Abhishek D. Parmar

Relative contributions of complications and failure to rescue on mortality in older patients undergoing pancreatectomy

Background:For pancreatectomy patients, mortality increases with increasing age. Our study evaluated the relative contribution of overall postoperative complications and failure to rescue rates on the observed increased mortality in older patients undergoing pancreatic resection at specialized centers. Methods:We identified 2694 patients who underwent pancreatic resection from the American College of Surgeons’ National Surgical Quality Improvement Pancreatectomy Demonstration Project at 37 high-volume centers. Overall morbidity and in-hospital mortality were determined in patients younger than 80 years (N = 2496) and 80 years or older (N = 198). Failure to rescue was the number of deaths in patients with complications divided by the total number of patients with postoperative complications. Results:No significant differences were observed between patients younger than 80 years and those 80 years or older in the rates of overall complications (41.4% vs 39.4%, P = 0.58). In-hospital mortality increased in patients 80 years or older compared to patients younger than 80 years (3.0% vs 1.1%, P = 0.02). Failures to rescue rates were higher in patients 80 years or older (7.7% vs 2.7%, P = 0.01). Across 37 high-volume centers, unadjusted complication rates ranged from 25.0% to 72.2% and failure to rescue rates ranged from 0.0% to 25.0%. Among patients with postoperative complications, comorbidities associated with failure to rescue were ascites, chronic obstructive pulmonary disease, and diabetes. Complications associated with failure to rescue included acute renal failure, septic shock, and postoperative pulmonary complications. Conclusions:In experienced hands, the rates of complications after pancreatectomy in patients 80 years or older compared to patients younger than 80 years were similar. However, when complications occurred, older patients were more likely to die. Interventions to identify and aggressively treat complications are necessary to decrease mortality in vulnerable older patients.

Current trends in preoperative biliary stenting in patients with pancreatic cancer

BACKGROUND Sufficient evidence suggests that preoperative biliary stenting is associated with increased complication rates after pancreaticoduodenectomy. METHODS Surveillance, Epidemiology, and End Results (SEER) and linked Medicare claims data (1992-2007) were used to identify patients with pancreatic cancer who underwent pancreaticoduodenectomy. We evaluated trends in the use of preoperative biliary stenting, timing of physician visits relative to stenting, and time to surgical resection and symptoms in stented and unstented patients. RESULTS Pancreaticoduodenectomy was performed in 2,573 patients, and 52.6% of patients underwent preoperative biliary stenting (N = 1,354). Of these, 75.3% underwent endoscopic stenting only, 18.9% received a percutaneous stent, and 5.8% underwent both procedures. The overall stenting rate increased from 29.6% of patients between 1992 and 1995 to 59.1% between 2004 and 2007 (P < .0001). Preoperative stenting was more common in patients with jaundice, cholangitis, pruritus, or coagulopathy (P < .05 for all). Of stented patients, 77.7% had had a stent placed prior to seeing a surgeon. Stenting prior to surgical consultation was associated with longer indwelling stent time compared to stenting after surgical consultation (37.3 vs 27.0 days, P < .0001). In addition, stented patients had longer times from surgeon visit to pancreatectomy than those who had not received stents (24.2 days vs 17.2 days, P < .0001). CONCLUSION Use of preoperative biliary stenting doubled between 1992 and 2007 despite evidence that stenting is associated with increased perioperative infectious complications. The majority of stenting occurred prior to surgical consultation and is associated with significant delay in time to operation. Surgeons should be involved early in order to prevent unnecessary stenting and improve outcomes.

Trajectory of care and use of multimodality therapy in older patients with pancreatic adenocarcinoma

INTRODUCTION Multimodality therapy with chemotherapy and operative resection is recommended for patients with locoregional pancreatic cancer but is not received by many patients. OBJECTIVE To evaluate patterns in the use and timing of chemotherapy and resection and factors associated with receipt of multimodality therapy in older patients with locoregional pancreatic cancer. METHODS We used Surveillance, Epidemiology, and End Results-linked Medicare data (1992-2007) to identify patients with locoregional pancreatic adenocarcinoma. Multimodality therapy was defined as receipt of both chemotherapy and pancreatic resection. Logistic regression was used to determine factors independently associated with receipt of multimodality therapy. Log-rank tests were used to identify differences in survival for patients stratified by type and timing of treatment. RESULTS We identified 10,505 patients with pancreatic adenocarcinoma. 5,358 patients (51.0%) received either chemotherapy or surgery, with 1,166 patients (11.1%) receiving both modalities. Resection alone was performed in 1,138 patients (10.8%), and chemotherapy alone was given to 3,054 (29.1%) patients. In patients undergoing resection as the initial treatment modality, 49.4% never received chemotherapy; 97.4% of patients who underwent chemotherapy as the initial treatment modality never underwent resection. The use of multimodality therapy increased from 7.4% of patients in 1992-1995 to 13.8% of patients in 2004-2007 (P < .0001). The 2-year survival was 41.0% for patients receiving multimodality therapy, 25.1% with resection alone, and 12.5% with chemotherapy alone (P < .0001). Of the patients receiving multimodality therapy, chemotherapy was delivered in the adjuvant setting in 93.1% and in the neoadjuvant setting in 6.9%, with similar 2-year survival with either approach (neoadjuvant vs adjuvant, 46.9% vs 40.6%; P = .16). Year of diagnosis, white race, less comorbidity, and no vascular invasion were independently associated with receipt of multimodality therapy. CONCLUSION Only half of older patients with locoregional pancreatic cancer receive any treatment, and fewer than one quarter of treated patients receive multimodality therapy. Nearly all patients receiving chemotherapy as the initial treatment modality did not undergo resection, whereas half of those undergoing resection first received chemotherapy. When multimodality therapy is used, the vast majority of patients had chemotherapy in the adjuvant setting with a similar survival, regardless of approach.

Preop-gallstones: A prognostic nomogram for the management of symptomatic cholelithiasis in older patients

OBJECTIVE AND BACKGROUND The decision regarding elective cholecystectomy in older patients with symptomatic cholelithiasis is complicated. We developed and validated a prognostic nomogram to guide shared decision making for these patients. METHODS We used Medicare claims (1996-2005) to identify the first episode of symptomatic cholelithiasis in patients older than 65 years who did not undergo hospitalization or elective cholecystectomy within 2.5 months of the episode. We described current patterns of care and modeled their risk of emergent gallstone-related hospitalization or cholecystectomy at 2 years. Model discrimination and calibration were assessed using a random split sample of patients. RESULTS We identified 92,436 patients who presented to the emergency department (8.3%) or physicians office (91.7%) and who were not immediately admitted. The diagnosis for the initial episode was biliary colic/dyskinesia (65.3%), acute cholecystitis (26.6%), choledocholithiasis (5.7%), or gallstone pancreatitis (2.4%). The 2-year emergent gallstone-related hospitalization rate was 11.1%, with associated in-hospital morbidity and mortality rates of 56.5% and 6.5%. Factors associated with gallstone-related acute hospitalization included male sex, increased age, fewer comorbid conditions, complicated biliary disease on initial presentation, and initial presentation to the emergency department. Our model was well calibrated and identified 51% of patients with a risk less than 10% for 2-year complications and 5.4% with a risk more than 40% (C statistic, 0.69; 95% confidence interval, 0.63-0.75). CONCLUSIONS Surgeons can use this prognostic nomogram to accurately provide patients with their 2-year risk of developing gallstone-related complications, allowing patients and physicians to make informed decisions in the context of their symptom severity and its impact on their quality of life.

Computed tomography identification of latent pseudoaneurysm after blunt splenic injury: pathology or technology?

BACKGROUND Serial computed tomography (CT) imaging of blunt splenic injury can identify the latent formation of splenic artery pseudoaneurysms (PSAs), potentially contributing to improved success in nonoperative management. However, it remains unclear whether the delayed appearance of such PSAs is truly pathophysiologic or attributable to imaging quality and timing. The objective of this study was to evaluate the influence of recent advancements in imaging technology on the incidence of the latent PSA. METHODS Consecutive patients with blunt splenic injury over 4.5 years were identified from our trauma registry. Follow-up CT was performed for all but low-grade injuries 24 hours to 48 hours after initial CT. Incidences of both early and latent PSA formation were reviewed and compared with respect to imaging technology (4-slice vs. >or=16-slice). RESULTS A total of 411 patients were selected for nonoperative management of blunt splenic injury. Of these, 135 had imaging performed with 4-slice CT, and 276 had imaging performed with CTs of >=16-slice. Mean follow-up was 75 days (range, 1-1178 days) and 362 patients (88%) had follow-up beyond 7 days. Comparing 4-slice CT with >or=16-slice CT, there were no significant differences in the incidence of early PSA (3.7% vs. 4.7%; p = 0.91) or latent PSA (2.2% vs. 2.9%; p = 0.90). In both groups, latent PSAs accounted for approximately 38% of all PSAs observed. Splenic injury grade on initial CT was not associated with latent PSA (p = 0.54). Overall, the failure rate of nonoperative management was 7.3%. Overall mortality was 4.6%. No mortalities were related to splenic or other intra-abdominal injury. CONCLUSIONS The incidences of both early and latent PSA have remained remarkably stable despite advances in CT technology. This suggests that latent PSA is not a result of imaging technique but perhaps a true pathophysiologic phenomenon. Injury grade is unhelpful concerning the prediction of latent PSA formation.

Evaluating Comparative Effectiveness With Observational Data Endoscopic Ultrasound and Survival in Pancreatic Cancer

A previous observational study reported that endoscopic ultrasound (EUS) is associated with improved survival in older patients with pancreatic cancer. The objective of this study was to reevaluate this association using different statistical methods to control for confounding and selection bias.

Physician follow-up and observation of guidelines in the post treatment surveillance of colorectal cancer

BACKGROUND Guidelines for post resection surveillance of colorectal cancer recommend a collection of the patients history and physical examination, testing for carcinoembryonic antigen (CEA), and colonoscopy. No consistent guidelines exist for the use of abdominal computed tomography (CT) and position emission tomography (PET)/PET-CT. The goal of our study was to describe current trends, the impact of oncologic follow-up on guideline adherence, and the patterns of use of nonrecommended tests. METHODS We used Texas Cancer Registry-Medicare-linked data (2000-2009) to identify physician visits, CEA testing, colonoscopy, abdominal CT, and PET/PET-CT scans in patients ≥ 66 years old with stage I-III colorectal cancer who underwent curative resection. Compliance with guidelines was assessed with a composite measure of physician visits, CEA tests, and colonoscopy use from start of surveillance. RESULTS In patients who survived 3 years, the overall compliance with guidelines was 25.1%. In patients seen regularly by a medical oncologist, compliance with guidelines increased to 61.5% compared with 8.8% for those not seen by a medical oncologist regularly (P < .0001). The use of abdominal CT and PET/PET-CT increased from 57.5% and 9.5%, respectively, in 2001 to 65.8% and 24.6% (P < .0001) in 2006. Patients who saw a medical oncologist were more likely to get cross-sectional imaging than those who did not (P < .0001). CONCLUSION Compliance with current minimum guidelines for post treatment surveillance of colorectal cancer is low and the use of nonrecommended testing has increased over time. Both compliance and use of nonrecommended tests are markedly increased in patients seen by a medical oncologist. The comparative effectiveness of CT and PET/PET-CT in the surveillance of colorectal cancer patients needs further examination.

Relative impact of surgeon and hospital volume on operative mortality and complications following pancreatic resection in Medicare patients

BACKGROUND Surgeon and hospital volume are both known to affect outcomes for patients undergoing pancreatic resection. The objective was to evaluate the relative effects of surgeon and hospital volume on 30-d mortality and 30-d complications after pancreatic resection among older patients. MATERIALS AND METHODS The study used Texas Medicare data (2000-2012), identifying high-volume surgeons as those performing ≥4 pancreatic resections/year, and high-volume hospitals as those performing ≥11 pancreatic resections/year, on Medicare patients. Three-level hierarchical logistic regression models were used to evaluate the relative effects of surgeon and hospital volumes on mortality and complications, after adjusting for case mix differences. RESULTS There were 2453 pancreatic resections performed by 490 surgeons operating in 138 hospitals. Of the total, 4.5% of surgeons and 6.5% of hospitals were high volume. The overall 30-d mortality was 9.0%, and the 30-d complication rate was 40.6%. Overall, 8.9% of the variance in 30-d mortality was attributed to surgeon factors and 9.8% to hospital factors. For 30-d complications, 4.7% of the variance was attributed to surgeon factors and 1.2% to hospital factors. After adjusting for patient, surgeon, and hospital characteristics, high surgeon volume (odds ratio [OR] = 0.54, 95% confidence interval [CI], 0.33-0.87) and high hospital volume (OR = 0.52; 95% CI, 0.30-0.92) were associated with lower risk of mortality; high surgeon volume (OR = 0.71, 95% CI, 0.55-0.93) was also associated lower risk of 30-d complications. CONCLUSIONS Both hospital and surgeon factors contributed significantly to the observed variance in mortality, but only surgeon factors impacted complications.

The Risk Paradox: Use of Elective Cholecystectomy in Older Patients Is Independent of Their Risk of Developing Complications

BACKGROUND We recently developed and validated a prognostic model that accurately predicts the 2-year risk of emergent gallstone-related hospitalization in older patients presenting with symptomatic gallstones. STUDY DESIGN We used 100% Texas Medicare data (2000 to 2011) to identify patients aged 66 years and older with an initial episode of symptomatic gallstones not requiring emergency hospitalization. At presentation, we calculated each patients risk of 2-year gallstone-related emergent hospitalization using the previously validated model. Patients were placed into the following risk groups based on model estimates: <30%, 30% to <60%, and ≥ 60%. Within each risk group, we calculated the percent of elective cholecystectomies (≤ 2.5 months from initial episode) performed. RESULTS In all, 161,568 patients had an episode of symptomatic gallstones. Mean age was 76.5 ± 7.3 years and 59.9% were female. The 2-year risk of gallstone-related hospitalizations increased from 15.9% to 41.5% to 65.2% across risk groups. For the overall cohort, 22.3% in the low-risk group, 20.9% in the moderate-risk group, and 23.2% in the high-risk group underwent elective cholecystectomy in the 2.5 months after the initial symptomatic episode. In patients with no comorbidities, elective cholecystectomy rates decreased from 34.2% in the low-risk group to 26.7% in the high-risk group. Of patients who did not undergo cholecystectomy, only 9.5% were seen by a surgeon in the 2.5 months after the initial episode. CONCLUSIONS The risk of recurrent acute biliary symptoms requiring hospitalization has no influence, or even a paradoxical negative influence, on the decision to perform elective cholecystectomy after an initial symptomatic episode. Translation of the risk prediction model into clinical practice can better align treatment with risk and improve outcomes in older patients with symptomatic gallstones.

Quality of post-treatment surveillance of early stage breast cancer in Texas

BACKGROUND Only annual mammography and physical examination are recommended for the post-treatment surveillance of early stage breast cancer. METHODS We used Texas Cancer Registry-Medicare linked data (2001-2007) to identify physician visits and use of mammography, magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET) CT in patients ≥ 66 years old with ductal carcinoma in situ and stage I-III ductal carcinoma who underwent curative-intent operations. We also evaluated the trends in use of recommended and nonrecommended tests. RESULTS We identified 8,598 patients with resected ductal carcinoma in situ (37.3%) or invasive ductal cancer (62.7%). Breast-conserving therapy was performed in 59%. Only 55% saw a physician twice a year for 2 years and underwent annual mammography for 2 consecutive years in the surveillance period. Mammography use decreased from 81% in 2001 to 75% in 2007 (P < .0001), and breast MRI use rose from 0.5% to 7.0% (P < .0001). For asymptomatic patients, the use of CT/MRI of the abdomen, chest, and head was 27%, 23%, and 22%, and this slightly increased during the study period. There was a significant increase in PET/PET CT use, from 2% in 2001 to 9% in 2007 (P < .0001). There was a concomitant decrease in bone scan use from 21% in 2001 to 13% in 2007 (P < .0001). CONCLUSION Adherence to evidence-based guidelines has been substandard and the use of nonrecommended tests has persisted over the study period. The rise in PET use and attendant decrease in bone scan implicates a population receiving PET scan in lieu of bone scan for surveillance of asymptomatic metastatic disease. In an elderly population of breast cancer patients in Texas, these findings imply both underuse and overuse.