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2.
HPB (Oxford) ; 2022 Apr 26.
Artigo em Inglês | MEDLINE | ID: mdl-35568654

RESUMO

BACKGROUND: Robotic-assisted pancreatectomy continues to proliferate despite limited evidence supporting its benefits from the patient's perspective. We compared patient-reported outcomes (PROs) between patients undergoing robotic and open pancreatectomies. METHODS: PROs, measured with the FACT-Hep, FACT-G, and HCS, were assessed in the immediate postoperative (i.e., preoperative to discharge) and recovery (i.e., discharge to three months postoperative) periods. Linear mixed models estimated the association of operative approach on PROs. Minimally important differences (MIDs) were also considered. RESULTS: Among 139 patients, 105 (75.5%) underwent robotic pancreatectomies. Compared to those who underwent open operations, those who underwent robotic operations experienced worse FACT-Hep scores that were both statistically and clinically significant (mean difference [MD] 8.6 points, 95% CI 1.0-16.3). Declines in FACT-G (MD 4.3, 95% CI -1.0 to 9.6) and HCS (MD 4.3, 95% CI 0.8-7.9) scores appeared to contribute equally in both operative approaches to the decline in total FACT-Hep score. Patients who underwent robotic versus open operations both statistically and clinically significantly improved due to improvements in HCS (MD 6.1, 95% CI 2.3-9.9) but not in FACT-G (MD 1.2, 95% CI - 5.1-7.4). CONCLUSION: The robotic approach to pancreas surgery might offer, from the patient's perspective, greater improvement in symptoms over the open approach by three months postoperatively.

3.
Surg Endosc ; 2022 Apr 25.
Artigo em Inglês | MEDLINE | ID: mdl-35467144

RESUMO

BACKGROUND: Despite advances in surgical technique, bile leak remains a common complication following hepatectomy. We sought to identify incidence of, risk factors for, and outcomes associated with biliary leak. STUDY DESIGN: This is an ACS-NSQIP study. Distribution of bile leak stratified by surgical approach and hepatectomy type were identified. Univariate and multivariate factors associated with bile leak and outcomes were evaluated. RESULTS: Robotic hepatectomy was associated with less bile leak (5.4% vs. 11.4%; p < 0.001) compared to open. There were no significant differences in bile leak between robotic and laparoscopic hepatectomy (5.4% vs. 5.3%; p = 0.905, respectively). Operative factors risk factors for bile leak in patients undergoing robotic hepatectomy included right hepatectomy [OR 4.42 (95% CI 1.74-11.20); p = 0.002], conversion [OR 4.40 (95% CI 1.39-11.72); p = 0.010], pringle maneuver [OR 3.19 (95% CI 1.03-9.88); p = 0.044], and drain placement [OR 28.25 (95% CI 8.34-95.72); p < 0.001]. Bile leak was associated with increased reoperation (8.7% vs 1.7%, p < 0.001), 30-day readmission (26.6% vs 6.8%, p < 0.001), 30-day mortality (2% vs 0.9%, p < 0.001), and complications (67.2% vs 23.4%, p < 0.001) for patients undergoing MIS hepatectomy. CONCLUSION: While MIS confers less risk for bile leak than open hepatectomy, risk factors for bile leak in patients undergoing MIS hepatectomy were identified. Bile leaks were associated with multiple additional complications, and the robotic approach had an equal risk for bile leak than laparoscopic in this time period.

4.
J Surg Educ ; 2022 Mar 26.
Artigo em Inglês | MEDLINE | ID: mdl-35351431

RESUMO

BACKGROUND: Robotic surgery has seen exponential growth over the past several years. However, there is no standardized training program implemented nationwide. Thus, there is a challenge in how to measure surgical proficiency and how to train future surgeons. METHODS: In this study, all PGY3 general surgery residents from the University of Chicago residency program were assigned the curriculum. The curriculum consisted of seven sections: instrument mastery, simulation curriculum, suturing, inanimate drills, laparoscopic/open comparisons, surveys, mentor sessions, and exposure in the operating room. It was administered via a 2-week dedicated robotic rotation. CONCLUSIONS: With the inevitable integration of robotic surgery in the operating room, it has become imperative to prepare future surgeons. However, learning curves and a resistance to voluntary compliance have halted progress. Thus, providing mastery-based training and protected time away from clinic duties is paramount. This curriculum aims to reduce these barriers and provide a standardizable training curriculum.

5.
Surg Endosc ; 2022 Feb 22.
Artigo em Inglês | MEDLINE | ID: mdl-35194662

RESUMO

BACKGROUND: The annual number of robotic surgical procedures is on the rise. Robotic surgery requires unique skills compared to other surgical approaches. Simulation allows basic robot skill acquisition and enhances patient safety. The purpose of this study was to evaluate the feasibility, effectiveness, and transferability of a mastery-based curriculum using a new virtual reality (VR) robotic simulator for surgery resident training. METHODS: Nineteen PGY2s and 22 PGY4s were enrolled. Residents completed a pretest and posttest consisting of five VR and three previously validated inanimate tasks. Training included practicing 33 VR tasks until a total score ≥ 90% ("mastery") was achieved using automated metrics (time, economy of motion). Inanimate performance was evaluated by two trained, blinded raters using video review metrics (time, errors, and modified OSATS). Outcomes were defined as: curriculum feasibility (completion rate, training time, repetitions), training effectiveness (pre/post training skill improvement), and skill transferability (skill transfer to validated inanimate drills). Wilcoxon signed-rank and Mann-Whitney U tests were used; median (IQR) reported. RESULTS: Thirty-four of 41 residents (83%) achieved mastery on all 33 VR tasks; median training time was 7 h (IQR: 5'26″-8'52″). Pretest vs. post-test performance improved (all p < 0.001) according to all VR and Inanimate metrics for both PGY2 and PGY4 residents. Significant pretest performance differences were observed between PGY2 and PGY4 residents for VR but not inanimate tasks; no PGY2 vs. PGY4 posttest performance differences were observed for both VR and inanimate tasks. CONCLUSION: This mastery-based VR curriculum was associated with a high completion rate and excellent feasibility. Significant performance improvements were noted for both the VR and inanimate tasks, supporting training effectiveness and skill transferability. Additional studies examining validity evidence may help further refine this curriculum.

6.
Clin Gastroenterol Hepatol ; 20(4): 886-897, 2022 04.
Artigo em Inglês | MEDLINE | ID: mdl-33278573

RESUMO

BACKGROUND & AIMS: The assessment of therapeutic response after neoadjuvant treatment and pancreatectomy for pancreatic ductal adenocarcinoma (PDAC) has been an ongoing challenge. Several limitations have been encountered when employing current grading systems for residual tumor. Considering endoscopic ultrasound (EUS) represents a sensitive imaging technique for PDAC, differences in tumor size between preoperative EUS and postoperative pathology after neoadjuvant therapy were hypothesized to represent an improved marker of treatment response. METHODS: For 340 treatment-naïve and 365 neoadjuvant-treated PDACs, EUS and pathologic findings were analyzed and correlated with patient overall survival (OS). A separate group of 200 neoadjuvant-treated PDACs served as a validation cohort for further analysis. RESULTS: Among treatment-naïve PDACs, there was a moderate concordance between EUS imaging and postoperative pathology for tumor size (r = 0.726, P < .001) and AJCC 8th edition T-stage (r = 0.586, P < .001). In the setting of neoadjuvant therapy, a decrease in T-stage correlated with improved 3-year OS rates (50% vs 31%, P < .001). Through recursive partitioning, a cutoff of ≥47% tumor size reduction was also found to be associated with improved OS (67% vs 32%, P < .001). Improved OS using a ≥47% threshold was validated using a separate cohort of neoadjuvant-treated PDACs (72% vs 36%, P < .001). By multivariate analysis, a reduction in tumor size by ≥47% was an independent prognostic factor for improved OS (P = .007). CONCLUSIONS: The difference in tumor size between preoperative EUS imaging and postoperative pathology among neoadjuvant-treated PDAC patients is an important prognostic indicator and may guide subsequent chemotherapeutic management.


Assuntos
Carcinoma Ductal Pancreático , Neoplasias Pancreáticas , Carcinoma Ductal Pancreático/diagnóstico por imagem , Carcinoma Ductal Pancreático/cirurgia , Endossonografia , Humanos , Terapia Neoadjuvante/métodos , Estadiamento de Neoplasias , Pancreatectomia , Neoplasias Pancreáticas/diagnóstico por imagem , Neoplasias Pancreáticas/cirurgia , Prognóstico , Estudos Retrospectivos
7.
J Surg Oncol ; 125(3): 392-398, 2022 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-34643276

RESUMO

BACKGROUND AND OBJECTIVES: The purpose of this article is to describe the procedural safety, technical success, and clinical success of endovascular management of portal and mesenteric venous obstruction in patients with hepatobiliary neoplasms. METHODS: Institutional Review Board (IRB)-approved HIPAA compliant retrospective review of 21 consecutive patients with hepatobiliary malignancies who underwent endovascular portal vein recanalization and stent placement between January 2012 and March 2020. Clinical diagnoses were pancreatic cancer (n = 19), colon cancer metastatic to the liver (n = 1), and cholangiocarcinoma (n = 1). Presenting signs and symptoms included: ascites, abdominal pain, abnormal liver function tests, diarrhea, and gastrointestinal bleeding. Stent patency and patient survival are presented with Kaplan-Meier method. RESULTS: The technical success rate was 100%. A transhepatic approach was used in 20 cases (95.2%); trans-splenic access in one. Primary stent patency was 95.2%, 84%, and 68% at 1, 3, and 6 months, respectively. All stent occlusions were caused by tumor progression. A total of 80% of patients reported symptomatic improvement. Patient survival at 10 months was 40%. The early death rate was 4.76%. There were no bleeding complications from the percutaneous tracts. CONCLUSION: Endovascular recanalization with stent placement is safe with high technical and clinical success.


Assuntos
Neoplasias dos Ductos Biliares/patologia , Procedimentos Endovasculares , Neoplasias Hepáticas/secundário , Neoplasias Pancreáticas/patologia , Veia Porta , Trombose Venosa/cirurgia , Idoso , Idoso de 80 Anos ou mais , Colangiocarcinoma/patologia , Neoplasias do Colo/patologia , Feminino , Humanos , Masculino , Veias Mesentéricas , Pessoa de Meia-Idade , Estudos Retrospectivos , Stents , Resultado do Tratamento , Trombose Venosa/diagnóstico , Trombose Venosa/etiologia
8.
Gut ; 71(5): 961-973, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-33849943

RESUMO

OBJECTIVE: Recent studies have found aristaless-related homeobox gene (ARX)/pancreatic and duodenal homeobox 1 (PDX1), alpha-thalassemia/mental retardation X-linked (ATRX)/death domain-associated protein (DAXX) and alternative lengthening of telomeres (ALT) to be promising prognostic biomarkers for non-functional pancreatic neuroendocrine tumours (NF-PanNETs). However, they have not been comprehensively evaluated, especially among small NF-PanNETs (≤2.0 cm). Moreover, their status in neuroendocrine tumours (NETs) from other sites remains unknown. DESIGN: An international cohort of 1322 NETs was evaluated by immunolabelling for ARX/PDX1 and ATRX/DAXX, and telomere-specific fluorescence in situ hybridisation for ALT. This cohort included 561 primary NF-PanNETs, 107 NF-PanNET metastases and 654 primary, non-pancreatic non-functional NETs and NET metastases. The results were correlated with numerous clinicopathological features including relapse-free survival (RFS). RESULTS: ATRX/DAXX loss and ALT were associated with several adverse prognostic findings and distant metastasis/recurrence (p<0.001). The 5-year RFS rates for patients with ATRX/DAXX-negative and ALT-positive NF-PanNETs were 40% and 42% as compared with 85% and 86% for wild-type NF-PanNETs (p<0.001 and p<0.001). Shorter 5-year RFS rates for ≤2.0 cm NF-PanNETs patients were also seen with ATRX/DAXX loss (65% vs 92%, p=0.003) and ALT (60% vs 93%, p<0.001). By multivariate analysis, ATRX/DAXX and ALT status were independent prognostic factors for RFS. Conversely, classifying NF-PanNETs by ARX/PDX1 expression did not independently correlate with RFS. Except for 4% of pulmonary carcinoids, ATRX/DAXX loss and ALT were only identified in primary (25% and 29%) and NF-PanNET metastases (62% and 71%). CONCLUSIONS: ATRX/DAXX and ALT should be considered in the prognostic evaluation of NF-PanNETs including ≤2.0 cm tumours, and are highly specific for pancreatic origin among NET metastases of unknown primary.


Assuntos
Deficiência Intelectual , Tumores Neuroendócrinos , Neoplasias Pancreáticas , Talassemia alfa , Proteínas Correpressoras/genética , Genes Homeobox , Proteínas de Homeodomínio , Humanos , Deficiência Intelectual/genética , Chaperonas Moleculares/genética , Recidiva Local de Neoplasia/genética , Tumores Neuroendócrinos/genética , Proteínas Nucleares/genética , Neoplasias Pancreáticas/patologia , Telômero/genética , Telômero/patologia , Fatores de Transcrição/genética , Proteína Nuclear Ligada ao X/genética , Talassemia alfa/genética
9.
Surg Endosc ; 36(1): 621-630, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-33543349

RESUMO

INTRODUCTION: Treatment of pancreaticobiliary pathology following Roux-en-Y gastric bypass (RYGB) poses significant technical challenges. Laparoscopic-assisted endoscopic retrograde cholangiopancreatography (LA-ERCP) can overcome those anatomical hurdles, allowing access to the papilla. Our aims were to analyze our 12-year institutional outcomes and determine the learning curve for LA-ERCP. METHODS: A retrospective review of cases between 2007 and 2019 at a high-volume pancreatobiliary unit was performed. Logistic regression was used to identify predictors of specific outcomes. To identify the learning curve, CUSUM analyses and innovative methods for standardizing the surgeon's timelines were performed. RESULTS: 131 patients underwent LA-ERCP (median age 60, 81% females) by 17 surgeons and 10 gastroenterologists. Cannulation of the papilla was achieved in all cases. Indications were choledocholithiasis (78%), Sphincter of Oddi dysfunction/Papillary stenosis (18%), management of bile leak (2%) and stenting/biopsy of malignant strictures (2%). Median total, surgical and ERCP times were 180, 128 and 48 min, respectively, and 47% underwent concomitant cholecystectomy. Surgical site infection developed in 9.2% and post-ERCP pancreatitis in 3.8%. Logistic regression revealed multiple abdominal operations and magnitude of BMI decrease (between RYGB and LA-ERCP) to be predictive of conversion to open approach. CUSUM analysis of operative time demonstrated a learning curve at case 27 for the surgical team and case 9 for the gastroenterology team. On binary cut analysis, 3-5 cases per surgeon were needed to optimize operative metrics. CONCLUSION: LA-ERCP is associated with high success rates and low adverse events. We identify outcome benchmarks and a learning curve for new adopters of this increasingly performed procedure.


Assuntos
Coledocolitíase , Derivação Gástrica , Laparoscopia , Colangiopancreatografia Retrógrada Endoscópica/métodos , Coledocolitíase/cirurgia , Feminino , Derivação Gástrica/efeitos adversos , Derivação Gástrica/métodos , Humanos , Laparoscopia/métodos , Curva de Aprendizado , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
11.
Surg Endosc ; 2021 Nov 19.
Artigo em Inglês | MEDLINE | ID: mdl-34799744

RESUMO

BACKGROUND: Robotic surgery may improve surgical performance during minimally invasive pancreatoduodenectomy as compared to 3D- and 2D-laparoscopy but comparative studies are lacking. This study assessed the impact of robotic surgery versus 3D- and 2D-laparoscopy on surgical performance and operative time using a standardized biotissue model for pancreatico- and hepatico-jejunostomy using pooled data from two randomized controlled crossover trials (RCTs). METHODS: Pooled analysis of data from two RCTs with 60 participants (36 surgeons, 24 residents) from 11 countries (December 2017-July 2019) was conducted. Each included participant completed two pancreatico- and two hepatico-jejunostomies in biotissue using 3D-robotic surgery, 3D-laparoscopy, or 2D-laparoscopy. Primary outcomes were the objective structured assessment of technical skills (OSATS: 12-60) rating, scored by observers blinded for 3D/2D and the operative time required to complete both anastomoses. Sensitivity analysis excluded participants with excess experience compared to others. RESULTS: A total of 220 anastomoses were completed (robotic 80, 3D-laparoscopy 70, 2D-laparoscopy 70). Participants in the robotic group had less surgical experience [median 1 (0-2) versus 6 years (4-12), p < 0.001], as compared to the laparoscopic group. Robotic surgery resulted in higher OSATS ratings (50, 43, 39 points, p = .021 and p < .001) and shorter operative time (56.5, 65.0, 81.5 min, p = .055 and p < .001), as compared to 3D- and 2D-laparoscopy, respectively, which remained in the sensitivity analysis. CONCLUSION: In a pooled analysis of two RCTs in a biotissue model, robotic surgery resulted in better surgical performance scores and shorter operative time for biotissue pancreatic and biliary anastomoses, as compared to 3D- and 2D-laparoscopy.

12.
J Surg Res ; 267: 695-704, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34348185

RESUMO

BACKGROUND: A virtual reality (VR) curriculum performed on the da Vinci Simulation System (DVSS) was previously shown to be effective in training fellows. The dV-Trainer is a separate platform with similar features to the da Vinci console, but its efficacy and utility versus the DVSS simulator are not well known. MATERIALS AND METHODS: A mastery-based VR curriculum was completed by surgical fellows on the DVSS (2014-2016) and on the dV-Trainer (2016-2018) at a large academic center. Pre-test/post-test scores were used to evaluate performance between the two groups. Data was collected prospectively. RESULTS: Forty-six fellows enrolled in the curriculum: surgical oncology (n=31), hepatobiliary (n=5), head/neck (n=4), endocrine (n=2), cardiothoracic (n=2), gynecology (n=1) and transplant surgery (n=1). Twenty-four used the DVSS and twenty-two used the dV-Trainer. Compared to the DVSS, the dV-Trainer was associated with lower scores on 2 of 3 VR modules in the pre-test (P=0.027, P<0.001, respectively) and post-test (P=0.021, P<0.001, respectively). Fellows in the dV-Trainer era scored lower on inanimate drills as well. Average VR curriculum score was lower on the dV-Trainer (71.3% vs 83.34%, P<0.001). dV-Trainer users spent more time completing the pre-test and post-test; however, overall simulator time to complete the curriculum was not significantly different (297 vs 231 minutes, P=0.142). Both groups showed improvement in scores after completion of the VR curriculum. CONCLUSIONS: The dV-Trainer simulator allows for more usability outside the operating room to complete VR modules; however, the DVSS simulator group outperformed the dV-Trainer group on the post-test.


Assuntos
Procedimentos Cirúrgicos Robóticos , Realidade Virtual , Competência Clínica , Simulação por Computador , Currículo , Procedimentos Cirúrgicos Robóticos/educação , Interface Usuário-Computador
13.
J Med Educ Curric Dev ; 8: 23821205211024074, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34263057

RESUMO

As robotic surgery has become more widespread, early exposure to the robotic platform is becoming increasingly important, not only to graduate medical education, but also for medical students pursuing surgical residency. In an effort to orient students to robotic technology and decrease the learning curve for what is likely to become an integral part of residency training, we created a formal, elective robotic surgery curriculum for senior medical students. Throughout this 2-week fourth year rotation, students completed online training modules and assessment; mastered exercises on the simulator system related to the console, camera, energy, dexterity, and suturing skills; attended didactics; utilized the dual console during one-on-one simulation lab sessions with attending robotic surgery experts; and translated new skills to biotissue anastomoses as well as bedside-assisting in the operating room. During cases, students were able to have more meaningful observation experiences, recognizing the significance of various robotic approaches employed and utilization of specific instruments. Future aims of this rotation will assess student experience as it impacts readiness for surgical residency.

14.
HPB (Oxford) ; 23(12): 1849-1855, 2021 12.
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.


Assuntos
Adenocarcinoma , Neoplasias Pancreáticas , Procedimentos Cirúrgicos Robóticos , Currículo , Humanos , Curva de Aprendizado , Mentores , Pancreatectomia/efeitos adversos , Neoplasias Pancreáticas/cirurgia , Complicações Pós-Operatórias , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/efeitos adversos
15.
Clin Transl Sci ; 14(5): 1822-1829, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34002944

RESUMO

SMAD4, a tumor suppressor gene, is lost in up to 60%-90% of pancreatic adenocarcinomas (PDAs). Loss of SMAD4 allows tumor progression by upregulating autophagy, a cell survival mechanism that counteracts apoptosis and allows intracellular recycling of macromolecules. Hydroxychloroquine (HCQ) is an autophagy inhibitor. We studied whether HCQ treatment in SMAD4 deficient PDA may prevent therapeutic resistance induced by autophagy upregulation. We retrospectively analyzed the SMAD4 status of patients with PDA enrolled in two prospective clinical trials evaluating pre-operative HCQ. The first dose escalation trial demonstrated the safety of preoperative gemcitabine with HCQ (NCT01128296). More recently, a randomized trial of gemcitabine/nab-paclitaxel +/- HCQ evaluated Evans Grade histopathologic response (NCT01978184). The effect of SMAD4 loss on response to HCQ and chemotherapy was studied for association with clinical outcome. Fisher's exact test and log-rank test were used to assess response and survival. Fifty-two patients receiving HCQ with neoadjuvant chemotherapy were studied. Twenty-five patients had SMAD4 loss (48%). 76% of HCQ-treated patients with SMAD4 loss obtained a histopathologic response greater than or equal to 2A, compared with only 37% with SMAD4 intact (p = 0.006). Although loss of SMAD4 has been associated with worse outcomes, in the current study, loss of SMAD4 was not associated with a detriment in median overall survival in HCQ-treated patients (34.43 months in SMAD4 loss vs. 27.27 months in SMAD4 intact, p = 0.18). The addition of HCQ to neoadjuvant chemotherapy in patients with PDA may improve treatment response in those with SMAD4 loss. Further study of the relationship among SMAD4, autophagy, and treatment outcomes in PDA is warranted.


Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/farmacologia , Carcinoma Ductal Pancreático/terapia , Hidroxicloroquina/farmacologia , Recidiva Local de Neoplasia/epidemiologia , Neoplasias Pancreáticas/terapia , Proteína Smad4/genética , Idoso , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Autofagia/efeitos dos fármacos , Autofagia/genética , Carcinoma Ductal Pancreático/genética , Carcinoma Ductal Pancreático/mortalidade , Carcinoma Ductal Pancreático/patologia , Intervalo Livre de Doença , Resistencia a Medicamentos Antineoplásicos/genética , Feminino , Humanos , Hidroxicloroquina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante , Recidiva Local de Neoplasia/genética , Recidiva Local de Neoplasia/prevenção & controle , Pâncreas/patologia , Pâncreas/cirurgia , Pancreatectomia , Neoplasias Pancreáticas/genética , Neoplasias Pancreáticas/mortalidade , Neoplasias Pancreáticas/patologia , Estudos Retrospectivos , Proteína Smad4/deficiência , Resultado do Tratamento
16.
Ann Surg Oncol ; 28(12): 7759-7769, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34027585

RESUMO

INTRODUCTION: A positive microscopic margin (R1) following resection of pancreatic ductal adenocarcinoma (PDAC) can occur in up to 80% of patients and is associated with reduced survival and increased recurrence. Our aim was to characterize the impact of neoadjuvant therapy (NAT) on survival and recurrence in patients with PDAC following an R1 resection. METHODS: A retrospective analysis of patients with PDAC who underwent pancreatectomy from 2008 to 2017 was performed. Patients were staged according to the American Joint Committee on Cancer 8th edition and stratified based on resection margin (R0 vs. R1) and treatment sequence (NAT vs. surgery first [SF]). Conditional survival analysis was performed using Cox regression and inverse probability weighted estimates. RESULTS: Among 580 patients, 59% received NAT and 41% underwent SF. On final pathology, the NAT cohort had smaller tumors and less lymph node (LN) positivity (p < 0.05). NAT was not associated with an R1 resection (50%, p = 0.653). Compared with the R1 cohort, the R0 cohort had a higher median overall survival (OS; 39.6 vs. 22.8 months; hazard ratio [HR] 1.6, p < 0.001) and disease-free survival (DFS; 19 vs. 13 months; HR 1.35, p = 0.004). After risk adjustment, NAT was not associated with OS, regardless of margin status (R0, 95% confidence interval [CI] (-)7.31-27.07, p = 0.26; or R1, 95% CI (-)36.99-15.25, p = 0.42). However, NAT was associated with improved DFS in the R1 cohort (95% CI 1.79-11.91, p = 0.008) but not in the R0 cohort (95% CI (-)11.22-10.54, p = 0.95). CONCLUSION: An R0 resection remains an important determinant of overall and disease-free survival, even when NAT is administered. For patients with an R1 resection, receipt of NAT may prolong DFS.


Assuntos
Carcinoma Ductal Pancreático , Neoplasias Pancreáticas , Carcinoma Ductal Pancreático/cirurgia , Humanos , Terapia Neoadjuvante , Recidiva Local de Neoplasia , Neoplasias Pancreáticas/cirurgia , Estudos Retrospectivos , Taxa de Sobrevida
18.
JMIR Cancer ; 7(2): e27975, 2021 Apr 27.
Artigo em Inglês | MEDLINE | ID: mdl-33904822

RESUMO

BACKGROUND: Cancer treatments can cause a variety of symptoms that impair quality of life and functioning but are frequently missed by clinicians. Smartphone and wearable sensors may capture behavioral and physiological changes indicative of symptom burden, enabling passive and remote real-time monitoring of fluctuating symptoms. OBJECTIVE: The aim of this study was to examine whether smartphone and Fitbit data could be used to estimate daily symptom burden before and after pancreatic surgery. METHODS: A total of 44 patients scheduled for pancreatic surgery participated in this prospective longitudinal study and provided sufficient sensor and self-reported symptom data for analyses. Participants collected smartphone sensor and Fitbit data and completed daily symptom ratings starting at least two weeks before surgery, throughout their inpatient recovery, and for up to 60 days after postoperative discharge. Day-level behavioral features reflecting mobility and activity patterns, sleep, screen time, heart rate, and communication were extracted from raw smartphone and Fitbit data and used to classify the next day as high or low symptom burden, adjusted for each individual's typical level of reported symptoms. In addition to the overall symptom burden, we examined pain, fatigue, and diarrhea specifically. RESULTS: Models using light gradient boosting machine (LightGBM) were able to correctly predict whether the next day would be a high symptom day with 73.5% accuracy, surpassing baseline models. The most important sensor features for discriminating high symptom days were related to physical activity bouts, sleep, heart rate, and location. LightGBM models predicting next-day diarrhea (79.0% accuracy), fatigue (75.8% accuracy), and pain (79.6% accuracy) performed similarly. CONCLUSIONS: Results suggest that digital biomarkers may be useful in predicting patient-reported symptom burden before and after cancer surgery. Although model performance in this small sample may not be adequate for clinical implementation, findings support the feasibility of collecting mobile sensor data from older patients who are acutely ill as well as the potential clinical value of mobile sensing for passive monitoring of patients with cancer and suggest that data from devices that many patients already own and use may be useful in detecting worsening perioperative symptoms and triggering just-in-time symptom management interventions.

19.
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
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