Long-Term Outcomes following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis of Colorectal Origin.

BACKGROUND: Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a major treatment of colorectal peritoneal carcinomatosis (CPC). The aim was to determine the disease-free survival (DFS) and overall survival (OS) of patients undergoing CRS-HIPEC for CPC and factors associated with long-term survival (LTS). METHODS: consecutive CPC patients who underwent CRS-HIPEC at a HIPEC center between 2007 and 2021 were included. Actual survival was calculated, and Cox proportional hazards models were used to identify factors associated with OS, DFS and LTS. RESULTS: there were 125 patients with CPC who underwent primary CRS-HIPEC, with mean age of 54.5 years. Median follow-up was 31 months. Average intraoperative PCI was 11, and complete cytoreduction (CC-0) was achieved in 96.8%. Median OS was 41.6 months (6-196). The 2-year and 5-year OS were 68% and 24.8%, respectively, and the 2-year DFS was 28.8%. Factors associated with worse OS included pre-HIPEC systemic therapy, synchronous extraperitoneal metastasis, and PCI ≥ 20 (p < 0.05). Progression prior to CRS-HIPEC was associated with worse DFS (p < 0.05). Lower PCI, fewer complications, lower recurrence and longer DFS were associated with LTS (p < 0.05). CONCLUSION: CRS and HIPEC improve OS in CPC patients but they have high disease recurrence. Outcomes depend on preoperative therapy response, extraperitoneal metastasis, and peritoneal disease burden.

Clinical Outcomes in T4 and/or N2 Rectal Cancer Treated With Neoadjuvant Chemoradiotherapy: A Retrospective Study.

INTRODUCTION: Total neoadjuvant therapy (TNT) in the management of locally advanced rectal cancer (LARC) did not show survival benefit over the standard long course chemoradiotherapy. Trials of TNT did not address the impact of each risk feature in isolation from other high-risk features. METHODOLOGY: In this retrospective study, we describe the clinical outcomes of patients with T4 and/or N2 rectal adenocarcinoma who were treated with chemoradiotherapy followed by total mesorectal excision (TME). After obtaining the local regulatory approvals, demographic and clinical data were collected for patients in Manitoba between January 2007 and December 2019. RESULTS: The cohort included 331 patients. 61 patients had T4-only disease and 218 had N2-only disease. Mean age was 59.65 years. 74.3% received adjuvant chemotherapy (ACT), but only 56.5% completed the planned course. R0 resection was achieved in 93.4% of patients (78.7% and 97.2% in T4 and N2, respectively). Median follow up was 4.93 years. 3-year overall recurrence rate was 29%. 3-year locoregional recurrence (LRR) rate was 8% (16% and 6% in T4 and N2, respectively). 3-year overall survival (OS) rate was 84% in the whole cohort (72.6% and 87.1% in T4 and N2, respectively). Incomplete surgical resection was a poor prognostic factor for both OS and LRR. ACT was associated with a survival benefit in the whole cohort (P = .001) and in the N2 sub-cohort (P = 003) but there was no survival benefit observed in T4 sub-cohort. ACT did not have an impact on LRR. CONCLUSIONS: Achieving R0 resection in LARC with neoadjuvant therapy improves recurrence and survival rates. T4 disease carries a worse clinical outcome than N2 and consideration should be given to upstage T4 to stage III. Different high-risk features in LARC predict different clinical outcomes. In the era of TNT, personalization of treatment strategy based on these factors could potentially improve outcomes.

Competency-based education in general surgery: Are Canadian residents ready?

Summary: Competency-based education (CBE) is currently being implemented by the Royal College of Physicians and Surgeons of Canada across all residency programs. This shift away from time-based residency is proposed to be the answer to maximize training opportunity in the era of work hour restrictions and growing concerns regarding accountability in medical education. A Web-based survey was conducted to obtain feedback from Canadian general surgery residents on their experience and perception of competence within core procedures, as well as attitudes toward CBE. A total of 244 residents completed the survey. For most procedures, more than 50% of residents felt they could perform the procedure with no guidance after completing 11-30 cases. Generally, residents were welcoming of CBE; however, medium-sized programs reported some concerns regarding inadequate exposure to cases and risk of training less well-rounded surgeons. This is valuable resident feedback for programs to consider during the implementation process.

Patients' treatment preferences for potentially resectable tumors of the head of the pancreas.

BACKGROUND: The primary aim of this study was to assess if patients with potentially resectable ductal adenocarcinoma (PDAC) of the head of the pancreas would choose a Whipple procedure versus palliative chemotherapy. METHODS: A cohort of adults with radiological resectable PDAC was enrolled at a tertiary Canadian teaching hospital. Participants were informed about treatment options, expected outcomes, and adverse events using data from the most recent scientific literature. Probability trade-off (PTO) was used to elicit treatment preferences. RESULTS: Surgery was preferred by all participants except one (96.7% vs. 3.3%; P = 0.0001). For 90% of participants preferring surgery, the main reason was the hope of being cured (P = 0.001). If the risk of perioperative mortality was higher than 57%, the risk of perioperative morbidity higher than 85% and the survival benefit was less than 4 months, half of the participants preferred palliative chemotherapy. The likelihood of needing blood transfusions, the length of hospital stay, and long-term consequences such as diabetes or pancreatic exocrine insufficiency were negligible concerns to participants. CONCLUSIONS: Informed patients with early-stage PDAC prefer resection over palliative chemotherapy. The dominating factor influencing their decision is the hope of a cure that overshadow the risks of complications, mortality and recurrent disease.

Squamous Cell Carcinoma with Regional Metastasis to Axilla or Groin Lymph Nodes: a Multicenter Outcome Analysis.

BACKGROUND: Cutaneous squamous cell carcinoma (cSCC) of the trunk/extremities with nodal metastasis represents a rare but significant clinical challenge. Treatment patterns and outcomes are poorly described. PATIENTS AND METHODS: Patients with cSCC who developed axilla/groin lymph node metastasis and underwent curative-intent surgery between 2005 and 2015 were identified at four Canadian academic centers. Demographics, tumor characteristics, treatment patterns, recurrence rates, and mortality were described. Overall survival (OS) and disease-free survival (DFS) were calculated using Kaplan-Meier analysis. Predictors of survival and any recurrence were explored using Cox regression and logistic regression models, respectively. RESULTS: Of 43 patients, 70% were male (median age 74 years). Median follow-up was 38 months. Median time to nodal metastasis was 11.3 months. Thirty-one and 12 patients had nodal metastasis to the axilla and groin, respectively. A total of 72% and 7% received adjuvant and neoadjuvant radiation, respectively, while 5% received adjuvant chemotherapy. Following surgery, 26% patients developed nodal and/or distant disease recurrence. Crude mortality rate was 39.5%. Mean OS was 5.3 years [95% confidence interval (CI) 3.9-6.8 years], and 5-year OS was 55.1%. Mean DFS was 4.8 years (95% CI 3.3-6.2 years), and five-year DFS was 49.3%. Any recurrence was the only independent predictor of death [p = 0.036, odds ratio (OR) = 29.5], and extracapsular extension (p = 0.028, OR = 189) and age (p = 0.017, OR = 0.823) were independent predictors of recurrence. CONCLUSIONS: This represents the largest contemporary series to date of outcomes for patients with axilla/groin nodal metastases from cSCC. Despite aggressive treatment, outcomes remain modest, indicating the need for a continued multidisciplinary approach and integration of new systemic agents.

Cytoreductive surgery and heated intraperitoneal chemotherapy for peritoneal carcinomatosis from rare etiologies.

BACKGROUND: Cytoreductive surgery and heated intraperitoneal chemotherapy (CRS/HIPEC) are commonly used in the treatment of peritoneal carcinomatosis (PC) originating from colorectal, appendiceal and ovarian cancers. It is unclear what benefit CRS/HIPEC might have for PC from uncommon etiologies, therefore we sought to describe local practice patterns and evaluate overall survival (OS). METHODS: All patients who had CRS/HIPEC between 2000 and 2016 were identified using our institutional cancer database. Patients with appendiceal, colorectal, and ovarian pathologies were excluded. Kaplan-Meier curves were used to estimate and demonstrate 5-year OS. Cox regression analysis was performed to determine factors associated with OS. RESULTS: Of all patients treated with CRS/HIPEC at our institution, 38 were treated for PC of rare origin. Etiologies included 23 patients with mesothelioma, 8 with primary peritoneal carcinoma, 4 with small bowel tumours and 3 with gastric cancer. Median OS of 35.4, 20.8, 25.4, and 20.2 months were obtained for each group respectively. 5-year OS for each pathology was 8.7%, 0.0%, 25.0%, and 33.3% respectively with corresponding mean PCI of 31.3, 23.6, 21.5, and 12.7. No independent prognostic factors were significant on Cox regression analysis. Median length of stay was 19 days. Readmission rate within 30 days of discharge was 7.9%. Rate of Grade III/IV complications was 34.2%. No thirty-day mortality. CONCLUSION: Survivals beyond 20 months can be obtained with the use of CRS/HIPEC for rare PC etiologies aligning with results of other groups. CRS/HIPEC in well-selected patients demonstrates a clinical benefit and this could be confirmed with a multi-institutional study.

Impact of body mass index on outcomes of 48281 patients undergoing first time cadaveric liver transplantation.

AIM: To investigate possible disparities in perioperative morbidity and mortality among different body mass index (BMI) groups and to simulate the impact that these differences might have had on the cohort of patients undergoing cadaveric liver transplantation (LT). METHODS: All adult recipients undergoing first time LT for benign conditions and receiving a whole graft from brain-dead donors were selected from the united network of organ sharing registry. From January 1994 to June 2013, 48281 patients satisfied the inclusion criteria and were stratified by their BMI. The hypothesis that abnormal BMIs were independent predictors of inferior outcomes was tested with univariate and multivariate regression analyses. RESULTS: In comparison to normal weight recipients, underweight and morbidly obese recipients had increased 90-d mortality (adjusted OR = 1.737; 95%CI: 1.185-2.548, P = 0.005) (adjusted OR = 1.956; 95%CI: 1.473-2.597, P = 0.000) respectively and inferior patients' survivals (adjusted HR = 1.265; 95%CI: 1.096-1.461, P = 0.000) (adjusted HR = 1.157; 95%CI: 1.031-1.299, P = 0.013) respectively. Overall, patients' 5-year survival were 73.9% for normal-weight, 71.1% for underweight, 74.0% for overweight, 74.4% for class I obese, 75.0% for class II obese and 71.5% for class III obese recipients. Analysis of hypothetical exclusion of underweight and morbidly obese patients from the pool of potential LT candidates would have improved the overall survival of the entire cohort by 2.7% (95%CI: 2.5%-3.6%). CONCLUSION: Selected morbidly obese patients undergoing LT for benign conditions had 5-year survival rates clinically comparable to normal weight recipients. Impact analysis showed that exclusion of high-risk recipients (underweight and morbid obese patients) would not significantly improve the overall survival of the entire cohort of patients requiring LT.

Societal reintegration following cadaveric orthotopic liver transplantation.

BACKGROUND: Studies on patients' societal reintegration following orthotopic liver transplantation (OLT) are scarce. METHODS: Between September 2006 and January 2008, all adults who were alive after 3 years post OLT were included in this prospective cohort study. Validated questionnaires were administered to all candidates with the primary aim of investigating the rate of their social re-integration following OLT and potential barriers they might have encountered. RESULTS: Among 157 eligible patients 110 (70%) participated. Mean participants' age was 57 years (SD 11.4) and 43% were females. Prior to OLT, 75% of patients were married and 6% were divorced. Following OLT there was no significant difference in marital status. Employment rate fell from 72% to 30% post-OLT. Patients who had been employed in either low-skill or advanced-skill jobs were less likely to return to work. After OLT, personal income fell an average of 4,363 Canadian dollars (CAN$) (SD 20,733) (P=0.03) but the majority of recipients (80%) reported high levels of satisfaction for their role in society. CONCLUSIONS: Although patients' satisfaction post-OLT is high, employment status is likely to be negatively affected for individuals who are not self-employed. Strategies to assist recipients in returning to their pre-OLT jobs should be developed to improve patients' economical status and societal ability to recoup resources committed for OLT.

Obesity and liver transplantation.

The percentage of overweight and obese patients (OPs) waiting for a liver transplant continues to increase. Despite the significant advances occurred in bariatric medicine, obesity is still considered a relative contraindication to liver transplantation (LT). The main aim of this review is to appraise the literature on the outcomes of OPs undergoing LT, treatments that might reduce their weight before, during or after surgery, and discuss some of the controversies and limitations of the current knowledge with the intent of highlighting areas where future research is needed.

The current state of pancreatic cancer in Canada: incidence, mortality, and surgical therapy.

OBJECTIVE: This study aimed to evaluate the trends in the incidence, survival, and surgical therapy for Canadian patients affected by pancreatic cancer (PC). METHODS: The incidence, mortality, number of resections, and outcomes of patients with PC stratified by year, sex, and province were extracted from Canadian cancer databases. RESULTS: In 2012, PC was diagnosed in 4600 Canadians and it was responsible for 4300 deaths. The age-standardized incidence was 9 to 10 new cases per 100,000 individuals. The mortality rate remained the highest among all the solid tumors with a case-to-fatality ratio of 0.93. The age-standardized 5-year relative survival was 9.1% (95% confidence interval [CI], 8.3-10). There were geographic variations among provinces with the highest survival registered in Ontario (10.9%; 95% CI, 9.9-12) and the lowest survival reported in Nova Scotia (4.7%; 95% CI, 2.8-7.2). The percentage of patients who underwent surgery decreased from 19% (2006-2007) to 17% (2009-2010). Pancreatic resections were performed in high-volume centers in 74% of cases. In-hospital mortality was 5%, 93% of patients were discharged home, and 36% of patients required home support after discharge. CONCLUSIONS: Long-term outcomes of Canadian patients affected by PC remain unsatisfactory, with only 9% of the patients surviving at 5 years. Surgical therapy was performed only in 17% to 19% of patients.

Effect of a preventive foot care program on lower extremity complications in diabetic patients with end-stage renal disease.

BACKGROUND: Lower extremity complications are a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD) and diabetes mellitus. Patient education programs may decrease the risk of diabetic foot complications. METHODS: A preventive program was instituted, consisting of regular assessments by a foot care nurse with expertise in foot care and wound management and patient education about foot care practices and footwear selection. Medical records were reviewed and patients were examined. A comparison was made with data about patients from a previous study done from this institution prior to development of the foot care program. RESULTS: Diabetic subjects more frequently had weakness of the left tibialis anterior, left tibialis posterior, and left peroneal muscles than non-diabetic subjects. A smaller percentage of diabetic subjects had sensory neuropathy compared with the previous study from 5years earlier, but a greater percentage of diabetic subjects had absent pedal pulses in the current study. The frequency of inadequate or poor quality footwear was less in the current study compared with the previous study. CONCLUSIONS: The current data suggest that a foot care program consisting of nursing assessments and patient education may be associated with a decrease in frequency of neuropathy and improved footwear adequacy in diabetic patients with ESRD.

Upper extremity complications in patients with chronic renal failure receiving haemodialysis.

Limited data are available about disability associated with upper extremity complications in patients who receive haemodialysis for end-stage renal disease. In this study of 123 patients receiving haemodialysis, the mean Disabilities of the Arm, Shoulder and Hand (DASH) score was 31 ± 22 points, indicating markedly greater disability than in a normal population. Dupuytren's contracture was the most frequent deformity. Brachial, radial and ulnar pulses were present in most upper limbs, but 14 (14%) of 102 patients had poor arterial perfusion pressures. Diabetic patients had residual or complete loss of protective sensation more frequently than nondiabetic patients. Motor testing with the index finger abduction and fifth finger flexion tests showed a significantly greater frequency of weakness in diabetic than nondiabetic patients. In summary, upper extremity disability was noted in haemodialysis patients, including loss of protective sensation and motor strength, both in diabetic and nondiabetic subjects.