Robotic Partial Segment VIII Resection White, M. G.; Tzeng, C. W.; Ikoma, N. ...
Annals of surgical oncology,
03/2021, Volume:
28, Issue:
3
Journal Article
Most current models for predicting survival after resection of colorectal liver metastasis include largest diameter and number of colorectal liver metastases as dichotomous variables, resulting in ...underestimation of the extent of risk variation and substantial loss of statistical power. The aim of this study was to develop and validate a new prognostic model for patients undergoing liver resection including largest diameter and number of colorectal liver metastases as continuous variables.
A prognostic model was developed using data from patients who underwent liver resection for colorectal liver metastases at MD Anderson Cancer Center and had RAS mutational data. A Cox proportional hazards model analysis was used to develop a model based on largest colorectal liver metastasis diameter and number of metastases as continuous variables. The model results were shown using contour plots, and validated externally in an international multi-institutional cohort.
A total of 810 patients met the inclusion criteria. Largest colorectal liver metastasis diameter (hazard ratio (HR) 1.11, 95 per cent confidence interval 1.06 to 1.16; P < 0.001), number of colorectal liver metastases (HR 1.06, 1.03 to 1.09; P < 0.001), and RAS mutation status (HR 1.76, 1.42 to 2.18; P < 0.001) were significantly associated with overall survival, together with age, primary lymph node metastasis, and prehepatectomy chemotherapy. The model performed well in the external validation cohort, with predicted overall survival values almost lying within 10 per cent of observed values. Wild-type RAS was associated with better overall survival than RAS mutation even when liver resection was performed for larger and/or multiple colorectal liver metastases.
The contour prognostic model, based on diameter and number of lesions considered as continuous variables along with RAS mutation, predicts overall survival after resection of colorectal liver metastasis.
Background
Organ/space surgical site infections (OSIs) constitute an important postoperative metric. We sought to assess the impact of a previously described air leak test (ALT) on the incidence of ...OSI following major hepatectomies.
Methods
A single-institution hepatobiliary database was queried for patients who underwent a major hepatectomy without biliary-enteric anastomosis between January 2009 and June 2015. Demographic, clinicopathologic, and intraoperative data—including application of ALT—were analyzed for associations with postoperative outcomes, including OSI, hospital length of stay (LOS), morbidity and mortality rates, and readmission rates.
Results
Three hundred eighteen patients were identified who met inclusion criteria, of whom 210 had an ALT. ALT and non-ALT patients did not differ in most disease and treatment characteristics, except for higher rates of trisegmentectomy among ALT patients (53 vs. 34 %,
p
= 0.002). ALT patients experienced lower rates of OSI and 90-day morbidity than non-ALT patients (5.2 vs. 13.0 %,
p
= 0.015 and 24.8 vs. 40.7 %,
p
= 0.003, respectively). In turn, OSI was the strongest independent predictor of longer LOS (OR = 4.89; 95 % CI, 2.80–6.97) and higher rates of 30- (OR = 32.0; 95 % CI, 10.9–93.8) and 45-day readmissions (OR = 29.4; 95 % CI, 10.2–84.6).
Conclusions
The use of an intraoperative ALT significantly reduces the rate of OSI following major hepatectomy and may contribute to lower post-discharge readmission rates.
Background
Adequate lymphadenectomy (AL) during surgical resection and delivery of multimodality therapy (MMT) are considered important for optimizing oncologic outcomes in patients with locally ...advanced gastric cancer. Both neoadjuvant and adjuvant approaches to MMT delivery are considered acceptable treatment strategies. Our goal was to evaluate the association between MMT treatment approach, hospital practice patterns, and survival and to explore whether AL and MMT might represent measures of quality for locally advanced gastric cancer.
Methods
A national cohort study of 5433 patients with locally advanced gastric cancer (≥cT2 and/or cN+) treated at 987 hospitals within the National Cancer Database (2006–2015). Patients were categorized as receiving a neoadjuvant therapy (NT) or adjuvant therapy (AT) approach. Patients were also categorized based on receipt of AL (≥15 nodes) and MMT (surgery with any preoperative, perioperative, or postoperative AT). Hospitals were stratified based on the predominant treatment approach and the proportion of patients that achieved performance benchmarks (AL ≥ 80%; MMT ≥ 75%). Multivariable Cox shared frailty modeling was used to evaluate the association with the overall risk of death.
Results
Overall, 54.5% of patients were treated with an AT and 45.6% with an NT approach. Relative to surgery alone, receipt of MMT by either approach was associated with decreased risk of death (NT—hazard ratio HR: 0.75, 95% confidence interval: 0.65–0.86; AT—HR: 0.80 0.71–0.90). Relative to care at mixed pattern hospitals, care at predominantly AT hospitals was associated with an increased risk of death (HR: 1.28 1.12–1.47). Relative to patients whose care achieved no quality measures, AL (HR: 0.75, 0.67–0.82) and MMT (HR: 0.68 0.60–0.76) were each associated with a reduced risk of death. Receipt of both measures was associated with an even greater reduction (HR: 0.47 0.40–0.56). Hospital performance on AL, MMT, or both measures was not associated with the risk of death.
Conclusion
Because over half of patients are treated with surgery first (many having surgery alone) and care at hospitals favoring a surgery first approach is associated with worse outcomes, quality improvement (QI) efforts should focus on increasing the use of NT strategies. Furthermore, delivery of AL and MMT together may represent an actionable, generalizable target for gastric cancer QI efforts because it improves survival and is unrelated to the context in which care is provided.
The COVID-19 booster vaccination rate has declined despite the wide availability of vaccines. As COVID-19 is becoming endemic and charges for regular booster vaccination are being introduced, ...measuring public acceptance and the willingness to pay for regular COVID-19 boosters is ever more crucial.
This study aims to (1) investigate public acceptance for regular COVID-19 boosters, (2) assess the willingness to pay for a COVID-19 booster shot, and (3) identify factors associated with vaccine hesitancy. Our results will provide crucial insights into and implications for policy response as well as the development of a feasible and effective vaccination campaign during Vietnam's waning vaccine immunity period.
A cross-sectional study was conducted among 871 Vietnamese online participants from April to August 2022. An online questionnaire based on the discrete choice experiment (DCE) design was developed, distributed using the snowball sampling method, and subsequently conjointly analyzed on the Qualtrics platform. A history of COVID-19 infection and vaccination, health status, willingness to vaccinate, willingness to pay, and other factors were examined.
Among the participants, 761 (87.4%) had received or were waiting for a COVID-19 booster shot. However, the willingness to pay was low at US $8.02, and most participants indicated an unwillingness to pay (n=225, 25.8%) or a willingness to pay for only half of the vaccine costs (n=222, 25.4%). Although information insufficiency and a wariness toward vaccines were factors most associated with the unwillingness to pay, long-term side effects, immunity duration, and mortality rate were the attributes the participants were most concerned with during the vaccine decision-making period. Participants who had children less than 18 years old in their homes infected with COVID-19 had a lower willingness to pay (odds ratio OR 0.54, 95% CI 0.39-0.74). Respondents who had children under 12 years old in their family who received at least 1 vaccine dose had a higher willingness to pay (OR 2.03, 95% CI 1.12-3.66). The burden of medical expenses (OR 0.33, 95% CI 0.25-0.45) and fear of the vaccine (OR 0.93, 95% CI 0.86-1.00) were negative factors associated with the level of willingness to pay.
A significant inconsistency between high acceptance and a low willingness to pay underscores the role of vaccine information and public trust. In addition to raising awareness about the most concerning characteristics of the COVID-19 booster, social media and social listening should be used in collaboration with health professionals to establish a 2-way information exchange. Work incentives and suitable mandates should continue to encourage workforce participation. Most importantly, all interventions should be conducted with informational transparency to strengthen trust between the public and authorities.
Background
Quality indicators are increasingly emphasized in the performance of colonoscopy. This study aimed to determine the standard of care rendered by surgeon-endoscopists in a Veterans Affairs ...(VA) medical center by evaluating the indications for colonoscopy and outcome performance measures according to established quality indicators for colonoscopy.
Methods
A prospective standardized computer endoscopic reporting database (ProVation MD) was retrospectively reviewed. All colonoscopies performed by attending surgeons at the San Diego VA medical center between 1 January 2004 and 31 July 2007 were included in the study. Patients with charts that had incomplete reporting were excluded. The quality indicators used included the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) criteria for colorectal cancer screening, the American Cancer Society (ACS) guidelines for postcancer resection surveillance, and the American Society of Gastrointestinal Endoscopists (ASGE) quality indicators for colonoscopy.
Results
The data for 558 patients (96% men) were analyzed. The average patient age was 63 years (range, 25–93 years). Almost all the colonoscopies (99%) were performed in accordance with established criteria. The most common indications for colonoscopy were screening (
n
= 143, 26%), non-acute gastrointestinal bleeding (
n
= 127, 23%), polyp surveillance (
n
= 100, 18%), postcancer resection surveillance (
n
= 91, 17%), abdominal pain (
n
= 19, 4%), and anemia (
n
= 14, 3%). Postcancer resection surveillance colonoscopies were performed according to recommended criteria in 98% of the cases. The cecal intubation rate was 97%, and the overall adenoma detection rate was 26%. Two patients (<1%) experienced complications requiring intervention.
Conclusion
The study data indicate that surgeon-performed colonoscopies meet standard quality criteria for indications and performance measures. The authors therefore conclude that surgeon-endoscopists demonstrate proficiency in the standard of care for colonoscopy examinations.
Although used as criterion for early drain removal, postoperative day (POD) 1 drain fluid amylase (DFA) ≤ 5000 U/L has low negative predictive value for clinically relevant postoperative pancreatic ...fistula (CR-POPF). It was hypothesized that POD3 DFA ≤ 350 could provide further information to guide early drain removal.
Data from a pancreas surgery consortium database for pancreatoduodenectomy and distal pancreatectomy patients were analyzed retrospectively. Those patients without drains or POD 1 and 3 DFA data were excluded. Patients with POD1 DFA ≤ 5000 were divided into groups based on POD3 DFA: Group A (≤350) and Group B (>350). Operative characteristics and 60-day outcomes were compared using chi-square test.
Among 687 patients in the database, all data were available for 380. Fifty-five (14.5%) had a POD1 DFA > 5000. Among 325 with POD1 DFA ≤ 5000, 254 (78.2%) were in Group A and 71 (21.8%) in Group B. Complications (35 (49.3%) vs 87 (34.4%); p = 0.021) and CR-POPF (13 (18.3%) vs 10 (3.9%); p < 0.001) were more frequent in Group B.
In patients with POD1 DFA ≤ 5000, POD3 DFA ≤ 350 may be a practical test to guide safe early drain removal. Further prospective testing may be useful.
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