Laparoscopic Conversion to Open Cholecystectomy: Is Incidental Gallbladder Cancer Any Different?

BACKGROUND: A majority of gallbladder cancers present incidentally. Operative risk factors and outcomes for laparoscopic converted to open cholecystectomy in incidental gallbladder cancer are not well characterized. METHODS: Patients with incidental gallbladder cancer and acute cholecystitis undergoing laparoscopic cholecystectomy and conversion to open cholecystectomy in the National Surgical Quality Improvement Program (NSQIP) database of the American College of Surgeons (ACS) from 2010-2019 were reviewed. The primary endpoint was risk factors for conversion to open cholecystectomy in incidental gallbladder cancer. Chi-squared test or Fisher's exact test was used for categorical variables. Continuous variables were compared using the Mann-Whitney U test. RESULTS: A total of 5,789 patients undergoing laparoscopic cholecystectomy were identified, of which, 50 (0.9%) had incidental gallbladder cancer. For incidental gallbladder cancer patients, there were no differences in preoperative profile and risk factors between laparoscopic and converted to open cholecystectomy groups. Incidental carcinoma patients undergoing conversion to open cholecystectomy had lower preoperative sodium levels than the laparoscopic cholecystectomy group (P=0.007). Hospital length of stay (days) was longer for those with a conversion to open cholecystectomy for incidental carcinoma compared to non-conversion, 14 (10.8, 18.8) vs 2 (0.3, 5) (P=0.004). The patients converted to open cholecystectomy also had higher rates of postoperative sepsis (50% vs 0%, P<0.001) and reoperation than the laparoscopic cohort (50% vs 2.2%, P<0.001). Readmission and mortality rates, among other complications, were not significantly different between both surgical approaches in incidental gallbladder cancer patients. CONCLUSIONS:  Patients with conversion to open cholecystectomy had worse outcomes including longer hospital stays and higher rates of sepsis and reoperation. It remains difficult to predict which incidental gallbladder patients will require a conversion to open surgery. Further study examining whether more complicated recovery results in worse oncologic outcomes is warranted.

Quality of life after pancreatoduodenectomy: Is the outcome predetermined by the diagnosis?

BACKGROUND AND OBJECTIVES: Non-physiological factors tied to the disease process may drive the diminished quality of life (QoL) after pancreatoduodenectomy (PD). We compared postoperative QoL among patients undergoing PD for either benign or malignant pathology. METHODS: From 2012 to 2021, 228 patients underwent PD in a large healthcare system. Eighty-two patients (36.0%) were interviewed using the EORTC QLQ-C30 questionnaire. A minimum of 6 months after surgery was required for the survey. QoL outcomes were compared based on diagnosis (benign vs. malignant). RESULTS: Patient mean age was 65 years (21-82), and forty-seven (57%) were men. Most patients underwent surgery for cancer, 76% (n = 62). Grade B postoperative pancreatic fistula incidence was higher in benign cases (30% vs. 6.5%, p = 0.024). Weight loss was more common in malignancy (79% vs. 50%, p = 0.016). Carcinoma patients felt less useful, hopeful, reported less control of their life and certainty of the future, and were less satisfied with their appearance. Carcinoma patients also reported diminished memory, fear of relapse, and greater financial burden. CONCLUSIONS: Long-term QoL is inferior in PD patients with carcinoma and is driven by the psychological and socioeconomic implications of malignancy. Supportive resources for pancreas cancer patients should be evaluated and optimized.

Timeliness of Multimodal Care for At-Risk Breast Cancer Patients at a Safety Net Institution.

INTRODUCTION: Because limited data exist, we sought to evaluate timeliness of multimodal treatments in a safety net breast cancer population. METHODS: Breast cancer patients treated at a safety net hospital from 2016 to 2020 were analyzed retrospectively. Time intervals were defined as primary time (PT) from diagnosis to initiation of primary intervention, secondary time (ST) from completion of primary to initiation of secondary intervention, and tertiary time (TT) from completion of secondary to initiation of tertiary intervention. Variables included primary language, insurance type, and race. RESULTS: Of 223 patients, 99 (44.4%) primarily spoke Spanish, 29 (13.0%) were of Black race, and 184 (82.5%) had Medicaid or uninsured status. Median (IQR) age at diagnosis was 55 (48-62) years. Primary intervention was surgical in 127/216 (58.8%); secondary intervention was systemic in 38/169 (22.5%); and tertiary intervention was radiation in 67/80 (83.8%). Overall, median days (IQR) for PT were 69 (53, 98), ST were 65 (42, 95), and TT were 69 (43, 88). PT was significantly longer in Black [105 (76, 142) days] patients compared to non-Hispanic White patients [68 (51, 107) days, P = 0.031)] and White Hispanic patients [65 (53,91) days, P = 0.014]. There were no significant differences in PT, ST, or TT by spoken language or insurance type. CONCLUSIONS: Black patients remain at risk due to prolonged time to intervention. Spanish-speaking status was not associated with inferior timeliness or completion of multimodal care at a safety net hospital. Identifying safety net hospital barriers to achieving benchmarks for timely completion of all phases of multimodal care warrants further attention.

Spanish-Speaking Status: A Protective Factor in Colorectal Cancer Presentation at a Safety-Net Hospital.

INTRODUCTION: Lower screening rates and poorer outcomes for colorectal cancer have been associated with Hispanic ethnicity and Spanish-speaking status, respectively. METHODS: We reviewed sequential colorectal cancer patients evaluated by the surgical service at a safety-net hospital (SNH) (2016-2019). Insurance type, stage, cancer type, surgery class (elective/urgent), initial surgeon contact setting (outpatient clinic/inpatient consult), operation (resection/diversion), and follow-up were compared by patient-reported primary spoken language. RESULTS: Of 157 patients, 85 (54.1%) were men, 91 (58.0%) had colon cancer, 67 (42.7%) primarily spoke Spanish, and late stage (III or IV) presentations occurred in 83 (52.9%) patients. The median age was 58 y, cancer resection was completed in 48 (30.6%) patients, and 51 (32.5%) patients were initially seen as inpatient consults. On univariate analysis, Spanish-speaking status was significantly associated with female sex, Medicaid insurance, being seen as an outpatient consult, and undergoing elective and resection surgery. On multivariable logistic regression, Spanish-speaking patients had higher odds of having Medicaid insurance (AOR 2.28, P = 0.019), receiving a resection (AOR 3.96, P = 0.006), and undergoing an elective surgery (AOR 3.24, P = 0.025). Spanish-speaking patients also had lower odds of undergoing an initial inpatient consult (AOR 0.34, P = 0.046). CONCLUSIONS: Spanish-speaking status was associated with a lower likelihood of emergent presentation and need for palliative surgery among SNH colorectal cancer patients. Further research is needed to determine if culturally competent infrastructure in the SNH setting translates into Spanish-speaking status as a potentially protective factor.

A Multicenter, 10-Year Experience With Hepatocellular Adenoma: Risk Factors and Disease Course.

BACKGROUND: Management of hepatocellular adenoma (HA) is marked by a paucity of recent studies. Long-term follow-up data from an equal access health care system may facilitate our understanding of the natural disease course of HA and identify modifiable risk factors. METHODS: A multi-institutional, retrospective review of patients with HA from 2008-2017 was performed. Patient demographics, disease characteristics, and clinical outcomes were analyzed. RESULTS: Of 124 patients identified, 94% were women with a mean age at diagnosis of 39.5 years (range 20-82). Median follow-up was 22.5 months (range 0-114) with thirty-four (27.4%) patients eventually undergoing hepatectomy. Mean BMI of the study population was 30.5 kg/m2 (range 16-72). Stratified by size, average BMI for adenomas ≥5 cm was 34 kg/m2 compared to 28 kg/m2 for those <5 cm (P < .05). The predominant symptom at presentation was abdominal pain (41.1%), while just 4% presented with acute rupture. Overall incidence of the malignancy was 2.5%. Among all patients, oral contraceptive use was documented in 74 (59.7%) patients, of whom 36 (29.0%) discontinued OC for at least six months. Regression after OC cessation occurred in seven patients (19.4%) while the majority (77.8%) remained stable. DISCUSSION: This decade-long review analyzing the impact of modifiable risk factors identifies a direct correlation between BMI and hepatocellular adenoma size. Rupture and malignant transformation are rare entities. Cessation of OC appears to be an effective strategy in the management of hepatic adenoma. Further investigations are warranted to determine if addressing modifiable risk factors such as BMI might induce further HA regression.

Redistribution of Outpatient Oncologic Surgical Specialty Referrals During COVID-19.

BACKGROUND: Initial reports of significantly worse outcomes for cancer patients with COVID-19 led to guidelines for triaging surgical cancer treatment. We sought to evaluate the effects of the COVID-19 pandemic on oncologic surgical specialty referrals. METHODS: We compared referrals to oncologic surgical specialty clinics at an academic tertiary care institution following implementation of stay-at-home orders in California (3/19/20-7/31/20, "COVID") to the same time period the year prior (3/19/19-7/31/19, "Pre-COVID"). The number of appointments, consulted surgical services, insurance types, acuity of diagnoses, and times from referral to first appointment (TRFA) were assessed. RESULTS: The overall number of patients seen in matched time periods decreased by 21.6% from 900 (pre-COVID) to 705 (COVID). Proportions of patients with malignant and suspicious diagnoses, surgical and thoracic oncology visits, and Medicaid insurance differed from comparison groups during the COVID period (P < .05). Overall median (interquartile range) TRFA decreased from 14 (20) to 12 (19) days (P = .001) during COVID. CONCLUSION: After implementation of stay-at-home orders, higher acuity and vulnerable patients were appropriately seen in oncologic surgical specialty clinics. While the long-term effects of decreased clinic visits during COVID remain uncertain, further examination of scheduling practices that led to shorter referral times may identify methods to improve timeliness of care and surgical oncologic outcomes in non-pandemic settings.

Compliance With Surgical Oncology Specialty Care at a Safety Net Facility.

BACKGROUND: Social determinants of health challenge in at-risk patients seen in safety net facilities. STUDY DESIGN: We performed a retrospective review of surgical oncology specialty clinic referrals at a safety net institution evaluating referral compliance and times to first appointment and initiation of definitive treatment. Main outcomes measured included completion of initial visit, initiation of definitive treatment, time from referral to first appointment, and time from first appointment to initiation of definitive treatment. RESULTS: Of 189 new referrals, English was not spoken by 52.4% and 69.4% were Hispanic. Patients presented without insurance in 39.2% of cases. Electronic patient portal was accessed by 31.6% of patients. Of all new referrals, 55.0% arrived for initial consultation and 53.4% initiated definitive treatment. Malignant diagnosis (P < .0001) and lack of insurance (P = .01) were associated with completing initial consultation. Initiation of definitive treatment was associated with not speaking English (P = .03), malignant diagnosis (P < .0001), and lack of insurance (P = .03). Times to first appointment and initiation of definitive treatment were not significantly affected by race/ethnicity, language, insurance, treatment recommended, or electronic patient portal access. CONCLUSION: Access to surgical oncology care for at-risk patients at a safety net facility is not adversely affected by lack of insurance, primary spoken language, or race/ethnicity. However, a significant proportion of all patients fail to complete the initial consultation and definitive treatment. Lessons learned from safety net facilities may help to inform disparities in health care found elsewhere.

A Flat Inferior Vena Cava on Computed Tomography Is Associated With Worse Outcomes in Emergency General Surgery.

BACKGROUND: Several trauma studies have shown that a "flat" inferior vena cava (IVC) is associated with poor clinical outcomes, including hypovolemic shock, major bleeding, transfusions and mortality. These studies utilize IVC measurements on computed tomography (CT) scans, and rarely include emergency general surgery patients. We examine the association between IVC flatness and clinical outcomes in a series of patients with perforated viscus. MATERIALS AND METHODS: Medical records at an academic hospital were reviewed of adults with perforated viscus. Patients who underwent laparotomy or laparoscopy were included if they underwent CT within 12 h prior to incision time. Perforated appendicitis was excluded. A ratio was calculated of the transverse to anterior-posterior diameter of the IVC at 3 locations, then averaged. Clinical outcomes were analyzed by the average IVC ratio. RESULTS: A total of 83 patients were included. Using binomial regression, the average IVC ratio significantly correlated with ICU admission (OR 3.6, 95% CI 1.2 to 11) and acute kidney injury (OR 2.3, 95% CI 1.0 to 5.3), but not postoperative shock (OR 1.2, 95% CI 0.56 to 2.6). CONCLUSIONS: A flat IVC on CT prior to an operation for perforated viscus was associated with worse outcomes, including increased rate of ICU admission and acute kidney injury. More outcomes research is needed to assess the potential role of IVC assessment in preoperative resuscitation.

Outcomes of bracing in juvenile idiopathic scoliosis until skeletal maturity or surgery.

STUDY DESIGN: Retrospective comparative study. OBJECTIVE: To evaluate the outcome of bracing in patients with juvenile idiopathic scoliosis (JIS) at either skeletal maturity or time of scoliosis surgery. SUMMARY OF BACKGROUND DATA: JIS is generally thought to have poor outcomes with high rates of surgical fusion. METHODS: All patients with JIS between the ages of 4 and 10 years treated with a brace at the Hospital for Sick Children (SickKids) between 1989 and 2011 were eligible. Data were collected from patient health records until either 2 years after skeletal maturity or date of surgery. RESULTS: The average age at diagnosis of 88 patients with JIS was 8.4 ± 1.4 years, with a female to male ratio of approximately 8:1. Pretreatment, Risser score was zero for 80 patients (91%); 72 (92%) of the females were premenarche; and primary Cobb angles ranged from 20° to 71°. Of the 88 patients, 60 (68%) had used a thoracolumbosacral orthosis exclusively; 28 (32%) patients used "other braces" (Milwaukee, Charleston, or a combination of braces), with an average treatment duration of 3.6 ± 1.9 years.As per Scoliosis Research Society definitions, a "non-curve-progression" (≤5° change) group consisted of 25 (28%) patients; and a "curve-progression" group consisted of 63 (72%) patients where the curve had progressed 6° or more.Of the 88 patients, 44 (50%) underwent surgery. The operative rate was higher for patients with curves 30° or more than those with curves 20° to 29° prior to brace treatment (37/58 [64%] vs. 7/30 [23%], respectively; P = 0.001); other braces compared with thoracolumbosacral orthosis (19/28 [68%] vs. 25/60 [42%], respectively; P = 0.02); Lenke I and III curves compared with Lenke VI curves (33/54 [61%] vs. 2/14 [14%], respectively; P = 0.007).

Serum-mediated activation of macrophages reflects TcVac2 vaccine efficacy against Chagas disease.

Chagas disease is endemic in Latin America and an emerging infectious disease in the United States. No effective treatments are available. The TcG1, TcG2, and TcG4 antigens are highly conserved in clinically relevant Trypanosoma cruzi isolates and are recognized by B and T cells in infected hosts. Delivery of these antigens as a DNA prime/protein boost vaccine (TcVac2) elicited lytic antibodies and type 1 CD8(+) T cells that expanded upon challenge infection and provided >90% control of parasite burden and myocarditis in chagasic mice. Here we determined if peripheral blood can be utilized to capture the TcVac2-induced protection from Chagas disease. We evaluated the serum levels of T. cruzi kinetoplast DNA (TckDNA), T. cruzi 18S ribosomal DNA (Tc18SrDNA), and murine mitochondrial DNA (mtDNA) as indicators of parasite persistence and tissue damage and monitored the effect of sera on macrophage phenotype. Circulating TckDNA/Tc18SrDNA and mtDNA were decreased by >3- to 5-fold and 2-fold, respectively, in vaccinated infected mice compared to nonvaccinated infected mice. Macrophages incubated with sera from vaccinated infected mice exhibited M2 surface markers (CD16, CD32, CD200, and CD206), moderate proliferation, a low oxidative/nitrosative burst, and a regulatory/anti-inflammatory cytokine response (interleukin-4 [IL-4] plus IL-10 > tumor necrosis factor alpha [TNF-α]). In comparison, macrophages incubated with sera from nonvaccinated infected mice exhibited M1 surface markers, vigorous proliferation, a substantial oxidative/nitrosative burst, and a proinflammatory cytokine response (TNF-α ≫ IL-4 plus IL-10). Cardiac infiltration of macrophages and TNF-α and oxidant levels were significantly reduced in TcVac2-immunized chagasic mice. We conclude that circulating TcDNA and mtDNA levels and macrophage phenotype mediated by serum constituents reflect in vivo levels of parasite persistence, tissue damage, and inflammatory/anti-inflammatory state and have potential utility in evaluating disease severity and efficacy of vaccines and drug therapies.

Antigenicity and diagnostic potential of vaccine candidates in human Chagas disease.

BACKGROUND: Chagas disease, caused by Trypanosoma cruzi, is endemic in Latin America and an emerging infectious disease in the US and Europe. We have shown TcG1, TcG2, and TcG4 antigens elicit protective immunity to T. cruzi in mice and dogs. Herein, we investigated antigenicity of the recombinant proteins in humans to determine their potential utility for the development of next generation diagnostics for screening of T. cruzi infection and Chagas disease. METHODS AND RESULTS: Sera samples from inhabitants of the endemic areas of Argentina-Bolivia and Mexico-Guatemala were analyzed in 1(st)-phase for anti-T. cruzi antibody response by traditional serology tests; and in 2(nd)-phase for antibody response to the recombinant antigens (individually or mixed) by an ELISA. We noted similar antibody response to candidate antigens in sera samples from inhabitants of Argentina and Mexico (n=175). The IgG antibodies to TcG1, TcG2, and TcG4 (individually) and TcG(mix) were present in 62-71%, 65-78% and 72-82%, and 89-93% of the subjects, respectively, identified to be seropositive by traditional serology. Recombinant TcG1- (93.6%), TcG2- (96%), TcG4- (94.6%) and TcG(mix)- (98%) based ELISA exhibited significantly higher specificity compared to that noted for T. cruzi trypomastigote-based ELISA (77.8%) in diagnosing T. cruzi-infection and avoiding cross-reactivity to Leishmania spp. No significant correlation was noted in the sera levels of antibody response and clinical severity of Chagas disease in seropositive subjects. CONCLUSIONS: Three candidate antigens were recognized by antibody response in chagasic patients from two distinct study sites and expressed in diverse strains of the circulating parasites. A multiplex ELISA detecting antibody response to three antigens was highly sensitive and specific in diagnosing T. cruzi infection in humans, suggesting that a diagnostic kit based on TcG1, TcG2 and TcG4 recombinant proteins will be useful in diverse situations.