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Introduction: Gallbladder cancer (GBC) incidence is rising, yet prognosis remains poor. Oncological resection of stage T1b or higher improves survival, yet many patients do not receive appropriate resection. This study aims to evaluate factors that may attribute to this discrepancy using the Surveillance, Epidemiology, and End Results-Medicare (SEER-Medicare) database., Materials and Methods: SEER Medicare (2008-2015) patients with GBC stage T1b or higher were classified as receiving cholecystectomy alone (CCY) or cholecystectomy and liver/biliary resection (oncologic resection). Outcomes and overall survival were compared, before and after propensity score matching on baseline characteristics, using Chi-square and Wilcoxon rank-sum tests for categorical and continuous variables, respectively., Results: We identified 1129 patients of which 830 underwent CCY (58.3% early stage/41.7% late stage) while 299 had complete resection (54.2% early stage/45.8% late stage). CCY patients were more often female (73.4% versus 65.6%; P = 0.0104), ≥80 y old (48.2% versus 22.4%; P < 0.0001), frail (44.5% versus 27.1%; P < 0.0001), treated by general surgeons (98.1% versus 84.9%; P < 0.0001) versus surgical oncologists, not undergoing chemotherapy (72.3% versus 54.5%; P < 0.0001), managed at nonacademic hospitals (51.2% versus 28.4%; P < 0.0001). After matching, oncologic resection demonstrated improved overall survival compared to CCY at 1-y (69.2% versus 47.2%; P < 0.0001), 3-y (42.8% versus 21.1%; P < 0.0001), and 5-y (37.5% versus 17.4%; P < 0.0001)., Conclusions: Most GBC patients may not be receiving appropriate oncological resection, especially patients who are female, older, frail, operated on by a general surgeon, not undergoing chemotherapy, or managed at nonacademic hospitals. Even when adjusting for patient factors, complete resection is associated with overall survival outcomes at multiple endpoints. Limiting sex, age, and frail status as factors and involving surgical oncologists or receiving management at academic centers may increase oncologic resection rates and thus improve survival for GBC patients., (Copyright © 2024. Published by Elsevier Inc.)

Background: The relationship between hospital volume and surgical mortality is well documented. However, complete centralization of surgical care is not always feasible. The present study investigates how overall volume of upper gastrointestinal surgery at hospitals influences patient outcomes following resection for gastric adenocarcinoma., Patients and Methods: National Cancer Database (2010-2019) patients with pathologic stage 1-3 gastric adenocarcinoma who underwent gastrectomy were identified. Three cohorts were created: low-volume hospitals (LVH) for both gastrectomy and overall upper gastrointestinal operations, mixed-volume hospital (MVH) for low-volume gastrectomy but high-volume overall upper gastrointestinal operations, and high-volume gastrectomy hospitals (HVH). Chi-squared tests were used to analyze sociodemographic factors and surgical outcomes and Kaplan-Meier method for survival analysis., Results: In total, 26,398 patients were identified (LVH: 20,099; MVH: 539; HVH: 5,760). The 5-year survival was equivalent between MVH and HVH for all stages of disease (MVH: 56.0%, HVH 55.6%; p = 0.9866) and when stratified into early (MVH: 69.9%, HVH: 65.4%; p = 0.1998) and late stages (MVH: 24.7%, HVH: 32.0%; p = 0.1480), while LVH had worse survival. After matching patients, postoperative outcomes were worse for LVH, but there was no difference between MVH and HVH in terms of adequate lymphadenectomy, margin status, readmission rates, and 90-day mortality rates., Conclusions: Despite lower gastrectomy volume for cancer, postoperative gastrectomy outcomes at centers that perform a high number of upper gastrointestinal cancer surgeries were similar to hospitals with high gastrectomy volume. These hospitals offer a blueprint for providing equivalent outcomes to high volume centers while enhancing availability of quality cancer care., (© 2024. Society of Surgical Oncology.)

Introduction: Diversity in medicine has a positive effect on outcomes, especially for Asian patients. We sought to evaluate representation of Asians across entry and leadership levels in surgical training., Methods: Publicly accessible population data from 2018 to 2023 were collected from the US Census Bureau, the Association of American Medical Colleges, and the American Board of Surgery (ABS). Frequencies based on self-identified Asian status were identified, and proportions were calculated., Results: The US census showed Asians constituted 4.9% of the US population in 2018 versus 6% in 2023. The proportion of Asian medical students rose from 21.6% to 24.8%; however, Asian surgical residency applicants remained constant at 20%. ABS certifications of Asians have increased from 13.7% to 18.5%. ABS examiners increased from 15.7% to 17.1%., Conclusions: In 5 years, Asians have made numeric gains in medical school and surgical training. However, Asian representation lags at Board examiner levels compared to the medical student population. The ABS has made recent efforts at transparency around examiner and examinee characteristics. A pillar of ensuring a well-trained surgical workforce to serve the public is to mandate that all surgical trainees and graduates undergo fair examinations, and are fairly assessed on their qualifications. Observed progress should further invigorate all surgical applicants, residents and leadership to take an even more active role in making surgery more diverse and welcoming to all, by including careful analyses of diversity at all levels., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Timely treatment for patients with colorectal cancer may have been disrupted by the COVID-19 pandemic. We evaluated the impact of the pandemic on delays to treatment with surgery or systemic therapy for patients with colorectal cancer and delineated factors predictive of delayed treatment., Methods: Using the National Cancer Database, patients diagnosed with colorectal cancer were categorized by year of diagnosis as COVID-19 era (2020) versus pre-COVID-19 (2018-2019). Categorical variables were compared by χ 2 analysis. Multivariate logistic regression was used to assess odds ratios for delayed time to surgery or chemoimmunotherapy, defined as >60 days., Results: In total, 50,689 patients colorectal cancer were diagnosed patients who were pre-COVID-19 vs 21,331 within the COVID-19-era. Patients diagnosed with COVID-19 had a higher stage at diagnosis. There were no differences in the proportion of delayed time to surgery for patients diagnosed in 2020, but patients who were tested for COVID-19 had increased proportions of delayed time to surgery (P < .0001). In multivariate analysis, Black race (P = .0026) and uninsured/underinsured status (P = .0017) were associated with delayed time to surgery. Diagnosis during COVID-19 did not increase delayed time to chemoimmunotherapy, regardless of COVID-19 testing or positivity; however, delays were seen for Black (P < .0001), Hispanic (P < .0001), and uninsured/underinsured patients (P < .0001)., Conclusion: Although the pandemic did not delay treatment for colorectal cancer overall, vulnerable and underserved populations were disproportionately affected by delays to all forms of therapy. The difference in colorectal cancer outcomes in the coming years as a result of delays in treatment may be significant for these patients., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Initial treatment for nonmetastatic breast cancer is resection or neoadjuvant systemic therapy, depending on tumor biology and patient factors. Delays in treatment have been shown to impact survival and quality of life. Little has been published on the performance of safety-net hospitals in delivering timely care for all patients., Methods: We conducted a retrospective study of patients with invasive ductal or lobular breast cancer, diagnosed and treated between 2009 and 2019 at an academic, safety-net hospital. Time to treatment initiation was calculated for all patients. Consistent with a recently published Committee on Cancer timeliness metric, a treatment delay was defined as time from tissue diagnosis to treatment of greater than 60 days., Results: A total of 799 eligible women with stage 1-3 breast cancer met study criteria. Median age was 60 years, 55.7% were non-white, 35.5% were non-English-speaking, 18.9% were Hispanic, and 49.4% were Medicaid/uninsured. Median time to treatment was 41 days (IQR 27-56 days), while 81.1% of patients initiated treatment within 60 days. The frequency of treatment delays did not vary by race, ethnicity, insurance, or language. Diagnosis year was inversely associated with the occurrence of a treatment delay (OR: 0.944, 95% CI 0.893-0.997, p value: 0.039)., Conclusion: At our institution, race, ethnicity, insurance, and language were not associated with treatment delay. Additional research is needed to determine how our safety-net hospital delivered timely care to all patients with breast cancer, as reducing delays in care may be one mechanism by which health systems can mitigate disparities in the treatment of breast cancer., (© 2023. Society of Surgical Oncology.)

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: Adherence to current recommendations for optimal time from diagnosis to treatment for patients with breast cancer may have been disrupted by the COVID-19 pandemic. This study aimed to evaluate the impact of the pandemic on time to surgery or systemic treatment with chemotherapy or immunotherapy for patients diagnosed with breast cancer., Methods: Using the National Cancer Database, patients diagnosed with breast cancer in 2020 were compared to those diagnosed from 2018-2019 (Pre-COVID). Sub-analyses were performed for patients who were tested for COVID-19 and those who had a positive result in 2020. Multivariate logistic regression was used assess odds ratios for delayed time to surgery (DTS, defined as > 90 days) or systemic therapy (defined as > 120 days)., Results: In total, 230,997 patients were diagnosed with breast cancer in 2018 and 2019 compared to 102,065 in 2020. Of the 2020 cohort, 47,659 (46.7%) received COVID-19 testing; of which, 3,158 (6.6%) resulted positive. A larger proportion of COVID-tested or COVID-positive patients had higher stage at diagnosis. DTS was more likely for patients who were diagnosed in 2020, uninsured or underinsured, non-white, Hispanic, less educated, or age < 70 years. Similar factors were predictive of delay to systemic therapy (less age < 70 years); however, diagnosis in 2020 was not., Conclusion: The COVID-19 pandemic was associated with significant DTS for breast cancer but spared time to systemic therapy. Delays disproportionately impacted vulnerable and underserved patient populations. The true clinical effects of these delays may yet be realized for breast cancer patients., (© 2023. Society of Surgical Oncology.)

Background: We previously demonstrated the importance of combined complex surgery volume on short-term outcomes of high-risk cancer operations. This study investigates the impact of combined common complex cancer operation volume on long-term outcomes at hospitals with low cancer-specific operation volumes., Patients and Methods: A retrospective cohort of National Cancer Data Base (2004-2019) patients undergoing surgery for hepatocellular carcinoma, non-small cell lung cancers, or pancreatic, gastric, esophageal, or rectal adenocarcinomas was utilized. Three separate cohorts were established: low-volume hospitals (LVH), mixed-volume hospitals (MVH) with low-volume individual cancer operations and high-volume total complex operations, and high-volume hospitals (HVH). Survival analyses were performed for overall, early-, and late-stage disease., Results: The 5 year survival was significantly better at MVH and HVH compared with LVH, for all operations except late-stage hepatectomy (HVH survival > LVH and MVH). The 5 year survival probability was similar between MVH and HVH for operations on late-stage cancers. Early and overall survival for gastrectomy, esophagectomy, and proctectomy were equivalent between MVH and HVH. While early and overall survival for pancreatectomy were benefited by HVH over MVH, the opposite was true for lobectomy/pneumonectomy, which were benefited by MVH over HVH; however, none of these differences were likely to have an effect clinically. Only hepatectomy patients demonstrated statistical and clinical significance in 5 year survival at HVH compared with MVH for overall survival., Conclusions: MVH hospitals performing sufficient complex common cancer operations demonstrate similar long-term survival for specific high-risk cancer operations to HVH. MVH provide an adjunctive model to the centralization of complex cancer surgery, while maintaining quality and access., (© 2023. Society of Surgical Oncology.)

Background: The COVID-19 pandemic resulted in disruption of healthcare services, including cancer screenings, yet data on this are limited. We sought to compare observed and expected cancer incidence rates for screenable cancers, quantifying potential missed diagnoses., Study Design: Lung, female breast, and colorectal cancer patients from 2010 to 2020 in the National Cancer Database were standardized to calculate annual incidence rates per 100,000. A linear regression model of 2010 through 2019 incidence rates (pre-COVID) was used to calculate predicted 2020 incidence compared with observed incidence in 2020 (COVID) with subanalyses for age, sex, race, ethnicity, and geographic region., Results: In total, 1,707,395 lung, 2,200,505 breast, and 1,066,138 colorectal cancer patients were analyzed. After standardizing, the observed 2020 incidence was 66.888, 152.059, and 36.522 per 100,000 compared with the predicted 2020 incidence of 81.650, 178.124, and 44.837 per 100,000, resulting in an observed incidence decrease of -18.1%, -14.6%, and -18.6% for lung, breast, and colorectal cancer, respectively. The difference was amplified on subanalysis for lung (female, 65 or more years old, non-White, Hispanic, Northeastern and Western region), breast (65 or more years old, non-Black, Hispanic, Northeastern and Western region), and colorectal (male, less than 65 years old, non-White, Hispanic, and Western region) cancer patients., Conclusions: The reported incidence of screenable cancers significantly decreased during the COVID-19 pandemic (2020), suggesting that many patients currently harbor undiagnosed cancers. In addition to the human toll, this will further burden the healthcare system and increase future healthcare costs. It is imperative that providers empower patients to schedule cancer screenings to flatten this pending oncologic wave., (Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Male breast cancer (MBC) is rare, and management is extrapolated from trials that enroll only women. It is unclear whether contemporary axillary management based on data from landmark trials in women may also apply to men with breast cancer. This study aimed to compare survival in men with positive sentinel lymph nodes after sentinel lymph node biopsy (SLNB) alone versus complete axillary dissection (ALND)., Patients and Methods: Using the National Cancer Database, men with clinically node-negative, T1 and T2 breast cancer and 1-2 positive sentinel nodes who underwent SLNB or ALND were identified from 2010 to 2020. Both 1:1 propensity score matching and multivariate regression were used to identify patient and disease variables associated with ALND versus SLNB. Survival between ALND and SLNB were compared using Kaplan-Meier methods., Results: A total of 1203 patients were identified: 61.1% underwent SLNB alone and 38.9% underwent ALND. Treatment in academic centers (36.1 vs. 27.7%; p < 0.0001), 2 positive lymph nodes on SLNB (32.9 vs. 17.3%, p < 0.0001) and receipt or recommendation of chemotherapy (66.5 vs. 52.2%, p < 0.0001) were associated with higher likelihood of ALND. After propensity score matching, ALND was associated with superior survival compared with SLNB (5-year overall survival of 83.8 vs. 76.0%; log-rank p = 0.0104)., Discussion: The results of this study suggest that among patients with early-stage MBC with limited sentinel lymph node metastasis, ALND is associated with superior survival compared with SLNB alone. These findings indicate that it may be inappropriate to extrapolate the results of the ACOSOG Z0011 and EORTC AMAROS trials to MBC., (© 2023. Society of Surgical Oncology.)

Academic surgery has changed along with the rest of the world in response to the COVID pandemic. With increasing rates of vaccination against COVID over the past 2 y, we have slowly but steadily made progress toward controlling the spread of the virus. Surgeons, academic surgery departments, health systems, and trainees are all attempting to establish a new normal in various domains-clinical, research, teaching, and in their personal lives. How has the pandemic changed these areas? At the 2022 Academic Surgical Congress Hot Topics session, we attempted to address these issues., (Published by Elsevier Inc.)

For this lecture, I was inspired by Dr. Bryan Richmond's Southeastern Surgical Congress presidential address, "Finding your own unique place in the house of surgery." I struggled to find my own place in cancer surgery. The choices available to me and those who came before me enabled the wonderful career I am blessed to enjoy. What I share as part of my own story. My words do not represent those of my institutions or any organizations of which I am privileged to belong.

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.)

Background: The COVID-19 pandemic strained oncologic care access and delivery, yet little is known about how it impacted hepatocellular carcinoma (HCC) management. Our study sought to evaluate the annual effect of the COVID-19 pandemic on time to treatment initiation (TTI) for HCC., Methods: The National Cancer Database was queried for patients diagnosed with clinical stages I-IV HCC (2017-2020). Patients were categorized based on their year of diagnosis as "Pre-COVID" (2017-2019) and "COVID" (2020). TTI based on stage and type of treatment first received was compared by the Mann-Whitney U test. A logistic regression model was used to evaluate factors of increased TTI and treatment delay (> 90 days)., Results: In total, 18,673 patients were diagnosed during Pre-COVID, whereas 5249 were diagnosed during COVID. Median TTI for any first-line treatment modality was slightly shorter during the COVID year compared with Pre-COVID (49 vs. 51 days; p < 0.0001), notably in time to ablation (52 vs. 55 days; p = 0.0238), systemic therapy (42 vs. 47 days; p < 0.0001), and radiation (60 vs. 62 days; p = 0.0177), but not surgery (41 vs. 41 days; p = 0.6887). In a multivariate analysis, patients of Black race, Hispanic ethnicity, and uninsured/Medicaid/Other Government insurance status were associated with increased TTI by factors of 1.057 (95% CI: 1.022-1.093; p = 0.0013), 1.045 (95% CI: 1.010-1.081; p = 0.0104), and 1.088 (95% CI: 1.053-1.123; p < 0.0001), respectively. Similarly, these patient populations were associated with delayed treatment times., Conclusions: For patients diagnosed during COVID, TTI for HCC, while statistically significant, had no clinically significant differences. However, vulnerable patients were more likely to have increased TTI., (© 2023. Society of Surgical Oncology.)

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.)

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.)

Competing Interests: The authors report no conflicts of interest.

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.)

In this series of talks and the accompanying panel session, leaders from the Society of Asian Academic Surgeons discuss issues faced by Asian Americans and the importance of the role of mentors and allyship in professional development in the advancement of Asian Americans in leadership roles. Barriers, including the model minority myth, are addressed. The heterogeneity of the Asian American population and disparities in healthcare and in research, specifically as relates to Asian Americans, also are examined., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: International Classification of Disease, ninth/tenth revision codes are used to identify patients with appendicitis and classify severity of disease for research and hospital reimbursement. We sought to determine accuracy of International Classification of Disease, ninth/tenth revision codes in classifying appendicitis as uncomplicated versus complicated (defined as perforated, necrotic, or abscess) compared with the clinical gold standard: surgeon characterization of the appendix in the operative report., Methods: Retrospective review of operative reports and discharge International Classification of Disease, ninth/tenth revision codes for patients ≥18 years old who underwent noninterval, nonincidental appendectomy between January 2012 and December 2019 at a tertiary referral center. Sensitivity, specificity, and positive predictive value were calculated for International Classification of Disease, ninth/tenth revision codes to classify appendicitis accurately as complicated compared with surgeon description. ICD-9/10 codes and surgeon description were categorized into complicated/uncomplicated based on the American Association for the Surgery of Trauma grading system., Results: In the study, 1,495 patients with acute appendicitis underwent appendectomy. Per surgeon description, 200 (13%) were complicated and 1,295 (87%) uncomplicated. Compared with surgeon description, discharge International Classification of Disease, ninth/tenth revision codes did not accurately identify complicated appendicitis: sensitivity = 0.68, positive predictive value = 0.77. As a sensitivity analysis, the cohort was stratified by public versus private payers, and the results did not change., Conclusion: International Classification of Disease, ninth/tenth revision codes do not accurately identify surgeon-described complicated appendicitis. Nearly one-third of the cases of complicated appendicitis were coded as uncomplicated. Such misclassification negatively impacts reimbursement for complicated appendicitis care and could lead to misleading results in research and quality improvement activities that rely on these codes., (Copyright © 2022 Elsevier Inc. All rights reserved.)

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.)

Objective: This study assesses how the volume of pancreatic-adjacent operations (PAO) impacts the outcomes of pancreaticoduodenectomy (PD)., Summary Background Data: It is well-established that regionalization benefits outcomes after PD. However, due to a multitude of factors, including geographic, financial, and personal, not all patients receive their care at high-volume pancreas surgery centers., Methods: The National Cancer Database was queried for pancreatic cancer patients who underwent PD. Hospital volume was calculated for PD and PAO (defined as gastric, hepatic, complex biliary, or pancreatic operations other than PD) and dichotomized as low- and high-volume centers based on the median. Three study cohorts were created: low-volume hospitals (LVH) for both PD and PAO, mixed-volume hospital (MVH) with low-volume PD but high-volume PAO, and high-volume PD hospital (HVH)., Results: In total, 24,572 patients were identified, with 41.5%, 7.2%, and 51.3% patients treated at LVH, MVH, and HVH, respectively. Thirty-day mortality for PD was 5.6% in LVH, 3.2% in MVH, and 2.5% in HVH. On multivariable analyses, LVH was predictive for higher 30-day mortality compared to HVH [odds ratio (OR) 2.068; 95% confidence interval (CI) 1.770-2.418; P< 0.0001]. However, patients at MVH demonstrated similar 30-day mortality to patients treated at HVH (OR 1.258; 95% CI 0.942-1.680; P = 0.1203)., Conclusions: PD outcomes at low-volume centers that have experience with complex cancer operations near the pancreas are similar to PD outcomes at hospitals with high PD volume. MVH provides a model for PD outcomes to improve quality and access for patients who cannot, or choose not to, receive their care at high-volume centers., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

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: 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: ICD codes are used to identify patients with appendicitis and to classify disease severity for reimbursement and research purposes. We sought to compare the accuracy of ICD-9 vs ICD-10 codes in classifying appendicitis as uncomplicated vs complicated (defined as perforated, necrotic, or abscess) compared with the clinical gold standard: surgeon characterization of the appendix in the operative report., Study Design: This is a retrospective review of operative reports and discharge ICD-9/10 codes for patients 18 years or older who underwent noninterval, nonincidental appendectomy from January 2012 to December 2019 at a tertiary referral center. Sensitivity, specificity, and positive predictive value were calculated for ICD-9/10 codes to classify appendicitis as complicated when compared with surgeon description. Chi-square testing was used to compare agreement between ICD-9/10 codes and surgeon description., Results: A total of 1,585 patients underwent appendectomy. ICD-9 codes had higher sensitivity than ICD-10 codes for complicated appendicitis (sensitivity 0.84 and 0.54, respectively) and a similar positive predictive value (0.77 and 0.76, respectively). Overall, 91% of ICD-9 codes agreed with surgical description of disease, but 84.4% of ICD-10 codes agreed with surgical description (p < 0.01). Among cases classified as complicated by the surgeon, 84% (79/94) had an accurate ICD-9 code for complicated disease, but only 53.8% (57/106) of cases had an accurate ICD-10 code (p < 0.01)., Conclusions: Compared with ICD-9 codes, ICD-10 codes were less accurate in characterizing severity of appendicitis. The ICD-10 coding schema does not provide an accurate representation of disease severity. Until this system is improved, significant caution is needed for people who rely on these data for billing, quality improvement, and research purposes., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: As fellowship training after general surgery residency has become increasingly common, the impact on resident education must be considered. Patient safety and procedure outcomes are often used as justification by attendings who favor fellows over residents in certain minimally invasive surgery (MIS) operations. The aim of the present study was to compare the impact of trainee level on the outcomes of selected MIS operations to determine if giving preference to fellows on grounds of outcomes is warranted., Methods: Patients who underwent elective laparoscopic hiatal hernia repair (LHHR), laparoscopic sleeve gastrectomy (LSG), laparoscopic Roux-en-Y gastric bypass (LRYGB), laparoscopic splenectomy (LS), laparoscopic cholecystectomy (LC), or laparoscopic ventral hernia repair (LVHR) with assistance of a general surgery chief resident or fellow were identified from the American College of Surgeon's National Surgical Quality Improvement Program database (2007-2012). Patients were matched 1:1 based on propensity score for the odds of undergoing operations assisted by a fellow., Results: 5145 patients underwent LHHR, 1396 LSG, 9656 LRYGB, 863 LS, 13,434 LC, and 3069 LVHR. Fellows assisted in 41.7% of LHHR, 49.2% of LSG, 56.4% of LRYGB, 25.7% of LS, 17.1% of LC, and 27.0% of LVHR cases. After matching, overall and severe complication rates were comparable between cases performed with assistance of a fellow or chief resident. Median operative time was longer for LSG, LRYGB, and LC when a fellow assisted., Conclusions: Surgical outcomes were similar between fellow and chief resident assistance in MIS operations, arguing that increased resident participation in basic and complex laparoscopic operations is appropriate without compromising patient safety., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: We sought to enhance opportunities for general surgery residents to conduct research during residency without having to take dedicated time out of clinical training. To this end, we created structured research rotations to facilitate and support resident research., Design: Research blocks of four week's duration were introduced for categorical interns and post-graduate year (PGY) 4 residents. Interns had no clinical responsibilities during their research blocks while PGY 4 residents shadowed their mentor in the clinical setting. Research projects were developed and prepared in advance to maximize productivity during the research rotation., Setting: General surgery residency program at an urban, academic, safety-net, tertiary care hospital PARTICIPANTS: Categorical general surgery interns and PGY 4 general surgery residents RESULTS: The research rotations were first offered in the 2019 to 2020 academic year (AY). 10 interns and 11 PGY 4 residents have since completed the rotations; of the PGY 4 residents, 6 had not previously taken any time off for research activities. Research projects varied between residents and focused on basic science, clinical outcomes, quality improvement, and education., Conclusions: Through establishment of dedicated research rotations, we were able to increase resident engagement in a variety of research activities. We provide a simple model for training programs seeking increased research engagement and productivity for their residents without extending training time., (Copyright © 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

There have been tremendous advances in the diagnosis and treatment of pancreatic cancer in the past decade, yet we are failing to achieve equitable outcomes for all patient populations. Disparities exist in the incidence, diagnosis, treatment, and outcomes of patients with pancreatic cancer. Inequities are based on racial and ethnic group, sex, socioeconomic status, and geography. To address disparities, future steps must focus on research methods, including collection and methodology, and policy measures, including access, patient tools, hospital incentives, and workforce diversity. Through these comprehensive efforts, we can begin to rectify inequitable care for treatment of patients with pancreatic cancer., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To Study the Outcomes of the First Virtual General Surgery Certifying Exam of the American Board of Surgery., Summary of Background Data: The ABS General Surgery CE is normally an in-person oral examination. Due to the COVID-19 outbreak, the ABS was required to reschedule these. After 2 small pilots, the CE's October administration represented the first large-scale remote virtual exam. The purpose of this report is to compare the outcomes of this virtual and the previous in-person CEs., Methods: CE candidates were asked to provide feedback on their experience via a survey. The passing rate was compared to the 1025 candidates who took the 2019-2020 in-person CEs., Results: Of the 308 candidates who registered for the virtual CE, 306 completed the exam (99.4%) and 188 completed the survey (61.4%). The majority had a very positive experience. They rated the virtual CE as very good/excellent in security (90%), ease of exam platform (77%), audio quality (71%), video quality (69%), and overall satisfaction (86%). Notably, when asked their preference, 78% preferred the virtual exam. There were no differences in the passing rates between the virtual or in-person exams., Conclusions: The first virtual CE by the ABS was completed using available internet technology. There was high satisfaction, with the majority preferring the virtual platform. Compared to past in-person CEs, there was no difference in outcomes as measured by passing rates. These data suggest that expansion of the virtual CE may be desirable., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, 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.)

Objective: To train practicing surgeons in robot-assisted distal pancreatectomy (RADP) and assess the impact on 5 domains of healthcare quality., Background: RADP may reduce the treatment burden compared with open distal pancreatectomy (ODP), but studies on institutional training and implementation programs are scarce., Methods: A retrospective, single-center, cohort study evaluating surgical performance during a procedure-specific training program for RADP (January 2006 to September 2017). Baseline and unadjusted outcomes were compared "before training" (ODP only; June 2012). Exclusion criteria were neoadjuvant therapy, vascular- and unrelated organ resection. Run charts evaluated index length of stay (LOS) and 90-day comprehensive complication index. Cumulative sum charts of operating time (OT) assessed institutional learning. Adjusted outcomes after RADP versus ODP were compared using a secondary propensity-score-matched (1:1) analysis to determine clinical efficacy., Results: After screening, 237 patients were included in the before-training (133 ODP) and after-training (24 ODP, 80 RADP) groups. After initiation of training, mean perioperative blood loss decreased (-255 mL, P<0.001), OT increased (+65 min, P < 0.001), and median LOS decreased (-1 day, P < 0.001). All other outcomes remained similar (P>0.05). Over time, there were nonrandom (P < 0.05) downward shifts in LOS, while comprehensive complication index was unaffected. We observed 3 learning curve phases in OT: accumulation (<31 cases), optimization (case 31-65), and a steady-state (>65 cases). Propensity-score-matching confirmed reductions in index and 90-day LOS and blood loss with similar morbidity between RADP and ODP., Conclusion: Supervised procedure-specific training enabled successful implementation of RADP by practicing surgeons with immediate improvements in length of stay, without adverse effects on safety., Competing Interests: The authors report no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

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: Gallbladder cancer has a high mortality rate and an increasing incidence. The current National Comprehensive Cancer Network (NCCN) guidelines recommend resection for all T1b and higher-stage cancers. This study aimed to evaluate re-resection rates and the associated survival impact for patients with gallbladder cancer., Methods: Patients with gallbladder adenocarcinoma who underwent resection were identified from the National Cancer Database (2004-2015). Re-resection was defined as definitive surgery within 180 days after the first operation. Propensity scores were created for the odds of a patient having a re-resection. Patients were matched 1:2. Survival analyses were performed using the Kaplan-Meier and Cox proportional hazard methods., Results: The study identified 6175 patients, and 466 of these patients (7.6%) underwent re-resection. Re-resection was associated with younger median age (65 vs 72 years; p < 0.0001), private insurance (41.6% vs 27.1%; p < 0.0001), academic centers (50.4% vs 29.7%; p < 0.0001), and treatment location in the Northeast (22.8% vs 20.4%; p = 0.0011). Compared with no re-resection, re-resection was associated with pT stage (pT2: 47.6% vs 42.8%; p = 0.0139) and pN stage (pN1-2: 28.1% vs 20.7%; p < 0.0001), negative margins on final pathology (90.1% vs 72.6%; p < 0.0001), and receipt of chemotherapy (53.7% vs 35.8%; p < 0.0001). The patients who underwent re-resection demonstrated significantly longer overall survival (OS) than the patients who did not undergo re-resection (median OS, 44.0 vs 23.0 months; p < 0.0001). After propensity score-matching, re-resection remained associated with superior survival (median OS, 44.0 vs 31.0 months; p = 0.0004)., Conclusions: Re-resection for gallbladder cancer is associated with improved survival but remains underused, particularly for early-stage disease.

Background: Ventral hernia repair is common in the expanding aging population, but remains challenging due to their frequent comorbidities. The purpose of this study is to compare the surgical outcomes of open vs. laparoscopic ventral hernia repair in elderly patients., Methods: Patients ≥ 65 years of age that underwent elective open or laparoscopic ventral hernia repair were identified from the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database. To reduce potential selection bias, propensity scores were created for the likelihood of undergoing laparoscopic surgery based on patients' demographics and comorbidities. Patients were matched based on the logit of the propensity scores. Thirty-day surgical outcomes were compared after matching using Chi-square test for categorical variables and the Wilcoxon Rank-Sum test for continuous variables., Results: 35,079 (71.1%) and 14,270 (28.9%) patients underwent open and laparoscopic ventral hernia repairs, respectively. Laparoscopic surgery was associated with a lower overall morbidity (5.9% vs. 9.1%; p < 0.001) compared to open repair. The incidence of surgical site infections (1.1% vs. 3.5%; p < 0.001), post-operative infections (2.7% vs. 3.6%; p < 0.001), and reoperation (1.7% vs. 2.1%; p = 0.009) were all lower after laparoscopic repair. All other major surgical outcomes were either better with laparoscopy or comparable between both treatment groups except for operative time., Conclusion: Although open surgery remains the most prevalent in the elderly population, the results of this study suggest that laparoscopic surgery is safe and associated with a lower risk of overall morbidity, surgical site infections, and reoperation.

Background: There is a long history of segregation in the U.S.A with enduring impacts on cancer outcomes today. We evaluated the impact of segregation on racial disparities in Hepatocellular Carcinoma (HCC) treatment and outcomes., Methods: We obtained data on black and white patients with HCC from the SEER program (2005-2015) within the 100 most populous participating counties. Our exposure was the index of dissimilarity (IoD), a validated measure of segregation. Outcomes were overall survival, advanced stage at diagnosis (Stage III/IV) and surgery for localized disease (Stage I/II). Cancer-specific survival was assessed using Kaplan-Meier estimates., Results: Black patients had a 1.18 times increased risk (95%CI 1.14,1.22) of presenting at advanced stage as compared to white patients and these disparities disappeared at low levels of segregation. In the highest quartile of IoD, black patients had a significantly lower survival than white (17 months vs 27 months, p < 0.001), and this difference disappeared at the lowest quartile of IoD., Conclusions: Our data illustrate that structural racism in the form racial segregation has a significant impact on racial disparities in the treatment of HCC. Urban and health policy changes can potentially reduce disparities in HCC outcomes., (Copyright © 2021 International Hepato-Pancreato-Biliary Association Inc. Published by Elsevier Ltd. All rights reserved.)

Background: Disparities in pancreatic cancer outcomes between black and white patients are well documented. This study aimed to use a more novel index to examine the impact of racial segregation on the diagnosis, management, and outcomes of pancreatic cancer in black patients compared with white patients., Methods: Black and white adults with pancreatic cancer in urban counties were identified using data from the 2018 submission of the Surveillance, Epidemiology and End Results (SEER) Program and the 2010 Census. The racial index of dissimilarity (IoD), a validated proxy of racial segregation, was used to assess the evenness with which whites and blacks are distributed across census tracts in each county. Multivariate Poisson regression was performed, and stepwise models were constructed for each of the outcomes. Overall survival was studied using the Kaplan-Meier method., Results: The study enrolled 60,172 adults with a diagnosis of pancreatic cancer between 2005 and 2015. Overall, the black patients (13.8% of the cohort) lived in more segregated areas (IoD, 0.67 vs 0.61; p < 0.05). They were less likely to undergo surgery for localized disease (relative risk [RR], 0.80; 95% confidence interval [CI], 0.76-0.83) and more frequently had a diagnosis of advanced-stage disease (RR, 1.09; 95% CI, 1.01-1.19) with increasing segregation. They also had shorter survival times (9.8 vs 11.4 months; p < 0.05)., Conclusions: Disparities in advanced-stage disease at diagnosis, surgery for localized disease, and overall survival are directly related to the degree of residential segregation, a proxy for structural racism. In searching for solutions to this problem, it is important to account for the historical marginalization of black Americans.

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.)

Introduction: Pancreaticoduodenectomy is one of the more complicated operations that exists in surgery, and is fraught with potential morbidity, the most well-known, and dreaded, of which is the pancreatic leak. While much of the risk associated with pancreatic leak is inherent to the operation, there have been no shortage of techniques employed by surgeons to try to mitigate that risk., Methods: We focused on four topics of greatest conjecture with regard to reconstruction after pancreaticoduodenectomy: (1) the type of anastomosis, (2) the enteral organ to which the pancreas is sewn, (3) whether to preserve the pylorus and (4) whether or not to use anastomotic silastic stents. We identified the most relevant randomized control trials on each topic, which were appropriately powered., Results: We identified a total of 15 studies for evaluation, (type of anastomosis: n = 4; enteral organ to which the pancreas is sewn: n = 4; whether to preserve the pylorus, n=3; and whether or not to use anastomotic silastic stents, n = 4). In each group of comparisons, there was no definitive conclusion to be made on superiority of reconstruction., Conclusion: While clear consensus on how best to reconstruct the anatomy after pancreaticoduodenectomy has not yet been reached, we present the following review in the hope of providing some understanding of the literature for the pancreatic surgeon.

Competing Interests: The authors report no conflicts of interest.

Objectives: Surgery residents have few opportunities to work closely with attending surgeons or conduct research during clinical time. We hypothesized that a mentorship elective with a required research project would benefit residents' career development, including their personal connections with faculty mentors, and would help them build their academic portfolio., Design: We created a mentorship elective designed as a one-on-one apprenticeship. Completion of a scholarly project was a core component of the elective. Residents, faculty, and the most senior resident ('non-mentee') on the same service as the elective resident were interviewed after the completion of their rotation., Setting: University-based surgery residency at Boston Medical Center, Boston, MA., Participants: All 5 residents in postgraduate year 4 (PGY-4) participated in the mentorship elective during the 2019 to 2020 academic year. Residents identified their faculty mentor. All mentees (5/5), most mentors (4/5), and all non-mentees (4/4) were interviewed., Results: All mentees reported interacting with their mentor daily, performing clinical duties or discussing their research project. For mentees, the top factor when selecting their mentor was the mentor's clinical expertise, and the most valuable aspect of the rotation was developing a relationship with their mentor. All mentors responded that their mentee gained an understanding of running an academic surgical practice and developed research skills. Four of 5 mentees completed critical portions of their scholarly project during the elective with one publishing in a peer-reviewed journal, 2 having their work accepted to a national conference, and one creating vascular surgery educational videos. All stated the elective was valuable., Conclusions: A structured apprenticeship rotation allowed for closer relationships with attending surgeons and increased the scholarly achievement of PGY-4 surgery residents. We provide an example of how to incorporate a successful elective rotation into the surgery curriculum that strengthens resident career development and research productivity., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The present study compares the senior level operative experience of graduates from the traditional vascular surgery fellowship (5 + 2) and integrated vascular surgery training programs (0 + 5) using contemporary operative case log data., Methods: The Accreditation Council for Graduate Medical Education integrated vascular surgery, vascular surgery fellowship, and general surgery case logs for trainees graduating between 2013 and 2018 were queried for vascular surgery procedures. "Senior" cases were categorized as cases logged as "surgeon fellow" by 5 + 2 trainees or "surgeon chief" (post graduate year-4,5) by 0 + 5 trainees. Overall case volume was defined as the combined volume of cases logged as "surgeon junior," "surgeon chief," "surgeon fellow," "teach assist," "first assist," or "secondary procedure." To reflect total vascular experience, all vascular cases done during general surgery residency were combined with cases performed during vascular surgery fellowship. Mean case volumes were compared for all operations/procedures., Results: The 5 + 2 trainees had higher mean volume of open repair of suprarenal aortic aneurysms (2.4 vs. 1.4, P = 0.0026) and open repair of thoracic aortic aneurysms (0.5 vs. 0.3, P = 0.004) at the fellow level compared to 0 + 5 surgeon chief cases. Additionally, 5 + 2 trainees performed more endovascular repair of abdominal aortoiliac aneurysm (44.7 vs. 28.4, P < 0.0001), endovascular repair of iliac artery aneurysm (1.9 vs. 1.2, P = 0.0003), and endovascular repair of thoracic aortic aneurysm (14.9 vs. 8.4, P < 0.0001). The 5 + 2 fellows performed more vein bypasses than 0 + 5 chief residents (femoral-popliteal 9.8 vs. 6.4, P = 0.002; infrapopliteal 13.9 vs. 8.8, P = 0.0490), extra-anatomic bypasses (axillofemoral 4.2 vs. 2.9, P = 0.0004; femoral-femoral 5.6 vs. 3.1, P = 0.034), carotid endarterectomies (47.3 vs. 29.3, P < 0.0001), carotid artery stenting (9.6 vs. 4.5, P = 0.0001), celiac/SMA endarterectomy or bypass (3.7 vs. 1.9, P < 0.0001), renal artery balloon angioplasty/stenting (5.0 vs. 2.5, P = 0.0006), thoracic outlet decompression (5.4 vs. 1.9, P < 0.0001), traumatic repairs [thoracic vessels (0.5 vs. 0.1, P < 0.0001), neck vessels (0.7 vs. 0.3, P = 0.0004), abdominal vessels (3.0 vs. 1.7, P = 0.0005), and peripheral vessels (6.6 vs. 3.1, P = 0.034)], as well as a higher mean volume of arteriovenous (AV) fistulas (30.7 vs. 15.7, P < 0.0001), AV grafts (10.7 vs. 5.1, P < 0.0001), and revision of AV access (16.1 vs. 8.0, P = 0.0003)., Conclusions: Although both pathways graduate trainees with a similar overall surgical experience, 5 + 2 trainees log significantly more "Senior" cases. Further studies investigating potential variation in operative autonomy between both pathways are necessary., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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.)