Prospective Database Research Articles

Commission on Cancer Standards for Lymph Node Sampling and Oncologic Outcomes After Lung Resection

BackgroundThe newest Commission on Cancer standards recommend sampling 3 mediastinal and 1 hilar lymph node stations, 3 (N2) 1 (N1), for lung cancer resections. However, the relationship between the Commission on Cancer standards and outcomes has not been thoroughly investigated. MethodsA prospective institutional database was queried for clinical stage I-III lung resections before the implementation of the new standards. The relationship between the 3 (N2) 1 (N1) standard (“guideline concordant”) and outcomes (upstaging, complications, receipt of adjuvant therapy, locoregional/distant recurrence, and survival) was assessed with multivariable models and stratified by stage. ResultsOf 9289 pulmonary resections, 3048 (33%) were guideline concordant and 6241 (67%) were not. Compared with nonconcordant, those that were guideline concordant had higher rates of nodal upstaging (21% vs 13%; odds ratio [OR], 1.32 [95% CI, 1.14-1.51]; P < .001) and in-hospital complications (34% vs 27%; OR, 1.17 [95% CI, 1.05-1.30]; P = .004) but similar adjuvant systemic therapy administration (19% vs 13%; OR, 1.09 [95% CI, 0.95-1.24]; P = .2; 98% chemotherapy). Locoregional and distant recurrences were not significantly improved with guideline concordance across clinical stage I, II, and III subsets. Overall survival was similar in clinical stages I and II, but improved survival was observed for guideline concordant clinical stage III patients (hazard ratio, 0.85 [95% CI, 0.74-0.97]; P = .02). ConclusionsSampling 3 (N2) 1 (N1) was associated with increased upstaging and complications but not with decreased recurrence or mortality in clinical stage I or II patients. Survival was improved for concordant, clinical stage III patients. Further study is indicated to determine the ideal lymph node sampling strategy across heterogeneous lung cancer patients.

Do class III obese patients achieve similar outcomes and satisfaction to nonobese patients following surgery for cervical myelopathy? A QOD study.

The aim of this study was to compare the rate of achievement of the minimal clinically important difference (MCID) in patient-reported outcomes (PROs) and satisfaction between cervical spondylotic myelopathy (CSM) patients with and without class III obesity who underwent surgery. The authors analyzed patients from the 14 highest-enrolling sites in the prospective Quality Outcomes Database CSM cohort. Patients were dichotomized based on whether or not they were obese (class III, BMI ≥ 35 kg/m2). PROs including visual analog scale (VAS) neck and arm pain, Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA), EQ-5D, and North American Spine Society patient satisfaction scores were collected at baseline and 24 months after cervical spine surgery. Of the 1141 patients with CSM who underwent surgery, 230 (20.2%) were obese and 911 (79.8%) were not. The 24-month follow-up rate was 87.4% for PROs. Patients who were obese were younger (58.1 ± 12.1 years vs 61.2 ± 11.6 years, p = 0.001), more frequently female (57.4% vs 44.9%, p = 0.001), and African American (22.6% vs 13.4%, p = 0.002) and had a lower education level (high school or less: 49.1% vs 40.8%, p = 0.002) and a higher American Society of Anesthesiologists grade (2.7 ± 0.5 vs 2.5 ± 0.6, p < 0.001). Clinically at baseline, the obese group had worse neck pain (VAS score: 5.7 ± 3.2 vs 5.1 ± 3.3), arm pain (VAS score: 5.4 ± 3.5 vs 4.8 ± 3.5), disability (NDI score: 42.7 ± 20.4 vs 37.4 ± 20.7), quality of life (EQ-5D score: 0.54 ± 0.22 vs 0.56 ± 0.22), and function (mJOA score: 11.6 ± 2.8 vs 12.2 ± 2.8) (all p < 0.05). At the 24-month follow-up, however, there was no difference in the change in PROs between the two groups. Even after accounting for relevant covariates, no significant difference in achievement of MCID and satisfaction was observed between the two groups at 24 months. Despite the class III obese group having worse baseline clinical presentations, the two cohorts achieved similar rates of satisfaction and MCID in PROs. Class III obesity should not preclude and/or delay surgical management for patients who would otherwise benefit from surgery for CSM.

Long term mechanical failure in well aligned adult spinal deformity patients

BACKGROUND CONTEXTMechanical complications (MC) are frequently linked to suboptimal postoperative alignment and represent a primary driver of revision surgery in the context of Adult Spinal Deformity (ASD). However, it's worth noting that even among those deemed "well aligned," the risk of experiencing MCs persists, hinting at the potential influence of factors beyond alignment. PURPOSEThe aim was to assess the incidence of MCs among well-aligned patients and delving into the relevant risk factors and surgical outcomes that come into play within this specific subgroup. STUDY DESIGN/SETTINGA retrospective analysis was conducted using data from a prospective multicenter database dedicated to ASD. PATIENT SAMPLEThe study focused on patients aged 55 years or older, who had a minimum follow-up period of 2 years, and exhibited a Global Alignment and Proportion (GAP) score of 2 points or less (excluding age) within 6 weeks of their index surgery. OUTCOME MEASURESMechanical complications such as rod fractures, pseudarthrosis, or junctional kyphosis or failure, METHODSPatients who developed mechanical complications were identified. Comparative analyses were performed, encompassing both continuous and categorical variables. Furthermore, binary logistic regression tests were employed to pinpoint risk factors, and ROC curves were used to determine the optimal threshold values for these variables. RESULTSA total of 83 patients met the inclusion criteria for this study, with a mean age of 66 years. On average, they had 10 instrumented levels, and 77% of them had fusion extending to the pelvis. Additionally, 27% of the patients had undergone 3-column osteotomies (3-CO). Among them, 33 patients (40%) experienced at least 1 MC during an average follow-up period of 4 years, which included 14 cases of proximal junctional kyphosis (PJK) and 20 cases of nonunion or rod breakage. 15 patients (18%) required revision surgery specifically for MC. In univariable analyses, patients who developed MC were characterized by higher body weight, poorer baseline general health (as indicated by worse SF-36 scores), and less favorable preoperative coronal and sagittal alignment. They also had longer hospital stays, a greater number of instrumented levels, and achieved less favorable postoperative coronal and sagittal alignment. Interestingly, factors such as 3-column osteotomies, postoperative bracing, and the addition of an anterior approach did not significantly alter the risk of MC in well-aligned adult spinal deformity (ASD) patients. Binary regression models revealed that independent risk factors for MC included the residual coronal lumbosacral curve, the number of instrumented levels, and Relative Spinopelvic Alignment (RSA). ROC curves identified an optimal threshold of a residual lumbosacral curve of ≤4° and RSA of ≤3°. Moreover, the rate of MCs showed a stepwise increase within the GAP-Proportioned group, with rates of 31% for GAP=0, 54% for GAP=1, and 75% for GAP=2, with RSA emerging as the most influential parameter. Lastly, patients with MC exhibited poorer functional and radiological outcomes at their last follow-up assessment. CONCLUSIONSThe rate of MCs remains elevated in sagittally “well-aligned” ASD patients that can be attributed to suboptimal residual sagittal and coronal malalignment, which in turn leads to poorer functional outcomes. This study reaffirms the multifaceted nature of MCs and underscores the significance of achieving impeccable postoperative alignment, particularly in the presence of additional risk factors such as extensive surgical correction, a high lever arm (involving instrumented vertebrae), excessive body weight, and frailty (as indicated by SF-36 scores).

771. EVOLUTION OF THE SURGICAL MANAGEMENT OF OESOPHAGEAL PERFORATION

Abstract Background Oesophageal perforations historically have been managed with open trans-thoracic operations. With the increasing experience of minimally invasive procedures, we have performed a case series of trans-hiatal repairs for oesophageal perforations. Our unit has maintained a prospective database of oesophageal perforations since 2014. Methods Retrospective review of outcomes of open trans-thoracic operation to laparoscopic trans-hiatal oesophageal perforation repairs. Results From 80 patients, our database demonstrates an evolution in the treatment of oesophageal perforations from open thoracotomy to either endoscopic intervention (20) or trans-hiatal repair (12). Conclusion Laparoscopic Trans-hiatal oesophageal Repair is comparable and feasible in carefully selected patients (a video recording of the repair will be part of the presentation)

Efficacy and safety of robotic liver surgery for the elderly: A propensity-score matched analysis of short-term outcomes with open liver surgery at a single center in Denmark.

The incidence of liver tumors requiring surgical treatment continues to increase in elderly patients. This study compared the short-term results of robotic liver surgery (RLS) versus open liver surgery (OLS) for liver tumors in elderly patients. A prospective database including all patients undergoing liver surgery at Copenhagen University Hospital between July 2019 and July 2022 was managed retrospectively. Short-term surgical outcomes of the two main cohorts (OLS and RLS) and subgroups were compared using propensity score matching (PSM) in elderly patients (age ≥ 70 years) with liver tumors. A total of 42 matched patients from each group were investigated: the RLS group had significantly larger tumor diameters, less blood loss (821.2 vs. 155.2 mL, p < .001), and shorter hospital stays (6.6 vs. 3.4 days, p < .001). Overall morbidity was comparable, while operative times were longer in the RLS group. The advantages observed with the robotic approach were replicated in the subgroup of minor liver resections. In patients ≥70 years, RLS for liver tumors results in significantly less blood loss and shorter hospital stays than OLS. RLS, especially minor liver resection, is safe and feasible in elderly patients with liver tumors.

502. COMPARING NEOADJUVANT TREATMENTS REGARDING DYSPHAGIA AND WEIGHT CHANGES FOR PATIENTS WITH OESOPHAGEAL OR GASTRO OESOPHAGEAL CANCER

Abstract Background Dysphagia is the main symptom for patients diagnosed with cancer in the oesophagus or gastro oesophageal junction (GOJ), but there are lack of recent studies confirming this. Several studies have reported relief of dysphagia during neoadjuvant treatment but there might also be side effects affecting nutritional status resulting in weight loss. We wanted to investigate if there are differences between the mainly used neoadjuvant treatments in Sweden today, namely CROSS, FLOT, and other treatments (OT), for example prolonged neoadjuvant treatment due to oligometastatic cancer. Aims of this study was to investigate dysphagia, weight changes, and main causes of healthcare referral. Methods All patients with cancer in the oesophagus or GEJ receiving neoadjuvant treatment followed by subsequent oesophagectomy at Karolinska University hospital in Stockholm, Sweden January 2017 to June 2022 were included in the study. Data were extracted from the local prospective database and the electronic medical records. To grade the severity of dysphagia we used the five graded Ogilvie score. The weight as well as the dysphagia score was evaluated before oncological treatment and before surgery. The patients were divided into three groups, them receiving CROSS, FLOT and OT, respectively. Results There were 69 patients receiving CROSS, 68 receiving FLOT and 28 receiving OT. The patients experienced relief of dysphagia in all groups, CROSS p&amp;lt;0.001, FLOT p&amp;lt;0.001 and OT p&amp;lt;0.001. Patients receiving CROSS lost 1.32 kg weight (-8.5 kg to 6.4 kg), while those receiving FLOT gained 0.08 kg (-5.5 kg to 11.1 kg) and OT lost 0.49 kg (-20 kg to 8 kg). Dysphagia was the main symptom for patients diagnosed with oesophageal cancer or GEJ (65%), other causes (9%), followed by anaemia (8 %), reflux (6%), pain (6%) and au passant (5%). Conclusion All groups experienced statistically significant relief of dysphagia during the neoadjuvant treatments. There were small differences in weight changes between the treatment groups, although patients undergoing chemoradiotherapy treatment lost more weight compared to those only receiving chemotherapy. Main cause of referral is dysphagia. Key words Oesophageal cancer, neoadjuvant therapy, dysphagia, weight

Long-term clinical evaluation of a decade with peroral endoscopic myotomy at a single European tertiary center

Peroral endoscopic myotomy (POEM) is an established treatment for achalasia with compelling midterm efficacy. In this study, we analyzed the long-term efficacy, sought predictors of failure, and comprehensively assessed post-POEM reflux. We performed a retrospective analysis of a prospective database of patients undergoing POEM at a high-volume center from December 2012 to June 2023. Patients who had completed a 3-month follow-up were included. Efficacy was assessed at 3, 6, and 8 years using the Eckardt score (ES). An ES≤2 was considered treatment success. At 3 months, gastroscopy, manometry, 24-hour pH monitoring, and fluoroscopy were performed, and gastroscopy was repeated at 2 and 3 years. At each visit, patients were assessed for reflux symptoms and quality of life. From 496 included patients, 3-, 6-, and 8-year follow-ups were completed in 302, 115, and 40 patients, respectively. The treatment success rates at 3, 6, and 8 years according to the Kaplan-Meier analysis were 90.2% (95% confidence interval [CI], 87.2-93.3), 82.3% (95% CI, 77.3-87.6), and 73.5% (95% CI, 64.8-83.5), respectively. Year of procedure was the only predictor of outcome. Fifty-three patients (10.7%) encountered failure or recurrence. Treatment success of redo-POEM (n= 20) at 1 year was significantly lower (62.9% [95% CI, 44.3-89.2] vs 96.9% [95% CI, 95.3-98.5], P< .001). At 3 months, 40.4% of patients had reflux esophagitis (RE), 43.6% of patients had an acid exposure time >4.5%, 39.2% of patients were using proton pump inhibitors (PPIs), but only 24.2% had reflux symptoms. At 2 to 3 years, 50.8% of patients took PPIs, whereas 39.6% were symptomatic. RE decreased to 20.2% at 6 years. The treatment success of POEM declines over time but remains sufficiently high in the long term. Experience with the procedure improves the outcome. Gastroesophageal reflux affects almost half of patients early after POEM and decreases substantially over time together with a rise in PPI use.

762. A PROPOSAL FOR CERVICAL ANASTOMOTIC LEAKAGE CLASSIFICATION AFTER ESOPHAGECTOMY

Abstract Background Anastomotic leak (AL), a potently life-threatening complication after esophagectomy, has a wide spectrum of presentation. There are also several treatment modalities but uncertainty about its clinical applicability remains, being mostly guided by personal experience and available resources. Regarding cervical anastomosis, literature is especially scarce. Although classically it was managed conservatively with cervical wound drainage, 60-70% have an intrathoracic manifestation, which is not only associated with worst clinical severity, as it appears more difficult to manage. In this study, we propose a new classification system for cervical esophago-gastric leak, based on its imaging presentation, with a standardized therapeutic approach. Methods Cervical AL classification and therapeutic protocol were developed through retrospective evaluation of a prospective database, including all patients submitted to esophagectomy with gastric conduit reconstruction and cervical anastomosis since the 1st January 2018 to the 31st March 2024, in an upper gastro-intestinal surgery unit, at a tertiary cancer center. AL manifestation was classified according to imaging appearance on CT scan, reviewed by a dedicated radiologist. Protocol was developed considering treatment patterns according to each manifestation and respective success rate. Results During this period, 253 esophagectomies were performed, 171 with cervical anastomosis and thus included to analysis. AL rate was 21.6%. Four types of AL manifestation were identified: A – exclusive cervical manifestation (32.4%); B – mediastinal drainage without pleural involvement (8.1%); C – apical pleural collection (8.1%); D – pleural involvement (51.2%). Based on these patterns, a standardized therapeutic algorithm was developed (figure 1): conservative treatment with cervical wound drainage for A, endoscopic therapy for B and C (first-line endoluminal esosponge®, stent as option) and for type D, in addition to endoscopic therapy, pleural drainage and empyema decortication in refractory cases. Conclusion Although well stablished and easy to apply, the Esophagectomy Complications Consensus Group (ECCG) classification for esophagectomy AL differentiates its severity, but does not guide its treatment. In this study, we identified four types of cervical AL manifestation, which we consider relevant to select the appropriate treatment modality. This protocol was recently adopted in our center and we pretend to evaluate its results in a short-term.

798. FEASIBILITY AND EFFICACY OF CISPLATIN, PACLITAXEL AND IMMUNE CHECKPOINT INHIBITORS AS CONVERSION THERAPY FOR LOCOREGIONALLY UNRESECTABLE ESOPHAGEAL SQUAMOUS CELL CARCINOMA

Abstract Background Induction therapy followed by conversion surgery is potentially curative for locoregionally unresectable esophageal squamous cell carcinoma (ESCC). However, the optimal induction treatment strategy is unclear. The study aimed to evaluate the feasibility and efficacy of cisplatin, paclitaxel and immune checkpoint inhibitors as conversion therapy for locoregionally unresectable ESCC. Methods Clinicopathological variables of cT4b ESCC patients who received neoadjuvant chemoimmunotherapy were retrieved from the prospective database of the Surgical Esophageal Cancer Patient Registry in West China Hospital, Sichuan University. Enhanced computed tomography, ultrasonography and bronchoscopy were routinely used for the diagnosis. The treatment protocol of neoadjuvant chemoimmunotherapy included 2 cycles of immunotherapy plus chemotherapy with the interval of 3 weeks among each cycle. All patients received 2 cycles of Pembrolizumab (200 mg, D1), Sintilimab (200 mg, D1), Tislelizumab (200 mg, D1) or Camrelizumab (200 mg, D1) intravenously. Concurrently all patients received 2 cycles of cisplatin (75 mg/m2 of body-surface area, D1) and paclitaxel (175 mg/m2 body-surface area, D1) intravenously. The perioperative parameters and short-term surgical outcomes were presented (Table). Results Between January 2020 and December 2022, a total of 317 ESCC patients who underwent neoadjuvant chemoimmunotherapy followed by surgery were screened. Twenty cT4b patients with middle or upper thoracic ESCC were finally enrolled in this study. Pretreatment tumor invades the trachea (4, 20%), left main bronchus (16, 80%), and aorta (6, 30%), respectively. All the patients were successfully performed by McKeown minimally invasive esophagectomy except for one patient conversion to thoracotomy. R0 resection was achieved in 15 patients, 4 patients underwent R1 resection and 1 patient underwent R2 resection. Mean operation duration was 290.4 ± 57.5 min. Mean estimated blood loss was 94.4 ± 108.8 ml. Three patients had postoperative pneumonia, two patients had postoperative pleural effusion and one patient had postoperative recurrent laryngeal nerve paralysis. No patient had postoperative anastomotic leak. No postoperative reoperation was needed and there was no perioperative mortality. Mean length of hospital stay was 10.9±1.4 days. 90-day mortality occurred in one patient with postoperative multiple systemic metastasis. Fifteen patients are alive with a median follow up of 18 months. One patient died with regional lymph node recurrence and three patients died with hematogenous dissemination. Conclusion Multimodal treatment strategy combining immunotherapy and chemotherapy may convert unresectable tumors into potentially operable ones, and achieved favorable survival. Longer follow-up and larger sample size are needed to verify our preliminary results.

The Brussels Breast Surgery Fellowship | A Three-Month Experience in Advancing Skills in Breast Surgery.

The Brussels Breast Surgery Fellowship at Brussels University Hospital offers a unique 3-month clinical immersion in reconstructive and aesthetic breast surgery. Under the guidance of fellowship director Prof. Moustapha Hamdi and his esteemed colleagues, the fellow is exposed to a high volume and wide breadth of cases spanning autologous and implant-based breast reconstruction, oncoplastic surgery, breast reduction and mastopexy, implant augmentation, revision breast surgery, and fat grafting. The multidisciplinary team approach, involving close collaboration with breast surgeons, provides valuable experience in oncoplastic planning and execution. In addition to time in the operating theater, the fellow gains knowledge through outpatient clinics, didactic teaching sessions, and clinical research opportunities leveraging the department's extensive prospective database. As the 2023 fellowship awardee, I had the privilege of learning directly from Prof. Dr. Moustapha Hamdi and participating in over 130 cases across the reconstructive and aesthetic spectrum. Unique features of the fellowship included exposure to lymphedema surgery utilizing the Symani robotic system, advanced techniques like the internal bra, volume distribution mastopexies, observation of private aesthetic clinic cases, and optional participation in academic workshops. This fellowship represents an outstanding opportunity to refine one's skills in breast surgery and microsurgery while experiencing the rich culture of Belgium.

Nurture growth: Ketogenic diet therapy and growth velocity in infants under 12 months with epilepsy − A systematic review and infant data study

Ketogenic diet therapy (KDT) is well established for the treatment of early epileptic encephalopathies and specific aetiologies; however, the impact on growth in infancy remains controversial. Our aim was to examine the influence of early KDT on growth velocity and height percentiles completing two tasks. First, we systematically reviewed the literature on growth in infants younger than 12 months. Second, we analysed data from our prospective database, including infants <12 months (n = 63) treated with KDT. The literature review (n = 7) remains descriptive and includes growth percentiles and z-scores as growth velocity was not described. Studies up to 2010 used fasting, calorie restrictions, and ratios >3:1. In individual cases, significant growth delays were found; other authors did not find any changes in growth parameters. Study endpoints in our own cohort included z-scores of growth velocity, standard deviation (SD) of height, weight, BMI, deviation from individual height percentile, and daily macronutrient intake. The median z-score of growth velocity was 1.03 (first year of life). After three months, median daily intake of protein and energy was 1.68 g/kg and 85 kcal/kg. Until the age of one year, neither growth velocity nor individual growth percentiles decreased. Infants showed distinct growth improvements at three months, likely due to continuous nutritional monitoring and reduction in seizures. In the second year of life, z-scores of growth velocity decreased in patients still receiving KDT (from 1.03 at 12 months to −1.5 at 24 months). Furthermore, younger age at epilepsy onset and at KDT start correlated with slower growth velocities in the first year of life.With appropriate nutritional intake and monitoring, KDT does not reduce growth in the first year of life. Future directions might be to study the impact of KDT on growth velocity and growth hormones throughout childhood.

Lymph node ratio prognosticates overall survival in patients with stage IV colorectal cancer

BackgroundLymph node ratio (LNR) is suggested to address the shortcomings of using only lymph node yield (LNY) or status in colorectal cancer (CRC) prognosis. This study explores how LNR affects survival in patients with metastatic colorectal cancer (mCRC), seeking to provide clearer insights into its application.MethodsThis observational cohort study investigated stage IV patients with CRC (1995–2021) who underwent an upfront resection of their primary tumour at Concord Hospital, Sydney. Clinicopathological data were extracted from a prospective database, and LNR was calculated both continuously and dichotomously (LNR of 0 and LNR > 0). The primary endpoint was overall survival (OS). The associations between LNR and various clinicopathological variables were tested using regression analyses. Kaplan–Meier and Cox regression analyses estimated OS in univariate and multivariate survival models.ResultsA total of 464 patients who underwent a primary CRC resection with clear margins (mean age 68.1 years [SD 13.4]; 58.0% M; colon cancer [n = 339,73.1%]) had AJCC stage IV disease. The median LNR was 0.18 (IQR 0.05–0.42) for colon cancer (CC) resections and 0.21 (IQR 0.09–0.47) for rectal cancer (RC) resections. A total of 84 patients had an LNR = 0 (CC = 66 patients; RC = 18 patients). The 5-year OS for the CC cohort was 10.5% (95% CI 8.7–12.3) and 11.5% (95% CI 8.4–14.6) for RC. Increasing LNR demonstrated a decline in OS in both CC (P < 0.001) and RC (P < 0.001). In patients with non-lymphatic dissemination only (LNR = 0 or N0 status), there was better survival compared with those with lymphatic spread (CC aHR1.50 [1.08–2.07;P = 0.02], RC aHR 2.21 [1.16–4.24;P = 0.02]).ConclusionsLNR is worthy of consideration in patients with mCRC. An LNR of 0 indicates patients have a better prognosis, underscoring the need for adequate lymphadenectomy to facilitate precise mCRC staging.

Brain and Heart Interactions Delineating Cardiac Dysfunction in Four Common Neurological Disorders: A Systematic Review and Meta-analysis.

Neurological and cardiovascular disorders are the leading causes of morbidity and mortality worldwide. While the effects of cardiovascular disease (CD) on the nervous system are well understood, understanding of the reciprocal relationship has only recently become clearer. Based on disability-adjusted life years, this systematic review and meta-analysis present the pooled incidence and association of CD in 4 selected common, noncommunicable neurological disorders: (1) migraine, (2) Alzheimer disease and other dementias, (3) epilepsy, and (4) head injury. Sixty-five studies, including over 4 and a half million patients, were identified for inclusion in this review. Among the 4 neurological disorders, the majority of patients (89.4%) had epilepsy, 9.6% had migraine, and 0.97% had head injury. Alzheimer disease and other dementias were reported in only 0.02% of patients. The pooled effect estimates (incidence and association) of CD in the 4 neurological disorders was 10% (95% CI: 5.8%-16.9%; I2 = 99.94%). When stratified by the neurological disorder, head injury was associated with the highest incidence of CD (28%). The 4 neurological disorders were associated with a 2-fold increased odds for developing CD in comparison to patients without neurological disorders. Epilepsy was associated with the greatest increased odds of developing CD (odds ratio: 2.25; 95% CI: 1.82-2.79; P = 0.04). In studies that reported this variable, the pooled hazard ratio was 1.64 (95% CI: 1.38-1.94), with head injury having the highest hazard ratio (2.17; 95% CI: 1.30-3.61). Large prospective database studies are required to understand the long-term consequences of CD in patients with neurological disorders.

Same-day parathyroidectomy for primary hyperparathyroidism -an over 20-year practice.

There has been a shift in recent years toward same-day parathyroidectomies due to the decrease in mutual costs with few significant differences in postoperative morbidity or mortality. We sought to determine if demographics, preoperative patient risk factors, or comorbidities were associated with a patient's likelihood of having same-day or inpatient surgery. A prospective database of parathyroid operations from 2001 to 2022 (n=2948 patients) was reviewed for surgeries completed for primary hyperparathyroidism. Patients were categorized as same-day or inpatient surgery; demographics, risk factors, and co-morbidities were examined and differences across practice patterns during the 21-year period were studied and also analyzed in a subset of patients from 2013 to 2022. In a recent subset of patients from 2013 to 2022, patients having inpatient surgery were more likely to be Black and use anticoagulation or antiplatelet therapy. Multivariable regression confirmed increased odds of aging and black patients requiring inpatient parathyroidectomy. Compared to 2001-2003, there was a significantly increased proportion of patients undergoing same-day surgery; compared to 2010-2012, there was a similar proportion of patients undergoing outpatient surgery between 2013 and 2018, and there was an increased proportion from 2019 through 2022. Same-day parathyroidectomies have been shown to be safe and has become the typical practice for high-volume parathyroid surgeons over the last decade. Complications such as postoperative hematoma or hypocalcemia were previously shown to be incompletely mitigated by increased LOS or inpatient surgery, although demographics are considered to increase the odds of inpatient parathyroidectomy.

The addition of pembrolizumab to neoadjuvant chemoradiotherapy did not increase the risk of developing postoperative anastomotic leakage for ESCC: an analysis from a prospective cohort

BackgroundTo compare the difference of postoperative anastomotic leakage (AL) rate between neoadjuvant chemoradiotherapy (NCRT) with pembrolizumab and NCRT group, and investigate the risk factors of developing AL for locally advanced esophageal squamous cell cancer (ESCC).Materials and methodsThe GF was contoured on the pretreatment planning computed tomography and dosimetric parameters were retrospectively calculated. Univariate and multivariate logistic regression analysis was performed to determine the independent risk predictors for the entire cohort. A nomogram risk prediction model for postoperative AL was established.ResultsA total of 160 ESCC patients were included for analysis. Of them, 112 were treated with NCRT with pembrolizumab and 44 patients with NCRT. Seventeen (10.6%) patients experienced postoperative AL with a rate of 10.7% (12/112) in NCRT with pembrolizumab and 11.4% (5/44) in NCRT group. For the entire cohort, mean, D50, Dmax, V5, V10 and V20 GF dose were statistically higher in those with AL (all p < 0.05). Multivariate logistic regression analysis indicated that tumor length (p = 0.012), volume of GF (p = 0.003) and mean dose of GF (p = 0.007) were independently predictors for postoperative AL. Using receiver operating characteristics analysis, the mean dose limit on the GF was defined as 14 Gy.ConclusionBased on our prospective database, no significant difference of developing AL were observed between NCRT with pembrolizumab and NCRT group. We established an individualized nomograms based on mean GF dose combined with clinical indicators to predict AL in the early postoperative period.

Partial pancreatoduodenectomy versus total pancreatectomy in patients with preoperative diabetes mellitus: Comparison of surgical outcomes and quality of life.

To reduce perioperative risks among patients with a preoperative diabetes mellitus (DM) a total pancreatectomy (TP) might be a alternative to pancreatoduodenectomy (PD). This study aimed to compare the postoperative quality of life (QoL) of patients with preoperative DM undergoing PD or TP. A single-centre retrospective study was conducted, all consecutive patients with preoperative DM undergoing PD or TP between 2011 and 2023 were identified in a prospective database. The primary endpoint was QoL, prospectively assessed using EORTC QLQ-C30 questionnaires at 3, 6, and 12months after surgery and then annually until death. Secondary endpoints were morbidity and mortality. Seventy-one patients were included, 17 after TP and 54 after PD. Insulin-dependent DM occurred in 21 (39%) of the PD patients. QoL was worse after TP, especially in terms of physical functioning (-31.7 points; 95% CI: -50.0 to -13.3; P < 0.001), role functioning (-41.3 points; 95% CI: -61.3 to -21.3; P < 0.001), emotional functioning (-27.5 points; 95% CI: -50.4 to -4.6; P = 0.019), fatigue symptoms (20 points; 95% CI: 2.7 to 37.4; P = 0.024) and pain symptoms (30.2 points; 95% CI: 4.1 to 56.3; P = 0.024). The rates of postoperative major complications (29% vs. 35%; P = 0.853) and mortality (11% vs. 7%; P = 0.857) were similar between TP and PD. Postoperative morbidity and mortality were comparable between PD and TP, however QoL is significantly lower after TP. Importantly, patients with preoperative DM have a 60% chance of remaining noninsulin-dependent after PD.

INFLUENCE OF MANUFACTURING CHARACTERISTICS OF HIGHLY CROSS-LINKED POLYETHYLENE ON FEMORAL HEAD PENETRATION IN TOTAL HIP ARTHROPLASTY: A TEN- TO 20-YEAR FOLLOW-UP STUDY

Highly cross-linked polyethylene (HXLPE) has decreased wear and revision rates in total hip replacement (THR) at a long-term. However, the effect of HXLPE manufacturing characteristics on femoral head penetration has not been clearly defined yet. We report this single-institution study to investigate the clinical and radiological results of different HXLPE liners in THR.In this retrospective cohort analysis of our prospective database, we identified 904 THRs performed between 2000 and 2013. Seven different HXLPE liner types were assessed: remelted (3), annealed (2), sequentially annealed (1) and vitamin E-infused (1). The linear femoral head penetration rate was measured at six weeks, one year, and annually thereafter, using the Roman Software v1.70 package.Thirty hips were revised for the following reasons: aseptic loosening (11), dislocation (12), periprosthetic femoral fracture (6), and infection (1). No hip was revised for wear or osteolysis. 741 THRs were evaluated for a mean follow-up of 15 years (range, 10 to 20). The mean total penetration 15 years after THR was 0.17 mm in the sequentially annealed, and 0.16 mm in the vitamin E-infused groups, whereas it was 0.26 mm in the melted 95 kGy, 0.27 mm in the melted 5 Mrad and 0.25 mm in the melted 100 kGy groups (p=0.001). From one to 15 years after surgery, the mean wear was 0.206 mm in cups with an acetabular inclination greater than 50º and 0.105 mm in those placed between 35º and 50º (p&lt;0.001).Although HXLPE characteristics can result in a different wear performance in patients undergoing THR at a mean follow-up of 15 years, the clinical results are excellent. The position of the acetabular component can influence on the femoral head penetration of modern HXLPEs. Nevertheless, these patients should continue to be monitored to detect future problems.

Correlation Between Near-Infrared Autofluorescence Properties and Sestamibi Uptakes of Parathyroid Glands in Primary Hyperparathyroidism.

Near-infrared autofluorescence (NIRAF) characteristics of parathyroid glands in primary hyperparathyroidism (pHPT) vary, with unclarity regarding the underlying mechanism. Similarly, 99mTc-sestamibi uptake in diseased parathyroid glands is variable. There is a suggestion that oxyphilic cell content may influence both imaging modalities. This study aims to analyze the relationship between NIRAF imaging characteristics, 99mTc-sestamibi uptake, and cellular composition in pHPT. Retrospective analysis of an Institutional Review Board-monitored prospective database. Single tertiary referral center. NIRAF characteristics of parathyroid glands of patients with pHPT between 2019 and 2024 were compared with 99mTc-sestamibi scan findings from a prospective database. Using third-party software, brightness intensity and heterogeneity index (HI) of the glands were calculated. A subgroup of parathyroid glands obtained from consecutive patients with pHPT in 2020 to 2021 underwent histological analysis. A total of 428 patients with 638 diseased parathyroid glands were analyzed. Forty-seven percent of the glands showed an uptake on 99mTc-sestamibi scans. The brightness intensity of the NIRAF signals from parathyroid glands that were seen versus not seen on sestamibi was 2.1 versus 2.3 (P = .002) and HI 0.18 versus 0.17 (P = .35), respectively. On multivariate analysis, low autofluorescence intensity, high gland volume, and single adenoma were associated with detectability on 99mTc-sestamibi scan (P < .0001). Intraglandular adipose tissue content was lower in diseased glands that were detected on 99mTc-sestamibi scans (0% vs 5%, P < .0001). Our findings indicate an inverse relationship between autofluorescence intensity and detectability on 99mTc-sestamibi scans and a lack of correlation between different cell types and autofluorescence properties.

Global trends in opioid use for pain management in acute pancreatitis: A multicentre prospective observational study.

Since there is no current international consensus on the optimal approach for pain management in acute pancreatitis (AP), analgesic practices may vary across different healthcare settings. This study explored global disparities in analgesic use, in particular opioids, during admission and at discharge in hospitalised AP patients. This was a post hoc analysis of the prospective PAINAP database, which included all admissions for AP between April and June 2022 with a 1-month follow-up. Demographic details, analgesic use, and clinical outcomes were recorded during admission and at discharge. Odds ratios (ORs) for opioid use during admission and at discharge were identified using multivariable regression analyses. Amongst the 1864 patients (52% males, median age 56 (interquartile range, 41-71))across three different continents, simple analgesics were predominantly used as the primary analgesic (70%). Opioid use during admission was lowest in European centres (67%). Admission in Asian (OR, 2.53 (95% confidence interval (CI), 1.59-4.04), p<0.001), and Australian (OR, 5.81 (95% CI, 3.19-10.56), p<0.001) centres was associated with opioid administration during admission compared with European centres. Increased pain severity, longer pre-admission pain duration, organ failure, and longer length of admission increased opioid use during admission. At discharge, Asian (OR, 2.01 (95% CI, 1.40-2.88), p<0.001) and Australian (OR, 1.91 (95% CI, 1.28-2.85), p=0.002) centres were associated with opioid prescription compared with European centres. Increased pain severity, longer pre-admission pain duration, acute necrotic collections, and walled-off necrosis also increased the likelihood of opioid prescription at discharge. There are substantial intercontinental differences in opioid use for AP pain. Accordingly, there is a need for international guidelines on pain management in AP.

Weighing your options-intragastric balloon versus semaglutide.

Over half of Americans and up to 78% of US Veteran population meet criteria for obesity. Perioperatively placed intragastric balloon (IGB) can accelerate weight loss goals for safe surgical candidacy, however weight regain is common after removal. Glucagon-like peptide-1-receptor agonists (GLP1RA) may provide a more sustainable weight loss solution after surgery. We hypothesize that weight regain will be less at 1year after initiation of GLP1RA than IGB placement in Veterans. Retrospective review of prospective databases of perioperatively placed intragastric balloon cohort from 1/2019-1/2023 compared to patients who received initiatory GLP1RA from 6/2021-8/2022 at a VA Medical Center(VAMC). All patients were enrolled in the VAMC MOVE! multidisciplinary weight management program for a minimum of 12weeks. Outcomes measured were patients' weights at 0, 3, 6, and 12months and weight change for these intervals. Exclusion criteria included history of bariatric surgery and incomplete weight loss data. Two-hundred-twenty-three patients met inclusion criteria; 110 (49%) patients excluded. Mean age was 54 ± 11years, the majority (78, 69%) were male, and the mean initial BMI was 37 ± 5.9kg/m2. Seventeen (15%) patients underwent IGB placement and 96 (85%) patients received semaglutide. Weight (kg) change was measured at intervals: 0-3months:-11.8(-17,-9.5) IGB vs. -5.1(-7.4,-2.3) semaglutide, p < 0.0001; 0-6months:-12.7(-18.4,-9.9) vs. -9.4(-12.6,-6.1), p = 0.03; 3-6months:-0.5(-2.3,2.3) vs. -4.3(-6.8,-1.6), p < 0.0001; 6-12months:3(0,7.3) vs. -1.9(-4.7,1), p = 0.0006. Weight loss occurs more rapidly in the first 6months after intragastric balloon placement compared to semaglutide (-12.7 vs. -9.4kg, p = 0.03). Despite ongoing attendance in a comprehensive weight loss program, weight regain is common after IGB removal by an average of 3kg (23.6%) at 1year. In contrast, patients on GLP1RA (semaglutide) continue to lose weight during this period. Further studies are needed to determine if optimal long-term outcomes may result from combination therapy with intragastric balloon and semaglutide.