Carlos M. Mery

Primary payer status affects mortality for major surgical operations.

Objectives:Medicaid and Uninsured populations are a significant focus of current healthcare reform. We hypothesized that outcomes following major surgical operations in the United States is dependent on primary payer status. Methods:From 2003 to 2007, 893,658 major surgical operations were evaluated using the Nationwide Inpatient Sample (NIS) database: lung resection, esophagectomy, colectomy, pancreatectomy, gastrectomy, abdominal aortic aneurysm repair, hip replacement, and coronary artery bypass. Patients were stratified by primary payer status: Medicare (n = 491,829), Medicaid (n = 40,259), Private Insurance (n = 337,535), and Uninsured (n = 24,035). Multivariate regression models were applied to assess outcomes. Results:Unadjusted mortality for Medicare (4.4%; odds ratio [OR], 3.51), Medicaid (3.7%; OR, 2.86), and Uninsured (3.2%; OR, 2.51) patient groups were higher compared to Private Insurance groups (1.3%, P < 0.001). Mortality was lowest for Private Insurance patients independent of operation. After controlling for age, gender, income, geographic region, operation, and 30 comorbid conditions, Medicaid payer status was associated with the longest length of stay and highest total costs (P < 0.001). Medicaid (P < 0.001) and Uninsured (P < 0.001) payer status independently conferred the highest adjusted risks of mortality. Conclusions:Medicaid and Uninsured payer status confers increased risk-adjusted mortality. Medicaid was further associated with the greatest adjusted length of stay and total costs despite risk factors or operation. These differences serve as an important proxy for larger socioeconomic and health system-related issues that could be targeted to improve surgical outcomes for US Patients.

Android Fat Distribution as Predictor of Severity in Acute Pancreatitis

Background/Aims: Obesity is considered an independent risk factor for the development of severe acute pancreatitis (AP). The purpose of this study was to define the type of fat distribution related to severity in AP. Methods: Eighty-eight patients with first-time AP underwent measurements of weight, height, waist and hip circumferences, and skinfold thickness on admission. Severity was defined according to Atlanta criteria. Results: AP was severe in 27 (31%) patients. There was a tendency for obese patients to develop severe AP (p = 0.11). Android fat distribution by waist-to-hip ratio and waist circumference above ideal cut-off value (ROC curves analysis) were significantly associated with severity (RR: 5.54, 95% CI 1.39–22.04, and RR: 4.36, 95% CI 1.40–13.57, respectively). After adjusting for potential confounders, both measurements remained predictors of severity in the logistic regression model (OR: 9.23, 95% CI 1.67–51.07, and OR: 13.41, 95% CI 2.43–73.97, respectively). Body fat percentage was not associated with incidence of severity. Conclusions: Patients with android fat distribution and higher waist circumference are at greater risk for developing severe AP. Findings could be related to the amount of abdominal fat but also to an overactive systemic inflammatory response that tend to be upregulated in android fat distribution.

Secondary sarcomas after radiotherapy for breast cancer: sustained risk and poor survival.

Radiotherapy (RT) has been a risk factor for development of soft tissue sarcomas (STS). The objective of the current study was to quantify the risk of STS after RT and surgery for breast cancer (BCa), assess time trends, and compare long‐term survival of patients with RT‐associated and non–RT‐associated angiosarcoma (AS) using the Surveillance, Epidemiology, and End Results (SEER) database.

Menopausal effects on presentation, treatment, and survival of women with non-small cell lung cancer

BACKGROUND Small population studies have reported higher survival rates for women than men with non-small cell lung carcinoma (NSCLC). Because human NSCLC cells express estrogen receptors, we evaluated hormonally active and inactive women to identify biologically mediated differences. METHODS A total of 14,676 US women with stage I through IV primary non-small cell lung cancer (NSCLC) from the 1992 to 1997 Surveillance, Epidemiology, and End Results database were grouped into two categories based on the average menopausal age of 51 years as defined by the American College of Obstetricians and Gynecologists: ages 31 to 50 premenopausal (n = 2,230, 15%) and ages 51 to 70 postmenopausal (n = 12,446, 85%). Extreme ages were excluded. Statistics were calculated with chi(2) or Mann-Whitney tests, Kaplan-Meier estimates with log-rank tests, and Cox proportional hazards models. RESULTS Premenopausal women more commonly presented with advanced clinical stage, less favorable histology (adenocarcinoma), and poorly differentiated tumors, and more often underwent pneumonectomies. Surgery with curative intent was performed in 31% premenopausal and 33% postmenopausal women (p = 0.03). Overall survival for premenopausal and postmenopausal women was not significantly different (median 10 and 9 months, all stages; 70 and 71 months, stages I and II). Adjusting for significant covariates (stage, histology, size, grade, extent of surgery), postmenopausal women had higher lung-cancer-related deaths (hazard ratio, 1.14; 95% confidence interval, 1.03 to 1.27). CONCLUSIONS Premenopausal women presented more often with advanced disease and underwent more extensive resection, yet had survival advantage after covariate adjustment. Additionally, postmenopausal women had a survival advantage compared with their male counterparts. Results suggest that estrogen exposure creates a milieu that may confer a protective effect through some yet unknown mechanisms that determine outcome of the neoplastic process and warrant further investigation.

The use of surgery to treat lung cancer in elderly patients

Lung cancer is a leading cause of cancer death and its cure depends on an adequate surgical approach. More than half of all lung cancers are diagnosed in patients aged 65 years or over. However, surgical risk increases in patients over 65 years old. Therefore, surgical procedures for lung cancer are far less frequent in elderly patients. Many clinicians avoid surgery, or minimise surgical procedures on the basis of age but recent advances in preoperative risk assessment and surgical and anaesthetic techniques have resulted in a significant decrease in operative mortality and morbidity for older patients. The treatment of lung cancer in elderly patients should no longer be based on the premise that surgery is too risky for elderly patients. Every effort should be made to assess risk and optimise treatment for this large and expanding proportion of the population.

Repeated and Aggressive Pulmonary Resections for Leiomyosarcoma Metastases Extends Survival

BACKGROUND Sarcoma frequently metastasizes to the lungs, and pulmonary metastasectomy is the only treatment modality that can provide a cure for these patients. We attempted to determine the clinicopathologic features and survival determinants of a common subset of patients who undergo pulmonary metastasectomy for leiomyosarcoma. METHODS All patients undergoing pulmonary metastasectomy at The Brigham and Womens Hospital from 1989 to 2004 were reviewed retrospectively. Analyzed variables included number, size, pathology, and location of metastases, age, gender, location of primary tumor, disease-free interval (DFI), surgical approach, margin status, adjuvant therapy, recurrence, number of metastasectomies, and disease-free and overall survival. RESULTS Eighty-two patients underwent pulmonary metastasectomy for metastases from sarcoma. Leiomyosarcoma was the most common histologic finding (n = 31; 38%). Fifteen patients with leiomyosarcoma (48%) underwent repeated pulmonary metastasectomy. Patients with leiomyosarcoma were more commonly female (77% versus 43%; p = 0.031), less frequently received chemotherapy for their primary tumor (48% versus 71%, p = 0.041), and presented with fewer number of pulmonary metastases than did patients with nonleiomyosarcoma metastases (1.9 ± 1.5 standard deviation [SD] versus 3.6 ± 4.4; p = 0.033). Although there was no difference in disease-free survival, patients with leiomyosarcoma demonstrated improved overall survival compared with those with nonleiomyosarcoma metastases (70 versus 24 months; p = 0.049). In multivariate analyses, the DFI from primary tumor resection to pulmonary metastases and the DFI from pulmonary metastasectomy to second pulmonary recurrence were identified as independent predictors of survival. CONCLUSIONS Leiomyosarcoma is a common subset of sarcomatous pulmonary metastases that behave more indolently compared with other pulmonary metastases from sarcoma. Long-term survival is achievable with an aggressive approach toward pulmonary metastasectomy and repeated pulmonary metastasectomy.

Incidence and treatment of chylothorax after cardiac surgery in children: analysis of a large multi-institution database.

OBJECTIVE There is limited information regarding the true incidence of and risk factors for chylothorax after pediatric cardiac surgery. The objective of this study was to determine, from a large multi-institution database, incidence, associated factors, and treatment strategy in patients undergoing pediatric cardiac surgery. METHODS All patients younger than 18 years in the Pediatric Health Information System (PHIS) database who underwent congenital heart surgery or heart transplant from 2004 to 2011 were included. Procedure complexity was assessed by Risk Adjustment for Congenital Heart Surgery-1. RESULTS In all, 77,777 patients (55% male) of median age 6.7 months were included. Overall incidence of chylothorax was 2.8% (n = 2205), significantly associated with increased procedure complexity, younger age, genetic syndromes, vein thrombosis, and higher annual hospital volume. Patients with multiple congenital procedures had the highest incidence. Incidence increased with time, from 2% in 2004 to 3.7% in 2011 (P < .0001). Chylothorax was associated with longer stay (P < .0001), increased adjusted risk for in-hospital mortality (odds ratio, 2.13; 95% confidence interval, 1.75-2.61), and higher cost (P < .0001), regardless of procedure complexity. Of all patients with chylothorax, 196 (8.9%) underwent thoracic duct ligation or pleurodesis a median of 18 days after surgery. Total parenteral nutrition, medium-chain fatty acid supplementation, and octreotide were used in 56%, 1.7%, and 16% of patients, respectively. CONCLUSIONS Chylothorax is a significant problem in pediatric cardiac surgery and is associated with increased mortality, cost, and length of stay. Strategies should be developed to improve prevention and treatment.

The effect of surgeon volume on mortality for off-pump coronary artery bypass grafting

OBJECTIVE Recent trials comparing on-pump (CABG) with off-pump coronary artery bypass grafting (OPCAB) have been criticized by those who believe that surgeon inexperience may explain the apparent worse outcomes for OPCAB. However, the true effect of surgeon volume on outcomes after OPCAB remains unknown. The purpose of this study was to examine the effect of surgeon volume on risk-adjusted mortality after OPCAB. METHODS From 2003 to 2007, 709,483 patients underwent coronary artery bypass grafting operations (CABG = 439,253; OPCAB = 270,230) within the Nationwide Inpatient Sample database. Hierarchic generalized linear regression modeling with spline functions for annual individual operating surgeon volume was used to assess the relationship between annual surgeon volume and inpatient mortality, adjusted for comorbid disease and other potential confounders. RESULTS OPCAB was performed in 38.1% of coronary artery bypass grafting operations. The average age for those undergoing OPCAB was 66.1 ± 11.1 years, and female patients accounted for 29.3% of operations with 1-vessel (20.4%), 2-vessel (36.6%), 3-vessel (20.5%), or 4 vessels or more (13.6%). Median surgeon volume for OPCAB was 105 (56-156) operations per year. A highly significant nonlinear relationship between surgeon volume and risk-adjusted mortality was observed for OPCAB operations (P < .01). Specifically, an estimated 5% decrease in the absolute probability of death occurred after OPCAB performed by the surgeons with the highest volume, which is greater than the 3% estimated decrease for conventional CABG. Of note, the effect of surgeon volume on mortality was significantly less than other risk factors, such as the presence of heart failure, renal failure, type of bypass conduit, and gender. CONCLUSIONS A significant surgeon volume-outcome relationship exists for mortality after OPCAB with a threshold of more than 50 operations per year. However, the contribution of surgeon volume to the probability of death is incrementally small compared with other patient and operative characteristics. This demonstrates that outcomes after OPCAB are more dependent on patient risk factors than on surgeon volume.

Anomalous Aortic Origin of a Coronary Artery: Toward a Standardized Approach

Anomalous aortic origin of a coronary artery (AAOCA) is a congenital abnormality of the origin or course of a coronary artery that arises from the aorta. It is the second most common cause of sudden cardiac death in young athletes. Its exact prevalence, the pathophysiological mechanisms that cause sudden cardiac death, the actual risk of death for the different types of AAOCA, the optimal way to evaluate these patients, and whether any treatment strategies decrease the risk of sudden cardiac death in patients diagnosed with AAOCA are unknown. This article analyzes what is currently known and unknown about this disease. It also describes the creation of a dedicated multidisciplinary coronary anomalies program and the development of a framework in an initial attempt to standardize the evaluation and management of these patients.

Profiling surgical staplers: effect of staple height, buttress, and overlap on staple line failure.

BACKGROUND Few studies have been designed to assess the performance of surgical staplers. In this study, we analyzed the effect of staple height, buttressing, and overlapping of staple lines on staple line failure. METHODS Staple lines created on fresh porcine small bowel segments ex vivo were tested for leak pressure by insufflating air into the bowel under water and recording pressure at failure. Three separate experiments were done and included staple height (white, 2.5 mm, n = 16; blue, 3.5 mm, n = 16; green, 4.1 mm, n = 16; one half of them buttressed); the absence (n = 12) or presence (n = 12) of an overlap in 3.5-mm staple lines; and the absence (n = 14) or presence (n = 11) of buttresses in 3.5-mm overlapping staple lines. Data are reported in median values and ranges; nonparametric tests were used for data analysis. RESULTS In the porcine small bowel, leak pressure was related to staple height; green loads had the worst profile (35 mm Hg, range 19-105) compared with the blue (79 mm Hg, range 9-177), and white (108 mm Hg, range 28-280) loads (P = .006). Buttressing uniformly improved leak pressure for all staple loads (P <.0001). No significant difference was found between lines with overlapping (59 mm Hg, range 32-121) and those without (42 mm Hg, range 22-75; P = .162). Buttressing also improved the leak pressure of overlapping staple lines from 65 mm Hg (range 47-121) to 93 mm Hg (range 75-187; P = .0014). CONCLUSION Great variability was found in the leak pressures among the different applications of the same stapler. Staple height is an important determinant of leak pressure. The presence of an overlap did not affect leak pressure; in fact, a trend toward improvement was seen with overlapping staple lines. Buttressing improved all types of staple lines.