Associations between income and survival in cholangiocarcinoma: A comprehensive subtype-based analysis.

Backgrounds/Aims: Socioeconomic determinants of health are incompletely characterized in cholangiocarcinoma (CCA). We assessed how socioeconomic status influences initial treatment decisions and survival outcomes in patients with CCA, additionally performing multiple sub-analyses based on anatomic location of the primary tumor. Methods: Observational study using the 2018 submission of the Surveillance, Epidemiology, and End Results (SEER)-18 Database. In total, 5,476 patients from 2004-2015 with a CCA were separated based on median household income (MHI) into low income (< 25th percentile of MHI) and high income (> 25th percentile of MHI) groups. Seventy-three percent of patients had complete follow up data, and were included in survival analyses. Survival and treatment outcomes were calculated using R-studio. Results: When all cases of CCA were included, the high-income group was more likely than the low-income to receive surgery, chemotherapy, and local tumor destruction modalities. Initial treatment modality based on income differed significantly between tumor locations. Patients of lower income had higher overall and cancer-specific mortality at 2 and 5 years. Non-cancer mortality was similar between the groups. Survival differences identified in the overall cohort were maintained in the intrahepatic CCA subgroup. No differences between income groups were noted in cancer-specific or overall mortality for perihilar tumors, with variable differences in the distal cohort. Conclusions: Lower income was associated with higher rates of cancer-specific mortality and lower rates of surgical resection in CCA. There were significant differences in treatment selection and outcomes between intrahepatic, perihilar, and distal tumors. Population- based strategies aimed at identifying possible etiologies for these disparities are paramount to improving patient outcomes.

Active narcotic use and post-peroral endoscopic myotomy outcomes in esophageal motility disorders.

BACKGROUND AND AIMS: Peroral endoscopic myotomy (POEM) is a minimally invasive technique used to treat esophageal motility disorders. Opioid use has been demonstrated to adversely affect esophageal dysmotility and is associated with an increased prevalence of esophageal motility disorders. Our aim was to investigate the effect of narcotic use on success rates in patients undergoing POEM. METHODS: This was a single-center, retrospective study of patients undergoing POEM between February 2017 and September 2021. Primary outcomes were post-POEM Eckardt score (ES), distensibility index, and length of procedure. Secondary outcomes included technical success, myotomy length, length of stay, adverse events, reintervention rates, and postprocedure GERD. RESULTS: During the study period, 90 patients underwent POEM for treatment of esophageal dysmotility disorders. Age, sex, race, indications for POEM, and body mass index were not significant between those with or without narcotic use. There were no differences in procedure time, preprocedure ESs, or length of stay. Postprocedure ESs were higher in the group with active narcotic use compared to the group with no prior history (2.73 vs 1.2, P = .004). Distensibility indexes measured with EndoFLIP (Medtronic, Minneapolis, Minn, USA) were not different in patients using narcotics compared with opioid-naïve patients. CONCLUSION: Active narcotic use negatively affects symptom improvement after POEM for the treatment of esophageal motility disorders.

Comparing clinical success and procedural difficulty between treatment-naïve and treatment-refractory patients with esophageal motility disorders during peroral endoscopic myotomy.

BACKGROUND AND AIMS: Peroral endoscopic myotomy (POEM) can successfully treat patients with achalasia. Prior therapy with Botox (Allergan, Madison, NJ, USA) injections, pneumatic dilation (PD), and/or laparoscopic Heller myotomy (LHM) is believed to increase the difficulty of POEM procedures. We aimed to determine if prior treatment methods were associated with longer procedure times or lower clinical success. METHODS: In this single-center retrospective study, consecutive patients who underwent POEM for achalasia between February 2017 and September 2021 were studied. Collected data were patient demographics, prior treatment, pre- and postprocedure Eckardt score (ES), distensibility indices (DIs), and procedure times. Primary outcomes were clinical success and procedure difficulty. RESULTS: Of 95 patients (mean age, 55.6 years; 45% women), 25 patients underwent POEM for type I achalasia, 31 for type II achalasia, and 33 for spastic esophageal pathologies. Thirty-three patients (34.7%) were treated for achalasia before POEM with onabotulinumtoxinA injections (n = 18), PD (n = 17), and LHM (n = 3). There were no significant differences in post-treatment ESs or technical success between the 2 groups (P = .98 and P = .66, respectively). Multivariate analysis showed that prior treatment was associated with decreased case time and easier tunneling during POEM. CONCLUSIONS: Prior treatment did not impact the clinical success rate of POEM and led to decreased case times and easier tunneling difficulty, likely because of persistent lower esophageal sphincter changes and differences in diagnostic indications. POEM should be considered for patients with treatment-refractory symptoms as a safe and feasible option. Further large-scale studies are needed to validate our findings.

The diagnostic performance of probe-based confocal laser endomicroscopy in the detection of gastric cancer: a systematic review and meta-analysis.

Background: Gastric cancer (GC) represents a significant global health burden with high morbidity and mortality, especially when diagnosed at advanced stages. Therefore, early detection of GC is critical. Probe-based confocal laser endomicroscopy (pCLE) is a new evolving technology that uses real-time, high-resolution imaging to inspect the mucosa at the cellular and microvascular level, using a confocal probe. Widespread studies using pCLE are limited at the current time. We aimed to investigate the diagnostic efficacy of this modality for the detection of GC. Methods: Multiple databases were searched from inception until November 2021. The diagnostic performance of pCLE was assessed by calculating its sensitivity, specificity and accuracy for the detection of GC, using pooled proportions and 95% confidence intervals (CI) with a random-effects model. Heterogeneity was assessed using I2. Results: Seven studies were included, with a total of 567 patients (mean age 61.7 years, 364 males). Pooled performance metrics of pCLE included a sensitivity of 87.9% (95%CI 81.4-92.4; P<0.001; I2=0%), specificity 96.5% (95%CI 91.5-98.6; P<0.001; I2=51.84%), and an accuracy of 94.7% (95%CI 89.5-97.4; P<0.001; I2=65.44%). Conclusions: pCLE is a highly effective diagnostic modality for detecting GC. Larger, randomized controlled studies are needed to determine its role in daily practice compared to conventional endoscopic practices.

Preoperative Factors Associated with 2-Year Postoperative Survey Completion in Knee Surgery Patients.

Patient-reported outcomes, such as the Patient-Reported Outcomes Measurement Information System (PROMIS) measures, have become increasingly valued as measures of treatment. The purpose of the study was to determine preoperative factors associated with survey compliance 2 years after elective knee surgery. Five hundred patients, age 17 years and older, undergoing knee surgery from August 2015 and March 2017 were administered questionnaires preoperatively and 2 years postoperatively. Questionnaires included the International Knee Documentation Committee (IKDC) score, Numeric Pain Scales (NPS), International Physical Activity Questionnaire (IPAQ), and six PROMIS Domains for physical function, pain interference, social satisfaction, fatigue, anxiety, and depression. Three hundred sixty-five patients (73.0%) completed both the preoperative and the 2-year surveys. A decreased likelihood of survey completion was significantly associated with black race, lower income, government-sponsored insurance, smoking, opioid use, fewer previous surgeries, lower expectations, lower PROMIS social satisfaction, higher PROMIS pain interference, and lower IPAQ physical activity. Multivariable logistic regression analysis confirmed that black race and lower IPAQ activity level were independent predictors of lower survey completion at 2-year follow-up with an area under the curve (AUC) of 0.62. A more robust multivariable model that included all variables with p < 0.05 in the bivariate analysis had an AUC of only 0.70. This study identified multiple preoperative factors that were associated with lower survey completion 2 years after elective orthopaedic knee surgery; however, all the factors measured in this study were not strong predictors of survey completion.