle, and apoptosis was evaluated., Results: 5-FU resistant EAC cells showed increased GPC-1 expression and knockdown of GPC-1 increased cell death and apoptosis. Importantly, the knockdown of GPC-1 enhanced the antitumor effects of 5-FU in vitro via down-regulating AKT/ERK/β-catenin signaling., Conclusion: Silencing GPC-1 has the potential to augment the efficacy of 5-FU chemotherapy in resistant EAC tumors., (Copyright © 2023 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Cardiac surgery prediction models and outcomes from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) have not been reported. The authors sought to develop preoperative prediction models and estimates of postoperative outcomes for cardiac surgery using the ACS-NSQIP and compare these to the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS-ACSD)., Methods: In a retrospective analysis of the ACS-NSQIP data (2007-2018), cardiac operations were identified using cardiac surgeon primary specialty and sorted into cohorts of coronary artery bypass grafting (CABG) only, valve surgery only, and valve+CABG operations using CPT codes. Prediction models were created using backward selection of the 28 non-laboratory preoperative variables in ACS-NSQIP. Rates of nine postoperative outcomes and performance statistics of these models were compared to published STS 2018 data., Results: Of 28 912 cardiac surgery patients, 18 139 (62.8%) were CABG only, 7872 (27.2%) were valve only, and 2901 (10.0%) were valve+CABG. Most outcome rates were similar between the ACS-NSQIP and STS-ACSD, except for lower rates of prolonged ventilation and composite morbidity and higher reoperation rates in ACS-NSQIP (all P <0.0001). For all 27 comparisons (9 outcomes × 3 operation groups), the c-indices for the ACS-NSQIP models were lower by an average of ~0.05 than the reported STS models., Conclusions: The ACS-NSQIP preoperative risk models for cardiac surgery were almost as accurate as the STS-ACSD models. Slight differences in c-indexes could be due to more predictor variables in STS-ACSD models or the use of more disease- and operation-specific risk variables in the STS-ACSD models., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Food deserts are low-income census tracts with poor access to supermarkets and are associated with worse outcomes in breast, colon, and a small number of esophageal cancer patients. This study investigated residency in food deserts on readmission rates in a multi-institutional cohort of esophageal cancer patients undergoing trimodality therapy., Methods: A retrospective review of patients who underwent trimodality therapy at 6 high-volume institutions from January 2015 to July 2019 was performed. Food desert status was defined by the United States Department of Agriculture by patient ZIP Code. The primary outcome was 30-day readmission after esophagectomy. Multilevel, multivariable logistic regression was used to model readmission on food desert status adjusted for diabetes, insurance type, length of stay, and any complication, treating the institution as a random factor., Results: Of the 453 records evaluated, 425 were included in the analysis. Seventy-three patients (17.4%) resided in a food desert. Univariate analysis demonstrated food desert patients had significantly increased 30-day readmission. No differences were seen in length of stay, complications, or 30-day mortality. In the adjusted logistic regression model, residing in a food desert remained a significant risk factor for readmission (odds ratio, 2.11; 95% CI, 1.07-4.15). There were no differences in 30-day, 90-day, or 1-year mortality based on food desert status, although readmission was associated with worse 90-day and 1-year mortality., Conclusions: Food desert residence was associated with 30-day readmission after esophagectomy in patients undergoing trimodality treatment for esophageal cancer in this multi-institutional population. Identification of patients residing in a food desert may allow surgeons to focus preventative interventions during treatment and postoperatively to improve outcomes., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: The purpose of this study was to determine whether the work relative value unit (workRVU) of a patient's operation can be useful as a measure of surgical complexity for the risk adjustment of surgical outcomes., Methods: We retrospectively analyzed the American College of Surgeon's National Surgical Quality Improvement Program database (2005-2018). We examined the associations of workRVU of the patient's primary operation with preoperative patient characteristics and associations with postoperative complications. We performed forward selection multiple logistic regression analysis to determine the predictive importance of workRVU. We then generated prediction models using patient characteristics with and without workRVU and compared c-indexes to assess workRVU's additive predictive value., Results: 7,507,991 operations were included. Patients who were underweight, functionally dependent, transferred from an acute care hospital, had higher American Society of Anesthesiologists class or who had medical comorbidities had operations with higher workRVU (all P < 0.0001). The subspecialties with the highest workRVU were neurosurgery (mean = 22.2), thoracic surgery (mean = 21.1), and vascular surgery (mean = 18.8) (P < 0.0001). For all postoperative complications, mean workRVU was higher for patients with the complication than those without (all P < 0.0001). For eight of 12 postoperative complications, workRVU entered the logistic regression models as a predictor variable in the 1st to 4th steps. Addition of workRVU as a preoperative predictive variable improved the c-index of the prediction models., Conclusions: WorkRVU was associated with sicker patients and patients experiencing postoperative complications and was an important predictor of postoperative complications. When added to a prediction model including patient characteristics, it only marginally improved prediction. This is possibly because workRVU is associated with patient characteristics., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Postoperative length of stay is a meaningful patient-centered outcome and an important determinant of healthcare costs. The Surgical Risk Preoperative Assessment System preoperatively predicts 12 postoperative adverse events using 8 preoperative variables, but its ability to predict postoperative length of stay has not been assessed. We aimed to determine whether the Surgical Risk Preoperative Assessment System variables could accurately predict postoperative length of stay up to 30 days in a broad inpatient surgical population., Methods: This was a retrospective analysis of the American College of Surgeons' National Surgical Quality Improvement Program adult database from 2012 to 2018. A model using the Surgical Risk Preoperative Assessment System variables and a 28-variable "full" model, incorporating all available American College of Surgeons' National Surgical Quality Improvement Program preoperative nonlaboratory variables, were fit to the analytical cohort (2012-2018) using multiple linear regression and compared using model performance metrics. Internal chronological validation of the Surgical Risk Preoperative Assessment System model was conducted using training (2012-2017) and test (2018) datasets., Results: We analyzed 3,295,028 procedures. The adjusted R 2 for the Surgical Risk Preoperative Assessment System model fit to this cohort was 93.3% of that for the full model (0.347 vs 0.372). In the internal chronological validation of the Surgical Risk Preoperative Assessment System model, the adjusted R 2 for the test dataset was 97.1% of that for the training dataset (0.3389 vs 0.3489)., Conclusion: The parsimonious Surgical Risk Preoperative Assessment System model can preoperatively predict postoperative length of stay up to 30 days for inpatient surgical procedures almost as accurately as a model using all 28 American College of Surgeons' National Surgical Quality Improvement Program preoperative nonlaboratory variables and has shown acceptable internal chronological validation., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Lung transplantation survival estimates are traditionally reported as fixed 1-, 5-, and 10-year mortality rates. Alternatively, this study aims to demonstrate how conditional survival models can provide useful prognostic information tailored to the time a recipient has already survived from the date of transplantation. Recipient data was obtained from the Organ Procurement and Transplantation Network database. Data from 24,820 adult recipients over age 18 who received a lung transplant between 2002 and 2017 were included in the study. Five-year observed conditional survival estimates were calculated by recipient age, sex, race, transplant indication, transplant type ( i.e. , single or double), and renal function at the time of transplantation. Significant variability exists in conditional survival following lung transplantation. Each specific recipient characteristic significantly impacted conditional survival during at least one time point in the first 5 years. Younger age and double lung transplantation were the two most positive predictors of improved conditional survival consistently throughout the 5-year study period. Conditional survival in lung transplantation recipients changes over time and across recipient characteristics. Hazards of mortality are not fixed and need to be dynamically evaluated as a function of time. Conditional survival calculations can provide more accurate prognostic predictions than unconditional survival estimates., Competing Interests: Disclosure: A.S.-P. received financial support from the American Association for Thoracic Surgery Cardiac Surgical Resident Investigator Award. The other authors have no conflicts of interest to report., (Copyright © ASAIO 2023.)

Background: Although some studies have compared esophagectomy outcomes by technique or approach, there is opportunity to strengthen our knowledge surrounding these outcomes. We aimed to perform a comprehensive comparison of esophagectomy postoperative complications., Methods: We retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program database (2007-2018). Esophagectomies were identified using Current Procedural Terminology codes and grouped by operative technique (Ivor Lewis, transhiatal, McKeown) and surgical approach (minimally invasive vs open esophagectomy). Twelve postoperative complications were compared. Significant complications underwent risk adjustment using multivariate logistic regression., Results: Analysis was performed on 13,457 esophagectomies: 11,202 (83.2%) open and 2255 (16.8%) minimally invasive. There were 7611 (56.6%) Ivor Lewis, 3348 (24.9%) transhiatal, and 2498 (18.6%) McKeown procedures. There were significant differences among the surgical techniques in 6 of 12 risk-adjusted complications. When comparing the outcomes of minimally invasive techniques, there were only significant differences in 2 of 12 complications: overall morbidity (minimally invasive Ivor Lewis 30.5%, minimally invasive transhiatal 43.4%, minimally invasive McKeown 40.3%, P = .0009) and infections (minimally invasive Ivor Lewis 15.4%, minimally invasive transhiatal 26.0%, minimally invasive McKeown 25.3%, P = .0003). Patients who underwent minimally invasive surgery were less likely to have overall morbidity (odds ratio, 0.68; 95% confidence interval, 0.62-0.75), respiratory complications (odds ratio, 0.77; 95% confidence interval, 0.68-0.87), urinary tract infection (odds ratio, 0.61; 95% confidence interval, 0.43-0.88), renal complications (odds ratio, 0.52; 95% confidence interval, 0.34-0.81), bleeding complications (odds ratio, 0.36; 95% confidence interval, 0.30-0.43), and nonhome discharge (odds ratio, 0.54; 95% confidence interval, 0.45-0.64), and had shorter length of stay (9.7 vs 13.2 days, P < .0001)., Conclusions: Patients undergoing minimally invasive esophagectomy have lower rates of postoperative complications regardless of esophagectomy techniques. The minimally invasive approach was associated with reduced complication variance among 3 common esophagectomy techniques., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Early recognition of esophageal perforation may prevent morbidity and mortality, and accurate diagnostic imaging facilitates triage. Stable patients with suspected perforation may be transferred to higher levels of care before appropriate work-up and diagnosis confirmation. We reviewed patients transferred for esophageal perforation to critically analyze the diagnostic workflow., Methods: We performed a retrospective review of patients transferred to our tertiary care institution from 2015-2021 for suspected esophageal perforation. Demographics, referring site characteristics, diagnostic studies, and management were analyzed. Bivariate comparisons were performed using Wilcoxon-Mann-Whitney tests for continuous variables and chi-squared or Fisher's exact tests for categorical variables., Results: Sixty-five patients were included. Etiology of suspected perforation was spontaneous in 53.8% and iatrogenic in 33.8%. Most patients were transferred within 24 hours from time of suspected perforation (66.2%). Transferring sites included seven states and were 101-300 miles (32.3%) or >300 miles (26.2%) away. CT imaging was obtained in 96.9% before transfer, most commonly demonstrating pneumomediastinum (46.2%). Only 21.5% of patients had an esophagram before transfer. Following transfer, 36.9% (n=24) were ultimately not found to have esophageal perforation, demonstrated by negative arrival esophagram in 79.1%. In patients with confirmed perforation (n=41), 58.5% had surgery, 26.8% endoscopic intervention, and 14.6% supportive care., Conclusions: After transfer a proportion of patients were ultimately found to not have esophageal perforation, typically demonstrated by negative esophagram upon arrival. We conclude that a recommendation of performing esophagram at the presenting site, when possible, may prevent unnecessary transfers, and will likely reduce costs, conserve resources, and decrease management delays., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-1798/coif). The authors have no conflicts of interest to declare., (2023 Journal of Thoracic Disease. All rights reserved.)

Background: The number of obese surgical patients continues to grow, and yet obesity's association with surgical outcomes is not totally clear. This study examined the association between obesity and surgical outcomes across a broad surgical population using a very large sample size., Methods: This was an analysis of the 2012 to 2018 American College of Surgeons National Surgical Quality Improvement database, including all patients from 9 surgical specialties (general, gynecology, neurosurgery, orthopedics, otolaryngology, plastics, thoracic, urology, and vascular). Preoperative characteristics and postoperative outcomes were compared by body mass index class (normal weight 18.5-24.9 kg/m 2 , overweight 25.0-29.9, obese class I 30.0-34.9, obese II 35.0-39.9, obese III ≥40). Adjusted odds ratios were computed for adverse outcomes by body mass index class., Results: A total of 5,572,019 patients were included; 44.6% were obese. Median operative times were marginally higher for obese patients (89 vs 83 minutes, P < .001). Compared to normal weight patients, overweight and obese patients in classes I, II, and III all had higher adjusted odds of developing infection, venous thromboembolism, and renal complications, but they did not exhibit elevated odds of other postoperative complications (mortality, overall morbidity, pulmonary, urinary tract infection, cardiac, bleeding, stroke, unplanned readmission, or discharge not home (except for class III patients)., Conclusion: Obesity was associated with increased odds of postoperative infection, venous thromboembolism, and renal but not the other American College of Surgeons National Surgical Quality Improvement complications. Obese patients need to be carefully managed for these complications., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Unplanned reoperation is an undesirable outcome with considerable risks and an increasingly assessed quality of care metric. There are no preoperative prediction models for reoperation after an index surgery in a broad surgical population in the literature. The Surgical Risk Preoperative Assessment System (SURPAS) preoperatively predicts 12 postoperative adverse events using 8 preoperative variables, but its ability to predict unplanned reoperation has not been assessed. This study's objective was to determine whether the SURPAS model could accurately predict unplanned reoperation., Methods: This was a retrospective analysis of the American College of Surgeons' National Surgical Quality Improvement Program adult database, 2012-2018. An unplanned reoperation was defined as any unintended operation within 30 d of an initial scheduled operation. The 8-variable SURPAS model and a 29-variable "full" model, incorporating all available American College of Surgeons' National Surgical Quality Improvement Program nonlaboratory preoperative variables, were developed using multiple logistic regression and compared using discrimination and calibration metrics: C-indices (C), Hosmer-Lemeshow observed-to-expected plots, and Brier scores (BSs). The internal chronological validation of the SURPAS model was conducted using "training" (2012-2017) and "test" (2018) datasets., Results: Of 5,777,108 patients, 162,387 (2.81%) underwent an unplanned reoperation. The SURPAS model's C-index of 0.748 was 99.20% of that for the full model (C = 0.754). Hosmer-Lemeshow plots showed good calibration for both models and BSs were similar (BS = 0.0264, full; BS = 0.0265, SURPAS). Internal chronological validation results were similar for the training (C = 0.749, BS = 0.0268) and test (C = 0.748, BS = 0.0250) datasets., Conclusions: The SURPAS model accurately predicted unplanned reoperation and was internally validated. Unplanned reoperation can be integrated into the SURPAS tool to provide preoperative risk assessment of this outcome, which could aid patient risk education., (Copyright © 2022 Elsevier Inc. All rights reserved.)