Ahmed Dehal

Impact of Body Mass Index on Survival After Colorectal Cancer Diagnosis: The Cancer Prevention Study-II Nutrition Cohort

PURPOSE The impact of body mass index (BMI) on survival after colorectal cancer diagnosis is poorly understood. This study assessed the association of pre- and postdiagnosis BMI with all-cause and cause-specific survival among men and women diagnosed with colorectal cancer in a prospective cohort. PATIENTS AND METHODS Participants in the Cancer Prevention Study-II Nutrition Cohort reported weight and other risk factor information via a self-administered questionnaire at baseline in 1992 to 1993. Updated information on current weight and incident cancer was reported via periodic follow-up questionnaires. This analysis includes 2,303 cohort participants who were diagnosed with nonmetastatic colorectal cancer between baseline and mid 2007 and were observed for mortality from diagnosis through December 2008. RESULTS A total of 851 participants with colorectal cancer died during the 16-year follow-up period, including 380 as a result of colorectal cancer and 153 as a result of cardiovascular disease (CVD). In analyses of prediagnosis BMI (weight reported at baseline in 1992 to 1993; mean, 7 years before colorectal cancer diagnosis), obese BMI (≥ 30 kg/m(2)) relative to normal BMI (18.5 to 24.9 kg/m(2)) was associated with higher risk of mortality resulting from all causes (relative risk [RR], 1.30; 95% CI, 1.06 to 1.58), colorectal cancer (RR, 1.35; 95% CI, 1.01 to 1.80), and CVD (RR, 1.68; 95% CI, 1.07 to 2.65). Postdiagnosis BMI (based on weight reported; mean, 1.5 years after diagnosis) was not associated with all-cause or cause-specific mortality. CONCLUSION This study suggests that prediagnosis BMI, but not postdiagnosis BMI, is an important predictor of survival among patients with nonmetastatic colorectal cancer.

Impact of Diabetes Mellitus and Insulin Use on Survival After Colorectal Cancer Diagnosis: The Cancer Prevention Study-II Nutrition Cohort

PURPOSE To examine the association between type 2 diabetes mellitus (T2DM) and survival among patients with colorectal cancer (CRC) and to evaluate whether this association varies by sex, insulin treatment, and durations of T2DM and insulin use. PATIENTS AND METHODS This study was conducted among 2,278 men and women diagnosed with nonmetastatic colon or rectal cancer between 1992 and 2007 in the Cancer Prevention Study-II Nutrition Cohort, a prospective study of cancer incidence. In 1992 to 1993, participants completed a detailed, self-administrated questionnaire. Vital status and cause of death were ascertained through the end of 2008. Multivariable-adjusted relative risks (RRs) and 95% CIs were estimated using Cox proportional hazards regression. RESULTS Among the 2,278 men and women with nonmetastatic CRC, there were 842 deaths by the end of follow-up (including 377 deaths from CRC and 152 deaths from cardiovascular disease [CVD]). Among men and women combined, compared with patients without T2DM, patients with CRC and T2DM were at higher risk of all-cause mortality (RR, 1.53; 95% CI, 1.28 to 1.83), CRC-specific mortality (RR, 1.29; 95% CI, 0.98 to 1.70), and CVD-specific mortality (RR, 2.16; 95% CI, 1.44 to 3.24), with no apparent differences by sex or durations of T2DM or insulin use. Insulin use, compared with no T2DM, was associated with increased risk of death from all causes (RR, 1.68; 95% CI, 1.22 to 2.31) and CVD (RR, 3.87; 95% CI, 2.12 to 7.08) but not from CRC (RR, 0.58; 95% CI, 0.28 to 1.19). CONCLUSION Patients with CRC and T2DM have a higher risk of mortality than patients with CRC who do not have T2DM, especially a higher risk of death from CVD.

Risk Factors for Neck Hematoma after Thyroid or Parathyroid Surgery: Ten-Year Analysis of the Nationwide Inpatient Sample Database

CONTEXT Postoperative neck hematoma is a well-known complication of thyroid and parathyroid surgery. Better understanding of risk factors for hematoma formation will help define high-risk populations. OBJECTIVE To examine possible risk factors for neck hematoma after thyroid or parathyroid surgery. DESIGN Retrospective analysis of hospital discharge data from the Nationwide Inpatient Sample database. METHODS Using the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and procedures codes, we identified adults who underwent thyroid or parathyroid surgery and in whom neck hematoma subsequently developed. Information about demographic, clinical, and hospital characteristics was collected. Multivariate regression analyses were used to predict independent risk factors for neck hematoma. RESULTS We identified 147,344 thyroid and parathyroid operations performed nationwide between 2000 and 2009. Overall incidence of postoperative neck hematoma was 1.5% (n = 2210). In multivariate analysis, age 65 years and older (odds ratio [OR] = 1.8, 95% confidence interval [CI] = 1.4-2.1), male sex (OR = 1.3, 95% CI = 1.2-1.4), African-American race (OR = 1.5, 95% CI = 1.2-1.7), being from the South (OR = 1.3, 95% CI = 1-1.4), comorbidity score of 3 or more (OR = 2, 95% CI = 1.6-2.6), history of alcohol abuse (OR = 2.7, 95% CI = 1.6-2.5), Graves disease (OR = 3, 95% CI = 2.1-4.1), and substernal thyroidectomy (OR = 3.3, 95% CI = 2.8-3.9) were associated with a higher risk of neck hematoma. CONCLUSION We identified demographic and clinical factors associated with increased risk of neck hematoma after thyroid or parathyroid surgery.

Intraperitoneal and extraperitoneal colonic perforation following diagnostic colonoscopy.

Combined intraperitoneal and extraperitoneal colonic perforation following colonoscopy is a rare and potentially serious complication of this common diagnostic and treatment modality.

The Power of Reflective Writing: Narrative Medicine and Medical Education

There is no doubt that medicine is an art and a science. Today, practicing medicine as science is probably much easier than practicing medicine as art, in light of the dazzling advances in medical technology and informatics. Even before technology gained the upper hand, patients were healed by physicians when most of the remedies were useless if not harmful, and when remedies were driven by theories that did not stand the test of time. To some extent, the art of fostering the sacred physician-patient relationship might have played a major role in the dramatic healing process. The physician-patient relationship is not limited to a comprehensive history and physical examination, a diagnostic workup, and the final discussion about a plan for action. Medicine requires that the physician establish deep connections by which s/he can dive deep into the crying soul of the patient. Healing an ailment is a complex process that must address two domains: disease, which is the alteration in the biologic structure and/ or function of the body; and illness, which is the psychological and social aspect of the ailment. Proper healing starts with open communication between physicians and patients. Patients draw on physicians’ attributes of honesty, integrity, empathy, and compassion to share their stories as they strive to heal. Narrative medicine offers a unique framework to explore and manage the complexity of healing. Its impact extends beyond the physician-patient relationship and into the relationships between physician and self, physician and colleagues, and physician and society. It is no wonder that many medical schools and residency programs have incorporated narrative medicine in the form of reflective writing into their curricula. Our learners, students and residents, are encouraged to be engaged in reflective writing as they search to understand what medical practice means to them, their patients, their colleagues, and society at large. Learners meet with the first author (SJ) on a regular basis to discuss and analyze their short, open-ended narratives. They are frequently asked to reflect on events of their choice that had a lasting impact on them, negative or positive, at any institution where they rotated. We (SJ and AD) are mesmerized by the insight of the learners and depth of their reflective capacity in their quest for self-identity, ideals, and values as they enter the complex environment of medical practice. It is only fitting to share some excerpts from learners’ narratives about valuable lessons from rich experiences in which they found themselves deeply immersed. One learner ruminated over the discrepancy between what we preach and how we act. He described his negative experience tagging along with his attending physician in a busy outpatient clinic. He wrote: I saw a 45-year-old patient with an advanced hepatocellular carcinoma. He came with his wife to learn about the results of his liver biopsy performed with [computed-tomography] guidance. He had no clue what was wrong with him, much less his prognosis. He was smiling and engaged in a conversation with his wife as I walked into the room. I asked him how much he knew about his condition. “They told me I might have a tumor, but I was told that you will be telling me more.” I was in my second month of training and did not feel comfortable breaking the bad news to him. I decided to leave it to my attending. A few minutes later, my attending and I went into the room. After introducing himself to the patient, the attending asked me to bring the ultrasound machine because he wanted to examine the patient for ascites. After he was done, he told the patient that there was no fluid and all this abdominal distension was probably due to an enlarged liver and suggested that the patient [go] to radiology for palliative chemo-embolization. While he was standing next to the door that was half open, the attending asked the patient “So, do you know what is going on with you?” The patient did not say anything but his [facial] expressions were enough for us to tell that he was not aware of how serious his condition was. “You have a very bad cancer and you will die in six months,” the attending said. Surprisingly, just [a] few days before that, the same attending gave us a lecture for an hour about palliative therapy of terminal cancer [patients]. The whole lecture was centered around dealing with terminal cancer patients and breaking bad news. He talked about some personal experiences as well as some skills and strategies of how to build a relationship with your patient[s] and how to earn their trust. “Touching the patient, sitting close to them, smiling, and some other simple things make all the difference in the world for them,” the attending had said. After we left the room, I was thinking of how shocking and overwhelming that was to the patient. I was wondering if being busy can be an acceptable excuse for not showing empathy and

Bilateral laparoscopic totally extraperitoneal repair without mesh fixation.

Background and Objectives: Mesh fixation during laparoscopic totally extraperitoneal repair is thought to be necessary to prevent recurrence. However, mesh fixation may increase postoperative chronic pain. This study aimed to describe the experience of a single surgeon at our institution performing this operation. Methods: We performed a retrospective review of the medical records of all patients who underwent bilateral laparoscopic totally extraperitoneal repair without mesh fixation for inguinal hernia from January 2005 to December 2011. Demographic, operative, and postoperative data were obtained for analysis. Results: A total of 343 patients underwent simultaneous bilateral laparoscopic totally extraperitoneal repair of 686 primary and recurrent inguinal hernias from January 2005 to December 2011. The mean operative time was 33 minutes. One patient was converted to an open approach (0.3%), and 1 patient had intraoperative bladder injury. Postoperative hematoma/seroma occurred in 5 patients (1.5%), wound infection in 1 (0.3%), hematuria in 2 (0.6%), and acute myocardial infarction in 1 (0.3%). Chronic pain developed postoperatively in 9 patients (2.6%); 3 of them underwent re-exploration. All patients were discharged home a few hours after surgery except for 3 patients. Among the 686 hernia repairs, there were a total of 20 recurrences (2.9%) in 18 patients (5.2%). Two patients had bilateral recurrences, whereas 16 had unilateral recurrences. Twelve of the recurrences occurred after 1 year (60%). Fourteen recurrences occurred among direct hernias (70%). Conclusion: Compared with the literature, our patients had fewer intraoperative and postoperative complications, less chronic pain, and no increase in operative time or length of hospital stay but had a slight increase in recurrence rate.

Postoperative antibiotic use and the incidence of intra-abdominal abscess in the setting of suppurative appendicitis: a retrospective analysis

BACKGROUND Although guidelines exist for postoperative antibiotic use in acute appendicitis that is perforated, gangrenous, or simple/uncomplicated, there are less data about its use in suppurative appendicitis. Here, we targeted this subgroup of patients to determine whether postoperative antibiotic administration affects incidence of intra-abdominal abscess formation. METHODS We retrospectively examined 1,192 patients who underwent laparoscopic appendectomy for acute appendicitis at Kaiser Permanente Fontana Hospital between August 2010 and August 2013. Suppurative appendicitis was described for 143 (12%) patients. Fifty-two patients received postoperative antibiotics for at least 1 week on discharge home, 91 did not. RESULTS Of 143 patients with suppurative appendicitis, 1 (1.9%) who received postoperative antibiotics came back with an intra-abdominal abscess within 1 month. Of the 91 patients in the no antibiotic group, 1 (1.1%) came back with an intra-abdominal abscess. CONCLUSIONS The administration of postoperative antibiotic in the setting of suppurative appendicitis has no effect on the rate of intra-abdominal abscess formation. Routine postoperative antibiotics may not be necessary in this patient population, and more evidence is needed to justify its use.

Primary Epithelial Neuroendocrine Tumors of the Retroperitoneum

Neuroendocrine tumors are either epithelial or neural in origin. Neuroendocrine tumors of the retroperitoneum are mostly metastatic. Primary epithelial neuroendocrine tumors of the retroperitoneum are exceedingly rare. We describe a case of a retroperitoneal tumor that was discovered incidentally during exploratory laparotomy for small-bowel obstruction. Histopathologic and immunochemical analyses of the biopsied mass were consistent with an epithelial neuroendocrine tumor. The tumor was subsequently removed and final analyses confirmed the initial diagnosis. No evidence of lymph nodes or paraganglia were found within the tumor on histologic examination. Extensive evaluation did not reveal any other primary or metastatic lesions. Therefore, the diagnosis of primary epithelial neuroendocrine tumor of the retroperitoneum was made. The literature is reviewed and discussed. To date, this is only the fifth reported case of primary epithelial retroperitoneal neuroendocrine tumor. Although extremely rare, the possibility of such diagnosis should be included in the differential diagnosis of a retroperitoneal tumor.

Resectable Distal Pancreas Cancer: Time to Reconsider the Role of Upfront Surgery

BackgroundNeoadjuvant chemotherapy (NAC) is increasingly utilized to optimize survival in proximal pancreatic adenocarcinoma. However, few studies have explored the impact of NAC in distal pancreas cancer.MethodsPatients with resectable pancreatic adenocarcinoma of the body or tail treated with either upfront pancreatectomy or NAC followed by surgery were identified in the 2006–2014 National Cancer Database. Trends in utilization, predictors of use, and impact of NAC on overall survival were determined.ResultsOf 1485 patients, 176 (11.9%) received NAC. Use of NAC increased from 9.3% in 2006 to 16.9% in 2013 [odds ratio 1.14; 95% confidence interval (CI) 1.05–1.24; p = 0.001]. NAC patients were younger, had higher clinical stage, and preoperative CA 19-9 levels (all p < 0.05). After adjustment for patient-, tumor-, and treatment-related factors, increased clinical stage was the greatest independent predictor of neoadjuvant approach (p < 0.001). On multivariable analysis, survival benefit from NAC did not reach threshold of significance (95% CI 0.66–1.04; p = 0.10) for the entire cohort. However, NAC was associated with a significant survival advantage in clinical stage III with a 51% decreased yearly risk of death (adjusted hazard ratio 0.49; 95% CI 0.25–0.98; p = 0.04). A trend towards improved survival with NAC was observed among stage IIA (p = 0.09) and IIB (p = 0.07) patients.ConclusionsNeoadjuvant chemotherapy is associated with improved overall survival in Stage III distal pancreatic adenocarcinoma and shows promise in earlier stage disease. However, only a small percentage of patients receive NAC. Prospective evaluation of NAC in distal pancreatic adenocarcinoma is warranted based on these findings.

Cutaneous Metastasis of Rectal Cancer: A Case Report and Literature Review

Cutaneous metastasis of rectal cancer is rare. It typically indicates widespread disease and poor prognosis. We report an exceedingly rare case of rectal cancer with metastasis to the skin and review the literature on cutaneous metastasis of rectal cancer. A 47-year-old man presented with stage IV unresectable adenocarcinoma of the rectum and received palliative chemoradiation for local pain control. About a year later he developed extensive skin lesions involving the genital area, bilateral groin, and perineum. Biopsy specimen showed mucinous adenocarcinoma compatible with rectal origin. Palliative treatment with radiation therapy was initiated. The patient responded well to treatment and is still alive more than a year after diagnosis of cutaneous metastasis. Surgeons should maintain strong suspicion of cutaneous metastases when patients with rectal cancer have new or evolving skin lesions.