Operationalizing a Free Flap Program for Head and Neck Reconstruction at a Veterans Affairs Hospital.

Objectives: We aimed to operationalize a head and neck microvascular free tissue transfer (MVFTT) program at a Veterans Affairs (VA) hospital with the emphasis on initiating radiotherapy within 6 weeks of surgery for cancer patients and minimizing readmissions. Study Design: Case series. Setting: Tertiary care VA hospital. Methods: A retrospective analysis was performed on consecutive head and neck MVFTT patients from May 1, 2017 and April 30, 2022. Demographics, patient and disease characteristics, per-operative data and postoperative outcomes were recorded from the electronic medical record. We sought to compare our rate of 30-day readmissions with those published in the literature. Results: One hundred and forty-one procedures were performed in the queried timeframe. Eighty-four percent (119) were performed after oncologic resections and 16% (22) were for nononcologic procedures. The rate of total flap loss was <1% and the rate of partial flap loss was 3.5%. For mucosal defects, the fistula rate was 2.3%. The rate of return to the OR for any reason within 30 days was 7.8%. The 30-day readmission rate was 6.4% while the rates reported in the literature range from 13% to 20%. One hundred and four patients required postoperative radiotherapy (PORT) and 76% started PORT within 42 days of surgery. Conclusion: Operationalizing a head and neck MVFTT program with a VA hospital is safe and allows for the successful delivery of multimodality treatment to cancer patients. These resources can be expanded for the care of head and neck cancer treatment sequelae, such as osteoradionecrosis, and other nononcologic patient needs.

SNAPPE II Score As a Predictor of Survival in Neonates with Congenital Diaphragmatic Hernia: A Single Center Experience.

Introduction Prediction of mortality and morbidity in newborns with congenital diaphragmatic hernia (CDH) is too complex for practical use and may not be accurate. The main objective of this study was to evaluate the usefulness of the CDH Study Group equation and Score of Neonatal Acute Physiology Perinatal Extension (SNAPPE) II score to predict short-term outcomes of newborns with CDH. Materials and Methods Fifty-two neonates were admitted with CDH at Children's Hospital of Michigan from November 2001 to July 2009. Retrospective chart analysis was performed. Predicted survival rates were calculated using the equation published by the CDH Study Group in 2001. SNAPPE II scores were also obtained within 12 hours of admission. Statistical analysis was performed using SPSS statistical package. Results Thirty out of 52 (58%) neonates survived to discharge. SNAPPE II score was significantly lower (p < 0.0001) in survivors (20 ± 15) versus nonsurvivors (41 ± 16). When neonates were stratified according to the CDH Study Group, low-risk patients had a survival rate of 68% (predicted 84%), moderate-risk patients had a survival rate of 43% (predicted 57%), and high-risk patients had a survival rate of 33% (predicted 36%). A total of 83% of the newborns who survived were operated within 48 hours of life, while only 17% of the nonsurvivors were operated within 48 hours of life. Conclusion SNAPPE II scores were better predictors of mortality than the CDH Study Group equation published in 2001. Further exploration is warranted to evaluate validity of survival advantage for those who were operated within 48 hours of life. A future study of combination of prenatal and postnatal factors may help in improved outcomes of the newborns with CDH.

Active Mental Illnesses Adversely Affect Surgical Outcomes.

Depression, anxiety, posttraumatic stress disorder (PTSD), and substance abuse are linked to higher rates of morbidity and mortality after various surgical procedures. Comparable data in general surgery are lacking. Records from 183 consecutive patients undergoing elective general surgery procedures at a single tertiary hospital were reviewed. Patients with depression, anxiety, PTSD, and substance abuse or any combination of these at the time of surgery were classified as having "active mental illness" (AMI). Thirty-day complications, readmissions, and emergency room (ER) visits were identified. Univariate analysis was performed followed by creation of multivariate regression models. 41.5 per cent (n = 76) met criteria for the AMI group and 58.5 per cent (n = 107) were without a mental illness (WAMI). The two groups had similar incidence of medical comorbidities and similar mean values of serum albumin and creatinine. The AMI group had higher rates of readmissions (14.5 vs 3.7 %, P = 0.009) and ER (19.7 vs 8.4 %, P = 0.025) visits compared with the WAMI group. Differences in length of stay and 30-day complications did not reach statistical significance. In patients undergoing elective general surgery, depression, anxiety, PTSD, and substance abuse are associated with higher rates of readmission and ER visits. These results suggest a need for further research on the impact of specific mental illnesses on postoperative complications.

Designing liver resections and pushing the envelope with resections for hepatic colorectal metastases.

Current concepts in the management of hepatic metastases have changed dramatically over the past two decades. Multidisciplinary therapies including chemotherapy, surgery, and regional therapy have alone and in combination significantly improved the survival of patients with metastatic colorectal cancer. Conditions that were previously considered hopeless and treated merely for palliation can now be approached with curative intent. In this paper, we review the surgical treatment for colorectal cancer liver metastasis (CRLM) and describe a paradigm-shift in the management of complex heretofore-considered unresectable CRLM. Utilizing advanced multidisciplinary treatment strategies has improved the prognosis of patients with stage IV colorectal cancer to the point where we may question whether CRLM are now a chronic disease.

Analysis of outcome in 298 extremely low-birth-weight infants with patent ductus arteriosus.

PURPOSE: Indomethacin is accepted therapy for patent ductus arteriosus (PDA) in ELBW infants (<1000 g). We hypothesize that surgical ligation may provide comparatively superior outcomes in select ELBW infants. METHODS: Predischarge outcomes of 298 ELBW infants with echocardiography-proven PDA were retrospectively compared by treatment provided: no treatment (group 1, n = 54), indomethacin (group 2, n = 140), ligation (group 3, n = 46), and ligation after indomethacin failure (group 4, n = 58). chi(2) and Wilcoxon rank sum tests were used to test for significance. Institutional review board approval was obtained (IRB/05-00395). RESULTS: Group 3 had significantly lower gestational age (P < .001), birth weight (P = .006), and 5-minute Apgar scores (P = .03) compared with group 2. Group 3 and group 1 had a higher rate of pretreatment intraventricular hemorrhage (IVH) compared with group 2 (P < .001). By contrast, posttreatment complications including acute renal failure, necrotizing enterocolitis, thrombocytopenia, and IVH occurred more frequently in groups 2 (P = .004) and 4 (P = .001) compared with group 3. Survival was 57.7% in group 1 compared with groups 2, 3, and 4 (82.4%, 86.0%, and 92.7% respectively; P = .001). Preoperative conditions associated with nonsurvival include gestational age (P = .009), birth weight (P = .002), maternal preeclampsia (P = .015), 5-minute Apgar score (P = .013), and sepsis (P = .018). Posttreatment complications associated with nonsurvival include acute renal failure (P = .002), thrombocytopenia (P = .002), and necrotizing enterocolitis (P = .034). Survival was not influenced by any congenital comorbidity, pre- or posttreatment IVH, diameter of the PDA, or recurrence of the PDA after indomethacin therapy. CONCLUSIONS: (1) Patent ductus arteriosis requires treatment in ELBW infants to maximize survival. (2) Indomethacin and surgical ligation permit equivalent survival in low-risk ELBW infants, but indomethacin results in a high failure and complication rate requiring operative salvage in a number of patients. (3) Surgical ligation permits survival of high-risk ELBW infants with a low complication rate and is preferable to indomethacin in ELBW infants with the above risk factors.