Explore the vast range of titles available.

Background The objective of the current study was to develop a model to predict the likelihood of occult lymph node metastasis (LNM) prior to resection of intrahepatic cholangiocarcinoma (ICC). Methods Patients who underwent hepatectomy for ICC between 2000 and 2017 were identified using a multi-institutional database. A novel model incorporating clinical and preoperative imaging data was developed to predict LNM. Results Among 980 patients who underwent resection of ICC, 190 (19.4%) individuals had at least one LNM identified on final pathology. An enhanced imaging model incorporating clinical and imaging data was developed to predict LNM ( https://k-sahara.shinyapps.io/ICC_imaging/ ). The performance of the enhanced imaging model was very good in the training data set (c-index 0.702), as well as the validation data set with bootstrapping resamples (c-index 0.701) and outperformed the preoperative imaging alone (c-index 0.660). The novel model predicted both 5-year overall survival (OS) (low risk 48.4% vs. high risk 18.4%) and 5-year disease-specific survival (DSS) (low risk 51.9% vs. high risk 25.2%, both p < 0.001). When applied among Nx patients, 5-year OS and DSS of low-risk Nx patients was comparable with that of N0 patients, while high-risk Nx patients had similar outcomes to N1 patients ( p > 0.05). Conclusion This tool may represent an opportunity to stratify prognosis of Nx patients and can help inform clinical decision-making prior to resection of ICC.

BackgroundThe objective of the current study was to assess the impact of serum CA19-9 and CEA and their combination on survival among patients undergoing surgery for intrahepatic cholangiocarcinoma (ICC).MethodsPatients who underwent curative-intent resection of ICC between 1990 and 2016 were identified using a multi-institutional database. Patients were categorized into four groups based on combinations of serum CA19-9 and CEA (low vs. high). Factors associated with 1-year mortality after hepatectomy were examined.ResultsAmong 588 patients, 5-year OS was considerably better among patients with low CA19-9/low CEA (54.5%) compared with low CA19-9/high CEA (14.6%), high CA19-9/low CEA (10.0%), or high CA19-9/high CEA (0%) (P < 0.001). No difference in 1-year OS existed between patients who had either high CA19-9 (high CA19-9/low CEA: 70.4%) or high CEA levels (low CA19-9/high CEA: 72.5%) (P = 0.92). Although patients with the most favorable tumor marker profile (low CA19-9/low CEA) had the best 1-year survival (87.9%), 15.1% (n = 39) still died within a year of surgery. Among patients with low CA19-9/low CEA, a high neutrophil-to-lymphocyte ratio (NLR) (odds ratio 1.09; 95% confidence interval 1.03-1.64) and large size tumor (odds ratio 3.34; 95% confidence interval 1.40–8.10) were associated with 1-year mortality (P < 0.05).ConclusionsPatients with either a high CA19-9 and/or high CEA had poor 1-year survival. High NLR and large tumor size were associated with a greater risk of 1-year mortality among patients with favorable tumor marker profile.

Background Laparoscopic liver resection (LLR) involves a difficult learning curve, for which multiple difficulty scores have been proposed to assist with safe adaptation. The IWATE Criteria is a 4-level difficulty score shown to correlate with conversion to open surgery, estimated blood loss (EBL), and operative time in Japanese and French cohorts. We set out to validate the IWATE Criteria in a North American cohort, describe the evolution of our LLR program, and analyze the IWATE Criteria’s ability to predict conversion to open surgery.MethodsPatients that underwent LLR between January 2006 and December 2019 were selected from a prospectively maintained database. Difficulty outcomes, including conversion to open surgery, EBL, operative time, and post-operative complications were analyzed according to IWATE difficulty level, both overall and between chronological eras. The IWATE Criteria’s ability to predict conversion to open surgery was assessed with a receiver operating characteristic (ROC) analysis.Results A total of 426 patients met inclusion criteria. Operative time, EBL, and conversion to open surgery increased in concordance with low to advanced IWATE difficulty. ROC analysis for conversion to open surgery demonstrated an overall area under the curve (AUC) of 0.694. Predictive performance was superior during the first two eras, with AUCs of 0.771 and 0.775; predictive value decreased as the LLR program gained experience, with AUCs of 0.708 and 0.551 for eras three and four.ConclusionsThis study validated the IWATE Criteria in a North American population distinct from previous Japanese and French cohorts, based on its correlation with operative time, EBL, and conversion to open surgery. The IWATE Criteria may be of utility for identification of LLR cases appropriate for surgeon experience, as well as determination of laparoscopic feasibility. Interval difficulty score recalibration may be warranted as surgeon perception of difficulty evolves.

BackgroundAccurate risk stratification and patient selection is necessary to identify patients who will benefit the most from surgery or be better treated with other non-surgical treatment strategies. We sought to identify which patients in the preoperative setting would likely derive the most or least benefit from resection of intrahepatic cholangiocarcinoma (ICC).MethodsPatients who underwent curative-intent resection for ICC between 1990 and 2017 were identified from an international multi-institutional database. A machine-based classification and regression tree (CART) was used to generate homogeneous groups of patients relative to overall survival (OS) based on preoperative factors.ResultsAmong 1146 patients, CART analysis revealed tumor number and size, albumin-bilirubin (ALBI) grade and preoperative lymph node (LN) status as the strongest prognostic factors associated with OS among patients undergoing resection for ICC. In turn, four groups of patients with distinct outcomes were generated through machine learning: Group 1 (n = 228): single ICC, size ≤ 5 cm, ALBI grade I, negative preoperative LN status; Group 2 (n = 708): (1) single tumor > 5 cm, (2) single tumor ≤ 5 cm, ALBI grade 2/3, and (3) single tumor ≤ 5 cm, ALBI grade 1, metastatic/suspicious LNs; Group 3 (n = 150): 2–3 tumors; Group 4 (n = 60): ≥ 4 tumors. 5-year OS among Group 1, 2, 3, and 4 patients was 60.5%, 35.8%, 27.5%, and 3.8%, respectively (p < 0.001). Similarly, 5-year disease-free survival (DFS) among Group 1, 2, 3, and 4 patients was 47%, 27.2%, 6.8%, and 0%, respectively (p < 0.001).ConclusionsThe machine-based CART model identified distinct prognostic groups of patients with distinct outcomes based on preoperative factors. Survival decision trees may be useful as guides in preoperative patient selection and risk stratification.

BackgroundSurgical resection of hepatic metastases remains the only potentially curative treatment option for patients with colorectal liver metastases (CRLM). Widely adopted prognostic tools may oversimplify the impact of model parameters relative to long-term outcomes.MethodsPatients with CRLM who underwent a hepatectomy between 2001 and 2018 were identified in an international, multi-institutional database. Bootstrap resampling methodology used in tandem with multivariable mixed-effects logistic regression analysis was applied to construct a prediction model that was validated and compared with scores proposed by Fong and Vauthey.ResultsAmong 1406 patients who underwent hepatic resection of CRLM, 842 (59.9%) had recurrence. The full model (based on age, sex, primary tumor location, T stage, receipt of chemotherapy before hepatectomy, lymph node metastases, number of metastatic lesions in the liver, size of the largest hepatic metastases, carcinoembryonic antigen [CEA] level and KRAS status) had good discriminative ability to predict 1-year (area under the receiver operating curve [AUC], 0.693; 95% confidence interval [CI], 0.684–0.704), 3-year (AUC, 0.669; 95% CI, 0.661–0.677), and 5-year (AUC, 0.669; 95% CI, 0.661–0.679) risk of recurrence. Studies analyzing validation cohorts demonstrated similar model performance, with excellent model accuracy. In contrast, the AUCs for the Fong and Vauthey scores to predict 1-year recurrence were only 0.527 (95% CI, 0.514–0.538) and 0.525 (95% CI, 0.514–0.533), respectively. Similar trends were noted for 3- and 5-year recurrence.ConclusionThe proposed clinical score, derived via machine learning, which included clinical characteristics and morphologic data, as well as information on KRAS status, accurately predicted recurrence after CRLM resection with good discrimination and prognostic ability.

Background The association of national quality benchmarking metrics with postoperative outcomes following complex surgery remains unknown. We assessed the relationship between the “quality trifactor” of Leapfrog minimum volume standards, Hospital Safety Grade A, and Magnet Recognition with outcomes of Medicare patients undergoing pancreatectomy. Methods The Standard Analytic Files (SAF) merged with Leapfrog Hospital Survey and Leapfrog Safety Scores Denominator Files were reviewed to identify Medicare patients who underwent pancreatic procedures between 2013 and 2015. Primary outcomes were overall and serious complications, as well as 30- and 90-day mortality. Multivariable logistic regression analyses were conducted to evaluate possible associations among hospitals meeting the quality trifactor and short-term outcomes. Results Among 4853 Medicare patients, 909 (18.7%) underwent pancreatectomy at hospitals meeting the quality trifactor. Among 260 hospitals, 7.3% ( n  = 19) met the quality trifactor. Safety Grade A (48.8%, n  = 127) was the most commonly met criterion followed by Magnet Recognition (36.2%, n  = 94); the Leapfrog minimum volume standards were achieved by 25% ( n  = 65) of hospitals. Patients undergoing surgery at hospitals that were only Safety Grade A and Magnet designated, but did not meet Leapfrog criteria, had higher odds of serious complications (OR 1.59, 95% CI 1.00–2.51). In contrast, patients undergoing treatment at hospitals having all three designations (i.e., the quality trifactor) had 40% and 39% lower odds of both serious complications (OR 0.60, 95% CI 0.37–0.97) and 90-day mortality (OR 0.61, 95% CI 0.42–0.89), respectively. In turn, patients undergoing pancreatectomy at quality trifactor hospitals had higher odds of experiencing the composite quality measure textbook outcome (OR 1.28, 95% CI 1.03–1.59) versus patients undergoing pancreatectomy at non-trifactor hospitals. Conclusion While Safety Grade A and Magnet designation alone were not associated with higher odds of an optimal composite outcome following pancreatectomy, compliance with Leapfrog criteria to achieve the “quality trifactor” metric was associated with lower odds of serious complications and mortality.

Background Although previous studies have suggested that drain management is highly variable, data on drain placement and timing of drain removal among patients undergoing hepatic resection remain scarce. The objective of the current study was to define the utilization of drain placement among patients undergoing major hepatic resection. Methods The ACS NSQIP-targeted hepatectomy database was used to identify patients who underwent major hepatectomy between 2014 and 2017. Association between day of drain removal, timing of discharge, and drain fluid bilirubin on postoperative day (POD) 3 (DFB-3) was assessed. Propensity score matching (PSM) was used to compare outcomes of patients with a drain removed before and after POD 3. Results Among 5330 patients, most patients had an abdominal drain placed at the time of hepatic resection ( n  = 3075, 57.7%). Of 2495 patients with data on timing of drain removal, only 380 patients (15.2%) had their drain removed by POD 3. Almost 1 in 6 patients ( n  = 441, 17.7%) were discharged home with the drain in place. DFB-3 values correlated poorly with POD of drain removal ( R 2  = 0.0049). After PSM, early drain removal (≤ POD 3) was associated with lower rates of grade B or C bile leakage (2.1% vs. 7.1%, p  = 0.008) and prolonged length of hospital stay (6.0% vs. 12.7%, p  = 0.009) compared with delayed drain removal (> POD 3). Conclusions Roughly 3 in 5 patients had a drain placed at the time of major hepatectomy and only 1 in 7 patients had the drain removed early. This study demonstrated the potential benefits of early drain removal in an effort to improve the quality of care following major hepatectomy.

Background The impact of preoperative cholangitis (PC) on perioperative outcomes among patients undergoing liver resection remains poorly defined. We sought to characterize the prevalence of PC among patients undergoing hepatectomy and define the impact of PC on postoperative outcomes. Methods Patients who underwent liver resection between 2013 and 2015 were identified using the Center for Medicare Services (CMS) 100% Limited Data Set (LDS) Standard Analytic Files (SAFs). Short-term outcomes after liver resection, stratified by the presence of PC, were examined. Subgroup analyses were performed to evaluate the relationship between the timing of liver resection relative to PC. Results Among 7392 patients undergoing liver resection, 251 patients (3.4%) experienced PC. Patients with PC were more likely to be male (59.0% vs. 50.6%) and to have a benign diagnosis (34.3% vs. 19.8%) compared with patients without PC (both p<0.05). On multivariable analysis, PC was associated with increased odds of experiencing a complication (OR 1.54, 95%CI 1.17–2.03), extended LOS (OR 2.60, 95%CI 1.99–3.39), 90-day mortality (OR 2.31, 95%CI 1.64–3.26), and higher Medicare expenditures (OR 3.32, 95%CI 2.55–4.32). Among patients with PC, requirement of both endoscopic and percutaneous biliary drainage (OR 5.16, 95%CI 1.36–9.61), as well as liver resection < 2 weeks after PC (OR 2.92, 95%CI 1.13–7.57) were associated with higher odds of 90-day mortality. Conclusion Approximately 1 in 30 Medicare beneficiaries undergoing liver resection had a history of PC. PC was associated with an increased risk of adverse short-term outcomes and higher healthcare expenditures among patients undergoing hepatectomy.

Aims: Evaluating the accuracy of the modified Endoscopic ABC (Endo ABC) classification with an electronic endoscopy with narrow band imaging without magnification in diagnosing Helicobacter pylori (H. pylori)-infected gastritis. Methods: A total of 576 patients were enrolled and they underwent modified Endo ABC. They were stratified into 5 groups (A to E) based on the grades of endoscopic findings. H. pylori-infected gastritis status was determined in the following ways: current H. pylori gastritis was defined as active gastritis and/or chronic atrophic gastritis (CAG) seen on endoscopy and positive H. pylori test, naïve H. pylori gastritis was defined as regular arrangement of collecting venules in the angle of the lesser curvature without CAG and negative H. pylori test, and previous H. pylori gastritis was defined as negative H. pylori tests regardless of the presence of CAG. Results: Endo A has 97% accuracy and 100% positive predictive value in diagnosing naïve H. pylori gastritis. Endo E has 97% accuracy and 100% positive predictive value in diagnosing previous H. pylori gastritis. The accuracy of Endo B and Endo C in diagnosing current H. pylori gastritis was 89 and 82% respectively. Endo D has 87% accuracy in diagnosing previous H. pylori gastritis. Conclusion: This study showed that the modified Endo ABC classification enables to accurately determine the H. pylori-infected gastritis status.

BackgroundThe role of routine lymphadenectomy in the surgical treatment of pancreatic neuroendocrine tumors (pNET) remains poorly defined. The objective of the current study was to investigate trends in the number of lymph nodes (LN) evaluated for pNET treatment at a nationwide level.MethodsPatients undergoing surgery for pNET between 2000 and 2016 were identified in the U.S. Neuroendocrine Tumor Study Group (US-NETSG) database as well as the Surveillance, Epidemiology, and End Results (SEER) database. The number of LNs examined was evaluated over time.ResultsThe median number of evaluated LNs increased roughly fourfold over the study period (US-NETSG, 2000: 3 LNs vs. 2016: 13 LNs; SEER, 2000: 3 LNs vs. 2016: 11 LNs, both p < 0.001). While no difference in 5-year OS and RFS was noted among patients who had 1–3 lymph node metastases (LNM) vs. ≥ 4 LNM between 2000–2007 (OS 73.5% vs. 69.9%, p = 0.12; RFS: 64.9% vs. 40.1%, p = 0.39), patients who underwent resection and LN evaluation during the period 2008–2016 had an incrementally worse survival if the patient had node negative disease, 1–3 LNM and ≥ 4 LNM (OS 86.8% vs. 82.7% vs. 74.9%, p < 0.001; RFS: 86.3% vs. 64.7% vs. 50.4%, p < 0.001). On multivariable analysis, a more recent year of diagnosis, pancreatic head tumor location, and tumor size > 2 cm were associated with 12 or more LNs evaluated in both US-NETSG and SEER databases.ConclusionThe number of LNs examined nearly quadrupled over the last decade. The increased number of LNs examined suggested a growing adoption of the AJCC staging manual recommendations regarding LN evaluation in the treatment of pNET.