Surgery最新文献

Background: Adequate postoperative pain control is essential after mastectomy. This study compares the influence of 2 regional analgesia techniques on length of stay and opioid use to systemic analgesia alone.

Methods: Patients treated with mastectomy from 2014 to 2020 were stratified according to perioperative analgesic modality (systemic analgesia versus thoracic epidural anesthesia or erector spinae plane block). Demographic, tumor, and treatment characteristics were compared. Outcome variables included postoperative anesthesia unit and hospital length of stay, postoperative day 1 and 2 discharge rates, and inpatient opioid use (in oral milligram morphine equivalents).

Results: Of 316 patients, 171 received systemic analgesia, 72 thoracic epidural anesthesia, and 73 erector spinae plane block. On univariate analysis, there were significant differences in age, neoadjuvant chemotherapy, bilateral surgery, immediate reconstruction, and Her2 positivity rates. Thoracic epidural anesthesia had the longest hospital length of stay, and erector spinae plane block the shortest, compared with systemic analgesia (52.1 vs 28 vs 30.6 hours, P < .0001). Postoperative day 1 discharge was more likely with erector spinae plane block than systemic analgesia and less likely with thoracic epidural anesthesia (89% vs 68.4% vs 30.6%, P < .0001). Erector spinae plane block required significantly less milligram morphine equivalents than thoracic epidural anesthesia or systemic analgesia on postoperative day 1 (10 vs 18.75 vs 20 milligram morphine equivalents, P < .0009), but no differences on postoperative day 2 (23.5 vs 20 vs 25 milligram morphine equivalents, P = .84). Total hospital opioid use was significantly lower for erector spinae plane block than thoracic epidural anesthesia or systemic analgesia (24 vs 32.3 vs 32 milligram morphine equivalents, P = .024). On multivariate analysis, thoracic epidural anesthesia was associated with significantly longer length of stay, whereas neither thoracic epidural anesthesia nor erector spinae plane block was associated with decreased opioid use.

Conclusion: Regional analgesia is not significantly associated with decreased opioid use or hospital length of stay.

Background: Surgery is the mainstay of therapy for thyroid cancer. A rising number of patients decline recommended surgical intervention. This study aimed to identify factors associated with the decision to decline surgery for well-differentiated thyroid cancer.

Methods: Patients with papillary or follicular thyroid cancer diagnosed between 2004 and 2017 were identified from the National Cancer Database. Patients were grouped based on patient-documented refusal of recommended surgery and patients who successfully completed surgery. Baseline characteristic comparison, univariable and multivariable logistic regression, and survival analyses were performed.

Results: A total of 221,664 patients met inclusion criteria: 565 (0.3%) patients declined and 221,099 (99.7%) underwent recommended surgery. Patients who declined surgery were older, male, Black or Asian, and not privately insured. They more frequently had Charlson-Deyo scores ≥3, were diagnosed at academic centers, and presented with larger tumors and advanced clinical stage. Multivariable modeling demonstrated that older age, Black or Asian race, diagnosis at an academic center, no insurance or lack of private insurance, clinical N stage ≥1a, and clinical M stage >0 were associated with higher odds of declining surgery (P < .001). A mean survival of 10 years was found among patients who declined surgery versus 16 years among patients who underwent surgery (P < .0001).

Conclusion: Most patients diagnosed with well-differentiated thyroid cancer undergo physician-recommended surgical intervention. Declining surgery is associated with worse overall survival and is more likely in older, male, Black, or Asian patients with socioeconomic disadvantage. This study underscores the importance of understanding barriers to thyroid cancer surgery and opportunities to optimize outcomes and reduce disparities for these populations.

Background: Intraductal papillary mucinous neoplasm is occasionally detected in the preoperative images of patients with gastrointestinal malignancies. Despite numerous studies examining the incidence of extrapancreatic malignancies in patients with intraductal papillary mucinous neoplasm, limited data exist on the prevalence of intraductal papillary mucinous neoplasm in those with gastrointestinal malignancies. Given that intraductal papillary mucinous neoplasm is a known risk factor for pancreatic cancer, this study aimed to evaluate the prevalence of intraductal papillary mucinous neoplasm in patients who underwent radical surgery for extrapancreatic gastrointestinal malignancies and its impact on pancreatic cancer development.

Methods: We retrospectively reviewed the preoperative computed tomography images of patients who underwent radical surgery for gastrointestinal malignancies between January 2017 and December 2021 for the presence of intraductal papillary mucinous neoplasm. Patients were divided into intraductal papillary mucinous neoplasm and non-intraductal papillary mucinous neoplasm groups, and clinicopathologic features and long-term outcomes, including pancreatic cancer development, were compared between groups.

Results: A total of 814 patients who underwent radical surgery for extrapancreatic gastrointestinal malignancies were included. Among them, 81 patients (10.0%) had intraductal papillary mucinous neoplasm. The median observation period was 39 (0-79) months. Notably, pancreatic cancer developed in 5 patients with intraductal papillary mucinous neoplasm and 1 without. The 5-year cumulative incidences of pancreatic cancer were 8.8% and 0.2% in the intraductal papillary mucinous neoplasm and non-intraductal papillary mucinous neoplasm groups, respectively (P < .001).

Conclusion: Intraductal papillary mucinous neoplasm is frequently detected in the preoperative images of patients with gastrointestinal malignancies and is associated with a significantly higher risk of developing pancreatic cancer. Consequently, long-term surveillance for pancreatic cancer is crucial in patients with intraductal papillary mucinous neoplasm, particularly those with extrapancreatic gastrointestinal malignancies.

Background: Non-Hispanic Black women have lower breast cancer incidence but twice the mortality of non-Hispanic White women. Recent data suggest that the overall survival difference may not be observed in older women. This study aims to determine overall survival in women aged ≥70 years with operable breast cancer by race and ethnicity and factors contributing to overall survival.

Methods: The National Cancer Database was queried to identify women aged ≥70 years with stage 0-III breast cancer from 2004 to 2018. Patients were separated by race and ethnicity: non-Hispanic White, non-Hispanic Black, Hispanic, and Other. To examine overall survival, a Cox proportional hazards model was created, and overall survival was calculated using the Kaplan-Meier method.

Results: There were 304,345 eligible patients. The mean age was 76.8 years (standard deviation 5.5 years), and most were non-Hispanic White (85.2%), had Medicare (86.8%), had hormone receptor-positive breast cancer (78.7%), and underwent partial mastectomy (64.5%). Compared with non-Hispanic White women, non-Hispanic Black women had a higher prevalence of stage III disease (10.8% vs 7.5%, P < .001) and triple-negative breast cancer (16.7% vs 8.7% P < .001), and a longer time to treatment initiation (39.2 vs 32.3 days, P < .001). Median follow-up was 5.38 years (interquartile range: 3.83-7.46 years). Non-Hispanic Black women had the lowest median survival time compared with non-Hispanic White women (9.7 vs 10.4 years, P < .001). After adjusting for insurance type, receptor status, stage, comorbidity, time to treatment, and facility type, there was no increased risk of death for non-Hispanic Black patients (hazard ratio: 0.99, 95% confidence interval: 0.96-1.01, P = .29).

Conclusion: Although overall survival was lower in older non-Hispanic Black women, this difference resolved on multivariate modeling, suggesting that other factors likely influence overall survival for this cohort.

Background: Tumor deposits are a unique histologic feature of colorectal cancer that is associated with adverse survival outcomes. The present study aimed to assess the association between tumor deposits and liver and lung metastases and to describe the characteristics of colorectal cancer associated with tumor deposits.

Methods: The Surveillance, Epidemiology, End Results (SEER) database was screened between 2010 and 2020 for patients with colorectal adenocarcinoma who underwent radical resection with data on tumor deposits. The primary outcome of the study was liver and lung metastases. The secondary outcome was the characteristics of patients with tumor deposits.

Results: A total of 205,294 patients (52% male, mean age 66.5 years) were included in the study. Tumor deposits were detected in 20,059 (9.7%) patients. Patients with tumor deposits were younger and presented more often with larger tumors, T3/T4 tumors, N+ tumors, stage IV disease, left-sided and rectal cancers, signet-ring cell carcinomas, high-grade adenocarcinomas, and perineural invasion. Multivariable binary regression analyses showed that tumor deposits were associated with 72% higher odds of liver metastases (odds ratio 1.72, 95% confidence interval 1.62-1.82, P < .001) and 68% higher odds of lung metastases (1.68, 1.51-1.86, P < .001). The odds of liver metastases increased by 3% (odds ratio 1.03, 95% confidence interval 1.03-1.04, P < .001) and the odds of lung metastases increased by 2% (1.02, 1.01-1.03, P < .001) for each tumor deposit detected.

Conclusions: Tumor deposit-positive colorectal cancers were larger, more often on the left side or in the rectum and presented with more advanced disease and unfavorable histology than tumor deposit-negative cancers. Tumor deposits were independently associated with 72% and 68% higher odds of liver and lung metastases, respectively.

Background: Conflicting literature suggests that larger defects in abdominal wall reconstruction both increase the risk of recurrence and have no impact on recurrence. In our prior work, hernias with defect areas ≥100 cm² were associated with increased discomfort, operative time, and length of stay but not recurrence or reoperation. Our goal was to determine if defect size, even in giant hernias, would impact recurrence after mesh repair with complete fascial closure.

Methods: A prospectively maintained hernia database was reviewed for clean, abdominal wall reconstruction with fascial closure and synthetic mesh. Patients were grouped and compared by defect area: moderate hernias <200 cm² (LT200) and giant hernias ≥200 cm² (GT200).

Results: Of 984 patients, 607 LT200 (average area: 92.8 ± 60.8 cm²) were compared with 377 GT200 (average area: 363.2 ± 196.7 cm²). LT200 and GT200 had similar mean age, body mass index, and smoking rate, but GT200 had higher rates of diabetes (22.1% vs 27.9%; P = .040), recurrent hernias (52.7% vs 63.4%; P = .001), preoperative Botox (0.7% vs 8.8%; P < .001), component separation (23.4% vs 59.9%; P < .001), panniculectomy (8.7% vs 15.4%; P = .001), and negative-pressure incisional vacuum placement (5.9% vs 13.5%; P < .001). GT200 had increased mesh size (753.5 ± 367.1 vs 1168.2 ± 412.0 cm²; P < .001), operative time (147.8 ± 55.7 vs 205.3 ± 59.9 minutes; P < .001), and length of stay (5.1 ± 3.2 vs 6.9 ± 4.4 days; P < .001). GT200 had more wound complications (24.7% vs 36.1%; P < .001) and readmissions (9.1% vs 15.1%; P = .004) but similar recurrence rates (3.0% vs 3.7%; P = .520) over the mean follow-up of 30.1 ± 38.9 and 23.0 ± 33.6 months for LT200 and GT200, respectively. On multivariable regression, previous abdominal wall reconstruction, lightweight mesh, and wound complications independently predicted recurrence; component separation was protective, but defect size was not predictive of recurrence.

Conclusion: GT200 required more complex measures to achieve fascial closure and resulted in increased length of stay, wound complications, and readmissions; however, GT200 had the same recurrence rate as smaller defects when fascial closure was achieved.

Aim: The immune system plays a crucial role in the outcome of colorectal cancer. Systemic chemotherapies modulate the immune cell composition. Little is known about these changes in peritoneal metastasized colorectal cancer. Thus, we aimed to characterize local and systemic immune cells in the course of systemic chemotherapy.

Methods: We included in total 20 patients with peritoneal metastasized colorectal cancer in our exploratory study. Initially, we investigated the peripheral blood cell distributions before and after systemic chemotherapy in a set of 11 retrospectively collected samples. Then, a prospective clinical cohort was set up to evaluate local and systemic immune cell distribution in detail (n = 9). Tumor tissue, peritoneal fluid, and peripheral blood were collected. The main immune cell subtypes were characterized using flow cytometry and immunohistochemistry, respectively.

Results: Neutrophils and the neutrophil-to-lymphocyte ratio significantly declined in response to systemic chemotherapy while circulating T cells increased (CD8⁺P = .015, CD4⁺P = .041). In peritoneal fluid, we observed a decrease of CD25⁺/FOXP3⁺/CD4⁺ regulatory T cells (P = .049) without loss of their ability to produce interferon gamma. T-cell infiltration in the tumor microenvironment showed a considerable variability between patients. However, the number of tumor-infiltrating CD8⁺ lymphocytes was not significantly changed by the application of systemic chemotherapy. Neither tumor cells nor lymphocytes or macrophages showed noteworthy expression of PD1 or PD-L1.

Conclusion: Our data show that immune cell distribution after systemic chemotherapy changes in peripheral blood. Interestingly, in peritoneal fluid only the inhibitory Treg population decreased and local T cells within peritoneal metastases remain unaffected. These data indicate little to no effect of systemic chemotherapy on the local immune system, supporting the need for new therapeutic options.

Background: Limited treatment options exist for inoperable thyroid cancers. We evaluated whether neoadjuvant use of systemic tyrosine kinase inhibitors facilitates surgery of differentiated thyroid cancers in this challenging context.

Methods: A single-institution experience of 42 patients receiving tyrosine kinase inhibitors for papillary, follicular and anaplastic thyroid carcinomas between 2018 and 2023 was reviewed to identify differentiated thyroid cancers treated with neoadjuvant tyrosine kinase inhibitors (dabrafenib/trametinib, lenvatinib/pembrolizumab, or lenvatinib alone) via multidisciplinary protocols.

Results: Nine patients with differentiated thyroid cancers (age 49 years, range 19-80, 5 women, 4 men) received neoadjuvant tyrosine kinase inhibitors with intent to improve resectability of primary or recurrent/residual tumors. All had locoregionally advanced disease deemed either unresectable or resectable with unacceptable morbidities. Six exhibited distant metastases (6 lungs, 6 vertebral/axial bones, 1 sternum). Tumors had BRAF V600E (6 papillary thyroid carcinoma) or RAS/TERT (2 follicular thyroid carcinoma) mutations or NCOA4-RET fusion. Most received neoadjuvant tyrosine kinase inhibitors for <6 months with visible results within weeks, radiologically and by examination. All patients completing surgery achieved R0 resection without major surgical complications or aerodigestive structure resection. Neoadjuvant tyrosine kinase inhibitors were generally well-tolerated (4 minor, 1 major toxicity that halted therapy but not surgery). Unique patients with distant metastases continued to receive adjuvant tyrosine kinase inhibitors. At median postoperative follow-up of 2 years, all patients are alive without new locoregional recurrence.

Conclusion: Neoadjuvant use of tyrosine kinase inhibitors seems extremely effective in downstaging surgically unresectable differentiated thyroid cancers to achieve R0 resection while avoiding unnecessary surgical morbidities. A multidisciplinary approach with early genomic profiling to guide personalized neoadjuvant use of tyrosine kinase inhibitors is essential. Prospective studies are urgently needed to define the potential role of neoadjuvant tyrosine kinase inhibitors in advanced thyroid cancer management.