Gastric cancer in Sub-Saharan Africa - a systematic review of primary data.

Introduction: Gastric cancer (GC) is the third leading cause of global cancer-related mortality. Despite the shifting burden of GC to low-and middle-income countries, the data regarding incidence, treatment, and outcomes in these settings are sparse. The primary aim of this systematic review was to aggregate all available data on GC in sub-Saharan Africa (SSA) to describe the variability in incidence across the region. Methods: Studies reporting population-based primary data on GC in SSA were considered. The inclusion was limited to primary studies published between January 1995 and March 2022 which comprised of adult patients in SSA with GC. Studies without accessible full text in either French or English language were excluded. Unadjusted GC incidence rates with their standard errors for each study were recalculated from the crude numerators and denominators provided in individual studies. Results: A total of 5,626 articles were identified in the initial search, of which, 69 studies were retained. Reported incidence rates ranged from a high of 5.56 GC cases per 100,000 in Greater Meru Kenya to a low of 0.04 GC cases per 100,000 people in Benin City Nigeria. The overall crude pooled incidence was 1.20 GC cases per 100, 000 (95%CI 1.15-1.26) with a variability of 99.83% (I2 p < 0.001). From the 29 high-quality population-based registry studies the crude pooled incidence was 1.71 GC cases per 100,000 people (95%CI 1.56-21.88) with a variability of 99.60%. Conclusion: This systemic review demonstrates that GC incidence is highly variable across SSA. The limited data on GC treatment, mortality, and survival presents a significant challenge to providing a complete epidemiologic description of the burden of GC in SSA. There is a need for further robust data collection, exploration, and research studies on cancer care in SSA, with continued assessment of primary data availability.

A Novel Machine Learning Approach to Predict Textbook Outcome in Colectomy.

BACKGROUND: Several calculators exist to predict risk of postoperative complications. However, in low-risk procedures such as colectomy, a tool to determine the probability of achieving the ideal outcome could better aid clinical decision-making, especially for high-risk patients. A textbook outcome is a composite measure that serves as a surrogate for the ideal surgical outcome. OBJECTIVE: To identify the most important factors for predicting textbook outcomes in patients with nonmetastatic colon cancer undergoing colectomy and to create a textbook outcome decision support tool using machine learning algorithms. DESIGN: This was a retrospective analysis study. SETTINGS: Data were collected from the American College of Surgeons National Surgical Quality Improvement Program database. PATIENTS: Adult patients undergoing elective colectomy for nonmetastatic colon cancer (2014-2020) were included. MAIN OUTCOME MEASURES: Textbook outcome was the main outcome, defined as no mortality, no 30-day readmission, no postoperative complications, no 30-day reinterventions, and a hospital length of stay of ≤5 days. Four models (logistic regression, decision tree, random forest, and eXtreme Gradient Boosting) were trained and validated. Ultimately, a web-based calculator was developed as proof of concept for clinical application. RESULTS: A total of 20,498 patients who underwent colectomy for nonmetastatic colon cancer were included. Overall, textbook outcome was achieved in 66% of patients. Textbook outcome was more frequently achieved after robotic colectomy (77%), followed by laparoscopic colectomy (68%) and open colectomy (39%, p < 0.001). eXtreme Gradient Boosting was the best performing model (area under the curve = 0.72). The top 5 preoperative variables to predict textbook outcome were surgical approach, patient age, preoperative hematocrit, preoperative oral antibiotic bowel preparation, and patient sex. LIMITATIONS: This study was limited by its retrospective nature of the analysis. CONCLUSIONS: Using textbook outcome as the preferred outcome may be a useful tool in relatively low-risk procedures such as colectomy, and the proposed web-based calculator may aid surgeons in preoperative evaluation and counseling, especially for high-risk patients. See Video Abstract . UN NUEVO ENFOQUE DE APRENDIZAJE AUTOMTICO PARA PREDECIR EL RESULTADO DE LOS LIBROS DE TEXTO EN COLECTOMA: ANTECEDENTES:Existen varias calculadoras para predecir el riesgo de complicaciones posoperatorias. Sin embargo, en procedimientos de bajo riesgo como la colectomía, una herramienta para determinar la probabilidad de lograr el resultado ideal podría ayudar mejor a la toma de decisiones clínicas, especialmente para pacientes de alto riesgo. Un resultado de libro de texto es una medida compuesta que sirve como sustituto del resultado quirúrgico ideal.OBJETIVO:Identificar los factores más importantes para predecir el resultado de los libros de texto en pacientes con cáncer de colon no metastásico sometidos a colectomía y crear una herramienta de apoyo a la toma de decisiones sobre los resultados de los libros de texto utilizando algoritmos de aprendizaje automático.DISEÑO:Este fue un estudio de análisis retrospectivo.AJUSTES:Los datos se obtuvieron de la base de datos del Programa Nacional de Mejora de la Calidad del Colegio Americano de Cirujanos.PACIENTES:Se incluyeron pacientes adultos sometidos a colectomía electiva por cáncer de colon no metastásico (2014-2020).MEDIDAS PRINCIPALES DE RESULTADO:El resultado de los libros de texto fue el resultado principal, definido como ausencia de mortalidad, reingreso a los 30 días, complicaciones posoperatorias, reintervenciones a los 30 días y una estancia hospitalaria ≤5 días. Se entrenaron y validaron cuatro modelos (regresión logística, árbol de decisión, bosque aleatorio y XGBoost). Finalmente, se desarrolló una calculadora basada en la web como prueba de concepto para su aplicación clínica.RESULTADOS:Se incluyeron un total de 20.498 pacientes sometidos a colectomía por cáncer de colon no metastásico. En general, el resultado de los libros de texto se logró en el 66% de los pacientes. Los resultados de los libros de texto se lograron con mayor frecuencia después de la colectomía robótica (77%), seguida de la colectomía laparoscópica (68%) y la colectomía abierta (39%) (p<0,001). XGBoost fue el modelo con mejor rendimiento (AUC=0,72). Los cinco principales variables preoperatorias para predecir el resultado en los libros de texto fueron el abordaje quirúrgico, la edad del paciente, el hematocrito preoperatorio, la preparación intestinal con antibióticos orales preoperatorios y el sexo femenino.LIMITACIONES:Este estudio estuvo limitado por la naturaleza retrospectiva del análisis.CONCLUSIONES:El uso de los resultados de los libros de texto como resultado preferido puede ser una herramienta útil en procedimientos de riesgo relativamente bajo, como la colectomía, y la calculadora basada en la web propuesta puede ayudar a los cirujanos en la evaluación y el asesoramiento preoperatorios, especialmente para pacientes de alto riesgo. (Traducción-Yesenia Rojas-Khalil ).

COVID-19, Racial Injustice, and Medical Student Engagement With Global Health: A Single-Institution Survey.

INTRODUCTION: United States medical schools continue to respond to student interest in global health (GH) and the evolution of the field through strengthening related curricula. The COVID-19 pandemic and superimposed racial justice movements exposed chasms in the US healthcare system. We sought to explore the possible relationship between the pandemic, US racial justice movements, and medical student interest in GH to inform future academic offerings that best meet student needs. METHODS: A novel, mixed-methods 30-question Qualtrics survey was disseminated twice (May-August 2021) through email and social media to all current students. Data underwent descriptive and thematic analysis. RESULTS: Twenty students who self-identified as interested in GH responded to the survey. Most (N = 13, 65%) were in preclinical training, and half were women (N = 10, 50%). Five (25%) selected GH definitions with paternalistic undertones, 11 (55%) defined GH as noncontingent on geography, and 12 (60%) said the pandemic and US racial justice movement altered their definitions to include themes of equity and racial justice. Eighteen (90%) became interested in GH before medical school through primarily volunteering (N = 8, 40%). Twelve (60%) students plan to incorporate GH into their careers. CONCLUSIONS: Our survey showed most respondents entered medical school with GH interest. Nearly all endorsed a changed perspective since enrollment, with a paradigm shift toward equity and racial justice. Shifts were potentially accelerated by the global pandemic, which uncovered disparities at home and abroad. These results highlight the importance of faculty and curricula that address global needs and how this might critically impact medical students.

Hand-Assisted Versus Pure Minimally-Invasive Distal Pancreatectomy: Is There a Downside to Lending a Hand?

BACKGROUND: Hand-assisted laparoscopic distal pancreatectomy (HALDP) is suggested to offer similar outcomes to pure laparoscopic distal pancreatectomy (LDP). However, given the longer midline incision, it is unclear whether HALDP increases the risk of postoperative hernia. Our aim was to determine the risk of postoperative incisional hernia development after HALDP. METHODS: We retrospectively collected data from patients undergoing HALDP or LDP at a single center (2012-2020). Primary endpoints were postoperative incisional hernia and operative time. All patients had at minimum six months of follow-up. Outcomes were compared using unadjusted and multivariable regression analyses. RESULTS: Ninety-five patients who underwent laparoscopic distal pancreatectomy were retrospectively identified. Forty-one patients (43%) underwent HALDP. Patients with HALDP were older (median, 67 vs. 61 years, p = 0.02). Sex, race, Body Mass Index (median, 27 vs. 26), receipt of neoadjuvant chemotherapy, gland texture, wound infection rates, postoperative pancreatic fistula, overall complications, and hospital length-of-stay were similar between HALDP and LDP (all p > 0.05). In unadjusted analysis, operative times were shorter for HALDP (164 vs. 276 min, p < 0.001), but after adjustment, did not differ significantly (MR 0.73; 0.49-1.07, p = 0.1). Unadjusted incidence of hernia was higher in HALDP versus LDP (60% vs. 24%, p = 0.004). After adjustment, HALDP was associated with an increased odds of developing hernia (OR 7.52; 95% CI 1.54-36.8, p = 0.014). After propensity score matching, odds of hernia development remained higher for HALDP (OR 4.62; 95% CI 1.28-16.65, p = 0.031) p = 0.03). CONCLUSIONS: Compared with LDP, HALDP was associated with increased likelihood of postoperative hernia with insufficient evidence that HALDP shortens operative times. Our results suggest that HALDP may not be equivalent to LDP.

AHPBA graduated fellows' assessments of strengths, weaknesses, opportunities and threats facing fellowship training in HPB surgery: "HPB training excellence means volume, knowledge, and mentorship".

BACKGROUND: Many fellowship programs in North America prepare surgeons for a career in Hepato-Pancreato-Biliary (HPB) surgery. Recent fellowship graduates were surveyed as part of a strengths, weaknesses, opportunities, and threats (SWOT) analysis commissioned by Americas Hepato-Pancreato-Biliary Association (AHPBA). METHODS: This was a cross-sectional study surveying AHPBA-certified fellowship graduates conducted August-December 2021. Survey data were analyzed using descriptive statistics. Free-text answers were analyzed using both grounded theory principles and thematic network analyses. RESULTS: Four main themes were identified: (i) concerns regarding the lack of standardization between HPB fellowship curricula (ii) concern for job market oversaturation, (iii) need to emphasize the value in HPB fellowship training and (iv) importance of diversity, inclusion, and equity in HPB training. DISCUSSION: Based on themes identified, the strengths of AHPBA-certified HPB programs include superior case volume and technical training. Areas of weakness and growth opportunities include standardizing training experiences. According to AHPBA-certificate awardees, optimizing future HPB fellowships would include strong sponsorship for job placement after graduation, and more intentional investments in diversity, equity, and inclusion.

Minimally Invasive Distal Pancreatectomy Techniques: A Contemporary Analysis Exploring Trends, Similarities, and Differences to Open Surgery.

Limited contemporary data has compared similarities and differences between total laparoscopic (LDP), hand-assisted (HALDP), and open distal pancreatectomy (ODP). This study aimed to examine similarities and differences in outcomes between these three approaches in a contemporary cohort. Methods: Patients undergoing elective LDP, HALDP, and ODP in the NSQIP dataset (2014−2019) were included. Descriptive statistics and multivariate regression analyses were employed to compare postoperative outcomes. Results: Among 5636 patients, 33.9% underwent LDP, 13.1% HALDP, and 52.9% ODP. Compared with the LDP approach, surgical site infections were more frequent in HALDP and ODP approaches (1.2% vs. 2.6% vs. 2.8%, respectively, p < 0.01). After adjustment, the LDP approach was associated with a significantly lower likelihood of surgical site infection (OR 0.25, p = 0.03) when compared to ODP. There was no difference in the likelihood of surgical site infection when HALDP was compared to ODP (OR 0.59, p = 0.40). Unadjusted operative times were similar between approaches (LDP = 192 min, HALDP = 193 min, ODP = 191 min, p = 0.59). After adjustment, the LDP approach had a longer operative time (+10.3 min, p = 0.04) compared to ODP. There was no difference in the adjusted operative time between HALDP and ODP approaches (+5.4 min, p = 0.80). Conclusions: Compared to ODP, LDP was associated with improved surgical site infection rates and slightly longer operative times. There was no difference in surgical site infection rates between ODP and HALDP. Surgeon comfort and experience should decide the operative approach, but it is important to discuss the differences between these approaches with patients.

Outcomes of Early Versus Late Tracheostomy in Patients With COVID-19: A Multinational Cohort Study.

Timing of tracheostomy in patients with COVID-19 has attracted substantial attention. Initial guidelines recommended delaying or avoiding tracheostomy due to the potential for particle aerosolization and theoretical risk to providers. However, early tracheostomy could improve patient outcomes and alleviate resource shortages. This study compares outcomes in a diverse population of hospitalized COVID-19 patients who underwent tracheostomy either "early" (within 14 d of intubation) or "late" (more than 14 d after intubation). DESIGN: International multi-institute retrospective cohort study. SETTING: Thirteen hospitals in Bolivia, Brazil, Spain, and the United States. PATIENTS: Hospitalized patients with COVID-19 undergoing early or late tracheostomy between March 1, 2020, and March 31, 2021. INTERVENTIONS: Not applicable. MEASUREMENTS AND MAIN RESULTS: A total of 549 patients from 13 hospitals in four countries were included in the final analysis. Multivariable regression analysis showed that early tracheostomy was associated with a 12-day decrease in time on mechanical ventilation (95% CI, -16 to -8; p < 0.001). Further, ICU and hospital lengths of stay in patients undergoing early tracheostomy were 15 days (95% CI, -23 to -9 d; p < 0.001) and 22 days (95% CI, -31 to -12 d) shorter, respectively. In contrast, early tracheostomy patients experienced lower risk-adjusted survival at 30-day post-admission (hazard ratio, 3.0; 95% CI, 1.8-5.2). Differences in 90-day post-admission survival were not identified. CONCLUSIONS: COVID-19 patients undergoing tracheostomy within 14 days of intubation have reduced ventilator dependence as well as reduced lengths of stay. However, early tracheostomy patients experienced lower 30-day survival. Future efforts should identify patients most likely to benefit from early tracheostomy while accounting for location-specific capacity.

AHPBA senior leaders' assessments of strengths, weaknesses, opportunities, and threats facing fellowship training in HPB surgery: "We need to standardize our training experiences".

BACKGROUND: Multiple fellowship programs in North America prepare surgeons for a career in Hepato-Pancreatico-Biliary (HPB) surgery. Inconsistent operative experiences and disease process exposures across programs and pathways produces variability in training product and therefore, lack of clarity around what trained HPB surgeons are prepared to do in early practice. Thus, a strengths, weaknesses, opportunities, and threats (SWOT) analysis of AHPBA fellowship training was conducted. METHODS: This was a mixed-methods, cross-sectional study. Eleven AHPBA-Founding Members (FM) and 24 current or former Program Directors (PD) of programs eligible for AHPBA certificates were surveyed and interviewed. Grounded theory principles and thematic network analysis were used to analyze interview transcripts. Descriptive statistics were used to analyze survey data. RESULTS: Three main themes were identified: (i) Concern for training rigor and consistency (ii) Desire to standardize curricula and broaden training requirements and, (iii) Need to validate both the value of training and job marketability via certification. DISCUSSION: Based on the themes identified, the strengths of AHPBA-certified HPB programs include superior technical training and case volumes. Areas of improvement included elevating baseline competencies by increasing required case volume and breadth to ensure minimally invasive experience, operative autonomy, and multidisciplinary care coordination.

The job market for HPB surgeons: leadership perspectives on surgeon skillsets, training pathways, and hiring.

BACKGROUND: Three tracks prepare Hepato-Pancreato-Biliary (HPB) surgeons: HPB, surgical oncology, and transplant fellowships. This study explored how surgical leaders thought about HPB surgery and evaluated potential candidates for HPB positions. METHODS: This descriptive qualitative study utilized interviews of healthcare leaders whose responsibilities included hiring HPB surgeons. We coded inductively then used thematic network analysis to organize the data. Individual codes formed basic themes, then larger secondary themes, then finally "primary" themes. RESULTS: Primary themes were: (1) What defines an HPB surgical practice?, (2) How do they assess candidates for HPB positions?, and (3) How will HPB practices continue to evolve? Leaders assessed applicants' training, behaviors and cultural fit, technical excellence, and more. Personal recommendations and professional networks significantly influenced the hiring process. HPB surgery needs were growing due to population changes, treatments advances, and changing market conditions. DISCUSSION: Surgical societies should focus on facilitating networking, promoting transparency, sharing quality data, providing evidence of technical skills and teamwork, mentorship, and providing guidance to general surgery residency program directors. There is great interest in unification and cooperation across the profession, protocol standardization enhancing quality, continued workforce diversification, and evaluation of the alignment between training and practice.

Identifying Good Candidates for Active Surveillance of Ductal Carcinoma In Situ: Insights from a Large Neoadjuvant Endocrine Therapy Cohort.

Ductal carcinoma in situ (DCIS) is a biologically heterogenous entity with uncertain risk for invasive ductal carcinoma (IDC) development. Standard treatment is surgical resection often followed by radiation. New approaches are needed to reduce overtreatment. This was an observational study that enrolled patients with DCIS who chose not to pursue surgical resection from 2002 to 2019 at a single academic medical center. All patients underwent breast MRI exams at 3- to 6-month intervals. Patients with hormone receptor-positive disease received endocrine therapy. Surgical resection was strongly recommended if clinical or radiographic evidence of disease progression developed. A recursive partitioning (R-PART) algorithm incorporating breast MRI features and endocrine responsiveness was used retrospectively to stratify risk of IDC. A total of 71 patients were enrolled, 2 with bilateral DCIS (73 lesions). A total of 34 (46.6%) were premenopausal, 68 (93.2%) were hormone-receptor positive, and 60 (82.1%) were intermediate- or high-grade lesions. Mean follow-up time was 8.5 years. Over half (52.1%) remained on active surveillance without evidence of IDC with mean duration of 7.4 years. Twenty patients developed IDC, of which 6 were HER2 positive. DCIS and subsequent IDC had highly concordant tumor biology. Risk of IDC was characterized by MRI features after 6 months of endocrine therapy exposure; low-, intermediate-, and high-risk groups were identified with respective IDC rates of 8.7%, 20.0%, and 68.2%. Thus, active surveillance consisting of neoadjuvant endocrine therapy and serial breast MRI may be an effective tool to risk-stratify patients with DCIS and optimally select medical or surgical management. Significance: A retrospective analysis of 71 patients with DCIS who did not undergo upfront surgery demonstrated that breast MRI features after short-term exposure to endocrine therapy identify those at high (68.2%), intermediate (20.0%), and low risk (8.7%) of IDC. With 7.4 years mean follow-up, 52.1% of patients remain on active surveillance. A period of active surveillance offers the opportunity to risk-stratify DCIS lesions and guide decisions for operative management.

Positive margins after mastectomy in patients with invasive lobular carcinoma of the breast: Incidence and management strategies.

BACKGROUND: Surgical treatment of invasive lobular carcinoma (ILC) is challenging due to its diffuse growth pattern, and the positive margin rate after mastectomy is poorly described. METHODS: We retrospectively determined the positive margin rate in those with stage I-III ILC undergoing mastectomy. We evaluated the relationship between management strategy and recurrence free survival (RFS). RESULTS: In 357 patients, the positive margin rate was 10.6% overall and 18.7% in those with T3 tumors. Having a positive margin was associated with significantly shorter RFS on multivariate analysis (p = 0.01). Undergoing additional local treatment (radiation or re-excision) for a positive margin was significantly associated with improved RFS (p = 0.004). Older women with positive margins were significantly less likely to undergo additional local therapy. CONCLUSIONS: Even mastectomy fails to clear margins in a high proportion of patients with large ILC tumors, a finding which may warrant testing neoadjuvant strategies even prior to planned mastectomy.

Contemporary Trends in Malignant Peritoneal Mesothelioma: Incidence and Survival in the United States.

Background: Malignant peritoneal mesothelioma (MPM) is a rare disease with a historically poor prognosis. Given the emergence of effective therapies, a contemporary analysis of MPM incidence and survival is warranted. Methods: The SEER-18 registry dataset was analyzed (2000−2018). Age-adjusted annual incidence was stratified by sex and histology. Joinpoint regression was used to estimate annual percent change (APC) in incidence. Multivariable cox proportional hazards models were used to investigate survival trends. Results: Of 1689 MPM cases, most were male (55.4%), >50 years (80.0%), and white (75.2%). Age-adjusted incidence of MPM remained stable over time, with an average annual incidence of 1.02 cases/million. Epithelioid histology increased by 240% (APC 2.6; 95% CI: 0.7, 4.5), while incidence of undefined histology decreased significantly (APC −2.1; 95% CI: −3.1, −1.1). Cases treated with cancer-directed surgery increased from 27% to 43%. Overall median age-standardized survival was 11.6 months. Median age-standardized survival was 16.6 months for epithelioid histology but 2.0 months for sarcomatoid histology. Diagnosis in recent years (2015−2018 HR 0.51; 95% CI: 0.38, 0.67) and receipt of cancer-directed surgery (HR 0.84; 95% CI: 0.72, 0.98) were associated with improved survival. Conclusions: Although the overall incidence of MPM remained stable, recognition of epithelioid histology increased. Concurrent with an increase in cancer-directed surgery, MPM survival has improved.

Person-centered antenatal care and associated factors in Rwanda: a secondary analysis of program data.

BACKGROUND: Research suggests that women's experience of antenatal care is an important component of high-quality antenatal care. Person-centered antenatal care (PCANC) reflects care that is both respectful of, and responsive to, the preferences, needs, and values of pregnant women. Little is known in Rwanda about either the extent to which PCANC is practiced or the factors that might determine its use. This is the first study to quantitatively examine the extent of and the factors associated with PCANC in Rwanda. METHODS: We used quantitative data from a randomized control trial in Rwanda. A total of 2150 surveys were collected and analyzed from 36 health centers across five districts. We excluded women who were less than 16 years old, were referred to higher levels of antenatal care or had incomplete survey responses. Both bivariate and multivariate logistic regression analyses were used to test the hypothesis that certain participant characteristics would predict high PCANC. RESULTS: PCANC level was found to be sub-optimal with one third of women leaving antenatal care (ANC) with questions or confused and one fourth feeling disrespected. In bivariate analysis, social support, greater parity, being in the traditional care (control group), and being from Burera district significantly predict high PCANC. Additionally, in the multivariate analysis, being in the traditional care group and the district in which women received care were significantly associated with PCANC. CONCLUSIONS: This quantitative analysis indicates sub-optimal levels of PCANC amongst our study population in Rwanda. We find lower levels of PCANC to be regional and defined by the patient characteristics parity and social support. Given the benefits of PCANC, improvements in PCANC through provider training in Rwanda might promote an institutional culture shift towards a more person-centered model of care.