Lu, Patricia G

ABSTRACT Background Post‐pancreatectomy exocrine insufficiency is common after resection for pancreatic cancer and requires pancreatic enzyme replacement therapy (PERT). We sought to determine the out‐of‐pocket cost of PERT and the association between PERT and survival. Methods The SEER‐linked Medicare database was queried for patients with pancreatic cancer who underwent pancreaticoduodenectomy (PD) or distal pancreatectomy (DP) from 2010 to 2019. Cumulative out‐of‐pocket costs were calculated and stratified by procedure and radiation. Results 11,854 Medicare beneficiaries with resected pancreatic cancer were identified, 4,653 (39%) required PERT and 7,201 (61%) did not. Median age was 73.0, 50.6% were female and 83.6% White. 25.9% underwent DP and 74.1% underwent PD; 7% received neoadjuvant radiation while 23.5% received adjuvant radiation. Logistic regression demonstrated that female sex (OR 1.25, 95% CI 1.16‐1.35, p < 0.001), neoadjuvant radiation (OR 1.93, 95% CI 1.67‐2.24, p < 0.001), and PD (OR 2.45, 95% CI 2.23‐2.7, p < 0.001) were risk factors for requiring PERT. Patients without subsidies who underwent DP paid a cumulative $4,736 out‐of‐pocket for PERT after 5 years, those who underwent PD paid $5,601 out‐of‐pocket. Conclusions Nearly 40% of Medicare beneficiaries took PERT after resection for pancreatic cancer and paid thousands in out‐of‐pocket costs. While a conservative estimate, these findings highlight the importance of addressing this financial burden to patients.

Background The 2015 American Thyroid Association (ATA) guidelines added thyroid lobectomy (TL) as the appropriate treatment for low-risk differentiated thyroid cancer (DTC). We aimed to investigate the population-level factors that influence the utilization of TL. Methods The Surveillance, Epidemiology and End Results (SEER) database was queried for all DTC patients fitting low-risk criteria as defined by the ATA. Trends in total thyroidectomy (TT) and TL were identified using a Cochrane–Armitage test. Multivariable logistic regression identified patient and socioeconomic characteristics associated with TL, and difference-in-difference analysis was used to control for secular trends over time. Results A total of 43,526 patients with low-risk DTC were identified in the SEER database; 39,411 pre-2015 and 4115 post-2015. After 2015, TT continued to outnumber TL (76.2% vs 23.8%), although the rate of TL increased significantly (11.6% to 23.8%, P < 0.001). However, difference-in-difference analysis found that age > 55 (OR 1.11, 95% CI 1.01–1.19, P < 0.001) and rurality (OR 1.16, 95% CI 1.05–1.28, P < 0.001) were independently associated with TT. TL was associated with T1 disease (OR 1.11, 95% CI 1.04–1.19, P = 0.001). Conclusion Although the 2015 ATA guideline update led to an increase in TL for low-risk DTC, most patients still underwent TT. Age and neighborhood significantly impact the odds of receiving guideline-appropriate TL for low-risk DTC, especially for T2 disease.

BACKGROUND: Acute diverticulitis in immunocompromised patients is associated with high morbidity and mortality rates with either medical or surgical treatment. Thus, management approach is controversial, especially for patients presenting with nonperforated disease. OBJECTIVE: This study aimed to report the Mayo clinic experience of acute diverticulitis management in immunocompromised patients. DESIGN: This design is based on a retrospective cohort study. SETTING: This study was conducted with institutional data composed from 3 tertiary referral centers. PATIENTS: Immunocompromised patients presenting with acute diverticulitis at 3 Mayo clinic sites between 2016 and 2020 were included. MAIN OUTCOME MEASURES: The main outcome measures were the management algorithm and short-term outcomes. RESULTS: Immunocompromised patients presenting with acute uncomplicated diverticulitis (86) were all managed nonoperatively at presentation with a success rate of 93% (80/86). Two patients (2.3%, 2/86) required surgery during the same admission, and 4 patients (4.8%, 4/84) had 30-day readmission. Complicated diverticulitis patients with abscess (22) were all managed nonoperatively first with a success rate of 95.4% (21/22). One patient (4.6%, 1/22) required surgery during the same admission. All the patients who presented with obstruction (2), fistula (1), or free perforation (11) underwent surgery except one who chose hospice. Overall, the major complication rate was 50% (8/16) and mortality rate was 18.8% (3/16) among patients who underwent surgery during the same admission. For patients who presented with perforated diverticulitis, the mortality rate was 27.3% (3/11), compared with 0% (0/111) for patients who presented with nonperforated disease. LIMITATIONS: This cohort was limited by its retrospective nature and heterogeneity of the patient population. CONCLUSIONS: Nonoperative management was safe and feasible for immunocompromised patients with colonic diverticulitis without perforation at our center. Perforated colonic diverticulitis in immunocompromised patients was associated with high morbidity and mortality rate. See Video Abstract at http://links.lww.com/DCR/B988. MANEJO DE LA DIVERTICULITIS AGUDA EN PACIENTES INMUNOCOMPROMETIDOS: EXPERIENCIA DE LA CLINICA MAYO ANTECEDENTES: La diverticulitis aguda en pacientes inmunocomprometidos se asocia con una alta tasa de morbilidad y mortalidad con el tratamiento médico o quirúrgico. Por lo tanto, el enfoque de manejo es controvertido, especialmente para pacientes que presentan enfermedad no perforada. OBJETIVO: El propósito fue informar la experiencia de la clínica Mayo en el manejo de la diverticulitis aguda en pacientes inmunocomprometidos. DISEÑO: Este es un estudio de cohorte retrospectivo ENTORNO CLÍNICO: Este estudio se realizó con datos institucionales compuestos de tres centros de referencia terciarios. PACIENTES: Se incluyeron pacientes inmunocomprometidos que presentaron diverticulitis aguda en tres sitios de la clínica Mayo entre 2016 y 2020. RESULTADO PRINCIPAL: Algoritmo de gestión y resultados a corto plazo. RESULTADOS: Los pacientes inmunocomprometidos que presentaban diverticulitis aguda no complicada (86) fueron tratados de forma no quirúrgica en la presentación inicial con una tasa de éxito del 93 % (80/86). Dos pacientes (2,3%, 2/86) requirieron cirugía durante el mismo ingreso y cuatro pacientes (4,8%, 4/84) tuvieron reingreso a los 30 días. Todos los pacientes con diverticulitis complicada con absceso (22) fueron tratados primero de forma no quirúrgica con una tasa de éxito del 95,4 % (21/22). Un paciente (4,6%, 1/22) requirió cirugía durante el mismo ingreso. Todos los pacientes que presentaron obstrucción (2), fístula (1) o perforación libre (11) fueron intervenidos excepto uno que optó por hospicio. La tasa global de complicaciones mayores fue del 50 % (8/16) y la tasa de mortalidad fue del 18,8 % (3/16) entre los pacientes que se sometieron a cirugía durante el mismo ingreso. Para los pacientes que presentaban diverticulitis perforada, la tasa de mortalidad fue del 27,3 % (3/11), en comparación con el 0 % (0/111) de los pacientes que presentaban enfermedad no perforada. LIMITACIONES: Esta cohorte estuvo limitada por su naturaleza retrospectiva y la heterogeneidad de la población de pacientes. CoNCLUSIÓNES: El manejo no quirúrgico fue seguro y factible para pacientes inmunocomprometidos con diverticulitis colónica sin perforación en nuestro centro. La diverticulitis colónica perforada en pacientes inmunocomprometidos se asoció con una alta tasa de morbilidad y mortalidad. Consulte Video Resumen en http://links.lww.com/DCR/B988. (Traducción— Dr. Ingrid Melo)