Predictors of Conversion During Minimally Invasive Gastrectomy for Malignancy.

INTRODUCTION: Implementation of minimally invasive gastrectomy (MIG) for malignancy is increasing. However, risk factors for conversion to open surgery during laparoscopic and robotic gastrectomy are poorly understood. This study aimed to determine the risk factors for, and impact of, conversion during oncologic resection. METHODS: The National Cancer Database (NCDB) was used to identify patients with clinical stage I-III gastric cancer from 2010 to 2017. Chi-squared test and t-test were used to compare the robotic versus laparoscopic groups. Propensity score weighted multivariable logistic regression was used to evaluate factors associated with conversion to open surgery. RESULTS: Of 6990 patients identified, 5702 (81.6%) underwent a laparoscopic resection and 1288 (18.4%) underwent robotic-assisted resection. Conversion rates were 14.7% and 7.8% for laparoscopic and robotic gastrectomy, respectively. The robotic approach was associated with lower likelihood of conversion compared to laparoscopic approach (odds ratio [OR] = 0.470, P < 0.001). Other factors predictive of conversion included tumor size >5 cm compared to <2 cm (OR 1.714, P = 0.010), total gastrectomy compared to partial gastrectomy (OR 2.019, P < 0.001), antrum/pylorus (OR 2.345, P < 0.001), and body (OR 2.152, P < 0.001) tumors compared to cardia tumors. Compared to those treated with laparoscopic and robotic gastrectomy, patients who underwent conversion experienced significantly longer hospital length of stay and higher rates of positive surgical margins. CONCLUSIONS: Laparoscopic gastrectomy was associated with a higher conversion rate compared to robotic gastrectomy. Conversion to open surgery was associated with a significantly longer length of stay and higher rates of positive margins. Identification of risk factors for conversion can aid in appropriate modality selection.

Postoperative chemotherapy and radiation improve survival following cardiac sarcoma resection.

OBJECTIVE: Cardiac sarcoma represents a rare and aggressive form of cancer with a paucity of data to produce outcome-driven evidence-based guidelines. Current surgical management consists of resection with postoperative therapy (chemotherapy, radiation, or both) offered on a selective, individualized basis. This study was designed to determine whether postoperative therapy was associated with improved overall survival after resection. METHODS: The National Cancer Database was used to identify patients with cardiac sarcoma between 2004 and 2015. Patient characteristics were stratified by treatment (surgical, nonsurgical, and none), and treatment was analyzed by stage. Overall survival, assessed with Kaplan-Meier methodology, was compared between patients who received postoperative therapy and those who did not following resection. Multivariable survival modeling using a Weibull model identified risk factors associated with survival while controlling for confounders. RESULTS: The study included 617 patients diagnosed with cardiac sarcoma. Only 24% (149/617) of patients were diagnosed with early-stage disease. Angiosarcoma represented 48% (298/617) of cases and was the most commonly identified histologic subtype. 60% (372/617) underwent surgical resection and 58% (216/372) of those patients were treated with postoperative therapy. Following surgery, median survival was more than doubled for patients treated with postoperative therapy (19 months vs 8 months, P = .026). However, 5-year overall survival was similar between the groups. Multivariable analysis confirmed an improvement in survival with postoperative therapy (hazard ratio, 0.68; 95% confidence interval, 0.51-0.91, P = .009). CONCLUSIONS: Postoperative therapy is associated with better median survival following resection of cardiac sarcoma. However, at 5 years, the difference in overall survival is not statistically significant.

Nurse staffing and outcomes for pulmonary lobectomy: Cost and mortality trade-offs.

BACKGROUND: Nurse staffing impacts patient outcomes, but little is known about the relationship between nurse staffing and outcomes for lung cancer patients undergoing pulmonary lobectomy. OBJECTIVES: To examine the association between nurse staffing and outcomes following lobectomy for lung cancer. METHODS: Patients (N = 16,994) with lung cancer between who underwent lobectomy between 2008-2011 were identified in the National Inpatient Sample. Nurse staffing was quantified using registered nurse full-time equivalents per adjusted patient days. Multivariable models were used to estimate the effect of RN FTEs on mortality, length of stay, and costs, controlling for covariates. RESULTS: Patients treated at hospitals using 5.6 or more RN FTEs had shorter hospitals stays by 0.37 days (p = 0.008), had 36% lower odds of mortality (OR = 0.64, p = 0.014), but incurred $4,388 (p < 0.0001) in additional costs. CONCLUSIONS: Hospital administrators face a troubling trade-off between costs and outcomes in decisions about nurse staffing mix for pulmonary lobectomy.

Management of Type A Aortic Dissection with Malperfusion Syndrome: A Case Report.

Acute type A aortic dissection (TAAD) with malperfusion syndrome remains a challenging diagnosis and optimal surgical management remains unsettled. We present a case and surgical approach employed for a patient with TAAD and malperfusion syndrome who presented with pulseless bilaterally extremities. Satisfactory outcomes can be achieved with early multidisciplinary collaboration and urgent repair of the aorta and simultaneous efforts to restore blood flow to ischemic tissue.

Epidemiology and Perioperative Mortality of Exploratory Laparotomy in Rural Ghana.

Background: Perioperative mortality rate (POMR) has been identified as an important measure of access to safe surgical and anesthesia care in global surgery. There has been limited study on this measure in rural Ghana. In order to identify areas for future quality improvement efforts, we aimed to assess the epidemiology of exploratory laparotomy and to investigate POMR as a benchmark quality measure. Methods: Surgical records were reviewed at a regional referral hospital in Eastern Region, Ghana to identify cases of exploratory laparotomy from July 2017 through June 2018. Patient demographics, health information, and outcomes data were collected. Logistic regression was used to identify predictors of perioperative mortality. Findings: The study included operations for 286 adult and 60 pediatric patients. Only 60% of patients were covered by National Health Insurance (NHI). The overall POMR was 11.5% (12.6% adults; 6.7% pediatric). Sixty percent of mortalities were referrals from outside hospitals and the mortality rate for referrals was 13.5%. Odds of mortality was 13 times greater with perforated peptic ulcer disease (OR = 13.1, p = 0.025) and 12 times greater with trauma (OR = 11.7, p = 0.042) when compared to the most common operation. Female sex (OR = 0.3, p = 0.016) and NHI (OR = 0.4, p = 0.031) were protective variables. Individuals 60 years and older (OR = 3.3, p = 0.016) had higher mortality. Conclusion: POMR can be an important outcome and quality indicator for rural populations. Interventions aimed at decreasing emergent hernia repair, preventing perforation of peptic ulcer disease, improving rural infrastructure for response to major trauma, and increasing NHI coverage may improve POMR in rural Ghana.

The Impact of Minimally Invasive Gastrectomy on Survival in the USA.

BACKGROUND: Minimally invasive surgical approaches for gastric adenocarcinoma are increasing in prevalence. Although recent studies suggest such approaches are associated with improvements in short-term outcomes, long-term outcomes have not been well studied. This study aimed to evaluate the impact of minimally invasive gastrectomy on long-term survival. METHODS: The National Cancer Database (NCDB) was used to identify patients who underwent gastrectomy for adenocarcinoma between 2010 and 2015. Patient characteristics were stratified by open and minimally invasive approaches and compared using chi-square and t tests. Unadjusted survival functions were estimated using Kaplan-Meier methodology. Multivariable modeling of risks factors for survival was analyzed with Cox proportional hazard models. Covariate imbalance was controlled using propensity score matching. RESULTS: The study included 17,449 patients who underwent gastrectomy. Cox proportional hazard modeling demonstrated that minimally invasive surgery improved survival (hazard ratio = 0.86, P < 0.0001). Predictors of worsened survival included community facility type, comorbidities, tumor size, extent of gastrectomy, clinical T and N staging (P < 0.0060 for all). After propensity score matching, minimally invasive surgery had a significantly improved survival at 5 years compared to an open approach, 51.9% versus 47.7% (P < 0.0001). Survival was not significantly different between propensity score-matched patients who received laparoscopic and robotic approaches (P = 0.2611). CONCLUSIONS: Minimally invasive approaches for gastric carcinoma are associated with improved long-term survival. There was no significant difference in survival when comparing laparoscopic to robotic gastrectomy. The mechanisms that drive these improvements deserve further investigation.

Readmissions After Lobectomy in an Era of Increasing Minimally Invasive Surgery: A Statewide Analysis.

OBJECTIVE: Utilization of minimally invasive surgical modalities for lobectomy is increasing. Lobectomy can be associated with notable rates of readmission. As use of these modalities increases, evaluation of the impact on readmission is warranted. METHODS: Data from the Pennsylvania Health Care Cost Containment Council were used to identify lobectomy operations performed in Pennsylvania from 2011 through 2014. Operations were stratified by approach: open, video-assisted thoracoscopic surgery (VATS) or robotic. Differences in patient characteristics were assessed with analysis of variance and chi-squared tests. Logistic regression modeled risk of 30-day readmission and linear regression modeled length of stay (LOS) after controlling for confounders. RESULTS: We evaluated 4,939 lobectomy operations (2,501 open, 1,944 VATS, 494 robotic) with 583 readmissions (11.8%). Robotic cases increased 333% over 4 years. VATS and open cases increased 38% and 22%, respectively. Surgical approach was not associated with hospital readmission (VATS odds ratio (OR) = 0.95; P = 0.632; and robotic OR = 1.02; P = 0.916). Longer LOS was associated with a greater likelihood of readmission (OR = 1.58; P = 0.002). LOS was 1 day less for VATS (P < 0.001) and 1.5 days less for robotic lobectomy (P < 0.001) when compared to an open approach. The most common reasons for readmission were respiratory complications and nonrespiratory infection. CONCLUSIONS: Surgical approach does not directly affect readmission. However, minimally invasive lobectomy appears to be associated with shorter LOS and results in more patients discharged home. Decreased LOS and discharge home are associated with fewer readmissions.

Perioperative chemotherapy is not associated with improved survival in stage I pleomorphic lung cancer.

OBJECTIVES: Pulmonary pleomorphic carcinoma represents an understudied, rare, and aggressive histologic subtype of non-small cell lung cancer. Better understanding of rare disease subtypes allows for improved individualization of patient care. This study aimed to evaluate current trends in treatment and survival of pleomorphic carcinoma. METHODS: The National Cancer Database was used to identify patients with staged, pleomorphic carcinoma and adenocarcinoma between 2004 and 2015. Patient characteristics and treatments were compared using χ2 tests. Cox proportional hazard models examined survival by stage after controlling for confounders. Propensity score matched Kaplan-Meier curves estimated survivor functions stratified by stage. Differences in survival following treatment for stage I pleomorphic carcinoma with surgery alone versus surgery plus chemotherapy were compared with Cox proportional hazard models and Kaplan-Meier survival curves. RESULTS: One thousand four hundred eight patients with pleomorphic carcinoma and 607,561 patients with adenocarcinoma were identified. Pleomorphic carcinoma accounted for 0.1% of all non-small cell lung cancers. Pleomorphic disease had poorer overall 5-year survival compared with adenocarcinoma for stages I through IV (49.4% vs 59.1%, 34.5% vs 43.8%, 16.9% vs 28.4%, and 5.7% vs 7.8%, respectively; P < .0047 for all). Perioperative chemotherapy was used more frequently for pleomorphic disease (17.5% vs 6.1%; P < .001). For stage I pleomorphic cancer, treatment with surgery alone (n = 253) and surgery with chemotherapy (n = 57) had overall 5-year survival rates of 55.2% and 53.7%, respectively, and were not significantly different (P = .2868). CONCLUSIONS: Pulmonary pleomorphic carcinoma is rare and aggressive, with worse survival when compared with adenocarcinoma. Perioperative chemotherapy has not demonstrated significant survival benefits in stage I pleomorphic cancer.

Minimally Invasive Lobectomy Modality and Other Predictors of Conversion to Thoracotomy.

OBJECTIVE: Minimally invasive approaches to lobectomy are increasing. Rates of conversion to thoracotomy are well reported but risk factors are poorly understood. This study aimed to determine the impact of surgical modality (video-assisted thoracoscopic surgery [VATS] and robotic) on conversion as well as to identify other risk factors for conversion. METHODS: The National Cancer Database (NCDB) was used to identify patients who underwent minimally invasive lobectomy between 2010 and 2015. Patient characteristics were compared between VATS and robotic approaches using chi-squared tests and t-tests. Logistic regression models were used to control for covariates and identify factors associated with all minimally invasive conversion, VATS conversion, and robotic conversion. Propensity score matching was used to compare conversion rates of VATS and robotic lobectomy. RESULTS: The study included 51,723 patients with lung cancer who underwent minimally invasive lobectomy (VATS or robotic). Conversion was identified in 7,109 (7.3%) operations. The odds of VATS conversions were nearly twice that of robotic conversions (OR 1.94 P < 0.0001). After controlling for VATS and robotic patient imbalances with propensity score matching, there was a 5% difference in conversion rates (14% vs. 9%, P < 0.0001). Other predictors of minimally invasive conversion included community hospitals, tumor size 4.5 cm or greater, and an increasing Charlson comorbidity index (P < 0.03 for all). CONCLUSIONS: VATS is associated with nearly twice the odds of conversion as robotic lobectomy. Identifying specific risk factors for both VATS and robotic conversions may aid in appropriate modality selection and reduction of conversions.

Lytic Therapy for Retained Traumatic Hemothorax: A Systematic Review and Meta-analysis.

BACKGROUND: Intrapleural lytic therapy has been established as an important modality of treatment for many pleural disorders, including hemothorax and empyema. Retained traumatic hemothorax is a common and understudied subset of pleural disease. The current standard of care for retained traumatic hemothorax is operative management. The use of lytic therapy for avoidance of operative intervention in the trauma population has not been well established. METHODS: Randomized controlled trials (RCTs) and non-RCTs reporting operative intervention following the use of intrapleural lytic treatment for retained traumatic hemothorax were identified in the literature. The primary outcome was avoidance of surgery following treatment with any lytic agent. Meta-analysis was performed to pool the results of those studies. Subgroup analysis by type of lytic therapy and analysis of length of stay were also performed. RESULTS: One RCT and nine non-RCTs including 162 patients were pooled in the analysis. Avoidance of surgery following treatment with any lytic agent was found to be 87% (95% CI, 81%-92%). Tissue plasminogen activator resulted in 83% operative avoidance (95% CI, 71%-94%), and other, non-tissue plasminogen activator lytic agents resulted in 87% operative avoidance (95% CI, 82%-93%). The average length of stay for patients undergoing lytic therapy was 14.88 days (95% CI, 12.88-16.88). CONCLUSIONS: Lytic therapy could reduce the need for operative intervention in trauma patients with retained traumatic hemothorax. RCTs are indicated to definitively evaluate the benefit of this approach.