Trends in access to minimally invasive pancreaticoduodenectomy for pancreatic cancers

BACKGROUND

Minimally invasive pancreaticoduodenectomy (MIPD), including robotic (RPD) and laparoscopy (LPD), is becoming more frequently employed in the management of pancreatic ductal adenocarcinoma (PDAC), though the majority of operations are still performed via open approach (OPD). Access to technologic advances often neglect the underserved. Whether disparities in access to MIPD exist, remain unclear.

METHODS

The National Cancer Database (NCDB) was queried (2010-2020) for patients who underwent pancreatoduodenectomy for PDAC. Cochran-Armitage tests assessed for trends over time. Social determinants of health (SDH) were compared between approaches. Multinomial logistic models identified predictors of MIPD.

RESULTS

Of 16,468 patients, 80.03 % underwent OPD and 19.97 % underwent MIPD (22.60 % robotic; 77.40 % laparoscopic). Black race negatively predicted LPD (vs white (OR 0.822; 95 % CI 0.701-0.964)). Predictors of RPD included Medicare/other government insurance (vs uninsured or Medicaid (OR 1.660; 95 % CI 1.123-2.454)) and private insurance (vs uninsured or Medicaid (OR 1.597; 95 % CI 1.090-2.340)). Early (2010-2014) vs late (2015-2020) diagnosis, stratified by race, demonstrated an increase in Non-White patients undergoing OPD (13.15 % vs 14.63 %; p = 0.016), but not LPD (11.41 % vs 13.57 %;p = 0.125) or RPD (14.15 % vs 15.23 %; p = 0.774).

CONCLUSION

SDH predict surgical approach more than clinical stage, facility type, or comorbidity status. Disparities in race and insurance coverage are different between surgical approaches.

Authorship Trends and Disparities in Cardiothoracic Surgery

BACKGROUND

Previous investigations have revealed significant gender disparities in the academic arenas of cardiothoracic surgery. However, the status of gender representation in cardiothoracic publications has not been well described. This study aimed to evaluate authorship trends by gender in two high-impact cardiothoracic surgical journals.

METHODS

In this bibliometric analysis, PubMed was searched for articles published in The Annals of Thoracic Surgery and the Journal of Thoracic and Cardiovascular Surgery from 2010 to 2021. The web-based application Genderize.io was used to classify names of first and last authors as men vs women. The Cochran-Armitage trend test and multivariable logistic regression were used to evaluate authorship per year and the association of first and last author gender, respectively.

RESULTS

Among 14,443 articles, 16.7% had women first authors and 8.1% had women last authors. The proportion of articles written by women authors increased, rising from 12.6% to 21.1% (P < .0001) for first and 5.4% to 11.5% (P < .0001) for last authors. Papers written with women as first author were associated with 2.0 higher odds of having a woman as last author (95% CI, 1.7-2.3; P < .0001). The mean number of last author publications was higher for men than for women (2.4 vs 1.7, P < .0001).

CONCLUSIONS

Over the past decade, despite a welcomed increase in women authorship in high-impact journals in cardiothoracic surgery, women represent a small proportion of published authors. Women first authors are more likely to publish with women last authors, demonstrating the impact of same-gender collaborations while emphasizing a need for cross-gender mentorship.

The Evaluation of Gallstone Disease in the Year Before Pancreatic Cancer Diagnosis

INTRODUCTION

Patients with pancreatic cancer can present with a variety of insidious abdominal symptoms, complicating initial diagnosis. Early symptoms of pancreatic cancer often mirror those associated with gallstone disease, which has been demonstrated to be a risk factor for this malignancy. This study aims to compare the incidence of gallstone disease in the year before diagnosis of pancreatic ductal adenocarcinoma (PDAC) as compared to the general population, and evaluate the association of gallstone disease with stage at diagnosis and surgical intervention.

METHODS

Patients with PDAC were identified from SEER-Medicare (2008-2015). The incidence of gallstone disease (defined as cholelithiasis, cholecystitis and/or cholecystectomy) in the 1 year before cancer diagnosis was compared to the annual incidence in an age-matched, sex-matched, and race-matched noncancer Medicare cohort.

RESULTS

Among 14,654 patients with PDAC, 4.4% had gallstone disease in the year before cancer diagnosis. Among the noncancer controls (n = 14,654), 1.9% had gallstone disease. Both cohorts had similar age, sex and race distributions. PDAC patients with gallstone disease were diagnosed at an earlier stage (stage 0/I-II, 45.8% versus 38.1%, P < 0.0001) and a higher proportion underwent resection (22.7% versus 17.4%, P = 0.0004) compared to patients without gallstone disease.

CONCLUSIONS

In the year before PDAC diagnosis, patients present with gallstone disease more often than the general population. Improving follow-up care and differential diagnosis strategies may help combat the high mortality rate in PDAC by providing an opportunity for earlier stage of diagnosis and earlier intervention.

Combined High-Volume Common Complex Cancer Operations Safeguard Long-Term Survival in a Low-Volume Individual Cancer Operation Setting

BACKGROUND

We previously demonstrated the importance of combined complex surgery volume on short-term outcomes of high-risk cancer operations. This study investigates the impact of combined common complex cancer operation volume on long-term outcomes at hospitals with low cancer-specific operation volumes.

PATIENTS AND METHODS

A retrospective cohort of National Cancer Data Base (2004-2019) patients undergoing surgery for hepatocellular carcinoma, non-small cell lung cancers, or pancreatic, gastric, esophageal, or rectal adenocarcinomas was utilized. Three separate cohorts were established: low-volume hospitals (LVH), mixed-volume hospitals (MVH) with low-volume individual cancer operations and high-volume total complex operations, and high-volume hospitals (HVH). Survival analyses were performed for overall, early-, and late-stage disease.

RESULTS

The 5 year survival was significantly better at MVH and HVH compared with LVH, for all operations except late-stage hepatectomy (HVH survival > LVH and MVH). The 5 year survival probability was similar between MVH and HVH for operations on late-stage cancers. Early and overall survival for gastrectomy, esophagectomy, and proctectomy were equivalent between MVH and HVH. While early and overall survival for pancreatectomy were benefited by HVH over MVH, the opposite was true for lobectomy/pneumonectomy, which were benefited by MVH over HVH; however, none of these differences were likely to have an effect clinically. Only hepatectomy patients demonstrated statistical and clinical significance in 5 year survival at HVH compared with MVH for overall survival.

CONCLUSIONS

MVH hospitals performing sufficient complex common cancer operations demonstrate similar long-term survival for specific high-risk cancer operations to HVH. MVH provide an adjunctive model to the centralization of complex cancer surgery, while maintaining quality and access.

The impact of social risk factors on the presentation, treatment and survival of patients with hepatocellular carcinoma at an urban, academic safety-net hospital

BACKGROUND

Vulnerable populations have worse hepatocellular carcinoma (HCC) outcomes. We sought to understand if this could be mitigated at a safety-net hospital.

METHODS

A retrospective chart review of HCC patients was conducted (2007-2018). Stage at presentation, intervention and systemic therapy were analyzed (Chi-square for categorical variables and Wilcoxon tests for continuous variables) and median survival calculated by Kaplan-Meier method.

RESULTS

388 HCC patients were identified. Sociodemographic factors were similar for stage at presentation, except insurance status (diagnosis at earlier stages for commercial insurance and later stages for safety-net/no insurance). Higher education level and origin of mainland US increased intervention rates for all stages. Early-stage disease patients had no differences in receipt of intervention or therapy. Late-stage disease patients with higher education level had increased intervention rates. Median survival was not impacted by any sociodemographic factor.

CONCLUSION

Urban safety-net hospitals with a focus on vulnerable patient populations provide equitable outcomes and can serve as a model to address inequities in HCC management.

Socioeconomic Mediation of Racial Segregation in Pancreatic Cancer Treatment and Outcome Disparities

OBJECTIVE

To understand the mediating effect of socioeconomic factors on the association between residential segregation and racial disparities in pancreatic cancer (PC).

BACKGROUND

Black patients with PC present at a later stage and have worse mortality than White patients. These disparities have been explained by the level of residential segregation.

METHODS

Data were obtained from Surveillance, Epidemiology, and End-Results (SEER) and included all Black and White patients who were diagnosed with PC between 2005 and 2015. The primary exposure variable was the Index of Dissimilarity, a validated measure of segregation. County-level socioeconomic variables from the US Census were assessed as mediators. The primary outcomes were advanced stage at diagnosis, surgical resection for localized disease, and overall mortality. Generalized structural equation modeling was used to assess the mediation of each of the socioeconomic variables.

RESULTS

Black patients in the highest levels of segregation saw a 12% increased risk [relative risk=1.12; 95% confidence interval (CI): 1.08, 1.15] of presenting at an advanced stage, 11% decreased likelihood of undergoing surgery (relative risk=0.89; 95% CI: 0.83, 0.94), and 8% increased hazards of death (hazard ratio=1.08; 95% CI: 1.03, 1.14) compared with White patients in the lowest levels. The Black share of the population, insurance status, and income inequality mediated 58% of the total effect on the advanced stage. Poverty and Black income immobility mediated 51% of the total effect on surgical resection. Poverty and Black income immobility mediated 50% of the total effect on overall survival.

CONCLUSIONS

These socioeconomic factors serve as intervention points for legislators to address the social determinants inherent to the structural racism that mediate poor outcomes for Black patients.

The Persistence of Poverty and its Impact on Cancer Diagnosis, Treatment and Survival

OBJECTIVE

To determine the effect of persistent poverty on the diagnosis, surgical resection and survival of patients with non-small cell lung (NSCLC), breast, and colorectal cancer.

BACKGROUND

Disparities in cancer outcomes exist in counties with high levels of poverty, defined as ≥20% of residents below the federal poverty level. Despite this well-established association, little is known about how the duration of poverty impacts cancer care and outcomes. One measure of poverty duration is that of "persistent poverty," defined as counties in high poverty since 1980.

METHODS

In this retrospective cohort study, patients with NSCLC, breast and colorectal cancer were identified from SEER (2012-2016). County-level poverty was obtained from the American Community Survey (1980-2015). Outcomes included advanced stage at diagnosis (stage III-IV), resection of localized disease (stage I-II) and cancer-specific survival. Hierarchical generalized linear models and accelerated failure time models with Weibull distribution were used, adjusted for patient-level covariates and region.

RESULTS

Overall, 522,514 patients were identified, of which 5.1% were in persistent poverty. Patients in persistent poverty were more likely to present with advanced disease [NSCLC odds ratio (OR): 1.12, 95% confidence interval (CI): 1.06-1.18; breast OR: 1.09, 95% CI: 1.02-1.17; colorectal OR: 1.00, 95% CI: 0.94-1.06], less likely to undergo surgery (NSCLC OR: 0.81, 95% CI: 0.73-0.90; breast OR: 0.82, 95% CI: 0.72-0.94; colorectal OR: 0.84, 95% CI: 0.70-1.00) and had increased cancer-specific mortality (NSCLC HR: 1.09, 95% CI: 1.06-1.13; breast HR: 1.18, 95% CI: 1.05-1.32; colorectal HR: 1.09, 95% CI: 1.03-1.17) as compared with those without poverty. These differences were observed to a lesser magnitude in counties with current, but not persistent, poverty and disappeared in counties no longer in poverty.

CONCLUSIONS

The duration of poverty has a direct impact on cancer-specific outcomes, with the greatest effect seen in persistent poverty and resolution of disparities when a county is no longer in poverty. Policy focused on directing resources to communities in persistent poverty may represent a possible strategy to reduce disparities in cancer care and outcomes.

The role of imaging and sentinel lymph node biopsy in patients with T3b-T4b melanoma with clinically negative disease

Background

Previous studies demonstrate minimal utility of pre-operative imaging for low-risk melanoma; however, imaging may be more critical for patients with high-risk disease. Our study evaluates the impact of peri-operative cross-sectional imaging in patients with T3b-T4b melanoma.

Methods

Patients with T3b-T4b melanoma who underwent wide local excision were identified from a single institution (1/1/2005 - 12/31/2020). Cross-sectional imaging was defined as body CT, PET and/or MRI in the perioperative period, with the following findings: in-transit or nodal disease, metastatic disease, incidental cancer, or other. Propensity scores were created for the odds of undergoing pre-operative imaging. Recurrence free survival was analyzed using the Kaplan-Meier method and log-rank test.

Results

A total of 209 patients were identified with a median age of 65 (IQR 54-76), of which the majority were male (65.1%), with nodular melanoma (39.7%) and T4b disease (47.9%). Overall, 55.0% underwent pre-operative imaging. There were no differences in imaging findings between the pre- and post-operative cohorts. After propensity-score matching, there was no difference in recurrence free survival. Sentinel node biopsy was performed in 77.5% patients, with 47.5% resulting in a positive result.

Conclusion

Pre-operative cross-sectional imaging does not impact the management of patients with high-risk melanoma. Careful consideration of imaging use is critical in the management of these patients and highlights the importance of sentinel node biopsy for stratification and decision making.

Update on the Financial Well-Being of Surgical Residents in New England

BACKGROUND

Poor personal financial health has been linked to key components of health including burnout, substance abuse, and worsening personal relationships. Understanding the state of resident financial health is key to improving their overall well-being.

STUDY DESIGN

A secondary analysis of a survey of New England general surgery residents was performed to understand their financial well-being. Questions from the National Financial Capability Study were used to compare to an age-matched and regionally matched cohort.

RESULTS

Overall, 44% (250 of 570) of surveyed residents responded. Residents more frequently reported spending less than their income each year compared to the control cohort (54% vs 34%, p < 0.01). However, 17% (39 of 234) of residents reported spending more than their income each year. A total of 65% of residents (152 of 234), found it "not at all difficult" to pay monthly bills vs 17% (76 of 445) of the control cohort (p < 0.01). However, 32% (75 of 234) of residents reported it was "somewhat" or "very" difficult to pay monthly bills. Residents more frequently reported they "certainly" or "probably" could "come up with" $2,000 in a month compared to the control cohort (85% vs 62% p < 0.01), but 16% (37 of 234) of residents reported they could not. In this survey, 21% (50 of 234) of residents reported having a personal life insurance policy, 25% (59 of 234) had disability insurance, 6% (15 of 234) had a will, and 27% (63 of 234) had >$300,000 worth of student loans.

CONCLUSIONS

Surgical residents have better financial well-being than an age-matched and regionally matched cohort, but there is still a large proportion who suffer from financial difficulties.

COVID-19 Did Not Stop the Rising Tide: Trends in Case Volume Logged by Surgical Residents

INTRODUCTION

The coronavirus pandemic has profoundly impacted all facets of surgical care, including surgical residency training. The objective of this study was to assess the operative experience and overall case volume of surgery residents before and during the pandemic.

METHODS

Using data from the Accreditation Council for Graduate Medical Education annual operative log reports, operative volume for 2015 to 2021 graduates of Accreditation Council for Graduate Medical Education -accredited general, orthopedic, neuro- and plastic surgery residency programs was analyzed using nonparametric Kendall-tau correlation analysis. The period before the pandemic was defined as AY14-15 to AY18-19, and the pandemic period was defined as AY19-20 to AY20-21.

RESULTS

Operative data for 8556 general, 5113 orthopedic, 736 plastic, and 1278 neurosurgery residency graduates were included. Between 2015 and 2021, total case volume increased significantly for general surgery graduates (Kendall's tau-b: 0.905, p = 0.007), orthopedic surgery graduates (Kendall's tau-b: 1.000, p = 0.003), neurosurgery graduates (Kendall's tau-b: 0.905, p = 0.007), and plastic surgery graduates (Kendall's tau-b: 0.810, p = 0.016). Across all specialties, the mean total number of cases performed by residents graduating during the pandemic was higher than among residents graduating before the pandemic, though no formal significance testing was performed. Among general surgery residents, the number of cases performed as surgeon chief among residents graduating in AY19-20 decreased for the first time in 5 years, though the overall volume remained higher than the prior year, and returned to prepandemic trends in AY20-21.

CONCLUSIONS

Over the past 7 years, the case volume of surgical residents steadily increased. Surgical trainees who graduated during the coronavirus pandemic have equal or greater total operative experience compared to trainees who graduated prior to the pandemic.

Disparities in the Receipt of Recommended Curative Treatment for Patients with Early-Stage Hepatocellular Carcinoma

BACKGROUND

In early-stage hepatocellular carcinoma (HCC), the receipt of recommended care is critical for long-term survival. Unfortunately, not all patients decide to undergo therapy. We sought to identify factors associated with the decision to decline recommended intervention among patients with early-stage HCC.

METHODS

The National Cancer Database was queried for patients diagnosed with clinical stages I and II HCC (2004-2017). Cohorts were created based on the receipt or decline of recommended interventions-hepatectomy, liver transplantation, and ablation. Multivariable logistic regression identified predictors for declining intervention, and propensity score analysis was used to calculate the respective odds. Survival analysis was performed using the Kaplan-Meier method.

RESULTS

Of 20,863 patients, 856 (4.1%) declined intervention. Patients who were documented as having declined intervention were more often Black (vs. other: OR, 1.3; 95% CI, 1.1-1.6; p = 0.0038), had Medicaid or no insurance (vs. Private, Medicare, or other government insurance): OR, 1.9; 95% CI, 1.6-2.3; p < 0.0001), lived in a low-income area (vs. other: OR, 1.4; 95% CI, 1.2-1.7; p < 0.0001), and received treatment at a non-academic center (vs. academic: OR, 2.1; 95% CI, 1.9-2.5; p < 0.0001). Patients who declined recommended interventions had worse survival compared to those who received treatment (22.9 vs. 59.2 months; p < 0.0001, respectively).

CONCLUSIONS

Racial and socioeconomic disparities persist in the decision to undergo recommended treatment. Underutilization of treatment acts as a barrier to addressing racial and socioeconomic disparities in early-stage HCC outcomes.

Thromboprophylaxis Timing After Blunt Solid Organ Injury: A Systematic Review and Meta-analysis

INTRODUCTION

Trauma patients with blunt abdominal solid organ injuries are at high risk for venous thromboembolism (VTE), but the optimal time to safely administer chemical thromboprophylaxis is controversial, especially for patients who are managed nonoperatively due to increased risk of hemorrhage. We sought to compare failure of nonoperative management (NOM) and VTE events based on timing of chemical thromboprophylaxis initiation.

METHODS

A systematic review was conducted in PubMed and Embase databases. Studies were included if they evaluated timing of initiation of chemical thromboprophylaxis in trauma patients who underwent NOM of blunt solid organ injuries. Outcomes included failure of NOM and incidence of VTE. A random-effects meta-analysis was performed comparing patients who received late (>48 h) versus early thromboprophylaxis initiation.

RESULTS

Twelve retrospective cohort studies, comprising 21,909 patients, were included. Three studies, including 6375 patients, provided data on adjusted outcomes. Pooled adjusted analysis demonstrated no difference in failure of NOM in patients receiving late versus early thromboprophylaxis (odds ratio [OR] 0.92, 95% confidence interval [CI]:0.4-2.14). When including all unadjusted studies, even those at high risk of bias, there remained no difference in failure of NOM (OR 1.16, 95% CI:0.72-1.86). In the adjusted analysis for VTE events, which had 6259 patients between two studies, patients receiving late chemical thromboprophylaxis had a higher risk of VTE compared with those who received early thromboprophylaxis (OR 1.89, 95% CI:1.15-3.12).

CONCLUSIONS

Based on current observational evidence, initiation of prophylaxis before 48 h is associated with lower VTE rates without higher risk of failure of NOM.

Exclusion criteria: Evaluating the impact of enrollment requirements in SEER-Medicare research

BACKGROUND

Enrollment criteria are routinely utilized in patient selection in SEER-Medicare but little is known about how this may be impacting research outcomes. This study evaluated demographics and survival among pancreatic cancer patients who are included and excluded from SEER-Medicare analyses.

METHODS

Patients ≥66 years old with pancreatic cancer were identified (SEER-Medicare, 2008-2015). Two patient cohorts were compared: included (continuous enrollment in Medicare Parts A and B and no enrollment in Medicare Advantage), and excluded. Mortality was assessed using a Standardized Mortality Ratio.

RESULTS

Among 49,017 patients with pancreatic cancer, 59.5% were in the included cohort. The excluded cohort was younger (median age 74 vs. 77) with more male (49.9% vs. 47.8%), non-white (33.0% vs. 21.3%) and urban-dwelling patients (91.0% vs. 85.0%). Those excluded had a higher mortality risk (SMR 1.06, 95%CI 1.04-1.07).

CONCLUSIONS

There are significant differences in patient demographics and mortality among those who are and are not routinely included in SEER-Medicare analyses and our study provides a critical opportunity to quantify this potential bias.

Impact of Patient Primary Language upon Immediate Breast Reconstruction After Mastectomy

BACKGROUND

Preoperative decision-making in patients who speak a primary language other than English is understudied. We investigated whether patient primary language is associated with differences in immediate breast reconstruction (IBR) after mastectomy.

PATIENTS AND METHODS

This retrospective observational study analyzed female patients undergoing mastectomy in the New Jersey State Inpatient Database (2009-2014). The primary outcome was the odds of IBR with a prespecified subanalysis of autologous tissue-based IBR. We used multivariable logistic regression and hierarchical generalized linear mixed models to control for patient characteristics and nesting within hospitals.

RESULTS

Of 13,846 discharges, 12,924 (93.3%) specified English as the patient's primary language, while 922 (6.7%) specified a language other than English. Among English-speaking patients, 6178 (47.8%) underwent IBR, including 2310 (17.9%) autologous reconstructions. Among patients with a primary language other than English, 339 (36.8%) underwent IBR, including 93 (10.1%) autologous reconstructions. Unadjusted results showed reduced odds of IBR overall [odds ratio (OR) 0.64, 95% CI 0.55-0.73], and autologous reconstruction specifically (OR 0.52, 95% CI 0.41-0.64) among patients with a primary language other than English. After adjustment for patient factors, this difference persisted among the autologous subgroup (OR 0.64, 95% CI 0.51-0.80) but not for IBR overall. A hierarchical model incorporating both patient characteristics and hospital-level effects continued to show a difference among the autologous subgroup (OR 0.75, 95% CI 0.58-0.97).

CONCLUSIONS

Primary language other than English was an independent risk factor for lower odds of autologous IBR after adjustments for patient and hospital effects. Focused efforts should be made to ensure that patients who speak a primary language other than English have access to high-quality shared decision-making for postmastectomy IBR.

Surveillance Patterns for Hepatocellular Carcinoma among Screening-Eligible Patients in the Medicare Population

INTRODUCTION

Routine screening plays a critical role in the diagnosis of hepatocellular carcinoma (HCC), but not all patients undergo consistent surveillance. This study aims to evaluate surveillance patterns and their association with diagnosis stage and survival among Medicare patients at risk for HCC.

PATIENTS AND METHODS

Patients with HCC and guideline-based screening eligibility who underwent imaging with ultrasound or abdominal magnetic resonance imaging (MRI) in the 2 years prior to diagnosis were identified from SEER-Medicare (2008-2015). Three surveillance cohorts were created: diagnostic (imaging only within 3 months prior), intermittent (imaging only once within 2 years prior, excluding diagnostic), and routine (at least two imaging encounters within 2 years prior, excluding diagnostic). Multivariable logistic regression was used to predict early-stage diagnosis (stage I-II), and 5-year survival was evaluated using the accelerated failure time method with Weibull distribution.

RESULTS

Among 2261 eligible patients, 26.1% were classified as diagnostic, 15.8% as intermittent, and 58.1% as routine surveillance. The median age was 74 years (IQR 70-78 years). The majority of patients had a preexisting cirrhosis diagnosis (81.5%). Routine and intermittent, compared with diagnostic, surveillance were predictive of early-stage disease (routine: OR 2.05, 95% CI 1.64-2.56; intermittent: OR 1.43, 95% CI 1.07-1.90). Patients who underwent routine surveillance had significantly lower risk of mortality (HR 0.84, 95% CI 0.75-0.94) compared with the diagnostic group.

CONCLUSIONS

A large proportion of screening-eligible patients do not undergo routine surveillance, which is associated with late-stage diagnosis and higher risk of mortality. These findings demonstrate the impact of timely and consistent healthcare access and can guide interventions for promoting surveillance among these patients.

Intraoperative fluorescence imaging in esophagectomy and its application to the robotic platform: a narrative review

Background and Objective

Robotic-assisted esophagectomy is an approach to minimally invasive esophagectomy (MIE) that has demonstrated equivalent or improved outcomes relative to open and other minimally invasive techniques. The robotic approach also allows unique opportunities to improve complications following esophagectomy through use of enhanced visualization tools, including intraoperative fluorescence imaging. In this review, we summarize the specific uses of intraoperative fluorescence imaging as an adjunct tool during esophagectomy and discuss its application to the robotic platform.

Methods

A literature search was conducted via PubMed in February 2022 with the following keywords: esophagectomy, esophageal cancer, infrared, near-infrared (NIR) and fluorescence. Peer-reviewed academic journal articles published in English between 2000 and 2021 were included.

Key Content and Findings

There is a growing body of literature evaluating the use of intraoperative fluorescence imaging in robotic-assisted esophagectomy. This includes assessment of gastric conduit perfusion, including feasibility, creation of the gastroesophageal anastomosis, and qualification of perfusion, along with lymphatic mapping and identification of critical anatomy. These tools are uniquely leveraged using the robotic platform to standardize and quantify key technical aspects of the operation.

Conclusions

Intraoperative fluorescence imaging provides the opportunity to assess perfusion and identify anatomy for more precise and patient-specific dissection and reconstruction. Among all the operative techniques for esophagectomy, robotic-assisted esophagectomy is uniquely suited to utilize these imaging modalities to optimize outcomes and minimize risk associated with esophagectomy.

Beyond insurance status: the impact of Medicaid expansion on the diagnosis of Hepatocellular Carcinoma

BACKGROUND

Medicaid expansion has led to earlier stage diagnoses in several cancers but has not been studied in hepatocellular carcinoma (HCC), a disease with complex risk factors. We examined the effect of Medicaid expansion on the diagnosis of HCC and associations with county-level social vulnerability.

METHODS

Patients with HCC <65 years of age were identified from the SEER database (2010-2016). County-level social vulnerability factors were obtained from the CDC SVI and BRFSS. A Difference-in-Difference analysis evaluated change in early-stage diagnoses (stage I-II) between expansion and non-expansion states. A Difference-in-Difference-in-Difference analysis evaluated expansion impact among counties with higher proportions of social vulnerability.

RESULTS

Of 19,751 patients identified, 81.5% were in expansion states. Uninsured status decreased in expansion states (6.3%-2.4%, p < 0.0001) and remained unchanged in non-expansion states (12.7%-14.8%, p = 0.43). There was no significant difference in the incidence of early-stage diagnoses between expansion states and non-expansion states. Results were consistent when accounting for social vulnerability.

CONCLUSION

Medicaid expansion was not associated with earlier stage diagnoses in patients with HCC, including those with higher social vulnerability. Unlike other cancers, expanded access did not translate into higher utilization of care in HCC, suggesting barriers on a multitude of levels.

The impact of upper gastrointestinal surgical volume on short term pancreaticoduodenectomy outcomes for pancreatic adenocarcinoma in the SEER-Medicare population

BACKGROUND

Patients undergoing pancreaticoduodenectomy (PD) at low volume PD hospitals with high volume for other complex operations have comparable outcomes to high volume PD centers. We evaluated the impact of upper gastrointestinal operations (UGI) hospital volume on the outcomes of elderly, high risk patients undergoing PD.

METHODS

Patients >65 years old who underwent PD for pancreatic adenocarcinoma were identified from SEER-Medicare (2008-2015). Four volume cohorts were created using PD tertiles and UGI median: low (1st tertile PD), mixed-low (2nd tertile PD, low UGI), mixed-high (2nd tertile PD, high UGI) and high (3rd tertile PD). Multivariable logistic and negative binomial regression assessed short-term complications.

RESULTS

In total, 2717 patients were identified with a median age of 74.5 years. Patients treated at low, mixed-low and mixed-high volume hospitals, versus high volume, had higher risk of short-term complications, including major complications (low: OR 1.441, 95%CI 1.165-1.783; mixed-low: OR 1.374, 95%CI 1.085-1.740; mixed-high: OR 1.418, 95%CI 1.098-1.832) and 90-day mortality (low: OR 2.16, 95%CI 1.454-3.209; mixed-low: OR 2.068, 95%CI 1.347-3.175; mixed-high: OR 1.96, 95%CI 1.245-3.086).

CONCLUSION

Patients with pancreatic adenocarcinoma who are older and more medically complex benefit from undergoing surgery at high volume PD centers, independent of the operative experience of that center.

A Rising Tide Lifts All Boats: Impact of Combined Volume of Complex Cancer Operations on Surgical Outcomes in a Low-Volume Setting

BACKGROUND

Centralization for complex cancer surgery may not always be feasible owing to socioeconomic disparities, geographic constraints, or patient preference. The present study investigates how the combined volume of complex cancer operations impacts postoperative outcomes at hospitals that are low-volume for a specific high-risk cancer operation.

STUDY DESIGN

Patients who underwent pneumonectomy, esophagectomy, gastrectomy, hepatectomy, pancreatectomy, or proctectomy were identified from the National Cancer Database (2004-2017). For every operation, 3 separate cohorts were created: low-volume hospitals (LVH) for both the individual cancer operation and the total number of those complex operations, mixed-volume hospital (MVH) with low volume for the individual cancer operation but high volume for total number of complex operations, and high-volume hospitals (HVH) for each specific operation.

RESULTS

LVH was significantly (all p ≤ 0.01) predictive for 30-day mortality compared with HVH across all operations: pneumonectomy (9.5% vs 7.9%), esophagectomy (5.6% vs 3.2%), gastrectomy (6.8% vs 3.6%), hepatectomy (5.9% vs 3.2%), pancreatectomy (4.7% vs 2.3%), and proctectomy (2.4% vs 1.3%). Patients who underwent surgery at MVH and HVH demonstrated similar 30-day mortality: esophagectomy (3.2 vs 3.2%; p = 0.993), gastrectomy (3.2% vs 3.6%; p = 0.637), hepatectomy (3.8% vs 3.2%; p = 0.233), pancreatectomy (2.8% vs 2.3%; p = 0.293), and proctectomy (1.2% vs 1.3%; p = 0.843). Patients who underwent pneumonectomy at MVH demonstrated lower 30-day mortality compared with HVH (5.4% vs 7.9%; p = 0.045).

CONCLUSION

Patients who underwent complex operations at MVH had similar postoperative outcomes to those at HVH. MVH provide a model for the centralization of complex cancer surgery for patients who do not receive their care at HVH.

The Effect of Hospital Versus Surgeon Volume on Short-Term Patient Outcomes After Pancreaticoduodenectomy: a SEER-Medicare Analysis

BACKGROUND

The volume-outcome relationship has been well-established for pancreaticoduodenectomy (PD). It remains unclear if this is primarily driven by hospital volume or individual surgeon experience.

OBJECTIVE

This study aimed to determine the relationship of hospital and surgeon volume on short-term outcomes of patients with pancreatic adenocarcinoma undergoing PD.

METHODS

Patients >65 years of age who underwent PD for pancreatic adenocarcinoma were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2008-2015). Analyses were stratified by hospital volume and then surgeon volume, creating four volume cohorts: low-low (low hospital, low surgeon), low-high (low hospital, high surgeon), high-low (high hospital, low surgeon), high-high (high hospital, high surgeon). Propensity scores were created for the odds of undergoing surgery with high-volume surgeons. Following matching, multivariable analysis was used to assess the impact of surgeon volume on outcomes within each hospital volume cohort.

RESULTS

In total, 2450 patients were identified: 54.3% were treated at high-volume hospitals (27.0% low-volume surgeons, 73.0% high-volume surgeons) and 45.7% were treated at low-volume hospitals (76.9% low-volume surgeons, 23.1% high-volume surgeons). On matched multivariable analysis, there were no significant differences in the risk of major complications, 90-day mortality, and 30-day readmission based on surgeon volume within the low and high hospital volume cohorts.

CONCLUSION

Compared with surgeon volume, hospital volume is a more significant factor in predicting short-term outcomes after PD. This suggests that a focus on resources and care pathways, in combination with volume metrics, is more likely to achieve high-quality care for patients undergoing PD across all hospitals.

Lymphadenectomy in gallbladder adenocarcinoma: Are we doing enough?

BACKGROUND

Current AJCC guidelines recommend evaluating ≥6 lymph nodes during gallbladder cancer resection but real world data suggest this is rarely achieved. We evaluated the extent of lymphadenectomy and survival among patients with gallbladder adenocarcinoma.

METHODS

Patients with resected pT1b-T3 gallbladder adenocarcinoma were identified from the NCDB (2004-2017). Propensity scores were created for the odds of sufficient lymphadenectomy (≥6 nodes), patients were matched 1:1 and survival was analyzed using the Kaplan-Meier method.

RESULTS

Overall, 4760 patients were identified: 16.7% underwent sufficient lymphadenectomy, which was predictive of nodal disease (OR 1.77, 95%CI 1.51-2.08) and demonstrated a survival benefit in N0 (median OS 140.8 versus 44.4 months; p < 0.0001) and N1-2 disease (median OS 27.7 versus 17.7 months; p < 0.0001) after matching.

CONCLUSIONS

The majority of patients with gallbladder adenocarcinoma do not undergo the recommended nodal dissection, resulting in a survival disadvantage, likely due to understaging, decisions regarding adjuvant therapy and local tumor recurrence.

Health Care Disparities and the Future of Pancreatic Cancer Care

There have been tremendous advances in the diagnosis and treatment of pancreatic cancer in the past decade, yet we are failing to achieve equitable outcomes for all patient populations. Disparities exist in the incidence, diagnosis, treatment, and outcomes of patients with pancreatic cancer. Inequities are based on racial and ethnic group, sex, socioeconomic status, and geography. To address disparities, future steps must focus on research methods, including collection and methodology, and policy measures, including access, patient tools, hospital incentives, and workforce diversity. Through these comprehensive efforts, we can begin to rectify inequitable care for treatment of patients with pancreatic cancer.

The Discordance of Clinical and Pathologic Staging in Locally Advanced Gastric Adenocarcinoma

BACKGROUND

Clinical staging guides decisions about optimal treatment sequence in patients with gastric cancer, although the preoperative accuracy is not strongly established. This study investigates concordance of clinical and pathologic stage as well as its impact on the survival of patients with gastric adenocarcinoma.

METHODS

Patients with clinical stage T2-4, N0, M0 gastric adenocarcinoma who underwent surgery without neoadjuvant therapy were identified from the National Cancer Database (2010-2015). The primary outcome was up-staging, defined as cT < pT, pN1-3, and/or pM1 (AJCC 7^th edition). Multivariable logistic regression analysis was performed to predict up-staging. Survival analysis was performed using the Kaplan-Meier method.

RESULTS

In total, 2254 patients were identified. cTNM staging was discordant with pTNM staging in 65.6% of cases, with 50.4% up-staged and 15.2% down-staged. On multivariable logistic regression, younger age (OR 0.991, 95% CI 0.984-0.999, p=0.0188), male sex (versus female; OR 1.392, 95% CI 1.158-1.673, p=0.0004), poor or undifferentiated tumor grade (versus well differentiated or moderately differentiated; OR 2.399, 95% CI 1.987-2.896; p<0.0001), positive margin status (versus negative; OR 4.575, 95% CI 3.360-6.230; p<0.0001), and days from diagnosis to surgery (15-32 days versus ≤ 14 days; OR 1.411, 95% CI 1.098-1.814, p=0.0072) were predictive of up-staging. Patients who were up-staged had a decreased survival compared to patients who were accurately staged (median survival 27.9 months versus 67.6 months; log-rank p<0.0001).

CONCLUSION

This study found a substantial discordance between clinical and pathologic staging of resectable locally advanced gastric adenocarcinoma. These data support that patients may have more advanced disease at presentation than reflected in clinical staging and may benefit from improved diagnostic modalities and neoadjuvant chemotherapy.

Combined Hepatopancreaticobiliary Volume and Hepatectomy Outcomes in Hepatocellular Carcinoma Patients at Low-Volume Liver Centers

BACKGROUND

The relationship between hospital volume and surgical outcomes is well-established; however, considerable socioeconomic and geographic barriers to high-volume care persist. This study assesses how the overall volume of hepatopancreaticobiliary (HPB) cancer operations impacts outcomes of liver resections (LRs).

STUDY DESIGN

The National Cancer Database (2004-2014) was queried for patients who underwent LR for hepatocellular carcinoma. Hospital volume was determined separately for all HPB operations and LRs. Centers were dichotomized as low and high volume based on the median number of operations. The following study cohorts were created: low-volume hospitals (LVHs) for both LRs and HPB operations, mixed-volume hospitals (MVHs) with low-volume LRs but high-volume HPB operations, and high-volume LR hospitals (HVHs) for both LRs and HPB operations.

RESULTS

Of 7,265 patients identified, 37.5%, 8.8%, and 53.7% were treated at LVHs, MVHs, and HVHs, respectively. On multivariable analysis, patients treated at LVHs had higher 30-day mortality compared with patients treated at HVHs (odds ratio 1.736; p < 0.001). However, patients treated at MVHs experienced 30-day mortality comparable with patients treated at HVHs (odds ratio 0.789; p = 0.318). Similar results were found for positive margin status, prolonged hospital stay, and overall survival.

CONCLUSIONS

LR outcomes at low-volume LR centers that have substantial experience with HPB cancer operations are similar to those at high-volume LR centers. Our results demonstrate that the volume to outcomes curve for HPB operations should be assessed more holistically and that patients can safely undergo liver operations at low-volume LR centers if HPB volume criteria are met.

Undertreatment of Gallbladder Cancer: A Nationwide Analysis

BACKGROUND

Gallbladder cancer has a high mortality rate and an increasing incidence. The current National Comprehensive Cancer Network (NCCN) guidelines recommend resection for all T1b and higher-stage cancers. This study aimed to evaluate re-resection rates and the associated survival impact for patients with gallbladder cancer.

METHODS

Patients with gallbladder adenocarcinoma who underwent resection were identified from the National Cancer Database (2004-2015). Re-resection was defined as definitive surgery within 180 days after the first operation. Propensity scores were created for the odds of a patient having a re-resection. Patients were matched 1:2. Survival analyses were performed using the Kaplan-Meier and Cox proportional hazard methods.

RESULTS

The study identified 6175 patients, and 466 of these patients (7.6%) underwent re-resection. Re-resection was associated with younger median age (65 vs 72 years; p < 0.0001), private insurance (41.6% vs 27.1%; p < 0.0001), academic centers (50.4% vs 29.7%; p < 0.0001), and treatment location in the Northeast (22.8% vs 20.4%; p = 0.0011). Compared with no re-resection, re-resection was associated with pT stage (pT2: 47.6% vs 42.8%; p = 0.0139) and pN stage (pN1-2: 28.1% vs 20.7%; p < 0.0001), negative margins on final pathology (90.1% vs 72.6%; p < 0.0001), and receipt of chemotherapy (53.7% vs 35.8%; p < 0.0001). The patients who underwent re-resection demonstrated significantly longer overall survival (OS) than the patients who did not undergo re-resection (median OS, 44.0 vs 23.0 months; p < 0.0001). After propensity score-matching, re-resection remained associated with superior survival (median OS, 44.0 vs 31.0 months; p = 0.0004).

CONCLUSIONS

Re-resection for gallbladder cancer is associated with improved survival but remains underused, particularly for early-stage disease.

Navigating by Stars: Using CMS Star Ratings to Choose Hospitals for Complex Cancer Surgery

Background

The Centers for Medicare and Medicaid Services (CMS) developed risk-adjusted “Star Ratings,” which serve as a guide for patients to compare hospital quality (1 star = lowest, 5 stars = highest). Although star ratings are not based on surgical care, for many procedures, surgical outcomes are concordant with star ratings. In an effort to address variability in hospital mortality after complex cancer surgery, the use of CMS Star Ratings to identify the safest hospitals was evaluated.

Methods

Patients older than 65 years of age who underwent complex cancer surgery (lobectomy, colectomy, gastrectomy, esophagectomy, pancreaticoduodenectomy) were evaluated in CMS Medicare Provider Analysis and Review files (2013-2016). The impact of reassignment was modeled by applying adjusted mortality rates of patients treated at 5-star hospitals to those at 1-star hospitals (Peters-Belson method).

Results

There were 105 823 patients who underwent surgery at 3146 hospitals. The 90-day mortality decreased with increasing star rating (1 star = 10.4%, 95% confidence interval [CI] = 9.8% to 11.1%; and 5 stars = 6.4%, 95% CI = 6.0% to 6.8%). Reassignment of patients from 1-star to 5-star hospitals (7.8% of patients) was predicted to save 84 Medicare beneficiaries each year. This impact varied by procedure (colectomy = 47 lives per year; gastrectomy = 5 lives per year). Overall, 2189 patients would have to change hospitals each year to improve outcomes (26 patients moved to save 1 life).

Conclusions

Mortality after complex cancer surgery is associated with CMS Star Rating. However, the use of CMS Star Ratings by patients to identify the safest hospitals for cancer surgery would be relatively inefficient and of only modest impact.