INTRODUCTION:Readmission after trauma remains a significant challenge in the geriatric population. Few studies have looked at geriatric trauma readmission (GTR) across a mature trauma network including at level IV centers. Our objective was to determine if discharge functional status predicts GTR across all levels of trauma centers. Secondary objective was to determine incidence and reason for GTR. METHODS:Institutional trauma registries were queried for all geriatric trauma admissions across our network (2018-2023). These data were merged with all-cause network readmission data. Demographics, injury characteristics, trauma center level, frailty, discharge functional status (functional independence measure [FIM]), disposition, and payor status were compared between non-GTR and GTR patients. Univariate, followed by multivariate, logistic regression was used to identify predictors of readmission. Reason for GTR and time to GTR were examined. RESULTS:A total of 11,270 patients were admitted across the network with a median age of 81 years (interquartile range, 74-88 years) and a median Injury Severity Score of 5 (4-9), while 6.6% (n = 741) had an Injury Severity Score of >16. All-cause GTR rate was 6.2% (n = 700). On multivariate analysis, FIM score (odds ratio [OR], 0.99 [0.95-1.02]; p  = 0.60), treatment at a level IV center, and disposition were not predictors of GTR. The results were similar after adjusting for frailty, with three or more comorbidities (OR, 1.708 [1.16-2.51]; p  < 0.01) and hospital length of stay (OR, 1.05 [1.01-1.09]; p  < 0.01) representing the highest predictors of GTR. Fourteen percent (n = 101/700) of GTR patients were readmitted for a trauma complication, 11% (n = 75) for new injury, 63% (n = 439) for a medical condition, and 12% (n = 84) because of prior refusal for rehab. The median time to GTR was 14 days (interquartile range, 6-21 days). Fifty-seven percent (n = 396) had incomplete follow-up. CONCLUSION:Hospital length of stay and more than three comorbidities but not FIM score predict GTR with most GTR for a new or preexisting medical condition. These variables represent suitable targets for GTR reduction. ( J Trauma Acute Care Surg . 2026;100: 730-738. Copyright © 2025 Wolters Kluwer Health, Inc. All rights reserved.). LEVEL OF EVIDENCE:Prognositc and Epidemiologic; Level IV.

Introduction: Surgical site infections (SSIs) are a substantial contributor to morbidity and mortality rates. 405 nm visible light disinfection (VLD) has been shown to reduce bacterial burden in operating rooms (ORs); however, its effect on SSIs is poorly described. Therefore, we investigated whether the usage of VLD correlated with a decrease in SSI rates.Methods: A prospective cohort study was conducted by comparing three operating rooms equipped with VLD and three operating rooms equipped with standard lights. Bacterial loads within the six ORs of interest were obtained before and after initiation of VLD. Patients of various surgical subspecialties were randomly assigned to rooms. SSI rates were tracked from July 2019 to June 2022. The primary outcome of interest was the SSI rate.Results: A total of 11,381 patients were included in the study, comprising 5,036 in VLD rooms and 6,345 in control rooms. Although age, gender, and body mass index were similar between the groups, there were differences in American Society of Anesthesiologists class, operation length, and wound class. There was a 66% reduction in bacterial load in the VLD rooms. No substantial difference was observed in SSI rates between the control and VLD rooms (0.8% vs. 0.8%, p = 0.71). There was no substantial difference in SSI rates by specialty. After adjusting for covariates, VLD was not independently associated with SSI rate.Conclusion: VLD effectively reduced overall operating room bacterial burden; however, this did not result in a substantial reduction in SSI rates. The cause of SSIs is multi-factorial and may be influenced more by patient and technical factors than overall operating room bacterial burden.

Inflammatory bowel disease (IBD) predisposes individuals to frailty, linked with adverse outcomes. While the Fried Frailty Index (FFI) is a well-established phenotypic tool to assess frailty, its administration is cumbersome. The FRAIL scale, simpler but not widely used in patients with IBD, presents an alternative. We aimed to assess the prevalence of frailty and compare the FRAIL scale with the FFI. A cohort of patients with IBD underwent assessment using both the FFI and the FRAIL scale. Patients were categorized as non-frail, pre-frail, or frail. The primary outcome was frailty prevalence, while secondary outcomes included comparison of FFI and FRAIL scale and associations between frailty and disease-related factors. Statistical analyses included chi-square tests, ANOVA, Kruskal–Wallis tests, and ROC curve analysis using SPSS v27, with p < 0.05 indicating significance. Among participants (53.5

The primary objective of this study was to gauge resident and faculty sentiments surrounding a general surgery program merger between two programs, and to assess the effect on workplace morale and productivity. Secondarily, the authors sought to objectively examine the impact program expansion had on in-service training exam results and operative volumes. This was a single-center, prospective, observational study that evaluated surgical resident and faculty feedback pertaining to the merger of two regional general surgery residency programs. The survey utilized the Likert scale at merger onset and post-merger to gather responses from residents and faculty from July 2020 to August 2021. Secondary outcomes evaluated case volume and ABSITE performance pre- and post-merger. A total of 27 residents and 31 faculty participated in the initial survey. The merger onset and post survey investigation found that there was increased workplace efficiency (78

BACKGROUND:Most patients who sustain a traumatic injury require outpatient follow-up. A common barrier to outpatient postadmission care is patient failure to follow-up. One of the most significant factors resulting in failure to follow-up is age more than 35 years. Recent work has shown that follow-up telephone calls reduce readmission rates. Our aim was to decrease no-show appointments by 10% in 12 months.STUDY DESIGN:The electronic medical records at our level I and II trauma centers were queried for all outpatient appointments for trauma between July 1, 2020, and June 9, 2021, and whether the patient attended their follow-up appointment. Patients with visits scheduled after August 1, 2021, received 24- and 48-hour previsit reminder calls. Patients with visits scheduled between July 1, 2020, and August 1, 2021, did not receive previsit calls. Both groups were compared using multivariable direct logistic regression models.RESULTS:A total of 1,822 follow-up opportunities were included in the study. During the pre-implementation phase, there was a no-show rate of 30.9% (329 of 1,064 visits). Postintervention, a 12.2% reduction in overall no-show rate occurred. A statistically significant 11.2% decrease (p < 0.001) was seen in elderly patients. Multivariate analysis showed standardized calls resulted in significantly decreased odds of failing to keep an appointment (adjusted odds ratio = 0.610, p < 0.001).CONCLUSIONS:Reminder calls led to a 12.2% reduction in no-show rate and were an independent predictor of a patient's likelihood of attending their appointment. Other predictors of attendance included insurance status and abdominal injury.

Increased adoption of robotics in foregut surgery evokes questions regarding efficacy, safety, and cost. To many, cost remains a barrier to adoption of a robotic approach. The authors’ aim to determine the difference in cost of a robotic (R-) vs laparoscopic (L-) approach for paraesophageal hernia repair (PEHR). Patients 18 years and older who underwent PEHR between July 2016 and June 2021 at a university health network were included. Variables of interest included 30 day outcomes, 1 year recurrence rates, and several cost variables including hospital length of stay, operating room (OR) time, chargeable supplies and implants, non-chargeable supplies, and indirect cost. Cost data were stratified by type and the presence of fundoplication, as well as the elective versus urgent nature of the procedures. Statistical analysis consisted of parametric and non-parametric analyses, with p < 0.05 denoting statistical significance. 405 patients were included in the study (n = 188 for R-, n = 217 for L-). Significant differences were observed in the type of anti-reflux procedure performed (p < 0.001), use of mesh (R- 70.2

OBJECTIVES:Patients presenting with suspected ST segment elevation myocardial infarction frequently have symptoms in addition to chest pain, including dyspnea, nausea or vomiting, diaphoresis, and lightheadedness or syncope. These symptoms are often regarded as supporting the diagnosis of infarction. We sought to determine the prevalence of the non-chest pain symptoms among patients who were confirmed as having a critically diseased coronary vessel as opposed to those with no angiographic culprit lesion. METHODS:Data from 1393 consecutive patients with ST segment elevation who underwent emergent coronary angiography were analyzed. Records were reviewed in detail for symptoms, ECG findings, prior history, angiographic findings, and in-hospital outcomes. RESULTS:Dyspnea was present in 50.8% of patients, nausea or vomiting in 36.5%, diaphoresis in 51.2%, and lightheadedness/syncope in 16.8%. On angiography, 1239 (88.9%) patients had a culprit lesion and 154 (11.1%) were found not to have a culprit. Only diaphoresis had a higher prevalence among the patients with, as compared with those without a culprit, with an odds ratio of 2.64 ( P  < 0.001). The highest occurrence of diaphoresis was among patients with a totally occluded artery, with an intermediate frequency among patients with a subtotal stenosis, and the lowest prevalence among those with no culprit. These findings were consistent regardless of ECG infarct location, affected vessel, patient age, or sex. Among the subset of patients who presented without chest discomfort, none of the symptoms were associated with the presence of a culprit. CONCLUSION:The presence of diaphoresis, but not dyspnea, nausea, or lightheadedness is associated with an increased likelihood that patients presenting with ST elevation will prove to have a culprit lesion. In patients who present with ST elevation but without chest discomfort, these symptoms should not be regarded as 'chest pain equivalents'. Further objective data among patients with angiographic confirmation of culprit lesion status is warranted.

Introduction There is scarce data about the association of metabolic syndrome (MetS) or its components with the development of colonic diverticulosis (CD) in the elderly. We aim to determine the association of MetS and its components with CD in the elderly aged ≥75 years. Methods We conducted a retrospective chart review at St. Luke's University Health Network to identify patients who underwent a colonoscopy between 2011 and 2020. We collected data on patient demographics, comorbidities, and colonoscopy findings. Statistical analyses were conducted to compute means and frequencies of patient characteristics and rates of CD, as well as to test for associations between potential risk factors and the presence of CD. Results A total of 1239 patients were included with a median age of 80 years, 57.6% females, 89.5% Caucasians, 72.9% with CD, and 66.7% having a left-sided disease. On bivariate analysis, the older age group (p=0.02), Caucasian ethnicity (p=0.01), and hypertension (p=0.04) were found to be significant risk factors for developing CD. Multivariate regression analysis showed older age group and hypertension (OR=1.47, 95% CI: 1.66-2.02, p=0.02) were major risk factors. A significant proportion of patients with left-sided disease had Caucasian ethnicity (p<0.001), while female gender, obesity, and iron deficiency anemia were also seen more frequently, although without statistical significance. Conclusion In the elderly (>75 years old), our study found hypertension to be associated with an increased risk of CD, while impaired fasting glucose (IFG) was protective. Most patients exhibited isolated left-sided diverticulosis, with pan-diverticulosis associated with higher proportions of adverse health indicators, including American Society of Anesthesiologists (ASA) score ≥3, IFG, hypertriglyceridemia, hypertension, and hypothyroidism. Further research with larger sample sizes in similar age groups is needed to expand upon these findings.

BACKGROUND:Both progestogens and cerclage are individually effective in preterm birth prevention in high risk pregnancies. However, national and international guidelines cite a lack of data available to comment on the potential benefit of concurrent progestogen therapy after cerclage has been placed. Studies to date have been small with mixed results regarding benefit of concurrent progestogen with cerclage leaving uncertainty regarding best clinical practice. OBJECTIVE:This study aimed to evaluate whether cerclage with progestogen therapy was superior to cerclage alone in the prevention of spontaneous preterm birth in singleton pregnancies. METHODS:This is an international retrospective cohort study of singleton pregnancies, without major anomaly or aneuploidy, and with cerclage placed at 10 different institutions in the United States and Colombia from June 2016 to June 2020. Exclusion criteria were lack of documentation regarding whether progestogen was prescribed, unavailable delivery outcome, and pregnancy termination (spontaneous or induced) before 16 weeks' gestation. The exposure of interest was progestogen use with cerclage placement, which included those who continued to use progestogen or who started progestogen after cerclage. The comparison group consisted of those without progestogen use after cerclage placement, which included those who had no progestogen use during the entire pregnancy or who initiated progestogen and then stopped it after cerclage placement. Progestogen type, cerclage indication, maternal baseline characteristics, and maternal/neonatal outcomes were collected. The primary outcome was spontaneous preterm birth at <37 weeks. The secondary outcomes were spontaneous preterm birth at <34 weeks, gestational age at delivery, and a composite neonatal outcome including ≥1 of the following: perinatal mortality, confirmed sepsis, grade III or IV intraventricular hemorrhage, retinopathy of prematurity, respiratory distress syndrome, and bronchopulmonary dysplasia. There were planned subgroup analyses by cerclage indication, progestogen type (vaginal progesterone vs 17-hydroxyprogesterone caproate), preterm birth history, and site. Continuous variables were compared in adjusted analyses with analysis of covariance, and categorical variables were compared with multivariable logistic regression, adjusting for potential confounders with adjusted odds ratio. A Cox regression survival curve was generated to compare latency to spontaneous delivery, censored after 37 weeks. RESULTS:During the study period, a total of 699 singletons met the inclusion criteria: 561 in the progestogen with cerclage group and 138 with cerclage alone. Baseline characteristics were similar, except the higher likelihood of previous spontaneous preterm birth in the progestogen group (61% vs 41%; P<.001). Within the progestogen group, 52% were on 17-hydroxyprogesterone caproate weekly, 44% on vaginal progesterone daily, and 3% on oral progesterone daily. Progestogen with cerclage was associated with a significantly lower frequency of spontaneous preterm birth <37 weeks (31% vs 39%; adjusted odds ratio, 0.59 [0.39-0.89]; P=.01) and <34 weeks (19% vs 27%; adjusted odds ratio, 0.55 [0.35-0.87]; P=.01), increased latency to spontaneous delivery (hazard ratio for spontaneous preterm birth <37 weeks, 0.66 [0.49-0.90]; P=.009), and lower frequency of perinatal death (7% vs 16%; adjusted odds ratio, 0.37 [0.20-0.67]; P=.001). In planned subgroup analyses, association with reduced odds of preterm birth <37 weeks persisted in those on vaginal progesterone, those without a previous preterm birth, those with ultrasound- or examination-indicated cerclage, those who started progestogen therapy before cerclage, and in sites restricted to the United States. CONCLUSION:Use of progestogen with cerclage was associated with reduced rates of spontaneous preterm birth and early spontaneous preterm birth compared with cerclage alone. Although this study was not sufficiently powered for subgroup analysis, the strength of evidence for benefit appeared greatest for those with ultrasound- or examination-indicated cerclage, and with vaginal progesterone. El resumen está disponible en Español al final del artículo.

Outcomes1. Utilizing data from this retrospective analysis, participants will be able to apply this scoring system in their own practice to aid in predicting risk of death or discharge to hospice in trauma patients.2. Participants will be able to utilize this study's approach to allow for earlier palliative care involvement for improved patient outcomes.Key MessageOur palliative scoring system was developed to assist in earlier palliative interventions. Based on retrospective analysis of trauma data at the largest trauma network in Pennsylvania, the creation of a standardized scoring system allows us to identify patients who are at risk of death or discharge to hospice.IntroductionThe incidence of geriatric trauma continues to rise across the United States. Current TQIP guidelines recommends goals of care discussions with geriatric trauma patients within 72 hours of admission. Studies show palliative care involvement within 6 days of hospital admission has reduced patient readmission rates and inpatient mortality.ObjectivesOur goal was to create a scoring system predicting risk of death or discharge to hospice in geriatric trauma patients. We aimed to demonstrate improved outcomes with earlier palliative intervention.MethodsOur institutional trauma database was queried for patients >64 years of age admitted to the trauma service between 2018 and 2023. Univariate analysis identified admission characteristics including demographics, physiologic parameters, identifying seniors at risk score (ISAR) and injury characteristics and their association with discharge to hospice or death. Multivariate analysis identified risk adjusted predictors of the composite outcome, with the resultant regression model used to develop a scoring system. C-statistic was used as a measure of the model's predictive capability.ResultsDuring the study period, 9,552 patients were evaluated with n=476 (4.7%) dying or discharging to hospice and n=9,076 (95.3%) surviving. After univariate analysis of the overall cohort, 3,938 patients had complete data for all significant predictors (n=245 death/hospice and n=3,693 alive at discharge). Multivariate analysis was used to determine risk adjusted predictors of death or hospice discharge. Internal validation using bootstrapping with 500 sample-replicated models revealed a bias-corrected c-statistic of 0.857, indicating very little optimism-based attenuation from the original model and further supporting our model findings.ConclusionA scoring system consisting of demographics, exam elements and injury characteristics can reliably predict risk of death or discharge to hospice at our trauma center with a high degree of discrimination. Given this data, it can open the door to further extrapolate this scoring system to include underrepresented populations as well.KeywordsSurgical Palliative Care / Models of Palliative Care Delivery

For the first time this study measures the electric brain activation in a semi-real scenario to investigate the representation of objects in the near/far space. We recorded electrical brain activity from a group of 22 participants who had to indicate whether or not they could reach or not several objects that appeared along a 52″ touchscreen display. We replicated previous results showing that reaction time to objects located in the near space was significantly faster than to objects located in far space. The effects of object location found here were significant even when their hand was not visible to them and retracted from the objects. ERP analysis showed a consistent N1 visual component with faster latencies and greater amplitudes for objects in near space. Importantly, this latency difference was not linked only to the physical distance but to a psychological division between near and far space based on their interactive potential (e.g. reachable vs. not reachable). At later stages LPP results showed significant effects of arousal at occipital electrode sites while parietal scalp locations were sensitive to spatial location supporting a ventral/dorsal dissociation of neuropsychological space.

The use of robotic-assisted (RA) surgery in the field of metabolic and bariatric surgery (MBS) is controversial because of cost concerns and issues related to efficiency. The objective of this study is to evaluate the operating room efficiency in performing RA-MBS prior and after the implementation of a standardized surgical approach. All MBS cases entered into our database between October 2017 and October 2022 were collected and analyzed before and after the introduction of the standardized approach (SA). The outcome variables consisted of operation time (OT), turnover time (TT), wheels in-wheels out (WW), and console time (CT). Procedures were divided into Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and revisional bariatric surgery (RBS). For RYGB (n = 185), we found a significant reduction in OT, TT, and WW after SA (129 min vs 139 min; 37 min vs 73 min; 165 min vs 175 min, respectively, p < 0.05). For SG (n = 253), we found a significant reduction in turnover time (TT) after SA. For RBS (n = 201), we also found a significant reduction in OT, TT, WW, and CT after SA ( 157 min vs 177 min; 36 min vs 72 min; 194 min vs 216 min; 119 min vs 134 min, respectively, p < 0.05). Using a standardized surgical approach, we were able to demonstrate improved operation room efficiency as demonstrated by a reduction in operation length, turnover time, and the overall time of the procedure for primary RYGB and revisional procedures and turnover time for primary sleeve procedures.

To determine if the use of progesterone reduces the risk of spontaneous preterm birth (sPTB) after a cerclage has been placed Retrospective cohort study of singletons managed with cerclage for any indication between 6/2016-8/2020 at 10 sites across the United States and Colombia. Participants with data available regarding progesterone use and delivery outcomes were included. The cohort was divided in those that used any kind of progesterone after cerclage placement and those with no progesterone post-cerclage. Progesterone use included any formulation (vaginal or oral progesterone, intramuscular or subcutaneous 17OHPC). Primary outcome was incidence of sPTB< 37 weeks. Secondary outcomes included sPTB< 34 weeks, NICU admission, birthweight, gestational age at delivery. Chi-square and t-test were used for univariate analysis. Multi-variable bivariate logistic regression with backward selection and ANCOVA were used for adjusted analyses; analyses were adjusted for indication for cerclage as well as baseline characteristics different at p< 0.20. 701 were included. 562 (80%) used any progesterone post-cerclage and 139 (20%) did not. Of those with progesterone use post cerclage, 246 (35%) initiated it before and continued post cerclage and 216 (45%) initiated progesterone post-cerclage. Progesterone formulations used post cerclage included vaginal progesterone (N=246, 35%) 17-OHPC (N=295, 42%). The overall rate of sPTB was 32% (N=223). Baseline characteristics were similar between groups except study site, suture type, and prior PTB history. Progesterone use was associated with reduced rates of sPTB at < 37 weeks aOR (95%CI 0.65 (0.44-0.97), < 34 weeks aOR 0.59 (0.37-0.92) Cox regression analysis demonstrated increased latency to sPTB ( (p=0.0009) Compared to no progesterone, progesterone therapy post-cerclage was associated with a reduced rate of sPTB. Concurrent progesterone use with cerclage placement may improve perinatal outcomesView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Introduction: To date, there is limited literature to guide emergency providers (EPs) on the proper dosing of prescription opioids. Our study aims to assess the self-reported opioid use, storage, and disposal practices of patients presenting to the emergency department (ED) with acute pain. Methods: This prospective cohort study employed a validated, cross-sectional survey of subjects identified using electronic medical records. The survey link was e-mailed to a continuous sample of eligible participants 3–4 weeks following ED discharge. Nonrespondents were surveyed through telephone after 1 week. We used descriptive and nonparametric statistics to report survey results. Results: Of 500 eligible subjects, 97 completed the questionnaire. Only 28% of respondents reported that they took all of the prescribed pills. Of the remaining responses, 20% stated that they did not take any pills, 33% took about one-fourth, 7.2% took about half, and 12.4% took about three-fourths of the pills. Among those who did not take any pills, 42% filled the prescription. Most (71.2%) reported storing their leftover pills; among those who stored their pills, less than one-fourth (23.8%) used a locked storage location. Conclusions: Our findings suggest that less than one-third of patients who receive prescriptions in the ED for acute pain use all of their prescribed pills, suggesting that many patients are unnecessarily prescribed opioids for acute conditions. The findings of this study also suggest that many patients with unused prescription opioids do not practice safe storage or proper disposal of leftover pills. This represents a potential opportunity for EPs to improve medication safety by educating patients on proper storage and disposal practices. Limitations include low response rate and the use of self-reporting.

The objective of this study is to evaluate the outcomes for Staple Line Reinforcement (SLR) in RA-SG based on the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for 2019. We selected patients who underwent RA-SG in the MBSAQIP PUF (Public Utility File) for the year 2019 and grouped them based on their SLR status: Oversewing (OS), Buttressing (BR), both OS and BR and neither. Our primary outcomes were bleeding, organ space infection (OSI), and adverse events (AEs), and our secondary outcomes were operation length, hospital length of stay, readmissions, and conversion to open rates. We conducted separate chi square or one-way analysis of variance (ANOVA) as appropriate and multivariable direct logistic regression models for the categorical outcomes. We found 115,621 patients with complete data of which there were 16,494 who underwent RA-SG. Our results did not show a statistically significant decrease in incidence of postoperative bleeding for BR and OS (Adjusted OR = 0.782, p = 0.2291 and Adjusted OR of 0.482, p = 0.054 for BR and OS respectively). There was a statistically significant effect for SLR status on operation length, with OS patients having the highest operative times (log-transformed mean = 2.03), followed by both BR + OS patients (log-transformed mean = 1.99). BR patients had the shortest operation length. SLR did not result in any significant differences related to bleeding, OSI or AEs following RA-SG according to MBSAQIP for the year 2019. However, OS resulted in significantly longer operative time compared to BR alone.

Background:The use of the robotic platform in bariatric surgery remains controversial because of lack of level I evidence to support its superiority compared to the laparoscopic approach and because of cost concerns. Recently, an extended use program (EUP) for robotic instruments was also introduced at our institution to help reduce the associated direct medical costs of robotic surgery. Objectives: To evaluate the direct medical costs of a robotic sleeve gastrectomy (R-SG) and compare it to a standard laparoscopic approach (L-SG). Setting: Academic, tertiary care center. Methods: The analysis included the last 50 R-SG performed at our institution between June 1st 2019 and October 31st 2020. Those cases were compared to the L-SG cases (29 cases) performed in the same time period. All revisions or conversions were then excluded which resulted in a total of 74 primary SG (R-SG = 45 and L-SG = 29). Direct medical costs included operating room cost, instrument cost, miscellaneous cost, and cost of hospital stay. Direct cost data was generated using the StrataJazz reporting module, which is fed daily from EPIC, our electronic health record system. Patients who underwent a primary SG or a primary SG with a concomitant Paraesophageal Hernia Repair (PEH) were analyzed separately using Mann–Whitney rank sum tests and Student’s t tests. An additional analysis and subanalysis of the groups was also performed after applying the potential savings of the Extended Use Program (EUP). Results: Overall, the direct medical cost of R-SG was comparable to L-SG ($6330.77 vs $6804.12 respectively, p = 0.07). The direct medical cost of patients undergoing SG alone without PEH was significantly lower in the R-group compared to the L-group ($5927.08 vs $6508.01, respectively, p = 0.04). When applying the EUP savings to our data, the predicted direct medical cost of R-SG becomes significantly lower than L-SG ($6145.77 vs $6804.12 respectively, p = 0.01). Conclusion: At our academic medical center, we found no difference in direct medical costs between R-SG and L-SG. With the application of the EUP, direct medical costs of R-SG can be significantly lowered compared to L-SG. It is important to consider that cost data are largely dependent upon the academic medical center of interest, and surgeons need to collect their own cost data to evaluate whether robotic surgery is feasible at their institution.

The primary objective of this study is to evaluate the outcomes of robotic-assisted (RA-) approach compared to the standard laparoscopic (L-) approach using the 2020 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry Public Use File (PUF). Our secondary objective is to establish standards for the reporting of outcomes using PUF. Using the PUF database (n = 168,568), patients were divided into sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), revisions, and conversions and then analyzed separately. We created balanced covariate through propensity score matching and inverse probability treatment weighting (IPTW). We also conducted multivariable relative risk regression to confirm our results. For RYGB, the incidence of “transfusion” was significantly lower in the RA-RYGB compared to the L-RYGB. There was no significant difference in the rate of Serious Event Occurrences (SEOs) or rate of intervention at 30 days. For SG, there was a higher rate of “transfusion” in the RA group. Incidence of SEOs was also significantly higher in the RA-group. There was no significant difference in SEOs for conversions; however, revisions had a trend toward a lower rate of SEOs favoring the robotic approach. Operative times were significantly higher for all RA-groups. RA- approach in metabolic and bariatric surgery (MBS) remains controversial because of differences in outcomes. The use of SEOs as reported by MBSAQIP in its semi-annual report can be used as a composite score to assess outcomes while using PUF. Further studies are needed to compare RA- to L- MBS.

Context: Enhanced Recovery After Surgery (ERAS) protocols have been shown to decrease length of stay and postoperative opioid usage in colorectal and bariatric surgeries performed at large academic centers. Hysterectomies are the second most common surgical procedure among women in the United States. Hysterectomies performed in an open fashion, or total abdominal hysterectomies (TAHs), account for a large portion of procedures performed by gynecologic oncologists secondary to current oncology guidelines and surgical complexity. Implementation of an ERAS protocol for gynecologic oncology TAHs is one way in which patient outcomes may be improved. Objectives: An ERAS protocol for gynecologic oncology surgeries performed in a community hospital was instituted with the goal to optimize patient outcomes preoperatively. The primary outcome of interest was to reduce patient opioid usage. Secondary outcomes included compliance with the ERAS protocol, length of stay, and cost. Thirdly, this study aimed to demonstrate the unique challenges of implementing a large-scale protocol across a community network. Methods: An ERAS protocol was implemented in 2018, with multidisciplinary input from the Departments of Gynecologic Oncology, Anesthesia, Pharmacy, Nursing, Information Technology, and Quality Improvement to develop a comprehensive ERAS order set. This was implemented across a 12-site hospital system network that consisted of both urban and rural hospital settings. A retrospective review of patient charts was performed to assess measured outcomes. Parametric and nonparametric tests were utilized for statistical analysis with p<0.05 denoting statistical significance. If the p value was >0.05 and <0.09, this was considered a trend toward significant. Results: A total of 124 patients underwent a TAH utilizing the ERAS protocol during 2018 and 2019. The control arm consisted of 59 patients who underwent a TAH prior to the ERAS protocol intervention, which was the standard of care in 2017. After 2 years of implementation of the ERAS protocol intervention, we found that 48 % of the ERAS patients had minimal opioid requirements after surgery (oral morphine equivalent [OME] range 0-40) with decreased postoperative opioid requirements in the ERAS group (p=0.03). Although not statistically significant, utilization of the ERAS protocol for gynecologic oncology TAHs trended toward shorter hospital length of stay from 5.18 to 4.17 days (p=0.07). The median total hospital costs per patient also showed a nonsignificant decrease in cost from $13,342.00 in the nonERAS cohort and $13,703.00 in the ERAS cohort (p=0.8). Conclusions: A large-scale quality improvement (QI) initiative is feasible utilizing amultidisciplinary teamto implement an ERAS protocol for TAHs in the division of Gynecologic Oncology with promising results. This large-scaleQI resultwascomparable to studies that conducted quality-improvement ERAS initiatives at single academic institutions and should be considered within community networks.