Kevin G. Billingsley

Reoperation as a Quality Indicator in Colorectal Surgery: A Population-Based Analysis

Objective:To describe unplanned procedures following colorectal cancer surgery that might be used as intermediate outcome measures, and to determine their association with mortality and length of stay. Summary Background:Variation in the quality of surgical care, especially for common illnesses like colorectal cancer, has received increasing attention. Nonfatal complications resulting in procedural interventions are likely to play a role in poor outcomes but have not been well explored. Methods:Cohort analysis of 26,638 stage I to III colorectal cancer patients in the 1992 to 1996 SEER-Medicare database. Independent variables: sociodemographics, tumor characteristics, comorbidity, and acuity. Primary outcome: postoperative procedural intervention. Analysis: Logistic regression identified patient characteristics predicting postoperative procedures and the adjusted risk of 30-day mortality and prolonged hospitalization among patients with postoperative procedures. Results:A total of 5.8% of patients required postoperative intervention. Patient characteristics had little impact on the frequency of postoperative procedures, except for acute medical conditions, including bowel perforation (relative risk [RR] = 3.0, 95% confidence interval [CI] = 2.5–3.6), obstruction (RR = 1.6; 95% CI = 1.4–1.8), and emergent admission (RR = 1.3; 95% CI = 1.1–1.4). After a postoperative procedure, patients were more likely to experience early mortality (RR = 2.4; 95% CI = 2.1–2.9) and prolonged hospitalization (RR = 2.2; 95% CI = 2.1–2.4). The most common interventions were performed for abdominal infection (31.7%; RR mortality = 2.9; 95% CI = 2.3–3.7), wound complications (21.1%; RR mortality = 0.7; 95% CI = 0.4–1.3), and organ injury (18.7%; RR mortality = 1.6; 95% CI = 1.1–2.3). Conclusions:Postoperative complications requiring additional procedures among colorectal cancer patients correlate with established measures of surgical quality. Prospective tracking of postoperative procedures as complication markers may facilitate outcome studies and quality improvement programs.

Residual Treatment Disparities After Oncology Referral for Rectal Cancer

BACKGROUND Black patients with rectal cancer are considerably less likely than white patients to receive adjuvant therapy. We examined the hypothesis that the lower treatment rate for blacks is due to underreferral to medical and radiation oncologists. METHODS We used 1992-1999 Surveillance, Epidemiology, and End Results-Medicare data to identify elderly (> or = 66 years of age) patients who had been hospitalized for resection of stage II or III rectal cancer (n = 2716). We used chi(2) tests to examine associations between race and 1) consultation with an oncologist and 2) receipt of adjuvant therapy. We then used logistic regression to analyze the influence of sociodemographic and clinical characteristics (age at diagnosis, sex, marital status, median income and education in area of residence, comorbidity, and cancer stage) on black-white differences in the receipt of adjuvant therapy. All statistical tests were two-sided. RESULTS There was no statistically significant difference between the 134 black patients and the 2582 white patients in the frequency of consultation with a medical oncologist (73.1% for blacks vs 74.9% for whites, difference = 1.8%, 95% confidence interval [CI] = > 5.9% to 9.5%, P = .64) or radiation oncologist (56.7% vs 64.8%, difference = 8.1%, 95% CI = > 0.5% to 16.7%, P = .06), but blacks were less likely than whites to consult with both a medical oncologist and a radiation oncologist (49.2% vs 58.8%, difference = 9.6%, 95% CI = 0.9% to 18.2%, P = .03). Among patients who saw an oncologist, black patients were less likely than white patients to receive chemotherapy (54.1% vs 70.2%, difference = 16.1%, 95% CI = 6.0% to 26.2%, P = .006), radiation therapy (73.7% vs 83.4%, difference = 9.7%, 95% CI = 0.4% to 19.8%, P = .06), or both (60.6% vs 76.9%, difference = 16.3%, 95% CI = 4.3% to 28.3%, P = .008). Patient and provider characteristics had minimal influence on the racial disparity in the use of adjuvant therapy. CONCLUSION Racial differences in oncologist consultation rates do not explain disparities in the use of adjuvant treatment for rectal cancer. A better understanding of patient preferences, patient-provider interactions, and potential influences on provider decision making is necessary to develop strategies to increase the use of adjuvant treatment for rectal cancer among black patients.

Evolving Preoperative Evaluation of Patients with Pancreatic Cancer: Does Laparoscopy Have a Role in the Current Era?

BACKGROUND Recent years have brought important developments in preoperative imaging and use of laparoscopic staging of patients with pancreatic adenocarcinoma (PAC). There are few data about the optimal combination of preoperative studies to accurately identify resectable patients. STUDY DESIGN We conducted a statewide review of all patients with surgically managed PAC from 1996 to 2003 using data from the Oregon State Cancer Registry, augmented with clinical information from primary medical record review. We documented the use of all staging modalities, including CT, endoscopic ultrasonography, and laparoscopy. Primary outcomes included resection with curative intent. The association between staging modalities, clinical features, and resection was measured using a multivariate logistic regression model. RESULTS There were 298 patients from 24 hospitals who met the eligibility criteria. Patients were staged using a combination of CT (98%), laparoscopy (29%), and endoscopic ultrasonography (32%). The overall proportion of patients who went to surgical exploration and were resected was 87%. Of patients undergoing diagnostic laparoscopy, metastatic disease that precluded resection was discovered in 24 (27.6%). For patients who underwent diagnostic laparoscopy and were not resected, vascular invasion was the most common determinant of unresectability (56.6%). In multivariate analysis, preoperative weight loss and surgeon decision to use laparoscopy predicted unresectability at laparotomy. CONCLUSIONS This population-based study demonstrates that surgeons appear to use laparoscopy in a subset of patients at high risk for metastatic disease. The combination of current staging techniques is associated with a high proportion of resectability for patients taken to surgical exploration. With current imaging modalities, selective application of laparoscopy with a dual-phase CT scan as the cornerstone of staging is a sound clinical approach to evaluate pancreatic cancer patients for potential resectability.

Race, treatment, and survival of veterans with cancer of the distal esophagus and gastric cardia.

Context. Prior studies have found racial differences in the use of invasive procedures and in cancer survival. Objective. To assess the influence of race on the treatment and survival of patients with distal esophageal cancer. Design. Retrospective cohort study. Setting. All Veterans Affairs Medical Centers. Patients. One thousand two hundred ninety white and 231 black male veterans with a new diagnosis of distal esophageal cancer during 1993 to 1997. Main Outcome Measures. Utilization of surgical resection, chemotherapy, radiation therapy, and survival. Results. Black patients with esophageal adenocarcinoma were less likely to undergo surgery (OR, 0.54; 95% CI, 0.30–0.96) but had similar odds of undergoing chemotherapy and radiation therapy. Black patients with squamous cell carcinoma (SCC) were less likely to undergo surgical resection (OR, 0.45; 95% CI, 0.29–0.70), but were more likely to undergo radiation therapy (OR, 1.72; 95% CI, 1.21–2.47) and chemotherapy (OR, 1.74; 95% CI, 1.19–2.54). Mortality was increased for black patients with SCC (adjusted risk ratio 1.33; 95% CI, 1.10–1.61) but not adenocarcinoma. Among those veterans who underwent surgical resection (n = 502), similar results were found. Conclusions. Black veterans with distal SCC are less likely than white veterans to undergo surgical resection, whereas the use of radiation therapy and chemotherapy, as well as mortality, is increased. Black patients with distal esophageal adenocarcinoma have lower odds of undergoing surgical resection but have similar utilization of radiation therapy and chemotherapy and similar survival. Despite the presence of an equal access medical system, treatment and outcomes differ for black and white veterans with distal esophageal cancer.

S0356: A Phase II Clinical and Prospective Molecular Trial With Oxaliplatin, Fluorouracil, and External-Beam Radiation Therapy Before Surgery for Patients With Esophageal Adenocarcinoma

PURPOSE Pathologic complete response (pCR) after neoadjuvant therapy for locally advanced esophageal adenocarcinoma is associated with improved survival. The Southwest Oncology Group designed a trimodality, phase II, single-arm trial with objectives of achieving a pCR rate of 40% with prospective exploratory analyses of intratumoral molecular markers postulated to affect response and survival. PATIENTS AND METHODS Patients with clinically staged II or III esophageal adenocarcinoma received oxaliplatin 85 mg/m(2) on days 1, 15, and 29; protracted-infusion fluorouracil (PI-FU) 180 mg/m(2)/d on days 8 through 43; and external-beam radiation therapy (EBRT) 5 days a week at 1.8 Gy/d for 25 fractions; surgery was performed 28 to 42 days after neoadjuvant therapy. Chemotherapy was planned after surgery. Tumors were analyzed for mRNA expression and polymorphisms in genes involved in drug metabolism and DNA repair. RESULTS Ninety-three patients were evaluable. Two deaths (2.2%) were attributable to preoperative therapy, and two deaths (2.2%) were attributable to surgery. Grade 3 and 4 toxicities were recorded for 47.3% and 19.4% of patients, respectively. Seventy-nine patients (84.9%) underwent surgery; 67.7% of patients had R0 resections. Twenty-six patients (28.0%) had confirmed pCR (95% CI, 19.1% to 38.2%). At a median follow-up of 39.2 months, estimates of median and 3-year overall survival (OS) were 28.3 months and 45.1%, respectively. Intratumoral ERCC-1 gene expression was inversely related to progression-free survival and OS. CONCLUSION Neoadjuvant oxaliplatin, PI-FU, and EBRT for esophageal adenocarcinoma is active and tolerable. Because the regimen failed to meet the primary end point, it does not define a new standard. However, future trials can be built on this platform to validate the role of ERCC-1 in determining the best systemic regimen for individual patients.

Argon plasma coagulation for rectal bleeding after prostate brachytherapy

PURPOSE To better define the efficacy and safety of argon plasma coagulation (APC), specifically for brachytherapy-related proctitis, we reviewed the clinical course of 7 patients treated for persistent rectal bleeding. Approximately 2-10% of prostate cancer patients treated with 125I or 103Pd brachytherapy will develop radiation proctitis. The optimum treatment for patients with persistent bleeding is unclear from the paucity of available data. Prior reports lack specific dosimetric information, and patients with widely divergent forms of radiation were grouped together in the analyses. METHODS AND MATERIALS Seven patients were treated with APC at the Veterans Affairs Puget Sound Health Care System and the University of Washington from 1997 to 1999 for persistent rectal bleeding due to prostate brachytherapy-related proctitis. Four patients received supplemental external beam radiation, delivered by a four-field technique. A single gastroenterologist at the Veterans Affairs Puget Sound Health Care System treated 6 of the 7 patients. If the degree of proctitis was limited, all sites of active bleeding were coagulated in symptomatic patients. An argon plasma coagulator electrosurgical system was used to administer treatments every 4-8 weeks as needed. The argon gas flow was set at 1.6 L/min, with an electrical power setting of 40-45 W. RESULTS The rectal V100 (the total rectal volume, including the lumen, receiving the prescription dose or greater) for the 7 patients ranged from 0.13 to 4.61 cc. Rectal bleeding was first noticed 3-18 months after implantation. APC (range 1-3 sessions) was performed 9-22 months after implantation. Five patients had complete resolution of their bleeding, usually within days of completing APC. Two patients had only partial relief from bleeding, but declined additional APC therapy. No patient developed clinically evident progressive rectal wall abnormalities after APC, (post-APC follow-up range 4-13 months). CONCLUSIONS Most patients benefited from APC, and no cases of clinically evident progressive tissue destruction were noted. Although APC appears to be efficacious and safe in the setting of the rectal doses described here, caution is in order when contemplating APC for brachytherapy patients.

Techniques and results of portal vein/superior mesenteric vein reconstruction using femoral and saphenous vein during pancreaticoduodenectomy

BACKGROUND Patients with pancreatic tumors may have portal vein (PV) and/or superior mesenteric vein (SMV) invasion. In such cases, lower extremity veins can provide an autogenous conduit for PV/SMV reconstruction. Little data exist, however, describing the technique of PV/SMV reconstruction, patency of such reconstructions, and the morbidity of using lower extremity veins for PV/SMV reconstruction during pancreaticoduodenectomy. METHODS Thirty-four patients underwent PV/SMV reconstruction during pancreaticoduodenectomy using lower extremity vein. The saphenous vein was preferred for patching and femoral vein for replacement. We analyzed preoperative imaging, reconstruction patency, vein harvest morbidity, and late mortality. RESULTS The mean age was 62.6 years. All 34 patients had preoperative computed tomography (CT) imaging and/or endoscopic ultrasound (EUS) scan. Fourteen of the 34 patients had evidence of PV/SMV invasion on CT or EUS scans, 14 did not, and six studies were indeterminate. Twenty-five patients had follow-up imaging, and 22 (88%) had patent reconstructions. Fifteen patients had PV/SMV replacement using femoral vein. Seven of these 15 had minor postoperative lower extremity edema that resolved over time, five had wound complications from the femoral vein harvest site, three of which required minor operative procedures for treatment. Fifteen patients had PV/SMV patching with the great saphenous vein, none had postoperative wound problems, and one had minimal postoperative lower extremity edema. Four patients had PV/SMV patching using femoral vein, none had postoperative wound problems, and one had minimal postoperative lower extremity edema. Compared with patients undergoing pancreaticoduodenectomy without PV/SMV reconstruction, by Kaplan-Meier analysis, there was no difference in late mortality. CONCLUSION Preoperative imaging may fail to detect PV/SMV involvement in patients undergoing pancreaticoduodenectomy. The PV/SMV reconstruction with leg vein provides good patency with minimal postoperative lower extremity complications and no increase in late mortality. The lower extremities should be routinely included in the operative field of patients undergoing pancreaticoduodenectomy.

Diagnostic laparoscopy for patients with potentially resectable pancreatic adenocarcinoma: Is it cost-effective in the current era?

IntroductionFor patients with potentially resectable pancreatic cancer, diagnostic laparoscopy may identify liver and peritoneal metastases that are difficult to detect with other staging modalities. The aim of this study was to utilize a population-based pancreatic cancer database to assess the cost effectiveness of preoperative laparoscopy.Material and MethodsData from a state cancer registry were linked with primary medical record data for years 1996–2003. De-identified patient records were reviewed to determine the role and findings of laparoscopic exploration. Average hospital and physician charges for laparotomy, biliary bypass, pancreaticoduodenectomy, and laparoscopy were determined by review of billing data from our institution and Medicare data for fiscal years 2005–2006. Cost-effectiveness was determined by comparing three methods of utilization of laparoscopy: (1) routine (all patients), (2) case-specific, and (3) no utilization.Results and DiscussionOf 298 potentially resectable patients, 86 underwent laparoscopy. The prevalence of unresectable disease was 14.1% diagnosed at either laparotomy or laparoscopy. The mean charge per patient for routine, case-specific, and no utilization of laparoscopy was

Coagulopathy after a liver resection: is it over diagnosed and over treated?

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The international normalized ratio overestimates coagulopathy in patients after major hepatectomy

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