Publications by authors named "Jennifer Tseng"

214 Publications

Combined Hepatopancreaticobiliary Volume and Hepatectomy Outcomes in Hepatocellular Carcinoma Patients at Low-Volume Liver Centers.

J Am Coll Surg 2021 Feb 25. Epub 2021 Feb 25.

Department of Surgery, Boston Medical Center, Boston University School of Medical, Boston, MA;. Electronic address:

Background: The relationship between hospital volume and surgical outcomes is well-established; however, considerable socioeconomic and geographic barriers to high-volume care persist. This study assesses how the overall volume of hepato-pancreatico-biliary (HPB) cancer operations impacts outcomes of liver resections (LR).

Study Design: The National Cancer Database (2004-2014) was queried for patients who underwent LR for hepatocellular carcinoma. Hospital volume was determined separately for all HPB operations and LR. Centers were dichotomized as low- and high-volume centers based on the median number of operations. Three study cohorts were created: low-volume hospitals (LVH) for both LR and HPB, mixed-volume hospital (MVH) with low-volume LR but high-volume HPB, and high-volume LR hospitals (HVH) for both LR and HPB.

Results: Of 7,265 patients identified, 37.5%, 8.8%, and 53.7% patients were treated at LVH, MVH, and HVH, respectively. On multivariable analysis, patients treated at LVH had higher 30-day mortality compared to patients treated at HVH (Odds Ratio [OR], 1.736; p<0.001). However, patients treated at MVH experienced comparable 30-day mortality to HVH (OR, 0.789; p=0.318). Similar results were found for positive margin status, prolonged hospital stay, and overall survival.

Conclusions: Liver resection outcomes at low-volume LR centers that have substantial experience with HPB cancer operations are similar to those at high-volume LR centers. Our results demonstrate that the volume-outcome curve for HPB surgery ought to be assessed more holistically and that patients may safely undergo liver operations at low-volume LR centers if HPB volume criteria are met.
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http://dx.doi.org/10.1016/j.jamcollsurg.2021.01.017DOI Listing
February 2021

Undertreatment of Gallbladder Cancer: A Nationwide Analysis.

Ann Surg Oncol 2021 Feb 10. Epub 2021 Feb 10.

Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA.

Background: Gallbladder cancer has a high mortality rate and an increasing incidence. The current National Comprehensive Cancer Network (NCCN) guidelines recommend resection for all T1b and higher-stage cancers. This study aimed to evaluate re-resection rates and the associated survival impact for patients with gallbladder cancer.

Methods: Patients with gallbladder adenocarcinoma who underwent resection were identified from the National Cancer Database (2004-2015). Re-resection was defined as definitive surgery within 180 days after the first operation. Propensity scores were created for the odds of a patient having a re-resection. Patients were matched 1:2. Survival analyses were performed using the Kaplan-Meier and Cox proportional hazard methods.

Results: The study identified 6175 patients, and 466 of these patients (7.6%) underwent re-resection. Re-resection was associated with younger median age (65 vs 72 years; p < 0.0001), private insurance (41.6% vs 27.1%; p < 0.0001), academic centers (50.4% vs 29.7%; p < 0.0001), and treatment location in the Northeast (22.8% vs 20.4%; p = 0.0011). Compared with no re-resection, re-resection was associated with pT stage (pT2: 47.6% vs 42.8%; p = 0.0139) and pN stage (pN1-2: 28.1% vs 20.7%; p < 0.0001), negative margins on final pathology (90.1% vs 72.6%; p < 0.0001), and receipt of chemotherapy (53.7% vs 35.8%; p < 0.0001). The patients who underwent re-resection demonstrated significantly longer overall survival (OS) than the patients who did not undergo re-resection (median OS, 44.0 vs 23.0 months; p < 0.0001). After propensity score-matching, re-resection remained associated with superior survival (median OS, 44.0 vs 31.0 months; p = 0.0004).

Conclusions: Re-resection for gallbladder cancer is associated with improved survival but remains underused, particularly for early-stage disease.
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http://dx.doi.org/10.1245/s10434-021-09607-6DOI Listing
February 2021

Landmark Series in Pancreatic Tumors: Anastomotic Techniques and Route of Reconstruction.

Ann Surg Oncol 2021 Feb 6. Epub 2021 Feb 6.

Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, USA.

Introduction: Pancreaticoduodenectomy is one of the more complicated operations that exists in surgery, and is fraught with potential morbidity, the most well-known, and dreaded, of which is the pancreatic leak. While much of the risk associated with pancreatic leak is inherent to the operation, there have been no shortage of techniques employed by surgeons to try to mitigate that risk.

Methods: We focused on four topics of greatest conjecture with regard to reconstruction after pancreaticoduodenectomy: (1) the type of anastomosis, (2) the enteral organ to which the pancreas is sewn, (3) whether to preserve the pylorus and (4) whether or not to use anastomotic silastic stents. We identified the most relevant randomized control trials on each topic, which were appropriately powered.

Results: We identified a total of 15 studies for evaluation, (type of anastomosis: n = 4; enteral organ to which the pancreas is sewn: n = 4; whether to preserve the pylorus, n=3; and whether or not to use anastomotic silastic stents, n = 4). In each group of comparisons, there was no definitive conclusion to be made on superiority of reconstruction.

Conclusion: While clear consensus on how best to reconstruct the anatomy after pancreaticoduodenectomy has not yet been reached, we present the following review in the hope of providing some understanding of the literature for the pancreatic surgeon.
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http://dx.doi.org/10.1245/s10434-021-09663-yDOI Listing
February 2021

The role of racial segregation in treatment and outcomes among patients with hepatocellular carcinoma.

HPB (Oxford) 2021 Jan 19. Epub 2021 Jan 19.

Department of Surgery, Boston University/Boston Medical Center, USA. Electronic address:

Background: There is a long history of segregation in the U.S.A with enduring impacts on cancer outcomes today. We evaluated the impact of segregation on racial disparities in Hepatocellular Carcinoma (HCC) treatment and outcomes.

Methods: We obtained data on black and white patients with HCC from the SEER program (2005-2015) within the 100 most populous participating counties. Our exposure was the index of dissimilarity (IoD), a validated measure of segregation. Outcomes were overall survival, advanced stage at diagnosis (Stage III/IV) and surgery for localized disease (Stage I/II). Cancer-specific survival was assessed using Kaplan-Meier estimates.

Results: Black patients had a 1.18 times increased risk (95%CI 1.14,1.22) of presenting at advanced stage as compared to white patients and these disparities disappeared at low levels of segregation. In the highest quartile of IoD, black patients had a significantly lower survival than white (17 months vs 27 months, p < 0.001), and this difference disappeared at the lowest quartile of IoD.

Conclusions: Our data illustrate that structural racism in the form racial segregation has a significant impact on racial disparities in the treatment of HCC. Urban and health policy changes can potentially reduce disparities in HCC outcomes.
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http://dx.doi.org/10.1016/j.hpb.2020.12.011DOI Listing
January 2021

Choledochal Cyst or Benign Biliary Dilation: Is Resection Always Necessary?

J Gastrointest Surg 2021 Jan 22. Epub 2021 Jan 22.

Department of Surgery, Boston University School of Medicine, Boston, MA, USA.

Background: Choledochal cysts (CC) are often diagnosed during the first few decades of life, when, due to the risk of malignancy, resection is advised. With an increasing number of patients undergoing abdominal imaging, many older patients have recently been radiographically diagnosed with biliary duct enlargement that meets the criteria of choledochal cysts. The management in these patients is less well defined, but resection is often recommended as it is for younger patients. We sought to better understand the significance of these biliary duct anomalies in adults.

Methods: We retrospectively reviewed all patients 18 years and older at our institution, who were given a radiographic diagnosis of choledochal cyst during the interval 2006-2019. Demographics, comorbidities, complications, readmissions, and follow-up imaging were evaluated.

Results: We identified 22 patients, of whom 40.9% (n = 9) underwent an operation. The remainder was observed. Median duct size was 15 mm (range 2-25 mm). There were no significant differences in demographics between the two cohorts. Of those who underwent resection, none had evidence of high-grade dysplasia or invasive carcinoma upon final pathology. However, 33.3% (n = 3) had subsequent readmissions for complications, including post-operative nausea and vomiting, cholangitis, and anastomotic stenoses that required stenting. In the observation group, there was no obvious growth of the cysts or development of worrisome features to suggest malignant degeneration (median follow-up = 68 months).

Conclusion: A radiographic diagnosis of choledochal cyst in older adults is likely a different entity than those diagnosed in childhood. Close surveillance of these biliary duct anomalies in older adults may be a better option than resection and reconstruction with the associated risks of long-term morbidity.
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http://dx.doi.org/10.1007/s11605-020-04896-wDOI Listing
January 2021

Acknowledgement, Reflection, and Action: The American Board of Surgery Leans into Antiracism.

Ann Surg 2020 Dec 18;Publish Ahead of Print. Epub 2020 Dec 18.

Department of Surgery, University of Illinois at Chicago, Chicago, Illinois Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania Department of Surgery, Boston University School of Medicine, Boston, Massachusetts American Board of Surgery, Philadelphia, Pennsylvania Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois.

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http://dx.doi.org/10.1097/SLA.0000000000004684DOI Listing
December 2020

Contemporary Multi-Institutional Cohort of 550 Cases of Phyllodes Tumors (2007-2017) Demonstrates a Need for More Individualized Margin Guidelines.

J Clin Oncol 2021 Jan 10;39(3):178-189. Epub 2020 Dec 10.

Department of Surgery, Mayo Clinic, Rochester, MN.

Purpose: Phyllodes tumors (PTs) are rare breast neoplasms, which have little granular data on margins. Current guidelines recommend ≥ 1 cm margins; however, recent data suggest narrower margins are sufficient, and for benign PT, a negative margin may not be necessary.

Methods: We performed an 11-institution contemporary (2007-2017) review of PT practices. Demographics, surgical, and histopathologic data were captured. Logistic regression was used to estimate the association of select covariates with local recurrence (LR).

Results: Of 550 PT patients, the majority underwent excisional biopsy (55.3%, n = 302/546) or lumpectomy (wide excision) (38.5%, n = 210/546). Median tumor size was 30 mm, 68.9% (n = 379) were benign, 19.6% (n = 108) borderline, and 10.5% (n = 58) malignant. Surgical margins were positive in 42% (n = 231) and negative in 57.3% (n = 311). A second operation was performed in 38.0% (n = 209) of the total cohort, including 51 patients with an initial margin (82.4% with < 2 mm), and 157 with an initial margin, with residual disease only found in six (2.9%). Notably, 32.0% (n = 74) of those with an initial positive margin did undergo a second operation, among whom only 2.7% (n = 2) recurred. Recurrence occurred in 3.3% (n = 18) of the total cohort (n = 15 LR, n = 3 distant), at median follow-up of 36.7 months. LR (all PT grades) was not reduced with wider negative margin width (≥ 2 mm < 2 mm: odds ratio [OR] = 0.39; 95% CI, 0.07 to 2.10; = .27) or final margin status (positive negative: OR = 0.96; 95% CI, 0.26 to 3.52; = .96).

Conclusion: In current practice, many patients are managed outside of current guidelines. For the entire cohort, a wider margin width was not associated with a reduced risk of LR. We do not recommend re-excision of a negative margin for benign PT, regardless of margin width, as a progressively wider surgical margin is unlikely to reduce LR.
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http://dx.doi.org/10.1200/JCO.20.02647DOI Listing
January 2021

Volume of Pancreas-Adjacent Operations Favorably Influences Pancreaticoduodenectomy Outcomes at Lower Volume Pancreas Centers.

Ann Surg 2020 Dec 2. Epub 2020 Dec 2.

Department of Surgery, Boston Medical Center, Boston University School of Medical, Boston, MA.

Objective: This study assesses how the volume of pancreatic-adjacent operations (PAO) impacts the outcomes of pancreaticoduodenectomy (PD).

Summary Background Data: It is well-established that regionalization benefits outcomes after PD. However, due to a multitude of factors, including geographic, financial and personal, not all patients receive their care at high-volume pancreas surgery centers.

Methods: The National Cancer Database was queried for pancreatic cancer patients who underwent pancreaticoduodenectomy. Hospital volume was calculated for PD and PAO (defined as gastric, hepatic, complex biliary, or pancreatic operations other than PD) and dichotomized as low- and high-volume centers based on the median. Three study cohort were created: low-volume hospitals (LVH) for both PD and PAO, mixed-volume hospital (MVH) with low-volume PD but high-volume PAO, and high-volume PD hospital (HVH).

Results: In total, 24,572 patients were identified, with 41.5%, 7.2%, and 51.3% patients treated at LVH, MVH, and HVH, respectively. 30-day mortality for PD was 5.6% in LVH, 3.2% in MVH, and 2.5% in HVH. On multivariable analyses, LVH was predictive for higher 30-day mortality compared to HVH (OR, 2.068; 95% CI, 1.770-2.418; p < 0.0001). However, patients at MVH demonstrated similar 30-day mortality to patients treated at HVH (OR, 1.258; 95% CI, 0.942-1.680; p = 0.1203).

Conclusions: PD outcomes at low-volume centers that have experience with complex cancer operations near the pancreas are similar to PD outcomes at hospitals with high PD volume. MVH provide a model for PD outcomes to improve quality and access for patients who cannot, or choose not to, receive their care at high-volume centers.
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http://dx.doi.org/10.1097/SLA.0000000000004432DOI Listing
December 2020

Editorial.

J Surg Educ 2020 Nov - Dec;77(6):1325-1326. Epub 2020 Oct 22.

Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address:

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http://dx.doi.org/10.1016/j.jsurg.2020.08.032DOI Listing
October 2020

The Impact of Residential Segregation on Pancreatic Cancer Diagnosis, Treatment, and Mortality.

Ann Surg Oncol 2020 Nov 1. Epub 2020 Nov 1.

Department of Surgery, Surgical Oncology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA.

Background: Disparities in pancreatic cancer outcomes between black and white patients are well documented. This study aimed to use a more novel index to examine the impact of racial segregation on the diagnosis, management, and outcomes of pancreatic cancer in black patients compared with white patients.

Methods: Black and white adults with pancreatic cancer in urban counties were identified using data from the 2018 submission of the Surveillance, Epidemiology and End Results (SEER) Program and the 2010 Census. The racial index of dissimilarity (IoD), a validated proxy of racial segregation, was used to assess the evenness with which whites and blacks are distributed across census tracts in each county. Multivariate Poisson regression was performed, and stepwise models were constructed for each of the outcomes. Overall survival was studied using the Kaplan-Meier method.

Results: The study enrolled 60,172 adults with a diagnosis of pancreatic cancer between 2005 and 2015. Overall, the black patients (13.8% of the cohort) lived in more segregated areas (IoD, 0.67 vs 0.61; p < 0.05). They were less likely to undergo surgery for localized disease (relative risk [RR], 0.80; 95% confidence interval [CI], 0.76-0.83) and more frequently had a diagnosis of advanced-stage disease (RR, 1.09; 95% CI, 1.01-1.19) with increasing segregation. They also had shorter survival times (9.8 vs 11.4 months; p < 0.05).

Conclusions: Disparities in advanced-stage disease at diagnosis, surgery for localized disease, and overall survival are directly related to the degree of residential segregation, a proxy for structural racism. In searching for solutions to this problem, it is important to account for the historical marginalization of black Americans.
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http://dx.doi.org/10.1245/s10434-020-09218-7DOI Listing
November 2020

Cancer stage at presentation for incarcerated patients at a single urban tertiary care center.

PLoS One 2020 15;15(9):e0237439. Epub 2020 Sep 15.

Boston University School of Medicine, Boston, MA, United States of America.

Patients who are incarcerated are a vulnerable patient population and may suffer from less access to routine cancer screenings compared to their non-incarcerated counterparts. Therefore, a thorough evaluation of potential differences in cancer diagnosis staging is needed. We sought to examine whether there are differences in cancer stage at initial diagnosis between non-incarcerated and incarcerated patients by pursuing a retrospective chart review from 2010-2017 for all patients who were newly diagnosed with cancer at an urban safety net hospital. Incarceration status was determined by insurance status. Our primary outcome was incarceration status at time of initial cancer diagnosis. Overall, patients who were incarcerated presented at a later cancer stage for all cancer types compared to the non-incarcerated (+.14 T stage, p = .033; +.23 N stage, p < .001). Incarcerated patients were diagnosed at later stages for colorectal (+0.93 T stage, p < .001; +.48 N stage, p < .001), oropharyngeal (+0.37 N stage, p = .003), lung (+0.60 N stage, p = .018), skin (+0.59 N stage, p = 0.014), and screenable cancers (colorectal, prostate, lung) as a whole (+0.23 T stage, p = 0.002; +0.17 N stage, p = 0.008). Incarcerated patients may benefit from more structured screening protocols in order to improve the stage at presentation for certain malignancies.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0237439PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7491712PMC
October 2020

A closer look at the natural history and recurrence patterns of high-grade truncal/extremity leiomyosarcomas: A multi-institutional analysis from the US Sarcoma Collaborative.

Surg Oncol 2020 Sep 30;34:292-297. Epub 2020 Jun 30.

Division of Surgical Oncology, Department of Surgery, Winship Cancer Institute, Emory University, Atlanta, GA, USA. Electronic address:

Background/objective: Natural history and outcomes for truncal/extremity (TE) soft tissue sarcoma (STS) is derived primarily from studies investigating all histiotypes as one homogenous cohort. We aimed to define the recurrence rate (RR), recurrence patterns, and response to radiation of TE leiomyosarcomas (LMS).

Methods: Patients from the US Sarcoma Collaborative database with primary, high-grade TE STS were identified. Patients were grouped into LMS or other histology (non-LMS). Primary endpoints were locoregional recurrence-free survival (LR-RFS), distant-RFS (D-RFS), and disease specific survival (DSS).

Results: Of 1215 patients, 93 had LMS and 1122 non-LMS. In LMS patients, median age was 63 and median tumor size was 6 cm. In non-LMS patients, median age was 58 and median tumor size was 8 cm. In LMS patients, overall RR was 42% with 15% LR-RR and 29% D-RR. The 3yr LR-RFS, D-RFS, and DSS were 84%, 65%, and 76%, respectively. When considering high-risk (>5 cm and high-grade, n = 49) LMS patients, the overall RR was 45% with 12% LR-RR and 35% D-RR. 61% received radiation. The 3yr LR-RFS (78vs93%, p = 0.39), D-RFS (53vs63%, p = 0.27), and DSS (67vs91%, p = 0.17) were similar in those who did and did not receive radiation. High-risk, non-LMS patients had a similar overall RR of 42% with 15% LR-RR and 30% D-RR. 60% of non-LMS patients received radiation. There was an improved 3yr LR-RFS (82vs75%, p = 0.030) and DSS (77vs65%,p = 0.007) in non-LMS patients who received radiation.

Conclusions: In our cohort, patients with LMS have a low local recurrence rate (12-15%) and modest distant recurrence rate (29-35%). However, LMS patients had no improvement in local control or long-term outcomes with radiation. The value of radiation in these patients merits further investigation.
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http://dx.doi.org/10.1016/j.suronc.2020.06.003DOI Listing
September 2020

Lymphadenectomy and Survival After Neoadjuvant Chemoradiation for Esophageal Adenocarcinoma: Is More Better?

J Gastrointest Surg 2020 Nov 1;24(11):2447-2455. Epub 2020 Sep 1.

Department of Surgery, Boston Medical Center, Boston University School of Medicine, 88 East Newton Street, Collamore C500, Boston, MA, 02118, USA.

Purpose: The purpose of this study was to assess the impact of number of lymph nodes examined on survival in patients with esophageal adenocarcinoma who underwent neoadjuvant chemoradiation.

Methods: The National Cancer Database was queried for patients who underwent neoadjuvant chemoradiation followed by surgery for esophageal adenocarcinoma. Propensity scores were created predicting the odds of undergoing resection of ≥ 25 nodes. Patients were matched on propensity score. Overall survival analyses were performed using the Kaplan-Meier method. Sensitivity analyses were performed using various nodal cutoffs.

Results: In total, 3953 patients who underwent neoadjuvant chemoradiation were identified. The median number of resected nodes was 14 nodes (IQR, 8-20 nodes). Resection of ≥ 15 (vs. < 15 nodes: 32 vs. 26 months; p < 0.001), ≥ 20 (vs. < 20 nodes: 36 vs. 28 months; p = 0.001), and ≥ 25 (vs. < 25 nodes: 37 vs. 29 months; p = 0.015) nodes was associated with higher median survival, but resection of ≥ 30 nodes was not (vs. < 30 nodes: 41 vs. 33 months; p = 0.367). Resection of ≥ 25 lymph nodes remained predictive for improved survival on subset analysis in patients with negative nodes and who underwent treatment at high-volume centers.

Conclusions: After neoadjuvant chemoradiation, resection of 25 or more lymph nodes was associated with longer median survival. Prospective trials are warranted to determine the optimal nodal yield after neoadjuvant chemoradiation.
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http://dx.doi.org/10.1007/s11605-020-04750-zDOI Listing
November 2020

A Structured Mentorship Elective Deepens Personal Connections and Increases Scholarly Achievements of Senior Surgery Residents.

J Surg Educ 2021 Mar-Apr;78(2):405-411. Epub 2020 Aug 27.

Department of Surgery, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts. Electronic address:

Objectives: Surgery residents have few opportunities to work closely with attending surgeons or conduct research during clinical time. We hypothesized that a mentorship elective with a required research project would benefit residents' career development, including their personal connections with faculty mentors, and would help them build their academic portfolio.

Design: We created a mentorship elective designed as a one-on-one apprenticeship. Completion of a scholarly project was a core component of the elective. Residents, faculty, and the most senior resident ('non-mentee') on the same service as the elective resident were interviewed after the completion of their rotation.

Setting: University-based surgery residency at Boston Medical Center, Boston, MA.

Participants: All 5 residents in postgraduate year 4 (PGY-4) participated in the mentorship elective during the 2019 to 2020 academic year. Residents identified their faculty mentor. All mentees (5/5), most mentors (4/5), and all non-mentees (4/4) were interviewed.

Results: All mentees reported interacting with their mentor daily, performing clinical duties or discussing their research project. For mentees, the top factor when selecting their mentor was the mentor's clinical expertise, and the most valuable aspect of the rotation was developing a relationship with their mentor. All mentors responded that their mentee gained an understanding of running an academic surgical practice and developed research skills. Four of 5 mentees completed critical portions of their scholarly project during the elective with one publishing in a peer-reviewed journal, 2 having their work accepted to a national conference, and one creating vascular surgery educational videos. All stated the elective was valuable.

Conclusions: A structured apprenticeship rotation allowed for closer relationships with attending surgeons and increased the scholarly achievement of PGY-4 surgery residents. We provide an example of how to incorporate a successful elective rotation into the surgery curriculum that strengthens resident career development and research productivity.
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http://dx.doi.org/10.1016/j.jsurg.2020.08.016DOI Listing
August 2020

National Disparities in COVID-19 Outcomes between Black and White Americans.

J Natl Med Assoc 2020 Aug 7. Epub 2020 Aug 7.

Department of Surgery, Boston University/Boston Medical Center; Boston University School of Medicine. Electronic address:

Background: There is very limited comprehensive information on disparate outcomes of black and white patients with COVID-19 infection. Reports from cities and states have suggested a discordant impact on black Americans, but no nationwide study has yet been performed. We sought to understand the differential outcomes for black and white Americans infected with COVID-19.

Methods: We obtained case-level data from the Centers for Disease Control and Prevention on 76,442 white and 48,338 non-Hispanic Black patients diagnosed with COVID-19, ages 0 to >80+, outlining information on hospitalization, ICU admission, ventilation, and death outcomes. Multivariate Poisson regressions were used to estimate the association of race, treating white as the reference group, controlling for sex, age group, and the presence of comorbidities.

Results: Black patients were generally younger than white, were more often female, and had larger numbers of comorbidities. Compared to white patients with COVID-19, black patients had 1.4 times the risk of hospitalization (RR 1.42, p < 0.001), and almost twice the risk of requiring ICU care (RR 1.68, p < 0.001) or ventilatory support (RR 1.81, p < 0.001) after adjusting for covariates. Black patients saw a 1.36 times increased risk of death (RR 1.36, p < 0.001) compared to white. Disparities between black and white outcomes increased with advanced age.

Conclusion: Despite the initial descriptions of COVID-19 being a disease that affects all individuals, regardless of station, our data demonstrate the differential racial effects in the United States. This current pandemic reinforces the need to assess the unequal effects of crises on disadvantaged populations to promote population health.
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http://dx.doi.org/10.1016/j.jnma.2020.07.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413663PMC
August 2020

Influence of race and sociodemographic factors on declining resection for gastric cancer: A national study.

Am J Surg 2021 01 7;221(1):155-161. Epub 2020 Jul 7.

Department of Surgery, Boston Medical Center, Boston University, 88 East Newton Street Collamore - C500, Boston, MA, 02118, USA. Electronic address:

Background: The purpose of this study was to determine whether racial or other demographic characteristics were associated with declining surgery for early stage gastric cancer.

Methods: Patients with clinical stage I-II gastric adenocarcinoma were identified from the NCDB. Multivariable logistic models identified predictors for declining resection. Patients were stratified based on propensity scores, which were modeled on the probability of declining. Overall survival was evaluated using the Kaplan-Meier method.

Results: Of 11,326 patients, 3.68% (n = 417) declined resection. Patients were more likely to refuse if they were black (p < 0.001), had Medicaid or no insurance (p < 0.001), had shorter travel distance to the hospital (p < 0.001) or were treated at a non-academic center (p = 0.001). After stratification, patients who declined surgery had worse overall survival (all strata, p < 0.001).

Conclusions: Racial and sociodemographic disparities exist in the treatment of potentially curable gastric cancer, with patients who decline recommended surgery suffering worse overall survival.
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http://dx.doi.org/10.1016/j.amjsurg.2020.06.022DOI Listing
January 2021

High neutrophil-lymphocyte ratio is not independently associated with worse survival or recurrence in patients with extremity soft tissue sarcoma.

Surgery 2020 10 28;168(4):760-767. Epub 2020 Jul 28.

Department of Surgery, Medical College of Wisconsin, Milwaukee, WI. Electronic address:

Background: Soft tissue sarcomas are a heterogenous group of neoplasms without well-validated biomarkers. Cancer-related inflammation is a known driver of tumor growth and progression. Recent studies have implicated a high circulating neutrophil-lymphocyte ratio as a surrogate marker for the inflammatory tumor microenvironment and a poor prognosticator in multiple solid tumors, including colorectal and pancreatic cancers. The impact of circulating neutrophil-lymphocyte ratio in soft tissue sarcomas has yet to be elucidated.

Methods: We performed a retrospective analysis of patients undergoing curative resection for primary or recurrent extremity soft tissue sarcomas at academic centers within the US Sarcoma Collaborative. Neutrophil-lymphocyte ratio was calculated retrospectively in treatment-naïve patients using blood counts at or near diagnosis.

Results: A high neutrophil-lymphocyte ratio (≥4.5) was associated with worse survival on univariable analysis in patients with extremity soft tissue sarcomas (hazard ratio 2.07; 95% confidence interval, 1.54-2.8; P < .001). On multivariable analysis, increasing age (hazard ratio 1.03; 95% confidence interval, 1.02-1.04; P < .001), American Joint Committee on Cancer T3 (hazard ratio 1.89; 95% confidence interval, 1.16-3.09; P = .011), American Joint Committee on Cancer T4 (hazard ratio 2.36; 95% confidence interval, 1.42-3.92; P = .001), high tumor grade (hazard ratio 4.56; 95% confidence interval, 2.2-9.45; P < .001), and radiotherapy (hazard ratio 0.58; 95% confidence interval, 0.41-0.82; P = .002) were independently predictive of overall survival, but a high neutrophil-lymphocyte ratio was not predictive of survival (hazard ratio 1.26; 95% confidence interval, 0.87-1.82; P = .22).

Conclusion: Tumor inflammation as measured by high pretreatment neutrophil-lymphocyte ratio was not independently associated with overall survival in patients undergoing resection for extremity soft tissue sarcomas.
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http://dx.doi.org/10.1016/j.surg.2020.06.017DOI Listing
October 2020

Analysis of textbook outcomes among patients undergoing resection of retroperitoneal sarcoma: A multi-institutional analysis of the US Sarcoma Collaborative.

J Surg Oncol 2020 Nov 21;122(6):1189-1198. Epub 2020 Jul 21.

Department of Surgery, The Ohio State University, Columbus, Ohio.

Background: The novel composite metric textbook outcome (TO) has increasingly been used as a quality indicator but has not been reported among patients undergoing surgical resection for retroperitoneal sarcoma (RPS) using multi-institutional collaborative data.

Methods: All patients who underwent resection for RPS between 2000 to 2016 from eight academic institutions were included. TO was defined as a patient with R0/R1 resection that discharged to home and was without transfusion, reoperation, grade ≥2 complications, hospital-stay >50th percentile, or 90-day readmission or mortality. Univariate and multivariable analyses were performed.

Results: Among 627 patients, 56.1% were female and the median age was 59 years. A minority of patients achieved a TO (34.9%). Factors associated with achieving a TO were tumor size <20 cm and low tumor grade, while ASA class ≥3, history of a prior cardiac event, resection of left colon/rectum, distal pancreatic resection, major venous resection and drain placement were associated with not achieving a TO (all P < .05). Achievement of a TO was associated with improved survival (median:12.7 vs 5.9 years, P < .01).

Conclusions: Among patients undergoing resection for RPS, failure to achieve TO is common and associated with significantly worse survival. The use of TO may inform patient expectations and serve as a measure for patient-level hospital performance.
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http://dx.doi.org/10.1002/jso.26136DOI Listing
November 2020

Contemporary Analysis of Senior Level Case Volume Variation between Traditional Vascular Surgery Fellows and Integrated Vascular Surgery Chief Residents.

Ann Vasc Surg 2021 Jan 6;70:245-251. Epub 2020 Jul 6.

Department of Surgery, Boston Medical Center, Boston University, School of Medicine, Boston, MA. Electronic address:

Background: The present study compares the senior level operative experience of graduates from the traditional vascular surgery fellowship (5 + 2) and integrated vascular surgery training programs (0 + 5) using contemporary operative case log data.

Methods: The Accreditation Council for Graduate Medical Education integrated vascular surgery, vascular surgery fellowship, and general surgery case logs for trainees graduating between 2013 and 2018 were queried for vascular surgery procedures. "Senior" cases were categorized as cases logged as "surgeon fellow" by 5 + 2 trainees or "surgeon chief" (post graduate year-4,5) by 0 + 5 trainees. Overall case volume was defined as the combined volume of cases logged as "surgeon junior," "surgeon chief," "surgeon fellow," "teach assist," "first assist," or "secondary procedure." To reflect total vascular experience, all vascular cases done during general surgery residency were combined with cases performed during vascular surgery fellowship. Mean case volumes were compared for all operations/procedures.

Results: The 5 + 2 trainees had higher mean volume of open repair of suprarenal aortic aneurysms (2.4 vs. 1.4, P = 0.0026) and open repair of thoracic aortic aneurysms (0.5 vs. 0.3, P = 0.004) at the fellow level compared to 0 + 5 surgeon chief cases. Additionally, 5 + 2 trainees performed more endovascular repair of abdominal aortoiliac aneurysm (44.7 vs. 28.4, P < 0.0001), endovascular repair of iliac artery aneurysm (1.9 vs. 1.2, P = 0.0003), and endovascular repair of thoracic aortic aneurysm (14.9 vs. 8.4, P < 0.0001). The 5 + 2 fellows performed more vein bypasses than 0 + 5 chief residents (femoral-popliteal 9.8 vs. 6.4, P = 0.002; infrapopliteal 13.9 vs. 8.8, P = 0.0490), extra-anatomic bypasses (axillofemoral 4.2 vs. 2.9, P = 0.0004; femoral-femoral 5.6 vs. 3.1, P = 0.034), carotid endarterectomies (47.3 vs. 29.3, P < 0.0001), carotid artery stenting (9.6 vs. 4.5, P = 0.0001), celiac/SMA endarterectomy or bypass (3.7 vs. 1.9, P < 0.0001), renal artery balloon angioplasty/stenting (5.0 vs. 2.5, P = 0.0006), thoracic outlet decompression (5.4 vs. 1.9, P < 0.0001), traumatic repairs [thoracic vessels (0.5 vs. 0.1, P < 0.0001), neck vessels (0.7 vs. 0.3, P = 0.0004), abdominal vessels (3.0 vs. 1.7, P = 0.0005), and peripheral vessels (6.6 vs. 3.1, P = 0.034)], as well as a higher mean volume of arteriovenous (AV) fistulas (30.7 vs. 15.7, P < 0.0001), AV grafts (10.7 vs. 5.1, P < 0.0001), and revision of AV access (16.1 vs. 8.0, P = 0.0003).

Conclusions: Although both pathways graduate trainees with a similar overall surgical experience, 5 + 2 trainees log significantly more "Senior" cases. Further studies investigating potential variation in operative autonomy between both pathways are necessary.
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http://dx.doi.org/10.1016/j.avsg.2020.06.056DOI Listing
January 2021

The Boston Medical Center Coronavirus Disease 2019 (COVID-19) Procedure Team: Optimizing the surgeon's role in pandemic care at a safety-net hospital.

Surgery 2020 09 4;168(3):404-407. Epub 2020 Jun 4.

Department of Surgery, Boston Medical Center, Boston University, School of Medicine, Boston, MA. Electronic address:

Background: The coronavirus disease 2019 pandemic has claimed many lives and strained the US health care system. At Boston Medical Center, a regional safety-net hospital, the Department of Surgery created a dedicated coronavirus disease 2019 Procedure Team to ease the burden on other providers coping with the surge of infected patients. As restrictions on social distancing are lifted, health systems are bracing for additional surges in coronavirus disease 2019 cases. Our objective is to quantify the volume and types of procedures performed, review outcomes, and highlight lessons for other institutions that may need to establish similar teams.

Methods: Procedures were tracked prospectively along with patient demographics, immediate complications, and time from donning to doffing of the personal protective equipment. Retrospective chart review was conducted to obtain patient outcomes and delayed adverse events. We hypothesized that a dedicated surgeon-led team would perform invasive bedside procedures expeditiously and with few complications.

Results: From March 30, 2020 to April 30, 2020, there were 1,196 coronavirus disease 2019 admissions. The Procedure Team performed 272 procedures on 125 patients, including placement of 135 arterial catheters, 107 central venous catheters, 25 hemodialysis catheters, and 4 thoracostomy tubes. Specific to central venous access, the average procedural time was 47 minutes, and the rate of immediate complications was 1.5%, including 1 arterial cannulation and 1 pneumothorax.

Conclusion: Procedural complication rate was less than rates reported in the literature. The team saved approximately 192 hours of work that could be redirected to other patient care needs. In times of crisis, redeployment of surgeons (who arguably have the most procedural experience) into procedural teams is a practical approach to optimize outcomes and preserve resources.
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http://dx.doi.org/10.1016/j.surg.2020.05.030DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7269960PMC
September 2020

Medical Student Research in Surgery: From Abstract Presentation to Publication.

J Surg Educ 2020 Nov - Dec;77(6):1450-1453. Epub 2020 Jun 12.

Department of Surgery, University of Chicago Medicine, Chicago, Illinois. Electronic address:

Objective: Early career mentorship in surgical research often begins in medical school, and scholarly activity in the forms of abstract presentations and publications is seen as a critical criterion in residency applications. The goal of this study was to examine how often medical student abstract presentations at the American College of Surgeons (ACS) Clinical Congress are eventually published as peer-reviewed publications.

Design: Medical student abstract presentations from ACS Clinical Congress 2014 to 2018 were reviewed. Abstract information was cross-referenced for companion peer-reviewed publication in the PubMed and Google Scholar databases.

Results: In total, 219 students presented abstracts at the ACS Clinical Congress between 2014 and 2018. Of these, 101 (46%) led to publications in 61 different journals. The percentage of presentations that were published was 63% from 2014, 51% from 2015, 56% from 2016, 39% from 2017, and 25% from 2018. Medical students were named as first authors on 54%, second authors on 19%, and third authors on 13% of publications. The basic science presentation category had the greatest conversion to publications (54%), followed by clinical research (48%) and outcomes (45%).

Conclusions: Forty-six percent of medical student abstract presentations at the ACS Clinical Congress were converted to peer-reviewed publications. While it is encouraging that the ACS Clinical Congress is a productive forum to showcase medical student scholarly activity, more can be done to encourage full translation of research activity to peer-reviewed work. Further studies should be performed to look at influential factors amongst medical students, faculty mentors, and medical schools.
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http://dx.doi.org/10.1016/j.jsurg.2020.05.011DOI Listing
June 2020

How Has COVID-19 Affected the Costs of the Surgical Fellowship Interview Process?

Authors:
Jennifer Tseng

J Surg Educ 2020 Sep - Oct;77(5):999-1004. Epub 2020 May 20.

Department of Surgery, The University of Chicago Medicine, Chicago, Illinois. Electronic address:

Objective: To evaluate the effect of COVID-19 on the costs of the surgical fellowship interview process.

Design: A literature review of the historical costs of surgical fellowship interviews and a summary of how the shift to virtual interviews has unintended positive and negative effects on costs for applicants and training programs.

Results: Transitioning fellowship interviews to virtual platforms affects expenditures of finances and time. Each fellowship candidate saves close to $6,000 in interview travel expenses. Applicants require less time off from their residency programs during this critical time of need for frontline healthcare workers. However, applicants miss some of the live aspects of interviewing, and training programs invest more effort upfront altering their interviews to virtual formats.

Conclusions: The COVID-19 public health crisis has had a significant impact on surgical education, including how selection is conducted. Virtual recruitment has the potential for cost savings but should continue to be refined. This is an opportune time to innovate and rethink how to recruit prospective surgical residency and fellowship candidates during the current and forthcoming interview seasons.
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http://dx.doi.org/10.1016/j.jsurg.2020.05.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237896PMC
September 2020

Perioperative Outcomes of Carotid Interventions in Octogenarians.

Ann Vasc Surg 2020 Oct 3;68:15-21. Epub 2020 Jun 3.

Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA. Electronic address:

Background: In octogenarians with carotid stenosis, data supporting the decision to intervene and choice of intervention with either carotid endarterectomy (CEA) or carotid artery stenting (CAS) have been conflicting. The purpose of this study was to compare the perioperative outcomes of CEA and CAS in octogenarians, and to identify patients at high risk for unfavorable outcomes.

Methods: The American College of Surgeons National Surgical Quality Improvement Program database (2011-2018) was queried for patients aged ≥80 years who underwent CAS or CEA. Propensity scores were created for the odds of undergoing CAS. Patients were matched 1:1 based on propensity score and outcomes were compared after matching. Multivariable logistic regression analyses were used to identify risk factors for unfavorable postoperative outcomes.

Results: In total, 15,858 and 527 patients who underwent CEA and CAS were identified. After matching, there was no difference between CEA and CAS in perioperative stroke (2.3% vs. 2.9%; P = 0.56), cardiac complications (2.3% vs. 2.3%; P = 0.99), mortality (1.1% vs. 1.7%; P = 0.44), length of stay (median [interquartile range], 2 [1-4] vs. 1 [1-4] days; P = 0.13), and 30-day readmission (11.8% vs. 11.6%; P = 0.92). On multivariable analysis, the following were predictive for postoperative stroke: urgent operation (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.68-2.69; P < 0.001), chronic obstructive pulmonary disease (COPD; OR, 1.52; 95% CI, 1.11-2.09; P = 0.009), and American Society of Anesthesiologists class > III (OR, 1.46; 95% CI, 1.15-1.86; P = 0.002). Urgent procedure (OR, 2.86; 95% CI, 2.11-3.87; P < 0.001), COPD (OR, 2.31; 95% CI, 1.61-3.32; P < 0.001), dependent functional status (OR, 2.05; 95% CI, 1.35-3.1; P < 0.001), and age ≥ 85 years (OR, 1.92; 95% CI, 1.43-2.57; P < 0.001) were predictive for 30-day mortality.

Conclusions: Outcomes of CEA and CAS were similar in octogenarians. Risk factors for worse intervention outcomes were identified, which may guide risk-benefit discussions and shared decision-making.
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http://dx.doi.org/10.1016/j.avsg.2020.05.066DOI Listing
October 2020

Germline Genetic Mutations in a Multi-center Contemporary Cohort of 550 Phyllodes Tumors: An Opportunity for Expanded Multi-gene Panel Testing.

Ann Surg Oncol 2020 Oct 5;27(10):3633-3640. Epub 2020 Jun 5.

Department of Surgery, Mayo Clinic, Rochester, MN, USA.

Background: A paucity of data exists regarding inherited mutations associated with phyllodes tumors (PT); however, some are reported (TP53, BRCA1, and RB1). A PT diagnosis does not meet NCCN criteria for testing, including within Li-Fraumeni Syndrome (TP53). We sought to determine the prevalence of mutations associated with PT.

Methods: We performed an 11-institution review of contemporary (2007-2017) PT practice. We recorded multigenerational family history and personal history of genetic testing. We identified patients meeting NCCN criteria for genetic evaluation. Logistic regression estimated the association of select covariates with likelihood of undergoing genetic testing.

Results: Of 550 PT patients, 59.8% (n = 329) had a close family history of cancer, and 34.0% (n = 112) had ≥ 3 family members affected. Only 6.2% (n = 34) underwent genetic testing, 38.2% (n = 13) of whom had only BRCA1/BRCA2 tested. Of 34 patients tested, 8.8% had a deleterious mutation (1 BRCA1, 2 TP53), and 5.9% had a BRCA2 VUS. Of women who had TP53 testing (N = 21), 9.5% had a mutation. Selection for testing was not associated with age (odds ratio [OR] 1.01, p = 0.55) or PT size (p = 0.12) but was associated with grade (malignant vs. benign: OR 9.17, 95% CI 3.97-21.18) and meeting NCCN criteria (OR 3.43, 95% confidence interval 1.70-6.94). Notably, an additional 86 (15.6%) patients met NCCN criteria but had no genetic testing.

Conclusions: Very few women with PT undergo germline testing; however, in those selected for testing, a deleterious mutation was identified in ~ 10%. Multigene testing of a PT cohort would present an opportunity to discover the true incidence of germline mutations in PT patients.
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http://dx.doi.org/10.1245/s10434-020-08480-zDOI Listing
October 2020

Adjuvant Therapy for Cutaneous Melanoma.

Surg Oncol Clin N Am 2020 Jul;29(3):455-465

Department of Surgery, University of Chicago, 5841 South Maryland Avenue # MC5094, Chicago, IL 60637, USA. Electronic address:

This article presents the current data supporting adjuvant therapy for patients with cutaneous melanoma. With the recent development of novel immunotherapy agents as well as targeted therapy, there are strong data to support the use of these therapies in patients at high risk of developing recurrent or metastatic disease.
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http://dx.doi.org/10.1016/j.soc.2020.02.009DOI Listing
July 2020

Provider-patient Language Discordance and Cancer Operations: Outcomes from a Single Center Linked to a State Vital Statistics Registry.

World J Surg 2020 10;44(10):3324-3332

Department of Surgery, Boston University School of Medicine, Boston, USA.

Introduction: Patterns of worldwide immigration have resulted in high rates of discordance between medical providers and the patients they treat. For example, in the USA, 25 million individuals in the USA self-identified that they speak English less than "very well." Previous studies have generated mixed results regarding differences in postoperative outcomes between English proficient (EP) and limited English proficient (LEP) patients. Our objective was to determine whether a difference in outcomes exists for non-English-speaking patients compared to English-speaking patients after operations commonly performed to treat cancer.

Study Design: A retrospective cohort study was performed in an urban, safety net and tertiary referral medical center over a five-year period. Adult patients undergoing cancer operations were stratified as EP and LEP. We evaluated 30-day revisit to the ED, length of stay (LOS), long-term all-cause mortality, and any major complication on index admission. Regression was used to adjust for baseline comorbidities, case risk, and socioeconomic factors.

Results: A total of 2467 patients were included. There was no difference in case risk between language groups, but EP had a larger proportion of high comorbidity scores. Patients in the non-English group were more likely to be uninsured/self-pay and live in neighborhoods with lower median income. After adjustment, we found no difference in long-term mortality [hazard ratio: 0.87 (95% CI 0.52-1.45)]. LEP patients had the same LOS compared to primary EP patients with an IRR of 0.99 (95% CI 0.88-1.10). There was no difference in the odds of revisit to hospital for LEP versus EP, with an OR of 1.08, 95% CI [0.75-1.53] and no difference in major complication (OR 0.76 (95% CI 0.39-1.45).

Conclusions: We found no association between language and outcomes after cancer operations. This lack of difference may reflect local efficacy at treating non-English-speaking patients, and health systems with fewer services for LEP patients might show different results.
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http://dx.doi.org/10.1007/s00268-020-05614-yDOI Listing
October 2020

Learning theories and principles in surgical education and technical learning.

Authors:
Jennifer Tseng

J Surg Oncol 2020 Jul 22;122(1):11-14. Epub 2020 May 22.

Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois.

What is important to think about in surgical education and technical skills training? Technical skills training is grounded in social cognitive theory and the concepts of modeling and self-efficacy. Cognitive and nontechnical learning is critical to supplement the overall proficiency of the surgical learner in performing an operation. Technical learning is cemented by deliberate practice and there is benefit to productive struggle and failure. External cognitive load should be minimized to maximized operative skills advancement.
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http://dx.doi.org/10.1002/jso.25936DOI Listing
July 2020