Use of Erector Spinae Fascial Plane Blocks in Enhanced Recovery for Open Abdominal Surgery.

BACKGROUND: Bilateral erector spinae fascial plane blocks (ESPB) offers a novel, alternative method of regional post-operative pain control to thoracic epidural analgesia (TEA). The aim of this study was to compare rates of postoperative hypotension, and other standard enhanced recovery after surgery (ERAS) endpoints, in patients receiving ESPB versus TEA for open hepatopancreaticobiliary (HPB) surgery. MATERIALS AND METHODS: This retrospective analysis compared historical controls of ERAS patients undergoing open HPB surgery with TEA versus ESPB. The incidence of postoperative hypotension and clinical outcomes, including opioid requirements, were compared. RESULTS: Forty patients receiving TEA were compared to 27 ESPB patients. Return of bowel function and length of stay (mean 7.2 versus7.4 days; P = 0.83) were similar. ESPB patients received less intraoperative colloid (142cc versus 340cc; P = 0.01) and had less postoperative hypotension versus TEA (22% versus 55%; P = 0.03). No ESPB patient required patient-controlled analgesia (versus 32.5% TEA; P< 0.001). ESPB MME requirements decreased over time, while TEA MME requirements increased over 72 hours (P = 0.019). CONCLUSIONS: ESPB is a novel method that shows promising outcomes in improving enhanced recovery parameters and minimizing opioid administration in open HPB surgery.

Pancreatic Adenocarcinoma in New Mexico Native Americans: Disparities in Treatment and Survival.

In this study, we examined the treatment and outcomes of pancreatic adenocarcinoma in New Mexico Native Americans (NA). METHODS: A retrospective review of patients treated for pancreatic adenocarcinoma at a university cancer center from 2002-2016 comparing demographic characteristics, disease presentation, treatment, and outcomes among three main ethnic groups in New Mexico. RESULTS: We identified 457 patients: 240 (52.5%) non-Hispanic Whites, 186 (40.7%) Hispanics, and 31 (6.8%) NA. Non-Hispanic Whites (OR 2.41; p=.026) and Hispanics (OR 2.37; p=.032) were more likely to receive or be offered chemotherapy than NA. More NA than non-Hispanic Whites died within one month of diagnosis (25.8% and 7.5%, respectively; p=.004). The NAs demonstrated a 26.2% one-year survival (CI 11.7-43.3), compared with 48.3% in non-Hispanic Whites (CI 40.9-55.2; p=.015). CONCLUSION: Significant disparities exist in the treatment and outcomes of pancreatic adenocarcinoma in New Mexico NA populations.

Gallbladder cancer: review of a rare orphan gastrointestinal cancer with a focus on populations of New Mexico.

Gallbladder cancer is a rare malignancy of the biliary tract with a poor prognosis, frequently presenting at an advanced stage. While rare in the United States overall, gallbladder cancer has an elevated incidence in geographically distinct locations of the globe including Chile, North India, Korea, Japan and the state of New Mexico in the United States. People with Native American ancestry have a much elevated incidence of gallbladder cancer compared to Hispanic and non-Hispanic white populations of New Mexico. Gallbladder cancer is also one of the few bi-gendered cancers with an elevated female incidence compared to men. Similar to other gastrointestinal cancers, gallbladder cancer etiology is likely multi-factorial involving a combination of genomic, immunological, and environmental factors. Understanding the interplay of these unique epidemiological factors is crucial in improving the prevention, early detection, and treatment of this lethal disease. Previous studies have failed to identify a distinct genomic mutational profile in gallbladder cancers, however, work to identify promising clinically actionable targets is this form of cancer is ongoing. Examples include, interest in the HER2/Neu signaling pathway and the recognition that chronic inflammation plays a crucial role in gallbladder cancer pathogenesis. In this review, we provide a comprehensive overview of gallbladder cancer epidemiology, risk factors, pathogenesis, and treatment with a specific focus on the rural and Native American populations of New Mexico. We conclude this review by discussing future research directions with the goal of improving clinical outcomes for patients of this lethal malignancy.

Racial disparities in treatment and survival of hepatocellular carcinoma in native Americans and Hispanics.

BACKGROUND: We investigated if there were any differences in disease presentation and survival between the 3 major ethnicities in New Mexico; non-Hispanic whites (NHW), native Americans (NA), and Hispanics (H). METHODS: A retrospective analysis of patients with hepatocellular carcinoma treated at our institution between 2000 and 2014 was performed. Overall survival was analyzed using the Kaplan-Meier and Cox regression models. RESULTS: We identified 326 patients; 106 (32.5%) NHW, 183 (56.1%) H, and 37 (11.4%) NA. No difference in disease stage, resectability, rate of offering surgery, or chemotherapy was found. Advanced cirrhosis was more common in H and NA than NHW (P = .01). NA had a higher incidence of nonviral hepatocellular carcinoma (P = .0009). NHW were more likely to receive transarterial chemoembolization/radiofrequency than NA or H (P = .04). Median survivals for NA, NHW, H were 24, 14, and 11 months, respectively, (P = .01). CONCLUSIONS: Although there was no difference in disease stage or resectability, NA and H had more advanced cirrhosis and were less likely to undergo transarterial chemoembolization and/or radiofrequency than NHW. NA had the best survival, whereas H had the worst survival.

Viral hepatitis status does not affect survival in patients with hepatocellular carcinoma.

BACKGROUND: There have been few studies on the impact of viral etiology on the prognosis in patients with hepatocellular carcinoma (HCC). The aim of this study was to evaluate the clinical characteristics and survival of patients with viral hepatitis-associated HCC (V-HCC), compared to patients with HCC of non-hepatitis B, non-hepatitis C (NBNC-HCC) etiology. METHODS: We performed a retrospective analysis of all patients with HCC treated at our comprehensive cancer center from 2000 through 2014. Patients were divided into two groups according to their viral hepatitis status. Presentation patterns, treatments, and survival data were analyzed. RESULTS: We evaluated 366 patients: 233 patients (63.7%) had V-HCC while 133 (36.3%) patients had NBNC-HCC. V-HCC patients were younger (P<0.0001) and more likely to be male (P=0.001). Decompensated cirrhosis was more prevalent in V-HCC patients (P=0.01). There was no difference in the resectability rate or disease stage. In patients with resectable disease, those with V-HCC were less likely to undergo hepatectomy (23.7% vs. 38%; P=0.04) for more advanced liver disease. The estimated median survival for V-HCC was 13 months compared to 16 months in NBNC-HCC patients (P=0.57). On multivariate analysis, disease stage (P<0.0001) and Child-Pugh class (P<0.0001) were independent factors affecting survival, but viral status was not (P=0.75). CONCLUSION: Despite presenting with more advanced cirrhosis and being less likely to undergo surgery, V-HCC patients had similar survival to patients with NBNC-HCC.

Leiomyosarcoma of the Inferior Vena Cava: A Case Series and Review of the Literature.

BACKGROUND: Leiomyosarcoma of the inferior vena cava (IVC) is an exceedingly rare smooth muscle sarcoma. Approximately 300 cases have been described in the literature, and further research is needed to understand the disease and guide its management. Surgery remains the only potential curative measure. METHODS: A retrospective chart review of patients who underwent surgical resection of IVC leiomyosarcoma at our institution over the past 3 years was performed. The patients were identified using a prospectively maintained database. RESULTS: Three patients with leiomyosarcoma of the infrahepatic IVC underwent radical resection carried out by a team of surgical oncologists and vascular surgeons. There were 2 males (66.7%) and 1 female (33.3%). Mean age at diagnosis was 60.3 years (range 43-78). Mean tumor size was 12.2 cm (range 5.6-22). The mean operative time was 320 min (range 180-421), mean estimated blood loss was 1,300 mL (100-2,000) mL, and average length of stay 8.67 days (6-12). All patients achieved grossly negative margins (R1 or R0 resections) and are alive with a mean overall survival of 21 months (range 12-30). Patient 1 was a 60-year-old man who presented with metachronous skin leiomyosarcomas at 2 different sites. He underwent PET/CT scan that revealed an IVC mass. Resection of the middle segment of the IVC and right kidney was performed with reconstruction with polytetrafluorethylene (PTFE) graft. Patient 2 was a 78-year-old man with an incidentally found a 9-cm IVC tumor. Resection of the tumor was performed, and no reconstruction was needed since the tumor had a completely extraluminal growth pattern. Patient 3 was a 43-year-old woman who presented with abdominal pain. Her work-up showed a 15-cm IVC mass. She underwent resection of the middle segment of the IVC, right nephrectomy, and cholecystectomy with reconstruction of the IVC with PTFE graft. CONCLUSIONS: Surgical resection is the mainstay of treatment in patients with leiomyosarcoma of the IVC. A collaborative approach involving surgical oncologists and vascular surgeons ensures adequate resection with functional reconstruction to achieve the best patient outcomes.

Interhospital transfer of liver trauma in New Mexico: a state of austere resources.

BACKGROUND: There is debate in the trauma literature regarding the effect of prolonged prehospital transport on morbidity and mortality. This study analyzes the management of hepatic trauma patients requiring surgery and compares the outcomes of the group that was transferred to the University of New Mexico Hospital (UNMH) from outside institutions, to the directly admitted group. MATERIALS AND METHODS: The UNMH Trauma Database was queried from 2005-2012. Of 674 patients who sustained liver injuries, 163 required surgery: 46 patients (28.2%) underwent interhospital transfer, and 117 (71.8%) were directly admitted. Variables examined included transfer status, trauma mechanism, transport type, injury severity score (ISS), liver injury grade, and associated injuries. Outcome variables included length of stay (LOS) and 30-day mortality. Outcomes of the transfer group (TG) and direct admit group (DAG) were compared. RESULTS: Both TG and DAG had the same median age (31 y, P = 0.33). The blunt-to-penetrating ratio was the same for each group (48% blunt: 52% penetrating, P = 1.0). Median ISS was 25 for the TG and 26 for the DAG. Grade III or higher injury occurred in 29 (63%) of the TG and in 68 (58%) of the DAG (P = 0.56). Median hospital LOS was 14 d for TG and 9 d for DAG (P = 0.15). Median intensive care unit LOS was 4 d for both groups (P = 0.71). Thirty-day mortality was 20% in each group (P = 0.27). Using a multiple logistic regression model for the outcome of mortality, only age, ISS, and liver injury grade, not transfer status or transport type, had a significant effect on mortality. CONCLUSIONS: There was no significant difference in liver injury grade, ISS, LOS, and mortality between TG and DAG. In the patient population of our study, transfer status did not affect outcome.

Pediatric melanoma in New Mexico American Indians, Hispanics, and non-Hispanic whites, 1981-2009.

BACKGROUND: Pediatric melanoma rates are increasing nationally. Our purpose was to determine the incidence of melanoma in New Mexico's (NM's) American Indian, Hispanic, and non-Hispanic white children. METHODS: A retrospective review (1981 to 2009) of the NM Tumor Registry was conducted. Melanomas diagnosed in children <19 years of age were identified. Average annual age-adjusted incidence rates per million were calculated. RESULTS: Sixty-four cases were identified. Rates per million were 7.4 for non-Hispanic whites, 2.1 for Hispanics, and 3.3 for American Indians. Fifty-nine percent were women. Fifty-five (86%) cases were localized, 6 (9%) were regional, and 1 (3%) case was metastatic. Majority of cases (49/64; 77%) occurred in children >14 years of age. American Indians presented with thicker melanomas as compared to whites and Hispanics. CONCLUSIONS: Incidence rates for pediatric melanoma in NM are highest for non-Hispanic whites. Distant metastasis is uncommon. Melanoma in children is rare, but practitioners must be aware of its occurrence for prompt diagnosis and treatment.

Up and down or side to side? A systematic review and meta-analysis examining the impact of incision on outcomes after abdominal surgery.

BACKGROUND: The aim of this study was to examine whether midline, paramedian, or transverse incisions offer potential advantages for abdominal surgery. DATA SOURCES: We searched MEDLINE, Embase, Web of Science, and The Cochrane Central Register of Controlled Trials from 1966 to 2009 for randomized controlled trials comparing incision choice. METHODS: We systematically assessed trials for eligibility and validity and extracted data in duplicate. We pooled data using a random-effects model. RESULTS: Twenty-four studies were included. Transverse incisions required less narcotics than midline incisions (weighted mean difference = 23.4 mg morphine; 95% confidence interval [CI], 6.9 to 39.9) and resulted in a smaller change in the forced expiratory volume in 1 second on postoperative day 1 (weighted mean difference = -6.94%; 95% CI, -10.74 to -3.13). Midline incisions resulted in higher hernia rates compared with both transverse incisions (relative risk = 1.77; 95% CI, 1.09 to 2.87) and paramedian incisions (relative risk = 3.41; 95% CI, 1.02 to 11.45). CONCLUSIONS: Both transverse and paramedian incisions are associated with a lower hernia rate than midline incisions and should be considered when exposure is equivalent.

Diversification and trends in biliary tree cancer among the three major ethnic groups in the state of New Mexico.

BACKGROUND: New Mexico's population is composed of 45% non-Hispanic whites, 42% Hispanics, 10% American Indians, and 3% other minorities. The purpose of this study was to compare the trends of biliary tract cancer among these groups over the past 3 decades. METHODS: The state's tumor registry was used to ascertain the incidence of gallbladder cancer, extrahepatic bile duct cancer, and intrahepatic bile duct cancer. RESULTS: A total of 1,449 new biliary cancers were diagnosed between 1981 and 2008. The contemporary incidence of gallbladder cancer remains several times higher among American Indians than in other ethnicities: for men, 4.1%, 1.1%, and .8% for American Indians, Hispanics, and non-Hispanic whites, respectively, and for women, 8.1%, 2.1%, and 1.0%, respectively. CONCLUSIONS: Biliary malignancies are more prevalent among American Indians. Despite a decline in the incidence of gallbladder cancer among American Indians and Hispanics, it remains higher compared with the state's non-Hispanic white population.

Renal clear cell carcinoma emerging in a transplanted kidney 3 years after return to dialysis. Case report and review of the literature.

We present a female patient with end-stage renal disease who was referred to the emergency department with sudden, excruciating pain over the right lower abdomen and flank. Radiologic evaluation following admission revealed a mass, solid in nature, located at the upper pole of the transplanted kidney. The patient was treated with empiric antibiotics and analgesics, and her symptoms subsided over the course of the week. Based on the clinical course and radiological findings, a self-limiting, spontaneous haemorrhage was thought to be the cause of the patient's symptoms. Nevertheless, background malignancy could not be ruled out. Therefore, an interval, elective graft nephrectomy was scheduled. Pathology confirmed the diagnosis of renal clear cell carcinoma.