Profile and Predictors of Long-term Morbidity in Breast Cancer Survivors

Background

A sound understanding of the benefits of different treatment options and their health-related quality of life (HRQoL) impacts is required for optimal breast cancer care.

Methods

A cross-sectional cohort study was conducted to determine the prevalence and severity of persistent functional decrements and symptoms and identify demographic, clinical and treatment variables associated with poorer outcomes. Four hundred English-speaking women treated for ductal carcinoma-in-situ or stage I to III breast cancer between 1999 and 2009, at least 12 months after surgery and currently disease free, were randomly selected and invited to complete (1) the Breast Cancer Treatment Outcome Scale and (2) the EORTC core Quality of Life Questionnaire, version 3.

Results

The response rate was 85.60 %. Many participants reported moderate to severe decrements in a number of HRQoL domains, including functional well-being (15 %), cosmetic status (32 %) and overall quality of life (21 %). There were significant associations (p < .05) between younger age and poorer HRQoL but none between time since surgery and morbidity (p > .05). Different treatments were associated with different HRQoL impacts. Poorer functional status was predicted by axillary dissection (p = .011), and adjuvant radiotherapy was a significant predictor of breast-specific pain (p < .05).

Conclusions

Many breast cancer survivors report long-term morbidity that is unaffected by time since surgery. The significant associations between the extent of locoregional therapies and poorer HRQoL outcomes emphasize the importance of the safe tailoring of these treatments.     

Chest and Upper Body Morbidity Following Immediate Postmastectomy Breast Reconstruction

Objective

The performance of a mastectomy for the treatment or prophylaxis of breast cancer may have long-term implications for both physical and mental well-being in women. The development of breast numbness and phantom breast sensations following mastectomy is well-known; however, relatively little is known about physical morbidity following postmastectomy breast reconstruction. The primary objective of this study was to evaluate the level of physical morbidity experienced following three surgical approaches: mastectomy alone, postmastectomy tissue expander/implant reconstruction, and postmastectomy autogenous tissue reconstruction.

Methods

We conducted a cross-sectional survey of a sample of women who had undergone mastectomy with or without reconstruction. Chest and upper body morbidity were evaluated using the BREAST-Q. Physical well-being was compared across three types of breast surgery.

Results

In total, 308 of 452 women who received a questionnaire booklet returned completed questionnaires. There was an overall difference in physical morbidity attributable to surgical treatment (P < 0.001). Patients who underwent autogenous tissue reconstruction had the highest (i.e., best) mean physical well-being score. Women who underwent expander/implant reconstruction also had less chronic physical morbidity than women who underwent mastectomy alone (P < 0.05).

Conclusions

Our findings suggest that women who undergo immediate autogenous tissue reconstruction experience significantly less chest and upper body morbidity than those who undergo either mastectomy with implant-based reconstruction or mastectomy alone. This information can be used to facilitate clinical decision-making, to validate individual experiences of breast cancer survivors, and to inform future innovations to decrease the long-term physical morbidity associated with breast cancer surgery.     

Surgical Resident Experience in Breast Disease: A National Study

Background

Management of breast disease is an integral component of general surgery. This study was performed to describe the exposure to breast disease by residents in Canadian general surgery programs.

Methods

This study involved a 20-item survey and pilot semistructured interviews. Surgical trainees at 12 training programs in Canada participated in the survey. Results were used to characterize resident experience with breast surgery and clinics.

Results

Residents across all post-graduate training years and from 12 Canadian medical schools responded (n = 162, 44 %). Residents had the most breast surgery experience in PGY2 and PGY3 years. One third of trainees performed ≤1 breast procedure per month. Only 25 % had attended more than one breast clinic per month. Lumpectomies were the most common procedure (20.7/year) and 94 % of residents performed sentinel lymph node biopsy. Four pilot semistructured interviews were performed. The greatest stated barriers to breast training were “lack of time” and the impression that these were “lower priority cases.”

Conclusions

Achieving competence in breast disease management is a key requirement for general surgery trainees. Surgical educators must ensure that the quality and quantity of residency training in breast diseases is sufficient for future surgeons to provide optimal patient care.     

The Impact of Reconstructive Procedures Following Bariatric Surgery on Patient Well-being and Quality of Life

Background

Massive weight loss following bariatric surgery may lead to an excess of lax, overstretched skin, causing physical discomfort which may affect the patient’s quality of life. Whereas the functional and aesthetic deformity is an expected result of massive weight loss, the role of the plastic surgeon in the multidisciplinary approach of the morbidly obese is still unclear. The purpose of the current study is to evaluate the results of reconstructive surgery following weight loss surgery, focusing on the impact on the physical and psycho-social well-being and quality of life of the patients.

Methods

Out of a group of 465 patients, 61 patients underwent reconstructive surgery following weight loss surgery. In 43 respondents, the quality of life after reconstructive surgery was measured by the Obesity Psychological State Questionnaire. Patient satisfaction was evaluated.

Results

Reconstructive surgery resulted in a significant improvement in quality of life in patients at a mean interval of 42 months between weight loss and reconstructive surgery. The most frequent procedures were abdominoplasty and breast reconstruction. The relative high complication rate of 27.9% was of no influence on quality of life and the majority of the patients (67%) were satisfied with reconstructive surgery.

Conclusions

This study shows that reconstructive surgery following weight loss after bariatric surgery results in a significant improvement in overall quality of life. Reconstructive surgery should be incorporated in the multidisciplinary care programme following weight loss surgery in the morbidly obese patient.     

Does the addition of magnesium to bupivacaine improve postoperative analgesia of ultrasound-guided thoracic paravertebral block in patients undergoing thoracic surgery?

Purpose

Magnesium is a plentiful intracellular cation that has been reported to possess analgesic effect. The present study was aimed to see whether addition of magnesium to bupivacaine in thoracic paravertebral block (TPVB) improved the analgesic effect after thoracic surgery.

Materials and methods

Fifty adult patients undergoing elective open thoracic surgery were divided into two equal groups. Group I received 12 ml of 0.5 % bupivacaine plus 0.9 % saline (3 ml) whereas Group II received 12 ml of 0.5 % bupivacaine plus 150 mg magnesium sulphate (in 3 ml 0.9 % saline) for TPVB. The following parameters were assessed: onset, dermatomal levels and duration of sensory block, duration of analgesia, visual analogue scale (VAS) for pain, postoperative intravenous morphine consumption, pulmonary function tests (peak expiratory flow rate [PEFR], forced expiratory volume in 1 s [FEV1] and forced vital capacity [FVC]) before and 24 h after surgery, and complications from the drugs and technique.

Results

Group II patients showed a significantly longer sensory block duration (224.6 ± 59.3 vs 160.1 ± 55.2 min, P < 0.05), longer duration of analgesia (388.8 ± 70.6 vs 222.2 ± 61.6 min, P < 0.05), less VAS during the postoperative 48 h, less need for postoperative morphine (16.2 ± 7.4 vs 29.5 ± 11.1 mg, P < 0.05) and lower incidence of somnolence (0 [0 %] vs 5 [20 %], P < 0.05). Furthermore, postoperative pulmonary function tests (PEFR, FEV1 and FVC) were significantly better in Group II whereas there was no significant difference between both groups regarding the sensory block dermatomal level or hemodynamic data.

Conclusion

Addition of magnesium to bupivacaine in TPVB improved the analgesic effect of bupivacaine in patients undergoing thoracic surgery.     

Evaluation of sexual function in sexually active women 1 year after transvaginal NOTES: a prospective cohort study of 106 patients

Purpose

The primary objective of this prospective cohort study was to investigate sexual function, quality of life and patient satisfaction in sexually active women 1 year after transvaginal hybrid natural orifice transluminal endoscopic surgery (NOTES).

Patients and methods

This prospective single-centre cohort study included sexually active female patients after transvaginal hybrid NOTES cholecystectomy or anterior resection. Sexual life impairment and quality of life were assessed by the Gastrointestinal Quality of Life Index (GIQLI) prior and 1 year after surgery. Patient satisfaction was assessed as well as the sexual function 1 year postoperatively using the validated German version of the Female Sexual Function Index (FSFI-D).

Results

Between September 2008 and December 2009, 106 sexually active women after transvaginal hybrid NOTES cholecystectomy or anterior resection were identified. Sexual life significantly improved (GIQLI scores 3.2?±?1.0 preoperatively vs. 3.7?±?0.7 1 year postoperatively, P?<?0.001), and painful sexual intercourse (3.3?±?1.0 vs. 3.6?±?0.7, P?=?0.008) decreased post-surgery. The mean FSFI-D total score after transvaginal NOTES was 28.1?±?4.6, exceeding the cutoff for sexual dysfunction defined as 26. Four (4.5 %) out of 88 patients who answered this question were not satisfied with the transvaginal hybrid NOTES procedure.

Conclusions

This prospective cohort study of female sexual function after transvaginal NOTES provides compelling evidence that the transvaginal access is safe and associated with high satisfaction rate.     

Higher Rate of Breast Surgery Complications in Patients with Metastatic Breast Cancer: An Analysis of the NSQIP Database

Background

Four percent of breast cancer patients present with metastatic disease. To date, no one has examined whether these patients are at higher risk of postoperative complications. The objective of this study was to determine morbidity and mortality associated with breast surgery in the metastatic setting.

Methods

We analyzed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, including breast cancer patients undergoing primary breast surgery from 2005 to 2012. Patients with bilateral surgery or severe comorbidities were excluded. Multivariable logistic regression was performed to determine the independent effect of metastatic breast cancer on postoperative morbidity and mortality.

Results

We identified 68,316 patients who underwent breast surgery for invasive breast cancer; 1,031 (1.5 %) had metastatic disease. The 30-day unadjusted morbidity was significantly higher in the metastatic cohort (7.5 vs. 3.7 %; p < 0.001), as was the all-cause 30-day mortality (1.8 vs. 0.06 %; p < 0.001). The metastatic cohort was more likely to experience an: infectious, respiratory, thromboembolic, cardiac, or bleeding complication than non-metastatic patients. However, preoperative chemo- and radiation therapy did not contribute to an overall increased complication rate. The adjusted odds ratio for postoperative complications in the setting of metastatic disease was 1.6 (95 % confidence limit 1.2–2.1).

Conclusions

This is the first study documenting the morbidity and mortality associated with breast surgery in metastatic breast cancer. The 30-day morbidity and mortality in this population is higher than in patients with stage I–III disease. Although the complication rate is increased, operating on the primary in metastatic breast cancer is relatively safe.     

Meningioma surgery in the very old—validating prognostic scoring systems

Background

Several studies acknowledge a higher risk of morbidity and mortality following intracranial meningioma surgery in the elderly, yet there is no consensus with regards to risk factors. Four prognostic scoring systems have been proposed. To evaluate their usefulness, we assess the very old meningioma patients in our neuro-oncological database according to the four methods, and correlate the findings with mortality and morbidity.

Methods

We retrospectively calculated scores according to the Clinical-Radiological Grading System (CRGS), the Sex, Karnofsky Performance Scale, American Society of Anesthesiology Class, Location of Tumor, and Peritumoral Edema grading system (SKALE), the Geriatric Scoring System (GSS) and the Charlson Comorbidity Index (CCI) from all patients aged 80–90 years who had primary surgery for intracranial meningiomas 2003–2013 (n?=?51), and related our findings to morbidity and mortality.

Results

The mortality rates were 3.9 %, 5.9 % and 15.7 % at 30-days, 3-months and 1-year post-surgery. The rate of complications requiring surgery was 13.7 %, 5.9 % had evacuation of intracerebral hematomas and two patients (3.9 %) had surgery for intracranial infection/osteitis. 15.7 % of the patients were neurologically worsened on discharge. The patients with SKALE scores ≤ 8 had significantly increased mortality rates. The GSS, the CRGS and the CCI were not found to correlate with mortality.

Conclusions

Retrospectively evaluating four proposed scoring systems, we find that the SKALE score reflects the mortality at 1 month and 1 year following primary surgery for intracranial meningiomas in our very old patients. It may represent a helpful adjunct to their preoperative assessment.     

Association of clinical parameters of operatively treated thoracolumbar fractures with quality of life parameters

Purpose

The intention of the current work was to assess the association between clinical parameters and seven different quality of life (QoL) instruments after surgical treatment of thoracolumbar spinal fractures after an average follow-up of 4.2 years.

Methods

The following human-related quality of life and PRO measures of 66 patients were correlated to clinical parameters such as fingertip-to-floor distance (FFD), Schober measurement, pressure and percussion pain in the lumbopelvine area (PPP), and paravertebral muscle tension: reALOS, SF-36, VAS, VAS spine score, BDI, the GBB-24, and the IES-R.

Results

Overall, there was a significant association between the clinical parameters of the thoracolumbar spine such as PPP, paravertebral muscle tension, FFD and Schober’s sign on one side, and the seven tested instruments on the other side.

Conclusions

PPP and FFD as well as a small Schober measurement are clinical parameters which significantly influence QoL after surgical treatment of thoracolumbar fractures.     

The Choice for Breast Cancer Surgery: Can Women Accurately Predict Postoperative Quality of Life and Disease-Related Stigma?

Background

To make an informed choice, breast cancer patients facing surgery must imagine the effect of surgery on their future life experiences. However, the accuracy of patient predictions of postoperative quality of life (QoL) and disease-related stigma is not well understood.

Materials and Methods

Four groups of breast cancer patients at the University of Michigan Medical Center were surveyed by mail and interview (response rate 76.3%): (1) preoperative (N = 59), (2) mastectomy (N = 146), (3) mastectomy with reconstruction (N = 250), and (4) breast conservation (N = 705). Subjects rated their QoL (1 = lowest, 100 = highest) and stigma (1 = lowest, 5 = highest) and estimated QoL and stigma associated with mastectomy alone, mastectomy with reconstruction, and breast conserving surgery (BCS). Mean scores were compared using linear regression controlling for age, race, partnered status, and income.

Results

Preoperatively, women inaccurately predicted postoperative QoL and stigma for all surgical options, particularly for mastectomy. Preoperative patients underestimated the postoperative QoL for mastectomy alone (predicted: 56.8 vs actual: 83.7; P < .001). Preoperative patients underestimated QoL following mastectomy following reconstruction (predicted: 73.4 vs actual: 83.9; P < .001) and BCS (predicted: 72.2 vs actual: 88.6; P < .001). Additionally, preoperative patients overestimated stigma related to mastectomy (predicted: 3.25 vs actual: 2.43; P < .001). Finally, preoperative women overestimated stigma related to mastectomy with reconstruction (predicted: 2.54 vs actual: 2.03; P < .001) and BCS (predicted: 1.90 vs actual: 1.76; P < .001).

Conclusion

Predicting QoL and stigma following breast cancer surgery is challenging for patients facing a diagnosis for surgery. Identifying strategies to better inform patients of surgical outcomes can improve the decision-making process.     

Incidence and Predictors of Neuropathic Pain Following Breast Surgery

Purpose

Neuropathic pain (NPP) following breast surgery extends morbidity in the postoperative period. The incidence and etiology of postoperative NPP remains unclear and under-reported in literature. This study aims to define the incidence of neuropathic pain following breast surgery and to identify patient characteristics that are predictors for developing postoperative NPP.

Methods

Consecutive female patients undergoing breast resection surgery over a 5-year period (2008–2012) with 1-year minimum follow-up were included in this single-center study. Retrospective chart review was performed to identify patient specific characteristics including the development of post-operative NPP. Data was analyzed using univariate and multivariate logistic regression.

Results

A total of 470 patients were identified for study inclusion. The incidence of postoperative NPP was 14.7 % (69 of 470). Significant predictors for the development of postoperative NPP in the univariate analyses included history of diabetes mellitus, diabetic neuropathy, or fibromyalgia, concomitant axillary surgery, axillary node dissection, and taxane-based chemotherapy regimen. Multivariate analysis identified African American race [odds ratio (OR) = 1.78; 95 % CI = 1.01–3.17; p = 0.05), history of diabetes mellitus (OR = 1.98; 95 % CI = 1.0–3.74; p = 0.01) or fibromyalgia (OR = 2.75; 95 % CI = 1.13–6.69; p = 0.03), and taxane-based chemotherapy regimen (OR = 2.85; 95 % CI = 1.23–6.58; p = 0.01) as being independently associated with the development of postoperative NPP.

Conclusions

NPP is a significant risk following breast surgery. African American race, history of either diabetes mellitus or fibromyalgia, and treatment with taxane-based chemotherapy regimens are all associated with an increased risk of NPP.     

Predictors of Weight Loss at 1 Year After Laparoscopic Adjustable Gastric Banding and the Role of Presurgical Quality of Life

Background

There is uncertainty regarding preoperative predictors of a successful outcome for bariatric surgery (BarSurg), on which to determine appropriateness for such a procedure. Our aims were to identify preoperative clinical and psychosocial predictors of success following BarSurg and to explore the influence of body mass index (BMI) on these parameters.

Methods

Preoperative data, including Impact of Weight on Quality of Life—Lite (IWQOL-Lite) scores transformed to Health-Related Quality of Life (HRQOL) scores, were accrued from 76 morbidly obese adults awaiting BarSurg. Pre- and postoperative data were also accrued for 26 patients who had completed 1-year follow-up post-bariatric surgery (laparoscopic adjustable gastric banding—LAGB). Statistical analysis was performed to assess the relationships between preoperative HRQOL scores, preoperative BMI and excess weight loss 1 year following BarSurg (EWL-1 year).

Results

Preoperative BMI showed a significant independent, negative linear correlation with the public distress domain of preoperative quality of life (QOL) (r?=??0.368, p?=?0.001; β?=??0.245, p?=?0.009). Preoperative BMI had a significant, positive and independent association with EWL-1 year (r?=?0.499, p?=?0.009; β?=?0.679, p?=?0.015). Preoperative QOL scores had no association with EWL-1 year.

Conclusions

Preoperative BMI appears to predict EWL-1 year following restrictive bariatric surgery (LAGB). Preoperatively, patients with higher BMI appear to manifest greater public distress. Preoperative QOL scores, however, do not appear to have any predictive value for EWL-1 year post-LAGB. Preoperative BMI should therefore be employed as a predictor of EWL-1 year post-LAGB. Other measures of successful outcomes of bariatric surgeries (such as effects on QOL scores at 1 year) should be explored in future, larger and longer term studies.     

Assessing Patterns of Practice of Sentinel Lymph Node Biopsy for Breast Cancer in Latin America

Introduction

There is a lack information regarding how sentinel lymph node biopsy (SLNB) for breast cancer is carried out today in developing countries and how it was adapted. To rectify this situation we performed a pattern-of-practice survey amongst practicing surgeons in Latin America (LA).

Methods

A survey was developed to assess current surgical practice in breast cancer, use of SLNB, limitations to the implementation, training, technique variations, and observed adverse events. A total of 30 surgical associations and breast surgery societies in 18 Latin American countries were invited to participate. Surveys were distributed among member of these associations and 76.7 % of those contacted answered the survey. Responses were limited only to those who reported treating breast cancer patients.

Results

A total of 463 surgeons who manage breast cancer responded. Over 53 % of surgeons do not have sub-specialty training. Only 47.7 % have a high-volume case load, of which 87.8 % routinely perform SLNB. The main limitations perceived to the implementation of SLNB were a lack of resources/equipment (48 %) and training opportunities (33 %). Over 60 % reported that fewer than half of their patients were eligible for SLNB and 67.8 % reported that they were involved in teaching this technique to residents.

Conclusions

A significant proportion of surgeons that treat breast cancer cases in LA have not had sub-specialty training or manage a low volume of cases. Among those surgeons with a high-volume caseload, SLNB is routinely performed. SLNB training during residency represents an opportunity for improvement in the region.     

Robotic total pelvic exenteration

Introduction

Pelvic exenteration is now becoming widely acceptable as a curative procedure rather than a palliative one. Performing these surgeries by minimally invasive techniques helps to improve the quality of life and decrease the morbidity of these extensive procedures.

Aims and objectives

To demonstrate the feasibility of performing a total pelvic exenteration robotically, and to study the morbidity associated with such extensive surgery.

Materials and methods

A 35-year-old female with advanced cervical cancer presented with a vesicovaginal fistula and a rectovaginal fistula. In view of these, we performed a total robotic pelvic exenteration with colo-anal anastomosis and uretero-sigmoidostomy. The patient refused an ileal-loop conduit for urinary tract diversion due to social reasons associated with a stoma.

Results

The total operative time was 240 min and the console time was 120 min. The estimated blood loss was 300 ml and the intensive care unit stay was 2 days. Post-operatively, the patient had good faecal and urinary continence and good quality of life.     

Male Urinary and Sexual Functions After Mesorectal Excision Alone or in Combination with Extended Lateral Pelvic Lymph Node Dissection for Rectal Cancer

Background

Mesorectal excision reduced the incidence of genitourinary dysfunction compared with conventional surgery. In Japan, extended lateral pelvic lymph node dissection (ELD) is added to mesorectal excision when lateral pelvic node metastasis is suspected. The aim of this study was to evaluate male genitourinary function after mesorectal excision or mesorectal excision plus ELD for rectal cancer.

Methods

According to the degree of pelvic-plexus preservation (PPP) and ELD, patients were grouped into PG1, mesorectal excision alone (bilateral PPP without ELD) (n = 27); PG2, bilateral PPP with ELD (n = 12); PG3, unilateral PPP with ELD (n = 26); and PG4, no PPP with ELD (n = 4). The assessment included measurements of the time interval to residual urine becoming <50 mL, interviews assessing sexual function, and nocturnal penile tumescence measurements.

Results

Proportions of patients with residual urine becoming <50 mL within 14 days after surgery were 96% in PG1, 73% in PG2, 23% in PG3, and 0% in PG4 (P < .001). Proportions of patients answering the ability to maintain sexual intercourse at 1 year were 95% in PG1, 56% in PG2, 45% in PG3, and 0% in PG4 (P < .001). Proportions of patients having nocturnal penile rigidity of >65% at 1 year were 95% in PG1, 33% in PG2, 50% in PG3, and 0% in PG4 (P < .001).

Conclusions

Patients undergoing mesorectal excision alone can expect excellent genitourinary function, but functional results after mesorectal excision plus ELD are far worse. Degrees of dysfunction depend on the extents of both autonomic nerve resection and ELD.     

Non-bridging external fixation employing multiplanar K-wires versus volar locked plating for dorsally displaced fractures of the distal radius

Background

The aim of this study was to compare non-bridging external fixation to palmar angular stable plating with respect to radiological outcome, wrist function, and quality of life.

Methods

One hundred and two consecutive patients (mean age: 63 years) were enrolled in the study. Fifty-two patients were randomized for plate osteosynthesis (2.4 mm, Synthes), 50 patients received non-bridging external fixation (AO small fixator). Objective (range of motion, grip strength), patient rated outcomes (quality of life, pain), and radiological outcome were assessed 8 weeks, 6 months, and 1 year after surgery.

Results

Loss of radial length of more than 3 mm was not detected in any group. Volar tilt was better restored by external fixation (7.2°) than by volar plating (0.1°). Wrist function was good in both groups. The external fixator was tolerated very well, and the quality of life assessment revealed comparable results in both groups. Osteoporosis was found in 54 % of patients and had no influence on radiological and functional outcome.

Conclusion

Non-bridging external fixation employing multiplanar K-wires is a suitable treatment option in intra- and extra-articular fractures of the distal radius even in osteoporotic bone.

Level of evidence

Prospective randomized trial, Level I.     

Transanal endoscopic microsurgery after neoadjuvant radiochemotherapy for locally advanced extraperitoneal rectal cancer: short-term morbidity and functional outcome

Background

Transanal endoscopic microsurgery (TEM) after radiochemotherapy (RCT) has been reported in selected cases of locally advanced rectal cancer as an alternative to traditional radical resection with total mesorectal excision with a curative intent or as diagnostic tool to confirm a pathological complete response of the primary tumor. No study has evaluated functional outcome after TEM in preoperatively irradiated patients.

Methods

This study was designed to evaluate short-term morbidity (according to Clavien’s classifications) and establish (by a questionnaire) continence and evacuative function after RCT and TEM, at 1 year from surgery, analyzing the impact of RCT on postoperative outcomes. Patients with locally advanced rectal cancer treated by RCT and TEM (group 1) or with early T1 or adenomas treated only by TEM (group 2) entered this cohort comparative study.

Results

Twenty-two patients entered the study as group 1 and 25 as group 2. No postoperative mortality occurred. The morbidity rate was 36.4 % in group 1 vs. 16 % in group 2 (p = 0.114). The rate of suture dehiscence was 22.7 % in group 1 vs. 4 % in group 2 (p = 0.068). No grade III complications, reoperation, or hospital readmission within 30 days was recorded in either group. One year after surgery, continence and evacuative scores in group 1 were 1.05 ± 1.25 and 24.72 ± 2.79, respectively, which were similar to group 2 (p = 0.081 and 0.288, respectively).

Conclusions

TEM after RCT in selected rectal cancer patients has an acceptable morbidity and functional results at 1 year from surgery. Preoperative irradiation could increase postoperative short-term morbidity, but it does not seem to influence evacuative or sphincter function after 1 year from surgery.     

Outcome Quality Standards in Pancreatic Oncologic Surgery

Purpose

To identify quality indicators and establish acceptable quality limits (AQLs) in pancreatic oncologic surgery using a formal statistical methodology.

Methods

Indicators have been identified through systematic literature reviews and guidelines for pancreatic surgery. AQLs were determined for each indicator with confidence intervals of 99.8 and 95 % above and below the weighted average by sample size from the different series examined.

Results

Several indicators have been identified with the following results as AQLs: resectability rate >59 %; morbidity, mortality, and pancreatic fistula rate in pancreaticoduodenectomy <55, <5, and <16 %, respectively; morbidity, mortality, and fistula rate in distal pancreatectomy <53, <4, and <31 %, respectively; number of lymph nodes retrieved >15; R1 resection <46 %; survival at 1, 3, and 5 years >54, >19, and >8 %, respectively.

Conclusions

A series of different indicators for quality surgical care outcome in pancreatic cancer, as well as their limits, have been determined according to a standard methodology.     

Delay to Curative Surgery Greater than 12 Weeks Is Associated with Increased Mortality in Patients with Colorectal and Breast Cancer but Not Lung or Thyroid Cancer

Background

Surgery for cancer is often delayed due to variety of patient-, provider-, and health system–related factors. However, impact of delayed surgery is not clear, and may vary among cancer types. We aimed to determine the impact of the delay from cancer diagnosis to potentially curative surgery on survival.

Methods

Cohort study based on representative sample of patients (n = 7,529) with colorectal, breast, lung and thyroid cancer with local or regional disease who underwent potentially curative surgery as their first therapeutic modality within 1 year of cancer diagnosis. They were diagnosed in 2006 and followed for mortality until April 2011, a median follow-up of 4.7 years.

Results

For colorectal and breast cancers, the adjusted hazard ratios (95 % confidence intervals) for all-cause mortality comparing a surgical delay beyond 12 weeks to performing surgery within weeks 1–4 after diagnosis were 2.65 (1.50–4.70) and 1.91 (1.06–3.49), respectively. No clear pattern of increased risk was observed with delays between 4 and 12 weeks, or for any delay in lung and thyroid cancers. Concordance between the area of the patient’s residence and the hospital performing surgery, and the patient’s income status were associated with delayed surgery.

Conclusions

Delays to curative surgery beyond 12 weeks were associated with increased mortality in colorectal and breast cancers, suggesting that health provision services should be organized to avoid unnecessary treatment delays. Health care systems should also aim to reduce socioeconomic and geographic disparities and to guarantee equitable access to high quality cancer care.     

Improvement in low back pain following spinal decompression: observational study of 119 patients

Study design

Prospective clinical observational study of low back pain (LBP) in patients undergoing laminectomy or laminotomy surgery for lumbar spinal stenosis (LSS).

Objectives

To quantify any change in LBP following laminectomy or laminotomy spinal decompression surgery.

Patients and methods

119 patients with LSS completed Oswestry Disability Index questionnaire (ODI) and Visual Analogue Scale for back and leg pain, preoperatively, 6 weeks and 1 year postoperatively.

Results

There was significant (p < 0.0001) reduction in mean LBP from a baseline of 5.14/10 to 3.03/10 at 6 weeks. Similar results were seen at 1 year where mean LBP score was 3.07/10. There was a significant (p < 0.0001) reduction in the mean ODI at 6 weeks and 1 year postoperatively. Mean ODI fell from 44.82 to 25.13 at 6 weeks and 28.39 at 1 year.

Conclusion

The aim of surgery in patients with LSS is to improve the resulting symptoms that include radicular leg pain and claudication. This observational study reports statistically significant improvement of LBP after LSS surgery. This provides frequency distribution data, which can be used to inform prospective patients of the expected outcomes of such surgery.