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Yee EJ, Gilbert D, Kaplan J, Wani S, Kim SS, McCarter MD, Stewart CL. Effect of Neoadjuvant Chemotherapy on Tumor-Infiltrating Lymphocytes in Resectable Gastric Cancer: Analysis from a Western Academic Center. Cancers (Basel) 2024; 16:1428. [PMID: 38611107 PMCID: PMC11010931 DOI: 10.3390/cancers16071428] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/29/2024] [Accepted: 04/06/2024] [Indexed: 04/14/2024] Open
Abstract
Tumor-infiltrating lymphocytes (TILs) are an emerging biomarker predictive of response to immunotherapy across a spectrum of solid organ malignancies. The characterization of TILs in gastric cancer (GC) treated with contemporary, multiagent neoadjuvant chemotherapy (NAC) is understudied. In this retrospective investigation, we analyzed the degree of infiltration, phenotype, and spatial distribution of TILs via immunohistochemistry within resected GC specimens treated with or without NAC at a Western center. We hypothesized that NAC executes immunostimulatory roles, as evidenced by an increased number of anti-tumor TILs in the tumor microenvironment. We found significantly elevated levels of conventional and memory CD8+ T cells, as well as total TILs (CD4+, CD8+, Treg, B cells), within chemotherapy-treated tumors compared with chemotherapy-naïve specimens. We also revealed important associations between survival and pathologic responses with enhanced TIL infiltration. Taken together, our findings advocate for an immunostimulatory role of chemotherapy and underscore the potential synergistic effect of combining chemotherapy with immunotherapy in resectable gastric cancer.
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Affiliation(s)
- Elliott J. Yee
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA; (D.G.); (M.D.M.); (C.L.S.)
| | - Danielle Gilbert
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA; (D.G.); (M.D.M.); (C.L.S.)
| | - Jeffrey Kaplan
- Department of Pathology, University of Colorado, Aurora, CO 80045, USA;
| | - Sachin Wani
- Division of Gastroenterology, Department of Medicine, University of Colorado, Aurora, CO 80045, USA;
| | - Sunnie S. Kim
- Division of Medical Oncology, Department of Medicine, University of Colorado, Aurora, CO 80045, USA;
| | - Martin D. McCarter
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA; (D.G.); (M.D.M.); (C.L.S.)
| | - Camille L. Stewart
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045, USA; (D.G.); (M.D.M.); (C.L.S.)
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Yee EJ, Gilbert D, Kaplan J, van Dyk L, Kim SS, Berg L, Clambey E, Wani S, McCarter MD, Stewart CL. Immune Landscape of Epstein-Barr Virus-Associated Gastric Cancer: Analysis From a Western Academic Institution. J Surg Res 2024; 296:742-750. [PMID: 38368775 PMCID: PMC10947842 DOI: 10.1016/j.jss.2024.01.043] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/15/2024] [Accepted: 01/19/2024] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Epstein-Barr virus-associated gastric cancer (EBVaGC) may be a meaningful biomarker for potential benefit from immunotherapy. Further investigation is needed to characterize the immune landscape of EBVaGC. We assessed our institutional frequency of surgically treated EBVaGC and analyzed the immunologic biomarker profile and tumor-infiltrating lymphocyte (TIL) phenotypes of a series of EBVaGC compared to non-EBVaGC cases. METHODS Available tissue samples from all patients with biopsy-confirmed gastric adenocarcinoma who underwent resection with curative intent from 2012 to 2020 at our institution were collected. In situ hybridization was used to assess EBV status; multiplex immunohistochemistry was performed to assess mismatch repair status, Programmed Death-Ligand 1 (PD-L1) expression, and phenotypic characterization of TILs. RESULTS Sixty-eight samples were included in this study. EBVaGC was present in 3/68 (4%) patients. Among all patients, 27/68 (40%) had positive PD-L1 expression; two of three (67%) EBVaGC patients exhibited positive PD-L1 expression. Compared to non-EBVaGC, EBV-positive tumors showed 5-fold to 10-fold higher density of TILs in both tumor and stroma and substantially elevated CD8+ T cell to Tregulatory cell ratio. The memory subtypes of CD8+ and CD4+ T cells were upregulated in EBVaGC tumors and stromal tissue compared to non-EBVaGC. CONCLUSIONS The incidence of surgically resected EBVaGC at our center was 4%. EBVaGC tumors harbor elevated levels of TILs, including memory subtypes, within both tumor and tumor-related stroma. Robust TIL presence and upregulated PD-L1 positivity in EBVaGC may portend promising responses to immunotherapy agents. Further investigation into routine EBV testing and TIL phenotype of patients with gastric cancer to predict response to immunotherapy may be warranted.
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Affiliation(s)
- Elliott J Yee
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Aurora, Colorado.
| | | | - Jeffrey Kaplan
- Department of Pathology, University of Colorado, Aurora, Colorado
| | - Linda van Dyk
- Department of Immunology & Microbiology, University of Colorado, Aurora, Colorado
| | - Sunnie S Kim
- Division of Medical Oncology, Department of Medicine, University of Colorado, Aurora, CO
| | - Leslie Berg
- Department of Immunology & Microbiology, University of Colorado, Aurora, Colorado
| | - Eric Clambey
- Department of Anesthesiology, University of Colorado, Aurora, Colorado
| | - Sachin Wani
- Division of Medical Oncology, Department of Medicine, University of Colorado, Aurora, CO
| | - Martin D McCarter
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Aurora, Colorado
| | - Camille L Stewart
- Division of Surgical Oncology, Department of Surgery, University of Colorado, Aurora, Colorado
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Stuart CM, Mott NM, Dyas AR, Byers S, Gergen AK, Mungo B, Stewart CL, McCarter MD, Randhawa SK, David EA, Mitchell JD, Meguid RA. ASO Visual Abstract: The Effect of Laparoscopic Gastric Ischemic Preconditioning Before Esophagectomy on Anastomotic Stricture Rate Compared with Esophagectomy-Alone Control. Ann Surg Oncol 2024:10.1245/s10434-024-15189-w. [PMID: 38498088 DOI: 10.1245/s10434-024-15189-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Affiliation(s)
- Christina M Stuart
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Nicole M Mott
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam R Dyas
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sara Byers
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anna K Gergen
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Benedetto Mungo
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Martin D McCarter
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Simran K Randhawa
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Elizabeth A David
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - John D Mitchell
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert A Meguid
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
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Stuart CM, Mott NM, Dyas AR, Byers S, Gergen AK, Mungo B, Stewart CL, McCarter MD, Randhawa SK, David EA, Mitchell JD, Meguid RA. The Effect of Laparoscopic Gastric Ischemic Preconditioning Prior to Esophagectomy on Anastomotic Stricture Rate and Comparison with Esophagectomy-Alone Controls. Ann Surg Oncol 2024:10.1245/s10434-024-15096-0. [PMID: 38413507 DOI: 10.1245/s10434-024-15096-0] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/08/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Benign anastomotic stricture is a recognized complication following esophagectomy. Laparoscopic gastric ischemic preconditioning (LGIP) prior to esophagectomy has been associated with decreased anastomotic leak rates; however, its effect on stricture and the need for subsequent endoscopic intervention is not well studied. METHODS This was a case-control study at an academic medical center using consecutive patients undergoing oncologic esophagectomies (July 2012-July 2022). Our institution initiated an LGIP protocol on 1 January 2021. The primary outcome was the occurrence of stricture within 1 year of esophagectomy, while secondary outcomes were stricture severity and frequency of interventions within the 6 months following stricture. Bivariable comparisons were performed using Chi-square, Fisher's exact, or Mann-Whitney U tests. Multivariable regression controlling for confounders was performed to generate risk-adjust odds ratios and to identify the independent effect of LGIP. RESULTS Of 253 esophagectomies, 42 (16.6%) underwent LGIP prior to esophagectomy. There were 45 (17.7%) anastomotic strictures requiring endoscopic intervention, including three patients who underwent LGIP and 42 who did not. Median time to stricture was 144 days. Those who underwent LGIP were significantly less likely to develop anastomotic stricture (7.1% vs. 19.9%; p = 0.048). After controlling for confounders, this difference was no longer significant (odds ratio 0.46, 95% confidence interval 0.14-1.82; p = 0.29). Of those who developed stricture, there was a trend toward less severe strictures and decreased need for endoscopic dilation in the LGIP group (all p < 0.20). CONCLUSION LGIP may reduce the rate and severity of symptomatic anastomotic stricture following esophagectomy. A multi-institutional trial evaluating the effect of LGIP on stricture and other anastomotic complications is warranted.
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Affiliation(s)
- Christina M Stuart
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Nicole M Mott
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam R Dyas
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sara Byers
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anna K Gergen
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Benedetto Mungo
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Martin D McCarter
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Simran K Randhawa
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Elizabeth A David
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - John D Mitchell
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert A Meguid
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Adult and Child Center for Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
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Hurst RD, Stewart CL. Hazards of surgical smoke from electrocautery: A critical review of the data. Am J Surg 2024:S0002-9610(24)00107-7. [PMID: 38365552 DOI: 10.1016/j.amjsurg.2024.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 01/23/2024] [Accepted: 02/08/2024] [Indexed: 02/18/2024]
Abstract
INTRODUCTION Concerns have been voiced regarding the possibility of health risks to the operating room personnel from exposure to surgical smoke generated from electrocautery. METHODS Ovid Medline was queried using search terms "surgical smoke", "electrosurgery," "smoke evacuator". The NIOSH Health Hazard Evaluations Database was searched using terms, "hospital", "operating room", "Ames", "mutagen", and "salmonella". RESULTS Levels of pollutants in the breathable airspace within the operating room have been repeatedly shown to be very low. Absolute counts of particulate matter in the operating room are low when compared to other environments. The possibility for virus transmission with electrocautery in the operating room is unknown. CONCLUSIONS The risks related to the exposure to electrocautery surgical smoke have been overstated. Rigid mandates requiring smoke evacuators in all situations are not justified at this time.
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Affiliation(s)
- Roger D Hurst
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA.
| | - Camille L Stewart
- University of Colorado School of Medicine, Department of Surgery, Aurora, CO, USA
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Dyas AR, Mungo B, Bronsert MR, Stuart CM, Mungo AH, Mitchell JD, Randhawa SK, David E, Stewart CL, McCarter MD, Meguid RA. National trends in technique use for esophagectomy: Does primary surgeon specialty matter? Surgery 2024; 175:353-359. [PMID: 38030524 DOI: 10.1016/j.surg.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/04/2023] [Accepted: 10/24/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Cardiothoracic surgeons and general surgeons (including surgical oncologists) perform most esophagectomies. The purpose of this study was to explore whether specialty-driven differences in surgical techniques and the use of minimally invasive surgical approaches exist and are associated with postoperative outcomes after esophagectomy. METHODS This was a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program esophagectomy-targeted participant user file (2016-2018). Patients who underwent esophagectomy were sorted into cardiothoracic and general surgeon cohorts based on surgeon specialty. Perioperative characteristics and postoperative outcomes were compared using the χ2 analysis or independent t test. Multivariable logistic regression controlling for perioperative variables was performed to generate risk-adjusted rates of postoperative outcomes compared by surgical specialty. RESULTS Of 3,247 patients included, 1,792 (55.2%) underwent esophagectomy by cardiothoracic surgeons and 1,455 (44.5%) by general surgeons as the primary surgeon. Cardiothoracic surgeons were more likely to use traditional minimally invasive surgical (P = .0004) or open approaches (P < .0001) and less likely to use robotic (P = .04) or a hybrid robotic and traditional approaches (P < .0001). Cardiothoracic surgeons performed more Ivor Lewis esophagectomies and fewer transhiatal and McKeown esophagectomies (P < .0001). After risk adjustment, there were no differences in rates of postesophagectomy complications, such as anastomotic leaks or positive margins, between cardiothoracic surgeons and general surgeons (all P > .05). However, cardiothoracic surgeons were more likely than general surgeons to treat anastomotic leaks with surgery rather than procedural interventions (odds ratio = 1.76; 95% confidence interval, 1.24-2.52). CONCLUSION Cardiothoracic surgeons and general surgeons use minimally invasive surgical subtypes differently when performing esophagectomy. However, there were no risk-adjusted differences in postoperative complications when compared by surgical subspecialty. Esophagectomy is being performed safely by surgeons with different specialties and training pathways.
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Affiliation(s)
- Adam R Dyas
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO.
| | - Benedetto Mungo
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
| | - Christina M Stuart
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO
| | - Alison H Mungo
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - John D Mitchell
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Simran K Randhawa
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Elizabeth David
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Camille L Stewart
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Martin D McCarter
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO
| | - Robert A Meguid
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
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Vavra AK, Furlough CL, Guerra A, Hekman KE, Yoo T, Duma N, Stewart CL, Yi JA. Unconscious bias in speaker introductions at a national vascular surgery meeting: The impact of rank, race and gender. Am J Surg 2023:S0002-9610(23)00615-3. [PMID: 38000937 DOI: 10.1016/j.amjsurg.2023.10.056] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/01/2023] [Accepted: 10/02/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVES Unconscious bias can impact manner of speaker introductions in formal academic settings. We examined speaker introductions at the Society of Vascular Surgeons Annual Meeting to determine factors associated with non-professional address. METHODS We examined speaker introductions from the 2019 SVS Vascular Annual Meeting. Professional title with either full name or last name was considered professional address. Speaker and moderator demographics were collected. Univariate and multivariate logistic regression analyses were performed to identify associations between introduction and speaker and moderator characteristics. RESULTS 336 talks met inclusion criteria. Both speakers and moderators were more likely to be white (63.4 % and 65.8 %,p = 0.92), man (75.6 % and 74.4 %,p = 0.82) and full professor rank (34.5 % and 42.3 %, p < 0.001). On multivariable regression, non-professional address was associated with speaker rank of trainee (OR 3.13, p = 0.05) and when moderator was white (OR 2.42, p = 0.03). CONCLUSIONS This study emphasizes the potential negative impact of unconscious bias at a national meeting for vascular surgeons and the need to mitigate this effect at the organization level.
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Affiliation(s)
- Ashley K Vavra
- Division of Vascular Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA.
| | - Courtney L Furlough
- Division of Vascular Surgery, Department of Surgery, University of Illinois Chicago, Chicago, IL, USA
| | - Andres Guerra
- Division of Vascular Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - Katherine E Hekman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory School of Medicine, Emory University, Atlanta, GA, USA
| | - Taehwan Yoo
- OhioHealth Grant Medical Center, Columbus, OH, USA
| | | | | | - Jeniann A Yi
- Department of Surgery, St. Anthony Hospital, Lakewood, CO, USA
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Stewart CL, Green C, Meara MP, Awad MM, Nelson M, Coker AM, Porterfield J. Common Components of General Surgery Robotic Educational Programs. J Surg Educ 2023; 80:1717-1722. [PMID: 37596106 DOI: 10.1016/j.jsurg.2023.07.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 07/06/2023] [Accepted: 07/11/2023] [Indexed: 08/20/2023]
Abstract
OBJECTIVE Robotically assisted surgery has become more common in general surgery, but there is limited guidance from the Accreditation Council for Graduate Medical Education (ACGME) regarding this type of training. We sought to determine common elements and differences in the robotic educational curricula developed by general surgery residency programs. DESIGN Robotic educational curricula were obtained from the 7 individuals who presented at the workshop, "Robotic Education in General Surgery" at the 2023 Association of Program Directors in Surgery annual meeting. RESULTS All 7 general surgery programs had training beginning intern year, required online robotic modules, had at least 1 dedicated simulation training console not used for clinical purposes, and ran dry and wet (tissue) robotic labs at least annually. All programs had bedside and console surgeon case minimums and had administrative support to run the educational programs. Differences existed regarding how training intern year was executed, the simulations required, clinical practice minimum requirements, how progress was monitored over time, and how case numbers were tracked. Some programs had salary support for a director of robotic education. CONCLUSIONS There are several common elements to robotic educational curricula in general surgery, however significant variation does exist between programs. Given the frequency of robotic use in general surgery and current lack of standardization, formal guidance from the ACGME specifically regarding robotic education in general surgery residency is warranted.
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Affiliation(s)
- Camille L Stewart
- Department of Surgery, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, Colorado.
| | - Courtney Green
- Department of Surgery, University of California San Francisco School of Medicine, San Francisco, California
| | - Michael P Meara
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Michael M Awad
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Megan Nelson
- Department of Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Alisa M Coker
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - John Porterfield
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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Stuart CM, Dyas AR, Byers S, Velopulos C, Randhawa S, David EA, Pritap A, Stewart CL, Mitchell JD, McCarter MD, Meguid RA. Social vulnerability is associated with increased postoperative morbidity following esophagectomy. J Thorac Cardiovasc Surg 2023; 166:1254-1261. [PMID: 37119966 DOI: 10.1016/j.jtcvs.2023.04.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/28/2023] [Accepted: 04/22/2023] [Indexed: 05/01/2023]
Abstract
OBJECTIVES The effect of a patient's Social Vulnerability Index (SVI) on complication rates after esophagectomy remains unstudied. The purpose of this study was to determine how social vulnerability influences morbidity following esophagectomy. METHODS This was a retrospective review of a prospectively collected esophagectomy database at one academic institution, 2016 to 2022. Patients were grouped into low-SVI (<75%ile) and high-SVI (>75%ile) cohorts. The primary outcome was overall postoperative complication rate; secondary outcomes were rates of individual complications. Perioperative patient variables and postoperative complication rates were compared between the 2 groups. Multivariable logistic regression was used to control for covariates. RESULTS Of 149 patients identified who underwent esophagectomy, 27 (18.1%) were in the high-SVI group. Patients with high SVI were more likely to be of Hispanic ethnicity (18.5% vs 4.9%, P = .029), but there were no other differences in perioperative characteristics between groups. Patients with high SVI were significantly more likely to develop a postoperative complication (66.7% vs 36.9%, P = .005) and had greater rates of postoperative pneumonia (25.9% vs 6.6%, P = .007), jejunal feeding-tube complications (14.8% vs 3.3%, P = .036), and unplanned intensive care unit readmission (29.6% vs 12.3%, P = .037). In addition, patients with high SVI had a longer postoperative hospital length of stay (13 vs 10 days, P = .017). There were no differences in mortality rates. These findings persisted on multivariable analysis. CONCLUSIONS Patients with high SVI have greater rates of postoperative morbidity following esophagectomy. The effect of SVI on esophagectomy outcomes warrants further investigation and may prove useful in identifying populations that benefit from interventions to mitigate these complications.
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Affiliation(s)
- Christina M Stuart
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colo.
| | - Adam R Dyas
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colo
| | - Sara Byers
- Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colo; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colo
| | - Catherine Velopulos
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Simran Randhawa
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Elizabeth A David
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Akshay Pritap
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Camille L Stewart
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - John D Mitchell
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Martin D McCarter
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo
| | - Robert A Meguid
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colo; Surgical Outcomes and Applied Research, University of Colorado School of Medicine, Aurora, Colo; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colo
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Gergen AK, Stuart CM, Byers S, Vigneshwar N, Madsen H, Johnson J, Oase K, Garduno N, Marsh M, Pratap A, Mitchell JD, David EA, Randhawa S, Meguid RA, McCarter MD, Stewart CL. ASO Visual Abstract: Prospective Evaluation of a Universally Applied Laparoscopic Gastric Ischemic Preconditioning Protocol Prior to Esophagectomy with Comparison to Historical Controls. Ann Surg Oncol 2023; 30:5828-5829. [PMID: 37355517 DOI: 10.1245/s10434-023-13796-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2023]
Affiliation(s)
- Anna K Gergen
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Christina M Stuart
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sara Byers
- Adult and Child Consortium for Health Outcomes Research (ACCORDS), University of Colorado School of Medicine, Aurora, CO, USA
| | - Navin Vigneshwar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Helen Madsen
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jocelyn Johnson
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kristen Oase
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nicole Garduno
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Megan Marsh
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Akshay Pratap
- Division of GI, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - John D Mitchell
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Elizabeth A David
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Simran Randhawa
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert A Meguid
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Adult and Child Consortium for Health Outcomes Research (ACCORDS), University of Colorado School of Medicine, Aurora, CO, USA
| | - Martin D McCarter
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Camille L Stewart
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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Stuart CM, Gergen AK, Byers S, Vigneshwar N, Madsen H, Johnson J, Oase K, Garduno N, Marsh M, Pratap A, Mitchell JD, David EA, Randhawa SK, Meguid RA, McCarter MD, Stewart CL. ASO Author Reflections: Gastric Ischemic Preconditioning Prior to Esophagectomy: Laparoscopic Gastric Ischemic Preconditioning. Ann Surg Oncol 2023; 30:5826-5827. [PMID: 37294387 DOI: 10.1245/s10434-023-13715-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 05/23/2023] [Indexed: 06/10/2023]
Affiliation(s)
- Christina M Stuart
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA.
| | - Anna K Gergen
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Sara Byers
- Adult and Child Consortium for Health Outcomes Research (ACCORDS), University of Colorado School of Medicine, Aurora, USA
| | - Navin Vigneshwar
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Helen Madsen
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Jocelyn Johnson
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, USA
| | - Kristen Oase
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, USA
| | - Nicole Garduno
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, USA
| | - Megan Marsh
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, USA
| | - Akshay Pratap
- Department of Surgery, Division of GI, Trauma, and Endocrine Surgery, University of Colorado School of Medicine, Aurora, USA
| | - John D Mitchell
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Elizabeth A David
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Simran K Randhawa
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
| | - Robert A Meguid
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado School of Medicine, Aurora, USA
- Adult and Child Consortium for Health Outcomes Research (ACCORDS), University of Colorado School of Medicine, Aurora, USA
| | - Martin D McCarter
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, USA
| | - Camille L Stewart
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, USA
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Gergen AK, Stuart CM, Byers S, Vigneshwar N, Madsen H, Johnson J, Oase K, Garduno N, Marsh M, Pratap A, Mitchell JD, David EA, Randhawa S, Meguid RA, McCarter MD, Stewart CL. Prospective Evaluation of a Universally Applied Laparoscopic Gastric Ischemic Preconditioning Protocol Prior to Esophagectomy with Comparison with Historical Controls. Ann Surg Oncol 2023; 30:5815-5825. [PMID: 37285095 DOI: 10.1245/s10434-023-13689-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 05/03/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Anastomotic leak after esophagectomy is associated with significant morbidity and mortality. Our institution began performing laparoscopic gastric ischemic preconditioning (LGIP) with ligation of the left gastric and short gastric vessels prior to esophagectomy in all patients presenting with resectable esophageal cancer. We hypothesized that LGIP may decrease the incidence and severity of anastomotic leak. METHODS Patients were prospectively evaluated following the universal application of LGIP prior to esophagectomy protocol in January 2021 until August 2022. Outcomes were compared with patients who underwent esophagectomy without LGIP from a prospectively maintained database from 2010 to 2020. RESULTS We compared 42 patients who underwent LGIP followed by esophagectomy with 222 who underwent esophagectomy without LGIP. Age, sex, comorbidities, and clinical stage were similar between groups. Outpatient LGIP was generally well tolerated, with one patient experiencing prolonged gastroparesis. Median time from LGIP to esophagectomy was 31 days. Mean operative time and blood loss were not significantly different between groups. Patients who underwent LGIP were significantly less likely to develop an anastomotic leak following esophagectomy (7.1% vs. 20.7%, p = 0.038). This finding persisted on multivariate analysis [odds ratio (OR) 0.17, 95% confidence interval (CI) 0.03-0.42, p = 0.029]. The occurrence of any post-esophagectomy complication was similar between groups (40.5% vs. 46.0%, p = 0.514), but patients who underwent LGIP had shorter length of stay [10 (9-11) vs. 12 (9-15), p = 0.020]. CONCLUSIONS LGIP prior to esophagectomy is associated with a decreased risk of anastomotic leak and length of hospital stay. Further, multi-institutional studies are warranted to confirm these findings.
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Affiliation(s)
- Anna K Gergen
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Christina M Stuart
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sara Byers
- Adult and Child Consortium for Health Outcomes Research (ACCORDS), University of Colorado School of Medicine, Aurora, CO, USA
| | - Navin Vigneshwar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Helen Madsen
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jocelyn Johnson
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kristen Oase
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nicole Garduno
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Megan Marsh
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Akshay Pratap
- Division of GI, Trauma, and Endocrine Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - John D Mitchell
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Elizabeth A David
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Simran Randhawa
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert A Meguid
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
- Adult and Child Consortium for Health Outcomes Research (ACCORDS), University of Colorado School of Medicine, Aurora, CO, USA
| | - Martin D McCarter
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Camille L Stewart
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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Madsen HJ, Carmichael H, Reinicke T, Gleisner AL, Del Chiaro M, Schulick RD, Stewart CL. Cannabis use and post-operative complications in patients undergoing pancreatic resection. HPB (Oxford) 2023; 25:431-438. [PMID: 36740564 DOI: 10.1016/j.hpb.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 11/20/2022] [Accepted: 01/16/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND Many states have legalized medical cannabis with various reported therapeutic benefits. However, there is little data assessing the effects of cannabis on surgical outcomes. We sought to compare post-operative pancreatic resection complications between cannabis users and non-users. METHODS This is a single-center, retrospective review of patients who underwent Whipple or distal pancreatectomy from 1/2017-12/2020. The primary outcome was any in-hospital complication, using Clavien-Dindo. Multivariable regression analysis was performed. RESULTS There were 486 patients who underwent Whipple (n=346, 71.2%) or distal pancreatectomy (n=140, 28.8%). Overall, 21.4% (n=104) reported cannabis use, of whom 80.8% were current users. Cannabis users were younger (60 vs. 66 years, p < 0.001), and more likely to have smoked tobacco (p=0.04), but otherwise had similar demographics as non-users. There were 288 (59.3%) patients who developed an in-hospital complication (grade 1-2, 75.3%; grade 3-5, 24.7%). A trend towards increased complications was observed with tobacco smoking (OR 1.33, 95% CI 0.91-1.94, p=0.14), but no association of cannabis use with complications was observed (OR 0.93, 95% CI 0.58-1.47, p=0.74). DISCUSSION A significant proportion of patients undergoing pancreatic resection report cannabis use. These results suggest that there was no association between cannabis use and post-operative complications, future prospective evaluation is warranted.
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Affiliation(s)
- Helen J Madsen
- Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th Avenue, MS C-310, Room 6602, Aurora, CO 80045, USA.
| | - Heather Carmichael
- Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th Avenue, MS C-310, Room 6602, Aurora, CO 80045, USA
| | - Trenton Reinicke
- Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th Avenue, MS C-310, Room 6602, Aurora, CO 80045, USA
| | - Ana L Gleisner
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th Avenue, MS C-310, Room 6602, Aurora, CO 80045, USA; University of Colorado Cancer Center, Denver, CO, USA
| | - Marco Del Chiaro
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th Avenue, MS C-310, Room 6602, Aurora, CO 80045, USA; University of Colorado Cancer Center, Denver, CO, USA
| | - Richard D Schulick
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th Avenue, MS C-310, Room 6602, Aurora, CO 80045, USA; University of Colorado Cancer Center, Denver, CO, USA
| | - Camille L Stewart
- Division of Surgical Oncology, Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th Avenue, MS C-310, Room 6602, Aurora, CO 80045, USA; University of Colorado Cancer Center, Denver, CO, USA
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14
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Stewart CL. Do we need to reduce surgical smoke? Ann Transl Med 2022; 10:1304. [PMID: 36660628 PMCID: PMC9843356 DOI: 10.21037/atm-22-5652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 12/13/2022] [Indexed: 01/01/2023]
Affiliation(s)
- Camille L Stewart
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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15
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Yee EJ, Stewart CL, Clay MR, McCarter MM. Lipoma and Its Doppelganger: The Atypical Lipomatous Tumor/Well-Differentiated Liposarcoma. Surg Clin North Am 2022; 102:637-656. [PMID: 35952693 DOI: 10.1016/j.suc.2022.04.006] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Lipomatous tumors are among the most common soft tissue lesions encountered by the general surgeon. Shared history and clinical presentation make differentiation between benign lipomas and low-grade liposarcomas a diagnostic dilemma. This article reviews the epidemiology, clinical history, diagnostic workup, management, natural history, and surveillance of benign lipomas and atypical lipomatous tumors/well-differentiated liposarcomas. Although it is important that aggressive, potentially malignant atypical lipomatous tumors and liposarcomas be managed in a multidisciplinary, preferably high-volume setting, it is equally as important for the nonspecialist general surgeon to be familiar with lipoma and its doppelganger-the well-differentiated liposarcoma.
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Affiliation(s)
- Elliott J Yee
- Department of Surgery, University of Colorado, 12605 East 16th Avenue, Aurora, CO 80045, USA.
| | - Camille L Stewart
- Department of Surgery, University of Colorado, 12605 East 16th Avenue, Aurora, CO 80045, USA
| | - Michael R Clay
- Department of Pathology, Univeristy of Colorado, 12605 East 16th Avenue, Aurora, CO 80045, USA
| | - Martin M McCarter
- Department of Surgery, University of Colorado, 12605 East 16th Avenue, Aurora, CO 80045, USA
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Stewart CL, Warner SG, De Andrade J, Nguyen A, Heslin M. Correction to: Data-Driven Respectful Discourse in the Society of Surgical Oncology. Ann Surg Oncol 2022; 29:5436. [DOI: 10.1245/s10434-022-11573-6] [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: 11/18/2022]
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17
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Stewart CL, Warner SG, De Andrade J, Nguyen A, Heslin M. ASO Visual Abstract: Data-Driven Respectful Discourse in the Society of Surgical Oncology. Ann Surg Oncol 2021. [PMID: 34716516 DOI: 10.1245/s10434-021-10937-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Camille L Stewart
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Anschutz Medical Campus, 12631 E. 17th Avenue, AO1, Mail Stop C-313, Aurora, CO, 80045, USA.
| | - Susanne G Warner
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - James De Andrade
- Department of Surgery, School of Medicine, University of Iowa, Iowa City, IA, USA
| | - Andrew Nguyen
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Martin Heslin
- Department of Surgery, University of South Alabama School of Medicine, Mobile, AL, USA
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18
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Stewart CL, Tran TB, Nguyen A, Zain J, Lai L, Fong Y, Woo Y. Cholecystectomy in patients with hematologic malignancies. Am J Surg 2021; 223:1157-1161. [PMID: 34711411 DOI: 10.1016/j.amjsurg.2021.10.037] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/01/2021] [Accepted: 10/21/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Cholecystectomy in patients with hematologic malignancies remains poorly understood. METHODS We retrospectively evaluated patients with hematologic malignancies who underwent cholecystectomy at a single institution. RESULTS Of 313 patients who presented for evaluation of abdominal pain, 64 underwent cholecystectomy for acute cholecystitis (34.4%), gangrenous cholecystitis (21.9%), chronic cholecystitis (23.4%), and cholelithiasis (20%). Most had a history of hematopoietic cell transplantation (62.5%) and/or immunosuppressive medication within 30 days of consultation (82.8%). Ultrasound had a 39% false-negative rate for acute nongangrenous cholecystitis. Operative time was 92 ± 39 min, 7 were performed open, 10 had intraoperative transfusions, and 4 had grade 3+ complications. Intraoperative transfusion was associated with increased postoperative length of stay (p = 0.03). Open procedure, operative time, estimated blood loss, intraoperative transfusion, and complications were not associated with timing of surgery. CONCLUSIONS Patients with hematologic malignancies can safely undergo cholecystectomy. Length of postoperative stay for inpatients is associated with intraoperative blood transfusion.
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Affiliation(s)
| | - Thuy B Tran
- Department of Surgery, City of Hope, Duarte, CA, USA
| | - Andrew Nguyen
- Department of Surgery, City of Hope, Duarte, CA, USA
| | - Jasmine Zain
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Lily Lai
- Department of Surgery, City of Hope, Duarte, CA, USA
| | - Yuman Fong
- Department of Surgery, City of Hope, Duarte, CA, USA
| | - Yanghee Woo
- Department of Surgery, City of Hope, Duarte, CA, USA.
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Torphy RJ, Friedman C, Ho F, Leonard LD, Thieu D, Lewis KD, Medina TM, Robinson WA, Gonzalez RC, Stewart CL, Kounalakis N, McCarter MD, Gleisner A. ASO Visual Abstract: Adjuvant Therapy for Stage III Melanoma without Immediate Completion Lymph Node Dissection. Ann Surg Oncol 2021. [PMID: 34564771 DOI: 10.1245/s10434-021-10854-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Robert J Torphy
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Chloe Friedman
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Felix Ho
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Laura D Leonard
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel Thieu
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Karl D Lewis
- Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Theresa M Medina
- Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - William A Robinson
- Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Rene C Gonzalez
- Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Camille L Stewart
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nicole Kounalakis
- Melanoma Sarcoma Specialists of Georgia, Northside Cancer Institute, Atlanta, GA, USA
| | - Martin D McCarter
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ana Gleisner
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Stewart CL, Warner SG, De Andrade J, Nguyen A, Heslin M. Data-Driven Respectful Discourse in the Society of Surgical Oncology. Ann Surg Oncol 2021; 29:821-826. [PMID: 34564772 DOI: 10.1245/s10434-021-10808-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 09/03/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND We previously reported that professional forms of address in speaker introductions were inconsistently used at the Society of Surgical Oncology (SSO) 2018 and 2019 annual meetings, suggesting unconscious bias in speaker introductions. We sought to better understand how speakers would like to be introduced, and if guidelines could improve consistency in speaker introductions. METHODS SSO 2021 abstract submitters received a survey regarding demographics and preferred form of address at the meeting. Respectful discourse guidelines were developed and distributed to meeting moderators. Speaker introductions were reviewed for the 2021 SSO annual meeting and were compared with the 2018 and 2019 meetings. RESULTS The survey response rate was 183/347 (53%) abstract submitters, most of whom (143/183, 78%) indicated preference for a professional form of address (Doctor/Professor) during speaker introductions, which was significantly greater than those who were introduced with a professional form of address during the 2018 and 2019 meetings (351/499, 70%; Chi-square = 4.08, p = 0.043). There was no difference in speaker introduction preference based on gender or race/ethnic identification. Respectful discourse guidelines were developed and distributed to meeting moderators. During the 2021 SSO annual meeting, professional forms of address were used for 104 (84%) speakers, significantly greater than during the 2018 and 2019 meetings (Chi-square = 9.23, p = 0.002). CONCLUSIONS More survey respondents preferred speaker introductions with a professional form of address than were used in prior meetings. This preference was similar across all demographic groups evaluated. Professional addresses during speaker introductions increased significantly after the distribution of guidelines encouraging consistency to decrease unconscious bias and promote an inclusive environment.
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Affiliation(s)
- Camille L Stewart
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Susanne G Warner
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - James De Andrade
- Department of Surgery, School of Medicine, University of Iowa, Iowa City, IO, USA
| | - Andrew Nguyen
- Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Martin Heslin
- Department of Surgery, University of South Alabama School of Medicine, Mobile, AL, USA
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21
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Torphy RJ, Friedman C, Ho F, Leonard LD, Thieu D, Lewis KD, Medina TM, Robinson WA, Gonzalez RC, Stewart CL, Kounalakis N, McCarter MD, Gleisner A. Adjuvant Therapy for Stage III Melanoma Without Immediate Completion Lymph Node Dissection. Ann Surg Oncol 2021; 29:806-815. [PMID: 34537899 DOI: 10.1245/s10434-021-10775-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/23/2021] [Indexed: 12/30/2022]
Abstract
INTRODUCTION For patients with stage III melanoma with occult lymph node metastasis, the use of adjuvant therapy is increasing, and completion lymph node dissection (CLND) is decreasing. We sought to evaluate the use of modern adjuvant therapy and outcomes for patients with stage III melanoma who did not undergo CLND. METHODS Patients with a positive SLNB from 2015 to 2020 who did not undergo CLND were evaluated retrospectively. Nodal recurrence, recurrence-free survival (RFS), distant metastasis-free survival (DMFS), and melanoma-specific survival were evaluated. RESULTS Among 90 patients, 56 (62%) received adjuvant therapy and 34 (38%) underwent observation alone. Patients who received adjuvant therapy were younger (mean age: 53 vs. 65, p < 0.001) and had higher overall stage (Stage IIIb/c 75% vs. 54%, p = 0.041). Disease recurred in 12 of 34 patients (35%) in the observation group and 11 of 56 patients (20%) in the adjuvant therapy group. The most common first site of recurrence was distant recurrence alone (5/34 patients) in the observation group and nodal recurrence alone (8/90 patients) in the adjuvant therapy group. Despite more adverse nodal features in the adjuvant therapy group, 24-month nodal recurrence rate and RFS were not significantly different between the adjuvant and observation cohorts (nodal recurrence rate: 26% vs. 20%, p = 0.68; RFS: 75% vs. 61%, p = 0.39). Among patients with stage IIIb/c disease, adjuvant therapy was associated with a significantly improved 24-month DMFS (86% vs. 59%, p = 0.04). CONCLUSIONS In this early report, modern adjuvant therapy in patients who forego CLND is associated with longer DMFS among patients with stage IIIb/c disease.
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Affiliation(s)
- Robert J Torphy
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Chloe Friedman
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Felix Ho
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Laura D Leonard
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Daniel Thieu
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Karl D Lewis
- Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Theresa M Medina
- Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - William A Robinson
- Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Rene C Gonzalez
- Division of Medical Oncology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Camille L Stewart
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nicole Kounalakis
- Melanoma Sarcoma Specialists of Georgia, Northside Cancer Institute, Atlanta, GA, USA
| | - Martin D McCarter
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ana Gleisner
- Division of Surgical Oncology, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Stewart CL, Raoof M, Lingeman R, Malkas L, Flores V, Caldwell K, Fong Y, Melstrom K. A Quantitative Analysis of Surgical Smoke Exposure as an Occupational Hazard. Ann Surg 2021; 274:306-311. [PMID: 33938490 DOI: 10.1097/sla.0000000000004920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We hypothesized that OR airborne PM was different in quantity and mutagenic potential than office air and cigarette smoke. SUMMARY OF BACKGROUND DATA Exposure to surgical smoke has been equated to cigarette smoking and thought to be hazardous to health care workers despite limited data. METHODS PM was measured during 15 operations in ORs with 24.8 ± 2.0 air changes/h, and in controls (cigarettes, office air with 1.9-2.9 air changes/h). Mutagenic potential was assessed by gamma Histone 2A family member X staining of DNA damage in small airway epithelial cells co-cultured with PM. RESULTS Average PM concentration during surgery was 0.002 ± 0.002 mg/m3 with maximum values at 1.08 ± 1.30 mg/m3. Greater PM correlated with more diathermy (ρ = 0.69, P = 0.006). Values were most often near zero, resulting in OR average values similar to office air (0.002 ± 0.001 mg/m3) (P = 0.32). Cigarette smoke average PM concentration was significantly higher, 4.8 ± 5.6 mg/m3 (P < 0.001). PM collected from 14 days of OR air caused DNA damage to 1.6% ± 2.7% of cultured cells, significantly less than that from office air (27.7% ± 11.7%, P = 0.02), and cigarette smoke (61.3% ± 14.3%, P < 0.001). CONCLUSIONS The air we breathe during surgery has negligible quantities of PM and mutagenic potential, likely due to low frequency of diathermy use coupled with high airflow. This suggests that exposure to surgical smoke is associated with minimal occupational risk.
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Affiliation(s)
- Camille L Stewart
- Department of Surgery, City of Hope National Medical Center, Duarte, California
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Mustafa Raoof
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Robert Lingeman
- Department of Molecular and Cellular Biology, City of Hope National Medical Center, Duarte, California
| | - Linda Malkas
- Department of Molecular and Cellular Biology, City of Hope National Medical Center, Duarte, California
| | - Viviana Flores
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Kerry Caldwell
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, California
| | - Kurt Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, California
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Leonard LD, Torphy RJ, Beaty L, de Araujo TB, Colborn K, Ho F, Albuqueque A, Lewis KD, Gonzalez R, Medina TM, McCarter M, Stewart CL, Gleisner A. Facility contextual effects influence the use of adjuvant immunotherapy in stage III melanoma. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e18758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18758 Background: There are now numerous effective adjuvant immunotherapy options for surgically resected stage III melanoma including novel checkpoint inhibitors and targeted therapies. Current guidelines recommend that the decision to treat stage III melanoma with adjuvant immunotherapy should be individualized and based upon disease burden, patient goals and anticipated therapy tolerance. We sought to assess the contribution of patient, tumor and facility factors on the implementation of immunotherapy in patients with surgically resected stage III melanoma. Methods: Using the National Cancer Database (NCDB), patients from 2012-2017 that underwent excision and were found to have a positive sentinel node were identified. A multivariable mixed effects logistic regression model with a random intercept for site was used to determine the effect of patient, tumor, and facility variables on the probability of immunotherapy. Reference Effect Measures (REM) were used to estimate the variation in immunotherapy use due to unmeasured facility factors (contextual effects) after adjusting for measured patient, tumor, and facility variables. Results: From 2012 to 2017, the percent of patients with stage III melanoma treated with adjuvant immunotherapy increased from 23.7% to 38.5% (p < 0.05). Overall, younger patients and patients with private insurance were more likely to receive immunotherapy. Tumor factors associated with increased use of adjuvant immunotherapy included increasing depth, mitotic rate ³1, ulceration, lymphovascular invasion (LVI), and undergoing a completion lymph node dissection (CLND). Additionally, treatment at a facility with a surgical volume <190 cases/year was associated with increased immunotherapy use. However, the width of the 90% REM range for unmeasured facility effects exceeded that of the measured facility, tumor, time, and patient demographics suggesting that contextual effects had a higher contribution to the variation in immunotherapy use. Conclusions: Our analysis suggests that uninsured patients and patients with government insurance (Medicaid and Medicare) are not receiving immunotherapy at the same frequency as privately insured patients with the same tumor characteristics treated at the same facility. Lastly, compared to known patient, tumor and facility factors, institutional contextual effects were the major drivers of the implementation of immunotherapy.[Table: see text]
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Affiliation(s)
| | | | - Laurel Beaty
- University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | | | - Felix Ho
- University of Colorado School of Medicine, Aurora, CO
| | | | - Karl D. Lewis
- University of Colorado Comprehensive Cancer Center, Aurora, CO
| | - Rene Gonzalez
- Division of Medical Oncology, University of Colorado Cancer Center, Aurora, CO
| | | | - Martin McCarter
- University of Colorado at Denver - Anschutz Medical Campus, Aurora, CO
| | | | - Ana Gleisner
- University of Colorado Comprehensive Cancer Center, Aurora, CO
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Fong AJ, Stewart CL, Lafaro K, LaRocca CJ, Fong Y, Femino JD, Crawford B. Robotic assistance for quick and accurate image-guided needle placement. Updates Surg 2021; 73:1197-1201. [PMID: 33394359 DOI: 10.1007/s13304-020-00956-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 11/29/2022]
Abstract
Computed tomography (CT) image-guided procedures including biopsy, drug delivery, and ablation are gaining increasing application in medicine. Robotic technology holds the promise for allowing surgeons, and other proceduralists, access to such CT-guided procedures by potentially shortening training, improving accuracy, decreasing needle passes, and reducing radiation exposure. We evaluated surgeon learning and proficiency for image-guided needle placement with an FDA-cleared robotic arm. Five out of six surgeons had no prior CT-guided procedural experience, while one had prior experience with freehand CT-guided needle placement. All surgeons underwent a 60-min training with the MAXIO robot (Perfint Healthcare, Redmond, WA). The robot was used to place needles into three different pre-specified targets on a spine model. Performance time, procedural errors, and needle placement accuracy were recorded. All participants successfully placed needles into the targets using the robotic arm. The average time for needle placement was 3:44 ± 1:43 min. Time for needle placement decreased with subsequent attempts, with average third placement taking 2:29 ± 1:51 min less than the first attempt. The average vector distance from the target was 2.3 ± 1.2 mm. One error resulted in the need for reimaging by CT scan. No errant needle placement occurred. Surgeons (attending fellows and residents) without previous experience and minimal training could successfully place percutaneous needles under CT guidance quickly, accurately, and reproducibly using a robotic arm. This suggests that robotic technology may be used to facilitate surgeon adoption of CT image-guided needle-based procedures in the future.
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Affiliation(s)
- Abigail J Fong
- Cedars-Sinai Medical Center, Los Angeles, CA, 90048, USA
| | - Camille L Stewart
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Kelly Lafaro
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Christopher J LaRocca
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA.
| | - Joseph D Femino
- Department of Surgery, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA, 91010, USA
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Abstract
: There is a long history of personal protective equipment (PPE) used by the surgeon to minimize the transmission of various pathogens. In the context of the present coronavirus disease 2019 pandemic there is significant controversy as to what forms of PPE are appropriate or adequate. This review aims to describe the pathogenic mechanism and route of spread of the causative virus, severe acute respiratory syndrome coronavirus, as it pertains to accumulated published data from experienced centers globally. The various forms of PPE that are both available and appropriate are addressed. There are options in the form of eyewear, gloves, masks, respirators, and gowns. The logical and practical utilization of these should be data driven and evolve based on both experience and data. Last, situations specific to surgical populations are addressed. We aim to provide granular collective data that has thus far been published and that can be used as a reference for optimal PPE choices in the perioperative setting for surgical teams.
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Affiliation(s)
- Camille L Stewart
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | | | - Don J Diamond
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Yuman Fong
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
| | - Laleh G Melstrom
- Department of Surgery, City of Hope National Medical Center, Duarte, CA
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26
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Stewart CL, De Andrade JP, Duma N, Ralph OK, Choong K, Gonzalez L, McClintock NC, Sandoval E, Melstrom LG, Warner SG. Unconscious Bias in Speaker Introductions at a Surgical Oncology Meeting: Hierarchy Reigns Over Gender. Ann Surg Oncol 2020; 27:3754-3761. [PMID: 32712891 DOI: 10.1245/s10434-020-08906-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 04/27/2020] [Accepted: 06/08/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Recent reviews of medical conferences have shown that women were less likely to receive a formal introduction compared with men. We examined speaker introductions at the Society of Surgical Oncology (SSO) annual meeting to determine whether similar biases exist within our organization. METHODS An observational study of video-archived speaker introductions at the 2018 and 2019 SSO annual meetings was conducted. Professional address was defined as professional title followed by full name or last name. Multivariable logistic regression was used to identify factors associated with form of address. RESULTS There were 499 speaker introductions reviewed. Speakers included 290 (58%) men and 238 (49%) post-graduate trainees (residents and fellows). A non-professional form of address was used to introduce 148 (30%) speakers and was most often used for post-graduate trainees (33%). Full professors were more likely than junior faculty to introduce speakers with a non-professional form of address (37% of full professors vs 18% of assistant professors, p < 0.001). In multivariable regression analysis these findings persisted. Trainees were 2.8 times more likely to receive a non-professional form of address (p = 0.003). Use of a non-professional introduction did not significantly vary by the speaker's nor the introducer's gender. CONCLUSIONS Residents and fellows were more likely to receive a non-professional form of address, and the likelihood of this increased with rising seniority of the introducer. The manner of speaker introduction did not vary by gender in our organization. More research is needed to explore the influence of these disparities on academic advancement for the next generation of surgical oncologists.
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Affiliation(s)
- Camille L Stewart
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA.
| | - James P De Andrade
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Narjust Duma
- Department of Medicine, Division of Hematology, Medical Oncology and Palliative Care, University of Wisconsin, Madison, WI, USA
| | - Oliver K Ralph
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Kevin Choong
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Lorena Gonzalez
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | | | - Ethan Sandoval
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Laleh G Melstrom
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Susanne G Warner
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
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27
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Stewart CL, Wong P, Selby L, Warner SG, Raoof M, Singh G, Fong Y, Melstrom LG. Minimally invasive distal pancreatectomy and the cost of conversion. J Surg Oncol 2020; 121:670-675. [PMID: 31967336 DOI: 10.1002/jso.25852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 12/21/2019] [Accepted: 12/26/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Minimally invasive surgery (MIS) is preferred for distal pancreatectomy but is not always attempted due to the risk of conversion to open. We hypothesized that the total cost for MIS converted to open procedures would be comparable to those that started open. METHODS A prospectively collected institutional registry (2011-2017) was reviewed for demographic, clinical, and perioperative cost data for patients undergoing distal pancreatectomy. RESULTS There were 80 patients who underwent distal pancreatectomy: 41 open, 39 MIS (11 laparoscopic and 28 robotic). Conversion to open occurred in 14 of 39 (36%, 3 laparoscopic and 11 robotic). Length of stay was shorter for the MIS completed (6 days; range, 3-8), and MIS converted to open (7 days; range, 4-10) groups, compared with open (10 days; range, 5-36; P = .003). Laparoscopic cases were the least expensive (P = .02). Robotic converted to open procedures had the highest operating room cost. However, the total cost for robotic converted to open cohort was similar to the open cohort due to cost savings associated with a shorter length of stay. CONCLUSIONS Despite the higher intraoperative costs of robotic surgery, there is no significant overall financial penalty for conversion to open. Financial considerations should not play a role in selecting a robotic or open approach.
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Affiliation(s)
| | - Paul Wong
- Department of Surgery, City of Hope, Duarte, California
| | - Luke Selby
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Mustafa Raoof
- Department of Surgery, City of Hope, Duarte, California
| | | | - Yuman Fong
- Department of Surgery, City of Hope, Duarte, California
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28
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Fong AJ, Stewart CL, Lafaro K, LaRocca CJ, Femino D, Crawford B. Surgeons Can Quickly and Accurately Perform Image Guided Needle Placement Using Robotic Assistance. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.1071] [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: 11/26/2022]
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29
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Stewart CL, Warner S, Ito K, Raoof M, Wu GX, Kessler J, Kim JY, Fong Y. Cytoreduction for colorectal metastases: liver, lung, peritoneum, lymph nodes, bone, brain. When does it palliate, prolong survival, and potentially cure? Curr Probl Surg 2018; 55:330-379. [PMID: 30526930 DOI: 10.1067/j.cpsurg.2018.08.004] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/28/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Camille L Stewart
- Division of Surgical Oncology, City of Hope National Medical Center, Duarte, CA
| | - Susanne Warner
- Division of Surgical Oncology, City of Hope National Medical Center, Duarte, CA
| | - Kaori Ito
- Department of Surgery, Michigan State University, Lansing, MI
| | - Mustafa Raoof
- Division of Surgical Oncology, City of Hope National Medical Center, Duarte, CA
| | - Geena X Wu
- Division of Thoracic Surgery, City of Hope National Medical Center, Duarte, CA
| | - Jonathan Kessler
- Department of Diagnostic Radiology, City of Hope National Medical Center, Duarte, CA
| | - Jae Y Kim
- Division of Thoracic Surgery, City of Hope National Medical Center, Duarte, CA
| | - Yuman Fong
- Division of Surgical Oncology, City of Hope National Medical Center, Duarte, CA.
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30
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Stewart CL, McCarter M. ASO Author Reflections: Should We Be Using Dextrose-Containing Carrier Solutions for Perfusion During HIPEC? Ann Surg Oncol 2018; 25:834-835. [PMID: 30276640 DOI: 10.1245/s10434-018-6794-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Camille L Stewart
- Department of Surgery, The University of Colorado School of Medicine, Aurora, CO, USA.
| | - Martin McCarter
- Department of Surgery, The University of Colorado School of Medicine, Aurora, CO, USA
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31
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Stewart CL, Warner S, Ito K, Raoof M, Wu GX, Kessler J, Kim JY, Fong Y. In Brief. Curr Probl Surg 2018. [DOI: 10.1067/j.cpsurg.2018.10.001] [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: 11/22/2022]
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32
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Desiderio J, Stewart CL, Sun V, Melstrom L, Warner S, Lee B, Schoellhammer HF, Trisal V, Paz B, Fong Y, Woo Y. Enhanced Recovery after Surgery for Gastric Cancer Patients Improves Clinical Outcomes at a US Cancer Center. J Gastric Cancer 2018; 18:230-241. [PMID: 30276000 PMCID: PMC6160527 DOI: 10.5230/jgc.2018.18.e24] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 07/13/2018] [Accepted: 07/30/2018] [Indexed: 12/15/2022] Open
Abstract
Purpose Enhanced recovery after surgery (ERAS) protocols for gastric cancer patients have shown improved outcomes in Asia. However, data on gastric cancer ERAS (GC-ERAS) programs in the United States are sparse. The purpose of this study was to compare perioperative outcomes before and after implementation of an GC-ERAS protocol at a National Comprehensive Cancer Center in the United States. Materials and Methods We reviewed medical records of patients surgically treated for gastric cancer with curative intent from January 2012 to October 2016 and compared the GC-ERAS group (November 1, 2015–October 1, 2016) with the historical control (HC) group (January 1, 2012–October 31, 2015). Propensity score matching was used to adjust for age, sex, number of comorbidities, body mass index, stage of disease, and distal versus total gastrectomy. Results Of a total of 95 identified patients, matching analysis resulted in 20 and 40 patients in the GC-ERAS and HC groups, respectively. Lower rates of nasogastric tube (35% vs. 100%, P<0.001) and intraabdominal drain placement (25% vs. 85%, P<0.001), faster advancement of diet (P<0.001), and shorter length of hospital stay (5.5 vs. 7.8 days, P=0.01) were observed in the GC-ERAS group than in the HC group. The GC-ERAS group showed a trend toward increased use of minimally invasive surgery (P=0.06). There were similar complication and 30-day readmission rates between the two groups (P=0.57 and P=0.66, respectively). Conclusions The implementation of a GC-ERAS protocol significantly improved perioperative outcomes in a western cancer center. This finding warrants further prospective investigation.
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Affiliation(s)
- Jacopo Desiderio
- Department of Digestive Surgery, St. Mary's Hospital, University of Perugia, Terni, Italy
| | - Camille L Stewart
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Virginia Sun
- Division of Nursing Research and Education, Department of Population Sciences, Beckman Research Institute, City of Hope National Medical Center, Duarte, CA, USA
| | - Laleh Melstrom
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Susanne Warner
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Byrne Lee
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Hans F Schoellhammer
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Vijay Trisal
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Benjamin Paz
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Yuman Fong
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
| | - Yanghee Woo
- Division of Surgical Oncology, Department of Surgery, City of Hope National Medical Center, Duarte, CA, USA
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33
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Stewart CL, Gleisner A, Halpern A, Ibrahim-Zada I, Luna RA, Pearlman N, Gajdos C, Edil B, McCarter M. Implications of Hyperthermic Intraperitoneal Chemotherapy Perfusion-Related Hyperglycemia. Ann Surg Oncol 2017; 25:655-659. [PMID: 29204776 DOI: 10.1245/s10434-017-6284-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Hyperthermic intraperitoneal chemotherapy (HIPEC) administration can be associated with hyperglycemia during perfusion. Little is known about this effect, and no previous studies have examined patient characteristics associated with perfusion-related hyperglycemia. METHODS We retrospectively identified consecutive patients at a single institution treated with HIPEC from 8/2003 to 10/2016 who had intraoperative blood glucose measured. Hypertonic 1.5% dextrose-containing peritoneal dialysate was used as carrier solution in all patients. Comparisons were made using parametric [Student's t test, analysis of variance (ANOVA)], and nonparametric tests (χ 2, Kruskal-Wallis) where appropriate. RESULTS There were 85 patients identified, with average age of 53 ± 12 years, 69 (81%) with appendiceal or colorectal peritoneal cancer. Most patients were perfused with mitomycin C (69%) or oxaliplatin (24%). Intraoperative hyperglycemia (> 180 mg/dL) affected the majority of patients (86%), with values up to 651 mg/dL. Insulin was required for treatment in 66% of patients. Peak hyperglycemia occurred within an hour of perfusion in 91%, and resolved by postoperative day one in 91% of patients. Glucose > 309 mg/dL (highest quartile) was associated with longer operating time (p = 0.03) and with use of oxaliplatin compared with mitomycin C (p = 0.01). No association was found with other comorbidities, peritoneal carcinomatosis index score, or postoperative outcomes. CONCLUSIONS Most patients experience hyperglycemia during HIPEC. This is not clearly associated with patient factors, and may be due to use of dextrose-containing carrier solution. Since perioperative hyperglycemia has potential negative impact, use of dextrose-containing carrier solution should be questioned and is worth investigating further.
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Affiliation(s)
- Camille L Stewart
- Department of Surgery, The University of Colorado School of Medicine, Aurora, CO, USA.
| | - Ana Gleisner
- Department of Surgery, The University of Colorado School of Medicine, Aurora, CO, USA
| | - Alison Halpern
- Department of Surgery, The University of Colorado School of Medicine, Aurora, CO, USA
| | - Irada Ibrahim-Zada
- Department of Surgery, The University of Colorado School of Medicine, Aurora, CO, USA
| | - Rodrigo Asturias Luna
- Department of Surgery, The University of Colorado School of Medicine, Aurora, CO, USA
| | - Nathan Pearlman
- Department of Surgery, The University of Colorado School of Medicine, Aurora, CO, USA
| | - Csaba Gajdos
- Department of Surgery, The University of Colorado School of Medicine, Aurora, CO, USA
| | - Barish Edil
- Department of Surgery, The University of Colorado School of Medicine, Aurora, CO, USA
| | - Martin McCarter
- Department of Surgery, The University of Colorado School of Medicine, Aurora, CO, USA
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34
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Stewart CL, Cornejo CM, Wanat KA, Sander I, Samimi S, Prouty S, Seykora J, Zhang P, Rosenbach M, Kim EJ, Micheletti RG. The immune reconstitution of the skin following sex-mismatched allogeneic haematopoietic stem cell transplant: a prospective case series utilizing fluorescence in situ hybridization and immunohistochemistry. Br J Dermatol 2017; 178:e55-e56. [PMID: 28796881 DOI: 10.1111/bjd.15878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- C L Stewart
- Department of Medicine, Division of Dermatology, University of Washington, Seattle, WA, U.S.A
| | - C M Cornejo
- Departments of Dermatology and Pathology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - K A Wanat
- Department of Dermatology, University of Iowa, Iowa City, IA, U.S.A.,Department of Pathology, University of Iowa, Iowa City, IA, U.S.A
| | - I Sander
- Department of Dermatology, Johns Hopkins University, Baltimore, MD, U.S.A
| | - S Samimi
- Departments of Dermatology and Pathology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - S Prouty
- Departments of Dermatology and Pathology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - J Seykora
- Departments of Dermatology and Pathology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - P Zhang
- Departments of Dermatology and Pathology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - M Rosenbach
- Departments of Dermatology and Pathology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - E J Kim
- Departments of Dermatology and Pathology, University of Pennsylvania, Philadelphia, PA, U.S.A
| | - R G Micheletti
- Departments of Dermatology and Pathology, University of Pennsylvania, Philadelphia, PA, U.S.A
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35
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Stewart CL, Acker SN, Pyle L, Smith DS, Bensard DD, Moulton SL. Mapping pediatric injuries to target prevention, education, and outreach. J Pediatr Surg 2017; 52:1287-1291. [PMID: 28073490 DOI: 10.1016/j.jpedsurg.2016.12.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2016] [Revised: 12/24/2016] [Accepted: 12/26/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Initiatives exist to prevent pediatric injuries, but targeting these interventions to specific populations is challenging. We hypothesized that mapping pediatric injuries by zip code could be used to identify regions requiring more interventions and resources. METHODS We queried the trauma registries of two level I trauma centers for children 0-17years of age injured between 2009 and 2013 with home zip codes in our state. Maps were created to identify outlier zip codes. Multivariate linear regression analysis identified predictors within these zip codes. RESULTS There were 5380 children who resided in the state and were admitted for traumatic injuries during the study period, with hospital costs totaling more than 200 million dollars. Choropleth mapping of patient addresses identified outlier zip codes in our metro area with higher incidences of specific mechanisms of injury and greater hospital charges. Multivariate analysis identified demographic features associated with higher rates of pediatric injuries and hospital charges, to further target interventions. CONCLUSIONS We identified outlier zip codes in our metro area with higher frequencies of pediatric injuries and higher costs for treatment. These data have helped obtain funding for prevention and education efforts. Techniques such as those presented here are becoming more important as evidence based public health initiatives expand. LEVEL OF EVIDENCE Type of Study: Cost Effectiveness, II.
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Affiliation(s)
- Camille L Stewart
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States.
| | - Shannon N Acker
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Laura Pyle
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Dwayne S Smith
- Children's Health Advocacy Institute, Children's Hospital Colorado, Aurora, CO, United States
| | - Denis D Bensard
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Department of Surgery, Denver Health Medical Center, Denver, CO, United States; Department of Surgery, Children's Hospital Colorado, Aurora, CO, United States
| | - Steven L Moulton
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States; Department of Surgery, Children's Hospital Colorado, Aurora, CO, United States
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Stewart CL, Wilson L, Hamm A, Bartsch C, Boniface M, Gleisner A, Mitchell JD, Weyant MJ, Meguid R, Gajdos C, Edil BH, McCarter M. Is Chemical Pyloroplasty Necessary for Minimally Invasive Esophagectomy? Ann Surg Oncol 2017; 24:1414-1418. [PMID: 28058546 DOI: 10.1245/s10434-016-5742-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Many centers use botulinum toxin for chemical pyloroplasty in minimally invasive esophagectomies as prophylaxis against delayed gastric emptying. No previous studies have compared botulinum toxin injection with no pyloric intervention for patients treated with a combined laparoscopic and thoracoscopic approach. The authors hypothesized that chemical pyloroplasty does not improve outcomes for these patients. METHODS The study investigated patients undergoing minimally invasive esophagectomies from September 2009 to June 2015. Delayed gastric emptying was defined as inability to tolerate a soft diet by postoperative day 10, as corroborated by esophagram, upper endoscopy, or both. Data were compared using Student's t test, χ 2 analysis, and Mann-Whitney U test where appropriate. RESULTS The study identified 71 patients treated with minimally invasive esophagectomy: 35 patients with chemical pyloroplasty treated from September 2009 to January 2014 and 36 patients without pyloric intervention from February 2014 to June 2015. The groups were statistically similar in age, gender distribution, T stage, percentage of patients receiving neoadjuvant therapy, body mass index, preoperative weight loss, preoperative serum albumin, and preoperative placement of feeding tubes (all p > 0.05). The overall incidence of delayed gastric emptying was low in both groups: 8.6% (3/35) of the patients with chemical pyloroplasty versus 5.6% (2/36) of the patients with no pyloric intervention (p = 0.62). The two groups also did not differ significantly in the development of aspiration pneumonia or the need for pyloric intervention. CONCLUSIONS In a well-matched cohort study with a historical control group, use of botulinum toxin for chemical pyloroplasty in minimally invasive esophagectomies was not associated with improved outcomes related to the pylorus versus no pyloric intervention. Although preliminary, these data suggest that chemical pyloroplasty is not necessary in minimally invasive esophagectomy.
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Affiliation(s)
- Camille L Stewart
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Lauren Wilson
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Aidan Hamm
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Christan Bartsch
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Megan Boniface
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ana Gleisner
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - John D Mitchell
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael J Weyant
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Robert Meguid
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Csaba Gajdos
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Barish H Edil
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Martin McCarter
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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Stewart CL, Gleisner A, Kwak J, Chapman B, Pearlman N, Gajdos C, McCarter M, Kounalakis N. Implications of Sentinel Lymph Node Drainage to Multiple Basins in Head and Neck Melanoma. Ann Surg Oncol 2017; 24:1386-1391. [DOI: 10.1245/s10434-016-5744-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Indexed: 11/18/2022]
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Stewart CL, Meguid C, Chapman B, Schulick R, Edil BH. Evolving Trends Towards Minimally Invasive Surgery for Solid-Pseudopapillary Neoplasms. Ann Surg Oncol 2016; 23:4165-4168. [PMID: 27510845 DOI: 10.1245/s10434-016-5491-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Solid-pseudopapillary neoplasms are rare pancreatic neoplasms with low malignant potential that predominantly arise in young women. We sought to characterize this population and the evolving trend at our institution towards laparoscopic management. METHODS We identified all patients at our institution that were surgically treated for solid-pseudopapillary neoplasm from 2008-2015. Demographic and clinical information were queried from the medical record, and descriptive statistics were performed. Student's t test and chi-square analysis were used for comparison where appropriate. RESULTS We identified 11 women and 1 man (average age 26 years; range 14-48 years) who were surgically treated for solid-pseudopapillary neoplasms; 5 with distal pancreatectomy (4 open, 1 laparoscopic), 6 with pancreaticoduodenectomy (3 open, 3 laparoscopic), and 1 open enucleation. From 2008 to 2013, seven of eight (87 %) procedures were performed open. Since 2014, three of four (75 %) procedures have successfully been completed laparoscopically (see video clips). Length of stay was similar for patients who had open versus laparoscopic procedures (8 vs. 9 days, p = 0.61). Two-thirds of patients (5/8) who had open procedures experienced postoperative complications compared with half (2/4) of patients who had laparoscopic procedures (p = 0.28). There have been no recurrences. CONCLUSIONS Minimally invasive surgical management of solid-pseudopapillary neoplasms is becoming more popular, can be performed safely, and appears to have comparable outcomes to an open approach. Quality of life is an important metric for this relatively young population and may be improved with a laparoscopic approach, which warrants further investigation.
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Affiliation(s)
- Camille L Stewart
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | | | - Brandon Chapman
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Richard Schulick
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,University of Colorado Hospital, Aurora, CO, USA
| | - Barish H Edil
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,University of Colorado Hospital, Aurora, CO, USA
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Stewart CL, Kulungowski AM, Tong S, Langer JC, Soden J, Sømme S. Rectal biopsies for Hirschsprung disease: Patient characteristics by diagnosis and attending specialty. J Pediatr Surg 2016; 51:573-6. [PMID: 26592956 DOI: 10.1016/j.jpedsurg.2015.10.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 10/10/2015] [Accepted: 10/12/2015] [Indexed: 12/24/2022]
Abstract
PURPOSE Hirschsprung disease (HD) is diagnosed with rectal biopsy. At our institution two services perform these biopsies: pediatric surgery and gastroenterology. Our objective was to review our institutional experience with rectal biopsies to diagnose HD and compare patients and outcomes between the two services. METHODS We reviewed all children undergoing a rectal biopsy for the evaluation of HD at our institution over a 10-year period. Comparisons were made using multiple logistic regression models. RESULTS We identified 518 children who underwent rectal biopsy for evaluation of HD; 451/518 (87%) were adequate and 56/518 (11%) were positive for HD. A positive biopsy was more likely with delayed passage of meconium (p<0.001), obstructive symptoms (p<0.001), trisomy 21 (p<0.001), full-term gestation (p=0.03), and male gender (p=0.02). Pediatric surgeons biopsied younger patients with more classic symptoms for HD compared to gastroenterologists. Pediatric surgeons were more likely to take adequate (OR 6.0, 95% CI 2.9-12.4, p<0.001) and positive biopsies (OR 6.7 95% CI 2.1-21.2, p=0.001) compared to gastroenterologists. CONCLUSION Infants with classic symptoms can reliably be diagnosed with HD by a pediatric surgeon. The work up for HD in older children with constipation should be a collaborative effort between pediatric surgery and gastroenterology.
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Affiliation(s)
- Camille L Stewart
- Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th, Ave., Aurora, CO 80045, USA; Division of Pediatric Surgery, Children's Hospital Colorado, 13123 East 16th Ave., Aurora, CO 80045, USA.
| | - Ann M Kulungowski
- Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th, Ave., Aurora, CO 80045, USA; Division of Pediatric Surgery, Children's Hospital Colorado, 13123 East 16th Ave., Aurora, CO 80045, USA.
| | - Suhong Tong
- Department of Pediatrics, University of Colorado School of Medicine, 12631 E. 17th, Ave., Aurora, CO 80045, USA.
| | - Jacob C Langer
- Division of Pediatric Surgery, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, Canada.
| | - Jason Soden
- Division of Pediatric Gastroenterology, Children's Hospital Colorado, 13123 East, 16th Ave., Aurora, CO 80045, USA.
| | - Stig Sømme
- Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th, Ave., Aurora, CO 80045, USA; Division of Pediatric Surgery, Children's Hospital Colorado, 13123 East 16th Ave., Aurora, CO 80045, USA.
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Acker SN, Trinh BB, Partrick DA, Stewart CL, Bensard DD. Is Routine Upper Gastrointestinal Contrast Study Necessary prior to Laparoscopic Gastrostomy Tube Placement in Children? Eur J Pediatr Surg 2016; 26:29-33. [PMID: 26382658 DOI: 10.1055/s-0035-1563675] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Before gastrostomy tube (GT) placement, many pediatric surgeons request that children undergo a preoperative upper gastrointestinal contrast study (UGI) to evaluate for the presence of either gastroesophageal reflux (GER) or intestinal malrotation. We hypothesized that routine UGI is unnecessary before GT placement. MATERIALS AND METHODS We performed a retrospective review of 500 consecutive children who had a GT placed in a single children's hospital from 2009 to 2012. RESULTS There were 403 children who underwent UGI before planned GT placement; 196 of which were placed during the same hospitalization. Only 1/403 (0.25%) diagnosis of malrotation was identified on UGI, and treated with a Ladd procedure at the time of GT placement. There were 154 children who had evidence of reflux on UGI; 97 underwent an antireflux procedure in conjunction with GT placement. An additional 57 children with no evidence of reflux on UGI also underwent a concurrent antireflux procedure. Of these 160 children who underwent concurrent fundoplication, only 3 (2%) had a confirmatory pH probe study performed before GT placement. CONCLUSIONS We found that in children undergoing routine preoperative UGI before GT placement (1) the risk of malrotation is less than 1%; (2) the decision to perform an antireflux procedure weakly correlates with the UGI findings of GER; and (3) one in five patients without radiographic GER still underwent concomitant fundoplication with or without confirmatory pH probe study. We conclude that the practice of routine UGI before laparoscopic gastrostomy placement in children is likely unnecessary.
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Affiliation(s)
- Shannon N Acker
- Department of Surgery, University of Colorado, Aurora, Colorado, United States
| | - Becky B Trinh
- Department of Surgery, University of Colorado, Aurora, Colorado, United States
| | - David A Partrick
- Department of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado, United States
| | - Camille L Stewart
- Department of Surgery, University of Colorado, Aurora, Colorado, United States
| | - Denis D Bensard
- Department of Surgery, Denver Health Medical Center, Aurora, Colorado, United States
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Stewart CL, Acker SN, Pyle LL, Kulungowski A, Cadnapaphornchai M, Bruny JL, Karrer F. Factors associated with peritoneal dialysis catheter complications in children. J Pediatr Surg 2016; 51:159-62. [PMID: 26572851 DOI: 10.1016/j.jpedsurg.2015.10.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 10/09/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND/PURPOSE Peritoneal dialysis (PD) is a common method of renal replacement therapy for children. However, placement of PD catheters has risk, and some are never used. METHODS We conducted a retrospective chart review of children with a PD catheter placed between 2000 and 2014. Logistic regression analyses were used to identify covariates associated with complications. RESULTS We identified 175 children with PD catheters. 110 complications developed in 80 children (45.7%). Complications including unexpected return to the operating room and peritonitis increased as the length of time a catheter was in place increased. Children who weighed <12.4 kg had 3.2 times greater odds of developing a leak (95% CI 1.21-8.63, p=0.02). Twelve children never used their PD catheters, 9 with acute kidney injury (AKI) who recovered from their disease more quickly than expected. No covariate was associated with nonuse. CONCLUSIONS Complications with PD catheters are common and increase the longer catheters are in place. Lower weight children are at greater risk of PD catheter leak. Decreased initial volumes of dialysate in smaller children may mitigate this risk. Nonuse may be reduced if dialysis is permitted the day of placement for children with AKI.
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Affiliation(s)
- Camille L Stewart
- Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th Ave., Aurora, CO 80045, USA.
| | - Shannon N Acker
- Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th Ave., Aurora, CO 80045, USA
| | - Laura L Pyle
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, 12631 E. 17th Ave., CO 80045, USA; Department of Biostatistics and Informatics, University of Colorado School of Public Health, 13001 E 17th Pl., Aurora, CO 80045, USA
| | - Ann Kulungowski
- Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th Ave., Aurora, CO 80045, USA; Division of Pediatric Surgery, Children's Hospital Colorado, 13123 East 16th Ave., Aurora, CO 80045, USA
| | - Melissa Cadnapaphornchai
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, 12631 E. 17th Ave., CO 80045, USA; Division of Pediatric Nephrology, Children's Hospital Colorado, 13123 East 16th Ave., Aurora, CO 80045, USA
| | - Jennifer L Bruny
- Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th Ave., Aurora, CO 80045, USA; Division of Pediatric Surgery, Children's Hospital Colorado, 13123 East 16th Ave., Aurora, CO 80045, USA
| | - Frederick Karrer
- Department of Surgery, University of Colorado School of Medicine, 12631 E. 17th Ave., Aurora, CO 80045, USA; Division of Pediatric Surgery, Children's Hospital Colorado, 13123 East 16th Ave., Aurora, CO 80045, USA
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Stewart CL, Nawn CD, Mulligan J, Grudic G, Moulton SL, Convertino VA. Compensatory Reserve for Early and Accurate Prediction of Hemodynamic Compromise: Case Studies for Clinical Utility in Acute Care and Physical Performance. J Spec Oper Med 2016; 16:6-13. [PMID: 27045488] [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] [Accepted: 03/01/2016] [Indexed: 06/05/2023]
Abstract
BACKGROUND Humans are able to compensate for significant loss of their circulating blood volume, allowing vital signs to remain relatively stable until compensatory mechanisms are overwhelmed. The authors present several clinical and performance case studies in an effort to demonstrate real-time measurements of an individual's reserve to compensate for acute changes in circulating blood volume. This measurement is referred to as the Compensatory Reserve Index (CRI). METHODS We identified seven clinical and two physical performance conditions relevant to military casualty and operational medicine as models of intravascular volume compromise. Retrospective analysis of photoplethysmogram (PPG) waveform features was used to calculate CRI, where 1 represents supine normovolemia and 0 represents hemodynamic decompensation. RESULTS All cases had CRI values suggestive of volume compromise (<0.6) not otherwise evident by heart rate and systolic blood pressure. CRI decreased with reduced central blood volume and increased with restored volume (e.g., fluid resuscitation). CONCLUSION The results from these case studies demonstrate that machine-learning techniques can be used to (1) identify a clinical or physiologic status of individuals through real-time measures of changes in PPG waveform features that result from compromise to circulating blood volume and (2) signal progression toward hemodynamic instability, with opportunity for early and effective intervention, well in advance of changes in traditional vital signs.
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Affiliation(s)
- Camille L. Stewart
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Christopher Raeburn
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Barish H. Edil
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
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Acker SN, Stewart CL, Roosevelt GE, Partrick DA, Moore EE, Bensard DD. When is it safe to forgo abdominal CT in blunt-injured children? Surgery 2015; 158:408-12. [DOI: 10.1016/j.surg.2015.03.037] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 03/13/2015] [Accepted: 03/17/2015] [Indexed: 11/28/2022]
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Stewart CL, Metzger RR, Pyle L, Darmofal J, Scaife E, Moulton SL. Helicopter versus ground emergency medical services for the transportation of traumatically injured children. J Pediatr Surg 2015; 50:347-52. [PMID: 25638635 DOI: 10.1016/j.jpedsurg.2014.09.040] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Accepted: 09/08/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Helicopter emergency medical services (HEMS) are a common mode of transportation for pediatric trauma patients. We hypothesized that HEMS improve outcomes for traumatically injured children compared to ground emergency medical services (GEMS). METHODS We queried trauma registries of two level 1 pediatric trauma centers for children 0-17 years, treated from 2003 to 2013, transported by HEMS or GEMS, with known transport starting location and outcome. A geocoding service estimated travel distance and time. Multivariate regression analyses were performed to adjust for injury severity variables and travel distance/time. RESULTS We identified 14,405 traumatically injured children; 3870 (26.9%) transported by HEMS and 10,535 (73.1%) transported by GEMS. Transport type was not significantly associated with survival, ICU length of stay, or discharge disposition. Transport by GEMS was associated with a 68.6%-53.1% decrease in hospital length of stay, depending on adjustment for distance/time. Results were similar for children with severe injuries, and with propensity score matched cohorts. Of note, 862/3850 (22.3%) of HEMS transports had an ISS<10 and hospitalization<1 day. CONCLUSIONS HEMS do not independently improve outcomes for traumatically injured children, and 22.3% of children transported by HEMS are not significantly injured. These factors should be considered when requesting HEMS for transport of traumatically injured children.
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Affiliation(s)
- Camille L Stewart
- University of Colorado School of Medicine, Department of Surgery, 12631 E. 17th Ave, C302, Aurora, CO 80045; Children's Hospital Colorado, Division of Pediatric Surgery, 13123 E. 16th Ave, B232, Aurora, CO 80045.
| | - Ryan R Metzger
- Primary Children's Hospital, Division of Pediatric Surgery, 100 N Mario Capecchi Dr, Suite 2600, Salt Lake City, UT 84113.
| | - Laura Pyle
- University of Colorado School of Medicine, Department of Pediatrics, 13001 E. 17th Place, C290, Aurora, CO 80045.
| | - Joe Darmofal
- Children's Hospital Colorado, Department of Transport & EMS Outreach and Education, 13123 E. 16th Ave, B245, Aurora, CO 80045.
| | - Eric Scaife
- Primary Children's Hospital, Division of Pediatric Surgery, 100 N Mario Capecchi Dr, Suite 2600, Salt Lake City, UT 84113.
| | - Steven L Moulton
- University of Colorado School of Medicine, Department of Surgery, 12631 E. 17th Ave, C302, Aurora, CO 80045; Children's Hospital Colorado, Division of Pediatric Surgery, 13123 E. 16th Ave, B232, Aurora, CO 80045.
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Abstract
PURPOSE Children with diabetes mellitus (DM) who develop acute appendicitis can present a diagnostic and clinical challenge. No studies have examined this population since the advent of multiple dose insulin therapy, computed tomography, and laparoscopic surgery. We sought to characterize these children to identify their differences and how to best care for them. METHODS We retrospectively examined the medical records of children with a preexisting diagnosis of DM treated for acute appendicitis. Values are presented as the mean±the standard error of the mean, and Student's t-test was used for statistical comparison. RESULTS We identified 18 diabetic children treated for acute appendicitis, making this the largest series of its kind. These children had similar presentations compared to non-diabetics, with the exception of often presenting without fever (83.3% with an initial temperature <38 C). All children developed significant postoperative hyperglycemia (average high 382±18mg/dL), and most had glycemic control for ≤50% of the hospitalization (14/18, 77.8%), but they otherwise had typical postoperative courses. CONCLUSIONS Diabetic children with appendicitis are often afebrile at presentation and have serum glucose levels that are difficult to control. Collaboration with pediatric endocrinologists is needed to appropriately manage these children during their hospitalization.
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Affiliation(s)
- Camille L Stewart
- Department of Surgery, University of Colorado School of Medicine, Aurora CO, United States; Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, United States.
| | - Colleen L Wood
- Department of Surgery, University of Colorado School of Medicine, Aurora CO, United States; Division of Pediatric Endocrinology, Children's Hospital Colorado, Aurora, CO, United States
| | - John F Bealer
- Department of Surgery, University of Colorado School of Medicine, Aurora CO, United States; Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, United States
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Holscher CM, Stewart CL, Peltz ED, Burlew CC, Moulton SL, Haenel JB, Bensard DD. Early tracheostomy improves outcomes in severely injured children and adolescents. J Pediatr Surg 2014; 49:590-2. [PMID: 24726119 DOI: 10.1016/j.jpedsurg.2013.09.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 08/03/2013] [Accepted: 09/01/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Early tracheostomy has been advocated for adult trauma patients to improve outcomes and resource utilization. We hypothesized that timing of tracheostomy for severely injured children would similarly impact outcomes. METHODS Injured children undergoing tracheostomy over a 10-year period (2002-2012) were reviewed. Early tracheostomy was defined as post-injury day ≤ 7. Data were compared using Student's t test, Pearson chi-squared test and Fisher exact test. Statistical significance was set at p<0.05 with 95% confidence intervals. RESULTS During the 10-year study period, 91 patients underwent tracheostomy following injury. Twenty-nine (32%) patients were < 12 years old; of these, 38% received early tracheostomy. Sixty-two (68%) patients were age 13 to 18; of these, 52% underwent early tracheostomy. Patients undergoing early tracheostomy had fewer ventilator days (p=0.003), ICU days (p=0.003), hospital days (p=0.046), and tracheal complications (p=0.03) compared to late tracheostomy. There was no difference in pneumonia (p=0.48) between early and late tracheostomy. CONCLUSION Children undergoing early tracheostomy had improved outcomes compared to those who underwent late tracheostomy. Early tracheostomy should be considered for the severely injured child. SUMMARY Early tracheostomy is advocated for adult trauma patients to improve patient comfort and resource utilization. In a review of 91 pediatric trauma patients undergoing tracheostomy, those undergoing tracheostomy on post-injury day ≤ 7 had fewer ventilator days, ICU days, hospital days, and tracheal complications compared to those undergoing tracheostomy after post-injury day 7.
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Affiliation(s)
| | | | | | - Clay Cothren Burlew
- University of Colorado School of Medicine, Aurora, CO, USA; Denver Health Medical Center, Denver, CO, USA
| | - Steven L Moulton
- University of Colorado School of Medicine, Aurora, CO, USA; Children's Hospital Colorado, Aurora, CO, USA
| | | | - Denis D Bensard
- University of Colorado School of Medicine, Aurora, CO, USA; Denver Health Medical Center, Denver, CO, USA.
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Abstract
BACKGROUND/PURPOSE We observed a high incidence of traumatic brain injuries (TBI) in properly restrained infants involved in higher speed motor vehicle crashes (MVCs). We hypothesized that car safety seats are inadequately protecting infants from TBI. METHODS We retrospectively queried scene crash data from our State Department of Transportation (2007-2011) and State Department of Public Health data (2000-2011) regarding infants who presented to a trauma center after MVC. RESULTS Department of Transportation data revealed 94% of infants in MVCs were properly restrained (782/833) with average speed of 44.6 miles/h when there was concern for injury. Department of Public Health data showed only 67/119 (56.3%) of infants who presented to a trauma center after MVC were properly restrained. Properly restrained infants were 12.7 times less likely to present to a trauma center after an MVC (OR=12.7, CI 95% 5.6-28.8, p<0.001). TBI was diagnosed in 73/119 (61.3%) infants; 42/73 (57.5%) properly restrained, and 31/73 (42.5%) improperly/unrestrained (p=0.34). Average head abbreviated injury scale was similar for properly restrained (3.2±0.2) and improperly/unrestrained infants (3.5±0.2, p=0.37). CONCLUSION Car safety seats prevent injuries. However, TBI is similar among properly restrained and improperly/unrestrained infants involved in higher speed MVCs who present to a trauma center.
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Affiliation(s)
- Camille L Stewart
- University of Colorado, Denver, CO, USA; Children's Hospital Colorado, Aurora, CO, USA.
| | | | | | - Steven L Moulton
- University of Colorado, Denver, CO, USA; Children's Hospital Colorado, Aurora, CO, USA
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Stewart CL, Holscher CM, Moore EE, Bronsert M, Moulton SL, Partrick DA, Bensard DD. Base deficit correlates with mortality in pediatric abusive head trauma. J Pediatr Surg 2013; 48:2106-11. [PMID: 24094965 DOI: 10.1016/j.jpedsurg.2013.05.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 05/09/2013] [Accepted: 05/10/2013] [Indexed: 01/21/2023]
Abstract
BACKGROUND/PURPOSE Children suffering from abusive head trauma (AHT) have worse outcomes compared to non-AHT, but the reasons for this are unclear. We hypothesized that delayed medical care associated with AHT causes prolonged pre-hospital hypotension and hypoxia as measured by admission base deficit (BD), and that this would correlate with outcome. METHODS We performed a 10-year retrospective chart review of children admitted for AHT at two academic level-I trauma centers. Statistics were performed using Student's t test, chi-square analysis, and multivariate logistic regression, and considered significant at p < 0.05. RESULTS Four-hundred twelve children with AHT were identified, and admission BD was drawn for 148/412 (36%) children, including 104 survivors and 44 non-survivors. Non-survivors had significantly higher BD compared to survivors (12.6 ± 1.6 versus 5.3 ± 0.6, p < 0.001). Non-survivors were more likely to be intubated pre-hospital and get cardiopulmonary resuscitation (CPR) (p < 0.001). Mortality increased with rising BD, according to CPR status. There was no difference in patterns of brain injury between survivors and non-survivors (p > 0.05). CONCLUSIONS BD correlates with mortality in children suffering severe AHT. Non-survivors are also more likely to be intubated pre-hospital and require CPR, with no difference in pattern of brain injury, suggesting that secondary injury is a major determinant of outcome in severe AHT.
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Ramanathan N, Ahmed M, Raffan E, Stewart CL, O'Rahilly S, Semple RK, Raef H, Rochford JJ. Identification and Characterisation of a Novel Pathogenic Mutation in the Human Lipodystrophy Gene AGPAT2 : C48R: A Novel Mutation in AGPAT2. JIMD Rep 2012; 9:73-80. [PMID: 23430550 PMCID: PMC3565662 DOI: 10.1007/8904_2012_181] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 09/10/2012] [Accepted: 09/11/2012] [Indexed: 12/12/2022] Open
Abstract
Loss-of-function mutations in AGPAT2, encoding 1-acylglycerol-3-phosphate-O-acyltransferase 2 (AGPAT2), produce congenital generalised lipodystrophy (CGL). We screened the AGPAT2 gene in two siblings who presented with pseudoacromegaly, diabetes and severe dyslipidaemia and identified a novel mutation in AGPAT2 causing a single amino acid substitution, p.Cys48Arg. We subsequently investigated the molecular pathogenic mechanism linking both this mutation and the previously reported p.Leu228Pro mutation to clinical disease. Wild-type and mutant AGPAT2 were expressed in control and AGPAT2-deficient preadipocyte cell lines. mRNA and protein expression was determined, and the ability of each AGPAT2 species to rescue adipocyte differentiation in AGPAT2-deficient cells was assessed. Protein levels of both p.Cys48Arg and p.Leu228Pro AGPAT2 were significantly reduced compared with that of wild-type AGPAT2 despite equivalent mRNA levels. Stable expression of wild-type AGPAT2 partially rescued adipogenesis in AGPAT2 deficient preadipocytes, whereas stable expression of p.Cys48Arg or p.Leu228Pro AGPAT2 did not. In conclusion, unusually severe dyslipidaemia and pseudoacromegaloid overgrowth in patients with diabetes should alert physicians to the possibility of lipodystrophy. Both the previously unreported pathogenic p.Cys48Arg mutation in AGPAT2, and the known p.Leu228Pro mutation result in decreased AGPAT2 protein expression in developing adipocytes. It is most likely that the CGL seen in homozygous carriers of these mutations is largely accounted for by loss of protein expression.
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Affiliation(s)
- N Ramanathan
- Institute of Metabolic Science, Addenbrooke's Hospital, University of Cambridge Metabolic Research Laboratories, Hills Road, Cambridge, CB2 0QQ, UK
- Institute of Medical Biology, Immunos, 8A Biomedical Grove, 138648, Singapore, Republic of Singapore
| | - M Ahmed
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, 3354, Riyadh, 11211, Saudi Arabia
| | - E Raffan
- Institute of Metabolic Science, Addenbrooke's Hospital, University of Cambridge Metabolic Research Laboratories, Hills Road, Cambridge, CB2 0QQ, UK
| | - C L Stewart
- Institute of Medical Biology, Immunos, 8A Biomedical Grove, 138648, Singapore, Republic of Singapore
| | - S O'Rahilly
- Institute of Metabolic Science, Addenbrooke's Hospital, University of Cambridge Metabolic Research Laboratories, Hills Road, Cambridge, CB2 0QQ, UK
| | - R K Semple
- Institute of Metabolic Science, Addenbrooke's Hospital, University of Cambridge Metabolic Research Laboratories, Hills Road, Cambridge, CB2 0QQ, UK
| | - H Raef
- Department of Medicine, King Faisal Specialist Hospital and Research Centre, 3354, Riyadh, 11211, Saudi Arabia
| | - J J Rochford
- Institute of Metabolic Science, Addenbrooke's Hospital, University of Cambridge Metabolic Research Laboratories, Hills Road, Cambridge, CB2 0QQ, UK.
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