Radiologic-pathologic correlation of lesions in resected liver specimens with an ex vivo MRI-compatible localization device.

OBJECTIVE: Liver lesion characterization is limited by the lack of an established gold standard for precise correlation of radiologic characteristics with their histologic features. The objective of this study was to demonstrate the feasibility of using an ex vivo MRI-compatible sectioning device for radiologic-pathologic co-localization of lesions in resected liver specimens. METHODS: In this prospective feasibility study, adults undergoing curative partial hepatectomy from February 2018 to January 2019 were enrolled. Gadoxetic acid was administered intraoperatively prior to hepatic vascular inflow ligation. Liver specimens were stabilized in an MRI-compatible acrylic lesion localization device (27 × 14 × 14 cm3) featuring slicing channels and a silicone gel 3D matrix. High-resolution 3D T1-weighted fast spoiled gradient echo and 3D T2-weighted fast-spin-echo images were acquired using a single channel quadrature head coil. Radiologic lesion coordinates guided pathologic sectioning. A final histopathologic diagnosis was prepared for all lesions. The proportion of successfully co-localized lesions was determined. RESULTS: A total of 57 lesions were identified radiologically and sectioned in liver specimens from 10 participants with liver metastases (n = 8), primary biliary mucinous cystic neoplasm (n = 1), and hepatic adenomatosis (n = 1). Of these, 38 lesions (67%) were < 1 cm. Overall, 52/57 (91%) of radiologically identified lesions were identified pathologically using the device. Of these, 5 lesions (10%) were not initially identified on gross examination but were confirmed histologically using MRI-guided localization. One lesion was identified grossly but not on MRI. CONCLUSIONS: We successfully demonstrated the feasibility of a clinical method for image-guided co-localization and histological characterization of liver lesions using an ex vivo MRI-compatible sectioning device. KEY POINTS: • The ex vivo MRI-compatible sectioning device provides a reliable method for radiologic-pathologic correlation of small (< 1 cm) liver lesions in human liver specimens. • The sectioning method can be feasibly implemented within a clinical practice setting and used in future efforts to study liver lesion characterization. • Intraoperative administration of gadoxetic acid results in enhancement in ex vivo MRI images of liver specimens hours later with excellent image quality.

Pancreatic cyst characterization: maximum axial diameter does not measure up.

BACKGROUND: Unidimensional size is commonly used to risk stratify pancreatic cysts (PCs) despite inconsistent performance. The current study aimed to determine if unidimensional size, demonstrated by maximum axial diameter (MAD), is an appropriate surrogate measurement for volume and surface area. METHODS: Patients with cross-sectional imaging of PCs from 2012 to 2013 were identified. Cyst MAD, volume, and surface area were measured using quantitative imaging software. Non-pseudocystic PCs >1 cm were selected for inclusion to assess MAD correlation with volume and surface area. Cysts imaged twice >1 year apart were selected to evaluate volumetric growth rate. RESULTS: In total, 195 cysts were included. Overall, MAD was strongly correlated with volume (r = 0.83) and surface area (r = 0.93). However, cysts 1-2 cm and 2-3 cm were weakly correlated with volume and surface area: r = 0.78, 0.57 and 0.82, 0.61, respectively. Cyst volumes and surface areas varied widely within unidimensional size groups with 51% and 40% of volumes and surface areas overlapping unidimensional size groups, respectively. Estimated changes in volume poorly predicted measured changes in volume with 42% of cysts having >100% absolute percent difference. CONCLUSIONS: Pancreatic cyst volume and surface area may be useful adjunct measurements to risk stratify patients and surveil cyst changes and deserves further study.

Specific Growth Rate as a Predictor of Survival in Pancreatic Neuroendocrine Tumors: A Multi-institutional Study from the United States Neuroendocrine Study Group.

BACKGROUND: Pancreatic neuroendocrine tumors (PNETs) are often indolent; however, identifying patients at risk for rapidly progressing variants is critical, particularly for those with small tumors who may be candidates for expectant management. Specific growth rate (SGR) has been predictive of survival in other malignancies but has not been examined in PNETs. METHODS: A retrospective cohort study of adult patients who underwent PNET resection from 2000 to 2016 was performed utilizing the multi-institutional United States Neuroendocrine Study Group database. Patients with ≥ 2 preoperative cross-sectional imaging studies at least 30 days apart were included in our analysis (N = 288). Patients were grouped as "high SGR" or "low SGR." Demographic and clinical factors were compared between the groups. Kaplan-Meier and log-rank analysis were used for survival analysis. Cox proportional hazard analysis was used to assess the impact of various clinical factors on overall survival (OS). RESULTS: High SGR was associated with higher T stage at resection, shorter doubling time, and elevated HbA1c (all P ≤ 0.01). Patients with high SGR had significantly decreased 5-year OS (63 vs 80%, P = 0.01) and disease-specific survival (72 vs 91%, P = 0.03) compared to those with low SGR. In patients with small (≤ 2 cm) tumors (N = 106), high SGR predicted lower 5-year OS (79 vs 96%, P = 0.01). On multivariate analysis, high SGR was independently associated with worse OS (hazard ratio 2.67, 95% confidence interval 1.05-6.84, P = 0.04). CONCLUSION: High SGR is associated with worse survival in PNET patients. Evaluating PNET SGR may enhance clinical decision-making, particularly when weighing expectant management versus surgery in patients with small tumors.

Impact of Insurance Status on Survival in Gastroenteropancreatic Neuroendocrine Tumors.

BACKGROUND: Insurance status predicts access to medical care in the USA. Previous studies have shown uninsured patients with some malignancies have worse outcomes than insured patients. The impact of insurance status on patients with gastroenteropancreatic neuroendocrine tumors (GEP-NETs) is unclear. PATIENTS AND METHODS: A retrospective cohort study of adult patients with resected GEP-NETs was performed using the US Neuroendocrine Tumor Study Group (USNETSG) database (2000-2016). Demographic and clinical factors were compared by insurance status. Patients ≥ 65 years were excluded, as these patients are almost universally covered by Medicare. Kaplan-Meier and log-rank analyses were used for survival analysis. Logistic regression was used to assess factors associated with overall survival (OS). RESULTS: The USNETSG database included 2022 patients. Of those, 1425 were aged 18-64 years at index operation and were included in our analysis. Uninsured patients were more likely to have an emergent operation (7.9% versus 2.5%, p = 0.01) and less likely to receive postoperative somatostatin analog therapy (1.6% versus 9.9%, p = 0.03). OS at 1, 5, and 10 years was significantly higher for insured patients (96.3%, 88.2%, and 73.8%, respectively) than uninsured patients (87.7%, 71.9%, and 44.0%, respectively) (p < 0.01). On Cox multivariate regression analysis controlling for T/M stage, tumor grade, ASA class, and income level, being uninsured was independently associated with worse OS [hazard ratio (HR) 2.69, 95% confidence interval (CI) 1.32-5.48, p = 0.006]. CONCLUSIONS: Insurance status is an independent predictor of survival in patients with GEP-NETs. Our study highlights the importance of access to medical care, disparities related to insurance status, and the need to mitigate these disparities.

PLR and NLR Are Poor Predictors of Survival Outcomes in Sarcomas: A New Perspective From the USSC.

BACKGROUND: Elevations in inflammatory biomarkers, including neutrophil-to-lymphocyte ratio (NLR) or platelet-to-lymphocyte ratio (PLR), are reportedly associated with decreased overall survival (OS) or recurrence-free survival (RFS) in patients with numerous cancers. A large multicenter sarcoma data set was used to determine if elevated NLR or PLR was associated with worse survival and can guide treatment selection. MATERIALS AND METHODS: A total of 409 patients with a primary retroperitoneal sarcoma (n = 268) or truncal (n = 141) sarcoma from 2000 to 2015 were analyzed using the US Sarcoma Collaboration database. Binary NLR and PLR values were developed using receiver operating characteristic curves. Kaplan-Meier model and Cox proportional hazards model identified predictors of decreased OS and RFS. Point biserial analyses were used to correlate binary and continuous data. RESULTS: Neither elevated NLR nor PLR was predictive of decreased OS or RFS. These findings persisted despite exclusion of comorbid inflammatory conditions. Further, NLR and PLR were not correlated with tumor grade. In multivariate models, decreased RFS was associated with tumor factors (e.g., positive margins, tumor grade, tumor size, necrosis, positive nodes); decreased OS was associated with histologic subtype, male gender, and nodal involvement. CONCLUSIONS: Although several small studies have suggested that elevated NLR and PLR are associated with decreased survival in patients with abdominal or truncal sarcoma, this large multicenter study demonstrates no association with decreased OS, decreased RFS, or tumor grade. Rather, survival outcomes are best predicted using previously established tumoral factors.

Impact of perioperative blood transfusion on survival in pancreatic neuroendocrine tumor patients: analysis from the US Neuroendocrine Study Group.

BACKGROUND: Packed red blood cell (PRBC) transfusion has been associated with worse survival in multiple malignancies but its impact on pancreatic neuroendocrine tumors (PNETs) is unknown. The aim of this study was to determine the impact of PRBC transfusion on survival following PNET resection. METHODS: A retrospective cohort study of PNET patients was performed using the US Neuroendocrine Tumor Study Group database. Demographic and clinical factors were compared. Kaplan-Meier and log-rank analyses were performed. Factors associated with transfusion, overall (OS), recurrence-free (RFS) and progression-free survival (PFS) were assessed by logistic regression. RESULTS: Of 1129 patients with surgically resected PNETs, 156 (13.8%) received perioperative PRBC transfusion. Transfused patients had higher ASA Class, lower preoperative hemoglobin, larger tumors, more nodal involvement, and increased major complications (all p < 0.010). Transfused patients had worse median OS (116 vs 150 months, p < 0.001), worse RFS (83 vs 128 months, p < 0.01) in curatively resected (n = 1047), and worse PFS (11 vs 24 months, p = 0.110) in non-curatively resected (n = 82) patients. On multivariable analysis, transfusion was associated with worse OS (HR 1.80, p = 0.011) when controlling for TNM stage, tumor grade, final resection status, and pre-operative anemia. CONCLUSION: PRBC transfusion is associated with worse survival for patients undergoing PNET resection.

Analysis of National Presentations of Surgical Case Series Discussions: What Matters to Surgeons?

BACKGROUND: Although the surgical case series is a useful study design for surgical disciplines, elements of its presentation have not been standardized with a widely accepted reporting guideline. Hence, case series may not include all components necessary for surgeons to best interpret their results. We aimed to determine core elements of case series through qualitative analysis of discussions after presentations at national meetings. METHODS: Case series with accompanying discussions in three high-impact journals from 2010 to 2015 were analyzed with conventional content analysis. All interrogative sentences were selected for analysis and were classified by a redundant iterative process into descriptive categories and subcategories. RESULTS: Two hundred twenty-one case series were identified, 56 of which included discussion transcripts. Four hundred seventy six unique interrogatives were classified into 4 categories and 13 subcategories. The main categories identified were "Application of Results to Patient Care," "Clarification of Study Methodology," "Facilitation of Author Insight," and "Request for Additional Study-Specific Data." The most frequent subcategories of inquiry pertained to the changes to current standard of care, clarification of study variables, and subgroup data and outcomes. CONCLUSIONS: We determined major themes of inquiry that reflected core elements surgeons use to evaluate case series for relevance and applicability to their own practice. Discussants frequently questioned how the study's results changed the author's standard of care. Specifically encouraging surgical case series authors to comment on changes they made to their practice as a result of their findings would allow the surgical audience to quickly assess potential clinical applicability.

Smoking and gastrointestinal cancer patients-is smoking cessation an attainable goal?

BACKGROUND AND OBJECTIVES: Negative consequences of tobacco use during cancer treatment are well-documented but more in-depth, patient-level data are needed to understand patient beliefs about continued smoking (vs cessation) during gastrointestinal (GI) cancer treatment. METHODS: We conducted semi-structured interviews with 10 patients who were active smokers being treated for GI cancers and 5 caregivers of such patients. All interviews were audio-recorded, transcribed verbatim, and uploaded to NVivo. We consensus coded data inductively using conventional content analysis and iteratively developed our codebook. We developed data matrices to categorize the themes regarding patient perspectives on smoking as well as presumed barriers to smoking cessation during active therapy. RESULTS: Our interviews revealed three consistent themes: (a) Smoking cessation is not necessarily desired by many patients who have received a cancer diagnosis; (b) Failure in past quit attempts may lead to feelings of hopeless about future attempts, especially during cancer treatment; (c) Patients perceived little to no access to smoking cessation treatment at the time of their cancer diagnosis. CONCLUSIONS: Well-designed systemic changes that promote the positive and efficacious effects of quitting smoking during cancer treatment, and that provide barrier-free access to such treatments may be helpful in promoting tobacco-free behavior during cancer treatment.

The impact of failure to achieve symptom control after resection of functional neuroendocrine tumors: An 8-institution study from the US Neuroendocrine Tumor Study Group.

BACKGROUND: The goals of resection of functional neuroendocrine tumors (NETs) are two-fold: Oncological benefit and symptom control. The interaction between the two is not well understood. METHODS: All patients with functional NETs of the pancreas, duodenum, and ampulla who underwent curative-intent resection between 2000 and 2016 were identified. Using Cox regression analysis, factors associated with reduced recurrence-free survival (RFS) were identified. RESULTS: Two-hundred and thirty patients underwent curative-intent resection. Fifty-three percent were insulinomas, 35% gastrinomas, and 12% were other types. Twenty-one percent had a known genetic syndrome, 23% had lymph node (LN) positivity, 80% underwent an R0 resection, and 14% had no postoperative symptom improvement (SI). Factors associated with reduced RFS included noninsulinoma histology, the presence of a known genetic syndrome, LN positivity, R1 margin, and lack of SI. On multivariable analysis, only the failure to achieve SI following resection was associated with reduced RFS. Considering only those patients with an R0 resection, failure to achieve SI was associated with worse 3-year RFS compared with patients having SI (36% vs 80%; P = 0.006). CONCLUSIONS: Failure to achieve symptomatic improvement after resection of functional NETs is associated with worse RFS. These patients may benefit from short-interval surveillance imaging postoperatively to assess for earlier radiographical disease recurrence.

Analysis of 90-day cost for open versus minimally invasive distal pancreatectomy.

BACKGROUND: Minimally invasive distal pancreatectomy (MIDP) is associated with improved peri-operative outcomes compared to the open approach, though cost-effectiveness of MIDP remains unclear. METHODS: Patients with pancreatic tumors undergoing open (ODP), robotic (RDP), or laparoscopic distal pancreatectomy (LDP) between 2012-2014 were identified through the Truven Health MarketScan® Database. Median costs (payments) for the index operation and 90-day readmissions were calculated. Multivariable regression was used to predict associations with log 90-day payments. RESULTS: 693 patients underwent ODP, 146 underwent LDP, and 53 RDP. Compared to ODP, LDP and RDP resulted in shorter median length of stay (6 d. ODP vs. 5 d. RDP vs. 4 d. LDP, p<0.01) and lower median payments ($38,350 ODP vs. $34,870 RDP vs. $32,148 LDP, p<0.01) during the index hospitalization. Total median 90-day payments remained significantly lower for both minimally invasive approaches ($40,549 ODP vs. $35,160 RDP vs. $32,797 LDP, p<0.01). On multivariable analysis, LDP and RDP resulted in 90-day cost savings of 21% and 25% relative to ODP, equating to an amount of $8,500-$10,000. CONCLUSION: MIDP is associated with >$8,500 in lower cost compared to the open approach. Quality improvement initiatives in DP should ensure that lack of training and technical skill are not barriers to MIDP.

Is hepatectomy safe following Yttrium-90 therapy? A multi-institutional international experience.

BACKGROUND: Single institution reports demonstrate variable safety profiles when liver-directed therapy with Yttrium-90 (Y-90) is followed by hepatectomy. We hypothesized that in well-selected patients, hepatectomy after Y90 is feasible and safe. METHODS: Nine institutions contributed data for patients undergoing Y90 followed by hepatectomy (2008-2017). Clinicopathologic and perioperative data were analyzed, with 90-day morbidity and mortality as primary endpoints. RESULTS: Forty-seven patients were included. Median age was 59 (20-75) and 62% were male. Malignancies treated included hepatocellular cancer (n = 14; 30%), colorectal cancer (n = 11; 23%), cholangiocarcinoma (n = 8; 17%), neuroendocrine (n = 8; 17%) and other tumors (n = 6). The distribution of Y-90 treatment was: right (n = 30; 64%), bilobar (n = 14; 30%), and left (n = 3; 6%). Median future liver remnant (FLR) following Y90 was 44% (30-78). Resections were primarily right (n = 16; 34%) and extended right (n = 14; 30%) hepatectomies. The median time to resection from Y90 was 196 days (13-947). The 90-day complication rate was 43% and mortality was 2%. Risk factors for Clavien-Dindo Grade>3 complications included: number of Y-90-treated lobes (OR 4.5; 95% CI1.14-17.7; p = 0.03), extent of surgery (p = 0.04) and operative time (p = 0.009). CONCLUSIONS: These data demonstrate that hepatectomy following Y-90 is safe in well-selected populations. This multi-disciplinary treatment paradigm should be more widely studied, and potentially adopted, for patients with inadequate FLR.

The Impact of Hospital Neoadjuvant Therapy Utilization on Survival Outcomes for Pancreatic Cancer.

BACKGROUND: Many surgeons advocate the use of neoadjuvant treatment for resectable pancreatic cancer, however little is known about variation in the utilization of neoadjuvant therapy (NAT) at the hospital level. METHODS: The National Cancer Data Base was used to identify patients undergoing resection for pancreatic cancer between 2006 and 2014 at high-volume centers. Hospitals were grouped by NAT utilization using standard deviations (SD) from the mean as follows: high neoadjuvant utilizers (> 2 SDs above the mean, > 40% of patients receiving NAT); medium-high (1-2 SDs, 27-40%), medium (0-1 SD, 14-26%); or low (- 1.1 to 0 SDs, < 14%). Overall survival (OS) was compared across NAT utilization groups. RESULTS: Among 107 high-volume centers, 20,119 patients underwent resection. The proportion of patients receiving NAT varied widely among hospitals, ranging from 0 to 74%, with only five centers using NAT in > 40% of patients. These five hospitals had the longest median OS at 28.9 months, compared with 21.1 months for low neoadjuvant utilizers (p < 0.001). On multivariable analysis, high and medium-high NAT utilization predicted improved OS, with a hazard ratio (HR) of 0.68 (95% confidence interval [CI] 0.56-0.83, p < 0.001) and 0.80 (95% CI 0.68-0.95, p = 0.010), respectively, compared with low utilizers. After excluding patients who underwent NAT, there remained an association of improved OS with high NAT utilization (HR 0.74, 95% CI 0.60-0.93, p = 0.009). CONCLUSION: High-volume hospitals that more commonly utilize NAT demonstrated longer survival for all patients treated at those centers. In addition to altering patient selection for surgery, high neoadjuvant utilization may be a marker of institutional factors that contribute to improved outcomes.

Adaptation and Implementation of a Transitional Care Protocol for Patients Undergoing Complex Abdominal Surgery.

BACKGROUND: Transitional care protocols are effective at reducing readmission for medical patients, yet no evidence-based protocols exist for surgical patients. A transitional care protocol was adapted to meet the needs of patients discharged to home after major abdominal surgery. APPROACH: The Coordinated-Transitional Care (C-TraC) protocol, initially designed for medical patients, was used as the initial framework for the development of a surgery-specific protocol (sC-TraC). Adaptation was accomplished using a modification of the Replicating Effective Programs (REP) model, which has four phases: (1) preconditions, (2) preimplementation, (3) implementation, and (4) maintenance and evolution. A random sample of five patients each month was selected to complete a phone survey regarding patient satisfaction. Preimplementation planning allowed for integration with current systems, avoided duplication of processes, and defined goals for the protocol. The adapted protocol specifically addressed surgical issues such as nutrition, fever, ostomy output, dehydration, drain character/output, and wound appearance. After protocol launch, the rapid iterative adaptation process led to changes in phone call timing, inclusion and exclusion criteria, and discharge instructions. OUTCOMES: Survey responders reported 100% overall satisfaction with the transitional care program. KEY INSIGHTS: The adaptable nature of sC-TraC may allow for low-resource hospitals, such as rural or inner-city medical centers, to use the methodology provided in this study for implementation of local phone-based transitional care protocols. In addition, as the C-TraC program has begun to disseminate nationally across US Department of Veterans Affairs (VA) hospitals and rural health settings, sC-TraC may be implemented using the existing transitional care infrastructure in place at these hospitals.

30-day Readmission After Pancreatic Resection: A Systematic Review of the Literature and Meta-analysis.

OBJECTIVE: The aim of this study was to identify and compare common reasons and risk factors for 30-day readmission after pancreatic resection. BACKGROUND: Hospital readmission after pancreatic resection is common and costly. Many studies have evaluated this problem and numerous discrepancies exist regarding the primary reasons and risk factors for readmission. METHODS: Multiple electronic databases were searched from 2002 to 2016, and 15 relevant articles identified. Overall readmission rate was calculated from individual study estimates using a random-effects model. Study data were combined and overall estimates of odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each risk factor. Multivariable data were qualitatively synthesized. RESULTS: The overall 30-day readmission rate was 19.1% (95% CI 17.4-20.7) across all studies. Infectious complications and gastrointestinal disorders, such as failure to thrive and delayed gastric emptying, together accounted for 58.9% of all readmissions. Demographic factors did not predict readmission. Heart disease (OR 1.37, 95% CI 1.12-1.67), hypertension (OR 1.44, 95% CI 1.09-1.91), and intraoperative blood transfusion (OR 1.45, 95% CI 1.15-1.83) were weak predictors of readmission, while any postoperative complications (OR 2.22, 95% CI 1.55-3.18) or severe complications (OR 2.84, 95% CI 1.65-4.89) were stronger predictors. CONCLUSIONS: Readmission after pancreatic resection is common and can largely be attributed to infectious complications and inability to maintain adequate hydration and nutrition. Focus on outpatient resources and follow-up to address these issues will prove valuable in reducing readmissions.

Variation in the Types of Providers Participating in Breast Cancer Follow-Up Care: A SEER-Medicare Analysis.

BACKGROUND: The current guidelines do not delineate the types of providers that should participate in early breast cancer follow-up care (within 3 years after completion of treatment). This study aimed to describe the types of providers participating in early follow-up care of older breast cancer survivors and to identify factors associated with receipt of follow-up care from different types of providers. METHODS: Stages 1-3 breast cancer survivors treated from 2000 to 2007 were identified in the Surveillance, Epidemiology and End results Medicare database (n = 44,306). Oncologist (including medical, radiation, and surgical) follow-up and primary care visits were defined using Medicare specialty provider codes and linked American Medical Association (AMA) Masterfile. The types of providers involved in follow-up care were summarized. Stepped regression models identified factors associated with receipt of medical oncology follow-up care and factors associated with receipt of medical oncology care alone versus combination oncology follow-up care. RESULTS: Oncology follow-up care was provided for 80 % of the patients: 80 % with a medical oncologist, 46 % with a surgeon, and 39 % with a radiation oncologist after radiation treatment. The patients with larger tumor size, positive axillary nodes, estrogen receptor (ER)-positive status, and chemotherapy treatment were more likely to have medical oncology follow-up care than older patients with higher Charlson comorbidity scores who were not receiving axillary care. The only factor associated with increased likelihood of follow-up care with a combination of oncology providers was regular primary care visits (>2 visits/year). CONCLUSIONS: Substantial variation exists in the types of providers that participate in breast cancer follow-up care. Improved guidance for the types of providers involved and delineation of providers' responsibilities during follow-up care could lead to improved efficiency and quality of care.

Disease severity and treatment does not affect satisfaction in diverticulitis.

BACKGROUND: Patient satisfaction is widely reported and impacts satisfaction despite a limited understanding of the clinical and structural determinants. Patients with diverticulitis are admitted to various services, with variable disease severities. They, therefore, represent a unique group to delineate relationships between these factors and satisfaction. We examined the factors that impact hospital satisfaction in patients with diverticulitis. MATERIALS AND METHODS: Patients admitted between 2009 and 2012 were identified using International Classification of Diseases 9th Revision (ICD-9) codes. The primary outcome of patient satisfaction was the Press Ganey Survey overall hospitalization satisfaction question because of a high response rate. This is a precursor survey to the widely available Hospital Consumer Assessment of Healthcare Systems and Providers Survey. There was high concordance between these items. Clinical and structural variables were collected retrospectively. Patients were divided into two groups based on whether they gave the topbox response for the overall hospital rating. RESULTS: Sixty-six patients were identified (56% female, 63 ± 14 years, length of stay: 5 ± 5 d). Seventy-four percent patients rated the hospitalization as topbox. Forty-four percent were admitted to a surgical service, and 21% of all patients underwent an operation. When comparing the topbox to the nontopbox group, demographics and disease severity were similar. Treatment modality, admitting service, and outpatient intravenous antibiotics did not influence patient satisfaction. CONCLUSIONS: Clinical and structural variables did not impact overall hospital satisfaction for patients admitted with diverticulitis. This indicates that less-tangible aspects of in-hospital care may be the primary determinants of hospital satisfaction in this group. Efforts aimed at defining these variables are needed to improve patient satisfaction.

Current technical aspects of oncological hepatic surgery.

BACKGROUND: With the recent advances in oncological hepatic surgery, major liver resections became more widely utilized procedures. The era of modern hepatic surgery witnessed improvements in patients care in preoperative, intraoperative and postoperative aspects. This significantly improved surgical outcomes regarding morbidity and mortality. This review article focuses on the recent advances in oncological hepatic surgery. DATA SOURCES: This review includes only data from peer-reviewed articles and journals. PubMed database was utilized as the primary source of the supporting literature to this review article on the latest advances in oncological hepatic surgery. Comprehensive and high sensitivity search strategies were performed to search related studies exhaustively up till June 2016. We critically and independently assessed over 50 recent publications written on this topic according to the selection criteria and quality assessment standard. We paid particular attention to the studies published in high impact journals that address the use of the surgical techniques mentioned in the articles in well-known institutions. RESULTS: Among all utilized approaches aiming at the preoperative assessment of the liver function, Child-Turcotte-Pugh classification remains the most reliable tool correlating with survival outcome. Although the primary radiological tools including ultrasonography, computed tomography and magnetic resonance imaging remain on top of the menu of tests utilized in assessment of focal hepatic lesions, intraoperative ultrasonography projects to be a powerful additional tool in terms of sensitivity and specificity compared to the other conventional techniques in assessment of the liver in the operative setting, a procedure that can change the surgical strategy in 27.2% of the cases and consequently improve the oncological surgical outcome. In addition to the conventional surgical techniques of liver resection and portal vein embolization, associating liver partition and portal vein ligation for staged hepatectomy "ALPPS" projects to be an alternative option in patients with marginally resectable tumors with an inadequate size of future liver remnant with an accepted surgical oncological outcome. CONCLUSIONS: Considering the clinicopathological nature of hepatic lesions, the comprehensive assessment and proper choice of the liver resection technique in highly selected patients is associated with improved surgical oncological outcome. Patients with underlying marginal future liver remnant volumes can now safely benefit from a wider range of surgical intervention, a breakthrough that significantly improved morbidity and mortality in this group of patients.

Utilization of preoperative endoscopic ultrasound for pancreatic adenocarcinoma.

BACKGROUND: Endoscopic ultrasound (EUS) is used for pancreatic adenocarcinoma staging and obtaining a tissue diagnosis. The objective was to determine patterns of preoperative EUS and the impact on downstream treatment. METHODS: The Surveillance, Epidemiology, and End Results (SEER) Medicare-linked database was used to identify patients with pancreatic adenocarcinoma. The staging period was the first staging procedure within 6 months of surgery until surgery. Logistic regression was used to determine factors associated with preoperative EUS. The main outcome was EUS in the staging period, with secondary outcomes including number of staging tests and time to surgery. RESULTS: 2782 patients were included, 56% were treated at an academic hospital (n = 1563). 1204 patients underwent EUS (43.3%). The factors most associated with receipt of EUS were: earlier year of diagnosis, SEER area, and a NCI or academic hospital (all p < 0.0001). EUS was associated with a longer time to surgery (17.8 days; p < 0.0001), and a higher number of staging tests (40 tests/100 patients; p < 0.0001). CONCLUSIONS: Factors most associated with receipt of EUS are geographic, temporal, and institutional, rather than clinical/disease factors. EUS is associated with a longer time to surgery and more preoperative testing, and additional study is needed to determine if EUS is overused.

Preoperative Helicobacter pylori Infection is Associated with Increased Survival After Resection of Gastric Adenocarcinoma.

BACKGROUND: Limited data exist on the prognosis of preoperative Helicobacter pylori (H. pylori) infection in gastric adenocarcinoma (GAC). METHODS: Patients who underwent curative-intent resection for GAC from 2000 to 2012 at seven academic institutions comprising the United States Gastric Cancer Collaborative were included in the study. The primary end points of the study were overall survival (OS), recurrence-free survival (RFS), and disease-specific survival (DSS). RESULTS: Of 559 patients, 104 (18.6 %) who tested positive for H. pylori were younger (62.1 vs 65.1 years; p = 0.041), had a higher frequency of distal tumors (82.7 vs 71.9 %; p = 0.033), and had higher rates of adjuvant radiation therapy (47.0 vs 34.9 %; p = 0.032). There were no differences in American Society of Anesthesiology (ASA) class, margin status, grade, perineural invasion, lymphovascular invasion, nodal metastases, or tumor-node-metastasis (TNM) stage. H. pylori positivity was associated with longer OS (84.3 vs 44.2 months; p = 0.008) for all patients. This relationship with OS persisted in the multivariable analysis (HR 0.54; 95 % CI 0.30-0.99; p = 0.046). H. pylori was not associated with RFS or DSS in all patients. In the stage 3 patients, H. pylori was associated with longer OS (44.5 vs 24.7 months; p = 0.018), a trend of longer RFS (31.4 vs 21.6 months; p = 0.232), and longer DSS (44.8 vs 27.2 months; p = 0.034). CONCLUSIONS: Patients with and without preoperative H. pylori infection had few differences in adverse pathologic features at the time of gastric adenocarcinoma resection. Despite similar disease presentations, preoperative H. pylori infection was independently associated with improved OS. Further studies examining the interaction between H. pylori and tumor immunology and genetics are merited.