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BACKGROUND: Utilization of evidence-based treatments for patients with colorectal liver metastasis (CRC-LM) outside high-volume centers is not well-characterized. We sought to describe trends in treatment and outcomes, and identify predictors of therapy within a nationwide integrated health system. METHODS: Observational cohort study of patients with CRC-LM treated within the Veterans Affairs (VA) health system (1998-2012). Secular trends and outcomes were compared on the basis of treatment type. Multivariate regression was used to identify predictors of no treatment (chemotherapy or surgery). RESULTS: Among 3270 patients, 57.3 % received treatment (chemotherapy and/or surgery) during the study period. The proportion receiving treatment doubled (38 % in 1998 vs. 68 % in 2012; trend test, p < 0.001), primarily driven by increased use of chemotherapy (26 vs. 57 %; trend test, p < 0.001). Among patients having surgery (16 %), the proportion having ablation (10 vs. 61.9 %; trend test, p < 0.001) and multimodality therapy (15 vs. 67 %; trend test, p < 0.001) increased significantly over time. Older patients [65-75 years: odds ratio (OR) 1.65, 95 % confidence interval (CI) 1.39-1.97; >75 years: OR 3.84, 95 % CI 3.13-4.69] and those with high comorbidity index (Charlson ≥3: OR 1.47, 95 % CI 1.16-1.85) were more likely to be untreated. Overall survival was significantly different based on treatment strategy (log-rank p < 0.001). CONCLUSIONS: The proportion of CRC-LM patients receiving treatment within the largest integrated health system in the US (VA health system) has increased substantially over time; however, one in three patients still does not receive any treatment. Future initiatives should focus on increasing treatment among older patients as well as on evaluating reasons leading to the no-treatment approach and increased use of ablation procedures.
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Neoplasias Colorretais/patologia , Prestação Integrada de Cuidados de Saúde/organização & administração , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/terapia , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Medicina Baseada em Evidências , Feminino , Hospitais de Veteranos , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Estados Unidos , United States Department of Veterans AffairsRESUMO
BACKGROUND: Ileostomy creation is associated with postoperative dehydration and readmission; however, the effect on renal function is unknown. Our goal was to characterize the impact of ileostomy creation on acute and chronic renal function. MATERIALS AND METHODS: A retrospective cohort study with patients undergoing colorectal cancer surgery at a tertiary referral institution (2005-2011). The relationship between ileostomy creation and acute kidney injury (AKI)-related readmission, severe chronic kidney disease (CKD) at 12 mo (glomerular filtration rate <30 mL/min/1.73 m2), and onset of severe CKD over time was evaluated using multivariable logistic and Cox regression and adjusted using propensity score stratification. RESULTS: Among 619 patients, 84 (13%) had ileostomy. AKI-related readmission and severe CKD at 12 mo were more common among ileostomy patients (17% versus 2%, P < 0.01 and 13.3% versus 5%, P = 0.02, respectively). After propensity score adjustment, ileostomy was a significant predictor of AKI-related readmissions (odds ratio: 10.3; 95% confidence interval [CI], 3.9-27.2), severe CKD at 12 mo (odds ratio: 4.1; 95% CI, 1.4-11.9), and onset of severe CKD over time (hazard ratio: 4.2; 95% CI, 2.3-6.6). CONCLUSIONS: Ileostomy creation is associated with increased risk of AKI-related readmissions and development of severe CKD. Future studies must focus on strategies to minimize kidney injury when ileostomy is a necessary component of colorectal cancer surgery and revisiting current indications for ileostomy creation.
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Injúria Renal Aguda/etiologia , Neoplasias Colorretais/cirurgia , Ileostomia/efeitos adversos , Complicações Pós-Operatórias/etiologia , Insuficiência Renal Crônica/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Pontuação de Propensão , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: Readmissions following colorectal surgery are common. However, there are limited data examining unplanned readmissions (URs) after colorectal cancer (CRC) surgery. The goal of this study was to identify reasons and predictors of UR, and to examine their clinical impact on CRC patients. METHODS: A retrospective cohort study using a prospective CRC surgery database of patients treated at a VA tertiary referral center was performed (2005-2011). Ninety-day URs were recorded and classified based on reason for readmission. Clinical impact of UR was measured using a validated classification for postoperative complications. Multivariate logistic regression analyses were performed to identify predictors of UR. RESULTS: 487 patients were included; 104 (21%) required UR. Although the majority of UR were due to surgical reasons (n = 72, 69%), medical complications contributed to 25% of all readmission events. Nearly half of UR (n = 44, 40%) had significant clinical implications requiring invasive interventions, intensive care unit stays, or led to death. After multivariate logistic regression, the following independent predictors of UR were identified: African-American race (odds ratio [OR] 0.47 [0.27-0.88]), ostomy creation (OR 2.50 [1.33-4.70]), and any postoperative complication (OR 4.36 [2.48-7.68]). CONCLUSIONS: Ninety-day URs following colorectal cancer surgery are common, and represent serious events associated with worse outcomes. In addition to postoperative complications, surgical details that can be anticipated (i.e., ileostomy creation) and medical events unrelated to surgery, both contribute as important and potentially preventable reasons for UR. Future studies should focus on developing and examining interventions focused at improving the process of perioperative care for this high-risk population.
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Neoplasias Colorretais/cirurgia , Readmissão do Paciente/estatística & dados numéricos , Idoso , Neoplasias Colorretais/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos/epidemiologia , United States Department of Veterans AffairsRESUMO
OBJECTIVE: To characterize transitional care needs (TCNs) after colorectal cancer (CRC) surgery and examine their association with age and impact on overall survival (OS). BACKGROUND: TCNs after cancer surgery represent additional burden for patients and are associated with higher short-term mortality. They are not well-characterized in CRC patients, particularly in the context of a growing elderly population, and their effect on long-term survival is unknown. METHODS: A retrospective cohort study of CRC patients (N = 486) having curative surgery at a tertiary referral center (2002-2011) was conducted. Outcomes included TCNs (home health or nonhome destination at discharge) and OS. Patients were compared on the basis of age: young (<65 years), old (65-74 years), and oldest (≥75 years). Multivariate logistic regression models were used to examine the association of age with TCNs, and OS was compared on the basis of TCNs and stage, using the Kaplan-Meier method. RESULTS: TCNs were required by 130 patients (27%). The oldest patients had highest TCNs (49%) compared with the other age groups (P < 0.01), with rehabilitation services as their primary TCNs (80%). After multivariate analysis, patients 75 years or older had significantly increased TCN risk (odds ratio, 4.7; 95% confidence interval, 2.6-8.5). TCN was associated with worse OS for patients with early- and advanced stage CRC (P < 0.001). CONCLUSIONS: TCNs after CRC surgery are common and significantly increased in patients 75 years or older, represent an outcome of postoperative recovery, and are associated with worse long-term survival. Preoperative identification of higher risk populations should be used for patient counseling, advanced preoperative planning, and to implement strategies targeted at minimizing TCNs.
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Neoplasias Colorretais/mortalidade , Neoplasias Colorretais/terapia , Continuidade da Assistência ao Paciente/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Cuidados Pós-Operatórios/mortalidade , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Neoplasias Colorretais/patologia , Feminino , Seguimentos , Humanos , Modelos Logísticos , Masculino , Análise Multivariada , Estadiamento de Neoplasias , Razão de Chances , Análise de Regressão , Estudos Retrospectivos , Análise de SobrevidaRESUMO
BACKGROUND: Sphincter preservation (SP) is an important goal of rectal cancer surgery. We hypothesized that SP rates among veteran patients have increased and are comparable to national rates, and that a subset of patients with early disease still undergo non-SP procedures. METHODS: Patients with nonmetastatic primary rectal adenocarcinoma who underwent curative-intent rectal resection were identified from the Veterans Affairs Central Cancer Registry (VACCR) database (1995-2010). SP trends over time were described and compared to the Surveillance, Epidemiology, and End-Results (SEER) population. Subset analysis was performed in patients with nonirradiated, pathologic stage 0-I rectal cancers, a population that may qualify for novel SP strategies. RESULTS: Of 5,145 study patients, 3,509 (68 %) underwent SP surgery. The VACCR SP rate increased from 59.9 % in 1995-1999 to 79.3 % in 2005-2010, when it exceeded that of SEER (76.9 %, p = 0.023). On multivariate analysis, recent time period was independently associated with higher likelihood of SP (odds ratio [OR] 2.64, p < 0.001). Preoperative radiotherapy (OR 0.51, p < 0.001) and higher pathologic stage (OR 0.37, stage III, p < 0.001) were negative predictors. In patients with nonirradiated pathologic stage 0-I cancers, SP rates also increased, but 25 % of these patients underwent non-SP procedures. Within this subset, patients with clinical stage 0 and I disease still had significant rates of abdominoperineal resection (7.7 and 17.0 %, respectively). CONCLUSIONS: SP rates among veterans have increased and surpass national rates. However, an unacceptable proportion of patients with stage 0-I rectal cancers still undergo non-SP procedures. Multimodal treatment with local excision may further improve SP rates in this subset of patients.
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Adenocarcinoma/cirurgia , Canal Anal/cirurgia , Tratamentos com Preservação do Órgão , Períneo/cirurgia , Neoplasias Retais/cirurgia , Adenocarcinoma/epidemiologia , Adenocarcinoma/patologia , Idoso , Canal Anal/patologia , Procedimentos Cirúrgicos do Sistema Digestório , Feminino , Seguimentos , Humanos , Masculino , Estadiamento de Neoplasias , Períneo/patologia , Prognóstico , Neoplasias Retais/epidemiologia , Neoplasias Retais/patologia , Programa de SEER , Estados Unidos/epidemiologia , VeteranosRESUMO
BACKGROUND: Tumor board (TB) conferences facilitate multidisciplinary cancer care and are associated with overall improved outcomes. Because of shortages of the oncology workforce and limited access to TB conferences, multidisciplinary care is not available at every institution. This pilot study assessed the feasibility and acceptance of using telemedicine to implement a virtual TB (VTB) program within a regional healthcare network. MATERIALS AND METHODS: The VTB program was implemented through videoconference technology and electronic medical records between the Houston (TX) Veterans Affairs Medical Center (VAMC) (referral center) and the New Orleans (LA) VAMC (referring center). Feasibility was assessed as the proportion of completed VTB encounters, rate of technological failures/mishaps, and presentation duration. Validated surveys for confidence and satisfaction were administered to 36 TB participants to assess acceptance (1-5 point Likert scale). Secondary outcomes included preliminary data on VTB utilization and its effectiveness in providing access to quality cancer care within the region. RESULTS: Ninety TB case presentations occurred during the study period, of which 14 (15%) were VTB cases. Although one VTB encounter had a technical mishap during presentation, all scheduled encounters were completed (100% completion rate). Case presentations took longer for VTB than for regular TB cases (p=0.0004). However, VTB was highly accepted with mean scores for satisfaction and confidence of 4.6. Utilization rate of VTB was 75%, and its effectiveness was equivalent to that observed for non-VTB cases. CONCLUSIONS: Implementation of VTB is feasible and highly accepted by its participants. Future studies should focus on widespread implementation and validating the effectiveness of this model.
Assuntos
Registros Eletrônicos de Saúde , Neoplasias/terapia , Comunicação por Videoconferência , Estudos de Viabilidade , Humanos , Louisiana , Equipe de Assistência ao Paciente , Estudos Prospectivos , Texas , VeteranosRESUMO
BACKGROUND: South Texas and the Rio Grande Valley (RGV) are medically underserved-communities near the Texas-Mexico border with the highest incidence of end-stage renal disease (ESRD) in the nation, and a shortage of available full-time equivalent (FTE) specialty-physicians. METHODS: Data on the incidence/prevalence of ESRD and workforce projections on vascular-surgeons and nephrologists were collected from the United States Renal Data System and Texas Department of State Health Services. We then merged data from both datasets to identify population-specific healthcare-trends. RESULTS: Texas had the highest rates of ESRD from 2016 to 2020, with its border regions leading the state. By 2032, vascular-surgery and nephrology are projected to have the 1st and 4th worst physician-shortages in the state respectively, with the percentage of these FTE specialty-physicians available to meet the need of the RGV ranging from 42.3 to 58.4 â%. CONCLUSIONS: The RGV is experiencing increased rates of ESRD, while having a paradoxical-decline in specialty-physicians available to provide adequate care.
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The traumatic pancreatoduodenectomy, also known as the traumatic Whipple, is a specialized surgical procedure often reserved for extreme cases in which an individual suffers traumatic injuries to the pancreas, duodenum, or periampullary structures. Traditionally, a Whipple procedure is a complex surgery involving the removal of the head of the pancreas, duodenum, and a portion of both the bile duct and stomach, for the management of pancreatic head cancer. In underserved communities where limited access to healthcare is coupled with a higher incidence of trauma, the lack of specialized and supportive care for patients suffering from pancreatic injuries may lead to an increased morbidity and mortality rate. This case report aims to provide a detailed analysis of a patient who underwent a traumatic pancreatoduodenectomy in a medically underserved region in South Texas, while discussing the rarity of the procedure, its incidence and mortality rates, as well as the subsequent outcomes faced by individuals in this patient population.
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BACKGROUND: Cirrhosis is a risk factor for postoperative morbidity and mortality after general surgical procedures. However, the impact of cirrhosis on outcomes of surgical resection for gastrointestinal (GI) malignancies has not been described. The authors' objective was to characterize early postoperative and transitional outcomes in cirrhotic patients undergoing GI cancer surgery. METHODS: Query of the National Inpatient Sample Database (2005-2008) identified 106,729 patients who underwent resection for GI malignancy; 1479 (1.4%) had cirrhosis. The association of cirrhosis with postoperative outcomes was examined. The primary outcome measure was in-hospital mortality. Secondary outcomes included length-of-stay (LOS) and discharge to long-term care facility (LTCF). RESULTS: Cirrhotic patients had higher risk of in-hospital mortality (8.9% vs 2.8%, P < .001), longer LOS (11.5 ± 0.26 vs 10.0 ± 0.03 days, P < .001), and higher rate of discharge to LTCF (19.0% vs 15.7%, P < .001). Mortality was highest in patients with moderate to severe liver dysfunction (21.5% vs 6.5%, P < .001). On multivariate analysis, cirrhosis was an independent predictor of in-hospital mortality (odds ratio [OR], 3.0; 95% confidence interval [CI] 2.5-3.7) and nonhome discharge (OR, 1.7; 95% CI, 1.4-2.0). In cirrhotic patients, moderate to severe liver dysfunction was the only independent predictor of in-hospital mortality (OR, 4.03; 95% CI, 2.7-5.9), but did not predict discharge disposition. CONCLUSIONS: Resection of GI malignancy in cirrhotics is associated with poor early postoperative and transitional outcomes, with severity of liver disease being the primary determinant of postoperative mortality. These data suggest that GI cancer operations can be performed safely in well-selected cirrhotic patients with mild liver dysfunction.
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Neoplasias Gastrointestinais/cirurgia , Cirrose Hepática/complicações , Idoso , Idoso de 80 Anos ou mais , Feminino , Neoplasias Gastrointestinais/complicações , Neoplasias Gastrointestinais/mortalidade , Mortalidade Hospitalar , Humanos , Cirrose Hepática/cirurgia , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Alta do Paciente , Vigilância da População , Período Pós-Operatório , Fatores de RiscoRESUMO
BACKGROUND: Radical rectal resection with total mesorectal excision is the current standard of care for the operative treatment of rectal cancer. Local excision is an acceptable alternative in selected patients with early disease (T(is)0-T(1)) and low-risk features, in whom radical resection may be associated with unacceptably high morbidity. With recent data demonstrating favorable results in well-selected patients, the role of local excision for rectal cancer is expanding.1 (,) 2 Transanal endoscopic microsurgery (TEM), which requires the use of an operating anoscope, has been used for the local excision of mid-upper rectal tumors. We describe an alternative approach to TEM for rectal cancer. METHODS: We present a stepwise technique for TEM using a single-incision laparoscopic (SILS) port. The patient is a 64 year-old male with a right anterolateral rectal polyp 7 cm from the anal verge, which on snare polypectomy demonstrated in-situ carcinoma with positive margins. Endoscopic ultrasound demonstrated uT(1) disease with no lymphadenopathy. He opted for local excision and underwent TEM. Our stepwise approach includes: (1) delineation of excision margins, (2) full thickness incision of the rectal wall, (3) circumferential dissection, and full thickness excision, and (4) suture repair. RESULTS: The procedure was performed without intraoperative or postoperative complications. Final pathology revealed in-situ carcinoma with widely negative margins. At 1- and 3-week follow-up visits, the patient was pain free with normal bowel activity and no rectal bleeding or genitourinary dysfunction. DISCUSSION: TEM using a SILS port is an effective technique for the local excision of mid-upper rectal cancer in well-selected patients.
Assuntos
Carcinoma in Situ/cirurgia , Laparoscopia/métodos , Microcirurgia/métodos , Neoplasias Retais/cirurgia , Canal Anal/cirurgia , Endoscopia , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Laparoscopic-assisted (LA) colorectal resections have improved short-term outcomes compared with open resections. Lack of tactile feedback, though, has led to lengthy operations and high conversion rates with attendant adverse effects on patients. Hand-assisted laparoscopy (HAL), in contrast, provides tactile feedback while still being minimally invasive. We hypothesize that HAL compared with LA for colorectal cancer resections will be associated with lower conversion rates and decreased operative times, without compromising the advantages of laparoscopy. MATERIALS AND METHODS: We performed a retrospective case-matched study of patients undergoing LA or HAL colorectal cancer resections from 2002 to 2010, using a prospectively maintained colorectal cancer database at a Veterans Affairs Medical Center. Short-term outcomes analyzed (using the Wilcoxon signed rank and McNemar's tests) included operative and perioperative variables and surrogate markers of adequacy of oncologic care. RESULTS: Forty-seven LA patients were matched 1:1 by age and resection with 47 HAL patients. Patients in the HAL group had significantly lower blood loss (100 versus 150 cc, P = 0.04), operative times (206 versus 252 min, P = 0.002), and conversion rates (6% versus 38%, P < 0.0005). They also spent fewer days in the intensive care unit (0 versus 1, P = 0.004) and had quicker return of flatus (3 versus 4 d, P = 0.03). HAL resulted in more lymph nodes resected (21 versus 15, P = 0.03) and a more adequate lymph node harvest (98% versus 77%, P = 0.01). CONCLUSIONS: HAL is associated with improved operative efficiency, conversion rates, and lymphadenectomy as compared with LA colorectal cancer resections. HAL should be considered in the management of colorectal cancer patients.
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Neoplasias Colorretais/cirurgia , Procedimentos Cirúrgicos do Sistema Digestório/estatística & dados numéricos , Laparoscopia Assistida com a Mão/métodos , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Texas/epidemiologiaRESUMO
OBJECTIVES: The goal of this study was to characterize the association of age with postoperative mortality and need for transitional care following hepatectomy for liver metastases. METHODS: A retrospective cohort study using the Nationwide Inpatient Sample (2005-2008) was performed. Patients undergoing hepatectomy for liver metastases were categorized by age as: Young (aged <65 years); Old (aged 65-74 years), and Oldest (aged ≥75 years). Multivariate logistic regression analyses were performed to identify predictors of in-hospital mortality and need for transitional care (non-home discharge). RESULTS: A total of 4026 patients were identified; 36.6% (n = 1475) were elderly (aged ≥65 years). Rates of in-hospital mortality and non-home discharge increased with advancing age group [1.3% vs. 2.2% vs. 3.3% (P = 0.005) and 2.1% vs. 6.1% vs. 18.3% (P < 0.001), respectively]. Independent predictors of in-hospital mortality were age within the Oldest category [odds ratio (OR) 2.21, 95% confidence interval (CI) 1.19-4.12] and a Deyo Comorbidity Index score of ≥3 (OR 6.95, 95% CI 3.55-13.60). Independent predictors for need for transitional care were age within the Old group (OR 2.44, 95% CI 1.66-3.58), age within the Oldest group (OR 8.48, 95% CI 5.87-12.24), a Deyo score of 1 (OR 2.00, 95% CI 1.40-2.85), a Deyo score of 2 (OR 4.70, 95% CI 2.93-7.56), a Deyo score of ≥3 (OR 6.41, 95% CI 3.67-11.20), and female gender (OR 1.56, 95% CI 1.15-2.11). CONCLUSIONS: Although increasing age was associated with higher risk for in-hospital mortality, the absolute risk was low and within accepted ranges, and comorbidity was the primary driver of mortality. Conversely, need for transitional care was significantly more common in elderly patients. Therefore, liver resection for metastases is safe in well-selected elderly patients, although consideration should be made for potential transitional care needs.
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Continuidade da Assistência ao Paciente , Serviços de Saúde para Idosos , Hepatectomia/mortalidade , Neoplasias Hepáticas/secundário , Neoplasias Hepáticas/cirurgia , Alta do Paciente , Fatores Etários , Idoso , Distribuição de Qui-Quadrado , Comorbidade , Hepatectomia/efeitos adversos , Mortalidade Hospitalar , Humanos , Neoplasias Hepáticas/mortalidade , Modelos Logísticos , Análise Multivariada , Razão de Chances , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Colorectal cancer staging criteria do not rely on examination of neuronal tissue. The authors previously demonstrated that perineural invasion is an independent prognostic factor of outcomes in colorectal cancer. For the current study, they hypothesized that neurogenesis occurs in colorectal cancer and portends an aggressive tumor phenotype. METHODS: In total, samples from 236 patients with colorectal cancer were used to create a tissue array and database. Tissue array slides were immunostained for protein gene product 9.5 (PGP9.5) to identify nerve tissue. The correlation between markers of neurogenesis and oncologic outcomes was determined. The effect of colorectal cancer cells on stimulating neurogenesis in vitro was evaluated using a dorsal root ganglia coculture model. RESULTS: Patients whose tumors exhibited high degrees of neurogenesis had 50% reductions in 5-year overall survival and disease-free survival compared with patients whose tumors contained no detectable neurogenesis (P = .002 and P = .006, respectively). Patients with stage II disease and high degrees of neurogenesis had greater reductions in 5-year overall survival and disease-free survival compared with lymph node-negative patients with no neurogenesis (P = .002 and P = .008, respectively). Patients with stage II disease and high degrees of neurogenesis had lower 5-year overall survival and disease-free survival compared with patients who had stage III disease with no neurogenesis (P = .01 and P = .008, respectively). Colorectal cancer cells stimulated neurogenesis and exhibited evidence of neuroepithelial interactions between nerves and tumor cells in vitro. CONCLUSIONS: Neurogenesis in colorectal cancer appeared to play a critical role in colorectal cancer progression. Furthermore, the current results indicated that neurogenesis functions as an independent predictor of outcomes and may play a role in therapy stratification for patients with lymph node-negative disease.
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Adenocarcinoma/patologia , Neoplasias Colorretais/patologia , Neurogênese , Adenocarcinoma/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Linhagem Celular Tumoral , Neoplasias Colorretais/fisiopatologia , Progressão da Doença , Intervalo Livre de Doença , Feminino , Humanos , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Prognóstico , Análise Serial de TecidosRESUMO
Colorectal cancer (CRC) is common among older adults and surgical resection with curative intent is the primary treatment of CRC. Despite the changing demographics of CRC patients and increasing prevalence of multiple comorbidities, surgery is increasingly performed in this complex aging population. Clinically important short-term outcomes have improved for this population, but little is known about long-term outcomes. We review the literature to evaluate trends in CRC surgery in the geriatric population and the outcomes of surgical treatment. We explore the specific gaps in understanding longitudinal patient-centered outcomes of CRC treatment. We then propose adaptations from the geriatrics literature to better predict both short and long-term outcomes after CRC surgery. Interventions, such as prehabilitation, coupled with comprehensive geriatric assessment may be important future strategies for identifying vulnerable older patients, ameliorating the modifiable causes of vulnerability, and improving patient-centered longitudinal outcomes. Further research is needed to determine relevant aspects of geriatric assessments, identify effective intervention strategies, and demonstrate their validity in improving outcomes for at-risk older adults.
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Colectomia/métodos , Neoplasias Colorretais/mortalidade , Neoplasias Colorretais/cirurgia , Continuidade da Assistência ao Paciente/organização & administração , Assistência Perioperatória/métodos , Idoso , Colectomia/mortalidade , Neoplasias Colorretais/diagnóstico , Comorbidade , Feminino , Seguimentos , Avaliação Geriátrica , Humanos , Masculino , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/terapia , Medição de Risco , Análise de Sobrevida , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The Clinical Outcomes of Surgical Therapy Group (COST) trial published in 2004 demonstrated that minimally invasive surgery (MIS) for colorectal cancer provided equivalent oncologic results and better short-term outcomes when compared to open surgery. Before this, MIS comprised approximately 3% of colorectal cancer cases. We hypothesized that there would be a dramatic increase in the use of MIS for colon cancer after this publication. METHODS: The National Inpatient Sample database was used to retrospectively review MIS and open colon resections from 2005 through 2007. ICD-9-specific procedure codes were used to identify open and MIS colon cancer resections. Statistical analyses performed included Pearson χ(2) tests and dependent t tests, and Cramer's V was used to measure the strength of association. RESULTS: A total of 240,446 colon resections were performed between 2005 and 2007. The percentage of resections performed laparoscopically increased from 4.7% in 2005 to 6.7% in 2007 for colon cancer and remained relatively unchanged for benign disease (25.2% in 2005 vs. 27.4% in 2007, P < 0.007). Patients undergoing laparoscopic colectomy were younger, had lower comorbidity scores, had lower rates of complications (20.1 vs. 25.1%, P < 0.001), had shorter lengths of stay (7.2 vs. 9.6 days, P < 0.001), and had lower mortality (1.5 vs. 3.0%, P < 0.001). Furthermore, when evaluating adoption trends, urban teaching hospitals adopted laparoscopy more rapidly than rural nonteaching centers. CONCLUSIONS: Adoption of MIS for the treatment of colorectal cancer has been slow. Additional studies to evaluate barriers in the adoption of MIS for colon cancer resection are warranted.
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Colectomia , Neoplasias do Colo/cirurgia , Laparoscopia , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Idoso , Feminino , Seguimentos , Humanos , Masculino , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: Minimally invasive surgery (MIS) for colorectal resection has been shown to improve short-term outcomes compared with open surgery in patients with colorectal cancer. Currently, there is a paucity of data demonstrating similar efficacy between MIS and open colorectal resection in the elderly population. We hypothesized that minimally invasive surgery provides improved short-term outcomes in elderly patients with colorectal cancer. METHODS: A review of 242 consecutive elderly (≥ 65 y of age) patients who underwent either open or MIS colorectal resection for adenocarcinoma at one institution was conducted. Short-term and oncologic outcomes were analyzed. Continuous variables were analyzed by the Mann-Whitney U test. Categorical variables were compared by χ(2) tests. Survival was compared by the Kaplan-Meier method using the log rank test for comparison. RESULTS: Of the 242 elderly patients with colorectal cancer (median American Society of Anesthesiology score (ASA) scores of 3), 80% (n = 195) of patients underwent open and 20% (n = 47) had MIS colorectal cancer resections. Patients undergoing MIS had a faster return of bowel function, decreased days to nasogastric tube removal, decreased days to flatus and bowel movement, and quicker advancement to clear liquid and regular diets. The overall length of hospital stay in the MIS group was decreased by 40% as well as a trend towards a 50% decrease in SICU stay. Additionally, there was 66% decrease in cardiac complications in the MIS group. When evaluating for oncologic adequacy as measured by number of lymph nodes and surgical resection margins, MIS surgery offered equivalent results as open resection. Furthermore, there was no significant difference in overall survival for MIS versus open colorectal surgery. CONCLUSION: Minimally invasive colorectal cancer resection leads to improved short-term outcomes as demonstrated by decreased length of hospital stay and faster return of bowel function. Additionally, there appears to be no difference in oncologic outcomes in the elderly. On the basis of our data, age alone should not be a contra-indication to laparoscopic colorectal cancer resection.
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Neoplasias Colorretais/cirurgia , Laparoscopia , Procedimentos Cirúrgicos Minimamente Invasivos , Complicações Pós-Operatórias/mortalidade , Recuperação de Função Fisiológica , Idoso , Idoso de 80 Anos ou mais , Neoplasias Colorretais/mortalidade , Bases de Dados Factuais , Intervalo Livre de Doença , Feminino , Humanos , Laparoscopia/mortalidade , Tempo de Internação , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos/mortalidade , Análise Multivariada , Alta do Paciente , Valor Preditivo dos Testes , Fatores de Risco , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: Colorectal cancer patients require care across different disciplines. Integration of multidisciplinary care is critical to accomplish excellent oncologic results. We hypothesized that the establishment of a dedicated colorectal cancer center (CRCC) around specialty-trained surgeons will lead to increased multidisciplinary management and improved outcomes in colorectal cancer patients. METHODS: We analyzed data from three periods: a baseline group, a period after the recruitment of specialty-trained surgeons, and a period after the creation of a dedicated multidisciplinary cancer center. Data analyzed included surrogate markers of surgical oncologic care, multidisciplinary integration, and oncologic outcomes. RESULTS: Recruitment of specialized surgeons led to improvements in surgical oncologic care; the establishment of the CRCC resulted in further improvements in surgical oncologic care and multidisciplinary integration. CONCLUSION: Our study suggests that although the recruitment of specialty-trained surgeons in a high volume center leads to improvement in surgical oncologic care, it is the establishment of a multidisciplinary center around the surgeons that leads to integrated care and improvements in oncologic outcomes.
Assuntos
Institutos de Câncer/organização & administração , Neoplasias Colorretais/mortalidade , Neoplasias Colorretais/cirurgia , Cirurgia Geral/organização & administração , Avaliação de Processos e Resultados em Cuidados de Saúde , Equipe de Assistência ao Paciente/organização & administração , Idoso , Intervalo Livre de Doença , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Seleção de Pessoal , Prognóstico , Fatores de Risco , Recursos HumanosRESUMO
BACKGROUND: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a program designed to measure and improve surgical care quality. In 2015, the study institution formed a multidisciplinary team to address the poor adult postoperative pneumonia performance (worst decile). STUDY DESIGN: The study institution is a 450+ bed tertiary care center that performs 12,000+ surgical procedures annually. From January 2016 to December 2019, the institution abstracted surgical cases and assigned postoperative pneumonia as a complication per the NSQIP operations manual. Using a plan-do-study-act approach, a multidisciplinary postoperative pneumonia prevention team implemented initiatives regarding incentive spirometry education, anesthetic optimization, early mobility, and oral care. The team measured the initiatives' success by analyzing semiannual reports (SAR) provided by the ACS NSQIP and regional adjusted percentile rankings provided by the Georgia Surgical Quality Collaborative (GSQC). RESULTS: The 2015 SAR postoperative pneumonia rate was 4.20% (odds ratio [OR] 3.86, confidence interval [CI] 2.92-5.11). After project initiation, the postoperative pneumonia rates decreased for all NSQIP cases, from 2.51% (OR 2.67, CI 1.89-3.77) in 2016 to 2.08% (OR 2.61, CI 1.82-3.74) in 2017, to 0.85% (OR 1.10, CI 0.69-1.75) in 2018, and then increased slightly to 1.14% (OR 1.27, CI 0.84-1.92) in 2019. The institution's adjusted percentile regional rank of participating regional ACS NSQIP hospitals' postoperative pneumonia rate improved from 14/14 (July 2015-June 2016) to 6/14 (July 2018-June 2019). CONCLUSIONS: The multidisciplinary postoperative pneumonia prevention team successfully decreased the postoperative pneumonia rate, therefore improving surgical patients' outcomes. Furthermore, this quality improvement project also saved valuable revenue for the hospital.
Assuntos
Implementação de Plano de Saúde/organização & administração , Pneumonia Associada a Assistência à Saúde/prevenção & controle , Equipe de Assistência ao Paciente/organização & administração , Complicações Pós-Operatórias/prevenção & controle , Melhoria de Qualidade/organização & administração , Pneumonia Associada a Assistência à Saúde/diagnóstico , Pneumonia Associada a Assistência à Saúde/epidemiologia , Pneumonia Associada a Assistência à Saúde/etiologia , Humanos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Espirometria , Resultado do Tratamento , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Over 70,000,000 American adults are overweight, and obesity accounts for $147 billion annually in medical expenses. Since measuring obesity by body mass index (BMI) fails to account for fat distribution and quantity, recent work has explored quantitative measures of visceral fat area (VFA) and subcutaneous fat area (SFA) obtained from CT imaging. However, use of CT to quantify adipose tissue has not been evaluated in colorectal cancer (CRC) patients and the optimal anatomic location for measuring VFA and SFA has yet to be determined. We measured VFA and SFA at three different anatomic locations to determine which location was optimal in CRC patients. METHODS: A database of patients undergoing CRC surgery from 2002 to 2009 was reviewed to identify patients with preoperative CT imaging. Quantitative measurements of both VFA and SFA were calculated at the level of L4-L5, L2-L3, and mid-waist. RESULTS: A total of 244 colorectal cancer patients had preoperative imaging available and 99% were men. VFA and SFA quantified by CT at the levels of L2-L3, L4-L5, and mid-waist were all significant independent predictors for medical complications of obesity including diabetes (HR 1.04 -1.06) and hypertension (HR 1.04-1.09) on multivariate analysis. The location used for imaging did not affect predictive power. Additionally, waist circumference was also a significant independent predictor of diabetes (HR 1.56) and hypertension (HR 1.70). CONCLUSIONS: Quantitative measures of obesity from CT imaging in CRC patients correlated significantly with medical conditions known to be associated with obesity. This indicates that direct measurement of adiposity is valid in colorectal cancer patients.
Assuntos
Neoplasias Colorretais/diagnóstico por imagem , Neoplasias Colorretais/epidemiologia , Obesidade/diagnóstico por imagem , Obesidade/epidemiologia , Tomografia Computadorizada por Raios X/normas , Idoso , Índice de Massa Corporal , Comorbidade , Diabetes Mellitus/epidemiologia , Feminino , Humanos , Hipertensão/epidemiologia , Gordura Intra-Abdominal/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Fatores de Risco , Gordura Subcutânea/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos , Circunferência da CinturaRESUMO
BACKGROUND: Obesity increases the risk of wound infections following surgery for colon cancer. Considerably less data is available, however, regarding the impact of obesity on infections and wound complications after resection for rectal cancer. Additionally, the impact of minimally invasive surgery (MIS) on complications in rectal surgery remains unclear. We hypothesized that obesity is associated with prolonged operative time and more infectious complications in obese patients undergoing both MIS and open surgery for rectal cancer. MATERIALS AND METHODS: Review of retrospective surgical database. RESULTS: One hundred fifty patients underwent surgery for rectal cancer from 2002 to 2009. Open cases accounted for 72% (n = 108) and MIS for 28% (n = 42) of cases. BMI did not correlate with increased operative time in open rectal surgery, but in MIS patients, operative time increased from a median of 254 min in the lowest quartile of BMI to 333 min in the highest quartile (P < 0.004). Superficial wound infections in open rectal surgery increased from 17% to 52% with increasing BMI (P < 0.005). The increased rate of wound complications persisted in the MIS group. Rate of superficial wound infections and subsequent open packing in the MIS group increased from 0% in the lowest BMI quartile to 33% in the highest quartile (P < 0.029 and P < 0.007, respectively). CONCLUSIONS: Elevated BMI is associated with increased wound complications in both minimally invasive and open rectal surgery. This trend may be related to prolonged operative time in obese patients, particularly in MIS. Our observations suggest that more aggressive techniques to prevent infection are warranted in obese patients undergoing rectal surgery.