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INTRODUCTION: Robotic surgery has become an increasingly utilized approach for resectable lung cancer. However, availability may be limited for certain patient populations, underscoring inequity in access to innovative surgical techniques. We hypothesize that there is an association between social determinants of health and robotic surgery utilization for resectable non-small cell lung cancer (NSCLC). METHODS: We queried the National Cancer Database (2010-2019) for patients with clinical stage I-III NSCLC who underwent resection, stratifying the cohort based on surgical technique. Multivariable logistic regression analysis was performed to identify associations between sociodemographic and clinicopathologic factors and the robotic approach. RESULTS: Among the 226,455 clinical stage I-III NSCLC patients identified, 34,059 (15%) received robotic resections, 78,039 (34.5%) underwent thoracoscopic resections, and 114,357 (50.5%) had open resections. Robotic surgery utilization increased from 3.1% in 2010 to 34% in 2019 (P < 0.001). Despite this, after adjusting by clinical stage, extent of resection, site of tumor, and receipt of neoadjuvant therapy, multivariable analysis revealed various sociodemographic and treatment facility factors that were associated with underutilization of this approach: lack of insurance (adjusted odds ratio [aOR] 0.83, 95% confidence interval [CI] 0.73-0.93), lower income brackets (aOR 0.93, 95% CI 0.91-0.96), provincial settings (urban aOR 0.79, 95% CI 0.76-0.82; rural aOR 0.57, 95% CI 0.51-0.64), and treatment at community centers (comprehensive community cancer programs aOR 0.73, 95% CI 0.70-0.75; community cancer programs aOR 0.51, 95% CI 0.47-0.55). CONCLUSIONS: This study suggests that disparities in determinants of health influence accessibility to robotic surgery for resectable NSCLC. Identification of these gaps is crucial to target vulnerable sectors of the population in promoting equality and uniformity in surgical treatment.
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BACKGROUND: Recently, there has been an increase in the representation of women within the cardiothoracic surgery workforce, with discussions about gender equity garnering interest. We sought to identify whether this increase is accompanied by commensurate selection for representation at national meetings. METHODS: Online archives of the Society of Thoracic Surgeons (STS) Annual Meetings were reviewed from 2015 to 2024. Data regarding the moderator gender were abstracted. The gender distribution of moderators across the various session categories were surveyed; subgroup analyses were performed. RESULTS: During the years of study, 983 moderators were selected by STS Annual Meeting Taskforce to participate in the conference, including 218 women. The representation of women moderators demonstrated a favorable, upward trend. In 2015, 12.1% of moderators were women, with a consistent rate from 2015 to 2018. There was a noticeable rise in invited women moderators in 2019, with 25.4% of moderators being women. This proportion increased to 36.9% women in 2024. General Thoracic sessions have consistently included a greater percentage of women moderators compared to other sessions. Other topic areas, such as Education and Quality Improvement and Critical Care, transitioned to greater representation of women in recent years. CONCLUSIONS: There has been an increase over time in women moderators selected for participation in the STS Annual Meeting, with progress in gender diversity seen in most session types. While the overall proportion of women within cardiothoracic surgery remains low, the STS has increasingly worked toward encouraging inclusivity. Efforts to further support well-rounded representation are of important benefit.
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BACKGROUND: The circumstances under which pneumonectomy should be performed are controversial. This study aims to investigate national trends in pneumonectomy use to determine which patients, in what geographic areas, and under what clinical circumstances pneumonectomy is performed in the United States. METHODS: We queried the National Cancer Database and included all patients undergoing anatomic surgical resection for non-small cell lung cancer (2015-2020). The association between demographic and clinical factors and the use of pneumonectomy were investigated. RESULTS: Who: A total of 128,421 patients were identified, of whom 738 (0.6%) underwent pneumonectomy. Those patients were younger (median 65 vs 68 years, P < .001), more often male (59.9% vs 44.9%, P < .001), more likely to be below median income level (44.2% vs 38.6%, P = .002), and more likely to have lower education indicators (53% vs 48.6%, P = .02) than those who underwent other anatomic resections. Notably, there was a decreasing trend in pneumonectomy use during the study period (0.9% down to 0.4%, P < .001). Where: Patients undergoing pneumonectomy were less likely to live in metropolitan areas (77.9% vs 81.7%, P = .008) and to live closer (<12 miles) to their treating facility (45% vs 49%, P = .02). Regional geographic differences also were identified (P < .001). Why: Patients who underwent pneumonectomy were more likely to have received neoadjuvant therapy (20.6% vs 5.3%, P < .001), to be clinically N (+) (39.3% vs 12.3%, P < .001), and to have more advanced tumors (cT3-4: 46.3% vs 11.3%, P < .001). CONCLUSION: Although primarily driven by advanced oncologic features, socioeconomic and geographic factors also were associated independently with the use of pneumonectomy. Standardizing pneumonectomy indications nationwide is crucial to prevent widening outcome gaps for patients with lung cancer.
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Carcinoma Pulmonar de Células não Pequenas , Bases de Dados Factuais , Neoplasias Pulmonares , Pneumonectomia , Humanos , Pneumonectomia/estatística & dados numéricos , Pneumonectomia/tendências , Pneumonectomia/métodos , Neoplasias Pulmonares/cirurgia , Neoplasias Pulmonares/patologia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Carcinoma Pulmonar de Células não Pequenas/patologia , Masculino , Feminino , Idoso , Estados Unidos/epidemiologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do TratamentoRESUMO
INTRODUCTION: Suboptimal weight loss or weight regain may occur after Roux-en-Y gastric bypass (RYGB). For this reason, revisional surgery has gained increasing interest. We aimed to compare the percentage of total body weight loss (%TBWL) at one-year follow-up among three different techniques: Jejuno-jejunostomy distalization (JJD), Sleeve resection of the gastrojejunostomy and gastric pouch (SRGJP), and the combination of both (JJD + SRGJP). METHODS: This retrospective cohort study included all patients who underwent revisional surgery after RYGB (2020-2021). The cohort was stratified by the type of revisional technique performed. Postoperative bariatric outcomes and nutritional deficiencies were compared among groups. RESULTS: A total of 78 patients underwent revisional surgery after RYGB: JJD was performed in 8 (10.3%), SRGJP in 34 (43.6%), and JJD + SRGJP in 36 (46.1%) patients. The most common indication for surgery was weight regain, in 72 (92.3%) patients. The median lengths of the BP limbs before and after distalization, were 50 cm (IQR 40-75 cm) and 175 cm (IQR 150-200 cm), respectively. The median length of the new common limb (NCL) and total alimentary limb length (TALL) were 277 cm (IQR 250-313 cm) and 400 cm (IQR 375-475 cm), respectively. Median percentage of total body weight loss (%TBWL) at one year was 15% (IQR 15-19%) for JJD, 20% (IQR 13-26%) for SRGJP, and 21% (IQR 15- 28%) for JJD + SRGJP (p = 0.40). CONCLUSIONS: In this study, the combined procedure (JJD + SRGJP) exhibited higher %TBWL at one year, however no statistically significant difference was identified among the three techniques.
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Derivação Gástrica , Obesidade Mórbida , Reoperação , Redução de Peso , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos de Coortes , Derivação Gástrica/métodos , Obesidade Mórbida/cirurgia , Estudos RetrospectivosRESUMO
BACKGROUND: Local therapy for the primary tumor is postulated to remove resistant cancer cells as well as immunosuppressive cells from the tumor microenvironment, potentially improving response to systemic therapy (ST). We sought to determine whether resection of the primary tumor was associated with overall survival (OS) in a multicentric cohort of patients with single-site synchronous oligometastatic non-small cell lung cancer. STUDY DESIGN: Using the National Cancer Database (2018 to 2020), we evaluated patients with clinical stage IVA disease who received ST and stratified the cohort based on receipt of surgery for the primary tumor (S). We used multivariable and propensity score-matched analysis to study factors associated with S (logistic regression) and OS (Cox regression and Kaplan-Meier), respectively. RESULTS: Among 12,215 patients identified, 2.9% (N = 349) underwent S and 97.1% (N = 11,886) ST (chemotherapy or immunotherapy) without surgery. Patients who underwent S were younger, more often White, had higher income levels, were more likely to have private insurance, and were more often treated at an academic facility. Among those who received S, 22.9% (N = 80) also underwent resection of the distant metastatic site. On multivariable analysis, metastasis to bone, N+ disease, and higher T-stages were independently associated with less S. On Cox regression, S and resection of the metastatic site were associated with improved survival (hazard ratio 0.67, 95% CI 0.56 to 0.80 and hazard ratio 0.80, 95% CI 0.72 to 0.88, respectively). After propensity matching, OS was improved in patients undergoing S (median 36.8 vs 20.8 months, log-rank p < 0.001). CONCLUSIONS: Advances in ST for non-small cell lung cancer may change the paradigm of eligibility for surgery. This study demonstrates that surgical resection of the primary tumor is associated with improved OS in selected patients with single-site oligometastatic disease.
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Carcinoma Pulmonar de Células não Pequenas , Bases de Dados Factuais , Neoplasias Pulmonares , Pontuação de Propensão , Humanos , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Carcinoma Pulmonar de Células não Pequenas/patologia , Carcinoma Pulmonar de Células não Pequenas/terapia , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/cirurgia , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/terapia , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Estados Unidos/epidemiologia , Taxa de Sobrevida , Estudos Retrospectivos , Pneumonectomia/métodos , Estadiamento de Neoplasias , Metástase NeoplásicaRESUMO
OBJECTIVES: Recent randomized data support the perioperative benefits of minimally invasive surgery (MIS) for non-small-cell lung cancer (NSCLC). Its utility for cT4 tumours remains understudied. We, therefore, sought to analyse national trends and outcomes of minimally invasive resections for cT4 cancers. METHODS: Using the 2010-2019 National Cancer Database, we identified patients with cT4N0-1 NSCLC. Patients were stratified by surgical approach. Multivariable logistic analysis was used to identify factors associated with use of a minimally invasive approach. Groups were matched using propensity score analysis to evaluate perioperative and survival end points. RESULTS: The study identified 3715 patients, among whom 64.1% (n = 2381) underwent open resection and 35.9% (n = 1334) minimally invasive resection [robotic-assisted in 31.5% (n = 420); and video-assisted in 68.5% (n = 914)]. Increased MIS use was noted among patients with higher income [≥$40 227, odds ratio (OR) 1.24; 95% confidence interval (CI) 1.01-1.51] and those treated at academic hospitals (OR 1.25; 95% CI 1.07-1.45). Clinically node-positive patients (OR 0.68; 95% CI 0.55-0.83) and those who underwent neoadjuvant therapy (OR 0.78; 95% CI 0.65-0.93) were less likely to have minimally invasive resection. In matched groups, patients undergoing MIS had a shorter median length of stay (5 vs 6 days, P < 0.001) and no significant differences between 30-day readmissions or 30/90-day mortality. MIS did not compromise overall survival (log-rank P = 0.487). CONCLUSIONS: Nationally, the use of minimally invasive approaches for patients with cT4N0-1M0 NSCLC has increased substantially. In these patients, MIS is safe and does not compromise perioperative outcomes or survival.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Robótica , Humanos , Carcinoma Pulmonar de Células não Pequenas/epidemiologia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Neoplasias Pulmonares/epidemiologia , Neoplasias Pulmonares/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos , Readmissão do PacienteRESUMO
BACKGROUND: For cT2N0M0 esophageal adenocarcinomas, the effects of neoadjuvant chemoradiotherapy (NT) on surgical outcomes and the oncological benefits to the patients are debatable. In this study, we investigated the optimal management for cT2N0M0 adenocarcinoma (1) assessing the perioperative impact of NT on esophagectomy and (2) evaluating the oncologic effect of NT in a homogeneous group of patients with clinical stage IIA. We hypothesized that NT does not negatively affect perioperative outcomes and provides an oncologic benefit to selected patients with cT2N0M0 disease. METHODS: The National Cancer Database was queried (2010-2019) for patients with cT2N0M0 esophageal adenocarcinoma undergoing esophagectomy. After propensity-matching to adjust for differences in patient and tumor characteristics, we compared postoperative outcomes (logistic regression) and survival (Kaplan-Meier and Cox regression) among those who underwent NT vs upfront surgery (S). RESULTS: This study included 3413 patients, of whom 2359 (69%) received NT, and 1054 (31%) S. In contrast to those who underwent S, in the matched cohort, patients treated with NT had comparable conversion rates (8% vs11.1%, p = 0.06), length of stay (9 vs 10 days, p = 0.078), unplanned readmission (5.4% vs 8.8%, p = 0.109), and 30- (3.9% vs 3.7%, p = 0.90) and 90-day mortality (5.7% vs 4.7%, p = 0.599). In addition, NT associated with improved survival in patients with cT2N0M0 tumors > 5 cm (HR 0.30, 95% CI 0.17-0.36). CONCLUSIONS: NT does not appear to increase technical complexity or to adversely affect postoperative outcomes after esophagectomy. Furthermore, minimally invasive esophagectomy is feasible following NT, with comparable conversion rates to those who had upfront surgery. Lastly, NT was selectively associated with improved survival in patients with cT2N0M0 esophageal cancer.
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Adenocarcinoma , Neoplasias Esofágicas , Humanos , Terapia Neoadjuvante , Esofagectomia , Estadiamento de Neoplasias , Estudos Retrospectivos , Neoplasias Esofágicas/patologia , Adenocarcinoma/patologia , Resultado do TratamentoRESUMO
OBJECTIVES: CALGB140503, in which nodal sampling was mandated, reported non-inferior disease-free survival for patients undergoing sublobar resection (SLR) compared to lobectomy (L). Outside of trial settings, the adequacy of lymphadenectomy during SLR has been questioned. We sought to evaluate whether SLR is associated with suboptimal lymphadenectomy, differences in pathologic upstaging and survival in patients with 1.5- to 2.0-cm tumours using real-world data. MATERIALS AND METHODS: Using the National Cancer Database(2018-2019), we evaluated patients with 1.5- to 2.0-cm non-small-cell lung cancer who underwent resection (sublobar versus lobectomy). We studied factors associated with nodal upstaging (logistic regression) and survival (Cox regression and Kaplan-Meier method) after propensity matching to adjust for differences among groups. RESULTS: Among 3196 patients included, SLR was performed in 839 (26.3%) (of which 588 were wedge resections) and L was performed in 2357 (73.7%) patients. More patients undergoing SLR (21.7%) compared to L (2.1%) had no lymph nodes sampled (P < 0.001). Those undergoing SLR had fewer total lymph nodes examined (4 vs 11, P < 0.001) and were less likely to have pathologic nodal metastases (4.7% vs 9%, P < 0.001) compared to L. Multivariable analysis identified L [adjusted odds ratio (aOR) 2.21, 95% confidence interval, 1.47-3.35] to be independently associated with pathologic N+ disease. Overall survival was not associated with the type of procedure but was significantly decreased in those with N+ disease. CONCLUSIONS: Despite comparable overall survival to L, SLR is associated with suboptimal lymphadenectomy in patients with 1.5-2.0 cm non-small-cell lung cancer. Surgeons should be careful to perform adequate lymphadenectomy when performing SLR to mitigate nodal under-staging and to identify appropriate patients for systemic therapy.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Humanos , Estudos Retrospectivos , Pneumonectomia/métodos , Estadiamento de Neoplasias , Linfonodos/cirurgia , Linfonodos/patologiaRESUMO
While P2X7 receptor expression on tumour cells has been characterized as a promotor of cancer growth and metastasis, its expression by the host immune system is central for orchestration of both innate and adaptive immune responses against cancer. The role of P2X7R in anti-tumour immunity is complex and preclinical studies have described opposing roles of the P2X7R in regulating immune responses against tumours. Therefore, few P2X7R modulators have reached clinical testing in cancer patients. Here, we review the prognostic value of P2X7R in cancer, how P2X7R have been targeted to date in tumour models, and we discuss four aspects of how tumours skew immune responses to promote immune escape via the P2X7R; non-pore functional P2X7Rs, mono-ADP-ribosyltransferases, ectonucleotidases, and immunoregulatory cells. Lastly, we discuss alternative approaches to offset tumour immune escape via P2X7R to enhance immunotherapeutic strategies in cancer patients.
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Neoplasias , Evasão Tumoral , Humanos , Receptores Purinérgicos P2X7 , Transdução de SinaisRESUMO
OBJECTIVES: Although adjuvant systemic therapy (AT) has demonstrated improved survival in patients with resected non-small-cell lung cancer (NSCLC), it remains underutilized. Recent trials demonstrating improved outcomes with adjuvant immunotherapy and targeted treatment imply that low uptake of systemic therapy in at-risk populations may widen existing outcome gaps. We, therefore, sought to determine factors associated with the underutilization of AT. METHODS: The National Cancer Database (2010-2018) was queried for patients with completely resected stage II-IIIA NSCLC and stratified based on the receipt of AT. Logistic regression was used to identify factors associated with AT delivery. The Kaplan-Meier method was applied to estimate survival after propensity-matching to adjust for confounders. RESULTS: Of 37 571 eligible patients, only 20 616 (54.9%) received AT. While AT rates increased over time, multivariable analysis showed that older age [adjusted odds ratio (aOR) 0.45, 95% confidence interval (CI) 0.43-0.47], male sex (aOR 0.88, 95% CI 0.85-0.93) and multiple comorbidities (aOR 0.86, 95% CI: 0.81-0.91) were associated with decreased AT. Socioeconomic factors were additionally associated with underutilization, including public insurance (aOR 0.70, 95% CI: 0.66-0.74), lower education indicators (aOR 0.93, 95% CI: 0.88-0.97) and living more than 10 miles from a treatment facility (aOR 0.89, 95% CI: 0.85-0.93). After propensity matching, receipt of adjuvant therapy was associated with improved overall survival (median 76.35 vs 47.57 months, P ≤ 0.001). CONCLUSIONS: AT underutilization in patients with resected stage II-III NSCLC is associated with patient, institutional and socioeconomic factors. It is critical to implement measures to address these inequities, especially in light of newer adjuvant immunotherapy and targeted therapy treatment options which are expected to improve survival.
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Carcinoma Pulmonar de Células não Pequenas , Neoplasias Pulmonares , Humanos , Masculino , Carcinoma Pulmonar de Células não Pequenas/epidemiologia , Carcinoma Pulmonar de Células não Pequenas/cirurgia , Neoplasias Pulmonares/epidemiologia , Neoplasias Pulmonares/cirurgia , Disparidades Socioeconômicas em Saúde , Quimioterapia Adjuvante , Terapia Combinada , Estadiamento de NeoplasiasRESUMO
BACKGROUND: Diabetic patients are at increased risk of acute kidney injury (AKI) following surgery. The significance of uncontrolled diabetes on kidney function after coronary artery bypass grafting (CABG) remains controversial. Our aim was to study the association between pre-operative hemoglobin A1c (HbA1c) and severe cardiac surgery-associated AKI (CSA-AKI) following CABG. METHODS: A single-center, retrospective cohort study including patients who underwent isolated CABG from 2010 to 2018 was performed. Patients were grouped into pre-operative HbA1c of <6.5 %, 6.5-8.5 %, and ≥8.5 %. Postoperative serum creatinine levels were queried for up to 30 days, and the 30-day risk of severe AKI was compared among groups. Multivariable logistic regression was used to study factors associated with severe CSA-AKI and the association of severe CSA-AKI with postoperative outcomes. Cox regression was used to study the association between severe CSA-AKI and all-cause mortality from the time of surgery to the last follow-up or death. RESULTS: A total of 2424 patients met the inclusion criteria. Patients were primarily male (70.5 %), with a median age of 64 years (IQR 57-71). Median bypass and cross-clamp times were 95 (IQR 78-116) and 78 min (IQR 63-95). Severe CSA-AKI occurred within 30 days in 5.7 %, 6.7 %, and 9.1 % of patients with pre-op HbA1c of <6.5 %, 6.5-8.5 %, and ≥8.5 %, respectively. After adjusting for covariates, HbA1c >8.5 %, was independently associated with severe CSA-AKI 30 days after CABG (aOR 1.59, 95%CI 1.06-2.40). In addition, severe CSA-AKI was associated with increased 30- (aOR 15.83,95%CI 7.94-31.56) and 90- day mortality (aOR 9.54, 95%CI 5.46-16.67), prolonged length of stay (aOR 3.46,95%CI 2.41-4.96) and unplanned 30-day readmission (aOR 2.64, 95%CI 1.77-3.94). Lastly, severe CSA-AKI was associated with increased all-cause mortality (aHR 3.19, 95%CI 2.43-4.17). CONCLUSION: Elevated preoperative HbA1c (≥8.5 %) was independently associated with an increased 30-day risk of severe CSA-AKI, which is a consistent predictor of adverse outcomes after CABG. Delaying surgery to achieve optimal glycemic control in an elective setting may be reasonable.
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BACKGROUND: In the past years, there has been increasing evidence that supports the use of permanent mesh in contaminated wounds. Given this increased evidence, the indications to opt for slowly absorbable "biosynthetic" prostheses have been questioned. To address this, we compared the outcomes of slowly absorbable mesh in contaminated cases in a well-matched multicentric cohort. METHODS: The Abdominal Core Health Quality Collaborative (ACHQC) database was queried for patients undergoing elective ventral hernia repair in Centers for Disease Control (CDC)-III operations (2013-2022). We compared demographics, hernia characteristics, and postoperative outcomes among types of mesh. We used propensity score matching to adjust for sex, diabetes, body mass index, smoking status, and operative time between mesh groups. Patients within other CDC classes and those with mesh positioned elsewhere than retro-rectus/preperitoneal space were excluded. RESULTS: A total of 760 patients were included in the analysis. Slowly absorbable synthetic mesh (SA) was utilized in only 7% of the cases, while permanent (P) and biologic (B) mesh in 77% and 16%, respectively. After matching, 255 patients were studied. There was no difference in surgical site occurrence (8% SA, 16% P, 10% B, p = 0.27), surgical site infection (20% SA, 17% P, 12% B p = 0.54), surgical site occurrence requiring intervention (18% SA, 13% P, 14% B p = 0.72), readmission (12% SA, 14% P, 12% B, p = 0.90), or reoperation (8% SA, 2% P, 4% B, p = 0.14) at 30 days. In patients with 1-year follow-up, there was no difference in recurrence among groups (20% SA, 26% P, 24% B p = 0.90). CONCLUSION: Based on our findings, SA has comparable outcomes to other types of mesh, particularly when an optimal retro-rectus repair is performed.
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Hérnia Ventral , Telas Cirúrgicas , Humanos , Herniorrafia , Próteses e Implantes , Índice de Massa Corporal , Hérnia Ventral/cirurgiaRESUMO
Introduction: Recent trials have reported promising results with the addition of immunotherapy to chemotherapy for patients with locally advanced NSCLC, but in practice, the proportion of patients who receive systemic therapy (ST) has historically been low. Underutilization of ST may be particularly apparent in patients undergoing pneumonectomy, in whom the physiologic insult and surgical complications may preclude adjuvant therapy (ADJ). We, therefore, evaluated the use of ST for patients with NSCLC undergoing pneumonectomy. Methods: We queried the National Cancer Database, including all patients with NSCLC who underwent pneumonectomy between 2006 and 2018. Logistic regression was used to identify associations with ST and neo-ADJ (NEO). Overall survival was compared after propensity score matching (1:1) patients undergoing ST to those undergoing surgery alone using Kaplan-Meier and Cox regression methods. Results: A total of 2619 patients were identified. Among these, 12% received NEO, 43% received ADJ, and 45% surgery alone. Age younger than 65 years (adjusted odds ratio [aOR] = 1.53, 95% confidence interval; [CI]: 1.10-2.11), Asian ethnicity (aOR = 2.68, 95% CI: 1.37-5.23), treatment at a high-volume center (aOR = 1.39, 95% CI: 1.06-1.81), and private insurance (aOR = 1.42, 95% CI: 1.05-1.94) were associated with NEO, whereas age younger than 65 years (aOR = 1.95, 95% CI: 1.61-2.38), comorbidity index less than or equal to 1 (aOR = 1.66, 95% CI: 1.29-2.16), and private insurance (aOR = 1.47, 95% CI: 1.20-1.80) were associated with any ST. In the matched cohort, ST was associated with better survival than surgery (adjusted hazard ratio = 0.67, 95% CI: 0.58-0.78). Conclusions: A high proportion of patients who undergo pneumonectomy do not receive ST. Patient and socioeconomic factors are associated with the receipt of ST. Given its survival benefit, emphasis should be placed on multimodal treatment strategies, perhaps with greater consideration given to neoadjuvant approaches.
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PURPOSE: The Memorial Sloan Kattering Frailty Index (MSK-FI) and the Skeletal Muscle Index (SMI) have recently gained attention as markers of frailty and decreased physiologic reserve, and are promising as predictors of adverse postoperative outcomes in patients undergoing oncologic surgery. The objective of this study was to establish the prognostic accuracy of these indexes in a cohort of patients with colorectal cancer subjected to surgical intervention. METHODS: We performed an observational study including all patients older than 60 years, subjected to colorectal cancer surgery between January 2010 and May 2020, and stratified our cohort based on the presence of frailty, as defined by MSK-FI ≥ 3. Computed tomography was used to calculate SMI, using a standardized institutional protocol. A multivariable analysis was used to study the association between these novel indexes with adverse postoperative outcomes in our cohort. RESULTS: A total of 216 patients were included. Among these, 56 (26%) qualified as frail and 132 (62%) had a low SMI. On multivariable analysis (adjusted by patient and intraoperative characteristics), frailty was associated with increased risk of having a major postoperative complication (OR 29.78, 95%CI 10.36-85.71) and increased admission to the intensive care unit (OR 4.99, 95%CI 1.55-16.06), while both frailty and low SMI were associated with prolonged length of stay (OR 11.22, 95%CI 8.91-13.53 and OR 0.14, 95% CI 0.06-0.20, respectively). CONCLUSION: MSK-FI ≥ 3 and low SMI are associated with adverse postoperative outcomes in elderly patients undergoing colorectal cancer surgery. Implementing this practical tool in routine clinical practice, may help identify patients that would benefit from surgical prehabilitation and preoperative optimization to improve outcomes.
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Neoplasias Colorretais , Fragilidade , Humanos , Idoso , Fragilidade/complicações , Músculo Esquelético , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Tomografia Computadorizada por Raios X/métodos , Neoplasias Colorretais/diagnóstico por imagem , Neoplasias Colorretais/cirurgia , Neoplasias Colorretais/complicações , Avaliação Geriátrica/métodosRESUMO
BACKGROUND: Traditionally, the use of absorbable mesh in contaminated fields aimed to reduce postoperative morbidity at the expense of increased hernia recurrence. This dogma has recently been challenged in randomized trials that demonstrate the advantages of permanent mesh in this setting. Although these studies are of high quality, their reproducibility across institutions is limited. We sought to compare the outcomes between permanent and absorbable mesh in a multicentric cohort from the Abdominal Core Health Quality Collaborative. STUDY DESIGN: Patients who underwent elective ventral hernia repair in class II and III surgeries from January 2013 to December 2021 were identified within the Abdominal Core Health Quality Collaborative. Outcomes were compared among permanent (P), absorbable synthetic (AS), and biologic (B) mesh at 30 days and 1 year using a propensity score-matched analysis. RESULTS: A total of 2,484 patients were included: 73.4% P, 11.2% AS, and 15.4% B. Of these, 64% were clean-contaminated and 36% contaminated interventions. After propensity score-matched analysis, there was no significant difference between groups regarding surgical site occurrence (P 16%, AS 15%, B 21%, p = 0.13), surgical site infection (P 12%, AS 14%, B 12%, p = 0.64), and surgical site occurrence requiring procedural intervention at 30 days (P 12%, AS 15%, B 17%, p = 0.1). At 1 year, the recurrence rate was significantly lower among the permanent group (P 23%, AS 40%, B 32%, p = 0.029). CONCLUSIONS: In this multicentric cohort, permanent mesh has equivalent 30-day outcomes and lower rates of hernia recurrence at 1 year after hernia repair in contaminated fields.
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Hérnia Ventral , Herniorrafia , Humanos , Telas Cirúrgicas , Reprodutibilidade dos Testes , Resultado do Tratamento , Estudos Retrospectivos , Hérnia Ventral/cirurgia , Centro Abdominal , RecidivaRESUMO
Background: International Medical Graduates (IMGs) are an important component of the US healthcare workforce. Prior studies have investigated bias against IMGs during the general surgery residency application in the United States. Minimally invasive surgery (MIS) is a growing field; The MIS fellowship match was established in 2004 and is a competitive process with a match rate of 47%. Opportunities for applicants who are non-US citizens are limited by a series of factors that are not related to their professional qualifications. Objectives: The aim of the study was to explore the challenges faced by IMG in the MIS fellowship match. Methods: This is a cross-sectional study analyzing the minimally invasive surgery application requirements of all the programs listed in the Fellowship Council. Individual program requirements were collected into a database and a descriptive analysis was performed comparing programs who accept IMGs versus those that do not. Further statistical analysis was performed to explore those differences and associated factors. Results: There were 148 MIS fellowship programs and 187 positions offered during the 2021 match year in the US. Ninety-seven programs (65.5%) were found to accept graduates of foreign medical schools if they were US-citizens, whereas only 49 programs (33.1%) were found to accept IMG and sponsor a visa for their training. University affiliated programs (88.9% vs 75.0%, p = 0.04), programs with a general surgery residency (94.4% vs 75.0%, p = 0.003), and older programs (63.0% vs 45.5%, p = 0.04) were more likely to accept IMGs requiring visa sponsorship. Conclusions: There is a significant bias against IMGs in the MIS fellowship match, with a reduced number of positions available based on factors not related to their professional performance or qualifications. Well established programs, university, and residency affiliated programs are more likely to consider these physicians for training.