Sonia T. Orcutt

Infectious postoperative complications decrease long-term survival in patients undergoing curative surgery for colorectal cancer: a study of 12,075 patients.

OBJECTIVE We sought to characterize the effect of postoperative complications on long-term survival after colorectal cancer (CRC) resection. BACKGROUND The impact of early morbidity on long-term survival after curative-intent CRC surgery remains controversial. METHODS The Veterans Affairs Surgical Quality Improvement Program and Central Cancer Registry databases were linked to acquire perioperative and cancer-specific data for 12,075 patients undergoing resection for nonmetastatic CRC (1999-2009). Patients were categorized by presence of any complication within 30 days and by type of complication (noninfectious vs infectious). Univariate and multivariate survival analyses adjusted for patient, disease, and treatment factors were performed, excluding early deaths (<90 days). Subset analysis was performed to determine the specific impact of severe postoperative infections. RESULTS The overall morbidity and infectious complication rates were 27.8% and 22.5%, respectively. Patients with noninfectious postoperative complications were older, had lower preoperative serum albumin, had worse functional status, and had higher American Society of Anesthesiologists scores than patients with infectious complications and without complications (all P < 0.001). The presence of any complication was independently associated with decreased long-term survival [hazard ratio, 1.24; 95% confidence interval (1.15-1.34)]. Multivariate analysis by complication type demonstrated increased risk only with infectious complications [hazard ratio, 1.31; 95% confidence interval (1.21-1.42)]. Subset analysis demonstrated this effect predominantly in patients with severe infections [hazard ratio, 1.41; 95% confidence interval (1.15-1.73)]. CONCLUSIONS The presence of postoperative complications after CRC resection is associated with decreased long-term survival, independent of patient, disease, and treatment factors. The impact on long-term outcome is primarily driven by infectious complications, particularly severe postoperative infections.

Postoperative transitional care needs in the elderly: an outcome of recovery associated with worse long-term survival.

OBJECTIVE To characterize transitional care needs (TCNs) after colorectal cancer (CRC) surgery and examine their association with age and impact on overall survival (OS). BACKGROUND TCNs after cancer surgery represent additional burden for patients and are associated with higher short-term mortality. They are not well-characterized in CRC patients, particularly in the context of a growing elderly population, and their effect on long-term survival is unknown. METHODS A retrospective cohort study of CRC patients (N = 486) having curative surgery at a tertiary referral center (2002-2011) was conducted. Outcomes included TCNs (home health or nonhome destination at discharge) and OS. Patients were compared on the basis of age: young (<65 years), old (65-74 years), and oldest (≥75 years). Multivariate logistic regression models were used to examine the association of age with TCNs, and OS was compared on the basis of TCNs and stage, using the Kaplan-Meier method. RESULTS TCNs were required by 130 patients (27%). The oldest patients had highest TCNs (49%) compared with the other age groups (P < 0.01), with rehabilitation services as their primary TCNs (80%). After multivariate analysis, patients 75 years or older had significantly increased TCN risk (odds ratio, 4.7; 95% confidence interval, 2.6-8.5). TCN was associated with worse OS for patients with early- and advanced stage CRC (P < 0.001). CONCLUSIONS TCNs after CRC surgery are common and significantly increased in patients 75 years or older, represent an outcome of postoperative recovery, and are associated with worse long-term survival. Preoperative identification of higher risk populations should be used for patient counseling, advanced preoperative planning, and to implement strategies targeted at minimizing TCNs.

Portal Vein Embolization as an Oncosurgical Strategy Prior to Major Hepatic Resection: Anatomic, Surgical, and Technical Considerations.

Preoperative portal vein embolization (PVE) is used to extend the indications for major hepatic resection, and it has become the standard of care for selected patients with hepatic malignancies treated at major hepatobiliary centers. To date, various techniques with different embolic materials have been used with similar results in the degree of liver hypertrophy. Regardless of the specific strategy used, both surgeons and interventional radiologists must be familiar with each other’s techniques to be able to create the optimal plan for each individual patient. Knowledge of the segmental anatomy of the liver is paramount to fully understand the liver segments that need to be embolized and resected. Understanding the portal vein anatomy and the branching variations, along with the techniques used to transect the portal vein during hepatic resection, is important because these variables can affect the PVE procedure and the eventual surgical resection. Comprehension of the advantages and disadvantages of approaches to the portal venous system and the various embolic materials used for PVE is essential to best tailor the procedures for each patient and to avoid complications. Before PVE, meticulous assessment of the portal vein branching anatomy is performed with cross-sectional imaging, and embolization strategies are developed based on the patient’s anatomy. The PVE procedure consists of several technical steps, and knowledge of these technical tips, potential complications, and how to avoid the complications in each step is of great importance for safe and successful PVE and ultimately successful hepatectomy. Because PVE is used as an adjunct to planned hepatic resection, priority must always be placed on safety, without compromising the integrity of the future liver remnant, and close collaboration between interventional radiologists and hepatobiliary surgeons is essential to achieve successful outcomes.

Postoperative mortality and need for transitional care following liver resection for metastatic disease in elderly patients: a population‐level analysis of 4026 patients

OBJECTIVES The goal of this study was to characterize the association of age with postoperative mortality and need for transitional care following hepatectomy for liver metastases. METHODS A retrospective cohort study using the Nationwide Inpatient Sample (2005-2008) was performed. Patients undergoing hepatectomy for liver metastases were categorized by age as: Young (aged <65 years); Old (aged 65-74 years), and Oldest (aged ≥75 years). Multivariate logistic regression analyses were performed to identify predictors of in-hospital mortality and need for transitional care (non-home discharge). RESULTS A total of 4026 patients were identified; 36.6% (n = 1475) were elderly (aged ≥65 years). Rates of in-hospital mortality and non-home discharge increased with advancing age group [1.3% vs. 2.2% vs. 3.3% (P = 0.005) and 2.1% vs. 6.1% vs. 18.3% (P < 0.001), respectively]. Independent predictors of in-hospital mortality were age within the Oldest category [odds ratio (OR) 2.21, 95% confidence interval (CI) 1.19-4.12] and a Deyo Comorbidity Index score of ≥3 (OR 6.95, 95% CI 3.55-13.60). Independent predictors for need for transitional care were age within the Old group (OR 2.44, 95% CI 1.66-3.58), age within the Oldest group (OR 8.48, 95% CI 5.87-12.24), a Deyo score of 1 (OR 2.00, 95% CI 1.40-2.85), a Deyo score of 2 (OR 4.70, 95% CI 2.93-7.56), a Deyo score of ≥3 (OR 6.41, 95% CI 3.67-11.20), and female gender (OR 1.56, 95% CI 1.15-2.11). CONCLUSIONS Although increasing age was associated with higher risk for in-hospital mortality, the absolute risk was low and within accepted ranges, and comorbidity was the primary driver of mortality. Conversely, need for transitional care was significantly more common in elderly patients. Therefore, liver resection for metastases is safe in well-selected elderly patients, although consideration should be made for potential transitional care needs.

Hand-assisted laparoscopy leads to efficient colorectal cancer surgery

BACKGROUND Laparoscopic-assisted (LA) colorectal resections have improved short-term outcomes compared with open resections. Lack of tactile feedback, though, has led to lengthy operations and high conversion rates with attendant adverse effects on patients. Hand-assisted laparoscopy (HAL), in contrast, provides tactile feedback while still being minimally invasive. We hypothesize that HAL compared with LA for colorectal cancer resections will be associated with lower conversion rates and decreased operative times, without compromising the advantages of laparoscopy. MATERIALS AND METHODS We performed a retrospective case-matched study of patients undergoing LA or HAL colorectal cancer resections from 2002 to 2010, using a prospectively maintained colorectal cancer database at a Veterans Affairs Medical Center. Short-term outcomes analyzed (using the Wilcoxon signed rank and McNemars tests) included operative and perioperative variables and surrogate markers of adequacy of oncologic care. RESULTS Forty-seven LA patients were matched 1:1 by age and resection with 47 HAL patients. Patients in the HAL group had significantly lower blood loss (100 versus 150 cc, P = 0.04), operative times (206 versus 252 min, P = 0.002), and conversion rates (6% versus 38%, P < 0.0005). They also spent fewer days in the intensive care unit (0 versus 1, P = 0.004) and had quicker return of flatus (3 versus 4 d, P = 0.03). HAL resulted in more lymph nodes resected (21 versus 15, P = 0.03) and a more adequate lymph node harvest (98% versus 77%, P = 0.01). CONCLUSIONS HAL is associated with improved operative efficiency, conversion rates, and lymphadenectomy as compared with LA colorectal cancer resections. HAL should be considered in the management of colorectal cancer patients.

Ninety-day readmission after colorectal cancer surgery in a Veterans Affairs cohort

BACKGROUND Readmissions following colorectal surgery are common. However, there are limited data examining unplanned readmissions (URs) after colorectal cancer (CRC) surgery. The goal of this study was to identify reasons and predictors of UR, and to examine their clinical impact on CRC patients. METHODS A retrospective cohort study using a prospective CRC surgery database of patients treated at a VA tertiary referral center was performed (2005-2011). Ninety-day URs were recorded and classified based on reason for readmission. Clinical impact of UR was measured using a validated classification for postoperative complications. Multivariate logistic regression analyses were performed to identify predictors of UR. RESULTS 487 patients were included; 104 (21%) required UR. Although the majority of UR were due to surgical reasons (n = 72, 69%), medical complications contributed to 25% of all readmission events. Nearly half of UR (n = 44, 40%) had significant clinical implications requiring invasive interventions, intensive care unit stays, or led to death. After multivariate logistic regression, the following independent predictors of UR were identified: African-American race (odds ratio [OR] 0.47 [0.27-0.88]), ostomy creation (OR 2.50 [1.33-4.70]), and any postoperative complication (OR 4.36 [2.48-7.68]). CONCLUSIONS Ninety-day URs following colorectal cancer surgery are common, and represent serious events associated with worse outcomes. In addition to postoperative complications, surgical details that can be anticipated (i.e., ileostomy creation) and medical events unrelated to surgery, both contribute as important and potentially preventable reasons for UR. Future studies should focus on developing and examining interventions focused at improving the process of perioperative care for this high-risk population.

Derivation and out-of-sample validation of a modeling system to predict length of surgery.

BACKGROUND We performed a retrospective study to compare the precision of a regression model (RM) system with the precision of the standard method of surgical length prediction using historical means (HM). METHODS Data were collected on patients who underwent carotid endarterectomy and lower-extremity bypass. Multiple linear regression was used to model the operative time length (OTL). The precision of the RM versus HM in predicting case length then was compared in a validation dataset. RESULTS With respect to carotid endarterectomy, surgeon, surgical experience, and cardiac surgical risk were significant predictors of OTL. For lower-extremity bypass, surgeon, use of prosthetic conduit, and performance of a sequential bypass or hybrid procedure were significant predictors of OTL. The precision of out-of-sample prediction was greater for the RM system compared with HM for both procedures. CONCLUSIONS A regression methodology to predict case length appears promising in decreasing uncertainty about surgical case length.

Impact of postoperative nadir hemoglobin and blood transfusion on outcomes after operations for atherosclerotic vascular disease

OBJECTIVE Controversy surrounds the topic of transfusion policy after noncardiac operations. This study assessed the combined impact of postoperative nadir hemoglobin (nHb) levels and blood transfusion on adverse events after open surgical intervention in patients who undergo operative intervention for atherosclerotic vascular disease. METHODS Consecutive patients who underwent peripheral arterial disease (PAD)-related operations were balanced on baseline characteristics by inverse weighting on propensity score calculated as their probability to have nHb greater than 10 gm/dL on the basis of operation type, demographics, and comorbidities, including the revised cardiac risk index. A multivariate generalized estimating equation analysis was performed to investigate associations between nHb, transfusion, and a composite outcome of perioperative death and myocardial infarction. Logistic and Cox proportional hazards regressions were used to assess the impact of nHb and transfusion on respiratory and wound complications; and a composite end point (CE) of death, myocardial infarction during a 2-year follow-up. Level of statistical significance was set at alpha of 0.0125 to adjust for the increased probability of type I error attributable to multiple comparisons. RESULTS The analysis cohort included 880 patients (1074 operations). After adjusting for nHb level, the number of units transfused was not associated with the perioperative occurrence of the CE (odds ratio [OR], 1.13; P = .025). Adjusted for the number of units transfused, nHb had no impact on the perioperative CE (OR, 0.62; P = .22). An interaction term between transfusion and nHb level remained nonsignificant (P = .312), indicating that the impact of blood transfusion was the same regardless of the nHb level. Perioperative respiratory complications were more likely in patients receiving transfusions (OR, 1.22; P = .009), and perioperative wound infections were less common in patients with nHb >10 gm/dL (OR, 0.65; P = .01). During an average follow-up of 24 months, transfused patients were more likely to develop the CE (hazard ratio [HR], 1.15, P = .009), whereas nHb level did not impact the long-term adverse event rate (HR, 0.78; P = .373). The above associations persisted even after adjusting the Cox regression model for the occurrence of perioperative cardiac events. CONCLUSIONS Although nHb less than 10 gm/dL is not associated with death or ACS after PAD-related operations, maintaining nHb greater than 10 gm/dL appears to decrease the risk of wound infection. Blood transfusion is associated with increased risk of perioperative respiratory complications. Until a randomized trial settles this issue definitively, a restrictive transfusion strategy is justified in patients undergoing operations for atherosclerotic vascular disease.

Impact of perioperative events on mortality after major vascular surgery in a veteran patient population

BACKGROUND The aim of this study was to characterize the impact of perioperative events on long-term mortality after major vascular surgery at a single institution. METHODS A retrospective analysis of patients undergoing major vascular surgery was performed. The primary end point was all-cause long-term mortality. Cox regression analyses were performed to identify predictors of this outcome. RESULTS A total of 1,182 procedures in 706 patients were identified, including endovascular or open aortic aneurysm repair, open repair of aortoiliac or infrainguinal occlusive disease, amputations, and carotid endarterectomy. Perioperative cardiac and respiratory complications occurred in 4.9% and 1.4% of operations, respectively. On multivariate Cox regression analysis, adjusting for patient factors and operation performed, perioperative cardiac (hazard ratio, 5.3; 95% confidence interval, 1.7-15.9) and respiratory complications (hazard ratio, 5.01; 95% confidence interval, 1.48-16.98) were significant predictors of long-term mortality. CONCLUSIONS Although serious perioperative cardiac and respiratory events are infrequent, they have a significant impact on long-term mortality after major vascular surgery, even when adjusted for comorbidities and type of operation.

Minimally invasive surgery in colon cancer patients leads to improved short-term outcomes and excellent oncologic results

BACKGROUND Minimally invasive surgery (MIS) techniques are beneficial compared with open techniques. There is a paucity of data of the potential advantages of MIS in colon cancer surgery for veterans. Therefore, we hypothesize that use of MIS in colon cancer resections in a Veterans Affairs Medical Center will lead to improved short-term outcomes without compromising oncologic outcomes. METHODS A retrospective analysis of a prospectively maintained database was performed. We compared surgical, short-term, and oncologic outcomes in MIS versus open surgery. RESULTS MIS patients had significantly less blood loss, surgical time, days to return of bowel function, and hospital and intensive care unit stays. Also, they had a greater and more adequate lymphadenectomy, and were less likely to experience a postoperative complication. Survival analyses showed no difference in overall and disease-free survival. CONCLUSIONS The use of MIS in colon cancer leads to improved short-term outcomes and similar oncologic outcomes when compared with open surgery.