Obesity and surgical complications of pancreaticoduodenectomy: An observation study utilizing ACS NSQIP.

BACKGROUND: An estimated 38% of US adults are obese. Obesity is associated with socioeconomic disparities and increased rates of comorbidities, and is a known risk factor for development of pancreatic cancer. As a fourth leading cause of death in the United States, pancreatic cancer is commonly treated with a pancreatico-duodenectomy (PD), or Whipple procedure. Data regarding the effects of obesity on post-operative complication rate primarily comes from specialized centers, however the results are mixed. Our aim is to elucidate the effects that obesity has on outcomes after PD for pancreatic head cancer using a national prospectively maintained clinical database. METHOD: The 2010-2015 American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) Participant Use Files (PUF) were used as the data source. We identified cases in which PD was performed (CPT code 48150) in the setting of a postoperative diagnosis of pancreatic cancer (ICD9 code 157.0). We excluded cases that had emergency admissions, BMI ≤18.5 kg/m2, intraoperative wound classification of III or IV, and disseminated cancer. Cases with missing BMI, preoperative albumin, operative time, LOS data were also excluded. Multiple imputation for missing sex, race, functional status, and ASA classification using chained equations was performed.16 Patients that had BMI ≥30 kg/m2 were considered obese, and patients with BMI <30 kg/m2 were used as control. RESULTS: 3484 patients underwent pancreaticoduodenectomy for pancreatic cancer. 860 patients were identified as obese. Propensity score analysis was performed matching age, sex, race, functional status, presence of dyspnea, diabetes, hypertension, acute renal failure, dialysis dependence, ascites, steroid use, bleeding disorders, history of chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), weight loss, American Society of Anesthesiologists (ASA) classification, and preoperative albumin levels. After matching, obese patients had higher risk of 30-day postoperative complications compared to control, including organ space wound infections (OR 1.38, 95% CI 1.07-1.79, p = 0.0128), returning to the operating room (OR 1.39, 95% CI 1.01-1.91, p = 0.0461), failure to extubate for greater than 48 h (OR 1.60, 95% CI 1.09-2.34, p = 0.0153), death (OR 1.68, 95% CI 1.01-2.78, p = 0.0453), septic shock (OR 2.22, 95% CI 1.46-3.38, p = 0.0002), pulmonary embolism (OR 2.42, 95% CI 1.07-5.45, p = 0.0332), renal insufficiency (OR 2.67, 95% CI 1.33-5.38, p = 0.0058). Sensitivity analysis yielded similar results with the exception of risk for return to the operating room, death, and pulmonary embolism, P > .05. CONCLUSION: In this large observational study using a national clinical database, obese patients undergoing PD for head of pancreas cancer had increased risk of postoperative complications and mortality in comparison to controls.

Is it time to rethink our management of dialysis patients undergoing elective ventral hernia repair? Analysis of the ACS NSQIP database.

PURPOSE: The number of patients on chronic dialysis is steadily increasing each year. There is little data that describes the outcomes in dialysis patients following elective ventral hernia repair, one of the most common general surgery procedures. Our objective was to compare the mortality and morbidity rates in dialysis versus nondialysis patients following elective ventral hernia repair. METHODS: We analysed the ACS NSQIP database to identify patients that underwent elective ventral hernia repair from 2005 to 2010. Univariate analysis and multivariate logistic regression was performed on all patients included. The main outcome variables were mortality and morbidity, length of hospital stay, and return to the operating room. RESULTS: Following elective ventral hernia repair, dialysis patients were more likely to die within 30 days or experience at least one morbidity. Dialysis patients were more likely to experience an infectious, pulmonary or vascular complication. Patients on dialysis also had a 2-fold greater risk of returning to the operating room within 30 days and stayed in the hospital an average of 1.3 days longer than nondialysis patients. Similar results were found after adjustment for demographics and comorbidities using multivariable logistic regression. CONCLUSION: This is one of the largest studies demonstrating the outcomes of a specific general surgery procedure in dialysis patients. Chronic dialysis prior to elective ventral hernia repair is associated with an increased risk of 30-day mortality, morbidity, and return to the operating room. Dialysis patients are susceptible to infectious, pulmonary, and vascular post-operative complications.

Survival among chronic renal failure patients requiring major abdominal surgery.

BACKGROUND: There is limited literature on survival of patients with chronic renal failure (CRF) who require major abdominal surgery. The goal of the present study was to evaluate indications for surgery and survival among dialysis patients undergoing major abdominal operations. STUDY DESIGN: Medical records for 26 CRF patients at our institution undergoing major nonvascular abdominal operations from 1990 to 1996 were reviewed. Results were evaluated by chi-square analysis. RESULTS: Surgery was performed emergently in 21 patients (81%) and electively in 5 patients (19%). The most common finding among the emergency surgery patients was ischemic colitis, occurring in 9 of 21 patients (43%). Postoperative (30-day) mortality among the emergency surgery patients was 38%. Longterm (1 year) survival was 28%. All 5 patients undergoing elective surgery are alive on followup of 1 to 5 years. The disparity in longterm survival between the emergency surgery versus the elective surgery patients was statistically significant (p = 0.004). CONCLUSIONS: Emergency surgery in patients with CRF is associated with poor survival rates. Colonic ischemia is a significant problem among these patients.

Age-related differences in breast cancer stage at diagnosis between black and white patients in an urban community hospital.

BACKGROUND: Breast cancer mortality is significantly higher among black patients compared to white patients. Black women are reportedly at increased risk for early-onset breast cancer. Our goal was to evaluate stage distribution relative to age among black and white breast cancer patients in an institution with a relatively high minority patient population. METHODS: We evaluated 425 patients diagnosed with breast cancer between 1990 and 1994: 56% white, 34% black, the remainder were other ethnicities. Patients were stratified by age: under 50 years versus 50 and older. Socioeconomic status was estimated by utilization of medical care in the private-practice setting versus the public clinic. RESULTS: Significantly more black patients were younger at diagnosis compared to white patients (32% vs. 20%; p = 0.008). There was a significantly more advanced stage distribution among the younger black patients, but not among the older black patients. Most of the black and white patients received private-practice care. CONCLUSIONS: These age-related differences in breast cancer stage distribution between black and white patients (which appeared independent of socioeconomic status) indicate that more aggressive screening and public education programs directed toward younger black women is warranted, and they lend support to the possibility of ethnicity-related variation in primary tumor biology.

Minimizing trochar site herniation in laparoscopic cholecystectomy.

The technique for laparoscopic cholecystectomy (LC) was originally devised and described has remained unchanged because of its efficacy. LC involves a 10-mm trochar in periumbilical region, 10-mm trochar in the epigastrium, and two 5-mm trochars at the right anterior axillary line and right midclavicular line. The exposure and dissection provided by the instruments placed through these trochars is usually adequate and the necessity for additional ports is rare. Our technique modification eliminates the epigastric 10-mm port and replaces it with a 5-mm epigastric port and also eliminates one of the lateral 5-mm ports. Recent articles have reported a significant incidence of Richter's or incisional hernias at the trochar sites. Our modification of the standard technique has the advantage of eliminating a potential incisional hernia at the epigastric port site and further improvement of cosmetic result.

Operative treatment of substernal goiters.

This report describes the operative experience in 72 patients with substernal goiters treated over the past 5.5 years. Even though the incidence of multinodular goiter has decreased in the United States due to the routine use of iodized salt, we continue to see a large number of patients with massive goiters, predominantly from Caribbean Islands. The diagnosis of substernal goiter was made on clinical examination augmented by such radiologic studies, as chest x-ray, barium esophagograms, airway films, and CT scans. Computed tomographic (CT) scanning was particularly helpful in evaluating the extent of substernal extension. Confirmation of the extent of disease was made at the time of operation. Ninety percent of the patients had tracheal deviation and 85% were symptomatic from airway compression. Esophageal compression was noted in 60% of the patients. All patients had a long history of goiter with recent onset of pressure symptoms. Flow-volume-loop studies were performed in 44% of the patients and were useful in the evaluation of pressure symptoms. However, the decision for operation was made primarily based on clinical evaluation of signs and symptoms. Sixteen patients in this group were admitted with acute airway distress requiring airway intubation or semi-emergency decompression. Only 1 patient required mediastinal splitting, while all others were operated by the cervical approach. The decision as to the extent of thyroidectomy was made at the time of operation. Drains were routinely used because of the large dead space. One patient developed a hematoma in the recovery room and required re-exploration.(ABSTRACT TRUNCATED AT 250 WORDS)

Warthin's tumor: multicentricity and increasing incidence in women.

Warthin's tumors comprised 14 percent of all parotid tumors operated on. The average patient age in our series was 57.2 years. Eighty-seven percent of the tumors occurred in the parotid tail. The rest were in the deep lobe, or in an extraparotid location. Fifteen patients had multifocal tumors. The maximum number of tumor foci in one patient was six. A significant increase in the female incidence was noted with a 1.5:1 male-to-female ratio as compared with the previous male dominant ratio of 8:1. Eighty-two percent of the female patients in our group were smokers. We correlated a very high incidence of cigarette smoking in our series when compared with age-matched groups in both sexes within the general population. Since it is estimated that one of eight patients with Warthin's tumor will have multifocal disease, we suggest wider exposure and more meticulous operative exploration to avoid overlooked synchronous tumor foci and subsequent recurrence.

Three synchronous multiorgan primary cancers. All stage I.

A patient who has three separate, synchronous, early (stage I) primary cancers of the right lung, right breast, and stomach and whose disease is simultaneously diagnosed and successfully treated sequentially within a single hospital admission is unique. While multiple primary malignant neoplasms are not uncommon, to our knowledge, there has been no report of triple stage I synchronous carcinomas in separate major organ systems. Age, immunodeficiency, somatotype, hereditary tendencies, hormonal and environmental factors, and previous therapy have been incriminated as etiologic factors. Accurate tissue diagnosis and tumor staging are mandatory. In patients with diagnosed cancer, pulmonary lesions should never be presumed metastatic. Individual tumors should be treated independently of other concomitant lesions, and each treatment approach should be curative in nature. Patients with proven multiple malignant neoplasms carry a higher risk of developing other primary neoplasms.

Survival following breast cancer surgery in the elderly.

A retrospective analysis was performed on a series of 780 patients with breast cancer who underwent surgery, with emphasis on survival in the 138 patients over 70 years of age (elderly group). Absolute survival rates were determined using life table methods. Relative survival figures were derived from absolute figures by adjusting for expected longevity in each group. Patients over 70 years of age had overall 5 and 10 year absolute survival rates of 54% and 41%, respectively, which did not differ significantly from survival rates of younger patients. Relative five-year survival rates for the elderly were actually higher than those of younger patients, being 90% for those with local disease and 65% for those with regional disease. Survival in the elderly was comparable to that of younger patients, irrespective of race, type of surgery, histology or tumor size. These findings support the conclusion that there is little justification for avoiding conventional operative treatment in elderly patients with breast cancer solely on the basis of advanced age.

Effect of triiodothyronine and reserpine on induction and growth of mammary tumors in rats by 3-methylcholanthrene.

This study was designed to investigate the effects of exogenous L-triiodothyronine (LT3) and reserpine administration on the induction and stimulation of 3-methylcholanthrene (3-MC) mammary tumors. Two hundred-fifty-eight 30-day-old virgin 100 gm Sprague Dawley rats were divided into eight groups. Groups I-IV received either reserpine, LT3, both, or saline 22 days after tumor induction with 3-MC. Groups V-VIII were pretreated with either reserpine, LT3, or both for 29 days prior to tumor induction, and treatment was continued after tumor induction in all except Group VII. All rats were observed for tumor growth and sacrificed at seven months. Reserpine administration resulted in a protective effect against tumor induction in all groups in which it was used, with the most striking effects observed in the pretreated groups. Early LT3 stimulation of tumor formation was reversed by simultaneous administration of reserpine. Prolonged administration was unnecessary when both agents were administered prior to 3-methylcholanthrene.

Synchronous leiomyosarcoma and adenocarcinoma of the rectum: report of a case and review of the literature.

A case report of rectal leiomyosarcoma coexisting with an adenocarcinoma of the rectosigmoid is presented. We believe this to be the first reported case of this condition.