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Romatoski KS, de Geus SWL, Miriyam B, Chung SH, Kenzik K, Papageorge MV, Rasic G, Ng SC, Tseng JF, Sachs TE. Overall Volume of Upper Gastrointestinal Surgery Positively Impacts Gastric Cancer Outcomes at Centers with Low Gastrectomy Volume. Ann Surg Oncol 2024; 31:5293-5303. [PMID: 38777899 DOI: 10.1245/s10434-024-15381-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/14/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND The relationship between hospital volume and surgical mortality is well documented. However, complete centralization of surgical care is not always feasible. The present study investigates how overall volume of upper gastrointestinal surgery at hospitals influences patient outcomes following resection for gastric adenocarcinoma. PATIENTS AND METHODS National Cancer Database (2010-2019) patients with pathologic stage 1-3 gastric adenocarcinoma who underwent gastrectomy were identified. Three cohorts were created: low-volume hospitals (LVH) for both gastrectomy and overall upper gastrointestinal operations, mixed-volume hospital (MVH) for low-volume gastrectomy but high-volume overall upper gastrointestinal operations, and high-volume gastrectomy hospitals (HVH). Chi-squared tests were used to analyze sociodemographic factors and surgical outcomes and Kaplan-Meier method for survival analysis. RESULTS In total, 26,398 patients were identified (LVH: 20,099; MVH: 539; HVH: 5,760). The 5-year survival was equivalent between MVH and HVH for all stages of disease (MVH: 56.0%, HVH 55.6%; p = 0.9866) and when stratified into early (MVH: 69.9%, HVH: 65.4%; p = 0.1998) and late stages (MVH: 24.7%, HVH: 32.0%; p = 0.1480), while LVH had worse survival. After matching patients, postoperative outcomes were worse for LVH, but there was no difference between MVH and HVH in terms of adequate lymphadenectomy, margin status, readmission rates, and 90-day mortality rates. CONCLUSIONS Despite lower gastrectomy volume for cancer, postoperative gastrectomy outcomes at centers that perform a high number of upper gastrointestinal cancer surgeries were similar to hospitals with high gastrectomy volume. These hospitals offer a blueprint for providing equivalent outcomes to high volume centers while enhancing availability of quality cancer care.
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Affiliation(s)
- Kelsey S Romatoski
- Department of Surgery, Section of Surgical Oncology, Boston Medical Center, Boston, MA, USA
- Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Susanna W L de Geus
- Department of Surgery, Section of Surgical Oncology, Boston Medical Center, Boston, MA, USA
- Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Bharath Miriyam
- Department of Surgery, Section of Surgical Oncology, Boston Medical Center, Boston, MA, USA
- Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Sophie H Chung
- Department of Surgery, Section of Surgical Oncology, Boston Medical Center, Boston, MA, USA
- Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Kelly Kenzik
- Department of Surgery, Section of Surgical Oncology, Boston Medical Center, Boston, MA, USA
- Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Marianna V Papageorge
- Department of Surgery, Section of Surgical Oncology, Boston Medical Center, Boston, MA, USA
- Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Department of Surgery, Yale Medical School, Yale New Haven Hospital, New Haven, CT, USA
| | - Gordana Rasic
- Department of Surgery, Section of Surgical Oncology, Boston Medical Center, Boston, MA, USA
- Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Sing Chau Ng
- Department of Surgery, Section of Surgical Oncology, Boston Medical Center, Boston, MA, USA
- Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Jennifer F Tseng
- Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Teviah E Sachs
- Department of Surgery, Section of Surgical Oncology, Boston Medical Center, Boston, MA, USA.
- Boston University, Chobanian & Avedisian School of Medicine, Boston, MA, USA.
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Shaikh CF, Woldesenbet S, Munir MM, Lima HA, Moazzam Z, Endo Y, Alaimo L, Azap L, Yang J, Katayama E, Dawood Z, Pawlik TM. Is surgical treatment of hepatocellular carcinoma at high-volume centers worth the additional cost? Surgery 2024; 175:629-636. [PMID: 37741780 DOI: 10.1016/j.surg.2023.06.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/02/2023] [Accepted: 06/18/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND Case volume has been associated with improved outcomes for patients undergoing treatment for hepatocellular carcinoma, often with higher hospital expenditures. We sought to define the cost-effectiveness of hepatocellular carcinoma treatment at high-volume centers. METHODS Patients diagnosed with hepatocellular carcinoma from 2013 to 2017 were identified from Medicare Standard Analytic Files. High-volume centers were defined as the top decile of facilities performing hepatectomies in a year. A multivariable generalized linear model with gamma distribution and a restricted mean survival time model were used to estimate costs and survival differences relative to high-volume center status. The incremental cost-effectiveness ratio was used to define the additional cost incurred for a 1-year incremental gain in survival. RESULTS Among 13,666 patients, 8,467 (62.0%) were treated at high-volume centers. Median expenditure was higher ($19,148, interquartile range $15,280-$29,128) among patients treated at high-volume centers versus low-volume centers ($18,209, interquartile range $14,959-$29,752). Despite similar median length-of-stay (6 days, interquartile range 4-9), a slightly higher proportion of patients were discharged to home from high-volume centers (n = 4,903, 57.9%) versus low-volume centers (n = 2,868, 55.2%) (P = .002). A 0.14-year (95% confidence interval 0.06-0.22) (1 month and 3 weeks) survival benefit was associated with an incremental cost of $1,070 (95% confidence interval $749-$1,392) among patients undergoing surgery at high-volume centers. The incremental cost-effectiveness ratio for treatment at a high-volume center was $7,951 (95% confidence interval $4,236-$21,217) for an additional year of survival, which was below the cost-effective threshold of $21,217. CONCLUSION Surgical care at high-volume centers offers the potential to deliver cancer care in a more cost-effective and value-based manner.
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Affiliation(s)
- Chanza Fahim Shaikh
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/cfshaikh
| | - Selamawit Woldesenbet
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Muhammad Musaab Munir
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH. https://twitter.com/musaabmunir
| | - Henrique A Lima
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Zorays Moazzam
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Yutaka Endo
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Laura Alaimo
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Lovette Azap
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Jason Yang
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Erryk Katayama
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Zaiba Dawood
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH
| | - Timothy M Pawlik
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, OH; Department of Surgery, The Urban Meyer III and Shelley Meyer Chair for Cancer Research, The Ohio State University Wexner Medical Center, Columbus, OH.
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Janssen HJB, Geraedts TCM, Simkens GA, Visser M, de Hingh IHJT, van Det MJ, Nieuwenhuijzen GAP, van Hillegersberg R, Luyer MDP, Nienhuijs SW. The impact of hospital experience in bariatric surgery on short-term outcomes after minimally invasive esophagectomy: a nationwide analysis. Surg Endosc 2024; 38:720-734. [PMID: 38040832 DOI: 10.1007/s00464-023-10560-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 10/22/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Minimally invasive esophagectomy (MIE) is a technically challenging procedure with a substantial learning curve. Composite volume of upper gastrointestinal (upper GI) procedures for cancer has been previously linked to postoperative outcomes. This study aimed to investigate an association between hospital experience in bariatric surgery and short-term outcomes in MIE. METHOD Data on esophagectomy patients between 2016 and 2020 were collected from the Dutch Upper Gastrointestinal Cancer Audit, a mandatory nationwide registry. Hospitals were categorized as bariatric or non-bariatric. Multivariable logistic regression investigated short-term postoperative outcomes, adjusting for case mix. RESULTS Of 3371 patients undergoing esophagectomy in sixteen hospitals, 2450 (72.7%) underwent MIE. Bariatric hospitals (N = 6) accounted for 1057 (43.1%) MIE. Annual volume of bariatric procedures was median 523 and esophagectomies 42. In non-bariatric hospitals, volume of esophagectomies was median 52 (P = 0.145). Overall postoperative complication rate was lower in bariatric hospitals (59.2% vs. 65.9%, P < 0.001). Bariatric hospitals were associated with a reduced risk of overall complications (aOR 0.76 [95% CI 0.62-0.92]), length of hospital (aOR 0.79 [95% CI 0.65-0.95]), and ICU stay (aOR 0.81 [95% CI 0.67-0.98]) after MIE. Surgical radicality (R0) did not differ. Lymph node yield (≥ 15) was lower in bariatric hospitals (90.0% vs. 94.7%, P < 0.001). Over the years, several short-term outcomes improved in bariatric hospitals compared to non-bariatric hospitals. CONCLUSION In this nationwide analysis, there was an association between bariatric hospitals and improved short-term outcomes after MIE. Characteristics of bariatric hospitals that could explain this phenomenon and whether this translates to other upper GI procedures may be warranted to identify.
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Affiliation(s)
- Henricus J B Janssen
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
| | - Tessa C M Geraedts
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Geert A Simkens
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
- Department of Cancer and Surgery, Imperial College London, London, UK
| | - Maurits Visser
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Ignace H J T de Hingh
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - Marc J van Det
- Department of Surgery, ZGT Hospital Group Twente, Almelo, The Netherlands
| | - Grard A P Nieuwenhuijzen
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | | | - Misha D P Luyer
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
- Department of Electrical Engineering, University of Technology Eindhoven, Eindhoven, The Netherlands
| | - Simon W Nienhuijs
- Department of Surgery, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
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Romatoski KS, Chung SH, de Geus SWL, Papageorge MV, Woods AP, Rasic G, Ng SC, Tseng JF, Sachs TE. Combined High-Volume Common Complex Cancer Operations Safeguard Long-Term Survival in a Low-Volume Individual Cancer Operation Setting. Ann Surg Oncol 2023; 30:5352-5360. [PMID: 37310536 DOI: 10.1245/s10434-023-13680-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/08/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND We previously demonstrated the importance of combined complex surgery volume on short-term outcomes of high-risk cancer operations. This study investigates the impact of combined common complex cancer operation volume on long-term outcomes at hospitals with low cancer-specific operation volumes. PATIENTS AND METHODS A retrospective cohort of National Cancer Data Base (2004-2019) patients undergoing surgery for hepatocellular carcinoma, non-small cell lung cancers, or pancreatic, gastric, esophageal, or rectal adenocarcinomas was utilized. Three separate cohorts were established: low-volume hospitals (LVH), mixed-volume hospitals (MVH) with low-volume individual cancer operations and high-volume total complex operations, and high-volume hospitals (HVH). Survival analyses were performed for overall, early-, and late-stage disease. RESULTS The 5 year survival was significantly better at MVH and HVH compared with LVH, for all operations except late-stage hepatectomy (HVH survival > LVH and MVH). The 5 year survival probability was similar between MVH and HVH for operations on late-stage cancers. Early and overall survival for gastrectomy, esophagectomy, and proctectomy were equivalent between MVH and HVH. While early and overall survival for pancreatectomy were benefited by HVH over MVH, the opposite was true for lobectomy/pneumonectomy, which were benefited by MVH over HVH; however, none of these differences were likely to have an effect clinically. Only hepatectomy patients demonstrated statistical and clinical significance in 5 year survival at HVH compared with MVH for overall survival. CONCLUSIONS MVH hospitals performing sufficient complex common cancer operations demonstrate similar long-term survival for specific high-risk cancer operations to HVH. MVH provide an adjunctive model to the centralization of complex cancer surgery, while maintaining quality and access.
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Affiliation(s)
- Kelsey S Romatoski
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sophie H Chung
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
| | - Susanna W L de Geus
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Marianna V Papageorge
- Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Alison P Woods
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gordana Rasic
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
| | - Sing Chau Ng
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
| | - Jennifer F Tseng
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA
| | - Teviah E Sachs
- Department of Surgery, Boston Medical Center, Chobanian & Avedisian School of Medicine, Boston University, Boston, MA, USA.
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5
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Magnin J, Bernard A, Cottenet J, Lequeu JB, Ortega-Deballon P, Quantin C, Facy O. Impact of hospital volume in liver surgery on postoperative mortality and morbidity: nationwide study. Br J Surg 2023; 110:441-448. [PMID: 36724824 DOI: 10.1093/bjs/znac458] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 11/17/2022] [Accepted: 12/13/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND This nationwide retrospective study was undertaken to evaluate impact of hospital volume and influence of liver transplantation activity on postoperative mortality and failure to rescue after liver surgery. METHODS This was a retrospective study of patients who underwent liver resection between 2011 and 2019 using a nationwide database. A threshold of surgical activities from which in-hospital mortality declines was calculated. Hospitals were divided into high- and low-volume centres. Main outcomes were in-hospital mortality and failure to rescue. RESULTS Among 39 286 patients included, the in-hospital mortality rate was 2.8 per cent. The activity volume threshold from which in-hospital mortality declined was 25 hepatectomies. High-volume centres (more than 25 resections per year) had more postoperative complications but a lower rate of in-hospital mortality (2.6 versus 3 per cent; P < 0.001) and failure to rescue (5 versus 6.3 per cent; P < 0.001), in particular related to specific complications (liver failure, biliary complications, vascular complications) (5.5 versus 7.6 per cent; P < 0.001). Liver transplantation activity did not have an impact on these outcomes. CONCLUSION From more than 25 liver resections per year, rates of in-hospital mortality and failure to rescue declined. Management of specific postoperative complications appeared to be better in high-volume centres.
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Affiliation(s)
- Josephine Magnin
- Department of Digestive Surgical Oncology, University Hospital of Dijon, Dijon, France
| | - Alain Bernard
- Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Centre, University Hospital of Dijon, Dijon, France.,Department of Thoracic and Cardiovascular Surgery, University Hospital of Dijon, Dijon, France
| | - Jonathan Cottenet
- Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Centre, University Hospital of Dijon, Dijon, France
| | - Jean-Baptiste Lequeu
- Department of Digestive Surgical Oncology, University Hospital of Dijon, Dijon, France
| | - Pablo Ortega-Deballon
- Department of Digestive Surgical Oncology, University Hospital of Dijon, Dijon, France
| | - Catherine Quantin
- Clinical Epidemiology/Clinical Trials Unit, Clinical Investigation Centre, University Hospital of Dijon, Dijon, France
| | - Olivier Facy
- Department of Digestive Surgical Oncology, University Hospital of Dijon, Dijon, France
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de Geus SW, Papageorge MV, Woods AP, Wilson S, Ng SC, Merrill A, Cassidy M, McAneny D, Tseng JF, Sachs TE. A Rising Tide Lifts All Boats: Impact of Combined Volume of Complex Cancer Operations on Surgical Outcomes in a Low-Volume Setting. J Am Coll Surg 2022; 234:981-988. [PMID: 35703786 PMCID: PMC9204842 DOI: 10.1097/xcs.0000000000000228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Centralization for complex cancer surgery may not always be feasible owing to socioeconomic disparities, geographic constraints, or patient preference. The present study investigates how the combined volume of complex cancer operations impacts postoperative outcomes at hospitals that are low-volume for a specific high-risk cancer operation. STUDY DESIGN Patients who underwent pneumonectomy, esophagectomy, gastrectomy, hepatectomy, pancreatectomy, or proctectomy were identified from the National Cancer Database (2004-2017). For every operation, 3 separate cohorts were created: low-volume hospitals (LVH) for both the individual cancer operation and the total number of those complex operations, mixed-volume hospital (MVH) with low volume for the individual cancer operation but high volume for total number of complex operations, and high-volume hospitals (HVH) for each specific operation. RESULTS LVH was significantly (all p ≤ 0.01) predictive for 30-day mortality compared with HVH across all operations: pneumonectomy (9.5% vs 7.9%), esophagectomy (5.6% vs 3.2%), gastrectomy (6.8% vs 3.6%), hepatectomy (5.9% vs 3.2%), pancreatectomy (4.7% vs 2.3%), and proctectomy (2.4% vs 1.3%). Patients who underwent surgery at MVH and HVH demonstrated similar 30-day mortality: esophagectomy (3.2 vs 3.2%; p = 0.993), gastrectomy (3.2% vs 3.6%; p = 0.637), hepatectomy (3.8% vs 3.2%; p = 0.233), pancreatectomy (2.8% vs 2.3%; p = 0.293), and proctectomy (1.2% vs 1.3%; p = 0.843). Patients who underwent pneumonectomy at MVH demonstrated lower 30-day mortality compared with HVH (5.4% vs 7.9%; p = 0.045). CONCLUSION Patients who underwent complex operations at MVH had similar postoperative outcomes to those at HVH. MVH provide a model for the centralization of complex cancer surgery for patients who do not receive their care at HVH.
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Affiliation(s)
- Susanna Wl de Geus
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Marianna V Papageorge
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Alison P Woods
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
- Division of Surgical Oncology, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD (Woods)
| | - Spencer Wilson
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Sing Chau Ng
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Andrea Merrill
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Michael Cassidy
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - David McAneny
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Jennifer F Tseng
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
| | - Teviah E Sachs
- From the Department of Surgery, Boston Medical Center, Boston University School of Medicine, Boston, MA (de Geus, Papageorge, Woods, Wilson, Chau Ng, Merrill, Cassidy, McAneny, Tseng, Sachs)
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