Jiong-Jie Yu

Is chronological age really not a contraindication to gastrectomy for very elderly patients

We read with great interest the article by Dr. Hikage et al. [1]. This retrospective study identified that chronological age alone is not a contraindication to gastrectomy for very elderly gastric cancer patients. However, we would like to raise the following considerations: This study found some almost significant differences between the elderly and very-elderly patients in certain characteristics, surgical outcomes, and pathological findings, including gender, ASA-PS score, ECOG-PS score, serum albumin level, operative time, lymphadenectomy and T classification (all P < 0.05). These confounding variables between the two groups suggested an unbalanced enrollment. Moreover, several characteristics, including the serum albumin level and operative time, have already been reported as risk factors for postoperative outcomes after gastrectomy [2, 3]. In fact, propensity score matching (PSM) analysis has been used in retrospective studies, to achieve better balance between groups across all potential risk factors and evaluate the extent of balanced match through a measurable approach [4, 5]. This method could be used in further studies based on the valuable data in the present study. In fact, a study published in 2018 [6] investigated a similar topic in relation to hepatectomy using this method, with the same conclusions. Moreover, the number of variables of characteristics investigated in this study seemed insufficient. For instance, tumor characteristics and preoperative hemoglobin level were not provided, even though they may impact on the prognosis after gastrectomy. Therefore, the reliability and accuracy of the conclusions of this study need further evaluation. In summary, we suggest that PSM analysis be used in further studies to confirm the true relationship between chronological age and postoperative outcomes after gastrectomy for gastric cancer. More details on the variables of patients’ characteristics should be included in this study. Clarification about the omissions we mention would greatly solidify the conclusions of the study by Hikage et al. [1].

Preoperative prealbumin level as an independent predictor of long-term prognosis after liver resection for hepatocellular carcinoma: a multi-institutional study

BACKGROUNDnSerum prealbumin is a sensitive and stable marker for nutritional status and liver function. Whether preoperative prealbumin level is associated with long-term prognosis in patients undergoing liver resection for hepatocellular carcinoma (HCC) is unclear.nnnMETHODSnPatients who underwent liver resection for HCC between 2001 and 2014xa0at six institutions were enrolled. These patients were divided into the low and normal prealbumin groups using a cut-off value of 170xa0mg/L for preoperative prealbumin level. The overall survival (OS) and recurrence-free survival (RFS) were compared between them.nnnRESULTSnIn 1483 patients, 437 (29%) had a low prealbumin level. The 3- and 5-year OS and RFS rates of patients in the low-prealbumin group were 57 and 31%, and 40 and 20%, respectively, which were significantly poorer than those in the normal-prealbumin group (76 and 43%, and 56 and 28%, respectively, both pxa0<xa00.001). Multivariable Cox-regression analyses revealed that preoperative prealbumin level was an independent predictor of OS (HR, 1.45, 95% CI: 1.24-1.70, pxa0<0.001) and RFS (HR, 1.28, 95% CI: 1.10-1.48, pxa0<0.001).nnnCONCLUSIONSnPreoperative prealbumin level could be used in predicting long-term prognosis for patients undergoing liver resection for HCC.

Multicentre study of the prognostic impact of preoperative bodyweight on long-term prognosis of hepatocellular carcinoma: Prognostic impact of preoperative bodyweight on prognosis of hepatocellular carcinoma

Whether preoperative bodyweight is associated with long‐term prognosis in patients after liver resection for hepatocellular carcinoma (HCC) is controversial. This study aimed to investigate the relationship of patient weight with long‐term recurrence and overall survival (OS) after curative liver resection for HCC.

Association between Concomitant Mediastinoscopy and Postoperative Pneumonia After Pulmonary Lobectomy

We read with great interest the article by Yendamuri et al. This retrospective study identified that mediastinoscopy may be associated with an increased risk of postoperative pneumonia after pulmonary lobectomy for patients with lung cancer. Herein, we would like to raise the following comments. As shown in Tables 1 and 4 of the study by Yendamuri et al., significant differences exist between patients with and without mediastinoscopy in some aspects of patient demographics and characteristics, both in the Roswell Cancer Institute (RPCI) cohort and the National Surgical Quality Improvement Program (NSQIP) cohort, including age, sex, American Society of Anesthesiologists class, history of chronic obstructive pulmonary disease, smoking status, forced expiratory volume in 1 s, and operating room time (all p 0.05), suggesting an imbalanced enrollment between the two groups due to these confounding variables. As a matter of fact, propensity score matching (PSM) analysis has generally been used in retrospective observational studies, which enables better balance between groups across all putative risk factors, and evaluates the extent of a balanced match in a measurable approach. Therefore, we suggest that PSM analysis be used here. In fact, a study published by Agostini et al. in 2017 investigated a similar topic on postoperative pulmonary complications using this method, with an opposite conclusion being drawn. We prefer the study using PSM analysis as it is more statistically convictive. In addition, the number of variables on patient demographics and characteristics investigated in the NSQIP cohort seemed far from enough. For instance, lung function, smoking status, etc., were not provided, which are in fact very likely to influence the incidence of postoperative pneumonia after pulmonary lobectomy for patients with lung cancer. In short, we suggest that PSM analysis be used in the present study for further confirmation of the real relationship between mediastinoscopy and postoperative pneumonia after pulmonary lobectomy for patients with lung cancer. Meanwhile, more details of variables on patient demographics and characteristics should be included in this study. Clarification regarding the abovementioned omissions would greatly solidify the conclusions of the study by Yendamuri et al.

Association Between Appendectomy Outcomes and Surgeons’ Seniority

Association Between Appendectomy Outcomes and Surgeons’ Seniority To the Editor We read with great interest the article by Siam et al.1 This study showed no significant difference in postoperative outcomes after appendectomy between senior general surgeons (SGSs) and general surgery residents (GSRs); the authors proposed that under standard conditions, more experienced surgical residents can be allowed to perform appendectomy alone. Herein, we would like to raise the following comments. As shown in Table 1,1 there were some differences in some aspects of preoperative presentation and operative course betweentheSGSandGSRgroups, includingpatients’meanage,percentage of surgeons performing laparoscopic surgeries, and use of laparoscopic staplers (all P < .001), suggesting an unbalanced enrollment between these 2 groups. In fact, propensity score matching analysis has been generally used in observational studies, which enables better balance between groups across all putative risk factors and evaluates the extent of balanced match in ameasurableapproach.2,3 Therefore,wesuggestthatthismethod be used here. In fact, a 2012 study by Graat et al4 investigated the sametopicusingthismethod,andtheirconclusionwasthesame. We prefer the study using propensity score matching analysis, as it is more statistically convictive. In addition, in this study, length of surgery was significantly shorter in the SGS group than in the GSR group by univariate analysis (mean length, 39.9 vs 48.6 minutes; P < .001).1 However, a higher proportion of patients in the SGS group underwent laparoscopic surgeries compared with the GSR group (95.8% vs 90.0%; P < .001), which, in our opinion, might be the main reason for the difference of length of surgery between these 2 groups. Therefore, we suggest that multivariate logistic regression analysis be used here to reveal which factors were significantly associated with length of surgery for appendectomy. In summar y, clarific ation regarding the abovementioned omissions would greatly solidify the conclusions of the study by Siam et al.1

Surgical site infections following pancreaticoduodenectomy

We read with interest the article by Richard A. Burkhart et al. This single-center retrospective study investigated which factors were associated with the occurrence of surgical site infection (SSI) following pancreaticoduodenectomy, and concluded that the use of an incisional negative pressure dressing (iVAC)was an independent protective factor. We would like to raise the following comments: Therewere differences in some variableswhichonly just failed to reach significance when comparing patients inwhom and without the use of an iVAC was or was not employed, including body mass index, preoperative biliary stenting, and estimated blood loss (all p < 0.1), suggesting that there may have been a degree of selection bias in the use of iVAC.Did the authors use iVAC for those patients with obesity, massive blood loss, or preoperative biliary stenting? Propensity score matching analysis could have been usefully adopted in this observational study, to adjust other confounding variables before comparison between the two groups. Since SSI is classified into incisional and organ/space types, it is theoretically possible that the use of an iVAC decreases the incisional SSI rate. However, it is hard to understand that iVAC could also prevent organ/space SSI. So, in this study, clarification of these issues could be addressed by means of subgroup analyses for incisional and organ/space SSI. Only in that way, can we understand how the use of an iVAC could possible prevent a specific type or all types of SSI following pancreaticoduodenectomy.