Is minimally invasive surgery for large gastric GIST actually safe? A comparative analysis of short- and long-term outcomes.

INTRODUCTION: While minimally invasive surgery (MIS) is frequently utilized to remove small gastric gastrointestinal stromal tumors (GIST), MIS surgery for tumors ≥ 5 cm is currently not endorsed by national guidelines as standard of care due to concerns of safety and inferior oncologic outcomes. Hence this study investigates the perioperative and long-term outcomes of MIS for T3 gastric GIST measuring 5-10 cm. METHODS: The National Cancer Database (NCDB) 2017 was queried for gastric GIST measuring 5-10 cm or T3 category. Inclusion criteria were known: stage, size, comorbidities, grade, lymphovascular invasion, type of surgery, approach, conversion info, margin status, mitotic rate, neoadjuvant and adjuvant treatment, hospital stay, readmission, 30- and 90-day mortality, complete follow-up, type of institution, and hospital gastric surgery case volume. Binary logistic regression, linear regression models, and Kaplan-Meier survival analysis were used. RESULTS: In 3765 patients, mean tumor size was 67.3 mm; 26.3% MIS; and 73.8% open. Median hospital stay was shorter for MIS (4.77 vs 7.04 days, p < 0.001). There was no significant difference in incidence of R1 margins [2.9% MIS vs. 3.1% open (p = 0.143)], unplanned readmission [2.9% MIS and 4.1% open (OR 0.474 p = 0.025)], 30-day mortality [0.5% MIS vs 1.2% open (OR 0.325, p = 0.031)], and 90-day mortality [0.9% MIS vs 2.1% open (OR 0.478 p = 0.036)]. Cox regression models for OS showed no difference in survival (p = 0.137, HR 0.808). CONCLUSION: This analysis provides substantial evidence that MIS for gastric GIST ≥ 5-10 cm may not only offer improved postoperative morbidity but also oncologic safety. Moreover, as both approaches lead to similar long-term survival, national guidelines may need to incorporate this new information.

Expansion coverage and preferential utilization of cancer surgery among racial and ethnic minorities and low-income groups.

BACKGROUND: The Affordable Care Act Medicaid expansion demonstrated inconsistent effects on cancer surgery utilization rates among racial and ethnic minorities and low-income Americans. This quasi-experimental study examines whether Medicaid expansion differentially increased the utilization of surgical cancer care for low-income groups and racial minorities in states that expanded their Medicaid programs. METHODS: A cohort of more than 81,000 patients 18 to 64 years of age who underwent cancer surgery were examined in Medicaid expansion versus nonexpansion states. This evaluation utilized merged data from the State Inpatient Database, American Hospital Association, and the Area Resource File for the years 2012 to 2015. Poisson interrupted time series analysis were performed to examine the impact of Medicaid expansion on the utilization of cancer surgery for the uninsured overall, low-income persons, and racial minorities, adjusting for age, sex, Elixhauser comorbidity score, population-level characteristics, and provider-level characteristics. RESULTS: For persons from low-income ZIP codes, Medicaid expansion was associated with an immediate 24% increase in utilization (P = .002) relative to no significant change in nonexpansion states. No significant trends, however, were observed after the Affordable Care Act expansion for racial and ethnic minorities in expansion versus nonexpansion states. CONCLUSION: Medicaid expansion was associated with greater utilization of cancer surgery by low-income Americans but provided no preferential effects for racial minorities in expansion states. Beyond the availability of coverage, these findings highlight the need for additional investigation to uncover other factors that contribute to race-ethnic disparities in surgical cancer care.

The Affordable Care Act's Medicaid expansion and utilization of discretionary vs. non-discretionary inpatient surgery.

BACKGROUND: While pre-Affordable Care Act expansions in Medicaid eligibility led to increased utilization of elective inpatient procedures, the impact of the Affordable Care Act on such preference-sensitive procedures (also known as discretionary procedures) versus time-sensitive non-discretionary procedures remains unknown. As such, we performed a hospital-level quasi-experimental evaluation to measure the differential effects of the Affordable Care Act's Medicaid expansion on utilization of discretionary procedures versus non-discretionary procedures. METHODS: The State Inpatient Database (2012-2014) yielded 476 hospitals providing selected discretionary procedures or non-discretionary procedures performed on 288,446 non-elderly, adult patients across 3 expansion states and 2 non-expansion control states. Discretionary procedures included non-emergent total knee and hip arthroplasty, while non-discretionary procedures included nine cancer surgeries. Mixed Poisson interrupted time series analyses were performed to determine the impact of the Affordable Care Act's Medicaid expansion on the number of discretionary procedures versus non-discretionary procedures provided among non-privately insured patients (Medicaid and uninsured patients) and privately insured patients. RESULTS: Analysis of the number of non-privately insured procedures showed an increase in discretionary procedures of +15.1% (IRR 1.15, 95% CI:1.11-1.19) vs -4.0% (IRR 0.96, 95% CI:0.94-0.99) and non-discretionary procedures of +4.1% (IRR 1.04, 95% CI:1.0-1.1) vs -5.3% (IRR 0.95, 95% CI:0.93-0.97) in expansion states compared to non-expansion states, respectively. Analysis of privately insured procedures showed no statistically meaningful change in discretionary procedures or non-discretionary procedures in either expansion or non-expansion states. CONCLUSION: In this multi-state evaluation, the Affordable Care Act's Medicaid expansion preferentially increased utilization of discretionary procedures versus non-discretionary procedures in expansion states compared to non-expansion states among non-privately insured patients. These preliminary findings suggest that increased Medicaid coverage may have contributed to the increased use of inpatient surgery for discretionary procedures.