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Ayabe RI, Mendoza T, Yennu S, Bruera E, Williams LA, Badgwell B. Symptom Burden in Patients with Malignant Bowel Obstruction Treated With or Without Surgery. J Am Coll Surg 2023; 236:514-522. [PMID: 36729796 DOI: 10.1097/xcs.0000000000000498] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Gastrointestinal obstruction is the most common indication for palliative surgical consultation. We sought to assess patient-reported outcomes and survival after surgical and nonsurgical treatment of malignant bowel obstruction. STUDY DESIGN This was a prospective observational study enrolling patients with advanced malignancy who underwent surgical consultation at a tertiary cancer center. Patient-reported outcomes were evaluated using a previously validated inventory, the MD Anderson Symptom Inventory-Gastrointestinal Obstruction (MDASI-GIO), administered at enrollment and 7 other time points for up to 90 days. RESULTS We enrolled 125 patients, of whom 37 underwent surgery and 88 did not. Patients treated nonsurgically were more likely to have carcinomatosis on imaging (71% vs 49%, p = 0.02). Pain medicine, palliative care, and chaplaincy consultations occurred in 17%, 30%, and 15% of patients within the first month of enrollment. Higher mean symptom scores were noted by surgical patients, although the only single scores with effect sizes 0.5 or greater were symptom interference with general activity and work. The composite score for interference in work, activity, and walking had the largest effect size at -0.37, indicating greater interference in patients undergoing surgery. Patients selected for surgery had extended overall survival (median 15 vs 3 months, p < 0.01). Carcinomatosis, palliative care evaluation, and venting gastrostomy tube were associated with increased risk of death, and ability to receive subsequent chemotherapy and surgical management were positive prognostic indicators. CONCLUSIONS In this first study evaluating patient-reported outcomes after treatment for malignant bowel obstruction, we found that selection for surgical treatment was associated with improved survival, but also more symptom interference in general activities and work. These results may be useful in palliative surgical decision-making and informing patients during consultation for malignant bowel obstruction.
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Affiliation(s)
- Reed I Ayabe
- From the Departments of Surgical Oncology (Ayabe, Badgwell), University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tito Mendoza
- Symptom Research (Mendoza, Williams), University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sriram Yennu
- Palliative Care Medicine (Yennu, Bruera), University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eduardo Bruera
- Palliative Care Medicine (Yennu, Bruera), University of Texas MD Anderson Cancer Center, Houston, TX
| | - Loretta A Williams
- Symptom Research (Mendoza, Williams), University of Texas MD Anderson Cancer Center, Houston, TX
| | - Brian Badgwell
- From the Departments of Surgical Oncology (Ayabe, Badgwell), University of Texas MD Anderson Cancer Center, Houston, TX
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2
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Affiliation(s)
- Julia R Berian
- Department of Surgery, University of Wisconsin-Madison, Madison, Wisconsin
| | - Joshua H Wolf
- Department of Surgery, LifeBridge Health, Baltimore, Maryland
| | - Hiroko Kunitake
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Popivanov G, Cirocchi R, Penchev D, Kjossev K, Konaktchieva M, Mutafchiyski V. Successful Negative Pressure Therapy of Enteroatmospheric Fistula after Right Colectomy for Complicated Crohn’s Disease —A Proposal for a Three-Drain Wound-Separation Technique. Medicina (B Aires) 2022; 58:medicina58020199. [PMID: 35208523 PMCID: PMC8880797 DOI: 10.3390/medicina58020199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 11/30/2022] Open
Abstract
Enteroatmospheric fistulas (EAFs) are still the worst complication of the open abdomen. They lead to a significantly prolonged intensive care unit and hospital stay and to high mortality. Despite the various techniques described in the literature EAFs remain “a nightmare” for the patient, the surgeon, and the hospital. Here we describe a case of right colectomy for obstructing Crohn’s disease in a 26-year-old. On the 19th postoperative day, he developed a superficial EAF. Due to the frozen abdomen, neither resection of the anastomosis, nor implementation of the known techniques for treatment of EAFs were possible. This prompted us to modify the Pepe technique. The EAF was isolated from the upper and lower parts of the wound through deep-skin and subcutaneous sutures and the application of two small pieces of non-adherent plastic foil. The lower holes of a single drain, put through a piece of black foam, were placed over the fistula. The upper holes, which were enveloped with the foam, remained in contact with the wound. The drain was connected to a negative pressure of 125 mmHg. NPWT (negative pressure wound therapy) was also applied by two separate sponges and drains in the upper and lower part. The mainstay of EAF treatment is the isolation of the EAF from the abdominal cavity and subcutaneous tissue, supported by control of the sepsis and adequate nutrition. The proposed technique is applicable in cases with a single, superficial EAF on the background of the frozen abdomen with minimal lateral fascial retraction. As of today, due to the rarity of the condition and lack of randomized trials, EAFs still represents a unique challenge often requiring improvisation.
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Affiliation(s)
- Georgi Popivanov
- Department of Surgery, Military Medical Academy, “Sv. G. Sofiiski” Str. 3, 1606 Sofia, Bulgaria; (D.P.); (K.K.); (V.M.)
- Correspondence: ; Tel.: +359-885-521-241; Fax: +359-2-95-26-536
| | - Roberto Cirocchi
- Department of Surgical Science, University of Perugia, 06123 Perugia, Italy;
| | - Dimitar Penchev
- Department of Surgery, Military Medical Academy, “Sv. G. Sofiiski” Str. 3, 1606 Sofia, Bulgaria; (D.P.); (K.K.); (V.M.)
| | - Kirien Kjossev
- Department of Surgery, Military Medical Academy, “Sv. G. Sofiiski” Str. 3, 1606 Sofia, Bulgaria; (D.P.); (K.K.); (V.M.)
| | - Marina Konaktchieva
- Department of Gastroenterology, Hepatology and Transplantology, Military Medical Academy, “Sv. G. Sofiiski” Str. 3, 1606 Sofia, Bulgaria;
| | - Ventsislav Mutafchiyski
- Department of Surgery, Military Medical Academy, “Sv. G. Sofiiski” Str. 3, 1606 Sofia, Bulgaria; (D.P.); (K.K.); (V.M.)
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Buchlak QD, Esmaili N, Leveque JC, Bennett C, Piccardi M, Farrokhi F. Ethical thinking machines in surgery and the requirement for clinical leadership. Am J Surg 2020; 220:1372-1374. [DOI: 10.1016/j.amjsurg.2020.06.073] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 06/27/2020] [Accepted: 06/28/2020] [Indexed: 12/12/2022]
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McDonald SR, Barbeito A, Lagoo-Deenadayalan SA. Reframing Surgical Risk Using Geriatric Assessment Measures. JAMA Surg 2020; 155:418-419. [PMID: 32159739 DOI: 10.1001/jamasurg.2020.0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Shelley R McDonald
- Department of Medicine, Duke University Medical Center, Durham, North Carolina.,Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, North Carolina.,Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina.,Durham VA Health Care System, Durham, North Carolina
| | - Atilio Barbeito
- Durham VA Health Care System, Durham, North Carolina.,Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Sandhya A Lagoo-Deenadayalan
- Geriatric Research, Education, and Clinical Center, Durham VA Medical Center, Durham, North Carolina.,Center for the Study of Aging, Duke University Medical Center, Durham, North Carolina.,Durham VA Health Care System, Durham, North Carolina.,Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Jakola AS, Sagberg LM, Gulati S, Solheim O. Advancements in predicting outcomes in patients with glioma: a surgical perspective. Expert Rev Anticancer Ther 2020; 20:167-177. [PMID: 32114857 DOI: 10.1080/14737140.2020.1735367] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Introduction: Diffuse glioma is a challenging neurosurgical entity. Although surgery does not provide a cure, it may greatly influence survival, brain function, and quality of life. Surgical treatment is by nature highly personalized and outcome prediction is very complex. To engage and succeed in this balancing act it is important to make best use of the information available to the neurosurgeon.Areas covered: This narrative review provides an update on advancements in predicting outcomes in patients with glioma that are relevant to neurosurgeons.Expert opinion: The classical 'gut feeling' is notoriously unreliable and better prediction strategies for patients with glioma are warranted. There are numerous tools readily available for the neurosurgeon in predicting tumor biology and survival. Predicting extent of resection, functional outcome, and quality of life remains difficult. Although machine-learning approaches are currently not readily available in daily clinical practice, there are several ongoing efforts with the use of big data sets that are likely to create new prediction models and refine the existing models.
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Affiliation(s)
- Asgeir Store Jakola
- Department of Clinical Neuroscience, Institute of Physiology and Neuroscience, Sahlgrenska Academy, Gothenburg, Sweden.,Department of Neurosurgery, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway
| | - Lisa Millgård Sagberg
- Department of Neurosurgery, St.Olavs Hospital, Trondheim, Norway.,Department of Public Health and Nursing, NTNU, Trondheim, Norway
| | - Sasha Gulati
- Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway.,Department of Neurosurgery, St.Olavs Hospital, Trondheim, Norway
| | - Ole Solheim
- Department of Neuromedicine and Movement Science, NTNU, Trondheim, Norway.,Department of Neurosurgery, St.Olavs Hospital, Trondheim, Norway
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Role of surgeon intuition and computer-aided design in Fontan optimization: A computational fluid dynamics simulation study. J Thorac Cardiovasc Surg 2020; 160:203-212.e2. [PMID: 32057454 DOI: 10.1016/j.jtcvs.2019.12.068] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/27/2019] [Accepted: 12/13/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Customized Fontan designs, generated by computer-aided design (CAD) and optimized by computational fluid dynamics simulations, can lead to novel, patient-specific Fontan conduits unconstrained by off-the-shelf grafts. The relative contributions of both surgical expertise and CAD to Fontan optimization have not been addressed. In this study, we assessed hemodynamic performance of Fontans designed by both surgeon's unconstrained modeling (SUM) and by CAD. METHODS Ten cardiac magnetic resonance imaging datasets were used to create 3-dimensional (3D) models of Fontans. Baseline computational fluid dynamics simulations assessed Fontan indexed power loss (iPL), hepatic flow distribution, and percentage of conduit surface area with abnormally low wall shear stress for venous flow (<1 dyne/cm2). Fontans not meeting thresholds were redesigned using 2 methods: SUM (ie, original venous anatomy without the Fontan was 3D printed and sent to surgeon for Fontan redesign with clay modeling) and CAD (ie, the same 3D geometry was sent to engineers for iterative Fontan redesign guided by computational fluid dynamics). Both groups were blinded to each other's results. RESULTS Eight Fontans were redesigned by SUM and CAD methods. Both SUM and CAD redesigns met iPL thresholds. SUM had lower iPL, whereas CAD demonstrated balanced hepatic flow distribution and lower wall shear stress percentage. Wall shear stress percentage shared an inverse relationship with iPL, preventing oversized Fontan designs. CONCLUSIONS Customized Fontan conduits with low iPL can be created by either a surgeon or CAD. CAD can also improve hepatic flow distribution and prevent oversized Fontan designs. Future studies should investigate workflows that combine SUM and CAD to optimize Fontan conduits.
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