Injury Pattern and Outcomes Following All-Terrain Vehicle Accidents in Kentucky Children: A Retrospective Study

PURPOSE

All-terrain vehicles (ATVs) pose a significant risk for morbidity and mortality amongst children. We hypothesize that current vague legislation regarding helmet use impacts injury patterns and outcomes in pediatric ATV accidents.

METHODS

The institutional trauma registry was queried for pediatric patients involved in ATV accidents from 2006 to 2019. Patient demographics and helmet wearing status were identified in addition to patient outcomes, such as injury pattern, injury severity score, mortality, length of stay, and discharge disposition. These elements were analyzed for statistical significance.

RESULTS

720 patients presented during the study period, which were predominantly male (71%, n = 511) and less than 16 years old (76%, n = 543). Most patients were not wearing a helmet (82%, n = 589) at time of injury. Notably, there were 7 fatalities. A lack of helmet use is positively associated with head injury (42% vs 23%, P < .01), intracranial hemorrhage (15% vs 7%, P = .03), and associated with lower Glasgow Coma Scale (13.9 vs 14.4, P < .01). Children 16 years and older were least likely to wear a helmet and most likely to incur injuries. Patients over 16 years had longer lengths of stay, higher mortality, and higher need for rehabilitation.

CONCLUSION

Not wearing a helmet is directly correlated with injury severity and concerning rates of head injury. Children 16 years and older are at greatest risk for injury, but younger children are still at risk. Stricter state laws regarding helmet use are necessary to reduce pediatric ATV-related injury burden.

LEVEL OF EVIDENCE

level III retrospective comparative study.

Evaluation of the learning curve for laparoscopic pyloromyotomy

BACKGROUND

Laparoscopic pyloromyotomy is the preferred surgical management of hypertrophic pyloric stenosis at most centers. We aimed to analyze the learning curve for laparoscopic pyloromyotomy using the experience of five fellowship-trained pediatric surgeons.

METHODS

A retrospective review of consecutive patients undergoing laparoscopic pyloromyotomy was performed. All cases were performed with general surgery residents. Cumulative sum (CUSUM) analysis for operating time was performed for up to the first 150 consecutive cases for individual surgeons. Outcomes were compared to identify different phases of the learning curve for operative competency.

RESULTS

A total of 414 patients were included in the analysis as not all surgeons had reached 150 cases at time of analysis. The mean operating time was 29.2 min for all cases across the 5 surgeons. CUSUM analysis for mean operating time revealed three phases of learning: Learning Phase (cases 1-16), Plateau Phase (cases 17-87), and a Proficiency Phase (cases 88-150). The mean operating time during the three phases was 34.1, 29.0, and 28.3 min, respectively (P = 0.005). There were no differences in complications, reoperations, length of stay, or readmissions across the three phases.

CONCLUSION

Three distinct phases of learning for laparoscopic pyloromyotomy were identified with no differences in outcomes across the phases. The operating time differed only for the Learning Phase, suggesting that some degree of proficiency occurs after 16 cases.

Development of a Prognostic Nomogram and Nomogram Software Application Tool to Predict Overall Survival and Disease-Free Survival After Curative-Intent Gastrectomy for Gastric Cancer

BACKGROUND

We sought to derive and validate a prediction model of survival and recurrence among Western patients undergoing resection of gastric cancer.

METHODS

Patients who underwent curative-intent surgery for gastric cancer at seven US institutions and a major Italian center from 2000 to 2020 were included. Variables included in the multivariable Cox models were identified using an automated model selection procedure based on an algorithm. Best models were selected using the Bayesian information criterion (BIC). The performance of the models was internally cross-validated via the bootstrap resampling procedure. Discrimination was evaluated using the Harrell's Concordance Index and accuracy was evaluated using calibration plots. Nomograms were made available as online tools.

RESULTS

Overall, 895 patients met inclusion criteria. Age (hazard ratio [HR] 1.47, 95% confidence interval [CI] 1.17-1.84), presence of preoperative comorbidities (HR 1.66, 95% CI 1.14-2.41), lymph node ratio (LNR; HR 1.72, 95% CI 1.42-2.01), and lymphovascular invasion (HR 1.81, 95% CI 1.33-2.45) were associated with overall survival (OS; all p < 0.01), whereas tumor location (HR 1.93, 95% CI 1.23-3.02), T category (Tis-T1 vs. T3: HR 0.31, 95% CI 0.14-0.66), LNR (HR 1.82, 95% CI 1.45-2.28), and lymphovascular invasion (HR 1.49; 95% CI 1.01-2.22) were associated with disease-free survival (DFS; all p < 0.05) The models demonstrated good discrimination on internal validation relative to OS (C-index 0.70) and DFS (C-index 0.74).

CONCLUSIONS

A web-based nomograms to predict OS and DFS among gastric cancer patients following resection demonstrated good accuracy and discrimination and good performance on internal validation.

Concurrent COVID-19 infection in children with acute appendicitis: A report of three cases

Literature describing patients with concomitant COVID-19 infection with acute appendicitis in pediatric patients is growing, and understanding the clinical picture of such patients is relevant in their treatment. We report 3 male children who were surgically treated for acute appendicitis and had concomitant SARS-CoV-2 infection. Our first patient was a 12-year-old male who presented with symptoms indicative of appendicitis but no respiratory symptoms associated with COVID-19 (eg cough, shortness of breath). Laboratory evaluation revealed leukopenia and an elevated C-reactive protein; imaging was consistent with acute appendicitis and an acute pulmonary viral infection. Though he lacked diffuse peritonitis on physical examination or a leukocytosis, he was found to have perforated appendicitis in the operating room. Our second patient was another 12-year-old male whose suspected appendicitis was confirmed via ultrasound and surgery. He tested positive for COVID-19 1 month prior and he continued to test positive for infection on admission without any associated respiratory symptoms. Our third patient was a 13-year-old patient who also presented with symptomatic acute appendicitis without apparent COVID-19 manifestations. These cases provide further examples of pediatric patients with concomitant acute appendicitis and COVID-19 infection, namely an unusual presentation of perforated appendicitis with asymptomatic COVID-19-related pulmonary infection and the more common acute appendicitis with asymptomatic COVID-19 infection.

Evaluation of Outcomes Following Surgery for Locally Advanced Pancreatic Neuroendocrine Tumors

IMPORTANCE

Although outcome of surgical resection of liver metastases from pancreatic neuroendocrine tumors (PNETs) has been extensively studied, little is known about surgery for locally advanced PNETs; it was listed recently by the European neuroendocrine tumor society as a major unmet need.

OBJECTIVE

To evaluate the outcome of patients who underwent surgery for locally aggressive PNETs.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective single-center case series reviewed consecutive patients who underwent resection of T3/T4 PNETs at a single academic institution. Data collection occurred from 2003 to 2018. Data analysis was performed in August 2019.

MAIN OUTCOMES AND MEASURES

Disease-free survival (primary outcome) and overall mortality (secondary outcome) were assessed with Kaplan-Meier analysis. Recurrence risk (secondary outcome, defined as identification of tumor recurrence on imaging) was assessed with Cox proportional hazard models adjusting for covariates.

RESULTS

In this case series, 99 patients with locally advanced nondistant metastatic PNET (56 men [57%]) with a mean (SEM) age of 57.0 (1.4) years and a mean (SEM) follow-up of 5.3 (0.1) years underwent surgically aggressive resections. Of those, 4 patients (4%) underwent preoperative neoadjuvant treatment (including peptide receptor radionuclide therapy and chemotherapy); 18 patients (18%) underwent pancreaticoduodenectomy, 68 patients (69%) had distal or subtotal pancreatic resection, 10 patients (10%) had total resection, and 3 patients (3%) had other pancreatic procedures. Additional organ resection was required in 86 patients (87%): spleen (71 patients [71%]), major blood vessel (17 patients [17%]), bowel (2 patients [2%]), stomach (4 patients [4%]), and kidney (2 patients [2%]). Five-year disease-free survival was 61% (61 patients) and 5-year overall survival was 91% (91 patients). Of those living, 75 patients (76%) had an Eastern Cooperative Oncology Group score of less than or equal to 1 at last followup. Lymph node involvement (HR, 7.66; 95% CI, 2.78-21.12; P < .001), additional organ resected (HR, 6.15; 95% CI, 1.61-23.55; P = .008), and male sex (HR, 3.77; 95% CI, 1.68-8.97; P = .003) were associated with increased risk of recurrence. Functional tumors had a lower risk of recurrence (HR, 0.23; CI, 0.06-0.89; P = .03). Required resection of blood vessels was not associated with a significant increase recurrence risk.

CONCLUSIONS AND RELEVANCE

In this case series, positive lymph node involvement and resection of organs with tumor involvement were associated with an increased recurrence risk. These subgroups may require adjuvant systemic treatment. These findings suggest that patients with locally advanced PNETs who undergo surgical resection have excellent disease-free and overall survival.

Pediatric unilobar resection in primary ciliary dyskinesia

Primary ciliary dyskinesia (PCD) causes chronic infections and progressive bronchiectasis that can lead to severe lung disease. Because there are no cures or regenerative therapy options for PCD, treatment of severe lung disease in PCD is focused on managing symptoms, including aggressive administration of antibiotics and diligent airway clearance. The Genetic Disorders of Mucociliary Clearance Consortium (GDMCC) does not recommend routine lobectomy, reserving its use for "rare cases of PCD with severe, localized bronchiectasis" and warns that a lobectomy should be treated with caution. However, if aggressive medical management fails, selective surgical removal of severely defective lung may result in maintenance or improvement of pulmonary function. Certainly, the decision to recommend lung resection in the face of chronic bronchiectasis from PCD requires an extensive discussion before it is considered as an alternative treatment. The purpose of this manuscript is to demonstrate that in selected cases of unilobar disease with bronchiectasis that are not responsive to other therapies (antibiotics and airway clearance), removal of localized necrotic areas of the lung along with prophylactic antibiotics can improve the quality of life of children with PCD associated bronchiectasis and improve growth and nutritional status, and pulmonary function.

Accuracy of the ACS NSQIP Online Risk Calculator Depends on How You Look at It: Results from the United States Gastric Cancer Collaborative

The objective of this study is to assess the accuracy of the American College of Surgeons National Surgical Quality Improvement Program online risk calculator for estimating risk after operation for gastric cancer using the United States Gastric Cancer Collaborative. Nine hundred and sixty-five patients who underwent resection of gastric adenocarcinoma between January 2000 and December 2012 at seven academic medical centers were included. Actual complication rates and outcomes for patients were compared. Most of the patients underwent total gastrectomy with Roux-en-Y reconstruction (404, 41.9%) and partial gastrectomy with gastrojejunostomy (239, 24.8%) or Roux-en-Y reconstruction (284, 29.4%). The C-statistic was highest for venous throm-boembolism (0.690) and lowest for renal failure at (0.540). All C-statistics were less than 0.7. Brier scores ranged from 0.010 for venous thromboembolism to 0.238 for any complication. General estimates of risk for the cohort were variable in terms of accuracy. Improving the ability of surgeons to estimate preoperative risk for patients is critically important so that efforts at risk reduction can be personalized to each patient. The American College of Surgeons National Surgical Quality Improvement Program risk calculator is a rapid and easy-to-use tool and validation of the calculator is important as its use becomes more common.

Accuracy of the ACS NSQIP Online Risk Calculator Depends on How You Look at It: Results from the United States Gastric Cancer Collaborative

The objective of this study is to assess the accuracy of the American College of Surgeons National Surgical Quality Improvement Program online risk calculator for estimating risk after operation for gastric cancer using the United States Gastric Cancer Collaborative. Nine hundred and sixty-five patients who underwent resection of gastric adenocarcinoma between January 2000 and December 2012 at seven academic medical centers were included. Actual complication rates and outcomes for patients were compared. Most of the patients underwent total gastrectomy with Roux-en-Y reconstruction (404, 41.9%) and partial gastrectomy with gastrojejunostomy (239, 24.8%) or Roux-en-Y reconstruction (284, 29.4%). The C-statistic was highest for venous thromboembolism (0.690) and lowest for renal failure at (0.540). All C-statistics were less than 0.7. Brier scores ranged from 0.010 for venous thromboembolism to 0.238 for any complication. General estimates of risk for the cohort were variable in terms of accuracy. Improving the ability of surgeons to estimate preoperative risk for patients is critically important so that efforts at risk reduction can be personalized to each patient. The American College of Surgeons National Surgical Quality Improvement Program risk calculator is a rapid and easy-to-use tool and validation of the calculator is important as its use becomes more common.

Impact of lymph node ratio in selecting patients with resected gastric cancer for adjuvant therapy

BACKGROUND

The impact of adjuvant chemotherapy and chemo-radiation therapy in the treatment of resectable gastric cancer remains varied. We sought to define the clinical impact of lymph node ratio on the relative benefit of adjuvant chemotherapy or chemo-radiation therapy among patients having undergone curative-intent resection for gastric cancer.

METHODS

Using the multi-institutional US Gastric Cancer Collaborative database, 719 patients with gastric adenocarcinoma who underwent curative-intent resection between 2000 and 2013 were identified. Patients with metastasis or an R2 margin were excluded. The impact of lymph node ratio on overall survival among patients who received chemotherapy or chemo-radiation therapy was evaluated.

RESULTS

Median patient age was 65 years, and the majority of patients were male (56.2%). The majority of patients underwent either subtotal (40.6%) or total gastrectomy (41.0%), with the remainder undergoing distal gastrectomy or wedge resection (18.4%). On pathology, median tumor size was 4 cm; most patients had a T3 (33.0%) or T4 (27.9%) lesion with lymph node metastasis (59.7%). Margin status was R0 in 92.5% of patients. A total of 325 (45.2%) patients underwent resection alone, 253 (35.2%) patients received 5-FU or capecitabine-based chemo-radiation therapy, whereas the remaining 141 (19.6%) received chemotherapy. Median overall survival was 40.9 months, and 5-year overall survival was 40.3%. According to lymph node ratio categories, 5-year overall survival for patients with a lymph node ratio of 0, 0.01-0.10, >0.10-0.25, >0.25 were 54.1%, 53.1 %, 49.1 % and 19.8 %, respectively. Factors associated with worse overall survival included involvement of the gastroesophageal junction (hazard ratio 1.8), T-stage (3-4: hazard ratio 2.1), lymphovascular invasion (hazard ratio 1.4), and lymph node ratio (>0.25: hazard ratio 2.3; all P < .05). In contrast, receipt of adjuvant chemo-radiation therapy was associated with an improved overall survival in the multivariable model (versus resection alone: hazard ratio 0.40; versus chemotherapy: hazard ratio 0.45, both P < .001). The benefit of chemo-radiation therapy for resected gastric cancer was noted only among patients with lymph node ratio >0.25 (versus resection alone: hazard ratio R 0.34; versus chemotherapy: hazard ratio 0.45, both P < .001). In contrast, there was no noted overall survival benefit of chemotherapy or chemo-radiation therapy among patients with lymph node ratio ≤0.25 (all P > .05).

CONCLUSION

Adjuvant chemotherapy or chemo-radiation therapy was utilized in more than one-half of patients undergoing curative-intent resection for gastric cancer. Lymph node ratio may be a useful tool to select patients for adjuvant chemo-radiation therapy, because the benefit of chemo-radiation therapy was isolated to patients with greater degrees of lymphatic spread (ie, lymph node ratio >0.25).

Transgastric pancreatic necrosectomy-expedited return to prepancreatitis health

BACKGROUND

The best operative strategy for necrotizing pancreatitis remains controversial. Traditional surgical necrosectomy is associated with significant morbidity; endoscopic and percutaneous strategies require repeated interventions with prolonged hospitalizations. We have developed a transgastric approach to pancreatic necrosectomy to overcome the shortcomings of the other techniques described.

MATERIALS AND METHODS

Patients with necrotizing pancreatitis treated from 2009 to 2016 at an academic center were retrospectively reviewed. Open or laparoscopic transgastric necrosectomy was performed if the area of necrosis was walled-off and in a retrogastric position on cross-sectional imaging. Study endpoints included postoperative complications and mortality.

RESULTS

Forty-six patients underwent transgastric necrosectomy (nine open and 37 laparoscopic). Median (interquartile range) preoperative Acute Physiologic and Chronic Health Evaluation II score was 6 (3-12). Seventy percent of patients had >30% necrosis on preoperative imaging; infected necrosis was present in 35%. Median total length of stay (LOS) was 6 (3-12) d. No patient required a second operative debridement; four patients (9%) had short-term postoperative percutaneous drainage for residual fluid collections. Median follow-up was 1 y; there were no fistula or wound complications. Six patients (13%) had postoperative bleeding; five patients received treatment by image-guided embolization. There was one death in the cohort.

CONCLUSIONS

Transgastric pancreatic necrosectomy allows for effective debridement with a single definitive operation. When anatomically suitable, this operative strategy offers expedited recovery and avoids long-term morbidity associated with fistulas and prolonged drainage.

To Roux or not to Roux: a comparison between Roux-en-Y and Billroth II reconstruction following partial gastrectomy for gastric cancer

BACKGROUND

Although the extent of resection frequently dictates the method of reconstruction following distal subtotal gastrectomy, it is unclear whether Roux-en-Y gastrojejunostomy compared with Billroth II gastrojejunostomy is associated with superior perioperative outcomes.

METHODS

Patients who underwent resection for gastric cancer with Roux-en-Y or Billroth II reconstruction between 2000 and 2012 in seven academic institutions (US Gastric Cancer Collaborative) were identified. Patients who underwent total gastrectomy, gastric wedge, or palliative resections (metastatic disease or R2 resections) were excluded.

RESULTS

Of a total of 965 patients, 447 met the inclusion criteria. A comparison between the Roux-en-Y (n = 257) and Billroth II (n = 190) groups demonstrated no differences in patient and tumor characteristics, except for Billroth II patients having a higher proportion of antral tumors (71 % vs. 50 %, p < 0.001). Roux-en-Y operations were slightly longer (244 min vs. 212 min, p < 0.001) and associated with somewhat higher blood loss (243 ml vs. 205 ml, p = 0.033). However, there were no significant differences in the length of hospital stay (8 days vs. 7 days), readmission rate (17 % vs. 18 %), 90-day mortality (5.1 % vs. 4.7 %), incidence (39 % vs. 41 %) and severity of complications, dependency on jejunostomy tube feeding at discharge (13 % vs. 12 %), same-patient decrease in serum albumin level from the preoperative to the postoperative value at 30, 60, and 90 days, receipt of adjuvant therapy (50 % vs. 53 %), or 5-year survival (44 % vs. 41 %).

CONCLUSIONS

Although long-term quality-of-life parameters were not compared, this study did not show an advantage of Roux-en-Y gastrojejunostomy over Billroth II gastrojejunostomy in short-term perioperative outcomes. Both techniques should be regarded as equally acceptable reconstructive options following partial gastrectomy for gastric cancer.

Interaction of Postoperative Morbidity and Receipt of Adjuvant Therapy on Long-Term Survival After Resection for Gastric Adenocarcinoma: Results From the U.S. Gastric Cancer Collaborative

BACKGROUND

Postoperative complications (POCs) can negatively impact survival after oncologic resection. POCs may also decrease the rate of adjuvant therapy completion. We evaluated the impact of complications on gastric cancer survival and analyzed the combined effect of complications and adjuvant therapy on survival.

METHODS

We analyzed 824 patients from 7 institutions of the U.S. Gastric Cancer Collaborative who underwent curative resection for gastric adenocarcinoma between 2000 and 2012. POC were graded using the modified Clavien-Dindo system. Survival probabilities were estimated using the method of Kaplan and Meier and analyzed using multivariate Cox regression.

RESULTS

Median follow-up was 35 months. The overall complication rate was 41 %. The 5-year overall survival (OS) and recurrence-free survival (RFS) of patients who experienced complications were 27 and 23 %, respectively, compared with 43 and 40 % in patients who did not have complications (p < 0.0001 for OS and RFS). On multivariate analysis, POC remained an independent predictor for decreased OS and RFS (HR 1.3, 95 % CI 1.1-1.6, p = 0.03 for OS; HR 1.3, 95 % CI 1.01-1.6, p = 0.03 for RFS). Patients who experienced POC were less likely to receive adjuvant therapy (OR 0.5, 95 % CI 0.3-0.7, p < 0.001). The interaction of complications and failure to receive adjuvant therapy significantly increased the hazard of death compared with patients who had neither complications nor adjuvant therapy (HR 2.3, 95 % CI 1.6-3.2, p < 0.001).

CONCLUSIONS

Postoperative complications adversely affect long-term outcomes after gastrectomy for gastric cancer. Not receiving adjuvant therapy in the face of POC portends an especially poor prognosis following gastrectomy for gastric cancer.

Laparoscopic hepatectomy in cirrhotics: safe if you adjust technique

BACKGROUND

Minimally invasive liver surgery is a growing field, and a small number of recent reports have suggested that laparoscopic liver resection (LLR) is feasible even in patients with cirrhosis. However, parenchymal transection of the cirrhotic liver is challenging due to fibrosis and portal hypertension. There is a paucity of data regarding the technical modifications necessary to safely transect the diseased parenchyma.

METHODS

Patients undergoing LLR by a single surgeon between 2008 and 2015 were reviewed. Patients with cirrhosis were compared to those without cirrhosis to examine differences in surgical technique, intraoperative characteristics, and outcomes (including liver-related morbidity and general postoperative complication rates).

RESULTS

A total of 167 patients underwent LLR during the study period. Forty-eight (29 %) had cirrhosis, of which 43 (90 %) had hepatitis C. Most had Child-Pugh class A disease (85 %). Compared to noncirrhotics, patients with cirrhosis were older, had more comorbidities, and were more likely to have hepatocellular carcinoma. Precoagulation before parenchymal transection was used more frequently in cirrhotics (65 vs. 15 %, P < 0.001), and mean portal triad clamping time was longer (32 vs. 22 min, P = 0.002). There were few conversions to open surgery, though hand-assisted laparoscopy was used as an alternative to converting to open in three patients with cirrhosis. Blood loss was relatively low for both groups. Although there were more postoperative complications among cirrhotics (38 vs. 13 %, P = 0.001), this was almost entirely due to a higher rate of minor (Clavien-Dindo I or II) complications. Liver-related morbidity, major complications, and mortality rates were similar.

CONCLUSIONS

LLR is safe for selected patients with cirrhosis. The added complexity associated with the division of diseased liver parenchyma may be overcome with some form of technique modification, including more liberal use of precoagulation, portal triad clamping, or a hand-assist port.

An economic analysis of pancreaticoduodenectomy: should costs drive consumer decisions?

BACKGROUND

Consumer groups campaign for cost transparency believing that patients will select hospitals accordingly. We sought to determine whether the cost of pancreaticoduodenectomy (PD) should be considered in choosing a hospital.

METHODS

Using the Nationwide Inpatient Sample database, we analyzed charges for patients who underwent PD from 2000 to 2010. Outcomes were stratified by hospital volume.

RESULTS

A total of 15,599 PDs were performed in 1,186 hospitals. The median cost was $87,444 (interquartile range $16,015 to $144,869). High volume hospitals (HVH) had shorter hospital stay (11 vs 15 days, P < .001) and mortality (3% vs 7.6%, P < .001). PD performed at low volume hospitals had higher charges compared with HVH ($97,923 vs $81,581, P < .001). On multivariate analysis, HVH was associated with a lower risk of mortality, while extremes in hospital costs, cardiac comorbidity, and any complication were significant predictors of mortality.

CONCLUSION

Although PDs performed at HVH are associated with better outcomes and lower hospital charges, costs should not be the primary determinant when selecting a hospital.

Preoperative Helicobacter pylori Infection is Associated with Increased Survival After Resection of Gastric Adenocarcinoma

BACKGROUND

Limited data exist on the prognosis of preoperative Helicobacter pylori (H. pylori) infection in gastric adenocarcinoma (GAC).

METHODS

Patients who underwent curative-intent resection for GAC from 2000 to 2012 at seven academic institutions comprising the United States Gastric Cancer Collaborative were included in the study. The primary end points of the study were overall survival (OS), recurrence-free survival (RFS), and disease-specific survival (DSS).

RESULTS

Of 559 patients, 104 (18.6 %) who tested positive for H. pylori were younger (62.1 vs 65.1 years; p = 0.041), had a higher frequency of distal tumors (82.7 vs 71.9 %; p = 0.033), and had higher rates of adjuvant radiation therapy (47.0 vs 34.9 %; p = 0.032). There were no differences in American Society of Anesthesiology (ASA) class, margin status, grade, perineural invasion, lymphovascular invasion, nodal metastases, or tumor-node-metastasis (TNM) stage. H. pylori positivity was associated with longer OS (84.3 vs 44.2 months; p = 0.008) for all patients. This relationship with OS persisted in the multivariable analysis (HR 0.54; 95 % CI 0.30-0.99; p = 0.046). H. pylori was not associated with RFS or DSS in all patients. In the stage 3 patients, H. pylori was associated with longer OS (44.5 vs 24.7 months; p = 0.018), a trend of longer RFS (31.4 vs 21.6 months; p = 0.232), and longer DSS (44.8 vs 27.2 months; p = 0.034).

CONCLUSIONS

Patients with and without preoperative H. pylori infection had few differences in adverse pathologic features at the time of gastric adenocarcinoma resection. Despite similar disease presentations, preoperative H. pylori infection was independently associated with improved OS. Further studies examining the interaction between H. pylori and tumor immunology and genetics are merited.

Gastric remnant cancer: A distinct entity or simply another proximal gastric cancer?

BACKGROUND

The purpose of this study was to compare outcomes following resection of gastric remnant (GRC) and conventional gastric cancer.

METHODS

Patients who underwent resection for gastric cancer in 8 academic institutions from 2000-2012 were evaluated to compare morbidity, mortality, and survival based on history of prior gastrectomy.

RESULTS

Of the 979 patients who underwent gastrectomy with curative-intent during the 12-year study period, 55 patients (5.8%) presented with GRC and 924 patients (94.4%) presented with conventional gastric cancer. Patients with GRC were slightly older (median 69 vs. 66 years). GRC was associated with higher rates of complication (56% vs. 41%, P = 0.028), longer operative times (301 vs. 237 min, P < 0.001), higher intraoperative blood loss (300 vs. 200 ml, P = 0.012), and greater need for blood transfusion (43% vs. 23%, P = 0.001). There were no significant differences in 30-day (3.6% vs. 4%) or 90-day mortality (9% vs. 8%) between the two groups. Overall survival rates were similar between GRC and conventional gastric cancer (5-year 20.3% vs. 38.6%, P = 0.446). Multivariate analysis revealed that history of gastrectomy was not predictive of survival while established predictors (older age, advanced T-stage, nodal involvement, blood transfusion, multivisceral resection, and any complication) were associated with poor survival.

CONCLUSIONS

Despite higher morbidity, prognosis after resection of gastric remnant cancer is similar to conventional gastric cancer.

The First Decade of Laparoscopic Pancreaticoduodenectomy in the United States: Costs and Outcomes Using the Nationwide Inpatient Sample

BACKGROUND

Minimally invasive pancreaticoduodenectomy (PD) remains an uncommon procedure, and the safety and efficacy remain uncertain beyond single institution case series. The aim of this study is to compare outcomes and costs between laparoscopic (LPD) and open PD (OPD) using a large population-based database.

METHODS

The Nationwide Inpatient Sample database (a sample of approximately 20 % of all hospital discharges) was analyzed to identify patients who underwent PD from 2000 to 2010. Patient demographics, comorbidities, hospital characteristics, inflation-adjusted total charges, and complications were evaluated using univariate and multivariate logistic regression. Hospitals were categorized as high-volume hospitals (HVH) if more than 20 PD (open and laparoscopic) were performed annually, while those performing fewer than 20 PD were classified as low-volume hospitals.

RESULTS

Of the 15,574 PD identified, 681 cases were LPD (4.4 %). Compared to OPD, patients who underwent LPD were slightly older (65 vs. 67 years; p = 0.001) and were more commonly treated at HVH (56.6 vs. 66.1 %; p < 0.001). Higher rates of complications were observed in OPD than LPD (46 vs. 39.4 %; p = 0.001), though mortality rates were comparable (5 vs. 3.8 %, p = 0.27). Inflation-adjusted median hospital charges were similar between OPD and LPD ($87,577 vs. $81,833, p = 0.199). However, hospital stay was slightly longer in the OPD group compared to LPD group (12 vs. 11 days, p < 0.001). Stratifying outcomes by hospital volume, LPD at HVH resulted in shorter hospital stays (9 vs. 13 days, p < 0.001), which translated into significantly lower median hospital charges ($76,572 vs. $106,367, p < 0.001).

CONCLUSIONS

Contrary to fears regarding the potential for compromised outcomes early in the learning curve, LPD morbidity in its first decade is modestly reduced, while hospital costs are comparable to OPD. In high-volume pancreatic hospitals, LPD is associated with a reduction in length of stay and hospital costs.

The importance of the proximal resection margin distance for proximal gastric adenocarcinoma: A multi-institutional study of the US Gastric Cancer Collaborative

BACKGROUND

A 5 cm margin is advocated for distal gastric adenocarcinoma (GAC). The optimal proximal resection margin (PM) length for proximal GAC is not established.

METHODS

Patients who underwent curative-intent resection for proximal GAC from 2000 to 2012 at 7 centers in the US Gastric Cancer Collaborative were included. PM length was sequentially dichotomized and analyzed at 0.5 cm increments (0.5-6.5 cm). Outcomes after negative margin (R0) and positive microscopic margin (R1) resections were compared. Primary endpoints were local recurrence (LR) and overall survival (OS).

RESULTS

All patients (n = 162) had R0 distal margins. 151 (93.2%) had an R0-PM with mean length of 2.6 cm (median:1.7 cm; range:0.1-15 cm). A greater PM distance was not associated with LR or OS. An R1-PM was associated with higher N-stage (N3:73% vs. 26%; P = 0.007) and increased LR (HR6.1; P = 0.009) but not associated with decreased OS. On multivariate analysis, an R1-PM was also not independently associated with LR.

CONCLUSIONS

For resection of proximal gastric adenocarcinoma, proximal margin length is not associated with local recurrence or overall survival. An R1 margin is associated with advanced N-stage but is not independently associated with recurrence or survival. When performing resection of proximal gastric adenocarcinoma, efforts to achieve a specific margin distance, especially if it necessitates an esophagectomy, should be abandoned.

Leiomyosarcoma: One disease or distinct biologic entities based on site of origin?

BACKGROUND

Leiomyosarcoma (LMS) can originate from the retroperitoneum, uterus, extremity, and trunk. It is unclear whether tumors of different origin represent discrete entities. We compared clinicopathologic features and outcomes following surgical resection of LMS stratified by site of origin.

METHODS

Patients with LMS undergoing resection at a single institution were retrospectively reviewed. Clinicopathologic variables were compared across sites. Survival was calculated using the Kaplan-Meier method and compared using log-rank and Cox regression analyses.

RESULTS

From 1983 to 2011, 138 patients underwent surgical resection for LMS. Retroperitoneal and uterine LMS were larger, higher grade, and more commonly associated with synchronous metastases. However, disease-specific survival, recurrence-free survival, and recurrence patterns were not significantly different across the four sites. Synchronous metastases (HR 3.20, P < 0.001), but not site of origin, size, grade, or margin status, were independently associated with worse DSS. A significant number of recurrences and disease-related deaths were noted beyond 5 years.

CONCLUSIONS

Although larger and higher grade, retroperitoneal and uterine LMS share similar survival and recurrence patterns with their trunk and extremity counterparts. LMS of various anatomic sites may not represent distinct disease processes based on clinical outcomes. The presence of metastatic disease remains the most important prognostic factor for LMS.

The Prognostic Value of Signet-Ring Cell Histology in Resected Gastric Adenocarcinoma

BACKGROUND

Conflicting data exist on the prognostic implication of signet-ring cell (SRC) histology in gastric adenocarcinoma (GAC).

METHODS

All patients who underwent curative-intent resection of GAC from the seven institutions of the U.S. Gastric Cancer Collaborative between 2000 and 2012 were included. Primary end points were recurrence-free survival (RFS) and overall survival (OS). Stage-specific analyses were performed.

RESULTS

A total of 768 patients met the inclusion criteria. SRC was present in 40.6 % of patients and was associated with female sex (52.9 vs. 38.6 %; p < 0.001), younger age (61 vs. 67 years; p < 0.001), poor differentiation (94.8 vs. 50.3 %; p < 0.001), perineural invasion (PNI) (41.4 vs. 23 %; p < 0.001), microscopically positive resection margins (R1, 24.7 vs. 8.6 %; p < 0.001), distal location (82.2 vs. 70.1 %; p < 0.001), receipt of adjuvant therapy (63 vs. 51.2 %; p = 0.002), and more advanced stage (stage 3: 55.2 vs. 36.5 %; p < 0.001). SRC was associated with earlier recurrence (56.7 months vs. median not reached; p = 0.009) and decreased OS (33.7 vs. 46.6 months; p = 0.011). When accounting for other adverse pathologic features, PNI (hazard ratio [HR] 1.57; p = 0.016) and higher stage (HR 2.64; p < 0.001) were associated with decreased RFS, but SRC was not. Although PNI (HR 1.52; p = 0.007), higher stage (HR 2.11; p < 0.001), greater size (HR 1.05; p = 0.016), and adjuvant therapy (HR 0.50; p < 0.001) were associated with OS, SRC was not. Similarly, when accounting for adverse pathologic factors on multivariate analysis, stage-specific analyses showed no association between SRC and RFS or OS.

CONCLUSIONS

SRC histology is associated with adverse pathologic features including poor differentiation, higher stage, and microscopically positive resection margins but is not independently associated with reduced RFS or OS. Identification of signet-ring histology during preoperative evaluation should not, in isolation, dictate treatment strategy.

Multivisceral Resection for Gastric Cancer: Results from the US Gastric Cancer Collaborative

BACKGROUND

Resection of an adjacent organ during gastrectomy for gastric cancer is occasionally necessary to achieve margin clearance. The short- and long-term outcomes of this approach remain unclear.

METHODS

Patients who underwent gastric cancer resection in seven U.S. academic institutions from 2000 to 2012 were evaluated to compare perioperative morbidity, mortality, and survival outcomes, stratified by the need for and type of multivisceral resection (MVR).

RESULTS

Of 835 patients undergoing curative-intent gastrectomy, 159 (19 %) had MVR. The most common adjacent organs resected were the spleen (48 %), pancreas (27 %), liver segments 2/3 (14 %), and colon (13 %). As extent of resection increased (gastrectomy only, n = 676; MVR without pancreatectomy, n = 116; and MVR with pancreatectomy, n = 43), perioperative morbidity was higher: any complication (45, 60, 59 %, p = 0.012), major complication (17, 31, 33 %, p = 0.001), anastomotic leak (5, 11, 19 %, p < 0.001), and respiratory failure (9, 15, 22 %, p = 0.012). However, perioperative mortality did not significantly increase (30-day: 3, 4, 2 %, p = 0.74; 90-day: 6, 8, 9 %, p = 0.61). Overall survival after resection decreased as extent of resection increased (5-year: 42, 28, 6 %). After controlling for age, race, T stage, N stage, grade, margin status, perineural invasion, adjuvant therapy, and blood transfusion, MVR with pancreatectomy (HR 1.67, p = 0.044), but not MVR without pancreatectomy (HR 0.97, p = 0.759), remained an independent predictor of poor survival.

CONCLUSION

In this modern, multi-institutional cohort of gastric cancer patients, multivisceral resection was associated with higher perioperative morbidity but not significantly higher perioperative mortality. If concomitant pancreatectomy is anticipated, patients should be selected with extreme caution because long-term survival remains poor.

Effect of Perioperative Transfusion on Recurrence and Survival after Gastric Cancer Resection: A 7-Institution Analysis of 765 Patients from the US Gastric Cancer Collaborative

BACKGROUND

The prognostic effect of perioperative blood transfusion on recurrence and survival in patients undergoing resection of gastric adenocarcinoma (GAC) remains controversial.

STUDY DESIGN

All patients who underwent resection for GAC from 2000 to 2012 at the 7 institutions of the US Gastric Cancer Collaborative were identified. The effect of transfusion on recurrence-free (RFS) and overall survival (OS) in the context of adverse clinicopathologic variables was examined by univariate and multivariate regression analyses.

RESULTS

Of 965 patients, 765 underwent curative intent R0 resection. Median follow-up was 44 months; 30-day mortalities were excluded. Median estimated blood loss (EBL) was 200 mL, and 168 patients (22%) received perioperative allogeneic blood transfusions. Transfused patients were less likely to receive adjuvant therapy (44% vs 56%; p = 0.01). Transfusion was associated with significantly decreased median RFS (13.5 vs 37.2 months, p < 0.001). Median OS was similarly decreased in patients receiving transfusions (18.6 vs 49.8 months, p < 0.001). On multivariate analysis, transfusion remained an independent risk factor for decreased RFS (hazard ratio [HR] 1.63; 95% CI 1.13 to 2.37; p = 0.010) and decreased OS (HR 1.79; 95% CI 1.21 to 2.67; p = 0.004), regardless of EBL or need for splenectomy. Timing (intraoperative vs postoperative) and volume of transfusion did not alter the negative prognostic effect of transfusion on survival.

CONCLUSIONS

Perioperative allogeneic blood transfusion is associated with decreased RFS and OS after resection of gastric cancer, independent of adverse clinicopathologic factors. This supports the judicious use of perioperative transfusion during resection of gastric cancer.

Value of Peritoneal Drain Placement After Total Gastrectomy for Gastric Adenocarcinoma: A Multi-institutional Analysis from the US Gastric Cancer Collaborative

BACKGROUND

The effect of routine drainage after abdominal surgery with enteric anastomoses is controversial. In particular, the role of peritoneal drain (PD) placement after total gastrectomy for adenocarcinoma is not well established.

METHODS

Patients who underwent total gastrectomy for gastric adenocarcinoma (GAC) at seven institutions from the US Gastric Cancer Collaborative, from 2000 to 2012, were identified. The association of PD placement with postoperative outcomes was analyzed.

RESULTS

Overall, 344 patients were identified and 253 (74 %) patients received a PD. The anastomotic leak rate was 9 %. Those with PD placement had similar American Society of Anesthesiologists score, tumor size, TNM stage, and the need for additional organ resection when compared with their counterparts. No difference was observed in the rate of any complication (54 vs. 48 %; p = 0.45), major complication (25 vs. 24 %; p = 0.90), or 30-day mortality (7 vs. 4 %; p = 0.51) between the two groups. In addition, no difference in anastomotic leak (9 vs. 10 %; p = 0.90), the need for secondary drainage (10 vs. 9 %; p = 0.92), or reoperation (13 vs. 8 %; p = 0.28) was identified. On multivariate analysis, PD placement was not associated with decreased postoperative complications. Subset analysis, stratified by patients who did not undergo concomitant pancreatectomy (n = 319) or those who experienced anastomotic leak (n = 31), similarly demonstrated no association of PD placement with reduced complications or mortality.

CONCLUSIONS

PD placement after total gastrectomy for GAC is associated with neither a decrease in the frequency and severity of adverse postoperative outcomes, including anastomotic leak and mortality, nor a decrease in the need for secondary drainage procedures or reoperation. Routine use of PDs is not warranted.

Number of Lymph Nodes Removed and Survival after Gastric Cancer Resection: An Analysis from the US Gastric Cancer Collaborative

BACKGROUND

Examination of at least 16 lymph nodes (LNs) has been traditionally recommended during gastric adenocarcinoma resection to optimize staging, but the impact of this strategy on survival is uncertain. Because recent randomized trials have demonstrated a therapeutic benefit from extended lymphadenectomy, we sought to investigate the impact of the number of LNs removed on prognosis after gastric adenocarcinoma resection.

STUDY DESIGN

We analyzed patients who underwent gastrectomy for gastric adenocarcinoma from 2000 to 2012, at 7 US academic institutions. Patients with M1 disease or R2 resections were excluded. Disease-specific survival (DSS) was calculated using the Kaplan-Meier method and compared using log-rank and Cox regression analyses.

RESULTS

Of 742 patients, 257 (35%) had 7 to 15 LNs removed and 485 (65%) had ≥16 LNs removed. Disease-specific survival was not significantly longer after removal of ≥16 vs 7 to 15 LNs (10-year survival, 55% vs 47%, respectively; p = 0.53) for the entire cohort, but was significantly improved in the subset of patients with stage IA to IIIA (10-year survival, 74% vs 57%, respectively; p = 0.018) or N0-2 disease (72% vs 55%, respectively; p = 0.023). Similarly, for patients who were classified to more likely be "true N0-2," based on frequentist analysis incorporating both the number of positive and of total LNs removed, the hazard ratio for disease-related death (adjusted for T stage, R status, grade, receipt of neoadjuvant and adjuvant therapy, and institution) significantly decreased as the number of LNs removed increased.

CONCLUSIONS

The number of LNs removed during gastrectomy for adenocarcinoma appears itself to have prognostic implications for long-term survival.

Optimal extent of lymphadenectomy in gastric adenocarcinoma: A seven-institution study of the U.S. Gastric Cancer Collaborative

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Background: The optimal extent of lymphadenectomy in the treatment of gastric adenocarcinoma continues to be a subject of intense debate. We aimed to compare gastrectomy outcomes following limited (D1) or extended (D2) lymphadenectomy. Methods: Using the multi-institutional U.S. Gastric Cancer Collaborative database, we reviewed the morbidity, mortality, recurrence, and overall survival (OS) of 727 patients receiving D1 or D2 lymphadenectomies. Patients with stage IV disease, prior gastrectomy, and age 85 or greater were excluded. Multivariate analyses included variables with p values less than 0.1. Results: Between 2000 and 2014, 266 (36.6%) and 461 (63.4%) patients received a D1 and D2 lymphadenectomy, respectively. ASA class, mean number of comorbidities, grade, stage, and signet ring cell subtypes were similar between groups. Neoadjuvant and adjuvant chemotherapy was more common in the D2 group (p<0.001). The mean number of lymph nodes recovered was significantly higher in patients receiving a D2 lymphadenectomy (21.5 for D2 vs. 17.1 for D1, p<0.001). Median follow up was 1.3 years. While Clavien III/IV major morbidity was similar (15.0% for D1 vs. 14.5% for D2, p=0.85), mortality was worse for those receiving a D1 lymphadenectomy (4.9% vs. 1.3%, p=0.004). Recurrence rates for patients receiving D1 and D2 lymphadenectomies were 25.8% and 27.0%, respectively (p=0.74). D2 lymphadenectomy was associated with improved median OS in stage I (4.7 years for D1 vs. not reached for D2, p=0.003) stage II (3.6 years for D1 vs. 6.3 for D2, p=0.42), and stage III patients (1.3 years for D1 vs. 2.1 for D2, p=0.01). After adjusting for significant predictors of OS which included ASA, stage, grade, neoadjuvant chemotherapy, and adjuvant radiation, D2 lymphadenectomy remained a significant predictor of improved survival when compared with D1 lymphadenectomy (HR 1.5, 95% CI 1.1-2.0, p=0.008). Conclusions: D2 lymphadenectomy is associated with improved survival that is more prominent in early stages of disease. It can be performed safely without increased risk of morbidity and perioperative mortality and should be the preferred lymphadenectomy technique for the treatment of gastric adenocarcinoma.

The prognostic value of preoperative helicobacter pylori infection in resected gastric cancer

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Background: Limited data exist on the prognostic implication of pre-operative Helicobacter pylori (H. pylori) infection in gastric adenocarcinoma (GAC). Our aim was to assess the association of H. pyloriwith recurrence and survival in patients undergoing resection of GAC. Methods: All patients who underwent curative intent resection for GAC from 2000 to 2012 at seven academic institutions comprising the US Gastric Cancer Collaborative were included. 30-day mortalities were excluded. Survival analyses were conducted with Kaplan Meier log rank and multivariate Cox regression. Primary endpoints were recurrence-free survival (RFS) and overall survival (OS). Results: Of 965 patients, 559 met inclusion criteria and had documented pre-operative H. pylori testing. 18.6% (n=104) of patients tested positive for H. pylori pre-operatively. Data regarding treatment of H. pylori was not available. H. pylori infection was associated with younger age (62.1 vs 65.1 years; p=0.041), distal tumor location (82.7% vs 71.9%; p=0.033), and receipt of adjuvant radiation therapy (47.0% vs 34.9%; p=0.032). There were no significant differences in ASA class, margin status, Grade, PNI, LVI, or nodal metastases. The distribution of TNM stage I-III was similar between the two groups. H. pylori status was not associated with tumor recurrence. However, pre-operative H. pylori infection was associated with longer OS (84.3 mo vs 44.2 mo; p=0.008). When accounting for differences in age, tumor location, and delivery of radiation therapy, H. pylori infection persisted as a positive prognostic factor for OS (HR 0.60; CI 0.40-0.91; p = 0.016). Conclusions: Patients with and without preoperative H. pylori infection had no significant differences in adverse pathologic factors including positive margin, high grade, lymph node metastases, or advanced TNM stage. Despite similar disease presentation, pre-operative H. pylori infection was independently associated with improved overall survival. Further studies examining the interaction between H. pylori and tumor immunology and genetics are needed to better understand the relationship between H. pylori and survival in gastric cancer.

The optimal length of the proximal resection margin in patients with proximal gastric adenocarcinoma: A multi-institutional study of the U.S. Gastric Cancer Collaborative

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Background: A 5cm margin is advocated for distal gastric cancers. The optimal length of the proximal resection margin (PM) for proximal (GEJ Siewert II and III, cardia, and fundus) gastric adenocarcinoma (GAC) is not established. Methods: Patients who underwent curative intent abdominal-approach resection for proximal GAC from 2000-2012 at 7 academic US institutions were included. Patients with positive distal margins were excluded. PM length was analyzed by 0.5cm increments and was also dichotomized at the mean and median value. Primary endpoints were local recurrence (LR), recurrence-free survival (RFS) and overall survival (OS). Results: Out of 965 patients, 211 had proximal GAC, and 162 had data available on PM length. 151 patients had negative microscopic margins with a mean value of 2.6cm and a median of 1.7cm (range 0.1-15cm). When PM length was sequentially dichotomized and analyzed at 0.5cm increments (0.5-6.5cm), a greater margin distance for each analysis was not associated with LR, RFS, or OS. Similarly, a PM distance greater than the mean or median value was not associated with LR, RFS, or OS. 11 patients had a positive PM (R1), which was associated with higher N-stage (N3: 73% vs 26%; p=0.007) and increased LR (HR6.1; p=0.009). When accounting for other adverse prognostic factors (grade, lymphovascular invasion, tumor size, T-stage, and N-stage), a positive PM was not independently associated with LR. A positive PM was also not associated with decreased RFS or OS. Conclusions: For an abdominal-approach resection of proximal gastric adenocarcinoma, the length of the proximal margin is not associated with local recurrence, recurrence-free survival, or overall survival. A positive microscopic margin is associated with advanced N-stage but is not independently associated with recurrence or survival. When performing an abdominal-approach resection of proximal gastric adenocarcinoma, a grossly negative proximal margin is sufficient. Efforts to achieve a specific margin distance, especially if it necessitates an esophagectomy, should be abandoned.

Is linitis plastica a contraindication for surgical resection? A 7-institution study of the U.S. Gastric Cancer Collaborative

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Background: Linitis plastica (LP) describes a diffusively infiltrative gastric adenocarcinoma that portends poor prognosis. Current treatment guidelines do not differentiate between LP and non-LP cancers and it is not known if the same staging system should be applied to both situations. Methods: Using the multi-institutional U.S. Gastric Cancer Collaborative database, 869 patients with gastric adenocarcinoma who underwent resection between 2000-2012 were identified. Clinicopathologic, perioperative and survival outcomes of the 58 patients with LP were compared to the 811 patients without LP. Results: Advanced disease (stage III/IV) at presentation was more common in patients with LP compared to non-LP patients (90 vs 44%, p<0.01). Despite the fact that most LP patients underwent total gastrectomy (88% vs 57%, p<0.01), positive margins were more common in LP patients (33 vs 7%, p<0.01). There was no difference in perioperative complications (48 vs 43%, p=0.45) or mortality (7 vs 3%, p=0.12) between LP and non-LP patients. While survival correlated with stage in non-LP patients, there was no difference in median overall survival (OS) of LP patients based on stage (I/II, 17.3 mos; III, 10.6 mos; IV, 12.0 mos; p=0.46). Median OS was significantly worse in patients with LP (11.6 vs 37.8 months, p<0.01) when margin status and extent of lymphadenectomy were not factored in the analysis. However, when analyzing only patients with optimal resections (R0, D2 lymphadenectomy), the median OS for stage III LP (n=22) and non-LP (n=185) patients was nearly identical (26.8 vs 25.3 mos, p=0.69). There were no independent prognostic factors identified to predict survival in LP patients undergoing curative resection. Conclusions: The poor prognosis of LP gastric cancer is due primarily to its advanced stage at diagnosis. However, LP patients who undergo optimal resections can expect similar long term survival compared to optimally resected non-LP patients with advanced stage disease. Patient selection and multidisciplinary management are paramount when considering surgical resection in patients with gastric LP.

The prognostic value of signet ring cell histology in resected gastric cancer

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Background: Conflicting data exist on the prognostic implication of signet ring cell (SRC) histology in gastric adenocarcinoma (GAC). Our aim was to assess the association of SRC with recurrence and survival in patients undergoing resection of GAC. Methods: All pts who underwent curative intent resection for GAC from 2000 to 2012 at 7 academic institutions comprising the US Gastric Cancer Collaborative were included. 30-day mortalities were excluded. Survival analyses included Kaplan Meier log rank and multivariate Cox regression. Primary endpoints were recurrence-free survival (RFS) and overall survival (OS). Stage-specific analysis was performed. Results: Of 965 pts, 768 met inclusion criteria. SRC was present in 39.5% and was associated with female gender (52.9% vs 38.6%; p<0.001), younger age (61 vs 67 yrs; p<0.001), poor differentiation (94.8% vs 50.3%; p<0.001), perineural invasion (PNI: 41.4% vs 23%; p<0.001), distal location (82.2% vs 70.1%; p<0.001), receipt of adjuvant therapy (63% vs 51.2%; p=0.002), and more advanced stage (Stage 3: 55.2% vs 36.5%; p<0.001). SRC was associated with earlier recurrence (56.7mo vs median not reached (MNR); p=0.009) and decreased OS (33.7mo vs 46.6mo; p=0.011). When accounting for other adverse pathologic features, PNI (HR 1.57; p=0.016) and higher TNM stage (HR 2.63; p<0.001) were associated with decreased RFS, but SRC was not. PNI (HR 1.53; p=0.006), higher TNM Stage (HR 2.10; p<0.001), greater size (HR 1.05; p=0.014), and adjuvant therapy (HR 0.50; p<0.001) were associated with OS. SRC was not an independent predictor of OS. Stage-specific analysis showed no association between SRC and RFS or OS in Stage 1 or 3. In Stage 2, SRC was associated with earlier recurrence (38.1mo vs MNR; p=0.005) but not OS. The negative association of SRC with decreased RFS persisted in multivariate analysis (HR 3.11; p=0.015). Conclusions: Signet ring histology is associated with other adverse pathologic features including higher grade and higher TNM stage but is not independently associated with reduced RFS or OS. Identification of signet ring histology during preoperative evaluation should not, in isolation, dictate treatment strategy.

Is it time to abandon the 5-cm margin rule during resection of distal gastric adenocarcinoma? A multi-institution study of the U.S. Gastric Cancer Collaborative

BACKGROUND

A proximal margin distance of 5 cm is advocated for resection of gastric adenocarcinoma (GAC). We assessed the prognostic value of proximal margin (PM) distance on survival outcomes after resection of distal GAC.

METHODS

All patients who underwent resection of distal GAC (antrum/body) from 2000 to 2012 at seven institutions of the U.S. Gastric Cancer Collaborative were included. Patients with positive distal margins or macroscopic residual disease were excluded. The prognostic value of PM distance (assessed in 0.5-cm increments) on overall (OS) and recurrence-free survival (RFS) was assessed by Kaplan-Meier and multivariate regression analysis.

RESULTS

A total of 465 patients underwent resection of distal GAC. Of these, 435 had R0 resections; 30 patients had a positive PM. 143 patients had stage I, and 322 had stage II-III tumors. Median follow-up was 44 months. Average PM distance was 4.8 cm. Median OS for patients with PM of 3.1-5.0 cm (n = 110) was superior to patients with PM ≤ 3.0 cm (n = 176) (48.1 vs. 29.3 months; p = 0.01), while a margin >5.0 cm (n = 179) offered equivalent survival to PM 3.1-5.0 cm (50.6 months, p = 0.72). The prognostic value of margin distance was stage specific. On multivariate analysis of stage I patients, PM 3.1-5.0 cm remained associated with improved OS [hazard ratio (HR), 0.16; 95 % confidence interval (95 % CI), 0.04-0.60; p = 0.01]. In stage II-III, neither PM 3.1-5.0 cm nor PM > 5.0 cm was significantly associated with OS; OS was dictated by T stage and nodal involvement.

CONCLUSIONS

The prognostic value of proximal margin distance after resection of distal gastric cancer appears stage specific. In stage I, a 3.1- to 5.0-cm proximal margin is associated with the same improved OS as a > 5.0-cm margin. In stage II-III disease, other adverse pathologic factors more strongly impact survival than proximal margin distance.

Laparoscopic spleen-preserving distal pancreatectomy: the technique must suit the lesion

Splenic preservation is currently recommended during minimally invasive surgery for benign tumors of the distal pancreas. The aim of this study was to evaluate the outcomes of patients undergoing laparoscopic spleen-preserving distal pancreatectomy, with particular attention paid to the technique used for spleen preservation (splenic vessel ligation vs preservation). A review of consecutive patients who underwent laparoscopic distal pancreatectomy with the intention of splenic preservation was conducted. Patient demographics, operative data, and outcomes were collected and analyzed. Fifty-five consecutive patients underwent laparoscopic distal pancreatectomy with the intention of splenic preservation; 5 required splenectomy (9 %). Of the remaining 50 patients, 31 (62 %) had splenic vessel ligation, and 19 (38 %) had vessel preservation. Patient demographics and tumor size were similar. The vessel ligation group had significantly more pancreas removed (95 vs 52 mm, P < 0.001) and longer operative times (256 vs 201 min, P = 0.008). Postoperative outcomes, complication rates, and splenic viability were similar between groups. Laparoscopic spleen-preserving distal pancreatectomy is a safe operation with a high rate of success (91 %). Vessel ligation was the chosen technical strategy for lesions that required resection of a greater length of pancreas. We found no advantage to either technique with respect to outcomes and splenic preservation. Operative approach should reflect technical considerations including location in the pancreas.

Utility of the proximal margin frozen section for resection of gastric adenocarcinoma: a 7-Institution Study of the US Gastric Cancer Collaborative

BACKGROUND

The proximal gastric margin dictates the extent of resection for gastric adenocarcinoma (GAC). The value of achieving negative margins via additional gastric resection after a positive proximal margin frozen section (FS) is unknown.

METHODS

The US Gastric Cancer Collaborative includes all patients who underwent resection of GAC at seven institutions from 2000-2012. Intraoperative proximal margin FS data and final permanent section (PS) data were classified as R0 or R1, respectively; positive distal margins were excluded. The primary aim was to evaluate the impact on local recurrence of converting a positive proximal FS-R1 margin to a PS-R0 final margin by additional resection. Secondary endpoints were recurrence-free survival (RFS) and overall survival (OS).

RESULTS

Of 860 patients, 520 had a proximal margin FS and 67 were positive. Of these, 48 were converted to R0 on PS by additional resection. R0 proximal margin was achieved in 447 patients (86 %), PS-R1 in 25 (5 %), and converted FS-R1-to-PS-R0 in 48 (9 %). The median follow-up was 44 months. Local recurrence was significantly decreased in the converted FS-R1-to-PS-R0 group compared to the PS-R1 group (10 vs. 32 %; p = 0.01). Median RFS was similar between the FS-R1-to-PS-R0 and PS-R1 cohorts (25 vs. 20 months; p = 0.49), compared to 37 months for the PS-R0 group. Median OS was similar between the FS-R1-to-PS-R0 conversion and PS-R1 groups (36 vs. 26 months; p = 0.14) compared to 50 months for the PS-R0 group. On multivariate analysis, increasing T-stage and N-stage were associated with worse OS; the FS-R1-to-PS-R0 proximal margin conversion was not significantly associated with improved RFS (p = 0.68) or OS (p = 0.44).

CONCLUSION

Conversion of a positive intraoperative proximal margin frozen section during gastric cancer resection may decrease local recurrence, but it is not associated with improved RFS or OS. This may guide decisions regarding the extent of resection.

Laparoscopic transgastric necrosectomy for the management of pancreatic necrosis

BACKGROUND

Traditional open necrosectomy for pancreatic necrosis is associated with significant morbidity and mortality. Although minimally invasive techniques have been described and offer some promise, each has considerable limitations. This study assesses the safety and effectiveness of laparoscopic transgastric necrosectomy (LTN), a novel technique for the management of necrotizing pancreatitis.

STUDY DESIGN

Between 2009 and 2013, patients with retrogastric pancreatic necrosis requiring debridement were evaluated for LTN. Debridement was performed via a laparoscopic transgastric approach using 2 to 3 ports and the wide cystgastrostomy left open. Patient demographics, disease severity, operative characteristics, and outcomes were collected and analyzed.

RESULTS

Twenty-one patients (13 men, median age 54 years; interquartile range [IQR] 46 to 62 years) underwent LTN during the study period. The duration between pancreatitis onset and debridement was 65 days (IQR 53 to 124 years). Indications for operation included infection (7 patients) and persistent unwellness (14 patients). Median duration of LTN was 170 minutes (IQR 136 to 199 minutes); there were no conversions. Control of the necrosis was achieved via the single procedure in 19 of 21 patients. Median postoperative hospital stay was 5 days (IQR 3 to 14 days) and the majority (71%) of patients experienced no (n = 9) or only minor postoperative complications (n = 6) by Clavien-Dindo grade. Complications of Clavien-Dindo grade 3 or higher developed in 6 patients, including 1 death (5%). With a median follow-up of 11 months (IQR 7 to 22 months), none of the patients required additional operative debridement or had pancreatic/enteric fistulae or wound complications develop.

CONCLUSIONS

Laparoscopic transgastric necrosectomy is a novel, minimally invasive technique for the management of pancreatic necrosis that allows for debridement in a single operation. When feasible, LTN can reduce the morbidity associated with traditional open necrosectomy and avoid the limitations of other minimally invasive approaches.

Impact of external-beam radiation therapy on outcomes among patients with resected gastric cancer: a multi-institutional analysis

BACKGROUND

Use of perioperative chemotherapy (CTx) alone versus chemoradiation therapy (cXRT) in the treatment of resectable gastric cancer remains varied. We sought to define the utilization and effect of CTx alone versus cXRT on patients having undergone curative-intent resection for gastric cancer.

METHODS

Using the multi-institutional US Gastric Cancer Collaborative database, we identified 505 gastric cancer patients between 2000 and 2012 who received perioperative therapy in addition to curative-intent resection. The impact of perioperative therapy on survival was analyzed by the use of propensity-score matching of clinicopathologic factors among patients who received CTx alone versus cXRT.

RESULTS

Median patient age was 62 years, and most patients were male (58.2 %). Most patients had a T3 (38.7 %) or T4 (36.8 %) lesion and lymph node metastasis (73.4 %). A total of 211 (42.8 %) patients received perioperative CTx alone, whereas the remaining 294 (58.2 %) patients received cXRT. Factors associated with receipt of cXRT were younger age (odds ratio, 1.93) and lymph node metastasis (odds ratio, 4.02; both P < 0.05). At a median follow-up of 28 months, the median overall survival (OS) was 33.4 months, and the 5-year OS was 36.7 %. Factors associated with worse overall survival included large tumor size [hazard ratio (HR), 1.83], T3 (HR 2.96) or T4 (HR 4.02) tumors, and lymph node metastasis (HR 1.57; all P < 0.05). In contrast, receipt of cXRT was associated with improved long-term OS (CTx alone, 20.9 months; cXRT, 46.7 months; HR 0.51; P < 0.001).

CONCLUSIONS

cXRT was utilized in 58 % of patients undergoing curative-intent resection for gastric cancer. With propensity score-matched analysis, cXRT was an independent factor associated with improved recurrence-free survival and OS.

Pancreatic neuroendocrine tumours: hypoenhancement on arterial phase computed tomography predicts biological aggressiveness

BACKGROUND

Contrary to pancreatic adenocarcinoma, pancreatic neuroendocrine tumours (PNET) are commonly hyperenhancing on arterial phase computed tomography (APCT). However, a subset of these tumours can be hypoenhancing. The prognostic significance of the CT appearance of these tumors remains unclear.

METHODS

From 2001 to 2012, 146 patients with well-differentiated PNET underwent surgical resection. The degree of tumour enhancement on APCT was recorded and correlated with clinicopathological variables and overall survival.

RESULTS

APCT images were available for re-review in 118 patients (81%). The majority had hyperenhancing tumours (n = 80, 68%), 12 (10%) were isoenhancing (including cases where no mass was visualized) and 26 (22%) were hypoenhancing. Hypoenhancing PNET were larger, more commonly intermediate grade, and had higher rates of lymph node and synchronous liver metastases. Hypoenhancing PNET were also associated with significantly worse overall survival after a resection as opposed to isoenhancing and hyperenhancing tumours (5-year, 54% versus 89% versus 93%). On multivariate analysis of factors available pre-operatively, only hypoenhancement (HR 2.32, P = 0.02) was independently associated with survival.

DISCUSSION

Hypoenhancement on APCT was noted in 22% of well-differentiated PNET and was an independent predictor of poor outcome. This information can inform pre-operative decisions in the multidisciplinary treatment of these neoplasms.

Impact of external-beam radiation therapy on outcomes among patients with resected gastric cancer: A multi-institutional analysis

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Background: Use of perioperative chemotherapy (CTx) alone versus chemo-radiation therapy (cXRT) in the treatment of resectable gastric cancer remains varied. We sought to define the utilization and effect of CTx alone versus cXRT on patients having undergone curative-intent resection for gastric cancer. Methods: Using the multi-institutional U.S. Gastric Cancer Collaborative database, we identified 505 patients between 2000 and 2012 with gastric cancer who received perioperative therapy in addition to curative-intent resection. The impact of perioperative therapy on survival was analyzed by the use of propensity-score matching of clinicopathologic factors among patients who received CTx alone versus cXRT. Results: Median patient age was 62 years and the majority of patients were male (58%). Surgical resection involved either partial gastrectomy (54%) or total gastrectomy (46%). On pathology, median tumor size was 5.0 cm; most patients had a T3 (37%) or T4 (36%) lesion and lymph node metastasis (74%). Margin status was R0 in most patients (89%). 211 (42%) patients received perioperative CTx alone whereas the remaining 294 (58%) patients received 5-FU based cXRT. Factors associated with receipt of cXRT were younger age (OR 0.98), T3 tumors (OR 1.52), and lymph node metastasis (OR 2.03) (all P < .05). Recurrence occurred in 214 (39%) patients. At a median follow-up of 28 months, median overall survival (OS) was 33.4 months and 5-year survival was 36.7%. Factors associated with worse OS included tumor size (HR 1.1), T-stage (HR 1.5), and lymph node metastasis (HR 1.58) (all P<0.05). In contrast, receipt of cXRT was associated with improved long-term OS (CTx alone: 21 months vs. cXRT 45 months; p<0.001). In the propensity-matched multivariate model that adjusted for tumor size, T-stage, and nodal status, cXRT remained associated with an improved long-term disease-free (HR 0.43) and overall (HR 0.41) survival (both P<0.001). Conclusions: XRT was utilized in 58% of patients undergoing curative-intent resection for gastric cancer. Using propensity-matched analysis, cXRT was an independent factor associated with improved recurrence-free and overall survival.

The effect of perioperative transfusion on recurrence and survival following gastric cancer resection: A seven-institution analysis of 765 patients from the U.S. Gastric Cancer Collaborative

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Background: Whether perioperative blood transfusion has a negative prognostic effect on recurrence and survival in patients undergoing resection of gastric adenocarcinoma (GAC) is unknown. Methods: All patients who underwent resection for GAC from 2000-2012 at 7 institutions were identified. The effect of transfusion on recurrence-free (RFS) and overall survival (OS) in the context of adverse clinicopathologic variables was examined by univariate (UV) and multivariate (MV) regression analyses. Results: Out of 965 pts, 765 underwent curative intent, R0 resection. Median FU for survivors was 44 mos; 30-day deaths were excluded. Median estimated blood loss (EBL) was 250cc and 166 pts (22%) received perioperative RBC transfusions. 5-yr RFS was 51% in transfused and 61% in non-transfused patients (p=0.01). Median OS was decreased in patients receiving transfusions (19 vs 50 mos, p<0.001). On MV analysis, transfusion remained an independent risk factor for decreased RFS (HR 2.8; 95% CI: 1.2-6.5; p=0.01) and decreased OS (Table), regardless of EBL or need for splenectomy. Timing (intraop vs postop) and volume (# of units) did not alter the effect of transfusion on survival. Non-transfused pts were more likely to receive adjuvant therapy (56% vs 44%; p=0.01). Conclusions: Perioperative blood transfusion is associated with decreased recurrence-free and overall survival following resection of gastric cancer, independent of adverse clinicopathologic factors. This supports the judicious use of perioperative transfusion during resection of gastric cancer. [Table: see text]

The effect of postoperative morbidity on survival after resection for gastric adenocarcinoma: Results from the U.S. Gastric Cancer Collaborative

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Background: The negative impact of postoperative complications (POCs) on survival is well documented for many cancer types, but has not been well described in gastric cancer. Here, we evaluated the effect of POCs on survival after surgery for gastric cancer in a cohort of patients from a multi-institutional database. Methods: Patients who underwent surgery with curative intent for gastric adenocarcinoma between 2000-2012 from participating institutions of the U.S. Gastric Cancer Collaborative were analyzed. Patients who died within 30 days of surgery were excluded. Ninety-day postoperative complication data were collected. Survival probabilities were estimated by Kaplan-Meier analysis and compared using the log-rank test. Results: A total of 853 patients from seven institutions met inclusion criteria. Median follow-up was 32 months. The overall complication rate was 40% (n=344). The most frequent complications were: infectious (25%, including surgical site infection [8%]), and anastomotic leak (6%). 7% of patients underwent reoperation during the same hospitalization. Five-year overall survival (OS) for patients without perioperative complications was 54%, compared with 39% for patients with POCs (p=0.001). Disease free survival (DFS) at five years was 61% for patients without POCs compared to 49% in patients with POCs (p=0.002). Patients without POCs were significantly more likely to receive adjuvant therapy (55% vs 42%; p<0.001). Conclusions: In a large, multi-institutional cohort, POCs were associated with decreased survival in patients undergoing surgery for gastric adenocarcinoma. This may be due, in part, to the negative impact of complications on the receipt of adjuvant therapy. Efforts aimed at reducing perioperative morbidity are important not only for short-term surgical outcomes, but also for enhancing long-term oncologic outcomes in patients with gastric cancer. [Table: see text]

Utility of the proximal margin frozen section for resection of gastric adenocarcinoma: A 7-institution study of the U.S. gastric cancer collaborative

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Background: The proximal gastric margin dictates the extent of resection for gastric adenocarcinoma (GAC). The value of achieving negative margins by additional gastric resection after a positive proximal margin frozen section (FS) is unknown. Methods: The US Gastric Cancer Collaborative includes all patients who had resection of GAC at 7 institutions by oncologic surgeons from 2000-2012. Intraoperative proximal margin FS data were classified as R0 or R1 based on final permanent section (PS); positive distal margins were excluded. Primary aim was to evaluate the impact on local recurrence (LR) of converting a positive proximal margin FS to an R0 final margin by additional resection. Secondary endpoints were recurrence-free (RFS) and overall survival (OS). Results: Of 860 pts, 520 had a proximal margin FS; 67 were positive. Of these 67, 48 were converted to R0 on PS by additional resection. R0 proximal margin was achieved in 447 pts (86%), R1 in 25 (5%), and R1 converted to R0 in 48 (9%). Median FU was 44 mos. Although LR was decreased in the converted R1 to R0 group compared to the R1 group (10% vs 32%, p=0.01), when accounting for other pathologic variables on multivariate (MV) analysis, R1 to R0 conversion was not associated with decreased LR. Median RFS was similar between the R1 to R0 and R1 cohort (37 vs 31 mos; p=0.6) compared to 110 mos for the R0 group. Median OS was similar between the R1 to R0 conversion and R1 groups (36 vs 26 mos; p=0.14) compared to 50 mos for the R0 group. On MV analysis, increasing T-stage and positive lymph nodes were associated with worse OS; R1 to R0 conversion of the proximal margin was not associated with improved OS (p=0.5; Table). Conclusions: Conversion of a positive intraoperative proximal margin frozen section during gastric cancer resection does not decrease local recurrence or improve recurrence-free or overall survival. This may guide decisions regarding the extent of resection. [Table: see text]