Utilization of Neoadjuvant Therapy in Gastrointestinal Stromal Tumors of the Stomach: Analysis of the 2006-2018 National Cancer Database.

BACKGROUND: Neoadjuvant tyrosine kinase inhibitor (TKI) therapy has reduced tumor burden and improved survival in both primary and recurrent gastrointestinal stromal tumors (GISTs). However, no clear guidelines exist on optimal patient selection for neoadjuvant therapy (NAT). Our aim was to analyze factors and outcomes associated with the therapeutic sequence of TKI therapy before and/or after surgery for gastric GISTs. METHODS: We performed a retrospective study of patients surgically treated for a gastric GIST utilizing the 2006-2018 National Cancer Database. We examined demographic, clinical, and pathological characteristics associated with NAT versus adjuvant therapy (AT) using logistic regression. RESULTS: Of the 3732 patients, 20.4% received NAT and 79.6% had AT. Among patients receiving therapy, NAT significantly increased over our study period (12% to 30.7%). A majority of the AT group received a partial gastrectomy (77.9%) compared with the NAT group who received more near-total/total gastrectomy or gastrectomy with en bloc resection (p < 0.001). In a multivariable model, patients were more likely to receive NAT when insured (private, aOR: 2.37, 95% CI: 1.31-4.29), treated at an academic/research program (aOR: 1.83, 95% CI: 1.49-2.56), had tumors located in the proximal stomach (aOR: 1.40, 95% CI: 1.06-1.86), tumor size > 10 cm (aOR: 1.88, 95% CI: 1.41-2.51), and received near-total/total gastrectomy (aOR: 1.81, 95% CI: 1.42-2.29). There were no differences in outcomes. CONCLUSION: NAT for gastric GIST has increased in utilization. NAT was used in patients with larger tumors and who underwent more extensive resection. Despite these factors, outcomes were similar to patients receiving only AT. More studies are required to determine the therapeutic sequence for gastric GISTs.

Single lumen endotracheal intubation with carbon dioxide insufflation for lung isolation in thoracic surgery.

INTRODUCTION: Double lumen tube (DLT) intubation is used for lung isolation but is not without disadvantages including increased intubation time, anesthesia expertise, risk of airway trauma, and costs over single lumen tube (SLT) intubation. SLT intubation with CO2 insufflation can be used as an alternative for lung isolation. We reviewed our experience with this technique during thoracoscopic surgery. METHODS: We performed a retrospective review of a prospectively maintained IRB-approved database from 2009 to 2018. Operations were performed with CO2 insufflation up to 15 mmHg. Indications for surgery, operative details, intraoperative complications, pathology, and postoperative complications were reviewed. RESULTS: We identified 123 patients (70 females [57%]) with a median age of 40 years (range 16-80 years) and a median BMI of 26.2 kg/m2 (range 15-59 kg/m2) that underwent minimally invasive thoracoscopic procedures with this technique. Procedures included: mediastinal mass resection or biopsy (41%), sympathectomy (37%), wedge resection (10%), first rib resection (6%), diaphragm plication (2%), segmentectomy (2%), decortication (2%), pleural biopsy (2%), and pericardial cyst resection (1%). Median operative time was 90 min (range 25-584 min) and median intraoperative blood loss was 10 mL (range 2-200 mL). Intraoperative hemodynamic parameters were obtained at procedure start, 1 h after CO2 insufflation, and at procedure completion: we observed significant changes in heart rate and systolic blood pressure (P = 0.027 and P < 0.001, respectively) although clinically inconsequential. Mean end-tidal CO2 1 h after insufflation was 36.6 ± 4.5 mmHg. There were no intraoperative complications and no conversions to a DLT. Median length of stay was 1 day (range 0-14 days). Five complications (4%) were observed and no mortalities. CONCLUSIONS: SLT intubation and CO2 insufflation is a feasible and safe alternative to DLT intubation for lung isolation. This can be a useful strategy to accomplish lung isolation for some thoracoscopic procedures, in particular when expertise for DLT placement is unavailable.