What is the Best Inguinal Hernia Repair?

As the management of inguinal hernias have evolved over hundreds of years, so too has our paradigm of what constitutes the "best repair." To best answer what the ideal inguinal hernia repair is, the authors take an in-depth look at considerations to the patient, the provider, and the health care system.

Hospital Costs Following Surgical Complications: A Value-driven Outcomes Analysis of Cost Savings Due to Complication Prevention.

OBJECTIVE: Surgical complications have substantial impact on healthcare costs. We propose an analysis of the financial impact of postoperative complications. SUMMARY OF BACKGROUND DATA: Both complications and preoperative patient risk have been shown to increase costs following surgery. The extent of cost increase due to specific complications has not been well described. METHODS: A single institution's American College of Surgeons National Surgical Quality Improvement Program data was queried from 2012 to 2018 and merged with institutional cost data for each encounter. A mixed effects multivariable generalized linear model was used to estimate the mean relative increase in hospital cost due to each complication, adjusting for patient and procedure-level fixed effects clustered by procedure. Potential savings were calculated based on projected decreases in complication rates and theoretical hospital volume. RESULTS: There were 11,897 patients linked between the 2 databases. The rate of any American College of Surgeons National Surgical Quality Improvement Program complication was 11.7%. The occurrence of any complication resulted in a 1.5-fold mean increase in direct hospital cost [95% confidence interval (CI) 1.49-1.58]. The top 6 most costly complications were postoperative septic shock (4.0-fold, 95% CI 3.58-4.43) renal insufficiency/failure (3.3-fold, 95% CI 2.91-3.65), any respiratory complication (3.1-fold, 95% CI 2.94-3.36), cardiac arrest (3.0-fold, 95% CI 2.64-3.46), myocardial infarction (2.9-fold, 95% CI 2.43-3.42) and mortality within 30 days (2.2-fold, 95% CI 2.01-2.48). Length of stay (6.5 versus 3.2 days, P < 0.01), readmission rate (29.1% vs 3.1%, P < 0.01), and discharge destination outside of home (20.5% vs 2.7%, P < 0.01) were significantly higher in the population who experienced complications. CONCLUSIONS: Decreasing complication rates through preoperative optimization will improve patient outcomes and lead to substantial cost savings.

Value Analysis of Methods of Inguinal Hernia Repair.

OBJECTIVE: Value is defined as health outcomes important to patients relative to cost of achieving those outcomes: Value = Quality/Cost. For inguinal hernia repair, Level 1 evidence shows no differences in long-term functional status or recurrence rates when comparing surgical approaches. Differences in value reside within differences in cost. The aim of this study is to compare the value of different surgical approaches to inguinal hernia repair: Open (Open-IH), Laparoscopic (Lap-IH), and Robotic (R-TAPP). METHODS: Variable and fixed hospital costs were compared among consecutive Open-IH, Lap-IH, and R-TAPP repairs (100 each) performed in a university hospital. Variable costs (VC) including direct materials, labor, and variable overhead ($/min operating room [OR] time) were evaluated using Value Driven Outcomes, an internal activity-based costing methodology. Variable and fixed costs were allocated using full absorption costing to evaluate the impact of surgical approach on value. As cost data is proprietary, differences in cost were normalized to Open-IH cost. RESULTS: Compared to Open-IH, VC for Lap-IH were 1.02X higher (including a 0.81X reduction in cost for operating room [OR] time). For R-TAPP, VC were 2.11X higher (including 1.36X increased costs for OR time). With allocation of fixed cost, a Lap-IH was 1.03X more costly, whereas R-TAPP was 3.18X more costly than Open-IH. Using equivalent recurrence as the quality metric in the value equation, Lap-IH decreases value by 3% and R-TAPP by 69% compared to Open-IH. CONCLUSIONS: Use of higher cost technology to repair inguinal hernias reduces value. Incremental health benefits must be realized to justify increased costs. We expect payors and patients will incorporate value into payment decisions.

Patient-centered Opioid Prescribing: Breaking Away From One-Size-Fits-All Prescribing Guidelines.

BACKGROUND: Procedure-based opioid-prescribing guidelines have reduced the amount of opioids prescribed after surgery; however, many patients are still overprescribed opioids. The 24-h predischarge opioid consumption (PDOC) metric has been proposed to guide patient-centered prescribing. MATERIALS AND METHODS: This is a single-institution, retrospective study of patients who underwent major abdominal surgery. We assessed the correlation between inpatient opioid use and discharge prescriptions using morphine milligram equivalents (MMEs). The adequacy of discharge prescriptions for individual patients was assessed using 2 models, one assuming constant opioid use (based on 24-h PDOC) and the other assuming a linear taper. RESULTS: Of 596 included patients, gastric bypass and colectomy were the most common operations. Median length of stay was 3.5 d. Inpatient opioid use and discharge prescriptions were weakly correlated (r = 0.35). Patients with no opioid use 24 h before discharge (n = 133, 22.3%) were frequently discharged with opioid prescriptions. Patients with high opioid use (24-h PDOC >60 MME) were often discharged with prescriptions that would have lasted <48 h (164/200, 82%). Assuming constant opioid use, discharge prescriptions would have lasted patients a median of 5.1 d. With linear opioid tapering, 440 (72.9%) patients would have had leftover pills. A theoretical discharge prescription of 4 times 24-h PDOC would reduce the median prescription by 130 MMEs and allow a linear taper for 97.6% of patients. CONCLUSIONS: At our institution, opioid prescribing was rarely patient-centered, with little correlation between patient's inpatient opioid use and discharge prescriptions. This leads to overprescribing for most patients and underprescribing for others.

Resolution of Chronic Shoulder Pain after Repair of a Posttraumatic Diaphragmatic Hernia: A 22-Year Delay in Diagnosis and Treatment.

Diagnosing traumatic diaphragmatic rupture (TDR) due to penetrating rib fractures is challenging because the lesions are often too small to be detected and may present years after injury. Patients with delays in diagnosis of TDR rarely present with orthopaedic-related complaints of pain. We report the case of a 52-year-old female who presented with chronic left shoulder pain following a motor vehicle accident (MVA). In addition to left-side lower rib fractures, she also sustained a left-sided splenic laceration, pneumothorax, and two-part upper humerus fracture. Fracture treatment was percutaneous pinning; the other injuries were treated nonoperatively. Her shoulder pain could not be attributed to shoulder or neck pathology. Twenty years after the MVA, she began experiencing episodes of left-sided abdominal pain and nausea. A CT scan obtained two years later revealed a diaphragm hernia, which was repaired laparoscopically. Unique aspects of this case include (1) presentation to an orthopaedic surgeon with a chief complaint of chronic shoulder pain; (2) at 22 years, this is the fourth longest case of a delay in diagnosis of TDR; and (3) the unique symptom of ipsilateral referred shoulder pain, which immediately improved after hernia repair.

Home Disposal Kits for Leftover Opioid Medications After Surgery: Do They Work?

BACKGROUND: Postoperative overprescribing is common, and many patients will have excess medications. An effective method to encourage disposal is lacking. We hypothesized that a convenient home disposal kit will result in more appropriate disposal of excess opioids. MATERIALS AND METHODS: We conducted a single-center prospective observational pilot study to evaluate the effectiveness of a postoperative opioid disposal kit. Patients in the intervention group received an opioid disposal kit and educational handout before discharge from the hospital. At the first follow-up visit, patients completed a survey in which they reported the remaining amount of pain medications from their original prescription and their plan for the excess medication. Patients were asked about risk factors for chronic opioid use. We used multivariable Poisson regression to identify independent factors associated with an increased likelihood of appropriate opioid disposal. RESULTS: The survey was offered to 904 patients with a response rate of 91.7%. After excluding those with missing data, 571 patients were included in the study. Overall, 83 (14.5%) patients never filled an opioid prescription, and 286 (60.0%) patients had tablets remaining at the time of the follow-up visit. Among those with tablets remaining, 52 received a home disposal kit, whereas 234 patients with tablets remaining did not. Patients who received the kit were more likely to dispose of opioid medications (54.9% versus 34.8%, relative risk = 1.8, 95% CI 1.3-2.5). No confounders were identified during multivariable analysis that increased a patient's likelihood of disposing excess medications. CONCLUSIONS: The provision of a convenient home disposal kit postoperatively increased patient-reported opioid disposal.

Esophageal and Esophagogastric Junction Cancers, Version 2.2019, NCCN Clinical Practice Guidelines in Oncology.

Esophageal cancer is the sixth leading cause of cancer-related deaths worldwide. Squamous cell carcinoma is the most common histology in Eastern Europe and Asia, and adenocarcinoma is most common in North America and Western Europe. Surgery is a major component of treatment of locally advanced resectable esophageal and esophagogastric junction (EGJ) cancer, and randomized trials have shown that the addition of preoperative chemoradiation or perioperative chemotherapy to surgery significantly improves survival. Targeted therapies including trastuzumab, ramucirumab, and pembrolizumab have produced encouraging results in the treatment of patients with advanced or metastatic disease. Multidisciplinary team management is essential for all patients with esophageal and EGJ cancers. This selection from the NCCN Guidelines for Esophageal and Esophagogastric Junction Cancers focuses on recommendations for the management of locally advanced and metastatic adenocarcinoma of the esophagus and EGJ.

Combining Surgical Outcomes and Patient Experiences to Evaluate Hospital Gastrointestinal Cancer Surgery Quality.

BACKGROUND: Assessments of surgical quality should consider both surgeon and patient perspectives simultaneously. Focusing on patients undergoing major gastrointestinal cancer surgery, we sought to characterize hospitals, and their patients, on both these axes of quality. METHODS: Using the American College of Surgeons' National Surgical Quality Improvement Program registry, hospitals were profiled on a risk-adjusted composite measure of death or serious morbidity (DSM) generated from patients who underwent colectomy, esophagectomy, hepatectomy, pancreatectomy, or proctectomy for cancer between January 1, 2015 and December 31, 2016. These hospitals were also profiled using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Highest-performing hospitals on both quality axes, and their respective patients, were compared to the lowest-performing hospitals. RESULTS: Overall, 60,526 patients underwent their cancer operation at 530 hospitals. There were 38 highest- and 48 lowest-performing hospitals. The correlation between quality axes was poor (ρ = 0.10). Compared to the lowest-performing hospitals, the highest-performing hospitals were more often NCI-designated cancer centers (29.0% vs. 4.2%, p = 0.002) and cared for a lower proportion of Medicaid patients (0.14 vs. 0.23, p < 0.001). Patients who had their operations at the lowest- versus highest-performing hospitals were more often black (17.2% vs. 8.4%, p < 0.001), Hispanic (8.3% vs. 3.5%, p < 0.001), functionally dependent (3.8% vs. 0.9%, p < 0.001), and not admitted from home (4.4% vs. 2.4%, p < 0.001). CONCLUSIONS: Hospital performance varied when assessed by both risk-adjusted surgical outcomes and patient experiences. In this study, poor-performing hospitals appeared to be disproportionately serving disadvantaged and minority cancer patients.

Single intervention for a reduction in portable chest radiography (pCXR) in cardiovascular and surgical/trauma ICUs and associated outcomes.

PURPOSE: Studies suggest that "on-demand" radiography is equivalent to daily routine with regard to adverse events. In these studies, provider behavior is controlled. Pragmatic implementation has not been studied. MATERIALS AND METHODS: This was a quasi-experimental, pre-post intervention study. Medical directors of two intervention ICUs requested pCXRs be ordered on an on-demand basis at one time point, without controlling or monitoring behavior or providing follow-up. RESULTS: A total of 11,994 patient days over 18months were included. Combined characteristics: Age: 56.7, 66% male, 96% survival, APACHE II 14 (IQR: 11-19), mechanical ventilation (MV) (occurrences)/patient admission: mean 0.7 (SD: 0.6; range: 0-5), duration (hours) of MV: 21.7 (IQR: 9.8-81.4) and ICU LOS (days): 2.8 (IQR: 1.8-5.6). Average pCXR rate/patient/day before was 0.93 (95% CI: 0.89-0.96), and 0.73 (95% CI: 0.69-0.77) after. Controlling for severity, daily pCXR rate decreased by 21.7% (p<0.001), then increased by about 3%/month (p=0.044). There was no change in APACHE II, mortality, and occurrences or duration of MV, unplanned re-intubations, ICU LOS. CONCLUSIONS: In critically ill adults, pCXR reduction can be achieved in cardiothoracic and trauma/surgical patients with a pragmatic intervention, without adversely affecting patient care, outside a controlled study.

Pyloroplasty Offers Relief of Postfundoplication Gastroparesis in Patients Who Improved After Botulinum Toxin Injection.

BACKGROUND: Endoscopic intrapyloric Botox (onabotulinumtoxin A; Allergan Pharmaceuticals) injections can improve postfundoplication gastroparesis, but responses are not durable. Surgical pyloroplasty may relieve gastroparetic symptoms, but patient selection criteria are poorly defined. We hypothesize that pyloroplasty provides durable improvement in patients whose symptoms improved after Botox injection. STUDY DESIGN: A retrospective chart review was performed of patients with postfundoplication gastroparesis who improved after Botox injection and then underwent pyloroplasty. Gastric emptying studies (GES), Gastroparesis Cardinal Symptom Index (GCSI) score, symptoms, and outcomes were reviewed. RESULTS: Ten patients received Heineke-Mikulicz pyloroplasty after reporting improvement with Botox injection. The mean operative time was 114 minutes (range 55-234 minutes). Three of 10 patients required conversion to open surgery, and the median length of stay was 3 days. Gastroparesis symptom improvement occurred in 9 of 10 patients. Postoperative GES normalized in 5/5 patients (median 205 decreased to 70 min, P < .05). Median preoperative GCSI was 3.67, improved to 2.22 at 1 month postsurgery (P = .010) and to 2.11 on most recent follow-up (P = .015). Median duration of follow-up was 34 months (range 1-101 months). CONCLUSION: Heineke-Mikulicz pyloroplasty can improve symptoms and gastric emptying times in patients with postfundoplication gastroparesis. Improvement with intrapyloric Botox injection may select candidates for pyloroplasty.

Validation of a Laparoscopic Ferromagnetic Technology-based Vessel Sealing Device and Comparative Study to Ultrasonic and Bipolar Laparoscopic Devices.

INTRODUCTION: Ferromagnetic heating is a new electrosurgery energy modality that has proven effective in hemostatic tissue dissection as well as sealing and dividing blood vessels and vascularized tissue. The purpose of this study was to evaluate a ferromagnetic-based laparoscopic vessel sealing device with respect to sealing and dividing vessels and vascularized tissue and to compare performance against current vessel sealing technologies. MATERIALS AND METHODS: A laparoscopic vessel sealing device, Laparoscopic FMsealer (LFM), was studied for efficacy in sealing and dividing blood vessels and comparative studies against predicate ultrasonic, Harmonic Ace+(US), and/or bipolar, LigaSure 5 mm Blunt Tip and/or Maryland (BP), devices in vivo using a swine model and in vitro for comparison of seal burst pressure and reliability. Mann-Whitney and Student t test were used for statistical comparisons. RESULTS: In division of 10 cm swine small bowel mesentery in vivo, the laparoscopic FMsealer [12.4±1.8 sec (mean±SD)], was faster compared with US (26.8±2.5 s) and BP (30.0±2.7 s), P<0.05 LFM versus US and BP. Blinded histologic evaluation of 5 mm vessel seals in vivo showed seal lateral thermal spread to be superior in LFM (1678±433 µm) and BP (1796±337 µm) versus US (2032±387 µm), P<0.001. In vitro, seal burst strength and success of sealing 2 to 4 mm arteries were as follows (mean±SD mm Hg, % success burst strength >240 mm Hg): LFM (1079±494 mm Hg, 98.1% success) versus BP (1012±463, 99.0%), P=NS. For 5 to 7 mm arteries: LFM (1098±502 mm Hg, 95.3% success) versus BP (715±440, 91.8%), P<0.001 in burst strength and P=NS in % success. Five 60 kg female swine underwent 21-day survival studies following ligation of vessels ranging from 1 to 7 mm in diameter (n=186 total vessels). Primary seal was successful in 97%, 99% including salvage seals. There was no evidence of postoperative bleeding at sealed vessels at 21-day necropsy. CONCLUSION: The Laparoscopic FMsealer is an effective tool for sealing and dividing blood vessels and vascularized tissue and compares favorably to current technologies in clinically relevant end points.

Gastric Cancer, Version 3.2016, NCCN Clinical Practice Guidelines in Oncology.

Gastric cancer is the fifth most frequently diagnosed cancer and the third leading cause of death from cancer in the world. Several advances have been made in the staging procedures, imaging techniques, and treatment approaches. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Gastric Cancer provide an evidence- and consensus-based treatment approach for the management of patients with gastric cancer. This manuscript discusses the recommendations outlined in the NCCN Guidelines for staging, assessment of HER2 overexpression, systemic therapy for locally advanced or metastatic disease, and best supportive care for the prevention and management of symptoms due to advanced disease.

Ferromagnetic Heating for Vessel Sealing and Division: Utility and Comparative Study to Ultrasonic and Bipolar Technologies.

INTRODUCTION: Vessel sealing technologies have improved surgical efficiency and outcomes. Ferromagnetic technology has potential utility in this area. The aim of this study was to evaluate ferromagnetic heating in sealing and dividing vessels. METHODS: A novel ferromagnetic (FM) sealer, FMsealer, was developed for sealing and dividing vessels. Using a swine in vivo model, the following endpoints were evaluated: (1) proof of concept, (2) 21-day survival surgery, and (3) comparison with ultrasonic (US) and/or bipolar (BP) devices for subjective outcomes. Seal burst strengths were measured in vitro. Mann-Whitney and Student's t test were used. RESULTS: After showing proof of concept, 5 swine underwent survival splenectomy, nephrectomy, hysterectomy, and mesenteric vessel division (arteries ranging from 1 to 7 mm in diameter) with necropsy after day 21 showing no evidence of surgical site bleeding. FM was equivalent to BP in tissue retention and superior to BP in spread/tissue desiccation, sticking, and charring (P ≤ .01). The FM was superior to US and BP in speed of 10 cm mesentery division (mean ± SD seconds): FM (12.9 ± 1.0 seconds), US (23.3 ± 4.4 seconds), BP (46.1 ± 5.2 seconds) (P ≤ .01 FM vs US or BP). Seal burst strength and success of sealing a 5-mm carotid artery were as follows (mean ± SD mmHg, % success burst strength >240 mm Hg): FM (710 ± 206 mm Hg, 94% success), US (848 ± 565 mm Hg, 79%), and BP (619 ± 373 mm Hg, 83%). CONCLUSION: Ferromagnetic heating is an effective and efficient technology for sealing and dividing of vessels. An initial prototype of the FMsealer compared favorably with commercially available products based on ultrasonic and bipolar technologies.

Esophageal and esophagogastric junction cancers, version 1.2015.

Esophageal cancer is the sixth most common cause of cancer deaths worldwide. Adenocarcinoma is more common in North America and Western European countries, originating mostly in the lower third of the esophagus, which often involves the esophagogastric junction (EGJ). Recent randomized trials have shown that the addition of preoperative chemoradiation or perioperative chemotherapy to surgery significantly improves survival in patients with resectable cancer. Targeted therapies with trastuzumab and ramucirumab have produced encouraging results in the treatment of advanced or metastatic EGJ adenocarcinomas. Multidisciplinary team management is essential for patients with esophageal and EGJ cancers. This portion of the NCCN Guidelines for Esophageal and EGJ Cancers discusses management of locally advanced adenocarcinoma of the esophagus and EGJ.

Acceptability of the decision support for safer surgery tool.

BACKGROUND: We examined providers' perceptions of the Decision Support for Safer Surgery (DS3) tool, which provided preoperative patient-level risk estimates of postoperative adverse events. METHODS: The DS3 tool was evaluated at 2 academic medical centers. During the validation study, surgeons provided usefulness ratings of the DS3 tool for each patient before surgery. At the end of the study, providers' perceptions of the DS3 tool were assessed via questionnaire. Data were analyzed using descriptive statistics and independent samples t tests. RESULTS: During the trial, 23 surgeons completed usefulness ratings of the DS3 tool for 1,006 patients. Surgeons rated the tool as "very useful" or "moderately useful" in 251 (25%) of the cases, "neutral" in 469 (46.6%) of the cases, and "moderately unuseful" or "not useful" in 286 (28.4%) cases. At the end of the trial, 32 providers completed the questionnaire; perceptions were relatively neutral, although several aspects were rated quite favorably. CONCLUSION: The DS3 tool may be most useful for achieving particular tasks (eg, training novice surgeons, increasing patient engagement) or encouraging specific processes (eg, team-based care) in surgical care settings.

Comparison of prospective risk estimates for postoperative complications: human vs computer model.

BACKGROUND: Surgical quality improvement tools such as NSQIP are limited in their ability to prospectively affect individual patient care by the retrospective audit and feedback nature of their design. We hypothesized that statistical models using patient preoperative characteristics could prospectively provide risk estimates of postoperative adverse events comparable to risk estimates provided by experienced surgeons, and could be useful for stratifying preoperative assessment of patient risk. STUDY DESIGN: This was a prospective observational cohort. Using previously developed models for 30-day postoperative mortality, overall morbidity, cardiac, thromboembolic, pulmonary, renal, and surgical site infection (SSI) complications, model and surgeon estimates of risk were compared with each other and with actual 30-day outcomes. RESULTS: The study cohort included 1,791 general surgery patients operated on between June 2010 and January 2012. Observed outcomes were mortality (0.2%), overall morbidity (8.2%), and pulmonary (1.3%), cardiac (0.3%), thromboembolism (0.2%), renal (0.4%), and SSI (3.8%) complications. Model and surgeon risk estimates showed significant correlation (p < 0.0001) for each outcome category. When surgeons perceived patient risk for overall morbidity to be low, the model-predicted risk and observed morbidity rates were 2.8% and 4.1%, respectively, compared with 10% and 18% in perceived high risk patients. Patients in the highest quartile of model-predicted risk accounted for 75% of observed mortality and 52% of morbidity. CONCLUSIONS: Across a broad range of general surgical operations, we confirmed that the model risk estimates are in fairly good agreement with risk estimates of experienced surgeons. Using these models prospectively can identify patients at high risk for morbidity and mortality, who could then be targeted for intervention to reduce postoperative complications.

Does travel distance influence length of stay in elective pancreatic surgery?

BACKGROUND: Length of stay (LoS) following elective surgery is being reported as an outcomes quality measure. Regional referral centres may care for patients travelling significant distances. The effect of travel distance on LoS in pancreatic surgery patients was examined. METHODS: National Surgical Quality Improvement Program data on pancreatic surgery patients, operated during the period from 2005 to 2011, were reviewed. Demographics, surgical variables and distance travelled were analysed relative to LoS. The LoS was log-transformed in general linear models to achieve normality. RESULTS: Of the 243 patients, 53% were male. The mean ± standard deviation (SD) age of the total patient sample was 60.6 ± 14 years. The mean ± SD distance travelled was 203 ± 319 miles (326.7 ± 513.4 km) [median: 132 miles (212.4 km); range: 3-3006 miles (4.8-4837.7 km)], and the mean ± SD LoS was 10.5 ± 7 days (range: 1-46 days). Univariate analysis showed a near significant increase in LoS with increased distance travelled (P = 0.05). Significant variables related to LoS were: age (P = 0.002); relative value units (P < 0.001), and preoperative American Society of Anesthesiologists class (P = 0.005). In a general linear model, for every 100 miles (160.9 km) travelled there is an associated 2% increase in LoS (P = 0.031). When the distance travelled is increased by 500 miles (804.7 km), LoS increases by 10.5%. CONCLUSIONS: Increased travel distance from a patient's home to the hospital was independently associated with an increase in LoS. If LoS is a reportable quality measure in pancreatic surgery, travel distance should be considered in risk adjustments.

Association between postoperative complications and clinical cancer outcomes.

INTRODUCTION: The treatment for a majority of solid organ tumors is surgical resection; 10-20 % of patients suffer a perioperative complication. Perioperative complications may contribute to cancer recurrence. This study examined the relationship between postoperative complications and risk-adjusted patient overall survival. METHODS: Data from 2003 to 2009 were linked from our clinical cancer registry, the National Surgery Quality Improvement Project (NSQIP), and medical records. Patients who had tumor extirpation for cure were included. The NSQIP was used to identify complications. Patients with a complication were matched to patients without a complication. χ (2) tests and Cox proportional hazard regression models were used. RESULTS: A total of 415 patients were included for survival analysis. The hazard ratio (HR) for mortality associated with having a complication was 2.17. The HR for mortality after 200 days postoperatively was 2.47. Infectious complications were associated with the highest association with increased mortality (HR = 3.56). Noninfectious complications were not associated with an increased risk of mortality. CONCLUSIONS: This study investigated the relationship of surgical infectious complications in cancer patients with long-term survival for patients who had a number of different types of cancer. After taking into account the site, histology, and stage of the cancer, we found that patients with infectious complications had earlier death.

Gastric cancer, version 2.2013: featured updates to the NCCN Guidelines.

The NCCN Clinical Practice Guidelines in Oncology for Gastric Cancer provide evidence- and consensus-based recommendations for a multidisciplinary approach for the management of patients with gastric cancer. For patients with resectable locoregional cancer, the guidelines recommend gastrectomy with a D1+ or a modified D2 lymph node dissection (performed by experienced surgeons in high-volume centers). Postoperative chemoradiation is the preferred option after complete gastric resection for patients with T3-T4 tumors and node-positive T1-T2 tumors. Postoperative chemotherapy is included as an option after a modified D2 lymph node dissection for this group of patients. Trastuzumab with chemotherapy is recommended as first-line therapy for patients with HER2-positive advanced or metastatic cancer, confirmed by immunohistochemistry and, if needed, by fluorescence in situ hybridization for IHC 2+.

Does travel distance influence length of stay in elective colorectal surgery?

BACKGROUND: Length of stay following elective colorectal surgery is being reported as a quality measure in surgical outcome registries, such as the National Surgical Quality Improvement Program. Regional referral centers with large geographic catchment areas attract patients from significant distances. OBJECTIVE: The aim of this study was to examine the effect of patient distance traveled, from primary residence to a tertiary care hospital, on length of stay in elective colorectal surgery patients. DESIGN: Retrospective population-based cohort study uses data obtained from the National Surgical Quality Improvement Program database. SETTINGS: This study was conducted at a tertiary referral hospital. PATIENTS: Data on 866 patients undergoing elective colorectal surgery from May 2003 to April 2011 were reviewed. MAIN OUTCOME MEASURES: Demographics, surgery-related variables, and distance traveled were analyzed relative to the length of stay. RESULTS: Of the 866 patients, 54% were men, mean age was 57 years, mean distance traveled was 145 miles (range, 2-2984 miles), and mean length of stay was 8.8 days. Univariate analysis showed a significant increase in length of stay with increased distance traveled (p = 0.02). Linear regression analysis revealed a significant association between increased length of stay and male sex (p = 0.006), increasing ASA score (p = 0.000), living alone (p = 0.009), and increased distance traveled (p = 0.028). For each incremental increase in log distance traveled, the length of stay increases by 2.5%. LIMITATIONS: This is a retrospective review that uses National Surgical Quality Improvement Program data. It is not known how many patients left the hospital and did not return to their primary residence. CONCLUSIONS: In a model that controlled for variables, increased travel distance from a patient's residence to the surgical hospital was associated with an increase in length of stay. If length of stay is a reportable quality measure in patients undergoing colorectal surgery, significant travel distance should be accounted for in the risk adjustment model calculations.