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Wehrle CJ, Perlmutter B, Hong H, Chang J, Stackhouse KA, Naples R, Shanaz Hossain M, Joyce D, Simon R, Kim J, Naffouje SA, Aucejo F, Kwon DCH, Walsh RM, Augustin T. Impact of autotransfusion on recurrence of colorectal cancer liver metastasis: Long-term follow-up of patients undergoing curative intent hepatectomy. J Surg Oncol 2024; 129:793-801. [PMID: 38151831 DOI: 10.1002/jso.27569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/30/2023] [Accepted: 12/10/2023] [Indexed: 12/29/2023]
Abstract
INTRODUCTION Colorectal cancer liver metastasis (CRLM) occurs in upto 50% of cases and drives patient outcomes. Up-front liver resection is the treatment of choice in resectable cases. There is no consensus yet established as to the safety of intraoperative autotransfusion in liver resection for CRLM. METHODS Patients undergoing curative-intent hepatectomy for CRLM at a single quaternary-care institution from 1999 to 2016 were included. Demographics, surgical variables, Fong Clinical Risk Score (FCRS), use of intraoperative auto and/or allotransfusion, and survival data were analyzed. Propensity score matching (PSM) was performed accounting for allotransfusion, extent of hepatectomy, FCRS, and systemic treatment regimens. RESULTS Three-hundred sixteen patients were included. The median follow-up was 10.4 years (7.8-14.1 years). The median recurrence-free survival (RFS) and overall survival (OS) in all patients were 1.6 years (interquartile range: 0.63-6.6 years) and 4.4 years (2.1-8.7), respectively. Before PSM, there was a significantly reduced RFS in the autotransfusion group (0.96 vs. 1.73 years, p = 0.20). There was no difference in OS (4.11 vs. 4.44 years, p = 0.118). Patients in groups of FCRS 0-2 and 3-5 both had reduced RFS when autotransfusion was used (p = 0.005). This reduction in RFS was further found when comparing autotransfusion versus no autotransfusion within the FCRS 0-2 group and within the FCRS 3-5 group (p = 0.027). On Cox-regression analysis, autotransfusion (hazard ratio = 1.423, 1.028-2.182, p = 0.015) remained predictive of RFS. After PSM, there were no differences in FCRS (p = 0.601), preoperative hemoglobin (p = 0.880), allotransfusion (p = 0.130), adjuvant chemotherapy (p = 1.000), immunotherapy (p = 0.172), tumor grade (p = 1.000), use of platinum-based chemotherapy (p = 0.548), or type of hepatic resection (p = 0.967). After matching, there was a higher rate of recurrence with autotransfusion (69.0% vs. 47.6%, p = 0.046). There was also a reduced time to recurrence in the autotransfusion group compared with the group without (p = 0.006). There was no difference in OS after PSM (p = 0.262). CONCLUSION Autotransfusion may adversely affect recurrence in liver resection for CRLM. Until further studies clarify this risk profile, the use of intraoperative autotransfusion should be critically assessed on a case-by-case basis only when other resuscitation options are not available.
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Affiliation(s)
- Chase J Wehrle
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Breanna Perlmutter
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Hanna Hong
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jenny Chang
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Kathryn A Stackhouse
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Rob Naples
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - M Shanaz Hossain
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Daniel Joyce
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Robert Simon
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jaekeun Kim
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Samer A Naffouje
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Federico Aucejo
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - David C H Kwon
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - R Matthew Walsh
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Toms Augustin
- Department of General Surgery, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Blake KE, Perlmutter B, Saieed G, Said SA, Maskal SM, Petro CC, Krpata DM, Rosen MJ, Prabhu AS. The impact of comorbidities on postoperative outcomes of ventral hernia repair: the patients' perspective. Hernia 2023:10.1007/s10029-023-02826-8. [PMID: 37410195 DOI: 10.1007/s10029-023-02826-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 06/15/2023] [Indexed: 07/07/2023]
Abstract
INTRODUCTION Ventral hernia repair (VHR) outcomes can be adversely affected by modifiable patient co-morbidities, such as diabetes, obesity, and smoking. Although this concept is well accepted among surgeons, the extent to which patients understand the significance of their co-morbidities is unknown, and a few studies have sought to determine patient perspectives regarding the impact of their modifiable co-morbidities on their post-operative outcomes. We attempted to determine how accurately patients predict their surgical outcomes after VHR compared to a surgical risk calculator while considering their modifiable co-morbidities. METHODS This is a prospective, single-center, survey-based study evaluating patients' perceptions of how their modifiable risk factors affect outcomes after elective ventral hernia repair. Pre-operatively, after surgeon counseling, patients predicted the percentage of impact that they believed their modifiable co-morbidities (diabetes, obesity, and smoking) had on 30-day surgical site infections (SSI) and hospital readmissions. Their predictions were compared to the Outcomes Reporting App for CLinicians and Patient Engagement (ORACLE) surgical risk calculator. Results were analyzed using demographic information. RESULTS 222 surveys were administered and 157 were included in the analysis after excluding for incomplete data. 21% had diabetes, 85% were either overweight with body mass index (BMI) 25-29.9 or obese (BMI ≥ 30), and 22% were smokers. The overall mean SSI rate was 10.8%, SSOPI rate was 12.7%, and 30-day readmission rate was 10.2%. ORACLE predictions correlated with observed SSI rates (OR 1.31, 95% CI 1.12-1.54, p < 0.001), but patient predictions did not (OR 1.00, 95% CI 0.98-1.03, p = 0.868). The correlation between patient predictions and ORACLE calculations was weak ([Formula: see text] = 0.17). Patient predictions were on average 10.1 ± 18.0% different than ORACLE, and 65% overestimated their SSI probability. Similarly, ORACLE predictions correlated with observed 30-day readmission rates (OR 1.10, 95% CI 1.00-1.21, p = 0.0459), but patient predictions did not (OR 1.00, 95% CI 0.975-1.03, p = 0.784). The correlation between patient predictions and ORACLE calculations for readmissions was weak ([Formula: see text] = 0.27). Patient predictions were on average 2.4 ± 14.6% different than ORACLE, and 56% underestimated their readmission probability. Additionally, a substantial proportion of the cohort believed that they had a 0% risk of SSI (28%) and a 0% risk of readmission (43%). Education, income and healthcare employment did not affect the accuracy of patient predictions. CONCLUSIONS Despite surgeon counseling, patients do not accurately estimate their risks after VHR when compared to ORACLE. Most patients overestimate their SSI risk and underestimate their 30-day readmission risk. Furthermore, several patients believed that they had a 0% risk of SSI and readmission. These findings persisted regardless of level of education, income level, or healthcare employment. Additional attention should be directed toward setting expectations prior to surgery and using applications such as ORACLE to assist in this process.
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Affiliation(s)
- K E Blake
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA.
- Department of General Surgery, University of Tennessee Medical Center, University of Tennessee Graduate School of Medicine, Knoxville, TN, USA.
| | - B Perlmutter
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - G Saieed
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - S A Said
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - S M Maskal
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - C C Petro
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - D M Krpata
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - M J Rosen
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
| | - A S Prabhu
- Department of General Surgery, Cleveland Clinic Center for Abdominal Core Health Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, A100, A10-133, Cleveland, OH, 44195, USA
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Perlmutter B, Said SAD, Hossain MS, Simon R, Joyce D, Walsh RM, Augustin T. Lessons learned and keys to success: Provider experiences during the implementation of virtual oncology tumor boards in the era of COVID-19. J Surg Oncol 2022; 125:570-576. [PMID: 34994401 PMCID: PMC9015483 DOI: 10.1002/jso.26784] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/12/2021] [Accepted: 12/14/2021] [Indexed: 11/09/2022]
Abstract
Background and Objectives The COVID‐19 pandemic required rapid adaptation of multidisciplinary tumor board conferences to a virtual setting; however, there are little data describing the benefits and challenges of using such a platform. Methods An anonymous quality improvement survey was sent to participants of tumor board meetings at a large academic institution. Participants answered questions pertaining to the relative strengths and weaknesses of in‐person and virtual settings. Results A total of 335 responses (23.3% response rate) were recorded, and 253 met inclusion criteria. Respondents represented 25 different tumor board meetings, with colorectal, breast, and liver (18.6%, 17.0%, and 13.0%, respectively) being the most commonly attended. Virtual tumor boards were equivalent to in‐person across 9 of 10 domains queried, while a virtual format was preferred for participation in off‐site tumor boards. The lack of networking opportunities was ranked by physicians to be a significant challenge of the virtual format. Consistent leadership and organization, engaged participation of all attendees, and upgrading technology infrastructure were considered critical for success of virtual meetings. Conclusions The implementation of virtual tumor board meetings has been associated with numerous challenges. However, improving several key aspects can improve participant satisfaction and ensure excellent patient care.
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Affiliation(s)
| | - Sayf Al-Deen Said
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Robert Simon
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniel Joyce
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - R Matthew Walsh
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Toms Augustin
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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Perlmutter B, Wynia E, McMichael J, Tu C, Scheman J, Simon R, Walsh RM, Augustin T. Effect of pre-operative opioid exposure on surgical outcomes in elective laparoscopic cholecystectomy. Am J Surg 2021; 223:764-769. [PMID: 34193351 DOI: 10.1016/j.amjsurg.2021.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 06/15/2021] [Accepted: 06/20/2021] [Indexed: 01/10/2023]
Abstract
BACKGROUND The effects of varying levels of pre-operative opioids on post-operative outcomes following elective laparoscopic cholecystectomy is largely unknown. METHODS Patients who underwent elective laparoscopic cholecystectomy from 2012 to 2019 were reviewed and categorized by the number of outpatient opioid prescriptions received in the 90 days preceding surgery: none (Naïve), one (1 Rx), two (2 Rx), or three or more (Chronic). Operative time, hospital length of stay, and 30-day readmission rate were analyzed. RESULTS Of the 11911 patients identified, 2958 (24.8%) used opioids pre-operatively. Among patients with an overnight admission, the Naïve, 1 Rx, and 2 Rx cohorts had a shorter length of stay compared to the Chronic cohort. The Naïve group had the lowest 30-day readmission rate (5.0%) followed by the 1 Rx (5.9%), 2 Rx and Chronic groups (9.1% and 8.7%, respectively) (p < 0.001). CONCLUSIONS Prevalence of pre-operative opioid use is high and warrants surgeon assessment to minimize adverse post-operative outcomes.
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Affiliation(s)
- Breanna Perlmutter
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Elisabeth Wynia
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA; United States Air Force. The Views Expressed in This Paper are Those of the authors and do not Reflect the Official Policy Or Stance of the Department of the Air Force, Department of Defense, Or the U.S. Government, USA
| | - John McMichael
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Chao Tu
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Judith Scheman
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Robert Simon
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - R Matthew Walsh
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Toms Augustin
- Department of General Surgery, Cleveland Clinic, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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Perlmutter B, Wynia E, McMichael J, Tu C, Scheman J, Simon R, Matthew Walsh R, Augustin T. Effect of Preoperative Opioid Exposure on Hospital Length of Stay and Operative Time in Patients Undergoing Elective Laparoscopic Cholecystectomy. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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AlMarzooqi R, Tish S, Perlmutter B, Fafaj A, Alkhatib H, Olson M, Prabhu AS, Krpata DM, Petro C, Rosen M. Outcomes of Complex Abdominal Wall Reconstruction with Concomitant Cholecystectomy. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.1053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Alkhatib H, Fafaj A, Tastaldi L, Zolin S, Tish S, Perlmutter B, Petro C, Krpata DM, Rosen M, Prabhu AS. Hernia Repair in Patients with Inflammatory Bowel Disease, Operative Techniques Offered, and Outcomes: A Retrospective Review from the Americas Hernia Society Quality Collaborative (AHSQC). J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.1034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Mullin JP, Perlmutter B, Schmidt E, Benzel E, Steinmetz MP. Radiographic feasibility study of cortical bone trajectory and traditional pedicle screw dual trajectories. J Neurosurg Spine 2016; 25:727-732. [DOI: 10.3171/2016.4.spine151483] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE
In 2009, Santoni and colleagues described a novel technique of posterior instrumentation; the cortical bone trajectory (CBT) was described as a caudocephalad and medial-to-lateral trajectory. Reported indications for CBT fixation include patients with osteoporosis, single-level degenerative disease, or adjacent-segment disease (ASD). In cases of revision surgery, it is technically possible and beneficial to place a traditional pedicle screw and a CBT screw at the same spinal level and side. It remains unclear as to the feasibility of placing both a traditional and a CBT screw at all levels of the lumbar spine and with varying trajectories of the preexisting traditional pedicle screws. Therefore, the authors conducted a study to radiographically assess the feasibility of using CBT and traditional pedicle screws at the same level in a large patient population.
METHODS
Using a 3D Spine Navigation WorkStation, the authors assessed 47 lumbar spine CT scans. These images were obtained from 2 disparate groups of patients: those who had previously undergone traditional pedicle instrumentation (prior surgery group) and those who had not (no prior surgery group). The authors virtually placed traditional pedicle and CBT screws at each lumbar level bilaterally. It was then determined if the dual trajectories were feasible, as defined by the presence or absence of a collision of the screw trajectories based on 3D imaging.
RESULTS
Overall, the authors evaluated 47 patients and were able to successfully plan dual trajectories in 50% of the pedicles. The no prior surgery group, compared with the prior surgery group, had a significantly greater success rate for dual trajectories. This difference was most significant in the lower lumbar levels (L3–5) where the prior instrumented group had success rates lower than 40% compared with the no prior surgery group's success rate, which was greater than 70%. There was a significant difference between each lumbar level in the lower spine.
CONCLUSIONS
There is a significant difference in the feasibility of planning CBT screws in patients who have undergone prior pedicle instrumentation compared with placing CBT and traditional pedicle screws simultaneously, but dual trajectory pedicle screws are a feasible option for posterior lumbar spinal instrumentation, especially as a de novo option in osteoporotic patients or in patients with ASD who underwent previous pedicle instrumentation. Ultimately, the practical clinical utility and biomechanical effects on the spine and instrumentation construct would require additional study.
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Perlmutter B, Kennedy RH, Seifen E, Soulsby M. Effects of norepinephrine on BAY K-8644-induced contraction in porcine coronary artery. Arch Int Pharmacodyn Ther 1987; 285:80-6. [PMID: 2437872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BAY K-8644 is a dihydropyridine calcium agonist which produces contraction in several isolated vascular preparations--including porcine coronary artery. This study examined the ability of norepinephrine to relax porcine coronary artery previously contracted with BAY K-8644 and compared this to effects on preparations contracted with histamine. Norepinephrine relaxed BAY K-8644 and histamine-treated preparations to approximately base line developed tension. The ED50 value for norepinephrine was the same in the presence of increasing concentrations of either BAY K-8644 or histamine.
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Kornfeld P, Perlmutter B. A simplified technique in the use of self-polymerizing acrylics for relines and repairs. Dent Dig 1968; 74:246-7. [PMID: 5239943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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