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Background Payers and regulatory bodies are increasingly placing emphasis on cost containment, quality/outcome measurement and transparent reporting. Significant cost variation occurs in many operative procedures without a clear relationship with outcomes. Clear cost‐benefit associations will be necessary to justify expenditures in the era of bundled payment structures. Methods All laparoscopic cholecystectomies (LCCKs) performed within a single health system over a 1‐year period were analysed for operating room (OR) supply cost. The cost was correlated with American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) outcomes. Results From July 2013 to June 2014, 2178 LCCKs were performed by 55 surgeons at seven hospitals. The median case OR supply cost was $513 ± 156. There was variation in cost between individual surgeons and within an individual surgeon's practice. There was no correlation between cost and ACS NSQIP outcomes. The majority of cost variation was explained by selection of trocar and clip applier constructs. Conclusions Significant case OR cost variation is present in LCCK across a single health system, and there is no clear association between increased cost and NSQIP outcomes. Placed within the larger context of overall cost, the opportunity exists for improved resource utilization with no obvious risk for a reduction in the quality of care.

With increased scrutiny on the quality and cost of health care, surgeons must be mindful of their outcomes and resource use. We evaluated surgeon-specific intraoperative supply cost (ISC) for pancreaticoduodenectomy and examined whether ISC was associated with patient outcomes.Patients undergoing open pancreaticoduodenectomy between January 2012 and March 2015 were included. Outcomes were tracked prospectively through postoperative day 90, and ISC was defined as the facility cost of single-use surgical items and instruments, plus facility charges for multiuse equipment. Multivariate logistic regression was used to test associations between ISC and patient outcomes using repeated measures at the surgeon level.There were 249 patients who met inclusion criteria. Median ISC was $1,882 (interquartile range [IQR] $1,497 to $2,281). Case volume for 6 surgeons ranged from 18 to 66. Median surgeon-specific ISC ranged from $1,496 to $2,371. Greater case volume was associated with decreased ISC (p0.001). Overall, ISC was not predictive of postoperative complications (p = 0.702) or total hospitalization expenditures (p = 0.195). At the surgeon level, surgeon-specific ISC was not associated with the surgeon-specific incidence of severe complication or any wound infection (p0.227 for both), but was associated with delayed gastric emptying (p = 0.004) and postoperative pancreatic fistula (p0.001).In a single-institution cohort of 249 pancreaticoduodenectomies, high-volume surgeons tended to be low-cost surgeons. Across the cohort, ISC was not associated with outcomes. At the surgeon level, associations were noted between ISC and complications, but these may be attributable to unmeasured differences in the postoperative management of patients. These findings suggest that quality improvement efforts to restructure resource use toward more cost-effective practice may not affect patient outcomes, although prospective monitoring of safety and effectiveness must be of the utmost concern.

Object The goal of this study was to examine the reasons for early readmissions within 30 days of discharge to a major academic neurosurgical service. Methods A database of readmissions within 30 days of discharge between April 2009 and September 2010 was retrospectively reviewed. Clinical and administrative variables associated with readmission were examined, including age, sex, race, days between discharge and readmission, and insurance type. The readmissions were then assigned independently by 2 neurosurgeons into 1 of 3 categories: scheduled, adverse event, and unrelated. The adverse event readmissions were further subcategorized into patients readmitted although best practices were followed, those readmitted due to progression of their underlying disease, and those readmitted for preventable causes. These variables were compared descriptively. Results A total of 348 patients with 407 readmissions were identified, comprising 11.5% of the total 3552 admissions. The median age of readmitted patients was 55 years (range 16–96 years) and patients older than 65 years totaled 31%. There were 216 readmissions (53% of 407) for management of an adverse event that was classified as either preventable (149 patients; 37%) or unpreventable (67 patients; 16%). There were 113 patients (28%) who met readmission criteria but who were having an electively scheduled neurosurgical procedure. Progression of disease (48 patients; 12%) and treatment unrelated to primary admission (30 patients; 7%) were additional causes for readmission. There was no significant difference in the proportion of early readmissions by payer status when comparing privately insured patients and those with public or no insurance (p = 0.09). Conclusions The majority of early readmissions within 30 days of discharge to the neurosurgical service were not preventable. Many of these readmissions were for adverse events that occurred even though best practices were followed, or for progression of the natural history of the neurosurgical disease requiring expected but unpredictably timed subsequent treatment. Judicious care often requires readmission to prevent further morbidity or death in neurosurgical patients, and penalties for readmission will not change these patient care obligations.

Malignant bowel obstruction (MBO), a serious problem in stage IV colorectal cancer (CRC) patients, remains poorly understood. Optimal management requires realistic assessment of treatment goals. This study's purpose is to characterize outcomes following palliative intervention for MBO in the setting of metastatic CRC.Retrospective review of a prospective palliative database identified 141 patients undergoing surgical (OR; n = 96) or endoscopic (GI; n = 45) procedures for symptoms of MBO.Median patient age was 58 years, median follow-up 7 months. Most (63%) had multiple sites of metastases. Computed tomography (CT) scan findings of carcinomatosis (p = 0.002), ascites (p = 0.05), and multifocal obstruction with carcinomatosis and ascites (p = 0.03) significantly predicted the need for percutaneous or open gastrostomy tube, or stoma. Procedure-associated morbidity for 81 patients with small bowel obstruction (SBO) was 37%; 7% developed an enterocutaneous fistula/anastomotic leak. Thirty-day mortality was 6%. Most (84%) patients were palliated successfully; some received additional chemotherapy (38%) or surgery (12%). Procedure-associated morbidity for 60 patients with large bowel obstruction (LBO) was 25%; 11 patients (18%) required other procedures for stent failure, with one death at 30 days. Symptom resolution was97%. Patients with LBO had improved symptom resolution, shorter length of stay (LOS), and longer median survival than patients with SBO.Patients with MBO and stage IV CRC were successfully palliated with GI or OR procedures. Patients with CT-identified ascites, carcinomatosis, or multifocal obstruction were least likely to benefit from OR procedures. CT plays an important role in preoperative planning. Sound clinical judgment and improved understanding are required for optimal management of MBO.

Objective. To obtain prospective outcomes data on patients (pts) undergoing palliative operative or endoscopic procedures for malignant bowel obstruction due to recurrent ovarian cancer. Methods. An institutional study was conducted from July 2002 to July 2003 to prospectively identify pts who underwent an operative or endoscopic procedure to palliate the symptoms of advanced cancer. This report focuses on pts with malignant bowel obstruction due to recurrent ovarian cancer. Procedures performed with an upper or lower gastrointestinal (GI) endoscope were considered “endoscopic.” All other cases were classified as “operative.” Following the procedure, the presence or absence of symptoms was determined and followed over time. All pts were followed until death. Results. Palliative interventions were performed on 74 gynecologic oncology pts during the study period, of which 26 (35%) were for malignant GI obstruction due to recurrent ovarian cancer. The site of obstruction was small bowel in 14 (54%) cases and large bowel in 12 (46%) cases. Palliative procedures were operative in 14 (54%) pts and endoscopic in the other 12 (46%). Overall, symptomatic improvement or resolution within 30 days was achieved in 23 (88%) of 26 patients, with 1 (4%) postprocedure mortality. At 60 days, 10 (71%) of 14 pts who underwent operative procedures and 6 (50%) of 12 pts who had endoscopic procedures had symptom control. Median survival from the time of the palliative procedure was 191 days (range, 33–902) for those undergoing an operative procedure and 78 days (range, 18–284) for those undergoing an endoscopic procedure. Conclusion. Patients with malignant bowel obstructions due to recurrent ovarian cancer have a high likelihood of experiencing relief of symptoms with palliative procedures. Although recurrence of symptoms is common, durable palliation and extended survival are possible, especially in those patients selected for operative intervention.

It is common to obtain radiological studies around the time of a positive sentinel lymph node biopsy (SLNB) to exclude patients with distant metastases from completion lymph node dissection. The yield of such a work-up is unknown.Patients were identified from a prospectively maintained database. Medical records were reviewed.Over an 8-year period, 181 patients had a positive SLNB. At least one study (computed tomography or magnetic resonance imaging of the brain; chest x-ray; computed tomography of the thorax, abdomen, or pelvis; positron-emission tomography scan; or bone scan) was obtained around the time of SLNB in 178 patients (98%). Studies were obtained after SLNB in 107 patients (59%). Studies ordered after SLNB resulted in indeterminate findings in 51 patients (48% of those studied). Among patients tested after SLNB, four were found to have metastatic disease (positive rate 3.7%). All of these patients had both a thick melanoma and macrometastasis within the SLN. The number of patients with indeterminate findings would be decreased and the yield of the work-up increased by 4 fold, by restricting the work-up to those with thick melanoma and macrometastasis.Radiological studies obtained after a positive SLN produce indeterminate findings in about half of the patients and identify distant disease in 3.7%. Restricting work-up to patients with thick melanoma and macrometastasis on SLNB would spare patients from indeterminate findings and increase the yield of the evaluation.

Metastatic gastric cancer has a dismal prognosis. We identified a subset of patients where surgical resection with therapeutic intent was undertaken in the setting of known metastatic disease. Review of a prospectively maintained database of gastric cancer patients at a single institution over a 19-year period was performed. Thirty-seven patients with metastatic disease known prior to resection with therapeutic intent were identified out of 3384 patients with gastric cancer (1%). Twelve patients had positive peritoneal cytology as the only evidence of metastasis, 21 had gross metastasis limited to peritoneal surfaces, one had peritoneal and ovarian metastasis, one had liver metastasis, one had retropancreatic lymph node metastasis, and one had a malignant pleural effusion. Thirty-six patients (97%) received chemotherapy prior to resection, and 30 (81%) received postoperative chemotherapy. The median time from diagnosis to resection was 4.5 months (range 1–22) in patients receiving preoperative chemotherapy. Median survival was 12 months after resection with no three-year survivors. Predictors of worse prognosis were cytologic or pathologic evidence of persistent metastatic disease at the time of resection or at laparoscopy within six weeks of resection (P

For patients with laparoscopic stage M1 gastric adenocarcinoma, no resection of the primary tumor, and systemic chemotherapy, this study investigated the incidence of subsequent palliative intervention and survival.Laparoscopy was performed for patients with computed tomography scan stage M0 disease and no significant obstruction or bleeding.A prospectively maintained database for 1993 to 2002 was used to identify 165 patients (median age, 63 years) with laparoscopic M1 disease in the peritoneum (P1, adjacent to stomach, 9%; P2, few distant sites, 35%; or P3, disseminated, 30%) or liver (10%) or both (16%). Functional performance status (FPS, Eastern Cooperative Oncology Group) was 0 to 1 (84%) or 2 (16%).Subsequent intervention was performed on 50% of patients, at median interval of 4 months (range, 1-35 months) after laparoscopy. Intervention was performed on the stomach for obstruction (33%), bleeding (8%), or perforation (1%) or on a distant site for a metastasis-related complication (20%). More than one intervention (maximum, 4) was performed in 21%. Laparotomy was necessary in 12%; the remainder had endoscopic or radiologic procedures or radiation therapy only. There was one intervention-related death. Median survival was 10 months, with 1-year survival of 39%. On multivariate analysis, better FPS (0-1; odds ratio, 4; P=0.001) and limited peritoneal metastasis (P1 or P2; 2; P=0.01) were independently associated with improved survival.The incidence of subsequent intervention was 50%, but few patients had laparotomy. Intervention-related mortality was minimal. The burden of metastatic disease and functional performance status were important prognostic factors.

The appropriate management of patients with cystic lesions of the pancreas is controversial. The identification of small asymptomatic pancreatic cysts is increasing, and the natural history of these lesions is unknown.1,2 Mucinous lesions, either intraductal papillary mucinous neoplasms (IPMN) or mucinous cystadenomas, are considered premalignant lesions; however, the time course of progression from benign to malignant has not been determined. Although serous cystadenomas are considered to be benign, local growth can result in symptoms. The growth rate of these lesions, and the size at which they become symptomatic is unknown. The present ability to determine the specific histopathology of a radiographically identified pancreatic cyst remains limited. Current laboratory, radiographic, and endoscopic studies are often able to distinguish mucinous from serous lesions, but their ability to identify malignancy within the mucinous subgroup is limited.3,4 Finally, although the mortality after pancreatectomy has decreased to less than 2% in high-volume centers, reported morbidity rates remain at approximately 40%, and reported mortality continues to be as high as 15% at lower volume hospitals.5,6 Because of the unknown natural history, and diagnostic uncertainty, some authors have recommended routine resection of all pancreatic cysts.7–9 These authors argue that because preoperative differentiation between benign and malignant is unreliable, and because the potential adverse consequences of nonresectional therapy are significant, all medically fit patients should undergo resection. Although this approach provides a guarantee to patients that no premalignant or malignant lesions will be observed, it exposes patients with benign lesions to the risks of operation with unclear benefit. Several recent reports, including a previous study from the authors’ institution, have recommended a more selective approach to resection.10–12 This approach argues that improved radiographic imaging techniques and an improved understanding of the various histologic entities allow the identification of a group of patients with an extremely low risk of malignancy. Most studies reporting selective management have recommended nonoperative management (radiographic follow-up) for patients with small, incidentally discovered cysts of the pancreas.10–12 This approach avoids the risks of operation in patients with benign lesions, but with current limitations in nonresectional diagnosis, cannot guarantee that a malignancy is not mistakenly being observed. This study was performed to further describe and review our selective approach to resection for patients with cystic lesions of the pancreas. The authors previously reported on a series of 209 patients.12 In that study, we identified the presence of a solid component, the cyst diameter, the presence of septations, and the presence of symptoms as factors associated with the decision to perform operative resection. The current data allow further assessment of these factors, and the ability to investigate the factors involved in the decision making process.

Pancreaticoduodenectomy (PD) is the standard surgical management of invasive ampullary neoplasms. A rational plan to use ampullectomy (AMP) for lesions at this location requires careful analysis of preoperative clinical information (comorbidity, lesion size, and histopathology) and intraoperative data (frozen section pathology and clinical impression) to properly select patients for this treatment.We identified 140 consecutive cases of nonfamilial ampullary neoplasms from our prospective institutional database over a 7-year period (1996-2003). Preoperative and intraoperative factors were analyzed and related to outcomes.AMP was planned for 37 patients with small lesions (median, 1.86 cm [range, 0-3 cm] vs. 2.6 cm [range, 0-8 cm] in PD). AMP was converted to PD because of the extent of disease in three and an intraoperative diagnosis of invasive cancer in five patients. Preoperative biopsy had a diagnostic accuracy of 79% (97 of 123) but missed 23 cancers. Intraoperative frozen section had a diagnostic accuracy of 84%; two cases of high-grade dysplasia and invasive cancer were missed. Patients with invasive cancer treated by AMP had a decreased recurrence-free and disease-specific survival compared with those treated by PD. Lymphatic spread of disease was associated with diminished long-term survival. Although both vascular invasion and tumor stage independently predicted lymphatic metastases, both were limited by their sensitivity.The reduced morbidity and mortality of AMP makes this the preferred treatment for benign lesions of the ampulla. Conversion to PD should be considered when intraoperative or final pathology identifies invasive adenocarcinoma. Refinement of clinicopathologic factors may reduce the occasional PD for benign disease and AMP for malignancy.

To prospectively evaluate surgical procedures performed with palliative intent.There is a paucity of outcomes data necessary to allow sound surgical decision-making and informed consent for palliative procedures.Procedures to palliate symptoms of advanced cancer were identified prospectively from all operations performed. Patients were observed for90 days or until death.There were 1022 palliative procedures performed in 823 patients from July 2002 to June 2003. Operative (713/1022) or endoscopic (309/1022) procedures were performed for gastrointestinal obstruction (34%), neurologic symptoms (23%), pain (12%), dyspnea (9%), jaundice (7%) or other symptoms (15%). Symptom improvement or resolution within 30 days was achieved in 80% (659/823). Median duration of symptom control was 135 days. Recurrence of the primary symptom occurred in 25% (165/659) while treatment of debilitating additional symptoms was required in 29% (191/659). Palliative procedures were associated with 30-day postoperative morbidity (29%) and mortality (11%). A major postoperative complication reduced the probability of symptom improvement to 17%. Median survival was 194 days from the time of the palliative procedure and was adversely associated with poor performance status (ECOGor = 2 [P0.001] or NCI fatigue score ofor =1 [P0.001]), poor nutrition (albumin3.5 [P = 0.005] or significant weight loss [P = 0.003]), and no previous cancer therapy (P = 0.002).In carefully selected patients, relief of symptoms following palliative procedures can be expected, but new or recurrent symptoms limit durability. Potential benefits are minimized by postoperative complications and are less predictable for patients with poor performance status, malnutrition and no prior cancer therapy.

Background Effective palliation rather than cure is often the most appropriate goal in the management of patients with advanced gastric cancer. The literature to date is limited by the imprecise use of the term palliative and subsequent variable designation of patients into evaluable groups. Study design Between July 1985 and July 2001, 1,595 patients were entered into a prospective database after undergoing a resection for gastric adenocarcinoma. Patients who received a noncurative (R1/R2) resection were identified. A procedure was defined as palliative if it was performed explicitly to palliate symptoms or improve quality of life. Results Three hundred seven patients received a noncurative gastric resection. The operation was palliative in 48% (147/307) and nonpalliative in 52% (160/307). Palliative operations included an esophageal anastomosis less frequently (46% versus 69%, p 65 years. Conclusions There are important differences among patients undergoing noncurative operations for gastric cancer. Studies designed to measure palliative interventions would benefit from precise designations of palliative intent in patients receiving noncurative operations.

Because of the inability to determine benign from malignant, many have recommended that all cystic lesions of the pancreas be resected. Patients evaluated between January 1995 and December 2000 for the ICD-9 diagnosis of pancreatic cyst (577.2) or benign neoplasm of the pancreas (211.6) were reviewed. Patient, cyst, and treatment characteristics were recorded. Comparisons were made between patients who underwent operative and nonoperative management. Over the 5-year period, 209 patients were evaluated. Nonoperative treatment was initially chosen for 144 patients (69%). In this group the average cyst diameter was 2.5 cm (range 0.5 cm to 13.0 cm), and the median change in diameter during follow-up was zero cm (range 1.5 cm to 4.0 cm). In six patients (4%) changes occurred within the cyst that resulted in resection. None of these patients had a malignant diagnosis. Operative treatment was initially chosen for 65 (31%) of the 209 patients. Malignancy was found in six of the operative patients (6 [9%] of 65). Differences in patient and cyst characteristics between groups included the cyst size, septations, a solid component, and the presence of symptoms. Selected patients with cystic lesions of the pancreas may be safely followed radiographically. Selection criteria identified in this study (symptoms, cyst size, solid component, and septations) and the utilization of new imaging techniques allow the creation of treatment plans for these patients that can be prospectively tested.

Exponential growth and increasing longevity of end-stage renal disease (ESRD) has resulted in significant ongoing changes in vascular access (VA) planning and management in the United States. There is a positive trend showing an increase in arteriovenous fistula (AVF) prevalence both in incident and prevalent patients and a decrease in tunneled dialysis catheters (TDCs) in prevalent patients. Current surgical training seems to provide adequate exposure to VA and an ample opportunity to develop skills required for safe surgical placement of VA. The prevalent differences in practice patterns suggest a need for standardization of VA care. There is a need for a structured curriculum in VA, which is a critical component in making sound decisions in access planning and management.

Decisions regarding the use of surgical procedures for the palliation of symptoms caused by advanced malignancies require the highest level of surgical judgment. Prospective analysis of palliative surgical care may facilitate a more effective and representative evaluation of these patients. Patients requiring surgery planned solely for the palliation of an advanced malignancy were offered entry onto this study. Outcome measurements were made before surgery and monthly thereafter until the patient’s death. Accepted techniques of pain assessment, quality of life, and functional status were used. Between May 1997 and December 1999, 26 patients were enrolled. Although 46% (12 of 26) of patients demonstrated improvement in pain control or quality of life after palliative surgery, these benefits lasted a median of only 3.4 months. Palliative surgery was associated with significant postoperative complications in 35% (9 of 26) patients. Although many patients had no apparent demonstrable benefit from surgery, surgeons were able to identify a group of patients who experienced significant benefits after a palliative procedure. The relationships between the patient and family members and the surgeon play an important role in decision-making throughout the palliative phase of cancer treatment.

BACKGROUND: In gastric adenocarcinoma, only complete resection (R0) translates into survival benefit. Given the potential for increased morbidity and mortality from multiple organ resection we asked the question as to whether extended (multiple organ) resection was justified for advanced gastric cancer. STUDY DESIGN: From July 1985 to July 2000, 1,283 patients underwent gastric resection for adenocarcinoma at Memorial Sloan-Kettering Cancer Center, and were entered and followed in a prospectively recorded database. Four hundred eighteen patients (33%) underwent primary resection and had one or more organs resected in addition to the stomach. Eight hundred twenty-six patients (64%) underwent gastrectomy alone, with 39 patients (3%) not undergoing gastrectomy. Clinicopathologic, operative, and morbidity data were evaluated in this group. Complications were categorized by severity on a scale from 0 to 5, 0 being no complication to 5 being death. Chi-square analysis and the logistic regression method were used to compare and estimate factors significantly associated with having a complication. RESULTS: Three hundred thirty-seven patients had a single additional organ resected, 63 had two organs, and 18 had three organs. Five hundred eighty complications occurred in 33% of patients (404 of 1,283). The perioperative mortality was 4% (48 patients). Logistic regression identified the number of organs resected, two or greater, to be predictive of complications (RR 2.0), as well as age greater than 70 years old (RR 1.57). When excluding minor complications (values 1 and 2), only the number of organs resected (RR 3.8) was a major factor for severe complications (values 3, 4, and 5). CONCLUSIONS: Resection of two or more adjacent organs in advanced gastric adenocarcinoma is associated with a greater risk of developing a complication. The use of a graded surgical complication scale is needed for better reporting and comparison of complications. Achieving an R0 resection should still be considered the goal, even in locally advanced gastric cancer, but resection of additional organs should be performed judiciously.

Studying surgical secondary events is an evolving effort with no current established system for database design, standard reporting, or definitions. Using the Clavien–Dindo classification as a guide, in 2001 we developed a Surgical Secondary Events database based on grade of event and required intervention to begin prospectively recording and analyzing all surgical secondary events (SSE). Events are prospectively entered into the database by attending surgeons, house staff, and research staff. In 2008 we performed a blinded external audit of 1,498 operations that were randomly selected to examine the quality and reliability of the data. Of 4,284 operations, 1,498 were audited during the third quarter of 2008. Of these operations, 79 % (N = 1,180) did not have a secondary event while 21 % (N = 318) had an identified event; 91 % of operations (1,365) were correctly entered into the SSE database. Also 97 % (129 of 133) of missed secondary events were grades I and II. There were 3 grade III (2 %) and 1 grade IV (1 %) secondary event that were missed. There were no missed grade 5 secondary events. Grade III–IV events are more accurately collected than grade I–II events. Robust and accurate secondary events data can be collected by clinicians and research staff, and these data can safely be used for quality improvement projects and research.

We sought to determine if discharge home with home health care (HHC) is an independent predictor of increased readmission after pancreatectomy.We examined 30-day readmissions in patients undergoing pancreatectomy using the Healthcare Cost and Utilization Project State Inpatient Database for California from 2009 to 2011. Readmissions were categorized as severe or nonsevere using the Modified Accordion Severity Grading System. Multivariable logistic regression models were used to examine the association of discharge home with HHC and 30-day readmission using discharge home without HHC as the reference group. Propensity score matching was used as an additional analysis to compare the rate of 30-day readmission between patients discharged home with HHC with patients discharged home without HHC.Of 3,573 patients who underwent pancreatectomy, 752 (21.0%) were readmitted within 30 days of discharge. In a multivariable logistic regression model, discharge home with HHC was an independent predictor of increased 30-day readmission (odds ratio = 1.37; 95% CI, 1.11-1.69; p = 0.004). Using propensity score matching, patients who received HHC had a significantly increased rate of 30-day readmission compared with patients discharged home without HHC (24.3% vs 19.8%; p0.001). Patients discharged home with HHC had a significantly increased rate of nonsevere readmission compared with those discharged home without HHC, by univariate comparison (19.2% vs 13.9%; p0.001), but not severe readmission (6.4% vs 4.7%; p = 0.08). In multivariable logistic regression models, excluding patients discharged to facilities, discharge home with HHC was an independent predictor of increased nonsevere readmissions (odds ratio = 1.41; 95% CI, 1.11-1.79; p = 0.005), but not severe readmissions (odds ratio = 1.31; 95% CI, 0.88-1.93; p = 0.18).Discharge home with HHC after pancreatectomy is an independent predictor of increased 30-day readmission; specifically, these services are associated with increased nonsevere readmissions, but not severe readmissions.

Background:We have developed a method to identify, filter, review, and distribute the published level I evidence for solid tumor oncology. Methods:A standardized MEDLINE search identified prospective randomized controlled trials (PRCTs) in solid tumor oncology. Only PRCTs with therapeutic end points were included. All references were reviewed by a surgical oncology fellow in consultation with experts in the field. The full citations were imported into a comprehensive database. Data on statistical methods according to the Consolidated Standard of Reporting Trials statement were tabulated along with reviewer’s comments. A designation of Ia was given to articles that were well designed and significant contributions to their field. The database powers a dynamic, easily searchable Web site on our intranet and is available in personal digital assistant (PDA) format. Results:By using standard search criteria, only .03% of the 11 million articles listed in MEDLINE are PRCTs concerning therapy for solid organ malignancies. Approximately 14% of reviewed articles were given a designation of Ia. Having comprehensive data readily available with intranet access or PDAs during conferences enhances their educational value and specificity. Conclusions:We have developed an exciting tool that uses a highly trained filter to screen and record the medical data available to the clinician. This information has been made available and portable by using the Internet and PDAs.

Limb salvage after primary site failure of extremity soft tissue sarcoma is a challenging problem. Amputation may be the most effective treatment option in selected patients with local recurrence. We compared the outcome of patients treated with amputation versus limb-sparing surgery (LSS) for locally recurrent extremity sarcoma.From 1982 to 2000, 1178 patients with localized primary extremity sarcoma underwent LSS. Of these, 204 (17%) developed local recurrence. Eighteen (9%) required major amputation and the remainder underwent LSS, of which 34 were selected for matched-pair analysis according to established prognostic variables. Rates of recurrence or death were estimated by the Kaplan-Meier method. Following adjustment for prognostic variables, a Mantel-Haenszel test was used to compare the outcome between the two treatment groups.Patients in each group were well matched. All patients had high-grade tumors deep to the fascia. Median time to local recurrence was similar for both groups. Median follow-up was 95 months. Amputation was associated with a significant improvement in local control of disease (94% vs. 74%; P = .04). We observed no difference in disease-free (P = .48), disease-specific (P = .74), or overall survival (P = .93) between the two groups. Median postrecurrence survival was 20 months and 5-year OS was 36% for the entire study group.Limb-sparing treatment achieves local control in the majority of recurrent extremity sarcomas for which amputation is infrequently indicated. Amputation improves local disease control but not survival under these circumstances.

Strategies based on evidence are required to accurately stage and effectively follow patients with melanoma. The goal of staging is to define the extent of disease at the time of presentation to direct and assign prognosis. Patient surveillance is performed to assess treatment results and detect recurrences amenable to further treatment. Staging and surveillance require careful use of resources to be cost effective. This article addresses preoperative staging and post-treatment surveillance of patients with melanoma and outlines a method of follow-up based on available data.

Purpose T his study was designed to determine whether a directed clinical evaluation could eliminate the need for routine daily chest X-rays (CXRs) in surgical intensive care unit patients. Methods All patients admitted to a 10-bed surgical intensive care unit in a university-affiliated medical center were eligible for evaluation. Patients were evaluated using a 20-point Clinical Evaluation Score (CES) prior to their routine daily CXRs. An evaluation was deemed positive if any parameter was scored as positive. Major CXR findings requiring intervention and minor CXR findings representing changes but not mandating intervention were recorded. Descriptive statistics were used to relate the CES to the CXR findings. Results Fifty-one patients had 216 CESs and CXRs compared. There were 77 positive CESs (36%) and 139 negative CESs (64%). A positive CES predicted 31 of 33 major CXR findings. For major CXR findings requiring intervention, CES had a sensitivity of 94% and a negative predictive value of 98%. Conclusions By utilizing a structured clinical evaluation to determine the need for a morning CXR in this study, we could have eliminated 64% of routine morning CXRs.

Several reports have demonstrated the accurate prediction of axillary nodal status with radiolocalization and selective resection of sentinel lymph nodes (SLNs) in patients with breast cancer (BC). Because of concerns over lymphatic disruption, several authors have proposed that prior excisional breast biopsy is a contraindication for SLN biopsy. Clear unfiltered 99mtechnetium-sulfur colloid (1.0 mCi) was injected around the perimeter of the breast lesion (palpable and nonpalpable) or prior biopsy site. Resection of the radiolocalized SLN was then performed. Axillary lymph node dissection was performed immediately after SLN biopsy in the first 57 patients. Eighty-two BC patients underwent SLN biopsy. The SLN was localized in 98 per cent (80 of 82). The type of previously performed diagnostic biopsy or the location of the primary lesion did not influence the ability to localize the sentinel lymph node. In the 57 patients who had axillary lymph node dissection, metastatic disease was identified in 23 per cent (13 of 57). Axillary nodal status was accurately predicted in 98 per cent (56 of 57). Early experience with radiolocalization and selective resection of SLN in BC remains promising. By demonstrating the effective localization of the SLN regardless of the extent of prior biopsy, these data support expanding the number of patients potentially eligible for SLN biopsy.

BACKGROUND: Strategies for the effective application of palliative procedures are infrequently standardized and incompletely understood. The effect on patient outcome as determined by elements such as resolution of chief complaints, quality of life, pain control, morbidity of therapy, and resource utilization should predominate decisions regarding surgical palliative care. METHODS: Articles published between 1990 and 1996 on the surgical palliation of cancer were identified by a MEDLINE search and reviewed for designated parameters considered important for good palliative care. RESULTS: A total of 348 citations were included. Entries considered these fundamental elements: cost (2%); pain control (12%); quality of life (17%); need to repeat the intervention (59%); morbidity and mortality (61%); survival (64%); and physiologic response (69%). Established methods for quality of life and pain assessment were sporadically utilized. CONCLUSIONS: In the current surgical literature, there is uncommon reporting of the range of data required to recommend sound palliative surgical choices.

In order to characterize the clinical and laboratory features of autonomously functioning thyroid nodules (AFTNs), and to assess optimal diagnosis and management of patients with this disorder, we performed a retrospective analysis of 49 such patients over a 22-year period encompassing January 1975 to November 1996. The following data were analyzed: thyroid hormone levels, thyroid scintiscan, radioiodine uptake, fine-needle aspiration biopsy, triiodothyronine (T3) suppression testing, thyrotropin-releasing hormone (TRH) stimulation test, and thyroid ultrasound. Clinical outcomes assessed included persistent hyperthyroidism, hypothyroidism, and nodule shrinkage after treatment, or in patients followed without definitive therapy, nodule growth, spontaneous degeneration, and progression to hyperthyroidism. Biochemical hyperthyroidism, often subclinical, was found in 73.5% of patients at presentation and in an additional 24.4% of patients during subsequent follow-up. The introduction of sensitive thyrotropin (TSH) testing during the period of study resulted in a decrease in the use of the T3-suppression test and TRH stimulation test from 100% and 20%, respectively, in the period from 1976-1980, to 4% each in the period from 1991-1996. T3-thyrotoxicosis occurred in 12.2% of patients. Thyrotoxicosis at any time during the course of follow-up was positively correlated with nodule size at diagnosis. Definitive therapy, used in 42.8% of patients, consisted of radioiodine ablation (38.1%) or thyroidectomy (61.9%). No patient had recurrence of thyrotoxicosis after definitive therapy, but 25% became hypothyroid. During follow-up for a mean of 30.9 months, nodules enlarged in 25% of patients overall, or 33% of patients not receiving definitive therapy. Cystic degeneration was documented in 26.5% of patients, although this change rarely reversed subclinical hyperthyroidism. The diagnosis of an AFTN requires a demonstration of TSH-independent nodular hyperfunction. The introduction of sensitive TSH assays has simplified the evaluation of AFTN patients and revealed a high prevalence of subclinical thyroid hyperfunction in this disorder. In view of current increased awareness of adverse consequences associated with subclinical hyperthyroidism and the rarity of spontaneous resolution of hyperthyroidism in AFTN patients (despite a propensity for spontaneous hemorrhage), definitive therapy is recommended. Both radioiodine and hemithyroidectomy have high cure rates and a low posttreatment incidence of hypothyroidism.

Several reports have demonstrated the accurate prediction of axillary nodal status (ANS) with radiolocalization and selective resection of sentinel lymph nodes (SLN) in breast cancer. To date, no technique has proven to be superior in localizing the SLN.1.0 mCi of clear unfiltered 99mtechnetium sulfur colloid was injected under ultrasonographic (US) guidance around the perimeter of the breast lesion (palpable and nonpalpable) or previous biopsy site. Resection of the radiolocalized nodes was performed, followed by complete axillary lymph node dissection (AXLND).Forty-two breast cancer patients underwent SLN biopsy after US-guided radiopharmaceutical injection. The SLN was localized in 41 patients (98%). The type of previously performed diagnostic biopsy did not influence the ability to localize the sentinel lymph node. Pathology revealed nodal metastasis in 7 of the 41 evaluable patients (17%). ANS was accurately predicted in 40 of 41 patients (98%).Early experience with radiolocalization and selective resection of SLN in breast cancer remains promising. Use of US-guided injection facilitates localization of the SLN, perhaps as a result of more accurate placement of the radionuclide marker. Use of this technique allowed for effective management of patients regardless of tumor size or the extent of prior biopsy, thereby expanding the potential number of eligible patients for SLN biopsy.

Although multiple tests are often performed prior to surgery for the primary treatment of breast cancer, the role of perioperative testing has yet to be clearly defined. The purpose of this study was to examine the use of perioperative testing in the Department of Defense (DOD) health care system. Records from all patients who received an operation for breast cancer between April 1, 1990 and March 1, 1992 in the DOD health care system were reviewed. The results of bone scans (BS), abdominal CT scans, brain scans (CT, MRI), chest radiographs (CXR), blood tests, and specified parameters from the history and physical examination were analyzed. Chi-square statistics were performed. 2,364 women underwent surgery for breast cancer during this period. The percentage of patients that received each test (A) and the percentage of the tests that were suggestive of metastatic disease (B) are as follows ([A%], [B%]): CXR (94%, 1.3%); BS (23%, 8%); abdominal CT (4%, 9%); and brain scans (1%, 11%). There were more abnormal BS in patients with an elevated alkaline phosphates than in those with a test that was normal or never performed (20% vs. 4.8%, p < 0.001). Elevated liver function tests or central nervous system signs or symptoms were not associated with abnormal studies. In the past, patients with breast cancer underwent an extensive array of blood tests, CXR, and scans of bones, liver, and brain in the attempt to detect occult metastatic disease prior to surgery. In a large and diverse system such as the DOD, however, a perioperative metastatic work-up, which includes a BS, brain scan, and abdominal CT scan is not routinely performed, suggesting that clinicians selectively perform specific tests during this period. Despite this tendency, when tests are performed on breast cancer patients in the perioperative period, they are infrequently suggestive of metastatic disease.

Pseudomyxoma peritonei (PMP) is a clinical syndrome with a poorly defined natural history. Relative contributions of tumor biology, patient selection, and the extent of treatment on ultimate outcome are not well characterized.Patients treated at the Memorial Sloan-Kettering Cancer Center between 1980 and 2002 with a diagnosis of PMP were identified. Patient characteristics, pathologic features, and details of treatment were analyzed retrospectively.The 97 patients included in this study underwent a mean 2.2 +/- 0.1 operations (range, 1-6). Although complete cytoreduction was achieved in 55% (53/97), disease recurred in 91% (48/53) of patients. The median disease-free interval after complete cytoreduction was 24 months. The median overall survival was 9.8 years and was independently associated with low-grade pathologic subtype (P0.001) and the ability to achieve complete cytoreduction (P0.001). Ten-year survival was attained in 21% (20/97) of the patients, of which 90% (18/20) had low-grade pathologic features. At the time of death or completion of follow-up, only 12% (12/97) of the patients were disease free.Outcome in patients with PMP is strongly associated with tumor biology. Although improved survival is associated with low-grade pathology and tumors amenable to complete cytoreduction, recurrence of PMP is common. Treatment may be beneficial, particularly in controlling symptoms, but absolute cure, defined as a prolonged disease-free state, is uncommon.

Operative site drainage (OSD) after elective hepatectomy remains widely used despite data suggesting limited benefit. Multi-institutional, quality-driven databases and analytic techniques offer a unique source from which the utility of OSD can be assessed.Elective hepatectomies from the 2014 American College of Surgeons (ACS) NSQIP Targeted Hepatectomy Database were propensity score matched on the use of OSD using preoperative and intraoperative variables. The influence of OSD on the diagnosis of postoperative bile leaks, rates of subsequent intervention, and other outcomes within 30 days were assessed using paired testing.Operative site drainage was used in 42.2% of 2,583 eligible hepatectomies. There were 1,868 cases matched, with 7.2% experiencing a post-hepatectomy bile leak. The incidence of bile leak initially requiring intervention was no different between the OSD and no OSD groups (n = 32 vs n = 24, p = 0.278), and OSD was associated with a greater number of drainage procedures to manage post-hepatectomy bile leak (n = 27 in the OSD group, n = 13 in the no OSD group, p = 0.034, relative risk [RR] 2.1 [95% CI 1.1 to 4.0]). The OSD group had a greater mean length of stay (+0.8 days, p = 0.004) and more 30-day readmissions (p0.001, RR 1.6 [95% CI 1.2 to 2.1]). On multivariate analysis, post-hepatectomy bile leak and receipt of additional drainage procedures were stronger predictors of increased length of stay and readmissions than OSD.In a propensity score matched cohort, OSD did not improve the rate of diagnosis of major bile leaks and was associated with increased interventions, greater length of stay, and more 30-day readmissions. These data suggest that routine OSD after elective hepatectomy may not be helpful in capturing clinically relevant bile leaks and has additional consequences.

Banking of high-quality, appropriately consented human tissue is crucial for the understanding of disease pathogenesis and translation of such knowledge into improvements in patient care. Traditionally, tissue banking has been thought of as primarily an academic research activity, but tissue and biospecimen banking is increasingly assuming clinical importance, especially with the advent of genetic and proteomic testing approaches that rely on fresh or fresh frozen tissue. These approaches are part of the revolution in personalized medicine. This revolution’s impact on biorepositories—their mission and day-to-day function—will be profound. Direct patient care will require structuring tissue procurement to become a routine part of patient care. Accordingly tissue banking will expand from its traditional research role in large academic medical centers into the everyday practice of surgical pathology. Successful implementation of this model will require consideration of several financial, medicolegal, and administrative issues.

BACKGROUND: Although systemic therapy for metastatic breast cancer (MBC) continues to evolve, there are scant data to guide physicians and patients when symptoms develop. In this article, the authors report the frequency and durability of palliative procedures performed in the setting of MBC. METHODS: From July 2002 to June 2003, 91 patients with MBC underwent 109 palliative procedures (operative, n ¼ 76; IR n ¼ 39, endoscopic n ¼ 3). At study entry, patients had received a mean of 6 prior systemic therapies for metastatic disease. System-specific symptoms included neurologic (33%), thoracic (23%), musculoskeletal (22%) and GI (14%). The most common procedures were thoracostomy with or without pleurodesis (27%), craniotomy with resection (19%) and orthopedic open reduction/internal fixation (19%). RESULTS: Symptom improvement at 30 days and 100 days was reported by 91% and 81% of patients, respectively, and 70% reported continued benefit for duration of life. At a median interval of 75 days from intervention (range, 8-918 days), 23 patients (25%) underwent 61 additional procedures for recurrent symptoms. The durability of palliation varied with system-specific symptoms. Patients with neurologic or musculoskeletal symptoms were least likely to require additional maintenance procedures (P < .0002). The 30-day complication rate was 18% and there were no procedure-related deaths. At a median survival of 37.4 mos from MBC diagnosis (range, 1.6-164 months) and 8.4 months after intervention (range, 0.2-73 months), 7 of 91 patients remained alive. CONCLUSIONS: Palliative interventions for symptoms of MBC are safe and provide symptom control for the duration of life in 70% of patients. Definitive surgical treatment of neurologic or musculoskeletal symptoms provided the most durable palliation; interventions for other symptoms frequently require subsequent procedures. The longer median survival for patients with MBC highlights the need to optimize symptom control to maintain quality of life. Cancer 2010;116:3338–47. V C 2010 American Cancer Society.

This article provides an overview of the approach to patients who may benefit from palliative care. While the article's details lend themselves to the treatment of complications secondary to advanced malignancies, the data herein can also be extrapolated to other chronic, terminal diseases. Guidelines for patient selection are discussed, using currently available outcomes data as a platform for the critical decision making process. Suggestions for a multidisciplinary team approach are offered, using the palliative triangle as the ideal model of communication and cooperation. Finally, methods for measuring success are detailed, along with proposals for how to better equip the surgeons of tomorrow with the knowledge and experience needed to tackle these difficult and intimate problems.

Hypothesis Roux-en-Y reconstruction (RYR) is associated with a reduction in morbidity and mortality associated with pancreatic anastomotic failure after pancreaticoduodenectomy compared with conventional loop reconstruction (CLR). Design Retrospective study of patients from 1991 to 2006. Setting Tertiary care center. Patients Records of patients undergoing CLR (n = 588) and patients undergoing RYR (n = 112) between February 1, 1991, and June 30, 2006, for pancreatic ductal adenocarcinoma at a single institution were retrospectively reviewed and compared. Main Outcome Measures Perioperative outcome and mortality were compared for patients who underwent RYR compared with those who underwent CLR. Results Overall, both groups required a similar rate of postoperative interventional radiology procedures (CLR, 6.8%; RYR, 9.8%;P = .24) and subsequent operations (CLR, 6.9%; RYR, 9.1%;P = .62). No significant difference was found in the rate of overall postoperative mortality (CLR, 2.6%; RYR, 0.9%;P = .49). The overall rate of pancreatic anastomotic failure was 7.2%, and pancreatic anastomotic failure was associated with a 6% mortality rate. Among patients who developed pancreatic anastomotic failure, no significant difference was seen between CLR (n = 32) and RYR (n = 16) in length of hospital stay (18 vs 19 days;P = .98) or postoperative mortality (3 patients [9.4%] vs none [0%];P = .54). Conclusion We found that RYR is not associated with a reduction in morbidity after pancreaticoduodenectomy for pancreatic adenocarcinoma compared with CLR, even among patients who develop pancreatic anastomotic failure.

An understanding of the methods of detection of recurrent melanoma after sentinel lymph node biopsy (SLNB) is essential for the coordination of a rational plan of follow-up.Clinical stage I/II melanoma patients who underwent SLNB from 1991 to 2004 were identified from a prospectively maintained single-institution database. Detection of recurrence by self (awareness of symptoms or abnormal physical findings) or physician (discovered on routine physical or scheduled test) and timing of clinic visit were recorded. Postoperative follow-up included physical exam every 3-4 months for the first year, every 3-6 months for the second year, and every 6-12 months thereafter. Serum lactate dehydrogenase (LDH) and chest X-ray (CXR) were obtained annually. Computed tomography (CT) and positron emission tomography (PET) were performed selectively.Of 1062 patients who underwent SLNB, 203 (19%) experienced 230 initial sites of recurrence; 198 patients were evaluable for follow-up. Median follow-up after first recurrence was 17 months. Symptoms and self-detected physical findings were present in 109 patients (55%); 85 patients (78%) were seen earlier than their scheduled visit. Self-detected physical findings identified in-transit (n = 26; 24%) and nodal (n = 25; 23%) disease. Physician detection occurred in 89 patients (45%), nearly half by a scheduled radiographic test (CXR, 16%; CT, 29%; PET, 1%). The method of detection significantly predicted post-recurrence survival (p0.05).More than half of melanoma recurrences are self-detected; these patients have the most favorable post-recurrence survival rates because of the type of recurrence detected. The mode of detection is a significant predictor of post-recurrence survival. This supports an aggressive program of patient education in self-examination after SLNB for melanoma.

From 1982 to 1987, 114 patients underwent operation at Memorial Sloan-Kettering Cancer Center for soft-tissue sarcoma of the retroperitoneum. A retrospective analysis of these patients defines the biologic behavior, surgical management of primary and recurrent disease, predictive factors for outcome, and impact of multimodality therapy. Complete resection was possible in 65% of primary retroperitoneal sarcomas and strongly predicts outcome (p less than 0.001). The rate of complete resection was not altered by histologic type, size, or grade of tumor. These patients had a median survival of 60 months compared to 24 months for those undergoing partial resection and 12 months for those with unresectable tumors. Forty-nine per cent of completely resected patients have had local recurrence. This is the site of first recurrence in 75% of patients. These patients undergo reoperation when feasible. Complete resection of recurrent disease was performed in 39 of 88 (44%) operations, with a 41-month median survival time after reoperation. Tumor grade was a significant predictor of outcome (p less than 0.001). High-grade tumors (n = 65) were associated with a 20-month median survival time compared to 80 months for low-grade tumors (n = 49). Gender, histologic type, size, previous biopsy, and partial resection versus unresectable tumors did not predict outcome by univariate analysis. Adjuvant radiation therapy and chemotherapy could not be shown to have significant impact on survival. Concerted attempt at complete resection of both primary and recurrent retroperitoneal soft-tissue sarcoma is indicated.

A case of melanoma of the upper extremity with a solitary metastasis to the common bile duct is reported. A comprehensive review of melanoma in the biliary tree is presented. Antemortem diagnoses of such cases are rare but are associated with a high percentage of disease clinically confined to the biliary tree. Patients with such lesions have survived long periods of time after palliative surgery. Therefore, surgical resection is recommended as the treatment of choice in patients able to tolerate surgery.

Background Improving surgical quality of care requires accurate reporting of postoperative complications. Study design Accuracy of a prospective surgical complication grading database was assessed by performing a retrospective review of 204 pancreaticoduodenectomies (PDs) entered into the database from January 1, 2001, to December 31, 2003. This updated database was then used to characterize 30-day morbidity and mortality after PD. Results On review, 13% of patients had a complication not identified in the prospective complication database, 8% of patients had a complication reclassified, and 4% of patients had a complication removed. At least 1 postoperative complication was experienced by 47% of patients. After PD, 45 different complications occurred. Postoperative mortality at 30 days was 1%, and 30-day readmission rate was 11%. The 30-day reoperation rate was 9%, and 14% of patients required a percutaneous drainage procedure. Pancreatic anastomotic leak (12%), wound infection (11%), and delayed gastric emptying (7%) were the 3 most common postoperative complications, and all were associated with an increased length of stay. Conclusions Our prospective surgical complication database accurately characterized outcomes after PD and facilitated information gathering and analysis. The accuracy, efficiency, and reproducibility of a prospective surgical complication database favor its widespread use in postoperative complication reporting.

Sentinel lymph node biopsy (SLNB) has become well accepted in management of patients with primary cutaneous melanoma. An understanding of the pattern of recurrence after SLNB is helpful in coordinating a rational plan of follow-up in these patients. We sought to determine the site and timing of initial recurrence and post-recurrence survival after SLNB. Stage I/II melanoma patients who underwent SLNB during 1991–2004 were identified from a prospective single-institution database. Site and date of first recurrence after SLNB were recorded. Patterns of recurrence after SLNB and post-recurrence survival were analyzed. One thousand and forty-six patients underwent SLNB. The sentinel lymph node (SLN) was positive in 164 patients (16%). Median follow-up was 36 months for survivors. Median and 3-year relapse-free survival for SLN-positive patients were 41 months and 56%, and for SLN-negative patients were not reached and 87%, respectively (P < .0001). Of the SLN-positive patients, 47% experienced recurrence, compared with 14% SLN-negative patients. The pattern of recurrence stratified by SLN status was similar between the two groups (P = NS). After recurrence, the site of recurrence was the only significant prognostic factor influencing survival (P < .0001). Although SLN-positive patients experience recurrence far earlier and more frequently than SLN-negative patients, the pattern of recurrence is similar. After recurrence, its site is the primary determinant of survival.

Melanoma has the potential to spread to virtually any organ, including the gallbladder. The role of intervention in this rare entity must be based on a thorough appreciation of the underlying disease biology.We present a review of all patients treated for gallbladder melanoma at Memorial Sloan-Kettering Cancer Center (MSKCC) between 1991 and 2003.The study group consisted of 13 patients with melanoma metastatic to the gallbladder. The median survival was 12 months following the diagnosis, and only 1 patient survived more than 42 months. Factors associated with improved outcome included symptomatic metastases and metastatic disease confined to the gallbladder (P.05). Cholecystectomy led to the resolution of right upper quadrant pain in all patients for the duration of their survival.In patients with melanoma metastatic to the gallbladder, overall survival is determined more by the biology of the disease than treatment. In the presence of symptoms, cholecystectomy is often effective palliation in carefully selected patients.

High-volume centers have low morbidity and mortality after pancreaticoduodenectomy (PD). Less is known about treatment pathways and their influence on intensive care unit (ICU) utilization. Patients who underwent PD at a tertiary cancer center during the five-year period between January 1998 and December 2003 were identified from a prospective database. Preoperative and intraoperative factors relating to ICU admission and outcome were analyzed. Five hundred ninety-one pancreaticoduodenectomies were performed during the study period. Of these, 536 patients had complete records for analysis. Of the 536 patients, 51 (10%) were admitted to the ICU after surgery. Admission to the ICU was associated with decreased overall survival (P < .0001). Of the preoperative predictors of ICU admission, serum creatinine, albumin, and increased body mass index (BMI) were associated with ICU admission (P = .02, .05, and .002, respectively). Age, blood glucose, diagnosis of diabetes mellitus, and chronic obstructive pulmonary disease were not predictive of ICU admission on univariate analysis. Of the intraoperative factors, longer operative time and estimated blood loss (EBL) correlated with ICU admission (P = .003 and .0001, respectively). On multivariate analysis, only preoperative BMI and intraoperative EBL were independent predictors of ICU admission (P = .03 and .003, respectively). Patients with a preoperative BMI greater than 30 had a substantially higher risk of ICU admission (relative risk 2.4). The majority of patients who undergo PD do not require admission to the ICU. Factors most associated with ICU admission after PD are increased preoperative BMI and intraoperative blood loss.

Hand-assisted laparoscopic distal pancreatectomy, with or without splenectomy, is gradually gaining acceptance, although its ultimate benefit is yet to be confirmed. This study aimed to report our initial experience with hand-assisted laparoscopic distal pancreatectomy.A retrospective review of a prospectively collected database including 17 patients during the period 2002-2004 was conducted. The median age was 60 years (range, 29-85 years), and the female-to-male ratio was 13:4. The preoperative diagnoses included benign and malignant conditions. Besides two to three ports, a hand port was placed in the upper midline to aid in dissection. The pancreas was divided with a stapler in all the patients, and drains were placed in 10 patients (70%).One patient was found to be unresectable because of celiac artery involvement, and 2 of the remaining 16 patients underwent conversion to an open procedure. The median operating time was 196 min (range, 128-235 min). The mean tumor size was 4 cm (range, 2-7 cm), and the estimated blood loss was 125 ml (range, 50-1,250 ml). The median time to resumption of a regular diet was 3.5 days (range, 2-9 days), and the time to conversion to oral pain medications was 3 days (range, 2-9 days). The length of hospital stay was 5.5 days (range, 4-18 days), with a majority of the patients (11 patients, 78%) staying less than 7 days. There were no mortalities. The overall postoperative morbidity rate was 25%, and the morbidities consisted of pancreatic leak/fistula (2 patients, 14%) and fever (1 patient). The margins were negative in 10 (76%) of the relevant 13 patients. At a median follow-up period of 3.8 months (range, 5-14 months), 11 (84%) of 13 patients had no evidence of disease recurrence.The minimally invasive approach to pancreatic disease is safe and technically feasible. Further large studies with longer follow-up periods are necessary to determine the role of laparoscopic surgery in the management of pancreatic disease.

It is not clear if more intense surveillance is associated with improved survival after curative resection for cancer. In the context of a followup program after curative gastrectomy, recurrence and survival were investigated for patients presenting with either symptomatic or asymptomatic recurrence.A prospectively maintained gastric cancer database was used to identify all patients who underwent a curative (R0) gastrectomy from July 1985 to June 2000. Survival curves were generated for patients with either symptomatic or asymptomatic recurrence, and the prognostic variables associated with outcomes were identified.Of 1,172 patients who underwent a curative (R0) gastrectomy, 561 patients (48%) had documented recurrence and 382 patients had complete data about symptoms. Median time to recurrence was 10.8months for asymptomatic patients and 12.4months for symptomatic patients (p = NS). Median postrecurrence survival was 13.5months for asymptomatic patients and 4.8months for symptomatic patients (p0.01). Median disease-specific survival was 29.4months for asymptomatic patients and 21.6months for symptomatic patients (p0.05). Variables predictive of poor postrecurrence survival included symptomatic recurrence, advanced stage (III/IV), poor differentiation, short disease-free interval (12months), and multiple sites of recurrence.Followup did not identify asymptomatic recurrence earlier than symptomatic recurrence. Patients with symptomatic recurrence have more aggressive disease with a shorter postrecurrence survival. The impact of detecting asymptomatic recurrence in the course of followup after curative gastrectomy could not be distinguished from the effects of four powerful biologic variables that also interact to govern outcomes.

Splenectomy has been associated with increased morbidity after gastrectomy for gastric cancer. Resection of proximal versus distal tumors is associated with a higher morbidity. Because splenectomy is more commonly performed in resection of proximal tumors, these analyses may be biased. The aim of this study was to describe the association of splenectomy with complications in patients undergoing resection of proximal gastric and gastroesophageal junction (GEJ) cancers.From July 1985 to August 2001, 335 patients underwent resection of proximal gastric or GEJ (type II and III) cancers. Clinical and pathologic factors were retrieved from a prospective database.Overall morbidity was 59% (infectious complications, 41%; noninfectious complications, 36%), and mortality was 4.5%. Splenectomy was associated with a higher rate of infectious complications (57% vs. 33%; P.01) but not of noninfectious complications (39% vs. 34%; not significant) or mortality (4% vs. 5%; not significant). Splenectomy was also associated with a higher rate of infectious complications on multivariate analysis (hazard ratio, 2.4; P.01).Morbidity after resection of proximal gastric and GEJ cancer is significant; splenectomy is associated with increased morbidity, but not mortality, in these patients. Because these complications can be managed without an increase in mortality, splenectomy should be performed when indicated by the extent of the tumor.

Background: Preparation of surgical trainees for oncological operative procedures is challenging. The purpose of this survey was to focus on identifying methods and resources used by trainees to prepare for procedures and to ascess the need for additional educational tools. Methods: A 34-item survey was mailed electronically to 97 surgical oncology fellows at 14 Society of Surgical Oncology–approved training programs. General surgery residents at an affiliate training program (n = 65) and residents attending an American Board of Surgery In-Training Examination review course (n = 129) were polled via hard-copy mailings. The survey was distributed with the Dillman method. Self-education practices, factors influencing operative education, and strengths/weaknesses of available resources were identified. Results: Response rates were 56% and 78% for fellows and residents, respectively. Trainees prepare for more than 50% of cases they perform (82%; 169 of 205), devoting up to 1 hour (87%; 178 of 205) in review the evening before a procedure (64%; 131 of 205). Time availability and attending of record were dominant factors influencing resident preparation, whereas case complexity was the most important variable motivating fellows. Surgical atlases, texts, anatomical references, and case discussion with attending staff were the most useful and available resources rated by trainees. Skills stations were recognized as the least valuable. Critical assessment of six educational resources identified no one particular area for improvement. Conclusions: There is a need for contemporary operative educational tools, incorporating time-sensitive and procedure-specific needs of surgical trainees preparing for oncological operative procedures.

Effective palliation rather than cure is often the most appropriate goal in the management of patients with advanced gastric cancer. The literature to date is limited by the imprecise use of the term palliative and subsequent variable designation of patients into evaluable groups.Between July 1985 and July 2001, 1,595 patients were entered into a prospective database after undergoing a resection for gastric adenocarcinoma. Patients who received a noncurative (R1/R2) resection were identified. A procedure was defined as palliative if it was performed explicitly to palliate symptoms or improve quality of life.Three hundred seven patients received a noncurative gastric resection. The operation was palliative in 48% (147/307) and nonpalliative in 52% (160/307). Palliative operations included an esophageal anastomosis less frequently (46% versus 69%, p0.001) and had a less extensive lymphadenectomy performed compared with nonpalliative operations. Surgical intent did not alter operative morbidity (54%) or mortality (6%) significantly. The overall median survival after a noncurative gastric resection was 10.6 months and was independently associated with operations performed with explicit palliative indications (8.3 months [palliative] versus 13.5 months [nonpalliative], p0.001) and patient age65 years.There are important differences among patients undergoing noncurative operations for gastric cancer. Studies designed to measure palliative interventions would benefit from precise designations of palliative intent in patients receiving noncurative operations.

Multiple systems have been developed for grading the adverse effects (AEs) of cancer treatment. The National Cancer Institute Common Toxicity Criteria (CTC) system has substantially evolved since its inception in 1983. The most recent version, CTCAE v3.0 (Common Terminology Criteria for Adverse Events version 3.0) represents the first comprehensive, multimodality grading system for reporting the acute and late effects of cancer treatment. The new CTC requires changes in the application of AE criteria including new guidelines regarding late effects, surgical and pediatric effects, multimodality issues, and for reporting the duration of an effect. It builds on the strengths of previous systems, represents a considerable effort among hundreds of participants, and signifies an international collaboration and consensus of the oncology research community. This article updates recent progress in the evolution of adverse effects grading systems and reviews the development of CTCAE v3.0.

Background Randomized prospective trials have addressed various treatment approaches to pancreatic adenocarcinoma in order to improve on the dismal prognosis associated with this disease. We conducted a comprehensive review of prospective randomized clinical trials and summarized the contemporary treatment of resectable pancreatic carcinoma. Study design A literature search strategy identified prospective randomized clinical trials for pancreatic carcinoma using standard medical subject heading terms. The articles were critically reviewed and ranked according to a standardized three-tiered system (Ia, Ib, Ic) by a panel of experts. Results Surgical studies have demonstrated that morbidity and mortality are similar for pylorus-preserving and classic pancreaticoduodenectomy. Extended retroperitoneal lymphadenectomy can be performed with similar mortality but increased morbidity compared with standard pancreaticoduodenectomy but does not prolong survival. Pancreaticogastrostomy and pancreaticojejunostomy appear to be comparable techniques for pancreatic duct reconstruction. Pancreatic-enteric anastomosis is associated with lower rates of pancreatic fistula and endocrine insufficiency than duct occlusion without anastomosis. Intraperitoneal drainage after pancreatic resection is unwarranted and may contribute to intraabdominal complications. Routine use of prophylactic octreotide does not lower the rate of pancreatic fistula; it should be considered for reoperative pancreatic resection or for a soft gland. Early trials found that adjuvant chemoradiation therapy prolongs survival. But in more recent studies chemoradiation after resection has failed to show a survival advantage over surgery alone. Conclusions Surgical resection remains the only potentially curative therapy for adenocarcinoma of the pancreas. There is no clear indication as to a single preferable resection approach.

Background The prospective randomized controlled trial (PRCT) is agreeably the gold standard in reporting data on patient management. This study evaluates the impact of specialty training on the leadership, development, and enrollment in PRCT. Methods Questionnaires were sent to surgical oncology as well as general surgery graduates from 1985 to 1999. Results A total of 67% (201 of 300) of the surgeons responded, with one half of the respondents completing a surgical oncology (SO) fellowship (50%, 100 of 201), 33% (66 of 201) another type of fellowship (OF), and 17% (35 of 201) general surgery (GS) training alone. The utilization of PRCT in the decision making of their clinical practice was reported by a majority of SO graduates (99%) as well as GS graduates (88%) with a smaller number (77%) of OF trained surgeons. The opinions on PRCT were evenly distributed with breast disease, colorectal cancer, and melanoma having the greatest impact on surgeons practicing in these fields. A greater percentage of SO (89%) reported participation in a PRCT than did the GS (42%) or OF (54%). The most frequent reason for the lack of participation in a PRCT by both GS and OF trained graduates was absence of active recruitment (80%) to participate with the second most common being no time available (18%). Conclusions PRCT are utilized and continue to change surgeons’ decision making for a majority of the surgeons surveyed. There are certain disease sites for which PRCT have failed to influence practice decisions. Unfortunately, few surgeons take a leadership role in PRCT. Emphasizing the existence of PRCT at both meetings, and in journals, with a more aggressive recruitment of participating surgeons with minimal time commitment, should enhance the patients included in prospective randomized controlled trials.

To characterize factors predictive of improved survival following gastrectomy with additional organ resection for the treatment of gastric cancer.Recent large series have reported significant survival disadvantages to patients who have undergone gastrectomy with splenectomy or pancreaticosplenectomy, and yet gastrectomy with additional organ resection is needed to accomplish an R0 resection in some cases. Gastrectomy with splenectomy and other organ resections has been associated with advanced T-stage, positive resection margins, and higher postoperative morbidity and mortality rather than an absolute predictor of survival.The authors reviewed the Department of Surgery prospective gastric database at Memorial Sloan-Kettering Cancer Center from July 1985 to July 2000. During this period, of the 2,112 patients with primary gastric cancer, 1,133 underwent an R0 resection. The R0 resection group included 865 patients who underwent gastrectomy alone and 268 patients who underwent gastrectomy with another organ resection. Clinicopathologic, operative, complication, and survival data were compared between these two groups. Chi-square analysis and the Kaplan-Meier method were used to compare and estimate median survival.The most common organs resected were the spleen and pancreas, with an even distribution of other organs. Pathologic factors revealed that the gastrectomy with organ resection group had significantly larger lesions, greater T-stage, and a higher incidence of advanced nodal disease than the group who did not undergo additional organ resection. The incidence of pathologically confirmed T4 cancers in the additional organ resection group was only 14%. The overall 5-year survival rate for patients with T3/T4 disease was 27% with additional organ resection. The overall 5-year survival rate for the gastrectomy with organ resection group (32%, median 32 months) was significantly less than the group that did not undergo additional resection (50%, median 63 months) on univariate analysis. However, additional organ resection was not a predictor of survival on multivariate analysis. Multivariate analysis identified advanced T-stage (T3 or greater) and nodal stage (N1 or greater) as adverse predictors of survival in this group.Long-term survival following gastrectomy with additional organ resection is possible. Depth of invasion and the extent of lymph node metastasis are the most important predictors of survival following gastrectomy with additional organ resection, and a R0 resection has been achieved. Judicious use of additional organ resection for the treatment of advanced gastric cancer must be emphasized, given the increased overall morbidity and infrequent finding of actual T4 disease. Additional organ resection can be performed with minimal morbidity and can improve the chance of overall survival in patients with advanced T-stage disease.