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Background Perioperative blood transfusion (PBT) is common in pancreatic surgery. Recent studies have suggested that PBT may be associated with worse long-term outcomes. Methods A systematic review and meta-analysis of studies comparing long-term clinical outcomes of cancer patients undergoing curative-intent pancreatic surgery with regard to occurrence of PBT was performed. Results A total of 23 studies (4339 patients) were included in the systematic review, and 19 studies (3646 patients) were included in the meta-analysis. Nearly half (45.8 %) of all patients were female (range 25–60 %), and median age ranged from 59 to 72 years. About half (46.5 %, range 19–72 %) of the patients were transfused. Most had pancreatic ductal adenocarcinoma (69.5 %), while others had ampullary carcinoma (15.0 %), cholangiocarcinoma (7.4 %), or exocrine tumors of pancreas (8.1 %). Most (91.1 %) underwent pancreaticoduodenectomy, while the remaining patients underwent a total or distal pancreatectomy. The 5-year overall survival for all patients ranged from 0 to 65 %. Thirteen and nine of 19 studies reported a detrimental effect of PBT on survival on univariable and multivariable analysis, respectively. Overall, PBT was associated with shorter overall survival (pooled odds ratio 2.43, 95 % confidence interval 1.90–3.10); this finding was reproduced in sensitivity analysis. Conclusions Patients receiving PBT had significantly lower 5-year survival after curative-intent pancreatic surgery. Further research should focus on implementing guidelines for and discerning factors associated with the poor outcomes after PBT.

Background Ethnicity and insurance status have been shown to impact odds of presenting with metastatic cancer, however, the interaction of these two predictors is not well understood. We evaluate the difference in odds of presenting with metastatic disease in minorities compared to white patients despite access to the same insurance across three common cancer types. Methods Using the National Cancer Database, a multilevel logistic regression model that estimated the odds of metastatic disease was fit, adjusting for covariates including year of diagnosis, ethnicity, insurance, income, and region. We included adults diagnosed with metastatic prostate, non–small cell lung cancer (NSCLC), and breast cancer from 2004 to 2015. Results The study cohort consisted of 1 191 241 prostate cancer (PCa), 1 310 986 breast cancer (BCa), and 1 183 029 NSCLC patients. Private insurance was the most protective factor against metastatic presentation. Odds of presenting with metastatic disease were 0.190 [95% CI, 0.182‐0.198], 0.616 [95% CI, 0.602‐0.630], and 0.270 [95% CI, 0.260‐0.279] for PCa, NSCLC, and BCa compared to uninsured patients, respectively. Private insurance provided the most significant benefit to non‐Hispanic White PCa patients with 81% reduction in odds of metastatic presentation and conferred the least benefit to African‐American NSCLC patients at 30.4% reduction in odds of metastatic presentation. Conclusions Insurance status provided the single most protective effect against metastatic presentation. This benefit varied for minorities despite similar insurance. Reducing metastatic disease presentation rates requires addressing social barriers to care independent of insurance. Ethnicity and insurance status have been shown to impact odds of presenting with metastatic cancer, however the interaction of these two predictors is not well understood. In this national‐level analysis, we found that insurance status provided the single most protective effect against metastatic presentation. This benefit varied for minorities despite similar insurance.

Background Although international studies of young gastric cancer patients have mainly reported favorable survival outcomes compared with older patients, US-based experiences have shown a wider spectrum of outcomes. We examined the impact of young age (under 45 years) on the presentation and survival outcomes of gastric adenocarcinoma. Methods A total of 33,236 patients with gastric adenocarcinoma were identified within the 1988–2006 Surveillance, Epidemiology, and End Results (SEER) registry. Multivariate regression analysis of relative survival was performed to adjust for covariate effects using generalized linear models. Results Young patients were more likely than older patients to have advanced nodal and distant metastatic disease at presentation ( P  < 0.001 for both). Unadjusted relative survival analysis demonstrated younger patients to have favorable stage-stratified survival when compared with middle-aged and older patients. These findings persisted after adjusting for covariates. After stratifying for receipt of cancer-directed surgery, younger age was associated with more favorable stage-stratified relative survival. Conclusions This is the largest US population-based study of age-related gastric cancer outcomes. Although young patients with gastric cancer present with more advanced disease, their adjusted stage-stratified relative survival is more favorable than that of older patients. This study supports a stage-dependent treatment approach in younger populations.

Background Prior studies in patients with BRAF‐mutant melanoma have shown increased density of tumor infiltrating lymphocytes (TIL) after 2 weeks of BRAF (BRAFi) ± MEK inhibition (MEKi), but did not characterize the functional state or clonal diversity of TIL over time. We evaluated sequential tumor biopsies during therapy to test the hypotheses that BRAF/MEKi would increase TIL to day 29, with increases in IFNγ signatures and T‐cell homing receptor ligands and expansion of functional intratumoral tumor‐reactive CD8 T‐cells and TIL clonality in the tumor microenvironment. Methods Subjects with biopsy‐accessible BRAF‐mutant advanced melanoma received vemurafenib+/−cobimetinib. Tumor biopsies were obtained at baseline and days 8, 15, and 29 on therapy. Tumors were analyzed by quantitative immunofluorescence (QIF), NanoString, and TCRseq. Results Five patients were enrolled. All had an initial tumor response followed by subsequent progression. In four patients, both CD8+ and CD4+ TIL density increased by day 8 or 15 per QIF and continued to increase at day 29 in two. Gene expression data showed upregulation of genes/pathways associated with immunologic rejection of cancer, including Class I and II MHC expression, antigen processing/presentation, and critical T‐cell attracting chemokines. TCRvβ clonal expansion was observed in 3 patients, but most diminished after day 15. Conclusions Data from this study provides provocative evidence that, while BRAF+/−MEK inhibitor therapy produces an increase in overall and clonal T cell infiltrates, there is limited evidence for generation of new or persistent tumor immunity. Thus, BRAFi/MEKi therapy may enable tumor‐reactive T cells to infiltrate tumors but tumor control does not appear to depend on priming new immune responses. We evaluated sequential tumor biopsies during therapy to test the hypotheses that BRAF/MEKi would increase TIL and lead to an expansion of functional intratumoral tumor‐reactive CD8 T‐cells and TIL clonality in the tumor microenvironment. Data from this study provides provocative evidence that, while BRAF+/−MEK inhibitor therapy produces an increase in overall and clonal T cell infiltrates, there is limited evidence for generation of new or persistent tumor immunity. Thus, BRAFi/MEKi therapy may enable tumor‐reactive T cells to infiltrate tumors but tumor control does not appear to depend on priming new immune responses.

Background The American College of Surgeons has always promoted education and collaborations with other countries and their scientific organizations. The International Guest Scholarship program was established in 1968 to support the travel of foreign surgeons to medical Institutions in the USA and Canada. The program has grown substantially over time and now includes different categories of scholarships and surgeons. The objective of this article is to describe the experiences gained by the international scholars who visited US and Canadian institutions through these ACS programs. Study design In order to collect information regarding these scholarships from the surgeons who have already participated in the program, an Internet-based survey was e-mailed to alumni. The surveys were constructed to gather career information on former scholars and to analyze the perceived impact of these programs on their careers. Results Among the international scholarships alumni, most are now Fellows of the American College of Surgeons. The majority of respondents maintained contact with their host surgeons in the USA or Canada; they began or continued research, surgical education and surgical quality improvement initiatives in their country of origin based upon their experiences as international scholars. Most of the alumni reported that the experience they had during the scholarship was inspiring, opened their minds and broadened their horizons. Conclusions The overall effect of ACS international scholarship program should be considered as positive, as 80–90% of respondent alumni consider their experience very helpful and feel that it provided them with opportunities that would not have been possible without it. It is incumbent upon the ACS to continue along this path by identifying funding and donation sources, as well as enriching the content and goals.

Introduction Mortality and complications following bariatric surgery occur at acceptable rates, but its safety in the elderly population is unknown. We hypothesized that short-term operative outcomes in bariatric surgery patients ≥65 years would be comparable to younger persons. Methods Patients with a body mass index ≥35 kg/m 2 who underwent bariatric surgery in the 2005–2009 American College of Surgeons National Surgical Quality Improvement Program were identified. Controlling for confounders, multivariate regression was used to predict the impact of age on mortality, major events and prolonged length of stay at 30 days. Results We identified 48,378 patients who underwent bariatric procedures between 2005 and 2009. Multivariate regression analysis demonstrated advancing age trended towards predicting mortality, but was not statistically significant. Additionally, patients ≥65 years did not experience higher risk of major complications for either open or laparoscopic procedures. However, patients age ≥65 years were more likely to experience prolonged length of stay for both open and laparoscopic procedures. Conclusion This multi-hospital study demonstrates older age predicts short-term prolonged length of stay but not major events following bariatric surgery. Older age trends toward predicting mortality, but it is not statistically significant.

In the original article, the top of Fig. 1 was inadvertently cut off. The original article has been corrected. The publisher regrets the error.In the original article, the top of Fig. 1 was inadvertently cut off. The original article has been corrected. The publisher regrets the error.

The incidence of esophageal adenocarcinoma (EAC) has surged by 600% in recent decades, with a dismal 5-year survival rate of just 15%. Barrett’s esophagus (BE), affecting about 2% of the population, raises the risk of EAC by 40-fold. Despite this, the transcriptomic changes during the BE to EAC progression remain unclear. Our study addresses this gap through comprehensive transcriptomic profiling to identify key mRNA signatures and genomic alterations, such as gene fusions. We performed RNA-sequencing on BE and EAC tissues from 8 individuals, followed by differential gene expression, pathway and network analysis, and gene fusion prediction. We identified mRNA changes during the BE-to-EAC transition and validated our results with single-cell RNA-seq datasets. We observed upregulation of keratin family members in EAC and confirmed increased levels of keratin 14 (KRT14) using immunofluorescence. More differentiated BE marker genes are downregulated during progression to EAC, suggesting undifferentiated BE subpopulations contribute to EAC. We also identified several gene fusions absent in paired BE and normal esophagus but present in EAC. Our findings are critical for the BE-to-EAC transition and have the potential to promote early diagnosis, prevention, and improved treatment strategies for EAC.

Medicaid beneficiaries do not have equal access to high-volume centers for complex surgical procedures. We hypothesize there is a large Medicaid Gap between those receiving emergency general vs complex surgery at the same hospital. Using the Nationwide Inpatient Sample, 1998 to 2010, we identified high-volume pancreatectomy hospitals. We then compared the percentage of Medicaid patients receiving appendectomies vs pancreatectomies at these hospitals. Hospital characteristics associated with increased Medicaid Gap were evaluated using generalized estimating equation models. A total of 602 hospital-years of data from 289 high-volume pancreatectomy hospitals were included. Median percentages of Medicaid appendectomies and pancreatectomies were 12.1% (interquartile range: 5.8% to 19.8%) and 6.7% (interquartile range: 0% to 15.4%), respectively. Hospitals that performed greater than or equal to 40 pancreatic resections per year had higher odds of having significant Medicaid Gap (odds ratio 2.3, 95% confidence interval 1.1 to 5.0). Gaps exist between the percentages of Medicaid patients receiving emergency general surgery vs more complex surgical care at the same hospital and may be exaggerated in hospitals with very high volume of complex elective surgeries.

BackgroundLimited data exist on safe discontinuation of antiprogrammed cell death protein 1 (PD-1) therapy in responding patients with advanced melanoma. The use of 18fluorodeoxyglucose (18FDG)-PET/CT scan and tumor biopsy for assessment of active disease may be an effective predictive biomarker to guide such treatment decisions.MethodsA retrospective study of 122 patients with advanced melanoma treated with anti-PD-1 monotherapy or anti-PD-1/anticytotoxic T-lymphocyte-associated protein 4 combination therapy at Georgetown Lombardi Comprehensive Cancer Center was conducted. Uveal melanoma patients and those receiving concurrent experimental therapy were excluded. Baseline characteristics, treatment outcomes, and survival were analyzed. Patients who decided to come off treatment typically after 12 months using CT scan radiographic complete response (CR), 18FDG-PET/CT scan complete metabolic response (CMR) or tumor biopsy of a non-CR/CMR tumor site negative for active disease (possible pathological CR) were identified and compared with patients who discontinued treatment due to toxicity while their disease was in control. Event-free survival (EFS) was assessed from the last dose of anti-PD-1 therapy to progression requiring subsequent treatment (surgery, radiation, and/or systemic therapy) or referral to hospice/death due to melanoma.Results24 (20%) patients discontinued treatment by choice with no active disease and 28 (23%) patients discontinued treatment due to toxicity with disease control after 12-month and 4-month median treatment durations, respectively. Similar baseline characteristics were observed between cohorts except higher prior receipt of ipilimumab (29% vs 7%; p=0.036) and fewer BRAF mutant positive disease (17% vs 41%; p=0.064) in patients off treatment by choice. Three-year EFS rates were 95% and 71%, respectively. No significant associations between EFS and sex, disease stage, lactate dehydrogenase elevation, BRAF status, prior systemic therapy, ECOG performance status, presence of brain metastases, or combination versus monotherapy were observed. Tumor biopsies led to alternative management in 3/10 patients due to active metastatic melanoma or second malignancy.ConclusionsAnti-PD-1 therapy discontinuation after 12 months when no active disease is observed on CT scan, PET/CT scan or tumor biopsy may have low rates of disease relapse in patients with advanced melanoma. Biopsy of residual disease may frequently lead to a change in management. These findings are undergoing validation in the EA6192 trial.