Journal of Surgical Oncology最新文献

Background and objectives: Randomized clinical trials have shown that sub-lobar resection for clinical stage (cStage) IA non-small cell lung cancer (NSCLC) is non-inferior to lobar resection. We evaluated traditional and conditional survival differences between lobectomy, wedge resection, and segmentectomy in patients with cStage IA NSCLC.

Methods: The National Cancer Database (2004-2019) was queried for patients with cStage IA (≤ 2 cm) NSCLC who underwent upfront lobectomy, segmentectomy, or wedge resection. Patients were stratified by extent of resection. Propensity-matched traditional (TSA) and conditional (CSA) survival analyses were performed. Propensity score included age, gender, histology, tumor grade, and Charlson-Deyo score. Number of lymph nodes (LN) harvested was also compared between groups.

Results: There were 46 395 patients who met the inclusion criteria, of whom 32 599 (70.3%) received lobectomy, 11 181 (24.1%) wedge resection, and 2615 (5.6%) segmentectomy. Following propensity matching, all groups contained 2615 patients. In the TSA, segmentectomy (hazard ratio [HR]: 1.19, 95% confidence interval [CI]: 1.08-1.32) and wedge resection (HR: 1.41, CI: 1.28-1.56) were associated with worse 5-year survival. This remained significant in CSA at 3- and 5-years post-resection in patients who underwent segmentectomy (HR: 1.24, CI: 1.08-1.43 and HR: 1.23, CI: 1.02-1.49, respectively) and wedge resection (HR: 1.42, CI: 1.24-1.63 and HR: 1.33, CI: 1.11-1.59, respectively). Wedge resection and segmentectomy were associated with a lower number of harvested LN (median = 4 and 6, respectively) compared to lobectomy (8, p < 0.001).

Conclusion: Analysis of real-world data suggests that lobectomy is associated with improved traditional and conditional 5-year survival as well as LN harvest.

Background: Patients undergoing abdominal-based free flap breast reconstruction are at risk for perioperative venous thromboembolism (VTE), but the optimal anticoagulation protocol remains unknown. We hypothesized that a standardized chemoprophylaxis protocol would minimize VTE events without increasing hematoma, flap loss, or reoperation.

Methods: A retrospective review was conducted on patients who underwent abdominal-based free flap breast reconstruction from 2010 to 2023. In 2015, we implemented an enhanced recovery after surgery (ERAS) protocol including preoperative enoxaparin. Patients with a BMI < 30 and > 30 received enoxaparin for 7 and 30 days postoperatively, respectively. 2010-2015 patients were pre-ERAS and 2015-2023 patients were the ERAS cohort. Patient demographics, comorbidities, and outcomes were analyzed. The primary outcomes were VTE, hematoma, flap loss, and reoperation.

Results: 2317 patients were included: 679 were pre-ERAS and 1638 were in the ERAS cohort. The incidence of deep vein thrombosis (0.7%) and pulmonary embolism (pre-ERAS 0.6% vs. ERAS 0.5%) was low in both cohorts with no significant differences. Hematoma (pre-ERAS 7.2% vs. ERAS 5.5%) and reoperation (pre-ERAS 7.8% vs. ERAS 9.7%) were similar, but the ERAS cohort had significantly lower flap failure (0.7% vs. 2.1%, p < 0.05).

Conclusions: A standardized perioperative anticoagulation protocol for abdominal-based breast reconstruction maintained low VTE rates without increasing hematoma, flap failure, or reoperation.

Background and objectives: The watch-and-wait (WW) strategy is a nonsurgical alternative for patients with rectal cancer exhibiting an excellent response to chemoradiotherapy. Studies on the WW strategy have primarily investigated 5-year oncological outcomes; few have focused on longer-term outcomes or the optimal patient selection approach for this therapeutic strategy.

Methods: This retrospective study enrolled patients with locally advanced rectal adenocarcinoma who had achieved complete response after chemoradiotherapy. Patients who achieved pathological complete response were categorized into a control group (n = 95) and those who achieved clinical complete response and were managed using the WW strategy were categorized into a case group (n = 33). Kaplan-Meier estimates were calculated for the between-group comparison of survival.

Results: The median follow-up duration was 89 months. Compared with the control group, the case group exhibited improved long-term sphincter preservation, particularly for low-lying tumors (p = 0.032), and inferior nonlocal-regrowth disease-free survival (p = 0.007). Within the case group, patients achieving a complete response by positron emission tomography exhibited 5-year survival rates similar to those achieving a complete endoscopic response.

Conclusion: The WW strategy is associated with improved sphincter preservation but worse nonlocal-regrowth disease-free survival. The potential of PET in patient selection for this strategy deserves further investigation.

Background and objectives: Parathyroid gland detection is a fundamental skill in endocrine surgery that is enhanced with experience. This study aims to investigate the impact of near-infrared autofluorescence (NIRAF) imaging on a surgical team's ability to recognize parathyroid glands during thyroidectomy and parathyroidectomy procedures across different training levels.

Methods: Patients who underwent thyroidectomy or parathyroidectomy under NIRAF guidance by three surgeons between March and June 2024 were included. Attending surgeons, endocrine surgery fellows, and general surgery residents were assessed regarding their ability to recognize parathyroid glands before and after NIRAF imaging during the procedures. Wilcoxon and Chi-Square tests were used for statistical analyses.

Results: Assessments were made in 32 thyroidectomy and 53 parathyroidectomy procedures, with eventual intraoperative identification of a total of 255 parathyroid glands. A total of 896 collective assessments were made. There were 250 assessments involving junior trainees, 288 involving senior trainees (fellows), and 358 involving the primary surgeon. Parathyroid detection rates for junior trainees, senior trainees, and attending surgeons before versus after NIRAF imaging were 46.5% versus 94.8%, 68% versus 97%, and 80% versus 100%, respectively (p < 0.0001). For the same groups, respectively, NIRAF imaging detected 48.3%, 29%, and 20% of parathyroid glands not initially visible on conventional view (p < 0.0001) and increased the confidence for 51.7%, 71%, and 80% of parathyroid glands that were already recognized on conventional view (p < 0.0001). Overall, for junior trainees, senior trainees, and attending surgeons, NIRAF made a positive impact in the recognition of 82.6% (n = 142/172), 62% (n = 124/200), and 42% (n = 107/255) of the total number parathyroid glands, ultimately identified during the surgical procedures respectively, (p < 0.0001).

Conclusions: Our results show that NIRAF imaging improved the whole surgical team's ability to recognize parathyroid glands, with the degree of impact inversely related to the level of surgical training.

Background: It is unknown if textbook outcomes (TBOs) correlate with patient-reported health-related quality of life (HRQoL) parameters in patients undergoing hepatic resection for colorectal liver metastasises. Understanding this relationship is required to inform treatment decisions and optimise patient care. This single-centre analysis aims to assess this correlation and provide insight into the impact of liver resection on patient well-being in this population.

Methods: Single-centre analysis of all liver resections performed for colorectal liver metastases (CRLM) at our centre from 2018 to 2023. The EuroQol-5D (EQ-5D) validated telephone questionnaire was used to assess HRQoL. The impact of a TBO on overall survival and recurrence-free survival was investigated using Kaplan-Meier curve analysis. A Cox model was used to determine factors associated with improved survival.

Results: 185 patients underwent liver resection for CRLM between 2018 and 2023. 55% of eligible patients completed the EQ-5D telephone questionnaire. TBOs were achieved in 68.2% of CRLM at our institution. Achieving TBOs in this cohort was associated with improved HRQoL (p = 0.061).

Conclusion: This study demonstrates excellent long-term HRQoL in patients who undergo resection for CRLM. Achieving TBO in this cohort is associated with improved patient-reported HRQoL. Our findings strengthen the utility of the previously defined textbook outcomes in CRLM.

Background: Surgical resection for pancreas ductal adenocarcinoma (PDAC) remains the mainstay of treatment. Regardless of enhanced survival rates, disparities in patient outcomes and experiences driven by the social determinants of health (SDH) persist. The area deprivation index (ADI) comprises 17 indicators related to education, employment, housing-quality, and poverty. We sought to examine the impact of ADI on surgical outcomes of PDAC patients.

Methods: Patients who underwent pancreatoduodenectomy or distal pancreatectomy for PDAC between January 2011 and December 2022 were identified. ADI was calculated using patient zip codes and categorized into quartiles, with the highest indicating the most marginalized. The primary outcome was loss to follow-up after surgical resection. To account for confounders, a competing risk multivariable regression analysis was used.

Results: A total of 1001 patients had a mean age of 66.6 (±9.64), with 46.3% (n = 463) of patients being female. A majority, 94.6% (n = 947), identified as white, and 64.1% (n = 641) had at least a college degree. The median length of follow-up after surgery was 1.8 years (interquartile range: 0.9-3.5). Multivariable analysis adjusting for competing risk of death, showed that patients who are least marginalized are 1.57 times more likely to have their follow-up than those most marginalized (hazard ratio: 1.57, 95% confidence interval: 1.08-2.29, p = 0.017).

Conclusion: SDH impact many aspects of patient's care including a higher risk of loss to follow-up for marginalized patients after surgery for PDAC. Future efforts should seek to identify and lower barriers faced by marginalized patients with system-level changes to ensure equitable access.

Introduction: Malignant bowel obstructions (MBO) are complex, heterogeneous disease processes which can be managed with surgical or endoscopic interventions. Patients with MBO often have advanced metastatic disease and poor functional status, which makes it difficult for providers to determine the best treatment strategy.

Methods: Patients with urgent or emergent admissions and a primary or secondary ICD-9/ICD-10 diagnosis of bowel obstruction with an additional diagnosis of disseminated cancer were identified from the National Inpatient Sample (2000-2017). Patients were stratified into operative and non-operative intervention groups. Multivariate regression determined factors associated with surgical treatment of MBO based on significant factors on univariate analysis. Trends in treatment over time were calculated using log-linear regression to determine the annual percent change (APC).

Results: Of 1118 patients, 18% underwent surgery and 7% underwent endoscopic intervention. From 2000 to 2017, a decreasing proportion of patients underwent surgery (APC -2.4, p = 0.023) with a commensurate increase in endoscopic interventions (APC 5.3, p = 0.042). There was also a decrease in the proportion of patients who died during hospitalization (APC -4.3, p = 0.029). Surgery was associated with longer mean lengths of stay (13 days vs. 7 days, p < 0.001) and higher rates of in-hospital mortality (13% vs. 6%, p = 0.001) compared to non-operative management.

Conclusion: The proportion of patients receiving surgery for MBO is decreasing and that receiving endoscopic interventions is increasing. In-hospital mortality is also decreasing proportionately, suggesting an improvement in patient selection.

Background and objectives: Although resection of colorectal liver metastases (CRLM) improves survival, factors including race and health insurance are associated with disparities in care. The aim of this study was to evaluate the effect of health insurance on racial disparities in CRLM resection.

Methods: A retrospective study of patients with CRC with synchronous CRLM was performed using the National Cancer Database (2004-2020). The primary outcome was resection liver resection. Multivariable logistic regression (MVR) was performed to evaluate the association of race and insurance with the odds of resection.

Results: Forty-four thousand and six hundred sixteen patients were included. Resection rates were lower among Blacks compared to White patients (12.9% vs. 17.3%). By MVR, Black patients (OR 0.76 vs. White), uninsured and Medicaid-insured patients (OR 0.49 and OR 0.71 vs. private insurance) were less likely to undergo resection. On MVR of race stratified by insurance, Black patients with private and Medicare insurance had decreased odds of resection compared to White (OR 0.71 and OR 0.64).

Conclusions: Although Black patients with CRLM have lower odds of hepatic resection compared to White, when stratified by insurance, this was only present among private- and Medicare-insured. Further investigation is warranted to understand other factors associated with racial disparities in this population.