Publications by authors named "David C Chang"

374 Publications

The Paradoxical Protective Effect of Immigration on Colorectal Cancer Survivals.

J Surg Res 2021 Jul 12;267:586-592. Epub 2021 Jul 12.

Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA. Electronic address:

Background: It is unknown whether the place of birth would affect colon cancer survival.

Methods: An observational study of colon cancer patient data using the SEER database from 1973 to 2010 was performed. Patients with more than one primary cancer in their lifetime or patients who were under age 18 were excluded. The primary outcome was cancer-specific survival. Cox proportional hazards analyses were performed, adjusting for patient demographics and oncological characteristics.

Results: A total of 262,618 colon cancer patients were analyzed, with the majority (86.0%) born in the US. The overall 5-year cancer-specific survival rate was 51.4% and was significantly lower for US-born than non-US born patients (50.4% vs 58.1%). This difference persisted in local/regional disease and in cases with distant metastasis, and across racial groups. On adjusted analysis, US-born patients had worse disease-specific survivals (HR 1.28, 95% CI 1.24-1.33), and this effect persisted in all racial groups except in Asians.

Conclusion: US-born patients have worse survivals than non-US born patients. This is paradoxical given known disparities in quality of care delivered to immigrant populations. It may be useful to consider including geographical histories in patient interviews.
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http://dx.doi.org/10.1016/j.jss.2021.06.005DOI Listing
July 2021

Predictors of Financial Distress Among Private U.S. Hospitals.

J Surg Res 2021 Jun 20;267:251-259. Epub 2021 Jun 20.

Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA. Electronic address:

Background: Hospitals are closing after poor financial performance leaving many patients without access to medical care. Identifying the factors associated with financial distress offers hospitals avenues for potential intervention to avoid bankruptcy and closure.

Materials And Methods: We performed a retrospective analysis of private U.S. hospitals' financial information from 2011 to 2018. A mixed effects logistic regression model was used with the primary outcome of hospital financial distress (based on the Altman Z-score).

Results: Our sample included 2,720 private hospitals contributing a total of 20,022 hospital-year observations. The proportion of hospitals experiencing financial distress each year ranged from 22.0% to 24.3%. For-profit status was associated with an increased odds of financial distress (adjusted odds ratio (aOR), 4.36 [95% Confidence Interval (CI) 3.05 - 6.24]) as compared to non-profit status. A higher share of hospital revenue from Medicaid was also associated with increased odds of financial distress (aOR for the highest quartile, 2.28 [95% CI 1.73 - 3.00]) as compared to the lowest quartile. A higher case mix index (aOR for the highest quartile, 0.32 [95% CI 0.23 - 0.46]) and an increased share of hospital revenue from outpatient services (aOR for the highest quartile, 0.34 [95% CI 0.23 - 0.49]) were associated with decreased odds of financial distress as compared to their respective lowest quartiles.

Conclusions: A significant proportion of private U.S. hospitals experience financial distress. Increasing case complexity and the proportion of patient revenue from outpatient services may represent avenues to avoid financial distress.
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http://dx.doi.org/10.1016/j.jss.2021.05.025DOI Listing
June 2021

Should all patients receive the same prophylaxis? Racial variation in the risk of venous thromboembolism after major abdominal operations.

Am J Surg 2021 Jun 10. Epub 2021 Jun 10.

Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, 55 Fruit Street, Boston, MA, USA; Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, MA, 165 Cambridge St, Suite 403, USA. Electronic address:

Background: Whether prevention strategy for postoperative venous thromboembolism (VTE) should be tailored across racial groups remains unknown.

Methods: Patients who underwent major abdominal operation in the Nationwide Inpatient Sample (NIS) were examined. Our primary outcome was postoperative VTE, and the secondary outcome was postoperative bleeding. Multivariable logistic regression analyses were performed and validated with the National Surgical Quality Improvement Program (NSQIP) database.

Results: 781,888 patients from NIS were analyzed. Overall VTE rate was 2.0%. Compared to White patients, Hispanic (OR 0.85, 95% CI 0.78-0.93, p < 0.01) and Asian patients (OR 0.49, 95% CI 0.40-0.61, p < 0.01) had significantly lower risks for VTE. In contrast, Asian patients had a significantly higher risk of bleeding (OR 1.39, 95% CI 1.24-1.56, p < 0.01). Similar trends were observed in NSQIP.

Conclusions: The risk-benefit ratio of postoperative VTE prophylaxis for Asian patients is roughly three times higher than that for White patients, suggesting a tailored approach is necessary.
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http://dx.doi.org/10.1016/j.amjsurg.2021.05.020DOI Listing
June 2021

Risk factors for recurrent spontaneous pneumothorax: A population level analysis.

Am J Surg 2021 Jun 10. Epub 2021 Jun 10.

Division of Thoracic Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, USA.

Background: We sought to determine the rate and risk factors of recurrent spontaneous pneumothorax in a diverse population.

Methods: Cohort study using the California Public Discharge Data file (1995-2010). We identified patients with first-time spontaneous pneumothorax. The primary outcome was recurrent pneumothorax. Associations with clinical, patient, and hospital characteristics were assessed using Cox regression analysis.

Results: Among 14,609 patients with a first-time episode of spontaneous pneumothorax, 26.2% developed a recurrence. Risk factors included age <35 (Hazard Ratio [HR] 1.24 95%-Confidence Interval [CI] 1.14-1.36), Asian race (HR 1.24, CI 1.13-1.37), and tube thoracostomy (HR 1.2, CI 1.15-1.31). Mechancial pleurodesis (HR 0.37 CI 0.31-0.45) was superior to chemical pleurodesis (HR 0.71 CI 0.58-0.86) in reducing recurrence risk.

Conclusions: The risk of recurrent pneumothorax is greatest in patients age <35, Asians, and those requiring a tube thoracostomy. The risks of operative intervention should be balanced against patient risk for recurrence.
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http://dx.doi.org/10.1016/j.amjsurg.2021.05.017DOI Listing
June 2021

The Resident-Run Minor Surgery Clinic: A Four-Year Analysis of Patient Outcomes, Satisfaction, and Resident Education.

J Surg Educ 2021 Jun 3. Epub 2021 Jun 3.

Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts. Electronic address:

Objective: A resident-run minor surgery clinic was developed to increase resident procedural autonomy. We evaluated whether 1) there was a significant difference between complications and patient satisfaction when procedures were independently performed by surgical residents vs. a surgical attending and 2) if participation was associated with an increase in resident procedural confidence.

Design: Third year general surgery residents participated in a weekly procedure clinic from 2014-2018. Post-procedure complications and patient satisfaction were compared between patients operated on by residents vs. the staff surgeon. Residents were surveyed regarding their confidence in independently performing a variety of clinic-based patient care tasks.

Setting: Massachusetts General Hospital General in Boston, MA; an academic tertiary care general surgery residency program.

Participants: Post-graduate year three general surgery residents that ran the clinic as part of a general surgery rotation.

Results: 1230 patients underwent 1592 procedures (612 in resident clinic, 980 in attending clinic). There was no significant difference in the 30-day complication rate between patients operated on by the resident vs. attending (2.5% vs. 1.9%, p = 0.49). 459 patient satisfaction surveys were administered with a 79.1% response rate. There was no significant difference in the overall quality of care rating between residents and the attending surgeon (87.5% top-box rating vs. 93.1%, p = 0.15). Twenty-one residents completed both a pre- and post-rotation survey (77.8% response rate). The proportion of residents indicating that they could independently perform a variety of patient care tasks significantly increased across the rotation (all p < 0.05).

Conclusion: Mid-level general surgery residents can independently perform office-based procedures without detriment to safety or patient satisfaction. The resident-run procedure clinic serves as an environment for residents to grow in confidence in both technical and non-technical skills. Given the high rate at which patients provide resident feedback, future work may investigate how to best incorporate patient derived evaluations into resident assessment.
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http://dx.doi.org/10.1016/j.jsurg.2021.04.003DOI Listing
June 2021

Response to: Comment on "Underemployment of Female Surgeons" The Global Challenge of Unequal Work Opportunities for Women in Surgery.

Ann Surg 2021 May 19. Epub 2021 May 19.

Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, MA 165 Cambridge St, Suite 403, Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, MA Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, MA 165 Cambridge St, Suite 403, Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, MA Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, MA.

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http://dx.doi.org/10.1097/SLA.0000000000004943DOI Listing
May 2021

Residential Segregation and Healthcare Segregation: Separate but not Equal.

Ann Surg 2021 Mar 29. Epub 2021 Mar 29.

Department of Surgery, Massachusetts General Hospital, Harvard Medical School.

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http://dx.doi.org/10.1097/SLA.0000000000004864DOI Listing
March 2021

Residential Segregation and Health Care Segregation: Separate But Not Equal.

Ann Surg 2021 06;273(6):1031-1033

Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA.

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http://dx.doi.org/10.1097/SLA.0000000000004864DOI Listing
June 2021

Nonoperative Management for Pregnant Individuals With Gallstone Disease in the Third Trimester.

JAMA Surg 2021 Apr 28. Epub 2021 Apr 28.

Department of Surgery, Washington University in St Louis, St Louis, Missouri.

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http://dx.doi.org/10.1001/jamasurg.2021.0637DOI Listing
April 2021

Contribution of unequal new patient referrals to female surgeon under-employment.

Am J Surg 2021 Mar 2. Epub 2021 Mar 2.

Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, 165 Cambridge Street, Suite 403, Boston, MA, USA. Electronic address:

Background: The literature shows that female surgeons have lower operative volumes than male surgeons. Since volume is dependent on new patient referrals for most surgeons, inequities in referrals may contribute to this employment disparity.

Methods: Using 1997-2018 data from a large medical center, we examined the number of new patient referrals for surgeons. Multivariate linear analysis was performed, adjusting for surgeon race, calendar year, seniority, and clinical subspecialty.

Results: A total of 121 surgeons across 12,410 surgeon-months were included. Overall, surgeons had a median of 14 new patient referrals per month (interquartile range (IQR) = 7, 27). On adjusted analysis, female surgeons saw 5.4 fewer new patient referrals per month (95% CI -6.4 to -4.5).

Conclusion: Female surgeons, with equal training and seniority, received fewer new patient referrals than their male peers, and this may contribute to female surgeon under-employment. Surgeon gender may be one of the factors contributing to this differential referral pattern.
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http://dx.doi.org/10.1016/j.amjsurg.2021.02.028DOI Listing
March 2021

Practitioner availability rather than surgical quality impacts the utilization of liver transplantation for hepatocellular carcinoma.

HPB (Oxford) 2021 Jun 21;23(6):861-867. Epub 2021 Jan 21.

Department of Surgery, Massachusetts General Hospital/Harvard Medical, Boston, MA, USA.

Background: Liver transplantation (LT) provides better outcome than surgical resection (SR) although both are acceptable surgical options for hepatocellular carcinoma (HCC). It is unclear whether non-clinical factors drive treatment decisions. Our goal is to identify factors that may affect treatment decisions.

Methods: Patients aged 18-74 with T2 HCC undergoing either LT or SR in Surveillance, Epidemiology, and End Results Database from 2004 to 2014 were included. Healthcare resources data were analyzed to assess factors that predict utilization of LT versus SR, adjusted for demographic, clinical outcomes, and socioeconomic factors.

Results: 51% of patients (Total N = 2616) received LT, with a substantial state-level variation in LT rates (0.0%-66.9%). Higher LT center density [OR = 1.04 per 1% increment, P < 0.01], male gender (OR = 1.38, P = 0.02), and numbers of potential donors (OR = 1.19, P = 0.03) were positively associated with LT utilization. Conversely, higher incidence of chronic liver disease/cirrhosis (OR = 0.41 per one additional case per 100,000 populations, P = 0.001) and minority populations were negatively correlated with LT utilization. Notably, short-term surgical outcomes (in-hospital LT & SR mortality) were not associated with LT utilization.

Conclusion: Liver transplant center density and organ availability, but not surgical outcomes, affect utilization of LT. Future studies should focus on increasing availability of resources.
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http://dx.doi.org/10.1016/j.hpb.2020.12.012DOI Listing
June 2021

Open hepatic resection in the elderly at two tertiary referral centers.

Am J Surg 2021 Jan 21. Epub 2021 Jan 21.

Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. Electronic address:

Background: Surgeons are being increasingly called upon to operate on the very elderly. This study aimed to evaluate outcomes following hepatectomy in patients ≥80 years of age at two tertiary care centers.

Methods: All adult patients who underwent liver resection from 2001 to 2017 were included. Primary outcome was 90-day postoperative mortality. Secondary outcomes included 30-day postoperative mortality and postoperative complications.

Results: Between 2001 and 2017, 2397 patients underwent liver resection. On unadjusted analysis, patients ≥80 years of age had higher rates of 90-day mortality (13.3% vs. 3.6%, p < 0.001), 30-day mortality (5.6% vs. 1.8%, p = 0.01), MI (7.9% vs. 3.5%, p = 0.04), and UTI (10.0% vs. 4.5%, p = 0.02). On multivariable analysis, age ≥80 years was significantly associated with 90-day postoperative mortality (OR 4.51, 95%CI 2.11-9.67, p < 0.001).

Conclusions: Across these two major referral tertiary care centers, very elderly patients had higher rates of 90-day and 30-day postoperative mortality on both unadjusted and adjusted analyses.
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http://dx.doi.org/10.1016/j.amjsurg.2021.01.024DOI Listing
January 2021

In Response.

Anesth Analg 2021 02;132(2):e26-e27

Department of Anesthesiology, University of Virginia, Charlottesville, Virginia.

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http://dx.doi.org/10.1213/ANE.0000000000004910DOI Listing
February 2021

Patient and Caregiver Considerations and Priorities When Selecting Hospitals for Complex Cancer Care.

Ann Surg Oncol 2021 Aug 7;28(8):4183-4192. Epub 2021 Jan 7.

Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA.

Background: Healthcare policies have focused on centralizing care to high-volume centers in an effort to optimize patient outcomes; however, little is known about patients' and caregivers' considerations and selection process when selecting hospitals for care. We aim to explore how patients and caregivers select hospitals for complex cancer care and to develop a taxonomy for their selection considerations.

Methods: This was a qualitative study in which data were gathered from in-depth interviews conducted from March to November 2019 among patients with hepatopancreatobiliary cancers who were scheduled to undergo a pancreatectomy (n = 20) at a metropolitan, urban regional, or suburban medical center and their caregivers (n = 10).

Results: The interviews revealed six broad domains that characterized hospital selection considerations: hospital factors, team characteristics, travel distance to hospital, referral or recommendation, continuity of care, and insurance considerations. The identified domains were similar between participants seen at the metropolitan center and urban/suburban medical centers, with the following exceptions: participants receiving care specifically at the metropolitan center noted operative volume and access to specific services such as clinical trials in their hospital selection; participants receiving care at urban/suburban centers noted health insurance considerations and having access to existing medical records in their hospital selection.

Conclusions: This study delineates the many considerations of patients and caregivers when selecting hospitals for complex cancer care. These identified domains should be incorporated into the development and implementation of centralization policies to help increase patient access to high-quality cancer care that is consistent with their priorities and needs.
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http://dx.doi.org/10.1245/s10434-020-09506-2DOI Listing
August 2021

Impact of Obesity on Treatment Approach for Resectable Esophageal Cancer.

Ann Thorac Surg 2020 Dec 17. Epub 2020 Dec 17.

Division of Thoracic Surgery, Massachusetts General Hospital, 55 Fruit Street, Founders 7, Boston, Massachusetts 02114. Electronic address:

Background: With the prevalence of obesity and its known association with esophageal cancer, there is increasing need to understand how obesity affects treatment.

Methods: Using the Society of Thoracic Surgeons General Thoracic Surgery Database, we retrospectively evaluated all patients who underwent esophagectomy with gastric conduit reconstruction between 2012 and 2016. Patients were categorized into five body mass index (BMI) groups. Associations between BMI and surgical technique, resection, lymphadenectomy, staging, and neoadjuvant treatment were evaluated using multivariable logistic regression models.

Results: 8,547 patients were included in the analysis. Obese and morbidly obese patients were more likely to undergo open procedures compared to normal weight patients (OR=1.18, p=0.016 and OR=1.45, p=0.007), with longer operative times. Morbidly obese patients had a higher rate of intraoperative conversion from minimally invasive to open approaches (OR=3.75, p=0.001). There were no differences in R0 resection or lymphadenectomy, and staging workup was similar. Obese patients were less likely to receive neoadjuvant therapy (OR=0.75, p=0.048), and overweight and obese patients were less likely to receive preoperative radiation (OR=0.75, p=0.017 and OR=0.71, p=0.010). Analyzing by stage, overweight and obese patients with cT2N0 disease were less likely to receive neoadjuvant treatment (OR=0.54, p=0.016 and OR=0.37, p<0.001). There were no differences in neoadjuvant therapy for cT3 or node-positive disease.

Conclusions: Higher BMI is associated with increased use of open versus minimally invasive esophagectomy and intraoperative conversion. While staging workup and oncologic outcomes of surgery are similar, overweight and obese patients with cT2N0 disease are less likely to undergo neoadjuvant treatments.
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http://dx.doi.org/10.1016/j.athoracsur.2020.12.002DOI Listing
December 2020

Use of noninvasive scores for advanced liver fibrosis can guide the need for hepatic biopsy during bariatric procedures.

Surg Obes Relat Dis 2021 Feb 8;17(2):292-298. Epub 2020 Oct 8.

Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.

Background: Patients with obesity are at increased risk for nonalcoholic fatty liver disease (NAFLD). The effectiveness of noninvasive screening tests for ruling out advanced fibrosis (stage 3-4) is unknown.

Objectives: To determine the prevalence of advanced fibrosis in patients undergoing routine liver biopsy during bariatric surgery and assess the effectiveness of existing noninvasive risk calculators.

Setting: Academic medical center in the United States.

Methods: Routine liver biopsies were obtained during first-time bariatric surgery (January 2001-December 2017). Patient demographic characteristics, co-morbidities, and preoperative laboratory values were compiled. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were compared between 3 noninvasive risk calculators for advanced fibrosis: the fibrosis-4 index, NAFLD fibrosis score, and aminotransferase-to-platelet ratio index (APRI).

Results: Among 2465 patients, the prevalence of advanced fibrosis (stage 3-4) was 3.4%. The mean age was 45.5 years, and the mean body mass index was 46.8. The sensitivity of noninvasive risk calculators ranged from 85% (NAFLD fibrosis score) to 24% (APRI). The NAFLD fibrosis score performed best in screening out advanced fibrosis, with an NPV of 99%. The PPV ranged from 9% to 65%. In this study cohort, the use of the NALFD fibrosis score correctly ruled out advanced fibrosis in 893 (36%) patients, with 13 false negatives.

Conclusions: The prevalence of advanced fibrosis in individuals undergoing routine first-time bariatric procedures is 3.4%. Use of the NALFD fibrosis score can rule out advanced fibrosis in one-third of this population, and guide surgical decision-making.
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http://dx.doi.org/10.1016/j.soard.2020.09.037DOI Listing
February 2021

Racially Conscious Cancer Screening Guidelines: A Path Towards Culturally Competent Science.

Ann Surg 2020 May 19. Epub 2020 May 19.

*Massachusetts General Hospital, Department of Surgery, Boston, Massachusetts †Massachusetts General Hospital, Healthcare Transformation Lab, Boston, Massachusetts ‡Massachusetts General Hospital, Codman Center for Clinical Effectiveness in Surgery, Boston, Massachusetts §Harvard Medical School, Boston, Massachusetts.

Objective: To review the racial composition of the study populations that the current USPSTF screening guidelines for lung, breast, and colorectal cancer are based on, and the effects of their application across non-white individuals.

Summary Of Background Data: USPSTF guidelines commonly become the basis for establishing standards of care, yet providers are often unaware of the racial composition of the study populations they are based on.

Methods: We accessed the USPSTF screening guidelines for lung, breast, and colorectal cancer via their website, and reviewed all referenced publications for randomized controlled trials (RCTs), focusing on the racial composition of their study populations. We then used PubMed to identify publications addressing the generalizability of such guidelines across non-white individuals. Lastly, we reviewed all guidelines published by non-USPSTF organizations to identify the availability of race-specific recommendations.

Results: Most RCTs used as basis for the current USPSTF guidelines either did not report race, or enrolled cohorts that were not representative of the U.S.

Population: Several studies were identified demonstrating the broad application of such guidelines across non-white individuals can lead to underdiagnosis and higher levels of advanced disease. Nearly all guideline-issuing bodies fail to provide race-specific recommendations, despite often acknowledging increased disease burden among non-whites.

Conclusion: Concerted efforts to overcome limitations in the generalizability of RCTs are required to provide screening guidelines that are truly applicable to non-white populations. Broader policy changes to improve the pipeline for minority populations into science and medicine are needed to address the ongoing lack of diversity in these fields.
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http://dx.doi.org/10.1097/SLA.0000000000003983DOI Listing
May 2020

Open innovation facilitates department-wide engagement in quality improvement: experience from the Massachusetts General Hospital.

Surg Endosc 2020 Oct 8. Epub 2020 Oct 8.

Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Background: Quality improvement (QI) initiatives commonly originate 'top-down' from senior leadership, as staff engagement is often sporadic. We describe our experience with a technology-enabled open innovation contest to encourage participation from multiple stakeholders in a Department of Surgery (DoS) to solicit ideas for QI. We aimed to stimulate engagement and to assist DoS leadership in prioritizing QI initiatives.

Methods: Observational study of a process improvement. The process had five phases: anonymous online submission of ideas by frontline staff; anonymous online crowd-voting to rank ideas on a scale whether the DoS should implement each idea (1 = No, 3 = Maybe, 5 = Yes); ideas with scores ≥ 95th percentile were invited to submit implementation plans; plans were reviewed by a multi-disciplinary panel to select a winning idea; an award ceremony celebrated the completion of the contest.

Results: 152 ideas were submitted from 95 staff (n = 850, 11.2%). All Divisions (n = 12) and all staff roles (n = 12) submitted ideas. The greatest number of ideas were submitted by faculty (27.6%), patient service coordinators (18.4%), and residents (17.8%). The most common QI category was access to care (20%). 195 staff (22.9%) cast 3559 votes. The mean score was 3.5 ± 0.5. 10 Ideas were objectively invited to submit implementation plans. One idea was awarded a grand prize of funding, project management, and leadership buy-in.

Conclusion: A web-enabled open innovation contest was successful in engaging faculty, residents, and other critical role groups in QI. It also enabled the leadership to re-affirm a positive culture of inclusivity, maintain an open-door policy, and also democratically vet and prioritize solutions for quality improvement.
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http://dx.doi.org/10.1007/s00464-020-08028-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8026763PMC
October 2020

A Claims Based Assessment of Reoperation and Acute Urinary Retention after Ambulatory Transurethral Surgery for Benign Prostatic Hyperplasia.

J Urol 2021 02 7;205(2):532-538. Epub 2020 Oct 7.

Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Purpose: We evaluated real-world use of common transurethral prostate procedures in the ambulatory surgical setting and compare subsequent rates of tr!eatment failure.

Materials And Methods: Using the New York Statewide Planning and Research Cooperative System database we identified men 40 years old or older undergoing ambulatory surgeries categorized as transurethral resection of the prostate, photoselective vaporization of the prostate, endoscopic enucleation or other (transurethral incision, microwave/radiofrequency ablation) from 2010 to 2016. Multivariate Cox proportional hazards regression was used to predict treatment failure, defined as reoperation or postoperative acute urinary retention greater than 30 days after procedure.

Results: We identified 15,982 men, median age 69 years (IQR 63-76), 61% of whom underwent photoselective vaporization of the prostate, 36% transurethral resection of the prostate, 1.5% endoscopic enucleation and 1.5% other transurethral prostate procedures from 2010 to 2016. At 7 years cumulative failure rates were 15.3% (transurethral resection of the prostate), 13.9% (photoselective vaporization of the prostate), 6.7% (endoscopic enucleation) and 17.8% (other procedures). Compared to transurethral resection of the prostate, photoselective vaporization of the prostate was not associated with increased hazards of treatment failure HR 1.07 (95% CI 0.93-1.22). Compared to transurethral resection of the prostate, endoscopic enucleation was associated with a nonsignificant trend toward lower treatment failure (HR 0.67, 95% CI 0.36-1.22), while other surgical modalities were associated with significantly higher treatment failure (HR 1.68. 95% CI 1.12-2.52). Among men treated from 2011 to 2012, endoscopic enucleations were associated with significantly lower failure than transurethral resection of the prostate (HR: 0.24, 95% CI 0.06-0.97).

Conclusions: Supporting the generalizability of previous randomized trial findings, in real-world practice we found no differences in treatment failure up to 7 years after photoselective vaporization of the prostate or transurethral resection of the prostate. By comparison, endoscopic enucleation, although underused, may be associated with lower rates of treatment failure than transurethral resection of the prostate.
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http://dx.doi.org/10.1097/JU.0000000000001390DOI Listing
February 2021

Underemployment of Female Surgeons?

Ann Surg 2021 02;273(2):197-201

Department of Surgery, Massachusetts General Hospital/ Harvard Medical School, Boston, MA.

Objective: To compare the complexity of operations performed by female versus male surgeons.

Background: Prior literature has suggested that female surgeons are relatively underemployed when compared to male surgeons, with regards to operative case volume and specialization.

Methods: Operative case records from a large academic medical center from 1997 to 2018 were evaluated. The primary end point was work relative value unit (wRVU) for each case with a secondary end point of total wRVU per month for each surgeon. Multivariate linear analysis was performed, adjusting for surgeon race, calendar year, seniority, and clinical subspecialty.

Results: A total of 551,047 records were analyzed, from 131 surgeons and 13,666 surgeon-months. Among them, 104,424 (19.0%) of cases were performed by female surgeons, who make up 20.6% (n = 27) of the surgeon population, and 2879 (21.1%) of the surgeon months. On adjusted analysis, male surgeons earned an additional 1.65 wRVU per case, compared to female surgeons (95% confidence interval 1.57-1.74). Subset analyses found that sex disparity increased with surgeon seniority, and did not improve over the 20-year study period.

Conclusions: Female surgeons perform less complex cases than their male peers, even after accounting for subspecialty and seniority. These sex differences are not due to availability from competing professional or familial obligations. Future work should focus on determining the cause and mitigating this underemployment of female surgeons.
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http://dx.doi.org/10.1097/SLA.0000000000004497DOI Listing
February 2021

Viability testing of discarded livers with normothermic machine perfusion: Alleviating the organ shortage outweighs the cost.

Clin Transplant 2020 11 23;34(11):e14069. Epub 2020 Sep 23.

Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.

Background: Over 700 donor livers are discarded annually in the United States due to high risk of poor graft function. The objective of this study was to determine the impact of using normothermic machine perfusion to identify transplantable livers among those currently discarded.

Study Design: A series of 21 discarded human livers underwent viability assessment during normothermic machine perfusion. Cross-sectional analysis of the Scientific Registry of Transplant Recipients database and cost analysis was performed to extrapolate the case series to national experience.

Results: 21 discarded human livers were included in the perfusion cohort. 11 of 20 (55%) eligible grafts met viability criteria for transplantation. Grafts in the perfusion cohort had a similar donor risk index compared with discarded grafts (n = 1402) outside of New England in 2017 and 2018 (median [IQR]: 2.0 [1.5, 2.4] vs. 2.0 [1.7, 2.3], P = .40). 705 (IQR 677-741) livers were discarded annually in the United States since 2005, translating to the potential for 398 additional transplants nationally. The median cost to identify a transplantable graft with machine perfusion was $28,099 USD.

Conclusions: Normothermic machine perfusion of discarded livers could identify a significant number of transplantable grafts, significantly improving access to liver transplantation.
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http://dx.doi.org/10.1111/ctr.14069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944462PMC
November 2020

Concordance of Clinical and Pathologic Nodal Staging in Resectable Lung Cancer.

Ann Thorac Surg 2021 04 25;111(4):1125-1132. Epub 2020 Aug 25.

Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts.

Background: Clinical staging of lung cancer may not reliably predict nodal disease, and its accuracy in The Society of Thoracic Surgeons General Thoracic Surgery Database is not described.

Methods: Among anatomic pulmonary resections for stages I to III lung cancer with complete clinical and pathologic staging (2012-2017), the accuracy of invasive mediastinal staging (IMS) was compared with noninvasive mediastinal staging only. Accuracy, defined as concordance between clinical and pathologic nodal status, was examined using logistic regression to determine factors associated with clinical nodal (cN) accuracy. Variation in accuracy across centers was recorded and categorized.

Results: We included 39,516 patients with stages I to III pulmonary cancer (adenocarcinoma, 66%; squamous, 23%; neuroendocrine, 5%; mixed, 3.3%; other, 2.4%), of whom 90.4% had cN0 disease. IMS was performed in 32.4%. The IMS group had more central tumors (14.8% vs 6.0%, P < .001) and cN1-2 (15.7% vs 6.8%, P < .001). Nodal accuracy was 79.8%. Although IMS had a lower nodal accuracy for cN0-2 disease (74.6% vs 82.6%, P < .001), IMS had higher accuracy when comparing patients with cN1-2 disease (53.9% vs 46.9%, P < .001). In multivariable analysis central tumors (odds ratio, 0.47; 95% confidence interval, 0.43-0.51) and >cN0 disease (odds ratio, 0.25; 95% confidence interval, 0.22-0.29) were associated with lower accuracy. Accuracy of IMS in the top 20 centers was 94.4% and in the bottom 20, 70.9%.

Conclusions: Staging accuracy in lung cancers selected for initial resection declines with >cN0 and central tumors. Noninvasive staging in tumors without cN involvement misses nearly 20% of cN1-2. Center-specific accuracy is a target for quality improvement.
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http://dx.doi.org/10.1016/j.athoracsur.2020.06.060DOI Listing
April 2021

Response: The Proliferation and Misinterpretation of "As Safe As" Statements in Surgical Science: A Call for Professional Discourse to Search for a Solution.

J Surg Res 2021 03 20;259:A12-A15. Epub 2020 Aug 20.

Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1016/j.jss.2020.03.074DOI Listing
March 2021

Relationship Between Diverticular Disease and Incisional Hernia After Elective Colectomy: a Population-Based Study.

J Gastrointest Surg 2021 05 3;25(5):1297-1306. Epub 2020 Aug 3.

Department of Surgery, Massachusetts General Hospital, 55 Fruit St, GRB-425, Boston, MA, 02114, USA.

Background: Recent genetic studies identified common mutations between diverticular disease and connective tissue disorders, some of which are associated with abdominal wall hernias. Scarce data exists, however, shedding light on the potential clinical implications of this shared etiology, particularly in the era of laparoscopic surgery.

Methods: The New York Statewide Planning and Research Cooperative System database was used to identify adult patients undergoing elective sigmoid and left hemicolectomy (open or laparoscopic) from January 1, 2010, to December 31, 2016, for diverticulitis or descending/sigmoid colon cancer. The incidences of incisional hernia diagnosis and repair were compared using competing risks regression models, clustered by surgeon and adjusted for a host of demographic/clinical variables. Subsequent abdominal surgery and death were considered competing risks.

Results: Among 8279 patients included in the study cohort, 6811 (82.2%) underwent colectomy for diverticulitis and 1468 (17.8%) for colon cancer. The overall 5-year risk of incisional hernia was 3.5% among patients with colon cancer, regardless of colectomy route, which was significantly lower than that among diverticulitis patients after both open (10.7%; p < 0.001) and laparoscopic (7.2%; p = 0.007) colectomies. Multivariable analyses demonstrated that patients with diverticulitis experienced a two-fold increase in the risk for hernia diagnosis (aHR 1.8; p < 0.001) and repair (aHR 2.1; p < 0.001), and these findings persisted after stratification by colectomy route.

Conclusions: Patients undergoing elective colectomy for diverticulitis, including via laparoscopic approach, experience higher rates of incisional hernia compared with patients undergoing similar resections for colon cancer. When performing resections for diverticulitis, surgeons should strongly consider adherence to evidence-based guidelines for fascial closure to prevent this important complication.
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http://dx.doi.org/10.1007/s11605-020-04762-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7854815PMC
May 2021

Operating Room Times For Teaching and Nonteaching Cases are Converging: Less Time for Learning?

J Surg Educ 2021 Jan-Feb;78(1):148-159. Epub 2020 Aug 1.

Department of Surgery, University of Michigan, Ann Arbor, Michigan. Electronic address:

Objective: To compare differences in operating room (OR) times between teaching and nonteaching cases across calendar years. We hypothesize that time devoted to intraoperative resident education is decreasing, therefore, OR times for teaching and nonteaching cases will be converging.

Background: Teaching cases take longer than similar nonteaching cases, in part due to intraoperative resident education. Pressures to improve OR efficiency and patient safety may threaten resident education and leave less time for intraoperative learning; however, the magnitude of impact is unknown.

Setting/participants: National Surgical Quality Improvement Program (NSQIP) deidentified national databases from 2006 to 2012, queried for 30 most common General surgery procedures and case teaching status (i.e., teaching vs. nonteaching cases).

Design: The NSQIP database was retrospectively reviewed to identify the 30 most common General Surgery procedures. Teaching cases included all operations in which a resident participated. Multivariable regression analyses were constructed to determine the impact of resident involvement on OR times, controlling for year, resident participation, procedure, and patient demographics and comorbidities. Difference-in-difference analysis was performed to assess OR time differences between teaching and nonteaching cases across calendar years and within subpopulations.

Results: A total of 693,223 cases met inclusion criteria. Average overall OR times were 98.89 minutes (teaching) vs. 74.22 minutes (nonteaching), with a difference of 24.67 minutes (95% confidence interval [CI] 24.34-24.99 minutes, p < 0.001). In multivariable analyses, the difference between teaching and nonteaching cases was 21.94 minutes (95% CI = 21.11-22.76) in 2006 and 13.95 minutes (95% CI = 10.62-17.28) in 2012, with a difference-in-difference of 7.99 minutes per case. A similar trend was observed across individual PGYs and several individual procedures.

Conclusions: OR times for teaching and nonteaching cases converged by approximately 8 minutes per general surgery procedure during the 7-year study period, representing a 36% reduction in the difference between groups. We must seek to better understand the source of this convergence, and in doing so ensure to preserve and enhance the intraoperative learning experience of surgical trainees.
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http://dx.doi.org/10.1016/j.jsurg.2020.06.029DOI Listing
June 2021

Emergency Resuscitative Thoracotomy: A Nationwide Analysis of Outcomes and Predictors of Futility.

J Surg Res 2020 11 1;255:486-494. Epub 2020 Jul 1.

Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts. Electronic address:

Background: Most studies on emergency resuscitative thoracotomy (ERT) suffer from either small sample size or unclear inclusion criteria. We sought to assess ERT outcomes and predictors of futility using a nationwide database.

Methods: Using a novel and comprehensive algorithm of combinations of specific International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision procedure codes denoting the multiple steps of an ERT (e.g., thoracotomy, pericardiotomy, cardiac massage) performed within the first 60 min of patient arrival, we identified ERT patients in the 2010-2016 Trauma Quality Improvement Program database. We defined the primary outcome as survival to discharge and the secondary outcomes as hospital length of stay (LOS), intensive care unit LOS, number of complications, and discharge destination. Univariate then backward stepwise multivariable logistic regression analyses were performed to assess independent predictors of mortality. Multiple imputations by chained equations were performed when appropriate, as additional sensitivity analyses.

Results: Of 1,403,470 patients, 2012 patients were included. The median age was 32, 84.0% were males, 66.7% had penetrating trauma, the median Injury Severity Score was 26, and 87.5% presented with signs of life (SOL). Of the 1343 patients with penetrating injury, 72.9% had gunshot wounds and 27.1% had stab wounds. The overall survival rate was 19.9%: 26.0% in penetrating trauma (stab wound 45.6% versus gunshot wound 18.7%; P < 0.001) and 7.6% in blunt trauma. Independent predictors of mortality were aged 60 y and older (odds ratio, 2.71; 95% confidence interval [95% CI], 1.26-5.82; P = 0.011), blunt trauma (odds ratio, 4.03; 95% CI, 2.72-5.98; P < 0.001), prehospital pulse <60 bpm (odds ratio, 3.43; 95% CI, 1.73-6.79; P < 0.001), emergency department pulse <60 bpm (odds ratio, 4.70; 95% CI, 2.47-8.94; P < 0.001), and no SOL on emergency department arrival (odds ratio, 3.64; 95% CI, 1.08-12.24; P = 0.037). Blunt trauma was associated with a higher median hospital LOS compared with penetrating trauma (28 d versus 13 d; P < 0.001), higher median intensive care unit LOS (19 d versus 6 d; P < 0.001), higher median number of complications (2 versus 1; P = 0.006), and more likelihood to be discharged to a rehabilitation facility instead of home (72.6% versus 28.7%; P < 0.001). ERT had the highest survival rates in patients younger than 60 y who present with SOL after penetrating trauma. None of the patients with blunt trauma who presented with no SOL survived.

Conclusions: The survival rates of patients after ERT in recent years are higher than classically reported, even in the patient with blunt trauma. However, ERT remains futile in patients with a blunt trauma presenting with no SOL.
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http://dx.doi.org/10.1016/j.jss.2020.05.048DOI Listing
November 2020

Impact of Adding Carotid Endarterectomy to Supra-aortic Trunk Surgical Reconstruction.

Ann Vasc Surg 2020 Nov 26;69:27-33. Epub 2020 Jun 26.

Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA. Electronic address:

Background: Up to 20% of patients requiring open supra-aortic trunk (SAT) reconstruction have significant carotid artery stenosis. The addition of carotid endarterectomy (CEA) to SAT has been described. Yet, additive risks are not well defined and controversy remains as to whether concomitant CEA increases stroke risk. This study assessed the perioperative effects of adding CEA to SAT.

Methods: Using the National Surgical Quality Improvement Program (NSQIP), patients who underwent SAT from 2005 to 2015 were evaluated. SAT + CEA were identified. An isolated SAT (ISAT) cohort was created by removing patients who underwent concurrent secondary procedures. Nonocclusive indications were excluded. SAT + CEA were compared with ISAT as well as a propensity-matched ISAT cohort. Primary outcomes were 30-day stroke, death, and composite stroke/death/myocardial infarction (SDM). Univariate and logistic regression analyses were performed.

Results: After review, 1,515 patients were identified: 1,245 ISAT (82%) and 270 SAT + CEA (18%). Most were women (56%), 86% were Caucasian, and 24% were symptomatic. Average age was 65 ± 12 years and SAT + CEA were older (69 vs. 64 years, P < 0.001). CEA + SAT were more likely to be men (53% vs. 42%, P < 0.001), have hypertension (86% vs. 75%, P < 0.001) and diabetes (26% vs. 20%, P = 0.04). SAT procedures included the following: carotid-subclavian bypass (68%), carotid-carotid bypass (16%), aorta-great vessel bypass (9%), and carotid-subclavian transposition (7%). ISAT were more likely to undergo carotid-subclavian bypass than SAT + CEA (71% vs. 54%, P < 0.001). Overall stroke was 2.3%, death 1.4%, and SDM 4.6%. There were no differences in 30-day stroke (ISAT 2.0% vs. SAT + CEA 3.7%, P = 0.09) or mortality (1.4% vs. 1.5%, P = 0.88). SAT + CEA had higher rates of SDM (7% vs. 4%, P = 0.03). On logistic regression, urgency was a predictor of SDM (operating room [OR] 3.6, 95% confidence interval [CI] 1.5-8.4, P = 0.003); addition of CEA was not predictive of stroke (OR 1.4, 95% CI 0.5-4.2, P = 0.52) or SDM (OR 1.5, 95% CI 0.6-3.6, P = 0.40). After propensity matching, there were no longer differences in demographics or primary end points between the 2 cohorts.

Conclusions: Addition of CEA does not confer increased perioperative stroke or SDM risk over ISAT. Perioperative outcomes appear to be more affected by disseminated disease risk factors than the addition of CEA. In patients undergoing SAT, it is reasonable to consider performing combined CEA in populations with tandem carotid bifurcation disease and appropriate operative risk profile.
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http://dx.doi.org/10.1016/j.avsg.2020.06.037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7669661PMC
November 2020

Platelet and neutrophil to lymphocyte ratios predict survival in patients with resectable colorectal liver metastases.

Am J Surg 2020 12 14;220(6):1579-1585. Epub 2020 May 14.

Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States. Electronic address:

Background: The prognostic significance of the platelet (PLR) and neutrophil (NLR) to lymphocyte ratios for patients with resectable colorectal cancer liver metastases (CLM) was evaluated.

Methods: Clinicopathologic data from patients who underwent hepatectomy for CLM at two tertiary care hospitals between 1995 and 2017 were collected. Blood counts were evaluated for prognostic significance.

Results: 151 patients met inclusion criteria. The median age was 58 years, 44% were female, and 58% had synchronous metastases. Median number of liver metastases was 2, and 59% of patients underwent lobectomy or extended lobectomy. On multivariable analysis, NLR ≥5 (HR 2.46 [1.08-5.60 CI], p = 0.032), PLR ≥ 220 (HR 2.10 [1.04-4.23 CI], p = 0.037), and greater than 2 liver metastases (HR 2.41 [1.06-5.45 CI], p = 0.035) were associated with reduced overall survival.

Conclusions: PLR ≥ 220 and NLR ≥ 5 may have utility as preoperative prognostic markers for overall survival in patients with resectable CLM.
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http://dx.doi.org/10.1016/j.amjsurg.2020.05.003DOI Listing
December 2020

Comment on: Socioecological factors associated with metabolic and bariatric surgery utilization: a qualitative study in an ethnically diverse sample.

Surg Obes Relat Dis 2020 06 13;16(6):795-797. Epub 2020 Mar 13.

Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, Massachusetts.

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http://dx.doi.org/10.1016/j.soard.2020.02.014DOI Listing
June 2020

Variation in long-term oncologic outcomes by type of cancer center accreditation: An analysis of a SEER-Medicare population with pancreatic cancer.

Am J Surg 2020 07 2;220(1):29-34. Epub 2020 Apr 2.

Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. Electronic address:

Background: Cancer center accreditation is designed to identify centers that provide high-quality cancer care. This also guides patients and referring physicians towards centers of excellence for specialized care. We sought to examine if cancer center accreditation was associated with improved long-term oncologic outcomes in patients with pancreatic adenocarcinoma.

Methods: Using the SEER-Medicare database, we identified patients who underwent pancreatectomy for pancreatic adenocarcinoma from 1996 to 2013. Hospitals were categorized into three groups: National Cancer Institute-designated (NCI-designated) centers, Commission on Cancer (CoC)-accredited centers, and "non-accredited" (NA) centers. Multilevel mixed-effects models were used to calculate adjusted examined lymph nodes, disease-specific survival (DSS), and overall survival (OS).

Results: We identified 5,118 patients who underwent pancreatectomy at 632 hospitals (41.0% NA, 49.6% CoC, 9.4% NCI). NCI-designated centers had a greater median number of lymph nodes examined compared with CoC-accredited or NA centers (14 vs. 10 vs. 11.0 nodes, respectively; p < 0.001). Patients treated at NCI centers had a higher 5-year DSS compared to those treated at CoC or NA centers (31.2% vs. 23.6% vs. 23.0%, respectively; p < 0.001). Finally, patients treated at NCI centers had a higher 5-year OS compared to those treated at CoC or NA centers (23.5% vs. 18.9% vs. 17.9%, respectively; p < 0.001). The associations held true when adjusted analyses were performed.

Conclusion: Patients with resected pancreatic cancer treated at NCI-designated centers were associated with improved long-term oncologic outcomes. There was no difference between CoC-accredited centers compared with NA centers. Meticulous validation of accreditation is warranted globally prior to implementation.
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http://dx.doi.org/10.1016/j.amjsurg.2020.03.035DOI Listing
July 2020
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