Surgical resection for adrenocortical carcinoma: Current trends affecting survival.

INTRODUCTION: Adrenocortical carcinoma (ACC) is associated with a poor prognosis. We reviewed the National Cancer Database (NCDB) to analyze the prognostic factors in surgically resected ACC patients and the association of surgical approaches with overall survival (OS). METHODS: A retrospective NCDB (2004-2014) review of patients undergoing curative-intent surgical resection for ACC was performed. Effects of patient demographics, tumor characteristics, histopathology, and perioperative course on OS were analyzed. Log-rank statistics were used to associate clinical variables with OS. The multivariable Cox proportional hazard model included only statistically significant variables. RESULTS: A total of 1599 patients with ACC were included. A majority of patients were female (60.73%) and presented with a Charlson-Deyo score of zero (75.42%). A majority of the ACC cases were Grade 3 (45.69%), and almost a third (30.64%) underwent margin-positive resections. Univariate analysis demonstrated a decrease in OS associated with increasing age and comorbidities. A negative resection margin and lack of lymphovascular invasion predicted better OS. Multivariable analysis showed that age, grade, surgical resection margins, and hospital length of stay were associated with OS. CONCLUSIONS: Advanced age, grade, presence of lymphovascular invasion, and positive surgical margins predicted a worse overall survival for adrenocortical cancer in our analysis. Resection with negative margins improves outcomes.

Paravertebral Nerve Block With Liposomal Bupivacaine for Pain Control Following Video-Assisted Thoracoscopic Surgery and Thoracotomy.

BACKGROUND: Some surgeons have adopted the use of video-assisted thoracoscopic surgery (VATS) or robotic surgery to perform resections for lung cancer. VATS is associated with less pain and a decrease in pulmonary complications compared with open thoracotomies. Long-acting liposomal bupivacaine (LB) intercostal nerve blocks are reported to provide superior pain relief compared with epidural catheters in the first 3 d after a thoracotomy. This study examined whether LB improves pain after VATS and if it provides effective analgesia after a thoracotomy. MATERIALS AND METHODS: A retrospective review was performed on 151 consecutive patients undergoing a VATS or thoracotomy who received paravertebral nerve blocks. VATS patients received paravertebral nerve blocks with LB (VATS-LB) or 0.25% bupivacaine with epinephrine (BE; VATS-BE). Thoracotomy patients received paravertebral nerve blocks via LB injections. Pain scores, narcotic utilization, complications, and hospital length of stay were examined. RESULTS: Fifty patients underwent a VATS-LB, 53 underwent a VATS-BE, and 32 underwent a thoracotomy. Thoracotomy and VATS-LB patients had pain scores lower than VATS-BE patients in the first 48 h after surgery (P < 0.004). Opioid use was not significantly different between the thoracotomy and VATS-LB patients throughout the first 2 wk postoperatively. CONCLUSIONS: LB paravertebral blocks significantly improve postoperative pain in comparison with 0.25% BE blocks in VATS patients. LB paravertebral blocks also provide effective analgesia in patients undergoing thoracotomies.

Conditional survival analysis of hepatocellular carcinoma.

BACKGROUND: Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide with an approximate 5-year survival of greater than 50% in patients after surgical resection. Survival estimates have limited utility for patients who have survived several years after initial treatment. We analyzed how conditional survival (CS) after curative-intent surgery for HCC predicts survival estimates over time. METHODS: NCDB (2004-2014) was queried for patients undergoing definitive surgical resection for HCC. Cumulative overall survival (OS) was calculated using the Kaplan-Meier method, and CS at x years after diagnosis was calculated as CS1 = OS (X+5) /OS(X) . RESULTS: The final analysis encompassed 11 357 patients. Age, negative margin status, grade severity and radiation before surgery were statistically significant predictors of cumulative overall conditional survival (P ≤ .0001). Overall unconditional 5-year survival was 65.7%, but CS estimates were higher. A patient who has already survived 3 years has an additional 2-year, or 5-year CS, estimate of 86.96%. CONCLUSION: Survival estimates following hepatic resection in HCC patients change according to survival time accrued since surgery. CS estimates are improved relative to unconditional OS. The impact of different variables influencing OS is likewise nonlinear over the course of time after surgery.

Next Generation of Global Surgeons: Aligning Interest With Early Access to Global Surgery Education.

BACKGROUND: Although interest in global surgery is increasing among medical students,1 several questions remain unanswered such as: the association of demographics with said interest, the extent that global surgical burden education has been integrated into medical education, and the availability of global surgery electives. This study aimed to assess the current state of global surgery education in the United States (U.S.) to support recommendations for future curriculum development. MATERIALS AND METHODS: An anonymous online survey was distributed to medical students currently enrolled in the U.S. Descriptive data were compiled regarding interest in and access to global surgery programs; demographic data were analyzed using chi-squared testing for categorical variables. RESULTS: A total of 754 students from 18 medical schools throughout the U.S. responded to the survey. Only complete responses were included in final analysis (n = 658). Most of the respondents (66%) reported interest in global surgery, with a higher proportion of those interested being in their preclinical years. However, the majority (79%) reported that global surgery issues are rarely or never addressed in their required curriculum. Over half of respondents were unaware of whether their school even offers such programs. CONCLUSIONS: Although interest in global surgery is on the rise among medical students, results suggest that many currently lack exposure to global surgery concepts in their medical education. To that end, early exposure may be most effective during the preclinical years, so that the next generation may align global surgery participation with clinical aspirations, with the ultimate goal of addressing global disparities.

Optimizing surgical education through the implementation of a feedback curriculum.

BACKGROUND: While the advent of work-hour restrictions contributes to increased resident well-being, new interventions are needed to ensure that surgical residents continue to be adequately trained. Our study aims to take the evidence supportive of enhanced feedback and apply it in the real world by creating a feedback training curriculum within a surgical residency. METHODS: A large academic general surgery residency program consisting of 42 residents was sequentially surveyed using the Kirkpatrick model to assess baseline attitudes towards feedback and the efficacy of a feedback training program for faculty and residents. RESULTS: After feedback training, the number of residents that believed their faculty were providing feedback effectively increased from 23% to 54%. Although limited by small sample size, improvements were likely seen in constructive feedback overall and quality feedback from senior residents. CONCLUSIONS: Formal feedback training should be incorporated into efforts to enhance educational skills among surgical faculty.

Publicly funded interfacility ambulance transfers for surgical and obstetrical conditions: A cross sectional analysis in an urban middle-income country setting.

INTRODUCTION: Interfacility transfers may reflect a time delay of definitive surgical care, but few studies have examined the prevalence of interfacility transfers in the urban low- and middle-income (LMIC) setting. The aim of this study was to determine the number of interfacility transfers required for surgical and obstetric conditions in an urban MIC setting to better understand access to definitive surgical care among LMIC patients. METHODS: A retrospective analysis of public interfacility transfer records was conducted from April 2015 to April 2016 in Cali, Colombia. Data were obtained from the single municipal ambulance agency providing publicly funded ambulance transfers in the city. Interfacility transfers were defined as any patient transfer between two healthcare facilities. We identified the number of transfers for patients with surgical conditions and categorized transfers based on patient ICD-9-CM codes. We compared surgical transfers from public vs. private healthcare facilities by condition type (surgical, obstetric, nonsurgical), transferring physician specialty, and transfer acuity (code blue, emergent, urgent and nonurgent) using logistic regression. RESULTS: 31,659 patient transports occurred over the 13-month study period. 22250 (70.2%) of all transfers were interfacility transfers and 7777 (35%) of transfers were for patients with surgical conditions with an additional 2,244 (10.3%) for obstetric conditions. 49% (8660/17675) of interfacility transfers from public hospitals were for surgical and obstetric conditions vs 32% (1466/4580) for private facilities (P<0.001). The most common surgical conditions requiring interfacility transfer were fractures (1,227, 5.4%), appendicitis (913, 4.1%), wounds (871, 3.9%), abdominal pain (818, 3.6%), trauma (652, 2.9%), and acute abdomen (271, 1.2%). CONCLUSION: Surgical and obstetric conditions account for nearly half of all urban interfacility ambulance transfers. The most common reasons for transfer are basic surgical conditions with public healthcare facilities transferring a greater proportion of patient with surgical conditions than private facilities. Timely access to an initial healthcare facility may not be a reliable surrogate of definitive surgical care given the substantial need for interfacility transfers.

Subcategorizing T1 Staging in Pancreatic Adenocarcinoma Predicts Survival in Patients Undergoing Resection: An Analysis of the National Cancer Database.

Purpose: According to the American Joint Committee on Cancer (AJCC) 7th edition, T1 staging of pancreatic adenocarcinoma (PC) is defined as tumor limited to the pancreas, ≤2 cm. The AJCC 8th edition subcategorizes T1 staging into T1a (≤5 mm), T1b (≤1 cm), and T1c (≤2 cm) for PC despite the absence of supporting evidence. We sought to determine whether this new subcategorization has prognostic significance. Methods: A retrospective review of patients undergoing definitive surgery for PC was performed by using the National Cancer Database (NCDB) from 2004 to 2014. Kaplan-Meier survival was computed for the subcategories. Multivariable analysis (MVA) was performed by using stepwise regression. Results: The NCDB captured 41,552 stages I and II patients who underwent definitive surgery for PC in this 10-year period. A total of 2090 of these patients were pathological T1N0. The 5-year overall survival (OS) for patients with T1a (n = 319), T1b (n = 296), and T1c (n = 1309) PC was 68.8%, 57%, and 46.6%, respectively. This subcategorization lost significance on MVA and when focused on T1N1-2 patients. Recategorizing T stage into T1a (≤1 cm) and T1b (≤2 cm) resulted in statistical significance on MVA. Conclusion: Subcategorization of the T1 stage into T1a, T1b, and T1c in resected PC does differentiate OS in patients with node-negative disease. We support the AJCC 8th edition T1 stage subcategorization, while understanding that it does not differentiate OS on MVA. When this is further subcategorized into T1a (≤1 cm) and T1b (≤2 cm), it predicts OS in resected, node-negative patients on MVA.

Disparities in hepatitis A virus (HAV) vaccination coverage among adult travelers to intermediate or high-risk countries: The role of birthplace and race/ethnicity.

BACKGROUND: While the hepatitis A virus (HAV) vaccine is recommended for United States (US) travelers to endemic regions, vaccination rates are lower among non-US-born adults and some racial minority groups. PURPOSE: We aimed to examine the relationship between birthplace, race and their interaction as predictors of self-reported HAV vaccination among adult travelers to high-risk countries (HRCs) through analysis of the National Health Interview Survey (NHIS), 2012-2015. METHODS: The study included 36,872 US adult participants in the 2012-2015 NHIS who traveled to countries where HAV is endemic. The main outcome was self-reported HAV vaccination (≥2 doses). Complex survey methods were applied to all models to provide statistical estimates that were representative of US adults. Multivariable logistic regression models adjusting for demographic, socioeconomic, medical, and access-to-care characteristics were fitted to examine the association between birthplace, race, race-by-birthplace (for interaction) and vaccination status. RESULTS: For adult travelers to HRCs, the adjusted odds ratio (AOR) of HAV vaccination was lower for non-US-born compared to US-born adults, AOR 0.86 (95% CI; 0.76, 0.98). For Hispanics, the AOR of HAV vaccination was 0.80 (95% CI; 0.70, 0.91) as compared to non-Hispanic-Whites. Furthermore, a significant qualitative interaction between birthplace and race was found (P-value 0.0005). Among non-Hispanic Blacks, the adjusted odds of HAV vaccination for non-US-born adults were 1.35 (95% CI; 1.06, 1.72) times the odds for US-born adults. In contrast, the AORs of HAV vaccination of non-US-born versus US-born adults were 36% (95% CI; 17%, 51%) and 30% (95% CI; 12%, 44%), lower for Asians and Hispanics, respectively. CONCLUSIONS: The association between birthplace and HAV vaccination status differs by race among travelers to HRCs, with US-born non-Hispanic Black and non-US-born Asian and Hispanic adults having lower odds of vaccination. Health care resources should be focused on these target populations to improve travel vaccination compliance.

A novel combined interventional radiologic and hepatobiliary surgical approach to a complex traumatic hilar biliary stricture.

INTRODUCTION: Benign strictures of the biliary system are challenging and uncommon conditions requiring a multidisciplinary team for appropriate management. PRESENTATION OF CASE: The patient is a 32-year-old male that developed a hilar stricture as sequelae of a gunshot wound. Due to the complex nature of the stricture and scarring at the porta hepatis a combined interventional radiologic and surgical approach was carried out to approach the hilum of the right and left hepatic ducts. The location of this stricture was found by ultrasound guidance intraoperatively using a balloon tipped catheter placed under fluoroscopy in the interventional radiology suite prior to surgery. This allowed the surgeons to select the line of parenchymal transection for best visualization of the stricture. A left hepatectomy was performed, the internal stent located and the right hepatic duct opened tangentially to allow a side-to-side Roux-en-Y hepaticojejunostomy (a Puestow-like anastomosis). DISCUSSION: Injury to the intrahepatic biliary ductal confluence is rarely fatal, however, the associated injuries lead to severe morbidity as seen in this example. Management of these injuries poses a considerable challenge to the surgeon and treating physicians. CONCLUSION: Here we describe an innovative multi-disciplinary approach to the repair of this rare injury.

Crystal cookery - using high-throughput technologies and the grocery store as a teaching tool.

Crystallography is a multidisciplinary field that links divergent areas of mathematics, science and engineering to provide knowledge of life on an atomic scale. Crystal growth, a key component of the field, is an ideal vehicle for education. Crystallization has been used with a 'grocery store chemistry' approach and linked to high-throughput remote-access screening technologies. This approach provides an educational opportunity that can effectively teach the scientific method, readily accommodate different levels of educational experience, and reach any student with access to a grocery store, a post office and the internet. This paper describes the formation of the program through the students who helped develop and prototype the procedures. A summary is presented of the analysis and preliminary results and a description given of how the program could be linked with other aspects of crystallography. This approach has the potential to bridge the gap between students in remote locations and with limited funding, and access to scientific resources, providing students with an international-level research experience.