Early Repair of Rib Fractures Is Associated with Superior Length of Stay and Total Hospital Cost: A Propensity Matched Analysis of the National Inpatient Sample.

Background and Objectives: Previous studies have suggested that early scheduling of the surgical stabilization of rib fractures (SSRF) is associated with superior outcomes. It is unclear if these data are reproducible at other institutions. We hypothesized that early SSRF would be associated with decreased morbidity, length of stay, and total charges. Materials and Methods: Adult patients who underwent SSRF for multiple rib fractures or flail chest were identified in the National Inpatient Sample (NIS) by ICD-10 code from the fourth quarter of 2015 to 2016. Patients were excluded for traumatic brain injury and missing study variables. Procedures occurring after hospital day 10 were excluded to remove possible confounding. Early fixation was defined as procedures which occurred on hospital day 0 or 1, and late fixation was defined as procedures which occurred on hospital days 2 through 10. The primary outcome was a composite outcome of death, pneumonia, tracheostomy, or discharge to a short-term hospital, as determined by NIS coding. Secondary outcomes were length of hospitalization (LOS) and total cost. Chi-square and Wilcoxon rank-sum testing were performed to determine differences in outcomes between the groups. One-to-one propensity matching was performed using covariates known to affect the outcome of rib fractures. Stuart-Maxwell marginal homogeneity and Wilcoxon signed rank matched pair testing was performed on the propensity-matched cohort. Results: Of the 474 patients who met the inclusion criteria, 148 (31.2%) received early repair and 326 (68.8%) received late repair. In unmatched analysis, the composite adverse outcome was lower among early fixation (16.2% vs. 40.2%, p < 0.001), total hospital cost was less (USD114k vs. USD215k, p < 0.001), and length of stay was shorter (6 days vs. 12 days) among early SSRF patients. Propensity matching identified 131 matched pairs of early and late SSRF. Composite adverse outcomes were less common among early SSRF (18.3% vs. 32.8%, p = 0.011). The LOS was shorter among early SSRF (6 days vs. 10 days, p < 0.001), and total hospital cost was also lower among early SSRF patients (USD118k vs. USD183k late, p = 0.001). Conclusion: In a large administrative database, early SSRF was associated with reduced adverse outcomes, as well as improved hospital length of stay and total cost. These data corroborate other research and suggest that early SSRF is preferred. Studies of outcomes after SSRF should stratify analyses by timing of procedure.

Modeling the COVID Pandemic: Do Delays in Surgery Justify Using Stereotactic Radiation to Treat Low-Risk Early Stage Non-Small Cell Lung Cancer?

INTRODUCTION: It was suggested that stereotactic radiation (SBRT) is an "alternative if no surgical capacity is available" for non-small cell lung cancer (NSCLC) care during the COVID-19 pandemic. The purpose of this study was to compare the oncologic outcomes of delayed surgical resection and early SBRT among operable patients with early stage lung cancer. METHODS: The National Cancer Database was queried for patients with cT1aN0M0 NSCLC who underwent surgery or SBRT (2010-2016) with no comorbidity. Patients with any comorbidities or age >80 were excluded. The outcome of interest was overall survival. Delays in surgical care were modeled using different times from diagnosis to surgery. A 1:1 propensity match was performed and survival was analyzed using multivariable Cox regression. RESULTS: Of 6720 healthy cT1aN0M0 NSCLC patients, 6008 (89.4%) received surgery and 712 (10.6%) received SBRT. Among surgery patients, time to surgery >30 d was associated with inferior survival (HR > 1.4, P ≤ 0.013) compared with patients receiving surgery ≤14 d. Relative to SBRT, surgery demonstrated superior survival at all time points evaluated: 0-30 d, 31-60 d, 61-90 d, and >90 d (all P < 0.001). Among a propensity-matched cohort of 256 pairs of patients, delayed surgery (>90 d) remained association with better overall survival relative to early SBRT (5-year survival 76.9% versus 32.3%, HR = 0.266, P < 0.001). CONCLUSIONS: Although longer time to surgery is associated with inferior survival among surgery patients, delayed surgery is superior to early SBRT. Surgical resection should remain the standard of care to treat operable early stage lung cancer despite delays imposed by the COVID-19 pandemic.

Risk factors for adverse outcomes following paraesophageal hernia repair among obese patients.

BACKGROUND: Although obesity is an established risk factor for adverse outcomes after paraesophageal hernia repair (PEHR), many obese patients nonetheless receive PEHR. The purpose of this study was to explore risk factors for adverse outcomes of PEHR among this high-risk cohort. We hypothesized that obese patients may have other risk factors for adverse outcomes following PEHR. METHODS: A retrospective study of adult obese patients who underwent minimally invasive PEHR from 2017 to 2019 was performed. Patients were excluded for BMI < 30 or if they had concomitant bariatric surgery at time of PEHR. The primary outcome of interest was a composite adverse outcome (CAO) defined as having any of the four following outcomes after PEHR: persistent GERD > 30 d, persistent dysphagia > 30 d, recurrence, or reoperation. Chi-square and t-test analysis was used to compare demographic and clinical characteristics. Multivariable logistic regression analysis was used to evaluate independent predictors of CAO. RESULTS: In total, 139 patients met inclusion criteria with a median follow-up of 19.7 months (IQR 8.8-81). Among them, 51/139 (36.7%) patients had a CAO: 31/139 (22.4%) had persistent GERD, 20/139 (14.4%) had persistent dysphagia, 24/139 (17.3%) had recurrence, and 6/139 (4.3%) required reoperation. On unadjusted analysis, patients with a CAO were more likely to have a history of prior abdominal surgery (86.3% vs 70.5%, p = 0.04) and were less likely to have undergone a preoperative CT scan (27.5% vs 45.5%, p = 0.04). On multivariable analysis, previous abdominal surgery was independently associated with an increased likelihood of CAO whereas age and preoperative CT scan had a decreased likelihood of CAO. CONCLUSIONS: Although there were adverse outcomes among obese patients, minimally invasive PEHR may be feasible in a subset of patients at specialized centers. These findings may help guide the appropriate selection of obese patients for PEHR.

Disparities and access to thoracic surgeons among esophagectomy patients in the United States.

Esophagectomy is a complex operation with significant morbidity and mortality. Previous studies have shown that sub-specialization is associated with improved esophagectomy outcomes. We hypothesized that disparities would exist among esophagectomy patients regarding access to thoracic surgeons based on demographic, geographic, and hospital factors. The Premier Healthcare Database was used to identify adult inpatients receiving esophagectomy for esophageal and gastric cardia cancer, Barrett's esophagus, and achalasia from 2015 to 2019 using ICD-10 codes. Patients were categorized as receiving their esophagectomy from a thoracic versus non-thoracic provider. Survey methodology was used to correct for sampling error. Backwards selection from bivariable analysis was used in a survey-weighted multivariable logistic regression to determine predictors of esophagectomy provider specialization. During the study period, 960 patients met inclusion criteria representing an estimated population size of 3894 patients. Among them, 1696 (43.5%) were performed by a thoracic surgeon and 2199 (56.5%) were performed by non-thoracic providers. On multivariable analysis, factors associated with decreased likelihood of receiving care from a thoracic provider included Black (OR 0.41, p < 0.001), Other (OR 0.21, p < 0.001), and Unknown race (OR 0.22, p = 0.04), and uninsured patients (OR 0.53, p = 0.03). Urban hospital setting was associated with an increased likelihood of care by a thoracic provider (OR 4.43, p = 0.001). In this nationally representative study, Nonwhite race, rural hospital setting, and lower socioeconomic status were factors associated with decreased likelihood of esophagectomy patients receiving care from a thoracic surgeon. Efforts to address these disparities and provide appropriate access to thoracic surgeons is warranted.

Concurrent diagnosis of anxiety increases postoperative length of stay among patients receiving esophagectomy for esophageal cancer.

OBJECTIVE: Psychiatric comorbidities disproportionately affect patients with cancer. While identified risk factors for prolonged length of stay (LOS) after esophagectomy are primarily medical comorbidities, the impact of psychiatric comorbidities on perioperative outcomes is unclear. We hypothesized that psychiatric comorbidities would prolong LOS in patients with esophageal cancer. METHODS: The 2016 National Inpatient Sample (NIS) was used to identify patients with esophageal cancer receiving esophagectomy. Concurrent psychiatric illness was categorized using Clinical Classifications Software Refined for ICD-10, creating 34 psychiatric diagnosis groups (PDGs). Only PDGs with >1% prevalence in the cohort were included in the analysis. The outcome of interest was hospital LOS. Bivariable testing was performed to determine the association of PDGs and demographic factors on LOS using rank sum test. Multivariable regression analysis was performed using backward selection from bivariable testing (α ≤ 0.05). RESULTS: We identified 1,730 patients who underwent esophagectomy for esophageal cancer in the 2016 NIS. The median LOS was 8 days (IQR 5-12). In bivariable testing, a concurrent diagnosis of anxiety was the only PDG associated with LOS (9 days (IQR 6-14) with anxiety diagnosis versus 8 days (IQR 5-12) with no anxiety diagnosis, p = 0.022). Multivariable modeling showed an independent association between anxiety diagnosis and increased LOS (OR 4.82 (1.25-25.23), p = 0.022). Anxiety was not associated with increased hospital cost or in-hospital mortality. CONCLUSIONS: This analysis demonstrates an independent effect of anxiety prolonging postoperative LOS after esophagectomy in the United States. These findings may influence perioperative care, patient expectations, and resource allocation.

Does Timing of Robotic Esophagectomy Adoption Impact Short-Term Postoperative Outcomes?

BACKGROUND: Robotic esophagectomies are increasingly common and are reported to have superior outcomes compared with an open approach; however, it is unclear if all institutions can achieve such outcomes. We hypothesize that early adopters of robotic technique would have improved short-term outcomes. METHODS: The National Cancer Database (2010-2016) was used to identify robotic esophagectomies. Early adopters were defined as programs which performed robotic esophagectomies in 2010-2011, late adopters in 2012-2013. Outcomes of esophagectomies performed between 2014 and 2016 were compared and included length of stay, number of lymph nodes evaluated, readmission, conversion rate, and 90-day mortality. Multivariable regressions, accounting for robotic esophagectomy volume, were used to control for confounding factors. RESULTS: There were 37 early adopters and 35 late adopters. Between 2014 and 2016, 683 robotic esophagectomies were performed: 446 (65.3%) by early adopters and 237 (34.7%) by late adopters. Early adopters were more likely to be academic programs (96.2 versus 72.8%, P < 0.01). Other clinical and demographic variables were similar. Late adopters were found to have decreased a number of lymph nodes evaluated (coefficient -2.407, P = 0.004) compared with early adopters. There were no significant differences in length of stay, readmissions, rate of positive margins, conversion from robotic to open, or 90-day mortality. CONCLUSIONS: When accounting for robotic esophagectomy volume, late adoption of robotic esophagectomy was associated with a reduced lymph node harvest, but other postoperative outcomes were similar. These data suggest that programs can safely start new robotic esophagectomy programs, but must ensure an adequate case load.

Palliative Surgery Outcomes for Patients with Esophageal Cancer: An National Cancer Database Analysis.

INTRODUCTION: Many patients with esophageal cancer are not candidates for surgical resection with curative intent, given the advanced stage of disease at presentation. Palliative surgery is one treatment option, but relative survival of palliative surgery has not been described. This study aims to describe the outcomes of palliative surgery in patients with esophageal cancer. METHODS: We used the National Cancer Database to identify patients with esophageal cancer who received palliative surgery or non-surgical palliation-which consisted of palliative radiation and palliative chemotherapy without any surgery. The outcome of interest was overall survival. Characteristics of patients were compared between the palliative surgery group and the non-surgical group using rank sum test or chi square test. Survival differences between groups were compared using Kaplan Meier estimate and log rank test, and Cox proportional hazards model. RESULTS: A total of 14,589 patients were included in the analysis, including 2,812 (19.2%) receiving palliative surgery and 11,777 (80.7%) receiving non-surgical palliation (6,512 palliative radiation and 5,265 palliative chemotherapy). Median overall survival in palliative surgery patients was 5.5 mo, shorter than non-surgical palliation (6.4 mo, P = 0.004). However, when correcting for age, sex, nodal status, metastases, Charlson score, histology, academic center, and private insurance, there was no difference in survival between palliative surgery and non-surgical palliation in Cox proportional hazard modeling (HR 1.03 (0.975-1.090), P = 0.281). CONCLUSIONS: Palliative surgery in advanced esophageal cancer is associated with poor overall survival but is similar to other palliative modalities. Palliative Surgery for esophageal cancer patients should be used sparingly given these poor outcomes.

Are We Underestimating the Morbidity of Single Rib Fractures?

PURPOSE: Previous studies suggest that patients with multiple rib fractures have poor outcomes, but it is unknown how isolated single rib fractures (SRF) are associated with morbidity or mortality. We hypothesized that patients with poor outcomes after SRF can be identified by demographics and comorbidities. The purpose of this study was to model adverse outcome after single rib fractures. MATERIALS AND METHODS: We used the 2016 National Inpatient Sample to identify patients with SRF associated with blunt trauma using ICD-10 coding. Comorbidities and abbreviated injury score (AIS) were also extracted. Patients with non-chest trauma were excluded. The primary outcome was an adverse composite outcome of death, pneumonia, tracheostomy, or hospitalization longer than twelve days. One-third of the cohort was reserved for validation. Backward selection multivariable modeling identified factors associated with adverse composite outcome. The model was used to create a nomogram to predict adverse composite outcome. The nomogram was then tested using the validation cohort. RESULTS: 2,398 patients with isolated SRF were divided into training (n = 1,598) and validation sets (n = 800). The average age was 69 and the majority were male (66%) and received care at academic institutions (61.6%). The adverse composite outcome occurred in 20.8%: 61 deaths (2.5%), 67 tracheostomies (2.8%), 319 pneumonias (13.3%), and 165 patients with hospital length of stay greater than twelve days (6.9%). Results of stepwise multivariable modeling had a C-statistic of 0.700. The multivariable model was used to create a nomogram which had a c-statistic of 0.672 in the validation cohort. CONCLUSION: 20% of isolated SRF patients had an adverse outcome. Demographics and comorbidities can be used to identify and triage high-risk patients for specialized care and proper counseling.

Robotic minimally invasive esophagectomy provides superior surgical resection.

INTRODUCTION: Robotic minimally invasive esophagectomy (RMIE) and "traditional" minimally invasive esophagectomy techniques (tMIE) have reported superior outcomes relative to open techniques. Differences in the outcomes of these two approaches have not been examined. We hypothesized that short-term outcomes of RMIE would be superior to tMIE. METHODS AND PROCEDURES: The National Cancer Database was used to analyze outcomes of patients undergoing RMIE and tMIE from 2010 to 2016. Patients with clinical metastatic disease were excluded. Trends in the number of procedures performed with each approach were described using linear regression testing. Primary outcome of interest was 90-day mortality rate. Secondary outcomes of interest were positive surgical margin rate, number of lymph nodes (LN) removed, adequate lymphadenectomy (> 15 LNs), length of hospitalization (LOS), readmission rate, and conversion to open rate. Outcomes of RMIE and tMIE were compared using Wilcoxon rank sum test and chi square test as appropriate. Multivariable regression was also performed to reduce the impact of differences in the cohorts of patients receiving RMIE and tMIE. RESULTS: 6661 minimally invasive esophagectomies were performed from 2010 to 2016 (1543/6661 (23.2%) RMIE and 5118/6661 (76.8%) tMIE). Over the study period, the proportion of RMIE increased from 10.4% (64/618) in 2010 to 27.2% (331/1216) in 2016 (p < 0.001) (Fig. 1). The primary outcome of 90-day mortality was similar between RMIE and tMIE (92/1170 (7.4%) vs 305/4148 (7.9%), p = 0.558) (Table 2). RMIE and tMIE also had similar readmission rate (6.3 vs 7%, p = 0.380). There was no difference between the cohorts based on sex, age, race, insurance, and tumor size. The cohorts of patients receiving RMIE and tMIE differed in that RMIE patients had lower rates of elevated Charlson scores, were more likely to be treated at an academic institution, had a higher rate of advanced clinical T-stage and clinical nodal involvement, and had received neoadjuvant therapy. In a univariate analysis, RMIE had a lower rate of positive margin (3.9 vs 6.1%, p = 0.001), more mean lymph nodes evaluated (16.6 ± 9.74 vs 16.1 ± 10.08 p = 0.018), lower conversion to open rate (5.4 vs 11.4%, p < 0.001), and a shorter mean length of stay (12.1 ± 10.39 vs 12.8 ± 11.18 days, p < 0.001). In multivariable analysis, RMIE was associated with lower risk of conversion to open (OR 0.51, 95% CI: 0.37-0.70, p < 0.001) and lower rate of positive margin (OR 0.62, 95% CI: 0.41-0.93, p = 0.021).). Additionally, in a multivariable logistic regression, RMIE demonstrated superior adequate lymphadenectomy (> 15 LNs) (OR 1.18, 95% CI 1.02-1.37, p < 0.032). CONCLUSION: In the National Cancer Database, robotic esophagectomy is associated with superior rate of conversion to open and positive surgical margin status. We speculate enhanced dexterity and visualization of RMIE facilitates intraoperative performance leading to improvement in these outcomes.

Outcomes of robotic esophagectomies for esophageal cancer by hospital volume: an analysis of the national cancer database.

BACKGROUND: Robotic minimally invasive esophagectomies (RMIE) have been associated with superior outcomes; however, it is unclear if these are specific to robotic technique or are present only at high-volume institutions. We hypothesize that low-volume RMIE centers would have inferior outcomes. METHODS: The National Cancer Database (NCDB) identified patients receiving RMIE from 2010 to 2016. Based on the total number of RMIE performed by each hospital system, the lowest quartile performed ≤ 9 RMIE over the study period. Ninety-day mortality, number of lymph nodes evaluated, margins status, unplanned readmissions, length of stay (LOS), and overall survival were compared. Regression models were used to account for confounding. RESULTS: 1565 robotic esophagectomies were performed by 212 institutions. 173 hospitals performed ≤ 9 RMIE (totaling 478 operations over the study period, 30.5% of RMIE) and 39 hospitals performed > 9 RMIE (1087 operations, 69.5%). Hospitals performing > 9 RMIE were more likely to be academic centers (90.4% vs 66.2%, p < 0.001), have patients with advanced tumor stage (65.3% vs 59.8%, p = 0.049), andadministered preoperative radiation (72.8% vs 66.3%, p = 0.010). There were no differences based on demographics, nodal stage, or usage of preoperative chemotherapy. On multivariable regressions, hospitals performing ≤ 9 RMIE were associated with a greater likelihood of experiencing a 90-day mortality, a reduced number of lymph nodes evaluated, and a longer LOS; however, there was no association with rates of positive margins or unplanned readmissions. Median overall survival was decreased at institutions performing ≤ 9 RMIE (37.3 vs 51.5 months, p < 0.001). Multivariable Cox regression demonstrated an association with poor survival comparing hospitals performing ≤ 9 to > 9 RMIE (HR 1.327, p = 0.018). CONCLUSION: Many robotic esophagectomies occur at institutions which performed relatively few RMIE and were associated with inferior short- and long-term outcomes. These data argue for regionalization of robotic esophagectomies or enhanced training in lower volume hospitals.

Surgery following neoadjuvant chemoradiation therapy in clinical N3 esophageal cancer results in improved survival: a propensity-matched analysis.

Esophageal cancer patients with extensive nodal metastases have poor survival, and benefit of surgery in this population is unclear. The aim of this study is to determine if surgery after neoadjuvant chemoradiotherapy (nCRT) improves overall survival (OS) in patients with clinical N3 (cN3) esophageal cancer relative to chemoradiation therapy (CRT) alone. The National Cancer Database was queried for all patients with cN3 esophageal cancer between 2010 and 2016. Patients who met inclusion criteria (received multiagent chemotherapy and radiation dose ≥30 Gy) were divided into two cohorts: CRT alone and nCRT + surgery. 769 patients met inclusion criteria, including 560 patients who received CRT alone, and 209 patients who received nCRT + surgery. The overall 5-year survival was significantly lower in the CRT alone group compared to the nCRT + surgery group (11.8% vs 18.0%, P < 0.001). A 1:1 propensity matched cohort of CRT alone and nCRT + surgery patients also demonstrated improved survival associated with surgery (13.11 mo vs 23.1 mo, P < 0.001). Predictors of survival were analyzed in the surgery cohort, and demonstrated that lymphovascular invasion was associated with worse survival (HR 2.07, P = 0.004). Despite poor outcomes of patients with advanced nodal metastases, nCRT + surgery is associated with improved OS. Of those with cN3 disease, only 27% underwent esophagectomy. Given the improved OS, patients with advanced nodal disease should be considered for surgery. Further investigation is warranted to determine which patients with cN3 disease would benefit most from esophagectomy, as 5-year survival remains low (18.0%).

Higher Doses of Neoadjuvant Radiation for Esophageal Cancer Do Not Affect the Pathologic Complete Response Rate or Survival: A Propensity-Matched Analysis.

BACKGROUND: Traditional neoadjuvant therapy for esophageal cancer has used chemoradiation doses greater than 45 Gy. This study aimed to examine the dose of preoperative radiation in relation to the pathologic complete response (pCR) rate and overall survival (OS) for patients with resectable esophageal cancer. METHODS: The National Cancer Database was queried for all patients with esophageal or gastroesophageal junction cancer who received neoadjuvant chemoradiation (CRT) followed by esophagectomy between 2006 and 2015. The radiation doses were divided into four ranges based on Grays (Gy) received: less than 39.6 Gy, 39.60-44.99 Gy, 45-49.99 Gy, and 50 Gy or more. RESULTS: The inclusion criteria were met by 10,293 patients. All patients received neoadjuvant CRT, with 689 patients (6.7%) receiving less than 39.6 Gy, 973 patients (9.5%) receiving 39.6-44.9 Gy, 3837 patients (37.3%) receiving 45-49.9 Gy, and 4794 patients (46.6%) receiving 50 Gy or more. The overall pCR rate was 17.2% (1769/10,293) and was significantly lower for those who received less than 39.6 Gy of radiation than for those who received 39.6 Gy or more (13.9% [96/689] vs. 17.4% [1673/9604]; p = 0.017). The median OS of 37.2 months was significantly better for those who received 39.6 Gy or more than for those who received less than 39.6 Gy (38 vs. 29.6 months (p < 0.0001). The pCR and OS did not differ between the three higher radiation doses (39.6-44.9 vs. 45-49.9 Gy vs. ≥ 50 Gy; pCR [p = 0.1] vs. OS [p = 0.097]). The patients who received 39.6-44.9 Gy were propensity matched with those who received 45 Gy or more of radiation. There remained no difference in pCR (p = 0.375) or OS (p = 0.957). CONCLUSIONS: In the United States, the heterogeneity in neoadjuvant CRT dosing is significant, with 84% of patients receiving more than 45 Gy. The benefit of neoadjuvant CRT in terms of pCR and overall  survival is seen with doses of 39.6 Gy or more, but not with doses higher than 45 Gy.

Conventional Computed Tomographic Calcium Scoring vs full chest CTCS for lung cancer screening: a cost-effectiveness analysis.

BACKGROUND: Conventional CTCS images the mid/lower chest for coronary artery disease (CAD). Because many CAD patients are also at risk for lung malignancy, CTCS often discovers incidental pulmonary nodules (IPN). CTCS excludes the upper chest, where malignancy is common. Full-chest CTCS (FCT) may be a cost-effective screening tool for IPN. METHODS: A decision tree was created to compare a FCT to CTCS in a hypothetical patient cohort with suspected CAD. (Figure) The design compares the effects of missed cancers on CTCS with the cost of working up non-malignant nodules on FCT. The model was informed by results of the National Lung Screening Trial and literature review, including the rate of malignancy among patients receiving CTCS and the rate of malignancy in upper vs lower portions of the lung. The analysis outcomes are Quality-Adjusted Life Year (QALY) and incremental cost-effectiveness ratio (ICER), which is generally considered beneficial when <$50,000/QALY. RESULTS: Literature review suggests that rate of IPNs in the upper portion of the lung varied from 47 to 76%. Our model assumed that IPNs occur in upper and lower portions of the lung with equal frequency. The model also assumes an equal malignancy potential in upper lung IPNs despite data that malignancy occurs 61-66% in upper lung fields. In the base case analysis, a FCT will lead to an increase of 0.03 QALYs comparing to conventional CTCS (14.54 vs 14.51 QALY, respectively), which translates into an QALY increase of 16 days. The associated incremental cost for FCT is $278 ($1027 vs $748, FCT vs CTCS respectively. The incremental cost-effectiveness ratio (ICER) is $10,289/QALY, suggesting significant benefit. Sensitivity analysis shows this benefit increases proportional to the rate of malignancy in upper lung fields. CONCLUSION: Conventional CTCS may be a missed opportunity to screen for upper lung field cancers in high risk patients. The ICER of FCT is better than screening for breast cancer screening (mammograms $80 k/QALY) and colon cancer (colonoscopy $6 k/QALY). Prospective studies are appropriate to define protocols for FCT.

Viruses and esophageal cancer.

Esophageal adenocarcinoma (EAC) has had the fastest increasing incidence of any solid tumor in the United States in the last 30 years. Long standing gastroesophageal reflux disease is a well-established risk factor with strong associations with obesity, alcohol and tobacco. However, there are likely additional contributing factors. Viruses such as human papillomavirus, ebstein-barr virus and herpes simplex virus have been implicated in the pathogenesis of esophageal cancer. This review will discuss the known literature linking viruses to esophageal adenocarcinoma and consider future relationships such as identifying prognostic and predictive molecular biomarkers to guide therapies.

Minimally invasive esophagectomy is associated with superior survival, lymphadenectomy and surgical margins: propensity matched analysis of the National Cancer Database.

Despite excellent short-term outcomes of minimally invasive esophagectomy (MIE), there is minimal data on long-term outcomes compared to open esophagectomy. MIE's superior visualization may have improved lymphadenectomy and complete resection rate and therefore improved long-term outcomes. We hypothesized that MIE would have superior long-term survival. Patients undergoing an esophagectomy for cancer between 2010 and 2016 were identified in the National Cancer Database. MIE included laparoscopic/robotic approach, and conversions were categorized as open. A 1:1 propensity match was performed. Lymphadenectomy and margin status were compared between MIE and open using Stuart Maxwell marginal homogeneity and Wilcoxon matched-pair signed-rank test. Survival was compared using log-rank test. 13,083 patients were identified: 8,906 (68%) open and 4,177 (32%) MIE. Propensity matching identified 3,659 'pairs' of MIE and open esophagectomy patients. Among them, MIE was associated with higher number lymph nodes examined (16 vs. 14, P < 0.001) and similar number of positive lymph nodes (0 vs. 0, P = 0.33). MIE had higher rate of negative pathologic margin (95 vs. 93.5%, P < 0.001). MIE was also associated with shorter hospitalization (9 vs. 10 days, P < 0.001). Survival was improved among MIE patients (46.6 vs. 41.4 months for open, P = 0.003) and among pathologic node-negative patients (71.4 vs. 61.5 months, P = 0.005). These data suggest that MIE has improved short-term outcomes (improved lymphadenectomy, pathologic margins, and length of stay) and also associated improved overall survival. The etiology of superior overall survival is likely secondary to many factors related and unrelated to surgical approach.

Accuracy of Clinical Staging and Outcome With Primary Resection for Local-Regionally Limited Esophageal Adenocarcinoma.

OBJECTIVE: The aim of this study was to determine the accuracy of clinical staging, to assess survival with surgical resection alone, and to determine factors associated with understaging in patients with esophageal adenocarcinoma thought to have limited local-regional disease. BACKGROUND: Primary surgical resection is the preferred treatment in patients with esophageal adenocarcinoma clinically staged to have limited nodal disease. This approach requires reliable clinical staging. METHODS: A retrospective chart review was performed of all patients who had primary esophagectomy for clinical stage T1-3 N0-1 adenocarcinoma (seventh edition AJCC) from January 2002 to May 2013. Clinical and pathologic stages were compared and overall survival was analyzed. RESULTS: There were 88 patients who met inclusion criteria. Final pathology confirmed appropriate clinical staging (≤T3N1) in 76% of patients (67/88). There were 21 patients who were understaged (>T3N1), and in all cases, understaging was based on the presence of advanced nodal (N2 or N3) disease. Factors independently associated with understaging were the presence of dysphagia, tumor length >3 cm, and poor differentiation. At a median follow-up of 35 months, 63% of all patients (55/88) remain alive. The 5-year survival in correctly staged patients was 67%, compared with 33% for those who were understaged (P < 0.0001). CONCLUSIONS: Modern clinical staging will accurately identify the majority of patients with esophageal adenocarcinoma and limited local-regional disease (≤pT3N1). Survival with surgery alone in correctly staged patients was excellent and unlikely to be improved with neoadjuvant therapy. A combination of dysphagia, poor differentiation, and tumor length >3 cm was associated with understaging in 92% of patients. Patients with these factors are likely to have more advanced disease than clinically suspected and may benefit from neoadjuvant therapy before resection.

Outcome with Primary En-bloc Esophagectomy for Submucosal Esophageal Adenocarcinoma.

BACKGROUND: Intramucosal esophageal adenocarcinoma can be reliably treated endoscopically. Controversy exists about the use of endotherapy versus esophagectomy for submucosal tumors. Increasingly endotherapy is considered for submucosal tumors in part because of the presumed high mortality with esophagectomy and the perceived poor prognosis in patients with nodal disease. This study was designed to assess survival following primary en bloc esophagectomy (EBE) in patients with submucosal esophageal adenocarcinoma (EAC). METHODS: This is a retrospective review of all patients who underwent EBE for submucosal EAC between 1998 and 2015. No patient had neoadjuvant therapy. RESULTS: There were 32 patients (28M/4F; median age 64 years). The median tumor size was 1.5 cm (0.4-8.0), and the median number of resected nodes was 48 (23-85). There was one perioperative death. Lymph node metastases were present in 7 patients (22%). There was one involved node in four patients and 2, 3, and 31 nodes in one patient each. The one N3 patient received adjuvant therapy. The median follow-up was 87 months. Overall survival at 5 and 10 years was 84 and 70% respectively. Disease-specific survival at 10 years was 90%. Eight patients died, but only three deaths (9%) were related to EAC. Disease-specific survival at 10 years in node-positive patients was 71%. CONCLUSIONS: Survival after primary en bloc esophagectomy for submucosal adenocarcinoma was excellent even in node-positive patients. Mortality with esophagectomy was low and far less than the 22% risk of node metastases in patients with submucosal tumor invasion. Esophagectomy should remain the preferred treatment for T1b esophageal adenocarcinoma.

Public perceptions on robotic surgery, hospitals with robots, and surgeons that use them.

OBJECTIVE: The use of robotic-assisted surgery (RS) has rapidly increased, but public perceptions about RS are largely unknown. The aim of this study was to gain insight into public perceptions about RS, hospitals that have robots, and surgeons that use them. METHODS: A Web-based survey was distributed worldwide. Surveys were collected from July to September 2014, and those with 50% or greater completion were used for analysis. RESULTS: There were 789 surveys, and 747 (95%) were used for analysis. The mean age of respondents was 38.5 years. Most (94%) were from the USA. Over half (53%) had a background in health care, and 13% were physicians. The majority of respondents (86%) had previously heard of RS, but almost 25% indicated that RS was like open, laser, or scarless surgery. Over 20% of respondents indicated that the robot had some degree of autonomy during surgery. Most respondents (72%) indicated that RS was safer, faster, and less painful or offered better results, but when asked if they would choose to have RS, 55% would prefer to have conventional minimally invasive surgery. Hospitals with a robot were thought to be better hospitals by 53% of the respondents. Fewer physicians perceived advantages to RS (30% physicians vs 78% non-physicians p < 0.001), and fewer physicians would prefer RS if they needed surgery (30 vs 49% p = 0.001). One-half of respondents would prefer remote RS by a renowned expert they had never met over having RS by a local non-expert surgeon. CONCLUSIONS: Most respondents perceived benefits to RS, but still preferred conventional minimally invasive surgery if necessary. Misperceptions about the robot indicate a need for patient education prior to RS. Interest by 50% of respondents in remote surgery might allow expert surgeons to do complex procedures without necessitating regionalization of care. Issues identified in this survey merit further exploration.

Rat Reflux Model of Esophageal Cancer and Its Implication in Human Disease.

OBJECTIVES: The epidemiologic shift in esophageal cancer from squamous cell carcinoma to esophageal adenocarcinoma coincided with popularization of proton pump inhibitors and has focused attention on gastroesophageal reflux disease as a causative factor in this shift. The aim of this study is to review the literature on the rat reflux model in an effort to elucidate this phenomenon. METHODS: An extensive online literature review (PubMed) was carried out to identify all seminal contributions to the study of esophageal adenocarcinoma using the rat reflux model. RESULTS: The rat reflux model is a validated reproducible model for the development of Barrett's esophagus and esophageal adenocarcinoma. Esophageal reflux of an admixture of gastric acid and duodenal juice induces Barrett's esophagus followed by adenocarcinoma. A high-pH environment created by surgical gastrectomy or proton pump inhibitor therapy in combination with a high-fat diet seems to potentiate the development of Barrett's esophagus and adenocarcinoma. Early surgical intervention to prevent reflux reduces the progression toward esophageal adenocarcinoma. Anti-inflammatory, antioxidant, and nitrate-trapping agents reduce the incidence of tumorigenesis. CONCLUSIONS: As in the rat so also in humans, reflux of an admixture of gastric acid and duodenal juice in a high-pH environment induces the development of Barrett's esophagus followed by esophageal adenocarcinoma. This has led to the hypothesis that to prevent Barrett's esophagus and subsequent esophageal adenocarcinoma in humans, the reflux of an admixture of acid and bile must be controlled before the development of Barrett's esophagus by methods other than acid-suppression therapy.