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Conroy PC, Wilhelm A, Rajwani T, Mulder M, Gosnell J, Shen WT, Duh QY, Roman S, Sosa JA. Nerve monitoring in endocrine surgery: Practice patterns differ among surgeons for parathyroidectomy and thyroidectomy. Surgery 2024; 175:1040-1048. [PMID: 38135552 DOI: 10.1016/j.surg.2023.11.024] [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: 06/12/2023] [Revised: 10/13/2023] [Accepted: 11/19/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND It is unknown whether intraoperative nerve monitoring is associated with reduced vocal cord dysfunction after parathyroidectomy. We aimed to investigate intraoperative nerve monitoring use among Collaborative Endocrine Surgery Quality Improvement Program surgeons and factors associated with vocal cord dysfunction after parathyroidectomy. METHODS Patients who underwent parathyroidectomy included in the Collaborative Endocrine Surgery Quality Improvement Program (2014-2022) were identified. The annual percent change in parathyroidectomies performed with intraoperative nerve monitoring was calculated using joinpoint regression. Multivariable logistic regression was used to compare outcomes between patients undergoing parathyroidectomy with/without intraoperative nerve monitoring. To compare surgeon-specific trends, Collaborative Endocrine Surgery Quality Improvement Program thyroidectomy and parathyroidectomy datasets (2014-2021) were combined. Parathyroidectomies performed by surgeons who used intraoperative nerve monitoring consistently in thyroidectomy were identified. Factors associated with intraoperative nerve monitoring were examined using multivariable logistic regression. RESULTS A total of 9,813 patients underwent parathyroidectomy. Intraoperative nerve monitoring was used in 49% of cases (n = 4,818). There was an increase in parathyroidectomies with intraoperative nerve monitoring from 2014 to 2018 (annual percent change 22.2, P = .01), followed by a plateau (2018-2022 annual percent change -0.66, P = .85). Few patients (0.44%, n = 43) developed vocal cord dysfunction. Vocal cord dysfunction was not associated with intraoperative nerve monitoring (adjusted odds ratio 0.92, P = .75). Whereas 41% (n = 56/138) of surgeons used intraoperative nerve monitoring routinely in parathyroidectomy, 65% (n = 90/138) used it routinely in thyroidectomy. Among surgeons who used intraoperative nerve monitoring routinely in thyroidectomy, only 57% used it routinely in parathyroidectomy; factors associated with intraoperative nerve monitoring during parathyroidectomy included reoperation (adjusted odds ratio 2.51, P < .01), secondary/tertiary hyperparathyroidism (adjusted odds ratio 1.42, P = .02), multiglandular disease (adjusted odds ratio 1.76, P < .001), and non-localized disease (adjusted odds ratio 1.65, P < .001). CONCLUSION Endocrine surgeons use intraoperative nerve monitoring selectively. Surgeons who routinely use intraoperative nerve monitoring during thyroidectomy are more likely to use it during parathyroidectomy. Future studies should determine who may benefit most from intraoperative nerve monitoring in parathyroidectomy.
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Affiliation(s)
| | - Alexander Wilhelm
- Department of Surgery, University of California, San Francisco, CA; Department of Surgery, Clarunis, St. Clara Hospital and University Hospital Basel, University of Basel, Switzerland
| | - Taufiq Rajwani
- Department of Surgery, University of California, San Francisco, CA
| | - Michelle Mulder
- Department of Surgery, University of California, San Francisco, CA
| | - Jessica Gosnell
- Department of Surgery, University of California, San Francisco, CA
| | - Wen T Shen
- Department of Surgery, University of California, San Francisco, CA
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco, CA
| | - Sanziana Roman
- Department of Surgery, University of California, San Francisco, CA
| | - Julie Ann Sosa
- Department of Surgery, University of California, San Francisco, CA.
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Ashraf Ganjouei A, Romero-Hernandez F, Conroy PC, Miller PN, Calthorpe L, Wang JJ, Lin JJ, Feng J, Kirkwood KS, Alseidi A, Sarin A, Adam MA. A Novel Machine Learning Approach to Predict Textbook Outcome in Colectomy. Dis Colon Rectum 2024; 67:322-332. [PMID: 37815314 DOI: 10.1097/dcr.0000000000003084] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
BACKGROUND Several calculators exist to predict risk of postoperative complications. However, in low-risk procedures such as colectomy, a tool to determine the probability of achieving the ideal outcome could better aid clinical decision-making, especially for high-risk patients. A textbook outcome is a composite measure that serves as a surrogate for the ideal surgical outcome. OBJECTIVE To identify the most important factors for predicting textbook outcomes in patients with nonmetastatic colon cancer undergoing colectomy and to create a textbook outcome decision support tool using machine learning algorithms. DESIGN This was a retrospective analysis study. SETTINGS Data were collected from the American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS Adult patients undergoing elective colectomy for nonmetastatic colon cancer (2014-2020) were included. MAIN OUTCOME MEASURES Textbook outcome was the main outcome, defined as no mortality, no 30-day readmission, no postoperative complications, no 30-day reinterventions, and a hospital length of stay of ≤5 days. Four models (logistic regression, decision tree, random forest, and eXtreme Gradient Boosting) were trained and validated. Ultimately, a web-based calculator was developed as proof of concept for clinical application. RESULTS A total of 20,498 patients who underwent colectomy for nonmetastatic colon cancer were included. Overall, textbook outcome was achieved in 66% of patients. Textbook outcome was more frequently achieved after robotic colectomy (77%), followed by laparoscopic colectomy (68%) and open colectomy (39%, p < 0.001). eXtreme Gradient Boosting was the best performing model (area under the curve = 0.72). The top 5 preoperative variables to predict textbook outcome were surgical approach, patient age, preoperative hematocrit, preoperative oral antibiotic bowel preparation, and patient sex. LIMITATIONS This study was limited by its retrospective nature of the analysis. CONCLUSIONS Using textbook outcome as the preferred outcome may be a useful tool in relatively low-risk procedures such as colectomy, and the proposed web-based calculator may aid surgeons in preoperative evaluation and counseling, especially for high-risk patients. See Video Abstract . UN NUEVO ENFOQUE DE APRENDIZAJE AUTOMTICO PARA PREDECIR EL RESULTADO DE LOS LIBROS DE TEXTO EN COLECTOMA ANTECEDENTES:Existen varias calculadoras para predecir el riesgo de complicaciones posoperatorias. Sin embargo, en procedimientos de bajo riesgo como la colectomía, una herramienta para determinar la probabilidad de lograr el resultado ideal podría ayudar mejor a la toma de decisiones clínicas, especialmente para pacientes de alto riesgo. Un resultado de libro de texto es una medida compuesta que sirve como sustituto del resultado quirúrgico ideal.OBJETIVO:Identificar los factores más importantes para predecir el resultado de los libros de texto en pacientes con cáncer de colon no metastásico sometidos a colectomía y crear una herramienta de apoyo a la toma de decisiones sobre los resultados de los libros de texto utilizando algoritmos de aprendizaje automático.DISEÑO:Este fue un estudio de análisis retrospectivo.AJUSTES:Los datos se obtuvieron de la base de datos del Programa Nacional de Mejora de la Calidad del Colegio Americano de Cirujanos.PACIENTES:Se incluyeron pacientes adultos sometidos a colectomía electiva por cáncer de colon no metastásico (2014-2020).MEDIDAS PRINCIPALES DE RESULTADO:El resultado de los libros de texto fue el resultado principal, definido como ausencia de mortalidad, reingreso a los 30 días, complicaciones posoperatorias, reintervenciones a los 30 días y una estancia hospitalaria ≤5 días. Se entrenaron y validaron cuatro modelos (regresión logística, árbol de decisión, bosque aleatorio y XGBoost). Finalmente, se desarrolló una calculadora basada en la web como prueba de concepto para su aplicación clínica.RESULTADOS:Se incluyeron un total de 20.498 pacientes sometidos a colectomía por cáncer de colon no metastásico. En general, el resultado de los libros de texto se logró en el 66% de los pacientes. Los resultados de los libros de texto se lograron con mayor frecuencia después de la colectomía robótica (77%), seguida de la colectomía laparoscópica (68%) y la colectomía abierta (39%) (p<0,001). XGBoost fue el modelo con mejor rendimiento (AUC=0,72). Los cinco principales variables preoperatorias para predecir el resultado en los libros de texto fueron el abordaje quirúrgico, la edad del paciente, el hematocrito preoperatorio, la preparación intestinal con antibióticos orales preoperatorios y el sexo femenino.LIMITACIONES:Este estudio estuvo limitado por la naturaleza retrospectiva del análisis.CONCLUSIONES:El uso de los resultados de los libros de texto como resultado preferido puede ser una herramienta útil en procedimientos de riesgo relativamente bajo, como la colectomía, y la calculadora basada en la web propuesta puede ayudar a los cirujanos en la evaluación y el asesoramiento preoperatorios, especialmente para pacientes de alto riesgo. (Traducción-Yesenia Rojas-Khalil ).
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Affiliation(s)
- Amir Ashraf Ganjouei
- Department of Surgery, University of California San Francisco, San Francisco, California
| | | | - Patricia C Conroy
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Phoebe N Miller
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Lucia Calthorpe
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Jaeyun Jane Wang
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Jackie J Lin
- School of Medicine, University of California San Francisco, San Francisco, California
| | - Jean Feng
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Kimberly S Kirkwood
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, California
| | - Adnan Alseidi
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, California
| | - Ankit Sarin
- Department of Surgery, University of California Davis, Sacramento, California
| | - Mohamed A Adam
- Division of Surgical Oncology, Department of Surgery, University of California San Francisco, San Francisco, California
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Wilhelm A, Conroy PC, Calthorpe L, Frye W, Sosa JA, Roman S. Routine use of intraoperative nerve monitoring is associated with a reduced risk of vocal cord dysfunction after thyroid cancer surgery. BMC Surg 2023; 23:215. [PMID: 37533002 PMCID: PMC10399064 DOI: 10.1186/s12893-023-02122-3] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 07/24/2023] [Indexed: 08/04/2023] Open
Abstract
BACKGROUND The aim of this study was to investigate the associations between individual surgeon's intraoperative nerve monitoring (IONM) practice and factors associated with vocal cord (VC) dysfunction in patients with thyroid cancer undergoing thyroidectomy. METHODS Using Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) 2014-21 data, multivariable logistic regression analyses investigated variables associated with short- and long-term VC-dysfunction, associations of routine use of IONM with postoperative outcomes, and patient characteristics associated with IONM use. RESULTS Among 5,446 patients (76.7% female, mean age 49 years), 68.5% had surgery by surgeons using IONM in ≥ 90% of cases (63% of surgeons, n = 73). Post-operative VC-dysfunction was diagnosed by laryngoscopy in 3.0% of patients in the short-term and 2.7% in the long-term. When surgeons routinely used IONM, the incidence of VC-dysfunction was 2.4% in the short-term and 2.2% in the long-term, compared to 4.4% and 3.7%, respectively, when surgeons did not routinely use IONM (p < 0.01). After adjustment, routine use of IONM was independently associated with reduced risk of short- (OR 0.48, p < 0.01) and long-term (OR 0.52, p < 0.01) VC-dysfunction, a lower risk of postoperative hypoparathyroidism in the short- (OR 0.67, p < 0.01) and long-term (OR 0.54, p < 0.01), and higher likelihood of same-day discharge (OR 2.03, p < 0.01). Extrathyroidal tumor extension and N1-stage were factors associated with postoperative VC-dysfunction in the short- (OR 3.12, p < 0.01; OR 1.92, p = 0.01, respectively) and long-term (OR 3.11, p < 0.01; OR 2.32, p < 0.01, respectively). CONCLUSION Routine use of IONM was independently associated with a lower risk of endocrine surgery-specific complications and greater likelihood of same-day discharge.
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Affiliation(s)
- Alexander Wilhelm
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
- Department of Surgery, Clarunis - St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Patricia C Conroy
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Lucia Calthorpe
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Willow Frye
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Julie Ann Sosa
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Sanziana Roman
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
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Calthorpe L, Romero-Hernandez F, Casey M, Nunez M, Conroy PC, Hirose K, Kim A, Kirkwood K, Maker AV, Corvera C, Nakakura E, Alseidi A, Adam MA. National Practice Patterns in Malignant Peritoneal Mesothelioma: Updates in Management and Survival. Ann Surg Oncol 2023; 30:5119-5129. [PMID: 37140748 DOI: 10.1245/s10434-023-13528-x] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 04/03/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Malignant peritoneal mesothelioma (MPM) is a rare malignancy with a historically poor prognosis. Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) has emerged as an effective therapy for patients with peritoneal malignancies. A contemporary analysis of trends in management of and survival from MPM is warranted. METHODS Patients with MPM were identified from the National Cancer Database (2004-2018). Patients were categorized by treatment (CRS-HIPEC, CRS-chemotherapy, CRS only, chemotherapy only, no treatment), and joinpoint regression was employed to compute the annual percent change (APC) in treatment over time. Multivariable Cox proportional hazards models were used to analyze factors associated with survival. RESULTS Of 2683 patients with MPM, 19.1% underwent CRS-HIPEC, and 21.1% received no treatment. Joinpoint regression revealed a statistically significant increase in the proportion of patients undergoing CRS-HIPEC over time (APC 3.21, p = 0.01), and a concurrent decrease in the proportion of patients who underwent no treatment (APC - 2.21, p = 0.02). Median overall survival was 19.5 months. Factors independently associated with survival included CRS-HIPEC, CRS, histology, sex, age, race, Charlson Comorbidity Index, insurance, and hospital type. Although there was a strong association between year of diagnosis and survival on univariate analysis (2016-2018 HR 0.67, p < 0.001), this association was attenuated after adjustment for treatment. CONCLUSIONS CRS-HIPEC is increasingly employed as a treatment for MPM. In parallel, there has been a decrease in patients receiving no treatment with an increase in overall survival. These findings suggest that patients with MPM may be receiving more appropriate therapy; however, a substantial proportion of patients may remain undertreated.
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Affiliation(s)
- Lucia Calthorpe
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | | | - Megan Casey
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Miguel Nunez
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Patricia C Conroy
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Kenzo Hirose
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Alex Kim
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH, USA
| | - Kimberly Kirkwood
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Ajay V Maker
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Carlos Corvera
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Eric Nakakura
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Adnan Alseidi
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Mohamed Abdelgadir Adam
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
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Calthorpe L, Romero-Hernandez F, Casey M, Nunez M, Conroy PC, Hirose K, Kim A, Kirkwood K, Maker AV, Corvera C, Nakakura E, Alseidi A, Adam MA. ASO Visual Abstract: National Practice Patterns in Malignant Peritoneal Mesothelioma-Updates in Management and Survival. Ann Surg Oncol 2023; 30:5131. [PMID: 37221399 DOI: 10.1245/s10434-023-13615-z] [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: 05/25/2023]
Affiliation(s)
- Lucia Calthorpe
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | | | - Megan Casey
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Miguel Nunez
- School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Patricia C Conroy
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Kenzo Hirose
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Alex Kim
- Division of Surgical Oncology, Department of Surgery , The Ohio State University, Columbus, OH, USA
| | - Kimberly Kirkwood
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Ajay V Maker
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Carlos Corvera
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Eric Nakakura
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Adnan Alseidi
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Mohamed Abdelgadir Adam
- Division of Surgical Oncology, Department of Surgery, University of California, San Francisco, San Francisco, CA, USA.
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Calthorpe L, Rashidian N, Cacciaguerra AB, Conroy PC, Hibi T, Hilal MA, Hoffman D, Park KM, Wang J, Adam MA, Alseidi A. Using the Comprehensive Complication Index to Rethink the ISGLS Criteria for Post-hepatectomy Liver Failure in an International Cohort of Major Hepatectomies. Ann Surg 2023; 277:e592-e596. [PMID: 34913896 PMCID: PMC9308484 DOI: 10.1097/sla.0000000000005338] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare different criteria for post-hepatectomy liver failure (PHLF) and evaluate the association between International Study Group of Liver Surgery (ISGLS) PHLF and the Comprehensive Complication Index (CCI)" and 90-day mortality. SUMMARY OF BACKGROUND DATA PHLF is a serious complication following hepatic resection. Multiple criteria have been developed to characterize PHLF. METHODS Adults who underwent major hepatectomies at twelve international centers (2010-2020) were included. We identified patients who met criteria for PHLF based on three definitions: 1) ISGLS, 2) Balzan (INR > 1.7 and bilirubin > 2.92mg/dL) or 3) Mullen (peak bilirubin >7mg/dL). We compared the 90-day mortality and major morbidity predicted by each definition. We then used logistic regression to determine the odds of CCI>40 and 90-day mortality associated with ISGLS grades. RESULTS Among 1646 included patients, 19 (1.1%) met Balzan, 68 (4.1%) met Mullen, and 444 (27.0%) met ISGLS criteria for PHLF. Of the three definitions, the ISGLS criteria best predicted 90-day mortality (AUC = 0.72; sensitivity 69.4%). Patients with ISGLS grades B&C were at increased odds of CCI > 40 (grade B OR 4.0; 95% CI: 2.2-7.2; grade C OR 137.0; 95% CI: 59.2-317.4). Patients with ISGLS grade C were at increased odds of 90-day mortality (OR 113.6; 95% CI: 55.6-232.1). Grade A was not associated with CCI> 40 or 90-day mortality. CONCLUSIONS In this diverse international cohort of major hepatectomies, ISGLS grade A was not associated with 90-day mortality or high CCI, calling into question the current classification of patients in this group as having clinically significant PHLF.
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Affiliation(s)
- Lucia Calthorpe
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Nikdokht Rashidian
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium
| | - Andrea Benedetti Cacciaguerra
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Trust, Southampton, UK
| | - Patricia C Conroy
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Taizo Hibi
- Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan
| | - Mohammad Abu Hilal
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
- Department of Surgery, University Hospital Southampton NHS Trust, Southampton, UK
| | - Daniel Hoffman
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Keon Min Park
- Division of Plastic Surgery, Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Jaeyun Wang
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | | | - Adnan Alseidi
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - International Post-Hepatectomy Liver Failure Study Group
- International Post-Hepatectomy Liver Failure Study Group: Yuta Abe (Department of Surgery, Keio University School of Medicine, Tokyo, Japan); Thomas Armstrong (Department of Surgery, University Hospital Southampton NHS Trust, Southampton, UK); Alessandro Ferrero (Department of General and Oncological Surgery, Umberto I Mauriziano Hospital, Largo Turati, Turin, Italy); Carlos Corvera (Department of Surgery, Division of Surgical Oncology, University of California San Francisco, San Francisco, CA, USA); Koki Hayashi (Department of Surgery, Keio University School of Medicine, Tokyo, Japan); Taisuke Imamura (Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Sunto-Nagaizumi, Shizuoka, Japan); Minoru Kitago (Department of Surgery, Keio University School of Medicine, Tokyo, Japan); Shoji Kubo (Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan); Masatsugu Ishii (Department of Pediatric Surgery and Transplantation, Kumamoto University Graduate School of Medical Sciences, Kumamoto, Japan); Federico Mocchegiani (Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy); Zenichi Morise (Department of Surgery, Okazaki Medical Center, Fujita Health University School of Medicine, Okazaki, Japan); Kosuke Ogawa (Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan); Yukiyasu Okamura (Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Sunto-Nagaizumi, Shizuoka, Japan); Shimpei Otsuka (Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Sunto-Nagaizumi, Shizuoka, Japan); John Primrose (Department of Surgery, University Hospital Southampton NHS Trust, Southampton, UK); Edoardo Rosso (Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy; Department of Surgery, Elsan Pôle Santé Sud, Le Mans, France); Fernando Rotellar (HPB and Liver Transplant Unit. Department of General and Digestive Surgery, Clínica Universidad de Navarra, Pamplona, Spain); Nadia Russolillo (Department of General and Oncological Surgery, Umberto I Mauriziano Hospital, Largo Turati, Turin, Italy); Shareef M Syed (Department of Surgery, Division of Abdominal Transplantation), University of California San Francisco, San Francisco, CA, USA); Minoru Tanabe (Department of Hepatobiliary and Pancreatic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan); Shogo Tanaka (Department of Hepato-Biliary-Pancreatic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan); Fumihiro Terasaki (Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Sunto-Nagaizumi, Shizuoka, Japan); Marco Vivarelli (Hepatobiliary and Abdominal Transplantation Surgery, Department of Experimental and Clinical Medicine, Riuniti Hospital, Polytechnic University of Marche, Ancona, Italy); Giuseppe Zimmitti (Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy)
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Lin JJ, Conroy PC, Romero-Hernandez F, Yilma M, Feng J, Hirose K, Nakakura E, Maker AV, Corvera C, Kirkwood K, Alseidi A, Adam MA. Hypertension Requiring Medication Use: a Silent Predictor of Poor Outcomes After Pancreaticoduodenectomy. J Gastrointest Surg 2023; 27:328-336. [PMID: 36624324 DOI: 10.1007/s11605-022-05577-6] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/17/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Although hypertension requiring medication (HTNm) is a well-known cardiovascular comorbidity, its association with postoperative outcomes is understudied. This study aimed to evaluate whether preoperative HTNm is independently associated with specific complications after pancreaticoduodenectomy. STUDY DESIGN Adults undergoing elective pancreaticoduodenectomy were included from the 2014-2019 NSQIP-targeted pancreatectomy dataset. Multivariable regression models compared outcomes between patients with and without HTNm. Endpoints included significant complications, any complication, unplanned readmissions, length of stay (LOS), clinically relevant postoperative pancreatic fistula (CR-POPF), and cardiovascular and renal complications. A subgroup analysis excluded patients with diabetes, heart failure, chronic obstructive pulmonary disease, estimated glomerular filtration rate from serum creatinine (eGFRCr) < 60 ml/min per 1.73 m2, bleeding disorder, or steroid use. RESULTS Among 14,806 patients, 52% had HTNm. HTNm was more common among older male patients with obesity, diabetes, congestive heart failure, chronic obstructive pulmonary disease, functional dependency, hard pancreatic glands, and cancer. After adjusting for demographics, preoperative comorbidities, and laboratory values, HTNm was independently associated with higher odds of significant complications (aOR 1.12, p = 0.020), any complication (aOR 1.11, p = 0.030), cardiovascular (aOR 1.78, p = 0.002) and renal (aOR 1.60, p = 0.020) complications, and unplanned readmissions (aOR 1.14, p = 0.040). In a subgroup analysis of patients without major preoperative comorbidity, HTNm remained associated with higher odds of significant complications (aOR 1.14, p = 0.030) and cardiovascular complications (aOR 1.76, p = 0.033). CONCLUSIONS HTNm is independently associated with cardiovascular and renal complications after pancreaticoduodenectomy and may need to be considered in preoperative risk stratification. Future studies are necessary to explore associations among underlying hypertension, specific antihypertensive medications, and postoperative outcomes to investigate potential risk mitigation strategies.
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Affiliation(s)
- Jackie J Lin
- School of Medicine, University of California, San Francisco, San Francisco, USA
| | - Patricia C Conroy
- Department of Surgery, University of California, San Francisco, San Francisco, USA
| | | | - Mignote Yilma
- Department of Surgery, University of California, San Francisco, San Francisco, USA
- National Clinician Scholars Program, University of California, San Francisco, San Francisco, USA
| | - Jean Feng
- Department of Epidemiology & Biostatistics, University of California, San Francisco, San Francisco, USA
| | - Kenzo Hirose
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Eric Nakakura
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Ajay V Maker
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Carlos Corvera
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Kimberly Kirkwood
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Adnan Alseidi
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA
| | - Mohamed A Adam
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, 513 Parnassus Avenue, HSW 1601, San Francisco, CA, 94143-0790, USA.
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Wilhelm A, Conroy PC, Calthorpe L, Shui AM, Kitahara CM, Roman SA, Sosa JA. Disease-Specific Survival Trends for Patients Presenting with Differentiated Thyroid Cancer and Distant Metastases in the United States, 1992-2018. Thyroid 2023; 33:63-73. [PMID: 36413032 PMCID: PMC9885538 DOI: 10.1089/thy.2022.0353] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective: Differentiated thyroid cancer (DTC) is associated with an excellent prognosis, but patients with distant metastatic DTC have a 10-year disease-specific survival (DSS) of just 50%. The incidence of distant metastatic DTC has steadily increased in the United States since the 1980s. The aim of this study was to examine trends in survival and treatment for patients with distant metastatic DTC. Methods: In this population-based, retrospective cohort study, patients with distant metastatic DTC were identified from the Surveillance, Epidemiology, and End Results-13 cancer registry program. Multivariable logistic and Cox regression analyses were used to examine factors associated with DSS and management. Annual percentage changes in treatment patterns were calculated using log-linear regression. Results: During 1992-2018, 1991 patients (69.7% white, 58.0% female, 47.5% aged ≥65 years) were diagnosed with distant metastatic DTC. Papillary thyroid cancer was the most common histological type (74.5%). While the 10-year DSS for overall DTC increased over time (95.4% for patients diagnosed in 1992-1998, 96.6% in 1999-2008, and 97.3% in 2009-2018; p < 0.01), 10-year DSS for DTC with distant metastases did not change (50.2%, 47.3%, and 52.4%, respectively; p = 0.48). Ten-year DSS rates were reduced for patients aged ≥65 years (28.1%), patients undergoing nonsurgical treatment with external beam radiation therapy and/or systemic therapy (6.0%), and patients undergoing no/unknown treatment (32.8%). On multivariable analysis, oncocytic carcinoma, age 65-79 and ≥80 years, male sex, node-positive disease, larger tumor size, nonsurgical treatment, and no/unknown treatment were associated with increased risk of thyroid cancer death. Between 1992 and 2018, the rate of nonsurgical treatment increased, on average, 1.3% per year (1992-1998: 22.9% vs. 2009-2018: 25.6%; p = 0.03), and the rate of patients receiving no/unknown treatment increased 1.9% per year (1992-1998: 11.3% vs. 2009-2018: 15.6%; p = 0.01). Patients aged 65-79 and ≥80 years were more likely than younger patients to receive nonsurgical management or no/unknown treatment. Conclusion: Patients diagnosed with distant metastatic DTC have experienced no improvement in DSS over the past three decades. An increasing proportion of patients diagnosed with distant metastatic DTC are receiving nonsurgical treatment or no/unknown treatment over time; the proportion was highest among the oldest patients.
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Affiliation(s)
- Alexander Wilhelm
- Department of Surgery and University of California, San Francisco, San Francisco, California, USA
- Department of Surgery, Clarunis – St. Clara Hospital and University Hospital Basel, Basel, Switzerland
| | - Patricia C. Conroy
- Department of Surgery and University of California, San Francisco, San Francisco, California, USA
| | - Lucia Calthorpe
- Department of Surgery and University of California, San Francisco, San Francisco, California, USA
| | - Amy M. Shui
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California, USA
| | - Cari M. Kitahara
- Radiation Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Sanziana A. Roman
- Department of Surgery and University of California, San Francisco, San Francisco, California, USA
| | - Julie Ann Sosa
- Department of Surgery and University of California, San Francisco, San Francisco, California, USA
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9
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Calthorpe L, Romero-Hernandez F, Miller P, Conroy PC, Hirose K, Kim A, Kirkwood K, Nakakura E, Corvera C, Maker AV, Alseidi A, Adam MA. Contemporary Trends in Malignant Peritoneal Mesothelioma: Incidence and Survival in the United States. Cancers (Basel) 2022; 15:229. [PMID: 36612225 PMCID: PMC9818958 DOI: 10.3390/cancers15010229] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 12/16/2022] [Accepted: 12/23/2022] [Indexed: 12/31/2022] Open
Abstract
Background: Malignant peritoneal mesothelioma (MPM) is a rare disease with a historically poor prognosis. Given the emergence of effective therapies, a contemporary analysis of MPM incidence and survival is warranted. Methods: The SEER-18 registry dataset was analyzed (2000−2018). Age-adjusted annual incidence was stratified by sex and histology. Joinpoint regression was used to estimate annual percent change (APC) in incidence. Multivariable cox proportional hazards models were used to investigate survival trends. Results: Of 1689 MPM cases, most were male (55.4%), >50 years (80.0%), and white (75.2%). Age-adjusted incidence of MPM remained stable over time, with an average annual incidence of 1.02 cases/million. Epithelioid histology increased by 240% (APC 2.6; 95% CI: 0.7, 4.5), while incidence of undefined histology decreased significantly (APC −2.1; 95% CI: −3.1, −1.1). Cases treated with cancer-directed surgery increased from 27% to 43%. Overall median age-standardized survival was 11.6 months. Median age-standardized survival was 16.6 months for epithelioid histology but 2.0 months for sarcomatoid histology. Diagnosis in recent years (2015−2018 HR 0.51; 95% CI: 0.38, 0.67) and receipt of cancer-directed surgery (HR 0.84; 95% CI: 0.72, 0.98) were associated with improved survival. Conclusions: Although the overall incidence of MPM remained stable, recognition of epithelioid histology increased. Concurrent with an increase in cancer-directed surgery, MPM survival has improved.
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Affiliation(s)
- Lucia Calthorpe
- Department of Surgery, University of California, San Francisco, CA 94143, USA
| | | | - Phoebe Miller
- Department of Surgery, University of California, San Francisco, CA 94143, USA
| | - Patricia C. Conroy
- Department of Surgery, University of California, San Francisco, CA 94143, USA
| | - Kenzo Hirose
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA 94143, USA
| | - Alex Kim
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, Columbus, OH 43210, USA
| | - Kimberly Kirkwood
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA 94143, USA
| | - Eric Nakakura
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA 94143, USA
| | - Carlos Corvera
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA 94143, USA
| | - Ajay V. Maker
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA 94143, USA
| | - Adnan Alseidi
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA 94143, USA
| | - Mohamed Abdelgadir Adam
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA 94143, USA
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10
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Romero-Hernandez F, Mohamedaly S, Miller P, Rodriguez N, Calthorpe L, Conroy PC, Ganjouei AA, Hirose K, Maker AV, Nakakura E, Corvera C, Kirkwood KS, Alseidi A, Adam MA. Minimally Invasive Distal Pancreatectomy Techniques: A Contemporary Analysis Exploring Trends, Similarities, and Differences to Open Surgery. Cancers (Basel) 2022; 14:5625. [PMID: 36428717 PMCID: PMC9688336 DOI: 10.3390/cancers14225625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/28/2022] [Accepted: 11/08/2022] [Indexed: 11/18/2022] Open
Abstract
Limited contemporary data has compared similarities and differences between total laparoscopic (LDP), hand-assisted (HALDP), and open distal pancreatectomy (ODP). This study aimed to examine similarities and differences in outcomes between these three approaches in a contemporary cohort. Methods: Patients undergoing elective LDP, HALDP, and ODP in the NSQIP dataset (2014−2019) were included. Descriptive statistics and multivariate regression analyses were employed to compare postoperative outcomes. Results: Among 5636 patients, 33.9% underwent LDP, 13.1% HALDP, and 52.9% ODP. Compared with the LDP approach, surgical site infections were more frequent in HALDP and ODP approaches (1.2% vs. 2.6% vs. 2.8%, respectively, p < 0.01). After adjustment, the LDP approach was associated with a significantly lower likelihood of surgical site infection (OR 0.25, p = 0.03) when compared to ODP. There was no difference in the likelihood of surgical site infection when HALDP was compared to ODP (OR 0.59, p = 0.40). Unadjusted operative times were similar between approaches (LDP = 192 min, HALDP = 193 min, ODP = 191 min, p = 0.59). After adjustment, the LDP approach had a longer operative time (+10.3 min, p = 0.04) compared to ODP. There was no difference in the adjusted operative time between HALDP and ODP approaches (+5.4 min, p = 0.80). Conclusions: Compared to ODP, LDP was associated with improved surgical site infection rates and slightly longer operative times. There was no difference in surgical site infection rates between ODP and HALDP. Surgeon comfort and experience should decide the operative approach, but it is important to discuss the differences between these approaches with patients.
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Affiliation(s)
| | - Sarah Mohamedaly
- Department of Surgery, University of California, San Francisco, CA 94143, USA
| | - Phoebe Miller
- Department of Surgery, University of California, San Francisco, CA 94143, USA
| | - Natalie Rodriguez
- Department of Surgery, University of California, San Francisco, CA 94143, USA
| | - Lucia Calthorpe
- Department of Surgery, University of California, San Francisco, CA 94143, USA
| | - Patricia C. Conroy
- Department of Surgery, University of California, San Francisco, CA 94143, USA
| | | | - Kenzo Hirose
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA 94143, USA
| | - Ajay V. Maker
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA 94143, USA
| | - Eric Nakakura
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA 94143, USA
| | - Carlos Corvera
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA 94143, USA
| | - Kimberly S. Kirkwood
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA 94143, USA
| | - Adnan Alseidi
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA 94143, USA
| | - Mohamed A. Adam
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA 94143, USA
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11
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Conroy PC, Ullmann T, Davis S, Gosnell J, Duh QY. Autofluorescence Guides Parathyroid Cryopreservation and Parathyroidectomy in Patients with Multiple Endocrine Neoplasia Type I. VideoEndocrinology 2022. [DOI: 10.1089/ve.2022.0018] [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: 11/12/2022] Open
Affiliation(s)
- Patricia C. Conroy
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Timothy Ullmann
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Stephanie Davis
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Jessica Gosnell
- Department of Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Quan-Yang Duh
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, California, USA
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12
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Conroy PC, Wilhelm A, Calthorpe L, Ullmann TM, Davis S, Huang CY, Shen WT, Gosnell J, Duh QY, Roman S, Sosa JA. Endocrine surgeons are performing more thyroid lobectomies for low-risk differentiated thyroid cancer since the 2015 ATA guidelines. Surgery 2022; 172:1392-1400. [PMID: 36002375 DOI: 10.1016/j.surg.2022.06.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/20/2022] [Accepted: 06/26/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND The 2015 American Thyroid Association guidelines recommended either total thyroidectomy or lobectomy for surgical treatment of low-risk differentiated thyroid cancer and de-escalated recommendations for central neck dissections. The study aim was to investigate how practice patterns among endocrine surgeons have changed over time. METHODS All adult patients with low-risk differentiated thyroid cancers (T1-T2, N0/Nx, M0/Mx) in the Collaborative Endocrine Surgery Quality Improvement Program (2014-2021) were identified. The outcomes between patients undergoing lobectomy versus total thyroidectomy were compared using multivariable logistic regression. The annual percent change in the proportion of lobectomies and central neck dissections performed was estimated using joinpoint regression. RESULTS In total, 5,567 patients with low-risk differentiated thyroid cancers were identified. Of these, 2,261 (40.6%) were very low-risk tumors ≤1 cm, and 2,983 (53.6%) were low-risk tumors >1 and <4 cm. Most patients (67.9%) underwent total thyroidectomy. Compared to total thyroidectomy, lobectomy was associated with outpatient surgery (adjusted odds ratio 5.19, P < .001), a decreased risk of postoperative emergency department visits (adjusted odds ratio 0.63, P = .03), and decreased risk of hypoparathyroidism events (adjusted odds ratio 0.03, P < .001). Compared to before (2014-2015), patients undergoing surgery after publication of the revised guidelines (2016-2021) had higher odds of lobectomy and lower odds of central neck dissection for tumors ≤1 cm (lobectomy adjusted odds ratio 2.70, P < .001; central neck dissections adjusted odds ratio 0.64, P = .03) and tumors between 1 and 4 cm (lobectomy adjusted odds ratio 2.27, P < .001; central neck dissection adjusted odds ratio 0.62, P < .001). CONCLUSION After publication of the 2015 American Thyroid Association guidelines, there has been an increase in thyroid lobectomies as a proportion of all thyroid operations performed by endocrine surgeons for low-risk differentiated thyroid cancer. This has implications for reduced health care use and costs, with potential population-level benefits.
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Affiliation(s)
- Patricia C Conroy
- Department of Surgery, University of California, San Francisco, CA. https://twitter.com/PatriciaCConroy
| | | | - Lucia Calthorpe
- Department of Surgery, University of California, San Francisco, CA. https://twitter.com/CalthorpeLucia
| | - Timothy M Ullmann
- Department of Surgery, University of California, San Francisco, CA. https://twitter.com/TUllmannMD
| | - Stephanie Davis
- Department of Surgery, University of California, San Francisco, CA. https://twitter.com/stedavis21_MD
| | - Chiung-Yu Huang
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
| | - Wen T Shen
- Department of Surgery, University of California, San Francisco, CA. https://twitter.com/wshen16
| | - Jessica Gosnell
- Department of Surgery, University of California, San Francisco, CA
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco, CA. https://twitter.com/EndoSurgSF
| | - Sanziana Roman
- Department of Surgery, University of California, San Francisco, CA. https://twitter.com/PheoSurgeon
| | - Julie Ann Sosa
- Department of Surgery, University of California, San Francisco, CA.
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13
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Conroy PC, Alseidi A, Adam MA. ASO Author Reflections: An Objective Hospital Volume Threshold for Minimally Invasive Pancreaticoduodenectomy. Ann Surg Oncol 2022; 29:1575-1576. [PMID: 34773192 PMCID: PMC9289436 DOI: 10.1245/s10434-021-11022-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 10/18/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Patricia C. Conroy
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Adnan Alseidi
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Mohamed A. Adam
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA
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14
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Conroy PC, Calthorpe L, Lin JA, Mohamedaly S, Kim A, Hirose K, Nakakura E, Corvera C, Sosa JA, Sarin A, Kirkwood KS, Alseidi A, Adam MA. Determining Hospital Volume Threshold for Safety of Minimally Invasive Pancreaticoduodenectomy: A Contemporary Cutpoint Analysis. Ann Surg Oncol 2022; 29:1566-1574. [PMID: 34724124 PMCID: PMC9289437 DOI: 10.1245/s10434-021-10984-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 06/11/2021] [Accepted: 10/07/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Guidelines recommend limiting minimally invasive pancreaticoduodenectomy (MIPD) to high-volume centers. However, the definition of high-volume care remains unclear. We aimed to objectively define a minimum number of MIPD performed annually per hospital associated with improved outcomes in a contemporary patient cohort. PATIENTS AND METHODS Resectable pancreatic adenocarcinoma patients undergoing MIPD were included from the National Cancer Database (2010-2017). Multivariable modeling with restricted cubic splines was employed to identify an MIPD annual hospital volume threshold associated with lower 90-day mortality. Outcomes were compared between patients treated at low-volume (≤ model-identified cutoff) and high-volume (> cutoff) centers. RESULTS Among 3079 patients, 141 (5%) died within 90 days. Median hospital volume was 6 (range 1-73) cases/year. After adjustment, increasing hospital volume was associated with decreasing 90-day mortality for up to 19 (95% CI 16-25) cases/year, indicating a threshold of 20 cases/year. Most cases (82%) were done at low-volume (< 20 cases/year) centers. With adjustment, MIPD at low-volume centers was associated with increased 90-day mortality (OR 2.7; p = 0.002). Length of stay, positive surgical margins, 30-day readmission, and overall survival were similar. On analysis of the most recent two years (n = 1031), patients at low-volume centers (78.2%) were younger and had less advanced tumors but had longer length of stay (8 versus 7 days; p < 0.001) and increased 90-day mortality (7% versus 2%; p = 0.009). CONCLUSIONS The cutpoint analysis identified a threshold of at least 20 MIPD cases/year associated with lower postoperative mortality. This threshold should inform national guidelines and institution-level protocols aimed at facilitating the safe implementation of this complex procedure.
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Affiliation(s)
- Patricia C. Conroy
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Lucia Calthorpe
- School of Medicine, University of California, San Francisco, San Francisco, San Francisco, CA, USA
| | - Joseph A. Lin
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Sarah Mohamedaly
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Alex Kim
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, Columbus, OH, USA
| | - Kenzo Hirose
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Eric Nakakura
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Carlos Corvera
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Julie Ann Sosa
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Ankit Sarin
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Kimberly S. Kirkwood
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Adnan Alseidi
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA
| | - Mohamed A. Adam
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, San Francisco, CA, USA
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15
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Conroy PC, Calthorpe L, Lin JA, Mohamedaly S, Kim A, Hirose K, Nakakura E, Corvera C, Sosa JA, Sarin A, Kirkwood KS, Alseidi A, Adam MA. ASO Visual Abstract: Determining Hospital Volume Threshold for the Safety of Minimally Invasive Pancreaticoduodenectomy: A Contemporary Cutpoint Analysis. Ann Surg Oncol 2022. [PMID: 35031919 DOI: 10.1245/s10434-021-11075-x] [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)
- Patricia C Conroy
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Lucia Calthorpe
- School of Medicine, University of California, San Francisco, CA, USA
| | - Joseph A Lin
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Sarah Mohamedaly
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Alex Kim
- Department of Surgery, Division of Surgical Oncology, The Ohio State University, Columbus, OH, USA
| | - Kenzo Hirose
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA, USA
| | - Eric Nakakura
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA, USA
| | - Carlos Corvera
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA, USA
| | - Julie Ann Sosa
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA, USA
| | - Ankit Sarin
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA, USA
| | - Kimberly S Kirkwood
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA, USA
| | - Adnan Alseidi
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA, USA
| | - Mohamed A Adam
- Department of Surgery, Division of Surgical Oncology, University of California, San Francisco, CA, USA.
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16
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Conroy PC, Hernandez S, Graves CE, Menut KCH, Pearlstein S, Liu C, Shen WT, Gosnell J, Sosa JA, Roman S, Duh QY, Suh I. Screening for Primary Aldosteronism is Underutilized in Patients with Obstructive Sleep Apnea. Am J Med 2022; 135:60-66. [PMID: 34508708 PMCID: PMC9289750 DOI: 10.1016/j.amjmed.2021.07.041] [Citation(s) in RCA: 3] [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: 03/17/2021] [Revised: 06/28/2021] [Accepted: 07/31/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Resistant hypertension is common in patients with primary aldosteronism and in those with obstructive sleep apnea. Primary aldosteronism treatment improves sleep apnea. Despite Endocrine Society guidelines' inclusion of sleep apnea and hypertension co-diagnosis as a primary aldosteronism screening indication, the state of screening implementation is unknown. METHODS All hypertensive adult patients with obstructive sleep apnea (n = 4751) at one institution between 2012 and 2020 were compared with a control cohort without sleep apnea (n = 117,815). We compared the association of primary aldosteronism diagnoses, risk factors, and screening between both groups. Patients were considered to have screening if they had a primary aldosteronism diagnosis or serum aldosterone or plasma renin activity evaluation. RESULTS Obstructive sleep apnea patients were predominantly men and had higher body mass index. On multivariable analysis, hypertensive sleep apnea patients had higher odds of drug-resistant hypertension (odds ratio [OR] 2.70; P < .001) and hypokalemia (OR 1.26; P < .001) independent of body mass index, sex, and number of antihypertensive medications. Overall, sleep apnea patients were more likely to be screened for primary aldosteronism (OR 1.45; P < .001); however, few patients underwent screening whether they had sleep apnea or not (pre-guideline publication 7.8% vs 4.6%; post-guidelines 3.6% vs 4.6%; P < .01). Screening among eligible sleep apnea patients remained low prior to and after guideline publication (4.4% vs 3.4%). CONCLUSIONS Obstructive sleep apnea is associated with primary aldosteronism risk factors without formal diagnosis, suggesting screening underutilization and underdiagnosis. Strategies are needed to increase screening adherence, as patients may benefit from treatment of concomitant primary aldosteronism to reduce sleep apnea severity and its associated cardiopulmonary morbidity.
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Affiliation(s)
| | - Sophia Hernandez
- Department of Surgery; School of Medicine, University of California San Francisco
| | - Claire E Graves
- Department of Surgery, University of California Davis, Sacramento
| | | | | | - Chienying Liu
- Department of Medicine, University of California San Francisco
| | | | | | - Julie A Sosa
- Department of Surgery; Department of Medicine, University of California San Francisco
| | | | | | - Insoo Suh
- Department of Surgery, New York University Langone Health, New York, NY.
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17
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Menut KCH, Pearlstein SS, Conroy PC, Roman SA, Shen WT, Gosnell J, Sosa JA, Duh QY, Suh I. Screening for primary aldosteronism in the hypertensive obstructive sleep apnea population is cost-saving. Surgery 2022; 171:96-103. [PMID: 34238603 PMCID: PMC9308489 DOI: 10.1016/j.surg.2021.05.052] [Citation(s) in RCA: 2] [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: 02/08/2021] [Revised: 04/08/2021] [Accepted: 05/04/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Guidelines recommend screening for primary aldosteronism in patients diagnosed with hypertension and obstructive sleep apnea. Recent studies have shown that adherence to these recommendations is extremely low. It has been suggested that cost is a barrier to implementation. No analysis has been done to rigorously evaluate the cost-effectiveness of widespread implementation of these guidelines. METHODS We constructed a decision-analytic model to evaluate screening of the hypertensive obstructive sleep apnea population for primary aldosteronism as per guideline recommendations in comparison with current rates of screening. Probabilities, utility values, and costs were identified in the literature. Threshold and sensitivity analyses assessed robustness of the model. Costs were represented in 2020 US dollars and health outcomes in quality-adjusted life-years. The model assumed a societal perspective with a lifetime time horizon. RESULTS Screening per guideline recommendations had an expected cost of $47,016 and 35.27 quality-adjusted life-years. Continuing at current rates of screening had an expected cost of $48,350 and 34.86 quality-adjusted life-years. Screening was dominant, as it was both less costly and more effective. These results were robust to sensitivity analysis of disease prevalence, test sensitivity, patient age, and expected outcome of medical or surgical treatment of primary aldosteronism. The screening strategy remained cost-effective even if screening were conservatively presumed to identify only 3% of new primary aldosteronism cases. CONCLUSIONS For patients with hypertension and obstructive sleep apnea, rigorous screening for primary aldosteronism is cost-saving due to cardiovascular risk averted. Cost should not be a barrier to improving primary aldosteronism screening adherence.
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Affiliation(s)
| | | | - Patricia C. Conroy
- Section of Endocrine Surgery, University of California, San Francisco, CA
| | - Sanziana A. Roman
- Section of Endocrine Surgery, University of California, San Francisco, CA
| | - Wen T. Shen
- Section of Endocrine Surgery, University of California, San Francisco, CA
| | - Jessica Gosnell
- Section of Endocrine Surgery, University of California, San Francisco, CA
| | - Julie Ann Sosa
- Section of Endocrine Surgery, University of California, San Francisco, CA
| | - Quan-Yang Duh
- Section of Endocrine Surgery, University of California, San Francisco, CA
| | - Insoo Suh
- Division of Endocrine Surgery, New York University Langone Health, New York, NY,Reprint requests: Insoo Suh, MD, NYU Endocrine Surgery Associates, 530 1st Ave, Ste 6H New York, NY 10016. (I. Suh)
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18
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Conroy PC, Mohamedaly S, Calthorpe L, Glencer A, Hirose K, Nakakura EK, Corvera CU, Kirkwood K, Alseidi A, Adam M. Which Pancreaticoduodenectomy Dunking Conduit Is Optimal in the Setting of Very Small Pancreatic Ducts? J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.310] [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: 11/25/2022]
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19
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Pearlstein SS, Conroy PC, Menut KC, Kim J, Graves CE, Ruiz-Cordero R, Duh QY. Evaluation of Necrosis as a Diagnostic and Prognostic Indicator in Adrenocortical Carcinoma. JAMA Surg 2021; 156:1173-1174. [PMID: 34495300 DOI: 10.1001/jamasurg.2021.3646] [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: 11/14/2022]
Affiliation(s)
| | | | | | - Jina Kim
- Inova Schar Cancer Institute, Fairfax, Virginia
| | | | | | - Quan-Yang Duh
- Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
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20
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Conroy PC, Nakakura E. Evidence-Based Guidelines for Branch-Duct Intraductal Papillary Mucinous Neoplasm Management: Still a Lot of Room to Grow. JAMA Surg 2021; 156:661-662. [PMID: 34009248 DOI: 10.1001/jamasurg.2021.1814] [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: 11/14/2022]
Affiliation(s)
- Patricia C Conroy
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, Department of Surgery, University of California, San Francisco (UCSF).,UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
| | - Eric Nakakura
- Division of Surgical Oncology, Section of Hepatopancreaticobiliary Surgery, Department of Surgery, University of California, San Francisco (UCSF).,UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, California
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21
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Phelps HM, Robinson JR, Chen H, Luckett TR, Conroy PC, Gillis LA, Hays SR, Lovvorn HN. Enhancing Recovery After Kasai Portoenterostomy With Epidural Analgesia. J Surg Res 2019; 243:354-362. [PMID: 31277012 DOI: 10.1016/j.jss.2019.05.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 02/07/2019] [Revised: 04/24/2019] [Accepted: 05/30/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Biliary atresia (BA) is a rare obstructive cholangiopathy that presents in early infancy. The Kasai portoenterostomy (PE) improves survival with the native liver. Epidural analgesia is an appealing option to control pain in this fragile patient population, yet its safety, efficacy, and potential benefits remain unproven. METHODS Patients undergoing PE for BA between 2001 and 2016 at a single institution were identified by ICD codes. Preoperative laboratories, procedure details, and recovery outcomes were reviewed retrospectively. Outcomes of interest were need for postoperative mechanical ventilation, pain scores, normalized opioid administration, return of bowel function, and length of hospital stay after PE. RESULTS Of 47 infants undergoing PE for BA, 25 received epidural analgesia, and 22 did not. Infants with epidurals received less systemic opioids over the first 96 h postoperatively than those without (P < 0.001). Epidurals were associated with lower pain scores between 6 and 30 h postoperatively (P = 0.01 to 0.04), during which the highest median 6-h interval pain score was 0.2 (IQR 0-1.3) for patients with epidurals yet 2.1 (IQR 1.2-3.3) for patients without. Patients with epidurals (88%, n = 22) were more commonly extubated before leaving the operating room than those without (59%, n = 13; P = 0.02). No significant difference was observed in time to first bowel movement (P = 0.48) or first oral feed (P = 0.81). However, infants with epidurals had shorter hospital stays after PE than those without (6 d [IQR 5-7] versus 8 d [IQR 6.3-11], P = 0.01). No major complications were associated with epidural catheters. CONCLUSIONS Epidural analgesia in patients undergoing PE for BA appears safe and effectively controls pain while minimizing the need for systemic opioids. Reduced need for mechanical ventilation postoperatively and shortened hospital stays serve as further evidence for using epidurals to enhance recovery after PE.
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Affiliation(s)
- Hannah M Phelps
- Vanderbilt University School of Medicine, Nashville, TN; Surgical Outcomes Center for Kids, Monroe Carell, Jr. Children's Hospital, Nashville, TN.
| | - Jamie R Robinson
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN; Department of Biomedical Informatics, Vanderbilt University, Nashville, TN
| | - Heidi Chen
- Surgical Outcomes Center for Kids, Monroe Carell, Jr. Children's Hospital, Nashville, TN; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Twila R Luckett
- Pediatric Pain Service, Monroe Carell, Jr. Children's Hospital, Nashville, TN
| | | | - Lynette A Gillis
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Stephen R Hays
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN; Department of Anesthesia, Vanderbilt University Medical Center, Nashville, TN
| | - Harold N Lovvorn
- Surgical Outcomes Center for Kids, Monroe Carell, Jr. Children's Hospital, Nashville, TN; Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
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22
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Robinson JR, Conroy PC, Hardison D, Hamid R, Grubb PH, Pietsch JB, Lovvorn HN. Rapid resolution of hyperammonemia in neonates using extracorporeal membrane oxygenation as a platform to drive hemodialysis. J Perinatol 2018; 38:665-671. [PMID: 29467521 PMCID: PMC6030490 DOI: 10.1038/s41372-018-0084-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/30/2018] [Accepted: 02/01/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE We aimed to clarify the impact of extracorporeal membrane oxygenation (ECMO) as a platform to drive hemodialysis (HD) for ammonia clearance on outcomes of neonates with severe hyperammonemia. STUDY DESIGN All neonates treated for hyperammonemia at a single children's hospital between 1992 and 2016 were identified. Patient characteristics and outcomes were compared between those receiving medical management or ECMO/HD. RESULT Twenty-five neonates were treated for hyperammonemia, of which 13 (52%) received ECMO/HD. Peak ammonia levels among neonates treated with ECMO/HD were significantly higher than those medically managed (1041 [IQR 902-1581] μmol/L versus 212 [IQR 110-410] μmol/L; p = 0.009). Serum ammonia levels in the ECMO/HD cohort declined to the median of medically managed within 4.5 (IQR 2.9-7.0) hours and normalized within 7.3 (IQR 3.6-13.5) hours. All neonates survived ECMO/HD, and nine (69.2%) survived to discharge. CONCLUSION ECMO/HD is an effective adjunct to rapidly clear severe hyperammonemia in newborns, reducing potential neurodevelopmental morbidity.
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Affiliation(s)
- Jamie R. Robinson
- Department of Biomedical Informatics, Vanderbilt University,Department of Pediatric Surgery, Vanderbilt University Medical Center
| | - Patricia C. Conroy
- School of Medicine, Vanderbilt University,Department of Surgery, University of California, San Francisco
| | - Daphne Hardison
- Department of Pediatric Surgery, Vanderbilt University Medical Center
| | - Rizwan Hamid
- Department of Pediatric Genetics, Vanderbilt University Medical Center
| | - Peter H. Grubb
- Department of Pediatrics, Neonatology, Vanderbilt University Medical Center,Department of Pediatrics, Neonatology, University of Utah,Primary Children’s Hospital, Intermountain Healthcare Corporation
| | - John B. Pietsch
- Department of Pediatric Surgery, Vanderbilt University Medical Center
| | - Harold N. Lovvorn
- Department of Pediatric Surgery, Vanderbilt University Medical Center
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