Introduction
Surgery remains the cornerstone treatment for gastric cancer. Previous studies have reported better lymphadenectomy with minimally invasive approaches. There is a paucity of data ...comparing robotic and laparoscopic gastrectomy in the US. Herein, we examined whether oncological adequacy differs between laparoscopic and robotic approaches.
Methods
The National Cancer Database was utilized to identify patients who underwent gastrectomy for adenocarcinoma between 2010 and 2019. A propensity score-matching analysis between robotic gastrectomy (RG) versus laparoscopic gastrectomy (LG) was performed. The primary outcomes were lymphadenectomy ≥ 16 nodes and surgical margins.
Results
A total of 11,173 patients underwent minimally invasive surgery for gastric adenocarcinoma between 2010 and 2019. Of those 8320 underwent LG and 2853 RG. Comparing the unmatched cohorts, RG was associated with a higher rate of adequate lymphadenectomy (63.5% vs 57.1%,
p
< .0.0001), higher rate of negative margins (93.8% vs 91.9%,
p
< 0.001), lower rate of prolonged length of stay (26.0% vs 29.6%,
p
< .0.001), lower 90-day mortality (3.7% vs 5.0%,
p
< 0.0001), and a better 5-year overall survival (OS) (56% vs 54%,
p
= 0.03). A propensity score-matching cohort with a 1:1 ratio was created utilizing the variables associated with lymphadenectomy ≥ 16 nodes. The matched analysis revealed that the rate of adequate lymphadenectomy was significantly higher for RG compared to LG, 63.5% vs 60.4% (
p
= 0.01), respectively. There was no longer a significant difference between RG and LG regarding the rate of negative margins, prolonged length of stay, 90-day mortality, rate of receipt of postoperative chemotherapy, and OS.
Conclusions
This propensity score-matching analysis with a large US cohort shows that RG was associated with a higher rate of adequate lymphadenectomy compared to LR. RG and LG had a similar rate of negative margins, prolonged length of stay, receipt of postoperative chemotherapy, 90-day mortality, and OS, suggesting that RG is a comparable surgical approach, if not superior to LG.
Background
The National Comprehensive Cancer Network guidelines recommend harvesting 16 or more lymph nodes for the adequate staging of gastric adenocarcinoma. This study examines the rate of ...adequate lymphadenectomy over recent years, its predictors, and its impact on overall survival(OS).
Study design
The National Cancer Database was utilized to identify patients who underwent surgical treatment for gastric adenocarcinoma between 2006–2019. Trend analysis was performed for lymphadenectomy rates during the study period. Logistic regression, Kaplan-Meier survival plots, and Cox proportional hazard regression were utilized.
Results
A total of 57,039 patients who underwent surgical treatment for gastric adenocarcinoma were identified. Only 50.5% of the patients underwent a lymphadenectomy of ≥ 16 nodes. Trend analysis showed that this rate significantly improved over the years, from 35.1% in 2006 to 63.3% in 2019 (
p
< .0001). The main independent predictors of adequate lymphadenectomy included high-volume facility with ≥ 31 gastrectomies/year (OR: 2.71; 95%CI:2.46–2.99), surgery between 2015–2019 (OR: 1.68; 95%CI: 1.60–1.75), and preoperative chemotherapy (OR:1.49; 95%CI:1.41–1.58). Patients with adequate lymphadenectomy had better OS than patients who did not: median survival: 59 versus 43 months (Log-Rank:
p
< .0001). Adequate lymphadenectomy was independently associated with improved OS (HR:0.79; 95%CI:0.77–0.81). Laparoscopic and robotic gastrectomies were independently associated with adequate lymphadenectomy compared to open, OR: 1.11, 95%CI:1.05–1.18 and OR: 1.24, 95%CI:1.13–1.35, respectively.
Conclusion
Although the rate of adequate lymphadenectomy improved over the study period, a large number of patients still lacked adequate lymph node dissection, negatively impacting their OS despite multimodality therapy. Laparoscopic and robotic surgeries were associated with a significantly higher rate of lymphadenectomy ≥ 16 nodes.
Background
Enhanced recovery protocols (ERPs) after metabolic and bariatric surgery (MBS) may help decrease length of stay (LOS) and postoperative nausea/vomiting but implementation is often fraught ...with challenges. The primary aim of this pilot study was to standardize a MBS ERP with a real-time data support dashboard and checklist and assess impact on global and individual element compliance. The secondary aim was to evaluate 30 day outcomes including LOS, hospital readmissions, and re-operations.
Methods and procedures
An ERP, paper checklist, and virtual dashboard aligned on MBS patient care elements for pre-, intra-, and post-operative phases of care were developed and sequentially deployed. The dashboard includes surgical volumes, operative times, ERP compliance, and 30 day outcomes over a rolling 18 month period. Overall and individual element ERP compliance and outcomes were compared pre- and post-implementation via two-tailed Student’s t-tests.
Results
Overall, 471 patients were identified (pre-implementation: 193; post-implementation: 278). Baseline monthly average compliance rates for all patient care elements were 1.7%, 3.7%, and 6.2% for pre-, intra-, and post-operative phases, respectively. Following ERP integration with dashboard and checklist, the intra-operative phase achieved the highest overall monthly average compliance at 31.3% (
P
< 0.01). Following the intervention, pre-operative acetaminophen administration had the highest monthly mean compliance at ≥ 99.1%. Overall TAP block use increased 3.2-fold from a baseline mean rate of 25.4–80.8% post-implementation (
P
< 0.01). A significant decrease in average intra-operative monthly morphine milligram equivalents use was noted with a 56% drop pre- vs. post-implementation. Average LOS decreased from 2.0 to 1.7 days post-implementation with no impact on post-operative outcomes.
Conclusion
Implementation of a checklist and dashboard facilitated ERP integration and adoption of process measures with many improvements in compliance but no impact on 30 day outcomes. Further research is required to understand how clinical support tools can impact ERP adoption among MBS patients.
Enhanced Recovery after Surgery (ERAS) protocols lead to expedited discharges and decreased cost. Bariatric centers have adopted such programs for safely discharging patients after sleeve gastrectomy ...(LSG) on the first postoperative day (POD1). Despite pathways, some bariatric patients cannot be discharged on POD1.
We performed a retrospective review of patients undergoing LSG, from 2013 through 2016, in a center of excellence, using a standardized enhanced recovery pathway. Patient variables and perioperative factors were analyzed, including multivariate regressions, for predictors of early discharge.
There were 573 patients who underwent LSG (83% female, mean age of 46.3 ± 11.7 years, and BMI of 46.0 ± 6.6 kg/m2). Mean hospital stay was 1.7 days ± 1.0 SD. Early discharge occurred in 38.2% of patients. Independently, early operating room start times and treated obstructive sleep apnea were associated with earlier discharge (p < 0.05). In contrast, preoperative opioid use, history of psychiatric illness, chronic kidney disease, and revision cases delayed discharge (p < 0.05). Age, sex, American Society of Anesthesiologists (ASA) class, diabetes, congestive heart failure, hypertension, distance to home, and insurance status were not significant. On regression modeling, early operating room start time and treated obstructive sleep apnea (OSA) reduced length of stay (LOS) (p < 0.05), while creatinine >1.5 mg/dL, ejection fraction < 50%, and increased case duration increased LOS (p < 0.05). Fifteen patients were readmitted within 30 days (2.6%).
Several clinical and operative factors affect early discharge after LSG. Knowing factors that enhance the success of ERAS as well as the causes and corrections for failed implementation allow teams to optimally direct care pathway resources.
The h-index is a widely utilized academic metric that measures both productivity and citation impact. The purpose of this study is to define the impact of self-citation among minimally invasive ...surgery (MIS) fellowship program directors.
Through the Fellowship Council's website, all program directors and associate program directors from the 148 MIS fellowship programs were identified. Using the Scopus database, we calculated the number of publications, citations, self-citations, and h-index for each surgeon.
A total of 274 surgeons were identified. The mean number±SD of publications, citations, and h-index for the cohort were 60.5 ± 77.2, 1765 ± 4024, and 16.0 ± 15.0, respectively. The self-citation rate for the entire cohort was 3.23%. Excluding self-citations reduces the mean number of citations to 1708 ± 3887 and h-index to 15.8 ± 14.6. The h-index remained unchanged for 77% (210/274) of surgeons. Only 5% (15/274) of surgeons had a change in h-index of greater than one integer and no surgeon had a change greater than three integers.
Self-citation is infrequent and has a minimal impact on the academic profile of program directors of MIS fellowships.
•The academic profiles of 274 surgeons from 148 MIS fellowships were analyzed.•The self-citation rate for the entire cohort was 3.23%.•The h-index remained unchanged for 77% (210/274) of surgeons.•Only 5% (15/274) of surgeons had a change in h-index of more than one integer.•No surgeon had a change in h-index greater than three integers.
OBJECTIVE:Pulmonary embolism (PE) following laparoscopic paraesophageal hernia repair (PEHR) is rare but occurs at a higher frequency than other laparoscopic procedures. We describe a series of ...patients who developed PEs after PEHR in hopes of capturing potential risk factors for further study.
MATERIALS AND METHODS:Five cases of PE after PEHR were observed between 2017 and 2018. Individual and perioperative risk factors, and postoperative courses were reviewed.
RESULTS:Patients had a mean age of 73 years (range, 59 to 86). All were female. Two patients presented acutely. Three patients underwent revisional surgery. The average procedure duration was 248 minutes (range, 162 to 324). All patients had gastrostomy tubes placed. The diagnosis of PE occurred within 3 to 19 days postoperatively. Four were treated with 3 months of oral anticoagulation; 1 was managed expectantly.
CONCLUSIONS:Highly complex cases, marked by revisional status, need for mesh, large hernia size, and percutaneous endoscopic gastrostomy placement are likely at increased risk for PEs. Preoperative venous thromboembolism chemoprophylaxis should be considered in the majority of laparoscopic PEHR patients.
Background and Objectives
Etiologies, levels, and associated factors of psychological distress in cancer patients facing surgery are poorly defined. We conducted a prospective comparative study of ...perioperative anxiety and depression in patients undergoing abdominal surgery for either malignant or benign disease.
Methods
With Institutional Review Board approval, patients consenting for surgery at our institution were enrolled. Surveys were completed at a preoperative visit and within 2 weeks of a postoperative appointment. Participants listed their top three sources of anxiety, and completed the Patient Health Questionnaire‐9 and the General Anxiety Disorder‐7.
Results
A total of 79 patients completed the preoperative assessment and 44 (58.7%) finished the postoperative survey. Forty‐one were male (51.9%), 12 (15.2%) had a psychiatric comorbidity (PSYHx), and 47 (59.5%) had cancer. Perioperative anxiety and depression did not differ by malignancy status. Patients were most concerned about surgery (22.5%) preoperatively and finances (27.9%) postoperatively. PSYHx, frailty, insurance status, and opioid use were all associated with perioperative psychological distress.
Conclusions
Cancer patients did not have significantly higher levels of perioperative psychological distress compared with benign controls. Socioeconomic worries are prevalent throughout the perioperative period, and efforts to alleviate distress should focus on providing adequate counseling.
