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OBJECTIVE: To evaluate if patient-derived organoids (PDOs) may predict response to neoadjuvant (NAT) chemotherapy in patients with pancreatic adenocarcinoma. BACKGROUND: PDOs have been explored as a biomarker of therapy response and for personalized therapeutics in patients with pancreatic cancer. METHODS: During 2017-2021, patients were enrolled into an IRB-approved protocol and PDO cultures were established. PDOs of interest were analyzed through a translational pipeline incorporating molecular profiling and drug sensitivity testing. RESULTS: One hundred thirty-six samples, including both surgical resections and fine needle aspiration/biopsy from 117 patients with pancreatic cancer were collected. This biobank included diversity in stage, sex, age, and race, with minority populations representing 1/3 of collected cases (16% Black, 9% Asian, 7% Hispanic/Latino). Among surgical specimens, PDO generation was successful in 71% (15 of 21) of patients who had received NAT prior to sample collection and in 76% (39 of 51) of patients who were untreated with chemotherapy or radiation at the time of collection. Pathological response to NAT correlated with PDO chemotherapy response, particularly oxaliplatin. We demonstrated the feasibility of a rapid PDO drug screen and generated data within 7 days of tissue resection. CONCLUSION: Herein we report a large single-institution organoid biobank, including ethnic minority samples. The ability to establish PDOs from chemotherapy-naive and post-NAT tissue enables longitudinal PDO generation to assess dynamic chemotherapy sensitivity profiling. PDOs can be rapidly screened and further development of rapid screening may aid in the initial stratification of patients to the most active NAT regimen.
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Adenocarcinoma , Antineoplásicos , Neoplasias Pancreáticas , Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/cirurgia , Antineoplásicos/uso terapêutico , Etnicidade , Humanos , Grupos Minoritários , Terapia Neoadjuvante , Organoides , Neoplasias Pancreáticas/tratamento farmacológico , Neoplasias PancreáticasRESUMO
BACKGROUND: Evaluation of robotic surgical skill has become increasingly important as robotic approaches to common surgeries become more widely utilized. However, evaluation of these currently lacks standardization. In this paper, we aimed to review the literature on robotic surgical skill evaluation. METHODS: A review of literature on robotic surgical skill evaluation was performed and representative literature presented over the past ten years. RESULTS: The study of reliability and validity in robotic surgical evaluation shows two main assessment categories: manual and automatic. Manual assessments have been shown to be valid but typically are time consuming and costly. Automatic evaluation and simulation are similarly valid and simpler to implement. Initial reports on evaluation of skill using artificial intelligence platforms show validity. Few data on evaluation methods of surgical skill connect directly to patient outcomes. CONCLUSION: As evaluation in surgery begins to incorporate robotic skills, a simultaneous shift from manual to automatic evaluation may occur given the ease of implementation of these technologies. Robotic platforms offer the unique benefit of providing more objective data streams including kinematic data which allows for precise instrument tracking in the operative field. Such data streams will likely incrementally be implemented in performance evaluations. Similarly, with advances in artificial intelligence, machine evaluation of human technical skill will likely form the next wave of surgical evaluation.
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Procedimentos Cirúrgicos Robóticos , Robótica , Inteligência Artificial , Competência Clínica , Humanos , Reprodutibilidade dos TestesRESUMO
BACKGROUND: Since 1997, the Fellowship Council (FC) has evolved into a robust organization responsible for the advanced training of nearly half of the US residency graduates entering general surgery practice. While FC fellowships are competitive (55% match rate) and offer outstanding educational experiences, funding is arguably vulnerable. This study aimed to investigate the current funding models of FC fellowships. METHODS: Under an IRB-approved protocol, an electronic survey was administered to 167 FC programs with subsequent phone interviews to collect data on total cost and funding sources. De-identified data were also obtained via 2020-2021 Foundation for Surgical Fellowships (FSF) grant applications. Means and ranges are reported. RESULTS: Data were obtained from 59 programs (35% response rate) via the FC survey and 116 programs via FSF applications; the average cost to train one fellow per year was $107,957 and $110,816, respectively. Most programs utilized departmental and grants funds. Additionally, 36% (FC data) to 39% (FSF data) of programs indicated billing for their fellow, generating on average $74,824 ($15,000-200,000) and $33,281 ($11,500-66,259), respectively. FC data documented that 14% of programs generated net positive revenue, whereas FSF data documented that all programs were budget-neutral. CONCLUSION: Both data sets yielded similar overall results, supporting the accuracy of our findings. Expenses varied widely, which may, in part, be due to regional cost differences. Most programs relied on multiple funding sources. A minority were able to generate a positive revenue stream. Although fewer than half of programs billed for their fellow, this source accounted for substantial revenue. Institutional support and external grant funding have continued to be important sources for the majority of programs as well. Given the value of these fellowships and inherent vulnerabilities associated with graduate medical education funding, alternative grant funding models and standardization of annual financial reporting are encouraged.
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Bolsas de Estudo , Internato e Residência , Educação de Pós-Graduação em Medicina , Humanos , Inquéritos e QuestionáriosRESUMO
INTRODUCTION: Current guidelines support laparoscopic cholecystectomy as the treatment of choice for pregnant women with symptomatic gallbladder disease, regardless of the trimester. Early intervention has remained the standard of care, but recent evidence has challenged this practice in pregnant women. We sought to compare surgical and maternal-fetal outcomes of antepartum versus postpartum cholecystectomy in New York State. METHODS: Between 2005 and 2014, the New York Statewide Planning and Research Cooperative System (SPARCS) database was queried for patients who underwent cholecystectomy within 3 months before (antepartum cholecystectomy, APCCY: n = 82) and after (postpartum cholecystectomy, PPCCY: n = 5040) childbirth to approximate third-trimester operations. All patients who underwent cholecystectomy during pregnancy (n = 971) were extracted to evaluate inter-trimester differences. Subgroup analysis compared APCCY patients who were not hospitalized within 1 year before APCCY (n = 80) and PPCCY patients who were hospitalized within 1 year before childbirth (n = 29) for symptomatic biliary disease. Multivariable generalized linear regression models were used to characterize the association between timing of cholecystectomy and several primary outcomes: length of stay (LOS), 30-day non-pregnancy, non-delivery readmission (NPND), bile duct injury (BDI), composite maternal outcome (antepartum hemorrhage, preterm delivery, cesarean section), any complications, and fetal demise. RESULTS: Third-trimester APCCY women had longer LOS (Ratio: 1.44, 95% CI [1.26-1.66], p < 0.0001) and greater incidence of preterm delivery (OR 2.54, 95% CI [1.37-4.43], p = 0.0019). Cholecystectomy timing was not independently associated with differences in composite maternal outcome (p = 0.1480), BDI (p = 0.2578), 30-day NPND readmission (p = 0.7579), any complications (p = 0.2506), and fetal demise (2.44% versus 0.44%, p = 0.0545). Subgroup analysis revealed no differences in any of the seven outcomes. CONCLUSIONS: New York Statewide data suggest that although laparoscopic cholecystectomy is safe in pregnancy, delay of cholecystectomy should be discussed in the third trimester due to an increased risk for preterm delivery.
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Colecistectomia Laparoscópica , Doenças da Vesícula Biliar , Complicações na Gravidez , Cesárea , Colecistectomia , Colecistectomia Laparoscópica/efeitos adversos , Feminino , Doenças da Vesícula Biliar/cirurgia , Humanos , Recém-Nascido , Gravidez , Complicações na Gravidez/cirurgia , Terceiro Trimestre da GravidezRESUMO
INTRODUCTION: Even though acute appendicitis is the most common general surgical condition encountered during pregnancy, the preferred approach to appendectomy in pregnant patients remains controversial. Current guidelines support laparoscopic appendectomy as the treatment of choice for pregnant women with appendicitis, regardless of trimester. However, recent published data suggests that the laparoscopic approach contributes to higher rates of fetal demise. Our study aims to compare laparoscopic and open appendectomy in pregnancy at a statewide population level. METHODS: ICD-9 codes were used to extract 1006 pregnant patients undergoing appendectomy between 2005 and 2014 from the NY Statewide Planning and Research Cooperative System (SPARCS) database. Surgical outcomes (any complications, 30-day readmission rate, length of stay (LOS)) and obstetrical outcomes (antepartum hemorrhage, preterm delivery, cesarean section, sepsis, chorioamnionitis) were compared between open and laparoscopic appendectomy. Multivariable generalized linear regression models were used to compare different outcomes between two surgical approaches after adjusting for possible confounders. RESULTS: The laparoscopic cohort (n = 547, 54.4%) had significantly shorter LOS than the open group (median ± IQR: 2.00 ± 2.00 days versus 3.00 ± 2.00 days, p value < 0.0001, ratio = 0.789, 95% CI 0.727-0.856). Patients with complicated appendicitis had longer LOS than those with simple appendicitis (p value < 0.0001, ratio = 1.660, 95% CI 1.501-1.835). Obstetrical outcomes (p value = 0.097, OR 1.254, 95% CI 0.961-1.638), 30-day non-delivery readmission (p value = 0.762, OR 1.117, 95% CI 0.538-2.319), and any complications (p value = 0.753, OR 0.924, 95% CI 0.564-1.517) were not statistically significant between the laparoscopic versus open appendectomy groups. Three cases of fetal demise occurred, all within the laparoscopic appendectomy group. CONCLUSIONS: The laparoscopic approach resulted in a shorter LOS. Although fetal demise only occurred in the laparoscopic group, these results were not significant (p value = 0.255). Our large population-based study further supports current guidelines that laparoscopic appendectomy may offer benefits over open surgery for pregnant patients in any trimester due to reduced time in the hospital and fetal and maternal outcomes comparable to open appendectomy.
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Apendicite , Laparoscopia , Apendicectomia , Apendicite/cirurgia , Cesárea , Feminino , Humanos , Recém-Nascido , Tempo de Internação , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Gravidez , Estudos RetrospectivosRESUMO
An amendment to this paper has been published and can be accessed via a link at the top of the paper.
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OBJECTIVE: The objective of this study was to determine the effects of open versus laparoscopic surgery on the development of adhesive small bowel obstruction (aSBO). SUMMARY BACKGROUND DATA: aSBO is a significant contributor to short and long-term postoperative morbidity. Laparoscopy has demonstrated a protective effect in colorectal surgery, but these effects have not been generalized to other abdominal procedures. METHODS: Population level California state data (1995-2010) was analyzed. We identified patients who underwent Roux-en-Y gastric bypass (RYGB), cholecystectomy, partial colectomy, appendectomy, and hysterectomy. The primary outcome was aSBO. Clinical, patient, and hospital characteristics were assessed using Kaplan-Meir methodology and Cox regression analysis adjusting for demographics, comorbidities, and operative approach. RESULTS: We included 1,612,629 patients with a median follow-up of 6.3 years. The 5-year incidence rate of aSBO was higher after open surgery compared with laparoscopic surgery for each procedure (RYGB 2.1% vs. 1.5%, P < 0.001; cholecystectomy 2.2% vs. 0.65%, P < 0.001; partial colectomy 5.5% vs. 2.8%, P < 0.001; appendectomy 0.58% vs. 0.35%, P < 0.001; and hysterectomy 0.89% vs. 0.54%, P < 0.001). The period of greatest risk for aSBO formation was within the first 2-years. In multivariate analysis, an open approach was associated with an increased risk of aSBO for each procedure [RYGB hazard ratio (HR) 1.24, P < 0.001; cholecystectomy HR 1.89, P < 0.001; partial colectomy HR 1.49, P < 0.001; appendectomy HR 1.45, P < 0.001; and hysterectomy HR 1.16, P < 0.001). CONCLUSIONS: Laparoscopy is associated with a significant and sustained reduction in the rate of aSBO. The period of greatest risk for aSBO is within the first 2 years after surgery.
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Colecistectomia , Procedimentos Cirúrgicos do Sistema Digestório , Histerectomia , Obstrução Intestinal/epidemiologia , Intestino Delgado , Laparoscopia/métodos , Complicações Pós-Operatórias/epidemiologia , Aderências Teciduais/epidemiologia , Adulto , Idoso , California/epidemiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
BACKGROUND: A novel coronavirus (COVID-19) erupted in the latter part of 2019. The virus, SARS-CoV-2 can cause a range of symptoms ranging from mild through fulminant respiratory failure. Approximately 25% of hospitalized patients require admission to the intensive care unit, with the majority of those requiring mechanical ventilation. High density consolidations in the bronchial tree and in the pulmonary parenchyma have been described in the advanced phase of the disease. We noted a subset of patients who had a sudden, significant increase in peak airway, plateau and peak inspiratory pressures. Partial or complete ETT occlusion was noted to be the culprit in the majority of these patients. METHODS: With institutional IRB approval, we examined a subset of our mechanically ventilated COVID-19 patients. All of the patients were admitted to one of our COVID-19 ICUs. Each was staffed by a board certified intensivist. During multidisciplinary rounds, all arterial blood gas (ABG) results, ventilator settings and ventilator measurements are discussed and addressed. ARDSNet Protocols are employed. In patients with confirmed acute occlusion of the endotracheal tube (ETT), acute elevation in peak airway and peak inspiratory pressures are noted in conjunction with desaturation. Data was collected retrospectively and demographics, ventilatory settings and ABG results were recorded. RESULTS: Our team has observed impeded ventilation in intubated patients who are several days into the critical course. Pathologic evaluation of the removed endotracheal tube contents from one of our patients demonstrated a specimen consistent with sloughed tracheobronchial tissues and inflammatory cells in a background of dense mucin. Of 110 patients admitted to our adult COVID-19 ICUs, 28 patients required urgent exchange of their ETT. CONCLUSION: Caregivers need to be aware of this pathological finding, recognize, and to treat this aspect of the COVID-19 critical illness course, which is becoming more prevalent.
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Brônquios/lesões , Infecções por Coronavirus/terapia , Intubação Intratraqueal/efeitos adversos , Pneumonia Viral/terapia , Respiração Artificial/efeitos adversos , Traqueia/lesões , Adulto , Betacoronavirus , COVID-19 , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pandemias , SARS-CoV-2RESUMO
INTRODUCTION: Percutaneous cholecystostomy tube (PCT) placement is often the initial management approach to severe acute cholecystitis in the unstable patient. However, the timing of cholecystectomy after PCT has not been carefully examined. The purpose of this study was to compare outcomes of early versus late cholecystectomy following PCT placement. METHODS: The New York SPARCS administrative database was searched for all patients undergoing PCT placement between 2000 and 2012. Patients were followed for subsequent cholecystectomy (CCX) procedures up to 2014. Subsequent cholecystectomies were divided into early (≤ 8 weeks) versus late (> 8 weeks) groups. Outcomes included overall complications, 30-day readmissions, 30-day Emergency Department (ED) visits, and length of stay (LOS). Multivariable regression models were used to examine the differences in clinical outcomes between these two groups, after adjusting for possible confounding factors. RESULTS: There were 9728 patients who underwent PCT placement identified during the time period, as early subsequent cholecystectomy was performed in 1211 patients (40.4%), while 1787 (59.6%) patients had a late cholecystectomy. Average time to cholecystectomy was 38 days in the early group, versus 203 days in the late group. After adjusting for other confounding factors, patients with early CCX had a significantly higher risk of overall complications and longer LOS compared to the late CCX group (P = 0.01 and P = 0.0004, respectively). There were no significant differences in 30-day readmissions and 30-day ED visits. Furthermore, there was no significant difference in the risk of CBD injury between the two groups (n = 21, 1.7% in the early cholecystectomy group and n = 26, 1.5% in the late cholecystectomy group). CONCLUSION: Early cholecystectomy (≤ 8 weeks) is associated with a higher risk of complications and longer hospital LOS compared to cholecystectomy performed at > 8 weeks. Surgeons should be aware and should delay cholecystectomy beyond 8 weeks to improve outcomes.
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Colecistectomia/métodos , Colecistite Aguda/cirurgia , Colecistostomia/efeitos adversos , Colecistostomia/métodos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Colecistectomia/efeitos adversos , Colecistite Aguda/epidemiologia , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Morbidade , New York/epidemiologia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
INTRODUCTION: The timing of cholecystectomy for acute cholecystitis has been debated with most studies favoring early cholecystectomy (< 72 h of onset). However, most reported studies are from single institution studies with only a few population-based studies. The purpose of this study is to compare clinical outcomes of patients undergoing cholecystectomy within 72 h of emergency department (ED) presentation to patients undergoing cholecystectomy following 72 h in a large statewide database. METHODS: The New York SPARCS administrative database was used to identify all adult patients presenting to the ED with a diagnosis of acute cholecystitis from 2005 to 2016. Patients aged < 18, missing data, or other biliary diagnoses were excluded from the analysis. Early cholecystectomy was defined as within 72 h of presentation to the emergency department. Early vs late groups were compared in terms of overall complications, bile duct injury (BDI), hospital length of stay (LOS), 30-days ED visits and readmissions. The linear trends of yearly early/late cholecystectomies were examined using a log-linear Poisson regression models. Multivariable logistic regression model was used to compare complications, BDI, and 30-day readmission/ED visits after controlling for confounding factors. Multivariable generalized linear regression for a negative binomial distributed count data was used to compare LOS. RESULTS: Following the application of the inclusion/exclusion criteria, there were 109,862 patients who presented to an ED with the diagnosis of acute cholecystitis. The majority of patients underwent early cholecystectomy (n = 93,761, 85.3%), whereas only 16,101 patients underwent late cholecystectomy (14.7%). There was an increasing trend of early cholecystectomy from 2005 (81.1%) to 2016 (87.8%). On multivariable regression, patients with early cholecystectomy were less likely to have complications (OR 0.542, 95% CI 0.518-0.566), had shorter LOS (ratio 0.461, 95% CI 0.458-0.465), were less likely to have 30-day readmission (OR 0.871, 95% CI 0.816-0.928), 30-day ED visits (OR 0.909, 95% CI 0.862-0.959), and bile duct injury (OR 0.654, 95% CI 0.444-0.962) compared to late cholecystectomy patients. CONCLUSION: Early cholecystectomy (< 72 h) is associated with fewer complications, specifically BDI, shorter LOS, and fewer 30-day readmissions and ED visits. For patients presenting to the ED for acute cholecystitis, early cholecystectomy should be preferred.
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Colecistectomia/efeitos adversos , Colecistite Aguda/cirurgia , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Adolescente , Adulto , Idoso , Doenças dos Ductos Biliares/epidemiologia , Doenças dos Ductos Biliares/etiologia , Ductos Biliares/lesões , Colecistectomia/estatística & dados numéricos , Colecistite Aguda/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , New York/epidemiologia , Readmissão do Paciente/estatística & dados numéricos , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: There is limited data examining specific annual surgeon procedural volumes associated with improvement of postoperative outcomes following Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). OBJECTIVES: Effect of surgeon volume on procedural outcomes. METHODS: Using the SPARCS Administrative database, patients undergoing laparoscopic RYGB or SG between 2010-2014 were analyzed. Multivariable generalized linear mixed regression models were first used to analyze the influences of 3 yearly mean volumes (combined, RYGB and SG mean volumes) on each of three surgical outcomes: 30-day readmission, peri-operative complications, and extended length of stay (LOS), while accounting for patient specific variables. RESULTS: A total of 46,511 laparoscopic bariatric procedures were included in the study. Risk for any complication and 30-day readmissions following RYGB decreased with increasing RYGB volume up to a specific volume and stayed similar afterward (OR 0.97, 95% CI 0.96-0.98 while volume < 247.9 cases/year and OR 0.99, 95% CI 0.98-0.99 while volume < 354.1 cases/year, respectively) while risk for extended LOS decreased with increasing combined bariatric mean volume up to a specific volume and stayed similar afterward (OR 0.9, 95% CI 0.85-0.95 while volume < 62.1 cases/year). Similar patterns were found for extended LOS and complications following SG (OR 0.82, 95% CI 0.72-0.93 while SG volume < 26.3 cases/year and OR 0.94, 95% CI 0.91-0.98 while combined volume < 62.1 cases/year, respectively), while 30-day readmission following SG significantly increased when combined bariatric volume being more than 138 cases/year (OR 1.10, 95% CI 1.00-1.21 while combined volume > 138 cases/year)). CONCLUSIONS: Bariatric procedure peri-operative outcomes are affected by procedure-specific annual surgeons' volume.
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Gastrectomia/estatística & dados numéricos , Derivação Gástrica/estatística & dados numéricos , Laparoscopia/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Cirurgiões/estatística & dados numéricos , Adulto , Bases de Dados Factuais , Feminino , Gastrectomia/efeitos adversos , Derivação Gástrica/efeitos adversos , Humanos , Laparoscopia/métodos , Tempo de Internação/estatística & dados numéricos , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Obesidade Mórbida/cirurgia , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Resultado do TratamentoRESUMO
INTRODUCTION: Management of patients on chronic anticoagulation (AC) in bariatric surgery may present a challenge, as there is a delicate balance between risks of bleeding and thrombotic events, such as deep vein thrombosis (DVT) and pulmonary embolism (PE). The purpose of this study was to evaluate and compare rates of bleeding, thrombotic events, and outcomes of patients on preoperative AC during bariatric surgery. METHODS: The MBSAQIP data sets for 2015 and 2016 was used to identify all patients undergoing adjustable gastric banding (AGB), sleeve gastrectomy (SG), and Roux-en-Y gastric bypass (RYGB). Clinical outcomes included length of stay, 30-day readmission, 30-day reoperations and interventions, perioperative and 30-day death events, need for transfusion, PE, and DVT. Following univariate analysis, multivariable logistic regression models and generalized linear regression model for a negative binomial distributed count outcomes were used after adjusting for surgery type and other factors related to each outcome. RESULTS: There were 269,243 records extracted, as there were 6541 (2.43%) patients on preoperative AC. Rates of transfusion, DVT, and PE were 0.67%, 0.18%, and 0.11%. Following multivariable logistic regression, patients with preoperative AC had higher risks of bleeding and DVT (OR 2.7, 95% CI 2.3-3.3, p-value < 0.0001 and OR 2.8, 95% CI 1.9-4, p-value < 0.0001, respectively). In addition, patients with pre-op AC had a higher risk of 30-day readmission (OR 2.1, 95% CI 1.9-2.3, p < 0.0001)/reoperation (OR 1.5, 95% CI 1.2-1.7, p < 0.0001)/reintervention (OR 2.1, 95% CI 1.8-2.4, p < 0.0001), mortality (OR 2.9, 95% CI 2.04-4.069, p < 0.0001), and longer LOS (ratio 1.2, 95% CI 1.199-1.241, p < 0.0001). CONCLUSION: Patients with preoperative AC had worse postoperative outcomes. Bariatric surgeons should be aware of the increased morbidity and mortality, and care must be taken to improve outcomes through close attention to postoperative AC protocols in this group of patients.
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Anticoagulantes/uso terapêutico , Cirurgia Bariátrica/efeitos adversos , Obesidade Mórbida/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Cuidados Pré-Operatórios , Adulto , Anticoagulantes/efeitos adversos , Cirurgia Bariátrica/métodos , Perda Sanguínea Cirúrgica/prevenção & controle , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente , Hemorragia Pós-Operatória/etiologia , Hemorragia Pós-Operatória/prevenção & controle , Embolia Pulmonar/etiologia , Embolia Pulmonar/prevenção & controle , Reoperação , Resultado do Tratamento , Trombose Venosa/etiologia , Trombose Venosa/prevenção & controleRESUMO
BACKGROUND: Pancreatic cancer (PC) hijacks innate cellular processes to promote cancer growth. We hypothesized that PC exploits PD-1/PD-L1 not only to avoid immune responses, but to directly enhance growth. We also hypothesized that immune checkpoint inhibitors (ICIs) have direct cytotoxicity in PC. We sought to elucidate therapeutic targeting of PD-1/PD-L1. METHODS: PD-1 was assessed in PC cells, patient-derived organoids (PDOs), and clinical tissues. Then, PC cells were exposed to PD-L1 to evaluate proliferation. To test PD-1/PD-L1 signaling, cells were exposed to PD-L1 and MAPK was examined. Radio-immunoconjugates with anti-PD-1 drugs were developed to test uptake in patient-derived tumor xenografts (PDTXs). Next, PD-1 function was assessed by xenografting PD-1-knockdown cells. Finally, PC models were exposed to ICIs. RESULTS: PD-1 expression was demonstrated in PCs. PD-L1 exposure increased proliferation and activated MAPK. Imaging PDTXs revealed uptake of radio-immunoconjugates. PD-1 knockdown in vivo revealed 67% smaller volumes than controls. Finally, ICI treatment of both PDOs/PDTXs demonstrated cytotoxicity and anti-MEK1/2 combined with anti-PD-1 drugs produced highest cytotoxicity in PDOs/PDTXs. CONCLUSIONS: Our data reveal PCs innately express PD-1 and activate druggable oncogenic pathways supporting PDAC growth. Strategies directly targeting PC with novel ICI regimens may work with adaptive immune responses for optimal cytotoxicity.
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Antígeno B7-H1/imunologia , Imunoterapia , Neoplasias Pancreáticas/tratamento farmacológico , Receptor de Morte Celular Programada 1/imunologia , Animais , Antígeno B7-H1/antagonistas & inibidores , Proliferação de Células/efeitos dos fármacos , Feminino , Humanos , Masculino , Camundongos , Organoides/efeitos dos fármacos , Organoides/imunologia , Neoplasias Pancreáticas/genética , Neoplasias Pancreáticas/imunologia , Neoplasias Pancreáticas/patologia , Cultura Primária de Células , Receptor de Morte Celular Programada 1/antagonistas & inibidores , Transdução de Sinais/efeitos dos fármacos , Ensaios Antitumorais Modelo de XenoenxertoRESUMO
BACKGROUND: Marginal ulcerations (MU) are a common and concerning complication following Roux-en-Y gastric bypass (RYGB) surgery. The aim of the present study was to examine the progression of MU and identify risk factors for the need for surgical intervention in patients with MU following RYGB. METHODS: A New York state longitudinal administrative database was queried to identify patients who underwent RYGB between 2005 and 2010 and who were followed for at least 4 years for the development of MU using ICD-9 and CPT codes. Patients with perforation as their first presentation of MU were excluded. Multivariable Cox proportional hazard model was built to identify risk factors for surgical intervention. Hazard ratios (HR) with 95% confidence intervals (CI) were reported. RESULTS: We identified 35,075 patients who underwent RYGB. Mean age was 42.47 ± 10.90 years and most were female (81.08%). There were 2201 (6.28%) patients with MU, of which 204 (9.27% of MU; 0.58% of RYGB overall) required surgery. The estimated cumulative incidence of having surgical intervention 1, 2, 5, and 8 years after MU diagnosis was 6% (95% CI 5-7%), 8% (95% CI 7-9%), 13% (95% CI 11-14%), and 17% (95% CI 13-20%), respectively. At time of MU diagnosis, younger age (HR 0.93 every 5 years, 95% CI 0.87-0.99), white race (HR 1.60, 95% CI 1.15-2.23), and weight loss (HR 2.82, 95% CI 1.62-4.88) were independent risk factors for subsequent surgical intervention for MU. Estimated cumulative incidence of MU recurrence was 15% (95% CI 9-22%) and 24% (95 CI% 15-32%) at 6 and 12 months after surgical intervention. CONCLUSIONS: The need for surgical intervention for MU after RYGB is uncommon. Young age, white race, and marked weight loss are risk factors for surgical intervention. Such patients may benefit from early intensive medical therapy at the time of MU diagnosis.
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Derivação Gástrica/efeitos adversos , Úlcera Péptica , Complicações Pós-Operatórias , Adulto , Feminino , Derivação Gástrica/métodos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Úlcera Péptica/diagnóstico , Úlcera Péptica/etiologia , Úlcera Péptica/prevenção & controle , Úlcera Péptica/cirurgia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/prevenção & controle , Complicações Pós-Operatórias/cirurgia , Modelos de Riscos Proporcionais , Reoperação/métodos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Redução de PesoRESUMO
BACKGROUND: Roux-en-Y-gastric bypass (RYGB) and sleeve gastrectomy (SG) are commonly performed bariatric procedures that are associated with a significant learning curve. The effect of surgeon experience on perioperative outcomes and safety is established, but the effect of trainee participation remains unclear. The purpose of this study was to assess the impact of trainees on early perioperative safety of bariatric surgery. METHODS: Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database for 2015 was used to identify non-revisional laparoscopic and robotic RYGB and SG procedures. Comparisons were made based on assistant level. Multivariable logistic and linear regression methodology was used to compare clinical outcomes. RESULTS: There were 35,354 laparoscopic RYGB, 2896 robotic RYGB, 79,717 laparoscopic SG, and 5449 robotic SG procedures examined. 21,257 (17%) and 11,322 (9%) of all procedures were performed with a resident or fellow, respectively. Fellow presence was independently associated with the development of complications for all procedure types except robotic SG when compared to non-trainee [odds ratio (OR) 1.31, 2.20, 1.28 for laparoscopic RYGB, robotic RYGB, and laparoscopic SG, respectively]. The most common events were urinary tract and superficial surgical site infections. This negative impact of fellow on overall complications was eliminated after accounting for operative duration. In laparoscopic SG, resident participation was associated with higher leak rate (OR 1.61), readmission (OR 1.18), re-intervention (OR 1.4), and complication rate (OR 1.32) compared to non-trainee, even after accounting for procedural duration. In robotic SG, there was no impact of trainee on outcomes. CONCLUSIONS: Although fellow training is associated with higher overall complication rate, there is no such impact on major safety benchmarks, including leak rate and re-operation. In contrast, the impact of resident trainees on SG outcomes is substantial. Operative involvement of trainees in bariatric surgery leads to different outcomes based on trainee level and should be judiciously considered during the programmatic design of bariatric educational curricula.
Assuntos
Cirurgia Bariátrica/educação , Educação de Pós-Graduação em Medicina/normas , Cirurgia Geral/educação , Laparoscopia/educação , Curva de Aprendizado , Obesidade Mórbida/cirurgia , Robótica/educação , Adulto , Cirurgia Bariátrica/normas , Feminino , Humanos , Laparoscopia/normas , Masculino , Estudos Retrospectivos , Robótica/normasRESUMO
BACKGROUND: Since the introduction of laparoscopic cholecystectomy (LC), there has been continued evolution in technique, instrumentation and postoperative management. With increased experience, LC has migrated to the outpatient setting. We asked whether increased availability and experience has impacted incidence of and indications for LC. METHODS: The New York (NY) State Planning and Research Cooperative System longitudinal administrative database was utilized to identify patients who underwent cholecystectomy between 1995 and 2013. ICD-9 and CPT procedure codes were extracted corresponding to laparoscopic and open cholecystectomy and the associated primary diagnostic codes. Data were analyzed as relative change in incidence (normalized to 1000 LC patients) for respective diagnoses. RESULTS: From 1995 to 2013, 711,406 cholecystectomies were performed in NY State: 637,308 (89.58 %) laparoscopic. The overall frequency of cholecystectomy did not increase (1.23 % increase with a commensurate population increase of 6.32 %). Indications for LC during this time were: 72.81 % for calculous cholecystitis (n = 464,032), 4.88 % for biliary colic (n = 31,124), 8.98 % for acalculous cholecystitis (n = 57,205), 3.01 % for gallstone pancreatitis (n = 19,193), and 1.59 % for biliary dyskinesia (n = 10,110). The incidence of calculous cholecystitis declined (-20.09 %, p < 0.0001) between 1995 and 2013; meanwhile, other diagnoses increased in incidence: biliary colic (+54.96 %, p = 0.0013), acalculous cholecystitis (+94.24 %, p < 0.0001), gallstone pancreatitis (+107.48 %, p < 0.0001), and biliary dyskinesia (+331.74 %, p < 0.0001). Outpatient LC incidence catapulted to 48.59 % in 2013, from 0.15 % in 1995, increasing >320-fold. Analysis of LC through 2014 revealed increasing rates of digestive, infectious, respiratory, and renal complications, with overall cholecystectomy complication rates of 9.29 %. CONCLUSION: A shifting distribution of operative indications and increasing rates of complications should prompt careful consideration prior to surgery for benign biliary disease. For what is a common procedure, LC carries substantial risk of complications, thus requiring the patient to be an active participant and to share in the decision-making process.
Assuntos
Doenças dos Ductos Biliares/cirurgia , Discinesia Biliar/cirurgia , Colecistectomia Laparoscópica , Colecistite/cirurgia , Adolescente , Adulto , Doenças dos Ductos Biliares/epidemiologia , Discinesia Biliar/epidemiologia , Colecistectomia Laparoscópica/métodos , Colecistite/epidemiologia , Feminino , Humanos , Incidência , Classificação Internacional de Doenças , Masculino , Pessoa de Meia-Idade , New York/epidemiologia , Complicações Pós-Operatórias , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Asymptomatic contralateral inguinal hernias are often present during initial inguinal hernia repair. Data on long-term results and progression to symptomaticity are sparse. The purpose of this study was to assess long-term rates and risk factors for contralateral inguinal hernia repair following unilateral inguinal hernia repair. METHODS: Using New York Statewide Planning and Research Collaborative administrative data, 32,384 adults who underwent initial inguinal hernia repair during 2002-2003 in New York State and achieved 10-year follow-up were identified. ICD-9 and CPT codes were used to identify patients. Patients were followed for 10 years subsequent to their operation to assess for contralateral repair. Those who did not achieve 10-year follow-up were excluded. Risk factors were compared using descriptive univariate statistics. Significant variables were then analyzed via multivariate regression models. RESULTS: For adult patients having primary unilateral hernia repair, 3364 patients (6.73 %) had contralateral repair during the follow-up period. After excluding "loss of follow-up" patients, the contralateral repair rate was 10.8 %. Contralateral hernia repairs first occurred at a mean of 3.9 ± 3.5 years and a median of 2.5 years after the initial surgery. Risk factors included age >45 years (OR 1.7 [1.4-2.0], p < 0.001), male gender (OR 2.2 [1.9-2.6], p < 0.0001), and white race (OR 1.6 [1.1-2.4], p < 0.001). Factors associated with decreased likelihood for repair included: congestive heart failure (OR 0.6 [0.4-0.9], p = 0.01), diabetes (OR 0.7 [0.5-0.8], p = 0.02), neurological disorders (OR 0.6 [0.4-0.9], p = 0.02), obesity (OR 0.3 [0.1-0.8], p = 0.01), and alcohol abuse (OR 0.2 [0.03-0.8], p = 0.03). CONCLUSION: The 10-year probability of necessitating a contralateral inguinal hernia repair is significant. Elderly white males were more likely to undergo repair. Those less likely to undergo repair had significant comorbid conditions, possibly due to their poor suitability for intervention. These data highlight a key benefit of the laparoscopic approach over open repairs. Based on these data, an argument for laparoscopy with routine contralateral inspection in higher-risk patients can be made.
Assuntos
Hérnia Inguinal/cirurgia , Herniorrafia/métodos , Adolescente , Adulto , Idoso , Alcoolismo/epidemiologia , Estudos de Coortes , Bases de Dados Factuais , Diabetes Mellitus/epidemiologia , Progressão da Doença , Etnicidade/estatística & dados numéricos , Feminino , Seguimentos , Insuficiência Cardíaca/epidemiologia , Hérnia Inguinal/epidemiologia , Herniorrafia/estatística & dados numéricos , Humanos , Incidência , Classificação Internacional de Doenças , Laparoscopia/métodos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Doenças do Sistema Nervoso/epidemiologia , New York/epidemiologia , Obesidade/epidemiologia , Fatores de Risco , Fatores Sexuais , População Branca/estatística & dados numéricos , Adulto JovemRESUMO
BACKGROUND: With increasing interest in natural orifice surgery, there has been a dramatic evolution of transanal and endoluminal surgical techniques. These techniques began with transanal endoluminal surgical removal of rectal masses and have progressed to transanal radical proctectomy for rectal cancer. The first transanal total mesorectal excision (taTME) was performed in 2009 by Sylla, Rattner, Delgado, and Lacy. The improved visibility and working space associated with the taTME technique is intriguing. This video manuscript outlines the training pathway followed by pioneers in the taTME technique, the process of implementation into clinical practice, and initial case report. METHODS: A double board-certified colorectal surgeon with expertise in rectal cancer, minimally invasive total mesorectal excision, transanal endoscopic surgery (TES), and intersphincteric dissection, underwent taTME training in male cadaver models. Institutional review board (IRB) approval for a phase I clinical trial was achieved. The entire operative team including surgeons, nurses, and operative staff underwent taTME cadaver training the day prior to the first clinical case. The case was proctored by an expert in taTME. RESULTS: A 66-year-old male with uT3N1M0 rectal cancer located in the posterior distal rectum, underwent taTME with laparoscopic abdominal assistance, hand sewn coloanal anastomosis, and diverting loop ileostomy. The majority of the TME was performed transanally with laparoscopic assistance for exposure, splenic flexure mobilization, and high ligation of the vascular pedicles. Operative time was 359 min. There were no intraoperative complications. Pathology revealed a ypT2N1 moderately differentiated invasive adenocarcinoma, grade I TME, 1 cm circumferential radial margin, and 2/13 positive lymph nodes. CONCLUSION: Implementation of taTME into practice can be achieved by surgeons with expertise in minimally invasive TME, TES, pre-clinical taTME training in cadavers, case observation, proctoring, and ongoing mentorship. IRB peer review process and participation in a clinical registry are additional measures that should be employed.
Assuntos
Adenocarcinoma/cirurgia , Canal Anal/cirurgia , Colo/cirurgia , Ileostomia/métodos , Mesentério/cirurgia , Neoplasias Retais/cirurgia , Reto/cirurgia , Cirurgia Endoscópica Transanal/métodos , Idoso , Anastomose Cirúrgica/educação , Anastomose Cirúrgica/métodos , Cadáver , Humanos , Ileostomia/educação , Laparoscopia/educação , Laparoscopia/métodos , Masculino , Duração da Cirurgia , Cirurgia Endoscópica Transanal/educaçãoRESUMO
OBJECTIVE: This study aims to determine the long-term outcomes of diverticulitis and to apply the findings to current practice patterns. BACKGROUND: The long-term morbidity and mortality of diverticulitis are not well defined. Current practice guidelines for diverticulitis are based on limited evidence. METHODS: The California Office of Statewide Health Planning and Development database was queried for longitudinal observations across all hospitals from 1995 to 2009. Recurrence up to 15 years, medical versus surgical treatment, and mortality after recurrence were analyzed for patients after emergent admission for diverticulitis. RESULTS: Among the 210,268 patients admitted emergently with diverticulitis, 179,649 (85%) were managed medically at their index admission. Of these medically managed patients, 27,450 (16.3%) suffered a second diverticulitis episode. On multivariable analysis, predictors of mortality with recurrence included the following [hazard ratio (95% confidence interval)]: age more than 50 years [5.19, (3.05-8.29)]; previous tobacco use [1.40 (1.18-1.66)]; and complicated initial presentation with obstruction [1.33 (1.06-1.65)], abscess [2.18 (1.60-2.97)], peritonitis [3.14 (1.99-4.97)], sepsis [1.88 (1.29-2.73)], and fistula [3.50 (2.17-5.66)]. The mortality of delayed elective surgical intervention after the first episode of emergent diverticulitis was 0.3% compared to 4.6% for emergent resection during a second episode. CONCLUSIONS: Eighty-five percent of emergent diverticulitis patients do not recur after initial medical treatment. However, in view of significantly worse outcomes associated with diverticulitis recurrence, resection should be strongly considered for diverticulitis patients older than 50 years or those who present with a complicated clinical picture.