Impact of Hospital Volume on Utilization of Minimally Invasive Surgery for Gastric Cancer.

BACKGROUND: Minimally invasive surgery (MIS) for gastric cancer is increasingly performed. The purpose of this study is to evaluate trends in utilization of laparoscopic and robotic techniques compared to open surgery as well as utilization based on hospital volume. METHODS: We used the National Cancer Database to query patients who underwent gastrectomy from 2010 to 2017 for adenocarcinoma. Regression analyses were used to determine associations between MIS and clinical factors, the trend of MIS over time, and survival. RESULTS: A total of 18,380 patients met inclusion criteria. The annual rates of MIS increased for all hospital volumes, though lower volume centers were less likely to undergo MIS. MIS was associated with a shorter length of stay compared to open, and robotic gastrectomy had a higher rate of obtaining at least 15 lymph nodes and lower rate of having a positive margin. CONCLUSIONS: MIS utilization for resection of gastric cancer increased over time, with robotic surgery increasing at a higher rate than laparoscopic surgery. Importantly, this occurred without increased in mortality or sacrificing adequate oncologic outcomes.

Cryoablation for Renal Cell Carcinoma Prior to Liver Transplantation: A Case Report.

Extrahepatic malignancies are a relatively rare incidental finding during liver transplant work-up that provides a significant barrier to continued transplant evaluation and requires treatment to limit the risk of recurrence. There have only been 11 previously reported cases of pre-liver transplant renal cell carcinoma (RCC), of which all underwent partial or radical nephrectomy. Percutaneous cryoablation therapy has been gaining acceptance as a curative treatment alternative for RCC and is a new therapeutic standard for patients who are poor candidates for surgical resection. Recent studies have demonstrated the safety and efficacy of cryoablation for RCC in native kidneys and in solid masses in kidney allografts, but there is no data on the efficacy or recurrence of RCC when cryoablation is used for the treatment of RCC in a native kidney prior to solid organ transplantation. The patient underwent percutaneous cryoablation therapy of a T1a RCC of the native kidney 10 months prior to orthotopic liver transplant (OLT) without subsequent partial or radical nephrectomy. At seven years post-ablation therapy, the patient has no evidence of tumor recurrence despite immunosuppressive therapy post-transplantation. Cryoablation is potentially a safe and highly effective means of treating RCC in patients who are not candidates for nephrectomy secondary to complications associated with end-stage liver disease. In our case, the patient was treated with cryoablation and received standard post-transplant immunosuppression without recurrence of RCC at seven years. More studies are needed to determine inclusion and exclusion criteria for cryoablation and to confirm long-term efficacy as well as a strategy for duration and frequency of surveillance in these patients.

Bedside Incentive Spirometry Predicts Risk of Pulmonary Complication in Patients with Rib Fractures.

This retrospective chart review demonstrates the relationship between bedside incentive spirometry (ICS) volumes and risk of pulmonary complications. Two hundred patients admitted for rib fractures between April and October 2016 were reviewed. The inclusion criteria were age 18-98 years, diagnosis of rib or sternal fractures, and no procedures requiring postoperative intubation within 48 hours of admission. The exclusion criteria were intubation before arrival, unable to participate in ICS, or previous tracheostomy. ICS volumes recorded in daily progress notes were collected. Of 200 charts reviewed, 154 met the inclusion criteria. In all, 25 endured at least one pulmonary complication. The average ICS on admission was 1355 cc. Patients who did not experience a complication had significantly higher admission ICS volumes than those who did (1441 ± 660 cc vs 920 ± 451 cc, P = 0.0003). They also achieved higher volumes at discharge (1705 ± 662 cc vs 1211 ± 453 cc, P = 0.006). The groups had similar demographics. An admission ICS volume <1 L was associated with 3.3× relative risk of pulmonary complication. Lower volumes were also associated with discharge to nonhome locations. Bedside ICS is a useful tool to identify patients at risk of pulmonary complications from rib fractures. Patients with admission ICS volume <1 L carry a higher risk of complication.

Evaluating the Clinical Validity of Hypertrophic Cardiomyopathy Genes.

BACKGROUND: Genetic testing for families with hypertrophic cardiomyopathy (HCM) provides a significant opportunity to improve care. Recent trends to increase gene panel sizes often mean variants in genes with questionable association are reported to patients. Classification of HCM genes and variants is critical, as misclassification can lead to genetic misdiagnosis. We show the validity of previously reported HCM genes using an established method for evaluating gene-disease associations. METHODS: A systematic approach was used to assess the validity of reported gene-disease associations, including associations with isolated HCM and syndromes including left ventricular hypertrophy. Genes were categorized as having definitive, strong, moderate, limited, or no evidence of disease causation. We also reviewed current variant classifications for HCM in ClinVar, a publicly available variant resource. RESULTS: Fifty-seven genes were selected for curation based on their frequent inclusion in HCM testing and prior association reports. Of 33 HCM genes, only 8 (24%) were categorized as definitive ( MYBPC3, MYH7, TNNT2, TNNI3, TPM1, ACTC1, MYL2, and MYL3); 3 had moderate evidence ( CSRP3, TNNC1, and JPH2; 33%); and 22 (66%) had limited (n=16) or no evidence (n=6). There were 12 of 24 syndromic genes definitively associated with isolated left ventricular hypertrophy. Of 4191 HCM variants in ClinVar, 31% were in genes with limited or no evidence of disease association. CONCLUSIONS: The majority of genes previously reported as causative of HCM and commonly included in diagnostic tests have limited or no evidence of disease association. Systematically curated HCM genes are essential to guide appropriate reporting of variants and ensure the best possible outcomes for HCM families.

Efficacy of Medical Student Surgery Journal Club.

BACKGROUND: Journal clubs exist in a variety of forms in medical schools across the United States. Many incorporate a full spectrum of medical specialties, some are specific to certain interest groups or specialties, and many widely vary in whether or not they are school mandated or student-run. While these clubs are ubiquitously scattered throughout medical education, there has been very little quantitative or qualitative analysis regarding the efficacy of these clubs in enhancing medical students' abilities to evaluate clinical literature. The purpose of this study was to evaluate the effects of attending Surgical Journal Club meetings at Eastern Virginia Medical School from both a qualitative and quantitative perspective. The authors' hypothesis was that regular attendance of these sessions would improve student performance from a multitude of perspectives and demonstrate the value of clinical literature analysis earlier in medical education. METHODS: A fifteen question Likert survey was administered on an optional basis to thirty-six medical students attending journal club. Responses were analyzed anonymously, and there was no incentive or demerit for completing the survey. Data was compiled and the mean, median, and mode for each question calculated with "5" corresponding to "Strongly Agree" and "1" corresponding to "Strongly Disagree." RESULTS: Twenty-seven of thirty-six attendees to our seventh journal club meeting completed the survey. Student responses were overwhelming positive, with all but one question reaching above "Agree" by analysis of the mean responses. CONCLUSION: Journal clubs remain an integral part of medical education but their importance has been diminished in recent years due to the increasing demands of other aspects of the first two years in medical school. We described a medical student run/established journal club that increased students' interest in surgery, their perceived knowledge-base, and comfort in critically analyzing medical journal articles.

Failure of Nonoperative Management of Splenic Injuries in Trauma Patients on Anticoagulation.

Although nonoperative management or embolization with preservation of splenic tissue is preferable, there is a significant risk of continued bleeding ultimately requiring splenectomy. It has been established that elderly patients on anticoagulation (AC) have an increased risk of splenic injury, but there are little data to show whether AC plays a role in outcomes of splenic injury in the setting of trauma. This is a retrospective cohort study, including 168 adults aged 50 to 79 years who presented as a trauma patient to Sentara Norfolk General Hospital from January 1, 2010, to March 31, 2018. The primary outcome is the management of the splenic injury. Of the 168 patients, 30 were presently taking AC at the time of their injury, and 138 were not taking any AC. These groups were similar in average Injury Severity Score, average grade of splenic injury, and average systolic blood pressure on arrival. However, the groups differed significantly in age and hemoglobin on arrival. We found that patients taking AC at the time of injury underwent splenectomy 23.3 per cent of the time, whereas patients not taking AC underwent splenectomy 11.6 per cent of the time (P = 0.045). Patients taking AC failed nonoperative management 20 per cent of the time, whereas patients not taking AC failed 0.7 per cent of the time (P < 0.05). We found that patients taking AC at the time of their traumatic injury were more likely to undergo splenectomy than patients not taking AC. We also found that patients taking AC were more likely to fail nonoperative management.