Publications by authors named "Vijaya Gottumukkala"

57 Publications

Scaling an Enhanced Recovery Program to an Institution-Wide Initiative: It Takes a Village.

Qual Manag Health Care 2021 Jul-Sep 01;30(3):200-206

Department of Anesthesiology and Perioperative Medicine (Dr Gottumukkala), Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston (Drs Kruse and Aloia, Mss Recinos and Amaku, and Mr Eska); and Department of Management, W. P. Carey School of Business at Arizona State University, Tempe (Dr Luciano).

Background And Objective: With the inclusion of Enhanced Recovery Programs (ERPs) into routine clinical practice, scaling programs across an institution is important to drive sustainable change in a patient-centric care delivery paradigm. A review of ERP implementation within a large institution was performed to understand key components that hinder or facilitate success of scaling an ERP.

Methods: From January 2018 to March 2018, a needs assessment was completed to review implementation of enhanced recovery across the institution. Implementation progress was categorized into one of 5 phases including Define, Implement, Measure, Analyze, and Optimize.

Results: Only 25% of service line ERPs reached the optimization phase within 5 years. One hundred percent of respondents reported more strengths (n = 41) and opportunities (n = 41) than weaknesses or threats (n = 25 and 14, respectively). Commonly identified strengths included established enhanced recovery pathways, functional team databases, and effective provider education. Weaknesses identified were inconsistencies in data quality/collection and a lack of key personnel participation including buy-in and time availability. Respondents perceived the need for data standardization to be an opportunity, while personnel factors were viewed as key threats.

Conclusion: Identification of strengths, weaknesses, opportunities, and threats could prove beneficial in helping scale an ERP across an institution. Successful optimization and expansion of ERPs require robust data management for continuous quality improvement efforts among clinicians, administrators, executives, and patients.
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http://dx.doi.org/10.1097/QMH.0000000000000306DOI Listing
May 2021

Development of a patient-reported outcome tool for assessing symptom burden during perioperative care in liver surgery: The MDASI-PeriOp-Hep.

Eur J Oncol Nurs 2021 Apr 28;52:101959. Epub 2021 Apr 28.

Institute for Cancer Care Innovation, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Purpose: Based on the MD Anderson Symptom Inventory (MDASI), we developed a Patient-reported outcomes tool for hepatectomy perioperative care (MDASI-PeriOp-Hep).

Methods: To establish the content validity, we generated PeriOp-Hep-specific candidate items from qualitative interviews of patients (n = 30), and removed items that lacked clinical relevance on the basis of input from panels of patients, caregivers, and clinicians. The psychometric properties of the MDASI-PeriOp-Hep were validated (n = 150). The cognitive debriefing and clinical interpretability were assessed to confirm the ease of comprehension, relevance, and acceptability of the tool.

Results: Five symptoms specific to hepatectomy (abdominal bloating, tightness, or fullness; abdominal cramping; muscle weakness, instability, or vertigo; constipation; and incisional tightness) were identified as module items to form the MDASI-PeriOp-Hep. The Cronbach αs for symptoms and for interference were 0.898 and 0.861, respectively. The test-retest reliability was 0.887 for all 18 symptom severity items. Compared to other commonly used tools, correlation of MDASI-PeriOp-Hep scores to performance status (all, P < 0.001) and to the phase of perioperative care confirmed known-group validity. Convergent validity was excellent against other standard Patient-reported outcomes tools. Cognitive debriefing demonstrated that the MDASI-PeriOp-Hep was an easy to use and understandable tool.

Conclusions: For integrating patient-reported outcomes in perioperative patient care, a procedure-specific tool is desirable. The MDASI-PeriOp-Hep is a valid, reliable, concise tool for measuring symptom severity and functional interference in patients undergoing liver surgery.
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http://dx.doi.org/10.1016/j.ejon.2021.101959DOI Listing
April 2021

Developing a Value Framework: Utilizing Administrative Data to Assess an Enhanced Care Initiative.

J Surg Res 2021 Jun 6;262:115-120. Epub 2021 Feb 6.

Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas. Electronic address:

Background: There remains no tool to quantify the total value of comparative processes in health care. Hospital administrative data sets are emerging as valuable sources to evaluate performance. Thus, we use a framework to simultaneously assess multiple domains of value associated with an enhanced recovery initiative using national administrative data.

Materials And Methods: Risk-stratified clinical pathways for patients undergoing pancreatic surgery were implemented in 2016 at our institution. We used a national administrative database to characterize changes in value associated with this initiative. Value metrics assessed included in-hospital mortality, complication rates, length of stay (LOS), 30-day readmission rates, and institutional costs. We compared our performance with other hospitals both before and after implementation of the pathways. Metrics were graphed on radar charts to assess overall value.

Results: 22,660 cases were assessed. Comparing 75 cases at our institution and 5520 cases at all other hospitals before pathway implementation, mean in-hospital LOS was 9.6 versus 10.8 d, in-hospital mortality was 0.0% versus 1.9%, mean costs were $23,585 versus $21,387, 30-day readmission rates were 1.3% versus 7.4%, and complication rates were 8.0% versus 11.2%, respectively. Comparing 334 cases at our institution and 16,731 cases at all other hospitals after pathway implementation, mean in-hospital LOS was 7.7 versus 10.3 d, in-hospital mortality was 0.3% versus 1.6%, mean costs were $19,428 versus $22,032, 30-day readmission rates were 6.6% versus 7.5%, and complication rates were 6.3% versus 10.3%, respectively. Notably, LOS and institutional costs were reduced at our institution after implementation of the enhanced clinical care pathways. Our costs were higher than comparators before implementation, but lower than comparators after implementation.

Conclusions: Herein, we used an analytic framework and used national administrative data to assess the value of an enhanced care initiative as benchmarked with data from other hospitals. We thus illustrate how to identify and measure opportunities for targeted improvements in health care delivery. We also recognize the limitations of the use of administrative data in a comprehensive assessment of value in health care.
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http://dx.doi.org/10.1016/j.jss.2020.12.061DOI Listing
June 2021

Assessment of physical function by subjective and objective methods in patients undergoing open gynecologic surgery.

Gynecol Oncol 2021 Apr 31;161(1):83-88. Epub 2021 Jan 31.

Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America.

Objective: To evaluate the utility of patient-reported outcomes (PROs) to measure physical functioning in perioperative care for patients with gynecological (GYN) tumors.

Methods: 180 patients with GYN tumors undergoing open surgery participated in this longitudinal study. The physical functioning was measured by a subjective PRO tool, the Interference subscales of the MD Anderson Symptom Inventory (MDASI-I); as well as by an objective tool, the Timed Up & Go test (TUGT), perioperatively. Longer time (>20 s) needed to complete the TUGT was defined as "Prolonged". Patients completed EuroQoL-5D as well. The association between the scores of MDASI-I items and TUGT was assessed via the Spearman correlation coefficient. The known-group validity was assessed using the t-test and Cohen's D effect size.

Results: Compliance rates at preoperative, discharge and postoperative time points of MDASI-I were 98%, 95%, 96%; while TUGT completion rates were 92%, 75%, and 80%, respectively. Patients who had refused TUGT at discharge reported a significantly worse "MDASI-general activity" score compared to patients who completed TUGT (mean score of 7.00 vs. 5.38, P = 0.020). Patient-reported "Walking" on MDASI-I significantly differentiated patients with prolonged vs. those with frail/normal TUGT at discharge (mean score of 4.89 vs. 2.79, Cohen's d effect size = 0.82, P < 0.001). MDASI-I demonstrated excellent known-group validity per performance status and for the EuroQoL-5D subscales.

Conclusion: Patient-reported physical functioning impairment after GYN surgery correspond with observed worse scores of the objective functioning measure test (TUGT). MDASI-I assessment represents a feasible and valid tool to evaluate functional status and warrants further implementation in the perioperative setting.
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http://dx.doi.org/10.1016/j.ygyno.2021.01.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7994186PMC
April 2021

Opioid-free anesthesia-caution for a one-size-fits-all approach.

Perioper Med (Lond) 2020 18;9:16. Epub 2020 Jun 18.

Department of Anesthesiology & Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas USA.

Post-operative pain management should ideally be optimized to ensure patient's mobilization and ability to partake in effective pulmonary exercises for patient's early recovery. Opioids have traditionally been the main mode for analgesia strategy in the perioperative period. However, the recent focus on opioid crisis in the USA has generated a robust discussion on rational use of opioids in the perioperative period and also raised the concept of "opioid-free anesthesia" in certain circles. Opioid-related adverse drug events (ORADE) and questionable role of opioids in cancer progression have further deterred some anesthesiologists from the routine perioperative use of opioids including their use for breakthrough pain. However, judicious use of opioid in conjunction with the use of non-opioid analgesics and regional anesthetic techniques may allow for optimal analgesia while reducing the risks associated with the use of opioids. Importantly, the opioid epidemic and opioid-related deaths seem more related to the prescription practices of physicians and post-discharge misuse of opioids. Focus on patient and clinician education, identification of high-risk patients, and instituting effective drug disposal and take-back policies may prove useful in reducing opioid misuse.
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http://dx.doi.org/10.1186/s13741-020-00147-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301466PMC
June 2020

Rethinking Sedation During Prolonged Mechanical Ventilation for COVID-19 Respiratory Failure.

Anesth Analg 2020 08;131(2):e125-e126

Department of Anesthesiology & Perioperative Medicine, MD Anderson Cancer Center, Houston, Texas.

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http://dx.doi.org/10.1213/ANE.0000000000004962DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7219845PMC
August 2020

Harnessing cancer immunotherapy during the unexploited immediate perioperative period.

Nat Rev Clin Oncol 2020 05 17;17(5):313-326. Epub 2020 Feb 17.

Neuro-Immunology Research Unit, School of Psychological Sciences, Tel-Aviv University, Tel Aviv-Yafo, Israel.

The immediate perioperative period (days before and after surgery) is hypothesized to be crucial in determining long-term cancer outcomes: during this short period, numerous factors, including excess stress and inflammatory responses, tumour-cell shedding and pro-angiogenic and/or growth factors, might facilitate the progression of pre-existing micrometastases and the initiation of new metastases, while simultaneously jeopardizing immune control over residual malignant cells. Thus, application of anticancer immunotherapy during this critical time frame could potentially improve patient outcomes. Nevertheless, this strategy has rarely been implemented to date. In this Perspective, we discuss apparent contraindications for the perioperative use of cancer immunotherapy, suggest safe immunotherapeutic and other anti-metastatic approaches during this important time frame and specify desired characteristics of such interventions. These characteristics include a rapid onset of immune activation, avoidance of tumour-promoting effects, no or minimal increase in surgical risk, resilience to stress-related factors and minimal induction of stress responses. Pharmacological control of excess perioperative stress-inflammatory responses has been shown to be clinically feasible and could potentially be combined with immune stimulation to overcome the direct pro-metastatic effects of surgery, prevent immune suppression and enhance immunostimulatory responses. Accordingly, we believe that certain types of immunotherapy, together with interventions to abrogate stress-inflammatory responses, should be evaluated in conjunction with surgery and, for maximal effectiveness, could be initiated before administration of adjuvant therapies. Such strategies might improve the overall success of cancer treatment.
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http://dx.doi.org/10.1038/s41571-019-0319-9DOI Listing
May 2020

Society of Onco-Anaesthesia and Perioperative Care consensus guidelines for perioperative management of patients for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC).

Indian J Anaesth 2019 Dec 11;63(12):972-987. Epub 2019 Dec 11.

Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India.

Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) for primary peritoneal malignancies or peritoneal spread of malignant neoplasm is being done at many centres worldwide. Perioperative management is challenging with varied haemodynamic and temperature instabilities, and the literature is scarce in many aspects of its perioperative management. There is a need to have coalition of the existing evidence and experts' consensus opinion for better perioperative management. The purpose of this consensus practice guideline is to provide consensus for best practice pattern based on the best available evidence by the expert committee of the Society of Onco-Anaesthesia and Perioperative Care comprising perioperative physicians for better perioperative management of patients of CRS-HIPEC.
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http://dx.doi.org/10.4103/ija.IJA_765_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6921319PMC
December 2019

Effect of reversal of deep neuromuscular block with sugammadex or moderate block by neostigmine on shoulder pain in elderly patients undergoing robotic prostatectomy.

Br J Anaesth 2020 02 26;124(2):164-172. Epub 2019 Nov 26.

Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA; Anesthesiology and Surgical Oncology Research Group, University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Background: For some laparoscopic procedures, deep neuromuscular block has been shown to facilitate lower insufflation pressures and lower patient pain scores, and enhance postoperative recovery. We investigated the impact of deep neuromuscular block and its reversal on postoperative shoulder pain and outcomes after robotic prostate surgery.

Methods: Elderly men undergoing robotic prostatectomy were randomised to deep neuromuscular block (target post-tetanic twitch of 1-2 at the facial nerve) with sugammadex reversal or moderate neuromuscular block (target 1-2 train-of-four ratio) with neostigmine reversal. The primary endpoint was postoperative shoulder pain. The secondary endpoints included intraoperative insufflation pressure, surgical rating score, incidence of residual neuromuscular block, and postoperative recovery.

Results: A total of 50 subjects for each treatment arm were included in the analysis. The degree of neuromuscular block had no effect on the incidence of shoulder pain (deep block group 12% vs moderate block group 10%; P=1.0) or average insufflation pressure (median [inter-quartile range]) (13.3 [12.5-13.6] mm Hg vs 13.3 [11.7-14] mm Hg, P=0.86). After surgery, the deep block group had a higher normalised train-of-four ratio (0.98 [0.79-1.11] vs 0.85 [0.74-1.00]; P=0.008). The presence of postoperative shoulder pain was associated with higher BMI (31.8 [28-33.9] kg mvs 28 [24.8-31.1] kg m; P=0.036) and longer insufflation time (186 [156-257] min vs 154 [126-198] min; P=0.028).

Conclusions: The use of deep neuromuscular block during surgery does not decrease postoperative shoulder pain or enhance recovery after robotic prostatectomy.

Clinical Trial Registration: NCT03210376.
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http://dx.doi.org/10.1016/j.bja.2019.09.043DOI Listing
February 2020

Patterns and predictors of outpatient opioid use after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy.

Int J Hyperthermia 2019 ;36(1):1058-1064

Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center , Houston , TX , USA.

Long-term opioid use is a well-known complication after surgery. In this retrospective study of adults who had undergone cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC), we sought to determine the rates and factors associated with outpatient opioid use within the sixth and twelfth postoperative months. Records of 288 opioid-naïve patients were included. Logistic regression models were used to determine factors prognostic of outpatient opioid use. The median patient age was 54 years, and 63% were female. Rates of outpatient opioid use within the sixth and twelfth postoperative months were 21 and 13%, respectively. In the multivariate analysis, every doubling in the amount of in-hospital postoperative opioid consumption was associated with a 44% increase in odds of opioid use within the sixth postoperative month (OR 1.44, 95% CI 1.11-1.87,  = .006) and a 70% increase within the twelfth postoperative month (OR 1.70, 95% CI 1.70-2.37,  = .001). Other factors associated with opioid use within the sixth postoperative month included physical status (OR 5.26, 95% CI 1.08-25.55,  = .039) and recent additional surgery (OR 23.02, 95% CI 2.03-261.30,  = .011). Age (OR 4.39, 95% CI 1.77-10.89,  = .001) and tumor grade (OR 3.31, 95% CI 1.31-8.41,  = .012) were associated with opioid use within the twelfth postoperative month. In this study, the amount of in-hospital postoperative opioid consumption was an important contributory factor to outpatient opioid use in the sixth and twelfth postoperative months. Synopsis In this study of adults who had undergone CRS-HIPEC, higher postoperative opioid consumption during hospitalization was associated with higher odds of opioid use within the sixth and twelfth postoperative months.
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http://dx.doi.org/10.1080/02656736.2019.1675912DOI Listing
April 2020

Enhanced recovery in liver surgery decreases postoperative outpatient use of opioids.

Surgery 2019 07 15;166(1):22-27. Epub 2019 May 15.

Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston. Electronic address:

Background: Pathways of enhanced recovery in liver surgery decrease inpatient opioid use; however, little data exist regarding their effect on discharge prescriptions and post-discharge opioid intake.

Methods: For consecutive patients undergoing liver resection from 2011-2018, clinicopathologic factors were compared between patients exposed to enhanced recovery vs. traditional care pathways. Multivariable analysis was used to determine factors predictive for traditional opioid use at the first postoperative follow-up. The enhanced recovery in liver surgery protocol included opioid-sparing analgesia, goal-directed fluid therapy, early postoperative feeding, and early ambulation.

Results: Of 244 cases, 147 enhanced recovery patients were compared with 97 traditional pathway patients. Enhanced recovery patients were older (median 57 years vs 52 years, P = .031) and more frequently had minimally invasive operations (37% vs 16%, P < .001), with fewer major complications (2% vs 9%, P = .011). Enhanced recovery patients were less likely to be discharged with a prescription for traditional opioids (26% vs 79%, P < .001) and less likely to require opioids at their first postoperative visit (19% vs 61%, P < .001) despite similarly low patient-reported pain scores (median 2/10 both groups, P = .500). On multivariable analysis, the traditional recovery pathway was independently associated with traditional opioid use at the first follow-up (odds ratio 6.4, 95% confidence interval 3.5-12.1; P < .001).

Conclusion: The implementation of an enhanced recovery in liver surgery pathway with opioid-sparing techniques was associated with decreased postoperative discharge prescriptions for opioids and outpatient opioid use after oncologic liver surgery, while achieving the same level of pain control. For this and other populations at risk of persistent opioid use, enhanced recovery strategies can eliminate excess availability of opioids.
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http://dx.doi.org/10.1016/j.surg.2019.02.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6579699PMC
July 2019

Association between intravenous acetaminophen and reduction in intraoperative opioid consumption during transsphenoidal surgery for pituitary tumors.

J Anaesthesiol Clin Pharmacol 2018 Oct-Dec;34(4):465-471

Anesthesiology and Surgical Oncology Research Group, Houston, Texas, USA.

Background And Aims: Pain during and after transsphenoidal surgeries originates from stimulation of branches of the trigeminal cranial nerve that supply the inner aspect of the nose cavity and dura mater. Thereby, patients undergoing transsphenoidal surgery may require moderate-to-large amounts of analgesics including opioids. Intravenous acetaminophen provides analgesia and reduces opioid consumption for a wide variety of surgeries. We hypothesized that the use of intravenous acetaminophen is associated with a reduction in intraoperative opioid consumption and provides significant analgesia during and after transsphenoidal surgery.

Material And Methods: This retrospective study included 413 patients who underwent transsphenoidal surgery for pituitary adenomas. The primary outcome of this study was intraoperative opioid consumption. Secondary outcomes included pain intensity, Richmond Agitation Sedation Scale scores, and nausea and vomiting upon arrival to postoperative anesthesia care unit. Patients were divided into two groups based on the intraoperative acetaminophen use. A prospensity score matching analysis was used to balance for important variables between the two groups of treatment. Regression models were fitted after matching the covariates. A < 0.05 was considered statistically significant.

Results: After matching, 126 patients were included in each group of treatment. Patients in the acetaminophen group required significantly less amount (a decrease by 14.9%) of opioids during surgery than those in the non-acetaminophen group. Postoperative pain, postoperative nausea and vomiting, and sedation scores were not significantly different between patients who received intravenous acetaminophen and those who did not.

Conclusion: Intravenous acetaminophen is associated with a reduction in intraoperative opioids during transsphenoidal pituitary surgery.
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http://dx.doi.org/10.4103/joacp.JOACP_276_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6360881PMC
February 2019

Impact of epidural analgesia on the systemic biomarker response after hepatic resection.

Oncotarget 2019 Jan 15;10(5):584-594. Epub 2019 Jan 15.

Anesthesiology and Surgical Oncology Research Group, Houston, TX, USA.

Background: Perioperative inflammation is associated with poor oncologic outcomes. Regional analgesia has been shown mitigate some of these inflammatory changes and be associated with better oncologic outcomes in patients with hepatic malignancies. The mechanism for this effect, however, remains unclear. The authors sought to compare systemic biomarker concentrations in a comprehensive and oncologically relevant panel in the perioperative setting between patients undergoing thoracic epidural analgesia (TEA) and intra-venous patient- controlled analgesia (IV-PCA) for resection of hepatic metastatic disease.

Results: Clinicopathologic variables and baseline biomarkers were similar between TEA ( = 46) and IV-PCA ( = 16) groups. Of the biomarkers which were significantly changed from baseline, there was a lower fold change from baseline in the TEA patients compared to IV-PCA including IL-6 (13.5vs19.1), MCP-1 (1.9vs3.0), IL-8 (2.4vs3.0), and Pentraxin-3 (10.8vs15.6). Overall decreased systemic concentrations of TGFb signaling were noted in TEA patients on POD1 TGFb3 (243.2 vs. 86.0, = 0.005), POD3 TGFb1 (6558.0 vs. 2063.3, = 0.004), POD3 TGFb2 (468.3 vs. 368.9, = 0.036), POD3 TGFb3 (132.2 vs. 77.8, = 0.028), and POD5 TGFb3 (306.5 vs. 92.2, = 0.032). POD1 IL-12p70 concentrations were significantly higher in TEA patients (8.3 vs. 1.6, = 0.024).

Conclusion: Epidural analgesia damped the postoperative inflammatory response and systemic immunosuppressive signaling, as well as promoted Th1 systemic signaling early in the post-operative period after hepatic resection for metastatic disease. These differences elaborate on known mechanisms for improved oncologic outcomes with regional anesthesia, and may be considered for biomarker monitoring of effective regional anesthesia in oncologic surgery.

Materials And Methods: Patient data, including clinicopathologic variables were collected for this study from the database of a randomized controlled trial comparing perioperative outcomes in patients undergoing hepatic resection with TEA vs. IV-PCA. Patients undergoing resection for metastatic disease were selected for this study. Plasma concentrations (pg/mL) of well-studied biomarkers (IL-1b/2/4/5/6/7/8/10/12p70/13/17, MCP-1 IFNγ, TNFα, MIP-1b, GM-CSF, G-CSF, VEGF, Resistin, TGFb1, TGFb2, and TGFb3), as well as novel perioperative markers (CXCL12, CXCL10, Omentin-1, sLeptin R, Vaspin, Pentraxin-3, Galactin-3, FGF-23, PON-1, FGF-21) were measured preoperatively, and on postoperative day (POD)1, POD3, and POD5 using multiplex bead assays. Clinicopathologic variables and perioperative variations in these biomarkers were compared between TEA vs IV-PCA groups.
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http://dx.doi.org/10.18632/oncotarget.26549DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6355178PMC
January 2019

Determining the Safety and Efficacy of Enhanced Recovery Protocols in Major Oncologic Surgery: An Institutional NSQIP Analysis.

Ann Surg Oncol 2019 Mar 9;26(3):782-790. Epub 2019 Jan 9.

Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, 1400 Herman Pressler Drive, Unit 1484, Houston, TX, 77030, USA.

Background: Enhanced-recovery (ER) protocols are increasingly being utilized in surgical practice. Outside of colorectal surgery, however, their feasibility, safety, and efficacy in major oncologic surgery have not been proven. This study compared patient outcomes before and after multispecialty implementation of ER protocols at a large, comprehensive cancer center.

Methods: Surgical cases performed from 2011 to 2016 and captured by an institutional NSQIP database were reviewed. Following exclusion of outpatient and emergent surgeries, 2747 cases were included in the analyses. Cases were stratified by presence or absence of ER compliance, defined by preoperative patient education and electronic medical record order set-driven opioid-sparing analgesia, goal-directed fluid therapy, and early postoperative diet advancement and ambulation.

Results: Approximately half of patients were treated on ER protocols (46%) and the remaining on traditional postoperative (TP) protocols (54%). Treatment on an ER protocol was associated with decreased overall complication rates (20% vs. 33%, p < 0.0001), severe complication rates (7.4% vs. 10%, p = 0.010), and median hospital length of stay (4 vs. 5 days, p < 0.0001). There was no change in readmission rates (ER vs. TP, 8.6% vs. 9.0%, p = 0.701). Subanalyses of high magnitude cases and specialty-specific outcomes consistently demonstrated improved outcomes with ER protocol adherence, including decreased opioid use.

Conclusions: This assessment of a large-scale ER implementation in multispecialty major oncologic surgery indicates its feasibility, safety, and efficacy. Future efforts should be directed toward defining the long-term oncologic benefits of these protocols.
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http://dx.doi.org/10.1245/s10434-018-07150-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6878764PMC
March 2019

International multicenter observational study on assessment of ventilatory management during general anaesthesia for robotic surgery and its effects on postoperative pulmonary complication (AVATaR): study protocol and statistical analysis plan.

BMJ Open 2018 08 23;8(8):e021643. Epub 2018 Aug 23.

Department of Anesthesiology, Hospital Clinic, University of Barcelona, Barcelona, Spain.

Introduction: Robotic-assisted surgery (RAS) has emerged as an alternative minimally invasive surgical option. Despite its growing applicability, the frequent need for pneumoperitoneum and Trendelenburg position could significantly affect respiratory mechanics during RAS. AVATaR is an international multicenter observational study aiming to assess the incidence of postoperative pulmonary complications (PPC), to characterise current practices of mechanical ventilation (MV) and to evaluate a possible association between ventilatory parameters and PPC in patients undergoing RAS.

Methods And Analysis: AVATaR is an observational study of surgical patients undergoing MV for general anaesthesia for RAS. The primary outcome is the incidence of PPC during the first five postoperative days. Secondary outcomes include practice of MV, effect of surgical positioning on MV, effect of MV on clinical outcome and intraoperative complications.

Ethics And Dissemination: This study was approved by the Institutional Review Board of the Hospital Israelita Albert Einstein. The study results will be published in peer-reviewed journals and disseminated at international conferences.

Trial Registration Number: NCT02989415; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2018-021643DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6112402PMC
August 2018

Comparing Postoperative Complications and Inflammatory Markers Using Total Intravenous Anesthesia Versus Volatile Gas Anesthesia for Pancreatic Cancer Surgery.

Anesth Pain Med 2017 Aug 21;7(4):e13879. Epub 2017 Aug 21.

Department of Anesthesiology and Perioperative Medicine, Houston, TX, USA.

Objectives: The objective of this study is to evaluate postoperative complications and inflammatory profiles when using a total intravenous anesthesia (TIVA) or volatile gas-opioid (VO) based anesthesia in patients undergoing pancreatic cancer surgery.

Methods: Design, retrospective propensity score matched cohort; Setting, major academic cancer hospital; Patients, all patients who had pancreatic surgery between November 2011 and August 2014 were retrospectively reviewed. Propensity score matched patient pairs were formed. A total of 134 patients were included for analysis with 67 matched pairs; Interventions, Patients were categorized according to type of anesthetic used (TIVA or VO). Patients in the TIVA group received preoperative celecoxib, tramadol, and pregabalin in addition to intraoperative TIVA with propofol, lidocaine, ketamine, and dexmedetomidine. The VO-group received a volatile-opioid based anesthetic; Measurements, demographic, perioperative clinical data, platelet lymphocyte ratios, and neutrophil lymphocyte ratios were collected. Complications were graded and collected prospectively and later reviewed retrospectively.

Results: Patients receiving TIVA were more likely to have no complication or a lower grade complication than the VO-group (P = 0.014). There were no differences in LOS or postoperative inflammatory profiles noted between the TIVA and VO groups.

Conclusions: In this retrospective matched analysis of patients undergoing pancreatic cancer surgery, TIVA was associated with lower grade postoperative complications. Length of hospital stay (LOS) and postoperative inflammatory profiles were not significantly different.
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http://dx.doi.org/10.5812/aapm.13879DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5750426PMC
August 2017

Intraoperative use of dexmedetomidine is associated with decreased overall survival after lung cancer surgery.

J Anaesthesiol Clin Pharmacol 2017 Jul-Sep;33(3):317-323

Sagol School of Neuroscience and School of Psychological Sciences, Tel Aviv University, Tel Aviv, Israel.

Background And Aims: The aim is to evaluate the association between the use of intraoperative dexmedetomidine with an increase in recurrence-free survival (RFS) and overall survival (OS) after nonsmall cell lung cancer (NSCLC) surgery.

Material And Methods: This was a propensity score-matched (PSM) retrospective study. Single academic center. The study comprised patients with Stage I through IIIa NSCLC. Patients were excluded if they were younger than 18 years. Primary outcomes of the study were RFS and OS. RFS and OS were evaluated using univariate and multivariate Cox proportional hazards models after PSM ( = 251/group) to assess the association between intraoperative dexmedetomidine use and the primary outcomes. The value of < 0.05 was considered statistically significant.

Results: After PSM and adjusting for significant covariates, the multivariate analysis demonstrated no association between the use of dexmedetomidine and RFS (hazard ratio [HR] [95% confidence interval (CI)]: HR = 1.18, 95% CI: 0.91-1.53; = 0.199). The multivariate analysis also demonstrated an association between the administration of dexmedetomidine and reduced OS (HR = 1.28, 95% CI: 1.03-1.59; = 0.024).

Conclusions: This study demonstrated that the intraoperative use of dexmedetomidine to NSCLC patients was not associated with a significant impact on RFS and but worsening OS. A randomized controlled study should be conducted to confirm the results of this study.
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http://dx.doi.org/10.4103/joacp.JOACP_299_16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5672519PMC
November 2017

Lidocaine Stimulates the Function of Natural Killer Cells in Different Experimental Settings.

Anticancer Res 2017 09;37(9):4727-4732

Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, U.S.A.

Background: One of the functions of natural killer (NK) cells is to eliminate cancer cells. The cytolytic activity of NK cells is tightly regulated by inhibitory and activation receptors located in the surface membrane. Lidocaine stimulates the function of NK cells at clinically relevant concentrations. It remains unknown whether this effect of lidocaine has an impact on the expression of surface receptors of NK cells, can uniformly stimulate across different cancer cell lines, and enhances the function of cells obtained during oncological surgery.

Materials And Methods: NK cells from healthy donors and 43 patients who had undergone surgery for cancer were isolated. The function of NK cells was measured by lactate dehydrogenase release assay. NK cells were incubated with clinically relevant concentrations of lidocaine. By flow cytometry, we determined the impact of lidocaine on the expression of galactosylgalactosylxylosylprotein3-beta-glucuronosytranferase 1, marker of cell maturation (CD57), killer cell lectin like receptor A, inhibitory (NKG2A) receptors and killer cell lectin like receptor D, activation (NKG2D) receptors of NK cells. Differences in expression at p<0.05 were considered statistically significant.

Results: Lidocaine increased the expression of NKG2D receptors and stimulated the function of NK cells against ovarian, pancreatic and ovarian cancer cell lines. Lidocaine also increased the cytolytic activity of NK cells from patients who underwent oncological surgery, except for those who had orthopedic procedures.

Conclusion: Lidocaine showed an important stimulatory activity on NK cells. Our findings suggest that lidocaine might be used perioperatively to minimize the impact of surgery on NK cells.
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http://dx.doi.org/10.21873/anticanres.11879DOI Listing
September 2017

Inflammation and pro-resolution inflammation after hepatobiliary surgery.

World J Surg Oncol 2017 Aug 10;15(1):152. Epub 2017 Aug 10.

Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.

Background: The magnitude of the perioperative inflammatory response plays a role in surgical outcomes. However, few studies have explored the mechanisms of the resolution of inflammation in the context of surgery. Here, we described the temporal kinetics of interleukin-6, cortisol, lipoxin A4, and resolvin D in patients who underwent oncologic liver resections.

Methods: All patients gave written informed consent. Demographic and perioperative surgical data were collected, along with blood samples, before surgery and on the mornings of postoperative days 1, 3, and 5. Interleukin-6, cortisol, lipoxin-A4, and resolvin D were measured in plasma. A P value < 0.05 was considered statistically significant.

Results: Forty-one patients were included in the study. Liver resection for colorectal metastatic disease was the most commonly performed surgery. The plasma concentrations of interleukin-6 were highest on day 1 after surgery and remained higher than the baseline up to postoperative day 1. Postoperative complications occurred in 14 (24%) patients. Cortisol concentrations spiked on postoperative day 1. The concentrations of lipoxin A4 and resolvin D were lowest on day 1 after surgery.

Conclusions: The inflammatory response associated with hepatobiliary surgery is associated with low circulating concentrations of lipoxin A4 and resolvin D that mirror, in an opposite manner, the kinetics of interleukin 6 and cortisol.

Trial Registration: NCT01438476.
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http://dx.doi.org/10.1186/s12957-017-1220-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5556621PMC
August 2017

A Randomized Controlled Trial of Postoperative Thoracic Epidural Analgesia Versus Intravenous Patient-controlled Analgesia After Major Hepatopancreatobiliary Surgery.

Ann Surg 2017 09;266(3):545-554

*Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX †Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX ‡Department of Surgery, Mayo Clinic, Rochester, MN §Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX ¶Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX.

Objectives: The primary objective of this randomized trial was to compare thoracic epidural analgesia (TEA) to intravenous patient-controlled analgesia (IV-PCA) for pain control over the first 48 hours after hepatopancreatobiliary (HPB) surgery. Secondary endpoints were patient-reported outcomes, total narcotic utilization, and complications.

Background: Although adequate postoperative pain control is critical to patient and surgeon success, the optimal analgesia regimen in HPB surgery remains controversial.

Methods: Using a 2.5:1 randomization strategy, 140 patients were randomized to TEA (N = 106) or intravenous patient-controlled analgesia (N = 34). Patient-reported pain was measured on a Likert scale (0-10) at standard time intervals. Cumulative pain area under the curve was determined using the trapezoidal method.

Results: Between the study groups key demographic, comorbidity, clinical, and operative variables were equivalently distributed. The median area under the curve of the postoperative time 0- to 48-hour pain scores was lower in the TEA group (78.6 vs 105.2 pain-hours, P = 0.032) with a 35% reduction in patients experiencing ≥7/10 pain (43% vs 62%, P = 0.07). Patient-reported outcomes and total opiate use further supported the benefit of TEA on patient experience. Anesthesia-related events requiring change in analgesic therapy were comparable (12.2% vs 2.9%, respectively, P = 0.187). Grade 3 or higher surgical complications (6.6% vs 9.4%), median length of stay (6 days vs 6 days), readmission (1.9% vs 3.1%), and return to the operating room (0.9% vs 3.1%) were similar (all P > 0.05). There were no mortalities in either group.

Conclusions: In major HPB surgery, TEA provides a superior patient experience through improved pain control and less narcotic use, without increased length of stay or complications.
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http://dx.doi.org/10.1097/SLA.0000000000002386DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5784834PMC
September 2017

Accelerated enhanced y following inimally nvasive colorectal cancer surgery (): a study protocol for a novel randomised controlled trial.

BMJ Open 2017 Jul 20;7(7):e015960. Epub 2017 Jul 20.

Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Introduction: Definitive treatment of localised colorectal cancer involves surgical resection of the primary tumour. Short-stay colectomies (eg, 23-hours) would have important implications for optimising the efficiency of inpatient care with reduced resource utilisation while improving the overall recovery experience with earlier return to normalcy. It could permit surgical treatment of colorectal cancer in a wider variety of settings, including hospital-based ambulatory surgery environments. While a few studies have shown that discharge within the first 24 hours after minimally invasive colectomy is possible, the safety, feasibility and patient acceptability of a protocol for short-stay colectomy for colorectal cancer have not previously been evaluated in a prospective randomised study. Moreover, given the potential for some patients to experience a delay in recovery of bowel function after colectomy, close outpatient monitoring may be necessary to ensure safe implementation.

Methods And Analysis: In order to address this gap, we propose a prospective randomised trial of accelerated enhanced y following inimally nvasive colorectal cancer surgery () that leverages the combination of minimally invasive surgery with enhanced recovery protocols and early coordinated outpatient remote televideo conferencing technology () to improve postoperative patien-provider communication, enhance postoperative treatment navigation and optimise postdischarge care. We hypothesise that RecoverMI can be safely incorporated into multidisciplinary practice to improve patient outcomes and reduce the overall 30-day duration of hospitalisation while preserving the quality of the patient experience. ETHICS AND DISSEMINATION: has received institutional review board approval and funding from the American Society of Colorectal Surgeons (ASCRS; LPG103). Results from RecoverMI will be published in a peer-reviewed publication and be used to inform a multisite trial.

Trial Registration Number: NCT02613728; Pre-results.
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http://dx.doi.org/10.1136/bmjopen-2017-015960DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5642654PMC
July 2017

American Society for Enhanced Recovery (ASER) and Perioperative Quality Initiative (POQI) joint consensus statement on measurement to maintain and improve quality of enhanced recovery pathways for elective colorectal surgery.

Perioper Med (Lond) 2017 17;6. Epub 2017 Mar 17.

Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina USA.

Background: This article sets out a framework for measurement of quality of care relevant to enhanced recovery pathways (ERPs) in elective colorectal surgery. The proposed framework is based on established measurement systems and/or theories, and provides an overview of the different approaches for improving clinical monitoring, and enhancing quality improvement or research in varied settings with different levels of available resources.

Methods: Using a structure-process-outcome framework, we make recommendations for three hierarchical tiers of data collection.

Discussion: Core, Quality Improvement, and Best Practice datasets are proposed. The suggested datasets incorporate patient data to describe case-mix, process measures to describe delivery of enhanced recovery and clinical outcomes. The fundamental importance of routine collection of data for the initiation, maintenance, and enhancement of enhanced recovery pathways is emphasized.
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http://dx.doi.org/10.1186/s13741-017-0062-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5356230PMC
March 2017

The Impact of Paravertebral Block Analgesia on Breast Cancer Survival After Surgery.

Reg Anesth Pain Med 2016 Nov/Dec;41(6):696-703

From the *Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center; †Anesthesiology and Surgical Oncology Research Group; and Departments of ‡Breast Medical Oncology, §Breast Surgical Oncology, and ∥Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX.

Background And Objectives: The impact of regional anesthesia on breast cancer recurrence is controversial. We tested the hypothesis that the use of paravertebral block (PVB) analgesia during breast cancer surgery prolongs the recurrence-free survival (RFS) and overall survival (OS) of women with breast cancer.

Methods: Seven hundred ninety-two women with nonmetastatic breast cancer were included in this retrospective study. Patients were divided based on the administration of PVB analgesia for mastectomy surgeries. One hundred ninety-eight (25%) were given a PVB, the remainder were treated with opioid-based analgesia. Propensity score matching was developed using several variables. Univariate and multivariate analyses were used to assess the impact of PVB analgesia on RFS and OS.

Results: The median follow-up times for RFS and OS were 5.8 and 6 years, respectively. In the propensity score matching model, a total of 396 women were included in each group of treatment (non-PVB group, n = 198 vs PVB group, n = 198). As expected, the fentanyl consumption was significantly lower in PVB (122.8 ± 77.85 μg) patients than non-PVB subjects (402.23 ± 343.8 μg). Other variables were not statistically significant. After adjusting for several important covariates, the analysis indicated that the use of PVB is not associated with a significant change in RFS [1.60 (0.81-3.16), P = 0.172] or OS [1.28 (0.55-3.01)] survival.

Discussion: This retrospective study does not support the hypothesis that the use of regional analgesia is associated with longer survival after surgery for breast cancer.
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http://dx.doi.org/10.1097/AAP.0000000000000479DOI Listing
March 2017

Anesthetic and operative considerations for laparoscopic liver resection.

Surgery 2017 05 18;161(5):1191-1202. Epub 2016 Aug 18.

Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX. Electronic address:

We enumerate the broad range of anesthetic considerations that affect the outcome of patients undergoing laparoscopic liver resection. Key elements for excellent outcomes after laparoscopic liver resection are careful patient selection and risk stratification, appropriate monitoring, techniques to reduce blood loss and transfusion, and active recovery management. Although some of these key elements are the same for open liver operation, there are specific anesthetic considerations of which both the surgical and anesthesia teams must be aware to achieve optimal patient outcomes after laparoscopic liver resection. While unique advantages of laparoscopic liver resection typically include decreased intraoperative bleeding, transfusion requirements, and a lower incidence of postoperative ascites, specific challenges include management of the complicated interplay between low-volume anesthesia and increased intraabdominal pressure due to pneumoperitoneum, with additional considerations regarding circulatory support to treat acute blood loss with need for emergent conversion in some cases. This article will address in detail the preoperative, intraoperative, and postoperative anesthetic considerations for patients undergoing laparoscopic liver resection that both the surgical and anesthesia team should be aware of to optimize outcomes.
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http://dx.doi.org/10.1016/j.surg.2016.07.011DOI Listing
May 2017

Identification of Risk Factors Associated With Postoperative Acute Kidney Injury After Esophagectomy for Esophageal Cancer.

J Cardiothorac Vasc Anesth 2017 Apr 21;31(2):474-481. Epub 2016 Jul 21.

Anesthesiology and Surgical Oncology Research Group, Houston, TX. Electronic address:

Objective: To identify risks factors associated with acute kidney injury (AKI) after esophageal cancer surgery.

Design: This was a retrospective study.

Setting: Single academic center.

Participants: Subjects with non-metastatic esophageal cancer. Patients were excluded if they were younger than 18 years and had missing data.

Measurements And Main Results: Primary outcome of the study was AKI according to AKI Network criteria. Demographic and perioperative variables were compared in patients with and without AKI. A multivariate Cox proportional model was used to assess the association between perioperative variables and AKI; p<0.05 was considered statistically significant. AKI was found in 107 (11.9%) of the 898 patients included in the study. The multivariate analysis also showed that BMI (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.03-1.11), number of comorbidities (OR 1.52, 95% CI 1.20-1.93, p = 0.001), and preoperative creatinine concentrations (OR 2.37, 95% CI 1.14-4.92, p = 0.02) were independent predictors for AKI. The use of dexamethasone was associated with a reduced risk for AKI.

Conclusions: In support of previous reports in the literature, the authors found that AKI was not an uncommon complication after esophageal surgery. Obesity, cardiovascular comorbidities, and high preoperative concentrations were predictors of AKI. Dexamethasone administration during surgery appeared to have a protective effect. This finding opens an opportunity to further study in a randomized controlled trial the efficacy of dexamethasone in the prevention of AKI.
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http://dx.doi.org/10.1053/j.jvca.2016.07.030DOI Listing
April 2017

Making the Case for the Subspecialty of Onco-Anesthesia.

Int Anesthesiol Clin 2016 ;54(4):19-28

*The Royal Marsden Trust, London, UK †Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas ‡Division of Cancer Surgery, Peter MacCallum Cancer Centre, East Melbourne, Vic., Australia §Anaesthesia, Perioperative and Pain Medicine Unit, Melbourne Medical School, The University of Melbourne, Melbourne, Vic., Australia.

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http://dx.doi.org/10.1097/AIA.0000000000000117DOI Listing
November 2018

The Impact of Postoperative Complications on a Timely Return to Intended Oncologic Therapy (RIOT): the Role of Enhanced Recovery in the Cancer Journey.

Int Anesthesiol Clin 2016 ;54(4):e33-46

*Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas †Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas ‡Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.

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http://dx.doi.org/10.1097/AIA.0000000000000113DOI Listing
November 2018

Platelet-to-Lymphocyte Ratio and Use of NSAIDs During the Perioperative Period as Prognostic Indicators in Patients With NSCLC Undergoing Surgery.

Cancer Control 2016 Jul;23(3):284-94

Department of Anesthesiology and Perioperative Medicine, MD Anderson Cancer Center, Houston, TX 77030.

Background: Hematological biomarkers of inflammation such as the neutrophil-to-lymphocytic rate have been reported as predictors of survival in a variety of cancers. The aim of the present study was to investigate the prognostic value of the perioperative platelet-to-lymphocyte ratio in patients with non-small-cell lung cancer (NSCLC) and to elucidate the effects of the perioperative use of nonsteroidal anti-inflammatory drugs (NSAIDs) on tumor recurrence and survival in patients undergoing surgical resection for NSCLC.

Methods: This retrospective study included data from 1,637 patients who underwent surgical resection for stage I, II, or III NSCLC. Perioperative data and tumor-related variables were included. Univariate and multivariable Cox proportional hazard ratio (HR) models were used to evaluate the association between perioperative platelet-to-lymphocyte ratio and NSAID use on recurrence-free survival (RFS) and overall survival (OS).

Results: Multivariate analysis showed that a preoperative platelet-to-lymphocyte ratio of at least 180 was associated with reduced rates of RFS (HR = 1.22; 95% confidence interval [CI], 1.03-1.45; P = .019) and OS (HR = 1.33; 95% CI, 1.10-1.62; P = .004). Perioperative use of NSAIDs showed no statistically significant changes in RFS and OS rates (P = .72 and P = .44, respectively).

Conclusions: A higher preoperative inflammatory status is associated with decreased rates of RFS and OS in patients with NSCLC undergoing curative surgery. Perioperative use of NSAIDs was not found to be an independent predictor of survival.
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http://dx.doi.org/10.1177/107327481602300312DOI Listing
July 2016