Risk factors and outcomes for patients with pancreatic cancer undergoing surgical exploration without resection due to metastatic disease: A national cohort study

BackgroundUnresectable disease is sometimes diagnosed during surgery in patients with pancreatic ductal adenocarcinoma (PDAC). This study aimed to identify preoperative risk factors for metastatic disease diagnosed at surgical exploration and to investigate and compare survival in resected and non-resected patients.MethodsPatients were identified from the Swedish National Pancreatic and Periampullary Cancer Registry 2010-2018. Predictors of metastatic disease were evaluated with a multivariable logistic regression model, and survival was evaluated with Kaplan-Meier estimates and log-rank tests.ResultsIn total, 1938 patients with PDAC were scheduled for surgery. An unresectable situation was diagnosed intraoperatively in 399 patients (20.6%), including 234 (12.1%) with metastasized disease. Independent risk factors for metastasis were involuntary weight loss (OR = 1.72; 95% CI: 1.27-2.33) and elevated carbohydrate antigen 19-9 (CA19-9) (35-599 U/mL, OR = 1.79, 95% CI: 1.11-2.89; ≥ 600 U/mL, OR = 3.24, 95% CI: 2.04-5.17). Overall survival was lower among patients with metastasized disease than that among patients with a resectable tumor (P < 0.001).ConclusionsInvoluntary weight loss and an elevation of CA19-9 are preoperative risk factors for diagnosing metastasized disease during surgical exploration.     

Is preoperative biliary stenting associated with increased rate of postoperative complications for patients undergoing pancreatoduodenectomy? A review of national surgical quality improvement program data

BackgroundJaundice in the setting of periampullary neoplasms is often treated with biliary stenting. Level 1 data demonstrated an increase in perioperative complications after pancreaticoduodenectomy in patients undergoing stent placement. However, the impact of this data on practice patterns in the US remains unknown.MethodsThe National Surgical Quality Improvement Program (NSQIP) Pancreatectomy Targeted Participant Use Data File was used to identify patients from 2014 to 2017 undergoing pancreatoduodenectomy. Chi-square test and multivariable logistic regression were used to compare outcomes between those with biliary stent and those without.ResultsOf the 5524 patients, 3321 (60.1%) had biliary stent placement. The stent group was older, had a higher ASA class, and had preoperative weight loss compared to the group without biliary stenting (all p < 0.05). When adjusting for demographic and operative characteristics, the non-stent group had lower associated overall complications and postoperative infections. There was no significant difference in mortality and pancreatic fistula rate between groups.ConclusionPreoperative biliary stenting is still common prior to pancreaticoduodenectomy. With a trend toward increased utilization of neoadjuvant chemotherapy, stenting will likely remain a common practice. Recognition of increased rates of complications associated with stent placement allows for appropriate risk-benefit analysis.     

Risk of venous thromboembolism in patients with elevated INR undergoing hepatectomy: an analysis of the American college of surgeons national surgical quality improvement program registry

BackgroundPatients undergoing hepatectomy can have elevated INR and may have venous thromboembolism (VTE) prophylaxis withheld as a result. We sought to examine the association between preoperative INR elevation and VTE following hepatectomy.MethodsHepatectomies captured in the American College of Surgeons National Surgical Quality Improvement Program registry between 2007 and 2016 were analyzed. Univariable and multivariable models examined the effect of incremental increases in preoperative INR on 30-day VTE, perioperative transfusion, serious morbidity, and mortality, adjusting for potential confounders.ResultsWe included 25,220 elective hepatectomies (62.4% partial lobectomies, 10.1% left hepatectomies, 18.6% right hepatectomies, 9.2% trisegmentectomies). The median age of the patients was 60 years and 49% were male. INR was elevated in 3089 patients (12.2%): 1.1–1.2 in 8.1%, 1.2–1.4 in 3.3%, and 1.4–2.0 in 0.9%. Incremental elevations in INR were independently associated with increasing risk for postoperative VTE [odds ratio (OR) 1.15, 95% confidence intervals 1.01–1.31], perioperative transfusion [OR 1.35 (1.28–1.43)], serious morbidity [OR 1.35 (1.28–1.43)], and mortality [OR 1.76 (1.56–1.98)].ConclusionElevation in preoperative INR was counter-intuitively associated with increased risk of both VTE and perioperative transfusion following hepatectomy. The role of perioperative thromboprophylaxis warrants further investigation to determine optimal care in patients with elevated preoperative INR.     

A quality improvement project for better glycemic control in hospitalized patients with diabetes

PURPOSE: A quality improvement (QI) study was designed to improve nursing interventions that impact glycemic control in hospitalized patients with diabetes. The objective was to improve the timing of premeal insulin to allow a half hour lag time for regular insulin. METHODS: An interdisciplinary planning team was established that included both medical and surgical units. Data were collected by concurrent review of electronic charts, evaluated monthly by management and the diabetes clinical coordinator, and shared with staff. RESULTS: This QI study increased staff nurses' awareness of the importance of their role in achieving better glycemic control for inpatients with diabetes. By the end of the study, the nurses delivered premeal insulin correctly 82% of the time on the medical unit, 65% of the time on the cardiac unit, and 61% of the time on the surgical unit. Even with concerted effort, however, it was difficult to consistently administer regular insulin with a half hour lag time in the hospital environment. CONCLUSIONS: By working together with the patient, family, and other staff, nurses can more consistently deliver premeal insulin at appropriate times to help improve glycemic control in the hospitalized patient with diabetes.     

Exercise for low-income patients with diabetes: a continuous quality improvement project

PURPOSE: The specific aim of this project was to form a partnership between a community health center (CHC) to improve access to exercise for low-income patients with type 2 diabetes. METHODS: Eligible participants were members of the Siouxland Community Health Center (SCHC), 19 years of age or older, with a diagnosis of type 2 diabetes. Patients were medically waived and received an invitation to exercise at the Siouxland YMCA. An exercise coach (pharmacist, registered nurse, or medical assistant) met with each patient and scheduled and conducted exercise visits for participating patients 2 times each week. Patients' baseline clinical variables were taken and assessed quarterly over a 12-month period. RESULTS: This collaboration established an ongoing exercise program with a total of 1297 exercise encounters in a 12-month period. Forty-eight of 130 eligible patients (36.9%) visited the YMCA on at least 1 occasion. Patients were categorized as experimental (56.3%), involved (25%), and regular (18.8%) exercisers. Nine (18.8%) of the 48 patients attended supplementary YMCA exercise encounters. Five (11%) of the 48 patients renewed and purchased a membership at the YMCA and adopted a self-management approach to regular exercise. CONCLUSION: The creation of a partnership between a community health center and an exercise organization permitted disadvantaged patients with diabetes an affordable exercise program and contributed to improved clinical measurements. The exercise program can be used as a model for other community health centers and health professionals who desire to improve the implementation of an exercise program for patients with diabetes.     

The improvement of insulin resistance in patients with adrenal incidentaloma by surgical resection

OBJECTIVE: Several recent studies have indicated that patients with adrenal incidentaloma often have disturbed glucose tolerance or/and hypertension. It is unclear whether these metabolic conditions could be caused by adrenal incidentaloma. We investigated the prevalence of disturbed glucose tolerance, hypertension and insulin resistance in the patients with non-functioning adrenal incidentaloma and evaluated the changes of the parameters such as glucose tolerance, blood pressure and insulin sensitivity after adrenalectomy. PATIENTS AND METHODS: Among 15 patients with incidentally discovered adrenal tumours in our department from 1996 to 1999, 4 patients were diagnosed as having pre-clinical Cushing's syndrome and the other 11 as having non-functioning tumours based on detailed endocrinological examinations including dexamethasone suppression testing. Four tumours with pre-clinical Cushing's syndrome and 8 tumours out of 11 patients with non-functioning tumours were diagnosed histopathologically as adrenocortical adenomas and the other 3 as of non-adrenal origin including a myelolipoma, an adrenal vascular cyst and an endothelioma. The prevalence of disturbed glucose tolerance was determined with an oral glucose tolerance test, and insulin sensitivity was evaluated by the method of steady state of plasma glucose (SSPG). RESULTS: All 12 patients with adrenocortical adenoma exhibited insulin resistance based on the SSPG (6.9-13.2 mmol/l). Before surgical removal of the tumours, the SSPG titre was relatively higher in the patients with pre-clinical Cushing's syndrome than in those with non-functioning with adrenocortical adenoma (mean value 11.65 vs. 8.99 mmol/l), whereas 2 of the 3 patients with non-adrenocortical tumours did not have insulin resistance. Among the 12 patients with adrenocortical adenoma, 7 (58%) and 9 (75%) patients exhibited hypertension and disturbed glucose tolerance, respectively. After removal of the tumours, SSPG of the patients with adrenocortical adenoma, but not that of the other 3 patients with non-cortical tumours, was significantly decreased compared to pre-adrenalectomy values. There are no significant differences in the changes of SSPG titres between in pre-clinical Cushing's syndrome and in non-functioning adrenocortical adenoma. Systolic blood pressure, but not diastolic blood pressure, was also significantly decreased in the patients with adrenocortical adenoma. CONCLUSION: High prevalences of disturbed glucose tolerance, insulin resistance and hypertension were found among the patients with non-functioning adrenocortical tumours. Adrenocortical adenoma may be one of the risk factors for insulin resistance that is believed to induce disturbed glucose tolerance and/or hypertension. Therefore, it is useful to evaluate insulin resistance for the patients with adrenal incidentalomas since results are likely to be helpful in deciding whether to remove the tumour by surgery.     

Postoperative weight loss during hospital stays in patients with gastric cancer undergoing surgical resection

BACKGROUND/AIMS: The timing of sampling weight loss in the patients with gastric cancer undergoing surgical resection can be divided into 2 categories: prior to operation and postoperative follow-up as an outpatient. In this study, a third timing is proposed; the postoperative period during hospital stay. The purposes of this report were to identify the clinical variables related to postoperative weight loss during the hospital stay in gastric cancer patients and to investigate the influence of the weight loss on the long-term survival. METHODOLOGY: Records of 313 patients who underwent gastrectomies for cancer between 1992 and 2003 were reviewed retrospectively. Patients were divided into 2 groups according to the median value of the rate of weight loss. Overall survival was estimated by the Kaplan-Meier Method. RESULTS: The postoperative hospital stays were significantly longer in the serious weight loss group than in the mild weight loss group. Developing complication, extended lymph node dissection, and operation time had the impact independently of the rate of weight loss. The overall survival was not different between the serious weight loss and the mild weight loss groups by a log-rank test (5-year survival, 70.1% vs. 70.5%, p = 0.82). CONCLUSIONS: Although the serious weight loss during hospital stay means the true surgical damage in gastric cancer patients, it has no influence on the long-term survival.     

A simplified draping of patients in the lithotomy-trendelenburg position for anterior resection by stapling or abdominoperineal excision of the rectum

Thorlakson RH. A simplified draping of patients in the lithotomy-Trendelenburg position for anterior resection by stapling or abdominoperineal excision of the rectum.     

Hepatic resection with and without surgical margins for hepatocellular carcinoma in patients with impaired liver function.

BACKGROUND/AIMS: The significance of a surgical margin for hepatic resection of hepatocellular carcinoma (HCC) in patients with impaired liver function was evaluated. METHODOLOGY: Sixty-eight patients, each with a solitary HCC, who had not received any prior treatments were divided into 2 groups, according to surgical margin: Group A included 25 patients who underwent resection with no margin (although the tumor was not exposed) and Group B included 43 patients with a sufficient surgical margin (mean distance: 9 mm). There were no significant differences in clinicopathologic variables between the 2 groups. The rate of stump recurrence, survival and recurrence-free survival were analyzed. RESULTS: Among the 38 patients who had cancer recurrence after a median follow-up of 58 months, 9 (Group A, n=4; Group B, n=5) (24%) had recurrent lesions at the stump. The surgical margin was not a significant factor related to survival or recurrence, irrespective of cirrhosis, capsule formation, cancer spread, or tumor size. CONCLUSIONS: Our results indicated that the HCC-free surgical margin is unlikely to be related to the survival of patients with impaired liver function unless the tumor is exposed on the raw liver surface.     

Surgical resection for patients with pulmonary aspergillosis in the national inpatient sample

BackgroundThe role of lung resection in patients with pulmonary aspergillosis is generally reserved for those with localized disease who fail medical management. We used a national database to investigate the influence of preoperative patient comorbidities on inpatient mortality and need for surgery.MethodsPatients admitted with pulmonary aspergillosis between 2007 to 2015 were identified in the National Inpatient Sample dataset. Inpatient mortality rates were compared between patients treated medically and surgically. Predictors of mortality, surgical intervention, and non-elective admission were evaluated using multivariable logistic regression.ResultsAmong a population estimate of 112,998 patients with pulmonary aspergillosis, 107,606 (95.2%) underwent medical management alone and 5,392 (4.8%) underwent surgical resection. Positive predictors for surgery included hemoptysis, and history of lung cancer or chronic pulmonary diseases. Surgically treated patients had a lower inpatient mortality when compared to those treated medically (11.5% vs. 15.1%, P<0.001) in univariate analysis, but this finding did not persist in multivariable analysis (AOR 0.97, P=0.509). The odds of mortality were lower in patients undergoing video assisted thoracoscopic surgery compared to an open approach (AOR 0.77, P=0.001). Among patients treated surgically, mortality was higher in those with a history of lung cancer, solid organ transplantation, liver disease, human immunodeficiency virus infection, hematologic diseases, chronic pulmonary diseases, and those admitted non-electively requiring surgery.ConclusionsIn this generalizable study, medical and surgical management of pulmonary aspergillosis were comparable in terms of inpatient mortality. However, non-elective admission and patients with select comorbidities have significantly worse outcomes after surgical intervention.     

Impact of muscle volume and muscle function decline in patients undergoing surgical resection for hepatocellular carcinoma

Background and Aim

This study investigated the prognostic impact of muscle volume loss (MVL) and muscle function decline in patients undergoing resection for hepatocellular carcinoma (HCC).

Methods

This study enrolled 171 naïve HCC patients treated with resection from 2007 to 2015, after excluding those lacking spirometry or computed tomography findings, who had received non‐curative treatments, or with restrictive or obstructive lung disorders. The median peak expiratory flow rate (%PEF) was set as the cut‐off value for muscle function decline, and MVL was diagnosed using a previously reported value. Clinical backgrounds and prognosis were retrospectively evaluated.

Results

Overall survival rate was lower in the MVL (n = 35) as compared with the non‐MVL (n = 136) group (1/3/5‐year overall survival rate = 88.2%/81.6%/55.6% vs 91.0%/81.5%/74.8%, respectively; P = 0.0083), while there were no differences regarding hepatic function or tumor burden between the groups. Child‐Pugh class B (hazard ratio [HR] 3.510, 95% confidence interval [CI]: 1.558–7.926, P = 0.0025), beyond Milan criteria (HR 1.866, 95%CI: 1.024–3.403, P = 0.042), and presence of MVL (HR 1.896, 95%CI: 1.052–3.416, P = 0.033) were significant prognostic factors. The decreased %PEF group (n = 84) showed a higher rate of postoperative delirium than the others (n = 87) (27.4% vs 11.5%, P = 0.0088). The cut‐off values for %PEF and age for postoperative delirium were 63.3% (area under receiver operating characteristic [AUROC] 0.697) and 73 years old (AUROC 0.734), respectively. Delirium was observed in 50.0% (14/28) of patients with both factors, 23.8% (15/63) of those with 1 factor, and 5.0% (4/80) of those without either factor.

Conclusion

Muscle volume loss is an independent prognostic factor in HCC patients treated with surgical resection, while advanced age and decreased muscle function might indicate high risk for postoperative delirium.     

Prevention or surgical treatment of gallstones in patients undergoing gastric bypass surgery for obesity

Opinion statement It is well known that obesity is a risk for gallstone formation and biliary sludge. Additionally, it has been clearly shown that rapid weight loss following bariatric surgery is a risk factor for cholesterol cholelithiasis. Multiple serious complications from gallstones such as cholecystitis, cholangitis, gallstone pancreatitis, and cholecystenteric fistulae may occur. Thus, it is necessary to employ medical or surgical methods to prevent or treat gallstones in this group. Therapy should be individualized. Although there is a high incidence of gallstones in this group, only a minority of individuals will develop symptomatic disease. When used in patients who are compliant, ursodeoxycholic acid therapy can be effective to prevent gallstone formation during rapid weight loss. The cost effectiveness of routine ursodeoxycholic acid therapy compared with the potential costs of complicated gallstone disease needs to be further investigated. Combined cholecystectomy with Roux-en-Y gastric bypass surgery is a safe and appropriate therapeutic option in those with preoperatively known gallstones, biliary sludge, and prior episodes of cholecystitis. However, routine cholecystectomy at the time of gastric bypass surgery is not warranted for all patients because of the increased time of operation and postoperative hospitalization, as well as all the potential complications after cholecystectomy. The approach of routine cholecystectomy in this setting subjects many patients to an unnecessary procedure because the majority will not develop symptoms or complications of gallstones. Furthermore, cholecystectomy is technically easier to perform after weight loss occurs.     

Survival rates for stage II colon cancer patients treated with or without chemotherapy in a population-based setting

Background and aims There is considerable uncertainty as to whether adjuvant 5-fluorouracil-based chemotherapy provides survival benefit for colon cancer patients with stage II disease. Consequently, the current rates of chemotherapy use for this disease are low despite 5-year survival rates of only 70–80%. The aim of the present study is to compare the survival rate of stage II colon cancer patients treated by surgery alone with that of patients also treated by chemotherapy. Patients and methods A population-based observational study was conducted on the survival of stage II colon cancer patients (n = 812) diagnosed in Western Australia from 1993 to 2003. The study was restricted to patients aged ≤75 years, of whom 18% (n = 142) were treated with chemotherapy. Only 0.9% of patients older than 75 years received chemotherapy. Results Patients who received chemotherapy were significantly younger (mean age 6 years) than those treated by surgery alone (65 years, P < 0.001), and their tumors were more often positive for vascular invasion (P = 0.007). Multivariate analysis that included all prognostic factors revealed adjuvant chemotherapy was associated with improved survival (HR = 0.62, 95% CI [0.39–0.98], P = 0.043), with women gaining more benefit (HR = 0.48, 95% CI [0.20–1.22], P = 0.09) than men (HR = 0.94, 95% CI [0.54–1.64], P = 0.8). Conclusions In view of the apparent survival benefit from chemotherapy for stage II colon cancer, the present study raises concerns about the current low rates of adjuvant treatment for this disease in the community, particularly for female patients. Melinda Morris was supported by a Surgeon–Scientist scholarship from the Royal Australasian College of Surgeons.     

Prognostic value of an immunohistochemical signature in patients with pulmonary squamous cell carcinoma undergoing complete surgical resection

BackgroundThe Tumor Node Metastasis (TNM) stage cannot accurately predict the prognosis of patients in pulmonary squamous cell carcinoma (SQCC). The aim of the present study was to evaluate the prognostic value of immunohistochemical (IHC)-based classifiers in patients with pulmonary SQCC who underwent complete surgery resection.MethodsFrom January 2010 to December 2014, a total of 556 patients with SQCC who underwent complete radical resection were included. The patients were grouped into a discovery group (n=334) and a validation group (n=222). Using the least absolute shrinkage and selection operator (LASSO) regression model, we extracted IHCs that were associated with progression-free survival (PFS) and then built classifiers. Clinicopathological variables and the IHC-based classifiers were analyzed using univariable and multivariable logistic regression analyses. A nomogram to predict PFS was constructed and validated using bootstrap resampling.ResultsFollowing the LASSO regression model, 4 IHC markers associated with PFS were identified. We used the IHC-based classifiers to stratify patients in both groups into high- and low-risk groups. PFS was better in the low-risk group than in the high-risk group in both the discovery and validation groups. Multivariate analysis demonstrated that the IHC-based classifiers were independently prognostic in predicting the PFS of patients with SQCC. The performance of the nomogram was evaluated and proven to be clinically useful.ConclusionsBy combining IHC-based classification and clinicopathology, we were able to have better insight into the prognostic assessment of patients with SQCC after surgery, which can inform postoperative patient management.     

Prognostic factors for surgical resection in patients with multidrug-resistant tuberculosis.

Although surgical lung resection could improve prognosis in some patients with multidrug-resistant tuberculosis (MDR-TB), there are no reports on the optimal candidates for this surgery. The aim of the present study was to elucidate the prognostic factors for surgery in patients with MDR-TB. Patients who underwent lung resection for the treatment of MDR-TB between March 1993 and December 2004 were included in the present study. Treatment failure was defined as greater than or equal to two of the five cultures recorded in the final 12 months of treatment being positive, any one of the final three cultures being positive, or the patient having died during treatment. The variables that affected treatment outcomes were identified through univariate and multivariate logistic regression analysis. In total, 79 patients with MDR-TB were included in the present study. The treatment outcomes of 22 (27.8%) patients were classified as failure. A body mass index <18.5 kg x m(-2), primary resistance, resistance to ofloxacin and the presence of a cavitary lesion beyond the range of the surgical resection were associated with treatment failure. Low body mass index, primary resistance, resistance to ofloxacin and cavitary lesions beyond the range of resection are possible poor prognostic factors for surgical lung resection in multidrug-resistant tuberculosis patients.