Hepatopancreaticobiliary Resection Arginine Immunomodulation (PRIMe) trial: protocol for a randomised phase II trial of the impact of perioperative immunomodulation on immune function following resection for hepatopancreaticobiliary malignancy

INTRODUCTION

Surgical stress results in immune dysfunction, predisposing patients to infections in the postoperative period and potentially increasing the risk of cancer recurrence. Perioperative immunonutrition with arginine-enhanced diets has been found to potentially improve short-term and cancer outcomes. This study seeks to measure the impact of perioperative immunomodulation on biomarkers of the immune response and perioperative outcomes following hepatopancreaticobiliary surgery.

METHODS AND ANALYSIS

This is a 1:1:1 randomised, controlled and blinded superiority trial of 45 patients. Baseline and perioperative variables were collected to evaluate immune function, clinical outcomes and feasibility outcomes. The primary outcome is a reduction in natural killer cell killing as measured on postoperative day 1 compared with baseline between the control and experimental cohorts.

ETHICS AND DISSEMINATION

This trial has been approved by the research ethics boards at participating sites and Health Canada (parent control number: 223646). Results will be distributed widely through local and international meetings, presentation, publication and ClinicalTrials.gov (identifier: NCT04549662). Any modifications to the protocol will be communicated via publications and ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov identifier: NCT04549662.

Tranexamic acid versus placebo to reduce perioperative blood transfusion in patients undergoing liver resection: protocol for the haemorrhage during liver resection tranexamic acid (HeLiX) randomised controlled trial

INTRODUCTION

Despite use of operative and non-operative interventions to reduce blood loss during liver resection, 20%-40% of patients receive a perioperative blood transfusion. Extensive intraoperative blood loss is a major risk factor for postoperative morbidity and mortality and receipt of blood transfusion is associated with serious risks including an association with long-term cancer recurrence and overall survival. In addition, blood products are scarce and associated with appreciable expense; decreasing blood transfusion requirements would therefore have health system benefits. Tranexamic acid (TXA), an antifibrinolytic, has been shown to reduce the probability of receiving a blood transfusion by one-third for patients undergoing cardiac or orthopaedic surgery. However, its applicability in liver resection has not been widely researched.

METHODS AND ANALYSIS

This protocol describes a prospective, blinded, randomised controlled trial being conducted at 10 sites in Canada and 1 in the USA. 1230 eligible and consenting participants will be randomised to one of two parallel groups: experimental (2 g of intravenous TXA) or placebo (saline) administered intraoperatively. The primary endpoint is receipt of blood transfusion within 7 days of surgery. Secondary outcomes include blood loss, postoperative complications, quality of life and 5-year disease-free and overall survival.

ETHICS AND DISSEMINATION

This trial has been approved by the research ethics boards at participating centres and Health Canada (parent control number 177992) and is currently enrolling participants. All participants will provide written informed consent. Results will be distributed widely through local and international meetings, presentation, publication and ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

NCT02261415.

Periop-01: A randomized controlled trial of extended perioperative tinzaparin to improve disease-free survival in patients with resectable colorectal cancer

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Background: Cancer patients undergoing surgical resection of their tumor are hypercoagulable beyond the period of hospitalization. Preclinical studies demonstrate that the postoperative hypercoagulable state promotes metastases, an effect that is abrogated by administration of perioperative low molecular-weight heparin (LMWH). Methods: We conducted a randomized, open label clinical trial to determine if extended duration thromboprophylaxis using subcutaneous LMWH (tinzaparin 4,500 IU daily), beginning at decision to operate and continuing for 56 days postoperatively, compared to inpatient postoperative thromboprophylaxis only, increased the 3-year disease-free survival (DSF) in patients undergoing resection for colorectal cancer. Secondary outcomes included 5-year overall survival (OS), postoperative bleeding and venous thromboembolism (VTE). Results: Trial recruitment was stopped prematurely after 614 of the planned 1075 patients were registered, following a pre-defined interim analysis for futility. The intention-to-treat analysis included 602 patients with demographics in the table. The 3-year DFS was 78.9% (63/299 recurrences) in the tinzaparin group and 80.5% (59/303 recurrences) in the control group (hazard ratio (HR) 1.09; [95% CI 0.91,1.31; p=0.3]). The 5-year OS was 91.3% in the tinzaparin group and 92.4% in the control group (HR 1.08; [95% CI 0.66,1.79; p=0.1]). The incidence of postoperative VTE was 1.7% and 1.3% in the tinzaparin and control groups, respectively (HR 1.3; [95% CI 0.30,5.69; p=0.7]. The incidence of major bleeding in the first postoperative week was 0.3% and 2% in the tinzaparin and control groups, respectively (HR 0.16; [95% CI 0.02,1.15; p=0.07]. Conclusions: Extended duration perioperative anticoagulation with tinzaparin did not improve DFS or OS in colorectal cancer patients undergoing surgical resection. The incidences of postoperative bleeding and VTE were low. Funded by Canadian Institute of Health Research and Leo Pharma Clinical trial information: NCT01455831. [Table: see text]

GATA6 Expression as a predictor of response to perioperative chemotherapy in resectable pancreatic adenocarcinoma: A multicenter Canadian phase II study (NeoPancONE)

TPS638

Background: Prospective studies of the benefit of neoadjuvant chemotherapy in resectable pancreatic adenocarcinoma (PDAC) have been reported. The ideal peri-operative regimen is yet to be determined. Adjuvant FOLFIRINOX (mFFX) in resected PDAC has been proven to improve overall survival (OS) relative to adjuvant gemcitabine. An accepted perioperative approach involves delivering the majority of chemotherapy (6-8 cycles) in the pre-operative setting, while the remainder (of 12 cycles) is administered post-operatively. This pre-operative treatment period may allow for chemosensitivity assessment, and better patient selection for surgery, thereby improving R0 resection rates and reducing the frequency of early post-operative recurrence. Data from the COMPASS trial (NCT02750657) has shown that shown that low levels of the transcription factor GATA6 expression is a putative surrogate for the RNA Moffit signature and predictive of a chemoresistant phenotype in advanced PDAC. NeoPancONE will evaluate clinical outcomes and molecular biomarkers including GATA6 and radiomic biomarkers in pts with resectable PDAC treated with perioperative mFFX. Methods: NeoPancONE is a Phase 2, open-label, single arm study in pts with resectable PDAC. Tissue and serum are collected for biomarker testing, including GATA6 by FISH and IHC (1) with expression levels measured by RNAseq, and longitudinal ctDNA analysis. Pts with histologically confirmed, resectable PDAC and ECOG PS 0-1 will be recruited over 2.5 years. Resectability will be determined by central review as per NCCN guidelines. The primary objective is to evaluate disease-free survival in resectable PDAC treated with peri-operative mFFX according to baseline tumor GATA6 expression level. The ratio of GATA6-high to low is expected to be approximately 4:1[1]. Assuming 1-year disease-free survival of 65% in the GATA6-high, compared to 34% in the GATA6-low cohort, this corresponds to a hazard ratio of 2.5. With 80% power and a 5% 2-sided significance level, a total of 84 patients will be enrolled with 67 events expected in the GATA6 high cohort and 17 in GATA6 low. Participants will receive up to 6 cycles of neoadjuvant mFFX. After neoadjuvant chemotherapy, definitive surgical resection will proceed as deemed appropriate by a hepatobiliary surgeon. Post-operatively, pts will receive up to 6 cycles of adjuvant chemotherapy. Secondary objectives include determination of overall response rate, incidence of R0 resection, OS, Moffit gene expression profiling (RNAseq), ctDNA, and radiomic signatures to predict outcomes. Enrolment for NeoPancONE began in October 2020 and is being conducted at 8 sites across Canada. To date, 23 pts have been recruited. The study duration will be five years. Reference: O’Kane G M et al. Clin Can Res Sep 2020. Clinical trial information: NCT04472910.

A single-arm, phase II study of intrahepatic chemotherapy in patients with unresectable colorectal liver metastases

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Background: In Canada, the standard of care for patients with unresectable colorectal liver metastases (uCRLM) is systemic chemotherapy and/or best supportive care. Intrahepatic chemotherapy using floxuridine (FUDR), in addition to systemic chemotherapy, is available in the United States but its adoption outside major centers has been limited. Methods: A single-center, prospective study of intrahepatic chemotherapy for the treatment of patients with uCRLM was initiated at Sunnybrook Health Sciences Centre in 2014. Patients underwent implantation of a hepatic infusion pump with resection of their primary tumor (if in place). Patients were treated with FUDR in addition to systemic chemotherapy (FOLFIRI or FOLFOX). Study objectives include the rate of conversion to complete resection, time to progression (TTP), disease-free survival (DFS), time to progression in liver, overall survival (OS), andresponse rate (RR). Results: From 2014 to present, 46 patients have been enrolled. Median age at the time of HAIP placement was 51 years (30-72 years). Males accounted for 61% (28/46). All patients received at least one cycle of systemic chemotherapy prior to surgery. 44 patients received a minimum of one cycle of FUDR, with the median number of cycles of FUDR received being 7.5 (0-28 cycles). Only one patient was unable to receive any FUDR after surgery. Response rate was 80% (n = 37/46). Three patients are too early for assessment. Eight (17.4%) patients have undergone liver resection. Median number of cycles of FUDR prior to resection was 7 (4-13 cycles). TTP, DFS, time to progression in liver, OS, and safety will be presented. Conclusions: The addition of intrahepatic chemotherapy to best systemic therapy may provide an increase in the rate of conversion to complete hepatic resection in patients with uCRLM. Clinical trial information: ON1233.

Predictors of Post-operative Pain and Opioid Consumption in Patients Undergoing Liver Surgery

BACKGROUND

Post-operative pain management is a critical component of perioperative care. Patients at risk of poorly controlled post-operative pain may benefit from early measures to optimize pain management. We sought to identify risk factors for post-operative pain and opioid consumption in patients undergoing liver resection.

METHODS

This is a multi-institutional prospective nested cohort study of patients undergoing open liver resection. Opioid consumption and pain scores were collected following surgery. To estimate the effects of patient factors on opioid consumption (oral morphine equivalents-OME) and on pain scores (NRS-11), we used generalized linear models and multivariable linear regression model, respectively.

RESULTS

One hundred and fifty-three patients who underwent open liver resection between 2013 and 2016 were included in the study. The mean patient age was 62.2 years, and 43.3% were female. Younger patients were significantly more likely to use more opioids in the early post-operative period (16.7 OME/10 years, p < 0.001). Patient factors that were significantly associated with increased NRS-11 pain scores also included younger patient age (difference in pain score of 0.3/10 years with cough and 0.2/10 years at rest, p < 0.01 for both) as well as a history of analgesic use (difference in pain score of 0.9 with cough and 0.6 at rest, p < 0.01 and p = 0.07, respectively).

CONCLUSION

Younger patients and those with a history of analgesic use are more likely to report higher post-operative pain and require higher doses of opioids. Early identification of these patients, and measures to better manage their pain, may contribute to optimal perioperative care.

Changes in preoperative endoscopic and percutaneous bile drainage in patients with periampullary cancer undergoing pancreaticoduodenectomy in Ontario: effect on clinical practice of a randomized trial

Background

In 2010, a multicentre randomized controlled trial reported increased postoperative complications in pancreaticoduodenectomy (pde) patients undergoing preoperative biliary decompression (pbd). We evaluated the effect of that publication on rates of pbd at the population level.

Methods

This retrospective observational cohort study identified patients undergoing pde for malignancy, 2005-2013, linking them with administrative health care databases covering medical services for a population of 13.5 million. Patients undergoing pbd within 6 weeks before their surgery were identified using physician billing codes and were divided into those undergoing pde before and after article publication, with a 6-month washout period. Chi-square tests were used to compare rates of pbd.

Results

Of 1997 pde patients identified, 963 underwent surgery before article publication, and 911, after (123 during the washout period). The rate of pbd was 47.5% before publication, and 41.6% after (p = 0.01). The lowest pbd rates occurred immediately after publication, in 2010 and 2011. Similar results were observed when the cohort was restricted to patients seen preoperatively by a gastroenterologist (n = 1412).

Conclusions

Rates of pbd have declined a small, but significant, amount after randomized trial publication. Persistence of pbd might relate to suboptimal knowledge translation, the role of pbd in diagnosis of periampullary malignancy, and treatment of complications (cholangitis, severe hyperbilirubinemia) or anticipation of delay from diagnosis to surgery. The nadir in pbd rates after article publication and the subsequent rise suggest an element of transience in the effect of article publication on clinical practice. Further investigation into the reasons for persistent pbd is needed.

Variation in the use of adjuvant chemotherapy following neoadjuvant radiotherapy and surgery for rectal cancer in a publicly-insured health care system

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Background: The efficacy of routine administration of adjuvant chemotherapy following sequential neoadjuvant chemoradiotherapy and surgery for rectal cancer is uncertain. This uncertainty may lead to practice pattern variations, with significant downstream discrepancies in oncological outcomes, patient-centered outcomes, and healthcare costs. The objective of this study, therefore, was to evaluate patient, disease, and health system factors associated with receipt of adjuvant chemotherapy following neoadjuvant radiotherapy and proctectomy. Methods: A retrospective cohort study of patients diagnosed with rectal cancer undergoing preoperative radiotherapy prior to proctectomy from January 1, 2010 to December 31, 2014 was performed using linked administrative healthcare databases. We compared the rate of chemotherapy administration (≥ 1 billing record) within 180 days of index rectal resection by healthcare administrative region in Ontario, Canada (2014 population: 13.4 million). Multivariable logistic regression models were constructed to assess patient, disease, and health system factors associated with differences in receipt of adjuvant chemotherapy. Results: We studied 1668 patients treated with preoperative radiotherapy and proctectomy, of whom 67% received chemotherapy within 180 days after surgery. The rate of adjuvant chemotherapy administration varied among health regions from 54% to 93%. On multivariable analysis, health region of residence, younger patient age, lower baseline comorbidity burden, and pathological nodal involvement were significant predictors of receipt of adjuvant chemotherapy. Conclusions: There is significant variation in receipt of adjuvant chemotherapy for patients receiving preoperative radiotherapy followed by proctectomy in Ontario. This variability is associated with patient, disease, and health system-related factors. Identifying the drivers of variability in cancer care practice may help to provide a basis for understanding and addressing discrepancies in clinical, patient-centered, and economic outcomes in healthcare systems.

Three-point transfusion risk score in hepatectomy

BACKGROUND

Perioperative red blood cell transfusions are required in up to 23 per cent of patients undergoing hepatectomy. Previous research has developed three transfusion risk scores to assess risk of perioperative red blood cell transfusion. Here, the performance of these transfusion risk scores was evaluated in a multicentre cohort of patients who underwent hepatectomy and compared with that of a simplified transfusion risk score.

METHODS

A database of patients undergoing hepatectomy at four specialized centres between 2008 and 2012 was developed. External validity was assessed by discrimination and calibration. Discrimination was evaluated using the area under the receiver operating characteristic (ROC) curve (AUC). Calibration was evaluated by the degree of agreement between predicted and actual red blood cell transfusion probabilities. A simplified transfusion risk score using variables common to the three models was created, and discrimination and calibration were evaluated.

RESULTS

There were 1287 patients included in this study, with 341 (26·5 per cent) receiving a red blood cell transfusion. Discriminative ability was similar between the three transfusion risk scores, with AUCs of 0·66-0·68 and good calibration. A new three-point risk score was developed based on factors present in all models: haemoglobin 12·5 g/dl or less, primary liver malignancy and major resection (at least 4 segments). Discriminative ability and calibration of the three-point model were similar to those of the three existing models, with an AUC of 0·66.

CONCLUSION

The three-point transfusion risk score simplifies assessment of perioperative transfusion risk in hepatectomy without sacrificing predictive ability.

The impact of perioperative red blood cell transfusion on long-term survival after hepatectomy for colorectal liver metastases

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Background: Perioperative red blood cell transfusions (RBCT) are associated with postoperative morbidity and may increase cancer recurrence through immunologic mechanisms following resection of colorectal liver metastases (CRLM). We sought to explore the relationship between RBCTs and long-term survival following resection of CRLM in the contemporary surgical era. Methods: We conducted a retrospective review of a prospective database including all patients undergoing partial hepatectomy for CRLM from 2003-2012. Data regarding date of death was abstracted from a validated, population-based cancer registry. Primary outcome was overall survival (OS), compared based on RBCT (defined as time of surgery to 30 days following surgery) and on number of RBC units received using Kaplan-Meier curves. Cox regression analysis was performed to examine the association between RBCT and OS, while adjusting for prognostic factors including Fong score and period of treatment (2003-2007 vs. 2008-2012). Results: We included 483 patients operated for CRLM, of which 27.5% received RBCT. 90-day post-operative mortality was 4.8% and median follow-up was 33 (IQR: 20.1-54.8) months. Median survival in patients who received RBCT was 44.5 months compared with 93.5 months in patients who did not(p<0.0001). The difference persisted in subgroup analysis excluding patients who died within 90 days of surgery (62.3 vs. 93.5 months, p=0.023). After adjustment for Fong score and period of treatment, RBCT was independently associated with decreased OS (HR 2.15; 95% CI: 1.52-3.04). Conclusions: Perioperative RBCT is independently associated with decreased OS following hepatectomy for CRLM. Interventions to minimize and rationalize the use of RBCT for hepatectomy are warranted in order to mitigate this detrimental effect on long-term outcomes.

Quality of life in RCT of pasireotide to reduce pancreatic complications following resection

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Background: A recent trial demonstrated that prophylactic pasireotide reduces pancreatic complication (PC) rates (primary objective). In this secondary analysis, we describe quality of life (QoL) in this population before and after resection using a standard instrument (the EORTC QLQ-C30) and the EORTC pancreatic cancer module (PAN26), which was recently developed to address the unmet need for QoL assessment in this subpopulation. Also of interest is assessing the association between PC and QoL and testing the hypothesis that pasireotide improves QoL. Methods: We conducted a randomized, double-blind, placebo-controlled trial of preoperative subcutaneous pasireotide in 300 patients undergoing pancreaticoduodenectomy or distal pancreatectomy. Participants completed the C30 and PAN26 preoperatively and on postoperative days 14 and 60. Scores were compared using paired t-tests. Results: All patients completed at least one questionnaire and 87% of patients completed all three. No major differences in QoL were seen between treatment groups so pooled results were reported. A significant worsening of function at 14 days was detected on all PAN26 and C30 function scales except hepatic and emotional functioning (EF), and all C30 symptom scales (all p<.01). These effects lessened by 60 days, but scores remained significantly worse than baseline with the exception of the sexuality, cognitive functioning, nausea and vomiting, insomnia and constipation scales, which returned to near baseline, and EF, which was significantly better than baseline (p=0.03). PC occurred in 45 patients and was associated with worse body image, dyspnea, financial difficulties and physical, role, emotional and social functioning at 14 and 60 days (all p<.05). Conclusions: During the first 14 days following resection, patients can be expected to have a significant decline in QoL. Many symptoms abate by 60 days, and EF improves. Although pasireotide effectively reduced PC, its effect did not appear to translate to improved QoL based on this sample of 300 patients. While PC was associated with worse QoL, most patients in both pasireotide and placebo groups did not experience PC, which may explain why no significant difference in QoL was observed. Clinical trial information: NCT00994110.

Hepatic arterial infusion pump chemotherapy for colorectal liver metastases: an old technology in a new era

Aggressive treatment of colorectal cancer (crc) liver metastases can yield long-term survival and cure. Unfortunately, most patients present with technically unresectable metastases; conventional therapy in such patients consists of systemic therapy. Despite advances in the effectiveness of systemic therapy in the first-line setting, the tumour response rate and median survival remain low in the second-line setting. The preferential blood supply from the hepatic artery to crc liver metastases allows for excellent regional delivery of chemotherapy. Here, we review efficacy and safety data for hepatic artery infusion (hai) pump chemotherapy in patients with metastatic crc from the 5-fluorouracil era and from the era of modern chemotherapy. In selected patients with liver-only or liver-dominant disease who have progressed on first-line chemotherapy, hai combined with systemic agents is a viable therapeutic option when performed at experienced centres. Furthermore, significantly improved survival has been demonstrated with adjuvant hai therapy after liver resection in the phase iii setting. The complication rates and local toxicities associated with hai pump therapy are infrequent at experienced centres and can be managed with careful follow-up and early intervention. The major obstacles to the wide adoption of hai therapy include technical expertise for pump insertion and maintenance, and for floxuridine dose modification. The creation of formal preceptor-focused education and training in hai therapy for interdisciplinary medical professionals might encourage the creation and expansion of this liver-directed approach.

Hepatic arterial infusion pump chemotherapy in the management of colorectal liver metastases: expert consensus statement

Despite significant improvements in systemic therapy for patients with colorectal liver metastases (crlms), response rates in the first-line setting are not optimal, and response rates in the second-line setting remain disappointing. Hepatic arterial infusion pump (haip) chemotherapy has been extensively studied in patients with crlms, but it remains infrequently used. We convened an expert panel to discuss the role of haip in the contemporary management of patients with crlm. Using a consensus process, we developed these statements: haip chemotherapy should be given in combination with systemic chemotherapy.haip chemotherapy should be offered in the context of a multidisciplinary program that includes expertise in hepatobiliary surgery, medical oncology, interventional radiology, nursing, and nuclear medicine.haip chemotherapy in combination with systemic therapy should be considered in patients with unresectable crlms who have progressed on first-line systemic treatment. In addition, haip chemotherapy is acceptable as first-line treatment in patients with unresectable colorectal liver metastases.haip chemotherapy is not recommended in the setting of extrahepatic disease outside the context of a clinical trial.haip chemotherapy in combination with systemic therapy is an option for select patients with resected colorectal liver metastases. These consensus statements provide a framework that clinicians who treat patients with crlm can use when considering treatment with haip.

Co-morbidities in elderly patients with hip fracture: recommendations of the ISFR-IOF hip fracture outcomes working group

INTRODUCTION

Hip fractures are the second leading cause of hospitalization in the aged and by 2041, epidemiologists forecast an increase in economic cost to $2.4 billion. The hip patient population often presents with comorbidities causing these patients to receive less aggressive medical treatment and have a low quality of life. We believe that physical function is a patient-important outcome for many medical and surgical interventions. The functional co-morbidity index (FCI), unlike prior co-morbidity indices, was developed with physical function as an outcome instead of being designed for administrative purposes or to predict mortality. Our objective was to evaluate the perceptions of practitioners in hip fracture care about the impact of comorbidities on physical function as primary outcome.

METHODS

We piloted and then distributed a self-administered survey to members of the International Society for Fracture Repair hip fracture outcomes working group. For each of the 18 diagnoses included in the FCI index, we asked in our survey whether the presence of the co-morbidity and whether the severity of the co-morbidity was perceived to impact physical function in patients following a hip fracture.

RESULTS

Seventeen out of 20 respondents completed the questionnaire. The presence and severity of arthritis was 'strongly' believed to predict physical function in those with hip fracture (69 and 85.7 %, respectively). Respondents 'agreed' (range 53-73 %) that 10/18 diagnoses would predict changes in physical function following hip fracture treatment. Whereas, 63 % of the practitioners'strongly disagreed' that diabetes types I and II would change physical function scores. Furthermore, dementia was listed as an additional diagnosis that would affect physical function.

CONCLUSION

The FCI may provide a useful instrument to predict functional outcome after hip fracture; however, the index may need to be modified for this specific population.

A qualitative study of patient and clinician attitudes regarding surveillance following resection of pancreatic and periampullary cancer

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Background: Pancreatic carcinoma is the fourth leading cause of cancer death in North America. Following surgical resection, most patients will develop recurrence within two years. Intense follow-up is often recommended; however, the impact on survival is unknown. We sought to qualitatively assess patient and clinician attitudes towards follow-up and the perceived benefits and challenges. Methods: The research team developed a semi-structured interview guide. Purposive sampling identified patients who had undergone curative attempt resection and were in active surveillance or had developed recurrence. Clinicians involved in patient care were also interviewed.Themes were derived using standard qualitative methods. Results: Fifteen patients and seven clinicians were interviewed. Patient themes included (1) Limited understanding of disease prognosis; (2) Desire for reassurance through follow-up; (3) Desire to know if and when recurrence occurred; (4) Challenging treatments; (5) Minimal difficulties with the follow-up protocol; and (6) Limited role of family doctors in pancreatic cancer follow-up. Clinician themes included (1) Expectation that patients are aware of recurrence risk; (2) Desire to provide reassurance to patients; (3) Support for intense follow-up protocol despite lack of supporting evidence; (4) Secondary goals for surveillance; (5) Perceived patient challenges in follow-up; (6) Openness to family doctors doing follow-up. Overall, the dominant theme was one of disconnect between patients and clinicians in the understanding of the disease and its prognosis. Conclusions: Patients with pancreatic or periampullary cancer have an intense need for reassurance and obtain this through the follow-up process. Consequently they express few difficulties with follow-up despite the intensity of testing. Oncologists recognize this desire for reassurance and provide it through follow-up despite the lack of evidence to show benefit. There appears to be a disconnect between patients and clinicians in the understanding of the disease and its prognosis suggesting further work is needed to improve patient-physician communication.

Open versus minimally invasive management of gastric GIST: An international multi-institutional analysis of short- and long-term outcomes

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Background: Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the GI tract. Overall surgical experience with minimally invasive surgery (MIS) has increased, however, published reports on MIS resection of GIST are currently limited to small, single institution experiences. Methods: 397 patients who underwent surgical resection of a gastric GIST between 1998 and 2012 were identified from an international, multi-center database. The impact of the MIS approach on recurrence and survival was analyzed by the use of propensity-score matching by comparing clinicopathologic factors between patients who underwent open vs MIS resection. Results: Median patient age was 65 years and 50% were female. Median tumor size was 4.3cm (IQR 3.0-7.6cm). A minority of patients received neoadjuvant therapy (6%). Overall, 186 (47%) patients had a MIS approach: laparoscopic (89%), laparoscopic hand assist (4%), combined laparo-endoscopic (3%) and robotic (4%). There were 19 (10%) conversions to open; the most common reasons for conversion were tumor more extensive than anticipated (26%) and unclear anatomy (16%). Patients who underwent MIS resections had smaller tumors (MIS: 3.5cm vs open: 5.8cm; p<0.01). MIS resections were associated with minimal blood loss (MIS: 50 cc vs open: 225 cc) and shorter operative time (MIS: 160 min vs open: 201 min) (both p<0.01). There was no difference in rates of tumor rupture (MIS: 1.1% vs open: 0.9%; p=0.81). An R0 resection was achieved in the majority of patients (MIS: 98% vs open: 92%; p=0.07). MIS patients had a lower incidence of grade 3 or 4 complications (MIS: 3% vs open: 10%; p=0.01) and a shorter length of stay (MIS: 3d vs open: 8d; p<0.01). After propensity score matching for age, sex, tumor size, mitotic rate and tumor rupture, there was no difference in risk of recurrence or overall survival for the MIS treated group vs. the open group (HR 0.65 & HR 0.76, respectively; both p>0.05). Conclusions: An MIS approach for gastric GIST is associated with a low incidence of complications and a comparable R0 resection rate. The long-term oncological outcome following MIS is excellent and therefore the MIS approach should be considered preferable.

Radiographic arthrosis after elbow trauma: interobserver reliability

PURPOSE

This study measured observer variation in radiographic rating of elbow arthrosis.

METHODS

Thirty-seven independent orthopedic surgeons graded the extent of elbow arthrosis in 20 consecutive sets of plain radiographs, according to the Broberg and Morrey rating system (grade 0, normal joint; grade 1, slight joint-space narrowing with minimum osteophyte formation; grade 2, moderate joint-space narrowing with moderate osteophyte formation; and grade 3, severe degenerative change with gross destruction of the joint). The kappa multirater measure (κ) was used to estimate reliability between observers, with 0 indicating no agreement above chance, and 1 indicating perfect agreement.

RESULTS

There was fair agreement in arthrosis ratings between surgeons. Surgeons with more than 10 years of experience had greater agreement than did surgeons with less experience, and surgeons who treated more than 10 elbow fractures per year had better agreement than did those treating fewer fractures. In post hoc analyses, 2 simplified binary rating systems (eg, "none or mild" vs "moderate or severe" arthrosis) resulted in moderate agreement among observers.

CONCLUSIONS

The 4 grades of the Broberg and Morrey classification system have only fair interobserver reliability that is influenced by subspecialty and experience. Binary rating systems might be more reliable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Population-based trend analysis of 2813 patients undergoing laparoscopic sigmoid resection

BACKGROUND

The use of laparoscopic sigmoid resection for diverticular disease has become increasingly popular. The objective of this trend analysis was to assess whether clinical outcomes following laparoscopic sigmoid resection for diverticular disease have improved over the past 10 years.

METHODS

The analysis was based on the prospective database of the Swiss Association of Laparoscopic and Thoracoscopic Surgery. Some 2813 patients undergoing elective laparoscopic sigmoid resection for diverticular disease from 1995 to 2006 were included. Unadjusted and risk-adjusted analyses were performed.

RESULTS

Over time, there was a significant reduction in the conversion rate (from 27.3 to 8.6 per cent; P(trend) < 0.001), local postoperative complication rate (23.6 to 6.2 per cent; P(trend) = 0.004), general postoperative complication rate (14.6 to 4.9 per cent; P(trend) = 0.024) and reoperation rate (5.5 to 0.6 per cent; P(trend) = 0.015). Postoperative median length of hospital stay significantly decreased from 11 to 7 days (P(trend) < 0.001).

CONCLUSION

This first trend analysis in the literature of clinical outcomes after laparoscopic sigmoid resection, based on almost 3000 patients, has provided compelling evidence that rates of postoperative complications, conversion and reoperation, and length of hospital stay have decreased significantly over the past 10 years.

Interobserver reliability of coronoid fracture classification: two-dimensional versus three-dimensional computed tomography

PURPOSE

This study tests the hypothesis that 3-dimensional computed tomography (CT) reconstructions improve interobserver agreement on classification and treatment of coronoid fractures compared with 2-dimensional CT.

METHODS

A total of 29 orthopedic surgeons evaluated 10 coronoid fractures on 2 occasions (first with radiographs and 2-dimensional CT and then with radiographs and 3-dimensional CT), separated by a minimum of 2 weeks. Surgeons classified fractures according to the classifications of Regan and Morrey and of O'Driscoll et al., identified specific characteristics, recommended the most appropriate treatment approach, and made treatment recommendations. The kappa multirater measure (kappa) was calculated to estimate agreement between observers.

RESULTS

Regardless of the imaging modality used, there was fair to moderate agreement for most of the observations. Three-dimensional CT improved interobserver agreement in Regan and Morrey's classsication (kappa(3-dimensional) = 0.51 vs kappa(2-dimensional) = 0.40; p < .001) and O'Driscoll et al.'s classifications (kappa(3-dimensional) = 0.48 vs kappa(2-dimensional) = 0.42; p = .009). There were trends toward better reliability for 3-dimensional reconstruction in recognition of coronoid tip fractures (kappa(3-dimensional) = 0.19, kappa(2-dimensional) = 0.03; p = .268), comminution (kappa(3-dimensional) = 0.41 vs kappa(2-dimensional) = 0.29; p = .133), and impacted fragments (kappa(3-dimensional) = 0.39 vs kappa(2-dimensional) = 0.27; p = .094), and in surgeons' opinions on the need for something other than screws or plate for surgical fixation (kappa(3-dimensional) = 0.31 vs kappa(2-dimensional) = 0.15; p = .138). Interobserver agreement on treatment approach was better with 2-dimensional CT (kappa(3-dimensional) = 0.27, kappa(2-dimensional) = 0.32; p = .015).

CONCLUSIONS

Three-dimensional CT reconstructions improve interobserver agreement with respect to fracture classification compared with 2-dimensional CT.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Choice of data extraction tools for systematic reviews depends on resources and review complexity

OBJECTIVE

To assist investigators planning, coordinating, and conducting systematic reviews in the selection of data-extraction tools for conducting systematic reviews.

STUDY DESIGN AND SETTING

We constructed an initial table listing available data-collection tools and reflecting our experience with these tools and their performance. An international group of experts iteratively reviewed the table and reflected on the performance of the tools until no new insights and consensus resulted.

RESULTS

Several tools are available to manage data in systematic reviews, including paper and pencil, spreadsheets, web-based surveys, electronic databases, and web-based specialized software. Each tool offers benefits and drawbacks: specialized web-based software is well suited in most ways, but is associated with higher setup costs. Other approaches vary in their setup costs and difficulty, training requirements, portability and accessibility, versatility, progress tracking, and the ability to manage, present, store, and retrieve data.

CONCLUSION

Available funding, number and location of reviewers, data needs, and the complexity of the project should govern the selection of a data-extraction tool when conducting systematic reviews.