Long-Term Outcomes following Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis of Colorectal Origin.

BACKGROUND: Cytoreductive surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is a major treatment of colorectal peritoneal carcinomatosis (CPC). The aim was to determine the disease-free survival (DFS) and overall survival (OS) of patients undergoing CRS-HIPEC for CPC and factors associated with long-term survival (LTS). METHODS: consecutive CPC patients who underwent CRS-HIPEC at a HIPEC center between 2007 and 2021 were included. Actual survival was calculated, and Cox proportional hazards models were used to identify factors associated with OS, DFS and LTS. RESULTS: there were 125 patients with CPC who underwent primary CRS-HIPEC, with mean age of 54.5 years. Median follow-up was 31 months. Average intraoperative PCI was 11, and complete cytoreduction (CC-0) was achieved in 96.8%. Median OS was 41.6 months (6-196). The 2-year and 5-year OS were 68% and 24.8%, respectively, and the 2-year DFS was 28.8%. Factors associated with worse OS included pre-HIPEC systemic therapy, synchronous extraperitoneal metastasis, and PCI ≥ 20 (p < 0.05). Progression prior to CRS-HIPEC was associated with worse DFS (p < 0.05). Lower PCI, fewer complications, lower recurrence and longer DFS were associated with LTS (p < 0.05). CONCLUSION: CRS and HIPEC improve OS in CPC patients but they have high disease recurrence. Outcomes depend on preoperative therapy response, extraperitoneal metastasis, and peritoneal disease burden.

Multicenter Adoption and Outcomes of Nodal Observation for Patients with Melanoma and Sentinel Lymph Node Metastases.

BACKGROUND: Following publication of the MSLT-II trial showing no survival benefit of completion lymphadenectomy (CLND) in patients with melanoma sentinel lymph node (SLN) metastases, it is expected that practice patterns have changed. The purpose of this study is to understand real-world practices and outcomes after publication of this landmark trial. PATIENTS AND METHODS: Patients with truncal/extremity melanoma SLN metastases diagnosed between 2013 and 2019 at four academic cancer centers were included in this retrospective cohort study. Descriptive statistics, Cox proportional hazards model, and multivariable regression were used to characterize the cohort and identify predictors of CLND, harboring non-SLN (NSLN) metastases, and survival. RESULTS: Results of 1176 patients undergoing SLN biopsy, 183 had SLN metastases. The number of patients who underwent CLND before versus after trial publication was 75.7.% versus 20.5% (HR 0.16, 95% CI 0.09-0.28). Of those undergoing nodal observation (NO), 92% had a first nodal-basin ultrasound, while 63% of patients had a fourth. In exploratory multivariable analyses, age ≥ 50 years was associated with lower rate of CLND (HR 0.58, 95% CI 0.36-0.92) and larger SLN deposit (> 1.0 mm) with increased rate of CLND (HR 1.87, 95% CI 1.17-3.00) in the complete cohort. Extracapsular extension was associated with increased risk of NSLN metastases (HR 12.43, 95% CI 2.48-62.31). Adjusted survival analysis demonstrated no difference in recurrence or mortality between patients treated with CLND versus NO at median 2.2-year follow-up. CONCLUSION: Nodal observation was rapidly adopted into practice in patients with melanoma SLN metastases at four centers in Canada. Younger age and higher nodal burden were associated with increased use of CLND after trial publication. Ultrasound (US) surveillance decreased with time from SLNB. In our study, CLND was not associated with a decreased risk of recurrence or mortality.

Contextual interference for skills development and transfer in laparoscopic surgery: a randomized controlled trial.

INTRODUCTION: Past education literature has shown benefits for random practice schedules (termed contextual interference) for skills retention and transfer to novel tasks. The purpose of fundamentals of laparoscopic surgery (FLS) training is to develop skills in simulation and transfer to new in vivo intraoperative experiences. The study objective was to assess whether individuals trained over a fixed number of trials in the FLS tasks would outperform untrained controls on an unpracticed previously validated bile duct cannulation task and scoring system and to determine whether random training schedules conferred any relative advantage. METHODS: 44 trainees with no laparoscopic experience were recruited to participate. 35 were randomized to practice the FLS tasks using either a blocked or random training schedule. Nine were randomized to no additional training (controls). Participant performance was measured throughout training to monitor skills acquisition and were then tested on an unpracticed bile duct cannulation simulation task 4 to 6 weeks later. Outcomes included previously validated FLS scores and hand-motion analyses. RESULTS: All 44 participants completed the study. Trained individuals in both groups showed significant improvements in all FLS tasks after training. There were no differences between groups in performance on the cannulation task median scores (Blocked: 89.8 [IQR:37.6]; Random: 83.2 [32.3]; Control: 83.6 [19.1]; p = 0.955), number of hand motions (Blocked: 42.5 [IQR:130.3]; Random: 75.3 [111.3]; Control: 63.0 [71.8]; p = 0.912), or distance traveled by participants hands (Blocked: 2.0 m [IQR:5.8]; Random: 3.8 [8.9]; Control: 2.6 [2.5]; p = 0.816). Cannulation task performance had no correlation with total FLS performance, R2 linear = 0.014, p = 0.445. CONCLUSIONS: Skills acquired from conventional FLS tasks did not effectively transfer to a laparoscopic bile duct cannulation task. Neither blocked nor random practice schedules conferred a relative advantage. These findings provide evidence that cannulation is a distinct skill from what is taught and assessed in FLS.

National survey of mentorship in Canadian general surgery residency programs: Where are we and what do we need?

BACKGROUND: The benefits of mentorship on residents are well established. The current state of mentorship in General Surgery (GS) residency programs in Canada is unknown. The objectives of this study were to obtain GS residents' and program directors' (PD) perspectives on resident mentorship. STUDY DESIGN: An electronic survey was developed and distributed to all 601 GS residents in Canada. All 17 PDs were invited for telephone interviews. RESULTS: A total of 179 of the 601 residents responded. Ninety-seven percent (n=173) felt mentorship was important. Only 67% (n=116) identified a mentor and only 53% (n=62) reported a mentorship program. Most who identified a mentor (n=87/110, 79%) were satisfied with the mentorship received. Significant variations in mentorship existed between demographic subgroups and mentorship program types. Overall, residents (n=121, 74%) favoured having a required mentorship program.A total of 11 out of 17 PDs participated in the telephone interviews. The majority of PDs (n=9, 82%) were satisfied with current resident mentorship but most acknowledged that barriers exist (n=8, 73%). CONCLUSION: GS programs in Canada should ensure they are providing equal opportunities for mentorship across demographic subgroups. Programs are encouraged to examine both their program's and their residents' needs as well as local barriers to improve mentorship.

A population-based assessment of melanoma: Does treatment in a regional cancer center make a difference?

BACKGROUND: Regionalization of care to specialized centers has improved outcomes for several cancer types. We sought to determine if treatment in a regional cancer center (RCC) impacts guideline adherence and outcomes for patients with melanoma. METHODS: In Alberta, Canada, 561 patients with stage I-IIIC primary melanoma were diagnosed between January 2009 and December 2010. The electronic health record was used to capture demographic and pathologic data. Provincial guidelines for sentinel lymph node biopsy (SLNB) and wide local excision (WLE) are based on recommendations of several pre-existing guidelines including the National Comprehensive Cancer Network. RESULTS: 148 of 561 patients were identified as having been treated at a RCC. Median follow-up was 45 months. Patients treated at the RCC presented with higher stage melanomas. The RCC was more likely to follow guideline recommendations for performing SLNB (81.3% vs. 55.4%, P < 0.0001) but not for the extent of WLE (76.6% vs. 84.1%, P = 0.054). Overall survival was impacted by tumor thickness (HR 1.14, P < 0.0001), ulceration (HR 5.58, P < 0.0001), and mitoses (HR 0.59, P = 0.05). CONCLUSIONS: The RCC more closely followed guidelines for SLNB but not for WLE. Despite patients treated at the RCC presenting with a more advanced stage, overall survival and disease-free survival appear to not be affected by treatment center.

Hyperthermic intraperitoneal chemotherapy + early postoperative intraperitoneal chemotherapy versus hyperthermic intraperitoneal chemotherapy alone: assessment of survival outcomes for colorectal and high-grade appendiceal peritoneal carcinomatosis.

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have improved survival for colorectal and high-grade appendiceal carcinomatosis. We compared the overall and recurrence-free survival (OS and RFS) of patients treated with HIPEC with mitomycin c and early postoperative intraperitoneal chemotherapy (EPIC) with fluorouracil versus HIPEC alone using oxaliplatin and simultaneous IV infusion of fluorouracil. METHODS: Ninety-three patients with colorectal or high-grade appendiceal carcinomatosis were treated with CRS and HIPEC + EPIC or HIPEC alone. OS and RFS were analyzed using Kaplan-Meier curves and log-rank testing. RESULTS: Survival did not differ between HIPEC regimens. The 3-year OS and RFS rates were 50% and 21% for HIPEC + EPIC and 46% and 6% for HIPEC alone (P = .72 and P = .89, respectively). HIPEC + EPIC patients experienced more grade III/IV complications (43.2% vs 19.6%, P = .01). CONCLUSIONS: There was no difference in OS and RFS between colorectal and high-grade appendiceal adenocarcinoma patients treated with CRS and HIPEC + EPIC versus HIPEC alone. However, HIPEC + EPIC patients suffered greater morbidity, making HIPEC alone the preferable regimen.

Quality of life, functional outcomes, and wound complications in patients with soft tissue sarcomas treated with preoperative chemoradiation: a prospective study.

BACKGROUND: Preoperative irradiation reduces local recurrence of soft tissue sarcomas (STSs), but major wound complication rates approach 25-35 %. Using a novel neoadjuvant chemoradiation protocol, we prospectively documented functional outcomes and quality of life (QOL) and hypothesized a lower major wound complication rate. METHODS: Patients with STS deep to muscular fascia were treated with 3 days of doxorubicin (30 mg/day) and 10 days of irradiation (300 cGy/day) followed by limb-sparing surgery. Wound complications were assessed, and functional assessment and QOL were followed prospectively using the Toronto Extremity Salvage Score (TESS), Musculoskeletal Tumor Society (MSTS), and Short Form (SF)-36 questionnaires preoperatively and 6 and 12 months postoperatively. RESULTS: Altogether, 52 consecutive patients were accrued during 2006-2011. Overall, 80.8 % of STSs were >5 cm, and 67.3 % involved the lower extremity. Seven (13.5 %) major wound complications occurred, all requiring reoperation. Preoperative scores for TESS, MSTS, and SF-36 physical (PCS) and mental (MCS) health components were 83.3, 86.7, 40.6, and 49.4, respectively. There were no differences seen 6 months postoperatively. By 12 months, however, patients showed improved functional scores (TESS 93.0, p = 0.02; MSTS 93.3, p < 0.01) and QOL scores (PCS 45.1, p = 0.02; MCS = 52.9, p = 0.05). No differences in scores were seen between patients with or without wound complications. CONCLUSIONS: Patients treated with our neoadjuvant chemoradiation protocol had stable QOL and functional scores 6 months postoperatively and showed improvement by 12 months. Importantly, the major wound complication rate was low.

The effect of blocked versus random task practice schedules on the acquisition and retention of surgical skills.

BACKGROUND: When learning multiple tasks, blocked or random training schedules may be used. We assessed the effects of blocked and random schedules on the acquisition and retention of laparoscopic skills. METHODS: Thirty-six laparoscopic novices were randomized to practice laparoscopic tasks using blocked, random, or no additional training. Participants performed immediate post-tests, followed by retention tests 6 weeks later. Outcomes included previously validated Fundamentals of Laparoscopic Surgery (FLS) and hand-motion efficiency scores. RESULTS: Both blocked and random groups had significantly higher FLS and hand-motion efficiency scores over baseline on post-tests for each task (P < .05) and higher overall FLS scores than controls on retention tests (P < .01). No difference was seen between the blocked and random groups in the amount of skill acquired or skill retained. CONCLUSIONS: Both blocked and random training schedules can be considered as valid training options to allow programs and learners to tailor training to their individual needs.

Preoperative computed tomography does not predict resectability in peritoneal carcinomatosis.

BACKGROUND: Obtaining a complete cytoreduction in patients with peritoneal carcinomatosis (PC) is one of the most significant prognostic variables for long-term survival. This study explored features on preoperative computed tomography (CT) to predict unresectability. METHODS: A retrospective case-control study was conducted of 15 patients with unresectable PC and 15 patients with completely resected PC matched by intraoperative peritoneal cancer index (PCI) and pathology type. Two surgical oncologists blindly analyzed all abdominopelvic CT scans. RESULTS: PCI estimated on imaging was not higher in unresectable patients (P = .851) and significantly underestimated intraoperative PCI measurement (P = .003). No single concerning feature was associated with unresectability. However, patients with 2 or more concerning features were more likely to be unresectable (87.5% vs 36.4%, P = .035). CONCLUSIONS: Two or more concerning CT imaging features appear to be associated with a higher risk of unresectability in patients with PC. However, no specific imaging feature should exclude a patient from an attempted cytoreduction.

Cytoreduction and heated intraperitoneal chemotherapy for colorectal cancer: are we excluding patients who may benefit?

BACKGROUND: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are increasingly used to treat peritoneal carcinomatosis from colorectal cancer. It is still relatively unknown which poor prognostic factors to avoid in order to optimize patient selection for CRS + HIPEC. METHODS: Between February 2003 and October 2011, 68 consecutive colorectal cancer patients who underwent CRS + HIPEC with a complete cytoreduction were identified from a prospective database. Survival analysis was performed using the Kaplan-Meier method, with log rank testing of differences between groups. Multivariate analysis was conducted using Cox proportional hazard regression. RESULTS: Median follow-up was 30.3 (range, 2-88) months amongst survivors. Patients with a peritoneal cancer index (PCI) of 10 or less showed improved survival over those with a PCI of 11 or higher (P = 0.03). No difference in survival was seen for the other potentially poor prognostic variables including lymph node status, synchronous peritoneal disease, peri-operative systemic chemotherapy, and rectal cancer primary. CONCLUSIONS: A low PCI was associated with improved survival. Complete CRS + HIPEC appears to result in similar survival outcomes regardless of delivery of peri-operative systemic chemotherapy. Rectal origin, lymph node status, and synchronous peritoneal disease should not be used as an absolute exclusion criteria for CRS + HIPEC based on current data.

Construct validity of individual and summary performance metrics associated with a computer-based laparoscopic simulator.

BACKGROUND: Computer-based surgical simulators capture a multitude of metrics based on different aspects of performance, such as speed, accuracy, and movement efficiency. However, without rigorous assessment, it may be unclear whether all, some, or none of these metrics actually reflect technical skill, which can compromise educational efforts on these simulators. We assessed the construct validity of individual performance metrics on the LapVR simulator (Immersion Medical, San Jose, CA, USA) and used these data to create task-specific summary metrics. METHODS: Medical students with no prior laparoscopic experience (novices, N = 12), junior surgical residents with some laparoscopic experience (intermediates, N = 12), and experienced surgeons (experts, N = 11) all completed three repetitions of four LapVR simulator tasks. The tasks included three basic skills (peg transfer, cutting, clipping) and one procedural skill (adhesiolysis). RESULTS: We selected 36 individual metrics on the four tasks that assessed six different aspects of performance, including speed, motion path length, respect for tissue, accuracy, task-specific errors, and successful task completion. Four of seven individual metrics assessed for peg transfer, six of ten metrics for cutting, four of nine metrics for clipping, and three of ten metrics for adhesiolysis discriminated between experience levels. Time and motion path length were significant on all four tasks. We used the validated individual metrics to create summary equations for each task, which successfully distinguished between the different experience levels. CONCLUSION: Educators should maintain some skepticism when reviewing the plethora of metrics captured by computer-based simulators, as some but not all are valid. We showed the construct validity of a limited number of individual metrics and developed summary metrics for the LapVR. The summary metrics provide a succinct way of assessing skill with a single metric for each task, but require further validation.

Equivalency of lymph node harvest in laparoscopic versus open colorectal cancer procedures: an early surgeon's perspective.

PURPOSE: To compare the number of lymph nodes harvested in laparoscopic versus open colorectal cancer surgery early in a surgeon's career. METHODS: We reviewed the data of 80 patients operated upon with a primary diagnosis of colorectal cancer between September 2006 and June 2008. All data were from a single fellowship trained colorectal surgeon. The effects of laparoscopic versus open surgery, and neoadjuvant radiation were examined to assess lymph node harvest. RESULTS: There was no statistically significant difference between the lymph nodes harvested during laparoscopic versus open surgery (17.4 vs 18.5; P=0.5920). The amount of lymph nodes harvested decreased with increasing American Society of Anesthesiology grade (22.4, 17.1, 19.2, 7.0 for American Society of Anesthesiology grade I, II, III, IV, respectively; P=0.0412) and with neoadjuvant radiotherapy (18.7 vs 13.2; P=0.0151). CONCLUSIONS: Laparoscopic colorectal cancer surgery results in the same number of lymph nodes being harvested as in open surgery.