Russell E. Brown

Readmission rates after abdominal surgery: the role of surgeon, primary caregiver, home health, and subacute rehab.

Objective:To prospectively evaluate predictive factors of hospital readmission rates in patients undergoing abdominal surgical procedures. Background:Recommendations from MedPAC that the Centers for Medicare and Medicaid Services (CMS) report upon and determine payments based in part on readmission rates have led to an attendant interest by payers, hospital administrators and far-sighted physicians. Methods:Analysis of 266 prospective treated patients undergoing major abdominal surgical procedures from September 2009 to September 2010. All patients were prospectively evaluated for underlying comorbidities, number of preop meds, surgical procedure, incision type, complications, presence or absence of primary and/or secondary caregiver, their education level, discharge number of medications, and discharge location. Univariate and multivariate analyses were performed. Results:Two hundred twenty-six patients were reviewed with 48 (18%) gastric-esophageal, 39(14%) gastrointestinal, 88 (34%) liver, 58 (22%) pancreas, and 33 (12%) other. Seventy-eight (30%) were readmitted for various diagnoses the most common being dehydration (26%). Certain preoperative and intraoperative factors were not found to be significant for readmission being, comorbidities, diagnosis, number of preoperative medications, patient education level, type of operation, blood loss, and complications. Significant predictive factors for readmission were age (≥69 years), number of discharged (DC) meds (≥9 medications), ⩽50% oral intake (52% vs. 23%), and DC home with a home health agency (62% vs. 11%) Conclusion:Readmission rates for surgeons WILL become a quality indicator of performance. Quality parameters among Home Health agencies are nonexistent, but will reflect on surgeons performance. Greater awareness regarding predictors of readmission rates is necessary to demonstrate improved surgical quality.

A Prospective Phase II Evaluation of Esophageal Stenting for Neoadjuvant Therapy for Esophageal Cancer: Optimal Performance and Surgical Safety

BACKGROUND Many surgeons are reluctant to use esophageal stents during neoadjuvant therapy for esophageal cancer because of concerns about nutritional status, stent-related complications, or added difficulties during esophagogastrectomy. We hypothesized that esophageal stenting during neoadjuvant therapy allows for optimal nutritional intake without adversely affecting perioperative outcomes. STUDY DESIGN This study is a prospective, dual-institution, single-arm, phase II evaluation of esophageal cancer patients undergoing neoadjuvant therapy before resection. All patients had a self-expanding polymer stent placed before neoadjuvant therapy. We monitored dysphagia symptoms, nutritional status, stent-related complications, and perioperative complications during the course of therapy and 90 days postoperatively. RESULTS We enrolled 32 patients with dysphagia and weight loss who were eligible for neoadjuvant therapy. After stent placement, 2 patients had stent migrations requiring replacement. No erosive complications were observed. During the course of neoadjuvant therapy, we noted improvement in dysphagia, mild weight loss, and maintenance of performance status. At a median of 50 days (range 18 to 92 days) after completion of neoadjuvant therapy, 20 patients underwent margin-negative esophagogastrectomy (16 Ivor Lewis, 4 minimally invasive) without problems with stent removal or difficulty in surgical dissection. Twelve patients did not undergo resection due to development of metastases (n = 8) or rapid decline in functional status (n = 4). Major perioperative complications included pulmonary embolism (n = 2), chyle leak (n = 1), and bronchial injury (n = 1). No surgical complications were attributed to stent placement. CONCLUSIONS Use of esophageal stents during neoadjuvant therapy is safe and results in resolution of dysphagia, mild weight loss, and maintenance of performance status without an effect on intraoperative dissection, perioperative complications, or delay in resection after neoadjuvant therapy.

Hepatic Resection for Colorectal Liver Metastases

Colorectal adenocarcinoma remains the third most common cause of cancer death in the United States, with an estimated 146,000 new cases and 50,000 deaths annually. Survival is stage dependent, and the presence of liver metastases is a primary determinant in patient survival. Approximately 25% of new cases will present with synchronous colorectal liver metastases (CLM), and up to one-half will develop CLM during the course of their disease. The importance of safe and effective therapies for CLM cannot be overstated. Safe and appropriately aggressive multimodality therapy for CLM can provide most patients with liver-dominant colorectal metastases with extended survival and an improved quality of life.

Evaluation of Quality of Life Following Placement of Self-Expanding Plastic Stents as a Bridge to Surgery in Patients Receiving Neoadjuvant Therapy for Esophageal Cancer

PURPOSE To determine whether self-expanding plastic stent (SEPS) placement significantly improves quality of life and maintains optimal nutrition while allowing full-dose neoadjuvant therapy (NAT) in patients with esophageal cancer. PATIENTS AND METHODS A prospective, dual-institution, single-arm, phase II (http://ClinicalTrials.gov: NCT00727376) evaluation of esophageal cancer patients undergoing NAT prior to resection. All patients had a self-expanding polymer stent placed prior to NAT. The European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-OG25, Functional Assessment of Cancer Therapy-Anorexia, and Functional Assessment of Cancer Therapy-General surveys were administered prior to stenting, within 1 week post-stent placement, and at the completion of neoadjuvant therapy. RESULTS Fifty-two patients were enrolled; 3 (5.8%) had stent migrations requiring replacement. There were no instances of esophageal erosion or perforation. All patients received some form of neoadjuvant therapy. Thirty-six (69%) received chemoradiation; 34 (93%) of these patients received the planned dose of chemotherapy, and 27 (75%) received the full planned dose of radiotherapy. There were 16 (31%) patients receiving chemotherapy alone; 12 (74%) of patients in the chemotherapy-alone group completed the planned dose of therapy. CONCLUSION Placement of SEPS appears to provide significant improvement in quality of life related to dysphagia and eating restriction in patients with esophageal cancer undergoing neoadjuvant therapy. Consideration of SEPS instead of percutaneous feeding tube should be initiated as a first line in dysphagia palliation and NAT nutritional support.

Differences between bipolar compression and ultrasonic devices for parenchymal transection during laparoscopic liver resection

OBJECTIVES   In laparoscopic liver resection, multiple options for parenchymal transection techniques exist; however, none have emerged as superior. The aim of this study was to compare operative characteristics and outcomes between bipolar compression and ultrasonic devices used for parenchymal transection during laparoscopic liver resection. METHODS   A review of a prospective hepatopancreatobiliary database from December 2002 to August 2009 identified 54 patients who underwent laparoscopic liver resection with parenchymal division using either a bipolar compression (n= 35) or an ultrasonic (n= 19) device. Operative data, histology and 90-day complication rates were compared between the groups using analysis of variance (anova) and Pearsons chi-squared test. RESULTS   The two groups did not differ significantly in terms of age, body mass index, parenchymal steatosis/inflammation or number of segments resected. A shorter time of parenchymal transection was noted for the bipolar compression device (median: 35 min; range: 20-65 min) vs. the ultrasonic device (median: 55 min; range: 29-75 min) (P < 0.001). Median total operative time was also shorter using the bipolar compression device (130 min) than the ultrasonic device (180 min) (P= 0.050). No significant differences between device groups were noted for estimated blood loss, complications of any type or liver-specific complications. CONCLUSIONS   Bipolar compression devices may offer advantages over ultrasonic devices in terms of decreased transection time and total operative time. No differences in postoperative complications in laparoscopic liver resection emerged between patients operated using the devices.

Hepatectomy after hepatic arterial therapy with either yttrium-90 or drug-eluting bead chemotherapy: is it safe?

BACKGROUND The use of hepatic arterial therapy (HAT) with either yttrium-90 or drug-eluting bead therapy for initially unresectable hepatic malignancies has risen significantly. The safety of hepatic resection after hepatic arterial therapy (HAT) is not established. OBJECTIVE The present study evaluates the safety profile for hepatic resection after HAT. METHODS We identified 840 patients undergoing hepatectomy for primary or metastatic lesions. Forty patients underwent HAT before hepatectomy (pre-HAT). A 1:4 case-matched analysis compared three groups: (i) pre-HAT and pre-operative chemotherapy (n=40); (ii) pre-operative chemotherapy (n=160); and (iii) no pre-operative therapy (n=640). Controls were matched for age, resection type, maximal tumour size and magnitude of resection. Morbidity and mortality among groups were compared using a graded complication scale. RESULTS   There were no differences in post-operative complications, grade of complication or liver-specific complications among the groups. A proportional hazards model for all patients did not demonstrate any association between increased complications and either pre-HAT or pre-operative chemotherapy when compared with patients without pre-operative therapy (P=0.7). CONCLUSIONS Pre-HAT demonstrated similar morbidity, liver-specific morbidity and intra-operative complications when compared with patients undergoing pre-operative chemotherapy alone or without pre-operative chemotherapy. These results suggest that pre-HAT is safe and should not preclude hepatectomy in carefully selected patients.

Impact of histology on survival in retroperitoneal sarcomas

BACKGROUND The current American Joint Committee on Cancer AJCC staging system applies to all soft-tissue sarcomas and does not allow for consideration of many features unique to retroperitoneal sarcomas (RPSs). The aim of this study was to analyze factors predictive of recurrence and survival for patients with resected RPSs. METHODS This was a retrospective analysis of consecutive patients with primary RPS who underwent resection. A 3-tiered histological classification was examined: atypical lipomatous tumors (ALTs), non-ALT liposarcomas (LPSs), and other. Univariate and multivariate analyses were used to identify factors associated with differences in disease-free survival (DFS) and overall survival (OS) among groups. RESULTS Sixty RPS patients were analyzed: 16 patients (27%) had ALTs, 7 patients (12%) had LPSs, and 37 patients (62%) had other histologies. A comparison of the 3 groups showed a significant difference in OS among groups (P < .017). High-grade tumors favored shorter DFS (P = .06) but were not associated with decreased OS when compared with low-grade tumors (P = .86). CONCLUSIONS These findings support an alternative staging system for RPS, inclusive of histology, which may prove useful in operative planning and prognostication.

Obesity rather than neoadjuvant chemotherapy predicts steatohepatitis in patients with colorectal metastasis

INTRODUCTION Neoadjuvant chemotherapy has been associated with an increased risk of surgery because of chemotherapy-associated steatohepatitis and sinusoidal obstruction. The aim of the current study was to assess for other predictors of steatohepatitis and sinusoidal obstruction and to determine the role of obesity as a risk factor in patients with colorectal liver metastasis (CLM). METHODS An institutional review board-approved prospectively maintained database of 1,605 patients who underwent hepatic procedures for CLM from 2001 to 2009 was reviewed. RESULTS In a review of 208 resected patients, body mass index was the only predictor of liver injury according to multivariate analysis (P < .001, odds ratio = 3.88). Diabetes, neoadjuvant chemotherapy, sleep apnea, alcohol use, tobacco use, age, and sex were not significant predictors. Among preoperative chemotherapy patients, BMI was a predictor of chemotherapy liver injury according to multivariate analysis (P < .0001). The rate of obesity (BMI >30) was 36%, and among obese patients (BMI >30) the rate of steatosis or steatohepatitis was 39%. CONCLUSIONS Obesity is the strongest predictor of steatosis and steatohepatitis in patients with CLM, and this risk is independent of the use of preoperative chemotherapy.

Impact of Post-Operative Complications on Quality of Life After Pancreatectomy

CONTEXT Pancreatectomies for malignant and benign diseases are increasingly being performed worldwide. Recent studies, that have evaluated quality of life in pancreatectomy, have reported conflicting outcomes. OBJECTIVE This study was undertaken to analyze the quality of life changes reported by patients with pancreatic cancer undergoing pancreatectomy. DESIGN Post-hoc analysis was performed of a clinical trial examining the safety of intraoperative autotransfusion during oncologic resections. MAIN OUTCOME MEASURES Perioperative (90-day) complications were graded prospectively using a validated 5-point scale. Quality of life parameters were recorded prospectively by a single trained interviewer preoperatively, at the first post-operative outpatient visit, and at 6 weeks, 3 months, and 6 months follow-up using the EORTC QLQ-C30 and FACT-An instruments. RESULTS Pancreatectomy for adenocarcinoma was performed in 34 patients with a median follow-up of 2 years (range: 1-1.5 years). Major (grade≥3) complications occurred in 12 (35.3%) of patients. Early (<6 month) recurrence was noted in 2 patients (5.9%). Increased severity of fatigue, pain, dyspnea, and loss of appetite over baseline were noted at initial follow-up (P<0.05); however, symptom scores normalized at 6-week follow-up, and remained stable at 6 months. No significant difference was noted in quality of life metrics between patients with or without major complications (P>0.11). A significant (P=0.023) decline in cognitive function vs. baseline was noted at 6-month follow-up after pancreatectomy. Using a repeated-measures generalized linear model, neither age, nor complication occurrence, nor adjuvant therapy, nor early recurrence accounted for this cognitive decline (P>0.10). CONCLUSION Quality of life metrics tend to normalize to preoperative levels after pancreatectomy at 6 weeks post-operatively. The occurrence of major complications does not predict a decreased quality of life. The decrease in self-reported cognitive function at six months in this cohort merits further study.

Ablative Therapies for Colorectal Liver Metastases

Ablative therapies remain a useful adjunct in the multidisciplinary treatment of patients with colorectal liver metastases not amenable to hepatic resection. This review summarizes the rationale, underlying mechanisms, techniques, complications, and outcomes of current and emerging ablative modalities.