Introduction Approximately eight per 1000 patients develop gastric cancer in the US. Surgery serves as part of curative intent treatment, but subsequent changes to diet, digestion, and financial burden may impact lifestyle for many. Health-related quality of life (HRQoL) changes following gastric cancer surgery have not been fully explored. Methods A cross-sectional study design explored patients’ HRQoL measures after undergoing total and subtotal gastrectomy. Participants were surveyed using European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaires (QLQ)-C30, gastric cancer-specific QLQ-STO22, and open-ended questions regarding impact of cancer on family life, social activity, finances, and life reflection. QLQ-C30 data were also compared to age-adjusted normative controls. Global health status, function, and symptom scales were assessed. Results Out of 92 eligible patients, 57 chose to participate (62%). A total of 45 patients had subtotal gastrectomy (79%) and 12 underwent total gastrectomy (21%), with median overall follow-up time of 71 mo. QLQ-30 measures of nausea, vomiting, and diarrhea occurred with greater frequency among patients' postgastrectomy (all P ≤ 0.041). Numerous QLQ-STO22 HRQoL measures were statistically marginal after total gastrectomy rather than subtotal (P ≤ 0.080). Themes of adjustment, outlook, and minimal disruption emerged from the data. One subject noted: “I just do everything normal. I don't even realize that… I don't have a stomach. It doesn't have any effect on anything I do.” Conclusions Assessing HRQoL provides information about patients’ health and experiences with their disease, which may influence clinical decision-making. Understanding patient experience is important to providing better and more individualized patient care.

Laparoscopic adjustable gastric banding (LAGB) was performed frequently from 2001 to 2012 in the U.S. Many patients still have bands in place, but evaluations of long-term outcomes are few. This study’s purpose was to identify predictors of 10-year optimal clinical response following LAGB procedures. Demographic, perioperative, and surgical outcomes data (2006–2013) from a single academic institution were analyzed. Electronic medical records were reviewed and patients were contacted using a standardized script for follow-up data. A logistic regression model identified predictors of optimal clinical response, ≥ 20

STUDY OBJECTIVE:To evaluate whether higher Distressed Communities Index (DCI) scores, as a measure of community-level socioeconomic distress, are associated with worse risk-adjusted postoperative outcomes and healthcare resource utilization after gynecologic surgery. DESIGN:This was a retrospective cohort study utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Gynecology Collaborative database. Generalized linear mixed-effect models and linear mixed-effect models were used to evaluate the association between DCI scores and surgical outcomes, with institution treated as a random effect and models adjusted for the ACS-NSQIP predicted morbidity percentage. SETTING:Six ACS-NSQIP Gynecology Collaborative sites in the United States, between January 1, 2018, and June 30, 2023. PARTICIPANTS:Adult patients undergoing gynecologic operations during the study period. Patient records, including ZIP Code data, were merged with DCI scores ranging from 0 (low distress) to 100 (high distress), with DCI > 75 identifying distressed communities. INTERVENTIONS:No therapeutic interventions were applied. Exposures of interest were community-level distress as measured by DCI. The primary outcome was a composite measure of postoperative morbidity. Secondary outcomes included markers of resource utilization (length of stay, discharge to nursing facility, and hospital readmission) and comparisons of outcomes between oncologic and benign procedures. MEASUREMENTS AND MAIN RESULTS:Patients with DCI > 75 had a higher mean body mass index, greater comorbidity burden, higher ACS-NSQIP predicted morbidity percentage, longer mean length of stay, and higher unadjusted composite postoperative complication rates compared with patients with DCI ≤ 75. In generalized and linear mixed-effect models adjusting for ACS-NSQIP predicted morbidity, DCI (modeled continuously or dichotomized at >75) was not independently associated with postoperative complications (OR 1.06, 95% CI 0.86-1.30, p = .62), discharge destination (OR 0.69, 95% CI 0.38-1.26, p = .23), unplanned readmission (OR 1.15, 95% CI 0.86-1.54, p = .34), or length of stay. By contrast, higher ACS-NSQIP predicted morbidity percentage remained strongly associated with composite complications and hospital length of stay. CONCLUSION:In our multicenter cohort, DCI showed no independent association with postoperative outcomes in multivariable analysis. Future research should include samples with higher proportions of participants from highly distressed communities, as well as more precise socioeconomic status measures (income, education, neighborhood), since ZIP code-based indicators may lack granularity. Such efforts could enhance individual risk stratification and targeted interventions. Linking clinical and community data is promising, but success requires rigorous harmonization, quality control, and methodological refinement.

INTRODUCTION:Early detection of rectal cancer improves outcomes, yet delays in presentation and diagnosis remain common. We examined whether the type of initial health care provider, presenting symptoms, and patient characteristics contributed to the delayed detection and diagnosis of rectal cancer. METHODS:We conducted a retrospective cohort study of patients undergoing surgical resection for rectal cancer at a single institution (2015-2022) using the American College of Surgeons' National Surgical Quality Improvement Program database with supplemental chart review. Socioeconomic distress was measured using the Distressed Communities Index. The primary outcome was presentation delay, defined as >30 days from symptom onset to first medical evaluation. Secondary outcomes included diagnosis delay, defined as >30 days from symptom onset to tissue diagnosis, and comparisons between emergency department versus primary care physician (PCP) for initial medical presentation. Univariable analyses and multivariable logistic regression were performed. RESULTS:Among 205 patients with available data, 147 (72%) experienced presentation delay. Patients younger than 50 y (29% versus 12%, P = 0.012) and those presenting with changes in bowel habits were more likely to experience delayed presentation (27% versus 5%, P = 0.004). Patients presenting to a PCP were more likely to experience diagnosis delay compared to those presenting to the emergency department (75% versus 55%, P = 0.012). On multivariable analysis, change in bowel habits (odds ratio (OR) 6.45, 95% confidence interval (CI): 1.54-34.83) and age <50 y (OR 3.93, 95% CI: 1.38-12.94) were associated with presentation delay, while diagnosis delay (OR 3.55, 95% CI: 1.47-9.07) and insurance status were associated with presentation to a PCP. CONCLUSIONS:Delayed presentation of rectal cancer is associated with younger age and indolent symptoms, while delays in diagnosis appear to be influenced by health care access pathways. Patients entering care through primary care settings may experience longer time to diagnosis. Efforts should be made to recognize more indolent symptoms, such as rectal bleeding and bowel habit changes, as potential signs of rectal cancer and improve referral processes to expedite evaluation of concerning symptoms.

BACKGROUND:Pancreatoduodenectomy is a high-risk operation. National cancer registry data can estimate trends in 90-day outcome measures but are not always included in surgical discussions. We aimed to study national trends in patient selection and postoperative outcomes to better guide shared decision-making between patients and surgeons. METHODS:Patients ≥18 years who underwent pancreatoduodenectomy between 2004 and 2020 were abstracted from the National Cancer Database. Primary outcome was 90-day mortality. Mortality was tabulated by year and stratified by tumor histology: adenocarcinoma, neuroendocrine neoplasm, or other (adenocarcinoma in the setting intraductal papillary mucinous neoplasm, colloid carcinoma, sarcomas, etc.). Multivariable logistic regression determined independent predictors of mortality and survival. RESULTS:A total of 63,283 patients were included. 51.7% were male, with median age of 66 (IQR 59, 73) years. The number of pancreatoduodenectomies per year more than doubled over time from 2219 in 2004 to 4613 in 2020. Tumors were categorized as adenocarcinoma in 91.0%, neuroendocrine in 6.6%, and other malignancies in 2.4%. Change in 90-day mortality over time differed by histology. For patients with pancreatic ductal adenocarcinoma, 90-day mortality decreased from 8.0% in 2004 to 5.3% in 2020 (p < 0.001); for neuroendocrine neoplasm mortality decreased from 8.6% to 3.4% (p < 0.001); for other tumors mortality decreased from 8.7% to 7.2% (N.S). Older age (p < 0.001) and Charlson-Deyo Score ≥3 (p < 0.001) were significant predictors of both 30- and 90-day mortality. CONCLUSIONS:90-day mortality following pancreatoduodenectomy continues to decrease significantly. Case volume more than doubled over this 16-year period. Continued improvements in patient selection, optimization, and refinement in operative technique may contribute to improving outcomes over time.

Background Letters of recommendation (LOR) are vital to surgical residency applications. Our prior study demonstrated differences in letter content by applicant sex, including more frequent reference to leadership and awards for male applicants. This study evaluates if leadership activities and awards as documented by the applicant’s curriculum vitae (CV) corroborate differences noted in corresponding recommendation letters. Methods LORs and CVs for 2016-2017 surgery resident applicants selected for interview at single academic institution were analyzed for documentation of leadership and awards and assessed for concordance. Results 89 applicant CVs (45 male, 44 female) and 332 LORs (165 male, 167 female) were reviewed for evidence of leadership and awards. While 94% of CVs had evidence of leadership, leadership was referenced in LORs more often for men than women (45% vs 30%, p=0.004). References to leadership skills (38% vs 21%, p=<0.001), elected/appointed office (33% vs 16%, p<0.001), and volunteer/work-related leadership role (12% vs 3%, p=0.001) occurred more commonly for men. Similarly, awards were present in 74% of CVs without difference by sex but referenced more commonly for men compared to women (64% vs 46%, p=0.001). Conclusion References to leadership and awards in LORs were more common for men than women applicants, which is not reflective of CV content. Although LOR need not recapitulate CVs, fair appraisal of leadership abilities is encouraged.

Abstract Background While existing risk calculators focus on mortality and complications, elderly patients are concerned with how operations will affect their quality of life, especially their independence. We sought to develop a novel clinically relevant and easy-to-use score to predict elderly patients’ loss of independence after gastrointestinal surgery. Methods This retrospective cohort study included patients age ≥ 65 years enrolled in the American College of Surgeons National Surgical Quality Improvement Program database and Geriatric Pilot Project who underwent pancreatic, colorectal, or hepatic surgery (January 1, 2014- December 31, 2018). Primary outcome was loss of independence – discharge to facility other than home and decline in functional status. Patients from 2014 to 2017 comprised the training data set. A logistic regression (LR) model was generated using variables with p < 0.2 from the univariable analysis. The six factors most predictive of the outcome composed the short LR model and scoring system. The scoring system was validated with data from 2018. Results Of 6,510 operations, 841 patients (13%) lost independence. Training and validation datasets had 5,232 (80%) and 1,278 (20%) patients, respectively. The six most impactful factors in predicting loss of independence were age, preoperative mobility aid use, American Society of Anesthesiologists classification, preoperative albumin, non-elective surgery, and race (all OR > 1.83; p < 0.001). The odds ratio of each of these factors were used to create a sixteen-point scoring system. The scoring system demonstrated satisfactory discrimination and calibration across the training and validation datasets, with Receiver Operating Characteristic Area Under the Curve 0.78 in both and Hosmer-Lemeshow statistic of 0.16 and 0.34, respectively. Conclusions This novel scoring system predicts loss of independence for geriatric patients after gastrointestinal operations. Using readily available variables, this tool can be applied in the urgent setting and can contribute to elderly patients and their family discussions related to loss of independence prior to high-risk gastrointestinal operations. The applicability of this scoring tool to additional surgical sub-specialties and external validation should be explored in future studies.

BACKGROUND:Patients undergoing hepato-pancreato-biliary (HPB) surgery are at high risk of readmissions and complications, including surgical site infections (SSI). LOCAL PROBLEM:Our local institution had not implemented a consistent strategy for identifying HPB SSIs post-discharge. METHODS:Quality improvement methods using Plan-Do-Study-Act cycles were implemented. INTERVENTIONS:Nurse practitioner (NP)-led telehealth visits were incorporated for early detection of SSIs and to promote patient satisfaction. Evaluation occurred through standardized documentation and post-visit patient satisfaction surveys. RESULTS:Thirty-six telehealth visits were conducted; 8 SSIs were identified (1 during the telehealth visit and 7 during subsequent clinic visits). Most patients (n = 7, 88%) with SSIs were re-hospitalized. Undergoing Whipple surgery (n = 5, 62.5%) and incisional drainage (n = 3, 37.5%) were the most common SSI indicators. Survey respondents (n = 28) validated usefulness and satisfaction with telehealth visits. CONCLUSIONS:SSIs were identified early in the post-discharge period through NP-led telehealth visits, positively impacting patient satisfaction.

Background: There has been tremendous effort to improve quality following colorectal surgery, including the proliferation of minimally invasive techniques, enhanced recovery protocols, and surgical site infection prevention bundles. While these programs have demonstrated improved postoperative outcomes at the institutional level, it is unclear whether similar benefits are present on a national scale. Methods: American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Targeted Colectomy data from 2012 to 2020 were used to identify patients undergoing minimally invasive surgery (MIS) or open partial colectomy (CPT 44140, 44204) or low anterior resection (CPT 44145, 44207). Chronological cohorts as well as annual trends in 30-day postoperative outcomes including surgical site infection, venous thromboembolism, and length of stay were assessed using both univariable and multivariable regression analyses. Results: 261,301 patients, 135,876 (52 %) female, with a median age of 62 (IQR 53-72) were included. Across all years, MIS partial colectomy was the most common procedure (37 %), followed by MIS low anterior resection (27 %), open partial colectomy (24 %), and open low anterior resection (12 %). MIS increased from 59 % in 2012-2014 to 66 % in 2018-2020 (p < 0.001). During this same period, postoperative length of stay decreased from a median of 5 days (IQR 4-7) in 2012-2014 to 4 days (IQR 3-6) in 2018-2020 (p < 0.001). Superficial surgical site infections decreased from 5.5 % in 2012-2014 to 2.9 % in 2018-2020 (p < 0.001). Deep surgical site infections similarly decreased from 1.1 % to 0.4% between these periods (p < 0.001). Pulmonary embolism also decreased from 0.6 % to 0.5 % between periods (p = 0.02). 30-day mortality was unchanged at 1.7 % between 2012-2014 and 2018-2020 (p = 0.40). After adjustment for ACS NSQIP estimated probability of morbidity and mortality, undergoing a colectomy in 2020 compared to 2012 was associated with a 14 % decrease in postoperative length of stay (p < 0.001). Conclusions: Between 2012 and 2020, significant improvements in postoperative outcomes after colectomy were observed in the United States. These results support the positive impact that the widespread adoption of quality improvement initiatives is having on colorectal patient care nationally.

BackgroundThe risk of venous thromboembolism (VTE) after hepatopancreatobiliary (HPB) surgery is high. Extended postdischarge prophylaxis in this patient population has been controversial. This study aimed to examine the safety of postdischarge extended VTE prophylaxis in patients at high risk of VTE events after HPB surgery.MethodsAdult patients risk stratified as very high risk of VTE who underwent HPB operations between 2014 and 2020 at a quaternary care center were included. Patients were matched 1:2 extended VTE prophylaxis to the control group (patients who did not receive extended prophylaxis). Analyses compared the proportions of adverse bleeding events between groups.ResultsA total of 307 patients were included: 103 in the extended prophylaxis group and 204 in the matched control group. Demographics were similar between groups. More patients in the extended VTE prophylaxis group had a history of VTE (9% vs 3%; P = .045). There was no difference in bleeding events between the extended VTE prophylaxis and the control group (6% vs 2%; P = .091). Of the 6 patients with bleeding events in the VTE prophylaxis group, 5 had gastrointestinal (GI) bleeding, and 1 had hemarthrosis. Of the 4 patients with bleeding events in the control group, 1 had intra-abdominal bleeding, 2 had GI bleeding, and 1 had intra-abdominal and GI bleeding.ConclusionPatients discharged with extended VTE prophylaxis after HPB surgery did not experience more adverse bleeding events compared with a matched control group. Routine postdischarge extended VTE prophylaxis is safe in patients at high risk of postoperative VTE after HPB surgery.

BACKGROUND: Human error is impossible to eliminate, particularly in systems as complex as healthcare. The extent to which judgment errors in particular impact surgical patient care or lead to harm is unclear. STUDY DESIGN: The American College of Surgeons NSQIP (2018) procedures from a single institution with 30-day morbidity or mortality were examined. Medical records were reviewed and evaluated for judgment errors. Preoperative variables associated with judgment errors were examined using logistic regression. RESULTS: Of the surgical patients who experienced a morbidity or mortality, 18% (31 of 170) experienced an error in judgment during their hospitalization. Patients with hepatobiliary procedure (odds ratio [OR] 5.4 [95% CI 1.23 to 32.75], p = 0.002), insulin-dependent diabetes (OR 4.8 [95% CI 1.2 to 18.8], p = 0.025), severe COPD (OR 6.0 [95% CI 1.6 to 22.1], p = 0.007), or with infected wounds (OR 8.2 [95% CI 2.6 to 25.8], p < 0.001) were at increased risk for judgment errors. CONCLUSIONS: Specific procedure types and patients with certain preoperative variables had higher risk for judgment errors during their hospitalization. Errors in judgment adversely impacted the outcomes of surgical patients who experienced morbidity or mortality in this cohort. Preventing or mitigating errors and closely monitoring patients after an error in judgment is prudent and may improve surgical safety.

ObjectivesMonitoring resident trainees’ patient outcomes is essential to improving surgical performance; however, resident-specific follow-up is rarely provided in the current surgical training environment. Whether there is a correlation between individual resident's surgical performance and patients’ clinical outcomes remains undefined. In this study, we aimed to use risk-adjusted patient outcomes as an educational tool to track individual surgical trainee performance.Study DesignAmerican College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) appendectomy and partial colectomy operations (2013-2021) were examined. Residents performing ≥25 operations were included. The primary outcome was ACS NSQIP-defined morbidity adjusted using estimated probability of morbidity. Observed-to-expected ratios (O/E) of morbidity measured overall performance and risk-adjusted cumulative sum (RA-CUSUM) methodology represented surgical resident's performance over time.SettingAcademic quaternary care institution.ParticipantsHighest-ranking surgical resident participating in an operation and included in Quality In-Training Initiative.ResultsA total of 449 operations were examined. 12 residents performed 343 appendectomy operations. 7 residents (29.3 ± 5.1 operations each) did not have any postoperative morbidity and demonstrated better-than-expected patient outcomes. Three residents did not have morbidity after their seventh/eleventh/fifteenth appendectomies. Two residents (case volume 29, 33) had an O/E ratio > 3. Partial colectomy (n = 106) performed by 4 residents had 2 residents (case volume 30, 26) with better-than-expected outcomes and 2 with worse-than-expected (case volume 25, 25).ConclusionLongitudinal monitoring of postoperative patient outcomes provides an opportunity for trainee self-reflection and system examination. RA-CUSUM methodology offers sequential monitoring allowing for early evaluation and intervention when RA-CUSUM results for a trainee demonstrate higher-than-expected morbidity.

BACKGROUND:Failure to rescue (FTR) is a quality metric defined as mortality after potentially preventable complications after surgery. Predicting patients who are at the highest risk of mortality after a complication may aid in preventing deaths. Thirty-day follow-up period inadequately captures postoperative deaths; alternatively, a 90-day follow-up period has been advocated. This study aimed to examine the association of a validated frailty metric, the risk analysis index (RAI), with 90-day FTR (FTR-90). METHODS:Patients aged ≥65 years who underwent a major abdominal operation between 2014 and 2020 at a quaternary care center were abstracted. Institutional data were merged with the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Geriatric Surgery Research File variables. The association between RAI and FTR-90 was evaluated using multivariable logistic regression. RESULTS:A total of 398 patients with postoperative complications were included. Fifty-two patients (13.1%) died during the 90-day follow-up. The FTR-90 group was older (median age: 76 vs 73 years, respectively; P = .002), had a greater preoperative American Society of Anesthesiologists classification score (P < .001), and had a higher ACS NSQIP estimated risk of morbidity (0.33% vs 0.20%, P < .001) and mortality (0.067% vs 0.012%, P < .001). The FTR-90 group had a greater median RAI score (23 vs 19; P = .002). The RAI score was independently associated with FTR-90 (odds ratio, 1.04; 95% CI, 1.0042-1.0770; P = .028) but not with FTR-30 (P = .13). CONCLUSION:Preoperative frailty, as defined by RAI, is independently associated with FTR at 90-day follow-up. FTR-90 captured nearly 60% more deaths than did FTR-30. Frailty has major implications beyond the typical 30-day follow-up period, and a longer follow-up period must be considered.

BACKGROUND:Preoperative geriatric-specific variables (GSV) influence short-term morbidity in surgical patients, but their impact on long-term survival in elderly patients with cancer remains undefined. STUDY DESIGN:This observational cohort study included patients ≥65 years who underwent hepatopancreatobiliary or colorectal operations for malignancy between 2014 and 2020. Individual patient data included merged ACS NSQIP data, Procedure Targeted, and Geriatric Surgery Research variables. Patients were stratified by age: 65-74, 75-84, and ≥85 and presence of these GSVs: mobility aid, preoperative falls, surrogate signed consent, and living alone. Bivariable and multivariable analyses were used to evaluate 1-year mortality and postoperative discharge to facility. RESULTS:577 patients were included: 62.6 % were 65-74 years old, 31.7 % 75-84, and 5.7 % ≥ 85. 96 patients were discharged to a facility with frequency increasing with age group (11.4 % vs 22.4 % vs 42.4 %, respectively, p < 0.001). 73 patients (12.7 %) died during 1-year follow-up, 32.9 % from cancer recurrence. One-year mortality was associated with undergoing hepatopancreatobiliary operations (p = 0.017), discharge to a facility (p = 0.047), and a surrogate signing consent (p = 0.035). Increasing age (p < 0.001), hepatopancreatobiliary resection (p = 0.002), living home alone (p < 0.001), and mobility aid use (p < 0.001) were associated with discharge to a facility. CONCLUSION:Geriatric-specific variables, living alone and use of a mobility aid, were associated with discharge to a facility. A surrogate signing consent and discharge to a facility were associated with 1-year mortality. These findings underscore the importance of preoperative patient selection and optimization, efficacious discharge planning, and informed decision-making in the care of elderly cancer patients.

Background Traditional surgical outcomes are measured retrospectively and intermittently, limiting opportunities for early intervention. Objectives The objective of this study was to use risk-adjusted cumulative sum (RA-CUSUM) to track perioperative surgical outcomes for laparoscopic gastric bypass. We hypothesized that RA-CUSUM could identify performance variations between surgeons. Setting Two mid-Atlantic quaternary care academic centers. Methods Patient-level data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) were abstracted for laparoscopic gastric bypasses performed by 3 surgeons at 2 high-volume centers from 2014 to 2021. Estimated probabilities of serious complications, reoperation, and readmission were derived from the MBSAQIP risk calculator. RA-CUSUM curves were generated to signal observed-to-expected odds ratios (ORs) of 1.5 (poor performance) and .5 (superior performance). Control limits were set based on a false positive rate of 5% (α = .05). Results We included 1192 patients: Surgeon A = 767, Surgeon B = 188, and Surgeon C = 237. Overall rates of serious complications, 30-day reoperations, and 30-day readmissions were 3.9%, 2.5%, and 5.2% respectively, with expected rates of 4.7%, 2.2%, and 5.8%. RA-CUSUM signaled lower-than-expected (OR < .5) rates of readmission and serious complication in Surgeon A, and higher-than-expected (OR > 1.5) readmission rate in Surgeon C. Surgeon A further demonstrated an early period of higher-than-expected (OR > 1.5) reoperation rate before April 2015, followed by superior performance thereafter (OR < .5). Surgeon B's performance generally reflected expected standards throughout the study period. Conclusions RA-CUSUM adjusts for clinical risk factors and identifies performance outliers in real-time. This approach to analyzing surgical outcomes is applicable to quality improvement, root-cause analysis, and surgeon incentivization.

Background: Patients undergoing hepatopancreaticobiliary (HPB) operations for malignancy are at high risk for venous thromboembolism (VTE) following surgery. Due to potential risk of bleeding, differing recommendations have been proposed for the use of extended VTE prophylaxis after hospital discharge in this patient population. This study aims to examine the safety of routine post-discharge extended VTE prophylaxis in patients at high risk for VTE events following HPB surgery.

Background Liver resection is commonly performed for hepatic tumors, however preoperative risk stratification remains challenging. We evaluated the performance of contemporary prediction models for short-term mortality after liver resection in patients with and without cirrhosis. Methods This retrospective cohort study examined National Surgical Quality Improvement Program data. We included patients who underwent liver resections from 2014 to 2019. VOCAL-Penn, MELD, MELD-Na, ALBI, and Mayo risk scores were evaluated in terms of model discrimination and calibration for 30-day post-operative mortality. Results A total 15,198 patients underwent liver resection, of whom 249 (1.6%) experienced 30-day post-operative mortality. The VOCAL-Penn score had the highest discrimination (area under the ROC curve [AUC] 0.74) compared to all other models. The VOCAL-Penn score similarly outperformed other models in patients with (AUC 0.70) and without (AUC 0.74) cirrhosis. Conclusion The VOCAL-Penn score demonstrated superior predictive performance for 30-day post-operative mortality after liver resection as compared to existing clinical standards.

Introduction: Medicaid expansion's (ME) impact on postoperative outcomes after abdominal surgery remains poorly defined. We aimed to evaluate ME's effect on surgical morbidity, mortality, and readmissions in a state that expanded Medicaid (Virginia) compared to a state that did not (Tennessee) over the same time period. Methods: Virginia Surgical Quality Collaborative (VSQC) American College of Surgeons Na-tional Surgical Quality Improvement Program data for Medicaid, uninsured, and private insurance patients undergoing abdominal procedures before Virginia's ME (3/22/18-12/31/ 18) were compared with post-ME (1/1/19-12/31/19), as were corresponding non-ME state Tennessee Surgical Quality Collaborative (TSQC) data for the same 2018 and 2019 time periods. Postexpansion odds ratios for 30-d morbidity, 30-d mortality, and 30-d unplanned readmission were estimated using propensity score-adjusted logistic regression models. Results: In Virginia, 4753 abdominal procedures, 2097 pre-ME were compared to 2656 post -ME. In Tennessee, 5956 procedures, 2484 in 2018 were compared to 3472 in 2019. VSQC's proportion of Medicaid population increased following ME (8.9% versus 18.8%, P < 0.001) while uninsured patients decreased (20.4% versus 6.4%, P < 0.001). Post-ME VSQC had fewer 30-d readmissions (12.2% versus 6.0%, P = 0.013). Post-ME VSQC Medicaid patients had significantly lower probability of morbidity (-8.18, 95% confidence interval:-15.52 w-0.84, P = 0.029) and readmission (-6.92, 95% confidence interval:-12.56 w-1.27, P 1/4 0.016) compared to pre-ME. There were no differences in probability of morbidity or readmission in the TSQC Medicaid population between study periods (both P > 0.05); there were no differences in mortality between study periods in VSQC and TSQC patient populations (both P > 0.05). Conclusions: ME was associated with decreased 30-d morbidity and unplanned readmissions in the VSQC. Data-driven policies accounting for ME benefits should be considered. 2023 Elsevier Inc. All rights reserved.