Understanding the impact of a clinical care pathway for major head and neck cancer resection on postdischarge healthcare utilization.

BACKGROUND: The purposes of this study were to explore the association of a postoperative clinical care pathway for patients undergoing major head and neck surgery with microvascular reconstruction on postdischarge health care utilization and cost and to compares a nonpathway group (n = 60) to a prospective, pathway-managed group (n = 54). Our primary purpose was to understand whether pathway-managed patients used postdischarge health care resources differently than patients managed without a care pathway. METHODS: Health care utilization data (counts and costs) were collected for the 3 months after discharge. Differences in utilization were compared using Poisson regression. The null hypothesis was that there were no differences in utilization between the pathway and nonpathway groups. RESULTS: Pathway patients had fewer postdischarge encounters in 2 of 4 sectors. Readmission costs were significantly less in the pathway group only. CONCLUSION: A postoperative inpatient clinical care pathway in patients with head and neck cancer is associated with decreased health care utilization and inpatient costs in the 3 months after discharge. © 2015 Wiley Periodicals, Inc. Head Neck 38: E1216-E1220, 2016.

A multicenter review of deep venous thrombosis prophylaxis practice patterns for blunt hepatic trauma.

BACKGROUND: Non-operative management of blunt hepatic trauma is successful in the majority of hemodynamically stable patients. Due to the risk of recurrent hemorrhage, pharmacologic deep venous thrombosis (DVT) prophylaxis is often delayed. The optimal timing of prophylaxis is unclear. A multi-centre, retrospective review of patients with blunt hepatic injuries presenting between 2000 and 2004 was performed. All patients had an ISS >/= 12 and a CT scan confirming hepatic trauma. Patients were categorized into: (1) early DVT prophylaxis (48 hrs), and (3) no prophylaxis. METHODS AND RESULTS: Thirty-seven (25%) and 45 (42%) patients received early and delayed DVT prophylaxis respectively. The remainder (32%) received none. Mean hepatic injury grades were lower in the early prophylaxis group (II) compared to the delayed and no prophylaxis cohorts (III)(p = 0.002). The number of patients requiring post-admission blood transfusions was highest in the delayed group (44%) compared to the early (26%) and no prophylaxis (6%) groups (p = 0.03). No patient in the early prophylaxis cohort developed a DVT or required delayed angiographic or operative intervention. Two patients in the delayed group failed non-operative management. Eight (18%) patients in the delayed group developed a clinically significant DVT; 1 (2%) progressed to a PE. CONCLUSION: Practice patterns indicate that chemical DVT prophylaxis initiated within 48 hours of admission may be safe in patients with significant blunt hepatic trauma. Delays in prevention result in venothromboembolic events, but not in fewer blood transfusions or a decreased need for subsequent angiographic or operative therapies.

Reoperation for intraluminal rectal cancer recurrence.

PURPOSE: Following curative resection for rectal cancer, approximately 5 percent of locoregional recurrences occur intraluminally, presumably because of tumor exfoliation during the initial operation. The rate of resectability, subsequent locoregional control, and survival in patients with isolated intraluminal recurrence have not been well studied. METHODS: From 1994 to 2003, nine patients (seven males; median age, 68 years) with isolated intraluminal rectal cancer recurrence were treated for cure at our center. RESULTS: Initial procedures performed were four high anterior resections and five low anterior resections for tumors having a median distance from the anal verge of 12.5 (range, 7.5-16) cm. Median resected distal margin was 2.5 (range, 1.2-4.0) cm. Original tumor staging was T2 N0 M0 in three, T3 N0 M0 in three, T3 N1 M0 in one, and T3 N2 M0 in two. Median time between primary resection and intraluminal recurrence was 21 (range, 8-53) months. Intraluminal recurrence distal to the anastomosis occurred in three of nine patients and anastomotic recurrence occurred in six of nine patients. Pathologically clear margins were obtained in all patients at the time of curative re-resection. Following re-resection, patients were followed for a mean of 30 (range, 6-59) months. No patient has developed locoregional recurrence to date or to the time of patient death. Six of nine patients are alive and disease-free with a median follow-up of 34.5 (range, 6-59) months. One patient died disease-free at 35 months. One patient died from pulmonary metastases 30 months postoperatively and another patient developed liver metastasis 11 months postoperatively. CONCLUSION: Endoscopic surveillance following sphincter-sparing rectal cancer resection is warranted as re-resection for intraluminal recurrence can result in locoregional control and significant disease-free survival.