Citations

ABSTRACT Background and Objectives There is increasing use of neoadjuvant treatment (NAT) for patients with pancreatic adenocarcinoma (PDAC). The role of additional adjuvant chemotherapy (AT) is not well‐defined. This study aims to determine the impact of lymphovascular invasion (LVI) and lymph node (LN) involvement on overall survival (OS) in patients with resected PDAC and determine the impact of AT after NAT. Methods This is an observational cohort study of patients with PDAC who underwent NAT and surgical resection. A multivariable model was used to assess for differences in OS. An interaction term between LVI or LN involvement and AT use was utilized to test the benefit of additional AT. Results Seven thousand four hundred and fourteen patients were included; group A (LVI‐, LN‐) had 2787 patients, B (LVI + , LN‐) 652, C (LVI‐, LN + ) 1,712, and D (LVI + , LN + ) 2263. Median OS differed significantly between groups, A had the most favorable survival (34.1 months), followed by B (27.8 months), C (26.3 months), and D (21.2 months, p < 0.001). In patients with persistent LVI or LN involvement after NAT, additional AT was not associated with OS (group A, HR: 0.94, p = 0.4; B and C, HR: 1.0, p = 0.99; D, HR: 0.94, p = 0.32). Conclusions LVI and LN involvement were independently associated with worse OS. After NAT, the use of AT in patients with persistent LVI and LN involvement was not associated with improved OS.

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: Subtotal cholecystectomy is increasingly recommended as a bailout strategy for the difficult gallbladder, yet its long-term durability and the risk profile of subsequent completion cholecystectomy remain incompletely defined. STUDY DESIGN: We performed a population-based retrospective cohort study of adults undergoing laparoscopic or open subtotal cholecystectomy for acute cholecystitis from 2012 to 2021 using Healthcare Cost and Utilization Project state databases from New York and Florida. The primary endpoint was remnant cholecystitis, defined as a postoperative emergency, inpatient, or outpatient diagnosis of cholecystitis or need for subsequent cholecystectomy. Kaplan–Meier analysis estimated cumulative incidence. Secondary outcomes included completion cholecystectomy and bile duct injury requiring surgical repair. RESULTS: Among 2,682 patients (98.7% laparoscopic), the cumulative incidence of remnant cholecystitis was 13.3% during a median follow-up of 2 years (interquartile range [IQR] 0.7 to 4.1). The median time to developing remnant cholecystitis was 28 days (IQR 13 to 91), with 79.7% occurring within 6 months. Only 70 patients (2.6%) underwent completion cholecystectomy at a median of 103 days (IQR 43 to 202). Completion cholecystectomy was performed via open surgery in 47.1% of patients and was associated with a 7.1% bile duct injury rate and median length of stay of 3 days (IQR 1 to 7), compared with a 0.9% bile duct injury rate for subtotal cholecystectomy overall. CONCLUSIONS: Although remnant cholecystitis occurred in 13.3% of patients after subtotal cholecystectomy, few required completion cholecystectomy. When necessary, completion cholecystectomy was frequently open and associated with a substantially higher bile duct injury rate, supporting referral to experienced hepatobiliary centers for reoperation.

Abstract Background Minimally invasive left-sided pancreatectomy (MIS-LP) is increasingly adopted for pancreatic neuroendocrine tumours (PNETs), yet its oncological safety compared with open surgery (O-LP) remains debated. Robust population-level evidence is required to guide practice. Methods Patients ≥65 years with grade 1–2 PNETs undergoing left pancreatectomy were identified from the SEER-Medicare database (2010–2019). Overall and cancer-specific survival outcomes were analysed using multilevel Cox regression after propensity-score matching (PSM). Landmark analysis from 6 months excluded early postoperative deaths. Results 772 patients were included: 257 (33%) MIS-LP and 515 (67%) O-LP. Median age was 71 years; 87% had grade 1 and 13% grade 2 tumours. Before matching, MIS-LP patients had lower comorbidity (median Charlson Index 2 versus 3, P = 0.011) and fewer with metastatic disease (2.0% versus 5.7%, P = 0.019). After PSM (MIS-LP n = 248; O-LP n = 441), 5-year overall survival was higher with MIS-LP (88.1% versus 84.5%, P = 0.03), while 5-year cancer-specific survival was similar (95.2% versus 93.5%, P = 0.11). O-LP was associated with increased risk of death (HR 1.75, 95% c.i. 1.05–2.91, P = 0.030), though not cancer-specific death (HR 1.97, 95% c.i. 0.86–4.54, P = 0.110). Notably, all 90-day mortalities (n = 15, 1.9%) occurred in the O-LP group. In landmark analysis beyond 6 months, surgical approach was no longer predictive of OS or CSS. Conclusions MIS-LP confers an early survival advantage, driven by reduced perioperative mortality, without compromising long-term oncological outcomes. As the largest population-based analysis in this setting, these findings support MIS-LP as the standard surgical approach for older patients with low- to intermediate-grade PNETs.

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: Metachronous cancer risk varies by mismatch repair mutation in patients with hereditary nonpolyposis colorectal cancer. Total colectomy offers decreased risk of metachronous colorectal cancers but decreased quality of life compared with segmental colectomy. OBJECTIVE: Compare segmental versus total colectomy for colon cancer via a mutation-specific Markov decision model. DESIGN: Simulated survival and colorectal metachronous occurrence among patients with MLH1, MSH2 , or MSH6 mutations undergoing either segmental or total colectomy. SETTINGS: National databases, literature review. PATIENTS: Simulated patients with hereditary nonpolyposis colorectal cancer. MAIN OUTCOME MEASURES: Overall survival, quality-adjusted life years based on procedure-specific utility states (segmental colectomy 0.99, total colectomy 0.95). RESULTS: Among patients aged 25 years, total colectomy offered less than 1 year of increased mean survival compared with segmental resection across all mutations ( MLH1: 0.8 years, MSH2: 0.9, MSH6: 0.3). This difference in survival decreased with increasing age. Segmental resection offered a small increase in quality-adjusted life years compared with total colectomy across all ages. This difference was highest for MSH6 (0.9 years vs MLH1 : 0.6 and MSH2 : 0.4 at age 25), particularly at younger ages of diagnosis. In a sensitivity analysis, lower total colectomy utility states resulted in greater increases in quality-adjusted life years with segmental colectomy across all mutations. LIMITATIONS: Metachronous cancer risk data do not distinguish between colon and rectal cancers and is extrapolated beyond age 70 years. CONCLUSIONS: Segmental and total colectomy offer similar survival and quality-adjusted life year outcomes. With decreased risk of metachronous cancers, patients with MSH6 mutations across all ages may prefer segmental resection owing to higher quality-adjusted life years and lower survival benefits from total colectomy compared with MLH1 and MSH2 patients. Operative strategy in patients with hereditary nonpolyposis colorectal cancer should be individualized, and this study shows that mutation-specific differences in survival and quality-adjusted life years are small. See Video Abstract . MODELO DE DECISIÓN ESPECÍFICO PARA LA MUTACIÓN EN LA COLECTOMÍA ABDOMINAL SEGMENTARIA FRENTE A LA COLECTOMÍA ABDOMINAL TOTAL EN EL CÁNCER COLORRECTAL HEREDITARIO NO POLIPOSO ANTECEDENTES: El riesgo de cáncer metacrónico varía según la mutación de reparación de desajustes en pacientes con cáncer colorrectal hereditario no poliposo. La colectomía total ofrece un menor riesgo de cánceres colorrectales metacrónicos, pero una menor calidad de vida en comparación con la colectomía segmentaria. OBJETIVO: Comparar la colectomía segmentaria con la colectomía total para el cáncer de colon mediante un modelo de decisión de Markov específico para mutaciones. DISEÑO: Simulación de la supervivencia y la aparición metacrónica de cáncer colorrectal en pacientes con mutaciones MLH1, MSH2 o MSH6 sometidos a colectomía segmentaria o total. ENTORNO: Bases de datos nacionales, revisión de la literatura. PACIENTES: Pacientes simulados con cáncer colorrectal hereditario no poliposo. PRINCIPALES MEDIDAS DE RESULTADO: Supervivencia global, años de vida ajustados por calidad basados en estados de utilidad específicos del procedimiento (colectomía segmentaria 0,99, colectomía total 0,95). RESULTADOS: Entre los pacientes de 25 años, la colectomía total ofreció menos de un año de aumento de la supervivencia media en comparación con la resección segmentaria en todas las mutaciones ( MLH1: 0,8 años, MSH2: 0,9, MSH6: 0,3). Esta diferencia en la supervivencia disminuyó con el aumento de la edad. La resección segmentaria ofreció un pequeño aumento en los años de vida ajustados por calidad en comparación con la colectomía total en todas las edades. Esta diferencia fue mayor para MSH6 (0,9 años frente a MLH1 : 0,6 y MSH2 : 0,4 a los 25 años), especialmente en las edades más jóvenes de diagnóstico. En un análisis de sensibilidad, los estados de utilidad más bajos de la colectomía total dieron lugar a mayores aumentos en los años de vida ajustados por calidad con la colectomía segmentaria en todas las mutaciones. LIMITACIONES: Los datos sobre el riesgo de cáncer metacrónico no distinguen entre cánceres de colon y recto y se extrapolan más allá de los 70 años. CONCLUSIONES: La colectomía segmentaria y la colectomía total ofrecen resultados similares en cuanto a la supervivencia y los años de vida ajustados por calidad. Con la disminución del riesgo de cánceres metacrónicos, los pacientes con mutaciones MSH6 de todas las edades pueden preferir la resección segmentaria debido a los mayores años de vida ajustados por calidad y los menores beneficios de supervivencia de la colectomía total en comparación con los pacientes MLH1 y MSH2 . La estrategia quirúrgica en pacientes con cáncer colorrectal hereditario no poliposo debe individualizarse, y este estudio muestra que las diferencias específicas de la mutación en la supervivencia y los años de vida ajustados por calidad son pequeñas. ( AI-generated translation )

Key Points Health care utilization rates in elderly kidney transplant were no different between the high kidney donor profile index and low kidney donor profile index group. Number of readmissions and surgical interventions in elderly kidney transplant was no different between the high kidney donor profile index and low kidney donor profile index group. Death censored graft loss was higher in the high kidney donor profile index group, whereas the patient survival was no different between the high kidney donor profile index and low kidney donor profile index groups. Background High kidney donor profile index (KDPI) kidneys (KDPI >85%) are often associated with increased risks of post-kidney transplant (KT) complications and greater health care utilization (HCU), particularly in elderly recipients with multiple comorbidities. These concerns frequently lead to underutilization of high KDPI kidneys in older transplant candidates, thereby limiting their access to transplantation despite potential clinical benefits. The aim of this study was to compare post-KT HCU between elderly recipients of high versus low KDPI deceased donor kidneys. The primary outcome included differences in hospital readmissions, surgical interventions, and outpatient service use at multiple post-transplant time points. Secondary outcome included graft function, graft survival, and patient survival. Methods A retrospective analysis of elderly solitary KT recipients (age ≥65 years) between January 1, 2011, and December 31, 2020. Patients were stratified into high KDPI (>85%, n =160) and low KDPI (≤85%, n =453) groups. We assessed inpatient and outpatient HCU, including readmissions at 30, 90, and 365 days post-transplant, surgical interventions, and outpatient visits (emergency department, transplant clinic, endocrine clinic, and ambulatory infusion units). Results There were no statistically significant differences between high and low KDPI groups in rates of hospital readmissions, surgical interventions, or outpatient visits (all P > 0.05). Delayed graft function rates were also similar ( P = 0.61). The low KDPI group had significantly higher eGFR at 4 months, 1, 2, and 3 years post-transplant (all P < 0.001). However, days alive and out of the hospital within 90 and 365 days post-transplant were comparable between the groups (all P > 0.05). Overall patient survival was similar ( P = 0.08), although death-censored graft loss was significantly higher in the high KDPI group ( P = 0.001). Conclusions Among elderly KT recipients, high KDPI kidney recipients had comparable post-transplant HCU and overall survival with those receiving low KDPI kidneys, despite lower long-term graft function. These findings suggest that high KDPI kidneys remain a viable option for older patients, offering timely access to transplantation.

Background Secondary lymphedema frequently occurs following surgery, malignancy, trauma, or radiation and is characterized by limb swelling, discomfort, and recurrent infections. Two advanced supermicrosurgical techniques—lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT)—have recently gained popularity as treatment options. However, long-term outcome data for these procedures remain limited. This systematic review and meta-analysis aim to evaluate the long-term efficacy of LVA and VLNT in patients with secondary lymphedema followed for more than 2 years postoperatively, focusing on outcomes such as cellulitis rates and limb circumference. Methods This study followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Inclusion criteria encompassed studies involving adult patients with secondary lymphedema treated with LVA or VLNT and with at least 24 months of follow-up. The primary outcomes were annual cellulitis incidence and limb circumference change, analyzed separately for upper and lower extremities. Meta-analysis was conducted using R version 4.3.1. Pooled effect sizes were estimated using random-effects models. Subgroup and sensitivity analyses were also performed. Results A total of 23 studies met the inclusion criteria, covering 648 limbs treated with either LVA (n = 216) or VLNT (n = 432). The weighted average patient age was 56.3 years, and the cohort was predominantly female (99.9%). For LVA, the pooled mean reduction in annual cellulitis events was −1.13 (95% confidence interval [CI], −1.70 to −0.57) for upper extremities and −1.32 (95% CI, −2.08 to −0.55) for lower extremities. VLNT yielded greater reductions in cellulitis, with pooled mean differences of −2.43 (95% CI, −3.36 to −1.50) and −1.38 (95% CI, −2.11 to −0.65) for upper and lower limbs, respectively. Additionally, VLNT reduced limb circumference by 42.7% (95% CI, 36.7–49.7) in upper extremities and 21.98% (95% CI, 19.8–24.4) in lower extremities. Conclusion LVA and VLNT both result in durable, long-term improvements in cellulitis rates, and VLNT was shown to reduce limb circumference. Given the significant impact on patient quality of life, these interventions should remain integral to the treatment algorithm for secondary lymphedema.

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.