Citations

ABSTRACT Background Postoperative venous thromboembolism (VTE) is a major source of morbidity and mortality. Real‐time risk stratification for VTE is important to guide measures for thromboprophylaxis. We sought to compare the discrimination of three VTE predictive systems in classifying 90‐day postoperative VTE among cancer patients undergoing pancreas and liver surgery using administrative data. Methods We conducted a retrospective analysis of the 2001–2015 SEER‐Medicare data for patients with newly diagnosed primary pancreatic or liver malignancies who underwent surgery. The primary outcome was 90‐day postoperative VTE (including deep venous thrombosis and pulmonary embolism [PE]). We used the 2001–2010 dataset to create a new VTE predictive model using multivariable logistic regression. We then compared the discrimination of the Caprini score (adapted for claims data), the Elixhauser comorbidity score, and the new predictive model using the 2011–2015 dataset. Results Our sample included 15 479 patients (12 005 pancreas and 3474 liver surgery). Median age was 74 years (interquartile range: 69–78) and 7619 were female (49%). The overall incidence of 90‐day VTE was 10.0% (90‐day PE: 4.5%). The new VTE model included age, race, history of VTE, cancer stage, preoperative chemotherapy, and Elixhauser score. The discrimination of all predictive models was modest for both VTE ( c ‐statistic 63.0%, 59.4%, and 67.8%) and PE (61.5%, 59.7%, 65.6% for Caprini, Elixhauser, and new score respectively). Conclusions The existing tools for predicting postoperative VTE show poor performance using claims data. Future research should supplement administrative data with additional data sources to better predict patients at high risk for postoperative VTE.

Background: ASCO recommends extended venous thromboembolism (VTE) prophylaxis with low-molecular-weight heparin (LMWH) or direct oral anticoagulants (DOACs) following cancer surgery. However, these recommendations were based on trials using routine venography, which detects asymptomatic VTEs, and real-life efficacy is not well studied. We aimed to assess the association of extended VTE prophylaxis with the incidence of clinically significant VTE after elective cancer surgery. Patients and Methods: In this retrospective, population-based cohort study, we identified patients who underwent surgical resection for lung, breast, esophageal, gastric, pancreas, and colon cancer from 2010 to 2017 using the SEER–Medicare linked dataset. Patients were divided into 1 of 2 main groups for comparative analyses: those who received extended VTE prophylaxis after cancer surgery and those who did not. Patients who received extended VTE prophylaxis after cancer surgery were identified as those prescribed prophylactic doses of LMWH or a DOAC within 7 days of discharge, as captured in Medicare Part D files. Results: A total of 113,739 Medicare beneficiaries were identified, of whom 1,570 (1.4%) received extended VTE prophylaxis. There was a year-over-year increase in the use of extended VTE prophylaxis during the study period, rising from 0.6% in 2010 to 3.3% in 2017. The overall incidence of VTE was 1.6% at 1 month, 4.3% at 6 months, 5.7% at 12 months, with significant differences observed across cancer types ( P <.001). However, patients who received extended VTE prophylaxis had a higher 1-year cumulative incidence of postoperative VTE compared with those who did not (11.4% vs 5.3%; P <.001), an association that was consistent across cancer sites. In adjusted analyses, extended VTE prophylaxis was independently associated with an increased risk of VTE (hazard ratio, 1.6; 95% CI, 1.3–2.0; P <.001). Extended prophylaxis was also associated with a higher 1-year incidence of bleeding events compared with patients who did not receive prophylaxis (12.0% vs 8.5%; P <.001). Conclusions: The utilization of extended VTE prophylaxis after cancer surgery remains low, although it has increased every year. Paradoxically, patients who received extended VTE prophylaxis had higher incidences of clinically significant VTE and bleeding compared with those who did not, likely reflecting patient selection and surveillance bias after surgery. In light of these findings, national guidelines recommending postoperative extended VTE prophylaxis, and its use as a surrogate for quality of care, should continue to be re-examined.

Background: Upfront resectable pancreatic ductal adenocarcinoma (PDAC) is defined by the NCCN as disease with ≤180° portomesenteric vein (PMV) abutment. However, the clinical significance of PMV abutment in this cohort remains unexplored, and we sought to investigate its impact. Methods: This multi-institutional study included patients who underwent pancreatoduodenectomy (PD) for upfront resectable PDAC from 2002 to 2023. Patients with PDAC with ≤180° PMV abutment were compared with those without. Overall survival (OS) was compared and stratified based on whether patients underwent upfront surgery or neoadjuvant therapy (NAT). Results: Among 1,446 patients included, 521 (36.0%) had PMV abutment. Median OS for patients with PMV abutment was 28.8 months compared with 31.2 months for those without ( P =.17). In a stratified analysis of patients who underwent upfront surgery, patients with PMV abutment had worse OS (19.2 vs 27.6 months; P <.05) and lower R0 resection rates (63.1% vs 87.2%; P <.05) compared with those without. However, in patients who underwent NAT, this difference in R0 resection rate was not observed (91.4% vs 94.0%, respectively; P =.27). Furthermore, there was no significant difference in median OS with NAT (42.5 vs 51.6 months, respectively; P =.48). Conclusions: In this largest cohort to date of patients with upfront resectable PDAC, PMV abutment was associated with worse OS compared with no PMV abutment when an upfront resection strategy was used. The use of NAT in patients with PMV abutment mitigated this survival difference with increased R0 resection rates. These findings suggest that patients with upfront resectable PDAC with PMV abutment benefit from a NAT approach for optimal survival outcomes, and that the current criteria guidelines need to be redefined.

BACKGROUND: Despite the widespread adoption of minimally invasive surgery in the US, disparities in its use persist. One unexplored contributor is geographic access to robotic surgical systems. This study evaluates the geospatial association between: (1) Social Vulnerability Index (SVI) and open surgery rates, (2) availability of robotic systems and open surgery, and (3) open surgery rates in demographically similar areas with differing robotic access. STUDY DESIGN: Data from 6 sources were linked at the ZIP Code Tabulation Area (ZCTA) level to identify hospitals and to extract procedure modality, presence of robotic systems, and area characteristics. Regression analysis assessed the association between SVI and open surgery rates. Open rates were then compared between hospitals with and without robotic systems. Propensity score matching was used to compare open rates across matched ZCTAs by robotic access and SVI levels. RESULTS: Higher social vulnerability was associated with increased open surgery rates (estimate = 0.20; p < 0.01), with rates ranging from 18.3% in low-vulnerability areas to 32.7% in high-vulnerability areas. Among 3,446 eligible ZCTAs, 57% had at least 1 robotic system. ZCTAs without robotic systems had higher open surgery rates (42.9 vs 19.4 per 100 procedures; relative rate = 2.21; p < 0.01). This association remained significant after matching (relative rate = 1.66; p < 0.01), for the low-mid- and high-SVI strata, and 3 of the 5 procedures examined. CONCLUSIONS: When correcting for geographic variation, the availability of robotic surgery was associated with a decrease in open surgery rates.

The authors explore the association of remnant cholesterol and CRP with the longitudinal development of cancer in a prospective cohort study and if there is an opportunity to modulate risk with bariatric surgery or GLP‐1 agonist.

This study examines the relevance of minimum case volume recommendations in contemporary practice.

Objective: Analyzing textbook outcome (TO) following rectal cancer resection and its association with long-term survival when compared to hospital case volume alone. Background: TO is a quality metric representing the ideal result following complex cancer surgery. Prior studies have suggested improved long-term survival for rectal cancer patients undergoing surgery at HV institutions. Methods: Patients undergoing surgery for rectal adenocarcinoma from 2014 to 2015 were identified using the National Cancer Database. Low (LV), medium (MV), and high-volume (HV) hospital strata were defined by quartile cutoffs (low <25th, high >75th, and 25–75th medium volume). TO was achieved with adequate lymph node count (≥12), negative margins (R0 resection), length of stay <75th percentile, absence of 30-day readmission/mortality event, and appropriate plus timely systemic therapy. Adjusted analyses for long-term survival were performed using a hierarchical multivariable Cox regression model. Results: TO was achieved in 28.5% of 48,484 patients. LV or MV hospital patients were more likely to be older, uninsured/Medicaid, and less likely to achieve a TO (HV 31.2% vs MV 29.6% vs LV 23.2%, P < 0.001). TO was associated with improved 5-year survival (84.0% vs 72.0%, P < 0.001). On multivariable analyses, TO was the strongest protective factor against mortality (HR 0.60, 95% confidence interval = 0.56–0.64), even after controlling for case volume. Conclusions: Only 28.5% of patients undergoing resection for rectal cancer achieve TO. However, they had a 40% reduction in long-term mortality independent of hospital volume. Optimizing long-term survival in patients with rectal cancer can be achieved by TO criteria rather than increasing surgical case volume.