The Log Odds of Positive Lymph Nodes Stratifies and Predicts Survival of High-Risk Individuals Among Stage III Rectal Cancer Patients.

INTRODUCTION: The log odds of positive lymph nodes (LODDS) is an empiric transform formula that incorporates positive and negative lymph node data into a single ratio for prognostic utility. We sought to determine the value of the log odds ratio as a prognostic indicator compared with established lymph node indices in advanced-stage rectal cancer patients who have undergone curative resection. METHODS: Retrospective analysis of rectal cancer operations from 1995 to 2013 identified all stage III cancer patients who underwent curative resection. Patients were stratified into three groups according to calculated lymph node ratios (LNRs) and log odds ratios (LODDS). The relationship between LNR, LODDS, and 5-year overall survival (OS) were assessed. RESULTS: OS for all patients was 81.4%. Both LNR and LODDS stratifications identified differences in 5-year OS. LODDS stratification was significantly associated with OS (p = .04). Additional significant clinicopathologic demographic variables included sex (p = .02), venous invasion (p = .02), tumor location (p < .001), and receipt of adjuvant chemotherapy (p = .047). LODDS separated survival among patients in the low LNR group (LNR1). CONCLUSION: This study confirms that the measure of lymph node involvement transformed by the log odds ratio is a suitable predictor of 5-year overall survival in stage III rectal cancer. LODDS may be applied to stratify high-risk patients in the management of adjuvant therapy. IMPLICATIONS FOR PRACTICE: Traditionally, clinicians have relied solely on the total number of positive lymph nodes affected when determining patient prognosis in rectal cancer. However, the current staging strategy does not account for "high-risk," biologically aggressive tumors that fall into the same risk categories as less clinically aggressive tumors. The log odds of positive lymph nodes is a logistic transform formula that uses pathologic lymph node data to stratify survival differences among patients within a single stage of disease. This formula allows clinicians to identify whether patients with clinically aggressive tumors fall into higher-risk groups, providing additional insight into how to better counsel patients and manage postoperative therapies.

Practicing Surgeons' Perception of Barriers to Palliative Care Delivery in British Columbia.

BACKGROUND: Utilization of palliative care remains low among surgical patients. We aim to characterize general surgeons' perceptions of barriers to access palliative care in British Columbia (BC). METHODS: Semi-structured interviews were carried out with a total of 11 surgeons in BC. Interviews were transcribed for thematic analysis via interpretive description. Dominant themes were identified and agreed upon between the authors. RESULTS: Several barriers were identified, which include system and institution, communication and surgical workflow barriers. At the system and institutional level, there were difficulties accessing patient information and continuity of care. Themes in the communication included patient misconceptions about palliative care and communication challenges with consulting services. Surgical workflow barriers influenced the overall perceived role of surgeons when caring for patients with palliative care needs. CONCLUSION: Understanding surgeons' perspectives on barriers to palliative care is an important step in changing management. This can aid in the development of strategies that ease access to palliative care.

Canadian Melanoma Conference Recommendations on High-Risk Melanoma Surveillance: A Report from the 14th Annual Canadian Melanoma Conference; Banff, Alberta; 20-22 February 2020.

Introduction: There are a lack of established guidelines for the surveillance of high-risk cutaneous melanoma patients following initial therapy. We describe a novel approach to the development of a national expert recommendation statement on high-risk melanoma surveillance (HRS). Methods: A consensus-based, live, online voting process was undertaken at the 13th and 14th annual Canadian Melanoma Conferences (CMC) to collect expert opinions relating to "who, what, where, and when" HRS should be conducted. Initial opinions were gathered via audience participation software and used as the basis for a second iterative questionnaire distributed online to attendees from the 13th CMC and to identified melanoma specialists from across Canada. A third questionnaire was disseminated in a similar fashion to conduct a final vote on HRS that could be implemented. Results: The majority of respondents from the first two iterative surveys agreed on stages IIB to IV as high risk. Surveillance should be conducted by an appropriate specialist, irrespective of association to a cancer centre. Frequency and modality of surveillance favoured biannual visits and Positron Emission Tomography Computed Tomography (PET/CT) with brain magnetic resonance imaging (MRI) among the systemic imaging modalities available. No consensus was initially reached regarding the frequency of systemic imaging and ultrasound of nodal basins (US). The third iterative survey resolved major areas of disagreement. A 5-year surveillance schedule was voted on with 92% of conference members in agreement. Conclusion: This final recommendation was established following 92% overall agreement among the 2020 CMC attendees.

Barriers to palliative care use among surgical patients: perspectives of practicing surgeons across Michigan.

BACKGROUND: Despite the clear benefits of palliative care, surgical patients are less likely to receive palliative care consultations when compared to their medical counterparts. In this context, we conducted semi-structured interviews with a diverse range of practicing surgeons to better understand surgeon attitudes and experiences with both palliative care approaches and specialty services. METHODS: Forty-six surgeons from community, tertiary-care, and academic institutions across the state of Michigan agreed to participate in this study. Each participant's interview lasted between 30 and 60 minutes and was digitally recorded. Audiotapes were transcribed verbatim and de-identified for names and places. The data were analyzed through iterative steps informed by thematic analysis. RESULTS: Six major themes emerged describing surgeon-reported barriers to palliative care approaches and use of palliative care services, which were observed at the surgeon-level, patient and family-level, and system-level. At the surgeon-level, the following three major themes emerged: surgeon knowledge and attitudes, prognostication challenges, and surgeon identity. At the patient and family-level, two major themes were identified: expectations and discordance. At the system-level, two major themes emerged: culture and resources. CONCLUSIONS: Among our cohort of surgeons, several key factors influenced their use of palliative approaches and specialty palliative care services. A better understanding of surgeon-perceived barriers may lead to future work aimed at creating meaningful, surgeon-specific interventions that address the underuse of this important care for surgical patients and patients being considered for surgery.

Surgery Residents' Experiences With Seriously-Ill and Dying Patients: An Opportunity to Improve Palliative and End-of-Life Care.

OBJECTIVE: To describe how and when surgery residents provided primary palliative care and engaged specialty palliative care services. DESIGN: Phase I consisted of a previously validated survey instrument supplemented with additional questions. We then conducted semistructured interviews with a subset of the survey respondents (Phase II). Using thematic analysis, we characterized surgery residents' perceptions of palliative care delivery among surgical patients. SETTING: General surgery residency programs across the state of Michigan. PARTICIPANTS: General surgery residents across the state of Michigan. All residents in participating programs were invited to complete the survey in Phase I. Phase II consisted of a subset of the survey respondents who underwent semistructured interviews. Interview respondents were sampled to reflect the overall surveyed group. RESULTS: Among 119 survey respondents (response rate 70%), all had encountered a palliative care specialist but only 58.8% had been taught when to consult or to refer to palliative care. Survey respondents reported on a multitude of barriers within the clinician, patient and family, and systemic domains. Interviews expanded on survey findings and 4 influential factors of palliative care delivery emerged: (1) Resident Education and Training; (2) Resident Attitudes Toward Palliative Care; (3) Knowledge of Palliative Care; and (4) Training within a Surgical Culture. CONCLUSIONS: This study reveals how surgery resident training and experiences impact palliative and end-of-life care for surgical patients at teaching institutions. Knowledge of how and when residents are providing primary palliative care and engaging with palliative care services will inform future knowledge and behavioral interventions for trainees who often provide care for patients nearing the end of life.

Autoimmune Diseases of the Biliary Tract: A Review.

The management of autoimmune hepatobiliary disorders remains a challenging and emerging area of investigation. An awareness of cholestatic liver diseases is critical to appropriate recognition and management of these challenging diseases, because patients often present asymptomatically, and diagnosis is limited by the lack of disease-specific markers and diagnostic studies. Furthermore, there is a paucity of treatment options because the pathophysiology underlying autoimmune biliary diseases remains largely unknown. This article discusses the natural history, clinical presentation, diagnosis, and medical and surgical management strategies for three dominant autoimmune biliary diseases: primary biliary cirrhosis, primary sclerosing cholangitis, and immunoglobulin G4-related hepatobiliary disease.

Delays in Palliative Care Referral Among Surgical Patients: Perspectives of Surgical Residents Across the State of Michigan.

CONTEXT: Palliative care services (PCS) are underutilized and frequently delayed among surgical patients. Surgical residents often serve at the forefront for patient issues, including conducting conversations regarding prognosis and goals of care. OBJECTIVES: This qualitative study identifies critical barriers to palliative care referral among seriously ill surgical patients from the perspective of surgical residents. METHODS: We conducted semistructured interviews with surgical residents (n = 18) across the state of Michigan, which focused on experiences with seriously ill surgical patients and PCS. Inductive thematic analysis was used to establish themes based on the research objectives and data collected. RESULTS: Four dominant themes of resident-perceived barriers to palliative care referral were identified: 1) challenges with prognostication, 2) communication barriers, 3) respect for the surgical hierarchy, and 4) surgeon mentality. Residents consistently expressed challenges in predicting patient outcomes, and verbalizing this to both attendings and families augmented this uncertainty in seeking PCS. Communicative challenges included managing discordant provider opinions and the stigma associated with PCS. Finally, residents perceived that an attending surgeon's decisive authority and mentality negatively influenced the delivery of PCS. CONCLUSIONS: Among resident trainees, unpredictable patient outcomes led to uncertainty in the timing and appropriateness of palliative care referral and further complicated communicating plans of care. Residents perceived and relied on the attending surgeon as the ultimate decision maker, wherein the surgeon's sense of responsibility to the patient was identified as a significant barrier to PCS referral. Further studies are needed to test surgeon-specific interventions to improve access to and delivery of PCS.

Surgeon Perspectives Regarding Death and Dying.

BACKGROUND: Surgical patients most commonly receive palliative care services within 24-48 hours of death, and reasons for this delay are poorly understood. Research with nonsurgeons suggests that physician characteristics and beliefs about death and dying may contribute to late referral. OBJECTIVE: To describe surgeon perspectives related to death and dying, and their relationship with delayed referrals to palliative care. DESIGN: Using a previously validated survey instrument supplemented by open-ended questions, deductive content analysis was used to describe surgeon preferences for end-of-life care. SETTINGS: Participants were all current nonretired members of the American Society of Colon and Rectal Surgeons. MAIN OUTCOME MEASURES: Surgeon descriptions of a "good death" and how personal experiences influence care provided. RESULTS: Among 131 survey respondents (response rate 16.5%), 117 (89.3%) completed all or part of the qualitative portion of the survey. Respondents consistently reported their personal preferences for end-of-life care, and four central themes emerged: (1) pain and symptom management, (2) clear decision making, (3) avoidance of medical care, and (4) completion. Surgeons also reflected on both good and bad experiences with patients and family members dying, and how these experiences impact practice. LIMITATIONS: The small sample size inherent to Internet surveys may limit generalizability and contribute to selection bias. CONCLUSION: This study reveals surgeon preferences for end-of-life care, which may inform initiatives aimed at surgeons who may underuse or delay palliative care services. Future studies are needed to better understand how surgeon preferences may directly impact treatment recommendations for their patients.

Efficacy of Intravenous Acetaminophen in Length of Stay and Postoperative Pain Control in Laparoscopic Roux-en-Y Gastric Bypass Surgery Patients.

Background: Opiate-based pain medications may incur adverse effects following bariatric surgery. The aim of this study was to evaluate the efficacy of intravenous Acetaminophen (IVAPAP) on length of stay (LOS) after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. Methods: This was a prospective, double-blind, randomized controlled trial conducted from October 2011 to March 2014 at a 416-bed teaching hospital. Eighty-nine total patients were included (control group, n = 45; treatment group, n = 44). Patients were administered either 1000 mg of IVAPAP or placebo every 6 h beginning preoperatively and continuing for four doses. LOS, total narcotic consumption, pain and nausea scores, time to return of flatus (ROF), and postoperative rescue pain medication used were measured during the first 24 h after surgery. Results: LOS was significantly decreased in the treatment group compared with control (2.72 days vs. 3.18 days; p = 0.03). There was significant reduction in time to ROF (1.87 days vs. 2.24 days; p = 0.04). Pain was significantly decreased in the first 2 postoperative hours in the treatment group (p = 0.02). Total opioid consumption, postoperative nausea scores, and use of rescue pain medications were not affected. Conclusions: The use of IVAPAP significantly decreases LOS following LRYGB, improves acute postoperative pain control, and mediates quicker return of bowel function.

A Pediatric Burn Outpatient Short Stay Program Decreases Patient Length of Stay With Equivalent Burn Outcomes.

Traditionally, small pediatric burns are managed with inpatient admission and daily dressing changes. In 2011, our burn center implemented an outpatient short stay (OSS) program in which small pediatric burns were managed as an outpatient utilizing Mepilex AgTM dressings changed under moderate sedation every 5 to 7 days. Pediatric burn cases were queried for 2 time periods: before the OSS program (2009-2010) and after the OSS program (2013-2014). Burns > 15% total body surface area (TBSA), children with polytrauma, and children > 10 years old were excluded. Independent t tests and chi-square tests were conducted to analyze differences in patient demographics, burn management, and burn outcomes between these groups. Two hundred nineteen cases were included in the analysis (77 pre-OSS and 142 post-OSS). There was no difference in patient age (P = 0.872) or TBSA (P = 0.786) between the groups. The post-OSS group had shorter inpatient length of stay (2.93 days vs 5.21 days; P < 0.001) and fewer dressing changes (2.32 vs 4.71; P < 0.001). There were no changes in readmission rates (P = 0.375) or burns requiring grafting (P = 0.155). Although not reaching statistical significance, less children in the post-OSS group had infectious complications (P = 0.054) or required reoperation in a 2-year follow-up period (P = 0.081). Patient and family satisfaction with the program was high. Children treated after the implementation of an OSS burn program at the University of Wisconsin had decreased inpatient length of stay and fewer painful burn dressing changes. These patients exhibited equivalent, if not superior burn outcomes.

Minimally Invasive Resection of Adrenocortical Carcinoma: a Multi-Institutional Study of 201 Patients.

BACKGROUND AND OBJECTIVES: Minimally invasive surgery for adrenocortical carcinoma (ACC) is controversial. We sought to evaluate the perioperative and long-term outcomes following minimally invasive (MIS) and open resection (OA) of ACC in patients treated with curative intent surgery. METHODS: Retrospective data from patients who underwent adrenalectomy for primary ACC at 13 tertiary care cancer centers were analyzed, including demographics, clinicopathological, and operative outcomes. Outcomes following MIS were compared to OA. RESULTS: A total of 201 patients were evaluated including 47 MIS and 154 OA. There was no difference in utilization of MIS approach among institutions (p = 0.24) or 30-day morbidity (29.3 %, MIS, vs. 30.9 %, OA; p = 0.839). The only preoperatively determined predictor for MIS was smaller tumor size (p < 0.001). There was no difference in rates of intraoperative tumor rupture (p = 0.612) or R0 resection (p = 0.953). Only EBL (p = 0.038) and T stage (p = 0.045) were independent prognostic indicators of overall survival after adjusting for significant factors. The surgical approach was not associated with overall or disease-free survival. CONCLUSION: MIS adrenalectomy may be utilized for preoperatively determined ACC ≤ 10.0 cm; however, OA should be utilized for adrenal masses with either preoperative or intraoperative evidence of local invasion or enlarged lymph nodes, regardless of size.

Low drain fluid amylase predicts absence of pancreatic fistula following pancreatectomy.

INTRODUCTION: Improvements in the ability to predict pancreatic fistula could enhance patient outcomes. Previous studies demonstrate that drain fluid amylase on postoperative day 1 (DFA1) is predictive of pancreatic fistula. We sought to assess the accuracy of DFA1 and to identify a reliable DFA1 threshold under which pancreatic fistula is ruled out. METHODS: Patients undergoing pancreatic resection from November 1, 2011 to December 31, 2012 were selected from the American College of Surgeons-National Surgical Quality Improvement Program Pancreatectomy Demonstration Project database. Pancreatic fistula was defined as drainage of amylase-rich fluid with drain continuation >7 days, percutaneous drainage, or reoperation for a pancreatic fluid collection. Univariate and multi-variable regression models were utilized to identify factors predictive of pancreatic fistula. RESULTS: DFA1 was recorded in 536 of 2,805 patients who underwent pancreatic resection, including pancreaticoduodenectomy (n = 380), distal pancreatectomy (n = 140), and enucleation (n = 16). Pancreatic fistula occurred in 92/536 (17.2%) patients. DFA1, increased body mass index, small pancreatic duct size, and soft texture were associated with fistula (p < 0.05). A DFA1 cutoff value of <90 U/L demonstrated the highest negative predictive value of 98.2%. Receiver operating characteristic (ROC) curve confirmed the predictive relationship of DFA1 and pancreatic fistula. CONCLUSION: Low DFA1 predicts the absence of a pancreatic fistula. In patients with DFA1 < 90 U/L, early drain removal is advisable.