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Maddalon B, Cenzi C, Tonello M, Pizzolato E, Barina A, De Simoni O, Franzato B, Gruppo M, Mattara G, Tolin F, Moretto V, Nardi M, Zagonel V, Pilati P, Sommariva A. Clinical benefits of symptom resolution after palliative surgery in advanced cancer: A single-center experience. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108368. [PMID: 38723448 DOI: 10.1016/j.ejso.2024.108368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/13/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Palliative surgery (PS) is defined as any surgical procedure aimed at improving quality of life or relieving symptoms caused by an advanced or metastatic cancer. The involvement of patients, caregivers, and other professional figures is crucial for obtaining optimal symptom relief and avoiding complications. This study aims to evaluate the short-term outcome and related factors in patients undergoing PS. PATIENTS AND METHODS A retrospective analysis was performed in consecutive patients who underwent palliative gastrointestinal surgery at our surgical unit during the period June 2018 to May 2023. Demographic, clinical, pathological and follow-up data were collected from a prospectively maintained department database. The main outcomes were complications, symptoms palliation, symptoms recurrence and return to systemic chemotherapy. Standard statistical analysis was performed. RESULTS During the study period, 127 patients underwent palliative surgery. The Clavien-Dindo 3-5 complication rate and mortality rate were 19.7 % and 6 %, respectively. The resolution of symptoms was achieved in 109 patients (89 %). Successful symptom palliation was significantly related to the possibility of returning to systemic chemotherapy (SC) (OR 9.30 95 % CI 0.1.83-47.18, p 0.007). The only factor related to survival in multivariate analysis was the return to systemic chemotherapy (HR 0.25 95 % CI 0.15-0.42 0.001). CONCLUSION PS in selected patients is effective for symptom resolution and improving overall survival, if the result is making anticancer therapy possible. Prospective data collection is in any case warranted in every institution performing PS for the purpose of monitoring appropriateness and quality of surgical care.
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Affiliation(s)
- Beatrice Maddalon
- Surgical Oncology of Digestive Tract, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Carola Cenzi
- Clinical Research Unit, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Marco Tonello
- Surgical Oncology of Digestive Tract, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Elisa Pizzolato
- Surgical Oncology of Digestive Tract, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Andrea Barina
- Surgical Oncology of Digestive Tract, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Ottavia De Simoni
- Surgical Oncology of Digestive Tract, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Boris Franzato
- Surgical Oncology of Digestive Tract, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Mario Gruppo
- Surgical Oncology of Digestive Tract, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Genny Mattara
- Surgical Oncology of Digestive Tract, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Francesca Tolin
- Surgical Oncology of Digestive Tract, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Valentina Moretto
- Nutritional Support Unit, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Mariateresa Nardi
- Nutritional Support Unit, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Vittorina Zagonel
- Department of Oncology, Oncology 1, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Pierluigi Pilati
- Surgical Oncology of Digestive Tract, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy
| | - Antonio Sommariva
- Surgical Oncology of Digestive Tract, Veneto Institute of Oncology IOV - IRCCS, Padua, Italy.
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Hengartner AC, Havlik J, David WB, Reeves BC, Freedman IG, Sarkozy M, Maloy G, Fernandez T, Craft S, Koo AB, Tuason DA, DiLuna M, Elsamadicy AA. Association Between Intravenous to Oral Opioid Transition Time and Length of Hospital Stay After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis. Int J Spine Surg 2023; 17:468-476. [PMID: 37076256 PMCID: PMC10312154 DOI: 10.14444/8448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Transitioning from intravenous (IV) to oral opioids after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) is necessary during the postoperative course. However, few studies have assessed the effects of longer transition times on hospital length of stay (LOS). This study investigated the impact of longer IV to oral opioid transition times on LOS after PSF for AIS. METHODS The medical records of 129 adolescents (10-18 years old) with AIS undergoing multilevel PSF at a major academic institution from 2013 to 2020 were reviewed. Patients were categorized by IV to oral opioid transition time: normal (≤2 days) vs prolonged (≥3 days). Patient demographics, comorbidities, deformity characteristics, intraoperative variables, postoperative complications, and LOS were assessed. Multivariate analyses were used to determine odds ratios for risk-adjusted extended LOS. RESULTS Of the 129 study patients, 29.5% (n = 38) had prolonged IV to oral transitions. Demographics and comorbidities were similar between the cohorts. The major curve degree (P = 0.762) and median (interquartile range) levels fused (P = 0.447) were similar between cohorts, but procedure time was significantly longer in the prolonged cohort (normal: 6.6 ± 1.2 hours vs prolonged: 7.2 ± 1.3 hours, P = 0.009). Postoperative complication rates were similar between the cohorts. Patients with prolonged transitions had significantly longer LOS (normal: 4.6 ± 1.3 days vs prolonged: 5.1 ± 0.8 days, P < 0.001) but similar discharge disposition (P = 0.722) and 30-day readmission rates (P > 0.99). On univariate analysis, transition time was significantly associated with extended LOS (OR: 2.0, 95% CI [0.9, 4.6], P = 0.014), but this assocation was not significant on multivariate analysis (adjusted OR: 2.1, 95% CI [1.3, 4.8], P = 0.062). CONCLUSIONS Longer postoperative IV to oral opioid transitions after PSF for AIS may have implications for hospital LOS. LEVEL OF EVIDENCE: 3
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Affiliation(s)
- Astrid C Hengartner
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - John Havlik
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Wyatt B David
- Department of Orthopedics, Yale University School of Medicine, New Haven, CT, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Isaac G Freedman
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Margot Sarkozy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Gwyneth Maloy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Tiana Fernandez
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Samuel Craft
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Dominick A Tuason
- Department of Orthopedics, Yale University School of Medicine, New Haven, CT, USA
| | - Michael DiLuna
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
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Stratification of Length of Stay Prediction following Surgical Cytoreduction in Advanced High-Grade Serous Ovarian Cancer Patients Using Artificial Intelligence; the Leeds L-AI-OS Score. Curr Oncol 2022; 29:9088-9104. [PMID: 36547125 PMCID: PMC9776955 DOI: 10.3390/curroncol29120711] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 11/11/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022] Open
Abstract
(1) Background: Length of stay (LOS) has been suggested as a marker of the effectiveness of short-term care. Artificial Intelligence (AI) technologies could help monitor hospital stays. We developed an AI-based novel predictive LOS score for advanced-stage high-grade serous ovarian cancer (HGSOC) patients following cytoreductive surgery and refined factors significantly affecting LOS. (2) Methods: Machine learning and deep learning methods using artificial neural networks (ANN) were used together with conventional logistic regression to predict continuous and binary LOS outcomes for HGSOC patients. The models were evaluated in a post-hoc internal validation set and a Graphical User Interface (GUI) was developed to demonstrate the clinical feasibility of sophisticated LOS predictions. (3) Results: For binary LOS predictions at differential time points, the accuracy ranged between 70-98%. Feature selection identified surgical complexity, pre-surgery albumin, blood loss, operative time, bowel resection with stoma formation, and severe postoperative complications (CD3-5) as independent LOS predictors. For the GUI numerical LOS score, the ANN model was a good estimator for the standard deviation of the LOS distribution by ± two days. (4) Conclusions: We demonstrated the development and application of both quantitative and qualitative AI models to predict LOS in advanced-stage EOC patients following their cytoreduction. Accurate identification of potentially modifiable factors delaying hospital discharge can further inform services performing root cause analysis of LOS.
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Bateni SB, Gingrich AA, Kirane AR, Sauder CAM, Gholami S, Bold RJ, Meyers FJ, Canter RJ. Chemotherapy After Diagnosis of Malignant Bowel Obstruction is Associated with Superior Survival for Medicare Patients with Advanced Malignancy. Ann Surg Oncol 2021; 28:7555-7563. [PMID: 33829359 PMCID: PMC8519893 DOI: 10.1245/s10434-021-09831-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/22/2021] [Indexed: 12/11/2022]
Abstract
Background Although malignant bowel obstruction (MBO) often is a terminal event, systemic therapies are advocated for select patients to extend survival. This study aimed to evaluate factors associated with receipt of chemotherapy after MBO and to determine whether chemotherapy after MBO is associated with survival. Methods This retrospective cohort study investigated patients 65 years of age or older with metastatic gastrointestinal, gynecologic, or genitourinary cancers who were hospitalized with MBO from 2008 to 2012 using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. Fine and Gray models were used to identify factors associated with receipt of chemotherapy accounting for the competing risk of death. Cox models identified factors associated with overall survival. Results Of the 2983 MBO patients, 39% (n = 1169) were treated with chemotherapy after MBO. No differences in receipt of chemotherapy between the surgical and medical patients were found in the univariable analysis (subdistribution hazard ratio [SHR], 0.96; 95% confidence interval [CI], 0.86–1.07; p = 0.47) or multivariable analysis (SHR, 1.12; 95% CI, 1.00–1.26; p = 0.06). Older age, African American race, medical comorbidities, non-colorectal and non-ovarian cancer diagnoses, sepsis, ascites, and intensive care unit stays were inversely associated with receipt of chemotherapy after MBO (p < 0.05). Chemotherapy with surgery was associated with longer survival than surgery (adjusted hazard ratio [aHR], 2.97; 95% CI, 2.65–3.34; p < 0.01) or medical management without chemotherapy (aHR, 4.56; 95% CI, 4.04–5.14; p < 0.01). Subgroup analyses of biologically diverse cancers (colorectal, pancreatic, and ovarian) showed similar results, with greater survival related to chemotherapy (p < 0.05). Conclusions Chemotherapy plays an integral role in maximizing oncologic outcome for select patients with MBO. The data from this study are critical to optimizing multimodality care for these complex patients. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-021-09831-0.
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Affiliation(s)
- Sarah B Bateni
- Division of Surgical Oncology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Alicia A Gingrich
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Amanda R Kirane
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Candice A M Sauder
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Sepideh Gholami
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Richard J Bold
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Frederick J Meyers
- Division of Hematology/Oncology, Department of Internal Medicine, UC Davis Medical Center, University of California, Sacramento, CA, USA
| | - Robert J Canter
- Division of Surgical Oncology, Department of Surgery, UC Davis Medical Center, University of California, Sacramento, CA, USA.
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Strother MC, Michel KF, Xia L, McWilliams K, Guzzo TJ, Lee DJ, Lee DI. Prolonged Length of Stay After Robotic Prostatectomy: Causes and Risk Factors. Ann Surg Oncol 2020; 27:1560-1567. [PMID: 32103416 DOI: 10.1245/s10434-020-08266-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Robot-assisted radical prostatectomy (RARP) can generally be performed with 1-2 nights of postoperative monitoring before discharge from the hospital. Little is known about what causes individual patients to remain in hospital beyond the second postoperative day. METHODS Data for RARPs performed between 2013 and 2015 were extracted from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. The fraction of cases with prolonged length of stay (PLOS) that can be reasonably attributed to complications was examined. Logistic regression was performed to identify risk factors for PLOS in the overall population and separately in the population of patients with PLOS without any perioperative complications. RESULTS Of 11,440 patients, 10,342 (90.4%) were discharged on postoperative days 0-2; 80.6% (887/1101) of patients with PLOS did not experience any perioperative complications. The most common complication was bleeding requiring transfusion, but this was present in only 5.6% (62/1101) of patients with PLOS. Logistic regression identified predictors of PLOS as age, race, wound class, American Society of Anesthesiologists class, smoking, diabetes, dyspnea, dependent functional health status, congestive heart failure, operative time, and pelvic lymph node dissection. Results of this regression were insensitive to the exclusion of patients who experienced no perioperative complications. CONCLUSIONS This study utilizes logistic regression on NSQIP data to identify risk factors for PLOS after RARP and, in particular, to evaluate the role of postoperative complications in PLOS. The analysis shows that postoperative complications account for a small minority of cases of PLOS after RARP.
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Affiliation(s)
- Marshall C Strother
- Department of Surgery, Division of Urology, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Katharine F Michel
- Department of Surgery, Division of Urology, University of Pennsylvania Health System, Philadelphia, PA, USA.
| | - Leilei Xia
- Department of Surgery, Division of Urology, University of Pennsylvania Health System, Philadelphia, PA, USA
| | | | - Thomas J Guzzo
- Department of Surgery, Division of Urology, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Daniel J Lee
- Department of Surgery, Division of Urology, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - David I Lee
- Department of Surgery, Division of Urology, University of Pennsylvania Health System, Philadelphia, PA, USA
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Lee KC, Walling AM, Senglaub SS, Kelley AS, Cooper Z. Defining Serious Illness Among Adult Surgical Patients. J Pain Symptom Manage 2019; 58:844-850.e2. [PMID: 31404642 PMCID: PMC7155422 DOI: 10.1016/j.jpainsymman.2019.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/01/2019] [Accepted: 08/02/2019] [Indexed: 12/21/2022]
Abstract
CONTEXT Palliative care (PC) for seriously ill surgical patients, including aligning treatments with patients' goals and managing symptoms, is associated with improved patient-oriented outcomes and decreased health care utilization. However, efforts to integrate PC alongside restorative surgical care are limited by the lack of a consensus definition for serious illness in the perioperative context. OBJECTIVES The objectives of this study were to develop a serious illness definition for surgical patients and identify a denominator for quality measurement efforts. METHODS We developed a preliminary definition including a set of criteria for 11 conditions and health states. Using the RAND-UCLA Appropriateness Method, a 12-member expert advisory panel rated the criteria for each condition and health state twice, once after an in-person moderated discussion, for validity (primary outcome) and feasibility of measurement. RESULTS All panelists completed both rounds of rating. All 11 conditions and health states defining serious illness for surgical patients were rated as valid. During the in-person discussion, panelists refined and narrowed criteria for two conditions (vulnerable elder, heart failure). The final definition included the following 11 conditions and health states: vulnerable elder, heart failure, advanced cancer, oxygen-dependent pulmonary disease, cirrhosis, end-stage renal disease, dementia, critical trauma, frailty, nursing home residency, and American Society of Anesthesiology Risk Score IV-V. CONCLUSION We identified a consensus definition for serious illness in surgery. Opportunities remain in measuring the prevalence, identifying health trajectories, and developing screening criteria to integrate PC with restorative surgical care.
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Affiliation(s)
- Katherine C Lee
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Surgery, University of California, San Diego, La Jolla, California, USA.
| | - Anne M Walling
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles, California, USA; Greater Los Angeles Veterans Affairs Healthcare System, David Geffen School of Medicine at University of California, Los Angeles, California, USA; Affiliated Adjunct Staff, RAND Health, Los Angeles, California, USA
| | - Steven S Senglaub
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Amy S Kelley
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zara Cooper
- The Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA; Hebrew SeniorLife Marcus Institute for Aging Research, Boston, Massachusetts, USA; Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Smith CG, Davenport DL, Gorski J, McDowell A, Burgess BT, Fredericks TI, Baldwin LA, Miller RW, DeSimone CP, Dietrich CS, Gallion HH, Pavlik EJ, van Nagell JR, Ueland FR. Clinical Factors Associated with Longer Hospital Stay Following Ovarian Cancer Surgery. Healthcare (Basel) 2019; 7:E85. [PMID: 31277282 PMCID: PMC6787623 DOI: 10.3390/healthcare7030085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 06/23/2019] [Accepted: 06/24/2019] [Indexed: 12/18/2022] Open
Abstract
Background: Ovarian cancer (OC) is the leading cause of death from gynecologic malignancy and is treated with a combination of cytoreductive surgery and platinum-based chemotherapy. Extended length of stay (LOS) after surgery can affect patient morbidity, overall costs, and hospital resource utilization. The primary objective of this study was to identify factors contributing to prolonged LOS for women undergoing surgery for ovarian cancer. Methods: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify women from 2012-2016 who underwent hysterectomy for ovarian, fallopian tube and peritoneal cancer. The primary outcome was LOS >50th percentile. Preoperative and intraoperative variables were examined to determine which were associated with prolonged LOS. Results: From 2012-2016, 1771 women underwent elective abdominal surgery for OC and were entered in the ACS-NSQIP database. The mean and median LOS was 4.6 and 4.0 days (IQR 0-38), respectively. On multivariate analysis, factors associated with prolonged LOS included: American Society of Anesthesiologists (ASA) Classification III (aOR 1.71, 95% CI 1.38-2.13) or IV (aOR 1.88, 95% CI 1.44-2.46), presence of ascites (aOR 1.88, 95% CI 1.44-2.46), older age (aOR 1.23, 95% CI 1.13-1.35), platelet count >400,000/mm3 (aOR 1.74, 95% CI 1.29-2.35), preoperative blood transfusion (aOR 11.00, 95% CI 1.28-94.77), disseminated cancer (aOR 1.28, 95% CI 1.03-1.60), increased length of operation (121-180 min, aOR 1.47, 95% CI 1.13-1.91; >180 min, aOR 2.78, 95% CI 2.13-3.64), and postoperative blood transfusion within 72 h of incision (aOR 2.04, 95% CI 1.59-2.62) (p < 0.05 for all). Conclusions: Longer length of hospital stay following surgery for OC is associated with many patient, disease, and treatment-related factors. The extent of surgery, as evidenced by perioperative blood transfusion and length of surgical procedure, is a factor that can potentially be modified to shorten LOS, improve patient outcomes, and reduce hospital costs.
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Affiliation(s)
- Christopher G Smith
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA.
| | - Daniel L Davenport
- Department of Surgery, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Justin Gorski
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Anthony McDowell
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Brian T Burgess
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Tricia I Fredericks
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Lauren A Baldwin
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Rachel W Miller
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Christopher P DeSimone
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Charles S Dietrich
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Holly H Gallion
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Edward J Pavlik
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - John R van Nagell
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
| | - Frederick R Ueland
- Department of Obstetrics & Gynecology, University of Kentucky, Lexington, KY 40536-0293, USA
- Division of Gynecologic Oncology, Markey Cancer Center, University of Kentucky, Lexington, KY 40536-0293, USA
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Bateni SB, Gingrich AA, Stewart SL, Meyers FJ, Bold RJ, Canter RJ. Hospital utilization and disposition among patients with malignant bowel obstruction: a population-based comparison of surgical to medical management. BMC Cancer 2018; 18:1166. [PMID: 30477454 PMCID: PMC6258444 DOI: 10.1186/s12885-018-5108-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 11/19/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Malignant bowel obstruction (MBO) is often a terminal event in end-stage cancer patients. The decision to intervene surgically is complex, given the risk of harm in patients with a limited lifespan. Therefore, we sought to compare clinically meaningful outcomes in MBO patients treated with surgical versus medical management using population-based data. METHODS We performed a retrospective analysis of hospitalized patients with MBO from 2006 to 2010 using the California Office of Statewide Health Planning and Development dataset. Hospital-free days (HFDs) at 30-, 90-, and 180-days were calculated accounting for all hospitalization, emergency department visit, and skilled nursing facility lengths of stay. Adjusted regression models were used to compare HFDs, disposition, complications, in-hospital death, and survival for surgical versus medical MBO cohorts, using inverse probability of treatment weighting with propensity scores. RESULTS Of 4576 MBO patients, 3421 (74.8%) were treated medically and 1155 (25.2%) were treated surgically. Surgical patients had higher rates of complications (44.0% vs. 21.3%, p < 0.0001) and in-hospital death (9.5% vs. 3.9%, p < 0.0001) with lower rates of disposition to home (76.3% vs. 89.8%, p < 0.0001). Surgical patients had fewer 30- and 90-day HFDs compared to medical patients (p < 0.01). However, at 180-days, there were no differences in HFDs between treatment groups. There was no difference in overall survival between surgical and medical patients (median 6.5 vs. 6.4 months). CONCLUSION In this population-based analysis, medical management was associated with less hospital utilization at 30- and 90-days, fewer in-hospital deaths, and more frequent discharges to home. These data underscore the potential benefits of medical management for MBO patients at the end-of-life.
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Affiliation(s)
- Sarah B. Bateni
- Division of Surgical Oncology, UC Davis Cancer Center, 4501 X Street, Suite 3010, Sacramento, CA 95817 USA
| | - Alicia A. Gingrich
- Division of Surgical Oncology, UC Davis Cancer Center, 4501 X Street, Suite 3010, Sacramento, CA 95817 USA
| | - Susan L. Stewart
- Department of Public Health Sciences, Division of Biostatistics, UC Davis School of Medicine, 4800 2nd Ave, Suite 2209, Sacramento, CA 95817 USA
| | - Frederick J. Meyers
- Division of Hematology/Oncology, Department of Internal Medicine, UC Davis Medical Center, 4610 X Street, Suite 3016, Sacramento, CA 95817 USA
| | - Richard J. Bold
- Division of Surgical Oncology, UC Davis Cancer Center, 4501 X Street, Suite 3010, Sacramento, CA 95817 USA
| | - Robert J. Canter
- Division of Surgical Oncology, UC Davis Cancer Center, 4501 X Street, Suite 3010, Sacramento, CA 95817 USA
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Cobert J, Hauck J, Flanagan E, Knudsen N, Galanos A. Anesthesia-Guided Palliative Care in the Perioperative Surgical Home Model. Anesth Analg 2018; 127:284-288. [DOI: 10.1213/ane.0000000000002775] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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10
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Bateni SB, Canter RJ, Meyers FJ, Galante JM, Bold RJ. Palliative Care Training and Decision-Making for Patients with Advanced Cancer: A Comparison of Surgeons and Medical Physicians. Surgery 2018; 164:S0039-6060(18)30078-3. [PMID: 29709369 PMCID: PMC6204113 DOI: 10.1016/j.surg.2018.01.021] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 01/18/2018] [Accepted: 01/29/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Surgical decision-making in patients with advanced cancer requires careful thought and deliberation to balance the high risks with the potential palliative benefits. We sought to compare surgical decision-making and palliative care training among surgeons and medical physicians who commonly treat advanced cancer patients. We hypothesized that surgeons will report less palliative care training compared with medical physicians, and deficits in palliative care training will be associated with more aggressive treatment recommendations in clinical scenarios of advanced cancer patients with symptomatic surgical conditions. STUDY DESIGN Practicing surgeons, medical oncologists, intensivists, and palliative care physicians from a large urban city and its surrounding areas were surveyed with a 32-item questionnaire consisting of a survey addressing palliative care training and 4 clinical vignettes depicting patients with advanced cancer and symptomatic surgical conditions. RESULTS Of the 299 physicians surveyed, 102 responded (response rate 34.1%). Surgeons reported fewer hours of palliative care training during residency, fellowship, and continuing medical education combined (median 10, IQR 2-15) compared with medical oncologists (median 30, IQR 20-80) and medical intensivists (median 50 IQR 30-100), P < .05. Additionally, 20% of surgeons reported no history of any palliative care training. Analysis of physician recommendations for treatment of the 4 clinical vignettes showed minimal consensus regardless of physician specialty. Absence of palliative care training was associated with recommending major operative intervention more frequently compared with physicians with ≥40 hours of palliative care training (0.7 ± 0.7 vs 1.6 ± 0.8, P =.01). CONCLUSION Substantial deficiencies in palliative care training persist among surgeons and are associated with more aggressive recommendations for treatment for the selected scenarios presented in patients with advanced cancer. These findings highlight the need for greater efforts systemwide in palliative care education among surgeons, including incorporation of a structured palliative care training curriculum in graduate and continuing surgical education.
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Affiliation(s)
- Sarah B Bateni
- Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA
| | - Robert J Canter
- Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA
| | - Frederick J Meyers
- Hematology/Oncology, Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, CA
| | - Joseph M Galante
- Division of Trauma, Acute Care Surgery and Surgical Critical Care, University of California, Davis Medical Center, Sacramento, CA
| | - Richard J Bold
- Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, CA.
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Bateni SB, Bold RJ, Meyers FJ, Canter DJ, Canter RJ. Comparison of common risk stratification indices to predict outcomes among stage IV cancer patients with bowel obstruction undergoing surgery. J Surg Oncol 2017; 117:479-487. [PMID: 29044598 DOI: 10.1002/jso.24866] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/01/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND OBJECTIVES Among patients with disseminated malignancy (DMa), bowel obstruction is common with high operative morbidity. Since preoperative risk stratification is critical, we sought to compare three standard risk indices, the American Society of Anesthesiology (ASA) classification, Charlson comorbidity index (CCI), and modified frailty index (mFI). METHODS We identified 1928 DMa patients with bowel obstruction who underwent an abdominal operation from 2007 to 2012 American College of Surgeons National Surgical Quality Improvement Program. Multivariate analyses assessed predictors of prolonged length of stay (LOS), 30-day serious morbidity and mortality. Receiver operating characteristics' areas under the curves (AUCs) for risk indices scores and 30-day mortality were assessed. RESULTS Serious morbidity and mortality rates were 20.4% and 14.8%. ASA and CCI did not predict serious morbidity or prolonged LOS, but were predictors of mortality. The mFI did not predict prolonged LOS, but did predict serious morbidity and mortality. Subgroup analyses showed similar results. There were no significant differences between ASA, CCI, and mFI AUCs for mortality. CONCLUSIONS ASA, CCI, and mFI are limited in their ability to predict postoperative adverse events among DMa patients undergoing surgery for bowel obstruction. These data suggest that a more tailored preoperative risk stratification tool would improve treatment planning.
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Affiliation(s)
- Sarah B Bateni
- Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, California
| | - Richard J Bold
- Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, California
| | - Frederick J Meyers
- Division of Hematology/Oncology, Department of Internal Medicine, University of California, Davis Medical Center, Sacramento, California
| | - Daniel J Canter
- Department of Urology, Ochsner Clinic, New Orleans, Louisiana
| | - Robert J Canter
- Divison of Surgical Oncology, Department of Surgery, University of California, Davis Medical Center, Sacramento, California
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12
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Park JS, Bateni SB, Bold RJ, Kirane AR, Canter DJ, Canter RJ. The modified frailty index to predict morbidity and mortality for retroperitoneal sarcoma resections. J Surg Res 2017; 217:191-197. [PMID: 28587892 DOI: 10.1016/j.jss.2017.05.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/07/2017] [Accepted: 05/05/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND The modified frailty index (mFI) is an important method to risk-stratify surgical patients and has been validated for general surgery and selected surgical subspecialties. However, there are currently no data assessing the efficacy of the mFI to predict acute morbidity and mortality in patients undergoing surgery for retroperitoneal sarcoma. METHODS Using the American College of Surgeons' National Surgical Quality Improvement Program from 2007 to 2012, we performed a retrospective analysis of patients with a diagnosis of primary malignant retroperitoneal neoplasm who underwent surgical resection. The mFI was calculated according to standard published methods. Univariate and multivariate statistical analyses including χ2 and logistic regression were used to identify predictors of 30-d overall morbidity, 30-d severe morbidity (Clavien III/IV), and 30-d mortality. RESULTS We identified 846 patients with the diagnosis of primary malignant retroperitoneal neoplasm who underwent surgical resection. The distribution mFI scores was 0 (48.5%) or 1 (36.3%), with only 4.5% of patients presenting with a score ≥3. Rates of 30-d overall morbidity, serious morbidity, and mortality were 22.6%, 12.9%, and 1.2%, respectively. Only selected mFI scores were associated with serious morbidity and overall morbidity on multivariate analysis (P < 0.05), and mFI did not predict 30-d mortality (P > 0.05). CONCLUSIONS Our data demonstrate that the majority of patients undergoing retroperitoneal sarcoma resections have few, if any, comorbidities. The mFI was a limited predictor of overall and serious complications and was not a significant predictor of mortality. Better discriminators of preoperative risk stratification may be needed for this patient population.
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Affiliation(s)
- Jiwon Sarah Park
- Division of Surgical Oncology, Department of Surgery, University of California Davis Medical Center, Sacramento, California
| | - Sarah B Bateni
- Division of Surgical Oncology, Department of Surgery, University of California Davis Medical Center, Sacramento, California
| | - Richard J Bold
- Division of Surgical Oncology, Department of Surgery, University of California Davis Medical Center, Sacramento, California
| | - Amanda R Kirane
- Division of Surgical Oncology, Department of Surgery, University of California Davis Medical Center, Sacramento, California
| | - Daniel J Canter
- Department of Urology, Ochsner Clinic, New Orleans, Louisiana
| | - Robert J Canter
- Division of Surgical Oncology, Department of Surgery, University of California Davis Medical Center, Sacramento, California.
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