Pub Date : 2024-10-21DOI: 10.1097/SLA.0000000000006571
Shuo Jin, Ming-Yu Lin, Can-Hong Xiang, Zhi-Peng Liu, Si-Yuan Wang, Nan Jiang, Li Li, Si-Qiao Shan, Jian-Ping Zeng, Hai-Xin Yin, Tao Zhang, Chang-Zhen Yang, Dong-Liang Yang, Hu Zhou, Zhi-Yu Chen, Jia-Hong Dong
Objective: This study aimed to investigate the prevalence and distribution of carcinoma in the liver margin (LM) of resected perihilar cholangiocarcinoma (pCCA) and establish a method for LM examination.
Background: LM is the largest margin in resected pCCA with undefined status and assessment method.
Methods: 227 pCCA cases underwent major hepatectomy were divided into a discovery cohort (n=101) assessed using serial whole-mount digital large sections (WDLS) combined with small sections, and a control cohort (n=126) assessed using only small sections.
Results: The LM R1 resection rate was 38.6% (39/101) in the discovery cohort and 5.6% (7/126) in the control cohort. WDLS identified more LM R1 cases compared to the small section in the discovery cohort (38.6% vs. 5.9%, P<0.001). R0 patients in the discovery cohort had better overall survival and recurrence-free survival than those in the control cohort (both P<0.05). Additionally, 95% of carcinoma was found within 20 mm of the proximal ductal margin (DM). A proximal DM distance of<5 mm was an independent risk factor for LM R1 resection. Patients with which are more likely to experience R1 compared to those with ≥ 5 mm (P<0.001).
Conclusions: Positive LM was the significant cause for R1 resection of pCCA and the utilization of WDLS improved the diagnostic accuracy of LM. An examination methodology was established, highlighting the necessity of examining LM within a 20 mm radius around the proximal DM, especially in patients with a proximal DM of<5 mm.
{"title":"The Status of Liver Margin in Perihilar Cholangiocarcinoma: A Multicenter Study.","authors":"Shuo Jin, Ming-Yu Lin, Can-Hong Xiang, Zhi-Peng Liu, Si-Yuan Wang, Nan Jiang, Li Li, Si-Qiao Shan, Jian-Ping Zeng, Hai-Xin Yin, Tao Zhang, Chang-Zhen Yang, Dong-Liang Yang, Hu Zhou, Zhi-Yu Chen, Jia-Hong Dong","doi":"10.1097/SLA.0000000000006571","DOIUrl":"https://doi.org/10.1097/SLA.0000000000006571","url":null,"abstract":"<p><strong>Objective: </strong>This study aimed to investigate the prevalence and distribution of carcinoma in the liver margin (LM) of resected perihilar cholangiocarcinoma (pCCA) and establish a method for LM examination.</p><p><strong>Background: </strong>LM is the largest margin in resected pCCA with undefined status and assessment method.</p><p><strong>Methods: </strong>227 pCCA cases underwent major hepatectomy were divided into a discovery cohort (n=101) assessed using serial whole-mount digital large sections (WDLS) combined with small sections, and a control cohort (n=126) assessed using only small sections.</p><p><strong>Results: </strong>The LM R1 resection rate was 38.6% (39/101) in the discovery cohort and 5.6% (7/126) in the control cohort. WDLS identified more LM R1 cases compared to the small section in the discovery cohort (38.6% vs. 5.9%, P<0.001). R0 patients in the discovery cohort had better overall survival and recurrence-free survival than those in the control cohort (both P<0.05). Additionally, 95% of carcinoma was found within 20 mm of the proximal ductal margin (DM). A proximal DM distance of<5 mm was an independent risk factor for LM R1 resection. Patients with which are more likely to experience R1 compared to those with ≥ 5 mm (P<0.001).</p><p><strong>Conclusions: </strong>Positive LM was the significant cause for R1 resection of pCCA and the utilization of WDLS improved the diagnostic accuracy of LM. An examination methodology was established, highlighting the necessity of examining LM within a 20 mm radius around the proximal DM, especially in patients with a proximal DM of<5 mm.</p>","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2024-10-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142456554","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
OBJECTIVEThis study aimed to investigate the prevalence and distribution of carcinoma in the liver margin (LM) of resected perihilar cholangiocarcinoma (pCCA) and establish a method for LM examination.BACKGROUNDLM is the largest margin in resected pCCA with undefined status and assessment method.METHODS227 pCCA cases underwent major hepatectomy were divided into a discovery cohort (n=101) assessed using serial whole-mount digital large sections (WDLS) combined with small sections, and a control cohort (n=126) assessed using only small sections.RESULTSThe LM R1 resection rate was 38.6% (39/101) in the discovery cohort and 5.6% (7/126) in the control cohort. WDLS identified more LM R1 cases compared to the small section in the discovery cohort (38.6% vs. 5.9%, P<0.001). R0 patients in the discovery cohort had better overall survival and recurrence-free survival than those in the control cohort (both P<0.05). Additionally, 95% of carcinoma was found within 20 mm of the proximal ductal margin (DM). A proximal DM distance of<5 mm was an independent risk factor for LM R1 resection. Patients with which are more likely to experience R1 compared to those with ≥ 5 mm (P<0.001).CONCLUSIONSPositive LM was the significant cause for R1 resection of pCCA and the utilization of WDLS improved the diagnostic accuracy of LM. An examination methodology was established, highlighting the necessity of examining LM within a 20 mm radius around the proximal DM, especially in patients with a proximal DM of<5 mm.
{"title":"The Status of Liver Margin in Perihilar Cholangiocarcinoma: A Multicenter Study.","authors":"Shuo Jin,Ming-Yu Lin,Can-Hong Xiang,Zhi-Peng Liu,Si-Yuan Wang,Nan Jiang,Li Li,Si-Qiao Shan,Jian-Ping Zeng,Hai-Xin Yin,Tao Zhang,Chang-Zhen Yang,Dong-Liang Yang,Hu Zhou,Zhi-Yu Chen,Jia-Hong Dong","doi":"10.1097/sla.0000000000006571","DOIUrl":"https://doi.org/10.1097/sla.0000000000006571","url":null,"abstract":"OBJECTIVEThis study aimed to investigate the prevalence and distribution of carcinoma in the liver margin (LM) of resected perihilar cholangiocarcinoma (pCCA) and establish a method for LM examination.BACKGROUNDLM is the largest margin in resected pCCA with undefined status and assessment method.METHODS227 pCCA cases underwent major hepatectomy were divided into a discovery cohort (n=101) assessed using serial whole-mount digital large sections (WDLS) combined with small sections, and a control cohort (n=126) assessed using only small sections.RESULTSThe LM R1 resection rate was 38.6% (39/101) in the discovery cohort and 5.6% (7/126) in the control cohort. WDLS identified more LM R1 cases compared to the small section in the discovery cohort (38.6% vs. 5.9%, P<0.001). R0 patients in the discovery cohort had better overall survival and recurrence-free survival than those in the control cohort (both P<0.05). Additionally, 95% of carcinoma was found within 20 mm of the proximal ductal margin (DM). A proximal DM distance of<5 mm was an independent risk factor for LM R1 resection. Patients with which are more likely to experience R1 compared to those with ≥ 5 mm (P<0.001).CONCLUSIONSPositive LM was the significant cause for R1 resection of pCCA and the utilization of WDLS improved the diagnostic accuracy of LM. An examination methodology was established, highlighting the necessity of examining LM within a 20 mm radius around the proximal DM, especially in patients with a proximal DM of<5 mm.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"40 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2024-10-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142486348","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-18DOI: 10.1097/SLA.0000000000006568
Daniel Roy Sadek Habib, George Lin, Alexander Langerman
{"title":"Gaps in Informed Consent for Intimate Exams Under Anesthesia.","authors":"Daniel Roy Sadek Habib, George Lin, Alexander Langerman","doi":"10.1097/SLA.0000000000006568","DOIUrl":"https://doi.org/10.1097/SLA.0000000000006568","url":null,"abstract":"","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2024-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142543244","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-16DOI: 10.1097/sla.0000000000006555
Teagan Telesnicki,Jordan Nantais,Charles De Mestral,Anthony de Buck van Overstraeten,David Gomez
OBJECTIVETo describe long-term re-presentations and interventions following non-operative management (NOM) of acute appendicitis (AA).SUMMARY BACKGROUND DATATrial data suggest NOM of AA carries a substantial risk of subsequent appendectomy, although NOM is increasingly offered to patients. Population-based data is required to understand the real-world long-term course of patients undergoing NOM of AA.METHODSThis population-based cohort study included all adult patients in Ontario, Canada who presented to any emergency department (ED) with AA between 2004-2019. Patients who did not undergo a procedure on index ED presentation or hospital admission were defined as NOM and followed for five years. The cumulative incidence of composite re-presentation or intervention (ED re-presentation, re-admission, emergency, or scheduled appendicitis procedure) was calculated accounting for competing risk of death.RESULTSOf 156,362 patients identified with AA, 13,200 underwent NOM. The cumulative incidence of composite re-presentation or intervention was 33% at 1-year (95%CI 32-33%) and 36% at 5-years (95%CI 36-37%). At 5-years, the incidence of appendicitis-specific ED re-presentation or hospital re-admission was 16% (95%CI 15-16%), the incidence of an emergency procedure for AA was 12% (95%CI 12-13%), and the incidence of scheduled surgery was 21% (95%CI 20-21%). In a subgroup of patients with uncomplicated AA, composite re-presentation or intervention was 28% at 1-year (95%CI 27-29%) and 32% at 5-years (95%CI 32-33%).CONCLUSIONSReal-world estimates of emergency re-presentation with or without urgent surgery following NOM of AA were lower than previously described. Scheduled appendectomy made up an important proportion of long-term interventions following NOM.
目的描述急性阑尾炎（AA）非手术治疗（NOM）后的长期再就诊情况和干预措施。这项基于人群的队列研究纳入了加拿大安大略省 2004-2019 年间因 AA 到急诊科（ED）就诊的所有成年患者。在急诊科就诊或入院时未接受手术的患者被定义为NOM，并随访五年。计算再次就诊或干预（ED 再次就诊、再次入院、急诊或计划阑尾炎手术）的累积发生率，并考虑死亡竞争风险。结果 在 156362 名被确诊为 AA 的患者中，13200 人接受了 NOM。1年后复合再就诊或干预的累计发生率为33%（95%CI 32-33%），5年后为36%（95%CI 36-37%）。5年后，阑尾炎特异性急诊室再次就诊或再次入院的发生率为16%（95%CI 15-16%），AA急诊手术的发生率为12%（95%CI 12-13%），计划手术的发生率为21%（95%CI 20-21%）。在无并发症的 AA 患者亚组中，1 年后再次就诊或干预的复合发生率为 28%（95%CI 27-29%），5 年后为 32%（95%CI 32-33%）。在NOM后的长期干预中，计划中的阑尾切除术占了很大比例。
{"title":"Long-term Outcomes Following Non-operative Management of Acute Appendicitis: A Population-based Analysis.","authors":"Teagan Telesnicki,Jordan Nantais,Charles De Mestral,Anthony de Buck van Overstraeten,David Gomez","doi":"10.1097/sla.0000000000006555","DOIUrl":"https://doi.org/10.1097/sla.0000000000006555","url":null,"abstract":"OBJECTIVETo describe long-term re-presentations and interventions following non-operative management (NOM) of acute appendicitis (AA).SUMMARY BACKGROUND DATATrial data suggest NOM of AA carries a substantial risk of subsequent appendectomy, although NOM is increasingly offered to patients. Population-based data is required to understand the real-world long-term course of patients undergoing NOM of AA.METHODSThis population-based cohort study included all adult patients in Ontario, Canada who presented to any emergency department (ED) with AA between 2004-2019. Patients who did not undergo a procedure on index ED presentation or hospital admission were defined as NOM and followed for five years. The cumulative incidence of composite re-presentation or intervention (ED re-presentation, re-admission, emergency, or scheduled appendicitis procedure) was calculated accounting for competing risk of death.RESULTSOf 156,362 patients identified with AA, 13,200 underwent NOM. The cumulative incidence of composite re-presentation or intervention was 33% at 1-year (95%CI 32-33%) and 36% at 5-years (95%CI 36-37%). At 5-years, the incidence of appendicitis-specific ED re-presentation or hospital re-admission was 16% (95%CI 15-16%), the incidence of an emergency procedure for AA was 12% (95%CI 12-13%), and the incidence of scheduled surgery was 21% (95%CI 20-21%). In a subgroup of patients with uncomplicated AA, composite re-presentation or intervention was 28% at 1-year (95%CI 27-29%) and 32% at 5-years (95%CI 32-33%).CONCLUSIONSReal-world estimates of emergency re-presentation with or without urgent surgery following NOM of AA were lower than previously described. Scheduled appendectomy made up an important proportion of long-term interventions following NOM.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"2 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2024-10-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142443756","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-16DOI: 10.1097/sla.0000000000006567
David Henault,Holden Kunde,Cody Zatzman,Daniela Bevacqua,Danielle LA Arshinoff,Sean P Cleary,Laura A Dawson,Elena Elimova,Robert Grant,Ali Hosni,Raymond W Jang,Jennifer J Knox,Aruz Mesci,Malcolm Moore,Carol-Anne E Moulton,Trevor W Reichman,Chaya Shwaartz,Erica S Tsang,Ian D McGilvray,Steven Gallinger
OBJECTIVE BACKGROUNDCombined pancreatic and vascular resections are increasingly performed for pancreatic ductal adenocarcinoma (PDAC). We evaluated the outcomes after pancreatectomy with non-vascular resection (NVR), venous resection (VR), and arterial resection (AR).METHODSRetrospective review (2011-2023) of 715 PDAC patients treated with curative-intent surgery. Associations among clinicopathological data, perioperative therapy, time to recurrence (TTR), and overall survival (OS) were evaluated.RESULTSInitial staging revealed 533 resectable, 98 borderline, and 84 locally advanced PDAC cases. Pancreaticoduodenectomy was the most common procedure (n=467). NVR was performed in 351 (58.2%) patients, VR in 181 (30.0%), and AR in 70 (11.8%). The median TTR and OS did not significantly differ according to the initial staging or type of pancreas resection. Median TTR and OS were significantly shorter for VR (14.5 and 22.7 mo) compared to NVR (18.6 and 30.5 mo, P<0.001) and AR (20.6 and 30.9 mo, P=0.004 and P=0.017). Chemotherapy or chemoradiation significantly prolonged TTR (20.1 vs. 10.2 mo, P<0.001 and 25.3 vs. 16.4 mo, P<0.001) and OS (31.5 vs. 17.2 mo, P<0.001 and 35.5 vs. 27.5 mo, P=0.030). AR was associated with higher 90-day mortality rates. In the multivariable analysis, vascular resection was not associated with OS. Perioperative therapy, pathological N0 status, and absence of perineural invasion were the key predictors of longer TTR and OS.CONCLUSIONSPancreatectomy with AR was not associated with worse oncological outcomes when controlling for perioperative therapy. However, AR was associated with higher 90-day mortality rates. Patient selection is crucial when performing AR in patients with PDAC.
目的 背景胰腺导管腺癌（PDAC）越来越多地采用胰腺和血管联合切除术。我们评估了非血管切除术（NVR）、静脉切除术（VR）和动脉切除术（AR）胰腺切除术后的预后。结果初步分期显示有533例可切除、98例边缘和84例局部晚期PDAC病例。胰十二指肠切除术是最常见的手术（n=467）。351例（58.2%）患者进行了NVR，181例（30.0%）进行了VR，70例（11.8%）进行了AR。中位 TTR 和 OS 与初始分期或胰腺切除类型无明显差异。与NVR（18.6和30.5个月，P<0.001）和AR（20.6和30.9个月，P=0.004和P=0.017）相比，VR（14.5和22.7个月）的中位TTR和OS明显较短。化疗或放疗可明显延长TTR（20.1个月对10.2个月，P<0.001；25.3个月对16.4个月，P<0.001）和OS（31.5个月对17.2个月，P<0.001；35.5个月对27.5个月，P=0.030）。AR与较高的90天死亡率相关。在多变量分析中，血管切除与OS无关。结论在控制围手术期治疗的情况下，AR胰切除术与较差的肿瘤预后无关。然而，AR与较高的90天死亡率有关。在对PDAC患者进行AR手术时，患者的选择至关重要。
{"title":"Vascular Resection for Pancreas Cancer - 10-year Experience from a Single High Volume-center.","authors":"David Henault,Holden Kunde,Cody Zatzman,Daniela Bevacqua,Danielle LA Arshinoff,Sean P Cleary,Laura A Dawson,Elena Elimova,Robert Grant,Ali Hosni,Raymond W Jang,Jennifer J Knox,Aruz Mesci,Malcolm Moore,Carol-Anne E Moulton,Trevor W Reichman,Chaya Shwaartz,Erica S Tsang,Ian D McGilvray,Steven Gallinger","doi":"10.1097/sla.0000000000006567","DOIUrl":"https://doi.org/10.1097/sla.0000000000006567","url":null,"abstract":"OBJECTIVE BACKGROUNDCombined pancreatic and vascular resections are increasingly performed for pancreatic ductal adenocarcinoma (PDAC). We evaluated the outcomes after pancreatectomy with non-vascular resection (NVR), venous resection (VR), and arterial resection (AR).METHODSRetrospective review (2011-2023) of 715 PDAC patients treated with curative-intent surgery. Associations among clinicopathological data, perioperative therapy, time to recurrence (TTR), and overall survival (OS) were evaluated.RESULTSInitial staging revealed 533 resectable, 98 borderline, and 84 locally advanced PDAC cases. Pancreaticoduodenectomy was the most common procedure (n=467). NVR was performed in 351 (58.2%) patients, VR in 181 (30.0%), and AR in 70 (11.8%). The median TTR and OS did not significantly differ according to the initial staging or type of pancreas resection. Median TTR and OS were significantly shorter for VR (14.5 and 22.7 mo) compared to NVR (18.6 and 30.5 mo, P<0.001) and AR (20.6 and 30.9 mo, P=0.004 and P=0.017). Chemotherapy or chemoradiation significantly prolonged TTR (20.1 vs. 10.2 mo, P<0.001 and 25.3 vs. 16.4 mo, P<0.001) and OS (31.5 vs. 17.2 mo, P<0.001 and 35.5 vs. 27.5 mo, P=0.030). AR was associated with higher 90-day mortality rates. In the multivariable analysis, vascular resection was not associated with OS. Perioperative therapy, pathological N0 status, and absence of perineural invasion were the key predictors of longer TTR and OS.CONCLUSIONSPancreatectomy with AR was not associated with worse oncological outcomes when controlling for perioperative therapy. However, AR was associated with higher 90-day mortality rates. Patient selection is crucial when performing AR in patients with PDAC.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"10 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2024-10-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142448048","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
OBJECTIVETo evaluate the morphologic landscape of pancreatic ductal adenocarcinoma (PDAC), intratumor spatial heterogeneity, and the resulting clinical impact following post-neoadjuvant pancreatectomy.SUMMARY BACKGROUND DATAThe clinical value of PDAC morphologic subtypes and intratumor spatial heterogeneity post-treatment remains an open issue.MATERIALS AND METHODSThe study cohort included patients who underwent post-neoadjuvant pancreatectomy for PDAC at the University of Verona Hospital Trust between 2013 and 2019. All hematoxylin and eosin-stained slides were reviewed to assess PDAC histomorphology and intratumor heterogeneity. The relationship with other clinicopathological variables, overall survival (OS), and recurrence-free (RFS) survival was evaluated using standard statistics.RESULTSThe study cohort included 400 patients. Histological revision identified ten different morphologic subtypes. Gland-forming PDAC with a conventional pattern was the most frequently identified subtype (41.8%). Overall, 247 tumors (61.7%) showed only one histological pattern and were classified as homogeneous, whereas 153 (38.3%) showed different morphologies and were classified as heterogeneous tumors. The median post-resection survival was 30.1 months (95%CI 26.6-33.5). There was a substantial survival variability according to the morphologic subtype, ranging from 19.1 months in the gyriform subtype to 47.0 months in the papillary subtype. Tumors with a heterogeneous morphology displayed a higher rate of nodal metastases, worse tumor regression metrics, and worse oncologic outcomes relative to spatially homogeneous tumors.DISCUSSIONThis paper provided a morphological taxonomy of residual tumors following post-neoadjuvant pancreatectomy for PDAC. The morphologic subtype and intratumor spatial heterogeneity have relevant prognostic implications and could be included in the pathology report to complement regression metrics.
{"title":"Morphologic Characterization of Pancreatic Ductal Adenocarcinoma following Post-neoadjuvant Pancreatectomy and Clinical value of Intratumor Heterogeneity.","authors":"Gabriella Lionetto,Paola Mattiolo,Calogero Ciulla,Giulia Savegnago,Fabio Casciani,Matteo De Pastena,Salvatore Paiella,Antonio Pea,Alessandro Esposito,Anna Crovetto,Massimo Donadelli,Carlotta Franzina,Matteo Fassan,Aldo Scarpa,Roberto Salvia,Giuseppe Malleo,Claudio Luchini","doi":"10.1097/sla.0000000000006565","DOIUrl":"https://doi.org/10.1097/sla.0000000000006565","url":null,"abstract":"OBJECTIVETo evaluate the morphologic landscape of pancreatic ductal adenocarcinoma (PDAC), intratumor spatial heterogeneity, and the resulting clinical impact following post-neoadjuvant pancreatectomy.SUMMARY BACKGROUND DATAThe clinical value of PDAC morphologic subtypes and intratumor spatial heterogeneity post-treatment remains an open issue.MATERIALS AND METHODSThe study cohort included patients who underwent post-neoadjuvant pancreatectomy for PDAC at the University of Verona Hospital Trust between 2013 and 2019. All hematoxylin and eosin-stained slides were reviewed to assess PDAC histomorphology and intratumor heterogeneity. The relationship with other clinicopathological variables, overall survival (OS), and recurrence-free (RFS) survival was evaluated using standard statistics.RESULTSThe study cohort included 400 patients. Histological revision identified ten different morphologic subtypes. Gland-forming PDAC with a conventional pattern was the most frequently identified subtype (41.8%). Overall, 247 tumors (61.7%) showed only one histological pattern and were classified as homogeneous, whereas 153 (38.3%) showed different morphologies and were classified as heterogeneous tumors. The median post-resection survival was 30.1 months (95%CI 26.6-33.5). There was a substantial survival variability according to the morphologic subtype, ranging from 19.1 months in the gyriform subtype to 47.0 months in the papillary subtype. Tumors with a heterogeneous morphology displayed a higher rate of nodal metastases, worse tumor regression metrics, and worse oncologic outcomes relative to spatially homogeneous tumors.DISCUSSIONThis paper provided a morphological taxonomy of residual tumors following post-neoadjuvant pancreatectomy for PDAC. The morphologic subtype and intratumor spatial heterogeneity have relevant prognostic implications and could be included in the pathology report to complement regression metrics.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"13 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2024-10-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142439357","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-15DOI: 10.1097/SLA.0000000000006566
Samir K Shah, Dan Neal, Terrie Vasilopoulos, Mark Segal, Scott Berceli, Joel S Weissman
Objective: To understand mortality and secondary outcomes in patients with both end-stage kidney disease (ESKD) and chronic limb-threatening ischemia (CLTI) after no procedural treatment, primary amputation, endovascular treatment, and open surgery.
Summary background data: ESKD and CLTI commonly cooccur and limited prior work has demonstrated poor outcomes including one-year survival despite treatment.
Methods: We conducted a retrospective national cohort study of United States Renal Data System data from January 1, 2016 to December 31, 2019 to determine mortality, major postoperative complications, and other outcomes. We performed an exploratory analysis comparing two-year survival by treatment using propensity matching.
Results: Of 1,876,652 records with a CLTI diagnosis, we identified 3,908 patients with ESKD and an incident CLTI diagnosis. Mean age at CLTI diagnosis was 65.7 years and 2,405 (61.5%) were male. 2,696 (69.0%) had no procedural treatment, 609 (15.6%) had major limb amputation, 439 (11.2%) had endovascular treatment, and 164 (4.2%) had open surgery. There was 44.9% mortality at one year, along with 41.8% major postoperative complications and 52.6% readmissions at 90 days. Comparing two-year survival, we found no differences between the amputation and endovascular cohorts (P=0.08) and between endovascular and open (P=.06). There was superior two-year survival in the open surgery cohort compared to the amputation cohort (P=0.002).
Conclusions: Patients living with both ESKD and CLTI experience poor outcomes irrespective of treatment. Exploratory analyses demonstrated that two-year survival among the three principal procedural treatments was similar except for superior survival among patients undergoing open therapy compared to primary amputation.
{"title":"Outcomes among Patients with End-Stage Kidney Disease and Chronic Limb-Threatening Ischemia: A Population-based Cohort Study.","authors":"Samir K Shah, Dan Neal, Terrie Vasilopoulos, Mark Segal, Scott Berceli, Joel S Weissman","doi":"10.1097/SLA.0000000000006566","DOIUrl":"https://doi.org/10.1097/SLA.0000000000006566","url":null,"abstract":"<p><strong>Objective: </strong>To understand mortality and secondary outcomes in patients with both end-stage kidney disease (ESKD) and chronic limb-threatening ischemia (CLTI) after no procedural treatment, primary amputation, endovascular treatment, and open surgery.</p><p><strong>Summary background data: </strong>ESKD and CLTI commonly cooccur and limited prior work has demonstrated poor outcomes including one-year survival despite treatment.</p><p><strong>Methods: </strong>We conducted a retrospective national cohort study of United States Renal Data System data from January 1, 2016 to December 31, 2019 to determine mortality, major postoperative complications, and other outcomes. We performed an exploratory analysis comparing two-year survival by treatment using propensity matching.</p><p><strong>Results: </strong>Of 1,876,652 records with a CLTI diagnosis, we identified 3,908 patients with ESKD and an incident CLTI diagnosis. Mean age at CLTI diagnosis was 65.7 years and 2,405 (61.5%) were male. 2,696 (69.0%) had no procedural treatment, 609 (15.6%) had major limb amputation, 439 (11.2%) had endovascular treatment, and 164 (4.2%) had open surgery. There was 44.9% mortality at one year, along with 41.8% major postoperative complications and 52.6% readmissions at 90 days. Comparing two-year survival, we found no differences between the amputation and endovascular cohorts (P=0.08) and between endovascular and open (P=.06). There was superior two-year survival in the open surgery cohort compared to the amputation cohort (P=0.002).</p><p><strong>Conclusions: </strong>Patients living with both ESKD and CLTI experience poor outcomes irrespective of treatment. Exploratory analyses demonstrated that two-year survival among the three principal procedural treatments was similar except for superior survival among patients undergoing open therapy compared to primary amputation.</p>","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2024-10-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142543246","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
OBJECTIVEThis systematic review and meta-analysis aimed to compare outcomes between abdominal drain placement and no drain placement post-pancreatectomy.BACKGROUNDLeft pancreatectomy (LP) is a surgical procedure commonly employed for various pancreatic conditions, often associated with postoperative complications like post-operative pancreatic fistula (POPF). While routine abdominal drainage following LP has been standard practice, recent evidence suggests potential benefits of omitting this approach.METHODSA comprehensive search was conducted on PubMed, Cochrane, and Embase from inception up to 15 March 2024, yielding nine studies comprising 15,817 patients. Data were extracted from randomized and non-randomized studies reporting primary and secondary outcomes. The analysis was performed in Revman. Risk ratios were calculated with 95% confidence intervals, and a P-value of <0.05 was considered statistically significant.RESULTSA total of 13,081 patients underwent drain placement after left pancreatectomy, and 2,736 patients were included in the no-drain group. Out of the total, 45.1% (n=7140) patients were male, with 45.9% (n=6012) males in the drain group and 41.2% (n=1128) males in the no-drain group. Major morbidity, defined as Clavien-Dindo grade ≥III complications, was significantly lower in the no-drain group (relative risk [RR]: 0.77, 95% confidence interval [CI]: 0.64-0.93, P=0.006). Similarly, lower rates of postoperative pancreatic fistula (POPF) (RR: 0.51, 95% CI: 0.38-0.67, P<0.00001), readmission (RR: 0.75, 95% CI: 0.59-0.96, P=0.02), and surgical site infections (RR: 0.82, 95% CI: 0.70-0.95, P=0.009) were observed in the no-drain group. Additionally, a shorter length of hospital stay was noted in this group (mean difference MD: -1.65, 95% CI: -2.50 to -0.81, P=0.0001).CONCLUSIONSOmitting routine drainage after left pancreatectomy is associated with reduced complications and shorter hospital stays, supporting its potential benefits in improving postoperative outcomes.
{"title":"Comparative Assessment of Outcomes: Abdominal Drain vs. No Abdominal Drain after Left Pancreatectomy-A Systematic Review and Meta-Analysis.","authors":"Aleena Ahmed,Maurish Fatima,Muhammad Hammad Khan,Muhammad Hashim Faisal,Ayesha Sehar,Muhammad Jahanzaib Khan,Hassan Aziz","doi":"10.1097/sla.0000000000006564","DOIUrl":"https://doi.org/10.1097/sla.0000000000006564","url":null,"abstract":"OBJECTIVEThis systematic review and meta-analysis aimed to compare outcomes between abdominal drain placement and no drain placement post-pancreatectomy.BACKGROUNDLeft pancreatectomy (LP) is a surgical procedure commonly employed for various pancreatic conditions, often associated with postoperative complications like post-operative pancreatic fistula (POPF). While routine abdominal drainage following LP has been standard practice, recent evidence suggests potential benefits of omitting this approach.METHODSA comprehensive search was conducted on PubMed, Cochrane, and Embase from inception up to 15 March 2024, yielding nine studies comprising 15,817 patients. Data were extracted from randomized and non-randomized studies reporting primary and secondary outcomes. The analysis was performed in Revman. Risk ratios were calculated with 95% confidence intervals, and a P-value of <0.05 was considered statistically significant.RESULTSA total of 13,081 patients underwent drain placement after left pancreatectomy, and 2,736 patients were included in the no-drain group. Out of the total, 45.1% (n=7140) patients were male, with 45.9% (n=6012) males in the drain group and 41.2% (n=1128) males in the no-drain group. Major morbidity, defined as Clavien-Dindo grade ≥III complications, was significantly lower in the no-drain group (relative risk [RR]: 0.77, 95% confidence interval [CI]: 0.64-0.93, P=0.006). Similarly, lower rates of postoperative pancreatic fistula (POPF) (RR: 0.51, 95% CI: 0.38-0.67, P<0.00001), readmission (RR: 0.75, 95% CI: 0.59-0.96, P=0.02), and surgical site infections (RR: 0.82, 95% CI: 0.70-0.95, P=0.009) were observed in the no-drain group. Additionally, a shorter length of hospital stay was noted in this group (mean difference MD: -1.65, 95% CI: -2.50 to -0.81, P=0.0001).CONCLUSIONSOmitting routine drainage after left pancreatectomy is associated with reduced complications and shorter hospital stays, supporting its potential benefits in improving postoperative outcomes.","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":"55 1","pages":""},"PeriodicalIF":9.0,"publicationDate":"2024-10-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142436033","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-14DOI: 10.1097/SLA.0000000000006560
Niyum Gandhi
{"title":"Shareholder Considerations in Healthcare.","authors":"Niyum Gandhi","doi":"10.1097/SLA.0000000000006560","DOIUrl":"10.1097/SLA.0000000000006560","url":null,"abstract":"","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2024-10-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142456550","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2024-10-14DOI: 10.1097/SLA.0000000000006563
Anouk J de Wilde, Evelien J M de Jong, Marco J Bruno, Marc G Besselink, Lydia G M van der Geest, Sandra M E Geurts, Bas Groot Koerkamp, Ignace H J T de Hingh, Vincent E de Meijer, Razvan L Miclea, Jan-Werner Poley, Iryna V Samarska, Hjalmar C van Santvoort, Martijn W J Stommel, Rogier P Voermans, Steven W M Olde Damink, Judith de Vos-Geelen, Stefan A W Bouwense
Objective: To evaluate treatment outcomes, overall survival (OS), and prognostic factors for OS in patients diagnosed with T1 ampullary cancer.
Background: Ampullary cancer is a rare gastrointestinal malignancy with limited data from large cohorts, especially regarding T1 disease.
Methods: Patients diagnosed with clinical (c) T1 ampullary cancer and patients with pathological (p) T1 in the case of cTx were included from the Netherlands Cancer Registry (2014-2021). Primary endpoint was OS, analyzed using the Kaplan-Meier estimator. Multivariable Cox proportional hazards regression was used to identify OS predictors.
Results: Overall, 244 patients with cT1 ampullary cancer were included, of whom 75% (n=184) underwent resection. Among these, 68% (n=125) were upstaged to a higher pathologically T classification (pT2:40%, pT3:22%, pT4:5%). Similarly, cN0 was upstaged to pN1 in 47% of patients (n=87). Next, 100 patients with pT1 and cTx ampullary cancer were included, making a total of 159 patients with pT1 tumor. 92% (146/159) underwent pancreatoduodenectomy while 8% (13/159) underwent endoscopic or local surgical resection. The 1- and 5-year OS for cT1N0 ampullary cancer were 72% and 36%, while for pT1N0 they were 94% and 75%. Independent poor prognostic factors for OS were pN1 classification (HR 2.12; 95%CI 1.15-3.94, P=0.017), pNx classification (i.e. locally resected patients) (HR 2.82; 95%CI 1.22-6.55, P=0.016), and poorly differentiated tumors (HR 4.05; 95%CI 1.33-12.40, P=0.014).
Conclusion: In patients with cT1 ampullary cancer, more than two-thirds had a pathologically higher T classification, and almost half had a pathologically higher N classification. These findings suggest that pancreatoduodenectomy is recommended for cT1 ampullary cancer.
{"title":"Population-Based Cohort Study on Treatment and Overall Survival of Patients Clinically Diagnosed With T1 Ampullary Cancer.","authors":"Anouk J de Wilde, Evelien J M de Jong, Marco J Bruno, Marc G Besselink, Lydia G M van der Geest, Sandra M E Geurts, Bas Groot Koerkamp, Ignace H J T de Hingh, Vincent E de Meijer, Razvan L Miclea, Jan-Werner Poley, Iryna V Samarska, Hjalmar C van Santvoort, Martijn W J Stommel, Rogier P Voermans, Steven W M Olde Damink, Judith de Vos-Geelen, Stefan A W Bouwense","doi":"10.1097/SLA.0000000000006563","DOIUrl":"https://doi.org/10.1097/SLA.0000000000006563","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate treatment outcomes, overall survival (OS), and prognostic factors for OS in patients diagnosed with T1 ampullary cancer.</p><p><strong>Background: </strong>Ampullary cancer is a rare gastrointestinal malignancy with limited data from large cohorts, especially regarding T1 disease.</p><p><strong>Methods: </strong>Patients diagnosed with clinical (c) T1 ampullary cancer and patients with pathological (p) T1 in the case of cTx were included from the Netherlands Cancer Registry (2014-2021). Primary endpoint was OS, analyzed using the Kaplan-Meier estimator. Multivariable Cox proportional hazards regression was used to identify OS predictors.</p><p><strong>Results: </strong>Overall, 244 patients with cT1 ampullary cancer were included, of whom 75% (n=184) underwent resection. Among these, 68% (n=125) were upstaged to a higher pathologically T classification (pT2:40%, pT3:22%, pT4:5%). Similarly, cN0 was upstaged to pN1 in 47% of patients (n=87). Next, 100 patients with pT1 and cTx ampullary cancer were included, making a total of 159 patients with pT1 tumor. 92% (146/159) underwent pancreatoduodenectomy while 8% (13/159) underwent endoscopic or local surgical resection. The 1- and 5-year OS for cT1N0 ampullary cancer were 72% and 36%, while for pT1N0 they were 94% and 75%. Independent poor prognostic factors for OS were pN1 classification (HR 2.12; 95%CI 1.15-3.94, P=0.017), pNx classification (i.e. locally resected patients) (HR 2.82; 95%CI 1.22-6.55, P=0.016), and poorly differentiated tumors (HR 4.05; 95%CI 1.33-12.40, P=0.014).</p><p><strong>Conclusion: </strong>In patients with cT1 ampullary cancer, more than two-thirds had a pathologically higher T classification, and almost half had a pathologically higher N classification. These findings suggest that pancreatoduodenectomy is recommended for cT1 ampullary cancer.</p>","PeriodicalId":8017,"journal":{"name":"Annals of surgery","volume":" ","pages":""},"PeriodicalIF":7.5,"publicationDate":"2024-10-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142543247","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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