Candice L. Wilshire

Defining the Cost of Care for Lobectomy and Segmentectomy: A Comparison of Open, Video-Assisted Thoracoscopic, and Robotic Approaches

BACKGROUND Knowledge about the cost of open, video-assisted thoracoscopic (VATS), or robotic lung resection and drivers of cost is crucial as the cost of care comes under scrutiny. This study aims to define the cost of anatomic lung resection and evaluate potential cost-saving measures. METHODS A retrospective review of patients who had anatomic resection for early stage lung cancer, carcinoid, or metastatic foci between 2008 and 2012 was performed. Direct hospital cost data were collected from 10 categories. Capital depreciation was separated for the robotic and VATS cases. Key costs were varied in a sensitivity analysis. RESULTS In all, 184 consecutive patients were included: 69 open, 57 robotic, and 58 VATS. Comorbidities and complication rates were similar. Operative time was statistically different among the three modalities, but length of stay was not. There was no statistically significant difference in overall cost between VATS and open cases (Δ =

Perioperative Risk of Laparoscopic Fundoplication: Safer than Previously Reported—Analysis of the American College of Surgeons National Surgical Quality Improvement Program 2005 to 2009

1,207) or open and robotic cases (Δ =

Dysphagia postfundoplication: More commonly hiatal outflow resistance than poor esophageal body motility

1,975). Robotic cases cost

The Use of Indwelling Tunneled Pleural Catheters for Recurrent Pleural Effusions in Patients With Hematologic Malignancies: A Multicenter Study

3,182 more than VATS (p < 0.001) owing to the cost of robotic-specific supplies and depreciation. The main opportunities to reduce cost in open cases were the intensive care unit, respiratory therapy, and laboratories. Lowering operating time and supply costs were targets for VATS and robotic cases. CONCLUSIONS VATS is the least expensive surgical approach. Robotic cases must be shorter in operative time or reduce supply costs, or both, to be competitive. Lessening operating time, eradicating unnecessary laboratory work, and minimizing intensive care unit stays will help decrease direct hospital costs.

Radiologic Evaluation of Small Lepidic Adenocarcinomas to Guide Decision Making in Surgical Resection

BACKGROUND Several prospective randomized controlled trials show equal effectiveness of surgical fundoplication and proton pump inhibitor therapy for the treatment of gastroesophageal reflux disease. Despite this compelling evidence of its efficacy, surgical antireflux therapy is underused, occurring in a very small proportion of patients with gastroesophageal reflux disease. An important reason for this is the perceived morbidity and mortality associated with surgical intervention. Published data report perioperative morbidity between 3% and 21% and mortality of 0.2% and 0.5%, and current data are uncommon, largely from previous decades, and almost exclusively single institutional. STUDY DESIGN The study population included all patients in the American College of Surgeons National Surgical Quality Improvement Program database from 2005 through 2009 who underwent laparoscopic fundoplication with or without related postoperative ICD-9 codes. Comorbidities, intraoperative occurrences, and 30-day postoperative outcomes were collected and logged into statistical software for appropriate analysis. Postoperative occurrences were divided into overall and serious morbidity. RESULTS A total of 7,531 fundoplications were identified. Thirty-five percent of patients were younger than 50 years old, 47.1% were 50 to 69 years old, and 16.8% were older than 69 years old. Overall, 30-day mortality was 0.19% and morbidity was 3.8%. Thirty-day mortality was rare in patients younger than age 70 years, occurring in 5 of 10,000 (0.05%). Mortality increased to 8 of 1,000 (0.8%) in patients older than 70 years (p < 0.0001). Complications occurred in 2.2% of patients younger than 50 years, 3.8% of those 50 to 69 years, and 7.3% of patients older than 69 years. Serious complications occurred in 8 of 1,000 (0.8%) patients younger than 50 years, 1.8% in patients 50 to 69 years, and 3.9% of those older than 69 years. CONCLUSIONS Analysis of this large cohort demonstrates remarkably low 30-day morbidity and mortality of laparoscopic fundoplication. This is particularly true in patients younger than 70 years, who are likely undergoing fundoplication for gastroesophageal reflux disease. These data suggest that surgical therapy carries an acceptable risk profile.

Clinical Outcomes of Reoperation for Failed Antireflux Operations

BACKGROUND Historically, risk assessment for postfundoplication dysphagia has been focused on esophageal body motility, which has proven to be an unreliable prediction tool. Our aim was to determine factors responsible for persistent postoperative dysphagia. METHODS Fourteen postfundoplication patients with primary dysphagia were selected for focused study. Twenty-five asymptomatic post-Nissen patients and 17 unoperated subjects served as controls. Pre- and postoperative clinical and high-resolution manometry parameters were compared. RESULTS Thirteen of the 14 symptomatic patients (92.9%) had normal postoperative esophageal body function, determined manometrically. In contrast, 13 of 14 (92.9%) had evidence of esophageal outflow obstruction, 9 of 14 (64.3%) manometrically, and 4 of 14 (28.6%) on endoscopy/esophagram. Median gastroesophageal junction integrated relaxation pressure was significantly greater (16.2 mm Hg) in symptomatic than in asymptomatic post-Nissen patients (11.1 mm Hg, P = .05) or unoperated subjects (10.6 mm Hg, P = .02). Sixty-four percent (9/14) of symptomatic patients had an increased mean relaxation pressure. Dysphagia was present in 9 of 14 (64.3%) preoperatively, and elevated postoperative relaxation pressure was independently associated with dysphagia. CONCLUSION These data suggest that postoperative alterations in hiatal functional anatomy are the primary factors responsible for post-Nissen dysphagia. Impaired relaxation of the neo-high pressure zone, recognizable as an abnormal relaxation pressure, best discriminates patients with dysphagia from those without symptoms postfundoplication.

Reflux-Associated Oxygen Desaturations: Usefulness in Diagnosing Reflux-Related Respiratory Symptoms

BACKGROUND Malignant pleural effusion is a common complication of advanced malignancies. Indwelling tunneled pleural catheter (IPC) placement provides effective palliation but can be associated with complications, including infection. In particular, hematologic malignancy and the associated immunosuppressive treatment regimens may increase infectious complications. This study aimed to review outcomes in patients with hematologic malignancy undergoing IPC placement. METHODS A retrospective multicenter study of IPCs placed in patients with hematologic malignancy from January 2009 to December 2013 was performed. Inclusion criteria were recurrent, symptomatic pleural effusion and an underlying diagnosis of hematologic malignancy. Records were reviewed for patient demographics, operative reports, and pathology, cytology, and microbiology reports. RESULTS Ninety-one patients (mean ± SD age, 65.4 ± 15.4 years) were identified from eight institutions. The mean × SD in situ dwell time of all catheters was 89.9 ± 127.1 days (total, 8,160 catheter-days). Seven infectious complications were identified, all of the pleural space. All patients were admitted to the hospital for treatment, with four requiring additional pleural procedures. Two patients died of septic shock related to pleural infection. CONCLUSIONS We present, to our knowledge, the largest study examining clinical outcomes related to IPC placement in patients with hematologic malignancy. An overall 7.7% infection risk and 2.2% mortality were identified, similar to previously reported studies, despite the significant immunosuppression and pancytopenia often present in this population. IPC placement appears to remain a reasonable clinical option for patients with recurrent pleural effusions related to hematologic malignancy.

Higher Versus Standard Preoperative Radiation in the Trimodality Treatment of Stage IIIa Lung Cancer

BACKGROUND The International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society classification of pulmonary adenocarcinomas identifies indolent lesions associated with low recurrence, superior survival, and the potential for sublobar resection. The distinction, however, is determined on the pathologic evaluation, limiting preoperative surgical planning. We sought to determine whether preoperative computed tomography (CT) characteristics could guide decisions about the extent of the pulmonary resection. METHODS We reviewed the preoperative CT scans for 136 patients identified to have adenocarcinomas with lepidic features on the final pathologic evaluation. The solid component on CT was substituted for the invasive component, and patients were radiologically classified as adenocarcinoma in situ, 3 cm or less with no solid component; minimally invasive adenocarcinoma, 3 cm or less with a solid component of 5 mm or less; or invasive adenocarcinoma, exceeding 3 cm or solid component exceeding 5 mm, or both. Analysis of variance, t test, χ(2) test, and Kaplan-Meier methods were used for analysis. RESULTS The radiologic classification identified 35 adenocarcinomas in situ (26%) and 12 minimally invasive (9%) and 89 invasive adenocarcinoma (65%) lesions. At a 32-month median follow-up, patient outcomes associated with the radiologic classification were similar to the pathologic-based classification: the radiologic classification identified 14 of 16 patients with recurrent disease and all 6 who died of lung cancer. In addition, patients with radiologic adenocarcinoma in situ and minimally invasive adenocarcinoma who underwent sublobar resections had no recurrence and 100% disease-free and overall survival at 5 years. CONCLUSIONS The radiologic classification of patients with lepidic adenocarcinomas is associated with similar oncologic and survival outcomes compared with the pathologic classification and may guide decision making in the approach to surgical resection.

Automated Remote Transapical Wound Closure System Study

BACKGROUND Up to 18% of patients undergoing antireflux operations will require reoperation. Authors caution that with each additional reoperation, fewer patients achieve satisfaction. The quality of life in patients who underwent revision operations was compared with patients who underwent primary antireflux operations to determine the effectiveness of revision operations. METHODS We retrospectively reviewed patients who underwent revision after failed antireflux operations from 2004 to 2014. Patients were divided into two groups: first reoperation (Reop[1]) and more than one reoperation (Reop[>1]). For comparison, a control group of patients who underwent primary antireflux operations was included. Patients underwent quality of life assessment preoperatively and postoperatively. RESULTS We identified 105 reoperative patients: 94 Reop(1), 11 Reop(>1), and 112 controls. The primary reason for failure was combined fundoplication herniation and slippage. Morbidity, mortality, and readmission rates were similar in all groups. Postoperative outcomes were improved in all groups but to a lesser degree in subsequent reoperations. Gastroesophageal Reflux Disease Health-Related Quality of Life: controls, 20.0 to 2.0; Reop(1), 26.5 to 4.0; and Reop(>1), 13.0 to 2.0. Quality of Life in Reflux and Dyspepsia: controls, 4.5 to 7.0; Reop(1), 3.7 to 6.7; and Reop(>1), 3.5 to 5.8. Dysphagia Severity Score: controls, 44.0 to 45.0; Reop(1), 36.0 to 45.0; and Reop(>1), 30.8 to 45.0. CONCLUSIONS Patients undergoing revision antireflux operations have improved quality of life, relatively normal swallowing, and primary symptom resolution at a median of 20 months postoperatively. However, patients who undergo more than one reoperation have lower quality of life scores and less improvement in dysphagia, suggesting that other procedures such as Roux-en-Y or short colon interposition, should be considered after a failed initial reoperation.

Pack-Year Cigarette Smoking History for Determination of Lung Cancer Screening Eligibility. Comparison of the Electronic Medical Record versus a Shared Decision-making Conversation

BackgroundCurrent diagnostic techniques establishing gastroesophageal reflux disease as the underlying cause in patients with respiratory symptoms are poor. Our aim was to provide additional support to our prior studies suggesting that the association between reflux events and oxygen desaturations may be a useful discriminatory test in patients presenting with primary respiratory symptoms suspected of having gastroesophageal reflux as the etiology.MethodsThirty-seven patients with respiratory symptoms, 26 with typical symptoms, and 40 control subjects underwent simultaneous 24-h impedance–pH and pulse oximetry monitoring. Eight patients returned for post-fundoplication studies.ResultsThe median number (interquartile range) of distal reflux events associated with oxygen desaturation was greater in patients with respiratory symptoms (17 (9–23)) than those with typical symptoms (7 (4–11, p < 0.001)) or control subjects (3 (2–6, p < 0.001)). A similar relationship was found for the number of proximal reflux-associated desaturations. Repeat study in seven post-fundoplication patients showed marked improvement, with reflux-associated desaturations approaching those of control subjects in five patients; 20 (9–20) distal preoperative versus 3 (0–5, p = 0.06) postoperative; similar results were identified proximally.ConclusionsThese data provide further proof that reflux-associated oxygen desaturations may discriminate patients presenting with primary respiratory symptoms as being due to reflux and may respond to antireflux surgery.