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BACKGROUND AND OBJECTIVES: Sociodemographic factors have been shown to impact surgical outcomes. However, the effects of these factors on patients undergoing cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) are not well known. This study aims to evaluate the impact of sociodemographic factors on patients undergoing CRS/HIPEC. METHODS: Adult patients at a tertiary center who underwent CRS/HIPEC were evaluated. Perioperative variables were collected and analyzed. A national database was also used to evaluate patients undergoing CRS/HIPEC. RESULTS: There were 90 patients who underwent CRS/HIPEC (32% non-White). There was no statistically significant difference in postoperative complications, length of stay, or discharge disposition based upon race (white vs. non-White patients), socioeconomic status (SES), or insurance type. Nationally, we found that Black and Hispanic patients were less likely to undergo CRS/HIPEC than Non-Hispanic white patients (Black: odds ratio [OR]: 0.60, [confidence interval {CI}: 0.39-0.94]; Hispanic: OR: 0.52, [CI: 0.28-0.98]). However, there were no significant differences in postoperative complications based upon race/ethnicity. CONCLUSION: Sociodemographic factors including race, SES, and insurance status did not impact postoperative outcomes in patients undergoing CRS/HIPEC at our single institution. On a national level, Black and Hispanic patients underwent CRS/HIPEC at lower rates compared to white patients.
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Hipertermia Induzida , Neoplasias Peritoneais , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Terapia Combinada , Procedimentos Cirúrgicos de Citorredução/efeitos adversos , Humanos , Hipertermia Induzida/efeitos adversos , Neoplasias Peritoneais/patologia , Neoplasias Peritoneais/terapia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores Sociodemográficos , Taxa de SobrevidaRESUMO
BACKGROUND: SOX9, a progenitor cell marker, is important for pancreatic ductal development. Our goal was to examine SOX9 expression differences in intraductal papillary mucinous neoplasms (IPMNs) and ductal adenocarcinoma (PDAC) compared with benign pancreatic duct (BP). METHODS: SOX9 expression was evaluated by immunohistochemistry performed on 93 specimens: 37 BP, 24 low grade (LG) IPMN, 12 high grade (HG) IPMN, and 20 PDAC. A linear mixed-effects model was used to compare the percentage of cells expressing SOX9 by specimen type. A separate linear mixed-effects model evaluated differences in SOX9 expression by staining intensity in pancreatic epithelial cells. RESULTS: Nuclear SOX9 expression was detected in the epithelial cells of 98% HG IPMN, 93% LG IPMN, 83% PDAC, and 60% BP. Compared with BP, SOX9 was expressed from a significantly greater percentage of cells in LG IMPN, HG IMPN, and PDAC (p < 0.001 for each). BP and PDAC showed greater variability in SOX9 expression in epithelial cells compared with IPMNs which showed strong, homogenous SOX9 expression in almost all cells. Compared with BP, both LG and HG IPMN showed significantly greater SOX9 expression (p < 0.001 for each), but there was no significant difference in SOX9 expression between LG and HG IPMN (p > 0.05). PDAC had significantly higher expression of SOX9 compared with BP but significantly lower SOX9 expression compared with LG or HG IPMN (p < 0.001 for each). CONCLUSIONS: IPMNs demonstrated the highest expression levels of SOX9. SOX9 expression in BP and PDAC demonstrated much more heterogeneity compared with the strong, uniform expression in IPMN.
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Adenocarcinoma Mucinoso/patologia , Carcinoma Ductal Pancreático/patologia , Carcinoma Papilar/patologia , Ductos Pancreáticos/patologia , Neoplasias Pancreáticas/patologia , Lesões Pré-Cancerosas/patologia , Fatores de Transcrição SOX9/metabolismo , Adenocarcinoma Mucinoso/metabolismo , Idoso , Biomarcadores Tumorais/metabolismo , Carcinoma Ductal Pancreático/metabolismo , Carcinoma Papilar/metabolismo , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Ductos Pancreáticos/metabolismo , Neoplasias Pancreáticas/metabolismo , Lesões Pré-Cancerosas/metabolismo , Prognóstico , Estudos RetrospectivosRESUMO
BACKGROUND: Infectious (INF) and venous thromboembolism (VTE) complication rates are targeted by surgical care improvement project (SCIP) INF and SCIP VTE measures. We analyzed how adherence to SCIP INF and SCIP VTE affects targeted postoperative outcomes (wound complication [WC], deep vein thrombosis, and pulmonary embolism [PE]) using all-payer data. MATERIALS AND METHODS: A retrospective review (2007-2011) was conducted using Healthcare Cost and Utilization Project State Inpatient Database Florida and Medicare's Hospital Compare. The association between SCIP adherence rates and outcomes across 355 included surgical procedures was measured using multilevel mixed-effects linear regression models. RESULTS: One hundred sixty acute care hospitals and 779,922 patients were included. Over 5 y, SCIP INF-1, -2, and -3 adherence improved by 12.5%, 8.0%, and 20.9%, respectively, whereas postoperative WC rate decreased by 14.8%. When controlling for time, SCIP INF-1 adherence was associated with improvement of postoperative WC rates (ß = -0.0044, P = 0.005), whereas SCIP INF-2 adherence was associated with increased WCs (ß = 0.0031, P = 0.018). SCIP VTE-1, -2 adherence improved by 14.6% and 20.2%, respectively, whereas postoperative deep vein thrombosis rate increased by 7.1% and postoperative PE rate increased by 3.7%. SCIP VTE-1 and -2 adherence were both associated with increased postoperative PE when controlling for time (SCIP VTE-1: ß = 0.0019, P < 0.001; SCIP VTE-2: ß = 0.0015, P < 0.001). Readmission analysis found SCIP INF-1 adherence to be associated with improved 30-d WC rates when controlling for patient and hospital characteristics (ß = -0.0021, P = 0.032), whereas SCIP INF-3 adherence was associated with increased 30-d WC rates when controlling for time (ß = 0.0007, P = 0.04). CONCLUSIONS: Only SCIP INF-1 adherence was associated with improved outcomes. The Joint Commission has retired SCIP INF-2, -3, and SCIP VTE-2 and made SCIP INF-1 and VTE-1 reporting optional. Our study supports continued reporting of SCIP INF-1.
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Fidelidade a Diretrizes/tendências , Assistência Perioperatória/normas , Embolia Pulmonar/prevenção & controle , Melhoria de Qualidade/normas , Infecção da Ferida Cirúrgica/prevenção & controle , Trombose Venosa/prevenção & controle , Adulto , Idoso , Feminino , Florida , Seguimentos , Fidelidade a Diretrizes/estatística & dados numéricos , Humanos , Modelos Lineares , Masculino , Medicare/normas , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Assistência Perioperatória/estatística & dados numéricos , Assistência Perioperatória/tendências , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Guias de Prática Clínica como Assunto , Embolia Pulmonar/epidemiologia , Embolia Pulmonar/etiologia , Melhoria de Qualidade/estatística & dados numéricos , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/epidemiologia , Estados Unidos , Trombose Venosa/epidemiologia , Trombose Venosa/etiologiaRESUMO
BACKGROUND AND OBJECTIVES: Epidural analgesia has become the preferred method of pain management for major abdominal surgery. However, the superior form of analgesia for pancreaticoduodenecomy (PD), with regard to non-analgesic outcomes, has been debated. In this study, we compare outcomes of epidural and intravenous analgesia for PD and identify pre-operative factors leading to early epidural discontinuation. METHODS: A retrospective review was performed on 163 patients undergoing PD between 2007 and 2011. We performed regression analyses to measure the predictive success of two groups of analgesia on morbidity and mortality and to identify predictors of epidural failure. RESULTS: Intravenous analgesia alone was given to 14 (9%) patients and 149 patients (91%) received epidural analgesia alone or in conjunction with intravenous analgesia. Morbidity and mortality were not significantly different between the two groups. Early epidural discontinuation was necessary in 22 patients (15%). Those older than 72 and with a BMI < 20 (n = 5) had their epidural discontinued in 80% of cases compared to 12% not meeting these criteria. However, early epidural discontinuation was not associated with increased morbidity and mortality. CONCLUSION: Epidural analgesia may be contraindicated in elderly, underweight patients undergoing PD given their increased risk of epidural-induced hypotension or malfunction.
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Analgesia Epidural/efeitos adversos , Hipotensão/etiologia , Dor Pós-Operatória/tratamento farmacológico , Neoplasias Pancreáticas/complicações , Pancreaticoduodenectomia/efeitos adversos , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Hipotensão/mortalidade , Masculino , Pessoa de Meia-Idade , Manejo da Dor , Dor Pós-Operatória/etiologia , Dor Pós-Operatória/mortalidade , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/cirurgia , Pancreaticoduodenectomia/mortalidade , Prognóstico , Estudos Prospectivos , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
For patients with locoregionally confined pancreatic ductal adenocarcinoma (PDAC), margin-negative surgical resection is the only known curative treatment; however, the majority of patients are not operable candidates at initial diagnosis. Among patients with resectable disease who undergo surgery alone, the 5-year survival remains poor. Adjuvant therapies, including systemic therapy or chemoradiation, are utilized as they improve locoregional control and overall survival. There has been increasing interest in the use of neoadjuvant therapy to obtain early control of occult metastatic disease, allow local tumor response to facilitate margin-negative resection, and provide a test of time and biology to assist with the selection of candidates most likely to benefit from radical surgical resection. However, limited guidance exists regarding the relative effectiveness of treatment options. In this systematic review, the American Radium Society multidisciplinary gastrointestinal expert panel convened to develop Appropriate Use Criteria evaluating the evidence regarding neoadjuvant treatment for patients with PDAC, including surgery, systemic therapy, and radiotherapy, in terms of oncologic outcomes and quality of life. The evidence was assessed using the Population, Intervention, Comparator, Outcome, and Study (PICOS) design framework and "Preferred Reporting Items for Systematic Reviews and Meta-analyses" 2020 methodology. Eligible studies included phases 2 to 3 trials, meta-analyses, and retrospective analyses published between January 1, 2012 and December 30, 2022 in the Ovid Medline database. A summary of recommendations based on the available literature is outlined to guide practitioners in the management of patients with PDAC.
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Terapia Neoadjuvante , Neoplasias Pancreáticas , Humanos , Neoplasias Pancreáticas/terapia , Neoplasias Pancreáticas/patologia , Adenocarcinoma/terapia , Adenocarcinoma/patologia , Carcinoma Ductal Pancreático/terapia , Carcinoma Ductal Pancreático/patologia , Guias de Prática Clínica como Assunto , Estados UnidosRESUMO
For patients with rectal cancer, the standard approach of chemotherapy, radiation therapy, and surgery (trimodality therapy) is associated with significant long-term toxicity and/or colostomy for most patients. Patient options focused on quality of life (QOL) have dramatically improved, but there remains limited guidance regarding comparative effectiveness. This systematic review and associated guidelines evaluate how various treatment strategies compare to each other in terms of oncologic outcomes and QOL. Cochrane and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology were used to search for prospective and retrospective trials and meta-analyses of adequate quality within the Ovid Medline database between January 1, 2012, and June 15, 2023. These studies informed the expert panel, which rated the appropriateness of various treatments in 6 clinical scenarios through a well-established consensus methodology (modified Delphi). The search process yielded 197 articles that advised voting. Increasing data have shown that nonoperative management (NOM) and primary surgery result in QOL benefits noted over trimodality therapy without detriment to oncologic outcomes. For patients with rectal cancer for whom total mesorectal excision would result in permanent colostomy or inadequate bowel continence, NOM was strongly recommended as usually appropriate. Restaging with tumor response assessment approximately 8 to 12 weeks after completion of radiation therapy/chemoradiation therapy was deemed a necessary component of NOM. The panel recommended active surveillance in the setting of a near-complete or complete response. In the setting of NOM, 54 to 56 Gy in 27 to 31 fractions concurrent with chemotherapy and followed by consolidation chemotherapy was recommended. The panel strongly recommends primary surgery as usually appropriate for a T3N0 high rectal tumor for which low anterior resection and adequate bowel function is possible, with adjuvant chemotherapy considered if N+. Recent data support NOM and primary surgery as important options that should be offered to eligible patients. Considering the complexity of multidisciplinary management, patients should be discussed in a multidisciplinary setting, and therapy should be tailored to individual patient goals/values.
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BACKGROUND: Eighty percent of patients with resected pancreatic ductal carcinoma (PDC) experience treatment failure within 2 years. We hypothesized that preoperative fixed-dose rate (FDR) gemcitabine (GEM) combined with the angiogenesis inhibitor bevacizumab (BEV) and accelerated 30 Gy radiotherapy (RT) would improve outcomes among patients with potentially resectable PDC. METHODS: This phase II trial tested induction FDR GEM (1,500 mg/m(2)) plus BEV (10 mg/kg IV) every 2 weeks for three cycles followed by accelerated RT (30 Gy in 10 fractions) plus BEV directed at gross tumor volume plus a 1-2 cm vascular margin. Subjects underwent laparoscopy and resection after day 85. Therapy was considered effective if the complete pathologic response rate exceeded 10 % and the margin-negative resection rate exceeded 80%. RESULTS: Fifty-nine subjects were enrolled; 29 had potential portal vein involvement. Two grade 4 (3.4%) and 19 grade 3 toxicities (32.8%) occurred. Four subjects manifested radiographic progression, and 10 had undetected carcinomatosis. Forty-three pancreatic resections (73%) were performed, including 19 portal vein resections (44%). Margin-negative outcomes were observed in 38 (88%, 95% confidence interval [CI] 75-96), with one complete pathologic response (2.3%; 95% CI 0.1-12). There were seven (6 grade 3; 1 grade 4) wound complications (13%). Median overall survival for the entire cohort was 16.8 months (95% CI 14.9-21.3) and 19.7 months (95% CI 16.5-28.2) after resection. CONCLUSIONS: Induction therapy with FDR GEM and BEV, followed by accelerated BEV/RT to 30 Gy, was well tolerated. Although both effectiveness criteria were achieved, survival outcomes were equivalent to published regimens.
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Adenocarcinoma/terapia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinoma Ductal Pancreático/terapia , Recidiva Local de Neoplasia/terapia , Neoplasias Pancreáticas/terapia , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adulto , Idoso , Anticorpos Monoclonais Humanizados/administração & dosagem , Bevacizumab , Carcinoma Ductal Pancreático/mortalidade , Carcinoma Ductal Pancreático/patologia , Terapia Combinada , Desoxicitidina/administração & dosagem , Desoxicitidina/análogos & derivados , Feminino , Seguimentos , Humanos , Laparoscopia , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/mortalidade , Recidiva Local de Neoplasia/patologia , Estadiamento de Neoplasias , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Cuidados Pré-Operatórios , Prognóstico , Dosagem Radioterapêutica , Indução de Remissão , Taxa de Sobrevida , GencitabinaRESUMO
BACKGROUND: Liver tumors are commonly encountered in oncology. The study aimed to assess the impact of magnetic resonance imaging (MRI)-guided stereotactic body radiation therapy (SBRT) (MRgSBRT) on disease-related outcomes and the toxicity profile. METHODS: Patients who received MRgSBRT from 2019 to 2021 for primary and metastatic liver tumors were included in this analysis. The protocol for treatment simulation included Gadoxetate disodium injection followed by a single-dimensional post-exhale MRI (0.35-T MRI linear accelerator) and computed tomography simulation. The patient demographics and treatment-related outcomes were assessed. The time-to-event curves were analyzed for freedom from local progression (FFLP) and overall survival (OS). RESULTS: A total of 35 patients were eligible for analysis with a median age of 70 years (range 25 to 95). The median follow-up was 19.4 months (range 1 to 37 mo). The one-year OS was 77.7%, with an estimated 3 years of 47.9%. Patients with the locally controlled disease had a better median OS of 27.8 months (95% CI [23.8-31.6]) compared with 13.5 months (95% CI [5.6-21.3], P =0.007) in patients with local disease progression. The 1-year FFLP was 95.6%, and 3-year estimated FFLP was 87.1%. Patients who received a radiation dose of biologically equivalent dose≥100 Gy had FFLP of 30.9 months (95% CI [28.7-33.1]) compared with 13.3 months (95% CI [5.3-21.3], P =0.004) in patients who received <100 Gy biologically equivalent dose. CONCLUSION: MRI-guided SBRT provides optimal local control, associated with improved OS in a heavily morbid, pretreated older cohort of patients with reasonable safety profiles.
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Neoplasias Hepáticas , Radiocirurgia , Humanos , Adulto , Pessoa de Meia-Idade , Idoso , Idoso de 80 Anos ou mais , Radiocirurgia/métodos , Neoplasias Hepáticas/diagnóstico por imagem , Neoplasias Hepáticas/radioterapia , Neoplasias Hepáticas/secundário , Resultado do Tratamento , Tomografia Computadorizada por Raios X , Imageamento por Ressonância MagnéticaRESUMO
BACKGROUND: Inclusion of pancreaticoduodenectomy has demonstrated higher rates of curative treatment in pancreatic cancer, yet prior research has suggested increased postoperative complications in octogenarians (patients older than 80 years). This study aimed to understand the impact of age on patients undergoing a pancreaticoduodenectomy, focusing on postoperative outcomes and return to intended oncologic treatment. MATERIALS AND METHODS: We conducted a single-institution retrospective cohort study for patients undergoing pancreaticoduodenectomy from 2007 to 2018. Collected data included demographics, preoperative comorbidities, and postoperative data (length of stay, 30-day mortality, 1-year mortality, infection, discharge location). Data were separated into 2 cohorts: octogenarians (≥ 80 years) and nonoctogenarians (< 80). χ2 and independent-sample t tests were used for analysis. RESULTS: A total of 649 patients underwent pancreaticoduodenectomy from 2007 to 2018; 63 (9.7%) were octogenarians. No differences were found in infectious complications (P = .607), 30-day mortality (P = .363), or 1-year mortality (P = .895). Octogenarians had a longer length of stay (P = .003) and were more likely to be discharged to skilled nursing facilities (P < .001). There was no significant difference in neoadjuvant chemotherapy administration, although octogenarians were less likely to receive adjuvant chemotherapy (P = .048) and declined adjuvant therapy at a higher rate (P = .003). CONCLUSION: Performing a pancreaticoduodenectomy in octogenarians can be safe and effective in a properly selected cohort. Although postoperative morbidity and mortality are similar to younger patients, elderly patients are more likely to be discharged to nursing facilities and less likely to receive adjuvant chemotherapy. This study suggests that age alone should not be a discriminating factor when discussing surgical therapy for pancreatic cancer treatment in octogenarians.
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BACKGROUND: Pancreatic neuroendocrine tumors are rare, with rising incidence and limited clinicopathological studies. METHODS: Adult patients with pNET at a single tertiary care center were retrospectively evaluated. RESULTS: In total, 87 patients with histologically confirmed pNET who underwent resection were evaluated. 11% of patients had functioning pNETs: 9 insulinoma and 1 VIPoma. The majority (88.5%) were nonfunctioning. The most common surgical procedure performed was distal pancreatectomy with splenectomy (36.8%). 35.6% of cases were performed with minimally invasive surgery (MIS). MIS patients had fewer postoperative complications, shorter length of stay, and fewer ICU admissions.Disease-free survival (DFS) was unaffected by tumor size (p = 0.5) or lymph node status (p = 0.62). Patients with high-grade (G3) tumors experienced significantly shorter DFS (p = 0.02). CONCLUSIONS: This series demonstrates that survival in patients with pNET is driven mostly by tumor grade, though overall most have long-term survival after surgical resection. Additionally, an MIS approach is efficacious in appropriately selected cases.
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Tumores Neuroendócrinos/mortalidade , Tumores Neuroendócrinos/cirurgia , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/cirurgia , Complicações Pós-Operatórias/epidemiologia , Adulto , Idoso , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos , Tumores Neuroendócrinos/patologia , Pancreatectomia , Neoplasias Pancreáticas/patologia , Estudos Retrospectivos , Esplenectomia , Análise de Sobrevida , Taxa de Sobrevida , Resultado do TratamentoRESUMO
INTRODUCTION: Medical schools and surgical programs have implemented a "boot camp" to assist medical students' transition into surgical interns and help them contend with a deluge of new responsibilities. This study aims to determine what faculty, residents, and medical students identify as the most critical topics for a surgical boot camp curriculum. METHODS: Forty-five-question survey was developed through an iterative review with multiple surgical colleagues in conjunction with the American College of Surgeons/Association of Program Directors/the Association of Surgical Education resident prep curricular modules. The questions were grouped into 3 broad categories, which included technical skills, practical knowledge, and clinical knowledge. Data were analyzed by a chi-squared test for proportions and continuous variables were compared using t test or ANOVA tests, when appropriate. RESULTS: There was a total of 62 participants, 19 (31%) were attending surgeons, 28 (45%) were general surgery residents, and 15 (24%) were fourth-year medical students (MS4). The response rate for attendings was 45%, residents was 72%, and fourth-year medical students was 43%. Practical knowledge was the most important skill by all participants, followed by clinical knowledge and technical skills (mean score 4.4 vs 3.9 vs 3.2, p < 0.001). The top 5 most important practical knowledge skills to have according to all participants included: how to communicate with senior residents/attendings/nurses, how to use the electronic medical record, how to perform effective handoffs, and how to write orders. CONCLUSIONS: Our study demonstrates that communication skills are the most important according to attendings, residents, and medical students. This study has implications for prioritizing the curricular components of an often tightly scheduled surgical boot camp.
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Cirurgia Geral , Internato e Residência , Competência Clínica , Comunicação , Currículo , Educação de Pós-Graduação em Medicina , Cirurgia Geral/educação , Humanos , Avaliação das NecessidadesRESUMO
INTRODUCTION: Few studies examine the impact of ethnicity on post-operative outcomes and costs associated with pancreaticoduodenectomy (PD). METHODS: Multivariable regression (MVR) was used to perform a risk-adjusted comparison of patients within the Healthcare Cost and Utilization Project Databases undergoing PD. RESULTS: 4742 patients underwent PD. 3871 (81%) were white, 456 (10%) black, and 415 (9%) Hispanic. Black and Hispanics were less likely than whites to undergo PD in high volume centers. Blacks and Hispanics had a higher risk of select post-operative complications, prolonged lengths of stay, and high-cost outliers. When PDs done in high volume centers were evaluated separately, blacks and Hispanics had a lower adjusted-risk of any serious morbidity (OR 0.44, 95% CI [0.33, 0.57], OR 0.56, 95% CI [0.43, 0.73]) than whites but costs for PD among the three ethnic groups were statistically identical. CONCLUSION: Racial and ethnic minorities undergoing PD are less likely to receive care at high-volume centers, are at an increased risk of post-operative morbidity, and have higher odds of being high-cost outliers than NHW.
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Disparidades em Assistência à Saúde/estatística & dados numéricos , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Grupos Minoritários/estatística & dados numéricos , Pancreaticoduodenectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Negro ou Afro-Americano/estatística & dados numéricos , Idoso , Feminino , Disparidades em Assistência à Saúde/economia , Hispânico ou Latino/estatística & dados numéricos , Custos Hospitalares/estatística & dados numéricos , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pancreaticoduodenectomia/economia , Pancreaticoduodenectomia/estatística & dados numéricos , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etiologia , Estados Unidos/epidemiologia , População Branca/estatística & dados numéricosRESUMO
BACKGROUND: Prior studies comparing the efficacy of laparoscopic (LHR) and open hepatic resection (OHR) have not evaluated inpatient costs. METHODS: We conducted a retrospective cohort study using the Healthcare Cost and Utilization Project State Inpatient Databases to identify patients undergoing hepatic resection between 2010 and 2014. RESULTS: 10,239 patients underwent hepatic resection. 865 (8%) underwent LHR and 9374 (92%) underwent OHR. On adjusting for hospital volume, patients undergoing LHR had a lower risk of respiratory (OR 0.64, 95% CI [0.52, 0.78]), wound (OR 0.48; 95% CI [0.29, 0.79]) and hematologic (OR 0.57; 95% CI [0.44, 0.73]) complication as well as a lower risk of being in the highest quartile of cost (0.58; 95% CI [0.43, 0.77]) than those undergoing OHR. Patients undergoing LHR in very high volume (>314 hepatectomies/year) centers had lower risk-adjusted 90-day aggregate costs of care than those undergoing OHR (-$8022; 95% CI [-$11,732, -$4311). DISCUSSION: Laparoscopic partial hepatectomy is associated with lower risk of postoperative complication than OHR. This translates to lower aggregate costs in very high-volume centers.
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Procedimentos Cirúrgicos Eletivos/economia , Hepatectomia/economia , Hospitais com Alto Volume de Atendimentos , Laparoscopia/economia , Fígado/cirurgia , Controle de Custos , Análise Custo-Benefício , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/estatística & dados numéricos , Feminino , Florida , Custos de Cuidados de Saúde , Doenças Hematológicas/epidemiologia , Hepatectomia/efeitos adversos , Hepatectomia/métodos , Hepatectomia/estatística & dados numéricos , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Humanos , Laparoscopia/efeitos adversos , Laparoscopia/estatística & dados numéricos , Hepatopatias/cirurgia , Masculino , Maryland , Pessoa de Meia-Idade , New York , North Carolina , Razão de Chances , Complicações Pós-Operatórias/epidemiologia , Transtornos Respiratórios/epidemiologia , Estudos Retrospectivos , WashingtonRESUMO
BACKGROUND: Few studies evaluate racial disparities in costs and clinical outcomes for patients undergoing distal pancreatectomy (DP). METHODS: We queried the Healthcare Cost and Utilization Project State Inpatient Databases to identify patients undergoing DP. Multivariable regression (MVR) was used to evaluate the association between race and postoperative outcomes. RESULTS: 2,493 patients underwent DP; 265 (10%) were black, and 221 (8%) were of Hispanic ethnicity. On MVR, black and Hispanic patients were less likely than whites to undergo surgery in high volume centers (OR 0.53, 95% CI [0.40, 0.71]; OR 0.45, 95% CI [0.32, 0.62]). Black patients had a greater risk of postoperative complication (OR 1.40, 95% CI [1.07, 1.83]), 90-day readmission (OR 1.53, 95% CI [1.15, 2.02]), prolonged length of stay (OR 1.74, 95% CI [1.25-2.44]), and of being a high cost outliers (OR 1.40, 95% CI [1.02, 1.91]) compared to white patients. CONCLUSION: Black patients have increased risk of having a postoperative complication, prolonged hospitalization, and of being a high-cost outlier than non-Hispanic whites.
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Negro ou Afro-Americano , Pancreatectomia/economia , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/etnologia , Idoso , Feminino , Humanos , Tempo de Internação/economia , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/economia , Determinantes Sociais da Saúde , Estados UnidosRESUMO
INTRODUCTION: Angiotensin system inhibitors are associated with improved prognosis in patients with gastrointestinal and hepatobiliary cancers. Data suggest that renin-angiotensin system signaling stimulates the tumor's immune microenvironment to impact overall survival. The goal of this study is to investigate the role of angiotensin system inhibitor use on the overall survival and disease-free survival of esophageal cancer patients. METHODS: Retrospective review of esophagectomy patients with esophageal adenocarcinoma and squamous cell cancer at a single institution tertiary care center from 2007 to 2018 was performed. Outcomes include overall survival and disease-free survival. Patient characteristics were compared with t test and χ2 test. Survival was analyzed with Kaplan-Meier and Cox proportional-hazards regression. RESULTS: One hundred seventy-one patients were identified and 123 underwent esophagectomy for cancer. No significant differences in patient demographics were found between angiotensin system inhibitor users and non-angiotensin system inhibitor users except for the rates of hypertension (40% vs 94%, Pâ¯<â¯.01) and diabetes (16% vs 47%, Pâ¯<â¯.01). Distributions of tumor neoadjuvant therapy, adjuvant therapy, pathology, staging, margins, and surgical approach were similar. Postoperatively, there was no difference in major adverse cardiovascular events or infection rates. This study did not find any differences in overall survival and disease-free survival between angiotensin system inhibitor users and non-angiotensin system inhibitor users. CONCLUSION: Angiotensin system inhibitors have been shown to improve survival and decrease relative risk for several types of cancers; however, our data do not support the same effect on esophageal cancer patients undergoing curative intent surgery. Further research is needed to investigate potential nuances in angiotensin system inhibitor dose, chronicity of use, esophageal pathology, and applicability to nonsurgical candidates.
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BACKGROUND: Pancreaticoduodenectomy remains the mainstay of surgical treatment of malignant periampullary disorders. Postoperative morbidity rates are driven by postoperative pancreatic fistula. Although most can be managed conservatively or with percutaneous techniques, complex fistulas including gastroenteric leakage frequently require operative reexploration. Endoscopic therapies in this setting offer an opportunity to avoid invasive reoperation. CASE REPORT: We present the case of a 67-year-old male individual who developed a complex intra-abdominal abscess after pancreaticoduodenectomy with confirmed pancreaticojejunal disruption, gastric staple line dehiscence, and enterocutaneous fistula. Five endoscopic sessions utilizing advanced techniques over a period of 60 days led to complete healing of the patient's external fistula, resolution of complex abdominal abscess, creation of functional communication between the gastric staple line disruption and the afferent jejunum, and return of normal gastrointestinal function. Baseline functional and dietary status was restored without gastrointestinal symptoms or necessity for supplemental tube feedings.
Assuntos
Fístula Anastomótica/cirurgia , Neoplasias Duodenais/cirurgia , Endoscopia , Fístula Intestinal/cirurgia , Pancreaticoduodenectomia/efeitos adversos , Deiscência da Ferida Operatória/cirurgia , Idoso , Fístula Anastomótica/diagnóstico , Fístula Anastomótica/etiologia , Neoplasias Duodenais/patologia , Humanos , Fístula Intestinal/diagnóstico , Fístula Intestinal/etiologia , Masculino , Deiscência da Ferida Operatória/diagnóstico , Deiscência da Ferida Operatória/etiologiaRESUMO
BACKGROUND: The utility of adjuvant systemic therapy in small bowel gastrointestinal stromal tumor remains unclear. METHODS: We queried the National Cancer Data Base for individuals having enterectomy to negative margins for small bowel gastrointestinal stromal tumor between 2010 and 2015. Subjects were categorized by tumor size (2.1-5 cm, 5.1-10 cm, >10 cm) and histologic grade (≤5 mitoses/50 high-power field and >5 mitoses/50 high-power field). Cox proportional hazard analysis was performed to evaluate the association between adjuvant therapy and overall survival. RESULTS: One thousand five hundred fifty-nine patients met the inclusion criteria. On univariate comparison to resection alone, adjuvant therapy was associated with improved overall survival for individuals with high-grade tumors of intermediate and large size (85% vs 48%, P = .010; 75% vs 47%, P = .003) but not for those with high-grade tumors of small size or low-grade tumors of any size. On multivariable analysis adjusted for age, comorbid disease state, and tumor size, adjuvant therapy was independently associated with reduced risk of mortality for high-grade (hazard ratio 0.37, 95% confidence interval: 0.21-0.64) but not low-grade tumors. CONCLUSION: Adjuvant therapy after R0 resection for small bowel gastrointestinal stromal tumor should be administered after careful consideration of the size and grade of a patient's tumor.
Assuntos
Antineoplásicos/uso terapêutico , Tumores do Estroma Gastrointestinal/tratamento farmacológico , Tumores do Estroma Gastrointestinal/cirurgia , Mesilato de Imatinib/uso terapêutico , Neoplasias Intestinais/tratamento farmacológico , Neoplasias Intestinais/cirurgia , Intestino Delgado/cirurgia , Idoso , Quimioterapia Adjuvante , Feminino , Tumores do Estroma Gastrointestinal/patologia , Humanos , Neoplasias Intestinais/patologia , Intestino Delgado/patologia , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Modelos de Riscos Proporcionais , Estudos RetrospectivosRESUMO
BACKGROUND: The value of adjuvant systemic therapy after margin-negative resection for gastric gastrointestinal stromal tumors (GISTs) remains unclear. METHODS: The National Cancer Data Base was queried to identify patients undergoing margin negative resections for gastric GISTs >2â¯cm between 2010 and 2015. Patients were stratified by tumor size (small: 2.1-5â¯cm, intermediate: 5.1-10â¯cm, large: >10â¯cm), histologic grade (low: ≤5 mitoses/50 HPF and high: >5 mitoses/50 HPF), and use of adjuvant therapy. Multivariable cox proportional hazard methods were used to compare overall survival (OS). RESULTS: 3520 patients met inclusion criteria. Adjuvant therapy was associated with a statistical improvement in OS (86% vs. 76%, pâ¯=â¯0.014) for those with large tumors but had no measurable effect in patients with small or intermediate sized tumors. On multivariable analysis, this association was independent of grade. CONCLUSIONS: Adjuvant therapy is associated with improved OS for patients with gastric GISTs >10â¯cm but provides no statistically significant benefit in OS for those with GISTs 2-10â¯cm.
Assuntos
Quimioterapia Adjuvante , Tumores do Estroma Gastrointestinal/tratamento farmacológico , Tumores do Estroma Gastrointestinal/cirurgia , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Feminino , Tumores do Estroma Gastrointestinal/mortalidade , Humanos , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Gradação de Tumores , Análise de Sobrevida , Carga TumoralRESUMO
BACKGROUND: Prior studies of adjuvant systemic therapy in pancreatic acinar cell carcinoma have been underpowered. METHODS: We queried the National Cancer Data Base to identify patients presenting with resectable (clinical stage I and II) acinar cell carcinoma between 2004 and 2015. Multivariable Cox Regression was used to evaluate the association between overall survival and systemic therapy. RESULTS: 298 patients met inclusion criteria: 38 received no treatment; 60 received systemic therapy alone; 84 received surgical resection alone; 116 underwent resection followed by adjuvant systemic therapy. On univariate analysis, resection was associated with a survival benefit compared to no treatment and systemic therapy alone (3-year overall survival: 57% vs. 26%, pâ¯<â¯0.001). On Cox analysis, use of adjuvant therapy was associated with a survival benefit compared to resection alone (HR 0.54, 95% CI: 0.33-0.89). CONCLUSIONS: Adjuvant therapy is associated with a significant survival benefit in patients with resectable acinar cell carcinoma.
Assuntos
Carcinoma de Células Acinares/cirurgia , Quimioterapia Adjuvante , Neoplasias Pancreáticas/cirurgia , Idoso , Carcinoma de Células Acinares/tratamento farmacológico , Carcinoma de Células Acinares/mortalidade , Feminino , Humanos , Metástase Linfática , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Pancreatectomia , Neoplasias Pancreáticas/tratamento farmacológico , Neoplasias Pancreáticas/mortalidade , Taxa de Sobrevida , Neoplasias PancreáticasRESUMO
BACKGROUND: The potential benefit of surgical resection of intrahepatic cholangiocarcinoma in patients with locoregionally advanced disease has not been definitively determined. METHODS: The National Cancer Database was queried to identify patients with clinical evidence of node-positive intrahepatic cholangiocarcinoma. Resected patients were stratified by margin status and lymph node ratio (nodes positive to nodes harvested). Risk of death was determined using Cox regression models and Kaplan-Meier survival functions. RESULTS: A total of 1,425 patients with T(any)N1M0 intrahepatic cholangiocarcinoma were identified. Two hundred twelve (14.9%) underwent surgical resection. On multivariable Cox regression, R0 resection afforded a survival benefit regardless of lymph node ratio (lymph node ratio > 0.5: hazard ratio 0.466, 95% confidence interval 0.304-0.715; lymph node ratio ≤ 0.5: hazard ratio 0.444, 95% confidence interval 0.322-0.611), whereas a survival benefit was only seen in R1 patients with lymph node ratio ≤ 0.5 (hazard ratio 0.470, 95% confidence interval 0.316-0.701). On Kaplan-Meier, median survival was 11.6 months with chemotherapy, 15.7 months with R0 resection in lymph node ratio > 0.5, and 22.2 months with R0 resection in lymph node ratio ≤ 0.5 (P < .001). DISCUSSION: Margin negative resection is associated with a risk-adjusted survival benefit for patients with clinically N1 intrahepatic cholangiocarcinoma regardless of the degree of regional lymph node involvement.