Impact of safety-net hospital burden on achievement of textbook oncologic outcomes following resection in for stage I-IV colorectal cancer.

BACKGROUND AND OBJECTIVES: Textbook oncologic outcome (TOO) is a benchmark for high-quality surgical cancer care but has not been studied at safety-net hospitals (SNH). The study sought to understand how SNH burden affects TOO achievement in colorectal cancer. METHODS: The National Cancer Database was queried for colorectal cancer patients who underwent resection for stage I-III plus stage IV with liver-only metastases (2010-2019). TOO was defined as R0 resection, AJCC-compliant lymphadenectomy (>12 nodes), no prolonged LOS, no 30-day mortality/readmission, and receipt of stage-appropriate adjuvant chemotherapy. RESULTS: Of 487,195 patients, 66.7% achieved TOO. Lower achievement was explained by adequate lymphadenectomy (87.3%), non-prolonged LOS (76.3%), and receipt of adjuvant chemotherapy in stage III (60.3%) and IV (54.1%). Treatment at high burden hospitals (HBH, >10% Medicaid/uninsured) was a predictor of non-TOO (Stage I/II: OR 0.83, III: OR 0.86, IV: OR 0.83; all p < 0.001). Achieving TOO was associated with decreased mortality (Stage I/II: HR 0.49, III: HR 0.48, IV: HR 0.57; all p < 0.001), and HBH treatment was a predictor of mortality (Stage I/II: HR 1.09, III: HR 1.05, IV: HR 1.07; all p < 0.05). CONCLUSIONS: Treatment at higher SNH burden hospitals was associated with less frequent TOO achievement and increased mortality. Quality improvement targets include receipt of adjuvant chemotherapy and avoidance of prolonged LOS.

SAGES peritoneal dialysis access guideline update 2023.

BACKGROUND: Minimally invasive surgery has been used for both de novo insertion and salvage of peritoneal dialysis (PD) catheters. Advanced laparoscopic, basic laparoscopic, open, and image-guided techniques have evolved as the most popular techniques. The aim of this guideline was to develop evidence-based guidelines that support surgeons, patients, and other physicians in decisions on minimally invasive peritoneal dialysis access and the salvage of malfunctioning catheters in both adults and children. METHODS: A guidelines committee panel of the Society of American Gastrointestinal and Endoscopic Surgeons reviewed the literature since the prior guideline was published in 2014 and developed seven key questions in adults and four in children. After a systematic review of the literature, by the panel, evidence-based recommendations were formulated using the Grading of Recommendations Assessment, Development and Evaluation approach. Recommendations for future research were also proposed. RESULTS: After systematic review, data extraction, and evidence to decision meetings, the panel agreed on twelve recommendations for the peri-operative performance of laparoscopic peritoneal dialysis access surgery and management of catheter dysfunction. CONCLUSIONS: In the adult population, conditional recommendations were made in favor of: staged hernia repair followed by PD catheter insertion over simultaneous and traditional start over urgent start of PD when medically possible. Furthermore, the panel suggested advanced laparoscopic insertion techniques rather than basic laparoscopic techniques or open insertion. Conditional recommendations were made for either advanced laparoscopic or image-guided percutaneous insertion and for either nonoperative or operative salvage. A recommendation could not be made regarding concomitant clean-contaminated surgery in adults. In the pediatric population, conditional recommendations were made for either traditional or urgent start of PD, concomitant clean or clean-contaminated surgery and PD catheter placement rather than staged, and advanced laparoscopic placement rather than basic or open insertion.

SAGES/AHPBA guidelines for the use of microwave and radiofrequency liver ablation for the surgical treatment of hepatocellular carcinoma or colorectal liver metastases less than 5 cm.

BACKGROUND: Primary hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) represent the liver's two most common malignant neoplasms. Liver-directed therapies such as ablation have become part of multidisciplinary therapies despite a paucity of data. Therefore, an expert panel was convened to develop evidence-based recommendations regarding the use of microwave ablation (MWA) and radiofrequency ablation (RFA) for HCC or CRLM less than 5 cm in diameter in patients ineligible for other therapies. METHODS: A systematic review was conducted for six key questions (KQ) regarding MWA or RFA for solitary liver tumors in patients deemed poor candidates for first-line therapy. Subject experts used the GRADE methodology to formulate evidence-based recommendations and future research recommendations. RESULTS: The panel addressed six KQs pertaining to MWA vs. RFA outcomes and laparoscopic vs. percutaneous MWA. The available evidence was poor quality and individual studies included both HCC and CRLM. Therefore, the six KQs were condensed into two, recognizing that these were two disparate tumor groups and this grouping was somewhat arbitrary. With this significant limitation, the panel suggested that in appropriately selected patients, either MWA or RFA can be safe and feasible. However, this recommendation must be implemented cautiously when simultaneously considering patients with two disparate tumor biologies. The limited data suggested that laparoscopic MWA of anatomically more difficult tumors has a compensatory higher morbidity profile compared to percutaneous MWA, while achieving similar overall 1-year survival. Thus, either approach can be appropriate depending on patient-specific factors (very low certainty of evidence). CONCLUSION: Given the weak evidence, these guidelines provide modest guidance regarding liver ablative therapies for HCC and CRLM. Liver ablation is just one component of a multimodal approach and its use is currently limited to a highly selected population. The quality of the existing data is very low and therefore limits the strength of the guidelines.

Surgical approach to microwave and radiofrequency liver ablation for hepatocellular carcinoma and colorectal liver metastases less than 5 cm: a systematic review and meta-analysis.

BACKGROUND: Primary hepatocellular carcinoma (HCC) and colorectal liver metastases (CRLM) represent the two most common malignant neoplasms of the liver. The objective of this study was to assess outcomes of surgical approaches to liver ablation comparing laparoscopic versus percutaneous microwave ablation (MWA), and MWA versus radiofrequency ablation (RFA) in patients with HCC or CRLM lesions smaller than 5 cm. METHODS: A systematic review was conducted across seven databases, including PubMed, Embase, and Cochrane, to identify all comparative studies between 1937 and 2021. Two independent reviewers screened for eligibility, extracted data for selected studies, and assessed study bias using the modified Newcastle Ottawa Scale. Random effects meta-analyses were subsequently performed on all available comparative data. RESULTS: From 1066 records screened, 11 studies were deemed relevant to the study and warranted inclusion. Eight of the 11 studies were at high or uncertain risk for bias. Our meta-analyses of two studies revealed that laparoscopic MW ablation had significantly higher complication rates compared to a percutaneous approach (risk ratio = 4.66; 95% confidence interval = [1.23, 17.22]), but otherwise similar incomplete ablation rates, local recurrence, and oncologic outcomes. The remaining nine studies demonstrated similar efficacy of MWA and RFA, as measured by incomplete ablation, complication rates, local/regional recurrence, and oncologic outcomes, for both HCC and CRLM lesions less than 5 cm (p > 0.05 for all outcomes). There was no statistical subgroup interaction in the analysis of tumors < 3 cm. CONCLUSION: The available comparative evidence regarding both laparoscopic versus percutaneous MWA and MWA versus RFA is limited, evident by the few studies that suffer from high/uncertain risk of bias. Additional high-quality randomized trials or statistically matched cohort studies with sufficient granularity of patient variables, institutional experience, and physician specialty/training will be useful in informing clinical decision making for the ablative treatment of HCC or CRLM.

Protective effect of phosphatidylserine blockade in sepsis induced organ dysfunction.

BACKGROUND: Phosphatidylserine is usually an intracellularly oriented cell membrane phospholipid. Externalized phosphatidylserine on activated cells is a signal for phagocytosis. In sepsis, persistent phosphatidylserine exposure is also a signal for activation of the coagulation and inflammatory cascades. As such, phosphatidylserine may be a key molecule in sepsis induced cellular and organ injury. We hypothesize that phosphatidylserine blockade provides a protective effect in sepsis induced organ dysfunction. METHODS: Sepsis was induced in adult female rats using an endotoxin model. Diannexin, a homodimer of annexin A5, was administered for phosphatidylserine blockade. Rats were allocated to control (n = 5), sepsis (n = 6), or sepsis and phosphatidylserine blockade (n = 9) groups. Gut, pulmonary, renal, and hematologic dysfunctions were evaluated by mesenteric microvascular fluid leak, partial pressure of oxygen, serum creatinine, activated clotting time, and glomerular fibrin deposition, respectively. RESULTS: Rats in the sepsis group demonstrated gut, renal, and hematologic dysfunction. Phosphatidylserine blockade reversed signs of gut dysfunction and mesenteric microvascular leak (P < .01). In addition, phosphatidylserine blockade corrected systemic coagulopathy, as measured by activated clotting time (P = .03) and glomerular fibrin deposition (P = .008). There was no difference in renal dysfunction (P = .1) or pulmonary dysfunction in any of the groups (P = .6). CONCLUSION: In sepsis, phosphatidylserine blockade had a protective effect on gut dysfunction and coagulopathy. Increased phosphatidylserine exposure may be a key mediator of organ dysfunction and coagulopathy during sepsis. These data may provide insights into novel treatment options for septic patients.

Type and Quantity of Pharmacologic Therapy for Crohn's Disease before Eventual Surgical Treatment.

Treatment of Crohn's disease (CD) relies on medical therapy with surgery reserved for medically refractory cases. This study measured pharmaceutical therapies that CD patients receive before surgery. Prospective data were collected on 558 patients undergoing surgery for medically refractory CD from November 1999 through June 2014. Patient demographics and preoperative medical therapies were tabulated, including types and number of doses of aminosalicylic acid, corticosteroids, immunomodulators, and biologic therapies. Most patients had been treated with preoperative aminosalicylic acid (72%), steroids (77%), or immunomodulators (69%). Forty-two per cent of patients were treated with a biologic before surgery with a mean number of 20 doses (range, 1-130). In 29 per cent of patients, all therapeutic modalities were used before surgery. Biologic therapy was more common in the last seven years of the study compared with the first eight years (64% vs 35%; P < 0.01). More patients had been treated with all therapeutic modalities before surgery in the second half of the study period (37% vs 19%; P < 0.01). CD patients undergoing surgery have had extensive pharmaceutical treatment. In the current era, more patients have been placed on biologic therapies and more than one third of them failed all available classes of medications before surgical intervention.

Lactate predicts massive transfusion in hemodynamically normal patients.

BACKGROUND: Trauma patients at risk of deterioration because of occult injury may be hemodynamically normal on arrival. Early identification of these patients may improve care, especially for those who require massive transfusion (MT). We hypothesized that elevated admission lactate would predict the need for MT in hemodynamically normal patients. MATERIALS AND METHODS: All trauma patients treated at our university-based urban center over a 5-year period were reviewed. We included hemodynamically normal patients who had an admission lactate performed. First, a receiver-operating curve was used to determine the threshold lactate value. Subsequent analyses were then based on this value. Variables were analyzed using chi-square and unpaired t-tests, and univariable and multivariable regressions. RESULTS: There were 3468 hemodynamically normal patients with an admission lactate. Those who received MT (n = 19) had higher lactate than those who did not (n = 3449; 5.6 versus 2.6 mmol/L, P ≤ 0.001). Receiver-operating curve curve analysis revealed a threshold lactate value of 4 mmol/L with an area under the curve of 0.71. Patients with a lactate of >4 mmol/L had increased mortality (8% versus 2%), longer hospital length of stay (LOS, 6 versus 3 days), longer intensive care unit (ICU) LOS (6 versus 3 days), greater need for MT (2.8% versus 0.3%), and greater blood requirement (219 versus 38 mL; all P values < 0.001). After controlling for confounding variables, the predictive value of admission lactate >4 remained strong (odds ratio, 5.2; 95% confidence interval, 1.87-14.2). CONCLUSIONS: In hemodynamically normal trauma patients, the admission lactate of >4 mmol/L is a robust predictor of MT requirement and associated with poor outcomes.

Timing of Chemical Thromboprophylaxis and Deep Vein Thrombosis in Major Colorectal Surgery: A Randomized Clinical Trial.

OBJECTIVE: To identify the optimal timing of perioperative chemical thromboprophylaxis (CTP) and incidence of occult preoperative deep vein thrombosis (OP-DVT) in patients undergoing major colorectal surgery. BACKGROUND: There is limited Level 1 data regarding the optimal timing of CTP in major colorectal surgery and the incidence of OP-DVT remains unclear. Both issues influence the occurrence of venous thromboembolism (VTE) and may impact Medicare reimbursement because of penalties for hospital-acquired conditions. METHODS: Patients undergoing major colorectal surgery underwent preoperative lower extremity venous duplex (LEVD) immediately before surgery. Those without OP-DVT were randomized to preoperative or postoperative CTP with 5000 units of subcutaneous heparin. Patients underwent repeat LEVD in the recovery room and on postoperative day 2. Outcome measures included early (48-hrs) and overall (30-days) postoperative VTE, bleeding complications, and OP-DVT. RESULTS: Eighteen patients (4.2%) had OP-DVT and were excluded. The randomized group included 376 patients (51.6% female) with mean age of 52.7 ±â€Š17.6 years. No pulmonary embolism occurred. There was no significant difference in preoperative versus postoperative CTP with respect to early postoperative DVT [3/184 (1.6%) vs 5/192 (2.6%); P = 0.72], DVT at 30 days (1.6% vs 3.6%; P = 0.34) or bleeding complications requiring reoperation (0.5% vs 1.6%; P = 0.62). CONCLUSIONS: The risk of OP-DVT is higher than that of perioperative DVT after colorectal surgery and preoperative screening LEVD should be considered to identify and treat patients at risk for pulmonary embolism. Preoperative and postoperative CTP are equally safe in protecting against VTE. CMS should account for these factors when assigning financial disincentives for perioperative VTE. TRIAL REGISTRATION: Clinicaltrials.gov #NCT01976988.

Effect of surgery resident change of shift on trauma resuscitations and outcomes.

INTRODUCTION: The ability of surgery residents to provide continuity of care has come under scrutiny with work hour restrictions. The impact of the surgery resident sign-out period (6-8am and 6-8pm) on trauma outcomes remains unknown. We hypothesize that during shift change, resuscitation times are prolonged with worse outcomes. METHODS: Records of patients treated at a university-based urban trauma center during 2008 and 2009 were reviewed. Patients were separated into a shift change group (6-8am and 6-8pm) and a control group of all other time periods and compared using ANOVA, chi square, and unpaired t-tests. RESULTS: We reviewed the charts of 4361 consecutive trauma patients. There was no difference in gender, acuity, resuscitation times, Glasgow Coma Scale, revised trauma score, injury severity score (ISS), or probability of survival score between patients arriving during shift change compared to other times (p>0.2). There was no difference in total emergency department time for patients arriving during shift change (p = 0.07), even when stratified by ISS (ISS<15, p = 0.09; ISS>15, p = 0.2). Length of stay was increased for patients arriving during shift change compared to other times (5 vs 4 days, p<0.05). This was more pronounced for those with ISS>15 (16 vs 11 days, p = 0.03); however, there was no impact on intensive care unit length of stay, ventilator days, and mortality (p>0.3) regardless of ISS. CONCLUSIONS: Trauma outcomes are generally unaffected by patient arrival during shift change when resident sign-outs occur. Although adaptations are being made to accommodate trauma patient arrival during these times, we need to continue paying close attention, especially to seriously injured patients, to ensure that there are no delays in care that may potentially affect patient outcomes.

Death or dialysis? The risk of dialysis-dependent chronic renal failure after trauma nephrectomy.

Although renal trauma is increasingly managed nonoperatively, severe renovascular injuries occasionally require nephrectomy. Long-term outcomes after trauma nephrectomy are unknown. We hypothesized that the risk of end-stage renal disease (ESRD) is minimal after trauma nephrectomy. We conducted a retrospective review of the following: 1) our university-based, urban trauma center database; 2) the National Trauma Data Bank (NTDB); 3) the National Inpatient Sample (NIS); and 4) the U.S. Renal Data System (USRDS). Data were compiled to estimate the risk of ESRD after trauma nephrectomy in the United States. Of the 232 patients who sustained traumatic renal injuries at our institution from 1998 to 2007, 36 (16%) underwent a nephrectomy an average of approximately four nephrectomies per year. The NTDB reported 1780 trauma nephrectomies from 2002 to 2006, an average of 356 per year. The 2005 NIS data estimated that in the United States, over 20,000 nephrectomies are performed annually for renal cell carcinoma. The USRDS annual incidence of ESRD requiring hemodialysis is over 90,000, of which 0.1 per cent (100 per year) of renal failure is the result of traumatic or surgical loss of a kidney. Considering the large number of nephrectomies performed for cancer, we estimated the risk of trauma nephrectomy causing renal failure that requires dialysis to be 0.5 per cent. National data regarding the etiology of renal failure among patients with ESRD reveal a very low incidence of trauma nephrectomy (0.5%) as a cause; therefore, nephrectomy for trauma can be performed with little concern for long-term dialysis dependence.

Confronting the chronically anticoagulated, acute care surgery patient as we evolve into the post-warfarin era.

There are a growing number of new anticoagulants used as an alternative to warfarin. Surgeons will be confronted with an increasing number of patients who may be on these outpatient medications and must be familiar with their management strategies. The purpose of this review is to examine the mechanisms, monitoring and therapeutic reversal of the non-warfarin antithrombotic agents now so frequently confronting the acute care surgeon.

Bedside thoracic ultrasonography of the fourth intercostal space reliably determines safe removal of tube thoracostomy after traumatic injury.

BACKGROUND: Thoracic ultrasonography is more sensitive than chest radiography (CXR) in detecting pneumothorax; however, the role of ultrasonography to determine resolution of pneumothorax after thoracostomy tube placement for traumatic injury remains unclear. We hypothesized that ultrasonography can be used to determine pneumothorax resolution and facilitate efficient thoracostomy tube removal. We sought to compare the ability of thoracic ultrasonography at the second through fifth intercostal space (ICS) to detect pneumothorax with that of CXR and determine which ICS maximizes the positive and negative predictive value of thoracic ultrasonography for detecting clinically relevant pneumothorax resolution. METHODS: A prospective, blinded clinical study of trauma patients requiring tube thoracostomy placement was performed at a university-based urban trauma center. A surgeon performed daily thoracic ultrasonographies consisting of midclavicular lung evaluation for pleural sliding in ICS 2 through 5. Ultrasonography findings were compared with findings on concurrently obtained portable CXR. RESULTS: Of the patients, 33 underwent 119 ultrasonographies, 109 of which had concomitant portable CXR results for comparison. Ultrasonography of ICS 4 or 5 was better than ICS 2 and 3 at detecting a pneumothorax, with a positive predictive value of 100% and a negative predictive value of 92%. The positive and negative predictive values for ICS 2 were 46% and 93% and for ICS 3 were 63% and 92%, respectively. CONCLUSION: Bedside, surgeon-performed, thoracic ultrasonography of ICS 4 for pneumothorax can safely and efficiently determine clinical resolution of traumatic pneumothorax and aid in the timely removal of thoracostomy tubes. LEVEL OF EVIDENCE: Diagnostic study, level II.

The heart of the matter: utility of ultrasound of cardiac activity during traumatic arrest.

BACKGROUND: The clinical utility of determining cardiac motion on ultrasound has been reported for patients presenting in pulseless medical cardiac arrest. However, the relationship between ultrasound-documented cardiac activity and the probability of surviving pulseless electrical activity has not been examined in populations with trauma. We hypothesized that cardiac activity on ultrasound predicts survival for patients presenting in pulseless traumatic arrest. METHODS: We conducted a retrospective analysis at our university-based urban trauma center of adult patients with trauma, who were pulseless on hospital arrival. Results of cardiac ultrasound performed during trauma resuscitations were compared with the electrocardiogram (EKG) rhythm and survival. RESULTS: Among 318 pulseless patients with trauma, 162 had both EKG tracings and a cardiac ultrasound, and 4.3% of these 162 patients survived to hospital admission. Survival was higher for those with cardiac motion than for those without it (23.5% vs. 1.9% for patients with EKG electrical activity, p = 0.002, and 66.7% vs. 0% for patients without EKG electrical activity, p < 0.001). The sensitivity of ultrasound cardiac motion to predict survival to hospital admission was 86% (specificity, 91%; positive predictive value, 30%; negative predictive value, 99%). When examined by mechanism, sensitivity was 100% for the 111 patients with penetrating trauma and 75% for the 50 patients with blunt trauma. CONCLUSION: Survival in pulseless traumatic arrest is very low, but survival for patients with no cardiac motion on ultrasound is also exceedingly rare. Cardiac ultrasound had a negative predictive value approaching 100% for survival to hospital admission. For patients with prolonged prehospital cardiopulmonary resuscitation, ultrasound evaluation of cardiac motion in pulseless patients with trauma may be a rapid way to help determine which patients have no chance of survival in the setting of lethal injuries, so that futile resuscitations can be stopped.

Emergency uncrossmatched transfusion effect on blood type alloantibodies.

BACKGROUND: Trauma patients receive emergency transfusions of unmatched Type O Rh-negative (Rh-) blood until matched blood is available. We hypothesized that patients given uncrossmatched blood may develop alloantibodies, placing them at risk for hemolytic transfusion reactions (HTRs). METHODS: Data regarding alloantibody profiles and HTR occurrence were collected from the records of trauma patients at our university-based trauma center who received emergency uncrossmatched blood from July 2008 to August 2010. RESULTS: A total of 132 patients received 1,570 units of packed red blood cells. Mean injury severity score was 28 ± 1.3. Forty-five (34%) patients died: 27 on hospital day 1; the remaining 18 had no evidence of HTR before death. Four Rh- female patients received Rh+ fresh frozen plasma, but none received Rh+ packed red blood cells. Three Rh- male patients received both Rh+ packed red blood cells and fresh frozen plasma, and one received Rh+ fresh frozen plasma. One patient developed anti-Rh D antibodies. None experienced HTR. One female patient had HTR from reactivation of anamnestic JK antibodies. Thirteen (33%) of 39 patients met criteria for HTR based on urinalysis and 29 (40%) of 72 patients tested met criteria for HTR based on hemoglobin and bilirubin values. Only one patient had confirmed HTR. CONCLUSION: High rates of injury recidivism in trauma patients increase the likelihood of multiple blood transfusions during their lifetime. Rh- patients who receive Rh+ blood are at risk of developing anti-Rh antibodies, putting them at risk for HTR. The conservation of Rh- blood for use in female patients may be detrimental to Rh- male patients. Laboratory diagnostic criteria for HTR are nonspecific in the trauma population and should be used with caution.