Avo Artinyan

The Management of Complicated Diverticulitis and the Role of Computed Tomography

PURPOSE:Acute diverticulitis is a disease with a wide clinical spectrum, ranging from a phlegmon (stage Ia), to localized abscesses (stages Ib and II), to free perforation with purulent (stage III) or feculent peritonitis (stage IV). While there is little debate about the best treatment for mild episodes and/or very severe episodes, uncertainty persists about the optimal management for intermediate stages (Ib and II). The aim of our study was therefore to define the role of computed tomography (CT) and to analyze its impact on the management of acute diverticulitis.METHODS:We retrospectively analyzed 511 patients (296 males, 215 females) admitted for acute diverticulitis between January 1994 and December 2003. Excluded were patients with stoma reversal only, “diverticulitis” mimicked by cancer, or significantly deficient patient records. Patients were analyzed either as a whole or subgrouped according to age (<40 yr, >40 yr). A modified Hinchey classification was used to stage the severity of acute diverticulitis.RESULTS:In 99 patients (19.4%), an abscess was found (74 pericolic, 25 pelvic, median diameter: 4.0 cm). CT-guided drainage was performed in 16 patients, one failure requiring a two-stage operation. Whereas conservative treatment failed in 6.8% in patients without abscess or perforation, 22.2% of patients with an abscess required an urgent resection (68.2%, one-stage, 31.8%, two-stage). Recurrence rates were 13% for mild cases, as compared to 41.2% in patients with a pelvic abscess (stage II) treated conservatively with/without CT-guided drainage. Of all surgical cases, resection/primary anastomosis was achieved in 73.6% with perioperative mortality of 1.1% and leak rate was 2.1%.CONCLUSIONS:CT evidence of a diverticular abscess has a prognostic impact as it correlates with a high risk of failure from nonoperative management regardless of the patients age. After treatment of diverticulitis with CT evidence of an abscess, physicians should strongly consider elective surgery in order to prevent recurrent diverticulitis.

Infectious postoperative complications decrease long-term survival in patients undergoing curative surgery for colorectal cancer: a study of 12,075 patients.

OBJECTIVE We sought to characterize the effect of postoperative complications on long-term survival after colorectal cancer (CRC) resection. BACKGROUND The impact of early morbidity on long-term survival after curative-intent CRC surgery remains controversial. METHODS The Veterans Affairs Surgical Quality Improvement Program and Central Cancer Registry databases were linked to acquire perioperative and cancer-specific data for 12,075 patients undergoing resection for nonmetastatic CRC (1999-2009). Patients were categorized by presence of any complication within 30 days and by type of complication (noninfectious vs infectious). Univariate and multivariate survival analyses adjusted for patient, disease, and treatment factors were performed, excluding early deaths (<90 days). Subset analysis was performed to determine the specific impact of severe postoperative infections. RESULTS The overall morbidity and infectious complication rates were 27.8% and 22.5%, respectively. Patients with noninfectious postoperative complications were older, had lower preoperative serum albumin, had worse functional status, and had higher American Society of Anesthesiologists scores than patients with infectious complications and without complications (all P < 0.001). The presence of any complication was independently associated with decreased long-term survival [hazard ratio, 1.24; 95% confidence interval (1.15-1.34)]. Multivariate analysis by complication type demonstrated increased risk only with infectious complications [hazard ratio, 1.31; 95% confidence interval (1.21-1.42)]. Subset analysis demonstrated this effect predominantly in patients with severe infections [hazard ratio, 1.41; 95% confidence interval (1.15-1.73)]. CONCLUSIONS The presence of postoperative complications after CRC resection is associated with decreased long-term survival, independent of patient, disease, and treatment factors. The impact on long-term outcome is primarily driven by infectious complications, particularly severe postoperative infections.

An increase in compliance with the Surgical Care Improvement Project measures does not prevent surgical site infection in colorectal surgery.

PURPOSE: The primary goal of the Surgical Care Improvement Project is to improve quality of care by implementing evidence-based health care practices that prevent surgical complications. This study was designed to test the hypothesis that an increase in compliance with quality process measures decreases the rate of surgical site infections in patients undergoing colorectal surgeries. METHODS: A multidisciplinary task force implemented and monitored compliance with individual quality measures in patients undergoing elective colorectal resections at a tertiary institution. Individual compliance rates and infections were collected prospectively and reviewed monthly. For data analysis, patients were assigned to 2 consecutive 14-month periods: period A (April 1, 2006 to May 31, 2007) and period B (June 1, 2007 to July 31, 2008). Comparisons between periods were performed to determine the association of compliance with process measures and outcomes in infections. RESULTS: A total of 491 consecutive patients were treated during the study periods (period A: n = 238; period B: n = 253). There were no statistically significant differences in patient characteristics, diagnoses, or surgical procedures between periods. Compliance with all process measures significantly increased within periods except for perioperative glucose control. Global compliance (compliance with all measures per patient) significantly improved from period A to B (40%–68%, respectively; P < .001). In total, 99 patients (19%) developed surgical site infections (period A, 18.9%; period B, 19.4%). CONCLUSION: An increase in compliance with the Surgical Care Improvement Project aimed to prevent surgical site infections does not translate into a significant reduction of surgical site infections in patients undergoing colorectal resections.

Race and ethnicity correlate with survival in patients with gastric adenocarcinoma

BACKGROUND Asian centers have consistently reported superior gastric cancer outcomes. Our study examines gastric cancer survival among different races and ethnicities in a large, heterogeneous USA population. PATIENTS AND METHODS Patients with gastric adenocarcinoma treated in Los Angeles County from 1988 to 2006 were identified from the Los Angeles County Cancer Surveillance Program. Patients were categorized by race and ethnicity as White, Asian, Hispanic and Black. RESULTS Of 13 084 patients, 39% were White, 22% Asian, 28% Hispanic, 11% Black and 2% other. Asian patients demonstrated higher survival than Whites, Hispanics and Blacks [median survival (MS) 16.3 versus 8.4, 8.7 and 7.9 months, respectively; log-rank P values < 0.001]. Multivariate Cox regression analysis showed that Asians had improved probability of survival [hazard ratio (HR) 0.76, 95% confidence interval (CI) 0.72-0.82; P < 0.001]. In patients who underwent curative-intent surgery, Asian patients demonstrated higher survival than Whites, Hispanics and Blacks (MS 32.7 versus 18.8, 19.9 and 18.9 months, respectively; log-rank P values < 0.001). Multivariate Cox regression analysis showed that Asians had improved probability of survival after surgery (HR 0.79, 95% CI 0.71-0.88; P < 0.001). CONCLUSIONS Asians with gastric adenocarcinoma have superior outcomes in Los Angeles County. These outcomes verify disparities in gastric cancer survival among different races and ethnicities independent of established clinical and pathologic factors.

Pancreatic resection without routine intraperitoneal drainage

BACKGROUND Most surgeons routinely place intraperitoneal drains at the time of pancreatic resection but this practice has recently been challenged. OBJECTIVE Evaluate the outcome when pancreatic resection is performed without operatively placed intraperitoneal drains. METHODS In all, 226 consecutive patients underwent pancreatic resection. In 179 patients drains were routinely placed at the time of surgery and in 47 no drains were placed. Outcomes for these two cohorts were recorded in a prospective database and compared using the χ(2) - /Fishers exact test for categorical variables, and Wilcoxons test for continuous variables. RESULTS Demographic, surgical and pathological details were similar between the two cohorts. Elimination of routine intraperitoneal drainage did not increase the frequency or severity of serious complications. However, when all grades of complications were considered, the number of patients that experienced any complication (65% vs. 47%, P= 0.020) and the median complication severity grade (1 vs. 0, P= 0.027) were increased in the group that had drains placed at the time of surgery. Eliminating intra-operative drains was associated with decreased delayed gastric emptying (24% vs. 9%, P= 0.020) and a trend towards decreased wound infection (12% vs. 2%, P= 0.054). The readmission rate (9% vs. 17% P= 0.007) and number of patients requiring post-operative percutaneous drains (2% vs. 11%, P= 0.001) was higher in patients who did not have operatively placed drains but there was no difference in the re-operation rate (4% vs. 0%, P= 0.210). CONCLUSION Abandoning the practice of routine intraperitoneal drainage after pancreatic resection may not increase the incidence or severity of severe post-operative complications.

The impact of lymph node number on survival in patients with lymph node-negative pancreatic cancer.

Objectives: The role of lymph node (LN) dissection for pancreatic cancer remains uncertain, and guidelines for a minimum LN number have not been established. We hypothesized that LN number in node-negative (N0) pancreatic cancer influences survival. Methods: The Surveillance, Epidemiology, and End Results database was queried for patients undergoing resection for N0 pancreatic adenocarcinoma between 1988 and 2003. Lymph node number was categorized as 1-10, 11-20, and >20. Results: In a cohort of 1915 patients, the median LN number was 7 (range 1-57); 1365 (71%) patients had <11 LN. Survival was significantly better in the 11 to 20 compared with the 1-10 group (median, 20 vs 15 months, respectively, P < 0.0001); no difference was observed between the 11-20 and >20 groups (median, 20 vs 23 months, respectively, P = 0.14). Multivariate analysis demonstrated the prognostic significance of LN number for determining overall survival (hazard ratio 0.98, 95% confidence interval: 0.97-0.99; P<0.0001). Conclusions: Pancreatic cancer lymphadenectomy with examination of >10 LN is associated with improved survival in N0 disease and should be considered a benchmark for adequacy of surgery and/or pathology. Currently, only a minority of patients are assessed by this measure. The variation in LN number may be indicative of diverse surgical technique and/or pathologic analysis and warrants further investigation.

Chemokine receptor CXCR4 enhances proliferation in pancreatic cancer cells through AKT and ERK dependent pathways.

Objectives: We previously detected CXCR4 expression in pancreatic intraepithelial neoplasia (PanIN) tissues and demonstrated CXCR4-enhanced proliferation of PanIN cells. Our objective was to determine if the CXCR4 targets AKT and ERK mediate CXCR4-dependent PanIN and pancreatic cancer proliferation. Methods: We exposed cultured murine-derived PanIN, invasive pancreatic cancer (5143PDA) and liver metastasis (5143LM) cells, and human pancreatic cancer PANC-1 cells to CXCL12, the specific CXCR4 ligand, and measured phosphorylation of AKT and ERK1/2. The roles of AKT and ERK1/2 in CXCR4-dependent cell proliferation were assessed by the PI/3K-AKT small molecular inhibitor LY294002 and the ERK signaling inhibitor UO126. Results: We discovered increases in phosphorylation of AKT in PanIN, 5143PDA, and PANC-1 cells but no increase in 5143LM cells after exposure to CXCL12. We also observed that exposure to CXCL12 over varying periods phosphorylated ERK1/2 in an oscillatory pattern for all cell lines. Administration of LY294002 resulted in complete abrogation of CXCL12-induced proliferation in PanIN, 5143LM, and PANC-1 cells but not 5143PDA cells, whereas UO126 resulted in complete abrogation of CXCR4-enhanced proliferation in all cell lines. Conclusions: Our studies show that CXCR4-induced proliferation is mediated by both AKT and ERK signaling in both murine and human pancreatic cancer cells.

Milan Criteria and UCSF Criteria: A Preliminary Comparative Study of Liver Transplantation Outcomes in the United States.

The application of orthotopic liver transplantation (OLT) for patients with hepatocellular cancer (HCC) necessitates highly selective criteria to maximize survival and to optimize allocation of a scarce resource. The objective of this study was to compare the outcomes of OLT for HCC in patients transplanted under Milan and UCSF criteria. The United Network of Organ Sharing (UNOS) database was queried for patients who had undergone OLT for HCC from 2002 to 2007, and 1,972 patients (Milan criteria, n = 1, 913; UCSF criteria, n = 59) were identified. Patients were stratified by pretransplant criteria (Milan versus UCSF), and clinical and pathologic factors and overall survival were compared. There were no differences in age, gender, diabetes mellitus, body mass index, and hepatitis B, or C status between the two groups. Overall survival was similar between the Milan and UCSF cohorts (1-, 2-, 3-, and 4-year survival rates: 88%, 81%, 76%, and 72% versus 91%, 80%, 68% and 51%, respectively, P = 0.21). Although the number of patients within UCSF criteria was small, our results nevertheless suggest that patients with HCC may have equivalent survival when transplanted under Milan and UCSF criteria. Long-term followup may better determine whether UCSF criteria should be widely adopted.

An interaction of race and ethnicity with socioeconomic status in rectal cancer outcomes.

Objective:Because appropriate rectal cancer care and subsequent outcomes can be influenced by several variables, our objective was to investigate how race, ethnicity, and socioeconomic status (SES) may impact rectal cancer outcomes. Background:The management of rectal cancer requires a multidisciplinary approach utilizing medical and surgical subspecialties. Methods:We performed an investigation of patients with rectal adenocarcinoma from Los Angeles County from 1988 to 2006 using the Los Angeles County Cancer Surveillance Program. Clinical and pathologic characteristics were compared among groups and overall survival was stratified by race/ethnicity and SES. Results:Of 9504 patients with rectal cancer, 53% (n = 4999) were white, 10% black, 18% Hispanic, and 14% Asian. Stratified by race/ethnicity, Asians had the best overall survival followed by Hispanics, whites, and blacks (median survival 7.7 vs. 5.7, 5.5, and 3.4 years, respectively; P < 0.001). Stratified by SES group, the highest group had the best overall survival followed by middle and lowest groups (median survival 8.4 vs. 5.1 and 3.8 years, respectively, P < 0.001). Similar results were observed for surgical patients. On multivariate analysis, race/ethnicity, and SES remained independent predictors of overall survival in patients with rectal adenocarcinoma. Furthermore, interaction analysis indicated that the improved survival for select racial/ethnic groups was not dependent on SES classification. Conclusions:Within the diverse Los Angeles County population, both race/ethnicity, and SES result in inequities in rectal cancer outcomes. Although SES may directly impact outcomes via access to care, the reasons for the association between race/ethnicity and outcomes remain uncertain.

An assessment of the necessity of transfusion during pancreatoduodenectomy

INTRODUCTION Perioperative transfusion of packed red blood cells (PRBC) has been associated with negative side effects. We hypothesized that a majority of transfusions in our series of patients who underwent pancreaticoduodenectomy (PD) were unnecessary. A retrospective analysis was performed to determine whether transfusions were indicated based on pre-determined criteria, and the impact of perioperative transfusions on postoperative outcomes was assessed. METHODS Our prospectively maintained database was queried for patients who underwent PD between 2004 and 2011. 200 patients were divided into Cohort 1 (no transfusion) and Cohort 2 (transfusion). Rates of various graded 90-day postoperative complications were compared. Categorical values were compared according to the Common Terminology Criteria for Adverse Events. All cases involving intraoperative blood transfusion were reviewed for associated blood loss, intraoperative vital signs, urine output, hemoglobin values, and presence or absence of EKG changes to determine whether the transfusion was indicated based on these criteria. RESULTS There were 164 patients (82%) in Cohort 1 (no transfusion) and 36 patients (18%) in Cohort 2 (transfused). Both groups had similar demographics. Patients in Cohort 2 had lesser median preoperative values of hemoglobin (12.3 vs 13.1, P = .002), a greater incidence of vein resection (33% vs. 16%, P = .021), longer operative times (518 vs 440 minutes, P < .0001), a greater estimated blood loss (850 vs. 300 mL, P < .001), and greater intraoperative fluid resuscitation (6,550 vs. 5,300 mL, P = .002). Ninety-day mortality was similar between the 2 groups (3% vs 1%, P = .328). Patients in Cohort 2 (transfused) had increased rates of delayed gastric emptying (36% vs. 20%, P = .031), wound infection (28% vs. 7%, P = .031), pulmonary complications (6% vs. 0%, P = .032), and urinary retention (6% vs. 0%, P = .032). A greater incidence of any complication of grade II severity (67% vs. 35%, P = .0005) or grade III severity (36% vs. 17%, P = .010) was also noted in Cohort 2. Of the 33 intraoperative transfusions, 15 (46%) did not meet any of the predetermined criteria: intraoperative hypotension (<90/60 mmHg), tachycardia (>110 beats per minute), low urine output (<10 mL/hour), decreased oxygen saturation (<95%), excessive blood loss (>1,000 mL), EKG changes, and low hemoglobin (<7.0 g/dL). CONCLUSION Perioperative transfusions among patients with PD were associated with increased rates of various postoperative complications. A substantive portion (∼46%) of perioperative transfusions in this patient population did not meet predetermined criteria, indicating a potential opportunity for improved blood product use. Further prospective studies are required to determine whether the implementation of these criteria may a positive impact on perioperative outcomes.