Katherine S. Virgo

Risk factors for morbidity and mortality after colectomy for colon cancer

PURPOSE: Comorbid conditions affect the risk of adverse outcomes after surgery, but the magnitude of risk has not previously been quantified using multivariate statistical methods and prospectively collected data. Identifying factors that predict results of surgical procedures would be valuable in assessing the quality of surgical care. This study was performed to define risk factors that predict adverse events after colectomy for cancer in Department of Veterans Affairs Medical Centers. METHODS: The National Veterans Affairs Surgical Quality Improvement Program contains prospectively collected and extensively validated data on more than 415,000 surgical operations. All patients undergoing colectomy for colon cancer from 1991 to 1995 who were registered in the National Veterans Affairs Surgical Quality Improvement Program database were selected for study. Independent variables examined included 68 preoperative and 12 intraoperative clinical risk factors; dependent variables were 21 specific adverse outcomes. Stepwise logistic regression analysis was used to construct models predicting the 30-day mortality rate and 30-day morbidity rates for each of the ten most frequent complications. RESULTS: A total of 5,853 patients were identified; 4,711 (80 percent) underwent resection and primary anastomosis. One or more complications were observed in 1,639 of 5,853 (28 percent) patients. Prolonged ileus (439/5,853; 7.5 percent), pneumonia (364/5,853; 6.2 percent), failure to wean from the ventilator (334/5,853; 5.7 percent), and urinary tract infection (292/5,853; 5 percent) were the most frequent complications. The 30-day mortality rate was 5.7 percent (335/5,853). For most complications, 30-day in-hospital mortality rates were significantly higher for patients with a complication than for those without. Thirty-day mortality rates exceeded 50 percent if postoperative coma, cardiac arrest, a pre-existing vascular graft prosthesis that failed after colectomy, renal failure, pulmonary embolism, or progressive renal insufficiency occurred. Preoperative factors that predicted a high risk of 30-day mortality included ascites, serum sodium >145 mg/dl, “do not resuscitate” status before surgery, American Society of Anesthesiologists classes III and IV OR V, and low serum albumin. CONCLUSIONS: Mortality rates after colectomy in Veterans Affairs hospitals are comparable with those reported in other large studies. Ascites, hypernatremia, do not resuscitate status before surgery, and American Society of Anesthesiologists classes III and IV OR V were strongly predictive of perioperative death. Clinical trials to decrease the complication rate after colectomy for colon cancer should focus on these risk factors.

Outcome After Colectomy for Clostridium Difficile Colitis

PURPOSEClostridium difficile colitis is a relatively common entity, yet large series of patients with fulminant C.difficile colitis are infrequently reported. This study was designed to identify risk factors, clinical characteristics, and outcome of patients who required colectomy for fulminant C. difficile colitis.METHODSA population-based study on all patients in 159 hospitals of the Department of Veterans Affairs from 1997 to 2001 was performed. Data were compiled from several national computerized Department of Veterans Affairs data sets. Supplementary information including demographic information, discharge summaries, operative reports, and pathology reports were obtained from local medical records. Patient variables were entered into a computerized database and analyzed using the Pearson chi-squared and Fisher’s exact tests. Statistical significance was designated as P < 0.05.RESULTSSixty-seven patients (mean age, 69 (range, 40–86) years; 99 percent males) were identified. All 67 patients had C. difficile verified in the colectomy specimens. Thirty-six of 67 patients (54 percent) developed C. difficile colitis during a hospitalization for an unrelated illness, and 30 of 36 patients (87 percent) after a surgical procedure. Thirty-one of 67 (46 percent) developed C. difficile colitis at home. There was no history of diarrhea in 25 of 67 patients (37 percent). Thirty of 67 patients (45 percent) presented in shock (blood pressure, <90 mmHg). Forty-three of 67 patients (64 percent) presented with an acute surgical abdomen. Mean white blood cell count was 27.2; mean percent bands was 12. Twelve of 67 patients (18 percent) had a negative C. difficile colitis stool assay. Abdominal computed tomography correctly diagnosed 45 of 46 patients (98 percent) who were imaged. Twenty-six of 67 patients (39 percent) underwent colonoscopy; all 26 were found to have severe inflammation or pseudomembranes. Fifty-three of 67 patients (80 percent) underwent total colectomy; 14 of 67 underwent segmental colonic resection. Perforation and infarction were found in 59 of 67 patients (58 percent) at surgery. Overall mortality was 48 percent (32/67). Mean hospitalization was 36 (range, 2–297) days.CONCLUSIONSPatients with fulminant C. difficile colitis often present with an unexplained abdominal illness with a marked leukocytosis that rapidly progresses to shock and peritonitis. Although frequently developed during a hospitalization and often after a surgical procedure, it may develop outside of a hospital setting. Diarrhea may be absent and stool cytology may be negative for C. difficile toxin. Perforation and infarction are frequently found at surgery. In those patients who survive, a prolonged hospitalization is common. Mortality from fulminant C. difficile colitis remains high despite surgical intervention.

The association of race/ethnicity, insurance status, and socioeconomic factors with breast cancer care

Few data are available on how race/ethnicity, insurance, and socioeconomic status (SES) interrelate to influence breast cancer treatment. The authors examined care for a national cohort of breast cancer patients to assess whether insurance and SES were associated with racial/ethnic differences in care.

Evaluation and management of men whose radical prostatectomies failed: results of an international survey

OBJECTIVES To determine how urologists evaluate and treat men who develop recurrent prostate cancer after radical prostatectomy. METHODS Surveys were mailed to 4467 American Urological Association members comprising 3205 U.S. and 1262 non-U.S. urologists randomly selected from a total membership of approximately 12,000. One thousand four hundred sixteen were returned and 1050 (760 U.S. and 290 non-U.S.) surveys were evaluable. RESULTS To evaluate men with an elevated or rising prostate-specific antigen (PSA) level more than 1 year after radical prostatectomy, 98% of respondents use digital rectal examination, 68% use bone scan, 54% use transrectal ultrasound with biopsy, 36% use abdominal or pelvic computed tomography scan, 31% use transrectal ultrasound without biopsy, 25% use prostatic acid phosphatase, 11% use monoclonal antibody scan, and 5% use abdominal or pelvic magnetic resonance imaging. Respondents evaluate men with an elevated or rising PSA within 1 year of radical prostatectomy similarly. To treat documented local recurrence, 81% of respondents recommend radiation therapy, 7% recommend orchiectomy or luteinizing hormone-releasing hormone (LHRH) agonists, 6% recommend observation only, and 5% recommend combined androgen ablation. To treat documented distant recurrence, 50% recommend combined androgen ablation, 42% recommend orchiectomy or LHRH agonists, and 7% recommend observation only. To treat PSA-only recurrence, 54% recommend observation only, 16% recommend combined androgen ablation, 15% recommend orchiectomy or LHRH agonists, and 13% recommend radiation therapy. CONCLUSIONS The evaluation of men whose radical prostatectomy failed varies among urologists and does not depend on time of recurrence. Radiation therapy is used by most urologists to treat local recurrence. Hormonal manipulation is used by more than 90% of urologists to treat distant recurrence. More than 50% of urologists recommend observation for men with biochemical-only recurrence.

Current follow-up strategies after resection of colon cancer

The follow-up of patients after potentially curative resection of colon cancer has important clinical and financial implications for patients and society, yet the ideal surveillance strategy is unknown. PURPOSE: The aim of this study was to determine the current follow-up practice pattern of a large, diverse group of experts. METHODS: The 1,663 members of The American Society of Colon and Rectal Surgeons were asked,viaa detailed questionnaire, how often they request nine discrete follow-up evaluations in their patients treated for cure with TNM Stage I, II, or III colon cancer over the first five post-treatment years. These evaluations were clinic visit, complete blood count, liver function tests, serum carcinoembryonic antigen (CEA) level, chest x-ray, bone scan, computerized tomographic scan, colonoscopy, and sigmoidoscopy. RESULTS: Forty-six percent (757/1663) completed the survey and 39 percent (646/1663) provided evaluable data. The results indicate that members of The American Society of Colon and Rectal Surgeons generally conduct follow-up on their patients personally after performing colon cancer surgery (rather than sending them back to their referral source). Routine clinic visits and CEA levels are the most frequently performed items for each of the five years. The large majority (>75 percent) of surgeons see their patients every 3 to 6 months for years 1 and 2, then every 6 to 12 months for years 3, 4, and 5. Approximately 80 percent of respondents obtain CEA levels every 3 to 6 months for years 1,2, and 3, and every 6 to 12 months for years 4 and 5. Colonoscopy is performed annually by 46 to 70 percent of respondents, depending on year. A chest x-ray is obtained yearly by 46 to 56 percent, depending on year. The majority of the members of The American Society of Colon and Rectal Surgeons do not routinely request computerized tomographic scan or bone scan at any time. There is great variation in the pattern of use of complete blood count and liver function tests. Members of The American Society of Colon and Rectal Surgeons from the United States tend to follow their patients more closely than do those living in other countries. The intensity of follow-up does not markedly vary across TNM Stages I to III. CONCLUSION: The surveillance strategies reported here rely most heavily on clinic visits and CEA level determinations, generally reflecting guidelines previously proposed in the current literature.

Sigmoid volvulus in Department of Veterans Affairs Medical Centers

PURPOSE: Sigmoid volvulus is the third leading cause of large-bowel obstruction. The optimal management strategy remains controversial. This study was undertaken to evaluate the care of patients with sigmoid volvulus recently treated at Department of Veterans Affairs hospitals. METHODS: All patients with the International Classification of Diseases, Ninth Revision, Clinical Modification, Third Edition code for colonic volvulus during the period 1991 to 1995 were identified in the computerized national Department of Veterans Affairs database. Data on patient demographics, clinical course, and outcomes were analyzed. RESULTS: Two hundred twenty-eight patients had volvulus of the sigmoid colon and sufficient clinical data for evaluation. The mean age was 70; all were males. Endoscopic decompression was attempted in 189 of 228 (83 percent) patients and was successful in 154 of 189 (81 percent). Management included celiotomy in 178 of 228 (78 percent) patients. There were no intraoperative deaths. Twenty-five of 178 (14 percent) patients died within 30 days of surgery. The mortality rate was 24 percent for emergency operations (19/79), and 6 percent for elective procedures (6/99). Mortality was correlated with emergent surgery (P<0.01) and necrotic colon (P<0.05). Among those 50 patients managed by decompression alone, six (12 percent) died during the index admission. Ten of the remaining 44 (23 percent) patients eventually developed recurrent volvulus requiring further treatment, and 2 of 10 (20 percent) patients died. CONCLUSIONS: In this cohort sigmoid volvulus often presents as a surgical emergency. Initial endoscopic decompression resolves the acute obstruction in the majority of cases. Surgical intervention carries a substantial risk of mortality, particularly in the setting of emergent surgery or in the presence of necrotic colon.

Experience with distal bile duct cancers in U.S. Veterans Affairs hospitals: 1987-1991.

Treatment selection and results were reviewed in a population with distal bile duct cancers.

Surveillance after curative colon cancer resection: practice patterns of surgical subspecialists.

AbstractBackground: In the literature, suggested strategies for the follow-up of colon cancer patients after potentially curative resections vary widely. The optimal regimen to monitor for recurrences and new primary tumors remains unknown. The nationwide cost impact of wide practice variation is also unknown. Methods: The 1,070 members of The Society of Surgical Oncology (SSO) were surveyed using a detailed questionnaire to measure the practice patterns of surgical experts nationwide. Respondents were asked how often they use nine separate methodologies in follow-up during years 1–5 postsurgery for TNM stage I, II, and III patients. Costs were estimated for representative less and more intensive strategies. Results: Evaluable responses were received from 349 members (33%). Office visit and carcinoembryonic antigen analysis were performed most frequently. SSO members generally see patients every 3 months in years 1–2, every 6 months in years 3–4, and annually thereafter. There was wide variability in test ordering patterns and moderate variation between SSO and previously surveyed American Society of Colon and Rectal Surgeons members. The charge differential between representative less and more intensive follow-up strategies for each annual U.S. patient cohort is ∼

Population-based analysis of treatment of pancreatic cancer and Whipple resection: Department of Defense hospitals, 1989–1994

800 million. Conclusions: Actual practice patterns vary widely, indicating lack of consensus regarding optimal follow-up. The enormous cost differential associated with such variation is difficult to justify because there is no proven benefit of more intensive follow-up.

Aminoglycosides for Intra-Abdominal Infection: Equal to the Challenge?

BACKGROUND The influence of hospital experience and referral patterns on the operative mortality rate of pancreaticoduodenectomy was studied in a worldwide hospital system. METHODS We analyzed computerized data on pancreatic cancer patients from U.S. Department of Defense (DOD) hospitals from 1989 to 1994. RESULTS Six hundred ninety-eight patients had pancreatic cancer, and 130 Whipple operations (105 for pancreatic and 25 for other cancers) were performed with an 8.5% 30-day operative mortality rate. Although most resections were done in teaching hospitals performing more than 1 Whipple procedure per year, their results were not superior to smaller, lower volume nonteaching hospitals. Patients transported for resection were younger than patients undergoing resection at their local DOD hospital but had similar outcomes. The operative mortality rate was higher after unusual resections and with increasing age; the tumor stage had no effect. Unresected patients undergoing combined radiation and chemotherapy had the longest survival times. Radiation therapy was associated with significantly longer survival times in patients without distant metastases, but chemotherapy was associated with a longer survival time when metastases were present. CONCLUSIONS This mortality rate 8.5% for Whipple resections matches that from other large populations. Equivalent results were obtained in DOD teaching hospitals and smaller, community-type institutions. Because the DOD medical system minimizes financial and logistic barriers to transfer, the even distribution of DOD pancreatectomy mortality suggests that these barriers may favorably influence single institutional outcomes.