Surgeon experience with insurance barriers to offering gastric bypass as an evidence-based operation for pathologic GERD.

INTRODUCTION: Obesity is an increasingly prevalent public health problem often associated with poorly controlled gastroesophageal reflux disease. Fundoplication has been shown to have limited long-term efficacy in patients with morbid obesity and does not address additional weight-related co-morbidities. Roux-en-Y gastric bypass (RYGB) is the gold standard operation for durable resolution of GERD in patients with obesity, and is also used as a salvage operation for GERD after prior foregut surgery. Surgeons report access to RYGB as surgical treatment for GERD is often limited by RYGB-specific benefit exclusions embedded within insurance policies, but the magnitude and scope of this problem is unknown. METHODS: A 9-item survey evaluating surgeon practice and experience with insurance coverage for RYGB for GERD was developed and piloted by a SAGES Foregut Taskforce working group. This survey was then administered to surgeon members of the SAGES Foregut Taskforce and to surgeons participating in the SAGES Bariatrics and/or Foregut Facebook groups. RESULTS: 187 surgeons completed the survey. 89% reported using the RYGB as an anti-reflux procedure. 44% and 26% used a BMI of 35 kg/m2 and 30 kg/m2 respectively as cutoff for the RYGB. 89% viewed RYGB as the procedure of choice for GERD after bariatric surgery. 69% reported using RYGB to address recurrent reflux secondary to failed fundoplication. 74% of responders experienced trouble with insurance coverage at least half the time RYGB was offered for GERD, and 8% reported they were never able to get approval for RYGB for GERD indications in their patient populations. CONCLUSION: For many patients, GERD and obesity are related diseases that are best addressed with RYGB. However, insurance coverage for RYGB for GERD is often limited by policies which run contrary to evidence-based medicine. Advocacy is critical to improve access to appropriate surgical care for GERD in patients with obesity.

Severe small intestinal bacterial overgrowth syndrome after jejunal feeding requiring surgical intervention: a case report and review of the literature.

BACKGROUND: Small intestinal bacterial overgrowth (SIBO) is a condition of unknown prevalence characterized by an excessive amount of bacteria in the small bowel, typically resulting in vague gastrointestinal symptoms with bloating being most commonly reported. Here we describe a severe case of SIBO leading to small bowel necrosis requiring surgical intervention. CASE PRESENTATION: A 55-year-old Hispanic female with gastric outlet obstruction secondary to a newly diagnosed gastric adenocarcinoma, receiving neoadjuvant chemotherapy, developed bloody gastrostomy output and rapidly progressing nausea and abdominal distention 3 days after jejunostomy tube placement and initiation of jejunal enteral nutrition. Imaging revealed diffuse pneumatosis and portal venous gas. Surgical exploration confirmed segmental bowel necrosis requiring resection. Histologic findings were consistent with SIBO. CONCLUSIONS: Presentation of severe SIBO in the setting of intestinal stasis secondary to gastric outlet after initiation of enteral feeds is a rare phenomenon. Early recognition and diagnosis of SIBO is critical in minimizing patient morbidity and mortality.

Review of Operative Treatment of Delayed Presentation of Acute Cholecystitis.

Treatment of patients with delayed acute cholecystitis (AC) includes antibiotics and interval cholecystectomy based on proposed change at 72 hours from symptom onset to a chronic fibrotic phase with concern for increased complication rates. The purpose of our study was to compare the outcomes of patients undergoing laparoscopic cholecystectomy (LC) for AC before and after this golden 72-hour window. After institutional review board approval, a retrospective study was performed of patients presenting over two years with AC, who underwent LC during the index admission. A chart review was performed, and patients were divided into symptoms <72 hours (group A) and symptoms >72 hours (group B). Complications were defined as postoperative bleeding, return to operating room, and bile leaks. One hundred and eighty-four patients met the study criteria. Group A included 96 patients managed 5 to 71 hours after symptom onset, whereas Group B encompassed 88 patients with symptoms 72 to 336 hours. Both groups had similar baseline demographics and disease severity. No statistically significant differences were noted between the groups regarding overall complications or 30-day morbidity; however, Group B had an increased hospital stay length (P < 0.0001) and estimated blood loss(P = 0.028). LC seems safe despite duration of symptomatology and should be considered during the index admission in all AC patients.

A Society of Gastrointestinal and Endoscopic Surgeons (SAGES) statement on closed social media (Facebook®) groups for clinical education and consultation: issues of informed consent, patient privacy, and surgeon protection.

INTRODUCTION: Closed social media groups (CSMG), including closed Facebook® groups, are online communities providing physicians with platforms to collaborate privately via text, images, videos, and live streaming in real time and optimize patient care. CSMG platforms represent a novel paradigm in online learning and education, so it is imperative to ensure that the public and patients trust the physicians using these platforms. Informed consent is an essential aspect of establishing this trust. With the launch of several of its own CSMG, Society of Gastrointestinal and Endoscopic Surgeons (SAGES) sought to define its position on CSMG platforms and provide an informed consent template for educating and protecting patients, surgeons, and institutions. METHODS: A review of the literature (2012-2018) discussing the informed consent process for posting clinical scenarios, photography, and/or videography on social media was performed. Pertinent articles and exemplary legal counsel-approved CSMG policies and informed consent forms were reviewed by members of the SAGES Facebook® Task Force. RESULTS: Eleven articles and two institutional CSMG policies discussing key components of the informed consent process, including patient transparency and confidentiality, provider-patient partnerships, ethics, and education were included. Using this information and expert opinion, a SAGES-approved statement and informed consent template were formulated. CONCLUSIONS: SAGES endorses the professional use of medical and surgical CSMG platforms for education, patient care optimization, and dissemination of clinical information. Despite the growing use of social media as an integral tool for surgical practice and education, issues of informed consent still exist and remain the responsibility of the physician contributor. Responsible, ethical, and compliant use of CSMG platforms is essential. Surgeons and patients embracing CSMG for quality improvement and optimized outcomes should be legally protected. SAGES foresees the use of this type of platform continuing to grow.

Does Self-Assessment Improve the Effectiveness of Grand Rounds Lectures in a Community-Based Teaching Hospital?

OBJECTIVE: To determine whether use of self-assessment (SA) questions affects the effectiveness of weekly didactic grand rounds presentations. DESIGN: From 26 consecutive grand rounds presentations from August 2013 to April 2014, a 52-question multiple-choice test was administered based on 2 questions from each presentation. SETTING: Community teaching institution. PARTICIPANTS: General surgery residents, students, and attending physicians. RESULTS: The test was administered to 66 participants. The mean score was 41.8%. There was no difference in test score based on experience with similar scores for junior residents, senior residents, and attending surgeons (43%, 46%, and 44%; p = 0.13). Most participants felt they would be most interested in presentations directly related to their surgical specialty. Participants, however, did not score differently on topics which were the focus of the program (40% vs. 42%; p = 0.85). Journal club presentations (39% vs. others 42%; p = 0.33) also did not affect the score. The Pearson correlation coefficient for attendance was 0.49 (p < 0.0001) demonstrated that attendance was very important. Participation in the weekly SA was significantly associated with improved score as those who participated in SA scored over 20% higher than those who did not (59% vs. 38%; p < 0.0001). Based on multiple linear regression for mean score, SA explained the variation in score more than attendance. CONCLUSIONS: The current study found that without preparation approximately 40% of material presented is retained after 10 months. Participation in weekly SA significantly improved retention of information from grand rounds presentations.

Revisional surgery after failed esophagogastric myotomy for achalasia: successful esophageal preservation.

BACKGROUND: Treatment failure with recurrent dysphagia after Heller myotomy occurs in fewer than 10 % of patients, most of whom will seek repeat surgical intervention. These reoperations are technically challenging, and as such, there exist only limited reports of reoperation with esophageal preservation. METHODS: We retrospectively reviewed the records of patients who sought operative intervention from March 1998 to December 2014 for obstructed swallowing after esophagogastric myotomy. All patients underwent a systematic approach, including complete hiatal dissection, takedown of prior fundoplication, and endoscopic assessment of myotomy. Patterns of failure were categorized as: fundoplication failure, inadequate myotomy, fibrosis, and mucosal stricture. RESULTS: A total of 58 patients underwent 65 elective reoperations. Four patients underwent esophagectomy as their initial reoperation, while three patients ultimately required esophagectomy. The remainder underwent reoperations with the goal of esophageal preservation. Of these 58, 46 were first-time reoperations; ten were second time; and two were third-time reoperations. Forty-one had prior operations via a trans-abdominal approach, 11 via thoracic approach, and 6 via combined approaches. All reoperations at our institution were performed laparoscopically (with two conversions to open). Inadequate myotomy was identified in 53 % of patients, fundoplication failure in 26 %, extensive fibrosis in 19 %, and mucosal stricture in 2 %. Intraoperative esophagogastric perforation occurred in 19 % of patients and was repaired. Our postoperative leak rate was 5 %. Esophageal preservation was possible in 55 of the 58 operations in which it was attempted. At median follow-up of 34 months, recurrent dysphagia after reoperation was seen in 63 % of those with a significant fibrosis versus 28 % with inadequate myotomy, 25 % with failed wrap, and 100 % with mucosal stricture (p = 0.10). CONCLUSIONS: Laparoscopic reoperation with esophageal preservation is successful in the majority of patients with recurrent dysphagia after Heller myotomy. The pattern of failure has implications for relief of dysphagia with reoperative intervention.

The effect of an evidence-based medicine curriculum on breast cancer knowledge and satisfaction of surgical residents.

OBJECTIVE: The current study was performed to determine if evidence-based medicine (EBM) curriculum would affect education of surgical residents. DESIGN: A 5-year prospective study was designed to determine if EBM curriculum could improve residents' satisfaction and understanding of breast cancer management during a breast surgical oncology rotation. During the first 2 years, 45 journal articles were used. During the subsequent 3 years, journal articles were not used. The proportion of patients seen in clinic was collected as an objective measure of the "effort" made by the resident. The final assessment was a 120-question examination. SETTING: Maricopa Medical Center, Phoenix, AZ. Safety net institution with General Surgery residency program. PARTICIPANTS: Postgraduate year 2 general surgery residents. RESULTS: Over 5 years, 30 postgraduate year 2 residents were involved. Univariate analysis showed that female sex (p = 0.04), residents with peer-reviewed publications (p = 0.03), younger age (p = 0.04), American Board of Surgery in-service training examination score (p = 0.01), and clinical effort (p < 0.01) were associated with higher scores. Although residents taught using the journal articles scored 7 points higher on the final examination, this was not significant (p = 0.10). Multivariate analysis showed that American Board of Surgery in-service training examination score and clinic efficiency remained statistically significant. Residents who were taught using the EBM curriculum had significantly higher satisfaction (4.4 vs 3.5, p = 0.001) compared with those who did not go through the EBM curriculum. CONCLUSIONS: The current study demonstrates that an EBM curriculum significantly improved resident satisfaction with the rotation. The EBM curriculum may improve residents' breast cancer knowledge. The most important predictor of resident performance was the effort of resident.

Needle before the knife: nonoperative management of pneumoperitoneum with image-guided aspiration after gastrointestinal perforation.

This case series documents the management of 3 acute gastrointestinal perforations secondary to upper endoscopic procedures and presents the use of nonoperative management with percutaneous aspiration in lieu of immediate surgical intervention. A growing number of endoscopists are using more advanced resection techniques, further potentiating the risk of gastrointestinal injury, including perforation. When localized perforations occur, endoscopic management has become an effective treatment option. Perforations that cannot be localized, sealed, or successfully treated with endoscopic closure have traditionally required an exploratory laparotomy. However, this series suggests that nonoperative management with percutaneous procedures may be successfully utilized in select patients. In 2 of the cases reported, no closure techniques were used and expectant management resulted in successful outcomes. This study suggests that the use of image-guided aspiration and serial abdominal exams can be utilized successfully in select patients. Image-guided needle aspiration of pneumoperitoneum can decrease patient discomfort and allow reliable serial physical examination, potentially eliminating unnecessary surgery.

Hypometabolizers: characteristics of obese patients with abnormally low resting energy expenditure.

Weight gain or loss is determined by the difference between calorie intake and energy expenditure. The Mifflin metabolic equation most accurately predicts resting energy expenditure (REE) in morbidly obese patients. Hypometabolizers have a measured REE that is much less than predicted and pose the greatest challenge for weight loss induced by restriction of calorie intake. We studied 628 morbidly obese patients (467 female and 161 men, aged 52.5 ± 15.7 years, body mass index [BMI] of 42.6 ± 7.6 m/kg(2) [mean ± SD]). REE was measured using the MedGem® device (REEm) and the percentage variance (ΔREE%) from the Mifflin-predicted expenditure (REEp) was calculated. Patients with ΔREE% more than 1 standard deviation from the mean were defined as hypometabolizers (REEm greater than 27% below REEp) and hypermetabolizers (REEm less than 13% above REEp), respectively. Hypometabolizers had greater REEp (1900 ± 301 vs 1719 ± 346 calories, P = 0.005) and lower REEm (1244 ± 278 vs 2161 ± 438 calories, P < 0.0001) than hypermetabolizers. Hypometabolizers, when compared with hypermetabolizers, were taller (167.2 ± 8.4 vs 164.0 ± 10.9 cm, P = 0.04), heavier (123.6 ± 22.2 vs 110.2 ± 23.1 kg, P = 0.006), and had increased BMI (44.1 ± 6.5 vs 40.8 ± 6.5 kg/m(2), P = 0.04). Other measured anthropometrics were not different between hypo- and hypermetabolizers. Hypometabolizers were less likely to be diabetic (23 vs 43%, P = 0.03) and more likely to be black (25 vs 5%, P = 0.002) than hypermetabolizers. This study defines hypometabolizers as having variance in REEm more than 27 per cent below that predicted by the Mifflin equation. We could not identify any distinguishing phenotypic characteristics of hypometabolizers, suggesting an influence unrelated to body composition.

Will there be a good general surgeon when you need one?

INTRODUCTION: The Public Policy & Advocacy Committee sponsored the panel on the topic of "Will There Be a General Surgeon When You Need One?" at the 2012 Annual Meeting of the SSAT. The panel of experts was convened to formulate recommendations to help general surgeons adapt to the changing landscape which will undoubtedly affect the practice of surgery in the future. The invited speakers were Drs. David Hoyt, Carlos Pellegrini, Kaye M. Reid-Lombardo, and David Rattner. The session was moderated by Drs. Ross Goldberg and Tara Kent. The invited presentations and audience commentary are the basis of this manuscript.

Laparoscopic partial sleeve duodenectomy (PSD) for nonampullary duodenal neoplasms: avoiding a whipple by separating the duodenum from the pancreatic head.

OBJECTIVE: To learn the clinical outcome of patients undergoing laparoscopic partial sleeve duodenectomy (PSD) for lesions, which require sleeve resection of the duodenum. Traditionally, these lesions require en bloc excision of the head of the pancreas performed in an open fashion. METHODS: A retrospective review of medical records of patients with nonampullary large or circumferential duodenal lesions, which were not amenable to endoscopic or local resection for complete removal, was performed. Characteristics, complications, and technical details were analyzed. RESULTS: Ten patients (5 men and 5 women; mean age, 70 years) with duodenal lesions including adenoma (n = 5), adenocarcinoma (n = 2), lymphangiolipoma (n = 1), leiomyoma (n = 1), and neuroendocrine tumor (n = 1) were included. All patients underwent a laparoscopic approach with either a proximal PSD (n = 3) or distal PSD (n = 7) after separation of the duodenum from the pancreatic head. Reconstruction was carried out by a side-to-side duodenojejunostomy (n = 7), end-to-side duodenojejunostomy (n = 2), or gastrojejunostomy (n = 1). Mean length of stay was 5.6 days, and complications were 20%. CONCLUSIONS: Laparoscopic PSD seems to be a safe and easily applicable technique for treatment of duodenal lesions not involving the ampulla, which requires separation of the duodenum from the pancreas head with sleeve resection of the duodenum and subsequent reconstruction.

Comparison of open with laparoscopic distal pancreatectomy: a single institution's transition over a 7-year period.

OBJECTIVES: Many studies have shown laparoscopic distal pancreatectomy (LDP) to have benefits over open distal pancreatectomy (ODP). This institution made a unique abrupt transition from an exclusively open approach to a preference for the laparoscopic technique. This study aimed to compare outcomes in patients undergoing LDP and ODP, respectively, over the period of transition. METHODS: A retrospective review of all patients undergoing LDP (n = 82) or ODP (n = 90) was performed. Surrogate oncologic markers for the subgroup of patients with malignant disease were also studied. RESULTS: The ODP and LDP groups were well matched with regard to demographics, comorbidities and tumour characteristics. Significant differences were noted in favour of the LDP group in which decreases were seen in estimated blood loss (<0.001), need for packed red blood cell transfusions (<0.001), length of hospital stay (<0.001) and intensive care unit stay (<0.001). No other significant differences in the occurrence of complications or oncologic outcomes were seen. Rates of Grade B and C fistulae were 10% and 6% in the ODP and LDP groups, respectively. Grade III-V complications occurred in 20% and 13% of the ODP and LDP groups, respectively. CONCLUSIONS: Laparoscopic distal pancreatectomy continues to compare favourably with ODP when well-matched patient series are reviewed. The results show a decreased need for blood transfusions and hospital resources in LDP. Additionally, there may be oncologic advantages associated with LDP compared with ODP in pancreatic malignancies.

Variability of NSQIP-assessed surgical quality based on age and disease process.

BACKGROUND: Recent national attention has focused on improving upon the surgical quality of hospitals across the United States. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database includes expected morbidity probability for each surgical patient. We sought to investigate the accuracy of this probability across the spectrum of general surgical operations and assess the variability based on the age and disease process. MATERIALS AND METHODS: Using the 2008 ACS-NSQIP database, we identified 190,929 operations that would be in the scope of practice of a modern general surgeon; the four most common included breast resection (n = 22,175; 11.6%), colon resection (n = 21,363; 11.2%), cholecystectomy (n = 20,889; 10.9%), and inguinal hernia repair (n = 11,709; 6.1%). We calculated the surgical observed versus expected morbidity rates (O/E) of each operation type and compared them by decile of patient age. We then determined the effect of case mix and patient age on theoretical hospitals performing at the NSQIP average. RESULTS: There is substantial variability in O/E ratios when comparing these disease processes across deciles of age. For patients undergoing breast resections, 67.2% of morbidities were solely attributed to 30-d reoperations; colon resections had an O/E ratio greater than 1 for all age deciles except over 90 y old. For cholecystectomies and the majority of patients undergoing inguinal hernia repairs, there was a lower morbidity rate than expected. Case mix and patient age were found to independently affect assessment of hospital quality. CONCLUSIONS: It is conceivable that general surgery case mix and patient age could independently affect the quality assessment of a hospital. This variability may have implications for overall quality measures.

Technical and perioperative outcomes of minimally invasive esophagectomy in the prone position.

BACKGROUND: Minimally invasive esophagectomy (MIE) is performed through various approaches, including using video-assisted thoracoscopic surgery for mediastinal esophageal dissection. The prone technique allows for gravity-aided retraction of the lung. The aim of this study was to examine perioperative outcomes after prone MIE in relation to patient preoperative comorbidities. METHODS: A retrospective cohort study from our single tertiary-care center is presented. Between January 2007 and August 2010, a total of 42 patients underwent three-field prone MIE. The majority of patients were male (37 vs. 5 female), with an average age of 68 years (range = 37-87). The diagnoses for patients who underwent MIE were 35 adenocarcinoma, four Barrett's esophagus with high-grade dysplasia, two achalasia, and one squamous cell carcinoma. Neoadjuvant chemotherapy with or without radiotherapy was administered to 16 (38 %) patients. Preoperative comorbidities were quantified using the Modified Charlson Comorbidity Index; low risk was defined as a score of 0-2 (23 patients), moderate risk 3-4 (14 patients), and high risk 5 or higher (five patients). Postoperative complications were stratified using the Clavien Classification Scale; minor complications were grades 1 and 2 and major complications were grades 3-5. RESULTS: Median length of hospital stay was 8 days (range = 6-51) and median ICU stay was 2 days (range = 1-26). Average prone surgical time was 108 min (range = 67-198). Thirty-seven of 42 patients (88 %) were extubated on the day of operation. Postoperatively, all five high-risk patients had a complication, three of which were major. Eight of the 14 moderate-risk patients had a complication and three were major, and 17 of the 23 low-risk group had a complication with nine being major. There was a total of 15 major complications. Predominant complications were arrhythmias (15) and pneumonia (five), with four anastomotic leaks and two postoperative 30-day mortalities. CONCLUSIONS: This series supports using prone MIE. Despite a clinical pathway, including immediate extubation postoperatively, there is still a risk of pulmonary complications that appears to correlate with higher preoperative comorbidity scores.

National trends in resection of the distal pancreas.

AIM: To investigate national trends in distal pancreatectomy (DP) through query of three national patient care databases. METHODS: From the Nationwide Inpatient Sample (NIS, 2003-2009), the National Surgical Quality Improvement Project (NSQIP, 2005-2010), and the Surveillance Epidemiology and End Results (SEER, 2003-2009) databases using appropriate diagnostic and procedural codes we identified all patients with a diagnosis of a benign or malignant lesion of the body and/or tail of the pancreas that had undergone a partial or distal pancreatectomy. Utilization of laparoscopy was defined in NIS by the International Classification of Diseases, Ninth Revision correspondent procedure code; and in NSQIP by the exploratory laparoscopy or unlisted procedure current procedural terminology codes. In SEER, patients were identified by the International Classification of Diseases for Oncology, Third Edition diagnosis codes and the SEER Program Code Manual, third edition procedure codes. We analyzed the databases with respect to trends of inpatient outcome metrics, oncologic outcomes, and hospital volumes in patients with lesions of the neck and body of the pancreas that underwent operative resection. RESULTS: NIS, NSQIP and SEER identified 4242, 2681 and 11,082 DP resections, respectively. Overall, laparoscopy was utilized in 15% (NIS) and 27% (NSQIP). No significant increase was seen over the course of the study. Resection was performed for malignancy in 59% (NIS) and 66% (NSQIP). Neither patient Body mass index nor comorbidities were associated with operative approach (P = 0.95 and P = 0.96, respectively). Mortality (3% vs 2%, P = 0.05) and reoperation (4% vs 4%, P = 1.0) was not different between laparoscopy and open groups. Overall complications (10% vs 15%, P < 0.001), hospital costs [44,741 dollars, interquartile range (IQR) 28 347-74 114 dollars vs 49 792 dollars, IQR 13 299-73 463, P = 0.02] and hospital length of stay (7 d, IQR 4-11 d vs 7 d, IQR 6-10, P < 0.001) were less when laparoscopy was utilized. One and two year survival after resection for malignancy were unchanged over the course of the study (ductal adenocarinoma 1-year 63.6% and 2-year 35.1%, P = 0.53; intraductal papillary mucinous neoplasm and nueroendocrine 1-year 90% and 2-year 84%, P = 0.25). The majority of resections were performed in teaching hospitals (77% NIS and 85% NSQIP), but minimally invasive surgery (MIS) was not more likely to be used in teaching hospitals (15% vs 14%, P = 0.26). Hospitals in the top decile for volume were more likely to be teaching hospitals than lower volume deciles (88% vs 43%, P < 0.001), but were no more likely to utilize MIS at resection. Complication rate in teaching and the top decile hospitals was not significantly decreased when compared to non-teaching (15% vs 14%, P = 0.72) and lower volume hospitals (14% vs 15%, P = 0.99). No difference was seen in the median number of lymph nodes and lymph node ratio in N1 disease when compared by year (P = 0.17 and P = 0.96, respectively). CONCLUSION: There appears to be an overall underutilization of laparoscopy for DP. Centralization does not appear to be occurring. Survival and lymph node harvest have not changed.

Breast surgery outcomes as quality measures according to the NSQIP database.

BACKGROUND: The National Surgical Quality Improvement Program (NSQIP) is a risk-adjusted database designed to benchmark quality initiatives. NSQIP captures uniform morbidity variables for all operations and calculates expected morbidity probabilities. Given the frequent need for reoperation following breast-conserving surgery (BCS) and mastectomy, we hypothesized that NSQIP may inaccurately reflect surgical morbidity after breast cancer operations. METHODS: Using the 2008 NSQIP database, we identified 24,447 breast surgery patients. We calculated the observed versus expected (O/E) morbidity ratios, compared them to other general surgery procedures, and analyzed the O/E morbidity ratios among benign and malignant breast diagnoses. RESULTS: The NSQIP database shows that breast surgery has an O/E morbidity ratio of 3.11, which is higher than other general surgery procedures. Additionally, breast operations for malignancy have higher O/E morbidity ratios (3.22) than those performed for benign disease (2.59). Analysis of malignant patients by CPT code revealed that BCS patients had an O/E morbidity ratio of 7.75 and attributed 89 % of morbidity to reoperation, whereas mastectomy patients had an O/E morbidity ratio of only 1.7. Elimination of the reoperation variable from morbidity calculations in breast surgery reduces the O/E morbidity ratio to less than expected in all breast procedures. DISCUSSION: Breast surgery has a higher O/E morbidity ratio than other general surgery procedures. Reoperations are expected in BCS for positive margins and in mastectomy for completion ALND. Breast surgeons should advocate for benchmarking by surgical site-specific metrics, because current NSQIP criteria may negatively affect the quality assessment of high-volume breast centers.