Frequency and Natural History of Emergency General Surgery Conditions in Cancer Patients: A SEER-Medicare Population Analysis.

OBJECTIVE: To determine if cancer patients experience variability in incidence or management of emergency general surgery (EGS) conditions compared to non-cancer patients. BACKGROUND: The true frequency, and natural history of EGS conditions among cancer patients has not been characterized. METHODS: We utilized SEER-Medicare data from January 2006-December 2015 to compare patients with breast, prostate, and lung cancer to a non-cancer cohort. Patients were followed from date of cancer diagnosis, or an index date for non-cancer patients, to the development of an EGS condition, death or last follow up. We assessed the cumulative incidence of EGS conditions over time, and fit multivariable Cox proportional hazards models to evaluate the impact of time-dependent surgical intervention on mortality. RESULTS: We identified 322,756 patients with breast (N=82,147), lung (N=128,618), and prostate cancer (N=111,991) and 210,429 non-cancer patients.. Cancer patients had a higher incidence of an EGS condition within the first year after diagnosis (4.8% vs. 3.2%), with lung (6.8%) and breast cancer (4.0%) showing consistent rends. Cancer patients were less likely to undergo surgery for (13% vs. 14%, P=0.005), though this varied by cancer type and EGS conditions. Patients with breast (HR 1.27, 95%CI 1.17-1.39) and lung cancer (HR 3.27, 95%CI 3.07-3.48) were more likely to die within 30-days of an EGS diagnosis. CONCLUSIONS: Cancer patients experience a higher incidence of EGS conditions within the first year following diagnosis, but are less likely to undergo surgery. Future research is needed to explore the interplay between EGS conditions, their management, and receipt of intended oncologic therapy, and resulting outcomes.

Safety of Selective Operative Drainage After Pancreatic Resection: A Retrospective Analysis of 2,607 Patients.

OBJECTIVE: To assess whether selective omission of operative drains after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP) is associated with adverse perioperative outcomes. BACKGROUND: The routine use of operative drains after pancreatectomy is widely practiced; however, prospective randomized clinical trials and retrospective analyses have shown mixed results. METHODS: Patients who underwent PD or DP between November 2009 and May 2021 were reviewed and stratified by operative drain placement. Patient demographics, morbidity, the need for additional procedures, and mortality were compared between patients who did or did not develop a clinically relevant post-operative pancreatic fistula (CR-POPF). RESULTS: In total, 1,855 PD and 752 DP cases were analyzed. Among PD patients with a CR-POPF (N=259, 14%), 160 (62%) had an operative drain placed, of whom 141 (88%) required at least 1 additional procedure. Within this subgroup, grade ≥ 4 complications (7.5% vs. 11.1%, P=0.37), 90-day mortality (3.8% vs. 6.1%, P=0.54), length of stay (LOS) (median 12 vs. 13 d, P=0.19) and readmission rates (63.1% vs. 54.6%, P=0.19) were similar between drained and non-drained patients. Of note, drained PD patients without a CR-POPF had a longer hospital stay (8 vs. 7 d, respectively, P=0.004) and more thromboembolic events (2.4% vs. 1.1%, respectively, P=0.04) Among DP patients with a CR-POPF (n=129), 44 had an operative drain, with 37 (84%) requiring an additional procedure. Within this subgroup, grade ≥ 4 complications (4.6% vs. 5.9%, P>0.95), 90-day mortality (0%), LOS (median 7 d for both, P=0.88) and readmission rates (72.7% vs. 80%, P=0.38) were similar in drained and non-drained patients. CONCLUSION: This study confirms that selective omission of operative drains does not compromise perioperative outcomes, as initially reported in our prospective randomized trial.

Gemcitabine with Cisplatin Versus Hepatic Arterial Infusion Pump Chemotherapy for Liver-Confined Unresectable Intrahepatic Cholangiocarcinoma.

BACKGROUND: A post-hoc analysis of ABC trials included 34 patients with liver-confined unresectable intrahepatic cholangiocarcinoma (iCCA) who received systemic chemotherapy with gemcitabine and cisplatin (gem-cis). The median overall survival (OS) was 16.7 months and the 3-year OS was 2.8%. The aim of this study was to compare patients treated with systemic gem-cis versus hepatic arterial infusion pump (HAIP) chemotherapy for liver-confined unresectable iCCA. METHODS: We retrospectively collected consecutive patients with liver-confined unresectable iCCA who received gem-cis in two centers in the Netherlands to compare with consecutive patients who received HAIP chemotherapy with or without systemic chemotherapy in Memorial Sloan Kettering Cancer Center. RESULTS: In total, 268 patients with liver-confined unresectable iCCA were included; 76 received gem-cis and 192 received HAIP chemotherapy. In the gem-cis group 42 patients (55.3%) had multifocal disease compared with 141 patients (73.4%) in the HAIP group (p = 0.023). Median OS for gem-cis was 11.8 months versus 27.7 months for HAIP chemotherapy (p < 0.001). OS at 3 years was 3.5% (95% confidence interval [CI] 0.0-13.6%) in the gem-cis group versus 34.3% (95% CI 28.1-41.8%) in the HAIP chemotherapy group. After adjusting for male gender, performance status, baseline hepatobiliary disease, and multifocal disease, the hazard ratio (HR) for HAIP chemotherapy was 0.27 (95% CI 0.19-0.39). CONCLUSIONS: This study confirmed the results from the ABC trials that survival beyond 3 years is rare for patients with liver-confined unresectable iCCA treated with palliative gem-cis alone. With HAIP chemotherapy, one in three patients was alive at 3 years.

Adapting Surgical Coaching: Feasibility and Perceptions of Intraoperative Resident Peer Coaching.

INTRODUCTION: Surgical coaching is utilized to enhance technical, nontechnical, and teaching skills. This study aims to evaluate the feasibility and benefit of a resident peer coaching program. METHODS: Chief residents (postgraduate year 5) acted as coaches for junior residents (postgraduate year 1-3, "coachees"). All participants completed the Harvard Surgical Coaching for Operative Performance Enhancement curriculum. The coaching structure included 1) preoperative goal setting, 2) unscrubbed intraoperative observation, and 3) postoperative debrief. Upon completion, residents were surveyed to assess their experience. Descriptive and thematic analyses were performed. RESULTS: There were 22 participants (6 coaches, 16 coachees). Five (83.3%) coaches and 14 (87.5%) coachees reported the program was useful, citing dedicated reflection outside the operating room, in-depth feedback, and structured self-assessment with increased accountability. Thirteen (81.3%) coachees reported perceived improvement in technical skills and 12 (75%) within nontechnical skills. All coaches felt they benefited and improved their ability to provide feedback. When asked how coaching compared to usual methods of operative feedback, 14 (87.5%) coachees and 5 (83.3%) coaches reported it was better, with only 1 coachee reporting it was worse. Benefits over typical operating room teaching included more feedback provided, more specific feedback, and the benefit of peer relationships. Twelve (54.5%) residents cited difficulty with coordinating sessions, but 21 (95.5%) reported that they would participate again. CONCLUSIONS: Implementation of a resident peer surgical coaching program is feasible. Both coaches and coachees perceive significant benefit with improvement in technical, nontechnical, and feedback delivery skills. Given preference over other methods of operative feedback, expansion of peer coaching programs is warranted.

Machine learning radiomics can predict early liver recurrence after resection of intrahepatic cholangiocarcinoma.

BACKGROUND: Most patients recur after resection of intrahepatic cholangiocarcinoma (IHC). We studied whether machine-learning incorporating radiomics and tumor size could predict intrahepatic recurrence within 1-year. METHODS: This was a retrospective analysis of patients with IHC resected between 2000 and 2017 who had evaluable computed tomography imaging. Texture features (TFs) were extracted from the liver, tumor, and future liver remnant (FLR). Random forest classification using training (70.3%) and validation cohorts (29.7%) was used to design a predictive model. RESULTS: 138 patients were included for analysis. Patients with early recurrence had a larger tumor size (7.25 cm [IQR 5.2-8.9] vs. 5.3 cm [IQR 4.0-7.2], P = 0.011) and a higher rate of lymph node metastasis (28.6% vs. 11.6%, P = 0.041), but were not more likely to have multifocal disease (21.4% vs. 17.4%, P = 0.643). Three TFs from the tumor, FD1, FD30, and IH4 and one from the FLR, ACM15, were identified by feature selection. Incorporation of TFs and tumor size achieved the highest AUC of 0.84 (95% CI 0.73-0.95) in predicting recurrence in the validation cohort. CONCLUSION: This study demonstrates that radiomics and machine-learning can reliably predict patients at risk for early intrahepatic recurrence with good discrimination accuracy.

Local Control and Survival After Induction Chemotherapy and Ablative Radiation Versus Resection for Pancreatic Ductal Adenocarcinoma With Vascular Involvement.

OBJECTIVE: We sought to compare overall survival (OS) and disease control for patients with localized pancreatic ductal adenocarcinoma (PDAC) treated with ablative dose radiotherapy (A-RT) versus resection. SUMMARY BACKGROUND DATA: Locoregional treatment for PDAC includes resection when possible or palliative RT. A-RT may offer durable tumor control and encouraging survival. METHODS: This was a single-institution retrospective analysis of patients with PDAC treated with induction chemotherapy followed by A-RT [≥98 Gy biologically effective dose (BED) using 15-25 fractions in 3-4.5 Gy/fraction] or pancreatectomy. RESULTS: One hundred and four patients received A-RT (49.8%) and 105 (50.2%) underwent resection. Patients receiving A-RT had larger median tumor size after induction chemotherapy [3.2 cm (undetectable-10.9) vs 2.6 cm (undetectable-10.7), P < 0.001], and were more likely to have celiac or hepatic artery encasement (48.1% vs 11.4%, P <0.001), or superior mesenteric artery encasement (43.3% vs 9.5%, P < 0.001); however, there was no difference in the degree of SMV/PV involvement (P = 0.123). There was no difference in locoregional recurrence/progression at 18-months between A-RT and resection; cumulative incidence was 16% [(95% confidence interval (CI) 10%-24%] versus 21% (95% CI 14%-30%), respectively (P= 0.252). However, patients receiving A-RT had a 19% higher 18-month cumulative incidence of distant recurrence/progression [58% (95% CI 48%-67%) vs 30% (95% CI 30%-49%), P= 0.004]. Median OS from completion of chemotherapy was 20.1 months for A-RT patients (95% CI 16.4-23.1 months) versus 32.9 months (95% CI 29.7-42.3 months) for resected patients (P < 0.001). CONCLUSION: Ablative radiation is a promising new treatment option for PDAC, offering locoregional disease control similar to that associated with resection and encouraging survival.

Discharge destination following rectal cancer resection: an analysis of preoperative and intraoperative factors.

PURPOSE: Rectal cancer resections can be associated with long and complicated postoperative recoveries. Many patients undergoing these operations are discharged to rehabilitation or skilled nursing facilities. The purpose of this study was to identify preoperative and intraoperative factors associated with increased risk for non-home discharge after rectal cancer resection. METHODS: Rectal cancer resections were identified in the National Surgical Quality Improvement Program Targeted Proctectomy Dataset (years 2016 through 2017) by ICD code. Patients with unknown discharge destination or who experienced in-hospital mortality were excluded. Univariate and multivariate logistic regression analyses were performed to identify preoperative and intraoperative variables associated with non-home discharge destination. Multiple imputation was used to account for missing values. RESULTS: Among the 3637 patients comprising the study sample, 292 (8.0%) patients were discharged to rehabilitation, skilled care, or acute care facilities. Preoperative factors associated with non-home discharge on multivariate analysis included older age, non-independent functional status, insulin-dependent diabetes, and hypoalbuminemia (all p < 0.05). Having received neoadjuvant chemotherapy was associated with home discharge (OR 0.625, 95% CI 0.427-0.914, p = 0.015). Intraoperative factors associated with non-home discharge on multivariate analysis were concurrent cystectomy (p = 0.004) and myocutaneous flap reconstruction (p < 0.001). Patients discharged to non-home facilities had longer initial lengths of stay (14.1 versus 7.0 days, p < 0.001) and higher reoperation rates (12.7 versus 5.0%, p < 0.001), but similar readmission rates (14.7 versus 15.0%, p = 1.0). CONCLUSION: Several preoperative and intraoperative factors are associated with increased risk for non-home discharge after rectal cancer resection. These data can aid in perioperative planning and discharge optimization.

Twenty-Three-Hour-Stay Colectomy Without Increased Readmissions: An Analysis of 1905 Cases from the National Surgical Quality Improvement Program.

BACKGROUND: Isolated case series from highly specialized centers suggest the feasibility of a 23-h hospital stay after colectomy. We sought to determine preoperative variables associated with discharge within 23 h after colectomy to identify patients best suited for a short-stay model. METHODS: The American College of Surgeons NSQIP Colectomy-Targeted database was used to identify patients who underwent elective colectomy from 2012 to 2017. All cases with missing length of stay or inpatient death were excluded. Patients with a postoperative hospital stay ≤1 day were identified. Univariate and multivariate analyses were conducted to identify factors associated with early discharge. RESULTS: A total of 1905 patients were discharged within 23 h after surgery (1.6%). These patients were noted to be younger (59 versus 61 years, p < 0.001) and less likely to have insulin-dependent diabetes (3.0 versus 4.4%, p < 0.001), preoperative dyspnea (2.2 versus 6.0%, p < 0.001), COPD (3.0 versus 4.2%, p = 0.011), and hypertension (40.7 versus 46.9%, p < 0.001) than patients who stayed longer. Shorter operative time (OR 0.986, 95% CI 0.985-0.987, p < 0.001), minimally invasive techniques (OR 2.969, 95% CI 2.686-3.282, p < 0.001), lack of ostomy (OR 0.614, 95% CI 0.478-0.788, p < 0.001), and lack of ureteral stenting (OR 0.641, 95% CI 0.500-0.821, p < 0.001) were associated with early discharge in multivariable analysis. There was no increased incidence of readmission in patients discharged within 23 h. CONCLUSIONS: Twenty-three-hour-stay colectomy is feasible on a national level and does not result in an increased incidence of readmission. Patients undergoing elective procedures without significant medical comorbidities may be eligible for early discharge. Preoperative factors may be used to select patients best suited for this short-stay model.

Risk prediction of 30-day mortality after lower extremity major amputation.

OBJECTIVE: Universal risk calculators may underestimate mortality risk, whereas purely observational administrative data may lack appropriate granularity to individualize risk. The purpose of this study was to create a simple risk prediction model to identify the factors associated with 30-day morality after lower extremity major amputation for ischemic vascular disease. METHODS: The Veterans Affairs Surgical Quality Improvement Program national data set was queried from 2005 to 2015 to identify 14,890 patients undergoing elective above-knee or below-knee amputation for rest pain, tissue loss, or gangrene. The data set was divided into a two-thirds derivation set and one-third validation set for the purpose of creating a risk prediction model. The primary end point was 30-day mortality. Eight independent risk factors for mortality resulted from the model and were assigned whole number integer risk scores. Summary risk scores were collapsed into categories and defined as low (0-3 points), moderate (4-7 points), high (8-10), and very high (>10). RESULTS: Mortality in the derivation data set was 4.6% (n = 453). By multivariable backward elimination, predictors of 30-day mortality (odds ratio [95% confidence limits]) included preoperative do not resuscitate order (3.1 [2.3-4.0]), congestive heart failure (2.8 [2.1-3.6]), age >80 years (1.8 [1.4-2.2]), chronic renal insufficiency (2.1 [1.7-2.5]), above-knee amputation (1.8 [1.4-2.2]), dependent functional status (2.0 [1.6-2.5]), coronary artery disease (1.3 [1.1-1.6]), and chronic obstructive pulmonary disease (1.3 [1.0-1.6]); the final model held a C statistic of 0.74. In both the derivation and validation sets, 30-day mortality correlated with risk category. Among the defined categories in the derivation set, 30-day mortality rates were 2.3% for low-risk patients, 4.3% for moderate-risk patients, 7.5% for high-risk patients, and 17.5% for very-high-risk patients, with similar results for the validation data set. CONCLUSIONS: This risk prediction model uses eight easily obtainable clinical metrics that allow early assessment of 30-day mortality risk of patients undergoing major lower extremity amputation for ischemic indications. The internal validation of the risk score demonstrates the increased mortality with increasing risk category. Reliable expected mortality prediction is critically important for surgeons to make recommendations in accordance with a patient's or family's goals of care. These data may also be used to set realistic expectations for hospital-based quality initiatives and to provide guidance in preoperative medical optimization.

The impact of bacterial colonization on graft success after total pancreatectomy with autologous islet transplantation: considerations for early definitive surgical intervention.

OBJECTIVE: The purpose of this study was to determine whether bacterial contamination of islets affects graft success after total pancreatectomy with islet autotransplantation (TPIAT). BACKGROUND: Factors associated with insulin independence after TPIAT are inconclusive. Although bacterial contamination does not preclude transplantation, the impact of bacterial contamination on graft success is unknown. METHODS: Patients who received TPIAT at the University of Virginia between January 2007 and January 2016 were reviewed. Patient charts were reviewed for bacterial contamination and patients were prospectively contacted to assess rates of insulin independence. RESULTS: There was no significant difference in demographic or perioperative data between patients who achieved insulin independence and those who did not. However, six of 27 patients analyzed (22.2%) grew bacterial contaminants from culture of the final islet preparations. These patients had significantly lower islet yield and C-peptide at most recent follow-up (P<.05), and none of these patients achieved insulin independence. CONCLUSIONS: Islet transplant solutions are often culture positive, likely secondary to preprocurement pancreatic manipulation and introduction of enteric flora. Although autotransplantation of culture-positive islets is safe, it is associated with higher rates of graft failure and poor islet yield. Consideration should be given to identify patients who may develop refractory chronic pancreatitis and offer early operative management to prevent bacterial colonization.

Cumulative sum: a proficiency metric for basic endoscopic training.

BACKGROUND: As work hour restrictions increasingly limit some operative experiences, personalized evaluative methods are needed. We prospectively assessed the value of cumulative sum (Cusum) to measure proficiency with percutaneous endoscopic gastrostomy (PEG) among surgical trainees. MATERIALS AND METHODS: Nine postgraduate year 1 surgery residents each underwent a 1-month rotation dedicated to endoscopy. Procedure durations for all PEG insertions were recorded prospectively. Criteria for task failure included need for attending takeover or procedure duration >10 min. Cusum parameters were defined a priori, with acceptable and unacceptable failure rates of 5% and 15%, respectively. Concurrently, expert endoscopists blinded to Cusum results evaluated trainee proficiency weekly using a multicategory, five-point Likert-scale survey. RESULTS: Nine surgical residents performed an average of 21 PEGs each. Expert evaluations and Cusum analyses identified eight and seven participants who attained proficiency after a median of 11.5 and 12 cases, respectively. For four of the residents who achieved proficiency by Cusum criteria, eventual relapses to inadequate performance were identified. These relapses were not detected by expert evaluation. Six participants who attained proficiency by both metrics performed a combined 32 superfluous cases, which could have been redistributed to poor-performing trainees. CONCLUSIONS: Although lacking the granular insight of expert evaluations, Cusum analysis is more sensitive to relapses of subproficient performance. Adding Cusum analysis to expert evaluations can provide longitudinal, formative feedback and promote efficient redistribution of operative experiences.

Self-Assessment and Coaching Techniques Utilized in an Intraoperative Resident Peer Coaching Program.

OBJECTIVES: To evaluate junior resident self-assessments and utilization of effective coaching principles by chief resident coaches in a resident peer surgical coaching program. DESIGN: All residents underwent the Surgical Coaching for Operative Performance Enhancement (SCOPE) coaching curriculum. Junior residents ("coachees") were paired with chief resident coaches. A case was selected for coaching. The coaching structure was: 1) junior resident preoperative goal setting, 2) unscrubbed, intraoperative case observation by the coach, 3) postoperative coaching debrief. Debriefs were recorded to determine frequency of junior resident self-assessment and use of the effective coaching principles (goal setting, collaborative analysis, constructive feedback, action planning). Deductive thematic analysis was conducted. SETTING: A general surgery residency at a single, large academic medical center. PARTICIPANTS: 16 junior resident (PGY1-3) coachees and 6 chief resident (PGY5) coaches. RESULTS: There were 18 recorded coaching debrief sessions that lasted an average of 12.65 minutes (range 4-31 minutes). All debrief sessions included self-assessments by the junior resident coachees. There were numerous examples of the 4 effective coaching principles with all debriefs including use of at least 3. The most commonly used were collaborative analysis and constructive feedback. For technical skills, these highlighted body positioning, needle angles, and dissection techniques, including instrument choice, laparoscopic instrument technique, and use of electrocautery. Collaborative analysis of nontechnical skills emphasized communication with the attending surgeon, specifically operative decision-making and advocating for resident autonomy. Nontechnical constructive feedback addressed strategies the coaches themselves used for managing stress, interacting with attendings, and excelling in the operating room. CONCLUSIONS: Self-assessments and use of effective coaching principles were frequent throughout peer coaching debriefs. Collaborative analysis and constructive feedback were employed to promote operative technical and nontechnical skill development. Within a peer coaching program, residents are able to employ high level teaching and coaching techniques to encourage operative performance enhancement.

Multi-parametric atlas of the pre-metastatic liver for prediction of metastatic outcome in early-stage pancreatic cancer.

Metastasis occurs frequently after resection of pancreatic cancer (PaC). In this study, we hypothesized that multi-parametric analysis of pre-metastatic liver biopsies would classify patients according to their metastatic risk, timing and organ site. Liver biopsies obtained during pancreatectomy from 49 patients with localized PaC and 19 control patients with non-cancerous pancreatic lesions were analyzed, combining metabolomic, tissue and single-cell transcriptomics and multiplex imaging approaches. Patients were followed prospectively (median 3 years) and classified into four recurrence groups; early (<6 months after resection) or late (>6 months after resection) liver metastasis (LiM); extrahepatic metastasis (EHM); and disease-free survivors (no evidence of disease (NED)). Overall, PaC livers exhibited signs of augmented inflammation compared to controls. Enrichment of neutrophil extracellular traps (NETs), Ki-67 upregulation and decreased liver creatine significantly distinguished those with future metastasis from NED. Patients with future LiM were characterized by scant T cell lobular infiltration, less steatosis and higher levels of citrullinated H3 compared to patients who developed EHM, who had overexpression of interferon target genes (MX1 and NR1D1) and an increase of CD11B+ natural killer (NK) cells. Upregulation of sortilin-1 and prominent NETs, together with the lack of T cells and a reduction in CD11B+ NK cells, differentiated patients with early-onset LiM from those with late-onset LiM. Liver profiles of NED closely resembled those of controls. Using the above parameters, a machine-learning-based model was developed that successfully predicted the metastatic outcome at the time of surgery with 78% accuracy. Therefore, multi-parametric profiling of liver biopsies at the time of PaC diagnosis may determine metastatic risk and organotropism and guide clinical stratification for optimal treatment selection.

Management of Recurrent Retroperitoneal Sarcoma.

Recurrence after resection of retroperitoneal sarcoma is common and varies by histological subtype. Pattern of recurrence is similarly affected by histology (e.g., well-differentiated liposarcoma is more likely to recur locoregionally, whereas leiomyosarcoma is more likely to develop distant metastases). Radiotherapy may provide effective locoregional control in limited circumstances and the data on the impact of chemotherapy are scant. Surgery for locally recurrent disease is associated with the greatest survival benefit; however, data are retrospective and from a highly selected subgroup of patients. Limited retrospective data have also suggested a survival association with the resection of limited distant metastases. Given the complexity of these patients, multidisciplinary evaluation at a high-volume sarcoma center is critical.

Hepatic disease control in patients with intrahepatic cholangiocarcinoma correlates with overall survival.

PURPOSE: The role of locoregional therapy compared to systemic chemotherapy (SYS) for unresectable intrahepatic cholangiocarcinoma (IHC) remains controversial. The importance of hepatic disease control, either as initial or salvage therapy, is also unclear. We compared overall survival (OS) in patients treated with resection, hepatic arterial infusion pump (HAIP) chemotherapy, or SYS as it relates to hepatic recurrence or progression. We also evaluated recurrence after resection to determine the efficacy of locoregional salvage therapy. PATIENTS AND METHODS: In this single-institution retrospective analysis, patients with biopsy-proven IHC treated with either curative-intent resection, HAIP (with or without SYS), or SYS alone were analyzed. Propensity score matching (PSM) was used to compare patients with liver-limited, advanced disease treated with HAIP versus SYS. The impact of locoregional salvage therapies in patients with liver-limited recurrence was analyzed in the resection cohort. RESULTS: From 2000 to 2017, 714 patients with IHC were treated, 219 (30.7%) with resectable disease, 316 (44.3%) with locally advanced disease, and 179 (25.1%) with metastatic disease. Resected patients were less likely to recur or progress in the liver (hazard ratio [HR] 0.41, 95% CI 0.34-0.45) versus those that received HAIP or SYS (HR 0.58, 95% CI 0.50-0.65 vs. HR 0.63, 95% CI 0.57-0.69, respectively). In resected patients, 161 (64.4%) recurred, with 65 liver-only recurrences. Thirty of these patients received subsequent locoregional therapy. On multivariable analysis, locoregional therapy was associated with improved OS after isolated liver recurrence (HR 0.46, 95% CI 0.29-0.75; p = 0.002). In patients with locally advanced unresectable or multifocal liver disease (with or without distant organ metastases), PSM demonstrated improved hepatic progression-free survival in patients treated with HAIP versus SYS (HR 0.65; 95% CI 0.46-0.91; p = 0.01), which correlated with improved OS (HR 0.59, 95% CI 0.43-0.80; p < 0.001). CONCLUSION: In patients with liver-limited IHC, hepatic disease control is associated with improved OS, emphasizing the potential importance of liver-directed therapy.

Intrahepatic Cholangiocarcinoma with Lymph Node Metastasis: Treatment-Related Outcomes and the Role of Tumor Genomics in Patient Selection.

PURPOSE: Lymph node metastasis (LNM) drastically reduces survival after resection of intrahepatic cholangiocarcinoma (IHC). Optimal treatment is ill defined, and it is unclear whether tumor mutational profiling can support treatment decisions. EXPERIMENTAL DESIGN: Patients with liver-limited IHC with or without LNM treated with resection (N = 237), hepatic arterial infusion chemotherapy (HAIC; N = 196), or systemic chemotherapy alone (SYS; N = 140) at our institution between 2000 and 2018 were included. Genomic sequencing was analyzed to determine whether genetic alterations could stratify outcomes for patients with LNM. RESULTS: For node-negative patients, resection was associated with the longest median overall survival [OS, 59.9 months; 95% confidence interval (CI), 47.2-74.31], followed by HAIC (24.9 months; 95% CI, 20.3-29.6), and SYS (13.7 months; 95% CI, 8.9-15.9; P < 0.001). There was no difference in survival for node-positive patients treated with resection (median OS, 19.7 months; 95% CI, 12.1-27.2) or HAIC (18.1 months; 95% CI, 14.1-26.6; P = 0.560); however, survival in both groups was greater than SYS (11.2 months; 95% CI, 14.1-26.6; P = 0.024). Node-positive patients with at least one high-risk genetic alteration (TP53 mutation, KRAS mutation, CDKN2A/B deletion) had worse survival compared to wild-type patients (median OS, 12.1 months; 95% CI, 5.7-21.5; P = 0.002), regardless of treatment. Conversely, there was no difference in survival for node-positive patients with IDH1/2 mutations compared to wild-type patients. CONCLUSIONS: There was no difference in OS for patients with node-positive IHC treated by resection versus HAIC, and both treatments had better survival than SYS alone. The presence of high-risk genetic alterations provides valuable prognostic information that may help guide treatment.

How Should a Surgeon and Anesthesiologist Cooperate During Intraoperative Cardiac Arrest?

Surgeons and anesthesiologists each have a unique sense of duty and responsibility to patients throughout all phases of perioperative care. Intraoperative cardiac arrest during elective, noncardiac surgery is rare, with an incidence between 0.8 to 4.3 per 10 000 cases. Fortunately, patients who suffer cardiac arrest during surgery are more likely to survive than patients who suffer cardiac arrest in other settings. This article considers factors that have been shown to influence outcomes after intraoperative cardiac arrest and offers a framework for analyzing and discussing these clinically, ethically, and emotionally complex cases.

Surgical site occurrences, not body mass index, increase the long-term risk of ventral hernia recurrence.

BACKGROUND: Recurrence rates after ventral hernia repair vary widely and evidence about risk factors for recurrence are conflicting. There is little evidence for risk factors for long-term recurrence. METHODS: Patients who underwent ventral hernia repair at our institution and were captured in the American College of Surgeons-National Surgical Quality Improvement Program database between 2002 and 2015 were included. We reviewed all demographic, procedural, and hernia-specific data. RESULTS: Six hundred and thirty patients were included for analysis with a median follow-up of 4.9 years (inter-quartile range, 2-7.3 years). By univariate analysis, index hernia repairs were more likely to recur if defect size was ≥4 cm (P = .019), no mesh was used (P = .026), or if the repair was for a recurrent hernia (P = .001). Five-year cumulative incidence of recurrence and reoperation was 24.3% and 16.0%, respectively. Patients with a perioperative surgical site occurrence, which included superficial, deep-incisional, and organ space surgical site infections as well as wound disruption, had a 5-year cumulative incidence of recurrence of 54.9% compared with 22.6% for those without surgical site occurrence. By multivariable analysis, non-primary hernia repair (hazard ratio 1.7, 95% confidence interval 1.2-2.4, P = .005) and any postoperative surgical site occurrence (hazard ratio 1.9, 95% confidence interval 1.1-3.6, P = .02) were the only risk factors predictive of recurrence. Patient body mass index had no independent effect on recurrence. CONCLUSION: 1 in 4 patients undergoing an open ventral hernia repair will have a recurrence after 5 years, and this risk is doubled among patients who experience any perioperative surgical site occurrence. After controlling for patient comorbidities, including body mass index, hernia size, and mesh position, the most significant risk factor for recurrence after ventral hernia repair was a non-primary hernia and surgical site occurrence.

Timing and Outcomes of Abdominal Surgery in Neutropenic Patients.

BACKGROUND: Surgery in neutropenic patients is challenging due to both atypical manifestations of common conditions and higher perioperative risk. We sought to describe the outcomes of neutropenic patients undergoing abdominal surgery and to identify factors contributing to morbidity and mortality. METHODS: A retrospective chart review was performed for all patients neutropenic in the 24-hours prior to an abdominal operation at our institution between 1998 and 2017. The primary and secondary outcomes were 30-day mortality and morbidity, respectively. The chi-square test and two-tailed Student's t test were used for univariable comparisons (non-parametric tests used when appropriate). To determine the optimal threshold of absolute neutrophil count (ANC) to discriminate 30-day mortality, we maximized the Youden index (J). RESULTS: Amongst 237 patients, mortality was 11.8% (28/237) and morbidity 54.5% (130/237). Absolute neutrophil count < 500 cells/µL (50% vs. 20.6%, P < 0.01) and perforated viscus (35.7% vs. 14.8%, P = 0.01) were associated with mortality. Perforated viscus (25.4% vs. 7.5%) was also associated with morbidity. Urgent operations were associated with higher morbidity (63.6% vs 34.7%, P < 0.001) and mortality (16.4% vs 1.4%, P = 0.002) when compared to elective operations. Transfer from an outside hospital (22.3% vs. 11.2%, P = 0.02) and longer median time from admission to operation (2 days (IQR 0-6) vs. 1 day (IQR 0-3), P < 0.01) were associated with morbidity. An ANC threshold of 350 provided the best discrimination for mortality. CONCLUSIONS: Elective surgery in the appropriately chosen neutropenic patient is relatively safe. For patients with obvious surgical pathology, we advocate for earlier operation and a lower threshold for surgical consultation in an effort expedite the diagnosis and necessary treatment.