Gopal C. Kowdley

Cancer Surgery in the Elderly

The proportions both of elderly patients in the world and of elderly patients with cancer are both increasing. In the evaluation of these patients, physiologic age, and not chronologic age, should be carefully considered in the decision-making process prior to both cancer screening and cancer treatment in an effort to avoid ageism. Many tools exist to help the practitioner determine the physiologic age of the patient, which allows for more appropriate and more individualized risk stratification, both in the pre- and postoperative periods as patients are evaluated for surgical treatments and monitored for surgical complications, respectively. During and after operations in the oncogeriatric populations, physiologic changes occuring that accompany aging include impaired stress response, increased senescence, and decreased immunity, all three of which impact the risk/benefit ratio associated with cancer surgery in the elderly.

Predicting gangrenous cholecystitis

BACKGROUND Gangrenous cholecystitis (GC) is often challenging to treat. The objectives of this study were to determine the accuracy of pre-operative diagnosis, to assess the rate of post-cholecystectomy complications and to assess models to predict GC. METHODS A retrospective single-institution review identified patients undergoing a cholecystectomy. Logistic regression models were used to examine the association of variables with GC and to build risk-assessment models. RESULTS Of 5812 patients undergoing a cholecystectomy, 2219 had acute, 4837 chronic and 351 GC. Surgeons diagnosed GC pre-operatively in only 9% of cases. Patients with GC had more complications, including bile-duct injury, increased estimated blood loss (EBL) and more frequent open cholecystectomies. In unadjusted analyses, variables significantly associated with GC included: age >45 years, male gender, heart rate (HR) >90, white blood cell count (WBC) >13,000/mm(3), gallbladder wall thickening (GBWT) ≥ 4 mm, pericholecystic fluid (PCCF) and American Society of Anesthesiology (ASA) >2. In adjusted analyses, age, WBC, GBWT and HR, but not gender, PCCF or ASA remained statistically significant. A 5-point scoring system was created: 0 points gave a 2% probability of GC and 5 points a 63% probability. CONCLUSION Using models can improve a diagnosis of GC pre-operatively. A prediction of GC pre-operatively may allow surgeons to be better prepared for a difficult operation.

Hereditary Pancreatic and Hepatobiliary Cancers

Hereditary etiologies of pancreatic and hepatobiliary cancers are increasingly recognized. An estimated >10% of pancreatic and increasing number of hepatobiliary cancers are hereditary. The cumulative risk of hereditary pancreatic cancer ranges from measurable but negligible in cystic fibrosis to a sobering 70% in cases of hereditary pancreatitis. Candidates for pancreatic cancer surveillance are those with a risk pancreatic cancer estimated to be >10-fold that of the normal population. Screening for pancreatic cancer in high-risk individuals is typically performed by endoscopic ultrasound and should begin at least 10 years prior to the age of the youngest affected relative. Disease states known to be associated with increased risk of hepatocellular cancer include hereditary hemochromatosis, autoimmune hepatitis, porphyria, and α1-antitrypsin deficiency, with relative risks as high as 36-fold. Although much less is known about hereditary bile-duct cancers, Muir-Torre syndrome and bile salt export pump deficiency are diseases whose association with hereditary carcinogenesis is under investigation.

Gallbladder Dysfunction: How Much Longer Will It Be Controversial?

Background: Motility disorders of the biliary tree [biliary dyskinesia, including both gallbladder dysfunction (GBD), and sphincter of Oddi dysfunction] are difficult to diagnose and to treat. Summary: There is controversy in the literature in particular regarding the criteria that should be used to select patients for cholecystectomy (CCY) in cases of suspected GBD. The current review covers the history, diagnosis, and treatment of GBD. Key Messages: Only >85% of patients with suspected GBD have relief following CCY, a much lower rate than the nearly 100% success rate following CCY for gallstone disease. Unfortunately, the literature is lacking, and there are no universally agreed-upon criteria for selecting which patients to refer for operation, although cholecystokinin (CCK)-enhanced hepatobiliary iminodiacetic acid scan is often used, with emphasis on an abnormally low gallbladder ejection fraction or pain reproduction at CCK administration. There is a clear need for large, well-designed, more definitive, prospective studies to better identify the indications for and efficacy of CCY in cases of GBD. i 2014 S. Karger AG, Basel

Effect of Residents on Operative Time and Complications: Focus on Laparoscopic Cholecystectomy in the Community ☆

OBJECTIVE To better understand important aspects of resident education in the perioperative setting, given that there are conflicting data regarding resident training and outcomes (e.g., operative times and complications). To study continuity of care in a resident-run outpatient hospital clinic. DESIGN Retrospective analysis of 2 databases. SETTING The study was set up in a community teaching hospital. RESULTS Of 4603 cases in a cholecystectomy database, 3302 (72%) were assisted by residents, with operative times ranging from 19 to 383 minutes, and 1576 (22.9%) were assisted by nonresidents. The average times were 93 and 77 minutes for resident- and non-resident-assisted cases, respectively. Complications were almost 3 times more likely for urgent vs. elective but were similar for resident-assisted vs. non-resident-assisted cases. The operative time was similar across PGY levels. Of 149 cases in a resident-run outpatient clinic, 100 (67%) of the residents participated in preoperative, intraoperative, and postoperative phases of case, but in only 4% of cases was it the same resident. CONCLUSION Resident assistance increased operative times but not complications. Counterbalanced effects of increasing skill and increasing participation may explain this time stability across PGY levels. Continuity of care is preserved in the era of the 80-hour workweek, but not to a patient-specific degree.

Implications of gallbladder cholesterolosis and cholesterol polyps

BACKGROUND The clinical significance of cholesterolosis has not been well established but there are some provocative, if not robust, studies of the role it may play in the pathophysiology of pancreatitis and biliary dyskinesia, as well as hypercholesterolemia. Our aim was to take advantage of a very large cholecystectomy (CCY) database to support or refute these potentially important reported associations. MATERIALS AND METHODS A retrospective review of 6868 patients who underwent CCY from 2001-2013 was performed. Comparisons were made using the student t-test for continuous and chi-square analysis for categorical, variables. RESULTS Among patients for whom the CCY was the primary operation, 1053 (18%) had cholesterolosis and 4596 did not. Compared to those without cholesterolosis, those with cholesterolosis were no more likely to have elevated cholesterol levels (P = 0.64) nor low gallbladder ejection fraction (P = 0.2). To evaluate cholesterolosis as a cause of pancreatitis, all patients with gallstones were eliminated, leaving 639 patients. Among these, not only was cholesterolosis not associated with more pancreatitis, but rather there was not a single patient with or without cholesterolosis who had pancreatitis. CONCLUSIONS Despite prior reports of associations between cholesterolosis and elevated serum cholesterol, depressed ejection fraction, and increased risk of pancreatitis, careful analysis of this current, larger data set does not support these associations. Any patient with stones or sludge, or with biliary dyskinesia, and appropriate symptoms, should be considered for CCY, with or without suspected cholesterolosis.

Energetic etiologies of acute pancreatitis: A report of five cases

There are several common causes of acute pancreatitis, principally excessive alcohol intake and gallstones, and there are many rare causes. However, cases of pancreatitis still occur in the absence of any recognizable factors, and these cases of idiopathic pancreatitis suggest the presence of unrecognized etiologies. Five cases of acute pancreatitis in four patients came to attention due to a strong temporal association with exposure to nerve stimulators and energy drinks. Given that these cases of pancreatitis were otherwise unexplained, and given that these exposures were not clearly known to be associated with pancreatitis, we performed a search for precedent cases and for mechanistic bases. No clear precedent cases were found in PubMed and only scant, weak precedent cases were found in public-health databases. However, there was a coherent body of intriguing literature in support of a mechanistic basis for these exposures playing a role in the etiology of pancreatitis.

Cholecystectomy Following Idiopathic Pancreatitis: How Much to Look for Stones?

Dear Editors, We would like to congratulate the authors for publishing their study on this very common and important question, viz., how does cholecystectomy influence recurrence of idiopathic acute pancreatitis? The authors performed a retrospective study of 2236 patients diagnosed with acute pancreatitis lacking a confirmed cause. Those who did and did not undergo cholecystectomy were compared regarding recurrence rate of acute pancreatitis (AP). BIdiopathic^AP (IAP) was defined as a case of pancreatitis in which Ba causative factor could not be determined through history, physical examination, laboratory studies, and noninvasive imaging such as transabdominal ultrasound [TAUS] or computerized tomography [CT].^ Inclusion criteria were TAUS, no prior cholecystectomy, no nonbiliary cause identified, and no gallstones seen on TAUS. Nonbiliary causes were excluded by Bclose review of clinical notes [and] radiologic investigations.^ Regarding alcohol, the authors were careful not to assume that no mention of alcohol means no alcohol; rather, patients were deemed not to have alcohol as an etiology only if Bthe clinician specifically remarked in the notes that alcohol was not thought to be a causative factor.^ Unfortunately, the results are still difficult to interpret since further details regarding assessment for etiology are not provided. For example, it is not reported how many patients had hypertriglyceridemia, which is such a common cause of AP (next most common after alcohol and gallstones), that its testing is part of the American College of Gastroenterology Guidelines. It would be helpful to know how many patients had, did not have, or can’t be known to have had or not, this third most common cause of AP. Although the proportion of all AP patients with hypertriglyceridemia is only 5%, the proportion among those lacking alcohol or gallstones is certainly much higher. Similarly, another 5% of all cases of AP are attributable to medications, but it is not reported how many patients are taking medications which could have caused AP, how many are not, and howmany have an incomplete medication history. Finally, there is the long list of other causes, including autoimmunity, genetic causes, environmental exposures, and obstruction from small tumors, divisum, sphincter of Oddi syndrome, the details of which are not reported. Further, hindering interpretation of this paper is the understandable (but still problematic) lack of endoscopic ultrasound (EUS). While the authors cannot be faulted for this lack (indeed, even a RCT <1 year prior did not include EUS), still, EUS is recommended by the IAP/APA evidence-based guidelines, since 32–88% of patients with so-called IAP are found to have an etiology, such as pancreatic-duct obstruction or missed stones or sludge. Therefore, if EUS had been done in all patients, not to mention reporting of other, nonlithiasis causes above, the composition of the two groups, and therefore the results, may have been drastically different. Also, not reported is whether the polyps are cholesterol or adenomatous polyps. Although some literature suggests the possibility that cholesterol polyps could be an occult cause of IAP, 8, 9 this seems not to be the case in a more recent study of 6868 patients undergoing cholecystectomy. Still, the point is controversial, and it would be interesting to know if these polyps were adenomatous polyps or cholesterol polyps. Despite these problems, the authors are to be commended for a long mean follow-up period of 50 months. And the authors’ results do agree with the abovementioned RCT * Steven Clark Cunningham Steven.Cunningham@stagnes.org

Age-related differences pre-, intra-, and postcholecystectomy: A retrospective cohort study of 6,868 patients

BACKGROUND Cholecystectomy (CCY) is increasingly performed in older individuals. We sought to examine age-related differences in pre-, intra-, and postoperative factors at a community hospital, using a very large, single-institution cholecystectomy database. MATERIALS AND METHODS A retrospective review of 6868 patients who underwent CCY from 2001 to 2013 was performed. ROC analysis identified the optimal age cutoff when complications reached a significant inflection point (<55 and ≥55 years). Multiple clinical features and outcomes were measured and compared by age. Logistic regression was used to examine how well a set of covariates predicted postoperative complications. RESULTS Older patients had significantly higher rates of comorbidities and underwent more extensive preoperative imaging. Intraoperatively, older patients had more blood loss, longer operative times, and more open operations. Postoperatively, older patients experienced more complications and had significantly different pathological findings. While holding age and gender constant, regression analyses showed that preoperative creatinine level, blood loss and history of previous operation were the strongest predictors of complications. The risk for developing complications increased by 2% per year of life. CONCLUSION Older patients have distinct pre-, intra-, and postoperative characteristics. Their care is more imaging- and cost-intensive. CCY in this population is associated with higher risks, likely due to a combination of comorbidities and age-related worsened physiological status. Pathologic findings are significantly different relative to younger patients. While removing the effect of age, preoperative creatinine levels, blood loss, and history of previous operation predict postoperative complications. Quantifying these differences may help to inform management decisions for older patients.

Verbal Aggressiveness Among Physicians and Trainees

OBJECTIVE To better understand verbal aggressiveness among physicians and trainees, including specialty-specific differences. DESIGN AND PARTICIPANTS The Infante Verbal Aggressiveness Scale (IVAS) was administered as part of a survey to 48 medical students, 24 residents, and 257 attending physicians. The 72 trainees received the IVAS and demographic questions, whereas the attending physicians received additional questions regarding type of practice, career satisfaction, litigation, and personality type. RESULTS The IVAS scores showed high reliability (Cronbach α = 0.83). Among all trainees, 56% were female with mean age 28 years, whereas among attending physicians, 63% were male with mean age 50 years. Average scores of trainees were higher than attending physicians with corresponding averages of 1.88 and 1.68, respectively. Among trainees, higher IVAS scores were significantly associated with male sex, non-US birthplace, choice of surgery, and a history of bullying. Among attending physicians, higher IVAS scores were significantly associated with male sex, younger age, self-reported low-quality of patient-physician relationships, and low enjoyment talking to patients. General surgery and general internal medicine physicians were significantly associated with higher IVAS scores than other specialties. General practitioners (surgeons and medical physicians) had higher IVAS scores than the specialists in their corresponding fields. No significant correlation was found between IVAS scores and threats of legal action against attending physicians, or most personality traits. Additional findings regarding bullying in medical school, physician-patient interactions, and having a method to deal with inappropriate behavior at work were observed. CONCLUSIONS Individuals choosing general specialties display more aggressive verbal communication styles, general surgeons displaying the highest. The IVAS scoring system may identify subgroups of physicians with overly aggressive (problematic) communication skills and may provide a backdrop for educating physician communicators. The relationship between verbal aggressiveness and efficacy of clinical communication merits inquiry.