Search

Introduction: Hemorrhage is a leading cause of death in trauma. Prehospital hemorrhage control techniques include tourniquet application for extremity wounds and direct compression; however, tourniquets are not effective in anatomic junctions, and direct compression is highly operator dependent. Balloon catheter compression has been employed previously in trauma care, but its use has been confined to the operating room and restricted to specific anatomic injuries. Methods: In a single-center retrospective review, we describe a technique for balloon catheter compression for hemorrhage control that can be employed across the continuum of trauma care, from the prehospital setting to the trauma bay, the operating room, and postoperative period. Results: Of 18,303 trauma patients in Venezuela, 45% of the 1757 patients with vascular injuries received Foley catheter compression for hemorrhage control. Of these catheters, the majority (75%) were placed in the emergency department, 5% in the prehospital setting, and 20% in the operating room. Over half (53.2%) of the balloon catheters were placed for hemorrhage control in non-compressible anatomic junctions. Conclusions: Foley catheter balloon compression is a useful addition to a provider's arsenal of hemorrhage control techniques, as it is effective in anatomic junctions, preserves collateral circulation through focused compression, and requires minimal active physical attention to maintain hemostasis. [ABSTRACT FROM AUTHOR]

Background: There is controversy regarding the widespread uptake of robotic surgery across several surgical disciplines. While it has been shown to confer clinical benefits such as decreased blood loss and shorter hospital stays, some argue that the benefits of this technology do not outweigh its high cost. We performed a retrospective insurance-based analysis to investigate how undergoing robotic surgery, compared to open surgery, may impact the time in which an employed individual returns to work after undergoing major surgery. Methods: We identified a cohort of US adults with employer-sponsored insurance using claims data from the MarketScan database who underwent either open or robotic radical prostatectomy, hysterectomy/myomectomy, and partial colectomy from 2012 to 2016. We performed multiple regression models incorporating propensity scores to assess the effect of robotic vs. open surgery on the number of absent days from work, adjusting for demographic characteristics and baseline absenteeism. Results: In a cohort of 1157 individuals with employer-sponsored insurance, those undergoing open surgery, compared to robotic surgery, had 9.9 more absent workdays for radical prostatectomy (95%CI 5.0 to 14.7, p < 0.001), 25.3 for hysterectomy/myomectomy (95%CI 11.0–39.6, p < 0.001), and 29.8 for partial colectomy (95%CI 14.8–44.8, p < 0.001) Conclusion: For the three major procedures studied, robotic surgery was associated with fewer missed days from work compared to open surgery. This information helps payers, patients, and providers better understand some of the indirect benefits of robotic surgery relative to its cost. [ABSTRACT FROM AUTHOR]

Purpose: Small bowel leiomyosarcoma (SB LMS) is a rare disease with few studies characterizing its outcomes. This study aims to evaluate surgical outcomes for patients with SB LMS. Methods: The National Cancer Database was queried from 2004 to 2016 to identify patients with SB LMS who underwent surgical resection. The primary outcome was overall survival. Results: A total of 288 patients with SB LMS who had undergone surgical resection were identified. The median age was 63, and the majority of patients were female (56%), White (82%), and had a Charlson comorbidity score of zero (76%). Eighty-one percent of patients had negative margins following surgical resection. Fourteen percent of patients had metastatic disease at the time of diagnosis. Nineteen percent of patients received chemotherapy and 3% of patients received radiation. One-year overall survival was 77% (95% CI: 72–82%) and 5-year overall survival was 43% (95% CI: 36–49%). Higher grade (HR: 1.98, 95% CI: 1.10–3.55, p = 0.02) and metastatic disease at diagnosis (HR: 2.57, 95% CI: 1.45–4.55, p = 0.001) were independently associated with higher risk of death. Conclusion: SB LMS is a rare disease entity, with treatment centering on complete surgical resection. Our results demonstrate that overall survival is higher than previously thought. Timely diagnosis to allow for complete surgical resection is key, and investigation into the possible role of chemotherapy or radiation therapy is needed. [ABSTRACT FROM AUTHOR]

Background: Local excision (LE) has been proposed as an alternative to radical resection for early distal rectal cancer, for which the optimal oncologic treatment remains unclear. Objective: The goal of this study was to compare the overall survival of rectal cancer patients with early distal tumors who underwent LE versus abdominoperineal resection (APR) using a large contemporary database. Methods: The National Cancer Database (2004–2013) was used to identify patients with early T-stage rectal adenocarcinoma who underwent LE or APR. Patients were split into groups based on T stage and type of surgery (LE vs. APR). The primary outcome measure was overall survival. An adjusted Cox proportional hazards model was used to evaluate the impact of treatment strategy on survival. Results: Overall, there were 2084 patients with T1 tumors and 912 patients with T2 tumors. For patients with T1 disease, after adjusting for age, sex, income level, race, Charlson score, insurance payor, and tumor size, there was no significant difference in survival between the LE and APR groups (hazard ratio [HR] 0.89, 95% confidence interval [CI] 0.65–1.22; P = 0.49). For patients with T2 disease, after adjusting for age, Charlson score, and tumor size, there was no significant difference in survival between patients undergoing LE + chemoradiation therapy (CRT) and APR (HR 1.11, 95% CI 0.84–1.45; P = 0.47). Conclusions: Patients with early distal rectal adenocarcinoma who underwent LE had similar survival to patients who underwent APR. LE is an acceptable oncologic treatment strategy for patients with T1 rectal cancers, and LE with CRT is an acceptable oncologic treatment for patients with T2 distal rectal cancers. [ABSTRACT FROM AUTHOR]

Background: Enhanced recovery after surgery (ERAS) programs are now standard of care for colorectal surgery. Efforts have been aimed at decreasing postoperative opioid consumption. The goal of this study is to evaluate the effect of liposomal bupivacaine transversus abdominis plane (TAP) blocks on opioid use and its downstream effect on rates of ileus and hospital length of stay (LOS). Methods: We performed a retrospective pre- and postintervention time-trend analysis (2016–2018) of ERAS patients undergoing laparoscopic colorectal surgery at two academic medical centers within the same hospital system. The intervention was liposomal bupivacaine TAP blocks versus standard local infiltration with bupivacaine with a primary outcome of total morphine milligram equivalents (MME) administered within 72 h of surgery. Secondary outcomes included hospital LOS and rate of postoperative ileus. Results: There were 556 patients included at the control hospital, and 384 patients were included at the treatment hospital. Patients at both hospitals were similar with regard to age, body mass index, comorbidities, and surgical indication. In an adjusted time-trend analysis, the treatment hospital was associated with a significant decrease in MME administered (– 15.9 mg, p = 0.04) and hospital LOS (– 0.8 days, p < 0.001). There was no significant decrease in the rate of ileus at the treatment hospital (– 6.9%, p = 0.08). Conclusions: In a time-trend analysis, the addition of liposomal bupivacaine TAP blocks into the ERAS protocol resulted in significantly reduced opioid use and shorter hospital LOS for patients undergoing surgery at the treatment hospital. Liposomal bupivacaine TAP blocks should be considered for inclusion in the standard ERAS protocol. [ABSTRACT FROM AUTHOR]

Background: Following abdominoperineal resection (APR) for rectal cancer, perineal wound complications are common. Omental flap creation may allow for decreased morbidity. The aim of this study was to assess wound complications in rectal cancer patients undergoing APR with and without the addition of an omental flap. Methods: The National Surgical Quality Improvement Program Proctectomy targeted database from 2016 to 2017 was used to identify all patients undergoing APR for rectal cancer. The primary outcomes were wound complications such as superficial site infection, deep wound infection, organ space infection, and wound dehiscence. Results: There were 3063 patients identified. One hundred seventy-three (5.6%) patients underwent APR with an omental flap repair while 2890 (94.4%) patients underwent APR without an omental flap repair. Patients in both groups were similar with regard to age, gender, body mass index, American Society of Anesthesia class, and neoadjuvant cancer treatment (all p > 0.05). Patients who underwent an omental flap repair were significantly more likely to have a postoperative organ space infection (10.4% vs. 6.5%, p = 0.04). There was no significant difference in rates of superficial site infection, deep wound infection, wound dehiscence, or reoperation between the two patient groups. In multivariable analysis, omental flap creation was independently associated with organ space infection (OR 1.72, 95%CI 1.02–2.90, p = 0.04). Conclusions: This is the largest study to evaluate omental flap use in rectal cancer patients undergoing APR. Omental flaps are independently associated with organ space infection. [ABSTRACT FROM AUTHOR]

Background: The American Joint Commission on Cancer, the European Neuroendocrine Tumor Society, and the North American Neuroendocrine Tumor Society all classify colon neuroendocrine tumor (NET) nodal metastasis as N0 or N1. This binary classification does not allow for further prognostication by the total number of positive lymph nodes. This study aimed to evaluate whether the total number of positive lymph nodes affects the overall survival for patients with colon NET. Methods: The National Cancer Database was used to identify patients with colon NET. Nearest-neighborhood grouping was performed to classify patients by survival to create a new nodal staging system. The Surveillance, Epidemiology, and End Results database was used to validate the new nodal staging classification. Results: Colon NETs were identified in 2472 patients. Distinct 5-year survival rates were estimated for the patients with N0 (no positive lymph nodes; 69.8%; 95% confidence interval [CI], 66.7–72.7%), N1a (1 positive lymph node; 63.9%; 95% CI, 59.6–68.0%), N1b (2–9 positive lymph nodes; 38.9%; 95% CI, 35.4–42.3%), and N2 (≥ 10 positive lymph nodes; 15.7%; 95% CI, 11.9–20.0%; p < 0.001) nodal classifications. The validation population showed distinct 5-year survival rates with the new nodal staging. In multivariable Cox regression, the new nodal stage was a significant independent predictor of overall survival. Conclusions: The number of positive locoregional lymph nodes in colon NETs is an independent prognostic factor. For patients with colon NETs, N0, N1a, N1b, and N2 classifications for nodal metastasis more accurately predict survival than current staging systems. [ABSTRACT FROM AUTHOR]

Purpose: Low anterior resection with coloanal anastomosis (CAA) for low rectal cancer is a technically difficult operation with limited data available on oncologic outcomes. We aim to investigate overall survival and operative oncologic outcomes in patients who underwent CAA compared to abdominoperineal resection (APR). Methods: The National Cancer Database (2004–2013) was used to identify patients with non-metastatic rectal adenocarcinoma who underwent CAA or APR. Patients were 1:1 matched on age, gender, Charlson score, tumor size, tumor grade, pathologic stage, and radiation treatment with propensity scores. The primary outcome was overall survival. Secondary outcomes included 30-day mortality and resection margins. Results: Following matching, 3536 patients remained in each group. No significant differences in matched demographic, treatment, or tumor variables were seen between groups. There was no significant difference in 30-day mortality (1.24% vs. 1.39%, p = 0.60). Following resection, margins were more likely to be negative after CAA compared with APR (5.26% vs. 8.14%, p < 0.001). When stratified by pathologic stage, there was a significant survival advantage for individuals undergoing CAA compared to APR (stage 1 HR 0.72, [95% CI 0.62–0.85], p < 0.001; stage 2 HR 0.76, [95% CI 0.65–0.88], p < 0.001; stage 3 HR 0.76, [95% CI 0.67–0.85], p < 0.001). Conclusions: Patients undergoing CAA compared with APR for rectal cancer have better overall survival and are less likely to have positive margins despite the technically challenging operation. [ABSTRACT FROM AUTHOR]

Background: Colorectal neuroendocrine tumors are a rare malignancy, yet their incidence appears to be increasing. The optimal treatment for the high-grade subset of these tumors remains unclear. We aimed to examine the relationship between different treatment modalities and outcomes for patients with high-grade neuroendocrine carcinomas (HGNECs) of the colon and rectum.Methods: The National Cancer Database (2004-2015) was used to identify patients diagnosed with colorectal HGNECs. The primary outcome was overall survival. A Cox Proportional hazard model was used to identify risk factors for survival.Results: Overall, 1208 patients had HGNECs; 452 (37.4%) patients had primary tumors of the rectum, and 756 (62.5%) patients had primary tumors of the colon. A total of 564 (46.7%) patients presented with stage IV disease. The median survival was 9.0 months [95% confidence interval (CI) 8.2-9.8]. In multivariable analysis, surgical resection [hazard ratio (HR) 0.54, 95% CI 0.44-0.66; p < 0.001], chemotherapy (HR 0.74, 95% CI 0.69-0.79; p < 0.001), and rectum as the primary site of tumor (HR 0.62, 95% CI 0.51-0.76; p < 0.001) were associated with better overall survival, while older age (HR 1.01, 95% CI 1.00-1.01; p = 0.02) and the presence of metastatic disease (HR 3.34, 95% CI 2.69-4.15; p < 0.001) were associated with worse survival.Conclusions: Patients with colorectal HGNECs selected for chemotherapy and surgical resection of the primary tumor demonstrated better overall survival than those managed without resection. Patients who were able to undergo systemic chemotherapy may benefit from potentially curative resection of the primary tumor. [ABSTRACT FROM AUTHOR]

Background: Anal melanoma is a rare disease with a poor prognosis. Limited data are available regarding oncologic outcomes during the last decade and surgical practice patterns. This study aimed to investigate survival and operative oncologic outcomes for patients with anal melanoma.Methods: The National Cancer Database (2004-2013) was used to identify patients with nonmetastatic anal melanoma who underwent surgical treatment. The primary outcome was overall survival.Results: The study enrolled 439 patients in the local excision group and 214 patients in the abdominoperineal resection (APR) group. The patients in the APR group were older (70 vs 65 years; p < 0.001) and had larger tumors (40 vs 25 mm; p < 0.001). After resection, the APR patients were more likely to have positive lymph nodes (65.7% vs 12.5%; p < 0.001) and less likely to have positive margins (10% vs 29.8%; p < 0.001). Overall survival did not differ significantly between the APR and local excision patients (hazard ratio [HR], 0.82; 95% confidence interval [CI], 0.67-1.01; p = 0.06). The patients undergoing local excision showed was a significant survival advantage for those with negative margins (HR, 0.70, 95% CI, 0.53-0.93; p = 0.009). Among the patients undergoing APR, a significant survival advantage was observed for those with negative nodes (HR, 0.50; 95% CI, 0.35-0.69; p = 0.002) and negative margins (HR, 0.34; 95% CI, 0.15-0.77; p < 0.001).Conclusions: The overall survival of anal melanoma patients is similar after local excision and APR. Patients with positive margins, positive lymph nodes, or both have a significantly decreased overall survival. [ABSTRACT FROM AUTHOR]