RESUMO
BACKGROUND: Palliative decompressive gastrostomy tubes are intended to relieve the severe physical symptoms of malignant small bowel obstruction (SBO) near the end of life. The objective of this study was to assess the impact of palliative decompressive gastrostomy tube on patient and caregiver well-being. PATIENTS AND METHODS: We prospectively enrolled patients with a malignant SBO and their caregivers at the time of informed consent for decompressive gastrostomy tube placement. We collected the Edmonton Symptom Assessment Scale (ESAS) and the Functional Assessment of Chronic Illness Therapy-Palliative (FACIT-Pal-14) surveys from patients at baseline and at 2-week post-procedure follow-up. The Caregiver Burden Scale survey was administered to caregivers at baseline. Survey scores were compared using paired t-tests. We also conducted semistructured interviews with patients and their caregivers at two-week follow-up until thematic saturation was reached. Content analysis was used to identify themes with two independent coders. RESULTS: We enrolled 15 patient-caregiver dyads. Preprocedure, the median caregiver burden scale score was 37.5 (significant burden ≥ 21). Eight patients (53%) survived to 2 weeks; among these patients, median ESAS scores (51 versus 43.5, p < 0.001) and median FACIT-Pal-14 scores (22 versus 32, p = 0.015) were significantly improved at 2-week follow-up. Interviews revealed three major themes: improved symptom management, new stressors, and opportunities for better education and resources. CONCLUSIONS: Decompressive gastrostomy tubes effectively alleviated symptoms in patients with inoperable malignant SBOs. This palliative intervention may provide greater benefit if performed earlier, and caregivers and patients need improved resources and education for tube management to minimize added stressors.
RESUMO
Importance: Adverse patient events are inevitable in surgical practice. Objectives: To characterize the impact of adverse patient events on surgeons and trainees, identify coping mechanisms, and assess whether current forms of support are sufficient. Design, Setting, and Participants: In this mixed-methods study, a validated survey instrument was adapted and distributed to surgical trainees from 7 programs, and qualitative interviews were conducted with faculty from 4 surgical departments in an urban academic health system. Main Outcomes and Measures: The personal impact of adverse patient events, current coping mechanisms, and desired forms of support. Results: Of 216 invited trainees, 93 (43.1%) completed the survey (49 [52.7%] male; 60 [64.5%] in third postgraduate year or higher; 23 [24.7%] Asian or Pacific Islander, 6 [6.5%] Black, 51 [54.8%] White, and 8 [8.6%] other race; 13 [14.0%] Hispanic or Latinx ethnicity). Twenty-three of 29 (79.3%) invited faculty completed interviews (13 [56.5%] male; median [IQR] years in practice, 11.0 [7.5-20.0]). Of the trainees, 77 (82.8%) endorsed involvement in at least 1 recent adverse event. Most reported embarrassment (67 of 79 trainees [84.8%]), rumination (64 of 78 trainees [82.1%]), and fear of attempting future procedures (51 of 78 trainees [65.4%]); 28 of 78 trainees (35.9%) had considered quitting. Female trainees and trainees who identified as having a race and/or ethnicity other than non-Hispanic White consistently reported more negative consequences compared with male and White trainees. The most desired form of support was the opportunity to discuss the incident with an attending physician (76 of 78 respondents [97.4%]). Similarly, faculty described feelings of guilt and shame, loss of confidence, and distraction after adverse events. Most described the utility of confiding in peers and senior colleagues, although some expressed unwillingness to reach out. Several suggested designating a departmental point person for event debriefing. Conclusions and Relevance: In this mixed-methods study of the personal impact of adverse events on surgeons and trainees, these events were nearly universally experienced and caused significant distress. Providing formal support mechanisms for both surgical trainees and faculty may decrease stigma and restore confidence, particularly for underrepresented groups.
Assuntos
Cirurgiões , Humanos , Masculino , Feminino , Cirurgiões/psicologia , Cirurgiões/educação , Adulto , Adaptação Psicológica , Erros Médicos/psicologia , Erros Médicos/estatística & dados numéricos , Internato e Residência , Inquéritos e Questionários , Cirurgia Geral/educaçãoRESUMO
BACKGROUND: This study assessed the relationship between surgeon volume, operative management, and resource utilization in adrenalectomy. METHODS: Isolated adrenalectomies performed within our health system were identified (2016-2021). High-volume surgeons were defined as those performing ≥6 cases/year. Outcomes included indication for surgery, perioperative outcomes, and costs. RESULTS: Of 476 adrenalectomies, high-volume surgeons (n â= â3) performed 394, while low-volume surgeons (n â= â12) performed 82. High-volume surgeons more frequently operated for pheochromocytoma (19% vs. 16%, p â< â0.001) and less frequently for metastasis (6.4% vs. 23%, p â< â0.001), more frequently used laparoscopy (95% vs. 80%, p â< â0.001), and had lower operative supply costs ($1387 vs. $1,636, p â= â0.037). Additionally, laparoscopic adrenalectomy was associated with shorter length of stay (-3.43 days, p â< â0.001), lower hospitalization costs (-$72,417, p â< â0.001), and increased likelihood of discharge to home (OR 17.03, p â= â0.008). CONCLUSIONS: High-volume surgeons more often resect primary adrenal pathology and utilize laparoscopy. Laparoscopic adrenalectomy is, in turn, associated with decreased healthcare resource utilization.
Assuntos
Neoplasias das Glândulas Suprarrenais , Laparoscopia , Feocromocitoma , Cirurgiões , Humanos , Adrenalectomia , Neoplasias das Glândulas Suprarrenais/cirurgia , Neoplasias das Glândulas Suprarrenais/patologia , Feocromocitoma/cirurgia , Hospitalização , Tempo de Internação , Estudos RetrospectivosRESUMO
BACKGROUND: Disparities have been previously described in the presentation, management, and outcomes of other thyroid cancer subtypes; however, it is unclear whether such disparities exist in anaplastic thyroid cancer (ATC). METHODS: We identified patients with ATC from the National Cancer Database (2004-2020). The primary outcomes were receipt of surgery, chemotherapy, and radiation. The secondary outcome was 1-year survival. Multivariable logistic and Cox proportional hazards regressions were used to assess the associations between sex, race/ethnicity, and the outcomes. RESULTS: Among 5359 patients included, 58% were female, and 80% were non-Hispanic white. Median tumor size was larger in males than females (6.5 vs. 6.0 cm; p < 0.001) and in patients with minority race/ethnicity than in white patients (6.5 vs. 6.0 cm; p < 0.001). After controlling for tumor size and metastatic disease, female patients were more likely to undergo surgical resection (odds ratio [OR]: 1.20; p = 0.016) but less likely to undergo chemotherapy (OR: 0.72; p < 0.001) and radiation (OR: 0.76; p < 0.001) compared with males. Additionally, patients from minority racial/ethnic backgrounds were less likely to undergo chemotherapy (OR: 0.69; p < 0.001) and radiation (OR: 0.71; p < 0.001) than white patients. Overall, unadjusted, 1-year survival was 23%, with differences in treatment receipt accounting for small but significant differences in survival between groups. CONCLUSIONS: There are disparities in the presentation and treatment of ATC by sex and race/ethnicity that likely reflect differences in access to care as well as patient and provider preferences. While survival is similarly poor across groups, the changing landscape of treatments for ATC warrants efforts to address the potential for exacerbation of disparities.