Impact of Body Mass Index ≥35 kg/m2 on Minimally Invasive Adrenalectomy.

Introduction: Obesity is associated with numerous chronic conditions and an increased risk for surgical complications. Laparoscopic and robotic adrenalectomy have proven effective in the resection of adrenal tumors. This study analyzes the outcomes of severely obese patients (body-mass index [BMI] ≥35 kg/m2) following minimally invasive adrenalectomy. Materials and Methods: A retrospective analysis of patients who underwent minimally invasive adrenalectomy at our institution between 2010 and 2023 was conducted. Two matching analyses were performed. The first analysis compared patients with BMI greater versus lower than 35 kg/m2. The second analysis compared outcomes between robotic and laparoscopic adrenalectomy in patients with a BMI ≥35 kg/m2. Results: A total of 278 patients were included in the study. The median tumor size was 29 mm. Adrenal tumors had similar laterality, and most were hormonally active (66.2%). The most common pathological diagnosis was pheochromocytoma (25.5%). No statistical difference was found in peri- and postoperative outcomes between patients with BMI ≥35 and <35 kg/m2 who underwent minimally invasive adrenalectomy. When the surgical approach was compared in severely obese patients, robotic adrenalectomy was associated with shorter hospital length of stay with similar operative time as the laparoscopic approach. Conclusions: Minimally invasive adrenalectomy is safe and feasible in patients with BMI ≥35 kg/m2. Robotic and laparoscopic approaches are both safe and efficient for the resection of adrenal tumors in severely obese patients.

A narrative review of prognostic indices in the evaluation of gastrointestinal cancers.

Background and Objective: Accurate cancer prognostication allows for conscious decision-making. There is a need for precise indices, along with predictive biomarkers, which aid cancer prognostication. We sought to conduct an overview of the current state of prognostic indices and biomarkers in the evaluation of gastrointestinal (GI) cancers, specifically esophageal, colon and rectal. Methods: We conducted a comprehensive review of articles in the PubMed database between September 2001 and February 2022. Only articles written in English were included. We reviewed retrospective analyses and prospective observational studies. Key Content and Findings: Nomograms are well-described tools that provide estimates of specific cancer-related events, such as overall survival (OS). They are also useful in unroofing specific patient-related variables, which may be associated with cancer survival. Certain prognostic indices have been tested against each other with the goal of discerning superiority. Finally, specific biomarkers have emerged as promising prognostic indicators. Conclusions: Nomograms play a significant role in the prognostication of GI cancer. The identification of specific biomarkers in cancer prognostication is evolving. As we embark on the era of precision medicine, further investigation of reliable prognostic indices and biomarkers is needed.

Association of Medical Appointment Cancellation Rates on Survival After Esophagectomy for Esophageal Cancer.

BACKGROUND: Cancelled healthcare appointments, especially in patients with complex cancers, such as esophageal cancer, risk delayed treatment and adverse outcomes. We hypothesized that patients with greater rates of healthcare appointment cancellations would have decreased survival after esophagectomy for esophageal cancer. METHODS: A retrospective analysis of patients from a single institution who underwent esophagectomy for esophageal cancer between 2004 and 2020 was performed. Appointment cancellations were queried 2 years pre-/post-esophagectomy and categorized as medical or ancillary. Continuous and categorical variables were compared by Mann-Whitney and chi-squared analyses, respectively. Survival associations post-esophagectomy were made by Kaplan-Meier analysis. RESULT: Seventy-six patients were identified. Total medical and ancillary appointments post-esophagectomy increased by 188% and 136%, respectively. Per patient, there was a median increase of 57.5 medical appointments in the post-esophagectomy period. Of medical appointments, 23.7% were cancelled pre-esophagectomy but 33.4% post-esophagectomy (p < 0.001). This trend held true for ancillary appointments. Patients with increased medical cancellation rates post-esophagectomy had shortened recurrence-free (p = 0.09) and overall survival (p < 0.01) versus patients with low cancellation rates. CONCLUSION: A significant increase in healthcare appointments is seen after esophagectomy. Patients with increased healthcare appointment cancellations have decreased post-esophagectomy survival which presents an opportunity to intervene in patients who historically have a high cancellation rate.

Preoperative computed tomography for acutely incarcerated ventral or inguinal hernia.

BACKGROUND: The utility of preoperative computed tomography for urgent abdominal wall hernia repair is unclear. This study tests the hypothesis that there is no difference in patient outcomes for acutely incarcerated ventral or inguinal hernias diagnosed by preoperative computed tomography versus clinical assessment alone. METHODS: This retrospective cohort analysis included 270 adult patients undergoing urgent repair of ventral or inguinal hernia. Demographics, risk factors for complications, operative management strategies, and 1-year outcomes were compared between patients with (n = 179) versus without (n = 91) preoperative computed tomography. RESULTS: Among 179 preoperative computed tomography scans, 15 (8.4%) were ordered by surgeons, and all others were ordered by referring providers. The computed tomography and no computed tomography groups had similar age (58 vs 58 years, P = .77), body mass index (30.7 vs 30.6 kg/m2, P = .30), American Society of Anesthesiologists class (3.0 vs 3.0, P = .39), incidence of the systemic inflammatory response syndrome (19.0% vs 20.9%, P = .75), and incidence of recurrent hernia (16.8% vs 19.8%, P = .61). The interval between admission and incision was longer in the computed tomography group (11.2 hours vs 6.6 hours, P < .001). The computed tomography and no computed tomography groups had similar duration of surgery (125 minutes in both groups, P = .88), proportions of patients with biologic mesh (21.2% vs 17.6%, P = .52) and synthetic mesh (35.2% vs 46.2%, P = .09) placement, and 1-year outcomes including incidence of superficial (8.4% vs 6.6%, P = .81) and deep or organ/space surgical site infection (5.0% vs 6.6%, P = .59), mesh explant for infection (2.2% vs 3.3%, P = .69), reoperation for recurrent hernia (3.9% vs 1.1%, P = .27), and mortality (7.8% vs 4.4%, P = .44). CONCLUSION: The performance of preoperative computed tomography was associated with a longer interval between admission and incision and no differences in mesh placement, mesh type, or 1-year patient outcomes. These results support the safety of performing urgent repair of acutely incarcerated ventral or inguinal hernias based on clinical assessment alone.

Survival and NF1 Analysis in a Cohort of Orthopedics Patients with Malignant Peripheral Nerve Sheath Tumors.

Neurofibromatosis type 1 (NF1) is an autosomal dominant tumor syndrome in which benign plexiform neurofibromas are at risk of transforming into malignant peripheral nerve sheath tumors (MPNSTs), a very rare soft-tissue sarcoma. The prognosis of patients with MPNSTs is poor, with most studies reporting <50% survival at five years. However, studies evaluating MPNSTs are limited and report heterogeneous results. Because no MPNST-specific evidence-based treatment guideline exists, individual institutional experiences are very informative to the field. The main objective of this study was to investigate and report MPNST prognostic clinical and genetic biomarkers from our institution's Orthopedics service experience treating 20 cases from 1992 to 2017. Most patients were treated with resection and adjuvant radiation. Extended follow-up, averaging 11.4 years (ranging 1.1 to 25.1), revealed excellent five-year survival rates: 70% for overall and 60% for metastatic disease. An S100 B immunonegative tumor phenotype was associated with a significantly worse outcome than MPNSTs with positive S100 B stain. In addition, NF1 gene mutation analysis was performed on 27 families with NF1 in which at least one affected family member developed MPNSTs. Of the 27 NF1 germline mutations, five were large deletions spanning (or nearly spanning) the gene (18.5%), substantially more than such deletions in NF1 in general, consistent with increased risk of MPNSTs in such cases.

Support with extracorporeal membrane oxygenation for over 1 year duration as a bridge to cardiac transplantation: a case report and review of the literature.

We present the case of a 13-year-old male with a complex congenital cardiac history who was supported with extracorporeal membrane oxygenation for 394 days while awaiting cardiac transplantation. The patient underwent successful cardiac transplantation after 394 days of support with veno-arterial extracorporeal membrane oxygenation and is currently alive 2 years after cardiac transplantation. We believe that this case represents the longest period of time that a patient has been supported with extracorporeal membrane oxygenation as a bridge to cardiac transplantation.We also review the literature associated with prolonged support with extracorporeal membrane oxygenation. This case report documents many of the challenges associated with prolonged support with extracorporeal membrane oxygenation, including polymicrobial bacterial and fungal infections, as well as renal dysfunction. It is possible to successfully bridge a patient to cardiac transplantation with prolonged support with extracorporeal membrane oxygenation of over 1 year; however, multidisciplinary collaboration is critical.