Therapeutic index of lymphadenectomy among patients with pancreatic neuroendocrine tumors: A multi‐institutional analysis

BackgroundThe benefit derived from lymph node dissection (LND) in patients with pancreatic neuroendocrine tumors (pNETs) based on clinicopathological characteristics remains unclear.MethodsPatients undergoing surgery for pNET between 1997 and 2016 were identified using a multi‐institutional dataset. The therapeutic index of LND relative to patient characteristics was calculated.ResultsAmong 647 patients, the median number of lymph nodes (LNs) evaluated was 10 (interquartile range: 4‐16) and approximately one quarter of patients had lymph node metastasis (LNM) (N = 159, 24.6%). Among patients with LNM, 5‐year recurrence‐free survival was 56.0%, reflecting a therapeutic index value of 13.8. The therapeutic index was highest among patients with a moderately/poorly‐differentiated pNET (21.5), Ki‐67 ≥ 3% (20.1), tumor size ≥2.0 cm (20.0), and tumor location at the head of the pancreas (20.0). Patients with ≥8 LNs evaluated had a higher therapeutic index than patients who had 1 to 7 LNs evaluated (≥8: 17.9 vs 1‐7: 7.5; difference of index: 11.4).ConclusionLND was mostly beneficial among patients with pNETs >2 cm, Ki‐67 ≥ 3%, and lesions located at the pancreatic head as identification of LNM was most common among individuals with these tumor characteristics. Evaluation of ≥8 LNs was associated with a higher likelihood of identifying LNM as well as a higher therapeutic index, and therefore this number of LNs should be considered the goal.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/151957/1/jso25689_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/151957/2/jso25689.pd

Editorial: Surgical Advances in Pancreaticobiliary Diseases

Pancreaticobiliary diseases include malignant tumors arising in organs with a complex anatomy, such as the pancreas and bile ducts, often presenting as locally advanced or metastatic lesions, and they frequently have a poor prognosis [...

Analysis of authorship in hepatopancreaticobiliary surgery: women remain underrepresented

Introduction Given the need to increase female representation in hepatopancreatobiliary (HPB) surgery, as well as the need to increase the academic pipeline of women in this subspecialty, we sought to characterize the prevalence of female authorship in the HPB literature. In particular, the objective of the current study was to determine the proportion of women who published HPB research articles as first, second, or last author over the last decade. Methods All articles pertaining to hepatopancreaticobiliary (HPB) surgery appearing in seven surgical journals (Annals of Surgery, British Journal of Surgery, JAMA Surgery, Annals of Surgical Oncology, HPB (Oxford), Surgery, and Journal of Gastrointestinal Surgery) were reviewed for the years 2008 and 2018. Information on sex of author, country of author’s institution, and article type was collected and entered into a computerized database. Results Among the 1473 index articles included in the final analytic cohort, 414 (28%) publications had a woman as the first or last author, while the vast majority (n = 1,059, 72%) had a man as the first or last author. The number of female first authors increased from 15.6% (n = 92/591) in 2008 to 25.7% (n = 227/882) in 2018 (p \u3c 0.001). There were no differences in the proportion of second (n = 123/536, 23.0% vs n = 214/869, 24.6%, p = 0.47) or last (n = 44/564, 7.8% vs n = 88/875, 10.1%, p = 0.15) authors. Women were more likely to publish papers appearing in medium-impact journals (OR 1.40, 95% CI 1.04–1.88) and articles with a female author were more likely to be from a North American institution (referent: North America, Asia OR 0.43, 95% CI 0.31–0.59 vs Europe OR 0.67, 95% CI 0.51–0.87). Conclusion Women first/last authors in HPB research articles have increased over the past 10 years from 22 to 32%. Women as last authors remain low, however, as only 1 in 10 papers had a senior woman author. These data should prompt HPB leaders to find solutions to the gap in female authorship including mentorship of young female researchers and surgeons

Neoadjuvant Therapy for Extrahepatic Biliary Tract Cancer: A Propensity Score-Matched Survival Analysis

Background: Although surgery is the mainstay of curative-intent treatment for extrahepatic biliary tract cancer (EBTC), recurrence following surgery can be high and prognosis poor. The impact of neoadjuvant therapy (NAT) relative to upfront surgery (US) among patients with EBTC remains unclear. Methods: The Surveillance, Epidemiology, and End Results (SEER) databases was utilized to identify patients who underwent surgery from 2006 to 2017 for EBTC, including gallbladder cancer (GBC) and extrahepatic cholangiocarcinoma (ECC). Trends in NAT utilization were investigated, and the impact of NAT on prognosis was compared with US using a propensity score-matched (PSM) analysis. Results: Among 6582 EBTC patients (GBC, n = 4467, ECC, n = 2215), 1.6% received NAT; the utilization of NAT for EBTC increased over time (Ptrend = 0.03). Among patients with lymph node metastasis, the lymph node ratio was lower among patients with NAT (0.18 vs. 0.40, p p = 0.14, 5-year CSS: 38.0% vs. 36.1%, p = 0.21). A subgroup analysis revealed that NAT was associated with improved OS and CSS among patients with stages III–IVA of the disease (OS: HR 0.65, 95%CI 0.46–0.92, p = 0.02, CSS: HR 0.62, 95%CI 0.41–0.92, p = 0.01). Conclusions: While NAT did not provide an overall benefit to patients undergoing surgery for EBTC, individuals with advanced-stage disease had improved OS and CSS with NAT. An individualized approach to NAT use among patients with EBTC may provide a survival benefit

Use of perioperative epidural analgesia among Medicare patients undergoing hepatic and pancreatic surgery

Background: We sought to characterize epidural analgesia (EA) use among Medicare patients undergoing hepatopancreatic (HP) procedures, identify factors associated with EA use and asses perioperative outcomes. Methods: Patients undergoing HP surgery were identified using the Inpatient Standard Analytic Files. Logistic regression was utilized to identify factors associated with EA receipt, and assess associations of EA with in-hospital outcomes and Medicare expenditures. Results: Among 20,562 patients included in the study, 6.7% (n =1362) had EA. There was no difference in the odds of complications (OR 1.05, 95% CI 0.93\u20131.19) or blood transfusions (OR 0.90, 95% CI 0.79\u20131.03) with EA versus conventional analgesia (CA). The odds of prolonged LOS (OR 1.16, 95% CI 1.03\u20131.30) were higher with EA; the odds of in-hospital mortality were higher with conventional analgesia (OR 1.90, 95% CI 1.28\u20132.83). Medicare payments for liver surgery were comparable among EA ($19,500) versus conventional analgesia ($19,300, p = 0.85) and slightly higher for EA ($23,600) versus conventional analgesia ($22,000, p < 0.001) for pancreatic procedures. Conclusion: EA utilization among Medicare patients undergoing HP was low. While EA was not associated with morbidity, it resulted in an average additional one day LOS and slightly higher expenditures in pancreatic surgery

Trends in the Incidence, Treatment and Outcomes of Patients with Intrahepatic Cholangiocarcinoma in the USA: Facility Type is Associated with Margin Status, Use of Lymphadenectomy and Overall Survival

Introduction: Intrahepatic cholangiocarcinoma (ICC) remains an uncommon disease with a rising incidence worldwide. We sought to identify trends in therapeutic approaches and differences in patient outcomes based on facility types. Methods: Between January 1, 2004, and December 31, 2015, a total of 27,120 patients with histologic diagnosis of ICC were identified in the National Cancer Database and were enrolled in this study. Results: The incidence of ICC patients increased from 1194 in 2004 to 3821 in 2015 with an average annual increase of 4.16% (p < 0.001). Median survival of the cohort improved over the last 6 years of the study period (2004\u20132009: 8.05 months vs. 2010\u20132015: 9.49 months; p < 0.001). Among surgical patients (n = 5943, 21.9%), the incidence of R0 resection, lymphadenectomy and harvest of 656 lymph nodes increased over time (p < 0.001). Positive surgical margins (referent R0: R1, HR 1.49, 95% CI 1.24\u20131.79, p < 0.001) and treatment at community cancer centers (referent academic centers; HR 1.24, 95% CI 1.04\u20131.49, p = 0.023) were associated with a worse prognosis. Patients treated at academic centers had higher rates of R0 resection (72.4% vs. 67.7%; p = 0.006) and lymphadenectomy (55.6% vs. 49.5%, p = 0.009) versus community cancer centers. Overall survival was also better at academic versus community cancer programs (median OS: 11 months versus 6 months, respectively; p < 0.001). Conclusions: The incidence of ICC has increased over the last 12 years in the USA with a moderate improvement in survival over time. Treatment at academic cancer centers was associated with higher R0 resection and lymphadenectomy rates, as well as improved OS for patients with ICC

Minimally Invasive Liver Resection for Early-Stage Hepatocellular Carcinoma: Inconsistent Outcomes from Matched or Weighted Cohorts

The aim of the current study was to re-evaluate the role of minimally invasive liver resection (MILR) among patients with early-stage (stage I or II) hepatocellular carcinoma (HCC) undergoing partial hepatectomy