PURPOSE:Although mentorship is described extensively in academic medical literature, there are few descriptions of mentorship specific to radiation oncology. The goal of the current study was to investigate the state of mentorship in radiation oncology through a scoping review of the literature.METHODS AND MATERIALS:A search protocol was defined according to Preferred Reporting Items for Systematic Reviews and Meta Analyses extension for scoping reviews (PRISMA-ScR) guidelines. Predefined search terms and medical subject headings were used to search PubMed for English language articles published after January 1, 1990, on mentorship in radiation oncology. Additionally, in-press articles from major radiation oncology and medical education journals were searched. Three reviewers determined article eligibility. Included articles were classified based on predefined evaluation criteria.RESULTS:Fourteen publications from 2008 to 2019 met inclusion criteria. The most commonly described form of mentorship was the dyad (64.3%), followed by team (14.3%) and peer (7.1%); 2 articles did not specify mentorship type (14.3%). The most commonly mentored participants were residents (35.7%), followed by medical students (35.7%) and attendings (21.4%); 1 study included participants of all levels (7.1%). Thirteen studies (92.9%) identified an experimental study design, most of which were cross-sectional (42.9%), followed by cohort studies (28.6%) and before/after (21.4%). Median sample size, reported in 12 of 13 experimental studies, was 132 (coefficient of variation, 1.06). Although outcomes varied widely, the majority described successful implementation of mentorship initiatives with high levels of participant satisfaction.CONCLUSIONS:Although few initiatives are currently reported, the present study suggests that these initiatives are successful in promoting career development and increasing professional satisfaction. The interventions overwhelmingly described mentorship dyads; other forms of mentorship are either less common or understudied. Limitations included interventions not being evaluated in a controlled setting, and many were assessed using surveys with low response rates. This review highlights rich opportunities for future scholarship to develop, evaluate, and disseminate radiation oncology mentorship initiatives.

BACKGROUND:Controversy exists over the timing of cholecystectomy for biliary pancreatitis in children. Some surgeons await normalization of serum lipase levels while others are guided by resolution of abdominal pain; however, there are minimal data to support either practice. We hypothesized that resolution of abdominal pain is equivalent in outcome to awaiting normalization of lipase levels in patients undergoing cholecystectomy for biliary pancreatitis.METHODS:After institutional review board (IRB) approval, the medical record was retrospectively queried for all cases of cholecystectomy for biliary pancreatitis at our institution from 2007 to 2017. Patients undergoing chemotherapy, admitted for another cause, or who had severe underlying comorbidities like ventilator dependence were excluded. Patients were stratified into two cohorts: those managed preoperatively by normalization of serum lipase levels versus resolution of abdominal pain. Demographics, serum lipase levels, postoperative complications, cost of stay, readmissions, and return to the emergency department were collected and analyzed using multivariate regression.RESULTS:Seventy-four patients met inclusion: 29 patients had lipase levels trended until normalization compared with 45 patients who had resolution of abdominal pain prior to cholecystectomy. Among the two cohorts there was no statistical difference in age, gender, race, ethnicity, or type of preoperative imaging used. Trended patients were found to have more serum lipase levels tested (8.5 ± 6.2 versus 3.4 ± 2.5, P < 0.0001). The trended lipase cohort was significantly more likely to require preoperative total parenteral nutrition (48% versus 11%, P = 0.007) and consequently a longer time before resuming a diet (10 ± 7.3 versus 4.6 ± 2.4 d, P < 0.0001). When comparing the two groups, we found no significant difference in the duration of surgery, postoperative complications, or readmissions. Lipase trended patients had a significantly longer length of stay compared with nontrended patients (11.5 ± 8.1 versus 4.2 ± 2.3 d, P < 0.0001) and had a higher total cost of stay ($38,094 ± 25,910 versus $20,205 ± 5918, P = 0.0007).CONCLUSIONS:Our data suggest that in children with biliary pancreatitis, proceeding with cholecystectomy after resolution of abdominal pain is equivalent in outcomes to trending serum lipase levels but is more cost-effective with a decreased length of stay and decreased need for preoperative total parenteral nutrition.

Purpose/objectives Three-dimensional (3D) printing is recognized as an effective clinical and educational tool in procedurally intensive specialties. However, it has a nascent role in radiation oncology. The goal of this investigation is to clarify the extent to which 3D printing applications are currently being used in radiation oncology through a systematic review of the literature. Materials/methods A search protocol was defined according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Included articles were evaluated using parameters of interest including: year and country of publication, experimental design, sample size for clinical studies, radiation oncology topic, reported outcomes, and implementation barriers or safety concerns. Results One hundred and three publications from 2012 to 2019 met inclusion criteria. The most commonly described 3D printing applications included quality assurance phantoms (26%), brachytherapy applicators (20%), bolus (17%), preclinical animal irradiation (10%), compensators (7%), and immobilization devices (5%). Most studies were preclinical feasibility studies (63%), with few clinical investigations such as case reports or series (13%) or cohort studies (11%). The most common applications evaluated within clinical settings included brachytherapy applicators (44%) and bolus (28%). Sample sizes for clinical investigations were small (median 10, range 1-42). A minority of articles described basic or translational research (11%) and workflow or cost evaluation studies (3%). The number of articles increased over time (P < 0.0001). While outcomes were heterogeneous, most studies reported successful implementation of accurate and cost-effective 3D printing methods. Conclusions Three-dimensional printing is rapidly growing in radiation oncology and has been implemented effectively in a diverse array of applications. Although the number of 3D printing publications has steadily risen, the majority of current reports are preclinical in nature and the few clinical studies that do exist report on small sample sizes. Further dissemination of ongoing investigations describing the clinical application of developed 3D printing technologies in larger cohorts is warranted.

BACKGROUND:Many patients undergoing decompressive craniectomy will develop persistent hydrocephalus before cranioplasty. Therefore, surgeons must decide whether to perform ventriculoperitoneal shunt (VPS) placement and cranioplasty simultaneously or in staged procedures. With limited, conflicting data reported, this decision has often been made by personal preference. The objective of the present study was to compare the surgical outcomes between patients undergoing concurrent or staged VPS placement and cranioplasty.METHODS:We performed a 10-year retrospective comparative analysis of patients who had undergone either simultaneous or staged VPS placement and cranioplasty at a tertiary academic medical center.RESULTS:Of the 40 patients, 18 had undergone concurrent procedures and 22 had undergone VPS placement before a separate cranioplasty procedure. The concurrent group was significantly older, had more often had the VPS placed in the external ventricular drain site, and had had more patients taking aspirin at surgery. The rates of infection, resorption, and reoperation did not differ significantly, although reoperation showed a trend toward occurring less frequently in the concurrent group. Hospital-acquired infection occurred significantly less frequently in the concurrent patients. The rate of VPS-associated outcomes did not differ significantly between the 2 groups.CONCLUSIONS:Because of the trend toward a reduced reoperation rate, the significantly reduced rate of hospital-acquired infection, and the reduction in the number of surgeries, we recommend that patients awaiting cranioplasty in the setting of persistent hydrocephalus undergo concurrent VPS placement and cranioplasty rather than staged procedures.

The Radiation Oncology Education Collaborative Study Group (ROECSG) is an international collaborative network of radiation oncology (RO) professionals with the goal of improving RO education. This report summarizes the first two ROECSG annual symposia including an overview of presentations and analysis of participant feedback. One-day symposia were held in June 2018 and May 2019. Programs included oral and poster presentations, RO education leadership perspectives, and keynote addresses. Post-symposia surveys were collected. Research presentations were recorded and made available online. The 2018 symposium was had 36 attendees from 25 institutions in three countries. The 2019 symposium had 76 individuals from 41 institutions in five countries. Attendees represented diverse backgrounds including attending physicians (46%), residents (13%), medical students (14%), physicists (2%), nurses (1%), and program coordinators (1%). Fifty-five oral presentations were given with 53 released online. Ninety percent of attendees rated the symposium as improving their knowledge of RO educational scholarship, 98% felt the symposium provided the opportunity to receive feedback on RO education scholarship, and 99% felt that the symposium fostered the development of collaborative RO education projects. ROECSG was rated higher than professional organizations in fostering educational scholarship (p<0.001). All attendees felt that the symposium produced new RO education scholarship ideas and provided unique networking opportunities. The first two ROECSG symposia drew a diverse population of attendees and provided unique opportunities for presentation of RO education scholarship. Future ROECSG symposia will be designed to enhance opportunities to present RO education scholarship and to facilitate networking.

Purpose Analyze the clinical presentation, microbiology, outcomes, and medical and surgical treatment strategies of intracranial extension of sinogenic infection in pediatric patients. Methods A retrospective, single-center study of patients < 18 years of age, presenting with intracranial extension of bacterial sinogenic infections requiring surgical intervention over a 5-year period, was conducted. Electronic medical records were reviewed for age, sex, primary symptoms, duration of symptoms, presence of sinusitis at initial presentation, microorganisms isolated, mode of surgery, timing of surgery, length of stay, and neurologic sequelae. Results Seventeen patients were identified; mean age was 10 years with 82.3% male predominance. Average duration of illness prior to presentation was 9.8 days, with 64.7% of patients displaying disease progression while on oral antibiotics prior to presentation. Sinusitis and intracranial extension were present in all patients upon admission. Simultaneous endoscopic endonasal drainage and craniotomy were performed on 70.5% of the patients, with the remaining 29.5% undergoing endonasal drainage only. Of the patients who underwent simultaneous endoscopic endonasal drainage and craniotomy, 17.6% required repeat craniotomy and 5.8% required repeat sinus surgery. The most commonly isolated organisms were S. intermedius (52.9%), S. anginosus (23.5%), and S. pyogenes (17.6%). All patients were treated postoperatively antibiotic on average 4-6 weeks. Frequently occurring long-lasting complications included seizures (29.4%) and focal motor deficits (17.6%); learning disability, anxiety disorders, impaired cognition, and sensory deficits occurred less frequently. Conclusion In the case of intracranial extension of bacterial sinogenic infection, early identification and surgical treatment are crucial to avoid neurological sequelae.

INTRODUCTION: Health care spending in the United States continues to draw national attention, accounting for 17.9 percent of total gross domestic product (GDP) or $3.5 trillion dollars in 2017, expected to rise to nearly 20 percent of GDP by 2026. In order to address these expenditures, further examination of rising hospital costs is required. Evidence suggests that for-profit hospitals may be established in areas with well-insured patient populations, while disproportionately offering high-cost, profit-driven interventions over less profitable services. The objective of this study is to compare inpatient mortality, operation rates, length of stay (LOS), and cost of care between private non-profit and for-profit hospitals in the treatment of intracranial hemorrhage. METHODS: This retrospective cohort study used data from the National Inpatient Sample (NIS) database. Primary outcomes including all-cause inpatient mortality, operative status, patient disposition, hospital LOS, total hospital charges, and per-day hospital charges were assessed for patients discharged with a primary diagnosis of intracranial (epidural, subdural, subarachnoid, or intraparenchymal) hemorrhage, while controlling for baseline demographic and comorbidity differences via propensity-score matching. RESULTS: Out of 155 977 unique hospital discharges included in this study, 133 518 originated from private non-profit hospitals and 22 459 from for-profit hospitals. Mortality rates were similar, at 13.80% for non-profit centers and 14.50% at for-profit hospitals. Non-profit hospitals appeared to be more intensive with ICP monitor placement, occurring in 5.50% of patients compared to 4.24% in for-profit centers. Although overall discharge disposition and rate of surgical intervention was similar, LOS was greater among for-profit hospitals at 7.46 d, compared to 6.71 d at non-profit centers. Care at for-profit hospitals was more expensive with total charges amounting to $136,845 versus $85,093 at non-profit institutions. CONCLUSION: Despite similar mortality and discharge disposition, hospital stays for ICH tend to be costlier and longer at for-profit hospitals compared to their non-profit counterparts.

Background: Management of perforated appendicitis in children remains controversial. Nonoperative (NO) and immediate operative (IO) strategies are used with varying outcomes. We hypothesized that IO intervention for patients with perforated appendicitis would be more cost-effective than NO management. Methods: A retrospective chart review of all patients with appendicitis from 2012 to 2015 was performed. Patients with perforated appendicitis were defined by evidence of perforation on imaging. We excluded patients who presented with sepsis, organ failure, and ventriculoperitoneal shunts. NO management was determined by surgeon preference. Univariate and multivariate analyses were performed. Results: IO was performed on 145 patients with perforated appendicitis, whereas 83 were treated with NO management. Compared to IO patients, NO patients incurred higher overall costs, greater length of stay, more readmissions, complications, peripherally inserted central venous catheter lines, interventional radiology drains, and unplanned clinic and emergency department visits (P < 0.0001 for all). Multivariate analysis adjusting for age, days of symptoms, admission C-reactive protein and white blood cell count revealed that NO management was independently associated with increased costs (OR 1.35, 1.12-1.62, 95% CI). Cost curves demonstrated that total cost for IO surpasses that of NO management when patients present with greater than 6.3 d of symptoms (P = 0.01). Conclusions: Our data suggest that IO is more cost-effective than NO management for patients with perforated appendicitis who present with less than 6.3 d of symptoms, after which point, NO management is more cost-effective. (C) 2019 Elsevier Inc. All rights reserved.

e23164 Background: Patient education (PE), the use of educational interventions to improve patient knowledge of healthcare, has been shown to reduce patient anxiety and facilitate shared decision making. In contrast to many other medical specialties, the state of radiation oncology (RO) PE is unclear. This scoping review aims to characterize the state of ROPE peer-review scholarship to describe strengths, identify gaps and guide future ROPE research. Methods: Predetermined medical subject headings and search terms were used to search PubMed for ROPE articles. Additional terms were identified from these articles and the search was repeated until no further articles were found. In-press articles in major RO and medical education (ME) journals were searched. English language articles published after 1/1/1990 that had a primary ROPE focus were included. Two independent reviewers performed the search and determined eligibility. Articles were categorized using the most predominant step of Kern’s six-step conceptual framework for ME curriculum development and the country and year of publication. Results: Of 11,756 identified articles, 182 met inclusion criteria. Articles per year increased over time (p < 0.01): 1990-1994 (5.5%); 1995-1999 (11.0%); 2000-2004 (13.7%); 2005-2009 (10.4%); 2010-2014 (25.8%); 2015-2019 (33.5%). Conceptual framework categorization was as follows: problem identification (22.0%); needs assessment (23.6%); goals and objectives (4.9%); education strategies (9.9%); implementation (7.7%); evaluation and feedback (31.9%). Regional breakdown was as follows with some articles spanning regions: Africa (1.1%); South America (2.2%); Asia (6.0%); Australia (15.4%); Europe (30.2%); North America (45.6%). Conclusions: Nearly half of articles are primarily problem identification or needs assessment (45.6%) which are descriptive in nature and only identify or clarify ROPE needs. Additionally while these results are limited to English language scholarship, there are significant regional maldistributions. Although there is an encouraging trend of increasing ROPE publications over time, this study identifies opportunities to further develop, implement and evaluate ROPE scholarship.

Purpose: The risks of laparotomy during extracorporeal life support (ECLS) are poorly defined. We examined risk factors associated with bleeding and mortality after laparotomy on ECLS. Methods: The Extracorporeal Life Support Organization (ELSO) database was queried for all pediatric patients [0-17 years] with a procedure code for laparotomy. Outcome data were analyzed to define factors contributing to laparotomy complications and mortality while on ECLS. Univariate and multivariate analyses were applied to determine independent risk factors. Results: 196 patients who met inclusion criteria were identified. The mortality rate in the entire cohort was 67.3%. In both univariate and multivariate analyses, surgical site bleeding did not significantly increase the risk of mortality (OR 0.8: 95% a 0.4-1.7). Logistic regression analysis revealed that lower gestational age, infectious complications and nonsurgical site hemorrhagic complications were independently increased mortality risk (all p < 0.05). Conclusion: Mortality following laparotomy on ECLS is not independently associated with surgical site bleeding, but is associated with lower gestational age, infectious and nonsurgical site hemorrhagic complications. Type of study: Retrospective comparative study. (C) 2019 Elsevier Inc. All rights reserved.

INTRODUCTION: The management of subdural hematoma (SDH) in the setting of antithrombotic (AT) therapy, which includes antiplatelet and anticoagulant therapy, is especially challenging. While there exists consensus that AT should be discontinued during initial workup and surgical treatment of SDH, guidance regarding whether and when to restart AT is lacking. This study aims to characterize the association between the timing of AT restart and rates of thrombotic and hemorrhagic adverse events among SDH patients previously on AT in order to inform future clinical decision making. METHODS: A 10-yr retrospective analysis of SDH patients treated with antiplatelet or anticoagulant therapy was performed. Patients were grouped based on time to restart of AT therapy from admission (within 14, 15-29, 30-44, 45-59 d, and not within 60 d), and multivariable regression was used to compare the rates of adverse events between these groups. Adverse events included bleeding, thromboembolism, myocardial infarction, deep vein thrombosis, and stroke. RESULTS: A total of 226 consecutive patients were included in this analysis. Groups based on AT restart time were similar in terms of demographics and rates of comorbidities. The rates of coronary artery disease, operative treatment, and chronicity of SDH differed significantly between groups. The 45 to 59 d group had significantly fewer total complications compared to the 60 + day group (P = .016) and trended towards fewer complications than the within 14 d group and the 15 to 29 d group (P = .062 and .065, respectively). CONCLUSION: Evidence supports a lower rate of overall adverse events in patients restarted between 45 and 59 d postadmission. This restart window may be the optimal time point for potential future clinical trials.

CASE:Heterotopic ossification (HO) is a pathological formation of bone in nonosseous tissue and is a common complication of orthopaedic procedures. Radiotherapy is often used to prevent HO despite the small risk of secondary malignancy. Here, we report a case of a patient who developed a periprosthetic, radiation-induced sarcoma after delivery of a single fraction of 7 Gy for HO prophylaxis. This sarcoma was found to lie entirely within the treatment field and occurred within 5 years of radiation.CONCLUSION:Appropriate counseling regarding radiation-induced sarcoma formation should be provided to patients considering radiotherapy for this HO prophylaxis.

OBJECTIVE: The use of autologous hone for cranioplasty offers superior cosmesis and cost-effectiveness compared with synthetic materials. The choice between 2 common autograft storage mechanisms (subcutaneous vs. frozen) remains controversial and dictated by surgeon preference. We compared surgical outcomes after autologous bone cranioplasty between patients with cryopreserved and subcutaneously stored autografts. METHODS: Ten-year retrospective comparative analysis of patients undergoing cranioplasty with autologous bone stored subcutaneously or frozen at a tertiary academic medical center. RESULTS: Ninety-four patients were studied, with 34 (36.2%) bone flaps stored subcutaneously and 59 (62.8%) frozen. The 2 groups were similar in demographics, comorbidities, and craniectomy indication, with only body mass index and race differing statistically. The mean operation time was greater within the subcutaneous group (P < 0.001), which also had a greater number of ventriculoperitoneal shunt (VPS) placements (P = 0.02). There were no significant differences in complications, read-missions, unplanned reoperations, or length of stay between the 2 groups. VPS placement during cranioplasty increased length of stay (P < 0.001), and placement prior to cranioplasty increased both length of stay (P = 0.009) and incidence of hospital-acquired infection (P = 0.03). CONCLUSIONS: Subcutaneous and frozen storage of autologous bone result in similar surgical risk profiles. Cryopreservation may be preferred because of shorter operation time and avoidance of complications with the abdominal pocket, whereas the portability of subcutaneous storage remains favorable for patients undergoing cranioplasty at a different institution. VPS placement prior to cranioplasty should be avoided, if possible, due to the increased risk of hospital-acquired infection.

BACKGROUND AND OBJECTIVE: Anterior temporal lobectomy (ATL) is the most common surgical procedure for refractory temporal lobe epilepsy. When scalp electroencephalography cannot adequately identify an epileptogenic site, electrode implantation may be used to monitor epileptic activity and localize a target focus before surgical resection. Whether the advantage of improved seizure localization justifies the added risk of electrode placement remains unclear. : The present study uses an international surgical database to explore whether a 2wo-stage approach, electrode implant followed by ATL, has a reasonable safety profile and is clinically worthwhile versus ATL alone. METHODS: Data from the American College of Surgeons National Surgical Quality Improvement Program for 2005 to 2016 were queried to identify patients undergoing ATL or electrode implant for epilepsy. The 30-day postoperative outcomes were analyzed for the electrode implant and ATL groups, and individual and combined risk profiles were determined. RESULTS: Patients undergoing electrode implant followed by ATL had a predicted reoperation rate of 7.6%, readmission rate of 14.6%, and a 30-day mortality rate of 1.2%. The combined rate of patients having >= 1 medical complication for 2-staged procedures was higher, at 14.7%. The most common complications encountered were urinary tract infection (2.7%) and sepsis (2.7%). CONCLUSIONS: Intracranial electrode placement increases the risk of complications when added to ATL. The severity of complications from electrode placement are mild, however, and as intracranial electrode recording provides a potentially large reduction in the surgical failure risk, electrode placement may be advisable for all but the most convincing seizure foci.

BACKGROUND: Management of pediatric skull defects after decompressive craniectomy (DC) poses unique problems, particularly in children younger than 24 months. These problems include complications such as resorption and infection as well as difficulties with plagiocephaly and reconstruction. The goal of this study was to evaluate bone resorption complications after cranioplasty in patients <24 months. METHODS: A single-center retrospective case study was performed of all patients younger than 24 months who underwent cranioplasty after DC between 2011 and 2018. The following variables were assessed: injury cause, age at craniotomy, time to cranioplasty, craniectomy size, mode of fixation, drain use, shunt use, subdural fluid collection, resorption, need for synthetic graft revision, and plagiocephaly. RESULTS: A total of 10 patients were identified who met inclusion criteria; 3 patients were excluded for insufficient follow-up. Ages ranged from <1 day to 19 months, with a mean of 10.7 months. Overall rate of cranioplasty resorption was 85.7%, 57.1% of which required revision with synthetic graft. There were univariate trends toward more frequent implant resorption with subdural fluid collection (P = 0.1071) and without shunt placement (P = 0.1429). These effects persisted through multivariable analysis and even reached statistical significance in the case of subdural collection when controlling for operative and demographic characteristics (P = 0.01138, P = 0.0694). In addition, univariate analysis showed a trend toward more frequent neurologic complications with greater craniotomy-to-cranioplasty intervals (P = 0.1043), which reached significance on multivariable analysis (P = 0.00518). CONCLUSIONS: In patients younger than 24 months undergoing cranioplasty subdural collection, a lack of shunt placement and increased time to cranioplasty were associated with increased rates of resorption.

OBJECTIVE:Much of the current discourse surrounding healthcare reform in the United States revolves around the role of the profit motive in medical care. However, there currently exists a paucity of literature evaluating the effect of for-profit hospital ownership status on neurological and neurosurgical care. The purpose of this study was to compare inpatient mortality, operation rates, length of stay, and hospital charges between private nonprofit and for-profit hospitals in the treatment of intracranial hemorrhage. METHODS:This retrospective cohort study utilized data from the National Inpatient Sample (NIS) database. Primary outcomes, including all-cause inpatient mortality, operative status, patient disposition, hospital length of stay, total hospital charges, and per-day hospital charges, were assessed for patients discharged with a primary diagnosis of intracranial (epidural, subdural, subarachnoid, or intraparenchymal) hemorrhage, while controlling for baseline demographics, comorbidities, and interhospital differences via propensity score matching. Subgroup analyses by hemorrhage type were then performed, using the same methodology. RESULTS:Of 155,977 unique hospital discharges included in this study, 133,518 originated from private nonprofit hospitals while the remaining 22,459 were from for-profit hospitals. After propensity score matching, mortality rates were higher in for-profit centers, at 14.50%, compared with 13.31% at nonprofit hospitals (RR 1.09, 95% CI 1.00-1.18; p = 0.040). Surgical operation rates were also similar (25.38% vs 24.42%; RR 0.96, 95% CI 0.91-1.02; p = 0.181). Of note, nonprofit hospitals appeared to be more intensive, with intracranial pressure monitor placement occurring in 2.13% of patients compared with 1.47% in for-profit centers (RR 0.69, 95% CI 0.54-0.88; p < 0.001). Discharge disposition was also similar, except for higher rates of absconding at for-profit hospitals (RR 1.59, 95% CI 1.12-2.27; p = 0.018). Length of stay was greater among for-profit hospitals (mean ± SD: 7.46 ± 11.91 vs 6.50 ± 8.74 days, p < 0.001), as were total hospital charges ($141,141.40 ± $218,364.40 vs $84,863.54 ± $136,874.71 [USD], p < 0.001). These findings remained similar even after segregating patients by subgroup analysis by hemorrhage type. CONCLUSIONS:For-profit hospitals are associated with higher inpatient mortality, lengths of stay, and hospital charges compared with their nonprofit counterparts.

BACKGROUND: Thoracic corpectomies are performed for various reasons, including spinal deformity, trauma, neoplasms, and infection. Regardless of indication, both anterior and posterior approaches are surgical options, selected based on pathology, anatomy, patient characteristics, and surgical experience. Risk profiles and outcomes for these procedures are poorly characterized, however, and the choice between the 2 approaches remains inconclusive. OBJECTIVE: To compare risk factors and complications for adult patients undergoing anterior and posterior thoracic corpectomies. METHODS: A review of the American College of Surgeons National Quality Improvement Program database was performed, with 30-day patient outcomes after anterior or posterior thoracic corpectomy queried from 2005 to 2016. Preoperative risk factors and postoperative outcomes (e.g., deaths, reoperations, readmissions) were identified and compared. RESULTS: In total, 1327 corpectomies were studied, 861 (64.9%) by an anterior approach and 465 (35.1%) by a posterior approach. Patients undergoing a posterior approach were generally male, older, and had a greater American Association of Anesthesiologists class, whereas those subject to anterior approaches had a greater average body mass index. After we controlled for these baseline characteristics, no significant difference to postoperative events was observed, with 9.3% of anterior approach patients and 7.1% of posterior approach patients returning to the operating room within 30 days. CONCLUSIONS: No significant difference in rates of reoperation, readmission, death, average length of stay, or medical complications exists between anterior and posterior thoracic corpectomy approaches. Both have relatively low-risk profiles and, in situations in which either strategy is reasonable, each can be selected at the surgeon's discretion with comparable risk.

Objectives Neoplasms involving the pineal gland are rare. When they do occur, tumor resection is anatomically challenging and is traditionally addressed by either a supratentorial or an infratentorial approach. To date, no large, multicenter studies have been performed that systematically analyze outcomes comparing these two approaches. This study aimed to evaluate outcomes for patients undergoing pineal neoplasm resection, comparing supratentorial and infratentorial approaches. Design Retrospective database review. Setting Multi-institutional database. Participants From 2005 to 2016, 60 patients were identified, with 13 undergoing a supratentorial approach and 47 undergoing an infratentorial approach. Main Outcome Measures Patient demographics, comorbidities, and 30-day postoperative outcomes were investigated using the American College of Surgeons National Surgical Quality Improvement Program database. Demographics, readmission, reoperation, and complication rates were analyzed and compared with previous studies. Results Patient demographics were similar between these two groups. The overall complication rates for the supratentorial and infratentorial approaches were 30.8 and 17%, respectively, and the difference was not statistically significant. The most common medical complications encountered were respiratory and hematological. Conclusion As the first multi-institutional database analysis of approaches to the pineal gland, this study provides an analysis of patient demographics, comorbidities, and postoperative complications. After controlling for preoperative risk factors and demographic characteristics, no statistically significant differences in postoperative outcomes were found between infratentorial and supratentorial approaches. The mean readmission, reoperation, and complication rates were found to be 2.1, 8.3, and 20%, respectively. The lack of significant difference between approaches suggests that clinical decision-making should depend upon anatomical considerations and physician preference, although the complications illustrated here may provide some preoperative guidance.

BACKGROUND:Chiari I malformations are common in adults and a frequent procedure in neurosurgical practice. Despite several studies, there is no consensus about the indications or surgical technique for this common condition. Increasing emphasis on value-based care has emphasized reduction of readmissions and reoperations and is particularly relevant in Chiari, which has traditionally been associated with a high complication rate.OBJECTIVE:To provide a contemporary surgical profile of risk factors and complications for Chiari I malformations in adults.METHODS:The American College of Surgeons National Surgical Quality Improvement Program database was queried to determine 30-day outcomes after surgery for Chiari I malformations in adults between 2005 and 2016. Demographics, clinical risk factors, and postoperative events were analyzed, along with reoperation and readmission reasons.RESULTS:A total of 672 adult patients were identified in the cohort, with a female predominance (80%). The overall cohort readmission rate was 9.3%, and 6.8% of patients returned to the operating room. Obesity (45.7%) was predictive of both readmission and reoperation risk. Male sex and American Society of Anesthesiologists class were predictive for reoperations. The most common reason for reoperation was cerebrospinal fluid leak, which was responsible for nearly two thirds of reoperations and 4% of the cohort.CONCLUSIONS:Surgery for Chiari in adults is common and carries a definitive risk profile, including rates of readmission and reoperation higher than other common neurosurgical procedures. This cohort provides a representative sample of contemporary neurosurgical outcomes in surgery for Chiari I malformations.

Bhimani, Abhiraj D; Esfahani, Darian R MD; Denyer, Steven BS, MS; Chiu, Ryan G BS; Rosenberg, David BS; Barks, Ashley L MD; Arnone, Gregory D MD; Mehta, Ankit I MD Author Information