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Objective To quantify risk for CRI based on PABX use in CVAP placement for cancer patients. Summary background data : Central venous access ports (CVAP) are totally implanted devices used for chemotherapy. There is a temporal risk for catheter related infection (CRI) to insertion and perioperative prophylactic antibiotics (PABX) use is a contested issue among practitioners. Methods Data was collected from a single center, academic oncology center. Treatment with a perioperative PABX was compared to non-treatment, to examine the incidence of 14-day CRI. Propensity scores with matched weights controlled for confounding, using 15 demographic, procedural and clinical variables. Results From 2007 to 2012, 1,091 CVAP were placed, where 59.7 % received PABX. The 14-day CRI rate was 0.82%, with 78% of those not receiving PABX. While results did not achieve statistical significance, use of PABX was associated with a 58% reduction in the odds of a 14-day CRI (OR = 0.42, 95% CI: 0.08-2.24, p = 0.31). Conclusion The findings suggest a reduction in early CRI with the use of PABX. Since CRI treatment can range from a course of oral antibiotics, port removal, to hospital admission, we suggest clinicians consider these data when considering PABX in this high-risk population.

Background Acute mechanical circulatory support (aMCS) can be a lifesaving therapy for patients with refractory cardiogenic shock. As device safety and technology improve, so will the ability to extend aMCS to patients at remote hospitals. The Intermountain West is unique because of the large geographical area, making transport of critically ill patients a logistical challenge. Methods We reviewed our experience of transporting patients in cardiogenic shock over long distances who had already been placed on aMCS: Impella and extracorporeal membrane oxygenator devices. Survival data was compared to international benchmark data published by the Extracorporeal Life Support Organization. Results A total of 11 patients (91% male; mean age 56 ± 5.4 y) were transported via fixed-wing aircraft to our center. The etiology of cardiogenic shock was ST-elevation myocardial infarction ( n = 4), acutely decompensated chronic systolic heart failure ( n = 4), postcardiotomy shock ( n = 2), and acute myocarditis ( n = 1). Average transport distance was 364 ± 139 miles (585 ± 264 km) and flight time was 170 ± 29 min. All patients were safely transported with no in-transit adverse events. The average duration of aMCS was 6.4 ± 3.3 d. Six patients (54.5%) survived to device explantation and 3 (27.2%) survived to hospital discharge. For comparison, Extracorporeal Life Support Organization benchmark data for adult cardiogenic shock patients report 56% survival to device explantation and 41% to hospital discharge. Conclusions Patient transport with aMCS over long distances can be done safely without serious adverse events using good protocols and well-trained personnel. Although survival data are slightly below benchmark data, they appear reasonable, given the severity of illness and challenges of transferring critically ill patients to an expert center.

The Barcelona technique for bowel anastomosis is not well described in the currently available literature, but it saves steps when compared to conventional stapled anastomoses. In short, the proximal and distal ends of a resection margin are approximated, small enterotomies made, a stapler is passed into both lumens creating a common channel, and lastly, this same stapler is used to create the anastomosis and amputate the specimen. We report on this technique with ileostomy reversal in terms of cost and complications. Review of ileostomy reversals (2006–2014) by a single surgical oncologist. Thirty patients had surgery using the Barcelona technique. Median age was 58 years, and median postoperative surgical stay was 3 days. The majority of patients had rectal cancer initially treated with low anterior resection and diverting loop ileostomy (80 %). One patient had a wound infection (3 %), and there were no anastomotic leaks, intra-abdominal abscesses, or strictures. This technique required fewer stapler loads saving $510 in charges per case. The Barcelona technique is safe and effective for ileostomy reversal. There are reduced costs related to equipment as compared to the conventional technique and thus the use of this method can result in significant medical cost savings.

Background The goals of this study were to evaluate the complication rate for intraoperative placement of a long-term central venous catheter (CVC) using intraoperative ultrasound (US) and fluoroscopy and to examine the feasibility for eliminating routine postprocedure chest X-ray. Methods Retrospective data pertaining to operative insertion of long-term CVC were collected and the rate of procedural complications was determined. Results From January 2008 to August 2013, 351 CVCs were placed via the internal jugular vein using US. Of these, 93% had a single, successful internal jugular vein insertion. The complications included 4 arterial sticks (1.14%). Starting in October 2012, postprocedure chest radiography (CXR) was eliminated in 170 cases, with no complications. A total of $29,750 in charges were deferred by CXR elimination. Conclusions This review supports the use of US for CVC placement with fluoroscopy in reducing the rate of procedural complications. Additionally, with fluoroscopic imaging, postprocedural CXR can be eliminated with associated healthcare savings.

Heart transplantation (HTx) is the preferred treatment for patients with end-stage heart failure and has been successful for30 y. The clinical course of recipients at the extreme of age is unknown. We reviewed our experience to determine the overall health and prevalence of Tx-related medical problems for recipients in their ninth decade.We reviewed the UCTP experience from 1985 to present to identify patients who survived into their 80s and matched (1:1) with other recipients for gender and age at HTx, but did not survive to ≥80 y. The end point was the prevalence of medical problems.Since 1985, 1129 adult HTx have been performed and 14 patients (1.2%) survived to ≥80 y old. The mean age at HTx was 63 ± 4 y. Of octogenarians, the majority were males with ischemic cardiomyopathy. The average survival after transplant was 19 ± 5 y in the octogenarians and 5 ± 5 y in the controls (P 0.01). Over time, the prevalence of comorbidities increased. Compared with nonoctogenarians, we observed higher prevalence of dyslipidemia (P = 0.02), and chronic renal insufficiency (P = 0.02) during follow-up. Cardiac function was normal (ejection fraction 55%) for all octogenarians at age 80 y.Despite improvements in posttransplant care, survival of HTx patients into the ninth decade is rare (1%). For those surviving into their 80s, cardiac function is preserved but dyslipidemia, renal insufficiency, and skin cancers are common. As the age of Htx patients continues to increase, posttransplant care should be tailored to minimize post-HTx complications and further extend survival.

Objective To evaluate the risk of neoadjuvant chemotherapy for surgical morbidity after mastectomy with or without reconstruction using 1:1 matching. Background Postoperative surgical complications remain a potentially preventable event for breast cancer patients undergoing mastectomy. Neoadjuvant chemotherapy is among variables identified as contributory to risk, but it has not been rigorously evaluated as a principal causal influence. Methods Data from American College of Surgeons National Surgical Quality Improvement Program (2006-2012) were used to identify females with invasive breast cancer undergoing planned mastectomy. Surgical cases categorized as clean and undergoing no secondary procedures unrelated to mastectomy were included. A 1:1 matched propensity analysis was performed using neoadjuvant chemotherapy within 30 days of surgery as treatment. A total of 12 preoperative variables were used with additional procedure matching: bilateral mastectomy, nodal surgery, tissue, and/or implant. Outcomes examined were 4 wound occurrences, sepsis, and unplanned return to the operating room. Results We identified 31,130 patient procedures with 2488 (7.5%) receiving chemotherapy. We matched 2411 cases, with probability of treatment being 0.005 to 0.470 in both cohorts. Superficial wound complication was the most common wound event, 2.24% in neoadjuvant-treated versus 2.45% in those that were not (P = 0.627). The rate of return to the operating room was 5.7% in the neoadjuvant group versus 5.2% in those that were not (P = 0.445). The rate of sepsis was 0.37% in the neoadjuvant group versus 0.46% in those that were not (P = 0.654). Conclusions This large, matched cohort study, controlled for preoperative risk factors and most importantly for the surgical procedure performed, demonstrates that breast cancer patients receiving neoadjuvant chemotherapy have no increased risk for surgical morbidity.