Post-operative morbidity after neoadjuvant chemotherapy and resection for gallbladder cancer: A national surgical quality improvement program analysis

BACKGROUND Gallbladder cancer is the most common malignancy of the biliary tract.Neo-adjuvant chemotherapy(NACT)has improved overall survival by enabling R0 resection.Currently,there is no consensus of guidelines for neoadjuvant therapy in gallbladder cancer.As investigations continue to analyze the regimen and benefit of NACT for ongoing care of gallbladder cancer patients,we examined American College of Surgeons National Surgical Quality Improvement Program(NSQIP)database to determine if there was higher morbidity among the neo-adjuvant group within the 30-day post-operative period.We hypothesized patients who underwent NACT were more likely to have higher post-operative morbidity.AIM To investigate the 30-day post-operative morbidity outcomes between patients who received NACT and underwent surgery and patients who only had surgery.METHODS A retrospective analysis of the targeted hepatectomy NSQIP data between 2015 and 2019 was performed to determine if NACT in gallbladder cancer increased the risk for post-operative morbidity(bile leak,infection rate,rate of converting to open surgery,etc.)compared to the group who only had surgery.To calculate the odds ratio for the primary and secondary outcomes,a crude logistic regression was performed.RESULTS Of the 452 patients,52 patients received NACT prior to surgery.There were no statistically significant differences in the odds of morbidity between the two groups,including bile leak[odds ratio(OR),0.69;95%confidence interval(95%CI):0.16-2.10;P=0.55],superficial wound infection(OR,0.58;95%CI:0.03-3.02;P=0.61),and organ space wound infection(OR,0.63;95%CI:0.18-1.63;P=0.61).CONCLUSION There was no significant difference in the risk of 30-day post-operative morbidity between the NACT and surgery group and the surgery only group.

The Synergized Quality Improvement Program in Teacher Education:A Policy for Improving the Quality of China's Rural Teachers

Purpose This study elucidates the rationale,implementation,values,and challenges of the Synergized Quality Improvement Program in Teacher Education(SQIPTE)—the first policy specifically dedicated to the development of teaching staff since the founding of the People's Republic of China.Design/Approach/Methods After introducing the primary structure and rationale of the SQIPTE,this study reviews the existing data and research to explain why the program focuses on local normal colleges and determine how it could be implemented more effectively.Findings In establishing group-based assistance under the principle of“1+M+N”(M≥N),the SQIPTE seeks to make normal colleges the primary force in the education of rural teachers and explores a collaborative operating mechanism to this end.Evidence suggests that this innovative program will provide new practical experience for the collaborative development and quality improvement of teachers.Originality/Value This study reviews the SQIPTE as a new Chinese intervention to improve the quality of rural teachers.There is strong evidence to suggest that this innovative program will inspire the construction of collaborative operating mechanisms incorporating multiple resources for teacher education systems across different areas.

Impact of pre- and peri-operative risk factors on length of stay and hospital readmission following minimally-invasive partial nephrectomy

Objective:We conducted an analysis of the American College of Surgeons National Surgical Quality Improvement Program database for minimally-invasive partial nephrectomy cases reported with the goal to identify pre-and peri-operative variables associated with length of stay(LOS)greater than 3 days and readmission within 30 days.Methods:Records from 2008 to 2018 for“laparoscopy,surgical;partial nephrectomy”for prolonged LOS and readmission cohorts were compiled.Univariate analysis with Chi-square,t-tests,and multivariable logistic regression analysis with odds ratios(ORs),p-values,and 95%confidence intervals assessed statistical associations.Results:Totally,20306 records for LOS greater than 3 days and 15854 for readmission within 30 days were available.Univariate and multivariable analysis exhibited similar results.For LOS greater than 3 days,undergoing non-elective surgery(OR=5.247),transfusion of greater than four units within 72 h prior to surgery(OR=5.072),pre-operative renal failure or dialysis(OR=2.941),and poor pre-operative functional status(OR=2.540)exhibited the strongest statistically significant associations.For hospital readmission within 30 days,loss in body weight greater than 10%in 6 months prior to surgery(OR=2.227)and bleeding disorders(OR=2.081)exhibited strongest statistically significant associations.Conclusion:Multiple pre-and peri-operative risk factors are independently associated with prolonged LOS and hospital readmission within 30 days of surgery using the American College of Surgeons National Surgical Quality Improvement Program data.Recognizing the risks factors that can potentially be improved prior to minimally-invasive partial nephrectomy is crucial to informing patient selection,optimization strategies,and patient education.

Radiation therapy prior to a pancreaticoduodenectomy for adenocarcinoma is associated with longer operative times and higher blood loss

BACKGROUND Pancreatic adenocarcinoma is currently the fourth leading cause of cancer-related deaths in the United States.In patients with“borderline resectable”disease,current National Comprehensive Cancer Center guidelines recommend the use of neoadjuvant chemoradiation prior to a pancreaticoduodenectomy.Although neoadjuvant radiotherapy may improve negative margin resection rate,it is theorized that its administration increases operative times and complexity.AIM To investigate the association between neoadjuvant radiotherapy and 30-d morbidity and mortality outcomes among patients receiving a pancreaticoduodenectomy for pancreatic adenocarcinoma.METHODS Patients listed in the 2015-2019 National Surgery Quality Improvement Program data set,who received a pancreaticoduodenectomy for pancreatic adenocarcinoma,were divided into two groups based off neoadjuvant radiotherapy status.Multivariable regression was used to determine if there is a significant correlation between neoadjuvant radiotherapy,perioperative blood transfusion status,total operative time,and other perioperative outcomes.RESULTS Of the 11458 patients included in the study,1470(12.8%)underwent neoadjuvant radiotherapy.Patients who received neoadjuvant radiotherapy were significantly more likely to require a perioperative blood transfusion[adjusted odds ratio(aOR)=1.58,95%confidence interval(CI):1.37-1.82;P<0.001]and have longer surgeries(insulin receptor-related receptor=1.14,95%CI:1.11-1.16;P<0.001),while simultaneously having lower rates of organ space infections(aOR=0.80,95%CI:0.66-0.97;P=0.02)and pancreatic fistula formation(aOR=0.50,95%CI:0.40-0.63;P<0.001)compared to those who underwent surgery alone.CONCLUSION Neoadjuvant radiotherapy,while not associated with increased mortality,will impact the complexity of surgical resection in patients with pancreatic adenocarcinoma.

Machine learning predicts unpredicted deaths with high accuracy following hepatopancreatic surgery

Background:Machine learning to predict morbidity and mortality-especially in a population traditionally considered low risk-has not been previously examined.We sought to characterize the incidence of death among patients with a low estimated morbidity and mortality risk based on the National Surgical Quality Improvement Program(NSQIP)estimated probability(EP),as well as develop a machine learning model to identify individuals at risk for“unpredicted death”(UD)among patients undergoing hepatopancreatic(HP)procedures.Methods:The NSQIP database was used to identify patients who underwent elective HP surgery between 2012-2017.The risk of morbidity and mortality was stratified into three tiers(low,intermediate,or high estimated)using a k-means clustering method with bin sorting.A machine learning classification tree and multivariable regression analyses were used to predict 30-day mortality with a 10-fold cross validation.C statistics were used to compare model performance.Results:Among 63,507 patients who underwent an HP procedure,median patient age was 63(IQR:54-71)years.Patients underwent either pancreatectomy(n=38,209,60.2%)or hepatic resection(n=25,298,39.8%).Patients were stratified into three tiers of predicted morbidity and mortality risk based on the NSQIP EP:low(n=36,923,58.1%),intermediate(n=23,609,37.2%)and high risk(n=2,975,4.7%).Among 36,923 patients with low estimated risk of morbidity and mortality,237 patients(0.6%)experienced a UD.According to the classification tree analysis,age was the most important factor to predict UD(importance 16.9)followed by preoperative albumin level(importance:10.8),disseminated cancer(importance:6.5),preoperative platelet count(importance:6.5),and sex(importance 5.9).Among patients deemed to be low risk,the c-statistic for the machine learning derived prediction model was 0.807 compared with an AUC of only 0.662 for the NSQIP EP.Conclusions:A prognostic model derived using machine learning methodology performed better than the NSQIP EP in predicting 30-day UD among low risk patients undergoing HP surgery.

An NSQIP evaluation of practice patterns and outcomes following surgery for anorectal abscess and fistula in patients with and without Crohn’s disease

Background:Patients with Crohn’s disease(CD)are believed to have more aggressive anorectal abscess and fistula disease.We assessed the types of procedures performed and perioperative complications associated with the surgical management of anorectal abscess and fistula disease in patients with and without CD.Methods:The American College of Surgeons National Surgical Quality Improvement Program database(ACS-NSQIP,2005-2010)was used to calculate 30-day outcomes using regression modeling,accounting for demographics,comorbidities and surgical procedures.ICD-9 codes for anorectal abscess or fistula were used for initial selection.Patients were then stratified,based on the presence or absence of underlying CD.Local procedures included incision and drainage of abscesses,fistulotomy and seton placement.Cutaneous fistulas were considered simple,while all others were classified as complex(-vaginal,-urethral and-vesical).Results:A total of 7,218 patients(mean age 45 years;64%male)met inclusion criteria,with underlying CD in 345(4.8%).CD patients were more likely to have a seton placed(9.9 vs 8.2%,P<0.001)and be on steroids(15.4 vs 4.3%,P<0.001).Thirty-seven percent of CD patients underwent local procedures,while 46%had a proctectomy and8%underwent diversion.Fistulotomy was more common in those without underlying CD(16 vs 11%,P<0.001).The overall complication rate after local treatment was 4.9%,with no difference between patients with and without CD(7.7 vs 4.9%,P=0.144).This was not affected by fistula type-simple(7.9 vs 3.9%,P=0.194)vs complex(33 vs 7.1%,P=0.21)—or when stratified by wound(3.8 vs 2.4%;P=0.26)or systemic complications(3.8 vs 2.5%;P=0.53).Yet,complications following emergency procedures were higher in patients with CD(21.4 vs 5.9%,P=0.047).Factors significantly associated with increased complications were Crohn’s disease(OR=8.2),lack of functional independence(OR=2.0),pre-operative weight loss(OR=2.6)and pre-operative acute renal failure(OR=5.6).Steroids were also associated with a 1.7-fold increase in complications,independent from CD.Conclusions:While most patients with anorectal abscess/fistula are treated with local procedures,proctectomy and diversion use is fairly common in those with underlying CD.Although complication rates following elective local procedures for anorectal abscess/fistula are similar in patients with and without CD,they are higher in patients on steroids and in CD patients undergoing emergent procedures.

A propensity score matched analysis of obesity as an independent risk factor for postoperative complications in reduction mammaplasty

Aim:Reduction mammaplasty is a commonly performed procedure for the treatment of symptomatic macromastia and is increasingly desired by the obese population.With the increasing prevalence obesity in the population,it is imperative to understand its effect on postoperative outcomes.The purpose of this study is to evaluate obesity as an independent risk factor for postoperative complications in breast reduction surgery using 1:1 patient matching through propensity scores between obese patients and non-obese controls.Methods:Between 2005 and 2013,the National Surgical Quality Improvement Program dataset identified a total of 6,016 patients as having undergone primary reduction mammaplasty with 30-day postoperative follow-up.Patients were divided into obese[body mass index(BMI)of 30 or more]vs.not obese(BMI below 30).Patients were initially analyzed using standard multivariable analysis.Using propensity scores obtained from a logistic regression model,patients were subsequently matched 1:1 according to preoperative and operative variables to truly isolate the effect of obesity on surgical outcomes.Outcomes were compared between the matched cohorts using McNemar’s test and the Wilcoxon signed rank test.Results:In unmatched multivariable analysis,rates of overall complications(7.2%vs.5.3%,P=0.0024),wound complications(5.5%vs.3.6%,P=0.0004),superficial surgical site infection(4.1%vs.2.8%,P=0.0050),and wound dehiscence(0.3%vs.1.1%,P=0.0005)were found to be statistically different between obese vs.non-obese,respectively.However,when comparing 1:1 matched obese and non-obese patients,only wound complications(4.6%vs.3.1%,P=0.0334)were significantly increased in the obese cohort.Conclusion:Using the most robust statistical tools available,obesity was determined to affect wound complications after breast reduction without increased detriment on other major complications when compared to the non-obese.Obesity should be a considered with other preoperative comorbidities,rather than an independent contraindication to surgery.Breast reduction appears to be safe in the obese patient who is otherwise healthy.