Perioperative outcomes in patients who undergo neoadjuvant chemoradiotherapy versus chemotherapy versus up-front surgery in patients with oesophageal cancer.

BACKGROUND: Oesophagectomy is the mainstay of curative treatment for oesophageal cancer. The role of neoadjuvant therapy has evolved over time as evidence for its survival benefit comes to hand. Clinician reluctance to offer patients neoadjuvant therapy may be based on the perception that patients receiving treatment before surgery may be exposed to a greater risk of perioperative complications. The aim of this study was to examine short-term outcomes in patients who undergo neoadjuvant therapy versus up-front surgery in patients with oesophageal cancer. METHODS: This was a retrospective cohort study of prospectively collated data from 2001 to 2020 of patients undergoing resection for oesophageal cancer. Patients who had neoadjuvant chemoradiotherapy, chemotherapy and up-front surgery were compared for perioperative morbidity (via the Clavien-Dindo classification), length of stay, unplanned readmission, and 30- and 90-day mortality. Logistic regression was performed to predict perioperative morbidity following surgery. RESULTS: In total, 284 patients underwent an oesophagectomy. Most patients received neoadjuvant treatment (41% received chemoradiotherapy (117/284), 33% received chemotherapy (93/284)), and 26% of patients received up-front surgery (74/284). Patients who received neoadjuvant chemoradiotherapy or up-front surgery were more likely to have a complication (57%, 67/117 and 57%, 43/74) than patients who received neoadjuvant chemotherapy only (38%, 35/93, P = 0.009). The 30- and 90-day mortality rates were 1.4% (n = 4) and 2.8% (n = 8), respectively, with no difference between the use of neoadjuvant therapy. CONCLUSION: In this series, we found that patients who received neoadjuvant treatment could undergo oesophagectomy with curative intent with acceptable postoperative morbidity and mortality.

Impact of pre-existing mesh at the hiatus at revisional hiatal hernia surgery.

Recurrence after laparoscopic hiatus hernia repair (LHR) is high, with few symptomatic patients undergoing redo LHR. Morbidity is higher in redo surgery compared with the primary operation. Tens of studies have explored the safety of redoing LHR. However, the impact of existing mesh on operative risk is rarely examined. We aim to assess the impact of mesh at the hiatus on the safety of redo LHR. This was a cohort study examining redo LHR patients from a prospectively maintained database from January 2002 to December 2023. The primary outcome was intra-/postoperative complications. Follow-up was extracted from clinical records. Predictors of complications were assessed using univariable and multivariable logistic regression analyses. Redo LHR was performed in 100 patients; 22 had previous mesh. One encountered mortality with 23 complications. Five patients had absorbable mesh, with the remainder nonabsorbable. Overall complications were significantly higher with mesh at nine (40.9%) compared to no mesh redo at 14 (17.9%), P = 0.023. There was no difference in rates of visceral injury with mesh at four (18.2%) and no mesh at six (7.7%), P = 0.22. The median follow-up was 7 months; there was no difference in reflux rates (P = 0.70) but higher rates of dysphagia (P = 0.010). Higher overall complications were noted in patients with previous hiatal mesh repair at the time of LHR. However, major visceral complications were similar regardless of mesh use. Mesh at the hiatus should not be a deterrent for reoperative hiatus surgery.

Geographic disparities in thyroid cancer staging at presentation: Insights from an Australian context.

BACKGROUND: Thyroid cancer diagnoses have increased over recent decades at a rate much higher than that of any other cancer in Australia. Rural patients are known to have reduced access to healthcare and may have different thyroid cancer presentation rates. This study examined the relationship between thyroid cancer diagnosis and patient rurality. METHODS: Data from the Australia and New Zealand Thyroid Cancer Registry from 2017 to 2022 were analyzed, stratifying patient postcodes into rurality groups using the Australian Statistical Geography Standard. The American Thyroid Association (ATA) guidelines were used to stratify risk categories and management to compare treatment adequacy between the groups. Statistical analysis assessed demographic, clinical, and management differences. RESULTS: Among 1766 patients, 70.6% were metropolitan (metro) and 29.4% were non-metropolitan (non-metro). Non-metro patients were older at diagnosis (median 56 vs. 50 years, p < 0.001), presented more frequently with T stage greater than 1 (stage 2-4, 41.9% vs. 34.8%, and p = 0.005), AJCC stage greater than 1 (stage 2-4, 18.5% vs. 14.6%, and p = 0.019), and cancers larger than 4 cm (14.3% vs. 9.9%, p = 0.005). No significant differences in treatment adequacy were observed between the groups for ATA low-risk cancers. CONCLUSIONS: Non-metropolitan patients in the registry present with more advanced thyroid cancer, possibly due to differences in healthcare access. Further research should assess long-term survival outcomes and influencing factors. Understanding the impact on patient outcomes and addressing healthcare access barriers can optimize thyroid cancer care across geographic regions in Australia.

Pancreatic body and tail adenocarcinoma: upfront resection versus neoadjuvant therapy, a contemporary analysis.

OBJECTIVES: There is a paucity of data regarding the use of neoadjuvant therapy in pancreatic body or tail ductal adenocarcinomas. Given the differing tumour biology and aggressive nature of pancreatic body or tail adenocarcinomas, patients presenting with these tumours may benefit from upfront resection. METHODS: A retrospective cohort study was performed analysing patients who underwent distal pancreatectomy for pancreatic ductal adenocarcinoma between January 2013 and June 2022. Patients who underwent upfront resection were compared to those who underwent neoadjuvant therapy. RESULTS: Forty-one patients underwent upfront distal pancreatectomy, while 40 patients underwent neoadjuvant therapy before curative intent resection. Neoadjuvant therapy did not improve overall survival (37 vs. 34 months, p = 0.962) or disease-free survival (13 vs. 15 months, p = 0.414), as compared with upfront resection. There was no significant difference in the rate or R0 resection or post-operative outcomes. CONCLUSION: No significant improvement in survival was demonstrated for patients undergoing neoadjuvant therapy for pancreatic ductal adenocarcinoma of the pancreatic body or tail when compared to upfront resection. Considering the potential for disease progression given the more aggressive tumour biology of pancreatic body and tail adenocarcinomas, appropriate surgical candidates should be offered upfront resection to provide the best chance of survival and cure.

Prognostic Factors and Treatment Effect Modifiers for Physical Health, Opioid Prescription, and Health Care Utilization in Patients With Musculoskeletal Disorders in Primary Care: Exploratory Secondary Analysis of the STEMS Randomized Trial of Direct Access to Physical Therapist-Led Care.

OBJECTIVE: The aims of the study were to identify prognostic factors associated with health care outcomes in patients with musculoskeletal conditions in primary care and to determine whether characteristics associated with choice of care modify treatment effects of a direct-access physical therapist-led pathway in addition to general practitioner (GP)-led care compared to GP-led care alone. METHODS: A secondary analysis of a 2-parallel-arm, cluster randomized controlled trial involving general practices in the United Kingdom was conducted. Practices were randomized to continue offering GP-led care or to also offer a direct-access physical therapist-led pathway. Data from adults with musculoskeletal conditions who completed the 6-month follow-up questionnaire were analyzed. Outcomes included physical health, opioid prescription, and self-reported health care utilization over 6 months. Treatment effect modifiers were selected a priori from associations in observational studies. Multivariable regression models identified potential prognostic factors, and interaction analysis tested for potential treatment effect modifiers. RESULTS: Analysis of 767 participants indicated that baseline pain self-efficacy, pain severity, and having low back pain statistically predicted outcomes at 6 months. Higher pain self-efficacy scores at baseline were associated with improved physical health scores, reduced opioid prescription, and less health care utilization. Higher bodily pain at baseline and having low back pain were associated with worse physical health scores and increased opioid prescription. Main interaction analyses did not reveal that patients' age, level of education, duration of symptoms, or musculoskeletal presentation influenced response to treatment, but visual trends suggested those in the older age group proceeded to fewer opioid prescriptions and utilized less health care when offered direct access to physical therapy. CONCLUSIONS: Patients with musculoskeletal conditions with lower levels of pain self-efficacy, higher pain severity, and presenting with low back pain have less favorable clinical and health care outcomes in primary care. Prespecified characteristics did not modify the treatment effect of the offer of a direct-access physical therapist-led pathway compared to GP-led care. IMPACT: Patients with musculoskeletal conditions receiving primary care in the form of direct-access physical therapist-led or GP-led care who have lower levels of self-efficacy, higher pain severity, and low back pain are likely to have a less favorable prognosis. Age and duration of symptoms should be explored as potential patient characteristics that modify the treatment response to a direct-access physical therapist-led model of care.

Quality-of-life measurement long-term after resection of colorectal liver metastases - is there an optimal assessment tool?

BACKGROUND: There is limited literature on health-related quality-of-life (HRQoL) in patients with colorectal liver metastases (CRLM). Furthermore, there is no consensus on which HRQoL tool is most appropriate. This study assessed the long-term HRQoL in patients who undergo liver resection for CRLM and assessed which HRQoL tool is most useful. METHODS: This was a cross-sectional study of patients who had curative resection for CRLM between 2010 and June 2021. Three validated instruments were used: The European Organisation for Research and Treatment of Cancer (EORTC), which consists of the QLQ-C30 (a generic questionnaire) and QLQ-LMC21 (CRLM specific); the EuroQol-5D (EQ-5D) and the 36-Item Short Form Survey. RESULTS: 121 patients underwent liver resection for CRLM, of which 85 were alive. There was a 61 % response rate (n = 52). The median post-operative time when the survey was completed was 4.0 years. Across all three questionnaires, patients performed exceptionally well in all domains, with median functional scores >90. The EQ-5D-5L VAS and the EROTC QLQ-C30 produced similar results. CONCLUSION: This study demonstrates excellent long-term HRQoL in patients who undergo resection for CRLM. The EQ-5D questionnaire is the preferred questionnaire because it is shorter and simpler to complete than the other tools without compromising accuracy.

The Impact of Age on the Post-operative Outcomes in Patients Undergoing Resection for Oesophageal and Gastric Cancer.

BACKGROUND: Within our ageing population, there is an increasing number of elderly patients presenting with oesophagogastric cancer. Resection remains the mainstay of curative treatment however it has substantial morbidity. The aim of this study was to assess whether age was an independent predictor of resection related complications in our unit. METHODS: A retrospective cohort study of prospectively collated data from 2002 to 2020 of patients undergoing resection for oesophageal and gastric cancers was analysed. Patients aged over 75 and 75 and under were compared for peri-operative morbidity (via the Clavien-Dindo classification), length of stay (LOS), unplanned readmission, 30- and 90-day mortality, and use of neoadjuvant therapy. RESULTS: Data for 466 consecutive patients undergoing oesophagogastric resection (277 oesophagectomy and 189 gastrectomy) were available for analysis. 22% of patients were aged over 75 (14% (39/277) of the oesophagectomy cohort, 34% (65/189) of the gastrectomy cohort). Oesophagectomy patients over 75 were more likely to develop post-operative complications, particularly cardiac or thromboembolic, (69.2%) than those in the younger cohort (50.4%, p = 0.029). There was no difference in complication rates between the younger and older patients undergoing gastrectomy (29.0% vs. 33.9% p = 0.495). The 30- and 90-day mortality rates were 1.4% (n = 4) and 2.5% (n = 7), respectively, for the oesophagectomy cohort and 1.1% (n = 2) and 1.6% (n = 3) for the gastrectomy cohort, with no difference between age groups. CONCLUSION: In this series, we found that patients over the age of 75 were able to undergo oesophageal and gastric resection with curative intent with acceptable post-operative morbidity and mortality.

Initial experience with laparoscopic gastric bypass in an Australian general foregut surgery unit.

BACKGROUND: Laparoscopic gastric bypass (LGB) is an increasingly utilized approach to bariatric surgery in Australia. A high proportion of those procedures are revisional due to Australia's legacy of laparoscopic adjustable gastric banding (LAGB), which is not the case internationally. The aim of this study was to compare post-operative outcomes in an Australian general foregut surgery unit against benchmarks published in the literature. METHODS: This is retrospective cohort study of morbidly obese patients undergoing primary or revisional laparoscopic Roux-en-Y gastric bypass (RYGB) or laparoscopic one anastomosis gastric bypass (OAGB) with the two senior authors between 5 May 2015 and 27 June 2019. Perioperative data for the unit's first 100 cases were collected prospectively, stored on a unit database and analysed. Post-operative complications at 30 days, 90 days, mortality, length of hospital stay, and Defined Adverse Events were chosen as indicators of the perioperative outcome (as defined in the Monash Bariatric Surgery Registry). RESULTS: In this cohort, 35% of procedures were RYGB and 65% were OAGB. The majority (58%) were revisional procedures. Most patients (74%) were female. The median age was 50. The comorbidity profile of the population was similar to those published internationally. The median hospital stay was 4 days. There was no mortality. Early complications occurred in 9% of patients, with 3% occurring late. CONCLUSION: Outcomes of our first 100 cases are comparable with those recorded in the literature, notwithstanding a much higher proportion of revisional cases. LGB can be safely introduced in Australian general foregut surgery units by experienced laparoscopic surgeons.

An Australian-based nomogram predicting nodal positivity for breast cancer in older patients.

INTRODUCTION: Regional nodal status is one of the most powerful prognosticators in breast cancer. The sentinel lymph node biopsy (SLNB) evaluates the first node in the axillary lymphatic basin theorised to drain the anatomical region of breast cancer. Recent literature has appropriately raised the query of the need for SLNB for breast cancer in older patients (BCOP). Though some early-stage older patients may safely have SLNB omitted, we are potentially missing the under-represented aggressive cancers. No sentinel lymph node metastases nomogram has been developed solely from BCOP data to date. This study aimed to identify older patients with breast cancer at risk for nodal involvement using a nomogram developed from their data alone. METHODS: A retrospective analysis of prospectively collected data on BCOP (aged ≥70 years) was performed using the Breast Surgery Quality Audit (BQA). Inclusion criteria were T1-2 invasive breast cancer patients that underwent a SLNB from 1st January 2001 to 31st December 2019. The primary outcome was nodal involvement. Data obtained from the dataset included: age, tumour type, tumour size in millimeters, histological grade, lymphovascular invasion, oestrogen receptor status, progesterone receptor status, HER2 status and referral source. Binary logistic regression was used to develop a nomogram. The model was internally validated by splitting the data set (80% for training and 20% for testing). A receiver operating characteristic curve was developed, with the area under the curve (AUC) and a calibration plot. RESULTS: There were 22,313 patients of which 14,856 (66.6%) were symptomatic presentations and 7457 (33.4%) were screen-detected. Invasive tumour type, tumour size, tumour grade, lymphovascular invasion, oestrogen receptors, and referral source indicated a statistically significant effect on predicting a nodal positivity event (Table 1). The AUC was 0.782 (95% CI 0.776-0.789) (Fig. 1a) and demonstrated good calibration (Fig. 1b). The negative predictive value established was 85%. CONCLUSION: We have developed an Australian sentinel lymph node metastasis nomogram for BCOP using routine histopathological data obtained pre-operatively (Fig. 2). This is the first Australian nomogram, as well as the first nomogram developed solely for BCOP - and maintains a superior AUC compared to other well-established nomograms.

Diffuse sclerosing variant papillary thyroid carcinoma has worse survival than classic papillary thyroid carcinoma: a meta-analysis.

Diffuse sclerosing variant (DSV) of papillary thyroid carcinomais a rare form of thyroid cancer that demonstrates more aggressive histopathology than classical papillary thyroid carcinoma (c-PTC); however, if this leads to worse survival is debated. Many DSVs are driven by fusion events which are of recent clinical importance due to the advent of targeted RET inhibitors. A systematic search and meta-analysis of the literature was performed to compare outcomes of disease-specific mortality (DSM), metastatic and recurrent disease and the incidence of fusion events between DSV and c-PTC to July 2022. The Newcastle-Ottawa Quality Assessment studies was used to assess quality. An odds ratio (OR) was utilised to measure outcomes with 95% CIs. The Preferred Reporting Items for Systematic Reviews and Meta-analysis guideline was followed. Seventeen studies were included with 874 DSV patients compared to 76,013 c-PTC patients. DSV patients had worse DSM (OR=2.50, 95% CI 1.39-4.51) and presented with a higher rate of metastatic lymph nodes (OR = 5.85, 95% CI 2.73-12.53) and more distant metastases (OR = 3.83, 95% CI 2.17-6.77). DSV patients had higher odds of recurrent disease (OR = 3.23, 95% CI 2.00-5.23) and overall distant metastasis (OR = 2.70, 95% CI 1.74-4.17). Rates of RET fusion alterations for DSV ranged from 25 to 83%. DSV has a worse prognosis than c-PTC with higher rates of recurrent disease and distant metastasis. The high prevalence of RET fusions offers the potential to improve outcomes for patients with DSV.

Lifetime direct healthcare costs of treating colorectal cancer: a systematic review.

Colorectal cancer is a global public health issue and imposes a significant economic burden on populations and healthcare systems. This paper systematically reviews the literature to estimate the direct costs of colorectal cancer incurred during different phases of treatment (initial, continuing and end of life). MEDLINE, EMBASE, Web of science, Evidence-based medicine reviews: National health service economic evaluation database guide, econlit and grey literature from the 1st of January 2000 to the 1st of February 2020. The methodological quality of the included studies was assessed using the Evers' Consensus on health economic criteria checklist. In total, 39,489 records were retrieved, and 17 studies were included. Costs by phase of treatment varied due to heterogeneity. However, studies that examined average costs for each phase of treatment showed a V-shaped distribution where the initial and end of life phases contribute the most and the continuing phase the least. The initial phase ranged from $7,893 to $60,289; the continuing annual phase ranged from $2,323 to $15,744; and the end of life phase ranged from $15,916 to $99,687. Studies that provided the total cost of each phase conversely showed that the continuing phase was the highest contributor to the cost of treating CRC. This study estimates the cost of the contemporary management of colorectal cancer despite the methodological heterogeneity. These costs place a heavy burden on healthcare providers, patients and their families. Identifying these costs can impact health care budgets and guide policymakers in making informed decisions for the future.

'Benched' the effect of the COVID-19 lockdown on injury incidence in sub-elite football in Australia: a retrospective population study using injury insurance records.

OBJECTIVES: The primary aim of this study was to compare injury rates pre- and post-COVID-19 lockdown in sub-elite football (soccer) players by analysing the full season and the first month of each season between 2018 and 2020. Secondary aims were to describe the incidence, location and type of injuries and to compare injuries by age group and sex. DESIGN: Descriptive epidemiological study. METHODS: A de-identified insurance database was retrospectively coded using the Orchard Sports Injury Classification System. Injury incidence per 1000 hours as well as incidence rate ratios (IRR) with confidence intervals were calculated. RESULTS: No significant difference was found in the overall incidence rate in 2020 compared with the 2018 and 2019 seasons (IRR, 1.04 [95% CI, 0.96-1.13]; p = 0.294). However, overall injuries increased by 26% (IRR: 1.26 [95% CI 1.07-1.47]; p < 0.005) and joint sprains increased by 45% (IRR: 1.45 [95% CI 1.14-1.84]; p < 0.005) in the first month of 2020 compared with 2018-2019. Between 2018 and 2020, there were 4149 injury insurance claims, with anterior cruciate ligament (ACL) ruptures accounting for 19% of all injuries. When comparing sex, female players had significantly more ankle sprains whilst male players suffered more dental injuries. CONCLUSIONS: This study adds to a growing body of evidence investigating injury rates post-COVID-19 lockdowns in sport. Sub-elite players appear to be at higher risk of joint injuries within the first month of training following a period of lockdown. Overall, stakeholders involved in sub-elite football should prioritise knee and ankle joint injury prevention.

Cost of colorectal cancer by treatment type from different health economic perspectives: A systematic review.

Advancements in colorectal cancer treatment have substantially improved overall survival. However, the cost of treating colorectal cancer places a significant economic burden on populations and healthcare systems. It is accepted that costs and what a health system charges may differ. This study aims to understand the expenditure on colorectal cancer globally. Specifically, this paper systematically reviews the literature to estimate the direct costs of each component in treating colorectal cancer, including primary care, diagnostics, surgery, chemotherapy, radiotherapy, and follow-up. MEDLINE, EMBASE, Web of Science, Evidence-Based Medicine Reviews: National Health Service Economic Evaluation Database Guide, Econlit and grey literature from the January 1, 2000 to the February 1, 2020. The methodological quality of the included studies was assessed using the Evers' Consensus on Health Economic Criteria checklist. In total, 39,489 records were retrieved, and after appropriate culling of non-relevant articles, 15 studies were included. Costs for treating colorectal cancer varied due to heterogeneity between different studies despite comparing similar clinical settings and study perspectives. Studies that presented an average cost per patient demonstrated that surgical costs ranged from $1,149 to $34,606, chemotherapy ranged from $1,883 to $18,021 and radiotherapy ranged from $2,037 to $5,347 in 2018 USD. Identifying these costs can impact health care budgets and guide policymakers in making informed decisions for the future.

Recurrence patterns predict survival after resection of colorectal liver metastases.

BACKGROUND: Effective treatment of colorectal liver metastases (CRLM) is challenging because recurrence occurs in many patients after curative-intent resection. This study evaluates the recurrence patterns after resection of CRLM and its association with survival. METHODS: A retrospective review of prospectively collected data of patients with CRLM managed with curative-intent resection from January 2007 to December 2017 was performed. The main outcomes and measures were the timing of recurrence, initial sites of recurrence, overall survival and recurrence-free survival. Early recurrence was defined as the detection of any organ recurrence ≤6 months from resection of CRLM. RESULTS: A cohort of 194 patients was included for analysis. After a median follow-up of 85.3 months, 145 patients (74.7%) were diagnosed with recurrence. The median overall survival was 67.6 months (95% CI 50.4-80.2) and the 5-year overall survival was 54.1%. After initial recurrence was detected, the median survival was 28.9 months (95% CI 23.6-37.8) months and the 5-year overall survival was 28.8%. Early recurrence occurred in 58 patients (29.9%). Initial recurrence patterns included: liver only in 53 patients (36.5%), multiple sites in 48 patients (33.1%), lung only in 30 patients (20.7%), and other single extrahepatic sites in 14 patients (9.6%). Early recurrence and initial multi-site recurrence were independent predictors of worse overall survival for patients who develop recurrence after resection of CLRM. CONCLUSION: The timing and initial sites of recurrence are prognostic factors in determining survival after curative-intent resection of CRLM.

Performance of prognostic models incorporating KRAS mutation status to predict survival after resection of colorectal liver metastases.

BACKGROUND: The Genetic And Morphologic Evaluation (GAME) score and modified clinical score (m-CS) are two novel prognostic models that incorporate KRAS mutation status to predict survival after resection of colorectal liver metastases (CRLM). This retrospective cohort study evaluated the performance of these two models. METHODS: A total of 103 patients who underwent resection of CRLM between 2007 and 2017 and had known KRAS mutation status were included, 39 (37.9%) of whom had KRAS mutated tumours. Complete case analysis of the patients was performed according to the Clinical Risk Score (CRS), m-CS, and GAME score. The primary outcome was overall survival stratified according to low-risk and high-risk scores. Harrell's C-index and Akaike information criterion (AIC) were used to compare the discrimination of the evaluated prognostic models. RESULTS: The GAME score demonstrated the largest difference in overall survival for patients stratified according to low-risk and high-risk groups. Harrell's C-index values for the CRS, m-CS, and GAME models were 0.583, 0.600, and 0.668, respectively. AIC values for the CRS, m-CS, and GAME models were 441, 439, and 427, respectively. CONCLUSION: The GAME score outperforms the CRS and m-CS in predicting overall survival after resection of CRLM in patients with known KRAS mutation status.

Corrigendum: Serum Biomarker Panel for Diagnosis and Prognosis of Pancreatic Ductal Adenocarcinomas.

[This corrects the article DOI: 10.3389/fonc.2021.708963.].

Serum Biomarker Panel for Diagnosis and Prognosis of Pancreatic Ductal Adenocarcinomas.

BACKGROUND: Patients with pancreatic ductal adenocarcinoma (PDAC) have late diagnosis which results in poor prognosis. Currently, surgical resection is the only option for curative intent. Identifying high-risk features for patients with aggressive PDAC is essential for accurate diagnosis, prognostication, and personalised care due to the disease burden and risk of recurrence despite surgical resection. A panel of three biomarkers identified in tumour tissue (S100A4, Ca125 and Mesothelin) have shown an association with poor prognosis and overall survival. The diagnostic and prognostic value of the serum concentration of this particular biomarker panel for patients with PDAC has not been previously studied. METHODS: Retrospectively collected blood samples of PDAC patients (n =120) and healthy controls (n =80) were evaluated for the serum concentration of select biomarkers - S100A4, S100A2, Ca-125, Ca 19-9 and mesothelin. Statistical analyses were performed for diagnostic and prognostic correlation. RESULTS: A panel of four biomarkers (S100A2, S100A4, Ca-125 and Ca 19-9) achieved high diagnostic potential (AUROC 0.913). Three biomarkers (S100A4, Ca-125 and Ca 19-9) correlated with poor overall survival in a univariable model (p < 0.05). PDAC patients with abnormal levels of 2 or more biomarkers in their serum demonstrated significantly lower survival compared to patients with abnormal levels of one or less biomarker (p < 0.05). CONCLUSION AND IMPACT: The identified biomarker panels have shown the potential to diagnose PDAC patients and stratify patients based on their prognostic outcomes. If independently validated, this may lead to the development of a diagnostic and prognosticating blood test for PDAC.

Gallbladder carcinoma outcomes in an Australian tertiary referral hospital.

BACKGROUND: This study aimed to examine the presentation, treatment, and long-term outcomes of patients with gallbladder carcinoma (GBC) managed in a surgical unit of an Australian tertiary referral hospital of a 19-year period. METHODS: A retrospective review of prospectively collected data of patients with GBC managed in the Royal North Shore Upper GI Surgical department from October 1999 to March 2018. RESULTS: A total of 104 patients with GBC were identified: 36 patients underwent palliative treatment, 61 patients with gallbladder adenocarcinoma underwent resection with curative intent. Seven patients were excluded. 'Simple cholecystectomy' was undertaken in eight patients, 'standard radical cholecystectomy' in 37 and 'extended radical resection' in 16. The median survival in these patients was 35 months (95% confidence interval (CI) 21.29-55.10), with a median follow up of 60 months (95% CI 38.18-78.39). This compares with an overall median survival of only 4.00 months (95% CI 2.79-6.24) in patients who did not undergo a potentially curative resection. Independent predictors of poor long-term survival included an elevated preoperative serum tumour marker, advanced tumour stage (T3/T4) or node positive disease (N1/N2). CONCLUSION: The biology and stage of GBC at presentation are major factors in determining patient outcome. There is a need for better pre- and post-operative predictors to improve risk stratification, and these are likely to be in the form of molecular markers. Although the focus of surgery should be to ensure an R0 resection, patients with advanced stage disease need to be carefully selected for surgical intervention, and ideally should be managed by a multidisciplinary team in a specialist centre.

Unsuspected choledocholithiasis found by routine intra-operative cholangiography during laparoscopic cholecystectomy.

BACKGROUND: The true incidence of unsuspected choledocholithiasis found during laparoscopic cholecystectomy (LC) is unknown. Untreated 'silent' stones may be associated with significant long-term risks. The aim of this study was to establish the incidence of unsuspected common bile duct stones (CBDS) and to determine the management and associated risk factors for unsuspected CBDS. METHODS: Retrospective review of a large consecutive series of patients from Australia who underwent LC in a tertiary referral setting. Percentages of unsuspected CBDS, management and complications were reported. Pre-operative and intra-operative factors associated with unsuspected CBDS were determined using multivariable logistic regression analysis. RESULTS: From a total of 1998 patients who underwent LC, 747 (37.4%) patients with no pre-operative suspicious factors were the subject of this study. CBDS were detected in 24 (3.2%) patients and all were managed either laparoscopically or endoscopically. Risk factors independently associated with unsuspected CBDS included patients >55 years of age (odds ratio 2.93, P = 0.038) and a large cystic duct size (odds ratio = 3.13, P < 0.001) on multivariable analysis. CONCLUSION: The incidence of patients with unsuspected CBDS on intra-operative cholangiography is low. Complete clearance of these stones can be achieved using a combination of laparoscopic and endoscopic methods.