Postoperative infectious complications worsen oncologic outcomes following pancreaticoduodenectomy for pancreatic ductal adenocarcinoma.

BACKGROUND: Pancreaticoduodenectomy (PD) remains the only curative option for patients with pancreatic adenocarcinoma (PDAC). Infectious complications (IC) can negatively impact patient outcomes and delay adjuvant therapy in most patients. This study aims to determine IC effect on overall survival (OS) following PD for PDAC. STUDY DESIGN: Patients who underwent PD for PDAC between 2010 and 2020 were identified from a single institutional database. Patients were categorized into two groups based on whether they experienced IC or not. The relationship between postoperative IC and OS was investigated using Kaplan-Meier and Cox-regression multivariate analysis. RESULTS: Among 655 patients who underwent PD for PDAC, 197 (30%) experienced a postoperative IC. Superficial wound infection was the most common type of infectious complication (n = 125, 63.4%). Patients with IC had significantly more minor complications (Clavien-Dindo [CD] < 3; [59.4% vs. 40.2%, p < 0.001]), major complications (CD ≥ 3; [37.6% vs. 18.8%, p < 0.001]), prolonged LOS (47.2% vs 20.3%, p < 0.001), biochemical leak (6.1% vs. 2.8%, p = 0.046), postoperative bleeding (4.1% vs. 1.3%, p = 0.026) and reoperation (9.6% vs. 2.2%, p < 0.001). Time to adjuvant chemotherapy was delayed in patients with IC versus those without (10 vs. 8 weeks, p < 0.001). Median OS for patients who experienced no complication, noninfectious complication, and infectious complication was 33.3 months, 29.06 months, and 27.58 months respectively (p = 0.023). On multivariate analysis, postoperative IC were an independent predictor of worse OS (HR 1.32, p = 0.049). CONCLUSIONS: IC following PD for PDAC independently predict worse oncologic outcomes. Thus, efforts to prevent and manage IC should be a priority in the care of patients undergoing PD for PDAC.

Impact of Extended Antibiotic Use After Pancreaticoduodenectomy for Patients with Preoperative Metallic Biliary Stenting Treated with Neoadjuvant Chemotherapy.

INTRODUCTION: Pancreaticoduodenectomy (PD) remains a complex surgical procedure with infectious complications affecting nearly 50% of patients. Patients who undergo biliary drainage with stent placement prior to neoadjuvant treatment (NAT) reportedly have higher infection rates following PD. The aim of the current study is to evaluate the differences in postoperative infectious complication rates based on the duration of post operative prophylactic antibiotics in patients with indwelling metal biliary stent who had NAT. METHODS: A retrospective institutional pancreatic cancer database was queried for patients who had a metal biliary stent placed prior to NAT initiation, followed by subsequent PD between 2014 and 2021. Duration of postoperative prophylactic antibiotics was defined as short (SC: ≤ 24 h) or extended (EC: > 24 h-7 days). The primary outcome of interest was surgical site infection (SSI). RESULTS: Two hundred and ninety-five (n = 295) patients were identified of which the majority (n = 205, 69.5%) received a short course of antibiotics postoperatively. Baseline characteristics were similar between the two cohorts including age, sex, BMI, and comorbidity index. EC patients received more NAT cycles (4 vs. 3, p < 0.001) and underwent an open PD more frequently (61.8% vs. 41.0%, p < 0.001). SSI occurred in 64 (21.7%) patients; SC cohort: 54, 26.3% vs. EC cohort:10, 11.1%, (p = 0.003). Additionally, the SC cohort demonstrated a higher incidence of major complications (Clavien-Dindo ≥ 3: 51 [24.9%] vs. 13 [14.4%], p = 0.045). On the logistic regression model examining factors associated with SSI, higher BMI (continuous variable) was associated with increased odds of SSI (OR: 1.05 [95%CI: 1.00, 1.10, p = 0.040), while EC was protective (OR: 0.36 [95%CI: 0.17, 0.75], p = 0.007). CONCLUSIONS: These data suggest that an extended course of perioperative antibiotic correlates with reductions in SSI and major morbidity following PD in patients with a metallic biliary stent placed prior to NAT course. These results require validation in a future randomized clinical trial examining a larger cohort of patients with further emphasis on the types of perioperative antibiotics administered.

Evaluation of Adjuvant Chemotherapy Survival Outcomes Among Patients With Surgically Resected Pancreatic Carcinoma With Node-Negative Disease After Neoadjuvant Therapy.

Importance: Neoadjuvant therapy (NAT) is rarely associated with a complete histopathologic response in patients with pancreatic ductal adenocarcinoma (PDAC) but results in downstaging of regional nodal disease. Such nodal downstaging after NAT may have implications for the use of additional adjuvant therapy (AT). Objectives: To examine the prognostic implications of AT in patients with node-negative (N0) disease after NAT and to identify factors associated with progression-free (PFS) and overall survival (OS). Design, Setting, and Participants: A retrospective review was conducted using data from 2 high-volume, tertiary care academic centers (University of Pittsburgh Medical Center and the Medical College of Wisconsin). Prospectively maintained pancreatic cancer databases at both institutes were searched to identify patients with localized PDAC treated with preoperative therapy and subsequent surgical resection between 2010 and 2019, with N0 disease on final histopathology. Exposures: Patients received NAT consisting of chemotherapy with or without concomitant neoadjuvant radiation (NART). For patients who received NART, chemotherapy regimens were gemcitabine or 5-fluoururacil based and included stereotactic body radiotherapy (SBRT) or intensity-modulated radiation therapy (IMRT) after all intended chemotherapy and approximately 4 to 5 weeks before anticipated surgery. Adjuvant therapy consisted of gemcitabine-based therapy or FOLFIRINOX; when used, adjuvant radiation was commonly administered as either SBRT or IMRT. Main Outcomes and Measures: The association of AT with PFS and OS was evaluated in the overall cohort and in different subgroups. The interaction between AT and other clinicopathologic variables was examined on Cox proportional hazards regression analysis. Results: In this cohort study, 430 consecutive patients were treated between 2010 and 2019. Patients had a mean (SD) age of 65.2 (9.4) years, and 220 (51.2%) were women. The predominant NAT was gemcitabine based (196 patients [45.6%]), with a median duration of 2.7 cycles (IQR, 1.5-3.4). Neoadjuvant radiation was administered to 279 patients (64.9%). Pancreatoduodenectomy was performed in 310 patients (72.1%), and 160 (37.2%) required concomitant vascular resection. The median lymph node yield was 26 (IQR, 19-34); perineural invasion (PNI), lymphovascular invasion (LVI), and residual positive margins (R1) were found in 254 (59.3%), 92 (22.0%), and 87 (21.1%) patients, respectively. The restricted mean OS was 5.2 years (95% CI, 4.8-5.7). On adjusted analysis, PNI, LVI, and poorly differentiated tumors were independently associated with worse PFS and OS in N0 disease after NAT, with hazard ratios (95% CIs) of 2.04 (1.43-2.92; P < .001) and 1.68 (1.14-2.48; P = .009), 1.47 (1.08-1.98; P = .01) and 1.54 (1.10-2.14; P = .01), and 1.90 (1.18-3.07; P = .008) and 1.98 (1.20-3.26; P = .008), respectively. Although AT was associated with prolonged survival in the overall cohort, the effect was reduced in patients who received NART and strengthened in patients with PNI (AT × PNI interaction: hazard ratio, 0.55 [95% CI, 0.32-0.97]; P = .04). Conclusions and Relevance: The findings of this cohort study suggest a survival benefit for AT in patients with N0 disease after NAT and surgical resection. This survival benefit may be most pronounced in patients with PNI.

Obesity Is Associated With Increased Risk for Adverse Postoperative Outcomes After Distal Pancreatectomy for Pancreatic Ductal Adenocarcinoma.

INTRODUCTION: Conflicting reports exist about the effect obesity has on adverse postoperative surgical outcomes after distal pancreatectomy (DP). The aim of this study is to explore the role of obesity in terms of morbidity and pancreas-specific complications following DP for pancreatic ductal adenocarcinoma (PDAC). METHODS: All patients who underwent DP at a single institution over 10 y were analyzed (2009-2020). Patients were categorized as nonobese (body mass index [BMI] < 30 kg/m2) and obese (BMI ≥ 30 kg/m2). Independent predictors of adverse postoperative outcomes were calculated using multivariate logistic regression models. Overall survival was assessed using Kaplan-Meier survival analysis. RESULTS: Of the 178 patients included, 58 (32.5%) were obese. Clinically relevant postoperative pancreatic fistula (CR-POPF) formation rate was significantly higher in the obese group (20.6% versus 7.5%, P value = 0.011). We did not identify any significant difference between obese and nonobese patients in median overall survival (30.2 mon versus 28.9 mon, P value = 0.811). On multivariate binary logistic regression analysis, BMI ≥ 30 was an independent predictor of morbidity (any complication) and CR-POPF formation after DP for PDAC. CONCLUSIONS: Obesity is associated with a significantly increased risk for CR-POPF in patients undergoing DP for PDAC. Obesity should be considered as a variable in fistula risk calculators for DP.

Appendectomy Is Oncologically Equivalent to Right Hemicolectomy for Well-Differentiated T1 Appendiceal Adenocarcinoma.

BACKGROUND: Right hemicolectomy is recommended for appendiceal adenocarcinoma but may not be needed for early stage disease. OBJECTIVE: This study aimed to determine whether appendectomy offers adequate oncologic outcomes for T1 appendiceal adenocarcinoma from a national cohort of patients. DESIGN: Patients with T1 appendiceal adenocarcinoma (mucinous and nonmucinous histology) treated with either a right hemicolectomy or appendectomy between 2004 and 2016 were retrieved. Multivariate Cox regression analysis was used to identify predictors of overall survival. SETTING: The study was conducted using a national cancer database. PATIENTS: A total of 320 patients (median age, 62 y; 47% women) were identified: 69 (22%) underwent an appendectomy and 251 (78%) underwent a right hemicolectomy. MAIN OUTCOME MEASURE: Overall survival was measured. RESULTS: Nonmucinous adenocarcinoma was identified in 194 (61%), whereas 126 (39%) had mucinous adenocarcinoma. Of the overall cohort, 43% had well-differentiated histology, 39% had moderately differentiated disease, and 4% had poorly differentiated tumors. The rate of lymph node metastasis was lower in well-differentiated tumors (3%) compared with moderately (10%) or poorly differentiated tumors (25%). On univariate survival analysis, right hemicolectomy was associated with improved 1-, 3-, and 5-year overall survival in patients with moderately/poorly differentiated disease ( p < 0.001) but not for well-differentiated disease ( p = 1.000). After adjustment, right hemicolectomy was associated with overall survival improvement for moderately/poorly differentiated T1 adenocarcinoma (HR = 0.26 [95% CI, 0.08-0.82]; p = 0.02) but not for well-differentiated disease. LIMITATIONS: This study was limited by its retrospective nature. CONCLUSIONS: The current analysis from the National Cancer Database demonstrates that appendectomy is associated with equivalent survival to right hemicolectomy for well-differentiated T1 adenocarcinoma, whereas for moderately and poorly differentiated disease, right hemicolectomy is oncologically superior to appendectomy. See Video Abstract at http://links.lww.com/DCR/B689 . LA APENDICECTOMA ES ONCOLGICAMENTE EQUIVALENTE A LA HEMICOLECTOMA DERECHA PARA EL ADENOCARCINOMA APENDICULAR T BIEN DIFERENCIADO: ANTECEDENTES:La hemicolectomía derecha se recomienda para el adenocarcinoma apendicular, pero puede no ser necesaria para la enfermedad en estadio temprano.OBJETIVO:Este estudio tuvo como objetivo determinar si la apendicectomía ofrece resultados oncológicos adecuados para el adenocarcinoma apendicular T1 de una cohorte nacional de pacientes.DISEÑO:Se recuperaron pacientes con adenocarcinoma apendicular T1 (histología mucinoso y no mucinoso) tratados con hemicolectomía derecha o apendicectomía entre 2004-2016. Se utilizó un análisis de regresión de Cox multivariante para identificar los predictores de la supervivencia global.ENTORNO CLÍNICO:Base de datos nacional sobre cáncer.PACIENTES:Se identificaron un total de 320 pacientes (mediana de edad 62 años, 47% mujeres): 69 (22%) se sometieron a una apendicectomía y 251 (78%) se sometieron a una hemicolectomía derecha.PRINCIPAL MEDIDA DE RESULTADO:Sobrevida global.RESULTADOS:Se identificó adenocarcinoma no mucinoso en 194 (61%) mientras que 126 (39%) tenían adenocarcinoma mucinoso. De la cohorte general, el 43% tenía una histología bien diferenciada, el 39% tenía una enfermedad moderadamente diferenciada y el 4% tenía tumores poco diferenciados. La tasa de metástasis en los ganglios linfáticos fue menor en los tumores bien diferenciados (3%) en comparación con los tumores moderadamente (10%) o pobremente diferenciados (25%). En el análisis de sobrevida univariante, la hemicolectomía derecha se asoció con una mejor sobrevida general a 1, 3, y 5 años en pacientes con enfermedad moderada / pobremente diferenciada ( p < 0,001) pero no para la enfermedad bien diferenciada ( p = 1,000). Después del ajuste, la hemicolectomía derecha se asoció con una mejora de la sobrevida general para el adenocarcinoma T1 moderadamente / poco diferenciado (HR = 0,26, IC del 95%: 0,08-0,82, p = 0,02) pero no para la enfermedad bien diferenciada.LIMITACIONES:Este estudio estuvo limitado por su naturaleza retrospectiva.CONCLUSIONES:El análisis actual de la base de datos nacional de cáncer demuestra que la apendicectomía se asocia con una sobrevida similar a la hemicolectomía derecha para el adenocarcinoma T1 bien diferenciado, mientras que para la enfermedad moderada y pobremente diferenciada, la hemicolectomía derecha es oncológicamente superior a la apendicectomía. Consulte Video Resumen en http://links.lww.com/DCR/B689 . (Traducción-Dr. Yazmin Berrones-Medina ).

Robotic Pancreaticoduodenectomy: Increased Adoption and Improved Outcomes: Is Laparoscopy Still Justified?

OBJECTIVE: To compare the rate of postoperative 30-day complications between laparoscopic pancreaticoduodenectomy (LPD) and robotic pancreaticoduodenectomy (RPD). BACKGROUND: Previous studies suggest that minimally invasive pancreaticoduodenectomy (MI-PD)-either LPD or RPD-is noninferior to open pancreaticoduodenectomy in terms of operative outcomes. However, a direct comparison of the two minimally invasive approaches has not been rigorously performed. METHODS: Patients who underwent MI-PD were abstracted from the 2014 to 2019 pancreas-targeted American College of Surgeons National Sample Quality Improvement Program (ACS NSQIP) dataset. Optimal outcome was defined as absence of postoperative mortality, serious complication, percutaneous drainage, reoperation, and prolonged length of stay (75th percentile, 11 days) with no readmission. Multivariable logistic regression models were used to compare optimal outcome of RPD and LPD. RESULTS: A total of 1540 MI-PDs were identified between 2014 and 2019, of which 885 (57%) were RPD and 655 (43%) were LPD. The rate of RPD cases/year significantly increased from 2.4% to 8.4% ( P =0.008) from 2014 to 2019, while LPD remained unchanged. Similarly, the rate of optimal outcome for RPD increased during the study period from 48.2% to 57.8% ( P <0.001) but significantly decreased for LPD (53.5% to 44.9%, P <0.001). During 2018-2019, RPD outcomes surpassed LPD for any complication [odds ratio (OR)=0.58, P =0.004], serious complications (OR=0.61, P =0.011), and optimal outcome (OR=1.78, P =0.001). CONCLUSIONS: RPD adoption increased compared with LPD and was associated with decreased overall complications, serious complications, and increased optimal outcome compared with LPD in 2018-2019.

Robotic Cyst Gastrostomy and Roux-en-Y Cyst Jejunostomy for a Bilobed Walled-Off Pancreatic Necroma.

BACKGROUND: Walled-off pancreatic necrosis (WON) represents delayed sequelae of necrotizing pancreatitis, generally developing in 5-15% of cases 4 weeks after the initial attack (Boskoski and Costamagna Ann Gastroenterol 27(2):93-94, 2014). They are characterized by a well-circumscribed, encapsulated collection of necrotic parenchyma with variable degree of gland liquefaction (Boskoski and Costamagna Ann Gastroenterol 27(2):93-94, 2014, Khreiss et al. J Gastrointest Surg 19(8):1441-1448, 2015). Although a significant number of WONs are asymptomatic and resolve spontaneously, some will ultimately require endoscopic or surgical intervention (Costa et al. Br J Surg 101(1):e65-e79, 2014). In this video, we demonstrate a robotic cyst gastrostomy and Roux-en-Y cyst jejunostomy performed for two simultaneous and complex WONs. METHODS: A 71-year-old female presented with a history of drug-induced necrotizing pancreatitis 2 years prior to surgical referral. This was complicated by the development of two separate WONs in the head and the body of the pancreas measuring 6.5 × 6.5 cm and 9.7 × 7.3 cm respectively, with significant necrotic debris. Due to the continued growth of both WONs and progressive discomfort, the decision was made to pursue simultaneous internal surgical drainage of both lesions using a minimally invasive approach. The procedure was performed using the DaVinci Si HD robotic Surgical System (Intuitive Surgical Inc.) and lasted 180 min with a total blood loss of approximately 25 ml. A cyst gastrostomy and a Roux-en-Y cyst jejunostomy were performed for the body and head WONs respectively following debridement of the necrotic tissue. The patient tolerated the procedure well, had an uneventful postoperative course, and was discharged on post-operative day 7. CONCLUSION: This case demonstrates that the robotic approach can be a safe and effective modality for the management of technically challenging and complex WONs. Although endoscopic or video-assisted retroperitoneal drainage procedures are alternative treatment modalities for WON, the complexity and size of this bilobed WON, coupled to the significant amount of necrotic debris and the need for a concomitant cholecystectomy, made this case ideal for internal surgical drainage via the robotic approach, since it allowed for definitive treatment with fewer reinterventions (Khreiss et al. J Gastrointest Surg 19(8):1441-1448, 2015).

The Role of Adjuvant Chemotherapy Following Right Hemicolectomy for Non-metastatic Mucinous and Nonmucinous Appendiceal Adenocarcinoma.

BACKGROUND: Appendiceal adenocarcinoma (AA) represents a heterogenous group of neoplasms with distinct histologic features. The role and efficacy of adjuvant chemotherapy (AC) in non-metastatic disease remain controversial. The aim of this study was to ascertain the role of AC in non-metastatic AA in a national cohort of patients. METHODS: The National Cancer Database (NCDB) was queried to identify patients diagnosed with stage I-III mucinous and nonmucinous AA who underwent right hemicolectomy between 2006 and 2016. Kaplan-Meier and Cox regression analyses were used to evaluate the impact of AC on overall survival (OS) stratified by each pathologic stage. RESULTS: A total of 1433 mucinous and 1954 nonmucinous AA were identified; 578 (40%) and 722 (40%) received AC respectively. In both AC groups, there was a higher proportion of T4 disease, lymph node metastasis, pathologic stage III, and poorly/undifferentiated grade (all P<0.05). On unadjusted analysis, there was no significant association between AC and OS for stage I-III mucinous AA. For nonmucinous AA, AC significantly improved OS only for stage II and III disease. On adjusted analysis, AC was independently associated with an improved OS for stage III nonmucinous AA (HR: 0.61, 95%CI 0.45-0.84, P=0.002), while for mucinous AA, AC was associated with worse outcomes for stage I/II disease (HR: 1.4, 95%CI 1.02-1.91, P=0.038) and had no significant association with OS for stage III disease. CONCLUSION: This current analysis of a national cohort of patients suggests a beneficial role for AC in stage III nonmucinous AA and demonstrates no identifiable benefit for stage I-III mucinous AA.

Stereotactic body radiation therapy for hepatocellular carcinoma: Practice patterns, dose selection and factors impacting survival.

BACKGROUND: Stereotactic body radiation therapy (SBRT) is an emerging option for unresectable hepatocellular carcinoma (HCC) without consensus regarding optimal dose schemas. This analysis identifies practice patterns and factors that influence dose selection and overall survival, with particular emphasis on dose and tumor size. MATERIALS/METHODS: Query of the National Cancer Database (NCDB) identified patients with unresectable, nonmetastatic HCC who received SBRT from 2004 to 2013. Biological Effective Dose (BED) was calculated for each patient in order to uniformly analyze different fractionation regimens. RESULTS: A total of 456 patients met the inclusion criteria. The median BED was 100 Gy (22.5-208.0), which corresponded to the most common dose fractionation (50 Gy in five fractions). Various factors influenced dose selection including tumor size (P < 0.001), tumor stage (P = 0.002), and facility case volume (<0.001). On multivariate analysis, low BED (<75 Gy, HR 2.537, P < 0.001; 75-100 Gy, HR 1.986, P = 0.007), increasing tumor size (HR 1.067, P = 0.032), elevated AFP (HR 1.585, P = 0.019), stage 3 (HR 1.962, P < 0.001), low-volume facilities (1-5 cases HR 1.687, P = 0.006), and a longer time interval from diagnosis to SBRT (>2 to ≤4 months, HR 1.456, P = 0.048; >4 months, HR 2.192, P < 0.001) were associated with worse survival. CONCLUSION: SBRT use is increasing for HCC, and multiple regimens are clinically employed. Although high BED was associated with improved outcomes, multiple factors contributed to the dose selection with favorable patients receiving higher doses. Continued efforts to enhance radiation planning and delivery may help improve utilization, safety, and efficacy.

Pancreatitis.

Acute pancreatitis is an inflammation of the glandular parenchyma of the retroperitoneal organ that leads to injury with or without subsequent destruction of the pancreatic acini. This inflammatory process can either result in a self-limited disease or involve life-threatening multiorgan complications. Chronic pancreatitis consists of endocrine and exocrine gland dysfunction that develops secondary to progressive inflammation and chronic fibrosis of the pancreatic acini with permanent structural damage. Recurrent attacks of acute pancreatitis can result in chronic pancreatitis; acute and chronic pancreatitis are different diseases with separate morphologic patterns. Acute pancreatitis has an increasing incidence but a decreasing mortality.

Disparities in access to care and outcomes in patients with adrenocortical carcinoma.

BACKGROUND: Surgical resection remains the mainstay of treatment for patients with adrenocortical carcinoma (ACC). The aim of the present study is to examine disparities in access to surgical resection and identify factors associated with overall survival following surgical resection. METHODS: The National Cancer Database was queried for patients with ACC (2004-2013). Patient characteristics and disease details were abstracted. Logistic regression analysis was performed to examine the factors associated with surgical resection, and a multivariate Cox proportional hazards model was used to identify predictors of survival in the surgical cohort. RESULTS: Surgical resection was performed in 2007/2946 (68%) ACC patients. On multivariate logistic regression analysis controlling for clinicodemographic factors, surgery was less likely to be performed in patients ≥56 y, males, African-Americans, patients with government insurance, or those treated at community cancer centers (P < 0.05). On a multivariate Cox proportional hazards model adjusting for clinicodemographic and treatment variables, older age (≥56 y) and presence of comorbidities were associated with worse overall survival. CONCLUSIONS: These findings suggest that there are demographic and socioeconomic disparities in access to surgical resection for ACC. However, after adjusting for patient and clinical characteristics, only patient age and presence of comorbidities were predictors of worse survival in patients undergoing surgery for ACC. More data are needed to determine the factors driving these disparities.

Liver transplantation in patients with incidental hepatocellular carcinoma/cholangiocarcinoma and intrahepatic cholangiocarcinoma: a single-center experience.

BACKGROUND: Reports of liver transplantation (LT) in patients with mixed hepatocellular carcinoma/cholangiocarcinoma (HCC/CC) and intrahepatic cholangiocarcinoma (ICC) are modest and have been mostly retrospective after pathological categorization in the setting of presumed HCC. Some studies suggest that patients undergoing LT with small and unifocal ICC or mixed HCC/CC can achieve about 40%-60% 5-year post-transplant survival. The study aimed to report our experience in patients undergoing LT with explant pathology revealing HCC/CC and ICC. METHODS: From a prospectively maintained database, we performed cohort analysis. We identified 13 patients who underwent LT with explant pathology revealing HCC/CC or ICC. RESULTS: The observed recurrence rate post-LT was 31% (4/13) and overall survival was 85%, 51%, and 51% at 1, 3 and 5 years, respectively. Disease-free survival was 68%, 51%, and 41% at 1, 3 and 5 years, respectively. In our cohort, four patients would have qualified for exception points based on updated HCC Organ Procurement and Transplantation Network imaging guidelines. CONCLUSIONS: Lesions which lack complete imaging characteristics of HCC may warrant pre-LT biopsy to fully elucidate their pathology. Identified patients with early HCC/CC or ICC may benefit from LT if unresectable. Additionally, incorporating adjunctive perioperative therapies such as in the case of patients undergoing LT with hilar cholangiocarcinoma may improve outcomes but this warrants further investigation.

Factors associated with palliative care use in patients undergoing cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

BACKGROUND: Peritoneal carcinomatosis represents widespread metastatic disease throughout the abdomen and/or pelvis. Cytoreductive surgery/hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) improves the overall survival compared to standard therapy alone. The role palliative care (PC) plays however, remains poorly studied among these patients. METHODS: Patients who had previously undergone HIPEC and who underwent an inpatient admission from 7/1/2013 to 6/30/2014 were identified to determine which patients were referred for inpatient or outpatient palliative consultation. Multivariable logistic regression analysis was performed to identify risk factors associated with the use of PC. RESULTS: Of the 60 patients analyzed, 23 (38.3%) had a PC consultation with a median time to PC referral of 310 (IQR: 151-484 days). Patients who were prescribed opioids (no PC referral versus PC referral: 46.0% versus 91.3%, P < 0.001), patients who reported the use of a cancer-related emetic (35.1% versus 87.0%, P < 0.001), patients reporting the use of total parenteral nutrition (16.2% versus 39.1%, P = 0.046), and patients dependent on a gastric tube for nutrition (5.4% versus 43.5%, P < 0.001) were more likely to be referred to a PC consultation. On multivariable analysis, use of opioids, use of a cancer-related antiemetic, and the use of a G-tube were independently associated with a greater odds for being referred to PC (all P < 0.05). CONCLUSIONS: Approximately one-third of patients were referred to PC following cytoreductive surgery/hyperthermic intraperitoneal chemotherapy. Palliative care referrals were most commonly used for patients with chronic symptoms, which are difficult to manage, especially toward the end of life.

External radiation or ablation for solitary hepatocellular carcinoma: A survival analysis of the SEER database.

BACKGROUND AND OBJECTIVES: Hepatocellular carcinoma (HCC) patients are often not candidates for resection. This study hypothesized that external beam radiation (XRT) could be equally effective compared to ablation therapy (AT) for selected HCC patients. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was used to identify HCC patients (2004-2012) undergoing XRT or AT for solitary HCC lesions. Propensity score modeling was utilized to adjust for baseline characteristics. RESULTS: Propensity matching identified 784 patients: 157 (20%) XRT and 627 (80%) AT. Median OS for XRT and AT was 22, and 32 months (P < 0.001), respectively. AT demonstrated improved OS for tumors 3-5 cm (30 vs 16 m, P < 0.001) and >5 cm (25 vs 9 m, P < 0.001). Similar survival was found in patients with tumor size <3 cm (37 vs 47 m P = 0.508). Following multivariate analyses, XRT was associated with an increased hazard ratio (HR = 1.64, P < 0.001). Elevated AFP at diagnosis (HR = 1.54, P = 0.001) and tumor size >3 were identified as negative predictors of survival. CONCLUSIONS: Similar survival for solitary HCC lesions <3 cm exists between XRT and AT. However, AT demonstrates improved survival rates compared to XRT for lesions >3 cm. This 3 cm reference point may serve as a valuable metric to guide treatment decisions and future investigations.

Evolution of a laparoscopic liver resection program: an analysis of 203 cases.

BACKGROUND: Techniques for laparoscopic liver resection (LLR) have been developed over the past two decades. The aim of this study is to analyze the outcomes and trends of LLR. METHODS: 203 patients underwent LLR between 2006 and 2015. Trends in techniques and outcomes were assessed dividing the experience into 2 periods (before and after 2011). RESULTS: Tumor type was malignant in 62%, and R0 resection was achieved in 87.7%. Procedures included segmentectomy/wedge resection in 64.5%. Techniques included a purely laparoscopic approach in 59.1% and robotic 12.3%. Conversion to open surgery was necessary in 6.4% cases. Mean hospital stay was 3.7 ± 0.2 days. 90-day mortality was 0% and morbidity 20.2%. Pre-coagulation and the robot were used less often, while the performance of resections for posteriorly located tumors increased in the second versus the first period. CONCLUSION: This study confirms the safety and efficacy of LLR, while describing the evolution of a program regarding patient and technical selection. With building experience, the number of resections performed for posteriorly located tumors have increased, with less reliance on pre-coagulation and the robot.

Palliative interventions for hepatocellular carcinoma patients: analysis of the National Cancer Database.

BACKGROUND: Palliative therapies are provided to a subset of hepatocellular carcinoma (HCC) patients with the aim of providing symptomatic relief, better quality of life and improved survival. The present study sought to assess and compare the efficacy of different palliative therapies for HCC. METHODS: The National Cancer Database (NCDB), a retrospective national database that captures approximately 70% of all patients treated for cancer in the US, was queried for patients with HCC who were deemed unresectable from 1998-2011. Patients were stratified by receipt of palliative therapy. Survival analysis was examined by log-rank test and Kaplan Meier curves, and a multivariate proportional hazards model was utilized to identify the predictors of survival. RESULTS: A total of 3,267 patients were identified; 287 (8.7%) received surgical palliation, 827 (25.3%) received radiotherapy (RT), 877 (26.8%) received chemotherapy, 1,067 (32.6%) received pain management therapy, while 209 (6.4%) received a combination of the previous three modalities. On multivariate analysis palliative RT was identified as a positive predictor of survival [hazards ratio (HR) 0.65; 95% CI, 0.50-0.83]. Stratifying by disease stage, palliative RT provided a significant survival benefit for patients with stage IV disease. CONCLUSIONS: Palliative RT appears to extend survival and should be considered for patients presenting with late stage HCC.

Optimal timing for a repeat fine-needle aspiration biopsy of thyroid nodule following an initial nondiagnostic fine-needle aspiration.

BACKGROUND: In the case of a nondiagnostic thyroid fine-needle aspiration (FNA) biopsy result, recent guidelines from the Bethesda system recommend repeat thyroid FNA after 3 months to prevent false-positive results. We aimed to examine our institutional data to determine whether the 3-month period affects the diagnostic yield of repeat biopsies. METHODS: A retrospective review of patient records over a 5-year period at our institution was performed. Patients who required repeat FNA due to nondiagnostic results were included. The time between the FNA biopsies, adequacy of the FNA specimens, as well as the surgical pathology diagnosis were analyzed. RESULTS: We identified 317 patients who required a repeat FNA. Of these, 96 (30.3%) patients had repeat FNAs less than 3 months after initial biopsy, while 221 (69.7%) patients had repeat FNAs in greater than 3 months. One hundred five patients were referred to our clinic with an initial nondiagnostic biopsy from an outside institution. Repeat FNA was nondiagnostic in 35 patients (11.04%) in the total study population. There was no difference in satisfactory diagnostic yield between repeat FNAs performed greater than 3 months (201 patients, 90.95%) or less than 3 months (81 patients, 84.38%) after the initial biopsy (P = .117). Of the 35 patients with repeat nondiagnostic biopsy, 17 patients underwent diagnostic lobectomy and 3 (17.6%) patients were found to have malignant disease. CONCLUSIONS: Early (<3 months) repeat FNA does not affect diagnostic yield of the subsequent sample. Patients with suspicious thyroid nodules could therefore receive a repeat FNA as soon as needed, rather than waiting 3 months. The shortened biopsy interval would alleviate stress on patients with benign nodules and expedite surgical intervention in patients with malignancy.

Parathyroidectomy for primary hyperparathyroidism improves sleep quality: A prospective study.

BACKGROUND: This prospective survey study assessed changes in sleep quality in patients with primary hyperparathyroidism after parathyroidectomy. METHODS: Patients undergoing parathyroidectomy for primary hyperparathyroidism (n = 110) or thyroidectomy for benign euthyroid disease (control group; n = 45) were recruited between June 2013 and June 2015 and completed the Pittsburgh Sleep Quality Index preoperatively and at 1- and 6 months postoperatively. "Poor" sleep quality was defined as a score >5; a clinically important and relevant improvement was a ≥3-point decrease. RESULTS: Preoperatively, parathyroid patients had worse sleep quality than thyroid patients (mean 8.1 vs 5.3; P < .001); 76 (69%) parathyroid and 23 (51%) thyroid patients reported poor sleep quality (P = .03). Postoperatively, only parathyroid patients demonstrated improvement in sleep quality; mean scores did not differ between the parathyroid and thyroid groups at 1 month (6.3 vs 5.3; P = .12) or 6 months (5.8 vs 4.6; P = .11). The proportion of patients with a clinically important improvement in sleep quality was greater in the parathyroid group at 1 month (37% vs 10%; P < .001) and 6 months (40% vs 17%; P = .01). Importantly, there was no difference in the proportion of patients with poor sleep quality between the 2 groups at 1 month (50% vs 40%; P = .32) and 6 months (40% vs 29%; P = .22). CONCLUSION: More than two-thirds of patients with primary hyperparathyroidism report poor sleep quality. After parathyroidectomy, over one-third experienced improvement, typically within the first month postoperatively.

Is Radiotherapy Warranted Following Intrahepatic Cholangiocarcinoma Resection? The Impact of Surgical Margins and Lymph Node Status on Survival.

BACKGROUND: The role of radiotherapy (RT) for surgically resected intrahepatic cholangiocarcinoma (ICC) remains poorly defined. Radiotherapy is often considered when positive resection margins exist. The present study sought to examine the impact of radiotherapy following ICC resection. METHODS: Patients with early-stage disease, who underwent surgical resection, were identified from the National Cancer Database (1998-2013). Patients were stratified by the receipt of RT. Survival outcomes were examined following propensity score matching (PS), and a Cox regression for survival analysis was used to examine predictors of survival. RESULTS: A total of 2897 patients were identified. R0 status was achieved in 1951 patients (67.3 %). RT was delivered to 525 patients (R0 = 255, R1/R2 = 230, unknown = 43). Following PS matching, the overall survival for R0 versus R1/R2 resection was 31.2 versus 19.5 months (p < .001), respectively. RT was associated with a trend toward improved survival for R1/R2 lymph node negative patients (39.5 vs. 21.1 months; p = .052). In a multivariate model accounting for different patient and disease characteristics, RT was not associated with survival. In contrast, age, comorbidities, tumor grade, resection margins, lymph nodes status, and tumor's T stage were identified as negative predictors of survival. CONCLUSIONS: Patients with negative resection margins demonstrated improved survival outcome among ICC patients. In patients with positive resection margins and node negative disease, radiotherapy did not provide a survival benefit. Further studies are warranted to confirm and further define these results.

A meta-analysis examining the independent association between thyroid nodule size and malignancy.

BACKGROUND: Tumor size is recognized as an important predictor of malignancy in many types of cancers. However, there is no clear line of characterization when it comes to the association between thyroid nodule size and malignancy risk prediction; and the current data remains inconsistent across different studies. The aim of our study is to examine the association between nodule size and malignancy using meta-analysis of the current literature. METHODS: Data sources were gathered through systemic search of PubMed, Embase and other scientific databases for articles published between January 1, 1996 and June 1, 2013. A reference group with nodule sizes <3 cm was set as a control group. Two other nodule size categories were established and these included nodules from 3-5.9 cm and nodules ≥6 cm in size. Primary outcome was a histologically proven malignancy per nodule size category. The effect sizes of clinicopathologic parameters, which are the quantitative measures of association strength between two variables, were calculated by the means of odds ratios (OR). The effect sizes were then combined using a random-effects model. RESULTS: Seven studies met our inclusion criteria with 10,817 thyroid nodules evaluated. Malignancy was identified in 2,206 (20.4%) nodules. After adjusting for patient age and gender, nodules that measured 3-5.9 cm had a 26% greater malignancy risk compared to those measuring <3 cm [OR, 1.26; 95% confidence interval (CI): 1.13-1.39]. However, nodules 6 cm or larger had a 16% lower risk of malignancy compared to those measuring <3 cm (OR, 0.84; 95% CI: 0.73-0.98). CONCLUSIONS: Thyroid nodule size predicts cancer risk. However, a threshold effect of thyroid nodule size 6 cm or greater is significantly associated with a more benign disease.