Monopolar diathermy versus a vessel-sealing device for reducing postoperative drain output after simple mastectomy: randomized clinical trial.

BACKGROUND: Electrosurgical devices are commonly used during mastectomy for simultaneous dissection and haemostasis, and can provide potential benefits regarding vessel and lymphatic ligation. The aim of this prospective RCT was to assess whether using a vessel-sealing device (LigaSure™) improves perioperative outcomes compared with monopolar diathermy when performing simple mastectomy. METHODS: Patients were recruited prospectively and randomized in a 1 : 1 manner to undergo simple mastectomy using either LigaSure™ or conventional monopolar diathermy at a single centre. The primary outcome was the number of days the drain remained in situ after surgery. Secondary outcomes of interest included operating time and complications. RESULTS: A total of 86 patients were recruited (42 were randomized to the monopolar diathermy group and 44 were randomized to the LigaSure™ group). There was no significant difference in the mean number of days the drain remained in situ between the monopolar diathermy group and the LigaSure™ group (7.75 days versus 8.23 days; P = 0.613) and there was no significant difference in the mean total drain output between the monopolar diathermy group and the LigaSure™ group (523.50 ml versus 572.80 ml; P = 0.694). In addition, there was no significant difference in the mean operating time between the groups, for simple mastectomy alone (88.25 min for the monopolar diathermy group versus 107.20 min for the LigaSure™ group; P = 0.078) and simple mastectomy with sentinel lymph node biopsy (107.20 min for the monopolar diathermy group versus 114.40 min for the LigaSure™ group; P = 0.440). CONCLUSION: In this double-blinded single-centre RCT, there was no difference in the total drain output or the number of days the drain remained in situ between the monopolar diathermy group and the LigaSure™ group. REGISTRATION NUMBER: EudraCT 2018-003191-13 BEAUMONT HOSPITAL REC 18/66.

Age alone is not a barrier to efficacy of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastases: analysis of 1138 patients from the UK and Ireland Colorectal Peritoneal Metastases Registry.

BACKGROUND: The management of colorectal peritoneal metastases continues to be a challenge but recent evidence suggests cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) can improve survival. Uncertainty about the relationship between age and tumour biology makes patient selection challenging particularly when reported procedure related morbidity is high and impact on survival outcomes unknown. The UK and Ireland Colorectal Peritoneal Metastases Registry was reviewed to assess the influence of age on efficacy of CRS and HIPEC. METHODS: A review of outcomes from the UK and Ireland Colorectal Peritoneal Metastases Registry was performed. Data from 2000 to 2021 were included from five centres in the UK and Ireland, and the cohort were sub-divided into three age groups; <45 years, 45-65 years and >65 years old. Primarily, we examined post-operative morbidity and survival outcomes across the three age groups. In addition, we examined the impact that the completeness of cytoreduction, nodal status, or adverse pathological features had on long-term survival. RESULTS: During the study period, 1138 CPM patients underwent CRS HIPEC. 202 patients(17.8%) were <45 years, 549 patients(48.2%) aged 45-65 years and 387 patients(34%) >65 years. Overall, median length of surgery (CRS and HIPEC), median PCI score and rate of HIPEC administration was similar in all three groups, as was overall rates of major morbidity and/or mortality. Complete cytoreduction rates (CC0) were similar across the three cohorts; 77%, 80.6% and 81%, respectively. Median overall survival for all patients was 38 months following complete cytoreduction. CONCLUSION: Age did not appear to influence morbidity or long-term survival following CRS and HIPEC. When complete cytoreduction is achieved survival outcomes are good. The addition of HIPEC can be performed safely and may reduce local recurrence within the peritoneum.

Defining a textbook outcome for the resection of colorectal liver metastases.

INTRODUCTION: Textbook outcomes (TBO) are composite measures of care which may be superior in assessing quality compared to traditional methods. We aim to define TBO which are specific to surgical resection of colorectal liver metastases, and investigate their impact on survival. METHODS: Single center analysis of all liver resections performed at our center from 2009 to 2020. A Cox model was used to identify perioperative outcomes which impacted on overall survival. These were retained with important postoperative outcomes to form a "TBO." The impact of a TBO on overall survival was investigated using Kaplan-Meier curve analysis. RESULTS: TBO was achieved in 72.2% (197/273) of resections. Major morbidity (Clavien-Dindo ≥3) at 19.4% was the major limiting factor in not achieving a TBO. TBO was associated with improved 3-year (77% vs. 55%), 5-year (60.7% vs. 42.5%), and median (93 vs. 44 months) overall survival (log-rank test, p = 0.006). Multivariable analysis revealed age >65 years, American Society of Anaesthesiologists Grade III-IV, and resection of >2 segments as factors predictive of not achieving a TBO. CONCLUSION: TBO is a useful composite measure in surgery for colorectal liver metastases. It can highlight areas which may be targeted for quality improvement and be useful as a tool to examine variation between centers. Achieving a TBO is associated with a significant improvement in survival.

Omission of intraoperative pyloric procedures in minimally invasive esophagectomy: assessing the impact on patients.

Pyloroplasty or pyloromyotomy is often undertaken during esophagectomy to aid gastric emptying postoperatively. Minimally invasive esophagectomy (MIE) frequently omits a pyloric procedure. The impact on perioperative outcomes and the need for subsequent interventions is unclear. This study assesses the requirements for endoscopic balloon dilation of the pylorus (EPD) following MIE. Patients undergoing MIE from 2016 to 2020 were reviewed. Patients undergoing open resection, or an intraoperative pyloric procedure were excluded. Demographic, clinical and pathological data were reviewed. Univariable and multivariable analysis were performed as appropriate. In total, 171 patients underwent MIE. There were no differences in age (median 65 vs. 65 years, P = 0.6), pathological stage (P = 0.10) or ASA status (P = 0.52) between those requiring and not requiring endoscopic pyloric dilation (EPD). Forty-three patients (25%) required EPD, with a total of 71 procedures. Twenty-seven patients (16%) had EPD on their index admission. Seventy-five patients (43%) had a postoperative complication. Higher ASA status was associated with increased requirement for EPD (odds ratio 10.8, P = 0.03). On multivariable analysis, there was no association between the need for a pyloric procedure and overall survival (P = 0.14). Eight patients (5%) required insertion of a feeding jejunostomy in the postoperative period, with no difference between those with or without EPD (P = 0.11). Two patients required subsequent surgical pyloromyotomy for delayed gastric emptying. Although pyloroplasty or pyloromyotomy can safely be excluded during MIE, a quarter of patients will require postoperative EPD procedures. The impact of excluding pyloric procedures on gastric emptying requires further study.

Is the use of a routine intraoperative cholangiogram necessary in laparoscopic cholecystectomy?

INTRODUCTION: Although laparoscopic cholecystectomy (LC) has been standard of care for symptomatic gallstone disease for almost 30 years, the use of routine intraoperative cholangiogram (IOC) remains controversial. There are marked variations in the use IOC during LC internationally. Debate has continued about its benefit, in part because of inconsistent benefit, time, and resources required to complete IOC. This literature review is presented as a debate to outline the arguments in favour of and against routine IOC in laparoscopic cholecystectomy. METHODS: A standard literature review of PubMed, Medline, OVID, EMBASE, CINHIL and Web of Science was performed, specifically for literature pertaining to the use of IOC or alternative intra-operative methods for imaging the biliary tree in LC. Two authors assembled the evidence in favour, and two authors assembled the evidence against. RESULTS: From this controversies piece we found that there is little discernible change in the number of BDIs requiring repair procedures. Although IOC is associated with a small absolute reduction in bile duct injury, there are other confounding factors, including a change in laparoscopic learning curves. Alternative technologies such as intra-operative ultrasound, indocyanine green imaging, and increased access to ERCP may contribute to a reduction in the need for routine IOC. CONCLUSIONS: In spite of 30 years of accumulating evidence, routine IOC remains controversial. As technology advances, it is likely that alternative methods of imaging and accessing the bile duct will supplant routine IOC.

Advances in the curative management of oesophageal cancer.

The incidence of oesophageal cancer, in particular adenocarcinoma, has markedly increased over the last four decades with adenocarcinoma becoming the dominant subtype in the West, and mortality rates are high. Nevertheless, overall survival of patients with oesophageal cancer has doubled in the past 20 years, with earlier diagnosis and improved treatments benefiting those patients who can be treated with curative intent. Advances in endotherapy, surgical approaches, and multimodal and other combination therapies have been reported. New vistas have emerged in targeted therapies and immunotherapy, informed by new knowledge in genomics and molecular biology, which present opportunities for personalised cancer therapy and novel clinical trials. This review focuses exclusively on the curative intent treatment pathway, and highlights emerging advances.

A Randomized Clinical Trial Evaluating the Efficacy and Quality of Life of Antibiotic-only Treatment of Acute Uncomplicated Appendicitis: Results of the COMMA Trial.

OBJECTIVE: Evaluate the efficacy and quality of life associated with conservative treatment of acute uncomplicated appendicitis. SUMMARY BACKGROUND DATA: Conservative management with antibiotics only has emerged as a potential treatment option for acute uncomplicated appendicitis. However the reported failure rates are highly variable and there is a paucity of data in relation to quality of life. METHODS: Symptomatic patients with radiological evidence of acute, uncomplicated appendicitis were randomized to either intravenous antibiotics only or undergo appendectomy. RESULTS: One hundred eighty-six patients underwent randomization. In the antibiotic-only group, 23 patients (25.3%) experienced a recurrence within 1 year following randomization. There was a significantly better EQ-VAS quality of life score in the surgery group compared with the antibiotic-only group at 3 months (94.3 vs 91.0, P < 0.001) and 12 months postintervention (94.5 vs 90.4, P < 0.001). The EQ-5D-3L quality-of-life score was significantly higher in the surgery group indicating a better quality of life (0.976 vs 0.888, P < 0.001). The accumulated 12-month sickness days was 3.6 days shorter for the antibiotics only group (5.3 vs 8.9 days; P < 0.01). The mean length of stay in both groups was not significantly different (2.3 vs 2.8 days, P = 0.13). The mean total cost in the surgery group was significantly higher than antibiotics only group (€4,816 vs €3,077, P < 0.001). CONCLUSIONS: Patients with acute, uncomplicated appendicitis treated with antibiotics only experience high recurrence rates and an inferior quality of life. Surgery should remain the mainstay of treatment for this commonly encountered acute surgical condition.

ADAM22/LGI1 complex as a new actionable target for breast cancer brain metastasis.

BACKGROUND: Metastatic breast cancer is a major cause of cancer-related deaths in woman. Brain metastasis is a common and devastating site of relapse for several breast cancer molecular subtypes, including oestrogen receptor-positive disease, with life expectancy of less than a year. While efforts have been devoted to developing therapeutics for extra-cranial metastasis, drug penetration of blood-brain barrier (BBB) remains a major clinical challenge. Defining molecular alterations in breast cancer brain metastasis enables the identification of novel actionable targets. METHODS: Global transcriptomic analysis of matched primary and metastatic patient tumours (n = 35 patients, 70 tumour samples) identified a putative new actionable target for advanced breast cancer which was further validated in vivo and in breast cancer patient tumour tissue (n = 843 patients). A peptide mimetic of the target's natural ligand was designed in silico and its efficacy assessed in in vitro, ex vivo and in vivo models of breast cancer metastasis. RESULTS: Bioinformatic analysis of over-represented pathways in metastatic breast cancer identified ADAM22 as a top ranked member of the ECM-related druggable genome specific to brain metastases. ADAM22 was validated as an actionable target in in vitro, ex vivo and in patient tumour tissue (n = 843 patients). A peptide mimetic of the ADAM22 ligand LGI1, LGI1MIM, was designed in silico. The efficacy of LGI1MIM and its ability to penetrate the BBB were assessed in vitro, ex vivo and in brain metastasis BBB 3D biometric biohybrid models, respectively. Treatment with LGI1MIM in vivo inhibited disease progression, in particular the development of brain metastasis. CONCLUSION: ADAM22 expression in advanced breast cancer supports development of breast cancer brain metastasis. Targeting ADAM22 with a peptide mimetic LGI1MIM represents a new therapeutic option to treat metastatic brain disease.

Perioperative prehabilitation and rehabilitation in esophagogastric malignancies: a systematic review.

Cancers of the esophagus and stomach are challenging to treat. With the advent of neoadjuvant therapies, patients frequently have a preoperative window with potential to optimize their status before major resectional surgery. It is unclear as to whether a prehabilitation or optimization program can affect surgical outcomes. This systematic review appraises the current evidence for prehabilitation and rehabilitation in esophagogastric malignancy. A literature search was performed according to PRISMA guidelines using PubMed, EMBASE, Cochrane Library, Google Scholar, and Scopus. Studies including patients undergoing esophagectomy or gastrectomy were included. Studies reporting on at least one of aerobic capacity, muscle strength, quality of life, morbidity, and mortality were included. Twelve studies were identified for inclusion, comprising a total of 937 patients. There was significant heterogeneity between studies, with a variety of interventions, timelines, and outcome measures reported. Inspiratory muscle training (IMT) consistently showed improvements in functional status preoperatively, with three studies showing improvements in respiratory complications with IMT. Postoperative rehabilitation was associated with improved clinical outcomes. There may be a role for prehabilitation among patients undergoing major resectional surgery in esophagogastric malignancy. A large randomized controlled trial is warranted to investigate this further.

Meta-analysis of outcomes of endoscopic ultrasound-guided gallbladder drainage versus percutaneous cholecystostomy for the management of acute cholecystitis.

BACKGROUND: Endoscopic ultrasound-guided gallbladder drainage is a novel method of treating acute cholecystitis in patients deemed too high risk for surgery. It involves endoscopic stent placement between the gallbladder and the alimentary tract to internally drain the infection and is an alternative to percutaneous cholecystostomy (PC). This meta-analysis assesses the clinical outcomes of high-risk patients undergoing endoscopic drainage with an acute cholecystoenterostomy (ACE) compared with PC in acute cholecystitis. METHODS: A literature search was performed using the preferred reporting items for systematic reviews and meta-analyses guidelines. Databases were searched for studies reporting outcomes of patients undergoing ACE or PC. Results were reported as mean differences or pooled odds ratios (OR) with 95% confidence intervals (95% CI). RESULTS: A total of 1593 citations were reviewed; five studies comprising 495 patients were ultimately selected for analysis. There were no differences in technical or clinical success rates between the two groups on pooled meta-analysis. ACE had significantly lower post-procedural pain scores (mean difference - 3.0, 95% CI - 2.3 to - 3.6, p < 0.001, on a 10-point pain scale). There were no statistically significant differences in procedure complications between groups. Re-intervention rates were significantly higher in the PC group (OR 4.3, 95% CI 2.0-9.3, p < 0.001). CONCLUSION: ACE is a promising alternative to PC in high-risk patients with acute cholecystitis, with equivalent success rates, improved pain scores and lower re-intervention rates, without the morbidities associated with external drainage.

The prognostic value of neutrophil-to-lymphocyte ratio in colorectal cancer: A systematic review.

BACKGROUND AND OBJECTIVES: The detection of a simple and reliable prognostic biomarker for colorectal cancer (CRC) outcomes remains a significant challenge. The use of neutrophil-to-lymphocyte ratio (NLR), has been reported to predict surgical and survival outcomes. The aim of our review was to assess the predictive value of pre-operative NLR in predicting post-operative outcomes in CRC. METHODS: A systematic review of the available studies on NLR in CRC was performed. Primarily, we assessed its ability to predict survival outcomes, and highlight values that would help adjuvant therapy choices. RESULTS: 19 studies comprising 10 259 patients were included. Eleven and eight studies reported on patients with localized CRC and colorectal liver metastasis, respectively. Five-year survival for those with localized CRC was 77.2% in patients with a "low" pre-operative NLR versus 50.8% in those with a "high" pre-operative NLR value. Alternatively, for patients with colorectal liver metastasis, patients with a "high" pre-operative NLR value had a 5-year survival of 27%. CONCLUSION: Elevated pre-operative NLR>5 is associated with poorer long-term survival in both patients with localized CRC and those with liver metastasis. NLR is a useful biomarker in delineating those patients with poorer prognosis and whom may benefit from adjuvant therapies.

The Utility of Neutrophil-to-Lymphocyte Ratio as a Severity Predictor of Acute Appendicitis, Length of Hospital Stay and Postoperative Complication Rates.

BACKGROUND: Numerous screening tools have been reported to aid in diagnosing appendicitis, but have poor severity prediction and lack accurate estimation of postoperative complications or total length of hospital stay (LOS). AIM: This study aims at evaluating the utility of neutrophil-to-lymphocyte (NLR) ratio in predicting the severity of appendicitis, LOS and 30-day complication rates. METHODS: Patients who underwent appendicectomy over a 4-year period were evaluated. Demographics, blood results, severity of appendicitis, LOS and 30-day complications were recorded. Recommended cut-off values of NLR and C-reactive protein (CRP) for severity of appendicitis were determined using receiver operating characteristic analysis. The Mann-Whitney test was performed to assess the correlations between LOS and 30-day complications with NLR. RESULTS: A total of 663 patients were included in the study of which 57.3% (n = 380) were male with mean patient age of 23.6 years, and 461 appendix specimens (69.6%) had simple inflammation on histological evaluation. A NLR of >6.35 or CRP of >55.6 were statistically associated with severe acute appendicitis, with a median of one extra hospital day admission (p < 0.0001). Mean NLR was statistically higher in patients with postoperative co(13.69 for severe vs. 7.29 for simple appendicitis group, p = 0.016). CONCLUSION: We advocate that NLR is a useful adjunct in predicting severity of appendicitis. It aids in delineating severe inflammation requiring surgery without substantial delay.

Impact of telehealth postoperative care on early outcomes following esophagectomy.

OBJECTIVES: To address the short-term clinical outcomes of patients postesophagectomy who underwent telehealth care following surgery. The primary objective was to compare the frequency of emergency department admission between telehealth and in-person cohorts. Secondary objectives included comparing the frequency of endoscopies and clinic visits, as well as reasons for emergency department admission. METHODS: We conducted a retrospective cohort study to assess the clinical outcomes of patients who underwent esophagectomy between March 2018 and May 2022. Patients attending telehealth (phone or video call) surgical follow-up visits, largely due to the COVID-19 pandemic, were compared with a pre-COVID cohort of patients attending standard in-person care. Demographic data, clinical and disease characteristics, and hospital visit data within 6 months of operation were collected. This included surgical clinic visits, endoscopies, and emergency department admissions. RESULTS: There were 168 patients who underwent esophagectomy and had follow-up care between March 2018 and May 2022; 76 telehealth and 92 in-person. Patients attending telehealth appointments had significantly fewer emergency department admissions (0.45 vs 0.79, P = .037) and more endoscopy visits (1.37 vs 0.91, P = .020) compared with patients attending in-person visits. The number of follow-up surgical clinic visits did not differ between the groups. The most frequent reasons for emergency visits for the telehealth cohort included dysphagia, feeding-tube problems, and failure to thrive. For the in-person cohort, feeding-tube complications, inflammation/infection, and failure to thrive were the most common reasons. CONCLUSIONS: A program of virtual follow-up, with integrated in person visits and endoscopy as required, is feasible and safe for following patients postesophagectomy.

The effect of a pre- and post- operative exercise program versus standard care on physical fitness of patients with oesophageal and gastric cancer undergoing neoadjuvant treatment prior to surgery (The PERIOP-OG Trial): a randomized controlled trial.

INTRODUCTION: Although the benefits of post-operative rehabilitation in cancer surgery are well established, the role of prehabilitation is less defined. Oesophagogastric cancers present a unique opportunity to study the impact of prehabilitation during the neoadjuvant window, whether with chemotherapy or chemoradiotherapy (NCT) in patients who are frequently nutritionally depleted. This trial examines the impact of a community-based exercise program on patient fitness during and after the neoadjuvant window. METHODS: A pragmatic, randomized controlled multi-centre trial was undertaken in three centres. Inclusion criteria were patients aged ≥ 18 years planned for NCT and esophagectomy or gastrectomy. Participants were randomized 1:1 to an exercise prehabilitation group (EX) or to usual care (UC). The primary endpoint was cardiorespiratory fitness between baseline and pre-surgery timepoint using the 6-min walk test. Secondary endpoints included hand dynamometer, 10-sec sit to stand, activity behaviour, body mass index, semi-structured interviews, questionnaires assessing quality of life, surgical fear, general self-efficacy and mastery. RESULTS: Between March 2019 and December 2020, 71 participants were recruited: EX (n=36) or UC (n=35). From baseline to pre-surgery, the difference-in-difference for EX showed a significant improvement in 6MWT of 50.7m (P=0.05) compared to UC [mean (SD): 522.1m (+/-104.3) to 582.1m (+/-108) vs. 497.5m (+/-106.3) to 506.0 m (+/-140.4). There was no statistically significant DID for secondary outcome measures. CONCLUSIONS: This community exercise prehabilitation program significantly improves physical fitness for surgery, is feasible and provides a standardized framework for prescription of exercise in esophagogastric cancer patients undergoing NCT.

Reducing recurrence rates in hiatal hernia repair: Results of a quality improvement study.

BACKGROUND: Patient and procedure factors are considered in the decision-making process for surgical repair of hiatal hernias. Recurrence is multi-factorial and has been shown to be related to size, type, BMI and age. AIMS: This study examined recurrence rates in a single institution, identified areas for improved surgical technique, and re-assessed recurrence following implantation of a quality improvement initiative. METHODS: A retrospective review of patients undergoing hiatal hernia repair surgery between 2018 and 2022 was conducted. Demographics, pre-operative characteristics, intra-operative procedures and recurrence rates were reviewed. RESULTS: Seventy-five patients from 2018 to 2020 and 34 patients from 2021 to 2022 were identified. The recurrence rate was 21% in 2018-2020, with 14% requiring a revisional procedure. Recurrence and re-operation were subsequently reduced to 6% in 2021 and 2022, which was statistically significant (p = 0.043). There was an increase in gastropexy from 21% to 41% following the review (p = 0.032), which was mainly reserved for large and giant hernias. Procedural and literature review, alongside gastropexy, can be attributed to recurrence rate reduction. CONCLUSIONS: It is important to educate patients on the likelihood and risk factors of recurrence. A comprehensive review of procedures and a quality improvement program in our facility for hiatal hernia repair is shown to reduce recurrence.

The safety and acceptability of using telehealth for follow-up of patients following cancer surgery: A systematic review.

INTRODUCTION: Although virtual consultations have played an increasing role in delivery of healthcare, the COVID-19 pandemic has hastened their adoption. Furthermore, virtual consultations are now being adopted in areas that were previously considered unsuitable, including post-operative visits for patients undergoing major surgical procedures, and surveillance following cancer operations. This review aims to examine the feasibility, safety, and patient satisfaction with virtual follow-up appointments after cancer operations. METHODS: A systematic review was conducted along PRISMA guidelines. Studies where patients underwent surgical resection of a malignancy with at least one study arm describing virtual follow-ups were included. Studies were assessed for quality. Outcomes including adverse events, detection of recurrence and patient and provider satisfaction were assessed and compared for those undergoing virtual or in-person post-operative visits. RESULTS: Eleven studies, with 3369 patients were included. Cancer types included were gynecological, colorectal, esophageal, lung, thyroid, breast, prostate and major HPB resections. Detection of recurrence and readmission rates were similar when comparing virtual consultations with in-person visits. Most studies showed high patient and healthcare provider satisfaction with virtual consultations following cancer resection. Concerns were raised about the integration of virtual consultations into workflows in fee-for-service settings, where reimbursement for virtual care may be an issue. CONCLUSION: Virtual follow-up care can provide timely and safe consultations in surgical oncology. Virtual consultations are as safe as in-person visits for assessing complications and recurrence. Where appropriate, virtual consultations can safely be integrated into the post-operative care pathway for those undergoing resection of malignancy.

Circulating fibrocyte percentage and neutrophil-lymphocyte ratio are accurate biomarkers of uncomplicated and complicated appendicitis: a prospective cohort study.

BACKGROUND: There is increasing evidence that uncomplicated appendicitis (UA) may be treated nonoperatively in cases of UA. This study aimed to evaluate and compare the diagnostic accuracy of circulating fibrocyte percentage (CFP), white blood cell count, C-reactive protein, and neutrophil-lymphocyte ratio (NLR) in diagnosing uncomplicated and complicated appendicitis. MATERIALS AND METHODS: Eighty consecutive adult patients presenting with suspected appendicitis were recruited in a cohort-based prospective study between June 2015 and February 2016 at University Hospital Limerick in Ireland. Peripheral venous samples were obtained at the presentation. Clinical, biochemical, radiological, and histopathological parameters were recorded. The CFP was determined by dual-staining for CD45 and collagen-I using flow cytometry analysis and correlated with histopathological diagnoses. RESULTS: Of the 46 patients who underwent appendicectomy, 34 (73.9%) had histologically proven acute appendicitis. A comparison of the diagnostic accuracy of biomarkers demonstrated the CFP had the highest diagnostic accuracy for UA (area under the curve=0.83, sensitivity=72.7%, specificity=83.3%, P=0.002). The NLR had the highest diagnostic accuracy in relation to complicated appendicitis (area under the curve=0.84, sensitivity=75.5%, specificity=83.3%, P=0.005). CONCLUSIONS: CFP and NLR are accurate biomarkers of UA and complicated appendicitis.

Nodal Yield <15 Is Associated With Reduced Survival in Esophagectomy and Is a Quality Metric.

BACKGROUND: Surgical resection after neoadjuvant therapy remains the cornerstone of curative management of esophageal adenocarcinoma and is frequently used for squamous cell carcinoma. The optimal extent of lymphadenectomy and whether increasing lymph node yields confer a survival benefit remains unclear. Guidelines suggest resecting and examining a minimum of 15 lymph nodes at esophagectomy. This study assessed the impact of lymph node yield and lymph node ratio (LNR) on survival, identifying factors influencing nodal yield and radicality of resection. METHODS: All patients undergoing esophagectomy with curative intent at a single institution (stage 1-4 inclusive) from January 1, 2010, to December 31, 2020, were reviewed. Clinical and pathologic variables were interrogated. LNR was calculated by dividing positive lymph nodes by the total nodes resected. RESULTS: Esophagectomy was performed in 397 patients, with 288 undergoing minimally invasive esophagectomy (MIE). Margin status (hazard ratio [HR], 1.80; 95% CI, 1.15-2.83; P < .01), nodal yield <15 (HR, 1.98; 95% CI, 1.29-3.04; P = .002), and elevated LNR (HR, 8.16; 95% CI, 2.89-23.06; P < .001) predicted survival. MIE had higher nodal yields compared with open procedures (30.7 vs 25.3, P < .001). Patients undergoing neoadjuvant chemoradiotherapy had lower nodal yields compared with those with no neoadjuvant therapy and those with neoadjuvant chemotherapy (26.4 vs 30.6 vs 36.8, respectively; P < .001). Regression analysis determined a LNR of <0.05 was associated with a survival benefit. CONCLUSIONS: Textbook lymphadenectomy is associated with improved survival. Low lymph node yield and a high LNR are associated with reduced overall survival. A LNR of <0.05 is associated with significant survival benefit. A minimum nodal yield of 15 should remain the standard of care.