Over 5 million Americans currently abuse prescription opioids. Patients' first exposure to opioids is often after surgery. Few opioid guidelines account for the challenges to health care institutions that serve wide catchment areas. We standardized postoperative opioid prescribing recommendations amongst surgical providers at our institutions and analyzed postoperative prescribing habits. The Upstate New York Surgical Quality Improvement (UNYSQI) collaborative met with surgical champions from 16 hospitals to standardize opioid prescribing for 21 surgical procedures. The guidelines were distributed to all surgical care providers at participating institutions. 581,465 pills were dispensed for 12,672 surgeries (average of 45.9 pills per procedure) before implementation. Post-implementation, 1,097,849 pills were dispensed for 28,772 surgeries (average of 38.2 pills per surgery) with over 222,000 fewer pills being prescribed. Our project suggests opioid prescribing guidelines for institutions that serve diverse communities.

In small hospitals, where the majority of colectomy surgery is performed in the United States, adopting more individual ERAS components improves outcomes. The accumulation of individual ERAS components influences outcome more than an “ERAS designation” and this can be used by small hospitals to improve outcomes.

Purpose To investigate the parameters of renal trauma, including emergent intervention type, that predict the mortality of patients with traumatic renal injury. Methods A retrospective database analysis was performed on patients who sustained a traumatic renal parenchymal injury identified by the 2017 National Trauma Data Bank. Data were analyzed to identify differences in hospital length of stay, ER and hospital disposition, and mortality based on patient age, gender, race, Injury Severity Score, renal injury grade, and need for emergent intervention (angioembolization versus open surgery). Logistic regression was used to correlate intervention type and trauma parameters to mortality. Results A total of 4,876 of 1,004,440 trauma patients (0.49%) had a traumatic renal injury. Of those, 220 (4.5%) underwent an emergent intervention-29 (0.59%) angioembolization and 191 (3.9%) open renal surgery. 83 patients with a blunt renal trauma (2.0%) underwent renal intervention, whereas 136 (21.0%) with a penetrating injury required a procedure. Forty-five of the 220 patients (20.5%) who had a renal intervention died, while 377 of 4,656 (8.1%) who did not have an intervention died. Multiple logistic regression identified black race, age > 45 years, penetrating trauma, and ISS > 15 to be independent predictors of mortality. Neither angioembolization nor open renal surgery was associated with a significantly higher likelihood of mortality in the multivariable model. Conclusion While procedural interventions are associated with higher mortality for patients with traumatic renal injury, other factors, such as race, age, trauma type, and injury severity may be more predictive of death under care.

Background Increased prevalence of patients on anticoagulants and the advent of new therapies raise concern over how these patients fare if they sustain a traumatic injury. We investigated the role of prehospitalization anticoagulation therapy in trauma-related mortality and postacute disposition. Methods A retrospective analysis was performed on patients who sustained traumatic injury identified in the 2017 National Trauma Data Bank (NTDB). Patients with and without anticoagulation therapy were analyzed to identify differences in demographics, injury type, Injury Severity Score (ISS), and trauma outcomes including hospital length of stay, ER, final hospital disposition, and mortality. Logistic regression was used to correlate anticoagulation to mortality and facility discharge. Results Of the 1 000 596 patients included, 73 602 (7%) patients were on anticoagulants at the time of their trauma. Increased age was the strongest predictor for anticoagulation therapy (odds ratio 5.54, 95% CI 5.44-5.63), but being female and white were also independent predictors of anticoagulation (P < .001). Patients on anticoagulants had a significantly longer length of stay (5.11 days; 95% CI 5.06-5.15) than those who were not (4.37 days, 95% CI 4.36-4.39), were 2.20 times more likely to die (95% CI 2.12-2.28, P < .001), and were 2.77 times more likely to be discharged to a facility (95% CI 2.73-2.81, P < .001). Anticoagulation remained a significant predictor of worse trauma outcomes even when accounting for age and ISS in multivariate analysis. Discussion Anticoagulation preceding trauma-related admission is associated with higher mortality and an increased likelihood of the need for a posthospital care facility.

Guidelines recommend colectomy for appendiceal carcinoid tumors larger than 2 cm, but physicians debate whether colectomy would be beneficial in treating smaller tumors. We sought to determine when colectomy confers a survival advantage over appendectomy. Appendiceal carcinoid patients in the US Surveillance, Epidemiology, and End Results (SEER) database (1988–2011) were stratified by age group, gender, TNM stage, tumor grade, and race. Kaplan-Meier and logistic regression analyses relating grade, stage, and receipt of colectomy to overall and cancer-specific survival were performed. Of 817 patients who underwent surgical extirpation of an appendiceal carcinoid, 338 (41%) had appendectomy alone and 479 (59%) had additional colectomy. Surprisingly, patients who underwent colectomy had worse cancer-specific survival (HR 1.98, 95% CI 1.32–2.98, p = 0.001) than those who underwent appendectomy, and colectomy did not confer a survival advantage over appendectomy in any subset analysis including low-grade or high-grade tumors, smaller or larger than 2 cm, or node-positive, non-metastatic tumors. Even when accounting for stage and grade, colectomy was not associated with significantly better survival rates. Furthermore, as colectomy frequency has increased over the last decade, the 5-year survival rate has trended down. The main predictors of cancer-specific mortality in carcinoid patients were high-grade (grades 3–4) and high-stage (node positive or metastatic) tumors. Survival in patients with carcinoid tumor of the appendix is primarily determined by tumor grade and stage. Our study found no survival advantage to colectomy over appendectomy in a large cohort of patients with the disease. Further investigation is necessary prior to recommending change of practice for patients with appendiceal carcinoid tumors.

Hospital readmissions after surgery are a significant concern for providers, patients, and health-care systems.1 Previous research has shown that surgical patients who are discharged without an already scheduled follow-up appointment are significantly more likely to be readmitted to the hospital. For example, patients undergoing colectomy are more than twice as likely to be readmitted within 30 days if discharged without a scheduled follow-up.2 Although some authors have identified specific risk factors for readmission such as postsurgical complications3 and comorbidities,4 less research has been carried out on ways to prospectively prevent readmissions. With a focus on prevention, the goal of this quality improvement project was to develop an easily replicable measure to reduce the number of patients lost to follow-up, with the hope of reducing readmissions. This retrospective cohort study originated from the realization that many patients did not have (and did not appear for) follow-up appointments after undergoing surgery at our institution. This intervention took place at a single, intermediate size (265 beds), academic medical center with 11 operating rooms. We instituted a change in our electronic medical record (Epic, Madison, WI) so that the surgeon must specify the timing of postoperative follow-up while booking a case. When a surgeon submits a case request, there are several required fields, including the name of the provider, the name of the procedure, and the urgency of booking. Our intervention was to make a “hardstop” when booking a case for the timing of the postoperative appointment. We hypothesized that by requiring surgeons to submit this information when booking a case, more patients would have a follow-up appointment already scheduled by the time of surgery, which would lead to fewer patients lost to follow-up. To evaluate our results, we examined a cohort of consecutive patients from our institution’s ACS NSQIP database. The preand postintervention samples each contained 100 patients. Of the 100 patients in the preintervention group, 36 had a follow-up appointment scheduled before arriving on the day of surgery. This number increased to 87 of the 100 patients in the postintervention group (P 4 0.001). Given that surgeon schedules are often booked out weeks in advance, we expected that patients would also be observed earlier in the postoperative period. This was found to be true, with the number of patients being observed by post-op day 14 increasing from 43 to 61 after the intervention (P4 0.01). Similarly, the average day seen in follow-up decreased from post-op day 18 to post-op day 13 after the intervention (P 4 0.002). In addition, the number of cancellations for any reason decreased from 18 to 16. We also analyzed the date on which the appointment was created. Before the intervention, patients received a follow-up slot on average one day after surgery. After the intervention, patients received an appointment time 23 days before undergoing surgery. This was statistically significant (P < 0.001). Of note, there was a slight increase in the proportion of patients who showed up to their follow-up appointment, which increased from 75 to 82 patients after the intervention. Finally, there were five patients in the preintervention group who were permanently lost to follow-up, whereas there were no patients in the postintervention “hard-stop” who were lost to followup. Not only were more patients seen in the immediate postoperative period but also fewer patients were permanently lost to follow-up after the intervention was instituted. The rate of readmission was also analyzed. Among the 100 patients in the preintervention group, there were eight readmissions in the immediate postoperative period. This number dropped to four readmissions among Presented at the ACS Quality and Safety Conference, July 21–24, 2017, New York, NY. Address correspondence and reprint requests to Ethan Talbot, M.D., Department of Surgery, Bassett Medical Center, One Atwell Road, Cooperstown, NY 13326. E-mail: ethan.a.talbot@gmail. com.

Chaudhary, Asadulla MD; Kennedy, Colin R. MD; Cooper, Shelby S. MD, FACS; Anderson, Mark R. RN; Hellenthal, Nicholas J. MD FACS; Kaufman, Theodor I. MD; Monie, Daphne PhD Author Information

Purpose: We sought to determine whether median household income (MHI) independently predicts surgical approach (partial vs. radical nephrectomy) and survival in patients with renal cell carcinoma.Methods: The U.S. Surveillance Epidemiology and End Results Database (1988-2011) was queried to examine kidney cancer cases and linked to the Area Health Resources File. We correlated surgical approach and survival, both overall and cancer-specific, with tumor stage, age, race, sex, and income data.Results: Of 152,589 patients diagnosed with renal cell carcinoma, 24,221 (16%) patients underwent partial nephrectomy, 102,771 (67%) patients underwent radical nephrectomy, and 25,597 (17%) patients had no surgery. There was no significant difference in stage of presentation between the wealthiest and poorest MHI quartiles, with approximately 35% of patients in each quartile presenting with T1aN0M0 disease and 17% of patients presenting with metastatic disease. Despite this, 18% of patients in the wealthiest quartile underwent partial nephrectomy compared to 14% of patients in the poorest quartile. Although the percentage of patients undergoing partial nephrectomy rose over the timeframe studied in both the wealthiest and poorest quartiles, the rate of rise was highest in the wealthier group. Those in the poorest quartile were 0.10 times more likely to die of all causes (95% CI: 1.09-1.11, P < 0.001) and 0.09 times more likely to die of kidney cancer (95% CI: 1.05-1.10, P < 0.001) than those in the wealthiest quartile over the timeframe studied.Conclusions: Despite presenting with similar stage, patients with lower MHI less commonly undergo partial nephrectomy and are more likely to die of kidney cancer than those in the highest MHIs. (C) 2017 Elsevier Inc. All rights reserved.

PURPOSE:The prognosis for primary tracheal cancer is dismal. We investigated whether there has been improvement in survival in tracheal cancer patients and how treatment modality affected overall and cancer-specific survival. MATERIALS AND METHODS:Using the Surveillance, Epidemiology, and End Results database, 1144 patients with tracheal cancer were identified between 1973 and 2011. Patients were stratified by age group, gender, race, tumor histology, and treatment modality. Radical surgery and survival rates based upon these stratifications were determined. Longitudinal analyses of survival and the percentage of patients undergoing surgery and radiation were conducted. RESULTS:In the final cohort, 327 tracheal cancer patients (34%) underwent radical surgery. Patients of younger age, female gender, and who presented with non-squamous cell tumors were statistically more likely to undergo surgery. Over time, utilization of radiation has declined while use of radical surgery has increased. Concomitantly, 5-year survival has increased from approximately 25% in 1973 to 30% by 2006. Those who did not have surgery were 2.50 times more likely to die of tracheal cancer (95% Confidence Interval 2.00-3.11, p<0.001) than those who did have surgery. Additionally, patients who underwent radical surgery alone (without adjuvant radiation therapy) were 50% or 19% less likely to die of tracheal cancer than those who underwent no treatment or combination therapy, respectively (both p<0.001). CONCLUSIONS:Survival in patients with tracheal cancer is improving over time. The utilization of radical surgery is increasing and confers the highest survival advantage to patients who are candidates.

Hensley, Bradley J. MD, MBA; Cooney, Robert N. MD, FACS; Hellenthal, Nicholas J. MD, FACS; Aquina, Christopher T. MD; Xu, Zhaomin MD; Noyes, Katia PhD, MPH; Monson, John R. MD, MB BCH, FRCS, FACS; Fleming, Fergal MD Author Information

BACKGROUND: Hospital readmissions remain a major medical and financial concern to the healthcare system and have become an area of interest in health outcomes performance metrics. There is a pressing need to identify process measures that may help reduce readmissions. OBJECTIVE: Our aim was to assess the patient characteristics and surgical factors associated with 30-day readmissions for colorectal surgery in Upstate New York. DESIGN: This was a retrospective cohort study. SETTINGS: The study included colectomy cases abstracted for the National Surgical Quality Improvement Program in the Upstate New York Surgical Quality Initiative from June 2013 to June 2014. PATIENTS: The study consists of 630 colectomies. Patients with a length of stay >30 days or who died during the index admission were excluded. MAIN OUTCOME MEASURES: Readmission within 30 days of surgery was the main outcome measure. RESULTS: Of 630 colectomy patients, 76 patients (12%) were readmitted within 30 days of surgery. Major and minor complications were associated with 30-day postoperative readmission (OR = 2.99 (95% CI, 1.70–5.28) and OR = 2.19 (95% CI, 1.09–4.43)) but excluded from final analysis because they included both predischarge and postdischarge complications. Risk factors independently associated with 30-day postoperative readmission included diabetes mellitus (OR = 1.94 (95% CI, 1.02–3.67)), smoker within the past year (OR = 2.01 (95% CI, 1.12–3.60)), no scheduled follow-up (OR = 2.20 (95% CI, 1.25–3.86)), and ileostomy formation (OR = 1.97 (95% CI, 1.03–3.77)). LIMITATIONS: Limitations include the retrospective design and only 30 days of postoperative follow-up. CONCLUSIONS: Consistent with national trends, 1 in 8 patients in the Upstate New York Surgical Quality Initiative program was readmitted within 30 days after colorectal surgery. This study identified several risk factors that may act as tangible targets for intervention, including preoperative smoking cessation programs, optimization of diabetic management, mandatory scheduled follow-up appointments on discharge, and ostomy care pathways.

Background: Studies suggest increased lymph node excision in patients with colon cancer portends improved survival. Guidelines recommend excising 12 or more lymph nodes during colectomy. There is an inverse correlation between the positive lymph node ratio and survival in patients of these patients.Objective: We sought to determine whether colon cancer patients have adequate lymph node excision and whether positive lymph node ratio can be used as a guiding factor for their treatment plan.Design: Retrospective, Observational.Settings: United States, 1988-2011.Patients: Utilizing the Surveillance, Epidemiology, and End Results registry, we identified 318,323 patients who underwent colectomy for colonic adenocarcinoma. Patients were stratified by age, tumor stage, tumor grade, race, ratio of positive nodes, and year of diagnosis.Main outcome measures: We determined the percentage of patients undergoing lymph node excision and mean number of nodes excised by year of diagnosis. In patients with adequate lymph node excision, positive lymph node ratio versus overall and cancer-specific survival was evaluated.Results: 302,620 patients (95%) had at least 1 lymph node excised and 164,583 patients (52%) had 12 or more lymph nodes excised. This correlates to an increase from approximately 30% in 1988 to 80% by 2011. The mean number of nodes excised doubled from 9 to 18 in the entire cohort over the timeframe studied. On multivariate analysis, the 4 year cluster of diagnosis was the largest predictor of receipt of adequate lymph node excision with a 1.68 times higher odds per 4-year increase from 1988 (95% CI 1.67-1.69, p < 0.001). Higher positive lymph node ratio correlated with significantly worse overall and cancer-specific survival in those who had 12 or more lymph nodes excised. At a positive lymph node ratio of 0.16, there is a 15.7% increased rate of cancer specific mortality.Conclusions: Despite improvement in the performance of lymph node excision in patients undergoing colectomy for colon adenocarcinoma since 1988, only 80% of patients had adequate lymph node excision in 2011. Increasing positive lymph node ratio predicts significantly worse cancer-specific survival and a ratio of 0.16 may be considered an indication for a more aggressive therapeutic plan.Category: Colorectal/Anal Neoplasia. Published by Elsevier Ltd.

We present a case of a 30-year-old woman with a suspected contained rupture of a renal artery aneurysm which was managed with staged embolization and nephrectomy. Pathology demonstrated that the collection around the presumed aneurysmal rupture was an associated ganglioneuroma.

Purpose Cancer control of partial nephrectomy for high-risk localized renal cell carcinoma is unclear. To assess whether PN provides adequate cancer control in high-risk disease (HRD), survival outcomes were compared in both a population-based cohort and an institutional cohort. Methods Surveillance, Epidemiology, and End Results database and a prospectively maintained institutional database were queried for patients with RCC who underwent PN or RN for a localized tumor ≤7 cm and were found to have high-grade and/or high-stage disease (HRD). Cancer-specific (CSS) or recurrence-free survival (RFS) and overall survival (OS) were primary outcomes measured and were compared between those who underwent PN and RN using multivariable Cox proportional hazards and propensity analysis. Results The population cohort consisted of 12,757 (24.9 %) patients with HRD, 85.2 and 14.8 % of which underwent RN and PN, respectively. RN was not associated with CSS (HR 1.23, p = 0.08) but was independently associated with poor OS (HR 1.16, p = 0.031). Propensity analysis showed that RN resulted in a 20 % increased risk of death from all causes ( p = 0.008). In the institutional cohort, of 317 patients, 35.9 % had HRD, 56 and 52 of which underwent RN and PN, respectively. Adjusting for age-adjusted Charlson index, RN was a predictor of poor OS (OR 6.20, p = 0.041). Propensity analysis showed that RFS and OS were not related to nephrectomy type (RN HR 0.65, p = 0.627 and RN HR 1.70, p = 0.484). Conclusions In patients with pathologic high-risk RCC, partial excision is associated with similar cancer control as compared to radical excision.

OBJECTIVE To determine whether discrepancies in testicular cancer outcomes between Caucasians and non-Caucasians are changing over time. Although testicular cancer is more common in Caucasians, studies have shown that other races have worse outcomes.MATERIALS AND METHODS Using the Surveillance, Epidemiology, and End Results registry, we identified 29,803 patients diagnosed with histologically confirmed testicular cancer between 1983 and 2011. Of these, 12,650 patients (42%) had 10-year follow-up data. We stratified the patients by age group, stage, race, and year of diagnosis and assessed 10-year overall and cancer-specific survival in each cohort. Cox proportional hazard models were used to determine the relative contributions of each stratum to cancer-specific survival.RESULTS Predicted overall 10-year survival of Caucasian patients with testicular cancer increased slightly from 88% to 89% over the period studied, whereas predicted cancer-specific 10-year survival dropped slightly from 94% to 93%. In contrast, non-Caucasian men demonstrated larger changes in 10-year overall (84%-86%) and cancer-specific (88%-91%) survival. On univariate analysis, race was significantly associated with testicular cancer death, with non-Caucasian men being 1.69 times more likely to die of testicular cancer than Caucasians (hazard ratio, 1.33-2.16; 95% confidence interval, <.001).CONCLUSION Historically, non-Caucasian race has been associated with poorer outcomes from testicular cancer. These data show a convergence in cancer-specific survival between racial groups over time, suggesting that diagnostic and treatment discrepancies may be improving for non-Caucasians. (C) 2015 Elsevier Inc.

Objectives: The incidence of metastatic disease in patients with renal cell carcinoma (RCC) correlates with tumor size. We sought to determine the incidence of metastatic disease by tumor size, and the utilization and impact of nephron-sparing surgery on survival in those with metastatic disease.Materials and methods: Utilizing the Surveillance, Epidemiology, and End Results (SEER) database, we identified 56,011 patients between 1988 and 2005 diagnosed with RCC. Patients were initially separated into two groups those with and without metastatic disease and stratified by tumor size. Cox proportional hazard modeling and Kaplan-Meier analyses were then utilized to evaluate the role of gender, age, grade, histology, tumor size, and type of surgery (radical vs. partial nephrectomy) on overall- and cancer-specific survival in patients with metastatic disease.Results: Eight thousand four hundred ninety-eight patients (15%) had metastatic disease. Four percent of patients with tumors less than 2 cm and 5% of patients with tumors between 2 and 3 cm presented with metastatic disease. Two thousand nine hundred fifty patients (35%) with metastatic disease underwent surgery (radical or partial nephrectomy). Seventy patients (2% of those undergoing surgery) had a partial nephrectomy. Those who underwent partial nephrectomy were 0.49 times less likely to die of RCC than those who underwent radical nephrectomy (95% CI 0.35-0.69, P < 0.001).Conclusions: Albeit small, the risk of metastases in patients with small kidney tumors is distinct and should be considered in management discussions. Partial nephrectomy, when able to be done, should be utilized in the setting of metastatic disease. (C) 2013 Elsevier Inc. All rights reserved.

PURPOSE:Previous studies of the impact of renal cell carcinoma histopathology on survival are conflicting and generally limited to institutional analyses. Thus, we determined the role of renal cell carcinoma histopathology on the stage specific survival rate in a large population based cohort. MATERIALS AND METHODS:We used the 2000 to 2005 National Cancer Institute SEER (Surveillance, Epidemiology and End Results) database to identify 17,605 patients who underwent surgery for renal cell carcinoma and met study inclusion criteria. Patients were stratified by histological subtype (clear cell, papillary, chromophobe, collecting duct and sarcomatoid differentiation) and pathological stage. We performed Cox proportional hazard modeling and Kaplan-Meier survival analysis to determine overall and cancer specific survival. RESULTS:Patients with papillary and chromophobe pathology were less likely to present with T3 or greater disease (17.6% and 16.9%, respectively) while patients with collecting duct and sarcomatoid variants were more likely to present with T3 or greater disease (55.7% and 82.8%, respectively) compared to those with clear cell histology (p <0.001). On multivariate analysis histology was significantly associated with overall and cancer specific survival. Patients with chromophobe pathology had improved survival (HR 0.56, 95% CI 0.40-0.78) while those with collecting duct and sarcomatoid variants had worse survival (HR 2.07, 95% CI 1.44-2.97 and 2.26, 95% CI 1.93-2.64, respectively). CONCLUSIONS:Renal cell carcinoma histological subtype predicts overall and cancer specific survival. Patients with collecting duct and sarcomatoid variants of renal cell carcinoma have poor survival, even those who present with low stage disease. These data suggest inherent differences in renal cell carcinoma biology and may ultimately form the basis of future histologically targeted therapies.

INTRODUCTION:Treatment of the elderly patient with a small renal mass is becoming a common conundrum with scant data available to support treatment decisions. Goals were to assess risk of surgical treatment for renal cell carcinoma (RCC) in the elderly as compared to their younger counterparts.MATERIALS AND METHODS:A prospectively maintained database consisting of all renal tumors between August 2004 and November 2009 was utilized. Patients who underwent extirpative treatment for RCC were divided into groups based on age cutoff of < 75 and ≥ 75 years old. Primary outcome measures were likelihood of partial nephrectomy versus radical nephrectomy, complication rates, and overall and cancer-specific survival. A secondary outcome investigated was renal function.RESULTS:Of 347 patients identified, 273 were < 75, and 74 were ≥ 75 years old. The elderly group was less likely to undergo partial nephrectomy (26% versus 43%, p = 0.045). They also had a higher rate of pT3 disease (20% versus 11%, p = 0.018), worse baseline renal function (46 mL/min/m(2) versus 92 mL/min/m(2), p < 0.001) and a longer length of stay (3.5 days versus 2.2 days, p < 0.001). Complication rates and survival outcomes were similar between the groups. Only Eastern Cooperative Oncology Group (ECOG) ≥ 1 and Charlson index ≥ 2 predicted likelihood of experiencing a complication.CONCLUSIONS:Despite a longer length of stay, renal surgery is safe in selected elderly patients with minimal comorbidity and good functional status. The elderly have reduced baseline renal function indicating nephron sparing should be chosen whenever possible, when surgical intervention is elected.