Role of Major Vascular Resection in Patients with Intrahepatic Cholangiocarcinoma

Background

Historically, direct vascular extension of intrahepatic cholangiocarcinoma (ICC) has often been considered a contraindication to resection. However, recent studies have suggested safety and efficacy of hepatectomy with major vascular resection in this patient population. The aim of this study was to investigate the short and long-term clinical outcomes of patients with ICC treated with hepatectomy with or without major vascular resection.

Methods

This retrospective cohort study included all patients with ICC who underwent major liver resection between 1997 and 2011. Clinical outcomes were compared between patients treated with major hepatectomy and vascular resection (VR) and those without vascular resection (NVR). Kaplan–Meier survival estimates were used to compare overall survival (OS) between patients in VR and NVR groups.

Results

A total of 121 patients (median age 60; 42 % male) underwent major hepatectomy for ICC. Major vascular resection was performed in 14 (12 %) patients (IVC = 9, PV = 5). Age, sex, American Society of Anesthesiology (ASA) class, tumor size, lymph node status, and CA-19 9 were comparable (all p ≥ 0.184) between VR and NVR groups. Major postoperative complications (Dindo-Clavien ≥3) occurred in four (29 %) patients in the VR group and 17 (16 %) in the NVR group (p = 0.263). Postoperative death occurred in one patient in the VR group due to liver failure. Median OS did not differ between patients treated with and without vascular resection (32 vs. 49 months, respectively, p = 0.268).

Conclusions

Hepatectomy combined with IVC or PV resection can be safely performed in patients with ICC. Major vascular resection does not affect short and long-term outcomes in this patient population.     

Epidemiology and Outcomes of Deep Surgical Site Infections Following Lung Transplantation

We conducted a retrospective study of deep surgical site infections (SSIs) among consecutive patients who underwent lung transplantation (LTx) at a single center from 2006 through 2010. Thirty‐one patients (5%) developed SSIs at median 25 days after LTx. Empyema was most common (42%), followed by surgical wound infections (29%), mediastinitis (16%), sternal osteomyelitis (6%), and pericarditis (6%). Pathogens included Gram‐positive bacteria (41%), Gram‐negative bacteria (41%), fungi (10%) and Mycobacterium abscessus, Mycoplasma hominis and Lactobacillus sp. (one each). Twenty‐three percent of SSIs were due to pathogens colonizing recipients' native lungs at time of LTx, suggesting surgical seeding as a source. Patient‐related independent risk factors for SSIs were diabetes and prior cardiothoracic surgery; procedure‐related independent risk factors were LTx from a female donor, prolonged ischemic time and number of perioperative red blood cell transfusions. Mediastinitis and sternal infections were not observed among patients undergoing minimally invasive LTx. SSIs were associated with 35% mortality at 1 year post‐LTx. Lengths of stay and mortality in‐hospital and at 6 months and 1 year were significantly greater for patients with SSIs other than empyema. In conclusion, deep SSIs were uncommon, but important complications in LTx recipients because of their diverse microbiology and association with increased mortality.     

Investigating Transitional Care to Decrease Post-pancreatectomy 30-Day Hospital Readmissions for Dehydration or Failure to Thrive

Background

Current literature emphasizes post-operative complications as a leading cause of post-pancreatectomy readmissions. Transitional care factors associated with potentially preventable conditions such as dehydration and failure to thrive (FTT) may play a significant role in readmission after pancreatectomy and have not been studied.

Methods

Thirty-one post-pancreatectomy patients, who were readmitted for dehydration or FTT between 2009 and 2014, were compared to 141 nonreadmitted patients. Medical record review and a questionnaire-based survey, specifically designed to assess transitional care, were used to identify predictors of readmissions for dehydration or FTT. Logistic regression models were used to evaluate outcomes.

Results

On multivariable analysis, the strongest predictors of readmission for dehydration and FTT were the patient’s lower educational level (P?=?0.0233), the absence of family during the delivery of discharge instructions (P?=?0.0098), episodic intermittent nausea at discharge (P?=?0.0019), uncertainty about quantity, quality, or frequency of fluid intake (P?=?0.0137), and the inability or failure to adhere to the clinician’s instructions in the outpatient setting (P?=?0.0048).

Conclusion

Transitional-care-related factors are found to be associated with post-pancreatectomy readmission for dehydration and FTT. Using these results to identify high-risk patients and implement focused preventive measures combining efficient communication and optimal inpatient and outpatient management could potentially decrease readmission rates.

     

Organizing: new ways to harness complexity

As systems evolve, their natural tendency is to become increasingly more complex. Studies in the field of complex systems have generated new perspectives on managing in social organizations such as hospitals. Much of this research appears as a natural extension of the cross-disciplinary field of systems theory. This is the second in a 5-part series on applying complex systems science to the traditional management concepts of planning, organizing, directing, coordinating, and controlling. In this article, the concept of organizing is explored from a complex systems perspective.     

An evaluation of hernia education in surgical residency programs

Purpose

The purpose of this study was to evaluate surgical residents’ educational experience related to ventral hernias.

Methods

A 16-question survey was sent to all program coordinators to distribute to their residents. Consent was obtained following a short introduction of the purpose of the survey. Comparisons based on training level were made using χ² test of independence, Fisher’s exact, and Fisher’s exact with Monte Carlo estimate as appropriate. A p value <0.05 was considered significant.

Results

The survey was returned by 183 residents from 250 surgical programs. Resident postgraduate year (PG-Y) level was equivalent among groups. Preferred techniques for open ventral hernia varied; the most common (32 %) was intra-abdominal placement of mesh with defect closure. Twenty-two percent of residents had not heard of the retrorectus technique for hernia repair, 48 % had not performed the operation, and 60 % were somewhat comfortable with and knew the general categories of mesh prosthetics products. Mesh choices, biologic and synthetic, varied among the different products. The most common type of hernia education was teaching in the operating room in 87 %, didactic lecture 69 %, and discussion at journal club 45 %. Number of procedures, comfort level with open and laparoscopic techniques, indications for mesh use and technique, familiarity and use of retrorectus repair, and type of hernia education varied significantly based on resident level (p < 0.05).

Conclusion

Exposure to hernia techniques and mesh prosthetics in surgical residency programs appears to vary. Further evaluation is needed and may help in standardizing curriculums for hernia repair for surgical residents.     

Systemic Lupus Erythematosus and Increased Prevalence of Atherosclerotic Cardiovascular Disease in Hospitalized Patients

ObjectiveTo assess the prevalence of atherosclerotic cardiovascular disease (ASCVD) and its individual phenotypes of coronary artery disease (CAD), peripheral artery disease (PAD), and cerebrovascular disease by age and sex in a large US cohort of hospitalized patients with systemic lupus erythematosus (SLE).MethodsA nested case-control study of adults with and without SLE was conducted from the January 1, 2008, through December 31, 2014, National Inpatient Sample. Hospitalized patients with SLE were matched (1:3) by age, sex, race, and calendar year to hospitalized patients without SLE. The prevalences of CAD, PAD, and cerebrovascular disease were evaluated, and associations with SLE were determined after adjustment for common cardiovascular risk factors.ResultsAmong the 252,676 patients with SLE and 758,034 matched patients without SLE, the mean age was 51 years, 89% were women, and 49% were white. Patients with SLE had a higher prevalence of ASCVD vs those without SLE (25.6% vs 19.2%; OR, 1.45; 95% CI, 1.44-1.47; P<.001). After multivariable adjustment, SLE was associated with a greater odds of ASCVD (adjusted odds ratio [aOR], 1.46; 95% CI, 1.41-1.51). The association between SLE and ASCVD was observed in women and men and was attenuated with increasing age. Also, SLE was associated with increased odds of CAD (aOR, 1.42; 95% CI, 1.40-1.44), PAD (aOR, 1.25; 95% CI, 1.22-1.28), and cerebrovascular disease (aOR, 1.68; 95% CI, 1.65-1.71).ConclusionIn hospitalized US patients, SLE was associated with increased ASCVD prevalence, which was observed in both sexes and was greatest in younger patients.     

Precursor forms of substance P (SP) in nervous tissue: detection with antisera to SP, SP-Gly, and SP-Gly-Lys.

Antisera generated to substance P-Gly (SP-G) and substance P-Gly-Lys (SP-G-K), the likely unamidated COOH-terminally extended forms of substance P, were used to quantify and localize substance P precursor forms in hamster brain stem and spinal cord. The precursor determinant SP-G-K was liberated from larger heterogeneous forms by mild trypsinization of tissue extracts and was converted into the second precursor determinant, SP-G, by subsequent treatment with carboxypeptidase B. The basal levels of SP-G-K in brain stem and spinal cord were approximately equal to 0.5 pg/mg of tissue and rose 43- to 64-fold after trypsinization. Basal levels of SP-G were comparable to those of SP-G-K and rose 10- to 29-fold after combined enzyme treatments. Immunohistochemical labeling of axons and somata with anti-SP-G-K increased dramatically after trypsinization. This labeling was eliminated by preadsorption with authentic SP-G-K but not substance P or SP-G. Gel-permeation chromatography revealed SP-G-K-like immunoreactivity in fractions corresponding to considerably higher molecular weight than mature substance P. Collectively, these results support the hypothesis that substance P is synthesized from larger precursors and demonstrate that extended precursor forms are normally present in the axons and somata of neural systems that synthesize substance P.