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Ultrasound accurately predicts trauma thoracotomy survival
SAN DIEGO – The few trauma patients who will survive a high-risk thoracotomy procedure for cardiac arrest can be predicted by the presence of cardiac motion as detected by a quick and inexpensive bedside ultrasound, a prospective study conducted at a level I trauma center showed.
Focused assessment with sonography in trauma (FAST) was 100% sensitive and 62% specific in predicting those who would survive or be eligible for organ donation after receiving a resuscitative thoracotomy for traumatic cardiac arrest, said Dr. Kenji Inaba of the department of surgery at the University of Southern California Medical Center in Los Angeles.
Resuscitative thoracotomy, said Dr. Inaba, is a salvage procedure performed after cardiac arrest. It is a “high-risk, resource-intensive procedure, with a low quantitative yield. And yet, patients do survive.” Previous retrospective studies found that of those receiving resuscitative thoracotomy for traumatic arrest, 7.4% survived, with more than 90% of survivors retaining neurologic function; an additional 4.2% of recipients were potentially eligible for organ donation. Thus, a tool to identify potential survivors among those who present in post-traumatic cardiac arrest would help avoid unnecessary use of a procedure with such risks and resource burdens.
FAST, an inexpensive procedure that is standard for other indications in trauma, has been effective in identifying potential survivors in thoracotomy for nontrauma cardiac arrests, Dr. Inaba said at the annual meeting of the American Surgical Association.
The technique “has near-universal availability, can be performed immediately at the bedside without moving the patient, and yields real-time results with no radiation involved,” he said.
For the current prospective study, the specific aim was to examine the ability of FAST to differentiate survivors and potential organ donors from those who would not survive resuscitative thoracotomy among those presenting in traumatic cardiac arrest. Dr. Inaba and his associates examined the predictive value of cardiac motion and the presence of pericardial fluid for survival, as well as the adequacy of the FAST study for each patient.
The single-center study, conducted from 2010 to 2014, enrolled 187 patients (mean age, 31; 84.5% male) presenting in traumatic arrest who received resuscitative thoracotomy in the emergency department and also received a FAST. The scans were performed by emergency medicine residents under direct faculty supervision. Of the 187 patients studied, 6 (3.2%) survived, 3 (1.6%) became organ donors, and 178 (95.2%) died but were not organ donor eligible.
Cardiac motion was detected by FAST in 54 (28.9%) individuals in the total study population; among these were all nine of the survivors and donors, yielding a sensitivity of 100% and a specificity of 73.7% for survival (P < .001). All 16 of the patients with pericardial fluid detected by FAST died, as did all 7 patients in whom the study was deemed inadequate. Put simply, Dr. Inaba said, “no cardiac motion equals no survival.”
If thoracotomies had been performed only on patients in the study group who had cardiac motion on FAST, more than half of the unsuccessful resuscitative thoracotomies would have been avoided, Dr. Inaba noted. The study, he said, has particular application for lower-volume trauma centers, which must carefully weigh the prolonged use of limited resources required in a resuscitative thoracotomy.
Dr. David Spain, chief of trauma and critical care surgery at Stanford (Calif.) University, asked whether the study captured the mechanism of injury. Though the study did not do so, said Dr. Inaba, he and his colleagues realized that a subset of patients who went immediately to the operating room were not included in the study, a potential limitation. This group of patients included those with a penetrating cardiac injury – a possible reason, he said, why no patients among the survivors had a cardiac injury.
The authors reported no relevant financial disclosures.
SAN DIEGO – The few trauma patients who will survive a high-risk thoracotomy procedure for cardiac arrest can be predicted by the presence of cardiac motion as detected by a quick and inexpensive bedside ultrasound, a prospective study conducted at a level I trauma center showed.
Focused assessment with sonography in trauma (FAST) was 100% sensitive and 62% specific in predicting those who would survive or be eligible for organ donation after receiving a resuscitative thoracotomy for traumatic cardiac arrest, said Dr. Kenji Inaba of the department of surgery at the University of Southern California Medical Center in Los Angeles.
Resuscitative thoracotomy, said Dr. Inaba, is a salvage procedure performed after cardiac arrest. It is a “high-risk, resource-intensive procedure, with a low quantitative yield. And yet, patients do survive.” Previous retrospective studies found that of those receiving resuscitative thoracotomy for traumatic arrest, 7.4% survived, with more than 90% of survivors retaining neurologic function; an additional 4.2% of recipients were potentially eligible for organ donation. Thus, a tool to identify potential survivors among those who present in post-traumatic cardiac arrest would help avoid unnecessary use of a procedure with such risks and resource burdens.
FAST, an inexpensive procedure that is standard for other indications in trauma, has been effective in identifying potential survivors in thoracotomy for nontrauma cardiac arrests, Dr. Inaba said at the annual meeting of the American Surgical Association.
The technique “has near-universal availability, can be performed immediately at the bedside without moving the patient, and yields real-time results with no radiation involved,” he said.
For the current prospective study, the specific aim was to examine the ability of FAST to differentiate survivors and potential organ donors from those who would not survive resuscitative thoracotomy among those presenting in traumatic cardiac arrest. Dr. Inaba and his associates examined the predictive value of cardiac motion and the presence of pericardial fluid for survival, as well as the adequacy of the FAST study for each patient.
The single-center study, conducted from 2010 to 2014, enrolled 187 patients (mean age, 31; 84.5% male) presenting in traumatic arrest who received resuscitative thoracotomy in the emergency department and also received a FAST. The scans were performed by emergency medicine residents under direct faculty supervision. Of the 187 patients studied, 6 (3.2%) survived, 3 (1.6%) became organ donors, and 178 (95.2%) died but were not organ donor eligible.
Cardiac motion was detected by FAST in 54 (28.9%) individuals in the total study population; among these were all nine of the survivors and donors, yielding a sensitivity of 100% and a specificity of 73.7% for survival (P < .001). All 16 of the patients with pericardial fluid detected by FAST died, as did all 7 patients in whom the study was deemed inadequate. Put simply, Dr. Inaba said, “no cardiac motion equals no survival.”
If thoracotomies had been performed only on patients in the study group who had cardiac motion on FAST, more than half of the unsuccessful resuscitative thoracotomies would have been avoided, Dr. Inaba noted. The study, he said, has particular application for lower-volume trauma centers, which must carefully weigh the prolonged use of limited resources required in a resuscitative thoracotomy.
Dr. David Spain, chief of trauma and critical care surgery at Stanford (Calif.) University, asked whether the study captured the mechanism of injury. Though the study did not do so, said Dr. Inaba, he and his colleagues realized that a subset of patients who went immediately to the operating room were not included in the study, a potential limitation. This group of patients included those with a penetrating cardiac injury – a possible reason, he said, why no patients among the survivors had a cardiac injury.
The authors reported no relevant financial disclosures.
SAN DIEGO – The few trauma patients who will survive a high-risk thoracotomy procedure for cardiac arrest can be predicted by the presence of cardiac motion as detected by a quick and inexpensive bedside ultrasound, a prospective study conducted at a level I trauma center showed.
Focused assessment with sonography in trauma (FAST) was 100% sensitive and 62% specific in predicting those who would survive or be eligible for organ donation after receiving a resuscitative thoracotomy for traumatic cardiac arrest, said Dr. Kenji Inaba of the department of surgery at the University of Southern California Medical Center in Los Angeles.
Resuscitative thoracotomy, said Dr. Inaba, is a salvage procedure performed after cardiac arrest. It is a “high-risk, resource-intensive procedure, with a low quantitative yield. And yet, patients do survive.” Previous retrospective studies found that of those receiving resuscitative thoracotomy for traumatic arrest, 7.4% survived, with more than 90% of survivors retaining neurologic function; an additional 4.2% of recipients were potentially eligible for organ donation. Thus, a tool to identify potential survivors among those who present in post-traumatic cardiac arrest would help avoid unnecessary use of a procedure with such risks and resource burdens.
FAST, an inexpensive procedure that is standard for other indications in trauma, has been effective in identifying potential survivors in thoracotomy for nontrauma cardiac arrests, Dr. Inaba said at the annual meeting of the American Surgical Association.
The technique “has near-universal availability, can be performed immediately at the bedside without moving the patient, and yields real-time results with no radiation involved,” he said.
For the current prospective study, the specific aim was to examine the ability of FAST to differentiate survivors and potential organ donors from those who would not survive resuscitative thoracotomy among those presenting in traumatic cardiac arrest. Dr. Inaba and his associates examined the predictive value of cardiac motion and the presence of pericardial fluid for survival, as well as the adequacy of the FAST study for each patient.
The single-center study, conducted from 2010 to 2014, enrolled 187 patients (mean age, 31; 84.5% male) presenting in traumatic arrest who received resuscitative thoracotomy in the emergency department and also received a FAST. The scans were performed by emergency medicine residents under direct faculty supervision. Of the 187 patients studied, 6 (3.2%) survived, 3 (1.6%) became organ donors, and 178 (95.2%) died but were not organ donor eligible.
Cardiac motion was detected by FAST in 54 (28.9%) individuals in the total study population; among these were all nine of the survivors and donors, yielding a sensitivity of 100% and a specificity of 73.7% for survival (P < .001). All 16 of the patients with pericardial fluid detected by FAST died, as did all 7 patients in whom the study was deemed inadequate. Put simply, Dr. Inaba said, “no cardiac motion equals no survival.”
If thoracotomies had been performed only on patients in the study group who had cardiac motion on FAST, more than half of the unsuccessful resuscitative thoracotomies would have been avoided, Dr. Inaba noted. The study, he said, has particular application for lower-volume trauma centers, which must carefully weigh the prolonged use of limited resources required in a resuscitative thoracotomy.
Dr. David Spain, chief of trauma and critical care surgery at Stanford (Calif.) University, asked whether the study captured the mechanism of injury. Though the study did not do so, said Dr. Inaba, he and his colleagues realized that a subset of patients who went immediately to the operating room were not included in the study, a potential limitation. This group of patients included those with a penetrating cardiac injury – a possible reason, he said, why no patients among the survivors had a cardiac injury.
The authors reported no relevant financial disclosures.
AT THE ASA ANNUAL MEETING
Key clinical point: Trauma arrest victims who will survive resuscitative thoracotomy can be predicted using focused assessment with sonography in trauma.
Major findings: FAST was 100% sensitive for detecting survivors after resuscitative thoracotomy for traumatic cardiac arrest.
Data source: A prospective series of 187 trauma patients in cardiac arrest undergoing resuscitative thoracotomy from 2010 to 2014 at a level I trauma center.
Disclosures: The authors reported no relevant financial disclosures.
VIDEO: Esophagectomy outcomes better in hospitals that handle complex cases
SEATTLE – Hospitals that perform at least one nongastric conduit esophageal reconstruction per year have half the esophagectomy mortality of hospitals that do not, according to a review by the Mayo Clinic in Rochester, Minn., of 11,211 esophagectomies in the Nationwide Inpatient Sample database from 2000 to 2011.
“There is tremendous variation in outcome after esophagectomy, and some advocate for regionalization to high-volume hospitals,” the investigators said. The findings suggest that case complexity could be one of the things that help define which hospitals do it best, they added.
The study seems to confirm that hospital case volume makes a difference in surgical outcomes, said Dr. Nabil Rizk, a thoracic surgeon at Memorial Sloan-Kettering Cancer Center in New York.
Dr. Rizk, a discussant on the paper at the American Association for Thoracic Surgery annual meeting, explained how the study fits into regionalization trends, but also shared his concerns about the work in an interview at the meeting.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SEATTLE – Hospitals that perform at least one nongastric conduit esophageal reconstruction per year have half the esophagectomy mortality of hospitals that do not, according to a review by the Mayo Clinic in Rochester, Minn., of 11,211 esophagectomies in the Nationwide Inpatient Sample database from 2000 to 2011.
“There is tremendous variation in outcome after esophagectomy, and some advocate for regionalization to high-volume hospitals,” the investigators said. The findings suggest that case complexity could be one of the things that help define which hospitals do it best, they added.
The study seems to confirm that hospital case volume makes a difference in surgical outcomes, said Dr. Nabil Rizk, a thoracic surgeon at Memorial Sloan-Kettering Cancer Center in New York.
Dr. Rizk, a discussant on the paper at the American Association for Thoracic Surgery annual meeting, explained how the study fits into regionalization trends, but also shared his concerns about the work in an interview at the meeting.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SEATTLE – Hospitals that perform at least one nongastric conduit esophageal reconstruction per year have half the esophagectomy mortality of hospitals that do not, according to a review by the Mayo Clinic in Rochester, Minn., of 11,211 esophagectomies in the Nationwide Inpatient Sample database from 2000 to 2011.
“There is tremendous variation in outcome after esophagectomy, and some advocate for regionalization to high-volume hospitals,” the investigators said. The findings suggest that case complexity could be one of the things that help define which hospitals do it best, they added.
The study seems to confirm that hospital case volume makes a difference in surgical outcomes, said Dr. Nabil Rizk, a thoracic surgeon at Memorial Sloan-Kettering Cancer Center in New York.
Dr. Rizk, a discussant on the paper at the American Association for Thoracic Surgery annual meeting, explained how the study fits into regionalization trends, but also shared his concerns about the work in an interview at the meeting.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT THE AATS ANNUAL MEETING
Palliative surgery eases pain at end of life
HOUSTON – Palliative surgery can alleviate pain and improve the quality of life for patients dying from advanced cancers, without compromising performance status, a study showed.
Among 202 patients with stage III or IV cancers who underwent surgery with palliation as the goal, pain scores were significantly improved after surgery, while Karnofsky Performance Status (KPS) scores remained unchanged, said Dr. Anne Falor, a surgical oncology fellow at City of Hope in Duarte, Calif.
“Surgical oncology has not been historically involved in palliative care. If a patient is deemed unresectable, his or her treatment is often the purview of medical or radiation oncology,” she said at the annual Society of Surgical Oncology Cancer Symposium.
But for patients who are likely to have prolonged disease-free intervals, palliative surgery can be performed with low morbidity, she said.
Dr. Falor and her colleagues reviewed their center’s experience with palliative surgery in 2011, during which time 202 patients with a predicted 5-year survival of less than 5% underwent a total of 247 palliative procedures.
The patients had malignancies at various sites, including the large intestine, lung, stomach, breast, prostate, lymph nodes, esophagus, pancreas, and ovaries.
The primary indications for the procedure included dysphagia, pain/wound problems, dyspnea, nausea and vomiting, and dysuria.
Most of the patients (83%) had a single procedure, but 13% had two operations, 4% had three operations, 1% had four procedures, and 0.4% had five or more interventions.
The majority of procedures performed were endoscopic interventions characterized as minor in nature, followed by minor genitourinary and thoracic interventions, although a nearly equal proportion of thoracic interventions (about 28%) were major procedures such as diverting ostomy.
When the investigators looked at 30-day outcomes following palliative surgery, they found that only 13% of patients needed an urgent care visit, 2% required a triage call, 22% were readmitted, and 60% had an institutional supportive care referral.
Total 30-day morbidity of any kind was seen in 37% of patients; 15% of patients died within 30 days of surgery.
Looking at quality of life outcomes, the investigators found no differences in the percentage of patients with KPS scores from 80 to 100 between the presurgery and postsurgery periods (78% and 70%, respectively, P = ns).
There were significant improvements, however, in pain scores, which dropped by a mean of 1.2 points from the preoperative period to discharge (P < .0001), and decreased by 0.6 points before surgery to the first follow-up visit (P = .0037).
Dr. Falor said that it’s important for patients and their care team to have a discussion regarding expectations for surgery and the goals of care.
The study was internally funded. Dr. Falor reported having no conflicts of interest.
Over the past decade palliative surgery has been increasingly discussed and scrutinized, as the concept of palliative care has gained greater traction with medical professionals and the public. Not too long ago the designation “palliative” when applied to a surgical procedure had an apologetic connotation because the operation would fail to heal. In some cases the term was even used to describe positive tumor margins at the conclusion of a resection – something totally irrelevant when assessing the direct impact of the operation upon a patient’s self-designated symptoms.
Only recently has a more positive perspective emerged, helped by data such as these researchers have presented. Palliative surgery now is not failing to cure, but succeeding to comfort.
New perspectives, however, will raise new and necessary questions to better define the role of surgery in the greater context of relief of suffering in all its manifestations. In our wish to respond surgically to pain and other symptoms we must be vigilant against the temptation to “do something” when surgery for cure or palliation is unlikely to help in order to assuage our feelings of hopelessness. Hopelessness is not an indication for surgery – pain, obstruction, and saving life are. Indications for surgery must be more specific, as this article points out, and it is more likely to help with localized and pressing symptoms. A rule of thumb passed down to me from my surgeon grandfather who practiced in an era when the vast majority of operations were palliative, the more pressing and clear the indication for surgery, the better the result.
Dr. Geoffrey Dunn, an ACS Fellow based in Erie, Pa.
Over the past decade palliative surgery has been increasingly discussed and scrutinized, as the concept of palliative care has gained greater traction with medical professionals and the public. Not too long ago the designation “palliative” when applied to a surgical procedure had an apologetic connotation because the operation would fail to heal. In some cases the term was even used to describe positive tumor margins at the conclusion of a resection – something totally irrelevant when assessing the direct impact of the operation upon a patient’s self-designated symptoms.
Only recently has a more positive perspective emerged, helped by data such as these researchers have presented. Palliative surgery now is not failing to cure, but succeeding to comfort.
New perspectives, however, will raise new and necessary questions to better define the role of surgery in the greater context of relief of suffering in all its manifestations. In our wish to respond surgically to pain and other symptoms we must be vigilant against the temptation to “do something” when surgery for cure or palliation is unlikely to help in order to assuage our feelings of hopelessness. Hopelessness is not an indication for surgery – pain, obstruction, and saving life are. Indications for surgery must be more specific, as this article points out, and it is more likely to help with localized and pressing symptoms. A rule of thumb passed down to me from my surgeon grandfather who practiced in an era when the vast majority of operations were palliative, the more pressing and clear the indication for surgery, the better the result.
Dr. Geoffrey Dunn, an ACS Fellow based in Erie, Pa.
Over the past decade palliative surgery has been increasingly discussed and scrutinized, as the concept of palliative care has gained greater traction with medical professionals and the public. Not too long ago the designation “palliative” when applied to a surgical procedure had an apologetic connotation because the operation would fail to heal. In some cases the term was even used to describe positive tumor margins at the conclusion of a resection – something totally irrelevant when assessing the direct impact of the operation upon a patient’s self-designated symptoms.
Only recently has a more positive perspective emerged, helped by data such as these researchers have presented. Palliative surgery now is not failing to cure, but succeeding to comfort.
New perspectives, however, will raise new and necessary questions to better define the role of surgery in the greater context of relief of suffering in all its manifestations. In our wish to respond surgically to pain and other symptoms we must be vigilant against the temptation to “do something” when surgery for cure or palliation is unlikely to help in order to assuage our feelings of hopelessness. Hopelessness is not an indication for surgery – pain, obstruction, and saving life are. Indications for surgery must be more specific, as this article points out, and it is more likely to help with localized and pressing symptoms. A rule of thumb passed down to me from my surgeon grandfather who practiced in an era when the vast majority of operations were palliative, the more pressing and clear the indication for surgery, the better the result.
Dr. Geoffrey Dunn, an ACS Fellow based in Erie, Pa.
HOUSTON – Palliative surgery can alleviate pain and improve the quality of life for patients dying from advanced cancers, without compromising performance status, a study showed.
Among 202 patients with stage III or IV cancers who underwent surgery with palliation as the goal, pain scores were significantly improved after surgery, while Karnofsky Performance Status (KPS) scores remained unchanged, said Dr. Anne Falor, a surgical oncology fellow at City of Hope in Duarte, Calif.
“Surgical oncology has not been historically involved in palliative care. If a patient is deemed unresectable, his or her treatment is often the purview of medical or radiation oncology,” she said at the annual Society of Surgical Oncology Cancer Symposium.
But for patients who are likely to have prolonged disease-free intervals, palliative surgery can be performed with low morbidity, she said.
Dr. Falor and her colleagues reviewed their center’s experience with palliative surgery in 2011, during which time 202 patients with a predicted 5-year survival of less than 5% underwent a total of 247 palliative procedures.
The patients had malignancies at various sites, including the large intestine, lung, stomach, breast, prostate, lymph nodes, esophagus, pancreas, and ovaries.
The primary indications for the procedure included dysphagia, pain/wound problems, dyspnea, nausea and vomiting, and dysuria.
Most of the patients (83%) had a single procedure, but 13% had two operations, 4% had three operations, 1% had four procedures, and 0.4% had five or more interventions.
The majority of procedures performed were endoscopic interventions characterized as minor in nature, followed by minor genitourinary and thoracic interventions, although a nearly equal proportion of thoracic interventions (about 28%) were major procedures such as diverting ostomy.
When the investigators looked at 30-day outcomes following palliative surgery, they found that only 13% of patients needed an urgent care visit, 2% required a triage call, 22% were readmitted, and 60% had an institutional supportive care referral.
Total 30-day morbidity of any kind was seen in 37% of patients; 15% of patients died within 30 days of surgery.
Looking at quality of life outcomes, the investigators found no differences in the percentage of patients with KPS scores from 80 to 100 between the presurgery and postsurgery periods (78% and 70%, respectively, P = ns).
There were significant improvements, however, in pain scores, which dropped by a mean of 1.2 points from the preoperative period to discharge (P < .0001), and decreased by 0.6 points before surgery to the first follow-up visit (P = .0037).
Dr. Falor said that it’s important for patients and their care team to have a discussion regarding expectations for surgery and the goals of care.
The study was internally funded. Dr. Falor reported having no conflicts of interest.
HOUSTON – Palliative surgery can alleviate pain and improve the quality of life for patients dying from advanced cancers, without compromising performance status, a study showed.
Among 202 patients with stage III or IV cancers who underwent surgery with palliation as the goal, pain scores were significantly improved after surgery, while Karnofsky Performance Status (KPS) scores remained unchanged, said Dr. Anne Falor, a surgical oncology fellow at City of Hope in Duarte, Calif.
“Surgical oncology has not been historically involved in palliative care. If a patient is deemed unresectable, his or her treatment is often the purview of medical or radiation oncology,” she said at the annual Society of Surgical Oncology Cancer Symposium.
But for patients who are likely to have prolonged disease-free intervals, palliative surgery can be performed with low morbidity, she said.
Dr. Falor and her colleagues reviewed their center’s experience with palliative surgery in 2011, during which time 202 patients with a predicted 5-year survival of less than 5% underwent a total of 247 palliative procedures.
The patients had malignancies at various sites, including the large intestine, lung, stomach, breast, prostate, lymph nodes, esophagus, pancreas, and ovaries.
The primary indications for the procedure included dysphagia, pain/wound problems, dyspnea, nausea and vomiting, and dysuria.
Most of the patients (83%) had a single procedure, but 13% had two operations, 4% had three operations, 1% had four procedures, and 0.4% had five or more interventions.
The majority of procedures performed were endoscopic interventions characterized as minor in nature, followed by minor genitourinary and thoracic interventions, although a nearly equal proportion of thoracic interventions (about 28%) were major procedures such as diverting ostomy.
When the investigators looked at 30-day outcomes following palliative surgery, they found that only 13% of patients needed an urgent care visit, 2% required a triage call, 22% were readmitted, and 60% had an institutional supportive care referral.
Total 30-day morbidity of any kind was seen in 37% of patients; 15% of patients died within 30 days of surgery.
Looking at quality of life outcomes, the investigators found no differences in the percentage of patients with KPS scores from 80 to 100 between the presurgery and postsurgery periods (78% and 70%, respectively, P = ns).
There were significant improvements, however, in pain scores, which dropped by a mean of 1.2 points from the preoperative period to discharge (P < .0001), and decreased by 0.6 points before surgery to the first follow-up visit (P = .0037).
Dr. Falor said that it’s important for patients and their care team to have a discussion regarding expectations for surgery and the goals of care.
The study was internally funded. Dr. Falor reported having no conflicts of interest.
Key clinical point: Palliative surgery in patients with advanced cancers can relieve pain with minimal morbidity.
Major finding: Pain scores improved significantly from the pre- to postoperative periods, without a significant decline in performance status scores.
Data source: Case series of 202 patients with stage III or IV malignancies who underwent 247 palliative procedures.
Disclosures: The study was internally funded. Dr. Falor reported having no conflicts of interest.
Perioperative treatment with diuretic linked with lower lung cancer recurrence
Patients with lung cancer who underwent surgery to remove solid tumors and who were treated with atrial natriuretic peptide (ANP) had significantly lower cancer recurrence than did untreated patients, according to a report published in the Proceedings of the National Academy of Sciences.
Investigators retrospectively evaluated patients with lung cancer who underwent surgical removal of tumors; 77 patients received perioperative treatment with ANP and 390 patients did not receive ANP treatment.
ANP-treated patients had significantly greater 2-year relapse-free survival (RFS) after surgery than did those who did not receive ANP (91% vs. 75%, P = .018). Analysis of propensity-matched patients also showed significantly greater 2-year RFS in the ANP group (91% vs. 67%, P = .0013), reported Dr. Takashi Nojiri of Osaka (Japan) University Graduate School of Medicine, and his associates.
“We demonstrated that cancer recurrence after curative surgery was significantly lower in ANP-treated patients than in control patients, suggesting that ANP could potentially be used to prevent cancer recurrence after surgery,” wrote Dr. Nojiri and colleagues (Proc. Natl. Acad. Sci. USA 2015 March 16 [doi:10.1073/pnas.1417273112]).
Atrial natriuretic peptide is a vasodilating hormone from the human heart and acts as a diuretic; previous studies have shown that administration during the perioperative period reduces inflammatory responses and has a prophylactic effect on postoperative cardiopulmonary complications in lung cancer surgery.
Patients with lung cancer who underwent surgery to remove solid tumors and who were treated with atrial natriuretic peptide (ANP) had significantly lower cancer recurrence than did untreated patients, according to a report published in the Proceedings of the National Academy of Sciences.
Investigators retrospectively evaluated patients with lung cancer who underwent surgical removal of tumors; 77 patients received perioperative treatment with ANP and 390 patients did not receive ANP treatment.
ANP-treated patients had significantly greater 2-year relapse-free survival (RFS) after surgery than did those who did not receive ANP (91% vs. 75%, P = .018). Analysis of propensity-matched patients also showed significantly greater 2-year RFS in the ANP group (91% vs. 67%, P = .0013), reported Dr. Takashi Nojiri of Osaka (Japan) University Graduate School of Medicine, and his associates.
“We demonstrated that cancer recurrence after curative surgery was significantly lower in ANP-treated patients than in control patients, suggesting that ANP could potentially be used to prevent cancer recurrence after surgery,” wrote Dr. Nojiri and colleagues (Proc. Natl. Acad. Sci. USA 2015 March 16 [doi:10.1073/pnas.1417273112]).
Atrial natriuretic peptide is a vasodilating hormone from the human heart and acts as a diuretic; previous studies have shown that administration during the perioperative period reduces inflammatory responses and has a prophylactic effect on postoperative cardiopulmonary complications in lung cancer surgery.
Patients with lung cancer who underwent surgery to remove solid tumors and who were treated with atrial natriuretic peptide (ANP) had significantly lower cancer recurrence than did untreated patients, according to a report published in the Proceedings of the National Academy of Sciences.
Investigators retrospectively evaluated patients with lung cancer who underwent surgical removal of tumors; 77 patients received perioperative treatment with ANP and 390 patients did not receive ANP treatment.
ANP-treated patients had significantly greater 2-year relapse-free survival (RFS) after surgery than did those who did not receive ANP (91% vs. 75%, P = .018). Analysis of propensity-matched patients also showed significantly greater 2-year RFS in the ANP group (91% vs. 67%, P = .0013), reported Dr. Takashi Nojiri of Osaka (Japan) University Graduate School of Medicine, and his associates.
“We demonstrated that cancer recurrence after curative surgery was significantly lower in ANP-treated patients than in control patients, suggesting that ANP could potentially be used to prevent cancer recurrence after surgery,” wrote Dr. Nojiri and colleagues (Proc. Natl. Acad. Sci. USA 2015 March 16 [doi:10.1073/pnas.1417273112]).
Atrial natriuretic peptide is a vasodilating hormone from the human heart and acts as a diuretic; previous studies have shown that administration during the perioperative period reduces inflammatory responses and has a prophylactic effect on postoperative cardiopulmonary complications in lung cancer surgery.
FROM PROCEEDINGS OF THE NATIONAL ACADEMY OF SCIENCES
Key clinical point: After surgical removal of tumors, lung cancer patients treated with atrial natriuretic peptide had a significantly lower recurrence rate than did patients who had not received atrial natriuretic peptide.
Major finding: Patients treated with atrial natriuretic peptide had significantly greater 2-year relapse-free survival than did untreated patients (91% vs. 75%, P = .018).
Data source: The retrospective study included 390 patients who were not treated with atrial natriuretic peptide and 77 patients who were.
Disclosures: Dr. Nojiri and two other authors have filed a patent related to atrial natriuretic peptide treatment for cancer metastasis with Daiichi-Sankyo Pharmaceutical Inc.
Stem cell divisions help dictate cancer risk
The lifetime risk of many different types of cancer are correlated (0.81) with the total number of divisions of their tissue stem cells, a recent study round.
This can allow any of the most common cancer types to be differentiated into replicative (R) or deterministic (D) types, according to the results of a correlative literature review comparing cancer incidence in tissues to their known stem cell behavior. Whether a cancer is R or D has profound implications for prevention and detection, according to a report in Science (2015;347:78-81).
Extreme variation in the lifetime incidence of cancer across various tissues exist, ranging from levels such as 6.9% in the lung down to 0.00072% for laryngeal cartilage, according to Cristian Tomasetti, Ph.D., of the Johns Hopkins Bloomberg School of Public Heath and Dr. Bert Vogelstein of the Johns Hopkins Kimmel Cancer Center, both in Baltimore.
Environmental exposure to known carcinogens seems to be a factor in some, but this cannot explain why cancers of the small intestinal epithelium are three times less common than brain tumors, even though the intestinal cells are exposed to much higher levels of environmental mutagens than are the brain cells, which are protected by the blood-brain barrier. And heredity fails as a complete explanation, with only 5%-10% of cancers having a heritable component.
“If heredity and environment factors cannot fully explain the differences in organ-specific cancer risk, how else can these differences be explained?” the authors asked. They postulated that somatic cell mutation during DNA replication as the result of cell division may be a critical factor, implying that the greater level of cell division, the greater level of mutagenesis, and hence cancer. Stem cells, which both self-renew and are responsible for tissue maintenance were the obvious candidates for such mutations, and recently the technology has developed to detect and quantify them.
Via a literature search, the authors identified 31 tissue types in which stem cells had been quantitatively assessed, then plotted the total number of stem cell divisions during an average human lifetime for each of these tissues on the X axis, and the lifetime risk in the United States for the associated cancer types from sources such as the Surveillance, Epidemiology, and End Results (SEER) database. Not only was there a strikingly high positive correlation (0.81), which indicated that 65% of the differences of cancer risk among different tissues can be explained by the total number of stem cell divisions in these tissues, the correlation extended across five orders of magnitude, “thereby applying to cancers with enormous differences in incidence,” according to Dr. Tomasetti and Dr. Vogelstein.
They then proceeded to attempt to distinguish the effect of this cell-replicative component from environmental and hereditary factors that contribute to the incidence of cancer. They defined an extra risk score (ERS) as the log product of the lifetime risk of cancer and the total number of stem cell divisions. They then used unsupervised machine learning methods to classify tumors based only on this score into two groups. The result was 9 tumors with high scores and 22 tumors with low ERS scores. If the ERS was high, it meant that there were added factors, such as heredity and environment, contributing to increase the cancer incidence. These they referred to as D-tumors (deterministic). If the ERS was low, that meant that stochastic factors during cell division were the main contributors to incidence, which they called R-tumors (replicative). Upon inspection, the D-tumors were indeed those that had been previously found to have a high hereditary or environmental component. A notable D-tumor, for example, was lung cancer in smokers, while lung cancer in nonsmokers was designated an R-tumor.
“These results have could have important public health implications,” the researchers indicated.
“The maximum fraction of tumors that are preventable through primary prevention (such as vaccines against infectious agents or altered lifestyle) may be evaluated from their ERS. For nonhereditary D-tumors, this fraction is high and primary prevention may make a major impact. ... For R-tumors, primary prevention measures are not likely to be effective, and secondary prevention should be the major focus,” Dr. Tomasetti and Dr. Vogelstein concluded.
The authors reported no relevant disclosures.
This paper published in Science addresses the question of why different tissues in the body are more prone to carcinogenesis than others. The authors hypothesize that environmental factors or inherited predispositions do not explain these differences. An example given is melanocytes and basal epidermal cells in the skin. Each are exposed to the same carcinogen (UV light) at an identical dose, yet melanomas are much less common than are basal cell carcinomas. The explanation arrived at by the authors focuses on stem cells in each tissue.
Stem cells are the only cells that can self-renew and serve to maintain a tissue’s architecture and development. The authors performed a literature search and plotted the total number of stem cell divisions during the average lifetime of a human vs. the lifetime risk for cancer in that tissue type. A linear correlation was performed and found that 65% of the differences in cancer risk among different tissues were explained by total number of stem cell divisions in those tissues. In other words, the more stem cells divide in a tissue, the greater chance of mutations occurring leading to malignancy.
The simple yet elegant concept helps explain the melanoma and basal cell carcinoma differences as well as why those with familial adenomatous polyposis (APC) are 30 times more likely to develop colon carcinoma than duodenal cancer. Human colons have 150-fold more stem cell divisions than the small intestine. Amazingly, mice have more stem cell divisions in their small intestines and in the presence of APC mutation for adenomatous polyps, small intestine tumors are more common than ones in the colon. The authors’ findings suggest in cases where these tumors develop independent of environmental and hereditary factors, secondary prevention such as early detection need to be the driving focus to improve clinical outcomes.
Dr. Michael J. Liptay is the Mary and John Bent Professor and chairman of cardiovascular and thoracic surgery, director of cardiothoracic surgery, and chief of thoracic surgery at Rush University Medical Center, Chicago, and the medical editor of Thoracic Surgery News.
This paper published in Science addresses the question of why different tissues in the body are more prone to carcinogenesis than others. The authors hypothesize that environmental factors or inherited predispositions do not explain these differences. An example given is melanocytes and basal epidermal cells in the skin. Each are exposed to the same carcinogen (UV light) at an identical dose, yet melanomas are much less common than are basal cell carcinomas. The explanation arrived at by the authors focuses on stem cells in each tissue.
Stem cells are the only cells that can self-renew and serve to maintain a tissue’s architecture and development. The authors performed a literature search and plotted the total number of stem cell divisions during the average lifetime of a human vs. the lifetime risk for cancer in that tissue type. A linear correlation was performed and found that 65% of the differences in cancer risk among different tissues were explained by total number of stem cell divisions in those tissues. In other words, the more stem cells divide in a tissue, the greater chance of mutations occurring leading to malignancy.
The simple yet elegant concept helps explain the melanoma and basal cell carcinoma differences as well as why those with familial adenomatous polyposis (APC) are 30 times more likely to develop colon carcinoma than duodenal cancer. Human colons have 150-fold more stem cell divisions than the small intestine. Amazingly, mice have more stem cell divisions in their small intestines and in the presence of APC mutation for adenomatous polyps, small intestine tumors are more common than ones in the colon. The authors’ findings suggest in cases where these tumors develop independent of environmental and hereditary factors, secondary prevention such as early detection need to be the driving focus to improve clinical outcomes.
Dr. Michael J. Liptay is the Mary and John Bent Professor and chairman of cardiovascular and thoracic surgery, director of cardiothoracic surgery, and chief of thoracic surgery at Rush University Medical Center, Chicago, and the medical editor of Thoracic Surgery News.
This paper published in Science addresses the question of why different tissues in the body are more prone to carcinogenesis than others. The authors hypothesize that environmental factors or inherited predispositions do not explain these differences. An example given is melanocytes and basal epidermal cells in the skin. Each are exposed to the same carcinogen (UV light) at an identical dose, yet melanomas are much less common than are basal cell carcinomas. The explanation arrived at by the authors focuses on stem cells in each tissue.
Stem cells are the only cells that can self-renew and serve to maintain a tissue’s architecture and development. The authors performed a literature search and plotted the total number of stem cell divisions during the average lifetime of a human vs. the lifetime risk for cancer in that tissue type. A linear correlation was performed and found that 65% of the differences in cancer risk among different tissues were explained by total number of stem cell divisions in those tissues. In other words, the more stem cells divide in a tissue, the greater chance of mutations occurring leading to malignancy.
The simple yet elegant concept helps explain the melanoma and basal cell carcinoma differences as well as why those with familial adenomatous polyposis (APC) are 30 times more likely to develop colon carcinoma than duodenal cancer. Human colons have 150-fold more stem cell divisions than the small intestine. Amazingly, mice have more stem cell divisions in their small intestines and in the presence of APC mutation for adenomatous polyps, small intestine tumors are more common than ones in the colon. The authors’ findings suggest in cases where these tumors develop independent of environmental and hereditary factors, secondary prevention such as early detection need to be the driving focus to improve clinical outcomes.
Dr. Michael J. Liptay is the Mary and John Bent Professor and chairman of cardiovascular and thoracic surgery, director of cardiothoracic surgery, and chief of thoracic surgery at Rush University Medical Center, Chicago, and the medical editor of Thoracic Surgery News.
The lifetime risk of many different types of cancer are correlated (0.81) with the total number of divisions of their tissue stem cells, a recent study round.
This can allow any of the most common cancer types to be differentiated into replicative (R) or deterministic (D) types, according to the results of a correlative literature review comparing cancer incidence in tissues to their known stem cell behavior. Whether a cancer is R or D has profound implications for prevention and detection, according to a report in Science (2015;347:78-81).
Extreme variation in the lifetime incidence of cancer across various tissues exist, ranging from levels such as 6.9% in the lung down to 0.00072% for laryngeal cartilage, according to Cristian Tomasetti, Ph.D., of the Johns Hopkins Bloomberg School of Public Heath and Dr. Bert Vogelstein of the Johns Hopkins Kimmel Cancer Center, both in Baltimore.
Environmental exposure to known carcinogens seems to be a factor in some, but this cannot explain why cancers of the small intestinal epithelium are three times less common than brain tumors, even though the intestinal cells are exposed to much higher levels of environmental mutagens than are the brain cells, which are protected by the blood-brain barrier. And heredity fails as a complete explanation, with only 5%-10% of cancers having a heritable component.
“If heredity and environment factors cannot fully explain the differences in organ-specific cancer risk, how else can these differences be explained?” the authors asked. They postulated that somatic cell mutation during DNA replication as the result of cell division may be a critical factor, implying that the greater level of cell division, the greater level of mutagenesis, and hence cancer. Stem cells, which both self-renew and are responsible for tissue maintenance were the obvious candidates for such mutations, and recently the technology has developed to detect and quantify them.
Via a literature search, the authors identified 31 tissue types in which stem cells had been quantitatively assessed, then plotted the total number of stem cell divisions during an average human lifetime for each of these tissues on the X axis, and the lifetime risk in the United States for the associated cancer types from sources such as the Surveillance, Epidemiology, and End Results (SEER) database. Not only was there a strikingly high positive correlation (0.81), which indicated that 65% of the differences of cancer risk among different tissues can be explained by the total number of stem cell divisions in these tissues, the correlation extended across five orders of magnitude, “thereby applying to cancers with enormous differences in incidence,” according to Dr. Tomasetti and Dr. Vogelstein.
They then proceeded to attempt to distinguish the effect of this cell-replicative component from environmental and hereditary factors that contribute to the incidence of cancer. They defined an extra risk score (ERS) as the log product of the lifetime risk of cancer and the total number of stem cell divisions. They then used unsupervised machine learning methods to classify tumors based only on this score into two groups. The result was 9 tumors with high scores and 22 tumors with low ERS scores. If the ERS was high, it meant that there were added factors, such as heredity and environment, contributing to increase the cancer incidence. These they referred to as D-tumors (deterministic). If the ERS was low, that meant that stochastic factors during cell division were the main contributors to incidence, which they called R-tumors (replicative). Upon inspection, the D-tumors were indeed those that had been previously found to have a high hereditary or environmental component. A notable D-tumor, for example, was lung cancer in smokers, while lung cancer in nonsmokers was designated an R-tumor.
“These results have could have important public health implications,” the researchers indicated.
“The maximum fraction of tumors that are preventable through primary prevention (such as vaccines against infectious agents or altered lifestyle) may be evaluated from their ERS. For nonhereditary D-tumors, this fraction is high and primary prevention may make a major impact. ... For R-tumors, primary prevention measures are not likely to be effective, and secondary prevention should be the major focus,” Dr. Tomasetti and Dr. Vogelstein concluded.
The authors reported no relevant disclosures.
The lifetime risk of many different types of cancer are correlated (0.81) with the total number of divisions of their tissue stem cells, a recent study round.
This can allow any of the most common cancer types to be differentiated into replicative (R) or deterministic (D) types, according to the results of a correlative literature review comparing cancer incidence in tissues to their known stem cell behavior. Whether a cancer is R or D has profound implications for prevention and detection, according to a report in Science (2015;347:78-81).
Extreme variation in the lifetime incidence of cancer across various tissues exist, ranging from levels such as 6.9% in the lung down to 0.00072% for laryngeal cartilage, according to Cristian Tomasetti, Ph.D., of the Johns Hopkins Bloomberg School of Public Heath and Dr. Bert Vogelstein of the Johns Hopkins Kimmel Cancer Center, both in Baltimore.
Environmental exposure to known carcinogens seems to be a factor in some, but this cannot explain why cancers of the small intestinal epithelium are three times less common than brain tumors, even though the intestinal cells are exposed to much higher levels of environmental mutagens than are the brain cells, which are protected by the blood-brain barrier. And heredity fails as a complete explanation, with only 5%-10% of cancers having a heritable component.
“If heredity and environment factors cannot fully explain the differences in organ-specific cancer risk, how else can these differences be explained?” the authors asked. They postulated that somatic cell mutation during DNA replication as the result of cell division may be a critical factor, implying that the greater level of cell division, the greater level of mutagenesis, and hence cancer. Stem cells, which both self-renew and are responsible for tissue maintenance were the obvious candidates for such mutations, and recently the technology has developed to detect and quantify them.
Via a literature search, the authors identified 31 tissue types in which stem cells had been quantitatively assessed, then plotted the total number of stem cell divisions during an average human lifetime for each of these tissues on the X axis, and the lifetime risk in the United States for the associated cancer types from sources such as the Surveillance, Epidemiology, and End Results (SEER) database. Not only was there a strikingly high positive correlation (0.81), which indicated that 65% of the differences of cancer risk among different tissues can be explained by the total number of stem cell divisions in these tissues, the correlation extended across five orders of magnitude, “thereby applying to cancers with enormous differences in incidence,” according to Dr. Tomasetti and Dr. Vogelstein.
They then proceeded to attempt to distinguish the effect of this cell-replicative component from environmental and hereditary factors that contribute to the incidence of cancer. They defined an extra risk score (ERS) as the log product of the lifetime risk of cancer and the total number of stem cell divisions. They then used unsupervised machine learning methods to classify tumors based only on this score into two groups. The result was 9 tumors with high scores and 22 tumors with low ERS scores. If the ERS was high, it meant that there were added factors, such as heredity and environment, contributing to increase the cancer incidence. These they referred to as D-tumors (deterministic). If the ERS was low, that meant that stochastic factors during cell division were the main contributors to incidence, which they called R-tumors (replicative). Upon inspection, the D-tumors were indeed those that had been previously found to have a high hereditary or environmental component. A notable D-tumor, for example, was lung cancer in smokers, while lung cancer in nonsmokers was designated an R-tumor.
“These results have could have important public health implications,” the researchers indicated.
“The maximum fraction of tumors that are preventable through primary prevention (such as vaccines against infectious agents or altered lifestyle) may be evaluated from their ERS. For nonhereditary D-tumors, this fraction is high and primary prevention may make a major impact. ... For R-tumors, primary prevention measures are not likely to be effective, and secondary prevention should be the major focus,” Dr. Tomasetti and Dr. Vogelstein concluded.
The authors reported no relevant disclosures.
FROM SCIENCE
Key clinical point: Only a third of the variation in cancer risk among tissues is because of the environment or inheritance, and this has implications with regard to prevention and detection.
Major finding: The lifetime risk of many different types of cancer are correlated (0.81) with the total number of divisions of their tissue stem cells.
Data source: Researchers performed a literature review to correlate cancer incidence in a variety of tissues with the nature, number, and hierarchical division patterns of the tissue’s stem cells.
Disclosures: The researchers reported no relevant disclosures.
Fast-track protocol cuts lung resection complications, LOS
CHICAGO – An enhanced recovery pathway reduces short-term complications and hospital stays following cancer-related lung resection without raising readmissions or emergency visits after discharge, a study showed.
“A multimodal pathway for open, elective lobectomy seems to improve efficiency and quality of care,” Dr. Amin Madani, from McGill University in Montreal, said at the annual meeting of the Central Surgical Association (CSA).
Prior research suggests that an enhanced recovery pathway (ERP), also known as fast-track protocols, can improve surgical outcomes, but there is little evidence to support its use and effectiveness in lung resection.
Surgeons at McGill established an integrated, multimodal approach to perioperative care of these patients after creating a written, evidence-based, step-by-step pathway. Key elements are standardized preoperative patient education; removal of urine drains on postoperative day 1; removal of the last chest tube by postop (POD) day 3, if there is <300 cc of drainage in 24 hours and no air leak; ambulation goals of more than 75 m thrice-daily by POD 3; introduction of solid food on POD 1; and a target discharge of POD 4; Dr. Madani explained.
To examine the effectiveness of the pathway, the authors retrospectively analyzed outcomes in 127 patients undergoing elective lung resection for primary or secondary lung cancer receiving traditional care and 107 patients treated after the ERP was implemented in September 2012. At baseline, the two groups were similar with respect to age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) scores, pulmonary function, and smoking history.
Hospital length of stay was significantly reduced after the ERP from a median of 7 days with traditional care to 6 days (P < .01), driven largely by patients with an uncomplicated hospital course who were discharged after a median of 5 days after the pathway was implemented, Dr. Madani said.
It was not the case that patients went home too early, as readmissions (5% vs. 6%) and ED visits (3% vs. 5%) were similar between both groups, he added.
After the pathway was implemented, patients had earlier Foley catheter removal (POD 2 vs. 1), IV discontinuation (POD 3 vs. 2), ambulation (POD 2 vs. 1), last chest tube removal (POD 5 vs. 4), and epidural removal (POD 5 vs. 4).
The enhanced recovery pathway group had fewer overall complications than did the traditional care group (37% vs. 50%; P = .03), a threefold decrease in urinary tract infections (3% vs. 12%; P < .01), and a trend toward fewer pulmonary complications (25% vs. 31%; P = .38) and surgical site infections (1% vs. 6%; P = .07), he said.
Despite significantly earlier removal of chest tubes after the pathway, there was no difference in the incidence of pneumothorax or pleural effusion requiring tube re-insertion, affirming that “Chest tubes were not being removed too early, causing harm to patients,” Dr. Madani said.
In multivariate regression analysis adjusted for age, sex, BMI, and ASA score, there was a significant negative association between implementation of an enhanced recovery pathway and length of stay (beta, –0.18; P < .01) and complications (odds ratio, 0.46; P < .01), but not readmissions (OR, 1.59; P = .44).
Early removal of chest tubes and urinary catheter were independent predictors of decreased length of stay.
Dr. L. Michael Brunt, a discussant from Washington University in St. Louis, said the development of care pathways to enhance recovery after surgery is gaining a lot of interest in the surgical community, but went on to ask how much it cost to implement.
The overall cost of the surgeon-driven initiative, involving multiple pathways for various surgical procedures, is about $120,000 annually, or $100/patient for the 1,200 patients undergoing surgery using an ERP program at the McGill University Health Centre each year, Dr. Madani said. This cost also includes a full-time nurse practitioner now serving as the pathway coordinator and roughly $13,000 for patient education booklets, but no additional staff.
An audience member questioned whether the authors have identified factors predicting which patients would fail to meet pathway goals, observing that in the colorectal field, there are patients such as the 80-year-old, narcotic-naive woman with diabetes, who simply won’t progress.
“That’s a very good point, and I agree there are some patients whom you can’t fast track,” Dr. Madani replied. “Part of the deal here is that, yes, we have this protocolized pathway; however, the surgeon still has the right to change that if they feel it is important. We didn’t look at the specifics of which patient [factors] achieved adherence, but we could at some point in the future.”
CSA president and session moderator Christopher McHenry, from MetroHealth Medical Center in Cleveland, said he was impressed with the study and called the findings very believable.
“I think all of these recovery pathways can be very beneficial,” Dr. McHenry said in an interview. “It helps us re-look at how we’re managing our patients and see if there are ways that we can improve on their postoperative management that may lead to earlier discharge.”
The study was funded by an investigator-initiated research grant from Ethicon Canada. Dr. Madani, his coauthors, Dr. Brunt, and Dr. McHenry reported having no financial conflicts.
CHICAGO – An enhanced recovery pathway reduces short-term complications and hospital stays following cancer-related lung resection without raising readmissions or emergency visits after discharge, a study showed.
“A multimodal pathway for open, elective lobectomy seems to improve efficiency and quality of care,” Dr. Amin Madani, from McGill University in Montreal, said at the annual meeting of the Central Surgical Association (CSA).
Prior research suggests that an enhanced recovery pathway (ERP), also known as fast-track protocols, can improve surgical outcomes, but there is little evidence to support its use and effectiveness in lung resection.
Surgeons at McGill established an integrated, multimodal approach to perioperative care of these patients after creating a written, evidence-based, step-by-step pathway. Key elements are standardized preoperative patient education; removal of urine drains on postoperative day 1; removal of the last chest tube by postop (POD) day 3, if there is <300 cc of drainage in 24 hours and no air leak; ambulation goals of more than 75 m thrice-daily by POD 3; introduction of solid food on POD 1; and a target discharge of POD 4; Dr. Madani explained.
To examine the effectiveness of the pathway, the authors retrospectively analyzed outcomes in 127 patients undergoing elective lung resection for primary or secondary lung cancer receiving traditional care and 107 patients treated after the ERP was implemented in September 2012. At baseline, the two groups were similar with respect to age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) scores, pulmonary function, and smoking history.
Hospital length of stay was significantly reduced after the ERP from a median of 7 days with traditional care to 6 days (P < .01), driven largely by patients with an uncomplicated hospital course who were discharged after a median of 5 days after the pathway was implemented, Dr. Madani said.
It was not the case that patients went home too early, as readmissions (5% vs. 6%) and ED visits (3% vs. 5%) were similar between both groups, he added.
After the pathway was implemented, patients had earlier Foley catheter removal (POD 2 vs. 1), IV discontinuation (POD 3 vs. 2), ambulation (POD 2 vs. 1), last chest tube removal (POD 5 vs. 4), and epidural removal (POD 5 vs. 4).
The enhanced recovery pathway group had fewer overall complications than did the traditional care group (37% vs. 50%; P = .03), a threefold decrease in urinary tract infections (3% vs. 12%; P < .01), and a trend toward fewer pulmonary complications (25% vs. 31%; P = .38) and surgical site infections (1% vs. 6%; P = .07), he said.
Despite significantly earlier removal of chest tubes after the pathway, there was no difference in the incidence of pneumothorax or pleural effusion requiring tube re-insertion, affirming that “Chest tubes were not being removed too early, causing harm to patients,” Dr. Madani said.
In multivariate regression analysis adjusted for age, sex, BMI, and ASA score, there was a significant negative association between implementation of an enhanced recovery pathway and length of stay (beta, –0.18; P < .01) and complications (odds ratio, 0.46; P < .01), but not readmissions (OR, 1.59; P = .44).
Early removal of chest tubes and urinary catheter were independent predictors of decreased length of stay.
Dr. L. Michael Brunt, a discussant from Washington University in St. Louis, said the development of care pathways to enhance recovery after surgery is gaining a lot of interest in the surgical community, but went on to ask how much it cost to implement.
The overall cost of the surgeon-driven initiative, involving multiple pathways for various surgical procedures, is about $120,000 annually, or $100/patient for the 1,200 patients undergoing surgery using an ERP program at the McGill University Health Centre each year, Dr. Madani said. This cost also includes a full-time nurse practitioner now serving as the pathway coordinator and roughly $13,000 for patient education booklets, but no additional staff.
An audience member questioned whether the authors have identified factors predicting which patients would fail to meet pathway goals, observing that in the colorectal field, there are patients such as the 80-year-old, narcotic-naive woman with diabetes, who simply won’t progress.
“That’s a very good point, and I agree there are some patients whom you can’t fast track,” Dr. Madani replied. “Part of the deal here is that, yes, we have this protocolized pathway; however, the surgeon still has the right to change that if they feel it is important. We didn’t look at the specifics of which patient [factors] achieved adherence, but we could at some point in the future.”
CSA president and session moderator Christopher McHenry, from MetroHealth Medical Center in Cleveland, said he was impressed with the study and called the findings very believable.
“I think all of these recovery pathways can be very beneficial,” Dr. McHenry said in an interview. “It helps us re-look at how we’re managing our patients and see if there are ways that we can improve on their postoperative management that may lead to earlier discharge.”
The study was funded by an investigator-initiated research grant from Ethicon Canada. Dr. Madani, his coauthors, Dr. Brunt, and Dr. McHenry reported having no financial conflicts.
CHICAGO – An enhanced recovery pathway reduces short-term complications and hospital stays following cancer-related lung resection without raising readmissions or emergency visits after discharge, a study showed.
“A multimodal pathway for open, elective lobectomy seems to improve efficiency and quality of care,” Dr. Amin Madani, from McGill University in Montreal, said at the annual meeting of the Central Surgical Association (CSA).
Prior research suggests that an enhanced recovery pathway (ERP), also known as fast-track protocols, can improve surgical outcomes, but there is little evidence to support its use and effectiveness in lung resection.
Surgeons at McGill established an integrated, multimodal approach to perioperative care of these patients after creating a written, evidence-based, step-by-step pathway. Key elements are standardized preoperative patient education; removal of urine drains on postoperative day 1; removal of the last chest tube by postop (POD) day 3, if there is <300 cc of drainage in 24 hours and no air leak; ambulation goals of more than 75 m thrice-daily by POD 3; introduction of solid food on POD 1; and a target discharge of POD 4; Dr. Madani explained.
To examine the effectiveness of the pathway, the authors retrospectively analyzed outcomes in 127 patients undergoing elective lung resection for primary or secondary lung cancer receiving traditional care and 107 patients treated after the ERP was implemented in September 2012. At baseline, the two groups were similar with respect to age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) scores, pulmonary function, and smoking history.
Hospital length of stay was significantly reduced after the ERP from a median of 7 days with traditional care to 6 days (P < .01), driven largely by patients with an uncomplicated hospital course who were discharged after a median of 5 days after the pathway was implemented, Dr. Madani said.
It was not the case that patients went home too early, as readmissions (5% vs. 6%) and ED visits (3% vs. 5%) were similar between both groups, he added.
After the pathway was implemented, patients had earlier Foley catheter removal (POD 2 vs. 1), IV discontinuation (POD 3 vs. 2), ambulation (POD 2 vs. 1), last chest tube removal (POD 5 vs. 4), and epidural removal (POD 5 vs. 4).
The enhanced recovery pathway group had fewer overall complications than did the traditional care group (37% vs. 50%; P = .03), a threefold decrease in urinary tract infections (3% vs. 12%; P < .01), and a trend toward fewer pulmonary complications (25% vs. 31%; P = .38) and surgical site infections (1% vs. 6%; P = .07), he said.
Despite significantly earlier removal of chest tubes after the pathway, there was no difference in the incidence of pneumothorax or pleural effusion requiring tube re-insertion, affirming that “Chest tubes were not being removed too early, causing harm to patients,” Dr. Madani said.
In multivariate regression analysis adjusted for age, sex, BMI, and ASA score, there was a significant negative association between implementation of an enhanced recovery pathway and length of stay (beta, –0.18; P < .01) and complications (odds ratio, 0.46; P < .01), but not readmissions (OR, 1.59; P = .44).
Early removal of chest tubes and urinary catheter were independent predictors of decreased length of stay.
Dr. L. Michael Brunt, a discussant from Washington University in St. Louis, said the development of care pathways to enhance recovery after surgery is gaining a lot of interest in the surgical community, but went on to ask how much it cost to implement.
The overall cost of the surgeon-driven initiative, involving multiple pathways for various surgical procedures, is about $120,000 annually, or $100/patient for the 1,200 patients undergoing surgery using an ERP program at the McGill University Health Centre each year, Dr. Madani said. This cost also includes a full-time nurse practitioner now serving as the pathway coordinator and roughly $13,000 for patient education booklets, but no additional staff.
An audience member questioned whether the authors have identified factors predicting which patients would fail to meet pathway goals, observing that in the colorectal field, there are patients such as the 80-year-old, narcotic-naive woman with diabetes, who simply won’t progress.
“That’s a very good point, and I agree there are some patients whom you can’t fast track,” Dr. Madani replied. “Part of the deal here is that, yes, we have this protocolized pathway; however, the surgeon still has the right to change that if they feel it is important. We didn’t look at the specifics of which patient [factors] achieved adherence, but we could at some point in the future.”
CSA president and session moderator Christopher McHenry, from MetroHealth Medical Center in Cleveland, said he was impressed with the study and called the findings very believable.
“I think all of these recovery pathways can be very beneficial,” Dr. McHenry said in an interview. “It helps us re-look at how we’re managing our patients and see if there are ways that we can improve on their postoperative management that may lead to earlier discharge.”
The study was funded by an investigator-initiated research grant from Ethicon Canada. Dr. Madani, his coauthors, Dr. Brunt, and Dr. McHenry reported having no financial conflicts.
AT THE ANNUAL MEETING OF THE CENTRAL SURGICAL ASSOCIATION
Key clinical point: An enhanced recovery pathway reduces complications and hospital stay following lung cancer resection without raising readmissions or ED visits.
Major finding: Patients in the enhanced recovery pathway vs. traditional care had fewer overall complications (37% vs. 50%; P = .03) and threefold fewer UTIs (3% vs. 12%; P < .01).
Data source: Observational study of 234 patients undergoing lung resection.
Disclosures: The study was funded by an investigator-initiated research grant from Ethicon Canada. Dr. Madani, his coauthors, Dr. Brunt, and Dr. McHenry reported having no financial conflicts.
Esophagogastric cancer patients on chemotherapy more likely to develop VTE
Incidence rates for developing venous thromboembolism (VTE) among esophagogastric cancer patients undergoing neoadjuvant chemotherapy in combination with curative intended surgery were significantly higher among patients with initial stage III and IV cancers and gastric cancer, according to a new study published in Thrombosis Research.
In the clinical prospective study, 129 patients with lower esophageal, gastroesophageal, and gastric cancer were examined between 2008 and 2011. Baseline assessments were recorded via bilateral compression ultrasound (biCUS) for deep vein thrombosis and computer tomography pulmonary angiography for pulmonary embolism. The patients received a chemotherapy regimen of oxaliplatin, capecitabine, and epirubicin, with curative intended surgery, and were examined before undergoing preoperative chemotherapy, surgery, and postoperative chemotherapy. The researchers encountered 21 VTE cases, or 16% of the total number of patients examined, with VTE incidences twice as likely to be asymptomatic than symptomatic.
The authors noted that state-of-the-art technology helped boost VTE detection rates among asymptomatic patients, and older studies may have underreported incidences of the disease.
“Although our study only included 129 patients, the systematic use of biCUS strongly suggests that the frequency of VTE is much greater than that previously reported for these types of cancer,” wrote Dr. Anders Christian Larsen and his associates at Aalborg University Hospital, Denmark.
Read more here (Thrombosis Research 2015 [doi:10.1016/j.thromres.2015.01.021]).
Incidence rates for developing venous thromboembolism (VTE) among esophagogastric cancer patients undergoing neoadjuvant chemotherapy in combination with curative intended surgery were significantly higher among patients with initial stage III and IV cancers and gastric cancer, according to a new study published in Thrombosis Research.
In the clinical prospective study, 129 patients with lower esophageal, gastroesophageal, and gastric cancer were examined between 2008 and 2011. Baseline assessments were recorded via bilateral compression ultrasound (biCUS) for deep vein thrombosis and computer tomography pulmonary angiography for pulmonary embolism. The patients received a chemotherapy regimen of oxaliplatin, capecitabine, and epirubicin, with curative intended surgery, and were examined before undergoing preoperative chemotherapy, surgery, and postoperative chemotherapy. The researchers encountered 21 VTE cases, or 16% of the total number of patients examined, with VTE incidences twice as likely to be asymptomatic than symptomatic.
The authors noted that state-of-the-art technology helped boost VTE detection rates among asymptomatic patients, and older studies may have underreported incidences of the disease.
“Although our study only included 129 patients, the systematic use of biCUS strongly suggests that the frequency of VTE is much greater than that previously reported for these types of cancer,” wrote Dr. Anders Christian Larsen and his associates at Aalborg University Hospital, Denmark.
Read more here (Thrombosis Research 2015 [doi:10.1016/j.thromres.2015.01.021]).
Incidence rates for developing venous thromboembolism (VTE) among esophagogastric cancer patients undergoing neoadjuvant chemotherapy in combination with curative intended surgery were significantly higher among patients with initial stage III and IV cancers and gastric cancer, according to a new study published in Thrombosis Research.
In the clinical prospective study, 129 patients with lower esophageal, gastroesophageal, and gastric cancer were examined between 2008 and 2011. Baseline assessments were recorded via bilateral compression ultrasound (biCUS) for deep vein thrombosis and computer tomography pulmonary angiography for pulmonary embolism. The patients received a chemotherapy regimen of oxaliplatin, capecitabine, and epirubicin, with curative intended surgery, and were examined before undergoing preoperative chemotherapy, surgery, and postoperative chemotherapy. The researchers encountered 21 VTE cases, or 16% of the total number of patients examined, with VTE incidences twice as likely to be asymptomatic than symptomatic.
The authors noted that state-of-the-art technology helped boost VTE detection rates among asymptomatic patients, and older studies may have underreported incidences of the disease.
“Although our study only included 129 patients, the systematic use of biCUS strongly suggests that the frequency of VTE is much greater than that previously reported for these types of cancer,” wrote Dr. Anders Christian Larsen and his associates at Aalborg University Hospital, Denmark.
Read more here (Thrombosis Research 2015 [doi:10.1016/j.thromres.2015.01.021]).
VIDEO: How to negotiate the robotic surgery learning curve
SAN FRANCISCO– Before attempting robotic surgery, it’s important to be comfortable with both the open and laparoscopic versions of the procedure, according to Dr. Kenneth Meredith, director of robotic surgery at the University of Wisconsin, Madison.
In experienced hands, robotic results can be good. In a case series of 138 robotic-assisted Ivor Lewis esophagectomies at the university for esophageal cancer, the median intensive care unit stay was 2 days and median hospital stay 9 days, Dr. Meredith. Complications occurred in about a quarter of patients.
In a video interview at the American College of Surgeons Clinical Congress, Dr. Meredith explained the significance of the findings and gave tips on how to negotiate the robotic surgery learning curve.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SAN FRANCISCO– Before attempting robotic surgery, it’s important to be comfortable with both the open and laparoscopic versions of the procedure, according to Dr. Kenneth Meredith, director of robotic surgery at the University of Wisconsin, Madison.
In experienced hands, robotic results can be good. In a case series of 138 robotic-assisted Ivor Lewis esophagectomies at the university for esophageal cancer, the median intensive care unit stay was 2 days and median hospital stay 9 days, Dr. Meredith. Complications occurred in about a quarter of patients.
In a video interview at the American College of Surgeons Clinical Congress, Dr. Meredith explained the significance of the findings and gave tips on how to negotiate the robotic surgery learning curve.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
SAN FRANCISCO– Before attempting robotic surgery, it’s important to be comfortable with both the open and laparoscopic versions of the procedure, according to Dr. Kenneth Meredith, director of robotic surgery at the University of Wisconsin, Madison.
In experienced hands, robotic results can be good. In a case series of 138 robotic-assisted Ivor Lewis esophagectomies at the university for esophageal cancer, the median intensive care unit stay was 2 days and median hospital stay 9 days, Dr. Meredith. Complications occurred in about a quarter of patients.
In a video interview at the American College of Surgeons Clinical Congress, Dr. Meredith explained the significance of the findings and gave tips on how to negotiate the robotic surgery learning curve.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT THE AMERICAN COLLEGE OF SURGEONS CLINICAL CONGRESS
VIDEO: Nonclinical factors affect lung resection survival
SAN FRANCISCO– A study of data from more than 200,000 patients identified several nonclinical factors ssociated with 30-day survival after lung resection for non–small cell lung cancer, Dr. Manu S. Sancheti reported at the annual clinical congress of the American College of Surgeons.
The analysis by Dr. Sancheti and his associates won the top prize for poster presentations at the congress.
In an interview at the award presentation, Dr. Sancheti of Emory University, Atlanta, described his results and ideas about how physicians and health care systems might use this information to improve care.
He reported having no financial disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @sherryboschert
SAN FRANCISCO– A study of data from more than 200,000 patients identified several nonclinical factors ssociated with 30-day survival after lung resection for non–small cell lung cancer, Dr. Manu S. Sancheti reported at the annual clinical congress of the American College of Surgeons.
The analysis by Dr. Sancheti and his associates won the top prize for poster presentations at the congress.
In an interview at the award presentation, Dr. Sancheti of Emory University, Atlanta, described his results and ideas about how physicians and health care systems might use this information to improve care.
He reported having no financial disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @sherryboschert
SAN FRANCISCO– A study of data from more than 200,000 patients identified several nonclinical factors ssociated with 30-day survival after lung resection for non–small cell lung cancer, Dr. Manu S. Sancheti reported at the annual clinical congress of the American College of Surgeons.
The analysis by Dr. Sancheti and his associates won the top prize for poster presentations at the congress.
In an interview at the award presentation, Dr. Sancheti of Emory University, Atlanta, described his results and ideas about how physicians and health care systems might use this information to improve care.
He reported having no financial disclosures.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @sherryboschert
AT THE ACS CLINICAL CONGRESS
The October issue of Thoracic Surgery News is now available online
Be sure to visit our interactive digital or PDF version of the October issue of Thoracic Surgery News, now available online.
This month we are featuring topics ranging from two stories with videos on local anesthesia and the new developments in TAVR, and a newly FDA-approved device for expanding the number of lungs available for transplant.
Also, in our News from the AATS section there is a call for abstracts and videos for AATS Week (comprising the 95th AATS Annual Meeting and the AATS Mitral Conclave), as well as information about signing up for the AATS Leadership Academy and for students and residents to get financial assistance to attend the 95th AATS Annual Meeting.
Click to view our October PDF here or the interactive digital edition.
Be sure to visit our interactive digital or PDF version of the October issue of Thoracic Surgery News, now available online.
This month we are featuring topics ranging from two stories with videos on local anesthesia and the new developments in TAVR, and a newly FDA-approved device for expanding the number of lungs available for transplant.
Also, in our News from the AATS section there is a call for abstracts and videos for AATS Week (comprising the 95th AATS Annual Meeting and the AATS Mitral Conclave), as well as information about signing up for the AATS Leadership Academy and for students and residents to get financial assistance to attend the 95th AATS Annual Meeting.
Click to view our October PDF here or the interactive digital edition.
Be sure to visit our interactive digital or PDF version of the October issue of Thoracic Surgery News, now available online.
This month we are featuring topics ranging from two stories with videos on local anesthesia and the new developments in TAVR, and a newly FDA-approved device for expanding the number of lungs available for transplant.
Also, in our News from the AATS section there is a call for abstracts and videos for AATS Week (comprising the 95th AATS Annual Meeting and the AATS Mitral Conclave), as well as information about signing up for the AATS Leadership Academy and for students and residents to get financial assistance to attend the 95th AATS Annual Meeting.
Click to view our October PDF here or the interactive digital edition.
