Participant User File Research Articles

Observed Changes in the Distribution of Colon Cancer Metastasis: A National Cancer Database Review and Institutional Experience.

The University of Louisville has observed a near 70% drop in resectable/borderline resectable metastatic colorectal cancer in the past 5 years. The aim of this study was to evaluate the distribution of colon cancer metastasis at diagnosis and at recurrence. Stage was defined by the American joint committee on cancer (AJCC) eighth edition. Institutional review board approval was granted for post hoc review of stage II and III patients with colon cancer from the University of Louisville prospective hepatic database from 2002 to 2023, as well as for the National cancer database (NCDB) Participant user file (PUF) 2021. The Surveillance epidemiology and end-results (SEER) 22 database was also utilized to corroborate the findings in the NCDB. Between 2018 and 2021 pathological M1a decreased annually (51.9-46.3%), while M1c increased year-over-year (26.6-32.4%) and M1b stayed relatively the same (21.4-21.3%). These differences were significant on chi-squared analysis with a p value of < 0.001. Univariate analysis of the post hoc review between 2017 and 2020 revealed significant differences between stage 4a and 4c in terms of race (p value 0.018), carcinoembryonic antigen (CEA) at diagnosis (p value 0.037), CEA at recurrence (p value 0.012), presence of liver metastasis (p value 0.003), and referral pattern (p value 0.014). Multivariate analysis identified stage 4b as an independent predictor for hepatic metastasis (odds ratio; OR 4.69, p value 0.011). A significant change in the distribution of colon cancer metastases has occurred at an institutional and national level over the past 3-5 years. Interdisciplinary treatment strategies will have to be modified accordingly.

Development of venous thromboembolic event risk calculator for metabolic and bariatric surgery patients to reduce mortality

IntroductionVenous thromboembolic events (VTEs) after Metabolic and Bariatric Surgery (MBS) result in significant morbidity and are the leading cause of mortality. The objective of this study was to identify patients who are at a high risk for developing VTE and who may benefit from extended chemoprophylaxis following MBS. MethodsUsing the 2015-2019 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) participant user file (PUF), we identified 696,069 patients who completed 30-day follow-up data and met the inclusion criteria. Using logistic regression analysis, we identified preoperative and postoperative risk factors associated with VTE and validated our model externally using the MBSAQIP 2020-2021 datasets (N = 273,692). The Hosmer–Lemeshow test was used for goodness of fit and calibration. We also compared our model’s discriminatory capability with that of other VTE risk assessment tools. We then used these risk factors to create an online open source application. ResultsThe overall incidence of VTE after MBS in the 696,069 (MBSAQIP 2015-2019 database) patients included in our analysis was .40% (2759 patients). Our model had a good predictive capability, with a C-statistic of .66. Our model also demonstrated good fit with a Hosmer–Lemeshow chi-square of 11.06 (P = .198). A cut-off point of .4% resulted in a sensitivity of 48.28%, with 24% of patients having a VTE risk greater than .4% within the 2015-2019 MBSAQIP dataset. Among all the perioperative factors selected in the PUF, high risk for VTE included African American race (AOR 1.625, P < .0001), operation length in minutes (AOR: 1.003, P < .0001), preop functional status (AOR 1.012, P = .007), procedure type (RYGB; AOR .768, P < .0001 and RBS; AOR .758, P = .019 with respect to sleeve), preop body mass index (BMI) (AOR 1.012, P < .001), history of pre-op vein thrombosis requiring therapy (AOR 5.041, P < .0001), post-op superficial or organ space surgical site infection (AOR 2.713, P < .0001), preop venous stasis (AOR 1.425, P = .019),at least one readmission within 30 days(AOR 1.583, P < .0001), or at least one reoperation within 30 days (AOR 4.399, P < .0001). ConclusionVTE after MBS can result in increased mortality rates. High-risk patients might benefit from extended chemoprophylaxis. Our model suggests that patients with a VTE risk ≥ .4% in the first 30 days following surgery may benefit from extended chemoprophylaxis.

Factors Precipitating Overnight Admission After Sialolithectomy.

To determine factors predicting overnight admission after sialolithectomy. Quality outcome database research. The National Surgical Quality Improvement Program American College of Surgeons Participant User Files. Current Procedural Terminology (CPT) codes 42330, 42335, and 42340 between 2007, and 2020 resulted 916 cases. Correlations between perioperative factors and overnight admission (ie, length of stay >0 days) were tested. Cases were stratified into endoscopic (ES) and nonendoscopic (NES) procedures using concurrent CPT codes 42660, 42669, and 42650. After sialolithectomy, 13.7% (126 cases) were admitted at least overnight. Upon multivariate analysis, wound Class 4 (odds ratio [OR]: 2.15, 95% confidence interval: 1.05, 4.40), American Society of Anesthesiologists (ASA) 3 classification (OR: 2.17, 1.06-4.46, P = .035), and the operative time (OR: 1.01 [1.01-1.01], P < .001) correlated with overnight stay; while Class 2 wounds had a lower risk of overnight admission (OR: 0.31 [0.12-1.63], P < .001). The ES cohort had longer operative times (56.1 vs 73.6minutes). In the NES cohort's multivariate analysis, ASA III (OR: 2.459 [1.13, 5.34], P < .001) and operative time (OR: 1.01 [1.01, 1.02], P < .001) correlated with overnight stay while Class 2 wound classifications protected against overnight stay (OR: 0.28 [0.15, 0.52], P < .001). This study highlights the correlation between intraoperative complexity, as operative time, wound classification and ASA Class 3, and the need for admission after a typically ambulatory sialolithectomy. The significantly longer operative time with evidence of a shorter length of stay in ES cases suggests a valuable trade off, within the limits of indication.

Addressing the Neck: An NCDB Study of Clinically Node-Negative Supraglottic Squamous Cell Carcinoma.

Identify the proportion of patients undergoing elective neck dissection (END) in surgically managed supraglottic squamous cell carcinoma (SCCa), assess associations between patient, tumor, and treatment factors with END, and assess associations between neck management and overall survival (OS). Retrospective study. National Cancer Database (NCDB) 2019 Participant User File. Patients with previously untreated, clinically node-negative (cN0) supraglottic SCCa treated with partial laryngectomy were queried from NCDB. Patients without known neck management and who underwent total laryngectomy were excluded. Patient and tumor factors associated with END were evaluated by logistic regression analysis. Univariable Cox proportional hazard analysis was used to examine associations between patient factors and OS, and factors with P < .05 were included on multivariable analysis. A total of 1352 patients met eligibility criteria. Eight hundred eleven (60%) patients had END performed with occult nodal metastasis identified in 177 (22%) patients. END was more likely to be performed at academic centers than nonacademic centers (odds ratio: [1.66], 95% confidence interval [CI]: 1.32-2.09, P < .001). On multivariable analysis, patients who underwent adjuvant radiation had worse OS (hazard ratio [HR]: 1.45, 95% CI: 1.13-3.29, P = .017). END was associated with improved OS overall on univariable analysis (HR: 0.83, 95% CI: 0.69-0.98, P = .026), but not on multivariable analysis. In this NCDB study, 22% of cN0 supraglottic SCCa patients had occult nodal metastatic disease. Despite this, 40% of patients do not receive END at the time of primary resection. Patients who receive END for supraglottic SCCa are more likely to avoid adjuvant radiation without impacting OS.

Demographic and Prognostic Factors of the Columnar Cell Variant of Papillary Thyroid Carcinoma: A National Cancer Database Study.

Objective The columnar cell variant of papillary thyroid carcinoma (PTC-CC) is a rare, malignant tumor of the thyroid gland. This study uses the National Cancer Database (NCDB) to analyze demographic and prognostic factors affecting the overall survival rates of PTC-CC. Methods From 2004 to 2020, 7,079 patients diagnosed with columnar cell papillary thyroid carcinoma were identified in the NCDB. Patient demographics were reviewed based on categories listed in the NCDB participant user file data dictionary. Kaplan-Meier curves, log-rank tests, and multivariable Cox hazard regression models were used to analyze the significance of demographic and prognostic factors on overall survival rates of PTC-CC. Results Multivariate analysis demonstrated each five-year increment in age was associated with a 30% increase in mortality (hazard ratio (HR) = 1.30, 95% confidence interval (CI): 1.25-1.36, P < 0.001). Charlson-Deyo scores displayed similar incremental increases, such that patients with a score ≥ 3 had a 154% increase in mortality risk relative to a score of 0 (HR = 2.54; 95% CI: 1.75-3.68, P < 0.001). Black individuals had a 70% increase in mortality compared to White individuals (HR = 1.70, 95% CI: 1.25-2.30, P < 0.001), while all Other races had the highest 10-year survival rate of 92.7%. Females had a significant 37% decrease in mortality compared to males (HR = 0.63, 95% CI: 0.54-0.73, P < 0.001). Patients in the lowest income quartiles were found to have a significant increase in mortality compared to the highest income group (HR = 0.54; 95% CI: 0.41-0.71, P < 0.001). Survival rates were negatively correlated with NCDB Analytic Staging increases. Conclusion In general, age, sex, race, education, income, comorbidities, and cancer staging were found to be predictive factors of overall survival rates of PTC-CC. However, insurance status and education levels did not result in significant differences.

Impact of Trauma Center Type on Outcomes in Pediatric Population Following Severe Isolated Blunt Traumatic Brain Injuries: A National Analysis.

This study aims to evaluate the association between trauma center type, verification level, and clinical outcomes in pediatric trauma patients with moderate and severe isolated blunt traumatic brain injury (TBI). This is a retrospective cohort study utilizing the American College of Surgeons (ACS) Trauma Quality Program (TQP) Participant Use File (PUF) database from 2017 to 2021. Severely injured pediatric (<18years) trauma patients with isolated moderate and severe TBI (AIS head >2, all other body regions <3) were included. Outcomes included in-hospital mortality, discharge disposition, intensive care unit length-of-stay (ICU-LOS), and ventilator-free days (VFDs). Patients treated at a level-I combined adult and pediatric trauma centers (CTCs) had significantly lower odds of in-hospital mortality than those treated at adult trauma centers (ATCs) (OR .495, 95% CI 0.291-.841, P = .009). Patients treated at level-I pediatric trauma centers (PTCs) (OR 2.726, 95% CI 2.059-3.609, P < .001) and level-II PTCs (OR 6.18, 95% CI 3.402-11.239, P < .001) were significantly more likely to be discharged home than equivalent-level ATCs. Pediatric patients with isolated blunt moderate and severe TBI treated at level-I PTCs and CTCs had reduced odds of in-hospital mortality compared to level-I ATCs. Patients at level I and II PTCs had significantly higher odds of discharge home than those at equivalent-level CTCs and ATCs.

Primary vs Staged Biventricular Repair for Neonatal IAA with VSD and LVOTO

BackgroundThis study sought to determine the safety of primary and staged biventricular repair in neonates with interrupted aortic arch (IAA), ventricular septal defect (VSD), and severe left ventricular outflow tract obstruction (LVOTO). MethodsPatients with a fundamental diagnosis of IAA and VSD between 2015 and 2020 were extracted from The Society of Thoracic Surgeons National Database by using a Participant User File. The objective was to compare outcomes for neonates undergoing primary and staged Yasui and Ross operations. Primary end points were operative morbidity and mortality. ResultsDuring the study period, 11.4% (123 of 1079) of neonates with a fundamental diagnosis of IAA and VSD underwent operations indicative of severe LVOTO. Of these patients, 42 (34%) underwent primary biventricular repair (Yasui or Ross/Ross-Konno), and 81 underwent a potential staging procedure (Norwood or hybrid stage I). No differences were observed in preoperative patient characteristics between groups. Neonates undergoing staged repair experienced fewer major complications (0 vs 1; P = .04) and total complications (2 vs 4; P = .02), but similar operative mortality (5% vs 12%; P = .27) as neonates undergoing primary repair. A total of 58 patients undergoing Rastelli, biventricular repair, Yasui, or Ross/Ross-Konno operations with a diagnosis of IAA and VSD and history of neonatal Norwood or hybrid stage I procedures were also identified. Operative mortality for second-stage biventricular conversion operations was 2% (1 of 58). Only 4 centers performed 1 or more complex biventricular repairs for IAA and VSD with LVOTO per year. ConclusionsPrimary and staged biventricular repairs for IAA and VSD with LVOTO are associated with low operative mortality in the modern era and may be favorable to long-term single-ventricle palliation.

The minimally invasive approach confers improved outcomes in frail cancer patients undergoing hepatectomy: an American College of Surgeons National Surgical Quality Improvement Program analysis

BackgroundMorbidity for liver resection has decreased, and frail patients are undergoing surgery. The effect of minimally invasive liver resection (MILR) is unknown. This study aimed to evaluate the effect of MILR on the outcomes in frail patients. MethodsElective hepatectomies from the 2014-2020 American College of Surgeons National Surgical Quality Improvement Program hepatectomy-specific Participant User File were reviewed. The 5-factor modified frailty index (mFI-5) was used. It includes diabetes mellitus, hypertension, functional status, heart failure, and dyspnea. Patients were considered frail if their mFI-5 score was ≥2. ResultsA total of 3116 patients were included: 2117 (67.9%) in the minor hepatectomy group and 999 (32%) in the major hepatectomy group. There were 2254 open cases and 862 MILRs. Postoperatively, patients in the minor hepatectomy group who underwent MILR had lower rates of prolonged length of stay (LOS), nonhome discharge, transfusion, major complications, and minor complications (P < .05). Postoperatively, patients in the major hepatectomy group who underwent MILR had lower rates of prolonged LOS and any complication (P < .05). In the minor hepatectomy group, MILR remained independently predictive of lower rates of prolonged LOS (odds ratio [OR], 0.34; 95% CI, 0.28-0.42), nonhome discharge (OR, 0.58; 95% CI, 0.41-0.84), transfusion (OR, 0.72; 95% CI, 0.54-0.96), major complication (OR, 0.78; 95% CI, 0.62-1.00), and any complication (OR, 0.73; 95% CI, 0.58-0.92). In the major hepatectomy group, MILR remained independently predictive of prolonged LOS (OR, 0.60; 95% CI, 0.40-0.89). ConclusionMILR resulted in lower rates of complications in the minor hepatectomy group and shorter LOS in the major hepatectomy group. The minimally invasive approach to hepatectomy may benefit frail patients with cancer.

Bowel preparation for elective colectomy in Crohn's disease: results from a global cohort study using the NSQIP database.

The role of bowel preparation before colectomy in Crohn's disease patients remains controversial. This retrospective analysis of a prospective cohort study aimed to investigate the clinical outcomes associated with mechanical and antibiotic colon preparation in patients diagnosed with Crohn's disease undergoing elective colectomy. Data were collected from the American College of Surgeons National Surgical Quality Improvement Program participant user files from 2016 to 2021. A total of 6244 patients with Crohn's disease who underwent elective colectomy were included. The patients were categorized into two groups: those who received combined colon preparation (mechanical and antibiotic) and those who did not receive any form of bowel preparation. The primary outcomes assessed were the rate of anastomotic leak and the occurrence of deep organ infection. Secondary outcomes included all-cause short-term mortality, clinical-related morbidity, ostomy creation, unplanned reoperation, operative time, hospital length of stay and ileus. Combined colon preparation was associated with significantly reduced risks of anastomotic leak (relative risk 0.73, 95% CI 0.56-0.95, P = 0.021) and deep organ infection (relative risk 0.68, 95% CI 0.56-0.83, P < 0.001). Additionally, patients who underwent colon preparation had lower rates of ostomy creation, shorter hospital stays and a decreased incidence of ileus. However, there was no significant difference in all-cause short-term mortality or the need for unplanned reoperation between the two groups. This study shows that mechanical and antibiotic colon preparation may have clinical benefits for patients with Crohn's disease undergoing elective colectomy.

National trends in technique use for esophagectomy: Does primary surgeon specialty matter?

BackgroundCardiothoracic 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. MethodsThis 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 χ2 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. ResultsOf 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). ConclusionCardiothoracic 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.

Comparative real-world survival outcomes of muscle-invasive bladder cancer treated with bladder-only vs. whole-pelvis concurrent chemoradiation.

Elective pelvic nodal irradiation for patients with muscle-invasive bladder cancer (MIBC) undergoing trimodal therapy (TMT ) is controversial. In patients with node-negative (N0) MIBC, the benefit of elective whole-pelvis concurrent chemoradiation (WP-CCR) compared to bladder-only (BO )-CCR has not been demonstrated. Using real-world data from the National Cancer Database (NCDB ), we sought to compare the overall survival (OS ) between BO-CCR and WP-CCR for MIBC. Using the 2020 NCDB Participant User File, we identified cases of MIBC diagnosed between 2017 and 2019. We selected patients with clinical T2-T4aN0M0 disease receiving CCR as first-line treatment. CCR was defined as transurethral resection of bladder tumor followed by ≥40 Gy radiation to the bladder with concurrent single- or multiple-agent chemotherapy. Based on elective nodal irradiation status, patients were stratified as having received BO-CCR vs. WP-CCR. OS analysis was performed using summary three-month conditional landmark, inverse probability treatment weighting (IPTW)-adjusted Kaplan-Meier estimates, and Cox regression. A total of 604 patients receiving CCR for MIBC were identified: 367 (60.8%) BO-CCR and 237 (39.2%) WP-CCR. Before IPTW, the groups were imbalanced in terms of baseline characteristics. The median followup of the weighted population was 42.3 months (interquartile range 18.1-49.1 months). In IPTW-adjusted Cox proportional hazards regression analysis, WP-CCR was associated with a significant OS benefit compared to BO-CCR (adjusted hazard ratio 0.72, 95% confidence interval 0.54-0.96, p=0.026). In the setting of CCR for N0 MIBC, this retrospective NCDB analysis revealed that WP-CCR was associated with a benefit in OS compared to BO-CCR.

Effect of conditions being present at time of surgery (PATOS) on outcomes in liver surgery

IntroductionInformation about condition(s) being present at time of surgery (PATOS) in the American College of Surgeons (ASC) National Surgical Quality Improvement Program (NSQIP) database can influence the postoperative complication rates after liver surgeries. Here, we compare the postoperative complication rates with and without taking condition(s) being PATOS into account. MethodsWe retrospectively reviewed the ACS NSQIP Participant User Files (PUFs) from 2015 through 2019. We analyzed rates of eight different postoperative complications: superficial surgical site infection (SSI), deep SSI, organ space SSI, pneumonia, urinary tract infection, ventilator, sepsis, and septic shock. In addition, we calculated the percent change in event rates after taking into account whether a condition is PATOS. ResultsOf the 22,463 patients in the ACS NSQIP PUFs for liver surgery, 334 (1.49%) had one or more conditions PATOS. The percentages of patients with PATOS events ranged from 2.03% for superficial SSI to 14.74% for sepsis. For all complications, event rates declined when taking condition(s) PATOS into account. From 2015 through 2019, the observed-to-expected ratios for most complications remained unchanged. ConclusionWhether a condition is PATOS is important in reporting postoperative complication rates for patients undergoing liver surgery. When taking whether a condition is PATOS into account, we demonstrated an overall decrease in event rates across all eight postoperative complications.

167. NATIONAL TRENDS IN TECHNIQUE UTILIZATION FOR ESOPHAGECTOMY: DOES PRIMARY SURGEON SPECIALTY MATTER?

Abstract Background Cardiothoracic surgeons (CTS) and general surgeons (GS; including surgical oncologists) perform the vast majority of esophagectomies nationwide. We hypothesize that different clinical focus and training background could lead to different distribution in the use of open and minimally invasive surgery (MIS) techniques. Furthermore, we sought to explore whether specialty driven differences in surgical approach affect outcomes. Methods In a retrospective review of the ACS-NSQIP esophagectomy targeted participant user file (2016–2018), patients who underwent esophagectomy were sorted into CTS and GS cohorts. Perioperative characteristics and postoperative outcomes were compared using chi-square analysis or independent t-tests. Multivariate logistic regression controlling for perioperative variables was performed to generate risk adjusted odds ratios of postoperative outcomes by specialty. Results Of 3247 patients included, 1792 (55.2%) underwent esophagectomy by CTS and 1455 (44.5%) by GS as primary surgeon. CTS were more likely to use traditional MIS (p = 0.0004) or open approach (p &amp;lt; 0.0001) and less likely to use robotic surgery (p = 0.04) or a hybrid robotic/traditional approach (p &amp;lt; 0.0001) (Figure). CTS performed more Ivor Lewis esophagectomies and fewer transhiatal and McKeown esophagectomies (p &amp;lt; 0.0001). After risk-adjustment, there were no differences in rates of post-esophagectomy complications or rate of positive margins between CTS and GS (all p &amp;gt; 0.05). However, CTS were more likely to treat anastomotic leaks with surgery rather than other procedural interventions. Conclusion CTS and GS use MIS subtypes differently within esophagectomy. However, all risk adjusted differences in postoperative complications were driven by patient and operative characteristics rather than surgical subspecialty. Esophagectomy is being performed safely by surgeons with different clinical specialties and training pathway, with no differences in perioperative and oncologic outcomes.

The differential effect of neoadjuvant chemotherapy and chemoradiation on nodal downstaging in pancreatic adenocarcinoma

Background/objectivesNeoadjuvant chemotherapy (NCT) and chemoradiotherapy (NCRT) enhance resectability in patients with pancreatic adenocarcinoma (PDAC). This study compares the effect of NCT and NCRT on lymph nodal downstaging and survival. MethodsThe 2004–2016 National Cancer Database Pancreas Participant User File was used to identify patients who underwent surgery for PDAC. Fisher's exact, Wilcoxon rank-sum, multivariate logistic regression, and log-rank were used. Downstaging was defined as clinically node-positive patients who demonstrated node-negativity on pathology. ResultsOf 42,545 patients meeting criteria, 3311 received NCT and 1511 received NCRT. After surgery for clinically node-positive disease, 23.3% of NCT patients and 41.3% of NCRT patients demonstrated nodal downstaging. Younger age and lower tumor grade independently predicted downstaging. Downstaging after neoadjuvant therapy was associated with improved survival versus no nodal treatment response (29.8 vs. 22.8 months, p < 0.001). Downstaging by NCT was associated with improved overall survival versus downstaging by NCRT (37.5 vs. 26.6 months, p = 0.001). No survival difference existed between those with no nodal response after NCT or NCRT (p = 0.101). ConclusionsAlthough nodal downstaging is more likely post-NCRT, survival is superior in those downstaged post-NCT. Overall survival is determined by the systemic burden of disease. Post-therapy histologic analysis may be less prognostic post-NCRT.

External Validation of the Breast Cancer Surgery Risk Calculator (BCSRc): A Predictive Model for Postoperative Complications.

The breast cancer surgical risk calculator (BCSRc) is a prognostic tool that determines a breast cancer patient's unique risk of acute complications following each possible surgical intervention. When used in the preoperative setting, it can help to stratify patients with an increased complication risk and enhance the patient-physician informed decision-making process. The objective of this study was to externally validate the four models used in the BCSRc on a large cohort of patients who underwent breast cancer surgery. The BCSRc was developed by using a retrospective cohort from the National Surgical Quality Improvement Program database from 2005 to 2018. Four models were built by using logistic regression methods to predict the following composite outcomes: overall, infectious, hematologic, and internal organ complications. This study obtained a new cohort of patients from the National Surgical Quality Improvement Program by utilizing participant user files from 2019 to 2020. The area under the curve, brier score, and Hosmer-Lemeshow goodness of fit test measured model performance, accuracy, and calibration, respectively. A total of 192,095 patients met inclusion criteria in the development of the BCSRc, and the validation cohort included 60,144 women. The area under the curve during external validation for each model was approximately 0.70. Accuracy, or Brier scores, were all between 0.04 and 0.003. Model calibration using the Hosmer-Lemeshow statistic found all p-values > 0.05. All of these model coefficients will be updated on the web-based BCSRc platform: www.breastcalc.org . The BCSRc continues to show excellent external-validation measures. Collectively, this prognostic tool can enhance the decision-making process, help stratify patients with an increased complication risk, and improve expectant management.

Body Mass Index (BMI) Related Morbidity with Thyroid Surgery.

The increase in incidence of thyroid cancer correlates with strict increases in body mass index (BMI) and obesity in the United States. Thyroid hormone dysregulation has been shown to precipitate circulatory volume, peripheral resistance, cardiac rhythm, and even cardiac muscle health. Theoretically, thyroid surgery could precipitate injury to the cardiopulmonary system. The American College of Surgery National Quality Improvement Program database was queried for thyroidectomy cases in the 2007-2020 Participant User files. Continuous and categorical associations between BMI and cardiopulmonary complications were investigated as reported in the database. The query resulted 186,095 cases of thyroidectomy procedures in which the mean age was 51.3 years and sample was 79.3% female. No correlation was evident in univariate and multivariate analyses between BMI and the incidence of postoperative stroke or myocardial infarction. The incidence of complications was extremely low. However, risk of deep venous thrombosis correlated with BMI in the categorical, univariate, and multivariate (OR 1.036, CI 1.014-1.057, p < 0.01) regression analysis. Additionally, increased BMI was associated with increased risk of pulmonary embolism (PE) (OR 1.050 (1.030, 1.069), p < 0.01), re-intubation (OR 1.012 (1.002, 1.023), p = 0.02), and prolonged intubation (OR 1.031 (1.017, 1.045), p < 0.01). Despite the rarity of cardiopulmonary complications during thyroid surgery, patients with very high BMI carry a significant risk of deep venous thrombosis, PE, and prolonged intubation. 3 Laryngoscope, 133:2823-2830, 2023.

Impact of the COVID pandemic on reporting of breast cancer cases and mortality.

e18842 Background: The National Cancer Database (NCDB) introduced COVID-specific variables in 2020 to assess the impact of the pandemic on cancer care. Variables include (1) any SARS-CoV-2 test and (2) SARS-CoV-2 test result. We evaluated patterns of breast cancer reporting and mortality compared to pre-pandemic. Methods: From the 2020 NCDB breast cancer participant user file, we separately examined reporting and mortality in the years 2017-2020. Pre-pandemic years (2017-2019) were used as a baseline to evaluate secular trends not related to the pandemic. For patients diagnosed in the study period, patient/hospital factors associated with complete reporting (CR) or no reporting (NR) of COVID variables were compared. For patients who died during the study period, yearly mortality rate and overall survival (OS) were examined overall and by stage. Patient/hospital factors were examined for associations with year of death. Results: Fewer breast cancer cases were reported in 2020 (232,023) compared to 2019 (268,210) and 2018 (260,259). In 2020, there were 97,810 (42%) with NR and 116,455 (50%) with CR of COVID variables. On multivariable analysis, patients with NR were more likely to be &gt; 70 years old, of Asian race, with Medicare coverage, lower education quartile, and treated at community hospitals and those in the Middle Atlantic region. There were 60,933 deaths in 2020, 64,502 in 2019, 63,865 in 2018, and 61,930 in 2017. There were significantly fewer stage 4 deaths in 2020 compared to prior (Table). Although there was a steady trend of increasing OS across the 4-year period, the incremental increase from 2019 to 2020 was higher than expected based on previous years. This finding was particularly true for stage 4 patients (median OS: 31.4 months in 2020, 20.2 months in 2019). On multivariable analysis, 2020 mortalities were less likely in patients &gt; 80 years old (OR 0.88, p &lt; .01) or with stage 3 (0.81, p &lt; .01) or stage 4 (0.64, p &lt; .01) disease, and more likely at academic centers (1.05, p &lt; .01) than in 2017-2019. Conclusions: Non-reporting of COVID data is not at random, and is more common in populations at risk. In addition, fewer breast cancer mortalities were reported in 2020, with higher than expected OS. These findings suggest that OS was artificially increased in 2020 due to underreporting of patients who may be at higher risk of mortality. Accurate and complete data is crucial for evaluating the pandemic's impact on patient care. Underreporting of patients who may be most vulnerable limits our ability to comment on the true impact of the pandemic. These limitations must be considered to avoid blind spots in evaluation of pandemic data and risk deepening disparities. [Table: see text]

Impact of cannabis on outcome in patients following traumatic injury

IntroductionOutcomes of trauma patients who tested positive for cannabis at the time of admission showed variable results. Sample size and research methodology that was used in prior studies may have resulted in the conflict. The purpose of the study was to evaluate the impact of cannabis use on outcomes in trauma patients using national data. Our hypothesis was that the use of cannabis will impact outcomes. MethodsThe trauma quality improvement program (TQIP) Participant Use File (PUF) database of the calendar years 2017 and 2018 were accessed for the study. All trauma patients aged 12 years old and above who were tested for cannabis at the time of initial evaluation were included in the study. Variables included in the study were: race, sex, injury severity score (ISS), Glasgow Coma Scale (GCS) Score, Abbreviated Injury Scale (AIS) score of different body regions and comorbidities. Excluded from the study were all patients who were not tested for cannabis or tested for cannabis but were also tested positive for alcohol and other drugs and those suffering from mental conditions. Propensity matched analysis was performed. The outcome of interest was overall in-hospital mortality and complications. ResultsPropensity matched analysis created 28,028 pairs. The analysis showed no significant difference in-hospital mortality between cannabis positive and cannabis negative groups (3.2% vs. 3.2%). The median length of hospital stay in both groups was not significantly different (4 [IQR: 3–8] vs. 4 [IQR: 2–8] days). No significant difference was found between the two groups regarding hospital complications except in pulmonary embolism (PE) with 0.1% less incidence of PE in the cannabis positive group compared to the cannabis negative group (0.4 vs. 0.5%). The incidence of DVT was identical in both groups (0.9% vs. 0.9%). ConclusionCannabis was not associated with overall in-hospital mortality or morbidity. There was a slight decrease in the incidence of PE in the cannabis positive group.

Number of Hepatic Resections and Association with Complication after Metastatic Neuroendocrine Tumor Debulking: An American College of Surgeons NSQIP Database Study.

Neuroendocrine tumor liver metastases (NELM) are a major source of morbidity and mortality in neuroendocrine tumor patients and can be treated with hepatic debulking surgery (HDS). This study aims to identify variables associated with postoperative morbidity in NELM HDS. This analysis uses the American College of Surgeons NSQIP targeted hepatectomy-specific Participant User File from 2014 to 2020. Surgeries were grouped by number of hepatic resections performed (1 to 5, 6 to 10, greater than 10). Multivariable logistic regression and matching were used to identify prognostic factors of morbidity. A total of 1,163 patients were included. A total of 1,011 (87%) had 1 to 5 hepatic resections, 101 (8.7%) had 6 to 10 resections, and 51 (4.4%) had greater than 10 resections. The overall complication rate was 35%, and surgical and medical complications reached 30% and 13%, respectively. Mortality occurred in 11 patients (0.9%). Significantly higher rates of any (34% vs 35% vs 53%, p = 0.021) and surgical complications (29% vs 28% vs 49%, p = 0.007) were noted for those undergoing greater than 10 resections (1 to 5 resections, 6 to 10, greater than 10). "Bleeding requiring transfusion" (p < 0.0001) occurred more frequently in the greater than 10 resection group. On multivariable logistic regression, greater than 10 resections were an independent risk factor for any (odds ratio [OR] 2.53, p = 0.002; OR 2.52, p =. 0013) and surgical (OR 2.53, p = 0.003; OR 2.88, p = 0.005) complications compared with 1 to 5 resections and 6 to 10 resections, respectively. Medical complications (OR 2.34, p = 0.020) and length of stay greater than 5 days (OR 1.98, p = 0.032) were also increased with greater than 10 vs 1 to 5 resections. As reported by NSQIP, NELM HDS were performed safely with low mortality. However, more hepatic resections, especially greater than 10, were associated with increased postoperative morbidity and length of stay.

External validation of the Codman score in colorectal surgery: a pragmatic tool to drive quality improvement.

The simple six-variable Codman score is a tool designed to reduce the complexity of contemporary risk-adjusted postoperative mortality rate predictions. We sought to externally validate the Codman score in colorectal surgery. The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) participant user file and colectomy targeted dataset of 2020 were merged. A Codman score (composed of six variables: age, American Society of Anesthesiologists score, emergency status, degree of sepsis, functional status and preoperative blood transfusion) was assigned to every patient. The primary outcome was in-hospital mortality and secondary outcome was morbidity at 30 days. Logistic regression analyses were performed using the Codman score and the ACS NSQIP mortality and morbidity algorithms as independent variables for the primary and secondary outcomes. The predictive performance of discrimination area under receiver operating curve (AUC) and calibration of the Codman score and these algorithms were compared. A total of 40 589 patients were included and a Codman score was generated for 40 557 (99.02%) patients. The median Codman score was 3 (interquartile range 1-4). To predict mortality, the Codman score had an AUC of 0.92 (95% CI 0.91-0.93) compared to the NSQIP mortality score 0.93 (95% CI 0.92-0.94). To predict morbidity, the Codman score had an AUC of 0.68 (95% CI 0.66-0.68) compared to the NSQIP morbidity score 0.72 (95% CI 0.71-0.73). When body mass index and surgical approach was added to the Codman score, the performance was no different to the NSQIP morbidity score. The calibration of observed versus expected predictions was almost perfect for both the morbidity and mortality NSQIP predictions, and only well fitted for Codman scores of less than 4 and greater than 7. We propose that the six-variable Codman score is an efficient and actionable method for generating validated risk-adjusted outcome predictions and comparative benchmarks to drive quality improvement in colorectal surgery.