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Salirrosas O, Vega EA, Panettieri E, Harandi H, Kozyreva O, Ghanta S, Conrad C. Solid Pseudopapillary Tumor of the Pancreas: Is Enucleation Safe? Ann Surg Oncol 2024; 31:4105-4111. [PMID: 38480561 DOI: 10.1245/s10434-024-15119-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/14/2024] [Indexed: 05/09/2024]
Abstract
BACKGROUND While solid pseudopapillary tumor (SPT) of the pancreas are oncologically low-risk tumors, their resection with pancreaticoduodenectomy (PD) or partial pancreatectomy (PP) carries a significant risk for morbidity. To balance the favorable prognosis with the surgical morbidity of pancreas resection, this study explores the oncologic safety of enucleation (EN). PATIENTS AND METHODS The National Cancer Database (NCDB) was queried for resected SPT from January 2004 through December 2020. Perioperative outcomes and survival were analyzed with Kruskal-Wallis tests, and Kaplan-Meier analysis (with log-rank test). Survival analysis was performed to compare patients with and without lymph node (LN) metastases and binary logistic regression for predictors of LN metastasis. RESULTS A total of 922 patients met inclusion criteria; 18 patients (2%) underwent EN, 550 (59.6%) underwent PP, and 354 (38.4%) underwent PD. Mean tumor size was 57.6 mm. Length of hospital stay was significantly shorter for EN compared with PP and PD groups (3.8 versus 6.2 versus 9.4 days, p < 0.001). There was a nonsignificant improvement in unplanned readmission [0% versus 8% versus 10.7% (p = 0.163)], 30-day mortality [0% versus 0.5% versus 0% (p = 0.359)], and 90-day mortality [0% versus 0.5% versus 0% (p = 0.363)] between EN, PP, and PD groups. Survival analyses showed no difference in OS when comparing EN versus PP (p = 0.443), and EN versus PD (p = 0317). Patients with LN metastases (p < 0.001) fared worse, and lymphovascular invasion, higher T category (T3-4) and M1 status were found as predictors for LN metastasis. CONCLUSIONS EN may be considered for select patients leading to favorable outcomes. Because survival was worse in the rare cohort of patients with LN metastases, the predictors for LN metastasis identified here may aid in stratifying patients to EN versus resection.
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Affiliation(s)
- Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Elena Panettieri
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Hamed Harandi
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Olga Kozyreva
- Department of Medical Oncology, Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Harvard Medical School, Boston, MA, USA
| | - Shree Ghanta
- Department of Medicine, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA.
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Salirrosas O, Vega EA, Panettieri E, Harandi H, Kozyreva O, Ghanta S, Conrad C. ASO Visual Abstract: Solid Pseudopapillary Tumor of the Pancreas-Is Enucleation Safe? Ann Surg Oncol 2024; 31:4125-4126. [PMID: 38619708 DOI: 10.1245/s10434-024-15259-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Affiliation(s)
- Oscar Salirrosas
- Department of Surgery, Hepato-Pancreato-Biliary Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Brighton, Boston, MA, USA
| | - Eduardo A Vega
- Department of Surgery, Hepato-Pancreato-Biliary Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Brighton, Boston, MA, USA
| | - Elena Panettieri
- Department of Surgery, Hepato-Pancreato-Biliary Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Brighton, Boston, MA, USA
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Hamed Harandi
- Department of Surgery, Hepato-Pancreato-Biliary Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Brighton, Boston, MA, USA
| | - Olga Kozyreva
- Department of Medical Oncology, Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Harvard Medical School, Boston, MA, USA
| | - Shree Ghanta
- Department of Medicine, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, Hepato-Pancreato-Biliary Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Brighton, Boston, MA, USA.
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Kawahara W, Vega EA, Salehi O, Mellado S, Salirrosas O, Freeman R, Panettieri E, Conrad C. Laparoscopic Dissection of Lymph Node Station 16-Why and How? Ann Surg Oncol 2024; 31:3003-3004. [PMID: 38411760 DOI: 10.1245/s10434-024-15040-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 01/18/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Dissection of para-aortic lymph nodes (Station 16) provides an important prognosticator for patients with gastrointestinal, colorectal, and hepatobiliary cancers.1-4 For example, a positive Station 16 lymph node has been shown to lead to 2-year survival of 3% in patients with pancreas adenocarcinoma, akin to stage IV disease.5,6 Thereby, Station 16 involvement can help with the risk/benefit stratification of the decision to move forward with radical surgery.7-9 Furthermore, it has been shown for gallbladder cancer that involvement of Station 16 cannot necessarily be predicted from the dissection of the hepatoduodenal ligament lymph nodes only.10,11 TECHNIQUE: With the patient in the French position, a complete Kocherization and a Cattel-Braasch maneuver is performed, allowing for visualization of LN station 16b. Station 16b is the inferior border of the station 16 compartment. The left renal vein (LRV) serves as an important landmark to identify the superior border of the dissection comprised by Stations 16a2 and 16b1. Station 16a2 dissection may be associated with a traction injury of the left renal vein or damage of right renal or suprarenal arteries and is dissected if there are specific concerns regarding involvement. CONCLUSIONS While station 16 provides important prognostic information for risk stratification, a strategic and stepwise approach is needed for a safe sampling. This is accomplished by wide mobilization of the duodenum, implementation of thermal fusion to minimize chyle leak, and careful dissection below the left renal vein.
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Affiliation(s)
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | | | - Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Richard Freeman
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Elena Panettieri
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA.
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Salirrosas O, Harandi H, Vega EA, Chirban AM, Conrad C. Laparoscopic Caudate Resection and Perihepatic Inflammation: Do We Have All the Tools We Need? Ann Surg Oncol 2024; 31:3110-3111. [PMID: 38416346 DOI: 10.1245/s10434-024-15092-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/08/2024] [Indexed: 02/29/2024]
Affiliation(s)
- Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Brighton, Boston, MA, USA
| | - Hamed Harandi
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Brighton, Boston, MA, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Brighton, Boston, MA, USA
| | - Ariana M Chirban
- San Diego School of Medicine, University of California, La Jolla, CA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Brighton, Boston, MA, USA.
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Salirrosas O, Kawahara W, Vega EA, Bhargava R, Salehi O, Conrad C. ASO Author Reflections: Lymph Node Station 16 Status-Becoming a Student of Your Patients' Cancer. Ann Surg Oncol 2024; 31:3031-3032. [PMID: 38424261 PMCID: PMC11048733 DOI: 10.1245/s10434-024-15099-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 02/08/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | | | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Rohit Bhargava
- Department of Bioengineering, Electrical and Computer Engineering, Mechanical Science and Engineering, Chemical and Biomolecular Engineering, and Chemistry, Beckman Institute for Advanced Science and Technology, Cancer Center at Illinois, University of Illinois Urbana-Champaign, Urbana, IL, USA
| | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA.
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Salirrosas O, Harandi H, Vega EA, Chirban AM, Conrad C. Laparoscopic Caudate Resection: How to Safely Manage the Spiegel/IVC Interface. Ann Surg Oncol 2024; 31:3098-3099. [PMID: 38353797 DOI: 10.1245/s10434-024-14994-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 01/18/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Minimally invasive caudate lobectomy, or even paracaval caudate resection, can be associated with significant bleeding due to its abutment of inferior vena cava (IVC), portal pedicle and hepatic veins.1-3 This risk can be magnified by cirrhosis as well as response to neoadjuvant therapy (a common phenomenon after excellent response to neoadjuvant chemotherapy), leading to obliteration or even fusion of the hepato-caval space.4-7 PATIENT: A 68-year-old female with stage IVa colorectal adenocarcinoma was found to have a single liver metastasis (3.8 × 3.1 cm) in the paracaval caudate lobe. The patient received four cycles of neoadjuvant chemotherapy, leading to inflammatory fusion of the hepato-caval space. Despite this, the patient underwent a safe laparoscopic Spiegel process resection. TECHNIQUE Prior to surgery, three-dimensional liver and port site modeling was performed to optimize the understanding of the spatial relationship between the tumor, IVC, and portal-hepatic veins. Following inflow control of portal veinous branches, the fused hepato-caval space was dissected. The adhesions were then sharply dissected to mobilize the paracaval caudate lobe off the IVC. Using scissors rather than an energy device reduced the risk of inadvertent thermal injury to the IVC. CONCLUSION Preoperative virtual hepatectomy facilitates surgical planning, increasing the understanding of the tumor/vessel relationship and port placement. In case of a fused hepato-caval space, low central venous pressure and judicious management of short hepatic vein branches are the key for a successful dissection. Moreover, anticipation of a fused hepato-caval space and its strategic management are paramount when performing a minimally invasive caudate resection.
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Affiliation(s)
- Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Hamed Harandi
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Ariana M Chirban
- San Diego School of Medicine, University of California, La Jolla, CA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA.
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Vega EA, Rotellar F. ASO Author Reflections: Confronting Challenges with Creativity: Innovating Minimally Invasive Pancreatic Surgery. Ann Surg Oncol 2024:10.1245/s10434-024-15290-0. [PMID: 38634963 DOI: 10.1245/s10434-024-15290-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/19/2024]
Affiliation(s)
- Eduardo A Vega
- Department of Surgery, Hepato-Pancreato-BiliarySurgery, Saint Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA.
| | - Fernando Rotellar
- Department of Surgery, Clinica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain
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Salirrosas O, Vega EA, Panettieri E, Harandi H, Kozyreva O, Ghanta S, Conrad C. ASO Author Reflections: Pseudopapillary Tumor of the Pancreas: Getting the Dosing of Surgery Right. Ann Surg Oncol 2024:10.1245/s10434-024-15252-6. [PMID: 38625600 DOI: 10.1245/s10434-024-15252-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 03/14/2024] [Indexed: 04/17/2024]
Affiliation(s)
- Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Brighton, Boston, MA, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Brighton, Boston, MA, USA
| | - Elena Panettieri
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Brighton, Boston, MA, USA
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Hamed Harandi
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Brighton, Boston, MA, USA
| | - Olga Kozyreva
- Department of Medical Oncology, Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Harvard Medical School, Boston, MA, USA
| | - Shree Ghanta
- Department of Medicine, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Brighton, Boston, MA, USA.
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Vega EA, Martí-Cruchaga P, Salehi O, Benito A, Zozaya G, López-Olaondo L, Lapuente F, Rotellar F. Enucleation of Sporadic Insulinoma in the Posterior Side of the Head of the Pancreas: The Retrolaparoscopic Approach. Ann Surg Oncol 2024:10.1245/s10434-024-15215-x. [PMID: 38565752 DOI: 10.1245/s10434-024-15215-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/10/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA.
| | - Pablo Martí-Cruchaga
- Department of Surgery, Clinica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain
| | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Alberto Benito
- Department of Surgery, Clinica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain
| | - Gabriel Zozaya
- Department of Surgery, Clinica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain
| | - Luis López-Olaondo
- Department of Surgery, Clinica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain
| | - Fernando Lapuente
- Department of Surgery, Clinica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain
| | - Fernando Rotellar
- Department of Surgery, Clinica Universidad de Navarra, Universidad de Navarra, Pamplona, Spain.
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Salirrosas O, Vega EA, Panettieri E, Salehi O, Kozyreva O, Harandi H, Ganta S, Conrad C. The impact of the COVID-19 pandemic on patients with pancreatic cancer. J Gastrointest Surg 2024:S1091-255X(24)00361-5. [PMID: 38570231 DOI: 10.1016/j.gassur.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/20/2024] [Accepted: 03/08/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND It remains unclear today whether the poor prognosis of pancreatic ductal adenocarcinoma (PDAC) was further worsened by the COVID-19 pandemic and whether this may affect providers and patients, today. Hence, this study aimed to investigate the effect of COVID-19 on care delivery and outcomes of patients with PDAC in the United States. METHODS The National Cancer Database was queried for PDAC, between 2017 and 2020. Changes in the number of diagnoses and treatment patterns were compared annually for the entire cohort. Changes in surgical outcomes and median time from diagnosis to treatment were compared and analyzed. Chi-square, Mann-Whitney U, and Kruskal-Wallis tests were performed. RESULTS Of 127,613 patients with PDAC, PDAC diagnoses from 2017 (30,573) to 2019 (33,465) increased but decreased in 2020 (31,218). The number of patients receiving surgery or radiotherapy was stable between 2017 to 2019 (21.75% ± 0.05% and 13.9% ± 0.3%, respectively) but decreased in 2020 (20.7% and 12.4% respectively). Although patients received chemotherapy with increasing frequently from 2016 (60.7%) to 2019 (63.5%), this trend stopped in 2020 (63%). Of 27,490 patients undergoing surgery, the mean time from diagnosis to surgery increased from 2017 (34 days) to 2019 (56 days), with an increase in delay in 2020 (81 days). Moreover, patients who were tested for COVID-19, had a longer median time from diagnosis to surgery even if tested negative (COVID+, 140 days; COVID-, 112 days; P < .001). CONCLUSION Although the oncologic quality of PDAC surgery remained the same during the pandemic, not only did the pandemic lead to an underdiagnosis of PDAC and care delays, but even the suspicion of COVID-19 in patients with a negative test adversely affected their care.
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Affiliation(s)
- Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Elena Panettieri
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States; Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Olga Kozyreva
- Department of Medical Oncology, Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Hamed Harandi
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Shree Ganta
- Department of Medicine, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States.
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Mellado S, Chirban AM, Shapera E, Rivera B, Panettieri E, Vivanco M, Conrad C, Sucandy I, Vega EA. Innovations in surgery for gallbladder cancer: A review of robotic surgery as a feasible and safe option. Am J Surg 2024:S0002-9610(24)00112-0. [PMID: 38443272 DOI: 10.1016/j.amjsurg.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/24/2024] [Accepted: 02/12/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND This study evaluates the efficacy and safety of robotic-assisted surgical techniques in the treatment of gallbladder cancer, comparing it with traditional open and laparoscopic methods. METHODS A systematic review of the literature searched for comparative analyses of patient outcomes following robotic, open, and laparoscopic surgeries, focusing on oncological results and perioperative benefits. RESULTS Five total studies published between 2019 and 2023 were identified. Findings indicate that robotic-assisted surgery for gallbladder cancer is as effective as traditional methods in terms of oncological outcomes, with potential advantages in precision and perioperative recovery. CONCLUSIONS Robotic surgery offers a viable and potentially advantageous alternative for gallbladder cancer treatment, warranting further research to confirm its benefits and establish comprehensive surgical guidelines.
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Affiliation(s)
- Sebastian Mellado
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA; Tufts University School of Medicine, Boston, MA, USA
| | - Ariana M Chirban
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA; University of California San Diego School of Medicine, San Diego, CA, USA
| | - Emanuel Shapera
- Digestive Health Institute, Advent Health Tampa, Tampa, FL, USA
| | - Belen Rivera
- Department of Surgery, Clinica Alemana de Santiago, Santiago, Chile
| | - Elena Panettieri
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA; Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marcelo Vivanco
- Department of Surgery, Clinica Alemana de Santiago, Santiago, Chile
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Iswanto Sucandy
- Digestive Health Institute, Advent Health Tampa, Tampa, FL, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA.
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Panettieri E, Vega EA, Salirrosas O, Harandi H, Kozyreva O, Mellado S, Conrad C. Does adjuvant treatment improve survival in R1 resected perihilar cholangiocarcinoma? The risk of overtreatment. J Gastrointest Surg 2024; 28:S1091-255X(24)00019-2. [PMID: 38577811 DOI: 10.1016/j.gassur.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/10/2023] [Accepted: 01/05/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Resection of perihilar cholangiocarcinoma (pCCA) is associated with positive margins in up to half of the patients. It remains unclear whether adjuvant therapies contribute to improved survival in patients undergoing R1 resection for pCCA. METHODS The National Cancer Database was queried for patients diagnosed with pCCA between 2004 and 2016. Patients with metastatic disease at the time of diagnosis were excluded. RESULTS A total of 1756 patients were included (286 surgical patients and 1470 nonsurgical patients). Patients who underwent R0 resection showed a significantly better median overall survival (OS) than that of patients who underwent R1 resection (41.7 vs 21.4 months, respectively; P = .003). Nevertheless, OS was better in patients who underwent R1 resection than in nonsurgical patients (21.4 vs 6.3 months, respectively; P < .001). Patients undergoing chemoradiation after R1 resection had similar OS to that of those receiving any other adjuvant therapy (21.4 vs 19.4 months, respectively; P = .789) or no adjuvant treatment (21.4 vs 19.8 months, respectively; P = .925). After uni- and multivariable analyses, T stage ≥3 and R1 margins were independently associated with worse survival after surgery. CONCLUSION As currently neither radiation, chemoradiation, nor chemotherapy seem to significantly improve survival in patients who underwent R1 resection for pCCA, high-quality surgical resection remains critically important. Moreover, the concern of overtreatment of patients who underwent R1 resection with current adjuvant therapeutic regimes exists.
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Affiliation(s)
- Elena Panettieri
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States; Hepatobiliary Surgery, Fondazione "Policlinico Universitario A. Gemelli", Scientific Institute for Research, Hospitalization and Healthcare, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Hamed Harandi
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Olga Kozyreva
- Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Boston, Massachusetts, United States
| | - Sebastian Mellado
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States; Tufts University School of Medicine, Boston, Massachusetts, United States
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States.
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Panettieri E, Vega EA, Salirrosas O, Ogiso S, Geller D, Conrad C. Global practice patterns of preoperative image reconstruction for liver surgery. J Gastrointest Surg 2024; 28:26-32. [PMID: 38353071 DOI: 10.1016/j.gassur.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/31/2023] [Accepted: 10/28/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND Three-dimensional (3-D) liver modeling is used globally; however, its actual practice is limited to a few centers. This study aimed to assess practice patterns and barriers to the use of 3-D modeling among liver surgeons worldwide. METHODS A survey approved by the International Hepato-Pancreato-Biliary Association research council consisting of 27 questions was conducted using an online questionnaire. Incomplete responses were excluded. RESULTS Of 235 respondents from 46 countries, 81.3% reported experience with 3-D modeling; however, only 21% used it in > 75% of cases. Surgeons using 3-D reconstruction were older (P = .025), worked more frequently at academic facilities (P = .007), and had more years of experience (P = .001), especially in minimally invasive liver surgery (MILS) (P = .038). In addition, 3-D rendering was performed by surgeons in 50.8% of cases. Liver volumetry was the most frequent indication (80.1%), and decreased postoperative complications were the main perceived benefit (53.6%). CONCLUSIONS More experience in liver surgery because of seniority, case volume, and openness to novel technology (MILS) is associated with a greater appreciation for the value of 3-D modeling. Our results suggest the need for senior surgeons to help early-career surgeons consider 3-D modeling for the reported benefit of reduced intra- and postoperative complications.
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Affiliation(s)
- Elena Panettieri
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States; Hepatobiliary Surgery Unit, Fondazione "Policlinico Universitario A. Gemelli" Istituto di Ricovero e Cura a Carattere Scientifico, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States
| | - Satoshi Ogiso
- Division of Hepato-Biliary-Pancreatic Surgery and Transplantation, Department of Surgery, Graduate School of Medicine, Kyoto University, Sakyo-ku, Kyoto, Japan
| | - David Geller
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, United States.
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14
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Vega EA, Mellado S, Chirban AM, Vinuela E. ASO Visual Abstract: Analysis of the Extent of Liver Oncologic Extended Resection for Incidental Gallbladder Cancer: How Much is too Much? Ann Surg Oncol 2023; 30:8016-8017. [PMID: 37481489 DOI: 10.1245/s10434-023-13999-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA.
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Sotero del Rio Hospital, Santiago, Chile.
| | - Sebastian Mellado
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - Ariana M Chirban
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
- University of California San Diego School of Medicine, San Diego, CA, USA
| | - Eduardo Vinuela
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Sotero del Rio Hospital, Santiago, Chile
- Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile
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15
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Vega EA, Vauthey JN. Reply to: "Comment on: Benchmarks and Geographic Differences in Gallbladder Cancer Surgery: An International Multicenter Study," by Shi, Li-jun et al. Ann Surg Oncol 2023; 30:7398-7399. [PMID: 37672145 DOI: 10.1245/s10434-023-14267-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 08/23/2023] [Indexed: 09/07/2023]
Affiliation(s)
- Eduardo A Vega
- Saint Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA.
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16
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Vega EA, Salehi O, Panettieri E, Salirrosas O, Brauner E, Mellado S, Dvir K, Perepletchikov A, Kozyreva O, Conrad C. Subsegmental approaches to S7: anatomic laparoscopic transdiaphragmatic and nonanatomic robotic transthoracic. Surg Endosc 2023; 37:8154-8155. [PMID: 37644157 DOI: 10.1007/s00464-023-10310-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 07/12/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Minimally invasive liver surgery of postero-superior segments (S4a, S7, S8) remains a challenge. The caudal view, an increased distance between trocars and the operative field, and the liver fulcrum limiting the view, contribute to the difficulty [1, 2]. We and other groups have previously reported the use of intercostal trocars to access subdiaphragmatic tumors (transdiaphragmatic approach) [3-5], only few reports on a laparoscopic total transthoracic approach, none (to our knowledge) dynamic manuscripts of a total transthoracic robotic approach, and none (to our knowledge) that use preoperative port site and anatomic modelling exist. Further, we developed a total transthoracic (thoracoscopic) approach to avoid a hostile abdomen, while bringing viewing axis and instruments close to the target [6-10]. In this context, this report details the advantages of a laparoscopic vs. robotic transthoracic approach. According to institutional protocol, reports of individual cases in print or video format do not require institutional review board approval. PATIENT A 68-year-old male on peritoneal dialysis with left colon adenocarcinoma and a single synchronous liver metastasis in S6-7 close to the root of the right hepatic vein underwent a laparoscopic transdiaphragmatic metastasectomy. Two years later, the patient developed a recurrent 1.5 cm liver metastasis in S7, which lend itself to a robotic transthoracic approach. TECHNIQUE Following 3-D modelling and virtual port placement planning, the first metastasectomy was performed laparoscopically using a transdiaphragmatic approach. The recurrence was managed transthoracically due to more apical, subdiaphragmatic location. For this operation, a robotic approach was optimal as robotic wrist articulation facilitates manipulation via the limited intercostal space. This was particularly helpful during the diaphragmatic reconstruction. CONCLUSIONS Total transthoracic liver surgery is certainly an advanced procedure requiring superior MIS liver skills. Recommendations for starting with a total transthoracic approach are not unlike from starting a standard, none-transthoracic liver surgery. Early on in the experience we recommend advanced liver MIS skills, and single, small, subdiaphragmatic tumors away from major vessels. Nonetheless, when these recommendations are followed a total transthoracic approach may be safer and result in less access trauma, than traversing a hostile abdomen to reach the posterior-superior liver. Both laparoscopic and robotic transthoracic approaches can facilitate the resection of subdiaphragmatic tumors, especially in patients with hostile abdomens. While the laparoscopic approach has advantages due to a broader spectrum of available surgical tools (flexible tip camera, parenchymal dissection, and energy devices), the robotic wrist articulation facilitates manipulation via the restricted intercostal space.
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Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Elena Panettieri
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Eran Brauner
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | | | - Kathrin Dvir
- Department of Oncology, Dana Farber Cancer Institute at St. Elizabeth's Medical Center, Boston, MA, USA
| | - Aleksandr Perepletchikov
- Department of Pathology, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Olga Kozyreva
- Department of Oncology, Dana Farber Cancer Institute at St. Elizabeth's Medical Center, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA.
- General Surgery and Surgical Oncology, Hepato-Pancreato-Biliary Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA.
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Mellado S, Chirban AM, Rivera B, Panettieri E, Vega EA. ASO Author Reflections: Precision in Gallbladder Cancer Care: Present Challenges and Future Directions. Ann Surg Oncol 2023; 30:6601-6602. [PMID: 37548834 DOI: 10.1245/s10434-023-14062-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 08/08/2023]
Affiliation(s)
- Sebastian Mellado
- Department of Surgery, Hepato-Pancreato-Biliary Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - Ariana M Chirban
- Department of Surgery, Hepato-Pancreato-Biliary Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
- University of California San Diego School of Medicine, San Diego, CA, USA
| | - Belen Rivera
- Faculty of Medicine, Universidad del Desarrollo, Santiago, Chile
| | - Elena Panettieri
- Department of Surgery, Hepato-Pancreato-Biliary Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
- Hepatobiliary Surgery Unit, Fondazione "Policlinico Universitario A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Eduardo A Vega
- Department of Surgery, Hepato-Pancreato-Biliary Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA.
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Vega EA, Agudile E, Salirrosas O, Chirban AM, Brauner E, Crocker A, Freeman R, Sorescu GP, Odisio BC, Conrad C. Clinical outcomes and cost of open, laparoscopic, and percutaneous ablation for hepatocellular carcinoma. J Surg Oncol 2023; 128:812-822. [PMID: 37395114 DOI: 10.1002/jso.27377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 04/28/2023] [Accepted: 06/11/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Open (OA), laparoscopic (LA), and percutaneous (PA) ablation are all ablation approaches for hepatocellular carcinoma (HCC) utilized in the United States today. However, it remains unclear today which approach is (A) most effective, (B) cost-efficient, and (C) nationally practiced. METHODS In-hospital mortality and cost were collected from the National Inpatient Sample (NIS) database for patients undergoing liver ablation from 2011 to 2018. Secondary outcomes included length of stay, disposition, and perioperative composite complications. We used inverse probability of treatment weighting (IPTW) to adjust for differences in patient and hospital baseline characteristics. RESULTS One thousand and one hundred and twenty-five LA, 1221 OA, and 1068 PA liver ablations were analyzed. After IPTW, in-hospital mortality risk was significantly lower in PA versus OA cohorts (0.57% vs. 2.90%, p < 0.001) and reduced among PA patients, yet not significantly different from the LA cohort (0.57% vs. 1.64%, p = 0.056). The median length of hospital stay was significantly lower in the PA and LA group compared to OA (2 days vs. 6 days, p < 0.001). The median hospitalization costs were significantly lower for PA ($44,884 vs. $90,187, p < 0.001) and LA ($61,445 vs. $90,187, p < 0.001) compared to OA. Moreover, we found significant regional differences regarding the use of each ablation approach, with the Midwest having the lowest rates of PA and LA. CONCLUSIONS Among patients hospitalized after ablation for HCC, PA leads to the lowest hospital cost. Both PA and LA result in lower peri-operative morbidity and mortality relative to OA. Despite these reported advantages, there are significant regional differences with respect to ablation availability suggesting the need to promote the standardization of best practices.
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Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Emeka Agudile
- Department of Medicine, Steward Carney Hospital, Dorchester, Massachusetts, USA
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Ariana M Chirban
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
- School of Medicine, University of California San Diego, La Jolla, California, USA
| | - Eran Brauner
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Andrew Crocker
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Richard Freeman
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - George P Sorescu
- Department of Medicine, Steward Carney Hospital, Dorchester, Massachusetts, USA
| | - Bruno C Odisio
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
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19
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Vega EA, Mellado S, Chirban AM, Panettieri E, Sanhueza M, Mege R, Diaz C, Brañes A, Briceño E, Viñuela E. Analysis of the Extent of Liver Oncological Extended Resection for Incidental Gallbladder Cancer: How Much Is Too Much? Ann Surg Oncol 2023; 30:6594-6600. [PMID: 37460736 DOI: 10.1245/s10434-023-13861-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 06/19/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Liver resection is pivotal in treating incidental gallbladder cancer (IGBC). However, the adequate volume of liver resection remains controversial. METHODS A cross-sectional retrospective analysis was performed on resected IGBC patients between 1999 and 2018. Morbidity was evaluated according to the Clavien-Dindo classification. The theoretical volume of a 2-cm and 1.5-cm wedge liver resection was calculated (105 cm3 and 77.5 cm3, respectively) and used as reference. Overall survival (OS) was estimated using Kaplan-Meier and Cox regression analyses. RESULTS Among 111 patients re-resected for IGBC, 84 provided sufficient data to calculate liver resection volume. Patients with a resection volume ≥ 105 cm3 had a higher rate of overall morbidity (P = 0.001) and length of stay (P = 0.012), with no difference in mortality. There was no significant difference in OS according to residual cancer or T-category. A resection volume ≥ 77.5 cm3 was more frequent in T ≥ 3 than in T1-2 patients (P = 0.026), and residual cancer was higher (P = 0.041) among patients with ≥ 77.5 cm3 resected. Cox multivariate regression showed that residual cancer (HR = 11.47, P < 0.001), perineural/lymphovascular invasion (HR = 2.48, P = 0.021), and Clavien-Dindo ≥ IIIa morbidity (HR = 5.03, P = 0.003) predict worse OS, but not liver volume resection. CONCLUSION There are no significant differences in OS based on resected liver volume of IGBC, when R0 is achieved. There is a significant difference in morbidity and length of stay when liver wedges are ≥ 105 cm3, which is lost when analyzed by Clavien-Dindo ≥ IIIa. A 77.5-105 cm3 resection is indicated in ≥ T3 patients, minimizing morbidity risk, while addressing concerns of overall survival.
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Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Hepato-Pancreato-BiliarySurgery, Boston University School of Medicine, Boston, MA, USA.
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Faculty of Medicine, Sotero del Rio Hospital, Pontificia Universidad Catolica of Chile, Santiago, Chile.
| | - Sebastian Mellado
- Department of Surgery, St. Elizabeth's Medical Center, Hepato-Pancreato-BiliarySurgery, Boston University School of Medicine, Boston, MA, USA
- Tufts University School of Medicine, Boston, MA, USA
| | - Ariana M Chirban
- Department of Surgery, St. Elizabeth's Medical Center, Hepato-Pancreato-BiliarySurgery, Boston University School of Medicine, Boston, MA, USA
- University of California San Diego School of Medicine, San Diego, CA, USA
| | - Elena Panettieri
- Department of Surgery, St. Elizabeth's Medical Center, Hepato-Pancreato-BiliarySurgery, Boston University School of Medicine, Boston, MA, USA
- Hepatobiliary Surgery Unit, Fondazione "Policlinico Universitario A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marcel Sanhueza
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Faculty of Medicine, Sotero del Rio Hospital, Pontificia Universidad Catolica of Chile, Santiago, Chile
- Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile
| | - Rosemarie Mege
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Faculty of Medicine, Sotero del Rio Hospital, Pontificia Universidad Catolica of Chile, Santiago, Chile
- Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile
| | - Cristian Diaz
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Faculty of Medicine, Sotero del Rio Hospital, Pontificia Universidad Catolica of Chile, Santiago, Chile
- Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile
| | - Alejandro Brañes
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Faculty of Medicine, Sotero del Rio Hospital, Pontificia Universidad Catolica of Chile, Santiago, Chile
- Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile
| | - Eduardo Briceño
- Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile
| | - Eduardo Viñuela
- Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Faculty of Medicine, Sotero del Rio Hospital, Pontificia Universidad Catolica of Chile, Santiago, Chile.
- Department of Digestive Surgery, Faculty of Medicine, Catholic University of Chile, Santiago, Chile.
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Vega EA, Newhook TE, Mellado S, Ruzzenente A, Okuno M, De Bellis M, Panettieri E, Ahmad MU, Merlo I, Rojas J, De Rose AM, Nishino H, Sinnamon AJ, Donadon M, Hauger MS, Guevara OA, Munoz C, Denbo JW, Chun YS, Tran Cao HS, Sanchez Claria R, Tzeng CWD, De Aretxabala X, Vivanco M, Brudvik KW, Seo S, Pekolj J, Poultsides GA, Torzilli G, Giuliante F, Anaya DA, Guglielmi A, Vinuela E, Vauthey JN. Benchmarks and Geographic Differences in Gallbladder Cancer Surgery: An International Multicenter Study. Ann Surg Oncol 2023; 30:4904-4911. [PMID: 37149547 DOI: 10.1245/s10434-023-13531-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/05/2023] [Indexed: 05/08/2023]
Abstract
BACKGROUND High-quality surgery plays a central role in the delivery of excellent oncologic care. Benchmark values indicate the best achievable results. We aimed to define benchmark values for gallbladder cancer (GBC) surgery across an international population. PATIENTS AND METHODS This study included consecutive patients with GBC who underwent curative-intent surgery during 2000-2021 at 13 centers, across seven countries and four continents. Patients operated on at high-volume centers without the need for vascular and/or bile duct reconstruction and without significant comorbidities were chosen as the benchmark group. RESULTS Of 906 patients who underwent curative-intent GBC surgery during the study period, 245 (27%) were included in the benchmark group. These were predominantly women (n = 174, 71%) and had a median age of 64 years (interquartile range 57-70 years). In the benchmark group, 50 patients (20%) experienced complications within 90 days after surgery, with 20 patients (8%) developing major complications (Clavien-Dindo grade ≥ IIIa). Median length of postoperative hospital stay was 6 days (interquartile range 4-8 days). Benchmark values included ≥ 4 lymph nodes retrieved, estimated intraoperative blood loss ≤ 350 mL, perioperative blood transfusion rate ≤ 13%, operative time ≤ 332 min, length of hospital stay ≤ 8 days, R1 margin rate ≤ 7%, complication rate ≤ 22%, and rate of grade ≥ IIIa complications ≤ 11%. CONCLUSIONS Surgery for GBC remains associated with significant morbidity. The availability of benchmark values may facilitate comparisons in future analyses among GBC patients, GBC surgical approaches, and centers performing GBC surgery.
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Affiliation(s)
- Eduardo A Vega
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Department of Surgery, Saint Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA.
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sebastian Mellado
- Department of Surgery, Saint Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
- Tuft University School of Medicine, Boston, MA, USA
| | - Andrea Ruzzenente
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy
| | - Masayuki Okuno
- Department of Gastroenterological Surgery, Hyogo Medical University, Nishinomiya, Hyogo, Japan
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mario De Bellis
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy
| | - Elena Panettieri
- Hepatobiliary Surgery Unit, Fondazione "Policlinico Universitario A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - M Usman Ahmad
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Ignacio Merlo
- General Surgery and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Jesus Rojas
- UGI & HPB Surgery Unit, Hospital Regional de Talca, Universidad Catolica del Maule, Talca, Chile
| | - Agostino M De Rose
- Hepatobiliary Surgery Unit, Fondazione "Policlinico Universitario A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Hiroto Nishino
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Andrew J Sinnamon
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Matteo Donadon
- Division of Hepatobiliary and General Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Marit S Hauger
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Oscar A Guevara
- Department of Surgery, Instituto Nacional de Cancerologia, Bogota, Colombia
| | - Cesar Munoz
- UGI & HPB Surgery Unit, Hospital Regional de Talca, Universidad Catolica del Maule, Talca, Chile
| | - Jason W Denbo
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Yun Shin Chun
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Hop S Tran Cao
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Rodrigo Sanchez Claria
- General Surgery and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Ching-Wei D Tzeng
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Xabier De Aretxabala
- Gallbladder Consortium Chile, Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Sotero del Rio Hospital and Clinica Alemana de Santiago, Santiago, Chile
| | - Marcelo Vivanco
- Gallbladder Consortium Chile, Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Sotero del Rio Hospital and Clinica Alemana de Santiago, Santiago, Chile
| | - Kristoffer W Brudvik
- Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Satoru Seo
- Department of Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Juan Pekolj
- General Surgery and Liver Transplant Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Guido Torzilli
- Division of Hepatobiliary and General Surgery, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Felice Giuliante
- Hepatobiliary Surgery Unit, Fondazione "Policlinico Universitario A. Gemelli" IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Daniel A Anaya
- Section of Hepatobiliary Tumors, Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL, USA
| | - Alfredo Guglielmi
- Department of Surgery, Dentistry, Gynecology and Pediatrics, Division of General and Hepatobiliary Surgery, G.B. Rossi University Hospital, University of Verona, Verona, Italy
| | - Eduardo Vinuela
- Gallbladder Consortium Chile, Department of Digestive Surgery, Hepato-Pancreato-Biliary Surgery Unit, Surgery Service, Sotero del Rio Hospital and Clinica Alemana de Santiago, Santiago, Chile
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Vega EA, Mellado S, Newhook TE, Vauthey JN. ASO Visual Abstract: Benchmarks and Geographic Differences in Gallbladder Cancer Surgery: An International Multi-center Study. Ann Surg Oncol 2023; 30:4914-4915. [PMID: 37179275 DOI: 10.1245/s10434-023-13616-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Affiliation(s)
- Eduardo A Vega
- Department of Surgery, Saint Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
- Department of Surgery, Saint Elizabeth's Medical Center, Boston University Medical School, Boston, MA, USA.
| | - Sebastian Mellado
- Department of Surgery, Saint Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Vega EA, Mellado S, Panettieri E, Newhook T, Vauthey JN. ASO Author Reflections: Harnessing the Power of Data- The Impact of Benchmarking in Healthcare. Ann Surg Oncol 2023; 30:4912-4913. [PMID: 37202572 DOI: 10.1245/s10434-023-13647-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/03/2023] [Indexed: 05/20/2023]
Affiliation(s)
- Eduardo A Vega
- Department of Surgery, Saint Elizabeth's Medical Center, Boston University Medical School, Boston, MA, USA.
| | - Sebastian Mellado
- Department of Surgery, Saint Elizabeth's Medical Center, Boston University Medical School, Boston, MA, USA
| | - Elena Panettieri
- Department of Surgery, Saint Elizabeth's Medical Center, Boston University Medical School, Boston, MA, USA
| | - Timothy Newhook
- Department of Surgery, Saint Elizabeth's Medical Center, Boston University Medical School, Boston, MA, USA
| | - Jean Nicolas Vauthey
- Department of Surgery, Saint Elizabeth's Medical Center, Boston University Medical School, Boston, MA, USA
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23
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Panettieri E, Vega EA, Chirban AM, Salirrosas O, Clancy TE, Malek A, Freeman R, Conrad C. Anatomic Laparoscopic Partial Hepatectomy of a Segment 4a B-Catenin Mutated Adenoma. Ann Surg Oncol 2023; 30:4234-4235. [PMID: 36752966 DOI: 10.1245/s10434-023-13106-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND Although a β-catenin mutated hepatocellular adenoma (HCA) is a benign liver tumor, it can cause bleeding, obstruction, pain, and hepatocellular carcinoma.1-3 Because surgery needs to balance these risks with its morbidity, a minimally invasive approach may be well suited.4-6 In this report, a strategic approach to minimally invasive resection of HCA encompassing segment 4a (S4a) is reviewed. PATIENT A 22-year-old woman with abdominal pain was found to have two liver lesions involving segment 4a (5 cm) and segment 8 (S8) (4.5 cm). Liver biopsy confirmed a β-catenin mutated HCA in the S4a lesion. After embolization, an anatomic S4a segmentectomy and a partial S8 resection were planned. TECHNIQUE Three-dimensional modeling was used to perform a preoperative virtual hepatectomy; to visualize the spatial relationship between the HCA, the portal bifurcation, and the hepatic veins; and to preplan the port sites.7 With the patient in the French position, after port placement, intraoperative ultrasound was performed to identify the transection plane.8 The main left portal pedicle and Rex's recessus were exposed, and the branches of S4a were dissected out, clipped, and divided. Using ultrasound, the middle hepatic vein was exposed to define the lateral border of the dissection plane. CONCLUSION Although a β-catenin mutated HCA in S4a does not necessitate a formal segmentectomy, understanding the anatomic structures outlining its borders can facilitate the resection, especially for a large HCA. Virtual hepatectomy helps to achieve a detailed comprehension of the complex borders of segment 4a. Preoperative embolization can firm up the tumor and minimize the risk of intraoperative rupture from manipulation.
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Affiliation(s)
- Elena Panettieri
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Ariana M Chirban
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
- School of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Thomas E Clancy
- Dana-Farber Brigham and Women's Cancer Center, Division of Surgical Oncology, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Anita Malek
- Department of Pathology, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Richard Freeman
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA.
- General Surgery and Surgical Oncology, Hepato-Pancreato-Biliary Surgery, Saint Elizabeth Medical Center, Boston University School of Medicine, Boston, MA, USA.
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Panettieri E, Vega EA, Conrad C. ASO Author Reflections: On the Road to Autonomous Liver Surgery? Ann Surg Oncol 2023; 30:4236-4237. [PMID: 36847959 DOI: 10.1245/s10434-023-13218-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 01/27/2023] [Indexed: 03/01/2023]
Affiliation(s)
- Elena Panettieri
- Department of Surgery, General Surgery and Surgical Oncology, Hepato-Pancreato-Biliary Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
- Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eduardo A Vega
- Department of Surgery, General Surgery and Surgical Oncology, Hepato-Pancreato-Biliary Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, General Surgery and Surgical Oncology, Hepato-Pancreato-Biliary Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, Boston, MA, USA.
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25
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Chirban AM, Vega EA, Kutlu OC, Mellado S, Kozyreva O, Zauls AJ, Panettieri E, Salirrosas O, Freeman R, Conrad C. R1 pancreatic cancer patients benefit from chemoradiation when initiation of adjuvant therapy is delayed. Surg Oncol 2023; 49:101961. [PMID: 37321066 DOI: 10.1016/j.suronc.2023.101961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 05/11/2023] [Accepted: 05/28/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Adjuvant chemotherapy (AC) following pancreaticoduodenectomy (PD) for pancreas cancer (PDAC) has been demonstrated to improve survival. However, the optimal adjuvant treatment (AT) regimen for R1-margin patients remains unclear. This retrospective study investigates the impact of AC vs. adjuvant chemoradiotherapy (ACRT) on survival (OS). MATERIAL AND METHODS The NCDB was queried for patients with PDAC who underwent PD between 2010 and 2018. Patients were divided into, (A) AC<60 days, (B) ACRT<60 days, (C) AC≥60 days, and (D) ACRT≥60 days. Kaplan-Meier survival analyses and Cox multivariable regression analyses were performed. RESULTS Among 13 740 patients, median OS was 23.7 months. For R1 patients, median OS for timely AC and ACRT, and delayed AC and ACRT was 19.91, 19.19, 15.24, 18.96 months, respectively. While time of AC initiation was an insignificant factor for R0 patients (p = 0.263, CI 0.957-1.173), a survival benefit was found for R1 patients who received AC<60 vs. ≥60 days (p = 0.041, CI 1.002-1.42). Among R1 patients, administration of delayed ACRT achieves the same survival benefit of timely AC initiation (p = 0.074, CI 0.703-1.077). CONCLUSION The study suggests value in ACRT for patients with R1 margins when delay of AT≥60 days cannot be avoided. Hence, ACRT may mitigate the negative impact of delayed AT initiation for R1-patients.
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Affiliation(s)
- Ariana M Chirban
- University of California, San Diego School of Medicine, 9500 Gilman Dr., La Jolla, CA, 92093, USA; Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA
| | - Onur C Kutlu
- Department of Surgery, Miller School of Medicine, University of Miami, 1120 NW 14th St f4, Miami, FL, 33136, USA
| | - Sebastian Mellado
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA, 02111, USA
| | - Olga Kozyreva
- Dana-Farber Cancer Institute, Harvard School of Medicine, 450 Brookline Ave, Boston, MA, 02215, USA
| | - Andris J Zauls
- Good Samaritan Medical Center, Radiation Oncology, 818 Oak Street, Brockton, MA, USA
| | - Elena Panettieri
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA; Hepatobiliary Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro Cuore, Via della Pineta Sacchetti, 217, 00168, Roma RM, Italy
| | - Oscar Salirrosas
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA
| | - Richard Freeman
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA.
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Vega EA, Salehi O, Conrad C. Central Pericystectomy for Hydatid Cyst Treatment. J Gastrointest Surg 2023:10.1007/s11605-023-05628-6. [PMID: 37069460 DOI: 10.1007/s11605-023-05628-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 01/28/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Compared to open resection for hepatic hydatid cysts, a laparoscopic approach may combine the benefit of reduced morbidity with complete cyst removal. Nonetheless, intraoperative cyst rupture during a laparoscopic approach due to reduced tactile feedback is a valid concern.1-3 Today, the laparoscopic experience remains limited even in high incidence regions.4 Here, a structured approach to laparoscopic pericystectomy is demonstrated. PATIENT A 37-year-old male from Uruguay presents with worsening abdominal pain, nausea, and vomiting. A 4-phase liver CT shows a large complex liver cyst (8.8 × 8.2 × 11.3 cm), encompassing the left hepatic lobe while abutting right hepatic vein (RHV), anterior fissure vein (AFV) and inferior vena cava (IVC). Further, the cyst causes mass effect on the hepatic vein vasculature. CT appearance is consistent with a large hydatid cyst with distorted hepatic anatomy resulting in compensatory hypertrophy of segments II, VI and VII. Appropriate institutional review board (IRB) and inform consent was obtained. TECHNIQUE Following neoadjuvant albendazole for 4 weeks to minimize any effects in case of inadvertent cyst spillage, the patient tested negative for echinococcal antibody. For surgical planning, the patient's anatomy was modeled to optimize the understanding of the complex spatial relationship between cyst, portal pedicle and hepatic veins. Further, port sites were preoperatively modelled to optimize port placement in the context of the altered anatomy from compensatory hepatic hypertrophy. During surgery, with the patient in a modified French position, the liver was completely mobilized. Then, a parenchymal transection plane was developed guided by RHV, AFV and IVC, while biliary radicals entering directly into the cyst were controlled individually. The complex transection plane resulted in preservation of the unaffected liver segments I, II, VI and VII. CONCLUSION The multimodal approach demonstrated here included pretreatment with albendazole followed by safe laparoscopic pericystectomy. In the preoperative setting, albendazole can reduce the risk of recurrence if spillage occurs during surgery. In inoperable patients, it has been previously shown to be an effective monotherapy for small (< 5 cm) CE1 and CE3a cysts.5 For preoperative planning, an automated image reconstruction software (Fujifilm Synapse 3D) is used. The software creates a 3D model of the liver segmentation and vessels from contrast-enhanced CT and MR images. In addition to modelling the liver, port placement in relation to the liver is being simulated prior to surgery to optimize port placement at the time of surgery. During the case, the parenchymal transection is guided by RHV, AFV and IVC. The common postoperative complication of persistent biliary leakage was avoided by controlling each biliary radicals entering the cyst from the liver parenchyma. Biliary leaks are a common complication and have been positively correlated with the cyst diameter (~ 79% of cysts with diameter of 7.5 cm or greater have cysto-biliary fistula).6 In this context, indocyanine green may help to identify relevant biliary radicals entering the cyst or aid in recognizing bile leaks. If the stepwise approach described here is followed, minimally invasive pericystectomy represents a safe alternative to open surgery, harnessing the advantages of minimal risk of recurrence due to complete cyst removal and low morbidity.
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Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Boston, MA, 02135, USA
| | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Boston, MA, 02135, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Boston, MA, 02135, USA.
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Li M, Vega EA, Mellado S, Salehi O, Kozyreva O, Conrad C. Colorectal cancer in young patients below screening age - Demographic and socioeconomic factors associated with incidence and survival. Surg Oncol 2023; 46:101906. [PMID: 36738697 DOI: 10.1016/j.suronc.2023.101906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 12/23/2022] [Accepted: 01/22/2023] [Indexed: 02/03/2023]
Abstract
BACKGROUND While early onset colorectal cancer (EOCRC) has previously been defined as CRC in patients younger than age 50, recent screening guidelines have been lowered to 45. With more younger patients aged 45-50 are now being screened, incidence trend and outcomes of very early EOCRC (20-44) remains unclear. METHOD Surveillance, Epidemiology, and End Results database was analyzed between 2006 and 2016 using Joinpoint tool to evaluate annual percentage change (APC) in incident rates, focusing on race/ethnicity and socioeconomic status (SES). Cancer specific survival (CSS) was assessed using univariate and multivariate analysis. RESULTS 41,815 EOCRC patients met inclusion criteria. Incidence has increased significantly in both age groups (APC in age group 20-44 = 1.21 and 45-49 = 1.06). Increase incidence of very early EOCRC was observed in White and Hispanic racial/ethnic groups (ACP 1.68 and 2.63), as well as population from counties with high poverty, unemployment, language barrier, foreign born resident, and high school dropout rates (ACP 2.07, 1.87, 1.21, 1.28 and 2.02 respectively). Further, the 5-year CSS was worse in Black patients, and patients from counties with high poverty, unemployment and high school dropouts rates (Age group 20-44, 63.11%, 66.39%, 67.48% and 66.95% respectively). On multivariate analysis, living in high poverty counties was an independent risk factor for poorer CSS for very early EOCRC (HR 1.20, 95% CI 1.07-1.34, p = 0.002). Multivariate analysis was adjusted by sex, pathology type, site of disease, disease extension and surgical treatment history. CONCLUSION Very early EOCRC incidence increases in White, Hispanic and poor patients, and outcomes are worse for minority and low-income patients. Further study on very early EOCRC is needed among those patients.
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Affiliation(s)
- Mu Li
- Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Boston, MA, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | | | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Olga Kozyreva
- Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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Crocker AB, Vega EA, Kutlu OC, Salehi O, Mellado S, Li M, Kozyreva O, Conrad C. Is minimally invasive surgery for large gastric GIST actually safe? A comparative analysis of short- and long-term outcomes. Surg Endosc 2022; 36:6975-6983. [PMID: 35312847 DOI: 10.1007/s00464-022-09066-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 01/17/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION While minimally invasive surgery (MIS) is frequently utilized to remove small gastric gastrointestinal stromal tumors (GIST), MIS surgery for tumors ≥ 5 cm is currently not endorsed by national guidelines as standard of care due to concerns of safety and inferior oncologic outcomes. Hence this study investigates the perioperative and long-term outcomes of MIS for T3 gastric GIST measuring 5-10 cm. METHODS The National Cancer Database (NCDB) 2017 was queried for gastric GIST measuring 5-10 cm or T3 category. Inclusion criteria were known: stage, size, comorbidities, grade, lymphovascular invasion, type of surgery, approach, conversion info, margin status, mitotic rate, neoadjuvant and adjuvant treatment, hospital stay, readmission, 30- and 90-day mortality, complete follow-up, type of institution, and hospital gastric surgery case volume. Binary logistic regression, linear regression models, and Kaplan-Meier survival analysis were used. RESULTS In 3765 patients, mean tumor size was 67.3 mm; 26.3% MIS; and 73.8% open. Median hospital stay was shorter for MIS (4.77 vs 7.04 days, p < 0.001). There was no significant difference in incidence of R1 margins [2.9% MIS vs. 3.1% open (p = 0.143)], unplanned readmission [2.9% MIS and 4.1% open (OR 0.474 p = 0.025)], 30-day mortality [0.5% MIS vs 1.2% open (OR 0.325, p = 0.031)], and 90-day mortality [0.9% MIS vs 2.1% open (OR 0.478 p = 0.036)]. Cox regression models for OS showed no difference in survival (p = 0.137, HR 0.808). CONCLUSION This analysis provides substantial evidence that MIS for gastric GIST ≥ 5-10 cm may not only offer improved postoperative morbidity but also oncologic safety. Moreover, as both approaches lead to similar long-term survival, national guidelines may need to incorporate this new information.
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Affiliation(s)
- Andrew B Crocker
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA
| | - Onur C Kutlu
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA
| | - Sebastian Mellado
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA
| | - Mu Li
- Department of Medical Oncology, Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Harvard School of Medicine, Boston, MA, USA
| | - Olga Kozyreva
- Department of Medical Oncology, Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Harvard School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA.
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Mellado S, Vega EA, Abudalou M, Kutlu OC, Salehi O, Li M, Kozyreva O, Freeman R, Conrad C. Trends in Preoperative Chemotherapy Utilization for Proximal Pancreatic Cancer: Are We Making Progress? J Gastrointest Surg 2022; 26:1-7. [PMID: 35508681 DOI: 10.1007/s11605-022-05336-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/16/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND While it has been shown that neoadjuvant chemotherapy (NCT) for pancreatic cancer (PDAC) undergoing pancreaticoduodenectomy (PD) is critical for optimal oncologic management, NCT is (A) not universally practiced and (B) the reasons ill-defined. This study investigates national rates, trends, and factors affecting NCT utilization. PATIENTS AND METHODS Using the National Cancer Database, patients who underwent PD for PDAC between 2006 and 2017 were identified. Changes in chemotherapy sequence over time were identified. For patients diagnosed after 2010, multivariable logistic regression models for factors affecting NCT were created. RESULTS A total of 128,980 patients were diagnosed and 23,206 underwent surgery. Three thousand five (12.9%) received NCT with a preoperative chemotherapy (NCT + PCT) utilization rate of 7.3% in 2004 that increased to 36.8% in 2017. Factors affecting utilization of preoperative chemotherapy were age (OR 0.972), academic and integrated network institutions (OR 1.916, OR 1.559), institutional case volume (OR 1.007), distance from the hospital (OR 1.002), stage (IB OR 3.108, IIA OR 3.133, IIB OR 3.775, III OR 3.782), grade IV (OR 1.977), and insurance status (private OR 2.371, Medicaid OR 1.811, and Medicare OR 2.191, government OR 2.645). CONCLUSION Even though more than 3/5 of patients receive no preoperative chemotherapy (NCT + PCT) and nearly 1/5 of patients still receive no chemotherapy at all, utilization of NCT is increasing. Moreover, since this study demonstrates that omission of NCT is associated with modifiable factors such as type of institution and health care disparity, mechanisms (reimbursement, policy) geared to change current national practice patterns may most immediately affect optimal oncologic management.
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Affiliation(s)
- Sebastián Mellado
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Mohammad Abudalou
- Department of Medicine, St. Elizabeth's Medical Center and Department of Medical Oncology, Boston, MA, USA
| | - Onur C Kutlu
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Mu Li
- Dana-Farber Cancer Institute, Harvard School of Medicine, Boston, MA, USA
| | - Olga Kozyreva
- Dana-Farber Cancer Institute, Harvard School of Medicine, Boston, MA, USA
| | - Richard Freeman
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.
- Hepato-Pancreato-Biliary Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA.
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30
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Salehi O, Vega EA, Kutlu OC, Lunsford K, Freeman R, Ladin K, Alarcon SV, Kazakova V, Conrad C. Poorly differentiated hepatocellular carcinoma: resection is equivalent to transplantation in patients with low liver fibrosis. HPB (Oxford) 2022; 24:1100-1109. [PMID: 34969618 DOI: 10.1016/j.hpb.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 11/28/2021] [Accepted: 12/08/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Organ allocation criteria for liver transplantation focus on tumor size and multifocality while tumor differentiation and existing liver damage are omitted. This study analyzes the impact of hepatocellular carcinoma (HCC) grade and liver fibrosis comparing resection (SX) to transplantation (LT). METHODS The National Cancer Database was queried between 2004 and 2016 for solitary HCC meeting Milan criteria undergoing SX vs LT. Two groups were created: low fibrosis (LF) vs high fibrosis (HF) and stratified by grade. Cox multivariable regression models, Kaplan-Meier survival analyses and log-rank tests were performed. RESULTS 1515 patients were identified; 780 had LT and 735 had SX. Median overall survival (mOS) was 39.7 months; LT mOS was 47.9 months vs SX mOS of 34.9 months (P < .001). Multivariate analysis revealed SX, no chemotherapy, longer hospital stays, and age to be associated with worse survival. However, while transplantation conferred survival benefit for well-moderately differentiated tumors, SX vs LT did not impact survival for poorly differentiated HCC in LF patients, independent of tumor size. DISCUSSION HCC differentiation and liver fibrosis, but not size, synergistically determine efficacy of SX vs LT. Therefore, current HCC transplantation criteria should incorporate tumor grade or liver fibrosis for optimal organ allocation.
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Affiliation(s)
- Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Onur C Kutlu
- Department of Surgery, University of Miami Health System, Miller School of Medicine, Miami, FL, USA
| | - Keri Lunsford
- Department of Surgery, Division of Transplant and Hepatobiliary Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Richard Freeman
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Keren Ladin
- Department of Occupational Therapy and Community Health, Tufts University, Boston, MA, USA
| | - Sylvia V Alarcon
- Department of Medical Oncology, Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Harvard Medical School, Boston, MA, USA
| | - Vera Kazakova
- Department of Medical Oncology, Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Harvard Medical School, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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31
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Salehi O, Vega EA, Mellado S, Core MJ, Li M, Kozyreva O, Kutlu OC, Freeman R, Conrad C. High-Quality Surgery for Gallbladder Carcinoma: Rare, Associated with Disparity, and Not Substitutable by Chemotherapy. J Gastrointest Surg 2022; 26:1241-1251. [PMID: 35396641 DOI: 10.1007/s11605-022-05290-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 02/26/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Oncologic surgery for T1b-T3 gallbladder carcinoma (GBC) consists of gallbladder fossa resection or bisegmentectomy IVb/V with negative margins and portal/retropancreatic lymphadenectomy. Frequency of high quality oncologic surgery, factors associated with its use, and the ability of chemotherapy to rescue low-quality surgery (LQS) remain unknown. METHODS The NCDB was queried for patients diagnosed with stage I-III (T1b-T3) GBC undergoing curative-intent surgery from 2004 to 2016. These patients were divided into two groups based on receiving high quality surgery (HQS) or not; HQS was defined as cholecystectomy with partial hepatectomy, lymph node harvest ≥ 6, and negative margins. Logistic regression and Kaplan-Meier survival analyses were performed. RESULTS A total of 3796 patients met inclusion criteria; only 364 (9.6%) met HQS criteria, and 3432 (90.4%) did not achieve HQS and were deemed low-quality surgery (LQS). HQS was associated with improved median overall survival (55.1 vs. 25.5 months, P < .001). Adjuvant chemotherapy (AC) was not able to rescue LQS with poorer survival compared to HQS without AC (27.9 vs 55.1 months, P < .001). Factors associated with HQS included private insurance (OR 1.809, P < .001), higher income (OR 1.380, P = .038), urban/rural residence (vs metropolitan) (OR 1.641, P = .001), higher education (OR 1.342, P = .031), Medicaid expansion states (OR 1.405, P = .005), stage 3 GBC (OR 1.642, P = .020), and reresection (OR 2.685, P < .001). Factors associated with LQS included older age (OR 0.974, P < .001), comorbidities (OR 0.701, P = .004), and laparoscopic approach (0.579, P < .001). Facility type incrementally improved HQS rate (integrated cancer network vs. comprehensive community, 9.8% vs. 6.1%, OR 1.694, P = .003; academic/research center vs. integrated cancer network, 14.9% vs. 9.8%, OR 1.599, P = .003). CONCLUSION While HQS for GBC strongly improves survival, it is infrequently practiced. The newly identified factors that improve survival for GBC, such as centralization, open approach, and insurance coverage, are modifiable and, therefore, should be considered to achieve optimal outcomes.
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Affiliation(s)
- Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, 11 Nevins St., Suite 201, Brighton, Boston, MA, 02135, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, 11 Nevins St., Suite 201, Brighton, Boston, MA, 02135, USA
| | | | - Michael J Core
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, 11 Nevins St., Suite 201, Brighton, Boston, MA, 02135, USA
| | - Mu Li
- Department of Medical Oncology, Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Harvard Medical School, Boston, MA, USA
| | - Olga Kozyreva
- Department of Medical Oncology, Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Harvard Medical School, Boston, MA, USA
| | - Onur C Kutlu
- Department of Surgery, University of Miami Health System, Miller School of Medicine, Miami, FL, USA
| | - Richard Freeman
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, 11 Nevins St., Suite 201, Brighton, Boston, MA, 02135, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Boston University School of Medicine, 11 Nevins St., Suite 201, Brighton, Boston, MA, 02135, USA.
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Vega EA, Salehi O, Loewenthal JV, Kutlu OC, Vellayappan U, Freeman R, Pomposelli F, Asbun HJ, Gayet B, Conrad C. Strategic response to bleeding in laparoscopic hepato-pancreato-biliary surgery: an intraoperative checklist. HPB (Oxford) 2022; 24:452-460. [PMID: 34598880 DOI: 10.1016/j.hpb.2021.08.944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/08/2021] [Accepted: 08/20/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim is to develop and test the utility of an event-initiated, team-based check list to optimize the response to bleeding during laparoscopic HPB surgery. METHODS To build a checklist for managing bleeding events, we conducted a systematic review. Using nominal group technique (NGT), a checklist consisting of four domains was developed. Following team-based training of anesthesia and surgical staff, the checklist was implemented. HPB cases before and after implementation of the checklist were compared for adverse outcomes, bleeding complications, and transfusions. RESULTS NGT identified four domains: Communicate Control, Expose, and Repair under which the checklist was organized. Supplemental Video for a detailed review of how each domain was applied to a specific case example. We compared 169 HPB cases before to 53 cases after implementation. We found a significant decrease in mean EBL (from 518 ± 852.8 to 151.5 ± 221.7 ml (P = 0.001)) for cases performed after implementation of the checklist and a trends toward less volume of pRBC transfused (2.7 ± 2.5 vs 2.3 ± 1.7 units/per patient, P = 0.611) and transfusion rates (22% vs 11%, P = 0.703). CONCLUSION An event-initiated, team-based response to an adverse bleeding event during laparoscopic HPB surgery correlates with positive effects on bleeding management, and transfusion rates.
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Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, United States
| | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, United States
| | - Julia V Loewenthal
- Division of Aging, Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, MA, United States
| | - Onur C Kutlu
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, United States
| | - Usha Vellayappan
- Department of Anesthesia, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, United States
| | - Richard Freeman
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, United States
| | - Frank Pomposelli
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, United States
| | - Horacio J Asbun
- Division of Hepatobiliary and Pancreas Surgery, Miami Cancer Institute, Miami, FL, United States
| | - Brice Gayet
- Department of Digestive Oncologic and Metabolic Surgery, Institute Mutualiste Montsouris, Université Paris Descartes, Paris, France
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, United States.
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Vega EA, Mellado S, Salehi O, Freeman R, Conrad C. Treatment of Resectable Gallbladder Cancer. Cancers (Basel) 2022; 14:1413. [PMID: 35326566 PMCID: PMC8945892 DOI: 10.3390/cancers14061413] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/18/2022] [Accepted: 03/06/2022] [Indexed: 02/04/2023] Open
Abstract
Gallbladder cancer (GBC) is the most common biliary tract cancer worldwide and its incidence has significant geographic variation. A unique combination of predisposing factors includes genetic predisposition, geographic distribution, female gender, chronic inflammation, and congenital developmental abnormalities. Today, incidental GBC is the most common presentation of resectable gallbladder cancer, and surgery (minimally invasive or open) remains the only curative treatment available. Encouragingly, there is an important emerging role for systemic treatment for patients who have R1 resection or present with stage III-IV. In this article, we describe the pathogenesis, surgical and systemic treatment, and prognosis.
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Affiliation(s)
- Eduardo A. Vega
- Department of Surgery, St. Elizabeth’s Medical Center, Boston University School of Medicine, Boston, MA 02135, USA; (E.A.V.); (O.S.); (R.F.)
| | | | - Omid Salehi
- Department of Surgery, St. Elizabeth’s Medical Center, Boston University School of Medicine, Boston, MA 02135, USA; (E.A.V.); (O.S.); (R.F.)
| | - Richard Freeman
- Department of Surgery, St. Elizabeth’s Medical Center, Boston University School of Medicine, Boston, MA 02135, USA; (E.A.V.); (O.S.); (R.F.)
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth’s Medical Center, Boston University School of Medicine, Boston, MA 02135, USA; (E.A.V.); (O.S.); (R.F.)
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Panettieri E, Maki H, Kim BJ, Kang HC, Cox V, Vega EA, Mizuno T, Pant S, Javle M, Vauthey JN, Kawaguchi Y. Arterial enhancement pattern predicts survival in patients with resectable and unresectable intrahepatic cholangiocarcinoma. Surg Oncol 2022; 40:101696. [PMID: 34995974 PMCID: PMC8863406 DOI: 10.1016/j.suronc.2021.101696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 12/21/2021] [Accepted: 12/28/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND In patients undergoing resection of intrahepatic cholangiocarcinoma (ICC), hypervascularity during the arterial phase of contrast-enhanced computed tomography (CT) is associated with better prognosis than hypovascularity. However, the prognostic implications of arterial enhancement pattern in patients with unresectable ICC are unknown. We assessed the prognostic implications of arterial enhancement pattern in patients with resectable and unresectable ICC. METHODS Consecutive patients who underwent surgery or gemcitabine-plus-cisplatin chemotherapy for ICC during 2003-2015 and CT with dynamic enhancement for diagnosis were included. After review by 2 radiologists, tumors were categorized according to the percentage of the tumor exhibiting arterial enhancement as hypervascular (>50% of tumor exhibiting enhancement), peripherally enhancing (10%-50%), and hypovascular (<10%). In each cohort (surgical and medical), overall survival (OS) curves were generated using the Kaplan-Meier method, and differences between curves were evaluated with Cox analysis. RESULTS The study included 56 patients treated surgically and 89 patients with unresectable ICC. Mean (standard deviation) tumor density in the hypervascular, peripherally enhancing, and hypovascular groups was 119.3 (45.2) Hounsfield units (HU), 72.1 (15.9) HU, and 59.9 (14.4) HU, respectively, in the surgical cohort and 93.6 (17.5) HU, 66.6 (16.2) HU, and 48.7 (14.3) HU, respectively, in the medical cohort. In both cohorts, the 5-year OS rate was significantly higher in the hypervascular group than in the hypovascular group (surgical, 67.6% vs 22.5%, P = .038; medical, 15.4% vs 0%, P = .030). In both cohorts, a Cox proportional hazards model analysis showed that hypervascularity was significantly associated with better OS. CONCLUSION Hypervascularity during the arterial CT phase is a prognostic biomarker in patients undergoing ICC resection and patients with unresectable ICC.
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Affiliation(s)
- Elena Panettieri
- Department of Surgical Oncology, The University of Texas MD
Anderson Cancer Center, Houston, Texas, USA
| | - Harufumi Maki
- Department of Surgical Oncology, The University of Texas MD
Anderson Cancer Center, Houston, Texas, USA
| | - Bradford J. Kim
- Department of Surgical Oncology, The University of Texas MD
Anderson Cancer Center, Houston, Texas, USA
| | - HyunSeon Christine Kang
- Department of Abdominal Imaging, The University of Texas MD
Anderson Cancer Center, Houston, Texas, USA
| | - Veronica Cox
- Department of Abdominal Imaging, The University of Texas MD
Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo A. Vega
- Department of Surgical Oncology, The University of Texas MD
Anderson Cancer Center, Houston, Texas, USA
| | - Takashi Mizuno
- Department of Surgical Oncology, The University of Texas MD
Anderson Cancer Center, Houston, Texas, USA
| | - Shubham Pant
- Department of Investigational Cancer Therapeutics, The
University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Milind Javle
- Department of Gastrointestinal Medical Oncology, The
University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD
Anderson Cancer Center, Houston, Texas, USA
| | - Yoshikuni Kawaguchi
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Abudalou M, Vega EA, Kondratiev S, Conrad C, Kozyreva O. Complete Pathological Response to Neoadjuvant Chemoimmunotherapy in a Patient With Metastatic Intrahepatic Cholangiocarcinoma With High Tumor Mutational Burden. Cureus 2021; 13:e20187. [PMID: 35004010 PMCID: PMC8727323 DOI: 10.7759/cureus.20187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2021] [Indexed: 11/09/2022] Open
Abstract
Intrahepatic cholangiocarcinoma (ICC) is an aggressive biliary tract cancer (BTC) with distinct anatomic, molecular, and clinical characteristics. Over the last 10-20 years, ICC has become the focus of increasing concern largely due to its rising incidence and high mortality rates in various parts of the world, including the United States. Surgery is the only potentially curative treatment option for ICC; however, recurrence rate is high, and prognosis is poor in patients with recurrent disease. The chemotherapy regimen of gemcitabine-cisplatin (GemCis) is still the standard of care for patients with unresectable metastatic ICC. There is limited data regarding pathologic ICC response to palliatively intentioned systemic treatment. Here, we report a case of a 47-year-old Caucasian male with metastatic ICC microsatellite stable (MSS) and TMB 49 mutation per megabase who achieved complete pathological response with sequential GemCis/nab-paclitaxel and pembrolizumab. This case highlights the effect of sequential neoadjuvant chemoimmunotherapy in a patient with high tumor mutational burden (TMB-H) ICC, emphasizing the importance of molecular testing, which provides valuable information that can be used in clinical practice to better select targeted chemotherapy regimens.
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Salehi O, Kazakova V, Vega EA, Kutlu OC, Alarcon SV, Freeman R, Kozyreva O, Conrad C. Selection criteria for minimally invasive resection of intrahepatic cholangiocarcinoma-a word of caution: a propensity score matched analysis using the national cancer database. Surg Endosc 2021; 36:5382-5391. [PMID: 34750709 DOI: 10.1007/s00464-021-08842-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/21/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND While minimally invasive liver resection (MILR) vs. open approach (OLR) has been shown to be safe, the perioperative and oncologic safety for intrahepatic cholangiocarcinoma (ICC) specifically, necessitating often complex hepatectomy and extended lymphadenectomy, remains ill-defined. METHODS The National Cancer Database was queried for patients with ICC undergoing liver resection from 2010 to 2016. After 1:1 Propensity Score Matching (PSM), Kruskal-Wallis and χ2 tests were applied to compare short-term outcomes. Kaplan-Meier survival analyses and Cox multivariable regression were performed. RESULTS 988 patients met inclusion criteria: 140 (14.2%) MILR and 848 (85.8%) OLR resulting in 115 patients MILR and OLR after 1:1 PSM with c-index of 0.733. MILR had lower unplanned 30-day readmission [OR 0.075, P = 0.014] and positive margin rates [OR 0.361, P = 0.011] and shorter hospital length of stay (LOS) [OR 0.941, P = 0.026], but worse lymph node yield [1.52 vs 2.07, P = 0.001]. No difference was found for 30/90-day mortality. Moreover, multivariate analysis revealed that MILR was associated with poorer overall survival compared to OLR [HR 2.454, P = 0.001]. Subgroup analysis revealed that survival differences from approach were dependent on major hepatectomy, tumor size > 4 cm, or negative margins. CONCLUSION MILR vs. OLR is associated with worse lymphadenectomy and survival in patients with ICC greater than 4 cm requiring major hepatectomy. Hence, MILR major hepatectomy for ICC should only be approached selectively and if surgeons are able to perform an appropriate lymphadenectomy.
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Affiliation(s)
- Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA.,Department of Surgery, Miller School of Medicine, University of Miami Health System, Miami, FL, USA
| | - Vera Kazakova
- Department of Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.,Department of Surgery, Miller School of Medicine, University of Miami Health System, Miami, FL, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA.,Department of Surgery, Miller School of Medicine, University of Miami Health System, Miami, FL, USA
| | - Onur C Kutlu
- Department of Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.,Department of Surgery, Miller School of Medicine, University of Miami Health System, Miami, FL, USA
| | - Sylvia V Alarcon
- Department of Surgery, Miller School of Medicine, University of Miami Health System, Miami, FL, USA.,Department of Medical Oncology, Harvard Medical School, Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Boston, MA, USA
| | - Richard Freeman
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA.,Department of Surgery, Miller School of Medicine, University of Miami Health System, Miami, FL, USA
| | - Olga Kozyreva
- Department of Surgery, Miller School of Medicine, University of Miami Health System, Miami, FL, USA.,Department of Medical Oncology, Harvard Medical School, Dana-Farber Cancer Institute at St. Elizabeth's Medical Center, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA. .,Department of Surgery, Miller School of Medicine, University of Miami Health System, Miami, FL, USA.
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Salehi O, Vega EA, Lathan C, James D, Kozyreva O, Alarcon SV, Kutlu OC, Herrick B, Conrad C. Race, Age, Gender, and Insurance Status: A Comparative Analysis of Access to and Quality of Gastrointestinal Cancer Care. J Gastrointest Surg 2021; 25:2152-2162. [PMID: 34027580 DOI: 10.1007/s11605-021-05038-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/07/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Socioeconomics, demographics, and insurance status play roles in healthcare access. Considering the limited resources available, understanding the relative impact of disparities helps prioritize programs designed to overcome them. This study evaluates gastrointestinal cancer care disparity by comparing the impact of different patient factors across oncologic care metrices. METHODS A multi-institutional prospectively maintained cancer database was reviewed retrospectively for gastrointestinal cancers (esophagus, stomach, liver, pancreas, colorectal, and hepato-pancreato-biliary) from 2007 to 2017 to assess quality of care provided. Quality of care was defined by clinical course following national guidelines for the respective cancer. This included surgical intervention, chemotherapy, palliative care, and minimal delay to treatment/diagnosis. Logistic regression was used to adjust for confounders and identify factors associated with quality of care. Kaplan-Meier survival curves were compared using log-rank test. RESULTS One thousand seventy-two patients were identified. Survival improved in patients with private insurance compared to government-funded options [median overall survival (mOS) 57.8 vs. 21.2 months; P < .001]. Private insurance also correlated with earlier stage at diagnosis [stages I-II = 50.9% vs. 37.5%, stages III-IV = 37.7% vs. 49.1%, P < .001], increased chemotherapy use [44.2% vs. 37.1%, P < .001], and more surgical intervention [62.4% vs. 48.8%, P < .001]. Outcomes were inferior for Black Americans, including trend towards lower rate of surgical treatment [42% vs. 54%, P = .058] and worse survival in private insurance carriers [mOS 7.8 vs. 57.8 months, P = .021] and those with early stage disease [mOS 39.2 vs. 81.5 months, P = .045] compared to White counterparts. CONCLUSIONS Insurance status has the strongest impact on the quality of gastrointestinal oncologic care with negative synergistic negative effect of race for Black Americans. While governmental programs aim to improve equality of care, there remains significant disparity compared to private insurance. Moreover, private insurance doesn't correct disparity for Black Americans, suggesting the need to address racial imbalances in cancer care.
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Affiliation(s)
- Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA
| | - Christopher Lathan
- Dana Farber Cancer Institute, Harvard School of Medicine, Boston, MA, USA
| | - Daria James
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA
| | - Olga Kozyreva
- Dana Farber Cancer Institute, Harvard School of Medicine, Boston, MA, USA
| | - Sylvia V Alarcon
- Dana Farber Cancer Institute, Harvard School of Medicine, Boston, MA, USA
| | - Onur C Kutlu
- Department of Surgery, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Beth Herrick
- Department of Radiation Oncology, St. Elizabeth's Medical Center, & University of Massachusetts School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, 11 Nevins St., Suite 201, Brighton, MA, 02135, USA.
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Abudalou M, Malkowski M, Robles MR, Vega EA, Slama MCC. A Rare Presentation of a Rare Disease: Oropharyngeal Dysphagia as The Main Manifestation of Myasthenia Gravis. Cureus 2021; 13:e16880. [PMID: 34513455 PMCID: PMC8411993 DOI: 10.7759/cureus.16880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2021] [Indexed: 12/02/2022] Open
Abstract
Oropharyngeal dysphagia is defined as the inability or difficulty to initiate swallowing. It has a wide array of etiologies including structural and neurologic diseases. Myasthenia gravis (MG) is a rare autoimmune condition caused by antibodies against the post-synaptic membranes of the neuromuscular junction, leading to fatigable weakness of skeletal muscles. Bulbar symptoms are less prevalent than ocular symptoms or limb weakness but can be particularly morbid. Non-neurologists are more likely to be the first providers to evaluate patients with dysphagia and should be familiar with MG. We report a unique case of newly diagnosed MG with the initial presentation of solid food and liquid dysphagia.
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Affiliation(s)
- Mohammad Abudalou
- Internal Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, USA
| | - Michael Malkowski
- Internal Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, USA
| | - Marcel R Robles
- Internal Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, USA
| | - Eduardo A Vega
- Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, USA
| | - Michael C C Slama
- Neurology, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, USA
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Abstract
A 74-year-old man with medical history significant for atrial fibrillation, hyperlipidaemia and coronary artery disease on atorvastatin presented to the emergency department with profound weakness. The patient reports he first noticed his weakness 4 weeks after starting colchicine, prescribed for recurrent pericarditis with pericardial effusion, a complication following recent coronary artery bypass grafting. The patient was also on prednisone therapy for presumed post-pericardiotomy syndrome. The weakness involved all four limbs but was more notable in the lower extremities, with preserved sensation and tenderness to palpation. Labs showed an elevated creatinine phosphokinase and serum creatinine consistent with rhabdomyolysis. Discontinuation of the offending medications, including colchicine and atorvastatin, as well as intravenous fluid resuscitation with physical rehabilitation, led to improvement in the patient's symptoms. He was eventually discharged to a rehabilitation facility to continue physical therapy.
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Affiliation(s)
- Mohammad Abudalou
- Medicine, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Ahmed S Mohamed
- Medicine, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Eduardo A Vega
- Surgery, St Elizabeth's Medical Center, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Ali Al Sbihi
- Internal Medicine, Wayne State University, Detroit, Michigan, USA .,Internal Medicine, Sinai Grace Hospital, Detroit, Michigan, USA
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Salehi O, Vega EA, Kutlu OC, Conrad C. ASO Visual Abstract: Does a Laparoscopic Approach to Distal Pancreatectomy for Cancer Contribute to Optimal Adjuvant Chemotherapy Utilization? Ann Surg Oncol 2021. [PMID: 34275049 DOI: 10.1245/s10434-021-10413-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Onur C Kutlu
- Department of Surgery, University of Miami Health System, Miller School of Medicine, Miami, FL, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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Vega EA, Newhook TE, Vauthey JN. ASO Visual Abstract: Conditional Recurrence-Free Survival After Oncologic Extended Resection for Gallbladder Cancer-An International Multicenter Analysis. Ann Surg Oncol 2021. [PMID: 33939047 DOI: 10.1245/s10434-021-09922-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.,Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Salehi O, Vega EA, Kutlu OC, Conrad C. ASO AUTHOR REFLECTIONS: Laparoscopic Distal Pancreatectomy for Pancreatic Cancer: Good, Bad, or Even Ugly? Ann Surg Oncol 2021; 28:8281-8282. [PMID: 34169382 DOI: 10.1245/s10434-021-10332-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 06/08/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Onur C Kutlu
- Department of Surgery, University of Miami Health System, Miller School of Medicine, Miami, FL, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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Salehi O, Vega EA, Kutlu OC, Krishnan S, Sleeman D, De La Cruz Munoz N, Alarcon SV, Kazakova V, Kozyreva O, Conrad C. Does a Laparoscopic Approach to Distal Pancreatectomy for Cancer Contribute to Optimal Adjuvant Chemotherapy Utilization? Ann Surg Oncol 2021; 28:8273-8280. [PMID: 34125349 DOI: 10.1245/s10434-021-10241-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 05/17/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although laparoscopic distal pancreatectomy (LDP) versus open approaches (ODP) for pancreatic adenocarcinoma (PDAC) is associated with reduced morbidity, its impact on optimal adjuvant chemotherapy (AC) utilization remains unclear. Furthermore, it is uncertain whether oncologic resection quality markers are equivalent between approaches. METHODS The National Cancer Database (NCDB) was queried between 2010 and 2016 for PDAC patients undergoing DP. Effect of LDP vs ODP and institutional case volumes on margin status, hospital stay, 30-day and 90-day mortality, administration of and delay to AC, and 30-day unplanned readmission were analyzed using binary and linear logistic regression. Cox multivariable regression was used to correct for confounders. RESULTS The search yielded 3411 patients; 996 (29.2%) had LDP and 2415 (70.8%) had ODP. ODP had higher odds of readmission [odds ratio (OR) 1.681, p = 0.01] and longer hospital stay [β 1.745, p = 0.004]. No difference was found for 30-day mortality [OR 1.689, p = 0.303], 90-day mortality [OR 1.936, p = 0.207], and overall survival [HR 1.231, p = 0.057]. The highest-volume centers had improved odds of AC [OR 1.275, p = 0.027] regardless of approach. LDP conferred lower margin positivity [OR 0.581, p = 0.005], increased AC use [3rd quartile: OR 1.844, p = 0.026; 4th quartile; OR 2.144, p = 0.045], and fewer AC delays [4th quartile: OR 0.786, p = 0.045] in higher-volume centers. CONCLUSIONS In selected patients, LDP offers an oncologically safe alternative to ODP for PDAC independent of institutional volume. However, additional oncologic benefit due to optimal AC utilization and lower positive margin rates in higher volume centers suggests that LDP by experienced teams can achieve best possible cancer outcomes.
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Affiliation(s)
- Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Onur C Kutlu
- Department of Surgery, University of Miami Health System, Miller School of Medicine, Miami, FL, USA
| | - Sandeep Krishnan
- Department of Gastroenterology, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Danny Sleeman
- Department of Surgery, University of Miami Health System, Miller School of Medicine, Miami, FL, USA
| | - Nestor De La Cruz Munoz
- Department of Surgery, University of Miami Health System, Miller School of Medicine, Miami, FL, USA
| | - Sylvia V Alarcon
- Dana-Farber Cancer Institute, Harvard School of Medicine, Boston, MA, USA
| | - Vera Kazakova
- Department of Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Olga Kozyreva
- Dana-Farber Cancer Institute, Harvard School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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Abstract
Indocyanine green (ICG) is a fluorescent iodide-based dye which is used in hepatic surgery to evaluate the biliary tree, liver perfusion, and function. While liver perfusion assessment and delineation of anatomic regions has been performed using ultrasound, ischemic demarcation, or indigo carmine/methylene blue staining, ICG staining can overcome limitations associated with these techniques, such as rapid washout, lack of precision, non-demarcation in damaged livers, and lack of intraparenchymal fidelity. ICG can be used to fluoresce target segments/tumors (Positive staining) or counterstain normal liver tissue leaving areas of interest unstained (negative staining). Moreover, ICG enhancement patterns vary for different tumors, such as colorectal liver metastases vs. hepatocellular carcinoma, providing not only help with detection but also assessment of differentiation. In the field of oncology, benefits of ICG include detection of small radiographically occult tumors, distinction between cirrhotic nodules and cancer, identification of necrotic tumors in chemotherapy-damaged livers, and determining margins when intraoperative ultrasound is inadequate. While ICG has important and expanding indications in hepatic surgery, limitations include small depth of penetrance, need for special monitors/equipment, and potential for dye spillage. ICG is well tolerated, has a small learning curve, minimally invasive surgical integration, and options of both portal vein and peripheral vein injection and hence is a safe and versatile method of anatomic liver mapping, tumor visualization, and liver graft perfusion evaluation in oncologic surgery and liver transplantation. Advancements in technique and technology associated with ICG will aid in increasing the indications in hepato-biliary surgery.
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Affiliation(s)
- Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Vera Kazakova
- Department of Medicine, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA -
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Vega EA, Salehi O, Conrad C. ASO Visual Abstract: Failure to Cure Patients with Colorectal Liver Metastases-The Impact of the Liver Surgeon. Ann Surg Oncol 2021. [PMID: 34057570 DOI: 10.1245/s10434-021-10184-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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Vega EA, Freeman R, Conrad C. Do We Still Need Liver Surgeons in the Treatment of Colorectal Liver Metastases? Ann Surg Oncol 2021; 28:7707-7708. [PMID: 34009513 DOI: 10.1245/s10434-021-10139-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 11/18/2022]
Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Richard Freeman
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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Vega EA, Salehi O, Nicolaescu D, Dussom EM, Alarcon SV, Kozyreva O, Simonds J, Schnipper D, Conrad C. Correction to: Failure to Cure Patients with Colorectal Liver Metastases: The Impact of the Liver Surgeon. Ann Surg Oncol 2021; 28:879. [PMID: 34003390 DOI: 10.1245/s10434-021-10185-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Diana Nicolaescu
- IOSUD Titu Maiorescu University of Bucharest, Medical Doctoral School, Tulcea Emergency Hospital, Bucharest, Romania
| | - Edward-Michael Dussom
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Sylvia V Alarcon
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Olga Kozyreva
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Jana Simonds
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Deborah Schnipper
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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Vega EA, Salehi O, Nicolaescu D, Dussom EM, Alarcon SV, Kozyreva O, Simonds J, Schnipper D, Conrad C. Failure to Cure Patients with Colorectal Liver Metastases: The Impact of the Liver Surgeon. Ann Surg Oncol 2021; 28:7698-7706. [PMID: 33939045 DOI: 10.1245/s10434-021-10030-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 03/27/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Lack of a liver surgeon (LS) may lead to failure to cure in patients with possibly resectable colorectal liver metastases (CRLM). This study aims to quantify the failure-to-cure rate due to noninclusion of an LS. PATIENTS AND METHODS All patients who underwent chemotherapy with palliative intent for CRLM at a community oncology network between 2010 and 2018 were identified from a prospectively maintained cancer registry. Two LS blinded to patient management and outcome reviewed pretreatment imaging and assigned each scan a newly developed resectability score. Nominal group technique and independent scores were combined to determine probability of curative-intent resection. Interobserver agreement was calculated using κ testing. RESULTS This study included 72 palliative CRLM patients. Demographic factors were: 44 (59%) male, median age 68 years (range 36-94 years), 23 (32%) rectal primary, 24 (33%) receiving oxaliplatin-based chemotherapy. Of the 72 patients with CRLM, 6 had left-sided metastases only. The median number of CRLM was 6 (1-8). Agreement on resectability was achieved in 32 (44%) patients for the entire cohort and 17 (54%) in patients without extrahepatic disease. A lower median number of CRLM was found in the group considered to be resectable by the two LS (2 versus 8; p = 0.001). Substantial agreement was found between liver surgeons in the group of patients without extrahepatic disease (κ = 0.9043). CONCLUSIONS Over 44% of patients who were assigned palliative chemotherapy at tumor boards without an LS were considered potentially resectable upon independent LS review.
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Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Omid Salehi
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Diana Nicolaescu
- IOSUD Titu Maiorescu University of Bucharest, Medical Doctoral School, Tulcea Emergency Hospital, Bucharest, Romania
| | - Edward-Michael Dussom
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Sylvia V Alarcon
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Olga Kozyreva
- Dana Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Jana Simonds
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Deborah Schnipper
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Claudius Conrad
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.
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Vega EA, Newhook TE, Vauthey JN. ASO Author Reflections: Gallbladder Cancer Research, "One for All and All for One" Strategy to Improve Research. Ann Surg Oncol 2021; 28:2683-2684. [PMID: 33718976 PMCID: PMC7955947 DOI: 10.1245/s10434-021-09628-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 12/30/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Eduardo A Vega
- Department of Surgery, St. Elizabeth's Medical Center, Tufts University School of Medicine, Boston, MA, USA.,Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Timothy E Newhook
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Abudalou M, Vega EA, Dhingra R, Holzwanger E, Krishnan S, Kondratiev S, Niakosari A, Conrad C, Stallwood CG. Solid pseudopapillary neoplasm-diagnostic approach and post-surgical follow up: Three case reports and review of literature. World J Clin Cases 2021; 9:1682-1695. [PMID: 33728313 PMCID: PMC7942041 DOI: 10.12998/wjcc.v9.i7.1682] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 11/23/2020] [Accepted: 01/23/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Solid pseudopapillary neoplasm (SPN) is a rare tumor that was first described by Frantz in 1959. Although this tumor is benign, some may have malignant potential that can be predicted based on demographics, imaging characteristics, and pathologic evaluation. This case series presents 3 SPN cases with discussion on gender differences, preoperative predictors of malignancy, and a suggested algorithm for diagnostic approach as well as post-surgical follow up.
CASE SUMMARY Three adult patients in a tertiary hospital found to have SPN, one elderly male and two young females. Each of the cases presented with abdominal pain and were discovered incidentally. Two cases underwent endoscopic ultrasound with fine needle aspiration and biopsy to assess tumor markers and immuno-histochemical staining (which were consistent with SPN before undergoing surgery), and one case underwent surgery directly after imaging. The average tumor size was 5 cm. Diagnosis was confirmed by histology. Two patients had post-surgical complications requiring intervention.
CONCLUSION Demographic and imaging characteristics can be sufficient to establish diagnosis for SPN, while malignant cases require pre-operative evaluation with endoscopic ultrasound fine needle aspiration/fine needle biopsy.
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Affiliation(s)
- Mohammad Abudalou
- Department of Internal Medicine, St. Elizabeth Medical Center, Brighton, MA 02135, United States
| | - Eduardo A Vega
- Department of General Surgery, St. Elizabeth Medical Center, Brighton, MA 02135, United States
| | - Rohit Dhingra
- Department of Gastroenterology, Tufts Medical Center, Boston, MA 02111, United States
| | - Erik Holzwanger
- Department of Gastroenterology, Tufts Medical Center, Boston, MA 02111, United States
| | - Sandeep Krishnan
- Department of Gastroenterology, St. Elizabeth Medical Center, Brighton, MA 02135, United States
| | - Svetlana Kondratiev
- Department of Pathology, St. Elizabeth Medical Center, Brighton, MA 02135, United States
| | - Ali Niakosari
- Department of Radiology, St. Elizabeth Medical Center, Brighton, MA 02135, United States
| | - Claudius Conrad
- Department of General Surgery, St. Elizabeth Medical Center, Brighton, MA 02135, United States
| | - Christopher G Stallwood
- Department of Gastroenterology, St. Elizabeth Medical Center, Brighton, MA 02135, United States
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