BACKGROUND:Pancreatic ductal adenocarcinoma outcomes are influenced by sociodemographic factors, including health insurance. Military beneficiaries, which include servicemembers, veterans, and their families, are often treated in civilian settings with TRICARE or Veterans Affairs acting as an insurance payor. We sought to examine outcomes among military and veteran beneficiaries with localized pancreatic cancer treated in civilian hospitals using the National Cancer Database. MATERIALS AND METHODS:Patients age <65 with stage I-III PDAC from 2010 to 2020 with private or other government insurance were included. Stage-stratified overall survival was analyzed using the Kaplan-Meier and multivariate Cox proportional hazards model. Logistic regression models were used to examine receipt of therapy and postoperative mortality. Survival analysis was examined after propensity score matching. RESULTS:Among 21,691 patients meeting inclusion criteria, 781 had other government insurance. Military beneficiaries were more likely than privately insured patients to be male and Black, and to live in low-income and rural areas. They traveled further for care and started treatment later. Furthermore, military beneficiaries were less likely to receive chemotherapy and undergo surgery. After adjusting for clinicopathologic factors, postoperative mortality was higher for military beneficiaries at 30 days (odds ratio 3.51, 95% confidence interval 1.70-7.27) and 90 days (odds ratio 3.36, 95% confidence interval 1.89-5.96). Median overall survival for privately insured patients was 18.5 months versus 14.7 for military (P < .001). Military insurance remained independently associated with worse overall survival (hazard ratio 1.15, 95% CI 1.03-1.29; P = .015). After propensity score matching, stage-stratified overall survival remained inferior for military beneficiaries (P = .004). CONCLUSIONS:Among patients with localized pancreatic cancer, military beneficiaries were less likely to receive cancer treatment, had worse postoperative mortality, and experienced worse risk-adjusted overall survival versus individuals with private insurance. Further research is needed to investigate potential disparities in access to care and treatment outcomes among military beneficiaries and to evaluate policies aimed at closing this gap.

BACKGROUND:Diagnosis, treatment, and outcomes of colon cancer in the United States differ between patients younger than age 50 (early-onset colon cancer [EOCC]) and those age 50 or older (average-onset [AOCC]) and may be impacted by access to care. Less is known about surgical quality and postoperative outcomes between patients with EOCC and AOCC. This study aimed to compare patients with EOCC and AOCC in surgical aspects and 30-day postoperative complications and readmissions in the Military Health System. METHODS:The cohort included patients diagnosed with stage I-III colon adenocarcinoma between 2001 and 2014 who received surgery. Poisson regression with robust standard errors estimated the adjusted risk ratios (ARRs) and 95% confidence intervals (CIs) in association with age at diagnosis for the outcomes. RESULTS:Among 333 patients with EOCC and 1369 patients with AOCC, there were no statistically significant differences in surgical delay, positive margins, or inadequate lymphadenectomy. Patients with EOCC had statistically higher adjusted 30-day risk of any complication (ARR = 1.31, 95% CI = 1.05 to 1.63), inclusive of general surgical (ARR = 1.64, 95% CI = 1.14 to 2.38) and gastrointestinal (ARR = 1.29, 95% CI = 1.00 to 1.65) complications, relative to patients with AOCC. There was no statistically significant difference in 30-day readmission for patients with EOCC (ARR = 1.30, 95% CI = 0.84 to 202) compared with patients with AOCC. CONCLUSION:In the Military Health System, patients with EOCC had higher adjusted 30-day risk of complications following surgery compared with patients with AOCC. This finding may have implications for care delivery and postoperative management of patients with EOCC to reduce complication burden and achieve optimal outcomes.

Robotic-assisted surgery has increased in prevalence, particularly in general surgery. The number of cases required to achieve adequate proficiency in robotic surgery, however, and the training metrics that correlate best with proficiency remain unclear. We sought to better define proficiency-based benchmarks in robotic-assisted cholecystectomies (RAC) and inguinal hernia repairs (RIHR) using a commercial crowd source based on competency platform. Multi-institutional cohort study in which 48 surgeons (senior residents, fellows, and practicing physicians) submitted representative videos of themselves performing a RAC and/or RIHR. Subjects subsequently underwent blinded case video reviews using the C-SATS platform, which utilizes the Global Evaluative Assessment of Robotic Skills (GEARS) rubric. Participating surgeons self-reported surgical case volume. Primary outcome was correlation of GEARS scores with historic procedure case volume. Secondary outcomes included construct validity of GEARS scores as an operative proficiency metric. Total GEARS scores and historical case volume showed positive correlation for both RAC (r = 0.65, p < 0.0001) and RIHR (r = 0.54, p = 0.001) among all performers. On subgroup analysis, no correlation was seen for resident/fellow physicians (r = 0.39, p = 0.11 for RAC; r = 0.22, p = 0.49 for RIHR) or those with < 50 historic case volume (r = 0.14, p = 0.55 for RAC; r = 0.21, p = 0.54 for RIHR). No difference in total GEARS scores was seen between resident/fellow and practicing physicians for either RAC (20.21 v 20.25, p = 0.82) or RIHR (20.45 v 20.46, p = 0.95), nor in those with < 50 or ≥ 50 historic case volume in RAC (20.16 v 20.33, p = 0.33) and RIHR (20.35 v 20.49, p = 0.48). GEARS scores by domain (bimanual dexterity, depth perception, efficiency, force sensitivity, and robotic control) and surgical step (exposure of triangle of calot, clipping and division of cystic artery/duct, and dissection of gallbladder; mobilizing peritoneal flap, hernia sac dissection, and mesh placement) were similar across both groups (p > 0.05). C-SATS-derived GEARS scores correlated to overall surgeon historical case volume for RA cholecystectomy and IHR, but not among novice performers. This methodology was unable to differentiate between novice and expert performers for these procedures. There remains a need for high-fidelity and discerning robotic skills evaluation platforms for trainees and novice surgeons.

INTRODUCTION:A hospital's approach (volume of cancer treatment services provided) to treating metastatic colorectal cancer influences a patient's treatment as strongly as patient disease status. The implications of hospital-level treatment approaches across disease stages remain understudied. We sought to determine if hospital service volume (SV) for metastatic colorectal cancer could be predictive of nonstandard treatment patterns in stages I-III colon cancer. MATERIALS AND METHODS:Using the National Cancer Database, we examined rates of nonstandard treatment patterns among patients with colon cancer between 2010 and 2017. After adjusting for clinicopathological characteristics using multivariable logistic regression, we evaluated the relationship between hospital-level SV for metastatic colorectal cancer and nonstandard treatment approaches for patients with stages I-III colon cancer. RESULTS:There were significant associations between hospital-level SV for metastatic colorectal cancer and the odds of chemotherapy overtreatment among patients with stage I-III colon cancer, as well as undertreatment among patients with stages II-III disease after adjusting for hospital-, patient-, and tumor-level covariates. Patients at the highest-level SV hospitals for metastatic disease had 1.29 higher odds (95% CI = 1.18-1.41; P < 0.0001) of receiving overtreatment compared to patients from lowest SV hospitals. The odds ratio of undertreatment in highest SV compared to lowest SV was 0.64 (95% CI 0.56-0.72; P< 0.0001). CONCLUSIONS:Hospital-level SV of patients with metastatic colon cancer is a significant indicator of nonstandard treatment patterns among patients with stage I-III colon cancer. Hospitals with the highest volume of cancer treatments have higher odds of providing overtreatment, while low SVs are associated with higher odds of undertreatment.

Abstract Introduction: Ultrasound is the imaging modality of choice in the evaluation of axillary involvement in breast cancer. Our group previously created a scoring method to predict axillary lymph node metastasis (ALNM) based on ultrasound characteristics. In this study we validated the model and tested it among different Memorial Sloan Kettering Breast Cancer Sentinel Lymph Node Metastasis Nomogram1 (MSK) subgroups. Methods: The ultrasound score (table 1) was previously developed using data collected at a single institution from 2019 – 2021 by allocating points based on the regression coefficients of variables found to significantly predict ALNM. Subsequent evaluation of the discrimination of this model found it was robust to different patient demographic and tumor characteristics based on receiver operating characteristic curve analysis2. In this study, we validated the test statistics of our score at an outside institution. We also pooled patients from both institutions and evaluated the score performance in different MSK subgroups by the likelihood for sentinel node metastasis based off of clinical and pathologic data without accounting for imaging findings. Results: Between 2019-2021, 140 patients with breast cancer were analyzed for validation of the axillary ultrasound scoring system and when combined with the dataset of patients from the index institution, 358 pooled patients were stratified by predicted ALNM positivity according to MSK. In the validation cohort, the NPV for low risk (0-1) scores was 87%, while the PPV for high-risk (5+) scores was 71%. Overall in the combined cohort, 241 (67%) patients had low risk (0-1) axillary ultrasound scores and 33 (9%) had high risk (5+) scores. In this combined cohort, NPV was 84% (203/241 low-risk score patients were node negative), while PPV for high-risk scores was 85% (28/33 high risk score patients were node positive). When analyzed according to level of MSK predicted ALNM rates, for patients with < 50% predicted ALNM positivity, the NPV of low-risk scores was 87-89% and the PPV for high-risk axillary scores was 100%. For patients with >50% predicted ALNM positivity, the NPV of low-risk scores was 66% and the PPV of high-risk scores was 82%. Conclusions: A scoring system to predict ALNM among biopsy proven breast cancer patients undergoing upfront surgery was successfully developed from a multivariate model based on axillary ultrasound characteristics. This model was validated at a separate institution. The scoring system shows advantageous negative and positive predictive values for axillary node metastasis, especially among patients with < 50% predicted nodal involvement based on the MSK nomogram. This data may help foster better communication about ALNM risk between radiologists and treating clinicians to inform treatment decisions. Table. Scoring System for Likelihood of ALNM based on Ultrasound Characteristics Citation Format: Spencer Van Decar, Elizabeth Carpenter, Alexandra Adams, Jason Shore, Iulian Dragusin, Erika Davis, Craig Tork, Robert Krell, Troy Graybeal, Katherine Clifton, Arianna Buckley, Guy Clifton. Validation of An Ultrasound-Based Scoring System of Axillary Metastasis in Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-07-10.

BACKGROUND The declining operative volume at Military Treatment Facilities (MTFs) has resulted in Program Directors finding alternate civilian sites for resident rotations. The continued shift away from MTFs for surgical training is likely to have unintended negative consequences. METHODS An anonymous survey was generated and sent to the program directors of military general surgery training programs for distribution to their residents. RESULTS A total of 42 residents responded (response rate 21%) with adequate representation from all PGY years. Ninety-five percent of residents believed that their programs provided the training needed to be a competent general surgeon. However, when asked about career choices, only 30.9% reported being likely/extremely likely to remain in the military beyond their initial service obligation, while 54.7% reported that it was unlikely/extremely unlikely and 19% reported uncertainty. Eighty-eight percent reported that decreasing MTF surgical volume directly influenced their decision to stay in the military, and half of respondents regretted joining the military. When asked to assess their confidence in the military to provide opportunities for skill sustainment as a staff surgeon, 90.4% were not confident or were neutral. CONCLUSION Although military surgical residents have a generally positive perception of their surgical training, they also lack confidence in their future military surgical careers. Our findings suggest that declining MTF surgical volume will likely negatively impact long-term retention of military surgeons and may negatively impact force generation for Operational Commander. LEVEL OF EVIDENCE Prognostic and Epidemiological, Level IV.

INTRODUCTIONThe 2020 Commission on Cancer accreditation standards 5.7 and 5.8 address total mesorectal excision for rectal cancer and lymph node sampling for lung cancer. The purpose of this review was to assess our institution's compliance with these operative standards, which will be required in 2022 and 2023, and provide recommendations to other military training facilities seeking to comply with these standards.MATERIALS AND METHODSA 2018-2020 single institution chart review was performed of operative and pathology reports. Identified deficits were addressed in meetings with colorectal and thoracic surgery leadership, and cases were followed to reassess compliance.RESULTSA total of 12 rectal and 48 lung cancer cases met the inclusion criteria and were examined. Pre-intervention compliance for standards 5.7 and 5.8 was 58% and 35%, respectively, because of inadequate synoptic reporting and lymph node sampling. After intervention, compliance was 100%.CONCLUSIONSOur institution requires changes to comply with new standards, including in areas of documentation and systematic pulmonary lymph node sampling. We provide lessons learned from our own institutional experience, including practical tips and recommendations to achieve compliance. All military training facilities performing lung and rectal oncologic resections should conduct an internal review of applicable cases in preparation for upcoming American College of Surgeons Commission on Cancer site visits.

Background: Patients with pancreas cancer may undergo palliative gastrointestinal or biliary bypass. Recent comparisons of post-operative outcomes following such procedures are lacking. Methods: We analyzed patients undergoing exploration, gastrojejunostomy, biliary bypass or double bypass for pancreatic cancer using data from the 2005-2019 American College of Surgeons National Surgical Quality Improvement Program. We compared 30-day mortality and complications across procedures and over time periods (2005-10, 2011-14, 2015-19) using multivariable regression models. Factors associated with postoperative mortality were identified. Results: Of 43,525 patients undergoing surgery with a postoperative diagnosis of pancreatic cancer, 5572 met inclusion criteria. Palliative operations included 1037 gastrojejunostomies, 792 biliary bypasses, 650 double bypasses, and 3093 explorations. The proportion of biliary and double bypass procedures decreased from 200510 to 2015-19. Gastrojejunostomy had higher 30-day mortality rate (11.5%) than other operations (p < 0.001). Adjusted 30-day mortality rates remained stable over time (7.8% vs 6.3%, p = 0.095), while rates of serious complications decreased over time (23.2% vs 17.1%, p < 0.001). Conclusions: Palliative bypass for pancreatic cancer has not become safer over time, and 30-day mortality and complications remain high.

Ward, Carson R; Carpenter, Elizabeth Lee MD; Pospiech, Emily MD, FACS; Chauviere, Matthew Victor MD; Krell, Robert W MD, FACS Author Information

Objective: To evaluate the efficacy of chemotherapy in patients with microsatellite instability (MSI)-high gastric cancer. Background: Although MSI-high gastric cancer is associated with a superior prognosis, recent studies question the benefit of perioperative chemotherapy in this population. Methods: Locally advanced gastric adenocarcinoma patients who either underwent surgery alone or also received neoadjuvant, perioperative, or adjuvant chemotherapy between 2000 and 2018 were eligible. MSI status, determined by next-generation sequencing or mismatch repair protein immunohistochemistry, was determined in 535 patients. Associations among MSI status, chemotherapy administration, overall survival (OS), disease-specific survival, and disease-free survival were assessed. Results: In 535 patients, 82 (15.3%) had an MSI-high tumor and ∼20% better OS, disease-specific survival, and disease-free survival. Grade 1 (90%–100%) pathological response to neoadjuvant chemotherapy was found in 0 of 40 (0%) MSI-high tumors versus 43 of 274 (16%) MSS. In the MSI-high group, the 3-year OS rate was 79% with chemotherapy versus 88% with surgery alone (P=0.48). In the MSS group, this was 61% versus 59%, respectively (P=0.96). After multivariable interaction analyses, patients with MSI-high tumors had superior survival compared with patients with MSS tumors whether given chemotherapy (hazard ratio=0.53, 95% confidence interval: 0.28–0.99) or treated with surgery alone (hazard ratio=0.15, 95% confidence interval: 0.02–1.17). Conclusions: MSI-high locally advanced gastric cancer was associated with superior survival compared with MSS overall, despite worse pathological chemotherapy response. In patients with MSI-high gastric cancer who received chemotherapy, the survival rate was ∼9% worse compared with surgery alone, but chemotherapy was not significantly associated with survival.

INTRODUCTION:Total abdominal colectomy (TAC) with ileostomy is the standard treatment for severe ulcerative colitis (UC). Partial colectomy (PC) with colostomy may present a less morbid treatment option. METHODS:The 2012-19 ACS-NSQIP database was queried to assess 30-day outcomes among patients undergoing TAC versus PC for UC, utilizing propensity score matching (PSM) techniques to account for differences in disease severity, patient selection, and presentation acuity. RESULTS:Before matching (n = 9888), patients undergoing PC were older, had more comorbidities, and experienced higher complication and 30-day mortality rates (P < 0.001). After matching (n = 1846), patients undergoing TAC experienced higher 30-day overall complications (41.9% versus 36.5%, P = 0.017) and serious complications (37.2% versus 31.5%, P = 0.011). Sensitivity analyses of older patients and those undergoing nonemergency surgery demonstrated higher overall rates of complications for patients receiving TAC. However, among patients undergoing emergency surgery only, no differences in complications were seen between the two surgical approaches. CONCLUSIONS:PC with colostomy in the setting of ulcerative colitis has similar 30-day outcomes to TAC with ileostomy. PC may be an acceptable surgical alternative to TAC in select patients. Studies investigating longer-term outcomes are necessary to further investigate this option.

While laparoscopic simulation-based training is a well-established component of general surgery training, no such requirement or standardized curriculum exists for robotic surgery. Furthermore, there is a lack of high-fidelity electrocautery simulation training exercises in the literature. Using Messick’s validity framework, we sought to determine the content, response process, internal content and construct validity of a novel inanimate tissue model that utilizes electrocautery for potential incorporation in such curricula. A multi-institutional, prospective study involving medical students (MS) and general surgery residents (PGY1-3) was conducted. Participants performed an exercise using a biotissue bowel model on the da Vinci Xi robotic console during which they created an enterotomy using electrocautery, followed by approximation with interrupted sutures. Participant performance was recorded and then scored by crowd-sourced assessors of technical skill, along with three of the authors. Construct validity was determined via difference in Global Evaluative Assessment of Robotic Skills (GEARS) score, time to completion, and total number of errors between the two cohorts. Upon completion of the exercise, participants were surveyed on their perception of the exercise and its impact on their robotic training to determine content validity. 31 participants were enrolled and separated into two cohorts: MS + PGY1 vs. PGY2-3. Time spent on the robotic trainer (0.8 vs. 8.13 h, p = 0.002), number of bedside robotic assists (5.7 vs. 14.8, p < 0.001), and number of robotic cases as primary surgeon (0.3 vs. 13.1, p < 0.001) were statistically significant between the two groups. Differences in GEARS scores (18.5 vs. 19.9, p = 0.001), time to completion (26.1 vs. 14.4 min, p < 0.001), and total errors (21.5 vs. 11.9, p = 0.018) between the groups were statistically significant as well. Of the 23 participants that completed the post-exercise survey, 87% and 91.3% reported improvement in robotic surgical ability and confidence, respectively. On a 10-point Likert scale, respondents rated the realism of the exercise 7.5, educational benefit 9.1, and effectiveness in teaching robotic skills 8.7. Controlling for the upfront investment of certain training materials, each exercise iteration cost ~ $30. This study confirmed the content, response process, internal structure and construct validity of a novel, high-fidelity and cost-effective inanimate tissue exercise which successfully incorporates electrocautery. Consideration should be given to its addition to robotic surgery training programs.