Christian P. Probst

Extended Intervals after Neoadjuvant Therapy in Locally Advanced Rectal Cancer: The Key to Improved Tumor Response and Potential Organ Preservation

BACKGROUNDnMany rectal cancer patients experience tumor downstaging and some are found to achieve a pathologic complete response (pCR) after neoadjuvant chemoradiotherapy (nCRT). Previous data suggest that there is an association between the time interval from nCRT completion to surgery and tumor response rates, including pCR. However, these studies have been primarily from single institutions with small sample sizes. The aim of this study was to examine the relationship between a longer interval after nCRT and pCR in a nationally representative cohort of rectal cancer patients.nnnSTUDY DESIGNnClinical stage II to III rectal cancer patients undergoing nCRT with a documented surgical resection were selected from the 2006 to 2011 National Cancer Data Base. Multivariable logistic regression analysis was used to assess the association between the nCRT-surgery interval time (<6 weeks, 6 to 8 weeks, >8 weeks) and the odds of pCR. The relationship between nCRT-surgery interval, surgical morbidity, and tumor downstaging was also examined.nnnRESULTSnOverall, 17,255 patients met the inclusion criteria. An nCRT-surgery interval time >8 weeks was associated with higher odds of pCR (odds ratio [OR] 1.12, 95% CI 1.01 to 1.25) and tumor downstaging (OR 1.11, 95% CI 1.02 to 1.25). The longer time delay was also associated with lower odds of 30-day readmission (OR 0.82, 95% CI 0.70 to 0.92).nnnCONCLUSIONSnAn nCRT-surgery interval time >8 weeks results in increased odds of pCR, with no evidence of associated increased surgical complications compared with an interval of 6 to 8 weeks. These data support implementation of a lengthened interval after nCRT to optimize the chances of pCR and perhaps add to the possibility of ultimate organ preservation (nonoperative management).

Failure of evidence-based cancer care in the United States: the association between rectal cancer treatment, cancer center volume, and geography.

Objective:This study examines recent adherence to recommended neoadjuvant chemoradiotherapy guidelines for patients with rectal cancer across geographic regions and institution volume and assesses trends over time. Background:A recent report by the Institute of Medicine described US cancer care as chaotic. Cited deficiencies included wide variation in adherence to evidence-based guidelines even where clear consensus exists. Methods:Patients operated on for clinical stage II and III rectal cancer were selected from the 2006–2011 National Cancer Data Base. Multivariable logistic regressions were used to assess variation in chemotherapy and radiation use by cancer center type, geographical location, and hospital volume. The analysis controlled for patient age at diagnosis, sex, race/ethnicity, primary payer, average household income, average education, urban/rural classification of patient residence, comorbidity, and oncologic stage. Results:There were 30,994 patients who met the inclusion criteria. Use of neoadjuvant radiation therapy and chemotherapy varied significantly by type of cancer center. The highest rates of adherence were observed in high-volume centers compared with low-volume centers (78% vs 69%; adjusted odds ratio = 1.46; P < 0.001). This variation is mirrored by hospital geographic location. Primary payer and year of diagnosis were not predictive of rates of neoadjuvant chemoradiotherapy. Conclusions:Adherence to evidence-based treatment guidelines in rectal cancer is suboptimal in the United States, with significant differences based on hospital volume and geographic regions. Little improvement has occurred in the last 5 years. These results support the implementation of standardized care pathways and a Centers of Excellence program for US patients with rectal cancer.

High volume improves outcomes: The argument for centralization of rectal cancer surgery

BACKGROUNDnCentralization of care to centers of excellence in Europe has led to improved oncologic outcomes; however, little is known regarding the impact of nonmandated regionalization of rectal cancer care in the United States.nnnMETHODSnThe Statewide Planning and Research Cooperative System (SPARCS) was queried for elective abdominoperineal and low anterior resections for rectal cancer from 2000 to 2011 in New York with the use of International Classification of Diseases, Ninth Revision codes. Surgeon volume and hospital volume were grouped into quartiles, and high-volume surgeons (≥ 10 resections/year) and hospitals (≥ 25 resections/year) were defined as the top quartile of annual caseload of rectal cancer resection and compared with the bottom 3 quartiles during analyses. Bivariate and multilevel regression analyses were performed to assess factors associated with restorative procedures, 30-day mortality, and temporal trends in these endpoints.nnnRESULTSnAmong 7,798 rectal cancer resections, the overall rate of no-restorative proctectomy and 30-day mortality decreased by 7.7% and 1.2%, respectively, from 2000 to 2011. In addition, there was a linear increase in the proportion of cases performed by both high-volume surgeons and high-volume hospitals and a decrease in the number of surgeons and hospitals performing rectal cancer surgery. High-volume surgeons at high-volume hospitals were associated independently with both less nonrestorative proctectomies (odds ratio 0.65, 95% confidence interval 0.48-0.89) and mortality (odds ratio 0.43, 95% confidence interval 0.21-0.87) rates. No patterns of significant improvement within the volume strata of the surgeon and hospitals were observed over time.nnnCONCLUSIONnThis study suggests that the current trend toward regionalization of rectal cancer care to high-volume surgeons and high-volume centers has led to improved outcomes. These findings have implications regarding the policy of health care delivery in the United States, supporting referral to high-volume centers of excellence.

Parastomal Hernia: A Growing Problem with New Solutions

Parastomal hernia is one of the most common complications following stoma creation and its prevalence is only expected to increase. It often leads to a decrease in the quality of life for patients due to discomfort, pain, frequent ostomy appliance leakage, or peristomal skin irritation and can result in significantly increased healthcare costs. Surgical technique for parastomal hernia repair has evolved significantly over the past two decades with the introduction of new types of mesh and laparoscopic procedures. The use of prophylactic mesh in high-risk patients at the time of stoma creation has gained attention in lieu of several promising studies that have emerged in the recent days. This review will attempt to demonstrate the burden that parastomal hernias present to patients, surgeons, and the healthcare system and also provide an overview of the current management and surgical techniques at both preventing and treating parastomal hernias. i 2014 S. Karger AG, Basel

The pitfalls of inguinal herniorrhaphy: Surgeon volume matters.

BACKGROUNDnThere is currently little information regarding the impact of procedure volume on outcomes after open inguinal hernia repair in the United States. Our hypothesis was that increasing procedure volume is associated with lesser rates of reoperation and resource use.nnnMETHODSnThe database of the Statewide Planning and Research Cooperative System was queried for elective open initial inguinal hernia repairs performed in New York State from 2001 to 2008 via the use of International Classification of Diseases, 9th Revision and Current Procedural Terminology codes. Surgeon and hospital procedure volumes were grouped into tertiles based on the number of open inguinal hernia repairs performed per year. Bivariate, hierarchical mixed effects Cox proportional-hazards, and negative binomial regression analyses were performed assessing for factors associated with reoperation for recurrence, procedure time, and downstream total charges.nnnRESULTSnAmong 151,322 patients who underwent open inguinal hernia repair, the overall rate of reoperation for recurrence within 5xa0years was 1.7% with a median time to reoperation of 1.9xa0years. An inverse relationship was seen between surgeon volume and reoperation rate, procedure time, and health care costs (Pxa0<xa0.001). After we controlled for surgeon, facility, operative and patient characteristics, low-volume surgeons (<25 repairs/year) had greater rates of reoperation (hazard ratio 1.23,95% confidence interval [95% CI] 1.11-1.36), longer procedure times (incidence rate ratio 1.22, 95% CI 1.21-1.24), and greater downstream costs (incidence rate ratio 1.13,95% CI 1.10-1.17) than high-volume surgeons (≥25 repairs/year).nnnCONCLUSIONnSurgeon volume <25 cases per year for open inguinal hernia repair was independently associated with greater rates of reoperation for recurrence, worse operative efficiency, and greater health care costs. Referral to surgeons who perform ≥25 inguinal hernia repairs per year should be considered to decrease reoperation rates and resource use.

Surgeon Volume Plays a Significant Role in Outcomes and Cost Following Open Incisional Hernia Repair

TitleSurgeon Volume Plays a Significant Role in Outcomes and Cost Following Open Incisional Hernia RepairPurposeIncisional hernia is a common complication following gastrointestinal surgery. Many surgeons elect to perform incisional hernia repairs despite performing only limited numbers of hernia repairs annually. This study examines the relationship between surgeon/facility volume and operative time, reoperation rates, and cost following initial open hernia repair.MethodsThe New York Statewide Planning and Research Cooperative System was queried for elective open initial incisional hernias repairs from 2001 to 2006. Surgeon/facility volumes were calculated as mean number of open incisional hernia repairs per year from 2001 to 2006. Reoperations for recurrent hernia over a 5-year period were identified using ICD-9/CPT codes. Multivariable regression was used to compare patient, surgeon, and facility characteristics with operative time, hernia reoperation, and hospital charges.ResultsEighteen thousand forty-seven patients met the inclusion criteria. The hernia reoperation rate was 9xa0%, and median time to reoperation was 1.4xa0years (meanu2009=u20091.8). After adjusting for clinical factors, surgeons performing an average of ≥36 repairs/year had significantly lower reoperation rates (HRu2009=u20090.59, 95xa0% confidence interval (CI)u2009=u20090.48,0.72), operative time (incidence rate ratio (IRR)u2009=u20090.67, 95xa0% CIu2009=u20090.64,0.71), and downstream charges (IRRu2009=u20090.63, 95xa0% CIu2009=u20090.57,0.69). Facility characteristics (volume, academic affiliation, location) were not associated with reoperation.ConclusionsThis study found a strong association between individual surgeon incisional hernia repair volume and hernia reoperation rates, operative efficiency, and charges. Preferential referral to high-volume surgeons may lead to improved outcomes and lower costs.

Timing of Discharge: a Key to Understanding the Reason for Readmission after Colorectal Surgery

PurposeThere is a growing interest in surgery regarding the balance between appropriate hospital length of stay (LOS) and prevention of unnecessary readmissions. This study examines the relationship between postoperative LOS and unplanned readmission after colorectal resection, exploring whether patients discharged earlier have different readmission risk profiles.MethodsPatients undergoing colorectal resection were selected by Common Procedural Terminology (CPT) code from the 2012 ACS National Surgical Quality Improvement Program (NSQIP) database. Patients were stratified by LOS quartile. Kaplan-Meier analysis was used to examine characteristics associated with 30-day unplanned readmission. Factors with a pu2009<u20090.1 were included in the Cox proportional hazards model. Subsequently, chi-square analysis compared LOS, patient, and perioperative factors with the primary reason for readmission. Factors with a pu2009<u20090.2 were included in a multivariable logistic regression for each readmission reason.ResultsFor 33,033 patients undergoing colorectal resection, the overall 30-day unplanned readmission rate was 11xa0%. After adjusting for patient and perioperative factors, a postoperative LOS ≥8xa0days was associated with a 55xa0% increase in the relative hazard of readmission. Patients with a ≤3-day LOS were more likely to be readmitted with ileus/obstruction (odds ratio (OR): 1.8, pu2009=u20090.001) and pain (OR: 2.2, pu2009=u20090.007). LOS was not significantly associated with readmission for intraabdominal infection or medical complications.ConclusionsPatients with longer LOS and complicated hospital courses continue to be high risk post-discharge, while straightforward early discharges have a different readmission risk profile. More targeted readmission prevention strategies are critical to focusing resource utilization for colorectal surgery patients.

Disease severity, not operative approach, drives organ space infection after pediatric appendectomy.

Objective:This study examines patient and operative factors associated with organ space infection (OSI) in children after appendectomy, specifically focusing on the role of operative approach. Background:Although controversy exists regarding the risk of increased postoperative intra-abdominal infections after laparoscopic appendectomy, this approach has been largely adopted in the treatment of pediatric acute appendicitis. Methods:Children aged 2 to 18 years undergoing open or laparoscopic appendectomy for acute appendicitis were selected from the 2012 American College of Surgeons Pediatric National Surgical Quality Improvement Program database. Univariate analysis compared patient and operative characteristics with 30-day OSI and incisional complication rates. Factors with a P value of less than 0.1 and clinical importance were included in the multivariable logistic regression models. A P value less than 0.05 was considered significant. Results:For 5097 children undergoing appendectomy, 4514 surgical procedures (88.6%) were performed laparoscopically. OSI occurred in 155 children (3%), with half of these infections developing postdischarge. Significant predictors for OSI included complicated appendicitis, preoperative sepsis, wound class III/IV, and longer operative time. Although 5.2% of patients undergoing open surgery developed OSI (odds ratio = 1.82; 95% confidence interval, 1.21–2.76; P = 0.004), operative approach was not associated with increased relative odds of OSI (odds ratio = 0.99; confidence interval, 0.64–1.55; P = 0.970) after adjustment for other risk factors. Overall, the model had excellent predictive ability (c-statistic = 0.837). Conclusions:This model suggests that disease severity, not operative approach, as previously suggested, drives OSI development in children. Although 88% of appendectomies in this population were performed laparoscopically, these findings support utilization of the surgeons preferred surgical technique and may help guide postoperative counsel in high-risk children.

Opportunity lost: Adjuvant chemotherapy in patients with stage III colon cancer remains underused.

INTRODUCTIONnThere is strong evidence supporting the efficacy of adjuvant chemotherapy for patients with pathologic, stage III colon cancer. This study examines differences in adherence to evidence-based adjuvant chemotherapy guidelines for pathologic, stage III colon cancer cases across hospital and patient subgroups.nnnMETHODSnPatients with stage III colon cancer were identified from the 2003 to 2011 National Cancer Data Base (NCDB). A logistic regression model was used to estimate the odds of receipt of adjuvant chemotherapy across varying hospital and patient characteristics. A multivariable Cox proportional hazards model was used to estimate the association between receipt of adjuvant chemotherapy and 5-year survival. Risk adjusted observed/expected (O/E) outcome ratios were calculated for each hospital to compare hospital-specific quality of care during the study period.nnnRESULTSnA total of 124,008 patients met the inclusion criteria. Adjuvant chemotherapy was not administered to 34%. The rates of adjuvant chemotherapy have shown little improvement over time (63% in 2003 vs 66% in 2011). The Cox model indicates that patients receiving adjuvant chemotherapy had better survival (hazard ratioxa0=xa00.48, 95% confidence interval 0.47-0.49). Analysis of risk adjusted O/E ratios indicated no consistent pattern as to which hospitals were performing optimally or subopitmally over time.nnnCONCLUSIONnThere has been no meaningful improvement in receipt of chemotherapy in patients with stage III colon cancer. The fact that chemotherapy is not being considered or offered to more than 20% of patients with node-positive colon cancer suggests that there are substantial process failures across many institutions and regions in the United States.

Visceral obesity, not elevated BMI, is strongly associated with incisional hernia after colorectal surgery.

BACKGROUND: High BMI is often used as a proxy for obesity and has been considered a risk factor for the development of an incisional hernia after abdominal surgery. However, BMI does not accurately reflect fat distribution. OBJECTIVE: The purpose of this work was to investigate the relationship among different obesity measurements and the risk of incisional hernia. DESIGN: This was a retrospective cohort study. SETTINGS: The study included a single academic institution in New York from 2003 to 2010. PATIENTS: The study consists of 193 patients who underwent colorectal cancer resection. MAIN OUTCOME MEASURES: Preoperative CT scans were used to measure visceral fat volume, subcutaneous fat volume, total fat volume, and waist circumference. A diagnosis of incisional hernia was made either through physical examination in medical chart documentation or CT scan. RESULTS: Forty-one patients (21.2%) developed an incisional hernia. The median time to hernia was 12.4 months. After adjusting for patient and surgical characteristics using Cox regression analysis, visceral obesity (HR 2.04, 95% CI 1.07–3.91) and history of an inguinal hernia (HR 2.40, 95% CI 1.09–5.25) were significant risk factors for incisional hernia. Laparoscopic resection using a transverse extraction site led to a >75% reduction in the risk of incisional hernia (HR 0.23, 95% CI 0.07–0.76). BMI > 30 kg/m2 was not significantly associated with incisional hernia development. LIMITATIONS: Limitations include the retrospective design without standardized follow-up to detect hernias and the small sample size attributed to inadequate or unavailable CT scans. CONCLUSIONS: Visceral obesity, history of inguinal hernia, and location of specimen extraction site are significantly associated with the development of an incisional hernia, whereas BMI is poorly associated with hernia development. These findings suggest that a lateral transverse location is the incision site of choice and that new strategies, such as prophylactic mesh placement, should be considered in viscerally obese patients.