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Sutherland GN, Cramer CL, Clancy Iii PW, Huang M, Turkheimer LM, Tran CA, Turrentine FE, Zaydfudim VM. Association of risk analysis index with 90-day failure to rescue following major abdominal surgery in geriatric patients. J Gastrointest Surg 2024; 28:215-219. [PMID: 38445911 DOI: 10.1016/j.gassur.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/22/2023] [Accepted: 12/10/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND Failure to rescue (FTR) is a quality metric defined as mortality after potentially preventable complications after surgery. Predicting patients who are at the highest risk of mortality after a complication may aid in preventing deaths. Thirty-day follow-up period inadequately captures postoperative deaths; alternatively, a 90-day follow-up period has been advocated. This study aimed to examine the association of a validated frailty metric, the risk analysis index (RAI), with 90-day FTR (FTR-90). METHODS Patients aged ≥65 years who underwent a major abdominal operation between 2014 and 2020 at a quaternary care center were abstracted. Institutional data were merged with the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) and Geriatric Surgery Research File variables. The association between RAI and FTR-90 was evaluated using multivariable logistic regression. RESULTS A total of 398 patients with postoperative complications were included. Fifty-two patients (13.1%) died during the 90-day follow-up. The FTR-90 group was older (median age: 76 vs 73 years, respectively; P = .002), had a greater preoperative American Society of Anesthesiologists classification score (P < .001), and had a higher ACS NSQIP estimated risk of morbidity (0.33% vs 0.20%, P < .001) and mortality (0.067% vs 0.012%, P < .001). The FTR-90 group had a greater median RAI score (23 vs 19; P = .002). The RAI score was independently associated with FTR-90 (odds ratio, 1.04; 95% CI, 1.0042-1.0770; P = .028) but not with FTR-30 (P = .13). CONCLUSION Preoperative frailty, as defined by RAI, is independently associated with FTR at 90-day follow-up. FTR-90 captured nearly 60% more deaths than did FTR-30. Frailty has major implications beyond the typical 30-day follow-up period, and a longer follow-up period must be considered.
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Affiliation(s)
- Grant N Sutherland
- School of Medicine, University of Virginia, Charlottesville, Virginia, United States
| | - Christopher L Cramer
- Division of Surgical Oncology, Department of Surgery, University of Virginia Health, Charlottesville, Virginia, United States; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia, United States
| | - Paul W Clancy Iii
- School of Medicine, University of Virginia, Charlottesville, Virginia, United States
| | - Minghui Huang
- School of Medicine, University of Virginia, Charlottesville, Virginia, United States
| | - Lena M Turkheimer
- Division of Surgical Oncology, Department of Surgery, University of Virginia Health, Charlottesville, Virginia, United States; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia, United States
| | - Christine A Tran
- Division of Surgical Oncology, Department of Surgery, University of Virginia Health, Charlottesville, Virginia, United States; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia, United States
| | - Florence E Turrentine
- Division of Surgical Oncology, Department of Surgery, University of Virginia Health, Charlottesville, Virginia, United States; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia, United States
| | - Victor M Zaydfudim
- Division of Surgical Oncology, Department of Surgery, University of Virginia Health, Charlottesville, Virginia, United States; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia, United States.
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Cramer CL, Cunningham M, Zhang AM, Pambianchi HL, James AL, Lattimore CM, Cummins KC, Turkheimer LM, Turrentine FE, Zaydfudim VM. Safety of postdischarge extended venous thromboembolism prophylaxis after hepatopancreatobiliary surgery. J Gastrointest Surg 2024; 28:115-120. [PMID: 38445932 DOI: 10.1016/j.gassur.2023.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/22/2023] [Accepted: 10/28/2023] [Indexed: 03/07/2024]
Abstract
BACKGROUND The risk of venous thromboembolism (VTE) after hepatopancreatobiliary (HPB) surgery is high. Extended postdischarge prophylaxis in this patient population has been controversial. This study aimed to examine the safety of postdischarge extended VTE prophylaxis in patients at high risk of VTE events after HPB surgery. METHODS Adult patients risk stratified as very high risk of VTE who underwent HPB operations between 2014 and 2020 at a quaternary care center were included. Patients were matched 1:2 extended VTE prophylaxis to the control group (patients who did not receive extended prophylaxis). Analyses compared the proportions of adverse bleeding events between groups. RESULTS A total of 307 patients were included: 103 in the extended prophylaxis group and 204 in the matched control group. Demographics were similar between groups. More patients in the extended VTE prophylaxis group had a history of VTE (9% vs 3%; P = .045). There was no difference in bleeding events between the extended VTE prophylaxis and the control group (6% vs 2%; P = .091). Of the 6 patients with bleeding events in the VTE prophylaxis group, 5 had gastrointestinal (GI) bleeding, and 1 had hemarthrosis. Of the 4 patients with bleeding events in the control group, 1 had intra-abdominal bleeding, 2 had GI bleeding, and 1 had intra-abdominal and GI bleeding. CONCLUSION Patients discharged with extended VTE prophylaxis after HPB surgery did not experience more adverse bleeding events compared with a matched control group. Routine postdischarge extended VTE prophylaxis is safe in patients at high risk of postoperative VTE after HPB surgery.
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Affiliation(s)
- Christopher L Cramer
- Division of Surgical Oncology, Department of Surgery, University of Virginia, Charlottesville, Virginia, United States; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia, United States
| | - Michaela Cunningham
- Division of Surgical Oncology, Department of Surgery, University of Virginia, Charlottesville, Virginia, United States; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia, United States
| | - Ashley M Zhang
- School of Medicine, University of Virginia, Charlottesville, Virginia, United States
| | - Hannah L Pambianchi
- School of Medicine, University of Virginia, Charlottesville, Virginia, United States
| | - Amber L James
- School of Medicine, University of Virginia, Charlottesville, Virginia, United States
| | - Courtney M Lattimore
- Division of Surgical Oncology, Department of Surgery, University of Virginia, Charlottesville, Virginia, United States; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia, United States
| | - Kaelyn C Cummins
- Division of Surgical Oncology, Department of Surgery, University of Virginia, Charlottesville, Virginia, United States; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia, United States
| | - Lena M Turkheimer
- Division of Surgical Oncology, Department of Surgery, University of Virginia, Charlottesville, Virginia, United States; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia, United States
| | - Florence E Turrentine
- Division of Surgical Oncology, Department of Surgery, University of Virginia, Charlottesville, Virginia, United States; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia, United States
| | - Victor M Zaydfudim
- Division of Surgical Oncology, Department of Surgery, University of Virginia, Charlottesville, Virginia, United States; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia, United States.
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Lattimore CM, Kane WJ, Subbarao S, Venitti C, Cramer CL, Turkheimer LM, Bauer TW, Turrentine FE, Zaydfudim VM. Long-term surveillance of branch-duct intraductal papillary mucinous neoplasms without worrisome or high-risk features. J Surg Oncol 2023; 128:1087-1094. [PMID: 37530526 PMCID: PMC10592219 DOI: 10.1002/jso.27414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 07/17/2023] [Accepted: 07/23/2023] [Indexed: 08/03/2023]
Abstract
INTRODUCTION Long-term data evaluating clinical outcomes in patients with branch-duct Intraductal papillary mucinous neoplasms (BD-IPMN) without high-risk stigmata (HRS) or worrisome features (WF) remain limited. METHODS This observational cohort study included all patients diagnosed with BD-IPMN without HRS or WF between 2003 and 2019 who were enrolled in a prospective surveillance program. Time-to-progression analysis was performed using a cumulative incidence function plot and survival analysis was conducted using Kaplan-Meier. RESULTS The median follow-up time for the 267 patient cohort was 44.5 months (interquartile range [IQR]: 24.1-72.2). Radiographic cyst growth was observed in 123 (46.1%) patients; 65 (24.3%) patients progressed to WF/HRS. Twenty-six (9.7%) patients were selected for resection during surveillance: 21 (80.8%) WF, 4 (15.4%) HRS; 1 (3.9%) transformed to mixed-duct. Of all the patients who underwent resection, 5 (19.2%) had adenocarcinoma, and 1 (3.8%) had carcinoma-in-situ. The probability of any radiographic progression was 21.3% (5-year) and 51.3% (10-year). For the entire cohort, there was 1.1% mortality secondary to pancreatic adenocarcinoma and 8.2% all-cause mortality. The 5-year overall survival rate was 91.5%, and at 10 years, 81.5%. CONCLUSION Approximately one in four patients with nonworrisome BD-IPMN have progression to WF/HRS stigmata during surveillance. However, the risk of malignant transformation remains low. Surveillance strategy remains prudent in this patient population.
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Affiliation(s)
- Courtney M. Lattimore
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | - William J. Kane
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | | | | | - Christopher L. Cramer
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | - Lena M. Turkheimer
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | | | - Florence E. Turrentine
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia
- Surgical Outcomes Research Center, University of Virginia
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Turrentine FE, Charles EJ, Marsh KM, Wang XQ, Ratcliffe SJ, Behrman SW, Clarke C, Reines HD, Jones RS, Zaydfudim VM. Impact of Medicaid Expansion on Abdominal Surgery Morbidity, Mortality, and Hospital Readmission. J Surg Res 2023; 291:586-595. [PMID: 37540976 PMCID: PMC10529060 DOI: 10.1016/j.jss.2023.06.047] [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] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 06/14/2023] [Accepted: 06/27/2023] [Indexed: 08/06/2023]
Abstract
INTRODUCTION Medicaid expansion's (ME) impact on postoperative outcomes after abdominal surgery remains poorly defined. We aimed to evaluate ME's effect on surgical morbidity, mortality, and readmissions in a state that expanded Medicaid (Virginia) compared to a state that did not (Tennessee) over the same time period. METHODS Virginia Surgical Quality Collaborative (VSQC) American College of Surgeons National Surgical Quality Improvement Program data for Medicaid, uninsured, and private insurance patients undergoing abdominal procedures before Virginia's ME (3/22/18-12/31/18) were compared with post-ME (1/1/19-12/31/19), as were corresponding non-ME state Tennessee Surgical Quality Collaborative (TSQC) data for the same 2018 and 2019 time periods. Postexpansion odds ratios for 30-d morbidity, 30-d mortality, and 30-d unplanned readmission were estimated using propensity score-adjusted logistic regression models. RESULTS In Virginia, 4753 abdominal procedures, 2097 pre-ME were compared to 2656 post-ME. In Tennessee, 5956 procedures, 2484 in 2018 were compared to 3472 in 2019. VSQC's proportion of Medicaid population increased following ME (8.9% versus 18.8%, P < 0.001) while uninsured patients decreased (20.4% versus 6.4%, P < 0.001). Post-ME VSQC had fewer 30-d readmissions (12.2% versus 6.0%, P = 0.013). Post-ME VSQC Medicaid patients had significantly lower probability of morbidity (-8.18, 95% confidence interval: -15.52 ∼ -0.84, P = 0.029) and readmission (-6.92, 95% confidence interval: -12.56 ∼ -1.27, P = 0.016) compared to pre-ME. There were no differences in probability of morbidity or readmission in the TSQC Medicaid population between study periods (both P > 0.05); there were no differences in mortality between study periods in VSQC and TSQC patient populations (both P > 0.05). CONCLUSIONS ME was associated with decreased 30-d morbidity and unplanned readmissions in the VSQC. Data-driven policies accounting for ME benefits should be considered.
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Affiliation(s)
- Florence E Turrentine
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Department of Surgery, Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia; Virginia Surgical Quality Collaborative, Charlottesville, Virginia
| | - Eric J Charles
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Katherine M Marsh
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Department of Surgery, Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia
| | - Xin-Qun Wang
- Department of Public Health Science, University of Virginia, Charlottesville, Virginia
| | - Sarah J Ratcliffe
- Department of Surgery, Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia; Department of Public Health Science, University of Virginia, Charlottesville, Virginia
| | - Stephen W Behrman
- Tennessee Surgical Quality Collaborative, Brentwood, Tennessee; Department of Surgery, Baptist Memorial Medical Education, Memphis, Tennessee
| | - Chris Clarke
- Tennessee Hospital Association, Brentwood, Tennessee
| | - H David Reines
- Virginia Surgical Quality Collaborative, Charlottesville, Virginia; Department of Surgery, Virginia Commonwealth University, InovaFairfax Medical Campus, Falls Church, Virginia
| | - R Scott Jones
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Department of Surgery, Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia; Virginia Surgical Quality Collaborative, Charlottesville, Virginia
| | - Victor M Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Department of Surgery, Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia.
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Zaydfudim VM, Goldaracena N. Living Donor Liver Transplantation for Patients with Unresectable Colorectal Cancer Liver Metastases: New Option for Highly Selected Patients. J Am Coll Surg 2023:00019464-990000000-00632. [PMID: 37158476 DOI: 10.1097/xcs.0000000000000728] [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: 05/10/2023]
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Mahmud N, Panchal S, Turrentine FE, Kaplan DE, Zaydfudim VM. Performance of risk prediction models for post-operative mortality in patients undergoing liver resection. Am J Surg 2023; 225:198-205. [PMID: 35985849 PMCID: PMC9994627 DOI: 10.1016/j.amjsurg.2022.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/22/2022] [Accepted: 07/28/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Liver resection is commonly performed for hepatic tumors, however preoperative risk stratification remains challenging. We evaluated the performance of contemporary prediction models for short-term mortality after liver resection in patients with and without cirrhosis. METHODS This retrospective cohort study examined National Surgical Quality Improvement Program data. We included patients who underwent liver resections from 2014 to 2019. VOCAL-Penn, MELD, MELD-Na, ALBI, and Mayo risk scores were evaluated in terms of model discrimination and calibration for 30-day post-operative mortality. RESULTS A total 15,198 patients underwent liver resection, of whom 249 (1.6%) experienced 30-day post-operative mortality. The VOCAL-Penn score had the highest discrimination (area under the ROC curve [AUC] 0.74) compared to all other models. The VOCAL-Penn score similarly outperformed other models in patients with (AUC 0.70) and without (AUC 0.74) cirrhosis. CONCLUSION The VOCAL-Penn score demonstrated superior predictive performance for 30-day post-operative mortality after liver resection as compared to existing clinical standards.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA; Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Sarjukumar Panchal
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Florence E Turrentine
- Department of Surgery, Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Victor M Zaydfudim
- Department of Surgery, Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
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Cramer CL, Kane WJ, Lattimore CM, Turrentine FE, Zaydfudim VM. Evaluating the Impact of Preoperative Geriatric-Specific Variables and Modified Frailty Index on Postoperative Outcomes After Elective Pancreatic Surgery. World J Surg 2022; 46:2797-2805. [PMID: 36076089 DOI: 10.1007/s00268-022-06710-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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pursuing pancreatic resection in elderly patients is often complex and limited by concern for functional status and postoperative risk. This study examines the associations between two different preoperative functional status metrics with postoperative outcomes in the geriatric population. METHODS Patients who participated in the ACS NSQIP Geriatric Surgery Research File pilot program (2014-2018) undergoing elective pancreatic operations were included. Two clinically meaningful functional status scores were calculated: the presence of one or more geriatric-specific variable (GSV) and a 5-factor modified frailty index (mFI-5). Multivariable logistic regression adjusting for ACS NSQIP-estimated risk was performed to evaluate associations between preoperative GSV, mFI-5 and 30-day outcome measures. RESULTS A total of 1266 patients were included: 808 (64%) age 65-74, 302 (24%) age 75-80, and 156 (12%) age ≥ 81; 843 (67%) patients underwent pancreatoduodenectomy. Operations were performed for pancreatic adenocarcinoma in 712 (56%) patients. Older patients had greater likelihood of postoperative morbidity (35% vs 31% vs 47%, by age group, p = 0.004) and discharge to a facility (12% vs 23% vs 48%, by age group, p < 0.001). Adjusting for ACS NSQIP predicted risk, patients with a preoperative GSV were more likely to require reoperation and discharge to a facility (OR 1.81 [95% CI 1.03-3.16] and 3.95 [95% CI 2.91-5.38], respectively). The mFI-5 was not associated with postoperative outcomes (all p ≥ 0.18). CONCLUSION The presence of a preoperative GSV is associated with reoperation and discharge to a skilled facility following elective pancreatic resection. Geriatric-specific variables should be considered in joint preoperative decision making to optimize care.
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Affiliation(s)
- Christopher L Cramer
- Division of Surgical Oncology, Department of Surgery, University of Virginia, PO Box 800709, Charlottesville, VA, 22908-0709, USA.,Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
| | - William J Kane
- Division of Surgical Oncology, Department of Surgery, University of Virginia, PO Box 800709, Charlottesville, VA, 22908-0709, USA.,Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
| | - Courtney M Lattimore
- Division of Surgical Oncology, Department of Surgery, University of Virginia, PO Box 800709, Charlottesville, VA, 22908-0709, USA.,Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
| | - Florence E Turrentine
- Division of Surgical Oncology, Department of Surgery, University of Virginia, PO Box 800709, Charlottesville, VA, 22908-0709, USA.,Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
| | - Victor M Zaydfudim
- Division of Surgical Oncology, Department of Surgery, University of Virginia, PO Box 800709, Charlottesville, VA, 22908-0709, USA. .,Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA.
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Rastogi R, Lattimore CM, Mehaffey JH, Turrentine FE, Maitland HS, Zaydfudim VM. Electronic Health Record Risk-Stratification Tool Reduces Venous Thromboembolism Events in Surgical Patients. Surg Open Sci 2022; 9:34-40. [PMID: 35620709 PMCID: PMC9127397 DOI: 10.1016/j.sopen.2022.04.003] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 04/13/2022] [Indexed: 11/28/2022] Open
Abstract
Background Venous thromboembolism is a preventable cause of morbidity and mortality after surgery. To ensure that patients receive appropriate venous thromboembolism chemoprophylaxis, a nonmandatory risk-stratification tool based on patient clinical condition was implemented through the electronic health record to stratify patient risk and recommend chemoprophylaxis. We hypothesized that implementing this tool would reduce postoperative venous thromboembolism events in general surgery as well as across all surgical services. Methods All adult patients undergoing inpatient surgical operations (January 2012–December 2019) at a single quaternary care center and Level 1 trauma center were abstracted from institutional electronic health record database and stratified into patients admitted before and after venous thromboembolism risk-stratification tool implementation. Bivariable analyses compared venous thromboembolism chemoprophylaxis prescription and venous thromboembolism events with implementation and screening among all surgical patients as well as in general surgery patient subset. Results A total of 64,377 adults underwent operations: 27,819 preimplementation and 36,558 postimplementation. A significant reduction in venous thromboembolism events occurred from pre- to post-tool implementation for all cases (0.77% vs 0.47%, P < .001). General surgery patients (n = 15,723) had a significant increase in chemoprophylaxis prescription (81.9% vs 86.0%, P < .001) and a significant reduction in venous thromboembolism events (1.41% vs 0.59%, P < .001). After tool implementation, use of extended postdischarge chemoprophylaxis was greater among general surgery patient subset than the entire patient cohort (46.7% vs 29.6%, P < .001). Conclusion The integration of a nonmandatory electronic health record risk-stratification tool was associated with a significant reduction in venous thromboembolism events. Extended chemoprophylaxis was prescribed in nearly half of general surgery patients at very high risk for postdischarge events. Implementing an electronic VTE risk-stratification tool reduced surgical VTE events. Even as a nonmandatory tool, risk stratification led to overall fewer VTE events. Postoperative VTE events were reduced by 39% after the tool was integrated in EHR. With the tool, general surgery had 58% less VTE events and improved prophylaxis use.
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Affiliation(s)
- Radhika Rastogi
- Department of Surgery, University of Virginia, Charlottesville, VA 22908
| | - Courtney M. Lattimore
- Department of Surgery, University of Virginia, Charlottesville, VA 22908
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA 22908
| | - J. Hunter Mehaffey
- Department of Surgery, University of Virginia, Charlottesville, VA 22908
| | - Florence E. Turrentine
- Department of Surgery, University of Virginia, Charlottesville, VA 22908
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA 22908
| | - Hillary S. Maitland
- Department of Medicine, Hematology/Oncology, University of Virginia, Charlottesville, VA 22908
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, VA 22908
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA 22908
- Corresponding author at: Division of Surgical Oncology, Department of Surgery, PO Box 800709, Charlottesville, VA, 22908-0709. Tel.: + 1-434-924-2839; fax: + 1 434-982-4778. @vz_surgery
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Hedrick TL, Zaydfudim VM. Management of Synchronous Colorectal Cancer Metastases. Surg Oncol Clin N Am 2022; 31:265-278. [DOI: 10.1016/j.soc.2021.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lattimore CM, Kane WJ, Fleming MA, Martin AN, Mehaffey JH, Smolkin ME, Ratcliffe SJ, Zaydfudim VM, Showalter SL, Hedrick TL. Disparities in telemedicine utilization among surgical patients during COVID-19. PLoS One 2021; 16:e0258452. [PMID: 34624059 PMCID: PMC8500431 DOI: 10.1371/journal.pone.0258452] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/27/2021] [Indexed: 11/19/2022] Open
Abstract
Background Telemedicine has been rapidly adopted in the wake of the COVID-19 pandemic. There is limited work surrounding demographic and socioeconomic disparities that may exist in telemedicine utilization. This study aimed to examine demographic and socioeconomic differences in surgical patient telemedicine usage during the COVID-19 pandemic. Methods Department of Surgery outpatients seen from July 1, 2019 to May 31, 2020 were stratified into three visit groups: pre-COVID-19 in-person, COVID-19 in-person, or COVID-19 telemedicine. Generalized linear models were used to examine associations of sex, race/ethnicity, Distressed Communities Index (DCI) scores, MyChart activation, and insurance status with telemedicine usage during the COVID-19 pandemic. Results 14,792 patients (median age 60, female [57.0%], non-Hispanic White [76.4%]) contributed to 21,980 visits. Compared to visits before the pandemic, telemedicine visits during COVID-19 were more likely to be with patients from the least socioeconomically distressed communities (OR, 1.31; 95% CI, 1.08,1.58; P = 0.005), with an activated MyChart (OR, 1.38; 95% CI, 1.17–1.64; P < .001), and with non-government or commercial insurance (OR, 2.33; 95% CI, 1.84–2.94; P < .001). Adjusted comparison of telemedicine visits to in person visits during COVID-19 revealed telemedicine users were more likely to be female (OR, 1.38, 95% CI, 1.10–1.73; P = 0.005) and pay with non-government or commercial insurance (OR, 2.77; 95% CI, 1.85–4.16; P < .001). Conclusions During the first three months of the COVID-19 pandemic, telemedicine was more likely utilized by female patients and those without government or commercial insurance compared to patients who used in-person visits. Interventions using telemedicine to improve health care access might consider such differences in utilization.
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Affiliation(s)
- Courtney M. Lattimore
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - William J. Kane
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Mark A. Fleming
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Allison N. Martin
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, United States of America
| | - J. Hunter Mehaffey
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Mark E. Smolkin
- Division of Biostatistics, Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, Virginia, United States of America
| | - Sarah J. Ratcliffe
- Division of Biostatistics, Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, Virginia, United States of America
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Shayna L. Showalter
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, United States of America
| | - Traci L. Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia, United States of America
- * E-mail:
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Vargas PA, McCracken EKE, Mallawaarachchi I, Ratcliffe SJ, Argo C, Pelletier S, Zaydfudim VM, Oberholzer J, Goldaracena N. Donor Morbidity Is Equivalent Between Right and Left Hepatectomy for Living Liver Donation: A Meta-Analysis. Liver Transpl 2021; 27:1412-1423. [PMID: 34053171 DOI: 10.1002/lt.26183] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 04/15/2021] [Accepted: 05/14/2021] [Indexed: 12/14/2022]
Abstract
Maximizing liver graft volume benefits the living donor liver recipient. Whether maximizing graft volume negatively impacts living donor recovery and outcomes remains controversial. Patient randomization between right and left hepatectomy has not been possible due to anatomic constraints; however, a number of published, nonrandomized observational studies summarize donor outcomes between 2 anatomic living donor hepatectomies. This meta-analysis compares donor-specific outcomes after right versus left living donor hepatectomy. Systematic searches were performed via PubMed, Cochrane, ResearchGate, and Google Scholar databases to identify relevant studies between January 2005 and November 2019. The primary outcomes compared overall morbidity and incidence of severe complications (Clavien-Dindo >III) between right and left hepatectomy in donors after liver donation. Random effects meta-analysis was performed to derive summary risk estimates of outcomes. A total of 33 studies (3 prospective and 30 retrospective cohort) were used to identify 7649 pooled patients (5993 right hepatectomy and 1027 left hepatectomy). Proportion of donors who developed postoperative complications did not significantly differ after right hepatectomy (0.33; 95% confidence interval [CI], 0.27-0.40) and left hepatectomy (0.23; 95% CI, 0.17-0.29; P = 0.19). The overall risk ratio (RR) did not differ between right and left hepatectomy (RR, 1.16; 95% CI, 0.83-1.63; P = 0.36). The relative risk for a donor to develop severe complications showed no differences by hepatectomy side (Incidence rate ratio, 0.97; 95% CI, 0.67-1.40; P = 0.86). There is no evidence that the overall morbidity differs between right and left lobe donors. Publication bias reflects institutional and surgeon variation. A prospective, standardized, multi-institutional study would help quantify the burden of donor complications after liver donation.
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Affiliation(s)
- Paola A Vargas
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Emily K E McCracken
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Indika Mallawaarachchi
- Division of Biostatistics, Department of Public Health Sciences, University of Virginia, School of Medicine, Charlottesville, VA
| | - Sarah J Ratcliffe
- Division of Biostatistics, Department of Public Health Sciences, University of Virginia, School of Medicine, Charlottesville, VA
| | - Curtis Argo
- Division of Gastroenterology, Department of Medicine, University of Virginia Health System, Charlottesville, VA
| | - Shawn Pelletier
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Victor M Zaydfudim
- Division of Surgical Oncology, Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Jose Oberholzer
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA
| | - Nicolas Goldaracena
- Division of Transplant Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA
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12
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Turrentine FE, Smolkin ME, McMurry TL, Scott Jones R, Zaydfudim VM, Davis JP. Determining the Association Between Unplanned Reoperation and Readmission in Selected General Surgery Operations. J Surg Res 2021; 267:309-319. [PMID: 34175585 DOI: 10.1016/j.jss.2021.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 04/19/2021] [Accepted: 05/04/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Unplanned reoperations and unplanned readmissions can increase morbidity and mortality. Few studies however, have explored the association of reoperation and readmission among general surgery patients. Our aim was to examine this relationship in selected abdominal operations. METHODS Data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data Files from 2014 to 2018 were utilized. Six groups of operations, defined by ACS NSQIP procedure codes for ventral hernia repair, colectomy, appendectomy, proctectomy, small bowel resection, and gastrectomy, were assessed. Patients discharged ≤ 14 days after operation were included in the study. This time period was selected to reduce ACS NSQIP 30 day post-surgery follow-up bias. Unplanned reoperations were defined as those occurring during the index hospitalization. The primary outcome was unplanned readmission that occurred ≤ 14 days from the date of discharge. Logistic regression models were used to examine variables associated with unplanned readmission for each procedure group. RESULTS A total of 787,118 patients were included: ventral hernia repair 35.2%, colectomy 30.6%, appendectomy 26.5%, proctectomy 3.7%, small bowel resection 3.2%, and gastrectomy 0.8%. Unplanned reoperation was independently associated with unplanned readmission for ventral hernia repair (OR 2.84, 95% CI 2.28-3.54, P < 0.001), colectomy (OR 1.58, CI 1.42- 1.76, P < 0.001), appendectomy (OR 2.91, CI 2.21-3.84, P < 0.001), and proctectomy (OR 1.41, CI 1.10-1.81, P = 0.006). Other clinically relevant covariates associated with readmission were partially dependent functional status before colectomy (OR 1.34, CI 1.23-1.46, P < 0.001), ventral hernia repair (OR 1.79, CI 1.54-2.09, P < 0.001), and small bowel resection (OR 1.44, CI 1.18-1.77, P < 0.001; and ASA 4/5 classification for colectomy (OR 2.71, CI 2.36-3.11, P < 0.001), proctectomy (OR 2.10, CI 1.48-2.97, P < 0.001), ventral hernia repair (OR 8.19, CI 6.78-9.88, P < 0.001), appendectomy (OR 2.80, CI 2.35-3.34, P < 0.001), and small bowel resection (OR 3.42, CI 2.20-5.32, P < 0.001). ASA 2, ASA 3 classification, age, and sex were also associated with unplanned readmission for most procedures. CONCLUSIONS Unplanned reoperations are associated with an increase in unplanned readmission after selected abdominal operations included in this study. This factor should be considered in discharge and follow-up planning to help reduce unplanned readmissions.
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Affiliation(s)
- Florence E Turrentine
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia
| | - Mark E Smolkin
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia; Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Timothy L McMurry
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia; Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - R Scott Jones
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia
| | - Victor M Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia
| | - John P Davis
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia.
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13
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Lattimore CM, Kane WJ, Turrentine FE, Zaydfudim VM. The impact of obesity and severe obesity on postoperative outcomes after pancreatoduodenectomy. Surgery 2021; 170:1538-1545. [PMID: 34059346 DOI: 10.1016/j.surg.2021.04.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 03/29/2021] [Accepted: 04/21/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The impact of obesity on postoperative outcomes after pancreatoduodenectomy remains insufficiently studied. METHODS All pancreatoduodenectomy patients were abstracted from the 2014 to 2018 American College of Surgeons National Surgical Quality Improvement Program data sets and were stratified into the following 3 body mass index categories: non-obese (body mass index 18.5-29.9), class 1/2 obesity (body mass index 30-39.9), and class 3 severe obesity (body mass index ≥ 40). Analyses tested associations between patient factors and four 30-day postoperative outcomes: mortality, composite morbidity, delayed gastric emptying, and postoperative pancreatic fistula. Multivariable logistic regression models tested independent associations between patient factors and these 4 outcome measures. RESULTS A total of 16,823 patients were included in the study: 12,234 (72.7%) non-obese, 4,030 (24%) obese, and 559 (3.3%) with severe obesity. Bivariable analyses demonstrated significant associations between obesity, severe obesity, and greater proportions of numerous preoperative comorbidities as well as a greater likelihood of postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, composite morbidity, and mortality (all P ≤ .001). After adjusting for significant covariates, obesity was independently associated with postoperative pancreatic fistula (odds ratio 1.49, 95% confidence interval: 1.33-1.67, P < .001), delayed gastric emptying (odds ratio 1.16, 95% confidence interval: 1.05-1.28, P = .004), composite morbidity (odds ratio 1.28, 95% confidence interval: 1.18-1.38, P < .001), and mortality (odds ratio 1.79, 95% confidence interval: 1.36-2.36, P < .001). CONCLUSION Obesity and severe obesity are significantly associated with worse short-term outcomes after pancreatoduodenectomy. Preoperative considerations, such as weight management strategies during individualized treatment planning, could improve outcomes in this population.
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Affiliation(s)
- Courtney M Lattimore
- Department of Surgery, University of Virginia, Charlottesville, VA; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia, USA
| | - William J Kane
- Department of Surgery, University of Virginia, Charlottesville, VA; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia, USA
| | - Florence E Turrentine
- Department of Surgery, University of Virginia, Charlottesville, VA; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia, USA
| | - Victor M Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, VA; Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia, USA.
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14
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Chen M, Cao J, Hu J, Topatana W, Li S, Juengpanich S, Lin J, Tong C, Shen J, Zhang B, Wu J, Pocha C, Kudo M, Amedei A, Trevisani F, Sung PS, Zaydfudim VM, Kanda T, Cai X. Clinical-Radiomic Analysis for Pretreatment Prediction of Objective Response to First Transarterial Chemoembolization in Hepatocellular Carcinoma. Liver Cancer 2021; 10:38-51. [PMID: 33708638 PMCID: PMC7923935 DOI: 10.1159/000512028] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [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: 03/04/2020] [Accepted: 09/23/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The preoperative selection of patients with intermediate-stage hepatocellular carcinoma (HCC) who are likely to have an objective response to first transarterial chemoembolization (TACE) remains challenging. OBJECTIVE To develop and validate a clinical-radiomic model (CR model) for preoperatively predicting treatment response to first TACE in patients with intermediate-stage HCC. METHODS A total of 595 patients with intermediate-stage HCC were included in this retrospective study. A tumoral and peritumoral (10 mm) radiomic signature (TPR-signature) was constructed based on 3,404 radiomic features from 4 regions of interest. A predictive CR model based on TPR-signature and clinical factors was developed using multivariate logistic regression. Calibration curves and area under the receiver operating characteristic curves (AUCs) were used to evaluate the model's performance. RESULTS The final CR model consisted of 5 independent predictors, including TPR-signature (p < 0.001), AFP (p = 0.004), Barcelona Clinic Liver Cancer System Stage B (BCLC B) subclassification (p = 0.01), tumor location (p = 0.039), and arterial hyperenhancement (p = 0.050). The internal and external validation results demonstrated the high-performance level of this model, with internal and external AUCs of 0.94 and 0.90, respectively. In addition, the predicted objective response via the CR model was associated with improved survival in the external validation cohort (hazard ratio: 2.43; 95% confidence interval: 1.60-3.69; p < 0.001). The predicted treatment response also allowed for significant discrimination between the Kaplan-Meier curves of each BCLC B subclassification. CONCLUSIONS The CR model had an excellent performance in predicting the first TACE response in patients with intermediate-stage HCC and could provide a robust predictive tool to assist with the selection of patients for TACE.
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Affiliation(s)
- Mingyu Chen
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China,Engineering Research Center of Cognitive Healthcare of Zhejiang Province, Hangzhou, China,Zhejiang University School of Medicine, Hangzhou, China
| | - Jiasheng Cao
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Jiahao Hu
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Win Topatana
- Zhejiang University School of Medicine, Hangzhou, China
| | - Shijie Li
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | | | - Jian Lin
- General Surgery, Longyou People's Hospital, Quzhou, China
| | - Chenhao Tong
- General Surgery, Shaoxing People's Hospital, Shaoxing, China
| | - Jiliang Shen
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Bin Zhang
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China
| | - Jennifer Wu
- Perlmutter Cancer Center, NYU Langone Health, New York, New York, USA
| | - Christine Pocha
- Avera McKennnan Hospital and University Medical Center, Sanford School of Medicine, University of South Dakota, Sioux Falls, South Dakota, USA
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University School of Medicine, Osaka, Japan
| | - Amedeo Amedei
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Franco Trevisani
- Department of Medical and Surgical Sciences, Semeiotica Medica, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Pil Soo Sung
- Department of Internal Medicine, College of Medicine, Eunpyeong St. Mary's Hospital, Seoul, Republic of Korea
| | - Victor M. Zaydfudim
- Department of Surgery, Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, Virginia, USA
| | - Tatsuo Kanda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Xiujun Cai
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, China,Engineering Research Center of Cognitive Healthcare of Zhejiang Province, Hangzhou, China,Zhejiang Research and Development Engineering Laboratory of Minimally Invasive Technology and Equipment, Hangzhou, China,*Xiujun Cai, Department of General Surgery, Sir Run-Run Shaw Hospital, No. 3 East Qingchun Road, Hangzhou 310016 (China),
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15
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Zaydfudim VM. Is there a role for a wound protector during pancreatoduodenectomy? Surgery 2020; 169:1016. [PMID: 33189364 DOI: 10.1016/j.surg.2020.10.007] [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] [Received: 10/04/2020] [Accepted: 10/05/2020] [Indexed: 10/23/2022]
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16
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Zaydfudim VM. Postoperative complications and long-term health-related quality of life (HRQOL) after esophagectomy. Surgery 2020; 169:988. [PMID: 33131788 DOI: 10.1016/j.surg.2020.09.023] [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] [Received: 09/05/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022]
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17
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Zaydfudim VM. Combined portal vein and hepatic vein embolization to augment hepatic lobar hypertrophy. Surgery 2020; 169:986. [PMID: 33759782 DOI: 10.1016/j.surg.2020.09.025] [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] [Received: 09/05/2020] [Accepted: 09/07/2020] [Indexed: 10/23/2022]
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18
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Hu Y, McMurry TL, Goudreau B, Leick KM, Le TM, Zaydfudim VM. Comparative Effectiveness of Lymphadenectomy Strategies During Curative Resection for Gastric Adenocarcinoma. J Gastrointest Surg 2020; 24:2212-2218. [PMID: 31515762 PMCID: PMC7065947 DOI: 10.1007/s11605-019-04393-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 09/01/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND The purpose of this study was to compare the long-term effectiveness of three lymphadenectomy strategies in patients with gastric cancer. We hypothesized that, compared with the traditional standard (D2) lymph node dissection strategy, the less aggressive modified standard (mD2) lymphadenectomy may offer superior effectiveness due to reduced operative morbidity and comparable long-term recurrence-free survival. METHODS A Markov decision analysis model was created to simulate 5-year outcomes across three lymphadenectomy approaches for gastric cancer: limited regional (D1), traditional standard (D2), and modified standard (mD2). The primary outcome was discounted quality-adjusted life-years (dQALY). Model variable estimates were derived from outcomes data and quality of life estimates published in Europe and America within the last 15 years. One-way and probabilistic sensitivity analyses were performed for clinically relevant variables. RESULTS The mD2 lymphadenectomy offered 3.03 dQALY over 5 years, outperforming D2 (2.62 dQALY) and D1 (2.37 dQALY). Monte Carlo simulations indicated that both mD2 and D2 lymph node dissection strategies outperformed D1 in 94.9% of simulations. Sensitivity analyses demonstrated that the mD2 approach would be less effective than D2 if the perioperative mortality rate of mD2 was greater than 6.9% (3.2% baseline). CONCLUSIONS Across modern series, the modified standard mD2 lymphadenectomy is an effective alternative to the traditional D2 lymphadenectomy for patients with gastric cancer. A D1-limited regional lymphadenectomy is not recommended during gastric cancer resection.
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Affiliation(s)
- Yinin Hu
- Division of Surgical Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Timothy L. McMurry
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville, VA,Surgical Outcomes Research Center, University of Virginia School of Medicine, Charlottesville, VA
| | - Bernadette Goudreau
- Division of Surgical Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Katie M. Leick
- Division of Surgical Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Tri M. Le
- Division of Hematology and Oncology, University of Virginia School of Medicine, Charlottesville, VA
| | - Victor M. Zaydfudim
- Division of Surgical Oncology, University of Virginia School of Medicine, Charlottesville, VA,Surgical Outcomes Research Center, University of Virginia School of Medicine, Charlottesville, VA
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Rastogi R, Mehaffey JH, Turrentine BE, Maitland HS, Zaydfudim VM. Implementation of an Electronic Medical Record Risk Stratification Tool to Reduce Venous Thromboembolism Events. J Am Coll Surg 2020. [DOI: 10.1016/j.jamcollsurg.2020.07.273] [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: 11/15/2022]
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20
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Affiliation(s)
- Victor M Zaydfudim
- Department of Surgery, Section of Hepatobiliary and Pancreatic Surgery, Division of Surgical Oncology, University of Virginia, Box 800709, Charlottesville, VA, 22908-0709, USA.
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21
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Martin AN, Hoagland DL, Turrentine FE, Jones RS, Zaydfudim VM. Safety of Major Abdominal Operations in the Elderly: A Study of Geriatric-Specific Determinants of Health. World J Surg 2020; 44:2592-2600. [PMID: 32318790 PMCID: PMC7223877 DOI: 10.1007/s00268-020-05515-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Preoperative assessment of geriatric-specific determinants of health may enhance perioperative risk stratification among elderly patients. This study examines effects of geriatric-specific variables on postoperative outcomes in patients undergoing elective major abdominal operations. METHODS Patients included in the ACS NSQIP pilot Geriatric Surgery Research File program who underwent elective pancreatic, liver, and colorectal operations between 2014 and 2016 were examined. Multivariable analyses were performed to evaluate associations between patient-specific geriatric variables and risk of death, morbidity, readmission, and discharge destination. RESULTS A total of 4165 patients were included. Patients ≥85 years were more likely to die, experience postoperative morbidity, and be discharged to a facility (all p ≤ 0.039) than younger patients. Preoperatively, patients ≥85 years were more likely to use a mobility aid, have a prior fall, have consent signed by a surrogate, and to live alone at home prior to operation (all p < 0.001). After adjustment for ACS NSQIP-estimated probabilities of morbidity or mortality, no geriatric-specific preoperative risk factors were significantly associated with increased risk of death or complications in any age group (all p > 0.055). Patients 75-84 and ≥85 years were more likely to be discharged to facility (OR 2.33 and 4.75, respectively, both p < 0.001) compared to patients 65-74 years. All geriatric-specific variables: use of mobility aid, living alone, consent signed by a surrogate, and fall history, were significantly associated with discharge to a facility (all p ≤ 0.001). CONCLUSIONS After adjusting for comorbid conditions, geriatric-specific variables are not associated with postoperative mortality and morbidity among elderly patients; however, geriatric-specific variables are significantly associated with discharge to a facility.
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Affiliation(s)
- Allison N Martin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Darian L Hoagland
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Florence E Turrentine
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
| | - R Scott Jones
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
| | - Victor M Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, VA, USA.
- Division of Surgical Oncology, Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Box 800709, Charlottesville, VA, 22908-0709, USA.
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA.
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22
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Hu Y, Zaydfudim VM. Quality of Life After Curative Resection for Gastric Cancer: Survey Metrics and Implications of Surgical Technique. J Surg Res 2020; 251:168-179. [PMID: 32151826 DOI: 10.1016/j.jss.2020.02.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 09/03/2019] [Revised: 01/07/2020] [Accepted: 02/01/2020] [Indexed: 02/07/2023]
Abstract
Gastric cancer is one of the most common cancers worldwide, and radical gastrectomy is an integral component of curative therapy. With improvements in perioperative morbidity and mortality, attention has turned to short- and long-term post-gastrectomy quality of life (QoL). This article reviews the common psychometric surveys and preference-based measures used among patients following gastrectomy. It also provides an overview of studies that address associations between surgical decision-making and postoperative health-related QoL. Further attention is focused on reported associations between technical aspects of the operation, such as extent of gastric resection, minimally-invasive approach, pouch-based conduits, enteric reconstruction, and postoperative QoL. While there are several randomized studies that include QoL outcomes, much remains to be explored. The relationship between symptom profiles and preference-based measures of health state utility is an area in need of further research.
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Affiliation(s)
- Yinin Hu
- Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Victor M Zaydfudim
- Division of Surgical Oncology, University of Virginia, Charlottesville, Virginia; Department of Surgery, Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia.
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Turrentine FE, Zaydfudim VM, Martin AN, Jones RS. Association of Geriatric-Specific Variables with 30-Day Hospital Readmission Risk of Elderly Surgical Patients: A NSQIP Analysis. J Am Coll Surg 2020; 230:527-533.e1. [PMID: 32081752 DOI: 10.1016/j.jamcollsurg.2019.12.032] [Citation(s) in RCA: 4] [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: 12/16/2019] [Accepted: 12/16/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Elderly patients (65 years of age and older) undergo an increasing number of operations performed annually in the US and they present with unique healthcare needs. Preventing postoperative readmission remains an important challenge to improving surgical care. This study examined whether geriatric-specific variables were independently associated with postoperative readmissions of elderly patients. METHODS The American College of Surgeons (ACS) Geriatric Surgery Research File (GSRF) was joined with the ACS NSQIP Participant Use Data Files for 2014 to 2016. This data set included 13 GSRF variables and 26 ACS NSQIP variables. Associations between clinically relevant variables and readmission were tested with multivariable logistic regression. RESULTS The data represented 6,039 general surgery patients age 65 years and older. Fifty-eight percent of patients had colorectal operations, 19% pancreatic or hepatobiliary, 15% hernia, 4% thyroid or esophageal, and 3% had appendix operations. Twenty-four percent of patients experienced an NSQIP-defined 30-day postoperative complication and 3% died within 30 days after operation. Eleven percent of patients had unplanned 30-day readmission. Standard NSQIP variables, including 30-day composite morbidity (odds ratio [OR] 5.11; 95% CI, 4.24 to 6.16; p < 0.001), reoperation (OR 2.8; 95% CI, 2.07 to 3.79; p < 0.001), and steroid use (1.42; 95% CI, 1.03 to 1.96; p = 0.03) were associated with readmission. In addition, GSRF variables, including incompetent on admission (OR 1.63; 95% CI, 1.11 to 2.38; p = 0.01), fall risk at discharge (OR 1.42; 95% CI, 1.11 to 1.82; p = 0.005), use of mobility aid (OR 1.26; 95% CI, 1.02 to 1.56; p = 0.03), and discharged home with skilled care (OR, 1.22; 95% CI, 1.0 to 1.49; p = 0.04) were associated with readmission. CONCLUSIONS Four GSRF and 3 current standard ACS NSQIP variables were important in the evaluation of postoperative readmission of elderly patients. Geriatric-specific variables contributed to the explanation of the relationship between clinical variables and readmissions in elderly surgical patients.
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Affiliation(s)
| | | | - Allison N Martin
- Department of Surgery, University of Virginia, Charlottesville, VA
| | - R Scott Jones
- Department of Surgery, University of Virginia, Charlottesville, VA
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Zaydfudim VM, Turrentine FE, Smolkin ME, Bauer TB, Adams RB, McMurry TL. The impact of cirrhosis and MELD score on postoperative morbidity and mortality among patients selected for liver resection. Am J Surg 2020; 220:682-686. [PMID: 31983407 DOI: 10.1016/j.amjsurg.2020.01.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/14/2020] [Accepted: 01/14/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Independent associations between chronic liver disease, MELD, and postoperative outcomes among patients selected for liver resection have not been completely established. We hypothesized independent associations between MELD, cirrhosis, and postoperative mortality. METHODS Patient-level data from the targeted hepatectomy module and ACS NSQIP PUF during 2014-2015 were merged. Multivariable regression models with interaction effect between MELD and liver texture (normal, congested/fatty, cirrhotic) tested the independent effects of covariates on mortality and morbidity. RESULTS 3,530 patients were included, of whom 668 patients (19%) had cirrhosis. ACS NSQIP defined mortality (3.9%vs1.1%) and morbidity (23.5%vs15.8%) were higher in patients with cirrhosis (both p < 0.001). In multivariable models, cirrhosis (OR = 2.24; 95%CI:1.16-4.34, p = 0.016) and MELD (OR = 1.10; 95%CI:1.03-1.18, p = 0.007) were independently associated with mortality. MELD (OR = 1.04; 95%CI:1.002-1.08, p = 0.038) was associated with postoperative morbidity. CONCLUSIONS Higher MELD and presence of cirrhosis have an independent negative effect on mortality after liver resection. MELD could be used to estimate postoperative risk in patients with and without cirrhosis.
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Affiliation(s)
- Victor M Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, VA, USA; Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA; Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, USA.
| | - Florence E Turrentine
- Department of Surgery, University of Virginia, Charlottesville, VA, USA; Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
| | - Mark E Smolkin
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Todd B Bauer
- Department of Surgery, University of Virginia, Charlottesville, VA, USA; Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Reid B Adams
- Department of Surgery, University of Virginia, Charlottesville, VA, USA; Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Timothy L McMurry
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, USA; Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
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Zaydfudim VM. Development, Growth, and Maturation of Pancreatoduodenectomy Program: Future Directions. World J Surg 2020; 44:2795-2796. [PMID: 31900567 DOI: 10.1007/s00268-019-05356-6] [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: 10/25/2022]
Affiliation(s)
- Victor M Zaydfudim
- Department of Surgery, Division of Surgical Oncology, Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Box 800709, Charlottesville, VA, 22908-0709, USA.
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Zaydfudim VM, Adams RB. Liver resection versus chemoembolization for patients with multifocal hepatocellular carcinoma. Hepatobiliary Surg Nutr 2019; 8:543-545. [PMID: 31673553 PMCID: PMC6791989 DOI: 10.21037/hbsn.2019.04.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 04/16/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Victor M Zaydfudim
- Department of Surgery, Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, USA
| | - Reid B Adams
- Department of Surgery, Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, USA
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Hu Y, Johnston LE, Shami VM, Bauer TW, Adams RB, Stukenborg GJ, Zaydfudim VM. Comparative Effectiveness of Resection vs Surveillance for Pancreatic Branch Duct Intraductal Papillary Mucinous Neoplasms With Worrisome Features. JAMA Surg 2019; 153:225-232. [PMID: 29167899 DOI: 10.1001/jamasurg.2017.4587] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Yinin Hu
- Department of Surgery, University of Virginia School of Medicine, Charlottesville
| | - Lily E. Johnston
- Department of Surgery, University of Virginia School of Medicine, Charlottesville
| | - Vanessa M. Shami
- Department of Gastroenterology, University of Virginia School of Medicine, Charlottesville
| | - Todd W. Bauer
- Department of Surgery, University of Virginia School of Medicine, Charlottesville
| | - Reid B. Adams
- Department of Surgery, University of Virginia School of Medicine, Charlottesville
| | - George J. Stukenborg
- Department of Public Health Sciences, University of Virginia School of Medicine, Charlottesville,Surgical Outcomes Research Center, University of Virginia School of Medicine, Charlottesville
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia School of Medicine, Charlottesville,Surgical Outcomes Research Center, University of Virginia School of Medicine, Charlottesville
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Martin AN, Wilkins LR, Das D, Johnston LE, Bauer TW, Adams RB, Zaydfudim VM. Efficacy of Radiofrequency Ablation versus Transarterial Chemoembolization for Patients with Solitary Hepatocellular Carcinoma ≤3 cm. Am Surg 2019. [DOI: 10.1177/000313481908500220] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Optimal treatment for small hepatocellular carcinoma (HCC) ≤ 3 cm remains controversial. Ablation and chemoembolization are considered for nonoperative candidates. This study compares survival among patients with solitary HCC ≤ 3 cm treated with radiofrequency ablation (RFA) and transarterial chemoembolization (TACE). Patients diagnosed with HCC ≤ 3 cm between 2005 and 2014 were included. Kaplan-Meier survival functions with log-rank tests were used to estimate recurrence-free survival and overall survival (OS) survival. Among 161 patients with solitary HCC ≤ 3 cm, 145 patients with mean age of 65.2 years (69.2) and 95 per cent prevalence of cirrhosis had operative treatment or TACE, and/or RFA. From this cohort, 27 (19%) patients had TACE, 27 (19%) patients had RFA, and 15 (10%) patients had TACE/RFA. The patients treated with definitive TACE, RFA, or TACE/RFA had a similar 1-year recurrence-free survival (23% vs 27% vs 36%, respectively, P = 0.445) and similar 5-year OS (21% vs 24% vs 33%, respectively, P = 0.287). Thirty-five (24%) patients were bridged to transplantation with TACE and/or RFA. The 5-year OS was significantly improved in patients bridged to transplantation (P < 0.001). Survival does not differ between patients with solitary HCC ≤ 3 cm treated with TACE or RFA. Patients who were bridged to transplantation had significantly greater OS compared with patients who were not transplanted.
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Affiliation(s)
- Allison N. Martin
- Section of Hepatobiliary and Pancreatic Surgery, Department of Surgery
| | | | - Deepanjana Das
- Section of Hepatobiliary and Pancreatic Surgery, Department of Surgery
| | - Lily E. Johnston
- Section of Hepatobiliary and Pancreatic Surgery, Department of Surgery
| | - Todd W. Bauer
- Section of Hepatobiliary and Pancreatic Surgery, Department of Surgery
| | - Reid B. Adams
- Section of Hepatobiliary and Pancreatic Surgery, Department of Surgery
| | - Victor M. Zaydfudim
- Section of Hepatobiliary and Pancreatic Surgery, Department of Surgery
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, Virginia
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Martin AN, Wilkins LR, Das D, Johnston LE, Bauer TW, Adams RB, Zaydfudim VM. Efficacy of Radiofrequency Ablation versus Transarterial Chemoembolization for Patients with Solitary Hepatocellular Carcinoma ≤3 cm. Am Surg 2019; 85:150-155. [PMID: 30819290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Optimal treatment for small hepatocellular carcinoma (HCC) ≤ 3 cm remains controversial. Ablation and chemoembolization are considered for nonoperative candidates. This study compares survival among patients with solitary HCC ≤ 3 cm treated with radiofrequency ablation (RFA) and transarterial chemoembolization (TACE). Patients diagnosed with HCC ≤ 3 cm between 2005 and 2014 were included. Kaplan-Meier survival functions with log-rank tests were used to estimate recurrence-free survival and overall survival (OS) survival. Among 161 patients with solitary HCC ≤ 3 cm, 145 patients with mean age of 65.2 years (±9.2) and 95 per cent prevalence of cirrhosis had operative treatment or TACE, and/or RFA. From this cohort, 27 (19%) patients had TACE, 27 (19%) patients had RFA, and 15 (10%) patients had TACE/RFA. The patients treated with definitive TACE, RFA, or TACE/RFA had a similar 1-year recurrence-free survival (23% vs 27% vs 36%, respectively, P = 0.445) and similar 5-year OS (21% vs 24% vs 33%, respectively, P = 0.287). Thirty-five (24%) patients were bridged to transplantation with TACE and/or RFA. The 5-year OS was significantly improved in patients bridged to transplantation (P < 0.001). Survival does not differ between patients with solitary HCC ≤ 3 cm treated with TACE or RFA. Patients who were bridged to transplantation had significantly greater OS compared with patients who were not transplanted.
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Martin AN, Narayanan S, Turrentine FE, Bauer TW, Adams RB, Zaydfudim VM. Pancreatic duct size and gland texture are associated with pancreatic fistula after pancreaticoduodenectomy but not after distal pancreatectomy. PLoS One 2018; 13:e0203841. [PMID: 30212577 PMCID: PMC6136772 DOI: 10.1371/journal.pone.0203841] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/28/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Pancreatic fistula remains a morbid complication after pancreatectomy. Since the proposed mechanism of pancreatic fistula is different between pancreaticoduodenectomy and distal pancreatectomy, we hypothesized that pancreatic gland texture and duct size are not associated with pancreatic fistula after distal pancreatectomy. METHODS All patients ≥18 years in the 2014-15 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) targeted pancreatectomy dataset were linked with the ACS NSQIP Public Use File (PUF). Pancreatic duct size (<3 mm, 3-6 mm, >6 mm) and pancreatic gland texture (hard, intermediate, soft) were categorized. Separate multivariable analyses were performed to evaluate associations between pancreatic duct size and gland texture after pancreaticoduodenectomy and distal pancreatectomy. RESULTS A total of 9366 patients underwent pancreaticoduodenectomy or distal pancreatectomy during the study period. Proportion of pancreatic fistula was similar after distal pancreatectomy (606 of 3132, 19.4%) and pancreaticoduodenectomy (1163 of 6335, 18.4%, p = 0.245). Both pancreatic gland texture and duct size were significantly associated with pancreatic fistula after pancreaticoduodenectomy (p<0.001). However, there was no association between pancreatic fistula and gland texture or duct size (all p≥0.169) after distal pancreatectomy. Operative approach (minimally invasive versus open) was not associated with pancreatic fistula after distal pancreatectomy (p = 0.626). Patients with pancreatic fistula after distal pancreatectomy had increased rate of postoperative complications including longer length of stay, higher rates of readmission and reoperation compared to patients who did not have a pancreatic fistula (all p<0.001). CONCLUSIONS Unlike among patients who had pancreaticoduodenectomy, pancreatic gland texture and duct size are not associated with development of pancreatic fistula following distal pancreatectomy. Other clinical factors should be considered in this patient population.
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Affiliation(s)
- Allison N. Martin
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
| | - Sowmya Narayanan
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
| | - Florence E. Turrentine
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, United States of America
| | - Todd W. Bauer
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
- Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, United States of America
| | - Reid B. Adams
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
- Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, United States of America
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, VA, United States of America
- Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA, United States of America
- Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, United States of America
- * E-mail:
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Narayanan S, Martin AN, Turrentine FE, Bauer TW, Adams RB, Zaydfudim VM. Mortality after pancreaticoduodenectomy: assessing early and late causes of patient death. J Surg Res 2018; 231:304-308. [PMID: 30278945 DOI: 10.1016/j.jss.2018.05.075] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/06/2018] [Accepted: 05/31/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Safety of pancreaticoduodenectomy has improved significantly in the past 3 decades. Current inpatient and 30-d mortality rates are low. However, incidence and causes of 90-d and 1-y mortality are poorly defined and largely unexplored. METHODS All patients who had pancreaticoduodenectomy between 2007 and 2016 were included in this single institution, retrospective cohort study. Distributions of pancreaticoduodenectomy-specific morbidity and cause-specific mortality were compared between early (within 90 d) and late (91-365 d) postoperative recovery periods. RESULTS A total of 551 pancreaticoduodenectomies were performed during the study period. Of these, 6 (1.1%), 20 (3.6%), and 91 (16.5%) patients died within 30, 90, and 365 d after pancreaticoduodenectomy, respectively. Causes of early and late mortality varied significantly (all P ≤ 0.032). The most common cause of death within 90 d was due to multisystem organ failure from sepsis or aspiration in 9 (45%) patients, followed by post-pancreatectomy hemorrhage in 5 (25%) patients, and cardiopulmonary arrest from myocardial infarction or pulmonary embolus in 3 (15%) patients. In contrast, recurrent cancer was the most common cause of death in 46 (65%) patients during the late postoperative period between 91 and 365 d. Mortality from failure to thrive and debility was similar between early and late postoperative periods (15% versus 19.7%, P = 0.76). CONCLUSIONS Most quality improvement initiatives in patients selected for pancreaticoduodenectomy have focused on reduction of technical complications and improvement of early postoperative mortality. Further reduction in postoperative mortality after pancreaticoduodenectomy can be achieved by improving patient selection, mitigating postoperative malnutrition, and optimizing preoperative cancer staging and management strategies.
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Affiliation(s)
- Sowmya Narayanan
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Allison N Martin
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Florence E Turrentine
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Surgery Outcomes Research Center, University of Virginia, Charlottesville, Virginia
| | - Todd W Bauer
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Division of Surgical Oncology, University of Virginia, Charlottesville, Virginia
| | - Reid B Adams
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Division of Surgical Oncology, University of Virginia, Charlottesville, Virginia
| | - Victor M Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, Virginia; Surgery Outcomes Research Center, University of Virginia, Charlottesville, Virginia; Division of Surgical Oncology, University of Virginia, Charlottesville, Virginia.
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Martin AN, Narayanan S, Turrentine FE, Bauer TW, Adams RB, Stukenborg GJ, Zaydfudim VM. Clinical Factors and Postoperative Impact of Bile Leak After Liver Resection. J Gastrointest Surg 2018; 22:661-667. [PMID: 29247421 PMCID: PMC5871550 DOI: 10.1007/s11605-017-3650-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [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: 09/28/2017] [Accepted: 11/28/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Despite technical advances, bile leak remains a significant complication after hepatectomy. The current study uses a targeted multi-institutional dataset to characterize perioperative factors that are associated with bile leakage after hepatectomy to better understand the impact of bile leak on morbidity and mortality. METHODS Adult patients in the 2014-2015 ACS NSQIP targeted hepatectomy dataset were linked to the ACS NSQIP PUF dataset. Bivariable and multivariable regression analyses were used to assess the associations between clinical factors and post-hepatectomy bile leak. RESULTS Of 6859 patients, 530 (7.7%) had a postoperative bile leak. Proportion of bile leaks was significantly greater in patients after major compared to minor hepatectomy (12.6 vs. 5.1%, p < 0.001). The proportion of patients with bile leak was significantly greater in patients after major hepatectomy who had concomitant enterohepatic reconstruction (31.8 vs. 10.1%, p < 0.001). Postoperative mortality was significantly greater in patients with bile leaks (6.0 vs. 1.7%, p < 0.001). After adjusting for significant covariates, bile leak was independently associated with increased risk of postoperative morbidity (OR = 4.55; 95% CI 3.72-5.56; p < 0.001). After adjusting for significant effects of postoperative complications, liver failure, and reoperation (all p<0.001), bile leak was not independently associated with increased risk of postoperative mortality (p = 0.262). CONCLUSION Major hepatectomy and enterohepatic biliary reconstruction are associated with significantly greater rates of bile leak after liver resection. Bile leak is independently associated with significant postoperative morbidity. Mitigation of bile leak is critical in reducing morbidity and mortality after liver resection.
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Affiliation(s)
- Allison N. Martin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Sowmya Narayanan
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Todd W. Bauer
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Reid B. Adams
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | | | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, VA, USA,Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA
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Zaydfudim VM, Stukenborg GJ. Effects of patient factors on inpatient mortality after complex liver, pancreatic and gastric resections. BJS Open 2018; 1:191-201. [PMID: 29951622 PMCID: PMC5989996 DOI: 10.1002/bjs5.33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 10/31/2017] [Indexed: 11/16/2022] Open
Abstract
Background There is mixed evidence that patients who receive care in hospitals with a low case volume for complex gastrointestinal and hepatobiliary operations have an increased risk of inpatient death. Methods A retrospective cohort study was performed of patients who had complex gastrointestinal and hepatobiliary operations in the Healthcare Cost and Utilization Project 2012 National Inpatient Sample. Multivariable weighted hierarchical generalized linear models were used to test the relationship between hospital case volume and probability of inpatient death, with detailed adjustments for the concurrent effects of differences in associated patient co‐morbidities. Results A total of 8260 pancreaticoduodenectomies, 2750 major hepatectomies and 3250 total gastrectomies were identified. Inpatient death occurred in 3·6 per cent of patients after pancreaticoduodenectomy, 4·9 per cent after major hepatectomy and 4·6 per cent after total gastrectomy. Mean hospital case volume was 50·6 (median 40) for pancreaticoduodenectomy, 23·6 (median 15) for major hepatectomy, 15·1 (median 10) for total gastrectomy and 70·2 (median 50) for any of the three operations. Hospital case volume was not a statistically significant predictor of mortality after any operation (all P ≥ 0·188). Patient characteristics including age and co‐morbidity were highly significant predictors of mortality (P < 0·001). No significant improvements in model performance were obtained by adding hospital case volume to any model that already included adjustments for patient‐level differences in age and co‐morbid disease, for any functional format (P ≥ 0·146 for all C statistic differences from baseline). Conclusion Patient co‐morbidity, not hospital case volume, was associated with significant differences in inpatient mortality following complex gastric, pancreatic and hepatobiliary resections.
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Affiliation(s)
- V M Zaydfudim
- Department of Surgery University of Virginia School of Medicine Charlottesville, Virginia USA.,Department of Surgical Outcomes Research Center University of Virginia School of Medicine Charlottesville, Virginia USA
| | - G J Stukenborg
- Department of Public Health Sciences University of Virginia School of Medicine Charlottesville, Virginia USA.,Department of Surgical Outcomes Research Center University of Virginia School of Medicine Charlottesville, Virginia USA
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Elwood NR, Martin AN, Turrentine FE, Jones RS, Zaydfudim VM. The negative effect of perioperative red blood cell transfusion on morbidity and mortality after major abdominal operations. Am J Surg 2018; 216:487-491. [PMID: 29475550 DOI: 10.1016/j.amjsurg.2018.02.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 01/30/2018] [Accepted: 02/05/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND This study aims to test associations between perioperative blood transfusion and postoperative morbidity and mortality after major abdominal operations. METHODS The 2014 ACS NSQIP dataset was queried for all patients who underwent one of the ten major abdominal operations. Separate multivariable regression models, were developed to evaluate the independent effects of perioperative blood transfusion on morbidity and mortality. RESULTS Of 48,854 patients in the study cohort, 4887 (10%) received a blood transfusion. Rates of transfusion ranged from 4% for laparoscopic gastrointestinal resection to 58% for open AAA. After adjusting for significant effects of NSQIP-estimated probabilities, transfusion was independently associated with morbidity and mortality after open AAA repair (OR = 1.99/14.4 respectively, p ≤ 0.010), esophagectomy (OR = 2.80/3.0, p < 0.001), pancreatectomy (OR = 1.88/3.01, p < 0.001), hepatectomy (OR = 2.82/5.78, p < 0.001), colectomy (OR = 2.15/3.17, p < 0.001), small bowel resection (OR = 2.81/3.83, p ≤ 0.004), and laparoscopic gastrointestinal operations (OR = 2.73/4.05, p < 0.001). CONCLUSIONS Perioperative blood transfusion is independently associated with an increased risk of morbidity and mortality after most major abdominal operations.
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Affiliation(s)
- Nathan R Elwood
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Allison N Martin
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Florence E Turrentine
- Department of Surgery, University of Virginia, Charlottesville, VA, USA; Surgery Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
| | - R Scott Jones
- Department of Surgery, University of Virginia, Charlottesville, VA, USA; Surgery Outcomes Research Center, University of Virginia, Charlottesville, VA, USA
| | - Victor M Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, VA, USA; Surgery Outcomes Research Center, University of Virginia, Charlottesville, VA, USA; Division of Surgical Oncology, University of Virginia, Charlottesville, VA, USA.
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Obeid JM, Kunk PR, Zaydfudim VM, Bullock TN, Slingluff CL, Rahma OE. Immunotherapy for hepatocellular carcinoma patients: is it ready for prime time? Cancer Immunol Immunother 2018; 67:161-174. [PMID: 29052780 PMCID: PMC11028155 DOI: 10.1007/s00262-017-2082-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 10/15/2017] [Indexed: 12/11/2022]
Abstract
Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and the second most common cause of cancer death worldwide. Current treatment options for patients with intermediate and advanced HCC are limited, and there is an unmet need for novel therapeutic approaches. HCC is an attractive target for immunomodulation therapy, since it arises in an inflammatory milieu due to hepatitis B and C infections and cirrhosis. However, a major barrier to the development and success of immunotherapy in patients with HCC is the liver's inherent immunosuppressive function. Recent advances in the field of cancer immunology allowed further characterization of immune cell subsets and function, and created new opportunities for therapeutic modulation of the immune system. In this review, we present the different immune cell subsets involved in potential immune modulation of HCC, discuss their function and clinical relevance, review the variety of immune therapeutic agents currently under investigation in clinical trials, and outline future research directions.
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Affiliation(s)
- Joseph M Obeid
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Paul R Kunk
- Division of Hematology-Oncology, Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | | | - Timothy N Bullock
- Department of Pathology, University of Virginia, Charlottesville, VA, USA
| | - Craig L Slingluff
- Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Osama E Rahma
- Department of Medical Oncology, Dana-Farber Cancer Institute Harvard Medical School, 450 Brookline Avenue, M1B13, Boston, MA, 02215, USA.
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Zaydfudim VM, Chapman WC, Nagorney DM. Challenges in patient selection for liver resection or transplantation in patients with hepatocellular carcinoma beyond Milan criteria. Hepatobiliary Surg Nutr 2017; 6:287-289. [PMID: 28848757 DOI: 10.21037/hbsn.2017.07.04] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Affiliation(s)
- Victor M Zaydfudim
- Division of Surgical Oncology, Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, VA, USA
| | - William C Chapman
- Department of Surgery, Section of Abdominal Transplantation, Washington University School of Medicine, St. Louis, MO, USA
| | - David M Nagorney
- Department of Surgery, Section of Hepatobiliary and Pancreas Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA
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Affiliation(s)
- Victor M Zaydfudim
- Section of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Shawn J Pelletier
- Charles O. Strickler Transplant Center, University of Virginia, Charlottesville, VA, USA
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Jolissaint JS, Langman LW, DeBolt CL, Tatum JA, Martin AN, Wang AY, Strand DS, Zaydfudim VM, Adams RB, Brayman KL. The impact of bacterial colonization on graft success after total pancreatectomy with autologous islet transplantation: considerations for early definitive surgical intervention. Clin Transplant 2016; 30:1473-1479. [PMID: 27623240 PMCID: PMC5183974 DOI: 10.1111/ctr.12842] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The purpose of this study was to determine whether bacterial contamination of islets affects graft success after total pancreatectomy with islet autotransplantation (TPIAT). BACKGROUND Factors associated with insulin independence after TPIAT are inconclusive. Although bacterial contamination does not preclude transplantation, the impact of bacterial contamination on graft success is unknown. METHODS Patients who received TPIAT at the University of Virginia between January 2007 and January 2016 were reviewed. Patient charts were reviewed for bacterial contamination and patients were prospectively contacted to assess rates of insulin independence. RESULTS There was no significant difference in demographic or perioperative data between patients who achieved insulin independence and those who did not. However, six of 27 patients analyzed (22.2%) grew bacterial contaminants from culture of the final islet preparations. These patients had significantly lower islet yield and C-peptide at most recent follow-up (P<.05), and none of these patients achieved insulin independence. CONCLUSIONS Islet transplant solutions are often culture positive, likely secondary to preprocurement pancreatic manipulation and introduction of enteric flora. Although autotransplantation of culture-positive islets is safe, it is associated with higher rates of graft failure and poor islet yield. Consideration should be given to identify patients who may develop refractory chronic pancreatitis and offer early operative management to prevent bacterial colonization.
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Affiliation(s)
| | - Linda W Langman
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Claire L DeBolt
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Jacob A Tatum
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Allison N Martin
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA
| | - Daniel S Strand
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, VA, USA
| | - Victor M Zaydfudim
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Reid B Adams
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Kenneth L Brayman
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA.
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Martin AN, Das D, Turrentine FE, Bauer TW, Adams RB, Zaydfudim VM. Morbidity and Mortality After Gastrectomy: Identification of Modifiable Risk Factors. J Gastrointest Surg 2016; 20:1554-64. [PMID: 27364726 PMCID: PMC4987171 DOI: 10.1007/s11605-016-3195-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [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: 03/22/2016] [Accepted: 06/20/2016] [Indexed: 01/31/2023]
Abstract
BACKGROUND Morbidity after gastrectomy remains high. The potentially modifiable risk factors have not been well described. This study considers a series of potentially modifiable patient-specific and perioperative characteristics that could be considered to reduce morbidity and mortality after gastrectomy. METHODS This retrospective cohort study includes adults in the ACS NSQIP PUF dataset who underwent gastrectomy between 2011 and 2013. Sequential multivariable models were used to estimate effects of clinical covariates on study outcomes including morbidity, mortality, readmission, and reoperation. RESULTS Three thousand six hundred and seventy-eight patients underwent gastrectomy. A majority of patients had distal gastrectomy (N = 2,799, 76.1 %) and had resection for malignancy (N = 2,316, 63.0 %). Seven hundred and ninety-eight patients (21.7 %) experienced a major complication. Reoperation was required in 290 patients (7.9 %). Thirty-day mortality was 5.2 %. Age (OR = 1.01, 95 % CI = 1.01-1.02, p = 0.001), preoperative malnutrition (OR = 1.65, 95 % CI = 1.35-2.02, p < 0.001), total gastrectomy (OR = 1.63, 95 % CI = 1.31-2.03, p < 0.001), benign indication for resection (OR = 1.60, 95 % CI = 1.29-1.97, p < 0.001), blood transfusion (OR = 2.57, 95 % CI = 2.10-3.13, p < 0.001), and intraoperative placement of a feeding tubes (OR = 1.28, 95 % CI = 1.00-1.62, p = 0.047) were independently associated with increased risk of morbidity. Association between tobacco use and morbidity was statistically marginal (OR = 1.23, 95 % CI = 0.99-1.53, p = 0.064). All-cause postoperative morbidity had significant associations with reoperation, readmission, and mortality (all p < 0.001). CONCLUSIONS Mitigation of perioperative risk factors including smoking and malnutrition as well as identified operative considerations may improve outcomes after gastrectomy. Postoperative morbidity has the strongest association with other measures of poor outcome: reoperation, readmission, and mortality.
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Affiliation(s)
- Allison N. Martin
- Department of Surgery, University of Virginia, Charlottesville, Virginia,Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA
| | - Deepanjana Das
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Florence E. Turrentine
- Department of Surgery, University of Virginia, Charlottesville, Virginia,Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA
| | - Todd W. Bauer
- Department of Surgery, University of Virginia, Charlottesville, Virginia,Division of Surgical Oncology, Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, Virginia
| | - Reid B. Adams
- Department of Surgery, University of Virginia, Charlottesville, Virginia,Division of Surgical Oncology, Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, Virginia
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, Virginia,Division of Surgical Oncology, Section of Hepatobiliary and Pancreatic Surgery, University of Virginia, Charlottesville, Virginia,Surgical Outcomes Research Center, University of Virginia, Charlottesville, VA
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Zaydfudim VM, Kerwin MJ, Turrentine FE, Bauer TW, Adams RB, Stukenborg GJ. The impact of chronic liver disease on the risk assessment of ACS NSQIP morbidity and mortality after hepatic resection. Surgery 2016; 159:1308-15. [DOI: 10.1016/j.surg.2015.11.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 11/09/2015] [Accepted: 11/25/2015] [Indexed: 12/23/2022]
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Abstract
IgG4-associated cholangitis can mimic hilar cholangiocarcinoma. Previously reported patients with IgG4-associated cholangitis mimicking cholangiocarcinoma had elevated serum IgG4 levels and long-segment biliary strictures. However, in the absence of other diagnostic criteria for malignancy, IgG4-associated cholangitis should remain a consideration among patients with normal serum IgG4 and a hilar mass suspicious for cholangiocarcinoma. The presence of a hilar mass and a malignant-appearing biliary stricture in two patients with normal serum IgG4 prompted further evaluation and subsequent concomitant liver and bile duct resection and reconstruction. The diagnosis of IgG4-associated cholangitis was established during the pathologic evaluation of the resected specimens. IgG4-associated cholangitis is a known imitator of hilar cholangiocarcinoma and should be considered in the differential diagnosis even among serologically IgG4-negative patients with a hilar mass prior to operative resection.
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Affiliation(s)
- Victor M Zaydfudim
- Section of Hepatobiliary and Pancreatic Surgery, Division of Surgical Oncology, USA
| | | | | | - Zimin Zhao
- Department of Pathology, University of Virginia, Charlottesville, VA, USA
| | | | - Todd W Bauer
- Section of Hepatobiliary and Pancreatic Surgery, Division of Surgical Oncology, USA
| | - Reid B Adams
- Section of Hepatobiliary and Pancreatic Surgery, Division of Surgical Oncology, USA
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Newhook TE, LaPar DJ, Walters DM, Gupta S, Jolissaint JS, Adams RB, Brayman KL, Zaydfudim VM, Bauer TW. Impact of Postoperative Venous Thromboembolism on Postoperative Morbidity, Mortality, and Resource Utilization after Hepatectomy. Am Surg 2015; 81:1216-23. [PMID: 26736156 DOI: pmid/26736156] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The impact of venous thromboembolism (VTE) after hepatectomy on patient morbidity, mortality, and resource usage remains poorly defined. Better understanding of thromboembolic complications is needed to improve perioperative management and overall outcomes. About 3973 patients underwent hepatectomy within NSQIP between 2005 and 2008. Patient characteristics, operative features, and postoperative correlates of VTE were compared with identify risk factors for VTE and to assess its overall impact on postoperative outcomes. Overall incidence of postoperative VTE was 2.4 per cent. Risk factors for postoperative VTE included older age, male gender, compromised functional status, degree of intraoperative blood transfusion, preoperative albumin level (all P < 0.05), and extent of hepatectomy (P = 0.004). Importantly, major postoperative complications, including acute renal failure, pneumonia, sepsis, septic shock, reintubation, prolonged ventilation, cardiac arrest, and reoperation were all associated with higher rates of VTE (all P < 0.05). Operative mortality was increased among patients with VTE (6.5% vs 2.4%, P = 0.03), and patients with VTE had a 2-fold increase in hospital length of stay (12.0 vs 6.0 days, P < 0.001). Postoperative VTE remains a significant source of morbidity, mortality, and increased resource usage after hepatectomy in the United States. Routine aggressive VTE prophylaxis measures are imperative to avoid development of VTE among patients requiring hepatectomy.
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Affiliation(s)
- Timothy E Newhook
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia, USA
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Newhook TE, Lapar DJ, Walters DM, Gupta S, Jolissaint JS, Adams RB, Brayman KL, Zaydfudim VM, Bauer TW. Impact of Postoperative Venous Thromboembolism on Postoperative Morbidity, Mortality, and Resource Utilization after Hepatectomy. Am Surg 2015. [DOI: 10.1177/000313481508101220] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The impact of venous thromboembolism (VTE) after hepatectomy on patient morbidity, mortality, and resource usage remains poorly defined. Better understanding of thromboembolic complications is needed to improve perioperative management and overall outcomes. About 3973 patients underwent hepatectomy within NSQIP between 2005 and 2008. Patient characteristics, operative features, and postoperative correlates of VTE were compared with identify risk factors for VTE and to assess its overall impact on postoperative outcomes. Overall incidence of postoperative VTE was 2.4 per cent. Risk factors for postoperative VTE included older age, male gender, compromised functional status, degree of intraoperative blood transfusion, preoperative albumin level (all P < 0.05), and extent of hepatectomy ( P = 0.004). Importantly, major postoperative complications, including acute renal failure, pneumonia, sepsis, septic shock, reintubation, prolonged ventilation, cardiac arrest, and reoperation were all associated with higher rates of VTE (all P < 0.05). Operative mortality was increased among patients with VTE (6.5% vs 2.4%, P = 0.03), and patients with VTE had a 2-fold increase in hospital length of stay (12.0 vs 6.0 days, P < 0.001). Postoperative VTE remains a significant source of morbidity, mortality, and increased resource usage after hepatectomy in the United States. Routine aggressive VTE prophylaxis measures are imperative to avoid development of VTE among patients requiring hepatectomy.
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Affiliation(s)
- Timothy E. Newhook
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Damien J. Lapar
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Dustin M. Walters
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Shruti Gupta
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Joshua S. Jolissaint
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Reid B. Adams
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Kenneth L. Brayman
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Victor M. Zaydfudim
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Todd W. Bauer
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
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Zaydfudim VM, McMurry TL, Harrigan AM, Friel CM, Stukenborg GJ, Bauer TW, Adams RB, Hedrick TL. Improving treatment and survival: a population-based study of current outcomes after a hepatic resection in patients with metastatic colorectal cancer. HPB (Oxford) 2015; 17:1019-24. [PMID: 26353888 PMCID: PMC4605341 DOI: 10.1111/hpb.12488] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Accepted: 07/01/2015] [Indexed: 12/12/2022]
Abstract
BACKGROUND Population-based studies historically report underutilization of a resection in patients with colorectal metastases to the liver. Recent data suggest limitations of the methods in the historical analysis. The present study examines trends in a hepatic resection and survival among Medicare recipients with hepatic metastases. METHODS Medicare recipients with incident colorectal cancer diagnosed between 1991 and 2009 were identified in the SEER(Surveillance, Epidemiology and End Results)-Medicare dataset. Patients were stratified into historical (1991-2001) and current (2002-2009) cohorts. Analyses compared treatment, peri-operative outcomes and survival. RESULTS Of 31.574 patients with metastatic colorectal cancer to the liver, 14,859 were in the current cohort treated after 2002 and 16,715 comprised the historical control group. The overall proportion treated with a hepatic resection increased significantly during the study period (P < 0.001) with pre/post change from 6.5% pre-2002 to 7.5% currently (P < 0.001). Over time, haemorrhagic and infectious complications declined (both P ≤ 0.047), but 30-day mortality was similar (3.5% versus 3.9%, P = 0.660). After adjusting for predictors of survival, the use of a hepatic resection [hazard ratio (HR) = 0.40, 95% confidence interval (CI): 0.38-0.42, P < 0.001] and treatment after 2002 (HR = 0.88, 95% CI: 0.86-0.90, P < 0.001) were associated with a reduced risk of death. CONCLUSIONS Case identification using International Classification of Diseases, 9th Revision (ICD-9) codes is imperfect; however, comparison of trends over time suggests an improvement in multimodality therapy and survival in patients with colorectal metastases to the liver.
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Affiliation(s)
- Victor M Zaydfudim
- Section of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of VirginiaCharlottesville, VA, USA,Surgical Outcomes Research Center, University of VirginiaCharlottesville, VA, USA
| | - Timothy L McMurry
- Surgical Outcomes Research Center, University of VirginiaCharlottesville, VA, USA,Department of Public Health Sciences, University of VirginiaCharlottesville, VA, USA
| | - Amy M Harrigan
- Surgical Outcomes Research Center, University of VirginiaCharlottesville, VA, USA,Section of Colorectal Surgery, Department of Surgery, University of VirginiaCharlottesville, VA, USA
| | - Charles M Friel
- Section of Colorectal Surgery, Department of Surgery, University of VirginiaCharlottesville, VA, USA
| | - George J Stukenborg
- Surgical Outcomes Research Center, University of VirginiaCharlottesville, VA, USA,Department of Public Health Sciences, University of VirginiaCharlottesville, VA, USA
| | - Todd W Bauer
- Section of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of VirginiaCharlottesville, VA, USA
| | - Reid B Adams
- Section of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of VirginiaCharlottesville, VA, USA
| | - Traci L Hedrick
- Surgical Outcomes Research Center, University of VirginiaCharlottesville, VA, USA,Section of Colorectal Surgery, Department of Surgery, University of VirginiaCharlottesville, VA, USA
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Newhook TE, LaPar DJ, Lindberg JM, Bauer TW, Adams RB, Zaydfudim VM. Morbidity and mortality of hepatectomy for benign liver tumors. Am J Surg 2015; 211:102-8. [PMID: 26307421 DOI: 10.1016/j.amjsurg.2015.06.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [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: 10/28/2014] [Revised: 05/29/2015] [Accepted: 06/01/2015] [Indexed: 12/22/2022]
Abstract
BACKGROUND This study compared the morbidity and mortality following hepatectomy for benign liver tumors and hepatic metastases. METHODS This retrospective cohort study compared patients who underwent hepatectomy for benign liver tumors and metastases reported to National Surgical Quality Improvement Program between 2005 and 2011. RESULTS A total of 5,542 patients underwent hepatectomy: 1,164 (21%) for benign and 4,378 (79%) for metastatic diseases. Patients with benign tumors were younger, predominantly female, and were less likely to have preoperative comorbidities (all P < .037). Rates of major complications including infections, embolism, renal failure, stroke, coma, cardiac arrest, reoperation, and ventilator dependence were similar between the 2 groups (all P ≥ .05). Thirty-day mortality was .9% among patients with benign tumors and 1.4% among patients with metastases (P = .128). After adjusting for significant effects of age and major complications (both P ≤ .007), benign vs malignant diagnosis and extent of hepatectomy was not associated with 30-day survival (both P ≥ .083). CONCLUSIONS Despite patients with benign disease being younger and healthier, risks of major complications are similar after hepatectomy for benign and metastatic disease. Hepatectomy should be offered selectively for patients with benign liver tumors.
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Affiliation(s)
- Timothy E Newhook
- Section of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Virginia Health System, Box 800709, 1215 Lee Street, Charlottesville, VA 22908, USA
| | - Damien J LaPar
- Section of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Virginia Health System, Box 800709, 1215 Lee Street, Charlottesville, VA 22908, USA
| | - James M Lindberg
- Section of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Virginia Health System, Box 800709, 1215 Lee Street, Charlottesville, VA 22908, USA
| | - Todd W Bauer
- Section of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Virginia Health System, Box 800709, 1215 Lee Street, Charlottesville, VA 22908, USA
| | - Reid B Adams
- Section of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Virginia Health System, Box 800709, 1215 Lee Street, Charlottesville, VA 22908, USA
| | - Victor M Zaydfudim
- Section of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Virginia Health System, Box 800709, 1215 Lee Street, Charlottesville, VA 22908, USA.
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Newhook TE, LaPar DJ, Lindberg JM, Bauer TW, Adams RB, Zaydfudim VM. Morbidity and mortality of pancreaticoduodenectomy for benign and premalignant pancreatic neoplasms. J Gastrointest Surg 2015; 19:1072-7. [PMID: 25801594 DOI: 10.1007/s11605-015-2799-y] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 03/08/2015] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Patients with benign neoplasms of the pancreas are selected for pancreaticoduodenectomy if there is concern for malignant transformation. This study compares outcomes after pancreaticoduodenectomy for patients with premalignant and malignant pancreatic neoplasms. STUDY DESIGN This retrospective cohort study included all patients who underwent pancreaticoduodenectomy for histologically confirmed benign/premalignant pancreatic neoplasms and primary pancreatic malignancy reported to National Surgical Quality Improvement Program (NSQIP) from 2005 to 2011. Patient characteristics, intraoperative and postoperative morbidity and mortality were compared. RESULTS A total of 6085 patients underwent pancreaticoduodenectomy: 744 (12.2 %) for benign/premalignant and 5341 (87.8 %) for malignant pancreatic neoplasms. Patients with benign/premalignant neoplasms were more commonly female, had lower American Society of Anesthesiologists (ASA) class, and were less likely to have major comorbidities (all p ≤ 0.003). After resection, patients with benign/premalignant neoplasms were more likely to develop organ space infection (13.4 vs. 8.5 %, p < 0.001) and sepsis (12.2 vs. 9.2 %, p = 0.009). Cardiovascular, pulmonary, renal, and other organ system complications (p = 0.12) as well as 30-day mortality (3.0 vs. 2.0 %, p = 0.128) did not differ. CONCLUSIONS Organ space infection and sepsis are more common after pancreaticoduodenectomy for benign/premalignant neoplasms. Planned improvements in NSQIP data capture should allow for better measurement of this morbidity. A carefully balanced risk and benefit discussion should precede resection in these patients.
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Affiliation(s)
- Timothy E Newhook
- Section of Hepatobiliary and Pancreatic Surgery, Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
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Abstract
Optimal treatment of hilar cholangiocarcinoma depends on location of the cancer and extent of biliary and vascular involvement. Candidates for resection or transplantation must be evaluated and managed by a multidisciplinary team at a high-volume hepatobiliary center. Success requires absence of distant nodal or extrahepatic metastases and an adequate functional liver remnant with a negative ductal margin. Ipsilateral portal vein resection and reconstruction should be performed in patients with venous involvement. Neoadjuvant chemoradiation and liver transplantation is the best treatment option for patients with unresectable hilar cholangiocarcinoma without nodal or distant metastases and for patients with underlying chronic liver disease.
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Affiliation(s)
- Victor M Zaydfudim
- Department of Surgery, University of Virginia, 1300 Jefferson Park Avenue, Charlottesville, VA 22908, USA
| | - Charles B Rosen
- Division of Transplantation Surgery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - David M Nagorney
- Department of Surgery, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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Parikh AA, Robinson J, Zaydfudim VM, Penson D, Whiteside MA. The effect of health insurance status on the treatment and outcomes of patients with colorectal cancer. J Surg Oncol 2014; 110:227-32. [DOI: 10.1002/jso.23627] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Accepted: 03/21/2014] [Indexed: 01/07/2023]
Affiliation(s)
- Alexander A. Parikh
- Division of Surgical Oncology; Department of Surgery; Vanderbilt University School of Medicine; Nashville Tennessee
| | - Jamie Robinson
- Division of Surgical Oncology; Department of Surgery; Vanderbilt University School of Medicine; Nashville Tennessee
| | - Victor M. Zaydfudim
- Division of Surgical Oncology; Department of Surgery; University of Virginia; Charlottesville Virginia
| | - David Penson
- Department of Urologic Surgery; Vanderbilt University School of Medicine; Nashville Tennessee
- Geriatric Research Education and Clinical Center; VA Tennessee Valley Healthcare System; Nashville Tennessee
| | - Martin A. Whiteside
- Tennessee Cancer Registry; Office of Cancer Surveillance; Tennessee Department of Health; Nashville Tennessee
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Zaydfudim VM, Smoot RL, Nagorney DM. What is the role of bone marrow-derived stem cells in hepatic hypertrophy after portal vein embolization? Ann Surg 2013; 261:e25-6. [PMID: 24368660 DOI: 10.1097/sla.0000000000000423] [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: 11/25/2022]
Affiliation(s)
- Victor M Zaydfudim
- Department of Surgery, University of Virginia, Charlottesville, VA Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN,
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Zaydfudim VM, Clark CJ, Kendrick ML, Que FG, Reid-Lombardo KM, Donohue JH, Farnell MB, Nagorney DM. Correlation of staging systems to survival in patients with resected hilar cholangiocarcinoma. Am J Surg 2013. [PMID: 23746658 DOI: 10.1016/j.amjsurg.2012.11020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND We aimed to identify staging parameters associated with survival in patients with hilar cholangiocarcinoma. METHODS Clinicopathologic characteristics were obtained retrospectively for all resected patients with Bismuth-Corlette III cholangiocarcinoma between 1993 and 2011. Patients were stratified by the American Joint Commission on Cancer (AJCC) (7th edition) and Memorial Sloan-Kettering Cancer Center (MSKCC) staging systems. Survival analyses tested the effects of clinicopathologic factors and staging covariates on recurrence-free and overall survival. RESULTS Eighty patients (mean age 63 ± 11 years, 63% male) underwent anatomic hepatectomy with bile duct resection/reconstruction for Bismuth-Corlette IIIa (53%) and IIIb (47%) cholangiocarcinoma. The median follow-up was 26 months (interquartile range = 12 to 50 months), and the median time to recurrence was 15 months (interquartile range = 6 to 38 months). Neither AJCC nor MSKCC staging systems were associated with recurrence-free survival (all P ≥ .059). MSKCC T-stage but not the AJCC staging system was associated with overall survival (P ≤ .026). CONCLUSIONS MSKCC T-stage classification but not AJCC staging is independently associated with overall survival for patients after resection of hilar cholangiocarcinoma.
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Affiliation(s)
- Victor M Zaydfudim
- Division of Gastroenterologic and General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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