Expecting the unexpected: incidental findings at a level 1 trauma center.

INTRODUCTION: Incidental findings on comprehensive imaging in the adult trauma population occur at rates as high as 54.8%. We sought to determine the incidence of potentially malignant or pre-malignant incidental findings in a high-volume level 1 trauma center and to evaluate follow-up recommendations. METHODS: This was a retrospective review of all patients with incidental findings on imaging who were admitted to the trauma service at our level 1 trauma center between January 1st, 2014, and October 1st, 2019. A multi-disciplinary team characterized findings as potentially malignant or pre-malignant. RESULTS: The study included 495 patients who had incidental findings, 410 of whom had potentially malignant or pre-malignant findings on imaging, resulting in a cumulative incidence of 6.6%. The mean age was 65 and 217 (52.9%) patients were male. The majority of "incidentalomas" were discovered on CT imaging (n=665, 98.1%); over half were solid (n=349, 51.5%), while 27.4% were cystic (n=186) in nature. The lungs (n=199, 29.4%), kidneys (n=154, 22.8%), liver (n=74, 10.9%), thyroid gland (n=58, 8.6%), and adrenal glands (n=53, 7.8%) harbored the most incidentalomas. Less than half of patients with incidental findings received specific follow-up recommendations on the radiologist's report (n=150, 39%). Sixty-one percent of patients (n=250) had their incidentalomas detailed in the discharge paperwork. CONCLUSION: The results of our study suggest that potentially malignant or pre-malignant incidental findings are common among trauma patients. Specific follow-up recommendations were not presented in 61% of the radiology reports, highlighting the need to standardize medical record capture of an incidentaloma to ensure adequate and appropriate follow-up.

Recurrence and survival after curative-intent treatment for colorectal liver metastases: Implications for adjuvant liver-directed regional chemotherapy.

BACKGROUND: This study investigates tumor recurrence patterns and their effect on postrecurrence survival following curative-intent treatment of colorectal liver metastases (CRLM) to identify those who stand to benefit the most from adjuvant liver-directed therapy. METHODS: This is a retrospective analysis of all patients that underwent liver resection and/or ablation for CRLM between 2007 and 2019. Postrecurrence survival was compared between recurrence locations. Risk factors for liver recurrence were sought. RESULTS: The study included 227 patients. Majority were treated with resection (71.0%) while combination resection/ablation (18.9%) and ablation alone (11.0%), were less common. At a median follow-up of 3.0 years, recurrence was observed in 151 (66.5%) patients. Of those, liver, lung, and peritoneal recurrence were most common at 66.9%, 49.6%, and 9.2%, respectively. Median postrecurrence survival after liver, lung, and multisite recurrence was 39.6-, 68.4-, and 33.6 months, respectively. High tumor grade (p < 0.014), perineural invasion (p = 0.002), and N0 node status (p = 0.017) of primary tumor correlated with liver recurrence on multivariate analysis. CONCLUSIONS: Tumor grade, perineural invasion, and N0 node status of the primary tumor are associated with increased risk of liver recurrence after CRLM resection and represent a target population that may benefit the most from adjuvant liver-directed regional chemotherapy.

Transgender Surgery: Perspectives Across Levels of Training in Medical and Surgical Specialties.

Purpose: Approximately 1.4 million adults identify as transgender in the United States. Transgender patients face societal, legal, and medical discrimination that can lead to health disparities. The objective of this study was to evaluate knowledge and perceptions of transgender health care across various levels of medical training and specialties. Methods: Between April 1, 2019 and May 1, 2019, an anonymous survey was distributed to residents and attendings, in both medical and surgical specialties, at a university-affiliated hospital. Participants were recruited into the study with survey distribution by email to residency program directors, residents, and residency-affiliated attendings. Results: There was a response rate of 29.5% (118/400). Across all respondents, 34.7%, 31.4%, and 39% knew where to refer transgender patients for hormone replacement, psychotherapy, or surgery, respectively. Only 37.9% of residents and 46.2% of attendings reported that they were confident of providing care for a transgender patient (p=0.130). In addition, less than one-third of surgical respondents reported sufficient knowledge to describe transgender surgery. The most common reasons affecting comfort level when caring for transgender patients were lack of exposure (53.4%) and lack of formal education (47.6%), with other reasons being personal, moral, and religious reasons (11%, 8.5%, and 6.8%, respectively). Conclusion: Despite literature demonstrating the effectiveness of formal didactics and education in transgender health, there remain disparities in the knowledge and comfort of residents and attendings across all specialties. To deliver competent health care to transgender patients, efforts must focus on improving the availability of system-wide resources and educational opportunities for all specialties.

Preoperative tranexamic acid does not reduce transfusion rates in major oncologic surgery: Results of a randomized, double-blind, and placebo-controlled trial.

BACKGROUND AND OBJECTIVES: Allogeneic blood transfusions are associated with worse postoperative outcomes in oncologic surgery. The aim of this study was to introduce a preoperative intervention to reduce transfusion rates in this population. METHODS: Adult patients undergoing major oncologic surgery in five categories with similar transfusion rates were recruited. Enrollees received a single preoperative intravenous dose of placebo or tranexamic acid (1000 mg). The primary outcome measure was perioperative transfusion rate. Secondary outcome measures included: estimated blood loss, thromboembolic events, morbidity, hospital length of stay, and readmission rate. RESULTS: Seventy-six patients were enrolled, 39 in the tranexamic acid group and 37 in the placebo group, respectively. Demographics and surgery type were equivalent between groups. The transfusion rates were 8 out of 39 (20.5%) in the tranexamic acid group and 5 out of 37 (13.5%) in the placebo group, respectively (P = .418). Median estimated blood loss was 400 mL (interquartile range [IQR] = 150-600) in the tranexamic acid group compared with 300 mL (IQR = 150-800) in the placebo group (P = .983). There was one pulmonary embolism in each arm and no deep venous thrombosis (P > .999). CONCLUSION: Preoperative administration of tranexamic acid at a 1000 mg intravenous dose does not decrease transfusion rates or estimated blood loss in patients undergoing major oncologic surgery.

Using next-generation sequencing to determine potential molecularly guided therapy options for patients with resectable pancreatic adenocarcinoma.

BACKGROUND: Genomic sequencing technology may identify personalized treatment options for patients with pancreatic adenocarcinoma. METHODS: The study was conducted using tissue specimens obtained from 2012 to 2014. Patients with resected pancreatic adenocarcinoma were identified. Next-generation sequencing was performed from paraffin-tumor blocks. Mutational profiles were reviewed to determine available targeted therapies and clinical trial eligibility. RESULTS: Thirty patients were identified. The incidence of mutations was: Kirsten rat sarcoma viral oncogene homolong (KRAS) = 87%, tumor protein 53 (TP53) = 63%, cyclin-dependent kinase inhibitor 2A (CDKN2A) = 20%, Mothers Against Decapentaplegic Homolog 4 (SMAD4) = 20%, epidermal growth factor receptor (EGFR) = 7%. Multiple mutations were found in 73%. All CDKN2A mutations occurred in male patients (P = .06), and there was a trend toward younger patient age in this group (P = .13). Potential for Federal Drug Administration (FDA)-approved targeted therapies was identified in 8 of 30 (27%). In addition, 29 of 30 (97%) had mutations applicable for ongoing phase I or II clinical trials. CONCLUSIONS: Next-generation sequencing of resected pancreatic adenocarcinoma specimens can determine common genetic mutations and identify patients who may be eligible for off-label use of targeted therapies or clinical trial enrollment.

Is there truly an oncologic indication for interval appendectomy?

BACKGROUND: The rate of recurrent appendicitis is low following nonoperative management of complicated appendicitis. However, recent data suggest an increased rate of neoplasms in these cases. METHODS: The study was a retrospective review of patients with acute appendicitis at 2 university-affiliated community hospitals over a 12-year period. The primary outcome measure was the incidence of appendiceal neoplasm following interval appendectomy. RESULTS: Six thousand thirty-eight patients presented with acute appendicitis. Appendectomy was performed in 5,851 (97%) patients at the index admission. Of the 188 patients treated with initial nonoperative management, 89 (47%) underwent interval appendectomy. Appendiceal neoplasms were identified in 11 of the 89 (12%) patients. These included mucinous neoplasms (n = 6), carcinoid tumors (n = 4), and adenocarcinoma (n = 1). The rate of neoplasm in patients over age 40 was 16%. CONCLUSIONS: There is a significant rate of neoplasms identified in patient over age 40 undergoing interval appendectomy. This should be considered following nonoperative management of complicated appendicitis.

Measuring the impact of the American College of Surgeons Oncology Group Z0011 trial on breast cancer surgery in a community health system.

BACKGROUND: The American College of Surgeons Oncology Group Z0011 trial has been lauded as practice changing. We sought to identify its impact on breast cancer surgery in the community hospital setting. METHODS: A retrospective review was performed from 8 community hospitals identifying patients with invasive breast cancer meeting the Z0011 criteria. The primary outcome measures were the rate of completion axillary lymph node dissection (ALND) and performance of intraoperative sentinel lymph node (SLN) analysis over time. RESULTS: A total of 1,125 lumpectomies with SLN biopsies were performed with 180 subjects meeting inclusion criteria. Performance of ALND (P < .0001) and intraoperative SLN analysis (P < .0001) declined during each time period. Patients more likely to undergo ALND included those with extracapsular extension (odds ratio [OR] 12.8, 95% confidence interval [CI] 2.5 to 67.1) and those who underwent reoperative surgery (OR 10.8, 95% CI 2.6 to 44.4) or intraoperative SLN analysis (OR 5.1, 95% CI 1.2 to 21.9). CONCLUSION: American College of Surgeons Oncology Group Z0011 trial has been rapidly practice changing in the community hospital setting.

Accuracy of endoscopic ultrasound in the evaluation of cystic pancreatic neoplasms: a community hospital experience.

OBJECTIVES: Reports on the use of endoscopic ultrasound (EUS) in differentiating benign, premalignant, and malignant pancreatic lesions have been widely variable, particularly with cystic neoplasms. We evaluated the use of EUS for cystic pancreatic lesions in a community hospital setting. METHODS: All patients who underwent EUS for cystic pancreatic neoplasms from 2007 to 2010 were reviewed. A final EUS diagnosis was determined based on the examiner's impression and fine-needle aspiration results if available. Lesions were stratified as benign, premalignant, or malignant. Patients underwent surgical resection, serial imaging studies, or medical oncology/palliative care consultation as indicated. RESULTS: One hundred eighteen patients with cystic pancreatic lesions underwent EUS during the study period. Endoscopic ultrasound diagnoses included 75 benign (63.6%), 35 premalignant (29.7%), and 8 malignant (4.2%) lesions. Thirty-eight patients (32.2%) underwent surgery, 77 (65.3%) were monitored with imaging, and 3 (2.5%) had unresectable malignancies. Elevated carcinoembryonic antigen levels showed a trend toward predicting mucinous cysts (P = 0.062). Accuracy, sensitivity, specificity, positive predictive value, and negative predictive value for cystic lesions were 87.3%, 86.8%, 87.5%, 76.7%, and 93.3%, respectively. CONCLUSIONS: Endoscopic ultrasound is a valuable diagnostic modality in the evaluation of cystic pancreatic neoplasms in a community hospital setting.

Esophagectomy in patients with prior percutaneous endoscopic gastrostomy tube placement.

BACKGROUND: The impact of preoperative percutaneous endoscopic gastrostomy (PEG) tube placement in patients undergoing esophagectomy is uncertain. METHODS: A retrospective review was performed in consecutive patients who underwent esophagectomy. Patients were divided into groups based on whether or not they had preoperative PEG placement. RESULTS: One hundred seventeen patients were studied, 102 without (PEG-) and 15 with PEG+ before PEG tube placement. The overall morbidity and mortality rates were 38% and 3%, respectively. The use of a gastric conduit was similar between groups (94% PEG- vs 87% PEG+, P = .27), and the presence of a PEG before PEG tube placement was not prohibitive in any case. Anastomotic leak rates were similar between groups (11% PEG- vs 15% PEG+, P = .65), and there were no leaks from previous PEG sites. CONCLUSION: It appears that preoperative PEG tube placement has no adverse effect on the performance of esophagectomy and may be considered in highly selected patients with poor nutritional status.