Short-Term Outcomes of Ablation Therapy for Hepatic Tumors: Evidence from the 2006–2009 Nationwide Inpatient Sample

Background

Radiofrequency ablation (RFA) for the treatment of hepatic tumors has been increasingly used across the United States. Whether treatment-related morbidity has remained low with broader adoption is unclear. We conducted this study to describe in-hospital morbidity associated with RFA for hepatic tumors and to identify predictors of adverse events in a nationally representative database.

Methods

Using the 2006?C2009 Nationwide Inpatient Sample, we evaluated all patients aged ??40?years who underwent an elective RFA for primary or metastatic liver tumors (N?=?1298). Outcomes included in-hospital procedure-specific and postoperative complications. Multivariable logistic regression analyses were performed to identify patient and facility predictors of complications.

Results

Most patients underwent a percutaneous (39.9?%) or laparoscopic (22.0?%) procedure for metastatic liver tumors (57.5?%). Procedure-specific complications were frequent (18.2?%), with transfusion requirements (10.7?%), intraoperative bleeding (4.3?%), and hepatic failure (2.8?%) being the most common. Arrhythmias [adjusted odds ratio (AOR)?=?1.93 (1.23?C3.04)], coagulopathy [AOR?=?4.65 (2.95?C7.34)], and an open surgical approach [AOR?=?2.77 (1.75?C4.36)] were associated with an increased likelihood of procedure-specific complications, whereas hospital RFA volume ??16/year was associated with a reduced likelihood [AOR?=?0.59 (0.38?C0.91)]. Postoperative complications were also common (12.0?%), with arrhythmias, heart failure, coagulopathy, and open surgical approach acting as significant predictors.

Conclusions

In-hospital morbidity is common after RFA for hepatic tumors. While several patient factors are associated with more frequent procedure-specific complications, treatment at hospitals with an annual volume ??16 cases/year was associated with a 41?% reduction in the odds of procedure-specific complications.     

Operative Trends for Pancreatic Diseases in the USA: Analysis of the Nationwide Inpatient Sample from 1998–2011

The epidemiology of pancreatic diseases is changing. Our aim was to determine the change in indications, frequency, and type of operations being performed for primary pancreatic diseases in the USA. Using the Nationwide Inpatient Sample, all patients aged ≥18 years who underwent pancreatic operations for a primary pancreatic indication between 1998–2011 were identified. Age- and sex-adjusted rates per million adult population were calculated using the 2010 US population as reference. Changes in patient characteristics and outcomes were analyzed. Of 151,454 operations, 82 % were resections and 64 % were performed for tumors (malignant 52 %, benign 12 %). Operative rates/million population increased from 41.36 in 1998 to 62.3 in 2011. Population rates increased significantly for distal pancreatectomy, but decreased significantly for drainage procedures (p?<?0.05). Additionally, operative rates increased significantly for tumors and cysts/pseudocysts, but decreased significantly for acute pancreatitis (p?<?0.05). During this period, mean age, and comorbidity burden for patients undergoing pancreatic operations increased significantly, while their length of hospital stay and in-hospital mortality decreased significantly (p trend <0.05). The number of pancreatic operations performed in the USA is increasing. Although being offered to older patients with more comorbidities, surgeries are being performed with increasing safety and better outcomes.     

Opioid-Free Anesthesia in Bariatric Surgery: a Propensity Score–Matched Analysis

Obesity Surgery - Patients undergoing bariatric surgery are at particular high risk of postoperative nausea and vomiting (PONV). Few studies have shown the superiority of opioid-free anesthesia...     

Results of Sleeve Gastrectomy—Data from a Nationwide Survey on Bariatric Surgery in Germany

Background  Beginning January 1, 2005, the status and outcomes of bariatric surgery were examined in Germany. Data are registered in cooperation with the An-Institute of quality assurance in surgery at the Otto-von-Guericke-University Magdeburg. The objective of this study was to examine the morbidity and mortality rates secondary to sleeve gastrectomy (SG) in Germany since 2006. Methods  Data collection occurred prospectively in an online data bank. All primary bariatric procedures performed were recorded as were all re-operations in patients that had already undergone a primary operation. Specific data compiled on the sleeve gastrectomy procedure were evaluated with a focus on operative details and complication rates. Results  The total study cohort contains 3,122 patients. From January 2006 to December 2007, 144 sleeve gastrectomy procedures were performed in the 17 hospitals participating in the study. The mean body mass index (BMI) of all patients was 48.8 kg/m². The BMI of patients undergoing SG was 54.5 kg/m². In total, 73.8% of the patients were female and 26.2% of the patients were male. There were no significant differences between patients undergoing SG. The general complication rate after SG was 14.1%, and the surgical complication rate was 9.4%. The postoperative mortality rate was 1.4%. Conclusions  The complication rate during the first 2 years after SG in Germany is similar to that published in the literature. In order to improve the quality of bariatric surgery, an evaluation of data from a German multicenter trial is necessary to evaluate the position of SG in the bariatric algorithm.     

Comparison of Outcomes of Laparoscopic Versus Open Appendectomy in Children: Data from The Nationwide Inpatient Sample (NIS), 2006–2008

Background  

The benefits of laparoscopic appendectomy (LA) remain undefined as compared to open appendectomy (OA) in children, particularly in cases of perforated appendicitis. The purpose of the present study was to evaluate the outcomes of LA versus OA in perforated and nonperforated appendicitis in children.     

Comparison of Outcomes of Laparoscopic Versus Open Appendectomy in Adults: Data from the Nationwide Inpatient Sample (NIS), 2006–2008

Introduction  

Although laparoscopic appendectomy (LA) is being performed with increased frequency, the utilization of laparoscopy in the management of acute appendicitis remains controversial, and it continues to be used selectively.     

A Cost–Benefit Analysis of Bariatric Surgery on the South Plains Region of Texas

The regional economic burdens of obesity have not been fully quantified. This study incorporated bariatric surgery demographics collected from a large university hospital with regional economic and employment data to evaluate the cost of obesity for the South Plains region of Texas. Data were collected from patients who underwent laparoscopic gastric bypass and laparoscopic banding between September 2003 and September 2005 at Texas Tech University Health Sciences Center. A regional economic model estimated the economic impact of lost productivity due to obesity. Comparisons of lost work days in the year before and after surgery were used to estimate the potential benefit of bariatric surgery to the South Plains economy. Total output impacts of obesity, over $364 million, were 3.3% of total personal income; total labor income impacts neared $364 million, were 3.3% of total personal income; total labor income impacts neared 60 million: the losses corresponded to 2,389 lost output and2,389 lost output and 390 lost labor income per household. Obesity cost the South Plains over 1,977 jobs and decreased indirect business tax revenues by over 13 million. The net benefit of bariatric surgery was estimated at13 million. The net benefit of bariatric surgery was estimated at 9.9 billion for a discount rate of 3%, $5.0 billion for a discount rate of 5%, and $5.0 billion for a discount rate of 5%, and 1.3 billion for a discount rate of 10%. Potential benefits to the South Plains economy of performing bariatric surgery more than outweigh its costs.     

The Cost, Quality of Life Impact, and Cost–Utility of Bariatric Surgery in a Managed Care Population

Our purpose was to assess the cost, quality of life impact, and the cost–utility of bariatric surgery in a managed care population. We studied 221 patients who underwent bariatric surgery between 2001 and 2005. We analyzed medical claims data for all patients and survey data for 122 survey respondents (55% response rate). Patients were generally middle-aged, female, and white. Sixty-four percent underwent open and 33% underwent laparoscopic Roux-en-Y procedures. One year after surgery, mean body mass index fell from 51 to 31 kg/m² in women and from 59 to 35 kg/m² in men with substantial improvements in comorbidities. Postsurgical mortality and morbidity were low. Total per member per month costs increased in the 6 months before bariatric surgery, were lower in the 12 months after bariatric surgery, but increased somewhat over the next 12 months. When presurgical quality of life was assessed prospectively, average health utility scores improved by 0.14 one year after surgery. In analyses that took a lifetime time horizon, projected future costs based on age and obesity and discounted costs and health utilities at 3% per year, the cost–utility ratio for bariatric surgery versus no surgery was approximately $1,400 per quality-adjusted life-year gained. In sensitivity analyses, bariatric surgery was more cost-effective in women, non-whites, more obese patients, and when performed laparoscopically. Although not cost-saving, bariatric surgery represents a very good value for money. Its long-term cost effectiveness appears to depend on the natural history and cost of late postsurgical complications and the natural history and cost of untreated morbid obesity.     

Primary Total Knee Arthroplasty Allogenic Transfusion Trends,Length of Stay,and Complications: Nationwide Inpatient Sample 2000–2009

Perioperative blood loss leading to blood transfusion continues to be an issue for total knee arthroplasty (TKA) patients. The US Nationwide Inpatient Sample (NIS) was used to determine annual trends in allogenic blood transfusion rates, and effects of transfusion on in-hospital mortality, length of stay (LOS), costs, discharge disposition, and complications of primary TKA patients. TKA patients between 2000 and 2009 were included (n = 4,544,999) and categorized as: (1) those who received a transfusion of allogenic blood, and (2) those who did not. Transfusion rates increased from 7.7% to 12.2%. For both transfused and not transfused groups, mortality rates and mean LOS declined, while total costs increased. Transfused patients were associated with adjusted odds ratios of in-hospital mortality (AOR 1.16; P = 0.184), 0.71 ± 0.01 days longer LOS (P < 0.0001), and incurred ($1777 ± 36; P < 0.0001) higher total costs per admission.     

Impaired Bone Health in Inflammatory Bowel Disease: A Case–Control Study in 80 Pediatric Patients

Previous studies have indicated that children with inflammatory bowel disease (IBD) may not achieve optimal bone mass. We evaluated the skeletal characteristics in children and adolescents with IBD. This cross-sectional cohort study comprised 80 IBD patients (median age 14.9?years, range 5-20) with a median disease duration of 3.4?years; 51 had ulcerative colitis, 26 Crohn disease, and 3 unspecified colitis. Eighty age- and gender-matched healthy subjects served as controls. Areal bone mineral density (aBMD), body composition, and vertebral fractures (VFs) were assessed by DXA. Bone age (BA) was determined for IBD patients. Findings were correlated with disease- and treatment-related parameters and biochemistry. IBD patients had lower BA-adjusted lumbar spine and whole-body aBMD (p?150?mg/kg for the preceding 3?years increased the risk for low whole-body aBMD (OR?=?5.5, 95?% CI 1.3-23.3, p?=?0.02). VFs were found in 11?% of patients and in 3?% of controls (p?=?0.02). IBD in childhood was associated with low aBMD and reduced bone mass accrual relative to muscle mass; the risk for subclinical VFs may be increased. These observations warrant careful follow-up and active preventive measures.     

Outcomes of Partial Mastectomy in Male Breast Cancer Patients: Analysis of SEER, 1983–2009

Background

Although mastectomy is considered the gold standard for male breast cancer (MBC), the utilization of lumpectomy and its impact on outcomes in MBC patients has not been previously studied.

Methods

The Surveillance, Epidemiology and End Results (SEER) database was used to identify all MBC patients who underwent either mastectomy or less than mastectomy (i.e., lumpectomy) between 1983 and 2009.

Results

A total of 4707 (86.8 %) men underwent mastectomy and 718 (13.2 %) underwent lumpectomy. A greater proportion of patients underwent lumpectomy later in the study period (1983 to 1986, 10.6 %, vs. 2007 to 2009, 15.1 %). A greater percentage of lumpectomy patients were 80 years or older (21.3 % vs. 16.3 %), had stage IV disease (7.3 % vs. 3.1 %), and received no lymph node sampling (34.3 % vs. 6.9 %). Only 35.4 % of patients underwent adjuvant radiotherapy after lumpectomy. Ten-year breast cancer-specific survival and overall survival were 82.8 % and 46.9 %, respectively, in lumpectomy patients vs. 77.3 % and 46.4 %, respectively, in mastectomy patients. On Cox proportional hazards regression, lumpectomy was not independently associated with worse breast cancer-specific survival (odds ratio 1.09, 95 % confidence interval 0.87–1.37) or overall survival (odds ratio 1.12, 95 % confidence interval 0.98–1.27) after controlling for age, race, stage, and grade, as well as whether radiotherapy was received.

Conclusions

Lumpectomy is performed in a small but growing proportion of MBC patients. These patients are not only older and more likely to have advanced disease at the time of diagnosis, but they also are less likely to receive standard of care therapy, such as lymph node sampling and adjuvant radiotherapy. Despite these observations, breast cancer-specific survival is unaffected by the type of surgery.     

Five Year Follow-Up of a Randomized Controlled Trial on Warming and Humidification of Insufflation Gas in Laparoscopic Colonic Surgery—Impact on Small Bowel Obstruction and Oncologic Outcomes

Warming and humidification of insufflation gas has been shown to reduce adhesion formation and tumor implantation in the laboratory setting, but clinical evidence is lacking. We aimed to test the hypothesis that warming and humidification of insufflation CO₂ would lead to reduced adhesion formation, and improve oncologic outcomes in laparoscopic colonic surgery. This was a 5-year follow-up of a multicenter, double-blinded, randomized, controlled trial investigating warming and humidification of insufflation gas. The study group received warmed (37°C), humidified (98%) insufflation carbon dioxide, and the control group received standard gas (19°C, 0%). All other aspects of patient care were standardized. Admissions for small bowel obstruction were recorded, as well as whether management was operative or nonoperative. Local and systemic cancer recurrence, 5-year overall survival, and cancer specific survival rates were also recorded. Eighty two patients were randomized, with 41 in each arm. Groups were well matched at baseline. There was no difference between the study and control groups in the rate of clinical small bowel obstruction (5.7% versus 0%, P 0.226); local recurrence (6.5% versus 6.1%, P 1.000); overall survival (85.7% versus 82.1%, P 0.759); or cancer-specific survival (90.3% versus 87.9%, P 1.000). Warming and humidification of insufflation CO₂ in laparoscopic colonic surgery does not appear to confer a clinically significant long term benefit in terms of adhesion reduction or oncological outcomes, although a much larger randomized controlled trial (RCT) would be required to confirm this. ClinicalTrials.gov Trial identifier: {"type":"clinical-trial","attrs":{"text":"NCT00642005","term_id":"NCT00642005"}}NCT00642005; US National Library of Medicine, 8600 Rockville Pike, Bethesda, MD 20894, USA.Key words: Adhesions, Small bowel obstruction, Laparoscopy, humidification, colectomy, ColorectalIn laparoscopic surgery, the abdominal wall is commonly distended using carbon dioxide (CO₂) insufflation to provide pneumoperitoneum.¹ The gas is delivered at room temperature (19–21°C) with a relative humidity approaching 0% at the point of entry into the peritoneal cavity.² Early data suggested that unconditioned gas can cause structural and biochemical injury to the peritoneal mesothelium, and that warming and humidification of the insufflation CO₂ resulted in reduced postoperative pain after laparoscopic procedures.^3–7 However, more recent evidence from high quality, randomized controlled trials and a Cochrane meta-analysis have shown this not to be the case, with no difference in postoperative pain scores or opiate use with warming and humidification.^8–10With no demonstrable difference in short-term clinical outcomes, attention has now shifted toward long-term outcomes, namely adhesion formation and oncological response. There is now laboratory evidence to suggest that conditioning of insufflation gas may in fact reduce postoperative adhesion formation,^11,12 and peritoneal tumor implantation.¹³ It is thought that this is because conditioning insufflation gas reduces the peritoneal inflammatory response. However, clinical evidence to confirm these findings has been lacking.We previously published a multicenter, double-blinded, randomized controlled trial investigating warming and humidification of insufflation gas in laparoscopic colonic surgery.⁸ This study showed that warming and humidification did not confer any clinically significant short-term recovery benefit in laparoscopic colonic surgery. In light of the recent laboratory study findings mentioned above, we aimed to test the hypothesis that warming and humidification of insufflation CO₂ leads to reduced adhesion formation, and improved oncologic outcomes in laparoscopic colonic surgery.     

Risk factors for acute respiratory failure in bariatric surgery: data from the Nationwide Inpatient Sample, 2006–2008

BackgroundAcute respiratory failure (ARF) can be a life-threatening postoperative complication after bariatric surgery and is defined as the presence of acute respiratory distress or pulmonary insufficiency. We sought to identify predictors of ARF in patients who underwent bariatric surgery.MethodsUsing the Nationwide Inpatient Sample database, from 2006 to 2008, the clinical data from morbidly obese patients who underwent bariatric surgery were examined. Multivariate regression analysis was performed to identify the independent factors predictive of ARF. The factors examined included patient characteristics, co-morbidities, payer type, teaching status of hospital, surgical techniques (laparoscopic versus open), and type of bariatric operation (gastric bypass versus nongastric bypass).ResultsA total of 304,515 patients underwent bariatric surgery during the 3-year period. The overall ARF rate was 1.35%. The greatest rate of ARF (4.10%) was observed after open gastric bypass surgery. The ARF rate was lower after laparoscopic than after the open surgical technique (.94% versus 3.87%, respectively; P < .01) and after nongastric bypass versus gastric bypass (.82% versus 1.54%, respectively; P < .01). Using multivariate regression analysis, congestive heart failure (adjusted odds ratio [AOR] 5.1), open surgery (AOR 3.3), chronic renal failure (AOR 2.9), gastric bypass (AOR 2.5), peripheral vascular disease (AOR 2.4), male gender (AOR 1.9), age >50 years (AOR 1.8), Medicare payer (AOR 1.8), alcohol abuse (AOR 1.8), chronic lung disease (AOR 1.6), diabetes mellitus (AOR 1.2), and smoking (AOR 1.1) were factors associated with greater rates of ARF. Compared with patients without ARF, patients with ARF had significantly greater in-hospital mortality (5.69% versus .04%, P < .01).ConclusionWe identified multiple risk factors that have an effect on the development of acute respiratory failure after bariatric surgery. Surgeons should consider these factors in surgical decision-making and inform patients of their risk of this potentially life-threatening complication.     

Impact of bariatric surgery on outcomes of patients with nonalcoholic fatty liver disease: a nationwide inpatient sample analysis, 2004–2012

Background

Bariatric surgery in eligible morbidly obese individuals may improve liver steatosis, inflammation, and fibrosis; however, population-based data on the clinical benefits of bariatric surgery in patients with nonalcoholic fatty liver disease (NAFLD) are lacking.

Cohort Study of Oligorecurrent Prostate Cancer Patients: Oncological Outcomes of Patients Treated with Salvage Lymph Node Dissection via Prostate-specific Membrane Antigen–radioguided Surgery

BackgroundIn a subset of patients with recurrent oligometastatic prostate cancer (PCa) salvage surgery with prostate-specific membrane antigen (PSMA)-targeted radioguidance (PSMA-RGS) might be of value.ObjectiveTo evaluate the oncological outcomes of salvage PSMA-RGS and determine the predictive preoperative factors of improved outcomes.Design, setting, and participantsA cohort study of oligorecurrent PCa patients with biochemical recurrence (BCR) after radical prostatectomy and imaging with PSMA positron emission tomography (PET), treated with PSMA-RGS in two tertiary care centers (2014–2020), was conducted.InterventionPSMA-RGS.Outcome measurements and statistical analysisKaplan-Meier and multivariable Cox regression models were used to assess BCR-free (BFS) and therapy-free (TFS) survival. Postoperative complications were classified according to Clavien-Dindo.Results and limitationsOverall, 364 patients without concomitant treatment were assessed. At PSMA-RGS, metastatic soft-tissue PCa lesions were removed in 343 (94%) patients. At 2–16 wk after PSMA-RGS, 165 patients reached a prostate-specific antigen (PSA) level of <0.2 ng/ml. Within 3 mo, 24 (6.6%) patients suffered from Clavien-Dindo complications grade III–IV. At 2 yr, BFS and TFS rates were 32% and 58%, respectively. In multivariable analyses, higher preoperative PSA (hazard ratio [HR]: 1.07, 95% confidence interval [CI]: 1.02–1.12), higher number of PSMA-avid lesions (HR: 1.23, CI: 1.08–1.40), multiple (pelvic plus retroperitoneal) localizations (HR: 1.90, CI: 1.23–2.95), and retroperitoneal localization (HR: 2.04, CI: 1.31–3.18) of lesions in preoperative imaging were independent predictors of BCR after PSMA-RGS. The main limitation is the lack of a control group.ConclusionsAs salvage surgery in oligorecurrent PCa currently constitutes an experimental treatment approach, careful patient selection is mandatory based on life expectancy, low PSA values, and low number of PSMA PET–avid lesions located in the pelvis.Patient summaryWe looked at the outcomes from prostate cancer patients with recurrent disease after radical prostatectomy. We found that surgery may be an opportunity to prolong treatment-free survival, but patient selection criteria need to be very narrow.