Andrew J. Smith

Results of an Aggressive Approach to Resection of Locally Recurrent Rectal Cancer

BackgroundThe value of resection for locally recurrent rectal cancer (LRRC) remains controversial. We analyzed outcomes of an aggressive approach to resection of LRRC.MethodsWe conducted a retrospective chart review of 52 consecutive patients who underwent resection of LRRC from September 1997 through August 2005. Overall and disease-free survival (OS, DFS) curves were constructed by the Kaplan–Meier method, and compared by log-rank analysis. Median follow-up time was 29xa0months (range 3–72).ResultsThirty-one patients (60%) were male. Median age was 60xa0years (range 36–88). Forty-six of the 52 patients were resected with curative intent, while 6 had known distant metastases at the time of resection. All 52 patients underwent grossly complete resection of local disease, and 41 (79%) had microscopically clear resection margins. An en bloc sacrectomy was performed in 28 (54%) patients. Postoperative mortality was nil; significant complications developed in 42% of patients. The complication rate was higher in patients with sacrectomy than without (50 vs. 33%, Pxa0=xa00.017, Chi square). For the entire cohort of 52 patients, median OS and DFS were 40 and 24xa0months, respectively. Survival was equivalent in patients with and without sacrectomy. In the 46 patients who had resection with curative intent, 4-year OS was 48%. Median OS in the six patients with distant metastases at the time of resection was 21xa0months. OS was predicted by the presence of metastases (Pxa0=xa00.01), and margin status (Pxa0<xa00.0001). DFS was predicted by margin status (Pxa0=xa00.0001).ConclusionsIn this series of patients who underwent resection of LRRC, microscopic margin status was the most significant predictor of OS and DFS. Requirement for en bloc sacrectomy was not associated with inferior survival. Carefully selected patients with distant metastases may benefit from resection of LRRC.

The Impact of an Acute Care Emergency Surgical Service on Timely Surgical Decision-Making and Emergency Department Overcrowding

BACKGROUNDnThis study evaluated how implementation of an acute care emergency surgery service (ACCESS) affected key determinants of emergency department (ED) length of stay, and particularly, surgical decision time. Also, we analyzed how ACCESS affected ED overcrowding.nnnSTUDY DESIGNnWe conducted a before and after study of all ED patients referred to ACCESS from January 1, 2007 to June 30, 2009. ACCESS was implemented on July 1, 2008. The primary outcome was surgical decision time; the secondary outcome was a measure of overall ED overcrowding: time-to-stretcher for all ED patients. The control groups were patients referred to internal medicine or urology. Patients with appendicitis were studied in order to analyze the impact on patient outcomes and to determine barriers to efficient ED patient flow.nnnRESULTSnOf 2,510 patients, 1,448 patients were pre-ACCESS, and 1,062 were after ACCESS implementation. Implementation of ACCESS was associated with a 15% reduction in surgical decision time (12.6 hours vs 10.8 hours, p < 0.01). During the same period, there were no significant changes in decision time for our control groups. Also, the mean time-to-stretcher for all ED patients decreased by 20%. In patients with appendicitis, we found that patient flow could be further improved by a timely request for surgical consultation and expedited imaging. Finally, we found that patients with nonperforated appendicitis with a fecalith on CT imaging were more likely to suffer perforation while waiting for surgery.nnnCONCLUSIONSnACCESS reduced surgical decision time for surgical patients. Also, ACCESS improved overall ED crowding, as measured by time-to-stretcher for ED patients. Further improvements could be made by improving time to imaging. Patients referred for nonperforated appendicitis with a fecalith on CT should have expedited surgery.

Clinically important aspects of lymph node assessment in colon cancer.

There has been considerable discussion in the literature regarding the importance and validity of lymph node retrieval and lymph node count for patients with colon cancer. In this article we summarize the importance of lymph node resection and assessment in contemporary colon cancer care, key clinical determinants of lymph node assessment, and discuss the role of lymph node assessment as a quality marker in colon cancer care. J. Surg. Oncol. 2009;99:248–255.

Guideline for optimization of colorectal cancer surgery and pathology.

There is evidence of gaps in care for colorectal cancer surgery related to obtaining negative resection margins and lymph node assessment. Recommendations on the surgical and pathological management of curable colon and rectal cancer were developed.

Compliance, attitudes and barriers to post‐operative colorectal cancer follow‐up

RATIONALEnMeta-analyses demonstrate that surveillance following curative-intent colorectal cancer (CRC) surgery can improve survival. Our multidisciplinary team adopted a stringent CRC follow-up (FU) guideline in 2000. The purpose of this study was to assess adherence and barriers to FU for CRC.nnnMETHODSnPatients with primary CRC aged 19-75 years, treated with curative intent surgery from July 2000 to December 2002 were identified from a prospective database. Compliance with FU was assessed primarily by chart review. We also surveyed patients and providers to explore attitudes and barriers to surveillance adherence using tenets of the Health Belief Model.nnnRESULTSn96 patients met inclusion criteria and were appropriate for FU. Median FU was 34 months. Guideline targets were met for 70% of clinic visits; 49% of carcinoembryonic antigen (CEA) determinations; and 62% of abdominal imaging studies. Post-operative colonoscopy did not occur in 6/93 patients. Seventy per cent of health care providers and 55% of patients completed a survey. Access to testing and confusion about which provider orders investigations were identified as important barriers to FU.nnnCONCLUSIONnPatterns of CRC FU were widely variable despite implementation of a guideline. Despite patient and provider agreement with the principles of CRC FU, adoption was inhibited by confusion among multiple providers regarding investigation coordination.

Predictors of Multivisceral Resection in Patients with Locally Advanced Colorectal Cancer

BackgroundPractice guidelines recommend en bloc multivisceral resection (MVR) for all involved organs in patients with locally advanced adherent colorectal cancer (LAACRC) to reduce local recurrence and improve survival. We found that MVR was performed in one-third of eligible American patients in the Surveillance, Epidemiology and End Results cancer registry but that study could not identify factors amenable to quality improvement. This study was conducted to examine rates, and predictors of MVR among Canadian patients with LAACRC.MethodsRates of MVR were examined by observational study. Eligible patients were aged 20–74xa0years who had surgery for nonmetastatic LAACRC from July 1997 to December 2000. Patient, tumor, surgeon, and hospital characteristics were extracted from medical records. Summary statistics were compared by type of surgery (MVR, partial MVR, standard resection). To identify factors associated with MVR we analyzed operative notes and transcripts from interviews with general surgeons using standard qualitative methods.ResultsFactors associated with MVR included fewer years in practice, preoperative treatment planning, involvement of surgical consultants, and access to diagnostic imaging and systems to enable preoperative multidisciplinary planning. Judgments regarding the nature of peritumoral adhesions, resectability, and personal technical skill may mediate decision-making. Many surgeons would prefer to refer patients than undertake complicated, lengthy cases.ConclusionFurther research is required to validate these findings in larger studies and among patients undergoing surgery for conditions other than LAACRC, and evaluate strategies to improve rates of MVR through enhanced individual awareness and system capacity.

The surgeon at workFascio-peritoneal patch repair of the IVC: a workhorse in search of work?1

A 52-year-old man with a history of nephrolithiasis presented with 2 years of intermittent right flank discomfort. This was a dull pain with no obvious initiating or alleviating factors. His physical examination, laboratory tests, abdominal x-rays, and IVP were all unrevealing. An ultrasound demonstrated a large mass adjacent to the right kidney. Subsequent CT scanning showed that this mass extended to the right lobe of the liver and encroached on the IVC, portal vein, and right hepatic vessels. He underwent exploratory laparotomy at a local hospital, where the tumor was deemed unresectable. An incisional biopsy revealed high-grade leiomyosarcoma. He presented to Memorial Sloan-Kettering Cancer Center for definitive management of this difficult problem. To further assess resectability, an MRI was performed with additional contrast-enhanced threedimensional gradient echo angiography through the upper abdomen (Fig. 1). This study demonstrated the mass encasing the right renal vein, with apparent invasion and compression of the posterior IVC and left renal vein. All of these vessels, however, remained patent. The celiac and mesenteric vessels were clear of tumor involvement. The patient was taken to the operating room for exploratory laparotomy using a thoracoabdominal approach. The large tumor was found to fill the right retroperitoneum from the retrohepatic space to the pelvic brim. The tumor was mobilized laterally to medially en bloc with the right kidney and adrenal gland. The right renal artery was ligated in continuity with the specimen. The right renal vein was dissected free from the tumor and then divided with a vascular stapling device. This left the tumor adherent to the posterior IVC at the confluence of the renal veins. Proximal and distal control of the IVC was obtained with vessel loops at the retrohepatic and infrarenal portions of the vessel. The left renal vein was divided after an adequate left gonadal vein was visualized. The IVC was then clamped proximally and distally, and the tumor was excised with a scalpel, leaving an 835-cm defect in the posterior IVC. The remaining anterior IVC measured approximately 4.5cm in width. A sizematched strip of peritoneum with posterior rectus fascia was harvested from the right supraumbilical abdominal wall by electrocautery. The patch was affixed, peritoneum inward, to the IVC using running 4-0 Prolene suture (Ethicon, Somerville, NJ) (Fig. 2). The clamps were removed, revealing vigorous caval flow. The patient tolerated the procedure well and was discharged home on postoperative day 6 with normal renal function. An ultrasound of the IVC 2 weeks after the procedure demonstrated a patent, although slightly narrowed vein (Fig. 3). Pathologic examination confirmed a 14312311-cm high-grade leiomyosarcoma with margins negative for tumor.

Opinion leaders and changes over time: a survey

BackgroundOpinion leaders represent one way to disseminate new knowledge and influence the practice behaviors of physicians. This study explored the stability of opinion leaders over time, whether opinion leaders were polymorphic (i.e., influencing multiple practice areas) or monomorphic (i.e., influencing one practice area), and reach of opinion leaders in their local network.MethodsWe surveyed surgeons and pathologists in Ontario to identify opinion leaders for colorectal cancer in 2003 and 2005 and to identify opinion leaders for breast cancer in 2005. We explored whether opinion leaders for colorectal cancer identified in 2003 were re-identified in 2005. We examined whether opinion leaders were considered polymorphic (nominated in 2005 as opinion leaders for both colorectal and breast cancer) or monomorphic (nominated in 2005 for only one condition). Social-network mapping was used to identify the number of local colleagues identifying opinion leaders.ResultsResponse rates for surgeons were 41% (2003) and 40% (2005); response rates for pathologists were 42% (2003) and 37% (2005). Four (25%) of the surgical opinion leaders identified in 2003 for colorectal cancer were re-identified in 2005. No pathology opinion leaders for colorectal cancer were identified in both 2003 and 2005. Only 29% of surgical opinion leaders and 17% of pathology opinion leaders identified in the 2005 survey were considered influential for both colorectal cancer and breast cancer. Social-network mapping revealed that only a limited number of general surgeons (12%) or pathologists (7%) were connected to the social networks of identified opinion leaders.ConclusionsOpinion leaders identified in this study were not stable over a two-year time period and generally appear to be monomorphic, with clearly demarcated areas of expertise and limited spheres of influence. These findings may limit the practicability of routinely using opinion leaders to influence practice.

Multiple factors influence compliance with colorectal cancer staging recommendations: an exploratory study

BackgroundFor patients with colorectal cancer (CRC) retrieval by surgeons, and assessment by pathologists of at least 12 lymph nodes (LNs) predicts the need for adjuvant treatment and improved survival. Different interventions (educational presentation, engaging clinical opinion leaders, performance data sent to hospital executives) to improve compliance with this practice had variable results. This exploratory study examined factors hypothesized to have influenced the outcome of those interventions.MethodsSemi-structured interviews were conducted with 26 surgeons and pathologists at eleven hospitals. Clinicians were identified by intervention organizers, public licensing body database, and referral from interviewees. An interview guide incorporating open-ended questions was pilot-tested on one surgeon and pathologist. A single investigator conducted all interviews by phone. Transcripts were analyzed independently by two investigators using a grounded approach,ho then compared findings to resolve differences.ResultsImprovements in LN staging practice may have occurred largely due to educational presentations that created awareness, and self-initiated changes undertaken by pathologists. Executives that received performance data may not have shared this with staff, and opinion leaders engaged to promote compliance may not have fulfilled their roles. Barriers to change that are potentially amenable to quality improvement included perceptions about the practice (perceived lack of evidence for the need to examine at least 12 LNs) and associated responsibilities (blaming other profession), technical issues (need for pathology assistants, better clearing solutions and laboratory facilities), and a lack of organizational support for multidisciplinary interaction (little communication between surgeons and pathologists) or quality improvement (no change leaders or capacity for monitoring).ConclusionUse of an exploratory approach provided an in-depth view of the way that numerous factors amenable to quality improvement influenced the adoption of new CRC LN staging recommendations. Continued interventions targeting physicians and executives, in the absence of a receptive organizational infrastructure, may be fruitless. Individualized rather than regional or punitive performance data, coupled with increased organizational capacity for change may stimulate greater surgical and organizational response to quality improvement. Descriptive or experimental studies are needed to test these hypotheses.

Surgical Site Infection Prevention: A Qualitative Analysis of an Individualized Audit and Feedback Model

BACKGROUNDnSurgical site infection (SSI) adversely affects patient outcomes and health care costs, so prevention of SSI has garnered much attention worldwide. Surgical site infection is recognized as an important quality indicator of patient care and safety. The purpose of this study was to use qualitative research methods to evaluate staff perceptions of the utility and impact of individualized audit and feedback (AF) data on SSI-related process metrics for their individual practice, as well as on overall communication and teamwork as they relate to SSI prevention.nnnSTUDY DESIGNnThis study was performed in a tertiary care center, based on patients treated in the colorectal and hepatic-pancreatic-biliary surgical oncology services. Eighteen clinicians were interviewed. Analysis of interviews via comparative analysis techniques and coding strategies were used to identify themes.nnnRESULTSnThe most important finding of this study was that although nearly all participants believed that the individualized AF model was useful in effecting individual practice change as well as improving awareness and accountability around individual roles in preventing SSIs, it was not seen as a means to enable the multidisciplinary teamwork required for sustainable practice changes. Moreover, such teamwork requires a team leader.nnnCONCLUSIONSnProvision of individualized AF data had a significant impact on promoting individual practice change. Despite this, we concluded that practice change is a shared responsibility, requiring a team leader. So, AF had little bearing on establishing a necessary multidisciplinary team approach to SSI prevention, to create more effective and sustainable practice change among an entire team.