Sarah B. Bateni

Current perioperative outcomes for patients with disseminated cancer

BACKGROUND Surgical morbidity and mortality (M&M) for patients with disseminated malignancy (DMa) is high, and some have questioned the role of surgery. Therefore, we sought to characterize temporal trends in M&M among DMa patients, hypothesizing that surgical intervention would remain prevalent. METHODS We queried the American College of Surgeons National Surgical Quality Improvement Program from 2006-2010. Excluding patients undergoing a primary hepatic operation, we identified 21,755 patients with DMa. Parametric and/or nonparametric statistics and logistic regression were used to evaluate temporal trends and predictors of M&M. RESULTS The prevalence of surgical intervention for DMa declined slightly over the time period, from 1.9%-1.6% of all procedures (P < 0.01). Among DMa patients, the most frequent operations performed were bowel resection, other gastrointestinal procedures, and multivisceral resections, these all showed small statistically significant decreases over time (P < 0.01). The rate of emergency operations also decreased (P < 0.01). In contrast, the rate of preoperative independent functional status rose, whereas the rate of preoperative weight loss and sepsis decreased (P < 0.01). Rates of 30-d morbidity (33.7 versus 26.6%), serious morbidity (19.8 versus 14.2%), and mortality (10.4 versus 9.3%) all decreased over the study period (P < 0.05). Multivariate analysis identified standard predictors (e.g., impaired functional status, preoperative weight loss, preoperative sepsis, and hypoalbuminemia) of worse 30-d M&M. CONCLUSIONS Thirty-day morbidity, serious morbidity, and mortality have decreased incrementally for patients with DMa undergoing surgical intervention, but surgical intervention remains prevalent. These data further highlight the importance of careful patient selection and goal-directed therapy in patients with incurable malignancy.

Tranexamic Acid use in Trauma: Effective but not Without Consequences

Background: Administration of tranexamic acid (TXA) is associated with reduced mortality in civilian and military settings. The purpose of this study was to assess a TXA treatment guideline in patients with traumatic injury in a Level I trauma center. The guideline was to give TXA to patients going directly to OR, or with SBP < 90, or for whom our massive transfusion guideline was activated. The hypothesis was that TXA would confer mortality benefit without increasing thromboembolic complications (DVT/PE) or acute kidney injury (AKI). Methods: Records of TXA recipients were reviewed. TXA recipients were compared to a random sample of historical controls that met administration criteria but did not receive TXA. Outcomes were compared for patients meeting any criteria for TXA administration and also for those going directly to the OR. Results: From Dec 2011 through July 2012, 52 trauma patients received TXA. When compared to 74 controls (SBP < 90), TXA recipients trended towards lower mortality (5.8% vs 17.6%, p=.05), higher DVT/PE (11.5% vs 0, p=.004), and more AKI (25% vs11%, p=.02). However baseline characteristics were not well matched. When controls were selected from hypotensive patients going directly the OR, baseline matching was excellent. Among well matched direct to the OR cohorts TXA recipients had lower 24h mortality (4.3% vs 19.1%, p=.03), more DVT/PE (12% vs 0%, p=.012), a trend towards more AKI (28% vs 15%, p=.12) but no transfusion differences. Conclusion: In civilian trauma, early TXA administration confers early survival advantage without affecting blood product usage but may increase the risk of DVT/PE and AKI.

Increased rates of prolonged length of stay, readmissions, and discharge to care facilities among postoperative patients with disseminated malignancy: Implications for clinical practice

Background The impact of surgery on end of life care for patients with disseminated malignancy (DMa) is incompletely characterized. The purpose of this study was to evaluate postoperative outcomes impacting quality of care among DMa patients, specifically prolonged length of hospital stay, readmission, and disposition. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for years 2011–2012. DMa patients were matched to non-DMa patients with comparable clinical characteristics and operation types. Primary hepatic operations were excluded, leaving a final cohort of 17,972 DMa patients. The primary outcomes were analyzed using multivariate Cox regression models. Results DMa patients represented 2.1% of all ACS-NSQIP procedures during the study period. The most frequent operations were bowel resections (25.3%). Compared to non-DMa matched controls, DMa patients had higher rates of postoperative overall morbidity (24.4% vs. 18.7%, p<0.001), serious morbidity (14.9% vs. 12.0%, p<0.001), mortality (7.6% vs. 2.5%, p<0.001), prolonged length of stay (32.2% vs. 19.8%, p<0.001), readmission (15.7% vs. 9.6%, p<0.001), and discharges to facilities (16.2% vs. 12.9%, p<0.001). Subgroup analyses of patients by procedure type showed similar results. Importantly, DMa patients who did not experience any postoperative complication experienced significantly higher rates of prolonged length of stay (23.0% vs. 11.8%, p<0.001), readmissions (10.0% vs. 5.2%, p<0.001), discharges to a facility (13.2% vs. 9.5%, p<0.001), and 30-day mortality (4.7% vs. 0.8%, p<0.001) compared to matched non-DMa patients. Conclusion Surgical interventions among DMa patients are associated with poorer postoperative outcomes including greater postoperative complications, prolonged length of hospital stay, readmissions, disposition to facilities, and death compared to non-DMa patients. These data reinforce the importance of clarifying goals of care for DMa patients, especially when acute changes in health status potentially requiring surgery occur.

Palliative Care Training and Decision-Making for Patients with Advanced Cancer: A Comparison of Surgeons and Medical Physicians

Background: Surgical decision‐making in patients with advanced cancer requires careful thought and deliberation to balance the high risks with the potential palliative benefits. We sought to compare surgical decision‐making and palliative care training among surgeons and medical physicians who commonly treat advanced cancer patients. We hypothesized that surgeons will report less palliative care training compared with medical physicians, and deficits in palliative care training will be associated with more aggressive treatment recommendations in clinical scenarios of advanced cancer patients with symptomatic surgical conditions. Study Design: Practicing surgeons, medical oncologists, intensivists, and palliative care physicians from a large urban city and its surrounding areas were surveyed with a 32‐item questionnaire consisting of a survey addressing palliative care training and 4 clinical vignettes depicting patients with advanced cancer and symptomatic surgical conditions. Results: Of the 299 physicians surveyed, 102 responded (response rate 34.1%). Surgeons reported fewer hours of palliative care training during residency, fellowship, and continuing medical education combined (median 10, IQR 2‐15) compared with medical oncologists (median 30, IQR 20‐80) and medical intensivists (median 50 IQR 30‐100), P < .05. Additionally, 20% of surgeons reported no history of any palliative care training. Analysis of physician recommendations for treatment of the 4 clinical vignettes showed minimal consensus regardless of physician specialty. Absence of palliative care training was associated with recommending major operative intervention more frequently compared with physicians with ≥40 hours of palliative care training (0.7 ± 0.7 vs 1.6 ± 0.8, P =.01). Conclusion: Substantial deficiencies in palliative care training persist among surgeons and are associated with more aggressive recommendations for treatment for the selected scenarios presented in patients with advanced cancer. These findings highlight the need for greater efforts systemwide in palliative care education among surgeons, including incorporation of a structured palliative care training curriculum in graduate and continuing surgical education.

Comparison of common risk stratification indices to predict outcomes among stage IV cancer patients with bowel obstruction undergoing surgery

Among patients with disseminated malignancy (DMa), bowel obstruction is common with high operative morbidity. Since preoperative risk stratification is critical, we sought to compare three standard risk indices, the American Society of Anesthesiology (ASA) classification, Charlson comorbidity index (CCI), and modified frailty index (mFI).

Lung resection is safe and feasible among stage IV cancer patients: An American College of Surgeons National Surgical Quality Improvement Program analysis

Background. Operative resection can be associated with improved survival for selected patients with stage IV malignancies but may also be associated with prohibitive acute morbidity and mortality. We sought to evaluate rates of acute morbidity and mortality after lung resection in patients with disseminated malignancy with primary lung cancer and non–lung cancer pulmonary metastatic disease. Methods. For 2011–2012, 6,360 patients were identified from the American College of Surgeons National Surgical Quality Improvement Program undergoing lung resections, including 603 patients with disseminated malignancy. Logistic regression analyses were used to compare outcomes between patients with and without disseminated malignancy. Results. After controlling for preoperative and intraoperative differences, we observed no statistically significant differences in rates of 30‐day overall and serious morbidity or mortality between disseminated malignancy and non–disseminated malignancy patients (P > .05). Disseminated malignancy patients were less likely to have a prolonged duration of stay and be discharged to a facility compared to non–disseminated malignancy patients (P < .05). Subgroup analyses by procedure type and diagnosis showed similar results. Conclusion. Disseminated malignancy patients undergoing lung resections experienced low rates of overall morbidity, serious morbidity, and mortality comparable to non–disseminated malignancy patients. These data suggest that lung resections may be performed safely on carefully selected, disseminated malignancy patients with both primary lung cancer and pulmonary metastatic disease, with important implications for multimodality care.