Delay in gastric cancer diagnosis is associated with inferior outcomes. The effects of pre-existing mental health disorders (MHDs) on delays in gastric cancer diagnosis and treatment disparities are not well-understood. In this study, we evaluated the impact of MHDs on time to gastric cancer diagnosis and receipt of guideline-concordant treatment. We performed a retrospective review of patients diagnosed with gastric adenocarcinoma between 2015 and 2022. Patients with pre-existing diagnoses of mood, affective, and substance use disorders were classified as having an MHD. Univariable and multivariable regression were used to analyze the association between MHDs and delay in diagnosis. The association between MHD and receipt of guideline-concordant care was also evaluated. Overall, 460 patients diagnosed with gastric cancer were included in the analytic group. Seventy patients (15

Background Minimally invasive surgery provides an unprecedented opportunity to review video for assessing surgical performance. Surgical video analysis is time-consuming and expensive. Deep learning provides an alternative for analysis. Robotic pancreaticoduodenectomy (RPD) is a complex and morbid operation. Surgeon technical performance of pancreaticojejunostomy (PJ) has been associated with postoperative pancreatic fistula. In this work, we aimed to utilize deep learning to automatically segment PJ RPD videos. Methods This was a retrospective review of prospectively collected videos from 2011 to 2022 that were in libraries at tertiary referral centers, including 111 PJ videos. Each frame of a robotic PJ video was categorized based on 6 tasks. A 3D convolutional neural network was trained for frame-level visual feature extraction and classification. All the videos were manually annotated for the start and end of each task. Results Of the 100 videos assessed, 60 videos were used for the training the model, 10 for hyperparameter optimization, and 30 for the testing of performance. All the frames were extracted (6 frames/second) and annotated. The accuracy and mean per-class F1 scores were 88.01% and 85.34% for tasks. Conclusion The deep learning model performed well for automated segmentation of PJ videos. Future work will focus on skills assessment and outcome prediction.

ObjectiveOur institution recently implemented a virtual reality (VR) skills curriculum for general surgery residents using the SimNow simulator. Based on a content alignment study, we revised the curriculum to include only 20 of 33 VR tasks and we added 3 previously validated inanimate tasks. The purpose of this study was to establish expert-derived proficiency levels for all tasks and to evaluate the validity of the scoring for the VR tasks.DesignTwo expert robotic surgeons performed 5 repetitions of each VR and inanimate task. The trimmed mean (lowest scoring attempt and outliers [>2 standard deviations] were eliminated) was defined as the expert level for each task. For the VR tasks, expert levels were compared to resident performance to evaluate validity.SettingThis study was conducted at the University of Texas Southwestern Medical Center (Dallas, TX), a tertiary care academic teaching hospital.ParticipantsTwo expert robotic surgeons participated in this study. The data from 42 residents (PGY2-4) who completed the original curriculum was used to represent novice performance.ResultsComparison of expert levels and resident performance was statistically significant for 15 VR tasks (supporting validity) and approached significance (p = 0.06, 0.09) for 2 VR tasks; expert levels were designated as proficiency levels for these 17 tasks. Group comparisons were clearly not significant (p = 0.2-0.8) for 3 VR tasks; 2 of these 3 tasks were retained as introductory exercises (with 3 repetitions required) and 1 was excluded. For the 3 inanimate tasks, expert levels minus 2 standard deviations were designated as proficiency levels.ConclusionsThis analysis generated validity evidence for 15 VR tasks and established expert-derived proficiency levels for 17 VR tasks and 3 inanimate tasks. Our proposed curriculum now consists of 19 VR and 3 inanimate tasks using the selected proficiency levels. We anticipate that this design will maximize curriculum efficiency and effectiveness.

Importance Robotic-assisted nipple-sparing mastectomies with multiport robots have been described in the US since 2015; however, significant hurdles to multiport robotic surgery exist in breast surgery.Objective To demonstrate that the single-port da Vinci SP (Intuitive Surgical) robotic system is feasible in patients undergoing robotic nipple-sparing mastectomy (rNSM).Design, Setting, and Participants An initial case series of 20 patients at a large university hospital underwent bilateral single-port robotic nipple-sparing mastectomies (SPrNSM) with tissue expander reconstruction from February 1, 2020, through January 4, 2023. Participants included women who met surgical criteria for nipple-sparing mastectomies, per standard of care.Intervention Surgery using a single-port robot and the surgical technique of the authors.Main Outcomes and Measures Age, indication, body mass index, breast size, operative time, conversion to open surgery, systemic complications, postoperative skin necrosis, and reported skin and nipple areolar complex (NAC) sensation.Results Twenty women aged 29 to 63 years (median, 40 years) underwent bilateral SPrNSM. Eleven patients completed prophylactic surgery due to a high risk for breast cancer (more than 20% lifetime risk) and 9 patients had breast cancer. Breast size ranged from A through D cup with median B cup and a body mass index range of 19.7 through 27.8 (median 24.4). The total duration of the procedure from incision to skin closure for both sides ranged from 205 minutes to 351 minutes (median, 277). The median robotic time for bilateral SPrNSM was 116 minutes and varied by cup size (A cup, 95 minutes; B cup, 140 minutes; C cup, 118 minutes; D cup, 114 minutes) with no inflection point in learning curve. No cases were converted to open and no immediate complications, such as hematoma, positive margins, or recurrence, were seen. In the first 10 patients prior to routine sensation testing, 20 resected breasts had measurable NAC sensation at a range from 4 to 36 months post-index resection (65%). In the second 10 patients of the cohort, measurable NAC was preserved in 13 of 20 resected breasts 2 weeks following the index operation (65%).Conclusion and Relevance In this case series, SPrNSM with immediate reconstruction was feasible and performed safely by an experienced breast surgeon with limited previous robotic training. Further studies confirming the preliminary data demonstrating improved NAC and skin sensation following SPrNSM are warranted.

There is a lack of data on whether hospitals with higher markup ratios have better outcomes after complex pancreatic surgeries. We studied the relationship between hospital markup ratio and the incidence of patient safety indicators (PSI) events following pancreatic surgery. We performed a retrospective analysis (2004-2017) of the Nationwide Inpatient Sample for elective pancreatic resections (n = 36,869). Agency for Healthcare Research and Quality patient safety indicators (PSIs) were used as a validated quality metric that provides information on potentially avoidable adverse events. Median hospital costs and charges were retrieved and adjusted for inflation using the annual producer price index. Hospitals were classified as high or low markup (HMHs or LMHs) if their ratio corresponded to ≥75th or <75th percentiles, respectively. Univariate analysis and Poisson regression adjusted for patient/procedure/hospital characteristics were used to predict PSI occurrence. Of 3651 US hospitals, LMHs, and HMHs represented 64% and 36%, respectively. HMH median charges almost doubled LMH ($203,169 vs. $111,028). Univariate analysis revealed that LMHs had a lower incidence of ≥1 PSI than HMHs (20% and 23%, respectively; all p < 0.001). Poisson's count model showed 17% increased odds of PSIs in HMHs compared to LMHs (p < 0.001). Older age, high Charlson Comorbidity Index, and total pancreatectomy were associated with increased PSIs (p < 0.001). Being female, having private insurance, and undergoing surgery at large bed-size-hospitals decreased PSI occurrence (p < 0.001) HMHs had a higher incidence of PSI events than LMHs. Regarding potentially avoidable adverse events after pancreatectomies, a higher markup ratio was not associated with higher quality of care.

Residency programs must prepare to train the next generation of surgeons on the robotic platform. The purpose of this study was to determine if baseline skills of residents on a virtual reality (VR) robotic simulator before intern year predicted future performance in a proficiency-based curriculum. Across two academic years, 21 general surgery PGY-1s underwent the robotic surgery boot camp at the University of Texas Southwestern. During boot camp, subjects completed five previously validated VR tasks, and their performance metrics (score, time, and economy of motion [EOM]) were extracted retrospectively from their Intuitive learning accounts. The same metrics were assessed during their residency until they reached previously validated proficiency benchmarks. Outcomes were defined as the score at proficiency, attempts to reach proficiency, and time to proficiency. Spearman’s rho and Mann–Whitney U tests were used; median (IQR) was reported. Significance level was set at p < 0.05. Twenty-one residents completed at least three out of the five boot camp tasks and achieved proficiency in the former during residency. The median average score at boot camp was 12.3 (IQR: 5.14–18.5). The median average EOM at boot camp was 599.58 cm (IQR: 529.64–676.60). The average score at boot camp significantly correlated with lower time to achieve proficiency (p < 0.05). EOM at boot camp showed a significant correlation with attempts to proficiency and time to proficiency (p < 0.01). Residents with an average baseline EOM below the median showed a significant difference in attempts to proficiency (p < 0.05) and time to proficiency (p < 0.05) compared to those with EOMs above or equal to the median. Residents with an innate ability to perform tasks with better EOM may acquire robotic surgery skills faster. Future investigators could explore how these innate differences impact performance throughout residency.

BACKGROUND:We aimed to describe the financial implications of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) in the USA.MATERIALS AND METHODS:We conducted a retrospective cost analysis of 100 CRS/HIPEC procedures to examine the impact of patient and procedural factors on hospital costs and reimbursement. A comparison of surgeons' work relative value units (wRVUs) between CRS/HIPEC and a representative sample of complex surgical oncology procedures was made to assess the physicians' compensation rate. Univariable and multivariable backward logistic regression was used to analyze the association between perioperative variables and high direct cost (HDCs).RESULTS:The median direct cost per CRS/HIPEC procedure was US $44,770. The median hospital reimbursement was US $43,066, while professional reimbursement was US $8608, resulting in a positive contribution margin of US $7493/procedure. However, the contribution margin significantly varied with the payer mix. Privately insured patients had a positive median contribution margin of US $23,033, whereas Medicare-insured patients had a negative contribution margin of US $13,034. Length of stay (LOS) had the most significant association with HDC, and major complications had the most significant association with LOS. Finally, CRS/HIPEC procedures generated a median of 13 wRVU/h, which is significantly lower than the wRVU/h generated by open pancreatoduodenectomies, open gastrectomies, and hepatectomies. However, higher operation complexity and multiple visceral resections help compensate for the relatively low wRVU/h.CONCLUSIONS:CRS/HIPEC is an expensive operation, and prolonged LOS has the most significant impact on the total cost of the procedure. High-quality care is essential to improve patient outcomes and maintain the economic sustainability of the procedure.

Introduction: Despite the importance of simulation-based training for robotic surgery, there is no consensus about its training curricula. Recently, a virtual reality (VR) platform (SimNow, Intuitive, Inc) was introduced with 33 VR drills but without evidence of their validity. As part of our creating a new robotic VR curriculum, we assessed the drills' validity through content mapping and the alignment between learning goals and drill content.Methods: Three robotically trained surgeons content-mapped all 33 drills for how well the drills incorporated 15 surgery skills and also rated the drills' difficulty, usefulness, rele-vance, and uniqueness. Drills were added to the new curriculum based on consensus about ratings and historic learner data. The drills were grouped according to similar skill sets and arranged in order of complexity.Results: The 33 drills were judged to have 12/15 surgery skills as primary goals and 13/15 as secondary goals. Twenty of the 33 drills were selected for inclusion in the new curriculum; these had 11/15 skills as primary goals and 11/15 as secondary goals. However, skills regarding energy sources, atraumatic handling, blunt dissection, fine dissection, and running suturing were poorly represented in the drills. Three previously validated inani-mate drills were added to the curriculum to address lacking skill domains.Conclusions: We identified 20 of the 33 SimNow drills as a foundation for a robotic surgery curriculum based on content-oriented evidence. We added 3 other drills to address iden-tified gaps in drill content.(c) 2022 Elsevier Inc. All rights reserved.

BackgroundWe aimed to describe the association of patient-related factors such as race, socioeconomic status, and insurance on failure to rescue (FTR) after hepato-pancreato-biliary (HPB) surgeries.MethodsUsing the National Inpatient Sample, we analyzed 98,788 elective HPB surgeries between 2004 and 2017. Major and minor complications were identified using ICD9/10 codes. We evaluated mortality rates and FTR (inpatient mortality after major complications). We used multivariate logistic regression analysis to assess racial, socioeconomic, and demographic factors on FTR, adjusting for covariates.ResultsOverall, 43 % of patients (n = 42,256) had pancreatic operations, 36% (n = 35,526) had liver surgery, and 21% (n = 21,006) had biliary interventions. The overall major complication rate was 21% (n = 20,640), of which 8% (n = 1655) suffered FTR. Factors independently associated with increased risk for FTR were male sex, older age, higher Charlson Comorbidity Index, Hispanic ethnicity, Asian or other race, lower income quartile, Medicare insurance, and southern region hospitals.ConclusionsMedicare insurance, male gender, Hispanic ethnicity, and lower income quartile were associated with increased risk for FTR. Efforts should be made to improve the identification and subsequent treatment of complications for those at high risk of FTR.

294 Background: Gastric cancer patients with malignant ascites often have poor functional status and malnutrition that precludes receipt of systemic therapies. Thus, these patients have a very poor prognosis. Beginning in 2019, our multidisciplinary gastric cancer disease-oriented team implemented a more aggressive supportive care plan for gastric cancer patients with malignant ascites. The initiative included measures such as supplemental enteral nutrition, ascites drainage, and initiation of chemotherapy on an inpatient basis. We compared outcomes for gastric cancer patients who presented with synchronous malignant ascites treated before and after the implementation of the care plan. Methods: We performed a retrospective review of our institutional database to identify patients diagnosed with gastric adenocarcinoma and synchronous malignant ascites between 2010-2022. We compared survival between patients diagnosed from 2010-2018, which will be referred to as the historical control era and patients diagnosed from 2019-2022, which will be called the aggressive supportive care era. Results: 54 patients were included in our analysis; 31 patients were treated in the historical control time frame and 23 patients treated during the aggressive supportive care era. Demographic, clinical, and pathologic characteristics were similar between groups. 3% of historical controls received supplemental tube feeds at diagnosis as compared to 30% of the aggressive supportive care cohort (p=0.008). 3% of historical controls received their first cycle of chemotherapy in the inpatient setting versus 39% of patients treated during the aggressive supportive care era (p=0.001). The median number of chemotherapy cycles received was 5 among historical controls and 9.5 among aggressive supportive care era patients (p = 0.02). There was no difference in the number of days spent as an inpatient between the two groups. The median overall survival for historical control patients was 5.4 months as compared to 10.4 months for patients treated during aggressive supportive care era (p=0.035). Conclusions: Gastric cancer patients with synchronous malignant ascites treated during a timeframe when our multidisciplinary team implemented more aggressive supportive care measures had improved OS as compared to historic controls.Our results suggest that aggressive supportive measures for these patients with highly challenging clinical issues and poor prognosis can prolong survival. Specifically, initiation of chemotherapy in the inpatient setting and supplemental nutrition should be considered for patients at high risk for treatment intolerance.

Cytoreductive surgery with hyperthermic peritoneal chemotherapy (HIPEC) is a technically challenging and resource-intensive operation.The financial burden of this operation often limits the initiation and maintenance of a peritoneal surface malignancy program.This report (https:// doi.org/ 10. 1245/ s10434-023-14442-y) describes the financial footprint of 100 consecutive cytoreduction and HIPEC operations.

Minimally invasive surgery affords the opportunity for video review. Procedures are unique and global assessments may not be helpful in identifying points of improvement. Robotic pancreaticoduodenectomy (RPD) is a complex procedure. Trainees typically start with the gastrojejunostomy (GJ) step. In this work, we aim to develop task-specific metrics for robotic GJ based on expert consensus and to evaluate these metric items relative to global grading schemes. This is a retrospective review of prospectively collected GJ RPD videos at two quaternary referral centers from 2011 to 2022. These videos were rated according to overall performance, objective structured assessment of technical skills (OSATs), global evaluative assessment of robotic skills (GEARS) and task-specific metrics (TSM). A second grader rated a subset of videos and intra-class correlation was calculated. The final task-specific metrics were developed using partial least squares regression (PLS) based on overall performance. A total of 49 videos were analyzed. These were rated according to OSATs, GEARS and task-specific metrics. Overall performance (Likert scale 1–5), total OSATs and total GEARS correlated poorly with total task scores (R = 0.55, P < 0.05), (R = 0.5, P < 0.05) and (R = 0.54, P < 0.05), respectively. After PLS, total scores for the final task-specific metrics correlated well with overall performance (R = 0.8, P < 0.05), OSATs (R = 0.76, P < 0.05) and GEARS (R = 0.74, P < 0.05). Task-specific metrics with good correlation with established rating schemes were derived for Robotic Gastrojejunostomy. These metrics may provide trainees with precise task-specific feedback to improve performance.

Introduction: Pancreatic surgery tends to have a high rate of postoperative complications due to its complex nature, significantly increasing hospital costs. Our aim was to describe the true association between complications and hospital costs in a national cohort of US patients.Methods: The National Inpatient Sample was used to conduct a retrospective analysis of elective pancreatic resections performed between 2004 and 2017, categorizing them based on whether patients experienced major complications (MaC), minor complications (MiC), or no complications (NC). Multivariable quantile regression was used to analyze how costs varied at different percentiles of the cost curve.Results: Of 37,893 patients, 45.3%, 28.6%, and 26.1% experienced NC, MiC, and MaC, respectively. Factors associated with MaC were a Charlson Comorbidity Index of =4, prolonged length of stay, proximal pancreatectomy, older age, male sex, and surgery performed at hospitals with a small number of beds or at urban nonteaching hospitals (all P < 0.01). Multivariable quantile regression revealed significant variation in MiC and MaC across the cost curve. At the 50th percentile, MiC increased the cost by $3352 compared to NC while MaC almost doubled the cost of the surgery, increasing it by $20,215 (both P < 0.01). The association between complications and cost was even greater at the 95th percentile, increasing the cost by $10,162 and $108,793 for MiC and MaC, respectively (P < 0.01).Conclusions: MiC and MaC were significantly associated with increased hospital costs. Furthermore, the relationship between MaC and costs was especially apparent at higher percentiles of the cost curve.

Background Diagnostic laparoscopy (DL) is a key component of staging for locally advanced gastric adenocarcinoma (GA). We hypothesized that utilization of DL varied between safety net (SNH) and affiliated tertiary referral centers (TRCs). Methods Patients diagnosed with primary GA eligible for DL were identified from the US Safety Net Collaborative database (2012-2014). Clinicopathologic factors were analyzed for association with use of DL and findings on DL. Overall survival (OS) was analyzed by Kaplan-Meier method. Results Among 233 eligible patients, 69 (30%) received DL, of which 24 (35%) were positive for metastatic disease. Forty percent of eligible SNH patients underwent DL compared to 21.5% at TRCs. Lack of insurance was significantly associated with decreased use of DL (OR 0.48, p < 0.01), while African American (OR 6.87, p = 0.02) and Asian race (OR 3.12, p <= 0.01), signet ring cells on biopsy (OR 3.14, p < 0.01), and distal tumors (OR 1.62, p < 0.01) were associated with increased use. Median OS of patients with a negative DL was better than those without DL or a positive DL (not reached vs. 32 vs. 12 months, p < 0.005, Figure 1). Conclusions Results from DL are a strong predictor of OS in GA; however, the procedure is underutilized. Patients from racial minority groups were more likely to undergo DL, which likely accounts for higher DL rates among SNH patients.

Introduction: Successful rescue of surgical patients from post-operative complications (POC) represents an important quality of care indicator. Our study aims to describe how racial, socioeconomic, and insurance-status factors affect failure to rescue (FTR) after complex hepato-pancreatico-biliary (HPB) surgeries nationwide. Methods: We conducted a retrospective analysis (2004-2017) of the US Nationwide Inpatient Sample for elective HPB surgeries (n=98,788). Major (MaC) and minor (MiC) were identified using validated ICD9/10 codes. Mortality and FTR (in-patient mortality after major complications) were calculated. Logistic regression was used to assess the impact of racial/socioeconomic/demographic factors on FTR occurrence adjusting for all covariates. Results: Of 90,788 patients, 35,526 (36%) underwent liver surgery, while 21,006 (21%) had biliary and 45,256 (43%) had pancreatic operations. 59% were cancer-related operations. The rates of MiC and MaC were 26% and 21% respectively. FTR occurred in 8% (n=1,655) and overall mortality rate was 2% (n=2,129). Factors independently associated with increased risk for FTR were: Charlson-comorbidity-index ≥ 4, lower-income quartile (<$38,999), Medicare insurance, older age, male sex, and Southern region hospitals (all p<0.001). Conversely, Black race, female gender, private insurance, high-income quartile (≥$63.000), and surgery in later study periods were associated with decreased odds of FTR (all p<0.05). Conclusions: Medicare insurance, male gender, lowest-income quartile, and surgery in the early years of the study period were associated with increased risk for FTR. Targeted efforts should be enacted to increase an equitable delivery of care in all racial, socioeconomic, and insurance status groups after complex HPB surgeries.

The annual number of robotic surgical procedures is on the rise. Robotic surgery requires unique skills compared to other surgical approaches. Simulation allows basic robot skill acquisition and enhances patient safety. The purpose of this study was to evaluate the feasibility, effectiveness, and transferability of a mastery-based curriculum using a new virtual reality (VR) robotic simulator for surgery resident training. Nineteen PGY2s and 22 PGY4s were enrolled. Residents completed a pretest and posttest consisting of five VR and three previously validated inanimate tasks. Training included practicing 33 VR tasks until a total score ≥ 90% (“mastery”) was achieved using automated metrics (time, economy of motion). Inanimate performance was evaluated by two trained, blinded raters using video review metrics (time, errors, and modified OSATS). Outcomes were defined as: curriculum feasibility (completion rate, training time, repetitions), training effectiveness (pre/post training skill improvement), and skill transferability (skill transfer to validated inanimate drills). Wilcoxon signed-rank and Mann–Whitney U tests were used; median (IQR) reported. Thirty-four of 41 residents (83%) achieved mastery on all 33 VR tasks; median training time was 7 h (IQR: 5′26″–8′52″). Pretest vs. post-test performance improved (all p < 0.001) according to all VR and Inanimate metrics for both PGY2 and PGY4 residents. Significant pretest performance differences were observed between PGY2 and PGY4 residents for VR but not inanimate tasks; no PGY2 vs. PGY4 posttest performance differences were observed for both VR and inanimate tasks. This mastery-based VR curriculum was associated with a high completion rate and excellent feasibility. Significant performance improvements were noted for both the VR and inanimate tasks, supporting training effectiveness and skill transferability. Additional studies examining validity evidence may help further refine this curriculum.