Advancing minimally invasive hepato-pancreato-biliary surgery: barriers to adoption and equitable access.

BACKGROUND: Despite a growing body of literature supporting the safety of robotic hepatopancreatobiliary (HPB) procedures, the adoption of minimally invasive techniques in HPB surgery has been slow compared to other specialties. We aimed to identify barriers to implementing robotic assisted surgery (RAS) in HPB and present a framework that highlights opportunities to improve adoption. METHODS: A modified nominal group technique guided by a 13-question framework was utilized. The meeting session was guided by senior authors, and field notes were also collected. Results were reviewed and free text responses were analyzed for major themes. A follow-up priority setting survey was distributed to all participants based on meeting results. RESULTS: Twenty three surgeons with varying robotic HPB experience from different practice settings participated in the discussion. The majority of surgeons identified operating room efficiency, having a dedicated operating room team, and the overall hospital culture and openness to innovation as important facilitators of implementing a RAS program. In contrast, cost, capacity building, disparities/risk of regionalization, lack of evidence, and time/effort were identified as the most significant barriers. When asked to prioritize the most important issues to be addressed, participants noted access and availability of the robot as the most important issue, followed by institutional support, cost, quality of supporting evidence, and need for robotic training. CONCLUSIONS: This study reports surgeons' perceptions of major barriers to equitable access and increased implementation of robotic HPB surgery. To overcome such barriers, defining key resources, adopting innovative solutions, and developing better methods of collecting long term data should be the top priorities.

Effect of surgical approach on early return to intended oncologic therapy after resection for pancreatic ductal adenocarcinoma.

BACKGROUND: Although robotic pancreatectomy may facilitate an earlier functional recovery, the impact of a robotic pancreatectomy program during its early experience on the timing of return to intended oncologic therapy (RIOT) after surgery is unknown. METHODS: In this retrospective cohort study, we used propensity score matching with a 1:2 ratio to compare patients who underwent robotic or open surgery (distal pancreatectomy or pancreatoduodenectomy) for pancreatic ductal adenocarcinoma (PDAC) during the first 3 years of our robotic pancreatectomy experience (January 2018-December 2021). Generalized estimating equations modeling was used to evaluate the effect of surgical approach on early RIOT, defined as adjuvant chemotherapy initiation within 8 weeks after surgery, and late RIOT, defined as initiation within 12 weeks after surgery. RESULTS: The matched cohort included 26 patients who underwent robotic pancreatectomy and 52 patients who underwent open pancreatectomy. Rates of receipt of adjuvant chemotherapy were 96.2% and 78.9%, respectively. Rate of early RIOT in the robotic group (73.1% was higher than that in the open group (44.2%; P = 0.018). In multivariable analysis, a robotic approach was associated with early RIOT (odds ratio, 3.54; 95% confidence interval 1.08-11.62; P = 0.038). Surgical approach did not impact late RIOT (odds ratio, 3.21; 95% confidence interval 0.71-14.38; P = 0.128). CONCLUSIONS: Compared with open pancreatectomy, robotic pancreatectomy did not delay RIOT. In fact, odds of early RIOT were increased, which supports the oncological safety of our robotic pancreatectomy program during its implementation.

Advancing minimally invasive hepato-pancreato-biliary surgery: ensuring safety with implementation.

BACKGROUND: Although minimally invasive hepato-pancreato-biliary (MIS HPB) surgery can be performed with good outcomes, there are currently no standardized requirements for centers or surgeons who wish to implement MIS HPB surgery. The aim of this study was to create a consensus statement regarding safe dissemination and implementation of MIS HPB surgical programs. METHODS: Sixteen key questions regarding safety in MIS HPB surgery were generated after a focused literature search and iterative review by three field experts. Participants for the working group were then selected using sequential purposive sampling and snowball techniques. Review of the 16 questions took place over a single 2-h meeting. The senior author facilitated the session, and a modified nominal group technique was used. RESULTS: Twenty three surgeons were in attendance. All participants agreed or strongly agreed that formal guidelines should exist for both institutions and individual surgeons interested in implementing MIS HPB surgery and that routine monitoring and reporting of institutional and surgeon technical outcomes should be performed. Regarding volume cutoffs, most participants (91%) agreed or strongly agreed that a minimum annual institutional volume cutoff for complex MIS HPB surgery, such as major hepatectomy or pancreaticoduodenectomy, should exist. A smaller proportion (74%) agreed or strongly agreed that a minimum annual surgeon volume requirement should exist. The majority of participants agreed or strongly agreed that surgeons were responsible for defining (100%) and enforcing (78%) guidelines to ensure the overall safety of MIS HPB programs. Finally, formal MIS HPB training, minimum case volume requirements, institutional support and infrastructure, and mandatory collection of outcomes data were all recognized as important aspects of safe implementation of MIS HPB surgery. CONCLUSIONS: Safe implementation of MIS HPB surgery requires a thoughtful process that incorporates structured training, sufficient volume and expertise, a proper institutional ecosystem, and monitoring of outcomes.

Cost Analysis for Robotic and Open Gastrectomy.

Objective: To determine the magnitude of the perioperative costs associated with robotic gastrectomy (RG). Background: A robotic surgery platform has a high implementation cost and requires maintenance costs; however, whether the overall cost of RG, including all perioperative costs, is higher than conventional open gastrectomy (OG) remains unknown. Methods: Patients who underwent a major gastrectomy during February 2018 through December 2021 were retrospectively identified. We calculated the perioperative costs of RG and OG and compared them overall as well as in different phases, including intraoperative costs and 30-day postsurgery inpatient and outpatient costs. We investigated factors potentially associated with high cost and estimated the likelihood of RG to reduce overall cost under a Bayesian framework. All cost data were converted to ratios to the average cost of all operations performed at our center in year FY2021. Results: We identified 119 patients who underwent gastrectomy. The incidence of postoperative complications (Clavien-Dindo >IIIa; RG, 10% vs OG, 13%) did not significantly differ between approaches. The median length of stay was 3 days shorter for RG versus OG (4 vs 7 days, P < 0.001). Intraoperative cost ratios were significantly higher for RG (RG, 2.6 vs OG, 1.7; P < 0.001). However, postoperative hospitalization cost ratios were significantly lower for RG (RG, 2.8 vs OG, 3.9; P < 0.001). Total perioperative cost ratios were similar between groups (RG, 6.1 vs OG, 6.4; P = 0.534). The multiple Bayesian generalized linear analysis showed RG had 76.5% posterior probability of overall perioperative cost reduction (adjusted risk ratio of 0.95; 95% credible interval, 0.85-1.07). Conclusions: Despite increased intraoperative costs, total perioperative costs in the RG group were similar to those in the OG group because of reduced postoperative hospitalization costs.

High symptom burden in patients undergoing gastrectomy for cancer.

BACKGROUND: There is little data describing symptom burden before or after gastrectomy for patients with cancer. We aimed to examine the perioperative patterns of symptom severity in patients undergoing gastrectomy. METHODS: In this single-institution prospective cohort study, patients scheduled to undergo gastrectomy for cancer completed serial symptom measurement questionnaires preoperatively, at postoperative day (POD) 1-3, and POD 4-7. The percent of patients with moderate to severe scores was calculated at each time point. RESULTS: Thirty-nine patients completed 94 surveys. Preoperatively, 46% reported at least one moderate/severe symptom. This increased to 88% during POD 1-3 and 79% during POD 4-7. During the preoperative period, 25% of patients reported moderate to severe interference in at least one aspect of daily life. This increased to 73% of patients at both POD 1-3 and POD 4-7. CONCLUSIONS: Patients undergoing gastrectomy for cancer frequently experience symptoms that interfere with daily life. A better understanding of these symptoms may improve patients' experiences with, and recovery from, gastrectomy.

Gender Disparities in Presentations at the Society of Surgical Oncology (SSO) Meetings From 2014 to 2019.

BACKGROUND: Participation in surgical society meetings serves as a proxy for academic success and is important for career development. This study aimed to investigate and report the gender breakdown of presenters at recent Society of Surgical Oncology (SSO) meetings. METHODS: Genders of presenters for poster, parallel, plenary, and video sessions at SSO meetings from 2014 through 2019 were collected. These data were broken down to first-last authorship relationships including female-female, female-male, male-female, and male-male. The proportions of female-to-male presenters were compared for each session type. Statistical significance was set at p value lower than 0.05. RESULTS: From 2014 through 2019, the SSO had 2920 presenters, and 47% were female. Women were listed as first authors more often for the poster session (48%) than for other sessions (parallel, plenary, and video) (p = 0.003). Women also were listed more often as senior authors for the poster session (31%) than for other sessions (p = 0.004). Female senior authors were fewer than male senior authors across all session types. Female first authors had the highest representation in breast (75%), endocrine (48%), and cutaneous (46%) specialties (p < 0.001). The most common combination of first and senior authors was male-male (43%), followed by female-male (28%), female-female (19%), and male-female (10%). CONCLUSION: Overall, female presentation at SSO is comparable with society demographics, and female first authorship is relatively equal to male first authorship in poster sessions. Whereas female first authorship improved over time, female senior authorship remained relatively flat. Opportunities to improve gender equality in senior authorship positions should be explored.

The Effect of Facility Volume on Survival Following Proctectomy for Rectal Cancer.

BACKGROUND: Prior studies assessing colorectal cancer survival have reported better outcomes when operations are performed at high-volume centers. These studies have largely been cross-sectional, making it difficult to interpret their estimates. We aimed to assess the effect of facility volume on survival following proctectomy for rectal cancer. METHODS: Using data from the National Cancer Database, we included all patients with complete baseline information who underwent proctectomy for non-metastatic rectal cancer between 2004 and 2016. Facility volume was defined as the number of rectal cancer cases managed at the treating center in the calendar year prior to the patient's surgery. Overall survival estimates were obtained for facility volumes ranging from 10 to 100 cases/year. Follow-up began on the day of surgery and continued until loss to follow-up or death. RESULTS: A total of 52,822 patients were eligible. Patients operated on at hospitals with volumes of 10, 30, and 50 cases/year had similar distributions of grade, clinical stage, and neoadjuvant therapies. 1-, 3-, and 5-year survival all improved with increasing facility volume. One-year survival was 94.0% (95% CI: 93.7, 94.3) for hospitals that performed 10 cases/year, 94.5% (95% CI: 94.2, 94.7) for 30 cases/year, and 94.8% (95% CI: 94.5, 95.0) for 50 cases/year. Five-year survival was 68.9% (95% CI: 68.0, 69.7) for hospitals that performed 10 cases/year, 70.8% (95% CI: 70.1, 71.5) for 30 cases/year, and 72.0% (95% CI: 71.2, 72.8) for 50 cases/year. CONCLUSIONS: Treatment at a higher volume facility results in improved survival following proctectomy for rectal cancer, though the small benefits are less profound than previously reported.

Barriers to Evidence-Based Colorectal Cancer Care in Ukraine.

BACKGROUND: The incidence of colorectal cancer (CRC) is increasing in many low- to middle-income countries, including Ukraine. Ukraine reports high mortality rates in CRC patients. To identify potential areas for targeted interventions to improve CRC care in Ukraine, we investigated Ukrainian clinician perspectives on evidence-based CRC treatment guidelines. METHODS: An explanatory sequential mixed-methods study design was used. A survey was administered to attendees of a regional surgical conference. Semi-structured interviews were subsequently performed with practicing clinicians in Ukraine. Interviews were coded to identify prominent themes. RESULTS: Quantitative: 105 clinicians completed the survey. 76% of respondents reported using guidelines in daily practice. Lack of English proficiency was cited by 28.6% of respondents as a barrier to guideline use. Improved knowledge and additional financial resources were reported as factors that would be helpful in providing evidence-based care. QUANTITATIVE: 15 clinicians were interviewed. Two major themes were identified: limitations in access to the medical literature resources (language barriers and financial barriers), and sense of clinician initiative and willingness to learn despite hardships. CONCLUSIONS: Clinicians in Ukraine have positive perspectives on utilization of evidence-based CRC treatment guidelines. However, they face major barriers in accessing resources needed to keep up-to-date on the current literature. Fortunately, there exists both willingness and initiative on the clinician level to pursue continuing education. Efforts should be made on the international society level to improve open-access and foreign language translation availability to support physicians in Ukraine and other low- to middle-income countries.

Surgical Management of Small Bowel Lymphoma.

BACKGROUND: Primary small bowel non-Hodgkin's lymphoma is a rare disease representing 2% of small intestine malignancies. There is limited data delineating the optimal treatment for these heterogeneous tumors. We aim to examine relationships between different treatment modalities and surgical outcomes in patients with small bowel lymphoma. MATERIALS AND METHODS: Patients diagnosed with stage I-III small bowel lymphoma in 2004-2015 who underwent surgery were identified in the National Cancer Database. Two cohorts were created based on systemic chemotherapy treatment status. The primary outcome was overall survival. An adjusted Cox proportional hazards model was used to evaluate the impact of treatment strategy on survival. RESULTS: 2283 patients met inclusion criteria Of these patients, 826 patients (36%) underwent surgical resection alone, and 1457 patients (64%) underwent resection with systemic chemotherapy. Chemotherapy was associated with improved overall survival in unadjusted (5-year overall survival, 55% versus 70%) and adjusted analysis (HR 0.54, 95% CI 0.47-0.63, p < 0.001). DISCUSSION: Patients with small bowel lymphoma have a low five-year overall survival after surgery. Chemotherapy is associated with improved survival, although one third of patients do not receive this therapy. Several other clinical factors are identified that are also associated with overall survival, including histology subtype, margin status, age, and medical comorbidities. This information can help with prognostication and potentially aid in treatment decision-making.

Racial Disparities in Treatment for Rectal Cancer at Minority-Serving Hospitals.

BACKGROUND: Racial disparities exist in patients with rectal cancer with respect to both treatment and survival. Minority-serving hospitals (MSHs) provide healthcare to a disproportionately large percent of minority patients in the USA. We examined the effects of rectal cancer treatment at MSH to understand drivers of these disparities. METHODS: The NCDB was queried (2004-2015), and patients diagnosed with stage II or III rectal adenocarcinoma were identified. Racial case mix distribution was calculated at the institutional level, and MSHs were defined as those within the top decile of Black and Hispanic patients. Logistic regression was used to identify predictors of receipt of standard of care treatment. Survival was assessed using the Kaplan-Meier method, and Cox proportional hazards models were used to evaluate adjusted risk of death. Analyses were clustered by facility. RESULTS: A total of 68,842 patients met the inclusion criteria. Of these patients, 63,242 (91.9%) were treated at non-MSH, and 5600 (8.1%) were treated at MSH. In multivariable analysis, treatment at MSH (OR 0.70 95%CI 0.61-0.80 p < 0.001) and Black race (OR 0.75 95%CI 0.70-0.81 p < 0.001) were associated with significantly lower odds of receiving standard of care. In adjusted analysis, Black patients had a significantly higher risk of mortality (HR 1.20 95%CI 1.14-1.26 p < 0.001). CONCLUSIONS: Treatment at MSH institutions and Black race were associated with significantly decreased odds of receipt of recommended standard therapy for locally advanced rectal adenocarcinoma. Survival was worse for Black patients compared to White patients despite adjustment for receipt of standard of care.

Lymph Node Positivity in T1/T2 Rectal Cancer: a Word of Caution in an Era of Increased Incidence and Changing Biology for Rectal Cancer.

BACKGROUND: The evaluation of lymph nodes in rectal cancer dictates treatment. The goals of this study are to characterize the contemporary rate of lymph node metastasis in early stage rectal cancer and to re-investigate histologic factors that predict positive lymph nodes. MATERIALS AND METHODS: Using the National Cancer Database, we identified patients with clinical stage I rectal adenocarcinoma. Multivariable logistic regression was used to determine risk factors for lymph node positivity. RESULTS: 12.2% of patients with T1 tumors and 18.0% of patients with T2 tumors had positive lymph nodes. For T1 tumors, positive lymph nodes were present in 9.3% with neither poor differentiation nor lymphovascular invasion (LVI), 17.3% with poor differentiation alone, 34.7% with LVI alone, and 45.0% with both poor differentiation and LVI. For T2 tumors, positive lymph nodes were present in 11.7% with neither poor differentiation nor LVI, 25.3% with poor differentiation alone, 47.3% with LVI alone, and 41.5% with both poor differentiation and LVI. LVI was an independent predictor of positive lymph nodes (OR;4.75,95%CI;3.17-7.11,p < 0.001) for T1 and (OR;6.20,95%CI;4.53-8.51,p < 0.001) T2 tumors. CONCLUSIONS: T1/T2 tumors have higher rates of positive lymph nodes when poor differentiation and LVI are present. These results should be taken into consideration prior to surgical treatment.

The Current Landscape of Staging and Treatment of Colorectal Cancer in a Region of Ukraine: a Mixed Methods Study.

BACKGROUND: In Ukraine, the 1-year mortality for colorectal cancer is much higher than that seen in high-income countries. We investigated practice patterns of colorectal cancer treatment in a region of Ukraine to account for high mortality rates. METHODS: An explanatory sequential mixed methods design was used. Data from patients who underwent surgery for colorectal cancer in Ivano-Frankivsk from 2011 to 2015 were collected via retrospective chart review, and descriptive statistics were calculated. Semi-structured interviews were performed with local practicing surgeons and oncologists until thematic saturation was reached. RESULTS: A total of 960 patients who underwent surgery were identified in the Ivano-Frankivsk region with colon (689) or rectal (271) cancer. 11.7% of patients underwent preoperative CT of the abdomen and pelvis, and only 1.7% underwent CT of the chest. 4.1% of patients underwent a complete preoperative colonoscopy, while 31.0% had incomplete colonoscopies. Postoperatively, 31.1% of patients with stage II colon cancer and 43.9% of patients with stage III colon cancer underwent adjuvant chemotherapy. For patients with stage II and III rectal cancers, 20.9% and 33.3% underwent chemotherapy, while 68.4% and 66.7% underwent radiation therapy, respectively. Fifteen physicians completed interviews. Two major themes emerged regarding physician perceptions on providing colorectal cancer care: lack of resources and systems level issues negatively impacting patient care. CONCLUSION: In this region in Ukraine, staging practices for colorectal malignancies are inconsistent and inadequate, and adjuvant treatments are varied. This is likely attributable to the lack of resources facing providers and the prohibitively high cost of care to patients.

Representation of women in speaking roles at annual surgical society meetings.

BACKGROUND: Women are disproportionately underrepresented in American academic surgery and surgical society leadership; we investigated the proportion of speaking roles held by women across a wide variety of surgical society meetings. METHODS: Publicly-available data on invited speakers, panelists, and moderators at 23 national surgical societies' annual meetings from 2002 to 2019 were collected. Mixed effects logistic regression was used to evaluate the adjusted trend of gender representation over time for each role. RESULTS: 15.9% of invited speakers were women. Adjusted analysis showed an 8% increase in odds of having female speakers per year (OR1.08, p = 0.002, 95%CI 1.03-1.14). 24.4% of moderators and 22.5% of panelists were female; there was increasing trend in adjusted analysis for both moderators (OR1.09, p < 0.001, 95%CI 1.07-1.11) and panelists (OR1.13, p < 0.001, 95%CI 1.11-1.43). CONCLUSIONS: There is a wide range in speaking roles held by women at surgical society meetings, but an encouraging trend towards greater parity was seen overall.

Factors Associated With the Professional Success of Female Surgical Department Chairs: A Qualitative Study.

Importance: Only 7% of US surgical department chairs are occupied by women. While the proportion of women in the surgical workforce continues to increase, women remain significantly underrepresented across leadership roles within surgery. Objective: To identify commonality among female surgical chairs with attention toward moderators that appear to have contributed to their professional success. Design, Setting, and Participants: A grounded theory qualitative study was conducted in academic surgical departments within the US. Participants included current and emeritus female chairs of American academic surgical departments. The study was conducted between December 1, 2018, and March 31, 2019. An eligible cohort of 26 women was identified. Interventions and Exposures: Participants completed semistructured telephone interviews conducted with an interview guide. Main Outcomes and Measures: Common themes associated with career success. Results: Of the eligible cohort of 26 women, 20 individuals (77%) participated. Sixteen participants were serving as active department chairs and 4 were former department chairs. Mean (SD) length of time served in the chair position, either active or former, was calculated at 5.6 (2.6) years. Two major themes were identified. First, internal factors emerged prominently. Personality traits, including confidence, resilience, and selflessness, were shared among participants. Adaptability was described as a major facilitator to career success. Second, participants described 2 subtypes of external factors, overt and subtle, each of which included barriers and bolsters to career development. Overt support from mentors of both sexes was described as contributing to success. Subtle factors, such as gender norms, on institutional and cultural levels, affected behavior by creating environments that supported or detracted from career advancement. Conclusions and Relevance: In this study, participants described both internal and external factors that have been associated with their advancement into leadership roles. Future attention toward encouraging intrinsic strengths, fostering environments that bolster career development, and emphasizing adaptability, along with work-system redesign, may be key components to career success and advancing diversity in surgical leadership roles.

Surgical resection improves overall survival of patients with small bowel leiomyosarcoma.

PURPOSE: Small bowel leiomyosarcoma (SB LMS) is a rare disease with few studies characterizing its outcomes. This study aims to evaluate surgical outcomes for patients with SB LMS. METHODS: The National Cancer Database was queried from 2004 to 2016 to identify patients with SB LMS who underwent surgical resection. The primary outcome was overall survival. RESULTS: A total of 288 patients with SB LMS who had undergone surgical resection were identified. The median age was 63, and the majority of patients were female (56%), White (82%), and had a Charlson comorbidity score of zero (76%). Eighty-one percent of patients had negative margins following surgical resection. Fourteen percent of patients had metastatic disease at the time of diagnosis. Nineteen percent of patients received chemotherapy and 3% of patients received radiation. One-year overall survival was 77% (95% CI: 72-82%) and 5-year overall survival was 43% (95% CI: 36-49%). Higher grade (HR: 1.98, 95% CI: 1.10-3.55, p = 0.02) and metastatic disease at diagnosis (HR: 2.57, 95% CI: 1.45-4.55, p = 0.001) were independently associated with higher risk of death. CONCLUSION: SB LMS is a rare disease entity, with treatment centering on complete surgical resection. Our results demonstrate that overall survival is higher than previously thought. Timely diagnosis to allow for complete surgical resection is key, and investigation into the possible role of chemotherapy or radiation therapy is needed.

Racial and Socioeconomic Disparities After Surgical Resection for Rectal Cancer.

BACKGROUND: There are various racial, socioeconomic, and tumor-specific factors that can impact rectal cancer outcomes. The current systematic review and meta-analysis evaluate the effect socioeconomic and racial variables on overall survival of rectal cancer patients after surgical resection. METHODS: A literature search was performed via electronic databases according to Systematic Reviews and Meta-Analyses and Meta-analysis Of Observational Studies in Epidemiology guidelines. All studies were evaluated by three authors and validated for data extraction. Predictive variables and survival profiles (1-, 5-, and 10-y survival and overall survival) reported by the studies were recorded for the systematic review. Hazard ratios, odds ratios, and 95% confidence intervals were extracted for meta-analysis. Forest plots were used to interpret the results. The primary outcome was the effect size of the predictive variables on overall survival after surgical resection. RESULTS: Of the 265 articles collected, 22 met inclusion criteria. Sixteen studies were used for the systematic review, and 17 studies were considered for meta-analysis. Overall, 662,053 subjects with rectal cancer were studied (439,766 with race reported), of which 344,193 (78.3%) were White and 60,283 (13.7%) were Black. The median survival was 56.8% for White patients and 47.9% for Black patients. Meta-analysis revealed that race, socioeconomic variables (education level, income level, and insurance status), and facility characteristics (type and volume) were significantly associated with overall survival in rectal cancer. CONCLUSIONS: Racial and socioeconomic disparities are present in outcomes for rectal cancer patients undergoing surgical resection. It is important to consider these disparities in the management of patients with rectal cancer to minimize any consequent disparities in surgical outcomes.