Pancreatic cancer in the USA: persistence of undertreatment and poor outcome.

PURPOSE: Despite decades of research, consensus on optimal treatment for pancreatic cancer has not been reached and survival remains bleak. This study aimed to evaluate predictors of treatment and survival among patients treated in community settings. METHODS: A sample of pancreatic cancer patients who were diagnosed in 2009 and reported to the National Cancer Institute's Surveillance Epidemiology and End Results (SEER) program (n = 977) was included. Logistic regression was used to assess factors associated with therapy modality. Survival was examined using the Kaplan-Meier method and Cox proportional hazards regression. All analyses were conducted stratified by tumor stage. RESULTS: Among stages I-II patients, 27 % received no treatment and only 47 % received surgery. Among these patients, no treatment was associated with older age, being a woman, not being married, lower income, and larger or unknown tumor size. Additionally, the type of adjuvant therapy received varied by tumor characteristics, race/ethnicity, and socioeconomic status. The most common therapies for stage III tumors were chemoradiation (40.8 %) and chemotherapy (21.9 %) alone. Half of stage IV patients received chemotherapy; chemotherapy was less common in patients who were older, in a minority race/ethnicity, and not married. Although treatment was associated with better prognosis, even among stages I-II patients who underwent surgery, a quarter succumbed to their disease within 17 months. CONCLUSION: A significant proportion of pancreatic cancer patients remain undertreated primarily due to nonclinical factors, including marital status. Further investigating what aspects of marriage are contributing to this association will provide a better understanding of pancreatic cancer treatment barriers.

Longer operative time: deterioration of clinical outcomes of laparoscopic colectomy versus open colectomy.

BACKGROUND: As laparoscopic surgery is applied to colorectal surgery procedures, it becomes imperative to delineate whether there is an operative duration where benefits diminish. OBJECTIVE: The purpose of this work was to determine whether benefits of a laparoscopic right colectomy compared with an open right colectomy are diminished by prolonged operative times. DESIGN: We performed a retrospective analysis comparing outcomes of patients undergoing laparoscopic right and open right colectomy for colon cancer with operative duration of less than and greater than 3 hours. SETTINGS: This study was based on data in the American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS: We queried the database for patients with laparoscopic and open right colectomy with a diagnosis of colorectal cancer between 2005 and 2010. MAIN OUTCOME MEASURES: Patients were stratified by operative technique and duration. Forward multivariable logistic regression analysis was performed for mortality, cerebrovascular/cardiovascular complications, and infectious complications. Predictors of operative time >3 hours in the laparoscopic cohort were identified by logistic regression. RESULTS: Of 4273 patients, operative duration was >3 hours for 18.4% of patients with a laparoscopic right colectomy and 11.3% with an open right colectomy. There was no benefit of the laparoscopic right colectomy with an operative duration >3 hours over open right colectomy with respect to mortality and cardiopulmonary and cerebrovascular complications. An operative duration >3 hours was an independent risk factor for infectious complications in patients undergoing a laparoscopic right colectomy. LIMITATIONS: This was a retrospective study and not an intention-to-treat analysis. CONCLUSIONS: At an operative duration of ≥3 hours, laparoscopic right colectomy has higher infectious complications than open right colectomy. Reduced mortality and less cardiopulmonary and cerebrovascular complications seen in the laparoscopic cohort with shorter operative duration were lost with an operative duration >3 hours. In patients at risk for prolonged laparoscopic right colectomy, early conversion to an open technique may be warranted.

Selection criteria for combined resection of synchronous colorectal cancer hepatic metastases: a cautionary note.

PURPOSE: Combined resection of primary colorectal cancer and synchronous hepatic metastases has been shown to be safe and associated with acceptable oncologic outcomes in selected patients. The purpose of this study was to determine if selection criteria for combined resection could be identified using major morbidity or mortality as an avoidable outcome. METHODS: We queried the American College of Surgeons National Surgery Quality Improvement Program dataset from 2005 to 2010 for combined liver and colorectal resections for colorectal cancer using procedure and diagnosis codes. These patients were compared to colorectal cancer patients receiving colectomy alone and patients receiving liver-directed surgery for secondary liver cancer. RESULTS: During the study period, 1,641 (53.1 %) of patients underwent colectomy alone, 1,113 (36 %) underwent liver-directed surgery alone, and 334 (10.9 %) underwent combined colectomy and liver-directed surgery for colorectal cancer. The combined patient population had statistically significant increases in American Society of Anesthesiologists class, preoperative ascites, preoperative systemic inflammatory response syndrome/sepsis, weight loss, functional dependence, and decreased serum albumin compared to the other cohorts. While major hepatectomy was less frequent in the combined cohort, the rate of rectal resection was similar to the colectomy-alone cohort. These selection disparities resulted in a subsequent increase in composite major morbidity, return to operating room, infectious complications, and length of stay in combined patients. CONCLUSIONS: While combined resection in patients with synchronous colorectal cancer hepatic metastases may be feasible, it is associated with considerable increase in morbidity without application of stringent selection criteria. We recommend only patients without known risk factors for perioperative morbidity and infectious complications be considered for this approach.

Morbid obesity and diverticulitis: results from the ACS NSQIP dataset.

BACKGROUND: We examined the relationship between morbid obesity, clinical presentation, and perioperative outcomes in patients offered surgery for diverticulitis. STUDY DESIGN: We queried the ACS NSQIP dataset from 2005 to 2010 for patients undergoing surgery for nonhemorrhaging diverticulitis. Univariate comparisons were made between normal weight (NL) and morbidly obese (MO) patients in terms of demographics, clinical presentation, and perioperative and postoperative outcomes variables using chi-square or rank tests. Multivariable regression was used to adjust for age in assessing the impact of MO on the likelihood of emergent surgery (ES), ostomy creation, open surgery, and undergoing procedures without an anastomosis. RESULTS: We identified 10,952 patients undergoing surgery for diverticulitis; morbidly obese (body mass index [BMI] ≥ 40 kg/m(2), n = 592, 5.7%), normal weight (BMI 18.5 to 25 kg/m(2), n = 2,530, 24.2%). Morbidly obese patients were younger than NL patients by an average of 9.4 years (p < 0.001). Morbidly obese patients underwent ES more frequently than NL patients (19.3% vs 15.4%; p = 0.025). Multivariable regression identified morbid obesity as an independent risk factor for ES (odds ratio [OR] 1.75, 95% CI 1.37 to 2.24, p < 0.001), ostomy creation (OR 1.67, 95% CI 1.34 to 2.08, p < 0.001), undergoing procedures without an anastomosis (OR 1.78, 95% CI 1.42 to 2.24, p < 0.001), and open surgery (OR 2.09, 95% CI 1.72 to 2.53, p < 0.001). Morbidly obese patients undergoing ES had more preoperative systemic inflammatory response syndrome/sepsis/septic shock than NL patients (72.8% vs 57.7%, p = 0.004). CONCLUSIONS: Morbidly obese patients undergoing surgery for diverticulitis are nearly 10 years younger than NL patients and are more likely to require ES, ostomy creation, open surgery, and to undergo procedures without an anastomosis. Morbidly obese patients undergoing ES also have more preoperative systemic inflammatory response syndrome/sepsis/septic shock.

Milan Criteria and UCSF Criteria: A Preliminary Comparative Study of Liver Transplantation Outcomes in the United States.

The application of orthotopic liver transplantation (OLT) for patients with hepatocellular cancer (HCC) necessitates highly selective criteria to maximize survival and to optimize allocation of a scarce resource. The objective of this study was to compare the outcomes of OLT for HCC in patients transplanted under Milan and UCSF criteria. The United Network of Organ Sharing (UNOS) database was queried for patients who had undergone OLT for HCC from 2002 to 2007, and 1,972 patients (Milan criteria, n = 1, 913; UCSF criteria, n = 59) were identified. Patients were stratified by pretransplant criteria (Milan versus UCSF), and clinical and pathologic factors and overall survival were compared. There were no differences in age, gender, diabetes mellitus, body mass index, and hepatitis B, or C status between the two groups. Overall survival was similar between the Milan and UCSF cohorts (1-, 2-, 3-, and 4-year survival rates: 88%, 81%, 76%, and 72% versus 91%, 80%, 68% and 51%, respectively, P = 0.21). Although the number of patients within UCSF criteria was small, our results nevertheless suggest that patients with HCC may have equivalent survival when transplanted under Milan and UCSF criteria. Long-term followup may better determine whether UCSF criteria should be widely adopted.

Robot-assisted total mesorectal excision: is there a learning curve?

BACKGROUND: Laparoscopic total mesorectal excision (TME) is associated with a steep learning curve, but the learning curve for robotic TME is unknown. This study aimed to evaluate the learning curve for robotic TME. METHODS: Between November 2004 and April 2009, 80 patients underwent robotic TME performed by a single surgeon. The operative experience was divided into two groups: group 1 (the first 40 cases) and group 2 (the subsequent 40 cases). Patient demographics, operative characteristics, and morbidities were compared. RESULTS: The two patient populations selected did not differ statistically in age, body mass index (BMI), preoperative risk assessment, stage, preoperative chemoradiotherapy, or tumor location. The mean operative times in group 1 (310 min) and group 2 (297 min) were similar (p = 0.55), and the mean robotic TME time did not differ between the two groups (60 vs. 64 min; p = 0.65). In addition, the operative times did not improve during the course of the study. There were no differences in EBL, margin status, or number of lymph nodes harvested. Furthermore, there were no differences in conversion rate, time to resumption of diet, length of hospital stay, or postoperative complications. CONCLUSION: Robot-assisted TME may attenuate the learning curve for laparoscopic rectal cancer resection. Further studies are necessary to establish the role of robotic surgery in minimally invasive rectal operations.

Racial and ethnic disparities in outcomes with radiation therapy for rectal adenocarcinoma.

BACKGROUND: Race/ethnicity may modify cancer outcomes and manifest as survival disparities for patients with rectal cancer. Our objective was to determine whether disparate rectal cancer outcomes result from variable efficacy of radiation therapy for major racial/ethnic groups. METHODS: The Los Angeles County Cancer Surveillance Program (CSP) identified patients with rectal adenocarcinoma between the years 1988 and 2006. Patients who underwent curative-intent surgery were grouped by race/ethnicity and by receipt (yes vs. no) and timing (neoadjuvant vs. adjuvant) of radiation therapy. The impact of receipt and timing of radiation therapy on overall survival was then assessed. RESULTS: Of 4,961 patients in CSP, 2,229 (45%) received radiation therapy. Overall, there was no difference in survival among patients according to receipt of radiation therapy. We then examined the radiation cohort, wherein 919 (41%) and 1,310 (59%) patients received neoadjuvant or adjuvant radiation, respectively. Overall, patients who received neoadjuvant compared to adjuvant radiation had improved survival (median survival (MS), 9.4 vs. 6.8 years, respectively; p < 0.001). Among those patients who received neoadjuvant radiation, whites, Hispanics, and Asians had significantly longer survival than blacks (MS, 10.4, 10.4, and 10.4 vs. 4.4 years, respectively; p = 0.003). On multivariate analysis, race/ethnicity was an independent predictor of survival (p = 0.001). CONCLUSIONS: To our knowledge, this is the first study examining the efficacy of radiation therapy for racial/ethnic groups with rectal cancer. Disparate outcomes were observed for the administration of radiation therapy for select racial/ethnic groups. The reasons for these disparities in outcomes should be investigated to better optimize radiation therapy for patients with rectal cancer.

Adjuvant chemotherapy improves survival in patients with American Joint Committee on Cancer stage II colon cancer.

BACKGROUND: It is unclear whether the administration of adjuvant chemotherapy improves survival in patients with American Joint Committee on Cancer (AJCC) stage II colon cancer. METHODS: The authors used the State of California Cancer Surveillance Program (CSP) to assess patients ages 18 to 80 years with AJCC stage II colon cancer (ie, T3 or T4 and N0) who underwent surgical resection during 1991 and 2006. Patients who had rectal and rectosigmoid cancers were excluded. The cohort was stratified according to the receipt of adjuvant chemotherapy, and clinical and pathologic characteristics and outcomes were assessed. RESULTS: From the CSP data, 3716 patients were identified who underwent curative-intent surgical resection for stage II colon cancer. When the 2 treatment groups (surgery plus adjuvant chemotherapy [n = 916] and surgery alone [n = 2800]) were compared, patients who received adjuvant chemotherapy were more likely to be younger and to have left-sided lesions with ≥ 12 lymph nodes examined. There was no difference in sex or tumor differentiation between the 2 groups. According to a Kaplan-Meier analysis, patients who received adjuvant chemotherapy had improved overall survival compared with patients who underwent surgery alone (median survival, 12 years vs 9.2 years, respectively; P < .001). In multivariate analysis, adjuvant chemotherapy was identified as an independent predictor of improved survival (hazard ratio, 0.88; 95% confidence interval, 0.78-0.99; P = .031). CONCLUSIONS: To the authors' knowledge, this is the first population-based analysis to identify a survival advantage for adjuvant chemotherapy in patients with AJCC stage II colon cancer. On the basis of the current findings, the authors concluded that the administration of adjuvant chemotherapy improves survival in select patients with stage II disease.

Selection criteria for complete cytoreduction after cytoreductive surgery for peritoneal surface malignancy: lessons learned from our first series of patients.

The appropriate selection criteria for complete cytoreduction in patients with peritoneal surface malignancies have not been determined. We performed a retrospective analysis of all patients receiving cytoreductive surgery (CRS) during the study period of 2004 to 2008 to determine appropriate selection criteria for successful complete cytoreduction. During the study period, 38 patients underwent attempted CRS. Cytoreduction was scored complete, incomplete, or not reported in 53 per cent (n = 20), 37 per cent (n = 14), and 11 per cent (n = 4), respectively. Median overall survival for compete and incomplete cytoreduction was 56 months versus 5 months (P = 0.011), respectively. Compared with incomplete cytoreduction, patients receiving complete cytoreduction were more likely to have a lower Peritoneal Cancer Index (PCI) and not have received preoperative systemic chemotherapy (CT). Univariate analysis verified PCI greater than 20 (hazard ratio [HR], 0.048; CI, 0.004 to 0.515; P = 0.01) and CT (HR, 0.17; 0.004 to 0.77; P = 0.021) as predictors of incomplete cytoreduction. Small bowel (100%), periportal region (33%), and mesentery (27%) were the most common sites of residual disease. In conclusion, PCI less than 20 and the need for preoperative chemotherapy should be strongly considered when selecting patients with peritoneal surface malignancy for attempted cytoreduction. Early evaluation of the small bowel, mesentery, and periportal region for resectability prevents unnecessary surgery.

An interaction of race and ethnicity with socioeconomic status in rectal cancer outcomes.

OBJECTIVE: Because appropriate rectal cancer care and subsequent outcomes can be influenced by several variables, our objective was to investigate how race, ethnicity, and socioeconomic status (SES) may impact rectal cancer outcomes. BACKGROUND: The management of rectal cancer requires a multidisciplinary approach utilizing medical and surgical subspecialties. METHODS: We performed an investigation of patients with rectal adenocarcinoma from Los Angeles County from 1988 to 2006 using the Los Angeles County Cancer Surveillance Program. Clinical and pathologic characteristics were compared among groups and overall survival was stratified by race/ethnicity and SES. RESULTS: Of 9504 patients with rectal cancer, 53% (n = 4999) were white, 10% black, 18% Hispanic, and 14% Asian. Stratified by race/ethnicity, Asians had the best overall survival followed by Hispanics, whites, and blacks (median survival 7.7 vs. 5.7, 5.5, and 3.4 years, respectively; P < 0.001). Stratified by SES group, the highest group had the best overall survival followed by middle and lowest groups (median survival 8.4 vs. 5.1 and 3.8 years, respectively, P < 0.001). Similar results were observed for surgical patients. On multivariate analysis, race/ethnicity, and SES remained independent predictors of overall survival in patients with rectal adenocarcinoma. Furthermore, interaction analysis indicated that the improved survival for select racial/ethnic groups was not dependent on SES classification. CONCLUSIONS: Within the diverse Los Angeles County population, both race/ethnicity, and SES result in inequities in rectal cancer outcomes. Although SES may directly impact outcomes via access to care, the reasons for the association between race/ethnicity and outcomes remain uncertain.

Neoadjuvant therapy is associated with improved survival in resectable pancreatic adenocarcinoma.

BACKGROUND: Neoadjuvant therapy has been used to improve survival in operable pancreatic cancer. The authors' objective was to compare long-term outcomes in patients receiving neoadjuvant versus adjuvant therapy for resectable pancreatic adenocarcinoma. METHODS: The California Cancer Surveillance Program for Los Angeles County retrospectively identified 458 patients with nonmetastatic pancreatic adenocarcinoma who underwent definitive pancreatic resection and received systemic chemotherapy between 1987 and 2006. The cohort was grouped by timing of systemic therapy-neoadjuvant or adjuvant. Clinicopathologic characteristics and overall survival were compared. Multivariate Cox regression analysis was used to determine the benefit of neoadjuvant therapy, independent of other significant factors. RESULTS: Of the 458 patients, 39 (8.5%) received neoadjuvant therapy, and 419 (91.5%) received adjuvant therapy. There was a significantly lower rate of lymph node positivity in the neoadjuvant group (45% vs 65%; P = .011) despite a higher rate of extrapancreatic tumor extension. On Kaplan-Meier analysis, the neoadjuvant group had significantly better overall survival compared with the adjuvant group (median survival, 34 vs 19 months; P = .003). Overall survival was also improved in the neoadjuvant therapy patients with extrapancreatic disease (median survival, 31 vs 19 months; P = .018). On multivariate Cox regression analysis, neoadjuvant therapy was an independent predictor of improved survival (hazard ratio, 0.57; 95% confidence interval, 0.37-0.89; P = .013). CONCLUSIONS: This is the first population-based study to compare neoadjuvant versus adjuvant treatment strategies in resectable pancreatic cancer. Neoadjuvant therapy is associated with a lower rate of lymph node positivity and improved overall survival and should be considered an acceptable alternative to the surgery-first paradigm in operable pancreatic cancer.

Improved outcomes in the management of esophageal cancer with the addition of surgical resection to chemoradiation therapy.

BACKGROUND: For patients with locally advanced esophageal cancer, prospective randomized clinical trials have reported no added value of surgical resection to chemoradiation alone. Using a large regional cancer registry, our objective was to determine whether curative-intent esophageal resection provided a survival advantage in the multimodality management of esophageal cancer. MATERIALS AND METHODS: Using the Los Angeles County Cancer Surveillance Program (CSP), we identified all patients with local and regional (i.e., AJCC Stages I-III) esophageal cancer during the years 1988-2006. Clinical and pathologic data included patient demographics, tumor information, indication for surgery, lymph node status, and timing of therapy. Overall survival was assessed by the Kaplan-Meier method, and multivariate Cox-regression analysis was performed. RESULTS: From CSP, 2233 patients with esophageal cancer were identified. Median survival (MS) of the entire cohort was 13.1 months. We stratified this cohort into patients who received chemoradiation alone (n = 645) and patients who received trimodality therapy (n = 286) (i.e., chemoradiation and surgery). Patients had significantly improved survival with trimodality therapy compared with chemoradiation alone (MS 25.2 vs. 12.3 months, respectively; P < 0.001). The survival advantage with trimodality therapy was observed for patients with squamous cell carcinoma (MS 24.5 vs. 12.8 months, respectively; P < 0.001) and adenocarcinoma (MS 25.9 vs. 10.6 months, respectively; P < 0.001). By multivariate analysis, trimodality therapy was a significant prognostic factor for improved survival in patients with esophageal cancer (hazard ratio [HR] 0.66, 95% confidence interval [95% CI]: 0.56-0.77, P < 0.001). CONCLUSIONS: Our data indicate that surgical resection remains an important component of the multimodality management of esophageal cancer.

Transarterial radioembolization with Yttrium-90 for regional management of hepatocellular cancer: the early results of a nontransplant center.

Selective arterial radioembolization with Yttrium-90 (Y-90) microspheres has shown promise for regional management of hepatocellular cancer (HCC). Our objective was to report our early experience with this treatment modality from a nontransplant center. Treatment of patients with HCC was discussed in a multidisciplinary tumor board. Patients with unresectable disease resulting from high lesion number, ill location of the tumor, poor hepatic reserve, or medical comorbidities were offered Y-90 treatment. Liver treatment was either lobar or tumor-targeted. Response to therapy was assessed by CT scan obtained within 3 months using Response Evaluation Criteria in Solid Tumors criteria. During 2007 to 2009, 40 Y-90 radioembolizations were performed in 20 patients with age that ranged from 16 to 87 years; four patients were 80 years old or older. After the first therapy, CT assessment of the treated area showed stable disease (n=15), partial response (n=3), and progression (n=2). Of the two patients who progressed, one was retreated with a subsequent complete response. The other patient died of progressive disease. The most common side effects were mild fatigue, anorexia, and nausea. In summary, our nontransplant center experience shows that Y-90 radioembolization is a well-tolerated treatment in select patients with unresectable HCC with an associated high rate of local tumor control.

The incidence and outcomes of pancreatectomy in patients with metastatic pancreatic adenocarcinoma.

CONTEXT: Despite current management guidelines, patients with metastatic pancreatic cancer continue to undergo pancreatic resection. OBJECTIVE: Our objective was to determine the incidence and outcomes of pancreatic resection in the setting of known metastatic disease. DESIGN: Using the Los Angeles County Cancer Surveillance Program, patients with pancreatic adenocarcinoma who underwent pancreatic resection with known M1 (AJCC stage IV) metastatic disease between the years 1988-2006 were assessed. SETTING: Large population based database query. PATIENTS: Patients with biopsy proven M1 pancreatic adenocarcinoma. INTERVENTIONS: Pancreatic resection, systemic chemotherapy, radiation therapy. MAIN OUTCOME MEASURE: Overall survival. RESULTS: Of 8,549 patients with pancreatic adenocarcinoma from Cancer Surveillance Program, 54% (n=4,649) initially presented with M1 disease. Within this M1 cohort, 2% (n=92) of patients underwent pancreatic resection and formed our final study cohort; these patients comprised 7% of the overall number of pancreatic resections performed for pancreatic adenocarcinoma during the study period. Only 35% (n=32) of the study cohort received adjuvant chemotherapy; and 13% (n=12) received adjuvant radiotherapy. Median survival for the study cohort was 6.3 months. Surgery provided no survival benefit over chemotherapy in patients with M1 disease and was associated with an 18% 30-day mortality. CONCLUSION: A large number of patients from Los Angeles County have undergone pancreatic resection despite the presence of known metastatic disease. Patient survival remains abysmal in this setting and these results are likely a microcosm of the surgical management of metastatic pancreatic cancer in the USA. These results highlight the necessary efforts to maintain appropriate standards of care in the management of pancreatic cancer.

Surgical resection and multidisciplinary care for primary and metastatic pancreatic islet cell carcinomas.

INTRODUCTION: The role of multidisciplinary management of islet cell cancers (ICC) has not been fully investigated in a population-based setting. METHODS: The Los Angeles County Cancer Surveillance Program was assessed for patients with ICC between the years 1982 to 2006. Patients were stratified by treatment received and clinicopathologic characteristics and survival were compared. RESULTS: We identified 236 patients with ICC; 86 patients underwent curative-intent surgery with median survival for local, regional, and distant disease of 17.3, 12.2, and 4.0 years, respectively. In comparison, 102 patients underwent medical management alone; survival was significantly shorter when compared to the surgical cohort for local, regional, and distant disease (p < 0.05). To determine whether adjuvant chemotherapy was associated with improved survival, we compared patients who underwent surgery alone compared to patients who underwent surgery followed by adjuvant chemotherapy. Although patients with metastatic disease had 3-year longer survival with adjuvant chemotherapy, these improvements in survival were not statistically significant. CONCLUSION: Surgical resection was associated with improved survival compared to medical management for any extent of disease in patients with ICC. Furthermore, adjuvant chemotherapy was not associated with survival but does warrant further examination in patients with metastatic disease.

Oncologic outcomes of robotic-assisted total mesorectal excision for the treatment of rectal cancer.

OBJECTIVE: To evaluate local recurrence and survival after robotic-assisted total mesorectal excision (RTME) for primary rectal cancer. SUMMARY BACKGROUND DATA: RTME is a novel approach for the treatment of rectal cancer and has been shown to be safe and effective. However, the oncologic results of this approach have not been reported in terms of local recurrence and survival rate. METHODS: Sixty-four consecutive rectal cancer patients with stage I-III disease treated between November 2004 and June 2008 were analyzed prospectively. RESULTS: All patients underwent RTME: 34 had colorectal anastomosis, 18 underwent coloanal anastomosis, and 12 received abdominoperineal resection. Operative mortality rate was 0%. The median operative time was 270 min and median blood loss was 200 mL. The conversion rate was 9.4%. Anastomotic leakage occurred in 4 of 52 (7.7%) patients with anastomosis. Median number of harvested lymph nodes was 14.5. Median distal margin of tumor was 3.4 cm. The circumferential resection margin was negative in all surgical specimens. No port-site recurrence occurred in any patient. Six patients developed recurrence: 2 combined local and distant, and 4 distal alone (mean follow-up of 20.2 months; range, 1.7-52.5). None of the patients developed isolated local recurrence. The mean time to local recurrence was 23 months. The 3-year overall and disease-free survival rates were 96.2% and 73.7%, respectively. CONCLUSIONS: RTME can be carried out safely and effectively in terms of recurrence and survival rates. Further prospective randomized trials are necessary to better define the absolute benefits and limitations of robotic rectal surgery.

Totally laparoscopic right colectomy with transvaginal specimen extraction: the authors' initial institutional experience.

BACKGROUND: The persistence of early and delayed wound complications related to both open and laparoscopic colectomy remains a significant health burden. Furthermore, as interest in natural orifice translumenal endosurgery (NOTES) continues to grow, bridging techniques may help to attenuate the learning curve associated with NOTES. The authors present their technique and short-term outcomes for totally laparoscopic right colectomy with transvaginal specimen extraction in a series of four patients. METHODS: Four consecutive patients from a prospectively maintained laparoscopic colectomy database were analyzed under an institutional review board-approved protocol. Clinicopathologic characteristics and short-term outcomes were reviewed. RESULTS: All the patients were women with no prior pelvic surgery. A four-trocar laparoscopic right colectomy with intracorporeal anastomosis was performed for cancer in two cases and for adenomatous polyp in two cases. Transvaginal extraction was possible in all cases. The average operating room time was 212.25 min. No patient experienced complications associated with the colpotomy; nor did any patient have pain or drainage from the extraction site postoperatively. The median hospital stay was 4.5 days. One patient experienced a bowel obstruction unrelated to the extraction site. The mean specimen length was 27 cm, and the mean number of lymph nodes retrieved was 15.75. CONCLUSION: Totally laparoscopic right colectomy with transvaginal extraction appears to be safe and feasible. This technique may provide both an attractive way to reduce abdominal wall morbidity and a bridge to NOTES colon surgery.

High-performance teams for current and future physician leaders: an introduction.

The scope of patient management increasingly crosses the defined lines of multiple medical specialties and services to meet patient needs. Concurrently, many hospitals and health-care systems have adapted new multidisciplinary team structures that provide patient-centric care as opposed to the more traditional discipline-centered delivery of care. As health care continues to evolve, the use of teams becomes even more critical in allowing interdependence between multiple disciplines to provide excellent care delivery and ongoing patient management. The use of teams permeates the health-care industry (and has done so for many years), but confusion about the structure, role, and use of teams contributes to limited effectiveness. The health-care industry's underuse of the fundamentals of corporate teamwork has, in part, created ineffective team leadership at the physician level. As the first in a series of documents on teamwork, this article is intended to introduce the reader to the rudiments of team theory and to present an introduction to a model of teamwork. The role of current and future physician leaders in ensuring team effectiveness is emphasized in this discussion. By educating health-care professionals on the foundations of high-performance teamwork, we hope to accomplish two main goals. The first goal is to help create a common and systematic taxonomy that physician leaders and institutional management can agree on and refer to concerning the development of high-performance health-care teams. The second goal is to stimulate the development of future physician leaders who use proven teamwork principles as a powerful modality to achieve efficient and optimal patient care. Most importantly, we wish to emphasize that health care, both philosophically and practically, is delivered best through high-performance teams. For such teams to perform properly, the organizational environment must support the team concept tangibly. In concert, we believe the best manner in which to cultivate knowledge and performance of the health-care organizational mission and goals is by using such teams.