Anne O. Lidor

Esophageal Cancer Treatment Is Underutilized Among Elderly Patients in the USA

ObjectivesLarge numbers of elderly patients in the USA receive no treatment for esophageal cancer, despite evidence that multimodality treatment can increase survival. Our goal is to identify factors that may contribute to lack of treatment.Materials and MethodsUsing Surveillance Epidemiology and End Results (SEER)-Medicare Linked Database (2001−2009), we identified regional esophageal cancer patients ≥65xa0years old. Treatment was defined as receiving any medical or surgical therapy for esophageal cancer. Logistic regression analysis was performed to identify factors associated with failure to receive treatment. Overall survival (OS) was analyzed using the Kaplan-Meier method and Cox proportional hazard model.ResultsThere were 5072 patients (median age, 75xa0years; interquartile range (IQR), 71–81xa0years). Majority were treated with definitive chemoradiation (48.49xa0%). Factors associated with lack of treatment included West geographic region and ≥80xa0years old. Patients who received therapy had better OS (log-rank, pu2009<u20090.001). Compared with treated patients, non-treated patients had worse adjusted OS (HR, 1.43; 95xa0% confidence interval (CI), 1.33–1.55; pu2009<u20090.001).ConclusionsElderly patients with locally advanced esophageal cancer who received treatment had improved 5-year survival compared with patients without treatment. Disparities in utilization of treatment are associated with regional and socioeconomic factors, not presence of comorbidities.

Influence of Specialty Training and Trainee Involvement on Perioperative Outcomes of Esophagectomy.

BACKGROUNDnHospitals and surgeons volume-outcome relationship have been reported in several esophagectomy studies with an inverse association of mortality and volume. The purpose of our study was to evaluate the outcomes of esophagectomy in the United States relative to the surgeons specialty.nnnMETHODSnThis was a retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program database (2006 to 2013). All patients (18 years of age and older) who underwent esophagectomy were divided into 2 groups according to whether the operation was performed by a general surgeon (GS) or a cardiothoracic surgeon (CTS). A comparison of intraoperative and postoperative outcomes between the groups was conducted. The primary outcome was 30-day mortality. Secondary outcomes included overall and serious morbidity, discharge destination, and length of hospital stay.nnnRESULTSnOf the 5,142 esophagectomies identified, 70.3% were performed by GS and 29.7% by CTS. Overall, CTS patients had significantly higher comorbidities and cancer rates (61% versus 53%). Both specialties preferred the transthoracic approach (59.41% for CTS versus 44.90% for GS). Trainee involvement was higher for CTS. There was no significant difference in mortality or overall morbidity. Patients operated on by GS had higher rates of wound infection, sepsis, shock, prolonged or unplanned intubation, and a longer hospital stay, whereas patients operated on by CTS had higher chance for bleeding and return to the operating room. Trainees involvement in esophagectomy was not associated with worse outcome.nnnCONCLUSIONSnOur study showed that a large number of esophagectomies in the United States are performed by GS, with the transthoracic approach being the most popular among both specialties. Trainees involvement in esophagectomy did not significantly affect patients outcomes. However CTS specialty was associated with lower incidence of infection and a shorter hospital stay.

The Impact of Operative Approach on Postoperative Complications Following Colectomy for Colon Caner

BackgroundColectomy is one of the most common major abdominal procedures performed in the USA. A better understanding of risk factors and the effect of operative approach on adverse postoperative outcomes may significantly improve quality of care.MethodsAdult patients with a primary diagnosis of colon cancer undergoing colectomy were selected from the National Surgical Quality Improvement Program 2013–2015 targeted colectomy database. Patients were stratified into five groups based on specific operative approach. Univariate and multivariate analyses were used to compare the five groups and identify risk factors for 30-day anastomotic leak, readmission, and mortality.ResultsIn total, 25,097 patients were included in the study, with a 3.32% anastomotic leak rate, 1.20% mortality rate, and 9.57% readmission rate. After adjusting for other factors, open surgery and conversion to open significantly increased the odds for leak, mortality, and readmission compared to laparoscopy. Additionally, smoking and chemotherapy increased the risk for leak and readmission, while total resection was associated with increased mortality and leak.ConclusionsOperative approach and several other potentially modifiable perioperative factors have a significant impact on risk for adverse postoperative outcomes following colectomy. To improve quality of care for these patients, efforts should be made to identify and minimize the influence of such risk factors.

Utilization of surgical treatment for local and locoregional esophageal cancer: Analysis of the National Cancer Data Base

Previous studies have suggested that esophagectomy is severely underused for patients with resectable esophageal cancer. The recent expansion of endoscopic local therapies, advances in surgical techniques, and improved postoperative outcomes have changed the therapeutic landscape. The impact of these developments and evolving treatment guidelines on national practice patterns is unknown.

The Optimal Approach to Symptomatic Paraesophageal Hernia Repair: Important Technical Considerations

While the asymptomatic paraesophageal hernia (PEH) can be observed safely, surgery is indicated for symptomatic hernias. Laparoscopic repair is associated with decreased morbidity and mortality; however, it is associated with a higher rate of radiologic recurrence when compared with the open approach. Though a majority of patients experience good symptomatic relief from laparoscopic repair, strict adherence to good technique is critical to minimize recurrence. The fundamental steps of laparoscopic PEH repair include adequate mediastinal mobilization of the esophagus, tension-free approximation of the diaphragmatic crura, and gastric fundoplication. Collis gastroplasty, mesh reinforcement, use of relaxing incisions, and anterior gastropexy are just a few adjuncts to basic principles that can be utilized and have been widely studied in recent years. In this article, we present a comprehensive review of literature addressing key aspects and controversies regarding the optimal approach to repairing paraesophageal hernias laparoscopically.

A structured, extended training program to facilitate adoption of new techniques for practicing surgeons

IntroductionLaparoscopic inguinal hernia repair has been shown to have significant benefits when compared to open inguinal hernia repair, yet remains underutilized in the United States. The traditional model of short, hands-on, cognitive courses to enhance the adoption of new techniques fails to lead to significant levels of practice implementation for most surgeons. We hypothesized that a comprehensive program would facilitate the adoption of laparoscopic inguinal hernia repair (TEP) for practicing surgeons.MethodsA team of experts in simulation, coaching, and hernia care created a comprehensive training program to facilitate the adoption of TEP. Three surgeons who routinely performed open inguinal hernia repair with greater than 50 cases annually were recruited to participate in the program. Coaches were selected based on their procedural expertise and underwent formal training in surgical coaching. Participants were required to evaluate all aspects of the educational program and were surveyed out to one year following completion of the program to assess for sustained adoption of TEP.ResultsAll three participants successfully completed the first three steps of the seven-step program. Two participants completed the full course, while the third dropped out of the program due to time constraints and low case volume. Participant surgeons rated Orientation (4.7/5), GlovesOn training (5/5), and Preceptored Cases (5/5) as highly important training activities that contributed to advancing their knowledge and technical performance of the TEP procedure. At one year, both participants were performing TEPs for “most of their cases” and were confident in their ability to perform the procedure. The total cost of the program including all travel, personal coaching, and simulation was

Student use and perceptions of mobile technology in clinical clerkships – Guidance for curriculum design

8638.60 per participant.DiscussionOur comprehensive educational program led to full and sustained adoption of TEP for those who completed the course. Time constraints, travel costs, and case volume are major considerations for successful completion; however, the program is feasible, acceptable, and affordable.

Impact of near-peer teaching rounds on student satisfaction in the basic surgical clerkship.

BACKGROUNDnWe examined the types of technology used by medical students in clinical clerkships, and the perception of technology implementation into the curriculum.nnnMETHODSnAn online survey about technology use was completed prior to general surgery clinical clerkship. Types of devices and frequency/comfort of use were recorded. Perceptions of the benefits and barriers to technology use in clerkship learning were elicited.nnnRESULTSn125/131 (95.4%) students responded. Most students owned a smart phone (95.2%), tablet (52.8%), or both (50%); 61.6% spentxa0>xa011xa0h/week learning on a device at the Johns Hopkins School of Medicine for educational purposes. Technology use was seen as beneficial by 97.6% of students. Classes that used technology extensively were preferred by 54% of students, although 47.2% perceived decreased faculty/classmate interaction.nnnCONCLUSIONSnStudents use mobile technology to improve how they learn new material, and prefer taking classes that incorporate information technology. However, in-person/blended curricula are preferable to completely online courses.

Concurrent bariatric surgery and paraesophageal hernia repair: comparison of sleeve gastrectomy and Roux-en-Y gastric bypass

BACKGROUNDnTeaching rounds are rarely featured in the surgery clerkship. Senior students interested in surgery are suited to precept teaching rounds. Near-peer teaching can provide benefits to both learners and preceptors.nnnMETHODSnNear-peer teaching rounds consisted of senior student-precetors leading groups of 3 clerkship students on teaching rounds once during the clerkship. We prospectively surveyed student satisfaction before and after instituting near-peer teaching rounds. We retrospectively gathered qualitative narratives from student-preceptors.nnnRESULTSnThe survey response rate was 93% before near-peer teaching rounds were instituted and 85% after. Satisfaction with the learning environment and the quality and amount of small-group teaching were significantly higher after the institution of near-peer teaching rounds (P ≤ .001 for all 3). Satisfaction with the overall clerkship and baseline interest in surgery were not significantly different. Student-preceptors reported gaining valuable experience for future roles in academia as residents and attending surgeons.nnnCONCLUSIONSnStudent satisfaction with small-group teaching and the learning environment increased after the institution of near-peer teaching rounds in the surgery clerkship. Student-preceptors gained early experience for careers in academic surgery.

Wisconsin's Enterra Therapy Experience: A multi-institutional review of gastric electrical stimulation for medically refractory gastroparesis

BACKGROUNDnParaesophageal hernia (PEH) is a common condition that bariatric surgeons encounter. Expert opinion is split on whether bariatric surgery and PEH repair should be completed concurrently or sequentially. We hypothesized that concurrent bariatric surgery and PEH repair is safe.nnnOBJECTIVESnWe examined 30-day outcomes after concomitant PEH repair and bariatric surgery.nnnSETTINGnNational database, United States.nnnMETHODSnUsing the American College of Surgeons National Surgical Quality Improvement Program database (2011-2014), we identified patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGB) or laparoscopic sleeve gastrectomy (LSG) with or without PEH repair. A propensity score-matching algorithm was used to compare patients who underwent either LRYGB or LSG with PEH repair. The primary outcome was overall morbidity. Secondary outcomes included mortality, serious morbidity, readmission, and reoperation.nnnRESULTSnOf the 76,343 patients in this study, 5958 (7.80%) underwent PEH repair concurrently with bariatric surgery. The frequency of bariatric operations that included PEH repair increased over time (2.14% in 2010 versus 12.17% in 2014, P<.001). The rate of PEH/LSG was higher than PEH/LRYGB in 2014 (8.9 % versus 3.2%). There were no significant differences in outcomes between the matched cohort of PEH and non-PEH patients. Subgroup analysis showed significantly greater rates of morbidity (6.20% versus 2.69%, P<.001), readmission (6.33% versus 3.06%, P<.001), and reoperation (3.00% versus 1.05%, P<.001) for PEH/LRYGB versus PEH/LSG.nnnCONCLUSIONSnA PEH repair at the time of bariatric surgery does not appear to be associated with increased morbidity or mortality. A concurrent approach to treat patients with severe obesity and PEH appears safe.