The factors identified provide a basis for assessment, planning, interventions, and follow-up of patients to help reduce the risk of readmission and, thus, poor outcomes.

Associate Editor m.J., a 28-year-old nonverbal autistic male, was referred to a comprehensive cancer center for a second opinion regarding recurrent metastatic mixed nonseminomatous germ cell testicular cancer in the left testis. m.J.'s medical history included an untreated cryptochidism (an undescended right testicle) but his left testicle was normal. m.J. was diagnosed with autism at age 2 and lives at home with his mother and father. He had been attending a day program prior to diagnosis and treatment of testicular cancer. His younger sister is a special education teacher and is very involved in his care. m.J. was diagnosed with cancer 18 months prior to his visit to the cancer center when his mother discovered a lump in his left testicle while bathing him. He underwent an inguinal orchiectomy at a local hospital. Pathology revealed an 80% bridle cell and 20% immature teratoma. no complications from the surgery were reported; however, a computed tomography scan after surgery revealed metastatic disease in his lungs and retroperitoneal areas. He was treated with four cycles of cisplatin and etoposide. m.J. was intubated and sedated during the first two cycles of chemotherapy because of behavior issues. Aspiration pneumonia resulted from being ventilated and complicated his recovery. m.J.'s mother stayed with him in the hospital for the last two cycles and reported that they walked almost continuously for the duration of each hospital stay. A computed tomography scan done at the completion of chemotherapy revealed a residual 8 cm cystic retroperitoneal mass consistent with nodal metastasis. The left kidney was displaced by the retroperitoneal tumor. The lung metastases had resolved.The urologic surgeon at the comprehensive cancer center believed that m.J. was a candidate for a retroperitoneal lymph node dissection despite an increased risk of complications after surgery from m.J.'s autism. m.J.'s behavior in the outpatient clinic had been difficult. He was unable to sit still for a physical examination and spent most of the visit running up and down the halls. realizing that certain arrangements would be needed during m.J.'s hospital stay, the surgeon notified the intensive care unit's clinical manager. The clinical manager and the clinical nurse specialist coordinated a literature search on autism and general needs of patients with autism. The clinical manager also visited m.J.'s home to meet him and his family and identify his needs prior to admission.The retroperitoneal bilateral lymph node dissection was completed but was complicated by a right renal artery injury that was repaired by vascular surgery. Bilateral ureteral stents were put in place. m.J. remained ventilated and sedated in the intensive care unit so he would not injure himself or dislodge any tubes. He was extubated the day after the surgery, but progressive dyspnea with desaturation required reintubation the following day. m.J.'s chest x-ray also showed evidence of bilateral aspiration pneumonia. He was extubated 12 days after surgery; however,...

A patient with a mucinous appendiceal cancer presents to the surgeon complaining of abdominal discomfort and nausea. Having undergone a prior right hemicolectomy, the patient has been disease free and on surveillance with clinical and carcinogenic antigen (CEA) monitoring. The CEA was noted to be elevated and a computed tomography scan revealed peritoneal nodules throughout the abdomen with a presumptive diagnosis of pseudomyxoma peritonei (progressive peritoneal implants from a mucinous primary). Several therapeutic options were offered and the patient selected to undergo cytoreductive surgery (CRS) with the potential to receive hyperthermic interoperative chemotherapy (HIPEC). Extensive resection was performed, including removal of the entire greater omentum, partial gastrectomy, and total pelvic exenteration with end colostomy and ileal conduit. Reassessment of the peritoneal cavity after the resections revealed almost complete cytoreduction. HIPEC was performed with mitomycin C and, after drainage and abdominal washing, the intestinal segments were anastomosed and the abdominal wall closed. Seven days postoperatively, an acute abdomen with septic shock developed as a result of a leak from the ileocolonic anastomosis. The patient returned to the operating room and an exploratory laparotomy, a small bowel resection, a resection of the ileocolonic anastomosis, and an abdominal washout were performed. Edema of the bowel caused by peritonitis resulting from the anastomotic leak necessitated delayed closure of the abdominal wall. A temporary abdominal closure using the ABThera™ Open Abdomen Negative Pressure Therapy system was applied and the abdomen was eventually closed.

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