Time Of Surgical Consultation Research Articles

Trifecta Outcomes After Use of 3-Dimensional Digital Models for Planning of Robotic Prostatectomy

Planning complex operations such as robotic-assisted laparoscopic radical prostatectomy (RALP) requires surgeons to review 2-dimensional magnetic resonance imaging (MRI) scans to understand 3-dimensional (3D) patient anatomy. Three-dimensional digital models for planning RALP may allow better understanding of patient anatomy and may lead to better patient outcomes, although data are currently limited. To determine surgical outcomes after RALP when surgeons reviewed 3D digital models during operative planning. This study was a planned secondary analysis of a multicenter, single-blind, randomized clinical trial conducted at 6 large teaching hospitals in the US. The study was conducted between January 1, 2019, and December 31, 2022, and included patients undergoing RALP. Patients were assessed and recruited at the time of surgical consultation. Final data analysis was conducted between August and December 2023. Patients were randomized to either a control group undergoing usual preoperative planning with prostate biopsy results and multiparametric MRI only or to an intervention group in which imaging and biopsy results were supplemented with a 3D digital model. This model was viewed on the surgeon's mobile phone in 3D format and picture-in-picture on the robotic console screen. The primary outcome measure for the overall study was oncologic outcomes after RALP, measured as prostate-specific antigen (PSA) detectability. Secondary outcomes were sexual function and urinary function, measured with Sexual Health Inventory for Men (SHIM) scores and rates of urinary incontinence, respectively, as well as use of salvage or adjuvant radiation therapy (RT) or androgen deprivation therapy (ADT). Trifecta outcomes were defined as undetectable PSA without RT or ADT, SHIM score categorically the same or greater than preoperatively, and complete continence. Univariate analysis was performed to compare outcomes between groups. This trial included 92 patients undergoing RALP (51 in the control group and 41 in the intervention group). Their mean (SD) age was 62 (7.4) years; 10 patients (10.9%) were Black and 67 (72.8%) were White. At 18 months postsurgery, the intervention group had lower rates of biochemical recurrence (PSA level >0.1 ng/mL, 0 vs 7 [17.9%]; absolute difference, 17.9% [95% CI, 1.8% to 31.8%]; P = .01) and were significantly less likely to undergo adjuvant or salvage RT (1 [3.1%] vs 12 [31.6%]; absolute difference, 28.5% [95% CI, 10.1% to 46.7%]; P = .002) compared with the control group. Sexual function at 18 months postsurgery was significantly better in the intervention group (mean [SD] SHIM score, 16.8 [8.7] vs 9.8 [7.7]; absolute difference, 7.0 [95% CI, 2.6 to 11.4]; P = .002) and urinary function was unchanged (total continence, 22 [78.6%] vs 29 [80.6%]; absolute difference, 2.0% [95% CI, -17.9% to 21.9%]; P = .84) compared with the control group. Trifecta outcomes were achieved for 12 (48.0%) patients in the intervention group and 3 patients (10.0%) in the control group (absolute difference, 38.0% [95% CI, 14.4% to 61.6%]; P = .002). In this secondary analysis of a randomized clinical trial, patients whose surgical planning of RALP involved 3D digital models had better oncologic and functional outcomes. Further work should assess the effect of 3D models in a broader set of patients, physicians, and hospital settings. ClinicalTrials.gov Identifier: NCT03943368.

Disparities in fetal surgery access: Association with twin-twin transfusion syndrome stage at initial consultation

Among individuals with twin-twin transfusion syndrome (TTTS), we sought to determine if insurance type was associated with advanced TTTS disease at the time of surgical consultation. This was a retrospective cohort study of individuals with Quintero stage I-IV TTTS undergoing laser surgery at a single center, 2015-2021. Excluded individuals had out-of-state residency, higher order multiples, surrogate or monoamniotic gestations. Primary exposure was insurance type, defined as private/commercial insurance (Commercial), public fee for service (FFS) or traditional Medi-Cal (e.g., California Medicaid), and public Medi-Cal/Covered California Group Plans including self-pay (Group). Primary outcome was Quintero stage III/IV (high TTTS stage), as determined during initial surgical consultation. Secondary outcomes included gestational age and fetal growth restriction (FGR). We compared sociodemographic and obstetric variables at initial consultation across insurance type. Outcomes with p< 0.10 in bivariate analyses were tested using multiple logistic regression models; demographic data were tested for relevance as covariates. Of 362 individuals in this contemporary cohort, 243 met study criteria. The Table provides cohort demographics. Non-Hispanic White individuals were more likely to have Commercial insurance (44.2% vs. FFS 12.8% vs. Group 19.3%, p< 0.0001). In bivariate analyses, high TTTS stage and FGR were associated with insurance type. In adjusted logistic regression, Group insurance was associated with increased odds of presenting with high TTTS stages (OR 2.33, 95%CI 1.16-4.70) and FGR (OR = 2.02, 95%CI 1.06-3.86) (Figure). FFS insurance was not associated with any of these outcomes. Individuals with public Group plans were more likely than those with Commercial plans to present with higher stage TTTS and FGR at initial surgical evaluation, suggesting there may be gaps or delays in access to fetal surgical care for individuals with public insurance.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Prospectively Assigned AAST Grade versus Modified Hinchey Class and Acute Diverticulitis Outcomes

BackgroundThe American Association for the Surgery of Trauma (AAST) recently developed a classification system to standardize outcomes analyses for several emergency general surgery conditions. To highlight this system's full potential, we conducted a study integrating prospective AAST grade assignment within the electronic medical record. MethodsOur institution integrated AAST grade assignment into our clinical workflow in July 2018. Patients with acute diverticulitis were prospectively assigned AAST grades and modified Hinchey classes at the time of surgical consultation. Support vector machine—a machine learning algorithm attuned for small sample sizes—was used to compare the associations between the two classification systems and decision to operate and incidence of complications. Results67 patients were included (median age of 62 y, 40% male) for analysis. The decision for operative management, hospital length of stay, intensive care unit admission, and intensive care unit length of stay were associated with both increasing AAST grade and increasing modified Hinchey class (all P < 0.001). AAST grade additionally showed a correlation with complication severity (P = 0.02). Compared with modified Hinchey class, AAST grade better predicted decision to operate (88.2% versus 82.4%). ConclusionsThis study showed the feasibility of electronic medical record integration to support the full potential of AAST classification system's utility as a clinical decision-making tool. Prospectively assigned AAST grade may be an accurate and pragmatic method to find associations with outcomes, yet validation requires further study.

In Search of the Optimal Outcome Measure for Patients with Advanced Cancer and Gastrointestinal Obstruction: A Qualitative Research Study.

Gastrointestinal obstruction (GIO) is the most common indication for palliative surgical consultation in patients with advanced cancer. The purpose of this study is to delineate the symptom burden and experience of these patients. Twenty patients with advanced cancer and GIO described symptoms at time of surgical consultation. We analyzed the content of interview transcripts and ranked symptoms by frequency and according to an assessment of relevance conducted by an expert panel (surgeons, palliative care physicians, nurses, and patients/caregivers). Among the 20 study patients, malignancy types included colorectal (n = 9), gastric (n = 4), urothelial/renal (n = 3), and other (n = 4), whereas sites of obstruction were the small bowel (n = 11), gastric outlet (n = 3), and large bowel (n = 6). Thirteen patients (65%) had received chemotherapy within 6weeks. Imaging evidence of a primary/recurrent tumor was documented in 13 patients (65%), carcinomatosis in 11 (55%), and ascites in 16 (80%). Thirty patient symptoms were identified on qualitative interviewing. Seven GIO-specific items were identified as relevant by the expert panel and will be added to the core symptom assessment inventory for further testing. We identified symptoms of importance that can be used to assess outcome after treatment of patients with advanced cancer and GIO. Testing for validity and reliability will be required before formal survey development.

The utility of radionucleotide imaging in the surgical management of axial neck pain from cervical facet joint arthropathy.

Axial neck pain is common and often debilitating. Diagnosis of the specific pain source can be a challenge, and this confounds effective treatment. Cervical facet arthropathy is implicated in many of these cases. The diagnosis is readily made on conventional cross-sectional imaging modalities, particularly CT imaging. However, this modality falls short in determining if an osteoarthritic facet joint is truly the source of symptoms. Radionucleotide imaging presents a noninvasive radiological adjunct to conventional cross-sectional imaging in the workup of patients with suspected facetogenic pain. Herein, the authors present the patient-reported outcomes (PROs) following posterior instrumented arthrodesis of the subaxial cervical spine from a consecutive case series of patients with a diagnosis of cervical facet joint arthropathy and a concordant positive radionucleotide tracer uptake. The clinical case series of patients treated by the senior author at a single tertiary care institution between September 2014 and April 2018 was reviewed. Patients were selected for inclusion if their primary symptom at presentation was axial neck pain without neurological deficits and if CT imaging revealed facet arthropathy of the cervical spine. These patients underwent radionucleotide imaging in the form of a planar 99mTc methylene diphosphonate (99mTc MDP) bone scintigraphy study. Those with a finding of radionucleotide tracer uptake at a location concordant with the facet arthropathy were selected to undergo posterior cervical instrumented arthrodesis of the affected levels. PROs were recorded at the time of surgical consultation (i.e., after nonoperative treatment) and at 6 weeks, 3 months, 6 months, and 1 year following surgery. These included neck and arm pain, the Neck Disability Index (NDI) and the 12-Item Short Form Health Survey responses. A total of 11 patients were included in this retrospective case series. The average reported neck pain and NDI scores were high at baseline; 7.6 ± 2.3 and 37.1 ± 13.9 respectively. Twelve months after surgical intervention, a significant decrease in reported neck pain of -4.5 (95% CI -6.9, -2.1; p = 0.015) and a significant decrease in NDI of -20.0 (95% CI -29.4, -10.6; p = 0.014) was observed. This case series represents the largest to date of patients undergoing surgical arthrodesis following a finding of facet arthropathy with a concordant positive radioisotope image study. These observations add support to a growing body of evidence that suggests the utility of radioisotope imaging for identification of a facetogenic pain generator in patients with primary axial neck pain and a finding of cervical facet arthropathy. These preliminary data should serve to promote future prospective, controlled studies on the incorporation of radionucleotide imaging into the workup of patients with suspected facetogenic pain of the cervical spine.

Abstract P4-11-05: Improving neoadjuvant breast cancer therapy rates uptake with education and technology

Abstract Background: Recent studies show that treating aggressive subtypes of breast cancer (BC) with neoadjuvant chemotherapy (NAC) improves clinical outcomes in addition to breast conservation therapy (BCT) rates. Yet a large multi-site population-level analysis shows that only 5.5% of NCCN-guideline eligible patients receive NAC (Ontilo et al, 2013). Multi-level interventions are needed to improve concordance with NCCN guidelines for NAC consideration in women who meet criteria for BCT (clinical stage IIA, IIB, and IIIA BC). Methods: A 2-part intervention was undertaken to improve adherence to NAC guidelines. Certified medical education (CME) was first provided on BC diagnostics and treatment (Tx), including NAC. Next patients were recruited to a point of care technology-based intervention. Eligibility included a new diagnosis of invasive BC, clinical stage T1c and/or N1 or greater, and no prior Tx. Patients interact with an electronic care planning system (CPS) at the time of surgical consultation to report preferences for decision-making and concerns, such as distress over losing a breast. The CPS displays these findings along with a draft care plan (CP) that suggests guideline based referrals and provides patient education about BC diagnosis and Tx options. After editing, surgeons finalize and deliver CPs at the visit. The goal is to describe referral rates to medical oncology for discussion of and receipt of NAC. Outcomes from chart abstraction are compared to historical rates in the literature and where available, the institution. Results: Data on 39 of 75 women are mature (remaining to be presented at meeting). Median age is 60 years (range 37-92) and clinical stage is IA=41% (N=16), IIA= 41% (N=16), IIB=8% (N=3), and III=10% (N=4). Of 39 patients, 44% were HR+HER2+, 10% were HR+HER2-, 13% had triple negative BC, and 33% had incomplete data. Per NCCN stage, 59% (N =23) were eligible for NAC evaluation. 96% (N=22) of those eligible were referred to MO. Follow up 2 months post-surgical appointment revealed 91% (N=21) of referred patients had completed a MO consultation. 39% (N=9) of those referred for evaluation (N=23) had a prescription for NAC and all prescriptions were guideline adherent, including regimens combining chemotherapy with trastuzumab and pertuzumab for HER2+ disease. Overall, 30.4% of women eligible for referral went on to receive NAC. Distress related to loss of breast was moderate (0-10 scale, M=4.83) and was significantly related to whether patients received a referral for NAC (B= -.304, Wald's=4.61, p=.03). Most of participating providers (80%, N=5) felt the CP was valuable to help with Tx decision-making. Conclusions: Preliminary results show CME and an electronic CPS may improve NAC uptake. Rates of prescription were clearly higher in this analysis than in a 4-center population database study, both overall (23.1% vs. 3.8%) and by NCCN eligibility (30.4% vs. 5.5%), and compared to baseline in 1 (of 3 planned) centers in the study who had a baseline rate of overall NAC prescription of 8.7% in the year prior to the study. The higher the distress over the loss of a breast, the more likely the patient received a referral for NAC. These data provide preliminary support for improving NAC uptake and warrant investigation in a RCT. Citation Format: Gary M, Keeler V, Rush S, Parsons P, Zhong X, Stricker CT, Wujcik D, DiGiovanni L, Davis A, Han LK. Improving neoadjuvant breast cancer therapy rates uptake with education and technology [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-11-05.

In search of the optimal outcome measure for patients with advanced cancer and gastrointestinal obstruction: A qualitative research study.

100 Background: Gastrointestinal obstruction (GIO) is the most common indication for palliative surgical consultation in patients with advanced cancer. The purpose of this study was to delineate the symptom burden and experience of patients with GIO. Methods: Twenty patients with advanced cancer and GIO described symptoms at the time of surgical consultation. We used content analysis of interview transcripts and symptoms were ranked by frequency and compared to a general symptom assessment survey (MD Anderson Symptom Inventory). Results: Malignancy type included colorectal (N = 9), gastric (N = 4), urothelial/renal (N = 3), and other (N = 4), while site of obstruction was small bowel in 11 (55%), gastric outlet in 3 (15%), and large bowel in 6 (30%). Thirteen patients (65%) had received chemotherapy within 6 weeks. Imaging evidence of a primary/recurrent tumor, carcinomatosis, or ascites was documented in 13 (65%), 11 (55%), and 16 (80%) patients, respectively. Thirty symptoms were identified on qualitative interviewing. MD Anderson Symptom Inventory symptoms of pain, nausea, and vomiting were frequently noted. Frequently mentioned GIO-specific symptoms included bloating, cramping, not having a bowel movement, and inability to eat. Conclusions: Qualitative research methodology can identify symptoms of importance to patients which can be used to assess improvement after treatment of GIO. Expert panel rating will be used to develop the final symptom item list prior to psychometric testing of the survey.

Surgical Pearl: Curettage before cutaneous surgery to identify an unidentifiable biopsy site

J Am Acad Dermatol 2002;46:591-2.

Wet Gangrene in Hemodialysis Patients with Calciphylaxisis is Associated with a Poor Prognosis

Calciphylaxis is a rare syndrome characterized by progressive vascular calcification and ischemic tissue loss in patients with chronic renal failure. We report our five-year experience with five patients who developed foot gangrene due to calciphylaxis. All five patients had characteristic clinical, laboratory, and radiologic findings of the disorder, but no diagnostic variable was uniformly present. All five had progressed to advanced gangrene at the time of surgical consultation. Despite aggressive local attempts to control infection, all five patients died of septic complications. Parathyroidectomy was performed in three patients but did not alter the course in any case. This small experience suggests that the outcome of foot gangrene associated with calciphylaxis is predicated on the degree of tissue loss. Aggressive local wound care does not appear to be adequate to control infection in patients who have already developed gangrene. Although parathyroidectomy may have important long-term advantages in patients with calciphylaxis, it does not appear to affect outcome in these advanced cases.

Wet gangrene in hemodialysis patients with calciphylaxisis is associated with a poor prognosis

Calciphylaxis is a rare syndrome characterized by progressive vascular calcification and ischemic tissue loss in patients with chronic renal failure. We report our five-year experience with five patients who developed foot gangrene due to calciphylaxis. All five patients had characteristic clinical, laboratory, and radiologic findings of the disorder, but no diagnostic variable was uniformly present. All five had progressed to advanced gangrene at the time of surgical consultation. Despite aggressive local attempts to control infection, all five patients died of septic complications. Parathyroidectomy was performed in three patients but did not alter the course in any case. This small experience suggests that the outcome of foot gangrene associated with calciphylaxis is predicated on the degree of tissue loss. Aggressive local wound care does not appear to be adequate to control infection in patients who have already developed gangrene. Although parathyroidectomy may have important long-term advantages in patients with calciphylaxis, it does not appear to affect outcome in these advanced cases.