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1.
Ann Surg Oncol ; 2021 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-34655352

RESUMO

BACKGROUND: The influence of social determinants of health (SDH) on participation in clinical trials for pancreatic cancer is not well understood. In this study, we describe trends and identify disparities in pancreatic cancer clinical trial enrollment. PATIENTS AND METHODS: This is a retrospective study of stage I-IV pancreatic cancer patients in the 2004-2016 National Cancer Database. Cohort was stratified into those enrolled in clinical trials during first course of treatment versus not enrolled. Bivariate analysis and logistic regression were used to understand the relationship between SDH and clinical trial participation. RESULTS: A total of 1127 patients (0.4%) enrolled in clinical trials versus 301,340 (99.6%) did not enroll. Enrollment increased over the study period (p < 0.001), but not for Black patients or patients on Medicaid. The majority enrolled had metastatic disease (65.8%). On multivariate analysis, in addition to year of diagnosis (p < 0.001), stage (p < 0.001), and Charlson score (p < 0.001), increasing age [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.96-0.97], non-white race (OR 0.54, CI 0.44-0.66), living in the South (OR 0.42, CI 0.35-0.51), and Medicaid, lack of insurance, or unknown insurance (0.41, CI 0.31-0.53) were predictors of lack of participation. Conversely, treatment at an academic center (OR 6.36, CI 5.4-7.4) and higher neighborhood education predicted enrollment (OR 2.0, CI 1.55-2.67 for < 7% with no high school degree versus > 21%). DISCUSSION: Age, race, insurance, and geography are barriers to clinical trial enrollment for pancreatic cancer patients. While overall enrollment increased, Black patients and patients on Medicaid remain underrepresented. After adjusting for cancer-specific factors, SDH are still associated with clinical trial enrollment, suggesting need for targeted interventions.

3.
World J Gastroenterol ; 27(27): 4383-4394, 2021 Jul 21.
Artigo em Inglês | MEDLINE | ID: mdl-34366611

RESUMO

Pancreatic ductal adenocarcinoma (PDAC) is an aggressive malignancy that is best treated in a multidisciplinary fashion using surgery, chemotherapy, and radiation. Adjuvant chemotherapy has shown to have a significant survival benefit in patients with resected PDAC. However, up to 50% of patients fail to receive adjuvant chemotherapy due to postoperative complications, poor patient performance status or early disease progression. In order to ensure the delivery of chemotherapy, an alternative strategy is to administer systemic treatment prior to surgery. Precision oncology refers to the application of diverse strategies to target therapies specific to characteristics of a patient's cancer. While traditionally emphasized in selecting targeted therapies based on molecular, genetic, and radiographic biomarkers for patients with metastatic disease, the neoadjuvant setting is a prime opportunity to utilize personalized approaches. In this article, we describe the current evidence for the use of neoadjuvant therapy (NT) and highlight unique opportunities for personalized care in patients with PDAC undergoing NT.


Assuntos
Adenocarcinoma , Carcinoma Ductal Pancreático , Neoplasias Pancreáticas , Protocolos de Quimioterapia Combinada Antineoplásica , Carcinoma Ductal Pancreático/tratamento farmacológico , Carcinoma Ductal Pancreático/terapia , Humanos , Terapia Neoadjuvante , Pancreatectomia , Neoplasias Pancreáticas/cirurgia , Medicina de Precisão
5.
Breast ; 59: 314-320, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34388697

RESUMO

PURPOSE: Low socioeconomic status (SES) is associated with advanced stage, lower-quality care, and higher mortality among breast cancer patients. The purpose of this study is to examine the association between neighborhood SES (nSES), surgical management, and disease-specific mortality in de novo metastatic breast cancer (MBC) patients in the Surveillance, Epidemiology, and End Results (SEER) Program. METHODS: MBC patients ages 18 to 85+ years diagnosed from 2010 through 2016 were identified in SEER. The cohort was divided into low, middle, and high nSES based on the NCI census tract-level index. Univariable and multivariable analyses were used to examine the relationship between nSES, surgery, and disease specific mortality in MBC patients. RESULTS: There were 24,532 de novo MBC patients who met study criteria, with 28.7 % undergoing surgery. Over the study period, surgery utilization decreased across all nSES groups. However, lower nSES was associated with a higher odds of undergoing surgery (low OR 1.25 [1.15-1.36] p < 0.001; middle OR 1.09 [1.01-1.18] p = 0.022; ref high). Living in an area with lower SES was associated with a worse disease specific mortality (low HR 1.24 [1.25, 1.44; ], middle 1.20 [1.1-1.29]: ref high). Specifically, there was a 9.26 month mean survival differences between the lowest (41.02 ± 0.47 months) and highest (50.28 ± 0.47 months) nSES groups. CONCLUSION: These results suggest area of residence may contribute to differences in surgical management and clinical outcomes among de novo MBC patients. Future studies should examine the contributions of patient characteristics and preferences within the context of surgeon recommendations.


Assuntos
Neoplasias da Mama , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/cirurgia , Estudos de Coortes , Feminino , Humanos , Renda , Pessoa de Meia-Idade , Características de Residência , Classe Social , Adulto Jovem
6.
Ann Surg Oncol ; 28(13): 8028-8045, 2021 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-34392460

RESUMO

BACKGROUND: "Textbook oncologic outcome" (TOO) is a composite quality measure representing the "ideal" outcome for patients undergoing cancer surgery. This study sought to assess the validity of TOO as a metric to evaluate hospital quality. METHODS: Patients who underwent curative-intent resection of gastric, pancreatic, colon, rectal, lung, esophageal, bladder, or ovarian cancer were identified in the National Cancer Database (2006-2017). Cancer site-specific TOO was defined as adequate lymph node yield, R0 resection, non-length-of-stay outlier, no hospital readmission, and receipt of guideline-concordant chemotherapy and/or radiation. Mixed-effects analyses estimated the adjusted TOO rate for each hospital stratified by cancer site. The association between hospital adjusted TOO rates and 5-year overall survival was assessed using mixed-effects Cox proportional hazards analyses. RESULTS: Among 852,988 cancer resections, the TOO rate varied across cancer sites as follows: stomach (31.8%), pancreas (25%), colon (66.9%), rectum (33.6%), lung (35.1%), esophagus (31.2%), bladder (43%), and ovary (44.7%). After characterization of adjusted hospital TOO rates into quintiles, an incremental improvement in overall survival was observed, with higher adjusted TOO rates. Similarly, with the adjusted hospital TOO rate treated as a continuous variable, there was a significant 4% to 12% improvement in overall survival for every 10% increase in the adjusted hospital TOO rate for gastric (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.85-0.91), pancreatic (HR, 0.90; 95% CI, 0.88-0.93), colon (0.93; 95% CI, 0.91-0.94), rectal (HR, 0.90; 95% CI, 0.87-0.93), lung (HR, 0.96; 95% CI, 0.95-0.97), esophageal (HR, 0.93; 95% CI, 0.90-0.95), bladder (HR, 0.94; 95% CI, 0.91-0.97), and ovarian (HR, 0.96; 95% CI, 0.94-0.98) cancer. CONCLUSIONS: A direct association exists between adjusted hospital TOO rates and survival after high-risk cancer procedures. As a valid hospital metric, TOO can be used to compare the overall quality of cancer care across hospitals.


Assuntos
Oncologia Cirúrgica , Feminino , Hospitais , Humanos , Readmissão do Paciente , Modelos de Riscos Proporcionais , Reto , Estudos Retrospectivos
7.
Breast Cancer Res Treat ; 190(1): 111-119, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34383180

RESUMO

PURPOSE: Black breast cancer patients have worse clinical outcomes than their White counterparts. There are few studies comparing clinical outcomes between Black male breast cancer (MBC) and female breast cancer (FBC) patients. The objective of this study is to examine differences in presentation, treatment, and mortality between Black MBC and FBC. METHODS: The National Cancer Database was queried for all Black MBC and FBC patients, ages 18-90, with hormone receptor-positive breast cancer diagnosed between 2010 and 2016. Hormone receptor positivity was defined as estrogen receptor-positive, progesterone-positive and HER 2-negative cancer. Sociodemographic and clinical variables were compared between MBC and FBC patients on bivariable analysis. After propensity score matching, overall survival was evaluated using the log-rank test and Cox proportional hazards. RESULTS: Compared to FBC patients, MBC patients had higher rates of metastatic disease (stage 4, MBC 4.4% vs. FBC 2.6%, p < 0.001), larger tumors (tumor size < 2 cm, MBC 32.1 vs. FBC 49.1%, p < 0.001) and a higher percentage of poorly differentiated tumors (grade 3, MBC 28.5% vs. FBC 21.4%, p < 0.001). MBC patients had lower rates of hormone therapy (MBC 66.4% vs. FBC 80.7%, p < 0.001) and neoadjuvant chemotherapy (MBC 5.8% vs. FBC 7.5%, p = 0.05) than FBC. On propensity score matched analysis, Black MBC patients had a higher overall mortality (p25 of 60 months vs. 74 months) compared to FBC patients (p = 0.0260). CONCLUSION: Among hormone receptor-positive Black MBC and FBC patients, there are sex-based disparities in stage, hormone therapy use and overall survival.


Assuntos
Neoplasias da Mama Masculina , Neoplasias da Mama , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/tratamento farmacológico , Neoplasias da Mama/epidemiologia , Neoplasias da Mama Masculina/tratamento farmacológico , Neoplasias da Mama Masculina/epidemiologia , Feminino , Hormônios , Humanos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Adulto Jovem
8.
Artigo em Inglês | MEDLINE | ID: mdl-34254268

RESUMO

OBJECTIVE: Breast cancer is the leading cause of cancer death among Hispanic women. Unfortunately, few studies disaggregate Hispanic patients by race to understand its implications on treatment and clinical outcomes such as mortality. The aim of this study is to examine surgical management and overall mortality among different subgroups of women who self-identify as Hispanic. METHODS: Hispanic female patients, ages 18-90, stages I-III, diagnosed with breast cancer between 2010 and 2015 from the National Cancer Data Base were identified. The study cohort was divided into three ethnoracial categories: (1) Hispanic White (HW), 2) Hispanic Black (HB), and 3) Hispanic Other (HO). Descriptive statistics and multivariate models were constructed to determine the relationship between sociodemographic factors, clinical variables, surgical management, and mortality when disaggregated by race. RESULTS: There were 56,675 Hispanic women who met the study criteria. Most where HW (n=50,599, 89.3%) and the rest were HB (n=1,334, 2.4%) and HO (n=4,742, 8.3%). There was no difference between the three groups on receipt of breast conservation therapy (P=0.12). HB (48.5%) and HO (46.6%) women were more likely to undergo reconstruction than those who identified as HW (38.7%) (P<0.001). Additionally, HB (38.3%) women were more likely to undergo tissue-based reconstruction than HW (29.0%) and HO women (30%) (P=0.0008). There was no difference between the groups in the utilization of contralateral prophylactic mastectomy (CPM) (P=0.078). On multivariable analysis, there was no difference in mortality between HB and HW patients (HR 1.18, 95%CI 0.92-1.51; Ref HW). However, HO women had a 24% relative risk reduction in mortality (HR 0.76, 95% CI 0.63-0.92; HW ref). CONCLUSION: Findings from this study suggest there are ethnoracial disparities in reconstruction utilization and mortality among Hispanic women. Future studies should examine how culture, language, healthcare access, and patient preferences contribute to these disparities.

9.
Nat Metab ; 3(6): 843-858, 2021 06.
Artigo em Inglês | MEDLINE | ID: mdl-34127858

RESUMO

Pre-operative exercise therapy improves outcomes for many patients who undergo surgery. Despite the well-known effects on tolerance to systemic perturbation, the mechanisms by which pre-operative exercise protects the organ that is operated on from inflammatory injury are unclear. Here, we show that four-week aerobic pre-operative exercise significantly attenuates liver injury and inflammation from ischaemia and reperfusion in mice. Remarkably, these beneficial effects last for seven more days after completing pre-operative exercising. We find that exercise specifically drives Kupffer cells toward an anti-inflammatory phenotype with trained immunity via metabolic reprogramming. Mechanistically, exercise-induced HMGB1 release enhances itaconate metabolism in the tricarboxylic acid cycle that impacts Kupffer cells in an NRF2-dependent manner. Therefore, these metabolites and cellular/molecular targets can be investigated as potential exercise-mimicking pharmaceutical candidates to protect against liver injury during surgery.


Assuntos
Metabolismo Energético , Imunidade Inata , Macrófagos do Fígado/imunologia , Macrófagos do Fígado/metabolismo , Exercício Pré-Operatório , Animais , Resistência à Doença , Inflamação/imunologia , Inflamação/metabolismo , Isquemia/imunologia , Isquemia/metabolismo , Camundongos
10.
J Card Fail ; 27(9): 974-980, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34153459

RESUMO

BACKGROUND: Many patients with American College of Cardiology/American Heart Association Stage D (advanced) heart failure are discharged home on chronic intravenous inotropic support (CIIS) as bridge to surgical therapy or as palliative therapy. This study analyzed the clinical trajectory of patients with advanced heart failure who were on home CIIS. METHODS: We conducted a single-institution, retrospective cohort study of patients on CIIS between 2010 and 2016 (n = 373), stratified by indication for initiation of inotropic support. Study outcomes were time from initiation of CIIS to cessation of therapy, time to death for patients who did not receive surgical therapy and rates of involvement with palliative care. RESULTS: Overall, patients received CIIS therapy for an average of 5.9 months (standard deviation [SD] 7.3). Patients on CIIS as palliative therapy died in an average of 6.2 months (SD 6.6) from the time of initiation of CIIS, and those on CIIS as bridge therapy who did not ultimately receive surgical therapy died after an average of 8.6 months (SD 9.3). Patients who received CIIS as bridge therapy were significantly less likely to receive palliative-care consultation than those on inotropes as palliative therapy, whether or not they underwent surgery. CONCLUSIONS: In this large cohort of patients with advanced HF, patients who on CIIS as palliative therapy survived for 6.2 months, on average, with wide variation among patients. Patients who were on CIIS as bridge therapy but did not ultimately receive surgical therapy received less palliative care despite the high mortality rate in this subgroup.


Assuntos
Fármacos Cardiovasculares , Insuficiência Cardíaca , Cardiotônicos/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Humanos , Cuidados Paliativos , Estudos Retrospectivos
11.
HPB (Oxford) ; 2021 May 05.
Artigo em Inglês | MEDLINE | ID: mdl-34059420

RESUMO

BACKGROUND: Minimally invasive distal pancreatectomy is the accepted standard of care. The robotic distal (RDP) learning curve is 20-40 surgeries with operating time (ORT) as the most significant factor. This study evaluates how formal mentorship and a robotic skills curriculum impact the learning curve for subsequent generation surgeons. METHODS: Consecutive RDP from 2008 to 2017 were evaluated. First Generation was two surgeons who started program without training or mentorship. Second Generation was the two surgeons who joined the program with mentorship. Third Generation was fellows who benefited from both formal training and mentorship. Multivariable models (MVA) were performed for ORT, clinically relevant pancreatic fistula (CR-POPF), and major complications (Clavien≥3). RESULTS: A total of 296 RDP were performed of which 187 did not include other procedures: First Generation (n = 71), Second Generation (n = 50), and Third Generation (n = 66). ORT decreased by generation (p < 0.001) without any differences in CR-POPF or Clavien≥3. On MVA, earlier generation (p = 0.019), pre-operative albumin (p = 0.001) and pancreatic adenocarcinoma (p = 0.019) were predictive of ORT. Increased BMI (p = 0.049) and neoadjuvant therapy (p = 0.046) were predictive of CR-POPF. Fellow participation at the console increased over time. CONCLUSION: Formal mentorship and a skills curriculum decreased the learning curve and complications were largely dependent on patient factors.

12.
Ann Surg Oncol ; 28(11): 6273-6282, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33791900

RESUMO

INTRODUCTION: To implement a mastery-based robotic surgery curriculum using virtual reality (VR) and inanimate reality (IR) drills at multiple Complex General Surgical Oncology (CGSO) fellowships. PATIENTS AND METHODS: A prospective study of curriculum feasibility and efficacy was conducted at four CGSO fellowship sites. All sites had simulators, and kits were provided to perform 19 biotissue drills. Fellows from three non-UPMC sites (n = 15) in 2016-2018 were compared with fellows from University of Pittsburgh (UPMC; n = 15) where the curriculum was validated in 2014-2018. RESULTS: All fellows completed the pre- and post-test. There was no difference in pre-test scores between UPMC and non-UPMC sites. Only 7 of 15 non-UPMC fellows completed the VR curriculum (47% compliance) compared with all 15 UPMC fellows completing the VR curriculum (100% compliance). UPMC had higher curriculum times (217 versus 93 mins) and % mastery (86% versus 55%). Time spent on curriculum was associated with % mastery (p = 0.01). Both groups showed improvement between pre- and post-test. Post-test VR scores trended higher for UPMC (221 versus 180). Between the non-UPMC sites, there was a difference in compliance (p = 0.03) and % mastery (p = 0.03). Zero non-UPMC fellows performed the biotissue drills, while five contemporary UPMC fellows completed 253 biotissue drills. Approximately 140 UPMC faculty and 300 staff hours were spent on the pilot. CONCLUSIONS: A proficiency curriculum can result in improved robotic console skills. However, multiple barriers to implementation potentially exist, including availability of simulators, availability of a training robot, on-site support staff, and universal buy-in from fellows, faculty, and leadership.


Assuntos
Procedimentos Cirúrgicos Robóticos , Robótica , Oncologia Cirúrgica , Competência Clínica , Currículo , Humanos , Projetos Piloto , Estudos Prospectivos , Oncologia Cirúrgica/educação
13.
HPB (Oxford) ; 23(10): 1550-1556, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33903049

RESUMO

BACKGROUND: There is an associated lag in achieving competency for robotic pancreaticoduodenectomy (PD), resulting in a learning curve. We hypothesize that the reported learning curve can be mitigated through a comprehensive graduated training protocol. METHODS: All patients (n = 237) who underwent an open (n = 197, 83.1%) or robotic (n = 40, 16.9%) PD between 2015-2019 were identified at The Ohio State University. The learning curve for operative time and surgical failure (defined as conversion to open, blood transfusion, or Clavien-Dindo complication grade ≥3) was analyzed using a risk adjusted cumulative summation technique. RESULTS: After 10 cases, operative time plateaued to a mean of 468.3 ± 96.3 minutes for robotic PD versus a mean of 332.5 ± 103.9 minutes for open PD (P < 0.001). There was no further apparent learning curve over time relative to rates of operative time or surgical failure. After propensity score-matching, patients undergoing robotic PD had a similar incidence of major complications, grade B/C postoperative pancreatic fistula, and delayed gastric emptying versus patients undergoing open PD (all P > 0.05). CONCLUSION: Completion of a comprehensive procedure-specific robotic training protocol for PD mitigated the learning curve for this operative approach by shifting the curve into the training/simulation phase rather than the live operating phase. These data hold important implications for the future training and accreditation of surgeons embarking on robotic PD.

15.
J Gastrointest Surg ; 25(11): 2889-2901, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-33768427

RESUMO

BACKGROUND: The utilization of cancer-directed treatment for patients with all stages of pancreatic cancer in the USA is unknown. This study sought to examine national practice patterns and identify patient, hospital, regional, and other factors associated with disparities in the use of guideline-concordant cancer-directed therapy. METHODS: Patients diagnosed with PDAC between 2004 and 2015 were queried from the National Cancer Data Base. Standard of care cancer-directed treatment was defined as surgical resection plus chemotherapy or chemoradiation for patients with stage 1 and 2 disease, chemotherapy for patients with metastatic disease (stage 4), and chemotherapy with or without surgery or chemoradiation for patients with locally advanced stage 3 disease. RESULTS: A total of 336,629 patients with stage 1 (n = 38,443, 11.4%), stage 2 (n = 93,923, 27.9%), stage 3 (n = 37,492, 11.1%), or stage 4 metastatic (n = 166,771, 49.5%) disease were identified. Adherence with stage-specific standard of care treatment occurred in only 45.3% (n = 152,560) of patients among the entire cohort and varied by stage of disease (stage 1: 14.6% vs. stage 2: 39.9% vs. stage 3: 67.6%, vs. stage 4: 50.9%). Older age (OR 0.95, 95%CI 0.94-0.95; p < 0.001), female sex (OR 0.94, 95%CI 0.943-0.97; p < 0.001), African Americans (OR 0.89, 95%CI 0.87-0.91; P < 0.001), and increasing comorbidity burden (Charlson-Deyo score ≥3: OR 0.52, 95%CI 0.50-0.55; P < 0.001) were associated with a lower likelihood of receiving stage-specific standard of care treatment. Conversely, treatment at a high-volume center (quartile 4: OR: 1.13, 95%CI 1.10-1.16; P < 0.001) and higher education level (OR 1.32, 95%CI 1.28-1.36; p < 0.001) was associated with higher likelihood of receiving stage-specific standard of care treatment. Patients who received standard of care treatment had a 47% lower risk of death compared with patients who did not receive standard of care treatment (HR 0.53, 95%CI 0.52-0.53; P < 0.001). CONCLUSION: Pancreatic adenocarcinoma is a complex disease requiring a multi-disciplinary approach for optimal outcomes. Receipt of stage-specific standard of care treatment for PDAC is associated with improved long-term oncological outcomes, but is only achieved in less than half of patients. Further studies are needed to evaluate interventions to address these treatment disparities for patients with PDAC.

16.
Ann Surg Oncol ; 28(12): 6965-6969, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33624173

RESUMO

INTRODUCTION: Pancreaticoduodenectomy (PD) is a highly complex operation with high rates of morbidity and significant potential for perioperative mortality. Enhanced recovery after surgery protocols following PD aim to standardize post-operative clinical pathways in an effort to decrease surgical stress, minimize practice variation, and accelerate postoperative recovery. We reviewed current evidence and provide recommendations for enhanced recovery after PD protocols. METHODS: Current evidence regarding enhanced recovery after PD were reviewed. Recommendations for enhanced recovery after PD protocols are provided based on evidence and expert opinion. RESULTS: Key clinical factors required for a enhanced recovery after PD protocol to reduce postoperative complications and promote a faster recovery include patient and provider education, preoperative oral nutrition until 2-3 h prior to surgery, goal-directed intravenous fluid management, early advancement of oral diet, multimodal analgesia, early mobilization, normoglycemia, and early removal of intra-abdominal drains when clinically indicated. A PD specific protocol has been shown to reduce rates of PD-specific and overall complications as well as shorten postoperative hospital length of stay. CONCLUSION: The key facilitator to a successful enhanced recovery after PD protocol is careful multi-disciplinary planning with input from all stakeholders. Evidenced-based enhanced recovery protocols have been shown to reduce postoperative morbidity and accelerate postoperative recovery following PD.


Assuntos
Recuperação Pós-Cirúrgica Melhorada , Neoplasias , Pancreaticoduodenectomia , Anastomose Cirúrgica , Deambulação Precoce , Humanos , Tempo de Internação , Assistência Perioperatória , Complicações Pós-Operatórias
17.
Surg Endosc ; 35(5): 2223-2228, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-32430521

RESUMO

INTRODUCTION: Assessment of regional lymph nodes (LN) is essential for determining prognosis among patients with gallbladder cancer (GBC). The impact of surgical technique on LN yield has not been well explored. We investigated the impact of minimally invasive surgery (MIS; robotic or laparoscopic) on the evaluation and retrieval of regional LN for patients with GBC. METHODS: We queried the National Cancer Database (NCDB) to identify patients with GBC who underwent curative-intent surgery between 2010 and 2015. Patients with metastatic disease or those with missing data on surgical resection or LN evaluation were excluded. RESULTS: We identified 2014 patients who underwent an open (n = 1141, 56.6%) or MIS approach (n = 873, 43.4%) for GBC and met the inclusion criteria. Patients who underwent MIS were older (open: 68 years, IQR: 60, 75 vs. MIS: 70 years, IQR (61, 77); P = 0.02), and were more commonly treated at a comprehensive community cancer program (P < 0.001). Approximately 3 out of 4 patients (n = 1468, 72.9%) underwent an evaluation of regional LN, with nearly half of these patients (n = 607, 41.7%) having LN metastasis. Among patients who underwent a regional lymphadenectomy, average lymph node yield was 3 (IQR: 1, 6) and was similar between the two groups (P = 0.04). After controlling for all factors, operative approach was not associated with likelihood of receiving a lymphadenectomy during curative-intent resection (OR 0.81, 95% CI 0.63-1.04; P = 0.11). CONCLUSION: In conclusion, patients undergoing curative-intent resection for GBC had similar rates of lymph node evaluation and yield regardless of operative approach. Over one-quarter of patients did not undergo a lymphadenectomy at the time of surgery. Further studies are needed to identify barriers to lymph node evaluation and yield among patients undergoing surgery for gallbladder cancer. Presented at the 2019 2nd World Congress of the International Laparoscopic Liver Society, Tokyo, Japan.


Assuntos
Adenocarcinoma/cirurgia , Neoplasias da Vesícula Biliar/cirurgia , Excisão de Linfonodo/métodos , Linfonodos/patologia , Adenocarcinoma/patologia , Idoso , Feminino , Neoplasias da Vesícula Biliar/patologia , Humanos , Laparoscopia/métodos , Metástase Linfática/patologia , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos , Estudos Retrospectivos
18.
Mol Biol Rep ; 47(9): 6887-6897, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32914263

RESUMO

The objective of the present work was the selection of cultivar, suitable medium and explant type for callus, root production, ascorbic acid, total ascorbic acid, dehydroascorbic and total protein of non-heading Chinese cabbage in two cultivars 'Caixin' and 'Suzhouqing'. We compared 10 types of MS media supplemented with 0.0, 1.0, 2.0 and 3.0 mg/l TDZ; 0.0, 0.25, 0.50 and 1.0 mg/l NAA and 0.0, 5.0, 7.5 and 9.0 mg/l AgNO3 and 5 kinds of explants as embryo, leaf, root, cotyledon and hypocotyl. Maximum frequency of callus fresh weight was recorded with hypocotyl explant, which were cultured on MS + 2.0 mg/l TDZ + 1.0 mg/l NAA + 9.0 mg/l AgNO3 in 'Suzhouqing', optimum callus dry weight was obtained on the same media. The highest result for root fresh and dry weight recorded with 'Caixin' with MS + 3.0 mg/l TDZ + 1.0 mg/l NAA + 9.0 mg/l AgNO3 when we used embryo as explant. The highest ascorbic acid content was found with callus cultured on MS + 1.0 mg/l TDZ + 0.25 mg/l NAA + 5.0 mg/l AgNO3, when used leaf explant in 'Caixin' or root in 'Suzhouqing', and there were no significant difference between them. While the highest value of total AsA content was registered with callus cultured on MS + 2.0 mg/l TDZ + 0.25 mg/l NAA + 5.0 mg/l AgNO3 extracted from cotyledon in 'Caixin'. The highest content of DHA was registered with MS + 2.0 mg/l TDZ + 0.25 mg/l NAA + 5.0 mg/l AgNO3 with cotyledon in 'Caixin'. Also, in 'Caixin' MS + 3.0 mg/l TDZ + 0.25 mg/l NAA + 5.0 mg/l AgNO3 recorded the highest value of total protein content with embryo explant.


Assuntos
Ácido Ascórbico/análise , Calo Ósseo/efeitos dos fármacos , Brassica rapa/metabolismo , Técnicas de Cultura de Células/métodos , Reguladores de Crescimento de Plantas/farmacologia , Raízes de Plantas/efeitos dos fármacos , Proteínas/análise , Ácido Ascórbico/análogos & derivados , Ácido Ascórbico/metabolismo , Calo Ósseo/crescimento & desenvolvimento , Calo Ósseo/metabolismo , Brassica rapa/crescimento & desenvolvimento , Células Cultivadas , Naftalenos/farmacologia , Compostos de Fenilureia/farmacologia , Células Vegetais/efeitos dos fármacos , Células Vegetais/metabolismo , Raízes de Plantas/crescimento & desenvolvimento , Raízes de Plantas/metabolismo , Nitrato de Prata/farmacologia , Tiadiazóis/farmacologia
19.
JAMA Surg ; 155(7): 607-615, 2020 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-32432666

RESUMO

Importance: Learning curves are unavoidable for practicing surgeons when adopting new technologies. However, patient outcomes are worse in the early stages of a learning curve vs after mastery. Therefore, it is critical to find a way to decrease these learning curves without compromising patient safety. Objective: To evaluate the association of mentorship and a formal proficiency-based skills curriculum with the learning curves of 3 generations of surgeons and to determine the association with increased patient safety. Design, Setting, and Participants: All consecutive robotic pancreaticoduodenectomies (RPDs) performed at the University of Pittsburgh Medical Center between 2008 and 2017 were included in this study. Surgeons were split into generations based on their access to mentorship and a proficiency-based skills curriculum. The generations are (1) no mentorship or curriculum, (2) mentorship but no curriculum, and (3) mentorship and curriculum. Univariable and multivariable analyses were used to create risk-adjusted learning curves by surgical generation and to analyze factors associated with operating room time, complications, and fellows completing the full resection. The participants include surgical oncology attending surgeons and fellows who participated in an RPD at University of Pittsburgh Medical Center between 2008 and 2017. Main Outcomes and Measures: The primary outcome was operating room time (ORT). Secondary outcomes were postoperative pancreatic fistula and Clavien-Dindo classification higher than grade 2. Results: We identified 514 RPDs completed between 2008 and 2017, of which 258 (50.2%) were completed by first-generation surgeons, 151 (29.3%) were completed by the second generation, and 82 (15.9%) were completed by the third generation. There was no statistically significant difference between groups with respect to age (66.3-67.3 years; P = .52) or female sex (n = 34 [41.5%] vs n = 121 [46.9%]; P = .60). There was a significant decrease in ORT (P < .001), from 450.8 minutes for the first-generation surgeons to 348.6 minutes for the third generation. Additionally, across generations, Clavien-Dindo classification higher than grade 2 (n = 74 [28.7%] vs n = 30 [9.9%] vs n = 12 [14.6%]; P = .01), conversion rates (n = 18 [7.0%] vs n = 7 [4.6%] vs n = 0; P = .006), and estimated blood loss (426 mL vs 288.6 mL vs 254.7 mL; P < .001) decreased significantly with subsequent generations. There were no significant differences in postoperative pancreatic fistula. Conclusions and Relevance: In this study, ORT, conversion rates, and estimated blood loss decreased across generations without a concomitant rise in adverse patient outcomes. These findings suggest that a proficiency-based curriculum coupled with mentorship allows for the safe introduction of less experienced surgeons to RPD without compromising patient safety.


Assuntos
Competência Clínica , Curva de Aprendizado , Mentores , Pancreaticoduodenectomia/educação , Pancreaticoduodenectomia/métodos , Procedimentos Cirúrgicos Robóticos/educação , Idoso , Currículo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fístula Pancreática/epidemiologia , Segurança do Paciente , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos
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