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Papers by Brent Matthews

Biomedicine Pharmacotherapy, Feb 1, 2002

W. Keat Cheah, MD,1 Orlo H. Clark, MD,2 Jan K. Horn, MD,3 Allan E. Siperstein, MD,1 Quan-Yang Duh... more W. Keat Cheah, MD,1 Orlo H. Clark, MD,2 Jan K. Horn, MD,3 Allan E. Siperstein, MD,1 Quan-Yang Duh, MD1 ... 1Department of Surgery, University of California San Francisco, Veterans Affairs Medical Center, 4150 Clement Street, San Francisco, California 94121, USA ...

Annals of Surgery, 2017

The aim of the study was to evaluate biosynthetic absorbable mesh in single-staged contaminated (... more The aim of the study was to evaluate biosynthetic absorbable mesh in single-staged contaminated (Centers for Disease Control class II and III) ventral hernia (CVH) repair over 24 months. Background: CVH has an increased risk of postoperative infection. CVH repair with synthetic or biologic meshes has reported chronic biomaterial infections and high hernia recurrence rates. Methods: Patients with a contaminated or clean-contaminated operative field and a hernia defect at least 9 cm 2 had a biosynthetic mesh (open, sublay, retrorectus, or intraperitoneal) repair with fascial closure (n ¼ 104). Endpoints included overall Kaplan-Meier estimates for hernia recurrence and postoperative wound infection rates at 24 months, and the EQ-5D and Short Form 12 Health Survey (SF-12). Analyses were conducted on the intent-totreat population, and health outcome measures evaluated using paired t tests. Results: Patients had a mean age of 58 years, body mass index of 28 kg/m 2 , 77% had contaminated wounds, and 84% completed 24-months follow-up. Concomitant procedures included fistula takedown (n ¼ 24) or removal of infected previously placed mesh (n ¼ 29). Hernia recurrence rate was 17% (n ¼ 16). At the time of CVH repair, intraperitoneal placement of the biosynthetic mesh significantly increased the risk of recurrences (P 0.04). Surgical site infections (19/104) led to higher risk of recurrence (P < 0.01). Mean 24-month EQ-5D (index and visual analogue) and SF-12 physical component and mental scores improved from baseline (P < 0.05). Conclusions: In this prospective longitudinal study, biosynthetic absorbable mesh showed efficacy in terms of long-term recurrence and quality of life for CVH repair patients and offers an alternative to biologic and permanent synthetic meshes in these complex situations.

Surgical Technology International, Nov 1, 2014

Although synthetic mesh has dramatically reduced recurrence in elective hernia repair, its use in... more Although synthetic mesh has dramatically reduced recurrence in elective hernia repair, its use in contaminated surgical fields has been traditionally associated with complications such as wound sepsis, enterocutaneous fistulas, and chronic prosthetic infection. Biologic meshes emerged in the late 1990s with a rapid popularity fueled largely by the demand for an appropriate substitute in lieu of synthetic mesh in these complex cases; however, the high cost and rate of hernia recurrence have tempered the initial enthusiasm. Biosynthetic meshes were developed as a possible cost-effective alternative to both synthetic and tissue-derived products. Using biodegradable polymers instead of animal or cadaver tissue, they provide a temporary scaffold for deposition of proteins and cells necessary for tissue ingrowth, neovascularization, and host integration. Herein we review the current status of biosynthetic meshes for hernia repair.

The American Surgeon, 2000

Nonfunctioning neuroendocrine tumors of the pancreas are rare slow-growing tumors with a more ind... more Nonfunctioning neuroendocrine tumors of the pancreas are rare slow-growing tumors with a more indolent natural history compared with pancreatic adenocarcinoma. This retrospective report reviews the surgical experience with nonfunctioning neuroendocrine tumors in an academic referral center. Statistical analysis was performed using Student's t test and Kaplan-Meier method compared with log-rank tests. Thirty-eight patients (24 males and 14 females) underwent surgery for a neuroendocrine tumor of the pancreas from 1984 through 1999. Twenty-eight patients with a mean age of 59.9 years had nonfunctioning islet cell tumors and 10 patients with a mean age of 59.1 years had functioning islet cell tumors (four gastrinomas, three glucagonomas, two insulinomas, and one vipoma). The nonfunctioning islet cell tumors were located in the head, neck, or uncinate process in 14 patients (50%), the body in seven (25%), and the tail in seven (25%). Operative procedures for the nonfunctioning islet cell tumors included nine pancreaticoduodenectomies, 12 distal pancreatectomies, three palliative bypasses, and four exploratory laparotomies without a resection or bypass. Mean survival for the four patients explored and not resected or bypassed was 7 months. Median survival for node-negative patients was 124 months, for node-positive patients 75 months, and for patients with metastasis to the liver 9 months. Estimated 2-year actuarial survival for the node-negative patients was 77.8 per cent, for node-positive patients 71.4 per cent, and for patients with metastasis to the liver 36.4 per cent. Six patients (60%) with node-negative disease, three (43%) with node-positive disease, and one (9%) with metastasis to the liver are alive at a mean follow-up of 41.8 months (range 1-167). Significant differences in median survival and 2-year survival were demonstrated between the node-positive/node-negative patients and those with metastasis to the liver (P = 0.003). Patients with localized nonmetastatic disease should be considered for pancreatic resection as estimated median survival is 75 months or greater. Hepatic metastasis is a major predictor of survival.

Surgical Endoscopy, 2011

This study aimed to compare the physicomechanical properties of composite prostheses for laparosc... more This study aimed to compare the physicomechanical properties of composite prostheses for laparoscopic ventral hernia repair (LVHR) through standard testing and a proposed classification system. Seven prostheses (four with absorbable barriers and 3 with nonabsorbable barriers) were evaluated. The barrier layer was removed, after which the area of the interstices and the diameter of the filaments were determined. The barrier layer was left intact during thickness, density, suture retention strength, tear resistance, uniaxial tensile, and ball-burst testing. Specimens were oriented parallel or perpendicular to their longest dimension during testing. One-way analysis of variance (ANOVA) with Tukey&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s posttest or an unpaired, two-tailed t-test was performed to determine whether differences existed due to mesh or orientation, and a p value&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.05 was considered significant. Significant differences were observed between mesh types and due to the orientation of the mesh during testing. Of the absorbable barrier meshes, Bard Sepramesh IP Composite demonstrated the greatest suture retention and tear strengths, followed by C-QUR mesh. Of the permanent barrier meshes, DUALMESH demonstrated the greatest suture retention strength in the perpendicular direction, followed by Bard Composix E/X. DUALMESH and Bard Composix E/X demonstrated equivalent suture retention strength in the parallel direction and equivalent tear resistance in both testing directions. All meshes demonstrated tensile strengths greater than the physiologically relevant range of 16-32 N/cm. This study provided a basic understanding of how the structural aspects of each mesh design influence functionality. Differences between composite barrier prostheses commonly used for LVHR were observed due to barrier type, mesh type, and orientation. A set of standard testing techniques and a classification system also were presented to define fully the properties of these materials.

The SAGES Manual of Hernia Repair, 2012

The US markets for soft tissue repair report prepared by the Millennium Research Group estimates ... more The US markets for soft tissue repair report prepared by the Millennium Research Group estimates that 305,900 ventral hernias were performed in the United States in 2006 [1], reaffirming ventral hernia repair as one of the most common procedures in general surgery. The 10-year cumulative rate of recurrence for suture repair of ventral hernias is as high as 63 %, which contributes to the high incidence of repair [2]. Significant risk factors for recurrence include surgical technique, history of previous failed hernia repairs, large hernia size, obesity, smoking habits, and patient comorbidities that contribute to diminished soft tissue integrity. To reduce recurrence to a 10-year cumulative rate <32 %, level A and B evidence supports reinforcement with synthetic or biologic materials for all incisional ventral hernia repairs [2, 3]. Likely attributable to evidence-based recommendations for material reinforcement, it is estimated that synthetic or biologic reinforcement materials were used in nearly 95 % of the ventral hernias performed in the United States in 2006 [1]. Market analysts predict a 7 % annual growth rate in the The US markets for soft tissue repair report prepared by the Millennium Research Group estimates that 305,900 ventral hernias were performed in the United States in 2006 [1], reaffirming ventral hernia repair as one of the most common procedures in general surgery. The 10-year cumulative rate of recurrence for suture repair of ventral hernias is as high as 63 %, which contributes to the high incidence of repair [2]. Significant risk factors for recurrence include surgical technique, history of previous failed hernia repairs, large hernia size, obesity, smoking habits, and patient comorbidities that contribute to diminished soft tissue integrity. To reduce recurrence to a 10-year cumulative rate <32 %, level A and B evidence supports reinforcement with synthetic or biologic materials for all incisional ventral hernia repairs [2, 3]. Likely attributable to evidence-based recommendations for material reinforcement, it is estimated that synthetic or biologic reinforcement materials were used in nearly 95 % of the ventral hernias performed in the United States in 2006 [1]. Market analysts predict a 7 % annual growth rate in the $1 billion United States soft tissue repair device industry, largely impelled by costly biologic scaffold materials for ventral hernia repair. The aging patient population, the prevalence of comorbidities contributing to diminished soft tissue integrity, the high incidence of obesity, and the rising demand for bariatric procedures with high potential for sequelae of incisional ventral hernias are major factors driving the anticipated market expansion for ventral hernia reinforcement materials. In particular, demand for biologic scaffold materials is expected to expand based on preclinical evidence that biologic materials enable revascularization of soft tissue repair sites and improved pathogen clearance in contaminated and infected surgical sites [4, 5] and clinical evidence that biologic materials do not necessarily require removal when exposed or infected [6–8]. billion United States soft tissue repair device industry, largely impelled by costly biologic scaffold materials for ventral hernia repair. The aging patient population, the prevalence of comorbidities contributing to diminished soft tissue integrity, the high incidence of obesity, and the rising demand for bariatric procedures with high potential for sequelae of incisional ventral hernias are major factors driving the anticipated market expansion for ventral hernia reinforcement materials. In particular, demand for biologic scaffold materials is expected to expand based on preclinical evidence that biologic materials enable revascularization of soft tissue repair sites and improved pathogen clearance in contaminated and infected surgical sites [4, 5] and clinical evidence that biologic materials do not necessarily require removal when exposed or infected [6–8].

The American surgeon, 2003

The purpose of this study is to review our initial experience with a minimally invasive approach ... more The purpose of this study is to review our initial experience with a minimally invasive approach to manage symptomatic epiphrenic esophageal diverticula. Five patients with symptomatic epiphrenic esophageal diverticula underwent surgical management between August 1997 and December 2002. All patients complained of dysphagia; had experienced symptoms for at least 12 months; and were evaluated preoperatively by a barium esophagram, esophagogastroduodenoscopy, and esophageal manometry. The epiphrenic esophageal diverticula measured 5 cm or less in all patients. Manometry demonstrated esophageal dysmotility in three patients. A minimally invasive technique was completed in all five patients. Four patients underwent laparoscopic diverticulectomy and myotomy including a concomitant Toupet fundoplication, and one patient underwent thoracoscopic diverticulectomy and myotomy. The mean operative time was 245 minutes (range 175-334). The longest operative time was for the thoracoscopic procedur...

Surgical technology international, 2014

Surgical Endoscopy, 2014

Expenditures on material supplies and medications constitute the greatest per capita costs for su... more Expenditures on material supplies and medications constitute the greatest per capita costs for surgical missions. We hypothesized that supply acquisition at non-profit organization (NPO) costs would lead to significant cost-savings compared with supply acquisition at US academic institution costs from the provider perspective for hernia repairs and minor procedures during a surgical mission in the Dominican Republic. Items acquired for a surgical mission were uniquely QR-coded for accurate consumption accounting. Both NPO and US academic institution unit costs were associated with each item in an electronic inventory system. Medication doses were recorded and QR codes for consumed items were scanned into a record for each sampled procedure. Mean material costs and cost-savings ± SDs were calculated in US dollars for each procedure type. Cost-minimization analyses between the NPO and the US academic institution platforms for each procedure type ensued using a two-tailed Wilcoxon matched-pairs test with α = 0.05. Item utilization analyses generated lists of most frequently used materials by procedure type. The mean cost-savings of supply acquisition at NPO costs for each procedure type were as follows: 482.86±482.86 ± 482.86±683.79 for unilateral inguinal hernia repair (n = 13); 332.46±332.46 ± 332.46±184.09 for bilateral inguinal hernia repair (n = 3); 127.26±127.26 ± 127.26±13.18 for hydrocelectomy (n = 9); 232.92±232.92 ± 232.92±56.49 for femoral hernia repair (n = 3); 120.90±120.90 ± 120.90±30.51 for umbilical hernia repair (n = 8); 36.59±36.59 ± 36.59±17.76 for minor procedures (n = 26); and 120.66±120.66 ± 120.66±14.61 for pediatric inguinal hernia repair (n = 7). Supply acquisition at NPO costs leads to significant cost-savings compared with supply acquisition at US academic institution costs from the provider perspective for inguinal hernia repair, hydrocelectomy, umbilical hernia repair, minor procedures, and pediatric inguinal hernia repair during a surgical mission in the Dominican Republic. Item utilization analysis can generate minimum-necessary material lists for each procedure type to reproduce cost-savings for subsequent missions.

Journal of the American College of Surgeons, 2011

For meshes to be used effectively for hernia repair, it is imperative that engineers and surgeons... more For meshes to be used effectively for hernia repair, it is imperative that engineers and surgeons standardize the terminology and techniques related to physicomechanical evaluation of these materials. The objectives of this study were to propose standard techniques, perform physicomechanical testing, and classify materials commonly used for inguinal hernia repair. Nine meshes were evaluated: 4 polypropylene, 1 polyester, 1 polytetrafluoroethylene, and 3 partially absorbable. Physical properties were determined through image analysis, laser micrometry, and density measurements. Biomechanical properties were determined through suture retention, tear resistance, uniaxial, and ball burst testing with specimens tested in 2 different orientations. A 1-way ANOVA with Tukey&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s post-test or a t-test were performed, with p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05. Significant differences were observed due to both mesh type and orientation. Areas of interstices ranged from 0.33 ± 0.01 mm² for ProLite (Atrium Medical Corp) and C-QUR Lite (Atrium Medical Corp) Large to 4.10 ± 0.06 mm² for ULTRAPRO (Ethicon), and filament diameters ranged from 99.00 ±8.1 μm for ProLite Ultra (Atrium Medical Corp) and C-QUR Lite Small to 338.8 ± 3.7 μm for Parietex Flat Sheet TEC (Covidien). These structural characteristics influenced biomechanical properties such as tear resistance and tensile strength. ProLite Ultra, C-QUR Lite Small, ULTRAPRO and INFINIT (WL Gore &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp; Associates) did not resist tearing as effectively as the others. All meshes exhibited supraphysiologic burst strengths except INFINIT and ULTRAPRO. Significant differences exist between the physicomechanical properties of polypropylene, polyester, polytetrafluoroethylene, and partially absorbable mesh prostheses commonly used for inguinal hernia repair. Orientation of the mesh was also shown to be critical for the success of meshes, particularly those demonstrating anisotropy.

Journal of the American College of Surgeons, 2014

Journal of Gastrointestinal Surgery, 1998

Internal hernias involve protrusion of viscera through the peritoneum or mesentery into a compart... more Internal hernias involve protrusion of viscera through the peritoneum or mesentery into a compartment in the abdominal cavity. Hernias occurring through the mesosigmoid are rare and the most common presentation of this entity is an acute small intestinal obstruction. Preoperative diagnosis is often difficult and the diagnosis is usually made at surgery. Traditionally, open surgery is used to manage a meso-sigmoid hernia. We report a patient with meso-sigmoid hernia causing intestinal obstruction managed successfully by the laparoscopic approach.

Annals of Surgery, 2013

The study purpose was to evaluate the associations between patient characteristics or surgical si... more The study purpose was to evaluate the associations between patient characteristics or surgical site classifications and the histologic remodeling scores of biologic meshes biopsied from abdominal soft tissue repair sites in the first attempt to generate a multivariable risk-prediction model of nonconstructive remodeling. Host characteristics and surgical site assessments may predict remodeling degree for biologic meshes used to reinforce abdominal tissue repair sites. Biologic meshes were biopsied from the abdominal tissue repair sites of n = 40 patients during an abdominal reexploration, stained with hematoxylin and eosin, and evaluated according to a semi-quantitative scoring system for remodeling characteristics (cell types, cell infiltration, extracellular matrix deposition, scaffold degradation, fibrous encapsulation, and neovascularization) and a mean composite score. Biopsies were stained with Sirius Red and Fast Green and analyzed to determine the collagen I:III ratio. On the basis of univariate analyses between subject clinical characteristics or surgical site classification and the histologic remodeling scores, cohort variables were selected for multivariable regression models using P ≤ 0.200. The model selection process for cell infiltration score yielded 2 variables: age at mesh implantation and mesh classification (C statistic = 0.989). For the mean composite score, the model selection process yielded 2 variables: age at mesh implantation and mesh classification (r = 0.449). These preliminary results constitute the first steps in generating a risk-prediction model that predicts the patients and clinical circumstances most likely to experience nonconstructive remodeling of abdominal tissue repair sites with biologic mesh reinforcement.

Annals of Surgery, 2012

The objective of this study was to characterize the physicomechanical, thermal, and degradation p... more The objective of this study was to characterize the physicomechanical, thermal, and degradation properties of several types of biologic scaffold materials to differentiate between the various materials. As more biologic scaffold materials arrive on the market, it is critical that surgeons understand the properties of each material and are provided with resources to determine the suitability of these products for specific applications such as hernia repair. Twelve biologic scaffold materials were evaluated, including crosslinked and non-crosslinked; those of bovine, human, and porcine origin; and derivatives of pericardium, dermis, and small intestine submucosa. Physicomechanical, thermal, and degradation properties were evaluated through biomechanical testing, modulated differential scanning calorimetry, and collagenase digestion assays, respectively. Biomechanical testing included suture retention, tear strength, uniaxial tensile, and ball burst techniques. All scaffolds exhibited suture retention strengths greater than 20 N, but only half of the scaffolds exhibited tear resistance greater than 20 N, indicating that some scaffolds may not provide adequate resistance to tearing. A wide range of burst strengths were observed ranging from 66.2 ± 10.8 N/cm for Permacol to 1,028.0 ± 199.1 N/cm for X-Thick AlloDerm, and all scaffolds except SurgiMend, Strattice, and CollaMend exhibited strains in the physiological range of 10% to 30% (at a stress of 16 N/cm). Thermal analysis revealed differences between crosslinked and non-crosslinked materials with crosslinked bovine pericardium and porcine dermis materials exhibiting a higher melting temperature than their non-crosslinked counterparts. Similarly, the collagenase digestion assay revealed that crosslinked bovine pericardium materials resisted enzymatic degradation significantly longer than non-crosslinked bovine pericardium. Although differences were observed because of cross-linking, some crosslinked and non-crosslinked materials exhibited very similar properties. Variables other than cross-linking, such as decellularization/sterilization treatments or species/tissue type also contribute to the properties of the scaffolds.

The American Surgeon, Dec 1, 2003

The type of incisional instrument used to create a surgical wound can influence the rate of wound... more The type of incisional instrument used to create a surgical wound can influence the rate of wound healing and overall wound strength. The purpose of this study was to evaluate several facets of wound healing within incisions created in the small intestine, uterus, and skin in a porcine model by using feedback circuit electrosurgical generators and a standard steel scalpel blade in a porcine model. Eighteen pigs were evaluated by creating surgical incisions in the skin, uterus, and small intestine utilizing 2 computerized electrosurgical generators (FX, ValleyLab, Boulder, CO, and PEGASYS, Ethicon Endo-Surgery, Inc., Cincinnati, OH) and a scalpel blade. All incisions were reapproximated with absorbable suture. Incision sites were evaluated histologically at 3, 7, or 14 days postincision according to randomization. The skin and small intestine samples were tested for wound tensile strength at 7 and 14 days. There were no statistically significant differences demonstrated with tensile strength testing comparing the electrosurgical devices to the scalpel-blade incisions for skin or small intestine at all time points. The only significant difference detected with respect to wound tensile strength was when different organ types were compared, regardless of device used (i.e., skin, 19.5 N/cm2 vs. small intestine, 5.78 N/cm2). Histologic evaluation demonstrated that the wounds created by the electrosurgical generators displayed decreased overall wound healing at 3, 7, and 14 days compared to the scalpel group. These findings indicate that the electrosurgical devices tested delay wound healing at the surgical site, but fail to demonstrate any significant difference in overall wound tensile strength. Wound healing may occur at a more rapid rate when a traditional scalpel blade is used to create the surgical incision, but no difference in global wound dynamics could be detected.

The American Surgeon, Aug 1, 2002

Surgical Endoscopy, Jun 1, 2009

The purpose of this study is to characterize the esophageal motor and lower esophageal sphincter ... more The purpose of this study is to characterize the esophageal motor and lower esophageal sphincter (LES) abnormalities associated with epiphrenic esophageal diverticula and analyze outcomes for laparoscopic esophageal diverticulectomy, myotomy, and partial fundoplication. The endoscopic, radiographic, manometric, and perioperative records for patients undergoing laparoscopic esophageal diverticulectomy, anterior esophageal myotomy, and partial fundoplication from 8/99 until 9/06 were reviewed from an Institutional Review Board (IRB)-approved outcomes database. Data are given as mean +/- standard deviation (SD). An esophageal body motor disorder and/or LES abnormalities were present in 11 patients with epiphrenic diverticula; three patients were characterized as achalasia, one had vigorous achalasia, two had diffuse esophageal spasm, and five had a nonspecific motor disorder. Presenting symptoms included dysphagia (13/13), regurgitation (7/13), and chest pain (4/13). Three patients had previous Botox injections and three patients had esophageal dilatations. Laparoscopic epiphrenic diverticulectomy with an anterior esophageal myotomy was completed in 13 patients (M:F; 3:10) with a mean age of 67.6 +/- 4.2 years, body mass index (BMI) of 28.1 +/- 1.9 kg/m2 and American Society of Anesthesiologists (ASA) 2.2 +/- 0.1. Partial fundoplication was performed in 12/13 patients (Dor, n = 2; Toupet, n = 10). Four patients had a type I and one patient had a type III hiatal hernia requiring repair. Mean operative time was 210 +/- 15.1 min and mean length of stay (LOS) was 2.8 +/- 0.4 days. Two grade II or higher complications occurred, including one patient who was readmitted on postoperative day 4 with a leak requiring a thoracotomy. After a mean follow-up of 13.6 +/- 3.0 months (range 3-36 months), two patients complained of mild solid food dysphagia and one patient required proton pump inhibitor (PPI) for gastroesophageal reflux disease (GERD) symptoms. The majority of patients with epiphrenic esophageal diverticula have esophageal body motor disorders and/or LES abnormalities. Laparoscopic esophageal diverticulectomy and anterior esophageal myotomy with partial fundoplication is an appropriate alternative with acceptable short-term outcomes in symptomatic patients.

Surgical Endoscopy, 2015

Introduction With the regionalization of surgical care, reduction in the rural workforce, rising ... more Introduction With the regionalization of surgical care, reduction in the rural workforce, rising healthcare costs, and increasing focus on surgical outcomes, appropriate transfer of surgical patients is an increasingly important aspect of health care. This study examines patients transferred for surgical intervention through a national sample. Methods The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2005 to 2012 for surgery patients who were transferred from an outside hospital or emergency department (ED) and compared patients undergoing surgery without transfer. Patients were divided into two time periods (TP): 2005-2008 (TP1) and 2008-2012 (TP2) for analysis; patient characteristics and top CPT codes for each TP were collected. Univariate analysis and matched cohorts were used to compare the groups. Results Overall, 61,204 patients were transferred and underwent surgery. The rate of transferred surgery patients increased from 3.2 % in TP1 to 4.5 % in TP2 (p \ 0.0001). Compared to non-transferred patients, transferred patients had higher rates of diabetes (23.4 vs. 17.6 %, p \ 0.0001), tobacco use (27.9 vs. 20.3 %, p \ 0.0001), Charlson comorbidity index (mean score 1.5 vs. 0.8, p \ 0.0001), preoperative sepsis (32.0 vs. 9.4 %, p \ 0.0001), and need for emergent surgery (41.3 vs. 14.4 %, p \ 0.0001). From TP1 to TP2, there was an increase in transferred patients who were obese (33.9-36.4 %, p \ 0.0001) and had emergent transfers (39.6-41.8 %, p \ 0.0001), with a decrease in diabetic patients (24.7-23.1 %, p \ 0.0001). From TP1 to TP2, transferred patients had more minor complications (17.7-31.0 %, p \ 0.0001), but fewer major complications (32.1-23.9 %, p \ 0.0001) and lower 30-day mortality (11.8-8.1 %, p \ 0.0001). Conclusions Patients transferred for surgery represent a higher acuity population than non-transferred patients, and the number of transfers continues to rise. Even when matched by comorbidities, transferred patients have worse outcomes. Surgical sub-specialization and physician tiering may complicate future transfer practices. Efficient transfers, effective physician communication, and ready availability of medical records are critical in improving patient transfers.