Adrenalectomy outcomes are superior with the participation of residents and fellows.

BACKGROUND: Adrenalectomy is a complex procedure performed in many settings, with and without residents and fellows. Patients often ask, "Will trainees be participating in my operation?" and seek reassurance that their care will not be adversely affected. The purpose of this study was to determine the association between trainee participation and adrenalectomy perioperative outcomes. STUDY DESIGN: We performed a cohort study of patients who underwent adrenalectomy from the 2005 to 2011 American College of Surgeons NSQIP database. Trainee participation was classified as none, resident, or fellow, based on postgraduate year of the assisting surgeon. Associations between trainee participation and outcomes were determined via multivariate linear and logistic regression. RESULTS: Of 3,694 adrenalectomies, 732 (19.8%) were performed by an attending surgeon with no trainee, 2,315 (62.7%) involved a resident, and 647 (17.5%) involved a fellow. The participation of fellows was associated with fewer serious complications (7.9% with no trainee, 6.0% with residents, and 2.8% with fellows; p < 0.001). In a multivariate model, the odds of serious 30-day morbidity were lower when attending surgeons operated with residents (odds ratio = 0.63; 95% CI, 0.45-0.89). Fellow participation was associated with significantly lower odds of overall (odds ratio = 0.51; 95% CI, 0.32-0.82) and serious (odds ratio = 0.31; 95% CI, 0.17-0.57) morbidity. There was no significant association between trainee participation and 30-day mortality. CONCLUSIONS: In this analysis of multi-institutional data, the participation of residents and fellows was associated with decreased odds of perioperative adrenalectomy complications. Attending surgeons performing adrenalectomies with trainee assistance should reassure patients of the equivalent or superior care they are receiving.

Impact of cardiac comorbidity on early outcomes after pancreatic resection.

BACKGROUND: In patients undergoing pancreatic resection (PR), identification of subgroups at increased risk for postoperative complications can allow focused interventions that may improve outcomes. STUDY DESIGN: Patients undergoing PR from 2005-2010 were selected from the American College of Surgeons National Surgical Quality Improvement Program database and categorized as having any history of cardiac disease (angina, congestive heart failure (CHF), myocardial infarction (MI), cardiac stent, or bypass) or as having acute cardiac disease (symptoms of CHF or angina within 30 days or MI within 6 months). These variables were utilized to examine the relationship between cardiac disease and outcomes after PR. RESULTS: The rate of serious complications and perioperative mortality in patients with any history of cardiac disease vs. those without was 34 vs. 24 % (p < 0.001) and 4.5 vs. 2.0 % (p < 0.001), respectively, and in patients with acute cardiac disease compared to patients without was 37 vs. 25 % (p < 0.001) and 8.6 vs. 2.2 % (p < 0.001), respectively. In multivariate analysis, the two cardiac disease variables remained associated with mortality. CONCLUSIONS: In patients undergoing PR, cardiac disease is a significant risk factor for adverse outcomes. These observations are critical for meaningful informed consent in patients considering pancreatectomy.

A multi-institutional international study of risk factors for hematoma after thyroidectomy.

BACKGROUND: Cervical hematoma can be a potentially fatal complication after thyroidectomy, but its risk factors and timing remain poorly understood. METHODS: We conducted a retrospective, case-control study identifying 207 patients from 15 institutions in 3 countries who developed a hematoma requiring return to the operating room (OR) after thyroidectomy. RESULTS: Forty-seven percent of hematoma patients returned to the OR within 6 hours and 79% within 24 hours of their thyroidectomy. On univariate analysis, hematoma patients were older, more likely to be male, smokers, on active antiplatelet/anticoagulation medications, have Graves' disease, a bilateral thyroidectomy, a drain placed, a concurrent parathyroidectomy, and benign pathology. Hematoma patients also had more blood loss, larger thyroids, lower temperatures, and higher blood pressures postoperatively. On multivariate analysis, independent associations with hematoma were use of a drain (odds ratio, 2.79), Graves' disease (odds ratio, 2.43), benign pathology (odds ratio, 2.22), antiplatelet/anticoagulation medications (odds ratio, 2.12), use of a hemostatic agent (odds ratio, 1.97), and increased thyroid mass (odds ratio, 1.01). CONCLUSION: A significant number of patients with a postoperative hematoma present >6 hours after thyroidectomy. Hematoma is associated with patients who have a drain or hemostatic agent, have Graves' disease, are actively using antiplatelet/anticoagulation medications or have large thyroids. Surgeons should consider these factors when individualizing patient disposition after thyroidectomy.

Wound complications after inguinal lymph node dissection for melanoma: is ACS NSQIP adequate?

BACKGROUND: In the treatment of melanoma, inguinal lymph node dissection (ILND) is the standard of care for palpable or biopsy-proven lymph node metastases. Wound complications occur frequently after ILND. In the current study, the multicenter American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) was utilized to examine the frequency and predictors of wound complications after ILND. METHODS: Patients with cutaneous melanoma who underwent superficial and superficial with deep ILND from 2005-2010 were selected from the ACS NSQIP database. Standard ACS NSQIP 30-day outcome variables for wound occurrences-superficial surgical site infection (SSI), deep SSI, organ space SSI, and disruption-were defined as wound complications. RESULTS: Of 281 total patients, only 14 % of patients had wound complications, a rate much lower than those reported in previous single institution studies. In a multivariable model, superficial with deep ILND, obesity, and diabetes were significantly associated with wound complications. There was no difference in the rate of reoperation in patients with and without wound complications. CONCLUSIONS: ACS NSQIP appears to markedly underreport the actual incidence of wound complications after ILND. This may reflect the program's narrow definition of wound occurrences, which does not include seroma, hematoma, lymph leak, and skin necrosis. Future iterations of the ACS NSQIP for Oncology and procedure-specific modules should expand the definition of wound occurrences to incorporate these clinically relevant complications.

Predictors of short-term postoperative survival after elective colectomy in colon cancer patients ≥ 80 years of age.

BACKGROUND: Individuals ≥ 80 years of age represent an increasing proportion of colon cancer diagnoses. Selecting these patients for elective surgery is challenging because of diminished overall health, functional decline, and limited data to guide decisions. The objective was to identify overall health measures that are predictive of poor survival after elective surgery in these oldest-old colon cancer patients. METHODS: Medicare beneficiaries ≥ 80 years who underwent elective colectomy for stage I-III colon cancer from 1992-2005 were identified from the Surveillance, Epidemiology and End Results(SEER)-Medicare database. Kaplan-Meier survival analysis determined 90-day and 1-year overall survival. Multivariable logistic regression assessed factors associated with short-term postoperative survival. RESULTS: Overall survival for the 12,979 oldest-old patients undergoing elective colectomy for colon cancer was 93.4 and 85.7 %, at 90 days and 1 year. Older age, male gender, frailty, increased hospitalizations in prior year, and dementia were most strongly associated with decreased survival. In addition, AJCC stage III (vs stage I) disease and widowed (vs married) were highly associated with decreased survival at 1 year. Although only 4.4 % of patients were considered frail, this had the strongest association with mortality, with an odds ratio of 8.4 (95 % confidence interval, 6.4-11.1). CONCLUSIONS: Although most oldest-old colon cancer patients do well after elective colectomy, a significant proportion (6.6 %) die by postoperative day 90 and frailty is the strongest predictor. The ability to identify frailty through billing claims is intriguing and suggests the potential to prospectively identify, through the electronic medical record, patients at highest risk of decreased survival.

Surgical treatment of colon cancer in patients aged 80 years and older : analysis of 31,574 patients in the SEER-Medicare database.

BACKGROUND: Age-related disparities in colon cancer treatment exist, with older patients being less likely to receive recommended therapy. However, to the authors' knowledge, few studies to date have focused on receipt of surgery. The objective of the current study was to describe patterns of surgery in patients aged ≥ 80 years with colon cancer and examine outcomes with and without colectomy. METHODS: Medicare beneficiaries aged ≥ 80 years with colon cancer who were diagnosed between 1992 and 2005 were identified from the Surveillance, Epidemiology, and End Results-Medicare database. Multivariable logistic regression analysis was used to assess factors associated with nonoperative management. Kaplan-Meier survival analysis determined 1-year overall and colon cancer-specific survival. RESULTS: Of 31,574 patients, 80% underwent colectomy. Approximately 46% were diagnosed during an urgent/emergent hospital admission, with decreased 1-year overall survival (70% vs 86% for patients diagnosed during an elective admission) noted among these individuals. Factors found to be most predictive of nonoperative management included older age, black race, more hospital admissions, use of home oxygen, use of a wheelchair, being frail, and having dementia. For both operative and nonoperative patients, the 1-year overall survival rate was lower than the colon cancer-specific survival rate (operative patients: 78% vs 89%; nonoperative patients: 58% vs 78%). CONCLUSIONS: The majority of older patients with colon cancer undergo surgery, with improved outcomes noted compared with nonoperative management. However, many patients who are not selected for surgery die of unrelated causes, reflecting good surgical selection. Patients undergoing surgery during an urgent/emergent admission have an increased short-term mortality risk. Because the earlier detection of colon cancer may increase the percentage of older patients undergoing elective surgery, the findings of the current study may have policy implications for colon cancer screening and suggest that age should not be the only factor driving cancer screening recommendations.

Impact of neoadjuvant chemotherapy on wound complications after breast surgery.

BACKGROUND: Use of neoadjuvant chemotherapy for breast cancer is increasing. The objective was to examine risk of postoperative wound complications in patients receiving neoadjuvant chemotherapy for breast cancer. METHODS: Patients undergoing breast surgery from 2005 to 2010 were selected from the American College of Surgeons National Surgical Quality Improvement Program database. Patients were included if preoperative diagnosis suggested malignancy and an axillary procedure was performed. We performed a stepwise multivariable regression analysis of predictors of postoperative wound complications, overall and stratified by type of breast surgery. Our primary variable of interest was receipt of neoadjuvant chemotherapy. RESULTS: Of 44,533 patients, 4.5% received neoadjuvant chemotherapy. Wound complications were infrequent with or without neoadjuvant chemotherapy (3.4% vs. 3.1%; P = .4). Smoking, functional dependence, obesity, diabetes, hypertension, and mastectomy were associated with wound complications. No association with neoadjuvant chemotherapy was seen (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.78-1.32); however, a trend was observed toward increased complications in neoadjuvant patients undergoing mastectomy with immediate reconstruction (OR, 1.58; 95% CI, 0.98-2.58). CONCLUSION: Postoperative wound complications after breast surgery are infrequent and not associated with neoadjuvant chemotherapy. Given the trend toward increased complications in patients undergoing mastectomy with immediate reconstruction, however, neoadjuvant chemotherapy should be among the many factors considered when making multidisciplinary treatment decisions.

Fine-needle aspiration optimizes surgical management in patients with thyroid cancer.

BACKGROUND: Fine-needle aspiration (FNA) is accurate in diagnosing papillary, medullary, and anaplastic thyroid cancer, as well as lymphoma. Although many surgeons routinely perform FNA before surgery, some question whether FNA influences operative management. Therefore, to determine whether FNA affects surgical management in patients with thyroid cancer, we reviewed our experience. METHODS: A total of 442 consecutive patients underwent thyroid surgery at 1 academic center. Of these, 411 had surgery for an index nodule in the absence of previous radiation or familial thyroid cancer. FNA, operative, and permanent histology findings were reviewed. RESULTS: The average patient age was 46 years, and 79% were female. A total of 211 patients (51%) had a preoperative FNA, and 71 (17%) had a final diagnosis of cancer. The sensitivity and specificity of FNA for thyroid cancer were 89% and 92%, respectively. In the FNA group, 1 (2.4%) of 41 patients with papillary thyroid cancer required completion thyroidectomy. In contrast, in the no-FNA group, 4 (40%) of 10 patients with papillary thyroid cancer required a second operation. No patient in the FNA group received thyroid resection for lymphoma, whereas three (100%) of three patients with lymphoma in the no-FNA group were treated surgically. A total of 98% of the FNA group, compared with 54% of the no-FNA group, received optimal surgical treatment for thyroid cancer. CONCLUSIONS: FNA is a sensitive and specific test for the diagnosis of thyroid cancer, allowing definitive initial surgery and avoiding unnecessary procedures. Therefore, we recommend routine use of preoperative thyroid FNA, even in those patients in whom a resection is already planned.

Classification of follicular thyroid tumors by molecular signature: results of gene profiling.

PURPOSE: Thyroid nodules are common, with a lifetime risk of developing a clinically significant thyroid nodule of 10% or higher. Preoperative diagnosis was greatly enhanced by the introduction of fine needle aspiration in the 1970s, but there has been little advancement since that time. Discrimination between benign and malignant follicular neoplasms is currently not possible by fine needle aspiration and can even be difficult after full pathologic review. The purpose of these studies is to identify genes expressed in follicular adenomas and carcinomas of the thyroid that will permit molecular differentiation of these neoplasms. EXPERIMENTAL DESIGN: Gene expression patterns of 17 thyroid follicular tumors were analyzed by oligonucleotide array analysis. Gene profiles for follicular adenomas and carcinomas were identified, and the two groups were compared for differences in expression levels. The differentially expressed genes were used to perform a hierarchical clustering analysis training set. Five follicular tumors with diagnosis undisclosed to the investigators and 2 minimally invasive carcinomas were entered into the cluster analysis as a test set to determine whether diagnosis by gene profile correlated with that obtained by pathologic evaluation. RESULTS: Thyroid follicular adenomas and carcinomas showed strikingly distinct gene expression patterns. The expression patterns of 105 genes were found to be significantly different between follicular adenoma and carcinoma. Many uncharacterized genes contributed to the distinction between tumor types. For five follicular tumors for which the final diagnosis was undisclosed, the clustering algorithm gave the correct diagnosis in all 5 cases. CONCLUSIONS: Gene profiling is a useful tool to predict the molecular diagnosis of follicular thyroid tumors. Genes were identified that reliably differentiate follicular thyroid carcinoma from adenoma. This study provides insight into genes that may be important in the molecular pathogenesis of follicular thyroid tumors, as well candidates for preoperative diagnosis of follicular thyroid carcinoma.