Contemporary Surgical Management of Colorectal Liver Metastases

Colorectal cancer is the third most common cancer in the United States and the second most common cause of cancer-related death. Approximately 20-30% of patients will develop hepatic metastasis in the form of synchronous or metachronous disease. The treatment of colorectal liver metastasis (CRLM) has evolved into a multidisciplinary approach, with chemotherapy and a variety of locoregional treatments, such as ablation and portal vein embolization, playing a crucial role. However, resection remains a core tenet of management, serving as the gold standard for a curative-intent therapy. As such, the input of a dedicated hepatobiliary surgeon is paramount for appropriate patient selection and choice of surgical approach, as significant advances in the field have made management decisions extremely nuanced and complex. We herein aim to review the contemporary surgical management of colorectal liver metastasis with respect to both perioperative and operative considerations.

The Influence of Patient Preference on Surgeons' Treatment Recommendations in the Management of Intraductal Papillary Mucinous Neoplasms

OBJECTIVE

We aimed to determine whether surgeon variation in management of intraductal papillary mucinous neoplasms (IPMN) is driven by differences in risk perception and quantify surgeons' risk threshold for changing their recommendations.

BACKGROUND

Surgeons vary widely in management of IPMN.

METHODS

We conducted a survey of members of the Americas HepatoPancreatoBiliary Association, presented participants with 2 detailed clinical vignettes and asked them to choose between surgical resection and surveillance. We also asked them to judge the likelihood that the IPMN harbors cancer and that the patient would have a serious complication if surgery was performed. Finally, we asked surgeons to rate the level of cancer risk at which they would change their treatment recommendation. We examined the association between surgeons' treatment recommendations and their risk perception and risk threshold.

RESULTS

One hundred and fifty surgeons participated in the study. Surgeons varied in their recommendations for surgery [19% for vignette 1 (V1) and 12% for V2] and in their perception of the cancer risk (interquartile range: 2%-10% for V1 and V2) and risk of surgical complications (V1 interquartile range: 10%-20%, V2 20%-30%). After adjusting for surgeon characteristics, surgeons who were above the median in cancer risk perception were 22 percentage points (27% vs. 5%) more likely to recommend resection than those who were below the median (95% CI: 11.34%; P <0.001). The median risk threshold at which surgeons would change their recommendation was 15% (V1 and V2). Surgeons who recommended surgery had a lower risk threshold for changing their recommendation than those who recommended surveillance (V1: 10.0 vs. 15.0, P =0.06; V2: 7.0 vs. 15.0, P =0.05).

CONCLUSIONS

The treatment that patients receive for IPMNs depends greatly on how their surgeons perceive the risk of cancer in the lesion. Efforts to improve cancer risk prediction for IPMNs may lead to decreased variations in care.

Risk Perceptions and Risk Thresholds Among Surgeons in the Management of Intraductal Papillary Mucinous Neoplasms

OBJECTIVES

We aimed to determine whether surgeon variation in management of intraductal papillary mucinous neoplasm (IPMN) is driven by differences in risk perception and quantify surgeons' risk threshold for changing their recommendations.

BACKGROUND

Surgeons vary widely in management of IPMN.

METHODS

We conducted a survey of members of the Americas HepatoPancreatoBiliary Association, presented participants with 2 detailed clinical vignettes and asked them to choose between surgical resection and surveillance. We also asked them to judge the likelihood that the IPMN harbors cancer and that the patient would have a serious complication if surgery was performed. Finally, we asked surgeons to rate the level of cancer risk at which they would change their treatment recommendation. We examined the association between surgeons' treatment recommendations and their risk perception and risk threshold.

RESULTS

One hundred fifty surgeons participated in the study. Surgeons varied in their recommendations for surgery [19% for vignette 1 (V1) and 12% for V2] and in their perception of the cancer risk (interquartile range: 2%-10% for V1 and V2) and risk of surgical complications (V1 interquartile range: 10%-20%, V2 20-30%). After adjusting for surgeon characteristics, surgeons who were above the median in cancer risk perception were 22 percentage points (27% vs 5%) more likely to recommend resection than those who were below the median (95% CI: 11%-4%; P <0.001). The median risk threshold at which surgeons would change their recommendation was 15% (V1 and V2). Surgeons who recommended surgery had a lower risk threshold for changing their recommendation than those who recommended surveillance (V1: 10.0 vs 15.0, P =0.06; V2: 7.0 vs 15.0, P =0.05).

CONCLUSIONS

The treatment that patients receive for IPMNs depends greatly on how their surgeons perceive the risk of cancer in the lesion. Efforts to improve cancer risk prediction for IPMNs may lead to decreased variations in care.

Progression of Site-Specific Recurrence of Pancreatic Cancer and Implications for Treatment

OBJECTIVE

This study aimed to analyze post-recurrence progression in context of recurrence sites and assess implications for post-recurrence treatment.

BACKGROUND

Most patients with resected pancreatic ductal adenocarcinoma (PDAC) recur within two years. Different survival outcomes for location-specific patterns of recurrence are reported, highlighting their prognostic value. However, a lack of understanding of post-recurrence progression and survival remains.

METHODS

This retrospective analysis included surgically treated PDAC patients at the NYU-Langone Health (2010-2021). Sites of recurrence were identified at time of diagnosis and further follow-up. Kaplan-Meier curves, log-rank test, and Cox-regression analyses were applied to assess survival outcomes.

RESULTS

Recurrence occurred in 57.3% (196/342) patients with a median time to recurrence of 11.3 months (95%CI:12.6 to 16.5). First site of recurrence was local in 43.9% patients, liver in 23.5%, peritoneal in 8.7%, lung in 3.6%, while 20.4% had multiple sites of recurrence. Progression to secondary sites was observed in 11.7%. Only lung involvement was associated with significantly longer survival after recurrence compared to other sites (16.9 months vs. 8.49 months, P=0.003). In local recurrence, 21 (33.3%) patients were alive after one year without progression to secondary sites. This was associated with a CA19-9 of <100U/ml at time of primary diagnosis (P=0.039), nodal negative disease (P=0.023), and well-moderate differentiation (P=0.042) compared to patients with progression.

CONCLUSION

Except for lung recurrence, post-recurrence survival after PDAC resection is associated with poor survival. A subset of patients with local-only recurrence do not quickly succumb to systemic spread. This is associated with markers for favorable tumor biology, making them candidates for potential curative re-resections when feasible.

Natural History of Stage IV Pancreatic Cancer. Identifying Survival Benchmarks for Curative-intent Resection in Patients With Synchronous Liver-only Metastases

OBJECTIVE

To evaluate long-term oncologic outcomes of patients with stage IV pancreatic ductal adenocarcinoma and to identify survival benchmarks for comparison when considering resection in these patients.

BACKGROUND

Highly selected cohorts of patients with liver-oligometastatic pancreas cancer have reported prolonged survival after resection. The long-term impact of surgery in this setting remains undefined because of a lack of appropriate control groups.

METHODS

We identified patients with clinical stage IV pancreatic ductal adenocarcinoma with synchronous liver metastases within our cancer registry. We estimated overall survival (OS) among various patient subgroups using the Kaplan-Meier method. To mitigate immortal time bias, we analyzed long-term outcomes of patients who survived beyond 12 months (landmark time) from diagnosis.

RESULTS

We identified 241 patients. Median OS was 7 months (95% CI, 5-9), both overall and for patients with liver-only metastasis (n=144). Ninety patients (38% of liver only; 40% of whole cohort) survived at least 12 months; those who received chemotherapy in this subgroup had a median OS of 26 months (95% CI, 17-39). Of these patients, those with resectable or borderline resectable primary tumors and resectable liver-only metastasis (n=9, 4%) had a median OS of 39 months (95% CI, 13-NR).

CONCLUSIONS

The 4% of our cohort that were potentially eligible for surgery experienced a prolonged survival compared with all-comers with stage IV disease. Oncologic outcomes of patients undergoing resection of metastatic pancreas cancer should be assessed in the context of the expected survival of patients potentially eligible for surgery and not relative to all patients with stage IV disease.

Patient Preference in Physician Decision-Making for Patients With Low- to Intermediate-Risk Differentiated Thyroid Cancer

This survey study describes the association between patient preference and physician decision-making in thyroid cancer.

Outcomes after primary tumor resection of metastatic pancreatic neuroendocrine tumors: An analysis of the National Cancer Database

INTRODUCTION

There is no consensus regarding the role of primary tumor resection for patients with metastatic pancreatic neuroendocrine tumors (panNET). We assessed surgical treatment patterns and evaluated the survival impact of primary tumor resection in patients with metastatic panNET.

METHODS

Patients with synchronous metastatic nonfunctional panNET in the National Cancer Database (2004-2016) were categorized based on whether they underwent primary tumor resection. We used logistic regressions to assess associations with primary tumor resection. We performed survival analyses with Kaplan-Meier survival functions, log-rank test, and Cox proportional hazard regression within a propensity score matched cohort.

RESULTS

In the overall cohort of 2613 patients, 68% (n = 839) underwent primary tumor resection. The proportion of patients who underwent primary tumor resection decreased over time from 36% (2004) to 16% (2016, p < 0.001). After propensity score matching on age at diagnosis, median income quartile, tumor grade, size, liver metastasis, and hospital type, primary tumor resection was associated with longer median overall survival (OS) (65 vs. 24 months; p < 0.001) and was associated with lower hazard of mortality (HR: 0.39, p < 0.001).

CONCLUSION

Primary tumor resection was significantly associated with improved OS, suggesting that, if feasible, surgical resection can be considered for well-selected patients with panNET and synchronous metastasis.

Time to Curative-Intent Surgery in Gastric Cancer Shows a Bimodal Relationship with Overall Survival

BACKGROUND

Time to treatment (TTT) varies widely for patients with gastric cancer. We aimed to evaluate relationships between time to treatment, overall survival (OS), and other surgical outcomes in patients with stage I-III gastric cancer.

METHODS

We identified patients with clinical stage I-III gastric cancer who underwent curative-intent gastrectomy within the National Cancer Database (2006-2015) and grouped them by treatment sequence: neoadjuvant chemotherapy or surgery upfront. We defined TTT as weeks from diagnosis to treatment initiation (neoadjuvant chemotherapy or definitive surgical procedure, respectively). Survival differences were assessed by Kaplan-Meier estimate, Cox proportional hazard regression, and log rank test.

RESULTS

Among the 22,846 patients with stage I-III gastric cancer, most (56%) received surgery upfront. Median TTT was 5 weeks (IQR 4-7) and 6 weeks (IQR 3-9) for patients in the neoadjuvant and surgery upfront groups, respectively. In the neoadjuvant group, increasing TTT was significantly associated with increasing median OS up to TTT of 5 weeks, with no change in median OS when TTT was > 5 weeks. In the surgery group, increasing TTT was significantly associated with increasing median OS up to 6 weeks; however, increasing TTT between 14 and 21 weeks was associated with decreasing median OS.

CONCLUSIONS

The relationship between time to treatment and survival outcomes is non-linear. Among patients who underwent surgery upfront, the relationship between time to treatment and OS was bimodal, suggesting that deferring definitive surgery, up to 14 weeks, is not associated with worse OS or oncologic outcomes. The relationship between time to treatment and overall survival among patients was bimodal, suggesting that deferring definitive surgery up to 14 weeks is not associated with worse OS.

Regional Patterns of Hospital-Level Guideline Adherence in Gastric Cancer: An Analysis of the National Cancer Database

BACKGROUND

Adherence to evidence-based guidelines for gastric cancer is low, particularly at the hospital level, despite a strong association with improved overall survival (OS). We aimed to evaluate patterns of hospital and regional adherence to National Comprehensive Cancer Network guidelines for gastric cancer.

METHODS

Using the National Cancer Database (2004-2015), we identified patients with stage I-III gastric cancer. Hospital-level guideline adherence was calculated by dividing the patients who received guideline adherent care by the total patients treated at that hospital. OS was estimated for each hospital. Associations between adherence, region, and survival were compared using mixed-effects, hierarchical regression.

RESULTS

Among 576 hospitals, the median hospital guideline adherence rate was 25% (range 0-76%) and varied significantly by region (p = 0.001). Adherence was highest in the Middle Atlantic (29%) and lowest in the East South Central region (19%); hospitals in the New England, Middle Atlantic, and East North Central regions were more likely to be guideline adherent than those in the East South Central region (all p < 0.05), after adjusting for patient and hospital mix. Most (35%) of the adherence variation was attributable to the hospital. Median 2-year OS varied significantly by region. After adjusting for hospital and patient mix, hazard of mortality was 17% lower in the Middle Atlantic (hazard ratio 0.82, 95% confidence interval 0.74-0.90) relative to the East South Central region, with most of the variation (54%) attributable to patient-level factors.

CONCLUSIONS

Hospital-level guideline adherence for gastric cancer demonstrated significant regional variation and was associated with longer OS, suggesting that efforts to improve guideline adherence should be directed toward lower-performing hospitals.

Outcomes After Surgical Palliation of Patients With Gastric Cancer

INTRODUCTION

Surgery is an option for symptom palliation in patients with metastatic gastric cancer. Operative outcomes after palliative interventions are largely unknown. Herein, we assess the trends of surgical palliation use for patients with gastric cancer and describe outcomes of patients undergoing surgical palliation compared to nonsurgical palliation.

METHODS

Patients with clinical Stage IV gastric cancer in the National Cancer Database (2004-2015) who received surgical or nonsurgical palliation were selected. We identified factors associated with palliative surgery. Survival differences were assessed by Kaplan-Meier estimate, Cox proportional hazard regression, and log rank test.

RESULTS

Six thousand eight hundred twenty nine patients received palliative care for gastric cancer. Most patients (87%, n = 5944) received nonsurgical palliation: 29% radiation therapy, 57% systemic treatment, and 14% pain management. The number of patients receiving palliative care increased between 2004 and 2015; however, use of surgical palliation declined significantly (22% in 2004, 8% in 2015; P < 0.001). Median overall survival (OS) for the cohort was 5.65 mo (95% confidence interval 5.45-5.85); 1-year and 2-year OS were 24% and 9%, respectively. Older age at diagnosis and diagnosis between 2004 and 2006 were significantly associated with undergoing surgical palliation. Patients who underwent surgical palliation had significantly shorter median OS and a 20% higher hazard of mortality than those who received nonsurgical palliation.

CONCLUSIONS

Patients with metastatic gastric cancer experience very short survival. While palliative surgery is used infrequently, the observed association with shorter median OS underscores the importance of careful patient selection. Palliative surgery should be offered judiciously and expectations about outcomes clearly established.

Perception of risk and treatment decisions in the management of differentiated thyroid cancer

BACKGROUND AND OBJECTIVES

The recent de-escalation of care for differentiated thyroid cancer (DTC) has broadened the range of initial treatment options. We examined the association between physicians' perception of risk and their management of DTC.

METHODS

Thyroid specialists were surveyed with four clinical vignettes: (1) indeterminate nodule (2) tall cell variant papillary thyroid cancer (PTC), (3) papillary thyroid microcarcinoma (mPTC), and (4) classic PTC. Participants judged the operative risks and likelihood of structural cancer recurrence associated with more versus less aggressive treatments. A logistic mixed effect model was used to predict treatment choice.

RESULTS

Among 183 respondents (13.4% response rate), 44% were surgical and 56% medical thyroid specialists. Risk estimates and treatment recommendation varied markedly in each case. Respondents' estimated risk of 10-year cancer recurrence after lobectomy for a 2.0-cm PTC ranged from 1% to 53% (interquartile range [IQR]: 3%-12%), with 66% recommending lobectomy and 34% total thyroidectomy. Respondents' estimated 5-year risk of metastastic disease during active surveillance of an 0.8-cm mPTC ranged from 0% to 95% (IQR: 4%-15%), with 36% choosing active surveillance. Overall, differences in perceived risk reduction explained 10.3% of the observed variance in decision-making.

CONCLUSIONS

Most of the variation in thyroid cancer treatment aggressiveness is unrelated to perceived risk of cancer recurrence.

The Association Between Risk Aversion of Surgeons and Their Clinical Decision-Making

BACKGROUND

The extent to which a surgeon's risk aversion influences their clinical decisions remains unknown. We assessed whether a surgeon's attitude toward risk ("risk aversion") influences their surgical decisions and whether the relationship can be explained by differences in surgeons' perception of treatment risks and benefits.

MATERIALS AND METHODS

We presented a series of detailed clinical vignettes to a national sample of surgeons (n = 1,769; 13.4% adjusted response rate) and asked them to complete an instrument that measured how risk averse they are within their clinical practice (scale 6-36; higher number indicates greater risk aversion). For each vignette, participants rated their likelihood of recommending an operation and judged the likelihood of complications or full recovery. We examined whether differences in perceived likelihood of complications versus recovery could explain why risk-averse surgeons may be less likely to recommend an operation.

RESULTS

Surgeons varied in their self-reported risk aversion score (median = 25, interquartile range[22,28]). Scores did not differ by level of surgeon experience or gender. Risk-averse surgeons were significantly less likely to recommend an operation for patients with exactly the same condition (65.5% for surgeons in highest quartile of risk aversion versus 62.3% for lowest quartile; P = 0.02). However, after controlling for surgeons' perception of the likelihood of complications versus recovery, there was no longer a significant association between surgeons' risk aversion and the decision to recommend an operation (64.7% versus 64.8%; P = 0.96).

CONCLUSIONS

Surgeons vary widely in their self-reported risk aversion. Risk-averse surgeons were significantly less likely to recommend an operation, a finding that was explained by a higher perceived probability of post-operative complications than their colleagues.

Is there a relationship between hospital volume and patient outcomes in gastroschisis repair?

PURPOSE

Given the well-established relationship between surgical volume and outcomes for many surgical procedures, we examined whether the same relationship exists for gastroschisis closure.

METHODS

We conducted a retrospective analysis of infants who underwent gastroschisis closure between 1999 and 2007 using a California birth-linked cohort. Hospitals were divided into terciles based on the number of gastroschisis closures performed annually. Using regression techniques, we examined the effects of hospital volume on patient mortality and length of stay while controlling for patient and hospital confounders.

RESULTS

We identified 1537 infants who underwent gastroschisis repair at 55 hospitals, 4 of which were high-volume and 42 of which were low-volume. The overall in-hospital mortality rate was 4.8% and the median length of stay was 46.5days. After controlling for other factors, patients treated at high-volume hospitals had significantly lower odds of inpatient mortality (OR 0.40; 95% CI 0.21, 0.76). There was a near-significant trend towards shorter hospital length of stay at highvolume hospitals (p=0.066).

CONCLUSIONS

Patients who undergo gastroschisis closure at high-volume hospitals in California experience lower odds of in-hospital mortality compared to those treated at low-volume hospitals. These findings offer initial evidence to support policies that limit the number of hospitals providing complex newborn surgical care.

Compliance With Evidence-Based Guidelines and Interhospital Variation in Mortality for Patients With Severe Traumatic Brain Injury

IMPORTANCE

Compliance with evidence-based guidelines in traumatic brain injury (TBI) has been proposed as a marker of hospital quality. However, the association between hospital-level compliance rates and risk-adjusted clinical outcomes for patients with TBI remains poorly understood.

OBJECTIVE

To examine whether hospital-level compliance with the Brain Trauma Foundation guidelines for intracranial pressure monitoring and craniotomy is associated with risk-adjusted mortality rates for patients with severe TBI.

DESIGN, SETTING, AND PARTICIPANTS

All adult patients (N = 734) who presented to a regional consortium of 14 hospitals from January 1, 2009, through December 31, 2010, with severe TBI (ie, blunt head trauma, Glasgow Coma Scale score of <9, and abnormal intracranial findings from computed tomography of the head). Data analysis took place from December 2013 through January 2015. We used hierarchical mixed-effects models to assess the association between hospital-level compliance with Brain Trauma Foundation guidelines and mortality rates after adjusting for patient-level demographics, severity of trauma (eg, mechanism of injury and Injury Severity Score), and TBI-specific variables (eg, cranial nerve reflexes and findings from computed tomography of the head).

MAIN OUTCOMES AND MEASURES

Hospital-level risk-adjusted inpatient mortality rate and hospital-level compliance with Brain Trauma Foundation guidelines for intracranial pressure monitoring and craniotomy.

RESULTS

Unadjusted mortality rates varied by site from 20.0% to 50.0% (median, 42.6; interquartile range, 35.5-46.2); risk-adjusted rates varied from 24.3% to 56.7% (median, 41.1; interquartile range, 36.4-47.8). Overall, only 338 of 734 patients (46.1%) with an appropriate indication underwent placement of an intracranial pressure monitor and only 134 of 335 (45.6%) underwent craniotomy. Hospital-level compliance ranged from 9.6% to 65.2% for intracranial pressure monitoring and 6.7% to 76.2% for craniotomy. Despite widespread variation in compliance across hospitals, we found no association between hospital-level compliance rates and risk-adjusted patient outcomes (Spearman ρ = 0.030 [P = .92] for ICP monitoring and Spearman ρ = -0.066 [P = .83] for craniotomy).

CONCLUSIONS AND RELEVANCE

Hospital-level compliance with evidence-based guidelines has minimal association with risk-adjusted outcomes in patients with severe TBI. Our results suggest that caution should be taken before using compliance with these measures as independent quality metrics. Given the complexity of TBI care, outcomes-based metrics, including functional recovery, may be more accurate than current process measures at determining hospital quality.

Relationship Between Hospital Performance on a Patient Satisfaction Survey and Surgical Quality

IMPORTANCE

The Centers for Medicare and Medicaid Services include patient experience as a core component of its Value-Based Purchasing program, which ties financial incentives to hospital performance on a range of quality measures. However, it remains unclear whether patient satisfaction is an accurate marker of high-quality surgical care.

OBJECTIVE

To determine whether hospital performance on a patient satisfaction survey is associated with objective measures of surgical quality.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective observational study of participating American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) hospitals. We used data from a linked database of Medicare inpatient claims, ACS NSQIP, the American Hospital Association annual survey, and Hospital Compare from December 2, 2004, through December 31, 2008. A total of 103 866 patients older than 65 years undergoing inpatient surgery were included. Hospitals were grouped by quartile based on their performance on the Hospital Consumer Assessment of Healthcare Providers and Systems survey. Controlling for preoperative risk factors, we created hierarchical logistic regression models to predict the occurrence of adverse postoperative outcomes based on a hospital's patient satisfaction scores.

MAIN OUTCOMES AND MEASURES

Thirty-day postoperative mortality, major and minor complications, failure to rescue, and hospital readmission.

RESULTS

Of the 180 hospitals, the overall mean patient satisfaction score was 68.0% (first quartile mean, 58.7%; fourth quartile mean, 76.7%). Compared with patients treated at hospitals in the lowest quartile, those at the highest quartile had significantly lower risk-adjusted odds of death (odds ratio = 0.85; 95% CI, 0.73-0.99), failure to rescue (odds ratio = 0.82; 95% CI, 0.70-0.96), and minor complication (odds ratio = 0.87; 95% CI, 0.75-0.99). This translated to relative risk reductions of 11.1% (P = .04), 12.6% (P = .02), and 11.5% (P = .04), respectively. No significant relationship was noted between patient satisfaction and either major complication or hospital readmission.

CONCLUSIONS AND RELEVANCE

Using a national sample of hospitals, we demonstrated a significant association between patient satisfaction scores and several objective measures of surgical quality. Our findings suggest that payment policies that incentivize better patient experience do not require hospitals to sacrifice performance on other quality measures.

Cost effectiveness of nonoperative management versus laparoscopic appendectomy for acute uncomplicated appendicitis

BACKGROUND

Appendectomy remains the gold standard in the treatment of acute, uncomplicated appendicitis in the United States. Nonetheless, there is growing evidence that nonoperative management is safe and efficacious.

METHODS

We constructed a decision tree to compare nonoperative management of appendicitis with laparoscopic appendectomy in otherwise healthy adults. Model variables were abstracted from a literature review, data from the Healthcare Cost and Utilization Project data, the Medicare Physician Fee schedule, and the American College of Surgeons Surgical Risk Calculator. Uncertainty surrounding parameters of the model was assessed via 1-way and probabilistic sensitivity analyses.

RESULTS

Operative management cost $12,213 per patient. Nonoperative management without interval appendectomy (IA) was the dominant strategy, costing $1,865 less and producing 0.03 more quality-adjusted life-years (QALYs). Nonoperative management with IA cost $4,271 more than operative management, but yielded only 0.01 additional QALY. One-way sensitivity analysis suggested operative management would become the preferred strategy if the recurrence rate was >40.5% or the total cost of appendectomy was decreased to <$5,468. Probabilistic sensitivity analysis confirmed nonoperative management without IA was the preferred strategy in 95.6% of cases.

CONCLUSION

Nonoperative management without IA is the least costly, most effective treatment for acute, uncomplicated appendicitis and warrants further evaluation in a disease thought to be definitively surgical.

Clinical registries and quality measurement in surgery: a systematic review

BACKGROUND

Surgical clinical registries provide clinical information with the intent of measuring and improving quality. This study aimed to describe how surgical clinical registries have been used to measure surgical quality, the reported findings, and the limitations of registry measurements.

METHODS

Medline, CINAHL, and Cochrane were queried for English articles with the terms: "registry AND surgery AND quality." Eligibility criteria were studies explicitly assessing quality measurement with registries as the primary data source. Studies were abstracted to identify registries, define registry structure, uses for quality measurement, and limitations of the measurements used.

RESULTS

A total of 111 studies of 18 registries were identified for data abstraction. Two registries were financed privately, and 5 registries were financed by a governmental organization. Across registries, the most common uses of process measures were for monitoring providers and as platforms for quality improvement initiatives. The most common uses of outcome measures were to improve quality modeling and to identify preoperative risk factors for poor outcomes. Eight studies noted improvements in risk-adjusted mortality with registry participation; one found no change. A major limitation is bias from context and means of data collection threatening internal validity of registry quality measurement. Conversely, the other major limitation is the cost of participation, which threatens the external validity of registry quality measurement.

CONCLUSION

Clinical registries have advanced surgical quality definition, measurement, and modeling as well as having served as platforms for local initiatives for quality improvement. The implication of this finding is that subsidizing registry participation may improve data validity as well as engage providers in quality improvement.

General surgical services at an urban teaching hospital in Mozambique

BACKGROUND

As surgery becomes incorporated into global health programs, it will be critical for clinicians to take into account already existing surgical care systems within low-income countries. To inform future efforts to expand the local system and systems in comparable regions of the developing world, we aimed to describe current patterns of surgical care at a major urban teaching hospital in Mozambique.

METHODS

We performed a retrospective review of all general surgery patients treated between August 2012 and August 2013 at the Hospital Central Maputo in Maputo, Mozambique. We reviewed emergency and elective surgical logbooks, inpatient discharge records, and death records to report case volume, disease etiology, and mortality.

RESULTS

There were 1598 operations (910 emergency and 688 elective) and 2606 patient discharges during our study period. The most common emergent surgeries were for nontrauma laparotomy (22%) followed by all trauma procedures (18%), whereas the most common elective surgery was hernia repair (31%). The majority of lower extremity amputations were above knee (69%). The most common diagnostic categories for inpatients were infectious (31%), trauma (18%), hernia (12%), neoplasm (10%), and appendicitis (5%). The mortality rate was 5.6% (146 deaths), approximately half of which were related to sepsis.

CONCLUSIONS

Our data demonstrate the general surgery caseload of a large, academic, urban training and referral center in Mozambique. We describe resource limitations that impact operative capacity, trauma care, and management of amputations and cancer. These findings highlight challenges that are applicable to a broad range of global surgery efforts.

Are primary care providers prepared to care for survivors of breast cancer in the safety net?

BACKGROUND

With the growing number of survivors of breast cancer outpacing the capacity of oncology providers, there is pressure to transition patients back to primary care. Primary care providers (PCPs) working in safety-net settings may have less experience treating survivors, and little is known about their knowledge and views on survivorship care. The current study was performed to determine the knowledge, attitudes, and confidence of PCPs in the safety net at delivering care to survivors of breast cancer.

METHODS

A modified version of the National Cancer Institute's Survey of Physician Attitudes Regarding Care of Cancer Survivors was given to providers at 2 county hospitals and 5 associated clinics (59 providers). Focus groups were held to understand barriers to survivorship care.

RESULTS

Although the majority of providers believed PCPs have the skills necessary to provide cancer-related follow-up, the vast majority were not comfortable providing these services themselves. Providers were adherent to American Society of Clinical Oncology recommendations for mammography (98%) and physical examination (87%); less than one-third were guideline-concordant for laboratory testing and only 6 providers (10%) met all recommendations. PCPs universally requested additional training on clinical guidelines and the provision of written survivorship care plans before transfer. Concerns voiced in qualitative sessions included unfamiliarity with the management of endocrine therapy and confusion regarding who would be responsible for certain aspects of care.

CONCLUSIONS

Safety-net providers currently lack knowledge of and confidence in providing survivorship care to patients with breast cancer. Opportunities exist for additional training in evidence-based guidelines and improved coordination of care between PCPs and oncology specialists.

Surgical salvage of acquired lung lesions in extremely premature infants

Acquired neonatal lung lesions including pneumatoceles, cystic bronchopulmonary dysplasia, and pulmonary interstitial emphysema can cause extrinsic mediastinal compression, which may impair pulmonary and cardiac function. Acquired lung lesions are typically managed medically. Here we report a case series of three extremely premature infants with acquired lung lesions. All three patients underwent aggressive medical management and ultimately required tube thoracostomies. These interventions were unsuccessful and emergency thoracotomies were performed in each case. Two infants with acquired pneumatoceles underwent unroofing of the cystic structure and primary repair of a bronchial defect. The third infant with pulmonary interstitial emphysema, arising from cystic bronchopulmonary dysplasia, required a middle lobectomy for severe and diffuse cystic disease. When medical management fails, tube thoracostomy can be attempted, leaving surgical intervention for refractory cases. Surgical options include oversewing a bronchial defect in the setting of a bronchopleural fistula or lung resection in cases of an isolated expanding lobe.