Major Oncologic Resections Research Articles

Disparities in organ preservation rate for high-risk stage I rectal cancer.

37 Background: Guidelines for the treatment of high-risk stage I rectal cancer is a curative oncologic resection, while recommendations for stage II/III rectal cancer include neoadjuvant therapy with the option for organ preservation. The paradoxical nature of treating less advanced stage cancer with more morbid surgery calls into question the use of organ preservation strategies (OP) for less advanced disease. While sphincter preservation is appealing, benefits from OP require commitment to preoperative therapy, which may require more significant time and financial commitments than a single-stage curative treatment. This study aims to evaluate disparities in social determinants of health regarding receipt of OP compared to major oncologic resection for high-risk stage I rectal cancer. Methods: The National Cancer Database was queried to analyze all patients with high-risk stage 1 rectal cancer between 2004-2021. High-risk stage 1 disease was defined as either T2 or T1 tumors with lymphovascular invasion, or grade 3 or 4 differentiation. Covariates in patients who underwent OP, defined as chemoradiation therapy without oncologic resection or local excision, were compared to those who underwent major oncologic resection. Additional variables included age, sex, race, great circle distance, insurance status, education, facility type, income, rurality, and comorbidity index. Univariate and multivariate analyses were utilized to compare association of covariates to OP. Results: Of the 63,762 patients included, 9,261 (14.5%) underwent OP. Increased rates of OP were seen with increasing age (OR 1.029, p<0.0001), female sex (OR 1.147, p<0.0001), higher education level (OR 1.179, p=0.0034), rurality (OR 1.273, p=0.0003) and lower income (OR 0.757 for income >74K, p <0.0001). Interestingly, OP was more frequently utilized at community cancer centers in comparison to comprehensive cancer centers (OR 0.78, p<0.0001) and academic centers (OR 0.842, p=0.0021). Race, insurance status, distance to treatment, and comorbidity index were not statistically significant predictors of OP. Of note, those who underwent OP had a considerable delay in time to first treatment, with median time to treatment of 36 days in comparison to 13 days for oncologic resection. Conclusions: Socioeconomic and demographic variables are associated with receipt of OP. While plausible that a treatment strategy that requires frequent office visits, travel expenses, and time off from work may preclude OP, lower income and rurality had increased odds of OP. Future aims should be directed to identifying root causes of disparities in treatment and their clinical consequences.

Oncologic Liver Resections in a Geriatric Population: Peri-operative,Long-Term and Quality-of-Life Outcomes-Experience from a High-Volume Centre in India.

Elderly patients can often be overlooked as candidates for a major hepatic resection, by virtue of their age. To enable better patient selection for hepatic resections in this age group, we analysed the outcomes of liver resections in elderly patients to identify any potential prognostic factors. We conducted a retrospective review of a prospectively maintained database of hepatic resections from 1 January 2010 to 31 October 2021 and analysed the post-operative outcomes in patients aged 65years or older. Short-term outcomes were analysed in terms of length of hospital stay, 90-day major morbidity, and 90-day mortality. Long-term outcome was defined by the disease-free survival, overall survival and quality of life. Over a period of 11years, 170 elderly patients underwent oncologic liver resections, of which 68 (40%) underwent a major hepatectomy. The overall morbidity and mortality rates were 32.8% and 5.3%, respectively. Extent of hepatic resection, increasing age, concomitant resection of other organs and a biliary-enteric anastomosis were independent predictors for poor immediate post-operative outcomes. Median disease-free survival and overall survival were 30months and 78months, respectively. The global health status was excellent in majority of patients with a mean score of 88.62. Major oncologic liver resections can be performed in well-selected geriatric population with acceptable peri-operative, long-term and quality-of-life outcomes.

Quality indicators for operative reporting in transanal endoscopic surgery.

SummaryTransanal endoscopic surgery (TES) platforms have become quite popular. Many surgeons across the country have begun excising rectal lesions using these platforms; however, the perioperative decision-making surrounding these excisions can be quite variable. To facilitate care between providers, it would be helpful to standardize the way TES is reported. Synoptic operative reports have previously been established as an effective and efficient communication tool. For patients with rectal cancer, synoptic reports are required for pathology, radiology and major oncologic resections, but never previously for TES. We used a Delphi process including 15 stakeholders from across Canada to develop a TES synoptic report. Participants submitted items according to 6 categories: team characteristics, patient demographics, preoperative work-up, lesion characteristics, procedure details and postoperative details. Twenty-six surgeon-entered and 41 auto-populated items reached final inclusion. This will allow generation of a synoptic reporting template to improve perioperative communication for these patients.

Surgery for primary extremity soft tissue sarcoma in frail elderly patients.

Background: Advances in healthcare have resulted in increasing numbers of older people undergoing oncological surgery. Previously, age has been considered a relative contraindication to major oncological resections. However even major limb surgery is well tolerated physiologically compared with intra-coelomic surgery. The definition of an elderly population is variable with some studies including all ages as low as 65. Frailty however is common only at 75 years or greater. As surgery is the mainstay of treatment for extremity soft tissue sarcomas (ESTS), we reviewed a cohort of very elderly patients to determine whether resection is safe and what impact frailty had on outcome

Racial differences in symptomatic postoperative venous thromboembolism rates after major oncologic resection

BackgroundRecent evidence suggests an increased incidence of venous thromboembolism among cancer patients of Black race. This study aimed to determine whether Black patients undergoing major oncologic resection experience increased rates of postoperative venous thromboembolism. MethodsA cohort study of patients who underwent major oncologic resection was performed using American College of Surgeons National Surgical Quality Improvement Program (2016−2018). Primary outcome was venous thromboembolism within 30 days of surgery. Multivariable logistic regression was performed to evaluate the independent association of race and venous thromboembolism. ResultsOf 91,707 patients, 67.7% were White, 9.5% Black, and 22.9% other race. Venous thromboembolism rates differed slightly by race: 2.2% among Whites, 2.4% Blacks, and 1.8% other (P = .002). Black patients were older, with higher rates of obesity, diabetes, and smoking. By multivariable logistic regression, risk of venous thromboembolism was lower among patients of other compared with White race (odds ratio 0.83; 95% confidence interval, 0.74–0.94). There was no difference in odds of venous thromboembolism among Black relative to White patients (odds ratio 1.08; 95% confidence interval, 0.93–1.26). When stratified by age, rates of venous thromboembolism were >50% higher among Black patients older than 75 years compared with White patients (odds ratio 1.54; 95% confidence interval, 1.17–2.03). ConclusionDespite evidence that Black patients with cancer experience higher rates of venous thromboembolism, they do not appear to have an increased risk in the postoperative period.

Perioperative Symptoms: A New Frontier for Surgical Palliative Care.

Perioperative Symptoms: A New Frontier for Surgical Palliative Care.

MORBIDITY AND MORTALITY ANALYSIS IN PATIENTS ACQUIRING COVID-19 FOLLOWING MAJOR ONCOLOGICAL SURGERY IN A TERTIARY CANCER CARE CENTRE

Introduction : SARS CoV-2 infection has been creating havoc in the world since it was first detected and reported in Wuhan, China in December, 2019. It gradually spread all over the world and became an international emergency. No age is immune to this virus and can affect anyone. Some carriers may be asymptomatic and may act as a potential source of infection. Cancer patients are considered to be a high risk group for contracting this infection with a higher morbidity and mortality. This article analyses the impact and outcome of COVID-19 after major oncological resections. Methods : A retrospective analysis on the morbidity and outcome of COVID-19 in cancer patients after major oncological resections were done from a prospectively maintained database. They were studied from 16th July, 2020 to 30th September, 2020. All surgical candidates underwent a mandatory RTPCR test for COVID-19 pre-operatively. Only the surgical cases who were pre-operatively negative for COVID-19 and then became positive in the post-operative period were taken for analysis. Results : A total of 299 major oncological surgeries were performed during the period of study. Out of these, 10 cases developed COVID-19 in the post-operative period and were taken up for the study. 7 out of the 10 cases were head and neck oncological resections. 4 cases had taken neo-adjuvant chemotherapy before surgery. 2 of the cases died which had probable handling of the aero-digestive tract as a part of the oncological resections. Conclusion : Cancer care has to continue even in the midst of an ongoing pandemic . Hence, identification of the factors which might increase the vulnerability of these patients are important so that extra care can be taken to protect them.

Internal jugular vein rupture after oncologic resections in the head and neck

BackgroundInternal jugular vein (IJV) blowout after major oncologic resections in the head and neck is a rare fatal yet preventable complication. The condition is unregistered sufficiently in the literature.ResultsThe records of patients who underwent oncologic neck surgery were retrospectively reviewed. The study included records between January 2014 and November 2019 at Kasr Al Ainy Educational Hospital. 275 patients underwent cervical ablative procedures. Ten patients developed IJV blowout. Six patients were saved. Four patients had diabetes mellitus with postoperative wound infection and dehiscence. Three patients were given primary radiotherapy; two of them developed flap necrosis. Eight patients acquired pharyngocutaneous fistula (PCF). Regional flap coverage was done in three patients. Sentinel hemorrhage occurred in all patients.ConclusionsIJV blowout is a rare potentially life-threatening complication usually preceded by sentinel hemorrhage. The condition is essentially preventable by the prompt and structured response.

Markedly increased risk of postoperative bleeding complications during perioperative bridging anticoagulation in general and visceral surgery

BackgroundIncreasing numbers of patients receiving oral anticoagulants are undergoing elective surgery. Low molecular weight heparin (LMWH) is frequently applied as bridging therapy during perioperative interruption of anticoagulation. The aim of this study was to explore the postoperative bleeding risk of patients receiving surgery under bridging anticoagulation.MethodsWe performed a monocentric retrospective two-arm matched cohort study. Patients that received perioperative bridging anticoagulation were compared to a matched control group with identical surgical procedure, age, and sex. Emergency and vascular operations were excluded. The primary endpoint was the incidence of major postoperative bleeding. Secondary endpoints were minor postoperative bleeding, thromboembolic events, length of stay, and in-hospital mortality. Multivariate analysis explored risk factors of major postoperative bleeding.ResultsA total of 263 patients in each study arm were analyzed. The patient cohort included the entire field of general and visceral surgery including a large proportion of major oncological resections. Bridging anticoagulation increased the postoperative incidence of major bleeding events (8% vs. 1%; p < 0.001) as well as minor bleeding events (14% vs. 5%; p < 0.001). Thromboembolic events were equally rare in both groups (1% vs. 2%; p = 0.45). No effect on mortality was observed (1.5% vs. 1.9%). Independent risk factors of major postoperative bleeding were full-therapeutic dose of LMWH, renal insufficiency, and the procedure-specific bleeding risk.ConclusionPerioperative bridging anticoagulation, especially full-therapeutic dose LMWH, markedly increases the risk of postoperative bleeding complications in general and visceral surgery. Surgeons should carefully consider the practice of routine bridging.

Preoperative Creatinine is Not Good Enough: Underestimation of Preoperative Renal Dysfunction by Creatinine Alone Has Implications for Acute Kidney Injury Requiring Dialysis and Mortality after Major Oncologic Resection

Preoperative Creatinine is Not Good Enough: Underestimation of Preoperative Renal Dysfunction by Creatinine Alone Has Implications for Acute Kidney Injury Requiring Dialysis and Mortality after Major Oncologic Resection

Unhealthy alcohol and drug use is associated with an increased length of stay and hospital cost in patients undergoing major upper gastrointestinal and pancreatic oncologic resections

BackgroundFew studies evaluate the impact of unhealthy alcohol and drug use on the risk and severity of postoperative outcomes after upper gastrointestinal and pancreatic oncologic resections. MethodsThe National Inpatient Sample was queried to identify patients undergoing total gastrectomy, esophagectomy, total pancreatectomy, and pancreaticoduodenectomy between 2012 and 2015. Unhealthy alcohol and drug use was assessed by the International Classification of Diseases, Ninth Revision, and National Inpatient Sample coder designation. Multivariable regression was used to identify associations between alcohol and drug use and postoperative complication, duration of stay, hospital cost, and mortality. ResultsIn the study, 59,490 patients met inclusion criteria; 2,060 (3.5%) had unhealthy alcohol use; 1,265 (2.1%) had unhealthy drug use. Postoperative complication rates were higher in patients with alcohol and drug use than in abstainers (67.5% vs 62.8% vs 57.2%; P < .01). On multivariable regression, alcohol use was independently associated with increased risk of a nonwithdrawal complication (odds ratio 1.33 [1.05, 1.68]), and alcohol and drug use were independently associated with increased length of stay (1.54 [0.12, 2.96]) and 2.22 [0.90, 3.55] days) and cost ($5,471 [$60, $10,881] and $4,022 [$402, $7,643]), but not mortality. ConclusionUnhealthy substance use is associated with increased rates of postoperative complications, prolonged length of stay, and costs in patients undergoing major upper gastrointestinal and pancreatic oncologic resections. Screening and abstinence interventions should be incorporated into the preoperative care pathways for these patients.

Risk Factors for Lymphedema after Thigh Sarcoma Resection and Reconstruction

Background:Secondary lymphedema can be a lifelong and debilitating consequence of lower extremity oncologic resection and reconstruction. The goal of this study was to identify risk factors for the development of lymphedema in patients treated for thigh sarcoma.Methods:A retrospective review analyzed all patients who underwent thigh sarcoma resection and reconstruction by a plastic surgeon at the Mayo Clinic between 1997 and 2014. Patient demographics, tumor characteristics, surgical management, adjunctive therapies, and complications of patients who did and did not develop postoperative lymphedema were compared.Results:A total of 148 patients were identified. Twelve percent of patients developed lymphedema postoperatively during an average follow-up of 26 months. Risk factors for the development of lymphedema included defect location in the medial thigh (P = 0.04), arterial resection (P = 0.001), arterial reconstruction (P = 0.027), and a history of cardiac disease (P = 0.03). Twenty-two percent of patients who developed lymphedema also experienced wound dehiscence compared with 4.6% of patients without lymphedema (P = 0.02). There were no differences in age, body mass index, smoking, history of deep venous thrombosis or venous stasis, wound dimensions, or type of reconstruction performed in patients with and without lymphedema.Conclusions:Lymphedema is common following major oncologic resection. Preexisting cardiac disease, tumor location in the medial thigh, and arterial resection and reconstruction were associated with a higher risk of postoperative lymphedema. Noninfectious wound dehiscence may be secondary to lymphedema or represent an early indicator of patients who will ultimately develop lymphedema.

Assessing Malnutrition Before Major Oncologic Surgery: One Size Does Not Fit All

There are multiple definitions for malnutrition, without evidence of superiority of any one definition to assess preoperative risk. Therefore, to aid in identification of patients that might warrant prehabilitation, we aimed to determine the optimal definition of malnutrition before major oncologic resection for 6 cancer types. The American College of Surgeons NSQIP database was queried for patients undergoing elective major oncologic operations from 2005 to 2017. Nutritional status was evaluated using the European Society for Parenteral and Enteral Nutrition definitions, NSQIP's variable for >10% weight loss during the previous 6 months, and the WHO BMI classification system. Multivariable logistic regression was performed to evaluate the adjusted effect of nutritional status on mortality and major morbidity. We identified 205,840 operations (74% colorectal, 10% pancreatic, 9% lung, 3% gastric, 3% esophageal, and 2% liver). A minority (16%) of patients met criteria for malnutrition (0.6% severe malnutrition, 1% European Society for Parenteral and Enteral Nutrition 1, 2% European Society for Parenteral and Enteral Nutrition 2, 6% NSQIP, and 6% mild malnutrition), 31% were obese, and the remaining 54% had a normal nutrition status. Both mortality and major morbidity varied significantly between the nutrition groups (both p < 0.0001). An interaction between nutritional status and cancer type was observed in the models for mortality and major morbidity (interaction term p < 0.0001 for both), indicating the optimal definition of malnutrition varied by cancer type. The definition of malnutrition used to assess postoperative risk is specific to the type of cancer being treated. These findings can be used to enhance nutritional preparedness in the preoperative setting.

Post-Gastrectomy Complications - An Overview.

Post-gastrectomy complications have been the associated sequelae after curative gastrectomy for long time. They include a conundrum of symptoms ranging from serious metabolic alterations to disorders attributed to mechanical and neural factors after reconstruction of the digestive continuity. Though, with the advancement in the surgical expertise and techniques and shift towards medical and endoscopic management for benign gastro-duodenal ulcer disease, there has been a decline in the incidence of these complications; they continue to raise "red flags" after major oncologic gastric resections. Identification of these symptoms and protocol based management of the same is of utmost importance in the surgical armamentarium of trainees and practicing physicians and surgeons.

Integrating cardiopulmonary exercise testing and 6-min walk test for predicting postoperative cardiopulmonary complications in patients undergoing lung cancer surgery: A narrative review

Cardiopulmonary exercise testing (CPET) is an effective method for the assessment of cardiopulmonary and neuromuscular reaction to physical stress. It offers an independent assessment of cardiopulmonary fitness and functional capacity in patients undergoing lung cancer surgery. The 6-min walk test (6MWT) can be used for the assessment of functional capacity when CPET is unavailable. Through this review, we aim to emphasize the importance of utilizing both CPET and 6MWT in the assessment of cardiorespiratory fitness/functional capacity in patients with lung cancer undergoing major thoracic oncological resections. We searched the PubMed electronic database using the MeSH system for articles reporting the use of CPET and 6MWT in cardiopulmonary fitness/functional capacity evaluation during cancer treatment. The full-text articles were assessed, and significant evidence was extracted. Only the articles written in the English language were selected. Using a combination of CPET and 6MWT for the assessment of cardiopulmonary fitness/functional capacity in patients with lung cancer undergoing complex oncological resections, could give a definite prediction of the possibility of postoperative cardiopulmonary complications in these patients.

Extended duration chemoprophylaxis for venous thromboembolism following abdominopelvic oncologic surgery.

Venous thromboembolism (VTE), including deep venous thrombosis and pulmonary embolism, is the most common cause of 30-day morbidity in oncology patients following surgery due to their hypercoagulable state. To combat this, VTE prophylaxis with anticoagulation extending beyond hospital discharge, termed extended duration chemoprophylaxis (EDCP), has been proposed, with the most recent guidelines recommending 28 post-operative days of EDCP. However, the literature has demonstrated poor compliance to these recommendations. We extended the duration of EDCP to 28 days post hospital discharge, effectively creating a standard discharge prescription for all surgical oncology patients. Our aim is to assess our EDCP protocol on patient compliance and VTE rate following major oncologic resection. We performed a retrospective, single institution, cohort study that involved chart review and telephone survey on patients who underwent major open abdominopelvic oncologic resection. A total of 130 patients were included; 60 received EDCP and 68 did not. VTE rate for the EDCP cohort was 0% and 7.4% for the non-EDCP cohort (p = 0.04). 85% of patients were fully compliant with EDCP. No bleeding related complications with EDCP were identified. Our data is consistent with prior literature in demonstrating a lower VTE rate with EDCP without an increase in bleeding related complications and we have demonstrated that it is possible to achieve a high rate of patient compliance with EDCP.

Discussion of: Efficacy and safety of transversus abdominis plane block versus thoracic epidural anesthesia in patients undergoing major abdominal oncologic resections: A prospective, randomized controlled trial

Discussion of: Efficacy and safety of transversus abdominis plane block versus thoracic epidural anesthesia in patients undergoing major abdominal oncologic resections: A prospective, randomized controlled trial

Efficacy and safety of transversus abdominis plane blocks versus thoracic epidural anesthesia in patients undergoing major abdominal oncologic resections: A prospective, randomized controlled trial

BackgroundThe purpose of this study was to compare patient outcomes for thoracic epidural anesthesia (TEA) with transversus abdominis plane (TAP) blocks. MethodsA prospective, randomized trial was performed for patients undergoing abdominal oncologic surgeries. ResultsThere were 32 TAP and 35 TEA subjects. The TEA group demonstrated increased episodes of hypotension in the first 24 h (3 v 0.6, p = 0.02). There was no difference in 24–48 h fluid balance between the groups. Overall parenteral morphine equivalents of opioids administered for the TEA group were higher for each postoperative day (p < 0.05). The post-operative survey did not demonstrate any difference in subjective pain between the TAP and TEA groups (6 v 6 p = 0.35). There was no attributable morbidity associated with either technique. ConclusionsTAP block use was associated with lower parenteral morphine equivalent usage and decreased incidence of hypotension in the early post-operative period compared to TEA.

Blood transfusion and postoperative complications: a cautionary comment.

In the recent issue of JAMA Surg , Ecker and coworkers (1) reported a large study aimed to evaluate trends in transfusion rates for major abdominal oncologic resections. This retrospective population-based study was using the American College of Surgeons National Surgical Quality Improvement Project database. Another study by Ferraris et al. (2) aimed to determine the role of transfusion for patients’ postoperative outcomes. This study was based on the same database. Ecker et al. (1) found transfusion was associated with occurrence of wound infection, renal insufficiency, and myocardial infarction. Ferraris et al (2) revealed that transfusion has a dose-dependent adverse effect on postoperative outcomes. Though some of these findings were confirmed by another population based study (3), we believe that some issues of these two articles require consideration.

Blood Transfusion in Major Abdominal Surgery for Malignant Tumors: A Trend Analysis Using the National Surgical Quality Improvement Program.

Blood transfusion can be a lifesaving treatment for the surgical patient, yet transfusion-related immunomodulation may underlie the association of allogeneic transfusion with increased perioperative morbidity and possibly poorer long-term oncologic outcomes. To evaluate trends in transfusion rates for major abdominal oncologic resections to assess changes in recent clinical practice (given the accumulating evidence of the deleterious effects of blood transfusion). Retrospective review of a population-based registry of all hospitals participating in the American College of Surgeons National Surgical Quality Improvement Project (2005-2013 Participant Use Data Files), which was queried for patients who underwent major resection of a pancreatic, hepatic, or gastric malignant tumor. Data analysis was performed from July to August 2015. The primary outcome was the transfusion of any quantity of packed red blood cells. Transfusion rates were calculated for the perioperative period, which was defined as the time from the start of surgery to 72 hours after surgery. Secondary outcomes included wound infection, myocardial infarction, and renal insufficiency, and the rates of these complications were calculated as well. Trend analysis was performed for each year of data to evaluate for changes over the study period. A total of 19 680 patients (median age, 65.0 years [interquartile range, 57.0-73.0 years]) were identified, of whom 5900 (30.0%) received a blood transfusion (of 13 657 patients who underwent a pancreatic resection, 4074 required transfusion [29.8%]; of 1605 patients who underwent a gastric resection, 378 required transfusion [23.6%]; and of 4418 patients who underwent a hepatic resection, 1448 required transfusion [32.8%]). There was a significant trend toward decreasing rates of transfusion during the study period (z = -7.89, P < .001), which corresponded to an absolute 6.1% decrease in the rate of transfusion of packed red blood cells from 2005 to 2013 (ie, from 32.8% to 26.7%). There was no significant change in the rates of postoperative wound infection or renal insufficiency during this time period, but there was an increased rate of perioperative myocardial infarction during the study period (0.33% absolute increase; z = 3.15, P = .002). Over 9 years of contemporary practice, a trend of less perioperative blood transfusions for oncologic abdominal surgery was observed. Further studies are needed to assess whether these trends reflect changes in operative techniques, hospital cohorts, or transfusion thresholds.