IMPORTANCE The number of geriatric patients who undergo surgery has been increasing, but there are insufficient tools to predict postoperative outcomes in the elderly. OBJECTIVE To design a ...predictive model for adverse outcomes in older surgical patients. DESIGN, SETTING, AND PARTICIPANTS From October 19, 2011, to July 31, 2012, a single tertiary care center enrolled 275 consecutive elderly patients (aged ≥65 years) undergoing intermediate-risk or high-risk elective operations in the Department of Surgery. MAIN OUTCOMES AND MEASURES The primary outcome was the 1-year all-cause mortality rate. The secondary outcomes were postoperative complications (eg, pneumonia, urinary tract infection, delirium, acute pulmonary thromboembolism, and unplanned intensive care unit admission), length of hospital stay, and discharge to nursing facility. RESULTS Twenty-five patients (9.1%) died during the follow-up period (median interquartile range, 13.3 11.5-16.1 months), including 4 in-hospital deaths after surgery. Twenty-nine patients (10.5%) experienced at least 1 complication after surgery and 24 (8.7%) were discharged to nursing facilities. Malignant disease and low serum albumin levels were more common in the patients who died. Among the geriatric assessment domains, Charlson Comorbidity Index, dependence in activities of daily living, dependence in instrumental activities of daily living, dementia, risk of delirium, short midarm circumference, and malnutrition were associated with increased mortality rates. A multidimensional frailty score model composed of the above items predicted all-cause mortality rates more accurately than the American Society of Anesthesiologists classification (area under the receiver operating characteristic curve, 0.821 vs 0.647; P = .01). The sensitivity and specificity for predicting all-cause mortality rates were 84.0% and 69.2%, respectively, according to the model’s cutoff point (>5 vs ≤5). High-risk patients (multidimensional frailty score >5) showed increased postoperative mortality risk (hazard ratio, 9.01; 95% CI, 2.15-37.78; P = .003) and longer hospital stays after surgery (median interquartile range, 9 5-15 vs 6 3-9 days; P < .001). CONCLUSIONS AND RELEVANCE The multidimensional frailty score based on comprehensive geriatric assessment is more useful than conventional methods for predicting outcomes in geriatric patients undergoing surgery.
Background Although laparoscopic surgery has many advantages, its application in pancreatic ductal adenocarcinoma has not been sufficiently studied. The objective of this study was to compare the ...surgical outcomes of laparoscopic distal pancreatectomy (LDP) to those of open distal pancreatectomy (ODP) for left-sided ductal adenocarcinoma. Study Design Among 167 consecutive patients between December 2006 and August 2013, 150 patients were included. Unmatched and propensity score-matched analyses were performed to compare the primary (oncologic adequacy) and secondary outcomes (hospital course and complications) between ODP and LDP groups. Results In unmatched patients, LDP was associated with an earlier return to diet and a shorter hospital stay compared with ODP. The 5-year survival rates were 27.6% in unmatched ODP (n = 80) and 32.5% in unmatched LDP (n = 70). Fifty-one patients from each group were selected by propensity score matching. In this matched patient comparison, LDP was again associated significantly with a shorter median postoperative time to restarting diet and a shorter hospital stay. The 2 groups did not differ significantly in terms of primary outcomes of operative time, number of harvested lymph nodes, resection margin status, and secondary outcomes of frequency of pancreatic fistula and complications. The 2 groups also had comparable patient survival (p = 0.91). Conclusions This large single-center study of laparoscopic surgery for left-sided pancreatic ductal adenocarcinoma indicated that LDP was safe and more efficacious than OPD after propensity score adjustment for presurgical variables of return to diet and length of stay.
Background
Laparoscopic distal pancreatectomy (LDP) has gained popularity for the treatment of left-sided pancreatic tumors. Robotic systems represent the most recent advancement in minimally ...invasive surgical treatment for such tumors. Theoretically, robotic systems are considered to have several advantages over laparoscopic systems. However, there have been few studies comparing both systems in the treatment of distal pancreatectomy. We compared perioperative and oncological outcomes between the two treatment modalities.
Methods
A retrospective analysis was conducted of all consecutive minimally invasive distal pancreatectomy cases performed by a single surgeon at a high-volume center between January 2015 and December 2017.
Results
The analysis included 228 consecutive patients (LDP,
n
= 182; Robotic-assisted laparoscopic distal pancreatectomy R-LDP,
n
= 46). Operative time was significantly longer in the R-LDP group than in the LDP group (166.4 vs. 140.7 min;
p
= 0.001). In a subgroup analysis of patients who underwent the spleen-preserving approach, the spleen preservation rate associated with R-LDP was significantly higher than that associated with LDP (96.8% vs. 82.5%;
p
= 0.02). In another subgroup analysis of patients with pancreatic cancer, there were no significant differences in median overall and disease-free survival between the two groups.
Conclusions
R-LDP is a safe and feasible approach with perioperative and oncological outcomes comparable to those of LDP. R-LDP offers an added technical advantage that enables the surgeon to perform a complex procedure with good ergonomic comfort.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Background
This study aims to investigate the noninferiority of Enhanced Recovery After Surgery (ERAS) for pancreaticoduodenectomy (PD).
Methods
In this single‐center trial, we randomly assigned 276 ...adult patients who underwent open PD into ERAS and conventional groups with 138 patients in each, from 2015 through 2017. The primary endpoint was the incidence of overall morbidity until postoperative 3 months. The secondary endpoints were in‐hospital or 30‐day mortality, postoperative length of stay (LOS), nutritional status and overall hospital costs.
Results
Overall morbidity was reported in 64 patients (52.0%, ERAS group) and in 68 patients (54.8%, conventional group) (risk difference RD −2.81 percentage points (pp); 90% two‐sided confidence interval −13.24 to 7.63). Mortality did not occur in any patients. The two groups did not differ significantly in median postoperative LOS (both 11 days; RD −8.46 pp), body mass index (22.4 ± 2.75 vs. 22.4 ± 2.65 kg/m2; RD −3.48 pp), Patient‐Generated Subjective Global Assessment score over 4 (45 40.5% vs. 50 43.1% patients; RD −2.56 pp), and median overall hospital cost (15.61 vs. 16.04, ×106 KRW; RD −6.08 pp).
Conclusions
Even in PD, modified ERAS protocol was not inferior to conventional protocol, while reducing treatment burden.
Highlight
This randomized clinical trial by Hwang and colleagues revealed that the Enhanced Recovery After Surgery (ERAS) protocol was not inferior to the conventional perioperative management protocol for pancreaticoduodenectomy regarding morbidity, mortality, length of stay and hospital cost. The ERAS protocol not only reduces treatment burden, but also facilitates treatment administration.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
Background
The effects of the surgical resection margin on the clinical outcomes in hepatocellular carcinoma (HCC) cases remain controversial. The objective of this study was to further examine this ...issue.
Methods
The details of all HCC patients who underwent hepatectomy between December 1999 and December 2009 at the Division of Hepatobiliary and Pancreas Surgery, Asan Medical Center were analyzed retrospectively. We divided 1022 HCC patients into two groups according to the most significant surgical margin length. To overcome any bias due to differences in the distribution of covariates between the two groups, the patients were in a matched 1:1 ratio by propensity score analysis.
Results
A surgical margin ≤1 mm was identified as the most significant surgical margin in both disease-free survival (DFS) and overall survival (OS) (
p
= 0.008 and
p
= 0.026, respectively). However, many clinicopathological factors were different between the resection margin ≤1 mm and >1 mm groups. To reduce these different clinicopathological factors, propensity score matching was performed using 21 selected factors. After matching, no significant difference was found in DFS and OS between the two groups (
p
= 0.688,
p
= 0.398). In addition, there was no significant difference in the intrahepatic recurrence rate and pattern between the resection margin groups. Except for the preoperative patient’s status and tumor stage, significant risk factors in OS were anatomical resection and postoperative morbidity (
p
= 0.002,
p
= 0.001).
Conclusion
We identified that the widths of the resection margin in resectable hepatocellular carcinoma did not influence the postoperative recurrence rates, overall survival, and recurrence pattern in multivariable analysis as well as propensity score match analysis.
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EMUNI, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UL, UM, UPUK, VKSCE, ZAGLJ
Stereotactic body radiation therapy (SBRT) is a promising treatment modality for locally advanced pancreatic cancer (LAPC). We evaluated the clinical outcomes of SBRT in patients with LAPC.
We ...retrospectively analyzed the medical records of patients with LAPC who underwent SBRT at our institution between April 2011 and July 2016. Fiducial markers were implanted using endoscopic ultrasound guidance one week prior to 4-dimensional computed tomography (CT) simulation and daily cone beam CT was used for image guidance. Patients received volumetric modulated arc therapy or intensity modulated radiotherapy using respiratory gating technique. A median dose of 28 Gy (range, 24-36 Gy) was given over four consecutive fractions delivered within one week. Survival outcomes including freedom from local disease progression (FFLP), progression-free survival (PFS), and overall survival (OS) were analyzed. Acute and late toxicities related to SBRT were assessed.
A total of 95 patients with LAPC were analyzed, 52 of which (54.7%) had pancreatic head cancers. Most (94.7%) had received gemcitabine-based chemotherapy. The 1-year FFLP rate was 80.1%. Median OS and PFS were 16.7 months and 10.2 months, respectively; the 1-year OS and PFS rates were 67.4% and 42.9%, respectively. Among 79 patients who experienced failure, the sites of first failures were isolated local progressions in 12 patients (15.2%), distant metastasis in 55 patients (69.6%), and both in 12 patients (15.2%). Seven patients (7.4%) were able to undergo surgical resection after SBRT and four had margin-negative resections. Three patients (3.2%) had grade 3 nausea/vomiting during SBRT, and late grade 3 toxicity was observed in another three patients.
LAPC patients who received chemotherapy and SBRT had favorable FFLP and OS with minimal treatment-related toxicity. The most common pattern of failure was distant metastasis, which warrants further studies on the optimal scheme of chemotherapy and SBRT.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Postoperative pancreatic fistula is a life-threatening complication with an unmet need for accurate prediction. This study was aimed to develop preoperative artificial intelligence-based prediction ...models. Patients who underwent pancreaticoduodenectomy were enrolled and stratified into model development and validation sets by surgery between 2016 and 2017 or in 2018, respectively. Machine learning models based on clinical and body composition data, and deep learning models based on computed tomographic data, were developed, combined by ensemble voting, and final models were selected comparison with earlier model. Among the 1333 participants (training, n = 881; test, n = 452), postoperative pancreatic fistula occurred in 421 (47.8%) and 134 (31.8%) and clinically relevant postoperative pancreatic fistula occurred in 59 (6.7%) and 27 (6.0%) participants in the training and test datasets, respectively. In the test dataset, the area under the receiver operating curve AUC (95% confidence interval) of the selected preoperative model for predicting all and clinically relevant postoperative pancreatic fistula was 0.75 (0.71-0.80) and 0.68 (0.58-0.78). The ensemble model showed better predictive performance than the individual ML and DL models.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Background
Though robotic pancreaticoduodenectomy(R‐PD) is gradually adopted, learning curve and its feasibility is still controversial. We analyzed our first 70 R‐PD cases, comparing surgical ...outcomes and feasibility to those of open pancreaticoduodenectomy (O‐PD).
Methods
Medical records of 70 patients of R‐PD and 269 patients of O‐PD between 2015 and 2019 were retrospectively analyzed. Cumulative sum analysis was used to determine learning curve. Surgical outcomes were compared between early(1‐35) and late cases(36‐70). Additional analyses with O‐PD using propensity score‐matching were done.
Results
Learning curve of R‐PD completed after 30 cases. Shorter operative time, lower estimated blood loss, and shorter length of stay were noted in later cases. Complication rate tended to decrease over time. In comparison with O‐PD after matching, R‐PD showed longer operation time(414.5 minutes vs 244.7 minutes; P < .001), with no differences in estimated blood loss, or length of stay. While overall complication rate was higher in R‐PD(45.5% vs 21.8%; P = .010), no statistically significant difference was observed in major complication rates(23.6% vs 10.9%; P = .084). R0 rate was equivalent.
Conclusion
Surgical performance of R‐PD improved over time. Learning curve of R‐PD completed after 30 cases. R‐PD is a promising modality, based on comparison of perioperative and oncologic feasibilities to those of O‐PD.
HighlightKim and colleagues analyzed the first 70 cases of robotic pancreaticoduodenectomy performed by a single surgeon at a single institution. The learning curve, analyzed on the basis of operative time, was completed after 30 cases. Perioperative outcomes and oncologic feasibility of robotic pancreaticoduodenectomy were comparable to those of open pancreaticoduodenectomy.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK
The survival of patients with pancreatic ductal adenocarcinoma (PDAC) is closely related to recurrence. It is necessary to classify the risk factors for early recurrence and to develop a tool for ...predicting the initial outcome after surgery. Among patients with resected resectable PDAC at Samsung Medical Center (Seoul, Korea) between January 2007 and December 2016, 631 patients were classified as the training set. Analyses identifying preoperative factors affecting early recurrence after surgery were performed. When the
-value estimated from univariable Cox's proportional hazard regression analysis was <0.05, the variables were included in multivariable analysis and used for establishing the nomogram. The established nomogram predicted the probability of early recurrence within 12 months after surgery in resectable PDAC. One thousand bootstrap resamplings were used to validate the nomogram. The concordance index was 0.665 (95% confidence interval CI, 0.637-0.695), and the incremental area under the curve was 0.655 (95% CI, 0.631-0.682). We developed a web-based calculator, and the nomogram is freely available at http://pdac.smchbp.org/. This is the first nomogram to predict early recurrence after surgery for resectable PDAC in the preoperative setting, providing a method to allow proceeding to treatment customized according to the risk of individual patients.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
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