Surgical versus non-surgical management for patients with malignant bowel obstruction (S1316): a pragmatic comparative effectiveness trial

BACKGROUND

Malignant small bowel obstruction has a poor prognosis and is associated with multiple related symptoms. The optimal treatment approach is often unclear. We aimed to compare surgical versus non-surgical management with the aim to determine the optimal approach for managing malignant bowel obstruction.

METHODS

S1316 was a pragmatic comparative effectiveness trial done within the National Cancer Trials Network at 30 hospital and cancer research centres in the USA, Mexico, Peru, and Colombia. Participants had an intra-abdominal or retroperitoneal primary cancer confirmed via pathological report and malignant bowel disease; were aged 18 years or older with a Zubrod performance status 0-2 within 1 week before admission; had a surgical indication; and treatment equipoise. Participants were randomly assigned (1:1) to surgical or non-surgical treatment using a dynamic balancing algorithm, balancing on primary tumour type. Patients who declined consent for random assignment were offered a prospective observational patient choice pathway. The primary outcome was the number of days alive and out of the hospital (good days) at 91 days. Analyses were based on intention-to-treat linear, logistic, and Cox regression models combining data from both pathways and adjusting for potential confounders. Treatment complications were assessed in all analysed patients in the study. This completed study is registered with ClinicalTrials.gov, NCT02270450.

FINDINGS

From May 11, 2015, to April 27, 2020, 221 patients were enrolled (143 [65%] were female and 78 [35%] were male). There were 199 evaluable participants: 49 in the randomised pathway (24 surgery and 25 non-surgery) and 150 in the patient choice pathway (58 surgery and 92 non-surgery). No difference was seen between surgery and non-surgery for the primary outcome of good days: mean 42·6 days (SD 32·2) in the randomised surgery group, 43·9 days (29·5) in the randomised non-surgery group, 54·8 days (27·0) in the patient choice surgery group, and 52·7 days (30·7) in the patient choice non-surgery group (adjusted mean difference 2·9 additional good days in surgical versus non-surgical treatment [95% CI -5·5 to 11·3]; p=0·50). During their initial hospital stay, six participants died, five due to cancer progression (four patients from the randomised pathway, two in each treatment group, and one from the patient choice pathway, in the surgery group) and one due to malignant bowel obstruction treatment complications (patient choice pathway, non-surgery). The most common grade 3-4 malignant bowel obstruction treatment complication was anaemia (three [6%] patients in the randomised pathway, all in the surgical group, and five [3%] patients in the patient choice pathway, four in the surgical group and one in the non-surgical group).

INTERPRETATION

In our study, whether patients received a surgical or non-surgical treatment approach did not influence good days during the first 91 days after registration. These findings should inform treatment decisions for patients hospitalised with malignant bowel obstruction.

FUNDING

Agency for Healthcare Research and Quality and the National Cancer Institute.

TRANSLATION

For the Spanish translation of the abstract see Supplementary Materials section.

Effect of Perioperative Palliative Care on Health-Related Quality of Life Among Patients Undergoing Surgery for Cancer: A Randomized Clinical Trial

Importance

Involvement of palliative care specialists in the care of medical oncology patients has been repeatedly observed to improve patient-reported outcomes, but there is no analogous research in surgical oncology populations.

Objective

To determine whether surgeon-palliative care team comanagement, compared with surgeon team alone management, improves patient-reported perioperative outcomes among patients pursuing curative-intent surgery for high morbidity and mortality upper gastrointestinal (GI) cancers.

Design, Setting, and Participants

From October 20, 2018, to March 31, 2022, a patient-randomized clinical trial was conducted with patients and clinicians nonblinded but the analysis team blinded to allocation. The trial was conducted in 5 geographically diverse academic medical centers in the US. Individuals pursuing curative-intent surgery for an upper GI cancer who had received no previous specialist palliative care were eligible. Surgeons were encouraged to offer participation to all eligible patients.

Intervention

Surgeon-palliative care comanagement patients met with palliative care either in person or via telephone before surgery, 1 week after surgery, and 1, 2, and 3 months after surgery. For patients in the surgeon-alone group, surgeons were encouraged to follow National Comprehensive Cancer Network-recommended triggers for palliative care consultation.

Main Outcomes and Measures

The primary outcome of the trial was patient-reported health-related quality of life at 3 months following the operation. Secondary outcomes were patient-reported mental and physical distress. Intention-to-treat analysis was performed.

Results

In total, 359 patients (175 [48.7%] men; mean [SD] age, 64.6 [10.7] years) were randomized to surgeon-alone (n = 177) or surgeon-palliative care comanagement (n = 182), with most patients (206 [57.4%]) undergoing pancreatic cancer surgery. No adverse events were associated with the intervention, and 11% of patients in the surgeon-alone and 90% in the surgeon-palliative care comanagement groups received palliative care consultation. There was no significant difference between study arms in outcomes at 3 months following the operation in patient-reported health-related quality of life (mean [SD], 138.54 [28.28] vs 136.90 [28.96]; P = .62), mental health (mean [SD], -0.07 [0.87] vs -0.07 [0.84]; P = .98), or overall number of deaths (6 [3.7%] vs 7 [4.1%]; P > .99).

Conclusions and Relevance

To date, this is the first multisite randomized clinical trial to evaluate perioperative palliative care and the earliest integration of palliative care into cancer care. Unlike in medical oncology practice, the data from this trial do not suggest palliative care-associated improvements in patient-reported outcomes among patients pursuing curative-intent surgeries for upper GI cancers.

Trial Registration

ClinicalTrials.gov Identifier: NCT03611309.

Surgeon and medical student response to patient death

BACKGROUND

Virtually all surgeons will experience patient death in their practice. Despite this, little is known about how surgeons cope with patient death or its potential adverse impact on surgeons' well-being. Education on how to respond to loss is not often incorporated into current wellness curricula in surgical training. In light of the ongoing COVID-19 pandemic and the significant hospital-related mortality, understanding surgical provider response to patient loss takes on unique import.

METHODS

A retrospective analysis was performed following administration of a 10-item survey that assessed healthcare provider (HCP) experience with patient death, activities used to cope with patient loss, and symptoms HCPs experienced. Participants included surgical faculty, residents, surgical advance practice providers and medical students on their surgical clerkship. Demographic characteristics were recorded: age, gender, academic level. Chi-squared test or Fisher exact test compared proportionality between those that did and did not experience patient loss. Logistic regression generated odds ratios examining impact of patient loss on symptoms experienced and activities engaged in after patient loss.

RESULTS

Fifty-six (75%) respondents experienced patient death. Common responses were to talk with colleagues (71%) and seek comfort from family/friends/partner (55%). Most respondents did not report symptoms related to patient death (53%); burnout was the most common symptom reported (36%). Respondents were less likely to seek interpersonal support for COVID-19-related death (P<0.008). Only 49% of participants received education on coping with patient death.

CONCLUSIONS

Few surgeons receive training related to patient death. Optimal coping strategies are unknown but may mitigate potential negative impacts, including burnout. The data presented here also suggests the need to establish medical education designed to mitigate the distress associated with patient loss.

Palliative Care for American Indians and Alaska Natives: A Review of the Literature

BACKGROUND

Little is known about optimal palliative and end-of-life care for American Indians and Alaska Natives (AIs/ANs).

METHODS

We searched MEDLINE, the Cochrane library, EBSCOhost, (PsycINFO, CINAHL Complete), and the University of New Mexico (UNM) Health Sciences Library and Informatics Center Native Health Database for search terms related to palliative care and AIs/ANs as of December 1, 2015. We included English language, peer-reviewed articles describing palliative care projects, programs, or studies in AI/AN populations or communities. We excluded case series, opinion or reflection pieces, and dissertations and articles addressing Pacific Islanders.

RESULTS

Our search strategy yielded 294 references, of which we included 10 publications. Study methods and outcome measures were heterogeneous, and many studies were small and/or subject to multiple biases. Common themes included the importance of culturally appropriate communication, multiple barriers to treatment, and less frequent use of advance directives than other populations.

CONCLUSIONS

Heterogeneity of study types, population, and small sample sizes makes it hard to draw broad conclusions regarding the best way to care for AIs/ANs. More studies are needed to assess this important topic.

Treatment options and surveillance strategies after therapy for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver and the third leading cause of cancer death worldwide. Recurrence rates after curative intent treatment for HCC are high; 5-year disease-free survival ranges from only 19 to 81 %. There is no direct evidence to guide the optimal frequency and method of surveillance for recurrent HCC after curative intent treatment. In contrast, there is strong evidence supporting both primary screening for HCC in patients with chronic liver disease. After resection, HCC tends to recur locally, whereas the pattern after transplantation is more at extrahepatic sites. In theory, if an HCC recurrence is discovered early, more therapeutic options are available for treatment of the recurrent HCC. As such, close surveillance after curative intent therapy may have the potential to prolong survival. We herein review the available literature derived from primary surveillance of patients with cirrhosis, as well as data on postoperative surveillance of HCC patients. In aggregate, although data remain scarce, close surveillance with α-fetoprotein and cross-sectional imaging every 3-4 months for 3 years after curative intent therapy, followed by surveillance every 6-12 months thereafter, seems the most prudent approach to follow-up of patients with HCC in the postsurgical setting.

Helical Tomotherapy Significantly Reduces Dose to Normal Tissues When Compared to 3D-CRT for Locally Advanced Rectal Cancer

Combined modality treatment (neoadjuvant chemoradiotherapy followed by surgery) for locally advanced rectal cancer requires special attention to various organs at risk (OAR). As a result, the use of conformal dose delivery methods has become more common in this disease setting. Helical tomotherapy is an image-guided intensity modulated delivery system that delivers dose in a fan-beam manner at 7 degree intervals around the patient and can potentially limit normal tissue from high dose radiation while adequately treating targets. In this study we dosimetrically compare helical tomotherapy to 3D-CRT for stage T3 rectal cancer. The helical tomotherapy plans were optimized in the TomoPlan system to achieve an equivalent uniform dose of 45 Gy for 10 patients with T3N0M0 disease that was at least 5cm from the anal verge. The GTV included the rectal thickening and mass evident on colonoscopy and CT scan as well as with the help of a colorectal surgeon. The CTV included the internal iliac, obturator, and pre-sacral lymphatic chains. The OAR that were outlined included the small bowel, pelvic bone marrow, femoral heads, and bladder. Anatom-e system was used to assist in delineating GTV, CTV and OAR. These 10 plans were then duplicated and optimized into 3-field 3D-CRT plans within the Pinnacle planning system. The V[45], V[40], V[30], V[20], V[10], and mean dose to the OAR were compared between the helical tomotherapy and 3D-CRT plans. Statistically significant differences were achieved in the doses to all OAR, including all volumes and means except for V[10] for the small bowel and the femoral heads. Adequate dosimetric coverage of targets were achieved with both helical tomotherapy and 3D-CRT. Helical tomotherapy reduces the volume of normal tissue receiving high-dose RT when compared to 3D-CRT treatment. Both modalities adequately dose the tumor. Clinical studies addressing the dosimetric benefits are on-going.

Transampullary pancreatic duct stenting decreases pancreatic fistula rate following left pancreatectomy

BACKGROUND/AIMS

Significant improvements in mortality following pancreatic surgery have been noted by high-volume centers in recent years. Despite this, morbidity from pancreatic resection remains high, with postoperative pancreatic fistula remaining a common problem following distal pancreatectomy (DP). Rates of pancreatic fistula following distal pancreatectomy have ranged from 0 to 61% in a recent meta-analysis of surgical techniques and impact upon pancreatic fistula rates. We postulated that intraoperative placement of a transampullary pancreatic duct stent (TAPDS) at the time of distal pancreatectomy, would decrease ampullary complex-mediated elevation in pancreatic duct pressures, improve healing of the ligated pancreatic duct and result in a decrease in pancreatic fistula following distal pancreatectomy.

METHODOLOGY

Sixteen consecutive patients underwent distal pancreatectomy plus TAPDS and were compared to 43 control patients who underwent distal pancreatectomy by the same surgeon, with identical management of the pancreatic remnant. Distal pancreatectomy was performed as the primary operation or as part of an en-bloc resection for a primary malignancy other than pancreatic adenocarcinoma. In patients who underwent transampullary pancreatic duct stenting (TAPDS), the pancreatic duct was identified after transection of the pancreatic parenchyma. A soft, pediatric feeding tube was inserted directly into the pancreatic duct and carefully fed into the duodenum (confirmed by palpation). The stent was placed distally, one centimeter from the cut-edge of the pancreatic duct, which was then ligated as described earlier. Closure of the pancreatic parenchyma was identical to those patients who did not undergo TAPDS placement. Common perioperative outcomes were assessed, including pancreatic fistula.

RESULTS

No statistically significant differences where found between the rates of intraabdominal abscess, intraabdominal hemorrhage or need for reoperation. Pancreatic fistula rates and average length of stay were significantly decreased in patients undergoing distal pancreatectomy with TAPDS (p<0.05 and p<0.0001 respectively).

CONCLUSIONS

Statistically significant reductions in pancreatic fistula and average length of stay were noted in patients who underwent stenting of the pancreatic duct with TAPDS.

Cytochrome c release from brain mitochondria is independent of the mitochondrial permeability transition

Ca2+ uptake by brain mitochondria induces the release of up to 40% of total cytochrome c in a cyclosporin A-insensitive manner. In the presence of ATP and Mg2+, this process is not accompanied by mitochondrial swelling. There is a moderate decrease in membrane potential under these conditions, but it is completely reversible upon removal of accumulated Ca2+ by addition of EGTA+A23187 but not by EGTA alone. These observations provide evidence that cytochrome c release from brain mitochondria does not require the membrane permeability transition. However, brain mitochondria can undergo the permeability transition in the absence of ATP and Mg2+, which results in cyclosporin A-sensitive large amplitude swelling, loss of Ca2+ uptake capacity and release of matrix solutes.

Epidemiology and molecular genetics of colorectal cancer

Colorectal cancer is among the most common cancers affecting the western world. By the age of 70 yr, at least 50% of the Western population will develop some form of colorectal tumor, spanning the spectrum from an early benign polyp to an invasive adenocarcinoma. It is estimated that approximately 10% of the benign polypoid lesions will progress to invasive carcinoma. The concept that serial genetic changes are responsible for the transition from benign to neoplastic disease is not new. The description of hereditary cancers and the demonstration of carcinogenic substances inducing DNA damage have provided the foundation for the field of molecular oncology. During the past three decades, our understanding of how genetic alterations culminate in cancer has progressed rapidly, though the complete process has not been fully defined. The research to date has spanned many oncologic diseases, but has been especially well defined in colorectal cancer. The knowledge of the genetic alterations that result in colorectal cancer has important ramifications for future prevention, detection, and treatment of this disease.

Outcomes of advance directive education of pulmonary rehabilitation patients

We performed a two-site prospective, controlled interventional study of patients enrolled in pulmonary rehabilitation to assess effects of advance directive education on completion of (1) living wills, (2) durable powers of attorney for health care (DPAHC), (3) patient-physician discussions about advance directives, and (4) discussions about life support, in addition to (5) patient impressions that their physicians understood their end-of-life preferences. The educational group had an increase (p < 0.05) in all five study outcomes compared with baseline values; the control group had an increase in three of five outcomes. The effect strength was greater in the educational compared with the control group for completion of DPAHC (odds ratio [OR] = 3.6, 95% confidence interval [CI] 1.1 to 12.9), advance directive discussions (OR = 2.9, 95% CI 1.1 to 8.3), initiation of life-support discussions (OR = 2.7, 95% CI 1.0 to 7.7), and development of patient assurance that their physicians understand their preferences (OR = 3.7, 95% CI 1.3 to 13.4). The educational intervention was an independent explanatory factor by multivariate analysis. We conclude that patients enrolled in pulmonary rehabilitation are receptive to advance care planning, which is promoted by education on end-of-life issues.

Attitudes regarding advance directives among patients in pulmonary rehabilitation

We performed a cross-sectional, descriptive questionnaire study in two pulmonary rehabilitation programs to assess: (1) attitudes of 105 subjects with chronic lung conditions about end-of-life decision-making; (2) the determinants of these attitudes; and (3) patient acceptance of rehabilitation programs as foci for education about advance directives (ADs). We found that 99 of the 105 subjects (94.3%) had health worries, the most common of which was fear of increasing dyspnea (33.3%). Although 93.8% had opinions about intubation, less than 42% had completed an AD. Most subjects wanted information about ADs (88.6%) and life-support (68.6%); pulmonary rehabilitation programs, lawyers, and physicians were preferred sources for AD information. Although 98.9% of the patients wanted patient-physician AD discussions, only 19.0% had such discussions, only 15.2% had discussed life-support, and only 14.3% thought that their physicians understood their end-of-life wishes. Subject willingness to undergo intubation varied with baseline health, likelihood of survival, and anticipated health following extubation. We conclude that patients in pulmonary rehabilitation programs desire more information about end-of-life issues than is currently provided by physicians. They regard pulmonary rehabilitation educators as valuable sources of AD education.

Advance directive education during pulmonary rehabilitation

We conducted a questionnaire survey of 346 pulmonary rehabilitation programs to determine the present utilization and potential value of these sites for promoting advance directive education for patients with chronic lung diseases. Responses were analyzed for all responding programs and for programs categorized by size. Eighty-two percent of the 218 responding programs discussed with patients prognostic information. Only 33% of programs asked patients if they had advance directives and 17% kept these documents on file. Thirty-three percent of programs provided some form of advance directive education, and 42% distributed directive educational material, usually through informal and unstructured methods. Seventy-seven percent of responders considered pulmonary rehabilitation an appropriate site for directive education, and 86% indicated willingness to incorporate directive education into their programs. Larger programs were more likely to present information about patient prognosis (p = 0.0003) and advance directives (p = 0.021). We conclude that most of the responding pulmonary rehabilitation programs do not educate patients about advance directives but are willing to do so if supplied with appropriate teaching materials. Rehabilitation programs may be valuable sites for educating patients with chronic disorders about advance directives and promoting an improved patient-physician dialogue about these issues.

Efficacy of tracheal insufflation of oxygen during oleic acid-induced pulmonary edema

STUDY OBJECTIVES

To determine whether tracheal insufflation of oxygen (TRIO) might be useful in field resuscitation of casualties with lung dysfunction.

DESIGN

Physiological measurements of cardiac and respiratory function were compared before and after oleic acid lung injury.

SETTING AND PARTICIPANTS

Beagles were studied in a laboratory.

INTERVENTIONS

Oleic acid (0.06 mL/kg) was injected over four minutes into the central venous port of a pulmonary artery catheter. Measurements were made during 30 minutes of TRIO before and after acute lung injury.

MEASUREMENTS

Hemodynamic and respiratory measurements, including intravascular pressures, heart rate, cardiac output, blood gases, respiratory system compliance, and O2 consumption were recorded during conventional mechanical ventilation and TRIO.

RESULTS

Before acute lung injury, PaO2 (mean +/- SD) increased (P less than .05) from 96 +/- 7.4 (13 +/- 1.0 kPa) during conventional mechanical ventilation to 360 +/- 123 mm Hg (48 +/- 16.4 kPa) after TRIO. PaCO2 (mean +/- SD) increased (P less than .05) from 39.5 +/- 1.1 (5.3 +/- 0.1 kPa) to 102 +/- 27.4 mm Hg (13.6 +/- 3.6 kPa). Arterial and mixed venous pH values decreased in proportion to PCO2. After acute lung injury, compliance decreased. PAO2 decreased (P less than .05) to 58 +/- 8.4 mm Hg (7.7 +/- 1.1 kPa) during conventional mechanical ventilation and increased (P less than .05) to 84 +/- 19.6 mm Hg (11.2 +/- 2.6 kPa) after 30 minutes of TRIO.

CONCLUSION

Despite poor gas exchange after acute lung injury, TRIO maintained adequate oxygenation and may be useful for emergency ventilation even when pulmonary edema complicates resuscitation.

Cocaine use and psychopathology: associations among young adults

Cocaine use has been associated with psychopathology in clinic and treatment samples and among chronic, excessive users. These relationships have been tested rarely in general epidemiological samples. This study examines the association between cocaine involvement and numerous measures of psychopathology in general community sample of 739 young adults. There were no sex differences in level of cocaine involvement, nor on associations between cocaine use and psychopathology. There were several small relationships between cocaine use and several indicators of psychopathology (i.e., increased sleep disturbance, decreased panic and phobia symptoms, a lack of purpose in life, increased psychotic proneness). It appears that the severe psychopathology associated with cocaine use often cited in the literature is the result of using clinic or treatment samples or chronic abusers, and that such strong associations are not apparent in the general population of young adults with relatively brief cocaine use careers.