Brett L. Ecker

Efficacy of adjuvant chemotherapy for small bowel adenocarcinoma: A propensity score–matched analysis

The role of adjuvant chemotherapy (AC) in the treatment of small bowel adenocarcinoma is poorly defined. Previous analyses have been limited by small sample sizes and have failed to demonstrate a survival advantage.

Implications of Lymph Node Staging on Selection of Adjuvant Therapy for Gastric Cancer in the United States: A Propensity Score-matched Analysis.

Objective:To compare the efficacy of adjuvant chemoradiotherapy (CRT) and chemotherapy alone (CA) in gastric adenocarcinoma patients undergoing gastrectomy in the United States (US). Background:A majority of US gastric adenocarcinoma patients are inadequately staged (<15 nodes examined). Despite this, and limited data comparing adjuvant CRT with CA in US patients, national guidelines endorse CA in selected patients undergoing D2 lymphadenectomy. Methods:Resected stage IB-III gastric adenocarcinoma patients receiving adjuvant CRT or CA (n = 3008) were identified in the National Cancer Database (1998–2006). Cox regression identified covariates associated with overall survival (OS). CRT and CA cohorts were matched (3:1) by propensity scores based on the likelihood of receiving CA. OS was compared by Kaplan-Meier estimates. Results:Adjuvant CA was associated with an increased risk of death (HR 1.29, P < 0.001) relative to CRT. Inadequate lymph node staging (LNS) and nodal positivity were strong predictors of risk-adjusted mortality (P < 0.001). After propensity score-matching, CRT demonstrated superior median OS compared with CA (36.1 vs 28.9 m; P < 0.0001), regardless of stage. CRT was superior to CA in inadequately staged patients (33.1 m vs 24.5 m; P < 0.001); this benefit was less pronounced with increasing nodal examination. CRT improved OS in node-positive disease (29.8 vs 22.2 m; P < 0.001), regardless of LNS adequacy. In node-negative disease, OS did not differ significantly between CRT and CA cohorts; however, node-negative patients undergoing inadequate LNS benefited from CRT. Conclusions:CRT is associated with improved stage-stratified OS compared with CA. Lymph node status and adequacy of surgical staging should influence adjuvant therapy selection in the United States.

Resident education in robotic-assisted vertical sleeve gastrectomy: outcomes and cost-analysis of 411 consecutive cases

BACKGROUND Robotic technology is increasingly prevalent in bariatric surgery, yet there are national deficiencies in exposure of surgical residents to robotic techniques. OBJECTIVES The purpose of this study is to accurately characterize the perioperative outcomes of a resident teaching model using the robotic-assisted sleeve gastrectomy. SETTING University Hospital. METHODS We identified 411 consecutive patients who underwent robotic sleeve gastrectomy at our institution from a prospectively maintained administrative database. Perioperative morbidity, operative time, and supply cost of the procedure were analyzed. RESULTS Mean operative time was 96.4±24.9 minutes; mean robot usage time was 63.9 minutes (range 30.0-122.0 min). Ninety-day morbidities included reoperation (0.72%), major bleeding complications (0.48%), staple line leak (0.24%), stricture (0.97%), need for blood transfusion (3.86%), surgical site infection (1.69%), deep vein thrombosis (0.48%), and pulmonary embolism (0.48%). Mortality was nil. The resident cohort achieved operative time plateaus after five consecutive cases. Subset analysis for fiscal year 2014 demonstrated significantly increased supply cost for robotic sleeve gastrectomy compared with its laparoscopic equivalent. CONCLUSION Robotic-assisted sleeve gastrectomy can be instituted as a model for resident robotic education with rates of morbidity and operative times equivalent to historical laparoscopic controls. The robots enhanced ergonomics and its opportunity for resident education must be weighed against its increased supply cost.

Blood Transfusion in Major Abdominal Surgery for Malignant Tumors: A Trend Analysis Using the National Surgical Quality Improvement Program

IMPORTANCE Blood transfusion can be a lifesaving treatment for the surgical patient, yet transfusion-related immunomodulation may underlie the association of allogeneic transfusion with increased perioperative morbidity and possibly poorer long-term oncologic outcomes. OBJECTIVE To evaluate trends in transfusion rates for major abdominal oncologic resections to assess changes in recent clinical practice (given the accumulating evidence of the deleterious effects of blood transfusion). DESIGN, SETTING, AND PARTICIPANTS Retrospective review of a population-based registry of all hospitals participating in the American College of Surgeons National Surgical Quality Improvement Project (2005-2013 Participant Use Data Files), which was queried for patients who underwent major resection of a pancreatic, hepatic, or gastric malignant tumor. Data analysis was performed from July to August 2015. MAIN OUTCOME AND MEASURES The primary outcome was the transfusion of any quantity of packed red blood cells. Transfusion rates were calculated for the perioperative period, which was defined as the time from the start of surgery to 72 hours after surgery. Secondary outcomes included wound infection, myocardial infarction, and renal insufficiency, and the rates of these complications were calculated as well. Trend analysis was performed for each year of data to evaluate for changes over the study period. RESULTS A total of 19 680 patients (median age, 65.0 years [interquartile range, 57.0-73.0 years]) were identified, of whom 5900 (30.0%) received a blood transfusion (of 13 657 patients who underwent a pancreatic resection, 4074 required transfusion [29.8%]; of 1605 patients who underwent a gastric resection, 378 required transfusion [23.6%]; and of 4418 patients who underwent a hepatic resection, 1448 required transfusion [32.8%]). There was a significant trend toward decreasing rates of transfusion during the study period (z = -7.89, P < .001), which corresponded to an absolute 6.1% decrease in the rate of transfusion of packed red blood cells from 2005 to 2013 (ie, from 32.8% to 26.7%). There was no significant change in the rates of postoperative wound infection or renal insufficiency during this time period, but there was an increased rate of perioperative myocardial infarction during the study period (0.33% absolute increase; z = 3.15, P = .002). CONCLUSIONS AND RELEVANCE Over 9 years of contemporary practice, a trend of less perioperative blood transfusions for oncologic abdominal surgery was observed. Further studies are needed to assess whether these trends reflect changes in operative techniques, hospital cohorts, or transfusion thresholds.

Minimally invasive gastrectomy for gastric adenocarcinoma in the United States: Utilization and short‐term oncologic outcomes

When performed at select centers, minimally invasive gastrectomy (MIG) for gastric adenocarcinoma is associated with reduced perioperative morbidity, and similar oncologic outcomes as compared to open gastrectomy (OG). Utilization of, and outcomes associated with, MIG in the United States have not been characterized.

A prognostic model for resectable soft tissue and cutaneous angiosarcoma.

Angiosarcoma is an aggressive tumor rising in incidence from use of therapeutic radiation. Because of its relative rarity, prognostic factors have not been clearly delineated.

Complications and Surveillance After Bariatric Surgery.

Opinion statementBariatric surgery represents a durable and safe treatment modality for morbid obesity. Bariatric surgery results in weight loss by one of two—and possibly both—primary mechanisms, reducing the amount of tolerable intake (restrictive) and reducing the amount of nutrients absorbed by bypassing absorptive intestine (malabsorptive). These procedures have consistently demonstrated superior resolution of obesity and many associated co-morbid conditions as compared to medical management. Beyond the periprocedural complications of surgery, there are longitudinal risks such as weight regain, anatomic complications, and micronutrient deficiencies. Complications related to the anatomic alteration after bariatric surgery include internal herniation, marginal ulcers, dumping syndrome, and gastric band-related complications. Physicians who take care of bariatric patients at any point in their post-operative care must be vigilant for these complications, as they may necessitate urgent intervention or re-operation. Micronutrient deficiencies, which commonly occur after malabsorptive procedures, may present with a wide range of symptoms—including neuropathies, anemia, poor wound healing, and hair loss, among others. Deficiencies of vitamins and minerals frequently result in the need for long-term supplementation and may necessitate intravenous repletion when severe. Bariatric surgery may also alter the absorption of commonly prescribed medications, including anti-psychotic medications.

Laparoscopic hand-assisted versus robotic-assisted laparoscopic sleeve gastrectomy: experience of 103 consecutive cases

BACKGROUND Laparoscopic sleeve gastrectomy has become a stand-alone procedure in the treatment of morbid obesity. There are very few reports on the use of robotic approach in sleeve gastrectomy. OBJECTIVES The purpose of this retrospective study is to report our early experience of robotic-assisted laparoscopic sleeve gastrectomy (RALSG) using a proctored training model with comparison to an institutional cohort of patients who underwent laparoscopic hand-assisted sleeve gastrectomy (LASG). SETTINGS University hospital. METHODS The study included 108 patients who underwent sleeve gastrectomy either via the laparoscopic-assisted or robot-assisted approach during the study period. Of these 108 patients, 62 underwent LASG and 46 underwent RALSG. The console surgeon in the RALSG is a clinical year 4 (CY4) surgery resident. All CY4 surgery residents received targeted simulation training before their rotation. The console surgeon is proctored by the primary surgeon with assistance as needed by the second surgeon. RESULTS The patients in the robotic and laparoscopic cohorts did not have a statistical difference in their demographic characteristics, preoperative co-morbidities, or complications. The mean operating time did not differ significantly between the 2 cohorts (121 min versus 110 min, P = .07). Patient follow-up in the LSG and RALSG were 91% and 90% at 3 months, 62% and 64% at 6 months, and 60% and 55% at 1 year, respectively. The mean percentage estimated weight loss (EWL%) at 3 months, 6 months, and 1 year was greater in the robotic group but not statistically significant (27 versus 22 at 3 mo [P = .05] and 39 versus 34 at 6 mo [P = .025], 57 versus 48 at 1 yr [P = .09]). There was no mortality in either group. CONCLUSION Early results of our experience with RALSG indicate low perioperative complication rates and comparable weight loss with LASG. The concept of a stepwise education model needs further validation with larger studies.

Characterization and Optimal Management of High-Risk Pancreatic Anastomoses During Pancreatoduodenectomy

Objective: The aim of this study was to identify the optimal fistula mitigation strategy following pancreaticoduodenectomy. Background: The utility of technical strategies to prevent clinically relevant postoperative pancreatic fistula (CR-POPF) following pancreatoduodenectomy (PD) may vary by the circumstances of the anastomosis. The Fistula Risk Score (FRS) identifies a distinct high-risk cohort (FRS 7 to 10) that demonstrates substantially worse clinical outcomes. The value of various fistula mitigation strategies in these particular high-stakes cases has not been previously explored. Methods: This multinational study included 5323 PDs performed by 62 surgeons at 17 institutions. Mitigation strategies, including both technique related (ie, pancreatogastrostomy reconstruction; dunking; tissue patches) and the use of adjuvant strategies (ie, intraperitoneal drains; anastomotic stents; prophylactic octreotide; tissue sealants), were evaluated using multivariable regression analysis and propensity score matching. Results: A total of 522 (9.8%) PDs met high-risk FRS criteria, with an observed CR-POPF rate of 29.1%. Pancreatogastrostomy, prophylactic octreotide, and omission of externalized stents were each associated with an increased rate of CR-POPF (all P < 0.001). In a multivariable model accounting for patient, surgeon, and institutional characteristics, the use of external stents [odds ratio (OR) 0.45, 95% confidence interval (95% CI) 0.25–0.81] and the omission of prophylactic octreotide (OR 0.49, 95% CI 0.30–0.78) were independently associated with decreased CR-POPF occurrence. In the propensity score matched cohort, an “optimal” mitigation strategy (ie, externalized stent and no prophylactic octreotide) was associated with a reduced rate of CR-POPF (13.2% vs 33.5%, P < 0.001). Conclusions: The scenarios identified by the high-risk FRS zone represent challenging anastomoses associated with markedly elevated rates of fistula. Externalized stents and omission of prophylactic octreotide, in the setting of intraperitoneal drainage and pancreaticojejunostomy reconstruction, provides optimal outcomes.

Preoperative radiotherapy in the management of retroperitoneal liposarcoma

Histological subtype influences both prognosis and patterns of treatment failure in retroperitoneal sarcoma. Previous studies on the efficacy of neoadjuvant radiotherapy (NRT) have incorporated multiple histological types with heterogeneous tumour biology. The survival impact of NRT specifically for patients with retroperitoneal liposarcoma is poorly defined.