'CROSS'-ing into the 'Real World': a retrospective cohort study of patients receiving trimodality and bimodality therapy for esophageal cancer.

Background: A standard of care for nonmetastatic esophageal cancer is trimodality therapy consisting of neoadjuvant chemoradiation and esophagectomy, with evidence for improved overall survival versus surgery alone in the ChemoRadiotherapy for Oesophageal cancer followed by Surgery Study (CROSS) trial. Patients who receive treatment with curative intent but are poor candidates for or decline surgery receive definitive bimodality therapy. Literature characterizing patients who receive bimodality therapy compared to trimodality therapy, and their relative outcomes, is sparse, especially among patients who are too old or too frail to qualify for clinical trials. In this study, we assess a single-institution real-world dataset of patients receiving bimodality and trimodality management. Methods: Patients treated for clinically resectable, nonmetastatic esophageal cancer between 2009 and 2019 who received bimodality or trimodality therapy were reviewed, generating a dataset of 95 patients. Clinical variables and patient characteristics were assessed for association with modality on multivariable logistic regression. Overall, relapse-free, and disease-free survival were assessed with Kaplan-Meier analyses and Cox proportional modeling. For patients nonadherent to planned esophagectomy, reasons for nonadherence were recorded. Results: Bimodality therapy was associated with greater age-adjusted comorbidity index, worse performance status, higher N-stage, presenting symptom other than dysphagia, and held chemotherapy cycles on multivariable analysis. Compared to bimodality therapy, trimodality therapy was associated with higher overall (3-year: 62% vs. 18%, P<0.001), relapse-free (3-year: 71% vs. 18%, P<0.001), and disease-free (3-year: 58% vs. 12%, P<0.001) survival. Similar results were observed among patients who did not meet CROSS trial qualifying criteria. Only treatment modality was associated with overall survival after adjusting for covariates (HR 0.37, P<0.001, reference group: bimodality). Patient choice accounted for 40% of surgery nonadherence in our population. Conclusions: Patients receiving trimodality therapy were observed to have superior overall survival compared to bimodality therapy. Patient preference for organ-preserving therapies appears to impact resection rate; further characterization of patient decision-making may be helpful. Our results suggest patients who wish to prioritize overall survival should be encouraged to pursue trimodality therapy and obtain early consultation with surgery. Development of evidence-based interventions to physiologically prepare patients before and during neoadjuvant therapy as well as efforts to optimize the tolerability of the chemoradiation plan are warranted.

The Impact of an Acute Care Surgery Model on General Surgery Service Productivity.

BACKGROUND: The Acute Care Surgery (ACS) model has been widely adopted by hospitals across the United States, with ACS services managing emergency general surgery (EGS) patients previously treated by general surgery (GS) services. We evaluated the operational and financial impact of an ACS service model on general surgeons at an academic medical center. METHODS: Using WiseOR® (Palo Alto, CA), we compared surgical case volumes for the GS service two years before (October, 2013 - September, 2015) and two years after (October, 2015 - September, 2017) implementation of an ACS service at the University of Vermont Medical Center. From financial reports, we obtained monthly wRVUs, clinical FTEs, net patient revenue, and payer mix for the GS service and compared the two years before and after ACS model implementation. RESULTS: There was a significant reduction in the average number of cases performed by the GS service following ACS service implementation (monthly mean ± SD, 139.1 ± 16.0 vs. 116.7 ± 14.0, p < 0.001). The normal-hours caseload remained stable, while a significant decrease in after-hours cases accounted for the reduction in overall volume. Despite the reduction in operative volume, the decrease in mean monthly wRVU/FTE for the GS service when comparing the pre- and post- ACS periods did not reach statistical significance (614.9 ± 82.9 vs. 576.3 ± 62.1, p = 0.08).There was a significant increase in average monthly clinic-derived wRVU/FTE for the GS service (106.3 ± 13.5 vs. 120.5 ± 16.4, p = 0.007). CONCLUSIONS: Shifting EGS patient management from the GS to ACS service did not negatively impact the productivity of the GS service.

Parastomal hernia repair.

Parastomal herniation is a common clinical occurrence. Historically, there has been a high recurrence rate after repair, and conservative management is usually recommended for patients with mild symptoms. When operative intervention is warranted, we opt for a laparoscopic mesh sublay over the fascial defect and lateralization of the stoma limb, or the Sugarbaker technique. In patients who are considered poor risk for laparoscopy/laparotomy requiring repair, we perform a fascial onlay with mesh utilizing an anterior circumstomal approach.