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Pancreatic fistula remains a morbid complication after pancreatectomy. Since the proposed mechanism of pancreatic fistula is different between pancreaticoduodenectomy and distal pancreatectomy, we hypothesized that pancreatic gland texture and duct size are not associated with pancreatic fistula after distal pancreatectomy. All patients ≥18 years in the 2014-15 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) targeted pancreatectomy dataset were linked with the ACS NSQIP Public Use File (PUF). Pancreatic duct size (<3 mm, 3-6 mm, >6 mm) and pancreatic gland texture (hard, intermediate, soft) were categorized. Separate multivariable analyses were performed to evaluate associations between pancreatic duct size and gland texture after pancreaticoduodenectomy and distal pancreatectomy. A total of 9366 patients underwent pancreaticoduodenectomy or distal pancreatectomy during the study period. Proportion of pancreatic fistula was similar after distal pancreatectomy (606 of 3132, 19.4%) and pancreaticoduodenectomy (1163 of 6335, 18.4%, p = 0.245). Both pancreatic gland texture and duct size were significantly associated with pancreatic fistula after pancreaticoduodenectomy (p<0.001). However, there was no association between pancreatic fistula and gland texture or duct size (all p≥0.169) after distal pancreatectomy. Operative approach (minimally invasive versus open) was not associated with pancreatic fistula after distal pancreatectomy (p = 0.626). Patients with pancreatic fistula after distal pancreatectomy had increased rate of postoperative complications including longer length of stay, higher rates of readmission and reoperation compared to patients who did not have a pancreatic fistula (all p<0.001). Unlike among patients who had pancreaticoduodenectomy, pancreatic gland texture and duct size are not associated with development of pancreatic fistula following distal pancreatectomy. Other clinical factors should be considered in this patient population.

Background Despite technical advances, bile leak remains a significant complication after hepatectomy. The current study uses a targeted multi-institutional dataset to characterize perioperative factors that are associated with bile leakage after hepatectomy to better understand the impact of bile leak on morbidity and mortality. Methods Adult patients in the 2014–2015 ACS NSQIP targeted hepatectomy dataset were linked to the ACS NSQIP PUF dataset. Bivariable and multivariable regression analyses were used to assess the associations between clinical factors and post-hepatectomy bile leak. Results Of 6859 patients, 530 (7.7%) had a postoperative bile leak. Proportion of bile leaks was significantly greater in patients after major compared to minor hepatectomy (12.6 vs. 5.1%, p  < 0.001). The proportion of patients with bile leak was significantly greater in patients after major hepatectomy who had concomitant enterohepatic reconstruction (31.8 vs. 10.1%, p  < 0.001). Postoperative mortality was significantly greater in patients with bile leaks (6.0 vs. 1.7%, p < 0.001). After adjusting for significant covariates, bile leak was independently associated with increased risk of postoperative morbidity (OR = 4.55; 95% CI 3.72–5.56; p  < 0.001). After adjusting for significant effects of postoperative complications, liver failure, and reoperation (all p<0.001), bile leak was not independently associated with increased risk of postoperative mortality ( p  = 0.262). Conclusion Major hepatectomy and enterohepatic biliary reconstruction are associated with significantly greater rates of bile leak after liver resection. Bile leak is independently associated with significant postoperative morbidity. Mitigation of bile leak is critical in reducing morbidity and mortality after liver resection.

This study aims to test associations between perioperative blood transfusion and postoperative morbidity and mortality after major abdominal operations. The 2014 ACS NSQIP dataset was queried for all patients who underwent one of the ten major abdominal operations. Separate multivariable regression models, were developed to evaluate the independent effects of perioperative blood transfusion on morbidity and mortality. Of 48,854 patients in the study cohort, 4887 (10%) received a blood transfusion. Rates of transfusion ranged from 4% for laparoscopic gastrointestinal resection to 58% for open AAA. After adjusting for significant effects of NSQIP-estimated probabilities, transfusion was independently associated with morbidity and mortality after open AAA repair (OR = 1.99/14.4 respectively, p ≤ 0.010), esophagectomy (OR = 2.80/3.0, p < 0.001), pancreatectomy (OR = 1.88/3.01, p < 0.001), hepatectomy (OR = 2.82/5.78, p < 0.001), colectomy (OR = 2.15/3.17, p < 0.001), small bowel resection (OR = 2.81/3.83, p ≤ 0.004), and laparoscopic gastrointestinal operations (OR = 2.73/4.05, p < 0.001). Perioperative blood transfusion is independently associated with an increased risk of morbidity and mortality after most major abdominal operations. •Ten percent of patients who have major abdominal operations receive perioperative blood transfusions.•Independent effects of perioperative blood transfusion within 72 h of index operation were evaluated.•Blood transfusion is associated with morbidity after 9 of 10 major abdominal operations studied.•Blood transfusion is associated with mortality after 8 of 10 major abdominal operations studied.

Background While existing risk calculators focus on mortality and complications, elderly patients are concerned with how operations will affect their quality of life, especially their independence. We sought to develop a novel clinically relevant and easy-to-use score to predict elderly patients’ loss of independence after gastrointestinal surgery. Methods This retrospective cohort study included patients age ≥ 65 years enrolled in the American College of Surgeons National Surgical Quality Improvement Program database and Geriatric Pilot Project who underwent pancreatic, colorectal, or hepatic surgery (January 1, 2014- December 31, 2018). Primary outcome was loss of independence – discharge to facility other than home and decline in functional status. Patients from 2014 to 2017 comprised the training data set. A logistic regression (LR) model was generated using variables with p  < 0.2 from the univariable analysis. The six factors most predictive of the outcome composed the short LR model and scoring system. The scoring system was validated with data from 2018. Results Of 6,510 operations, 841 patients (13%) lost independence. Training and validation datasets had 5,232 (80%) and 1,278 (20%) patients, respectively. The six most impactful factors in predicting loss of independence were age, preoperative mobility aid use, American Society of Anesthesiologists classification, preoperative albumin, non-elective surgery, and race (all OR > 1.83; p  < 0.001). The odds ratio of each of these factors were used to create a sixteen-point scoring system. The scoring system demonstrated satisfactory discrimination and calibration across the training and validation datasets, with Receiver Operating Characteristic Area Under the Curve 0.78 in both and Hosmer-Lemeshow statistic of 0.16 and 0.34, respectively. Conclusions This novel scoring system predicts loss of independence for geriatric patients after gastrointestinal operations. Using readily available variables, this tool can be applied in the urgent setting and can contribute to elderly patients and their family discussions related to loss of independence prior to high-risk gastrointestinal operations. The applicability of this scoring tool to additional surgical sub-specialties and external validation should be explored in future studies.

Aim Prior studies have demonstrated a reoperation rate ranging from 5.8 to 7.6% following colorectal surgery. However, the indications for reoperation have not been extensively evaluated. We aimed to describe the indications for reoperation and associated procedures following colorectal resection. Methods This is a retrospective cohort study of all patients undergoing colorectal resection at a single institution from 2003 to 2013. For patients who returned to the operating room, the primary indication was categorized into mutually exclusive categories and all procedures performed within 30 days of the initial operation were indexed. Univariate and multivariate analyses were performed. Results We identified 2793 patients who underwent colorectal operations, of which 407 (14.6%) were emergent. A total of 178 (6.7%) patients returned to the operating room. On multivariate analysis, emergent operation, malnutrition, corticosteroid use, and operative duration were independently associated with reoperation; independent functional status was protective. The most common indications for reoperation were anastomotic leak and bowel obstruction. The most common procedures performed were ostomy creation, bowel resection, and adhesiolysis. Conclusions Reoperation after colorectal surgery is a relatively common occurrence for which we have identified the risk factors, most common indications, and specific procedures performed. This knowledge will help identify areas for improvement.

Letters of recommendation (LOR) are vital to surgical residency applications. Our prior study demonstrated differences in letter content by applicant sex, including more frequent reference to leadership and awards for male applicants. This study evaluates if leadership activities and awards as documented by the applicant's curriculum vitae (CV) corroborate differences noted in corresponding recommendation letters. LORs and CVs for 2016–2017 surgery resident applicants selected for interview at single academic institution were analyzed for documentation of leadership and awards and assessed for concordance. 89 applicant CVs (45 male, 44 female) and 332 LORs (165 male, 167 female) were reviewed for evidence of leadership and awards. While 94 ​% of CVs had evidence of leadership, leadership was referenced in LORs more often for men than women (45 ​% vs 30 ​%, p ​= ​0.004). References to leadership skills (38 ​% vs 21 ​%, p=<0.001), elected/appointed office (33 ​% vs 16 ​%, p ​< ​0.001), and volunteer/work-related leadership role (12 ​% vs 3 ​%, p ​= ​0.001) occurred more commonly for men. Similarly, awards were present in 74 ​% of CVs without difference by sex but referenced more commonly for men compared to women (64 ​% vs 46 ​%, p ​= ​0.001). References to leadership and awards in LORs were more common for men than women applicants, which is not reflective of CV content. Although LOR need not recapitulate CVs, fair appraisal of leadership abilities is encouraged. •Content and language may differ in recommendation letters by applicant sex.•Leadership is a valued trait among applicants to general surgery residency.•Evidence of leadership is common in residency applicant curriculum vita.•Leadership references less frequent in recommendation letters for women applicants.

Procedural checklists may be useful for increasing the reliability of safety-critical processes because of their potential capacity to improve teamwork, situation awareness, and error catching. To test the hypothesized utility and adaptability of checklists to surgical teams, we performed a randomized controlled trial of procedural checklists to determine their capacity to increase the frequency of safety-critical behaviors during 47 laparoscopic cholecystectomies. Ten attending surgeons at an academic tertiary care center were randomized into two equal groups - half of these surgeons received basic team training and used a preprocedural checklist whereas the other half performed standard laparoscopic cholecystectomies. All procedures were videotaped and scored by trained reviewers for the presence of safety-critical behaviors. There were no differences detected in patient outcomes, case times, or technical proficiency between groups. Cases performed by surgeons in the intervention (checklist) group were significantly more likely to involve positive safety-related team behaviors such as case presentations, explicit discussions of roles and responsibilities, contingency planning, equipment checks, and postcase debriefings. Overall, situational awareness did not significantly differ between the intervention and control groups. Participants in the intervention (checklist) group consistently rated their cases as involving less satisfactory subjective levels of comfort, team efficiency, and communication compared with those performed by surgeons in the control group. Surgical procedural safety checklists have the capacity to increase the frequency of positive team behaviors in the operating room during laparoscopic surgery. Adapting to the use of a procedural checklist may be initially uncomfortable for participants.

Liver resection is commonly performed for hepatic tumors, however preoperative risk stratification remains challenging. We evaluated the performance of contemporary prediction models for short-term mortality after liver resection in patients with and without cirrhosis. This retrospective cohort study examined National Surgical Quality Improvement Program data. We included patients who underwent liver resections from 2014 to 2019. VOCAL-Penn, MELD, MELD-Na, ALBI, and Mayo risk scores were evaluated in terms of model discrimination and calibration for 30-day post-operative mortality. A total 15,198 patients underwent liver resection, of whom 249 (1.6%) experienced 30-day post-operative mortality. The VOCAL-Penn score had the highest discrimination (area under the ROC curve [AUC] 0.74) compared to all other models. The VOCAL-Penn score similarly outperformed other models in patients with (AUC 0.70) and without (AUC 0.74) cirrhosis. The VOCAL-Penn score demonstrated superior predictive performance for 30-day post-operative mortality after liver resection as compared to existing clinical standards. •Preoperative risk stratification for liver resection remains a clinical challenge.•In a dataset of patients undergoing liver resection, prediction scores were compared for 30-day postoperative mortality.•The VOCAL-Penn score had superior discrimination and adequate calibration versus MELD, MELD-Na, ALBI, and Mayo risk scores.

There has been tremendous effort to improve quality following colorectal surgery, including the proliferation of minimally invasive techniques, enhanced recovery protocols, and surgical site infection prevention bundles. While these programs have demonstrated improved postoperative outcomes at the institutional level, it is unclear whether similar benefits are present on a national scale. American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Targeted Colectomy data from 2012 to 2020 were used to identify patients undergoing minimally invasive surgery (MIS) or open partial colectomy (CPT 44140, 44204) or low anterior resection (CPT 44145, 44207). Chronological cohorts as well as annual trends in 30-day postoperative outcomes including surgical site infection, venous thromboembolism, and length of stay were assessed using both univariable and multivariable regression analyses. 261,301 patients, 135,876 (52 ​%) female, with a median age of 62 (IQR 53–72) were included. Across all years, MIS partial colectomy was the most common procedure (37 ​%), followed by MIS low anterior resection (27 ​%), open partial colectomy (24 ​%), and open low anterior resection (12 ​%). MIS increased from 59 ​% in 2012–2014 to 66 ​% in 2018–2020 (p ​< ​0.001). During this same period, postoperative length of stay decreased from a median of 5 days (IQR 4–7) in 2012–2014 to 4 days (IQR 3–6) in 2018–2020 (p ​< ​0.001). Superficial surgical site infections decreased from 5.5 ​% in 2012–2014 to 2.9 ​% in 2018–2020 (p ​< ​0.001). Deep surgical site infections similarly decreased from 1.1 ​% to 0.4 ​% between these periods (p ​< ​0.001). Pulmonary embolism also decreased from 0.6 ​% to 0.5 ​% between periods (p ​= ​0.02). 30-day mortality was unchanged at 1.7 ​% between 2012-2014 and 2018–2020 (p ​= ​0.40). After adjustment for ACS NSQIP estimated probability of morbidity and mortality, undergoing a colectomy in 2020 compared to 2012 was associated with a 14 ​% decrease in postoperative length of stay (p ​< ​0.001). Between 2012 and 2020, significant improvements in postoperative outcomes after colectomy were observed in the United States. These results support the positive impact that the widespread adoption of quality improvement initiatives is having on colorectal patient care nationally. •National colectomy outcomes have improved significantly between 2012 and 2020.•Outcome improvements have primarily been in surgical site infections and length of stay.•Use of minimally-invasive colectomy has also increased significantly between 2012 and 2020.

Background Morbidity after gastrectomy remains high. The potentially modifiable risk factors have not been well described. This study considers a series of potentially modifiable patient-specific and perioperative characteristics that could be considered to reduce morbidity and mortality after gastrectomy. Methods This retrospective cohort study includes adults in the ACS NSQIP PUF dataset who underwent gastrectomy between 2011 and 2013. Sequential multivariable models were used to estimate effects of clinical covariates on study outcomes including morbidity, mortality, readmission, and reoperation. Results Three thousand six hundred and seventy-eight patients underwent gastrectomy. A majority of patients had distal gastrectomy ( N  = 2,799, 76.1 %) and had resection for malignancy ( N  = 2,316, 63.0 %). Seven hundred and ninety-eight patients (21.7 %) experienced a major complication. Reoperation was required in 290 patients (7.9 %). Thirty-day mortality was 5.2 %. Age (OR = 1.01, 95 % CI = 1.01–1.02, p  = 0.001), preoperative malnutrition (OR = 1.65, 95 % CI = 1.35–2.02, p  < 0.001), total gastrectomy (OR = 1.63, 95 % CI = 1.31–2.03, p  < 0.001), benign indication for resection (OR = 1.60, 95 % CI = 1.29–1.97, p  < 0.001), blood transfusion (OR = 2.57, 95 % CI = 2.10–3.13, p  < 0.001), and intraoperative placement of a feeding tubes (OR = 1.28, 95 % CI = 1.00–1.62, p  = 0.047) were independently associated with increased risk of morbidity. Association between tobacco use and morbidity was statistically marginal (OR = 1.23, 95 % CI = 0.99–1.53, p  = 0.064). All-cause postoperative morbidity had significant associations with reoperation, readmission, and mortality (all p  < 0.001). Conclusions Mitigation of perioperative risk factors including smoking and malnutrition as well as identified operative considerations may improve outcomes after gastrectomy. Postoperative morbidity has the strongest association with other measures of poor outcome: reoperation, readmission, and mortality.