Background Minimally invasive approaches to esophagectomy have gained popularity worldwide; however, unplanned conversion to an open approach is not uncommon. This study sought to investigate risk factors associated with converting to an open approach and to evaluate outcomes following conversion. Methods Patients undergoing minimally invasive esophagectomy (MIE) for cancer were identified using the 2016-2019 Procedure Targeted NSQIP Database. Multivariable, stepwise logistic regression analysis was performed to investigate factors associated with unplanned conversion to open esophagectomy. Propensity-matched comparison of robotic (RAMIE) to traditional MIE was performed. Results A total of 1347 patients were included; 140 patients (10%) underwent conversion to open. Morbid obesity, diabetes, hypertension, American Society of Anesthesiologists class, and squamous cell carcinoma were associated with a higher likelihood of conversion. A robotic approach was associated with a lower likelihood of conversion to open (OR .57, 95% CI 0.32-.99). On multivariable analysis, squamous cell carcinoma pathology was the only variable independently associated with higher odds of conversion (OR 2.66, 95% CI 1.02-6.98). Propensity-matched comparison of RAMIE vs MIE showed no significant difference in conversion rate (6.5% vs 9.1%, P = .298), morbidity, or mortality. Discussion A robotic approach to esophagectomy was associated with a lower likelihood of unplanned conversion to open, and patients who were converted to open experienced worse outcomes. Future studies should aim to determine why a robotic esophagectomy approach may lead to fewer open conversions as it may be an underappreciated benefit of this newest operative approach.

Objective: To perform a cost-effectiveness analysis to examine the utility and effectiveness of OS performed at the time of elective cholecystectomy [laparoscopic cholecystectomy (LAP-CHOL)]. Summary Background Data: OS has been adopted as a strategy to reduce the risk of ovarian cancer in women undergoing hysterectomy and tubal sterilization, although the procedure is rarely performed as a risk reducing strategy during other abdominopelvic procedures. Methods: A decision model was created to examine women 40, 50, and 60 years of age undergoing LAP-CHOL with or without OS. The lifetime risk of ovarian cancer was assumed to be 1.17%, 1.09%, and 0.92% for women age 40, 50, and 60 years, respectively. OS was estimated to provide a 65% reduction in the risk of ovarian cancer and to require 30 additional minutes of operative time. We estimated the cost, quality-adjusted life-years, ovarian cancer cases and deaths prevented with OS. Results: The additional cost of OS at LAP-CHOL ranged from $1898 to 1978. In a cohort of 5000 women, OS reduced the number of ovarian cancer cases by 39, 36, and 30 cases and deaths by 12, 14, and 16 in the age 40–, 50–, and 60-year-old cohorts, respectively. OS during LAP-CHOL was cost-effective, with incremental cost-effectiveness ratio of $11,162 to 26,463 in the 3 age models. In a probabilistic sensitivity analysis, incremental cost-effectiveness ratio for OS were less than $100,000 per quality-adjusted life-years in 90.5% or more of 1000 simulations. Conclusions: OS at the time of LAP-CHOL may be a cost-effective strategy to prevent ovarian cancer among average risk women.

Background: The Achilles heel of antireflux surgery is hiatal hernia recurrence, and no treatment modalities to date have improved this outcome. Platelet-rich plasma (PRP) is an autologous therapy that promotes wound healing by upregulating extracellular matrix proteins, and it has excellent results in numerous surgical fields. Animal studies evaluating PRP use in hiatal hernia repair show favorable outcomes, yet its application in hiatal hernia repair in humans has not been described. Methods: This is a feasibility study of patients with large (>5 cm) paraesophageal hernia (PEH) who underwent PEH repair with PRP from 2/2021 to 1/2022. Safety, feasibility, and postoperative outcomes were investigated. Results: PRP was successfully administered during PEH repair in 12 consecutive patients. There were no significant adverse events. The methods for applying PRP to the repair were modified several times to optimize the technique. Administering PRP added an average of 5 minutes to the operative time. There were no significant postoperative complications or hernia recurrence on diagnostic imaging at latest follow up, with good subjective reflux control. Conclusion: PRP has excellent clinical outcomes in other surgical fields and may become an important new adjunct in antireflux surgery. This study shows PRP is safe and feasible in PEH repair, with little effect on operative time.

Introduction: Magnetic sphincter augmentation (MSA) is an effective treatment option for gastroesophageal reflux disease (GERD), with similar outcomes to fundoplication. MSA has yet to be compared to fundoplication specifically in patients with severe GERD. The objective of this study was to compare MSA and fundoplication in patients with severe GERD. Methods: A retrospective cohort study was performed of patients with severe GERD (preoperative DeMeester score >50) who underwent MSA or fundoplication at 3 high-volume centers from 2016 to 2019. Nissen and partial fundoplications were included. GERD control was measured by GERD health-related quality of life (GERD-HRQL) scores and discontinuation of acid suppressive medication (ASM). Other outcomes included postoperative gas-bloat symptoms, dysphagia requiring dilation, and esophagitis. Results: A total of 122 patients were included: 82 (67%) underwent MSA and 40 (33%) underwent fundoplication (23% Nissen, 77% partial). The groups were similar regarding gender, GERD duration, hiatal hernia size, preoperative GERD-HRQL score, severe esophagitis, and DeMeester score. Median follow-up was 24 [12-34] months. Postoperative GERD-HRQL scores (5 vs 3, P = .36), ASM discontinuation (80% vs 86%, P = .41), gas-bloat symptoms (18% vs 23%, P = .58), dysphagia requiring dilation (19% vs 8%, P = .11), and esophagitis (7% vs 10%, P = .08) were similar between the groups. A subset analysis was performed comparing outcomes of MSA, Nissen fundoplication, and partial fundoplication. No significant differences were found. Conclusion: In this cohort of patients with severe GERD, MSA was just as effective as Nissen and partial fundoplication with regards to improved quality of life and side effect profile at 24-month follow-up.

Introduction Although mortality rates after esophagectomy have decreased over the last 30 years, anastomotic leaks still commonly persist and portend significant morbidity. Previous studies have analyzed patient and perio-perative risk factors for leaks, yet data describing the association of leaks and an open or minimally invasive approach are lacking. The purpose of this study was to evaluate the impact of operative approach on leak rates and subsequent management of the leaks. Methods We queried the Procedure-Targeted National Surgical Quality Improvement Program Database for patients undergoing esophagectomy for cancer in the years from 2016 to 2019. Patient demographics, disease-related information, peri-operative data, and short-term outcomes were reviewed. Multivariable, stepwise logistic regression analysis was performed to investigate factors associated with post-operative anastomotic leaks. Results Of the 2696 patients who underwent esophagectomy for cancer, anastomotic leaks occurred in 374 (14%). Based on approach, 13% of open, 14% of laparoscopic, and 18% of robotic cases were complicated by leak (P = .123). Multivariable analysis identified the following significant risk factors for leak: diabetes (OR 1.32, P = .047), hypertension (OR 1.32, P = .022), and longer operative time (OR 1.61, P < .001). The percentage of leaks requiring endoscopic or operative intervention was 75% for open, 79% for laparoscopic, and 54% for robotic cases (P = .004). Conclusions Anastomotic leaks after esophagectomy for cancer occur frequently regardless of surgical approach. Furthermore, these leaks are managed differently after an open, laparoscopic, or robotic approach. Robotic esophagectomies complicated by anastomotic leak required less invasive management.

INTRODUCTION: Obesity is prevalent among economically disadvantaged, racially underrepresented, and publicly insured populations. This study analyzes outcomes of bariatric surgery at a private hospital (PH) vs a safety-net hospital (SNH). METHODS: Retrospective review of laparoscopic sleeve gastrectomy (LSG) performed by the same surgeons at an academic PH and SNH in a large metropolitan, urban setting. Demographics, socioeconomic status, insurance status, weight metrics, and perioperative outcomes were compared. Multivariable logistic regression was performed to analyze predictors of failed excess weight loss (EWL) at 6 months. RESULTS: Of the 243 LSG performed, 141 (58%) occurred at PH vs 102 (42%) at SNH. Most patients at SNH were Hispanic, lower socioeconomic status, and had government-sponsored insurance. Patients had higher initial BMI at SNH vs PH (48 vs 46 kg/m2; p < 0.01). There were no significant differences in postoperative outcomes across cohorts. The 2 groups had similar %EWL at all time points up to 36 months (Figure). However, patients at PH had greater resolution of diabetes (28% vs 80%; p < 0.01) and hypertension (24% vs 58%; p < 0.01) after surgery. On univariate and multivariable analysis, the only factors associated with failure to achieve 50% EWL at 6 months were preoperative weight metrics: higher initial BMI (odds ratio [OR] 1.13; p < 0.01) and lower preoperative %EWL (OR 0.91; p < 0.01). CONCLUSION: Weight loss outcomes after bariatric surgery are similar across disparate racial and socioeconomic groups. Future directions should advocate for and not overlook these populations for bariatric surgery.Figure

Obesity is prevalent among economically disadvantaged and racially underrepresented populations. It has been suggested that socioeconomic factors, race, and lifestyle habits are important factors associated with weight loss and comorbidity remission after bariatric surgery. This study analyzes outcomes of bariatric surgery at a private hospital (PH) versus an affiliated safety-net hospital (SNH). Retrospective review of laparoscopic sleeve gastrectomies (LSG) performed by the same surgeons at a PH and SNH in a large metropolitan setting. Demographics, socioeconomic status, insurance status, weight metrics, and perioperative outcomes were compared. A postoperative telephone survey was conducted to study dietary and lifestyle differences between cohorts. Of the 243 LSG performed, 141 (58

BACKGROUND: Liver transplantation (LT) is the preferred treatment for early hepatocellular carcinoma (HCC) in select patients. Differences in outcomes after LT have been previously described between recipient races, but the role of donor race is not well defined. This study sought to examine the effect of donor-recipient race-matching on overall survival after liver transplantation for HCC in African-American patients (AA). STUDY DESIGN: Adult AA patients with HCC undergoing liver transplantation were identified using the Organ Procurement and Transplantation Network database (1994 to 2015). Recipient and donor demographic and clinical characteristics were collected. Patients were separated into unadjusted cohorts based on whether the liver donor was AA (matched) or another race (unmatched). The primary outcome was overall survival, which was analyzed by log-rank test and graphed using the Kaplan-Meier method. Multivariate regression modeling was used to determine adjusted hazard ratios (HR) for overall survival. RESULTS: Of 1,384 AA patients identified, 325 (23.5%) were race-matched. Matched patients experienced significantly better median overall survival when compared with the unmatched cohort (135 vs 78 months, p = 0.007). Multivariate analysis revealed an adjusted hazard ratio of 0.66 for race-matched transplantation (95% CI 0.49 to 0.88; p = 0.004). Matched patients also experienced an improved 5-year survival (64.2% vs 56.9%; p = 0.019). CONCLUSIONS: African-American HCC patients undergoing liver transplantation experienced significantly improved overall survival when the donor race matched the recipient race. Donor-recipient race-matching remained an independent predictor of improved survival after adjusting for comorbidities and disease characteristics. Race-matching should be considered in the process of organ allocation because it may affect long-term survival in African-American HCC patients. (C) 2019 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.

BACKGROUND: Contemporary mortality after bariatric surgery is low and has been decreasing over the past 2 decades. Most studies have reported inpatient or 30-day mortality, which may not represent the true risk of bariatric surgery. The objective of this study was to examine 1-year mortality and factors predictive of 1-year mortality after contemporary laparoscopic bariatric surgery. STUDY DESIGN: Using the 2008 to 2012 Bariatric Outcomes Longitudinal Database (BOLD), data from 158,606 operations were analyzed, including 128,349 (80.9%) laparoscopic Roux-en-Y gastric bypass (LRYGB) and 30,257 (19.1%) laparoscopic sleeve gastrectomy (LSG) operations. Multivariate logistic regression was used to determine independent risk factors associated with 1-year mortality for each type of procedure. RESULTS: The 30-day and 1-year mortality rates for LRYGB were 0.13% and 0.23%, respectively, and for LSG were 0.06% and 0.11%, respectively. Risk factors for 1-year mortality included older age (LRYGB: adjusted odds ratio [AOR] 1.05 per year, p < 0.001; LSG: AOR 1.08 per year, p < 0.001); male sex (LRYGB: AOR 1.88, p < 0.001); higher BMI (LRYGB: AOR 1.04 per unit, p < 0.001; LSG: AOR 1.05 per unit, p = 0.009); and the presence of 30-day leak (LRYGB: AOR 25.4, p < 0.001; LSG: AOR 35.8, p < 0.001), 30-day pulmonary embolism (LRYGB: AOR 34.5, p < 0.001; LSG: AOR 252, p < 0.001), and 30-day hemorrhage (LRYGB: AOR 2.34, p = 0.001). CONCLUSIONS: Contemporary 1-year mortality after laparoscopic bariatric surgery is much lower than previously reported, at < 0.25%. It is important to continually refine techniques and perioperative management in order to minimize leaks, hemorrhage, and pulmonary embolus after bariatric surgery because these complications contribute to a higher risk of mortality. (C) 2018 by the American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Background: Surgical approach may influence morbidity following hepatectomy. This study sought to compare outcomes in minimally invasive surgery (MIS), conversion from MIS to open, and planned open hepatectomy patients and analyze factors leading to conversion. Methods: The 2014 National Surgical Quality Improvement Program dataset was queried for patients undergoing hepatectomy. Patients were divided into three cohorts: MIS, open, or conversion. Propensity matching was performed to compare MIS vs. conversion (3: 1) and open vs. conversion (8: 1). The logistic regression model was used to identify odds ratios for conversion. Results: Patients undergoing conversion had a higher transfusion rate (26% vs. 9%, p < 0.001), longer length of stay (5 vs. 3 days, p < 0.001), and higher morbidity (38% vs. 18%, p < 0.001) than MIS patients. Patients who underwent conversion had similar short-term outcomes to those who had planned open procedures. Independent predictors of conversion included hypertension (OR 1.91; 95% CI 1.12-3.26) and right lobectomy (OR 20.23; 95% CI 3.74-109.35). Conclusion: Patients with hypertension and those undergoing right lobectomy had a higher risk of conversion to open procedure. Conversion resulted in higher morbidity and longer length of stay compared to MIS patients, but outcomes were similar to planned open procedures.

Objectives: Orthotopic liver transplantation (OLT) is the preferred treatment for hepatocellular carcinoma (HCC) in select patients. Many patients listed for OLT have a history of prior upper abdominal surgery (UAS). Repeat abdominal surgery increases operative complexity and may cause a greater incidence of complication. This study sought to compare outcomes after liver transplantation for patients with and without prior UAS. Methods: Adult HCC patients undergoing OLT were identified using the database from the Organ Procurement and Transplantation Network (1987-2015). Patients were separated by presence of prior UAS into 2 propensity-matched cohorts. Overall survival (OS) and graft survival (GS) were analyzed by log-rank test and graphed using Kaplan-Meier method. Recipient and donor demographic and clinical characteristics were also studied using Cox regression models. Results: A total of 15,043 patients were identified, of whom 6,205 had prior UAS (41.2%). After 1:1 propensity score matching, cohorts (UAS versus no UAS) contained 4,669 patients. UAS patients experienced shorter GS (122 months vs 129 months; P < .001) and shorter OS (130 months vs 141 months; P < .001). Median duration of stay for both cohorts was 8 days. Multivariate Cox regression models revealed that prior UAS was associated with an increased hazard ratio (HR) for GS (HR 1.14; 95% confidence interval (CI) 1.06-1.22; P < .001) and OS (HR 1.14; 95% CI 1.06-1.23; P < .001). Conclusion: Prior UAS is an independent negative predictor of GS and OS after OLT for HCC. OLT performed in patients with UAS remains a well-tolerated and effective treatment for select HCC patients but may alter expected outcomes and influence follow-up protocols. (C) 2017 Elsevier Inc. All rights reserved.

Ablation is a common treatment modality for malignant primary liver tumors(PLTs), outcomes following laparoscopic (LA) versus open ablation (OA) are ill‐defined. This project compares peri‐procedural outcomes of LA versus OA for PLTs.

Locoregional therapy treatments for hepatic adenoma (HA) are typically limited to selective hepatic arterial embolization (HAE) to control acute hemorrhage. This systematic review sought to report the utilization of HAE and ablation for non-emergent treatment of HA.

Objective: Surgical approach for hepatectomy influences perioperative outcomes. This study sought to examine the role of race in intended surgical approach for hepatectomy. Methods: The National Surgical Quality Improvement Program Database identified African American (AA) and Caucasian patients undergoing hepatectomy in between January 1, 2014 and December 31, 2014. All other races were excluded. Demographic information, intended surgical approach, and short-term postoperative outcomes were compared. Results: All 2280 patients included in the study were AA (9.9%, n=225) or Caucasian (90.1%, n=2055). Minimally invasive hepatectomy (MIS) (p=0.621) and unplanned conversion to open hepatectomy (p=0.832) were similar between groups. AA patients were more likely to smoke (p=0.026), had higher BMI (p=0.0312), and higher rates of diabetes (p=0.003), hepatitis (p<0.001), hepatocellular carcinoma (p=0.002), hypertension (p<0.001), poor functional status (p<0.001), and increased American Society of Anesthesiology (ASA) classification (p=0.033). Both cohorts had similar hospital length of stay, however AA patients had a higher rate of readmission (12.4% vs. 11.1%, p=0.025). No significant difference in 30-day morbidity (34.2% vs. 33.8%, p=0.892) or mortality (1.78% vs. 1.41%, p=0.662) was seen between groups. Conclusion: Despite differences in patient characteristics between AA and Caucasian patients, race does not appear to be associated with procedure selection or perioperative morbidity or mortality following hepatectomy. Increased readmission rates in AA patients could be explained by patient characteristics and comorbidities. Further analysis is necessary to establish the independent predictors of readmission and clarify the role of race.

Objective: This study sought to examine the role of BMI in intended surgical approach for hepatectomy and short-term perioperative outcomes. Methods: The National Surgical Quality Improvement Program Database identified patients undergoing hepatectomy between January 1, 2014 and December 31, 2014. Patients were stratified by BMI as Underweight (BMI < 18.5), Normal (BMI 18.5–24.9), Overweight (BMI 25–29.9), Obese (BMI 30–39.9), or Morbidly Obese (BMI ≥ 40). Demographic information, surgical approach, and short-term postoperative outcomes were compared. Results: A total of 3,027 patients were included in the study. Most patients were Overweight (35.18%, n = 1,065), followed by Normal (30.33%, n = 918), Obese (28.01%, n = 848), Morbidly Obese (4.56%, n = 138), and Underweight (1.92%, n = 58). Patients with lower BMI were more likely to undergo formal lobectomy (p < 0.001). When compared to all other patients, Morbidly Obese patients were more likely to be offered minimally invasive surgery (29.1% vs. 18.5%, p = 0.003), and had a higher rate of conversion to open (7.9% vs. 3.9%, p = 0.007). Wound dehiscence was most common in Morbidly Obese patients (p = 0.011), but overall morbidity was similar among cohorts (p = 0.464). No difference in 30-day mortality existed among cohorts (p = 0.055). Conclusion: Despite differences in surgical approach, patient characteristics, and comorbidities associated with obesity, morbidity and 30-day mortality were similar. Morbidly obese patients were more likely to undergo minimally invasive surgery, however conversion to open hepatectomy and postoperative wound dehiscence was more likely and long term potential benefits are unknown.

Objective: AFP has been used as a surveillance tool for HCC recurrence, but the prognostic utility of an elevated pretreatment AFP level is poorly defined. This review sought to analyze the ability of elevated AFP levels to predict overall survival and recurrence free survival prior to treatment for HCC. Methods: PubMed was searched for clinical studies published from January 2012 to July 2016 including terms: alpha fetoprotein, hepatocellular carcinoma, prognosis, factor, survival, and outcome. Included studies were required to report AFP levels before treatment with curative intent for HCC and report long term survival data. Cox regressions were analyzed to determine hazard ratios (HR) of elevated AFP. Meta-analysis of overall survival (OS) and recurrence free survival (RFS) HR was performed using the random-effects model. Results: The literature search returned 64 studies. A total of 13 studies with 5383 total patients met inclusion criteria and were examined for review and meta-analysis. In studies reporting the number of patients with elevated AFP, 45.8% of HCC patients met the definition of elevated pre-treatment AFP. In the meta-analysis, elevated pre-treatment AFP was associated with increased risk of disease recurrence (HR: 1.41, 95% CI: 1.17–1.70) and increased HR for survival (1.74, 95% CI: 1.46–2.07). Conclusion: Elevated pretreatment serum AFP level is an independent predictor of overall survival and recurrence free survival in HCC patients. Serum AFP measurement may have prognostic value for HCC at the time of diagnosis. Further research is aimed to determine optimal baseline AFP values.

Background. Operative resection remains the definitive curative therapy for retroperitoneal sarcoma. Data published recently show a correlation between improved outcomes for complex oncologic operations and treatment at academic centers. For large retroperitoneal sarcomas, operative resection can be complex and require multidisciplinary care. We hypothesized that survival rates vary between type of treating center for patients undergoing resection for retroperitoneal sarcoma. Methods. Patients with stage 1 to 111 nonmetastatic retroperitoneal sarcomas who underwent operative resection were identified from the National Cancer Database during the years 2004-2013. Treating centers were categorized as academic cancer centers or community cancer centers. Overall survival was analyzed by log-rank test and graphed using Kaplan-Meier method. Results. A total of 2,762 patients were identified. A majority of patients (59.4%, n = 1,642) underwent resection at an academic cancer centers. Median age at diagnosis was 63 years old. Neoadjuvant radiotherapy was more common at academic cancer centers, while adjuvant radiotherapy was more common at community cancer centers. Improved overall survival was seen at academic cancer centers across all stages compared with community cancer centers (P=.014) but, after multivariable Cox regression analysis, was not a significant independent predictor of survival (hazard ratio = 0.91, 95% confidence interval, 0.79-1.04, P=.171). Academic cancer centers exhibited a greater rate of R0 resection (55.9% vs 47.0%, P<.001) and a lesser odds of positive margins (odds ratio 0.83, 95% confidence interval, 0.69-0.99, P=.044) after multivariable logistic regression. Conclusion. Resection for retroperitoneal sarcoma performed at academic cancer centers was an independent predictor of margin-negative resection but was not a statistically significant factor for survival. This observation suggests that site of care may contribute to some aspect of improved oncologic resection for retroperitoneal sarcoma. (C) 2017 Elsevier Inc. All rights reserved.