Liver Stiffness Measurement and Risk Prediction of Hepatocellular Carcinoma After HCV Eradication in Veterans With Cirrhosis.

BACKGROUND & AIMS: Patients with cirrhosis secondary to chronic hepatitis C virus (HCV) are at risk for hepatocellular carcinoma (HCC) despite a sustained virological response (SVR). We examined whether post-SVR liver stiffness measurement (LSM) could be used to stratify HCC risk. METHODS: This was a retrospective cohort study of 1850 participants identified from the Veterans Health Administration, with HCV cirrhosis and SVR, followed up over 5099 person-years, from the time of post-SVR elastography until death, HCC, or the end of the study. RESULTS: The risk of HCC increased by 3% with every 1-kPa increase in LSM (adjusted hazard ratio [aHR], 1.03, 95% confidence interval [CI], 1.01-1.04; P < .001) and decreased with the number of years from SVR (aHR, 0.79; 95% CI, 0.70-0.90; P = .0003). The adjusted annual risk of HCC was 2.03% among participants with post-SVR LSM <10 kPa, 2.48% in LSM 10-14.9 kPa (aHR, 1.71; 95% CI, 1.01-2.88; P = .046), 3.22% for LSM 15-19.9 kPa (aHR, 1.59; 95% CI, 0.78-3.20; P = .20), 5.07% among LSM 20-24.9 kPa (aHR, 2.55; 95% CI, 1.30-5.01; P = .01), and 5.44% in LSM ≥25 kPa (aHR, 3.03; 95% CI, 1.74-5.26; P < .0001). The adjusted annual risk of HCC was < 0.4% in participants with LSM <5 kPa and without diabetes mellitus. CONCLUSIONS: LSM predicts rates of HCC in patients with HCV cirrhosis after SVR at multiple cutoff levels and offers a single test to predict portal hypertension-related complications and HCC. Patients with LSM <5 kPa in the absence of diabetes mellitus had a low risk of HCC in which surveillance could be discontinued.

Comparison of infection-induced and vaccine-induced immunity against COVID-19 in patients with cirrhosis.

BACKGROUND AND AIMS: Immunity to SARS-CoV-2 can be infection or vaccine-induced. Cirrhosis is associated with vaccine hyporesponsiveness, but whether there is decreased immunity after SARS-CoV-2 infection in unvaccinated patients with cirrhosis is unknown.The objective of our study was to compare infection-induced and vaccine-induced immunity against COVID-19 among patients with cirrhosis. METHODS: This was a retrospective cohort study among US Veterans with cirrhosis between November 27, 2020, and November 16, 2021, comparing a vaccine-induced immunity group, defined as participants without a documented SARS-CoV-2 infection but fully vaccinated with two doses of an mRNA vaccine, and infection-associated immunity group, defined as unvaccinated participants who had a positive SARS-CoV-2 polymerase chain reaction (PCR). Both groups were propensity score matched for observed characteristics, including location, and the date of the immunity acquiring event, to control for the community prevalence of COVID-19 variants. The outcome was a positive SARS-CoV-2 PCR more than 60 days after previous infection in the infection-induced, or after full vaccination in the vaccine-induced immunity group. RESULTS: We compared 634 participants in the infection-induced immunity group with 27,131 participants in the vaccine-induced immunity group using inverse propensity of treatment weighting. Vaccine-induced immunity was associated with a reduced odds of developing SARS-CoV-2 infection (adjusted hazard ratio [aHR], 0.18; 95% confidence interval [CI], 0.16-0.20, p < 0.0001). On multivariable logistic regression, vaccine-induced immunity was associated with reduced odds of developing symptomatic (adjusted odds ratio [aOR], 0.36; 95% CI, 0.33-0.41, p < 0.0001), moderate/severe/critical (aOR, 0.27; 95% CI, 0.22-0.31, p < 0.0001), and severe or critical COVID-19 (aOR, 0.20; 95% CI, 0.16-0.26, p < 0.001), compared with infection-induced immunity. CONCLUSIONS: In participants with cirrhosis, vaccine-induced immunity is associated with reduced risk of developing COVID-19, compared with infection-induced immunity.

Third dose of COVID-19 mRNA vaccine appears to overcome vaccine hyporesponsiveness in patients with cirrhosis.

BACKGROUND & AIMS: Cirrhosis is associated with immune dysregulation and hyporesponsiveness to several vaccines including those against COVID-19. Our aim was to compare outcomes between patients with cirrhosis who received 3 doses of either the Pfizer BNT162b2 mRNA or Moderna mRNA-1273 vaccines to a propensity-matched control group of patients at similar risk of infection who received 2 doses. METHODS: This was a retrospective cohort study of patients with cirrhosis who received 2 or 3 doses of a COVID-19 mRNA vaccine at the Veterans Health Administration. Participants who received 3 doses of the vaccine (n = 13,041) were propensity score matched with 13,041 controls who received 2 doses, and studied between July 18, 2021 and February 11, 2022, when B.1.617.2 (delta) and B.1.1.529 (omicron) were the predominant variants. Outcomes were aggregated as all cases with COVID-19, symptomatic COVD-19, with at least moderate COVID-19, or severe or critical COVID-19. RESULTS: Receipt of the third dose of a COVID-19 mRNA vaccine was associated with an 80.7% reduction in COVID-19 (95% CI 39.2-89.1, p <0.001), an 80.4% reduction in symptomatic COVID-19, an 80% reduction in moderate, severe or critical COVID-19, (95% CI 34.5-87.6%, p = 0.005), a 100% reduction in severe or critical COVID-19 (95% CI 99.2-100.0, p = 0.01), and a 100% reduction in COVID-19-related death (95% CI 99.8-100.0, p = 0.007). The magnitude of reduction in COVID-19 was greater with the third dose of BNT 162b2 than mRNA-1273 and among participants with compensated rather than decompensated cirrhosis. CONCLUSIONS: Administration of a third dose of a COVID-19 mRNA vaccine was associated with a more significant reduction in COVID-19 in patients with cirrhosis than in the general population, suggesting that the third dose can overcome vaccine hyporesponsiveness in this population. LAY SUMMARY: Cirrhosis is associated with decreased responsiveness to several vaccines, including those against COVID-19. In this study of 26,082 participants with cirrhosis during the delta and omicron surge, receipt of the third dose of the vaccine was associated with an 80% reduction in COVID-19, a 100% reduction in severe/critical COVID-19, and a 100% reduction in COVID-19-related death. These findings support the importance of a third dose of mRNA vaccine among patients with cirrhosis.

Comparison of Costs and Outcomes for In-Office and Operating Room Excision of Nonmelanoma Skin Cancer.

INTRODUCTION: With increasing health care expenses and limited resources, it is important to evaluate potential means of reducing cost while maintaining efficacy and safety. The purpose of our study was to compare the cost and outcomes of surgical excision of nonmelanoma skin cancer (NMSC) in the operating room versus an outpatient procedure clinic. METHODS: A retrospective review of patients undergoing excision of biopsy-confirmed NMSC at the Miami Veterans Affairs Hospital between December 1, 2015, and December 1, 2016, was completed. Patients treated in the operating room and procedure clinic were included. Treatment outcomes were assessed for all identified patients. Patients undergoing excision and primary closure were included for cost comparison.Procedure costs were estimated using Current Procedural Terminology codes for treatments provided and the 2017 conversion factor of $35.7751. If a second operation for positive margins was necessary, cost to treat the lesion included costs from both procedures. If multiple lesions were treated, total cost was divided by the number of lesions to calculate cost per lesion treated. Costs per lesion managed in the operating room and clinic were compared using the Student t test. RESULTS: Sixty-five patients underwent excision of 94 NMSCs in the operating room. Nineteen patients underwent excision of 20 NMSCs in the procedure clinic. One patient treated in the clinic required re-excision in the operating room with frozen section for a positive margin.Thirty-three patients managed in the operating room and 19 patients managed in the procedure clinic were included for cost analysis. Average costs per lesion excised in the operating room and procedure clinic were calculated to be $1923.43 ± 616.27 and $674.88 ± 575.22, respectively (P < 0.001). CONCLUSIONS: Excellent oncologic outcomes were achieved for both operating room and procedure clinic excision. Excision in the operating room excision was significantly more expensive than in the procedure clinic. Excision in a procedure clinic offers an opportunity to reduce costs while maintaining quality care.

Telemedicine broadening access to care for complex cases.

BACKGROUND: Surgical and nonsurgical specialists are highly centralized, making access to high-quality care difficult for many Americans. We explored the feasibility, benefits, preliminary outcomes, and patient satisfaction with a new type of health visit, in which a surgical oncologist used video telecommunication to manage and treat complex cancer diseases, including patients with severe comorbidities. MATERIALS AND METHODS: Patients visited local VA medical centers throughout Florida to engage in video telecommunication visits with a centralized surgical oncologist in Miami, who directed their oncology treatment. The average length of stay and rate of unplanned readmission were calculated within each organ. The total mileage saved was calculated by subtracting the distance between the patient's home address and the local VA from the distance between the patient's home address and the Miami VA. Travel costs were determined by the VA's reimbursement of $0.415/mile for health-related travel and reimbursement of $150.00 for an overnight hotel stay. A Likert scale with both positively and negatively keyed questions was used to assess patient satisfaction. RESULTS: In 24 mo, seven unplanned readmissions occurred among 195 operations. Patients experienced an 80.7% reduction in travel distance and saved a total of 213,007.58 miles by visiting their local VA instead of the Miami VA. Survey results indicate that 86% of patients believed that the telemedicine program made medical care more accessible. CONCLUSIONS: The Specialist-Directed Telemedicine Model can save patients substantial time and money by not traveling to centralized areas, while delivering greater continuity of care and patient satisfaction.

Association Between American Board of Surgery In-Training Examination Scores and Resident Performance.

IMPORTANCE: The American Board of Surgery In-Training Examination (ABSITE) is designed to measure progress, applied medical knowledge, and clinical management; results may determine promotion and fellowship candidacy for general surgery residents. Evaluations are mandated by the Accreditation Council for Graduate Medical Education but are administered at the discretion of individual institutions and are not standardized. It is unclear whether the ABSITE and evaluations form a reasonable assessment of resident performance. OBJECTIVE: To determine whether favorable evaluations are associated with ABSITE performance. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis of preliminary and categorical residents in postgraduate years (PGYs) 1 through 5 training in a single university-based general surgery program from July 1, 2011, through June 30, 2014, who took the ABSITE. EXPOSURES: Evaluation overall performance and subset evaluation performance in the following categories: patient care, technical skills, problem-based learning, interpersonal and communication skills, professionalism, systems-based practice, and medical knowledge. MAIN OUTCOMES AND MEASURES: Passing the ABSITE (≥30th percentile) and ranking in the top 30% of scores at our institution. RESULTS: The study population comprised residents in PGY 1 (n = 44), PGY 2 (n = 31), PGY 3 (n = 26), PGY 4 (n = 25), and PGY 5 (n = 24) during the 4-year study period (N = 150). Evaluations had less variation than the ABSITE percentile (SD = 5.06 vs 28.82, respectively). Neither annual nor subset evaluation scores were significantly associated with passing the ABSITE (n = 102; for annual evaluation, odds ratio = 0.949; 95% CI, 0.884-1.019; P = .15) or receiving a top 30% score (n = 45; for annual evaluation, odds ratio = 1.036; 95% CI, 0.964-1.113; P = .33). There was no difference in mean evaluation score between those who passed vs failed the ABSITE (mean [SD] evaluation score, 91.77 [5.10] vs 93.04 [4.80], respectively; P = .14) or between those who received a top 30% score vs those who did not (mean [SD] evaluation score, 92.78 [4.83] vs 91.92 [5.11], respectively; P = .33). There was no correlation between annual evaluation score and ABSITE percentile (r(2) = 0.014; P = .15), percentage correct unadjusted for PGY level (r(2) = 0.019; P = .09), or percentage correct adjusted for PGY level (r(2) = 0.429; P = .91). CONCLUSIONS AND RELEVANCE: Favorable evaluations do not correlate with ABSITE scores, nor do they predict passing. Evaluations do not show much discriminatory ability. It is unclear whether individual resident evaluations and ABSITE scores fully assess competency in residents or allow comparisons to be made across programs. Creation of a uniform evaluation system that encompasses the necessary subjective feedback from faculty with the objective measure of the ABSITE is warranted.

Summary of the panel session at the 38th Annual Surgical Symposium of the Association of VA Surgeons: what is the big deal about frailty?

Owing to the phenomenon known as "global graying," elderly-specific conditions, including frailty, will become more prominent among patients undergoing surgery. The concept of frailty, its effect on surgical outcomes, and its assessment and management were discussed during the 38th Annual Surgical Symposium of the Association of VA Surgeons panel session entitled "What's the Big Deal about Frailty?" and held in New Haven, Connecticut, on April 7, 2014. The expert panel discussed the following questions and topics: (1) Why is frailty so important? (2) How do we identify the frail patient prior to the operating room? (3) The current state of the art: preoperative frail evaluation. (4) Preoperative interventions for frailty prior to operation: do they work? (5) Intraoperative management of the frail patient: does anesthesia play a role? (6) Postoperative care of the frail patient: is rescue the issue? This special communication summarizes the panel session topics and provides highlights of the expert panel's discussions and relevant key points regarding care for the geriatric frail surgical patient.

Management of recurrent inguinal hernias after total extraperitoneal (TEP) herniorrhaphies.

INTRODUCTION: The laparoscopic repair offers clear advantages in recurrent inguinal hernias after open herniorrhaphy. Less clear is the role of laparoscopy for recurrences after previous laparoscopic inguinal herniorrhaphies. In this paper, we present our experience with both laparoscopic and open inguinal hernia repair of laparoscopic recurrences. METHODS: All patients who had undergone repair of recurrences after previous laparoscopic hernia repair from July 2004 to July 2007 were included in this study. Charts were reviewed for all these patients. RESULTS: Six patients were diagnosed with 7 recurrent inguinal hernias after laparoscopic repairs. All the initial laparoscopic repairs, except for one, were total preperitoneal (TEP) with the placement of lightweight polypropylene mesh. The average time from the initial repair to the diagnosis of recurrence was 20 months (range 3-84). Four of the 7 recurrences were treated with a laparoscopic approach. The other three recurrences were repaired in an open fashion as per the preoperative plan. In 2 of the laparoscopic cases, the peritoneal flap was not able to cover the mesh, so a tissue-separating mesh with fibrin sealant was utilized to cover the myopectineal orifice. No intra- or postoperative complications were recorded. There were no recurrences at an average follow-up of 14 months (range, 11-17). CONCLUSIONS: Laparoscopic repair can be offered to those patients with a recurrence after a previous laparoscopic repair. Further studies comparing laparoscopic repair versus open repair of recurrences after laparoscopic inguinal hernia repair will be helpful in defining the best approach when encountering these recurrences.

Use of biologic mesh for a complicated paracolostomy hernia.

BACKGROUND: Parastomal hernias are among the most frustrating and incapacitating complications of permanent colostomies. Because the traditional surgical options of primary repair with or without ostomy repositioning have led to disappointing results, the use of mesh is indicated, especially in the setting of multiple recurrences. METHODS: After laparoscopic lyses of adhesions, the colostomy is pushed against the lateral abdominal wall, and a bovine pericardium graft is gently stretched and draped over the colostomy (the Sugarbaker technique). Transfascial sutures and tacks are placed along the perimeter of the mesh and around the colon to prevent small bowel herniation. RESULTS: The patient developed a small seroma postoperatively, which resolved spontaneously. At his 17-month follow-up, the patient had no evidence of recurrence, he was pain free, and he was satisfied with his cosmetic results. CONCLUSION: Although several studies indicate the feasibility and efficacy of synthetic permanent mesh repair, the concerns of mesh infection, erosion, and ostomy obstruction still persist. The authors suggest parietalizing the bowel and using a biologic mesh.

Neoadjuvant, surgery and adjuvant chemotherapy without radiation for esophageal cancer.

BACKGROUND: A phase II trial to evaluate neoadjuvant (NAD), surgery and adjuvant (AD) combination chemotherapy without radiation therapy (RT) for patients with esophageal adenocarcinoma staged with endoscopic ultrasound and CT as T3N1 was carried out. METHODS: Thirty-three eligible patients were enrolled. NAD therapy was administered in two 49-day cycles and included cisplatin, floxuridine, paclitaxel and leucovorin. Esophageal resection was performed followed by AD therapy. RESULTS: Thirty-three patients initiated NAD therapy; 10 experienced grade 3 and 4 toxicities, which included leucopenia, fatigue, nausea, diarrhea and stomatitis. Additionally, 16 patients experienced grade 1 and 2 hematologic and non-hematologic toxicities. Fifteen patients were down-staged, of whom five were T2, seven were T1, and three had nodal disease with no evidence of residual cancer in the esophageal bed. Fifteen patients remained T3, and two showed progressive disease. Thirty-two patients proceeded to surgery and 30 were resected. Although all resected patients were eligible for AD therapy, 15 did not receive it either because of patient refusal or surgeon recommendation. Fifteen patients received AD therapy: nine who had remained T3 and six who had down-staged. Three patients experienced grade 3 and 4 toxicities similar to those in NAD therapy. Six patients had grade 1 and 2 toxicities. Kaplan-Meier estimates of overall survival at 1, 3 and 5 years were 73% (95% CI: 58-88%), 52% (95% CI: 34-69%) and 29% (95% CI: 13-45%), respectively. Median survival was 42 months. CONCLUSION: Deletion of RT may safely allow for more aggressive chemotherapy and increase chances of survival. The results need to be confirmed in a randomized phase II or larger phase III trial.

Retroperitoneal and truncal sarcomas: prognosis depends upon type not location.

BACKGROUND: Prognostication of truncal and retroperitoneal soft tissue sarcomas has traditionally been predicated on tumor location and grade. OBJECTIVE: To compare outcomes for patients with retroperitoneal or truncal sarcomas. METHODS: Retrospective analysis of a prospective cancer data registry from 1977 to 2004 was performed and outcomes were determined. RESULTS: The study group numbered 312 patients (median age 58 years, 54% male, 56% Caucasian, 14% black, 29% Hispanic). The most common tumor types were liposarcoma (35.9%), leiomyosarcoma (30.1%), and malignant fibrous histiocytoma (MFH) (19.5%). Tumor distributions were retroperitoneal (38.9%), pelvic (24.7%), abdominal (18.6%) and thoracic (17.9%). Median overall survival was 74 months. Operative resection was undertaken in 89.4% of cases and multiple surgeries (range 2-5) in 42.2%. Negative resection margins were obtained in 72.7% of patients. Univariate analysis comparing retroperitoneal versus truncal location demonstrated no significant differences in survival. Survival was improved in lower grade tumors (P < 0.02). Liposarcoma and fibrosarcoma were associated with improved survival (P < 0.0001). Multivariate analysis of pre-treatment variables showed increasing age, grade, histopathology (leiomyosarcoma and MFH) and metastasis to be associated with worse outcomes. Multivariate analysis of the treatment variables showed that surgery and negative resection margins were associated with improved survival (P < 0.001). No advantage for chemoradiotherapy could be demonstrated. CONCLUSIONS: Successful operative resection can confer prolonged disease-free survival and cure for truncal and retroperitoneal sarcomas. Histological subtype, not location, is predictive of long-term survival. Future studies should focus on histological subtype rather than tumor location for truncal and retroperitoneal sarcomas.

A technique for emergency liver packing.

Control of liver hemorrhage may present a daunting clinical scenario. Use of liver packing techniques is highly effective to control bleeding but can result in significant recurrent bleeding with pack removal. Such bleeding is particularly a problem when large portions of the hepatic parenchymal surface and Glisson's capsule have been disrupted. We describe, herein, our approach to hepatic packing in scenarios where a large component of hepatic capsular disruption has occurred. Use of a non-stick bowel bag is employed on the disrupted liver surface, which, when removed, will not result in liver rebleeding. This technique has been used successfully in the management of five cases of severe liver injury with extensive capsular disruption. Familiarity with such an approach may facilitate management of similar liver injuries.

Intraductal oncocytic papillary neoplasm of the extrahepatic biliary tree: first report.

Tumors with oncocytic differentiation may occur in a variety of organs, but are extremely rare in the biliary system. Intraductal oncocytic papillary neoplasms (IOPNs) were first described in the pancreas to differentiate a rare subset of pancreatic neoplasm from the intraductal papillary mucinous neoplasms (IPMNs). IOPN of the extrahepatic biliary tree has not been previously described. We describe the first case of an intraductal oncocytic papillary neoplasm at the bifurcation of the common hepatic duct in a 52-year-old white male with a two-year history of intermittent biliary obstruction.

Gallbladder cystadenoma and common bile duct obstruction.

Cystadenomas are usually found in the extra-hepatic bile ducts in conjunction with multilocular cysts in the liver. Cystadenoma of the gallbladder itself is a rare finding, cited only once in the literature as the cause of extrinsic obstruction of the common bile duct (5). In this report, we describe the endoscopic retrograde cholangiopancreaticographic (ERCP) detection of intrinsic obstruction of the cystic duct and common bile duct by such a tumor in a 47-yr-old woman.