Is minimally invasive surgery for large gastric GIST actually safe? A comparative analysis of short- and long-term outcomes.

INTRODUCTION: While minimally invasive surgery (MIS) is frequently utilized to remove small gastric gastrointestinal stromal tumors (GIST), MIS surgery for tumors ≥ 5 cm is currently not endorsed by national guidelines as standard of care due to concerns of safety and inferior oncologic outcomes. Hence this study investigates the perioperative and long-term outcomes of MIS for T3 gastric GIST measuring 5-10 cm. METHODS: The National Cancer Database (NCDB) 2017 was queried for gastric GIST measuring 5-10 cm or T3 category. Inclusion criteria were known: stage, size, comorbidities, grade, lymphovascular invasion, type of surgery, approach, conversion info, margin status, mitotic rate, neoadjuvant and adjuvant treatment, hospital stay, readmission, 30- and 90-day mortality, complete follow-up, type of institution, and hospital gastric surgery case volume. Binary logistic regression, linear regression models, and Kaplan-Meier survival analysis were used. RESULTS: In 3765 patients, mean tumor size was 67.3 mm; 26.3% MIS; and 73.8% open. Median hospital stay was shorter for MIS (4.77 vs 7.04 days, p < 0.001). There was no significant difference in incidence of R1 margins [2.9% MIS vs. 3.1% open (p = 0.143)], unplanned readmission [2.9% MIS and 4.1% open (OR 0.474 p = 0.025)], 30-day mortality [0.5% MIS vs 1.2% open (OR 0.325, p = 0.031)], and 90-day mortality [0.9% MIS vs 2.1% open (OR 0.478 p = 0.036)]. Cox regression models for OS showed no difference in survival (p = 0.137, HR 0.808). CONCLUSION: This analysis provides substantial evidence that MIS for gastric GIST ≥ 5-10 cm may not only offer improved postoperative morbidity but also oncologic safety. Moreover, as both approaches lead to similar long-term survival, national guidelines may need to incorporate this new information.

Selection criteria for minimally invasive resection of intrahepatic cholangiocarcinoma-a word of caution: a propensity score matched analysis using the national cancer database.

BACKGROUND: While minimally invasive liver resection (MILR) vs. open approach (OLR) has been shown to be safe, the perioperative and oncologic safety for intrahepatic cholangiocarcinoma (ICC) specifically, necessitating often complex hepatectomy and extended lymphadenectomy, remains ill-defined. METHODS: The National Cancer Database was queried for patients with ICC undergoing liver resection from 2010 to 2016. After 1:1 Propensity Score Matching (PSM), Kruskal-Wallis and χ2 tests were applied to compare short-term outcomes. Kaplan-Meier survival analyses and Cox multivariable regression were performed. RESULTS: 988 patients met inclusion criteria: 140 (14.2%) MILR and 848 (85.8%) OLR resulting in 115 patients MILR and OLR after 1:1 PSM with c-index of 0.733. MILR had lower unplanned 30-day readmission [OR 0.075, P = 0.014] and positive margin rates [OR 0.361, P = 0.011] and shorter hospital length of stay (LOS) [OR 0.941, P = 0.026], but worse lymph node yield [1.52 vs 2.07, P = 0.001]. No difference was found for 30/90-day mortality. Moreover, multivariate analysis revealed that MILR was associated with poorer overall survival compared to OLR [HR 2.454, P = 0.001]. Subgroup analysis revealed that survival differences from approach were dependent on major hepatectomy, tumor size > 4 cm, or negative margins. CONCLUSION: MILR vs. OLR is associated with worse lymphadenectomy and survival in patients with ICC greater than 4 cm requiring major hepatectomy. Hence, MILR major hepatectomy for ICC should only be approached selectively and if surgeons are able to perform an appropriate lymphadenectomy.

Poorly differentiated hepatocellular carcinoma: resection is equivalent to transplantation in patients with low liver fibrosis.

BACKGROUND: Organ allocation criteria for liver transplantation focus on tumor size and multifocality while tumor differentiation and existing liver damage are omitted. This study analyzes the impact of hepatocellular carcinoma (HCC) grade and liver fibrosis comparing resection (SX) to transplantation (LT). METHODS: The National Cancer Database was queried between 2004 and 2016 for solitary HCC meeting Milan criteria undergoing SX vs LT. Two groups were created: low fibrosis (LF) vs high fibrosis (HF) and stratified by grade. Cox multivariable regression models, Kaplan-Meier survival analyses and log-rank tests were performed. RESULTS: 1515 patients were identified; 780 had LT and 735 had SX. Median overall survival (mOS) was 39.7 months; LT mOS was 47.9 months vs SX mOS of 34.9 months (P < .001). Multivariate analysis revealed SX, no chemotherapy, longer hospital stays, and age to be associated with worse survival. However, while transplantation conferred survival benefit for well-moderately differentiated tumors, SX vs LT did not impact survival for poorly differentiated HCC in LF patients, independent of tumor size. DISCUSSION: HCC differentiation and liver fibrosis, but not size, synergistically determine efficacy of SX vs LT. Therefore, current HCC transplantation criteria should incorporate tumor grade or liver fibrosis for optimal organ allocation.

Strategic response to bleeding in laparoscopic hepato-pancreato-biliary surgery: an intraoperative checklist.

BACKGROUND: The aim is to develop and test the utility of an event-initiated, team-based check list to optimize the response to bleeding during laparoscopic HPB surgery. METHODS: To build a checklist for managing bleeding events, we conducted a systematic review. Using nominal group technique (NGT), a checklist consisting of four domains was developed. Following team-based training of anesthesia and surgical staff, the checklist was implemented. HPB cases before and after implementation of the checklist were compared for adverse outcomes, bleeding complications, and transfusions. RESULTS: NGT identified four domains: Communicate Control, Expose, and Repair under which the checklist was organized. Supplemental Video for a detailed review of how each domain was applied to a specific case example. We compared 169 HPB cases before to 53 cases after implementation. We found a significant decrease in mean EBL (from 518 ± 852.8 to 151.5 ± 221.7 ml (P = 0.001)) for cases performed after implementation of the checklist and a trends toward less volume of pRBC transfused (2.7 ± 2.5 vs 2.3 ± 1.7 units/per patient, P = 0.611) and transfusion rates (22% vs 11%, P = 0.703). CONCLUSION: An event-initiated, team-based response to an adverse bleeding event during laparoscopic HPB surgery correlates with positive effects on bleeding management, and transfusion rates.

Does a Laparoscopic Approach to Distal Pancreatectomy for Cancer Contribute to Optimal Adjuvant Chemotherapy Utilization?

BACKGROUND: Although laparoscopic distal pancreatectomy (LDP) versus open approaches (ODP) for pancreatic adenocarcinoma (PDAC) is associated with reduced morbidity, its impact on optimal adjuvant chemotherapy (AC) utilization remains unclear. Furthermore, it is uncertain whether oncologic resection quality markers are equivalent between approaches. METHODS: The National Cancer Database (NCDB) was queried between 2010 and 2016 for PDAC patients undergoing DP. Effect of LDP vs ODP and institutional case volumes on margin status, hospital stay, 30-day and 90-day mortality, administration of and delay to AC, and 30-day unplanned readmission were analyzed using binary and linear logistic regression. Cox multivariable regression was used to correct for confounders. RESULTS: The search yielded 3411 patients; 996 (29.2%) had LDP and 2415 (70.8%) had ODP. ODP had higher odds of readmission [odds ratio (OR) 1.681, p = 0.01] and longer hospital stay [ß 1.745, p = 0.004]. No difference was found for 30-day mortality [OR 1.689, p = 0.303], 90-day mortality [OR 1.936, p = 0.207], and overall survival [HR 1.231, p = 0.057]. The highest-volume centers had improved odds of AC [OR 1.275, p = 0.027] regardless of approach. LDP conferred lower margin positivity [OR 0.581, p = 0.005], increased AC use [3rd quartile: OR 1.844, p = 0.026; 4th quartile; OR 2.144, p = 0.045], and fewer AC delays [4th quartile: OR 0.786, p = 0.045] in higher-volume centers. CONCLUSIONS: In selected patients, LDP offers an oncologically safe alternative to ODP for PDAC independent of institutional volume. However, additional oncologic benefit due to optimal AC utilization and lower positive margin rates in higher volume centers suggests that LDP by experienced teams can achieve best possible cancer outcomes.

Western population-based study of oncologic surgical quality and outcomes of laparoscopic versus open gastrectomy for gastric adenocarcinoma.

BACKGROUND: While studies have reported improved morbidity of laparoscopic (LG) compared with open gastrectomy (OG), it remains unclear whether comparable oncologic outcomes can be achieved. This study aims at comparing not only short-term outcomes, including 30- and 90-day mortality, but also survival of LG vs OG. METHODS: The National Cancer Database was searched for adult patients with histologically proven gastric cancer and complete information regarding M0 disease, tumor size, differentiation grade, T stage, nodal status, comorbidities, type of hospital, hospital stay, type of surgery, oncological treatment and survival data were included. Logistic regression analyses were performed to analyze margin status, 30- and 90-day mortality, and 30-day re-admission rate. Linear regression was performed for length of hospital stay and lymph node yield. Kaplan-Meier survival analyses were performed to evaluate median survival. Cox multivariable regression models were created to correct for confounders and identify factors affecting survival. RESULTS: A query of the National Cancer Database identified 13,538 patients with complete dataset. A significant regression equation favoring LG for lymph node yield, hospital stay, and unplanned re-admission rate was identified. There was no significant effect of surgical approach on R1 margin rate, 30-day mortality, or 90-day mortality. Median survival was comparable between LG and OG (44.8 vs 40.2 months, p = 0.804). CONCLUSION: LG offers a safe surgical approach to gastric cancer with shorter hospital stay and lower re-admission rates than OG, and also similar and sometimes improved operative oncologic quality parameters (margin, lymph node yield). More importantly, this Western series demonstrates that equivalent long-term outcomes of LG vs. OG are being achieved.

Laparoscopic pancreatectomy for cancer in high volume centers is associated with an increased use and fewer delays of adjuvant chemotherapy.

BACKGROUND: This study aimed to investigate the relationship between hospital case volume, surgical approach and AC-use in patients who underwent pancreatectomy for pancreatic ductal adenocarcinoma (PDAC). METHODS: Patients were divided into quartiles by institutional pancreatectomy case volume, resection type (pancreaticoduodenectomy [PD], distal pancreatectomy [DP], or total pancreatectomy [TP]) and surgical approach (laparoscopic vs. open). The rates and contributing factors of AC administration and delay >90 days were compared among volume quartiles and surgical approaches. RESULTS: This study identified 23,494 patients who had undergone pancreatectomy for PDAC between 2010 and 2016 and met inclusion criteria. After correcting for confounders, compared to low volume hospitals patients at high-case-volume hospitals had the highest rates of AC administration after PD and DP. Moreover, compared to open surgery for all resection types, laparoscopic surgery was associated with a higher rate of AC use at high and highest-case-volume hospitals and less delay to chemotherapy at high-volume hospitals. For DP, laparoscopic approach had a positive impact on AC delay >90-day at the highest volume institutions only. CONCLUSIONS: Laparoscopic surgery for pancreatic cancer leads to higher utilization and lower probability of delay of AC in high and highest volume hospitals.

High Mitotic Rate Predicts Sentinel Lymph Node Involvement in Thin Melanomas.

BACKGROUND: Indications for sentinel lymph node (SLN) biopsy in the population with thin melanoma have frequently changed over time. The objective of our study was to evaluate T1 melanoma pathologic features predictive of SLN positivity with a primary focus on identifying a specific mitotic value that is most predictive of lymph node disease. Further detailed predictive features would help physicians select patients with thin melanoma for SLN biopsy. METHODS: The Surveillance, Epidemiology, and End Results database was queried for all patients diagnosed with trunk or extremity cutaneous melanoma with ≤1 mm depth who underwent SLN biopsy between the years of 2010 and 2013. Patient demographics and tumor characteristics including depth, mitotic rate (MR), ulceration, and tumor location were evaluated. MR was dichotomized at multiple cut points to identify the ideal number of mitosis for MR as a predictor of SLN status. Multivariable logistic regression analyses were performed to identify the factors affecting nodal positivity and the impact of MR threshold. Kaplan-Meir curves were used for overall survival (OS) analysis. RESULTS: Factors significantly associated with SLN positivity in the entire cohort included MR (P < 0.001, OR 1.24, 95% CI 1.18-1.31), tumor location (P = 0.017, OR 1.48, 95% CI 1.07-2.05), and ulceration (P < 0.001, OR 2.01, 95% CI 1.39-2.93,). An MR ≥ 4 was significant for SLN positivity (P = 0.049, OR 1.08, 95% CI 1.01-1.38). Mean OS was 46.7 mo for MR < 4 compared with 43.2 mo for MR ≥ 4 (P < 0.001). CONCLUSIONS: MR ≥ 4 was significant and associated with SLN positivity in thin melanomas and asulceration. Thus, MR ≥ 4 should be considered as an indication for SLN biopsy in thin melanoma.

Comprehensive Analysis of Severe Viral Infections of Respiratory Tract admitted to PICUs during the Winter Season in Turkey.

OBJECTIVES: To analyze the course of seasonal viral infections of respiratory tract in patients hospitalized in pediatric intensive care units (PICU) of 16 centers in Turkey. MATERIALS AND METHODS: It is a retrospective, observational, and multicenter study conducted in 16 tertiary PICUs in Turkey includes a total of 302 children with viral cause in the nasal swab which required PICU admission with no interventions. RESULTS: Median age of patients was 12 months. Respiratory syncytial virus (RSV) was more common in patients over one year of age whereas influenza, human Bocavirus in patients above a year of age was more common (p <0.05). Clinical presentations influencing mortality were neurologic symptoms, tachycardia, hypoxia, hypotension, elevated lactate, and acidosis. The critical pH value related with mortality was ≤7.10, and critical PCO2 ≥60 mm Hg. CONCLUSION: Our findings demonstrate that patients with neurological symptoms, tachycardia, hypoxia, hypotension, acidosis, impaired liver, and renal function at the time of admission exhibit more severe mortal progressions. Presence of acidosis and multiorgan failure was found to be predictor for mortality. Knowledge of clinical presentation and age-related variations among seasonal viruses may give a clue about severe course and prognosis. By presenting the analyzed data of 302 PICU admissions, current study reveals severity of viral respiratory tract infections and release tips for handling them. HOW TO CITE THIS ARTICLE: Kockuzu E, Bayrakci B, Kesici S, Citak A, Karapinar K, Emeksiz S, et al. Comprehensive Analysis of Severe Viral Infections of Respiratory Tract admitted to PICUs During the Winter Season in Turkey. Indian J Crit Care Med 2019;23(6):263-269.

Open Pancreaticoduodenectomy Case Volume Predicts Outcome of Laparoscopic Approach: A Population-based Analysis.

OBJECTIVE: To determine if laparoscopic pancreaticoduodenectomy (LPD) is safe and offers benefits over open pancreaticoduodenectomy (OPD) at institutions with lower pancreaticoduodenectomy (PD) volume. BACKGROUND: Although a hospital-based case volume-outcome relationship for morbidity, mortality, and oncologic quality has been reported for OPD, comparative trends for LPD have yet to be investigated. METHODS: A total of 4739 patients with complete data were identified in National Cancer Data Base between 2010 and 2011; 4309 patients had OPD and 430 patients had LPD. Institutions were categorized into quartiles based on PD case volume. For the entire cohort and within each quartile, LPD and OPD were compared for 30-day and 90-day mortality, length of hospital stay, 30-day unplanned readmission rate, and margin status. Binary logistic regression, linear regression, and propensity score matching was performed. RESULTS: Hospitals with low PD case volume (≤25 PDs per year; 91% of all hospitals in the US and 25% of cases) had the highest 30- and 90-day mortality, highest margin positivity rates, and lowest lymph node counts. These trends were more pronounced in the LPD group. Only in the highest-volume hospitals was LPD associated with shorter hospital stay and lower readmission compared with OPD. CONCLUSIONS: These findings confirm that risks of postoperative mortality and suboptimal oncologic surgical quality following PD are higher in low-volume hospitals. Furthermore, these risks are more profound with LPD compared with OPD. These data suggest that the putative benefits of LPD are unlikely to be observed in institutions performing ≤25 PDs per year.

Minimally invasive management of the entire treatment sequence in patients with stage IV colorectal cancer: a propensity-score weighting analysis.

BACKGROUND: In patients with stage IV colorectal cancer (CRC), minimally invasive surgery (MIS) may offer optimal oncologic outcome with low morbidity. However, the relative benefit of MIS compared to open surgery in patients requiring multistage resections has not been evaluated. METHODS: Patients who underwent totally minimally invasive (TMI) or totally open (TO) resections of CRC primary and liver metastases (CLM) in 2009-2016 were analyzed. Inverse probability of weighted adjustment by propensity score was performed before analyzing risk factors for complications and survival. RESULTS: The study included 43 TMI and 121 TO patients. Before and after adjustment, TMI patients had significantly less cumulated postoperative complications (41% vs. 59%, p = 0.001), blood loss (median 100 vs. 200 ml, p = 0.001) and shorter length of hospital stay (median 4.5 vs. 6.0 days, p < 0.001). Multivariate analysis identified TO approach vs. MIS (OR = 2.4, p < 0.001), major liver resection (OR = 4.4, p < 0.001), and multiple CLM (OR = 2.3, p = 0.001) as independent risk factors for complications. 5-year overall survival was comparable (81% vs 68%, p = 0.59). CONCLUSION: In patients with CRC undergoing multistage surgical treatment, MIS resection contributes to optimal perioperative outcomes without compromise in oncologic outcomes.

Comparative effectiveness of first-line radiofrequency ablation versus surgical resection and transplantation for patients with early hepatocellular carcinoma.

BACKGROUND: Significant controversy exists as to which treatment modality is most effective for small, solitary hepatocellular carcinomas (HCCs): radiofrequency ablation (RFA), surgical resection (RXN), or transplantation (TXP). Size cutoff values ranging from 20 to 50 mm have been proposed to achieve complete ablation. The current study compares outcomes between RFA, RXN, and TXP as first-line therapy for patients with HCC tumors measuring as large as 50 mm. METHODS: The Surveillance, Epidemiology, and End Results database was queried for patients with HCC tumors measuring up to 50 mm who were treated with RFA, RXN, or TXP between 2004 and 2013. Overall survival (OS) and disease-specific survival (DSS) were examined in patients with tumors measuring ≤20 mm, 21 to 30 mm, or 31 to 50 mm. The impact of an increase in tumor size of only 5 mm beyond 30 mm was evaluated by also examining outcomes in patients with tumors measuring 31 to 35 mm. RESULTS: Of 1894 cases, patients with HCC tumors measuring ≤20 mm and 21 to 30 mm demonstrated no difference in OS or DSS regardless of whether RFA and RXN was used. RFA was associated with a worse OS and DSS than TXP, whereas there was no difference in OS observed between RXN and TXP. In patients with tumors measuring 31 to 50 mm, OS and DSS were worse with RFA compared with RXN or TXP. Most important, the inferior DSS and OS noted with RFA were observed with only a 5-mm increase in tumors measuring >30 mm. CONCLUSIONS: Although RFA frequently is used as first-line treatment of HCC tumors measuring as large as 50 mm, it is associated with worse results than RXN or TXP for tumors measuring >30 mm. To the best of the authors' knowledge, the results of the current study are the first to demonstrate that although RFA is an appropriate option for patients with HCC tumors measuring ≤30 mm, its use for tumors even slightly larger than 30 mm is associated with inferior outcomes. Cancer 2017;123:1817-1827. © 2017 American Cancer Society.

High Ligation of the Inferior Mesenteric Artery in Left-Sided Colon and Rectal Cancer Resection: Rates of Success and Outcomes.

BACKGROUND: High ligation of the inferior mesenteric artery, defined as ligation before the takeoff of the left colic artery, is often described as the gold standard in low left-sided colon and rectal cancer surgery. The aim of this study is to quantify the rate of ligation at the described level at a single academic center. Additionally, we examined the relationship between level of ligation and cancer-related outcomes. METHODS: This retrospective cohort study included patients ages 18 and over with low left-sided colon, rectal, and anal cancers undergoing surgical resection. Radiographic evidence of high ligation was defined as ligation of the inferior mesenteric artery before the takeoff of the left colic artery. Patients with and without radiographic evidence of high ligation on CT were compared. Secondary outcomes include lymph node yield and positivity, need for adjuvant therapy, and time from surgery to adjuvant therapy. RESULTS: 169 patients (54% male) were included in the study. 61.5% of operative reports described high ligation of the IMA. There was radiographic evidence of high ligation in 55.6% of total patients and in 70.2% of patients where high ligation was intended. There was no significant difference in surgeon experience, surgical procedure, or surgical approach. There was no difference in lymph node yield, time to adjuvant chemotherapy, or recurrence rates. CONCLUSION: This study demonstrates good technical success rate of high ligation of the inferior mesenteric artery but shows no difference in short-term patient-measured outcomes between high and low ligation (or successful and unsuccessful high ligation).

Comparison of upper gastrointestinal series and symptom questionnaires with intraoperative diagnosis of hiatal hernia during sleeve gastrectomy.

BACKGROUND: Hiatal hernias are common in bariatric surgery patients, but the utility of preoperative hiatal hernia diagnosis prior to sleeve gastrectomy (SG) is debated. OBJECTIVE: This study compared preoperative and intraoperative hiatal hernia detection rates in patients undergoing laparoscopic SG. SETTING: University hospital, United States. METHODS: As part of a randomized trial evaluating the role of routine crural inspection during SG, an initial cohort was prospectively studied to assess the correlation between preoperative upper gastrointestinal (UGI) series, reflux and dysphagia symptoms, and intraoperative hiatal hernia diagnosis. Preoperatively, patients completed the Gastroesophageal Reflux Disease Questionnaire (GerdQ), the Brief Esophageal Dysphagia Questionnaire (BEDQ), and a UGI series. Intraoperatively, patients with an anteriorly visible defect underwent hiatal hernia repair followed by SG. All others were randomized to standalone SG or posterior crural inspection with repair of any hiatal hernia identified prior to SG. RESULTS: Between November 2019 and June 2020, 100 patients (72 female patients) were enrolled. Preoperative UGI series identified hiatal hernia in 28% (26 of 93) of patients. Intraoperatively, hiatal hernia was diagnosed during initial inspection in 35 patients. Diagnosis was associated with older age, lower body mass index, and Black race but did not correlate with GerdQ or BEDQ. Using the standard conservative approach, compared with intraoperative diagnosis, sensitivity and specificity of the UGI series were 35.3% and 80.7%, respectively. Hiatal hernia was identified in an additional 34% (10 of 29) of patients randomized to posterior crural inspection. CONCLUSION: Hiatal hernias are highly prevalent in SG patients. However, GerdQ, BEDQ, and a UGI series unreliably identify hiatal hernia in the preoperative setting and should not influence intraoperative evaluation of the hiatus during SG.

R1 pancreatic cancer patients benefit from chemoradiation when initiation of adjuvant therapy is delayed.

BACKGROUND: Adjuvant chemotherapy (AC) following pancreaticoduodenectomy (PD) for pancreas cancer (PDAC) has been demonstrated to improve survival. However, the optimal adjuvant treatment (AT) regimen for R1-margin patients remains unclear. This retrospective study investigates the impact of AC vs. adjuvant chemoradiotherapy (ACRT) on survival (OS). MATERIAL AND METHODS: The NCDB was queried for patients with PDAC who underwent PD between 2010 and 2018. Patients were divided into, (A) AC<60 days, (B) ACRT<60 days, (C) AC≥60 days, and (D) ACRT≥60 days. Kaplan-Meier survival analyses and Cox multivariable regression analyses were performed. RESULTS: Among 13 740 patients, median OS was 23.7 months. For R1 patients, median OS for timely AC and ACRT, and delayed AC and ACRT was 19.91, 19.19, 15.24, 18.96 months, respectively. While time of AC initiation was an insignificant factor for R0 patients (p = 0.263, CI 0.957-1.173), a survival benefit was found for R1 patients who received AC<60 vs. ≥60 days (p = 0.041, CI 1.002-1.42). Among R1 patients, administration of delayed ACRT achieves the same survival benefit of timely AC initiation (p = 0.074, CI 0.703-1.077). CONCLUSION: The study suggests value in ACRT for patients with R1 margins when delay of AT≥60 days cannot be avoided. Hence, ACRT may mitigate the negative impact of delayed AT initiation for R1-patients.

Diaphragmatic Hernia With Incarcerated Spleen as a Complication After Lateral Anterior Column Realignment.

BACKGROUND: The creation of sagittal balance of the spine is critical in the treatment adult spinal deformity. Anterior column release (ACR) has gained traction as a minimally invasive alternative to pedicle subtraction osteotomy. By releasing the anterior longitudinal ligament, the anterior column can be lengthened and physiologic lordosis restored. Risks such as transient psoas weakness and thigh numbness have been well documented in the literature; however, diaphragmatic hernia has never been reported. OBJECTIVE: To highlight the difficulties encountered in diagnosing, managing, and treating iatrogenic diaphragmatic hernia in the setting of ACR and stress the relevant retropleural, retroperitoneal, and diaphragmatic structures during the surgical approach. METHODS: In this technical note, we discuss the relevant anatomy in a direct lateral approach to the thoracolumbar junction and the management of an iatrogenic diaphragmatic hernia, which occurred in a patient who underwent a L1 ACR. RESULTS: Three months after surgery, our patient was assessed in clinic and endorsed significant improvements in her pain and mobility. Her 3-month postoperative scoliosis x-rays demonstrated a significant improvement in her sagittal alignment, and she experienced no further negative sequelae from the iatrogenic hernia. CONCLUSION: Iatrogenic diaphragmatic hernia with an intrathoracic spleen after direct lateral ACR is a risk spine surgeons should be aware of and address promptly.

Trends in Preoperative Chemotherapy Utilization for Proximal Pancreatic Cancer: Are We Making Progress?

BACKGROUND: While it has been shown that neoadjuvant chemotherapy (NCT) for pancreatic cancer (PDAC) undergoing pancreaticoduodenectomy (PD) is critical for optimal oncologic management, NCT is (A) not universally practiced and (B) the reasons ill-defined. This study investigates national rates, trends, and factors affecting NCT utilization. PATIENTS AND METHODS: Using the National Cancer Database, patients who underwent PD for PDAC between 2006 and 2017 were identified. Changes in chemotherapy sequence over time were identified. For patients diagnosed after 2010, multivariable logistic regression models for factors affecting NCT were created. RESULTS: A total of 128,980 patients were diagnosed and 23,206 underwent surgery. Three thousand five (12.9%) received NCT with a preoperative chemotherapy (NCT + PCT) utilization rate of 7.3% in 2004 that increased to 36.8% in 2017. Factors affecting utilization of preoperative chemotherapy were age (OR 0.972), academic and integrated network institutions (OR 1.916, OR 1.559), institutional case volume (OR 1.007), distance from the hospital (OR 1.002), stage (IB OR 3.108, IIA OR 3.133, IIB OR 3.775, III OR 3.782), grade IV (OR 1.977), and insurance status (private OR 2.371, Medicaid OR 1.811, and Medicare OR 2.191, government OR 2.645). CONCLUSION: Even though more than 3/5 of patients receive no preoperative chemotherapy (NCT + PCT) and nearly 1/5 of patients still receive no chemotherapy at all, utilization of NCT is increasing. Moreover, since this study demonstrates that omission of NCT is associated with modifiable factors such as type of institution and health care disparity, mechanisms (reimbursement, policy) geared to change current national practice patterns may most immediately affect optimal oncologic management.