What Is Appropriate Treatment for Carcinoma of the Thoracic Esophagus?

Recent advances in the treatment of esophageal cancer have yielded a variety of new options for management of this highly lethal disease. Various approaches to surgical resection have been proposed. Chemotherapy and radiotherapy with or without surgery have been tested in numerous trials, the results of which are often conflicting and confusing for clinicians. The changing epidemiology of the disease between East and West adds to the controversy. In this review, the authors address some of the more controversial debates. The following questions are asked: What is the appropriate approach for surgical resection? What is the appropriate extent of resection? Is multimodality treatment appropriate for esophageal cancer?     

Is Resurfacing Arthroplasty Appropriate for Posttraumatic Osteoarthritis?

Background  

High survival has been reported for resurfacing arthroplasty in patients with femoral deformities. Also, hardware removal may not always be necessary with resurfacing arthroplasty and may eliminate some of the difficulties performing total hip arthroplasty (THA) in patients with posttraumatic osteoarthritis.     

Delayed Laparoscopic Cholecystectomy for Acute Calculous Cholecystitis: Is it Time for a Change?

Background

Our aim was to evaluate the advantages and limitations of delayed laparoscopic cholecystectomy (LC) in a tertiary center.

Materials and methods

A retrospective analysis of all patients admitted to our institution with acute calculous cholecystitis (ACC) between January 2003 and December of 2012 was performed. Data collected included patient demographics and comorbidities, presenting symptoms, laboratory findings, imaging results, length of stay (LOS), time to surgery, and surgical complications.

Results

A total of 1078 patients were admitted with ACC. There were 593 females (55%), and the mean age was 57 ± 0.6 years. Mean LOS at initial admission, re-admission until surgery, and following surgery was 7.9 ± 0.2, 1.5 ± 0.1, and 3.4 ± 0.2 days, respectively. Percutaneous cholecystostomy (PC) tube was inserted in 24% of the patients. Only 640 (59%) patients eventually underwent LC. Mean time to surgery was 97 ± 9.8 days, and 16.4% of patients were readmitted in this time period resulting in a mean total LOS of 10.6 ± 0.2 days. Conversion rate to open surgery was 5.8% and bile duct injury occurred in 1.1%. Postoperative complications occurred in 9.8% of the patients, and 30-day mortality was 0.6%. Patients with more severe inflammation according to Tokyo Criteria grade were more likely to undergo PC, were more likely to be readmitted while waiting for LC, and also had more postoperative complications.

Conclusions

Delayed LC is associated with significant loss of follow-up, long LOS, and higher than expected use of PC. Conversion rates are lower than in the literature while rates of bile duct injury and mortality are comparable. We believe these data as well as the available literature are sufficient to change our hospital policy regarding the surgical treatment of ACC from delayed to early same admission surgery in appropriate cases.

     

Primary Extremity Sarcoma: What Is the Appropriate Follow-Up?

Background: Our objective was to evaluate the effectiveness of follow-up tests for detecting first local and distant recurrences in patients with primary extremity soft tissue sarcoma.Methods: We retrospectively analyzed all adult cases of primary extremity soft tissue sarcoma (n 5 174) treated between 1982 and 1992. Patients were observed every 3 months for 2 years, every 4 months the third year, every 6 months the next 2 years, and annually, thereafter. Each visit consisted of taking the patients history, a physical examination, a complete blood count, a blood chemistry panel, and a chest x-ray. For high-grade tumors, the primary site was imaged annually when clinically appropriate.Results: Of 141 patients who were assessable, 29 patients developed local recurrence and 57 developed distant recurrence. All but one of the local recurrences was detected on the basis of an abnormal physical examination. Of the 29 patients who developed local recurrence, 25 were resected. Distant metastases were detected because of symptoms in 21 cases. Of the 36 asymptomatic lung recurrences, 30 were detected by follow-up chest x-ray. Of the 36 asymptomatic lung recurrences, 24 patients underwent metastasectomy. The positive and negative predictive values of surveillance chest x-ray were 92% and 97%, respectively. Laboratory testing never led to the detection of recurrence.Conclusions: Close surveillance by clinical assessment and chest x-ray is appropriate for follow-up observation of patients with primary extremity soft tissue sarcoma.Presented at the 52nd Annual Meeting of Society of Surgical Oncology, Orlando, Florida, March 4–7, 1999.     

Is the New Outpatient Prospective Payment System Classification for Outpatient Total Knee Arthroplasty Appropriate?

BackgroundIn 2018, the Centers for Medicare and Medicaid Services removed total knee arthroplasty (TKA) from the inpatient-only list, resulting in payment through the Outpatient Prospective Payment System with an average $3157 reduction. The purpose of this study is to determine if the reimbursement is justified by comparing the difference in facility costs between inpatient and outpatient TKAs.MethodsWe identified 4496 consecutive primary TKA procedures performed at 2 hospitals from 2015 to 2019. Itemized facility costs were calculated using a time-driven activity-based costing algorithm. Outpatient procedures were defined as those with a length of stay of less than 2 midnights (3851, 86%). Patient demographics, comorbidities, and itemized costs were compared between groups. A multivariate regression analysis was performed to determine the independent effect of outpatient status on true facility costs.ResultsOutpatient TKA patients had lower mean postoperative personnel costs ($1809 vs $947, P < .001), supply costs ($4347 vs $4229, P < .001), and overall total facility costs ($7371 vs $6937, P < .001) than inpatient TKA patients. Controlling for a younger patient cohort with fewer medical comorbidities, outpatient status was associated with a reduction in total facility costs of $972 (95% confidence interval $883-$1060, P < .001) compared to inpatient TKA.ConclusionOutpatient TKA costs hospitals nearly $1000 per patient less than inpatient TKA, yet the average difference in Medicare reimbursement for an outpatient procedure is $3157 less per patient. Centers for Medicare and Medicaid Services should reconsider the Outpatient Prospective Payment System classification of TKA to better incentivize surgeons to perform TKA as a lower cost outpatient procedure when safe and appropriate.     

Treatment Strategies and Survival Trends for Anorectal Melanoma: Is it Time for a Change?

World Journal of Surgery - Immunotherapy advances for the treatment of cutaneous melanoma question its efficacy in treating anorectal mucosal melanoma (ARMM). We aimed to identify the prevalence,...     

Is Reverse Shoulder Arthroplasty Appropriate for the Treatment of Fractures in the Older Patient?: Early Observations

Background  

The treatment of comminuted proximal humerus fractures in older patients is challenging. Variable values of functional outcomes scores, ROMs, patient satisfaction, and bony healing have been reported with conventional techniques, including open reduction and internal fixation, percutaneous pinning, and hemiarthroplasty. Another alternative is reverse total shoulder arthroplasty, although it is unclear whether this provides better ROM or function.     

Study Types in Orthopaedics Research: Is My Study Design Appropriate for the Research Question?

When performing orthopaedic clinical research, alternative study designs can be more appropriate depending on the research question, availability of data, and feasibility. The most common observational study designs in total joint arthroplasty research are cohort and cross-sectional studies. This article describes methodological considerations for different study designs with examples from the total joint arthroplasty literature. We highlight the advantages and feasibility of experimental and observational study designs using real-world examples. We illustrate how to avoid common mistakes, such as incorrect labeling of matched cohort studies as case-control studies. We further guide investigators through a step-by-step design of a case-control study. We conclude with considerations when choosing between alternative study designs. Please visit the following https://youtu.be/Zvce61cMYi8 for videos that explain the highlights of the article in practical terms.     

Is Delayed Liver Resection Appropriate for Patients with Metachronous Colorectal Metastases?

Background

In terms of timing of resection for synchronous liver metastases from colon cancer, some reports recommend leaving an interval (e.g., 3 months) after primary colorectal resection, because of reports of occasional and rapid remnant recurrence of residual liver metastases after simultaneous colorectal and liver resection (LR). For patients with metachronous liver metastasis (MLM), we prospectively examined the appropriateness of a 3-month interval to LR (i.e., delayed resection) following initial detection of hepatic lesions from the viewpoints of (1) detection of new metastases during this interval and (2) postoperative outcome.

Methods

Seventy-nine consecutive patients with modified Japanese criteria H1 class MLM (i.e., ≤4 nodules, 6 cm or less in diameter) and without obvious extrahepatic lesions, presenting between 1990 and 2008, were included in this study. Between 1990 and 2001, 52 patients were treated by LR without an interval (i.e., nondelayed group); from 2002, 27 patients were prospectively scheduled for LR at an interval of 3 months after initial detection of metastases (i.e., delayed group). During the 3-month interval, no adjuvant chemotherapy was given. Just prior to LR, patients were re-evaluated using computed tomography (CT) and deoxy-2-[¹⁸F]fluoro-d-glucose positron emission tomography (FDG-PET) to exclude cases unsuitable for surgery.

Results

Out of 27 patients in the delayed group, 2 (7.4%) did not undergo LR after the 3-month interval and were excluded from the analysis: one because of multiple nodules in the bilateral lobe of the liver with pulmonary metastases and another because of para-aortic lymph node metastasis. Of the 25 patients for whom LR was indicated, 24 underwent LR as initially planned. In the remaining patient, after the 3-month interval, invasion of the tumor had occurred into the inferior vena cava (IVC) and other surgery in addition to the planned operation was required. When comparing the postoperative outcome data of the delayed group (n = 25) with the nondelayed group (n = 52), overall early recurrence within 1 year after LR was noticed in 30.9% (16/52) of the nondelayed group and 28.0% (7/25) of the delayed group; the incidence of only early extrahepatic recurrence decreased 5.1% in the delayed group (21.1% versus 16.0%, respectively). When comparing disease-free survival after liver resection, however, there was no significant difference between the groups.

Conclusions

Delayed LR for MLM patients after initial detection of hepatic lesions is of no clinical benefit. Only in cases when extrahepatic lesions with MLM are suspected could an interval make such lesions clearer and assist in deciding on a suitable management plan.     

Gastric Bypass for Obesity in the Elderly: Is It as Appropriate as for Young and Middle-Aged Populations?

Background

Obesity prevalence increases in elderly population. Bariatric surgery has been underused in patients over 60 because of fears of complications and lower weight loss. We postulated worse outcomes in the elderly in comparison to young and middle-aged population 1 year after gastric bypass.

Methods

We retrospectively analyzed gastric bypass outcomes in young (<40 years), middle-aged (40 to 55 years), and elderly (>60 years) patients between 2007 and 2013. Each subject over 60 (n?=?24) was matched with one subject of both the other groups according to gender, preoperative body mass index (BMI), surgical procedure, and history of previous bariatric surgery (n?=?72).

Results

Older subjects demonstrated higher prevalence of preoperative metabolic comorbidities (70 vs 30 % in the <40-year-old group, p?p?=?0.69). Age was not predictive of weight loss failure 1 year after surgery. Remission and improvement rates of comorbidities were similar between age groups 6 months after surgery.

Conclusions

Our study confirms weight loss efficacy of gastric bypass in the elderly with acceptable risks. Further studies evaluating the benefit-risk balance of bariatric surgery in the elderly population will be required so as to confirm the relevance of increasing age limit.     

What Is the Value of Undergoing Surgery for Spinal Metastases at Dedicated Cancer Centers?

BackgroundThe Alliance of Dedicated Cancer Centers is an organization of 11 leading cancer institutions and affiliated hospitals that are exempt from the Medicare prospective system hospital reimbursement policies. Because of their focus on cancer care and participation in innovative cancer treatment methods and protocols, these hospitals are reimbursed based on their actual billings. The perceived lack of incentive to meet a predetermined target price and reduce costs has spurred criticism of the value of cancer care at these institutions. The rationale of our study was to better understand whether dedicated cancer centers (DCCs) deliver high-value care for patients undergoing surgical treatment of spinal metastases.Question/purposeIs there a difference in 90-day complications and reimbursements between patients undergoing surgical treatment (decompression or fusion) for spinal metastases at DCCs and those treated at nonDCC hospitals?MethodsThe 2005 to 2014 100% Medicare Standard Analytical Files database was queried using ICD-9 procedure and diagnosis codes to identify patients undergoing decompression (03.0, 03.09, and 03.4) and/or fusion (81.0X) for spinal metastases (198.5). The database does not allow us to exclude the possibility that some patients were treated with fusion for stabilization of the spine without decompression, although this is likely an uncommon event. Patients undergoing vertebroplasty or kyphoplasty for metastatic disease were excluded. The Medicare hospital provider identification numbers were used to identify the 11 DCCs. The study cohort was categorized into two groups: DCCs and nonDCCs. Although spinal metastases are known to occur among nonMedicare and younger patients, the payment policies of these DCCs are only applicable to Medicare beneficiaries. Therefore, to keep the study objective relevant to current policy and value-based discussions, we performed the analysis using the Medicare dataset. After applying the inclusion and exclusion criteria, we included 17,776 patients in the study, 6% (1138 of 17,776) of whom underwent surgery at one of the 11 DCCs. Compared with the nonDCC group, DCC group hospitals operated on a younger patient population and on more patients with primary renal cancers. In addition, DCCs were more likely to be high-volume facilities with National Cancer Institute designations and have a voluntary or government ownership model. Patients undergoing surgery for spinal metastases at DCCs were more likely to have spinal decompression with fusion than those at nonDCCs (40% versus 22%; p < 0.001) and had a greater length and extent of fusion (at least four levels of fusion; 34% versus 29%; p = 0.001). Patients at DCCs were also more likely than those at nonDCCs to receive postoperative adjunct treatments such as radiation (16% versus 13.5%; p = 0.008) and chemotherapy (17% versus 9%; p < 0.001), although this difference is small and we do not know if this meets a minimum clinically important difference. To account for differences in patients presenting at both types of facilities, multivariate logistic regression mixed-model analyses were used to compare rates of 90-day complications and 90-day mortality between DCC and nonDCC hospitals. Controls were implemented for baseline clinical characteristics, procedural factors, and hospital-level factors (such as random effects). Generalized linear regression mixed-modeling was used to evaluate differences in total 90-day reimbursements between DCCs and nonDCCs.ResultsAfter adjusting for differences in baseline demographics, procedural factors, and hospital-level factors, patients undergoing surgery at DCCs had lower odds of experiencing sepsis (6.5% versus 10%; odds ratio 0.54 [95% confidence interval 0.40 to 0.74]; p < 0.001), urinary tract infections (19% versus 28%; OR 0.61 [95% CI 0.50 to 0.74]; p < 0.001), renal complications (9% versus 13%; OR 0.55 [95% CI 0.42 to 0.72]; p < 0.001), emergency department visits (27% versus 31%; OR 0.78 [95% CI 0.64 to 0.93]; p = 0.01), and mortality (39% versus 49%; OR 0.75 [95% CI 0.62 to 0.89]; p = 0.001) within 90 days of the procedure compared with patients treated at nonDCCs. Undergoing surgery at a DCC (90-day reimbursement of USD 54,588 ± USD 42,914) compared with nonDCCs (90-day reimbursement of USD 49,454 ± USD 38,174) was also associated with reduced 90-day risk-adjusted reimbursements (USD -14,802 [standard error 1362] ; p < 0.001).ConclusionBased on our findings, it appears that DCCs offer high-value care, as evidenced by lower complication rates and reduced reimbursements after surgery for spinal metastases. A better understanding of the processes of care adopted at these institutions is needed so that additional cancer centers may also be able to deliver similar care for patients with metastatic spine disease.Level of EvidenceLevel III, therapeutic study.