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Al Abbas AI, Kuchta K, Talamonti MS, Hogg ME. The Minimally Invasive Approach Confers Improved Outcomes in Frail Cancer Patients Undergoing Hepatectomy: An ACS NSQIP Analysis. J Gastrointest Surg 2024:S1091-255X(24)00392-5. [PMID: 38574963 DOI: 10.1016/j.gassur.2024.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/15/2024] [Accepted: 03/30/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Morbidity for liver resection has decreased and frail patients are undergoing surgery. The impact of the minimally invasive approach (MILR) is unknown. This study aims to evaluate the impact of approach on outcomes in frail patients. METHODS Elective hepatectomies from the 2014-2020 ACS-NSQIP Hepatectomy-specific PUF were reviewed. The five-factor modified frailty index (mFI-5) was used. It includes diabetes, hypertension, functional status, heart failure and dyspnea. Patients were considered frail if their mFI-5 was >2. RESULTS 3,116 patients were included: 2117 (67.9%) minor and 999 (32%) major. There were 2, 254 open cases and 862 MILR. Postoperatively (minor) MILR conferred lower risk of prolonged LOS, discharge not-to-home, transfusion, major complications, and minor complications (P<0.05). Postoperatively (major) MILR had lower incidence of prolonged LOS and any complication (P<0.05). In the minor group, MILR remained independently predictive of lower rates of prolonged LOS (OR: 0.34, 95% CI: 0.28-0.42), discharge not-to-home (0.58, 0.41-0.84), transfusion (0.72, 0.54-0.96), major complication (0.78, 0.62-1) and any complication (0.73, 0.58-0.92). In the major group, MILR remained independently predictive of prolonged LOS (0.60, 0.40-0.89). CONCLUSION MILR conferred lower rates of complications in minor as well as shorter LOS in major hepatectomy. The minimally invasive approach to hepatectomy may benefit frail cancer patients.
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Affiliation(s)
| | | | - Mark S Talamonti
- Northshore University HealthSystem, Northshore, IL; University of Chicago, Chicago, IL
| | - Melissa E Hogg
- Northshore University HealthSystem, Northshore, IL; University of Chicago, Chicago, IL
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Katipally RR, Martinez CA, Pugh SA, Bridgewater JA, Primrose JN, Domingo E, Maughan TS, Talamonti MS, Posner MC, Weichselbaum RR, Pitroda SP. Integrated Clinical-Molecular Classification of Colorectal Liver Metastases: A Biomarker Analysis of the Phase 3 New EPOC Randomized Clinical Trial. JAMA Oncol 2023; 9:1245-1254. [PMID: 37471075 PMCID: PMC10360005 DOI: 10.1001/jamaoncol.2023.2535] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 05/09/2023] [Indexed: 07/21/2023]
Abstract
Importance Personalized treatment approaches for patients with oligometastatic colorectal liver metastases are critically needed. We previously defined 3 biologically distinct molecular subtypes of colorectal liver metastases: (1) canonical, (2) immune, and (3) stromal. Objective To independently validate these molecular subtypes in the phase 3 New EPOC randomized clinical trial. Design, Setting, and Participants This retrospective secondary analysis of the phase 3 New EPOC randomized clinical trial included a bi-institutional discovery cohort and multi-institutional validation cohort. The discovery cohort comprised patients who underwent hepatic resection for limited colorectal liver metastases (98% received perioperative chemotherapy) from May 31, 1994, to August 14, 2012. The validation cohort comprised patients who underwent hepatic resection for liver metastases with perioperative chemotherapy (fluorouracil, oxaliplatin, and irinotecan based) with or without cetuximab from February 26, 2007, to November 1, 2012. Data were analyzed from January 18 to December 10, 2021. Interventions Resected metastases underwent RNA sequencing and microRNA (miRNA) profiling in the discovery cohort and messenger RNA and miRNA profiling with microarray in the validation cohort. Main Outcomes and Measures A 31-feature (24 messenger RNAs and 7 miRNAs) neural network classifier was trained to predict molecular subtypes in the discovery cohort and applied to the validation cohort. Integrated clinical-molecular risk groups were designated based on molecular subtypes and the clinical risk score. The unique biological phenotype of each molecular subtype was validated using gene set enrichment analyses and immune deconvolution. The primary clinical end points were progression-free survival (PFS) and overall survival (OS). Results A total of 240 patients were included (mean [range] age, 63.0 [56.3-68.0] years; 151 [63%] male), with 93 in the discovery cohort and 147 in the validation cohort. In the validation cohort, 73 (50%), 28 (19%), and 46 (31%) patients were classified as having canonical, immune, and stromal metastases, respectively. The biological phenotype of each subtype was concordant with the discovery cohort. The immune subtype (best prognosis) demonstrated 5-year PFS of 43% (95% CI, 25%-60%; hazard ratio [HR], 0.37; 95% CI, 0.20-0.68) and OS of 63% (95% CI, 40%-79%; HR, 0.38; 95% CI, 0.17-0.86), which was statistically significantly higher than the canonical subtype (worst prognosis) at 14% (95% CI, 7%-23%) and 43% (95% CI, 32%-55%), respectively. Adding molecular subtypes to the clinical risk score improved prediction (the Gönen and Heller K for discrimination) from 0.55 (95% CI, 0.49-0.61) to 0.62 (95% CI, 0.57-0.67) for PFS and 0.59 (95% CI, 0.52-0.66) to 0.63 (95% CI, 0.56-0.70) for OS. The low-risk integrated group demonstrated 5-year PFS of 44% (95% CI, 20%-66%; HR, 0.38; 95% CI, 0.19-0.76) and OS of 78% (95% CI, 44%-93%; HR, 0.26; 95% CI, 0.08-0.84), superior to the high-risk group at 16% (95% CI, 10%-24%) and 43% (95% CI, 32%-52%), respectively. Conclusions and Relevance In this prognostic study, biologically derived colorectal liver metastasis molecular subtypes and integrated clinical-molecular risk groups were highly prognostic. This novel molecular classification warrants further study as a possible predictive biomarker for personalized systemic treatment for colorectal liver metastases. Trial Registration isrctn.org Identifier: ISRCTN22944367.
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Affiliation(s)
- Rohan R. Katipally
- Department of Radiation and Cellular Oncology, The University of Chicago Medicine, Chicago, Illinois
| | - Carlos A. Martinez
- Department of Radiation and Cellular Oncology, The University of Chicago Medicine, Chicago, Illinois
| | - Siân A. Pugh
- Department of Oncology, Addenbrooke’s Hospital, Cambridge, England, United Kingdom
| | - John A. Bridgewater
- UCL Cancer Institute, University College London, London, England, United Kingdom
| | - John N. Primrose
- Department of Surgery, University of Southampton, Southampton, England, United Kingdom
| | - Enric Domingo
- Department of Oncology, University of Oxford, Oxford, England, United Kingdom
| | - Timothy S. Maughan
- MRC Oxford Institute for Radiation Oncology, Department of Oncology, University of Oxford, Oxford, England, United Kingdom
| | - Mark S. Talamonti
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois
| | - Mitchell C. Posner
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois
| | - Ralph R. Weichselbaum
- Department of Radiation and Cellular Oncology, The University of Chicago Medicine, Chicago, Illinois
| | - Sean P. Pitroda
- Department of Radiation and Cellular Oncology, The University of Chicago Medicine, Chicago, Illinois
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Choi SH, Kuchta K, Rojas A, Mehdi SA, Ramirez Barriga M, Hays S, Talamonti MS, Hogg ME. Residents perform better technically, have less stress and workload, and prefer robotic to laparoscopic technique during inanimate simulation. Surg Endosc 2023; 37:7230-7237. [PMID: 37395804 DOI: 10.1007/s00464-023-10216-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/11/2023] [Indexed: 07/04/2023]
Abstract
INTRODUCTION With the widespread adoption of minimally invasive surgery, there is a growing need for surgical residents to be trained by a procedure-specific curriculum. This study aimed to evaluate the technical performance and feedback of surgical residents undergoing the robotic and laparoscopic hepaticojejunostomy (HJ) and gastrojejunostomy (GJ) biotissue modules. METHODS A total of 23 PGY-3 surgical residents participated in this study and performed the laparoscopic and robotic HJ and GJ drills, which were recorded and scored by two independent graders using the modified objective structured assessment of technical skills (OSATS). After completing each drill, all participants filled out the NASA Task Load Index (NASA-TLX), Borg Exertion Scale, and Edwards Arousal Rating Questionnaire. RESULTS Twenty-two (95.7%) residents had already received fundamentals of laparoscopic surgery certification. Eighteen (78.3%) residents had robotic virtual simulation training and the median (range) number of robotic surgery console experience was 4 (0-30). In the HJ comparison of the six OSATS domains, the robotic system was superior in Gentleness (p = 0.031). In the GJ comparison, the robotic system was superior in Time and Motion (p < 0.001), Instrument Handling (p = 0.001), Flow of Operation (p = 0.002), Tissue Exposure (p = 0.013), and Summary (p < 0.001). Participants answered significantly higher demand scores for laparoscopy on all six facets of NASA-TLX for both HJ and GJ (p < 0.05). The Borg Level of Exertion was > 2 points higher for laparoscopic HJ and GJ (p < 0.001). Residents rated more Nervousness and Anxiety for laparoscopic compared to robotic (p < 0.05) HJ and GJ. Additionally, when asked to score preference for robotic and laparoscopic approach in terms of technique and ergonomics, residents scored robot as better (laparoscopy worse) for both HJ and GJ in both domains. CONCLUSIONS The robotic surgical system provided a more favorable environment for trainees with less mental and physical burden for minimally invasive HJ and GJ curriculum.
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Affiliation(s)
- Sung Hoon Choi
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Walgreens Building - Floor 2, 2650 Ridge Road, Evanston, IL, 60201, USA
- Division of Hepatobiliary and Pancreas, Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Kristine Kuchta
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Walgreens Building - Floor 2, 2650 Ridge Road, Evanston, IL, 60201, USA
| | - Aram Rojas
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Walgreens Building - Floor 2, 2650 Ridge Road, Evanston, IL, 60201, USA
| | - Syed Abbas Mehdi
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Walgreens Building - Floor 2, 2650 Ridge Road, Evanston, IL, 60201, USA
| | | | - Sarah Hays
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Mark S Talamonti
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Walgreens Building - Floor 2, 2650 Ridge Road, Evanston, IL, 60201, USA
| | - Melissa E Hogg
- Department of Surgery, Evanston Hospital, NorthShore University HealthSystem, Walgreens Building - Floor 2, 2650 Ridge Road, Evanston, IL, 60201, USA.
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Shi Z, Wei J, Rifkin AS, Wang CH, Billings LK, Woo JSH, Talamonti MS, Vogel TJ, Moore E, Brockstein BE, Khandekar JD, Dunnenberger HM, Hulick PJ, Duggan D, Zheng SL, Lee CJ, Helfand BT, Tafur AJ, Xu J. Cancer-associated thrombosis by cancer sites and inherited factors in a prospective population-based cohort. Thromb Res 2023; 229:69-72. [PMID: 37419004 DOI: 10.1016/j.thromres.2023.06.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 05/23/2023] [Accepted: 06/23/2023] [Indexed: 07/09/2023]
Abstract
Cancer-associated thrombosis (CAT) is common and associated with mortality. We estimated CAT rate by cancer sites and inherited factors among cancer patients from the UK Biobank (N =70,406). The 12-month CAT rate after cancer diagnosis was 2.37% overall but varied considerably among cancer sites. Among the 10 cancer sites classified as 'high-risk' of CAT by the National Comprehensive Cancer Network guidelines, 6 had CAT rate <5%. In contrast, 5 cancer sites classified as 'average-risk' by the guidelines had CAT rate >5%. For inherited risk factors, both known mutation carriers in two genes (F5/F2) and polygenic score for venous thromboembolism (VTE) (PGSVTE) were independently associated with increased CAT risk. While F5/F2 identified 6% patients with high genetic-risk for CAT, adding PGSVTE identified 13 % patients at equivalent/higher genetic-risk to CAT than that of F5/F2 mutations. Findings from this large prospective study, if confirmed, provide critical data to update guidelines for CAT risk assessment.
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Affiliation(s)
- Zhuqing Shi
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, IL, USA
| | - Jun Wei
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, IL, USA
| | - Andrew S Rifkin
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, IL, USA
| | - Chi-Hsiung Wang
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, IL, USA
| | - Liana K Billings
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL, USA; University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Jonathan S H Woo
- Division of Hospital Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | | | - Elena Moore
- Kellogg Cancer Center, NorthShore University HealthSystem, Evanston, IL, USA
| | - Bruce E Brockstein
- Kellogg Cancer Center, NorthShore University HealthSystem, Evanston, IL, USA
| | - Janardan D Khandekar
- Kellogg Cancer Center, NorthShore University HealthSystem, Evanston, IL, USA; Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Henry M Dunnenberger
- Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - Peter J Hulick
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL, USA; Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL, USA
| | - David Duggan
- Affiliate of City of Hope, Translational Genomics Research Institute, Phoenix, AZ, USA
| | - S Lilly Zheng
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, IL, USA
| | - Cheong Jun Lee
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Brian T Helfand
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, IL, USA; University of Chicago Pritzker School of Medicine, Chicago, IL, USA; Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Alfonso J Tafur
- Cardiovascular Institute, NorthShore University HealthSystem, Evanston, IL, USA.
| | - Jianfeng Xu
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, IL, USA; University of Chicago Pritzker School of Medicine, Chicago, IL, USA; Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA; Neaman Center for Personalized Medicine, NorthShore University HealthSystem, Evanston, IL, USA.
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Schwarz JL, Kuchta KM, Rojas A, Mehdi S, Hoon Choi S, Keutgen XM, Talamonti MS, Hogg ME. Number of Hepatic Resections and Association with Complication after Metastatic Neuroendocrine Tumor Debulking: An American College of Surgeons NSQIP Database Study. J Am Coll Surg 2023; 237:157-168. [PMID: 37022773 DOI: 10.1097/xcs.0000000000000701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
BACKGROUND Neuroendocrine tumor liver metastases (NELM) are a major source of morbidity and mortality in neuroendocrine tumor patients and can be treated with hepatic debulking surgery (HDS). This study aims to identify variables associated with postoperative morbidity in NELM HDS. STUDY DESIGN This analysis uses the American College of Surgeons NSQIP targeted hepatectomy-specific Participant User File from 2014 to 2020. Surgeries were grouped by number of hepatic resections performed (1 to 5, 6 to 10, greater than 10). Multivariable logistic regression and matching were used to identify prognostic factors of morbidity. RESULTS A total of 1,163 patients were included. A total of 1,011 (87%) had 1 to 5 hepatic resections, 101 (8.7%) had 6 to 10 resections, and 51 (4.4%) had greater than 10 resections. The overall complication rate was 35%, and surgical and medical complications reached 30% and 13%, respectively. Mortality occurred in 11 patients (0.9%). Significantly higher rates of any (34% vs 35% vs 53%, p = 0.021) and surgical complications (29% vs 28% vs 49%, p = 0.007) were noted for those undergoing greater than 10 resections (1 to 5 resections, 6 to 10, greater than 10). "Bleeding requiring transfusion" (p < 0.0001) occurred more frequently in the greater than 10 resection group. On multivariable logistic regression, greater than 10 resections were an independent risk factor for any (odds ratio [OR] 2.53, p = 0.002; OR 2.52, p =. 0013) and surgical (OR 2.53, p = 0.003; OR 2.88, p = 0.005) complications compared with 1 to 5 resections and 6 to 10 resections, respectively. Medical complications (OR 2.34, p = 0.020) and length of stay greater than 5 days (OR 1.98, p = 0.032) were also increased with greater than 10 vs 1 to 5 resections. CONCLUSIONS As reported by NSQIP, NELM HDS were performed safely with low mortality. However, more hepatic resections, especially greater than 10, were associated with increased postoperative morbidity and length of stay.
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Affiliation(s)
- Jason L Schwarz
- From the Department of Surgery, University of Chicago Medicine, Chicago, IL (Schwarz, Keutgen)
| | - Kristine M Kuchta
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL (Kuchta, Rojas, Mehdi, Hoon Choi, Talamonti, Hogg)
| | - Aram Rojas
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL (Kuchta, Rojas, Mehdi, Hoon Choi, Talamonti, Hogg)
| | - Syed Mehdi
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL (Kuchta, Rojas, Mehdi, Hoon Choi, Talamonti, Hogg)
| | - Sung Hoon Choi
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL (Kuchta, Rojas, Mehdi, Hoon Choi, Talamonti, Hogg)
| | - Xavier M Keutgen
- From the Department of Surgery, University of Chicago Medicine, Chicago, IL (Schwarz, Keutgen)
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL (Kuchta, Rojas, Mehdi, Hoon Choi, Talamonti, Hogg)
| | - Melissa E Hogg
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL (Kuchta, Rojas, Mehdi, Hoon Choi, Talamonti, Hogg)
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D’Angelica MI, Ellis RJ, Liu JB, Brajcich BC, Gönen M, Thompson VM, Cohen ME, Seo SK, Zabor EC, Babicky ML, Bentrem DJ, Behrman SW, Bertens KA, Celinski SA, Chan CHF, Dillhoff M, Dixon MEB, Fernandez-del Castillo C, Gholami S, House MG, Karanicolas PJ, Lavu H, Maithel SK, McAuliffe JC, Ott MJ, Reames BN, Sanford DE, Sarpel U, Scaife CL, Serrano PE, Smith T, Snyder RA, Talamonti MS, Weber SM, Yopp AC, Pitt HA, Ko CY. Piperacillin-Tazobactam Compared With Cefoxitin as Antimicrobial Prophylaxis for Pancreatoduodenectomy: A Randomized Clinical Trial. JAMA 2023; 329:1579-1588. [PMID: 37078771 PMCID: PMC10119777 DOI: 10.1001/jama.2023.5728] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 03/23/2023] [Indexed: 04/21/2023]
Abstract
Importance Despite improvements in perioperative mortality, the incidence of postoperative surgical site infection (SSI) remains high after pancreatoduodenectomy. The effect of broad-spectrum antimicrobial surgical prophylaxis in reducing SSI is poorly understood. Objective To define the effect of broad-spectrum perioperative antimicrobial prophylaxis on postoperative SSI incidence compared with standard care antibiotics. Design, Setting, and Participants Pragmatic, open-label, multicenter, randomized phase 3 clinical trial at 26 hospitals across the US and Canada. Participants were enrolled between November 2017 and August 2021, with follow-up through December 2021. Adults undergoing open pancreatoduodenectomy for any indication were eligible. Individuals were excluded if they had allergies to study medications, active infections, chronic steroid use, significant kidney dysfunction, or were pregnant or breastfeeding. Participants were block randomized in a 1:1 ratio and stratified by the presence of a preoperative biliary stent. Participants, investigators, and statisticians analyzing trial data were unblinded to treatment assignment. Intervention The intervention group received piperacillin-tazobactam (3.375 or 4 g intravenously) as perioperative antimicrobial prophylaxis, while the control group received cefoxitin (2 g intravenously; standard care). Main Outcomes and Measures The primary outcome was development of postoperative SSI within 30 days. Secondary end points included 30-day mortality, development of clinically relevant postoperative pancreatic fistula, and sepsis. All data were collected as part of the American College of Surgeons National Surgical Quality Improvement Program. Results The trial was terminated at an interim analysis on the basis of a predefined stopping rule. Of 778 participants (378 in the piperacillin-tazobactam group [median age, 66.8 y; 233 {61.6%} men] and 400 in the cefoxitin group [median age, 68.0 y; 223 {55.8%} men]), the percentage with SSI at 30 days was lower in the perioperative piperacillin-tazobactam vs cefoxitin group (19.8% vs 32.8%; absolute difference, -13.0% [95% CI, -19.1% to -6.9%]; P < .001). Participants treated with piperacillin-tazobactam, vs cefoxitin, had lower rates of postoperative sepsis (4.2% vs 7.5%; difference, -3.3% [95% CI, -6.6% to 0.0%]; P = .02) and clinically relevant postoperative pancreatic fistula (12.7% vs 19.0%; difference, -6.3% [95% CI, -11.4% to -1.2%]; P = .03). Mortality rates at 30 days were 1.3% (5/378) among participants treated with piperacillin-tazobactam and 2.5% (10/400) among those receiving cefoxitin (difference, -1.2% [95% CI, -3.1% to 0.7%]; P = .32). Conclusions and Relevance In participants undergoing open pancreatoduodenectomy, use of piperacillin-tazobactam as perioperative prophylaxis reduced postoperative SSI, pancreatic fistula, and multiple downstream sequelae of SSI. The findings support the use of piperacillin-tazobactam as standard care for open pancreatoduodenectomy. Trial Registration ClinicalTrials.gov Identifier: NCT03269994.
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Affiliation(s)
| | - Ryan J. Ellis
- Memorial Sloan Kettering Cancer Center, New York, New York
- American College of Surgeons, Chicago, Illinois
| | - Jason B. Liu
- American College of Surgeons, Chicago, Illinois
- Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Mithat Gönen
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Susan K. Seo
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Emily C. Zabor
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | | | | | | | | | | | | | | | | | - Paul J. Karanicolas
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Harish Lavu
- Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | | | | | | | | | - Umut Sarpel
- Mount Sinai Medical Center, New York, New York
| | | | | | | | | | | | | | - Adam C. Yopp
- University of Texas Southwestern Medical Center, Dallas
| | - Henry A. Pitt
- American College of Surgeons, Chicago, Illinois
- Rutgers Cancer Institute of New Jersey, New Brunswick
| | - Clifford Y. Ko
- American College of Surgeons, Chicago, Illinois
- Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles
- Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, California
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Choi SH, Kuchta K, Rojas AE, Paterakos P, Talamonti MS, Hogg ME. Does minimally invasive surgery have a different impact on recurrence and overall survival in patients with pancreatic head versus body/tail cancer? J Surg Oncol 2023. [PMID: 36938987 DOI: 10.1002/jso.27240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/22/2023] [Accepted: 03/07/2023] [Indexed: 03/21/2023]
Abstract
OBJECTIVE This study sought to investigate the impact of minimally invasive surgery (MIS) on recurrence and overall survival between patients with pancreatic head versus body/tail cancers. METHODS The risk factors associated with recurrence and long-term outcomes were analyzed according to tumor location and operative modality. RESULTS A total of 288 and 87 patients underwent surgical resection for pancreatic head cancer and body/tail cancer, respectively. The perioperative outcomes and histopathologic results were comparable in open and MIS approach in both head and body/tail groups. There was no difference in local or systemic recurrence patterns and disease-free and overall survival rates according to primary tumor location and surgical modality. During subgroup analysis by stage; however, patients with stage III pancreatic head cancer in the MIS group had a decreased disease-free survival compared with those in the open surgery group (p = 0.020). On multivariate analysis, MIS was not a risk factor of total or local recurrences. CONCLUSIONS Recurrence patterns and overall survival rates of patients did not differ according to tumor location and surgical approach. However, patients with stage III pancreatic head cancer in the MIS group showed inferior disease-free survival relative to patients who underwent open surgery.
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Affiliation(s)
- Sung Hoon Choi
- Department of Surgery, Evanston Hospital, North Shore University Health System, Evanston, Illinois, USA.,Division of Hepatobiliary and Pancreas, Department of Surgery, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Kristine Kuchta
- Department of Surgery, Evanston Hospital, North Shore University Health System, Evanston, Illinois, USA
| | - Aram Eduardo Rojas
- Department of Surgery, Evanston Hospital, North Shore University Health System, Evanston, Illinois, USA
| | - Pierce Paterakos
- Department of Surgery, Evanston Hospital, North Shore University Health System, Evanston, Illinois, USA
| | - Mark S Talamonti
- Department of Surgery, Evanston Hospital, North Shore University Health System, Evanston, Illinois, USA
| | - Melissa E Hogg
- Department of Surgery, Evanston Hospital, North Shore University Health System, Evanston, Illinois, USA
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Sood D, Kuchta K, Paterakos P, Schwarz JL, Rojas A, Choi SH, Vining CC, Talamonti MS, Hogg ME. Extended postoperative thromboprophylaxis after pancreatic resection for pancreatic cancer is associated with decreased risk of venous thromboembolism in the minimally invasive approach. J Surg Oncol 2023; 127:413-425. [PMID: 36367398 DOI: 10.1002/jso.27135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/17/2022] [Accepted: 10/23/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is associated with increased venous thromboembolism (VTE). We sought to compare rates of bleeding complications and VTE in patients receiving extended postoperative thromboprophylaxis (EPT) to those who did not, and identify risk factors for VTE after pancreatectomy for PDAC. METHODS This is a retrospective review of pancreatectomies for PDAC. EPT was defined as 28 days of low molecular weight heparin. Multivariable analysis (MVA) was performed to identify independent risk factors of VTE. RESULTS Of 269 patients included, 142 (52.8%) received EPT. Of those who received EPT, 7 (4.9%) suffered bleeding complications, compared to 6 (4.7%) of those who did not (p = 0.938). There was no significant difference in VTE rate at 90 days (2.8% vs. 2.4%, p = 0.728) or at 1 year (6.3% vs. 7.9%, p = 0.624). On MVA, risk factors for VTE included worse performance status, lower preoperative hematocrit, R1/R2 resection, and minimally invasive (MIS) approach. Among those who received EPT, there was no difference in VTE rate between MIS and open approach. CONCLUSIONS EPT was not associated with a difference in VTE risk or bleeding complications. MIS approach was associated with a higher risk of VTE; however, this was significantly lower among those who received EPT.
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Affiliation(s)
- Divya Sood
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Kristine Kuchta
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Pierce Paterakos
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Jason L Schwarz
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Aram Rojas
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Sung H Choi
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Charles C Vining
- Department of Surgery, The Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Melissa E Hogg
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois, USA
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9
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Rojas A, Paterakos P, Talamonti MS, Hogg ME. Robotic Pancreaticoduodenectomy for Intraductal Papilary Mucinous Neoplasm in a Patient post Roux-en-Y Gastric Bypass. Obes Surg 2023; 33:1309-1310. [PMID: 36745332 DOI: 10.1007/s11695-023-06479-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/11/2023] [Accepted: 01/19/2023] [Indexed: 02/07/2023]
Affiliation(s)
- Aram Rojas
- Department of Surgery, NorthShore University HealtSystem, Room 2527, Walgreen Building, 2650 Ridge Ave, Evanston, IL, 60201, USA.
| | - Pierce Paterakos
- Department of Surgery, NorthShore University HealtSystem, Room 2527, Walgreen Building, 2650 Ridge Ave, Evanston, IL, 60201, USA
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealtSystem, Room 2527, Walgreen Building, 2650 Ridge Ave, Evanston, IL, 60201, USA
| | - Melissa E Hogg
- Department of Surgery, NorthShore University HealtSystem, Room 2527, Walgreen Building, 2650 Ridge Ave, Evanston, IL, 60201, USA
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10
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Rojas A, Paterakos P, Talamonti MS, Hogg ME. Robotic ampullectomy for benign tumors: A video technique demonstration. Cir Esp 2023; 101:58. [PMID: 35508297 DOI: 10.1016/j.cireng.2022.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/14/2022] [Indexed: 01/26/2023]
Affiliation(s)
- Aram Rojas
- NorthShore University HealthSystem, Department of Surgery, Division of HPB Surgery, Evanston, IL, USA
| | - Pierce Paterakos
- NorthShore University HealthSystem, Department of Surgery, Division of HPB Surgery, Evanston, IL, USA
| | - Mark S Talamonti
- NorthShore University HealthSystem, Department of Surgery, Division of HPB Surgery, Evanston, IL, USA
| | - Melissa E Hogg
- NorthShore University HealthSystem, Department of Surgery, Division of HPB Surgery, Evanston, IL, USA.
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11
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Ramirez Barriga M, Rojas A, Roggin KK, Talamonti MS, Hogg ME. Development of a Two-Week Dedicated Robotic Surgery Curriculum for General Surgery Residents. J Surg Educ 2022; 79:861-866. [PMID: 35351431 DOI: 10.1016/j.jsurg.2022.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 01/24/2022] [Accepted: 02/28/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Robotic surgery has seen exponential growth over the past several years. However, there is no standardized training program implemented nationwide. Thus, there is a challenge in how to measure surgical proficiency and how to train future surgeons. METHODS In this study, all PGY3 general surgery residents from the University of Chicago residency program were assigned the curriculum. The curriculum consisted of seven sections: instrument mastery, simulation curriculum, suturing, inanimate drills, laparoscopic/open comparisons, surveys, mentor sessions, and exposure in the operating room. It was administered via a 2-week dedicated robotic rotation. CONCLUSIONS With the inevitable integration of robotic surgery in the operating room, it has become imperative to prepare future surgeons. However, learning curves and a resistance to voluntary compliance have halted progress. Thus, providing mastery-based training and protected time away from clinic duties is paramount. This curriculum aims to reduce these barriers and provide a standardizable training curriculum.
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Affiliation(s)
- M Ramirez Barriga
- Department of Surgery, Northshore University HealthSystem, Evanston, Illinois.
| | - Aram Rojas
- Department of Surgery, Northshore University HealthSystem, Evanston, Illinois
| | - Kevin K Roggin
- Division of General Surgery, Department of Surgery, University of Chicago Medicine, Evanston, Illinois
| | - Mark S Talamonti
- Department of Surgery, Northshore University HealthSystem, Evanston, Illinois; Division of General Surgery, Department of Surgery, University of Chicago Medicine, Evanston, Illinois
| | - Melissa E Hogg
- Department of Surgery, Northshore University HealthSystem, Evanston, Illinois; Division of General Surgery, Department of Surgery, University of Chicago Medicine, Evanston, Illinois
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12
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Vining CC, Kuchta K, Al Abbas AI, Hsu PJ, Paterakos P, Schuitevoerder D, Sood D, Roggin KK, Talamonti MS, Hogg ME. Bile leak incidence, risk factors and associated outcomes in patients undergoing hepatectomy: a contemporary NSQIP propensity matched analysis. Surg Endosc 2022; 36:5710-5723. [PMID: 35467144 DOI: 10.1007/s00464-021-08938-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 12/06/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite advances in surgical technique, bile leak remains a common complication following hepatectomy. We sought to identify incidence of, risk factors for, and outcomes associated with biliary leak. STUDY DESIGN This is an ACS-NSQIP study. Distribution of bile leak stratified by surgical approach and hepatectomy type were identified. Univariate and multivariate factors associated with bile leak and outcomes were evaluated. RESULTS Robotic hepatectomy was associated with less bile leak (5.4% vs. 11.4%; p < 0.001) compared to open. There were no significant differences in bile leak between robotic and laparoscopic hepatectomy (5.4% vs. 5.3%; p = 0.905, respectively). Operative factors risk factors for bile leak in patients undergoing robotic hepatectomy included right hepatectomy [OR 4.42 (95% CI 1.74-11.20); p = 0.002], conversion [OR 4.40 (95% CI 1.39-11.72); p = 0.010], pringle maneuver [OR 3.19 (95% CI 1.03-9.88); p = 0.044], and drain placement [OR 28.25 (95% CI 8.34-95.72); p < 0.001]. Bile leak was associated with increased reoperation (8.7% vs 1.7%, p < 0.001), 30-day readmission (26.6% vs 6.8%, p < 0.001), 30-day mortality (2% vs 0.9%, p < 0.001), and complications (67.2% vs 23.4%, p < 0.001) for patients undergoing MIS hepatectomy. CONCLUSION While MIS confers less risk for bile leak than open hepatectomy, risk factors for bile leak in patients undergoing MIS hepatectomy were identified. Bile leaks were associated with multiple additional complications, and the robotic approach had an equal risk for bile leak than laparoscopic in this time period.
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Affiliation(s)
- Charles C Vining
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Kristine Kuchta
- Department of Surgery, NorthShore University HealthSystem, Walgreens Building-Floor 2, 2650 Ridge Road, Evanston, IL, 60201, USA
| | - Amr I Al Abbas
- Department of Surgery, University of Texas Southwestern, Dallas, USA
| | - Phillip J Hsu
- Department of Surgery, University of Chicago, Chicago, USA
| | - Pierce Paterakos
- Department of Surgery, NorthShore University HealthSystem, Walgreens Building-Floor 2, 2650 Ridge Road, Evanston, IL, 60201, USA
| | | | - Divya Sood
- Department of Surgery, University of Chicago, Chicago, USA
| | - Kevin K Roggin
- Department of Surgery, University of Chicago, Chicago, USA
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystem, Walgreens Building-Floor 2, 2650 Ridge Road, Evanston, IL, 60201, USA
| | - Melissa E Hogg
- Department of Surgery, NorthShore University HealthSystem, Walgreens Building-Floor 2, 2650 Ridge Road, Evanston, IL, 60201, USA.
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13
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Sood D, Kuchta KM, Paterakos P, Vining CC, Talamonti MS, Hogg ME. Extended Postoperative Thromboprophylaxis after Pancreatic Resection for Pancreatic Cancer Is Associated with Decreased Risk of Venous Thromboembolism in the Minimally Invasive Approach. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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14
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Ferral H, Alonzo MJ, Datri J, Hogg ME, Marsh R, Talamonti MS. Endovascular management of portal vein obstruction in hepatobiliary cancer patients. J Surg Oncol 2021; 125:392-398. [PMID: 34643276 DOI: 10.1002/jso.26713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 10/02/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND OBJECTIVES The purpose of this article is to describe the procedural safety, technical success, and clinical success of endovascular management of portal and mesenteric venous obstruction in patients with hepatobiliary neoplasms. METHODS Institutional Review Board (IRB)-approved HIPAA compliant retrospective review of 21 consecutive patients with hepatobiliary malignancies who underwent endovascular portal vein recanalization and stent placement between January 2012 and March 2020. Clinical diagnoses were pancreatic cancer (n = 19), colon cancer metastatic to the liver (n = 1), and cholangiocarcinoma (n = 1). Presenting signs and symptoms included: ascites, abdominal pain, abnormal liver function tests, diarrhea, and gastrointestinal bleeding. Stent patency and patient survival are presented with Kaplan-Meier method. RESULTS The technical success rate was 100%. A transhepatic approach was used in 20 cases (95.2%); trans-splenic access in one. Primary stent patency was 95.2%, 84%, and 68% at 1, 3, and 6 months, respectively. All stent occlusions were caused by tumor progression. A total of 80% of patients reported symptomatic improvement. Patient survival at 10 months was 40%. The early death rate was 4.76%. There were no bleeding complications from the percutaneous tracts. CONCLUSION Endovascular recanalization with stent placement is safe with high technical and clinical success.
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Affiliation(s)
- Hector Ferral
- Department of Radiology, Section of Interventional Radiology, NorthShore University HealthSciences, Evanston, Illinois, USA
| | - Marc J Alonzo
- Department of Radiology, Section of Interventional Radiology, NorthShore University HealthSciences, Evanston, Illinois, USA
| | - Jewel Datri
- Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Melissa E Hogg
- Department of Surgery, Hepatobiliary Surgery, NorthShore University HealthSciences, Evanston, Illinois, USA
| | - Robert Marsh
- Department of Medicine, Oncology, NorthShore University HealthSciences, Evanston, Illinois, USA
| | - Mark S Talamonti
- Department of Surgery, Hepatobiliary Surgery, NorthShore University HealthSciences, Evanston, Illinois, USA
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15
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Vining CC, Kuchta K, Berger Y, Paterakos P, Schuitevoerder D, Roggin KK, Talamonti MS, Hogg ME. Robotic pancreaticoduodenectomy decreases the risk of clinically relevant post-operative pancreatic fistula: a propensity score matched NSQIP analysis. HPB (Oxford) 2021; 23:367-378. [PMID: 32811765 DOI: 10.1016/j.hpb.2020.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 06/08/2020] [Accepted: 07/07/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND A single-institution study demonstrated robotic pancreaticoduodenectomy (RPD) was protective against clinically-relevant postoperative pancreatic fistula (CR-POPF) compared to open pancreaticoduodenectomy (OPD). We sought to compare the national rate of CR-POPF by approach. METHODS Procedure-targeted pancreatectomy Participant User Data File was queried from 2014 to 2017 for all patients undergoing pancreaticoduodenectomy. A modified fistula risk score was calculated and patients were stratified into risk categories. Multivariate logistic regression and propensity score matching was used. RESULTS The rate of CR-POPF (15.6% vs. 11.9%; p = 0.026) was higher in OPD compared to RPD. On subgroup analysis, OPD had higher CR-POPF in high risk patients (32.9% vs. 19.4%; p = 0.007). On multivariable analysis OPD was a predictor of increased CR-POPF (Odds Ratio [OR] = 1.61 [1.15-2.25]; p = 0.005). Other operative factors associated with increased CR-POPF included soft pancreatic texture (OR = 2.65 [2.27-3.09]; p < 0.001) and concomitant visceral resection (OR = 1.41 [1.03-1.93]; p = 0.031). Increased duct size (reference <3 mm) was predictive of decreased CR-POPF: 3-6 mm (OR = 0.70 [0.61-0.81]; p < 0.001) and ≥6 mm (OR = 0.47 [0.37-0.60]; p < 0.001). Following propensity score matching, RPD continued to be protective against the occurrence of CR-POPF (OR = 1.54 [1.09-2.17]; p = 0.013). CONCLUSIONS This is the largest multicenter study to evaluate the impact of RPD on POPF. It suggests that RPD can be protective against POPF, especially for high risk patients.
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Affiliation(s)
| | - Kristine Kuchta
- NorthShore University HealthSystem, Department of Surgery, USA
| | - Yaniv Berger
- University of Chicago, Department of Surgery, USA
| | | | | | | | | | - Melissa E Hogg
- NorthShore University HealthSystem, Department of Surgery, USA.
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16
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Shi Z, Wei J, Na R, Resurreccion WK, Zheng SL, Hulick PJ, Helfand BT, Talamonti MS, Xu J. Cystic fibrosis F508del carriers and cancer risk: Results from the UK Biobank. Int J Cancer 2020; 148:1658-1664. [PMID: 33300603 DOI: 10.1002/ijc.33431] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/05/2020] [Accepted: 11/24/2020] [Indexed: 01/05/2023]
Abstract
Cystic fibrosis (CF) carriers carrying one defective copy of a CFTR germline mutation are common in the general population. A recent study reported associations of CF carriers with risk for cancers of digestive organs and pancreatic cancer. In the current study, we assessed associations of CFTR F508del carriers with the risk for 54 types of cancers in the UK Biobank, a large population-based study. In Caucasians, compared to the carrier rate of 3.15% (12 357/392274) in noncancer subjects, the rate was significantly higher in cancer patients overall (2621/79619 = 3.29%), especially in patients with colorectal cancer (247/6667 = 3.70%), cancers of gallbladder and biliary tract (21/351 = 5.98%), thyroid cancer (30/665 = 4.51%) and unspecified non-Hodgkin's lymphoma (74/1805 = 4.10%), all P ≤ .05. In contrast, the carrier rate in patients with cancers of lung and bronchus was significantly lower (89/3463 = 2.57%), P = .05. The association of CFTR F508del carriers with these types of cancer remained significant after adjusting for respective cancer-specific risk factors. For pancreatic cancer, although a higher carrier rate (38/1004 = 3.78%) was found in patients with this cancer, the difference was not statistically significant (P = .26). This null association was unlikely due to lack of statistical power; the large sample size of our study had >80% power, at a significance level of .05, to detect an association of >1.5-fold increased risk. In conclusion, the identified associations of CFTR F508del carriers with multiple types of cancer may have potential biological and clinical implications if confirmed in independent study populations.
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Affiliation(s)
- Zhuqing Shi
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Jun Wei
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Rong Na
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - W Kyle Resurreccion
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - S Lilly Zheng
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Peter J Hulick
- Department of Medicine, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Brian T Helfand
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, Illinois, USA.,Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Mark S Talamonti
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, Illinois, USA.,Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois, USA
| | - Jianfeng Xu
- Program for Personalized Cancer Care, NorthShore University HealthSystem, Evanston, Illinois, USA.,Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois, USA
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17
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Vining CC, Kuchta K, Schuitevoerder D, Paterakos P, Berger Y, Roggin KK, Talamonti MS, Hogg ME. Risk factors for complications in patients undergoing pancreaticoduodenectomy: A NSQIP analysis with propensity score matching. J Surg Oncol 2020; 122:183-194. [DOI: 10.1002/jso.25942] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/05/2020] [Indexed: 12/20/2022]
Affiliation(s)
- Charles C. Vining
- Department of Surgery University of Chicago Medicine Chicago Illinois
| | - Kristine Kuchta
- Department of Surgery NorthShore University Health System Evanston Illinois
| | | | - Pierce Paterakos
- Department of Surgery NorthShore University Health System Evanston Illinois
| | - Yaniv Berger
- Department of Surgery University of Chicago Medicine Chicago Illinois
| | - Kevin K. Roggin
- Department of Surgery University of Chicago Medicine Chicago Illinois
| | - Mark S. Talamonti
- Department of Surgery NorthShore University Health System Evanston Illinois
| | - Melissa E. Hogg
- Department of Surgery NorthShore University Health System Evanston Illinois
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18
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Vining CC, Eng OS, Hogg ME, Schuitevoerder D, Silverman RS, Yao KA, Winchester DJ, Roggin KK, Talamonti MS, Posner MC, Turaga KK, Tseng J. Virtual Surgical Fellowship Recruitment During COVID-19 and Its Implications for Resident/Fellow Recruitment in the Future. Ann Surg Oncol 2020; 27:911-915. [PMID: 32424589 PMCID: PMC7233675 DOI: 10.1245/s10434-020-08623-2] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Indexed: 01/18/2023]
Abstract
Background The COVID-19 pandemic has overlapped with the scheduled interview periods of over 20 surgical subspecialty fellowships, including the Complex General Surgical Oncology (CGSO) fellowships in the National Resident Matching Program and the Society of Surgical Oncology’s Breast Surgical Oncology fellowships. We outline the successful implementation of and processes behind a virtual interview day for CGSO fellowship recruitment after the start of the pandemic. Methods The virtual CGSO fellowship interview process at the University of Chicago Medicine and NorthShore University Health System was outlined and implemented. Separate voluntary, anonymous online secure feedback surveys were email distributed to interview applicants and faculty interviewers after the interview day concluded. Results Sixteen of 20 interview applicants (80.0%) and 12 of 13 faculty interviewers (92.3%) completed their respective feedback surveys. Seventy-five percent (12/16) of applicants and all faculty respondents (12/12) stated the interview process was ‘very seamless’ or ‘seamless’. Applicants and faculty highlighted decreased cost, time savings, and increased efficiency as some of the benefits to virtual interviewing. Conclusions Current circumstances related to the COVID-19 pandemic require fellowship programs to adapt and conduct virtual interviews. Our report describes the successful implementation of a virtual interview process. This report describes the technical steps and pitfalls of organizing such an interview and provides insights into the experience of the interviewer and interviewee.
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Affiliation(s)
- Charles C Vining
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Oliver S Eng
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Melissa E Hogg
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA
| | | | | | - Katharine A Yao
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA
| | - David J Winchester
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA
| | - Kevin K Roggin
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Mark S Talamonti
- Department of Surgery, NorthShore University Health System, Evanston, IL, USA
| | - Mitchell C Posner
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Kiran K Turaga
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Jennifer Tseng
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA.
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19
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20
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Denham M, Ujiki M, Stocker SJ, Wang CH, Winchester DJ, Talamonti MS, Linn JG. Incisional Hernia Development after Pancreatic Resections. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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21
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Kantor O, Pitt HA, Talamonti MS, Roggin KK, Bentrem DJ, Prinz RA, Baker MS. Minimally invasive pancreatoduodenectomy: is the incidence of clinically relevant postoperative pancreatic fistula comparable to that after open pancreatoduodenectomy? Surgery 2018; 163:587-593. [PMID: 29454444 DOI: 10.1016/j.surg.2017.12.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 11/07/2017] [Accepted: 12/01/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Studies evaluating the efficacy of minimally invasive approaches to pancreatoduodenectomy (MIS-PD) compared to open pancreatioduodenectomy (OPD) have been limited by selection bias and mixed outcomes. METHODS ACS-NSQIP 2014-2015 pancreas procedure-targeted data were used to identify patients undergoing PD. Intention-to-treat analysis was performed. RESULTS Of 7907 PD patients, 1277 (16%) underwent MIS-PD: 776 (61%) robotic or laparoscopic PD, 304 (24%) hybrid, and 197 (15%) unplanned conversions. There were no differences in demographics or comorbidities. Patients undergoing MIS-PD were less likely to have pancreatic ductal adenocarcinoma (30.9% vs 53.9%, P < 0.01) and less likely to have a dilated pancreatic duct (21.8% vs 46.7%, P < 0.01). 30-day morbidity was less for MIS-PD (63.6% vs 76.9%, P < 0.01), due to decreased delayed gastric emptying DGE) in the MIS-PD group (8.6% vs 15.5%, P < 0.01). 30-day mortality, length-of-stay, and readmissions were not significantly different. Patients undergoing MIS-PD had greater rates of CR-POPF (15.3% vs 13.0%, P = 0.03). On adjusted multivariable analysis, MIS-PD was not associated with CR-POPF (OR 1.05, 95% CI 0.87-1.26) but was associated with decreased DGE (OR 0.57, 95% CI 0.46-0.71). CONCLUSION MIS-PD has comparable short-term outcomes to open PD. While CR-POPF rates are greater for MIS-PD, this increased risk appears related to case-selection bias and not inherent to the MIS-approach.
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Affiliation(s)
- Olga Kantor
- Department of Surgery, University of Chicago, Chicago, IL
| | - Henry A Pitt
- Department of Surgery, Temple University, Philadelphia, PA
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL; Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Kevin K Roggin
- Department of Surgery, University of Chicago, Chicago, IL
| | | | - Richard A Prinz
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL; Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Marshall S Baker
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL; Pritzker School of Medicine, University of Chicago, Chicago, IL.
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22
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Kantor O, Talamonti MS, Wang CH, Roggin KK, Bentrem DJ, Winchester DJ, Prinz RA, Baker MS. The extent of vascular resection is associated with perioperative outcome in patients undergoing pancreaticoduodenectomy. HPB (Oxford) 2018; 20:140-146. [PMID: 29191690 DOI: 10.1016/j.hpb.2017.08.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 07/24/2017] [Accepted: 08/13/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Few studies have examined the relation between extent of vascular resection and morbidity following pancreaticoduodenectomy (PD) with vein resection (PDVR). METHODS Patients undergoing PD for malignancy were identified using the American College of Surgeons National Surgical Quality Improvement Project from 2006 to 2013. Current procedural terminology codes were used to characterize PDVR. RESULTS 9235 patients underwent PD, 977 (10.6%) had PDVR - 640 with direct and 224 with graft repair. PDVR had longer operative times (456 ± 136 vs 374 ± 128 min, p < 0.05) and higher intraoperative transfusions (1.8 ± 3.4 vs 4.3 ± 4.9 units, p < 0.05) than PD alone. On adjusted multivariable regression, PDVR with either direct or graft repairs was associated with higher rates of overall morbidity (OR [odds ratio] 1.50 for direct, 1.74 for graft, p < 0.05), bleeding (OR 2.18 for direct, 3.26 for graft, p < 0.05), and DVT (OR 2.12 for direct, 2.62 for graft, p < 0.05) compared to PD alone. Graft repair was further associated with increased risk of reoperation (OR 1.59), septic shock (OR 2.77) and 30-day mortality (OR 2.72), all p < 0.05. DISCUSSION The risk of significant morbidity and mortality for PDVR is associated with the extent of vascular resection, with graft repairs having increased morbidity and mortality rates.
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Affiliation(s)
- Olga Kantor
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Mark S Talamonti
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA; Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Chi-Hsiung Wang
- Center for Biomedical Research Informatics, NorthShore University HealthSystem, Evanston, IL, USA
| | - Kevin K Roggin
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - David J Bentrem
- Department of Surgery, Northwestern University, Chicago, IL, USA
| | - David J Winchester
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA; Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Richard A Prinz
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA; Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Marshall S Baker
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA; Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.
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Benjamin AJ, Baker TB, Talamonti MS, Bodzin AS, Schneider AB, Winschester DJ, Roggin KK, Bentrem DJ, Suss NR, Baker MS. Liver transplant offers a survival benefit over margin negative resection in patients with small unifocal hepatocellular carcinoma and preserved liver function. Surgery 2018; 163:582-586. [PMID: 29370929 DOI: 10.1016/j.surg.2017.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 12/04/2017] [Accepted: 12/05/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Studies comparing orthotopic liver transplantation to margin negative resection for patients with small unifocal hepatocellular carcinoma have not controlled for degree of cirrhosis. METHODS The National Cancer Database was used to identify patients with preserved liver function (Model for End-stage Liver Disease score ≤12) who underwent orthotopic liver transplantation or margin negative resection for American Joint Committee on Cancer stage I hepatocellular carcinoma lesions <3 cm between 2010 and 2013. Multivariable and Cox regression adjusting for age, demographics, comorbid disease burden, Model for End-stage Liver Disease score, tumor size, and operation were used to compare overall survival between cohorts. RESULTS In the study, 241 (53%) patients underwent orthotopic liver transplantation. In addition, 219 (47%) underwent margin negative resection. On multivariable regression, patients having a Charlson comorbidity score ≥2 were more likely to undergo orthotopic liver transplantation, (odds ratio 1.94, P=.03). African American patients (odds ratio 0.44, P=.02), and patients of advanced age (odds ratio 0.92, P<.001) were more likely to undergo margin negative resection. Patients undergoing orthotopic liver transplantation had longer overall survival than those undergoing margin negative resection (median OS not reached versus 67.6 months, P<.001). Multivariable Cox regression identified surgical procedure as the only independent determinant of survival with margin negative resection conferring a nearly 3-fold increased risk of death (hazard ratio 2.86, P<.001). CONCLUSION Orthotopic liver transplantation offers a survival advantage relative to margin negative resection for patients with small unifocal hepatocellular carcinoma and preserved liver function.
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Affiliation(s)
| | - Talia B Baker
- Department of Surgery, University of Chicago, Chicago, IL
| | - Mark S Talamonti
- Department of Surgery, Northshore University HealthSystem, Evanston, IL
| | - Adam S Bodzin
- Department of Surgery, University of Chicago, Chicago, IL
| | | | | | - Kevin K Roggin
- Department of Surgery, University of Chicago, Chicago, IL
| | | | - Nicholas R Suss
- Department of Surgery, Northshore University HealthSystem, Evanston, IL
| | - Marshall S Baker
- Department of Surgery, Northshore University HealthSystem, Evanston, IL.
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Suss NR, Talamonti MS, Bryan DS, Wang CH, Kuchta KM, Stocker SJ, Bentrem DJ, Roggin KK, Winchester DJ, Marsh R, Prinz RA, Murad FM, Baker MS. Does adjuvant radiation provide any survival benefit after an R1 resections for pancreatic cancer? Surgery 2018; 163:1047-1052. [PMID: 29336810 DOI: 10.1016/j.surg.2017.09.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 08/04/2017] [Accepted: 09/12/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The benefit of adding external beam radiation to adjuvant chemotherapy in patients that have undergone a margin positive resection for early stage, pancreatic ductal adenocarcinoma has not been determined definitively. METHODS The National Cancer Data Base was queried to evaluate the utility of adjuvant radiation in patients with pathologic stage I-II pancreatic ductal adenocarcinoma who underwent upfront pancreatoduodenectomy with a positive margin (margin positive resection) between 2004 and 2013. RESULTS In the study, 1,392 patients met inclusion criteria, of whom 263 (18.9%) were lymph node-negative (pathologic stages IA, IB, IIA) and 1,129 (81.1%) were node-positive (pathologic stage IIB); 938 (67.4%) patients received adjuvant radiation and chemotherapy, while 454 (32.6%) received adjuvant chemotherapy alone. Cox modeling stratified by nodal status demonstrated the benefit of radiation to be statistically significant only in node positive patients (hazard ratio 0.81, 95% confidence interval, 0.71-0.93). Node-positive patients receiving adjuvant radiation and chemotherapy had an adjusted median survival of 17.5 months vs 15.2 months for those receiving adjuvant chemotherapy alone (P=.003). In patients who had negative nodes, there was no difference in overall survival with radiation (22.5 vs 23.6 months, P=.511). CONCLUSION Addition of radiation to adjuvant chemotherapy after a margin positive resection confers a survival benefit albeit limited (about 2 months) in patients with node-positive pancreatic head cancer. (Surgery 2017;160:XXX-XXX.).
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Affiliation(s)
- Nicholas R Suss
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, United States
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, United States
| | - Darren S Bryan
- Department of Surgery, University of Chicago Medicine, Chicago, IL, United States
| | - Chi-Hsiung Wang
- Bioinformatics and Research Core, NorthShore University HealthSystem, Evanston, IL, United States
| | - Kristine M Kuchta
- Bioinformatics and Research Core, NorthShore University HealthSystem, Evanston, IL, United States
| | - Susan J Stocker
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, United States
| | - David J Bentrem
- Department of Surgery, Northwestern University, Chicago, IL, United States
| | - Kevin K Roggin
- Department of Surgery, University of Chicago Medicine, Chicago, IL, United States
| | - David J Winchester
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, United States
| | - Robert Marsh
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL, United States
| | - Richard A Prinz
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, United States
| | - Faris M Murad
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, United States
| | - Marshall S Baker
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, United States; Department of Surgery, University of Chicago Medicine, Chicago, IL, United States.
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Namm JP, Thakrar KH, Wang CH, Stocker SJ, Sur MD, Berlin J, Dale W, Talamonti MS, Roggin KK. A semi-automated assessment of sarcopenia using psoas area and density predicts outcomes after pancreaticoduodenectomy for pancreatic malignancy. J Gastrointest Oncol 2017; 8:936-944. [PMID: 29299352 PMCID: PMC5750184 DOI: 10.21037/jgo.2017.08.09] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/08/2017] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Sarcopenia has been associated with increased adverse outcomes after major abdominal surgery. Sarcopenia defined as decreased muscle volume or increased fatty infiltration may be a proxy for frailty. In conjunction with other preoperative clinical risk factors, radiographic measures of sarcopenia using both muscle size and density may enhance prediction of outcomes after pancreaticoduodenectomy (PD) for malignancy. METHODS Preoperative computed tomography (CT) scans of patients undergoing PD for malignancy were analyzed from a prospective pancreatic surgery database. Sarcopenia was assessed both manually and with a semi-automated technique by measuring the total psoas area index (TPAI) and average Hounsfield units (HU) at the L3 lumbar level to estimate psoas muscle volume and density, respectively. Adjusting for known pre-operative risk factors, preoperative sarcopenia measurements were analyzed relative to perioperative outcomes. RESULTS Sarcopenia assessments of 116 subjects demonstrated good correlation between the semi-automated and the manual techniques (P<0.0001). Lower TPAI (OR 0.34, P=0.009) and HU (OR 0.84, P=0.002) measurements were predictive of discharge to skilled nursing facility (SNF), but not major complications, length of stay, readmissions or recurrence on univariate analysis. Lower TPAI was protective against the risk of organ/space surgical site infection (SSI) including pancreatic fistula (OR 3.12, P=0.019). On multivariate analysis, the semi-automated measurements of TPAI and HU remained as independent predictors of organ/space SSI including pancreatic fistula (OR 4.23, P=0.014) and discharge to SNF (OR 0.79, P=0.019) respectively. CONCLUSIONS When combined with preoperative clinical assessments in patients with pancreatic malignancy, semi-automated sarcopenia metrics are a simple, reproducible method that may enhance prediction of outcomes after PD and help guide clinical management.
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Affiliation(s)
- Jukes P. Namm
- Department of Surgery, Loma Linda University Health, Loma Linda, USA
| | - Kiran H. Thakrar
- Department of Radiology, NorthShore University HealthSystem, Evanston, USA
| | - Chi-Hsiung Wang
- Center for Biomedical Research Informatics, NorthShore University HealthSystem, Evanston, USA
| | - Susan J. Stocker
- Department of Surgery, NorthShore University HealthSystem, Evanston, USA
| | - Malini D. Sur
- Department of Surgery, Mount Sinai Health System, New York, USA
| | - Jonathan Berlin
- Department of Radiology, NorthShore University HealthSystem, Evanston, USA
| | - William Dale
- Department of Supportive Care Medicine, City of Hope, California, USA
| | - Mark S. Talamonti
- Department of Surgery, NorthShore University HealthSystem, Evanston, USA
| | - Kevin K. Roggin
- Department of Surgery, The University of Chicago Medicine, Chicago, USA
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Liu JB, Baker TB, Suss NR, Talamonti MS, Roggin KK, Winchester DJ, Baker MS. Orthotopic liver transplantation provides a survival advantage compared with resection in patients with hepatocellular carcinoma and preserved liver function. Surgery 2017; 162:1032-1039. [DOI: 10.1016/j.surg.2017.07.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 06/07/2017] [Accepted: 07/14/2017] [Indexed: 01/27/2023]
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Gore RM, Pickhardt PJ, Mortele KJ, Fishman EK, Horowitz JM, Fimmel CJ, Talamonti MS, Berland LL, Pandharipande PV. Management of Incidental Liver Lesions on CT: A White Paper of the ACR Incidental Findings Committee. J Am Coll Radiol 2017; 14:1429-1437. [DOI: 10.1016/j.jacr.2017.07.018] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 07/19/2017] [Indexed: 02/06/2023]
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de W Marsh R, Talamonti MS, Baker MS, Posner M, Roggin K, Matthews J, Catenacci D, Kozloff M, Polite B, Britto M, Wang C, Kindler H. Primary systemic therapy in resectable pancreatic ductal adenocarcinoma using mFOLFIRINOX: A pilot study. J Surg Oncol 2017; 117:354-362. [PMID: 29044544 DOI: 10.1002/jso.24872] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 09/11/2017] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Surgery followed by gemcitabine and/or a fluoropyrimidine is standard therapy for resectable PDAC. mFOLFIRINOX (oxaliplatin 85 mg/m2 , irinotecan 180 mg/m2 , leucovorin 400 mg/m2 Day 1, 5-FU 2400 mg/m2 × 48 h IV, peg-filgrastim 6 mg SQ day 3, every 14 days) has substantial activity in metastatic PDAC. We wished to determine the tolerability/efficacy of peri-operative mFOLFIRINOX in resectable PDAC. METHODS Patients with resectable PDAC (ECOG PS 0/1) received four cycles of mFOLFIRINOX pre- and post-surgery. The primary endpoint was completion of preoperative chemotherapy plus resection. Secondary endpoints included completion of all therapy, R0 resection, treatment related toxicity, PFS, and OS. RESULTS Twenty-one patients enrolled: median age 62 (47-78); 20/21 (95%) completed four cycles of preoperative mFOLFIRINOX; response by RECIST was 1 CR, 3 PR, 16 SD; 17/21 (81%) completed resection, 16/21 (76%) R0; 14/21 (66%) completed four cycles of postoperative mFOLFIRINOX. Grade 3 and 4 toxicity occurred in 23% and 14% patients pre-operatively, 26% and 6.0% post-operatively. Nine patients are alive with median follow-up of 27.7 (3.1-47.1) months. CONCLUSIONS PST using mFOLFIRINOX in resectable PDAC is feasible and tolerable. R0 resection rate is high and survival promising, requiring longer follow-up and larger studies for definitive assessment.
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Affiliation(s)
- Robert de W Marsh
- Department of Medicine, Kellogg Cancer Center, NorthShore University HealthSystem, Evanston, Illinois
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois
| | - Marshall S Baker
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois
| | - Mitchell Posner
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois
| | - Kevin Roggin
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois
| | - Jeffrey Matthews
- Department of Surgery, The University of Chicago Medicine, Chicago, Illinois
| | - Daniel Catenacci
- Department of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Mark Kozloff
- Department of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Blase Polite
- Department of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Michele Britto
- Department of Medicine, Kellogg Cancer Center, NorthShore University HealthSystem, Evanston, Illinois
| | - Chi Wang
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois
| | - Hedy Kindler
- Department of Medicine, The University of Chicago Medicine, Chicago, Illinois
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Kantor O, Bryan DS, Talamonti MS, Lutfi W, Sharpe S, Winchester DJ, Prinz RA, Baker MS. Laparoscopic Distal Pancreatectomy for Cancer Provides Oncologic Outcomes and Overall Survival Identical to Open Distal Pancreatectomy. J Gastrointest Surg 2017; 21:1620-1625. [PMID: 28766272 DOI: 10.1007/s11605-017-3506-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/11/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy (LDP) has been shown to provide short-term clinical outcomes similar to open distal pancreatectomy (ODP) for patients with benign tumors. Our aim was to better define oncologic outcomes and long-term survival profiles following LDP for pancreatic ductal adenocarcinoma (PDAC). METHODS We queried the National Cancer Database to identify patients with pathologic stage I-III PDAC who underwent distal pancreatectomy between 2010 and 2013. Logistic regression was performed to examine predictors of oncologic outcomes. Cox modeling was used for survival analysis and to estimate median overall survival (OS). RESULTS One thousand five hundred fifty-four patients were included in the analysis. Patients undergoing LDP and ODP demonstrated identical probabilities of an adequate lymph node sampling and 90-day mortality. Those undergoing LDP demonstrated an increased probability of margin-negative resection (OR 1.78, CI 1.25-2.52) and a decreased probability of a prolonged hospital stay (OR 0.55, CI 0.32-0.95) or readmission (OR 0.56, CI 0.33-0.95) relative to those undergoing ODP. There was no difference in OS between groups (29.6 vs. 23.8 months, p = 0.10). CONCLUSION LDP is an effective modality for managing resectable cancer in the pancreatic body and tail. LDP provides short-term oncologic outcomes and long-term OS rates identical to those for ODP while affording an accelerated recovery.
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Affiliation(s)
- Olga Kantor
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Darren S Bryan
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Waseem Lutfi
- Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Susan Sharpe
- Department of Surgery, MetroHealth Medical Center, Cleveland, OH, USA
| | - David J Winchester
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Richard A Prinz
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Marshall S Baker
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.
- Pritzker School of Medicine, University of Chicago, Chicago, IL, USA.
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Xia BT, Ahmad SA, Al Humaidi AH, Hanseman DJ, Ethun CG, Maithel SK, Kooby DA, Salem A, Cho CS, Weber SM, Stocker SJ, Talamonti MS, Bentrem DJ, Abbott DE. Time to Initiation of Adjuvant Chemotherapy in Pancreas Cancer: A Multi-Institutional Experience. Ann Surg Oncol 2017; 24:2770-2776. [PMID: 28600732 DOI: 10.1245/s10434-017-5918-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Despite randomized trials addressing adjuvant therapy (AT) for pancreas cancer, the ideal time to initiate therapy remains undefined. Retrospective analyses of the ESPAC-3 trial demonstrated that time to initiation of AT did not impact overall survival (OS). Given the absence of confirmatory data outside of a clinical trial, we sought to determine if AT timing in routine clinical practice is associated with OS differences. METHODS Perioperative data of pancreatectomies for ductal adenocarcinoma from five institutions (2005-2015) were assessed. Delay in AT was defined as initiation >12 weeks after surgery. Multivariate analysis was performed to identify predictors of mortality. RESULTS Of 867 patients, 172 (19.8%) experienced omission of AT. Improved OS was observed in patients who received AT compared with patients who did not (24.8 vs. 19.1 months, p < 0.01). Information on time to initiation of AT was available in 488 patients, of whom 407 (83.4%) and 81 (16.6%) received chemotherapy ≤12 and >12 weeks after surgery, respectively. There were no differences in recurrence-free survival or OS (all p > 0.05) between the timely and delayed AT groups. After controlling for perioperative characteristics and tumor pathology, patients who initiated AT ≤ 12 or > 12 weeks after surgery had a 50% lower odds of mortality than patients who only underwent resection (p < 0.01). CONCLUSIONS In a multi-institutional experience of resected pancreas cancer, delayed initiation of AT was not associated with poorer survival. Patients who do not receive AT within 12 weeks after surgery are still appropriate candidates for multimodal therapy and its associated survival benefit.
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Affiliation(s)
- Brent T Xia
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Syed A Ahmad
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Ali H Al Humaidi
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Dennis J Hanseman
- Division of Surgical Oncology, Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Cecilia G Ethun
- Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Shishir K Maithel
- Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
| | - David A Kooby
- Division of Surgical Oncology, Department of Surgery, Emory University, Atlanta, GA, USA
| | - Ahmed Salem
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Clifford S Cho
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA.,Division of Surgical Oncology, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Sharon M Weber
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Susan J Stocker
- Department of Surgery, Northwestern University, Chicago, IL, USA.,Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - David J Bentrem
- Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Daniel E Abbott
- Division of Surgical Oncology, Department of Surgery, University of Wisconsin, Madison, WI, USA.
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Kantor O, Talamonti MS, Pitt HA, Vollmer CM, Riall TS, Hall BL, Wang CH, Baker MS. Using the NSQIP Pancreatic Demonstration Project to Derive a Modified Fistula Risk Score for Preoperative Risk Stratification in Patients Undergoing Pancreaticoduodenectomy. J Am Coll Surg 2017; 224:816-825. [DOI: 10.1016/j.jamcollsurg.2017.01.054] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 01/03/2017] [Accepted: 01/04/2017] [Indexed: 02/08/2023]
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Lutfi W, Talamonti MS, Kantor O, Wang CH, Stocker SJ, Bentrem DJ, Roggin KK, Winchester DJ, Marsh R, Prinz RA, Baker MS. Neoadjuvant external beam radiation is associated with No benefit in overall survival for early stage pancreatic cancer. Am J Surg 2017; 213:521-525. [DOI: 10.1016/j.amjsurg.2016.11.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 11/22/2016] [Accepted: 11/25/2016] [Indexed: 02/06/2023]
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Ajmani G, Hensing TA, Kim KW, Krantz SB, Prinz RA, Talamonti MS, Baker M, Bentrem DJ, Roggin KK, Marsh RDW. Adjuvant chemotherapy and overall survival in patients with node positive esophageal adenocarcinoma treated with neoadjuvant therapy and esophagectomy: A retrospective analysis using the National Cancer Database. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.4_suppl.97] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
97 Background: Node positive disease (N+) is frequent (~40%) following neoadjuvant therapy (NAT) and esophagectomy, yet limited data exist regarding the efficacy of adjuvant chemotherapy (AC) in this setting. There are no randomized studies addressing this question and single-institution, retrospective studies have reported mixed findings. Methods: A retrospective analysis was conducted using the National Cancer Database. 2,258 N+ patients were identified who had received NAT (83.3% chemoradiation and 17.7% chemotherapy alone) followed by esophagectomy. Patients with either incomplete staging or treatment data were excluded, as were those who died within 90 days following esophagectomy. Multivariate logistic regression was used to test for differences in patient characteristics between those who did (AC+) or did not (AC-) receive AC. Overall survival (OS) after surgery, by AC status, was analyzed using Cox regression in a sample propensity matched on relevant demographic and clinical factors. Results: 433/2258 patients received AC (19.2%). Patients who received AC tended to be younger (OR 0.98 per 1-year increase, P = .03) and had a higher socioeconomic status (SES) (OR 1.47 for high vs. low SES, P = .01). Although there were no significant differences in comorbidity (P = .32), AC+ patients had significantly shorter hospital stays after surgery (OR 0.98 per 1-day increase, P = .03). Pathologic T classification was unrelated to the likelihood of receiving AC (P = .39), however patients with a higher pathologic N stage were more likely receive AC (OR 2.12 for pN3 vs. pN1, P < .001). Those receiving AC had demonstrably longer OS from the time of surgery than those who did not (HR 0.78, P = .004). Median OS for the entire cohort was 22.6 months, whereas the administration of AC was associated with an improvement in median OS of 6.2 months (26.3 vs. 20.1 months). Conclusions: This retrospective analysis indicates that AC is associated with a significant improvement in OS (median 6.2 months) in N+ patients following NAT and esophagectomy. Further studies are needed to clarify the optimal role of AC in this setting.
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Affiliation(s)
- Gaurav Ajmani
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - Thomas A. Hensing
- NorthShore University Health System/University of Chicago, Evanston, IL
| | - Ki-Wan Kim
- Kellogg Cancer Center, NorthShore University Health System, Evanston, IL
| | - Seth B. Krantz
- Kellogg Cancer Center, NorthShore University Health System, Evanston, IL
| | - Richard A Prinz
- Department of Surgery, University of Chicago-NorthShore University HealthSystem, Evanston, IL
| | | | - Marshall Baker
- Kellogg Cancer Center, NorthShore University Health System, Evanston, IL
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Kantor O, Talamonti MS, Sharpe S, Lutfi W, Winchester DJ, Roggin KK, Bentrem DJ, Prinz RA, Baker MS. Laparoscopic pancreaticoduodenectomy for adenocarcinoma provides short-term oncologic outcomes and long-term overall survival rates similar to those for open pancreaticoduodenectomy. Am J Surg 2016; 213:512-515. [PMID: 28049562 DOI: 10.1016/j.amjsurg.2016.10.030] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 09/29/2016] [Accepted: 10/14/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND The long-term efficacy of laparoscopic pancreaticoduodenectomy (LPD) relative to open pancreaticoduodenectomy (OPD) for pancreatic adenocarcinoma has not been well studied. METHODS The National Cancer Data Base was used to compare patients undergoing LPD and OPD for stage I-II pancreatic adenocarcinoma between 2010 and 2013. RESULTS 828 (10%) patients underwent LPD and 7385 (90%) OPD. There were no differences in tumor or demographic characteristics between groups. On multivariable analysis adjusted for hospital volume, LPD was associated with a lower rate of readmission (p < 0.01) and trends toward shorter initial length of stay (p = 0.14) and time to adjuvant chemotherapy (p = 0.11). There were no differences between patients undergoing LPD and those undergoing OP in rates of margin negative resection, number of lymph nodes examined, perioperative mortality and median overall survival (20.7 vs 20.9 months, p = 0.68). CONCLUSIONS For patients with localized pancreatic adenocarcinoma, LPD provides short-term oncologic and long-term overall survival outcomes identical to OPD and is associated with decreased rates of readmission and a trend towards accelerated recovery.
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Affiliation(s)
- Olga Kantor
- Department of Surgery, University of Chicago, Chicago, IL, United States
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, United States; Pritzker School of Medicine, University of Chicago, Chicago, IL, United States
| | - Susan Sharpe
- Department of Surgery, University of Chicago, Chicago, IL, United States; Department of Surgery, MetroHealth Medical Center, Cleveland, OH, United States
| | - Waseem Lutfi
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, United States
| | - David J Winchester
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, United States; Pritzker School of Medicine, University of Chicago, Chicago, IL, United States
| | - Kevin K Roggin
- Department of Surgery, University of Chicago, Chicago, IL, United States; Pritzker School of Medicine, University of Chicago, Chicago, IL, United States
| | - David J Bentrem
- Department of Surgery, Northwestern University, Chicago, IL, United States
| | - Richard A Prinz
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, United States; Pritzker School of Medicine, University of Chicago, Chicago, IL, United States
| | - Marshall S Baker
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, United States; Pritzker School of Medicine, University of Chicago, Chicago, IL, United States.
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Kantor O, Talamonti MS, Lutfi W, Wang CH, Winchester DJ, Marsh R, Prinz RA, Baker MS. External radiation is associated with limited improvement in overall survival in resected margin-negative stage IIB pancreatic adenocarcinoma. Surgery 2016; 160:1466-1476. [DOI: 10.1016/j.surg.2016.07.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 05/26/2016] [Accepted: 07/19/2016] [Indexed: 11/26/2022]
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Brown CS, Gwilliam NR, Lapin B, Lufti W, Kyrillos A, Kim KW, Howington JA, Krantz SB, Talamonti MS, Ujiki M. Minimally Invasive Esophagectomy for Esophageal Cancer: Predictors of Utilization and Outcomes in the National Cancer Data Base. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.06.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Namm JP, Thakrar KH, Wang CE, Stocker SJ, Sur MD, Berlin J, Dale W, Talamonti MS, Roggin KK. A Semi-Automated Assessment of Radiographic Sarcopenia Using Psoas Area and Density Predicts Outcomes after Pancreaticoduodenectomy for Malignancy. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Marsh RDW, Zhang SQ, Baker M, Catenacci DV, Kozloff M, Polite BN, Posner MC, Roggin KK, Talamonti MS, Wroblewski K, Kindler HL. Peri-operative modified FOLFIRINOX in resectable pancreatic cancer: A pilot study. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.4103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Marshall Baker
- Kellogg Cancer Center, NorthShore University Health System, Evanston, IL
| | | | | | | | | | | | | | - Kristen Wroblewski
- Health Studies, Pritzker School of Medicine, The University of Chicago, Chicago, IL
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Marsh RDW, Baker M, Catenacci DV, Kozloff M, Polite BN, Posner MC, Roggin KK, Talamonti MS, Kindler HL. Peri-operative modified FOLFIRINOX (mFOLFIRINOX) in resectable pancreatic cancer (PDAC): A pilot study. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.4_suppl.312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
312 Background: Surgical resection plus adjuvant gemcitabine or 5-FU is standard therapy for resectable PDAC. Infusional 5-FU, leucovorin, irinotecan and oxaliplatin (FOLFIRINOX) has substantial activity in metastatic PDAC. Efficacy and tolerability of peri-operative FOLFIRINOX in resectable PDAC is unknown. Methods: Patients (pts) with ECOG PS 0/1 and resectable PDAC confirmed by multidisciplinary review received 4 cycles of mFOLFIRINOX (mFFX)(oxaliplatin 85 mg/m2, irinotecan 180 mg/m2, leucovorin 400 mg/m2 day 1, 5-FU 2400 mg/m2 x 48 hours, peg-filgrastim 6 mg SQ day 3) pre- and 4 cycles post- surgery. Results: 21/21 enrolled pts started therapy (median age: 63 (47-78), 81% ECOG 0). 20/21 pts completed 4 cycles of preoperative mFFX (1 withdrew for toxicity), 17/21 pts had successful surgical resection (3 had disease noted in the liver at surgery) and 14/21 completed 4 cycles of postoperative mFFX (2 pts expired prior to postoperative mFFX within 90 days of surgery -1 from an M.I. and 1 from a GI bleed; 1 pt had excessive toxicity after cycle 5). Radiographic response by RECIST following preoperative therapy was 1 CR, 3 PR, 16 SD, 0 PD. Of the 17 (81%) patients undergoing curative-intent surgery, 16/17 (94%) had R0 resections. Treatment effect was seen in 10/17 specimens with 1 pathologic CR. Doses were modified per protocol in 30% pts preoperatively (neuropathy 1; thrombocytopenia 2; neutropenia 3; diarrhea 2) and 26% postoperatively (neuropathy 3; diarrhea 3; allergic reaction 1). Grade III and IV adverse events were observed in 23% and 14% pts (overlapping) in the preoperative, and 26% and 0.06% pts in the postoperative phases. 18 pts are alive with a median follow up of 17.3 months. Conclusions: 17/21 (81%) pts completed neoadjuvant mFFX and surgical resection. 14/21 (66%) pts completed all planned therapy. Radiographic responses were rare but efficacy is suggested by the high R0 resection rate: 16/17 (94%) in pts undergoing resection, and 16/21 (76%) pts overall. Toxicity was manageable and within the expected range. 8 cycles of mFFX is a feasible and tolerable peri-operative regimen in pts with resectable PDAC and ECOG PS 0/1. Definitive assessment of efficacy will require longer follow up and larger studies. Clinical trial information: NCT01660711.
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Affiliation(s)
| | - Marshall Baker
- Kellogg Cancer Center, NorthShore University Health System, Evanston, IL
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Kantor O, Talamonti MS, Stocker SJ, Wang CH, Winchester DJ, Bentrem DJ, Prinz RA, Baker MS. A Graded Evaluation of Outcomes Following Pancreaticoduodenectomy with Major Vascular Resection in Pancreatic Cancer. J Gastrointest Surg 2016; 20:284-92. [PMID: 26493974 DOI: 10.1007/s11605-015-2957-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 09/14/2015] [Indexed: 01/31/2023]
Abstract
Previous studies examining short- and long-term outcomes of pancreaticoduodenectomy with vascular resection for pancreatic adenocarcinoma have not graded perioperative complication severity. These studies may provide incomplete assessments of the efficacy of vascular resection. In the current study, we evaluated 36 patients who had pancreaticoduodenectomy with major vascular resection. These were matched 1:3 by tumor stage and age to patients who had pancreaticoduodenectomy without vascular resection. Charts were reviewed to identify all complications and 90-day readmissions. Complications were graded as either severe or minor adverse postoperative outcomes, taking into account the total length of stay. There were no statistical differences in patient demographics, comorbidities, or symptoms between the groups. Patients who had vascular resection had significantly increased rates of severe adverse postoperative outcomes, readmissions, lengths of hospital stay, as well as higher hospital costs. Hypoalbuminemia and major vascular resection were independent predictors of severe adverse postoperative outcomes. On multivariate Cox-regression survival analysis, patients who had vascular resection had decreased recurrence-free (12 vs. 17 months) and overall (17 vs. 29 months) survival. Major vascular resection was a predictor of mortality, may be an independent prognostic factor for survival, and may warrant incorporation into future staging systems.
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In H, Kantor O, Sharpe SM, Baker MS, Talamonti MS, Posner MC. Adjuvant Therapy Improves Survival for T2N0 Gastric Cancer Patients with Sub-optimal Lymphadenectomy. Ann Surg Oncol 2016; 23:1956-62. [DOI: 10.1245/s10434-015-5075-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Indexed: 01/17/2023]
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Marsh RDW, Talamonti MS, Katz MH, Herman JM. Pancreatic cancer and FOLFIRINOX: a new era and new questions. Cancer Med 2015; 4:853-63. [PMID: 25693729 PMCID: PMC4472208 DOI: 10.1002/cam4.433] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 01/10/2015] [Accepted: 01/12/2015] [Indexed: 12/24/2022] Open
Abstract
FOLFIRINOX (FFX) was introduced to clinical practice in 2010 following publication of the PRODIGE 4/ACCORD 11 study, which compared this novel regimen to gemcitabine in metastatic pancreatic cancer. Median overall survival, progression-free survival, and objective responses were all superior with FFX and there was improved time to definitive deterioration in quality of life. Despite initial concerns over toxicity, there has been rapid uptake of this regimen, both revolutionizing management and opening the door to innovative research. As experience with FFX has accrued, many questions have arisen including the management of toxicities, the impact of frequent modifications, the optimal number of cycles, integration with other regimens and modalities, interpretation of radiologic and serologic response, utility of molecular signatures, and potential benefit in unique clinical settings such as pre- and postsurgery. This review will closely examine these issues, not only to summarize current knowledge but also to fuel scientific debate.
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Affiliation(s)
- Robert De W Marsh
- Department of Medicine, NorthShore University HealthSystemEvanston, Illinois, 60201
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystemEvanston, Illinois, 60201
| | - Matthew Harold Katz
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer CenterHouston, Texas
| | - Joseph M Herman
- Department of Radiation Oncology and Molecular Radiation Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins HospitalBaltimore, Maryland
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Sharpe SM, Talamonti MS, Wang CE, Prinz RA, Roggin KK, Bentrem DJ, Winchester DJ, Marsh RDW, Stocker SJ, Baker MS. Early National Experience with Laparoscopic Pancreaticoduodenectomy for Ductal Adenocarcinoma: A Comparison of Laparoscopic Pancreaticoduodenectomy and Open Pancreaticoduodenectomy from the National Cancer Data Base. J Am Coll Surg 2015; 221:175-84. [PMID: 26095569 DOI: 10.1016/j.jamcollsurg.2015.04.021] [Citation(s) in RCA: 138] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Revised: 04/06/2015] [Accepted: 04/20/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND There is considerable debate about the safety and clinical equivalence of laparoscopic pancreaticoduodenectomy (LPD) and open pancreaticoduodenectomy (OPD) for pancreatic ductal adenocarcinoma (PDCA). STUDY DESIGN We queried the National Cancer Data Base to identify patients undergoing LPD and OPD for PDCA between 2010 and 2011. Chi-square and Student's t-tests were used to evaluate differences between the 2 approaches. Multivariable logistic regression modeling was performed to identify patient, tumor, or facility factors associated with perioperative mortality. RESULTS Four thousand and thirty-seven (91%) patients underwent OPD. Three hundred and eighty-four (9%) patients underwent LPD. There were no statistical differences between the 2 surgical cohorts with regard to age, race, Charlson score, tumor size, grade, stage, or treatment with neoadjuvant chemoradiotherapy. Laparoscopic pancreaticoduodenectomy demonstrated a shorter length of stay (10 ± 8 days vs 12 ± 9.7 days; p < 0.0001) and lower rates of unplanned readmission (5% vs 9%; p = 0.027) than OPD. In an unadjusted comparison, there was no difference in 30-day mortality between the LPD and OPD cohorts (5.2% vs 3.7%; p = 0.163). Multivariable logistic regression modeling predicting perioperative mortality controlling for age, Charlson score, tumor size, nodal positivity, stage, facility type, and pancreaticoduodenectomy volume identified age (odds ratio [OR] = 1.05; p < 0.0001), positive margins (OR = 1.45; p = 0.030), and LPD (OR = 1.89; p = 0.009) as associated with an increased probability of 30-day mortality; higher hospital volume was associated with a lower risk of 30-day mortality (OR = 0.98; p < 0.0001). In institutions that performed ≥10 LPDs, the 30-day mortality rate of the laparoscopic approach was equal to that for the open approach (0.0% vs 0.7%; p = 1.00). CONCLUSIONS Laparoscopic pancreaticoduodenectomy is equivalent to OPD in length of stay, margin-positive resection, lymph node count, and readmission rate. There is a higher 30-day mortality rate with LPD, but this appears driven by a surmountable learning curve for the procedure.
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Affiliation(s)
- Susan M Sharpe
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Mark S Talamonti
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - Chihsiung E Wang
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - Richard A Prinz
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - Kevin K Roggin
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - David J Bentrem
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - David J Winchester
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - Robert D W Marsh
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - Susan J Stocker
- Department of Surgery, NorthShore University Health System, Evanston, IL
| | - Marshall S Baker
- Department of Surgery, NorthShore University Health System, Evanston, IL.
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Talamonti MS. Screening Strategies for Pancreatic Cancer in High-Risk Patients: Opportunities to Make a Real Impact But Many Questions and Challenges Still Ahead. JAMA Surg 2015; 150:518-9. [PMID: 25853232 DOI: 10.1001/jamasurg.2015.0391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois
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45
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Liu JB, Meiselman MS, Talamonti MS. Interval Asymptomatic Infected Postpancreatic Resection Fluid Collections Managed with Endoscopic Ultrasound-guided Drainage. Am Surg 2015. [DOI: 10.1177/000313481508100404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Jason B. Liu
- University of Chicago Medical Center Chicago, Illinois
| | - Mick S. Meiselman
- Department of Gastroenterology Advanced Endoscopy Program NorthShore University Health System Evanston, Illinois
| | - Mark S. Talamonti
- Department of Surgery NorthShore University Health System Evanston, Illinois
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46
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Liu JB, Meiselman MS, Talamonti MS. Interval asymptomatic infected postpancreatic resection fluid collections managed with endoscopic ultrasound-guided drainage. Am Surg 2015; 81:E146-E147. [PMID: 25831160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Jason B Liu
- University of Chicago Medical Center, Chicago, Illinois, USA
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47
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Brown CS, Lapin B, Wang C, Goldstein JL, Linn JG, Denham W, Haggerty SP, Talamonti MS, Howington JA, Carbray J, Ujiki MB. Reflux control is important in the management of Barrett's Esophagus: results from a retrospective 1,830 patient cohort. Surg Endosc 2015; 29:3528-34. [PMID: 25676204 DOI: 10.1007/s00464-015-4103-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 01/27/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND It is unknown whether acid/reflux control prevents progression in Barrett's esophagus. In this study, we investigate whether medical or surgical control of reflux is associated with a decreased risk of progression to dysplasia/esophageal adenocarcinoma. METHODS We retrospectively collected and analyzed data from a cohort of Barrett's esophagus patients participating in this single-center study comprised of all patients diagnosed with Barrett's esophagus at NorthShore University Health System hospitals and clinics over a 10-year period. Patients were followed in order to identify those progressing from Barrett's esophagus to low-grade dysplasia, high-grade dysplasia, and esophageal adenocarcinoma. We collected information from the patient's electronic medical records regarding demographic, endoscopic findings, histological findings, smoking/alcohol history, medication use including proton-pump inhibitors, and history of bariatric and antireflux surgery. Risk-adjusted modeling was performed using multivariable logistic regression. RESULTS This study included 1,830 total Barrett's esophagus patients, 102 of which had their Barrett's esophagus progress to low-grade dysplasia, high-grade dysplasia, or esophageal adenocarcinoma (confirmed by biopsy) with an annual incidence rate of 1.1%. Mean follow-up period was 5.51 years (10,083 patient-years). Compared to the group that did not progress, the group that progressed was older (69.3 ± 13.7 vs. 63.9 ± 13.4 years. p < 0.001) and likely to be male (75 vs. 61%, p < 0.01). In the multivariable analysis, patients who had a history of antireflux surgery (n = 44) or proton-pump inhibitor use without surgery (n = 1,641) were found to progress at significantly lower rates than patients who did not have antireflux surgery or were not taking PPI's (OR 0.18, 95% CI 0.09-0.36). CONCLUSIONS Reflux control was associated with decreased risk of progression to low-grade dysplasia, high-grade dysplasia, or esophageal adenocarcinoma. These results support the use of reflux control strategies such as proton-pump inhibitor therapy or surgery in patients with non-dysplastic Barrett's esophagus for the prevention of progression to dysplasia/adenocarcinoma.
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Affiliation(s)
- Craig S Brown
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave., Suite B665, Evanston, IL, 60201, USA.
- Pritzker School of Medicine, University of Chicago, Chicago, IL, 60637, USA.
| | - Brittany Lapin
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave., Suite B665, Evanston, IL, 60201, USA
| | - Chi Wang
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave., Suite B665, Evanston, IL, 60201, USA
| | - Jay L Goldstein
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave., Suite B665, Evanston, IL, 60201, USA
| | - John G Linn
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave., Suite B665, Evanston, IL, 60201, USA
| | - Woody Denham
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave., Suite B665, Evanston, IL, 60201, USA
| | - Stephen P Haggerty
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave., Suite B665, Evanston, IL, 60201, USA
| | - Mark S Talamonti
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave., Suite B665, Evanston, IL, 60201, USA
| | - John A Howington
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave., Suite B665, Evanston, IL, 60201, USA
| | - Joann Carbray
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave., Suite B665, Evanston, IL, 60201, USA
| | - Michael B Ujiki
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Ave., Suite B665, Evanston, IL, 60201, USA.
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Sur MD, In H, Sharpe SM, Baker MS, Weichselbaum RR, Talamonti MS, Posner MC. Defining the Benefit of Adjuvant Therapy Following Resection for Intrahepatic Cholangiocarcinoma. Ann Surg Oncol 2014; 22:2209-17. [PMID: 25476031 DOI: 10.1245/s10434-014-4275-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intrahepatic cholangiocarcinoma (ICC) is rare but is increasing in incidence. While hepatectomy can be curative, the benefit of adjuvant therapy (AT) remains unclear. We utilized the National Cancer Data Base (NCDB) to isolate predictors of overall survival, describe the national pattern of AT administration, and identify characteristics of patients who experience a survival benefit from AT following resection for ICC. METHODS Patients who were diagnosed with ICC between 1998 and 2006 and underwent surgical resection were identified through the NCDB. Kaplan-Meier and Cox regression analyses evaluated differences in overall survival between patients who received AT and those who did not. RESULTS Overall, 638 patients who underwent surgery for ICC were identified. Multivariate Cox regression analysis identified positive lymph nodes, unexamined lymph nodes, positive margins, and lack of AT as predictors of decreased overall survival; 28.1 % of patients had positive margins while 20.1 % had positive nodes. These patients, as well as those who were younger and had fewer co-morbid conditions, were most likely to receive AT. After adjusting for other prognostic variables, patients were found to significantly benefit from AT if they had positive lymph nodes [chemotherapy: hazard ratio (HR) 0.54, p = 0.0365; chemoradiation: HR 0.50, p = 0.005] or positive margins (chemotherapy: HR 0.44, p = 0.0016; chemoradiation: HR 0.57, p = 0.0039). CONCLUSIONS Positive lymph nodes and positive margins were associated with poor survival after resection for ICC. After controlling for other prognostic factors, AT was associated with significant survival benefits among patients with positive nodes or positive margins.
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Affiliation(s)
- Malini D Sur
- Department of Surgery, The University of Chicago, Chicago, IL, USA,
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Cherenfant J, Talamonti MS, Hall CR, Thurow TA, Gage MK, Stocker SJ, Lapin B, Wang E, Silverstein JC, Mangold K, Odeleye M, Kaul KL, Lamzabi I, Gattuso P, Winchester DJ, Marsh RW, Roggin KK, Bentrem DJ, Baker MS, Prinz RA. Comparison of tumor markers for predicting outcomes after resection of nonfunctioning pancreatic neuroendocrine tumors. Surgery 2014; 156:1504-10; discussion 1510-1. [PMID: 25456943 DOI: 10.1016/j.surg.2014.08.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 08/19/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND This study compares the predictability of 5 tumor markers for distant metastasis and mortality in pancreatic neuroendocrine tumors (PNETs). METHODS A total of 128 patients who underwent pancreatectomy for nonfunctioning PNETs between 1998 and 2011 were evaluated. Tumor specimens were stained via immunochemistry for cytoplasmic and nuclear survivin, cytokeratin 19 (CK19), c-KIT, and Ki67. Univariate and multivariate regression analyses and receiver operating characteristics curve were used to evaluate the predictive value of these markers. RESULTS A total of 116 tumors (91%) were positive for cytoplasmic survivin, 95 (74%) for nuclear survivin, 85 (66.4%) for CK19, 3 for c-KIT, and 41 (32%) for Ki67 >3%. Twelve (9%) tumors expressed none of the markers. Survivin, CK19, and c-KIT had no substantial effect on distant metastasis or mortality. Age >55 years, grade 3 histology, distant metastasis, and Ki67 >3% were associated with mortality (P < .05). A cut-off of Ki67 >3% was the best predictor (83%) of mortality with an area under the curve of 0.85. Ki67 >3% also predicted occurrence of distant metastases with odds ratio of 9.22 and 95% confidence interval of 1.55-54.55 (P < .015). CONCLUSION Of the 5 markers studied, only Ki67 >3% was greatly associated with distant metastasis and death. Survivin, CK19, and c-KIT had no prognostic value in nonfunctioning PNETs.
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50
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Ginsburg M, Ferral H, Alonzo MJ, Talamonti MS. Percutaneous transhepatic placement of a stent-graft to treat a delayed mesoportal hemorrhage after pancreaticoduodenectomy. World J Surg Oncol 2014; 12:315. [PMID: 25315011 PMCID: PMC4203967 DOI: 10.1186/1477-7819-12-315] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 09/25/2014] [Indexed: 12/19/2022] Open
Abstract
Postoperative hemorrhage is one of the most severe complications after pancreaticoduodenectomy. While detection of bleeding from adjacent arteries via conventional angiography and treatment with endovascular arterial coil embolization has been well established, to date no reports of percutaneous therapy for mesoportal hemorrhage have been published. This article describes an unusual case of delayed post-pancreaticoduodenectomy hemorrhage detected on a fluoroscopic drain check and treated with percutaneous transhepatic covered stent placement.
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Affiliation(s)
| | - Hector Ferral
- Department of Radiology, NorthShore University HealthSystem, 2650 Ridge Avenue, Evanston, Illinois 60201, USA.
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