Shariq, Omair A.

Adrenocortical carcinoma (ACC) is a rare, aggressive malignancy with an annual incidence of ~1 case per million population. Differentiating between ACC and benign adrenocortical tumors can be challenging in patients who present with an incidentally discovered adrenal mass, due to the limited specificity of standard diagnostic imaging. Recently, urine steroid metabolite profiling has been prospectively validated as a novel diagnostic tool for the detection of malignancy with improved accuracy over current modalities. Surgery represents the only curative treatment for ACC, although local recurrence and metastases are common, even after a margin-negative resection is performed. Unlike other intra-abdominal cancers, the role of minimally invasive surgery and lymphadenectomy in ACC is controversial. Adjuvant therapy with the adrenolytic drug mitotane is used to reduce the risk of recurrence after surgery, although evidence supporting its efficacy is limited; it is also currently unclear whether all patients or a subset with the highest risk of recurrence should receive this treatment. Large-scale pan-genomic studies have yielded insights into the pathogenesis of ACC and have defined distinct molecular signatures associated with clinical outcomes that may be used to improve prognostication. For patients with advanced ACC, palliative combination chemotherapy with mitotane is the current standard of care; however, this is associated with poor response rates (RR). Knowledge from molecular profiling studies has been used to guide the development of novel targeted therapies; however, these have shown limited efficacy in early phase trials. As a result, there is an urgent unmet need for more effective therapies for patients with this devastating disease.

BACKGROUND: Discharge on postoperative day 3 after laparoscopic colorectal resections is now common, and same-day discharge has been proposed recently as an option. OBJECTIVE: The purpose of this study was to determine the safety of same-day and next-day discharge after laparoscopic colorectal surgery and to delineate which characteristics may make a patient eligible for this pathway. DESIGN: This was a retrospective cohort study. SETTINGS: The American College of Surgeons National Surgical Quality Improvement Project Targeted Colectomy Participant User File was used. PATIENTS: Patients underwent elective laparoscopic colorectal resection and were discharged without complications on or before postoperative day 5 (early discharge: postoperative day 0 or 1, intermediate: postoperative day 2, standard: postoperative day 3 to 5). MAIN OUTCOME MEASURES: Early readmission (on or before postoperative day 7), anastomotic leak, ileus, and overall readmission were measured. RESULTS: Of 36,526 patients total, 906 (2.5%) were discharged on postoperative day 0 or 1. Patients discharged on postoperative day 0/1 tended to have shorter-duration operations, a diagnostic indication more commonly of benign neoplasm, and underwent less low pelvic anastomoses. The readmission rate within 7 days was only 2%. Overall rates of anastomotic leak (0.6% early, 1.0% intermediate, 1.2% standard), ileus (1.9% early, 1.5% intermediate, 2.1% standard), and readmission (early 4.8%, intermediate 5.1%, standard 5.8%) were equivalent to decreased in patients discharged early versus those discharged in the intermediate or standard discharge groups. On multivariable analysis, dismissal day remained a noncontributory-to-protective factor against anastomotic leak, ileus, and readmission. LIMITATIONS: Specific follow-up pathways used were unknown, and selection bias exists in deciding what day patients can be discharged. CONCLUSIONS: Discharge on the same day or next day after surgery was not associated with increased risk compared with discharge on postoperative day 3 to 5, and it did not result in a high rate of early readmissions. Increased use of expedited discharge pathways would reduce hospital costs and resource use. See Video Abstract at http://links.lww.com/DCR/B331. ¿Es razonable el alta el mismo día o al día siguiente, después de la colectomía laparoscópica en pacientes seleccionados ANTECEDENTES: Es común el alta hospitalaria en el 3er día postoperatorio, después de resecciones colorrectales laparoscópicas. Recientemente se ha propuesto como una opción, el alta el mismo día. OBJETIVO: Determinar la seguridad de alta el mismo día o al día siguiente después de la cirugía colorrectal laparoscópica, y delinear qué características pueden hacer que un paciente sea elegible para esta vía. DISEÑO: Estudio de cohorte retrospectivo. AJUSTES: American College of Surgeons National Surgical Quality Improvement Project Targeted Colectomy Participant User File. PACIENTES: Se sometieron a resección colorrectal laparoscópica electiva, y se dieron de alta sin complicaciones durante el 5° día postoperatorio o antes (alta temprana: día 0 o 1 postoperatorio; intermedia: día 2 postoperatorio; estándar: día 3-5 postoperatorio). PRINCIPALES MEDIDAS DE RESULTADO: Reingreso temprano (en o antes del día 7 postoperatorio), fuga anastomótica, íleo y reingreso general. RESULTADOS: De 36,526 pacientes en total, 906 (2.5%) fueron dados de alta en el día 0 o 1 postoperatorio. Los pacientes dados de alta en el día 0/1 postoperatorio, tendieron a presentar operaciones de menor duración, indicación diagnóstica más frecuente de neoplasia benigna, y sometidos a menos anastomosis de pelvis baja. La tasa de readmisión dentro de los siete días, fue del 2%. Las tasas generales de fuga anastomótica (0.6% temprana, 1.0% intermedia, 1.2% estándar), íleo (1.9% temprana, 1.5% intermedia, 2.1% estándar) y reingreso (temprana 4.8%, intermedia 5.1%, estándar 5.8%) fueron equivalentes a la disminución en pacientes dados de alta temprana, versus aquellos dados de alta en los grupos intermedia o estándar. En el análisis multivariable, el día de alta no contribuyó al factor protector contra la fuga anastomótica, el íleo y el reingreso. LIMITACIONES: Se desconocen las vías de seguimiento específicas utilizadas y existe un sesgo de selección al decidir en qué día se puede dar de alta a los pacientes. CONCLUSIONES: El alta el mismo día o al día siguiente después de la cirugía, no se asoció con un mayor riesgo, en comparación con el alta en el postoperatorio en los días 3-5, y no dio lugar a una alta tasa de reingresos tempranos. Mayor utilización de las vías de alta acelerada, reducirían costos hospitalarios y utilización de recursos. Consulte Video Resumen en http://links.lww.com/DCR/B331. (Traducción—Dr Fidel Ruiz Healy)

AbstractBackgroundAdhesive small bowel obstruction (ASBO) severity has been associated with important clinical outcomes. However, the impact of ASBO severity on hospitalization cost is unknown. The American Association for the Surgery of Trauma (AAST) developed an Emergency General Surgery (EGS) disease severity grading system for ASBO. We stratified patients’ ASBO severity and captured hospitalization costs hypothesizing that increased disease severity would correlate with greater costs.MethodsThis was a single‐center study of hospitalized adult patients with SBO during 2015–2017. Clinical data and estimated total cost (direct + indirect) were abstracted. AAST EGS grades (I–IV) stratified disease severity. Costs were normalized to the median grade I cost. Univariate and multivariate analyses evaluated the relationship between normalized cost and AAST EGS grade, length of hospital and ICU stay, operative time, and Charlson comorbidity index.ResultsThere were 214 patients; 119 (56%) were female. AAST EGS grades included: I (62%, n = 132), II (23%, n = 49), III (7%, n = 16), and IV (8%, n = 17). Relative to grade I, median normalized cost increased by 1.4‐fold for grade II, 1.6‐fold for grade III, and 4.3‐fold for grade IV disease. No considerable differences in patient comorbidity between grades were observed. Pair‐wise comparisons demonstrated that grade I disease cost less than higher grades (corrected p < 0.001). Non‐operative management was associated with lower normalized cost compared to operative management (1.1 vs. 4.5, p < 0.0001). In patients who failed non‐operative management, normalized cost was increased 7.2‐fold. Collectively, the AAST EGS grade correlated well with cost (Spearman's p = 0.7, p < 0.0001). After adjustment for covariates, AAST EGS grade maintained a persistent relationship with cost.ConclusionIncreasing ASBO severity is independently associated with greater costs. Efforts to identify and mitigate costs associated with this burdensome disease are warranted.Level of evidenceIII, economic/decision.

AbstractIntroductionPatients undergoing unilateral adrenalectomy for primary aldosteronism (PA) may have a solitary adenoma, unilateral hyperplasia, or multiple adenomas on final pathology. This study investigated whether the underlying pathological diagnosis was associated with differences in clinical presentation and postoperative outcomes.MethodsA retrospective cohort study of patients undergoing unilateral adrenalectomy for PA from 2004 to 2015 at our institution was performed. Baseline clinical and laboratory parameters, as well as postoperative biochemical and hypertension cure rates, were compared across the three aforementioned pathological groups.ResultsOf 206 patients who met criteria for inclusion, 152 (73.8%) had a single adenoma, 33 (16%) had unilateral hyperplasia, and 21 (10.2%) had multiple unilateral adenomas. Patients with unilateral hyperplasia were more likely to be male (81.2% vs 57.9%, P = .03), undergo left‐sided adrenalectomy (78.8% vs 47.4%, P < .01), and had a lower median adrenal venous sampling lateralization index (9.8 vs 19.8, P = .04) compared to those with solitary, but not multiple unilateral adenomas. No differences were seen in age, duration of hypertension, preoperative plasma aldosterone levels, plasma renin activities, 24‐h urinary aldosterone excretion, serum potassium concentrations, and the number of preoperative antihypertensive medications across all three pathological groups. All patients achieved biochemical cure following adrenalectomy, and no significant differences in the rates of hypertension cure or improvement were observed in comparisons across pathological subtype.ConclusionsClinical presentation and postoperative outcomes are similar regardless of underlying pathology in patients with PA. Because one in four patients may harbor unilateral hyperplasia or multiple adenomas, total unilateral adrenalectomy should be performed as the operation of choice over adrenal‐sparing approaches.

BACKGROUND: Metabolic syndrome is associated with poorer postoperative outcomes after various abdominal operations. However, the impact of metabolic syndrome on outcomes after colorectal cancer surgery remains poorly described. OBJECTIVE: The purpose of this study was to determine the association between metabolic syndrome and short-term postoperative outcomes in patients undergoing elective colorectal cancer surgery. DESIGN: This was a retrospective cohort study. SETTINGS: This study used a national multicenter database. PATIENTS: Adult patients who underwent elective colectomy for colorectal cancer from 2010 to 2016 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. MAIN OUTCOME MEASURES: Thirty-day postoperative mortality and morbidity, unplanned reoperation, unplanned readmission, operative time, and length of stay were measured. RESULTS: A total of 91,566 patients were analyzed; 7603 (8.3%) had metabolic syndrome. On unadjusted analysis, metabolic syndrome was associated with an increased risk of 30-day overall morbidity, pulmonary complications, renal complications, septic complications, cardiac complications, wound complications, blood transfusion, longer length of stay, and unplanned readmissions. On multivariable analysis, metabolic syndrome remained significantly associated with renal complications (OR = 1.44 (95% CI, 1.29–1.60)), superficial surgical site infection (OR = 1.46 (95% CI, 1.32–1.60)), deep surgical site infection (OR = 1.40 (95% CI, 1.15–1.70)), wound dehiscence (OR = 1.47 (95% CI, 1.20–1.80)), and unplanned readmissions (HR = 1.24 (95% CI, 1.15–1.34)). The risks of overall morbidity, cardiac and septic complications, and prolonged length of stay for laparoscopic procedures were significantly associated with diabetes mellitus rather than metabolic syndrome as a composite entity. LIMITATIONS: This study was limited by its retrospective design and inability to analyze outcomes beyond 30 days. CONCLUSIONS: Patients with metabolic syndrome undergoing elective surgery for colorectal cancer have an increased risk of 30-day postoperative renal complications, wound complications, and unplanned hospital readmissions. A multidisciplinary approach involving lifestyle modifications and pharmacologic interventions to improve the components of metabolic syndrome should be implemented preoperatively for these patients. See Video Abstract at http://links.lww.com/DCR/A909.