Surgical palliation of advanced gastrointestinal tumors.

Patients with advanced gastrointestinal tumors suffer a spectrum of progressive symptoms that reduce their quality of life (QOL). Operative palliative strategies seeking to improve QOL and decrease symptom burden are poorly studied. This study seeks to measure the effect of operations on symptoms and QOL in patients with advanced gastrointestinal malignancies. Patients undergoing World Health Organization (WHO)-defined palliative operations for gastrointestinal cancers were prospectively followed with monthly QOL and Distress Thermometer surveys until 6 months post-operatively. Comparisons were made between preoperative and 3-month postoperative data. Parameters of physical, psychological, social, and spiritual QOL were measured on a scale of 0 (worst) to 5 (best). Frequency of occurrence and degree of distress caused by that specific symptom were scored from 0 (rarely/not at all) to 5 (most of the time/severely). Thirty-five patients had gastrointestinal cancer. The median age was 55.3 years. The most common symptoms were pain and obstruction. Thirty-three operations were abdominal. Ultimately, 34 patients (97%) were discharged home. When preoperative data were compared to 3 months postoperative, the frequency of the primary symptom improved by 2.22 (p = 0.001) and the distress it caused decreased by 1.82 (p = 0.004). Physical QOL decreased by 0.61 (p = 0.009), psychological QOL decreased by 0.50 (p = 0.015), social QOL decreased by 0.48 (p = 0.017), spiritual QOL decreased by 0.42 (p = 0.008), and overall QOL decreased by 0.50 (p = 0.012). Because of the unrelenting nature of gastrointestinal tumors, QOL over time will inevitably decrease. Palliative operations effectively improve symptom frequency and distress without greatly affecting the expected decline in QOL and its parameters.

Symptom concerns and resource utilization in patients with lung cancer.

OBJECTIVE: Lung cancer remains a major source of death in the United States. With the aging of the population, health policy makers are challenged to develop systems of care for the complex needs of these patients. This study sought to determine quality of life and symptom concerns in lung cancer patients. The study also sought to determine how supportive care resources were being used to address these concerns. METHODS: One hundred consecutive patients with newly diagnosed lung cancer presenting over a 12-month period were selected from the tumor registry. Charts were reviewed for demographic data, treatment history, treatment received, number and type of practitioner encounters, readmissions, and complications for a 6-month period. RESULTS: Of the 100 charts retrospectively reviewed, 4 patients had small cell and 96 patients had non-small cell lung cancer. The median age was 67 years. Fifty-three patients were men. The most common symptoms were pain, cough, dyspnea, and fatigue. A total of 114 referrals in 57 patients were made. Nutrition consultation was the most common. CONCLUSIONS: This study serves to guide the institution in the development of more effective support services for patients with lung cancer to address quality of life concerns through collaboration between clinicians and researchers.

Survival in patients with papillary thyroid cancer is not affected by the use of radioactive isotope.

INTRODUCTION: Papillary cancer is the most common neoplasm of the thyroid. The mainstay of treatment is thyroidectomy, but most patients are additionally treated with radioactive iodine (RAI). Its utility is controversial. This study seeks to determine whether RAI use affects patient outcome and to identify specific cohorts of patients that benefit from its use. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database is a large-scale sample of approximately 14% of the US population. It was used to identify patients with papillary carcinoma of the thyroid. Statistical analyses were used to compare prognostic factors such as lymph node status, age, tumor size, and treatment with RAI. RESULTS: A total of 14,545 patients were identified in SEER as having papillary cancer of the thyroid. Multivariate analysis showed significantly worse outcome in patients with age>45 years, tumor size >2 cm, lymph node disease, and distant metastases. Multivariate analysis failed to show RAI significantly affecting mortality. Survival between those not treated with RAI was similar to those whose treatment included it (P = 0.9176). Subgroup analysis identified patients older than 45 years with primary tumors >2 cm and disease in the lymph nodes with distant metastatic disease as the only group positively affected by RAI. CONCLUSIONS: Despite its widespread use in the treatment of well-differentiated papillary cancer of the thyroid, RAI only affects a survival advantage in older patients with large primary tumors involving the lymph nodes and with distant spread. Treating other patient groups is costly and offers no improvement in outcome.

The surgeon and palliative care.

The incidence of cancer will continue to rise in the United States as the population ages. Despite the many advances in cancer prevention, detection, and treatment of neoplastic diseases, the number of people succumbing to their cancers will similarly increase. As these patients encounter symptoms toward the end of life, palliative means, both surgical and nonsurgical, must be employed to alleviate pain and suffering. This article reviews the definitions of palliative care, methods for evaluating quality of life and effect of interventions, unique aspects of surgical palliation, attitudes of surgeons concerning palliative surgery, and data from palliative surgery studies.

Factors affecting survival in patients with anal melanoma.

Anal melanoma is an aggressive tumor with a predilection for early infiltration and distant spread, resulting in poor overall survival. Because anal melanoma is rare, only small case series are reported in the literature, making it difficult to draw conclusions about optimal treatment and outcome. The Surveillance, Epidemiology, and End Results database was used to identify patients with anal melanomas from 1973 to 2001. In addition to demographics, disease extent at presentation, treatment administered, overall survival, and survival by decade of diagnosis were collected. A total of 126 patients with a mean age of 69.2 years was diagnosed with anal melanoma. Sixty-one per cent were female. Median follow-up was 22.5 months. Median survival was 10 months for those with distant disease, 13 months for patients with regional spread, and 34 months for patients with local disease (P = 0.0001). Five-year survival was 32 per cent, 17 per cent, and 0 per cent for patients presenting with local, regional, and distant disease, respectively (P = 0.0001). Neither age at diagnosis, operation performed, nor use of radiation significantly affected survival. Anal melanoma remains an uncommon but lethal disease. Extent of disease correlates with overall survival. Survival is improving, but the use and extent of operation are not associated with improved overall survival.

Radioactive iodine offers survival improvement in patients with follicular carcinoma of the thyroid.

BACKGROUND: The use of radioactive iodine (RAI) in patients with follicular thyroid carcinoma is well established. How its use affects patient outcome and which patients benefit is understood poorly. This study seeks to determine how RAI influences survival and to delineate the populations that are impacted most. METHODS: The Surveillance, Epidemiology, and End Results database is a sample of approximately 14% of the US population. It was used to identify patients with follicular thyroid carcinomas and the treatment that they received. Factors such as the presence of lymph node and distant metastases, age, and tumor size were included for analysis. RESULTS: A total of 4317 patients were identified with follicular thyroid carcinoma. Of these, the records of 2112 patients who were entered in the study after 1988 contained the required data and were included for analysis. Median follow-up time was 95 months. Factors that were associated with increased risk of death included distant metastatic disease, cervical lymph node disease, and the lack of RAI use. Protective factors were tumor size of <2 cm and age of <45 years. Some patients with a greater number of risk factors benefited from RAI. CONCLUSION: RAI provides survival benefit to some patients with follicular carcinoma of the thyroid. The greatest improvements were seen in those patients with locoregional or distant disease spread.

Surgical management of hepatic breast cancer metastases.

Tremendous gains have been made regarding the treatment of breast cancer. The combination of chemotherapy, radiation therapy, and surgery have vastly improved patient course. Hepatic manifestations of metastatic breast cancer are extremely difficult to treat. Traditionally, chemotherapy and hormonal treatment of hepatic metastases of breast carcinoma have not significantly improved survival. For patients with breast cancer metastases isolated to the liver, operative treatment is increasingly being used to prolong life and disease-free intervals. This article reviews the use of surgery for treatment of isolated breast cancer metastases to the liver.

The implication of lymph node metastasis on survival in patients with well-differentiated thyroid cancer.

Though survival for well-differentiated thyroid cancer is very good, specific populations suffer greater recurrence and mortality. Defining these cohorts can significantly influence prognosis and extent of treatment. This study, using a large, multi-institutional database, seeks to determine how the presence of lymph node disease in patients with well-differentiated thyroid cancer affects outcome. The Surveillance, Epidemiology, and End Results (SEER) database is a large-scale sample of 14 per cent of the U.S. population. It was used to identify patients with papillary and follicular thyroid carcinomas and identify the prognostic implications of lymph node metastasis. Additional factors, including presence of metastasis, age, and tumor size, were compared using multivariate and chi2 analyses. Of 19,918 patients identified, lymph node status was known for 9,904 (49.7%). On multivariate analysis, age > 45 years, presence of distant metastasis, large tumor size, and lymph node involvement significantly predicted poor outcome. Overall survival at 14 years was 82 per cent for node negative and 79 per cent for node positive patients (P < 0.05). This study shows that the survival of patients with well-differentiated thyroid cancer is adversely affected by lymph node metastases. The optimum treatment for this cohort needs further delineation, as particular populations are at greater risk of recurrence and death.

Effect of the 80-hour workweek on resident burnout.

HYPOTHESIS: With the introduction of the newly mandated restrictions on resident work hours, we expected improvement in subjective feelings of personal accomplishment and lessened emotional exhaustion and depersonalization. DESIGN: Residents and faculty members completed an anonymous online Maslach Burnout Inventory Human Services Survey (3rd ed; Consulting Psychologist Press Inc, Palo Alto, Calif) and work-hour registry before and after implementation of new restrictions. SETTING: Urban, university-based department of surgery. PARTICIPANTS: All house staff (n = 37) and faculty (n = 27). INTERVENTION: Introduction of new Institutional Standards for Resident Duty Hours 2003. Main Outcome Measure Resident work hours and levels of emotional exhaustion, perceived degree of depersonalization, and personal accomplishment. RESULTS: Resident work hours per week decreased from 100.7 to 82.6 (P < .05) with introduction of the new schedule. Home call and formal educational activity time within working hours (eg, clinical conferences) significantly (P < .05) decreased from 11.5 and 4.8 hours to 4.6 and 2.5 hours per week, respectively. Operating room hours, clinic time, and duration of rounds did not show a significant change. Changes in parameters of resident and faculty emotional exhaustion, depersonalization, and personal accomplishment did not show statistical significance (P > .05). CONCLUSIONS: Despite successful reductions in resident work hours, measures of burnout were not significantly affected. However, important clinical activities such as time spent in the operating room, clinic, and making rounds were maintained. Formal in-hospital education time was reduced.

Carcinoid tumors of the common bile duct: report of two cases.

We report two cases of carcinoid tumors of the common bile duct. The first patient was a 65-year-old woman in whom a carcinoid tumor of the distal bile duct was incidentally found during an open cholecystectomy for cholecystitis. The second patient was a 27-year-old man in whom a distal common bile duct carcinoid was incidentally found during orthotopic liver transplantation for sclerosing cholangitis and multiple biliary strictures. There are few reports of carcinoid tumors of the extrahepatic ducts, and a brief review of the relevant literature is discussed following these case reports.

Complications after laparoscopic gastric bypass: a review of 3464 cases.

HYPOTHESIS: The type and frequency of complications after open Roux-en-Y gastric bypass (GBP) have changed with the development of laparoscopic technique. BACKGROUND: The number of laparoscopic GBP cases performed in the United States has increased dramatically during the past several years. We compared the type and frequency of complications after laparoscopic and open GBP. METHODS: We searched MEDLINE from January 1, 1994, through December 31, 2002, using the keywords morbid obesity, laparoscopy, bariatric surgery, and gastric bypass. We selected studies on laparoscopic or open GBP with more than 50 patients and published in the English language for analysis. We excluded studies with reoperative Roux-en-Y GBP cases or other bariatric procedures. The type and frequency of postoperative complications were recorded from each study. We used chi2 and Fisher exact tests to determine statistical significance. RESULTS: Ten laparoscopic GBP studies with 3464 patients and 8 open GBP studies with 2771 patients were considered. The mean of the reported average age for patients undergoing laparoscopic GBP was 41 years compared with 43 years for open GBP. The mean percentages of female patients were 87% for laparoscopic GBP and 82% for open GBP; the mean reported average body mass index (calculated as weight in kilograms divided by the square of height in meters), 48.7 and 49.5, respectively. Compared with open GBP, laparoscopic GBP was associated with a decrease in the frequency of iatrogenic splenectomy, wound infection, incisional hernia, and mortality; however, there was an increase in the frequency of early and late bowel obstruction, gastrointestinal tract hemorrhage, and stomal stenosis. There were no significant differences in the frequency of anastomotic leak, pulmonary embolism, or pneumonia. CONCLUSIONS: The type and frequency of postoperative complications after laparoscopic and open GBP are different. Certain complications increase with laparoscopic GBP, probably owing to the learning curve of this complex procedure, whereas other complications decrease because of the advantages of the smaller access incision.

Serial abdominal closure technique (the "SAC" procedure): a novel method for delayed closure of the abdominal wall.

Abdominal compartment syndrome may occur after any elective or emergent abdominal operations that are complicated by postoperative hemorrhage or in the trauma patient who has massive fluid replacement for intra-abdominal bleeding. Once the abdomen is decompressed the type of closure varies as much as the surgeon performing the procedure. We have devised a simple, reproducible, inexpensive, and safe method to close the abdomen at the bedside. Serial abdominal closure (SAC) was performed on three patients 45, 54, and 14 years of age who had developed abdominal compartment syndrome secondary to an upper gastrointestinal bleed requiring massive transfusion, a tear of the superior mesenteric vein, and a grade 4 liver laceration respectively, all necessitating abdominal decompression. All three patients had their abdominal wounds closed at the bedside over the course of several days with our SAC technique. Subsequent postoperative course was uneventful and the abdominal wall was free of defects at one-year follow-up. SAC is an efficient, inexpensive, and easily reproducible method of managing the open abdomen. The use of SAC prevented abdominal closure-related complications such as enteric fistula and hernia formation in our three patients.

Reducing the noneducational and nonclinical workload of the surgical resident; defining the role of the health technician.

PURPOSE: Recent controversy over excessive resident work hours has prompted surgical educators and program directors to search for more efficient methods to limit the nonclinical and noneducational workload of surgical residents. Health technicians were employed at a large Veteran's Administration Medical Center to allow residents more time for direct patient care in the clinics and wards and in educational activities. METHODS: In a two-week period, daily data cards were collected from each intern and health technician identifying total hours spent in work, operations, clinics, and conferences. Each intern recorded the number and type of tasks performed and those tasks assigned to the health technician. The number and type of task performed were tabulated and averaged for each health technician and physician. RESULTS: Each intern (n = 3) and health technician (n = 8) completed 100% of the required data forms. In a control survey, each intern worked a mean of 16.9 hours per weekday and 5.0 hours per weekend day. With the addition of the health technicians, interns worked 12.9 hours per weekday and 6.8 hours per weekend day (when the health technicians were not present). Following the addition of the health technicians, resident time in the operating room increased from 3.3 hours per week to 9.8 hours per week. Each health technician aided the intern by performing an average of 20.25 tasks per day. CONCLUSIONS: This study shows that health technicians can be effective in reducing the overall hours and workload of surgical residents and increasing time spent in the operating room. Consideration should be given to including the health technician as integral members of the health care team in the teaching hospital.

Choosing general surgery: insights into career choices of current medical students.

HYPOTHESIS: The number of unfilled general surgery programs in the United States increased from 4 in 1999 to 41 in 2001. This study seeks to determine if changes in student attitudes occurring during their medical school careers and during the third-year general surgery clerkship contribute to a decline in interest in a surgical career. DESIGN: Prospective survey of medical students at a public medical school in California. PARTICIPANTS AND METHODS: Each medical student received a survey via the Internet. Responses were anonymous. Once quantified, chi(2) analysis was used for comparison and analysis of survey results. Comparisons were made between individual class years and on the basis of whether the respondent completed the third-year general surgery clerkship. RESULTS: Of 368 surveys sent, 232 (63%) were successfully completed and included in the study. Comparison of students' attitudes before and after completion of their general surgery clerkship showed that following surgical course exposure more students believed surgery lacked breadth of expertise, limitations over stress, control over one's time, regularity of schedule, adequacy of leisure time, and income commensurate to workload (P<.05). These results are also consistent in comparisons between individual class years. CONCLUSIONS: Data suggest that medical students seem to be more concerned with issues of "controllable lifestyle" such as adequacy of family and/or leisure time, high level of stress, and amount of work and commitment. The erosion of income differential between demanding and less taxing specialties was also an important cause cited for the flagging interest in surgical disciplines.

Intra-abdominal Sepsis in Elderly Persons.

Elderly patients represent a greater percentage of the population now than ever before, with 12.4% of North Americans being >65 years of age. Intra-abdominal illnesses in this population often have different etiologies than those seen in younger populations. Because of a variety of physiologic changes that occur as people age, elderly persons have different sites of infection, may present with vague symptoms and longer histories, are more gravely ill, and, overall, have worse prognoses. The major causes of intra-abdominal sepsis in elderly persons are reviewed, explanations for the differences in presentation and prognosis are offered, and the treatments of each cause are reviewed.