Gianturco Z-stent placement for the treatment of chronic central venous occlusive disease: implantation of 208 stents in 137 symptomatic patients.

PURPOSE: To report the technical successes, adverse events, and long-term stent patency rates of Gianturco Z-stents for management of chronic central venous occlusive disease. METHODS: Overall, 137 patients, with mean age 48.6±16.1 years (range, 16-89 years), underwent placement of Gianturco Z-stents for chronic central venous occlusions. Presenting symptoms included lower extremity edema (n=66, 48.2%), superior vena cava syndrome (n=30, 21.9%), unilateral upper extremity swelling (n=20, 14.6%), hemodialysis fistula or catheter dysfunction (n=11, 8.0%), ascites (n=8, 5.8%), and both ascites and lower extremity edema (n=2, 1.5%). Most common etiologies of central venous occlusion were prior central venous access placement (n=58, 42.3%), extrinsic compression (n=29, 21.2%), and post-surgical anastomotic stenosis (n=27, 19.7%). Number of stents placed, stent implantation location, stent sizes, technical successes, adverse events, need for re-intervention, follow-up evaluation, stent patencies, and mortality were recorded. Technical success was defined as recanalization and stent reconstruction with restoration of in-line venous flow. Adverse events were defined by the Society of Interventional Radiology Adverse Event Classification criteria. Primary and primary-assisted stent patencies were analyzed using Kaplan-Meier analysis. RESULTS: In total, 208 Z-stents were placed. The three most common placement sites were the inferior vena cava (n=124, 59.6%), superior vena cava (n=44, 21.2%), and brachiocephalic veins (n=27, 13.0%). Technical success was achieved in 133 patients (97.1%). There were two (1.5%) severe adverse events (two cases of stent migration to the right atrium), one (0.7%) moderate adverse event, and one (0.7%) mild adverse event. Mean follow-up was 43.6±52.7 months. Estimated 1-, 3-, and 5-year primary stent patency was 84.2%, 84.2%, and 82.1%, respectively. Estimated 1-, 3-, and 5-year primary-assisted patency was 92.3%, 89.6%, and 89.6%, respectively. The 30- and 60- day mortality rates were 2.9% (n=4) and 5.1% (n=7), none of which were directly attributable to Z-stent placement. CONCLUSION: Gianturco Z-stent placement is safe and effective for the treatment for chronic central venous occlusive disease with durable short- and long-term patencies.

Capacity Prioritization Initiative Reduced the Wait Time for Port Placement and Facilitated Increased Volume of Port Placements at a Large County Health System.

DESCRIPTION OF THE PROBLEM: Wait time from request to placement of ports in interventional radiology had increased from 14 to 27 days over a 4-month period. The goal of this project was to reduce the wait time by 15% within 4 months while accommodating additional volume. INSTITUIONAL APPROACH TO ADDRESS PROBLEM: Capacity analysis revealed 2 bottlenecks: (1) inadequate provider capacity for preprocedural visits in interventional radiology clinic and (2) inadequate number of spots for port placement in the angiography schedule. The intervention consisted of: (1) 2 reserved slots in the attending physician's morning clinic schedule and (2) 3 daily guaranteed spots for port placement in the angiography suite. Both changes were integrated into the electronic medical record scheduling system. DESCRIPTION OF OUTCOMES: After the intervention, per biweekly period, the number of port requests increased by 17% (Preintervention: 16.6 ± 3.1, Postintervention: 20.1 ± 4.1, P = 0.03), the number of completed clinic visits increased by 19% (Preintervention: 16.7 ± 5.1, Postintervention: 20.5 ± 3.6, P = 0.05), and the number of port placements increased by 19% (Preintervention: 16.9 ± 3.9, Postintervention: 21.0 ± 3.5, P = 0.02). The average wait time from request to placement decreased by 22% (Preintervention: 22.2 ± 4.4 days, Postintervention: 18.3 ± 3.4 days, P = 0.03), driven by a 49% decrease in wait time between request and clinic visit (Preintervention: 11.0 ± 2.3 days, Postintervention: 7.4 ± 1.0 days, P = 0.03). CONCLUSIONS: Prioritization of clinic and angiography suite capacity, integrated into the electronic scheduling system, significantly reduced the wait time for port placement, even with significant increases in the volume of port requests.

Comparison of radiofrequency and microwave ablation and identification of risk factors for primary treatment failure and local progression.

PURPOSE: To compare percutaneous radiofrequency ablation (RFA) and microwave ablation (MWA) for treatment of Hepatocellular carcinoma (HCC) and to identify risk factors for treatment failure and local progression. METHODS: 145 unique HCC [87 (60%) RFA, 58 (40%) MWA] were retrospectively reviewed from a single tertiary medical center. Adverse events were classified as severe, moderate, or mild according to the Society of Interventional Radiology Adverse Event Classification system. Primary and secondary efficacy, as well as local progression, were determined using mRECIST. Predictors of treatment failure and time to local progression were analyzed using generalized estimating equations and Cox regression, respectively. RESULTS: Technical success was achieved in 143/145 (99%) HCC. There were 1 (0.7%) severe and 2 (1.4%) moderate adverse events. Of the 143 technically successful initial treatments, 136 (95%) completed at least one follow-up exam. Primary efficacy was achieved in 114/136 (84%). 9/22 (41%) primary failures underwent successful repeat ablation, so secondary efficacy was achieved in 128/136 (90%) HCC. Local progression occurred in 24 (19%) HCC at a median of 25 months (95% CI = 19-32 months). There was no difference in technical success, primary efficacy, or time to local progression between RFA and MWA. In HCC treated with MWA, same-day biopsy was associated with primary failure (RR = 9.0, 95% CI: 1.7-47, P = 0.015), and proximity to the diaphragm or gastrointestinal tract was associated with local progression (HR = 2.40, 95% CI:1.5-80, P = 0.017). CONCLUSION: There was no significant difference in primary efficacy or time to local progression between percutaneous RFA and MWA.

Lower extremity endovenous reconstruction for symptomatic occlusive disease in pediatric patients: techniques, clinical outcomes, and long-term stent patencies.

BACKGROUND: Endovascular stent reconstruction is the standard of care for chronic venous occlusive disease in adults, but it has not been reported in pediatric patients. OBJECTIVE: This study reports the technical success, complications, clinical outcomes, and stent patency of iliocaval stent reconstruction for chronic iliocaval thrombosis in pediatric patients. MATERIALS AND METHODS: Fourteen patients, 13 (93%) male with a mean age of 16.4 years (range: 8-20 years), underwent iliocaval stent reconstruction for chronic iliocaval thrombosis. The mean number of prothrombotic risk factors was 2.5 (range: 0-4), including 7 (50%) patients with inferior vena cava atresia. At initial presentation, the Clinical, Etiology, Anatomy, and Pathophysiology classification (CEAP) score was C3 in 2 (14%) patients, C4 in 11 (79%) patients, and C6 in 1 (7.1%) patient. Time course of presenting symptoms included chronic (>4 weeks) (n=7; 50%) and acute worsening of chronic symptoms (2-4 weeks) (n=7; 50%). Aspects of recanalization and reconstruction, stenting technical success, complications, clinical outcomes and stent patency were recorded. Clinical success was defined as a 1-point decrease in the CEAP. Primary, primary-assisted, and secondary patency were defined by Cardiovascular and Interventional Radiological Society of Europe guidelines. RESULTS: Most procedures employed three access sites (range: 2-4). Intravascular ultrasound was employed in 11 (79%) procedures. Blunt and sharp recanalization techniques were used in 12 (86%) and 2 (14%) patients, respectively. Stenting technical success was 100%. Two (14%) minor adverse events occurred and mean post-procedure hospitalization was 2.8 days (range: 1-8 days). Clinical success rates at 2 weeks, 6 months and 12 months were 85%, 82%, and 83%, respectively. At a mean final clinical follow-up of 88 months (range: 16-231 months), clinical success was 93%. Estimated 6- and 12-month primary stent patencies were 86% and 64%, respectively. Six- and 12-month primary-assisted and secondary stent patency rates were both 100%. CONCLUSION: Iliocaval stent reconstruction is an effective treatment for symptomatic chronic iliocaval thrombosis in pediatric patients with high rates of technical success, 6- and 12-month clinical success, and 6- and 12-month primary-assisted and secondary patency rates.

Total endovenous recanalization and stent reconstruction for naïve non-inferior vena cava filter-associated chronic iliocaval occlusive disease: Placement of 352 venous stents in 69 debilitated patients.

The aim of this study was to report the technical success, adverse events, clinical outcomes, and long-term stent patency of iliocaval stent reconstruction for naïve, non-inferior vena cava (IVC) filter-related, chronic iliocaval thrombosis. A total of 69 patients, including 47 (68%) men, with a mean age of 36 years (range: 8-71 years), underwent first-time iliocaval stent reconstruction for non-IVC filter-associated iliocaval thrombosis. The mean number of prothrombotic risk factors was 2.2 (range: 0-5), including 30 (43%) patients with IVC atresia. Upon initial presentation, the Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification was C3 in 55 (80%) patients, C4 in four (5.8%) patients, C5 in one (1.4%) patient, and C6 in seven (10%) patients. Technical aspects of stent reconstruction, technical success, adverse events, 2-week and 6, 12, and 24-month clinical response, and 6, 12, and 24-month primary, primary-assisted, and secondary stent patency rates were recorded. Technical success was defined as recanalization and stent deployment. Adverse events were reported according to the Society of Interventional Radiology classification system. Clinical success was defined as a 1-point decrease in CEAP classification and stent patency was defined by the Cardiovascular and Interventional Radiological Society guidelines. The technical success rate was 100%. There were 352 venous stents deployed during stent reconstructions. One (1.4%) severe, four (5.8%) moderate, and four (5.8%) minor adverse events occurred and median post-procedure hospitalization was 1 day (range: 1-45 days). Clinical success at 2 weeks and 6, 12, and 24 months was 76%, 85%, 87%, and 100%, respectively. The estimated 6, 12, and 24-month primary patency rates were 91%, 88%, and 62%, respectively. The estimated 6, 12, and 24-month primary-assisted patency rates were 98%, 95%, and 81%, respectively. The estimated 6, 12, and 24-month secondary-assisted patency rates were all 100%. In conclusion, iliocaval stent reconstruction is an effective treatment for non-IVC filter-associated chronic iliocaval thrombosis with high rates of technical success, clinical responses, and stent patency.

Approach, Technical Success, Complications, and Stent Patency of Sharp Recanalization for the Treatment of Chronic Venous Occlusive Disease: Experience in 123 Patients.

PURPOSE: To report the technical success and complications following sharp recanalization of chronic venous occlusions. MATERIALS AND METHODS: A total of 123 patients, including 75 (61.0%) men and 48 (39.0%) women, with mean age of 50.5 ± 17.5 years (range 19-90 years), underwent sharp recanalization of chronic venous occlusions. The etiologies of occlusion were chronic deep venous thrombosis (n = 43; 35.0%), prior central venous access (n = 39; 31.7%), indwelling cardiac leads (n = 21; 17.1%), and occluded venous stents (n = 20; 16.3%). The sites of venous occlusion included 59/123 (48.0%) thoracic central veins, 37 (30.1%) non-thoracic central veins, and 27 (22.0%) peripheral veins. Median length of occlusion was 3.2 ± 1.4 cm (range 1.3-10.9 cm). RESULTS: Sharp recanalization was most commonly attempted with transseptal needles in 108/123 (87.8%), with a mean number of 1.2 ± 0.4 crossing devices per patient (range 1-4 devices). Targeting devices included a loop snare (n = 92; 74.8%), partially deployed Wallstent (n = 21; 17.1%), partially deployed Amplatzer vascular plug (n = 8; 6.5%), and an angioplasty balloon (n = 3; 2.4%). Technical success was achieved in 111 (90.2%) patients. There were 3 (2.4%) severe, 1 (0.8%) moderate, and 7 (5.7%) minor adverse events. Severe adverse events included 1 case each of pericardial tamponade, hemothorax, and inferior vena cava filter occlusion. 88 (71.5%) patients had venous stents placed; at the last follow-up examination, 68/86 (79.0%) stents were patent. CONCLUSION: Sharp recanalization has a high technical success and low rate of adverse events in the recanalization of chronic venous occlusions.

Acute Limb Ischemia Therapies: When and How to Treat Endovascularly.

Acute limb ischemia is an emergent limb and life-threatening condition with high morbidity and mortality. An understanding of the presentation, clinical evaluation, and initial workup, including noninvasive imaging evaluation, is critical to determine an appropriate management strategy. Modern series have shown endovascular revascularization for acute limb ischemia to be safe and effective with success rates approaching surgical series and with similar, or even decreased, perioperative morbidity and mortality. A thorough understanding of endovascular techniques, associated pharmacology, and perioperative care is paramount to the endovascular management of patients presenting with acute limb ischemia. This article discusses the diagnosis and strategies for endovascular treatment of acute limb ischemia.

Impact of Anemia and Transfusion on Readmission and Length of Stay After Spinal Surgery: A Single-center Study of 1187 Operations.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine whether receipt of blood transfusion and preoperative anemia are associated with increased rates of 30-day all-cause readmission, and secondarily with a prolonged hospital stay after spinal surgery. SUMMARY OF BACKGROUND DATA: Increased focus on health care quality has led to efforts to determine postsurgical readmission rates and predictors of length of postoperative hospital stay. Although there are still no defined outcome measures specific to spinal surgery to which providers are held accountable, efforts to identify appropriate measures and to determine modifiable risk factors to optimize quality are ongoing. METHODS: Records from 1187 consecutive spinal surgeries at Northwestern Memorial Hospital in 2010 were retrospectively reviewed and data were collected that described the patient, surgical procedure, hospital course, complications, and readmissions. Presence or absence of transfusion during the surgery and associated hospital course was treated as a binary variable. Multivariate negative binomial regression and logistic regression were used to model length of stay and readmission, respectively. RESULTS: Nearly one fifth (17.8%) of surgeries received transfusions, and the overall readmission rate was 6.1%. After controlling for potential confounders, we found that the presence of a transfusion was associated with a 60% longer hospital stay [adjusted incidence rate ratio=1.60 (1.34-1.91), P<0.001], but was not significantly associated with an increased rate of readmission [adjusted odds ratio=0.81 (0.39-1.70), P=0.582]. Any degree of preoperative anemia was associated with increased length of stay, but only severe anemia was associated with an increased rate of readmission. CONCLUSIONS: Both receipt of blood transfusion and any degree of preoperative anemia were associated with increased length of hospital stay after controlling for other variables. Severe anemia, but not receipt of blood transfusion, was associated with increased rate of readmission. Our findings may help define actions to reduce length of stay and decrease rates of readmission.

Usefulness of nuclear whole-body bone scanning for diagnosis of leprosy.

Leprosy, or Hansen's disease, is rare in the United States. Given its rarity, as well as the pathognomonic dermatologic findings, there are few cases in which nuclear medicine imaging plays a role in the diagnostic workup. We present a 39-year-old man who presented with chronic abdominal pain, skin ulcers, and hypercalcemia who underwent computed tomography of the chest and a whole-body bone scan to evaluate for possible underlying neoplasm due to his profound hypercalcemia. Although the diagnosis of leprosy had been established by lower-extremity skin biopsy upon admission, workup for other potential concurrent etiologies of hypercalcemia was performed before initiating therapy. We present the computed tomography scans, nuclear medicine images, and corresponding skin findings of this case.

Single-Center Comparison of Overall Survival and Toxicities in Patients with Infiltrative Hepatocellular Carcinoma Treated with Yttrium-90 Radioembolization or Drug-Eluting Embolic Transarterial Chemoembolization.

PURPOSE: To compare overall survival and toxicities after yttrium-90 (90Y) radioembolization and chemoembolization with drug-eluting embolics (DEE) in patients with infiltrative hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Retrospective review of 50 patients with infiltrative HCC without main portal vein invasion who were treated with 90Y radioembolization (n = 26) or DEE chemoembolization (n = 24) between March 2007 and August 2012 was completed. Infiltrative tumors were defined by cross-sectional imaging as masses that lacked well-demarcated boundaries, and treatment allocations were made by a multidisciplinary tumor board. Median age was 63 years; median tumor diameter was 9.0 cm; and there were no significant differences between groups in performance status, severity of liver disease, or HCC stage. Toxicities were graded by Common Terminology Criteria for Adverse Events v4.03. Overall survival from treatment was assessed by Kaplan-Meier analysis, with analysis of potential predictors of survival with log-rank test. RESULTS: There was no difference in the average number of procedures performed in each treatment group (DEE, 1.5 ± 1.1; 90Y, 1.6 ± 0.5; P = .97), and technical success was achieved in all cases. Abdominal pain (73% vs 33%; P = .004) and fever (38% vs 8%; P = .01) were more frequent after DEE chemoembolization. There was no significant difference in median overall survival between treatment groups after treatment (DEE, 9.9 months; 90Y, 8.1 months; P = .11). CONCLUSIONS: 90Y radioembolization and DEE chemoembolization provided similar overall survival in the treatment of infiltrative HCC without main portal vein invasion. Abdominal pain and fever were more frequent after DEE chemoembolization.

Long-Term Percutaneous Nephrostomy Management of Malignant Urinary Obstruction: Estimation of Optimal Exchange Frequency and Estimation of the Financial Impact of Patient Compliance.

PURPOSE: To estimate the least costly routine exchange frequency for percutaneous nephrostomies (PCNs) placed for malignant urinary obstruction, as measured by annual hospital charges, and to estimate the financial impact of patient compliance. MATERIALS AND METHODS: Patients with PCNs placed for malignant urinary obstruction were studied from 2011 to 2013. Exchanges were classified as routine or due to 1 of 3 complication types: mechanical (tube dislodgment), obstruction, or infection. Representative cases were identified, and median representative charges were used as inputs for the model. Accelerated failure time and Markov chain Monte Carlo models were used to estimate distribution of exchange types and annual hospital charges under different routine exchange frequency and compliance scenarios. RESULTS: Long-term PCN management was required in 57 patients, with 87 total exchange encounters. Median representative hospital charges for pyelonephritis and obstruction were 11.8 and 9.3 times greater, respectively, than a routine exchange. The projected proportion of routine exchanges increased and the projected proportion of infection-related exchanges decreased when moving from a 90-day exchange with 50% compliance to a 60-day exchange with 75% compliance, and this was associated with a projected reduction in annual charges. Projected cost reductions resulting from increased compliance were generally greater than reductions resulting from changes in exchange frequency. CONCLUSIONS: This simulation model suggests that the optimal routine exchange interval for PCN exchange in patients with malignant urinary obstruction is approximately 60 days and that the degree of reduction in charges likely depends more on patient compliance than exact exchange interval.

Analysis of the RENAL and mRENAL Scores and the Relative Importance of Their Components in the Prediction of Complications and Local Progression after Percutaneous Renal Cryoablation.

PURPOSE: To determine if modified RENAL (mRENAL) score and its individual components have superior predictive value relative to the RENAL nephrometry score in prediction of complications and recurrence after percutaneous renal cryoablation. MATERIALS AND METHODS: Primary masses treated with CT-guided percutaneous renal cryoablation between June 2007 and May 2016 were retrospectively reviewed. RENAL and mRENAL scores were used to stratify masses into low, medium, and high complexity tertiles. Complications were characterized by SIR criteria. Predictors of complications and local progression were analyzed using multivariate logistic regression and Kaplan-Meier analysis. RESULTS: There were 95 renal cryoablation procedures in 86 patients. Of ablations, 89 had at least 1 follow-up imaging study, with median follow-up of 29 months. There were 11 (12.4%) complications, including 5 (6.5%) major complications. Mass complexity, as measured by mRENAL complexity tertile, was associated with increased risk of complications on multivariate analysis (P = .045). Endophytic location was the only individual ordinal component of the RENAL and mRENAL scores associated with complications (P = .021). Local progression occurred in 7 (8.3%) masses. Complexity as measured by either scoring system was not associated with local progression. Only diameter > 3 cm was associated with increased risk of local progression (hazard ratio = 9.9, 95% confidence interval = 2.1-45, P = .003). CONCLUSIONS: mRENAL score was predictive of complications and tumor size was predictive of recurrence. Use of mRENAL score for complications and tumor size for recurrence should allow for simpler risk stratification and more accurate patient counseling.

Association between smoking at diagnosis and cause-specific survival in patients with rectal cancer: Results from a population-based analysis of 10,794 cases.

BACKGROUND: Currently, the 5-year survival rate for rectal cancer remains at <60%. The identification of potentially modifiable prognostic factors would be of considerable public health importance. A few studies have suggested associations between smoking and survival in rectal cancer; however, the evidence is inconsistent, and most of these studies were relatively small. In a large population-based cohort study, we investigated whether smoking at diagnosis is an independent prognostic factor for cancer-specific survival in rectal cancer and whether the association varies by sex, age, or treatment. METHODS: Rectal cancers (ICD10 C19-20) diagnosed between 1994 and 2012 were abstracted from the National Cancer Registry Ireland and classified by smoking status at diagnosis. Follow-up was for 5 years or until December 31, 2012. Multivariable Cox proportional hazards models were used to compare cancer-specific death rates in current smokers, ex-smokers, and never smokers. Subgroup analyses by age at diagnosis, sex, and treatment were conducted. RESULTS: A total of 10,794 rectal cancers were diagnosed. At diagnosis, 25% were current smokers, 24% were ex-smokers, and 51% were never smokers. Compared with never smokers, current smokers had a significantly greater rate of death from cancer (multivariable hazard ratio [HR], 1.15; 95% confidence interval [CI], 1.06-1.24), but ex-smokers did not (HR, 1.02; 95% CI, 0.94-1.11). The association was slightly stronger in men (current versus never smokers: HR = 1.13, 95% CI, 1.02-1.24) than females (HR, 1.05; 95% CI, 0.90-1.23), but the test for interaction was not significant (P = .75). The effect of smoking was not modified by age or receipt of tumor-directed surgery, radiotherapy, or chemotherapy. CONCLUSIONS: Rectal cancer patients who smoke at diagnosis have a statistically significant increased cancer death rate. Elucidation of the underlying mechanisms is urgently required. Cancer 2017;123:2543-50. © 2017 American Cancer Society.

An Outcome and Cost Analysis Comparing Single-Level Minimally Invasive Transforaminal Lumbar Interbody Fusion Using Intraoperative Fluoroscopy versus Computed Tomography-Guided Navigation.

BACKGROUND: Minimally invasive transforaminal lumbar interbody fusion (TLIF) has undergone significant evolution since its conception as a fusion technique to treat lumbar spondylosis. Minimally invasive TLIF is commonly performed using intraoperative two-dimensional fluoroscopic x-rays. However, intraoperative computed tomography (CT)-based navigation during minimally invasive TLIF is gaining popularity for improvements in visualizing anatomy and reducing intraoperative radiation to surgeons and operating room staff. This is the first study to compare clinical outcomes and cost between these 2 imaging techniques during minimally invasive TILF. METHODS: For comparison, 28 patients who underwent single-level minimally invasive TLIF using fluoroscopy were matched to 28 patients undergoing single-level minimally invasive TLIF using CT navigation based on race, sex, age, smoking status, payer type, and medical comorbidities (Charlson Comorbidity Index). The minimum follow-up time was 6 months. The 2 groups were compared in regard to clinical outcomes and hospital reimbursement from the payer perspective. RESULTS: Average surgery time, anesthesia time, and hospital length of stay were similar for both groups, but average estimated blood loss was lower in the fluoroscopy group compared with the CT navigation group (154 mL vs. 262 mL; P = 0.016). Oswestry Disability Index, back visual analog scale, and leg visual analog scale scores similarly improved in both groups (P > 0.05) at 6-month follow-up. Cost analysis showed that average hospital payments were similar in the fluoroscopy versus the CT navigation groups ($32,347 vs. $32,656; P = 0.925) as well as payments for the operating room (P = 0.868). CONCLUSIONS: Single minimally invasive TLIF performed with fluoroscopy versus CT navigation showed similar clinical outcomes and cost at 6 months.

Percutaneous Cryoablation for the Treatment of Primary and Metastatic Lung Tumors: Identification of Risk Factors for Recurrence and Major Complications.

PURPOSE: To identify risk factors for local recurrence and major complications associated with percutaneous cryoablation of lung tumors. MATERIALS AND METHODS: All cases between April 2007 and September 2014 at 1 institution were retrospectively reviewed. Procedures were performed using computed tomography guidance and a double freeze-thaw protocol. Tumor progression was determined via World Health Organization guidelines, and complications were classified using SIR reporting standards. Measures of efficacy were calculated via Kaplan-Meier analysis. Predictors of local progression and major complications were identified by Cox proportional hazards and logistic regression. RESULTS: There were 47 tumors (25 primary, 22 metastatic) treated with median follow-up of 11.1 months. Mean diameter before treatment was 2.4 cm, and an average of 2.1 cryoprobes were used per procedure. Major complications (most commonly, pneumothorax requiring chest tube) occurred in 12 (25%) cases, and minor complications occurred in 13 (27%) cases. Median time to local progression was 14 months (16 mo for primary tumors and 10 mo for metastatic tumors), and median overall survival was 33 months (43 mo for patients with primary tumors and 22 mo for patients with metastatic tumors). On multivariate analysis, tumor diameter > 3 cm was associated with local progression (hazard ratio = 3.2, P = .013), and use of multiple cryoprobes (relative risk [RR] = 7.2, P = .045) and previous local therapy (RR = 15, P = .030) were associated with major complications. CONCLUSIONS: Percutaneous cryoablation of lung tumors is technically feasible with a complication rate comparable to other percutaneous ablation techniques. Percutaneous cryoablation is more efficacious and has fewer complications when offered to patients with small, previously untreated lesions.

Tracheostomy and infection prolong length of stay in hospital after surgery for head and neck cancer: a population based study.

OBJECTIVE: To determine the factors that predict length of stay (LOS) in hospital after head and neck cancer (HNC) surgery for patients treated in public hospitals in Ireland between 2002 and 2010. STUDY DESIGN: Cancer registry data on patients with carcinoma of the oropharynx/larynx were identified and linked with hospital in-patient discharge records. Associations between clinical (e.g., surgery type, neoadjuvant chemoradiation), health service factors, and LOS were investigated by using negative binomial regression. RESULTS: Of the patients diagnosed with HNC, 50% (n = 1651) underwent HNC surgery. Median LOS was 10 days (range: 1-289). Variables associated with prolonged LOS included tracheostomy (neck dissection + tracheostomy versus neck dissection only: incident rate ratio [IRR] 2.66; 95% confidence interval [CI] 2.01-3.50); postoperative infection (IRR 2.26; 95% CI 1.94-2.62); and neoadjuvant radiotherapy (IRR 2.15; 95% CI 1.64-2.82). Advanced stage, gastrostomy, and reconstruction were also associated with prolonged LOS. CONCLUSIONS: Tracheostomy and postoperative infection were associated with prolonged LOS. Further investigation of these modifiable risk factors is warranted.

Utility of Readmission Rates as a Quality of Care Measure and Predictors of Readmission Within 30 Days After Spinal Surgery: a Single-Center, Multivariate Analysis.

STUDY DESIGN: A retrospective review. OBJECTIVE: The aim of this study was to establish clinically relevant readmission rates that permit accurate comparisons, improve risk-stratification, and direct efforts to minimize readmissions. SUMMARY OF BACKGROUND DATA: The 30-day hospital readmission rate is a quality of care measure that is now being used to compare hospitals in a publicly available manner. METHODS: Records from 1187 consecutive spinal surgeries at Northwestern Memorial Hospital in 2010 were retrospectively reviewed and data were collected that described the patient, surgical procedure, hospital course, complications, and readmissions. The primary outcome of interest was readmission to the hospital within 30 days. Potential risk factors were examined for association with the outcome first via bivariate analysis, with significant predictors further examined by a multivariable model. Identified readmissions were independently reviewed by attending spinal neurosurgeons not involved with the cases to determine whether the readmissions were procedure related or procedure unrelated with respect to accepted criteria. RESULTS: The overall readmission rate was 6.1%. Of these readmissions, 37.5% were deemed procedure related upon attending review, leading to a procedure-related readmission rate of 2.3%. Upon multivariate analysis, only 3 variables were found to be significant predictors of readmission: 2 or more patient comorbidities [odds ratio (OR) 3.72, 95% confidence interval (95% CI) 1.62-8.56], an admission to the ICU (OR 2.68, 95% CI 1.45-4.95), and each additional spinal level involved (OR 1.11, 95% CI 1.02-1.21). CONCLUSIONS: Our study suggests that predictors for all-cause 30-day readmission following spinal procedures include number of spinal levels performed during the surgery, number of patient comorbidities present at the time of surgery, and whether the admission required an ICU stay. Future work should focus on developing best practices to modify medical risk factors and comorbidities that have the potential to decrease 30-day readmission rates. LEVEL OF EVIDENCE: 3.

Smoking at diagnosis is an independent prognostic factor for cancer-specific survival in head and neck cancer: findings from a large, population-based study.

BACKGROUND: Some studies suggest smoking may result in poorer clinical outcomes in head and neck cancer, but the evidence is heterogeneous and some of it is poor quality. In a large, population-based, study we investigated: (i) whether smoking at diagnosis is an independent prognostic factor for cancer-specific survival in head and neck cancer; and (ii) whether the association varies by site and treatment. METHODS: Head and neck cancers (ICD10 C01-C14, and C30-32) diagnosed from 1994 to 2009 were abstracted from the National Cancer Registry Ireland, and classified by smoking status at diagnosis. Follow-up was for 5 years or until December 31, 2010. Multivariate Cox proportional hazards models were used to compare cancer-specific death rates in current, ex-, and never smokers. Subgroup analyses by site and treatment were conducted. RESULTS: In total, 5,652 head and neck cancers were included. At diagnosis, 24% were never smokers, 20% ex-smokers, and 56% current smokers. Compared with never smokers, current smokers had a significantly raised death rate from cancer [multivariate HR, 1.36; 95% confidence interval (CI), 1.21-1.53]. The association was similar after restriction to squamous cell tumors. A significantly increased cancer-related death rate was seen for current smokers with oral cavity, pharyngeal, and laryngeal cancers. The association was stronger in surgically treated patients [HR, 1.49; 95% CI, 1.25-1.79; P(interaction) = 0.01]. Neither radiotherapy nor chemotherapy modified the effect of smoking. CONCLUSIONS: Patients with head and neck cancer who smoke at diagnosis have a significantly increased cancer death rate. IMPACT: Greater efforts are needed to encourage and support smoking cessation in those at risk of, and diagnosed with, head and neck cancer.