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A multimodality approach to enhance recovery after bowel surgery is demonstrated to reduce complications and decrease patient length of stay (LOS). This study evaluates the factors that influence patient LOS within a formal enhanced recovery protocol. From January 2014 to December 2016, all consecutive patients admitted to one ward, who had undergone bowel resection and were enrolled in an enhanced recovery protocol, were evaluated prospectively. We entered every patient's data into the American College of Surgeons Risk Calculator (ACSRC) to compare predicted versus actual outcomes. Statistical analysis of clinical factors, patient participation, and outcomes compared with the overall LOS was performed. Of 670 bowel resections performed during the study period, a total of 127 (19%) patients met the criteria and were analyzed for comorbidities, type of surgery, complications, and participation in recovery protocols. The median length of stay (mLOS) for all patients was 4.0 days (1.8–24.6 days). Factors influencing mLOS included laparoscopic versus open surgery (P = 0.006), COPD (P = 0.003), missing 24 hours of ambulation (P < 0.001), use of patient-controlled analgesia (P = 0.011), and diagnosis of insulin-dependent diabetes mellitus (P = 0.041). Increasing the use of morphine equivalents (MEs) increased mLOS beyond the ACSRC estimate (P = 0.003). Developing a major complication increased mLOS by 8.5 times the ACSRC estimate. Conclusion: A multimodality approach to enhance surgical recovery after bowel surgery decreases the LOS. The surgical approach, participation in ambulation, insulin-dependent diabetes mellitus, and COPD influenced the overall LOS. Increasing use of morphine equivalents and developing a complication increased mLOS beyond the ACSRC preoperative risk estimates.

Background Merkel cell carcinoma (MCC) is associated with Merkel cell polyomavirus (MCPyV) infection. MCPyV antibodies (MCPyV-Ab) in plasma correlate with survival, while MCPyV-Ab within the tumor has never been investigated. This study evaluated plasma MCPyV-Ab and tumor MCPyV-Ab titers to evaluate their role in outcomes and prognostication. Methods A single-institution, prospective database was retrospectively reviewed for patients diagnosed with MCC from 2014 to 2021. MCPyV-Ab plasma and tumor titers, as well as patient and treatment factors, were collected. Two-year overall survival (OS) and disease-free survival (DFS) were examined based on MCPyV-Ab presence in tumor. Results Forty patients were identified, with a median follow-up of 27.6 months. Patients were stratified into four groups based on the presence of MCPyV-Ab in plasma (P+, P−) and tumor (T+, T−). Most patients (60.0%) were P−/T−. Of the remaining patients, 22.5% were P+/T+, 12.5% were P−/T+, and 5.0% were P+/T−. Two-year DFS of the P−/T− group was 16.6 months, which was not different from the other groups ( p  = 0.79). Two-year OS of P−/T− was 18.3 months, and 2-year OS of P−/T+ was 28.1 months, which was similar between groups ( p  = 0.80). Conclusions Most patients P+ for MCPyV had antibody-positive tumors (T+), and P− patients were also T−; however, there was a subset of patients where plasma and tumor antibody findings were incongruent. Patients with MCPyV-Ab in either plasma or tumor had a trend toward improved 2-year DFS and OS, but was limited by a small cohort. This study offers an exploratory investigation into the relationship between plasma and tumor antibodies to MCPyV on which to base future work.

BackgroundMerkel cell polyomavirus (MCPyV) is associated with the development of Merkel cell carcinoma (MCC). Antibody (MCPyV-Ab) titers may have prognostic implications. This study evaluated the impact of the presence or absence of MCPyV-Ab on the 2-year overall survival (OS) and disease-free survival (DFS) of MCC patients. MethodsThis single-center, IRB-approved, retrospective cohort study evaluated 51 adult patients with MCC from 2014 to 2021 using a prospectively maintained database. Patients were compared by MCPyV-Ab status, and Kaplan-Meier analysis was used to evaluate 2-year OS and DFS.ResultsOf the 51 patients, 13 (25.4%) were seropositive, 41 (80.4%) underwent wide excision, 40 (80.0%) received radiotherapy, and 43 (84.3%) received multimodal therapy. The median follow-up period was 15.5 months (range 1–69.5 months). The median 2-year OS of the entire cohort was not reached. The median 2-year OS was not reached for either the seronegative or the seropositive patients. The difference in 2-year OS between the groups was not statistically significant (p = 0.37). Eight patients, all seronegative, were never rendered disease-free and were removed from recurrence analysis. The seropositive patients experienced no recurrences. Of the 30 seronegative patients, 9 (30.0%) experienced recurrence. The median 2-year DFS of the entire cohort was not reached. The median 2-year DFS of the seronegative group was 22.2 months. The 2-year DFS was not reached for the seropositive cohort. Seropositivity conferred a significantly better 2-year DFS than seronegativity (p = 0.04).ConclusionThe MCPyV-Ab seropositive patients demonstrated improved 2-year DFS. The seropositive patients showed a strong trend toward improved 2-year OS, although the difference not statistically significant. This study substantiated the value of MCPyV-Ab assessment for MCC.

On occasion, patients followed with positron emission tomographic (PET)/computed tomographic (CT) imaging for nonbreast malignancies will have incidental breast findings concerning for second primary breast cancers. The aim of this study was to determine the predictive value of PET/CT imaging to identify breast cancers in these patients. Patients with primary nonbreast malignancies and findings concerning for second primary breast cancers were identified from a prospectively acquired nuclear medicine database from January 2005 to July 2008. Chart reviews were then performed. Nine hundred two women underwent PET/CT imaging to evaluate nonbreast malignancies. Nine women (1%) had concerning breast findings, and 5 (56%) had subsequent breast cancer diagnoses. The positive predictive value of PET/CT imaging in these patients was 63%. Evidence of compliance with current screening guidelines was present in only 22% of these patients. The data suggest that findings concerning for an additional primary breast cancer should be evaluated and that age-appropriate screening tools should not be abandoned.

An intraductal tubular carcinoma is a rare entity in which the pancreatic duct reveals a nodular or polypoid appearance with a monotonous tubular growth pattern and without papillary projection or mucin hypersecretion, whereas, in comparison, IPMNs are usually mucus-secreting tumors with dilatation of or around the main pancreatic duct.3 On histologic examination, intraductal tubular carcinoma cells tend to demonstrate a tubular growth pattern with cuboidal tumor cells resembling pancreatic ducts and no similarity to goblet cells, versus IPMNs that tend to show papillary projections of mucin-producing cells with a stromal stalk.3 Radiographic variation between the two entities is also noted; IPMNs are primarily associated with downstream dilation of the pancreatic duct because of mucin hypersecretion, whereas intraductal tubular carcinomas tend to result in obstructive dilation of the upstream main pancreatic duct. When a nonmucinous mass that produces upstream dilation of the main pancreatic duct is noted, intraductal tubular carcinomas should be considered. Because it has a better prognosis than other malignant entities within the pancreas, further research is needed to determine whether intraductal tubular carcinomas should be separately classified from IPMNs by defining more specific diagnostic criteria.

Skin substitutes have shown success in complex wound reconstruction. We evaluate the use of a human acellular dermal matrix (ADM) as a viable alternative to autologous skin grafting for defects secondary to skin cancer excision. An institutional review board–approved, retrospective review of ADM-reconstructed defects secondary to skin cancer excision between 2012 and 2018 was conducted. ADM was indicated in patients with preclusive factors for general anesthesia, protracted procedure time, reluctance for additional donor site wound, and personal choice. We reviewed defect characteristics, healing time, postoperative outcomes, and patient demographics. The 228 participants (151 males, 77 females) had a median age of 72 years (range, 29–95 years), with melanoma diagnosed in 113 (49.6%), squamous cell carcinoma in 61 (26.8%), and basal cell carcinoma in 28 (12.2%) patients. The median interval to complete epidermal coverage was 42 days, with graft failure evident in six patients (2.6%). ADM is a viable, low-morbid alternative for reconstruction of defects secondary to skin cancer excision, with no donor site morbidity. With exception to complete healing time, outcomes are similar to those of autologous grafting.

Postoperative pain managed with opioids has contributed to the opioid crisis through over-prescribing practices. We assessed opioid-prescribing habits and their use by patients undergoing surgery for cutaneous malignancies. An Institutional Review Board–approved retrospective analysis was conducted for patients who underwent skin cancer resection between January 2018 and June 2018. Data were collected from the electronic medical record, and opioid-related data were collected from patient interviews and state registries. There were 120 study participants (42 females and 78 males) with a median age of 67 years (range, 21–94 years). All received preincision local anesthetic: 64 had liposomal bupivacaine (LB) (53%) and 56 had non-LB bupivacaine (47%). Most participants (n = 88) used 0 opioids (73%), including 43 LB-anesthetic (67%) and 45 non–LB-anesthetic (80%). No significance was seen between those with a diagnosis of chronic pain, narcotic tolerance, an area of resection, and nodal sampling groups in opioid use. Four patients (3%) requested a refill. Of 105 prescriptions written for opioids, 99 had leftover opioids for an over-prescribing rate of 94 per cent. This study suggests pain after skin cancer surgery is manageable with very limited opioid requirements. Our results support prescribing no more than five opioid tablets for postoperative pain control in patients undergoing resection for skin malignancies.

Pneumatosis intestinalis (PI) identified on computed tomography (CT) suggests an underlying pathology including bowel ischemia. Patients receiving tube feeds can develop PI, potentially requiring surgical intervention. We identify clinical factors in PI to predict those that may be safe to observe versus those that need immediate intervention. We retrospectively reviewed patients from a single institution from 2008 to 2016 with CT findings of PI and an enteric feeding tube. Patients who had not received tube feeds within one week of the CT were excluded. We analyzed clinical, operative, and outcome data to differentiate benign from pathologic outcomes. P values < 0.05 were set as significant. Forty patients were identified. We classified 24 as benign (no intervention) and 16 as pathologic (requiring intervention). A pathologic outcome was demonstrated for free fluid on CT [odds ratio (OR) = 5.00, confidence interval (CI) 1.23-20.30, P = 0.03)], blood urea nitrogen (BUN) elevation (OR = 8.27, CI 1.53-44.62, P = 0.01), creatinine (Cr) elevation (OR = 5.00, CI 1.27-19.62, P = 0.02), BUN/Cr ratio >30 (OR = 8.57, CI 1.79-40.98, P = 0.006), and vomiting/ feeding intolerance (OR = 9.38, CI 1.64-53.62, P = 0.01). Bowel function within 24 hours of the CT, bowel dilatation (small ≥ 3 cm; large ≥6 cm), and lactic acidemia were not significant. Peritonitis was only seen in pathologic states, but this did not reach statistical significance (P = 0.06). This represents the largest single-center retrospective analysis of tube feeding-induced PI to date. The presence of free fluid on CT, BUN and Cr elevation, BUN/Cr >30, vomiting/feeding intolerance and peritonitis were predictive of a pathologic etiology of PI.

Background Incidences of esophageal cancer and obesity are both rising in the United States. The aim of this study was to determine the influence of elevated body mass index on outcomes after esophagectomy for cancer. Methods Overall and disease-free survivals in obese (BMI ≥ 30), overweight (BMI 25–29), and normal-weight (BMI 20–24) patients undergoing esophagectomy constituted the study end points. Survivals were calculated by the Kaplan–Meier method, and differences were analyzed by log rank method. Results The study included 166 obese, 176 overweight, and 148 normal-weight patients. These three groups were similar in terms of demographics and comorbidities, with the exception of younger age (62.5 vs. 66.2 vs. 65.3 years, P  = 0.002), and higher incidence of diabetes (23.5 vs. 11.4 vs. 10.1%, P  = 0.001) and hiatal hernia (28.3 vs. 14.8 vs. 20.3%, P  = 0.01) in obese patients. Rates of adenocarcinoma histology were higher in obese patients (90.8 vs. 90.9 vs. 82.5%, P  = 0.03). Despite similar preoperative stage, obese patients were less likely to receive neoadjuvant treatment (47.6 vs. 54.5 vs. 66.2%, P  = 0.004). Response to neoadjuvant treatment, type of surgery performed, extent of lymphadenectomy, rate of R0 resections, perioperative complications, and administration of adjuvant chemotherapy were not influenced by BMI. At a median follow-up of 25 months, 5-year overall and disease-free survivals were longer in obese patients (respectively, 48, 41, 34%, P  = 0.01 and 48, 44, 34%, P  = 0.01). Conclusions In our experience, an elevated BMI did not reduce overall and disease-free survivals after esophagectomy for cancer.

Cytoreductive therapy for metastatic carcinoid provides symptomatic relief and improvement in overall survival. We evaluated whether CgA and 5HIAA could predict symptomatic relief and control of disease progression after cytoreductive surgery. We retrospectively reviewed 70 patients who underwent cytoreductive surgery for neuroendocrine hepatic metastases between 1996 and 2005. Twenty-two patients had pre and post-operative CgA and/or 5HIAA levels measured. Reduction of biomarkers following cytoreduction was correlated with patient symptoms and progression of disease following surgery. Our study consisted of 14 males and 8 females with a mean age of 55 (+/-12 years). Median follow-up was 18 months (range 5-64 months). Six patients (26.1%) had complete (R0) cytoreduction, while 4 (17.4%) and 13 (56.5%) had microscopic (R1) and gross (R2) disease remaining. All patients reported improvements in their symptoms, with 12 (54.5%) reporting complete resolution (CR) and 10 (45.5%) reporting partial resolution (PR). Reduction of CgA of >or= 80% was highly predictive of complete resolution of symptoms (P = 0.007) and stabilization of disease (P = 0.034). Reduction of 5HIAA levels of >or= 80% (or normalization) was predictive of symptomatic relief, but not progression of disease (P = 0.026 and P = 0.725). Five of six patients who had R0 resections had CR and were free of disease at last follow-up (median 24.5 months, range: 11-48, P = 0.002). We conclude that >or= 80% reduction in CgA level following cytoreductive surgery for carcinoid tumors is predictive of subsequent symptom relief and disease control. Substantial reduction in CgA is associated with improved patient outcomes, even after incomplete cytoreduction.