Citations

Background and Objective: Enhanced Recovery After Surgery (ERAS) protocols and minimally invasive techniques may accelerate recovery following pancreatoduodenectomy (PD). We evaluated the feasibility and safety of combining minimally invasive PD with a tailored ERAS protocol on post-PD outcomes and quality of life (QoL). Methods: Patients undergoing PD from 2023 to 2025 were identified. The 2019 ERAS Society recommendations for PD were implemented. Multivariable regression was used for adjusted analyses, with performance assessed by area under the curve (AUC) and Brier scores. QoL was measured using the European Organisation for Research and Treatment of Cancer QLQ-C30 and PAN-26 modules. Results: Of 113 patients, 67.3% underwent robotic and 32.7% open PD with comparable baseline characteristics. Postoperative day (POD) 3 discharge occurred in 34.2% of robotic cases and none of the open cases ( P < 0.001). POD 3 discharge correlated with fewer cumulative 90-day hospital days (3 days vs 5 days, P < 0.001) and overall complications (42.3% vs 68.0%, P = 0.031), without differences in major complications, readmissions, or 90-day mortality. POD 1 drain fluid amylase (DFA) was lower in POD 3 discharges (40 U/L vs 808 U/L, P = 0.014), and DFA <300 U/L identified patients likely to achieve POD 3 discharge without adverse events with good discrimination and calibration (AUC = 0.843; Brier = 0.120). Early discharge was associated with improved overall QoL (+5.6 vs −15.0; P = 0.006) without differences in pain scores (+8.3 vs +12.5; P = 0.240). Conclusions: ERAS protocols with minimally invasive PD facilitated safe POD 3 discharge. POD 1 DFA <300 U/L may help identify patients safe for early discharge without compromising outcomes or QoL.

Background General surgery malpractice premiums vary across states. We examined whether legal, regulatory, and payment measures were associated with premium levels and annual changes. Methods We analyzed 50 states during 2013-2023, expressing monetary measures in 2023 dollars. Between-state regressions evaluated mean premiums; annual models included state- and year-fixed effects. Generalized caps included restrictions on noneconomic recovery in at least one ordinary medical-liability claim category. Policy-change analyses were exploratory. Results Among 550 state-years, each additional mean annual payment report per million residents was associated with 2.32% higher mean premiums across states (95% CI, 1.20%-3.44%; P < .001). The adjusted cap association was −18.53% (95% CI, −37.11% to 5.53%; P = .118); judicial climate and premium regulation were also nonsignificant. Within-state payment-frequency and payment-size associations were nonsignificant. Three states changed generalized cap status; event-time estimates showed pre-change differences (joint P = .016), limiting causal interpretation. Discussion Higher payment frequency was associated with higher average premiums across states, but year-to-year changes in payment frequency within a given state were not detectably associated with that state’s own premium changes. Cap estimates varied depending on how caps were defined and remained statistically uncertain. These ecological findings do not establish causal effects or support specific policy prescriptions.

Background Sarcopenia is associated with worse outcomes in pancreatic cancer patients, but longitudinal body composition changes during neoadjuvant therapy remain poorly understood. Methods A retrospective review identified patients who underwent pancreatectomy, either upfront or after neoadjuvant therapy, for pancreatic adenocarcinoma between 2011 and 2021. Skeletal muscle area, index, and mean attenuation were calculated from CT images throughout the treatment course to assess sarcopenia. Multivariable generalized linear and logistic regression models were used to assess associations between sarcopenia, neoadjuvant therapy, and postoperative outcomes. Results A total of 72 patients were included: 32 who underwent neoadjuvant therapy and 40 who underwent upfront surgery. Forty-one (57%) patients had sarcopenia at diagnosis (65% upfront surgery vs 47% neoadjuvant, P = 0.154). Post-neoadjuvant therapy, 15.6% developed and 18.8% resolved sarcopenia. Median skeletal muscle mean attenuation increased by 2.4 HU after neoadjuvant therapy ( P = 0.02). Patients receiving neoadjuvant therapy were more likely to undergo nutrition consultation prior to surgery (61% vs 7%, P = 0.003). Neoadjuvant therapy was also associated with higher postoperative albumin levels (β = 0.244; 95% CI 0.041-0.446). Baseline sarcopenia diagnosed by skeletal muscle area was associated with increased postoperative complications (OR 13.696; 95% CI 2.537-73.921), while neoadjuvant therapy did not significantly impact complications (OR 0.384; 95% CI 0.12-1.226). Conclusions Patients who completed neoadjuvant therapy and underwent resection did not have increased rates of sarcopenia and were more likely to receive preoperative nutrition consultation and have higher postoperative albumin levels. The neoadjuvant period may represent an opportunity for sarcopenia assessment, nutritional optimization, and multimodal prehabilitation prior to pancreatectomy.

Background: Robotic cholecystectomy use is increasing, but comparisons with laparoscopic cholecystectomy have largely excluded bailout procedures, limiting assessment of difficult acute cholecystitis. We compared bailout use, downstream outcomes, and 1-year costs between approaches. Study Design: This retrospective cohort study used Healthcare Cost and Utilization Project databases from New York and Florida (2012–2021) to identify adults undergoing inpatient, unscheduled robotic or laparoscopic cholecystectomy for acute cholecystitis. Bailout included conversion to open, subtotal cholecystectomy, or cholecystostomy tube placement. Multilevel regression evaluated bailout, and postoperative outcomes were assessed through 1 year. Results: Among 384,617 patients, 4% underwent robotic and 96% laparoscopic cholecystectomy. Robotic cholecystectomy had higher bailout rates (1.7% vs 1.4%; adjusted OR 1.38, 95% CI 1.21-1.58), including higher odds of conversion to open (OR 1.61, 95% CI 1.28-2.03) and subtotal cholecystectomy (OR 2.02, 95% CI 1.68-2.43), but lower odds of cholecystostomy tube placement (OR 0.42, 95% CI 0.28-0.62). Bile duct injury rates were similar (1.6% for both; p=0.998). Among 5,448 patients requiring bailout, robotic cholecystectomy was associated with fewer postoperative endoscopic biliary (3.1% vs 7.7%; p=0.007) and surgical interventions (2.3% vs 7.5%; p=0.002). Median 1-year cumulative costs remained higher with robotic cholecystectomy ($29,702 vs $24,483; p=0.002). Conclusions: Robotic cholecystectomy was associated with marginally higher bailout use and similar bile duct injury rates but fewer downstream interventions after bailout. These potential benefits did not offset higher 1-year costs.

ABSTRACT Human intestinal diseases, including inflammatory bowel disease (IBD), are difficult to model because existing animal and in vitro systems do not capture the intestine’s integrated vascular, immune, and metabolic complexity. Here, we establish a custom normothermic machine perfusion platform that maintains surgically resected human intestinal tissue for up to 72 hours under near-physiological conditions. Discarded specimens from patients with nonmalignant intestinal diseases, including IBD and diverticulitis, were continuously perfused at 37°C with real-time hemodynamic and metabolic monitoring. Perfusion preserved tissue viability, mucosal architecture, epithelial integrity, oxygen consumption, metabolic activity, and vascular patency. Daily perfusate sampling enabled longitudinal profiling and experimental modulation of inflammatory mediators, revealing patient-specific immune states. This long-duration platform bridges reductionist in vitro models and clinical disease, enabling mechanistic studies of intestinal inflammation and future testing of personalized therapies in intact patient-derived tissue.

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.

BACKGROUND: Patients with locally advanced rectal cancer face substantial costs related to multimodal therapy. However, the extent of this burden is poorly characterized. OBJECTIVE: To characterize the prevalence and predictors of patient-reported financial toxicity after treatment for locally advanced rectal cancer. DESIGN: Multicenter retrospective cohort study with a cross-sectional survey administered to assess patients’ financial concerns as well as clinicodemographic data. SETTING: Three high-volume tertiary academic centers. PATIENTS: Patients who completed treatment for pathological stage II to III rectal adenocarcinoma between 2000 and 2019 and were alive. MAIN OUTCOME MEASURES: Patient-reported financial toxicity and risk factors associated with financial toxicity. RESULTS: A total of 523 patients were identified, 190 (36.3%) responded to the survey, and 2 were excluded for incomplete surveys. Of the responders, 163 (86.7%) were identified as having financial toxicity related to their cancer diagnosis, and most (96.8%) had insurance. Patients with financial toxicity were less likely to have fully paid medical leave (39.8% vs 75%; p = 0.03) compared to patients without financial toxicity. They also reported increased difficulty paying bills ( p < 0.001) and decreased monthly household income ( p < 0.001) due to their diagnosis. Furthermore, these patients reported increased difficulty paying for transportation to medical appointments ( p = 0.002) and were less likely to be completely satisfied with their insurance coverage ( p = 0.003). Feeling well informed regarding treatment-related costs was associated with decreased odds of financial toxicity (OR 0.14; 95% CI, 0.02–0.78; p = 0.02), whereas taking unpaid leave for treatment was associated with increased odds of financial toxicity (OR 4.71; 95% CI, 1.36–16.34; p = 0.01). LIMITATIONS: Cross-sectional design and moderate response rate may introduce selection and recall bias. CONCLUSIONS: Patients undergoing treatment for locally advanced rectal cancer, including those insured, are at risk for financial toxicity due to direct and indirect costs. Effective communication between these patients and physicians regarding the economic implications of treatment is essential to reducing financial toxicity. See Video Abstract . TOXICIDAD FINANCIERA TRAS EL TRATAMIENTO DEL CÁNCER RECTAL LOCALMENTE AVANZADO ANTECEDENTES: Los pacientes con cáncer de recto localmente avanzado enfrentan costos sustanciales relacionados con la terapia multimodal. Sin embargo, la magnitud de esta carga está poco caracterizada. OBJETIVO: Caracterizar la prevalencia y los predictores de la toxicidad financiera reportada por los pacientes después del tratamiento para el cáncer de recto localmente avanzado. DISEÑO: Estudio de cohorte retrospectivo multicéntrico con una encuesta transversal para evaluar las preocupaciones financieras de los pacientes, así como datos clínico-demográficos. ESCENARIO: Tres centros académicos terciarios de alto volumen. PACIENTES: Pacientes que completaron el tratamiento para el adenocarcinoma de recto en estadio patológico II-III entre 2000 y 2019 y estaban vivos. PRINCIPALES MEDIDAS DE RESULTADOS: Toxicidad financiera reportada por los pacientes y factores de riesgo asociados con la toxicidad financiera. RESULTADOS: Se identificó a un total de 523 pacientes, 190 (36,3%) respondieron a la encuesta y 2 fueron excluidos por encuestas incompletas. De los encuestados, 163 (86,7 %) presentaron toxicidad financiera relacionada con su diagnóstico de cáncer, y la mayoría (96,8 %) contaba con seguro médico. Los pacientes con toxicidad financiera tuvieron menos probabilidades de tener licencia médica con goce de sueldo completo (39,8 % frente a 75 %; p = 0,03) en comparación con los pacientes sin toxicidad financiera. También informaron mayor dificultad para pagar facturas ( p < 0,001) y una disminución de los ingresos familiares mensuales ( p < 0,001) debido a su diagnóstico. Además, estos pacientes informaron mayor dificultad para pagar el transporte a las citas médicas ( p = 0,002) y menor probabilidad de estar completamente satisfechos con su cobertura médica ( p = 0,003). Sentirse bien informado sobre los costos relacionados con el tratamiento se asoció con una menor probabilidad de toxicidad financiera (OR: 0,14; IC del 95 %: 0,02-0,78; p = 0,02), mientras que tomar una licencia sin sueldo para el tratamiento se asoció con una mayor probabilidad de toxicidad financiera (OR: 4,71; IC del 95 %: 1,36-16,34; p = 0,01). LIMITACIONES: El diseño transversal y la tasa de respuesta moderada pueden introducir sesgos de selección y de recuerdo. CONCLUSIONES: Los pacientes en tratamiento para el cáncer de recto localmente avanzado, incluidos los asegurados, corren el riesgo de sufrir toxicidad financiera debido a los costos directos e indirectos. Una comunicación eficaz entre estos pacientes y los médicos sobre las implicaciones económicas del tratamiento es esencial para reducir la toxicidad financiera. ( AI-generated translation )

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.

AbstractWith the proliferation of cancer research based on large databases, misalignment of research questions and data set capabilities is inevitable. Nationally maintained databases are appealing to cancer researchers because of the ease of access to large amounts of patient data available for analysis and risk estimation. Data sets that are commonly used in cancer research include the National Cancer Database, the SEER (Surveillance, Epidemiology, and End Results) program of the National Cancer Institute, the SEER–Medicare database, the American College of Surgeons National Surgical Quality Improvement Program, and the Healthcare Cost and Utilization Project databases, among others. Each data set has pros and cons with respect to variable availability and the ability to analyze cancer‐specific outcomes. It is critical for researchers to understand the strengths and limitations of each database. Changing variable definitions, the length of postoperative data collection, and the availability of patient‐reported outcomes or social determinants of health data are examples of factors that researchers must consider when selecting a data set for research purposes. For the current review, the authors summarized the advantages and disadvantages of various national data sets for cohort studies in cancer populations.

The incidence of biliary tract cancer in Ontario, Canada, is rising, highlighting the urgency of clinical trial enrollment to move the needle in cancer‐specific outcomes. The integration of natural language processing and population registries demonstrate the immense potential of future generation registries in allowing us to more accurately discern population‐level data.