Simultaneous Hepatic and Visceral Resection: Preoperative Risk Stratification and Implications on Return to Intended Oncologic Therapy.

PURPOSE: Sequence of therapies for synchronous liver metastasis (LM) is complex, with data supporting individualized approaches, although no guiding tools are currently available. We assessed the impact of simultaneous hepatic and visceral resections (SHVR) on textbook outcome (TO) and return to intended oncologic therapy (RIOT), and provide risk-stratification tools to guide individualized decision making and counseling. METHODS: Patients with synchronous LM undergoing hepatectomy ± SHVR were included (2015-2021). Primary and secondary outcomes were TO and RIOT (days), respectively. Using multivariable modeling, a risk score for TO was developed. Decision tree analysis using recursive partitioning was performed for hierarchical risk stratification. The associations between SHVR, TO, and RIOT were examined. RESULTS: Among 533 patients identified, 124 underwent SHVR. TO overall was 71.7%; 79.2% in the non-SHVR group and 46.8% in the SHVR group (p < 0.001). SHVR was the strongest predictor of non-TO (right colon/small bowel: odds ratio [OR] 4.63, 95% confidence interval [CI] 2.65-8.08; left colon/rectum: OR 6.09, 95% CI 2.59-14.3; stomach/pancreas: OR 6.69, 95% CI 1.46-30.7; multivisceral: OR 10.9, 95% CI 3.03-39.5). A composite score was developed yielding three risk strata for TO (score 0-2: 89% vs. score 3-5: 67% vs. score ≥ 6: 37%; p < 0.001). Decision tree analysis was congruent, identifying SHVR as the most important determinant of TO. In patients with colorectal LM, SHVR was associated with delayed time to RIOT (p = 0.004); the risk-stratification tool for TO was equally predictive of RIOT (p < 0.01). CONCLUSIONS: SHVR is associated with reduced likelihood of TO and in turn delayed RIOT. As SHVR is increasingly performed in order to consolidate cancer care, patient selection considering these different outcomes is critical.

Denervation as a Treatment for Arthritis of the Hands: A Systematic Review of the Current Literature.

Joint denervation has been proposed as a less invasive option for surgical management of hand arthritis that preserves joint anatomy while treating pain and decreasing postoperative recovery times. The purpose of this systematic review was to investigate the efficacy and safety of surgical joint denervation for osteoarthritis in the joints of the hand. EMBASE, MEDLINE, and PubMed databases were searched from January 2000 to March 2019. Studies of adult patients with rheumatoid arthritis or osteoarthritis of the hand who underwent joint denervation surgery were included. Two reviewers performed the screening process, data abstraction, and risk of bias assessment (Methodological Index for Non-Randomized Studies). This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with PROSPERO (#125811). Ten studies were included, 9 case series and 1 cohort study, with a total of 192 patients. In all studies, joint denervation improved pain and hand function at follow-up (M = 36.8 months, range = 3-90 months). Pooled analysis of 3 studies on the first carpometacarpal joint showed a statistically significant (P < .001) reduction in pain scores from baseline (M = 6.61 ± 2.03) to postoperatively (M = 1.69 ± 1.27). The combined complication rate was 18.8% (n = 36 of 192), with neuropathic pain or unintended sensory loss (8.8%, n = 17 of 192) being the most common. This review suggests that denervation may be an effective and low-morbidity procedure for treating arthritis of the hand. Prospective, comparative studies are required to further understand the outcomes of denervation compared with traditional surgical interventions.

Clockwise Anterior-to-Posterior-Double Isolation (CAP-DI) Approach for Portal Lymphadenectomy in Biliary Tract Cancer: Technique, Yield, and Outcomes.

Background: Portal lymphadenectomy (PLND) is the current standard for oncologic resection of biliary tract cancers (BTCs). However, published data show it is performed infrequently and often yields less than the recommended 6 lymph nodes. We sought to identify yield and outcomes using a Clockwise Anterior-to-Posterior technique with Double Isolation of critical structures (CAP-DI) for PLND. Methods: Consecutive patients undergoing complete PLND for BTCs using CAP-DI technique were identified (2015−2021). Lymph node (LN) yield and predictors of LN count were examined. Secondary outcomes included intraoperative and postoperative outcomes, which were compared to patients having hepatectomy without PLND. Results: In total, 534 patients were included; 71 with complete PLND (36 gallbladder cancers, 24 intrahepatic cholangiocarcinomas, 11 perihilar cholangiocarcinomas) and 463 in the control group. The median PLND yield was 5 (IQR 3−8; range 0−17) and 46% had at least 6 nodes retrieved. Older age was associated with lower likelihood of ≥6 node PLND yield (p = 0.032), which remained significant in bivariate analyses with other covariates (p < 0.05). After adjustment for operative factors, performance of complete PLND was independently associated with longer operative time (+46.4 min, p = 0.001), but no differences were observed in intraoperative or postoperative outcomes compared to the control group (p > 0.05). Conclusions: Yield following PLND frequently falls below the recommended minimum threshold of 6 nodes despite a standardized stepwise approach to complete clearance. Older age may be weakly associated with lower PLND yield. While all efforts should be made for complete node retrieval, failure to obtain 6 nodes may be an unrealistic metric of surgical quality.

Pilot trial of remote monitoring to prevent malnutrition after hepatopancreatobiliary surgery.

BACKGROUND: Patients undergoing hepatopancreatobiliary (HPB) surgery, such patients with pancreatic, periampullary, and liver cancer, are at high risk for malnutrition. Malnutrition increases surgical complications and reduces overall survival. Despite its severity, there are limited interventions addressing malnutrition after HPB surgery. The aim of this pilot trial was to examine feasibility, acceptability, usability, and preliminary efficacy of a remote nutrition monitoring intervention after HPB surgery. METHODS: Participants received tailored nutritional counseling before and after surgery at 2 and 4 weeks after hospital discharge. Participants also recorded nutritional intake daily for 30 days, and these data were reviewed remotely by registered dietitians before nutritional counseling visits. Descriptive statistics were used to describe study outcomes. RESULTS: All 26 patients approached to participate consented to the trial before HPB surgery. Seven were excluded after consent for failing to meet eligibility criteria (e.g., did not receive surgery). Nineteen participants (52.6% female, median age = 65 years) remained eligible for remote monitoring post-surgery. Nineteen used the mobile app food diary, 79% of participants recorded food intake for greater than 80% of study days, 95% met with the dietitian for all visits, and 89% were highly satisfied with the intervention. Among participants with complete data, the average percent caloric goal obtained was 82.4% (IQR: 21.7). CONCLUSIONS: This intervention was feasible and acceptable to patients undergoing HPB surgery. Preliminary efficacy data showed most participants were able to meet calorie intake goals. Future studies should examine intervention efficacy in a larger, randomized controlled trial. TRIAL REGISTRATION: Clinicaltrials.gov. Registered 16 September 2019, https://clinicaltrials.gov/ct2/show/NCT04091165 .

Quantitative nuclear phenotype signatures predict nodal disease in oral squamous cell carcinoma.

BACKGROUND: Early-stage oral squamous cell carcinoma (OSCC) patients have a one-in-four risk of regional metastasis (LN+), which is also the most significant prognostic factor for survival. As there are no validated biomarkers for predicting LN+ in early-stage OSCC, elective neck dissection often leads to over-treatment and under-treatment. We present a machine-learning-based model using the quantitative nuclear phenotype of cancer cells from the primary tumor to predict the risk of nodal disease. METHODS AND FINDINGS: Tumor specimens were obtained from 35 patients diagnosed with primary OSCC and received surgery with curative intent. Of the 35 patients, 29 had well (G1) or moderately (G2) differentiated tumors, and six had poorly differentiated tumors. From each, two consecutive sections were stained for hematoxylin & eosin and Feulgen-thionin staining. The slides were scanned, and images were processed to curate nuclear morphometric features for each nucleus, measuring nuclear morphology, DNA amount, and chromatin texture/organization. The nuclei (n = 384,041) from 15 G1 and 14 G2 tumors were randomly split into 80% training and 20% test set to build the predictive model by using Random Forest (RF) analysis which give each tumor cell a score, NRS. The area under ROC curve (AUC) was 99.6% and 90.7% for the training and test sets, respectively. At the cutoff score of 0.5 as the median NRS of each region of interest (n = 481), the AUC was 95.1%. We then developed a patient-level model based on the percentage of cells with an NRS ≥ 0.5. The prediction performance showed AUC of 97.7% among the 80% (n = 23 patient) training set and with the cutoff of 61% positive cells achieved 100% sensitivity and 91.7% specificity. When applying the 61% cutoff to the 20% test set patients, the model achieved 100% accuracy. CONCLUSIONS: Our findings may have a clinical impact with an easy, accurate, and objective biomarker from routine pathology tissue, providing an unprecedented opportunity to improve neck management decisions in early-stage OSCC patients.

Combined use of advanced practice providers and care pathways reduces the duration of stay after surgery for gastrointestinal malignancies.

BACKGROUND: The gastrointestinal surgical oncology service at our comprehensive cancer center sought to improve the quality of postsurgical inpatient care while increasing discharge efficiency. METHODS: A stakeholder team established standard postsurgical care pathways and dedicated inpatient advanced practice provider positions. We compared postsurgical length of stay before (July 2017 to April 2018) and after (May 2018 to April 2019) the interventions using Wilcoxon rank-sum tests. We benchmarked length of stay to National Surgical Quality Improvement Project and Centers for Medicare and Medicaid Services geometric mean length of stay. We also compared readmission rates and surgeon-specific Hospital Consumer Assessment of Health Care Provider and Systems and Press-Ganey scores. RESULTS: There were 462 cases before and 563 after the interventions. Postintervention, median length of stay decreased from 6.50 to 6.00 days (P = .017). There was a ≥1-day reduction for 10 of 14 case types with significant length of stay decreases for robotic esophagectomy (P = .001), liver resection (P = .023), and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (P = .030). More case types met or exceeded Centers for Medicare and Medicaid Services and National Surgical Quality Improvement Project benchmarks after the interventions. Readmission rates were stable (preintervention 9.3%, postintervention 10.3%, P = .585). Press-Ganey and HCAHPS measures were stable or improved in all evaluated domains. CONCLUSION: Incorporating advanced practice providers and care pathways into gastrointestinal surgical oncology inpatient care was associated with reduced length of stay without declination in readmission rates or patient experience measures.

Tumor microRNA profile and prognostic value for lymph node metastasis in oral squamous cell carcinoma patients.

Neck lymph node metastasis (LN+) is one of the most significant prognostic factors affecting 1-in-2 patients diagnosed with oral squamous cell carcinoma (OSCC). The different LN outcomes between clinico-pathologically similar primary tumors suggest underlying molecular signatures that could be associated with the risk of nodal disease development. MicroRNAs (miRNAs)are short non-coding molecules that regulate the expression of their target genes to maintain the balance of cellular processes. A plethora of evidence has indicated that aberrantly expressed miRNAs are involved in cancers with either an antitumor or oncogenic role. In this study, we characterized miRNA expression among OSCC fresh-frozen tumors with known outcomes of nodal disease (82 LN+, 76 LN0). We identified 49 differentially expressed miRNAs in tumors of the LN+ group. Using penalized lasso Cox regression, we identified a group of 10 miRNAs of which expression levels were highly associated with nodal-disease free survival. We further reported a 4-miRNA panel (miR-21-5p, miR-107, miR-1247-3p, and miR-181b-3p) with high accuracy in discriminating LN status, suggesting their potential application as prognostic biomarkers for nodal disease.

Intraoperative SPY Reduces Post-mastectomy Skin Flap Complications: A Systematic Review and Meta-Analysis.

BACKGROUND: Indocyanine-green and laser-assisted fluorescence angiography, known as the SPY system, is a recently developed tool that has shown promise in assessing tissue perfusion. Its intraoperative use is becoming more common particularly in breast surgery. This systematic review aims to determine whether SPY technology can reduce postoperative complications related to tissue ischemia, specifically skin necrosis of the mastectomy native breast skin flaps. METHODS: A systematic review of the literature was performed based on the PRISMA guideline. All studies that involved use of the SPY system to assess perfusion of postmastectomy skin flaps from January 1, 1960, to March 1, 2018 were included. Postoperative complications, including mastectomy skin flap necrosis were extracted from the selected studies. The perfusion-related complication rates and unexpected reoperation rates across multiple studies were then reviewed. RESULTS: Five relevant articles were identified including 902 patients undergoing mastectomy and native breast flap reconstructive procedures. Groups that used indocyanine-green angiography had statistically less incidence of native breast skin flap necrosis and unexpected reoperations due to perfusion-related complications compared with groups that monitored flaps with only clinical observation (odds ratio 0.54 for skin necrosis, and 0.36 for reoperation). CONCLUSIONS: In this systematic review, the incidence of native breast skin flap necrosis and unexpected reoperations were found to be statistically lower in cases where SPY was used. However, more prospective studies are required to establish SPY angiography as an accurate and cost-effective tool for assessment of tissue perfusion.

Elbow flexion angle during graft fixation for ulnar collateral ligament reconstruction: a systematic review of outcomes and complications.

BACKGROUND: The ulnar collateral ligament (UCL) of the elbow is commonly injured in overhead athletes, especially baseball pitchers. UCL reconstruction has shown good outcomes regarding return to play, but revision rates are on the rise. This review was conducted to determine the effect of elbow flexion angle during graft fixation on outcomes and complications after UCL reconstruction. METHODS: MEDLINE, Embase, and PubMed were searched from database inception to November 16, 2017. Patient demographics, surgical technique, graft selection, outcomes, and complications were extracted from the included studies. The quality of each study was assessed in duplicate with the Methodological Index for Non-Randomized Studies criteria. Descriptive statistics are presented. RESULTS: Six studies, with a total of 1168 patients, were included, and all were case series. Excellent Conway scores were present in 83.8% of patients for the 0° to 30° group and in 91.1% of patients for the 45° to 70° group, with no significant differences in return to play between the groups. The rate of revision UCL reconstruction was significantly higher with graft fixation at 0° to 30° (1.4%) compared with fixation at 45° to 70° (0%; P < .01). CONCLUSIONS: Elbow flexion angle during graft fixation may not influence return to the same or higher level of competition but appears to influence the need for a revision after UCL reconstruction. However, the available current evidence possesses a high degree of fragility, and further studies are needed with objective measurements to determine the optimal elbow flexion angle for graft fixation.

Activated B Cells Participating in the Anti-Myelin Response Are Excluded from the Inflamed Central Nervous System in a Model of Autoimmunity that Allows for B Cell Recognition of Autoantigen.

Once activated, T cells gain the ability to access both healthy and inflamed nonlymphoid tissues. They are then reactivated to remain in the tissue and exert their effector function only if they encounter their specific Ag. In this study, we set out to determine if the same is true for B cells using a mouse model of CNS autoimmunity that incorporates both T and B cell recognition of a myelin autoantigen. Both T and B cells were common infiltrates of spinal cords in diseased mice. However, unlike T cells, anti-myelin B cells were excluded from the inflamed tissue. Further, CNS B cells did not have a phenotype consistent with Ag-specific activation as it occurs in lymphatic tissue. Instead, they expressed elevated levels of CD80, indicating that B cells may contribute to local inflammation through nonantigen-specific mechanisms.