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Neoplasias Esofágicas , Esofagectomia , Humanos , Esofagectomia/efeitos adversos , Neoplasias Esofágicas/cirurgia , Neoplasias Esofágicas/complicações , Complicações Intraoperatórias/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/cirurgia , Resultado do Tratamento , Estudos RetrospectivosRESUMO
The National Surgical Quality Improvement Project (NSQIP) dataset was used to identify perioperative variables associated with the length of stay (LOS) and early discharge among cancer patients undergoing colectomy. Patients who underwent non-emergent right colectomy for colon cancer from 2012 to 2019 were identified from the NSQIP and colectomy-targeted databases. Postoperative LOS was analyzed based on postoperative day (POD) of discharge, with patients grouped into Early Discharge (POD 0-2), Standard Discharge (POD 3-5), or Late Discharge (POD ≥ 6) cohorts. Multivariable ordinal logistic regression was performed to identify risk factors associated with early discharge. The NSQIP query yielded 26,072 patients: 3684 (14%) in the Early Discharge, 13,414 (52%) in the Standard Discharge, and 8974 (34%) in the Late Discharge cohorts. The median LOS was 4.0 days (IQR: 3.0-7.0). Thirty-day readmission rates were 7% for Early Discharge, 8% for Standard Discharge, and 12% for Late Discharge. On multivariable regression analysis, risk factors significantly associated with a shorter LOS included independent functional status, minimally invasive approach, and absence of ostomy or additional bowel resection (all p < 0.001). Perioperative variables can be used to develop a model to identify patients eligible for early discharge after right colectomy for colon cancer. Efforts to decrease the overall median length of stay should focus on optimization of modifiable risk factors.
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Neoplasias do Colo , Melhoria de Qualidade , Humanos , Alta do Paciente , Estudos Retrospectivos , Colectomia/efeitos adversos , Complicações Pós-Operatórias/etiologiaRESUMO
BACKGROUND: Prognostic nomograms for patients with resected extremity soft tissue sarcoma (STS) include the Sarculator and Memorial Sloan Kettering (MSKCC) nomograms. We sought to validate these two nomograms within a large, modern, multi-institutional cohort of resected primary extremity STS patients. METHODS: Resected primary extremity STS patients from 2000 to 2017 were identified across nine high-volume U.S. institutions. Predicted 5- and 10-year overall survival (OS) and distant metastases cumulative incidence (DMCI), and 4-, 8-, and 12-year disease-specific survival (DSS) were calculated with Sarculator and MSKCC nomograms, respectively. Predicted survival probabilities stratified in quintiles were compared in calibration plots to observed survival assessed by Kaplan-Meier estimates. Cumulative incidence was estimated for DMCI. Harrell's concordance index (C-index) assessed discriminative ability of nomograms. RESULTS: A total of 1326 patients underwent resection of primary extremity STS. Common histologies included: undifferentiated pleomorphic sarcoma (35%), fibrosarcoma (13%), and leiomyosarcoma (9%). Median tumor size was 8.0 cm (IQR 4.5-13.0). Tumor grade distribution was: Grade 1 (13%), Grade 2 (9%), Grade 3 (78%). Median OS was 172 months, with estimated 5- and 10-year OS of 70% and 58%. C-indices for 5- and 10-year OS (Sarculator) were 0.72 (95% CI 0.70-0.75) and 0.73 (95% CI 0.70-0.75), and 0.72 (95% CI 0.69-0.75) for 5- and 10-year DMCI. C-indices for 4-, 8-, and 12-year DSS (MSKCC) were 0.71 (95% CI 0.68-0.75). Calibration plots showed good prognostication across all outcomes. CONCLUSIONS: Sarculator and MSKCC nomograms demonstrated good prognostic ability for survival and recurrence outcomes in a modern, multi-institutional validation cohort of resected primary extremity STS patients. External validation of these nomograms supports their ongoing incorporation into clinical practice.
Assuntos
Sarcoma , Neoplasias de Tecidos Moles , Extremidades/patologia , Extremidades/cirurgia , Humanos , Nomogramas , Prognóstico , Sarcoma/patologia , Neoplasias de Tecidos Moles/cirurgiaRESUMO
OBJECTIVES: Patients undergoing oesophagectomy frequently experience malnutrition, which in combination with the catabolic effects of surgery can result in loss of muscle mass and function. Safe swallowing requires preservation of muscle mass. Swallowing dysfunction puts postoperative patients at risk for aspiration and pneumonia. Modified Barium Swallow Study (MBSS) enables assessment of postoperative swallowing impairments. The current study assessed incidence and risk factors associated with swallowing dysfunction and restricted diet at discharge in patients after oesophagectomy in a high-volume surgical centre. METHODS: Patients with an MBSS after oesophagectomy were identified between March 2015 to April 2020 at a high-volume surgical centre. Swallowing was quantitatively evaluated on MBSS with the Rosenbek Penetration-Aspiration Scale (PAS). Muscle loss was evaluated clinically with preoperative hand grip strength (HGS). Univariable and multivariable logistic and linear regression analyses were performed. RESULTS: 129 patients (87% male; median age 66 years) underwent oesophagectomy with postoperative MBSS. Univariate analysis revealed older age, preoperative feeding tube, lower preoperative HGS and discharge to non-home were associated with aspiration or penetration on MBSS. Age and preoperative feeding tube remained as independent predictors in the multivariable analysis. Both univariate and multivariable analyses revealed increased age and preoperative feeding tube were associated with diet restrictions at discharge. CONCLUSIONS: Swallowing dysfunction after oesophagectomy is correlated with increased age and need for preoperative enteral feeding tube placement. Further research is needed to understand the relationship between muscle loss and aspiration with the goal of enabling preoperative physiological optimisation and patient selection.
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Transtornos de Deglutição , Deglutição , Idoso , Transtornos de Deglutição/epidemiologia , Transtornos de Deglutição/etiologia , Nutrição Enteral , Esofagectomia/efeitos adversos , Feminino , Força da Mão , Humanos , MasculinoRESUMO
BACKGROUND: For locally advanced esophageal squamous cell carcinoma (ESCC), chemoradiation (ChemoRT) followed by surgery offers the best chance of cure, with a 35-50% pathologic complete response (pCR) rate. Given the morbidity of esophagectomy and the possibility of pCR with ChemoRT, a 'watch and wait' strategy has been proposed, particularly for squamous cell carcinoma. The ability to accurately predict which patients will have pCR from ChemoRT is critical in treatment decision making. This study assessed positron emission tomography (PET) in predicting pCR after neoadjuvant ChemoRT for ESCC. METHODS: ESCC patients treated with ChemoRT followed by surgery were identified. Maximum standard uptake value (SUV), metabolic tumor volume, total lesion glycolysis, and first-order textual features of standard deviation, kurtosis and skewness were measured from PET. Univariable and multivariable generalized linear method analyses were performed. A metabolic complete response (mCR) was defined as a post-therapy PET scan with maximum SUV < 4.0. RESULTS: Twenty-seven patients underwent ChemoRT followed by surgery, with overall pCR seen in 11 (41%) patients and radiographic mCR seen in 12 (44%) patients. Final pathology for these 12 patients revealed pCR (ypT0N0M0) in 5 (42%) patients and persistent disease in 7 (58%) patients. Univariate analysis did not reveal PET parameters predictive of pCR. CONCLUSION: Treatment of ESCC with ChemoRT often results in a robust clinical response. Among patients with an mCR after ChemoRT, disease persistence was found in 58%. The inability of PET to predict pCR is important in the context of a 'watch and wait' strategy for ESCC treated with ChemoRT.
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Neoplasias Esofágicas , Carcinoma de Células Escamosas do Esôfago , Quimiorradioterapia , Neoplasias Esofágicas/tratamento farmacológico , Neoplasias Esofágicas/terapia , Carcinoma de Células Escamosas do Esôfago/tratamento farmacológico , Carcinoma de Células Escamosas do Esôfago/terapia , Esofagectomia , Fluordesoxiglucose F18 , Humanos , Terapia Neoadjuvante , Tomografia por Emissão de Pósitrons , Compostos Radiofarmacêuticos/uso terapêutico , Estudos RetrospectivosRESUMO
BACKGROUND: In cancer, malnutrition is common and negatively impacts tolerance and outcomes of anti-tumor therapies. The aim of this study was to evaluate the prevalence of malnutrition risk and compare the clinicodemographic features between those with high malnutrition screening tool (MST) scores (i.e., ≥ 2 of 5 = high risk for malnutrition, H-MST) to low scores (L-MST). METHODS: A cohort of 3585 patients (May 2017 through December 2018), who completed the MST at least once at the time of diagnosis of any stage solid tumor, were analyzed. Logistic regression tested for associations between clinicodemographic factors, symptom scores, and H-MST prevalence. RESULTS: The median age was 64 years (25-75 IQR, 55-72), with 62% females and 81% White. Most common tumor primary sites were breast (28%), gastrointestinal (GI) (21%), and thoracic (13%). Most had non-metastatic disease (80%). H-MST was found in 28%-most commonly in upper (58%) and lower GI (42%), and thoracic (42%) tumors. L-MST was most common in breast (90%). Multivariable regression confirmed that Black race (OR 1.9, 95% CI 1.5-2.4, p = < 0.001), cancer primary site (OR 1.6-5.7, p = < 0.001), stage IV disease (OR 1.8, 95% CI 1.4-2.2, p = < 0.001), low BMI (OR 4.2, 95% CI 2.5-6.9 p = < 0.001), and higher symptom scores were all independently associated with H-MST. CONCLUSIONS: Twenty-eight percent of solid tumor oncology patients at diagnosis were at high risk of malnutrition. Patients with breast cancer rarely had malnutrition risk at diagnosis. Significant variation was found in malnutrition risk by cancer site, stage, race, and presence of depression, distress, fatigue, and trouble eating/swallowing.
Assuntos
Desnutrição , Neoplasias , Detecção Precoce de Câncer , Feminino , Humanos , Masculino , Desnutrição/diagnóstico , Desnutrição/epidemiologia , Desnutrição/etiologia , Programas de Rastreamento , Pessoa de Meia-Idade , Neoplasias/epidemiologia , Avaliação Nutricional , Estado NutricionalRESUMO
BACKGROUND: Sarcopenia, loss of muscle mass and strength, has been associated with more frequent complications after esophagectomy. This study compared hand-grip strength, muscle mass, and intramuscular adipose tissue as predictors of postoperative outcomes and mortality after esophagectomy. METHODS: Minimally invasive esophagectomy was performed on 175 patients with esophageal cancer. Skeletal muscle index and skeletal muscle density were derived from preoperative CTs. Hand-grip strength was measured using dynamometer. Univariate and multivariable analyses were performed. RESULTS: Preoperative hand-grip strength was normal in 91 (52%), intermediate in 43 (25%), and weak in 41 (23%) patients. Hand-grip strength was significantly correlated with both skeletal muscle index and skeletal muscle density. Postoperative pneumonia occurred in 8/41 (20%) patients with weak strength compared to 4/91 (4%) with normal strength (p = 0.006; Cochran-Armitage Test). Prolonged postoperative ventilation occurred in 11/41 (27%) patients with weak strength compared to 11/91 (12%) with normal strength (p = 0.036). Median length of stay was 9 days in patients with weak strength compared to 7 days for those with normal strength (p = 0.005; Kruskal-Wallis Test). Discharge to non-home location occurred in 15/41 (37%) with weak strength compared to 8/91 (9%) with normal strength (p < 0.001). Postoperative mortality at 90 days was 4/41 (10%) with weak strength compared with no mortalities (0/91) in the normal strength group (p = 0.004). Mortality at 1 year was 18/39 (46%) in patients with weak strength compared to 6/81 (7%) with normal strength, among 158 patients with 1-year follow-up (p < 0.001). CONCLUSIONS: Preoperative hand-grip strength was found to be a powerful predictor of postoperative pneumonia, length of stay, discharge to non-home location, and mortality after esophagectomy.
Assuntos
Neoplasias Esofágicas , Força da Mão , Sarcopenia , Neoplasias Esofágicas/cirurgia , Esofagectomia/efeitos adversos , Humanos , Músculo Esquelético , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Sarcopenia/etiologiaRESUMO
BACKGROUND AND OBJECTIVES: Prognostic nomograms for patients undergoing resection of retroperitoneal sarcoma (RPS) include the Sarculator and Memorial Sloan Kettering (MSK) sarcoma nomograms. We sought to validate the Sarculator and MSK nomograms within a large, modern multi-institutional cohort of patients with primary RPS undergoing resection. METHODS: Patients who underwent resection of primary RPS between 2000 and 2017 across nine high-volume US institutions were identified. Predicted 7-year disease-free (DFS) and overall survival (OS) and 4-, 8-, and 12-year disease-specific survival (DSS) were calculated from the Sarculator and MSK nomograms, respectively. Nomogram-predicted survival probabilities were stratified in quintiles and compared in calibration plots to observed survival outcomes assessed by Kaplan-Meier estimates. Discriminative ability of nomograms was quantified by Harrell's concordance index (C-index). RESULTS: Five hundred and two patients underwent resection of primary RPS. Histologies included leiomyosarcoma (30%), dedifferentiated liposarcoma (23%), and well-differentiated liposarcoma (15%). Median tumor size was 14.0 cm (interquartile range [IQR], 8.5-21.0 cm). Tumor grade distribution was: Grade 1 (27%), Grade 2 (17%), and Grade 3 (56%). Median DFS was 31.5 months; 7-year DFS was 29%. Median OS was 93.8 months; 7-year OS was 51%. C-indices for 7-year DFS, and OS by the Sarculator nomogram were 0.65 (95% confidence interval [CI]: 0.62-0.69) and 0.69 (95%CI: 0.65-0.73); plots demonstrated good calibration for predicting 7-year outcomes. The C-index for 4-, 8-, and 12-year DSS by the MSK nomogram was 0.71 (95%CI: 0.67-0.75); plots demonstrated similarly good calibration ability. CONCLUSIONS: In a diverse, modern validation cohort of patients with resected primary RPS, both Sarculator and MSK nomograms demonstrated good prognostic ability, supporting their ongoing adoption into clinical practice.
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Nomogramas , Neoplasias Retroperitoneais/patologia , Sarcoma/patologia , Procedimentos Cirúrgicos Operatórios/mortalidade , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Neoplasias Retroperitoneais/cirurgia , Estudos Retrospectivos , Sarcoma/cirurgia , Taxa de SobrevidaRESUMO
BACKGROUND: Gastrectomy is the cornerstone of treatment for gastric cancer. Recent studies demonstrated significant surgical outcome advantages for patients undergoing minimally invasive versus open gastrectomy. Lymph node harvest is an indicator of adequate surgical resection, and greater harvest is associated with improved staging and patient outcomes. This study evaluated lymph node harvest based on surgical approach. METHODS: Gastric adenocarcinoma patients were identified from NCDB who underwent gastrectomy between 2010 and 2016. Patients were classified by surgical approach into three cohorts: robotic, laparoscopic, or open gastrectomy. Clinical and demographic data were collected. Lymph node harvest was compared with univariate analysis and multivariable generalized linear mixed model. Univariate analysis with propensity matching was also performed to control for differences in patient population across cohorts. RESULTS: We identified 10,690 patients that underwent gastrectomy for gastric adenocarcinoma, with 68% males and median age of 66 (IQR 5774) years. 7161 (67%) underwent open, 2841 (26.6%) laparoscopic, and 688 (6.4%) robotic gastrectomy. Multivariable analysis revealed robotic was associated with a significantly higher median node harvest (18, IQR 1326) compared to laparoscopic (17, IQR 1125) and open gastrectomy (16, IQR 1023). Laparoscopic was also associated with significantly higher node harvest then open gastrectomy. Propensity-matched analysis (6950 patients) showed robotic gastrectomy was still associated with significantly higher node harvest (18, IQR 1226) compared to laparoscopic (17, IQR 1125) and open (17, IQR 1124); however, laparoscopic and open were not significantly different. CONCLUSION: Robotic approach is associated with increased node harvest compared to laparoscopic and open approach in gastrectomy patients.
Assuntos
Adenocarcinoma/cirurgia , Gastrectomia/métodos , Laparoscopia/métodos , Linfonodos/patologia , Sistema de Registros , Procedimentos Cirúrgicos Robóticos/métodos , Neoplasias Gástricas/cirurgia , Adenocarcinoma/secundário , Idoso , Bases de Dados Factuais , Feminino , Humanos , Metástase Linfática , Masculino , Estudos Retrospectivos , Neoplasias Gástricas/diagnósticoRESUMO
Adequate preoperative and perioperative nutrition has been shown to improve outcomes for patients undergoing esophagectomy. The most effective way to provide enteral nutrition for patients after esophagectomy is via jejunostomy tube. There is an open debate whether a feeding jejunostomy tube is necessary at the time of esophagectomy. This study evaluated short term surgical outcomes for patients undergoing esophagectomy with and without concurrent jejunostomy tube placement. Esophageal cancer patients were identified from the NSQIP database who underwent esophagectomy between 2005 through 2016. Patients were classified into 2 cohorts: patients with concurrent jejunostomy tube placement and those without jejunostomy placement at the time of esophagectomy. Clinical and demographic data was collected. Differences in short term outcomes were assessed by univariate and multivariable analysis, including prolonged hospital stay (>30 days), in-hospital mortality, and 30-day mortality for both cohorts. We identified 8,632 patients that underwent esophagectomy for esophageal cancer with 80% males and mean age of 63.2±10.6 years. Twenty percent (n=1,723) had preoperative weight loss in the 6-month period preceding surgery. Forty-five percent (n=3,900) patients had jejunostomy placement at the time of esophagectomy. Overall, the rate of prolonged hospital stay (P=0.006), in-hospital mortality (P<0.001) and 30-day mortality (P<0.001) were significantly higher in patients without concurrent jejunostomy in both univariable and multivariable models. This study demonstrates that patients with jejunostomy placement at the time of esophagectomy have improved short term perioperative outcomes.
RESUMO
There has been increasing utilization of minimally invasive surgical approaches. This study evaluates the effect of surgical approach on total lymph node harvest in gastrectomy. Patients undergoing gastrectomy for gastric adenocarcinoma between 2007 and 2018 were reviewed retrospectively. Data collected included age, gender, race, BMI, neoadjuvant therapy, tumor stage, surgical approach, and total number of lymph nodes harvested. The total number of harvested lymph nodes for open, laparoscopic, and robotic gastrectomy was compared using the Kruskal-Wallis test for univariate analysis and a Poisson regression model for multivariable analysis. One hundred four patients were identified. Median node harvest for open, laparoscopic, and robotic approaches were 16, 17, and 36, respectively. Multivariable analysis controlling for gender, BMI, pathological T stage, and year of operation demonstrates that surgical approach is statistically significantly associated with lymph node harvest (F = 83.4, P < 0.0001). In multivariable analysis, robotic approach was associated with greater lymph node harvest than both open (P < 0.0001) and laparoscopic (P < 0.0001) approaches, whereas laparoscopic approach was associated with greater lymph node harvest than open (P < 0.0001) approach. These data demonstrate that for patients undergoing gastrectomy for gastric adenocarcinoma at our institution, robotic approach is associated with greater lymph node harvest than both laparoscopic and open approaches.
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Adenocarcinoma/cirurgia , Gastrectomia/métodos , Excisão de Linfonodo/métodos , Procedimentos Cirúrgicos Robóticos , Neoplasias Gástricas/cirurgia , Adenocarcinoma/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Gastroscopia , Humanos , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Estudos Retrospectivos , Neoplasias Gástricas/patologiaRESUMO
BACKGROUND AND OBJECTIVES: Stage IV colorectal cancer is often treated with palliative chemotherapy with the primary tumor in place. Low rates of unplanned surgical intervention (due to obstruction or perforation) have been reported. We examined a large national dataset to determine the rate of unplanned surgical intervention in these patients. METHODS: Surveillance Epidemiology and End Results-Medicare were queried for patients with metastatic colorectal cancer receiving chemotherapy (1998-2013). Patient who underwent planned surgery to the primary or metastasectomy were excluded. The primary outcome was the need for nonelective surgery. Time to surgery or death was measured. Conditional analyses were performed to determine the risk of surgical intervention at 6-month, 1-, and 2-year after diagnosis. RESULTS: The analytic cohort consisted of 4692 patients (median age = 75). At 24 months, 80% of the patients had died. The overall unplanned intervention rate was 12%. The probability of requiring unplanned surgery between 6 and 12 months was 8.1%; 12 and 24 months = 6.7%, and >24 months = 5.3%. Males, those with right-sided tumors, and older patients were less likely to require surgery. CONCLUSIONS: Patients treated with palliative chemotherapy who are not resected upfront are unlikely to require unplanned surgery. Prophylactic surgery to reduce the risk of perforation or obstruction may not be necessary.
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Neoplasias Colorretais/tratamento farmacológico , Neoplasias Colorretais/cirurgia , Idoso , Quimioterapia Adjuvante , Estudos de Coortes , Neoplasias Colorretais/patologia , Procedimentos Cirúrgicos de Citorredução/métodos , Procedimentos Cirúrgicos de Citorredução/estatística & dados numéricos , Feminino , Humanos , Masculino , Medicare , Terapia Neoadjuvante , Estadiamento de Neoplasias , Cuidados Paliativos/métodos , Cuidados Paliativos/estatística & dados numéricos , Estudos Retrospectivos , Programa de SEER , Estados UnidosRESUMO
BACKGROUND: Optimal nutrition after esophagectomy is challenging due to alterations in eating, both from the tumor and during surgical recovery. Enteral nutrition via feeding tube is commonly used. The impact of feeding tubes on post-esophagectomy outcomes was examined in a large national data set. METHODS: Patients with esophageal cancer (1998-2013) undergoing esophagectomy were extracted from the Surveillance Epidemiology and End Results-Medicare database. Chi-square and t tests were used to compare categorical and continuous variables. Time trend analyses were performed with Cochran-Armitage survival using log-rank and multivariable analysis with generalized linear modeling. RESULTS: The study examined 2495 patients. The majority had enteral feeding access (71%, n = 1794) during the perioperative period. Mortality among the patients with feeding tubes was lower at 30 days (5.4% vs 8.4%), 60 days (9.0% vs 13.0%), and 90 days (12.2% vs 15.8%). In the multivariable analysis, the patients with feeding tubes had improved short-term survival at 30 days (odds ratio [OR], 0.65, 95% confidence interval [CI], 0.46-0.93), 60 days (OR, 0.64; 95% CI, 0.49-0.85), and 90 days (OR, 0.70; 95% CI, 0.54-0.90). The hospital stay was shorter for the patients undergoing enteral feeding tube placement (17.9 vs 19.5 days; p = 0.04). Discharge destination (home vs health care facility) showed no difference. CONCLUSIONS: Feeding tubes in patients undergoing esophagectomy were associated with an increase in short-term survival up to 90 days after surgery. Feeding tube placement was not associated with higher rates of non-home discharges and did not prolong the hospital stay.
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Nutrição Enteral , Neoplasias Esofágicas/cirurgia , Esofagectomia/mortalidade , Intubação Gastrointestinal/métodos , Tempo de Internação/estatística & dados numéricos , Complicações Pós-Operatórias , Idoso , Estudos de Coortes , Neoplasias Esofágicas/patologia , Feminino , Seguimentos , Humanos , Masculino , Apoio Nutricional , Prognóstico , Programa de SEER , Taxa de SobrevidaRESUMO
INTRODUCTION: The standard technique for Ivor Lewis minimally invasive esophagectomy involves a two-stage approach necessitating repositioning mid-procedure. TECHNIQUE: We describe our technique for a one-stage hand-assisted minimally invasive esophagectomy that allows sequential access to the chest and abdomen within the same surgical field, eliminating the need for repositioning. The patient is positioned in a "corkscrew" configuration with the abdomen supine and the chest rotated to the left to allow access to the right chest. The abdomen and chest are prepped into a single operative field. This technique allows sequential access to the abdomen for gastric mobilization, chest for division of the esophagus, abdomen for construction of the gastric conduit, and chest for intrathoracic anastomosis. CONCLUSION: This approach enables extracorporeal construction of the conduit, which helps ensure a clear distal margin on the specimen and facilitates conduit length by placing the stomach on stretch during stapling.
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Neoplasias Esofágicas/cirurgia , Esofagectomia/métodos , Esôfago/cirurgia , Posicionamento do Paciente , Estômago/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Anastomose Cirúrgica/métodos , Feminino , Humanos , Laparoscopia/métodos , Masculino , Pessoa de Meia-Idade , Toracoscopia/métodosRESUMO
BACKGROUND: Esophagectomy is a complex operation in which outcomes are profoundly influenced by operative experience and volume. We report the effects of experience and innovation on outcomes in minimally invasive esophagectomy. METHODS: Esophageal resections for cancer from 2007 to 2016 at Levine Cancer Institute at Carolinas Medical Center (Charlotte, NC) were reviewed. During this time, three changes in technique were made to improve outcomes: vascular evaluation of the gastric conduit to improve anastomotic healing (beginning at case #63), one-stage approach to permit access to abdomen and chest through one draped surgical field (case #82), and adoption of a lung-protective anesthetic protocol (case #101). Mortality, operative time, complications, and length of stay were analyzed relative to these interventions using GLM regression. RESULTS: 200 patients underwent minimally invasive esophagectomy. There were no mortalities at 30 days, and no change in mortality rate at 60 and 90 days. Anastomotic leak decreased significantly after the introduction of intraoperative vascular evaluation of the gastric conduit (3.6 vs 19.4%). Operative time decreased with adoption of a one-stage approach (416 vs 536 min). Pulmonary complications decreased coincident with a change in anesthetic technique (pneumonia 6 vs 28%). Lymph node harvest increased over time. Length of stay was driven primarily by complications and decreased with operative experience. CONCLUSIONS: Postoperative complications, operative time, and length of stay decreased with case experience and alterations in surgical and anesthetic technique. We believe that adoption of the techniques and technology described herein can reduce complications, reduce hospital stay, and improve patient outcomes.
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Adenocarcinoma/mortalidade , Carcinoma Neuroendócrino/mortalidade , Carcinoma de Células Escamosas/mortalidade , Neoplasias Esofágicas/mortalidade , Esofagectomia/mortalidade , Procedimentos Cirúrgicos Minimamente Invasivos/mortalidade , Melhoria de Qualidade , Adenocarcinoma/patologia , Adenocarcinoma/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Neuroendócrino/patologia , Carcinoma Neuroendócrino/cirurgia , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/cirurgia , Neoplasias Esofágicas/patologia , Neoplasias Esofágicas/cirurgia , Feminino , Seguimentos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias , Prognóstico , Taxa de SobrevidaRESUMO
BACKGROUND: Current National Comprehensive Cancer Network guidelines for resectable small bowel neuroendocrine tumors (NETs) recommend regional lymphadenectomy. However, no consensus exists on the optimal nodal harvest. METHODS: The National Cancer Database was queried for patients with resectable small bowel NETs (1998-2013). Patients with metastatic disease and missing lymph node harvest data were excluded. We performed logistic regression of factors determining nodal positivity and multivariable survival analyses. RESULTS: Of 11,852 patients, 81.8% underwent lymphadenectomy. 79.3% were node positive (N+) and 46.9% of patients had tumors < 1 cm. Independent predictors of N+ were large tumor size, ileal location, and neuroendocrine carcinoma histology. Logistic regression found no difference between observed and expected proportions of N+ patients with lymphadenectomy greater than or equal to eight nodes. Lower metastatic node ratio predicted improved survival on multivariable analysis and is associated with high-volume institutions. CONCLUSION: Small bowel NETs have high rates of nodal metastasis, even in patients with small tumors, and many patients do not undergo lymphadenectomy despite the clear benefit. Lymphadenectomy of eight nodes is optimal to identify N+ patients. Additionally, minimizing metastatic node ratio with complete regional lymphadenectomy is associated with improved survival in these patients.
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Neoplasias do Íleo/patologia , Neoplasias do Jejuno/patologia , Excisão de Linfonodo , Linfonodos/patologia , Linfonodos/cirurgia , Tumores Neuroendócrinos/secundário , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bases de Dados Factuais , Feminino , Humanos , Neoplasias do Íleo/cirurgia , Intestino Delgado , Neoplasias do Jejuno/cirurgia , Metástase Linfática , Masculino , Pessoa de Meia-Idade , Tumores Neuroendócrinos/cirurgia , Taxa de Sobrevida , Carga Tumoral , Adulto JovemRESUMO
BACKGROUND: Pathologic complete response (pCR) of rectal cancer following neoadjuvant therapy is associated with decreased local recurrence and increased overall survival. This study utilizes a national dataset to identify predictors of pCR in patients with rectal cancer. METHODS: The National Cancer Database was queried for patients with nonmetastatic rectal cancer (2004-2014) who underwent neoadjuvant therapy and surgical resection. Unadjusted associations were assessed using rank-sum tests and χ 2 tests where appropriate. Backward elimination and forward selection multivariable logistic regression models were created to determine the relationship of annual surgical volume with pCR rate, adjusting for preoperative characteristics and radiation-surgery interval. Statistical tests were two-sided, with a significance level of p ≤ 0.05. Analyses were performed using SAS version 9.4. RESULTS: A total of 27,532 patients from 1179 participating hospitals met the inclusion criteria. Generalized linear mixed models demonstrated that the odds of achieving pCR was independently associated with more recent diagnosis, female sex, private insurance, lower grade, lower clinical T classification, lower clinical N classification, increasing interval between the end of radiation and surgery, and treatment at higher-volume institutions. CONCLUSIONS: pCR was associated with favorable tumor factors, insurance status, time between radiation and surgery, and institutional volume. It is not clear what is driving the higher rates of pCR at high-volume institutions. Research targeted at understanding processes that are associated with pCR in high-volume institutions is needed so that similar results can be achieved across the spectrum of facilities caring for patients in this population.
Assuntos
Adenocarcinoma/patologia , Terapia Neoadjuvante , Neoplasias Retais/patologia , Adenocarcinoma/terapia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Quimiorradioterapia Adjuvante , Terapia Combinada , Bases de Dados Factuais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Neoplasias Retais/terapia , Indução de Remissão , Estudos Retrospectivos , Taxa de Sobrevida , Adulto JovemRESUMO
BACKGROUND: Studies suggest that the biology of pediatric and adolescent melanoma differs from that of adult disease. We report the largest series to date examining the natural history of pediatric and adolescent melanoma. We aim to elucidate the natural history of pediatric and adolescent melanoma and to examine the appropriateness of diagnostic and therapeutic modalities developed for adults and that are currently being used in children. METHODS: A retrospective cohort study was conducted of patients with an index diagnosis of cutaneous non-metastatic melanoma from 1998 to 2011 using the National Cancer Data Base (NCDB; n = 420,416). Three age-based cohorts were analyzed: 1-10 years (pediatric), 11-20 years (adolescent), and ≥21 years (adult). Multivariate analyses were used to identify factors associated with overall survival (OS). RESULTS: Pediatric melanoma patients have longer OS than their adolescent (hazard ratio [HR] 0.50, 95 % CI 0.25-0.98) and adult counterparts (HR 0.11, 95 % CI 0.06-0.21). Adolescents have longer OS than adults. No difference was found in OS in pediatric patients who are node-positive versus node-negative. In pediatric patients, sentinel lymph node biopsy and completion lymph node dissection are not associated with increased OS. In adolescents, nodal positivity is a significant negative prognostic indicator (HR 4.82, 95 % CI 3.38-6.87). CONCLUSIONS: Age-based differences in melanoma outcomes warrant different considerations for diagnostic and therapeutic approaches in each group in order to maximize quality of life while minimizing complications and costs. Prospective, multicenter studies should evaluate the role of diagnostic procedures for pediatric patients.