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Dhimal T, Loria A, Juviler P, Hilty BK, Levatino E, Schiralli MP, Fleming FJ. Quality improvement in surgical collaboratives: Characterizing resources and care variation to facilitate implementation and dissemination. Surgery 2024:S0039-6060(24)00195-8. [PMID: 38729886 DOI: 10.1016/j.surg.2024.03.030] [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: 01/02/2024] [Revised: 03/04/2024] [Accepted: 03/21/2024] [Indexed: 05/12/2024]
Affiliation(s)
- Totadri Dhimal
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Anthony Loria
- Department of Surgery, University of Rochester Medical Center, Rochester, NY.
| | - Peter Juviler
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Bailey K Hilty
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Elizabeth Levatino
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | | | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
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Melucci AD, Loria A, Aquina CT, McDonald G, Schymura MJ, Schiralli MP, Cupertino A, Temple LK, Ramsdale E, Fleming FJ. New Onset Geriatric Syndromes and One-year Outcomes Following Elective Gastrointestinal Cancer Surgery. Ann Surg 2024; 279:781-788. [PMID: 37782132 DOI: 10.1097/sla.0000000000006108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
OBJECTIVE To assess whether older adults who develop geriatric syndromes following elective gastrointestinal surgery have poorer 1-year outcomes. BACKGROUND Within 10 years, 70% of all cancers will occur in older adults ≥65 years old. The rise in older adults requiring major surgery has brought attention to age-related complications termed geriatric syndromes. However, whether postoperative geriatric syndromes are associated with long-term outcomes is unclear. METHODS A population-based retrospective cohort study using the New York State Cancer Registry and the Statewide Planning and Research Cooperative System was performed including patients >55 years with pathologic stage I-III esophageal, gastric, pancreatic, colon, or rectal cancer who underwent elective resection between 2004 and 2018. Those aged 55 to 64 served as the reference group. The exposure of interest was a geriatric syndrome [fracture, fall, delirium, pressure ulcer, depression, malnutrition, failure to thrive, dehydration, or incontinence (urinary/fecal)] during the surgical admission. Patients with any geriatric syndrome within 1 year of surgery were excluded. Outcomes included incident geriatric syndrome, 1-year days alive and out of the hospital, and 1-year all-cause mortality. RESULTS In this study, 37,998 patients with a median age of 71 years without a prior geriatric syndrome were included. Of those 65 years or more, 6.4% developed a geriatric syndrome. Factors associated with an incident geriatric syndrome were age, alcohol/tobacco use, comorbidities, neoadjuvant therapy, ostomies, open surgery, and upper gastrointestinal cancers. An incident geriatric syndrome was associated with a 43% higher risk of 1-year mortality (hazard ratio, 1.43; 95% confidence interval, 1.27-1.60). For those aged 65+ discharged alive and not to hospice, a geriatric syndrome was associated with significantly fewer days alive and out of hospital (322 vs 346 days, P < 0.0001). There was an indirect relationship between the number of geriatric syndromes and 1-year mortality and days alive and out of the hospital after adjusting for surgical complications. CONCLUSIONS Given the increase in older adults requiring major surgical intervention, and the establishment of geriatric surgery accreditation programs, these data suggest that morbidity and mortality metrics should be adjusted to accommodate the independent relationship between geriatric syndromes and long-term outcomes.
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Affiliation(s)
- Alexa D Melucci
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Anthony Loria
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Christopher T Aquina
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY
- Surgical Health Outcomes Consortium, Digestive Health and Surgery Institute, Advent Health Orlando, Orlando, FL
| | - Gabriela McDonald
- School of Medicine and Dentistry, University of Rochester, Rochester, NY
| | - Maria J Schymura
- New York State Cancer Registry, New York State Department of Health, Albany, NY
| | | | - AnaPaula Cupertino
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Larissa K Temple
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Erika Ramsdale
- Hematology/Oncology, University of Rochester Medical Center, Rochester, NY
| | - Fergal J Fleming
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY
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Loria A, Ramsdale EE, Aquina CT, Cupertino P, Mohile SG, Fleming FJ. From Clinical Trials to Practice: Anticipating and Overcoming Challenges in Implementing Watch-and-Wait for Rectal Cancer. J Clin Oncol 2024; 42:876-880. [PMID: 38315943 DOI: 10.1200/jco.23.01369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 11/10/2023] [Accepted: 12/12/2023] [Indexed: 02/07/2024] Open
Affiliation(s)
- Anthony Loria
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Erika E Ramsdale
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | - Christopher T Aquina
- Departments of Colorectal Surgery and Surgical Oncology, AdventHealth Orlando, Orlando, FL
| | - Paula Cupertino
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Supriya G Mohile
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
- James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, NY
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LaGuardia JS, Milek D, Lebens RS, Chen DR, Moghadam S, Loria A, Langstein HN, Fleming FJ, Leckenby JI. A Scoping Review of Quality-of-Life Assessments Employed in Abdominal Wall Reconstruction. J Surg Res 2024; 295:240-252. [PMID: 38041903 DOI: 10.1016/j.jss.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/08/2023] [Accepted: 10/27/2023] [Indexed: 12/04/2023]
Abstract
INTRODUCTION Surgeons use several quality-of-life instruments to track outcomes following abdominal wall reconstruction (AWR); however, there is no universally agreed upon instrument. We review the instruments used in AWR and report their utilization trends within the literature. METHODS This scoping review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews guidelines using the PubMed, Embase, Web of Science, ClinicalTrials.gov, and Cochrane databases. All published articles in the English language that employed a quality-of-life assessment for abdominal wall hernia repair were included. Studies which focused solely on aesthetic abdominoplasty, autologous breast reconstruction, rectus diastasis, pediatric patients, inguinal hernia, or femoral hernias were excluded. RESULTS Six hernia-specific tools and six generic health tools were identified. The Hernia-Related Quality-of-Life Survey and Carolinas Comfort Scale are the most common hernia-specific tools, while the Short-Form 36 (SF-36) is the most common generic health tool. Notably, the SF-36 is also the most widely used tool for AWR outcomes overall. Each tool captures a unique set of patient outcomes which ranges from abdominal wall functionality to mental health. CONCLUSIONS The outcomes of AWR have been widely studied with several different assessments proposed and used over the past few decades. These instruments allow for patient assessment of pain, quality of life, functional status, and mental health. Commonly used tools include the Hernia-Related Quality-of-Life Survey, Carolinas Comfort Scale, and SF-36. Due to the large heterogeneity of available instruments, future work may seek to determine or develop a standardized instrument for characterizing AWR outcomes.
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Affiliation(s)
- Jonnby S LaGuardia
- Department of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Rochester, New York.
| | - David Milek
- Department of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Rochester, New York
| | - Ryan S Lebens
- Department of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Rochester, New York
| | - David R Chen
- Department of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Rochester, New York
| | - Shahrzad Moghadam
- Department of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Rochester, New York
| | - Anthony Loria
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Howard N Langstein
- Department of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Rochester, New York
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Jonathan I Leckenby
- Department of Plastic and Reconstructive Surgery, University of Rochester Medical Center, Rochester, New York
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Loria A, Cai X, Gao S, Zhao T, Juviler P, Li Y, Cupertino P, Fleming FJ. Development and validation of multivariable predictive models for recurrence and mortality following nonoperative management of sigmoid volvulus. Colorectal Dis 2024; 26:356-363. [PMID: 38151763 DOI: 10.1111/codi.16849] [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: 07/20/2023] [Revised: 10/10/2023] [Accepted: 11/13/2023] [Indexed: 12/29/2023]
Abstract
AIM Sigmoid volvulus is a challenging condition, and deciding between elective surgery or expectant management can be complex. The aim of this study was to develop a tool for predicting the risk of recurrent sigmoid volvulus and all-cause mortality within 1 year following initial nonoperative management. METHOD This is a retrospective cohort study using Medicare claims data from 2016 to 2018 of beneficiaries admitted urgently/emergently for volvulus, undergoing colonic decompression and discharged alive without surgery (excluding those discharged to hospice). The primary outcomes were recurrent sigmoid volvulus and all-cause mortality within 1 year. Proportional hazards models and logistic regression were employed to identify risk factors and develop prediction equations, which were subsequently validated. RESULTS Among the 2078 patients managed nonoperatively, 36.1% experienced recurrent sigmoid volvulus and 28.6% died within 1 year. The prediction model for recurrence integrated age, sex, race, palliative care consultations and four comorbidities, achieving area under the curve values of 0.63 in both the training and testing samples. The model for mortality incorporated age, palliative care consultations and nine comorbidities, with area under the curve values of 0.76 in the training and 0.70 in the testing sample. CONCLUSION This study provides a straightforward predictive tool that utilizes easily accessible data to estimate individualized risks of recurrent sigmoid volvulus and all-cause mortality for older adults initially managed nonoperatively. The tool can assist clinicians and patients in making informed decisions about such risks. While the accuracy of the calculator was validated, further confirmation through external validation and prospective studies would enhance its clinical utility.
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Affiliation(s)
- Anthony Loria
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York, USA
| | - Shan Gao
- Department of Biostatistics and Computational Biology, University of Rochester, Rochester, New York, USA
| | - Tony Zhao
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Peter Juviler
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Yue Li
- Division of Health Policy and Outcomes Research, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Paula Cupertino
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Fergal J Fleming
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
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Norris P, Gow J, Arthur T, Conway A, Fleming FJ, Ralph N. Metabolic syndrome and surgical complications: a systematic review and meta-analysis of 13 million individuals. Int J Surg 2024; 110:541-553. [PMID: 37916943 PMCID: PMC10793842 DOI: 10.1097/js9.0000000000000834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/28/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Metabolic syndrome (MetS) is characterised by the presence of at least three of the five following components: insulin resistance, obesity, chronic hypertension, elevated serum triglycerides, and decreased high-density lipoprotein cholesterol concentrations. It is estimated to affect 1 in 3 people around the globe and is reported to affect 46% of surgical patients. For people with MetS who undergo surgery, an emerging body of literature points to significantly poorer postoperative outcomes compared with nonaffected populations. The aim of this study is to review the current evidence on the risks of surgical complications in patients with MetS compared to those without MetS. METHODS Systematic review and meta-analysis using PRISMA and AMSTAR reporting guidelines. RESULTS The meta-analysis included 63 studies involving 1 919 347 patients with MetS and 11 248 114 patients without MetS. Compared to individuals without the condition, individuals with MetS were at an increased risk of mortality (OR 1.75 95% CI: 1.36-2.24; P <0.01); all surgical site infection types as well as dehiscence (OR 1.64 95% CI: 1.52-1.77; P <0.01); cardiovascular complications (OR 1.56 95% CI: 1.41-1.73; P <0.01) including myocardial infarction, stroke, cardiac arrest, cardiac arrythmias and deep vein thrombosis; increased length of hospital stay (MD 0.65 95% CI: 0.39-0.9; P <0.01); and hospital readmission (OR 1.55 95% CI: 1.41-1.71; P <0.01). CONCLUSION MetS is associated with a significantly increased risk of surgical complications including mortality, surgical site infection, cardiovascular complications, increased length of stay, and hospital readmission. Despite these risks and the high prevalence of MetS in surgical populations there is a lack of evidence on interventions for reducing surgical complications in patients with MetS. The authors suggest prioritising interventions across the surgical continuum that include (1) preoperative screening for MetS; (2) surgical prehabilitation; (3) intraoperative monitoring and management; and (4) postoperative rehabilitation and follow-up.
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Affiliation(s)
- Philip Norris
- School of Nursing and Midwifery, University of Southern Queensland, Australia
| | - Jeff Gow
- School of Commerce, University of Southern Queensland, Toowoomba, Australia
- Senior Research Associate, School of Accounting, Economics and Finance, University of KwaZulu- Natal, Durban, South Africa
| | - Thomas Arthur
- Department of Surgery and Adjunct Professor, Toowoomba Hospital, Centre for Health Research, University of Southern Queensland, Toowoomba, Australia
| | - Aaron Conway
- Peter Munk Cardiac Centre, University Health Network, Toronto, Canada, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
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Loria A, Tejani MA, Temple LK, Justiniano CF, Melucci AD, Becerra AZ, Monson JRT, Aquina CT, Fleming FJ. Practice Patterns for Organ Preservation in US Patients With Rectal Cancer, 2006-2020. JAMA Oncol 2024; 10:79-86. [PMID: 37943566 PMCID: PMC10636650 DOI: 10.1001/jamaoncol.2023.4845] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/08/2023] [Indexed: 11/10/2023]
Abstract
Importance In March 2023, the National Comprehensive Cancer Network endorsed watch and wait for those with complete clinical response to total neoadjuvant therapy. Neoadjuvant therapy is highly efficacious, so this recommendation may have broad implications, but the current trends in organ preservation in the US are unknown. Objective To describe organ preservation trends among patients with rectal cancer in the US from 2006 to 2020. Design, Setting, and Participants This retrospective, observational case series included adults (aged ≥18 years) with rectal adenocarcinoma managed with curative intent from 2006 to 2020 in the National Cancer Database. Exposure The year of treatment was the primary exposure. The type of therapy was chemotherapy, radiation, or surgery (proctectomy, transanal local excision, no tumor resection). The timing of therapy was classified as neoadjuvant or adjuvant. Main Outcomes and Measures The primary outcome was the absolute annual proportion of organ preservation after radical treatment, defined as chemotherapy and/or radiation without tumor resection, proctectomy, or transanal local excision. A secondary analysis examined complete pathologic responses among eligible patients. Results Of the 175 545 patients included, the mean (SD) age was 63 (13) years, 39.7% were female, 17.4% had clinical stage I disease, 24.7% had stage IIA to IIC disease, 32.1% had stage IIIA to IIIC disease, and 25.7% had unknown stage. The absolute annual proportion of organ preservation increased by 9.8 percentage points (from 18.4% in 2006 to 28.2% in 2020; P < .001). From 2006 to 2020, the absolute rate of organ preservation increased by 13.0 percentage points for patients with stage IIA to IIC disease (19.5% to 32.5%), 12.9 percentage points for patients with stage IIIA to IIC disease (16.2% to 29.1%), and 10.1 percentage points for unknown stages (16.5% to 26.6%; all P < .001). Conversely, patients with stage I disease experienced a 6.1-percentage point absolute decline in organ preservation (from 26.4% in 2006 to 20.3% in 2020; P < .001). The annual rate of transanal local excisions decreased for all stages. In the subgroup of 80 607 eligible patients, the proportion of complete pathologic responses increased from 6.5% in 2006 to 18.8% in 2020 (P < .001). Conclusions and Relevance This case series shows that rectal cancer is increasingly being managed medically, especially among patients whose treatment historically relied on proctectomy. Given the National Comprehensive Cancer Network endorsement of watch and wait, the increasing trends in organ preservation, and the nearly 3-fold increase in complete pathologic responses, international professional societies should urgently develop multidisciplinary core outcome sets and care quality indicators to ensure high-quality rectal cancer research and care delivery accounting for organ preservation.
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Affiliation(s)
- Anthony Loria
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | | | - Larissa K. Temple
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Carla F. Justiniano
- Division of Colon and Rectal Surgery, Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Alexa D. Melucci
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Adan Z. Becerra
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - John R. T. Monson
- Departments of Colorectal Surgery and Surgical Oncology, AdventHealth Orlando, Orlando, Florida
| | - Christopher T. Aquina
- Departments of Colorectal Surgery and Surgical Oncology, AdventHealth Orlando, Orlando, Florida
| | - Fergal J. Fleming
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York
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Loria A, Fleming FJ. Restoration of Quality of Life and Functional Recovery After Colorectal Cancer Surgery in Older Adults. J Clin Oncol 2023; 41:5225-5227. [PMID: 37390379 DOI: 10.1200/jco.23.01066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 05/31/2023] [Indexed: 07/02/2023] Open
Affiliation(s)
- Anthony Loria
- Department of Surgery, University of Rochester Medial Center, Rochester, NY
| | - Fergal J Fleming
- Department of Surgery and Oncology, University of Rochester Medical Center, Rochester, NY
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Melucci AD, Flodman K, Loria A, Swanson HL, Robinson MK, Hasselberg MJ, Evans L, Temple LK, Fleming FJ. Is there an outcome benefit? Patient engagement technology in addition to the electronic medical record patient portal following elective colorectal surgery. Surg Endosc 2023; 37:9275-9282. [PMID: 37880445 DOI: 10.1007/s00464-023-10478-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 09/17/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Patient engagement technologies (PET) are an area of growing innovation and investment, but whether PET use in the setting of electronic medical record (EMR) supported patient portals are associated with improved outcomes is unknown. Therefore, we assessed PET and EMR activation among patients undergoing elective colorectal surgery on an enhanced recovery pathway. METHODS We identified adults undergoing elective colorectal surgery between 1/2017 and 7/2021. EMR activations were assessed and patients were considered PET users if they used a proprietary PET application. Multivariable logistic regression was used to identify factors associated with PET use and determine whether the level of engagement (percentage of messages read by the patient) was associated with 30-day outcomes. RESULTS 484 patients (53.5% PET users, 81.6% with an activated EMR patient portal, 30.8% ≥ 70 years of age) were included. PET users were younger, more likely to have their EMR portal activated and had decreased odds of prolonged length of stay [odds ratio (OR) 0.5, 95% confidence interval (CI) 0.4-0.8]. Among patients ≥ 70 years, PET users had reduced odds of readmissions (OR 0.2, 95% CI 0.1-0.9) compared to PET non-users. The most engaged PET users had decreased morbidity (OR 0.2, 95% CI 0.1-0.8) and readmissions (OR 0.3, 95% CI 0.1-0.8) compared to the least engaged PET users. CONCLUSION When controlling for EMR activation, patients who use PET, specifically those with higher levels of engagement or aged ≥ 70, have improved outcomes following elective colorectal surgery. Interventions aimed at increasing the adoption of PET among older adults may be warranted.
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Affiliation(s)
- Alexa D Melucci
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA.
- Surgical Health Outcomes & Research Enterprise (SHORE), The University of Rochester Medical Center, Saunders Research Building, Suite 124003, 265 Crittenden Blvd, Rochester, NY, 14642, USA.
| | - Kiersten Flodman
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, 14642, USA
| | - Anthony Loria
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Holli L Swanson
- Division of Colorectal Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Mary K Robinson
- Division of Colorectal Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Michael J Hasselberg
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Lara Evans
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Larissa K Temple
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
- Division of Colorectal Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Fergal J Fleming
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
- Division of Colorectal Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
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Melucci AD, Loria A, Swanson H, White Q, Moalem J, Fleming FJ, Temple LK. Are postoperative opioid stewardship protocols sustainable? Results from a 2-year quality improvement project. Surgery 2023; 174:517-523. [PMID: 37407396 DOI: 10.1016/j.surg.2023.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 04/28/2023] [Accepted: 05/24/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Opioid stewardship protocols reduce opioid overprescription, but many require corrective action within 1 year. Because there are limited data on the sustainability of opioid reduction protocols, we sought to evaluate prescribing trends beyond 1 year. METHODS We reviewed prescribing data from a tertiary care center to establish a consensus discharge opioid-prescribing guideline. Subsequently, we performed a prospective quality-improvement study for patients on an enhanced recovery protocol undergoing elective colectomies, proctectomies, and stoma-related procedures. We gathered process (protocol compliance), balance (rates of patient-controlled analgesia and nerve blocks, inpatient opioid utilization, pain scores within 48 hours of discharge), and clinical measures (median discharge opioid pills, postdischarge day 7 satisfaction). RESULTS In total, 1,049 patients with similar ages, operative indications, and rates of substance use pre- and postintervention were included. Over 2 years, compliance was 88.6%, and there was a 43.6% reduction in the total discharge number of opioid pills. Phone calls for opioid refills were stable (10.2% pre- vs 7.8% postintervention, P = .16), and the following all decreased significantly: intraoperative nerve blocks, patient-controlled analgesia use, and final 48-hour and total median inpatient opioid use. There was a clinically negligible, statistically significant reduction in pain scores within 48 hours of discharge. Fifty patients provided satisfaction data, and 92% were satisfied or somewhat satisfied with their analgesia. CONCLUSION Over 2 years, reduced opioid prescribing was maintained without escalating resources. Sustainability suggests that after successfully implementing an opioid reduction protocol, institutions may safely redeploy quality improvement resources elsewhere.
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Affiliation(s)
- Alexa D Melucci
- Surgical Health Outcomes Research Enterprise, Department of Surgery, University of Rochester Medical Center, NY; Department of Surgery, University of Rochester Medical Center, NY.
| | - Anthony Loria
- Surgical Health Outcomes Research Enterprise, Department of Surgery, University of Rochester Medical Center, NY; Department of Surgery, University of Rochester Medical Center, NY. http://www.twitter.com/apl2018
| | - Holli Swanson
- Department of Surgery, University of Rochester Medical Center, NY
| | - Quarnisha White
- Department of Surgery, University of Rochester Medical Center, NY
| | - Jacob Moalem
- Department of Surgery, University of Rochester Medical Center, NY. http://www.twitter.com/jacobmoalem
| | - Fergal J Fleming
- Surgical Health Outcomes Research Enterprise, Department of Surgery, University of Rochester Medical Center, NY; Department of Surgery, University of Rochester Medical Center, NY. http://www.twitter.com/fergaljfleming
| | - Larissa K Temple
- Surgical Health Outcomes Research Enterprise, Department of Surgery, University of Rochester Medical Center, NY; Department of Surgery, University of Rochester Medical Center, NY
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Uccello TP, Lesch ML, Kintzel SA, Gradzewicz LB, Lamrous L, Murphy SP, Fleming FJ, Mills BN, Murphy JD, Hughson A, Hannon G, Garrett-Larsen J, Qiu H, Drage MG, Ye J, Gavras NW, Keeley DC, Love TMT, Repasky EA, Lord EM, Linehan DC, Gerber SA. New insights into the responder/nonresponder divide in rectal cancer: Damage-induced Type I IFNs dictate treatment efficacy and can be targeted to enhance radiotherapy. Cell Death Dis 2023; 14:470. [PMID: 37495596 PMCID: PMC10372053 DOI: 10.1038/s41419-023-05999-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 06/13/2023] [Accepted: 07/13/2023] [Indexed: 07/28/2023]
Abstract
Rectal cancer ranks as the second leading cause of cancer-related deaths. Neoadjuvant therapy for rectal cancer patients often results in individuals that respond well to therapy and those that respond poorly, requiring life-altering excision surgery. It is inadequately understood what dictates this responder/nonresponder divide. Our major aim is to identify what factors in the tumor microenvironment drive a fraction of rectal cancer patients to respond to radiotherapy. We also sought to distinguish potential biomarkers that would indicate a positive response to therapy and design combinatorial therapeutics to enhance radiotherapy efficacy. To address this, we developed an orthotopic murine model of rectal cancer treated with short course radiotherapy that recapitulates the bimodal response observed in the clinic. We utilized a robust combination of transcriptomics and protein analysis to identify differences between responding and nonresponding tumors. Our mouse model recapitulates human disease in which a fraction of tumors respond to radiotherapy (responders) while the majority are nonresponsive. We determined that responding tumors had increased damage-induced cell death, and a unique immune-activation signature associated with tumor-associated macrophages, cancer-associated fibroblasts, and CD8+ T cells. This signature was dependent on radiation-induced increases of Type I Interferons (IFNs). We investigated a therapeutic approach targeting the cGAS/STING pathway and demonstrated improved response rate following radiotherapy. These results suggest that modulating the Type I IFN pathway has the potential to improve radiation therapy efficacy in RC.
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Affiliation(s)
- Taylor P Uccello
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, NY, USA
| | - Maggie L Lesch
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, NY, USA
| | - Sarah A Kintzel
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
- Department of Biomedical Engineering, University of Rochester, Rochester, NY, USA
| | - Lauren B Gradzewicz
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Lillia Lamrous
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Shawn P Murphy
- Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY, USA
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Bradley N Mills
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Joseph D Murphy
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, NY, USA
| | - Angela Hughson
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Gary Hannon
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Jesse Garrett-Larsen
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Haoming Qiu
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | - Michael G Drage
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Jian Ye
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Nicholas W Gavras
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - David C Keeley
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Tanzy M T Love
- Department of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, NY, USA
| | - Elizabeth A Repasky
- Roswell Park Comprehensive Cancer Institute, University at Buffalo, Buffalo, NY, USA
| | - Edith M Lord
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, NY, USA
| | - David C Linehan
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Scott A Gerber
- Department of Microbiology and Immunology, University of Rochester Medical Center, Rochester, NY, USA.
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA.
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY, USA.
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Loria A, Z Becerra A, D Melucci A, Ghaffar A, Croft A, A Hanchett V, K Temple L, J Fleming F. Major renal morbidity following elective rectal cancer resection by the type of diverting ostomy. Colorectal Dis 2023; 25:404-412. [PMID: 36237178 DOI: 10.1111/codi.16375] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 07/14/2022] [Revised: 09/14/2022] [Accepted: 10/03/2022] [Indexed: 12/13/2022]
Abstract
AIM Patients with rectal cancer often undergo faecal diversion, yet the existing literature cursorily reports renal sequelae by the type of ostomy. We aimed to determine whether the presence of an ileostomy or colostomy was associated with postoperative renal morbidity. METHODS We identified patients with rectal cancer undergoing elective resection with primary anastomosis without diversion, with an ileostomy and with a colostomy by 21 possible procedures in the colectomy- and proctectomy-specific National Surgical Quality Improvement Program files. The odds of major renal events (renal failure [dialysis initiated] or progressive renal insufficiency [>2 mg/dl increase in creatinine without dialysis]), progressive renal insufficiency alone and readmissions were assessed using propensity score weighting and logistic regression. RESULTS Of 15 075 patients (63.7% Stage II-III, 85.7% creatinine values obtained ≤30 days preoperatively), 37.7% were not diverted, 39.5% had an ileostomy and 22.9% a colostomy. Compared to non-diverted patients, diversion was associated with major renal events (ileostomy, odds ratio [OR] 2.1, 95% confidence interval [CI] 1.6-2.9; colostomy, OR 1.8, 95% CI 1.3-2.5), progressive renal insufficiency (ileostomy, OR 2.5, 95% CI 1.7-3.5; colostomy, OR 2.0, 95% CI 1.4-2.9), readmissions for renal failure (ileostomy, OR 3.2, 95% CI 2.1-5.0; colostomy, OR 2.5, 95% CI 1.6-4.1) and readmissions for fluid/electrolyte abnormalities (ileostomy, OR 2.3, 95% CI 1.6-3.3; colostomy, OR 1.8, 95% CI 1.2-2.6). CONCLUSION Diverting ostomies after elective rectal cancer resection are strongly associated with renal morbidity. The decision to divert is complex, and it is unclear whether select patients may benefit from a colostomy from a renal perspective.
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Affiliation(s)
- Anthony Loria
- University of Rochester Medical Center, Department of Surgery, New York, USA
- University of Rochester Medical Center, Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, New York, USA
| | - Adan Z Becerra
- Rush University Medical Center, Department of Surgery, Chicago, Illinois, USA
| | - Alexa D Melucci
- University of Rochester Medical Center, Department of Surgery, New York, USA
- University of Rochester Medical Center, Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, New York, USA
| | - Aqsa Ghaffar
- University of Rochester Medical Center, Department of Surgery, New York, USA
| | - Ashley Croft
- University of Rochester Medical Center, Department of Surgery, New York, USA
| | - Virginia A Hanchett
- University of Rochester Medical Center, Department of Surgery, New York, USA
| | - Larissa K Temple
- University of Rochester Medical Center, Department of Surgery, New York, USA
- University of Rochester Medical Center, Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, New York, USA
| | - Fergal J Fleming
- University of Rochester Medical Center, Department of Surgery, New York, USA
- University of Rochester Medical Center, Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, New York, USA
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Loria A, Marianetti I, Cook CA, Melucci AD, Ghaffar A, Juviler P, Temple LK, Jones CMC, Fleming FJ. Epidemiology and healthcare utilization for rectal foreign bodies in United States adults, 2012–2021. Am J Emerg Med 2023; 69:76-82. [PMID: 37060632 DOI: 10.1016/j.ajem.2023.03.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/15/2023] [Accepted: 03/21/2023] [Indexed: 04/03/2023] Open
Abstract
INTRODUCTION Presentations to the emergency department for rectal foreign bodies are common, but there is little epidemiologic information on this condition. This limits the ability to provide evidence-based education to trainees regarding the populations affected, the types and frequency of foreign bodies, and factors associated with hospitalization. To address this, we analyzed national estimates of emergency department presentations for rectal foreign bodies from 2012 to 2021 in the US. METHODS We queried the National Electronic Injury Surveillance System for any injury to the 'pubic region' or 'lower trunk' with an accompanying diagnosis of foreign body, puncture, or laceration. Two authors manually reviewed all clinical narratives to identify cases of rectal foreign bodies. National estimates were determined using weighting and strata variables, incidence rates calculated using census data, trends assessed by linear regression, and factors associated with hospitalization identified by multivariable logistic regression. RESULTS From 885 cases, there were an estimated 38,948 (95% CI, 32,040-45,856) emergency department visits for rectal foreign bodies among individuals ≥15 years from 2012 to 2021. The average age was 43, 77.8% were male, 55.4% of foreign bodies were sexual devices, and 40.8% required hospitalization. The annual incidence of presentations for rectal foreign bodies increased from 1.2 in 2012 to 1.9 per 100,000 persons in 2021 (R2 = 0.84, p < 0.01). Males have a bimodal age distribution peaking in the fifth decade, while females have a right-skewed age distribution peaking in the second decade. Female sex (odds ratio [OR] 0.4; 95% confidence interval [CI], 0.2-0.6) and, compared to sexual devices, balls/marbles (OR 0.2; 95% CI, 0.05-0.6) or drugs/paraphernalia (OR 0.1; 95% CI, 0.05-0.4) are associated with a reduced odds of hospitalization. CONCLUSIONS Presentations to the emergency department for rectal foreign bodies increased for males and females from 2012 to 2021 in the United States. These epidemiologic estimates for a complex form of anorectal trauma provide preclinical information for emergency medicine, surgery, and radiology trainees.
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Affiliation(s)
- Anthony Loria
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA.
| | - Ila Marianetti
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Caitlin A Cook
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Alexa D Melucci
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Aqsa Ghaffar
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Peter Juviler
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Larissa K Temple
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Courtney M C Jones
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, USA; Department of Public Health Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Fergal J Fleming
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
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14
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Uccello TP, Lesch ML, Ullman NA, Kintzel SA, Gradzewicz LB, Velagaleti T, Fleming FJ, Mills BN, Murphy JD, Garrett-Larsen J, Qiu H, Drage MG, Ye J, Gavras NW, Johnston CJ, Love TMT, Repasky EA, Linehan DC, Lord EM, Gerber SA. Radiation Therapy Exacerbates Tumor-Promoting Innervation and Nerve Signaling in Rectal Cancer. Int J Radiat Oncol Biol Phys 2023; 115:733-745. [PMID: 36202180 PMCID: PMC9898185 DOI: 10.1016/j.ijrobp.2022.09.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 08/24/2022] [Accepted: 09/24/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Many solid tumors present with perineural invasion (PNI), and innervation correlates with worsened prognosis. The effects that commonly administered therapies such as radiation therapy (RT) have on PNI status remain unknown. We investigated the contribution of RT on the nervous system and elucidated the implications that increased nerve signaling can have on tumor burden using our previously developed orthotopic murine model of rectal cancer (RC) and our targeted and clinically relevant short-course RT (SCRT) regimen. METHODS Medical charts for patients with RC treated at the Wilmot Cancer Institute were obtained and PNI status was analyzed. Human data were accompanied by an orthotopic murine model of RC. Briefly, luciferase-expressing murine colon-38 (MC38-luc) tumor cells were injected orthotopically into the rectal wall of C57BL6 mice. Targeted SCRT (5 gray (Gy) per fraction for 5 consecutive fractions) was administered to the tumor. Intratumoral innervation was determined by immunohistochemistry (IHC), local norepinephrine (NE) concentration was quantified by enzyme-linked immunosorbent assay (ELISA), and β2-adrenergic receptor (B2AR) expression was assessed by flow cytometry. Chronic NE signaling was mirrored by daily isoproterenol treatment, and the effect on tumor burden was determined by overall survival, presence of metastatic lesions, and tumor size. Isoproterenol signaling was inhibited by administration of propranolol. RESULTS Human RC patients with PNI have decreased overall survival compared with patients without PNI. In our mouse model, SCRT induced the expression of genes involved in neurogenesis, increased local NE secretion, and upregulated B2AR expression. Treating mice with isoproterenol resulted in decreased overall survival, increased rate of metastasis, and reduced SCRT efficacy. Interestingly, the isoproterenol-induced decrease in SCRT efficacy could be abrogated by blocking the BAR through the use of propranolol, suggesting a direct role of BAR stimulation on impairing SCRT responses. CONCLUSIONS Our results indicate that while SCRT is a valuable treatment, it is accompanied by adverse effects on the nervous system that may impede the efficacy of therapy and promote tumor burden. Therefore, we could speculate that therapies aimed at targeting this signaling cascade or impairing nerve growth in combination with SCRT may prove beneficial in future cancer treatment.
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Affiliation(s)
- Taylor P Uccello
- Departments of Microbiology, Immunology and University of Rochester Medical Center, Rochester, New York
| | - Maggie L Lesch
- Departments of Microbiology, Immunology and University of Rochester Medical Center, Rochester, New York
| | - Nicholas A Ullman
- Departments of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Sarah A Kintzel
- Department of Biomedical Engineering, University of Rochester, Rochester, New York
| | - Lauren B Gradzewicz
- Departments of Microbiology, Immunology and University of Rochester Medical Center, Rochester, New York
| | - Trishna Velagaleti
- Departments of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Fergal J Fleming
- Departments of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Bradley N Mills
- Departments of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Joseph D Murphy
- Departments of Microbiology, Immunology and University of Rochester Medical Center, Rochester, New York
| | - Jesse Garrett-Larsen
- Departments of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Haoming Qiu
- Departments of Radiation Oncology, University of Rochester Medical Center, Rochester, New York
| | - Michael G Drage
- Departments of Pathology and Laboratory, University of Rochester Medical Center, Rochester, New York
| | - Jian Ye
- Departments of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Nicholas W Gavras
- Departments of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Carl J Johnston
- Departments of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Tanzy M T Love
- Departments of Biostatistics and Computational Biology, University of Rochester Medical Center, Rochester, New York
| | - Elizabeth A Repasky
- Roswell Park Comprehensive Cancer Institute, University at Buffalo, Buffalo, New York
| | - David C Linehan
- Departments of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Edith M Lord
- Departments of Microbiology, Immunology and University of Rochester Medical Center, Rochester, New York
| | - Scott A Gerber
- Departments of Microbiology, Immunology and University of Rochester Medical Center, Rochester, New York; Departments of Surgery, University of Rochester Medical Center, Rochester, New York; Departments of Radiation Oncology, University of Rochester Medical Center, Rochester, New York.
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15
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Brady JT, Bingmer K, Bliggenstorfer J, Xu Z, Fleming FJ, Remzi FH, Monson JRT, Wexner SD, Dietz DW. Could meeting the standards of the National Accreditation Program for Rectal Cancer in the National Cancer Database improve patient outcomes? Colorectal Dis 2023; 25:916-922. [PMID: 36727838 DOI: 10.1111/codi.16503] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 09/17/2022] [Revised: 01/13/2023] [Accepted: 01/23/2023] [Indexed: 02/03/2023]
Abstract
AIM The National Accreditation Program for Rectal Cancer (NAPRC) was developed to improve rectal cancer patient outcomes in the United States. The NAPRC consists of a set of process and outcome measures that hospitals must meet in order to be accredited. We aimed to assess the potential of the NAPRC by determining whether achievement of the process measures correlates with improved survival. METHODS The National Cancer Database was used to identify patients undergoing curative proctectomy for non-metastatic rectal cancer from 2010 to 2014. NAPRC process measures identified in the National Cancer Database included clinical staging completion, treatment starting <60 days from diagnosis, carcinoembryonic antigen level measured prior to treatment, tumour regression grading and margin assessment. RESULTS There were 48 669 patients identified with a mean age of 62 ± 12.9 years and 61.3% of patients were men. The process measure completed most often was assessment of proximal and distal margins (98.4%) and the measure completed least often was the serum carcinoembryonic antigen level prior to treatment (63.8%). All six process measures were completed in 23.6% of patients. After controlling for age, gender, comorbidities, annual facility resection volume, race and pathological stage, completion of all process measures was associated with a statistically significant mortality decrease (Cox hazard ratio 0.88, 95% CI 0.81-0.94, P < 0.001). CONCLUSION Participating institutions provided complete datasets for all six process measures in less than a quarter of patients. Compliance with all process measures was associated with a significant mortality reduction. Improved adoption of NAPRC process measures could therefore result in improved survival rates for rectal cancer in the United States.
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Affiliation(s)
- Justin T Brady
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Katherine Bingmer
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | | | - Zhaomin Xu
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Feza H Remzi
- Department of Surgery, New York University Langone Medical Center, New York, New York, USA
| | - John R T Monson
- AdventHealth Surgical Health Outcomes Consortium, AdventHealth, Orlando, Florida, USA
| | - Steven D Wexner
- Ellen Leifer Shulman and Steven Shulman Digestive Disease Center Cleveland Clinic Florida, Weston, Florida, USA
| | - David W Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Loria A, Glance LG, Melucci AD, Boodry C, Justiniano CF, Dunne RF, Mustian KM, Becerra AZ, Jusko TA, Temple LK, Fleming FJ. Low Preoperative Serum Creatinine is Common and Associated With Poor Outcomes After Nonemergent Inpatient Surgery. Ann Surg 2023; 277:246-251. [PMID: 36448909 DOI: 10.1097/sla.0000000000005760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To assess the association between low preoperative serum creatinine and postoperative outcomes. BACKGROUND The association between low creatinine and poor surgical outcomes is not well understood. METHODS We identified patients with creatinine in the 7 days preceding nonemergent inpatient surgery in the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2020. Multivariable logistic regression was used to examine the association between creatinine and 30-day mortality and major complications. RESULTS Of 1,809,576 patients, 27.8% of males and 23.5% of females had low preoperative serum creatinine, 14.6% experienced complications, and 1.2% died. For males, compared with the reference creatinine of 0.85 to 1.04, those with serum creatinine ≤0.44 had 55% increased odds of mortality [ adjusted odds ratio (aOR), 1.55; 95% CI, 1.29-1.86] and 82% increased odds of major complications (aOR, 1.82; 95% CI, 1.69-1.97). Similarly, for females, compared with the reference range of 0.65 to 0.84, those with serum creatinine ≤0.44 had 49% increased odds of mortality (aOR, 1.49; 95% CI, 1.32-1.67) and 76% increased odds of major complications (aOR, 1.76; 95% CI, 1.70-1.83). These associations persisted for the total cohort, among those with mildly low albumin, and for those with creatinine values measured 8 to 30 days preoperatively. CONCLUSIONS A low preoperative creatinine is common and associated with poor outcomes after nonemergent inpatient surgery. A low creatinine may help identify high-risk patients who may benefit from further evaluation and optimization.
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Affiliation(s)
- Anthony Loria
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, New York
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York.,Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York.,RAND Health, Rand, Boston, MA
| | - Alexa D Melucci
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, New York
| | - Courtney Boodry
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, New York
| | - Carla F Justiniano
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, New York
| | - Richard F Dunne
- Department of Medicine, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Karen M Mustian
- Department of Surgery, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Adan Z Becerra
- Department of Surgery, Rush University Medical Center, Chicago, IL
| | - Todd A Jusko
- Department of Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Larissa K Temple
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, New York
| | - Fergal J Fleming
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, New York
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Loria A, Melucci AD, Burchard PR, Ghaffar A, Levatino E, Temple LK, Fleming FJ. Implementation of a new definition for acute kidney injury in the National Surgical Quality Improvement Project: What is the impact? Surgery 2023:S0039-6060(22)01014-5. [PMID: 36610895 DOI: 10.1016/j.surg.2022.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 11/14/2022] [Accepted: 11/23/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND The National Surgical Quality Improvement Project is the preeminent surgical quality database, but it undercaptures acute kidney injury. Recently, the National Surgical Quality Improvement Project lowered the thresholds for acute kidney injury for the first time, so we assessed the impact of implementing the definition change on the rate of acute kidney injuries. METHODS For this interrupted time series analysis, we assembled 2 institutional National Surgical Quality Improvement Project files to identify adults undergoing inpatient noncardiac nonvascular surgery. The acute kidney injury definition changed on July 1, 2021, so patients were stratified by their operative date into 12-month pre and post groups. Weighted covariate propensity score matching and logistic regression were used to balance the periods and compare outcomes. RESULTS In total, 4,784 adults were eligible (55% pre and 45% post change). The overall rate of postoperative outcomes was similar, aside for acute kidney injury (pre 0.3%, post 5.6%, P < .0001). Regardless of the period, patients with acute kidney injuries had significantly longer lengths of stay and morbidity and mortality rates compared to those without an acute kidney injury. After the definition change, 81% of acute kidney injuries were stage I, and none were identified by urine output alone. After matching, surgery after the definition change was associated with an increased weighted odds of an acute kidney injury compared to surgery before the change (odds ratio 26.2; 95% confidence interval, 12.1-56.8). CONCLUSION In the year after the definition change, there was a 1,700% relative increase in the rate of reported acute kidney injuries. Newly identified acute kidney injuries are associated with high complication rates, and this definition change has implications for patient counseling, research, and quality reporting.
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Affiliation(s)
- Anthony Loria
- Department of Surgery, University of Rochester Medical Center, NY; Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, NY.
| | - Alexa D Melucci
- Department of Surgery, University of Rochester Medical Center, NY; Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, NY
| | - Paul R Burchard
- Department of Surgery, University of Rochester Medical Center, NY
| | - Aqsa Ghaffar
- Department of Surgery, University of Rochester Medical Center, NY; Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, NY
| | | | - Larissa K Temple
- Department of Surgery, University of Rochester Medical Center, NY; Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, NY
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, NY; Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, NY
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18
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Loria A, Jacobson T, Melucci AD, Bartell N, Nabozny MJ, Temple LK, Fleming FJ. Sigmoid volvulus: Evaluating identification strategies and contemporary multicenter outcomes. Am J Surg 2023; 225:191-197. [PMID: 35934559 DOI: 10.1016/j.amjsurg.2022.07.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 07/15/2022] [Accepted: 07/26/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND There is limited epidemiologic data on sigmoid volvulus (SV) from non-endemic regions. Therefore, we performed a multicenter study to report contemporary outcomes and appraise literature-based methods that pair diagnostic and procedural codes to identify SV. METHOD Using an automated search for patients with 'volvulus' in our system from 2011 to 2021, we reviewed electronic charts to clarify the diagnosis, automatically replicate three strategies to identify SV, and retrieved 6-month outcomes. RESULTS Of 895 patients, 109 had SV. Literature-based strategies poorly identified SV. At the index admission, patients underwent endoscopic reduction alone (33%), emergent (16.5%), semi-elective (34%), or elective (16.5%) surgery. Endoscopic reduction alone had high recurrence rates and delayed surgery was associated with worse outcomes. CONCLUSION Literature-based strategies to identify SV suffer from misclassification bias which affects patient counseling. In this large series, one-third of patients do not undergo during their index admission despite improved outcomes with earlier surgery.
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Affiliation(s)
- Anthony Loria
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA; Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA.
| | - Tricia Jacobson
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Alexa D Melucci
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA; Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Nicholas Bartell
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY, 146242, USA
| | - Michael J Nabozny
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Larissa K Temple
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA; Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
| | - Fergal J Fleming
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA; Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, USA
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Fahy MR, Kelly ME, Aalbers AGJ, Abdul Aziz N, Abecasis N, Abraham-Nordling M, Akiyoshi T, Alberda W, Albert M, Andric M, Angeles MA, Angenete E, Antoniou A, Auer R, Austin KK, Aytac E, Aziz O, Bacalbasa N, Baker RP, Bali M, Baransi S, Baseckas G, Bebington B, Bedford M, Bednarski BK, Beets GL, Berg PL, Bergzoll C, Beynon J, Biondo S, Boyle K, Bordeianou L, Brecelj E, Bremers AB, Brunner M, Buchwald P, Bui A, Burgess A, Burger JWA, Burling D, Burns E, Campain N, Carvalhal S, Castro L, Caycedo-Marulanda A, Ceelan W, Chan KKL, Chang GJ, Chang M, Chew MH, Chok AY, Chong P, Clouston H, Codd M, Collins D, Colquhoun AJ, Constantinides J, Corr A, Coscia M, Cosimelli M, Cotsoglou C, Coyne PE, Croner RS, Damjanovich L, Daniels IR, Davies M, Delaney CP, de Wilt JHW, Denost Q, Deutsch C, Dietz D, Domingo S, Dozois EJ, Drozdov E, Duff M, Eglinton T, Enriquez-Navascues JM, Espín-Basany E, Evans MD, Eyjólfsdóttir B, Fearnhead NS, Ferron G, Flatmark K, Fleming FJ, Flor B, Folkesson J, Frizelle FA, Funder J, Gallego MA, Gargiulo M, García-Granero E, García-Sabrido JL, Gargiulo M, Gava VG, Gentilini L, George ML, George V, Georgiou P, Ghosh A, Ghouti L, Gil-Moreno A, Giner F, Ginther DN, Glyn T, Glynn R, Golda T, Griffiths B, Harris DA, Hagemans JAW, Hanchanale V, Harji DP, Helewa RM, Hellawell G, Heriot AG, Hochman D, Hohenberger W, Holm T, Hompes R, Hornung B, Hurton S, Hyun E, Ito M, Iversen LH, Jenkins JT, Jourand K, Kaffenberger S, Kandaswamy GV, Kapur S, Kanemitsu Y, Kazi M, Kelley SR, Keller DS, Ketelaers SHJ, Khan MS, Kiran RP, Kim H, Kim HJ, Koh CE, Kok NFM, Kokelaar R, Kontovounisios C, Kose F, Koutra M, Kristensen HØ, Kroon HM, Kumar S, Kusters M, Lago V, Lampe B, Lakkis Z, Larach JT, Larkin JO, Larsen SG, Larson DW, Law WL, Lee PJ, Limbert M, Loria A, Lydrup ML, Lyons A, Lynch AC, Maciel J, Manfredelli S, Mann C, Mantyh C, Mathis KL, Marques CFS, Martinez A, Martling A, Mehigan BJ, Meijerink WJHJ, Merchea A, Merkel S, Mehta AM, Mikalauskas S, McArthur DR, McCormick JJ, McCormick P, McDermott FD, McGrath JS, Malde S, Mirnezami A, Monson JRT, Navarro AS, Negoi I, Neto JWM, Ng JL, Nguyen B, Nielsen MB, Nieuwenhuijzen GAP, Nilsson PJ, Nordkamp S, Nugent T, Oliver A, O’Dwyer ST, O’Sullivan NJ, Paarnio K, Palmer G, Pappou E, Park J, Patsouras D, Peacock O, Pellino G, Peterson AC, Pinson J, Poggioli G, Proud D, Quinn M, Quyn A, Rajendran N, Radwan RW, Rajendran N, Rao C, Rasheed S, Rausa E, Regenbogen SE, Reims HM, Renehan A, Rintala J, Rocha R, Rochester M, Rohila J, Rothbarth J, Rottoli M, Roxburgh C, Rutten HJT, Safar B, Sagar PM, Sahai A, Saklani A, Sammour T, Sayyed R, Schizas AMP, Schwarzkopf E, Scripcariu D, Scripcariu V, Selvasekar C, Shaikh I, Simpson A, Skeie-Jensen T, Smart NJ, Smart P, Smith JJ, Solbakken AM, Solomon MJ, Sørensen MM, Sorrentino L, Steele SR, Steffens D, Stitzenberg K, Stocchi L, Stylianides NA, Swartling T, Spasojevic M, Sumrien H, Sutton PA, Swartking T, Takala H, Tan EJ, Taylor C, Tekin A, Tekkis PP, Teras J, Thaysen HV, Thurairaja R, Thorgersen EB, Toh EL, Tsarkov P, Tsukada Y, Tsukamoto S, Tuech JJ, Turner WH, Tuynman JB, Valente M, van Ramshorst GH, van Zoggel D, Vasquez-Jimenez W, Vather R, Verhoef C, Vierimaa M, Vizzielli G, Voogt ELK, Uehara K, Urrejola G, Wakeman C, Warrier SK, Wasmuth HH, Waters PS, Weber K, Weiser MR, Wheeler JMD, Wild J, Williams A, Wilson M, Wolthuis A, Yano H, Yip B, Yip J, Yoo RN, Zappa MA, Winter DC. Minimum standards of pelvic exenterative practice: PelvEx Collaborative guideline. Br J Surg 2022; 109:1251-1263. [PMID: 36170347 DOI: 10.1093/bjs/znac317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 07/18/2022] [Accepted: 08/18/2022] [Indexed: 12/31/2022]
Abstract
This document outlines the important aspects of caring for patients who have been diagnosed with advanced pelvic cancer. It is primarily aimed at those who are establishing a service that adequately caters to this patient group. The relevant literature has been summarized and an attempt made to simplify the approach to management of these complex cases.
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Melucci AD, Loria A, Ramsdale E, Temple LK, Fleming FJ, Aquina CT. An assessment of left-digit bias in the treatment of older patients with potentially curable rectal cancer. Surgery 2022; 172:851-858. [PMID: 35843744 DOI: 10.1016/j.surg.2022.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/27/2022] [Accepted: 04/29/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Patient age is associated with poorer rectal cancer treatment compliance. However, it is unknown whether left-digit bias (disproportionate influence of leftmost age digit) influences this association. METHODS The patients diagnosed with stage I-III rectal cancer between 2006 to 2017 in the National Cancer Database were identified. The association between age and receipt of guideline-adherent care was assessed using mixed-effects multivariable analyses. RESULTS Among 97,960 patients, 46.2% received guideline-adherent overall treatment and 73.3% underwent guideline-adherent surgical resection. Of those who underwent guideline-adherent surgery, 86.4% received guideline-adherent radiotherapy and 56.6% received guideline-adherent chemotherapy. After risk-adjustment, each decade increase in age was associated with 36% decreased odds of guideline-adherent therapy (odds ratio = 0.64, 95% confidence interval = 0.63-0.65). Patients aged 58 to 59 (odds ratio = 1.15, 95% confidence interval = 1.02-1.27) and 78 to 79 (odds ratio = 1.28, 95% confidence interval = 1.08-1.51) had higher odds of guideline-adherent overall treatment compared with patients aged 60 and 80, respectively. However, there were no significant differences in the receipt of guideline-adherent treatment between patients aged 60 vs 61-62 and 80 vs 81-82. CONCLUSION Older patients with rectal cancer are less likely to receive guideline-adherent care, and a left-digit bias is present. Geriatric assessment-guided treatment decisions could help mitigate this bias.
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Affiliation(s)
- Alexa D Melucci
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY.
| | - Anthony Loria
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY. https://twitter.com/apl2018
| | - Erika Ramsdale
- Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, NY
| | - Larissa K Temple
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY
| | - Fergal J Fleming
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY. https://twitter.com/FergaljFleming
| | - Christopher T Aquina
- Department of Surgery, Surgical Health Outcomes and Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, NY; Surgical Health Outcomes Consortium (SHOC), Digestive Health and Surgery Institute, Advent Health Orlando, Orlando, FL. https://twitter.com/AdventHealth
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21
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Glance LG, Benesch CG, Holloway RG, Thirukumaran CP, Nadler JW, Eaton MP, Fleming FJ, Dick AW. Association of Time Elapsed Since Ischemic Stroke With Risk of Recurrent Stroke in Older Patients Undergoing Elective Nonneurologic, Noncardiac Surgery. JAMA Surg 2022; 157:e222236. [PMID: 35767247 DOI: 10.1001/jamasurg.2022.2236] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Importance Perioperative strokes are a major cause of death and disability. There is limited information on which to base decisions for how long to delay elective nonneurologic, noncardiac surgery in patients with a history of stroke. Objective To examine whether an association exists between the time elapsed since an ischemic stroke and the risk of recurrent stroke in older patients undergoing elective nonneurologic, noncardiac surgery. Design, Setting, and Participants This cohort study used data from the 100% Medicare Provider Analysis and Review files, including the Master Beneficiary Summary File, between 2011 and 2018 and included elective nonneurologic, noncardiac surgeries in patients 66 years or older. Patients were excluded if they had more than 1 procedure during a 30-day period, were transferred from another hospital or facility, were missing information on race and ethnicity, were admitted in December 2018, or had tracheostomies or gastrostomies. Data were analyzed May 7 to October 23, 2021. Exposures Time interval between a previous hospital admission for acute ischemic stroke and surgery. Main Outcomes and Measures Acute ischemic stroke during the index surgical admission or rehospitalization for stroke within 30 days of surgery, 30-day all-cause mortality, composite of stroke and mortality, and discharge to a nursing home or skilled nursing facility. Multivariable logistic regression models were used to estimate adjusted odds ratios (AORs) to quantify the association between outcome and time since ischemic stroke. Results The final cohort included 5 841 539 patients who underwent elective nonneurologic, noncardiac surgeries (mean [SD] age, 74.1 [6.1] years; 3 371 329 [57.7%] women), of which 54 033 (0.9%) had a previous stroke. Patients with a stroke within 30 days before surgery had higher adjusted odds of perioperative stroke (AOR, 8.02; 95% CI, 6.37-10.10; P < .001) compared with patients without a previous stroke. The adjusted odds of stroke were not significantly different at an interval of 61 to 90 days between previous stroke and surgery (AOR, 5.01; 95% CI, 4.00-6.29; P < .001) compared with 181 to 360 days (AOR, 4.76; 95% CI, 4.26-5.32; P < .001). The adjusted odds of 30-day all-cause mortality were higher in patients who underwent surgery within 30 days of a previous stroke (AOR, 2.51; 95% CI, 1.99-3.16; P < .001) compared with those without a history of stroke, and the AOR decreased to 1.49 (95% CI, 1.15-1.92; P < .001) at 61 to 90 days from previous stroke to surgery but did not decline significantly, even after an interval of 360 or more days. Conclusions and Relevance The findings of this cohort study suggest that, among patients undergoing nonneurologic, noncardiac surgery, the risk of stroke and death leveled off when more than 90 days elapsed between a previous stroke and elective surgery. These findings suggest that the recent scientific statement by the American Heart Association to delay elective nonneurologic, noncardiac surgery for at least 6 months after a recent stroke may be too conservative.
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Affiliation(s)
- Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York.,Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York.,RAND Health, RAND, Boston, Massachusetts.,Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York
| | - Curtis G Benesch
- Department of Neurology, University of Rochester School of Medicine, Rochester, New York
| | - Robert G Holloway
- Department of Neurology, University of Rochester School of Medicine, Rochester, New York
| | - Caroline P Thirukumaran
- Department of Public Health Sciences, University of Rochester School of Medicine, Rochester, New York.,Department of Orthopedics, University of Rochester School of Medicine, Rochester, New York
| | - Jacob W Nadler
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Michael P Eaton
- Department of Anesthesiology and Perioperative Medicine, University of Rochester School of Medicine, Rochester, New York
| | - Fergal J Fleming
- Department of Surgery, University of Rochester School of Medicine, Rochester, New York
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22
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Geiger JT, Fleming FJ, Stoner M, Doyle A. Surgeon volume and established hospital perioperative mortality rate together predict for superior outcomes after open abdominal aortic aneurysm repair. Eur J Vasc Endovasc Surg 2022. [DOI: 10.1016/j.ejvs.2022.01.025] [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: 11/28/2022]
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Justiniano CF, Becerra AZ, Loria A, Xu Z, Aquina CT, Temple LK, Fleming FJ. Is robotic utilization associated with increased minimally invasive colorectal surgery rates? Surgeon-level evidence. Surg Endosc 2022; 36:5618-5626. [PMID: 35024928 PMCID: PMC8757409 DOI: 10.1007/s00464-022-09023-1] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 01/03/2022] [Indexed: 11/26/2022]
Abstract
Background It is unclear whether robotic utilization has increased overall minimally invasive colorectal surgery rates or if robotics is being adopted instead of laparoscopy. The goal was to evaluate whether increasing robotic surgery utilization is associated with increased rates of overall colorectal minimally invasive surgery. Methods The Statewide Planning and Research Cooperative System (New York) was used to identify patients undergoing elective colectomy or proctectomy from 2009 to 2015. Individual surgeons were categorized as having increasing or non-increasing robotic utilization (IRU or non-IRU, respectively) based on the annual increase in the proportion of robotic surgery performed. The odds of surgical approach across the study period were evaluated with multinomial regression. Results Among 72,813 resections from 2009 to 2015, minimally invasive-surgery increased (47–61%, p < 0.0001). For colectomy, overall minimally invasive-surgery rates increased (54–66%, p < 0.0001), laparoscopic remained stable (53–54%), and robotics increased (1–12%). For proctectomy, overall minimally invasive-surgery rates increased (22–43%, p < 0.0001), laparoscopic remained stable (20–21%), and robotics increased (2–22%). Over the study period, 2487 surgeons performed colectomies. Among 156 surgeons with IRU for colectomies, robotics increased (2–29%), while laparoscopy decreased (67–44%), and open surgery decreased (31–27%). Overall, surgeons with IRU performed minimally invasive colectomies 73% of the time in 2015 versus 69% in 2009. Over the study period, 1131 surgeons performed proctectomies. Among 94 surgeons with IRU for proctectomies, robotics increased (3–42%), while laparoscopy decreased (25–15%), and open surgery decreased (73–44%). Overall, surgeons with IRU performed minimally invasive proctectomy 56% of the time in 2015 versus 27% in 2009. Patients in the latter study period had 57% greater odds of undergoing robotic surgery. Conclusions Overall, minimally invasive colorectal resections increased from 2009 to 2015 largely due to increasing robotic utilization, particularly for proctectomies.
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Affiliation(s)
- Carla F Justiniano
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box SURG, Rochester, NY, 14642, USA.
| | - Adan Z Becerra
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Anthony Loria
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box SURG, Rochester, NY, 14642, USA
| | - Zhaomin Xu
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box SURG, Rochester, NY, 14642, USA
| | - Christopher T Aquina
- Division of Surgical Oncology, Department of Surgery, The Ohio State Medical Center, Columbus, OH, USA
| | - Larissa K Temple
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box SURG, Rochester, NY, 14642, USA
| | - Fergal J Fleming
- Surgical Health Outcomes & Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box SURG, Rochester, NY, 14642, USA
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Noyes K, Zapf AL, Depner RM, Flores T, Huston A, Rashid HH, McNeal D, Constine LS, Fleming FJ, Wilding GE, Sahler OJZ. Problem-solving skills training in adult cancer survivors: Bright IDEAS-AC pilot study. Cancer Treat Res Commun 2022; 31:100552. [PMID: 35358820 PMCID: PMC9106910 DOI: 10.1016/j.ctarc.2022.100552] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/19/2022] [Accepted: 03/22/2022] [Indexed: 05/13/2023]
Abstract
PURPOSE Cancer patients experience significant distress and burden of decision-making throughout treatment and beyond. These stressors can interfere with their ability to make reasoned and timely decisions about their care and lead to low physical and social functioning and poor survival. This pilot study examined the impact of offering Problem-Solving Skills Training (PSST) to adult cancer survivors to help them and their caregivers cope more successfully with post-treatment decision-making burden and distress. PATIENTS AND METHODS Fifty patients who completed their definitive treatment for colorectal, breast or prostate cancer within the last 6 months and reported distress (level > 2 on the National Comprehensive Cancer Network distress thermometer) were randomly assigned to either care as usual (CAU) or 8 weekly PSST sessions. Patients were invited to include a supportive other (n = 17). Patient and caregiver assessments at baseline (T1), end of intervention or 3 months (T2), and at 6 months (T3) focused on problem-solving skills, anxiety/depression, quality of life and healthcare utilization. We compared outcomes by study arm and interviewed participants about PSST burden and skill maintenance. RESULTS Trial participation rate was 60%; 76% of the participants successfully completed PSST training. PSST patients reported reduction in anxiety/depression, improvement in QoL (p < 0.05) and lower use of hospital and emergency department services compared to CAU patients (p = 0.04). CONCLUSIONS The evidence from this pilot study indicates that a remotely delivered PSST is a feasible and potentially effective strategy to improve mood and self-management in cancer survivors in community oncology settings.
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Affiliation(s)
- Katia Noyes
- University at Buffalo, Buffalo, NY, United States of America.
| | - Alaina L Zapf
- University of Rochester Medical Center, Rochester, NY, United States of America
| | - Rachel M Depner
- Alpert Medical School of Brown University, Providence, RI, United States of America
| | - Tessa Flores
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States of America
| | - Alissa Huston
- University of Rochester Medical Center, Rochester, NY, United States of America
| | - Hani H Rashid
- University of Rochester Medical Center, Rochester, NY, United States of America
| | - Demetria McNeal
- University of Colorado Anschutz Medical Campus, Aurora, CO, United States of America
| | - Louis S Constine
- University of Rochester Medical Center, Rochester, NY, United States of America
| | - Fergal J Fleming
- University of Rochester Medical Center, Rochester, NY, United States of America
| | | | - Olle Jane Z Sahler
- University of Rochester Medical Center, Rochester, NY, United States of America
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Loria A, Melucci A, Speranza J, Cellini C, Salloum R, Temple LK, Fleming FJ, Justiniano CF. Acute kidney injury is a common and significant complication following ileostomy formation. Colorectal Dis 2022; 24:102-110. [PMID: 34536959 DOI: 10.1111/codi.15917] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/21/2021] [Accepted: 09/09/2021] [Indexed: 12/13/2022]
Abstract
AIM The aim was to characterize the incidence and short-term prognostic value of an acute kidney injury (AKI) during the admission where an ileostomy is formed. METHODS Adults with a baseline serum creatinine measurement discharged alive after ileostomy formation from 2014 to 2016 were included. All patients had daily basic metabolic panels and the Kidney Diseases Improving Global Outcomes criteria were used to determine the presence and severity of any AKI. Dehydration was defined by a single urine abnormality or clinical criteria combined with an objective abnormality in vitals or basic metabolic panels. RESULTS Of 262 patients, 19.4% sustained an AKI (74.5% Stage I, 15.7% Stage II, 9.8% Stage III) during the index admission. Predictors of incident AKI were increasing age, male sex, higher baseline creatinine and open surgery. Patients with AKI had significantly longer length of stay and 45% had creatinine <1.0 mg/dl at discharge. Of the total cohort, 11% were readmitted with dehydration and the independent predictors were AKI during the index admission, high ileostomy output, age >65 years, male sex and prior ileostomy. Of those readmitted with dehydration, 79% had AKI at readmission. CONCLUSIONS Nearly 20% of patients with ileostomies develop an AKI during the index admission with almost half resolving by discharge. Patients with AKIs are at high risk for 30-day dehydration-related readmission and AKI is present in nearly 80% of those readmitted with dehydration. Since AKI is objective, based on routine laboratory measures, and has known prognostic value it is probably a more robust outcome than dehydration for researchers, surgeons and patients.
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Affiliation(s)
- Anthony Loria
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Alexa Melucci
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Jenny Speranza
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Christina Cellini
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Rabih Salloum
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Larissa K Temple
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Carla F Justiniano
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
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Poles G, Kaur R, Ramsdale E, Schymura MJ, Temple LK, Fleming FJ, Aquina CT. Factors affecting short-term survival in patients older than 85 treated with resection for stage II and III colon cancer. Surgery 2021; 171:1200-1208. [PMID: 34838330 DOI: 10.1016/j.surg.2021.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 10/06/2021] [Accepted: 10/08/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patients ≥85 years of age have high rates of colon cancer but disproportionately poor outcomes. Factors affecting short-term (90-day) survival in patients ≥85 undergoing surgery for stage II and III colon cancer were examined to identify potentially modifiable factors to improve outcomes. METHODS The New York State Cancer Registry and Statewide Planning Research and Cooperative System were queried for patients ≥85 years who underwent colectomy for stage II and III colon cancer between 2004 and 2012. Regression analyses were performed for factors associated with 90-day mortality and stratified by elective and nonelective surgery. RESULTS In total, 3,779 patients ≥85 years of age underwent colectomy between 2004 and 2012 for stage II or III colon cancer. Of these, 48.4% underwent nonelective colectomy, 79.9% had an open operation, and 90-day survival was 83.2%. Worse survival was associated with nonelective surgery (odds ratio = 3.81, 95% confidence interval = 3.03-4.89). Improved survival in the nonelective and overall groups was associated with a minimally invasive operation (nonelective group: odds ratio = 0.35, 95% confidence interval = 0.21-0.58; overall group: odds ratio = 0.50, 95% confidence interval = 0.36-0.73) and discharged to another health care facility (nonelective group: odds ratio = 0.30, 95% confidence interval = 0.22-0.39; overall group: odds ratio = 0.42, 95% confidence interval = 0.33-0.53). High surgeon annual operating volume was associated with improved survival in the elective and nonelective groups (P < .001). CONCLUSION Factors associated with greater odds of 90-day mortality in this population include nonelective surgery, preoperative weight loss, and multiple comorbidities, whereas a minimally invasive approach was associated with lower mortality. Potential areas to improve outcomes in this population include using a multidisciplinary team approach, addressing frailty preoperatively when possible, and potentially reconsidering screening guidelines for colorectal cancer to reduce rates of emergency operations.
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Affiliation(s)
- Gabriela Poles
- Department of Surgery, Division of Colorectal Surgery, University of Rochester Medical Center, Rochester, NY.
| | - Roma Kaur
- Surgical Health Outcomes & Research Enterprise, University of Rochester Medical Center, Rochester, NY
| | - Erika Ramsdale
- Department of Medicine, Division of Oncology, University of Rochester Medical Center, Rochester, NY
| | - Maria J Schymura
- New York State Cancer Registry, New York State Department of Health, Albany, NY
| | - Larissa K Temple
- Surgical Health Outcomes & Research Enterprise, University of Rochester Medical Center, Rochester, NY
| | - Fergal J Fleming
- Surgical Health Outcomes & Research Enterprise, University of Rochester Medical Center, Rochester, NY
| | - Christopher T Aquina
- Surgical Health Outcomes & Research Enterprise, University of Rochester Medical Center, Rochester, NY; Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, OH
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Geiger JT, Fleming FJ, Stoner M, Doyle A. Surgeon volume and established hospital perioperative mortality rate together predict for superior outcomes after open abdominal aortic aneurysm repair. J Vasc Surg 2021; 75:504-513.e3. [PMID: 34560221 DOI: 10.1016/j.jvs.2021.08.077] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/18/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND In 2018, the Society for Vascular Surgery (SVS) published hospital volume guidelines for elective open abdominal aortic aneurysm (AAA) repair, recommending that elective open surgical repair of AAAs should be performed at centers with an annual volume of ≥10 open aortic operations of any type and a documented perioperative mortality of ≤5%. Recent work has suggested a yearly surgeon volume of at least seven open aortic cases for improved outcomes. The objective of the present study was to assess the importance of hospital volume and surgeon volume at these cut points for predicting 1-year mortality after open surgical repair of AAAs. METHODS We evaluated patients who had undergone elective open AAA repair using the New York Statewide Planning and Research Cooperative System database from 2003 to 2014. The effect of the SVS guidelines on postoperative mortality and complications was evaluated. Confounding between the hospital and surgeon volumes was identified using mixed effects multivariate Cox proportional hazards analysis. The effect of the interactions between hospital volume, established hospital perioperative survival, and surgeon volume on postoperative outcomes was also investigated. RESULTS The cohort consisted of 7594 elective open AAA repairs performed by 542 surgeons in 137 hospitals during the 12-year study period. Analysis of the 2018 guidelines using the Statewide Planning and Research Cooperative System database revealed 1-year and 30-day mortality rates of 9.2% (range, 8.3%-10.1%) and 3.5% (range, 2.9%-4.1%) for centers that were within the SVS guidelines and 13.6% (range, 12.5%-14.7%) and 6.9% (range, 6.1%-7.8%) for those that were outside the guidelines, respectively (P < .001 for both). Multivariate survival analysis revealed a hazard ratio for a surgeon volume of ≥7, hospital volume of ≥10, and hospital 3-year perioperative mortality of ≤5% of 0.80 (95% confidence interval [CI], 0.70-0.93; P = .003), 0.91 (95% CI, 0.77-1.08; P = .298), and 0.72 (95% CI, 0.62-0.82; P < .001), respectively. Additionally, procedures performed by surgeons with a yearly average volume of open aortic operations of at least seven and at hospitals with an established elective open AAA repair perioperative mortality rate of ≤5% showed improved 1-year (33.2% relative risk reduction; P < .001) and 30-day (P = .001) all-cause survival and improved postoperative complication rates. CONCLUSIONS These data have demonstrated that centers that meet the SVS AAA volume guidelines are associated with improved 1-year and 30-day all-cause survival. However, the results were confounded by surgeon volume. A surgeon open aortic volume of at least seven procedures and an established hospital perioperative mortality of ≤5% each independently predicted for 1-year survival after open AAA repair, with the hospital volume less important. These results indicate that surgeons with an annual volume of at least seven open aortic operations of any type should perform elective open AAA repair at centers with a documented perioperative mortality of ≤5%.
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Affiliation(s)
- Joshua T Geiger
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Fergal J Fleming
- Surgical Health Outcomes and Research Enterprise, University of Rochester Medical Center, Rochester, NY
| | - Michael Stoner
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY
| | - Adam Doyle
- Division of Vascular Surgery, University of Rochester Medical Center, Rochester, NY.
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Aquina CT, Becerra AZ, Fleming FJ, Cloyd JM, Tsung A, Pawlik TM, Ejaz A. Variation in outcomes across surgeons meeting the Leapfrog volume standard for complex oncologic surgery. Cancer 2021; 127:4059-4071. [PMID: 34292582 DOI: 10.1002/cncr.33766] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND A large body of evidence supports regionalization of complex oncologic surgery to high-volume surgeons at high-volume hospitals. However, whether there is heterogeneity of outcomes among high-volume surgeons at high-volume hospitals remains unknown. METHODS Patients who underwent esophagectomy, lung resection, pancreatectomy, or proctectomy for primary cancer were identified within the Medicare 100% Standard Analytic File (2013-2017). Mixed-effects analyses assessed the association between Leapfrog annual volume standards for surgeons (esophagectomy ≥7, lung resection ≥15, pancreatectomy ≥10, proctectomy ≥6) and hospitals (esophagectomy ≥20, lung resection ≥40, pancreatectomy ≥20, proctectomy ≥16) relative to postoperative complications and 90-day mortality. Additional analyses using New York's all-payer Statewide Planning and Research Cooperative System (2004-2015) were performed. RESULTS Among 112,154 Medicare beneficiaries, high-volume surgeons at high-volume hospitals were associated with lower adjusted odds of complications (esophagectomy: odds ratio [OR], 0.73 [95% CI, 0.61-0.86]; lung resection: OR, 0.88 [95% CI, 0.82-0.94]; pancreatectomy: OR, 0.73 [95% CI, 0.66-0.80]; proctectomy: OR, 0.92 [95% CI, 0.85-0.99]) and 90-day mortality (esophagectomy: OR, 0.60 [95% CI, 0.44-0.76]; lung resection: OR, 0.82 [95% CI, 0.73-0.93]; pancreatectomy: OR, 0.66 [95% CI, 0.56-0.76]; proctectomy: OR, 0.74 [95% CI, 0.65-0.85]). For the average patient at the average high-volume hospital, there was a 2-fold difference in the adjusted complication rate between the best-performing and worst-performing high-volume surgeon for all operations (esophagectomy, 28%-55%; lung resection, 7%-21%; pancreatectomy, 16%-35%; proctectomy, 16%-28%). Wide variation was also present in adjusted 90-day mortality for esophagectomy (3.5%-9.3%). Results from New York's all-payer database were similar. CONCLUSIONS Even among high-volume surgeons meeting the Leapfrog volume standards, wide variation in postoperative outcomes exists. These findings suggest that volume alone should not be used as a quality indicator, and quality metrics should be continuously evaluated across all surgeons and hospital systems. LAY SUMMARY Previous studies have demonstrated a surgical volume-outcome relationship for high-risk operations-that is high-volume surgeons and hospitals that perform a specific surgical procedure more frequently have better outcomes for that operation. Although most high-volume surgeons had better outcomes, this study demonstrated that some high-volume surgeons did not have better outcomes. Therefore, volume is an important factor but should not be the only factor considered when assessing the quality of a surgeon and a hospital for cancer surgery.
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Affiliation(s)
- Christopher T Aquina
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Adan Z Becerra
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Fergal J Fleming
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Jordan M Cloyd
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Allan Tsung
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Timothy M Pawlik
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Justiniano CF, Loria A, Hellenthal NJ, Schiralli MP, Soto FC, Albright JB, Giangreco L, Temple LK, Fleming FJ. The accumulation of ERAS (enhanced recovery after surgery) components reduces post-colectomy length of stay at small and low volume hospitals. Am J Surg 2021; 223:744-752. [PMID: 34311949 DOI: 10.1016/j.amjsurg.2021.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/02/2021] [Accepted: 07/03/2021] [Indexed: 11/29/2022]
Abstract
In small hospitals, where the majority of colectomy surgery is performed in the United States, adopting more individual ERAS components improves outcomes. The accumulation of individual ERAS components influences outcome more than an "ERAS designation" and this can be used by small hospitals to improve outcomes.
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Affiliation(s)
- Carla F Justiniano
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA.
| | - Anthony Loria
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | | | | | - Flavia C Soto
- Department of Surgery, State University of New York Upstate Medical Center, Syracuse, NY, USA
| | - Jeffrey B Albright
- Department of Surgery, State University of New York Upstate Medical Center, Syracuse, NY, USA
| | | | - Larissa K Temple
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Fergal J Fleming
- Surgical Health Outcomes & Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
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Hsu S, Rosen KJ, Temple L, Fleming FJ. The Association between Pathologic Complete Response after Neoadjuvant Chemoradiotherapy and Postoperative Complications. Dig Surg 2021; 38:300-306. [PMID: 34062543 DOI: 10.1159/000515725] [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: 12/22/2020] [Accepted: 03/08/2021] [Indexed: 12/10/2022]
Abstract
INTRODUCTION With growing interest in the watch-and-wait strategy, the benefits of avoiding surgery and its complications must be weighed against possible recurrence and need for salvage surgery. However, the relationship between pathologic complete response (pCR) and postoperative complications has not been well established. METHODS This is a retrospective study using the National Surgical Quality Improvement Program Proctectomy and Colectomy Procedure-Targeted databases from 2016 to 2018. The association between pCR and major complications, sepsis, anastomotic leak or organ space infection, return to the operating room, or septic shock was analyzed. RESULTS A total of 3,878 rectal cancer patients who received chemotherapy or radiation therapy within 90 days of surgery were included in this study. The pCR rate was 12.8%. There was no statistically significant association between pCR and major complications (adjusted odds ratio (OR) = 0.48, p = 0.12) after risk adjustment. Those with pCR had no statistically significant association with anastomotic leak or organ space infection, return to the operating room, or septic shock but had significantly lower odds of sepsis (adjusted OR = 0.42, p = 0.03). CONCLUSIONS It is reassuring that pCR is not associated with postoperative complications and that those with pCR are less likely to have postoperative sepsis after risk adjustment since postoperative sepsis after rectal surgery has been associated with poorer oncologic outcomes.
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Affiliation(s)
- Shawn Hsu
- Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, New York, USA
| | - Katherine J Rosen
- Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, New York, USA
| | - Larissa Temple
- Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, New York, USA
| | - Fergal J Fleming
- Surgical Health Outcomes & Research Enterprise (SHORE), University of Rochester Medical Center, Rochester, New York, USA
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Kleckner A, Reschke JE, Altman BJ, Belcher E, Dunne RF, Fleming FJ, Gilmore N, Jensen-Battaglia M, Kleckner I, Lin PJ, Mustian KM, Peppone LJ. A 10-hour time-restricted eating intervention to address cancer-related fatigue among cancer survivors. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.12109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
12109 Background: Cancer-related fatigue is a common, debilitating condition that can persist for months or years after cancer treatment. Time-restricted eating has been shown to improve circadian rhythm and strengthen rest and activity patterns, and therefore could help reduce persistent fatigue. Herein, we evaluated the feasibility of recruiting cancer survivors to a two-week, single-arm, time-restricted eating intervention with a 10-h eating window, assessed safety of the intervention, monitored adherence, and obtained initial estimates of within-group change in patient-reported fatigue. Methods: We recruited adults 4-60 months post-cancer treatment who had a fatigue level ≥3 on a scale from 0-10 and who did not already consume food within a 10-h window. Participants were asked to consume all food and beverages within a self-selected 10-h eating window for 14 days; water was allowed at all times. Participants completed a daily diary indicating when they began and stopped eating each day. To assess fatigue, participants completed the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) and the Brief Fatigue Inventory (BFI) at pre- and post-intervention. We report mean±standard deviation and used a t-test to assess differences in pre- vs. post-intervention scores. Results: A total of 21 participants consented (20 breast cancer, 1 prostate cancer; 20 female; age 57.7±11.4 years; 1.6±1.1 years post-primary treatment). The study was feasible: 19/21 (90.5%) completed pre- and post-intervention assessments and daily diaries. It was also safe: there were two mild adverse events—one unlikely (insomnia) and one possibly related to the intervention (acute headache) and no severe adverse events. Most of the participants adhered to the intervention; 14/19 (73.7%) ate all of their food within a 10-h window at least 80% of the days, and 16/19 (84.2%) reported an average eating window ≤10 h. Fatigue scores improved a clinically meaningful degree for FACIT-F total score, FACIT-F fatigue subscale, and the BFI total score from pre- to post-intervention per established cutoffs (Table). Conclusions: Cancer survivors were willing and able to adhere to a two-week time-restricted eating intervention, and the intervention was safe. Also, fatigue was reduced with moderate to large effect sizes after two weeks of time-restricted eating. Based on our results, a follow-up randomized controlled trial to investigate time-restricted eating to alleviate cancer-related fatigue among cancer survivors is indicated. Funding: NIH/NCI UG1CA189961, T32CA102618. Clinical trial information: NCT04243512. [Table: see text]
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Affiliation(s)
| | | | | | | | | | | | | | | | - Ian Kleckner
- University of Rochester Medical Center, Rochester, NY
| | - Po-Ju Lin
- University of Rochester Medical Center, Rochester, NY
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Noyes K, Sahler OJ, Zapf A, Depner R, Huston A, McNeal D, Flores T, Rashid HH, Fleming FJ, Constine LS. Problem-solving skills training in adult cancer survivors: Bright IDEAS-AC. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e24109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e24109 Background: Cancer patients experience significant distress throughout treatment and especially during transition back to normal life with greater burden on socially disadvantaged patients and those with medical comorbidities. Patient stressors can interfere with their ability to make reasoned and timely decisions about survivorship care and lead to poor quality of life and low physical and social functioning. This pilot effectiveness-implementation study examined the impact and feasibility of offering the Bright IDEAS system of Problem-Solving Skills Training (PSST) to adult cancer survivors to help them and their caregivers cope more successfully with decision making and distress. Methods: Patients with breast (21), prostate (9) or colorectal (20) cancer who completed their definitive cancer treatment within the last 6 months and had their cancer survivorship visit were recruited from two regional cancer centers and affiliated community oncology clinics. Patients with an NCCN distress level > 2 were randomly assigned to either care as usual (CAU) or 8 weekly PSST sessions provided by a trained therapist in person or remotely. Patients were invited but not required to include a supportive other (n = 17). Patient and caregiver assessments at baseline (T1), end of intervention/3 months (T2), and 3 months post intervention/6 months (T3) focused on problem-solving skills (SPSI-25), distress (HADS) and quality of life (FACT). We also collected healthcare utilization data. We compared outcome changes T1-T2 and T1-T3, by study arm, using t-tests. Multivariate regression analysis identified subgroups of patients with positive and negative responses to skills training. Results: Average age of the participants was 63 years (45 to 87) with racial and ethnic distributions representative of the local population (88% white). Two thirds were women (n = 32), one third of the patients were recruited and received therapy fully remotely due to COVID-19-related protocol changes. Patients who received PSST reported a reduction in dysfunctional problem-solving style and improvement in constructive style while problem-solving skills of CAU patients trended in the opposite direction. Patients in the PSST arm also reported significant reduction in anxiety and depression and improvement in cancer-specific quality of life (p < 0.05) that was sustained at 6 months. Patients in the PSST arm reported lower use of hospital and ED services compared to CAU patients (p = 0.07). Better improvement in outcomes was driven by lower problem-solving skills at baseline. Conclusions: Despite the logistical complexity of running a clinical trial during quarantine, patients and caregivers in the PSST arm demonstrated meaningful improvement in distress and quality of life. The evidence from this pilot study will help guide development of a future multi-site randomized clinical trial of the effect of PSST on cancer survivorship care and outcomes. Clinical trial information: NCT03567850.
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Affiliation(s)
- Katia Noyes
- University of Rochester Medical Center, Rochester, NY
| | | | - Alaina Zapf
- University of Rochester Medical Center, Rochester, NY
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Aquina CT, Becerra AZ, Ejaz A, Monson JR, Fleming FJ. Comprehensive or specialty-specific cancer care in the United States: A story of continuing underperformance. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.6577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6577 Background: “Textbook oncologic outcome” (TOO) is a composite measure representing the “ideal” outcome for patients undergoing cancer surgery and is associated with improved survival. Using TOO as the primary outcome, we asked whether hospitals are high-performing across multiple cancer types. Methods: Patients undergoing potentially curative breast, colon, rectal, lung, or pancreatic cancer resection were identified within the National Cancer Database (2010-2016). Organ-specific TOO was defined as: adequate lymph node yield, R0 resection, non-length of stay outlier, no hospital readmission, no 90-day postoperative mortality, and receipt of guideline-concordant chemotherapy and/or radiation. Mixed-effects analyses estimated the risk-adjusted TOO rate for each hospital stratified by cancer type. Results: Among 1,094,550 cancer resections (breast = 690,442; colon = 213,918; lung = 121,771; rectum = 40,315; pancreas = 28,104), 434 hospitals performed ≥10 resections for each cancer type. Only 11 hospitals (2.5%) ranked in the top quartile for adjusted TOO rate for all five cancer types. Of the 323 hospitals (74.4%) that ranked in the top quartile for one cancer type, 149 hospitals (46.1%) also ranked in the bottom quartile for another cancer type. There was a weak correlation between hospital rankings across cancer types with the strongest correlations between colon and rectal cancer (R2= 0.148) and lung and pancreatic cancer (R2= 0.098). Conclusions: Most U.S. hospitals do not provide high-quality care across cancer types with respect to TOO. Perhaps this knowledge should be used to guide referral for oncology care.
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Affiliation(s)
- Christopher Thomas Aquina
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
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Noyes K, Zapf A, Depner R, Flores T, Huston A, Rashid HH, McNeal D, Sahler OJ, Constine LS, Fleming FJ. Feasibility of fully remote administration of problem-solving skills training (PSST) to adult cancer survivors in community settings. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.1536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
1536 Background: Cancer survivors experience significant stress throughout cancer treatment and especially during transition back to normal life. These stressors are particularly severe for rural or socially disadvantaged patients with limited access to care. Improving their problem-solving skills is known to help patients make reasoned and timely decisions about survivorship care that reduce stress and enhance quality of life, physical and social functioning, and overall cancer prognosis. This pilot implementation study examined barriers to and facilitators of providing Problem-Solving Skills Training (PSST) to adult cancer survivors and their caregivers in community settings. Methods: Patients (n = 50) who completed their definitive cancer treatment and cancer survivorship visit within the previous 6 months were recruited from two regional cancer centers and affiliated community cancer clinics. Patients with NCCN distress level >2 were randomly assigned to either care as usual (CAU) or 8 weekly PSST sessions using the Bright IDEAS system of teaching problem solving. Training was offered by a trained therapist in person at the patient’s preferred location or remotely. Patients were invited but not required to include a supportive other (SO). Patient outcomes were assessed at baseline (T1), the end of the intervention/3 months (T2), and 3 months post intervention/6 months (T3). We examined patient and caregiver preferences for mode of communication and therapy, barriers to PSST participation, and adherence rates. An independent consultant interviewed patients and caregivers about factors that promote or inhibit intervention sustainability and its wider adaptation and usefulness. Results: Average age of the participants was 63 years (45-87) with gender, racial and ethnic distributions representative of the local population (64% women, 88% white). Women were 80% less likely to include a SO than men. Among the third of the patients recruited fully remotely, 50% preferred receiving consent materials via regular mail and 18% preferred electronic communication. Among the two patients lost to follow-up before PSST completion and one patient who withdrew despite reporting significant distress, none had a SO in the study. Seventy-six percent of the PSST patients completed the training (defined as > 6 sessions). After study completion, all patients and caregivers reported high satisfaction with Bright IDEAS and high probability of continuing to use the skills learned. Conclusions: Despite significant distress and numerous reported social challenges, patients and caregivers in the PSST arm demonstrated high adherence, skill retention and overall satisfaction. Future research should be tailored to accommodate the preferred type of communication and recruitment approaches of the targeted population and emphasize the positive role of informal caregivers. Clinical trial information: NCT03567850.
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Affiliation(s)
- Katia Noyes
- University of Rochester Medical Center, Rochester, NY
| | - Alaina Zapf
- University of Rochester Medical Center, Rochester, NY
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Aquina CT, Becerra AZ, Ejaz A, Monson JR, Fleming FJ. How to choose your surgeon for colorectal cancer: The influence of fellowship training on outcomes. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e18603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e18603 Background: Rectal cancer has a well-established volume-outcome relationship. However, the impact of fellowship training on outcomes following colorectal cancer resection is unknown. Methods: Patients who underwent stage I-III colorectal adenocarcinoma resection (2004-2014) were identified in the New York State Cancer Registry and Statewide Planning & Research Cooperative System. Hierarchical analyses assessed the association between surgeon American Board of Colorectal Surgery (ABCRS) certification and postoperative outcomes and survival. Derived from volume tertiles, surgeons who performed ≥15 annual colon cancer resections or ≥10 annual rectal cancer resections were characterized as high-volume colon (HVCSs) or rectal (HVRSs) surgeons, respectively. Results: 47,491 colorectal cancer resections (right colon = 23,824, 50.2%; left colon = 18,154, 38.2%; rectal cancer = 5,513, 11.6%) met inclusion criteria. ABCRS-certified HVCSs (N = 92) comprised only 5.5% of the surgeon cohort but performed 20.6% of the colon cancer resections. Similarly, ABCRS-certified HVRSs (N = 31) comprised only 3.8% of the surgeon cohort but performed 16.5% of the rectal cancer resections. Despite no significant difference in complications, ABCRS-certified HVCS/HVRSs overall had better postoperative outcomes and were associated with improved survival following colorectal cancer resection. Conclusions: These results suggest that for the best outcomes and long-term survival following colon and rectal cancer resection, referral to high-volume, ABCRS-certified surgeons may be the best choice.[Table: see text]
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Affiliation(s)
- Christopher Thomas Aquina
- Division of Surgical Oncology, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Aslam Ejaz
- Division of Surgical Oncology, Department of Surgery, The Ohio State University, Columbus, OH
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Xu Z, Fleming FJ. The treatment-travel tradeoff of colorectal cancer care. Surgery 2020; 169:989-990. [PMID: 33220976 DOI: 10.1016/j.surg.2020.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/08/2020] [Accepted: 10/11/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Zhaomin Xu
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, Division of Colorectal Surgery, University of Rochester Medical Center, NY; Department of Colorectal Surgery, Cleveland Clinic, OH.
| | - Fergal J Fleming
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, Division of Colorectal Surgery, University of Rochester Medical Center, NY
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Becerra AZ, Xu Z, Fleming FJ, Temkin SM. Response Regarding: Complications and Survivorship Trends After Primary Debulking Surgery for Ovarian Cancer. J Surg Res 2020; 255:652. [PMID: 32561031 DOI: 10.1016/j.jss.2020.05.047] [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: 04/17/2020] [Accepted: 05/03/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Adan Z Becerra
- Department of Surgery, Rush University Medical Center, Chicago, Illinois.
| | - Zhaomin Xu
- Department of Surgery, Surgical Health Outcomes and Research Enterprise, University of Rochester Medical Center, Rochester, New York
| | - Fergal J Fleming
- Department of Surgery, Surgical Health Outcomes and Research Enterprise, University of Rochester Medical Center, Rochester, New York
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Xu Z, Fleming FJ. Quality Assurance, Metrics, and Improving Standards in Rectal Cancer Surgery in the United States. Front Oncol 2020; 10:655. [PMID: 32411608 PMCID: PMC7202129 DOI: 10.3389/fonc.2020.00655] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 04/08/2020] [Indexed: 12/20/2022] Open
Abstract
Rectal cancer surgery has seen significant improvement in recent years. This has been possible in part due to focus on surgeon education and training, specific surgical quality metrics, and longitudinal tracking of data through the use of registries. In countries that have implemented such efforts, data has shown significant improvement in outcomes. However, there continues to be significant variation in rectal cancer outcomes and practices worldwide. Just within the United States, county level mortality rates from rectal cancer range from 8-15 per 100,000 to 38-59 per 100,000. In order to continue to improve rectal cancer patient outcomes, there needs to be evidence based guidelines and standards centered around the framework of structure, process, and outcomes. In addition, there must be a feedback system by which programs can continually assess their performance. Obtaining evidence for specific standards and measures can be challenging and requires analyzing available data and literature, some of which may be conflicting. This article evaluates the evolution of metrics and standards used for quality improvement in rectal cancer and ongoing efforts to further improve patient outcomes.
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Affiliation(s)
- Zhaomin Xu
- Surgical Health Outcomes and Research Enterprise (SHORE), Division of Colorectal Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Fergal J Fleming
- Surgical Health Outcomes and Research Enterprise (SHORE), Division of Colorectal Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY, United States
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Xu Z, Becerra AZ, Justiniano CF, Aquina CT, Fleming FJ, Boscoe FP, Schymura MJ, Sinno AK, Chaoul J, Morrow GR, Minasian L, Temkin SM. Complications and Survivorship Trends After Primary Debulking Surgery for Ovarian Cancer. J Surg Res 2019; 246:34-41. [PMID: 31561176 DOI: 10.1016/j.jss.2019.08.027] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 07/29/2019] [Accepted: 08/29/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND We examined factors associated with postoperative complications, 1-year overall and cancer-specific survival after epithelial ovarian cancer (EOC) diagnosis. METHODS Patients who underwent surgery for EOC between 2004 and 2013 were included. Multivariable models analyzed postoperative complications, overall survival, and cancer-specific survival. RESULTS Among 5223 patients, surgical complications were common. Postoperative complications correlated with increased odds of overall and disease-specific survival at 1 y. Receipt of chemotherapy was similar among women with and without postoperative complications and was independently associated with a reduction in the hazard of overall and disease-specific death at 1-year. Extensive pelvic and upper abdomen surgery resulted in 2.26 times the odds of postoperative complication, but was associated with longer 1-year overall 0.53 (0.35, 0.82) and disease-specific survival 0.54 (0.34, 0.85). CONCLUSIONS Although extent of surgery was associated with complications, the survival benefit from comprehensive surgery offset the risk. Tailored surgical treatment for women with EOC may improve outcomes.
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Affiliation(s)
- Zhaomin Xu
- Department of Surgery, Surgical Health Outcomes and Research Enterprise, University of Rochester Medical Center, Rochester, New York
| | - Adan Z Becerra
- Department of Surgery, Surgical Health Outcomes and Research Enterprise, University of Rochester Medical Center, Rochester, New York; Department of Public Health Sciences, Social & Scientific Systems, Silver Spring, Maryland.
| | - Carla F Justiniano
- Department of Surgery, Surgical Health Outcomes and Research Enterprise, University of Rochester Medical Center, Rochester, New York
| | - Christopher T Aquina
- Department of Surgery, Surgical Health Outcomes and Research Enterprise, University of Rochester Medical Center, Rochester, New York
| | - Fergal J Fleming
- Department of Surgery, Surgical Health Outcomes and Research Enterprise, University of Rochester Medical Center, Rochester, New York
| | - Francis P Boscoe
- New York State Cancer Registry, New York State Department of Health, Albany, New York
| | - Maria J Schymura
- New York State Cancer Registry, New York State Department of Health, Albany, New York
| | - Abdulrahman K Sinno
- Department of Gynecology and Obstetrics, Olive View-UCLA Medical Center, Kagel Canyon, California
| | - Jessica Chaoul
- Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Gary R Morrow
- Department of Surgery, James P. Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York
| | - Lori Minasian
- Division of Cancer Prevention, National Cancer Institute, Bethesda, Maryland
| | - Sarah M Temkin
- Department of Ob/Gyn, Virginia Commonwealth University Medical Center, Richmond, Virginia
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Lee L, Dietz DW, Fleming FJ, Remzi FH, Wexner SD, Winchester D, Monson JRT. Accreditation Readiness in US Multidisciplinary Rectal Cancer Care: A Survey of OSTRICH Member Institutions. JAMA Surg 2019; 153:388-390. [PMID: 29238809 DOI: 10.1001/jamasurg.2017.4871] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Lawrence Lee
- Center for Colon and Rectal Surgery, Florida Hospital, Orlando
| | - David W Dietz
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Fergal J Fleming
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Feza H Remzi
- Department of Surgery, New York University Langone Medical Center, New York
| | - Steven D Wexner
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston
| | - David Winchester
- Division of Research and Optimal Patient Care (Cancer), American College of Surgeons, Chicago, Illinois
| | - John R T Monson
- Center for Colon and Rectal Surgery, Florida Hospital, Orlando
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Aquina CT, Becerra AZ, Xu Z, Justiniano C, Peyre CG, Linehan D, Temple LKF, Fleming FJ. Can high-volume surgeons achieve optimal outcomes at low-volume hospitals? Implications for the Leapfrog Initiative and regionalization of high-risk surgical oncology procedures. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.6585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6585 Background: The Leapfrog group recently released surgeon and hospital procedure volume standards for several surgical oncology procedures. This study investigated trends in volume and whether high-volume surgeons at low-volume hospitals achieve equivalent outcomes to high-volume surgeons at high-volume hospitals. Methods: New York’s Statewide Planning and Research Cooperative System was queried for esophagectomy, lung resection, pancreatectomy, and proctectomy for cancer from 2004-2015. Mixed-effects analyses assessed the association among Leapfrog surgeon/hospital volume standards and 90-day mortality. Results: Among 55,528 cases, high-volume surgeons performed 64.7% of cases (esophagectomy = 52%; lung resection = 75.6%; pancreatectomy = 56.7%; proctectomy = 53%), and high-volume hospitals performed 59.5% of cases (esophagectomy = 55.5%; lung resection = 58.3%; pancreatectomy = 63.4%; proctectomy = 61%). After risk-adjustment, high-volume surgeons at high-volume hospitals had lower odds of 90-day mortality compared to high-volume surgeons at low-volume hospitals for each organ system except for pancreas. Despite trends toward regionalization, between 2012-2015, there were large differences in the number of hospitals and median annual case number between high-volume and low-volume centers for esophagectomy (8 vs. 56 hospitals; 31.5 vs. 3 cases), lung resection (22 vs. 89 hospitals; 69.5 vs. 7 cases), pancreatectomy (15 vs. 56 hospitals; 36 vs. 3 cases), and proctectomy (38 vs. 117 hospitals; 28 vs. 3 cases). Conclusions: This study supports the Leapfrog initiative for performance of high-risk surgical oncology procedures by high-volume surgeons at high-volume hospitals. However, it remains unclear whether full regionalization to high-volume centers is feasible. [Table: see text]
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Affiliation(s)
| | | | - Zhaomin Xu
- University of Rochester Medical Center, Rochester, NY
| | | | | | - David Linehan
- University of Rochester Medical Center, Rochester, NY
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Xu Z, Becerra AZ, Fleming FJ, Aquina CT, Dolan JG, Monson JR, Temple LK, Jusko TA. Treatments for Stage IV Colon Cancer and Overall Survival. J Surg Res 2019; 242:47-54. [PMID: 31071604 DOI: 10.1016/j.jss.2019.04.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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: 01/28/2019] [Revised: 03/21/2019] [Accepted: 04/09/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND The role of primary tumor resection (PTR) for asymptomatic stage IV colon cancer with unresectable metastases remains unclear. Increasingly there has been a trend away from resection. The aim of this study was to examine trends in the treatment of stage IV colon cancers, impact of different treatments on long-term mortality, and factors associated with receipt of postoperative chemotherapy. METHODS The 2006-2012 National Cancer Data Base was queried for stage IV colon cancer patients. Treatments were grouped into PTR and chemotherapy, PTR only, chemotherapy only, and no treatment. A descriptive analysis was performed examining patient and hospital characteristics associated with different treatments. A Cox regression analysis was used to assess the adjusted effect of different treatments on long-term survival. A multivariable logistic regression was used to examine factors associated with postoperative chemotherapy. RESULTS Of 31,310 patients, who met inclusion criteria, 22% of the patients underwent PTR and chemotherapy, 37.5% received chemotherapy only, 11.9% underwent PTR, and 28.6% received no treatment. Patients who received no treatment had the highest hazard of death at 1, 3, and 5 y, followed by PTR only, and chemotherapy only compared with PTR combined with chemotherapy. Patients who were older and had more comorbidities were less likely to receive postoperative chemotherapy. CONCLUSIONS Primary tumor resection in conjunction with postoperative chemotherapy among stage IV colon cancer patients with unresectable metastases was associated with a long-term survival benefit compared with other treatment options. Efforts should be made to increase the use of postoperative chemotherapy where feasible.
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Affiliation(s)
- Zhaomin Xu
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Adan Z Becerra
- Department of Surgery, University of Rochester Medical Center, Rochester, New York; Department of Public Health Sciences, Social and Scientific Systems, Silver Spring, Maryland; Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York.
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Christopher T Aquina
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - James G Dolan
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
| | - John R Monson
- Department of Surgery, Center for Colon and Rectal Surgery, Florida Hospital Medical Group, Orlando, Florida
| | - Larissa K Temple
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Todd A Jusko
- Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York
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Justiniano CF, Aquina CT, Becerra AZ, Xu Z, Boodry CI, Swanger AA, Monson JRT, Fleming FJ. Postoperative Mortality After Nonelective Surgery for Inflammatory Bowel Disease Patients in the Era of Biologics. Ann Surg 2019; 269:686-691. [PMID: 29232213 DOI: 10.1097/sla.0000000000002628] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim of the study was to analyze recent trends in the rate of nonelective surgery and corresponding mortality for inflammatory bowel disease (IBD) patients since the rise of biologic use. BACKGROUND Modern biologic therapy has improved outcomes for IBD, but little is known about the impact on mortality rates after nonelective surgery. METHODS New York's Statewide Planning & Research Cooperative System was queried for hospital admissions for ulcerative colitis (UC) with concurrent colectomy and Crohn disease (CD) with concurrent small bowel resection or colectomy from 2000 to 2013. Mixed-effects analyses assessed patient, surgeon, and hospital-level factors and hospital-level variation associated with 30-day mortality after nonelective surgery. RESULTS Between 2000 to 2006 and 2007 to 2013, the number of unscheduled IBD-related admissions increased by 50% for UC and 41% for CD, but no change in the proportion of nonelective surgery cases was observed (UC=38% vs 38%; CD=45% vs 42%) among 15,837 intestinal resections (UC=5,297; CD=10,540). Nonelective surgery mortality rates between 2000 to 2006 and 2007 to 2013 were high and increased for UC (10.2% vs 15%) but decreased for CD (3.3% vs 2.2%). Nonelective surgery in 2007 to 2013 was associated with an 82% increased risk of 30-day mortality in UC cases (odds ratio: 1.82; confidence interval: 1.19-2.62). After controlling for patient-level factors, large hospital-level variation was observed with 23-fold difference in mortality for both UC and CD. CONCLUSIONS Although nonelective IBD surgery rates have remained stable, associated 30-day mortality for UC has doubled in recent years despite advances in medical management. Current clinical decision-making and care pathways must be further evaluated to improve outcomes in this high-risk population.
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Affiliation(s)
- Carla F Justiniano
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | | | - Adan Z Becerra
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
- Department of Public Health Sciences, Division of Epidemiology, University of Rochester Medical Center, Rochester, NY
| | - Zhaomin Xu
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Courtney I Boodry
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - Alex A Swanger
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
| | - John R T Monson
- Center for Colon and Rectal Surgery, Florida Hospital Medical Group, University of Central Florida, College of Medicine, Orlando, FL
| | - Fergal J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, NY
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Cummings MA, Usuki KY, Fleming FJ, Tejani MA, Katz AW. Short course radiation therapy for rectal cancer in the elderly: can radical surgery be avoided? J Gastrointest Oncol 2019; 10:357-361. [PMID: 31032106 DOI: 10.21037/jgo.2018.09.05] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Rectal cancer in elderly patients can be difficult to manage. Short course radiation therapy (SCRT) has shown to be effective when given immediately prior to surgery. Here we report outcomes of elderly patients who underwent SCRT either alone or prior to resection. Between 2010 and 2015, elderly patients with rectal cancer and no distant metastatic disease were identified. Symptoms at diagnosis, therapies, toxicities, and pathologic and clinical response were recorded from patient charts. The SCRT prescription dose was 5 Gy ×5 to the rectal tumor and 4 Gy ×5 to the mesorectum, omitting the iliac nodes. Twenty patients were identified with median age of 85 years (range, 71-93 years). No patient received systemic therapy. Sixty percent of patients were cT3 at diagnosis. Half underwent resection post SCRT and half received SCRT as definitive therapy. The 1- and 2-year overall survival was 75% and 54%. Overall survival did not differ between patients treated with SCRT and surgery compared to SCRT alone (P=0.8). Of the 10 surgical patients, 3 had a complete pathologic response at time of resection and 3 patients died within 2 weeks due to perioperative complications. Of patients treated with SCRT alone, 8 were symptomatic at presentation and 5 had a clinician defined symptomatic response. No patient treated with SCRT monotherapy required additional palliative measures for outflow obstruction, but 2 progressed locally and died. SCRT is well tolerated, results in pathologic complete responses in a small percentage of patients, and achieves 63% symptom improvement rate as monotherapy. A high peri-operative complication rate was observed in this small series. In elderly patients, SCRT as initial treatment with a watch and wait approach for surgery is feasible and should be evaluated prospectively.
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Affiliation(s)
- Michael A Cummings
- Department of Radiation Oncology, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | - Kenneth Y Usuki
- Department of Radiation Oncology, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | - Fergal J Fleming
- Department of Colorectal Surgery, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | - Mohamedtaki A Tejani
- Department of Medicine, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | - Alan W Katz
- Department of Radiation Oncology, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, NY, USA
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Deeb AP, Aquina CT, Monson JRT, Blumberg N, Becerra AZ, Fleming FJ. Allogeneic Leukocyte-Reduced Red Blood Cell Transfusion Is Associated with Postoperative Infectious Complications and Cancer Recurrence after Colon Cancer Resection. Dig Surg 2019; 37:163-170. [PMID: 30836367 DOI: 10.1159/000498865] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 01/30/2019] [Indexed: 12/10/2022]
Abstract
BACKGROUND/AIMS Transfusion rates in colon cancer surgery are traditionally very high. Allogeneic red blood cell (RBC) transfusions are reported to induce immunomodulation that contributes to infectious morbidity and adverse oncologic outcomes. In an effort to attenuate these effects, the study institution implemented a universal leukocyte reduction protocol. The purpose of this study was to examine the impact of leukocyte-reduced (LR) transfusions on postoperative infectious complications, recurrence-free survival, and overall survival (OS). METHODS In a retrospective study, patients with stage I-III adenocarcinoma of the colon from 2003 to 2010 who underwent elective resection were studied. The primary outcome measures were postoperative infectious complications and recurrence-free and OS in patients that received a transfusion. Bivariate and multivariable regression analyses were performed for each endpoint. RESULTS Of 294 patients, 66 (22%) received a LR RBC transfusion. After adjustment, transfusion of LR RBCs was found to be independently associated with increased infectious complications (OR 3.10, 95% CI 1.24-7.73), increased odds of cancer recurrence (hazard ratio [HR] 3.74, 95% CI 1.94-7.21), and reduced OS when ≥3 units were administered (HR 2.24, 95% CI 1.12-4.48). CONCLUSION Transfusion of LR RBCs is associated with an increased risk of infectious complications and worsened survival after elective surgery for colon cancer, irrespective of leukocyte reduction.
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Affiliation(s)
- Andrew-Paul Deeb
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA,
| | - Christopher T Aquina
- Department of Surgery, Surgical Health Outcomes and Research Enterprise, University of Rochester Medical Center, Rochester, New York, USA
| | - John R T Monson
- Center for Colon and Rectal Surgery, Florida Hospital Medical Group, University of Central Florida College of Medicine, Orlando, Florida, USA
| | - Neil Blumberg
- Department Pathology and Laboratory Medicine (Transfusion Medicine Unit), University of Rochester Medical Center, Rochester, New York, USA
| | - Adan Z Becerra
- Department of Surgery, Surgical Health Outcomes and Research Enterprise, University of Rochester Medical Center, Rochester, New York, USA
| | - Fergal J Fleming
- Department of Surgery, Surgical Health Outcomes and Research Enterprise, University of Rochester Medical Center, Rochester, New York, USA
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Justiniano CF, Aquina CT, Fleming FJ, Xu Z, Boscoe FP, Schymura MJ, Temple LK, Becerra AZ. Hospital and surgeon variation in positive circumferential resection margin among rectal cancer patients. Am J Surg 2019; 218:881-886. [PMID: 30853095 DOI: 10.1016/j.amjsurg.2019.02.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 01/09/2019] [Revised: 02/15/2019] [Accepted: 02/26/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND The objective of this study was to evaluate variation in positive CRM at the surgeon and hospital levels and assess impact on disease-specific survival. METHODS Patients with stage I-III rectal cancer were identified in New York State. Bayesian hierarchical regressions estimated observed-to-expected (O/E) ratios for each surgeon/hospital. Competing-risks analyses estimated disease-specific survival among patients who were treated by surgeons/hospitals with O/E > 1 compared to those with O/E ratio ≤ 1. RESULTS Among 1,251 patients, 208 (17%) had a positive CRM. Of the 345 surgeons and 118 hospitals in the study, 99 (29%) and 48 (40%) treated a higher number of patients with CRM than expected, respectively. Patients treated by surgeons with O/E > 1 (HR = 1.38, 95% CI = 1.16, 1.67) and those treated at hospitals with O/E > 1 (HR = 1.44, 95% CI = 1.11, 1.85) had worse disease-specific survival. DISCUSSION Surgeon and hospital performance in positive CRM is associated with worse prognosis suggesting opportunities to enhance referral patterns and standardize care.
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Affiliation(s)
- Carla F Justiniano
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Christopher T Aquina
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Fergal J Fleming
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Zhaomin Xu
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Francis P Boscoe
- New York State Cancer Registry, New York State Department of Health, Albany, NY, USA
| | - Maria J Schymura
- New York State Cancer Registry, New York State Department of Health, Albany, NY, USA
| | - Larissa K Temple
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Adan Z Becerra
- Surgical Health Outcomes and Research Enterprise, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA; Department of Public Health Sciences, Division of Epidemiology, University of Rochester Medical Center, Rochester, NY, USA.
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Justiniano CF, Xu Z, Becerra AZ, Aquina CT, Boodry CI, Temple LK, Fleming FJ. Effect of care continuity on mortality of patients readmitted after colorectal surgery. Br J Surg 2019; 106:636-644. [PMID: 30706462 DOI: 10.1002/bjs.11078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/21/2018] [Accepted: 11/06/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND Postoperative readmission after colorectal resection is common. It is unknown whether patients who receive readmission care from the surgeon who performed the index surgery have improved mortality. This study evaluated whether postdischarge continuity of care, defined at the hospital and surgeon level, was associated with decreased mortality after colorectal surgery. METHODS The Statewide Planning and Research Cooperative System was queried for patients who had colorectal resections from 2004 to 2014, and were readmitted within 30 days of discharge. Propensity-adjusted logistic regression analysis was used to evaluate the association between 30-day mortality and readmission care continuity. RESULTS A total of 20 016 patients readmitted within 30 days of discharge were eligible for analysis. Some 39·5 per cent of readmitted patients experienced hospital and surgeon care continuity, 47·1 per cent hospital but not surgeon continuity, 1·0 per cent surgeon but not hospital continuity, and 12·4 per cent neither hospital nor surgeon care continuity. A total of 1349 patients (6·7 per cent) died within 30 days of readmission. Patients readmitted with absence of surgeon but not of hospital care continuity had 2·04 (95 per cent c.i. 1·72 to 2·42) times the risk of 30-day mortality compared with those who experienced surgeon and hospital continuity. Absence of both surgeon and hospital care continuity was associated with 2·65 (2·18 to 3·30) times the risk of death compared with presence of both. CONCLUSION Readmission after colorectal resection not under the care of the index operating surgeon is associated with an increased risk of 30-day mortality. Addressing processes of care that are affected by surgeon care continuity may decrease surgical deaths.
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Affiliation(s)
- C F Justiniano
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Z Xu
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - A Z Becerra
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA.,Division of Epidemiology, Department of Public Health Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - C T Aquina
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - C I Boodry
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - L K Temple
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - F J Fleming
- Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
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Aquina CT, Becerra AZ, Xu Z, Justiniano CF, Noyes K, Monson JRT, Fleming FJ. Population-based study of outcomes following an initial acute diverticular abscess. Br J Surg 2018; 106:467-476. [DOI: 10.1002/bjs.10982] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 07/08/2018] [Accepted: 07/23/2018] [Indexed: 12/15/2022]
Abstract
Abstract
Background
Studies examining long-term outcomes following resolution of an acute diverticular abscess have been limited to single-institution chart reviews. This observational cohort study compared outcomes between elective colectomy and non-operative management following admission for an initial acute diverticular abscess.
Methods
The Statewide Planning and Research Cooperative System was queried for unscheduled admissions for an initial acute diverticular abscess in 2002–2010. Bivariable and propensity-matched multivariable analyses compared stoma rates and use of healthcare in patients who had an elective resection and those receiving non-operative management. Diverticulitis recurrence rates were analysed for non-operative management.
Results
Among 10 342 patients with an initial acute diverticular abscess, one-third (3270) underwent surgical intervention within 30 days despite initial non-operative management. Of the remaining 7072 patients, 1660 had an elective colectomy within 6 months. Of 5412 patients receiving non-operative management, 1340 (24·8 per cent) had recurrence of diverticulitis within 5 years (median 278 (i.q.r. 93·5–707) days to recurrence). Elective colectomy was associated with higher stoma rates (10·0 per cent, compared with 5·7 per cent for non-operative observation, P < 0·001; odds ratio 1·88, 95 per cent c.i. 1·50 to 2·36), as well as more inpatient hospital days for diverticulitis-related admissions (mean 8·0 versus 4·6 days respectively, P < 0·001; incidence rate ratio (IRR) 2·16, 95 per cent c.i. 1·89 to 2·47) and higher mean diverticulitis-related cost (€70 107 versus €24 490, P < 0·001; IRR 3·11, 2·42 to 4·01).
Conclusion
Observation without elective colectomy following resolution of an initial diverticular abscess is a reasonable option with lower healthcare costs than operation.
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Affiliation(s)
- C T Aquina
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - A Z Becerra
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Z Xu
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - C F Justiniano
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - K Noyes
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - J R T Monson
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
- Center for Colon and Rectal Surgery, Florida Hospital Group, University of Central Florida, College of Medicine, Orlando, Florida, USA
| | - F J Fleming
- Surgical Health Outcomes and Research Enterprise (SHORE), Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
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Dunne RF, Roussel B, Culakova E, Pandya C, Fleming FJ, Hensley B, Magnuson AM, Loh KP, Gilles M, Ramsdale E, Maggiore RJ, Jatoi A, Mustian KM, Dale W, Mohile SG. Characterizing cancer cachexia in the geriatric oncology population. J Geriatr Oncol 2018; 10:415-419. [PMID: 30196027 DOI: 10.1016/j.jgo.2018.08.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [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: 04/04/2018] [Revised: 07/31/2018] [Accepted: 08/10/2018] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Cancer cachexia, characterized by weight loss and sarcopenia, leads to a decline in physical function and is associated with poorer survival. Cancer cachexia remains poorly described in older adults with cancer. This study aims to characterize cancer cachexia in older adults by assessing its prevalence utilizing standard definitions and evaluating associations with components of the geriatric assessment (GA) and survival. MATERIALS AND METHODS Patients with cancer older than 65 years of age who underwent a GA and had baseline CT imaging were eligible in this cross-sectional study. Cancer cachexia was defined by the international consensus definition reported in 2011. Sarcopenia was measured using cross-sectional imaging and utilizing sex-specific cut-offs. Associations between cachexia, sarcopenia, and weight loss with survival and GA domains were explored. RESULTS Mean age of 100 subjects was 79.9 years (66-95) and 65% met criteria for cancer cachexia. Cachexia was associated with impairment in instrumental activities of daily living (IADL) (p = .017); no significant association was found between sarcopenia or weight loss and IADL impairment. Cachexia was significantly associated with poorer survival (median 1.0 vs 2.1 years, p = .011). CONCLUSIONS Cancer cachexia as defined by the international consensus definition is prevalent in older adults with cancer and is associated with functional impairment and decreased survival. Larger prospective studies are needed to further describe cancer cachexia in this population.
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Affiliation(s)
- Richard F Dunne
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States; University of Rochester NCI Community Oncology Research Program (UR NCORP), Rochester, NY, United States.
| | - Breton Roussel
- Department of Medicine, Brown University, Providence, RI, United States
| | - Eva Culakova
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States; University of Rochester NCI Community Oncology Research Program (UR NCORP), Rochester, NY, United States
| | - Chintan Pandya
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States
| | - Fergal J Fleming
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States
| | - Bradley Hensley
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States
| | - Allison M Magnuson
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States; University of Rochester NCI Community Oncology Research Program (UR NCORP), Rochester, NY, United States
| | - Kah Poh Loh
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States
| | - Maxence Gilles
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States
| | - Erika Ramsdale
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States; University of Rochester NCI Community Oncology Research Program (UR NCORP), Rochester, NY, United States
| | - Ronald J Maggiore
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States
| | - Aminah Jatoi
- Mayo Clinic, Department of Oncology, Rochester, MN, United States
| | - Karen M Mustian
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States; University of Rochester NCI Community Oncology Research Program (UR NCORP), Rochester, NY, United States
| | - William Dale
- City of Hope, Department of Supportive Care Medicine, Duarte, CA, United States
| | - Supriya G Mohile
- Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States; University of Rochester NCI Community Oncology Research Program (UR NCORP), Rochester, NY, United States
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Becerra AZ, Wexner SD, Dietz DW, Xu Z, Aquina CT, Justiniano CF, Swanger AA, Temple LK, Noyes K, Monson JR, Fleming FJ. Nationwide Heterogeneity in Hospital-Specific Probabilities of Rectal Cancer Understaging and Its Effects on Outcomes. Ann Surg Oncol 2018; 25:2332-2339. [DOI: 10.1245/s10434-018-6530-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Indexed: 01/09/2023]
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