Trends in the surgical treatment of ulcerative colitis over time: increased mortality and centralization of care.

BACKGROUND: New medical therapies available to ulcerative colitis (UC) patients have influenced operative mortality for patients requiring colectomy. We sought to examine trends in treatment and outcome for UC patients treated surgically. METHODS: A review of 36,447 UC patients from the Nationwide Inpatient Sample was performed, comparing the pre-monoclonal antibody era (1990-1996) to the present-day era (2000-2006). Patients treated with total colectomy with ileostomy or proctocolectomy with ileal pouch were reviewed for outcome measures and practice setting (rural, urban non-teaching, urban teaching). Our main outcome measures were in-hospital mortality, length of stay, and total charges. RESULTS: Total colectomy (n = 30,362) was performed five times more often than proctocolectomy (n = 6,085). When comparing the two study periods, mortality after total colectomy increased 3.8% to 4.6% (p = 0.0003). This difference was primarily due to increasing mortality in later years; when 1995-1996 was compared to 2005-2006, mortality increased from 3.6% to 5.6% (p < 0.0001). There were no deaths in the proctocolectomy group (p < 0.0001). The distribution by practice setting shifted over the two study periods, decreasing in rural (7.0% to 4.8%) and urban non-teaching (43.7% to 28.4%) centers, and increasing in urban teaching centers (49.3% to 66.8%). The total inflation-adjusted charges per patient increased significantly ($34,638 vs. $43,621; p < 0.0001). CONCLUSIONS: The mortality rate after total colectomy is increasing, and the difference is accentuated in the years since widespread use of monoclonal antibody therapy. The care of these patients is being shifted to urban teaching centers and is becoming more expensive.

Surgical treatment of intrahepatic cholangiocarcinoma: outcomes and predictive factors.

BACKGROUND: Intrahepatic cholangiocarcinoma (ICC) remains a rare tumour, although its incidence is increasing. Surgical resection is the mainstay of treatment. Published data regarding prognostic factors and optimal patient selection for resection are scant. We sought to determine the clinicopathologic characteristics of resectable ICC and outcomes following surgical treatment. METHODS: We reviewed prospectively collected clinical data including patient, pathologic and operative details. Survival and recurrence outcomes were analysed using Cox hazard models and the Kaplan-Meier method. RESULTS: We identified 31 surgically treated patients. Their 3-year overall survival rate (OS) was 40.1%; median follow-up was 16.2 months (range: 0.2-86.9 months). R0 resection was associated with significantly improved OS compared with R1/R2 resection (3-year OS was 68.6% in R0 vs. 24.0% in R1/R2; P= 0.042). The postoperative complication rate was 58.1%. Two patients died of postoperative liver failure within 30 days. Preoperative hypoalbuminaemia was significantly associated with worse survival. CONCLUSIONS: Surgical therapy for ICC is associated with longterm survival in the subset of nutritionally replete patients in whom an R0 resection can be achieved. Surgical mortality is significant in patients undergoing extended resection. The margin involvement rate is high and surgeons should consider the infiltrative nature of the disease in operative planning.

Case log review produces translational change in surgical oncology education.

BACKGROUND: The recently mandated reduction in surgical resident work hours led to concerns that surgical cancer education would suffer, as measured by cancer case exposure. METHODS: Final operative logs submitted to the American Board of Surgery by chief residents graduating from our program were compared for 2 time periods: prior to the mandate (2002-2003) and after (2006-2007). RESULTS: Case logs from graduating residents (n = 36) showed a nonsignificant decrease in cancer as the percentage of total major cases, due to an actual increase in total major cases. Conversely, endoscopy and minor cancer case experience both decreased. CONCLUSIONS: Exposure to minor cancer cases and endoscopies has decreased; this has led to a requirment for a minimum number of endoscopies/graduating resident, and to strategies for increasing exposure to minor cancer cases.

Nadir Hematocrit on Bypass and Rates of Acute Kidney Injury: Does Sex Matter?

BACKGROUND: Reports have associated nadir hematocrit (Hct) on cardiopulmonary bypass with the occurrence of renal dysfunction. Recent literature has suggested that women, although more often exposed to lower nadir Hct, have a lower risk of postoperative renal dysfunction. We assessed whether this relationship held across a large multicenter registry. METHODS: We undertook a prospective, observational study of 15,221 nondialysis-dependent patients (10,376 male, 68.2%; 4,845 female, 31.8%) undergoing cardiac surgery between 2010 and 2014 across 26 institutions in Michigan. We calculated crude and adjusted OR between nadir Hct during cardiopulmonary bypass and stage 2 or 3 acute kidney injury (AKI), and tested the interaction of sex and nadir Hct. The predicted probability of AKI was plotted separately for men and women. RESULTS: Nadir Hct less than 21% occurred among 16.6% of patients, although less commonly among men (9.5%) than women (31.9%; p < 0.001). Acute kidney injury occurred among 2.7% of patients, with small absolute differences between men and women (2.6% versus 3.0%, p = 0.20). There was a significant interaction between sex and nadir Hct (p = 0.009). The effect of nadir Hct on AKI was stronger among male patients (adjusted odds ratio per 1 unit decrease in nadir Hct 1.10, 95% confidence interval: 1.05 to 1.13) than female patients (adjusted odds ratio 1.01, 95% CI: 0.96, 1.06). CONCLUSIONS: Lower nadir Hct was associated with an increased risk of AKI, and the effect appears to be stronger among men than women. Understanding of the mechanism underlying this association remains uncertain, although these results suggest the need to limit exposure to lower nadir Hct, especially for male patients.

Sentinel lymph node biopsy for melanoma: comparison of lymphocele rates by surgical technique.

Lymphocele is a common wound complication of sentinel lymph node biopsy (SLNB). The surgical technique may play a key role in lymphocele formation. This study compared rates of postoperative lymphocele formation by different surgical techniques (Harmonic Scalpel [HS], LigaSure [LS], and traditional electrocautery with clips) after SLNB in the groin or axilla for the staging of clinically node-negative cutaneous melanoma. Patients were selected by convenience sample from a single-institution, single-surgeon, prospectively collected melanoma database over a 27-month period. One hundred fifty consecutive patients underwent SLNB, 70 with clips, 37 with HS, and 43 with LS. The median number of nodes removed was two and did not vary significantly between groups. Twenty-three lymphoceles occurred for an overall rate of 15 per cent; rates were 9.9 and 26.5 per cent for the axilla and groin, respectively. Sixteen (70%) were aspirated for size or symptoms; lymphoceles after groin SLNB were significantly (P = 0.03) more likely to require aspiration. Lymphocele rates for the clip, HS, and LS groups were 20.0, 18.9, and 4.7 per cent, respectively. The differences between the LS and other groups were statistically significant. Use of the LS may lead to lower lymphocele rates after groin and axillary SLNB compared with electrocautery and clips.

Impact of American College of Surgeons Oncology Group Z0011 and National Surgical Adjuvant Breast and Bowel Project B-32 trial results on surgeon practice in the Pacific Northwest.

BACKGROUND: Recent clinical trials have suggested no survival benefit for completion axillary node dissection (CALND) after sentinel lymph node biopsy (American College of Surgeons Oncology Group Z0011) and no clinically meaningful benefit for the routine use of immunohistochemistry (National Surgical Adjuvant Breast and Bowel Project B-32) in clinically node-negative breast cancer. METHODS: A 12-question electronic survey was distributed to members of 3 Pacific Northwest surgical societies. Surgeons were queried regarding the impact of the trial results on their surgical management of breast cancer. RESULTS: The 181 respondents reported performing fewer CALNDs (63%), fewer intraoperative frozen sections (21%), and no immunohistochemistry (12%) because of trial data. However, 28% of surgeons continued to perform CALND in patients with 1 to 2 positive sentinel lymph nodes undergoing lumpectomy and postoperative radiation. CONCLUSIONS: Recent trial data have impacted the performance of CALNDs and the pathological evaluation of sentinel lymph nodes among Pacific Northwest surgeons. Our results suggest a need for regional surgical societies to disseminate practice-changing trial data to members.

Trends in research time, fellowship training, and practice patterns among general surgery graduates.

SUMMARY: A comparison of research experience, fellowship training, and ultimate practice patterns of general surgery graduates at a university-based surgical residency program. Research experience correlated with pursuing fellowship training and predicted an eventual academic career. More recently, graduates have been able to obtain fellowships without a dedicated research year, perhaps reflecting shifting fellowship training opportunities. BACKGROUND: We hypothesized that the relationships among dedicated research experience during residency, fellowship training, and career choices is changing as research and fellowship opportunities evolve. METHODS: Comparison of research experience, fellowship training, and ultimate practice patterns of general surgery graduates for 2 decades (1990-1999, n = 82; 2000-2009, n = 98) at a university-based residency program. Main outcome measures were number of years and area of research, fellowship training, and practice setting. RESULTS: Compared by decade, graduates became increasingly fellowship-trained (51.2% vs 67.3%; p < 0.05) and pursuit of fellowship training increased for both research and nonresearch participating graduates. The number of residents completing more than 1 year of research doubled (9.8% vs 22.4%, p < 0.05). By decade, the percentage of female graduates increased significantly (22% vs 41%, p = 0.005), with more women participating in dedicated research (17% vs 51%, p < 0.001) and seeking fellowships. The number of graduates going into specialty practice and academic/clinical faculty positions increased over time. CONCLUSIONS: Surgical residents have completed more dedicated research years and became increasingly fellowship-trained over time. The proportion of female graduates has increased with similar increases in research time and fellowship training in this subgroup. In the earlier decade, dedicated research experiences during surgical residency correlated with pursuing fellowship training, and predicted an eventual academic career. More recently, graduates have obtained fellowships and academic positions without dedicated research time, perhaps reflecting shifting fellowship opportunities.

Intraoperative oncologic staging and outcomes for lung cancer resection vary by surgeon specialty.

BACKGROUND: In the United States the majority of lung cancer resections are performed by general surgeons, although surgeons specializing in thoracic surgery have demonstrated superior perioperative and long-term oncologic outcomes. Why these differences exist has not been well studied. We hypothesized that the completeness of intraoperative oncologic staging may explain some of these differences. METHODS: The Nationwide Inpatient Sample (NIS) database was used to review 222,233 patients with primary lung cancer treated surgically with wedge resection, segmentectomy, lobectomy, or pneumonectomy from 1998 to 2007. Surgeons were classified as general thoracic surgeons if they performed greater than 75% general thoracic operations and less than 10% cardiac operations; they were classified as cardiac surgeons if they performed greater than 10% cardiac operations; they were classified as general surgeons if they performed less than 75% thoracic operations and less than 10% cardiac operations. The main outcome measure was the performance of lymphadenectomy or mediastinoscopy during the same admission as the cancer resection. RESULTS: The overall lymphadenectomy rate was 56% (n = 125,115) and was highest for general thoracic surgeons at 73% (n = 13,313), followed by 55% (n = 65,453) for general surgeons, and 54% (n = 46,349) for cardiac surgeons (p < 0.0001). General surgeons had a significantly higher risk for in-hospital mortality (odds ratio [OR], 1.47; confidence interval [CI], 1.14 to 1.90; p = 0.003) and postoperative complications (OR, 1.17; CI, 1.00 to 1.36; p = 0.043) compared with general thoracic surgeons. CONCLUSIONS: Surgeon specialty impacts the adequacy of oncologic staging in patients undergoing resection for primary lung cancer. Specifically, general thoracic surgeons performed intraoperative oncologic staging significantly more often than did their general surgeon and cardiac surgeon counterparts while achieving significantly lower in-hospital mortality and complication rates.

Comparison of pulmonary nodule detection rates between preoperative CT imaging and intraoperative lung palpation.

BACKGROUND: Recent advances in computed tomographic (CT) imaging have improved the detection rate of pulmonary metastasis. The aim of this study was to test the hypothesis that the pulmonary nodule detection rate for preoperative CT imaging and intraoperative palpation are now equivalent. METHODS: A retrospective review of 108 pulmonary metastasectomies in 84 patients was performed. The number of nodules detected on preoperative CT imaging by radiologist report was compared with the number of malignant nodules identified on pathology. Secondary outcome measures were operative approach and primary malignancy. RESULTS: Sarcoma metastases were the most common indication for resection (n = 54 [50%]). Thirty-three percent of metastasectomies were performed using a thoracoscopic approach. When thoracotomy was used, significantly more nodules were palpated and resected than were identified on preoperative CT imaging (3.24 vs 2.12, P < .001). Significantly more of these nodules were confirmed malignant on final pathology (2.40 vs 1.60, P = .01). This difference was not seen for thoracoscopic resections. CONCLUSIONS: Although the sensitivity of CT imaging has improved, a significant number of malignant pulmonary nodules are detected intraoperatively that are not identified on preoperative imaging. Patients undergoing pulmonary metastasectomy require careful intraoperative palpation of lung parenchyma, and therefore open thoracotomy remains the standard of care.

Sentinel lymph node staging of cutaneous melanoma: predictors and outcomes.

BACKGROUND: The authors updated their experience with sentinel lymph node (SLN) biopsy of clinically node negative (N0) melanoma to clarify indications, predictive factors, and outcomes. METHODS: A review of patients from the authors' institution's prospective database (n = 397) was performed; survival statistics were obtained from the institutional tumor registry. RESULTS: The SLN-positive (SLN+) rate was 16% (47 of 282) for lesions >1 mm thick; only 2 of 105 T1 lesions were SLN+. Thickness >2 mm, upper extremity primary, and ulceration predicted SLN+ status. Most SLN+ patients underwent completion node dissection; 12% had additional positive nodes. The false-negative SLN biopsy rate was 4.0%; the majority involved lower extremity and head and neck primaries. The overall complication rate was 26%; all were minor and resolved within 6 months. Overall 5-year survival rates were 73% and 92% for SLN+ and SLN-negative patients, respectively. SLN status was the most significant predictor of survival. CONCLUSIONS: SLN status, the most important determinant of outcome for clinically N0 melanoma, correlated with T stage, ulceration, and site. Staging of T1 lesions had low yield. A minority of completion node dissections yielded additional positive nodes.

Gastric malignancies in breast cancer survivors: pathology and outcomes.

BACKGROUND: As the number of breast cancer survivors increases, the appearance of second malignancies and unusual metastatic patterns likely also is increasing. In particular, we and others have observed gastric malignancies in breast cancer survivors. METHODS: We reviewed 3 regional hospital system tumor databases, comprising 19,049 analytic breast cancer cases, to determine the number, types, and outcomes of subsequent gastric malignancies. RESULTS: Twenty-eight patients developed subsequent gastric malignancies, representing .15% of breast cancer survivors; 82% of patients had gastric symptoms. Overall survival for the cohort was 39%. Twenty-four patients (86%) had gastric primaries and 13 died of their second cancers. Four patients had gastric metastases; all had lobular histology in both their primary tumors and metastatic lesions. Five patients had gastrointestinal stromal tumors; all patients underwent resection and currently are alive. CONCLUSION: Gastric symptoms in breast cancer survivors may represent malignant lesions, often second primaries. All gastric metastases in our series were of lobular histology.